On the track to adulthood: the missions of the young human being, dodging the risks and gaining the tools

Medical staff are expected to cooperate with other professions and agencies in helping the young human in achieving the goal of becoming a healthy, well- functioning adult that expresses her/his maximal potential. Achieving this goal should be cost-effective. Cost includes not just the economic burden but also psychosocial determinants such as emotional disruption, stress, living at risk, malfunctioning, and dependency. Acknowledging the risks and the expected achievements at each age are useful in analyzing the failure of community health programs and in planning preventive modalities and needed remedies.

Should we consider alternatives to universal well-child behavioral-developmental screening?

The prevalence of developmental disabilities in the young age is of the order of 15%. When behavioral and social-emotional disorders, physical impairments, and sensory disorders are included, the need for special intervention increases to one out of four children. As the sensitivity and specificity of the best screening tests are in the range of 70-80%, their predictive value is controversial. The cost of conducting definitive tests and repeat screening for those who fail the screening tests is high. Children with severe disorders can be identified clinically without a screening test. The poor predictability, difficulty in implementation, and the high costs of developmental testing suggest that children, particularly those in high-risk communities, might be better served by implementing intervention programs for all, instead of trying to identify the outliers through screening.

Voluntary dehydration among elementary school children residing in a hot arid environment

BACKGROUND

Voluntary dehydration is a condition where humans do not drink appropriately in the presence of an adequate fluid supply. This may adversely affect their physical and intellectual performance. The present study aimed to describe the prevalence of voluntary dehydration among elementary school children of different ethnicities and countries of birth.

METHODS

Four hundred and twenty-nine elementary school children, aged 8-10 years, from four subpopulations (Israeli-born Jewish and Bedouin-Arab children, and immigrant children who recently arrived to Israel from Eastern Europe and from Ethiopia) were studied. The level of dehydration was determined by noontime urine osmolality, from samples taken over 1 week in mid-summer. Urine osmolality <500 mOsmol kg(-1) H(2)O was considered to be an appropriate level of hydration.

RESULTS

Mean urine osmolality was 862 +/- 211 mOsmol kg(-1) H(2)O. Osmolality above 800 mOsmol kg(-1) H(2)O was detected in 67.5% of the urine samples; among these, 25% were above 1000 mOsmol kg(-1) H(2)O. The most dehydrated group was that of Israeli-born Jewish children, whereas the Bedouin-Arab children were the least dehydrated.

CONCLUSIONS

A high proportion of children who reside in a hot and arid environment were found to be in a state of moderate to severe dehydration. Bedouin ethnicity was associated with better hydration, whereas Israeli-born Jews were most severely dehydrated. Educational intervention programmes promoting water intake should start in early childhood and continue throughout life.

Who accompanies a child to the office of the physician?

The arrival of a minor, unaccompanied by a parent, for a clinic visit, is challenging to the physician with legal, ethical, and practical implications. This prospective study, conducted in three community pediatric clinics, examined the relationship of accompanying persons to the minors visiting the clinics. About 90% of the 1,104 visits were with an accompanying parent, mostly a mother. Over 9% of minors, especially adolescents, arrived at the clinic unaccompanied by a parent. A regression analysis demonstrated that for each increase of one month in age there was a 2% increased chance for a visit without a parent (p < .0001). Adolescents were more likely to be among the 6% of minors, who visited the clinic alone, with a rate 0.066 per 1,000 visits in the more affluent community, compared to 0.019 and 0.016 in the middle and low income communities (p < .001). Physicians as well as parents should be made aware of the regulations regarding accompaniment of minors on a visit to the clinic. Policies regarding unaccompanied visits should take into account the risk posed by the absence of a parent versus the right of adolescents for independence and privacy.

Respiratory distress secondary to esophageal foreign body: a case report

The ingestion or aspiration of a foreign body is a common, but preventable occurrence in childhood. Primary healthcare personnel should alert parents to the risk of swallowing a foreign object, the signs and the need for immediate medical attention. It should be emphasized that protecting children from access to objects that can be swallowed or aspirated is the best preventive measure. A case of an eight year old child, who had swallowed a marble ball is presented and the symptoms and intervention discussed. Medical staff should be aware of the symptomatic variation in ingested foreign body presentation and the importance of rapid diagnosis and management.

The effect of voluntary dehydration on cognitive functions of elementary school children

AIMS

(1) To describe the occurrence of voluntary dehydration in two classes of elementary school students as expressed by their morning and noon-time urine osmolality; and (2) to determine the relationship between the children's scores on cognitive tests and their state of hydration.

METHODS

Group comparison among fifty-eight sixth-grade students (age range 10.1-12.4 y old) during mid-June at two schools in a desert town. Morning and noon-time urine samples were collected in school, and five cognitive tests were scored in the morning and at noon-time.

MAIN OUTCOME MEASURES

(1) morning and noon-time urine osmolality; (2) scores of five cognitive tests (hidden figures, auditory number span, making groups, verbal analogies, and number addition) that were applied in the morning and at noon-time.

RESULTS

Thirty-two students were dehydrated (urine osmolality above 800 mosm/kg H(2)O) in the morning. An individual's noon-time urine osmolality was highly related to morning osmolality (r=0.67, p=0.000). The morning cognitive scores were similar in the hydrated and dehydrated students (p=0.443). The adjusted mean scores of the noon-time tests, with the morning test scores as covariates, demonstrated an overall positive trend in four of the five tests in favor of the hydrated group (p=0.025). The effect was mainly due to the auditory number span test (p=0.024).

CONCLUSION

Voluntary dehydration is a common phenomenon in school-aged children that adversely affects cognitive functions.

Child health care centres: an academic model for comprehensive child health care in the community

The challenge of the discipline of paediatrics in the 21st century is to promote health and development of children in a way that will enable them to maximize their biological and social potential. The community child health centre (CHC) in Israel is a model of community health care service built to provide comprehensive health care to children and adolescents, as well as an academic setting for under- and postgraduate paediatric training. Today there are 34 CHCs in Israel, serving a population of 220 000 children from birth to 18 years of age. The CHC combines the advantages of group practice with those of an academic medical centre and enables flexibility and mutual learning. Further expansion and development are required to realize the CHC's mission of a true comprehensive academic centre for paediatric community health.

Adolescents, accidents and the need to extend our scope of research

Accidents in adolescence result in mortality and disability that in many cases could have been prevented. The issue is a multi-factorial complex phenomenon, where new research ideas are needed to improve outcome. This short communication presents several research ideas that could provide new relevant answers.

[Primary care approach to children with special needs]

Children with special needs have medical, educational, social and emotional needs which are significantly greater than the average needs of their healthy peers. They and their families have to struggle with the physical, economical and emotional burden imposed on them by their special needs. The role of primary physicians is to lead a team that is capable of diagnosing, treating and coordinating treatment and support for the child and the family. Case management and anticipatory guidance are the cornerstone of the art of dealing with children who have special needs. Primary community physicians are expected to conduct a survey in order to identify the children with special needs in the community and to prepare an intervention plan for each of them. Early detection and proper management of the problems are expected to help these children to maximize their potential and integration in society.

Deletion of 8.5 Mb, including the FMR1 gene, in a male with the fragile X syndrome phenotype and overgrowth

A four-year-old boy with severe psychomotor retardation, facial appearance consistent with the fragile X syndrome, hypotonia, and overgrowth was found to have a deletion including the fragile X gene (FMR1). The breakpoints of the deletion were established between CDR1 and sWXD2905 (approximately 200 kb apart) at Xq27.1 (centromeric) and between DXS8318 (612-1078L) and DXS7847 (576-291L) (approximately 250 kb apart) at Xq28, about 500 kb telomeric to the FMR1 gene. The total length of the deletion is approximately 8.5 Mb. The propositus's mother, who was found to be a carrier of the deletion, showed very mild mental impairment. Except for mental retardation, which is a common finding in all cases reported with similar deletions of chromosome Xq, this patient had generalized overgrowth, exceeding the 97th centile for height and weight. Obesity and increased growth parameters have been reported in other patients with deletions either overlapping or within a distance of 0.5 Mb from the deletion in the present patient. Thus, it is suggested that a deletion of the 8-Mb fragment centromeric to the FMR1 gene might have an effect on growth.

Double-blind study comparing erythromycin and mupirocin for treatment of impetigo in children: implications of a high prevalence of erythromycin-resistant Staphylococcus aureus strains

Staphylococcus aureus has been consistently isolated from a high proportion of impetiginous lesions, and in several recent studies, it was present in the majority of the cases. Since recently a large proportion of S. aureus strains in our community showed erythromycin resistance, we undertook a prospective double-blind controlled study comparing topical mupirocin with oral erythromycin to determine (i) the prevalence of erythromycin-resistant S. aureus strains in impetigo and (ii) whether an increased rate of failure of erythromycin treatment was associated with such resistance. A total of 102 patients 3 to 185 months old (median = 49 months) were enrolled. Culture was positive for 97 of 102 (95%) patients, and S. aureus was present in 93% of the patients for whom cultures were positive. S. aureus was the single pathogen in 64% of these patients. Erythromycin-resistant S. aureus strains were present in 27 of 91 (28%) patients for whom cultures were positive. In all cases but one, S. aureus was resistant to penicillin, and in all cases it was sensitive to mupirocin. A marked difference was observed in favor of mupirocin in the clinical courses of the disease. However, only patients with erythromycin-resistant S. aureus strains had unfavorable courses compared with those treated with mupirocin (failure rate, 47 versus 2%, respectively). Patients with erythromycin-susceptible S. aureus strains who received erythromycin had a failure rate of 8%. In four patients, S. aureus strains initially susceptible to erythromycin became resistant during treatment. We conclude that erythromycin-resistant S. aureus strains are commonly isolated from impetigo in our region.(ABSTRACT TRUNCATED AT 250 WORDS)

Cryptosporidium in Bedouin and Jewish infants and children in southern Israel

We conducted a 1-year prospective study in two clinics and a hospital in the Negev region of southern Israel to determine the epidemiological and clinical patterns of Cryptosporidium diarrhea among Jewish and Bedouin infants and children living in the same geographical area. A total of 612 episodes were studied: 398 in Bedouins and 214 in Jews, of which 449 occurred in patients with diarrhea and 164 in controls. Cryptosporidium was detected in 13 of 382 patients (3.4%) with diarrhea and in 1 of 138 controls (0.7%) (P = 0.078). In 5 of 13 Cryptosporidium-positive patients (38%) another pathogen was detected. No significant difference in Cryptosporidium detection rates was observed between Jews and Bedouins or between hospitalized or nonhospitalized patients. The frequency of Cryptosporidium detection did not differ significantly when three age-groups were compared (less than 6 months old, 7-12 and 13-36 months old). The rate of Cryptosporidium detection was similar among malnourished and well-nourished patients, as determined by weight-for-height percentiles. Cryptosporidium was detected more frequently during the summer months (8.3%) than during the rest of the year (1.2%) (P less than 0.001). Patients with Cryptosporidium diarrhea did not differ clinically from patients with other causes of diarrhea. However, they were characterized by the absence of fecal leukocytes. Cryptosporidium is not a rare cause of diarrhea in southern Israel. It is more prevalent during the hot and dry season and can be detected in a relatively high prevalence among very young infants. Its clinical features are indistinguishable from those of patients with non-cryptosporidial diarrhea.

Rotavirus diarrhea in Jewish and Bedouin children in the Negev region of Israel: epidemiology, clinical aspects and possible role of malnutrition in severity of illness

We conducted a 1-year prospective study in the Negev region of southern Israel to determine the epidemiologic and clinical patterns of rotavirus diarrhea. A total of 605 patients were studied, 392 Bedouins and 213 Jews, 441 of whom had diarrhea (449 episodes) and 164 did not. Rotavirus was the most common organism detected in children with diarrhea (63 of 444; 14%) but was rarely found in controls (3 of 163; 2%) (P less than 0.001). In 22% (12 of 54) of the rotavirus-positive patients, at least one other organism was also detected. The rate of rotavirus detection decreased as age increased, from 18% in the first year to 8% in the third year of life. Hospitalization with rotavirus diarrhea occurred more frequently in the summer. However, during winter, when diarrhea was less prevalent in the community, the proportion of cases associated with rotavirus was higher. Compared with controls, malnourished children were more likely to be hospitalized. However, rotavirus was detected in similar proportions among well-nourished and malnourished cases with diarrhea. The most prevalent rotavirus serotype was type 1 (in 69%), followed by types 4 and 2 (18 and 13%, respectively). We estimated that during the study period, approximately 2% of all Bedouin infants vs. only 0.2% of Jewish infants were hospitalized with rotavirus disease in their first year of life. Clinical signs and symptoms and stool appearance were not useful in predicting rotavirus detection. Malnutrition seems to be an important indicator of disease severity, which may explain why the toll of rotavirus-associated morbidity and mortality is particularly high among children in developing countries.

Comparison of amoxicillin and clavulanic acid (augmentin) for the treatment of nonbullous impetigo

We undertook a prospective double-blind controlled study to compare the efficacy of a drug that usually has no antistaphylococcal activity (amoxicillin trihydrate) with the efficacy of the same drug with an addition of a beta-lactamase inhibitor (amoxicillin plus clavulanic acid [Augmentin]) in the treatment of nonbullous impetigo. Fifty-one culture-positive patients, aged 6 months to 9 years, were included, 26 in the amoxicillin group and 25 in the Augmentin group. The study groups were clinically and bacteriologically comparable at the start of the study. Staphylococcus aureus was isolated from all patients and beta-hemolytic streptococcus from 14 (29%). All staphylococci were sensitive to Augmentin but resistant to amoxicillin. Forty-nine patients completed the study. The clinical response was significantly better among the Augmentin recipients (marked improvement in 71% and 95% of patients after 2 and 5 days, respectively; no new lesions during the treatment course) than among the amoxicillin recipients (marked improvement in 44% and 68% of patients after 2 and 5 days, respectively; new lesions appeared in 20% of patients). Recurrence within 3 weeks occurred in 12 (26%) of 49 patients, and no difference was observed between the two groups. We conclude that S aureus is common in nonbullous impetigo, and that at least in some cases it plays an important role in the course of the disease that can be altered by specific therapy.