The diagnosis of innocent murmurs in childhood

Innocent murmurs are common in childhood. They require accurate diagnosis to avoid unnecessary anxiety and/or restrictions. With this in mind, we studied prospectively children diagnosed by a paediatric cardiologist as having innocent murmurs to review the necessity of investigations in excluding organic abnormalities. We included 63 children in the study. The majority had the so-called Still's, or musical/vibratory murmur. None had abnormal investigations, suggesting that such investigations are largely superfluous for the purpose of diagnosis in those patients with innocent murmurs seen by a paediatric cardiologist. They are often done, nonetheless, as part of the assessment and/or expectations of the parent or the referring physician.

Common pulmonary vein atresia: a diagnostic and therapeutic challenge

Following Doppler echocardiographic evaluation, a 16 hour-old infant underwent successful surgical repair of common pulmonary vein atresia. Investigations for prolonged postoperative ventilatory assistance, including cardiac catheterization and computerized tomography, led to a clinical diagnosis of associated pulmonary lymphangiectasia. Although this has caused continuing tachypnoea, at 16 months of age, he remains otherwise well but with an uncertain prognosis.

Thrombus on an ASD closure device: A call for caution

Use of per-catheter atrial septal defect closure devices is becoming increasingly widespread. We report a case of left atrial thrombus formation on a StarFLEX device raising concerns regarding the general use of these devices and as a means of preventing paracloxical embolism in particular.

Clinical features and management of isolated cleft mitral valve in childhood

OBJECTIVES

We reviewed an institutional experience of isolated cleft mitral valve (ICMV), its clinical features, and management in a pediatric population.

BACKGROUND

As ICMV is relatively uncommon, earlier reports highlighted its anatomical and echocardiographic features. Few studies have collated their clinical features with their outcome.

METHODS

All patients with ICMV were retrospectively reviewed. Patients who were considered to have an atrioventricular septal defect or variant were excluded.

RESULTS

Twenty patients (9 male, 11 female) were diagnosed with ICMV. Seven patients had associated cardiac lesions. The median age of diagnosis was 5.2 years (range 0.4 to 13.6 years). Echocardiography aided by color Doppler demonstrated the ICMV in all patients. However, an incomplete diagnosis was made in 4 of 20 patients before surgery. The severity of the mitral regurgitation (MR) at presentation was mild in 11, moderate in 8, and severe in 1 patient. In the 13 patients without associated cardiac lesions, 5 underwent mitral valve (MV) repair at median age of 5.2 years (range 1.2 to 7.7 years) for moderate to severe MR, 4 being symptomatic. The severity of the MR in seven of the eight unoperated patients has remained unchanged over the follow-up period (median 8.3 years, range 0.7 to 14.4 years). In total, 10 patients underwent MV repair (median 6.4, range 0.4 to 13.8 years). No patient required MV replacement. None of the 10 patients had more than mild MR over the follow-up period (median 0.6, range 0.2 to 11.0 years).

CONCLUSIONS

Now readily diagnosable by echocardiography, ICMV is a correctable cause of MR with a good outcome. Surgery is indicated in those patients with moderate to severe MR and probably should be done early following diagnosis.

Device closure of an atrial septal defect following successful balloon valvuloplasty in a neonate with critical pulmonary valve stenosis and persistent cyanosis

Persistent cyanosis after successful balloon valvuloplasty for neonatal critical pulmonary valve stenosis is often related to poor right ventricular compliance and right-to-left shunting at the atrial level. A successful catheter closure of an atrial septal defect was performed with a dramatic increase in systemic oxygen saturation alleviating the need for a surgical systemic-to-pulmonary artery shunt.

Pre-excitation syndrome secondary to cardiac rhabdomyomas in tuberous sclerosis

Rhabdomyomas are not uncommon in infants with tuberous sclerosis. We describe a neonate who presented with hydrops fetalis arising from a tachyarrhythmia during fetal life related to rhabdomyomas. After reversion of the arrhythmia, pre-excitation was noted on an interval electrocardiogram. Following regression of the tumours, the delta wave disappeared with no further arrhythmias noted.

Parental non-compliance--a paediatric dilemma. A medical and psychodynamic perspective

Considerable resources have been directed towards the recognition and management of child physical and sexual abuse and/or neglect. However, the issue of parental non-compliance is less well defined and under recognized. While outwardly seeking advice, non-compliant parents, especially if anxious, are unable or unwilling to comply with the recommendations made. Conflicts of interest between the parent(s)' and the health professionals' perceptions regarding the best interest of the child may arise. Parental non-compliance is centred around the parents' perception of the child's current problems and its relationship to past problems. Such non-compliance may reflect ignorance or misunderstanding of the clinical situation. Ignorance may be readily addressed if the parents are receptive and trusting. However, non-compliance more commonly arises from the parents' inability to cope emotionally with the stresses surrounding the recommended treatment. Parents may be vulnerable to psychological reactions which inhibit rational thinking. Parental anxieties are best understood in terms of psychological constructs, including 'defences' such as 'denial' and 'splitting', 'repetition compulsion' and the need to 'work through' psychological barriers so that the child's best interest is served. Parental non-compliance can serve to protect the parents from overwhelming fears and anxieties, which if addressed may transform parental defensiveness to co-operation. Extreme parental non-compliance may represent a special form of child abuse where, due to parental psychopathology, parents are unable to consider the child's best interest. Clinical vignettes arising from a consultant private and hospital ambulatory setting will focus on management strategies for successful outcomes. Recommendations offered on ways to reduce the risk of parental non-compliance include building trust, eliciting the aid of a parental partner, and organizing a second opinion, thereby improving the chances of a successful outcome.

Coronary arterial fistulas in childhood

We reviewed 16 patients with coronary arterial fistulas seen between 1976 and 1997, and aged 2 days to 16 years, with a median age of 3.2 years. Only four patients were symptomatic: two had heart failure, one had exertional dyspnoea, and one infective endocarditis. The fistulas originated from the right coronary artery in seven patients, from the left coronary artery in seven, from both coronary arteries in one patient, while the origin was not clearly defined in the final patient. Associated cardiac anomalies were discovered in six patients, with three of the fistulas being diagnosed at the same presentation. Cross-sectional echocardiography had revealed a dilated coronary artery in 7 out of 11 subjects. The ratio of pulmonary to systemic flows ranged between 0.9 to 3.0, with a median of 1.5. Ten patients were referred for corrective surgery without any mortality. Trans-catheter closure was successfully undertaken in one patient, while spontaneous closure of the fistula was noted in two patients. We conclude that coronary arterial fistulas, although rare and potentially serious, are generally treatable.

Infective endocarditis on an occluder closing an atrial septal defect

Closure of atrial septal defects be means of intravenous catheterisation has been undertaken using a variety of devices as an alternative to surgical closure. We describe the first case, to the best of our knowledge, of infective endocarditis complicating a successful transcatheter closure. This highlights the potential risk of this procedure, and emphasises the need for appropriate antibiotic prophylaxis until complete endothelialization of the device has occurred.

Is our appearance important to our patients?

OBJECTIVES

We aimed to explore patients' attitudes towards family physicians' and nurses' appearance.

METHODS

One hundred and sixty-eight patients from three teaching Family Medicine clinics in Beer-Sheva, Israel, were interviewed in the clinics regarding the medical staff's dress code. They were also asked to choose one picture for either a male or female physician which, in their opinion, was the most suited for their own family physician, from a selection of pictures of the same male and female doctors dressed in different attires.

RESULTS

One hundred and twenty-six patients (75%) replied that the attire of the physician had no influence on their decision in choosing their own family doctor. Fifty-two per cent of the patients preferred the doctor in a white coat and 71 % had the same preference for the nurse. Older age was associated with increased preference for a white coat. The dressing items which scored high for male doctor were a name tag, a formal suit or a shirt with a tie and sports shoes. For a female doctor a name tag, short haircut, trousers and sports shoes ranked highly. Long hair, earrings, and sandals scored low for a male physician, while mini-dress, shorts and tight clothes scored low for a female physician.

CONCLUSION

About half of patients still prefer the doctor to be dressed in a white coat. Patients prefer a more formal dressing for male and female physicians in family medicine clinics. Most of the patients claimed that the attire of the physician had no influence on their choice of family physician.

Counselling strategies for parents of infants with congenital heart disease

Congenital heart disease is a significant cause of morbidity and mortality in the newborn. Its diagnosis may lead to a crisis in the affected families; there are the perceived implications of having an abnormality of so vital an organ. To that may be added the assumed guilt or blame, grief and at times anger, frequently experienced by parents of abnormal infants. It often befalls the paediatric cardiologist to initiate counselling while providing the expert information concerning the abnormality and its optimum management. Such counselling differs from that needed for minor lesions as compared for more complex abnormalities where a fatal outcome may ensure. While it is important to provide an accurate diagnosis and management plan to the parents, early detailed information is often confusing and may not be assimilated at a time of great stress. The parents seem more concerned as to whether the infant will survive, what the long term outlook will be, whether he or she will attend school, play, work and so on. With the more severe cardiac abnormalities, especially where there is a family history, one need be aware of the often perceived guilt of the parents. At times, it may be necessary to help the parents retain sufficient 'self-control', delaying the grieving process to enable them to contribute to the decision making. Where the infant has died, a follow-up appointment can facilitate grieving and help deal with unresolved issues. Through skilled counselling, the cardiologist in addition to his/her diagnostic and management skills, may meaningfully influence the ongoing care of the infant. They may help avoid the development of unrealistic fears or an over-optimistic outlook, thereby fostering the normal development of the child.

Serious sequels of Kawasaki disease

A male infant, aged 2 month, with Kawasaki disease had a myocardial infarction despite intravenous infusions of gamma globulin and aspirin at high dosage. He developed progressively a thin walled, dilated aneurysm of the apex of the left ventricle which became lined with thrombus despite treatment with warfarin. Another boy, aged 6 years, was noted on the 10th day of the evolution of Kawasaki disease to have developed a giant aneurysm of the main stem of the left coronary artery. Despite infusion of gamma globulin, the aneurysm remained unaltered and developed a thrombus. The thrombus resolved following treatment with warfarin, though the giant aneurysm has persisted. These two cases illustrate the serious consequences that can follow Kawasaki disease despite management optimal by current standards.

Holt-Oram syndrome and multiple ventricular septal defects: an association suggesting a possible genetic marker?

A family is described where the father has the many skeletal, but none of the cardiac abnormalities associated with the Holt-Oram syndrome. His two daughters have similar skeletal anomalies, but with identical cardiac lesions, as does another patient, raising the possibility of an associated genetic marker.

Psychiatric collaboration in a paediatric department

OBJECTIVE

To review the impact of integrating child psychiatry services into a paediatric department.

METHOD

Following the arrival of a new head of paediatrics, a mandatory multidisciplinary meeting was set up to review, diagnose and manage selected patients under the care of the paediatricians and/or a child psychiatrist. A prospective audit was undertaken of the patients discussed with a brief review of their outcome. The educational value of the meetings and their overall impact on the department was reviewed.

RESULTS

Over an 8-month period 30 patients were discussed in some detail with diagnoses ranging from a psychiatric disorder to a chronic organic illness, each subjected to the deliberations of the multidisciplinary team of the attending paediatrician, resident staff, child psychiatrist/psychologists, nurses, social worker, etc. Recommendations included further assessment by the psychiatric team, or management by the paediatricians with or without guidance of the former, involvement of an outside agency, etc. Such interventions generally had positive outcomes: at times dramatic, although early discharge often resulted in limited goals. There was also an overall increased awareness within the department of the psychological needs of the child and family and the importance of serious physical illness; this awareness is essential in the training of paediatricians and psychiatric staff.

CONCLUSION

Closer integration of the two disciplines led to benefits both to the patients and staff. The initiation of a mandatory multidisciplinary meeting facilitated the process, overseen by a psychologically-minded new head of paediatrics. His departure led to a loss of some goals achieved, raising the question as to how such collaboration may be self-generating and ongoing. In addition, the issue of how to deal with those patients with ongoing difficulties not addressed during their limited inpatient stay was unresolved.

Monozygotic twins discordant for congenital complete heart block

OBJECTIVE

Isolated congenital complete heart block (CCHB) occurs in 1/20,000 live births. More than 85% of mothers giving birth to affected infants are anti-Ro antibody positive, but only approximately 1% of babies with anti-Ro-positive mothers develop CCHB. We studied 2 sets of monozygotic twins discordant for CCHB.

METHODS

Monozygosity was determined using placental examination and DNA microsatellite analysis. HLA typing was performed. Autoantibody studies were performed using counterimmunoelectrophoresis, immunoblotting, Ro 52 and Ro 60 enzyme-linked immunosorbent assay (ELISA), and indirect immunofluorescence (IIF) on Ro 60- and Ro 52-transfected HEp-2 cells.

RESULTS

Both sets of twins were monozygotic. They had similar birth weights. Twin 2 in the second set required a pacemaker at age 2 months. Both mothers were positive for anti-Ro 52 and anti-Ro 60 antibody, and neither had anti-La antibody on immunoblot. One set of twins was studied at birth. Similar titers of anti-Ro 52 and anti-Ro 60 antibody were found by IIF and ELISA.

CONCLUSION

There are no previous well-documented reports of monozygotic twins discordant for CCHB. These cases demonstrate that there is still discordance in the development of CCHB despite identical genetics and environmental exposure to anti-Ro antibody.

Mitral valve replacement for severe mitral regurgitation in infants with anomalous left coronary artery from the pulmonary artery

Infants with anomalous left coronary artery from the pulmonary artery (ALCAPA) may present with heart failure, mitral regurgitation, and dilated cardiomyopathy. Reestablishment of a two coronary artery system markedly improves the morbidity and mortality. However, the mitral regurgitation may continue to deteriorate despite surgical correction of the ALCAPA because of previous ischemic damage to the papillary muscles and chordae. Surgical intervention, including mitral valve replacement, may be required even during infancy. We present two infants with ALCAPA who required early mitral valve replacement for severe mitral regurgitation and have done well subsequently.

A low allergen diet is a significant intervention in infantile colic: results of a community-based study

BACKGROUND

The effect of diet change in 38 bottle-fed and 77 breast-fed "colicky" infants, referred from community-based pediatric facilities was studied over a 1-week period in a double-blind (within each feeding mode), randomized, placebo-controlled trial.

METHODS

Bottle-fed infants were assigned to either casein hydrolysate or cow's milk formula. All mothers of breast-fed infants were started on an artificial color-free, preservative-free, additive-free diet and also randomized to an active low allergen diet (milk-, egg-, wheat-, nut-free) or a control diet.

RESULTS

The response to diet was assessed on day 1 and day 8 with the use of a previously validated infant distress chart on which parents recorded distress levels. If successful outcome was defined as a reduction in distress of 25% or more, after adjusting for age and feeding mode, infants on active diet had a significantly higher rate of improvement than those on the control diet (odds ratio, 2.32; 95% confidence interval, 1.07-5.0; p = 0.03). Analysis of the day 8 to day 1 distress ratio, again adjusted for age and feeding mode, showed that infants on the active diet had distress reduced by 39% (95% confidence interval, 26-50) compared with 16% (95% confidence interval, 0-30) for those on the control diet (p = 0.012).

CONCLUSION

The results suggest a period of dietary modification with a low allergen diet and appropriate nutritional support should be considered in healthy infants with colic.

Surgical intervention for infective endocarditis in infancy and childhood

BACKGROUND

Infective endocarditis is an uncommon but serious disease in children. Optimal treatment strategy, especially surgical indications, continues to evolve.

METHODS

Retrospective review of 98 patients treated for infective endocarditis during the past 13 years at the Royal Children's Hospital, including medically and surgically treated patients.

RESULTS

Thirty of 98 patients had surgical intervention with 6.7% hospital mortality, and 76% survival probability at 45 months. The remaining patients were treated medically, with 10% hospital mortality and 52% 5-year survival probability. The incidence of structural heart disease, congestive heart failure, and spectrum of organisms was similar in the two groups.

CONCLUSIONS

Despite advances in antibiotic therapy, early surgical intervention is required in a significant subset. Concurrent intracardiac repair may be appropriate.

Recurrent dermatitis from jellyfish envenomation

Jellyfish envenomation can cause an immediate local skin reaction, which is usually a painful linear vesiculourticarial eruption. Persistent, delayed, or recurrent dermatitis is less common. Because jellyfish sting reactions and their management are unfamiliar to family physicians, we describe a case of recurrent local dermatitis after jellyfish envenomation and suggest appropriate treatment.