Zinc supplementation for diarrhea has been in the news for quite some time now. This randomized study from Pakistan evaluated the potential benefit of dietary supplementation of a rice-lentil (Khitchri) and yogurt diet with elemental zinc (as zinc sulfate) in hospitalized malnourished children (age 6-36 months) with 'persistent diarrhea. Although there was satisfactory recovery in malnourished children with persistent diarrhea receiving the Khitchri-yogurt diet, there was no evidence of improved weight gain or acceleration of recovery from diarrhea with zinc supplementation. In contrast, the reduction in plasma copper levels in zinc- supplemented malnourished children suggests that caution should be exercised in supplementing severely malnourished children with zinc alone (Pediatrics 1999; 103: e42).

Exercise training programes in asthmatic children are controversial, but two small studies add to the evidence supporting their use. In the first (Thorax 1999; 54: 196), individually tailored swimming training improved fitness and reduced exercise induced bronchoconstriction in eight children; in the second (Thorax 1999; 54: 202), training on an exercise bicycle for two months had a short term impact on participant's use of medication. These observations raise an inter- esting possibility that aerobic conditioning may reduce the airway response to specific stimuli. An associated editorial (Thorax 1999; 54: 190) however warns, that the available evidence is still too weak to justify modifying conventional asthma treatments.
I:) Adverse reactions are common after snake antivenom administration. A study was

carried out to assess the efficacy of subcutaneous low dose adrenaline in preventing acute adverse reactions to polyspecific anti-venom serum in patients admitted to hospital after snake bite. In this study, 56 patients received adrenaline and 49 a placebo as pretreatment. Out of these, six (11 %) adrenaline patients and 21 (43%) control patients developed acute adverse reactions to antivenom serum. The study found that the prophylactic use of 1: 1000 adrenaline in a dose of 0.25 ml given subcutaneously immediately before infusion of antivenom serum significantly reduces the risk of acute adverse reactions (BMJ 1999; 318: 1041).

Breastfeeding on demand seems to mean different things in different countries (Lancet 1999; 353: 1152). In Germany it means an average of 5.7 feeds a day, in Portugal it means 8.5 feeds a day, and in Spain mothers feed 2 month old infants 7 times a day. The same study, which covered most of Europe, found that women who took professional advice on feeding, fed their children less often then other women. Perhaps midwives, genera" practitioners, and obstetricians are bigger fans of scheduled feeding, conclude the authors. A related study from Mexico found that counseling from peers in the community improves the rate of exclusive breastfeeding among mothers and infants. (Lancet 1999; 353).

A lot has been said about hypoglycemia in the last month's journals. A study carried out to investigate the effects of neonatal hypoglycemia on small-for-gestational-age neonates, found that recurrent episodes of hypoglycemia were strongly correlated with persistent neurodevelopmental and physical growth deficits and were a more predictable factor for long-term effects than the severity of a single hypoglycemic episode (J Pediatr 1999; 134: 492-498). In another study, the risk factors for hypoglycemia were assessed in preterm infants. Cesarean section, intrauterine malnutrition (SGA), NICU hospitalization, gestational age between' 30 and 33 weeks and twinning were identified as risk factors for hypoglycemia (blood sugar <40 mg/dl). Severe hypoglycemia <20 mg/dl) was associated with cardiopulmonary resusctiation at birth, neonatal respiratory distress. syndrome and gestational age between 26 and 29 weeks (Fetal Diagnosis and Therapy 1999; 14: 63). Another study has . identified mutations in the paternal Sulfonylurea receptors (SUR 1 gene) as a cause for diazoxide resistant hyperinsulinemia. A related editorial (NETM 1999; 340: 1005); stressed on the need to rule out hyperinsulinemia in cases of severe hypoglycemia with glucose requirements greater than 10 mg per kilogram of body weight per minute.

The lesser we know about a disease, the more the hypothesis. Placental damage during pregnancy may predispose children to sudden infant death syndrome (SillS). This could be because these infants who were subject to . fetal hypxia may be less able to respond to the warning signs of asphyxiation that a normally developed child would. The authors suggest that mothers who suffered placental difficulties during pregnancy should monitor their baby more frequently, at least for the first six months of life (Am J Epid 1999; 149: 608).

A multicenter randomized controlled trial on the effects of inhaled nitric oxide (iNO) therapy on gas exchange in children with acute hypoxemic respiratory failure. In this study on 108 children, two subgroups (immunocompromised and an entry oxygen index >25) appeared to have had a more sustained improvement in oxygenation. The authors conclude that these subgroups may benefit from prolonged therapy (J Pediatr 1999; 134: 406).

In a study on 18 patients with ARDS, researchers have found that an essential protein found in lung surfactant-called specific-protein A-is damaged. This could explain why artificial surfactant treatments fail in ARDS patients. The researchers conclude that giving drugs to protect specific protein A in the lungs from damage from proteases may help patients and added that a combination of surfactant and antiprotease therapy may improve therapeutic prospects (Lancet 1999; 353).

Cisapride is a prokinetic drug that has been shown to be effective in the treatment of gastroesophageal reflux (GER) in adults. However in a study on 68 infants it has been found to be no better than placebo for relief of uncomplicated GER symptoms. At the end of 2 weeks there were no significant differences between the treatment and placebo groups in terms of infants' symptoms of crying, vomiting, or gagging. Nor was there any difference in parental ratings of overall symptom intensity. The authors note, however, that cisapride did appear to decrease the amount of time that esophageal mucosa was exposed to acid (J Pediatr 1999; 134: 287).

Giving the patient a hand! This has now really come true. The first human hand allograft from an unrelated cadeveric donor to an individual with amputated upper limb was performed on 23 Sep 98 in Lyon, France and the six month follow up has shown success. The motor and sensory recovery in the grafted forearm was found to be comparable with those in large series of Autoreconstructions. However, a commentary cautions that the potential advantages of a transplanted limb over a prosthesis could be outweighed by the toxic effects of immunosuppression and poor nerve recovery after microsurgery (Lancet 1999; 353: 1315).

A study on use of pacifiers reports that infants offered pacifiers spent less time overall breastfeeding. According to this study, infants who used pacifiers were breastfed an average of 8 times a day, compared with 9 times a day in infants who were not offered pacifiers. In addition, mothers who used pacifiers weaned their babies off the breast about 1 month earlier than mothers who used breastfeeding alone. The authors stress the importance of not offering pacifiers until breastfeeding has been strongly established (Pediatrics 1999; 103: e33).

The epidemiology of nosocomial infections in pediatric intensive care units (ICUs) in the United States was studied using data collected between 1992 and 1997. Data on 110,709 patients with 6290 nosocomial infections were analayzed. Bloodstream infections (28%), were the most common nosocomial infection, followed by pneumonia (21 %), and urinary tract infections (15%) and were almost always associated with use of an invasive device. Urinary tract infections were reported more frequently in children >5 years old compared with younger children, Coagulase-negative staphylococci (38%) were the most common bloodstream isolates, the aerobic Gram-negative bacilli were reported in 25% of primary bloodstream infections. The distribution of infection sites and pathogens differed with age and from that reported from adult ICUs, concluded the study.

A study was done to evaluate total and differential leukocyte counts during the first 5 days of life in relation to the method of delivery. The mean leukocyte and neutrophil counts in cord blood and up to 12 hours of life were higher in infants born by vaginal delivery as compared to cesarean deliveries. However, no significant differences were observed in the immature: total neutrophil ratios between the two groups of infants. The study concluded that the method of delivery produces a variation in the total leukocyte and neutrophil counts only during the first 12 hours after birth (BioI Neonate 1999; 75: 294).

Intensive chemotherapy improves the prognosis for children with acute lymphoblastic leukemia (ALL), but results in considerable morbidity, primarily due to myelosuppressions with resultant neutropenia. A study on the potential benefits of recombinant granulocyte colony-stimulating factor (G-CSF) in reducing the hematological toxicity found that there were significant reductions in the duration of neutropenia, severe neturopenia, duration of hospitalization and improved compliance with treatment scheduling (Med Pediatr Oncol 1999; 32: 331). A related study on the optimal timing for introduction of G-CSF found that a delayed start (+5 days postchemotherapy) reduced the costs of this treatment, but was not followed by more prolonged neutropenia or febrile neturopenias (Med Pediatr Oncol 1999; 32: 326).
 

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