Lionel Lubitz

Symptomatic zinc deficiency in breast‐fed term and premature infants

Two 3‐month‐old exclusively breast‐fed infants, one born at full‐term and the other born prematurely, developed symptomatic zinc deficiency manifested by an acrodermatitis enteropathica‐like eruption. Inadequate breast milk zinc was demonstrated in both cases. A rapid clinical response followed oral zinc supplementation after which their serum zinc levels returned to normal. The infants remained asymptomatic following cessation of zinc therapy. Reports of similar cases suggest that in a group of infants breast milk does not meet their nutritional zinc requirements. Inadequate breast milk zinc is thought to result from a defect in transfer of zinc from maternal serum to breast milk.

Effect of antireflux medication, placebo and infant mental health intervention on persistent crying: A randomized clinical trial

Objective: To assess the effect of medical antireflux treatment, and of an infant mental health consultation (IMHC), on persistent crying in infants and maternal distress.

Clinical predictors of pathological gastro-oesophageal reflux in infants with persistent distress

Background: Gastro‐oesophageal reflux (GOR) is common in infants with persistent crying. Empirical treatment with antireflux medications is common practice, although on clinical grounds it may be difficult to determine whether GOR is abnormal.

Graduated exercise training and progressive resistance training in adolescents with chronic fatigue syndrome: a randomized controlled pilot study:

Objective: To investigate the differential effects of aerobic graded exercise and progressive resistance training on exercise tolerance, fatigue and quality of life in adolescent patients with chronic fatigue syndrome (CFS). Design: Single-blind, randomized controlled pilot trial. Setting: A major metropolitan hospital in Melbourne, Australia. Subjects: Twenty-two adolescents aged 13—18 years diagnosed with CFS and admitted to the inpatient chronic fatigue rehabilitation programme. Intervention: Patients were randomized to either graded aerobic exercise training or a progressive resistance training programme, for five days/week for four weeks. The graded aerobic training consisted of 20—40 minutes of stationary cycling and treadmill exercise. The progressive resistance training involved 16 exercises performed with single set, moderate load and high repetitions. Main measures: Exercise tolerance (time to fatigue) measured on a graded sub-maximal treadmill test, metabolic equivalents and quality of life, along with muscular strength (maximium push-ups) and endurance (sit-to-stand) and questionnaires evaluating depressive symptoms and fatigue severity. Results: No intervention was significantly better than the other for any outcome. However, physical capacity and quality of life significantly improved in both groups, while fatigue severity and symptoms of depression improved only with aerobic training. Conclusions: Resistance and aerobic training resulted in similar changes to physical capacity, quality of life and fatigue severity. Generally, patients who completed resistance training or aerobic training experienced significant improvements in outcomes from baseline when they entered the programme. Whether these improvements can be attributed to the treatment is unknown.

Promising outcomes of an adolescent chronic fatigue syndrome inpatient programme

Introduction:  Chronic fatigue syndrome (CFS) is a condition of prolonged and disabling fatigue, which is accompanied by characteristic constitutional and neuropsychiatric symptoms. In children and adolescents, this condition occurring at a developmentally vulnerable time adds to the disability affecting self‐concept, autonomy, body image, socialisation, sexuality and academic problems. This case series looks at the effects of a graded exercise programme on physical outcomes, fatigue and mental state in an adolescent population.

Paediatric chronic fatigue syndrome: complex presentations and protracted time to diagnosis.

The diagnosis and management of paediatric chronic fatigue syndrome (CFS) remain ongoing challenges for paediatric clinicians, particularly given its unknown aetiology and the little research on effective treatments for this condition. The aim of this study was to describe the presenting features of new patients attending a specialist chronic fatigue clinic at a tertiary‐level Australian childrens hospital.

How is paediatric chronic fatigue syndrome/myalgic encephalomyelitis diagnosed and managed by paediatricians? An Australian Paediatric Research Network Study

The diagnosis and management of paediatric chronic fatigue syndrome/myalgic encepnalomyelitis (CFS/ME) represent ongoing challenges for paediatricians. A better understanding of current approaches at a national level is important in informing where research and education could improve treatment outcomes. We aimed to examine current diagnosis and management practices for CFS/ME by Australian paediatricians.

MYCOTIC PSEUDOANEURYSM OF THE LINGUAL ARTERY: A RARE COMPLICATION OF PARAPHARYNGEAL ABSCESS

Unilateral cervical lymphadenitis is a common presentation to hospital. Catastrophic vascular complications associated with these infections are rare, and very few cases have been reported in children. We report a case of a mycotic pseudoaneurysm secondary to a parapharyngeal infection with reactive lymphadenitis. A previously healthy 20-month-old girl presented with a 5-day history of fever and lethargy. On examination a large, tender, non-fluctuant right-sided submandibular neck swelling was discovered (Fig. 1). Examination of her oropharynx revealed a medialised right tonsil with no trismus, stridor, airway compromise or dysphagia. The diagnosis of lymphadenitis was made and no imaging was performed. Treatment with 3 days of intravenous ticarcillin-clavulanate led to significant improvement, and she was discharged with 7 days of amoxycillin-clavulanate. One week later the patient presented with an acute recurrence of the right neck swelling and fever. An ultrasound of the neck, suggested the diagnosis of a pseudoaneurysm, but was not definitive. A computed tomography (CT) scan was performed (despite our reluctance to employ that modality in view of high radiation exposure) to provide a diagnosis and detailed anatomy that assisted the vascular surgeon in devising a safe management approach. CT angiogram of the neck (Fig. 2) confirmed a pseudoaneurysm of the right lingual artery (a branch of the external carotid artery) (13 ¥ 8.5 ¥ 7.4 mm) within a large irregular parapharyngeal collection (58 ¥ 28 ¥ 44 mm in maximal dimensions). Neck exploration and repair of the pseudoaneurysm were performed on the same day. The right external carotid artery was ligated and the collection drained. The organism identified was Streptococcus anginosus (Streptococcus milleri). Blood cultures taken were negative for bacterial growth. Two weeks of intravenous antibiotics was completed (initially ticarcillinclavulanate and benzyl penicillin, and later changed to ceftriaxone on the basis of microbiological sensitivities). On review there were no cranial nerve deficits. Repeat ultrasound revealed no fluid collection. She made an excellent recovery. Mycotic pseudoaneurysm of a branch of the external carotid artery is a rare complication from infection in the head and neck region. In children, this can occur from loco-regional spread from adjacent soft tissue abscess or embolisation from an infected thrombus. In our case, the patient had adenitis, which initially responded to treatment, but then had recurrence in the second week of treatment. This led to further investigations, revealing the parapharyngeal collection and pseudoaneurysm. The most common species of bacteria that cause mycotic aneurysms are Staphylococcus and Salmonella. However, any organism that can cause skin or mucous membrane infections in the head and neck region can cause adenitis in the lymph nodes. The untreated mortality from pseudoaneurysm of the carotid artery is reported to be up to 77%, most likely due to catastrophic haemorrhage into the upper aero-digestive tract. However, with treatment this rate is reduced to 35%. In conclusion, pseudoaneurysm of the branch of the external carotid artery is a rare complication of parapharyngeal abscess. A notable feature in both our case and those referenced was the recurrence of disease after the second week of treatment. Conflict of interest: None declared. Fig. 1 Clinical appearance of patient at presentation.

Measuring quality of life and fatigue in adolescents with chronic fatigue syndrome: estimates of feasibility, internal consistency and parent–adolescent agreement of the PedsQLTM

The aim of this study was to investigate the psychometric properties of the Paediatric Quality of Life Inventory (PedsQLTM) in measuring health-related quality of life (HRQOL) and fatigue in adolescents with chronic fatigue syndrome (CFS), using both adolescent-reported and caregiver proxy ratings. Eighty-four participants (42 adolescents and 42 parent proxies) recruited consecutively through CFS specialist clinics at a tertiary paediatric hospital completed the PedsQLTM Core Generic Module (CGM) and Multidimensional Fatigue Scale (MFS). Overall, feasibility, floor/ceiling effects and internal consistency were found to be acceptable for the PedsQLTM CGM and the MFS according to predetermined criteria. For parent–adolescent agreement, intra-class correlations between adolescent and parent report on the PedsQLTM CGM and MFS were statistically significant and rated as ‘fair’ (range 0.45–0.68). At a group level, statistically significant discrepancies between mean adolescent and parent scores for the PedsQLTM CGM were noted on all scales (except school functioning). On the MFS, there were no significant differences between parent and adolescent mean scores. Bland–Altman plots revealed significant variability in the discrepancies between parent and adolescent reports on the PedsQLTM CGM and MFS. Based on the psychometric properties assessment, findings of this study suggest that the parent and adolescent PedsQLTM CGM and MFS are promising scales for use in adolescents with CFS. Parent and adolescent reports offer unique perspectives on HRQOL and fatigue in adolescents with CFS and ideally, reports should be sought from both parties.

A multidisciplinary approach to the management of psychosocial admissions to a general paediatric ward

Abstract This study investigated the cheracteristics of all new in‐patients with major psychological and/or social problems admitted to a medical ward over a 4‐week period. Fifteen successive patients were studied prospectively. The professional time spent by the medical and paramedical personnel involved in the initial assessment and management was reviewed, and the children followed‐up 6 months later.