Showing papers in "Archives of Disease in Childhood in 1996"

Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.

Abstract: A two year prospective study was performed to determine the epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation in the UK and the Republic of Ireland. Cases were notified to the British Paediatric Association Surveillance Unit from September 1992 to August 1994 if a formal case conference had been held for the first time during that period to discuss any of the above conditions. A total of 128 cases were identified: 55 suffered Munchausen syndrome by proxy alone, 15 poisoning, and 15 suffocation; 43 suffered more than one type of abuse. The majority of children were aged under 5 years, the median age being 20 months. On 85% of occasions the perpetrator was the child's mother. In 42% of families with more than one child, a sibling had previously suffered some form of abuse. Eighty five per cent of notifying paediatricians considered the probability of their diagnosis as virtually certain before a case conference was convened. The commonest drugs used to poison were anticonvulsants; opiates were the second commonest. Sixty eight children suffered severe illness of whom eight died. The combined annual incidence of these conditions in children aged under 16 years is at least 0.5/100,000, and for children aged under 1, at least 2.8/100,000.

Exhaled nitric oxide in paediatric asthma and cystic fibrosis.

Abstract: Nitric oxide (NO) is present in exhaled air of humans. This NO is mostly produced in the upper airways, whereas basal NO excretion in the lower airways is low. Children with Kartagener's syndrome have an almost total lack of NO in nasally derived air, whereas adult asthmatics have increased NO in orally exhaled air. NO excretion was measured in the nasal cavity and in orally exhaled air in 19 healthy children, in 36 age matched subjects with asthma, and in eight children with cystic fibrosis. NO levels in orally exhaled air were similar in controls and in children with cystic fibrosis, at 4.8 (SD 1.2) v 5.8 (0.8) parts per billion (ppb), but were increased in asthmatic children who were untreated or were being treated only with low doses of inhaled steroids (13.8 (2.5) ppb). Nasal NO levels were reduced by about 70% in children with cystic fibrosis compared to controls and asthmatics. Measurements of airway NO release in different parts of the airways may be useful in non-invasive diagnosis and monitoring of inflammatory airway diseases.

Reduced upper airway nitric oxide in cystic fibrosis.

Abstract: Nitric oxide (NO) produced within the respiratory tract is detectable in exhaled and nasal air. Its synthesis may be induced by inflammatory cytokines and reduced by glucocorticoids. Increased concentrations have been found in asthma and bronchiectasis. In this study, NO concentrations were determined in 63 children with cystic fibrosis, of whom 13 were on inhaled steroids (mean age 13.3 years) and 50 were not (mean age 12.3 years); 57 normal children (mean age 12.2 years) were also studied. NO was measured by chemiluminescence analyser, exhaled NO following a relaxed vital capacity manoeuvre, and nasal NO with the breath held following a full inspiration. Mean concentration of exhaled NO in cystic fibrosis patients (no steroids) was 4.7 parts per billion (ppb) (95% confidence interval (CI) 4.0 to 5.3); this did not differ from values in normal children (mean 4.8 ppb, 95% CI 3.8 to 5.8) or in cystic fibrosis patients on inhaled steroids (mean 3.6 ppb, 95% CI 2.5 to 4.8). Nasal concentrations were significantly lower in cystic fibrosis patients, with or without inhaled steroids, than in normal children (cystic fibrosis, no inhaled steroids: 460 ppb, 95% CI 399 to 520; cystic fibrosis, inhaled steroids: 522 ppb, 95% CI 313 to 730, v normal children: 1024 ppb, 95% CI 896 to 1152, p < 0.0001). Considering the inflammatory nature of cystic fibrosis, it is surprising exhaled NO levels were not increased, but this may have been due to alteration in NO diffusion through thick mucus. The low nasal NO concentrations, which are probably the result of impaired flow from the paranasal sinuses, may contribute to the recurrent respiratory infections typical of cystic fibrosis.

Family structure, neonatal infection, and hay fever in adolescence.

Abstract: OBJECTIVE: To determine whether increased numbers of siblings and infection in early life protect against allergic sensitisation DESIGN: Historical cohort study SETTING: Sheffield, UK SUBJECTS: 11,765 children aged 11-16 years for whom a history of neonatal infectious illness had been recorded systematically at 1 month of age METHODS: A history of hay fever and family structure was obtained by postal questionnaire; neonatal illness history was ascertained from health visitor records; 723 children underwent skin prick testing with mixed grass pollen extract RESULTS: The prevalence of hay fever was reduced (p < 00001) among children of younger mothers, and those from larger families The number of older siblings exerted a stronger independent effect than the number of younger siblings (p < 0001) Infants breast fed exclusively during the first month were at higher risk (p < 005) of subsequent hay fever, independent of demographic factors Adolescents at high risk of hay fever by virtue of their family structure were more likely to be sensitised to grass pollen (p < 0002) No significant relations emerged between hay fever and infection in the first month of life, even among children born in June CONCLUSIONS: The association of hay fever with family structure is not due to reporting bias and reflects an environmental influence on allergic sensitisation The effects of sibship size, birth order, and infant feeding are consistent with a protective influence of postnatal infection The first month of life and the first postnatal exposure to allergen are not the critical periods during which this protective effect is determined

Parental and neonatal risk factors for atopy, airway hyper-responsiveness, and asthma.

Abstract: BACKGROUND: Previous studies have not resolved the importance of several potential risk factors for the development of childhood atopy, airway hyperresponsiveness, and wheezing, which would allow the rational selection of interventions to reduce morbidity from asthma. Risk factors for these disorders were examined in a birth cohort of 1037 New Zealand children. METHODS: Responses to questions on respiratory symptoms and measurements of lung function and airway responsiveness were obtained every two to three years throughout childhood and adolescence, with over 85% cohort retention at age 18 years. Atopy was determined by skin prick tests at age 13 years. Relations between parental and neonatal factors, the development of atopy, and features of asthma were determined by comparison of proportions and logistic regression. RESULTS: Male sex was a significant independent predictor for atopy, airway hyper-responsiveness, hay fever, and asthma. A positive family history, especially maternal, of asthma strongly predicted childhood atopy, airway hyperresponsiveness, asthma, and hay fever. Maternal smoking in the last trimester was correlated with the onset of childhood asthma by the age of 1 year. Birth in the winter season increased the risk of sensitisation to cats. Among those with a parental history of asthma or hay fever, birth in autumn and winter also increased the risk of sensitisation to house dust mites. The number of siblings, position in the family, socioeconomic status, and birth weight were not consistently predictive of any characteristic of asthma. CONCLUSIONS: Male sex, parental atopy, and maternal smoking during pregnancy are risk factors for asthma in young children. Children born in winter exhibit a greater prevalence of sensitisation to cats and house dust mites. These data suggest possible areas for intervention in children at risk because of parental atopy.

The epidemiology of paediatric inflammatory bowel disease.

Abstract: A retrospective study of the incidence and prevalence of paediatric inflammatory bowel disease over an 11 year period was undertaken in South Glamorgan. Over this time the incidence of Crohn's disease more than doubled from 1.30 cases per 100,000 childhood population per year in the period 1983-1988, to 3.11 cases per 100,000 population per year in the period 1989-1993. In contrast, the incidence of ulcerative colitis remained the same throughout the study period at 0.71 per 100,000 per year. In 1993 the prevalence of Crohn's disease in the childhood population was 16.6 per 100,000 and of ulcerative colitis, 3.42 per 100,000.

Prevalence and severity of asthma, rhinitis, and eczema in Singapore schoolchildren.

Abstract: This study was part of an international effort to evaluate the epidemiology of asthma and allergic diseases around the world. The aim was to assess the prevalence and severity of these disorders in Singapore schoolchildren. The international study of asthma and allergies in childhood (ISAAC) written questionnaire was administered to 6238 schoolchildren. The respondents were parents of a 6-7 year cohort (n = 2030), and schoolchildren aged 12-15 years (n = 4208). The overall cumulative and 12 month prevalence of wheezing were 22% and 12%, respectively. The prevalence of doctor diagnosed asthma was 20%. Rhinitis was reported by 44% and chronic rashes by 12%. Multiple logistic regression analysis showed that a higher prevalence of wheezing and rhinitis was associated with males, and subjects of higher socioeconomic status (based on type of housing and total family income). More severe asthma related symptoms were present in Malays and Indians than in the Chinese. Allergic disorders are common in Singapore and prevalence is comparable to some populations in the West. Demographic and socioeconomic factors appear to influence the prevalence and severity of these disorders.

Outcome of children born to epileptic mothers treated with carbamazepine during pregnancy.

Abstract: AIM: The purpose of the study was to assess whether there was an increased rate of congenital anomalies or significant developmental delay in infants of women with epilepsy who had been treated with carbamazepine during pregnancy. METHODS: 47 children were studied, aged 6 months-6 years, who were born to 37 epileptic mothers on carbamazepine monotherapy (group A). All children had a complete physical and neurodevelopmental assessment by a developmental paediatrician, and 41 a complete psychological evaluation. They were compared with 47 children of similar socioeconomic status (group B). RESULTS: Six of the 47 children in group A had typical facial features of 'carbamazepine syndrome'. The average cognitive score of children in group A was significantly lower than in group B. This was mainly because all six children with carbamazepine syndrome had a development quotient or intelligence quotient below 90. There were no differences between the two groups in physical growth or in the rate of major anomalies. Two children in group A had cleft palate but in each case this was found in a parent as well. CONCLUSIONS: In utero exposure to carbamazepine may result in 'carbamazepine syndrome' characterised by facial dysmorphic features and mild mental retardation. Prevalence of carbamazepine syndrome does not seem to be related to the dose of carbamazepine or the presence of maternal convulsions. It may depend upon heredofamilial factors that have yet to be defined. One possible factor is decreased activity of the enzyme epoxide hydrolase with resulting increased concentrations of carbamazepine epoxide which may be teratogenic.

Growth and endocrine sequelae of craniopharyngioma.

Abstract: The growth and endocrine sequelae of 75 children (33 girls and 42 boys) with craniopharyngioma, treated from 1973 to 1994, were studied by retrospective review and by follow up assessment in 66 survivors, with a mean time from initial surgery of 6.7 years (range 1.5 to 19.8 years). Although infrequently complained of, 71% of patients had symptoms to suggest an endocrinopathy at diagnosis. After surgery, multiple endocrinopathies were almost universal, such that 75% of children had panhypopituitarism at follow up. Hypoadrenal crises in association with intercurrent illness contributed significantly to morbidity and mortality, as did the metabolic consequences of concomitant antidiuretic hormone (ADH) insufficiency and absent thirst. Final height in 25 patients was significantly below genetic target height, particularly in the girls, with loss of height potential occurring during the pubertal years. The endocrine morbidity associated with craniopharyngioma and its treatment remains high but manageable with appropriate hormone replacement. However, the combination of ADH insufficiency and an impaired sense of thirst following aggressive surgery and severe hypothalamic injury remains one of the most complex management problems.

Pain, quality of life, and coping in sickle cell disease.

Abstract: This study examined the frequency and severity of sickle related pain, its impact on quality of life, and methods of coping for 25 children with sickle cell disease, aged 6-16 years. Subjects were matched with non-affected peers and asked to complete the Central Middlesex Hospital Children's Health Diary for four weeks. Results indicated that sickle pain occurred on average one in 14 days, and total summary pain scores indicated significantly greater pain than for controls. Children with sickle cell disease could discriminate sickle pain and did not adopt sick role responses to ordinary childhood ailments. Nearly all sickle pain was dealt with at home. Sickle pain resulted in over seven times increased risk of not attending school and was highly disruptive of social and recreational activities. Careful assessment of sickle pain in the home environment is an essential part of a community focused pain management service, which effectively supports children's resilience and improves their quality of life.

Impact of age and drug resistance on mortality in typhoid fever.

Abstract: The risk factors for mortality were analysed in a consecutive group of 1158 children presenting to the Aga Khan University Medical Center, Karachi, with multidrug resistant typhoid fever that had been proved on culture. There were 19 deaths, representing an overall case fatality rate of 1.6%. Multidrug resistant typhoid was associated with a more severe clinical illness and higher rates of toxicity, hepatomegaly, hypotensive shock, and death. Irrespective of drug resistance status, typhoid fever was found to be a more severe illness in young infants with significantly higher rates of diarrhoea, hypotensive shock, and mortality. Univariate analysis of admission characteristics associated with increased risk for mortality revealed significant association with younger age (p < 0.05), hypotensive shock or hypothermia (p < 0.001), obtundation (p < 0.001), seizures (p < 0.05), anaemia at admission (p < 0.005), and leucocytosis (p < 0.001). Logistic regression analysis of risk factors for mortality showed persistent association of hypothermia, toxicity, and anaemia with mortality. The data provides evidence that multidrug resistant typhoid in childhood is associated with increased risk of mortality, especially in infancy and closer attention to several risk factors for increased morbidity and case fatality rates may lead to improved outcome of treatment.

3-Phosphoglycerate dehydrogenase deficiency: an inborn error of serine biosynthesis.

Abstract: Serine concentrations were markedly decreased in the cerebrospinal fluid of two brothers with congenital microcephaly, profound psychomotor retardation, hypertonia, epilepsy, growth retardation, and hypogonadism. The youngest boy also had congenital bilateral cataract. Magnetic resonance imaging of the brain showed evidence of dysmyelination. Plasma serine as well as plasma and cerebrospinal fluid glycine concentrations were also decreased but to a lesser extent. Treatment with oral serine in the youngest patient significantly increased cerebrospinal fluid serine and abolished the convulsions. In fibroblasts of both patients, a decreased activity was demonstrated of 3-phosphoglycerate dehydrogenase, the first step of serine biosynthesis (22% and 13% of the mean control value). This is an unusual disorder as the great majority of aminoacidopathies are catabolic defects. It is a severe but potentially treatable inborn error of metabolism that has not been previously reported in man.

Final height in central precocious puberty after long term treatment with a slow release GnRH agonist.

Abstract: OBJECTIVE: To study the resumption of puberty and the final height achieved in children with central precocious puberty (CPP) treated with the GnRH agonist triptorelin. PATIENTS: 31 girls and five boys with CPP who were treated with triptorelin 3.75 mg intramuscularly every four weeks. Girls were treated for a mean (SD) of 3.4 (1.0) years and were followed up for 4.0 (1.2) years after the treatment was stopped. RESULTS: The rate of bone maturation decreased during treatment and the predicted adult height increased from 158.2 (7.4) cm to 163.9 (7.5) cm at the end of treatment (p < 0.001). When treatment was stopped bone maturation accelerated, resulting in a final height of 161.6 (7.0) cm, which was higher than the predicted adult height at the start of treatment (p < 0.001). Height at the start of treatment was the most important factor positively influencing final height (r = 0.75, p < 0.001). Bone age at cessation of treatment negatively influenced final height (r = -0.52, p = 0.03). A negative correlation between bone age and height increment after discontinuation of treatment was observed (r = -0.85, p = 0.001). Residual growth capacity was optimal when bone age on cessation of treatment was 12 to 12.5 years. Body mass index increased during treatment and remained high on cessation. At final height, the ratio of sitting height to subischial leg length was normal. Menarche occurred at 12.3 (1.1) years, and at a median (range) of 1.1 (0.4 to 2.6) years after treatment was stopped. The ovaries were normal on pelvic ultrasonography. CONCLUSIONS: Treatment of CPP with triptorelin increases final height, with normal body proportions, and seems to increase body mass index. The best results were achieved in girls who were taller at the start of treatment. Puberty was resumed after treatment, without the occurrence of polycystic ovaries.

Estimation of the age of bruising.

Abstract: Paediatricians are often requested to give an opinion on the age of a non-accidental bruise. In forensic textbooks, the colour changes which a bruise undergoes with time are not based on research in children. The purpose of this study was to document the sequence of colour changes in photographs taken following accidental bruising in children. Fifty accidental bruises of known age in 23 children were photographed by a medical photographer using the same equipment throughout. The photographs were reviewed by a single observer, blind to the true age of the injury, who described the colours present in the bruise. Red colouration was seen in 15 out of 37 bruises which were less than one week old. Yellow colouration was seen in 10 out of 42 bruises over one day old. Aging of bruises from photographs was much less precise than textbooks imply.

How much coughing is normal

Abstract: A new multiparametric device (RBC-7) was used for recording cough in ambulatory children over a 24 hour period. The number of coughs and the pattern of coughing can easily be studied with the aid of a personal computer and dedicated computer software. Forty one 'normal' children were recorded, identified from a primary school with the aid of a questionnaire. They were free from any respiratory infection for one month, and had a normal examination and spirometry immediately before recording. Cough frequency was 11.3, range 1 to 34, cough episodes per 24 hours. This was unaffected by passive smoking or the presence of furry pets in the home. Nocturnal and prolonged coughing was unusual in these children. The device was highly acceptable to the children, and no adverse effects were reported. Such objective data on cough outside the laboratory setting are unique, help to determine what is normal, and may help in the diagnosis and assessment of many respiratory diseases.

Placental weight, birth measurements, and blood pressure at age 8 years.

Abstract: OBJECTIVE: To examine relationships between blood pressure during childhood and both placental weight and body size at birth, in an Australian population. DESIGN: A follow up study of a birth cohort, undertaken when cohort members were aged 8 years. SETTING: Adelaide, South Australia. SUBJECTS: 830 children born in the Queen Victoria Hospital in Adelaide, South Australia, during 1975-6. MAIN OUTCOME MEASURES: Systolic and diastolic blood pressure measured when the children were aged 8 years. RESULTS: Blood pressure at 8 years was positively related to placental weight and inversely related to birth weight, after adjusting for the child's current weight. For diastolic pressure there was a decrease of 1.0 mm Hg for each 1 kg increase in birth weight (95% confidence interval (CI) = -0.4 to 2.4) and an increase of 0.7 mm Hg for each 100 g increase in placental weight (95% CI = 0.1 to 1.3). Diastolic pressure was also inversely related to chest circumference at birth, independently of placental weight, with a decrease of 0.3 mm Hg for each 1 cm increase in chest circumference (95% CI = 0.2 to 0.5). CONCLUSIONS: These findings are further evidence that birth characteristics, indicative of fetal growth patterns, are related to blood pressure in later life.

Respiratory health in a total very low birthweight cohort and their classroom controls.

Abstract: AIMS: To compare the respiratory health and function at 8 to 9 years of age of a total population based cohort of 300 very low birthweight (VLBW) children with that of two classroom controls (n = 590) matched for age and sex. STUDY DESIGN: Cohort study with controls. SETTING: Schools throughout Scotland. RESULTS: The VLBW children were more likely than their peers to use an inhaler, to be absent from school, and to be admitted to hospital because of respiratory illness. They were significantly shorter than their classroom controls, but even after adjusting for differences in height, the VLBW children had reduced forced vital capacity (FVC); this was associated with a history of prolonged ventilation (> 28 days) and pneumothorax in the neonatal period. There were no significant differences between the groups in forced expiratory volume in one second (FEV1)/FVC but twice as many (7.9% v 3.7%) of the VLBW children had ratios 40% oxygen. Exercise induced airway narrowing was increased in VLBW children (odds ratio = 2.0; 95% confidence interval 1.2 to 3.4) and was very little changed by adjustment for inhaler use and exposure to cigarette smoke. CONCLUSIONS: As in other low birthweight cohorts, respiratory morbidity was increased. Unlike previous studies, FVC was more affected than expiratory function in this VLBW population. Our findings support the hypothesis that poorer lung function is associated with very low birth weight, but not with intrauterine growth retardation.

Ketoacidosis at the diagnosis of type 1 (insulin dependent) diabetes mellitus is related to poor residual beta cell function. Childhood Diabetes in Finland Study Group.

Abstract: The determinants of the degree of metabolic decompensation at the diagnosis of type 1 (insulin dependent) diabetes mellitus (IDDM) and the possible role of diabetic ketoacidosis in the preservation and recovery of residual beta cell function were examined in 745 Finnish children and adolescents. Children younger than 2 years or older than 10 years of age were found to be more susceptible to diabetic ketoacidosis than children between 2 and 10 years of age ( 10 years: 33.3%). Children from families with poor parental educational level had ketoacidosis more often than those from families with high parental educational level (24.4% v 16.9%). A serum C peptide concentration of 0.10 nmol/l or more was associated with a favourable metabolic situation. Low serum C peptide concentrations, high requirement of exogenous insulin, low prevalence of remission, and high glycated haemoglobin concentrations were observed during the follow up in the group of probands having diabetic ketoacidosis at the diagnosis of IDDM. Thus diabetic ketoacidosis at diagnosis is related to a decreased capacity for beta cell recovery after the clinical manifestation of IDDM in children.

Why are brain tumours still being missed

Abstract: The prediagnosis period of 74 children with primary brain tumours was assessed to examine their presentation and reasons for any delay in diagnosis. Medical case notes were reviewed and parents were interviewed and asked to complete psychological questionnaires. Mean (SD) duration of clinical history was 20.0 (29.1) weeks. Most common symptoms were vomiting (65%) and headache (64%). Only 34% of headaches were always associated with vomiting and only 28% occurred 'early morning'. Changes in the child's personality (47%) were also common. The average number of consultations before diagnosis was 4.6. Migraine was diagnosed in 24% of children and a psychological aetiology in 15%. One quarter of the children had altered levels of consciousness on arrival at the unit. Results indicate that delay in diagnosis still occurs, despite strong parental concern. The nonspecificity of symptoms and a high incidence of psychological symptoms may confound the clinical picture and are considered along with other possible contributory factors.

Natural history and treatment effects in Guillain-Barré syndrome: a multicentre study.

Abstract: A retrospective multicentre study was performed to investigate the natural history and treatment effects in childhood Guillain-Barre syndrome in a large number of patients. Structured questionnaires were sent to 155 paediatric hospitals for details of patients who conformed to internationally accepted diagnostic criteria and who were treated from spring 1989 to summer 1994. Sixty nine hospitals reported data of 175 patients aged 11 months to 17.7 years. At the height of the disease 26% of the patients remained able to walk, but 16% had to be artificially ventilated. The median time from onset of symptoms to first recovery was 17 days, to walk unaided 37 days, and to be free of symptoms 66 days. There was a large group with a benign and a smaller one with a more protracted course. At long term follow up, 98/106 patients were free of symptoms and the remainder were able to walk unaided. Maximum disability grade was the most powerful prognostic factor. In children unable to walk but not yet tetraplegic, immunoglobulins were able to accelerate recovery. Corticosteroids were less potent. Plasmapheresis could not be evaluated because it was administered only in the most severe cases. The natural history of Guillain-Barre syndrome in children is extremely variable and more benign than in adults. Treatment with immunoglobulins should be considered in patients unable to walk. Corticosteroids are not as effective and should be withheld except when, in protracted courses, suspicion of chronic inflammatory demyelinating polyneuropathy arises.

Primary vesicoureteric reflux--how useful is postnatal ultrasound?

Abstract: The presence or absence of pelvicalyceal dilatation on postnatal ultrasound continues to appear within diagnostic algorithms to select patients for micturating cystourethrography (MCU) in the investigation of antenatally diagnosed hydronephrosis. Postnatal ultrasound findings were assessed in a population diagnosed as having antenatal hydronephrosis due solely to primary vesicoureteric reflux (VUR) to see whether this is justified. The postnatal ultrasound and MCU findings in 177 patients with primary VUR detected as antenatal hydronephrosis were reviewed retrospectively. A total of 132 (75%) were boys. Reflux was unilateral in 103 cases and bilateral in 74 (42%). Altogether 37% of boys and 33% of girls with a renal pelvic diameter of < or = 10 mm had grade III-V VUR. Calyceal and/or ureteric dilatation had specificities of 87-96% for grade III-V VUR, but sensitivities of only 37-54%. Fifty eight per cent of male and 75% of female renal units with grade III VUR and 17% of male units with grade IV-V VUR were normal on ultrasound. Approximately 25% of ultrasonically normal renal units had grade III-V VUR on MCU. Postnatal ultrasound criteria correlate poorly with the presence and degree of VUR in children with antenatally diagnosed hydronephrosis and should not be used to direct the use of cystography.

Randomised trial of biofeedback training for encopresis.

Abstract: AIMS: To evaluate biofeedback training in children with encopresis and the effect on psychosocial function DESIGN: Prospective controlled randomised study PATIENT INTERVENTIONS: A multimodal treatment of six weeks Children were randomised into two groups Each group received dietary and toilet advice, enemas, oral laxatives, and anorectal manometry One group also received five biofeedback training sessions MAIN OUTCOME MEASURES: Successful treatment was defined as less than two episodes of encopresis, regular bowel movements, and no laxatives Psychosocial function after treatment was assessed using the Child Behaviour Checklist RESULTS: Children given laxatives and biofeedback training had higher success rates than those who received laxatives alone (39% v 19%) at the end of the intervention period At 12 and 18 months, however, approximately 50% of children in each group were successfully treated Abnormal behaviour scores were initially observed in 35% of children Most children had improved behaviour scores six months after treatment Children with an initial abnormal behaviour score who were successfully treated had a significant improvement in their behavioural profiles CONCLUSIONS: Biofeedback training had no additional effect on the success rate or behaviour scores Psychosocial problems are present in a subgroup of children with encopresis The relation between successful treatment and improvement in behavioural function supports the idea that encopresis has an aetiological role in the occurrence and maintenance of behavioural problems in children with encopresis

Comparing efficacy and tolerability of ibuprofen and paracetamol in fever.

Abstract: The purpose of this study was to compare antipyretic activity and evaluate tolerability of ibuprofen and paracetamol suspension in the treatment of febrile children. It was designed as a double blind, parallel group, multiple dose study comparing ibuprofen (20 mg/kg/24 hours) with paracetamol (50 mg/kg/24 hours) given at six hourly intervals for a maximum of 12 doses. Children on paediatric wards between the ages of 0.2 and 12 years, with fever as defined by an axillary temperature > or = 37.5 degrees C, were included. The main outcome measures were: change in axillary temperature; palatability of medication; changes in irritability and clinical condition; overall efficacy at the end of treatment; and number and nature of adverse events. The mean temperature change from baseline at four hours was -1.8 degrees C and -1.6 degrees C in ibuprofen and paracetamol groups respectively. In both groups: median palatability score was 'no reaction'; median irritability score at end point was 'not irritable'; median score for change in clinical condition was 'improved'; and median score for overall efficacy was 'good effect'. The proportion of patients experiencing adverse events was similar in both groups, the majority of events having doubtful or no relationship to therapy and being mild in severity. In conclusion, ibuprofen suspension was as effective and well tolerated as paracetamol in treatment of fever in young children.

The role of Epstein-Barr virus in Hodgkin's disease from different geographical areas

Abstract: Recent studies have suggested that Epstein-Barr virus (EBV) may play a role in the aetiology of Hodgkin's disease. To determine the role of EBV in childhood Hodgkin's disease in different geographical areas, immunohistochemical staining and in situ hybridisation were used to analyse latent membrane protein 1 (LMP 1) and small nuclear non-transcribed RNAs (EBER-1) respectively. Testing for EBV within the Reed-Sternberg and Hodgkin's cells was carried out in childhood Hodgkin's disease from 10 different countries. The proportion of LMP 1 positive cases varied significantly, being 50% of cases from the United Kingdom (38/75), South Africa (9/18), Egypt (7/14), and Jordan (8/16), 60% from the United Arab Emirates (6/10), 70% from Australia (11/16), 81% from Costa Rica (34/42), 88% from Iran (7/8), 90% from Greece (20/22), and 100% of the 56 cases from Kenya. A sensitive polymerase chain reaction based EBV strain typing technique was established using archival tissues. EBV strain type 1 was shown to be predominant in childhood Hodgkin's disease from the United Kingdom, South Africa, Australia, and Greece. Type 2 was predominant in Egypt. EBV strain types 1 and 2 were both detected in some cases of childhood Hodgkin's disease in the United Kingdom, Costa Rica, and Kenya. The high incidence of EBV and the presence especially in developing countries of dual infection with both strain types 1 and 2 may reflect socioeconomic conditions leading to malnutrition induced immunological impairment. The possibility of HIV infection also needs to be explored.

A community based study of failure to thrive in Israel.

Abstract: OBJECTIVE: To examine the characteristics of infants suffering from failure to thrive in a community based cohort in Israel and to ascertain the effect of failure to thrive on their cognitive development. METHODS: By review of records maintained at maternal and child health clinics in Jerusalem and the two of Beit Shemesh, epidemiological data were obtained at age 15 months on a cohort of all babies born in 1991. For each case of failure to thrive, a matched control was selected from the same maternal and child health clinic. At age 20 months, cognitive development was measured, and at 25 months a home visit was carried out to assess maternal psychiatric status by questionnaire, and the HOME assessment was performed to assess the home environment. RESULTS: 3.9% of infants were found to have fallen below the third centile in weight for at least three months during the first year of life. Infants with failure to thrive did not differ from the general population in terms of obstetric or neonatal complications, birth order, or parents' ethnic origin, age, or years of education. The infants with failure to thrive did have lower birthweights and marginally smaller head circumferences at birth. Developmental assessment at 20 months of age showed a DQ of 99.7 v 107.2 in the matched controls, with 11.5% having a DQ below 80, as opposed to only 4.6% of the controls. No differences were found in maternal psychiatric problems as measured by a self report questionnaire. There were, however, significant differences in subscales of the HOME scale. CONCLUSIONS: (1) Infants who suffered from failure to thrive had some physiological predispositions that put them at risk; (2) failure to thrive may be an early marker of families providing suboptimal developmental stimulation.

Haemoglobin and ferritin concentrations in infants at 8 months of age.

Abstract: AIM: To identify the optimum age to screen for iron deficiency, the normal distribution of haemoglobin and ferritin in a representative population sample was investigated. METHODS: Normal values for haemoglobin and ferritin were measured from heel prick capillary samples obtained from a representative cohort of 1175 infants at 8 months old who were randomly selected from children taking part in the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC). RESULTS: Haemoglobin was normally distributed: mean (SD) 117 (11) milligrams, 95% confidence interval (CI) 116 to 118, and range 72-153 milligrams. Ferritin was log normally distributed: geometric mean 38.5 micrograms/l, 95% CI 37.0 to 39.9, range 7.1-224 micrograms/l. The 5th centile for haemoglobin was 97 milligrams and for ferritin 16.9 micrograms/l. No correlation was found between haemoglobin and ferritin. Multiple regression analysis showed ferritin concentrations to be positively related to birth weight (p < 0.0001) and the sex of the child (girls with higher concentrations) (p < 0.0001) but negatively with the child's weight at 8 months (p < 0.0001). Haemoglobin concentrations were positively related to the child's weight at 8 months (p = 0.04). Neither haemoglobin nor ferritin concentrations were related to social class as measured by maternal education level. CONCLUSION: These data define the normal range for haemoglobin and ferritin in capillary samples in the UK population, and suggest that anaemia is common in infancy. Using current recommendations, 23% of infants would be identified as anaemic. For British infants at 8 months of age, a more representative 'cut off' for anaemia would be haemoglobin concentration < 97 milligrams and for iron deficiency ferritin < 16 micrograms/l.

Developmental and behavioural characteristics of cri du chat syndrome.

Abstract: Developmental and behavioural characteristics were assessed in 27 children with cri du chat syndrome using the Society for the Study of Behavioural Phenotypes questionnaire, which gave information on prenatal and perinatal conditions, neurological problems, and developmental and behavioural difficulties. The findings suggest that the behavioural profile of children with cri du chat syndrome incorporates self injurious behaviour, repetitive movements, hypersensitivity to sound, clumsiness, and obsessive attachments to objects. In terms of a developmental profile, children with cri du chat syndrome were able to communicate their needs, socially interact with others, and have some degree of mobility.

Nutrient intakes and impact of fortified breakfast cereals in schoolchildren.

Abstract: OBJECTIVE: To report micronutrient intakes in Northern Ireland schoolchildren, and to establish the contribution of fortified breakfast cereal to overall nutrient intakes and achievement of current dietary recommendations. DESIGN: Analysis of dietary intakes and physical characteristics of participants in a randomly selected 2% population sample of 1015 schoolchildren aged 12 and 15 years in Northern Ireland during the 1990/1 school year. MAIN OUTCOME MEASURES: Dietary intakes, physical characteristics, and their association with consumption of fortified breakfast cereal. RESULTS: Mean micronutrient intakes were generally adequate with the exception of low intakes of folate (boys and girls) and iron (girls). Fortified breakfast cereals, consumed by a high proportion (94% boys; 83% girls) of the sample, were associated with higher daily intakes of most micronutrients and fibre and with a macronutrient profile consistent with current nutritional recommendations. Appreciable proportions of subjects who did not consume fortified breakfast cereals had daily intakes that fell below the lower reference nutrient intake for riboflavin, niacin, folate, vitamin B-12, and iron (girls). CONCLUSIONS: The results demonstrate the potential of fortification in contributing to micronutrient intakes of schoolchildren, particularly where requirements are high, or for those on marginal diets of low nutritional quality.

Hyponatraemia and dehydration in severe malaria.

Abstract: The prevalence and likely cause of hyponatraemia in severe childhood malaria were investigated. One hundred and thirty two children, 47 of whom had cerebral malaria, were prospectively recruited and serial simple indices of fluid and electrolyte balance and renal function monitored during admission. In 55%, hyponatraemia (sodium < 135 mmol/l) was present on admission. Hyponatraemia was pronounced (sodium < or = 130 mmol/l) in 21%, and these children gained less weight during admission (mean weight gain 2.4% v 4.3%) than children with a normal sodium (135-145 mmol/l). Overall, 31% of survivors were at least moderately dehydrated on admission (5% weight gain by discharge). These children had higher plasma urea concentrations on admission (6.1 v 4.5 mmol/l) and were more acidotic (mean base excess -12.1 v -8.0) than children who were not dehydrated. There were changes in simple indices of renal function between admission and discharge in children who survived (creatinine 65.7 v 37.9 mumol/l and urea 5.5 v 1.9 mmol/l). The results suggest that dehydration is common in severe childhood malaria, that it may contribute to mild impairment in renal function, and that hyponatraemic children are less water depleted, showing appropriate rather than inappropriate secretion of antidiuretic hormone.