Hospital to home paediatric enteral nutrition--parents need support.

This study assessed the provision of education and support to parents of children on home enteral nutrition (HEN), current dietetic support available and perceived challenges facing parents and carers. From the 39 responses (13%), 29 (83%, n = 35) parents suggested services for HEN need improvement. 29 (74%, n = 39) parents wanted more structured follow up and 22 (56%) would like one person to co-ordinate HEN, education and discharge. 7 parents (18%) reported a need for further education of health care professionals (HCP). Hospital dietitians were the most common HCPs reported to provide support to patients following discharge. Specialist paediatric HEN dietetic services working in a dedicated HEN team, who would provide accurate training and education and liaise with both parents and community care services post discharge should be in place. This would facilitate transfer to community care, reduce hospital re-admissions, outpatient department attendances and costs.

Lap belt injuries in children.

The use of adult seat belts without booster seats in young children may lead to severe abdominal, lumbar or cervical spine and head and neck injuries. We describe four characteristic cases of lap belt injuries presenting to a tertiary children's hospital over the past year in addition to a review of the current literature. These four cases of spinal cord injury, resulting in significant long-term morbidity in the two survivors and death in one child, arose as a result of lap belt injury. These complex injuries are caused by rapid deceleration characteristic of high impact crashes, resulting in sudden flexion of the upper body around the fixed lap belt, and consequent compression of the abdominal viscera between the lap belt and spine. This report highlights the dangers of using lap belts only without shoulder straps. Age-appropriate child restraint in cars will prevent these injuries.

A case of disseminated miliary tuberculosis in a five-year-old child.

A five-year old girl was referred, by the local area medical officer, as she had a positive Mantoux test and a chest x-ray consistent with miliary tuberculosis. She had initially been identified three months previously as a contact of a case of open pulmonary tuberculosis. A CT scan of the brain at the time of presentation showed multiple intracranial tuberculomae. A CT Brain scan three months into the treatment regime showed a significant reduction in the number and size of nodules indicating a favourable response to treatment. This case emphasises the importance of rapid tracing of paediatric tuberculosis contacts, if serious complications and their consequences are to be avoided.

Bilateral subdural collections--an unusual feature of possible Kawasaki disease.

A case of possible Kawasaki disease presenting with bilateral subdural collections is reported. A 6-month-old boy was admitted to hospital following a prolonged partial seizure. He showed signs of worsening encephalopathy and was treated for presumed infective meningoencephalitis. Imaging revealed bilateral subdural collections. Pyrexia and irritability continued despite appropriate antibiotic and antiviral therapy suggesting a vasculitic process. The mucocutaneous signs normally associated with Kawasaki disease were subtle and fleeting in this infant. There was a dramatic clinical response to intravenous immunoglobulin and high dose aspirin. At 2-year follow-up the boy has made a complete recovery with no echocardiographic evidence of coronary artery aneurysm and resolution of subdural collections. Kawasaki disease or other vasculitides should be considered in the differential diagnosis of acute subdural collections in infancy.

From the other side: parents' views of their early contacts with health professionals.

The parents of 84 school-age children with cerebral palsy were interviewed about their early experiences of dealing with health professionals. Seventy per cent of families expressed dissatisfaction with some aspects of their contact with the health services during the initial period of diagnosis and referral. Lack of explanation, either about the child's condition or the reasons for follow-up, was the commonest complaint (58%), followed by having their worries dismissed by doctors and the need to make repeated visits before their child's problem was recognized (51%). Twenty per cent complained about the manner in which they had been told about their child's disability and 5% were critical of the lack of understanding on the part of doctors of the practical difficulties they faced. A high level of dissatisfaction was found among parents of children who had recognized perinatal problems but dissatisfaction was not found to be proportional to the severity of the child's handicap. Ways in which the quality and delivery of services could be improved are discussed.

Serious infection in a neonatal intensive care unit: a two-year survey.

Over a two-year period 160 episodes of serious infection occurred in 139 infants admitted to a regional neonatal intensive-care unit. Eighty-seven (26%) of very low birth weight (VLBW) neonates and 52 (8%) of infants of birth weight greater than 1500 g were infected. The majority (84%) had bacteraemia alone. Though the clinical features of infection were not distinctive, in 94% of episodes the peripheral white blood cell or band counts were abnormal. Thirty-three (21%) of the infections occurred in infants under 48 h old and 15 of these followed prolonged rupture of membranes (greater than 48 h). All of the infections due to group B streptococci (5), Streptococcus viridans (2) and Haemophilus influenzae (3) occurred in this group. Coagulase-negative staphylococci (CONS) accounted for 49% of the infections and there was a marked increase in incidence of such infections during the survey. Infections with CONS were not necessarily associated with parenteral nutrition, the presence of intra-arterial catheters or mechanical ventilation but the rise in incidence was coincident with change in skin disinfectant usage and the general use of a third-generation cephalosporin to which the CONS were resistant. Although VLBW infants with meningitis were more likely to die than those of higher birthweight, the risk for those with bacteriaemia was the same in both groups. Infants with CONS sepsis were less likely to die than those with infections due to Gram-negative bacteria and the time from onset of infection to death was significantly longer for the former.

Tranexamic acid in the prevention of periventricular haemorrhage.

Increased fibrinolytic activity in the ganglionic eminence of the preterm human brain has been proposed as a factor in the aetiology of periventricular haemorrhage. The effect of tranexamic acid in preventing periventricular haemorrhage was evaluated in 100 infants in a double blind, randomised controlled trial. Haemorrhages developed in 22 infants who received tranexamic acid and in 20 of those who received placebo. A significant reduction in fibrin degradation products in treated infants was seen. Our study suggests that excessive fibrinolytic activity is not an important factor in the aetiology of periventricular haemorrhage and that treatment with tranexamic acid will not prevent its occurrence.

Candida albicans skin abscesses.

Two neonates who developed Candida albicans skin abscesses are described. One developed disseminated infection. In the newborn abscesses cannot be assumed to be of bacterial origin.

Juvenile discitis.

Over a period of three years four girls and two boys presented with discitis. All were less than 5 years old at presentation, and each had a short history of symptoms. Three were initially thought to have pathological defects of the abdomen. All children showed abnormal posturing with exaggerated lumbar lordosis. Diagnosis was essentially clinical. All cultures were sterile. The erythrocyte sedimentation rate was increased in all the children and all had mild pyrexia. Symptoms lasted from two to 8 weeks. Discitis should be considered in any child with fever, abnormal posturing, and refusal to walk. Early recognition may avoid unnecessary diagnostic and treatment procedures.

Convexity cerebral haemorrhage in the neonate: in vivo ultrasound diagnosis.

In vivo diagnosis of subdural or subarachnoid haematoma was made in five neonates by realtime ultrasound scanning. A combination of asphyxia and sequelae of exchange transfusion were probable precipitating factors. Persistent ultrasound abnormalities relate to quality of outcome in survivors.

Intervention in child abuse: experience in Liverpool.

The subsequent life events and development of 50 abused Liverpool children who had been removed from their parents and taken into the care of the Local Authority have been determined. Information was obtained by interviewing the district social worker responsible for each child's supervision. Medical progress and school performance was assessed in each case. Following their period in care, 26 children have had an unsatisfactory outcome indicated by the presence, either alone or in combination, of abnormal physical development, emotional disturbance, poor educational progress and occurrence of further abuse. Rehabilitation at home after varying periods of time was attempted for 25 children, five of whom suffered further abuse. The prognosis was worse the older the child on reception into care and the more placements while in care. The children who best survived their experiences after being taken into care were those for whom an early decision was made to sever parental contact and to place the child permanently with a substitute family.