The efficacy of inhaled nedocromil sodium (NS) for children with a persistent cough was studied. Children aged 4-12 years with a persistent cough for >1 month were recruited and entered a 2-week baseline period during which an asthma diary was kept. Children with a cough score of >20 received inhaled NS via a spacer, 4mg qid for 2 weeks followed by 4mg bd for another 4 weeks. Twenty-two (42%) of 52 children recruited fulfilled treatment criteria. Four children were withdrawn from the study (2 developed wheezing and 2 were not compliant). The baseline cough score (29.1 +/- 13.6) improved after 2 weeks of treatment (15.2 +/- 9.3, p < 0.01) and improvement was sustained after 6 weeks (14.2 +/- 13.0, p = 0.01). Parents and patients had a more favourable perception of its efficacy compared to physicians (72% vs 50%, p = 0.01) Inhaled NS may be considered for treatment of persistent cough in children.
Study site: Paediatric clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
The treatment preferences of 109 general practitioners (GPs) for childhood asthma were determined. Availability and adherence to clinical practice guidelines (CPG) for the treatment of childhood asthma was also assessed. Ninety eight (90%), 60 (55%) and 33 (30%) GPs considered nocturnal symptoms > 2 times/week, exercise induced wheeze and cough respectively as indications for preventer therapy. An oral preparation was preferred for relief medication [72 (66%) for 2-5 years, 60 (55%) for > 5 years]. An inhaled preparation was however preferred for preventer medication [60 (55%) for 2-5 years, 85 (78%) for > 5 years]. The oral form was more likely prescribed for asthmatic children 2-5 years (p < 0.001). Corticosteroids and ketotifen were the commonest inhaled and oral preventer treatment prescribed respectively. Only 36(33%) GPs have a CPG copy for reference. Children with asthma symptoms that require preventer therapy may not always be identified in general practice. The oral route remains important for asthma medication especially in young children. The accessibility to the CPG among GPs is disappointing.
Study site: General practitioners attending a pharmaceutical industry sponsored asthma management workshop
Acute respiratory distress syndrome (ARDS) associated with severe respiratory syncytial virus infection is rare. We report a 5-month-old Indian girl who was admitted to our intensive care ward with severe respiratory failure who fulfilled the criteria for ARDS using both Murray's Lung Injury Score of > 2.5 and the American-European Consensus Conference definition for ARDS. She developed diffuse bilateral alveolar infiltrates, severe hypoxaemia (PaO2/FiO2 < 100) and required high PEEP (> 15 cm H2O) 24 hours after admission. RSV was isolated from her nasopharyngeal secretion. She also had clinical features suggestive of a primary immunodeficiency and had laboratory evidence of combined T and B cell defect. There was unsustained clinical improvement with a dose of surfactant administered at 36 hours of PICU stay, and she continued to deteriorate and succumbed after 19 days in the PICU.
An 18-month analysis of 52 percutaneously placed central venous catheters in 48 critically ill children was done. Success rate were 91.7% (33/36) and 93.8% (15/16) for femoral and non-femoral catheters respectively. Presence of hypotension (48.1%) and significant coagulopathy (26.9%) did not affect the success rate significantly. Minor bleeding and venous congestion was seen in 5.5% (2/36) of patients with femoral catheters. Infections were found in 2.7% (1/36) of femoral and 6.6% (1/15) of non-femoral catheters. The low incidence of complications and the relative ease of insertion makes the femoral route the preferred site for trainee medical officers in critically ill children when central access is indicated.
Accessibility of research done locally to clinicians remains limited unless it is in the published form. The publication rate of research presentations at the Annual Malaysian Paediatric Association, Perinatal Society of Malaysia and Academy of Medicine Malaysia in 1997 and 1998 was determined. One hundred and five (95.5%) of 110 research presentations were carried out in Malaysia. Thirty-seven (35.2%) presentations were published. University-affiliated institutions were more likely to publish their research presentations as compared to Ministry of Health hospitals (OR 3.1 95% CI 1.4-6.8, p < 0.01). There is a need to encourage publication of local research presentations. University-affiliated institutions performed better due to institution pressure for career advancement.
Severe bronchiolitis requiring mechanical ventilation is uncommon and is associated with the risk of barotrauma. We report our experience with 25 (42%) of 60 infants admitted to the Paediatric Intensive Care Unit (PICU) with severe bronchiolitis who required mechanical ventilation. Eighteen patients (72%) had severe hypoxaemia (PaO2/FiO2 < 250). The mean airway pressure required ranged from 5.8 to 15.6 cmH2O with median ventilation duration of 4.0 days (range 2.0-14.0 days). Oxygenation improved significantly within 12 hours of intubation. There was only one death. Mechanical ventilation is required in a subset of patients for severe bronchiolitis and is effective and generally well tolerated.
Swyer-James-MacLeod syndrome is a rare complication of respiratory tract infection occurring in early childhood. We report two children with chronic cough and recurrent wheezing who fulfilled the diagnostic criteria for this disorder: 1) Unilateral loss of lung volume with hyperlucency on chest x-ray. 2) Unilateral reduction in vascularity on CT scan of the chest. 3) Unilateral loss of perfusion on Technetium 99c lung scan.
To determine the impact of the haze on asthma symptomatology in children with chronic asthma on inhaled prophylaxis. The study was prospective and collected information on asthma symptoms from children attending the asthma clinic. A comparison of peak expiratory flow rate (PEFR) measurements before and during the haze was performed for children above 7 years. A total of 97 children were included into the study. Forty (41%) children complained of an increase in nocturnal cough (55%) followed by nasal symptoms (40%), daytime cough (40%), nocturnal wheeze (25%) and daytime wheeze (18%). About half of the children who had increased symptomatology during the haze had to limit outdoor activities. In the 43 children in whom PEFR studies were available, 29 (67%) of them had a fall in the PEFR. However, children with no increase in asthma symptomatology showed a similar fall in PEFR measurement when compared to children with increased asthma symptomatology. The haze appeared to be detrimental to the well being of some children with chronic asthma despite being on inhaled prophylaxis.
Study site: Asthma clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Cystic fibrosis (CF) is an autosomal recessive disease commonly found among the Caucasian population. The availability of sweat test and with increasing experience have made it possible to diagnose more cases of CF. Our first case of CF was diagnosed 16 years ago and to date we have managed sixteen cases of CF. Sixteen children were diagnosed with CF in our units at the Paediatric Institute and University Malaya Medical Centre (UMMC). They were referred with either one or all of the following symptoms: i) recurrent pneumonia, ii) bronchiectasis, iii) failure to thrive, iii) malabsorption or iv) history of meconium ileus obstruction during the neonatal period. When the clinical features suggested strongly of CF, sweat tests will be performed in duplicates and considered positive when the sweat chloride or sweat sodium was more than 60 mmol/l for both results. Seventy- two hours fecal fat excretion or stool for fat globule was performed to document malabsorption. From the year 1987 to 2003, 16 patients were confirmed to have cystic fibrosis in Malaysia by positive sweat tests. Thirteen patients were diagnosed in Paediatric Institute while the remaining three were diagnosed in UMMC. On follow-up two patients died due to severe bronchopneumonia at the age of two years old. Although once considered rare, CF should now be considered in any children with clinical presentations of recurrent chest infections, bronchiectasis, in the presence or absence of malabsoption stmptoms and in neonates with meconium ileus obstruction.
Eosinophilic inflammation in the airways is important in the pathogenesis of childhood asthma. Serum eosinophilic cationic protein (ECP), a marker of eosinophil activation was measured in 20 asthmatic children and 19 non-asthmatic controls. There was no difference in the socio-demography, passive smoke exposure, urinary cotinine levels and family history of asthma between the 2 groups. The median serum ECP in asthmatic children was 27.0 mcg/L (IQ1 8.8, IQ3 59.0); which was higher than in non-asthmatic controls [5.9 mcg/L (IQ1 3.0, IQ3 11.9), p=0.002]. An elevated serum ECP level can be helpful as supportive evidence in the diagnosis of bronchial asthma in Malaysia children.
Blood pressure examination was done manually in 1756 healthy school children aged 6-12 years. Korotkoff 1 represented the systolic blood pressure (SBP) and Korotkoff 5 was taken as the diastolic blood pressure (DBP). Blood pressure percentile charts were then drawn up based on age group and sex regardless of ethnicity. There was a significant correlation between both SBP and DBP to increasing height, weight and body mass index.
An open lung biopsy was performed in 12 children with diffuse parenchymal lung disease. A definitive histopathological diagnosis was obtained from all procedures but determined treatment options in only 10 children (83%). Three (25%) children were ventilated for respiratory failure prior to the procedure. Four (44%) of the other 9 children required ventilatory support after the procedure. Three (25%) children developed post-op pneumothorax that resolved fully with chest tube drainage. There were no deaths as a direct result of the procedure. Open lung biopsy is useful in providing a definitive diagnosis in children with diffuse parenchymal lung disease and determining treatment in the majority of cases. The procedure was well-tolerated with minimal complications.