A catch in the Reye.

Twenty-six cases of Reye syndrome from The Children's Hospital, Camperdown, Australia, occurring between 1973 and 1982 were reviewed. Of these, 20 cases met the US Public Health Service Centers for Disease Control criteria for the diagnosis of Reye syndrome. Aspirin or salicylate ingestion had occurred in only one of the 20 cases (5%), and paracetamol (acetaminophen) had been administered in only six of the cases (30%). Pathologic confirmation of the diagnosis of Reye syndrome was accomplished in 90% of the cases. The incidence of Reye syndrome in New South Wales, Australia, is estimated from this study to be approximately nine cases per 1 million children compared with recent US data of ten to 20 cases per 1 million children and three to seven cases per 1 million children in Great Britain. The mortality for these Reye syndrome cases in Australia was 45% as compared with a 32% case-fatality rate in the United States. In Australia, the pediatric usage of aspirin has been extremely low for the past 25 years (less than 1% of total dosage units sold), with paracetamol (acetaminophen) dominating the pediatric analgesic and antipyretic market. Reye syndrome may be disappearing from Australia despite a total lack of association with salicylates or aspirin ingestion, since there were no cases found at The Children's Hospital in 1983, 1984, or 1985.

Hospital management of severe poisoning.

Prompt diagnosis and appropriate early treatment will prevent most poisoning episodes from becoming serious. The hazards of any treatment must be weighed against its benefits, and specific indications must be observed in the use of pharmacologic antagonists and chelating agents. Supportive therapy is of predominant importance.

Epiglottic enlargement secondary to laryngeal sarcoidosis.

A case of laryngeal sarcoidosis manifesting as epiglottic enlargement in a 15-year-old boy is presented. Sarcoidosis of the larynx is unusual in children but should be included in the differential diagnosis of epiglottic enlargement.

Should routine childhood immunizations be compulsory?

Routine childhood immunizations are compulsory in a small number of countries, including the United States of America. Arguments used to justify making immunizations compulsory include enhancing the health of the community and treating as paramount the rights of the child to be protected against vaccine-preventable diseases. But compulsory immunization infringes the autonomy of parents to make choices about child rearing, an autonomy which we generally respect unless doing so seriously endangers the child's health. We present a historical review and ethics discussion on whether routine childhood immunizations should be compulsory. We conclude that, for both ethical and practical reasons, routine immunization should not be compulsory if adequate levels of immunization can be achieved by other means.

Methylmalonic aciduria: a variant form of methylmalonyl coenzyme A apomutase deficiency.

Sisters aged 3 and 4 1/2 years, respectively, who had grown and developed normally were found to have methylmalonic aciduria. The elder had had only one previous illness, at 18 months, and was thriving at six years without treatment; she was excreting up to 2 gm methylmalonic acid per day. The younger sister died during her third episode of illness, at 3 years of age. Studies of cultured skin fibroblasts showed deficient methylmalonyl coenzyme A mutase apoenzyme activity; cobalamin metabolism was normal. There was a moderate response in cultured cells to large amounts of added hydroxycobalamin; but treatment of the patient with high doses of intramuscular vitamin B12 for ten days failed to lower the urinary excretion of methylmalonic acid.

Outcome evaluation of early discharge of asthmatic children from hospital: a randomized control trial.

The objective of our study was to compare the safety and efficacy of discharging asthmatic children from hospital on three versus four hourly nebulized salbutamol. The setting was a tertiary referral paediatric hospital in Sydney, NSW, Australia. The design was a randomized controlled parallel group study. All children admitted to hospital with acute asthma and who were over 18 months of age were eligible to enter the study. Patients were excluded if they had non-English speaking parents, no telephone, or chronic cardiac or neurological disease. Children were treated according to standard asthma management but were randomly allocated to be discharged on three or four hourly nebulized salbutamol. Patients were surveyed using a telephone questionnaire 1 to 2 weeks after discharge. The primary outcome measure was re-presentation to the Emergency Department (ED) within 7 days. Other outcomes included readmission to hospital, re-presentation to the local doctor, parental satisfaction and length of hospital stay. A total of 63 children were enrolled in the study (32 in the three hourly group and 31 in the four hourly group). There were no re-presentations to the ED or hospital readmissions within 1 to 2 weeks in either group. However, re-presentations to the local doctor were common, 71.8% in the three hourly and 74.1% in the four hourly groups, respectively. These were predominantly for routine review. The mean (+/- SD) hospital length of stay was not significantly different between the three and four hourly groups, 48.94 (+/- 20.61) and 54.88 (+/- 32.59) hours, respectively (P = 0.672). Parents felt the timing of discharge was 'too early' in five (15.6%) of three hourly and five (16.1%) of four hourly patients. Three (9.7%) of the four hourly but none of the three hourly patients felt they were sent home 'later than necessary'. Five (15.1%) of the three hourly and three (9.7%) of the four hourly group parents did not feel comfortable looking after their child at home immediately after discharge. None of these differences were statistically significant. Discharge of asthmatic children from hospital on three hourly nebulized salbutamol is as safe and effective as on four hourly. Parents are generally very satisfied with timing of discharge, irrespective of frequency of nebulization. Earlier discharge benefits both the child and their family, and improves hospital bed utilization.

Pain and symptom control in paediatric palliative care.

Important differences become evident in a comparison of cancer pain between children and adults. Management of pain in children is commonly multidisciplinary, is less dependent on invasive measures and relies more on systemic therapy. Children are not little adults: their immaturity, developing cognition and dependence all influence their experience and interpretation of pain. Much progress has been made in altering practices such as under-prescribing and underdosing that have adversely affected adequate control of pain in children. The challenge for paediatric health care providers in the mid 1990s is not only to be informed of current practices in pain and symptom control in paediatric palliative care, but also to remember to establish those practices in day to day management. Even though pain and its effects in children are now better understood, it is often still not managed optimally. Good management of pain in children depends on accurate assessment. In the past 10 years, assessment of pain in children has advanced considerably. However, assessment of pain in the preverbal child is still inadequate and in need of attention. Sedation, tolerance and involuntary movements may occur as side effects of opioids in children and may cause significant problems in management of the dying child. Psychostimulants can diminish sedation to some extent, but there is little information as yet on the value of these drugs in children. Tolerance to opioids may develop quickly, leading to poor control of pain and distress for the child. Strategies to improve management of tolerance include use of regional anaesthetic techniques such as the epidural/intrathecal route for opioid administration. Involuntary movements induced by opioids are uncommon but have the potential to cause significant distress. The mechanisms underlying these side effects of opioids need to be established. Strategies are needed for the effective treatment and prevention of these side effects. Neuropathic pain can be severe, distressing and difficult to treat. Experience of its treatment in terminally ill children is limited. Effective use of tricyclic antidepressants and systemically administered local anaesthetics is still to be determined. Regional anaesthetic techniques may be of great benefit when neuropathic pain cannot be controlled with systemic therapy. Procedural pain is more common than pain related to disease in the management of paediatric cancer. Further research is needed to identify the best approach to its management. We have found nitrous oxide to be of great benefit in management of procedural pain in children. Non-pharmacological methods of treatment of pain in children, such as transcutaneous electrical nerve stimulation or acupuncture, may also be useful and should receive continuing evaluation. There are significant and current issues in paediatric palliative care besides management of pain. There are difficulties in the provision of home nursing care for children with cancer in the terminal phase of their illness, including lack of community nursing services at night and on weekends and lack of adequate home help for parents. Attitudes of staff involved in the care of the child and family and their commitment to working as a multidisciplinary team strongly influence the quality and success of care given. Pain control and palliative medicine are evaluable by measures of quality assurance or outcome, and adoption of such evaluations should improve standards of care. Euthanasia in children is even more difficult as an ethical dilemma than in adults. Optimum symptom control with current techniques should almost always obviate its consideration. We are opposed to euthanasia. Psychosocial and cultural issues all influence the family's experience of palliative care. Further research is necessary in all of these areas.(ABSTRACT TRUNCATED)

Rational therapy for thyroid storm.

An approach to the management of patients with thyroid storm is described. The treatment regimen, which is directed against the abnormalities as they are presently understood, incorporates: (a) Propranolol to inhibit the catecholamine-mediated peripheral effects of the circulating thyronines; (b) Propylthiouracil to inhibit thyroid hormone synthesis and to inhibit peripheral conversion of thyroxine to triiodothyronine (T3), the predominant source of T3 production; (c) Iodine to block the glandular release of thyroid hormones; (d) Dexamethasone along with general supportive therapy. The regimen has been used for a 13 year old schoolgirl with thyroid storm, and the induced rapid fall in serum T3 levels is illustrated. It has also been used in patients with florid thyrotoxicosis undergoing emergency surgery and has resulted in marked clinical improvement associated with rapid decreases in serum T3 levels. It is a simple and efficient regimen, rendering cumbersome forms of therapy such as plasmapheresis and peritoneal dialysis unnecessary.

Ventilator-dependent children.

The issue of the ventilator-dependent child is a relatively-new one in Australia. Ventilator-dependent children pose complex and unique ethical, medical, economic and psychological problems. The experience of two Australian centres that are involved with the care of ventilator-dependent children is reported. Most of these children now are being cared for at home. Aspects of home care are outlined. After the initial period, the technical aspects are not a problem for most parents for whom the major issues are the provision and funding of nursing support. The complex ethical issues that are involved are discussed. It is concluded that undergoing ventilation at home rather than in a hospital appears to make the best of an otherwise almost-intolerable situation for ventilator-dependent children, but that much more information is required about the outcome for these children and the long-term psychosocial impact of this treatment.

Seizures associated with 1% cyclopentolate eyedrops.

A 4.5 year old boy with cerebral palsy presented with seizures associated with facial flushing and tachycardia following the instillation of 1% cyclopentolate, a commonly used mydriatic in paediatric practice. He had no prior history of convulsions. This case demonstrates the uncommon, though serious, atropine-like side effect of cyclopentolate eyedrops (Cyclogyl, Alcon) in usual dosage in a brain damaged child without an epileptic focus.