Acute childhood asthma in Galway city from 1985-2005: relationship to air pollution and climate.

We examine the relationship of air pollution and climatic variables to asthma admission rates of children in Galway city over a 21 year period. Paediatric asthma admissions were recorded from 1985-2005, and admission rates per thousand calculated for pre-school (1-4 years), school aged (5-14 years) and all children (1-14 years) on a monthly and annual basis. These data were compared to average monthly and annual climatic variables (rainfall, humidity, sunshine, wind speed and temperature) and black smoke levels for the city. Simple correlation and Poisson Generalized Additive Models (GAM) were used. Admission rates each month are significantly correlated with smoke levels (p = 0.007). Poisson GAM also shows a relationship between admissions and pollution (p = 0.07). Annual smoke levels impact more on admission rates of preschoolers (p = 0.04) than school age children (p = 0.10). These data suggest that air pollution is an important factor in the epidemiology of acute childhood asthma.

Services for children with diabetes.

This is the first assessment of the services available and care received by children and adolescents with Type 1 Diabetes in the Republic of Ireland. Questionnaires were mailed to 19 centres in 2006 identified as providing care for children and adolescents with Diabetes. Replies were received from all centres. 29 consultants provide care for a reported 2040 patients in the 19 centres. 16 (50%) paediatricians surveyed expressed a special interest in Diabetes while 27 (94%) see children in a designated Diabetes clinic. The average caseload per whole-time-equivalent (WTE) Diabetes Nurse Specialists (DNS) is 162 patients and 416 patients per WTE Dietician. 13 of the 19 centres (70%) have no access to Psychology services. This review of children's diabetes services highlights the current deficiencies, particularly in relation to support staff, with respect to international recommendations. Improvements in resources to reduce long-term complications needs urgent addressing at both local and national levels.

Self-reported pre-pregnancy maternal body mass index and infant birth-weight.

This analysis examines the association between maternal characteristics, particularly body mass index (BMI) and infant birth weight in 1048 live infants. Mean reported pre pregnancy BMI of mothers was 23.74 kg/m2 (SD 4.21). The educational level of the mother's parents was independently associated with maternal BMI, those with higher educated parents having a lower reported BMI (F = 2.787, p = 0.029). Mean infant birth weight was 3493 g (SD 18.1) and there was a strong graduated relationship to estimated gestational age. In a sub-group of participating maternal grandmothers (n = 171), reported BMI was 26.7Kg/m2. The BMI of expectant mothers was significantly associated with their own mother's BMI. (r = 0.179, p = 0.005) in this sub-group. These preliminary findings, which will be investigated further with recorded height and weight information, suggest that familial factors are influential, perhaps through genetic predisposition or shared socio-cultural factors such as diet.

Mothers' dietary patterns during pregnancy and risk of asthma symptoms in children at 3 years.

There is increasing evidence that dietary factors in early life play a role in the aetiology of childhood asthma. Our objective in this analysis was to assess whether maternal dietary patterns during pregnancy, as measured by a validated food frequency questionnaire, influenced general practitioner diagnosis of asthma by the age of 3 years in the Life-ways cohort of children. General Practice follow-up records were available for 631 of 1001 singleton children, twins having been excluded (63% follow-up rate). Overall 10.4% of children had diagnosed asthma, a prevalence rate comparable with other studies. In logistic regression models, based on quartiles of intake, which adjusted for maternal lifestyle and socio-economic circumstances, relatively higher maternal fruit and vegetable intake and oily fish consumption were associated with lower risk of children developing asthma, whilst those with relatively higher spreadable fat intake had a higher risk of asthma. These findings warrant further investigation as they imply an important role for maternal diet in childhood asthma, though the confounding effect of other social and lifestyle factors should be assessed as the children get older.

Prevalence of asthma in Galway school children 2004.

We aimed to ascertain the prevalence of asthma amongst Galway schoolchildren aged 9-10, and to compare the results to a similar study carried out in 1992. A questionnaire was distributed to parents of all children attending 4th class in Galway city schools. 652 of 750(87%) questionnaires were returned. Prevalence of "wheeze ever" was 27.6%, and "current wheeze" 16.3%. The prevalence of asthma was 18.5%. Of those with asthma there was a 2 to 1 male preponderance, 80% had mild asthma, 14% moderate, and 6% severe asthma. 80% were taking anti-asthma therapy, with 48% taking regular inhaled steroids. 84% had a diagnosis of asthma made by a doctor. Comparison with the study of 1992 shows little change in the prevalence of current wheeze, or asthma. There has however been a significant decline in the severity of asthma, and an increase in the use of prophylactic anti-asthma medication. Asthma prevalence appears to be stable in the age group studied. There is a much greater willingness to diagnose, and treat asthma in the community. The severity of asthma, as measured by attack frequency, has declined.

Patterns of asthma admissions in children.

Admissions for childhood asthma have declined over the past 10 years in the U.K. The reasons for this decline are not known. There are few published data on Irish children. The study was completed in a paediatric unit in a regional general hospital, with a stable urban/rural catchment population of approximately 45,000 children under 15 years. H.I.P.E. data on paediatric asthma admissions were analysed from 1990-2004. A prospective study of all acute asthma admissions of children aged 1-14 years over a 12 -month period was also undertaken, data were compared to a similar study in 1990, and a retrospective study in 1995. The number of admissions rose to a peak in 1995, and there was a large decline in the number of admissions thereafter. The fall was most marked in school age children. The prospective study showed that the treatment of asthma in the community, and in hospital was more aggressive. There were more children diagnosed, and on prophylactic therapy prior to admission. There was greater use of oxygen and nebulised ipratropium in hospital; milder cases were discharged sooner. Subjective assessment of severity of attacks on admission indicated increased severity, but objective measures showed less change. We have shown that the fall in asthma admissions was accompanied by more aggressive management in the community, with little changes in the attack severity in those admitted. The reduction in admissions was most evident in school age children. These data are consistent with the hypothesis that better management of asthma in the community is responsible for the reduction in admissions.

Access of asylum seeker children to acute paediatric services.

To investigate the interface between primary care and paediatric services in the referral of asylum seekers. Over a 3 month period a questionnaire was administered, and clinical data gathered on every child attending the A&E department of UCHG whose parents were seeking asylum in this country. Control data was obtained for the next Irish child seen on-call. At the time of presentation to the paediatric service, an Irish child was 4 times more likely (32%) to have initially been seen and referred by a GP than an asylum seeker child (8%); 80% of asylum seeker families had registered with a GP, compared to 96% of controls. 24% of asylum seeker families had called and used an emergency response ambulance to get to hospital, compared to just 4% of Irish children. The rate of subsequent admission to the paediatric ward from A&E was nearly that in asylum seeker children (24%) compared to Irish controls (40%), get to hospital, compared to just 4% of Irish children. Asylum seeker children are less likely to have seen a GP prior to A&E presentation, more likely to go to hospital by ambulance and less likely to be subsequently admitted, suggesting an over-dependence on paediatric hospital services in this population.

Medical graduates of the National University of Ireland in 1978: who and where are they?

To inform debate on medical manpower planning and aspects of medical education, we gathered data on graduates of three Irish medical schools in 1978. Twenty six years later, four of the 236 graduates had died and seven were untraceable. All but one of the remainder were in clinical practice and in a wide range of disciplines. A third were overseas. The implications of these findings are briefly discussed.

Knowledge of statistical methods and their implications for clinical practice: a survey of paediatricians.

Improvements in computer software have contributed to an increase in the use of multivariate statistical analyses e.g. multipLe regression in recent times. Our aim was to assess the familiarity with, and understanding of these complex statistical methods among Irish paediatricians. Questionnaires were sent to all paediatric specialist registrars (SpRs) and consultants in the Republic of Ireland. The questionnaire detailed information about clinical practice, and contained a short quiz on statistical methods. 137 questionnaires were distributed, and 62 (45.6%) were returned. Eighty four percent of respondents aimed to read journals weekly but only 46.7% managed to. The commonest journals used were; Archives of Disease in Childhood (93%), Pediatrics (53%), British Medical Journal (46%) and Journal of Paediatrics (45%). 28 of 61 (45.9%) of respondents have had further training in statistics. Only 19% felt they had a clear understanding of regression. Fifty-eight of 62 respondents (93.5%) completed the short test. The average score was 5.1/10. Sixty seven percent of questions on basics were answered correctly, 37.9% of questions on application of tests were answered correctly and 25.8% of questions on regression were answered correctly. Only 3.4% answered all questions on regression correctly. The overall knowledge of advanced statistical methods was poor. There is a poor overall understanding of the concept of regression, despite its increasingly common use.

Management of bronchiolitis: current practices in Ireland.

To establish current practice for hospital-based treatment of uncomplicated respiratory syncytial virus (RSV) infection in the Republic of Ireland. A questionnaire was sent to all consultant general paediatricians in the Republic of Ireland. The questionnaire described a clinical scenario and this was followed by a list of management questions. The scenario was of a 3-month-old infant with uncomplicated but moderately severe RSV infection requiring hospitalization. Seventy-three questionnaires were sent. 63/73 (86%) of the questionnaires were returned. With respect to management of this case almost all (61/63) the paediatricians felt that oxygen therapy was necessary (oxygen saturation described in the case was 90%). With respect to bronchodilator therapy, ipratropium bromide (38/63--60%) was chosen much more frequently than salbutamol (15/63--24%). Chest physiotherapy would have been prescribed by 8/63--13% of paediatricians. Oral steroids were infrequently chosen (1/63--2%) but nebulised steroids were selected in 7/63 (11%) cases. The routine use of RSV monoclonal antibody, palivizumab, for RSV prophylaxis was reported by 49% (31/63) of paediatricians. Prematurity with bronchopulmonary dysplasia was considered an indication for its administration by all of these but only 23% considered prematurity alone to be an indication. The management of infants with RSV bronchiolitis varies greatly among consultant paediatricians in Ireland. Evidence based guidelines may be of value in establishing a more uniform national treatment approach.

Can we increase breast feeding rates?

Breast feeding rates in Ireland have stagnated at around 33% over the past 10 years. We aimed to assess the effect of a simple intervention in late pregnancy on breast feeding rates. The study was randomised and prospective. In the intervention group a sheet illustrating eight positive aspects of breast feeding was presented to mothers at their 36 week antenatal visit. This information was reinforced with a questionnaire on the topic of breast feeding. The control group received a routine antenatal care. There were 98 mothers in the intervention group and 95 controls. A similar percentage in each group had medical cards. On discharge from hospital 31.5% of controls and 43.9% of the test group were breast feeding. This difference just failed to reach statistical significance (P = 0.07). The intervention, which took just three minutes of a medical student's time, appeared to result in an improved breast feeding rate. Though the difference did not reach statistical significance, this reflects, in part, the small numbers in the study. About half of the women in the study indicated that no doctor had offered any advice on the choice of feeding. Since this minor intervention produced a good response, it would seem appropriate to adopt a more positive attitude in the promotion of breast feeding.

Coeliac disease in Galway, Ireland 1971-1990.

Recent studies have reported changes in the incidence of coeliac disease and in its presentation. We carried out a retrospective study looking at the incidence and clinical features of coeliac disease in Galway children over a 20 year period. The study period was divided in two parts. (I) Patients diagnosed between 1971 and 1980 and (II) between 1981 and 1990. Comparison was made between demographic and clinical data in these two periods. There were 97 cases of coeliac disease diagnosed in children resident in Galway over the 20 year period. 71 patients were diagnosed in period I and 26 in period II. The median age at diagnosis in period I was 1.41 years and 4.95 years in period II. There were more females diagnosed in period I. Growth data, histology and enzyme levels were similar in both groups. Diarrhoea and vomiting were the major presenting symptoms in both periods but more patients presented with wasting or abdominal protuberance in the latter period. Our data support the concept that coeliac disease in childhood is declining, and is presenting at a later age.

Massive thymic hemorrhage in a neonate: an entity revisited.

The authors describe a case of early neonatal death of a full-term infant who had respiratory distress and anemia after fetal distress during labor. Postmortem examination disclosed mediastinal compression by a large fresh hemorrhage into the left lobe of the thymus. Massive thymic hemorrhage is an extremely rare but sometimes lethal occurrence; it may represent a manifestation of early-onset hemorrhagic disease of the newborn.

Benign neonatal sleep myoclonus.

Benign neonatal sleep myoclonus is a disorder characterised by abnormal episodic jerky movements, which occur exclusively during sleep. When the history is suggestive of the diagnosis, and physical examination and basic investigations are normal, a confident diagnosis can usually be reached, and other potentially more serious neonatal seizure disorders excluded. This allows the doctor to reassure the parents as to the prognosis--the condition resolves spontaneously within the first year, most often within the first three months, with no sequelae. We describe four patients who presented to one unit with this condition.

Home environment and childhood asthma.

The prevalence of childhood asthma has increased dramatically in the past 20 years. The reasons for the increase are unclear but many authors suggest that changes in the home environment favourable to proliferation of the house dust mite are to blame. Our study aimed to compare home environment of children with asthma and controls. A questionnaire on home environment was administered to the parents of 134 children with asthma and 118 controls. Detailed studies of home temperature, humidity and dust mite allergen (DERp1) levels were performed in 20 homes (10 from each group). The questionnaire response rate was 86%. There were no significant differences between asthma and control homes with respect to social class, type of housing, smoking habits, pets, insulation, home heating, bedding, carpeting and domestic cleaning habits. A first degree family history of atopy was obtained in 42% of asthmatic families and in 16% of controls. Temperature, humidity and dust mite allergen levels were similar in both groups. The majority gave readings exceeding recommended norms. Values for DERp1 were above thresholds by a factor of 5 in 48%. Home environment does not significantly differ in children with or without asthma. The home environment is now generally mite friendly, and large segments of the childhood population are now exposed to high levels of DERp1. This may account for the increasing prevalence as more and more children with an atopic background develop overt symptoms in response to high levels of allergen load.

Spectrum of childhood asthma in Galway.

We administered a questionnaire to the parents of 832 children in 4th class. 134 had wheezed in the previous 12 months. These children and matched controls were invited to attend for a brief clinical evaluation. 118 children with a history of wheeze and 118 age and sex matched wheeze free controls were seen. A brief questionnaire was administered. Heights and peak flow were measured. Children were assessed for the presence of chest deformity and eczema. There was a male predominance (1.7:1). Exercise induced symptoms were noted by 86% of children, but only 65% of parents in contrast, 65% of parents complained of night cough as against 28% of children. Over half had missed school because of asthma. Controls were asymptomatic. Height and peak flow measurements were similar in both groups. Chest deformity was evident in 25% of children with asthma, 8% had eczema and 27% were taking prophylactic medication. Childrens perception of asthma differs from that of their parents. School absence remains a problem and clinical evidence of hyper-inflation is common, though the absence of an overt effect on height and peak flow is encouraging.

Prevalence of asthma in Galway city school children.

To determine the prevalence of asthma in the past 12 months in nine year old Galway school children, a questionnaire on respiratory symptoms was distributed to children for completion by parents and returned to the school. We issued 896 questionnaires and 832 (426 boys and 406 girls) were returned completed. The overall response was 93%. The prevalence of wheeze in the past 12 months was 16.1%. A history of wheeze was more common in boys than in Girls. (19.7% Vs 12.3%). Overall, 67% of those reporting wheeze also reported a history of diagnosed asthma and 74% had used a bronchodilator. 60% reported a history of exercise induced wheezing and 67% had nocturnal cough. 28% were taking prophylactic medication. The current prevalence of asthma in Galway city school children is high. There is an increased willingness to diagnose and treat asthma in this community.

Randomized trial of umbilical arterial catheter position: clinical outcome.

In order to determine if umbilical arterial catheter position affects the incidence of necrotizing enterocolitis, clinical outcome was analysed in 308 infants whose umbilical arterial catheter had been randomly allocated to a high (n = 162) or a low (n = 146) position. Necrotizing enterocolitis was classified as suspected or confirmed; all renal, lower limb and local catheter complications were also recorded. High umbilical arterial catheters were in place for longer than low catheters, provided more samples and were removed as an emergency less often. Lower limb blanching and cyanosis were more common with low catheters. Eleven cases of confirmed necrotizing enterocolitis occurred in the "high" group and nine in the "low" group. One case of fatal aortic thrombosis was encountered in the high group. Positioning umbilical arterial catheters in a high position allowed longer functional use and did not increase the incidence of necrotizing enterocolitis.

Childhood asthma, can admissions be avoided?

Since admissions with asthma continue to increase and account for considerable morbidity, we chose to prospectively study asthma admissions over a one year period to assess the severity of patients' asthma, their need for treatment available only in hospital, and to assess the adequacy of their prehospital treatment. A study proforma was completed soon after the admission of each child. Data gathered between the 1st January and 31st December 1990 are presented. There were 105 children admitted, two-thirds of those were boys and just over half were aged less than 5 years. Eighty-seven children had a previous diagnosis of asthma. Overall the attacks were not severe, only 10 patients were treated with intravenous medication and 18 children required continuous oxygen. Sixteen patients required hospitalisation for more than 48 hours, the remainder were discharged within 2 days. Suboptimal prehospital care was identified in a third of patients, inappropriate management of the acute attack, failure of adequate prophylactic medication and non-compliance with prescribed regimes were common. In our hospital, admissions with acute severe asthma have declined in 1990, attention to simple treatment schedules may further reduce hospitalisation.