Developmental dysplasia of the hip in South Australia in 1991: Prevalence and risk factors

To determine the prevalence of developmental dysplasia of the hip (DDH) in South Australia (SA) in 1991, the proportion of cases detected in the neonatal period and the perinatal risk factors for DDH.

Methodology:

Cases of DDH born in SA in 1991 were identified from multiple sources and their clinical data linked to perinatal data provided by midwives; five controls per case were obtained randomly from SA livebirths without congenital abnormalities and adjusted odds ratios (OR) for potential risk factors obtained by logistic regression analysis. South Australia perinatal data were also used to estimate numbers of births with perinatal risk factors for targeted screening.

Results:

Two hundred and six cases of isolated DDH were identified, giving a prevalence of 10.5 per 1000 births. Of these, 173 (84%) had been detected in the neonatal period. The perinatal risk factors for DDH were identified as breech presentation (OR 9.65), female babies (OR 4.04), first births (OR 1.91) and maternal age of 25 years or more (OR 1.53). Screening breech and firstborn female babies (23% of births) would yield approximately 51% of cases of DDH.

Conclusions:

Isolated DDH had a prevalence of 10.5 per 1000 births and 84% of cases had been detected in the neonatal period in SA. Repeated screening during infancy of 'at risk' groups of babies is recommended.     

Prevalence of maternal depression and its relationship to ADL skills in children with developmental delay

To determine the prevalence of maternal affective symptoms in children with developmental problems compared to a control group, and to examine their relationship to the child's Activities of Daily Living (ADL), socialization skills and behaviour.

Methodology:

This study examined prospectively the prevalence of symptoms of maternal depression, maternal anxiety, stress and adverse life events in 65 mothers whose children were attending a Child Development Clinic. ADL and socialization skills were measured using the Vinelands Adaptive Behaviour Scales, and behaviour using a checklist.

Results:

Symptoms of maternal depression ( P =0.04), maternal anxiety ( P =0.01) and number of adverse life events ( P =0.03) were increased in the study compared to control mothers. Presence of maternal symptoms was unrelated to ADL or socialization skills though was associated with increased behavioural symptoms in the child.

Conclusion:

Affective disturbance in mothers of children with developmental problems are common and should be addressed as part of a comprehensive assessment of such children.     

The immunogenicity of Haemophilus influenzae: Meningococcal protein conjugate vaccine in Polynesian and non-Polynesian New Zealand infants

To examine the comparative immunogenicity of the Haemophilus influenzae type b-meningococcal protein (PRP-OMP) conjugate vaccine in Polynesian and non-Polynesian New Zealand infants.

Methodology:

Fifty-six Polynesian and 53 non-Polynesian infants aged 2–7 months recruited from primary health care settings in Auckland received a two-dose primary series of PRP-OMP. A sub-sample of 83 participants received a booster dose of PRP-OMP at 12–16 months of age. Anti-PRP antibody concentrations were measured in pre- and post-vaccination blood samples.

Results:

Antibody responses consistent with long-term protection (≥1.00 μg/mL) were observed in 72, 85 and 95% of children following the first, second and booster doses.

Conclusions:

Despite differences in disease epidemiology, PRP-OMP was highly immunogenic in Polynesian and non-Polynesian infants.     

Preliminary study of glycopyrrolate in the management of drooling

A study was undertaken to assess the efficacy of an oral anticholinergic drug, glycopyrrolate, in the management of drooling in children and young adults with disabilities.

Methodology:

Glycopyrrolate was used by 24 children and young adults for up to 28 months. Parents/carers were asked to complete a questionnaire on the effects of the drug on severity and frequency of drooling and to report any side-effects.

Results:

Twenty-two questionnaires were returned. There was a statistically significant decrease in both severity and frequency of drooling with minimal side-effects reported.

Conclusion:

In this preliminary study, glycopyrrolate was found to be an effective and well-tolerated addition to the management of drooling in children with disabilities.     

Longitudinal study of rotavirus infection in child-care centres

To describe the epidemiology of symptomatic and asymptomatic rotavirus infection among young children attending Sydney child-care centres during the 1994 rotavirus season.

Methods:

Children aged 0–36 months in 11 child-care centres participated in the study. A weekly stool specimen was collected from each subject and tested for rotavirus antigen by commercial enzyme immunoassay.

Results:

One hundred and seventy-eight children (76 girls and 102 boys) with a mean age of 18.2 ± 6.5 (SD) months were enrolled for a total of 2249 child-weeks. Of 1653 weekly faecal specimens, 59 (3.6%) were positive for rotavirus antigen. Positivity for rotavirus antigen peaked at 8.0% and 7.4% of specimens in weeks 6 and 7, respectively. The 59 positive specimens were obtained from 44 children in eight of the 11 study centres. One child appeared to suffer a second episode. Eighty-two per cent of episodes were associated with symptoms of gastroenteritis. Overall, 32% of the children in the eight affected centres were infected; 52% of those <12 months were infected compared to 26% of older children. Secondary spread to household contacts was also documented.

Conclusions:

Rotavirus infection poses a significant health problem in under-3-year-old children attending child-care centres in Sydney. We believe that these results are applicable to all Australian children of this age attending group child care.     

Extreme sodium derangement in a paediatric inpatient population

To determine the aetiology, symptoms and outcome of extreme sodium derangement in a paediatric inpatient population.

Methodology:

A retrospective study of children with extreme disturbance of their plasma sodium (≥ 165 mmol/L or ≤ 115 mmol/L) admitted to a tertiary referral centre during a 72-month period.

Results:

Twenty-seven cases of hypernatraemia and 21 of hyponatraemia were reviewed. Sodium disturbance developed after hospital admission in 27/57 cases (57%). Gastroenteritis was the most common cause of hypernatraemia (8/27; 30%), four of 27 (15%) had iatrogenic hypernatraemia. Water overload accounted for 8/21 (38%) cases of hyponatraemia. Neurologic symptoms occurred in 19/24 (79%) with hypernatraemia and in 11/19 (58%) with hyponatraemia. Ten (37%) with hypernatraemia and four (19%) with hyponatraemia died. A deterioration in functional status was seen in two patients with hypernatraemia. There was no apparent deterioration in the survivors with hyponatraemia.

Conclusion:

Extreme sodium disturbance often develops after admission to hospital and is caused by a variety of diseases and interventions. Neurologic symptoms are common and the mortality rate is high. The outcome in survivors is most likely to be dependent on the underlying disease process.     

The overlap of attention deficit hyperactivity disorder with other common mental disorders

The literature on the overlap (co-morbidity) of attention deficit hyperactivity disorder (ADHD) with conduct disorder, specific learning disability, and anxiety disorders was reviewed to examine: (i) the evidence for ADHD being a syndrome distinct from the other conditions; and (ii) the evidence for co-morbid patterns representing meaningful subtypes of ADHD.

Methodology:

Narrative review of the literature.

Conclusions:

Conduct disorder is distinguished from ADHD by prognosis, patterns of association and familial aggregation. 'Pure' disorders are uncommon, however, and there is little evidence to support a distinct co-morbid subtype. There are few data that reliably distinguish ADHD from specific learning disabilities, but there are weaknesses in research to date. A specific ADHD + learning disabled subtype may exist, but as yet the implications for treatment are not known. Attention deficit hyperactivity disorder is distinguished from anxiety by symptom discrimination, factor analysis, patterns of association, familial aggregation and treatment response. There is evidence for a distinct ADHD + anxiety subtype.     

A follow-up study of infants ≤ 2000 g birthweight treated in central Queensland

This follow-up study was undertaken in an effort to ascertain the morbidity in the survivors of infants ≤2000 g birthweight cared for in the two Rockhampton intensive care nurseries.

Methodology:

The records of all infants ≤2000 g delivered in or transferred to Rockhampton during the 11 year period 1979 through 1989 inclusive were extracted. Efforts were made to contact and examine all of these children. Those found to be disabled were assessed as being mildly, moderately or severely affected.

Results:

Of the 482 infants of birthweight ≤2000 g treated in the period under review, 393 survived to be discharged from hospital. Eight were known to have died subsequently. Of the remaining 385 children, 288 (74.8%) were able to be contacted and their health status determined. A total of 36 infants were found to have significant disabilities. Twenty-four were mildly affected, five moderately and seven severely affected. Severe disability in infants of ≤1000 g was 16% (3/19).

Conclusions:

The incidence of disability was established in 74.8% of the surviving population, It was not dissimilar to the incidence of disability in similar birthweight groups in some Australian tertiary centres for the years under study. It is emphasized that the follow-up was incomplete and recognized that the survival rates and incidence of disability in survivors has improved in tertiary centres since the time frame of this study.     

Vigabatrin as first line therapy in infantile spasms: Review of seven patients

To study the efficacy of vigabatrin as initial therapy in infantile spasms.

Methodology:

We reviewed seven patients with newly diagnosed infantile spasms referred to Tuen Mun Hospital, Hong Kong from 1994 to 1995. Vigabatrin was given as the initial monotherapy at therapeutic dose of 50–100 mg/kg. Efficacy was evaluated at the end of second week of treatment.

Results:

Significant improvement was observed in four patients, 50–75% seizure reduction in two and no response in one patient. Efficacy was noted within the first week of treatment in five of the six patients who responded. No adverse effects were observed. Vigabatrin monotherapy could be continued in five patients.

Conclusion:

Vigabatrin could be considered as the first line treatment in infantile spasms. A period of 2 weeks may be sufficient to evaluate its efficacy.     

Emergency management skills of South Australian paediatric trainees

This article describes a theoretical and practical assessment of the emergency management skills of South Australian paediatric trainees. The aim was to identify strengths and weaknesses so as to optimally orientate future training in this area, and to provide a baseline that could be used to assess effectiveness of future interventions.

Methodology:

Thirty-four paediatric trainee medical officers responsible for after hours emergency care in Adelaide were asked to anonymously complete a 24 question theory assessment based on recognized emergency management training programmes, and to perform a mock clinical resuscitation. Response rate was 90% for the theoretical section and 69% for the practical.

Results:

The average trainee was found to be deficient in one quarter to one third of the theoretical precepts, and required an average of 2 min to establish effective bag-valve-mask ventilation with an infant manikin.

Conclusions:

There is a range of theoretical and practical resuscitation deficits that may currently hinder effective emergency management by paediatric trainees.     

V-shaped pillows and unsafe infant sleeping

To investigate the possibility that adult size V-shaped pillows may be associated with accidental asphyxial deaths in infants.

Methodology:

Review was undertaken of all cases of sudden infant death presenting to the Women's and Children's Hospital in Adelaide involving infants who had been found on adult size V-shaped pillows.

Results:

Four cases of sudden infant death were found in which infants were found sleeping on V-shaped pillows. All of the deaths had occurred in 1995. In two of the cases the pillows were considered to be implicated in the cause of death as the potential for obstruction of the infants' airways could be demonstrated on death scene reconstruction.

Conclusion:

Adult size V-shaped pillows may be unsafe for use in small infants who may accidentally suffocate if trapped between the two arms, or under, the pillow. The use of such pillows to maintain the body position of sleeping infants should be discouraged.     

Prospective study of New Zealand very low birthweight infants: Outcome at 7–8 years

To determine the survival and sensorineural outcome at 7–8 years in very low birthweight (VLBW) infants born in New Zealand in 1986.

Methodology:

In 1986 all VLBW New Zealand infants admitted to neonatal units were enrolled in a prospective study of acute retinopathy of prematurity. Surviving infants were traced and were assessed at a home visit. Parents were asked a comprehensive questionnaire, and children underwent a visual assessment including photorefraction and were tested with the Revised Wechsler Intelligence Scale for Children (WISC-R).

Results:

Four hundred and thirteen VLBW infants were admitted to neonatal units in 1986, 338 (81.8%) surviving to discharge. 12 children died after discharge, 17 were traced to overseas, seven declined to participate and four were untraced, leaving 298 (96% survivors resident in New Zealand) who were assessed at a mean age of 7.6 (± 0.4 years. 15 children (5.0%) had severe disability, 14 (4.7%) moderate disability, and 46 (15.4%) mild disability. Blindness (vision worse than 6/60) occurred in eight children (2.7%), deafness requiring aids in four (1.3%), any form of cerebral palsy in 17 (5.7%), and an IQ score on the WISC-R>1 SD below the mean in 62 (20.8%). There was no significant difference in outcome for children with birthweight <1000 g and 1000–1499 g.

Conclusions:

Long-term (7–8 year) survival and disability rates in this national cohort of VLBW infants is comparable with that reported from other populations. Although a majority of children have no disability a sizeable proportion do perform poorly on the WISC-R. This may relate in part to problems such as a short attention span and poor visual-motor integration.     

Erythromycin treatment for gastrointestinal dysmotility in preterm infants

To report our clinical experience on the use of oral erythromycin for the treatment of severe gastrointestinal dysmotility in preterm infants.

Methodology:

A case series study of seven preterm infants (six were very low birthweight) with severe intestinal dysmotility in a tertiary neonatal centre.

Results:

All responded favourably without adverse effects and tolerated full enteral feeding within 1–2 weeks of the commencement of the drug.

Conclusions:

As prolonged total parenteral nutrition carries significant risk of complications, this therapy could be considered in selected preterm infants who fail to establish enteral feeding after an extended period, and in whom an anatomically obstructive lesion of the gastrointestinal tract has been excluded. Meanwhile, we would caution against the widespread implementation of this therapeutic approach until formal evaluation by randomized controlled trials have established the exact role of erythromycin, or its analogues, in the treatment of intestinal dysmotility in preterm infants.     

Fat gram target to achieve high energy intake in cystic fibrosis

Higher fat and energy intakes confer a survival advantage in cystic fibrosis (CF). There is a need to develop effective nutrition programmes that ensure optimal energy intake in CF.

Methodology:

A cross-sectional measurement of clinical characteristics and energy and fat intakes in patients attending the CF outpatients clinic of the John Hunter Hospital, Newcastle was undertaken. Twenty-nine subjects, mean age 12 years (range 4.3–20.2), completed weighed food records to determine the contribution of fat to the percentage of the recommended energy intake obtained and to document use of pancreatic enzyme replacement therapy.

Results:

Diets with a high percentage of energy derived from fat did not guarantee that individuals with CF met their energy requirements. Subjects with total fat intakes of 100 g per day or greater, however, achieved in excess of 110% recommended daily intake (RDI) for energy. Up to 47% of subjects consumed more pancreatic enzyme replacement capsules than shown to give maximum effectiveness.

Conclusion:

Setting a 100 g daily fat target is a realistic way of ensuring high energy intakes in CF. Fat ready reckoners would identify the fat content of food and prescribe specific numbers of pancreatic enzyme replacement capsules to be consumed with each meal or food item.     

Prolonged low-dose indomethacin therapy for patent ductus arteriosus in very low birthweight infants

To determine the efficacy and side-effects of prolonged low-dose indomethacin therapy in very low birthweight (VLBW; <1500 g) infants with a haemodynamically significant patent ductus arteriosus (hsPDA).

Methodology:

Very low birthweight infants admitted over a 16 month period were studied (6 months, retrospectively and 10 months, prospectively). Cross-sectional and M-Mode echocardiograms with pulsed-wave and colour Doppler were performed to assess the significance of ductal patency.

Results:

Forty-one (28%) of 148 VLBW infants were diagnosed to have hsPDA. Indomethacin therapy was successful in 90% after the first course, increasing to 95% after the second course. The recurrence rate after the first course was 3%. Minor and transient complications included oliguria, urea retention, hyponatraemia and thrombocytopenia. Although three infants had focal bowel perforation and the fourth had bowel perforation associated with necrotizing enterocolitis, the incidence of gastrointenstinal pathology was not significantly different from infants without hsPDA and not given indomethacin.

Conclusions:

Very low birthweight infants with hsPDA have a high response rate and low recurrence rate to prolonged lowdose indomethacin therapy. Side-effects were mild and transient. However, it is prudent to be cautious when administering indomethacin in critically ill infants <1000 g with hsPDA who manifest clinical features of bowel ischaemia.     

Chronic lung disease in very low birthweight infants: A 5-year review

To determine the incidence, clinical spectrum and outcome of very low birthweight (VLBW) infants with chronic lung disease (CLD), and evaluate associated factors.

Methodology:

Retrospective review of 265 VLBW infants managed in the NICU from January 1988 to December 1992.

Results:

The overall neonatal survival rate for VLBW infants was 83%. Sixty-five (25%) infants had CLD, of whom 42% had severe CLD. Mortality in infants with CLD was 11%. In contrast with infants without CLD, CLD infants had significantly higher risk of adverse neurodevelopment with cerebral palsy documented in 13.5% and functional disability recorded in 34.6% at 2 years corrected age. Factors associated with the development of CLD included; decreasing birthweight (OR 0.98, Cl 0.97–0.99), septicaemia (OR 4.96, Cl 1.57–15.65), necrotizing enterocolitis (OR 119.07, Cl 4.98–2845.04), hyaline membrane disease (OR 5.34, Cl 1.83–15.55), patent ductus arteriosus (OR 4.46, CI 1.75–11.36) and increasing fraction of inspired oxygen concentration in the first week of life (OR 1.09, Cl 1.04–1.14).

Conclusions:

Chronic lung disease occurs frequently in VLBW infants and is associated with a high incidence of adverse neurodevelopment. Further studies to clarify the role of non-respiratory factors such as patent ductus arteriosus (PDA) and sepsis in the pathogenesis of CLD may reduce the incidence or prevent the development of CLD in these preterm infants.     

Abnormalities in surfactant in sudden infant death syndrome as a postmortem marker and possible test of risk

To determine whether physical abnormalities in lung surfactant, particularly inversion of the hysteresis between surface tension and surface area, are an effective postmortem marker for sudden infant death syndrome (SIDS).

Methodology:

Bronchoalveolar lavage (BAL) was employed to obtain lung rinsings from 55 infants under 24 months of age at autopsy, comprising 34 index cases and 21 controls. Folch reagent was used to extract the lipoid content which was then applied at two surface concentrations, fixed and BAL-determined (BALD), to the pool of a Langmuir trough in which surface tension (γ) was measured continuously by the Wilhelmy method as surface area ( A ) was cycled.

Results:

The γ: A loops from SIDS samples were inverted relative to controls (i.e. they were hysteresis reversed, this inversion being quantified by an empirical surface tension:area reversal (STAR) score). There was a wide scatter of STAR scores, but a critical value was found which offered a significant ( P = 0.017) separation of SIDS cases from controls for a fixed surface concentration and a highly significant separation ( P = 1.0 × 10^-4) for BALD surface concentrations. Differences in the yields of phospholipid and proteolipid, or their correlation to STAR scores, did not reach statistical significance.

Conclusions:

Inversion of the γ: A loops (i.e. hysteresis inversion) would appear to offer a better postmortem marker of SIDS than any reported previously, the procedure having potential for development as a prospective test indicating the risk of this disease.     

Chronic illness perception in adolescence: Implications for the doctor-patient relationship

To describe the inter-relationship of chronic illness severity as perceived by adolescents with both psychosocial well-being and objective measures of illness severity. Additionally to compare the adolescents' perception of illness severity with how their physicians believe that the adolescents perceive their illness severity.

Methods:

The psychological well-being of 48 adolescents with either cystic fibrosis (CF) or insulin-dependent diabetes mellitus (IDDM) was measured by four standardized questionnaires. The adolescents' perception of severity of illness was measured using an original instrument (PSCI), and this measure was compared to their physicians' estimates of how the adolescents perceived the severity of their illness and clinical illness.

Results:

There were 24 patients in both the CF and IDDM groups. Both groups were found to function well psychosocially; although, there were more patients with low self image compared to normative values. Depression and low self image were associated with a greater adolescent perception of illness severity. For both chronic illness groups, physicians' assessment of assumed adolescent perception of disease severity correlated with clinical indices of disease severity and was higher than the perception of illness severity reported by the adolescents. For adolescents with CF, but not with IDDM, perception of severity of chronic illness correlated with clinical indices.

Conclusions:

For adolescents with chronic illness, their perception of illness severity is an important indicator of psychosocial well-being. Physicians do not accurately infer their patients' perception of illness severity.     

A national study of risk factors associated with mortality in very low birthweight infants in the Malaysian neonatal intensive care units

To determine the risk factors associated with mortality in very low birthweight (VLBW) infants admitted to the neonatal intensive care units (NIUC) in Malaysia.

Method:

A prospective observational study of outcome of all VLBW infants born between 1 January 1993 and 30 June 1993 and admitted to the NICU.

Results:

Data of 868 VLBW neonates from 18 centres in Malaysia were collected. Their mean birthweight was 1223 g (95% confidence intervals: 1208–1238 g). Thirty-seven point four per cent (325/868) of these infants died before discharge. After exclusion of all infants with congenital anomalies ( n =66, and nine of them also had incomplete records) and incomplete records ( n =82), stepwise logistic regression analysis of the remaining 720 infants showed that the risk factors that were significantly associated with increased mortality before discharge were: delivery in district hospitals, Chinese race, lower birthweight, lower gestation age, persistent pulmonary hypertension of the newborn, pulmonary airleak, necrotizing enterocolitis of stage 2 or 3, confirmed sepsis, hypotension, hypothermia, acute renal failure, intermittent positive pressure ventilation, and umbilical arterial catheterization. Factors that were significantly associated with lower risk of mortality were: use of antenatal steroid, oxygen therapy, surfactant therapy and blood transfusion.

Conclusion:

The mortality of VLBW infants admitted to the Malaysian NICU was high and was also associated with a number of preventable risk factors.     

Perinatal outcome following conservative management of mid-trimester pre-labour rupture of the membranes

To assess perinatal outcome and the effect of antenatal steroid use following conservative management of 86 consecutive singleton pregnancies complicated by pre-labour rupture of membranes (ROM) in the mid-trimester (13–26 weeks; mean 22.8 weeks).

Methodology:

Review of obstetric and neonatal case notes between 1 January 1990 and 31 December 1993.

Results:

The duration of ruptured membranes (latent period) ranged from 1.25 to 105 days (mean 23.8 days; median 14 days) and was inversely related to gestational age at ROM. There was clinical evidence of chorioamnionitis in 39.5% with placental histological changes consistent with chorioamnionitis in 76.6%. All infants were delivered before 33 weeks gestation (mean 26 weeks). Overall, the mortality rate was 43.0% but 62.5% in infants with ROM before 24 completed weeks gestation. Adverse outcome (defined as death, severe intraventricular haemorrhage (IVH) or periventricular leucomalacia (PVL)) occurred in 46.5% and was significantly related to both gestation at delivery and gestation at ROM. In the group ( n = 40) with ROM before 24 weeks gestation, adverse outcome occurred in 65% and was inversely related to gestation at ROM independent of gestation at delivery. Antenatal steroid administration resulted in less adverse outcome independent of gestation at delivery (OR 0.31; 95% CI (0.09–0.98; P = 0.046)).

Conclusion:

From the neonatal perspective conservative management is justified for pregnancies with ROM at or after 24 weeks gestation; in this group the use of antenatal steroids prior to delivery may improve perinatal outcome. A poor outcome is associated with ROM that occurs before 24 weeks gestation.