Agreement between Cochrane Neonatal reviews and clinical practice guidelines for newborns in Denmark: a cross-sectional study.

OBJECTIVE: To assess agreement between Cochrane Neonatal Group reviews and clinical practice guidelines in Denmark. DESIGN: Retrospective analysis of clinical guidelines for newborn infants. MATERIALS: All Cochrane neonatal reviews and Danish clinical guidelines for newborn infants. MAIN OUTCOME MEASURES: The recommendations from the Cochrane reviews and local clinical guidelines were compared and classified as being in agreement, in partial agreement or in disagreement. Authors of guidelines were asked whether Cochrane reviews had been considered during guideline development and reasons for any disagreements. Heterogeneity among departments was assessed. RESULTS: 173 interventions evaluated in Cochrane neonatal reviews were included. All 17 Danish neonatal departments agreed to participate, but only 14 (82%) delivered data. Agreement between reviews and guidelines was observed for a median of 132 interventions (76%) (range 129-134), partial agreement was observed for 31 interventions (18%) (range 29-33), and disagreement was observed for 10 interventions (6%) (range 8-13) (kappa = 0.56, range 0.53-0.59). Most of the latter 10 interventions were not recommended in the reviews but were recommended in the guidelines. There were numerous reasons for disagreement, the most common being usage of evidence with higher bias risks than randomised trials in guidelines development. Overall, Cochrane reviews were rarely (10%) used during guideline development. For nine guideline topics (5%) there was diversity among the Danish departments' recommendations. CONCLUSIONS: There is good agreement between Cochrane reviews and neonatal guidelines in Denmark. However, Cochrane reviews were rarely used for guideline development. Heterogeneity among guidelines produced by the various neonatal departments seems moderate.

Impact of blood sampling in very preterm infants.

In a prospective investigation, 99 very preterm infants (gestational age (GA) 24 32 weeks, birthweight 560-2,255 g) were studied during the first 4 weeks of life. The infants were divided into two groups: infants born extremely early (GA <28 weeks, n = 20) and infants of GA 28 - 32 weeks; the groups were then subdivided into critically ill or not. Diagnostic blood sampling and blood transfusion events were recorded. In total, 1905 blood samples (5,253 analysis) were performed, corresponding to 0.7 samples (1.9 analysis) per day per infant. The highest frequencies were found during the first week, in infants with extremely low GA and in critically ill infants. The mean blood loss and transfusion volume values were 13.6 ml/kg and 6.3 ml/kg, respectively. In total, 19 infants (19%) received 34 transfusions corresponding to 0.3 transfusions per infant. Thirteen out of 20 infants of extremely low GA received 28 blood transfusions, corresponding to 27.0 ml/kg of blood on average during the study period. Four developed late anaemia; thus, in total, 14 (70%) of the infants born extremely early received 35 transfusions during the first 3 months of life, corresponding to a total mean of 34.8 ml/kg. For the extremely preterm infants a significant correlation between sampled and transfused blood volume was found (mean 37.1 and 33.3 ml/kg, respectively, r = + 0.71, p = 0.0003). The most frequently requested analyses were glucose, sodium and potassium. Few blood gas analyses were requested (1.9/ infant). No blood losses attributable to excessive generous sampling were detected. The results show an acceptable low frequency of sampling and transfusion events for infants of GA 28-32 weeks. The study emphasizes the necessity of thorough reflection and monitoring of blood losses when ordering blood sampling in extremely preterm, critically ill infants.

[High-frequency oscillatory ventilation of newborn infants]. / Højfrekvens oscillatorisk ventilation af nyfødte børn.

Ventilator-induced lung injuries remain an important factor regarding morbidity and mortality in newborns requiring assisted ventilation. Numerous different modes of ventilation have been tried without achieving recognition. High-frequency oscillatory ventilation (HFO) is a new mode of ventilation which employs active inspiration and expiration at frequencies up to 20 Hz with a tidal volume below dead space. Progression of severe respiratory distress syndrome may be reduced by applying early HFO beside modern treatment modes. It has been demonstrated that immediate initial treatment of premature babies with high tidal volumes can cause lung damage. Clinical studies of HFO indicate, that it is possible to improve oxygenation, reduce short-term mortality, surfactant redosing, ventilator-time, use of extra corporeal membrane oxygenation (ECMO) and costs of hospitalization. Morbidity related to lung injury and cerebral damage is apparently unchanged compared to conventional mechanical ventilation. The use of HFO in milder cases awaits further clinical studies.

[Danish primary school teachers' knowledge about epilepsy in children]. / Danske folkeskolelaereres viden om epilepsi hos børn.

A questionnaire survey undertaken among 169 Danish primary school teachers revealed a comparatively good general understanding of epilepsy. Sixty-five percent had taught pupils with epilepsy and 78% had witnessed a child having a fit. Only 18% had attended courses on epilepsy, despite 63% stating a desire for training. Only 5% of the teachers judged their present knowledge on the subject as being sufficient. A considerable lack of confidence and knowledge on issues such as provoking factors, surveillance and management including medical treatment was found. The survey revealed a good understanding of restrictions that might be imposed on children with epilepsy. Only 18% of the teachers thought that children with epilepsy in general have learning problems. To achieve an optimal care for children with epilepsy a sufficient knowledge and confidence is necessary. It is recommended that education concerning epilepsy is introduced for teachers that have pupils with epilepsy in their classes. Such education might be provided by the local health services.

[Anterior fontanel bone--a rare normal variant]. / Anterior fontanelleknogle--en sjaelden normalvariant.

The anterior fontanel bone is a very rare true accessory bone. Radiographic demonstration is especially important in those babies suspected to have premature closure of the cranial sutures or fractures. The bone is considered as a normal variant. It does not interfere with cranial growth nor with the normal development of the child.

[Knowledge about asthma among Danish primary school teachers. Results of a questionnaire study]. / Danske folkeskolelaereres viden om astma. Resultat af en spørgeskemaundersøgelse.

An anonymous questionnaire inquiry performed among 324 school teachers in the Randers area with the purpose of elucidating teachers' knowledge about asthma is presented. To a series of statements about asthma, the teachers should answer yes, no or don't know. A limited knowledge about asthma in children was found. The knowledge about medicamental treatment was particularly limited. Only 57 per cent knew that wheezing after physical exertion is a strong indicator of asthma. Only five per cent had received proper instruction. This latter group had a significantly better knowledge of medical treatment (p < 0.0001-0.05). It is recommended that instruction in children's diseases, especially asthma should be reintroduced in teachers' training colleges.

[Efficiency of eye shields during phototherapy]. / Effektiviteten af øjenbeskyttelse under fototerapi.

The penetrance of light through 21 different types of eye shields used in Danish neonatal care units was evaluated. A phototherapy unit (Dräger Phototherapiegerät 800) with a visual illuminance of 8317 Lux was placed in a distance of 39 cm from a photographic lightmeter (Minolta Autometer IIIF). The opening of the meter was covered by the various shields tested. The penetrance varied between 1.0 and 2886 Lux. The most effective shield was made of three layers of green, tightly woven cotton. A commercially made eye shield (Posey Eye Protector 4646) was able to reduce visual illuminance to 118 Lux (ambient light in our nursery was 20-139 Lux). A tubular stockinette covering was found to be ineffective as thicknesses of 1-16 layers was able to reduce penetrance to only 2886-1055 Lux. The use of an eye protector made of three layers of green cotton, sized 140 x 50 mm is recommended.

Danish primary schoolteachers' knowledge about asthma: results of a questionnaire.

We present an anonymous questionnaire inquiry involving 334 primary schoolteachers in the Randers area with the purpose of elucidating teachers' knowledge about asthma. To a series of statements about asthma, the teachers answered yes, no or don't know. A limited knowledge of different aspects of asthma in children was found, although 57% had asthma children in their classes. Specially limited was knowledge about medical treatment. Five percent had received proper instruction about asthma and had a significantly better knowledge of medical treatment (p less than 0.001-0.05). Only 57% knew that wheezing after physical exertion is a strong indicator of asthma and only 33% knew that exertion in cold weather increases the risk of an attack. It is recommended that instruction in children's diseases, especially asthma, is introduced in teacher training colleges.

["Fifth day fits": a syndrome of neonatal convulsions. Can this condition be defined as an independent disease entity in Denmark?]. / "Fifth day fits": et syndrom af neonatale kramper. Kan denne tilstand afgraenses som en selvstaendig sygdomsenhed i Danmark?

A 12-year retrospective study to elucidate the incidence of "fifth day fits" including 127 infants with neonatal convulsions was carried out in the Randers area of Denmark. The incidence of neonatal convulsions was 8.3/1,000 live-born infants. The etiology in 74 cases of latent and 53 cases of convulsive seizures was asphyxia (38%), intracranial hemorrhage (17%), hypoglycaemia (9%), hypocalcaemia (4%), infections (6%) and developmental defects (4%). In 28 cases (22%) the etiology was unknown. In only two of these cases, the seizures started on day 4-6, and no peak incidence was found.

[Removal of a displaced nasopharyngeal tube from the esophagus using an inflated catheter]. / Fjernelse af dislokeret nasofaryngeal tube fra esophagus ved hjaelp af oppusteligt ballonkateter.

A safe and easily employed method of removal of a blunt foreign body from the oesophagus is described. The present case was a newly born infant with Pierre Robin's syndrome and congenital heart disease. A nasal tube had become displaced and the clinical condition did not permit endoscopic removal. By means of an inflatable balloon catheter introduced through the tube to the stomach, the foreign body could be removed without difficulty.

[Intussusception in children]. / Intussusception hos børn.

The records of 22 children (sex rate boy/girl 1.75, mean age 2 7/12 year) treated for intussusception in Randers Central Hospital during the period 1975-1989 were reviewed. In 27% of the cases this diagnosis was made before admission, gastroenteritis being the most frequent differential diagnosis (18%). The mean duration of symptoms before admission was 24 hours. No significant correlation between low age and late diagnosis was found. Symptoms were vomiting (100%), abdominal colic (95%), palpable abdominal tumour (73%), diarrhoea with blood and mucus (63%) and low-grade fever (64%). Treatment by barium enema had a low success-rate (29%); the best results were recorded in children with symptoms for less than 24 hours. The mean duration of the hospital stay was 3.5 days in children treated by barium reduction and 8.5 days in children treated surgically. Early diagnosis seems to increase the success-rate of non-operative treatment. Absence of the classical triad of paroxysmal pain, abdominal mass and red currant jelly stool (found in 41% of the cases) does not exclude the possibility of intussusception.

[Safety of children in cars. Safety systems, their use and misuse possibilities]. / Børns sikkerhed i biler. Sikkerhedssystemer, deres anvendelse og fejlmuligheder.

In Denmark 11-30 children and infants are killed every year in car accidents. In this country, there is no legislation concerning children under 3 years as car passengers, in spite of the fact that child restraints have proved effective in reducing the morbidity and mortality. Legislation concerning seat belts and chairs may reduce the frequency of injury and death by at least 25% and by 50% in children under one year. Children and infants are not "small adults" and require specially designed restraints. Only 83% use safety-chairs and belts, and in 63-74% the devices are incorrectly used. This reduces the effectiveness seriously and may even, per se, injure the children. The restraint systems (baby chair, child seat, cushion, belt and seat) are described together with the correct use and the possibilities for misuse. The use of rearfacing infant chairs on the back-seat for children under 4 years of age is recommended. Prevention by further information, legislation, rental programs, reduced taxes and a new design of seats is discussed. Profylactic information concerning the correct use of child restraint devices given by the family's general practitioner, is recommended.

[Fever during treatment for bacterial meningitis in children]. / Feber hos børn under behandling for bakteriel meningitis.

Eighty-seven infants and children aged 1 month to 15 years admitted to the Pediatric Department, Randers Central Hospital 1975-1988 with bacterial meningitis were evaluated with special interest in the course of fever and its relation to sequelae. The children were treated with ampicillin (400 mg/kg/day). We found that 94% were afebrile after six days. 10% had persisting fever, 1% prolonged fever and 38% were found to develop secondary fever. Significantly more children infected with H. Influenzae had secondary fever. In most cases, no reason for secondary fever was found (46%). 18% had drug fever and only one case of relapse was found. 23% had severe sequelae. No significant relationships between persistent, prolonged or secondary fever and sequelae were found.

[Purulent meningitis in childhood. Treatment results in 87 children between 7 month and 15 years of age]. / Purulent meningitis i barnealderen. Opgørelse af behandlingsresultater gennem en 14 års periode hos børn i alderen 1 måned til 15 år.

The children were admitted over a 14-year period (1975-1988) from an admission area of average Danish population distribution. The incidence was 15.5/100,000 children per year. The area had endemics of meningococcal disease in the years 1983-1984. The etiology was meningococcal in 43%, Hemophilus influenzae in 33% and pneumococci in 9% of the patients. Regardless of etiology, the antibiotic schedule was ampicillin 400 mg/kg body weight/day. Resistance to ampicillin was not found in any of the bacterial cultures. Within two weeks before admission 59% of the children had experienced a febrile illness. The diagnosis of meningitis was missed before admission in 24% of the cases. On admission, 93% had typical clinical signs of meningitis. 87% were lethargic or comatose. 31% had convulsion and in 13% the peripheral circulation was compromised. Recrudescence was suspected in one patient. Sequelae were most commonly found in children with meningococcal meningitis and were persistent in 23% of all the children. Severe or less severe neurological handicaps were seen in 29% (psychomotor retardation, epilepsy, cerebral palsy and hearing loss). One patient with Waterhouse-Friederichsens syndrome died. Thus the overall mortality was 1.2%, which is low compared to treatment results reported by others.

Topographical distribution of trabecular bone strength in the human os calcanei.

Mechanical properties of twenty human os calcanei were determined by uniaxial compression testing of bone specimens from facies articularis talaris posterior, facies articularis cuboidea, and tuber calcanei. Specimens were taken oriented perpendicular to the planes of the facies articularis, and in tuber along the presumed loading axis throughout the gait cycle. Young's modulus and strength at facies articularis cuboidea and facies articularis talaris posterior were about three times those at the tuber calcanei. The variation of the relationship between Young's modulus and apparent density indicated differences in the orientation of the trabecula, in relation to the direction of evaluation between these locations. A more detailed analysis of the topographical variation of strength within each location was made using penetration testing of a further nineteen specimens. The results of both types of measurements indicated that the major part of the load during walking is carried by facies articularis talaris posterior and facies articularis cuboidea.

[Peritonsillar abscess in a child caused by ampicillin resistant Haemophilus influenzae]. / Peritonsillaer absces hos barn forårsaget af ampicillinresistent Haemophilus influenzae.

An unusual case of peritonsillar abscess in a six year old boy is presented. The abscess was initially treated with penicillin without success and afterwards with ampicillin and tonsillectomy. Cultivation of pus from the abscess revealed beta-lactamase producing Haemophilus influenzae. The patient was finally successfully treated with sulfamethizole.

[Acute alcohol intoxication in children. Diagnosis, treatment and complications]. / Akut alkoholforgiftning hos børn. Diagnose, behandling og komplikationer.

The purpose of this review is to describe the diagnosis, emergency treatment and further observation and complications. Alcohol poisoning and complications are underdiagnosed problems. Intoxication in young children is accidental and due to lack of experience in older children. Strong spirits are usually involved. The speed of elimination is greater than in adults and presumably 3-8 mmol/l/h. Fatal cases with alcohol concentrations less than 3.0% have been reported. The lethal dose is presumably 3 g/kg. Symptoms are as in adults but appear at lower concentrations. Infants do not reach a stage of exitation. Children are more prone to develop complications such as hypothermia, acidosis, electrolyte disturbance and trauma. Hypoglycaemia develops in 24-50% of cases, more frequently in infants and after starvation. The treatment is aspiration, admission to hospital, close observation, determination of core temperature, alcohol concentration, blood glucose-concentration and determination of serum-electrolytes. Blood glucose should be monitored. Treatment is conservative but severely intoxicated children may require dialysis.

[Acute alcohol poisoning in children in the Randers area 1978-1988]. / Akut alkoholforgiftning hos børn i Randers-området 1978-1988.

The purpose is to examine retrospectively the circumstances, clinical course and sequelae in 37 children (32 boys, 5 girls) admitted with acute alcohol intoxication during the 11 years 1978-1988. It is concluded, that the number of admissions has increased. Two distinct populations are found: 0-3 and 8-15 years. Strong spirits were usually involved, excessive amounts ingested because of inexperience and not at home. Admission is within two hours from last ingestion and most often at week-ends. 24% had histories of chronic behaviour problems. 32% had minor injuries. The maximal alcohol concentration found was 2.9%. None of the patients were found to be hypoglycaemic or had long term sequelae.