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A conservative approach to the management of tear duct obstruction in babies does not lead to an excess of epiphora at the age of seven. A cohort study in Dundee (Eye1998;12:669–71) showed no relation between congenital nasolacrimal duct obstruction and excess tearing in 7 year olds. Almost 8% of 7 year olds were said by their parents to have excess tearing but at that age it seemed to be related either to atopy or to viral upper respiratory infections.

Improved hearing is only one outcome to be considered after insertion of grommets for glue ear. A parent questionnaire survey in Liverpool and Southport (Journal of Laryngology and Otology1998;112:732–41) showed that after the operation 67% of parents thought their child could hear the television better, 63% thought the child’s general health was improved, reported behaviour problems at school or nursery fell from 49% to 7%, and speech difficulties from 37% to 21%. The parents also reported postoperative reductions in earache and in prescriptions for antibiotics. These parental perceptions may explain why parents who have experience of grommet insertion in one child are often keen for subsequent children to have the same operation.

Thickened, whitened, broken finger nails in young children are not usually a sign of fungal inflection. In Bologna, Italy 20 children aged 1–10 years at disease onset were given a diagnosis of parakeratosis pustulosa (Pediatric Dermatology1998;15:259–63). None had a fungal infection but eight had, or developed evidence of, psoriasis, four had allergic contact dermatitis, and two atopic dermatitis. On follow up for one to nine years 11 children recovered completely and nine were left with only mild nail changes.

Amputated noses can be reimplanted. “How would a nose come to be amputated?” Lucina asked herself. In the cases of two American children (Archives of Otolaryngology—Head and Neck Surgery1998;124 :907–10) the answer was a dog bite. Neither reimplantation was completely successful and both children needed repeated surgery but the end results were much better than they would have been without any attempt at reimplantation.

A 98% pertussis immunisation rate in Finland has not eliminated bordetella infections (Journal of the American Medical Association 1998;280:635–7). Of 584 patients aged 7 days to 74 years with a paroxysmal cough 153 had bordetella infection, 61% B pertussis, 32%B parapertussis, and 7% both. In schoolchildren and adults B pertussis was the more common organism but in preschool childrenB pertussis and B parapertussis were equally common. In this study the two organisms caused similar disease. Protection againstB parapertussis may be an important factor to be taken into account in the development of new vaccines.

Lucina’s advisers in political correctness invariably consider her penchant for the scientific method to be antediluvian whenever the subject of alternative medicine crops up. An editorial in the New England Journal of Medicine(1998;339:839–41) lays out the scientific and reasoned position quite clearly. It has been claimed that chiropractic spinal manipulation may be beneficial not only in spinal conditions but also in non-spinal conditions such as asthma. In Canada (Ibid, 1013–20) 91 children with mild or moderate asthma receiving conventional treatment were randomly assigned to active or dummy chiropractic manipulation. Although both groups improved there was no difference between the groups and the researchers concluded that chiropractic spinal manipulation did not benefit these children.

A study in Canada (New England Journal of Medicine1998:339:947–52) has shown that biphosphonate treatment benefits children with severe osteogenesis imperfecta. Thirty children aged 3–16 were given intravenous infusions of pamidronate (four-hour infusions on three successive days repeated every four to six months for 1.3–5 years). During treatment the fracture rate fell from 2.3 to 0.6 per year and all of the children felt relief from chronic pain and fatigue. Bone density increased by 42% per year, vertebral bodies increased in size, and metacarpal cortices became thicker. There were no serious adverse effects but most (26 of 30 children) had a febrile reaction on the second day of the first series of infusions, which did not recur.

Sudden death may be preventable by surgery in some children with hypertrophic cardiomyopathy. In Toronto (New England Journal of Medicine1998;339:1201–9) 10 of 36 children with this disease had systolic compression of a coronary artery by heart muscle (myocardial bridging) on angiography. These patients were prone to myocardial ischaemia and cardiac arrest. Three patients, each of whom had been resuscitated from numerous cardiac arrests, underwent surgical deroofing of the affected coronary artery. Two had had no more cardiac arrests after six months and five years; the third had had only one episode of arrhythmia and no longer had cardiac ischaemia on exercise.

About 250 million children around the world are at risk of vitamin A deficiency. Vitamin A supplementation works but the unanswered question is how best to give it. A large trial in Ghana, India, and Peru (Lancet1998;352:1257–63) has shown that giving the vitamin to breast feeding mothers in the first 6 weeks and to their babies along with diphtheria, pertussis and tetanus, and polio immunisations at 6, 10, and 14 weeks slightly, but significantly, reduced the prevalence of vitamin A deficiency (low serum retinol) at 6 months, but did not affect serum retinol levels at 9 and 12 months. It had no effect on morbidity or mortality in the first year. Vitamin A supplements, therefore, need to be continued beyond the age of 6 months.

People have been searching for the Holy Grail for diagnosis of neonatal sepsis for as long as Lucina can remember. Work in Germany, Slovakia, and Austria (Lancet1998;352:1271–7) has confirmed that C-reactive protein (CRP) is not good enough but plasma concentrations of interleukin-1 receptor antagonist were raised in 26 of 28 very low birthweight babies on the day of clinical diagnosis of sepsis and in 18 on the day before. The test was 92% specific. Interleukin-6 concentrations were slightly less reliable but still much better than CRP. It takes about 90 minutes to get a result.

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