16 e-Letters

  • Lack of sensitivity of ASQ communication domain remains a problem.

    We thank Professor Squires for her interest in our work and we agree that concern about any neurodevelopmental problem merits early comprehensive assessment of all developmental domains. We would like to reassure her that all the participants in our study received the full ASQ, interpreted by the family’s health visitor who took action according to the overall assessment. We were, however interested specifically in the performance of the ASQ’s communication domain in terms of identifying developmental language disorders. Even when we included children in the ‘Monitoring Zone’ of that domain we found that at least a third of children with significant problems were missed.
    To our surprise, parental concern about their child’s language did not improve the performance of the Sure Start Language Measure (SSLM): parental concern was associated with an increased likelihood of false positivity among the screen-positive children.
    We therefore suggest that if the ASQ is to be used without an additional language measure such as the SSLM on a universal level with 24-30 month old children, consideration should be given at least to lowering the thresholds for monitoring or referral within the communication domain.

  • User Beware: For accurate screening, use complete tests

    As a developer and researcher of the Ages & Stages Questionnaires, I read with interest Universal Language Development Screening: Comparative Performance of Two Questionnaires by Wilson et al., published January 6, 2022. I was not able to review this manuscript prior to publication; there are several methodological errors that severely limit the design and consequent outcomes of this study.

    First, the ASQ was developed to be used in total—all 30 items, 5 domains, at each administration point. Domains or areas were not designed to be used individually or independently. The psychometric properties of the ASQ will be robust only if/when the entire test is administered, ideally at periodic intervals over time.

    Second, a research design that uses only the communication domain of the ASQ-3 is flawed. The communication domain contains 3 expressive language items and 3 receptive items. Additionally, because of the overall interdependence of young children’s skills, communication items are embedded throughout the interval in other domains. For example in the intervals targeted by Wilson et al., (i.e., 24, 27, and 30 month ASQ-3) there are a total of 7 items focused on communication skills (e.g., listening, repeating, following directions) at 24 months; 10 items at 27 months, and 12 items at 30 months. Therefore analyzing only the 6 items under the domain heading is not looking at communication as broadly as does the test in its entirety.

    Third, th...

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  • Similar experience of low-acuity paediatric ED visits in Northern Europe

    Dear Editor,

    We have read the interesting clinical report on Swiss low-acuity paediatric ED visits by Manon Jaboyedoff and coworkers, published in the BMJ Paediatrics Open in November 2021.

    Their main study findings confirm in much detail what our research group has already found and reported in a series of systematic clinical studies on paediatric ED care at our university hospital in southern Sweden five years ago [1-4], also defended as a PhD thesis, entitled Paediatric emergency care - seeking, triage and management, in 2018 at Lund University, Malmö, Sweden.

    Most Swedish parents are aware of prehospital medical alternatives before attending a paediatric ED, and less-urgent visits can be safely redirected already on ED arrival according to predefined protocols. Lower socio-economic status is associated with less-urgent care seeking, and direct seeking of paediatric ED care is promoted by perceived medical urgency, by overestimation of actual severity, and by low availability of prehospital medical facilities, particularly outside office-hours. Hospital-based primary care facilities out-of-office-hours enable efficient management of less-urgent paediatric ED cases at more appropriate levels of medical care.

    The close similarity in main findings between the present study and ours is far from surprising, when also taking the similar healthcare systems and social security patterns in various part of Europe into account.

    We therefore c...

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  • Interesting research

    In regards to your observational study : Oxygen saturation after birth in resuscitated neonates in Uganda, your findings of A high proportion of neonates resuscitated with PPV after birth failing to reach the AHA SpO2 target is probably due to the apnoeic neonates ≥34 weeks which were chosen in the first place. Secondly i didn't come across the maternal health status in your research. and that makes me wonder whether the mother's were previously diabetic, hypertensive, vaccinated? or maybe they were anemic. Inadequate hemoglobin concentration might be the cause of the subpar SpO2 targets. That being said hypoxic-ischaemic encephalopathy is absolutely certain. Further studies are needed to evaluate baseline data and the need for supplemental O2 and optimal SpO2 during PPV since the goal here is to have the right guidelines to act upon and save as many lives as we can.

  • Paediatric dog bites in another English tertiary children's hospital

    Dear Authors,

    We are interested to read this paper highlighting changes in dog bite attendance during the COVID-19 pandemic at Alder Hey Hospital, particularly as our own experiences of dog bite attendances experiences for the Midlands tertiary paediatric referral centre during the COVID-19 pandemic has been different.

    Liverpool and Birmingham have had similar overall numbers of Accident and Emergency (A&E) attendances over the last few years. Birmingham Children’s Hospital (BCH) had 5017 mean monthly attendances January 2016-March 2020 compared to 5035 mean monthly attendances over the same period at Alder Hey. At the start of the COVID-19 public health restrictions, a similar drop in A&E attendances was seen with 2236 A&E attendances in April 2020 at BCH, compared to 2056 A&E attendances in April 2020 at Alder Hey.

    During July 2020, however, in contrast to the Liverpool experience, numbers of attendances to A&E with dog bites at BCH remained consistent with previous years (15 attendances in July 2020, compared to 15 in July 2019, 16 in July 2018, 14 in July 2017 and <5 in July 2016). We did see greater variability in other months, with higher levels of attendances with dog bites in May 2020 (12 attendances compared to <5 in 2019 and 2018, and 6 in 2017 and 2016), and in August 2020 (17 attendances compared to 13 in 2019, 12 in 2018, 9 in 2017 and 6 in 2016), but the overall impact was not significant.

    The contrast be...

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  • Take opportunity to improve paediatric dental services

    COVID-19 has widened existing oral health inequalities as a result of unprecedented disruption to care and public health programmes, as well as poor lockdown diets and increased poverty.

    Children across the UK have been taken from their normal routines. Schools have closed, parents have had to work from home, home school their kids in many cases and try to juggle the two. For anyone who found themselves furloughed, out of work or their income severely strained, this is a problem in itself, but for those close to the breadline they may have suddenly found themselves on the wrong side of that. For example, budget constraints often mean healthy and nutritious food is put to one side in favour of multibuy deals. This is not a problem created by the pandemic, but rather one that has made worse.

    The impact of social determinants of health on oral health should not be overlooked. Families are more likely to make healthier choices when the environment allows that; stable housing, financial stability and family support – oral health prevention alone will not work, and we need to aim to tackle the social determinants of health through an upstream approach. There are opportunities to integrate oral health and dental services into general health services through the emerging Primary Care Networks and Integrated Care Systems.

    COVID-19 provides an important lesson and should be a driver to re-evaluate and improve local paediatric dental services. In particular, ora...

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  • Some conclusions are not supported by data

    The authors conclude that:

    "Development of robust evidence of the putative effectiveness of the non-mainstream treatments being used should be a priority given that they are being used by carers."

    This reads as a call for studies based on confirmation bias. The purpose of research is to test a hypothesis, not to develop an evidence base to support a belief.

    "... paediatric doctors are increasingly turning to more natural treatments"

    No evidence to support this claim is presented, either in the study data or via references. Longitudinal data were not collected. There is nothing natural about homeopathy, as its claimed mode of action violates laws of physics and chemistry.

  • Time to go back to school: national governments prejudice children's rights

    Crawley E et al, in their excellent editorial (1) stress the harmful effects of school closings and social distances affecting children and adolescents following the COVID-19 pandemic. There are other different reasons that must push governments to conscientious school measures and educational supports as a significant damage to the educational and mental health of children and adolescents.

    First, as all international agencies have highlighted, prolonged closure yields serious consequences for all children and particularly for those already living in difficult circumstances, such as extreme poverty, disability, or violent environments (2,3).
    UNESCO estimates that at least 177 countries have instituted school closures at national level and several other countries have established closings at regional or local level (4). With over 90% of students worldwide (more than 1.5 billion young people) currently out of the educational context, it is clear that the greatest threats from Covid-19 to children and adolescents are to be found in educational loss, poorer nutrition, increased exposure to intrafamiliar violence, rising incidence of mental health disorders and lack of physical activity rather than in the clinical consequences of Covid-19 infection (4-8). Inequality in education and health will increase dramatically as consequences are inevitably greater for vulnerable children due to social, material and educational poverty, disability and chronic diseases, specia...

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  • Inaccuracy in reporting CEBA part II

    Malik et al. conducted a randomized trial of cognitive-behavioral therapy (CBT) combined with music therapy for adolescents with chronic fatigue (CF) following Epstein-Barr virus infection. (1) Unfortunately, there are several problems with how the findings of this trial are reported.

    First, it appears that the study was rephrased as a feasibility trial when the intervention failed to provide the expected effect sizes. The trial was only powered to detect large effects and both the protocol (2) and statistical analysis (3) plan suggest that the authors were expecting to find large improvements in the intervention group. In their power calculation for the primary outcome (mean number of steps per day) they wrote: “In the present study, the power to detect an increment of 2000 steps/day is at least 80 % (α=0.05). This effect size is rather large (0.8 times the standard deviation); however, as CBT alone is documented to have small to moderate effect size in CFS/ME, only a substantial effect size is of direct clinical interest. Also, the FITNET study suggests that larger treatment effects might be assumed in adolescent CFS/ME patients as compared to adults (Nijhof 2012).” (2) The protocol (2) and trial registration (4) include more than 20 outcome measures suggesting the study aimed to test the efficacy rather than the feasibility of the intervention.

    Second, Malik et al. conclude that “combined CBT and music therapy is feasible and acceptable in adolescent posti...

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  • Adapting to living with CFS/ME

    The authors' aim to explore the underlying patterns of physical activity among youth with mild to moderate CFS/ME found sub-groups of activity patterns including active light, and non-active as measured by accelerometer. While the authors discuss the relationship between physical activity and symptoms of CFS/ME, the authors do not operationalize the vigorous or increase in physical activity prior to the analysis. Thus it is unclear how to compares the physical activity observed in the study to that found in other studies or with populations where fatigue is a prominent symptom of a chronic disease.

    Additionally, missing from the analysis is a baseline of youth activity to control for any changes that the accelerometer might produce or as a result of participating in the study. The importance of this baseline also establishes if past activity patterns might indicate 'moments' of vigorous activity or increased activity that lead to physical crashes reported by many people living with ME/CFS. Avoiding vigorous activity or becoming anxious about physical activity might also explain the levels of activity discussed in the study. Adding a qualitative protocol to this study might highlight relationships between quantitative variables such as physical activity and anxiety or other variables not previously identified by the researchers.

    Finally, the researchers indicate that consulting a patient advisory group, but do not provide any descriptions o...

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