I am sure many readers will support Chapman et al’s call to action around the need for greater confidence with, and involvement in, the treatment of very low weight eating-disordered states by paediatricians on paediatric wards. Since the article’s publication, many eating disorders resources have been made available, free of charge, which should help with this upskilling project.
However, if increasing paediatrician skill and confidence is to translate into greater acceptance of the presence of this group of young people on paediatric wards, the whole hospital paediatric workforce will need to feel more comfortable with treating very low weight eating-restriction. I am thinking here of the nurses and healthcare assistants who spend so much more time with this group of inpatients. And I am also thinking of the ward dietician.
As Chapman et al note, paediatricians have a vital role with psycho-education, in regularly reviewing the child or young person’s physical state, and in making treatment decisions based on this. However, they do not spend sustained periods of time each day at the bedside. They do not have to tolerate - for such long periods - the powerful emotional ‘projections’ that accompany each mealtime or each ng insertion ie the spoken-aloud emotional statements, as well as the belly ‘vibes’ (feelings) that one person can generate in another. It is this aspect of the daily care of children and young people in dangerous states of eating-disordered...
I am sure many readers will support Chapman et al’s call to action around the need for greater confidence with, and involvement in, the treatment of very low weight eating-disordered states by paediatricians on paediatric wards. Since the article’s publication, many eating disorders resources have been made available, free of charge, which should help with this upskilling project.
However, if increasing paediatrician skill and confidence is to translate into greater acceptance of the presence of this group of young people on paediatric wards, the whole hospital paediatric workforce will need to feel more comfortable with treating very low weight eating-restriction. I am thinking here of the nurses and healthcare assistants who spend so much more time with this group of inpatients. And I am also thinking of the ward dietician.
As Chapman et al note, paediatricians have a vital role with psycho-education, in regularly reviewing the child or young person’s physical state, and in making treatment decisions based on this. However, they do not spend sustained periods of time each day at the bedside. They do not have to tolerate - for such long periods - the powerful emotional ‘projections’ that accompany each mealtime or each ng insertion ie the spoken-aloud emotional statements, as well as the belly ‘vibes’ (feelings) that one person can generate in another. It is this aspect of the daily care of children and young people in dangerous states of eating-disordered extreme malnutrition that takes a huge emotional toll on staff, and in some hospitals has been the reason some healthcare staff cite as their reason for leaving a particular paediatric ward post.
Building skill and confidence in understanding the treatment approaches used in inpatient anorexia care is clearly key for all paediatric staff; the treatment approach can often feel a lot less collaborative than most paediatric scenarios warrant and staff may worry about being “mean” or a “bully”.
Central, therefore, is reframing the nursing approaches as being entirely the same ones that are used with any other high dependency patient ie accurately recording input and output, being firm about taking necessary medicines ( in this case calories), even when, as is so often the case during cancer treatments, a child might be refusing/ not wanting to accept the intervention that needs to happen. Being able to stay in touch with the fact that they are delivering care that is in the child’s best interests, even when the child is vocal in stating their aversion to this intervention, is hard. And this is where some kind of regular group supervision for staff is so important.
Skills and knowledge are necessary to delivering effective care for this group of children and young people, but if wards are to embrace this work in a manner that does not create toxic effects in staff, either in terms of unhelpful attitudes towards eating-disordered patients, or in terms of staff burn out, the emotional impact of the tasks involved must be factored into the day-to-day running of the ward.
Dr Virginia Davies
MRCP FRCPsych MRCGP
Consultant in paediatric liaison
Paediatric mental health team
Whittington Hospital
The importance of objective assessment of prenatal exposure to alcohol through measurement of biomarkers in meconium
Oscar Garcia-Algar1,2,3*, Luigi Tarani4, Francesco Paolo Busardò5, Simona Pichini3,5, Emilia Marchei5
1. Neonatology Unit, Hospital Clinic-Maternitat, ICGON, BCNatal, Barcelona Centre for Maternal Foetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Barcelona, Spain
2. Department de Cirurgia i Especialitats Mèdico-Quirúrgiques, Universitat de Barcelona, Barcelona, Spain
3. European Foetal Alcohol Spectrum Disorders Alliance (EUFASD), Stockholm, Sweden
4. Department of Pediatrics, Sapienza University of Rome, Rome, Italy
5. National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
Dear Editor,
We read with attention the paper by Henderson et al. concerning comparison of confidential postnatal maternal interview and measurement of alcohol biomarkers in meconium (1). We would like to draw attention on their conclusion: “Fatty acid ethyl esters (FAEEs) and Ethylglucuronide (EtG) measured in meconium have low sensitivity and specificity for self-reported alcohol consumption after 20 weeks’ gestation in an unselected Scottish population and measurement of these alcohol biomarkers in meconium cannot currently be recommended for the identification of newborns at risk of Fetal Alcohol Spectrum Disorders (FASD).”
It has been more than 20 years since meconium analy...
The importance of objective assessment of prenatal exposure to alcohol through measurement of biomarkers in meconium
Oscar Garcia-Algar1,2,3*, Luigi Tarani4, Francesco Paolo Busardò5, Simona Pichini3,5, Emilia Marchei5
1. Neonatology Unit, Hospital Clinic-Maternitat, ICGON, BCNatal, Barcelona Centre for Maternal Foetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Barcelona, Spain
2. Department de Cirurgia i Especialitats Mèdico-Quirúrgiques, Universitat de Barcelona, Barcelona, Spain
3. European Foetal Alcohol Spectrum Disorders Alliance (EUFASD), Stockholm, Sweden
4. Department of Pediatrics, Sapienza University of Rome, Rome, Italy
5. National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
Dear Editor,
We read with attention the paper by Henderson et al. concerning comparison of confidential postnatal maternal interview and measurement of alcohol biomarkers in meconium (1). We would like to draw attention on their conclusion: “Fatty acid ethyl esters (FAEEs) and Ethylglucuronide (EtG) measured in meconium have low sensitivity and specificity for self-reported alcohol consumption after 20 weeks’ gestation in an unselected Scottish population and measurement of these alcohol biomarkers in meconium cannot currently be recommended for the identification of newborns at risk of Fetal Alcohol Spectrum Disorders (FASD).”
It has been more than 20 years since meconium analysis has been used to objectively assess prenatal exposure to alcohol (2-12). Several studies have been reported in the literature regarding the use of this biological matrix for the determination of alcohol biomarkers such as FAEEs and EtG and to be used in epidemiological studies verifying alcohol drinking during pregnancy and consequentially prenatal exposure. These studies not only assessed prenatal exposure to gestational alcohol, but also demonstrated underreporting and misreporting of pregnant women concerning gestational drinking habits. To this concern, the majority of studies from our group showed no relationship between biomarker measurement and maternal self-reported declarations, at least in the Mediterranean area where investigations were carried out (13-26).
In this paper, an anonymised, observational population-based study questionnaire on alcohol consumption in pregnancy was matched with measurement of alcohol biomarkers in meconium in a cohort of mother/infant dyads from Glasgow, UK. Of 828 women enrolled in the study, 384 (46.4%) reported alcohol consumption at any time in pregnancy and for 114 (13.6%) this was after 20 weeks’ gestation. When meconium was positive for FAEEs (≥ 600 ng/g) and for EtG (≥ 30 ng/g), 14.5% and 10.7% of mothers reported alcohol consumption after 20 weeks’ gestation, respectively. Similar percentages were observed when meconium was negative for FAEEs (13.0%, ≤ 600 ng/g) and for EtG (14.0%, ≤ 30 ng/g). The authors concluded that FAEE and EtG measured in meconium showed low sensitivity and specificity for self-reported alcohol consumption after 20 weeks of gestation.
Based on the determination of biomarkers, FAEEs were identified in all meconium samples analyzed and 39.6% had a concentration greater than or equal to 600 ng/mg (cut-off used to discriminate positive from negative samples). As far as EtG is concerned, 14.5% of the analyzed meconium samples had a concentration greater than or equal to 30 ng/g (cut-off used to discriminate positive samples from negative ones). In summary, if the biomarkers are also considered, the percentage of potentially exposed children increases, therefore it is possible to intervene also on those who, from the questionnaire, would have appeared to be newborns of non-drinking women and therefore excluded from any follow-up.
Early diagnosis of foetal alcohol spectrum disorders is of crucial importance to perform a targeted follow up of newborns prenatally exposed to alcohol and avoid secondary neurodevelopmental disabilities. A positive meconium testing for the presence of EtG or FAEEs is an objective first element to assess prenatal exposure to alcohol, whereas a maternal self-reported admission of gestational consumption of alcohol is not.
The only use of self-reported questionnaires to disclose alcohol drinking during pregnancy can’t be recommended. In addition, we do not have to forget transplacental passage of this teratogen, which differs in each mother-infant dyad and can either allow or prevent alcohol migration from the mother to the foetus.
In conclusion, we reiterate the importance of objective assessment of gestational drinking and consequent foetal exposure by measuring alcohol metabolites not only in neonatal meconium, but also in maternal hair to associate the results of these measurements to a potential brief intervention on the risks of gestational alcohol to mothers and neurodevelopmental targeted follow up for exposed newborns (18, 26).
References
1. Henderson EM, Tappin D, Young D, et al Assessing maternal alcohol consumption in pregnancy: comparison of confidential postnatal maternal interview and measurement of alcohol biomarkers in meconium. Arch. Dis. Child. 2023, 2022-325028.
2. Bearer CF, Lee S, Salvator AE, et al. Ethyl linoleate in meconium: a biomarker for prenatal ethanol exposure. Alcohol Clin Exp Res. 1999, 23, 487-493.
3. Klein J, Karaskov T, Korent G. Fatty acid ethyl esters: a novel biologic marker for heavy in utero ethanol exposure: a case report. Ther Drug Monit. 1999, 21, 644-646.
4. Ostrea EM Jr, Hernandez JD, Bielawski DM et al. Fatty acid ethyl esters in meconium: are they biomarkers of fetal alcohol exposure and effect? Alcohol Clin Exp Res. 2006, 30, 1152-1159.
5. Gareri J, Lynn H, Handley M, et al.. Prevalence of fetal ethanol exposure in a regional population-based sample by meconium analysis of fatty acid ethyl esters. Ther Drug Monit. 2008, 30, 239-245.
6. Pichini S, Pellegrini M, Gareri J, et al. Liquid chromatography-tandem mass spectrometry for fatty acid ethyl esters in meconium: assessment of prenatal exposure to alcohol in two European cohorts. J Pharm Biomed Anal. 2008, 48, 927-933.
7. Morini L, Marchei E, Pellegrini M, et al. Liquid chromatography with tandem mass spectrometric detection for the measurement of ethyl glucuronide and ethyl sulfate in meconium: new biomarkers of gestational ethanol exposure? Ther Drug Monit. 2008, 30, 725-732.
8. Pichini S, Morini L, Marchei E, et al. Ethylglucuronide and ethylsulfate in meconium to assess gestational ethanol exposure: preliminary results in two Mediterranean cohorts. Can J Clin Pharmacol. 2009, 16, e370-e375.
9. Hastedt M, Krumbiegel F, Gapert R, et al. Fatty acid ethyl esters (FAEEs) as markers for alcohol in meconium: method validation and implementation of a screening program for prenatal drug exposure. Forensic Sci Med Pathol. 2013, 9, 287-295.
10. Pichini S, Morini L, Pacifici R, et al. Development of a new immunoassay for the detection of ethyl glucuronide (EtG) in meconium: validation with authentic specimens analyzed using LC-MS/MS. Preliminary results. Clin Chem Lab Med. 2014, 52, 1179-1185.
11. Abernethy C, McCall KE, Cooper G, et al. Determining the pattern and prevalence of alcohol consumption in pregnancy by measuring biomarkers in meconium. Arch Dis Child Fetal Neonatal Ed. 2018, 103, F216-F220.
12. Woźniak MK, Banaszkiewicz L, Aszyk J, et al. Development and validation of a method for the simultaneous analysis of fatty acid ethyl esters, ethyl sulfate and ethyl glucuronide in neonatal meconium: application in two cases of alcohol consumption during pregnancy. Anal Bioanal Chem. 2021, 413, 3093-3105.
13. Derauf C, Katz AR, Easa D. Agreement between maternal self-reported ethanol intake and tobacco use during pregnancy and meconium assays for fatty acid ethyl esters and cotinine. Am J Epidemiol. 2003, 158, 705-709.
14. Garcia-Algar O, Kulaga V, Gareri J, et al. Alarming prevalence of fetal alcohol exposure in a Mediterranean city. Ther Drug Monit. 2008, 30, 249-254.
15. Pichini S, Garcia-Algar O, Klein J, et al. FAEEs in meconium as biomarkers of maternal drinking habit during pregnancy. Birth Defects Res A Clin Mol Teratol. 2009, 85, 230; author reply 231-232.
16. Bakhireva LN, Savage DD. Focus on: biomarkers of fetal alcohol exposure and fetal alcohol effects. Alcohol Res Health. 2011, 34, 56–63.
17. Zelner I, Shor S, Lynn H, et al. Clinical use of meconium fatty acid ethyl esters for identifying children at risk for alcohol-related disabilities: the first reported case. J Popul Ther Clin Pharmacol. 2012, 19, e26-31.
18. Pichini S, Marchei E, Vagnarelli F, et al. Assessment of prenatal exposure to ethanol by meconium analysis: results of an Italian multicenter study. Alcohol Clin Exp Res. 2012, 36, 417-424.
19. Manich A, Velasco M, Joya X, et al. Validez del cuestionario de consumo materno de alcohol para detectar la exposición prenatal [Validity of a maternal alcohol consumption questionnaire in detecting prenatal exposure]. An Pediatr (Barc). 2012, 76, 324-328.
20. Memo L, Gnoato E, Caminiti S, et al. Fetal alcohol spectrum disorders and fetal alcohol syndrome: the state of the art and new diagnostic tools. Early Hum Dev. 2013, 89, S40-3.
21. Joya X, Marchei E, Salat-Batlle J, et al. Fetal exposure to ethanol: relationship between ethyl glucuronide in maternal hair during pregnancy and ethyl glucuronide in neonatal meconium. Clin Chem Lab Med. 2016, 54, 427-435.
22. Chiandetti A, Hernandez G, Mercadal-Hally M, et al. Prevalence of prenatal exposure to substances of abuse: questionnaire versus biomarkers. Reprod Health. 2017, 14, 137.
23. Gomez-Roig MD, Marchei E, Sabra S, et al. Maternal hair testing to disclose self-misreporting in drinking and smoking behavior during pregnancy. Alcohol. 2018, 67, 1-6.
24. Min MO, Minnes S, Momotaz H, et al. Fatty acid ethyl esters in meconium and substance use in adolescence. Neurotoxicol Teratol. 2021, 83,106946.
25. Maschke J, Roetner J, Goecke TW, et al. Prenatal Alcohol Exposure and the Facial Phenotype in Adolescents: A Study Based on Meconium Ethyl Glucuronide. Brain Sci. 2021, 11, 154.
26. La Maida N, Di Giorgi A, Pellegrini M, et al. Reduced prevalence of fetal exposure to alcohol in Italy: a nationwide survey. Am J Obstet Gynecol MFM. 2023, 25:100944.
Many thanks for an important study. It raises the question if a distinction between Reactive Attachment Disorder and autism based on the presumed aetiology can be sustained. The genetic aetiology of autism spectrum conditions was established on the impressive difference in concordance rates between MZ and DZ twins but there are epigenetic mechanisms which could explain this difference. MZ twins have exactly equal biochemical exposures before conception (preconception environment) whereas DZ twins do not. A number of environmental exposures in prior generations are associated with autism (Magdelena 2020, Golding 2021). A huge study of the MSSNG database finds a genetic cause involving different 134 genes in only 14% of autistic individuals (Trost 2023). What then is being acquired or inherited? If the answer is early childhood stress, the rise in autism need not be spurious.
Great work Nicki. I have long argued the need for more paediatric respirologists to service this expanding population. There is a shortage of pediatric pulmonologists [sic] in the USA and most in practice are graying. Now we have data to support this argument. Of greater concern is the (lack of) availability of home nursing support, placing tremendous stress on family. In part due to the “mass resignation” arising during and after the pandemic, there is critical shortage of trained personnel to care for such children in their homes. We have been forced to start weaning patients from mechanical ventilatory support – chiefly those with chronic lung disease of prematurity – while they are still hospitalized before initial NICU discharge. Indeed, we may have our first decannulation of one such child in the next few months! Thank you for undertaking this study and reporting the trend we all foresaw.
Pubertal staging is rarely needed in a general paediatric clinic and I wonder if there is a way to avoid the difficult issues in examining older children and young people.
I think the issues around chaperones are complex, as a male doctor, male patients often do not want a female nurse as a chaperone and on the whole peri-pubertal girls do not want to be examined at all by a male doctor.
My strategy, when needed, is therefore to ask older children and young people to let me know what they think their pubertal stage is - testicular size can be self-assessed using a standard orchidometer, all other changes can be described with reference to standard drawings from a growth chart.
I realise this is not evidence based practice but wonder if there is the possibility of a trial to compare paediatrician-assessed as opposed to self-assessed staging in non-specialist clinics?
Dear authors, the article made for some interesting reading especially as the current DKA ICP recommended by BSPED has now been in force for almost 2 years. It provides some perspective on whether the difference in liberalized vs conservative management is clinically significant or otherwise. Our question relates to whether the authors found any data in the studies regarding change in osmolarity / rate of rise of sodium which are early predictors for risk of cerebral oedema.
Dear editor, we read with interest the randomised controlled trial by Borgström et al.1 showing the lack of effectiveness of daytime urotherapy as first-line treatment of nocturnal enuresis. While the study has the remarkable point of strength of a prospective trial with a control, we take exception with some of the authors’ statements, and believe that some limits should be acknowledged.
Reduction of enuresis frequency was evaluated after 7 and 8 weeks since the beginning of the study while previous studies showed effectiveness for longer treatments, lasting four months, with a 60% success rate2. While the authors acknowledge this difference they simply state that a longer duration would disqualify the therapy as a first-line choice anyway, increasing the risks of drop out. We believe that this is, as the author state in the discussion, simply their view, which is not based on any evidence. The length of a treatment should not necessarily rule out it as a first line option, especially when weighted against the costs of other options, specifically unpleasantness of the alarm and possible adverse effects of desmopressin. As a matter of fact, it could be speculated that 8 weeks are a too short period in a physiological perspective to develop different voiding patterns after years of an enuretic bladder function.
Moreover, patients’ follow-up consisted only in contact by phone after 2 and 6 weeks, without clinical examination, and this could have contributed t...
Dear editor, we read with interest the randomised controlled trial by Borgström et al.1 showing the lack of effectiveness of daytime urotherapy as first-line treatment of nocturnal enuresis. While the study has the remarkable point of strength of a prospective trial with a control, we take exception with some of the authors’ statements, and believe that some limits should be acknowledged.
Reduction of enuresis frequency was evaluated after 7 and 8 weeks since the beginning of the study while previous studies showed effectiveness for longer treatments, lasting four months, with a 60% success rate2. While the authors acknowledge this difference they simply state that a longer duration would disqualify the therapy as a first-line choice anyway, increasing the risks of drop out. We believe that this is, as the author state in the discussion, simply their view, which is not based on any evidence. The length of a treatment should not necessarily rule out it as a first line option, especially when weighted against the costs of other options, specifically unpleasantness of the alarm and possible adverse effects of desmopressin. As a matter of fact, it could be speculated that 8 weeks are a too short period in a physiological perspective to develop different voiding patterns after years of an enuretic bladder function.
Moreover, patients’ follow-up consisted only in contact by phone after 2 and 6 weeks, without clinical examination, and this could have contributed to poor effectiveness of urotherapy too.
Lastly and above all, the authors considered daytime incontinence and voiding dysfunction among the exclusion criteria of the study, but it is well known that many enuretic children present daytime symptoms too in up to 90% of cases2 or bladder dysfunction even with enuresis as the only detectable symptom.3 These disorders, once identified, must be treated because they can lead to urological dysfunctions in adulthood4 and behavioural therapy still represents a cornerstone of treatment. We believe that this is a further reason why urotherapy should not be disqualified as a first-line treatment only without the evidence of long term treatment data.
In conclusion, we suggest that daytime urotherapy studies need to be carried out for longer periods to confirm or rule out its effectiveness. Until then urotherapy should not be considered an alternative choice to alarm therapy and pharmacological treatment but a complementary one, in order to obtain a global approach to nocturnal enuresis in children.
Bibliography
1. Borgström M, Bergsten A, Tunebjer M, et al. Daytime urotherapy in nocturnal enuresis: a randomised, controlled trial. Archives of Disease in Childhood Published Online First: 24 January 2022. doi: 10.1136/archdischild-2021-323488
2. Pennesi M, Pitter M, Bordugo A, Minisini S, Peratoner L. Behavioral therapy for primary nocturnal enuresis. J Urol. 2004; 171(January):408-410. doi:10.1097/01.ju.0000097497.75022.e8
3. Yeung CK, Chiu HN, Sit FKY. Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis. J Urol. 1999; 162:1049-1055.
4. Bower WF, Sit FKY, Yeung CK. Nocturnal Enuresis in Adolescents and Adults is Associated With Childhood Elimination Symptoms. J Urol. 2006; 176(October):1771-1775. doi:10.1016/j.juro.2006.04.087
By excluding all deaths, it is possible that a significant number of high-cost high-need patients were missed? Some deaths will follow a prolonged admission and care may have been escalated, for example to PICU, prior to death.
This review1, listing all the pros and cons of covid vaccinations for children, is to be welcomed but the authors have omitted some important questions on the downside. They rightly state that a large proportion of children might already be immune and point to waning immunity after vaccinations, suggesting that primary infection at young age with boosting exposure over time might be a better strategy. But they do not cite recent evidence that people who are first vaccinated then exposed afterwards, appear to mount brisk IgG response to the spike protein since this is already in their immune memory, but may fail to mount the broader response associated with natural infection, including N-antibodies2. For those children (>75%) already immune, there is no significant benefit to vaccination with an emergency use authorised product. For otherwise healthy children who are not yet immune, they can obtain this by natural infection over the months ahead, at minimal risk to themselves or to the vaccinated adults around them.
Under the heading ‘Long-term safety’, the authors rightly quote concerns of possible ongoing effects of myocarditis, but they make no mention of any other potential as yet unknown effects of these novel technologies. If there are effects on T-cell function, then there is risk for autoimmune diseases3 and also for potential cancer cells4 to pass unchecked. There are also no adequate animal reproductive studies and the nanoparticles have been shown b...
This review1, listing all the pros and cons of covid vaccinations for children, is to be welcomed but the authors have omitted some important questions on the downside. They rightly state that a large proportion of children might already be immune and point to waning immunity after vaccinations, suggesting that primary infection at young age with boosting exposure over time might be a better strategy. But they do not cite recent evidence that people who are first vaccinated then exposed afterwards, appear to mount brisk IgG response to the spike protein since this is already in their immune memory, but may fail to mount the broader response associated with natural infection, including N-antibodies2. For those children (>75%) already immune, there is no significant benefit to vaccination with an emergency use authorised product. For otherwise healthy children who are not yet immune, they can obtain this by natural infection over the months ahead, at minimal risk to themselves or to the vaccinated adults around them.
Under the heading ‘Long-term safety’, the authors rightly quote concerns of possible ongoing effects of myocarditis, but they make no mention of any other potential as yet unknown effects of these novel technologies. If there are effects on T-cell function, then there is risk for autoimmune diseases3 and also for potential cancer cells4 to pass unchecked. There are also no adequate animal reproductive studies and the nanoparticles have been shown by Pfizer to concentrate in the ovaries and testes5 in rats. These more theoretical risks may be of less concern to adults, particularly those a relatively high risk from covid. But for children, with their whole lives ahead of them, we absolutely must remember the maxim, ‘First do no harm’.
Most importantly, the authors state that, ‘Subjecting children to potential risk of vaccine adverse effects to drive indirect effects with little or no direct benefit might be ethically questionable’. I would contest that is unethical to ask children to take a vaccine to boost herd immunity or to offset political decisions such as school closures, at a stage when the drug trials have still to be completed. Policy makers would do well to re-read the Universal Declaration on Bioethics and Human Rights6 and to follow the authors’ guidance to ‘weigh up the risks and benefits with caution and to proceed with care’.
1. Zimmermann P, Pittet LF, Finn A, et al. Should children be vaccinated against COVID-19? Archives of Disease in Childhood Published Online First: 03 November 2021. https://doi.org/10.1136/archdischild-2021-323040
2. UK Health Security Agency. COVID-19 vaccine surveillance report Week 44 https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
3. Ishay Y, Kenig A, Tsemach-Toren T, et al. Autoimmune phenomena following SARS-CoV-2 vaccination. Int Immunopharmacol. 2021;99:107970. https://doi.org/10.1016/j.intimp.2021.107970
4. Jiang, H, Mei, Y-F. SARS–CoV–2 Spike Impairs DNA Damage Repair and Inhibits V(D)J Recombination In Vitro. Viruses 2021, 13, 2056. https://doi.org/10.3390/v13102056
5. Pfizer biodistribution data. https://www.naturalnews.com/files/Pfizer-bio-distribution-confidential-d...
6. Universal Declaration on Bioethics and Human Rights (2005). http://portal.unesco.org/en/ev.php-URL_ID=31058&URL_DO=DO_TOPIC&URL_SECT...
The Centers for Disease Control and Prevention (CDC) now recommends a Covid -19 vaccine for children ages 5 and older. Johns Hopkins Medicine encourages all families to have eligible children vaccinated with the Covid - 19 vaccine. Currently, Pfizer's vaccine is the only approved Covid-19 vaccine for children and its side effects are still the same in children. Children might notice pain at the injection site (upper arm), and could feel more tired than usual. Headache, achy muscles or joints, and even fever and chills are also possible and these side effects are usually temporary and generally clear up with 48 hours.
I am sure many readers will support Chapman et al’s call to action around the need for greater confidence with, and involvement in, the treatment of very low weight eating-disordered states by paediatricians on paediatric wards. Since the article’s publication, many eating disorders resources have been made available, free of charge, which should help with this upskilling project.
However, if increasing paediatrician skill and confidence is to translate into greater acceptance of the presence of this group of young people on paediatric wards, the whole hospital paediatric workforce will need to feel more comfortable with treating very low weight eating-restriction. I am thinking here of the nurses and healthcare assistants who spend so much more time with this group of inpatients. And I am also thinking of the ward dietician.
As Chapman et al note, paediatricians have a vital role with psycho-education, in regularly reviewing the child or young person’s physical state, and in making treatment decisions based on this. However, they do not spend sustained periods of time each day at the bedside. They do not have to tolerate - for such long periods - the powerful emotional ‘projections’ that accompany each mealtime or each ng insertion ie the spoken-aloud emotional statements, as well as the belly ‘vibes’ (feelings) that one person can generate in another. It is this aspect of the daily care of children and young people in dangerous states of eating-disordered...
Show MoreThe importance of objective assessment of prenatal exposure to alcohol through measurement of biomarkers in meconium
Oscar Garcia-Algar1,2,3*, Luigi Tarani4, Francesco Paolo Busardò5, Simona Pichini3,5, Emilia Marchei5
1. Neonatology Unit, Hospital Clinic-Maternitat, ICGON, BCNatal, Barcelona Centre for Maternal Foetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Barcelona, Spain
2. Department de Cirurgia i Especialitats Mèdico-Quirúrgiques, Universitat de Barcelona, Barcelona, Spain
3. European Foetal Alcohol Spectrum Disorders Alliance (EUFASD), Stockholm, Sweden
4. Department of Pediatrics, Sapienza University of Rome, Rome, Italy
5. National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
Dear Editor,
Show MoreWe read with attention the paper by Henderson et al. concerning comparison of confidential postnatal maternal interview and measurement of alcohol biomarkers in meconium (1). We would like to draw attention on their conclusion: “Fatty acid ethyl esters (FAEEs) and Ethylglucuronide (EtG) measured in meconium have low sensitivity and specificity for self-reported alcohol consumption after 20 weeks’ gestation in an unselected Scottish population and measurement of these alcohol biomarkers in meconium cannot currently be recommended for the identification of newborns at risk of Fetal Alcohol Spectrum Disorders (FASD).”
It has been more than 20 years since meconium analy...
Many thanks for an important study. It raises the question if a distinction between Reactive Attachment Disorder and autism based on the presumed aetiology can be sustained. The genetic aetiology of autism spectrum conditions was established on the impressive difference in concordance rates between MZ and DZ twins but there are epigenetic mechanisms which could explain this difference. MZ twins have exactly equal biochemical exposures before conception (preconception environment) whereas DZ twins do not. A number of environmental exposures in prior generations are associated with autism (Magdelena 2020, Golding 2021). A huge study of the MSSNG database finds a genetic cause involving different 134 genes in only 14% of autistic individuals (Trost 2023). What then is being acquired or inherited? If the answer is early childhood stress, the rise in autism need not be spurious.
Great work Nicki. I have long argued the need for more paediatric respirologists to service this expanding population. There is a shortage of pediatric pulmonologists [sic] in the USA and most in practice are graying. Now we have data to support this argument. Of greater concern is the (lack of) availability of home nursing support, placing tremendous stress on family. In part due to the “mass resignation” arising during and after the pandemic, there is critical shortage of trained personnel to care for such children in their homes. We have been forced to start weaning patients from mechanical ventilatory support – chiefly those with chronic lung disease of prematurity – while they are still hospitalized before initial NICU discharge. Indeed, we may have our first decannulation of one such child in the next few months! Thank you for undertaking this study and reporting the trend we all foresaw.
Pubertal staging is rarely needed in a general paediatric clinic and I wonder if there is a way to avoid the difficult issues in examining older children and young people.
I think the issues around chaperones are complex, as a male doctor, male patients often do not want a female nurse as a chaperone and on the whole peri-pubertal girls do not want to be examined at all by a male doctor.
My strategy, when needed, is therefore to ask older children and young people to let me know what they think their pubertal stage is - testicular size can be self-assessed using a standard orchidometer, all other changes can be described with reference to standard drawings from a growth chart.
I realise this is not evidence based practice but wonder if there is the possibility of a trial to compare paediatrician-assessed as opposed to self-assessed staging in non-specialist clinics?
Dear authors, the article made for some interesting reading especially as the current DKA ICP recommended by BSPED has now been in force for almost 2 years. It provides some perspective on whether the difference in liberalized vs conservative management is clinically significant or otherwise. Our question relates to whether the authors found any data in the studies regarding change in osmolarity / rate of rise of sodium which are early predictors for risk of cerebral oedema.
Dear editor, we read with interest the randomised controlled trial by Borgström et al.1 showing the lack of effectiveness of daytime urotherapy as first-line treatment of nocturnal enuresis. While the study has the remarkable point of strength of a prospective trial with a control, we take exception with some of the authors’ statements, and believe that some limits should be acknowledged.
Reduction of enuresis frequency was evaluated after 7 and 8 weeks since the beginning of the study while previous studies showed effectiveness for longer treatments, lasting four months, with a 60% success rate2. While the authors acknowledge this difference they simply state that a longer duration would disqualify the therapy as a first-line choice anyway, increasing the risks of drop out. We believe that this is, as the author state in the discussion, simply their view, which is not based on any evidence. The length of a treatment should not necessarily rule out it as a first line option, especially when weighted against the costs of other options, specifically unpleasantness of the alarm and possible adverse effects of desmopressin. As a matter of fact, it could be speculated that 8 weeks are a too short period in a physiological perspective to develop different voiding patterns after years of an enuretic bladder function.
Moreover, patients’ follow-up consisted only in contact by phone after 2 and 6 weeks, without clinical examination, and this could have contributed t...
Show MoreBy excluding all deaths, it is possible that a significant number of high-cost high-need patients were missed? Some deaths will follow a prolonged admission and care may have been escalated, for example to PICU, prior to death.
This review1, listing all the pros and cons of covid vaccinations for children, is to be welcomed but the authors have omitted some important questions on the downside. They rightly state that a large proportion of children might already be immune and point to waning immunity after vaccinations, suggesting that primary infection at young age with boosting exposure over time might be a better strategy. But they do not cite recent evidence that people who are first vaccinated then exposed afterwards, appear to mount brisk IgG response to the spike protein since this is already in their immune memory, but may fail to mount the broader response associated with natural infection, including N-antibodies2. For those children (>75%) already immune, there is no significant benefit to vaccination with an emergency use authorised product. For otherwise healthy children who are not yet immune, they can obtain this by natural infection over the months ahead, at minimal risk to themselves or to the vaccinated adults around them.
Show MoreUnder the heading ‘Long-term safety’, the authors rightly quote concerns of possible ongoing effects of myocarditis, but they make no mention of any other potential as yet unknown effects of these novel technologies. If there are effects on T-cell function, then there is risk for autoimmune diseases3 and also for potential cancer cells4 to pass unchecked. There are also no adequate animal reproductive studies and the nanoparticles have been shown b...
The Centers for Disease Control and Prevention (CDC) now recommends a Covid -19 vaccine for children ages 5 and older. Johns Hopkins Medicine encourages all families to have eligible children vaccinated with the Covid - 19 vaccine. Currently, Pfizer's vaccine is the only approved Covid-19 vaccine for children and its side effects are still the same in children. Children might notice pain at the injection site (upper arm), and could feel more tired than usual. Headache, achy muscles or joints, and even fever and chills are also possible and these side effects are usually temporary and generally clear up with 48 hours.
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