1130 Archives of Disease in Childhood, 1986, 61
patients who had had meconium ileus equivalent did
not have less well controlled steatorrhoea than those
who had not had meconium ileus equivalent, and
neither prophylactic treatment nor newer pancreatic
enzyme supplements has reduced the incidence of
meconium ileus equivalent.
The failure of prophylaxis necessitates adequate
treatment to relieve attacks. Surgery is hazardous
and should be avoided wherever possible.3 Currently described regimens of medical management3 4
are effective but unpleasant and require admission
to hospital.
Gastrografin is a radiological contrast medium,
containing sodium diatrizoate 100 mg/ml, meglumine diatrizoate 660 mg/ml, and iodine 370 mg/ml,
plus flavouring and wetting agents. It is hypertonic
with an osmolality of 2150 MOsm/kg H20 at 37°C.
Absorption from the intestine is minimal.
When Gastrografin is given by enema to relieve
obstruction in the newborn, or in older patients with
cystic fibrosis with meconium ileus equivalent, the
manufacturers recommend that it be diluted fourfold with water. In our hospital children who require
Gastrografin enemas to relieve meconium ileus
equivalent have been given 100-200 ml Gastrografin
in three times that volume of water, under fluoroscopic control.
We have found smaller oral doses, 50 ml in
children under 8 years and 100 ml in those 8 years

and older, to be effective. All children drink at least
four times that volume of water or fruit squash with
the Gastrografin. None of our patients has developed dehydration after these doses of Gastrografin, and electrolytes measured in inpatients were
normal.
Oral Gastrografin is contraindicated where there
is pre-existing dehydration, prolonged obstruction,
or evidence of acute abdomen or iodine sensitivity
but may otherwise safely be given to children aged
over 5 years as outpatients.
Oral Gastrografin is a simple, safe, and effective
outpatient treatment. We consider it to be the
treatment of choice in acute meconium ileus equivalent in cystic fibrosis.
References
Hodson ME, Norman AP, Batten JC. Cystic fibrosis. London:
Bailliere Tindall, 1983:153-7.
2
Lloyd Still JD. Textbook of cystic fibrosis. Boston: John Wright
PSG, 1983:159-61, 360-1.
3 Hodson ME, Mearns MB, Batten JC. Meconium ileus equivalent in adults with cystic fibrosis of the pancreas. Br Med J
1976;ii:790-1.
4 Pilling DW, Steiner GM. The radiology of meconium ileus
equivalent. Br J Radiol 1981;50:562-5.

Correspondence to Dr D P Heaf, Respiratory Unit, Alder Hey
Children's Hospital, Eaton Road, Liverpool L12 2AP, England.
Received 6 June 1986

Spontaneous subhyaloid and retinal haemorrhages in an infant
N J MCLELLAN, R PRASAD, AND J PUNT

Departments of Child Health and Paediatric Neurosurgery, University Hospital, Queen's Medical Centre,
Nottingham
SUMMARY A 6 week old girl from a socially isolated
family presented with seizures and was found to
have a full fontanelle, retinal and subhyaloid
haemorrhages, and anaemia. These findings were
not the result of a shaking injury but of a ruptured
intracerebral arterial aneurysm.

With vigilance for child abuse and awareness of the
possibility of cerebral injury from shaking increasing, alternative explanations of the characteristic
clinical features of shaking may be overlooked. We
describe a child in whom the initial impression of
abusive shaking was false.

Case report
The girl was born uneventfully at term weighing
3300 g, the first child to unmarried white parents
living in poor circumstances. Her mother was aged
16 and her father 21 and unemployed. On the day of
the child's admission at the age of 6 weeks, her
father thought she was well when he fed her
at 0600h. Four hours later her mother noticed a one
minute episode of twitching of the left arm and
hand. Similar episodes occurred at each feed of the
day, but she sucked well and seemed normal
between them. She screamed uncontrollably during
her evening bath, with a further left sided seizure.
At 2300h she awoke screaming and looked pale and

Spontaneous subhyaloid and retinal haemorrhages in an infant 1131
sweaty. Her father telephoned the family doctor and
returned to bed but later accompanied her to
hospital and said that he had recently bounced the
baby, sleeping in her pram, down the few steps to
the garden.
Shortly after admission she had several momentary episodes of left sided clonic seizures. She was
afebrile but pale and irritable. The fontanelle was
full. There were extensive bilateral retinal haemorrhages and a large right subhyaloid haemorrhage.
There were no signs of direct injury or neglect, no
cranial bruit, and normal femoral pulses. The head
circumference was normal.
Her haemoglobin concentration was 8-5 g/dl.
Other investigations with normal findings included
white blood cell count and blood film, coagulation
studies, platelets, and a full x ray skeletal survey.
Lumbar puncture showed moderataly blood stained
cerebrospinal fluid with a xanthochromic supernatant and no evidence of infection.
A diagnosis was made of intracranial haemorrhage, probably resulting from shaking injury. She
was transferred to the intensive care unit where an
urgent computed tomogram of the brain showed a
large intracerebral haematoma (Fig. 1). This was

Fig. 1 Computed tomogram of the brain of our case
without contrast on admission showing a localised
haematoma in the right frontoparietal area.
(Compare with Fig. 2.)

considered to be incompatible with injury and to
suggest spontaneous bleeding.
Her condition stabilised rapidly without further
seizures. Transfemoral right common carotid
angiography was performed 36 hours after admission. This showed an arterial aneurysm lying distally
in an ascending frontal branch of the right middle
cerebral artery. At craniotomy on the seventh
hospital day the haematoma was evacuated and the
aneurysm in its cavity removed. The only postoperative complication was a transient left sided weakness
and at the age of 1 year she is clinically and
developmentally normal.
Discussion

It is increasingly recognised that infants are particularly susceptible to cerebral injury by shaking.' 2
This may be accompanied by other clinical or
radiological evidence of trauma but is often more
subtle and difficult to establish. Retinal and subhyaloid haemorrhages are considered to be highly
suggestive, if not pathognomonic, of the condition
in infancy.' 2 We emphasise that they are not
necessarily the hallmark of shaking and the presence
of such haemorrhages should not become uncriti-

Fig. 2 Computed tomogram of the brain without contrast
in an 8 week old child with fatal shaking injury, showing a
posterior interhemispheric subdural haemorrhage (arrow),
which contrasts with the normal density of the falx

anteriorly.

1132 Archives of Disease in Childhood, 1986, 61

cally incorporated into 'standard practice' as the
sine qua non of abuse. Equal open mindedness to
the interpretation of social factors in such cases
should be maintained until a definite diagnosis has
been made.
Like any other haemorrhage, those in the optic
fundus may be traumatic or spontaneous. Among
the spontaneous causes, a bleeding diathesis should
be considered.' Diagnostic evaluation by computed
tomography of the brain is also important. A
localised intracerebral haematoma is most unlikely
to be traumatic if there is no other evidence of
parenchymal injury. Shaking may cause generalised
brain contusion.3 Alternatively, a subdural haemorrhage may be induced and a posterior interhemispheric distribution is particularly characteristic of
shaking injury (Fig. 2).4
Recognition of a subdural haemorrhage by aspiration through the anterior fontanelle should also be
considered critically. Any intracranial haemorrhage
may leak into the subarachnoid space and a subdural
haematoma can develop if an aneurysm or arteriovenous malformation ruptures through the arachnoid mater. Such a finding has been described in a 3
month old child with an intracerebral aneurysm.5
Arteriovenous malformations may also occur
within the meninges and so bleed directly into the
subdural space. We can see little value in performing diagnostic subdural taps when access to computed tomography facilities are available.

We suggest that a computed tomogram of the
brain should be considered urgently in the evaluation of cases of possible shaking injury or unexplained fundal haemorrhages. This should clarify
the appropriate course to follow and prevent misinterpretation. A ruptured intracerebral arterial
aneurysm may be eminently suitable for curative
neurosurgery.
We thank Dr Ian Holland for his neuroradiological expertise.
References
Caffey J. The whiplash shaken infant syndrome: manual shaking
by the extremities with whiplash induced intracranial and
intraoccular bleedings, linked with residual permanent brain
damage and mental retardation. Pediatrics 1974;54:396-403.
2 Ludwig S, Warman M. Shaken baby syndrome: a review of 20
cases. Ann Emerg Med 1984;13:104-7.
Ellison PH, Tsai FY, Largent JA. Computed tomography in
child abuse and cerebral contusion. Pediatrics 1978;62:151-4.
4 Zimmerman RA, Bilaniuk LT, Bruce D, et al. Computed
tomography of craniocerebral injury in the abused child.
Radiology 1979;130:687-90.
5 Vapalanti PM, Schugk P, Tarkkanen L, Af-Bjorkesten G.
Intracranial arterial aneurysm in a 3 month old infant.
J Neurosurg 1969;30:169-71.
6 Crisostomo EA, Leaton E, Rosenblum EL. Features of intracranial aneurysms in infants and report of a case. Dev Med Child
Neurol 1986;28:68-72.

Correspondence to Dr N McLellan, Consultant Paediatrician, Selly
Oak Hospital, Raddlebarn Road, Birmingham B29 6JD, England.
Received 19 May 1986

Topical anaesthesia for venepuncture
S CLARKE AND M RADFORD

Department of Child Health, Southampton General Hospital
SUMMARY A topical anaesthetic cream was tested
in a randomised, double blind, placebo controlled
trial of 15 children. The severity of pain experienced
during venepuncture was assessed, using visual
analogue and verbal rating scales. The topical
anaesthetic cream was found to be significantly
superior to placebo using each form of assessment.

Venepuncture is probably the commonest procedure carried out on paediatric patients requiring
medical treatment. Many children tolerate the
procedure well, but for some it is a major ordeal. A
topical preparation that could be applied without

discomfort and alleviate the pain of venepuncture
would be particularly useful for children receiving
repeated venepunctures.
To penetrate intact skin a topical anaesthetic
cream should contain local anaesthetic in high
concentrations. This has hitherto been difficult to
achieve because most anaesthetic bases are crystalline at room temperature and unstable in high
concentrations. By mixing two anaesthetic bases,
lignocaine and prilocaine, in equal proportions, an
eutectic mixture is obtained that is liquid at room
temperature. This mixture, known as EMLA
(Eutectic Mixture of Local Anaesthetics), can be
incorporated into an emulsion without first dissolving the bases in oil, making it possible to attain a