[The practice guideline 'Volume suppletion in critically-ill neonates and children up to the age of 18 years' of the Dutch Paediatric Association]. / Richtlijn 'Volumesuppletie bij kritisch zieke pasgeborenen en kinderen tot 18 jaar' van de Nederlandse Vereniging voor Kindergeneeskunde.

Hypovolaemia is the most common cause of circulatory failure in children. Treatment consists of volume suppletion with a crystalloid or colloid solution; which agent is the best in children is not clear. This evidence-based practice guideline formulates recommendations as to which fluid should be used for volume suppletion in critically-ill neonates and children up to the age of 18 years with hypovolaemia. Before the guideline development first-choice fluid for volume resuscitation was in 50% a colloid and in 50% a crystalloid solution for both neonatologists and paediatric intensivists. The neonatologists used human albumin as a priority, and the paeditric intensivists predominantly used a synthetic colloid. The guideline was developed on the basis of a comprehensive search and analysis of the literature according to the principles of evidence-based guideline development. The recommendations were formulated by a committee based on evidence from the literature and, when evidence from the literature was insufficient, on consensus after discussion in the committee. Since colloids are much more expensive than crystalloids and can give an anaphylactic reaction, their added value over crystalloids must be proven. In sick neonates and children, insufficient clinical trials have been done to reach the conclusion that colloids are more effective than crystalloids in hypovolaemia. A number of meta-analyses in adults revealed excess mortality in the group treated with albumin, but one recent, large, randomised study showed no difference in mortality. No added value could be demonstrated for the administration of synthetic colloids. On the basis of data from the literature and considerations regarding the applicability of evidence in adults to children and neonates, the side effects of resuscitation fluids, pathophysiology and costs, the first-choice fluid for neonates and children with hypovolaemia is isotonic saline. Albumin should not be used for the treatment of hypovolaemia. The volume to be administered and the infusion rate depend on the severity of the hypovolaemia and should be determined on an individual basis.

Immune complex associated complications in the subacute phase of meningococcal disease: incidence and literature review.

AIM: To determine the incidence of immune complex associated complications (IAC) after severe meningococcal disease (SMD) in a group of Dutch children admitted to a paediatric intensive care unit (PICU). METHODS: Retrospective chart analysis and follow up of 130 survivors of SMD admitted to PICU. Signs of IAC, inflammatory parameters, and temperature profile were reviewed. RESULTS: Of 130 children with SMD, 20 (15.3%) showed one or more of the three manifestations of IAC: 18 (13.8%) developed arthritis (effusion, with or without erythema/arthralgia), 11 (8.4%) vasculitis, and five (3.8%) pleuritis. Eighteen of 20 (90%) patients with IAC had a secondary rise in temperature; in patients with no IAC this was 48 of 110 (43.6%). IAC was associated with leucocytosis in 82.3% versus 47.7% in patients without IAC, and with increased CRP in 86.6% versus 47.2% in patients without IAC. Leucocytes on admission were significantly lower in patients who would later develop IAC (mean 8.6 versus 13.8x10(9)/l). CONCLUSION: IAC is a common complication of SMD, mainly occurring 4-10 days after systemic disease. IAC presents clinically as arthritis or vasculitis, mostly accompanied by secondary fever and raised inflammatory parameters.

Adrenocorticotropic hormone and cortisol levels in relation to inflammatory response and disease severity in children with meningococcal disease.

This prospective observational study investigated the relationship of the hypothalamic-pituitary-adrenal axis to inflammatory markers and to disease severity in children with meningococcal disease. In total, 32 children were studied: 10 with distinct meningococcal meningitis (MM), 10 with MM and septic shock, and 12 with fulminant meningococcal septicemia (FMS). Levels of adrenocorticotropic hormone (ACTH) and interleukin (IL)-6, IL-8, and IL-10 were lowest in the MM group and dramatically elevated in the FMS group. Cortisol and C-reactive protein levels were highest in the MM group and relatively low in the FMS group. Levels of ACTH and inflammatory markers decreased within the first 24 h of admission, but cortisol levels did not fluctuate. Cortisol was significantly inversely correlated with IL-6, IL-8, and IL-10 (P < or =.04). These results suggest that the adrenal reserve in children is insufficient to handle the extreme conditions and stress associated with severe meningococcal disease.

[Family with malaria: from the asymptomatic to life-threatening]. / Een gezin met malaria: van asymptomatisch tot levensbedreigend.

Five members of a Dutch family of Nigerian origin (three girls aged 1, 6 and 8 years and their parents, mother aged 32 and father aged 41 years), had been infected with Plasmodium falciparum during a visit to Nigeria. The mildest infection could be treated at home with oral medication. The severest case had to be admitted to the paediatric intensive care unit for respiratory support and exchange transfusions. Four patients were treated with quinine. A combination of atovaquone and proguanil was added, resulting in a quick decline of the parasitaemia. Whenever a patient is suspected of malaria, laboratory tests should be carried out immediately and treatment should be started as soon as possible, in order to prevent possible complications. The early recognition of any of the alarm symptoms, for example, lowered consciousness, abnormal respiratory movements, cold extremities, convulsions, hypoglycaemia, severe anaemia and a high parasitaemia, whether at casualty or the general practitioner's surgery is crucial.

Pulse methylprednisolone therapy for impending cardiac tamponade in immunoglobulin-resistant Kawasaki disease.

We describe a boy with Kawasaki disease (KD) whose clinical course was marked by a rapid improvement upon treatment with intravenous immunoglobulin (IVIG) and oral aspirin, which - within 14 days - was followed by the development of a large pericardial effusion with symptoms of impending cardiac tamponade as part of a polyserositis syndrome (pleural effusions, ascites). Upon treatment with pulsed methylprednisolone, the pericardial and pleural effusions and ascites rapidly disappeared within 48 h. This is the first case reported with a polyserositis syndrome and impending cardiac tamponade during KD.

[A child with hyperpyrexia syndrome and multiple organ failure caused by and an orthopedic corset]. / Een kind met hyperpyrexiesyndroom en multi-orgaanfalen door een orthopedisch korset.

A 4-year-old boy who each night was placed in an orthopaedic corset because of congenital multiple arthrogryposis developed heat stroke with hyperpyrexia and multiorganic failure in a hot summer. Treatment consisted of administration of fluids, antibiotics and anticonvulsive agents; the child recovered completely. In children who are sick and have fever, the use of such corsets should temporarily be suspended.