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PANCURONIUM BELLY
870 NUMBER OF HOSPITAL CASES OF IHPS IN FUNEN COUNTY, INCIDENCE PER 1000 LIVE BIRTHS, AND PERCENTAGE OF SURGICALLY TREATED PATIENTS
I
I
1950-83
I
notes from the hospitals serving the region with the diagnoses of congenital pyloric stenosis and pylorospasm. Most cases were admitted to the regional paediatric unit at Odense University Hospital but some were admitted to eight local hospitals. Attitudes to the surgical treatment of IHPS varied, especially at the local
case
hospitals. Between 1950 and 1983 a total of 213 430 live births were and 662 children fulfilling the clinical criteria of IHPS were admitted to hospital. 650 were diagnosed as congenital pyloric stenosis and 12 as pylorospasm (8 operated on). The diagnosis of pylorospasm was not used after 1965. The incidence was 3 -1per 1000 live births with a male:female ratio of 4 - 2:1 - 0. We related the number of hospital cases with IHPS per 1000 live births to the percentage of operated cases. The attitude to surgery is reflected in the increasing frequency of pyloromyotomy, done in all cases of IHPS in 1980-83 (table). The incidence over the past twenty years, when probably all patients were admitted to hospital and nearly all treated surgically, fluctuated around 3 -5per 1000 live births. This figure is considered to represent a true incidence. A similar figure was found in the West Midlands region of England in 1980.2 During the early years ofour study the incidence was slightly lower. In those days medical treatment was usually the initial approach, and this was often started at home before hospital admission, as in the UK.9 The increasing number-of surgically treated patients with IHPS may reflect a change in referral pattern, with early admission even of mild cases. In addition, the disappearance of the diagnosis pylorospasm during the late 1960s may have resulted from an increased preference for surgery. Figures from the West Midlands reflect a similar trend.2 Thus, our data do not indicate an increased incidence of IHPS.
registered
Department of Paediatrics, Odense University Hospital, DK 5000 Odense C, Denmark
LARS RASMUSSEN LARS PETER HANSEN
1. Editorial. Incidence of infantile hypertrophic pyloric stenosis. Lancet 1984; i: 888-89. 2. Knox EG, Armstrong E, Haynes R. Changing incidence of infantile hypertrophic pyloric stenosis. Arch Dis Child 1983; 58: 582-85. 3. Walsworth-Bell JP. Infantile hypertrophic pyloric stenosis in Greater Manchester. J Epidemiol Commun Health 1983; 37: 149-52. 4. Kerr AM. Unprecedented rise in incidence of infantile hypertrophic pyloric stenosis. Br Med J 1980; 281: 714-15. 5. Webb AR, Lari J, Dodge JA. Infantile hypertrophic pyloric stenosis in South Glamorgan 1970-79. Arch Dis Child 1983; 58: 586-90. 6. Walpole IR. Some epidemiological aspects of pyloric stenosis in British Columbia. Am J Med Genet 1981; 10: 237-44. 7. Dodge JA. Infantile hypertrophic pyloric stenosis in Belfast 1957-69. Arch Dis Child 1975; 50: 171-78. 8. Wallgren A. Is the rate of hypertrophic pyloric stenosis declining? Acta Paediatr 1960; 49: 530-35. 9. Jacoby NM. Pyloric stenosis: Selective medical and surgical treatment. Lancet 1962; i: 119-21.
PANCURONIUM BELLY 2-7kg
’SlR,—A girl born at 37 weeks’ gestation had severe neonatal pneumonia necessitating assisted ventilation. On day 3 she was paralysed with pancuronium because of deteriorating blood gases. A radiograph taken a few hours before pancuronium was given revealed a normal abdominal gas distribution. A radiograph done 24 h later to confirm the position of the arterial catheter suggested an almost completely gas-free abdomen. This was worrying but a contrast study showed the small bowel to be normal.
Abdominal X-ray appearances in infant. 3 h before Lower: 24 h later.
Upper:
pancuronium.
The radiological changes observed were due to pancuronium. Although babies paralysed with this neuromuscular blocking agent cannot swallow, the relative absence of autonomic blocking activity allows peristalsis to continue. Dillard et al,I who noted this effect in the newborn, postulated that much of the gas in the intestines at the onset of drug therapy is evacuated and that without swallowing no further air is introduced. The appearances developed about 3 h after the first dose. With the increasing use of pancuronium in neonatal ventilation this radiological finding will become more common. Its benign nature needs to be more widely appreciated if unnecessary investigations are to be avoided.
Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff CF4 4XN
S. THOMAS C. SAINSBURY J. F. MURPHY
1. Dillard RG, Crowe JE, Sumner TE. Pancuronium and abnormal abdominal roentgenograms. Am J Dis Child 1980; 134: 821-23.
PYRIDOXAL-5’-PHOSPHATE CONCENTRATION AS MARKER FOR VITAMIN-B6-DEPENDENT SEIZURES IN THE NEWBORN
SIR,-The two known types of vitamin-B6-related seizures in the newborn ("B6 deficiency" and "B6 dependency") have in common neurological symptoms, electroencephalographic disturbances, and a prognosis of mental retardation if the baby is not treated. Seizures of the B6-deficient type can be corrected promptly by administration of pyridoxine while patients with B6-dependent seizures require continuous high doses of pyridoxine.2Animal experiments show that reduced pyridoxal-5’-phosphate (PLP) concentration in the brain, which can result in low glutamic acid decarboxylase activities, is responsible for the seizures. 3,4 Observations of an aberration in the affinity of PLP-dependent
I
I
1950-83
I
notes from the hospitals serving the region with the diagnoses of congenital pyloric stenosis and pylorospasm. Most cases were admitted to the regional paediatric unit at Odense University Hospital but some were admitted to eight local hospitals. Attitudes to the surgical treatment of IHPS varied, especially at the local
case
hospitals. Between 1950 and 1983 a total of 213 430 live births were and 662 children fulfilling the clinical criteria of IHPS were admitted to hospital. 650 were diagnosed as congenital pyloric stenosis and 12 as pylorospasm (8 operated on). The diagnosis of pylorospasm was not used after 1965. The incidence was 3 -1per 1000 live births with a male:female ratio of 4 - 2:1 - 0. We related the number of hospital cases with IHPS per 1000 live births to the percentage of operated cases. The attitude to surgery is reflected in the increasing frequency of pyloromyotomy, done in all cases of IHPS in 1980-83 (table). The incidence over the past twenty years, when probably all patients were admitted to hospital and nearly all treated surgically, fluctuated around 3 -5per 1000 live births. This figure is considered to represent a true incidence. A similar figure was found in the West Midlands region of England in 1980.2 During the early years ofour study the incidence was slightly lower. In those days medical treatment was usually the initial approach, and this was often started at home before hospital admission, as in the UK.9 The increasing number-of surgically treated patients with IHPS may reflect a change in referral pattern, with early admission even of mild cases. In addition, the disappearance of the diagnosis pylorospasm during the late 1960s may have resulted from an increased preference for surgery. Figures from the West Midlands reflect a similar trend.2 Thus, our data do not indicate an increased incidence of IHPS.
registered
Department of Paediatrics, Odense University Hospital, DK 5000 Odense C, Denmark
LARS RASMUSSEN LARS PETER HANSEN
1. Editorial. Incidence of infantile hypertrophic pyloric stenosis. Lancet 1984; i: 888-89. 2. Knox EG, Armstrong E, Haynes R. Changing incidence of infantile hypertrophic pyloric stenosis. Arch Dis Child 1983; 58: 582-85. 3. Walsworth-Bell JP. Infantile hypertrophic pyloric stenosis in Greater Manchester. J Epidemiol Commun Health 1983; 37: 149-52. 4. Kerr AM. Unprecedented rise in incidence of infantile hypertrophic pyloric stenosis. Br Med J 1980; 281: 714-15. 5. Webb AR, Lari J, Dodge JA. Infantile hypertrophic pyloric stenosis in South Glamorgan 1970-79. Arch Dis Child 1983; 58: 586-90. 6. Walpole IR. Some epidemiological aspects of pyloric stenosis in British Columbia. Am J Med Genet 1981; 10: 237-44. 7. Dodge JA. Infantile hypertrophic pyloric stenosis in Belfast 1957-69. Arch Dis Child 1975; 50: 171-78. 8. Wallgren A. Is the rate of hypertrophic pyloric stenosis declining? Acta Paediatr 1960; 49: 530-35. 9. Jacoby NM. Pyloric stenosis: Selective medical and surgical treatment. Lancet 1962; i: 119-21.
PANCURONIUM BELLY 2-7kg
’SlR,—A girl born at 37 weeks’ gestation had severe neonatal pneumonia necessitating assisted ventilation. On day 3 she was paralysed with pancuronium because of deteriorating blood gases. A radiograph taken a few hours before pancuronium was given revealed a normal abdominal gas distribution. A radiograph done 24 h later to confirm the position of the arterial catheter suggested an almost completely gas-free abdomen. This was worrying but a contrast study showed the small bowel to be normal.
Abdominal X-ray appearances in infant. 3 h before Lower: 24 h later.
Upper:
pancuronium.
The radiological changes observed were due to pancuronium. Although babies paralysed with this neuromuscular blocking agent cannot swallow, the relative absence of autonomic blocking activity allows peristalsis to continue. Dillard et al,I who noted this effect in the newborn, postulated that much of the gas in the intestines at the onset of drug therapy is evacuated and that without swallowing no further air is introduced. The appearances developed about 3 h after the first dose. With the increasing use of pancuronium in neonatal ventilation this radiological finding will become more common. Its benign nature needs to be more widely appreciated if unnecessary investigations are to be avoided.
Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff CF4 4XN
S. THOMAS C. SAINSBURY J. F. MURPHY
1. Dillard RG, Crowe JE, Sumner TE. Pancuronium and abnormal abdominal roentgenograms. Am J Dis Child 1980; 134: 821-23.
PYRIDOXAL-5’-PHOSPHATE CONCENTRATION AS MARKER FOR VITAMIN-B6-DEPENDENT SEIZURES IN THE NEWBORN
SIR,-The two known types of vitamin-B6-related seizures in the newborn ("B6 deficiency" and "B6 dependency") have in common neurological symptoms, electroencephalographic disturbances, and a prognosis of mental retardation if the baby is not treated. Seizures of the B6-deficient type can be corrected promptly by administration of pyridoxine while patients with B6-dependent seizures require continuous high doses of pyridoxine.2Animal experiments show that reduced pyridoxal-5’-phosphate (PLP) concentration in the brain, which can result in low glutamic acid decarboxylase activities, is responsible for the seizures. 3,4 Observations of an aberration in the affinity of PLP-dependent