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Children who wear hyoscine skin patches to control drooling may develop eye problems and need ophthalmological assessment and provision of appropriate glasses. In Glasgow (Developmental Medicine and Child Neurology 2007; 49: 426‐8) five patients aged 8‐18 years with quadriplegic cerebral palsy and severe learning difficulties were assessed. They all wore hyoscine patches. They had large pupils that constricted poorly to light and little accommodative response. Three of them showed evidence of photophobia. All five were given glasses designed to provide a focused image at 1 metre (considered the primary sphere of interest) and the photophobic patients were provided with photochromic lenses. On follow up, parents and teachers reported improvements; the children reached out for objects and looked at toys and books more readily and the photophobia was less evident.
There should be greater investment in large‐scale banking of umbilical cord blood and both cord‐blood banks and bone‐marrow donor registries should be searched simultaneously whenever a child needs a haemopoietic stem cell transplant from an unrelated donor. These are the conclusions of a non‐randomised study (Lancet 2007;369:1947–54; see also Comment, ibid: 1906–8) using data from the Center for International Blood and Marrow Transplant Research and the National Cord Blood Program of the New York Blood Center. The study included 785 children aged <17 years with acute leukaemia, 503 given umbilical cord blood (UCB) transplants and 282 bone marrow (BM) transplants. Five‐year leukaemia‐free survival was highest (60%) with HLA‐matched UCB transplants and lowest (33%) with UCB and two mismatches. The rates for matched or mismatched BM were 38% and 37%. For UCB transplants with one mismatch the 5‐year leukaemia‐free survival rate was 45% with high cell dose and 36% with low cell dose. Compared with matched BM the risk of transplant‐related death was not significantly increased after UCB transplant either matched or with one‐antigen mismatch and high cell dose. The rates of chronic or severe acute graft versus host disease were similar for all UCB and matched BM transplants. Only 30% of children in need of a transplant have an HLA‐matching sibling for marrow transplantation.
Although phenobarbitone is now rarely used for the treatment of epilepsy in children in affluent countries it is frequently used in poorer countries. The WHO recommends phenobarbitone as first choice treatment for partial or generalised tonic‐clonic seizures in resource‐poor countries but in richer countries the behavioural and cognitive side effects are usually thought to be prohibitive. Several reports from developing countries, however, have suggested these side effects may not be as severe as is widely thought. In Bangladesh (BMJ 2007;334:1207–10; see also editorial, ibid: 1175–6) 108 children aged 2–15 years with generalised tonic‐clonic, partial, or secondarily generalised seizures were randomised to treatment with phenobarbitone or carbamazepine. Ten children developed behaviour problems (four on phenobarbitone and six on carbamazepine) and they were severe in four (one vs three). Freedom from seizures in the second half of the first year of treatment was achieved in 45% vs 55% of those assessed in the phenobarbitone and carbamazepine groups respectively. These researchers conclude that in Bangladesh phenobarbitone is no more likely to cause behavioural side effects than is carbamazepine. The writer of the editorial points to methodological problems with most trials of phenobarbitone but calls for epilepsy management programmes that are fully integrated within community healthcare delivery systems with well educated health professionals and public, reliable drug supplies, and adequate drug storage and dispensing. About 85% of people with epilepsy in developing countries get no treatment at all.
Children with congenital cataract may undergo numerous procedures, experience demanding treatment, have many and frequent hospital visits, and be uncertain about their visual prognosis. A questionnaire study of a UK national cohort (Br J Ophthalmol 2007;91:922–6) has shown that their health‐related quality of life (HRQOL) may be seriously reduced. HRQOL was assessed using child and parent versions of a paediatric instrument (PedsQL 4.0) and replies were received from 41/42 parents and 33/42 children aged 5–19 years (median 6.8 years). The mean total scores on a scale of 0–100, with higher scores indicating better HRQOL, were 75.9 for both parent and child reports but there was a wide range of child‐parent disagreement. Psychosocial health was rated less than physical health. It is concluded that the HRQOL scores of children with cataracts is comparable to those reported for some children with severe chronic diseases such as rheumatological diseases and some cancers. Specific vision‐related quality of life measures for children are needed.
Where vitamin A deficiency is common vitamin A supplements for preschool children reduce all‐cause mortality by about 30%. The standard WHO dosage is 200000 IU to the mother soon after the birth, 100000 IU to the infant at 9 months and 200000 IU every 4–6 months after that. It has been suggested, however, that larger doses to the mother (two doses, each of 200000 IU) and earlier doses to the infant (50000 IU at 6, 10 and 14 weeks) might be better. In rural Gambia (Lancet 2007;369:2088–96; see also Comment, ibid: 2054–6) 220 mother‐infant pairs were randomised to one or the other regimen. Over 12 months of follow up the two groups did not differ significantly as regards maternal or infant plasma vitamin A concentrations, maternal or infant pneumococcal carriage, infant Helicobacter pylori infection, or infant gut mucosal damage. The new regimen group had more clinic attendances in the first 6 months of life. It is concluded that the new regimen should not replace the standard WHO regimen.
Children with cerebral palsy have reported their own quality of life as being similar to that of other children. In six European countries (Lancet 2007;369:2171–8; see also Comment, ibid: 2137–8) a total of 818 children aged 8–12 years with cerebral palsy were studied. Five hundred of these children were able to report their quality of life using the KIDSCREEN instrument. Their quality of life scores were similar to those of children in the general population in eight of the ten KIDSCREEN domains. The exceptions were schooling (evidence equivocal) and physical wellbeing (comparison not possible). Pain was common and reduced scores in all domains but explained only 7% of the variation in quality of life. Severely limited mobility reduced scores for physical wellbeing, intellectual impairment reduced scores for moods, emotions and autonomy, and speech difficulties reduced scores for relationships with parents. Impairments explained only up to 3% of variation in quality of life.