A new model for low-dose food challenge in children with allergy to milk or egg

Background: Atopic eczema and food allergy are common in early childhood. Children seem to gradually develop tolerance to milk and egg, and it is a relief for families when their child can tolerate small amounts of these basic foods, even if larger doses may still cause symptoms. Aim: To develop a model for low-dose oral food challenge, facilitating re-/introduction of milk or egg. Methods: In 39 children sensitized to milk and/or egg, we performed 52 challenges using a new standardized model for low-dose oral food challenge. The recipes were validated for blinding with sensorial tests. Results: Four children challenged to milk had a positive challenge outcome. There were no significant differences with respect to family history, associated atopic manifestations, nutritional supply, eczema severity, or skin-prick test compared with the non-reacting children, but total and specific IgE values were significantly higher. All but two of the non-reacting children were able to introduce milk and egg into their diet without problems.
Conclusion: We report recipes and a protocol to be used for standardized open and double-blind placebo-controlled low-dose food challenge in young children, enabling the introduction of small amounts of egg and milk into the diet during tolerance development.     

Feeding during acute diarrhea as a risk factor for persistent diarrhea

Dietary intake during diarrhea in children less than three years of age was estimated from information recorded on illustrated dietary forms used by children's caretakers during the first week of illness in a prospective community-based study of diarrheal diseases in Lima, Peru. The frequency of consumption and the amount consumed of food groups and selected commonly consumed foods were analyzed by the final duration of the diarrheal episode. Cereals were less frequently consumed during the acute phase of diarrheal episodes that ultimately became persistent (>14 days'duration), apparently shortening the duration of the episode by one day (median duration of four days in children not consuming vs three days in children consuming cereals during diarrhea, p <0.02 Kaplan-Meier logrank test). Only roots and tubers (mainly potatoes) were consumed in greater quantity during episodes that became persistent. There was no evidence that consumption of breast milk or non-maternal milk was associated with an alteration in diarrheal duration. This study provides further evidence of the beneficial effects of continuing feeding during diarrhea using foods available at the home level, especially cereals, which are commonly used in the diet of young children.     

Fatal unintentional traumatic asphyxia in childhood

OBJECTIVE: The present study was undertaken to examine specific features of unintentional traumatic asphyxial deaths in childhood. METHODS: Coronial files and records at the Forensic Science Centre in Adelaide, South Australia, were examined over a 35-year period from 1966 to 2000 for all cases of traumatic asphyxial death occurring in children under the age of 17 years. RESULTS: Six cases of unintentional fatal traumatic asphyxia were identified. All of the victims were boys with an age range of 2-15 years (mean 6.8 years) and all were found dead at the scene. Fatal traumatic asphyxia resulted from entrapment beneath a chest of drawers, beneath a table tennis table, between a pile of wooden pallets and a metal fence, between a conveyor belt and its frame, and under a motor vehicle (in two cases). CONCLUSIONS: Fatal traumatic asphyxia in childhood is a rare event, with younger children commonly being trapped by furniture or by industrial equipment while playing, and older children being trapped under motor vehicles in similar circumstances to adult traumatic asphyxial deaths. Unsupervised play of young children around heavy and potentially unstable pieces of furniture may be dangerous, particularly if more than one child is present. Unsupervised play of young children in industrial yards should be avoided.     

Clinical manifestations and outcome of Haemophilus influenzae type b disease

Objectives: To document clinical manifestations, laboratory findings and outcome of childhood Haemophilus influenzae type b (Hib) infections.
Methodology: Medical records of 235 children with Hib disease admitted to hospital during a 2 year period were reviewed; additional information was obtained by questionnaire and follow up 6 weeks after discharge.
Results: Three-quarters of patients presented with either meningitis or epiglottitis. Children with epiglottitis were older, had shorter illnesses and were less likely to have had antibiotics before admission than those with meningitis; 38% of the latter had been given some antibiotic therapy, with no apparent effect on the outcome. Fever persisted for 7 days or more in 23% of patients with meningitis. Death from meningitis occurred in 3.8% of patients and was due to fulminating disease.
Conclusions: These data will assist in recognition and appropriate management of Hib disease as the clinical manifestations become less familiar following the introduction of immunization. Specific laboratory diagnosis is required for accurate surveillance, which should be maintained in order to ensure high immunization rates.     

Thrombocytopenia after immunization of Canadian children, 1992 to 2001

BACKGROUND: Thrombocytopenia occasionally follows immunization of children, especially after administration of measles-containing vaccines. The purpose of this study was to describe the clinical features of postimmunization thrombocytopenia, with emphasis on the rate of complications and outcome. METHODS: A prospective survey was conducted by 12 pediatric centers in Canada during 1992 to 2001. At each center a nurse monitor searched for inpatient cases. Cases were defined as having onset of clinical signs or laboratory measures of thrombocytopenia (platelet count, <50 x 10(9)/l) within 30 days after immunization. Cases were described in a standardized manner, including follow-up data as available. RESULTS: Sixty-one cases were detected, an average of 6 per year or approximately 1 case per 15,000 general hospital admissions. Median age of cases was 13 months. The mean platelet count at diagnosis was 8.6 x 10(9)/l. Most cases (79%) followed measles-containing vaccines. Only 1 child had a serious (fatal) complication. Platelet counts returned to normal within 30 days of onset in 46 of 57 children (80.7%) with information available. Five children (8.2%) had persistent or intermittent thrombocytopenia for 3 months or more. CONCLUSION: Thrombocytopenia associated with routine immunization of children is rare and usually benign, resolving within 1 month in most children.     

Lumbar disc herniation in young children

Aim:  This article explores lumbar disc herniation in young children through focusing on matters relevant to patient presentation, physical examination, differential diagnosis, imaging and treatment.
Methods:  Major databases were searched for studies that addressed lumbar disc herniation in young children.
Results:  Diagnosis of lumbar disc herniation in young children is usually delayed because of the rarity and lack of experience with this entity and the difficulty in extracting a reliable medical history. Nevertheless, lumbar disc herniation should be considered in the differential diagnosis of any young child presenting with a chief complaint of back pain and/or radiculopathy, especially in the setting of recent trauma. This should be coupled with a directed physical examination to elicit signs and narrow the differential diagnosis. Imaging studies, mainly magnetic resonance imaging, will help establish a diagnosis; yet radiographs are still required to exclude other spinal lesions. The initial management of lumbar disc herniation in children is the same as that in adults and consists of conservative treatment unless lumbar disc herniation affects the patient's motor and neurological functions in which case, early surgical treatment must be undertaken. Although the latter remains more difficult, current experience suggests a favourable outcome.
Conclusion:  Awareness of lumbar disc herniation will help the paediatrician extract a relevant medical history, perform a directed physical examination, and order appropriate imaging studies. This will aid in initiating early intervention, be it conservative or operative, and achieving a favourable outcome.     

Severe food-allergic reactions in children across the UK and Ireland, 1998-2000

Aim: Medical and lay concerns about food allergy are increasing. Whilst food allergy may be becoming more common, fatal reactions to food in childhood are very rare and their rate is not changing. We sought to establish how common severe reactions are. Methods: Prospective survey, 1998 to 2000, of hospital admissions for food-allergic reactions—conducted primarily through the British Paediatric Surveillance Unit, covering the 13 million children in the United Kingdom and Ireland. Results: 229 cases reported by 176 physicians in 133 departments, yielding a rate of 0.89 hospital admissions per 100 000 children per year. Sixty-five per cent were male, 41% were under 4 y and 60% started at home. Main allergens were peanut (21%), tree nuts (16%), cow's milk (10%) and egg (7%). Main symptoms were facial swelling (76%), urticaria (69%), respiratory (66%), shock (13%), gastrointestinal (4%). Fifty-eight cases were severe. Three were fatal, six near fatal, and 8 of these 9 had asthma with wheeze being the life-threatening symptom. Three near-fatal cases received excess intravenous epinephrine. None of the non-fatal reactions resulted in mental or physical impairment. Seven of 171 non-severe and 6/58 severe cases might have had a worse outcome if epinephrine auto-injectors had been unavailable. Six of the severe cases might have benefited if auto-injectors had been more widely prescribed.

Conclusion: In the United Kingdom and Ireland, the incidence of severe reactions is low. The study highlights that: asthma is a strongly significant risk factor for a severe reaction and therefore warrants optimal management; severe wheeze is a prominent feature of severe reactions and warrants optimal management; intravenous epinephrine should be used with great care if needed. Epinephrine auto-injectors do not always prevent death, but our study design and data do not allow a definite statement about whether overall they are beneficial.     

Video-assisted thoracoscopic surgery in the paediatric population

Objective: Video-assisted thoracoscopic surgery (VATS) is now widely practised in adults but there are few publications on its application in the paediatric population.
Methodology: Retrospective review of the authors' experience with VATS in children under 16 years old during an 18 month period in a university teaching hospital.
Results: From September 1993 to March 1994, VATS was attempted in 14 patients. Five were unsuccessful because of pleural symphysis or inability to collapse the upper lung. Ten cases of VATS were successfully performed in the remaining nine patients (eight males, one female; age range from 22 days to 15 years old). These included two drainages and limited decortications for loculated pleural effusion, one guided drainage of pericardial effusion, one thymectomy for thymic hyperplasia, three wedge resections for metastatic pulmonary osteosarcoma and three bleb excisions and pleurodesis for primary spontaneous pneumothoraces. There were no intra-operative complications. There was one death from dysrhythmia following an uneventful wedge resection. The mean duration of chest tube drainage was 1.4 days and postoperative hospital stay 2.6 days excluding two patients who stayed for further medical treatment.
Conclusion: VATS is a useful approach in selected cases but further development of this approach awaits refinement of anaesthetic technique and endoscopic instrumentation.     

Suspected infections in children treated for ALL

Aim:  The aim of our study was to get epidemiological information on bacterial infections in children treated for ALL and to analyse which patients have an enhanced infection risk.
Methods:  Episodes of suspected or confirmed infections were evaluated during the first 12 months of treatment for childhood acute lymphoblastic leukaemia (ALL).
Results:  The number of patients was 73 (43 boys). The median age was 4.6 years. A total of 179 episodes occurred, varying from none in six patients to eight in one. Bacteria were cultured in 57 episodes (31.8%), the most common being coagulase-negative staphylococci. The number of episodes fell significantly with increasing age for suspected and confirmed infections (p < 0.001 and p = 0.03). The proportion of confirmed infections was significantly higher (p < 0.001) in the first episodes. The average number of suspected infections was higher in girls than in boys (p = 0.03), but confirmed infections were not.
Conclusion:  Most of the serious infections occur early in the treatment and the number of suspected and confirmed infections falls with age. Suspicion of infection is more likely in girls, but the number of confirmed infections is equal in both sexes. Coagulase-negative staphylococcus was most commonly isolated, highlighting the importance of careful handling of central venous devices.     

Egg allergy

Egg allergy is one of the most common food allergies in infants and young children. The great majority is not life-threatening and management involves exclusion of egg from the diet and regular review with the expectation that the majority of children will outgrow the allergy by school age. Judgment is required as to when the dietary elimination of egg is no longer required. This decision may be helped by demonstrating loss of sensitivity by skin prick or specific IgE testing and in some cases a supervised food challenge. Particular issues in management arise with more severe, potentially life-threatening reactions, with immunization with vaccines prepared in eggs, with the diagnosis of egg hypersensitivity as a cause of delayed exacerbations of eczema which can be non-IgE mediated, and in deciding whether a child can be allowed to ingest small amounts of cooked egg through egg-containing foods while continuing to avoid raw egg or larger amounts of whole egg. Cases which illustrate these issues are presented.     

Gender differences in food-related concerns, beliefs and behaviours of North Queensland adolescents

Objective : To describe the beliefs, attitudes, behaviours and knowledge of North Queensland adolescents about food and nutrition.
Methodology : A questionnaire surveyed 791 Year 8 students from private schools.
Results : More girls than boys felt guilt about food, sometimes ate from boredom, reported trying to select foods that were good for them and were concerned about the fat content of food; 30% of boys and 17% of girls thought they should be concerned about their food intake only when overweight.
Low daily dietary intakes were reported for: bread, fruit, vegetables and dairy products with only 24% eating at least one fruit, one vegetable, one dairy product and one core cereal food daily. Fat and sugar intake was high: 41% students ate high fat savoury foods and 53% ate high sugar foods at least seven times during the week.
Parents, television and school provided information about food and nutrition to 70-80% of these students, followed by friends and magazines with doctors and teachers providing information on weight and weight loss to 10% of students.
Conclusions : Doctors should be aware of the low intake of recommended foods as well as the high intakes of fat and sugar among adolescents and the gender differences in food related beliefs and behaviours when treating nutrition related diseases and providing guidance for their prevention.     

Fire‐related child deaths: What do newspaper case reports tell us?

Objective:   To describe the accuracy and public health relevance of newspaper accounts of child deaths from fire-related incidents.
Methods:   Domestic fire-related deaths of children aged under 15 years in Auckland, New Zealand, over a 10-year period were retrospectively identified from fire service records and the national minimum mortality dataset. Forensic pathology and fire service records were reviewed and this information was compared with reports published within 3 days of the index event in the region's sole daily newspaper.
Results:   All 14 fatal fire-related events (19 deaths) identified using fire service records and the national minimum dataset during the study period were reported in the newspaper with a high degree of detail and accuracy. Only four news items informed readers of specific measures that could prevent such events.
Conclusions:   Daily newspapers can provide reliable, useful and timely surveillance data on the incidence of fire-related childhood deaths. However, these reports often represented missed opportunities to disseminate public health messages that raised awareness of sources of risk and means of preventing fire-related deaths.     

An experimental test of parenting practices as a mediator of early childhood physical aggression

Background:  Parenting practices predict early childhood physical aggression. Preventive interventions that alter parenting practices and aggression during early childhood provide the opportunity to test causal models of early childhood psychopathology. Although there have been several informative preventive intervention studies that test mediation models in older children, no such studies have been conducted with younger children at high risk for psychopathology.
Method:  Within the context of a randomized controlled trial, we examined whether changes in parenting practices mediate the effects of a family intervention on observed physical aggression among African American and Latino younger siblings of adjudicated youths.
Results:  Improved parenting practices partially mediated the intervention effect on physical aggression. Improvements in harsh parenting, responsive parenting, and stimulating parenting explained a significant amount of the intervention effect on child physical aggression observed in the context of parent–child interactions. Parenting practices accounted for 38% of the intervention effect on physical aggression.
Conclusions:  There was support for the hypothesized model of the prevention of physical aggression during early childhood. Intervention benefits on parenting practices partially accounted for intervention effects on physical aggression in young high-risk children.     

Prevalence and impact of chronic childhood conditions in Auckland, New Zealand

Objective : To establish the prevalence of specific chronic conditions of childhood in the Auckland area and to quantify resource use by these children.
Methodology : Estimates were made from available registry data and published data sources of the population of children with selected chronic conditions resident in the Auckland Area Health Board area. Resource use data were extracted for admissions to Auckland public hospitals and from providers of community based technology services.
Results : The largest community prevalence groups are those with asthma, intellectual handicap, congenital heart disease and epilepsy. Children aged 0-14 with chronic conditions accounted for at least 14340 hospital days stay in Auckland in 1992 at an estimated minimum cost of $7.9 million. Over 200 children are dependent on technological aids at home.
Conclusions : There are sparse data on the numbers and needs of children with chronic conditions in the population. A non-categorical approach which crosses disease entities may be the best method of meeting common needs.     

The accuracy of the clinical histories given by mothers of seriously ill African children

The mothers of 87 Gambian children with a potentially fatal illness were interviewed at the time that their children were admitted to hospital and attempts were made to establish a diagnosis using the mothers' history alone. In 66 cases (76%) initial diagnoses corresponded to the diagnoses established finally by clinical and laboratory investigations. Diagnoses established at second interviews held with 51 mothers 1 month after their children had left hospital were accurate in 88% of cases. Gambian mothers can describe accurately a serious illness in their children and they can, therefore, be relied upon to give accurate information about an illness from which a child has died.     

Fatal Bacterial Infections in the Antibiotic Era

Summary and Conclusions
Some fatal cases of bacterial infections from a children's hospital are presented and analysed. The total mortality in such diseases is now low in Sweden. In order to reduce it still further, the following precautions are suggested:
1. Early clinical and bacteriological diagnosis (especially in infants regarding capillary bronchitis and meningitis).
2. Bacteriological examinations (sensitivity tests included), repeated in cases with poor response to treatment. Early report of results.
3. Good hospital hygiene. The hospital should not be dangerous for the patients.
4. No prophylaxis with antibiotics. Limited use of broad spectrum antibiotics for treatment.
5. In fatal cases with proven or suspected infections bacteriological examinations post mortem are important for complete evaluation.     

Sunburn and sun protection among young children

Objective: To examine the extent of sun exposure, sun protection and experience of sunburn among young New Zealand children on summer weekends.
Methods: In a telephone survey of 1243 respondents, those with children in the household were asked about sun exposure and protection for the youngest child in the family. Information was obtained for 285 children aged from infancy to 10 years.
Results: Over 90% of the children were reported to be outside on the preceding Saturday and/or Sunday; 7% of those outside experienced some degree of sunburn. The worst burning was on the face, head, neck or ears. On either day about half the children were wearing sunscreen and 60% were wearing a hat. Parental use of sun protection was the strongest predictor of sun protection among the children.
Conclusions: While reports of sun protection among young children were encouraging, many children in the community are still at high risk of sunburn. Efforts to promote sun protection as a family responsibility may reduce the experience of burning among the young.     

Deliberate self-harm by under-15-year-olds: characteristics, trends and outcome

Background:  Relatively little information is available about the characteristics and long-term outcome of children and adolescents aged under 15 years who present to general hospitals because of deliberate self-harm (DSH).
Method:  Information was collected on 710 consecutive under-15-year-olds presenting to a general hospital in central England with DSH over a 26-year period (1978–2003). Outcome in terms of death was investigated from national statistics in 464 cases presenting during the first 20 years of the study.
Results:  Most individuals were aged 12–14 years. In this age group the female:male ratio was 6.5:1. Nearly all (680/710, 95.8%) had taken overdoses, over half of these episodes involving paracetamol (acetaminophen). Few had a history of prior (7.7%) or current psychiatric treatment (7.7%), although a quarter (150/559, 26.8%) had a history of previous DSH. Suicidal intent was usually low. The most frequent problems were difficulties in relationships with family members (77.3%) and with friends (38.9%), and school/study problems (37.9%). The long-term risk of suicide was low, 1.1% ( N  = 5) having died by probable suicide after a mean follow-up period of 11 years 2 months.
Conclusions:  DSH in children and young adolescents is usually related to life problems, is generally of low suicidal intent, and is associated with a relatively low long-term risk of suicide.