- Email: [email protected]
FLUIDS FOR DIARRHŒA IN YOUNG CHILDREN
545 of the premature’infant could be damaging. In particular we are concerned that certain forms of neonatal therapy may an infant to dangerous levels of noise. Our measurements have shown that continuous positive airways pressure
expose
by a headbox, simple headboxes for oxygen administration, and certain humidifiers inside incubators may all give rise on occasions to sound-levels of approximately 70 dB up to frequencies of 5000 Hz. These forms of treatment may be maintained continuously for several days and could therefore be a potential hazard. We feel that simple alterations in design of such equipment should eliminate this potential danger. The three types of incubators that we have studied have produced substantial noise-levels only in the frequencies below 500-1000 Hz,.and in fact the incubator walls attenuate the more dangerous high-frequency sounds produced outside by about 20 dB at 5000 Hz-thus producing a sound environment which resembles to some extent that in utero.4 S. E. BARNES J. D. BAUM P. ROLFE
Department of Pædiatrics, John Radcliffe Hospital, Oxford 0X3 9DU
FLUIDS FOR DIARRH
Department of Child Ninewells Hospital, Dundee DD2 1UB
NECROTISING ENTEROCOLITIS
SIR,-Your editorial
on
London,
’
cases.
Severe symptoms occurred in two apparently normal fullbabies and one well premature baby (birth weight 2070 and a third normal full-term baby had moderately severe g), symptoms. Of thethree babies with severe symptoms, one premature and one full term needed major surgery; the other full-term baby who had extensive intramural gas and shock was referred for surgery but this was not needed. The baby was at first thought to have a normal heart, both here and at the hospital to which she was referred, but she was later shown to have inoperable congenital heart-disease. The decision to close was made because of serious illnesses in a period of three weeks in these four babies, who all appeared at the time to be free of the predisposing conditions listed in your editorial. Milder symptoms occurred in another five-three premature and two normal full-term babies. Only one baby (mildly affected) had umbilical-vessel catheterisation and none had exchange transfusion. Other units in London have remained open although affected by similar clusters of babies with N.E.C., but it appears that in the babies in these units the predisposing conditions were present, or the disease was not so severe as to indicate surgery. None of our babies who were breast fed by their own mothers were affected. Clostridia spp. (not welchit) were isolated from blood cultures in three severely affected babies, but this could be because of secondary invasion. Three babies did not have nasogastric tubes or umbilical-vessel catheters. No further babies have been affected in a 10-day period, and on the proposed date for reopening we expect there to have been term
17-day period.
The isolation of clostridia is interesting in view of earlier observations,’ while our cluster shows clearly that some cases can occur in full term healthy babies who have had no apparent contact with plasticisers.2 The
findings will be reported
in
more
detail later.
D. M. FLYNN F. M. HOWARD
Royal Free Hospital, London NW3 2QG
J. BRADLEY P. NOONE
4. Henshall, W. R. Am. J. Obstet. Gynec. 1972, 112, 576. 1 Pedersen,P. V., Hansen, F. H., Halveg, A. B., Christiansen, T., Høgh,P. Lancet, 1976, ii, 715. 2 Rogers, A. F., Dunn, P. M. ibid. 1969, ii, 1246.
E. D.,
Health,
TONY WATERSTON
DRUGS FOR TYPHOID FEVER
necrotising enterocolitis (N.E.C.) (Feb. 26, p. 459) refers to the cluster of cases at the Royal Free as a major outbreak. Whilst we agree that Hospital, this is a major-in the sense of important-outbreak, it is, perhaps, important more in terms of the type of baby who was severely affected rather than because of the number of severe
no new cases over a
IN YOUNG CBNDREN
is famed for its medicinal properSIR,-Derbyshire alone or as a 5% glucose solueither but elsewhere ties, water, tion, is unphysiological as a replacement solution in diarrhoea.1 Dr Chambers proposes (Feb. 19, p. 431) that the haphazard administration of sugar and salt water is undesirable, but the same might equally well be said of antibiotics and many other remedies for many diseases: the argument should rather be for the correct use of an electrolyte solution, than for its disuse. Two excellent alternatives designed for the home treatment of diarrhoea (and this is where most cases should be treated) are ’Electrosol’ tablets and sodium chloride and dextrose compound powder B.P.C.; 22g of the powder dissolved in 500 ml of water gives a solution containing 35mmol sodium, 37mmol chloride, 20 mmol potassium and 18 mmol bicarbonate per litre. water
Justesen,
SIR,-We would like to comment on the paper by Snyder
et
al. on the comparative efficacy of chloramphenicol, ampicillin, and co-trimoxazole in the treatment of typhoid fever: (1.) The criteria for entry to the study exclude seriously ill
patients. (2.) Snyder et al. refer to ill patients with "culture-positive" typhoid and paratyphoid fever, but do not state whether cultures were from blood or faeces. A positive blood culture is usually accepted as essential for entry into a therapeutic trial in typhoid fever. Most authorities would similarly be unwilling to accept changes in antibody titres as diagnostic for the purpose of a clinical trial. (3.) No comment is made about the two patients who were withdrawn from groups 1 and 3 because of intestinal perfor-
ation : Surely this must be considered to be failure of therapy and not a reason for withdrawal once the patient has entered the trial. (4.) Four patients in the co-trimoxazole group required change of treatment to chloramphenical. The reasons given for this are persistence of pyrexia and also symptoms. It is possible that drug fever was responsible for the pyrexia since blood cultures were negative from day 2 onwards. In our experience, resolution of pyrexia is a poor guide to the eventual outcome of typhoid fever. We cannot, therefore, accept the significance of the differences between the drug regimens claimed by Snyder et al. on the basis of this point alone. Royal Naval Hospital, Haslar
P. D. CLARKE
East Birmingham Hospital, Birmingham B9 5ST
A. M. GEDDES
** This letter has been shown to Dr Snyder and his colleagues, whose
reply follows.-ED. L.
SiR,—Thank you for the opportunity to reply to Surgeon Lieut.-Commander Clarke and Dr Geddes’ comments. (1.) The patients excluded were those who could not be placed randomly on study drugs or whose response to therapy would have been difficult to evaluate. More with mild than with severe disease were excluded. The most common reasons for exclusion were spontaneous abatement of fever, history of chloramphenicol therapy before admission, and lack of clinical evidence of typhoid fever; three-quarters of the exclusions were for these reasons. 6 patients were excluded because of the severity of their disease-2 because they needed steroids to 1.
2.
Hirschhorn, N. Br. med. J. 1976, i, 1079. Snyder, M. J., and others Lancet, 1976, ii, 1b55.
,
expose
by a headbox, simple headboxes for oxygen administration, and certain humidifiers inside incubators may all give rise on occasions to sound-levels of approximately 70 dB up to frequencies of 5000 Hz. These forms of treatment may be maintained continuously for several days and could therefore be a potential hazard. We feel that simple alterations in design of such equipment should eliminate this potential danger. The three types of incubators that we have studied have produced substantial noise-levels only in the frequencies below 500-1000 Hz,.and in fact the incubator walls attenuate the more dangerous high-frequency sounds produced outside by about 20 dB at 5000 Hz-thus producing a sound environment which resembles to some extent that in utero.4 S. E. BARNES J. D. BAUM P. ROLFE
Department of Pædiatrics, John Radcliffe Hospital, Oxford 0X3 9DU
FLUIDS FOR DIARRH
Department of Child Ninewells Hospital, Dundee DD2 1UB
NECROTISING ENTEROCOLITIS
SIR,-Your editorial
on
London,
’
cases.
Severe symptoms occurred in two apparently normal fullbabies and one well premature baby (birth weight 2070 and a third normal full-term baby had moderately severe g), symptoms. Of thethree babies with severe symptoms, one premature and one full term needed major surgery; the other full-term baby who had extensive intramural gas and shock was referred for surgery but this was not needed. The baby was at first thought to have a normal heart, both here and at the hospital to which she was referred, but she was later shown to have inoperable congenital heart-disease. The decision to close was made because of serious illnesses in a period of three weeks in these four babies, who all appeared at the time to be free of the predisposing conditions listed in your editorial. Milder symptoms occurred in another five-three premature and two normal full-term babies. Only one baby (mildly affected) had umbilical-vessel catheterisation and none had exchange transfusion. Other units in London have remained open although affected by similar clusters of babies with N.E.C., but it appears that in the babies in these units the predisposing conditions were present, or the disease was not so severe as to indicate surgery. None of our babies who were breast fed by their own mothers were affected. Clostridia spp. (not welchit) were isolated from blood cultures in three severely affected babies, but this could be because of secondary invasion. Three babies did not have nasogastric tubes or umbilical-vessel catheters. No further babies have been affected in a 10-day period, and on the proposed date for reopening we expect there to have been term
17-day period.
The isolation of clostridia is interesting in view of earlier observations,’ while our cluster shows clearly that some cases can occur in full term healthy babies who have had no apparent contact with plasticisers.2 The
findings will be reported
in
more
detail later.
D. M. FLYNN F. M. HOWARD
Royal Free Hospital, London NW3 2QG
J. BRADLEY P. NOONE
4. Henshall, W. R. Am. J. Obstet. Gynec. 1972, 112, 576. 1 Pedersen,P. V., Hansen, F. H., Halveg, A. B., Christiansen, T., Høgh,P. Lancet, 1976, ii, 715. 2 Rogers, A. F., Dunn, P. M. ibid. 1969, ii, 1246.
E. D.,
Health,
TONY WATERSTON
DRUGS FOR TYPHOID FEVER
necrotising enterocolitis (N.E.C.) (Feb. 26, p. 459) refers to the cluster of cases at the Royal Free as a major outbreak. Whilst we agree that Hospital, this is a major-in the sense of important-outbreak, it is, perhaps, important more in terms of the type of baby who was severely affected rather than because of the number of severe
no new cases over a
IN YOUNG CBNDREN
is famed for its medicinal properSIR,-Derbyshire alone or as a 5% glucose solueither but elsewhere ties, water, tion, is unphysiological as a replacement solution in diarrhoea.1 Dr Chambers proposes (Feb. 19, p. 431) that the haphazard administration of sugar and salt water is undesirable, but the same might equally well be said of antibiotics and many other remedies for many diseases: the argument should rather be for the correct use of an electrolyte solution, than for its disuse. Two excellent alternatives designed for the home treatment of diarrhoea (and this is where most cases should be treated) are ’Electrosol’ tablets and sodium chloride and dextrose compound powder B.P.C.; 22g of the powder dissolved in 500 ml of water gives a solution containing 35mmol sodium, 37mmol chloride, 20 mmol potassium and 18 mmol bicarbonate per litre. water
Justesen,
SIR,-We would like to comment on the paper by Snyder
et
al. on the comparative efficacy of chloramphenicol, ampicillin, and co-trimoxazole in the treatment of typhoid fever: (1.) The criteria for entry to the study exclude seriously ill
patients. (2.) Snyder et al. refer to ill patients with "culture-positive" typhoid and paratyphoid fever, but do not state whether cultures were from blood or faeces. A positive blood culture is usually accepted as essential for entry into a therapeutic trial in typhoid fever. Most authorities would similarly be unwilling to accept changes in antibody titres as diagnostic for the purpose of a clinical trial. (3.) No comment is made about the two patients who were withdrawn from groups 1 and 3 because of intestinal perfor-
ation : Surely this must be considered to be failure of therapy and not a reason for withdrawal once the patient has entered the trial. (4.) Four patients in the co-trimoxazole group required change of treatment to chloramphenical. The reasons given for this are persistence of pyrexia and also symptoms. It is possible that drug fever was responsible for the pyrexia since blood cultures were negative from day 2 onwards. In our experience, resolution of pyrexia is a poor guide to the eventual outcome of typhoid fever. We cannot, therefore, accept the significance of the differences between the drug regimens claimed by Snyder et al. on the basis of this point alone. Royal Naval Hospital, Haslar
P. D. CLARKE
East Birmingham Hospital, Birmingham B9 5ST
A. M. GEDDES
** This letter has been shown to Dr Snyder and his colleagues, whose
reply follows.-ED. L.
SiR,—Thank you for the opportunity to reply to Surgeon Lieut.-Commander Clarke and Dr Geddes’ comments. (1.) The patients excluded were those who could not be placed randomly on study drugs or whose response to therapy would have been difficult to evaluate. More with mild than with severe disease were excluded. The most common reasons for exclusion were spontaneous abatement of fever, history of chloramphenicol therapy before admission, and lack of clinical evidence of typhoid fever; three-quarters of the exclusions were for these reasons. 6 patients were excluded because of the severity of their disease-2 because they needed steroids to 1.
2.
Hirschhorn, N. Br. med. J. 1976, i, 1079. Snyder, M. J., and others Lancet, 1976, ii, 1b55.
,