Recombinant erythropoietin (EPO) is known to accelerate erythropoiesis in preterm infants. In this preliminary study, the effect of erythropoietin administered orally was studied on 6 preterm infants (age <34 weeks, birth weight <1800 g) with an equal number as controls. The study group was administered EPO (rH-EPO, cilag) 600 u/kg/week (given on alternate days), started at a mean age of 24 days, with a treatment length of 21 days. The study group reported a significant increase in plasma EPO levels, reticulocyte count and a decrease in serum ferritin levels. The authors conclude that oral EPO is absorbed and enhances erythropoiesis in premature infants (Lancet 1999; 353: 1849).

Mortality rates among severely malnourished children in developing countries, even in hospital, are high. A team from Bangladesh had developed and adopted a standardized treatment protocol, that included slow rehydration with an emphasis on oral rehydration and oral feeds for severely mal- nourished children with diarrhea. Compared with the non-protocol management (n=293) used before the study began, the standardized protocol (n=334) resulted in fewer episodes of hypoglycemia, less need for intravenous fluids, and a 47% reduction in mortality. This study concludes that the use of a standardized protocol is simple, practical, and prescriptive and easily understood by trainee physicians and nurses (Lancet 1999; 353: 1919).

Type I diabetes and asthma do not go together. A recent European study has indeed shown that the risk of asthma was significantly decreased in children with type-I diabetes. In addition, it showed that protection extends to non-diabetic siblings also. Type-I diabetes is thought to be mediated by T- helper-I (Th 1) lymphocytes, whereas asthma and other atopie conditions are characterized by a preponderant T-helper-2 (Th2) response. These observations offer a demonstration of the potential importance of the balance between Th1 and Th2 responses in mediating the clinical outcome in the two common chronic diseases of childhood. Deviation of the immune" response from Th1 to Th2 is seen as a promising route to diabetes prevention, (Lancet 1999; 353: 1850).

Another association with type 1 diabetes! The insulin requirement among patients with type I diabetes and H. pylori infection was compared with uninfected coutnerparts. Of the 71 subjects who were evaluated, II
(15.5%) were found to the infected. Infected children were found to require more insulin and their glycosylated hemoglobin A level was higher than in uninfected subjects. The probable reason could be that Helicobacter pylori induces gastric inflammation and the production of cytokines in infected individuals. This increased production of cytokines could be deleterious for the control of the glycemia of patients with diabetes (Pediatrics 1999; 103: e83).

If you don't put your finger into the rectum you may end up putting your foot in it"! According to this study, this quotation rarely applies to the pediatric age group. (Brit J Surgery 1999: 86: 376). This study has concluded that rectal examination causes discomfort to children, rarely influences clinical management, and on the few occasions when it is necessary should be done only by an experienced clinician, It can usually be avoided by using alternative strategies such as careful observation, ultrasound imaging, or examination and endoscopy under anesthesia (Abstracted from Arch Dis Child 1999; 81: 100).

There is good news for MMR vaccine. The publication last year of a hypothesis that measles, mumps, and rubella (MMR) vaccination may be causally linked with autism was followed by a fall in acceptance of this vaccinaton in the UK. A population-based investigation of this issue has found no evidence to support an association with either the initiation of autism or the onset of regression (Lancet 1999; 353). The lack of an association is supported by the findings of several other analyses in an accompanying commentary. The commentary expects that these essentially negative findings should also attract as much publicity as the original association between MMR and autism (Lancet 1999; 353: 1987).

Oral coticosteroids are the drugs given most often during acute asthma attacks. But the results of a randomized control trial suggest that the addition of inhaled corti costeroids can reduce the number of relapses after discharge from emergency departments. In a study on 188 patients with acute asthma, all participants were discharged with a 7-day course of oral prednisone. In addition, 94 patients were given 1600 mg/day of inhaled budesonide for 21 days; the other 94 participants were given a placebo inhaler. After 21 days, 8% patients given inhaled corticosteroid had a relase compared with 5% patients given placebo. The study concluded that patients given inhaled corticosteroid use ~2-agonists less often than did control patients. They also reported fewer symptoms and a better quality of life during the 21-day study (JAMA 1999; 281: 2119).

C-reactive protein has been found useful in distinguishing Gram stain-negative bacterial meningitis from viral meningitis in children. Common CSF indices, blood leukocyte coutns, and serum CRP values were compared between patients with bacterial meningtiis (n = 355) who had a positive CSF bacterial culture but a negative Gram stain (n = 52) and patients with viral meningitis (n= 182). Only serum CRP was capable of distinguishing Gram stain-negative bacterial meningitis from viral meningitis on admission with high sensitivity (96%), high specificity (93%), and high negative predictive value (99%). This study concludes that exclusion of bacterial meningitis with only the conventional tests is difficult and that careful physical examination, CSF analyses and serum CRP measurement affords substantial aid (J Pediatr 1999; 134: 725).

Single-dose dexamethasone has been found effective in management of severe arterial hypotension of newborn infants. In this study, twenty preterm infants (median birth weight 690 g, gestational age 28 weeks, age at intervention 2 days) who did not respond to a standardized treatment protocol (blood/colloid followed by dopamine infusion stepwsie increased to 15Ilg/kg/minute) were started on an epinephrine infusion and were randomly allocated to receive either dexamethasone (0.25 mg/kg) or placebo intravenously. Epi- nephrine infusion was discontinued in 5 of 8 infants with dexamethasone but in only 1 of 9 infants in the control group. The duration of epinephrine infusion was significantly shorter in the dexamethasone group. The authors conclude that dexamethasone was effective for the management of severe arterial hypo- tension in preterm infants not responding to standardized treatment (J Pediatr 1999; 134: 701).

A simplified gentamicin dosing protocol for all neonates, using a loading dose and once-daily dosing has an equal or lower incidence of toxicity and improved effectiveness compared with the current regimen. A loading dose followed by once-daily dosing was shown to result in serum drug levels (SDL) in the safe. and therapeutic range in all term neonates in this study. In low birth weight neonates, this regimen resulted in peak and trough SDL throughout therapy that were similar to those observed in the control group (Pediatrics] 999; 103: ] 228).

Hepatitis B vaccine given at 0, 12 months and 24 months has been found to be as effective as the conventional 0, 1, 6 month regimen. A total of 389 children, 5 through 16 years of age, received hepatitis B vaccine (10 /lg) at a schedule of either 0-, 1-, and 6- month intervals or 0-, ]2-, and 24-month intervals. One month after the third dose, 98% of all children in both groups had anti-HBs concentrations 10 mIU/mL and high geo- metric mean antibody concentrations. The study concludes that hepatitis B vaccine administered on a 0-, 12-, and 24-month schedule is highly immunogenic and that providers should consider this alternate immunization schedule for children who are at low risk of immediate exposure to hepatitis B infections. (Pediatrics 1999; 103: 1243).

Recent studies in cerebral palsy have highlighted the importance of more subtle deficits, which are not apparent from simple clinical examination, and which suggest that impairment of sensorimotor learning may be a major contributor to the poor manual dexterity of people with cerebral palsy. Two studies on hemiplegic palsy emphasize that the impairment of manipulation in these patients cannot be thought of as a motor problem or as a sensory plus a motor problem, and that it can be understood only in the context of sensorimotor integration. More effective therapies and rehabilitation may be possible by targeting these features of manipulation to assist children with cerebral palsy to learn how to optimize their manipulative capacities (Dev Med Child Neurol 1999; 41: 166, 176).

While maternal nutritional deficiency is an important predisposing factor to congenital neural tube defects (NTD), maternal obesity is not. In a study on 72,915 cases, NTD (incidence of 1.08 per 1,000 pregnancies) complicated seventy-nine pregnancies. Differences between maternal weight ranges were not statistically significant. The study concluded that the present results do not support an association between maternal obesity and NTD (Fetal Diagnosis Therapy 1999, 14: 185).

A study on the vertical transmissin of toxoplasmosis analyzed 603 cases of con- firmed maternal toxoplasmosis infection. The overall rate of maternal - fetal transmission was 29%, with a rate of 6% in the first trimester which increased to 72% in the third trimester. However, the fetuses infected in early pregnancy were more likely to show clinical signs of infection (Lancet 1999; 353: 1829). Another study analyzed the effectiveness of screening for toxoplasmosis in Denmark, a low incidence area for toxoplasmosis infection. This study concluded that a prenatal screening program might not be justified in an area of low incidence. However, a neonatal screening program based on detection of toxoplasma specific IgM antibodies alone will identify between 70%-80% of cases of con- genital toxoplasmosis (Lancet 1999; 353:, 1834).
 

C. Vidyashankar,
Department of Pediatrics,
Base Hospital, Delhi Cantonment,
Delhi 110010, India.
e-mail: [email protected]