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BACKGROUND—Candida species are frequently isolated from stools of children with diarrhoea but are not proven enteropathogens. It is hypothesised that faecal candida causes diarrhoea. AIMS—To determine the prevalence of faecal candida in childhood diarrhoea and the relation between faecal yeasts and diarrhoea. METHODS—Comparison of clinical and laboratory data, including quantitative stool culture for yeasts from 107 children hospitalised with diarrhoea and 67 age matched controls without diarrhoea. RESULTS—Yeast species, predominantly candida, were identified in the stools of 43 children (39%) with diarrhoea and 26 (36%) without diarrhoea. The concentration of candida was positively associated with recent antibiotic use (p = 0.03) and with the presence of another enteric pathogen (p < 0.005), but not with patient age, nutritional status, or duration of diarrhoea. CONCLUSION—Candida species do not cause childhood diarrhoea in well nourished children.

AIM—To assess the outcome of imaging investigations carried out in children with urinary tract infection (UTI), to compare the investigations with national guidelines, and to assess the impact on management. METHODS—Retrospective review of inpatients and outpatients, aged 0-12 years, referred to the University Hospital of Wales Healthcare Trust between February 1997 and January 1998 with UTI. All children without bacterial evidence of UTI and children previously investigated for antenatal urological anomalies, major congenital anomalies, or UTI were excluded. RESULTS—A total of 164 children (51 boys, 113 girls) were included. Thirteen of 56 infants (23%) and 82/108 older children (76%) were diagnosed at home over one year. The prevalence of dilatation on ultrasound was 8%, renal scarring on dimercaptosuccinic acid (DMSA) scan was 11%, and vesicoureteric reflux (VUR) was 34% when investigations were carried out following guidelines published by the Royal College of Physicians. In children aged 1-6 years, the prevalence of scarring was 1/54 (2%) in those treated at home and 6/18 (33%) in inpatients. CONCLUSION—The low yield of positive results and lack of evidence of impact on management indicate that DMSA scanning, with all the implications of isotope exposure, intravenous injection, staff time, psychological trauma, and expense, could be omitted in children over 1 year with first simple UTI not sufficiently ill to be admitted to hospital. The low rate of detection of UTI in primary care in infants may represent under diagnosis.

AIM—To compare final height in two groups of low birth weight children examined for short stature: the first group untreated because of normal growth hormone (GH) secretion, the second treated with human growth hormone (hGH) because of abnormal secretion. METHODS—A total of 49 subjects born at term of birth weight below the 10th centile were consecutively examined for idiopathic short stature. The first group of subjects (n = 20) with normal GH peaks after pharmacological tests (>8 µg/l) spontaneously reached final height. The second group (n = 29) with abnormal secretion were treated with hGH (20 U/m2/week) for 36-84 months. At diagnosis the two groups were of similar height for chronological age and bone age, and had similar target height. RESULTS—In both groups final height was significantly lower than target height (−0.65 (SEM 0.20) in untreated cases, −0.61 (0.18) in treated cases). Fewer than one third of subjects had a final height above target height. Final height data of untreated and treated cases were not different. In the treated group the best results were obtained by those subjects who improved their height for bone age after three years of therapy. CONCLUSIONS—Our subjects with birth weight below the 10th centile remained as short adults with final height below target height. Treatment with hGH 20 U/m2/week in those diagnosed as deficient was not effective, with final results overlapping those of untreated subjects.

A total of 195 children were randomised to zidovudine (immediate) or matching placebo (deferred) in a multicentre double blind trial in vertically HIV infected children with early disease (the PENTA 1 trial). Median follow up in the blinded phase was 1.9 years. Thereafter, individual children were unblinded following the results of adult trials showing a benefit of combination antiretroviral therapy (ART) over monotherapy, but follow up continued and is reported here until December 1998 (total follow up 4.6 years). Median time to starting ART in the deferred group was 2.7 years; 19% of deferred children had not started ART by 1999. Throughout follow up, the percentage of time spent on no ART, monotherapy, dual, and triple ART was 21%, 44%, 29%, and 6% respectively for immediate and 62%, 12%, 18%, and 8% for deferred groups. During the blinded phase eight (7.8%) immediate and 12 (13.3%) deferred children developed AIDS or died (log rank p = 0.24); overall 21 immediate and 20 deferred children progressed. In an analysis including all children regardless of original allocation, the risk of progression to AIDS or death, adjusting for age and time since trial entry was significantly lower during 1997-98 (2.4 per 100 child years) than during 1992-96 (6.6 per 100 child years), most likely a result of increased use of combination ART.

Background—Seizures are a prominent feature of childhood cerebral malaria, and are associated with an increased risk of death and neurological sequelae. We present the electroencephalographic (EEG) findings from a detailed clinical and electrophysiological study. Methods—Children with cerebral malaria had EEGs recorded within six hours of admission, and at 12 hourly intervals until recovery of consciousness. Ten deeply comatose children underwent intracranial pressure monitoring. Children were not mechanically ventilated, which made it possible to directly correlate the clinical and EEG findings. Results—Of 65 children aged 9 months and above, 40 had one or more seizures, and 18 had an episode of status epilepticus. Most seizures were partial motor, and spike wave activity consistently arose from the posterior temporo‐parietal region, a border zone area lying between territories supplied by the carotid and vertebrobasilar circulations. Fifteen children had seizures that were clinically subtle or electrographic. Clinical seizures were associated with an abrupt rise in intracranial pressure. Fifty children recovered fully, seven died, and eight had persistent neurological sequelae. Initial EEG recordings of very slow frequency, or with background asymmetry, burst suppression, or interictal discharges, were associated with an adverse outcome. Conclusions—Serial EEG recording has uncovered a range of clinical, subtle, and electrographic seizures complicating childhood cerebral malaria, and has emphasised their importance in the pathogenesis of coma. Further work is required to determine the most appropriate regimen for the prophylaxis and treatment of seizures in cerebral malaria, in order to improve outcome. (Arch Dis Child 2001;84:247‐253)

AIMS—To compare the clinical efficacy of hypo-osmolar oral rehydration salt (ORS) solution (224 mmol/l) and standard ORS solution (311 mmol/l) in severely malnourished (marasmic) children having less than 60% Harvard standard weight for age with dehydrating acute watery diarrhoea. METHODS—In a double blind, randomised, controlled trial, 64 children aged 6-48 months were randomly assigned standard (n = 32) or hypo-osmolar ORS (n = 32). RESULTS—Stool output (52.3 v 96.6 g/kg/day), duration of diarrhoea (41.5 v 66.4 hours), intake of ORS (111.5 v 168.9 ml/kg/day), and fluid intake (214.6 v 278.3 ml/kg/day) were significantly less in the hypo-osmolar group than in the standard ORS group. Percentage of weight gain on recovery in the hypo-osmolar group was also significantly less (4.3 v 5.4% of admission weight) than in the standard ORS group. A total of 29 (91%) children in the standard ORS group and 32 (100%) children in the hypo-osmolar group recovered within five days of initiation of therapy. Mean serum sodium and potassium concentrations on recovery were within the normal range in both groups. CONCLUSION—Our findings suggest that hypo-osmolar ORS has beneficial effects on the clinical course of dehydrating acute watery diarrhoea in severely malnourished (marasmic) children. Furthermore, children did not become hyponatraemic after receiving hypo-osmolar ORS.

AIMS—To develop and implement an evidence based guideline for the treatment of acute asthma using a metered dose inhaler and spacer combination. METHODS—Defined strategies were used for the development and implementation of a guideline, assessed by a prospective, descriptive, study using notes review, and patient, nursing, and medical staff telephone contact. The setting was a tertiary referral hospital in Victoria, Australia with 25 000 yearly admissions, and asthma accounting for about 7% of total. The first 200 children and families to use the guideline after its introduction were evaluated. RESULTS—A total of 191 (95.5%) children were treated according to the guideline. Six (3.0%) children were given nebulisers appropriately based on severity; five (2.5%) were given nebulisers at parental or child choice; and four (2.0 %) who did not have severe asthma, received nebulised treatment inappropriately. CONCLUSIONS—Successful implementation of a new evidence based guideline can be achieved using specific strategies for promoting the application of research findings in the clinical arena.

AIM To establish the prevalence of central nervous system (CNS) abnormalities on magnetic resonance imaging (MRI) in a population of children with congenital melanocytic naevi (CMN) over the head and/or spine, and to compare this with clinical findings. METHODS Forty three patients identified from outpatient clinics underwent MRI of the brain and/or spine. These were reported by a paediatric radiologist and findings compared with the clinical picture. RESULTS Nine patients had abnormal clinical neurology, seven had abnormal findings on MRI, and six had both abnormal clinical and radiological findings. Only three of the abnormal MRIs showed features of intracranial melanosis. Three others showed structural brain abnormalities: one choroid plexus papilloma, one cerebellar astrocytoma, and one posterior fossa arachnoid cyst; the first two of these have not previously been described in association with CMN. The last abnormal MRI showed equivocal changes requiring reimaging. CONCLUSIONS The prevalence of radiological CNS abnormality in this group of children was 7/43. Six of these developed abnormal clinical neurological signs within the first 18 months of life, but two did not do so until after the MRI. Two of the CNS lesions were operable; for this reason we support the routine use of early MRI in this group.

OBJECTIVE To investigate the cause and outcome of high fever in Jamaican children with homozygous sickle cell disease. DESIGN Retrospective review of febrile episodes in a three year period (1 September 1993 to 31 August 1996). SETTING Sickle cell clinic, an outpatient clinic in Kingston run by the Medical Research Council Laboratories (Jamaica). PATIENTS Patients with homozygous sickle cell disease under 17 years of age presenting with an axillary temperature ⩾ 39.0°C (102.4°F). MAIN OUTCOME MEASURES Diagnosis, death. RESULTS There were 165 events in 144 patients (66 (45.8%) boys) with a median age of 6.1 years. Bacteraemia was found in 10 (6.1%) events (three Streptococcus pneumoniae , two Haemophilus influenzae type b, two Salmonella sp, one Escherichia coli , one Enterobacter sp, and one Acinetobacter sp), and urinary tract infections in four (2.4%). All cultures of cerebrospinal fluid were sterile. Acute chest syndrome occurred in 36 (21.8%) events. A painful crisis was associated with 45 (27.3%) events and was the only pathology identified in 20 events (12.1%). Hospital admission was necessary in 66 cases including all those with bacteraemia and 31 with acute chest syndrome. There were two deaths: a 5 year old boy with septic shock associated with H influenzae septicaemia, and a 3 year old boy with the acute chest syndrome. CONCLUSIONS Painful crisis and acute chest syndrome were the most common complications associated with high fever, but other important associated features included bacteraemia and urinary tract infection. Enteric Gram negative organisms accounted for 50% of positive blood cultures.

AIM To determine the incidence and nature of unlicensed and off label prescribing of drugs for children in general practice. METHODS A retrospective analysis of all prescriptions for one year involving children (aged 12 years or under) from a single suburban general practice in the English Midlands. Prescribed drugs were categorised as licensed, unlicensed (without a product licence), or used in an off label way (outside the terms of their product licence). RESULTS During 1997 there were 3347 prescription items involving 1175 children and 160 different drugs. A total of 2828 (84.5%) prescriptions were for licensed medicines used in a licensed way; 10 (0.3%) were for unlicensed medicines; and 351 (10.5%) were licensed medicines used in an off label way. For 158 (4.7%) the information was insufficient to determine licence status. CONCLUSION This is the first study to show that a significant number of drugs prescribed for children by general practitioners are off label and highlights the anomalies and inadequacies of drug information for prescribers.

Aim—To determine the incidence of hypocalcaemia in critically ill children with meningococcal disease. Methods—In a prospective cohort study, 70 of 80 patients admitted consecutively with a clinical diagnosis of meningococcal disease to intensive care had measurements of total and ionised calcium on admission. Parathormone and calcitonin were measured in a proportion of the children. Results—Total and ionised calcium concentrations were low in 70% of the children. There was a weak relation of calcium concentration to the volume of blood derived colloid which had been given, but a good relation to disease severity, where sicker children had lower calcium concentrations. Although the parathormone concentration was higher in children with lower calcium concentrations, some children had low ionised calcium concentrations, without an increase of parathormone concentration. Serum calcitonin concentration was not related to calcium concentrations. Conclusion—Hypocalcaemia is common in meningococcal disease. (Arch Dis Child 2000;83:510‐513)

AIMS To determine the extent of off label and unlicensed drug use in French office based paediatric practice. METHODS A prospective one day survey of all written prescriptions, for patients under 15 years, among 95 office based paediatricians in the Paris, France metropolitan area. Main outcome measures were: comparison of the use of each drug with its product licence for age, indication, dose, and route of administration. RESULTS A total of 2522 prescriptions were administered to 989 patients; 844 (33%) were used either in an unlicensed (4%) or an off label (29%) manner. A total of 550 (56%) paediatric patients received one or more off label prescriptions. CONCLUSIONS Off label prescriptions (that is, outside the terms of the Summary of Product Characteristics) are widespread in office based paediatric practice, while unlicensed drug use is rare in our study. New regulations in the licensing process in Europe are needed to allow children to receive drugs that have been fully evaluated in their specific age group.

BACKGROUND AND AIMS—The recollections of critically ill children following discharge from the paediatric intensive care unit (PICU) have not previously been described. We have interviewed such children to establish the nature of their recollections. METHODS—Children aged 4 years and above were interviewed following discharge from the PICU at the Queens Medical Centre, Nottingham, either in hospital or at home, using a semistructured interview. Their recollections were recorded and interpreted by content analysis. RESULTS—A total of 38 interviews were carried out; 44 specific recollections were reported, the majority being neutral (60%) or positive (25%). Only 15% of recollections were negative. Negative recollections related to aspects of medical care and environmental factors. No child treated with neuromuscular blocking agents remembered any period of therapeutic paralysis. CONCLUSIONS—Children's recollections of PICU are mainly neutral or positive. Mechanically ventilated children sedated with midazolam and morphine remember little of endotracheal intubation.

BACKGROUND There are few data on paediatric community acquired pneumonia (PCAP) in the UK. AIMS To investigate the aetiology and most useful diagnostic tests for PCAP in the north east of England. METHODS A prospective study of hospital admissions with a diagnosis of PCAP. RESULTS A pathogen was isolated from 60% (81/136) of cases, and considered a definite or probable cause of their pneumonia in 51% (70/136). Fifty (37%) had a virus implicated (65% respiratory syncytial virus) and 19 (14%) a bacterium (7% group A streptococcus, 4% Streptococcus pneumoniae ), with one mixed infection. Of a subgroup (51 patients) in whom serum antipneumolysin antibody testing was performed, 6% had evidence of pneumococcal infection, and all were under 2 years old. The best diagnostic yield was from paired serology (34%, 31/87), followed by viral immunofluorescence (33%, 32/98). CONCLUSION Viral infection accounted for 71% of the cases diagnosed. Group A streptococcus was the most common bacterial infective agent, with a low incidence of both Mycoplasma pneumoniae and S pneumoniae . Pneumococcal pneumonia was the most common bacterial cause of pneumonia in children under 2 years but not in older children. Inflammatory markers and chest x ray features did not differentiate viral from bacterial pneumonia; serology and viral immunofluorescence were the most useful diagnostic tests.

METHODS—The clinical and epidemiological features of 102 children with extra-pulmonary tuberculosis, diagnosed between 1982 and 1998at P & A Kyriakou Children's Hospital were reviewed. RESULTS—During the past decade, a 50% increase of admissions for extra-pulmonary tuberculosis was observed. The source of infection was disclosed in 48 patients. Diagnoses included superficial lymphadenitis (n = 48), pleural effusion (n = 27), meningitis (n = 16), skeletal tuberculosis (n = 5), miliary tuberculosis (n = 3), abdominal tuberculosis (n = 2), and pericarditis (n = 1). Miliary tuberculosis developed in infants, lymphadenitis and meningitis in preschool children, and pleural effusion and skeletal tuberculosis in older children. None of the patients with extra-pulmonary tuberculosis died; however, six patients with meningitis developed permanent neurological deficits. In these patients, antituberculous treatment was introduced at a median of six days following admission as compared with one day in patients with no complications. Poverty, immigration, and limited access to medical services were common among patients with meningitis.

AIM—To measure drug adherence in children with mild asthma receiving long term prophylactic treatment. METHODS—Double blind randomised placebo controlled trial. Patients received inhaled budesonide 100 µg or 200 µg daily, or placebo for 27 months. All participants were asked to inhale medication or placebo from two different Turbuhalers (morning and evening) during the study. A total of 122 children (80 boys, 42 girls) aged 7-16 years with mild asthma (mean FEV1 103.7% of predicted) were included in the trial. Drug adherence was assessed by counting the number of remaining doses in the inhaler when study medication was returned at six month intervals. RESULTS—A statistically significant and continuing decrease in measured drug adherence was found from three to nine months and then to 27 months, reaching mean values of 40.6% and 46.9% for inhaled morning and evening medication respectively. Drug adherence declined more rapidly in the placebo group (compared to active treatment); this difference became significant after two years of treatment. Children aged 9 years or less had better drug adherence during the entire study period, but the difference was only significant for the first three months of the study. Measured drug adherence was significantly higher for evening medication compared to morning medication for all study intervals after nine months. CONCLUSION—Measured drug adherence diminishes significantly when treating children with mild asthma in a long term trial. This emphasises the importance of monitoring compliance in clinical trials.

AIMS—To determine effects on short term growth and collagen turnover of adding formoterol (Eformoterol) to half the glucocorticoid dose in children with asthma, treated with inhaled budesonide (Pulmicort Turbuhaler). DESIGN—A randomised double blind, placebo controlled crossover study with two six-week periods. SETTING—Outpatient clinic in secondary referral centre. SUBJECTS—A total of 27 prepubertal children aged 6-13 years. INTERVENTIONS—Formoterol 12 µg and dry powder budesonide 100 µg twice daily in one period; placebo and dry powder budesonide 200 µg twice daily in the other. OUTCOME MEASURES—Primary outcome measures were lower leg growth rate, and serum and urine markers of type I and type III collagen turnover. Secondary outcome measures were inflammation markers in serum, and parameters of asthma control. RESULTS—During budesonide 200 µg twice daily treatment, mean lower leg growth rate was 0.14 mm/week (p = 0.02) lower than during the formoterol and budesonide period. Similar statistically significant effects on markers of collagen turnover were found, whereas inflammation markers and asthma control did not vary statistically significantly between the two periods. CONCLUSIONS—In children treated with inhaled glucocorticoids, halving the dose and adding formoterol is associated with faster short term growth and an increase in markers of collagen turnover, with no loss of asthma control.

Background—In adults, erythema multiforme (EM) is thought to be mainly related to herpes infection and Stevens‐ Johnson syndrome (SJS) to drug reactions. Aims—To investigate this hypothesis in children, and to review our experience in the management of these patients. Methods—A retrospective analysis of 77 paediatric cases of EM or SJS admitted to the Children’s Hospital in Bordeaux between 1974 and 1998. Results—Thirty five cases, inadequately documented or misdiagnosed mostly as urticarias or non-EM drug reactions were excluded. Among the remaining 42 patients (14 girls and 28 boys), 22 had EM (11 EM minor and 11 EM major), 17 had SJS, and three had isolated mucous membrane involvement and were classified separately. Childhood EM was mostly related to herpes infection and SJS to infectious agents, especially Mycoplasma pneumoniae. Only two cases were firmly attributed to drugs (antibiotics). No patient died. EM and SJS sequelae were minor and steroids were of no overall benefit. Conclusion—In paediatric practice EM is frequently misdiagnosed. The proposal that SJS is drug related in adults does not apply to children, and in our recruitment EM and SJS are mostly triggered by infectious agents. The course of both diseases, even though dramatic at onset, leads to low morbidity and mortality when appropriate symptomatic treatment is given. (Arch Dis Child 2000;83:347‐352)

AIMS—To audit the management of community acquired pneumonia before and after the introduction of a protocol. To determine the aetiology of pneumonia using routine investigations and polymerase chain reaction (PCR). METHODS—Retrospective and prospective audit following the introduction of a management protocol. Prospective cases were investigated routinely and with PCR on blood and nasopharyngeal aspirate. RESULTS—There was a significant increase in rational prescribing following introduction of the protocol with 75% of children receiving intravenous penicillin or erythromycin compared with 26% beforehand. Of 89 children in the prospective group, 51 microbiological diagnoses were achieved in 48 children. Seven children had Streptococcus pneumoniae infection, 14 had Mycoplasma infection, six had pertussis, and one had Chlamydia pneumoniae infection. Twenty three children had a viral cause of which respiratory syncytial virus was commonest. CONCLUSIONS—Introduction of the protocol led to improved prescribing. PCR increased the diagnostic yield and the results support the management protocol.

BACKGROUND Nurse led clerking is currently practiced in a growing number of UK centres, but there is a paucity of evidence to underpin the safety of this innovation. AIM To assess the safety of nurse led clerking in paediatric day case and minor surgery. METHODS Children aged 3 months to 15 years were randomly assigned to clerking by either a nurse or a senior house officer (SHO) (resident). All children were then independently reassessed by a specialist registrar anaesthetist to provide a “gold standard” against which practitioner performance could be judged. RESULTS In 60 children studied, nurses identified a significantly greater proportion of the detectable abnormalities present in the sample (p = 0.16). This difference is attributable to nurses9 greater accuracy in history taking (p = 0.04); no conclusions regarding the comparability of nurses9 and SHOs9 skills in physical examination can be derived from the current study. CONCLUSION Evidence attests to the likelihood of nursing having superior skills in history taking to SHOs. Exploration of nursing safety in undertaking physical examination, however, requires the conduct of a large scale equivalence study. Only then can conclusions be drawn as to whether nurse led physical assessment offers children a standard of care equivalent to that which they currently receive from SHOs.

Aim—To document the impact that rapid increases in HIV infection in hospitalised children at Chris Hani Baragwanath Hospital has had on in-hospital mortality. Methods—Hospital discharge summaries from January 1992 to the end of 1996 were reviewed. Results—There were 20 733 admissions in the five year period; 7985 (39%) were tested for HIV. In tested admissions above 15 months of age, 4.9% were HIV infected in 1992, increasing to 35% in 1996. Under 15 months of age, 9% of tested admissions were positive in 1992, increasing to 46% in 1996. The proportion of all hospital deaths occurring in children considered HIV infected (ELISA testing together with clinical features if 15 months or younger) increased from 6.7% in 1992 to 46.1% in 1996 (p < 0.001). In-hospital mortality for all children increased by 21% from 4.3% in 1992 to 5.2% in 1996. Mortality rates declined in uninfected children from 5.4% in 1992 to 4.5% in 1996 (˜ 2 trend 3.3; p = 0.06). Conclusion—The mortality rate of children has increased at Chris Hani Baragwanath Hospital as a result of HIV infection.Almost half the deaths were HIV related in 1996. HIV infection is threatening the advances that have been made on child survival in South Africa over the last few decades. (Arch Dis Child 2000;83:227‐230)

AIM—To study bone turnover following renal transplantation using a panel of biochemical markers and to correlate the results with both areal and volumetric bone mineral density (BMD). PATIENTS—A total of 31 patients aged 18.1 years were transplanted 5.4 years before this study. Control patients (n = 31) were age and gender matched. METHODS—In addition to measurement of biochemical markers, BMD was measured by single photon absorptiometry and peripheral quantitative computed tomography on the non-dominant radius. RESULTS—Patients had reduced glomerular filtration rate, raised concentrations of serum phosphate, serum procollagene type I carboxy terminal propeptide, osteocalcin, and serum procollagene type I cross linked carboxy terminal telopeptide. The differences were still significant if only patients with normal intact parathyroid hormone were considered. BMD single photon absorptiometry Z score for age was significantly decreased. Following standardisation for height the differences were no longer present. With volumetric techniques patients had normal trabecular but decreased cortical and total BMD compared to age matched controls, but there was no difference from height matched controls. CONCLUSION—Markers of bone turnover are increased following renal transplantation. However, the biochemical analysis did not allow conclusions to be drawn on the bone mineral content. BMD single photon absorptiometry Z score corrected for height and BMD measured by quantitative computed tomography compared to height matched controls were normal in paediatric renal transplantation patients. Height matched controls should be used in both areal and volumetric BMD measurements in states of growth failure.

BACKGROUND Acute asthma is associated with elevated serum concentrations of products of activated T cells and eosinophils. AIMS To compare the changes in concentrations of these products with disease severity and changes in lung function following oral prednisolone treatment. METHODS Twenty patients (mean age 8.7 years) were recruited on admission with acute asthma to a district general hospital. Disease severity was recorded before and after treatment with oral prednisolone using a validated pulmonary index score. Serum concentrations of interleukin (IL)-4, IL-5, soluble (s)CD25 (soluble IL-2 receptor), using a specific enzyme linked immunosorbent assay, and eosinophil cationic protein (ECP), using radioimmunoassay, were measured concomitantly. Non-asthmatic children (n = 6, mean age 9.2 years) undergoing elective surgery were recruited as controls, and serum samples were obtained on one occasion without treatment. Main outcome measures were changes in serum concentrations of cytokines and ECP, clinical asthma severity score, and peak expiratory flow rate. RESULTS As expected, oral glucocorticoid treatment in the children with asthma was associated with clinical improvement and also with significant reductions in serum concentrations of IL-5 (mean 5.59 to 2.19 pg/ml, p = 0.0001), sCD25 (mean 2236 to 1772 pg/ml, p = 0.002), and ECP (mean 54.3 to 33.1 pg/ml, p = 0.0001). Serum IL-4 concentrations, in most patients and all the controls, remained below the sensitivity of the assay. However, serum concentrations of IL-5, sCD25, and ECP remained significantly higher than in controls, even after treatment with oral glucocorticoids (p = 0.03). CONCLUSIONS These data suggest that T cell mediated inflammation may persist in childhood asthma despite apparent clinical remission associated with conventional doses of prednisolone. The long term consequences of persistent inflammation after an apparently treated acute attack of asthma require clarification. Clinical assessment and pulmonary function are inadequate surrogates for airway inflammation.

As part of an ongoing study aiming to define the clinical spectrum of neuroborreliosis in childhood, we have identified four patients with unusual clinical manifestations. Two patients suffered from a primarily chronic form of neuroborreliosis and displayed only non-specific symptoms. An 11 year old boy presented with long standing symptoms of severe weight loss and chronic headache, while the other patient had pre-existing mental and motor retardation and developed seizures and failure to thrive. Two further children who presented with acute hemiparesis as a result of cerebral ischaemic infarction had a cerebrovascular course of neuroborreliosis. One was a 15 year old girl; the other, a 5 year old boy, is to our knowledge the youngest patient described with this course of illness. Following adequate antibiotic treatment, all patients showed substantial improvement of their respective symptoms. Laboratory and magnetic resonance imaging findings as well as clinical course are discussed and the relevant literature is reviewed.

BACKGROUND Dystrophic epidermolysis bullosa (DEB) is an uncommon genetic disorder of the skin and mucosae. In 1996, we reported the occurrence of lethal dilated cardiomyopathy (DCM) in two affected children. METHODS In the past seven years we have routinely screened patients with severe DEB who have been under the care of this hospital by yearly clinical review, echocardiography, and quantification of plasma selenium and carnitine concentrations, as deficiency of these micronutrients is known to be associated with the development of DCM. RESULTS Six of 61 children have developed DCM over the seven year period of this study, four of whom have not been previously reported, and three of whom have since died. We compared the concentrations of selenium and free and total carnitine in the children who developed DCM to concentrations in those with severe DEB who did not. The concentrations of free and total carnitine when first measured were significantly lower in the children with DCM, but the selenium concentrations were not. CONCLUSIONS We now believe that DCM is a not infrequent complication of severe recessive DEB, and may be related in part to carnitine concentrations, though the exact mechanism remains unclear. We therefore recommend that patients with this condition should undergo regular cardiac review including echocardiography.

AIM—To determine the outcome and identify predictive factors in children with psychogenic non-epileptic seizures (PNES). METHOD—The biographies of 35 children with PNES, attending a tertiary paediatric neurology centre, were reviewed. RESULTS—Thirty five children attending the department between 1987 and 1997 were evaluated at a mean follow up of 4.6 years. The age range was 6-18 years. Twenty four were girls and 11 were boys. Eleven patients had a diagnosis of epilepsy with PNES, the remainder having PNES alone. Cause fell into four categories: a history of violence, abuse, or neglect; a high level of anxiety; dysfunctional family relationships; and attention seeking or avoidance behaviour. Management in all but five cases involved assessment and follow up by a child psychologist or child psychiatrist. The outcome was encouraging, with 66% of patients becoming PNES free. A further 23% have > 50% reduction in the frequency of PNES. Only two have had no reduction. Outcome was best in the group without epilepsy. CONCLUSION—These results suggest that the prognosis of PNES is better in children than in adults, perhaps because causes are more likely to be external to the child, more easily identified, and more amenable to prompt intervention. The importance of good assessment, good communication, and a treatment plan that includes both symptom management and addressing the precipitating and perpetuating factors is emphasised.

BACKGROUND—There is controversy about whether the inflammatory response observed in the cystic fibrosis (CF) lung occurs secondary to bacterial infection or is caused by a dysregulation of the inflammatory response associated with the basic cellular defect of CF. AIMS—To study the inflammatory response in the gastrointestinal tract of children with CF; and to investigate whether there is increased inflammation in the gastrointestinal tract of CF children with fibrosing colonopathy. METHODS—Whole gut lavage was performed on 21 pancreatic insufficient children with CF, who were clinically well, five children with CF and fibrosing colonopathy, and 12 controls. Intestinal outputs of plasma derived proteins (albumin, α1 antitrypsin, IgG), secretory immunoglobulins (IgA and IgM), cellular constituents (eosinophil cationic protein and neutrophil elastase), and cytokines (interleukin 8 and interleukin 1β) were measured. RESULTS—Compared to controls, the 21 CF patients, with no intestinal complications, had increased intestinal outputs of albumin, IgG, IgM, eosinophil cationic protein, neutrophil elastase, interleukin 1β, and interleukin 8. Similar values were obtained for the CF patients with fibrosing colonopathy. CONCLUSIONS—These data suggest that there is immune activation in the gastrointestinal mucosa of children with cystic fibrosis, which may result from the basic cellular defect. Fibrosing colonopathy does not appear to be associated with increased inflammation.

BACKGROUND—Nijmegen breakage syndrome (NBS) is a rare autosomal recessive disorder. NBS-1, the gene defective in NBS, is located on chromosome 8q21 and has recently been cloned. The gene product, nibrin, is a novel protein, which is member of the hMre11/hRad50 protein complex, suggesting that the gene is involved in DNA double strand break repair. AIMS—To study the clinical and laboratory features of NBS as well as the genotype-phenotype relation. METHODS—Fifty five patients with NBS, included in the NBS registry in Nijmegen were evaluated. The majority of the patients were of eastern European ancestry. Most of them had shown a truncating 5 bp deletion 657-661 delACAAA. Four further truncating mutations have been identified in patients with other distinct haplotypes. RESULTS AND CONCLUSIONS—Essential features found in NBS were microcephaly, usually without severe retardation, typical facial appearance, immunodeficiency, chromosomal instability, x ray hypersensitivity, and predisposition to malignancy. In 40% of the patients cancer was noted before the age of 21 years. Important additional features were skin abnormalities, particularly café au lait spots and vitiligo, and congenital malformations, particularly clinodactyly and syndactyly. Congenital malformations, immunodeficiency, radiation hypersensitivity, and cancer predispostion were comprehensible in case of dysfunctioning of DNA repair mechanisms. No specific genotype-phenotype relation could be found. Patients with the same genotype may show different phenotypes and patients with different genotypes may express the same phenotype. Specific mutations did not lead to specific clinical features.

Current British guidelines oppose the use of deep sedation by non-anaesthetists.1 2 but all reflect the needs and experience of adult practice. Despite this, and without reference to paediatric opinion, the Royal College of Surgeons of Edinburgh in 1993 stated: “Intravenous sedation is hazardous in children as the therapeutic margin between sedation and anaesthesia is very narrow. In view of this it should be administered only under very special circumstances.”2 At about the same time quite different conclusions were being reached within the paediatric guidelines produced by the American Academy of Pediatrics in 19853 and revised in 1992.4 These guidelines stated: “ …deep sedation in children is an acceptable end point . . .” and that it is “ . . .not mandatory that deep sedation be supervised by an anaesthetist . . .”. For some time paediatricians have sought the optimal method to reduce the level of consciousness either to allow a procedure to be performed or to avoid the psychological sequelae of a painful or unpleasant procedure. With increasing emphasis on evidence based practice and risk management it was clearly important that this subject was approached with these factors in mind. Stephen Murphy wrote an article for this journal on paediatric sedation in 1997, which focused on the issues of efficacy and safety.5 A highly respected paediatric anaesthetist wrote in September 1995 “Sedating children in order to carry out MRI scans is dangerous and inappropriate and general anaesthesia is the only (safe) choice” (Bray RJ, personal communication, 1995). This article will attempt to determine whether this view can be sustained and will assess the information regarding deep sedation in children undergoing magnetic resonance imaging (MRI) without repeating the arguments put forward in the previous article,5 which are taken as read. As movement interferes …

OBJECTIVE—To evaluate short and long term effects of giving nebulised budesonide early in respiratory syncytial viral (RSV) bronchiolitis. DESIGN—A multicentre randomised double blind placebo controlled trial. SUBJECTS—Infants admitted to hospital with their first episode of RSV positive bronchiolitis. INTERVENTION—Randomisation to receive either 1 mg of nebulised budesonide (Bud) or placebo (Pla) twice daily from admission until 2 weeks after discharge. Follow up was for 12months. MAIN OUTCOME MEASURES—Duration of hospital admission, time taken to become symptom free, re-admission rates, general practitioner consultation rates, and use of antiwheeze medication during follow up. RESULTS—161 infants were studied. Both arms were similar with respect to initial clinical severity, age, sex, socioeconomic class, and tobacco exposure. Median time from first nebulisation to discharge: Bud and Pla, 2 days. Median number of days for 50% of infants to be symptom free for 48 hours: Bud, 10 days; Pla, 12 days. Respiratory re-admission rates in the 12 month follow up: Bud, 16%; Pla, 18%; median difference (95% confidence interval (CI)), −2 (−14 to 10). Median respiratory related general practitioner attendances: Bud, 4.0; Pla, 4.5; median difference (95% CI), −1 (−2 to 0). Percentage of infants receiving at least one prescription for antiwheeze medication during follow up, corticosteroids: Bud, 50%; Pla, 60%; difference (95% CI), −10 (−26 to 6); bronchodilators: Bud, 60%; Pla, 67%; difference (95% CI), −7 (−22 to 8). CONCLUSIONS—There are no short or long term clinical benefits from the administration of nebulised corticosteroids in the acute phase of RSV bronchiolitis.

BACKGROUND Pneumocystis carinii is an important pathogen in immunodeficiency but may be an unrecognised cause of respiratory compromise. OBJECTIVES To ascertain the incidence of P carinii pneumonia (PCP) at presentation of severe combined immunodeficiency (SCID), whether it had been diagnosed, and the effect of treatment on outcome. SETTING The supraregional paediatric bone marrow transplant unit for primary immunodeficiencies at Newcastle General Hospital. METHODS Retrospective case note review of infants referred with a diagnosis of SCID from 1992 to 1998. RESULTS Ten of 50 infants had PCP at presentation; only one was diagnosed before transfer. Eight were diagnosed by bronchoalveolar lavage and two by lung biopsy. In only one was P carinii identified in nasopharyngeal secretions. Five required ventilation for respiratory failure but all were successfully treated with co-trimoxazole and methylprednisolone with or without nebulised budesonide. Nine survived to bone marrow transplantation and four are long term survivors after bone marrow transplantation; no deaths were related to PCP. CONCLUSIONS PCP is a common presenting feature of SCID but is rarely recognised. Bronchoalveolar lavage or lung biopsy are needed for diagnosis. Treatment with co-trimoxazole is highly successful.

OBJECTIVE—To evaluate whether sensitivity and specificity of tachypnoea for the diagnosis of pneumonia change with age, nutritional status, or duration of disease. METHODS—Diagnostic testing of 110 children with acute respiratory infection, 51 of whom presented with tachypnoea. The gold standard was a chest roentgenogram. Thirty five children had a radiological image of pneumonia; 75 were diagnosed as not having pneumonia. Sensitivity, specificity, and percentage of correct classification of tachypnoea, by itself or in combination with other clinical signs for all children, by age groups, nutritional status, and disease duration were calculated. RESULTS—Tachypnoea as the sole clinical sign showed the highest sensitivity (74%) and a specificity of 67%; 69% of cases were classified correctly. Sensitivity was reduced when other clinical signs were combined with tachypnoea, and there was no significant increase in correct classification, although specificity increased to 84%. In children with a disease duration of less than three days, tachypnoea had a lower sensitivity and specificity (55% and 64%, respectively), and a lower percentage of correct classification (62%). In children with low weight for age (< 1 Z-score), tachypnoea had a sensitivity of 83%, a specificity of 48%, and 60% correct classification. Sensitivity and specificity did not vary with age groups. CONCLUSIONS—Tachypnoea used as the only clinical sign is useful for identifying pneumonia in children, with no significant variations for age. In children with low weight for age, tachypnoea had higher sensitivity, but lower specificity. However, during the first three days of disease, the sensitivity, specificity, and percentage of correct classification were significantly lower.

OBJECTIVE—To study the association between "pregnancy" prevalence (affected births and terminations) of neural tube defects in postcode districts of Glasgow and lead concentrations in domestic water. SETTING—Postcode districts of Glasgow supplied by water from the Loch Katrine reservoir. DESIGN—An ecological study. Lead concentrations from 1911 randomly selected domestic water samples were obtained from the Glasgow 93 lead study. Neural tube defects (affected births and terminations) were identified from the Glasgow register of congenital anomalies for the period 1983-95 for each postcode district in the study population. Correlations were sought between lead concentrations and pregnancy prevalence of neural tube defects/1000 live births in postcode districts. RESULTS—No correlation was found between domestic water lead concentrations > 10 µg/litre and pregnancy prevalence of neural tube defects within postcode districts. Areas of Glasgow previously with high domestic water lead concentrations did not have a higher prevalence of neural tube defects. Houses with the lowest domestic water lead concentrations were in Carstairs deprivation categories 1 (least deprived), 6, and 7 (most deprived). The highest pregnancy prevalence of neural tube defects was found in the most deprived areas. CONCLUSION—Deprivation is a risk factor for neural tube defects and might have been a confounding factor in previous studies looking at the association between such defects and domestic water lead concentrations. This study does not support the hypothesis that levels of lead > 10 µg/litre in domestic water supplies are associated with a higher pregnancy prevalence of neural tube defects. The reasons behind the decline in pregnancy prevalence of neural tube defects seen in the past two decades remain unexplained.

OBJECTIVE—To evaluate the respiratory rate as an indicator of hypoxia in infants < 2 months of age. SETTING—Pediatric emergency unit of an urban teaching hospital. SUBJECTS—200 infants < 2 months, with symptom(s) of any acute illness. METHODS—Respiratory rate (by observation method), and oxygen saturation (SaO2) by means of a pulse oximeter were recorded at admission. Infants were categorised by presence or absence of hypoxia (SaO2 ⩽ 90%). RESULTS—The respiratory rate was ⩾ 50/min in 120 (60%), ⩾ 60/min in 101 (50.5%), and ⩾ 70/min in 58 (29%) infants. Hypoxia (SaO2⩽ 90%) was seen in 77 (38.5%) infants. Respiratory rate and SaO2 showed a significant negative correlation (r = −0.39). Respiratory rate ⩾ 60/min predicted hypoxia with 80% sensitivity and 68% specificity. CONCLUSION—These results indicates that a respiratory rate > 60/min is a good predictor of hypoxia in infants under 2 months of age brought to the emergency service of an urban hospital for any symptom(s) of acute illness.

BACKGROUND—The safety of medicines used in children is of considerable public interest, yet available data to monitor the safety of medicines in children is limited. AIMS—To raise awareness and stimulate reporting of adverse drug reactions (ADRs) in children in the Trent region. METHODS—A pilot Paediatric Regional Monitoring Centre (PRMC) has been established in the Trent region. The scheme operates as an extension of the UK's spontaneous reporting scheme, the Yellow Card Scheme run by the Medicines Control Agency and the Committee on Safety of Medicines. Proactive interventions including a monthly reminder letter and presentations to staff in the identified hospitals have been made. RESULTS—During the first year of the PRMC, 95 reports were received from the Trent region compared to 40 for the previous year. Twenty four of these reports were for medicines used "off label". The 95 reports involved 105 drugs and 171 suspected ADRs. Twenty six of the ADRs (15%) were considered medically significant. CONCLUSIONS—The number of ADR reports from the Trent region has increased considerably in the first year of the scheme. The results show that intensive education and promotion of ADR reporting can result in a major increase in reporting. This initiative will increase our knowledge about the safety of medicines used to treat children and so help protect public health.

BACKGROUND—The outcome for children with acute renal failure (ARF) may be poor. However, relatively few published studies have considered prognosis of these patients. METHODS—We prospectively studied, from 1978 to 1998, 92 such children without heart disease to try to identify risk factors for mortality. RESULTS—Forty five per cent of children with tumours, shock, and other causes died compared with none of those with a primary urinary tract related problem. ARF did not seem to be the cause of death in any case. Univariate analysis showed that in the non-primary urinary problem group (55 cases), patients with hypotension, high values of BUN or creatinine, or who needed mechanical ventilation or dialysis, had a poor outcome. Multivariate analysis showed that probability of death can be estimated using the following score: −0.02 + 0.28 (hypotension) + 0.19 (ventilation) + 0.27(dialysis) + 0.01(BUN). CONCLUSIONS—Mortality of patients with ARF was related to aetiology, the need for dialysis and/or ventilator use, hypotension, and BUN values.

Base deficit is a parameter often used to guide further treatment in acidotic children and is taken as a measure of how "sick" they are. Five children with septic shock are presented who had persisting base deficit after large volume resuscitation with 0.9% saline. Stewart's strong ion theory of acid-base balance is able to quantify the causes of metabolic acidosis and is used to show that our patients had a hyperchloraemic metabolic acidosis. We show how the chloride content of the saline loads given to our patients caused this hyperchloraemia. It is concluded that 0.9% saline and other chloride rich fluids may not be ideal resuscitation fluids; if used, clinicians must be aware of their potential to cause a persistent base deficit.

BACKGROUND—Congenital facial palsy (CFP) is clinically defined as facial palsy present at birth. It is associated with considerable disfigurement and causes functional and emotional problems for the affected child. The aetiology of the majority of cases however, remains elusive. AIMS—To investigate the role of a neuroanatomical abnormality as a cause of unilateral CFP. METHODS—Magnetic resonance imaging (MRI) scans were performed on 21 patients with unilateral CFP. Fifteen patients had unilateral CFP only; six suffered from syndromes which can include unilateral CFP. RESULTS—Of the 15 patients with unilateral CFP only, four (27%) had an abnormal nucleus or an abnormal weighting of this area on the MRI scan, compared to one (17%) of the remaining six patients. CONCLUSION—Developmental abnormalities of the facial nucleus itself constitute an important, and previously ignored, cause of monosymptomatic unilateral CFP.

Aims—To evaluate the cognitive outcome of a cohort of children with galactosaemia in relation to genotype. Methods—The cohort was drawn from children notified to the British Paediatric Surveillance Unit galactosaemia study which ran from 1988 to 1990. Cognitive outcome was assessed using the Wechsler Intelligence Scale for Children or the Wechsler Preschool and Primary Scale of Intelligence. Parents completed a questionnaire detailing educational status, and the attending paediatrician returned a questionnaire regarding age at diagnosis and biochemical outcome over the previous two years. Results—A total of 45 children were genotyped: 30 were homoallelic for the Q188R mutation, the remainder being heteroallelic for Q188R with K285N (n = 4), L195P (n = 4), or other mutations (n = 7). Psychometric evaluation was available in 34 cases: mean full scale IQ was 79, verbal quotient 79, and performance quotient 82. Genotype was not related to galactose-1phosphate (Gal-1-P) concentrations. However, children homoallelic for the Q188R mutation had significantly lower IQ scores than those who were heteroallelic (73.6 v 94.8). This diVerence was independent of social and demographic influences and Gal-1-P concentrations over the previous two years. Conclusions—In children with galactosaemia, cognitive outcome appears to relate to genotype rather than metabolic control, as reflected by Gal-1-P concentrations. The value of measuring Gal-1-P concentrations routinely once successfully established on a galactosaemia diet is questionable as concentrations do not appear to aVect outcome. In the UK population, homozygosity for the Q188R mutation is invariably associated with a poor outcome, and there is evidence that variability in neurocognitive outcome is at least part dependent on allelic heterogeneity. (Arch Dis Child 2000;83:248‐250)

AIMS To investigate the use of the aminobisphosphonate, disodium pamidronate, in children with vertebral osteoporosis. METHODS Five children (aged 10–15 years) with vertebral osteoporosis who developed compression fractures in the thoracic and/or lumbar spine as a consequence of five different conditions, received treatment with intravenous disodium pamidronate in doses ranging from 0.5 to 12 mg/kg/y. RESULTS Each child had rapid pain relief following the first treatment, followed by large increments in lumbar spine bone density over one year; the change in bone density standard deviation score ranged from 0.5 to 2.5 with percentage increments of 26% to 54%. CONCLUSION Intravenous pamidronate appears to be a useful therapeutic option in childhood osteoporosis, but its use in children must still be regarded as experimental and therefore closely monitored.

AIM To assess the changes in services for children with diabetes in the south west of England between two regionwide audits performed in 1994 and 1998. METHODS Questionnaires were sent to consultant paediatricians, specialist diabetes nurses, dietitians, and Local Diabetes Service Advisory Groups. Information was gathered on consultant and nursing caseload, clinic structure, dietetic and psychological services, glycated haemoglobin use, and screening services. RESULTS In 1994 there were 21 consultant paediatricians caring for children with diabetes, only seven of whom fulfilled the British Paediatric Association definition of a specialist. By 1998 there were 14, 12 of whom fulfilled this definition. In 1994 a significant number of children were being seen in general paediatric clinics; by 1998 all centres stated that children were being seen in designated diabetes clinics. Between the two audits, despite a decrease in the average caseload of specialist diabetes nurses, nursing services in many centres remained deficient, as did dietetic and psychology services. Glycated haemoglobin use increased from 16 of 21 consultants to all consultants. In 1998 there was still patchy paediatric representation on Local Diabetes Service Advisory Groups. CONCLUSIONS The 1994 audit was followed by a change in clinical practice, in contrast to continuing deficiencies in resources, despite the availability of national recommendations and the widespread distribution of the audit report to those in a position of influence.

Reflex sympathetic dystrophy (RSD), an unusual diagnosis in general paediatrics, is well recognised by paediatric rheumatologists. This study reports the presentation and the clinical course of 46 patients (35 female, age range 8-15.2) with RSD. The patients saw professionals from an average of 2.3 specialties (range 1-5). Twenty five (54%) had a history of trauma. Median time to diagnosis was 12 weeks (range 1-130). Many children had multiple investigations and treatments. Once diagnosis was made, treatment followed with physiotherapy and analgesics. Median time to recovery was seven weeks (range 1-140), with 27.5% relapsing. Nine children required assessment by the child and adolescent psychiatry team. This disease, though rare, has significant morbidity and it is therefore important to raise clinicians' awareness of RSD in childhood. Children with the condition may then be recognised and referred for appropriate management earlier, and spared unnecessary investigations and treatments which may exacerbate the condition.

An audit loop for patients failing to attend a paediatric outpatient department was completed by repeating the analysis three years after interventions were put into place. The 1995 study had shown non-attendance for clinic visits was 34%, varying from 32.5% for Europeans and 50% for Asian patients. A follow up study in 1998 showed a fall to 12.04% and 13.5%, respectively, with an overall rate of 12.3%. The Manor Hospital NHS Trust had the lowest non-attendance rate of the 30 hospitals in the West Midlands region for the year 1996-7.

BACKGROUND The diagnosis of acute appendicitis is often delayed, which may complicate the further course of the disease. AIMS To review appendectomy cases in order to determine the incidence of diagnostic delay, the underlying factors, and impact on the course of the disease. METHODS Records of all children who underwent appendectomy from 1994 to 1997 were reviewed. The 129 cases were divided into group A (diagnostic period within 48 hours) and group B (diagnostic period 48 hours or more). RESULTS In the group with diagnostic delay, significantly more children had first been referred to a paediatrician rather than to a surgeon. In almost half of the cases in this group initial diagnosis was not appendicitis but gastroenteritis. The perforation rate in group A was 24%, and in group B, 71%. Children under 5 years of age all presented in the delayed group B and had a perforation rate of 82%. The delayed group showed a higher number of postoperative complications and a longer hospitalisation period. CONCLUSIONS Appendicitis is hard to diagnose when, because of a progressing disease process, the classical clinical picture is absent. The major factor in diagnostic delay is suspected gastroenteritis. Early surgical consultation in a child with deteriorating gastroenteritis is advised. Ultrasonographs can be of major help if abdominal signs and symptoms are non-specific for appendicitis.

Aim—To test a paediatric intensive care mortality prediction model for UK use. Method—Prospective collection of data from consecutive admissions to five UK paediatric intensive care units (PICUs), representing a broad cross section of paediatric intensive care activity. A total of 7253 admissions were analysed using tests of the discrimination and calibration of the logistic regression equation. Results—The model discriminated and calibrated well. The area under the ROC plot was 0.84 (95% CI 0.819 to 0.853). The standardised mortality ratio was 0.87 (95% CI 0.81 to 0.94). There was remarkable concordance in the performance of the paediatric index of mortality (PIM) within each PICU,and in the performance of the PICUs as assessed by PIM. Variation in the proportion of admissions that were ventilated or transported from another hospital did not aVect the results. Conclusion—We recommend that UK PICUs use PIM for their routine audit needs. PIM is not aVected by the standard of therapy after admission to PICU, the information needed to calculate PIM is easy to collect, and the model is free. (Arch Dis Child 2001;84:125‐128)

BACKGROUND—In the past 10 years, medication errors have come to be recognised as an important cause of iatrogenic disease in hospital patients. AIMS—To determine the incidence and type of medication errors in a large UK paediatric hospital over a five year period, and to ascertain whether any error prevention programmes had influenced error occurrence. METHODS—Retrospective review of medication errors documented in standard reporting forms completed prospectively from April 1994 to August 1999. Main outcome measure was incidence of error reporting, including pre- and post-interventions. RESULTS—Medication errors occurred in 0.15% of admissions (195 errors; one per 662 admissions). While the highest rate occurred in neonatal intensive care (0.98%), most errors occurred in medical wards. Nurses were responsible for most reported errors (59%). Errors involving the intravenous route were commonest (56%), with antibiotics being the most frequent drug involved (44%). Fifteen (8%) involved a tenfold medication error. Although 18 (9.2%) required active patient intervention, 96% of errors were classified as minor at the time of reporting. Forty eight per cent of parents were not told an error had occurred. The introduction of a policy of double checking all drugs dispensed by pharmacy staff led to a reduction in errors from 9.8 to 6 per year. Changing the error reporting form to make it less punitive increased the error reporting rate from 32.7 to 38 per year. CONCLUSION—The overall medication error rate was low. Despite this there are clear opportunities to make system changes to reduce error rates further.

BACKGROUND—Helicobacter pylori has recently been detected in the stomach and trachea of cases of sudden infant death syndrome (SIDS) and proposed as a cause of SIDS. AIMS—To establish the incidence of H pylori in the stomach, trachea, and lung of cases of SIDS and controls. METHODS—Stomach, trachea, and lung tissues from 32 cases of SIDS and eight control cases were examined retrospectively. Diagnosis of SIDS was based on established criteria. Controls were defined by death within 1 year of age and an identifiable cause of death. Tissues were examined histologically for the presence of bacteria. Extracted DNA from these tissues was tested for H pylori ureC and cagA sequences by nested polymerase chain reaction and amplicons detected by enzyme linked immunosorbent assay (ELISA). The cut off for each ELISA for each of the tissue types was taken as the mean optical density plus two times the standard deviation of a range of negative controls. RESULTS—Ages of SIDS cases ranged from 2 to 28 weeks. Ages of controls ranged from 3 to 44 weeks. For the ureC gene, 25 SIDS cases were positive in one or more tissues compared with one of the controls. For the cagA gene, 25 SIDS cases were positive in one or more tissues compared with one of the controls. CONCLUSIONS—There is a highly significant association between H pylori ureC and cagA genes in the stomach, trachea, and lung of cases of SIDS when compared with controls.

Aims—To assess the sensitivity, specificity, and predictive value of procalcitonin (PCT) in diVerentiating bacterial and viral causes of pneumonia. Methods—A total of 72 children with community acquired pneumonia were studied. Ten had positive blood culture for Streptococcus pneumoniae and 15 had bacterial pneumonia according to sputum analysis (S pneumoniae in 15, Haemophilus influenzae b in one). Ten patients had Mycoplasma pneumoniae infection and 37 were infected with viruses, eight of whom had viral infection plus bacterial coinfection. PCT concentration was compared to C reactive protein (CRP) concentration and leucocyte count, and, if samples were available, interleukin 6 (IL-6) concentration. Results—PCT concentration was greater than 2 µg/l in all 10 patients with blood culture positive for S pneumoniae ;i n eight of these, CRP concentration was above 60 mg/l. PCT concentration was greater than 1 µg/l in 86% of patients with bacterial infection (including Mycoplasma and bacterial superinfection of viral pneumonia).A CRP concentration of 20 mg/l had a similar sensitivity but a much lower specificity than PCT (40% v 86%) for discriminating between bacterial and viral causes of pneumonia. PCT concentration was significantly higher in cases of bacterial pneumonia with positive blood culture whereas CRP concentration was not. Specificity and sensitivity were lower for leucocyte count and IL-6 concentration. Conclusions—PCT concentration, with a threshold of 1 µg/l is more sensitive and specific and has greater positive and negative predictive values than CRP, IL-6, or white blood cell count for diVerentiating bacterial and viral causes of community pneumonia in untreated children admitted to hospital as emergency cases. (Arch Dis Child 2001;84:332‐336)

Renal stone disease remains a significant health problem in the adult population, with the incidence of urolithiasis estimated to be as high as 12%.1 The true incidence in childhood is not known, but a frequency of two children per million UK population per annum has been suggested.2 Understanding the factors involved in urinary stone formation and the appropriate investigations for a child presenting with signs and symptoms of renal stone disease, will allow for earlier recognition of the problem and may assist in the prevention of recurrent stone formation. The term “nephrocalcinosis” implies an increase in calcium content in the kidney, and is distinct from urolithiasis (stone in the urinary tract), although the two conditions may coexist. Nephrocalcinosis occurs less frequently than urolithiasis and may be focal, occurring in an area of previously damaged parenchyma, or generalised, usually as a result of an underlying metabolic disorder. The incidence and composition of renal stones differs significantly with regard to geographic region.3 In European children infection related stones predominate. These stones are often located in the upper urinary tract, are composed of struvite (magnesium ammonium calcium phosphate), and are frequently related to proteus urinary tract infection.2 Hypercalciuria is the most common metabolic cause of stones in Western children. No diagnosis is determined in a quarter of cases. If more detailed investigations are undertaken it is possible that the number of “idiopathic” cases will decrease. The aim of this paper is to increase awareness of the importance of urolithiasis in children and to suggest an outline of investigations that will assist the physician in elucidating any underlying disorder. The formation of renal calculi is a complex process and depends on the interaction of several factors, including