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It is a little known fact that if you remove the pineal gland from newborn chickens they develop a spinal deformity similar to that of human adolescent idiopathic scoliosis. So could pineal insufficiency be a cause of idiopathic scoliosis? Unfortunately for the theory, a Viennese study (Journal of Bone and Joint Surgery2000;82-B:399–403) has shown no difference in circadian serum concentrations of melatonin between adolescents with idiopathic scoliosis and controls.
Workers in St Mary's Hospital, London (Journal of Bone and Joint Surgery 2000;82-B:387–91) have described their experience in managing 14 children with meningococcal septicaemia and limb ischaemia. Eight of the nine survivors had 14 limb segment amputations. They recommend that all ischaemic limbs should have Doppler and Duplex studies and compartment pressures should be measured. Fasciotomy should be done only in the lower limbs and only in the first 24 hours and if there is no contraindication such as excessive bleeding. Amputation should be delayed and elective.
Data from the 1946 Medical Research Council British birth cohort study have been used in an attempt to define the childhood antecedents of medically unexplained symptoms in adults (British Journal of Psychiatry2000;176:273–80). The risk of hospital admission for such symptoms was increased if the father was reported to be in poor health during the patient's childhood. Maternal ill health had no such effect. Recurrent abdominal pain in childhood increased the risk of admission for unexplained symptoms as an adult more than fourfold but the increase in risk was less for admission with unexplained abdominal pain (threefold) than for other unexplained symptoms (fivefold).
In a study in Brazil, Canada, and South Africa (British Journal of Dermatology2000;142:965–8) 60 of 61 children with tinea capititis were cured, both clinically and myocologically, with weekly fluconazole in a dose of 8 mg/kg. Most were cured with eight weeks of treatment but those withTrichophyton infection sometimes needed 12 weeks and patients with Microsporum canisinfection occasionally needed 16 weeks of treatment. The one failure was with M canis infection.
Whatever the causes of postnatal depression in mothers, early hospital discharge does not seem to add to them. In an Australian study including almost 1300 women (Medical Journal of Australia2000;172:532–6) there was no significant difference in rate of depression in the first six postnatal months between those discharged early (within 72 hours of birth) and those discharged later.
Among US paediatricians there appears to be a vogue for treating childhood fever with alternating doses of paracetamol (acetaminophen) and ibuprofen (Pediatrics2000;105:1009–12). The practice seems to have little or no scientific basis and it is suggested that it may lead to parental confusion, overdosing, or underdosing.
The transmission of infection is a risk of preschool child day care. Reports from Australia (Pediatrics2000;105:738–42 and 743–6) show that education of staff about infection control techniques may have some effect. For upper respiratory viral infections, compliance with infection control techniques reduced colds in children under 2 years (by 17%) but not in older children. For the control of diarrhoea, however, the age effect was the opposite; there was a 66% reduction in the over twos but none in younger children.
It is important that cells, especially those subject to mechanical stress—such as those of heart muscle and skin, should stick together. Plakoglobin is important in maintaining cell to cell adherence and its gene is at 17q 21. Now it has been shown that Naxos disease (autosomal recessive arrhythmogenic right ventricular cardiomyopathy, palmoplantar keratoderma, and woolly hair, described in families on the Greek island of Naxos) is caused by a mutation of this gene (Lancet2000;355:2119–24). Such a fundamental defect of cell function could have important implications for other heart and skin conditions. [Where is Naxos? It is one of the Cyclades islands and is about halfway on a line between Athens and Rhodes.]
Stem cell transplantation from HLA-identical siblings using umbilical cord blood is associated with a reduced risk of acute or chronic graft versus host disease, slower rates of engraftment, and similar mortality compared with bone marrow transplantation from such donors (New England Journal of Medicine2000;342:1846–54). As such umbilical cord blood is uncommonly available, comparable data are needed about transplantations from unrelated donors.
In San Diego, California (Journal of the American Medical Association 2000;283:2680–5) enterovirus-specific polymerase chain reaction testing of cerebrospinal fluid from 267 children with suspected aseptic meningitis was positive in half of them. A positive test meant that fewer other tests were done, antibiotic treatment was stopped earlier, and the child sent home sooner.
Fungal infection of the nails does occur in children although the diagnosis may often be missed. In Chicago (Archives of Pediatrics and Adolescent Medicine2000;154:614–18), 17 children aged 3–14 years were given itraconazole oral pulsed treatment (once or twice daily for one week of each month for three to five months). All patients but one were cured and there were no relapses after cure on follow up for between one and four years. There were no clinical adverse reactions.
Children with enterohaemorrhagic E coli infection should not be given antibiotics. In a prospective series in four states in the northwest of the USA (New England Journal of Medicine 2000;342:1930–6; see also editorial, Ibid: 1990–1), nine of 71 children withE coli 0157:H7-associated diarrhoea were given antibiotics. The incidence of haemolytic-uraemic syndrome was 5/9 (56%) in those given an antibiotic and 5/62 (8%) in those not given an antibiotic. Of those who developed the syndrome after antibiotic treatment, three had received a cephalosporin and two cotrimoxazole. Antibiotics may increase the release of verotoxin from the organisms.
In the USA it is recommended that adult seat belts in cars should not be used for children until the age of about 9 years. A study in 15 states (Pediatrics2000;105:1179–83) has shown that 2–5 year old children in seat belts are more than three times more likely to suffer significant injury, and more than four times more likely to suffer significant head injury in a crash than children in child restraint systems.
Seventeen years ago a team in Birmingham showed that the two year outcome in children with severe vesicoureteric reflux was the same whether they were treated medically or surgically. Now analysis of records in Australia and New Zealand (Pediatrics2000;105:1236–41) has shown no evidence that treatment of vesicouretic reflux since the early 1960s has resulted in a reduction in incidence of end stage renal disease due to reflux nephropathy. A randomised trial comparing treatment with no treatment is suggested.
A study of 123 children in Nigeria with pyogenic meningitis (Developmental Medicine and Child Neurology2000;42:462–9) has emphasised the potential danger of cerebral herniation. In 99 patients who had a lumbar puncture, death or neurological sequelae occurred in 21/81 (26%) of those with no clinical evidence of herniation and in 16/18 (89%) of those with such evidence either before or after lumbar puncture (or both before and after). (Patients with clinical evidence of cerebral herniation on presentation were treated with intravenous mannitol before lumbar puncture.) More severely ill patients had a much higher risk of herniation at presentation. These workers conclude that a selective policy for lumbar puncture might improve the outcome of pyogenic meningitis in developing countries.