beta-Endorphin and some hormonal levels in children with acute stress hyperglycaemia

The levels of beta-endorphin, insulin, cortisol, GH, glucagon, prolactin and TSH were measured in serum samples of 9 hyperglycaemic patients (3 female, 6 male) with a mean age of 4.1 years admitted to the pediatric emergency unit. All patients were in acute stress due to severe diseases (acute gastroenteritis, bronchopneumonia, septicaemia, etc.). Initial and repeat blood samples for hormone determination were taken at admission and in the recovery phase (after 4-6 weeks of treatment). OGTT was also performed in the recovery phase. The hyperglycaemia, monitored hourly following the initial determination, returned to normal in all patients in 1-5 h without specific treatment. Mean serum glucose values at admission and in the recovery phase were 287.0 and 84.1 mg/dl. Concomitant to the hyperglycaemia encountered in these patients in the acute phase of stress, an increase was noted in all hormone levels excluding glucagon and cortisol. All elevated hormone levels fell to normal in 4-6 weeks with significant differences from initial levels for beta-endorphin (P < 0.05) and insulin (P < 0.01). OGTT gave a normal curve. These results indicate that stress hyperglycaemia, despite high insulin levels, is associated with an increase in beta-endorphin levels. The results also show that hyperglycaemia in acute disease does not alter OGTT in short-term follow up.

Paraprofessional women as health care facilitators in mother and child health

The aim of the study was to compare the performance of midwives with that of lady home visitors (LHV; paraprofessionals). The project area was divided into six according to the population map. One midwife or one LHV was assigned to each visiting area. Home visits were carried out to identify and offer guidance on family planning (FP), antenatal care, well-child control, immunizations and other mother and child health related issues to those at high risk. Criteria taken for evaluation were the numbers of pregnant women identified in the last trimester; pregnant women receiving antenatal care; deliveries attended by a health care provider; modern FP users; continuation rate of the new users; pregnancy rate in new users; immunization status of children; well-child visits of the children. No significant differences were found in these health measurements between areas visited by LHV and areas visited by midwives. Response rates to the invitation was also similar in both areas. An important observation was the good performance of the LHV in communicating with the families. Women with limited school attainment from the community can be used effectively and efficiently in community health services.

Estimation of annual height velocity based on short- versus long-term measurements

We assessed the relationships between annual height velocity, calculated from two measurements taken at intervals of 6, 12 and 24 months, in 69 healthy prepubertal children (34 male, 35 female) aged 6.5 years (range 6.25-6.75 yrs) who were followed for 2.5 years and measured biannually. Initial height values for age were within normal ranges except for one child with a height SDS of -2.0. Mean annual velocities also conformed to British norms. Significant differences were observed between consecutive six-monthly velocities and these values failed to predict annual velocities calculated from measurements taken at 12- or 24-month intervals. Seasonal effects were thought to have some impact on the six-monthly velocity differences. Height velocity, based on measurements taken at intervals of 12 months, was essentially similar to two-year velocity values. The results indicate that in estimating annual height velocity, six-month intervals between measurements may be misleading while 12-monthly measurements are as reliable as height velocity values based on measurements taken at two-year intervals.

Growth response to growth hormone-releasing hormone(1-29)-NH2 compared with growth hormone

To assess the growth-promoting effect of different doses of growth hormone-releasing hormone(1-29)-NH2 (GHRH(1-29)-NH2) in GH deficiency (GHD) of hypothalamic origin, 43 prepubertal children aged between 4.3 and 18.9 years (mean 10.4 +/- 2.9 years) were randomly assigned to three treatment regimens: low-dose GHRH(1-29)-NH2 (LD group; n = 15), high-dose GHRH(1-29)-NH2 (HD group; n = 12) and GH (GH group; n = 16). The LD group received GHRH(1-29)-NH2 at 30 micrograms/kg/day s.c. in three daily doses, the HD group received 60 micrograms/kg/day s.c. in three daily doses and the GH group received GH, 0.1 IU/kg/day s.c. once daily. All children were treated for a period of 6 months. Evaluation included anthropometry, bone age, intravenous and subcutaneous GHRH(1-29)-NH2 tests and determination of insulin-like growth factor I (IGF-I) levels. An increase in height velocity of 2 cm/year or more was observed in all except two children. Height velocity during treatment was lowest in the LD group, but comparable in the HD and GH groups. An increase in height SDS for bone age occurred only in the GH-treated group. GH responses to intravenous GHRH(1-29)-NH2 showed a priming effect of the LD GHRH(1-29)-NH2 treatment, while a decrease in response occurred in the GH-treated group. Following a subcutaneous test dose of one-third of the daily dose of GHRH(1-29)-NH2, GH levels remained unchanged in both the LD and HD groups. There was accumulation of GHRH immunoreactivity over time in the HD group, but there was no correlation between measured GHRH and GH levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of Kasabach-Merritt syndrome following needle aspiration of a hemangioma

A case of Kasabach-Merritt syndrome that developed following needle aspiration in an infant with hemangioma is presented. Enlargement of the tumor leading to severe respiratory distress accompanied by hemorrhages occurred within six to eight hours after this simple intervention. The symptoms continued despite repeated thrombocyte transfusions and prednisolone therapy. Radiotherapy and local intraarterial corticosteroid therapy were attempted and led to some improvement. It took approximately three months for the platelet count and one year for the clinical state to revert to normal. This case illustrates that minor trauma may lead to life-threatening symptoms in a young infant with congenital hemangioma.

Experiences of a health team working in a new urban settlement area in Istanbul

A project aiming at creating a model for comprehensive maternal and child health care for urban underdeveloped areas was started in a new settlement area of migrants in the vicinity of Istanbul. The project had an impact on health care status, particularly among infants and children, but the results indicated that more effort was needed to reach the mothers. It was noted that building space and the appearance of the work place influenced the prestige of the team. Absentee problems could be partly surmounted by repeated home visits. Based on this experience, it was concluded that health services in underdeveloped areas need to be supported by non medical personnel to act as home visitors and as mediators between the community and the health team. It was also concluded that an established recording system to include both clinical data and attendance is needed to define the cases who need special care.

An educational intervention on promotion of breast feeding

This study was designed to search for an effective method to promote exclusive breast feeding among Turkish city women delivering in hospitals. Four hundred and forty-two primiparae with uncomplicated deliveries and with healthy infants with birthweights of greater than 2500 g were exposed to a group educational session on breast feeding after birth, followed by one repeat session at home. Four hundred and ninety-nine women served as controls. All homes were visited monthly for 6 months by independent observers and data relevant to the feeding of the infants were collected. Weight measurements of 176 infants were taken at age 4 months. The study and control mothers were similar in sociodemographic characteristics which reflected a low socio-economic/educational background but relatively good housing conditions. Although significant differences in frequency of exclusive breast feeding were found between the study and control groups, the impact of the intervention was much lower than our expectations and short-lived. Type of feeding was not related to sex or birthweight of the infant, nor to maternal variables. Weight at age 4 months was within normal limits and similar in the study and control groups. It was concluded that lack of up-to-date information on infant feeding was the main obstacle to breast feeding in urban groups in Turkey, and that the impact of an educational intervention limited to the first week after delivery was lost within the first 2 months.

An educational intervention on promotion of breast feeding complemented by continuing support

The study, aiming to document the effect of continued support for mothers on frequency of exclusive breast feeding, was carried out by inclusion of breast feeding counselling in the context of well-baby care. One hundred and forty-six mothers who had been exposed to two educational sessions on breast feeding after delivery were given appointments to bring their baby to the paediatric hospital for well-baby care. The mother-infant pairs were followed by the same two residents for 4 months. Mean number of visits was six. A conscious effort was made during all visits to influence the mothers and their close relatives towards exclusive breast feeding. It was observed that in a large proportion of the infants, breast milk was being supplemented with water at the time of the first visit and no further effort was made to change this traditional behaviour. Comparison of the results with a group of mothers who had been exposed to similar educational sessions after delivery but without further support showed a striking increase in frequency of exclusive breast feeding (breast milk and water) in the supported group.

Oral rehydration therapy: studies on potassium balance

The clinical response and changes in potassium balance were studied during oral rehydration therapy (ORT) with a solution containing 20 mmol potassium per litre in well-nourished and malnourished infants of 3 to 15 months of age as well as in neonates and young infants less than 2 months old (range 5-60 days). All infants were successfully rehydrated orally. The potassium intake considerably exceeded the potassium output in all groups during the entire rehydration period. The stool and urine potassium output were about the same in the 3 groups of patients. The retention of potassium increased during ORT in all groups at about the same rate. The study thus demonstrates that an oral rehydration solution (ORS) containing 20 mmol potassium per litre provides enough potassium to all patients. An increase in the potassium concentration of the ORT is therefore not recommended.

Experience with diarrheal disease in a university pediatric hospital

In 1987, 3227 diarrhea cases, half of which were infants, presented at the Out-patient Department of the Istanbul University Children's Hospital. An examination of these cases showed that in 1,066 cases diarrheal disease (DD) was accompanied by a coexisting infection or other disease. The cases with severe dehydration, shock or severe systemic disease were immediately hospitalized. All the remaining cases were administered oral rehydration therapy (ORT) in the Diarrhea Unit, and 94.7 percent of them were successfully rehydrated with ORT. Severe dehydration, shock, severe systemic infection, abdominal distention, failure of rehydration by the enteral route, severe protein energy malnutrition (PEM), and the presence of convulsions were the indications for i.v. therapy. The overall mortality rate was 11 percent. Our experience with DD indicates that widespread implementation of ORT in diarrheal disease and the establishment of Diarrhea Units in large hospitals will contribute not only to saving more lives but will also have an economic impact by reducing the number of admissions.

Beta-endorphin levels of children in acute stress

In this study aiming to clarify the relationships between beta-endorphin and glucose levels, beta-endorphin levels were determined in children in acute stress. The study was carried out on 32 critically ill children between 5 days and 12 years presenting with clinical symptoms of acute infectious conditions. 11 healthy children were taken as controls. The results showed that although beta-endorphin levels were elevated in all critically ill patients, these levels were significantly higher than control values in hyperglycaemic cases. The insulin levels were also elevated. A follow-up of nine of the hyperglycaemic cases showed a significant decline in beta-endorphin and insulin levels with recovery. Glucose tolerance was also normal. These results confirm the reports of many other studies on the role of beta-endorphin as a stress hormone.

Salt and water homeostasis during oral rehydration therapy in neonates and young infants with acute diarrhoea. II. Rehydration with a solution containing 90 mmol sodium per litre (ORS90)

The clinical response and changes in water and salt homeostasis were studied during oral rehydration therapy (ORT) with a solution containing 90 mmol sodium per 1 (ORS90) in 9 infants less than 2 months old (range 2-60 days). Two infants were still dehydrated 36 hours after starting ORT and were excluded from the study. Fluid was retained more rapidly and also to a larger extent than in infants of the same age treated with a solution with a sodium concentration of 60 mmol/l (ORS60). The stool sodium output was higher than that found previously in infants of the same age treated with ORS60. We conclude that during ORT the gut plays an active role in the regulation of salt homeostasis. When the sodium intake is high the percentage of sodium remaining unabsorbed is higher than when the intake is low. This mechanism reduces the risk of hypernatremia in young infants treated with ORS90. The study thus demonstrates that ORS90 is effective and also seems to be safe in the treatment of neonates and young infants with dehydration secondary to diarrhoea if fluid intake is kept around 200 ml/kg/day during the rehydration period.

Oral rehydration therapy in neonates and young infants with infectious diarrhoea

The clinical response and changes in water and salt homeostasis during ORT was studied in 15 infants less than 2 months old (range 2-50 days) with acute diarrhoea. Eight patients were neonates and 7 were 1-2 months old. The oral rehydration solution contained 60 mmol sodium per litre. All patients except one were successfully rehydrated. The fluid retention was significantly higher in neonates and young infants than in infants above 3 months of age treated in the same way. One patient in the group of neonates who had a normal sodium level on admission developed hypernatremia with a sodium level of 162 mmol/l 36 hours after the start of ORT. The urinary sodium excretion was lower in the neonates than in the young infants. The results show that neonates and young infants have a lower capacity than older infants to excrete water and salt and therefore run a great risk of developing fluid and salt retention during ORT. The risk is most pronounced in neonates who, due to immaturity of the renal function, are unable to excrete excess fluid and salt.

Thyroid function in critically ill infants with infections

To investigate thyroid function in critical illness in infancy, serum thyroxine (T4), triiodothyronine (T3), reverse triiodothyronine (rT3) and thyroid-stimulating hormone (TSH) concentrations were measured in serum in 13 such patients. T4 and TSH values were found to be comparable to control values, while T3 values were significantly low and rT3 values were high. When the patients were evaluated according to prognosis, significantly lower initial and subsequent T4 values were found in the fatal group as compared with the control group. Initial T3 concentrations both in fatal cases and in patients who recovered were significantly lower than those in the controls. Subsequent T3 values in the group who recovered showed a relative increase, but in the fatal cases a further decrease, in T3 levels, accompanied by a decrease in rT3 levels to values comparable to those of the controls, was observed in the terminal stage.

Oral rehydration therapy in malnourished infants with infectious diarrhoea

The clinical response and changes in water and salt homeostasis was studied for 36 hours during oral rehydration therapy with a rehydration solution containing 60 mmol sodium/l (ORS60) in 14 malnourished 3- to 15-month-old Turkish infants with acute infectious diarrhoea. All patients were successfully rehydrated with this treatment. Sodium was efficiently absorbed from the gut and water balance was rapidly restored. Because of excess fluid retention following the initial rehydration period about 50% of the patients became oedematous. Urine volume and urinary sodium excretion were found to be much lower than in well-nourished patients of the same age with acute diarrhoea who were treated in the same way. In all of the malnourished infants the serum sodium level remained within the normal range during treatment. The results show that malnourished infants retain much more fluid and sodium than infants who are in a normal nutritional state. Excessive retention of water and salt seem to be due to an inability of the kidneys to control sodium and fluid homeostasis while orally administered sodium and fluid are being absorbed from the gut. The results show that ORT is safe and efficient in the treatment of malnourished infants with acute diarrhoea. But since these infants run a high risk of developing a severe retention of fluid and salt, and consequently may develop circulatory failure due to hypervolaemia during oral rehydration therapy, it is important to carefully monitor the volume of fluid that is given.

Oral rehydration therapy in infectious diarrhoea. Comparison of rehydration solutions with 60 and 90 mmol sodium per litre

The clinical response and changes in water and salt homeostasis as judged from serum sodium levels, salt and water retention and renal handling of sodium was studied during 36 hours following the start of oral rehydration therapy (ORT) with a solution containing 60 mmol Na/l (ORS60) in 17 well-nourished, moderately dehydrated Turkish infants aged 3 to 15 months who had acute infectious diarrhoea (7 with rotavirus, 3 with enteropathogenic E. coli 0 111: B 84, and one with enteropathogenic E. coli 0 125: B 15, one with salmonella and 5 of unknown etiology. In the successfully treated patients sodium and water balance was normalized within 36 hours. In the cases with hypernatremic dehydration the serum sodium concentration rapidly became normal. The results were compared with those obtained in a previous study of the same type of patients who were rehydrated with a solution containing 90 mmol Na/l (ORS90). Although retention was considered to be satisfactory after ORS60 it was less than after ORS90. The changes in the fractionary urinary sodium excretion and the potassium sodium quotient in the urine indicated a less rapid normalization after ORS60 than after ORS90.

Unsuccessful oral rehydration therapy in an infant with enteropathogenic E. coli diarrhoea. Studies of fluid and electrolyte homeostasis

A 4-month-old male infant with severe hyponatremic dehydration due to an enteropathogenic E. coli O125: B15-induced diarrhoea had continued very high stool fluid output with a very elevated sodium concentration after hospitalization and the institution of oral rehydration therapy (ORT). Thirty-six hours after start of ORT intravenous therapy was required. The results of studies of fluid and salt homeostasis in this patient have been compared with those obtained in 3 other patients who had acute diarrhoea of the same severity but caused by another strain of enteropathogenic E. coli (O111:B14) and who were successfully treated with ORT. On ORT the patient with treatment failure had a stool volume which was almost 8 times larger and a stool sodium output which was about 5 times higher than in the successfully treated patients. During the 36-hour-period of ORT fluid losses were about the same as the fluid intake. The results as regards urinary fractional sodium excretion and the urinary potassium/sodium quotient indicate that the severe sodium depletion which was present on admission in the unsuccessfully treated patient persisted during ORT. The reason for ORT failure may be that the infectious E. coli strain had bacilli-adherent qualities that cause damage of microvilli.

Alterations of chromium metabolism and effect of chromium supplementation in Turner's syndrome patients

This study was conducted to investigate chromium metabolism and the effect of chromium supplementation in patients with Turner's syndrome, a condition noted for its high incidence of diabetes. Oral glucose tolerance tests were performed in 14 patients 8 to 19 yr of age. Eight of the 14 subjects were given 30 g of brewer's yeast containing 50 micrograms of chromium every day for 8 wk and glucose tolerance tests repeated. Urine samples were collected before and after each glucose load. Serum lipids were also investigated. Before supplementation, urinary chromium/creatinine ratio was high, and the urinary chromium response to oral glucose tolerance test was absent. Cholesterol and/or triglyceride levels were high in three of the patients. After supplementation, a decrease in urinary Cr/Cre ratio, and an improvement in glucose area index total were noted. A decrease in cholesterol and/or triglyceride levels occurred in the three patients with high initial levels as well as an increase in high-density lipoprotein cholesterol. These findings indicate a state of chromium deficiency and support the hypothesis that chromium deficiency may have a role in the pathogenesis of the abnormal glucose tolerance tests encountered in Turner patients.