[Dermatomyositis. Presentation of a mild to moderate case with early dysphagia]. / Dermatomiositis. Aportación de un caso de afectación leve-moderada y disfagia precoz.

We report the case of a twelve year old female patient with juvenile dermatomyositis. The diagnosis was made in our unit a few days after starting with proximal muscular weakness and a skin rash. A combination of oral corticosteroids and methotrexate was administered. There was an initial improvent in the skin lesions, but with no changes in the muscle weakness. The appearance of dysphagia a few days after starting the treatment led us to add three pulses of parenteral methylprednisolone to her initial treatment. We report the case to illustrate the difficulties in deciding initial treatment options.

[Chemical pollution and breast milk: Taking positions]. / Contaminantes químicos y lactancia materna: tomando posiciones.

Chemical pollution affects all ecosystems of our planet. Human milk has been used as a biomarker of environmental pollution as, due to bioaccumulation processes in fat tissue, many chemical compounds reach measurable concentrations that can be readily tested in breast milk. Quite frequently information about the presence of contaminants in breast milk appears in the media, leading to misunderstanding among parents and health professionals, and in some cases breastfeeding the child is stopped. In this article, the Breastfeeding Committee of the Spanish Association of Paediatrics stresses the importance of promoting breastfeeding as the healthiest option, because its benefits clearly outweigh any health risks associated with chemical contaminants in breast milk. Breast milk contains protective factors that counteract the potential effects related to prenatal exposure to environmental pollutants. This article summarises the key recommendations to reduce the level of chemical contaminants in breast milk. It also highlights the importance of government involvement in the development of programs to eliminate or reduce chemical contamination of food and the environment. In this way, the negative effects on child health resulting from exposure to these toxic compounds through the placenta and breast milk may be prevented.

[Use of pacifiers and breastfeeding]. / Uso del chupete y lactancia materna.

Pacifiers are widely used in developed societies. They are used for soothing infants, reducing their stress and pain during procedures and to help them sleep. The use of pacifiers has been associated, however, with a shorter duration and exclusivity of breastfeeding, with higher rates of otitis media and dental problems, as well as a higher risk of accidents during infancy. Recent studies have also described a relationship between pacifier use and SIDS, especially when used during infant́s sleep. Other described benefits are analgesia and stimulation of non-nutritive sucking in preterm and term infants. There is, at present, wide debate and controversy on whether or not to recommend its use; thus it seems important for professionals and parents to be aware of the risks and benefits associated to its use, particularly related to breastfeeding. Due to the existing controversy of scientific findings, the Committee on Breastfeeding of the Spanish Paediatrics Society, publishes this review, trying to summarise present evidence with the objective of, after analysing scientific results and recommendations, making recommendations regarding the use of the pacifier in the breastfed infant.

[Iatrogenic botulism: a complication to be taken into account in the treatment of child spasticity]. / Botulismo yatrógeno: una complicación a tener en cuenta en el tratamiento de la espasticidad en la infancia.

INTRODUCTION: During the last decades the use of botulinum toxin for management of muscular disorders and spasticity associated to cerebral palsy has become a widespread practice. CASE REPORT: A 6-years female suffering of cerebral palsy secondary to a partial agenesis of the corpus callosum who was receiving bolulinum toxin since October 2001. One week after the last dose (Dysport 46 U/kg/dose) she started high grade fever, malaise, food refusal, choking, constipation, eyelid ptosis, absence of deep tendon reflexes, and abundant mucous discharge. Such features were so progressively severe that ventilatory support became mandatory. After a previous dose five months before, she developed similar features but they were less severe and thought to be related to a respiratory infection. CONCLUSIONS: At the present, there are two forms of botulinum toxin commercially available: the British brand Dysport and the American brand Botox. Bio equivalences are 1 U Botox to 2 or 6 U Dysport. Dosing (U/kg per session) has been established as follows: 5 U for Botox, 35 U for Dysport. Safety limits are a wide range with a therapeutic toxic index rate of 1:10. Generalized side effects after diffusion to blood of locally injected botulinum toxin are rare.

[Breast feeding: knowledge, attitudes and sociocultural ambiguity]. / Lactancia materna: conocimientos, actitudes y ambigüedad sociocultural.

OBJECTIVES: Found sociocultural attitude with regard to breast-feeding (BF) between the sanitary (SP) and no sanitary personnel (NSP) of health centers. DESIGN: Descriptive, cross-sectional study. SETTING: 4 health centres and 3 hospitals of Valencia. PARTICIPANTS: 442 workers of these centres. INTERVENTION: Structured questionnaire. MAIN RESULTS: 88% of SP and 76% of NSP (p < 0.05) believed that BF has many advantages comparing with artificial-feeding in a developed country. SP said more advantages of BF than NSP (p < 0.0001). Most renowned advantages were immunological, affective relationship and comfort. Main inconveniences were dependence, work reasons, aesthetic nature and insecurity in the ingested amount. 56% of SP and 86% of NSP (p < 0.0001) believed milk's analysis necessary. 56% women and 38% men (p < 0.001) didn't see correct give BF in public. Men were more concerned than women (p < 0.05) for local problems of chest, aesthetic results, milk's quality and transmission of illnesses. CONCLUSIONS: It's necessary to support knowledge and re-evaluating the trust in the nutritious capacity of maternal milk between the personnel of health centers and hospitals. Generic ambiguity toward functions of feminine breast exists and public'BF isn't acceptable. It's necessary recover socioculturally the image of BF and keep in mind the existent ambiguity upon designing campaigns of promotion.

[Inappropriate use of pediatric hospitalization]. / Utilización inapropiada de la hospitalización pediátrica.

OBJECTIVE: Our aim was to identify the inappropriate utilization of pediatric hospitalization, its reasons and associated factors. PATIENTS AND METHODS: Three hundred twenty-three medical records were randomly selected among the patients aged 6 months to 14 years and hospitalized in 1995 in a public hospital of the Community of Valencia. The validated Spanish version of the "Pediatric Appropriateness Evaluation Protocol" was retrospectively applied. The proportions of inappropriate admissions and stays and their reasons were estimated and their association with certain factors analyzed. RESULTS: Of the admissions 17.7% (95% CI: 13.5-21.8) and 15.5% of the stays (95% CI: 11.5-19.4) were considered inappropriate. The most frequent reason for inappropriate admission was that diagnostic and therapeutic needs might have been solved by ambulatory care. Inappropriate stays were in mot cases (70%) due to that doctors did not pay attention to keeping the patient in the hospital although acute care was no longer needed. Female patients, non-elective admissions, admissions by general pediatricians or traumatology and weekend stays had significantly higher proportions of inappropriate utilization. CONCLUSIONS: A considerable proportion of inappropriate admissions and stays was observed, although it is in the lower range of those observed in other studies in pediatric patients. The most frequent reasons were attributed to an excessively conservative medical practice.

[Inappropriate utilization of pediatric hospitalization. Validation of the pediatric appropriateness evaluation protocol Spanish version]. / Uso inapropiado de la hospitalización en Pediatría. Validación de la versión española del Pediatric Appropriateness Evaluation Protocol.

OBJECTIVE: To validate the Spanish version of the Pediatric Appropriateness Evaluation Protocol (PAEP). METHODS: The protocol was applied by two independent reviewers to a sample of 104 clinical records of pediatric patients (age 6 months to 14 years) admitted to a general hospital in the Valentian Community. Reliability was tested by comparing their results. Validity was tested by comparing the results of one reviewer with the judgment of three pediatricians. The following measures were calculated: overall agreement (IO), specific agreement (IE), Cohen's κ, inappropriate use ratio, and, to evaluate the predictive value, sensitivity, specificity and positive and negative predictive value. RESULTS: Interobserver reliability was high: the IO for admissions was 94.2% and 96.2% for days of care. The IE was 66.7% and 75% respectively, and κ showed values of excellent agreement: 0.77 (95% CI 0.59-0.94) for admissions and 0.83 (95% CI 0.68-0.99) for days of care. Validity was moderate: the IO for admissions was 92.35, and 90.4% for days of care. The IE was 60% and 58.3% respectively, and κ showed values of good agreement: 0.70 (95% CI 0.51-0.90) for admissions and 0.68 (95% CI 0.50-0.86) for days of care. Inappropriate use ratio was 1.13 for admissions and 0.73 for days of care. The sensitivity and specificity were high for admissions (80% and 94% respectively), while sensitivity was lower for days of care (64% and 98%). Regarding the prevalence of inappropriate use of this study, the positive predictive value ranged between 71% and 88%, and the negative predictive value ranged between 97% and 91%. CONCLUSIONS: PAEP has a high reliability, moderate validity and good predictive value face to clinical judgment, and it is a useful instrument for assessing the inappropriate utilization of pediatric hospitalization.

[Health examination of children from the Democratic Sahara Republic (North West Africa) on vacation in Spain]. / Examen de salud de niños de la República Arabe Saharaui Democrática (noroeste de Africa) de vacaciones en España.

OBJECTIVE: We present results of a global health evaluation of groups of children from the Democratic Sahara Republic who came to Spain for vacation. PATIENTS AND METHODS: Clinical and analytical tests of 242 Sahara children from refugee camps in Tindouf (Algeria) that were adopted temporarily by Spanish families between July 1993 and July 1997 are reported. We have used standard groups graphics from the World Health Organization. RESULTS: The results were as follows: sex, 53% girls; mean age, 11.1 +/- 1.6 years and age range, 7-16 years (mode 11). Sixty percent of the children had a weight lower than the 10th percentile and 28% less than the 3rd percentile. Fifty-one percent of the children had a height lower than the 10th percentile and 32% less than the 3rd percentile. The corporal mass was lower than the 10th percentile in 19% and less than the 3rd percentile in 8%. The mean hemoglobin was 12.7 +/- 1.2 gr/dl (17% Hb < 12), iron 66 +/- 32 micrograms/dl (23% Fe < 40), and ferritin 28 +/- 24 ngr/ml (26% Fe < 12). Between 1 and 3 intestinal parasites were found in 75% of the children. Isolated were: Entamoeba coli (38%), Blastocystis hominis (22%), Lamblia (18%), Endolimax nana (17%), Hymenolepis nana (11%), and Oxiuros (5%). Sixteen percent of the children had dental caries and 54% dental malocclusion. Ophthalmological problems were found in 28%, generally myopia. Mantoux > 9 mm was found in 5%. Other pathologies included: 5 kyphoscoliosis, 2 cardiopathies, 2 poliomyelitis sequels, 1 gastric ulcer, 1 epilepsy, 1 spherocytosis and 1 euthyroid goiter. Those with weight in p < 3 and/or functional murmur had Hb < 12 in 61% of the cases and Fe < 40 in 48%. CONCLUSIONS: Anamnesis is difficult because of ignorance of the pathological antecedents and date of birth. For physical exploration and collection of parasites they were extremely modest. Feeding and conditions of life would explain low weight and height percentiles, ferropenic anemia and intestinal parasite rates. It would be better to give anti-parasite drugs and systematic ferroprofilaxis as routine and perform blood tests only in those with weight p < 3.

[Medical responsibilities concerning maternal breast-feeding]. / Los cargos sanitarios ante la lactancia materna.

OBJECTIVE: The objective of this study was to determine the knowledge of high ranking officers in Servei-Valencià-Salut (SVS) about breast-feeding (BF) and national and international regulation related to it, in addition to determining what sanitary policies were undertaken by them to promote BF. PATIENTS AND METHODS: A survey was sent by mail to all high ranking officers (HO) of SVS and all pediatric chief staff services (PC) in our community. To analyze data between both groups a Chi square test and odds ratio in the qualitative variables and variance in the quantitative. RESULTS: Of the surveys sent, 100% were answered by the PC and 44% the HO. Breast-feeding was ranked as superior to artificial feeding by 100% of PC and 73% of HO (p < 0.05). Both groups believed in the necessity of carrying out policies to promote BF in developed countries. Only two PC seemed to know the 1981 OMS's code. All PC carried out policies of BF promotion in their area of influence, while in the HO the percentages varied from 64% to 0% according to their position in the health service organization. CONCLUSIONS: It is necessary to spread the knowledge of and to apply the OMS/UNICEF normatives and to involve al HO with real decision-making power in the development of sanitary policies.

[Is the pediatric service coordinated? Survey of pediatricians in Valencia and solutions]. / Está coordinado el Servicio de Pediatría? Encuesta a pediatras de Valencia y soluciones.

OBJECTIVE: The objective of this study was to identify existing problems in the coordination between the different levels of the pediatric care system and suggest possible solutions. PATIENTS AND METHODS: A poll of 66% of the health center pediatricians (HCP) of the greater metropolitan area of Valencia (city + 30 km) on the problems in the coordination between HCP and hospital pediatricians (HP), possible solutions and the number of patients per HCP per day, including the average and range, was performed. RESULTS: Answers were received from 54% of the HCP (n = 51), which represented 81% of the sample. Problems were identified in coordination (100%), institutional organization (98%), communication (96%), access to reports from outpatient clinics (84%), lack of time and mobility of the HCP (33%), and in the structure of the emergency service for primary child care (ESPCC; 4%). The suggested solutions were; None (6%), global institutional organization (94%) by creating a hierarchy in the HP and HCP, meetings and protocols by consensus, rotation of HP, HCP and pediatric residents between health centers and hospitals, institutionalized intercommunication, allotting time and work mobility to HCP, limiting patients per day and planning ESPCC in hospitals. The average number of patients per day was 32 +/- 8 patients/day (pd), range: 5-100 pd, with 92% of the HCP seeing > 20 pd, 63% > 30 pd, 17% > 40 pd and 2% > 50 pd. At > 6 km from the city there is no coordination and the number of patients/day is greater (p < 0.02). CONCLUSIONS: There is no institutionalized coordination between HP and NCP. The greater the distance from the city, the greater the overload and the lower the coordination. There is a lack of institutional organization.

[Patterns of use, popular beliefs and proneness to accidents of a baby walker (go-cart). Bases for a health information campaign]. / Patrones de uso, creencias populares y accidentabilidad por andador infantil (tacatá). Bases para una campaña de información sanitaria.

Baby walkers are a potential cause of accidents in infants from 6 months to 1 year of age. We conducted a study to determine the patterns of walker use, the different points of view of the parents and the baby walker-related injuries in our health district. For this purpose, between November 1, 1992 and January 31, 1993, a questionnaire was given to 207 parents of infants between the ages of 3 and 24 months in order to evaluate the socioeconomic situation and to determine the patterns of walker use. We found that 42% of the infants between 4.3 and 13.4 months of age had a baby walker and 46.7% of them used it daily. There was a significant inverse relationship between the walker usage and the maternal level of education. Of the infants who used walkers, 24.9% had experienced an accident (falls 76.2%, injuries 14.3% and hospital admission 4.8%). The accidents were significantly more common in boys. The advantages reported by parents (for using walkers) were: 46.3% none, 34.2% comfort, 10.9% infant amusement, 12.9% help to walk earlier. Dangers reported by the parents included: 27.2% none, 33.5% leg deformities, 43% accidents (33.5% injuries and 12% falling down stairs). In conclusion, our results show a slightly lower number of walker users and walker related accidents when compared to other reports. Parents have mistaken notions about the use of baby walkers. Hence, the need for continued health education campaigns related to this subject remain.

[Necrosis of undescended testis caused by incarcerated inguino-scrotal hernia in a newborn]. / Necrosis de testículo no descendido por hernia inguino-escrotal incarcerada en recién nacido.

Presentation of an uncommon case referring necrosis of an ectopic inguino-femoral testis caused by an incarcerated inguino-scrotal hernia in a 15-days old baby with a permeable peritoneum-vaginal process. In this case, the hernial incarceration episode was responsible for the organ necrosis due to an haemorrhagic infarction. Orchiectomy was performed, and the pathoanatomical diagnosis was testicular haemorrhagic infarction. Review of the pathogenic mechanisms of testicular ectopia, associated anomalies and likely acute complications: torsion, hernial strangulation, traumatism and infections simulating acute abdomen which, in spite of their rarity, may have serious consequences with regard to testicular viability.

[Variations in hospitalization rates of non-neonatal hospital admissions to pediatric departments of three district hospitals]. / Variaciones en las tasas de hospitalización pediátrica no neonatal en tres hospitales de distrito.

Hospitalization rates of children from three health districts were analyzed. The rates ranged from 30 to 40 admissions per 1000 children. The length of hospital stay, the rates of transfers and deaths were similar. Admission rates were different for certain selected diagnoses: gastroenteritis, pneumonia, bronchiolitis, head trauma and ear, nose and throat procedures. The variations were not related to differences in physician or bed supply, nor to severity or the disease of a delay in getting medical care. The demographic and geographic characteristics and the different patterns of practice can be associated with the observed variations. The health status of these children must be determined before considering which rate is correct.

[Four years of pediatric emergencies. Relationship between the increase in their number and personal initiatives in complementary examinations as well as hospital admissions]. / Cuatro años de urgencia pediátrica. Relación de su incremento y de la iniciativa propia en el número de exploraciones complementarias e ingresos hospitalarios.

In 16,848 paediatric emergencies taken care of from 1986 to 1989 in a regional hospital which had started work in 1985, we have confirmed an initial increase of over 20& per year in the number of paediatric emergencies that have become stable as we have reached full coverage of the total paediatric population in area. We have also stated that the volume of personal initiative emergencies has been increasing rather meaningluffly every year, going up from an initial 55% to a 75% in four years. On opposite the number of complementary checkups has decreased significantly from 38% to 35% and children hospital entries including those that required urgency observation have also gone down from a 21,69 in 1986 to a 15,8 in 1989. The growing tendency to overuse paediatric emergencies indiscriminately on the part of the population, leads us to make a serious proposal towards the adaptation and suitabilisation of emergency service in hospitals in order to be prepared to deal with non-urgent pathology.

[Epidemiology of mental deficiency. The Safor study (II): age at detection, person making the diagnosis, medical studies]. / Epidemiología de la deficiencia mental. El estudio de la Safor (II): edad de detección, agente que lo detecta y estudio médico.

As part of an epidemiological study on Mental Deficiency which was carried out in an area of the region of Valencia, a study has been made of the age when Mental Deficiency can be detected, who made this discovery, and which children have been the object of a medical study. 12% of the cases were detected at birth, 16% before the age of 3, 7% at 3, and 64% after the age of 4. In 16% of the cases the deficiency was detected by the family, in 20% of the cases a doctor and a psychologist in 62% of the cases. A medical study to discovered the causes of the Mental Deficiency was only carried out in 44% of the cases.