Student-initiated revision in child health.

Most teaching of child health in Cardiff takes place in block attachments of 8 weeks. There is an introductory seminar of 2 days followed by a 6-week clinical attachment in a district general hospital in Wales, and then a revision period of one week designed to help students formalize and structure their basic knowledge and to clarify aspects of child health which they may have had difficulty in understanding. The revision programme has to take into account: the short time available, the small number of teaching staff, the most relevant basic knowledge and active participation by the student. This paper describes how this week has been improved through the use of student-initiated revision (SIR). The students' appraisal of this revision and in particular SIR is presented.

Fatty infiltration in the liver in medium chain acyl CoA dehydrogenase deficiency.

Fatty infiltration of the liver at postmortem examination has been recommended as a criterion for selection of infants who have died suddenly and unexpectedly for further biochemical investigation for disorders of fatty acid oxidation. We describe a boy with medium chain acyl CoA dehydrogenase deficiency who died four months after diagnosis and in whom only minimal hepatic fatty infiltration was found.

Epidural versus general anaesthesia for elective caesarean section. Effect on Apgar score and acid-base status of the newborn.

Elective Caesarean section deliveries over a 5-year period were studied to compare the effect of epidural block with general anaesthesia on the condition of the infant at birth. The Apgar score and umbilical arterial acid-base status were used as determinants of the latter. Epidural block was used in 139 (22.8%) mothers while 471 (77.2%) were performed under general anaesthesia. No babies in the epidural group were severely depressed (Apgar less than 4), compared with 6.2% in the general anaesthesia group. Only 4.3% of the epidural sections were moderately depressed (Apgar 4-6), compared with 15.4% of the others. These differences remained highly significant when infants of less than 2500 g were excluded, and when matched groups were compared. Mean umbilical arterial pH was similar within the two groups (pH 7.28), and was not consistent with asphyxia in almost 90% of the depressed infants. The findings suggest that general anaesthesia, rather than asphyxia or aortocaval compression, is responsible for most of the depressed infants born by elective Caesarean section. This may involve over 20% of babies delivered in this manner, so greater use of epidural block for elective Caesarean section is recommended. Further investigations are required to improve results with general anaesthesia.

Plasma zinc concentration and catch up growth in preterm infants.

Changes in plasma zinc concentration during the period of catch up growth were examined in 44 preterm infants. Blood samples were collected at birth, 6, 12 and 24 weeks. Plasma zinc concentration showed a mean of 13.6 mumol/l at birth and dropped to 9.8 mumol/l at 6 weeks and rose to 11.3 and 15.4 mumol/l at 12 and 24 weeks respectively. Plasma zinc concentrations showed significant correlation with weight velocity at 12 weeks. Male infants had significantly lower plasma zinc concentrations than females at 12 weeks. Infants of gestational age more than 32 weeks had lower plasma zinc concentrations at 12 and 24 weeks than those of earlier gestations. At the same time males were growing faster than females and also infants of gestational ages more than 32 weeks were growing faster than those born at earlier gestations. These observations, together with the finding that the decline in zinc occurred during the phase of rapid growth, suggest that growth is the predominant modulator of plasma zinc concentration.

Catch up growth in preterm infants.

Seventy-one surviving infants were followed up from birth to 24 weeks of postnatal age. Their mean gestational age was 32 weeks with a range of 26-36 weeks and a standard deviation of 2.1 weeks. Their mean birth weight was 1,805 kg with a range of 0.675-2.5 kg and a standard deviation of 0.408 kg. Their weights, lengths and head circumferences were measured at birth, 6, 12 and 24 weeks. Curves for the mean weight, length and head circumference were produced and superimposed on the available intrauterine and extrauterine growth charts. The growth curves of the preterm infants did not show the flattening noted in the intrauterine curves towards term. The curve of the mean weight of the preterm infants started at the 50th centile for Gairdner & Pearson (1971) at birth to drop below that shortly after birth. At 40 weeks of postconceptional age the mean weight curve of preterm infants crossed the 50th centile and continued above it to reach the 90th centile at 60 weeks. The curves of mean length and head circumference started below the 50th centile at birth and crossed it at 40 weeks and continued above it to approach the 90th centile at 60 weeks. Growth velocity was calculated as a relative gradient using the straight line equation (y = a + bx), where y is the weight, length or head circumference, and x is the independent variable and here it is the group mean of the parameter at the corresponding ages. Catch up growth is taken as a relative gradient significantly greater than one. The first 24 weeks of postnatal life are defined as a period of catch up growth with the first 8 weeks as an interval of maximum head velocity.

Infection-associated haemophagocytic syndrome in an infant.

We describe the case of an infant with haemophagocytic syndrome initiated by severe infection. The difficulties of diagnosing and managing the condition as well as its pathogenesis are discussed.

Neonatal parenteral nutrition with a fat emulsion containing medium chain triglycerides.

Fifty-one newborn infants requiring parenteral nutrition were randomly assigned to receive a 50% medium chain triglyceride/50% long chain triglyceride lipid emulsion or the conventional 100% long chain triglyceride emulsion. Fat was administered daily for 20 hours, to a maximum of 3 g/kg/day. Plasma triglycerides, cholesterol, free fatty acids, ketones, glucose and capillary blood gases were monitored daily up to the sixth day of fat infusion. There were no significant differences in mean plasma triglycerides and free fatty acids between the two groups. No cases of hyperketonaemia were detected in the infants studied. Hyperglycaemic episodes were detected with similar frequency in both groups. The group who received the emulsion containing medium chain triglycerides had significantly lower mean plasma cholesterol values during the study. After 6 days of intravenous fat administration mean plasma cholesterol was more than 100% higher in the group which received the conventional emulsion. Differences in cholesterol content between the emulsions and a cholesterol lowering effect of medium chain triglycerides are possible explanations for these findings.

Cranial diabetes insipidus in early infancy.

We report an infant who developed cranial diabetes insipidus after septicaemic shock. This condition should be considered in any child who suffers an acute collapse and it may be more common in the high risk neonate than has previously been recognised.

Growth of children from 0-5 years: with special reference to mother's smoking in pregnancy.

A cohort of 1163 pregnant women in two small towns in South Wales, UK, was identified and followed until the children born to them were five years of age. Growth in these children is described and a number of determinants identified. Social-class differences were very small at birth but differences in height became clear by the age of two years and in head circumference before this. In height the differences were largely accounted for by greater growth in social class I, but there was a gradient in head circumference throughout all the social classes. The social class effects gradually increased as the children became older. Parity of the mothers had a small effect on size at birth but age of the mother had no effect once parity was allowed for. Data on illnesses in the children were collected but no effect on growth could be detected. By far the most important determinant of growth which could be controlled is maternal smoking. About 40% of the women smoked, about 17% heavily (15 or more cigarettes per day) and the prevalence of smoking altered little during pregnancy. There was a graded effect of smoking on growth up to a 9% deficit in birth-weight, a 2% deficit in length at birth and a 1.5% deficit in head circumference in the babies born to the mothers who smoked most heavily (25 or more cigarettes per day) compared with non-smokers. There effects decreased with age but there were still residual effects at age five years.

Assessment of adrenocortical activity in term newborn infants using salivary cortisol determinations.

Salivary cortisol concentrations were collected every 2 hours over a 24-hour period in eight healthy 2-day-old term neonates. Two maxima in cortisol output were noted, neither being related to the time of day or time since birth. Salivary cortisol concentrations ranged from 2.5 to 57.4 nmol/L (0.09 to 2.08 micrograms/dL), and throughout the 24 hours showed considerable variation (21% to 42%) not related to the state of arousal. The validity of the method was confirmed by collecting matched plasma and saliva samples from another group of 36 neonates. The correlation between plasma and saliva cortisol was r = 0.83. We suggest that salivary cortisol is a useful, noninvasive method of studying adrenocortical status in the newborn infant.

Plasma alkaline phosphatase activity and its relation to rickets in pre-term infants.

Sequential measurements of plasma alkaline phosphatase activity were made in 84 pre-term infants delivered before 38 weeks gestation. In 67% of infants, without evidence of rickets but in whom three or more measurements were made and the peak activity was less than 10 times the adult reference range, the activity rose to a peak and declined to previous levels, or lower. The time taken for these changes varied greatly. The range of values was inspected at each week of age, and in all but six cases the level did not exceed 10 times the upper limit of the adult reference range. Three infants had radiological evidence of rickets, and of the six cases in whom higher levels were found, only one had radiological evidence of rickets; the remainder did not. It is recommended that in the latter, the high plasma alkaline phosphatase activity should be regarded as evidence of subclinical bone disease.

Parental involvement in the lives of children in hospital.

A care by parent scheme was established in the children's department of a university hospital. It was seen as the natural extension of the increased involvement of parents in the care of their children in hospital. A structured observational study was carried out to monitor its effect on the lives of child patients. Children in the scheme spent far less time awake alone, cried less, and slept less than those nursed unaccompanied. They had far more social interaction with a smaller number of adults, most of their contacts being with family members rather than hospital staff. Children with a resident parent but outside the scheme were generally in an intermediate position on these factors.

Care by parents of their children in hospital.

A care by parent option was introduced into a general paediatric ward without any additional finance or facilities. Most parents coped successfully and were grateful for the opportunity of caring for their children. All believed that their children benefited from their active involvement. The nurses believed that their role was enhanced and their job satisfaction increased. This system offers advantages and could become more generally used in paediatric wards in Britain.

Cotside EEG monitoring using computerised spectral analysis.

The application and interpretation of computerised spectral analysis of the neonatal electroencephalogram (EEG) using the Neuroscience Berg Fourier Analyser (BFA) is described. Recordings are immediately available at the cotside. Electrophysiological changes can be recognised by individuals with no previous experience in EEG technology. The compact nature of the analysis allows long periods of recording to be viewed within minutes. In addition to the unequivocal demonstration of both clinical and subclinical seizures, the BFA is useful in the evaluation of interseizure activity--that is, disturbance of sleep patterns, electrical output, and hemisphere asymmetry.