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MRI IN DAYTIME URINARY INCONTINENCE
Daytime wetting is a common reason for referral to general and community paediatric clinics. Investigations are rarely necessary, beyond excluding urinary tract infection, polyuria, psychological distress and—perhaps—constipation. Such a course of action will miss the few children who have neuropathic vesicourethral dysfunction in association with a spinal cord anomaly. Diagnosis is by MRI of the spine but the indications are not clear. This month we publish a retrospective study of children referred from a tertiary neuro-urology clinic for exclusion of such an anomaly. Forty-eight children were studied, 5 proving positive. Wraige and Borzyskowski from Guy's Hospital, London have used their findings to offer guidance on which children merit imaging, including in their paper a suggested investigative protocol
You should think MRI if daytime wetting is associated with abnormal neurological signs in the lower limbs, an abnormal lumbar spine x ray, lumbosacral birthmarks, or anorectal anomalies. Think twice, but do videourodynamic studies first, in those with symptoms such as voiding difficulty, urinary retention or impaired bladder sensation. See page 151
ANTIBIOTICS IN URINARY INFECTION
Adults with urinary tract infection (UTI) are frequently prescribed an ultra short course of an appropriate antibiotic, for example amoxicillin 3g repeated once after 12 hours. Paediatricians have been reluctant to follow this example; indeed the British National Formulary does not offer a dose recommendation of this type for children. Michael and colleagues from New South Wales have conducted a systematic review of RCTs of short and standard duration of treatment for UTI. They found 10 such studies suitable for analysis and uncovered the usual depressing list of scientific inadequacies. Nonetheless they report no significant differences of outcome at the end of treatment or in recurrence rates between 10 days and 15 months. Confidence intervals are wide so the authors calculated how many children would need to be studied to nail the answer to the wall. This turns out to be an impracticable 8–10 thousand. For the time being they suggest their data indicate that 2–4 days treatment is unlikely to pose a disadvantage for children with lower tract UTI. See page 118
ALL THAT WHEEZES IS ASTHMA (OR IS IT?)
Previously we have published studies casting doubt on the usually accepted definitions for childhood asthma used in population studies involving parental questionnaires. In 2000, we reported that parents and their doctors agreed less than half the time on whether a particular child wheezed.1 In 2001, the same team showed parents video clips of children who either wheezed or made some other respiratory sound. Once again, around half of the parents labelled the sounds wrongly, whether or not their own child was asthmatic.2 In the same issue of ADC, ATOMS made gentle sport at the expense of another intrepid audio-visual team, who introduced us to ruttles and rattles.3
This month, researchers from the University of Leicester (UK) attempt to define how to improve the quality of parental reports when investigating the prevalence of asthma. A semi-structured interview was used to analyse how parents made judgements about respiratory signs. Once again, it is clear that parents vary in how they interpret key questions commonly used in surveys such as the ISAAC questionnaire4 For example, the word “whistling” is used in ISAAC but caused confusion for many parents interviewed. The authors offer sound advice on how to refine the questions to be asked.
No doubt this story has not yet run out of steam. See page 131
EARLYBIRD CATCHES THE COUCH POTATO
Nobody should be complacent about the pandemic of childhood obesity. In studying the problem it has proved easier to measure how much food than how much exercise children take. Metcalf and colleagues from the EarlyBird Research Centre in Plymouth (UK) present an intriguing study of physical activity in children aged 5 using an unobtrusive accelerometer, worn on the hip for up to 7 days. The device was acceptable to most of these young children. The resulting analysis showed that boys exercised more than girls and physical activity was less generally and of a smaller range on school days than at weekends. Those children who were inactive during the week were also inactive at weekends. The authors point out that, paradoxically, school attendance seems to constrain physical activity when it could have the potential to encourage it. See page 166
I expect readers frequently think that papers in medical journals are useless but rarely tell us so. Our innovative problem-solving series, Archimedes, continues to provoke. Nine paediatricians on an MMedSci course were challenged to try the technique for themselves and were asked whether the effort was worthwhile. They tell us it was. So, what do you make of that Dr Tony Lopez?5See page 168