12 e-Letters

published between 2018 and 2021

  • 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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  • Targeting activity levels in ME/CFS

    Michiel Tack

    Email Address *

    Occupation *
    ME/CFS patient

    Affiliation *
    Independent researcher

    Contrary to what is claimed by Solomon-Moore et al., [1] the study by Van der Werf et al., (reference 17) [2] found little evidence of a boom and bust activity pattern in adult patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The Dutch researchers measured physical activity using actimeters worn for 12 consecutive days. There was no significant difference in day-to-day fluctuations in physical activity between ME/CFS patients and controls. The peak amplitude and peak duration of physical activity were larger in controls than in ME/CFS patients while the latter had longer rest duration after an activity peak. Another actimeter study [3] found no supporting evidence of a more fluctuating activity pattern in patients with ME/CFS compared to controls, during the day, nor during consecutive days. Now, Solomon-Moore et al. report that in children and adolescents with ME/CFS, no fluctuating active or boom-bust physical activity pattern could be identified.

    It would be helpful if the authors could clarify how the actimeter data impacted the treatments in the MAGENTA trial. According to the trial protocol [4], one of the interventions aimed to “convert a boom–bust pattern of activity (lots 1 day and little the next) to a baseline with the same da...

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  • Are you administering just "maintenance" fluid?

    Graham, Smith

    Email Address * smithgc@cardiff.ac.uk

    Occupation * Consultant Paediatric Nephrologist

    Affiliation * University Hospital of Wales

    This is another article on the potential risks of using hypotonic intravenous solutions and the perceived risk of promoting hyponatraemia. I am concerned that this, as with other publications on the topic, uses the term "maintenance fluids" when the fluid being prescribed is also serving the role of "resuscitation" and/or "replacement". While this study may not have seen any cases of hypernatraemia in patients receiving 0.9% saline, we have. The idea that the prescription of just one type of fluid i.e. an isotonic one, is suitable in all paediatric patients covered by this studies' selection criteria reflects laziness on the part of the doctor.

    For accurate prescribing of intravenous fluid, the doctor should think of three different requirements:
    1. Resuscitation fluid
    2. Replacement fluid
    3. Maintenance fluid

    Resuscitation fluid is administered to correct a deficit in the ECF volume. I wonder if this study tries to eliminate this by excluding children with "urinary osmolarity greater than 100 mOsm/kg and a weight change >2% in the first 24 hours". Unfortunately it is not clear by how much the 48 hour study period of fluid administration overlapped with the first 24 hours of admissi...

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  • Junior soldiers

    I spend 2 years training junior soldiers. I have to say it was the most rewarding job I had in the army, taking 16 year olds from all parts of Scotland we turned these youths in to proud, responsible, enthusiastic young men. These men and their families would be the first to support the system ! Many of them went on to senior positions in their regiments.
    It is madness to deprive young people of these opportunities based on politically motivated medical mumbo jumbo. With the current youth/knife crime crisis most intelligent folk say kids need some form of structure and opportunity in their lives.

  • Reply to letter from Professor Gorodischer and colleagues on access to health care in Palestine

    We thank Professor Gorodischer and colleagues for their comments on our article on Access for Health Care for children in Palestine.
    We believe that politics and health are inextricably intertwined, and this view is shared by WHO in the Commission on Social Determinants of Health and by many commentators such as Professor David Hunter https://www.bmj.com/content/350/bmj.h1214
    We consider that health is politically determined and this is evident in relation to public health issues such as the role of the tobacco industry in smoking, the role of the food industry in nutrition, and the relevance of pharmaceutical industry funding of politicians in determining health policy in the USA.
    In relation to the connection between the occupation of Palestine and the health of its population, this is not controversial but is a fact, corroborated by WHO, UN, UNRWA, the Lancet and many non-governmental organisations such as Medical Aid to the Palestinians. For example -

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