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The recognition of endocrine-related hypernatraemia would be enhanced
if account were taken, not only of biochemically overt hypernatraemia(1),
but also of the possibility that this biochemical derangement might be
masked by co-existing inability to excrete salt-free water. The clinical
counterpart of this phenomenon is encapsulated in the statement "the
symptoms of cranial diabetes insipidus may be ma...
The recognition of endocrine-related hypernatraemia would be enhanced
if account were taken, not only of biochemically overt hypernatraemia(1),
but also of the possibility that this biochemical derangement might be
masked by co-existing inability to excrete salt-free water. The clinical
counterpart of this phenomenon is encapsulated in the statement "the
symptoms of cranial diabetes insipidus may be masked by concomitant ACTH
deficiency...(since) glucocorticoids are necessary for the kidneys to
excrete salt-free water"(2). This scenario has no adverse iatrogenic
sequelae if the recognition and treatment of cranial diabetes insipidus
antedates replacement therapy for co-existing ACTH deficiency. The danger
arises where glucocorticoid replacement therapy is instituted in the face
of unsuspected cranial diabetes insipidus because this might be
accompanied by a rapid rise in plasma sodium which, in one instance, was a
rise from pre-treatment hyponatraemia to post treatment hypernatraemia,
with consequent myelinosis(3). Even the use of ACTH for dynamic testing of
the hypothalamo/pituitary/adrenal axis may have an unmasking effect, this
time by precipitating profound polyuria as was the case in a patient with
suspected anterior pituitary failure in whom co-existing cranial diabetes
insipidus had not been identified(4). Where the investigators deliberately
set out to identify both anterior and posterior pituitary failure in 12
patients with suspected panhypopituitarism. 4 patients in whom unequivocal
carnial diabetes insipidus(charcterised by a negligible increase in plasma
vasopressin following hypertonic saline infusion) co-existed with ACTH
deficiency nevertheless had normal plasma sodium levels(range 140-143
mmol/l)(5). Patients in whom this constellation of parameters is
associated with blunted diuresis are the ones most likely to be missed if,
as in one study, the co-existence of hypernatraemia and polyuria is relied
upon as one of the screening tests for cranial diabetes insipidus(6).
References:
(1) Haycock GB
Hypernatraemia:diagnosis and treatment
Arch Dis Child 2006:91:ep8-ep13
(2) Bayliss PH and Cheetham T
Diabetes insipidus
Arch Dis Child 1998:79:84-89
(3)Lasheen I., Doi SAR., Al-Shoumer KAS
Glucocorticoid replacement in panyhpopituitarism complicated by myelinosis
Medical principles and Practice 2005:14:115-117
(4) Schwartz AR and Leddy AL
Recognition of diabetes insipidus in postpartum hypopituitarism
Obstetrics and Gynecology 1982:59:394-8
(5) Iwasaki Y., Oiso Y., Yamauchi K., et al
Neurohypophyseal function in postpartum hypopituitarism: impaired plasma
vasopressin respnse to osmotic stimuli
Journal of Clinical Endocrinology and Metabolism 1989:68:560-5
(6) Agha A., Rogers B., Mylotte D., et al
Neuroendocrine dysfunction in the acute phase of traumatic brain injury
Clinical Endocrinology 2004:60:584-91
I read with interest the article of Elspeth Webb (Arch Dis Child Educ
Pract Ed 2005;90: ep11-14). I find the content interesting and well set
out and would agree what is in the article. However, I do feel there is a
section missing. I feel that some visitors to this country, be they short
term or permanent, seem to take no responsibility for their own welfare
when it comes to language barriers. Emphasis...
I read with interest the article of Elspeth Webb (Arch Dis Child Educ
Pract Ed 2005;90: ep11-14). I find the content interesting and well set
out and would agree what is in the article. However, I do feel there is a
section missing. I feel that some visitors to this country, be they short
term or permanent, seem to take no responsibility for their own welfare
when it comes to language barriers. Emphasis is placed in the article on
partnership. I believe partnership must be two ways and I would have
liked to have seen in the article some comment about ethnic groups
particularly from Arab speaking countries being guided towards taking
their own responsibility for interpretation of the English language, most
particularly under circumstances illustrated in the Emergency Departments
and out of hours. I would not wish to question the superiority of trained
interpreters being present wherever possible but I do feel that
partnership as laid out in this article is very much one way.
Williams [1] highlights the key points in the management of inhaled foreign bodies (FB). One of the important points is to request inspiratory and expiratory chest radiographs if FB aspiration is suspected. Because young children are unable to co-operate, paired inspiratory and expiratory films are not always possible. The lateral decubitus film is a useful and convenient method to determine the presence of...
Williams [1] highlights the key points in the management of inhaled foreign bodies (FB). One of the important points is to request inspiratory and expiratory chest radiographs if FB aspiration is suspected. Because young children are unable to co-operate, paired inspiratory and expiratory films are not always possible. The lateral decubitus film is a useful and convenient method to determine the presence of air trapping [2] as we show in the following case. When the child is placed on his side, the splinting of the dependent hemithorax results in restriction of movement of the thoracic cage on that side and under aeration of the lung while the hemithorax on the opposite side is unrestricted and the lung is well aerated.
A 22 months old, previously healthy, child presented with a 10 days history of cough, and fever. He had not improved after a week’s antibiotic course. A history of foreign body aspiration was not forthcoming. He had low-grade pyrexia, saturation of 91% on air, tachypnoea, mild recessions, reduced air entry on the left hemithorax and no added sounds. A chest x ray (fig 1) showed loss of the right heart border with generalised air space shadowing through out the lung, no midline shift and relatively hyperlucent left lung. On senior review and further direct questioning, possibility of choking on a peanut was elicited. As he was unable to cooperate for an expiratory film, a left lateral decubitus film (fig 2) was performed. This showed over expansion of the left (air trapping in the involved lung making it more hyperlucent despite being in the dependent position) but normally aerated right hemithorax. On a rigid bronchoscopy a peanut was removed piecemeal from the left main bronchus.
The statement by Sidebotham that "the consultant convened a strategy
meeting" is misleading. Under Working Together social services and the
police are responsible for convening this type of meeting. Paediatricians
can 'request' a strategy meeting as can any other professional. It is
important that responsibilities of the various agencies are clearly
defined and understood by all.
Professor Smyth describes the occurrence of non-specific arthritis in
some patients with cystic fibrosis (CF) in her recent article on diagnosis
and management of cystic fibrosis.[1] As a consequence of the increased
life expectancy in CF, rheumatic diseases are more likely to be observed,
particularly in older patients.[2]
Two specific arthropathies are described in CF; an episodic arthriti...
Professor Smyth describes the occurrence of non-specific arthritis in
some patients with cystic fibrosis (CF) in her recent article on diagnosis
and management of cystic fibrosis.[1] As a consequence of the increased
life expectancy in CF, rheumatic diseases are more likely to be observed,
particularly in older patients.[2]
Two specific arthropathies are described in CF; an episodic arthritis
(EA), or cystic fibrosis arthropathy (CFA), more common in children than
adults, and hypertrophic pulmonary osteoarthropathy (HPOA), seen usually
in adults but does occur in children.[2]
CFA [3, 4] is characterised by recurrent, painful attacks of mono- or
polyarthritis. Patients are frequently found to have erythema nodosum-like
rash, and more rarely purpuric skin lesions. The synovitis usually lasts
between 1 day to several weeks. While it can resolve, active disease
persists in many cases with progression to a chronic arthritis. These
patients are negative for both rheumatoid factor (RF) and antinuclear
antibodies (ANA).[2, 3, 4] However, Schidlow et al. [5] describe one
female patient with CF and arthritis found to have a raised RF, whose
titres increased with worsening lung function.
HPOA is characterised by abnormal proliferation of the skin and
distal osseous tissue of the extremities resulting in digital clubbing.
This is associated with long bone pain, radiological evidence of
periosteal new bone formation and impaired pulmonary function. Onset is
often insidious, causing pain in the wrists, knees and ankles. The disease
pattern is frequently symmetrical, with associated joint swelling and
periarticular tenderness.[2] The pain associated with HPOA is often
initially responsive to anti-inflammatory medication, but drug therapy
becomes less effective with disease progression.
Arthritis associated with CF has previously been little recognised.
It has specific forms now acknowledged to be a major cause of disability
in about 10% of young adults with the disease.[2]
Alexandra Colebatch, Richard Hull
Paediatric Rheumatology, Queen Alexandra Hospital, Portsmouth
References
[1] Smyth, R. Diagnosis and Management of Cystic Fibrosis. Arch Dis
Child Educ Pract Ed. 2005; 90: ep1-ep6.
[2] Dixey, J., Redington, A., Butler, R., et al. The Arthropathy of
Cystic Fibrosis. Annals of the Rheumatic Diseases. 1988; 47, 218-223.
[3] Merkel, P. Rheumatic Disease and Cystic Fibrosis. Arthritis and
Rheumatism. 1999; 8: 1563-1571.
[4] Newman, A., Ansell, B. Episodic Arthritis in Children with Cystic
Fibrosis. The Journal of Pediatrics. 1979; 94: 594-596.
[5] Schidlow, D., Goldsmith, D., Palmer, J., Huang, N. Arthritis in
Cystic Fibrosis. Archives of Disease in Childhood. 1984; 59: 377-379.
The guidelines regarding the milk banks may not be applicable for the
developing countries, because these countries can not afford to have milk
banks due to its cost. But the very fact the viruses particularly human
immunodefiency virus can be inactivated by pasteurisation method is
notable. The dilemma of advising breast milk feeding to the infants born
to the HIV positive mothers in the developing cou...
The guidelines regarding the milk banks may not be applicable for the
developing countries, because these countries can not afford to have milk
banks due to its cost. But the very fact the viruses particularly human
immunodefiency virus can be inactivated by pasteurisation method is
notable. The dilemma of advising breast milk feeding to the infants born
to the HIV positive mothers in the developing countries may be lessened to
a large extent. But the pasteurisation method has to be simplified so that
an uneducated mother can understand and follow. High temparature short
time method (HTST) may suitable for small homes than the low temparature
longer time method described in the guidelines. The effect of high
temparature on the nutritional contents have not been delineated clearly.
If the studies can prove HTST method is as effective, then boiling the
breast milk for a shorter period of time will definitely help to bring
down the HIV transmission in children, in the developing countries.
I am a corporate member of UKAMB and consider issue
three of the Guidelines to be an excellent reference.
However, to minimise the risks after feed preparation
the thermal treatment (Pasteurisation)requirements
should not only mirror issue two published by RCPCH
but also include the following amplification of
treatment, based on work by the late Prof J David
Baum.
I am a corporate member of UKAMB and consider issue
three of the Guidelines to be an excellent reference.
However, to minimise the risks after feed preparation
the thermal treatment (Pasteurisation)requirements
should not only mirror issue two published by RCPCH
but also include the following amplification of
treatment, based on work by the late Prof J David
Baum.
The Pasteurisation method is raising the
temperature of the milk to 62.5°C, holding for 30
minutes, immediately cooled rapidly to less than
10 C. within the Pasteurisation Cycle.
Bottles must be submerged during the heating cycle
Bottles should not be submerged during the cooling
cycle (unless foil sealed bottles are used).
Independent verification of satisfactory treatment of
the milk (not the water bath) for the complete cycle
(heating & cooling) must be kept for future
reference.
A free fully evidence based 25 year practice proven
treatment guide can be obtained
from: info@sterifeed.com
In presenting various therapeutic approaches for the
management of Cystic Fibrosis (CF), Smyth RL primarily considers evidence
obtained from The Cochrane Library as either systematic reviews of
randomised controlled trials (RCTs) or RCTs .[1] The antibiotic treatment
of Pseudomonas aeruginosa (PA) when first isolated, is still an open
question. When discussing this aspect, Smyth RL considers only the...
In presenting various therapeutic approaches for the
management of Cystic Fibrosis (CF), Smyth RL primarily considers evidence
obtained from The Cochrane Library as either systematic reviews of
randomised controlled trials (RCTs) or RCTs .[1] The antibiotic treatment
of Pseudomonas aeruginosa (PA) when first isolated, is still an open
question. When discussing this aspect, Smyth RL considers only the RCT by
Valerius et al.[2]
In our critical review of published clinical studies evaluating the
early antibiotic treatment in asyntomatic PA-colonised CF patients [3], we
identified 3 relevant RCTs (2 vs placebo).[2,4,5] Our study also included
8 cohort studies, 2 of which with historical controls. Overall, 309
patients (range 7-91) were recruited. There was a high variability between
the individual studies for age, outcomes measures, duration of follow-up
and treatment (3 studies- 2 RCTs, 1 cohort used only aerosol tobramycin,
1 colistin, 4 aerosol colistin plus ciprofloxacin, 1 used intravenous
treatment and 2 miscellaneous therapy).
An overall critical evaluation
indicated that early antibiotic treatment can reduce the rate of positive
cultures and of anti-PA antibody titres. Long-term benefit is expected but
not yet proven. Moreover, we recently conducted an observational study
which found that nearly all CF centres in Italy treat asyntomatic PA-colonised patients in order to prevent or postpone chronic pulmonary
infection (unpublished data). However, the adopted prescribing practice
varies largely even within the same centre, highlighting the existing lack
of formal consensus on this subject.
Several therapeutic options (aerosol therapy alone or oral therapy
associated with aerosol inhalation) are available for the early treatment
of PA colonisation but no direct comparison has so far been made.
Prospective multi-centre randomised studies with relevant outcomes
measures [6] are needed to investigate which of the different proposed
antibiotic schemes has the best benefit/risk ratio and the best patient
compliance.
Department of Paediatrics Institute of Child Health Burlo Garofolo
University of Trieste
Via dell'Istria 65/1 34100 Trieste Italy
Competing interests: None declared
References
1. Smyth RL. Diagnosis and management of cystic fibrosis. Arch Dis
Child Ed Pract 2005;90:ep1-ep6.
2. Valerius N, Koch C, Hoiby N. Prevention of chronic Pseudomonas
aeruginosa colonisation in cystic fibrosis by early treatment. Lancet
1991;338:725–6.
3. Marchetti F, Giglio L, Candusso M, Faraguna D, Assael BM. Early
antibiotic treatment of pseudomonas aeruginosa colonisation in cystic
fibrosis: a critical review of the literature Eur J Clin Pharmacol
2004;60:67-74.
4. Wiesemann HG, Steinkamp G, Ratjen F et al Placebo-controlled,
double-blind, randomized study of aerosolized tobramycin for early
treatment of Pseudomonas aeruginosa colonization in cystic fibrosis.
Pediatr Pulmonol 1998;25(2):88-92.
5. Gibson RL, Emerson J, McNamara S, et al. Significant
microbiological effect of inhaled tobramycin in young children with cystic
fibrosis. Am J Respir Crit Care Med 2003;167 (6):841-9.
6. Ramsey BW, Boat TF. Outcome measures for clinical trials in cystic
fibrosis. J Pediatr 1994; 124:177-192.
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article
on “The Obese Child” [1], we cannot agree with her conclusion that obesity
fulfils most of the criteria for a condition that justifies screening.
Our own local experience in Solihull, West Midlands, might illustrate this
point.
Using a grant from the Children’s Fund,
(www.cypu.gov.uk/corporate/childrenstrust/index,cfm)...
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article
on “The Obese Child” [1], we cannot agree with her conclusion that obesity
fulfils most of the criteria for a condition that justifies screening.
Our own local experience in Solihull, West Midlands, might illustrate this
point.
Using a grant from the Children’s Fund,
(www.cypu.gov.uk/corporate/childrenstrust/index,cfm) we aimed to set up a
“Fit Club” serving children aged 7-11 in 7 wards in Solihull, with DETRI
deprivation indices ranging from 7.53 to 54.49. All 7 wards contain
enumeration districts with deprivation indices in the worse 15% of the
country.
We attempted to recruit 20 children, for an initial consultation
phase, in which they and their families would be able to discuss with our
multi disciplinary team the kinds of services they would like to tackle
the child’s weight. They would be able to try out various exercise
programmes if they wished, as well as receiving dietetic advice, and as an
incentive we also offered £10.00 worth of fresh fruit and vegetables. The
only criterion for recruitment was that the child should be perceived to
have a weight problem both by their family and professionals.
We attempted to recruit children via contact with school nurses,
recommendation from General Practitioners, and an advertisement in the
local paper. To our disappointment, we found that we were able to recruit
only 4 children. GPs had forwarded 7 names, of whom one actually made
contact with the service, whilst the school nurses informally fed back
that families felt that their child’s weight was not an issue upon which
they needed to take action. A final attempt at recruitment, based on one
large primary school with support of teaching staff, was similarly
completely unsuccessful. It would seem likely that a difference in
perception of the seriousness of overweight and the need for action
between parents and professionals explained our disappointing outcomes. [2]
Our experience thus leads us to believe that detecting obese or
overweight children by screening will not substantially alter the scale of
these problems on a population basis, although services for those that do
request them are clearly justified.
References
(1). Mary C J Rudolph. The Obese Child. Arch Dis Child Educ Pract Ed
2004;89:ep 57-ep 62
(2). A N Jeffery, L D Voss, B S Metcalf, S Alba, T J Wilkin. Parents’
Awareness of Overweight in Themselves and Their Child: Cross Sectional
Study Within a Cohort (EarlyBird21), BMJ 2005;330:23-24
In India, we come across many cases of status epilepticus in
toddler age group. These children usually do not have a fever associated and
have an history of improper breast feeding and weaning.
The children may have clinical evidence of rickets, which had been
neglected. The common cause of these children getting rickets is
dietary, namely lack of vit D and inadequate sun exposure. The chil...
In India, we come across many cases of status epilepticus in
toddler age group. These children usually do not have a fever associated and
have an history of improper breast feeding and weaning.
The children may have clinical evidence of rickets, which had been
neglected. The common cause of these children getting rickets is
dietary, namely lack of vit D and inadequate sun exposure. The children
invariably present with status epilepticus due to associated
hypocalcemia and they do not respond promptly to sedation and muscle
relaxants. We need to collect blood for Calcium analysis and give
empirical IV Calcium gluconate which settles seizures in a minute.
I find that the metabolic cause of status epilepticus always gets
neglected in developing countries and invariably the child lands up being
loaded with 2-3 anticonvulsants and at times on ventilator.
With the high incidence of nutritional hypocalcemia, hypomagnesemia
in developing countries, I recommend that all status epilepticus (at least
in malnourished children)should get IV Calcium gluconate as a secondline
therapy, if not replacing IV diazepam, but definitely before loading with
other anticonvulsants.
Dear Editor,
The recognition of endocrine-related hypernatraemia would be enhanced if account were taken, not only of biochemically overt hypernatraemia(1), but also of the possibility that this biochemical derangement might be masked by co-existing inability to excrete salt-free water. The clinical counterpart of this phenomenon is encapsulated in the statement "the symptoms of cranial diabetes insipidus may be ma...
Dear Editor,
I read with interest the article of Elspeth Webb (Arch Dis Child Educ Pract Ed 2005;90: ep11-14). I find the content interesting and well set out and would agree what is in the article. However, I do feel there is a section missing. I feel that some visitors to this country, be they short term or permanent, seem to take no responsibility for their own welfare when it comes to language barriers. Emphasis...
Dear Editor,
Williams [1] highlights the key points in the management of inhaled foreign bodies (FB). One of the important points is to request inspiratory and expiratory chest radiographs if FB aspiration is suspected. Because young children are unable to co-operate, paired inspiratory and expiratory films are not always possible. The lateral decubitus film is a useful and convenient method to determine the presence of...
Dear Editor,
The statement by Sidebotham that "the consultant convened a strategy meeting" is misleading. Under Working Together social services and the police are responsible for convening this type of meeting. Paediatricians can 'request' a strategy meeting as can any other professional. It is important that responsibilities of the various agencies are clearly defined and understood by all.
Dear Editor,
Professor Smyth describes the occurrence of non-specific arthritis in some patients with cystic fibrosis (CF) in her recent article on diagnosis and management of cystic fibrosis.[1] As a consequence of the increased life expectancy in CF, rheumatic diseases are more likely to be observed, particularly in older patients.[2]
Two specific arthropathies are described in CF; an episodic arthriti...
Dear Editor
The guidelines regarding the milk banks may not be applicable for the developing countries, because these countries can not afford to have milk banks due to its cost. But the very fact the viruses particularly human immunodefiency virus can be inactivated by pasteurisation method is notable. The dilemma of advising breast milk feeding to the infants born to the HIV positive mothers in the developing cou...
Dear Editor,
I am a corporate member of UKAMB and consider issue three of the Guidelines to be an excellent reference.
However, to minimise the risks after feed preparation the thermal treatment (Pasteurisation)requirements should not only mirror issue two published by RCPCH but also include the following amplification of treatment, based on work by the late Prof J David Baum.
The Pasteurisati...
Dear Editor,
In presenting various therapeutic approaches for the management of Cystic Fibrosis (CF), Smyth RL primarily considers evidence obtained from The Cochrane Library as either systematic reviews of randomised controlled trials (RCTs) or RCTs .[1] The antibiotic treatment of Pseudomonas aeruginosa (PA) when first isolated, is still an open question. When discussing this aspect, Smyth RL considers only the...
Dear Editor,
Whilst we greatly enjoyed Mary C J Rudolph’s “Best Practice” article on “The Obese Child” [1], we cannot agree with her conclusion that obesity fulfils most of the criteria for a condition that justifies screening. Our own local experience in Solihull, West Midlands, might illustrate this point.
Using a grant from the Children’s Fund, (www.cypu.gov.uk/corporate/childrenstrust/index,cfm)...
Dear Editor,
In India, we come across many cases of status epilepticus in toddler age group. These children usually do not have a fever associated and have an history of improper breast feeding and weaning.
The children may have clinical evidence of rickets, which had been neglected. The common cause of these children getting rickets is dietary, namely lack of vit D and inadequate sun exposure. The chil...
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