Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Preventing Child Deaths in Asia
- Dewan S. Billal Ph.D, Professor Noboru Yamanaka (16 May 2008)
-
Parent's Ten Commandments
- Hugh Mann (20 May 2008)
-
Preventing child deaths
- Colin J Morley, Timothy Cole (18 September 2008)
-
Re: Preventing child deaths
- Michael D Innis (21 September 2008)
|
|
|||
|
Dewan S. Billal Ph.D, Postdoctoral Fellow Department of Otolaryngology, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan, Professor Noboru Yamanaka
Send response to journal:
|
In Editorials Jane Freemantle and Anne Read emphasize1 the need to review the circumstances of death for preventing child death in developed countries like United Kingdom, Australia and America. In the current issue the most worrying cases for child death are; less competencies of the healthcare practitioner, inadequate systems in place, to enable accurate diagnosis or treatment or to facilitate efficient communication. But child deaths in developing countries in Asia may differ from developed countries in the world. Children in Asia are at great risk of dying from injuries such as drowning and road accidents. Surveys from Bangladesh, China, the Philippines, Thailand and Vietnam revealed that injury was the leading cause of death and disability among children older than one year of age in these countries, with drowning taking the heaviest toll2. A child born in Asia is still at greatest risk of dying in the first month of life. Nearly half of all child deaths happened after the age of five. The most easily preventable causes were suffocation and drowning which mostly occurred in children under five years of age2. Bangladesh was one of the first countries where such a survey was conducted in 2004, revealing that drowning claims 1 of 4 lives among children aged between 1 and 17 years. It is currently estimated that 46 children drown everyday in Bangladesh and 17,000 annually. The drowning death toll peaks during the floods. In 2007, drowning was responsible for 87 percent of the total child deaths caused by the floods2. After undertook a pilot initiative by UNICEF to respond to this situation, this project has proved that most deaths could be averted by some simple safety interventions like giving swimming lessons to children, bamboo fencing of ponds, community awareness and daycare centers that provide supervised care for children. The evidence overwhelmingly confirms that injury is and has been a major killer2. Findings from the five-country household surveys in Asia indicate that the causes of injury differ by age group and are associated with exposure to different types of risks2: œInfants younger than 1 year, have limited exposure to injury because mothers and caregivers tend to provide a protective environment. While the child is dependent upon them, the risks are limited to choking, suffocation and falls. œ Toddlers aged 1-4 years, exposed to hazards in and around the home, are at greatest risk of drowning. œ School-aged children aged 5-9 years, spend a lot of time outside the home, either in school or engaged in social activities, and are thus at greatest risk from drowning and road traffic accidents. œ Adolescents aged 10-17 years, are navigating the difficult transition to adulthood and are thus more exposed to risk-taking behavior in addition to exposure to violence. Alarmingly, most of the surveys indicated that intentional injury - homicide and suicide - was the leading cause of death among adolescents. Taking into account the difficulty and sensitivity in collecting such information through interviews, it was believed that even this new reported incidence is likely to underestimate the magnitude of the problem2. Many injuries, especially those that are fatal, are rarely reported to hospitals. As a result, the cause of these deaths was often missing from national health statistics and civil registry systems. This creates a major challenges to accurately monitor child mortality, especially among children 5 years and older, and it underscores the need for adequate systems to track and record births and children's deaths2. If Asia is ultimately going to meet the Millennium Development Goal to reduce child mortality, it is imperative that it need to take action to address the causes of childhood injury. Investing more in awareness campaigns to equipping children and their parents with knowledge and skills can prevent the majority of these deaths. UNICEF and The Alliance for Safe Children (TASC), are calling for better systems to record births and deaths as well as the expansion of child injury prevention programs in Asia. These include campaigns for better road safety to lessen road traffic accidents, increased supervision and swimming lessons for children to prevent drowning and household safety education to prevent suffocation, falls, poisoning and animal bites. We declare that we have no conflict of interest *Dewan Sakhawat Billal Ph.D Noboru Yamanaka MD, Ph.D billalds@wakayama-med.ac.jp Division of Infection and Immunity research Center, Department of Otolaryngology-Head and NecK Surgery, Wakayama Medical University, Wakayama 641-8509, Japan References 1. Freemantle J and Read A. Preventing child deaths. BMJ 2008; 336: 1089(17th May). 2. UNICEF, Bangladesh. http://www.unicef.org/bangladesh/index.html Competing interests: None declared |
|||
|
|
|||
|
Hugh Mann, Physician Eagle Rock, MO 65641 USA
Send response to journal:
|
1. Feed, shelter, and clothe your child. Competing interests: None declared |
|||
|
|
|||
|
Colin J Morley, Professor of Neonatal Medicine Royal Women's Hospital, Parkville, Vistoria 3052, Australia, Timothy Cole
Send response to journal:
|
Dear Sir,
We have read with interest the two articles, “Hospitals should use a scoring system to spot serious illness in children” (1), “Preventing Child deaths” (2) and the CEMACH report “Why Children Die” (3) to which they refer. Back in 1990 we recognised that parents and doctors found assessing the severity of illness in infants very difficult and that some infants were admitted to hospital late in their illness or died because no one recognised they were seriously ill. We therefore undertook a large study to investigate the importance of all the different symptoms and signs of illness in 1007 infants under 6 months of age. Two hundred and ninety eight infants were seen at home to investigate the symptoms and signs of illness in those who were well or not very ill, and 709 were seen on admission to hospital. This study resulted in the publication of Baby Check (4-6),and several papers about its use (7-11) and the effectiveness of different symptoms and signs of illness alone and in combination (12-14). Baby Check is a simple yet sophisticated scoring system designed specifically to help parents and professionals assess the severity of an infant’s illness. It contains 19 checks each with a score based on ordinal regression analysis of the data. Each check scores zero if absent and between 3 and 15 if present. The Baby Check score is the sum of the individual scores. An infant can be rescored at any time to see if the illness is getting better or worse. The positive predictive value for requiring hospital admission increases with the score, rising to 100% for scores of 20 or more 7. We make these points because all three articles mirror our original concerns about detecting serious illness in infancy: • “Healthcare professionals need to be better trained in recognising serious illness in infants ... an early warning scoring system should be routinely used in hospitals … in several cases healthcare practitioners, in primary care and in hospitals had difficulty in recognising serious illness in children”. Susan Mayor (1)
Thus all three highlight the problems with assessing severity of illness in infants, yet they do not refer to Baby Check or the related papers, resources that have been available for 17 years. The CEMACH report goes on to consider the skills that professionals need: • “Primary care professionals must ensure that they maintain their skills in the recognition of serious illness in children. .... Whilst precision of diagnosis may not be possible, it is critical that GPs remain alert to symptoms and signs which could represent serious illness.”
Jewell wrote, "Baby Check is a good tool to help family doctors assess an infant’s illness, even if they are not very experienced" (15). Kai reported on the use of Baby Check in socioeconomically disadvantaged families: the parents found that it was helpful, reducing anxiety and increasing their confidence in coping with illness and dealing with doctors.(16) In a study where Baby Check was used by family doctors (9) 92% of them thought it gave an accurate assessment of the illness, 100% said they would trust it and 94% wanted mothers in their practice to use it. Baby Check helps with clinical assessment as it contains standardised questions and examination for specific important signs. This is very helpful for those unfamiliar with the important symptoms and signs of illness in infants. The Baby Check scoring system is very accurate at detecting serious illness in infants in the first few months of life, when it is most difficult for carers to appreciate the severity of the child’s illness. If this simple scoring system were made widely available to parents and doctors, it would help them identify those infants who were seriously ill and thereby ensure they were appropriately treated. It would almost certainly have helped the parents and junior doctors in the illustrative case, in the CEMACH report, of the infant who died from meningitis after delay in admission because of an inappropriate assessment. Dr Jewell concluded, “If used widely by mothers and professionals, Baby Check could improve the quality of many consultations, and might yet prevent some deaths in infancy.” (15) Further research is always needed, but in the meantime we commend to you a tried and tested scoring system that can be used by anyone caring for an infant to assess the severity of an illness.* Yours sincerely, Colin J Morley MD FRCPCH FRACP. Professor of Neonatal Medicine, The Royal Women’s and Royal Children’s Hospitals, Melbourne, Victoria, Australia Tim J Cole PhD ScD HonFRCPCH FMedSci. Professor of Medical Statistics, UCL Institute of Child Health, London, UK References (1) Mayor S. Hospitals should use scoring system to spot serious illness in children, report says. B M J 2008; 336(7653):1089. (2) Freemantle J, Read A. Preventing child deaths. B M J 2008; 336(7653):1083-1084. (3) Pearson GA. Why Children Die: A Pilot Study 2006; England (South West, North East and West Midlands), Wales and Northern Ireland. 2008. London, CEMACH. Ref Type: Report (4) Cole TJ, Morley CJ, Thornton AJ, Hewson PH, Fowler MA. A scoring system to quantify illness in babies under six months of age. Journal of the Royal Statistical Society A 1991; 154(2):287-304. (5) Morley CJ, Thornton AJ, Cole TJ, Hewson PH, Fowler MA. Baby Check: a scoring system to grade the severity of acute systemic illness in babies under 6 months old [see comments]. Arch Dis Child 1991; 66(1):100-105. (6) Morley CJ. Baby Check: a system for accurately grading the severity of illness in babies. Maternal and Child Health 1991; 16:385-388. (7) Thornton AJ, Morley CJ, Cole TJ, Green SJ, Walker KA, Rennie JM. Field trials of the Baby Check score card in hospital. Arch Dis Child 1991; 66(1):115-120. (8) Thornton AJ, Morley CJ, Green SJ, Cole TJ, Walker KA, Bonnett JM. Field trials of the Baby Check score card: mothers scoring their babies at home. Arch Dis Child 1991; 66(1):106-110. (9) Morley CJ, Thornton AJ, Green SJ, Cole TJ. Field trials of the Baby Check score card in general practice. Arch Dis Child 1991; 66(1):111-114. (10) Cole TJ, Thornton AJ, Green SJ, Morley CJ. Field trials of Baby Check: a scoring system to quantify illness in babies under 6 months. Medical Informatics 1990; 15(3):261-268. (11) Cole TJ, Gilbert RE, Fleming PJ, Morley CJ, Rudd PT, Berry PJ. Baby Check and the Avon infant mortality study. Arch Dis Child 1991; 66(9):1077-1078. (12) Morley CJ, Thornton AJ, Cole TJ, Fowler MA, Hewson PH. Symptoms and signs in infants younger than 6 months of age correlated with the severity of their illness. Ped 1991; 88(6):1119-1124. (13) Morley CJ, Thornton AJ, Cole TJ, Hewson PH. Interpreting the symptoms and signs of illness in infants. In: David T, editor. Recent Advances in Paediatrics. London: Churchill Livingstone; 1991. 137-155. (14) Thornton AJ, Morley CJ, Hewson PH, Cole TJ, Fowler MA, Tunnacliffe et al. Symptoms in 298 infants under 6 months old, seen at home. Arch Dis Child 1990; 65(3):280-285. (15) Jewell D. Helping parents identify severe illnesses in their children. B M J 1999; 318(7200):1711-1712. (16) Kai J. 'Baby Check' in the inner city--use and value to parents. Family Practice 1994; 11(3):245-250. * The individual checks can be seen at http://nicutools.org/MediCalcs/BabyCheck.php3. An illustrated version of the Baby Check booklet, designed for parents, is being reprinted by the Foundation for the Study of Infant Deaths. Competing interests: Both authors were the developers of Baby Check. They have no financial interests in Baby Check |
|||
|
|
|||
|
Michael D Innis, Medicolegal Consultant Home 4575
Send response to journal:
|
Editor, Professor Morely says, “the Baby Check scoring system is very accurate at detecting serious illness in infants in the first few months of life, when it is most difficult for carers to appreciate the severity of the child’s illness,” but it evidently mistakenly diagnosed infanticide in a case report of the New South Wales Supreme Court in June this year[1]. Evidence was given that the child received the usual 2 monthly immunization schedule and 6 days later was admitted to hospital with “skull fracture, subdural intracranial haemorrhages and subacute collection in the occipital region and posterior fossa, probably of different ages, suspected fractures of the seventh and eighth left ribs, the fourth and fifth right ribs, and a possible fracture of the left humerus. Subsequent examination of the deceased revealed bilateral intra- retinal haemorrhages and shearing injury to sections of the brain consistent with or suggestive of a non-accidental injury such as violent shaking”. The child was found to have deficiencies of Vitamin C, D and K. Evidence was given that “the role of vitamin k in bone strength is not yet established”. The verdict of Judge Harrison J was “NOT GUILTY”, presumably because one of the fractures occurred when the infant was in the care of the hospital and not in the care of the father. That doctors are still ignoring deficiencies of Vitamin C, D and K is likely to cause further accusations of child abuse and should be addressed by the “Baby Care Scoring system” that Professor Morley advocates. Michael Innis FRCPA; FRCPath Reference 1. R v Jeong Ming Foo [2008] NSWSC 587. 12TH June 2008. Competing interests: My advice was sought by the Defence. |
|||