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Aims: To determine whether the use of negative pressure ventilation (NPV) was associated with a lower rate of endotracheol intubation in infants with recurrent apnoea secondary to acute bronchiolitis. Methods: Retrospective review of two paediatric intensive care units (PICU) databases and case notes; one PICU offered NPY. Results: Fifty two infants with bronchiolitis related apnoea were admitted to the two PICUs (31 to the NPV centre). There were no significant differences between infants in the two centres in age and weight on admission, gestational age at birth, birth weight, history of apnoea of prematurity or chronic lung disease, days ill before referral, respiratory syncytial virus status, oxygen requirement before support, and numbers retrieved from secondary care centres. Respiratory support was provided to all 31 infants in the NPV centre (23 NPV, 8 PPV), and 19/21 in the non-NPV centre (18 PPV, 1 CPAP); the NPV centre had lower rates of endotracheal intubation rates (8/31 v 18/21), shorter durations of stay (median 2 v 7 days), and less use of sedation (16/31 v 18/21). In the Iwo years after the NPV centre discontinued use of NPV, 14/ 17 (82%) referred cases were intubated, with a median PICU stay of 7.5 days. Conclusions: The use of NPV was associated with a reduced rate of endotracheal intubation, and shorter PICU stay. A prospective randomised controlled trial of the use of NPV in the treatment of bronchiolitis related apnoea is warranted. [ABSTRACT FROM AUTHOR]

A cohort of 53 patients (age range 1.9-16.5 years) with sickle cell disease (49 homozygous SS and four S beta zero-thalassaemia) was studied for evidence of sleep related upper airway obstruction (UAO). This involved (i) a clinical assessment based on a history of snoring, a score of tonsillar size, and (for 50 patients) overnight multichannel respiratory recordings, and (ii) a blinded analysis of arterial oxygen saturation (SaO2) from the above recordings, and comparison with results from 50 healthy age matched controls of both white (n = 25) and Afro-Caribbean race. There was no difference in the baseline SaO2 values of the white and Afro-Caribbean controls. Eighteen patients with sickle cell disease (36%) were found to have sleep related UAO. The blinded analysis showed that eight patients (16%) had episodic hypoxaemia (SaO2 less than or equal to 80%, a value not observed in controls) and/or low baseline SaO2 values (less than 95.8%, the lowest value seen in the controls). Postoperative assessment was undertaken in 15 patients who underwent adenotonsillectomy. All demonstrated an improvement in symptoms and a reduction or abolition of episodic hypoxaemia. Of the 47 patients assessed when free of UAO (not demonstrated on screening, n = 32, or resolved following surgery, n = 15), seven continued to show baseline hypoxaemia. Sleep related UAO and baseline hypoxaemia are common complications of sickle cell disease in children. [ABSTRACT FROM AUTHOR]

Imposed upper airway obstruction was diagnosed as the cause of recurrent and severe cyanotic episodes in 14 patients. Episodes started between 0.8 and 33 months of age (median 1.4) and occurred over a period of 0.8 to 20 months (median 3.5). Diagnosis was made by covert video surveillance, instituted after either (a) the observation that episodes began only in the presence of one person, or (b) characteristic findings on physiological recordings, lasting between 12 hours and three weeks, performed in hospital or at home. Surveillance was undertaken for between 15 minutes and 12 days (median 24 hours) and resulted in safety for the patient and psychiatric assessment of the parent: mother (n = 12), father (n = 1), and grandmother (n = 1). These revealed histories of sexual, physical, or emotional abuse (n = 11), self harm (n = 9), factitious illness (n = 7), eating disorder (n = 10), and previous involvement with a psychiatrist (n = 7). Management of the abusing parents is complex, but recognition of their psychosocial characteristics may allow earlier diagnosis. Imposed upper airway obstruction should be considered and excluded by physiological recordings in any infant or young child with recurrent cyanotic episodes. If physiological recordings fail to substantiate a natural cause for episodes, covert video surveillance may be essential to protect the child from further injury or death. [ABSTRACT FROM AUTHOR]

The prevalence of sleep related upper airway obstruction (UAO) was studied in a cohort of 34 children with Down's syndrome from a geographically defined area. Thirty two (94%) of the children, ranging in age between 0.1 and 4.9 years (median 1.4), underwent full clinical assessment for UAO including parental questionnaires and overnight tape recordings of chest wall movements and arterial oxygen saturation (SaO2). Compared with controls, children with Down's syndrome had (a) an increased incidence of stridor and chest wall recession during sleep, (b) an increased frequency of a pattern on inspiration indicating increased upper airway resistance, (c) a reduced baseline oxygen saturation (having excluded recordings on four children with potential for right to left intracardiac shunting), and (d) an increased number of episodes with SaO2 less than or equal to 90% despite continued chest wall movements. At their initial assessment seven children (22%) had evidence of UAO. The 18 youngest children (less than or equal to 1.7 years) underwent repeated recordings and clinical assessment until they had all reached 2 years of age. A further three were found to have developed UAO. Sleep related UAO is a common problem in children with Down's syndrome, occurring in 10 of 32 (31%) of this population based sample. [ABSTRACT FROM AUTHOR]

Twenty three patients (age range 0.5-40 months) with recurrent cyanotic episodes underwent physiological recordings, including transcutaneous oxygen tension (TcPO2) from a monitor modified for use at home (Kontron 821S). Of 69 episodes in which the arterial oxygen saturation (SaO2, Nellcor N200) was less than or equal to 80% for greater than or equal to 20 seconds and/or central cyanosis was present, the TcPO2 monitor alarmed (less than or equal to 20 mmHg or 2.67 kPa) in every episode. The pulse oximeter identified hypoxaemia in 62 out of 69 episodes, failing in seven episodes due to signal loss from movement artefact. In only seven of 69 episodes was there an accompanying apnoeic pause (greater than or equal to 20 seconds), and heart rate fell to less than or equal to 80 beats/minute in only five of 28 episodes in which an electrocardiogram was recorded. In 32 episodes in which SaO2 fell to less than or equal to 60%, the TcPO2 monitor alarmed after a median time interval of 16 seconds (maximum time interval 30 seconds). The TcPO2 monitor was then used in an uncontrolled trial at home in 350 patients at increased risk of sudden death and/or hypoxaemia. Indications for monitoring included apparent life threatening events or cyanotic episodes (n = 163), prematurity and prematurity related disorders (n = 86), and sudden unexpected death in one or more siblings (n = 122). The TcPO2 monitor detected cyanotic episodes at home in 81 patients, 52 of whom received vigorous stimulation and/or mouth to mouth resuscitation. Twenty one of these 52 patients had further hypoxaemic episodes documented in hospital with pulse oximetry. In 30 patients, the TcPo2 monitor also identified the gradual development of hypoxaemia, as confirmed by pulse oximetry. Twenty of these needed additional inspired oxygen and six subsequently needed ventilatory support in hospital. This TcPo2 monitor is a reliable detector of both sudden and gradual onset hypoxaemia and is able to be used by parents in the home. [ABSTRACT FROM AUTHOR]

Overnight 12 hour tape recordings of arterial oxygen saturation (SaO2, pulse oximeter in the beat to beat mode), breathing movements, and airflow were made on 66 preterm infants (median gestational age 34 weeks, range 25-36) who had reached term (37 weeks) and were ready for discharge from the special care baby unit. No infant was given additional inspired oxygen during the study. The median baseline SaO2 was 99.4% (range 88.9-100%). Eight infants had baseline SaO2 values below 97%, the lowest value observed in a study on full term infants. All but one infant had short-lived falls in SaO2 to less than or equal to 80% (desaturations), which were more frequent (5.4 compared with 0.9/hour) and longer (mean duration 1.5 compared with 1.2 seconds) than in full term infants. There was no evidence that gestational age at birth influenced the frequency or duration of desaturations among the preterm infants. The frequency of relatively prolonged episodes of desaturation (SaO2 less than or equal to 80% for greater than or equal to 4 seconds), however, decreased significantly with increasing gestational age (0.5, 0.4, 0.2, and 0.1 episodes/hour in infants at less than or equal to 32, 33-34, 35, and 36 weeks' gestational age, respectively). Analysis of the respiratory patterns associated with such episodes showed that 5% occurred despite both continued breathing movements and continuous airflow. Five infants had outlying recordings: three had baseline SaO2 values of less than 95% (88.9, 92.7, and 93.8%), and two had many prolonged desaturations (14 and 92/hour; median for total group 0.2, 95th centile 2.3). None of these five infants had been considered clinically to have dis order of oxygenation. Although these data are insufficient to provide information about outcome, we conclude that reference data on arterial oxygenation in preterm infants are important to enable the identification of otherwise unrecognized hypoxaemia. [ABSTRACT FROM AUTHOR]

Overnight 12 hour tape recordings were made of arterial oxygen saturation (SaO2, pulse oximeter in the beat to beat mode) and abdominal wall breathing movement on 67 healthy, full term infants between the ages of 29 and 54 (median 39) days. The median baseline SaO2 during regular breathing was 99.8% (range 97.0-100%). Fifty four infants (81%) had shortlived episodes during which SaO2 fell to 80% or less (desaturation); the median rate was 0.9 desaturations/hour, and the median duration of each desaturation was 1.2 seconds. The 97th centile value for the duration of all episodes in which SaO2 fell to less than or equal to 80% was 4.0 seconds. The frequency of desaturations was significantly higher, and their duration significantly longer, when the breathing pattern was non-regular rather than regular. The percentage of apnoeic pauses (greater than or equal to 4 seconds in duration) followed by a desaturation was higher during non-regular than regular breathing; it was particularly high during periodic breathing. A knowledge of normal variability of baseline measurements of oxygenation and of the relationship between oxygenation and breathing patterns in infants is essential to the use of pulse oximetry in clinical practice. [ABSTRACT FROM AUTHOR]

The pathophysiology of recurrent cyanotic episodes has been investigated in 51 infants and children. Episodes began at a median age of 7 weeks (range 1 day to 22 months, 39 at less than 4 months). They were characterised by the rapidity of onset and progression of severe hypoxaemia with early loss of consciousness from cerebral hypoxia. The most common precipitating factor was a sudden naturally occurring stimulus from pain, fear, or anger. In uncontrolled trials, cyanotic episodes were reduced in frequency and severity by tetrabenazine (n = 15) and additional inspired oxygen (n = 10). Eight patients died suddenly and unexpectedly (four during cyanotic episodes). Twenty eight patients underwent physiological studies during cyanotic episodes. There was no evidence of seizure activity at the onset and although prolonged absence of inspiratory effort with continued expiratory efforts was common, breathing sometimes continued. Episodes were not caused by upper airway obstruction and sometimes occurred during positive airway pressure ventilation. The rapidity of fall in arterial oxygen pressure and continued breathing suggested a right to left shunt of sudden onset. The results of contrast echocardiography and lung imaging studies confirmed that this was occurring within the lungs. These cyanotic episodes included both intrapulmonary shunting and prolonged expiratory apnoea. They are best explained by interactions between central sympathetic activity, brainstem control of respiration and vasomotor activity, reflexes arising from around and within the respiratory tract, and the matching of ventilation to perfusion in the lungs. They are a cause of sudden unexpected death in infancy and early childhood. [ABSTRACT FROM AUTHOR]

Hyperventilation, which occurs in some patients with severe mental handicap, is a prominent feature in the histories of most girls with Rett syndrome but its mechanism and effects have not been established. Respiratory function was therefore studied in 18 patients with Rett syndrome and 23 healthy controls. Ten of the patients (56%), but none of the controls, hyperventilated only when awake, and began doing so after a period of normal breathing without hypoxaemia. After hyperventilation was established it was interspersed with prolonged periods of apnoea (over 19 seconds) accompanied by Valsalva manoeuvres. Hypoxaemia (less than 90%) occurred in 47% of these periods of apnoea and five (50%) of the patients had oxygen saturation values of under 50%. During hyperventilation severe hypocapnia developed in every patient, and recorded arterial pH measurements ranged from 7.47 to 7.60. A further four patients (22%) did not hyperventilate, but had clear histories of hyperventilation when younger. All had frequent apnoeic pauses accompanied by Valsalva manoeuvres. The remaining four girls (22%) neither hyperventilated nor gave a clear history of doing so. Three had occasional apnoeic pauses associated with the Valsalva manoeuvres. All but one of the 18 patients had increased quantities of periodic apnoea compared with the control subjects. The hypocapnic alkalaemia and hypoxaemia resulting from hyperventilation may contribute to the cerebral impairment in Rett syndrome. Since the hyperventilation is 'primary', and not secondary to preceding apnoea, it is potentially treatable. Further studies will determine if treatment is practical and of benefit. [ABSTRACT FROM AUTHOR]

Overnight tape recordings of breathing movements, airflow, and arterial oxygen saturation from six infants aged 3 weeks to 7 months, who had cyanotic episodes associated with pertussis, were compared with recordings from 12 age matched healthy controls. In all patients clinically apparent apnoeic episodes were associated with the rapid onset and progression of central cyanosis. When overnight recordings were compared, patients with pertussis had a greater frequency of apnoeic pauses (particularly those greater than or equal to 12.0 seconds duration) and a greater frequency of episodes of hypoxaemia (oxygen saturation less than or equal to 80% for greater than or equal to 0.5 seconds) associated with apnoeic pauses. In addition to episodes of hypoxaemia associated with a prolonged absence of breathing movements, patients with pertussis had frequent dips in oxygen saturation in association with continued breathing movements with and without continued inspiratory airflow. These episodes of hypoxaemia during continued breathing movements were more common in patients with pertussis. These findings suggest that episodes of abnormal apnoea accompanied by evidence of a mismatch between ventilation and perfusion of the lungs may produce the rapid onset of severe hypoxaemia in infants with pertussis. [ABSTRACT FROM AUTHOR]

Pulse oximeter (SaO2P) measurements were compared with direct arterial line oxygen saturation (SaO2) from co-oximeters in 92 instances in 43 patients, and with arterial line oxygen measurements (PaO2) in 169 instances in 81 patients. The mean (SD) absolute difference between SaO2P and SaO2 was 2.6% (2.4) after attempt to correct for the co-oximeter falsely measuring a proportion of fetal haemoglobin as carboxy haemoglobin. For 19 infants and children greater than or equal to 5 months old, who have very little fetal haemoglobin, the mean (SD) absolute difference of 27 comparisons was 1.8% (2.1). Comparison of SaO2P and PaO2 measurements in 46 instances when PaO2 was less than 6.67 kPa showed SaO2 to be less than 90% on 40 occasions. In 24 instances when PaO2 was greater than or equal to 13.3 kPa the SaO2P was greater than or equal to 98% on 22 occasions. In 23 infants undergoing neonatal intensive care, transcutaneous oxygen monitors were compared with arterial PO2 measurements in 60 instances. The mean (SD) absolute difference between PaO2 and transcutaneous oxygen measurements was 1.60 kPa (1.73). Ten of the 60 comparisons had differences greater than 2.67 kPa and three greater than 5.33 kPa (maximum 8.40 kPa). Pulse oximetry is a clinically useful technique for managing oxygenation but further studies are needed to confirm its safety in premature infants at risk of retinopathy of prematurity. [ABSTRACT FROM AUTHOR]

Clinical data and 24 hour tape recordings of electrocardiogram (ECG) and abdominal breathing movements were collected from 301 infants who had had a sibling who had suffered the sudden infant death syndrome (SIDS). Of these, 261 were referred cases, and 40 were recorded prospectively as part of a population based study; none of the 301 subsequently died. Fifty five of the referred siblings who had been born at full term (greater than or equal to 37 week gestation) were randomly selected for a detailed analysis of heart rate and breathing patterns, as were all siblings born at full term from the prospective study (16 with a previous sibling in whom SIDS had occurred and seven with a sibling born at full term and in whom SIDS had subsequently occurred). The control group consisted of 197 recordings on 170 infants born at full term and matched by postnatal age. The mothers of the siblings smoked and consumed alcohol more often during pregnancy than the mothers of control babies. The siblings had lower Apgar scores and were more often breast fed than controls. There were no significant differences in the number of apnoeic pauses in the quantities of periodic breathing or in the heart and respiratory rates during regular breathing between the siblings and the controls. [ABSTRACT FROM AUTHOR]

Of a population of 9856 children followed up from birth, 9251 of whom underwent 24 hour tape recordings of electrocardiograms and abdominal wall breathing movements during early infancy, five died suddenly and unexpectedly at home at ages ranging from 16 months to 4 years. Postmortem examination, including full histological and microbiological investigations. failed to identify abnormalities ordinarily associated with death in all five cases. Two of the children were known to have had frequent cyanotic episodes and died during these events. In the three remaining cases there was no previous history of cyanotic or apnoeic episodes. The death of one of these three children was seen by his parents and the clinical features suggested that apnoea rather than a cardiac arrhythmia was the primary mechanism for his death. As in infancy, sudden and unexpected death for which no adequate cause is found at necropsy seems to constitute a major component of mortality between 1 and 5 years. [ABSTRACT FROM AUTHOR]

Standard electrocardiogram recordings were performed on a total of 7254 newly born infants from two maternity hospitals. Fifteen recordings were obtained on 15 infants who subsequently suffered sudden infant death syndrome. None showed lengthening of QT intervals sufficient to warrant the description of 'long QT syndrome'. When the QT intervals corrected for heart rate of cases with sudden infant death syndrome were compared with controls in age matched groups or after individual matching for postnatal age, hospital of birth, and weight at birth, no significant differences could be identified. [ABSTRACT FROM AUTHOR]

OBJECTIVE--To investigate the feasibility of negative extrathoracic pressure ventilation as a respiratory support following phrenic nerve palsy after cardiac surgery. DESIGN--An uncontrolled pilot study. PATIENTS--14 patients aged one week to 30 months (median 5.3 months) with phrenic nerve palsy diagnosed by phrenic nerve conduction tests and diaphragmatic electromyograms. Four had bilateral and 10 unilateral palsy. Before treatment all required oxygen and 10 were receiving positive pressure ventilation. One of the patients with bilateral and four of the patients with unilateral palsies had undergone a plication before negative pressure ventilation was started. INTERVENTION--Treatment was started 6-65 days (median 23) after operation with a newly designed system which included a Perspex chamber, which gave easy access to the child, and an elastic latex neck seal. Continuous negative pressure was used in conjunction with intermittent positive pressure ventilation while continuous or intermittent negative pressure ventilation was used in extubated infants. RESULTS--All four patients with bilateral palsy survived with long-term intermittent negative pressure ventilation and did not require further surgery. Of the 10 with unilateral lesions, seven required no further surgery, two underwent plication, and one had a re-plication. Three patients with unilateral palsy died of non-respiratory causes. The duration of positive pressure ventilation after starting negative pressure ranged from 0 to 23 days (median 6). Treatment with negative pressure lasted for 3-241 days (median 32) and was predominantly administered off the intensive care unit, including at home. CONCLUSIONS--Negative pressure ventilation may be an alternative to positive airway pressure ventilation in the management of phrenic nerve palsy. A multicentre randomised controlled trial is now required to assess further the role of negative pressure ventilation in phrenic nerve palsy. [ABSTRACT FROM PUBLISHER]

OBJECTIVE--To determine whether there was a difference in the relation between heart rate and RT intervals in infants who later died of sudden infant death syndrome (SIDS) and controls. DESIGN--A blinded, computer analysis of prospectively acquired physiological data on SIDS cases and controls. SETTING--Physiological data obtained from infants at home (collaborative analysis National Heart and Lung Institute and Exeter University). PARTICIPANTS--Nine fullterm infants who subsequently died of SIDS and 10 surviving controls matched for age and birth weight. INTERVENTIONS--24 hour tape recordings of the electrocardiogram at home between three and 11 weeks of age. MAIN OUTCOME MEASURES--Mean value of the constant b, which relates by linear regression the log of each RT interval to the log of its proceeding RR interval, and any difference between SIDS cases and controls. RESULTS--The mean (2SEM) values for b were 0.20 (0.03) for the 10 controls and 0.19 (0.03) for the nine SIDS infants. Cyclical correlations between RT and RR intervals of varying strength were identified in both SIDS infants and controls. CONCLUSIONS--Infants who subsequently died of SIDS did not show an impaired ability to modify RT intervals in response to change in heart rate. [ABSTRACT FROM PUBLISHER]

The fetal heart beat, detected by ultrasound, was recorded for five minutes from 934 antenatal women--266 at 30 to 35 weeks' gestation and 718 at 36 to 41 weeks. Episodes of bradycardia < 100/minute ranging from 5-30 seconds' duration occurred in 3 (1.1%) of the former and in 9 (1.3%) of the latter group. Tachycardia > 180/minute ranging from 30-90 seconds' duration occurred in 1 (0.4%) of the former and in 4 (0.6%) of the latter. Premature beats were not detected between 30 and 35 weeks, but occurred in 12 (1.7%) of 720 at 36 to 41 weeks' gestation. 50 subjects were monitored at both 30 and 35 weeks and 36 to 41 weeks' gestation and in one woman premature beats were present in the latter but not in the former recording. The incidence (1.7% of premature beats in the fetus at 36 to 41 weeks' gestation was similar to that in the healthy neonate (0.8%). Recordings of arrhythmias or rates outside the range 100-180/minute were replayed through a standard antepartum fetal heart rate monitor. The monitor failed to detect premature beats, 2 to 4 episodes of tachycardia > 180/minute, and 9 of 12 episodes of bradycardia < 100/minute, stressing its unreliability for detecting rapidly changing rates. [ABSTRACT FROM AUTHOR]

Two neonates with arrhythmias and the long QT syndrome are described. The arrhythmias were detected in utero and both infants were apparently well after birth. The first infant, although well, had a bradycardia for the first 9 days of life. A normal heart rate was documented at 10 days but a prolonged QT interval was not appreciated on the ECG. He was discharged from hospital but died suddenly and unexpectedly 3 days later. A post-mortem examination failed to find a cause for his death which therefore fell into the category of the sudden infant death syndrome (SIDS). A retrospective analysis of the perinatal electrocardiogram showed a probable junctional rhythm with 2:1 conduction to the ventricle; the QT interval was prolonged at 0.52 seconds (QTC = 0.63). The second infant had a QT interval of 0.52 seconds (QTC = 0.54) and frequent ventricular premature beats on a 24-hour electrocardiogram. She was treated with propranolol and remains well 2 years later. Sudden infant death has often been described in the siblings of children with the long QT syndrome and one other report described a case of SIDS which was said to have had a prolonged QT interval on the perinatal ECG. This report, however, provides unquestionable evidence, in one case, of an association between the long QT syndrome and SIDS. [ABSTRACT FROM AUTHOR]

Twenty-four hour electrocardiographic recordings were made on 104 randomly selected, healthy 7 to 11-year-old children. Ninety-two were technically adequate and suitable for analysis. The mean highest heart rate measured by direct electrocardiographic analysis over nine beats was 164 +/- 17. The mean lowest heart rates were 49 +/- 6 over three beats', and 56 +/- 6 over nine beats' duration. The maximum duration of heart rates less than 55/minute was 40 minutes. At their lowest heart rates 41 children (45 per cent) had junctional escape rhythms, the maximum duration of which was 25 minutes. Nine children showed PR intervals greater than or equal to 0.20 s and included three with Mobitz type I second degree atrioventricular block. Nineteen (21%) had isolated supraventricular or ventricular premature beats (less than 1/hour). Sixty subjects (65%) had sinus pauses that could not be distinguished on the surface electrocardiogram from those previously described as sinuatrial exit block or sinus arrest. The maximum duration of sinus pause measured over 24 hours on each child was 1.36 +/- 0.23 seconds. Thus apparently healthy children show variations in heart rate and rhythm over 24 hours hitherto considered to be abnormal. [ABSTRACT FROM PUBLISHER]

Twenty-four-hour electrocardiograms were recorded in the first 10 days of life on 134 healthy full-term infants with birthweights greater than 2.5 kg. The highest heart rate a minute, measured over nine beats, was 175 +/- 19 (SD). The lowest rates, measured over three, five, and nine beats were 82 +/- 12, 87 +/- 12, and 93 +/- 12, respectively. At their lowest rates 109 infants had sinus bradycardia and 25 had junctional escape rhythms. Thirty-three infants showed changes in P wave configuration with or without pronounced variation in PR interval. Atrial premature beats were present in 19 infants but only one had more than 12 per hour. In a randomly selected subgroup of 71 infants sinus pauses were found in 51 (72%). Five (7%) had electrocardiographic patterns and rhythm disturbances that could not be differentiated from those previously described as complete sinuatrial exit block or sinus arrest, eight (11%) had patterns indistinguishable from 2:1 sinuatrial block, and 23 (32%) had pattern indistinguishable from sinuatrial Wenckebach block. This study shows that normal infants have variations in heart rate and rhythm hitherto considered to be abnormal. [ABSTRACT FROM PUBLISHER]

A mother and three children presenting with syncope induced by exercise and emotion were diagnosed as epileptic. They, and three symptom free children, showed frequent ventricular and supraventricular tachyarrhythmias on ambulatory electrocardiographic monitoring. Three died before the correct diagnosis of disordered sympathetic innervation of the heart was made, but episodes of syncope and cardiac arrhythmias in the survivors have been successfully treated by propranolol. [ABSTRACT FROM AUTHOR]

24-hour recordings of the ECG and respiration, the latter from an impedance technique, have shown a phenomenon which could account for hitherto unexplained failures of impedance apnoea alarm systems. Whenever apnoea is accompanied by bradycardia there is a pronounced increase in the amplitude of the cardiac impulse on the respiration carrier. This imitates the respiration signal and prevents the alarm from sounding. Conversely, apnoea unaccompanied by bradycardia does not present this problem and is detected by the alarm. If impedance alarm systems are to be used to detect apnoea they must be accompanied by a heart rate (ECG) detector. [ABSTRACT FROM AUTHOR]

The authors reflect on the results of the study lead by professor K. Maitland and colleagues which examines the role of fluid boluses in managing children with febrile illness in Africa. They argue that treating ill febrile children without confirmation of advance hypovolaemic shocks can cause clinical deterioration. They believe that the study was improperly designed. They mention the need for a structured assessment and treatment approach for critically ill children.

In a recent article in this journal our unit was accused of a number of errors of judgment in applying covert video surveillance (CVS) to infants and children suspected of life-threatening abuse. The article implied, that on moving from the Royal Brompton Hospital in London to North Staffordshire Hospital, we failed to present our work to the Research Ethics Committee (REC). We did send our protocol to the REC though we did not consider that, after a total of 16 patients had been documented as being the subject of life-threatening abuse, this was research. The REC in Staffordshire agreed with us. We were also accused of undertaking work that should be pursued by the Police. We agree with this. However, unlike the Metropolitan Police the Staffordshire Police would not undertake CVS. We fail to agree that 'working together' with parents is necessarily practical or safe when trying to protect children from life-threatening abuse of this kind.