Current Literature: 1

Objective Anaphylaxis after immunization, although rare, is serious and potentially life‐threatening. Understanding risk factors for this reaction is therefore important. Gelatin is added to many vaccines as a heat stabilizer. Japanese researchers have demonstrated a strong association between immediate hypersensitivity reactions to measles, mumps, rubella, varicella, and Japanese encephalitis immunizations and subsequent detection of antigelatin immunoglobulin E (IgE) antibodies. They suggested that previous receipt by these patients of diphtheria–tetanus–acellular pertussis vaccines with trace amounts of gelatin was responsible for the sensitization. We aimed to assess whether a similar association exists for vaccinees in the United States who reported anaphylaxis after receipt of measles–mumps–rubella (MMR) or measles vaccines and to review recent trends in reporting of hypersensitivity reactions. Methods We conducted a retrospective case–control study. Cases of anaphylaxis that met a predefined case definition were identified from the US Vaccine Adverse Event Reporting System (VAERS). Mayo Clinic patients who received MMR vaccine uneventfully served as controls. The study subjects were interviewed to obtain the history of allergies. Sera from study subjects and their matched controls were tested for IgE antibodies to gelatin, whole egg and vaccine viral antigens using solid‐phase radioimmunoassay. Data from the Biologics Surveillance System on annual numbers of doses of MMR and varicella vaccines distributed in the United States were used to evaluate possible changes in reporting of selected allergic adverse events. Results Fifty‐seven study subjects were recruited into the study and interviewed. Of these, 22 provided serum samples for IgE testing. Twenty‐seven subjects served as a comparison group and provided a sample for IgE testing; 21 of these completed an allergy history questionnaire. Self‐reported history of food allergies was present more frequently in the interviewed study subjects than in the controls, whereas the proportions of people with other characteristics were similar in both groups. None of the interviewed people had a history of food allergy to gelatin. The level of antigelatin IgE antibodies was significantly higher among study subjects than among controls, whereas the levels of IgE antibodies against egg and all three viral antigens did not differ significantly. Of 22 study subjects, six (27%) tested positive for antigelatin IgE, whereas none of the 27 controls did. The rate of anaphylactic reactions reported to VAERS after measles virus‐containing immunization in the United States between 1991 and 1997 is 1.8 per 1 million doses distributed. No substantial increase in the number of reported allergic events after frequently used gelatin containing MMR and varicella vaccines could be observed during the first 4 years (1997–2000) since the introduction of diphtheria–tetanus–acellular pertussis vaccines for use in infancy. Conclusion Anaphylactic reactions to MMR in the United States are rare. The reporting rate has the same order of magnitude as estimates from other countries. Almost one‐quarter of patients with reported anaphylaxis after MMR seem to have hypersensitivity to gelatin in the vaccine. They may be at higher risk of developing anaphylaxis to subsequent doses of other gelatin‐containing vaccines. These people should seek an allergy evaluation before such immunization.     

Current Literature: 6

Aims   To evaluate the effect of site specific advice from a school travel coordinator on school travel patterns.
Methods   Cluster randomised controlled trial of children attending 21 primary schools in the London boroughs of Camden and Islington. A post-intervention survey measured the proportion of children walking, cycling, or using public transport for travel to school, and the proportion of parents/carers very or quite worried about traffic and abduction. The proportion of schools that developed and implemented travel plans was assessed.
Results   One year post intervention, nine of 11 intervention schools and none of 10 control schools had travel plans. Proportions of children walking, cycling, or using public transport on the school journey were similar in intervention and control schools. The proportion of parents who were very or quite worried about traffic danger was similar in the intervention (85%) and control groups (87%). However, after adjusting for baseline and other potential confounding factors we could not exclude the possibility of a modest reduction in parental concern about traffic danger as a result of the intervention.
Conclusions   Having a school travel coordinator increased the production of school travel plans but there was no evidence that this changed travel patterns or reduced parental fears. Given the uncertainty about effectiveness, the policy of providing school travel coordinators should only be implemented within the context of a randomised controlled trial.     

Current Literature: 4

Background The Clifton area of Nottingham with a total population of nearly 20 000 and a child population of 4500. Aim To track the changes in clinical services provided by community paediatricians in Clifton from 1983 to 1999. Methods The paper tracks changes through a series of reports produced over time by the paediatricians working in the Clifton area. The 5 reports are dated 1983, 1985, 1989–91, 1995, 1999–2000. Results The child population in Clifton dropped somewhat from 4700 to 3900 during the study period. A child health clinic (CHC) with no appointment system and providing Child Health Surveillance was staffed by a senior community paediatric trainee in 1983. This had transformed into a referral clinic with an appointment system by 1995 (still staffed by the trainee). By 2000, the clinic had added a consultation element for GPs, HVs, school nurses and school support teachers for a session a week and added a clinical psychologist to its staff. Trainees staff the clinics still (a lecturer and an SHO) but an Associate Specialist session has been added to provide better continuity of care. In 1983, each infant was seen 26.7 times (range 9–51): 61% at the CHC (mostly for weighing), 31% at the GP surgery. By 1991, GPs had taken on CHS and the clinic had a formal appointment system but with a ‘drop in’ period when necessary. Total attendances dropped by almost a half between 1989 and 1991, as did those attending for immunizations. Primary care referrals accounted for 15.5% of those seen in 1991. Major diagnostic categories included weight and feeding, development, behaviour and ‘minor problems’. By 2000, there were 3 referral clinics a week with the additional consultation clinic. No CHS was provided. Developmental difficulties (61) and behaviour difficulties (60) now top the list of referral categories and the latter include self‐harm, anorexia, Tourette’s, ADHD and conduct disorder, with 8 of these excluded from school. Medical diagnoses (49) such as short stature, epilepsy and various syndromes come next with child protection referrals (28) and weight and feeding (26) following on behind. Hospital consultants had referred some children to be managed by the community paediatricians. Conclusions The authors point out the invisibility of the changes in community paediatric services compared with the more apparent hospital changes. The lack of regular reporting of community data reinforces this invisibility. However they also sound a hopeful note that the community services have shown a constant ability to innovate and respond to changing demand and that this should stand us in good stead in the future.     

Current Literature: 2

An examination is made of a meta-analysis by Attewell et al . (Attewell R, Glase K and McFadden M. (2001) Bicycle helmet efficacy: a meta-analysis. Accident Analysis and Prevention, 33, 345–352), which concludes that bicycle helmets prevent serious injury, to the brain in particular, and that there is mounting scientific evidence of this. The Australian Transport Safety Bureau (ATSB) initiated and directed the meta-analysis of 16 observational studies dated 1987–98. This examination concentrates on injury to the brain and shows that the meta-analysis and its included studies take no account of scientific knowledge of its mechanisms. Consequently, the choice of studies for the meta-analysis and the collection, treatment and interpretation of their data lack the guidance needed to distinguish injuries caused through fracture of the skull and by angular acceleration. It is shown that the design of helmets reflects a discredited theory of brain injury. The conclusions are that the meta-analysis does not provide scientific evidence that such helmets reduce serious injury to the brain, and the Australian policy of compulsory wearing lacks a basis of verified efficacy against brain injury.     

Current Literature: 3

Objective   To identify which clinical situations are the most difficult to manage for general paediatricians in Victoria, Australia.
Methods     Self-administered questionnaires were sent to general paediatricians in Victoria. They were asked their opinions regarding what were the most difficult and the most dangerous clinical situations with which they deal.
Results     The response rate was 64% (63 out of 98 questionnaires sent). The general paediatricians surveyed believed that behavioural, developmental and psychosocial conditions were the most difficult to deal with; conduct disorder was the most nominated clinical category (26% of respondents). The 'dangerous' cases nominated were predominately traditional medical cases. The most commonly nominated category was sepsis and shock (21% of respondents). The most difficult and dangerous clinical situations overall for general paediatricians in Victoria appear to be in the areas of sepsis, child protection, paediatric and neonatal resuscitation, depression and suicide, raised intracranial pressure, intravenous fluid management, and communication with parents and adolescents.
Conclusions     The present survey provides useful information to help with training-programme design and it gives trainee paediatricians an idea of what experienced paediatricians find difficult. Severe behavioural, family and social difficulties, as well as neonatal and childhood resuscitation, severe sepsis, raised intracranial pressure, and intravenous fluid management were the clinical situations most frequently described as difficult.