Highlights from this issue
The final act of Philip Roth’s achingly poignant novel, Nemesis, based on the 1944 polio epidemic condenses the trajectories of each of the main protagonists’ lives as a result of events that sultry summer, Bucky Cantor, swapping life stories with a former pupil at his school. Though both had survived the illness, their subsequent lives were permanently altered, Cantor’s in particular unfolding (imploding) inexorably. Like all Roth’s works, this is a tragedy, in this instance played out with the backdrop of stifling heat of that summer. Each of the players was altered by those events and, though I’m not claiming any direct analogy between that and our current era is valid, I have found it hard not to keep returning to the book, unable to stop drawing parallels about those events and the ones we are now witnessing. SARS-Cov-2 To date, children have appeared less susceptible to the...
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Assessing pulsus paradoxus in severe exacerbations of asthma
Normal breathing will cause fluctuations of left ventricular stroke volume and blood pressure due to changes in intrathoracic pressure during the breathing cycle. Pulsus paradoxus is defined as a decrease in systolic blood pressure of more than 10 mm Hg during inspiration. A severe exacerbation of asthma, tension pneumothorax or cardiac tamponade can result in pulsus paradoxus. We are all taught to look for pulsus paradoxus as a measure of severity, but we rarely perform this part of the examination because it is not easy to measure accurately; it is subjective with poor inter-rater reliability and is simply not practical. Even with a high-fidelity electronic stethoscope and audio video recording, manually measured pulsus paradoxus does not correlate with severity of acute asthma in children1 because of poor inter-rater reliability. Pulse oximetry is now routinely used in acute medicine. Can this bedside tool help us assess the severity of...
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Anthropometrys promise and pitfalls in the diagnosis of undernutrition among infants
Anthropometry, the rigorous methods used to measure the physical dimensions of the human body, is widely used in medicine and public health to identify and label individuals with suboptimal nutritional status. In paediatrics, anthropometry’s tool set and international standards are widely used throughout resource-constrained areas of the world to identify and label children with malnutrition, which is often given further descriptive labels such as ‘acute’ and ‘chronic’, ‘severe’ and ‘moderate’. But what is often glossed over is that these various forms of malnutrition are only screened for by anthropometry—these measurements are not the disease in and of itself; they only imply risk, to guide clinical care, to generate advocacy. Anthropometric standards are but a mere proxy for nutritional status, not an end point, as they tell us surprisingly little about what really matters to clinicians and policymakers—optimal child development, which encompasses the physical, cognitive, social, linguistic and emotional development...
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Criteria for undernutrition screening in hospitalised infants under 6 months: a diagnostic accuracy study in a resource-poor setting
Purpose We aimed to describe the prevalence of undernutrition in hospitalised infants aged under 6 months and test the utility of simple index measures to detect undernutrition. Design Diagnostic accuracy study: weight, length, mid-upper arm circumference (MUAC), triceps and subscapular skinfolds were measured in infants aged 2 weeks to 6 months admitted to a Teaching Hospital in Enugu, Nigeria. Index criteria : low (<–2SD) weight-for-age Z-scores (WAZ), weight-for-length Z-scores (WLZ); MUAC <11 cm. Reference definition: weight faltering (conditional weight gain below fifth percentile for healthy Nigerian infants) or sum of skinfolds (SSF) <10 mm. Results Of 125 hospitalised infants, only 5% (6) were admitted specifically for undernutrition, but low SSF were found in 33% (41) and, 24% (25) with known birth weight had weight faltering, giving an undernutrition prevalence of 36%. Low WAZ was the most discriminating predictor of undernutrition (sensitivity 69%, positive predictive value 86%, likelihood ratio 5.5; area under receiver operator curves 0.90) followed by MUAC (73%, 73%, 4.9; 0.86), while WLZ performed least well (49%, 67%, 2.9; 0.84). Where both MUAC and WAZ were low, there was sensitivity 90%, positive predictive value 82% and likelihood ratio 8.7. Conclusions Infants aged under 6 months admitted to hospital in Nigeria had a high prevalence of undernutrition. In young, high-risk population, a low WAZ alone was a valuable screening criterion, while combining weight with MUAC gave even higher discrimination. Measurement of length to calculate WLZ was a less useful predictor in this population.
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