Showing papers in "Acta Paediatrica in 2001"

Changing panorama of cerebral palsy in Sweden. VIII. Prevalence and origin in the birth year period 1991-94.

Abstract: UNLABELLED This 8th Swedish population-based cerebral palsy (CP) report comprises 241 children born 1991-94. The live birth prevalence was 2.12 per 1000. Excluding 7 postnatally-derived cases, the gestational age-specific prevalences were 86 for extremely preterm children, 60 for very preterm and 6 for moderately preterm, and 1.3 for term children per 1000. Spastic hemiplegic, diplegic and tetraplegic subtypes accounted for 33%, 44% and 6%, dyskinetic CP for 12% and simple ataxia for 4%. Neuroimaging had been performed in 90%. Probable aetiology was identified in 73% of preterm and 86% of term children. Among preterm children it was considered prenatal in 12%, peri/neonatal in 61% and unclassifiable in 27%, while it was 51%, 36% and 14% among term children. CONCLUSION The live birth prevalence for CP in the birth year period 1991-94 continued to decrease slightly. Gestational age-specific prevalences increased marginally in extremely and very preterm births, continued to decrease in moderately preterm births and decreased slightly in term births. Probable aetiology and timing of the brain insult could be revealed in 81%, birth asphyxia being the likely cause in 28% of term children.

Long chain polyunsaturated fatty acids (LC-PUFA) and perinatal development

Abstract: This paper reports on the conclusions of a workshop on the role of long chain polyunsaturated fatty acids (LC-PUFA) in maternal and child health The attending investigators involved in the majority of randomized trials examining LC-PUFA status and functional outcomes summarize the current knowledge in the field and make recommendations for dietary practice. Only studies published in full or in abstract form were used as our working knowledge base. Conclusions: For healthy infants we recommend and strongly support breastfeeding as the preferred method of feeding, which supplies preformed LC-PUFA. Infant formulas for term infants should contain at least 0.2% of total fatty acids as docosahexaenoic acid (DHA) and 0.35% as arachidonic acid (AA). Since preterm infants are born with much less total body DHA and AA, we suggest that preterm infant formulas should include at least 0.35% DHA and 0.4% AA. Higher levels might confer additional benefits and should be further investigated because optimal dietary intakes for term and preterm infants remain to be defined. For pregnant and lactating women we consider it premature to recommend specific LC-PUFA intakes. However, it seems prudent for pregnant and lactating women to include some food sources of DHA in their diet in view of their assumed increase in LC-PUFA demand and the relationship between maternal and foetal DHA status.

Enterobacter sakazakii infection in the newborn.

Abstract: UNLABELLED Enterobacter sakazakii, a Gram-negative bacillus, previously known as "yellow pigmented Enterobacter cloacae", is a rare cause of neonatal infection. We describe the detailed clinical presentation of two cases in whom E. sakazakii was isolated in our neonatal service during the course of 1 mo. These include one case of sepsis and meningitis complicated by cerebral infarction, and one case of sepsis. In addition, three cases of intestinal colonization were identified. The source of the organism was thoroughly sought and was found to be a blender in the milk kitchen that was used for preparation of the reconstituted powdered milk formula. CONCLUSION Our paper adds clinical and laboratory information about the disease spectrum caused by this relatively rare organism and emphasizes the importance of a thorough search for the source of the infection.

Neonatal withdrawal syndrome after in utero exposure to selective serotonin reuptake inhibitors.

Abstract: UNLABELLED Selective serotonin reuptake inhibitors (SSRIs) are a new group of antidepressants used in mild to moderate cases of depression. In studies evaluating the safety of SSRIs during pregnancy, no increase in major anomalies has been reported. This might have led to increasing off-label prescription of SSRIs to pregnant women. Neonatal withdrawal syndrome commonly occurs in infants exposed during the third trimester to drugs known to cause addiction. We report five cases of neonatal withdrawal syndrome after third trimester in utero SSRI exposure. In three cases the mother used paroxetine in doses from 10 to 40 mg, one mother used citalopram 30 mg, and one mother fluoxetine 20 mg. Withdrawal symptoms occurred within few days after birth and lasted up to one month after birth. Four of the infants needed treatment with chlorpromazine. Symptoms were irritability, constant crying, shivering, increased tonus, eating and sleeping difficulties and convulsions. CONCLUSION Neonatal withdrawal syndrome can occur after third trimester in utero SSRI exposure. Further research should focus on whether it is safe to use SSRIs during the last trimester. All neonates exposed to SSRIs during the last trimester should be followed-up closely for withdrawal symptoms after birth.

Prevalence of iron deficiency in 12-mo-old infants from 11 European areas and influence of dietary factors on iron status (Euro-Growth study)

Abstract: A prospective longitudinal cohort study was performed to assess the prevalence of iron deficiency in European infants at 12 mo of age, and to study the influence of socio-economic status, dietary factors, growth and morbidity on iron status. The cohort consisted of 488 normal term infants from primary healthcare centres in 11 European areas. Assessed were socio-economic variables, dietary intake, anthropometry and morbidity at regular intervals from birth to 12 mo, and haemoglobin, serum ferritin, mean corpuscular volume, transferrin saturation and serum transferrin receptor concentrations at age 12 mo. The prevalence of anaemia was 9.4%, of iron deficiency 7.2%, and of iron deficiency anaemia 2.3%. More than 40% of anaemia was associated with normal iron status and associated with an increased frequency of recent infections. Iron deficiency anaemia was significantly more frequent with low (5.1%) than high socio-economic status (0%). Dietary factors accounted for most of this variation in multiple regression analysis. Early introduction of cows' milk was the strongest negative determinant of iron status. Feeding of iron-fortified formula was the main factor positively influencing iron status. Other dietary factors, including breastfeeding, did not play a significant role as determinants of iron status at age 12 mo. Conclusion. Iron deficiency anaemia is present in 2.3% of 12-mo-old European infants. The prevalence of iron deficiency anaemia varies strongly with socio-economic status. Avoidance of cows' milk feeding during the first year of life is the key measure in the prevention of iron deficiency.

Breast odour as the only maternal stimulus elicits crawling towards the odour source

Abstract: Varendi H, Porter RH. Breast odour as the only maternal stimulus elicits crawling towards the odour source. Acta Paediatr 2000; 90: 372‐375. Stockholm. ISSN 0803-5253 In previous studies, newborn infants placed on their mother’s chest grasped a nipple and sucked without assistance. Furthermore, neonates sucked preferentially from an untreated breast rather than the alternative breast that had been washed to eliminate its natural odour. This study investigated the ine uence of breast odours per se on orientated physical movement of neonates. In total, 22 babies were observed during two trials on a warming bed. In one trial, a pad carrying the mother’s breast odour was placed 17 cm in front of the baby’s nose; in the other trial a clean pad was used. More babies moved towards and reached the breast pad than the clean pad. Conclusion: Natural breast odours unsupported by other maternal stimuli therefore appear to be sufe cient to attract and guide neonates to the odour source.

Vitamin D deficiency in Iranian mothers and their neonates: a pilot study

Abstract: UNLABELLED: We conducted a pilot study to assess the prevalence of hypovitaminosis D among Iranian women and their newborns. Blood samples were taken from 50 mothers (age 16-40 yr) and their neonates at term delivery in the largest Tehran hospital. The results showed that 80% of the women had 25-hydroxyvitamin D (25-OHD) concentrations of less than 25 nmol/l. Mean maternal plasma calcium and phosphatase alkaline concentrations were in the normal range. The mean maternal serum immunoreactive parathyroid hormone concentration of women with hypovitaminosis D (i.e., 25-OHD levels <25 nmol/l) was above normal range and significantly different from that of women without hypovitaminosis D. CONCLUSION: The mean cord serum 25-OHD concentration was very low (4.94+/-9.4 nmol/l) and that of infants of mother with hypovitaminosis D were almost undetectable (1.2+/-1.2 nmol/l).

Body mass index, triceps skinfold and waist circumference in screening for adiposity in male children and adolescents

Abstract: UNLABELLED Simple anthropometric measurements and indices are the most commonly used tools for assessing body composition. Only a few papers have examined the sensitivity and specificity of the body mass index (BMI) against total body fat percentage (TBF%) from underwater weighing in children and adolescents. The objective of the study was to evaluate the screening performance of BMI, triceps skinfold thickness and waist circumference for excess TBF%. A total of 175 healthy volunteer males, aged 7.0-16.9 y, participated in the study. TBF% was measured using underwater weighing as the reference method. Receiver operating characteristic (ROC) curves were constructed to assess the value of the three anthropometric measurements as a screening measure for total adiposity. Sensitivity and specificity were calculated at several percentile cut-offs for BMI, triceps skinfold and waist circumference. The areas under the ROC curves were also calculated, and were 0.86 for BMI, 0.90 for triceps skinfold and 0.88 for waist circumference. The point on the ROC curve closest to 1 corresponded to the 70th percentile for BMI, to the 75th percentile for triceps skinfold, and to the 70th percentile for waist circumference. CONCLUSION BMI, triceps skinfold and waist circumference predicted total fat content well in male children and adolescents.

Sociodemographic differences in patterns of sedentary and physically active behavior in older children and adolescents.

Abstract: UNLABELLED Numerous studies have found that involvement in moderate-intensity and strenuous activity has positive effects on health. This study considered the prevalence of different aspects of physical activity and sedentary behavior in 11-16-y-olds based on a representative national survey of 3270 Icelandic primary schoolchildren (91% response rate). All-day sedentary behavior was extremely rare ( or = 3 times per week) during school or leisure time, thanks largely to school physical education. Only 39% were physically active (> or = 3 times per week) during leisure time, and only 29% engaged in regular (> or = 3 times per week) leisure time strenuous exercise. Girls were more sedentary, less leisure time physically active, and less involved in leisure time strenuous exercise. Sedentary behavior increased and physically active behavior decreased with age, especially after early adolescence. However, there were no age differences in strenuous leisure time exercise. Upper-class students were less sedentary and more physically active during leisure time than working-class students. Finally, rural students were more sedentary during leisure time, and less physically active than students from urban areas. An interaction was found between age and residence when predicting leisure time physical activity, indicating that the inverse age-activity relationship in urban areas is partly reversed in rural areas. CONCLUSION Compulsory school physical education frequently failed to translate into voluntary physical involvement. Sociodemographic differences in physical activity were greater during leisure time, than during school and leisure time combined.

Cystic fibrosis‐related diabetes mellitus: clinical impact of prediabetes and effects of insulin therapy*

Abstract: UNLABELLED: In patients with cystic fibrosis (CF), glucose intolerance preceding diabetes (prediabetes) may have adverse effects on nutritional status and respiratory function, which are reversible after the start of insulin therapy. Respiratory function (forced vital capacity and forced expiratory volume in one second) and body mass index (BMI) were compared retrospectively in a French cohort of 14 patients during the 5 y preceding insulin therapy for diabetes and in 14 age- and sex-matched controls with normal oral glucose tolerance tests. In the diabetic group, all three parameters deviated increasingly from the values in the controls; the differences became statistically different during the 6 mo before insulin therapy. The effect was more important in patients for whom diabetes mellitus was diagnosed on the basis of symptoms of hyperglycaemia than in patients for whom it was diagnosed by systematic screening, but still present in the latter. After insulin was started, respiratory function improved and the BMI returned to normal within 1 y. The annual insulin requirement increased from 0.62 during the first year to 1.25 during the fifth year. Glycosylated haemoglobin (HbAIc) values ranged from 6.6 to 7.8%. Only 2 episodes of severe hypoglycaemia were recorded over 42 patient-years of follow-up. The insulin regimen most often used was two daily injections of a mixture of short- and intermediate-acting insulin (n = 10) given with an insulin pen. CONCLUSION: The clinical status of CF patients who will need insulin therapy deteriorates before the start of insulin. In patients with CF-related diabetes, with or without fasting hyperglycaemia, insulin therapy improves anabolism and provides good glycaemic control with few severe hypoglycaemic episodes.

Malassezia pachydermatis fungaemia in a neonatal intensive care unit.

Abstract: UNLABELLED Malassezia pachydermatis, a non-obligatory lipophilic yeast, has occasionally been implicated in nosocomial fungaemias. This study investigated a cluster of eight cases of M. pachydermatis infection and colonization in a neonatal intensive care unit over a 6 mo period. All patients were preterm with very low birthweight and suffered from various underlying diseases. Prolonged use of indwelling catheters and parenteral lipid formulations were important predisposing factors for their infection. All M. pachydermatis strains were susceptible to amphotericin B, fluconazole and itraconazole but resistant against flucytosine. CONCLUSION Molecular typing by random amplification of polymorphic DNA showed distinct banding profiles for each blood isolate. Since no epidemiological association among the strains could be shown, the reason for this cluster of nosocomial fungaemias remains unclear.

Breast milk from mothers of very low birthweight infants: variability in fat and protein content.

Abstract: UNLABELLED: While breast milk appears to be superior to formula for the development of very low birthweight (VLBW) infants, it is supplemented to meet the metabolic demands of the rapidly growing premature infant. To estimate the nutritional variability of breast milk from mothers of VLBW infants, protein (bicinchoninic acid method) and fat content (creamatocrit) were measured in breast-milk spot samples from mothers of 20 VLBW infants, collected 4 times a day during the first 4 wk of lactation. Protein content (median 1.9 g dl(-1), range 1.1-3.5 g dl(-1)) and fat content (3.8/1.0-14.6 g dl(-1)) were highly variable and lacked a normal distribution over all samples and in individual women's milk. There was only a weak correlation between fat and protein (rs=0.416, p < 0.001). Fat but not protein was lower in morning samples than in samples collected later in the day (p < 0.001). Protein but not fat content decreased during the weeks of lactation (rs =-0.446, p < 0.001). No impact of the baby's gestational age was observed. CONCLUSION: The fat and protein content of breast milk from mothers of VLBW infants is highly variable, calling into question the clinical feasibility of individualized supplementation of breast milk for VLBW infants based on spot sample measurements.

Breastfeeding and complementary feeding practices in rural Malawi

Abstract: UNLABELLED: To facilitate optimal growth of newborns, many countries have developed infant feeding recommendations, usually suggesting 4-6 mo of exclusive breastfeeding and then the gradual introduction of complementary foods. We prospectively studied the changes in infant diets and predictors of adherence to national infant feeding recommendations in a cohort of 720 newborn babies in rural Malawi, Sub-Saharan Africa. Monthly interviews of the main guardians indicated that breastfeeding was universal for 18 mo. As most babies were given water or other supplemental foods soon after birth, the exclusive breastfeeding rates were only 19%, 8%, 2% and 0% at ages 1, 2, 3 and 4 mo, respectively. Complementary foods and family foods were introduced at median ages of 2.5 and 6.3 mo, i.e. much earlier than recommended. Better adherence to recommendations was associated with smaller number of children in the family, increased maternal education and some other socio-economic or environmental variables. CONCLUSION: Exclusive breastfeeding is uncommon and complementary foods were introduced early to newborns among these rural families. Education and family planning may improve adherence to infant feeding recommendations and reduce the incidence of early childhood malnutrition in Malawi.

Causes of childhood deaths in Bangladesh: an update.

Abstract: Knowledge of the causes of child death is important for health-sector planning since they relate to available interventions. Little is known about causes of child death in Bangladesh from the conventional sources since there is no vital registration system and very few deaths are attended by a qualified physician. To determine the cause structure of child deaths verbal autopsy interviews were conducted in the Bangladesh Demographic and Health Survey (BDHS) 1993/94 national sample. Verbal autopsy is a method of finding out the causes of death based on an interview with the next of kin or other caregivers. Between BDHS 1993/94 and BDHS 1996/97 1–4-y-old child mortality in Bangladesh declined by about 27.0%. This impressive decline prompted a verbal autopsy study using the BDHS 1996/97 national sample to determine whether the cause structure had changed. The same verbal autopsy instrument and methods to collect the data and the same computer algorithm to assign causes of death were used in both surveys. Comparison of BDHS 1993/94 and 1996/97 cause-specific mortality rates revealed that deaths due to almost all causes had declined although significantly so only for acute respiratory infections (ARI) persistent diarrhoea and drowning. Deaths due to neonatal tetanus acute watery diarrhoea and undernutrition had not decreased at all. (authors)

Infantile genetic agranulocytosis, morbus Kostmann: Presentation of six cases from the original “Kostmann family” and a review

Abstract: UNLABELLED In 1956 Rolf Kostmann reported on six children with severe neutropenia associated with a block in myelopoiesis at the promyelocyte/myelocyte stage and an autosomal recessive inheritance. He named the new syndrome infantile genetic agranulocytosis. Today it is known as Kostmann's syndrome or severe congenital neutropenia. In 1975 an additional 10 cases from northern Sweden were published. This article reports on the only long-term survivor from the 1975 report plus another five patients born after 1975 who belong to the original "Kostmann family". Treatment and survival have changed dramatically since Kostmann's first publication. In the pre-antibiotic era, Kostmann's syndrome was inevitably fatal during the first year of life. CONCLUSION Since the introduction of recombinant human granulocyte colony-stimulating factor (G-CSF) about 10 y ago, most patients now enjoy a normal life span and a greatly improved quality of life. Although the threat of death has disappeared, patients still have problems with infections, especially chronic gingivitis and periodontitis. In other groups of severe neutropenia, not related to the original "Kostmann family", an increased incidence of myeloid leukaemia has been observed. However, in this small cohort none of the children on chronic G-CSF therapy have developed malignancies.

Insulin improves clinical status of patients with cystic‐fibrosis‐related diabetes mellitus

Abstract: Cystic-fibrosis-related diabetes mellitus is frequently underdiagnosed and associated with deterioration of overall clinical status. The purpose of this prospective study was to investigate the influence of insulin on nutrition, lung function and clinical status of cystic fibrosis patients. For a period of 5 y, and at 6-mo intervals, body mass index, forced expiratory volume in 1 sec, Shwachman score, intravenous glucose tolerance test and first-phase insulin response were determined in 30 cystic fibrosis patients (age range 10-35 y) with exocrine pancreatic insufficiency. During the study period, six patients (3M and 3F; age range 15-22 y) developed diabetes and required insulin therapy. The decrease of first-phase insulin response coincided with deterioration of nutritional and clinical status, which improved significantly 6 mo after the institution of insulin. Conclusion Insulin, as an anabolic hormone, could have an influence on body mass, which may affect pulmonary function and clinical condition in cystic fibrosis. It is important to identify cystic fibrosis individuals at risk of developing diabetes so that early insulin therapy is instituted.

Limiting light-induced lipid peroxidation and vitamin loss in infant parenteral nutrition by adding multivitamin preparations to Intralipid.

Abstract: UNLABELLED Parenteral lipids are susceptible to light-induced peroxidation, particularly under phototherapy. Ascorbic acid is protective. The aim of this study was to investigate whether dark delivery tubing and/or coadministration of multivitamin preparations could prevent peroxidation of Intralipid without undue vitamin loss. In experiments carried out on the benchtop, lipid peroxidation occurred in ambient light and was more extensive under phototherapy. Dark tubing decreased peroxide formation, but only by about 65%. In simulated clinical conditions in which solutions were pumped through standard clear or dark minibore plastic tubing. Intralipid accumulated lipid peroxides as measured by the FOX assay (280 microM) or as triglyceride hydroperoxides (52 microM). Multivitamin preparations (MVIP or Soluvit/Vitlipid) inhibited peroxide formation almost completely, and were fully protective when used with dark tubing. There was loss of riboflavin (65% from Soluvit and 35% from MVIP) in clear tubing but this was decreased to 18% and 11%, respectively, in dark tubing. Ascorbate loss was 20% (MVIP) and 50% (Soluvit) and only slightly less in dark tubing. Ascorbate loss was also seen in the absence of Intralipid and is due to riboflavin-induced photo-oxidation. CONCLUSION Multivitamin preparations protect Intralipid against light-induced formation of lipid hydroperoxides, and administering multivitamins with Intralipid via dark delivery tubing provides a practical way of preventing peroxidation of the lipid while limiting vitamin loss. This procedure should be considered for routine use as well as with phototherapy.

Maternal employment and the initiation of breastfeeding

Abstract: UNLABELLED This study examines whether planning to be employed postpartum has an effect on initiation of breastfeeding. Data were collected from questionnaires completed by mothers who were subjects in the prospective, population-based, Avon Longitudinal Study of Pregnancy and Childhood. The mothers of 10,530 full-term singleton infants gave information during pregnancy on their postpartum employment plans and their initial infant feeding methods. Information was also given by 7642 of these mothers on the timing of their postpartum employment plans. Adjusted logistic regression was performed to identify associations between (a) "any" plans to work postpartum and the initiation of breastfeeding, and (b) the timing of the commencement of work postpartum, and the initiation of breastfeeding. A total of 8316 (79%) of the women initiated breastfeeding. The decision to breastfeed was not associated with "any" plans to work postpartum. However, women who planned to commence work prior to 6 wk postpartum were significantly less likely to initiate breastfeeding compared with those not intending to work postpartum. Older, more highly educated women, women who had or were planning to attend childbirth classes, women who were breastfed as infants, women who did not smoke and women who were giving birth to their first child were significantly more likely to initiate breastfeeding. CONCLUSION Planning to return to employment prior to 6 wk postpartum reduces the likelihood of initiating breastfeeding. As increasing numbers of mothers are returning to work shortly after the birth of their child, this finding could have implications for maintaining the current level of breastfeeding.

Levels of certain metals, organochlorine pesticides and dioxins in cord blood, maternal blood, human milk and some commonly used nutrients in the surroundings of the Aral Sea (Karakalpakstan, Republic of Uzbekistan)

Abstract: Since the 1960s a massive decline in the volume of the Aral Sea has occurred as a result of the diversion of the supplying rivers to cotton irrigation schemes. The contaminated sediment of the former seabed has been disseminated over the surrounding area by strong winds. This deterioration of the ecosystem has created a hazardous situation for the health of approximately 3.5 million people. This pilot study was undertaken to assist Karakalpak health workers in investigating the degree of exposure to metals, persistent organochlorine pesticides (OCPs) and dioxins during the most vulnerable prenatal and postnatal period and to provide guidelines for future research. All subjects came from areas located within 200 km of the southern border of the Aral Sea. Blood was obtained from 18 pregnant women and 28 newborns (cord blood) to determine the levels of metals, lead, cadmium, zinc and selenium and the OCPs alpha-, beta- and gamma -hexachlorocyclohexane (HCH; lindane is the product name of gamma -hexachlorocyclohexane), hexachlorobenzene (HCB), and isomers and metabolites of dichlorodiphenyltrichloroethane (DDT), i.e. op-DDT, pp-DDT, pp-DDE and pp-TDE. Levels of metals were also determined in blood from 28 non-pregnant women. In addition, levels of 17 dioxins were determined in 41 human milk samples and I batch of formula. Information about possible dietary sources of the fat-soluble OCPs and dioxins was obtained from a pooled sample of butter and from seven cottonseed oil samples. A mass-selective detector coupled to a gas chromatograph equipped with a large volume injector was used to analyse the selected OCPs, whereas the dioxins were determined by gas chromatography with high-resolution mass spectrometry. The levels of metals in cord and maternal blood were consistent with concentrations observed in European countries. Only three women (7%) had lead levels greater than 100 ppb. The most notable pollutants in maternal and cord blood were the OCPs, notably HCB, beta -HCH, pp-DDE and the most toxic dioxin, 2,3,7,8-TCDD, when calculated as TEQs. A similar pattern was observed in human milk: beta -HCH and pp-DDE levels of more than 1000 ng g(-1) fat were found in 68 and 43% of the subjects, respectively. Levels of 2,3,7,8-TCDD were six times higher than those observed in Western Europe. Traces of pp-DDE were detected in the batch of formula milk. Contaminated animal fat, but not cottonseed oil, is the most likely dietary source of OCPs and dioxins. Conclusion: Further epidemiological research is needed to elucidate the health implications of these pollutants on perinatal and maternal health, including lactation. More importantly, an investigation should be initiated to identify the emission sources of persistent organic pollutants in Karakalpakstan and adjacent regions.

Shorter PFA-100 closure times in neonates than in adults: role of red cells, white cells, platelets and von Willebrand factor.

Abstract: Compared with adults, neonates have poor in vitro platelet function and very low levels of some procoagulatory factors (1). Their platelets react hyporesponsively to a variety of physiological agonists, resulting in decreased platelet activation and aggregation (2).

Fifteen year trends in water intake in German children and adolescents: Results of the DONALD Study

Abstract: UNLABELLED Water intake was evaluated and time trends in water intake and beverage consumption were assessed on the basis of 3 d weighed dietary records (n = 3,736) of 2-13-y-old males (n = 354) and females (n = 379) enrolled in the DONALD Study (Dortmund Nutritional and Anthropometric Longitudinally Designed Study, 1985-1999). Total water intake increased with age from 1,114 g d(-1) in the 2-3-y-olds to 1,363 g d(-1) in the 4-8-y-olds and further to 1,801 g d(-1) (1,676 g d(-1)) in the 9-13-y-old boys (girls); 33-38% came from food, 49-55% from beverages and 12-13% from oxidation. Total water intake per body weight decreased with age from 77.5 g kg(-1) (boys and girls) to 48.9 and 42.6 g kg(-1) in boys and girls, respectively. Milk (9-17%) and mineral water (12-15%) were the most important source of total water intake. In the 15 y period a significant increase in total water intake (+1.7 to +3.2 g MJ(-1) y(-1)) in all three age groups irrespective of sex was found. The increase of total water intake was mainly due to an increase in beverage consumption (+0.32 to +0.47% y(-1)). This study offers a differentiated insight into water intake and patterns of beverage consumption in German children and adolescents. CONCLUSION The comparison of these data with other surveys points to a low total water intake, especially a low tap water intake, in German children and adolescents and underlines cultural influences on food and drinking habits.

A randomized double-blind, placebo-controlled trial of the EMLA patch for the reduction of pain associated with intramuscular injection in four to six-year-old children.

Abstract: The effectiveness of a eutectic mixture lidocaine-prilocaine topical anaesthetic cream (EMLA R ) patch compared with a placebo patch in the reduction of pain associated with intramuscular immunization was evaluated. As part of the study, 161 children (aged 4-6-y) undergoing routine diphtheria, pertussis, tetanus and polio (DPTP) immunization in five urban and five rural private office settings were randomly assigned to an EMLA R patch (n = 83) or a placebo patch control group (n = 78). Pain measurements included: child's self-report on a Faces Pain Scale; facial action on the Child Facial Coding System: the Children's Hospital of Eastern Ontario Pain Scale and parent and technician ratings on a Visual Analogue Scale. Parents also rated their own and their child's immunization-related anxiety on a Visual Analogue Scale. The EMLA R patch group had significantly less pain on all four pain measures compared with the placebo group. Of the children in the placebo group, 43% had clinically significant pain, compared with 17% of children in the EMLA R patch group. No severe adverse symptoms occurred as a result of either EMLA R or placebo patch application. Conclusion: The EMLA R patch reduced immunization pain in 4 to 6-y-old children during needle injection.

Oral sucrose compares favourably with lidocaine-prilocaine cream for pain relief during venepuncture in neonates.

Abstract: UNLABELLED To compare the relative efficacy of oral sucrose versus EMLA cream for pain relief during venepuncture, 51 full-term newborns (38M, 13F; postnatal age <4 d) in a stable condition were randomly allocated to one of four treatment groups: placebo (2 ml spring water); 2 ml sucrose 24% w/v; 1 g lidocaine-prilocaine 5% cream (EMLA); or EMLA plus sucrose. Water or a single dose of sucrose solution was administered orally 2 min before venepuncture. EMLA cream was applied in the antecubital fossa 45-60 min before venepuncture and covered by a Tegaderm dressing. A pacifier was given before skin puncture, but it was not actively held or replaced during the procedure or observation periods. In total, 55 venepunctures were performed blindly, always for clinical reasons. As indicators of pain, the total crying time was recorded and heart rate, respiratory rate and arterial oxygen saturation were measured blindly at baseline, immediately post-venepuncture, and 2 and 4 min afterwards. The main effects observed were: (i) time spent crying decreased significantly in the sucrose alone (p = 0.001) and EMLA plus sucrose (p = 0.008) groups; (ii) the above treatments attenuated significantly (p < 0.05) the immediate heart rate response to pain; and (iii) the concomitant use of EMLA did not increase further the analgesic efficacy of sucrose. CONCLUSION This study shows that a 24% oral sucrose solution compares favourably with EMLA cream as a safe and cheap analgesic procedure to decrease pain responses to venepuncture in newborns.

Fertility in Prader-Willi syndrome: a case report with Angelman syndrome in the offspring.

Abstract: UNLABELLED We report on a 32-y-old woman with Prader-Willi syndrome (PWS) and her daughter with Angelman syndrome (AS). PWS in the mother was confirmed as due to a deletion of 15q11-q13, and molecular analysis in the neonate indicated an inherited maternal deletion of the same region. Features of AS in early infancy, such as jerky movements, feeding problems and poor sleep, were observed. At 5 mo of age, a triphasic high voltage EEG pattern was reported. CONCLUSIONS This case confirms the non-Mendelian inheritance of PWS and AS and, in addition to previous reports, provides evidence of fertility in PWS women. We recommend the provision of information regarding fertility in females with PWS to parents, guardians and individuals with PWS, and frequent EEG monitoring for early AS diagnosis. Given the different genetic aetiologies for PWS and AS, cytogenetic and molecular genetic analysis is strongly indicated for counselling and risk estimation.

Organic abnormalities in recurrent abdominal pain in children.

Abstract: UNLABELLED Using an investigation protocol, the aim of this study was to determine the frequency of organic abnormalities in children with recurrent abdominal pain, as new diagnostic approaches may reveal a higher prevalence of organic disease in this group than has been found in most studies. Included in the study were 44 children (mean age 8.3 y; 2-15) with more than three bouts of abdominal pain severe enough to affect the daily activities of the child and lasting more than 3 mo. The investigation covered a detailed medical story, a physical examination, blood, urine and stool samples. The somatic investigation was completed by abdominal X-ray and ultrasound, lactose-breath-hydrogen test and 24-h pH monitoring in the lower oesophagus. A Child Behaviour Checklist was completed to assess psychosocial aspects of the illness. The blood, urine and stool samples were normal, and abdominal ultrasound did not give any results related to the symptoms. Constipation was diagnosed in 7 patients (16%); 9 patients (21%) had gastro-oesophageal reflux and oesophagitis was found in another 3 children. One child had nodular antral gastritis with colonization by Helicobacter pylori, and three children had pathological lactose-breath-hydrogen tests. Twenty-four children (55%) did not have any signs of organic disease. The total score for the CBCL was in the normal range in 89%. CONCLUSION Our observations indicate a higher proportion of organic abnormalities in recurrent abdominal pain than has been found in most previously reported studies, though a multicausal approach seems important.

Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures.

Abstract: UNLABELLED Physicians often have to perform a lumbar puncture to ascertain the diagnosis in patients with meningeal signs, because of the serious consequences of missing bacterial meningitis. The aim of this study was to derive and validate a clinical rule to predict bacterial meningitis in children with meningeal signs, to guide decisions on the performance of lumbar punctures. Information was collected from records of patients (aged 1 mo to 15 y) consulting the emergency department of the Sophia Children's Hospital between 1988 and 1998 with meningeal signs. Bacterial meningitis was defined as cerebrospinal fluid (CSF) leucocyte count >5 cells microl(-1) with a positive bacterial culture of CSF or blood. The diagnostic value of predictors was judged using multivariate logistic modelling and area under the receiver operating characteristic curves (ROC area). In the derivation set (286 patients, years 1988-1995) the duration of the main complaint, vomiting, meningeal irritation, cyanosis, petechiae and disturbed consciousness were independent clinical predictors of bacterial meningitis. The ROC area of this model was 0.92. The only independent predictor from subsequent laboratory tests was the serum C-reactive protein concentration, increasing the ROC area to 0.95. Without missing a single case, this final model identified 99 patients (35%) without bacterial meningitis. Validation on 74 consecutive patients in 3 subsequent years (1996-1998) yielded similar results. CONCLUSION This prediction rule identifies about 35% of the patients with meningeal signs in whom a lumbar puncture can be withheld without missing a single case of bacterial meningitis. For the individual patient this prediction rule is valuable in deciding whether or not to perform a lumbar puncture.

Do normal leucocyte count and C-reactive protein value exclude acute appendicitis in children?

Abstract: UNLABELLED The present study aimed to determine the role of leucocyte count and C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis in children. In particular, children with acute appendicitis but normal leucocyte count and CRP level were sought. The present study protocol was identical to those used in earlier studies on adult patients with suspected acute appendicitis. The mean preoperative leucocyte count and CRP value in 100 consecutive children with an uninflamed appendix at appendicectomy (group A) and in 100 consecutive patients with acute appendicitis (group B) were calculated. The numbers of patients with (i) both values normal, (ii) only leucocyte count raised, (iii) only CRP level raised, and (iv) both values raised were calculated in both groups A and B. Leucocyte count effectively (p < 0.001) separated children with uninflamed appendix (mean +/- SEM 10.2 +/- 0.4 x 10(9) l(-1)) from those with acute appendicitis (15.0 +/- 0.4 x 10(9) l(-1)), but the CRP value was of no use in this respect (p = 0.866; 31 +/- 4 mg l(-1) and 30 +/- 4 mg l(-1)). The most conspicuous finding was that in children with acute appendicitis, both values were normal in 7 out of 100 patients. CONCLUSION Contrary to adult patients, normal leucocyte count and CRP value do not effectively exclude acute appendicitis in children.

Information and socioeconomic factors associated with early breastfeeding practices in rural and urban Morogoro, Tanzania.

Abstract: A cross-sectional study was undertaken in a rural and an urban area in Tanzania with the aim of identifying factors related to early infant feeding practices. The study included 320 mothers from each area with infants below 7 months of age. A significant proportion of both rural and urban mothers had erroneous beliefs about infant feeding practices. None of the socioeconomic demographic or biological variables studied were associated with feeding practices. Urban residence was positively associated with the duration of exclusive but not predominant breast-feeding. Better knowledge about specific breast-feeding issues was positively associated with the duration of both exclusive and predominant breast-feeding. Ownership of a radio was positively associated with both exclusive and predominant breast-feeding in the rural area. Although both rural and urban mothers had a high antenatal clinic attendance rate 65% of the rural and 14% of the urban mothers delivered at home. Urban mothers informed about breast-feeding at the antenatal clinic had better feeding practices. The authors hypothesize that exclusive breast-feeding is not a traditionally recognized practice and thus its duration is mainly associated with information and knowledge about breast-feeding. This suggests that information programs to provide knowledge beginning at antenatal visits may reduce premature complementation though additional support may also be required. (authors)

High prevalence of stress hyperglycaemia in children with febrile seizures and traumatic injuries

Abstract: UNLABELLED Although hyperglycaemia is relatively frequent in the course of severe illnesses and may be looked upon as the possible result of an uncoordinated insulin response to the increased glucose that the body may need during periods of stress, it is generally agreed that it does not constitute a prediabetic condition. Numerous studies have aimed to explain the pathophysiology of this occurrence but none has looked at which conditions are more prone to develop stress hyperglycaemia (SH). Therefore, the aim of this study was to evaluate the main clinical conditions that may be associated with SH in children. A total of 1199 children was studied: 833 children (439 M, 394 F, mean age 5.2 +/- 4.5 y) admitted for an acute illness or injury constituted the stress-exposed group, while 366 children (222 M, 144 F, mean age 6.2 +/- 4.6 y) admitted for elective minor surgery represented the stress-unexposed group and were considered as the control group. SH was defined as plasma glucose concentrations > or = 8.3 mmol l(-1) during an acute illness. Stress-exposed patients had significantly higher glycaemic levels than controls (5.6 +/- 1.4 vs 4.7 +/- 0.7 mmol l(-1); p 39 degrees C (14%) than in those with a temperature < or = 39 degrees C (4%; p < 0.0008). SH was more prevalent in clinical conditions of fever associated with seizures or pain (12.9% and 12.5%, respectively) than fever alone (4.4%). After a mean period of 3.5 +/- 0.6 y of follow-up none of the hyperglycaemic patients had developed diabetes mellitus. CONCLUSION Traumatic injuries, febrile seizures or conditions in which an elevated body temperature may be found are frequently associated with SH in children. In the presence of these conditions specific studies directed towards unmasking a prediabetic state may be unnecessary.

Current diagnosis, management and morbidity in paediatric inflammatory bowel disease

Abstract: UNLABELLED In the 1970s several reports highlighted the long delay in diagnosis often experienced by children with Crohn's disease. In recent years this disorder has attracted much publicity, and many believe that the incidence has increased substantially. The aim of this investigation was to determine whether heightened awareness had shortened the interval to diagnosis, improved clinical management and reduced morbidity. A retrospective study was therefore carried out on 112 children with inflammatory bowel disease (64 Crohn's disease, 41 ulcerative colitis, 7 indeterminate colitis) referred to a paediatric gastroenterology department in the UK between 1994 and 1998. In Crohn's disease the median interval to diagnosis was 47 wk (maximum 7 y). In those without diarrhoea this was longer (66 vs 28 wk; p = 0.005). In ulcerative colitis the median interval was 20 wk (maximum 3 y). Even in severe colitis the median interval was 5.5 wk (range 3-9 wk) and 4 required urgent colectomy soon after referral. Many with unrecognized Crohn's disease had undergone inappropriate treatments, such as growth hormone or psychiatric therapy. Nineteen (17%) had undergone endoscopic investigations in adult units prior to referral. Malnutrition was equally common in Crohn's disease and ulcerative colitis (11%). Short stature was present in 19% with Crohn's disease, and 5% with ulcerative colitis, and was severe in 8% with Crohn's disease. There was a significant correlation between symptom duration and the degree of growth impairment present (r(s) = -0.4; p = 0.004). CONCLUSION This study suggests that late diagnosis and inappropriate investigation and management are still significant problems.