An 8 year study of risk factors for SIDS: bed-sharing versus non-bed-sharing

Background

It is unclear if it is safe for babies to bed share with adults. In Ireland 49% of sudden infant death syndrome (SIDS) cases occur when the infant is bed‐sharing with an adult.

Objective

To evaluate the effect of bed‐sharing during the last sleep period on risk factors for SIDS in Irish infants.

Design

An 8 year (1994–2001) population based case control study of 287 SIDS cases and 831 controls matched for date, place of birth, and sleep period. Odds ratios and 95% confidence intervals were calculated by conditional logistic regression.

Results

The risk associated with bed‐sharing was three times greater for infants with low birth weight for gestation (UOR 16.28 v 4.90) and increased fourfold if the combined tog value of clothing and bedding was ⩾10 (UOR 9.68 v 2.34). The unadjusted odds ratio for bed‐sharing was 13.87 (95% CI 9.58 to 20.09) for infants whose mothers smoked and 2.09 (95% CI 0.98 to 4.39) for non‐smokers. Age of death for bed‐sharing and sofa‐sharing infants (12.8 and 8.3 weeks, respectively) was less than for infants not sharing a sleep surface (21.0 weeks, p<0.001) and fewer bed‐sharing cases were found prone (5% v 32%; p = 0.001).

Conclusion

Risk factors for SIDS vary according to the infant''s sleeping environment. The increased risk associated with maternal smoking, high tog value of clothing and bedding, and low z scores of weight for gestation at birth is augmented further by bed‐sharing. These factors should be taken into account when considering sleeping arrangements for young infants.     

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is associated with a prolonged gestational age

Background

The timing of parturition in most mammals is thought to be linked to a late gestational rise in corticosteroid production by the fetal adrenal gland. We hypothesised that gestational age would be prolonged in our patients with impaired cortisol production secondary to congenital adrenal hyperplasia (CAH) due to 21‐hydroxylase deficiency.

Methods

We compared the gestational age of patients affected by salt‐wasting CAH due to 21‐hydroxylase deficiency (born 1978–2004; n = 31) with that of children with congenital hypothyroidism (born 1981–2003; n = 30) and a control group of short normal children (born 1980–2002; n = 120). Each group was compared with national (England 2002–3) and regional (2003–4) data on gestational age from hospital episode statistics. Post‐term delivery was defined as birth beyond 41 completed weeks.

Results

National statistics reveal a frequency of 4.4% for singleton deliveries beyond 41 weeks. In our region the frequency was 4.6%. In the group of children with CAH, the frequency of post‐term delivery was 19.3% (p<0.001). In patients with congenital hypothyroidism, the frequency was 13.3% (p = 0.02). The proportion of short children who did not have a recognised endocrinopathy born post term was comparable to national and regional data at 6.7%.

Conclusions

A prolonged gestation is more likely in pregnancies where the fetus has the salt‐wasting form of CAH. This may be due to impaired cortisol production, although other changes in steroidogenesis may also be contributory.     

Does splenectomy in cystic fibrosis related liver disease improve lung function and nutritional status? A case series

Aims

To review the effect of total splenectomy on lung function and nutrition in children with cystic fibrosis related liver disease (CFLD) and associated portal hypertension. The stated indications for surgery and the short and long term risks of the procedure were also documented.

Method

Over a 25 year period from January 1980 to June 2005, approximately 650 patients with cystic fibrosis (CF) were treated at the Royal Children''s Hospital, Melbourne, Australia. Nine patients with CFLD who underwent a splenectomy during that time were identified and their medical records were reviewed.

Results

FEV₁% predicted dropped by −16±11% in the two years pre‐splenectomy. This contrasts with the increase in FEV₁% predicted of 2±16% in the two years post‐splenectomy (p = 0.05). The cumulative gain in WAZ score (ΔWAZ pre) over the two years prior to splenectomy of 0.045±0.69 was not significantly different from the cumulative gain in WAZ score (ΔWAZ post) for the two years after splenectomy of 0.15±0.36 (p = 0.65). The average age at splenectomy was 14.8 years (SD = 3 years). The average weight of an excised spleen was 983 g (SD = 414 g). There were no deaths associated with splenectomy. The median length of follow up post‐splenectomy was 6.0 years (range 0.7–15.8). There were no episodes of bacterial peritonitis or overwhelming sepsis.

Conclusions

Splenectomy may have a beneficial effect on lung function although this may not manifest itself until the second year post‐splenectomy. Splenectomy in patients with CFLD appears to be a safe procedure.     

Adaptation of the Manchester-Minneapolis Quality of Life instrument for use in the UK population

Introduction

The availability of health‐related quality of life (HRQL) measures that are reliable, valid, brief and comprehensible and appropriate for use with UK children is limited. We report the validation of a HRQL measure suitable for UK use in healthy children, children with chronic disease conditions and socially disadvantaged children.

Patients

A total of 1238 children took part in the study, including healthy children as controls (n = 824) and five exemplar groups: children diagnosed with asthma (n = 87), diabetes (n = 103) or inflammatory bowel disease (IBD; n = 69), children in remission from cancer (n = 68) and children in public care (n = 87).

Methods

In phase I, the Manchester‐Minneapolis Quality of Life instrument (MMQL) Child Form was translated into UK English. In phases II and III, the questionnaire was shortened and validated.

Results

MMQL was anglicised and shortened to five components comprising 29 items. Good internal reliability was found with α reaching at least 0.69 for all subscales. Construct validity was established through moderate correlations with comparable PedsQL subscales (Pearson''s r ranged from 0.38 to 0.58, p<0.01). Discriminant validity was also demonstrated in children with asthma and IBD, children in remission from cancer and children in public care, all of whom reported significantly lower HRQL than healthy children. Children with diabetes showed similar HRQL to their healthy peers. Good reproducibility and moderate responsiveness were demonstrated for the new measure.

Conclusions

The anglicised and shortened MMQL was shown to be valid and reliable and could be a valuable new tool for the assessment of HRQL in children.     

Association between allergic rhinitis, bottle feeding, non-nutritive sucking habits, and malocclusion in the primary dentition

Aim

To determine the association between allergic rhinitis, bottle feeding, non‐nutritive sucking habits, and malocclusion in the primary dentition.

Methods

Data were collected on 1160 children aged 4–5 years, who had been longitudinally followed since the age of 4 months, when they were admitted to nurseries in a suburban area of Tampico–Madero, Mexico. Periodically, physical examinations were conducted and a questionnaire was given to their parents or tutors.

Results

Malocclusion was detected in 640 of the children (51.03% had anterior open bite and 7.5% had posterior cross‐bite). Allergic rhinitis alone (adjusted odds ratio = 2.87; 95% CI 1.57 to 5.25) or together with non‐nutritive sucking habits (adjusted odds ratio = 3.31; 95% CI 1.55 to 7.09) had an effect on anterior open bite. Bottle feeding alone (adjusted odds ratio = 1.95; 95% CI 1.07 to 3.54) or together with allergic rhinitis (adjusted odds ratio = 3.96; 95% CI 1.80 to 8.74) had an effect on posterior cross‐bite. Posterior cross‐bite was more frequent in children with allergic rhinitis and non‐nutritive sucking habits (10.4%).

Conclusions

Allergic rhinitis alone or together with non‐nutritive sucking habits is related to anterior open bite. Non‐nutritive sucking habits together with allergic rhinitis seem to be the most important factor for development of posterior open bite in children under the age of 5 years.     

Respiratory infections for which general practitioners consider prescribing an antibiotic: a prospective study

Objective

To determine the viral aetiology of respiratory infections in children presenting to primary care with “more than a simple cold”.

Design

Observational study in 18 Oxfordshire general practices over four winters (2000–01 to 2003–04).

Patients

425 children aged 6 months to 12 years with cough and fever for whom general practitioners considered prescribing an antibiotic.

Methods

Nasopharyngeal aspirate obtained from 408 (96%) children was subjected to PCR for respiratory viruses. Parents completed an illness diary for the duration of illness.

Results

A viral cause of infection was detected in most (77%) children. Clinical symptoms correctly identified the infecting virus in 45% of cases. The duration of illness was short and the time course was very similar for all infecting viruses. One third of children were prescribed an antibiotic (34%), but this made no difference to the rate of parent‐assessed recovery (Kruskal‐Wallis, p = 0.67). About one in five children with influenza who did not receive an antibiotic had persistent fever on day 7 compared to no children receiving antibiotics (p = 0.02); this difference remained after adjustment for severity and other factors and was not seen with other viruses.

Conclusions

Most children receiving antibiotics for respiratory symptoms in general practice have an identifiable viral illness. In routine clinical practice, neither the specific infecting virus nor the use of antibiotics has a significant effect on the time course of illness. Antibiotics may reduce the duration of fever in children with influenza which could reflect an increased risk of secondary bacterial infection for such children.     

Birth anthropometric measures, body mass index and allergic diseases in a birth cohort study (BAMSE)

Objective

We aimed to assess increased birth weight or birth length in relation to allergic diseases at 4 years of age, taking body mass index (BMI) at age 4 as a covariate in the adjustment.

Methods

The parents of a large prospective birth cohort answered questionnaires on environmental factors and allergic symptoms when their children were 2 months and 1, 2 and 4 years old. Perinatal data on weight and length at birth were received from the child care health centres. The children were clinically examined at 4 years of age and height and weight recorded. Blood was drawn for analysis of specific IgE antibodies to common inhalant allergens. Risk associations between birth anthropometric measures and wheeze, allergic diseases or sensitisation were estimated in multivariate logistic regression analyses (n = 2869).

Results

There were no clear overall associations between birth weight and allergic diseases at 4 years of age. Birth length ⩾90th percentile was inversely associated with any wheeze at age 4 (adjusted OR 0.64, 95% CI 0.44 to 0.92) but was significantly associated only with late‐onset wheeze (adjusted OR 0.40, 95% CI 0.21 to 0.77). No such associations were seen for persistent or transient wheeze, eczema, rhinitis or allergic sensitisation. Transient wheeze during the first 2 years of age tended to be associated with increased BMI at age 4.

Conclusion

Increased birth weight was not associated with wheeze or allergic disease. Increased birth length may play a protective role in late‐onset wheeze in early childhood.     

Characterisation of morbidity in a UK, hospital based, obesity clinic

Aim

To identify clinical features which predict those most at risk of co‐morbidities within an obesity clinic.

Methods

Children attending an obesity clinic had fasting glucose, insulin, and lipids measured prior to a standard oral glucose tolerance test (OGTT). History and examination established birth weight, family history of type 2 diabetes/obesity, pubertal status, and presence of acanthosis nigricans. Central and total fat mass was estimated by bio‐impedance.

Results

Of the 126 children evaluated, 10.3% (n = 13) had impaired glucose tolerance (IGT); the majority (n = 11) of these would not have been identified on fasting glucose alone. Those with IGT were more likely to have a parental history of type 2 diabetes (relative risk 3.5). IGT was not associated with acanthosis nigricans. Twenty five per cent (n = 19) of those evaluated (n = 75) had evidence of the “metabolic syndrome” (MS). HDL cholesterol and triglyceride levels were related to insulin sensitivity (HOMA‐R); HDL cholesterol was also related to birth weight SDS. We observed a trend for those with MS to have a lower birth weight SDS. The severity of obesity did not influence the likelihood of IGT or MS.

Conclusions

Significant numbers of obese children have associated co‐morbidities. Analysis of fasting blood glucose samples alone is not satisfactory to adequately evaluate glucose homoeostasis. The overall level of obesity does not predict co‐morbidities. Special attention should be given to those with parental diabetes and a history of low birth weight who are more likely to have IGT and abnormal lipid profiles respectively.     

Objective measurement of levels and patterns of physical activity

Objective

To measure the levels and patterns of physical activity, using accelerometers, of 11‐year‐old children participating in the Avon Longitudinal Study of Parents and Children (ALSPAC).

Design

Cross‐sectional analysis.

Setting

ALSPAC is a birth cohort study located in the former county of Avon, in the southwest of England. This study used data collected when the children were 11 years old.

Participants

5595 children (2662 boys, 2933 girls). The children are the offspring of women recruited to a birth cohort study during 1991–2. The median age (95% CI) of the children is now 11.8 (11.6 to 11.9) years.

Methods

Physical activity was measured over a maximum of 7 consecutive days using the MTI Actigraph accelerometer.

Main outcome measures

Level and pattern of physical activity.

Results

The median physical activity level was 580 counts/min. Boys were more active than girls (median (IQR) 644 (528–772) counts/min vs 529 (444–638) counts/min, respectively). Only 2.5% (95% CI 2.1% to 2.9%) of children (boys 5.1% (95% CI 4.3% to 6.0%), girls 0.4% (95% CI 0.2% to 0.7%) met current internationally recognised recommendations for physical activity. Children were most active in summer and least active in winter (difference = 108 counts/min). Both the mother and partner''s education level were inversely associated with activity level (p for trend <0.001 (both mother and partner)). The association was lost for mother''s education (p for trend = 0.07) and attenuated for partner''s education (p for trend = 0.02), after adjustment for age, sex, season, maternal age and social class.

Conclusions

A large majority of children are insufficiently active, according to current recommended levels for health.Regular physical activity in children is associated with improved health.^1,2,3 A recent systematic review of the evidence relating physical activity to health concluded that children should spend at least 60 min in moderate to vigorous physical activity (MVPA) each day, in order to promote a broad range of health improvements.³ Few studies^4,5,6 worldwide have collected objective physical activity data in large samples of children and we lack population‐based objective data describing levels and patterns of children''s activity. Nevertheless, physical activity is frequently implicated in the escalating levels of type 2 diabetes⁷ and obesity^8,9,10,11,12 in children. We report here on objectively measured physical activity levels and patterns in a large contemporary cohort of 11‐year‐old children—the Avon Longitudinal Study of Parents and Children (ALSPAC).     

Comparison of complementary and alternative medicine use: reasons and motivations between two tertiary children's hospitals

Aims

To compare prevalence, reasons, motivations, initiation, perceived helpfulness, and communication of complementary and alternative medicine (CAM) use between two tertiary children''s hospitals.

Methodology

A study, using a face‐to‐face questionnaire, of 500 children attending the University Hospital of Wales, Cardiff, UK was compared to an identical study of 503 children attending the Royal Children''s Hospital, Melbourne, Australia.

Results

One year CAM use in Cardiff was lower than Melbourne (41% v 51%; OR = 0.67, 95% CI 0.52–0.85), reflected in non‐medicinal use (OR = 0.41, 95% CI 0.29–0.58) and general paediatric outpatients (OR = 0.38, 95% CI 0.21–0.67). Compared to Melbourne, factors associated with lower CAM use in Cardiff included families born locally (father: OR = 0.58, 95% CI 0.44–0.77) or non‐tertiary educated parents (mother: OR = 0.54, 95% CI 0.38–0.77). Cardiff participants used less vitamin C (OR = 0.31, 95% CI 0.18–0.51) and herbs (OR = 0.49, 95% CI 0.34–0.71), attended less chiropractors (OR = 0.25, 95% CI 0.06–0.37) and naturopaths (OR = 0.08, 95% CI 0.02–0.33), but saw more reflexologists (OR = 3.33, 95% CI 1.08–10.29). In Cardiff, CAM was more popular for relaxation (OR = 1.92, 95% CI 1.03–3.57) but less for colds/coughs (OR = 0.4, 95% CI 0.27–0.73). Most CAM was self‐initiated (by parent) in Cardiff and Melbourne (74% v 70%), but Cardiff CAM users perceived it less helpful (OR = 0.46, 95% CI 0.31–0.68). Non‐disclosure of CAM use was high in Cardiff and Melbourne (66% v 63%); likewise few doctors/nurses documented recent medicinal CAM use in inpatient notes (0/21 v 2/22).

Conclusions

The differences in CAM use may reflect variation in sociocultural factors influencing reasons, motivations, attitudes, and availability. The regional variation in use and poor communication highlights the importance of local policy development.     

Glucose and leucine kinetics in idiopathic ketotic hypoglycaemia

Aims

To investigate glucose and leucine kinetics in association with metabolic and endocrine investigations in children with ketotic hypoglycaemia (KH) in order to elucidate the underlying pathophysiology.

Methods

Prospective interventional study using stable isotope tracer in nine children (mean age 4.23 years, range 0.9–9.8 years; seven males) with KH and 11 controls (mean age 4.57 years, range 0.16–12.3 years; four males).

Results

Plasma insulin levels were significantly lower in KH compared to subjects in the non‐KH group. Plasma ketone body levels were significantly higher in KH than in non‐KH. Basal metabolic rate was significantly higher in subjects with KH (45.48±7.41 v 31.81±6.72 kcal/kg/day) but the respiratory quotients were similar in both groups (KH v non‐KH, 0.84±0.05 v 0.8±0.04. Leucine oxidation rates were significantly lower in children with KH (12.25±6.25 v 31.96±8.59 μmol/kg/h). Hepatic glucose production rates were also significantly lower in KH (3.84±0.46 v 6.6±0.59 mg/kg/min).

Conclusions

KH is caused by a failure to sustain hepatic glucose production rather than by increased glucose oxidation rates. Energy demand is significantly increased, whereas leucine oxidation is reduced.     

Adrenocortical suppression increases the risk of relapse in nephrotic syndrome

Objective

Children with nephrotic syndrome (NS) are usually treated with long‐term low dose alternate day prednisolone with or without glucocorticoid sparing therapy, such as levamisole or ciclosporin, to maintain remission. The degree of hypothalamic‐pituitary‐adrenal axis (HPA) suppression with such therapeutic strategies has not been studied systematically. HPA suppression could cause a relapse or adrenal crisis.

Study design

To study the risks of HPA suppression, a modified low dose synacthen test (0.5 μg) was administered to 32 patients (22 male,10 female) with a mean age of 9.7 years (range 3.8–17.6 years) with NS receiving long‐term alternate day prednisolone for over 12 months. Twelve patients received alternate day prednisolone, 11 alternate prednisolone+levamisole and nine alternate prednisolone+ciclosporin. All patients were followed up for 3 years and the relapse rate noted.

Results

20/32 (62.5%) patients had a peak serum cortisol concentration of <500 nmol/l, which suggested suboptimal cortisol secretion and possible HPA suppression. 10/12 children in the prednisolone group and 8/11 in the levamisole group had a suboptimal cortisol response compared with 2/9 in the ciclosporin group. During follow‐up, the 20 children who had a suboptimal cortisol response had significantly more relapses (95 relapses) compared to the 12 children with a normal cortisol response who had 24 relapses (p = 0.01).

Conclusions

Children with NS receiving long‐term alternate day prednisolone therapy are at risk of developing HPA suppression and should be evaluated using the modified synacthen test. Children with evidence of HPA suppression are at a greater risk of relapse.     

Growth hormone treatment in children with rheumatic disease, corticosteroid induced growth retardation, and osteopenia

Background

In children with severe rheumatic disease (RD), treatment with corticosteroids (CS) is frequently needed and growth retardation and osteopenia may develop. A beneficial effect of human growth hormone (hGH) has been reported but mostly in trials without a control group.

Aims

To study the effect of hGH on growth, bone mineral density (BMD), and body composition, taking the disease activity and CS use into account.

Methods

Randomised controlled trial on 17 prepubertal RD patients with growth retardation and/or decreased BMD. The hGH group (n = 10) received treatment with hGH 4 IU/m²/day (∼0.045 mg/kg/day) during two years. The controls (n = 7) received no GH treatment.

Results

During the two year study period the disease activity, and use of CS and methotrexate (MTX) did not differ between the groups. There was a significant mean increase in height standard deviation score (HSDS) in the hGH group (0.42±0.16 SDS) and a non‐significant decrease in the controls (−0.18±0.11 SDS). Change in BMD did not differ significantly between the groups, although the increase in BMD for lumbar spine within the hGH group was significant. Lean body mass improved significantly in the hGH group compared to controls (0.64±0.19 SDS versus −0.20±0.17 SDS), while the decrease in percentage fat was not significant.

Conclusions

There was a significant effect of hGH on growth and lean body mass, but a longer duration of treatment might be necessary to evaluate the effect of hGH on BMD.     

Is omitting post urinary‐tract‐infection renal ultrasound safe after normal antenatal ultrasound? An observational study

Background

Guidelines recommend obtaining a renal ultrasonogram (RUS) for young children after a first urinary tract infection (UTI).

Objective

The aim of the current study was to assess the concordance of prenatal and post‐UTI RUS findings in children with a first simple UTI.

Methods

This was a prospective study and included all children aged 5 years or younger who were hospitalised with a first simple UTI (determined as clinical response and normalisation of temperature within 48 h on initiation of antibacterial therapy with no complications). Data were collected from each child regarding the results of prenatal and post‐UTI RUS.

Results

Overall, 250 children were included in the study and the results of late‐pregnancy and post‐UTI RUS were available for 84% (n = 209). Complete concordance between the two RUS was demonstrated in 96% (n = 201). The predictive value of normal antenatal to normal post‐UTI RUS was 96% (95% CI: 93% to 99%). These results include four children with mild transient pelvic dilatation. In eight children in whom renal anomalies were demonstrated only in post‐UTI RUS, the influence of these anomalies on the children''s management was negligible.

Conclusions

Prenatal‐RUS have been performed in most children <5 years old hospitalised with a first simple UTI. Concordance with post‐infection tests is very high. Findings which appear only in post‐infectious RUS usually have negligible effects on children''s management. Thus, in such children with normal antenatal RUS omitting post‐UTI RUS could be considered.     

Comparison of alteplase and heparin in maintaining the patency of paediatric central venous haemodialysis lines: a randomised controlled trial

Objectives

To determine whether the tissue plasminogen activator, alteplase, is more effective than heparin in preventing blood clots developing in children''s haemodialysis central lines between dialysis sessions.

Design

A prospective double‐blind, within‐patient multiperiod cross‐over controlled trial of instilling a “lock” of either heparin 5000 U/ml or alteplase 1 mg/ml into the central lines of two children haemodialysed twice weekly, and seven dialysed thrice weekly, over 10 weeks.

Setting

A UK paediatric nephrology unit.

Main outcome measures

Weight of blood clot aspirated from the line at the start of the next dialysis session.

Results

The odds of a clot forming was 2.4 times greater with heparin than alteplase (95% CI 1.4 to 4.0; p = 0.001), and when present they were 1.9 times heavier (31 vs 15 mg; 95% CI 1.5 to 2.4; p<0.0005). There was no effect of inter‐dialytic interval. One child required an alteplase infusion to clear a blocked line following a heparin lock. We subsequently changed our routine locks from heparin to alteplase. Comparing the year before and after that change, the incidence of blocked lines requiring an alteplase or urokinase infusion fell from 2.7 to 1.2 per child (p<0.03), and the need for surgical replacements from 0.7 to nil (p<0.02).

Conclusion

Alteplase is significantly more effective than heparin in preventing clot formation in central haemodialysis lines. This reduces morbidity and improves preservation of central venous access. It is more expensive, though relatively economic if packaged into syringes and stored frozen until needed, but reduces the costs of unblocking or replacing clotted lines.     

Polyethylene glycol 3350 plus electrolytes for chronic constipation in children: a double blind, placebo controlled, crossover study

Objectives

To assess the efficacy and safety of polyethylene glycol 3350 plus electrolytes (PEG+E) for the treatment of chronic constipation in children.

Design

Randomised, double blind, placebo controlled crossover trial, with two 2‐week treatment periods separated by a 2‐week placebo washout.

Setting

Six UK paediatric departments.

Participants

51 children (29 girls, 22 boys) aged 24 months to 11 years with chronic constipation (lasting ⩾3 months), defined as ⩽2 complete bowel movements per week and one of the following: pain on defaecation on 25% of days; ⩾25% of bowel movements with straining; ⩾25% of bowel movements with hard/lumpy stools. 47 children completed the double blind treatment.

Main outcome measures

Number of complete defaecations per week (primary efficacy variable), total number of complete and incomplete defaecations per week, pain on defaecation, straining on defaecation, faecal incontinence, stool consistency, global assessment of treatment, adverse events and physical examination.

Results

The mean number of complete defaecations per week was significantly higher for children on PEG+E than on placebo (3.12 (SD 2.05) v 1.45 (SD 1.20), respectively; p<0.001). Further significant differences in favour of PEG+E were observed for total number of defaecations per week (p = 0.003), pain on defaecation (p = 0.041), straining on defaecation (p<0.001), stool consistency (p<0.001) and percentage of hard stools (p = 0.001). Treatment related adverse events (all mild or moderate) occurred in similar numbers of children on PEG+E (41%) and placebo during treatment (45%).

Conclusions

PEG+E is significantly more effective than placebo, and appears to be safe and well tolerated in the treatment of chronic constipation in children.Constipation affects 5–10% of school aged children in the UK¹ and accounts for 3% of general paediatric consultations and 25% of consultations with paediatric gastroenterologists.² Chronic constipation can follow an inadequately managed acute problem.³Measures to induce defaecation in chronically constipated children include regular use of laxatives, increased consumption of fruit and green fibre, ensuring that the child drinks adequate fluids, and encouraging the child to sit on the toilet three or four times a day after meals. Despite common practice, the evidence for the use of laxatives in children is poor; for example, in a recent Cochrane review,⁴ no randomised controlled trials of the use of stimulant laxatives were found in the literature.Movicol (Norgine, Uxbridge, UK) is formulated as a powder containing the osmotic agent polyethylene glycol (PEG) 3350 and electrolytes. When the powder is dissolved in the correct volume of water, the resulting solution is iso‐osmolar with respect to colonic extracellular fluid and therefore does not draw fluid into the colon from the body. This distinct mode of action is in contrast to that of hypertonic inorganic laxatives (eg, magnesium hydroxide or sodium sulphate) and organic laxatives (eg, lactulose), and means that PEG resists the normal drying action of the bowel to remove water from the faecal mass. As a result, the faeces are hydrated and bulked, stimulating peristalsis.The combination of PEG 3350 with electrolytes (PEG+E) has been shown to be effective for treating chronic constipation and faecal impaction in adults⁵ and faecal impaction in children.⁶ The present trial was conducted to assess the efficacy and safety of PEG+E in children with chronic constipation who were being managed in a specialist paediatric outpatient setting.     

Effect of parental smoking on cotinine levels in newborns

Background

Smoking is a major risk factor for cot death. Many infants smoke passively as a result of parental smoking. This paper reports on infants exposed to a smoking environment and how they accumulate metabolites of cigarette smoke, such as cotinine, which may be physiologically harmful.

Aim

To assess cotinine levels in infants of smoking parents.

Method

Cotinine excretion in urine was assessed in 104 infants, of whom 71 had smoking parents and 33 had non‐smoking parents. All cotinine levels were measured at approximately 12 weeks of age. The subjects were selected from a database of infants in developmental physiological studies which assessed the impact of various factors on early postnatal development.

Results

On average babies with at least one parent who was a current cigarette smoker excreted 5.58 (95% CI 3.4 to 9.5) times as much cotinine in the urine as did the babies of non‐smoking parents. Maternal smoking was the largest contributing factor. Co‐sleeping (p = 0.037) and the minimum room temperature (p = 0.028) were significant contributory factors.

Conclusion

Infants from smoking households accumulate cotinine, a metabolite of nicotine, which may have a detrimental effect on the cardiorespiratory system.     

Randomised trial of infant sleep location on the postnatal ward

Objective

To determine whether postnatal mother–infant sleep proximity affects breastfeeding initiation and infant safety.

Design

Randomised non‐blinded trial analysed by intention to treat.

Setting

Postnatal wards of the Royal Victoria Hospital (RVI), Newcastle upon Tyne, UK.

Participants

64 newly delivered mother–infant dyads with a prenatal intention to breastfeed (vaginal deliveries, no intramuscular or intravenous opiate analgesics taken in the preceding 24 h).

Intervention

Infants were randomly allocated to one of three sleep conditions: baby in mother''s bed with cot‐side; baby in side‐car crib attached to mother''s bed; and baby in stand‐alone cot adjacent to mother''s bed.

Main outcome measures

Breastfeeding frequency and infant safety observed via night‐time video recordings.

Results

During standardised 4‐h observation periods, bed and side‐car crib infants breastfed more frequently than stand‐alone cot infants (mean difference (95% confidence interval (CI)): bed v stand‐alone cot = 2.56 (0.72 to 4.41); side‐car crib v stand‐alone cot = 2.52 (0.87 to 4.17); bed v side‐car crib = 0.04 (−2.10 to 2.18)). No infant experienced adverse events; however, bed infants were more frequently considered to be in potentially adverse situations (mean difference (95% CI): bed v stand‐alone cot = 0.13 (0.03 to 0.23); side‐car crib v stand‐alone cot = 0.04 (−0.03 to 0.12); bed v side‐car crib = 0.09 (−0.03–0.21)). No differences were observed in duration of maternal or infant sleep, frequency or duration of assistance provided by staff, or maternal rating of postnatal satisfaction.

Conclusion

Suckling frequency in the early postpartum period is a well‐known predictor of successful breastfeeding initiation. Newborn babies sleeping in close proximity to their mothers (bedding‐in) facilitates frequent feeding in comparison with rooming‐in. None of the three sleep conditions was associated with adverse events, although infrequent, potential risks may have occurred in the bed group. Side‐car cribs are effective in enhancing breastfeeding initiation and preserving infant safety in the postnatal ward.Although the beneficial effects of early and frequent suckling and skin‐to‐skin contact on breastfeeding initiation are well known,^1,2,3,4,5,6 there has been little work on the effect of subsequent mother–infant contact in the initial postnatal days. Night‐time rooming‐in has been shown to enhance breastfeeding on demand in comparison with night‐time nursery care^7,8; however, “rooming‐in” involves babies sleeping in stand‐alone cots that do not allow continuous contact or spontaneous feeding between mothers and infants. Yet, such contact may be of importance for mothers to understand their babies'' signals and to respond effectively.Unhindered contact can only be provided for mother and baby at night in the postnatal ward through some arrangement whereby both of them can maintain continuous contact to allow spontaneous breastfeeding. Two forms of bedding‐in currently practised in UK hospitals include either the baby sleeping in the mother''s bed, usually with the provision of removable cot‐sides to prevent falls, or the baby sleeping in a side‐car crib that is attached to the frame of the mother''s bed and is enclosed on three sides, allowing the baby a separate sleep surface, but one that is contiguous with the mother''s bed. We also recognised that breastfeeding mothers commonly take their babies into their own beds for feeding, and that both parties often fall asleep in this situation, whether or not this was planned, or advised against by midwives, or whether appropriate cot‐sides were provided.We therefore designed a trial to determine the way in which different degrees of mother–infant contact in the immediate postnatal period affects infant care, including breastfeeding, and to ascertain whether infant safety is compromised when babies and mothers are in close proximity.     

A parent-completed respiratory questionnaire for 1-year-old children: repeatability

Background and aims

There are few standardised questionnaires for the assessment of respiratory symptoms in preschool children. We have developed and tested the short‐term repeatability of a postal questionnaire on respiratory symptoms for 1‐year‐old children.

Methods

A newly developed postal questionnaire for the assessment of wheeze and other respiratory symptoms was sent to parents of a population‐based random sample of 4300 children aged 12–24 months. After an interval of 3 months, a random sample of 800 respondents received the questionnaire a second time. The responses were compared using Cohen''s kappa (κ) to assess agreement corrected for chance.

Results

The first questionnaire was returned by 3194 (74%) families, the second one by 460/800 (58%). Repeatability was excellent (κ 0.80–0.96) for questions on household characteristics, environmental exposures and family history, good (κ 0.61–0.80) for questions on prevalence, severity and treatment of wheeze, and moderate (κ 0.39–0.66) for chronic cough and upper respiratory symptoms.

Conclusions

This short postal questionnaire designed for use in population‐based studies has excellent repeatability for family and household characteristics and good repeatability for questions on wheeze. Short‐term changes in symptom status might be responsible for variable answers on recent chronic cough and upper respiratory symptoms. Overall, the questionnaire is a valuable instrument for community‐based research on respiratory symptoms in 1 to 2‐year‐old children.