Evaluation of monitoring strategies for childhood asthma.

INTRODUCTION: The goal of monitoring pediatric asthma is to obtain and maintain asthma control, which is defined as minimizing asthma symptoms, restrictions to daily activities and the use of rescue medication. Long term goals include reducing the risk of fixed airflow limitation, and preventing asthma exacerbations and side effects of treatment. Several monitoring tools are available but no consensus exists on how to monitor patients in the most optimal way. Areas covered: In this review, we provide an overview of different tools and address general considerations on monitoring childhood asthma. Asthma care should be tailored to the individual patient. The health care professional should decide which monitoring strategy and frequency is optimal for the individual patient. Expert commentary: Personalized medicine should be the key issue in monitoring asthma in children. It is crucial to monitor disease activity and deterioration but there is no monitoring strategy that is clearly superior compared to others: The optimal strategy and frequency will vary between patients. Actually, both treatment and monitoring of pediatric asthma probably benefit from a personalized approach.

A previously healthy 11-year-old girl with behavioural disturbances, desquamation of the skin and loss of teeth.

An 11-year-old girl was admitted with backpain, weight loss, fatigue and behavioural disturbances, starting seven weeks before admission. Physical examination showed acrodynia, tremor, cachexia, hypertension and extensive gingival ulceration. Routine laboratory tests were normal, except for a CRP of 98 mg/l. Screening tests for recreational drugs as well as antibody assays for HIV, hepatitis B and borrelia burgdorferia were negative. Chest X-ray, brain CAT and MRI scan were all normal. Lumbar puncture didn't show any abnormalities. Eventually a 24-hour urine test confirmed the diagnosis that was suspected by further questioning.

EEG findings in an eleven-year-old girl with mercury intoxication.

An 11-year-old female was seen at our outpatient clinic with a broad variety of symptoms that were due to elemental mercury intoxication. Electromyography and sequential electroencephalography findings obtained at days 2, 36, 88 and 148 are described. The patient was treated with chelation therapy during which she clinically improved considerably. A profound decrease in urinary mercury concentration occurred as well as normalization of the electroencephalogram.

[Treatment of neonatal hypoglycaemia: more frequent latching onto the breast versus supplementary feeding with formula; retrospective study of patient files]. / Behandeling van neonatale hypoglykemie: frequenter aanleggen aan de borst versus bijvoeden met flesvoeding; retrospectiefstatusonderzoek.

OBJECTIVE: To evaluate the effects of frequent latching versus supplementary feeding of breastfed infants with hypoglycaemia on blood glucose concentrations and breastfeeding. DESIGN: Retrospective study of patient files. METHOD: All breastfed infants born in the period of investigation (June 1st 2004-April 30th 2005) by artificial or breech delivery were included. In the group with supplementary feeding (June 1st 2004 until December 12th 2004) mild neonatal hypoglycaemia, defined as glucose concentrations between 1.8 and 2.5 mmol/l, with symptoms, or between 1.3 and 1.7 mmol/l, without symptoms, was treated with supplementary feeding with formula. In the group with more frequent latching (December 13th 2004-April 30th 2005) mild neonatal hypoglycaemia (defined as glucose levels of 1.8-2.1 mmol/l) was treated with more frequent latching without supplementary feeding. The change in feeding policy (mid December 2004) was introduced because of excessive numbers of supplementary feedings, which jeopardized breastfeeding. Blood glucose determinations were carried out with the HemoCue B-glucose system. Risk factors for hypoglycaemia were listed, enabling the assessment of data of neonates who did not run an increased risk of hypoglycaemia, a kind of 'control group'. RESULTS: 232 newborn infants were included: 158 in the supplementary feeding group and 74 in the group with more frequent latching. In the supplementary feeding group, 63% (100/158) of the children developed hypoglycaemia, versus 55% (41/77) in the group with more frequent latching. The latter had lower blood glucose concentrations than the supplementary feeding group. This difference was only significant for infants without risk factors: the mean difference in lowest glucose concentration between supplementary feeding and more frequent latching in the group without risk factors was 0.50 mmol/L (SD: 0.69; 95% CI: 0.06-0.93; p = 0.03) versus 0.20 mmol/l (SD: 0.79; 95% CI: -0.05-0.45; p = 0.14) in the group with risk factors. Supplementary feedings decreased by 39% (95% CI: 28-50). The number of infants discharged with breastfeeding only increased by 14% (95% CI: 2-26). Symptomatic hypoglycaemic episodes were not found in the group with supplementary feeding or in the group with more frequent latching. CONCLUSION: Frequent latching instead of supplementary (formula) feeding in infants with mild neonatal hypoglycaemia was associated with lower blood glucose concentrations but with higher percentages of breastfeeding only at discharge.

Stevens-Johnson syndrome in a child with chronic mercury exposure and 2,3-dimercaptopropane-1-sulfonate (DMPS) therapy.

INTRODUCTION: Stevens-Johnson syndrome (SJS) is an uncommon and potentially serious mucocutaneous disease. The most important step in the management of SJS is early recognition and immediate withdrawal of the causative agent. We present a patient with SJS associated with dimercaptopropane-1-sulfonate (DMPS) therapy. CASE REPORT: An asymptomatic 11-year old boy who had been exposed chronically to mercury vapour had a 24-hour urine mercury concentration of 37 microgram/L (reference value <10 microgram/L). Exposure to the mercury vapour was stopped and treatment with oral DMPS was begun. After two weeks of therapy, he developed a disseminated cutaneous eruption of red pruritic macules on his chest and back, which three days later had spread all over his body with the discrete maculae becoming confluent; erosions and crusts developed on his lips and he had blisters in his mouth. The diagnosis of SJS was made, the DMPS was stopped, and the SJS resolved gradually. DISCUSSION: Chelation agents like DMPS or DMSA are increasingly used and are available over the counter in some countries. These drugs are used in patients with complaints that are attributed to mercury-containing dental amalgams and in children with autism. CONCLUSION: The reported association suggests that SJS may be a potential complication of DMPS therapy, and this should be considered in the risk-benefit analysis of chelation. The reported association suggests that SJS may be a potential complication of DMPS therapy, and this should be considered in the risk-benefit analysis of chelation.

Vermindering van diagnostiek en overbehandeling bij RS-virus-bronchiolitis na geprotocolleerde behandeling.

PURPOSE: Evaluating the guideline 'Diagnosis and treatment of respiratory syncytial (RS) virus bronchiolitis' on the number of chest X-rays, C-reactive proteïn (CRP) counts, leukocyte counts, and antibiotic prescriptions in infants admitted to hospital with RS bronchiolitis. DESIGN: Retrospective 'before-after' cohort study. LOCATION: Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands. PATIENTS: Infants admitted with proven RS virus infection. METHODS: Guidelines, including sound restriction of performance of X-rays, CRP and leukocytes, were introduced in February 2003. Data from infants admitted with RS virus infection during 1997- 1999 (cohort A) were compared with those admitted from 2003- April 2006 (cohort B)Results: There were 155 infants in cohort A and 170 in cohort B. Implementation of guidelines led to significant reductions of CRP and leukocyte determinations: 49.0% and 48.2%, respectively (both p<0.001) and X-rays: 30.3% (p=0.020). Numbers of antibiotic prescriptions decreased with 55% (p<0.001). The chance of antibiotic prescription increased significantly when X-rays (OR=5.2), CRP (OR=5.4), or leukocytes (OR=4.2) were done. After implementation of the guidelines, the median stay in hospital decreased significantly from 8.0 to 6.0 days (p<0.001; ranges 1-13 days and 2-23 days, respectively). Performing X-ray, CRP or leukocytes, or antibiotic prescription did not significantly alter the total duration of hospital stay. CONCLUSION: Implementation of the guidelines led to significant decreases in numbers of X-rays, CRP and leukocytes determinations, and antibiotic prescriptions. Our data support the restrictive use of chest X-rays, CRP and leukocyte determinations in infants, admitted to hospital with RS virus bronchiolitis.

A neonate with an intact congenital umbilical appendix: an alternative theory on the etiology of the appendico-umbilical fistula.

Neonatal umbilical anomalies usually represent remains of the vitelline duct or the allantois. We describe a case of an umbilical appendix in a neonate. The vermiform appendix was found to be positioned in the umbilical cord. In a brief literature review we found eight other reports concerning umbilical appendices. In this article we describe a possible embryological explanation for the development of an umbilical appendix, and discuss whether or not the appendiceal umbilical fistulae reported are congenital or iatrogenic. The possible association between an umbilical appendix and different forms of malpositioning and rotation of the gut is also discussed. Protrusion of the neonatal appendix into the umbilical cord represents a different entity of congenital anomalies. It is important to realize that, in the case of an unrecognized umbilical appendix, medical procedures (e.g., canulation or clamping of the umbilicus) may produce an iatrogenic appendico-umbilical fistula. Careful inspection and palpation of the umbilical cord prior to these procedures may prevent a fistula being created. Furthermore, because the possible association between umbilical appendices and different kinds of malpositioning of the gut is so far not wholly elucidated, we recommend further (radiological) investigation in each case of an umbilical appendix. Correct positioning of the bowel needs to be confirmed in order to rule out possible future complications.

[Optimal breastfeeding to prevent hyperbilirubinaemia in healthy, term newborns]. / Optimale borstvoeding ter preventie van hyperbilirubinemie bij gezonde, voldragen pasgeborenen.

In a newborn infant, frequent bowel movements diminish the enterohepatic circulation of bilirubin, thereby increasing bilirubin excretion. In breastfed newborn infants, the frequency of latching on and administration of supplementary feeds are associated with serum bilirubin concentrations. Frequent breast feeding (at least 8 times a day) and fewer supplementary feeds will result in increased breast milk intake, less weight loss, and lower bilirubin concentrations. In the case of a breastfed infant presenting with neonatal hyperbilirubinaemia, the advice should be to breastfeed more frequently and to withhold supplementary feedings. An icteric newborn infant should be seen and weighed daily. If the infant has lost more than 10% of its birth weight, drinks poorly, or fails to gain weight despite latching onto the breast frequently, it should be referred to the paediatrician for further diagnosis and treatment. To ensure optimal production of breast milk during the first days after birth, early latching on is recommended, preferably within one hour after birth.

[Primary meningococcal-monoarthritis (Neisseria meningitidis serotype C) in a child]. / Primaire meningokokkenmonoartritis (Neisseria meningitidis serotype C) bij een kind.

A 26-month-old girl had a painful, swollen right knee, accompanied by fever and vomiting. She had had an upper respiratory tract infection for a number of days. Following a positive culture of synovial fluid, monoarthritis caused by Neisseria meningitidis serotype C without other signs of illness was diagnosed. She recovered completely after one joint aspiration and intravenous and oral antibiotic therapy. N. meningitidis serotype C infections without meningitis or septicaemia are rare, but should form part of the differential diagnosis of septic monoarthritis.