Fairley et al(1) describe differences in growth between White and
Pakistani infants in the BiB study using mixed effects linear splines, an
approach becoming popular in the analysis of serial anthropometry. Linear
splines were used because they summarize noisy data in meaningful
parameters: an intercept and linear slope terms (connected by knots)
governing different age sections. Adding an exposure obtained estimates of...
Fairley et al(1) describe differences in growth between White and
Pakistani infants in the BiB study using mixed effects linear splines, an
approach becoming popular in the analysis of serial anthropometry. Linear
splines were used because they summarize noisy data in meaningful
parameters: an intercept and linear slope terms (connected by knots)
governing different age sections. Adding an exposure obtained estimates of
differences between ethnicities in size at the intercept and in rate of
change for each age section. Linear splines are an appealing analytical
choice, but their biological and statistical limitations are often
overlooked.
Growth follows a complex pattern of age related change and linear
splines (by their very nature) have limited ability to describe this
process. A traditional structural growth model (e.g., Berkey-Reed 1st
order(2)) may be a better choice to "describe the growth pattern". Careful
selection of knots might have improved matters (e.g., given neonatal
weight loss, a knot at age two weeks would make sense). Instead, knots
developed in the ALSPAC study were used, thereby assuming that the growth
process was the same for BiB infants (with different defining
characteristics) compared to ALSPAC infants. Further, when investigating
the effects of an exposure on growth, does it make sense to impose the
same inflection points (i.e., knots) on each response of that exposure? A
major assumption of the mixed effects linear splines used by Fairley et
al(1) was that all individuals shared the same inflection points. Applying
conventional regression to hierarchical data produces incorrect standard
errors(3) and linear spline specification that does not account for
between individual variation may have similar consequences.
Methods in other disciplines(4) have extended the flexibility of
linear splines to incorporate individual level inflection points at knots
that do not need to be specified a priori, but instead are data driven. A
promising avenue of research is to extend mixed effects linear splines for
growth modelling to include individual level inflection points; this could
be done in existing Bayesian modelling framework software(5).
1. Fairley L, Petherick ES, Howe LD, Tilling K, Cameron N, Lawlor DA,
et al. Describing differences in weight and length growth trajectories
between white and Pakistani infants in the UK: analysis of the Born in
Bradford birth cohort study using multilevel linear spline models.
Archives of Disease in Childhood 2013;98:274-9.
2. Berkey CS, Reed RB. A model for describing normal and abnormal growth
in early childhood. Human Biology 1987;59:973-87.
3. Goldstein H. Efficient statistical modelling of longitudinal data.
Annals of Human Biology 1986;13:129-41.
4. van den Hout A, Muniz-Terrera G, Matthews FE. Change point models for
cognitive tests using semi-parametric maximum likelihood. Computational
Statistics & Data Analysis 2013;57:684-98.
5. Lunn DJT, A. Best, N. Spiegelhalter, D. WinBUGS - a Bayesian modelling
framework: concepts, structure, and extensibility. Statistics and
Computing 2000;10:325-37.
Eisenhut raises the possibility that food was the source of the
outbreak of group A streptococcal disease at the primary school. This
hypothesis was considered, but was rejected as implausible for several
reasons; firstly the outbreak was not a true point source as it was
preceded by five sentinel cases over a 12 day period, in addition the peak
on the 16th May was inflated as it included cases with on...
Eisenhut raises the possibility that food was the source of the
outbreak of group A streptococcal disease at the primary school. This
hypothesis was considered, but was rejected as implausible for several
reasons; firstly the outbreak was not a true point source as it was
preceded by five sentinel cases over a 12 day period, in addition the peak
on the 16th May was inflated as it included cases with onset over the two
day weekend period. The pattern of illness did not suggest any link with
school meal consumption - some of the initial cases were in the reception
class who did not have school meals, a number of the older children among
the initial cases did not have school meals and none of the staff who ate
school meal were ill. The possibility that the school water fountain or
the childrens' water bottles were the source of infection was considered
but neither was compatible with the pattern of illness. Person-to-person
spread, as indicated by the outbreak curve appeared to largely explain the
course of the outbreak.
Eisenhut also comments that exclusion of children with features of
respiratory infection, with the option of immediate treatment of cases
with penicillin rather than waiting for culture confirmation can prevent
secondary cases. This was not our experience, despite the use of the most
rigorous practical exclusion policy and the encouragement of general
practitioners to treat cases symptomatically. We conclude that the
management of contacts requires evaluation as a possible control measure.
I read with great interest the arguments whether 0.9% saline with 5%
dextrose would be a more appropriate choice than 0.45% saline with 5%
dextrose for maintenance fluids in hospitalized children. In 1975, WHO and
the United Nations Children's Fund (UNICEF) decided to promote a single
ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80,
base 30, and glucose 111 (2%) for use among diverse populations....
I read with great interest the arguments whether 0.9% saline with 5%
dextrose would be a more appropriate choice than 0.45% saline with 5%
dextrose for maintenance fluids in hospitalized children. In 1975, WHO and
the United Nations Children's Fund (UNICEF) decided to promote a single
ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80,
base 30, and glucose 111 (2%) for use among diverse populations. This
composition enabled a single solution to be used for treatment of
diarrhoea caused by different infectious agents and associated with
varying degrees of electrolyte loss. WHO-ORS has been demonstrated during
>25 years of use to be safe and effective at rehydration and
maintenance for children and adults with all types of infectious
diarrhea.1 However, more recent multiple controlled trials summarized in a
meta-analysis by Hahn et al has supported adoption of a lower osmolarity
ORS with proportionally reduced concentrations of sodium and glucose.2
Lower osmolarity ORS was associated with less vomiting, less stool output,
and reduced need for unscheduled intravenous infusions compared with
standard ORS among infants and children with non-cholera diarrhoea. In
cholera infection, there was no clinical difference between subjects
treated with the lower osmolarity solution and those treated with the
standard solution, apart from an increased incidence of asymptomatic
hyponatremia.3 On the basis of these findings, UNICEF and WHO convened a
technical meeting of experts on oral rehydration at New York that
recommended a reduced osmolarity solution for global use.4 In May 2002,
WHO announced a new ORS formulation consistent with these recommendations,
with 75 mEq/L sodium, 75 mmol/L glucose, and total osmolarity of 245
mOsm/L.5 The newer WHO-ORS was also recommended for use in treating adults
and children with cholera. The need for unscheduled supplemental IV
therapy in children given this solution was reduced by 33%. In a combined
analysis of this study and studies with other reduced osmolar-ity ORS
solutions (osmolarity 210-268 mOsm/l, sodium 50-75 mEq/l) stool output was
also reduced by about 20% and the incidence of vomiting by about 30%. The
245 mOsm/l solution also appeared safe and at least as effective as
standard ORS for use in children with cholera. It would now appear that
the earlier argument on WHO-ORS has come a full circle with JA Morgan's
article that presents current evidence that strongly favours the use of
isotonic fluids (0.9% saline with 5% dextrose) as standard for intravenous
maintenance fluid prescription in children, and 0.45% saline with 5%
dextrose and other similar hypotonic solutions should be reserved for
specific cases and used on a case-by-case basis.6 The one thing that is
universally agreed is that the use of 0.18% saline is not recommended as
standard maintenance fluid either by WHO or by Morgan.
References
1. Managing Acute Gastroenteritis Among Children:
Oral Rehydration, Maintenance, and Nutritional Therapy. Morbidity and
Mortality Weekly Report. Recommendations and Reports November 21, 2003 /
Vol. 52 / No. RR-16
2. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration
solution for treating dehydration due to diarrhoea in children: systematic
review. BMJ 2001; 323: 81-5.
3. Alam NH, Majumder RN, Fuchs GJ. Efficacy and safety of oral
rehydration solution with reduced osmolarity in adults with cholera: a
randomised double-blind clinical trial. CHOICE Study Group. Lancet 1999;
354:296-9.
4. World Health Organization. Reduced osmolarity oral rehydration
salts (ORS) formulation. New York, NY: UNICEF House, 2001. Available at
http://www.who.int/child-adolescent-
health/New_Publications/NEWS/Expert_consultation.htm.
5. World Health Organization. Oral rehydration salts (ORS): a new
reduced osmolarity formulation. Geneva, Switzerland: World Health
Organization, 2002.
6. Jessie Anne Morgan. Question 2: Should 0.9% saline be used for
maintenance fluids in hospitalised children? Arch Dis Child 2015; 100:715-
717 doi:10.1136/archdischild-2015-308821
We read with great interest the article on capillary refill time
(CRT) in children. Crook J and Taylor RM have carried out a simple and yet
very relevant study on CRT in children.CRT is almost universally checked
by child care providers particularly in emergency room or intensive care
setting and is taken as a surrogate of the perfusion status. However, two
issues have plagued this simple bedside te...
We read with great interest the article on capillary refill time
(CRT) in children. Crook J and Taylor RM have carried out a simple and yet
very relevant study on CRT in children.CRT is almost universally checked
by child care providers particularly in emergency room or intensive care
setting and is taken as a surrogate of the perfusion status. However, two
issues have plagued this simple bedside test:
(i) There seems to be no uniformity in the way this test is carried
out across the world. We recently published a letter to editor (1)
describing the variations in eliciting CRT amongst the various standard
texts and references. After analysis of all the references, it seemed
prudent to follow the Pediatric advanced life support(PALS )guideline for
CRT in children (finger tip) and the WHO guideline for CRT in young
infants (finger tip and sternum) with a pressure application of at least
3 seconds. There continue to be issues with eliciting CRT from the
peripheries in neonates (2).In the current article ,the authors have
rightly suggested a uniform practice for assessing CRT though it wasn't in
the purview of their study.
(ii) There have been various studies questioning the utility of CRT
.Even the APLS manual suggests use of caution in interpreting CRT as a
standalone measure of shock. Another recent article suggests poor inter-
rater reliability and poor correlation with cardiac output in non-acutely
ill children (3).The confusion with respect to studies on CRT perhaps
stems from the lack of a simple gold standard for assessing perfusion
status of the tissues. It could be the pulse pressure, skin temperature
gradient, central venous oxygen saturations (ScVO2), lactate , near infra
red spectroscopy (NIRS) etc or a mixture of such variables. It is also
important to remember that in an attempt to perfuse the vital organs in
shock , the blood is usually diverted from the skin and hence the delay in
CRT is supposed to reflect the degree of shock. As pointed out by
Carcillo JA in an excellent editorial(4) ,there are numerous studies
supporting the use of CRT and hence it is a useful tool for evaluation of
the hemodynamic status in children.
The authors of this current study have carried out both sternal and
finger tip CRT in normal children and found that there was a poor
correlation between the two. Another interesting finding was that the
finger tip CRT was faster than the sternal CRT.This finding is rather
strange and seems difficult to fit in despite the complex and intricate
relationship between arteriolar resistance, venular resistance, viscosity,
microvessel patency, polycythemia etc involved in the capillary refill. It
was also premature on part of the authors to consider resuscitation
council(RC) to re-evaluate their recommendations on CRT.
It is important for us to ensure that the CRT is carried out with
some uniform method by all child care providers and that studies on CRT
should consider assessing its utility against a set of surrogate variables
of perfusion in the normal and sick children. One must be aware of the
limitations of CRT and analyse it in conjunction with the other markers of
hemodynamic status. A normal CRT in a sick child except perhaps in warm
shock has a good negative predictive value. One could consider inventing a
simple device akin to a ball point pen with a stopwatch which delivers a
standard pressure for appropriate time on the skin surface so as to make
the process of eliciting CRT more uniform. It would be even better if the
refill measurement could be digitized to avoid any subjective error.
Irrespective of the technique used, a resource limited country is likely
to use only clinical signs or low cost devices for assessment of perfusion
in sick children with shock.
References:
1. Pandey A,John BM.Capillary refill time:Is it time to fill the
gaps.Medical Journal Armed Forces India 2013;69:97-98.
2. Gale C.Is capillary refill time a useful marker of hemodynamic
status in neonates? Arch Dis Child 2010; 95:395-397
3. Lobos A,Lee S,Menon K. Capillary refill time and cardiac output in
children undergoing cardiac catheterization. Pediatr Crit Care Med 2012;
13:136 -140
4. Carcillo JA. Capillary refill time is a very useful clinical sign
in early recognition and treatment of very sick children. Editorial on
Pediatr Crit Care Med 2012; 13:136 -140
In their observational study Sammons et al. showed that general
anaesthesia (GA) is more convenient and better tolerated than procedural
sedation (PS) for paediatric neuroimaging.1 These findings are fully
consistent with what can be obviously concluded from recent literature: in
paediatric neuroimaging, and especially in magnetic resonance imaging,
standard sedatives lack optimal effectiveness. The obvious explanation is...
In their observational study Sammons et al. showed that general
anaesthesia (GA) is more convenient and better tolerated than procedural
sedation (PS) for paediatric neuroimaging.1 These findings are fully
consistent with what can be obviously concluded from recent literature: in
paediatric neuroimaging, and especially in magnetic resonance imaging,
standard sedatives lack optimal effectiveness. The obvious explanation is
the unpredictability of onset, depth and duration of sedation. Although
the incidence of sedation failure is usually below 10%, delay, motion
artefacts, interruption of procedure for supplementary sedation and
interference with scanning schedule occur frequently. In addition, the
long half-life makes an extensive monitored recovery period imperative,
generating an extra burden for health care. Finally, these drugs may cause
unexpectedly deep sedation that might interfere with respiratory
reflexes.2 Their use must therefore be restricted to settings with high
safety standards for monitoring, professional competences and rescue
facilities. From a cost-benefit point-of-view one may question the
justifiability of implying these standards in a sedation practice that
applies suboptimal sedatives. Simply replacing PS by GA is not a
reasonable alternative, given the generally limited anaesthesia services
for neuroimaging.
Recent literature yields interesting new concepts. The anaesthetic
propofol is an excellent sedative for PS in spontaneously breathing
children. Its short induction and recovery times and optimal titratability
make propofol a suitable alternative for GA in neuroimaging.3 Furthermore,
there is good evidence that well-trained non-anaesthesiologists may
provide propofol sedation safely.4 Appropriate safety precautions,
monitoring and professional skills, rather than professional title, are
determinants for its safe and effective use. 5 Time has come to further
explore these concepts and to move to practical implementation. Optimally
safe and effective PS in paediatric neuroimaging needs competent sedation
providers who are specifically trained in deep sedation using highly
effective drugs within a context of transparency and ongoing quality
control.
Piet LJM Leroy1, Hans (J) TA Knape2
1Paediatric Sedation Unit, Department of Paediatrics, Maastricht
University Medical Centre, P.O. Box 5800,
6202 AZ Maastricht, The Netherlands
2Department of Anaesthesiology, University Medical Centre, P.O. Box 85500,
3508 GA Utrecht, The Netherlands
References
1. Sammons HM, Edwards J, Rushby R, et al. General anaesthesia or sedation
for paediatric neuroimaging: current practice in a teaching hospital.
Archives of disease in childhood;96(1):114.
2. Motas D, McDermott NB, VanSickle T, et al. Depth of consciousness and
deep sedation attained in children as administered by
nonanaesthesiologists in a children's hospital. Paediatric anaesthesia
2004;14(3):256-60.
3. Mallory MD, Baxter AL, Kost SI. Propofol vs pentobarbital for sedation
of children undergoing magnetic resonance imaging: results from the
Pediatric Sedation Research Consortium. Paediatric anaesthesia
2009;19(6):601-11.
4. Cravero JP, Beach ML, Blike GT, et al. The incidence and nature of
adverse events during pediatric sedation/anesthesia with propofol for
procedures outside the operating room: a report from the Pediatric
Sedation Research Consortium. Anesthesia and analgesia 2009;108(3):795-
804.
5. Green SM, Krauss B. Barriers to propofol use in emergency medicine.
Annals of emergency medicine 2008;52(4):392-8.
I agree with the editorialists that bed sharing is a decision that
each parent must make based on their own risk profile and the benefits
that they receive. A dogmatic single message approach is not appropriate
for this widespread practice when it has such a small affect on absolute
risk of SIDS in many families. I would like to bring to their attention a
very useful app (available for android and apple devices) from the...
I agree with the editorialists that bed sharing is a decision that
each parent must make based on their own risk profile and the benefits
that they receive. A dogmatic single message approach is not appropriate
for this widespread practice when it has such a small affect on absolute
risk of SIDS in many families. I would like to bring to their attention a
very useful app (available for android and apple devices) from the infant
sleep lab at Durham University, called Infant Sleeplab. It includes a risk
stratification tool for parents on bed-sharing as well as other evidence-
based information on infant sleep. https://www.isisonline.org.uk/app/
Conflict of Interest:
I have used the Infant Sleeplab app and associated website to inform my own parenting decisions. I have shared a bed with my second child since she was a few weeks of age.
We are grateful to Dr Ladhani and Dr Ramsay [1] for their thoughtful
editorial that accompanied the publication of our paper [2]. We would
agree that, despite discrepant observational data in the UK regarding the
waning of antibody titres [2, 3], there is now a large body of evidence
[4] demonstrating that, even where antibody titres have waned, booster
doses are not required if an adequate primary schedule has been comp...
We are grateful to Dr Ladhani and Dr Ramsay [1] for their thoughtful
editorial that accompanied the publication of our paper [2]. We would
agree that, despite discrepant observational data in the UK regarding the
waning of antibody titres [2, 3], there is now a large body of evidence
[4] demonstrating that, even where antibody titres have waned, booster
doses are not required if an adequate primary schedule has been completed.
As discussed in the editorial, the pragmatic priority is to ensure
that all children complete the course and receive at least one further
dose after their initial (accelerated) schedule at 0, 1, 2 months.
Routine immunisation visits are a convenient time to do this, and the
pre-school booster presents one such opportunity. However, as Dr Ladhani
and Dr Ramsay have noted elsewhere, almost all UK children diagnosed with
chronic hepatitis B infection acquire this through vertical transmission
[5]. Having a named clinician responsible for delivery of the 0, 1, 2
month schedule can improve its delivery , and the 12 month routine vaccine
visit is more timely than the pre-school booster for ensuring its
completion.
1. Ladhani SN, Ramsay ME. The importance of a preschool booster for
children born to hepatitis B-positive mothers. Arch Dis Child. 2013; 98:
395-396.
2. Yates TA, Paranthaman K, Yu LM, et al. UK vaccination schedule:
persistence of immunity to hepatitis B in children vaccinated after
perinatal exposure. Arch Dis Child. 2013; 98: 429-433.
3. Boxall EH, A Sira J, El-Shuhkri N, et al. Long-term persistence of
immunity to hepatitis B after vaccination during infancy in a country
where endemicity is low. J Infect Dis. 2004; 190(7): 1264-9.
4. Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose.
Clin Infect Dis. 2011; 53(1): 68-75.
5. Flood J, Amirthalingam G, Ramsay ME, et al. The diagnosis of chronic
Hepatitis B infection among children born in England after introduction of
universal antenatal HBV screening programme. Poster presented at the
European Society of Paediatric Infectious Disease Meeting, The Hague, June
2011. http://www.kenes.com/ espid2011/cd/pdf/P774.pdf.
Conflict of Interest:
Our study was supported by the NIHR Oxford Biomedical Research Centre and GlaxoSmithKline Biologicals. SL has undertaken paid work for vaccine manufacturers for provision of travel health training and attendance at advisory group meetings. AJP and MDS have conducted clinical trials on behalf of Oxford University sponsored by manufacturers of vaccines. AJP and MDS do not accept any personal payments from vaccine manufacturers: grants for support of educational activities are paid to an educational/administrative fund held by the Department of Paediatrics, Oxford University. MDS has received support from vaccine manufacturers to attend academic conferences. ED, SBW, SJH, KP and TAY declare no conflicts of interest besides funding received for the study.
The authors of this study are to be congratulated on a unique and useful collection of data which, in the present climate, is increasingly difficult to achieve. Unfortunately the title is somewhat misleading and the abstract potentially open to mis-interpretation. Although parents collected diary data on their children during concurrent weeks, this is presented by the authors in a cross sectional, not longitudinal manner. Thus, wh...
The authors of this study are to be congratulated on a unique and useful collection of data which, in the present climate, is increasingly difficult to achieve. Unfortunately the title is somewhat misleading and the abstract potentially open to mis-interpretation. Although parents collected diary data on their children during concurrent weeks, this is presented by the authors in a cross sectional, not longitudinal manner. Thus, when the authors report just 6.7% of "collections" among premobile infants had at least one bruise, this refers to a single week of observation. Lost in the text of the results section is the information that 27% had a bruise over all weeks surveyed. The true proportion of infants with a bruise over the whole of the 0-11 month period must be significantly higher than this as parents did not necessarily provide data for the whole period. Equally although a bruise was recorded in just 2.2% of one week "collections" among infants unable to roll over, it seems likely that the true figure over the 17 weeks or so at that developmental stage is likely to be very much higher - perhaps as high as 10%!
Although we should continue to ensure that health and care services maintain a high level of vigilance, it is important for paediatricians to assess each case on its merits looking for features such as clusters of bruises and bruises in areas typical of child abuse rather than responding to these and other data with a "one rule fits all" response thereby subjecting large numbers of infants to unnecessary and harmful investigation and parents to huge anxiety and intrusion. A further concern, and from my own experience from attempting to design a similar longitudinal approach, is that ethics committees and safeguarding boards are increasingly likely to make it very difficult to collect this type of essential longitudinal data without unacceptable intrusion.
Harvey Marcovitch suggests that it is "good news" that only 4% of
cases are settled in court. Nearly half (43%) are settled out of court.
Is this because in these cases it is not clear to either party whether
there has been negligence or not; or is it because medical attendants have
simply performed below average? At any one time half of us, by
definition, will perform below average. A settlement out of court, to many
p...
Harvey Marcovitch suggests that it is "good news" that only 4% of
cases are settled in court. Nearly half (43%) are settled out of court.
Is this because in these cases it is not clear to either party whether
there has been negligence or not; or is it because medical attendants have
simply performed below average? At any one time half of us, by
definition, will perform below average. A settlement out of court, to many
people, equates with negligence. So could it be that in 43% of cases,
paediatricians have been deemed negligent when they have simply been
performing below average?
It used to be thought that in half of all cot deaths the cause was medical
negligence. A change in sleeping position brought dramatic improvement,
to show that many paediatricians had suffered false condemnation. Are
paediatricians still being falsely condemned by rushing into out of court
settlements?
Thank you for your response to our research 'The agreement of
fingertip and sternum capillary refill time (CRT) in children'
We agree that there is a lack of gold standard for assessing tissue
perfusion in a simple and timely manner and continue to extrapolate that
in shock, blood is usually diverted from the skin in an attempt to perfuse
vital organs. Current practice and guidance assumes that CRT is a
reflecti...
Thank you for your response to our research 'The agreement of
fingertip and sternum capillary refill time (CRT) in children'
We agree that there is a lack of gold standard for assessing tissue
perfusion in a simple and timely manner and continue to extrapolate that
in shock, blood is usually diverted from the skin in an attempt to perfuse
vital organs. Current practice and guidance assumes that CRT is a
reflection of this (1-7).
We were not expecting to find fingertip CRT to be faster than sternum CRT,
although we did not find it strange. We agree and also suspect that
different sites have different refill times because of the complex and
intricate relationships involved, which are not practical or possible to
record prior to carrying out the CRT (such as arteriolar resistance,
venular resistance etc. as discussed in Carcillo (1)). There is a
substantial amount of research in CRT in vascular medicine which we
decided not to include in our literature review prior to this study,
although our findings might indicate it would be more appropriate to
examine this area in more detail. We do know that the fingertip pulp is
rich in arterio-venous anastomoses which may explain why it had the
quickest CRT and that vascular resistance is increased in peripheral beds
and this may explain why it also had the slowest CRT.
We agree that there needs to be standardisation of the technique,
greater awareness of CRT limitations and it should be analysed in
conjunction with other haemodynamic markers. We suggested that guidance
provided by the Resuscitation Council (RC) (2-4), amongst others, be
reviewed for exactly these reasons. The RC highlight CRT as one of the
five parameters to observe when examining circulation, giving it equal
weighting to heart rate, pulse volume, blood pressure and end organ
perfusion status. The RC guidance does advise to consider CRT with other
cardiovascular signs but importantly does not consider the fingertip site
or variables such as inter and intra observer reliability and skin colour.
Carcillo's editorial is interesting; however this purposive review is
not balanced or systematic and does not provide a comprehensive overview
of the literature relating to CRT. Interestingly although Carcillo is
discussing sick children we are informed that CRT is age dependant and
rightly references the study that discovered this in 1988, there is no
evidence that tells us otherwise, yet we can find no guidance by the RC or
other group that utilises an age dependant model, why is that?
Our study did not set out to examine the usefulness of the test, but
led us to question the way CRT is conducted in current clinical practice.
In an era where we try to practice evidence based medicine, if this test
is recommended for use in practice (something our research cannot answer)
then we have a duty to generate the evidence to support the way in which
it is conduced.
1. Carcillo JA. Capillary refill time is a very useful clinical
signin early recognition and treatment of very sick children. Editorial on
Pediatr Crit Care Med 2012; 13:136 -140
2. Resuscitation Council. Medical Emergencies and Resucitation--
Standards for clinical
practice and training for dental practitioners and dental care
professionals in
general dental practice. http://www.resus.org.uk/pages/MEdental.pdf
(accessed May
2013):24.
3. Resuscitation Council. European paediatric life support (EPLS).
3rd edn. London:
4. Resuscitation Council 2011:12. Resuscitation Council. A systematic
approach to the acutely ill patient, adapted from the ALERTTM.
http://www.resus.org.uk/pages/alsABCDE.htm (accessed May 2013).
5. Jevon P. Measuring capillary refill time. Nurs Times 2007;103:26-
7.
6. Lima A, Jansen TC, Van Bommel J, et al. The prognostic value of
the subjective assessment of peripheral perfusion in critically ill
patients. Crit Care Med 2009;37:934-8.
7. Graham C, Parke T. Critical care in the emergency department:
shock and circulatory support. Emerg Med J 2005;22:17-21.
Fairley et al(1) describe differences in growth between White and Pakistani infants in the BiB study using mixed effects linear splines, an approach becoming popular in the analysis of serial anthropometry. Linear splines were used because they summarize noisy data in meaningful parameters: an intercept and linear slope terms (connected by knots) governing different age sections. Adding an exposure obtained estimates of...
Editor
Eisenhut raises the possibility that food was the source of the outbreak of group A streptococcal disease at the primary school. This hypothesis was considered, but was rejected as implausible for several reasons; firstly the outbreak was not a true point source as it was preceded by five sentinel cases over a 12 day period, in addition the peak on the 16th May was inflated as it included cases with on...
I read with great interest the arguments whether 0.9% saline with 5% dextrose would be a more appropriate choice than 0.45% saline with 5% dextrose for maintenance fluids in hospitalized children. In 1975, WHO and the United Nations Children's Fund (UNICEF) decided to promote a single ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80, base 30, and glucose 111 (2%) for use among diverse populations....
Dear Editor,
We read with great interest the article on capillary refill time (CRT) in children. Crook J and Taylor RM have carried out a simple and yet very relevant study on CRT in children.CRT is almost universally checked by child care providers particularly in emergency room or intensive care setting and is taken as a surrogate of the perfusion status. However, two issues have plagued this simple bedside te...
In their observational study Sammons et al. showed that general anaesthesia (GA) is more convenient and better tolerated than procedural sedation (PS) for paediatric neuroimaging.1 These findings are fully consistent with what can be obviously concluded from recent literature: in paediatric neuroimaging, and especially in magnetic resonance imaging, standard sedatives lack optimal effectiveness. The obvious explanation is...
I agree with the editorialists that bed sharing is a decision that each parent must make based on their own risk profile and the benefits that they receive. A dogmatic single message approach is not appropriate for this widespread practice when it has such a small affect on absolute risk of SIDS in many families. I would like to bring to their attention a very useful app (available for android and apple devices) from the...
We are grateful to Dr Ladhani and Dr Ramsay [1] for their thoughtful editorial that accompanied the publication of our paper [2]. We would agree that, despite discrepant observational data in the UK regarding the waning of antibody titres [2, 3], there is now a large body of evidence [4] demonstrating that, even where antibody titres have waned, booster doses are not required if an adequate primary schedule has been comp...
Harvey Marcovitch suggests that it is "good news" that only 4% of cases are settled in court. Nearly half (43%) are settled out of court. Is this because in these cases it is not clear to either party whether there has been negligence or not; or is it because medical attendants have simply performed below average? At any one time half of us, by definition, will perform below average. A settlement out of court, to many p...
Thank you for your response to our research 'The agreement of fingertip and sternum capillary refill time (CRT) in children'
We agree that there is a lack of gold standard for assessing tissue perfusion in a simple and timely manner and continue to extrapolate that in shock, blood is usually diverted from the skin in an attempt to perfuse vital organs. Current practice and guidance assumes that CRT is a reflecti...
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