The place of oral penicillin in paediatrics.

In the treatment of sick children the disadvantages of a drug which can be administered only by injection are serious. This applies particularly to wasted infants in the throes of a severe infection. Here the minimum of handling is almost as important as the drug. In February, 1947, it was decided to start an investigation at the Children's Hospital, Birningham, to determine the reliability of penicillin given by mouth in infancy. Two papers had already appeared in this country. Henderson and McAdam (1946) recorded the results of this method of administation to thirty-seven infants. However, only nine of them were over one month old. Wben a dose of 10,000 units was used, bacteriostatic serum levels persisted as long as six hours, while 10,000 units produced a serum concentration persisting as long as fifteen hours. Buchanan (1946) determined the results of administering a dose of 4,000 units per pound of expected body weight per day divided up so that it could be administered before feeds. Satisfactory results were claimed in the twenty-five infants investigated, but again they were mostly under the age of one month. Further work at the same school has shown that it is only in premature infants and in the first month of life that consistently reliable serum levels can be obtained with this dose (Guthre and Montgomery, 1947). During the course of this work, several publications have appeared. Husson (1947) has investigated the serum levels in twenty-two infants up to the age of five months following a dose of 20,000 units orally. In every case be was able to demonstrate a serum level of at least 0 06 units after an interval of three hours. Suchett-Kaye and Latter (1947) treated twenty-five children suffering from pneumonia with oral penicillin. Their ages ranged from three months to two years. The doses used varied from 10,000 to 40,000 units at threeto four-hourly intervals. In only six of the thirteen estimations performed at three hours after the dose was a bacteriostatic level recorded. Despite this, good clinical results were obtained in all but the four most seriously ill cases. One of these was infected with a penicillin-sistant organism. Hoffman et al. (1948)' have performed an extensive survey of this problem in children from infancy up to the age of twelve years. Forty-two infants up to the age of one year suffering from respiratorytract infections were treated with oral doses of 20,000 units three-hourly. In six of them no level was recorded at an interval of three hours, and in five it was only 0-03 unit. The problem has been tackled in older children, but all workers agree that the results obtained are less reliable and the serum levels less sustained than in infancy even with the use of massive doses. Markowitz and Kuttner (1947) gave 50,000 units before breakfast to twenty children up to the age of twelve years. The serun levels in no. case persisted longer than two hous Further, there was an unaccountable variation in the levels obtained in the same individual on successive days with the same dose. Reisman et aL (1947), using a dose of 100,000 units, did not obtain any better result. A case of bacterial endocarditis responding to oral penicillin has been recorded (Burke et al., 1946). This was a girl of eleven years who received 100,000 units three-hourly for fourteen days. There is complete uniformity of opinion that the drug should be given on an empty stomach in order to ensure maximum absorption. The use of buffered solutions now receives little support. Stewart and May (1947) show that an aqueous unbuffered solution gives the best result. Further, their investigations demonstrate that unless the pH of the gastric secretion falls below a level of 3, it exerts no desuctive action on penicillin. They also found that in some cases the administation of glucose with the drug increased the maintenance of the serum level.