Showing papers in "Archives of Disease in Childhood in 2003"

Health consequences of obesity

Abstract: The recent epidemic of childhood obesity(1) has raised concern because of the possible clinical and public health consequences.(2,)(3) However, there remains a widespread perception among health professionals that childhood obesity is a largely cosmetic problem, with minor clinical effects. No systematic review has yet focused on the diverse array of possible consequences of childhood obesity, though older non-systematic reviews are available.(4,)(5) In addition, no review to date has considered the vast body of evidence on the health impact of childhood obesity which has been published recently. The aim of the present review was therefore to provide a critically appraised, evidence based, summary of the consequences of childhood obesity in the short term (for the child) and longer term (in adulthood).

The confidential enquiry into maternal and child health (CEMACH)

Abstract: A review of the history of confidential enquiries The Confidential Enquiry into Maternal and Child Health (CEMACH) was established in April 2003. It replaces CESDI (the Confidential Enquiry into Stillbirths and Deaths in Infancy) and CEMD (the Confidential Enquiry into Maternal Deaths); this gives it a truly perinatal focus, but its remit is now wider and includes all childhood death. This paper reviews the history of confidential enquiries, some of the principle findings of CEMACH’s predecessors, and the methodology and aims of CEMACH. The current system of confidential enquiries started in 1952, just four years after the inception of the NHS. Before that, maternal deaths were reported to the Ministry of Health on an ad hoc basis.1 The first report of CEMD covered 1952–54, capturing 77% of maternal deaths during that period. From 1985–87 onwards, a single report was published triennially for the whole of the United Kingdom.2 The purposes of the CEMD were to assess the main causes of maternal deaths and, through the identification of avoidable causes, to reduce maternal morbidity and mortality by recommending improvements in clinical care and service provision; it also indicated directions for future research and audit. CESDI was established in 1992, after the Department of Health directed that the 14 regions of England should undertake perinatal mortality surveys. CESDI’s remit was to improve understanding of the causes of death in late fetal life and infancy—that is, from 20 weeks post-conception to one year after birth. Its aim was to reduce mortality by identifying suboptimal patterns of practice and service provision related to those deaths and to make recommendations for improvement. Combining CEMD and CESDI, CEMACH retains this regional organisation and these overall aims. There are two other national confidential enquiries: the National Confidential Enquiry into Perioperative Deaths (NCEPOD) and the Confidential …

Presenting features of inflammatory bowel disease in great britain and Ireland

Abstract: Background: Reports from individual referral centres suggest that a significant proportion of children with inflammatory bowel disease (IBD) present after prolonged delays and with impaired growth. Aims: To prospectively document the presenting features, delay in presentation, disease localisation, and growth in newly diagnosed cases of IBD. Methods: For 13 months, between June 1998 and June 1999, 3247 paediatricians, adult gastroenterologists, and surgeons across the UK and Ireland were prospectively surveyed each month and asked to report every newly diagnosed case of childhood IBD. Results: A total of 739 new IBD cases aged less than 16 years were identified. Only one quarter of Crohn’s disease (CD) cases presented with the “classic triad” of diarrhoea, weight loss, and abdominal pain; nearly half did not report diarrhoea. The median delay from onset of symptoms to diagnosis was 5 months (mean 11 months), with one fifth having symptoms of more than one year. Delays were most common in CD and in younger children. Short stature was noted only in those with CD and not with ulcerative colitis. One fifth of CD cases had disease activity in the jejunum and this group had significantly reduced stature. Ileo-colonic involvement was documented in most CD cases, with only a small minority having isolated ileal or isolated colonic disease. Pan-colitis was reported in most UC cases, with very few having only an isolated proctitis. Conclusions: Many children are diagnosed after prolonged delays and have growth failure. Improved knowledge of the presenting features of IBD, and earlier investigation of suspected cases, may help reduce the delays noted.

Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India

Abstract: Background: Postnatal depression is a recognised cause of delayed cognitive development in infants in developed countries Being underweight is common in South Asia Aims: To determine whether postnatal depression contributes to poor growth and development outcomes in Goa, India Methods: Cohort study for growth outcomes with nested case-control study for developmental outcomes A total of 171 babies were weighed and measured at 6–8 weeks following birth The following measures were used: Edinburgh Postnatal Depression Scale for maternal mood, and sociodemographic and infant health variables Outcome measures were: weight (<5th centile), length (<5th centile), and Developmental Assessment Scale for Indian Infants scores at six months Results: Postnatal depression was a strong, and independent, predictor of low weight and length and was significantly associated with adverse mental development quotient scores Conclusions: This study provides evidence for the first time that postnatal depression, a potentially treatable disorder, is a cause of poor growth and development in South Asia

Deficits in attention, motor control, and perception: a brief review

Abstract: The concept of DAMP (deficits in attention, motor control, and perception) has been in clinical use in Scandinavia for about 20 years. DAMP is diagnosed on the basis of concomitant attention deficit/hyperactivity disorder and developmental coordination disorder in children who do not have severe learning disability or cerebral palsy. In clinically severe form it affects about 1.5% of the general population of school age children; another few per cent are affected by more moderate variants. Boys are overrepresented; girls are currently probably underdiagnosed. There are many comorbid problems/overlapping conditions, including conduct disorder, depression/anxiety, and academic failure. There is a strong link with autism spectrum disorders in severe DAMP. Familial factors and pre- and perinatal risk factors account for much of the variance. Psychosocial risk factors appear to increase the risk of marked psychiatric abnormality in DAMP. Outcome in early adult age was psychosocially poor in one study in almost 60% of unmedicated cases. There are effective interventions available for many of the problems encountered in DAMP.

Adverse health effects of prenatal and postnatal tobacco smoke exposure on children

Abstract: Parents who choose to smoke are possibly not aware of, or deny, the negative effects of passive smoking on their offspring. This review summarises a wide range of effects of passive smoking on mortality and morbidity in children. It offers paediatricians, obstetricians, specialists in preventive child health care, general practitioners, and midwives an approach to promote smoking cessation in smoking parents before, during, and after pregnancy.

Breast feeding and respiratory morbidity in infancy: a birth cohort study

Abstract: Aim: To examine the relation between the duration of breast feeding and morbidity as a result of respiratory illness and infection in the first year of life. Methods: Prospective birth cohort study of 2602 live born children ascertained through antenatal clinics at the major tertiary obstetric hospital in Perth, Western Australia. Main outcome measures were hospital, doctor, or clinic visits, and hospital admissions for respiratory illness and infection in the first year of life. Main exposure measures were the duration of predominant breast feeding (defined as the age other milk was introduced) and partial (any) breast feeding (defined as the age breast feeding was stopped). Main confounders were gender, gestational age less than 37 weeks, smoking in pregnancy, older siblings, maternal education, and maternal age. Results: Hospital, doctor, or clinic visits for four or more upper respiratory tract infections were significantly greater if predominant breast feeding was stopped before 2 months or partial breast feeding was stopped before 6 months. Predominant breast feeding for less than six months was associated with an increased risk for two or more hospital, doctor, or clinic visits and hospital admission for wheezing lower respiratory illness. Breast feeding for less than eight months was associated with a significantly increased risk for two or more hospital, doctor, or clinic visits or hospital admissions because of wheezing lower respiratory illnesses. Conclusions: Predominant breast feeding for at least six months and partial breast feeding for up to one year may reduce the prevalence and subsequent morbidity of respiratory illness and infection in infancy.

Chronic pain in adolescents: evaluation of a programme of interdisciplinary cognitive behaviour therapy

Abstract: Aim: To determine the effectiveness of an interdisciplinary cognitive behavioural treatment for adolescents with chronic pain. Methods: Fifty seven adolescents (mean age 14.28 years) with chronic pain and 57 accompanying adults underwent an interdisciplinary three week residential programme of group cognitive behavioural therapy. Mean chronicity of pain was 4.02 years; 75% were absent from full time education (mean absence 17 months). Results: Post-treatment adolescents reported significant improvements for self report of disability (mean difference 3.37 (95% CI 0.65 to 6.09)), physical function (mean difference timed walk of 2.61seconds (1.02 to 4.2) and sit to stand of 3.22 per minute (0.79 to 5.65)). At three months post-treatment adolescents maintained physical improvements and reduced anxiety (mean difference 1.7 (0.72 to 2.67)), disability (mean difference 4.3 (1.44 to 7.17)), and somatic awareness (mean difference 4.43 (1.53 to 7.33)). Following treatment adults reported significant improvement in their report of adolescent disability (mean difference 4.43 (2.17 to 6.7)), adult anxiety (mean difference 1.73 (0.54 to 2.92)), depression (mean difference 1.16 (0.34 to 1.98)), and parental stress (mean difference 10.81 (2.91 to 18.78)). At three months significant improvements were maintained. At three months 64% improved school attendance; 40% had returned to full time education. Conclusions: Interdisciplinary cognitive behavioural pain management (with family involvement) is a promising approach to the management of pain, pain related distress, and disability.

A controlled study of sleep related disordered breathing in obese children

Abstract: Background: Unlike the adult sleep related disordered breathing (SDB) patients who are typically obese, the relation between obesity and childhood SDB is not clear. Aims: To investigate whether obese children are more at risk of obstructive SDB when compared to normal population, and whether this risk is potentiated by the presence of pharyngeal lymphoid tissue. Methods: Forty six obese children (age 10.8 (SD 2.3) years; BMI 27.4 (SD 5.1)), and 44 sex and age matched normal weight children (age 11.7 (SD 2.1) years; BMI 18 (SD 1.8)) were studied. All children underwent a set of physical examinations (including the upper airways) and sleep studies. Results: The obese children were different from the normal weight children in terms of type (predominantly obstructive), frequency, and severity of respiratory disturbances. Depending on the criteria used, 26% or 32.6% of obese children had SDB; 2.3% of normal controls had OAI ⩾1 and 4.5% had RDI ⩾5. Presence of SDB was related to presence of tonsils (size >2; range 0–4) (OR 12.67, 95% CI 2.14 to 75.17) and BMI (OR 1.20, 95% CI 1.08 to 1.33). Conclusions: Results suggest that obese children are at increased risk of obstructive SDB; the presence of any pharyngeal lymphoid tissue enlargement in obese children should therefore be aggressively managed.

Growth impairment in the very preterm and cognitive and motor performance at 7 years

Abstract: Background: Infants born of low birth weight often have poor subsequent growth (especially if they were born very preterm), which has been shown to relate to later motor and cognitive development. Aims: To assess a cohort of preterm infants at the age of 7 years for growth, motor, and cognitive measures, and investigate the effects of growth impairment on school performance. Methods: A cohort of 280 children born before 32 completed weeks of gestation were tested, together with 210 term controls. Results: Pretem children were significantly lighter and shorter than term controls and had smaller heads and lower body mass index (BMI). Median centiles for weight, height, head circumference, and BMI were 25, 25, 9, and 50 for boys and 50, 25, 9, and 50 for girls compared with 50, 50, 50, and 75 for controls. They performed significantly less well on all tests with a mean score of 91 (9.2) on the Developmental Test of Visual-Motor Integration, 89 (14.5) on the Wechsler-III IQ test, and 30.7% scoring at or below the 5th centile on the Movement Assessment Battery for Children. In boys, short stature and small heads were the best predictors of poor performance; in girls, a small head alone was a predictor for poor motor and cognitive performance. Conclusion: Poor postnatal growth in preterm infants, especially of the head, is associated with increased levels of motor and cognitive impairment at 7 years of age. This growth restriction appears to occur largely in the postnatal rather than antenatal period and may be amenable to intervention and subsequent improvement in outcome.

Respiratory problems in children with neurological impairment

Abstract: Children with severe neurological impairment have a high incidence of respiratory problems which are multifactorial and may be related to or dependent on the underlying disability. In addition, common respiratory conditions such as asthma will be represented in this group as in the general paediatric population. In order to maximise quality of life and reduce morbidity and mortality, each child should be carefully assessed and treated, making adjustments where necessary in the treatment regime to take account of the disability.

Low back pain in schoolchildren: the role of mechanical and psychosocial factors

Abstract: Background: Low back pain (LBP) in schoolchildren with no apparent clinical cause is known to be a common problem, but considerably less is understood regarding the aetiology of such pain. Aim: To assess the role of both mechanical and psychosocial factors (including emotional and behavioural problems and other somatic pain complaints) in childhood LBP. Methods: A cross sectional study was carried out in a population of 1446 schoolchildren aged 11–14 years. Information on these potential risk factors for LBP was sought using a self complete questionnaire and a five day bag weight diary. Results: Mechanical factors such as physical activity and school bag weight were not associated with LBP. However, strong associations with LBP were observed for emotional problems, conduct problems, troublesome headaches, abdominal pain, sore throats, and daytime tiredness. Conclusion: Results suggest that psychosocial factors rather than mechanical factors are more important in LBP occurring in young populations and could possibly be a reflection of distress in schoolchildren.

The effects of obesity on pulmonary function

Abstract: Methods: Sixty four obese patients underwent physical examination, standardised pulmonary function tests (spirometry, lung volumes, and single breath diffusion capacity for carbon monoxide), and DEXA scan measurements. The trunk and subtotal (total - head) body fat mass were used as surrogate index of body adiposity. Results: Sixteen girls and 48 boys with median age and body mass index (BMI) of 12 years (interquartile range (IQR): 10–14) and 30.1 kg/m2 (IQR: 27.2–32.8) respectively were studied. None of the patients had clinical evidence of cardiopulmonary disease. Reduction in functional residual capacity (median FRC 93% predicted, IQR: 68.5–116.5%) and impairment of diffusion capacity (median DLco 83.5% predicted, IQR: 70.0–100.7%) were the most common abnormalities in our cohort, being observed in 30 (46%) and 21 (33%) patients respectively. Obstructive ventilatory impairment was found in three patients. There was significant negative correlation between the degree of reduction of FRC but not DLco with DEXA scan measurements, but such a relation was not found when BMI was used as the indicator of obesity. Conclusion: Reduction in FRC and diffusion impairment were the commonest abnormalities found in our cohort of obese patients. Reduction in static lung volume was correlated with the degree of obesity.

Epidemiology of paediatric renal stone disease in the UK

Abstract: Background: The previous epidemiological study of paediatric nephrolithiasis in Britain was conducted more than 30 years ago. Aims: To examine the presenting features, predisposing factors, and treatment strategies used in paediatric stones presenting to a British centre over the past five years. Methods: A total of 121 children presented with a urinary tract renal stone, to one adult and one paediatric centre, over a five year period (1997–2001). All children were reviewed in a dedicated stone clinic and had a full infective and metabolic stone investigative work up. Treatment was assessed by retrospective hospital note review. Results: A metabolic abnormality was found in 44% of children, 30% were classified as infective, and 26% idiopathic. Bilateral stones on presentation occurred in 26% of the metabolic group compared to 12% in the infective/idiopathic group (odds ratio 2.7, 95% CI 1.03 to 7.02). Coexisting urinary tract infection was common (49%) in the metabolic group. Surgically, minimally invasive techniques (lithotripsy, percutaneous nephrolithotomy, and endoscopy) were used in 68% of patients. Conclusions: There has been a shift in the epidemiology of paediatric renal stone disease in the UK over the past 30 years. Underlying metabolic causes are now the most common but can be masked by coexisting urinary tract infection. Treatment has progressed, especially surgically, with sophisticated minimally invasive techniques now employed. All children with renal stones should have a metabolic screen.

Severe and unrecognised: pertussis in UK infants.

Abstract: Aims: To diagnose pertussis using culture, polymerase chain reaction, and serology, in children admitted to intensive care units (PICUs) and some paediatric wards in London, and in their household contacts to determine the source of infection. Methods: Infants <5 months old admitted to London PICUs between 1998 and 2000 with respiratory failure, apnoea and/or bradycardia, or acute life threatening episodes (ALTE), and children <15 years admitted to paediatric wards at St Mary’s and St George’s Hospitals between 1999 and 2000 with lower respiratory tract infection, apnoea, or ALTE were studied. Results: Sixty seven per cent of eligible children (142/212) were recruited; 23% (33/142) had pertussis, 19.8% (25/126) on the PICU and 50% (8/16) on wards. Two died. Only 4% (6/142) were culture positive. Pertussis was clinically suspected on admission in 28% of infants (7/25) on the PICU and 75% (6/8) on the wards. Infants on PICU with pertussis coughed for longer, had apnoeas and whooped more often, and a higher lymphocyte count than infants without pertussis. Pertussis and respiratory syncytial virus (RSV) co-infection was frequent (11/33, 33%). Pertussis was confirmed in 22/33 (67%) of those who were first to become ill in the family. For 14/33 children the source of infection was a parent; for 9/33 the source of pertussis was an older fully vaccinated child in the household. Conclusions: Severe pertussis is under diagnosed. An RSV diagnosis does not exclude pertussis. Future changes to the UK vaccination programme should aim to reduce pertussis transmission to young infants by their parents and older siblings.

Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials

Abstract: Aims: To evaluate the benefits and harms of treatments for vesicoureteric reflux in children. Methods: Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate. Results: Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1–2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment. Conclusion: It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.

Bone densitometry in children assessed by dual x ray absorptiometry: uses and pitfalls

Abstract: The importance of bone growth and mineralisation during childhood for bone health in adult life is increasingly accepted, with both nutritional factors 1 and exercise 2 being recognised as influential for normal skeletal development. The appreciation that infancy and childhood are important periods of life for bone development has led to a need for suitable methods for monitoring bone health, both for research purposes and for clinical monitoring of individuals, and hence to an increasing use of bone densitometry in children. This review discusses the role and potential pitfalls of this technique.

Bronchoalveolar lavage cellularity in infants with severe respiratory syncytial virus bronchiolitis

Abstract: Aim: To examine over time, the cellular response within the lungs of infants ventilated with respiratory syncytial virus (RSV) bronchiolitis and to compare this response in infants born at term with those born preterm. Methods: Non-bronchoscopic bronchoalveolar lavage (BAL) samples were taken from 47 infants (24 born at term and 23 born preterm) who were ventilated for RSV positive bronchiolitis and 10 control infants. BAL cellularity and differential cell counts were calculated using standard techniques. Results: Total cellularity in BAL over the first four days of ventilation in infants with RSV bronchiolitis was greater in term infants (median 2.2 (IQR 4.27) x 106 cells/ml) compared with preterm infants (0.58 (1.28) x 106 cells/ml). The magnitude of the cellular response in preterm infants with bronchiolitis was similar to that in the control group measured on day 1 (0.62 (0.77) x 106 cells/ml). BAL cellularity decreased progressively from the time of intubation in term infants, but remained relatively constant in preterm infants up to seven days after intubation. Conclusions: There are differences in the magnitude and type of pulmonary cellular response in term and preterm infants ventilated with RSV bronchiolitis. The cellular response in term infants with bronchiolitis differs from that in a control group of infants. These differences may reflect variations in cellular recruitment in the lung and/or variations in airway calibre.

Therapeutic implications of sex differences in asthma and atopy.

Abstract: Clear sex differences exist in asthma and atopy with a preponderance of boys before puberty. There is a reversal of this sex ratio during puberty with girls having more asthma and atopy throughout the reproductive years. Elucidating the reasons for the switch in the sex ratio should provide fresh insights into asthma and atopy with a real prospect of novel therapies for these troublesome diseases. The challenge is to match the epidemiology and physiology with the accumulating scientific knowledge on gender differences in immune responses. Hormonal changes have been implicated in the reversal of the sex ratio. Testosterone is an immunosuppressant and is likely to be protective, while female sex steroids are proinflammatory and will increase the susceptibility to atopy. Modified so as to be non-virilising/feminising, sex steroids could therefore play a useful part in modulating the immunological and inflammatory processes that underlie asthma and other allergic disorders, complementing the currently used glucocorticoid derived steroids.

A pilot study of motivational interviewing in adolescents with diabetes

Abstract: Aims: To obtain preliminary data on the impact of motivational interviewing, a counselling approach to behaviour change, on glycaemic control, wellbeing, and self-care of adolescents with diabetes. Methods: Twenty two patients aged 14–18 years participated in motivational interviewing sessions during a six month intervention. The effects of the intervention on HbA1c and a range of psychological factors were assessed. Results: Mean HbA1c decreased from 10.8% to 9.7% during the study and remained significantly lower after the end of the study. Fear of hypoglycaemia was reduced and diabetes was perceived as easier to live with. There were no other significant changes in the psychological measures. By contrast no reduction in HbA1c values was observed in a comparison group who did not receive the motivational interviewing intervention. Conclusion: The findings of this pilot study indicate that motivational interviewing may be a useful intervention in helping adolescents improve their glycaemic control. A larger, longer term randomised controlled study is indicated to clarify the mechanisms and extent of these benefits.

The clinical and health economic burden of respiratory syncytial virus disease among children under 2 years of age in a defined geographical area

Abstract: Aims: To describe the clinical and health economic impact of respiratory syncytial virus (RSV) disease in children under 2 years of age. Methods: Hospitalised children less than 2 years of age with a respiratory illness were studied over three consecutive RSV seasons (1996–99). Results: The rates (per 1000 infants under 1 year of age) of hospitalisations from bronchiolitis and RSV illness were 30.8 and 24.4 respectively. The rates of death, intensive care admission, and need for ventilatory assistance during RSV related hospitalisation were 0.2%, 2.7%, and 1.5% respectively. From a cohort of 841 preterm infants, 6.3% had an RSV related hospitalisation during the study period, with the rate rising to 9.2% among those who were either born before 36 weeks gestation and were under 6 months of age at the onset of the RSV seasons, or were less than 2 years of age with chronic lung disease needing home oxygen therapy. Eight of 25 children on home oxygen therapy had RSV related rehospitalisation. Need for assisted ventilation during the neonatal period and discharge home on oxygen therapy were significantly associated with the risk of subsequent RSV related hospitalisation in preterm infants less than 6 months of age. The direct health authority cost of all RSV hospitalisations was £542 203, while the currently recommended immunoprophylaxis for the high risk infants would have cost £652 960. Conclusions: Preterm infants receiving assisted ventilation and those on home oxygen therapy are particularly at risk of RSV related hospitalisation. Serious adverse outcomes are however uncommon even among these high risk infants.

Maternal recall of exclusive breast feeding duration.

Abstract: Background: Both the pattern and duration of breast feeding are important determinants of health outcomes. In vertical HIV transmission research, reliable documentation of early breast feeding practices is important in order to correctly attribute postnatal transmission to feeding pattern. Aims: To validate methods of collecting data on the duration of exclusive breast feeding (EBF) in an area of South Africa with a high HIV prevalence rate. Methods: A total of 130 mothers were interviewed weekly, postnatally. At every interview a 48 hour and a seven day recall breast feeding history were taken. A subset of 70 mothers also received two intermediate visits per week during which additional 48 hour, non-overlapping, recall interviews were conducted. Ninety three infants were revisited at 6–9 months of age when mothers’ recall of EBF duration from birth was documented. The different methods of recalling EBF status were compared against an a priori “best comparison” in each case. Results: Reported breast feeding practices over the previous 48 hours did not reflect EBF practices since birth (specificity 65–89%; positive predictive value 31–48%). Six month EBF duration recall was equally poor (sensitivity at 2 weeks 79%; specificity 40%). Seven day recall accurately reflected EBF practices compared with thrice weekly recall over the same time period (sensitivity 96%, specificity 94%). Conclusions: 48 hour EBF status does not accurately reflect feeding practices since birth. Long term recall data on EBF are even more inaccurate. We recommend that data on duration of EBF be collected prospectively at intervals of no longer than one week.

Diagnosis and treatment of bacterial meningitis

Abstract: This review focuses on recent advances of topical interest regarding the diagnosis and treatment of common causes of bacterial meningitis occurring in children beyond the neonatal period. Tuberculous meningitis is beyond the scope of this review.

Monitoring cardiac function in intensive care

Abstract: Systolic cardiac function results from the interaction of four interdependent factors: heart rate, preload, contractility, and afterload. Heart rate can be quantified easily at the bedside, while preload estimation has traditionally relied on invasive pressure measurements, both central venous and pulmonary artery wedge. These have significant clinical limitations; however, adult literature has highlighted the superiority of several novel preload measures. Measurement of contractility and afterload is difficult; thus in clinical practice the bedside assessment of cardiac function is represented by cardiac output. A variety of techniques are now available for cardiac output measurement in the paediatric patient. This review summarises cardiac function and cardiac output measurement in terms of methodology, interpretation, and their contribution to the concepts of oxygen delivery and consumption in the critically ill child.

Bacterial susceptibility to oral antibiotics in community acquired urinary tract infection

Abstract: Background: The most common oral antibiotics used in the treatment of urinary tract infection (UTI) are sulphonamides and cephalosporins, but emerging resistance is not unusual. Aims: To assess the change in susceptibility of urinary pathogens to oral antibiotics during the past decade in children with community acquired UTI. Methods: The study sample included two groups of children with a first community acquired UTI: 142 children enrolled in 1991 and 124 enrolled in 1999. UTI was diagnosed by properly collected urine specimen (suprapubic aspiration, transurethral catheterisation, or midstream specimen in circumcised males) in symptomatic patients. Antimicrobial susceptibility of the isolates was compared between the two groups. Results: The pathogens recovered in the two groups were similar: in 1991— E coli 86%, Klebsiella 6%, others 8%; in 1999— E coli 82%, Klebsiella 13%, and others 5%. A slight but generalised decrease in bacterial susceptibility to common antibiotics in the two groups was shown: ampicillin 35% versus 30%; cephalexin 82% versus 63% (p Conclusions: This study shows a slight but generalised decrease in bacterial susceptibility to common oral antibiotics in the past decade in our population. Empirical initial treatment with co-trimoxazole or cephalexin is inadequate in approximately one third of UTI cases. A larger number of pathogens may be empirically treated with amoxicillin-clavulanate (24% resistance); 95% of organisms are susceptible to cefuroxime-axetil.

Vulvovaginitis in prepubertal girls

Abstract: This retrospective study evaluated the clinical features and findings in bacterial cultures and in microscopic examination of vaginal secretions in 80 prepubertal girls, aged 2‐12 years, with vulvovaginitis. Vaginal secretions were obtained directly from the vagina with a sterile catheter carefully inserted into the vagina. Pathogenic bacteria were isolated in 36% of cases. In 59% of these cases the isolated pathogen was group A β-haemolytic streptococcus. Candida was not found in any of the patients. The finding of leucocytes in vaginal secretions as an indicator for growth of pathogenic bacteria had a sensitivity of 83% and a specificity of 59%. Antimicrobial treatment should therefore be based on bacteriological findings of vaginal secretions and not on the presence of leucocytes alone. V ulvovaginitis is the most common gynaecological problem in prepubertal girls. 1‐3 Factors that explain the increased susceptibility of children to vulvovaginitis include: the close anatomical proximity of the rectum; lack of labial fat pads and pubic hair; small labia minora; thin and delicate vulvar skin; thin, atrophic, anoestrogenic vaginal mucosa; and children’s tendency to have poor local hygiene and to explore their bodies. 14 Most cases of vulvovaginitis are of non-specific aetiology.However,in some patients the symptoms are caused by infections with specific bacterial pathogens. The present retrospective report summarises the clinical features, results of bacterial cultures, and findings in microscopic examination of vaginal secretions from 80 prepubertal girls suffering from vulvovaginitis. Subjects with suspected sexual abuse were excluded.

Coexistence of social inequalities in undernutrition and obesity in preschool children: population based cross sectional study

Abstract: Aims: To test for the coexistence of social inequalities in undernutrition and obesity in preschool children. Methods: Retrospective, cross sectional, study of routinely collected data from 74 500 children aged 39–42 months in 1998/99. Main outcome measures were weight, height, sex, and age routinely recorded by health visitors. Body mass index (BMI) standardised for age and sex, relative to UK 1990 reference data, was used to define undernutrition (BMI 95th centile; BMI >98th centile). Social deprivation was assessed as Carstairs deprivation category (1 = most affluent to 7 = most deprived). Results: Both undernutrition (3.3%) and obesity (8.5% above 95th centile; 4.3% above 98th centile) significantly exceeded expected frequencies from UK 1990 reference data. Undernutrition and obesity were significantly more common in the more deprived families. Odds ratios in deprivation category 7 relative to category 1 were 1.51 (95% CI 1.22 to 1.87) for undernutrition (BMI 98th centile). The cumulative prevalence of under and overnutrition (malnutrition) in the most deprived group was 9.5% compared to 6.9% in the least deprived group. Conclusions: Undernutrition and obesity are significantly more common than expected in young children and strongly associated with social deprivation. Both undernutrition and obesity have adverse short and long term health effects. Public health strategies need to tackle malnutrition (both undernutrition and obesity) in children and take into consideration the association with social deprivation.

Increasing antibiotic resistance among urinary tract isolates

Abstract: A five year retrospective study was performed to identify organisms isolated from the urinary tract of 2815 children in the community and 1314 children with underlying renal problems and their antimicrobial susceptibilities. Isolates from children in the latter group were generally more resistant to commonly used antibiotics. In particular, up to a third of E coli isolates from children in the community and almost two thirds of E coli isolates from children with underlying renal disease may be resistant to trimethoprim.

Update on childhood rhabdomyosarcoma

Abstract: The overall survival of childhood rhabdomyosarcoma has improved dramatically over the past 10 years. Early diagnosis and appropriate referral to a specialised centre leading to an accurate and timely diagnosis reflects on overall outcome. Recent molecular studies have identified different biological subtypes resulting in the recognition of poorer subgroups and allowing more appropriate treatment to be administered. Clinical trials remain the cornerstone to further improve outcome, now carried out on an international basis.

Group B streptococcal conjugate vaccines

Abstract: Linkage of bacterial capsular polysaccharides to proteins to create conjugate vaccines has had a dramatic impact on the health of children. Although unconjugated polysaccharides are poorly immunogenic in infants and some older children and adults, their covalent coupling with proteins stimulates T cell dependent antigenic recognition that profoundly enhances immunogenicity. In the decade since the introduction and widespread use of Haemophilus influenzae type b polysaccharide conjugate vaccines in the United States, invasive H influenzae infections have become a rarity in childhood. Similarly, the conjugation of polysaccharides of Streptococcus pneumoniae to a derivative of diphtheria toxoid and the addition of pneumococcal conjugate vaccine to infant immunisation schedules carries with it promise for a similar decline in the incidence of invasive pneumococcal disease in paediatric patients.