Terminal symptoms in children dying suddenly and unexpectedly at home. Preliminary report of the DHSS multicentre study of postneonatal mortality.

Terminal symptoms in 145 children who died suddenly and unexpectedly at home were investigated and compared with symptoms in 154 control children. Eighty-five (59%) of the children who died had had terminal symptoms, which in 69 cases (48%) appeared to have been major. Non-specific symptoms were especially common among the children who died. Symptoms were often present for several days before death. Only 12 of the 69 children who died with major symptoms had been seen by a doctor within 24 hours before death. We conclude that many deaths in young children might be prevented if doctors and parents were more aware of the importance of non-specific symptoms as markers of life-threatening illness.     

Investigation into use of drugs preceding death from asthma.

Copies of death certificates were provided by the Registrar General for all deaths attributed to asthma in persons aged 5 to 34 years which were registered in England and Wales in the last quarter of 1966 and the first quarter of 1967. Information was obtained from the relevant general practitioners about 177 of the 184 subjects, and necropsy data were obtained for 113 of the 124 cases in which a post-mortem examination was known to have been made. Ninety-eight per cent. of the subjects for whom evidence was obtained were known to have been suffering from asthma, and signs of severe asthma (overdistended lungs and small bronchi plugged with mucus) were found in 91% of necropsies (57% of all deaths). Evidence that death might have been due to any other pathological condition was rare. Death was sudden and unexpected in 81% of the subjects (137 out of 171), and 59% of all deaths were referred to coroners. In 39% of cases (67 out of 171) the practitioner had not regarded the patient as suffering from severe asthma in his terminal episode. Corticosteroids and sympathomimetic preparations were the only drugs to have been used by a large proportion of patients. Two-thirds of the patients had received corticosteroids before the terminal episode, but detailed information about their use provided no suggestion that excess use could have been responsible for any large proportion of the deaths. Eighty-four per cent. of the patients were known to have used pressurized aerosol bronchodilators, and several instances of their use in excess were described. Routine inquiries about their use in the hours immediately preceding death were not made, and further evidence is required before their effect can be assessed adequately.     

Unrecognised HIV related deaths.

OBJECTIVES--To establish whether follow up of deaths from selected HIV related causes could increase the number of cases of HIV infection reported to the Public Health Laboratory Service Communicable Disease Surveillance Centre (CDSC), and to estimate the proportion of deaths among HIV positive men that occurred in men who were not known to be HIV positive at the time of death by the person who signed the death certificate. DESIGN--Follow up of draft death entries received by the Office of Population Censuses and Surveys on which one of 11 medical or external causes likely to be related to HIV was stated; letters were sent to the people who signed the certificates. The respondents were invited to report men known to have been HIV positive who were not already on the CDSC register. SETTING--England and Wales. SUBJECTS--Men aged 15-54 who died in February 1989 to July 1989 with one of the 11 selected HIV related diseases as cause of death on their death certificates. MAIN OUTCOME MEASURES--Number of men reported to the CDSC as a result of this follow up; estimate of excess deaths due to an HIV related cause; estimate of the proportion of excess deaths that occurred in those who were not known to be HIV positive at the time of death. RESULTS--Replies were received for 473 deaths (86%). Forty were for men known to have been HIV positive, 31 of whom had been reported to CDSC by the time they died; six were subsequently reported. The respondent did not know that the decreased was HIV positive for 20 (35%) of the 57 excess deaths in men for whom one of the medical causes was stated and 41 (93%) of the 44 excess deaths in men for whom one of the external causes was stated. CONCLUSION--Follow up of death registrations is not an efficient way of increasing the number of cases of HIV infection reported to CDSC. Between 35% and 60% of HIV positive people for whom certain causes are stated may be dying without HIV positivity having been diagnosed. There may be implications for those caring for people with these conditions and those who carry out postmortem examinations.     

Inflicted burns and scalds in children.

Ten children who had been burnt and six who had been scalded by parents or those caring for them were seen over three years. In no case did the thermal injury affect more than 5% of the body surface and there were no deaths. In seven the perineum or buttocks were in the burnt area. In 12 children there was evidence of other inflicted injury including six recent fractures. Staff caring for burnt children should be aware of this type of inflicted injury. X-ray skeletal surveys should be carried out in doubtful cases and a case conference initiated with the appropriate social work services to consider supervising the family after the child''s discharge or taking legal care proceedings.     

Indications for and results following exploration of the common bile duct for stones

Among 100 consecutive patients who had removal or drainage of the gallbladder and exploration of the common bile duct for stones, there were no serious, immediate or late complications and there were no operative deaths. Ninety-six of the 100 patients had stones in the gallbladder, in the common duct, or in both, and 52 of these patients had one or more stones in the common duct. Ten patients died subsequently of unrelated causes. Six patients were lost to followup. Of the 84 patients whose present condition is known, 75 or 89 per cent have had a completely satisfactory result. Six more patients have minor residual symptoms, and for them the result has been classified as good. In three patients, the results were unsatisfactory. Cholangiograms taken before the removal of the T-tube showed residual stones in two patients. In each instance, the stone or stones have been subsequently passed and both patients are in excellent condition.     

INDICATIONS FOR AND RESULTS FOLLOWING EXPLORATION OF THE COMMON BILE DUCT FOR STONES

Among 100 consecutive patients who had removal or drainage of the gallbladder and exploration of the common bile duct for stones, there were no serious, immediate or late complications and there were no operative deaths. Ninety-six of the 100 patients had stones in the gallbladder, in the common duct, or in both, and 52 of these patients had one or more stones in the common duct.Ten patients died subsequently of unrelated causes. Six patients were lost to followup. Of the 84 patients whose present condition is known, 75 or 89 per cent have had a completely satisfactory result. Six more patients have minor residual symptoms, and for them the result has been classified as good. In three patients, the results were unsatisfactory. Cholangiograms taken before the removal of the T-tube showed residual stones in two patients. In each instance, the stone or stones have been subsequently passed and both patients are in excellent condition.     

Birth interval, mortality and growth of children in a rural area in Kenya

The impact of the length of birth intervals on mortality and growth of children from the perinatal period to 2 years in the Northern Division of Machakos District, Eastern Province, Kenya, were analyzed. There are 2 types of birth intervals: 1) the prospective birth interval--between the birth concerned (the 1st birth of the interval pair) and the subsequent birth; and 2) the retrospective birth interval--between the birth considered (the 2nd of the interval pair) and the preceeding birth. This study includes 3019 women who had at least 1 live birth between April, 1974 and April, 1981. They gave birth to 6778 children (including stillbirths). Births occurring in 1974 are excluded in the analysis because of considerable underregistration. 102 stillbirths and 213 deaths in the 1st 2 years are analyzed. They have been grouped into deaths during the perimatal period; the 1st year after the 1st week of life (infant period); and the 2nd year of life. The most convient method of analysis of the relation between retrospective birth interval and mortality is multivariate analysis, as the intermedicate biological and behavioral factors through which birth intervals can affect health are simultaneously influenced by other variables like maternal age and birth order; the log linear model is applied here. The probability of dying is the dependent variable. The impact of short prospective intervals are closely associated. Only infant and child deaths occurring after the conception of the next child are included. The size of cohorts in which these deaths occur can be calculated with a life table approach. The mortality probability between 5 and 12 months for children with short prospective intervals is .034. This is higher than the corresponding rate for all children in the area (P0.05). It is shown that children with short retrospective or prospective birth intervals do not run a greater risk of mortality or growth retardation than children with longer intervals, neither during the perinatal period nor during the 1st 2 years of life.     

Head Injuries in Children

Two-hundred children with head injury admitted consecutively to paediatric wards in the two main hospitals in Newcastle upon Tyne have been studied. Eight children required neurosurgical operation. There were two deaths. Details of the cause and consequences of the accidents have been analysed and an attempt has been made to identify psychological or physical factors that may predispose to injury. There was a slightly higher proportion of children with what are regarded as adverse personality factors among the head injuries than in a control group and there were more left-handed children than would be expected in the general population. The results suggest that the modern “high-rise” bicycle may carry a special risk of head injury.     

Deaths in children with a diagnosis of acute appendicitis in England and Wales 1980-4.

Thirty five children died of acute appendicitis in England and Wales in 1980-4 compared with 204 in 1963-7. Thirteen of the 35 deaths in 1980-4 took place at home or on the day of admission to hospital before operation and a further 18 on the day of operation or the first day after it. Thirty one of the children had peritonitis. A third of the deaths were in children aged 0-4 years, and the hospital fatality rate in this age group was one death in 320 cases compared with one death in 4760 cases in children aged 5-14 years. The fall in the number of deaths between the 1960s and the 1980s was due to improvements in medical care, a reduction in the incidence of appendicitis, and changes in the age structure of the child population. Difficulty and delay in diagnosis and inadequate intravenous therapy are now the main factors contributing to death.     

TRANSURETHRAL PROSTATECTOMIES—A Review of 560 Cases

Of 560 prostatectomies in an 11-year period on patients with benign or malignant disease of the prostate gland, almost 98 per cent were done transurethrally.Although many of the patients were considered to be in poor condition preoperatively, results achieved by the transurethral operation were excellent or good in 91 per cent of those who had benign disease of the prostate and in 84 per cent of those with malignant invasion. The rate of deaths attributable to the operation was 3.1 per cent in the group of patients with benign disease, 5.3 per cent in patients who had cancer.Complications, such as urinary incontinence, persistent pyuria, epididymitis, strictures of the urethra and of the meatus, and contracture of the neck of the bladder, arose in a surprising number of cases.     

Family and community factors associated with infant deaths that might be preventable.

A detailed psychosocial study was made of all deaths in babies aged between 8 days and 2 years in Sheffield over two years. An identical assessment was made of a group of control children matched for age. Sixty five children who died and 102 controls were studied. Each index and control child was assessed for 13 potentially adverse social and family factors. The deaths were classified into causal groups. The families of children who died during the course of potentially treatable diseases (those with infections and those who presented as cot deaths but had treatable infection) had a significantly greater number of adverse social factors than the families of children who died from conditions with a poor prognosis, children who presented as completely unexplained cot deaths, and controls. The adverse factors studied, although often related to economic state, appeared to be independent of social class.     

The influence of the use of improved sanitation facilities and improved drinking-water sources on the diarrhea-associated deaths in children under 5 years

Diarrhea is one of the main causes of children's death. Due to the importance of health in children under 5 years, this study has been conducted to determine the influence of the use of improved sanitation facilities (UISF) and the use of improved drinking-water sources (UIDWS) on the diarrhea-associated deaths per 1000 live births in this age group. An ecologic study was conducted in 75 countries, and the data on UIDWS and UISF information have been collected by World Health Organization (WHO) under a program named “Global Analysis and Assessment of Sanitation and Drinking-Water” (GLAAS). To determine the correlation between UIDWS and UISF with the diarrhea-associated deaths in children, Pearson correlation was applied. Besides, a linear regression analysis was used to investigate the relationship between UIDWS and UISF with the diarrhea-associated deaths in children. According to the findings, there was a significant statistical relationship between UIDWS and UISF with the diarrhea-associated deaths in children (p < 0.001). The diarrhea-associated deaths in children under 5 years are influenced by factors such as UIDWS and UISF, and this rate can be reduced making UISF and UIDWS available for people and especially people of rural areas.     

How many deaths can be prevented by newborn screening for congenital adrenal hyperplasia?

BACKGROUND/AIMS: Congenital adrenal hyperplasia (CAH) is increasingly being included in newborn screening programs. Screening can prevent neonatal mortality in children with salt-wasting CAH, but the number of deaths prevented is not known. Cost-effectiveness analyses of screening require estimates of the probability of mortality in CAH. METHODS: We reviewed the literature to identify cohort studies of children with CAH ascertained clinically in the absence of screening. We abstracted the numbers of infant deaths attributable to CAH. We also addressed sex ratios among children with clinically detected CAH and the contribution of ascertainment bias to unbalanced ratios. RESULTS: The evidence suggests a probability of infant death due to adrenal crises in salt-wasting CAH of 4% or less in contemporary advanced economies without screening for CAH. This is lower than previous estimates, although the rate of mortality could be considerably higher in populations with limited clinical awareness or access. CONCLUSION: Although screening for CAH is conducted in a number of countries, further research is still needed to provide reliable estimates on the numbers of prevented deaths, along with evidence-based assessments of the potential benefits, harms, and costs of screening.     

Follow up study of children born elsewhere but attending schools in Seascale,West Cumbria (schools cohort).

Records on 1546 children who were identified as having attended schools in Seascale up to November 1984 and were born since 1950 but not in the civil parish were studied. These children lived in or near Seascale for a period of time while they were attending one or more of three local schools and are an additional group to the 1068 children who were identified as born to mothers resident in Seascale in an accompanying study. Even though some of the schoolchildren apparently remained in the village for a short period only all but 7% were followed up through the National Health Service Central Register. Mortality among these children to 30 June 1986 is comparable to that expected at national rates. From all causes there were 10 observed deaths compared with 12.69 expected--a ratio of 0.79 (95% confidence interval 0.38 to 1.45)--and from cancer one observed death compared with 2.04 expected--a ratio of 0.49 (95% CI 0.01 to 2.73). No deaths from leukaemia or lymphoma were reported, but only 0.83 was expected. Since 1971 (the year when cases of cancer were first notified to the NHS Central Register) three non-fatal cases of cancer were reported, including two lymphomas, compared with 2.04 expected and two cases of carcinoma in situ of the cervix compared with 1.79 expected. In addition, there was a case of leukaemia among the schoolchildren which was known previously and had been diagnosed in 1968. There is an interesting difference between the results of this study and the results of the study of children born to mothers who were resident in Seascale. In the latter study there was an excess of leukaemia and of other cancers, but a similar finding is not apparent among children who spent some time at schools in Seascale but were born elsewhere. This raises the question of whether one or more aetiological factors in childhood cancer were acting on a locality specific basis before birth or early in life. This cannot be answered from these cohort studies, but it is hoped that the case-control study that is under way in West Cumbria will provide relevant information.     

Poor prognosis of acute lymphoblastic leukaemia in Asian children living in the United Kingdom.

A study of the results of treatment of acute lymphoblastic leukaemia in Asian (Indian and Pakistani) children living in the United Kingdom showed that they had a poorer prognosis than native white children due mainly to deaths during remission. Similar proportions of Asian and white children suffered relapse. Lower socioeconomic status, poor nutrition, and difficulties in communication may have contributed to the worse outcome in the Asian children.     

Role of respiratory viruses in childhood mortality.

Respiratory viruses have been identified at necropsy in the lungs of 13 out of 24 children who died with observed acute respiratory illness. The histological appearances of the lungs supported the association between virus and death in each of these 13 children and suggested an unidentified virus aetiology in a further five cases. Histological appearances compatible with bacterial infection were found in the lungs of only two of the 24 children. Similar virus and histological findings have been reported in about one-third of victims of the sudden infant death syndrome (cot deaths), indicating a rapid unobserved respiratory virus infection as the most likely mode of death in this group. Evidence that respiratory viruses may be involved in a larger proportion of sudden unexpected deaths, perhaps as antigens in a hypersensitivity reaction, is discussed. Respiratory viruses seem the major identifiable agents contributing to the maintenance of the postneonatal mortality rate since acute respiratory illness and the sudden infant death syndrome together account for about two-thirds of deaths at this age.     

Reproductive measures, fitness, and migrating Mennonites: an evolutionary analysis

Given the same reproductive span, more children with shorter interbirth intervals and less parental attention per child should not do as well. There should be intermediate optima in family sizes, but only two studies have demonstrated optima. The goal here is to determine whether the relationship between fitness and fertility is linear and whether this relationship masks underlying variation in reproductive behaviors in a Mennonite congregation that lived in two disease settings, Prussia/Russia vs. Kansas. The relationships between children born and fitness were determined by calculating linear and quadratic regressions for total, Prussia/Russia vs. Kansas, and families with deaths vs. families with no deaths for total, Prussia/Russia, and Kansas. Variation was examined in terms of measures of reproductive success and reproductive span. Comparisons were made by t tests with Bonferroni correction. Regressions demonstrate equally well that the more children women bear, the higher the reproductive success, whether in the harsher disease ecology of rural Prussia/Russia or in less challenging rural Kansas and whether the women experience deaths or not. Prussian/Russian mothers bore significantly more children (6.5+/-0.3) than Kansan mothers (5.6+/-0.2) over longer reproductive spans but did not significantly increase the number of surviving children (4.9+/-0.2 vs. 4.7+/-0.2, respectively). Families experiencing deaths vs. no deaths exhibit significantly longer reproductive spans, reflecting a significantly earlier start at childbearing and a later finish, and produce significantly more children (5.4+/-0.2 vs. 4.2+/-0.2). Cox regressions were run, and the most significant covariates to negatively affect survivorship to 15 years were death in the family and length of the previous interbirth intervals. There was variation in families, but perhaps most had adequate nutrition, which may explain the lack of optima in fitness.     

Deaths from rhesus haemolytic disease in England and Wales in 1982 and 1983.

Examination of death certificates and the clinical notes of the patients concerned showed that the number of deaths from rhesus (D) haemolytic disease in England and Wales was 44 and 34 during 1982 and 1983, respectively, a substantial decrease from the figure of 106 for 1977. Of the 78 women whose infants died in 1982 and 1983, 49 had not received anti-Rh immunoglobulin after previous pregnancies with Rh positive infants; most of these deaths would presumably have been prevented had postnatal anti-Rh immunoglobulin been given. In 13 women anti-D was detected during, or immediately after, a first pregnancy, and in 15 women rhesus immunisation developed despite administration of anti-Rh immunoglobulin postnatally. One or two apparent failures of treatment may have been due to underdosage, but it must be concluded that about one third of the deaths in 1982 and 1983 could have been prevented only by giving anti-Rh immunoglobulin antenatally as well as postnatally.     

Pertussis immunisation and serious acute neurological illnesses in children.

OBJECTIVE--To determine long term outcome in children who had a severe acute neurological illness in early childhood associated with pertussis immunisation. DESIGN--Follow up study of cases and matched controls. SETTING--Assessment of children at home and at school throughout Britain. SUBJECTS--Children recruited into the national childhood encephalopathy study in 1976-9 were followed up, with one of their two original matched controls, in 1986-9. MAIN OUTCOME MEASURES--Performance in educational attainment tests; behaviour problems reported by teachers and parents; continuing convulsions; evidence of other neurological or physical dysfunction. RESULTS--Over 80% of cases and controls were traced. Case children were significantly more likely than controls to have died or to have some form of educational, behavioural, neurological, or physical dysfunction a decade after their illness. The prevalence of one or more of these adverse outcomes in case children who had been immunised with diphtheria, tetanus, and pertussis vaccine within seven days before onset of their original illness was similar to that in case children who had not been immunised recently. The relative risk for recent diphtheria, tetanus, and pertussis immunisation in children who had died or had any dysfunction in comparison with controls was 5.5 (95% confidence interval 1.6 to 23.7). However, the number of cases associated with vaccine (12) was extremely small and statistically vulnerable, and other possible agents or predisposing factors could not be excluded. CONCLUSIONS--Diphtheria, tetanus, and pertussis vaccine may on rare occasions be associated with the development of severe acute neurological illnesses that can have serious sequelae. Some cases may occur by chance or have other causes. The role of pertussis vaccine as a prime or concomitant factor in the aetiology of these illnesses cannot be determined in any individual case. The balance of possible risk against known benefits from pertussis immunisation supports continued use of the vaccine.     

Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports.

OBJECTIVE--To examine the possible contribution of sedation with propofol in the deaths of children who were intubated and required intensive care. DESIGN--Case note review. SETTING--Three intensive care units. SUBJECTS--Five children with upper respiratory tract infections aged between 4 weeks and 6 years. RESULTS--Four patients had laryngotracheo-bronchitis and one had bronchiolitis. All were sedated with propofol. The clinical course in all five cases was remarkably similar: an increasing metabolic acidosis was associated with brady-arrhythmia and progressive myocardial failure, which did not respond to resuscitative measures. All children developed lipaemic serum after starting propofol. These features are not usually associated with respiratory tract infections. No evidence was found of viral myocarditis, which was considered as a possible cause of death. CONCLUSION--Although the exact cause of death in these children could not be defined, propofol may have been a contributing factor.