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When 150 children with diabetes were admitted to hospital in Paris for overnight hourly blood glucose monitoring nearly a half had nocturnal hypoglycaemia and half of those were asymptomatic (Journal of Pediatrics 1997;131:27–33). Risk factors for nocturnal hypoglycaemia were more than one previous episode of severe hypoglycaemia, daily insulin dose over 0.85 IU/kg, more than 5% of recent home blood glucose values of 3.3 mmol/l or less, young age, and low blood glucose values before the evening meal (5.2 mmol/l or less at 7.30 pm) or in the early morning (6.7 mmol/l or less at 7.00 am).
Treatment with terbutaline (which stimulates adrenaline release) could prevent night time hypoglycaemia in people with insulin dependent diabetes. Researchers in Missouri, USA (Diabetes Care 1997; 20 :1231–6) studied 15 patients and showed that terbutaline was better than alanine plus glucose, or a bedtime snack, at preventing hypoglycaemia during the second half of the night. Nocturnal hypoglycaemia occurred 10 times after a bedtime snack and once after terbutaline.
In Wisconsin, USA, over 650 000 newborn babies were screened for cystic fibrosis using serum immunoreactive trypsinogen and, later, DNA analysis (New England Journal of Medicine 1997;335:963–9) but only half were assigned to early diagnosis by following up positive screening tests with sweat tests. The mean age at diagnosis (in infants who did not present with meconium ileus) was 12 weeks in the early diagnosis group and 72 weeks in the controls. The early diagnosis group were better nourished both at the time of diagnosis and on follow up.
At Johns Hopkins Hospital, Baltimore between 1968 and 1996 hemispherectomy was performed on 58 children, 27 for Rasmussen’s encephalopathy, 24 for cortical dysplasias, and seven for Sturge-Weber syndrome (Pediatrics1997; 100 :163–71). Four children died perioperatively but all 54 survivors were considered by parents and doctors to have benefited, 44 very much so. Seizures stopped in 54% and became only occasional in 24%. For Rasmussen’s encephalopathy the operation was followed by freedom from seizures or only occasional, “non-handicapping”, seizures in 90% of patients.
Routine screening for retinopathy of prematurity appears to cause distress to babies (British Journal of Ophthalmology 1997;81:762–4). In Dublin a series of 38 infants was examined, half of them placed on a standard cot blanket (controls) and half “nested” (placed on a soft padded surface with boundaries which maintained a flexed posture but with free limb movement). The nested babies cried less and showed less distress behaviour but their heart rates and oxygen saturation did not differ from those of controls.
In the US the birth weights of black babies tend to be less than those of white babies. Researchers in Illinois estimated that US born black people have about 25% European derived genes. They therefore proposed (New England Journal of Medicine 1997; 337 :1209–14) that, if the low birth weight of black babies is mainly genetically determined, babies of US born black mothers should have a greater mean birth weight than those of African born black mothers living in the USA. They found, however, the opposite; African born mothers in Illinois had bigger babies than US born black mothers, nearly as big as the babies of white mothers. These data are taken as evidence against a genetic hypothesis but it has also been difficult to explain racial birth weight differences on socioeconomic grounds. One suggestion is that socioeconomic factors working across several generations may be important. African born mothers in the USA are likely to have come from the more affluent section of African society.
Reports from Finland (Lancet1997;350:1205–9) and Venezuela (New England Journal of Medicine 1997;337:1181–7) have shown a quadrivalent rhesus-human rotavirus oral vaccine to be effective in both prosperous and poor countries. In Venezuela there was an 88% reduction in severe rotavirus diarrhoea and in Finland 91%. The Finnish workers estimate that the vaccine would reduce severe childhood diarrhoea overall by about 60%.
Eating disorders in adolescent girls and young women are newsworthy but how common are they? In Cambridgeshire over 1000 schoolgirls aged 11–16 were studied (British Journal of Psychiatry 1997; 171 :542–4). Significant concerns about weight or body shape were expressed by 15% of 11–12 year olds and 13–14 year olds but by 19% of 15–16 year olds. The younger girls did not show behavioural or ideational disturbance but 10% of the older girls with significant concerns about weight or shape had bulimic episodes. There seems to be a potential for conflict between those who are concerned about the effects of obesity and those who fear that attempted dietary restrictions may precipitate eating disorders.
At a New York hospital over a period of three years 100 children had endoscopic removal of recently swallowed foreign bodies and five were treated for foreign bodies ingested two months to two years previously (Journal of Pediatric Surgery1997;32:1429–31). The five ranged from 2 to 3.5 years and all had swallowed metallic objects which lodged in the oesophagus. Excessive salivation and recent onset asthma were the main symptoms but oesophageal erosion was the main danger. One child died of massive bleeding from an oesophagoaortic fistula when endoscopic removal of the foreign body was attempted. Another had a fistula from the oesophagus into a bronchus and in a third child the foreign body, a toy soldier, was part in the oesophagus and part in the mediastinum. Two children had fever due to mediastinal inflammation. Longstanding oesophageal foreign bodies may be difficult to remove and may need thoracotomy. All five children had been seen by a doctor soon after the ingestion but had not had a chest x ray.
Petechiae (<2 mm diameter) in children with fever do not seem to have the same serious significance as purpura. In a series of 411 children presenting to an emergency department in Boston, Massachusetts with petechiae and fever (Journal of Pediatrics 1997; 131 :398–404) only six had septicaemia (two meningococcal, one group A streptococcal, three organism unknown) and two had pneumococcal bacteraemia. All of those with septicaemia were ill looking and the two with meningococcal septicaemia also had purpura. No child with septicaemia had a blood white cell count in the range 5–15×109/l. Lucina is instinctively cautious about these things and these American workers advise a period of observation to exclude progressive petechiae before considering allowing a well looking child with fever, petechiae, and a normal white cell count to go home.