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Rapid Responses: Rapid Responses published:
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Allergy in children forgotten again !
- harry morrow brown (6 August 2007)
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A correction is required in this article
- E.S. Prakash (8 August 2007)
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Long acting beta-2 agonists and not antagonists
- Gerald CH Koh, Wong Teck Yee, Cheong Seng Kwing (8 August 2007)
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TYPO ?
- SIMON BIRCH (8 August 2007)
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Corrections
- Tim Lancaster (8 August 2007)
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Untreatable asthma could be latent tetany in young infants, so get ionized Ca2+ investigated.
- Kishan Kumar Jani, Neeru Gupta, Naresh Bhatia. (12 August 2007)
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Corticosteroids for episodic viral wheeze
- Israel Amirav, Anthony S. Luder (13 August 2007)
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Correction published
- Sharon Davies (17 August 2007)
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harry morrow brown, consultant allergist MD FRCP FAAAAI Highfield House, Highfield gardens, derby DE22 1HT
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The review of asthma in children by Townshend et al(1) mentions "Atopic" asthma, yet "Allergy" is not mentioned even once! It would appear that all we have to offer the asthmatic child in the UK is supressive drugs, without enquiry into why they are so necesary. Few British paediatricians appear interested in allergies as a cause of the growing numbers of asthmatic children. Even simple prick skin tests, which could indicate environmental factors such as pets which could be removed or avoided, are seldom available. Allergy is more important in childhood than adult life, therefore childhood should be the optimum time for investigation to identify and avoid causative factors. Perhaps the allergic march from eczema to rhinitis and asthma which may persist into adult life could be influenced by such an approach. There is no mention that in severe asthma intensive allergy investigation may lead to avoidance can result in better control and even decreased drug requirements. Competing interests: None declared |
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E.S. Prakash, Senior Lecturer, School of Medicine, Asian Institute of Medicine, Science & Technology, Bedong, Malaysia
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I have just read the extract of this article by Townshend J et al. In the "summary points" section (sentences 2 & 3), I thought "long acting beta 2 antagonists" should be replaced with long acting beta 2 agonists. Competing interests: None declared |
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Gerald CH Koh, Assistant Professor COFM Dept, Yong Loo Lin School of Medicine, National University of Singapore, Wong Teck Yee, Cheong Seng Kwing
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It was with great interest we read your article by Townshend et al on 'Management of asthma in children'. However, we think there are typos in both the online and hard copies of the paper. Under summary points, long- acting beta-2 agonists are referred to as long-acting beta-2 antagonists. However, the main text correctly refers to long-acting beta-2 agonists. The classes of pharmaco-antagonists used in asthma include leukotriene receptor antagonists and the less used anti-cholinergics. Beta-2 antagonists exacerbate asthma, and not relieve it. We think a correction is needed here. Nevertheless, we commend Townshend and colleagues for an informative and timely review of paediatric asthma management. Competing interests: None declared |
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SIMON BIRCH, CONSULTANT PAEDIATRICIAN ST. MARY'S HOSPITAL, PORTSMOTUH
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Generally a very helpful article, but under 'Long acting beta- agonists' after the first few lines the text keeps referring to 'SHORT acting beta agonists'- am I missing aomething or is this a typo? Competing interests: None declared |
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Tim Lancaster, General practitioner Jericho Health Centre, Oxford, OX2 6NW
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There appear to be copy-editing errors in the section entitled 'Long acting beta agonists'. On a number of occasions, the text refers to short acting beta agonists when the authors are in fact referring to long acting beta agonists. Competing interests: None declared |
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Kishan Kumar Jani, Chief Medical Officer Civil Hospital, Shahdra, Delhi-110032, Neeru Gupta, Naresh Bhatia.
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Hypocalcemia may lead to asthma like picture in young infants. One child was ill since birth and was having visible breathing movements and wheeze just like in asthma and was given anti-asthmatic treatment with nebulization. But no symptomatic relief for months together and one day after deep hiccups with spells of apnea for that day, at night child had a deep hiccup and became pulseless in opisothotonus. The panicked mother, a doctor too, prayed to God and did resuscitation along with father of child using Ambu’s bag and mask. The child came back to life but with fist tightly closed and thumb inside the fist, having a seizure. The parents rushed to a near Nursing Home within minutes. As if God has listened to prayers, getting clue from the attitude of thumb and convulsion, the father, a pediatrician along with the consultant pediatrician at Nursing Home made a diagnosis of hypocalcemia and got the serum total Ca2+ investigated in emergency which was 7.9 mg% and considering the fact that child was hyperventilating the two pediatricians realized that ionized Ca2+ would be lower due to alkalosis. Immediately intravenous Ca2+ was given and child soon became normal with silent and calm breathing. The hyperventilation was also due to hyperirritability of the nerves causing higher responsiveness of the bronchi. So it was a vicious circle leading to lower ionzed Ca2+, hypocalcemia leading to hyperventilation and hyperventilation causing alkalosis further reducing ionized Ca2+. Parents also recalled that thumb was always bent on palm and inside the fist since birth and condition further got aggravated because of cow’s milk which has non-available Ca2+ due to high phosphate content and mother had not taken Calcium tablets regularly during her antenatal period. The hiccups and apnea on the day the child became pulseless, were due to laryngeal spasm. Vitamin D deficiency and consequent hypocalcaemia are seen in association with severe and life threatening infant heart failure1. Literature has also reported hypocalcemia as a cause of untreatable seizures in neonates and children2,3. Durmaz et al reported case of an 8-year-old boy with uncontrolled seizures receiving two antiepileptic drugs and laboratory blood analyses, performed because of his uncontrolled seizure episodes, revealed hypocalcemia2. Gorman et al recently described two siblings with neonatal hypocalcemic seizures whose mother took topiramate during both pregnancies. Apart from hypocalcemia, the patients had no identifiable etiology for their seizures3. Nelson’s Text book of pediatrics says in the clinical manifestation of tetany there can be laryngospasm which causes high pitched croup and can be confused with laryngotracheaitis and asthma4. Tetany is a series of symptoms characterized by painful muscle cramp that derives from enhanced neuromuscular excitability due to hypocalcemia, hypomagnesemia or alkalosis. In a broad sense, tetany includes associated sensory disturbance. Typical symptoms of tetany include carpopedal spasm, laryngospasm and generalized seizure. Chvostek and Trousseau signs are provocative tests for diagnosis of latent tetany. Many diseases including endocrine disorders like hypoparathyroidism and alkalosis by hyperventilation can cause tetany. Infusion of calcium or magnesium is effective as an acute therapy for tetany. However, subsequent diagnosis and treatment of underlining diseases are mandatory5. Hence, a proportion of untreatable asthma may also be investigated for hypocalcemia in young infants. References: 1. Maiya S, Sullivan I, Allgrove J, Archer N, Tulloh R, Daubeney P, Malone M, Mok Q, Yates R, Brain C, Burch M. Clin Calcium.Hypocalcaemia and Vitamin D deficiency: an important, but preventable cause of life threatening infant heart failure. Heart. 2007 Aug 9; [Epub ahead of print] 2. Durmaz C, Tulgar Kinik S, Ozyürek E, Erol I, Canan O, Alehan F. Should we routinely perform blood tests in children with uncontrolled seizures? J Child Neurol. 2006 Oct;21(10):896-8. 3. Gorman MP, Soul JS.Neonatal hypocalcemic seizures in siblings exposed to topiramate in utero. Pediatr Neurol. 2007;36(4):274-6. 4. Nelson’s Textbook of Pediatrics. 15th Edition:219. 5. Ito N, Fukumoto S. [Hypoparathyroidism Update Symptom and management of tetany.] [Article in Japanese] 2007 Aug;17(8):1234-9. Competing interests: None declared |
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Israel Amirav, Pediatric Pulmonology Ziv Medical Center, Safed Israel, Anthony S. Luder
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A useful and practical review. However, the “Summary Point” that “low dose inhaled corticosteroids (ICS)should not be used as preventative treatment for episodic viral wheeze” is too sweeping and may be misleading. It is supported neither by the review text itself, nor by the new 2007 BTS/Scottish guidelines. The only statement for which evidence exists is that treatment of infants with ICS does not prevent later development of asthma. ICS does however reduce exacerbation frequency and improves quality of life. There is still a place for “preventative” treatment (it is a matter of semantics what preventative means) in episodic viral wheeze. There was very little about the place and relative merits of leukotriene anatgonists (LA) versus ICS and long-acting agonists. Fig. 2 and 3 indicate that LA should be added only if ICS alone has failed or is impractical, yet literature exists suggesting that LA is as effective as ICS and may be used a s a first-line prophylactic. Competing interests: None declared |
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Sharon Davies, Letters editor BMJ
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The correction published here http://www.bmj.com/cgi/content/full/335/7615/0-a clarifies the points made by several rapid responders. Competing interests: None declared |
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