Letters to the Editor

2 June 2011Dear Editor,

WHAT IS BEING PUBLISHED? A WORD CLOUD OF TITLES FROM THEJOURNAL OF PAEDIATRICS AND CHILD HEALTH

We were interested in determining the priorities of paediatricresearchers, particularly in the Australian context. While mostclinicians are adept at visualising quantitative data, textual dataare less frequently explored in a visual manner. We used a wordcloud to perform a visual analysis of this topic. Word clouds arepictures created from words, where the frequency with which aword appears in the submitted text is reflected in the promi-nence with which a word is displayed. The more frequent aword appears in the text, the larger it appears in the wordcloud.1 The advantage of this form of visualisation is that it iseasy to spot the most commonly occurring words and theirrelative frequency compared to others. On the other hand, it isdifficult to make accurate estimates of those frequencies.1

Using PubMed, we retrieved the title of every article pub-lished by the Journal of Paediatrics and Child Health from February1990 to 1 March 2011. These article titles were then enteredinto an online word cloud generator,2 and a word cloud wascreated in a similar manner to a previous analysis.3 Prepositionslike ‘for’, ‘or’ and ‘in’ were excluded from the word cloud.

As Figure 1 demonstrates, the most striking feature of theword cloud is the dominance of the word ‘children’, which isnot surprising, but very reassuring. It indicates that the paedi-atric research community, which publishes in the journal, arestrongly focussed on children. Age subgroups of children appearprominently as well as general descriptors such as study loca-tion, syndrome and disease descriptors. Few specific disease

terms (with the exception of infection and asthma) are easilyrecognisable, and study types such as randomised trials do notappear strongly.

This word cloud provides an alternative technique for visual-ising topics considered important by Australasian paediatricresearchers. This method relies on articles using explicit titlesand so may not truly reflect the content of the articles; however,it does clearly indicate that the Journal of Paediatrics and ChildHealth remains squarely focussed on Australian children.

Acknowledgements: Richard McGee is a recipient of a post-graduate research scholarship from the National Health andMedical Research Council, Australia.

Dr Richard G McGee1,3

Professor Jonathan C Craig1,2,3

1Centre for Kidney Research2Cochrane Renal Group

The Children’s Hospital at WestmeadLocked Bag 4001

Westmead3Sydney School of Public Health

University of SydneySydney, New South Wales

Australia

References

1 Viégas F, Wattenberg M. Tag clouds and the case for vernacularvisualization. Interactions 2008; 15: 49–52.

2 Leung H. Tagxedo – Creator, 2010. Available from: http://www.tagxedo.com/app.html [accessed 1 March 2011].

3 McGee RG, McGee LM. A picture is worth a thousand words. Am. J.Transplant. 2011; 4: 871–2.

Fig. 1 A word cloud created from the titles of every article published by the Journal of Paediatrics and Child Health from 1990 to 2011.

doi:10.1111/j.1440-1754.2012.02455.x

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Journal of Paediatrics and Child Health 48 (2012) 452–454© 2012 The Authors

Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

452

31 May 2011Dear Editor,

VIRAL BRONCHIOLITIS FOR THE CLINICIAN

An evidence base of therapies of viral bronchiolitis is slowlygrowing and is well pointed to in Dominic Fitzgerald’s recentreview in this journal.1 However, many areas of uncertaintyremain, and, within these, there is potential for iatrogenic injuryin the management of this condition.

Harm arises when side effects of therapies outweigh anytherapeutic advantage or from overuse of invasive investiga-tions which always unsettle the patient but may lead to nouseful interventions.

While mild dehydration is clearly common on presentation, itis also clear that, particularly if over-vigorous, intravenous (IV)fluid resuscitation can contribute to serious problems such ashyponatraemia or fluid overload. I favour nasogastric milkfeeding, starting with low volumes, over IV fluid replacement asit is less invasive, provides ongoing nutrition and diminishesanxiety associated with hunger. Potential problems includingmicro-aspiration have been suggested and arguments may beresolved by an ongoing trial.2

Blood gas analysis is rarely helpful in differentiating whichbabies need some form of respiratory support. ‘Stab’ specimensfor blood gas, be they arterial, venous or capillary, are toounreliable to recommend routinely, and arterial catheters areusually too difficult and traumatic to place and keep in place.Infants who appear to be tiring and needing increasing FiO2

should commence on respiratory support in an environmentwhere they can be closely clinically monitored. Evidence favour-ing less invasive forms of support over intubation is mounting.3

Chest X-rays and blood tests do not contribute in routinecases. Even if a lobar collapse is seen, this does not stronglypoint to a bacterial aetiology, although may suggest a baby morelikely to need future support.4 Differentiation of the smallnumber of babies with bacterial pneumonia is difficult and it isnot unreasonable that some deteriorating babies end up on IVantibiotics.

Screaming or irritated babies clearly breathe less efficiently,leading to fatigue and desaturation. I advocate a ‘minimal han-dling’ policy in bronchiolitic infants including minimisation ofinvestigation.

Dr Christopher WilliamsPaediatric/Intensivist

Royal Hobart HospitalNPICU

Hobart, TasmaniaAustralia

References

1 Fitzgerald DA. Viral bronchiolitis for the clinician. J. Paediatr. ChildHealth 2011; 47: 160–6.

2 The Paediatric Research in Emergency Departments InternationalCollaborative (PREDICT), Oakley, ED, Babl FE et al. A prospectiverandomised trial comparing nasogastric with intravenous hydration inchildren with bronchiolitis (protocol): the comparative rehydration inbronchiolitis study (CRIB). BMC Pediatr. 2010; 10: 37.

3 Tasker RC. CPAP and HFOV: different guises of the same underlyingintensive care strategy for supporting RSV bronchiolitis. Intensive CareMed. 2008; 34: 1560–1.

4 Dawson K, Long A, Kennedy J, Mogridge N. The chest radiograph inacute bronchiolitis. J. Paediatr. Child Health 1990; 26: 209–11.

17 May 2011Dear Editor,

We read with great interest the article by Fitzgerald.1 The authorhas emphasized that the aim of hospital treatment is to ensureadequate hydration and oxygenation, and, other than supple-mental oxygen, pharmacological treatment has no role on thecourse of the illness or the risk of wheezing in the monthsfollowing bronchiolitis.

In a recently published systematic review,2 the authors foundadrenaline to be beneficial for short-term outcomes among out-patients, including admission rates from the emergency depart-ment, and adrenaline dexamethasone combination showinglonger-term effects, reducing admission rates up to 7 days afterthe emergency department visit, although later was from asingle precise trial. Except adrenaline, no other pharmaco-therapy has a clear-cut relevant clinical benefit. Although theauthors did not find any serious or frequent short-term adverseevents from any of the studied interventions in the absence ofcomorbidities, the long-term adverse events was unclear, asnone of the studies examined the later. So, should the currentpractice of outpatient management of bronchiolitis changebased on these findings? The answer is still unclear, if we con-sider the following limitations in the review.

There was high risk of bias among the included studies in theabove review and the resulting GRADE evidence was moderateor low (future research might change the result). Again, therewas no clear description about the type of intervention. Asvarious trials have used various doses and formulations ofadrenaline and found varied responses,3,4 description of type ofintervention would have been more meaningful. Moreover,whether all children with bronchiolitis or only those with mod-erate to severe illness benefit from epinephrine is not clear.Regarding the beneficial effects of use of combined adrenalineand dexamethasone, this was based on a single study report andthere are concerns of dangerous side effects in young infantsreceiving high-dose steroids. As the prevalence of infection(including tuberculosis) is high in children in low-income coun-tries, the combination therapy (containing high dose steroid)cannot be recommended in these countries prior to analysis ofthe risk–benefit ratio in these areas.

We hope that future trials will try to address these issuesbefore any firm recommendation can be made, and, until then,physicians might consider treating children with bronchiolitiswith epinephrine according to individual protocol preferences.This should supplement the good old time-honoured supportivecare, rather than replacing them.

Dr Rashmi Ranjan DasDepartment of Pediatrics

All India Institute of Medical Sciences (AIIMS)New Delhi, India

Letters to the Editor

Journal of Paediatrics and Child Health 48 (2012) 452–454© 2012 The AuthorsJournal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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References

1 Fitzgerald DA. Viral bronchiolitis for the clinician. J. Paediatr. ChildHealth 2011; 47: 160–6.

2 Hartling L, Fernandes RM, Bialy L et al. Steroids and bronchodilators foracute bronchiolitis in the first two years of life: systematic review andmeta-analysis. BMJ 2011; 342: d1714.

3 Abul-Ainine A, Luyt D. Short term effects of adrenaline in bronchiolitis:a randomised controlled trial. Arch. Dis. Child. 2002; 86: 276–9.

4 Wainwright C, Altamirano L, Cheney M et al. A multicenter,randomized, double-blind, controlled trial of nebulized epinephrine ininfants with acute bronchiolitis. N. Engl. J. Med. 2003; 349: 27–35.

19 May 2011Dear Editor,

TRIAL OF A DEVELOPMENTAL SCREENING TOOL

We write in response to the paper published in vol. 47 January–February 2011 Journal of Paediatrics and Child Health by D’Apranoand colleagues – ‘Trial of a developmental screening tool inremote Australian Aboriginal communities: A cautionary tale’.The stated aim of the research was to ‘trial the Brigance devel-opmental screening tool as an instrument for identifying Aus-tralian Aboriginal children at risk of developmental disabilityand requiring diagnostic developmental assistance’1 (p. 12).That is, the Brigance tool was on trial, not the Aboriginal chil-dren. The authors rightly concluded that ‘Language and culturalrelevance, and the method of administration limit the use of thisscreening tool1 (p. 12). Our concern is that the results of the testhave been reported as though they are actually a valid measureof these children’s development. However, the limitations ofboth the tool and testing process reported in their paper clearlydemonstrate that the test results cannot be considered valid forthis population.

The authors acknowledge that all the children speak a lan-guage other than Standard English as their first language and,not surprisingly, reported that ‘they struggled with the itemsrequiring competent levels of expressive and receptive English’1

(p. 16). The authors also acknowledge limitations in culturalrelevance stating that ‘some items were clearly not relevant’ andthat: ‘the items therefore may not be testing skills that are a truereflection of the child’s ability’1 (p. 16). Also, the authors iden-tified a number of factors related to test administration whichmay have impacted negatively on results, for example, theinfluence of an examiner who is not known to the children andunfamiliarity with a process which requires responses to ques-tions which seem irrelevant or to which the examiner alreadyknows the answer1 (p. 15).

While the authors argue that their ‘findings cannot beexplained by the lack of culturally relevant items and languagetasks alone’1 (p. 14), the reality is that the limitations related toculture and language are extremely serious. By reporting find-

ings from a test that is clearly not valid for the target population,the authors perpetuate the interpretation of difference as deficitand do not in any way progress our understanding of thegenuine needs of these children and their families or the mosteffective and appropriate way to work with them to addressthese needs.

Also, administration of a test in a foreign language based onirrelevant cultural concepts renders invisible the developmentalstrengths of these children. The publication of results such asthese derived from invalid tools contributes to a damagingmisrepresentation characterized by lack of recognition of thedevelopmental differences between Aboriginal and non-Aboriginal children, as well as Aboriginal children’s uniquestrengths, capacities, knowledge and abilities that can be drawnand built upon in educational settings. There also seems littlejustification for a study to yet again ‘trial’ an approach that hasbeen so thoroughly discredited in the past.2–7 However, there isan urgent need, as the authors suggest, for a collaborative andculturally-responsive approach which does have the potential toidentify strengths, as well as the needs of Indigenous childrenwho are genuinely experiencing developmental problems.

Dr Anne Lowell1

Dr Melanie Lotfali2

Dr Sue Kruske3

Dr Merridy Malin4

1Principal Research Fellow2Research Associate

3Adjunct Professor, Maternal and Child Health4Research Capacity Building lecturer, Adjunct Senior Lecturer

Charles Darwin UniversityDarwin, Northern Territory

Australia

References

1 D’Aprano A, Carapetis J, Andrews R. Trial of a developmental screeningtool in remote Australian Aboriginal communities: a cautionary tale. J.Paediatr. Child Health. 2011; 47: 12–7.

2 Bernhard J. Child development, cultural diversity, and the professionaltraining of early childhood educators. Can. J. Educ./Revue Canadiennede l’Education 1995; 20: 415–36.

3 Rogoff B. The Cultural Nature of Human Development. New York:Oxford University Press, 2003.

4 Rogoff B, Morelli G. Perspectives on children’s development fromcultural psychology. Am. Psychol. 1989; 44: 343–8.

5 Forman E, Minick N, Stone C. Contexts for Learning: SocioculturalDynamics in Children’s Development. New York: Oxford UniversityPress, 1993.

6 Reser J. Cultural relativity or cultural bias: a response to Hippler. Am.Anthropol. 1982; 84: 399–404.

7 McElwain D, Kearney G. The Queensland Test Manual: A Manual forUse with Assessment of General Cognitive Capacity Under Conditionsof Reduced Communication. Melbourne: Australian Council forEducational Research, 1970.

Letters to the Editor

Journal of Paediatrics and Child Health 48 (2012) 452–454© 2012 The Authors

Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

454