Fifteen-minute consultation: Troublesome crying in infancy.

There is much written in the medical and lay literature about managing babies who cry too much. Healthcare professional often feel bewildered about how to go about trying to help a baby and their carer, usually the mother. They often undertake investigations, prescribe medication or alter the baby's diet. The assumption made by this approach is that the crying reflects pain or discomfort. In a normal infant who is growing well, it is rare to be able to identify any quickly treatable medical underlying disorder. Those who are inexperienced may find the idea of a behavioural approach very challenging but perhaps this would be a better alternative.

Reference ranges for interrupter resistance technique: the Asthma UK Initiative.

Measuring interrupter resistance (R(int)) is an increasingly popular lung function technique and especially suitable for preschool children because it is simple, quick and requires only passive cooperation. A European Respiratory Society (ERS)/American Thoracic Society (ATS) Task Force recently published empirical recommendations related to procedures, limitations and interpretation of the technique. However, for valid interpretation, high-quality reference equations are required and these have been lacking. The aim of the present study was to collate R(int) data from healthy children in order to produce more robust reference equations. A further aim was to examine the influence of methodological differences on predicted R(int) values. R(int) data from healthy children were collected from published and unpublished sources. Reference equations for expiratory and inspiratory R(int) were developed using the LMS (lambda, mu, sigma) method. Data from 1,090 children (51% males) aged 3-13 yrs were collated to construct sex-specific reference equations for expiratory R(int) and data from 629 children (51% males) were collated for inspiratory R(int). Height was the best independent predictor of both expiratory and inspiratory R(int). Differences between centres were clinically irrelevant, and differences between ethnic groups could not be examined. The availability of a large and generalisable sample and the use of modern statistical techniques enabled the development of more appropriate reference equations for R(int) in young children.

Linear growth and body mass index in pediatric patients with Cushing's disease or simple obesity.

BACKGROUND: Increasing prevalence of childhood obesity has resulted in an accelerating rate of referrals of overweight patients to pediatric clinics for exclusion of endocrine or metabolic etiologies. The exclusion of Cushing's disease (CD) requires complex and potentially invasive investigations. OBJECTIVE: To evaluate the sensitivity of accurate measurements of height, weight and body mass index (BMI) in discriminating between simple obesity and CD. METHODS AND PATIENTS: Height, weight and BMI were measured at diagnosis in 25 patients with CD; 14 males, 11 females, mean age 12.9 yr (6.4-17.8) and 41 patients with simple obesity (SO), defined as BMI >2.0 SD; 20 males, 21 females, mean age 9.4 yr (3.5-15.6). RESULTS: Mean (+/-SE) BMI SDS in the CD patients was 2.41+/-0.5 and in the SO patients 3.71+/-1.3. Height SDS in the CD patients was -1.88+/-0.24 and in the SO patients 1.18+/-0.19 (p<0.05). The mean (+/-SE) BMI SDS to height SDS ratio was significantly decreased in the CD compared with the SO patients; -1.81+/-0.54 vs +0.90+/-1.17 (p<0.0001). CONCLUSIONS: Simple, accurate measurement of height and BMI SDS values provides a quick, and sensitive diagnostic discriminator in pediatric patients with CD or SO, thus potentially avoiding complex investigations.

Skin-prick testing as a diagnostic aid for childhood asthma.

Diagnosing asthma is problematic when based solely on reported symptoms. The purpose of this study was to evaluate skin-prick testing as a diagnostic aid for asthma in children. Skin-prick testing (SPT) was undertaken in children aged 2-10 years with either no history of wheeze (n = 149) or recent doctor-observed wheeze which responded to treatment with a bronchodilator, the "gold standard" (n = 164). Children with moderate or severe asthma were excluded. SPT positivity increased sharply at age 5 years in wheezers. Data were therefore divided into two age groups: 2- < 5 years (57 controls, 97 wheezers) and 5-10 years (92 controls, 67 wheezers). The sensitivity, specificity, and likelihood ratios of SPT positivity for wheeze were 32%, 89%, and 2.9, respectively, in the younger children, and 82%, 85%, and 5.5, respectively, in the older children. For a prevalence of 30% for asthma, the positive predictive values of a positive SPT were 55% and 70% for the younger and older age groups, respectively. The test characteristics of SPT for helping diagnose asthma in schoolchildren are good. The prevalence of wheeze in preschool children is high, and so SPT should be helpful even in this group. We suggest that clinicians consider skin-prick testing as a diagnostic aid for asthma.

Airway resistance by the interrupter technique: which algorithm for measuring pressure?

Airway resistance using the interrupter technique (Rint) can be measured using commercial devices which employ different algorithms for estimating pressure change. We aim to describe differences in Rint due to algorithm. We compared Rint and change in Rint after bronchodilator, using four algorithms to estimate pressure change following interruption: 1) two-point back-extrapolation to interruption from points 70 msec and 30 msec from interruption, and similarly 2) to 15 msec from interruption, 3) at two-thirds from interruption, and 4) near end-interruption. Flow was measured immediately before interruption. Our subjects were 39 asymptomatic children 2-5 years old with previous intermittent wheeze. Rint differed significantly with algorithm. Geometric mean Rint (95% confidence interval (CI)) for algorithms 1-4 were 1.21 kPa x l(-1) x sec (1.18-1.24 kPa x l(-1) x sec), 1.31 kPa x l(-1) x sec (1.28-1.34 kPa x l(-1) x sec), 1.57 kPa x l(-1) x sec (1.54-1.61 kPa x l(-1) x sec) and 1.71 kPa x l(-1) x sec (1.67-1.75 kPa x l(-1) x sec), respectively. Measurement of change in R(int) following bronchodilator (BDR) did not differ on average with algorithm. Geometric means (95% CI) for BDR measurements for algorithms 1-4 were 29.9% (26.0-34.0%), 30.4% (26.4-34.5%), 32.9% (28.8-37.1%), and 31.7% (27.6-35.8%), respectively. However, measurement of change in individuals could differ by up to 40%, depending on algorithm. In conclusion, there are significant differences in Rint, depending on algorithm used to estimate pressure change. Measurement of change in Rint is unaffected on average, although in individuals there could be significant differences. Each laboratory should state its method and use the same algorithm for longitudinal and group data.

Difficult asthma: defining the problems.

A retrospective survey was undertaken of children with difficult asthma, attending a respiratory clinic. The clinical and laboratory profiles of asthmatic children who were poorly controlled on > or = 800 microg of inhaled corticosteroids (ICS) were studied and compared to children well-controlled on > or = 800 microg ICS. Assessments were made of atopy, growth, lung function, treatment adherence, home environment, and responsiveness to corticosteroids (CS). Fiftyseven "difficult" and 23 well-controlled children were studied. Significant differences in the home environment were identified. Smoking was significantly more common in the difficult-to-control group. Nine children had alternative diagnoses. Poor CS responsiveness was present in 10 children. Adverse home environments, poor treatment supervision, alternative diagnoses, and unresponsiveness to CS were the most important factors in difficult asthma. A full assessment, including bronchoscopy, is indicated to avoid unnecessary increases in CS to doses that could cause side-effects.

Comparison of pulse oximeters in healthy sleeping infants.

Four commercially available pulse oximeters were compared on normal infants to determine incidence and correct identification of movement artefact, and to assess their other features, in order to guide the potential user in the most appropriate choice of a machine to suit their purposes. Measurements of arterial oxygen saturation by pulse oximetry are distorted by movement artefact. During five one hour recording periods, over 100 artefacts occurred with each machine. The incidence of movement artefact differed between oximeters. Twice as many occurred when the Criticare 500 was used. The four oximeters differed in their ability to identify artefacts. The Novametrix 500 was best able to do this. A visual display aided observer recognition of artefacts. Other features of the different machines are described. An expansion of the use of pulse oximetry beyond the intensive care unit is suggested.

Prescribing for persistent cough in children.

To identify the medications general practitioners consider for the treatment of persistent isolated cough, we undertook a postal questionnaire survey of a sample of general practitioners in east London. Fewer than 10% indicated that they never prescribed for such cough. About 70% sometimes considered antibiotics and/or bronchodilators in all age groups. Inhaled steroids and cromoglycate were considered by about 30% of prescribers for infants compared with over 60% for older age groups. As yet there is no evidence that medication is beneficial for persistent isolated cough. The role of asthma drugs for children with this symptom needs to be evaluated so that we can better identify those who are likely to benefit.

A new method for investigating regional lung function in children with localized lung disease.

Lung function studies using 13Nitrogen have been used to determine regional and total lung function in 16 children suspected of having localized lung disease amenable to surgery. This method is simple, requires no active co-operation on the part of the child and gives a radiation dosage of about one-third of that for a bronchogram. The studies provided information about the severity and localization of the disease, and in addition, information about the remaining lung areas.

Advice to a Moscow children's hospital.

At the request of the largest children's hospital in Moscow, McKenzie and colleagues made recommendations for improving the service. Restrictions on visiting and fears of contracting illness from non-disposable needles have discouraged the local population from using the hospital. Consequently the hospital is underused and overstaffed. Serious shortages of drugs and surgical supplies compromise care. Fundamental changes are needed in nursing and postgraduate education. The authors encouraged their Russian colleagues to address the health care needs of their local population and to develop family centred care, and they offered training in London.