I am pleased to see a recommendation for shared paediatric/mental
health clinics in treating CFS/ME. My clinical impression in a non-
specialist hospital department is that most of these patients do not
experience or exhibit anxiety or depression as much as profound
frustration. This is similar to the presentation of children who cannot
attend school ('school refusal') which of course is often a feature of CFS
too.
I am pleased to see a recommendation for shared paediatric/mental
health clinics in treating CFS/ME. My clinical impression in a non-
specialist hospital department is that most of these patients do not
experience or exhibit anxiety or depression as much as profound
frustration. This is similar to the presentation of children who cannot
attend school ('school refusal') which of course is often a feature of CFS
too.
More evident in the clinic is an irritable relationship with mother,
who has to be very active to get help for her child who leaves most of the
organisational and emotional work to her. In the presence of a
paediatrician a mental health colleague can identify this pattern as
necessary for the time being. After all, a sick child tends to regress to
a more dependent stage.
The therapeutic task is to support slow progress towards an
adolescent relationship between child and parents. For those that recover
this will be alarmingly unfamiliar since the child will have been stuck at
a typically pre-pubertal stage. Fathers can be invited to joint
consultations, which need not be frequent because nothing changes very
fast. Alongside a graded exercise regime supervised by a physiotherapist,
this represents a 'graded attachment programme' in a general paediatric
setting, where outcomes have mainly been good.
Dr Webb's article highlights the fact that ADHD can be considered as
a behavioural problem caused by many different aetiologies, including
significan physical and emotional abuse. She identifies that the sort of
abuse that triggers this behaviour is often longstanding and at a level
that becomes tolerated by statutory services who are usually quick to
intervene when there is physical harm, but allow emotional and social...
Dr Webb's article highlights the fact that ADHD can be considered as
a behavioural problem caused by many different aetiologies, including
significan physical and emotional abuse. She identifies that the sort of
abuse that triggers this behaviour is often longstanding and at a level
that becomes tolerated by statutory services who are usually quick to
intervene when there is physical harm, but allow emotional and social
problems to fester.
It raises the question as to what is an appropriate safeguarding
response to children presenting with ADHD? A child presenting with a
subdural haemorrhage or unexplained fracture would have some level of
safeguarding investigation performed - unless there was a clear non
abusive history of trauma. Minimally this would be at a hospital level,
but more likely escalated to police and social services.
Given the high incidence of disturbing and abusive behaviours in
families with ADHD, it can be deduced that the child's condition is a
result of this in much the same way that a subdural haemorrhage may be
caused by shaking. Both conditions carry a guarded long term prognosis and
are therefore manifestations of 'significant harm.'
It seems sensible to suggest that when making a diagnosis of ADHD in
a child, serious consideration should be given to referring the family for
a multiagency safeguarding assessment.
Drs Bajaj and Offiah present compelling reasons for performing
skeletal surveys in all children under 2 years of age with unexplained
injury, as recommended by the RCPCH guidelines. We have followed this
practice
for a number of years but an audit of our skeletal surveys came to a very
different conclusion.
We reviewed the results of the skeletal surveys requested in our
hospital over a period of 7 years and 4...
Drs Bajaj and Offiah present compelling reasons for performing
skeletal surveys in all children under 2 years of age with unexplained
injury, as recommended by the RCPCH guidelines. We have followed this
practice
for a number of years but an audit of our skeletal surveys came to a very
different conclusion.
We reviewed the results of the skeletal surveys requested in our
hospital over a period of 7 years and 4 months - from the time of
introducing a computerised radiology programme till the time of the study
(November 2007-January 2015). During this time 135 skeletal surveys were
requested. Of these 28 were for the investigation of medical conditions,
27 were performed following infant death and 80 were performed for
suspected abuse. In 30 cases the skeletal survey
included a CT of the head.
Of the 80 children with suspected abuse 31 presented with an injury
shown to be a fracture on initial X-ray who then proceeded to a skeletal
survey and 49 had a presenting injury that did not obviously include
a fracture. The age range was from 1-102 months, mean age 13.6 months. 45
children were less than one year of age. None had a second skeletal survey
performed.
Of the skeletal surveys performed 3 identified fractures additional
to the presenting injury. The remaining 77 skeletal surveys did not detect
any
additional fractures.The three children in this series that had additional
fractures all presented with features to suggest that they had been
subjected to
very serious assaults -a long bone fracture in a non -ambulant child,
bilateral subdural haematomata, and widespread bruising-.
In those children with an equivocal presentation the skeletal survey
, in our experience, did not identify any unexpected injuries. It might be
argued that delayed skeletal surveys may have been more useful.
The value of a skeletal survey may be determined by
how the figures are prepared. So, in our study 31/80 (39%) of children
undergoing a skeletal survey had fractures. This is within the range
quoted for postive skeletal surveys of 10-55% and could therefore be
considerd as a support for skeletal survey. However in these cases it was
the evidence of a fracture in a single X ray that prompted further
investigation and the fracture was identified before the skeletal survey
was requested.
As regards information beyond the index injury, as
mentioned ,we found additional fractures in 3 studies (3.75% of the total
or 10% of those with one fracture). In all cases there was clinical
evidence to suspect multiple injuries.
We believe that if the figures are interpreted in this way, there is
scope to suggest that current guidelines may overstate the value of
skeletal survey -especially
given the radiation risk as highlighted by Bajaj and Offiah, and the use
of clinical judgement and limited skeletal surveys may have a place in the
management of these children.
Giles at al. highlights a significant issue which has previously been
recognised but not always as well framed. It is vital for patient safety
that specialists in all fields have had the opportunity to develop their
skills once their core competencies have been achieved. The continuing
need for trainees in the UK to provide an active service while at the same
time undertake and be involved in post-graduate education is not...
Giles at al. highlights a significant issue which has previously been
recognised but not always as well framed. It is vital for patient safety
that specialists in all fields have had the opportunity to develop their
skills once their core competencies have been achieved. The continuing
need for trainees in the UK to provide an active service while at the same
time undertake and be involved in post-graduate education is not
sustainable and this was highlighted in the Temple report(1).
However the solution to the problem is not the number of hours
available to a particular doctor. The survey implies non-specialty duties
are being performed in- and out- of hours. Were the 48 hour limit be
lifted there would be no reason to think the doctor would not continue to
be required to perform service activities.
The RCPCH "Facing the Future" service standards (2) set out a model
which would require 10 WTE trainees on each rota. This would enable
trainees to access essential training opportunities but provide a safe and
reliable service. In order to achieve this goal reconfiguration must occur
which may be unpalatable to some. Without this, ultimately, patients may
not get the high quality service they deserve and expect.
1. Time For Training. Sir John Temple on behalf of Medical Education
England
2. Facing the Future. Standards for Paediatric Services. December
2010 RCPCH.
Conflict of Interest:
I am currently chair of the RCPCH and AoMRC Trainees Committee
We thank Dr. Johnson for his interest in our paper [1] and for the
opportunity to discuss methods for modelling child growth. Many methods
for modelling repeated measures data are available, and the strengths and
limitations of each method will depend on many factors, including the
specific research question of interest and the structure of the data being
analysed.[2] In our analysis, we used linear spline multilevel mode...
We thank Dr. Johnson for his interest in our paper [1] and for the
opportunity to discuss methods for modelling child growth. Many methods
for modelling repeated measures data are available, and the strengths and
limitations of each method will depend on many factors, including the
specific research question of interest and the structure of the data being
analysed.[2] In our analysis, we used linear spline multilevel models.
Such models divide age into separate 'pieces' joined with knot points, and
model a different linear slope between each pair of knots. Individual-
level random effects allow individuals to differ in both starting size
(birth length or weight) and in their rate of growth in each period of
childhood. Clearly, such a piecewise linear model is an approximation of
the true complex underlying growth pattern. However, a key advantage of
using linear splines to model infant and child growth is that they are
easy to interpret. As well as being a useful way of creating interpretable
summaries of growth trajectories, the linear spline approach provided good
fit to our data, for all ethnic and sex groups, as seen in Supplementary
web table 2 of our original paper.
Selection of knot points for linear spline models is an important
issue. However, Dr. Johnson is incorrect when he states that we used the
same knot points that had been derived from the Avon Longitudinal Study of
Parents and Children (ALSPAC) data. As reported in the statistical
analysis section of our paper, [1] we considered a series of models with
knot points at different ages, and selected the best fitting models for
the Born in Bradford data. These knot points were slightly different to
those used in the ALSPAC study. However, it is interesting to note that
this methodology has now been employed in several cohorts in varied
geographical settings and with different ethnic and socioeconomic
composition and that in each case, similar knot points that best fit the
data in these different studies have been identified.[3-8] The fact that
best-fitting models using data from very different populations have such
similar knot points gives some biological credibility to the periods of
growth identified by these models.
In the Born in Bradford cohort we had insufficient data in the first
month of life to model neonatal weight loss. When these methods are
applied to datasets with a greater number of measurements in early life,
it is possible to model neonatal weight loss. For example in the
Generation XXI cohort, based in Porto, Portugal, a median of ten growth
measures are available for each child within the first few years of life,
with almost all children having multiple growth measurements recorded in
the first months of life. In this cohort, linear spline multilevel models
with knot points at 10 days, 3 months and 1 year fit the data well.[8]
Dr. Johnson suggests that individual knot points should have been
used in our study. In contrast to our analyses, such models allow the age
of change points within growth trajectories to vary between individuals.
Allowing for individual-specific knot points may result in better fit of
the statistical model to the data.[9] But this increased model fit comes
at the cost of complexity and interpretability. The timing of knot points
is likely to be related to the rate of change before and after that knot
point, and thus these quantities would need to be interpreted carefully.
The potential added benefits of using this approach to address our
question of ethnic differences in growth depend on two main factors: how
variable knot points are likely to be between individuals, and whether the
timing of individual-specific knot points is of interest in its own right.
We do not feel that either of these actually support the use of this
method to address the research question we were answering. Individual
variation in, for example, the timing of puberty onset or the timing of
cognitive decline in older age [10] is likely to be considerably greater
than individual variation in the timing of changes in growth velocity in
infancy and early childhood; therefore models incorporating individual-
specific knot points may be more useful in the former situations than in
the latter. Likewise, our research question concerned describing ethnic
differences in rates of growth and was not concerned with ethnic
differences in the timing of features of early growth. Such an approach
would be useful when the research question centres on the timing of change
and how this timing relates to earlier exposures or later outcomes, for
example, when assessing whether age at puberty is associated with later
cardiovascular health, one would need to estimate individual age at onset
of puberty rather than assuming that this was constant across the
population.
We once again thank Dr. Johnson for his interest in our paper. Whilst
we recognise that linear spline models represent a simplification of the
true underlying growth process, we feel that they are a suitable
compromise between model fit, which was good in our study, and
interpretability. Examination of growth using different models is
important for triangulation, and different methods will be relevant for
different research questions.
Reference List
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. Arch
Dis Child 2013,98:274-279.
2. Hauspie R, Cameron N, Molinari L. Methods in Human Growth
Research: Cambridge University Press; 2004.
3. Howe LD, Tilling K, Galobardes B, Smith GD, Gunnell D, Lawlor DA.
Socioeconomic differences in childhood growth trajectories: at what age do
height inequalities emerge? J.Epidemiol.Community Health 2012,66:143-148.
4. Paternoster L, Howe LD, Tilling K, Weedon MN, Freathy RM, Frayling
TM, et al. Adult height variants affect birth length and growth rate in
children. Hum.Mol.Genet. 2011,20:4069-4075.
5. Matijasevich A, Howe LD, Tilling K, Santos IS, Barros AJ, Lawlor
DA. Maternal education inequalities in height growth rates in early
childhood: 2004 Pelotas birth cohort study. Paediatr.Perinat.Epidemiol.
2012,26:236-249.
6. Tilling K, Davies N, Windmeijer F, Kramer MS, Bogdanovich N,
Matush L, et al. Is infant weight associated with childhood blood
pressure? Analysis of the Promotion of Breastfeeding Intervention Trial
(PROBIT) cohort. Int.J.Epidemiol. 2011,40:1227-1237.
7. Tilling K, Davies NM, Nicoli E, Ben-Shlomo Y, Kramer MS, Patel R,
et al. Associations of growth trajectories in infancy and early childhood
with later childhood outcomes. Am.J.Clin.Nutr. 2011,94:1808S-1813S.
8. Howe LD. Individual trajectories of childhood growth in five
cohorts: the application of linear spline multi-level models. In:
EUCCONET/ Society for Longitudinal and Life Course Studies. Paris; 2012.
9. Bellera CA, Hanley JA, Joseph L, Albertsen PC. Hierarchical
changepoint models for biochemical markers illustrated by tracking
postradiotherapy prostate-specific antigen series in men with prostate
cancer. Ann Epidemiol 2008,18:270-282.
10. van den Hout A, Muniz-Terrera G, Matthews FE. Change point models
for cognitive tests using semi-parametric maximum likelihood. Comput Stat
Data Anal 2013,57:684-698.
Thank you for your helpful response to the Archivist feature on
neonatal Vitamin A supplementation, pointing out the difficulty in
attributing any benefit to pre-existing deficiency. Obviously it is not
possible to include a full discussion of the conflicting literature on
this subject in a short article. I did not intend to endorse any
conclusions from the editorial, but merely to stimulate...
Thank you for your helpful response to the Archivist feature on
neonatal Vitamin A supplementation, pointing out the difficulty in
attributing any benefit to pre-existing deficiency. Obviously it is not
possible to include a full discussion of the conflicting literature on
this subject in a short article. I did not intend to endorse any
conclusions from the editorial, but merely to stimulate interest amongst
readers, in the hope that they will read the articles and draw their own
conclusions. I am sure that there will be much discussion about this in
The Lancet.
Robert Scott-Jupp
Associate Editor
Lucina and Archivist
We read with interest the paper by Villa F et al (1) and we would
like to add some conclusions reached by our group after a clinical
research evaluating peripheral muscle function in children with asthma
treated with inhaled corticosteroids. (2)
Asthma is one of the most prevalent chronic diseases in children, and its
secondary exercise limitation, among other several effects, usually cause
a decre...
We read with interest the paper by Villa F et al (1) and we would
like to add some conclusions reached by our group after a clinical
research evaluating peripheral muscle function in children with asthma
treated with inhaled corticosteroids. (2)
Asthma is one of the most prevalent chronic diseases in children, and its
secondary exercise limitation, among other several effects, usually cause
a decreased health-related quality of life. As the authors mention, the
relationship between this limitation and peripheral muscle weakness in
pediatric patients had not been widely studied before. The negative effect
on muscle function of long term treatment with corticosteroids had been
described for oral treatment. We only found two cases in the literature
(3) that related myopathy in children to inhaled corticosteroids, both
detected after months of very high doses of fluticasone.
The study led by our group (2) involved patients over 7 years old (N=12)
with asthma, that had previously received inhaled steroids during at least
two years at intermediate doses (budesonide ?400 ?g, or fluticasone ?200
?g). They were compared to a healthy control group (N=7), paired by age.
Peripheral skeletal muscle function was one of the parameters measured. No
evidence was found that continuous high doses of inhaled corticosteroids
lead to a deterioration in respiratory or peripheral muscle function in
asthmatic children, which agrees to the results of the aforementioned
study. (1)
On the other hand, respiratory muscles showed to develop an adaptation to
the long-term overload of work they have to deal with, the so-called
"training effect" of persistent asthma. This effect was detected by
measuring the maximal inspiratory and respiratory pressures in the
patient's mouth. However, the adaptation phenomena seem to be limited only
to the inspiratory muscles and it is probably related to the disease and
not to corticosteroids exposure.
References
1. Villa F, Beltran A, Pastorino A, Santar?m J, Arruda M, Miuki C, et
al. Aerobic capacity and skeletal muscle function in children with asthma.
Arch Dis Chil. 10.1136/adc.2011.212431.
2. D?az J, Busquets RM, Garc?a-Algar O, Ram?rez A, Orozco M. Changes in
respiratory and peripheral muscle function in asthmatic children: Effects
of inhaled corticoids. An Pediatr (Barc). 2010;72:42-8.
3. De Swert LF, Wouters C, De Zegher F. Myopathy in children receiving
high-dose inhaled fluticasone. N Engl J Med. 2004;350:1157-9.
We would like to thank Dr Clifford for his interest in our research.
We do not agree with him that the title and abstract are misleading. The
study was a longitudinal one and the results reflect that; for example we
looked at the children over time and assessed the importance of within-
child variation over time compared to between-child variation. It is very
important to distinguish between a collection, that is a point...
We would like to thank Dr Clifford for his interest in our research.
We do not agree with him that the title and abstract are misleading. The
study was a longitudinal one and the results reflect that; for example we
looked at the children over time and assessed the importance of within-
child variation over time compared to between-child variation. It is very
important to distinguish between a collection, that is a point in time at
which data were collected, and the child on whom the data were collected,
since a single child may have multiple collections. In summarising the
data by collections we were reflecting the occurrence of bruising over the
whole study.
The situation most closely resembling the presentation of a child to
a clinician is the first collection on that child. The prevalence of
bruising at the first collection, that is the percentage of children who
had at least one bruise, was 5.3%, (95% CI 2.6 - 10.5) in pre-mobile
children, and only 1.3%, (95% CI 0.2 - 6.9) for those infants who are not
yet rolling. The percentage of pre-mobile children who experienced a
bruise at some time in up to 12 collections is necessarily much higher,
but that does not estimate the prevalence. The situation is analogous to
the occurrence of the common cold. At any one time during the year, the
prevalence is quite low - probably below 10% - but most people have a cold
at some time during a year.
We agree that each case must be assessed on its own merit with a
clear and detailed history taken for the cause of bruising, a careful
examination and appropriate investigations to determine the cause of the
injury; indeed that is the message of the concluding paragraph of the
paper. Undertaking this type of work is indeed challenging and did require
a high level of co-operation from our group of parents for which we are
most grateful. The author of the letter is right to point out that a more
intrusive approach would be unethical and impractical'.
In future work we will compare patterns between the children in this
study, those with bleeding disorders and those who have been confirmed as
victims of child abuse to seek methods for discriminating between them.
I suggest breast feeding increases infant DHEA which positively
affects growth and development. Please read "DHEA is the Reason Breast
Milk is Beneficial," at: http://anthropogeny.com/DHEA%20Breast%20Milk.htm
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 am pleased to see a recommendation for shared paediatric/mental health clinics in treating CFS/ME. My clinical impression in a non- specialist hospital department is that most of these patients do not experience or exhibit anxiety or depression as much as profound frustration. This is similar to the presentation of children who cannot attend school ('school refusal') which of course is often a feature of CFS too.
...Dr Webb's article highlights the fact that ADHD can be considered as a behavioural problem caused by many different aetiologies, including significan physical and emotional abuse. She identifies that the sort of abuse that triggers this behaviour is often longstanding and at a level that becomes tolerated by statutory services who are usually quick to intervene when there is physical harm, but allow emotional and social...
Drs Bajaj and Offiah present compelling reasons for performing skeletal surveys in all children under 2 years of age with unexplained injury, as recommended by the RCPCH guidelines. We have followed this practice for a number of years but an audit of our skeletal surveys came to a very different conclusion.
We reviewed the results of the skeletal surveys requested in our hospital over a period of 7 years and 4...
Giles at al. highlights a significant issue which has previously been recognised but not always as well framed. It is vital for patient safety that specialists in all fields have had the opportunity to develop their skills once their core competencies have been achieved. The continuing need for trainees in the UK to provide an active service while at the same time undertake and be involved in post-graduate education is not...
We thank Dr. Johnson for his interest in our paper [1] and for the opportunity to discuss methods for modelling child growth. Many methods for modelling repeated measures data are available, and the strengths and limitations of each method will depend on many factors, including the specific research question of interest and the structure of the data being analysed.[2] In our analysis, we used linear spline multilevel mode...
Dear Professor Aaby
Thank you for your helpful response to the Archivist feature on neonatal Vitamin A supplementation, pointing out the difficulty in attributing any benefit to pre-existing deficiency. Obviously it is not possible to include a full discussion of the conflicting literature on this subject in a short article. I did not intend to endorse any conclusions from the editorial, but merely to stimulate...
Dear Editor,
We read with interest the paper by Villa F et al (1) and we would like to add some conclusions reached by our group after a clinical research evaluating peripheral muscle function in children with asthma treated with inhaled corticosteroids. (2) Asthma is one of the most prevalent chronic diseases in children, and its secondary exercise limitation, among other several effects, usually cause a decre...
We would like to thank Dr Clifford for his interest in our research. We do not agree with him that the title and abstract are misleading. The study was a longitudinal one and the results reflect that; for example we looked at the children over time and assessed the importance of within- child variation over time compared to between-child variation. It is very important to distinguish between a collection, that is a point...
I suggest breast feeding increases infant DHEA which positively affects growth and development. Please read "DHEA is the Reason Breast Milk is Beneficial," at: http://anthropogeny.com/DHEA%20Breast%20Milk.htm
Conflict of Interest:
None declared
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...
Pages