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If only British and North American paediatricians would agree about what they mean by the term ‘bronchiolitis’ it might save a good deal of misunderstanding. Many American writings appear to include almost any child under the age of 2 who wheezes for the first time and would embrace what in Britain has been called ‘wheezy bronchitis’ or might even be asthma. Little surprise, therefore, that we do not agree about treatment. A meta-analysis in Archives of Pediatrics and Adolescent Medicine(1996;150:1166-72) comes out in favour of bronchodilator therapy (salbutamol or ipratropium) for children with ‘bronchiolitis’. The mean rate of respiratory syncytial virus positivity in the analysed trials was around 40% and in at least one trial it got as low as 3%. There’s no mistaking the disease which affects young babies and tends to fill up our hospital cots at the end of the year. How can we communicate about it? Lucina can only think of the term ‘epidemic infantile acute bronchiolitis’—any other suggestions?
It is reckoned that up to 70% of neural tube defects (NTDs) are preventable by folate supplementation. Now work on a mouse model of folate resistant NTDs suggests that many of the remaining defects could be preventable with inositol (Nature Medicine 1997;3:60-6, plus commentary Ibid: 24-5). Researchers at the Institute of Child Health, London administeredmyo-inositol (a water soluble B-complex vitamin which stimulates protein kinase C activity and increases expression of retinoic acid receptor β in the caudal region of the embryo) intraperitoneally to the pregnant mice and also cultured mouse embryos in various inositol concentrations. They found an almost fourfold reduction in spine bifida in the first case and a significant increase in neuropore closure with higher inositol levels in the second.
Attempts to find a vaccine for AIDS are dependent on work on monkeys using the simian immunodeficiency virus (SIV) which is genetically similar to HIV. SIVΔ3 is a strain which has been made avirulant by genetic manipulation and it is effective in protecting adult and young monkeys. The snag, however, is that large doses of SIVΔ3 can cause an AIDS-like disease in newborn monkeys raising the possibility of neonatal disease arising from maternal transmission of the vaccine strain. Work at Harvard on a relatively small number of animals has suggested that neonatal disease would only occur if the fetus or newborn got a very large dose from an unimmunised mother, a circumstance unlikely to occur in the human (Nature Medicine1997;3:32-6). Nevertheless more needs to be known about factors which either stimulate or suppress neonatal immune function before a live-attenuated vaccine can be ready for clinical trials (see commentary Nature Medicine1997;3:17-8).
Severe meningococcal disease could be an indication for ECMO (extracorporeal membrane oxygenation). At centres in London, Leicester, and Melbourne 12 patients aged 4 months to 18 years (10 below 6) were treated over a period of eight years (Lancet 1997;349:466-9). Five had severe acute (adult-type) respiratory distress syndrome and seven intractable shock. Eight patients survived and six were said to be normal on follow up.
Desensitising injections have been used to treat respiratory allergy for over 80 years. Now researchers at Johns Hopkins have shown no benefit from such injections in children with perennial atopic asthma (New England Journal of Medicine1997;336:324-31). Using up to seven allergens chosen on the basis of skin tests and RAST tests they were unable to show any significant differences between treatment and control groups as regards antiasthma medication use, symptoms, or airway sensitivity on follow up for over two years.
Although fewer than 1% of groin hernias in children are femoral hernias it is important for surgeons to keep the possibility in mind when an inguinal hernial sac is not found on groin exploration (British Journal of Surgery 1997;84:58-60). Surgeons in Leeds have described four personal cases, a further 10 from the records of the Leeds General Infirmary over the last 11 years, and 214 from a 30 year literature review. Boys are affected slightly more than girls and the incidence increases gradually through the first decade. About 60% are right sided and most are misdiagnosed as inguinal hernias. Incarceration or strangulation may occur. Surgery should include excision of the hernial sac and repair of the femoral canal.
In Sweden the incidence of malignant melanoma in the postpubertal teenage years has almost doubled in the last 10 to 15 years. (Archives of Dermatology1997;133:295-7). The national Swedish Cancer Registry shows that over a period of 35 years (1958–92) there were 287 cases in people under 20 of whom only 43 were under 14. The incidence rose rapidly after puberty. The cause of the recent increase is unknown but one unsubstantiated suggestion which will be of concern to paediatricians is that there might be a connection with neonatal phototherapy. There must surely be data available to either support or squash that suggestion fairly rapidly. The subject of malignant melanoma in childhood is extensively reviewed (133 references) in the same issue (pages 363-71).
An American survey (Journal of the American Medical Association 1997;277:1052-7) has shown that, compared with uncircumcised men, circumcised men are possibly slightly more likely to have had a sexually transmitted disease, are less likely to suffer erectile dysfunction, especially as they get older, and have a greater variety of sexual practices. The implications for recommendations as regards neonatal circumcision are unclear.
A baby in Italy developed heart failure with dilated cardiomyopathy at 3 weeks and at 6 months was thought to be dying. Because of one previous report, she was treated with intramuscular thiamine hydrochloride and she recovered (Lancet1997;349:616). She remained well at 20 months taking oral lipophilic thiamine (benfotiamine). Uptake of physiological amounts of thiamine is active and saturable but pharmacological amounts are absorbed by diffusion. The defect in this child was a failure of saturable thiamine uptake and the parents had reduced uptake, suggesting autosomal recessive inheritance. Infants with dilated cardiomyopathy of unknown cause should either have a serum thiamine measured or be treated with thiamine empirically.