While the observations and analysis are interesting, one of your conclusions - "The current national guidelines do not fully encompass the wide range of approaches. The country’s guidelines should reflect the existing range of opinions, possibly through a broad survey of caregivers
before setting the guidelines and recommendations" - is surprising.
Guidelines for clinical management of patients should be based on scientific evidence. Interpretations and opinions follow later in chronology, not the other way round.
Opinions, by their very nature, are heterogenous and dynamic; thus if the guideline was based on opinions, it may need to change with the shift of opinion, even if the science had not.
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.
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 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 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.
Kind regards,
Jonas Åkeson, MD, PhD, EDAIC, ETP
Professor/Senior Consultant
Anaesthesiology and Intensive Care Medicine
Julia Ellbrant, MD, PhD
Consultant
General Surgery
Pia Karlsland Åkeson, MD, PhD
Associate Professor/Senior Consultant
Paediatrics
Lund University, Faculty of Medicine
Malmö
Sweden
References:
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.
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 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.
Kind Regards,
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 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, 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.
Dear Authors.
I read your paper with interest.
While the observations and analysis are interesting, one of your conclusions - "The current national guidelines do not fully encompass the wide range of approaches. The country’s guidelines should reflect the existing range of opinions, possibly through a broad survey of caregivers
before setting the guidelines and recommendations" - is surprising.
Guidelines for clinical management of patients should be based on scientific evidence. Interpretations and opinions follow later in chronology, not the other way round.
Opinions, by their very nature, are heterogenous and dynamic; thus if the guideline was based on opinions, it may need to change with the shift of opinion, even if the science had not.
Yours sincerely
Mallinath Chakraborty
chakrabortym@cardiff.ac.uk
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, th...
Show MoreDear 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...
Show MoreIn 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.
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...
Show MoreCOVID-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...
Show More