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LATE PRESENTING DEVELOPMENTAL DYSPLASIA OF THE HIP
Sharpe et al describe the epidemiology of late presenting developmental dysplasia of the hip (DDH) in South Australia. Of 1281 cases of DDH identified in the context of a screening programme based on repeated clinical examinations 27 cases were first identified late (after 3 months of age). Earlier work by the same group indicated that around 40% of all cases that ultimately required surgery presented late. The late presenting cases were often identified by family members rather than clinicians. Only one of the 27 who presented late was born in the breech position. Normal delivery, rural birth and early discharge from hospital were associated with higher risk of late presentation. It is unclear whether the risk factors for late presentation are truly different from those in cases diagnosed early or whether a greater success in identifying DDH in infants with traditionally recognised risk factors has skewed the characteristics of the remainder. Whichever is the case, the fact that a substantial proportion of those who ultimately require surgery do not have obvious risk factors around the time of birth highlights the need to regard all newborn infants as at risk of the problem.
See page 158
PACIFIERS EASE EXAM MISERY
Yet more benefits to pacifier use! Eye examinations for the purposes of retinopathy of prematurity screening look painful and this is reflected in elevated pain scores related to the procedure. Boyle et al studied the effect of sucrose solution and pacifier use on infant pain scores during eye exams and found that sucrose alone had no significant effect, but pacifier use appeared to be effective in reducing pain scores.
See page 166
EARLY POSTNATAL ALLOPURINOL DOES NOT IMPROVE SHORT-TERM OUTCOME AFTER SEVERE BIRTH ASPHYXIA
This trial of early postnatal allopurinol after asphyxia was halted early as it was clear that the treatment was not going to benefit the infants under study. The infants were severely damaged and had 76% mortality. The authors hypothesise that the treatment was given too late and have started a study where the treatment begins in labour when fetal distress is identified. Whether early postnatal hypothermia may extend the therapeutic window for other interventions such as this will also be of interest.
See page 163
INVASIVE FUNGAL INFECTION
Clerihew et al describe the epidemiology of invasive fungal infection in very low birth weight (VLBW) infants in the United Kingdom. Their prospective national surveillance study suggests that 1% of such infants are affected. The vast majority of cases occurred in infants with birth weight less than 1000 g, with just over 2% affected. This figure is considerably lower than data from other populations and series. Ascertainement does not appear to be the most likely explanation. The extent to which antifungal prophylaxis is used in the UK is unknown. The mortality of affected infants was 43%.
See page 188
RE-INVENTING THE SEPSIS WORK UP
The goal of a test that identifies infants with true sepsis early enough to guide initial therapy, without missing any cases and minimises the treatment of infants who are infection free remains elusive. Mishra et al review the various candidate markers and suggest that the answer lies in molecular genetic techniques that have the promise to identify the pathogen and the antibiotic sensitivities long before blood cultures would be available.
See page 208
CIRCULATORY SUPPORT IN THE NEWBORN INFANTS: WHAT SHOULD WE DO?
Nick Evans reminds us that no study has shown any improvement in any meaningful clinical outcome, short or long term, from any inotrope. He provides a thorough review of the lower levels of evidence to which so many lengthy ward round debates return and on which his own approach is based. Assessing the circulation is complex and designing trials that produce more answers than questions will be a major challenge.
See page 213
THIS MONTH IN ARCHIVES
How should paediatricians interact with formula milk manufacturers to serve the best interests of children? Weaver, Wright and Waterson get stuck in to this controversy. (See page 383 and 386 of ADC)