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.
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, the number of items in a test matters--more items focused on a domain will yield more accurate results. The 50 items of the Sure Start Language Measure should provide a more reliable measure of the child’s overall language than 6 ASQ items. In assessment, more is better--results will tip in favor of the longer, more complete inventory of skills in that area.
Fourth, the ASQ is meant to be used in conjunction with the Overall questions asking about parent concerns in each in interval. Parent concerns are equally weighed with developmental scores and referral decisions are based BOTH on ASQ scores as well as any parent concerns. Parents are often aware their child is not talking quite like the neighbor’s child; asking about concerns allows parents to voice their worries in addition to answering the scored questionnaire items. Asking about concerns enhances the sensitivity of screening outcomes and referral decisions. The Overall section asks 2 additional questions about the quality of a child’s speech in the 24 month and 27 month intervals, and 3 additional questions in the 30 month interval.
Our hopes, as ASQ developers, is that the screening tool can be used by UK pediatric professionals to improve outcomes for young children and can be used in an efficient way that strengthens pediatric and early childhood procedures such as home visiting and early childhood education. When ASQ scores are in the referral range (i.e. below the cut score in any one domain) and/or parents have concerns, the child should be immediately referred to Early Intervention/Early Childhood Education or other community providers for more in-depth assessment. A monitoring zone result should trigger a healthcare provider to look more carefully at the other ASQ domains as well as Overall questions. If other domains have monitoring zone scores along with parents indicate concerns, the child should again receive a referral. On-going surveillance in combination with periodic screening using the ASQ or other standardized test as defined by the AAP are necessary for early identification and optimal outcomes for children and families.
In sum, Wilson et al are investigating a topic of critical importance. We hope that their work increases thorough general developmental assessment as well as more specific language evaluation with those children in need. We also hope that the ASQ is used as developed and in total to make screening decisions in the future.
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...
We therefore consider it worth emphasising that the present study from central Europe confirms what has recently also been found regarding low-acuity paediatric ED visits in northern Europe.
Jonas Åkeson, MD, PhD, EDAIC, ETP
Anaesthesiology and Intensive Care Medicine
Julia Ellbrant, MD, PhD
Pia Karlsland Åkeson, MD, PhD
Associate Professor/Senior Consultant
Lund University, Faculty of Medicine
1. Ellbrant J, Åkeson J, Karlsland Åkeson P. Pediatric emergency department management benefits from appropriate early redirection of nonurgent visits. Pediatr Emerg Care 2015; 31: 95-100.
2. Ellbrant J, Åkeson J, Karlsland Åkeson P. Influence of awareness and availability of medical alternatives on parents seeking paediatric emergency care. Scand J Public Health 2018; 46: 456-62.
3. Ellbrant J, Åkeson J, Eckner J, Karlsland Åkeson P. Impact of socioeconomic characteristics on use of paediatric emergency care: A questionnaire based study. BMC Emerg Med 2018; 18: 59.
4. Ellbrant J, Åkeson J, Sletten H, Eckner J, Karlsland Åkeson P. Adjacent primary care may reduce less urgent pediatric emergency department visits. J Prim Care Commun Health 2020; 11: 1–6.
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.
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...
The contrast between our experiences may suggest different urban environments experienced the impact of COVID-19 public health restrictions on dog bites in children in different ways. We agree that the lack of sensitive data definitions adds complexity to monitoring these life changing injuries, and it is important that there is accurate and systematic capture of emergency department data at NHS Trusts to inform policy and practice. We also share your concern that strategies to prevent dog bites in at risk groups are important, particularly with increased dog ownership in the UK associated with the COVID-19 pandemic.
Dr Majel McGranahan, Public Health Specialty Registrar
Dr Chris Chiswell, Consultant in Public Health Medicine
Ms Andrea Jester, Consultant Surgeon
Birmingham Women’s and Children’s NHS Foundation Trust
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...
COVID-19 provides an important lesson and should be a driver to re-evaluate and improve local paediatric dental services. In particular, oral health inequalities need to be highlighted within any relevant health system-wide networks. A more holistic approach to children’s health, which includes oral health, is likely to provide the best outcomes.
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.
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...
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, special educational needs, and lack of access to distance learning technologies (1). The risk of dangerous habits, such as increasing screen time and unhealthy feeding will also increase.
IIn Italy. 9,040,000 children and youngsters and over one million children from nursery schools and early childhood education services have been forced out of schools. Among these, 42% live in overcrowded homes, 12% in poverty, 7% in domestic environments at greater risk of abuse (9).
Second, irrespective of the magnitude of the estimates - scattered across a wide range of variability - of the contribution of school closure to reduced attack rates of the infection, they cannot be simply converted in corresponding risk of increased infection attack rates consequent to school reopening, since schools and preschool services should be not be reopened just as they were before, but following a series of safety requisites regarding teachers, accompanying caregivers, school environment and children themselves.
Third, the risk of school reopening should be measured against the risk of uncontrolled child socialization which will occur anyway, particularly when parents go back to work after lockdown and children are left with grandparents, neighbors or simply remain alone.
Finally, schools and school life represent not only a pillar of community development but also an important part of community identity. The Covid-19 pandemia will cause directly and indirectly a dramatic burden of disease and an economic catastrophe for many countries. A sensible, gradual but prompt reopening of preschool and school activities will not only reduce the risk of a dramatic crisis in child rights (2) but also contribute to restore hope in our communities.
The multidimensional adverse consequences for children of the Covid-19 pandemia have been highlighted at global level by international agencies, but they do not seem to be taken in adequate consideration at country level. Based on global knowledge about the features of the Covid-19 infection and on local epidemiological data, guidelines should be prepared for school reopening at country and local level, with a more holistic perspective of families’ and children’s needs.
A different balance must be found between the risk of increasing the number of Covid-19 cases and causing serious prejudice to children's rights.
1. Crawley E, Loades M, Feder G, et al. Wider collateral damage to children in the UK because of the social distancing measures designed to reduce the impact of COVID-19 in adult. BMJ Paediatrics Open 2020;4:e000701. doi:10.1136/bmjpo-2020-000701
2. UNICEF, WHO, IFRC. Interim guidance for Covid-19 prevention and control in schools. March 2020. https://www.wfp.org/publications/interim-guidance-covid-19-prevention-an... (accessed 7 May 2020)
3. Iqbal SA, Azevedo JP, Gven K, Hasan A, Patrinos HA. We should avoid flattening the curve in education - Possible scenarios for learning loss during the school lockdowns. World Bank, April 13th, 2020. https://blogs.worldbank.org/education/we-should-avoid-flattening-curve-e...
4. UNESCO. COVID-19 impact on education. https://en.unesco.org/covid19/educationresponse. accessed 7 May, 2020
5. Rosenthal DM, Ucci M, Heys M, Hayward A, Lakhanpaul M. Impacts of Covid- 19 on vulnerable children in temporary accommodation in the UK. Lancet Public Health 2020 March 31 https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30080-3/fulltext
6. Van Lancker W, Parolin Z. Covid-19, school closures, and child poverty: a social crisis in the making. Lancet Public Health 2020 Apr 7 https://doi.org/10.1016/S2468-2667(20)30084-0
7. Green P. Risks to children and young people during Covid-19 pandemic. BMJ 2020;369:m1669 doi: 10.1136/bmj.m1669 (Published 28 April 2020)
8. Xie X, Xue Q, Zhou Y, et al. Mental health status among children in home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China. JAMA Pediatrics 2020, April 24 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2765196
9. Tamburlini G, Marchetti F. Covid -19 pandemia: reasons and indications for reopening education services. Medico e Bambino 2020; 5 May https://www.medicoebambino.com/lib/covid19_10.pdf
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...
Second, Malik et al. conclude that “combined CBT and music therapy is feasible and acceptable in adolescent postinfectious CF.” (1) The authors refer to high compliance and a lack of statistically significant differences in reported harms between the intervention and control group. The latter, however, could also be explained by a lack of power as the trial had only 43 participants and could only detect large differences between the groups. There were also some indications that the intervention might not be acceptable to patients. More than half of the eligible adolescents refused participation in the trial. In the protocol (2) and statistical analysis plan (3), the authors assumed that only 5 percent would decline participation. There was also a higher drop-out rate in the intervention (29%) compared to the control group (5%).
Third, according to Malik et al. “the study indicates that the mental training programme may improve symptoms and lead to higher recovery rate over time.” (1) This statement is not supported by the data. The primary outcome measure was mean steps per day assessed with an accelerometer 12 weeks post-randomization. For this outcome, the intervention group showed lower activity levels than the control group, a difference that reached statistical significance in the per-protocol but not the Intention-to-treat analysis. Unfortunately, the authors do not discuss this rather surprising finding. Patients in the control group only received “care as usual.” The paper explains that “‘care as usual’ implies that the relevant individuals would not receive any healthcare for their CF condition in the follow-up period apart from the follow-up visits in the present study.” (1) So it seems that for the primary outcome, the intervention did worse than doing nothing. The time and energy spent on CBT and music therapy could have prevented patients from resuming their normal activities. This explanation is in line with a high drop-out rate in the intervention group and more than half of eligible patients declining to participate in the study.
Fourth, the authors highlight trends toward statistical significance even though more than 20 secondary outcomes measures were used in the study (each taken at two time frames) while no corrections for multiple comparisons were performed. It, therefore, seems inappropriate to highlight that the intervention “may improve […] symptoms of postexertional malaise, justifying a full-scale trial.” Postexertional malaise was assessed with a single question and seems to be added post hoc as it is not listed as an outcome in the protocol (1), statistical analysis plan (2), or trial registration (3). The maximum difference for postexertional malaise between the intervention and control group was only 0.5 points, a third of the standard deviation for the intervention group at baseline. In the intention-to-treat analysis, this difference decreases to 0.2 points at follow-up. It is unclear why the authors think these results justify a full-scale trial given that the intervention group did worse on the primary outcome than the control group.
Fifth, the abstract also highlights a trend towards a higher recovery rate in the intervention group. The authors defined recovery as a score lower than 4 points on the Chalder Fatigue Scale using a dichotomous scoring method (range 0-11 points). A score of 4 or higher on the Chalder Fatigue Scale, however, was already used as an inclusion criterium. This means that participants could be classified as recovered as a result of reporting an improvement of just 1 point on the Chalder Fatigue Scale. It should also be noted that the Chalder Fatigue Scale does not assess the intensity or impact of fatigue. Instead, it assesses whether participants experience fatigue-related symptoms such as having ”problems starting things” or finding it “more difficult to find the right word” more than usual. Consequently, it seems inappropriate to use the term “recovery rate” for the percentage of participants who score lower than the threshold of 4 points on the Chalder Fatigue Scale. Post-treatment there was no difference in the percentage of patients meeting this 4-point threshold between the intervention and control group. The intention-to-treat analysis of the Chalder Fatigue Scale ordinal scoring (range 0-33) was also reported and this showed little difference between the two groups. A plausible explanation for what the authors describe as “a trend towards higher recovery rate in the intervention group” is the high drop-out rate. At follow-up, only 13 patients were in the intervention group. The analysis highlighted by the authors does not take into account the 8 persons who were in the intervention group but were lost to follow-up. There are little reasons to suggest that more patients in the intervention group recovered than in the control group. It is unfortunate that the authors have used this term in their manuscript.
In conclusion, CBT combined with music therapy was associated with a high drop-out rate and lower activity levels than participants who received no intervention. Contrary to what Malik et al. conclude these results question whether a full-scale clinical trial is justified.
1. Malik S, Asprusten TT, Pedersen M, Mangersnes J, Trondalen G, Roy B van, et al. Cognitive–behavioural therapy combined with music therapy for chronic fatigue following Epstein-Barr virus infection in adolescents: a feasibility study. BMJ Paediatr Open. 2020 Apr 1;4(1):e000620.
2. Akershus University Hospital. Research Protocol - processing. Mental training for chronic fatigue syndrome (CFS/ME) following EBV infection in adolescents: a randomised controlled trial. Available from: https://www.ahus.no/seksjon/forskning/Documents/Forskningsgrupper/Barne- og ungdomsklinikken/Paedia/Forskningsprotokoll - behandling.pdf
3. Akershus University Hospital. Statistical analysis plan – CEBA part 2. Available from: https://www.ahus.no/seksjon/forskning/Documents/Forskningsgrupper/Barne- og ungdomsklinikken/Paedia/Statistisk analyseplan del 2.pdf
4. ClinicalTrials.gov Identifier: NCT02499302. Available from: https://clinicaltrials.gov/ct2/show/NCT02499302
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...
Finally, the researchers indicate that consulting a patient advisory group, but do not provide any descriptions of the participants - such as length of time they have been living with ME/CFS, gender, ethnicity, or illness severity - or the role of this group in the design of the research study and selection of instruments for the study. This background information can explain the relationship between the patient advisory group and the study.