Growth patterns among infants with language deficits: a case-control study

We compared growth parameters in infants with language delay to those in children with global delay and to typical controls. Thirty infants with expressive language delay and 36 with combined expressive and receptive language delay were compared with 27 infants with general development delay and with 124 controls. Data on weight, height, head circumference, and feeding behavior were obtained from birth up to age 78 weeks, and converted to percentiles. Medical and sociodemographic data were also evaluated. The weight curves in the combined expressive and receptive language delay group were significantly lower than in the comparison groups, but no cases of failure to thrive were noted. Height and head circumference curves in the combined expressive and receptive language delay group were also lower than in the typical controls. Infants with combined expressive and receptive language delay were lighter and shorter than controls. However, none of the parameters were more than two standard deviations below the mean. It is possible that this finding is of constitutional origin.

Infants with a thumb-in-fist posture

OBJECTIVE

In early infancy the infant's thumb is not infrequently enclosed within the palm, ie, thumb-in-fist (TIF). This posture has received scant attention in the neurodevelopmental literature. Its prevalence, resolution, and clinical associations were investigated in this study.

METHODOLOGY

Two hundred sequentially born, apparently healthy full-term newborn infants comprised the cohort. The whole study group was followed up until the disappearance of the TIF occurred. In the first 150 of the cohort, additional data on development and the neurological status were obtained at 12 months of life.

RESULTS

In 125 infants (62.5%) of the total cohort, a TIF was noted. The mean age of disappearance was 1.5 months, and no TIF persisted after 7 months old. No relationship was noted between the TIF resolution and abnormal neurological signs or gross or fine motor development. The only association noted between age of resolution of the TIF and the neurodevelopmental status was a delay in language attainment at the 12-month screening.

CONCLUSIONS

The TIF posture in infancy was noted in 65% of our cohort, and it had resolved in all infants by 7 months old. Therefore, a TIF posture after this age should alert the clinician to the possibility of possible neurological dysfunction. An unanticipated association of a delay in the 12-month language milestone attainment was noted in those infants with later resolution of the TIF posture. No data on language development in this group were obtained after 12 months old; therefore, the clinical significance of this finding is not yet elucidated.

Sleep position, bedding and heating practices in high- and low-risk ethnic groups for unexpected death in infancy (UDI)

In a previous study, a significant increased risk for unexpected death in infancy (UDI) among Arab infants as compared to Jews (RR: 5.2) was found. The incidence has significantly decreased in both groups during the 'back to sleep' campaign. The objective of this study was to compare the prevalence of three risk factors, i.e. positioning, night dressing/covering and heating practices in these ethnic groups. A community sampling procedure was employed, resulting in the participation of 264 Jewish and 146 Arab mothers of infants between 1 and 4 months, born at term and with no chronic illness at the time of the study. A questionnaire in Arabic and Hebrew was designed, pertaining to sleep positioning at the time of the study and of the previous infant, prior to the SIDS prevention campaign, as well as clothing and heating practices. Significantly, more Arab infants were put to sleep in a supine or side position as compared to Jewish infants both during the study (p = 0.002) as well as prior to the SIDS campaign (p = 0.001). No ethnic difference was related to clothing practices. Open heating, however, was significantly more common in the Arab sector (p = 0.001). A logistic procedure for each of the practices indicated that ethnicity is related significantly to both sleep position (p = 0.002) and beating practices (p = 0.001). Prone sleep positioning was still prevalent (32.2%) more so among Jews (35.2%) than Arabs (27%).

CONCLUSION

Sleep positioning and overdressing do not appear to be the major attributable risk factors for UDI among Arab infants as compared to Jews. The compliance with positioning recommendations is lower than expected in both ethnic groups.

Outcome of idiopathic apparent life-threatening events: infant and mother perspectives

The objective of this study was to determine the neurodevelopmental and temperamental outcome of infants who suffered an idiopathic apparent life-threatening event (IALTE) and their mothers' perceptions of such an event, and to compare such infants with a matched group of babies hospitalized for nonthreatening events. Infants (N = 19) who were hospitalized at a mean age of 2.8 months for an IALTE with no underlying disease and matched controls hospitalized for an acute nonthreatening illness were sequentially recruited to the study at a mean age of 24 months (SD, 14 months). Physical, neurological, developmental, and temperamental status were assessed. Mothers' stress was assessed by their salivary cortisol response to the physical examination of their infants and completion of appropriate questionnaires assessing their infants' temperament. The investigators were not blinded to the assignment of the infants to each of the study groups. Infants' perceived "difficultness" was positively correlated with the time interval following the event (r = 0.5, P = 0.001), mothers' stress as related to their child (r = 0.4, P = 0.004), and mothers' cortisol response (r = 0.5, P = 0.01) among the study group mothers only. IALTE during early infancy was associated with developmentally and neurologically normal outcome in infancy. We conclude that mothers of infants with IALTE differed in the way they perceived their infants' temperament over time, and in their stress response compared to mothers of a control group of hospitalized children who had not experienced an IALTE.

The effect of parental traumatic brain injury on parenting and child behavior

OBJECTIVES

To examine (1) the parenting skills of individuals with traumatic brain injury (TBI) and their spouses, (2) the effects of parental TBI on children, and (3) the effects of parental TBI on levels of depression for all family members.

DESIGN

Independent two-tailed t tests and Pearson chi-square analyses were utilized to compare parents with TBI versus parents without TBI, spouses of parents with TBI versus spouses of parents without TBI, and children of parents with TBI versus children of parents without TBI.

SETTING

Urban, suburban, and rural New York State.

PARTICIPANTS

32 families participated in the study; in 16 families one parent had a TBI and in the remaining 16 families, no parent had a TBI. Eighteen children from families with parental TBI and 26 children from families without TBI were interviewed. On average, parents with TBI were 9 years post-onset of injury at the time of interview.

MAIN OUTCOME MEASURES

The parents' battery explored parents' perspectives of their own parenting skills (Parent Behavior Form, Parent Practices Questionnaire, Parenting Dimensions Inventory), their mood (Beck Depression Inventory), and the behaviors of their children (Children's Problem Checklist, Behavior Rating Profile). The child's battery tapped the children's perspective of their own behaviors (Behavior Rating Profile), their mood (Children's Depression Inventory), and the parental abilities of both parents (Parent Behavior Form, Parent Practices Questionnaire).

RESULTS

Although parents with TBI and their spouses were similar to their comparison group in many parenting skills, parents with TBI reported less goal setting, less encouragement of skill development, less emphasis on obedience to rules and orderliness, less promotion of work values, less nurturing, and lower levels of active involvement with their children. Spouses of individuals with TBI, compared to their counterparts, reported less feelings of warmth, love, and acceptance toward their children. Children from families in which a parent had a TBI perceived both parents as more lax in their discipline, with the parent without TBI perceived as less actively involved in parenting roles. No differences in the frequency of behavioral problems were found between children of parents with TBI and children of parents without TBI. Parents with TBI and their children experienced more symptoms of depression relative to their respective comparison groups.

CONCLUSION

Parental TBI has select consequences for all family members: individuals with TBI, their spouses, and their children. Prospective clinical evaluations of family members and proactive interventions to maximize family adjustment and minimize affective distress are indicated.

[Nasopharyngeal colonization with Streptococcus pneumoniae in pediatric respiratory infections]

During the winter of 1995, nasopharyngeal colonization of Streptococcus pneumoniae was evaluated in 204 children with respiratory infection and 107 normal control children. There was no difference in gender or mean age between the groups, and no difference in carrier rate between sick (24.5%) and normal (22%) children (p = 0.6). Carrier rates were 19%, 32%, 31% and 17% at 6, 12, 24 and 48 months, respectively. Penicillin-resistant pneumococci (PRP) were found in 42% of sick and 16.6% of normal children, (p < 0.05). Resistance to more than 2 antibiotics was found in 28% of sick and in 12.5% of normal children. PRP were found in 67% and 34% of sick children with and without prior antibiotic treatment (p < 0.05). We conclude that there is no difference in the carrier rate of Streptococcus pneumoniae between sick and normal children. However, the high prevalence of PRP in children with respiratory infections is probably due to prior antibiotic treatment.

The effect of employment on quality of life and community integration after traumatic brain injury

OBJECTIVES

To investigate the effect of employment on perceived quality of life (QOL), social integration, and home and leisure activities for individuals with traumatic brain injuries (TBIs).

DESIGN

A number of demographic and injury-related variables (age at injury, time since injury, severity of injury, education, gender, preinjury household income, and marital status) were analyzed for their association first with employment and then with the QOL, social integration, and home and leisure activities. Any of these variables showing significant associations were then included along with level of employment in three final multivariate analyses of variance (MANOVAs), again predicting QOL, social integration, and home and leisure activities.

SETTING

Urban, suburban, and rural New York state.

PARTICIPANTS

337 adults with TBI who resided in New York state and were between the ages of 18 and 65 years.

MAIN OUTCOME MEASURES

The Craig Handicap Assessment Capacity Technique, the Bigelow Quality of Life Questionnaire, the Flanagan Scale of Needs (adapted), and a global QOL measure.

RESULTS

Employment showed a strong and consistent relationship with perceived QOL, social integration within the community, and home and leisure activities. Part-time employment may have been superior to full-time employment for individuals with TBI: part-time workers had fewer unmet needs, were more socially integrated, and were more engaged in home activities than full-time workers. Loss of consciousness, as a measure of severity, was unexpectedly predictive of diminished sense of QOL for individuals with less severe injuries.

CONCLUSIONS

Being employed contributes to one"s sense of well-being, social integration, and pursuit of leisure and home activities. Select advantages of working part-time for individuals with TBI were identified.

The differences in health concerns between mothers and health care professionals in a preventive community set up

To assess the degree to which mothers, nurses and pediatricians share common concerns regarding infants' health and well-being a cross-sectional survey with stratified demographic sampling was conducted. A 12-item questionnaire pertaining to health concerns was administered to 22 mothers of infants between 1 and 18 months of age, treated at six Well Baby community clinics with 36 nurses and 25 pediatricians. Mothers and health care professionals expressed significantly different concerns. Pediatricians and nurses shared a more similar order of concerns. However, they too differed on the degree of concern related to some of the health issues, i.e. nurses perceived the issues related to feeding, behaviour, skin, sleep and daily routines as significantly more important than did pediatricians. Additional efforts should be devoted to improve and clarify communication between mothers and health care professionals.

The role of the capnography head-up tilt test in the diagnosis of syncope in children and adolescents

OBJECTIVES

To evaluate the role of the capnography head-up tilt test (CHUTT) in the diagnosis of syncope in pediatric patients.

METHODS

The CHUTT is a head-up tilt test with concomitant capnometry. Hyperventilation on CHUTT was diagnosed when the patient's end-tidal carbon dioxide pressure (ETPCO2) was </=25 mm Hg. Hyperventilation syncope was diagnosed when three criteria were met: loss of consciousness, ETPCO2 </=25 mm Hg, and no significant drop in blood pressure. The cohort included 65 consecutive children and adolescents (mean age, 14.2 years) who were assessed for syncope by routine investigations and CHUTT.

RESULTS

The cause of the syncope was established in 67% of cases: cardioinhibitory reaction in 17%, vasodepressor in 20%, psychogenic in 22%, and mixed neurally mediated-psychogenic in 8% of the patients. The history indicated a cause of syncope in 40%, the CHUTT in 49%, and a combination of the history and positive CHUTT in 66% of patients. Neither the patients' clinical data nor values of the blood pressure, heart rate, respiratory rate, and ETPCO2 measured during recumbency predicted which patients would manifest hyperventilation or hyperventilation syncope on tilt.

CONCLUSIONS

The CHUTT contributes substantially to the diagnosis of syncope in pediatric patients. The CHUTT advances the understanding of the pathophysiological mechanisms of syncope and enables the physician to reassure the patient regarding the essentially benign nature of the condition. Because it is not possible to predict which patients would develop a hyperventilation syncope on the standard tilt test, the modification of this procedure by measuring the ETPCO2 for the assessment of children with syncope should be considered.

The clinical significance of rigors in febrile children

The objective of the study was to evaluate the significance of rigor as a predictor of bacterial infection in hospitalized febrile infants and children. One hundred febrile children with rigor were studied and compared to 334 febrile matched controls without rigor. All underwent clinical evaluation and appropriate laboratory investigations. The patients were then divided into "bacterial" and "non bacterial" infection groups, as defined in the text. It was demonstrated that 66% of the patients with rigor belonged to the bacterial infection group versus 50% in the non-rigor group (P < 0.005). There was a significantly greater yield of positive blood cultures in the patients with rigor (P < 0.04), especially those over the age of 1 year (P < 0.015). The only laboratory examination of potential value as a predictor of bacterial infection in children with rigor was the band count. An absolute band count of more than 1500/mm was significantly more frequent in the rigor group (P < 0.003), and the combination of a rigor and band count of more than 1500 increased the relative risk for a bacterial infection by a factor of 1.35. These data demonstrate that rigor in hospitalized febrile infants or children significantly increase the likelihood of bacterial infection.

CONCLUSION

Although the absence of rigors in febrile children does not exclude bacterial aetiology, their presence significantly increase the probability of an infection requiring appropriate workup and a reader institution of antibiotic therapy.

Progressive familial intrahepatic cholestasis among the Arab population in Israel

BACKGROUND

Progressive familial intrahepatic cholestasis, which constitutes a heterogeneous group of imperfectly delineated syndromes and appears to be inherited as an autosomal recessive condition, has not been hitherto reported from the Middle East, in spite of the high rate of consanguineous marriage in this region.

METHODS

Sixteen affected children from six Israeli Arab families were evaluated over 30 years. All were born to consanguineous parents.

RESULTS

Jaundice appeared during the first 3 weeks of life in 15 babies. When first referred, 10 had hepatomegaly and nine had splenomegaly. A progression toward cirrhosis was the rule. Serum levels of conjugated bilirubin, liver enzymes, and alkaline phosphatase were raised; gamma-glutamyl transpeptidase levels were normal in all three infants in whom it was examined, but elevated in two siblings of another family at ages 2 and 3 years. No abnormal bile acids were detected in the serum and urine of patients. Histologic examination of the liver showed giant-cell transformation, paucity of intrahepatic bile ducts, cholestasis, fibrosis, or cirrhosis. The pattern of liver pathology differed at times among affected members within the same family. Therapeutic trials with phenobarbital, cholestyramine, or ursodeoxycholic acid were ineffective. Survival of the patients was from 5 to 18 months in four families; in the other two families, three children received liver transplants, and one is awaiting liver transplantation.

CONCLUSIONS

Progressive familial intrahepatic cholestasis should be included in the differential diagnosis of infants with cholestatic jaundice of unknown etiology, especially those born to consanguineous Arab parents.

Combination gene transfer to potentiate tumor regression

Recent efforts to treat malignancy using gene transfer have met with varying degrees of success. In this paper, we report the results of studies using two recombinant adenoviral vectors to examine the efficacy of combination gene transfer to cause tumor regression in vivo. One of these vectors encodes the murine MHC class I gene, H-2Kb (ADV-Kb), which induces an immune response that stimulates tumor regression. The second vector encodes the human p21 cyclin dependent kinase inhibitor (ADV-p21). This gene product arrests cell cycle progression and prevents proliferation of tumor cells. Both vectors were tested in a murine model in vivo for antitumor effect. As previously shown, a significant reduction of tumor size was observed with each vector. Combination treatment, in which both vectors were administered, resulted in a trend toward a reduced tumor growth greater than with either vector alone. In order to characterize the mechanism of tumor regression, cytolytic T lymphocyte (CTL) assays against the allogeneic molecule, H-2Kb, were performed. Mice treated with ADV-Kb showed specific CTL activity against the H-2Kb molecule, demonstrating that the immune response against the H-2Kb gene product involved in tumor regression was potentiated by expression of the p21 gene which affects cell cycle progression.

The capnography-tilt test for the diagnosis of hyperventilation syncope

We describe the capnography tilt test (CTT) for the diagnosis of hyperventilation syncope. The CTT is a 10-min supine, 30-min head-up tilt test with simultaneous monitoring of end-tidal PCO2 (ETPCO2). Hyperventilation (HV) was defined as ETPCO2 < or = 25 mmHg. Hyperventilation syncope (HV syncope) was defined as loss of consciousness with ETPCO2 < or = 25 mmHg and no significant drop in blood pressure. Four groups of patients had the CTT: group I (n = 14), patients presenting with syncope who during a prior tilt test had lost consciousness without concomitant fall in blood pressure; group II (n = 50), syncope, primary evaluation, no prior tilt test done; group III (n = 20), generalized anxiety disorder, no syncope; group IV (n = 80), arterial hypertension, no syncope. Hyperventilation was found in 11/14 patients in group I, 5/50 in group II, 7/20 in group III, and none in group IV; HV syncope was diagnosed in seven patients, all in group I. None of the parameters measured in the evaluation, including ETPCO2, predicted HV syncope on tilting. The mechanisms of resting HV and HV during tilt are not well understood. We confirm the existence of HV syncope. The tilt test should probably be used to screen patients presenting with syncope, with the CTT reserved for patients who lose consciousness during the tilt test without an associated fall in blood pressure, as HV is not always clinically obvious.

Neonatal intussusception as a presenting sign of Hirschsprung's disease

A case of ileocecal intussusception as a presenting sign of Hirschsprung's disease in the neonatal period is presented with a review of the literature.

Reversible brain atrophy and reversible developmental retardation in a malnourished infant

An 11-month-old infant suffering from microcephalus, developmental delay, severe failure to thrive and marked cortical atrophy on brain CT is presented. The cause of this condition was total calorie malnutrition induced by the emotional dysfunction of the mother. Improvement of the maternal-infant relationship, combined with appropriate nutrition, transformed the infant within 2 months into a normally developing baby with body weight and head circumference within the normal percentile range. A corresponding improvement was found in the brain CT.

Apnea of infancy, seizures, and gastroesophageal reflux: an important but infrequent association

Seventeen infants between 3 and 37 weeks of age were sequentially admitted for investigation of apnea of infancy or apparent life-threatening events associated with suspected regurgitation. They all underwent an overnight polygraphic study, including esophageal pH monitoring. In nine infants, gastroesophageal reflux was diagnosed. In five of them, the reflux was associated with apnea. However, unassociated episodes of apnea and gastroesophageal reflux occurred (7.1 times and four times, respectively) more frequently than associated episodes. In two of the five infants, a seizure preceded both reflux and apnea and might have acted as a trigger for the apparent life-threatening events. Infants with apparent life-threatening events or apnea of infancy frequently demonstrate gastroesophageal reflux that cannot be consistently related to their events. However, when the association is demonstrated, a common epileptic convulsive etiology should be considered.