In relation to the concern (3) about mypaper on vitamin D deficiency rickets, I wouldemphasize that the lack of overt radiologicalsigns especially in younger infants is well rec-ognized and should not diminish the effort toexclude rickets as a cause of unexplained frac-tures. I am aware of the possibility that apatient with undoubted vitamin D deficiencycould also have been abused. From my fullinvestigation into these four patients, I wasconvinced that this was unlikely.
I can appreciate that even the smallestworry that the application of the accepted wis-dom of the last thirty years might have causedgratuitous harm to children and their familieswould be distinctly uncomfortable. I recognizethe sincerity of those who hold views differentfrom my own but hope that a normal debateon the evidence rather than the personalitieswill mean that damaging injustices will not berepeated in the next thirty years.
References1. Marcovitch H, Mughal MZ. Cases do not support
temporary brittle bone disease. Acta Paediatr2010; 99: 485–6.
2. Spivak BS, Otterman GJ. Does temporary brittlebone disease exist? Not by the evidence offered.Acta Paediatr 2010; 99: 486.
3. Feldman KW, Done S. Vitamin D deficiencyrickets and allegations of non accidental injury.Acta Paediatr 2010; 99: 486–7.
DOI:10.1111/j.1651-2227.2010.01879.x
Colin R Paterson ([email protected])Temple Oxgates, Longforgan, Dundee, Scotland
Correspondence: Colin R Paterson, Temple Oxgates,Longforgan, Dundee DD2 5HS, Scotland.Tel: +44 1382 360240 |Email: [email protected]
Are Paterson’s critics too biasedto recognize rickets?Sir,
Paterson’s critics and child abuse prose-cution expert witnesses Feldman and Done(1) ignored an obviously rachitic wrist, fail-ing to recognize that a dense metaphysis ischaracteristic of healing rickets, and misin-terpreted a typical rachitic finding in themedial proximal tibia as a classical meta-physeal lesion (CML). We suggest theyreview their own published paper (2) inwhich ‘CMLs’ in the humeri (Fig. 1) of a
non-abused, rachitic infant were overlookedproving that CMLs are non-specific. Fur-thermore, their published case of rachiticulnar cupping is far less impressive thanPaterson’s (Fig. 2), which they refuted. Theybelieve isolated ulnar cupping, a criteriathey themselves relied upon heavily in theirown study, is normal.
Feldman and Done confused us when theystated it was ‘clear’ Paterson’s cases sufferedmetabolic bone disease yet conceded hisradiographs provided ‘evidence against hisinterpretations’. We also failed to see any‘strong evidence’ that several infants wereabused.
Abuse expert Jenny challenged Paterson’scredibility by focusing on the controversialGMC’s disciplinary action over a plausiblebut politically unpopular medical hypothesis(3) while her own credibility should be closelyexamined. In 2008, Jenny reported the highlyimprobable absence of any vitamin D defi-ciency (VDD) among 1800 allegedly abusedchildren annually (for several years) whileunder her evaluation in Rhode Island (4). Dis-turbingly, during a similar period and just83 km away, substantially higher rates ofVDD (12.1%) and rickets (0.8%) werereported in healthy Bostonian infants andtoddlers (5).
References1. Feldman KW, Done S. Vitamin D deficiency
rickets and allegations of non-accidental injury.Acta Paediatr 2010; 99: 486–7.
2. Chapman T, Sugar N, Done S, Marasigan J,Wambold N, Feldman K. Fractures in infantsand toddlers with rickets. Pediatr Radiol 2010;40: 1184–9.
3. Jenny C. Multiple unexplained fractures ininfants – the need for clear thinking. Acta Paedi-atr 2010; 99: 491–3.
4. Jenny C. Rickets or abuse? Pediatr Radiol 2008;38: 1219–20.
5. Gordon CM, Feldman HA, Sinclair L, WilliamsAL, Kleinman PK, Perez-Rossello J, et al. Preva-lence of vitamin D deficiency among healthyinfants and toddlers. Arch Pediatr Adolesc Med2008; 162: 505–12.
DOI:10.1111/j.1651-2227.2010.01927.x
David Ayoub ([email protected])1, JohnPlunkett2, Kathy A. Keller3, Patrick D. Barnes4
1.Clinical Radiologists, SC, Memorial Medical Center,Springfield, IL, USA2.Welch, MN, USA3.Pediatric Teleradiology, Stanford, CA, USA4.Stanford University, Stanford CA, USA
Correspondence: D Ayoub, Memorial Medical Cen-ter, 701 N First Street, Springfield, IL 62781, USA.Tel: +1-217-788-3245 |Fax: +1-217-778-5588 |Email: [email protected]
Figure 1 Close-up of figure 3C (2) shows CML changes (black arrows) in bilateral humeri in an infant with
rickets but no history of abuse.
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1282 ª2010 The Author(s)/Journal Compilation ª2010 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1280–1284
Re: ‘The use of iNO in thenewborn period: results fromthe European iNO registry’To the Editor:
We read with interest the article by Dew-hurst et al. titled: ‘The use of iNO in the new-born period: results from the European iNOregistry’ (1).We were surprised to notice thatthey made reference to the studies of Schreiberet al. (ref no. 11 & 12) and Kinsella et al. (refno. 13) as well as the EUNO trial (ref no. 16,to our knowledge, only available as anabstract, not yet published in a peer-reviewedjournal) but there was no mention of our trial,which was published in the same issue ofNEJM (2).
We conducted a randomized, stratified, dou-ble-blind, placebo-controlled trial of inhalednitric oxide at 21 centres, involving a total of582 infants (294 receiving iNO, 288 receivingplacebo). We reported a rate of survivalwithout bronchopulmonary dysplasia (BPD)of 43.9% in the group receiving nitric oxide,versus 36.8% in the placebo group (p=0.042).We have previously clarified some statisticalissues in a letter to the Editor of Pediatrics, inresponse to the meta-analysis article by Bar-rington and Finer
Our study included further publications,where the effectiveness of iNO in the NOCLD trial included improved pulmonary out-come at 1 year, and there was evidence forapparent safety, as we did not find anyincrease in airway inflammatory mediators oroxidative ⁄ nitrosative stress, even when iNOcaused dose-related increases in NO metabo-lites in the circulation as well as lung fluid.
In fact, in the most recent publication fromthe NO CLD trial, we concluded that ‘Inhalednitric oxide improved survival free of BPD,with no adverse neurodevelopmental effects at2 years of age’ (3).
We believe that, if the authors hadincluded the population studied by the NOCLD study group, they would modify theirphrase in the introduction regarding the ‘lackof benefits in clinically important outcomes’,as indeed our trial has shown a ‘discernibleeffect on CLD and ⁄ or long-term neurodis-ability’.
References1. Dewhurst C, Ibrahim H, Göthberg S, Jónsson B,
Subhedar N. Use of inhaled nitric oxide in thenew born period: results from the Europeaninhaled nitric oxide registry. Acta Paediatr 2010;99: 854–60.
2. Ballard RA, Truog WE, Cnaan A, Martin RJ,Ballard PL, Merrill JD, et al. Inhaled nitricoxide in preterm infants undergoing mechani-cal ventilation. N Engl J Med 2006; 355: 343–53.
3. Walsh MC, Hibbs AM, Martin CR, Cnaan A,Keller RL, Vittinghoff E, et al. NO CLD StudyGroup. Two-year neurodevelopmental outcomesof ventilated preterm infants treated with inhalednitric oxide. J Pediatr 2010; 156: 556–61.e1. Epub2010 Feb 6.
DOI:10.1111/j.1651-2227.2010.01847.x
Sergio G. Golombek1 ([email protected]), William E. Truog2, Roberta A. Ballard3,Philip L. Ballard3
1.The Regional Neonatal Center, Maria FareriChildren’s Hospital at Westchester Medical Center,New York Medical College, Valhalla, NY, USA2.Section of Neonatology, Children’s Mercy Hospi-tals and Clinics, Department of Pediatrics, Universityof Missouri-Kansas City School of Medicine, KansasCity, MO, USA3.Department of Pediatrics, University of California,San Francisco, CA, USA
Correspondence: Sergio G. Golombek, M.D., MPH,The Regional neonatal Center, Maria Fareri Chil-dren’s Hospital at Westchester Medical Center, NewYork Medical College, Valhalla, NY 10595, USA.Tel: 914-493-8488 |Fax: 914-493-1005 |Email: [email protected]
Figure 2 Left: Rachitic wrist from Paterson’s figure 3 shows classical radial fraying and ulnar cupping. Right: Figure 3A from paper co-authored by Feldman and Done
(2) showing infant’s rachitic wrist. In spite of the greater degree of ulnar cupping and radial splaying in Paterson’s case (left), Feldman and Done deny that this exem-
plifies rickets.
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