Measures to combat transmission of the coronavirus presented unprecedented challenges for safeguarding and child protection practice, including through withdrawal of routine opportunities to observe and engage with children and families and disruption of systems for inter-agency communication and coordination. This article reports on a two-stage study designed to identify shared learning from adaptations to professional practice in response to the measures. Interviews with 67 London-based senior safeguarding leads from seven professional groups undertaken during the summer of 2020 informed an England-wide survey to similar groups in February-March 2021. SPSS was used to analyse 417 responses, which were supplemented by answers to open questions. Findings are reported using the six practice themes which the Child Safeguarding Practice Review Panel expects to inform shared learning to improve safeguarding at national and local levels. The study revealed the formidable barriers facing professionals in understanding the changing environments in which children were living and in identifying and assessing new or altered risks due to the pandemic; steps taken to respond to changing risks and to keep in touch and re-engage families; strategies to support critical thinking and challenge among professionals working under unprecedented pressure; and opportunities for enhanced multiagency working and inter-agency collaboration.

covid-19 and the resulting “lockdown” and social distancing measures significantly disrupted the mechanisms by which child maltreatment may be identified or disclosed and children’s voices in relation to their protection are heard. This paper reports on the first stage of a multi-disciplinary study in which 67 interviews were undertaken with strategic and operational leads in all professions with child protection responsibilities from 24 London boroughs in June to early September 2020. Findings highlight disruptions to communication pathways caused by redeployment and the closure of universal and early help services, and concerns about the effectiveness and safety of distanced interactions. Innovations in practice to overcome these challenges are reported, including risk reevaluation exercises, keeping in touch strategies and online innovations. Lundy’s model of participation rights is employed to identify lessons for addressing the invisibility of some groups of children, enhancing access to and quality of communication, and embedding responsibility for listening to children.

Purpose Information sharing and joint working between agencies undertaking direct work with children have long been recognised as fundamental to robust and effective safeguarding and child protection arrangements. The public health response to Covid-19 disrupted those arrangements abruptly. This study aims to identify some of the innovative practices that have been implemented and how responses might inform planning for multi-agency working in the future. Design/methodology/approach This study presents reflections on preliminary fieldwork from a study of how agencies in London are responding to the challenges for multi-agency safeguarding arrangements created by the Covid-19 measures. It draws on the experience of expert practitioners in the research team as well as interviews with 17 senior professionals from local authorities, safeguarding partnerships and health. Findings The study participants endorsed known concerns around increased risks to children and raised new concerns about particular groups of children that under normal circumstances would not have been at risk. They identified some unexpected benefits derived from new arrangements, especially in relation to engagement with remote working. Originality/value Early insights are offered into promising initiatives to preserve strong multi-agency arrangements in crises and strengthen the resilience of the child protection system.

Aim To analyse trends and any link between child protection medical assessments (CPMA) and strategy discussion invitations (SDI) within a community paediatric service. Background Working Together to Safeguard Children1 states that, ‘whenever there is reasonable cause to suspect a child is suffering or is likely to suffer from harm,’ there should be a strategy discussion to share information and formulate a plan to safeguard the child with minimum attendees including a health representative.1 Method The number of non-accidental injury (NAI), child sexual abuse (CSA) and total CPMA and SDI in an inner London borough were collected from 2010 to 2017. Spearman’s Rank Correlation was applied to NAI, CSA and total data to investigate any link between numbers of CPMA and SDI. Results CPMA reduced from 212 to 144 (by 32%) and SDI from 204 to 31 (by 84.8%) despite the same criteria for assessment and attendance. Spearman’s Rank Correlation coefficient for NAI CPMA/SDI was 0.5; a moderate correlation. The coefficient for both CSA and total CPMA/SDI was 0.84; very strong correlations. Conclusions The Munro Review of Child Protection emphasised that, ‘coordination and communication between professionals and agencies is crucial to success,’2 in safeguarding children. A decrease in strategy discussions may be multifactorial, including the development of HAVEN provision, but community paediatric discussion is important in ensuring optimal information sharing. A decline in the number of CPMA and SDI may reflect barriers in communication between agencies and this data has supported interagency training. The additional finding of a strong correlation between CPMA and SDI may not be causal but reflects general barriers in communication between Children’s Social Care and Community Paediatrics. Both the decline in CPMA and SDI as well as the correlation in the trends, merit further evaluation locally and may be relevant for other child protection services. References . Working Together to Safeguard Children. A guide to interagency working to safeguard and promote the welfare of childrenMarch 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf [Accessed: 17/10/2017]. . Munroe E. Munro review of child protection: Final report. A Child-centred systemMay 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/175391/Munro-Review.pdf [Accessed: 17/10/2017].

Background All Unaccompanied Asylum Seeking Children (UASC) entering local authority care in England must have a holistic health assessment. Within our local authority this includes history and physical examination using a standardised proforma and Strengths and Difficulties Questionnaire (SDQ). Methods Retrospective review of records from Jan – August 2016. Recording SDQ scores, experiences of abuse and mental health difficulties. Results 99 UASC; median age 16 (range 12–17) years, 96% male. Ten nationalities, mostly Afghani 39% or Eritrean 35%. High levels of negative life experiences; 46% had experienced the death of a close family member; 75% not in contact with any family. In addition to adversity prior to departure, 51% experienced trauma en route to the UK. 32% reported detention, 27% physical assault and 12% were tortured. Libya was most commonly named, however European countries such as Belgium, Hungary and Bulgaria were also identified as locations of abuse. SDQ scores outside the normal range for emotional distress in 37%, peer relationships in 17% and overall stress in 13%. There was a statistically significant association (Fisher’s exact test; p=0.0003) between high SDQ score for emotional distress and adverse experiences during transit to the UK. 43 (43%) were identified as needing referral to mental health services. Discussion Data from our cohort demonstrates a high burden of distress, with large numbers of UASC experiencing abuse in transit to the UK. This is significantly associated with high levels of emotional distress in our cohort. The predictable need in this population should be accounted for in planning for and increasing access to mental health services.

Aim To evaluate housing provision for children with complex physical needs in an inner city. Methods All community physiotherapists from an area serving around 65,000 children and young people, having a caseload of children with significant physical disability, were asked about any housing concerns impacting on education or safety. Results 29 children aged 2–14 (median 6.5) years had significant problems with housing affecting wellbeing and safety. Disabilities included; cerebral palsy (13), chromosomal (6), neuro-degenerative (3), neuro-metabolic (2), seizure disorder (2), spina bifida (2), acquired brain injury (1). Housing issues identified were as follows; 20 properties with a wheelchair inaccessible front door, 13 had external, and 15 internal stairs, 11 properties where both bathroom and bedrooms were inaccessible, 10 bathrooms with inadequate space, 12 properties without space to move in a wheelchair or walker, and 10 with no space for equipment. These properties could not be adapted to fully meet the needs of the child and family. Impact on families included; parents and carers (including pregnant mothers and grandparents) carrying children upstairs resulting in safety risk and back pain, difficulty leaving the house causing social isolation and missed education and an inability to use mobility aids in the home. Issues were discussed with the Local Authority, and factors were identified relating to hospital discharge, temporary accommodation, social issues and lack of suitable local housing stock. Models of provision are discussed including the role of voluntary and private sectors. Conclusion Many families with children with complex physical needs have inadequate housing resulting in social isolation, reduced access to education and safety concerns. Similar issues have been identified over many years nationwide (Beresford and Rhodes 2008). This is likely to be an ongoing widespread problem affecting child and disability rights, related to old housing stock, issues of housing allocation and social factors. This must be evaluated and addressed as a matter of urgency through policy, interagency working and flexible models of service delivery. Reference Beresford and Rhodes 2008 https://www.jrf.org.uk/report/housing-and-disabled-children

Aims To evaluate school doctor service with regard to weight problems in a Secondary School for students with special needs Background School medicals are only offered based on teacher’s concerns and there was no existing health screen of potential need. The school doctor was concerned about potential unaddressed weight problems. Methods All students were offered a medical by opt-out permission letters to parents, also asking about concerns (diet, sleep, behaviour or other). Teachers were asked to identify students they felt had an unhealthy BMI. All students consenting were measured by multidisciplinary team (School doctors, School Nurse, Special Needs specialist dietician, Specialist nurse for obesity). We calculated BMI centile on WHO growth charts. An action plan was developed by the school doctor and team as part of this service evaluation. Results 1 family and 2 students refused. 2 parents concerned about appetite. Teachers correctly identified 13 / 29 students as having a problem with their weight. 76 / 79 students assessed. BMI range 15 to 50. 30/76 (35%) met criteria for referral to special needs dietician, increasing service yearly caseload by a third. 27/76 (35%) were ≥91st BMI centile. 13/76 (17%) were ≥98th centile (see Figures 1 and 2). There was no local Tier 2 or 3 weight management services available for this age group. The school doctor action plan included education of teachers on obesity and introducing Tier 2 lifestyle weight management programme as pilot for secondary students. The special needs dietician negotiated a reduction of puddings. The dietetics service commissioners were informed of the need, resulting in plans to expand the service. Conclusions There were many overweight students previously unidentified that required further management. Teachers did not accurately identify students that are overweight and therefore might not be best placed to initiate referrals. There are gaps in school health service including screening for obesity and services that should be in place for this age group according to NICE guidance. In today’s obesogenic environment the school doctor role should include advocating for students to attain healthy weight, (Measuring Up 2013). Acknowledgments School nurses, Teachers, Kitchen Staff, Dietician, Students and Parents, Tier 2 Team

Methods Evaluation of referrals of families referred to Tier 3 obesity service for children 4–12 years with BMI > 98th centile (or 91st centile with complexity), previously unengaged. Project ethos based in principles of systemic family psychotherapy, approached the problem following NICE 2013 guideline Childhood Obesity. Family therapist, dietician, activities specialist and paediatrician, offered a comprehensive outreach approach including home visits. Initial assessment explored causes and complications of obesity including Strengths and Difficulties questionnaire SDQ and assessment of child’s mental health. Goals were set with families including parenting/family therapy. Families were seen fortnightly for 3 months, assessed 3 monthly, up to 1 year. Results 144 referred: School Nursing Team (71); Community Paediatricians (37); Others (36). 120/144 (83%) met criteria for clinic. Of these 72/120(60%) accepted first appointment (no response from 20/120(16%), declined by 28/120(23%)) Ethnicity of children: White 19%, Black British/African/Caribbean 60%, Other 20%. English as additional language 33/72(46%), 9 requiring interpreter. All were >98 th centile BMI. Almost all children engaged stabilised BMI z scores at 3 months. (20/23 (87%). Frequent psychosocial factors identified includied lone parent 27/72(38%); siblings/parent physically disabled;12/72(17%); no parent employed 17/72(24%), current/previous social services 12/72(17%), domestic violence 9/72(13%), parental mental illhealth:8/72(11%). Neurodevelopmental disorders included autism, Down’s syndrome, ADHD, Cerebral palsy, learning disability and medical problems, plus significant behavioural difficulties. Initial SDQ indicated substantial risk of clinical significance 19/72(26%). Two children were suicidal and self harm concerns in four. Referrals were made to social services for CIN or CP concerns (12/72) (17%). Conclusion Extreme obesity in children is systemic and multifactorial, often associated with concerning psychosocial problems in families. Paediatricians who care for children who are extremely obese should enquire about mental health, parenting, development and psychosocial factors, and make appropriate referrals. Childhood obesity often indicates family distress and unmet need including important child mental health difficulties.

Immunisation of infants born to hepatitis B virus (HBV) infected mothers is an important public health measure to prevent mother-to-child transmission of HBV. Post-vaccination serological tests (PVST) inform the success of the infant HBV immunisation programme and identify infected infants. Previous studies suggested that the rates of PVST in the UK programme were unsatisfactory. We introduced an intensified local follow-up programme and offered an earlier PVST 2-3 months after the third vaccination at age 4-5 months. Of 219 infants born between 2009 and 2011, 193 infants (88.1%) had at least one PVST: 145 (66.2%) early; 94 (42.9%) standard; 46 (21.0%) both and 26 (11.9%) never tested. Twenty-four infants were identified as high risk for mother-to-child transmission according to national criteria and received both hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine at birth. These infants had a significantly lower hepatitis B surface antibody (anti-HBs) levels at early PVST compared to the lower risk group who received hepatitis B vaccine only (median of 59 vs. 376 mIU/ml, P=0.006). None of the infants tested were infected with hepatitis B. This study illustrates that the rate of PVST can be improved by using an intensified follow-up programme offering an early PVST. The significantly lower anti-HBs levels in the HBIG subgroup is of concern as this group of infants is already at higher risk for acquiring HBV infection. Infants with poor antibody responses can be identified by an early PVST and offered a timely extra booster dose.

Background Looked After Children (LAC) are over-represented in the population of teenage mothers1. A local report indicated that the highest proportion of these in an inner-city London Borough were Unaccompanied Asylum Seeking Children (UASC) 2. Aim To determine the socio-demographic profile of the teenage mothers within the UASC population of this borough. Objectives To determine any differences in the socio-demographic profile between UASC who became teenage mothers compared to those who did not. To inform relevant delivery of social care to this population. Methods Retrospective case file analysis of all female UASC records held from 2004 to 2011 by Children and Young People9s Services. Anonymised data analysis using SPSS statistical software; Kruskal-Wallis test/chi-squared test, and t-tests. Results UASC contributed to 20% of teenage LAC mothers. Of female UASC assigned to the Unaccompanied Minors Team, 19/211 (9%) became mothers under the age of 18 and of the teenage mothers 12/19, (63%) originated from West and Central Africa (n= 80). There were no teenage mothers originating from East Africa (n= 107). Of mothers with recorded date entering care, 10/13 (77%) were pregnant prior to being accommodated. UASC mothers were as likely to attend college or university as the other female UASC. Statistically significant links were found for; country of origin (p=0.006), older age entering care (p=0.002), shorter time in care (p=0.041), and more addresses in care (p=0.009). Conclusion Most teenage motherhood occurred in girls originating from West and Central Africa and were initiated prior to the children becoming accommodated; with implications for safeguarding interventions in this population. UASC mothers were as likely to complete higher education as other UASC despite being older when they were accommodated and moving address more. These issues need further exploration for the LAC population as a whole.

OBJECTIVE:The present study aimed to assess the mental and physical health of children held within a British immigration detention center.METHOD:A total of 24 detained children (aged 3 months to 17 years) were assessed with their parents or carer after being referred by a registered legal charity. Thirteen were seen by a pediatrician alone, 4 by a psychologist alone, and 7 by both professions using semi-structured clinical interviews. The psychologist also used standardized self-report questionnaires to measure psychopathology.RESULTS:During the psychological assessment of 11 children, 8 met criteria for psychiatric "caseness" on the Strengths and Difficulties Questionnaire. All 11 reported symptoms of depression and anxiety. Sleep problems, somatic complaints, poor appetite, emotional symptoms, and behavioral difficulties were common. Symptoms of global distress were also reported by all 9 parents. According to pediatric assessment 8 out of 20 children had lost weight. Six had missed health appointments and 2 were taken to hospital. Nutritional, developmental, educational, and child protection concerns were raised.CONCLUSIONS:Detained children were found to be experiencing mental and physical health difficulties of recent onset, which appeared to be related to the detention experience. These findings support previous Australian studies demonstrating that detention is not in the best interest of the child. It suggests that current UK policies regarding the detention of children for purposes of immigration control should be re-examined. Further research in the area is required.PRACTICE IMPLICATIONS:Although high levels of mental and physical health problems, as well as child protection concerns were detected, detained families had very limited access to appropriate assessment, support or treatment. The traumatic experience of detention itself also has implications for the sizeable proportion of psychologically distressed children who are eventually released from detention and expected to successfully reintegrate into British society; while those children who are deported are returned with increased vulnerability to future stressors.

This study investigated the accuracy of prediction of neurodevelopmental outcome at 1 year using cerebral proton magnetic resonance spectroscopy (MRS) and structured neonatal neurological assessment in term infants after presumed hypoxic–ischaemic brain injury. Eighteen control infants and 28 infants with presumed hypoxic–ischaemic brain injury underwent proton MRS investigation. Studies were carried out as soon as possible after the cerebral insult, most within 48 hours. Infants had an early structured neurological assessment at a median of 19 hours (range 0 hours to 9 days) from the presumed hypoxic–ischaemic insult and a late assessment at a median of 7 days (range 3 to 25 days) during recovery. The maximum cerebral peak–area ratio lactate:N‐acetylaspartate measured by proton MRS accurately predicted adverse outcome at 1 year with a specificity of 93% and positive predictive value of 92%. Neurological assessment had a tendency for false‐positive predictions. However, both early and late neurological examination can be used as a reliable indicator for a favourable outcome at 1 year having negative predictive values of 100% and 91% respectively.

Glycopeptide-resistant Enterococcus faecium (GREF) and Enterococcus faecalis have been called the nosocomial pathogens of the 1990s [1.Spera Jr, RV Farber BF Multiple-resistant Enterococcus faecium: the nosocomial pathogen of the 1990s.JAMA. 1992; 268: 2563-2564Crossref PubMed Scopus (90) Google Scholar]. GREF can be resistant not only to glycopeptides but often also to several other antibiotics [2.Woodford N. Johnson AP Morrison D Speller DCE Current perspectives on glycopeptide resistance.Clin Microbiol Rev. 1995; 8: 585-615PubMed Google Scholar]. This severely limits the available therapeutic options for treatment of infections with these organisms. This is likely to be particularly true in neonatal units, where there are even fewer options for antibiotic therapy. We describe the investigation and management of an outbreak of GREF in a neonatal unit; few, if any, reports of this have been previously published. The neonatal unit at Lewisham Hospital is designed to admit up to 26 patients. On 27 March 1996 a strain of GREF was isolated from blood cultures taken from a baby on the unit. On 10 April blood cultures taken from two other babies on the unit also yielded GREF strains with identical susceptibility profiles. It was decided that these strains constituted a possible outbreak, and appropriate investigative and control measures were implemented. The outbreak was contained by 1 May 1996. Microbiological investigations showed 12 of the 43 babies of both sexes admitted to the unit during the outbreak to be colonized with GREF. All affected babies were admitted between 25 January 1996 and 22 April 1996. The age of the babies ranged from 24 to 40 weeks, and they were admitted to the unit for a variety of reasons, including prematurity, surgery and neonatal complications. Many of the babies had been treated with teicoplanin for possible sepsis caused by Staphylococcus epidermidis isolated from blood cultures taken during episodes of clinical deterioration. Although three of the babies had blood cultures positive for GREF, these were not considered to be clinically significant by the pediatricians, and the babies were not given any specific treatment. Repeat blood cultures were negative. All 12 affected babies had gastrointestinal colonization with GREF. The neonatal unit has three rooms where the patients were treated. Babies in room 1 required the most intensive nursing care, and those in room 3 the least. The first carrier was detected in room 2. Subsequent carriers were distributed between all three rooms in the unit. Perusal of the medical and nursing records established that many of the carriers had been transferred from one room to another prior to the detection of the outbreak. These transfers mainly reflected particular nursing requirements. We also observed that each transfer of a carrier to a new location was associated with development of secondary carriers. Rectal swabs and other clinical specimens were screened using a selective medium containing vancomycin [3.Gopal Rao G. Ghanekar K Ojo F Selective medium for screening for vancomycin-resistant enterococci in faeces.Eur J Clin Microbiol Infect Dis. 1996; 15: 175-177Crossref PubMed Scopus (20) Google Scholar]. Presumptive glycopeptide-resistant enterococcal strains (11 GREF and one E. gallinarum) were confirmed by referral to the Antibiotic Reference Unit, Colindale, London. All the GREF isolates were resistant to penicillin, ampicillin, erythromycin. vancomycin (MIC >32 mg/L), teicoplanim (MIC >128 mg/L), gentamicin and ciprofloxacin, according to breakpoint sensitivity testing based on the recommendations of a working party of the British Society for Antimicrobial Chemotherapy [4.Philips I A guide to sensitivity testing. Report of the working party on Antibiotic Sensitivity Testing of the British Sociery for Antimicrobial Chemotherapy.J Antimicrob Chemother. 1991; 27: 1-47Google Scholar]. These isolates were sensitive to tetracycline, chloramphenicol and quinupristin/dalfopristin (an unlicensed drug belonging to the streptogramin class of antibiotics). The in vitro antibiotic susceptibility tests were initially done by the comparative disk diffusion method (Stoke's method) at the Lewisham Hospital and later confirmed at the Antibiotic Reference Unit by the agar dilution method. All GREF isolates carried van A genes and were also indistinguishable by pulsed-field gel electrophoresis (PFGE) using methods described previously [5.Woodford N. Morrison D Johnson AP Bateman AC Hastings JG Cookson B Plasmid mediated VanB glycopeptide resistance in enterococci.Microb Drug Res. 1995; 1: 235-240Crossref PubMed Scopus (40) Google Scholar]. Environmental screening, which included surfaces, sinks, incubators and other equipment, did not detect any GREF isolates. Parents and staff were not screened because the published literature did not suggest that exclusion of carriers or measures to eliminate carriage contribute to the management of GREF outbreaks [6.The Hospital infection Control Practices Advisory Committee (HICPAC)Recommendations for preventing the spread of vancomycin resistance.Am J Infect Control. 1995; 23: 87-94Abstract Full Text PDF PubMed Scopus (165) Google Scholar]. The outbreak was managed through cohort nursing and stringent hand hygiene. In addition, guidelines to restrict the use of cephalosporins and glycopeptides to unequivocal cases of sepsis and central venous catheter (CVC)-associated infection, respectively, were instituted. No specific antibiotic therapy was given for the eradication of GREF. Although the outbreak was deemed to have ended by 1 May 1996, surveillance for GREF continued until either the affected babies were discharged to their homes or there was clearance of fecal carriage. A majority of the affected babies had spontaneous clearance of GREF within 6-8 weeks. This outbreak of GREF highlights several aspects of the epidemiology and measures for control of GREF in a neonatal unit. We have demonstrated the spread of GREF in a neonatal unit using traditional epidemio-logic methods in conjunction with molecular methods. The traditional approach has merit in that it demonstrated clearly how the infection was spread in the unit, and is particularly relevant in that in neonatal units it is conventional to transfer babies from one area to another according to the level of care required. Identified risk factors for the acquisition of GREF are most often prior consumption of glycopeptides and cephalosporins [2.Woodford N. Johnson AP Morrison D Speller DCE Current perspectives on glycopeptide resistance.Clin Microbiol Rev. 1995; 8: 585-615PubMed Google Scholar, 5.Woodford N. Morrison D Johnson AP Bateman AC Hastings JG Cookson B Plasmid mediated VanB glycopeptide resistance in enterococci.Microb Drug Res. 1995; 1: 235-240Crossref PubMed Scopus (40) Google Scholar, 6.The Hospital infection Control Practices Advisory Committee (HICPAC)Recommendations for preventing the spread of vancomycin resistance.Am J Infect Control. 1995; 23: 87-94Abstract Full Text PDF PubMed Scopus (165) Google Scholar, 7.Gopal Rao G Ojo F Kolokithas D Vancomycin-resistant Gram positive cocci: risk factors for faecal carriage.J Hosp Infect. 1997; 35: 63-69PubMed Google Scholar]. Excessive use of teicoplanin to treat suspected S. epidermidis infections on the unit is likely to have played an important role in the selection of GREF in the gastrointestinal tract [6.The Hospital infection Control Practices Advisory Committee (HICPAC)Recommendations for preventing the spread of vancomycin resistance.Am J Infect Control. 1995; 23: 87-94Abstract Full Text PDF PubMed Scopus (165) Google Scholar, 7.Gopal Rao G Ojo F Kolokithas D Vancomycin-resistant Gram positive cocci: risk factors for faecal carriage.J Hosp Infect. 1997; 35: 63-69PubMed Google Scholar]. As it is difficult to obtain blood cultures aseptically in neonates, contamination with S. epidermidis is extremely common and can be misleading [8.Paisley JW. Lauer BA Paediatric blood cultures.Clin Lab Med. 1994; 14: 17-30PubMed Google Scholar]. Pediatricians should resist the temptation to treat these isolates unless there is unequivocal evidence of sepsis, usually associated with the presence of CVCs. Removal/replacement of long lines should be an integral part of the management of CVC-associated sepsis. Fortunately, in this situation none of the affected babies required treatment. This, however, should not detract from the fact that the few antibiotics available for treatment were either contraindicated in children (tetracycline) or unlicensed (quinupristin/dalfopristin). It is likely that the spread of GREF in the unit was controlled by emphasizing the importance of hand hygiene and rationalizing the use of cephalosporins and teicoplanin. We acknowledge the help of many people in the neonatal unit and microbiology department in the management of the outbreak. We thank the Division of Hospital Infection, Central Public Health Laboratory, Colindale for identifying and typing the strains of GREF, and Mrs V. Witcombe for the secretarial assistance in preparation of this paper.

Studies of the brains of severely birth-asphyxiated infants using proton( 1 H) magnetic resonance spectroscopy (MRS) have shown changes indicating a rise in cerebral lactate (Lac) and a fall in N- acetylaspartate (Naa). The aim of this study was to test two hypotheses: 1 ) that these changes can be reproduced in the newborn piglet after transient reversed cerebral hypoxia-ischemia, and their time course determined; and 2 ) that changes in Lac peak-area ratios are related to changes in phosphorylation potential as determined by phosphorus( 31 P) MRS. Eighteen piglets aged <24 h were anesthetized and ventilated. Twelve underwent temporary occlusion of the carotid arteries and hypoxemia, and six served as sham-operated controls. 1 H and 31 P spectra were acquired alternately, both during the insult and for the next 48 h, using a 7-tesla spectrometer. During hypoxia-ischemia, the median Lac/total creatine (Cr) peak-area ratio rose from a baseline of 0.14 (interquartile range 0.07-0.27), to a maximum of 4.34 (3.33-7.45). After resuscitation, Lac/Cr fell to 0.75 (0.45-1.64) by 2 h, and then increased again to 2.43(1.13-3.08) by 48 h. At all stages after resuscitation Lac/Cr remained significantly above baseline and control values. Naa/Cr was significantly reduced below baseline and control values by 48 h after resuscitation. The increases in the Lac peak-area ratios were concomitant with the falls in the[phosphocreatine (PCr) * ]/[inorganic phosphate (P i )] ratio, during both acute hypoxia-ischemia and delayed energy failure. The maximum Lac/Naa during delayed energy failure correlated strongly with the minimum[nucleotide triphosphate (NTP)]/[exchangeable phosphate pool (EPP)]( r = -0.94, p < 0.0001). We conclude that both hypotheses have been confirmed.

This study tested the hypothesis that mild hypothermia after severe transient hypoxia-ischemia reduces the subsequent delayed rise in cerebral lactate peak-area ratios as determined by proton (1H) magnetic resonance spectroscopy (MRS) in the newborn piglet. Nine piglets aged <24 h underwent temporary occlusion of the common carotid arteries and hypoxemia. Resuscitation was started when cerebral [phosphocreatine]/[inorganic phosphate] had fallen close to zero and [nucleotide triphosphate(NTP)]/[exchangeable phosphate pool (EPP)] was below about a third of baseline. On resuscitation rectal and tympanic temperatures were lowered to 35°C for 12 h after which normothermia (38.5 °C) was resumed. 1H MRS data collected over 48 or 64 h after resuscitation were compared with concurrently established data from 12 piglets similarly subjected to transient cerebral hypoxia-ischemia, but maintained normothermic, and six shamoperated controls. The severity of the primary insult (judged from the time integral of depletion of [NTP]/[EPP]) was similar in the hypothermic and normothermic groups. The maximum lactate/N-acetylaspartate ratio observed between 24 and 48 h after resuscitation in the hypothermic group was 0.10 (0.05-0.97), median (interquartile range), which was significantly lower than that observed in the normothermic group, 1.28 (0.97-2.14), and not significantly different from that observed in the control group, 0.08 (0.06-0.11). Similar results were obtained for lactate/choline and lactate/total creatine. We conclude that mild hypothermia after a severe acute cerebral hypoxic-ischemic insult reduces the delayed elevation in lactate peak-area ratios, thus reflecting reduced lactate accumulation.

A newborninfant withanacutemetabolic encephalopathy causedbyisovaleric acidaemiahadsevere impairment ofcerebral energymetabolism. Thiswasdetected by phosphorus andprotonmagneticresonancespectroscopy. Aftertreatment she madeexcellent clinical recovery, herspectroscopic abnormalities resolved, andshe wasneurologically normalattheageof1 year. (Arch DisChild 1996;74:F211-F213)

Previous studies of the brains of normal infants demonstrated lower lactate (Lac)/choline (Cho), Lac/creatine (Cr), and Lac/N-acetylaspartate (Naa) peak-area ratios in the thalamic region (predominantly gray matter) compared with occipitoparietal (mainly unmyelinated white matter) values. In the present study, thalamic Cho, Cr, and Naa concentrations between 32-42 weeks' gestational plus postnatal age were greater than occipito-parietal: 4.6 +/- 0.8 (mean +/- SE), 10.5 +/- 2.0, and 9.0 +/- 0.7 versus 1.8 +/- 0.6, 5.8 +/- 1.5, and 3.4 +/- 1.1 mmol/kg wet weight, respectively: Lac concentrations were similar, 2.7 +/- 0.6 and 3.3 +/- 1.3 mmol/kg wet weight, respectively, In the thalamic region, Cho and Naa T(2)s increased, and Cho and Lac concentrations decreased, during development. Lower thalamic Lac peak-area ratios are principally due to higher thalamic concentrations of Cho, Cr, and Naa rather than less Lac. The high thalamic Cho concentration may relate to active myelination; the high thalamic Naa concentration may be due to advanced gray-matter development including active myelination. Lac concentration is higher in neonatal than in adult brain.

A new method for noninvasive, in vivo quantitation of cerebral phosphorus (31P) metabolites is described. The technique employs point-resolved spectroscopy (PRESS) to obtain both 31P-metabolite and proton (1H) water spectra: brain water is used as an internal concentration reference. Spin-spin relaxation times (T2s) of cerebral 31P metabolites are much longer than the minimum echo time (TE) usable on a spectrometer equipped with actively shielded gradient coils. With short-TE (≈10 ms) 31P PRESS, T2 relaxation is minimal and phase modulation of the nucleotide triphosphate (NTP) multiplets can be accounted for. 1H water spectra were acquired using several TEs so that extra- and intracellular water signals could be separated from that due to cerebrospinal fluid. Prior calibration of the 31P and 1H spectrometer channels and an assumed brain-water concentration enabled estimations of metabolite concentrations. Using this method, mean 31P metabolite concentrations in the brains of eight normal infants of gestational plus postnatal age 34 to 39 wk were: phosphomonoester (PME) 5.6 (SD 0.9); inorganic phosphate 1.4 (0.4); mobile phosphodiester 2.3 (0.6); phosphocreatine 2.9 (0.3); nucleotide triphosphate 2.8 (0.6); and total mobile phosphate 21.4 (2.8) mmol/kg wet.

A newborn infant with an acute metabolic encephalopathy caused by isovaleric acidaemia had severe impairment of cerebral energy metabolism. This was detected by phosphorus and proton magnetic resonance spectroscopy. After treatment she made excellent clinical recovery, her spectroscopic abnormalities resolved, and she was neurologically normal at the age of 1 year.