Refusal of Food by Children

(Hong Kong—Hong Kong Practitioner, May 1998, p. 291.) Refusal of food is common in children and may be the result of physical, emotional or social factors. Food refusal may occur rarely after episodes of choking or as a manifestation of abuse or prepubertal anorexia nervosa. Other uncommon causes of food refusal include food fads, autism, emotional disturbance in the child or excessive anxiety on the part of the parents. Most cases of food refusal are related to a combination of irregular meal times, inappropriate quantities of food, unrestrained access to food between meals, excessive emphasis on eating (often extending to threats or recriminations for failure to eat), failure to reward the child appropriately for correct use of food, and inappropriate bargaining and conflict resolution between the child and the parents. A thorough history should include assessment of the emotional state of the child and the parents in addition to information about actual and desired eating habits. If an underlying cause for food refusal is found, it should be addressed. The majority of cases respond to simple advice and reassurance. Advice should include minimization of distractions during meals, timing of meals and removal of uneaten food, restriction of access to food between meals, rewards for appropriate eating behaviors, and prompt, consistent, appropriate handling of all conflicts between parents and children, including food refusal conflicts.

Skin Lesions and Rashes in Travelers

(Great Britain—The Practitioner, May 1998, p. 366.) The diagnosis of skin abnormalities in patients who have recently returned from a tropical area can be complex, and the entire clinical picture must be considered in addition to the characteristics of the rash or skin lesions. Maculopapular rashes occurring predominately on the trunk are characteristic of typhoid and arbovirus infections such as dengue. Dengue fever also may produce a petechial rash similar to that characteristic of rickettsial infections and meningococcal sepsis. An annular rash that migrates and is associated with headache, myalgia, lymphadenopathy and fever often indicates Lyme disease. Ulcerating lesions are characteristic of leishmaniasis. These lesions are usually painless and occur in several forms depending on the infecting species, which is usually determined by the region in which the infection was acquired. Intensely pruritic lesions may indicate parasitic infestation such as guinea worm, Ancylostoma, loa loa, Strongyloides and Schistosoma.

Dengue Fever

(Great Britain—The Practitioner, May 1998, p. 342.) The increasing incidence of dengue fever in tropical countries means that physicians in temperate climates must consider this diagnosis in febrile patients who have recently returned from a tropical area. After an incubation period of up to eight days, dengue fever presents as fever, headache, pain in the bones and joints, and a rash that may be maculopapular or diffusely erythematous. The severity of musculoskeletal pain justifies the name “breakbone fever.” The clinical presentation resembles that of malaria but, in cases of dengue fever, the blood film is negative for parasites. Hypovolemia and thrombocytopenia may occur. Depression may complicate the prolonged recovery phase of dengue fever. Prevention of dengue fever depends on avoidance of Aedes aegypti mosquitoes, which bite during the day, in contrast to malaria-transmitting Anopheles mosquitoes, which bite at night.

Zinc Lozenges for the Common Cold

(Canada—Canadian Family Physician, May 1998, p. 1037.) The recent substantial public interest in zinc as a treatment for the common cold led a Canadian researcher to evaluate the published evidence about the efficacy of zinc in relieving symptoms attributed to viral upper respiratory tract infection. Marshall identified seven randomized controlled trials performed in otherwise healthy adults 18 to 65 years of age. Despite difficulties in defining cases, self-reporting of symptoms and differences in study design, the meta-analysis revealed some evidence for benefit from treatment with zinc gluconate lozenges. To reduce the duration and severity of cold symptoms, treatment should begin within 48 hours of the onset of symptoms. The minimal effective dosage appears to be 13.3 mg taken every two hours during waking hours. Side effects include nausea and persistent bad taste in the mouth; very prolonged courses of therapy have occasionally resulted in neutropenia and copper deficiency. The effectiveness of zinc formulations may be diminished by the use of various additives, such as citric acid, sorbitol and mannitol, which bind free zinc.