Medication options when treating children and adolescents with ADHD: interpreting the NICE guidance 2006.

In recent years the medication options for the treatment of ADHD in children and young people have increased. The National Institute for Health and Clinical Excellence (NICE) produced updated guidelines in 2006. This paper aims to interpret these guidelines by reviewing the medication options in light of relevant research and clinical practice. The properties of methylphenidate, dexamfetamine and atomoxetine are discussed.

The effect of ADHD on the life of an individual, their family, and community from preschool to adult life.

Attention deficit/hyperactivity disorder (ADHD) may affect all aspects of a child's life. Indeed, it impacts not only on the child, but also on parents and siblings, causing disturbances to family and marital functioning. The adverse effects of ADHD upon children and their families changes from the preschool years to primary school and adolescence, with varying aspects of the disorder being more prominent at different stages. ADHD may persist into adulthood causing disruptions to both professional and personal life. In addition, ADHD has been associated with increased healthcare costs for patients and their family members.

Parents' views of community care for children with motor disabilities.

In this study we have ascertained the views of 40 parents of 4-year-old children with motor disabilities, on the health and education services, social service and the availability of respite care. The children with moderate or severe motor disability who were born in 1985, were identified from the Oxford Regional Register of Early Childhood Impairment. Thirty-three (83%) completed a questionnaire taken to the home by the health visitor. Although most parents had access to a range of services, lack of information in the early years, fragmentation of services and limited choices were identified as problems. Parents regarded the breadth of care provided by the pre-school teacher counsellor and the nursery school as very useful, whereas the health service and social services were perceived as less appropriate. This small study suggests that for some families, the objectives of community care as identified in the Griffiths Report (Griffiths 1988) and reiterated in the Children Act (1989) are not yet being met.

Humidification of incubators.

The effect of increasing the humidity in incubators was examined in 62 infants of less than 30 weeks' gestation. Thirty three infants nursed in high humidity for two weeks were compared retrospectively with 29 infants from an earlier study who were nursed under plastic bubble blankets or with topical paraffin but without raised humidity. Humidification reduced skin water loss and improved maintenance of body temperature from birth, but did not delay the normal postnatal maturation of the skin. Infants nursed without humidity frequently became hypothermic in spite of a high incubator air temperature. These advantages must be weighed against the finding that overheating was more common and Pseudomonas was more commonly isolated from the infants. It is recommended that incubator humidity is raised for babies under 30 weeks' gestation in the first days of life but meticulous attention should be paid to fluid balance, avoiding overheating, and cleansing of the humidifier reservoir.

Making heel pricks less painful.

A mechanical lancet, the Autolet, was compared with a manual heel prick in 36 newborn infants undergoing routine blood sampling for the Guthrie test and hypothyroid screening. Each method was equally effective in obtaining satisfactory blood samples but the Autolet was considerably less painful.

Barrier properties of the newborn infant's skin.

The barrier properties of the skin were examined in 223 studies in 70 newborn infants of 25 to 41 weeks' gestation, aged from 1 hour to 26 days. Percutaneous drug absorption was studied by observing the blanching response to solutions of 1% and 10% phenylephrine applied to a small area of abdominal skin. Skin water loss was measured at the same site using an evaporimeter. Infants of 37 weeks' gestation or more showed little or no drug absorption and had low skin water losses, indicating that their skin is an effective barrier. By contrast, infants of 32 weeks' gestation or less showed marked drug absorption and high skin water losses in the early neonatal period, indicating that their skin is defective as a barrier. Both drug absorption and water loss in these infants fell steadily; by about 2 weeks of age the skin of the most immature infants functioned like that of mature infants. The varying barrier properties can be explained by the poor development of the stratum corneum in the more premature infants at birth and its rapid maturation after birth. The trauma caused to the skin by use of adhesive tape and the fixation of transcutaneous oxygen electrodes resulted in increased drug absorption and water loss from the damaged area.

Responses of the newborn infant to overheating.

The responses of newborn babies to overheating were investigated by exposing them to progressively higher incubator air temperatures until either sweating occurred or the rectal temperature reached 37.9 degrees C. 112 studies were performed on 83 healthy term and preterm infants. Activity, posture, heart rate, respiratory rate, skin colour and abdominal skin and hand temperature were monitored. Most babies regardless of gestational age became less active, and they frequently fell asleep at the warmest setting. The majority of infants altered their posture from predominantly flexion to extension. There were no significant changes in heart rate or respiratory rate. The skin of almost all the babies became redder, and the difference between central and peripheral skin temperatures decreased with warming. The pattern of these changes varied with maturity suggesting the development of vasomotor control. It is a surprising finding that even the most immature babies appear to make appropriate responses to heat stress. These responses may aid in the recognition of a baby who is too warm.

Development of emotional sweating in the newborn infant.

Sweating from the palm and sole occurs independently of ambient temperature but is influenced by emotional factors. It thus provides a useful objective measure of emotional state. The development of this emotional sweating in the newborn was investigated by measuring palmar water loss and relating it to the infant's state of arousal. Although 433 individual measurements were made on 124 babies of gestational age 25 to 41 weeks and postnatal age 15 hours to 9 weeks. Palmar water loss was also recorded continuously in 22 infants undergoing heel prick for routine blood sampling. In babies of 37 weeks' gestation or more, there was a clear relationship between palmar water loss and arousal from the day of birth, and by the third week levels on vigorous crying were comparable with those of an anxious adult. Less mature babies did not show emotional sweating at birth; it was first seen at the equivalent of 36 to 37 weeks' gestation regardless of maturity. Continuous recordings confirmed the cross-sectional data and illustrated the abrupt nature of the response. Emotional sweating could be a useful tool for the assessment of emotional state of the newborn.

Sweating in preterm babies.

The development of thermal sweating was investigated in 117 studies on 85 term and preterm infants. The babies were nursed naked in an incubator and exposed to progressively higher air temperatures until sweating occurred or until the rectal temperature reached 37.9 degrees C. Most babies of 36 weeks' gestation or more were able to sweat from the first day. Babies of less than 36 weeks' gestation did not sweat initially. However, postnatal existence hastened the development of sweating so that by 13 days all babies studied were able to sweat. Sweating occurred first and was most marked on the forehead. The intensity and extent of the sweat response depended on gestational age. With postnatal age the extent of the response rapidly increased but the intensity only rose slowly. The air temperature required to induce sweating was higher in the more immature babies but fell with postnatal ge. Although even the most immature infant soon develops the ability to sweat in response to heat stress, the efficiency of sweating as a thermoregulatory process is poor.

Can village mothers prepare oral rehydration solution?

PIP: Both the prepackaged glucose-electrolyte powder and the domestic rehydration solution have received wide publicity, yet there has been little evaluation of how accurate the mother can be in preparing the mixture. The 2 studies described here attempted to measure this human factor in actual field situations in India and Trinidad. The 1st study attempted to quantify the variability in the size of the 2-finger and thumb pinch of salt. The 2nd study measured the different concentrations when mothers diluted a standard packet of glucose and electrolytes in domestic vessels. In India and Trinidad, mothers of children with diarrhea were instructed about making up local salt-sugar-water mixtures for home treatment. They were shown how to take a 2-finger and thumb pinch of salt in a way which had previously been agreed upon. Multiple pinches--5 in Trinidad and 10 in India--were then weighed on standard laboratory scales to find the average salt picked up. The fingers of the mothers were measured to see if the weight of salt picked up correlated with hand size. Other factors which could influence the pinch size were also considered: type and quality of salt available and the relative humidity. In the packet dilution study, mothers in rural India were instructed in the local language by an indigenous nurse who used diagrams in the teaching. The glucose concentrations of the mixture made up by 66 village mothers were analyzed in the field by a pocket refractometer. The finger-pinch method of measuring salt was very inaccurate in field tests. At least 1 mother in 20 would pick up double the amount of salt intended. There was no statistical correlation between finger size and the weight of a pinch of salt. In the packet dilution study there was a wide range of concentrations, but over 83% of the mothers mixed the solution to within 40 mmol/liter of the "correct" value.^ieng