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Problem The shortage of doctors in Liberia limits the provision of comprehensive emergency obstetric and neonatal care. Approach In a pilot project, two midwives were trained in advanced obstetric procedures and in the team approach to the in-hospital provision of advanced maternity care. The training took two years and was led by a Liberian consultant obstetrician with support from international experts. Local setting The training took place in CB Dunbar Maternity Hospital. This rural hospital deals with approximately 2000 deliveries annually, many of which present complications. In February 2015 there were just 117 doctors available in Liberia. Relevant changes In the first 18 months of training, the trainees were involved with 236 caesarean sections, 35 manual evacuations of products of conception, 25 manual removals of placentas, 21 vaginal breech deliveries, 14 vacuum deliveries, four repairs of ruptured uteri, the management of four cases of shoulder dystocia, three hysterectomies, two laparotomies for ruptured ectopic pregnancies and numerous obstetric ultrasound examinations. The trainees also managed 41 cases of eclampsia or severe pre-eclampsia, 25 of major postpartum haemorrhage and 21 of shock. Although, initially they only assisted senior doctors, the trainees subsequently progressed from direct to indirect supervision and then to independent management. Lessons learnt To compensate for a shortage of doctors able to undertake comprehensive emergency obstetric and neonatal care, experienced midwives can be taught to undertake advanced obstetric care and procedures. Their team work with doctors can be particularly valuable in rural hospitals in resource-poor countries. Probleme Au Liberia, la penurie de medecins limite la fourniture de soins complets en obstetrique et neonatologie d'urgence. Approche Dans le cadre d'un projet pilote, deux sages-femmes ont ete formees aux procedures obstetricales avancees ainsi qu'a l'approche d'equipe a adopter pour pratiquer des soins avances de maternite en milieu hospitalier. Cette formation a dure deux ans. Elle a ete dirigee par un consultant obstetricien liberien, avec le soutien d'experts internationaux. Environnement local La formation a eu lieu au CB Dunbar Maternity Hospital. Cet hopital rural gere environ 2 000 accouchements par an, dont beaucoup presentent des complications obstetricales. En fevrier 2015, seuls 117 medecins etaient disponibles au Liberia. Changements significatifs Au cours des 18 premiers mois de la formation, ces sages-femmes ont participe a 236 accouchements par cesarienne, 35 evacuations manuelles des produits de conception, 25 extractions manuelles du placenta, 21 accouchements par voie basse avec presentation par le siege, 14 accouchements par ventouse obstetricale, 4 reparations de ruptures uterines ainsi qu'a la prise en charge de 4 cas de dystocie des epaules, 3 hysterectomies, 2 laparotomies pour des grossesses extra-uterines rompues_et a de nombreuses echographies obstetricales. Les beneficiaires de la formation ont egalement gere41 casd'eclampsiesoudepre-eclampsies graves, 25 cas d'hemorragies du post-partum importantes et 21 cas de chocs. Meme si, initialement, les beneficiaires de la formation n'ont fait qu'assister des medecins experimentes, par la suite, elles sont progressivement passees d'une supervision directe a une supervision indirecte jusqu'a intervenir de facon independante. Lecons tirees Pour compenser une penurie de medecins capables de pratiquer des soins complets en obstetrique et neonatologie d'urgence, il est possible de former des sages-femmes experimentees aux procedures et soins obstetricaux avances. .Leur intervention en equipe aupres des medecins peut s'averer particulierement precieuse dans les hopitaux ruraux des pays a faibles ressources. Situacion La escasez de medicos en Liberia reducela disponibilidad de atencion obstetrica y neonatal de emergencia completa. Enfoque En un proyecto piloto, dos pateras recibieron formacion en procesos obstetricos avanzados y en el enfoque de equipo sobre la atencion materna avanzada hospitalaria. La formacion duro dos anos y estuvo dirigida por un asesor obstetra liberiano, con apoyo de expertos internacionales. Marco regional La formacion se realizo en el CB Dunbar Maternity Hospital. Este hospital rural se ocupa de alrededor de 2 000 partos al ano, muchos de los cuales presentan complicaciones. En febrero de 2015, unicamente habia 117 medicos disponibles en Liberia. Cambios importantes Durante los primeros 18 meses de formacion, las alumnas participaron en 236 cesareas, 35 evacuaciones manuales de productos de la concepcion, 25 extracciones manuales de placentas, 21 partos de nalgas por via vaginal, 14 partos de extraccion por vacio, 4 reparaciones de desgarros uterinos, la gestion de 4 casos de distocia del hombro, 3 histerectomias, 2 laparotomias para rupturas de embarazos ectopicos y numerosas ecografias obstetricas. Las alumnas tambien se enfrentaron a 41 casos de eclampsia o preeclampsia grave, 25 de hemorragias posparto Intensas y 21 de shock. A pesar de que al principio unicamente asistian a medicos, las alumnas fueron progresando de supervision directa a indirecta y llegaron a realizar una gestion independiente. Lecciones aprendidas Para compensar la escasez de medicos disponibles para atencion obstetrica y neonatal de emergencia completa, las parteras con experiencia pueden aprender a realizar procedimientos y medidas de atencion obstetrica avanzada. Trabajan en equipo con medicos, lo que puede resultar especialmente valioso en hospitales rurales de paises con pocos recursos., Introduction In February 2012, Maternal and Childhealth Advocacy International approached the Liberian Ministry of Health and the World Health Organization (WHO), proposing a collaborative partnership to reduce rates of maternal [...]

Health care facilities for children are Afghanistan are exceptionally inadequate. Embroiled in civil war, many medical personnel have left the country, facilities have been damaged, and supplies and equipment have been stolen or damaged. Doctors receive small salaries, and often are not paid. Sterile supplies are reused, facilities are dirty, and running water is lacking on some medical wards. Acetaminophen is among the strongest pain relievers available, and facilities for surgery are limited., ABBREVIATIONS. MCH, maternal child health clinic; CAI, Child Advocacy International. Primary and secondary health care systems for children in Afghanistan are barely functioning. On average, 4 children die each day [...]

Covert video surveillance (CVS) could be vital in the detection of severe child abuse by parents who may otherwise deceive authorities. Thirty-nine children perceived to be at risk for abuse by induced illness were hospitalized in their parent's care while being watched by hidden cameras. Deliberate suffocation attempts were observed in 30 cases. Many of these parents appeared caring and kind while in the presence of others. In addition to the diagnosis of abuse, this technique also provides evidence for legal prosecution of the parents and immediate protection for the children., ABSTRACT. Objective. To describe historic markers and clinical observations of life-threatening child abuse as diagnosed using covert video surveillance (CVS). Design. A descriptive, retrospective, partially controlled case study. Setting. Two hospitals (in London and North Staffordshire, UK) receiving referrals for the investigation of apparent life-threatening events (ALTE), with the availability of CVS. Patients. A total of 39 children (age range at CVS, 2 to 44 months; median, 9 months) in whom hospital CVS was used to investigate suspicions of induced illness. Thirty-six were referred for investigation of ALTE, one with suspected epilepsy, one with failure to thrive, and one with suspected strangulation. A control group consisted of 46 children with recurrent ALTE proven on physiologic recordings to be attributable to a natural medical cause (9 attributable to epileptic seizures, and 37 attributable to respiratory problems). Intervention. Collection of historic details from medical, social service, and police records; interagency collaboration in planning, investigations, and management; development and use of CVS as a clinical tool in the investigation of patients in whom there was suspicion of induced illness. Outcome. Confirmation of attempted suffocation or other child abuse from CVS. Results. CVS revealed abuse in 33 of 39 suspected cases, with documentation of intentional suffocation observed in 30 patients. Poisonings (with disinfectant or anticonvulsant), a deliberate fracture, and other emotional and physical abuse were also identified under surveillance. The first ALTE occurred at a median age corrected for the expected date of delivery of 3.6 months in the CVS patients and of 0.3 months in controls. Three CVS patients and 27 of the control children (including 20 at < 32 weeks&apos; gestation) were born prematurely. Bleeding from the nose and/or mouth was reported in 11 of the 38 patients with ALTE undergoing CVS but in none of the 46 controls. Four patients who had been subjected to recurrent suffocation before CVS had permanent neurologic deficits and/or required anticonvulsant therapy for epileptic seizures resulting from hypaxic cerebral injury. The 39 patients undergoing CVS had 41 siblings, 12 of whom had previously died suddenly and unexpectedly. Eleven of the deaths had been classified as sudden infant death syndrome but after CVS, four parents admitted to suffocating eight of these siblings. One additional sibling who had died suddenly with rotavirus gastroenteritis was reinvestigated after CVS of her sister revealed poisoning, and death was found to be caused by deliberate salt poisoning. Other signs of abuse were documented in the medical, social, and police records of an additional 15 of the siblings. In the 52 siblings of the 46 controls, 2 had died: one from hypoplastic left heart at 5 days and the other suddenly and unexpectedly (classified as sudden infant death syndrome) at 7 weeks. Twenty-three of the abusive parents were diagnosed by a psychiatrist as having personality disorders. Conclusions. Induced illness is a severe form of abuse that may cause death or permanent neurologic impairment. It may be accompanied by other severe forms of abuse, may result in behavioral disorders, and may be accompanied by immeasurable suffering. Detection of this abuse requires careful history-taking; thorough examination of the health, social, and police records; and close and focused collaboration between hospital and community child health professionals, child psychiatrists, workers, and police officers. CVS may help investigate suspicions and ensure that children are protected from additional abuse. When parents have failed to acknowledge that they have deceived health professionals, partnership with them in seeking to protect their children may be neither safe nor effective., Pediatrics 1997;100:735-760; child abuse, sudden infant death syndrome (SIDS), apparent life-threatening events (ALTE), apnea of infancy, suffocation, poisoning, Munchausen syndrome by proxy. ABBREVIATIONS. CVS, covert video surveillance; ALTE, apparent life-threatening [...]

A negative pressure chamber around the infant's body may assist breathing efforts in newborns with breathing difficulties. Researchers randomly assigned 244 newborns to conventional care or care in a specially designed incubator. Among infants receiving negative pressure therapy, 5% fewer patients required intubation, total duration of oxygen therapy among infants surviving to 56 days was 21 days versus 39 days, and the average duration of oxygen use overall was 18 versus 34 days. This resulted in fewer infants experiencing permanent lung injury. However, there was a trend toward more deaths, lung perforations, and abnormal ultrasound brain scans., ABSTRACT. Objective. In uncontrolled clinical trials negative extrathoracic pressure has been shown to be an effective respiratory support. We aimed to assess its role in the context of current neonatal intensive care. Design. A randomized controlled trial, with sequential analysis of matched pairs of infants. Matching was undertaken by stratified randomization from 15 groups divided according to gestational age, oxygen requirement, and whether patients were intubated at 4 hours of age. Setting. Two neonatal intensive care units. Patients. Two hundred forty-four patients (birth weight 1.53 [+ or -] 0.69 kg (mean [+ or -] SD); gestational age 30.4 [+ or -] 3.5 weeks) with respiratory failure. Interventions. Patients were randomized at 4 hours of age to receive either standard neonatal intensive care, or standard care plus continuous negative extrathoracic pressure (CNEP, -4 to -6 cm[H.sub.O]) applied within a purpose-designed neonatal incubator. Outcome Scores. Clinical scores were calculated for each infant at 56 days of age, or death if earlier. Scores included measures for mortality, respiratory outcome, the presence of cerebral ultrasound abnormalities, patent arterial duct, necrotizing enterocolitis, and retinopathy. The treatment given for the higher score for each pair was recorded and the cumulative net number of pairs favoring CNEP plotted in the sequential analysis to provide an ethical early termination strategy. Individual components of the outcome score and other secondary measurements were analyzed on completion of the trial. Results. The sequential analysis reached a decision boundary after 122 out of a possible maximum of 124 pairs were completed. The overall outcome score showed an overall significant benefit for CNEP. Secondary analysis showed that the use of CNEP was associated with an increase in mortality, cranial ultrasound abnormalities, and pneumothoraces, which were not statistically significant. However, 5% fewer patients were intubated (95% confidence interval [CI], 0-10), and the total duration of oxygen therapy among surviving infants at n days was lower (20.5 days, compared with 38.9 in controls; difference 18.4 days, 95% CI 3.8 to 33.0). Among all infants, the mean total duration of oxygen therapy was 18.3 days among CNEP-treated infants compared with 33.6 days among the controls (difference -15.3 days, 95% CI -0.2 to -30.4 This reduction in mean levels is entirely attributable to substantially fewer patients requiring prolonged oxygen therapy, the median duration of treatment being very similar in the two groups. As a result, commensurately fewer surviving infants showed chronic lung disease of prematurity. Conclusions. The use of continuous negative pressure improves the respiratory outcome for neonates with respiratory failure. Pediatrics 1996;98:1154-1160; respiratory distress syndrome, mechanical ventilation, negative pressure., Negative pressure respiratory support was used successfully in neonatal respiratory distress syndrome in the 1960s and 1970s.[1,2] Monin et al[1] compared intermittent positive pressure ventilation (IPPV) and intermittent negative pressure [...]

Preterm infants who seem well may experience episodes of lack of oxygen which may go undetected by heart and breathing movement monitors. Additional monitoring devices such as pulse oximeters and TcPO2 monitors should be used to detect these episodes in preterm infants. Researchers monitored 96 preterm infants who were able to breath room air for 25 hours, and found that 88 prolonged episodes of lack of oxygen occurred in 15 infants. Thirty episodes occurred in 10 infants without pauses in breathing or abnormally slow heart rates. Infants experienced more severe oxygen shortages during these periods than during those occurring with apnea or slow heart rate. Hospital staff should not rely on heart and breathing movement monitors alone to prevent episodes of oxygen shortage in preterm infants., Objective. To determine whether episodes of prolonged hypoxemia occur without prolonged apneic pauses ([greater than or equal to]20 seconds) and without bradycardia (pulse rate, [less than or equal to]100 beats per minute) in apparently well preterm infants. Methods. Long-term recordings of arterial oxygen saturation as measured by pulse oximetry (Sp[O.sub.2]), photoplethysmographic (pulse) waveforms from the oximeter, and breathing movements were performed in 96 preterm infants (median gestational age at birth, 34 weeks; range, 28 to 36 weeks) who were breathing room air. Recordings started at a median age of 4 days (range, 1 to 60 days). Results. During a median duration of recording of 25 hours, 88 episodes in which Sp[O.sub.2] fell to 80% or less and remained there for 20 seconds or longer were identified in 15 infants. The median duration of these prolonged desaturations was 27 seconds (range, 20 to 81 seconds). In 73 episodes (83%), Sp[O.sub.2] continued to fall to 60% or less. Twenty-three desaturations were associated with prolonged apneic pauses and 54 with bradycardia; 19 of these were associated with both apnea and bradycardia. Thirty desaturations (34%; 10 infants) occurred without bradycardia and without prolonged apnea. Conclusions. These results indicate that a proportion of apparently well preterm infants exhibit episodes of severe prolonged hypoxemia unaccompanied by prolonged apneic pauses or bradycardia. Such episodes, therefore, would be difficult to detect if only breathing movements and heart rate are monitored. Indications for the use of oxygenation monitors in preterm infants should be reconsidered. Pediatrics 1995; 95:860--863; hypoxemia, pulse oximetry, preterm infant, apnea, oxygenation monitors., ABBREVIATIONS. Sp[O.sub.2], arterial oxygen saturation as measured by pulse oximetry; bpm, beats per minute; TcP[o.sub.2], transcutaneous P[o.sub.2]. It is common practice in most neonatal units in Europe and the United [...]

A type of epilepsy affecting infants in the first year of life can trigger life-threatening episodes of breathing cessation or inadequate respiration (apnea) and thus inadequate amounts of oxygen in the blood. Data were gathered from six infants between two and twelve months of age. All were full-term, vaginally born infants. Two were neurologically abnormal at the onset of the oxygen deficiency problem. The four neurologically normal children continued to test normal. Twenty-three life-threatening events were documented among the children in which the apneic event was preceded by abnormal changes in an electroencephalogram tracing. Medication to control seizures was effective in four children and reduced the number of seizures in two. This type of epilepsy does not fit the known patterns in that seizures began spontaneously in infants with no preexisting neurologic damage., ABSTRACT. Objective. To describe the physiologic changes that occur during epileptic seizure (ES)-induced apparent life-threatening events (ALTE) and to provide an explanation for the mechanism whereby the hypoxemia characterizing these events occurred. Patients and design. Six infants were retrospectively selected from a group of 17 because they had ALTE documented on physiologic recordings where the first change in signals was in the electroencephalogram (EEG). The 17 infants had clinical features suggestive of partial seizures (but normal standard EEGs) and were from a sample of 172 infants with recurrent ALTE. All 17 infants underwent continuous recordings of breathing electrocardiogram (ECG), oxygenation, and EEG, but only in 6 was an ES-induced ALTE recorded and the physiologic changes described. Results. Twenty-three ALTE were documented in six infants. Events commenced with an abnormality in the EEG, followed by a decrease in [SaO.sub.2] after a median interval of 27 seconds (range 2 to 147). Despite resuscitation, the median duration of severe hypoxemia ([SaO.sub.2] [less than or equal to] 60%) was 40 seconds (range 8 to 74). In 18 events five infants) there was a median of four apneic pauses (range 1 to 9) preceding the decrease in [SaO.sub.2] by a median duration of 24 seconds (range 3 to 48). The longest apneic pause per event lasted a median of 19 seconds (range 8 to 47). Breathing movements continued in five events (four infants), and expiratory airflow in one. Sinus tachycardia was found in 19 of the 23 events (six infants), but there were no cardiac arrhythmias. Conclusions. ES in infants can manifest as ALTE and be accompanied by potentially life-threatening episodes of severe hypoxemia and apnea, despite a normal EEG between events. Pediatrics 1994,94:148-156; epilepsy, apnea, hypoxemia, sudden infant death syndrome.

Transcutaneous partial pressure of oxygen (Po2) monitors and pulse oximeters should be used together to accurately assess the levels of blood gases, particularly in premature infants. Premature infants being given oxygen are an especial concern because of the danger of hyperoxemia, in which oxygen levels in the blood are too high. Both kinds of monitors have their drawbacks. Transcutaneous PO2 monitors are more difficult to use, requiring repeated calibration, and the response time is slow. Pulse oximeters may give unreliable measurements when the patient moves, when the probe is placed incorrectly, or when a condition of hypoxemia (too little oxygen) exists. Despite their inconvenience, transcutaneous Po2 monitors should not categorically be replaced by pulse oximeters even though this is a current trend., Objective. To review the technical principles of transcutaneous [Po.sub.2] (tc[Po.sub.2]) monitors and pulse oximeters and to discuss methodological and practical issues related to the use of these devices in infants and children. Design. Literature review and summary of personal experience. Results. tc[Po.sub.2] measurements are influenced by skin thickness, sensor temperature, amount of contact gel used, and state of peripheral perfusion. The average in vivo response time to a rapid decrease in Pa[o.sub.2] is approximately 16 seconds. Sensitivity to both hypoxemia (Pa[o.sub.2] < 50 mm Hg) and hyperoxemia (Pa[o.sub.2] > 80 to 100 mm Hg) is approximately 85%. Pulse oximeters require careful sensor placement (to avoid optical shunts) and adequate pulse pressures (>20 mm Hg). They are prone to movement artifact. There are considerable differences in bias and precision between different brands, resulting, for example, in quite different upper alarm limits required to detect hyperoxemia reliably. The normal range of oxygen saturation measured by pulse oximetry, measured with one brand of pulse oximeter (Nellcor) during regular breathing, is 95% to 100% in preterm infants and 97% to 100% in full-term infants and children. Conclusions. Because both devices have their specific shortfalls, they should ideally be used in combination, particularly in critically ill preterm neonates. Where this is not feasible or necessary, clinicians must be aware of the limitations of the device they are using. Pediatrics 1994;93:737-746; pulse oximetry, transcutaneous oxygen monitoring, hypoxemia, hyperoxemia.

Many healthy children and adolescents may have apneic pauses during the night lasting up to 20 seconds. An apneic pause is characterized by the cessation of breathing. Most of these apneic pauses do not result in abnormal blood gas levels. Researchers tape recorded the breathing movements of 70 healthy children between two and 16 years old during the night. They simultaneously monitored the arterial oxygen saturation (SaO2), heart rate and respiration rate of the children. All the children had apneic pauses during the night. The frequency of these pauses was not affected by age. The total number of apneic pauses was 5,854, but a drop in SaO2 to 80% or less occurred only six times., Objective. To obtain information on breathing patterns and oxygenation in children. Design. Overnight tape recordings of arterial oxygen saturation ([Sao.sub.2]; Nellcor N200 in beat-to-beat mode), photoplethysmographic waveforms, and breathing movements in 70 healthy children (mean age 8.0 years, range 2 through 16). Analysis of recordings for pauses in breathing movements of [greater than or equal to] 4 seconds (apneic pauses), for episodes in which [Sao.sub.2] fell to [less than or equal to] 90% (desaturations) and, only during the state of regular breathing, for baseline [Sao.sub.2], heart rate, and respiratory rate. Results. Both baseline heart rate and respiratory rate decreased with increasing age (r = -.7 and -.3, respectively, P < .01). Baseline [Sao.sub.2] was similar to that previously observed in infants (median 99.5%, range 95.8 to 100, 5th centile 96.6%). Every recording showed apneic pauses, with a frequency that did not vary consistently with age (median 7.7/h, range 0.6 to 25.5). One hundred nineteen apneic pauses in 43 recordings lasted for 15 to 19.9 seconds, and 23 lasted for [greater than or equal to] 20 seconds (longest 28.8 seconds). The number of episodic falls in [Sao.sub.2] to [less than or equal to] 90% decreased with age (r = -3, P < .01); such episodes were found in 47% of childre aged 2 through 6 years, but in only 13% of those aged 12 through 16 years. The 95th centile for desaturation frequency in the total group was 0.6/h. In six episodes in four patients, [Sao.sub.2] fell to [less than or equal to] 80%. Conclusions. Apneic pauses, some of which can last for more than 20 seconds, are a normal phenomenon in healthy children and adolescents, but only a small minority of apenic pauses affect blood gas homeostasis. Information concerning oxygenation may be more relevant to our understanding of the maturation of respiratory control than the recording of breathing signals alone. Pediatrics 1993;92:686-690; arterial oxygen saturation, apnea, healthy children.

Infants at increased risk of the sudden infant death syndrome (SIDS) show abnormal patterning of sleep-waking states. It was hypothesized that infants who were to die of SIDS would show abnormalities of sleep state distribution prior to their deaths. Twenty-two 12-hour recordings were obtained from infants who subsequently died of SIDS, and sleep state patterns were compared in these records and 66 records of age-matched control infants. Each 1-minute epoch was classified as quiet sleep, rapid eye movement (REM) sleep, waking, indeterminate state, or artifact-contaminated. Victims of SIDS showed less waking and more sleep than control infants during the early-morning hours. Victims of SIDS younger than 1 month of age showed significantly more epochs classified as REM sleep across the night and significantly fewer epochs contaminated by artifacts relative to control infants. Further analysis indicated that the increased number of REM epochs resulted from fewer artifact-contaminated epochs, suggesting reduced motility during REM sleep in the SIDS victims compared with the control infants. The finding of decreased waking time during the early morning is of particular importance since most SIDS deaths occur during this portion of the day. The findings of altered sleep patterns in SIDS victims suggest that central neural changes are associated with SIDS risk. Pediatrics 1992;89:865-870

Heart rates and breathing patterns in infants have frequently been analyzed. The incidence of apneic pauses, periods during which infants do not breathe, decreases during the first six months, but the frequency of pauses after that age has not been well studied. Infants who have frequent apneic pauses, probably related to abnormal regulation of breathing, are often considered to be at risk for sudden infant death syndrome and families are supplied with home monitors which sound an alarm if apnea persists 15 seconds or more. However, some prospective studies have not shown an association between prolonged apnea and risk for sudden infant death syndrome. In addition, normal breathing patterns beyond the first six months are not well understood. Heart rates and breathing patterns in 42 healthy infants (20 female and 22 male) were evaluated at six weeks and two years. Two-year-old children had significantly lower heart and respiratory rates. Apneic pauses were present in all the children. Periodic apnea occurred in 29 infants at 6 weeks and in 28 children at 2 years. The average total duration of apnea was similar in the two age groups. Although the frequency of apneic pauses was significantly lower in the older group, the average duration was significantly longer and in some children was over 15 seconds. Children of either age who had more isolated apneic pauses also tended to have more periodic apnea (a sequence of three or more pauses, each separated by 20 seconds). The study suggests that the proportion of time spend in periodic apnea was similar in both groups. The mechanism underlying increased duration of apnea at two years is unclear, but this effect should be kept in mind when apnea in older children is being considered. (Consumer Summary produced by Reliance Medical Information, Inc.)

Infants at risk for sudden infant death syndrome (SIDS) have slight abnormalities in various physiological functions, including increased heart and breathing rates. Various characteristics of apnea (pauses in breathing) have been reported in SIDS infants, including differences in the number of apneic pauses. These pauses may differ during various stages of sleep. The frequency and duration of apneic pauses during the stages of quiet sleep and rapid eye movement were examined in 22 infants between 2 to 65 days of age, who subsequently died of SIDS, and 66 control infants. During the first month of life, no difference was seen in the number of breathing pauses in the infants who died of SIDS and the control infants. However, during the second month of life, from 40 to 65 days, the SIDS infants showed fewer breathing pauses than control infants in both sleep states. Therefore, the time period of breathing irregularities was occurred in the second month of life. This precedes the time when infants are at the greatest risk for SIDS, which is from two to six months of age. This finding may provide some insight into the cause of SIDS. (Consumer Summary produced by Reliance Medical Information, Inc.)

Abstract A system to improve the management of emergencies during pregnancy, childbirth, infancy and childhood in a region of The Gambia (Brikama) with a population of approximately 250,000 has been developed. This was accomplished through formal partnership between the Gambian Ministry of Health, the World Health Organisation, Maternal Childhealth Advocacy International and the Advanced Life Support Group. Since October 2006, the hospital in Brikama has been renovated and equipped and more efficiently provided with emergency medicines. An emergency ambulance service now links the community with the hospital through a mobile telephone system. Health professionals from community to hospital have been trained in obstetric, neonatal and paediatric emergency management using skills' based education. The programme was evaluated in log books detailing individual resuscitations and by external assessment. The hospital now has constant water and electricity, a functioning operating theatre and emergency room; the maternity unit and children's wards have better emergency equipment and there is a more reliable supply of oxygen and emergency drugs, including misoprostol (for treating post partum haemorrhage) and magnesium sulphate (for severe pre-eclampsia). There is also a blood transfusion service. Countrywide, 217 doctors, nurses, and midwives have undergone accredited training in the provision of emergency maternal, newborn and child care, including for major trauma. 33 have received additional education through Generic Instructor Courses and 15 have reached full instructor status. 83 Traditional Birth Attendants and 48 Village Health Workers have been trained in the recognition and initial management of emergencies, including resuscitation of the newborn. Eleven and ten nurses underwent training in peri-operative nursing and anaesthetics respectively, to address the acute shortage required for emergency Caesarean section. Between May 2007 and March 2010, 109 patients, mostly pregnant mothers, were stabilised and transported to hospital by the new emergency ambulance service. 293 resuscitation attempts were documented in personal logbooks. A sustainable system for better managing emergencies has been established and is helping to negate the main obstacle impeding progress: the country's lack of available trained medical and nursing staff. However, insufficient attention was paid to improving staff morale and accommodation representing significant failings of the programme.

To the Editor.-- I was deeply moved by Fig 1 in the article by Southall et al entitled "The Child-Friendly Healthcare Initiative (CFHI): Healthcare Provision in Accordance With the UN [...]

To the Editor.-- There have been many allegations in the British press in the last 6 years that the conduct of the randomized trial of noninvasive respiratory support for preterm [...]

Reviewing the past 50 years of publications related the field of child abuse and neglect in Pediatrics is clearly less daunting a task than one would face if the field [...]