Showing papers in "Archives of Disease in Childhood in 1979"

Food allergy Response to treatment with sodium cromoglycate

Abstract: Two children with food allergy could not be successfully managed on dietary restriction alone. There was a good response to treatment with oral sodium cromoglycate but none to placebo treatment. The use of sodium cromoglycate in the management of food allergy should be studied further.

Pulmonary hypoplasia: lung weight and radial alveolar count as criteria of diagnosis.

Abstract: A working definition of pulmonary hypoplasia (PH) was established by retrospective assessment of lung growth both in recognised and hypothetical PH-associated conditions. Lung weight: body weight ratios (LW:BW) were calculated, and morphometry was determined by the radial alveolar count (RAC) (Emery and Mithal, 1960). Both parameters were reduced compared with those of normal controls in diaphragmatic hernia, anencephalus, anuric renal anomalies, chondrodystrophies, and osteogenesis inperfecta. Comparison of LW:BW ratio and RAC indicated that the RAC was the more reliable criterion of PH, LW:BW ratio of less than or equal to 0.12 (67%) of mean normal ratio) and/or RAC of less than or equal to 4.1 (75% of mean normal count) are suggested as diagnostic criteria of PH. Evidence of PH was incidentally discovered in a number of clinically unsuspected cases and retrospectively clarified the clinical and radiological findings. Routine assessment of lung growth should be an essential part of the neonatal necropsy.

Foetus into Man: Physical Growth from Conception to Maturity

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Reflux and Renal Scarring

Abstract: some of the more important growing aspects of the diagnosis and management of congenital heart disease, and contributors from America and Europe were chosen for their special experience in the subjects covered. These of necessity tend to be rather restricted, so that the book in no way represents a comprehensive account of modern paediatric cardiological practice as its title might suggest. As with all international symposia, the standard of contributions is variable. There is an excellent account of the new terminology in congenital heart disease and its relevance to the precise diagnosis of complex lesions, using the method of sequential chamber localisation which the editors themselves have done so much to promote during the last few years. Likewise, the sections on ventricular septal defect, Fallot's tetralogy, and atrioventricular canal defects, contain interesting material which is well presented. In particular, Rudolph's introductory review of ventricular septal defect in infancy is a small masterpiece of clarity and concise organisation of essential information. However, in other parts of the book, especially where the subject matter is more abstruse, both text and format tend to suffer from an unfortunate degree of repetitiveness. The free discussion that follows each major section, and which is generally of a high standard, enhances the interest and understanding of each subject. Because of its specialised and selective content, this book cannot be recommended as a work of reference for undergraduates

The diagnosis of coeliac disease. A commentary on the current practices of members of the European Society for Paediatric Gastroenterology and Nutrition (ESPGAN).

Abstract: In 1977, 53 members of ESPGAN completed a questionnaire on their current practice in diagnosing coeliac disease. The usefulness of the 'Interlaken' criteria enumerated 9 years previously was reassessed. Details were obtained about the initial diagnostic approach, the acceptable histological criteria of the initial jejunal biopsy, and the timing, technique, response, and interpretation of early and late rechallenges with gluten. Answers indicated that, although the initial mucosal lesion is usually 'flat' at the time of diagnosis, a few infants may present at a time when the mucosal lesion is less completely damaged. Furthermore, the degree of histological change after gluten challenge that is acceptable as a positive response may vary according to the state of the mucosa before challenge. It was noted that there are still no generally agreed criteria by which the histological lesions may be described, so that (after further discussions at the Third International Coeliac Conference in Galway) a European panel has been set up to make recommendations. In the experience of ESPGAN members, most coeliac children will have a histological relapse within 2 years of reintroduction of gluten. But a small number of unorthodox cases were reported that suggest that (a) histological relapse may take longer than 2 years to appear, or (b) the degree of sensitivity to gluten may vary at different ages. Very long-term follow-up will be needed to explain these anomalies. Meanwhile the search continues for 'the basic defect'.

Current status of zinc in health and disease states

Abstract: Even though brass, a zinc-copper alloy, had been known for centuries, metallic zinc was not isolated in Europe until 1509. The metal was then named zinken because of its superficial similarity to tin (German-zinn) (Wootton, 1910). Zinc (atomic number 30; atomic weight 65 37) has a completed d subshell with 2 s electrons and the divalent cation is the only naturally occurring oxidation state. This relative stability, its ability to co-ordinate 4 or occasionally 6 ligands, and its capacity to act as a Lewis acid are probably fundamental to zinc's biological role. The biological importance of zinc was first discovered when Raulin (1869) demonstrated that it was necessary for the growth of Aspergillus niger. Subsequently, the ubiquitous distribution of zinc in nature was appreciated and the essentiality of zinc for higher plants (Maze, 1914) and animals (Todd et al., 1934) was established. In man the medicinal use of calamine (zinc carbonate) is first recorded in Papyrus Ebers of 1550 BC (Ebers, 1937) but it was not until 1939 that it was suggested that zinc deficiency might contribute to the clinical manifestations of human vitamin deficiency syndromes such as beriberi (Eggleton, 1939). The first human zinc deficiency syndrome was identified in the early 1960s in malnourished adolescent boys in Iran and Egypt (Halsted et al., 1972). A more profound deficiency state became apparent when Moyanhan and Barnes (1973) showed that treatment with zinc induced a complete and rapid clinical remission in a patient with acrodermatitis enteropathica.

The lungs in congenital bilateral renal agenesis and dysplasia.

Abstract: A detailed quantitative analysis was made of the lungs from 8 infants dying with bilateral renal agenesis or dysplasia. Total lung volume was reduced in all cases, particularly in those with renal agenesis. In both groups there was a reduction in number of airway generations, indicating interference with development at between 12 and 16 weeks' gestation. The alveoli in each acinus were reduced in size and, in some cases, number--although their stage of differentiation was normal for age--pointing to a disturbance of growth during later fetal life also. As liquor is largely non-renal in origin at least up to 16 weeks' gestation, it seems that there are factors other than the oligohydramnios interfering in early lung growth in these cases, such as reduced proline production by the kidney.

Water loss from the skin of term and preterm babies.

Abstract: Water loss from the skin of term and preterm babies, nursed naked in incubators under neutral thermal conditions, was measured by a method based on estimating the water vapour pressure gradient close to the skin surface. 199 sets of measurements were made on 78 babies whose gestational ages ranged from 26 to 41 weeks, during the first 4 weeks of life. Babies of 34 to 41 weeks' gestation had high water losses in the first 4 hours after birth, which then fell to low levels averaging 6 g/m2 per hour. Babies of 30 to 33 weeks' gestation had high water losses in the first week which then fell to levels similar to those of mature babies. Babies less than 30 weeks' gestation had strikingly high losses, averaging 32 g/m2 per hour in the first 4 days of life. At 2 weeks, levels were still higher than those of mature babies. Light-for-dates babies had skin water losses appropriate for their gestations. The high water losses in extremely preterm babies are probably transepidermal and the result of a thin, poorly keratinised stratum corneum. Water loss from the palms and soles was high in term babies and although low in preterm babies it rose steadily in the first 4 weeks of life. This is thought to represent the onset of emotional sweating. In terms of actual heat and water lost, skin water loss is relatively unimportant in term babies nursed naked under neutral thermal conditions. However, in babies less than 30 weeks' gestation, weighing less than 1 kg, skin water loss makes a major contribution to overall water balance. Furthermore, evaporative heat loss from the skin may exceed resting heat production. It is suggested that reduction of skin water loss in these babies may increase their chances of survival and their rates of growth.

Maturation of caffeine elimination in infancy.

Abstract: The developmental changes in caffeine elimination were studied in 7 infants aged between 2 1/2 weeks and 6 months. Adult plasma clearance rate of caffeine was achieved at 3 to 4 1/2 months of age. Plasma half-life and elimination rate reached adult levels after 3 to 4 1/2 months and seemed to exceed adult capacity thereafter. No significant changes in apparent volume of distribution were noted. Our data provide some indication of the age in infancy when the low rates of caffeine elimination in the neonate increase to the adult rate.

Rectal administration of diazepam in solution in the acute treatment of convulsions in infants and children.

Abstract: In a prospective study 44 children, aged 6 months to 5 years, admitted to hospital with febrile convulsions or epilepsy, were treated with diazepam in solution administered rectally during 59 generalised attacks. Rectal administration of diazepam was effective in the acute treatment of convulsions in 80% of cases. In 10% the treatment failed, whereas diazepam administered intravenously had prompt effect; another 10% of the convulsions wer resistant to diazepam, irrespective of the route of administration. The therapeutic effect was significantly correlated with the duration of convulsions before treatment started. Early treatment (convulsions less than or equal to 15 minutes) had effect in 96%, and late treatment (convulsions greater than 15 minutes) in 57% of cases. A total of 317 children admitted with febrile convulsions were treated prophylactically with diazepam administered rectally whenever the temperature was greater than or equal to 38.5 degrees C. No case of significant respiratory depression or other serious side effects was observed. The rapid and reliable anticonvulsant effect of diazepam given rectally and the very few side effects makes this treatment a valuable alternative to IV administration in childhood.

Role of viruses and bacteria in acute wheezy bronchitis in childhood: a study of sputum.

Abstract: Sputum, nasal swabs, and throat swabs were obtained from 22 children aged between 5 and 15 years during 72 attacks of wheezy bronchitis. A virus, most commonly a rhinovirus, was isolated in 49% of all episodes and in 64% of 22 severe episodes requiring treatment with corticosteroids; the isolation rate was higher early in the illness than later. Virus was recovered more often from sputum than from the nose or throat, suggesting that viral replication occurs freely in the lower respiratory tract: the cytological findings in sputum were compatible with an inflammatory response to viral infection. Pathogenic bacteria appeared to play a minor role compared with viruses, and routine antibiotic treatment was probably of little value in moost cases. The significance of the results is discussed in relation to the pathogenesis of childhood wheezy bronchitis.

Effect of puberty on rates of bone growth and mineralisation: with observations in male delayed puberty.

Abstract: The bone mineral content (BMC) and body height were measured in 301 normal children and adolescents aged 7--20 years, and in 8 boys with constitutional delayed puberty aged 14--17 years. Serum testosterone was measured in the last group as well as in a subpopulation of the normal children and adolescents. The growth spurt, which coincided with a steep increase of serum testosterone in boys, indicated a great change in skeletal growth and mineralisation in both sexes. After the growth spurt, linear growth slowed down considerably while bone mineralisation rose steeply. When low levels of serum testosterone were maintained, as in delayed puberty, these combined changes of skeletal growth and mineralisation did not occur. It is suggested that gonadal hormones are the true initiators of the short-lived growth spurt as well as of prolonged acceleration of bone mineralisation.

Mourning by the Family after a Stillbirth or Neonatal Death

Abstract: Failure of the parents to mourn after the sorrow of a stillbirth or neonatal death can result in dire consequences for the well-being of the family. Doctors and nurses should learn how to facilitate mourning and should accept the strange and sometimes bizarre forms this may take. When mourning is facilitated, the family is likely to adjust better to its bereavement.

Childhood asthma. A controlled trial of family psychotherapy.

Abstract: In an attempt to evaluate the effectiveness of family psychotherapy as an adjunct conventional treatment in childhood asthma, children with moderate to severe asthma were randomly allocated to a control group or to an experimental group; the latter group received 6 hours of family treatment during a 4-month period, and both groups had standard medical treatment. While there was no significant difference between the two groups on three parameters, the experimental group were significantly better in day-wheeze score and thoracic gas volume. These results suggest that family treatment in selected cases may have a place in the overall management of childhood asthma, and that more research with larger numbers of children is necessary.

Hearing loss in very low birthweight infants treated with neonatal intensive care.

Abstract: The hearing of 111 perinatal intensive care survivors of birthweights 1500 g or less was assessed at a mean age of 6 1/2 years (range 4--12). These 111 infants included 86% of the long-term survivors of this birthweight cared for in the newborn unit of University College Hospital, London, during the years 1966--72. All these infants were nursed in commercially available incubators for periods ranging from 2 to 80 days (mean 37) in which the mean noise threshold was 65 dB. Ten (9%) had sensory neural nearing losses, one (1%) infant had a congenital conductive hearing loss, and 21 (19%) infants had exudative otitis media with a mean loss of 25 dB. Apnoeic attacks in the neotal period were the most significant predictors of hearing loss in these infants (P less than 0.05) and an indirect serum filirubin level of at least 170 micromol/l (10 mg/100 ml) in the neonatal period had an additive effect (P less than 0.05). There was no evidence that ambient noise had affected the hearing of these very low birthweight infants.

Caffeine secretion into breast milk.

Abstract: Serum and milk concentrations of caffeine were measured in 5 breast-feeding mothers after a standardised oral dose of caffeine. Peak concentrations of caffeine in serum and milk were attained 60 minutes later. Binding of caffeine by constituents of serum and breast milk was low (25 and 3.2% respectively). In breast milk, caffeine binding is associated with the cream layer, and correlates with the butter fat content. Caffeine does not diffuse freely into breast milk and concentrations in milk are lower than in maternal serum.

Total parenteral nutrition in very low birthweight infants: a controlled trial.

Abstract: 34 preterm infants with birthweights <1200 g were randomly assigned to total parenteral nutrition (TPN) or oral (Milk) feeding regimens for the first 2 weeks after birth. Infants in the TPN group were started on a modified Vamin-based glucose amino-acid infusion and Intralipid. The daily amounts of carbohydrate, amino-acids, and fat infusions were increased. In the Milk group, infants were started on intermittent gavage feeding, supplemented with a glucose-electrolyte infusion as necessary. The overall mortality rate did not differ in the two groups. Four infants in the Milk group developed necrotising enterocolitis but none did in the TPN group. Despite mean daily energy intakes which were not greatly different, there were much higher mean daily intakes of carbohydrate and protein in the TPN group compared with the Milk group. Fat intake in the TPN group was lower than in the Milk group in the 1st week because of neonatal jaundice which contraindicated the use of Intralipid. There was no difference in the mean daily fat intake by the 2nd week. Although mean daily weight loss in the 1st week and the maximum postnatal weight loss in the two groups were similar, infants in the TPN group had a greater mean daily weight gain in the 2nd week and took less time to regain and maintain birthweight. Metabolic complications were equally common in both groups and were reversible with early recognition. Limits of tolerance for water and most nutrients tended to be variable and the nutritional programme had to be adjusted for each baby. Nevertheless, we found that TPN, when properly managed, is an effective and safe procedure in very low birthweight infants.

Role of viruses in febrile convulsions.

Abstract: A disseminated viral illness was demonstrated by isolating a virus from the CSF, blood or urine in 27% of 73 children who were admitted to hospital after a first febrile convulsion. However, a viral aetiology could be implicated for 86% of the children after combining results of tissue culture, electron microscopy, mouse inoculation, complement fixation tests, and interferon assay. Parallel bacterial cultures showed a possible pathogen in 29% of children, but in only 4% was the pathogen isolated from the CSF, blood, or urine. No correlation was found between the nature of the pathogen (or evidence of its dissemination) and the severity of the convulsion, degree of fever, CSF protein, CSF white cells, or the WBC. The results suggest that a febrile convulsion could be a response to invasion of the blood stream or central nervous system by a micro-organism which is usually a virus. Invasion may be of such brief duration that successful isolation of the virus from the blood, CSF, or urine in not more commonly achieved.

A year's experience of the rotavirus syndrome and its association with respiratory illness.

Abstract: In a hospital study rotavirus was identified in 51% of 152 children with diarrhoea. These patients showed a clinical pattern that was distinct from patients in whom the diarrhoea was associated with bacteria, other viruses, or no pathogens. A respiratory illness was described in 66% of rotavirus patients and usually preceded the gastrointestinal symptoms. Vomiting lasted between one and 3 days and was curtailed by substituting the normal diet with clear fluids. Watery diarrhoes continued for 4 or 5 days, even when rehydration was by the intravenous rather than the oral route. Prolonged diarrhoea was rare. Most children infected with rotavirus were under 2 years of age, but dehydration was most severe in infants aged between 12 and 18 months. A clinician can thus recognise the rotavirus syndrome and expect spontaneous recovery if adequate rehydration is maintained for a critical few days.

Clinical events relating to intraventricular haemorrhage in the newborn.

Abstract: Continuous measurements of arterial pressures, heart rates, respiratory movements, and respiratory rates were made from birth in 44 infants at risk from intraventricular haemorrhage (IVH). 17 babies died with IVH, in 10 of whom the event was timed objectively. Events in these babies were compared with survivors of similar birthweights, gestational ages, severity of birth asphyxia, and severity of hyaline membrane disease (HMD). IVH followed severe HMD and was associated with cessation of the babies' own respiratory efforts while on a ventilator and also with characteristic cardiorespiratory events. The minimum arterial pressure before IVH was lower than in comparable babies who survived. It is suggested that fluctuations of systemic blood pressure from initial low levels may be important in the pathogenesis of IVH. It is possible that changes in cerebral blood flow are of even greater significance.

Absorption of chlorhexidine from the intact skin of newborn infants.

Abstract: 34 newborn infants who had been bathed in a standard manner with Hibiscrub were studied to find out whether it was absorbed percutaneously. Low levels of chlorhexidine were found in the blood of all 10 babies sampled by heel prick, and 5 of 24 from whom venous blood was taken. The detection of chlorhexidine varied greatly with the method and timing of sampling, and no correlation was found between gestational or postnatal age and chlorhexidine levels.

Mycoplasma pneuminia infection. A follow-up study of 50 children with respiratory illness.

Abstract: Fifty children with a previous history of Mycoplasma pneumoniae respiratory tract infection were assessed clinically, and pulmonary function tests carried out after an interval ranging from 1 1/2 to 9 1/2 years (median 2 1/2). 23 suffered from recurrent wheezy bronchitis or asthma, and in 5 the index illness appeared to precipitate the wheezing tendency. All were symptom-free when respiratory function tests were performed. Simple tests of ventilatory function (PEFR, FEV, and FVC) were within normal limits. Increased bronchial reactivity after exercise (a fall in PEFR greater than 15% resting value) was demonstrated only in children known to have asthma. Maximum expiratory flow rates in air at 50% of vital capacity (V mas50) were within the normal range in all patients with the exception of two. The response in flow rate at 50% of vital capacity after inalation of an 80% helium and 20% oxygen mixture delta V max50) was reduced (P less than 0.001) in asymptomatic patients with a history of M. pneumoniae respiratory infection, when compared with normal data from 48 healthy schoolchildren without a background of significant respiratory illnesses. These findings indicate impairment of small airways function, even in totally symptom-free children in the study group.

Frequency and weight of normal stools in infancy.

Abstract: These data give a guide to the range of stool weights and their frequency at different ages in infancy. The constancy of stool water content is emphasised.

Intellectual performance in children after circulatory arrest with profound hypothermia in infancy.

Abstract: 38 children were assessed 22 months to 6 years after open heart surgery using circulatory arrest with deep hypothermia. The mean IQ of the group was 99.2 (SD 19.5). No correlation was found between IQ and the age or weight at operation or the duration of circulatory arrest. The results suggest that the technique gives effective protection to the brain during periods of circulatory arrest for up to 60 minutes.

Nutritional status of light-for-date infants at birth and its influence on early postnatal growth.

Abstract: The ponderal index (PI) (g/cm3 X 100) was used to define the state of nutrition at birth of 47 light-for-date (LFD) term infants and to determine how intrauterine undernutrition influences growth during the first 6 months of postnatal life, at four age intervals: birth--4, 5--8, 9--12, 13--26 weeks. With the exception of one baby, each PI was less than 50th centile on the Miller and Hassanein standards: in 24 (51%) babies the PI was less than 3rd centile. This suggests that, generally, LFD infants are underweight for length, and by inference, are likely to have experienced intrauterine undernutrition. In the first month the 24 'wasted' infants (PI less than 3rd centile) gained more rapidly in weight, and grew more quickly in head circumference and length than the 16 'nonwasted' infants (PI greater than 10th centile). Thereafter growth rates were similar. With the exception of weight in the 'nonwasted' infants during the first month, rates of growth (weight, length, and head circumference) in both groups of babies in each of the 3 months after birth were greater than in normal infants. The first 3 months after birth can therefore be defined as the period of 'catch-up' growth in LFD term infants.

Recognition and management of children with increased lead absorption.

Abstract: Childhood lead poisoning has been increasingly recognised in the USA where large-scale screening programmes detect some 40 000 cases of undue lead absorption a year. This contrasts with data from the UK where about 100 cases are recognised each year. The situation in other countries is largely unknown, although small surveys have revealed cases from a wide variety of sources. These apparent discrepancies probably reflect differences in clinical awareness, the availability of practical screening tests, and differences in the definition of acceptable degrees of exposure. Within the last few years practical and effective screening tests for the early detection of undue lead absorption have been developed, but these have not been generally introduced. They include the determination of lead and erythrocyte protoporphyrin (FEP) in microlitre samples of blood. These tests have provided evidence of undue lead absorption from previously unrecognised sources. Thus, dusts contaminated with lead derived from atmospheric deposition, industrial clothing, and degradation of paint films, have now been shown to be important contributory factors. Many children thus affected are asymptomatic, and classical childhood plumbism and encephalopathy at present are rare. The identification of asymptomatic children has as its objective the institution of effective management in order to prevent serious poisoning and its consequences, and to diminish the potential risks of prolonged low level overexposure. While these risks have not been conclusively demonstrated, it has nevertheless been suggested that subtle neural and behavioural impairments may occur. Moreover, the existence of some children in the population with

Congenital complete heart block in the newborn associated with maternal systemic lupus erythematosus and other connective tissue disorders.

Abstract: Four babies with complete heart block associated with maternal systemic lupus erythematosus (SLE) are described, together with a 5th baby whose mother had serological abnormalities only. One baby had a rapidly fatal outcome, one has required digoxin for heart failure, and the remaining 3 are asymptomatic but remain in complete heart block. Additional manifestations were present in 2 of them. The spectrum of neonatal abnormalities that may occur in association with maternal SLE and related connective tissue disorders is discussed, together with the possible causes and the prognosis. We conclude that congenital heart block is more common than had previously been appreciated.

Factors affecting neonatal jaundice

Abstract: Plasma bilirubin was estimated on 690 term infants on about the 6th day of life. Perinatal factors were recorded and the results analysed. Hyperbilirubinaemia was defined as a level greater than 205 micromol/1 (12 mg/100 ml) and this was present in 20% of cases. Three factors--epidural analgesia, breast feeding, and poor weight recovery--showed highly significant associations with jaundice. The relative importance of these is discussed and compared with recent reports. Induction of labour, for reasons other than postmaturity, and a gestational age less than 39 weeks showed a slightly increased incidence of jaundice. There was no correlation with other factors tested including oxytocic drug administration. Despite the high incidence (20%) of hyperbilirubinaemia, only 2.5% infants needed treatment and none required exchange transfusion. Radical changes in obstetric management or infant feeding are not indicated.

Persistent pulmonary hypertension and abnormal prostaglandin E levels in preterm infants after maternal treatment with naproxen.

Abstract: Twins and a singleton were born at 30 weeks' gestation although naproxen (d-2 (6'methoxy-2-naphthyl) propionic acid) had been given to the mothers in an attempt to delay parturition. Inhibition of prostaglandin synthesis was shown by very low plasma concentrations of prostaglandin E and the ductus arteriosus remained closed despite signs of pulmonary hypertension with severe hypoxaemia. Abnormalities in blood clotting, renal function, and bilirubin metabolism were also found and one infant died. Further studies of the benefits and risks of the inhibition of prostaglandin synthesis are required before this treatment of preterm labour is accepted.

New technique for servo-control of arterial oxygen tension in preterm infants.

Abstract: Equipment has been developed for the servo-control of arterial oxygen tension in sick, newborn babies. Using an indwelling umbilical arterial oxygen electrode as sensor, the equipment successfully regulated the administration of oxygen to 12 newborn babies with respiratory distress syndrome, significantly improving the stability of arterial oxygen tension and lessening the duration of episodes of hypoxia and hyperoxia.