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To Lucina a comedone was just a comedone. Now she learns (British Journal of Dermatology 2000;142:1084–91) that there are many types including micro-, macro-, ordinary, missed, sandpaper, submarine, drug induced, chlorine induced, naevoid, and conglobate comedones. Unless you are able to recognise the various types you may prescribe the wrong treatment for acne. For instance, macrocomedones may flare up on treatment with isotretinoin and are probably best treated with cautery under local anaesthesia.

Oesophagitis may not always be due to acid reflux. In Melbourne, Australia (Journal of Pediatrics2000;136:641–7), nineteen infants had persisting distress and vomiting unresponsive to a change of formula milk (mostly to hydrolysed formula). Only two of 14 infants tested had a fractional reflux time of over 10% on oesophageal pH monitoring but nine had biopsy proved oesophagitis. All lost their symptoms within two weeks of changing to a hypoallergenic amino acid based formula and after three months, on double blind placebo controlled challenge with the previously best tolerated formula milk, 12 relapsed.

Parents and general practitioners (GPs) may think differently about hyperactivity in children (British Journal of General Practice 2000;50:199–202). A study of 10 inner London GPs and 29 parents of hyperactive children showed that the parents (many of whom had attended a tertiary psychiatric referral centre with their children or were members of a hyperactivity support group) believed the problem to be biological, long lasting, and in need of diagnosis and treatment, whereas the GPs tended to consider the hyperactivity to be a temporary response to family stress not worthy of a diagnostic label and often related to faulty parenting. Both groups could be right in the context of their own experience but there is a clear potential for clashes, especially when the degree of hyperactivity is outside the usual experience of the GP.

Lucina recently referred to the successful treatment of tinea capitis with fluconazole. Those seeking guidelines and a review of the options in the treatment of this condition should look in theBritish Journal of Dermatology(2000;143:53–8).

For many years paediatricians have been familiar with the concept of liver enzyme induction by anticonvulsant drugs and the possibility of reduced effectiveness of other drugs as a result. Therefore, it seems surprising that it has taken until now to show that treatment for acute lymphoblastic leukaemia may be affected in this way. At the St Jude Children's Research Hospital in Memphis, Tennessee (Lancet2000;356:285–90) concomitant anticonvulsant treatment (with phenytoin, phenobarbitone, or carbamazepine) was associated with reduced event free survival and increased haematological and CNS relapse rate in children with B lineage leukaemia but not in those with T cell leukaemia. Clearance of teniposide and methotrexate, but not cytarabine, was increased. Valproate, benzodiazepines, or gabapentin are suggested as preferred anticonvulsants in these circumstances.

Mothers in Connecticut (Pediatrics2000;106:1–5) who had children with breath holding spells or seizure disorders showed more stress than control mothers, and the mother–child relationship seemed to be even more affected in the case of breath holding spells than if the child had a seizure disorder. Written information about breath holding spells or seizure disorders was shown to be very helpful to the mothers.

Some cases of severe gastro-oesophageal reflux in childhood may have a genetic basis. A study of five American families identified through a patient support group, each with several members affected by severe reflux in childhood (JAMA2000;284:325–34) has shown a pattern of autosomal dominant inheritance with high penetrance and the gene was mapped to the long arm of chromosome 13 (13q14).

A study in Quebec (Pediatrics2000;106:67–74) has shown that over half (56%) of children talk in their sleep at some time and the incidences of other parasomnias—such as, sleepwalking, night terrors, restless legs, and bruxism, are between 14% and 32%. Symptoms usually appear in early childhood and stop by the age of 13, but talking in sleep, restless legs, and sleep bruxism are still common at that age.

Studies in the advantaged world have shown that twins have a higher mortality than singletons not only in the neonatal period but also in infancy and later childhood. Now a study in Malawi, Tanzania, and Zambia (International Journal of Epidemiology2000;29:678–83) has shown that twins there have a sixfold increase in neonatal mortality and a 2.3-fold increase in postneonatal childhood mortality compared with singletons. Most of the excess postneonatal mortality is in infancy. The extra deaths in twins affect particularly boys, unwanted children, those born after a short interval between pregnancies, and socially and economically disadvantaged children.

Of all babies born at 20–25 weeks gestation in the United Kingdom and Ireland in March–December 1995 (New England Journal of Medicine2000;343:378–84), 70% were stillborn, 9% died in the delivery room, and 21% were admitted to neonatal intensive care, of whom 37% survived to go home. Of the survivors assessed at 30 months' corrected age, about half were normal, a quarter had mild or moderate disability, and a quarter had severe disability.

After major heart surgery children develop transient secondary hypothyroidism. In Germany (Lancet2000;356:529–34), a randomised trial which included 40 children showed that those given intravenous infusions of triiodothyronine after operation had better systolic function and fewer intensive care procedures than the placebo group.

A 1996 UK Department of Health recommendation of wet combing (“bug busting”) for the treatment of head lice was not apparently evidence-based. Now a trial in north Wales (Lancet2000;356:540–4) has shown cure rates of 38% with wet combing, and 78% with 0.5% malathion lotion, even though the lice there are known to have an intermediate degree of resistance to malathion.

In holoendemic malarial areas in Tigray, Ethiopia (Lancet2000;356:550–5), teaching mothers to give chloroquine early to their young (under 5) children with symptoms of malaria reduced overall under 5 mortality by 40%. Chloroquine resistance and varying community, social, economic, and political factors could, however, reduce the effectiveness of the policy in other areas of Africa.

Racecadotril inhibits encephalinase which degrades encephalines. Encephalines reduce gut levels of cyclic AMP by activating endogenous opiate receptors, which leads to reduced secretion of water and electrolytes. In 3 to 35 month old children with watery diarrhoea in Peru, oral racecadotril reduced 48 hour stool weight by 46% and duration of diarrhoea by 56% (New England Journal of Medicine2000;343:463–7). The drug was equally effective in children with and without rotavirus infection even though the postulated mechanism should, in theory, have been less effective in rotavirus associated diarrhoea.

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