q Pain has important physiologic and psychological effects in neonates. In a randomised trial assessing the efficacy of eutectic mixture of local anaesthetics (EMLA) in reducing pain in newborns undergoing lumbar puncture, the topical agent was found to effectively reduce the pain associated with needle insertion and withdrawal. In this randomized double-blind placebo controlled trial, the use of 1 g of EMLA 60 -90 minutes before the procedure caused significantly less increment in heart rates and change in behavioral score in comparison to placebo. The facial expressions of neonates were recorded on video film during the procedure and graded according to Neonatal Facial Coding System. However, there was no statistically significant difference in the oxygen saturation between the two groups. (Arch Pediatr Adolesc Med 2003; 157: 1065-1070).

q Children with clinically suspected pneumonia may or may not show infiltrates on chest radiograph. To identify the factors predictive of presence of infiltrates on chest X-ray, a prospective study was done among children (1-16 years age) with clinically suspected pneumonia. The data collected from those with and those without focal infiltrates on chest X-ray was analyzed and a multivariate prediction rule was developed using logistic regression analysis. A total of 570 children were included. Risk factors for the presence of focal infiltrates included history of fever, decreased breath sounds, crackles, retractions, grunting, tachypnea, and tachycardia. This rule was found to have a good sensitivity (93.1%-98%) but poor specificity (5.7%-19.4%). Further clinical studies may be required for validation of this multivariate prediction rule. (Pediatrics 2004; 113(3); e186-e189).

q The implementation of Integrated Management of Childhood Illnesses (IMCI) was envisaged to bring about a reduction in childhood morbidity and mortality in limited resource settings. The impact of training of health workers in management of pediatric illnesses (as per IMCI) was studied as a pre- and post-intervention trial at Ballabhgarh Rural Health Services Project. The outcome variable was reduction in Infant Mortality Rate (IMR), which was 37 per 1000 live births prior to the start of the intervention in November 1999. The workers were trained for 4 days through didactics, video-films, patient demonstrations, etc. and their management of pediatric morbidity was assessed based on the post-training knowledge gain, forms filled by them, and referrals seen at the secondary level. The knowledge of the workers on disease and their management improved after the initial training but reached a plateau at a 50 per cent score. Also, their disease classification and management was not satisfactory, especially for pneumonia and sick neonates but was better for fever, measles, dysentery, and diarrhea. There was no impact on IMR for the next 2 years. The authors stressed on the need for increased emphasis on training and supervision before implementing IMCI through health workers. Community level issues, such as healthcare seeking, female neglect, etc., may limit the scope of reduction in IMR due to implementation of IMCI. (J Trop Pediatr 2004; 50: 41-47)

q There is still considerable controversy over treatment with steroids for Henoch Schonlein Purpura (HSP), the most common vasculitis of childhood. A double-blind, randomized, placebo-controlled study evalua-ting the role of early administration of corticosteroids in 40 children with HSP was done to assess reduction in rate of acute gastrointestinal complications and delayed renal complications at 1 year. The cases were randomized to receive oral prednisone (n=21), 2 mg/kg/day for one week, with weaning over a second week, while the placebo group (n = 19) received an identical appearing placebo. The study concluded that early prednisone therapy in HSP does not appear to reduce the risk of renal involvement at one year, or the risk of acute gastrointestinal complications. There may be a reduced risk of intussusception. Hence the routine, early use of prednisone in uncomplicated HSP cannot be recommended at this time. (BMC Medicine 2004, 2:7)

q The presence of reduced lung function early in life along with atopy and airway hyper responsiveness may be associated with increased risk of persistent wheeze and asthma later in life. This was studied in a longitudinal fashion in infants whose VmaxFRC was recorded at 1 month age and they were followed up for the presence of wheeze upto 11 years of age. At 11 years of age, airway responsiveness (AR) to inhaled histamine and atopy were assessed and it was found that reduced airway function in early infancy is associated with persistent wheeze at 11 years of age, and this relationship is independent of the effect of increased AR and atopy in childhood. Wheeze between 4 and 6 years that persisted at 11 years was most prevalent among those with reduced lung function at 1 month and atopy at 11 years (p = 0.002) or reduced lung function and increased airway responsiveness at 11 years (p = 0.015). (Am J Resp Crit Care Med 2004; 169: 921-927)

q Croup is a common cause of acute upper airway obstruction and treatment with cool mist, nebulized racemic epinephrine and iv steroids are well-accepted therapeutic modalities. The other possible routes of steroid administration, namely nebulized, parenteral and oral, were compared in a trial using nebulized Budesonide, oral and intramuscular dexamethasone. A total of 60 children (6-36 months) were randomized to receive each of these in addition to nebulized salbutamol and other supportive measures. The patients were assessed using Westley Croup Score at 24, 48 and 72 hours and although there was significant difference in steroid and placebo group but there were no differences among the three modes of steroid administration. (Int J Pediatr Otorhinolaryngol 2004; 68: 453-456).

q Exposure to noxious stimuli in early life may have long-term consequences in terms of brain growth and intelligence. But their effect on incidence of psyhosomatic disorders hadn't been recognized. A matched case-control study was done using birth records for 494 mothers who delivered two or more children with birth weight at least 2.5kg, provided one of the two children had perinatal complication or birth asphyxia. Nationwide hospital discharge records were scanned for functional gastrointestinal symptoms among these children and 96 cases were identified with 116 unaffected sibling controls. The overall prevalence of functional GI symptoms was higher in these children than in general population. Multivariate logistic regression analyses showed that gastric suction at birth was associated with functional intestinal disorders during later life (odds ratio, 2.99; 95% confidence interval, 1.32-6.79; P = 0.009), whereas maternal, perinatal, or other confounding variables were not significant. The authors concluded that noxious stimulation caused by gastric suction at birth may promote the development of long-term visceral hypersensitivity and cognitive hypervigilance, leading to an increased prevalence of functional intestinal disorders in later life. (J Pediatr 2004; 144: 449-454).

q Treatment of Meconium Aspiration Syndrome (MAS) by three different therapeutic modalities was compared in a trial, which included standard treatment (group 1), bronchoalveolar lavage (BAL) with diluted surfactant (group 2), and diluted surfactant BAL plus a single early dexamethasone dose (group 3). Full-term newborns (n=24) with severe MAS (needing mechanical ventilation and with oxygenation index > or = 15) were divided into these three groups and at 12 hours, groups II and III showed a significant improvement in oxygenation index (OI) compared with group I (p = 0.012). Group III also showed a significantly lower OI than group I at 24 h and at 48 h. Group III, in comparison to group I, showed a lower FiO2 requirement at 12 h (0.66 vs 1), at 24 h (0.4 vs 0.87) and at 48 h (0.35 vs 0.67), and a decrease in the number of days of inhaled nitric oxide administration, mechanical ventilation, oxygen therapy and hospitalisation period. All patients from groups II and III survived and none developed pneumothorax or respiratory infections. The authors concluded that diluted surfactant BAL in the first hours of life combined with an intravenous single dose of dexamethasone may be an effective treatment for severe MAS. (Acta Paediatr 2004; 93: 60-65).

q Nasal sumatriptan is a novel mode of therapy for treatment of acute migraine attacks in children. A double blind, placebo controlled two-way crossover trial was conducted among 8 to 17 year olds diagnosed to have migraine by the International Headache Society criteria (1998). These children were randomised to receive nasal sumatriptan during two attacks at home and the primary efficacy endpoint was headache relief by two grades on a 5-grade face scale at 2 hours. Children reached the primary endpoint twice as frequently with nasal sumatriptan than with placebo. Other endpoints, including child's preference and using rescue medication, also favored sumatriptan. The most common adverse effect was a bad taste after sumatriptan, reported in 29% (n = 26/90) of the attacks. No serious adverse effects were observed. The authors concluded that nasal sumatriptan is an effective and well-tolerated treatment for migraine attacks in children over 8 year of age. (Neurology 2004; 62: 883-887)

q Treatment of Kawasaki Disease with Intravenous Immunoglobulin (IVIg) is standard practice but the role of steroids is still controversial. A trial conducted in Japan evaluated the efficacy of combined IVIg with steroids for acute Kawasaki Disease. Historical controls who were treated with IVIg alone in the past were taken for comparison and the clinical outcome and Vascular Endothelial Growth Factor (VEGF) levels were measured in these patients. No serious adverse effect was noted in either group and there were no differences in baseline and post-treatment laboratory data except for C-reactive protein between the groups. Post-treatment C-reactive protein in the DEX group was lower than that in the control group (P=0.033 by Mann-Whitney U test). In addition, the mean duration of fever after the first IVIG infusion was 2.2 days in the DEX group and 2.8 days in the control group (P=0.015 by Mann-Whitney U test). The new regimen did not reduce VEGF levels. Two patients in each group developed small- or medium-sized coronary artery aneurysms. The authors concluded that although this regimen did not affect coronary outcome, intravenous immune globulin therapy combined with dexamethasone was safe and may accelerate the resolution of systemic inflammation. (Eur J Pediatr 2004; 163: 229-233).

Lokesh Guglani,
Block No. N.I.L., House No 30 - A,
Malviya Nagar, New Delhi - 110017,
India.
E-mail: [email protected]