No increased risk of relapse after meningococcal C conjugate vaccine in nephrotic syndrome.

OBJECTIVES: To investigate whether meningococcal C conjugate vaccine (MCCV) caused relapse in children with steroid-responsive nephrotic syndrome. DESIGN: A population-based study was conducted using an active surveillance system, developed to assess adverse events following vaccination, which linked hospital record information on relapses of nephrotic syndrome to community child health population MCCV data. An ecological study looking at hospital admissions for nephrotic syndrome in different age cohorts of children before and after the MCCV introductory campaign was also carried out. SETTINGS: South East England, and England and Wales. PATIENTS: 52 children having 162 relapses of nephrotic syndrome. Also, all hospital admissions of children aged 2-18 years with steroid-responsive nephrotic syndrome in England and Wales between 1995 and 2003, relating admissions to when MCCV was introduced in specific age cohorts. MAIN OUTCOME MEASURES AND ANALYSIS METHOD: Self-controlled case series analysis looking for increased risk of relapse following MCCV and changes in admission rates for nephrotic syndrome (incidence ratio) following the introduction of MCCV to different age cohorts of children. RESULTS: There was no increased risk of relapse following MCCV in the self-control case series, where a relative incidence of 0.95 (95% confidence interval (CI) 0.61-1.47) was found in the 6-month post-vaccination period, or in the ecological study, which gave an incidence rate ratio of 1.05 (95% CI 0.95 to 1.15) for the quarter when MCCV was introduced and the following two quarters. CONCLUSIONS: We found no association between MCCV and nephrotic syndrome, which is therefore not a contraindication to meningococcal vaccination.     

Diagnoses made in a secondary care "fits, faints, and funny turns" clinic

Aims

To investigate the diagnoses made for children referred to a “fits, faints, and funny turns” clinic.

Methods

Prospective study of 380 children referred to a dedicated secondary care clinic over an eight year period.

Results

Twenty three per cent of children were given a final diagnosis of one of the childhood epilepsies, with 48% of these having a specific epilepsy syndrome. Syncope was the commonest cause of a non‐epileptic event (syncope and reflex anoxic seizures comprised 100/238, 42%) but there were a wide variety of other causes. Fifty three events (14%) were unclassified and managed without a diagnostic label or treatment.

Conclusions

In children with funny turns referred to secondary care, the diagnostic possibilities are numerous; among non‐epileptic events, syncopes predominate. The majority do not have epilepsy. Unclassifiable events with no clear epileptic or non‐epileptic cause are common and can be safely managed expectantly.     

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is associated with a prolonged gestational age

Background

The timing of parturition in most mammals is thought to be linked to a late gestational rise in corticosteroid production by the fetal adrenal gland. We hypothesised that gestational age would be prolonged in our patients with impaired cortisol production secondary to congenital adrenal hyperplasia (CAH) due to 21‐hydroxylase deficiency.

Methods

We compared the gestational age of patients affected by salt‐wasting CAH due to 21‐hydroxylase deficiency (born 1978–2004; n = 31) with that of children with congenital hypothyroidism (born 1981–2003; n = 30) and a control group of short normal children (born 1980–2002; n = 120). Each group was compared with national (England 2002–3) and regional (2003–4) data on gestational age from hospital episode statistics. Post‐term delivery was defined as birth beyond 41 completed weeks.

Results

National statistics reveal a frequency of 4.4% for singleton deliveries beyond 41 weeks. In our region the frequency was 4.6%. In the group of children with CAH, the frequency of post‐term delivery was 19.3% (p<0.001). In patients with congenital hypothyroidism, the frequency was 13.3% (p = 0.02). The proportion of short children who did not have a recognised endocrinopathy born post term was comparable to national and regional data at 6.7%.

Conclusions

A prolonged gestation is more likely in pregnancies where the fetus has the salt‐wasting form of CAH. This may be due to impaired cortisol production, although other changes in steroidogenesis may also be contributory.     

Assessing the population impact of low rates of breast feeding on asthma, coeliac disease and obesity: the use of a new statistical method

Background

Lack of breast feeding has been reported to be associated with a number of chronic childhood disorders.

Aim

To use a recently described measure, the population impact number of eliminating a risk factor over a time period (PIN‐ER‐t), to quantify the burden of low rates of breast feeding in a UK population of babies born in 2002 with regard to asthma, coeliac disease and obesity.

Methods

We performed literature searches for systematic reviews with meta‐analyses that had investigated the association between breast feeding and asthma, coeliac disease and obesity. Based on these data, and published data on the prevalence of breast feeding and the prevalence of the disorders, we calculated PIN‐ER‐t and estimated the number of cases of each disorder which could be prevented by eliminating “no breast feeding” as a risk factor.

Results

In the population of the 596 122 babies born in England and Wales in 2002, the number of cases of asthma, coeliac disease and obesity that could be prevented over 7–9 years if “no breast feeding” as a risk factor was eliminated were 33 100 (95% CI 17 710 to 47 543), 2655 (95% CI 1937 to 3343) and 13639 (95% CI 7838 to 19308), respectively.

Conclusions

The population burden of low breast feeding rates is high with regard to these chronic disorders. The use of PIN‐ER‐t allows the population burden of low breast feeding rates to be quantified and communicated in a way that will make it easier for both the general public and decision makers to understand.     

Association between allergic rhinitis, bottle feeding, non-nutritive sucking habits, and malocclusion in the primary dentition

Aim

To determine the association between allergic rhinitis, bottle feeding, non‐nutritive sucking habits, and malocclusion in the primary dentition.

Methods

Data were collected on 1160 children aged 4–5 years, who had been longitudinally followed since the age of 4 months, when they were admitted to nurseries in a suburban area of Tampico–Madero, Mexico. Periodically, physical examinations were conducted and a questionnaire was given to their parents or tutors.

Results

Malocclusion was detected in 640 of the children (51.03% had anterior open bite and 7.5% had posterior cross‐bite). Allergic rhinitis alone (adjusted odds ratio = 2.87; 95% CI 1.57 to 5.25) or together with non‐nutritive sucking habits (adjusted odds ratio = 3.31; 95% CI 1.55 to 7.09) had an effect on anterior open bite. Bottle feeding alone (adjusted odds ratio = 1.95; 95% CI 1.07 to 3.54) or together with allergic rhinitis (adjusted odds ratio = 3.96; 95% CI 1.80 to 8.74) had an effect on posterior cross‐bite. Posterior cross‐bite was more frequent in children with allergic rhinitis and non‐nutritive sucking habits (10.4%).

Conclusions

Allergic rhinitis alone or together with non‐nutritive sucking habits is related to anterior open bite. Non‐nutritive sucking habits together with allergic rhinitis seem to be the most important factor for development of posterior open bite in children under the age of 5 years.     

Neonatal vitamin K prophylaxis in Great Britain and Ireland: the impact of perceived risk and product licensing on effectiveness

Objective

To determine current use of vitamin K (VK) prophylaxis in newborns and review the efficacy and effectiveness of regimens used.

Design

Efficacy and effectiveness calculated using current practice details, data from Southern Ireland and two previous surveys, together with contemporaneous studies of vitamin K deficiency bleeding (VKDB).

Setting

Current survey: United Kingdom (Great Britain and Northern Ireland). Efficacy and effectiveness tables: United Kingdom and Southern Ireland.

Main outcome measures

Current VK prophylaxis following uncomplicated term deliveries. Relative risk of VKDB calculated for the VK actually received and for “intention to treat”.

Results

Questionnaire response rate 95% (n = 243), all recommending VK prophylaxis. No association between unit size and route of administration. For uncomplicated term deliveries, 60% recommended intramuscular (IM) prophylaxis, 24% oral and 16% offered both routes without bias. All units offering IM gave a single dose, mostly 1 mg Konakion Neonatal. Oral regimens showed more variation: two thirds gave 2 mg (range 0.5–2 mg), the number of doses ranged from 1 to 11 and many used preparations off‐licence or the unlicensed Orakay. IM prophylaxis, if given, provided the best protection (most efficacious) against VKDB. However, on an intention‐to‐treat basis (effectiveness), there is no statistically significant difference between the risks of VKDB after intended IM VK and after oral prophylaxis intended to continue beyond a week.

Conclusions

Although the principles of VK prophylaxis is now accepted by all, there is no uniformity in practice. Omission of prophylaxis appears to be a greater problem for IM than for multi‐dose oral prophylaxis, affecting overall effectiveness.     

The misdiagnosis of epilepsy in children admitted to a tertiary epilepsy centre with paroxysmal events

Aims

To determine the proportion of children admitted with difficult to treat paroxysmal events to a tertiary epilepsy centre who did not have epilepsy.

Methods

In an observational retrospective study, all case notes of 223 children admitted in 1997 were examined. The referral was made from the local paediatric department in 51% of cases, other departments in 27%, and from general or specialist practitioners in 22%. Doubt regarding the diagnosis of epilepsy was expressed in the referral note in 17%. On admission, 86% were on antiepileptic drug treatment. During admission all children were subjected to a comprehensive intensive observation and 62% had EEG monitoring.

Results

In total, 39% (87/223) were found not to have epilepsy. In 30% of children (55/184) referred without any doubts about the epilepsy diagnosis, the diagnosis was disproved. Of the 159 children admitted for the first time, 75 (47%) were discharged with a diagnosis of non‐epileptic seizures. Of 125 children admitted for the first time with no doubts about the diagnosis of epilepsy, 44 (35%) did not have epilepsy. Staring episodes were the most frequently encountered non‐epileptic paroxysmal event. Psychogenic non‐epileptic seizures were found in 12 children. A total of 34 (15%) had their medication tapered off; a further 22 (10%) had tapered off medication before admission.

Conclusion

The present study supports the view that misdiagnosis of epilepsy is common. The treating physician should be cautious in diagnosis, especially of staring episodes. A diagnostic re‐evaluation should be undertaken in difficult cases with continuing paroxysmal events in order to avoid unnecessary drug treatment and restrictions on the child''s lifestyle.     

Respiratory infections in schoolchildren: co-morbidity and risk factors

Aims

To assess co‐morbidity and risk factors for otitis media, tonsillopharyngitis, and lower respiratory infections in school children.

Methods

Logistic regression analysis of co‐morbidity and risk factors for airway infections in a population based sample of 10 year old children living in Oslo, Norway. Main outcome measures: otitis media, tonsillopharyngitis, and lower respiratory infections in past 12 months.

Results

Airway infections in 10 year old children were common, and significant co‐morbidity was found between the various airway infections. Home dampness was a risk factor for all infections, adjusted odds ratios ranging from 1.2 (95% CI 1.0 to 1.5) to 1.4 (95% CI 1.1 to 1.6) for otitis media and tonsillopharyngitis respectively. Atopic disease was a constitutional risk factor, particularly strong for lower airway infections (adjusted odds ratio 2.4, 95% CI 1.8 to 3.1). African or Asian ethnicities were associated with the airway infections, adjusted odds ratios ranging from 1.2 (95% CI 0.9 to 1.7) to 1.7 (95% CI 1.2 to 2.3).

Conclusions

Respiratory tract infections were common in 10 year old children. There was substantial co‐morbidity between upper and lower airway infections. Environmental and constitutional factors were identified and positively associated with the infections. Results support the hypothesis of 1957 that the whole respiratory tract is one unit.     

Acceptability of perinatal rapid point-of-care HIV testing in an area of low HIV prevalence in the UK

Objective

To determine the uptake of current antenatal HIV testing, the prevalence of risk factors for HIV in pregnant women and the acceptability of the rapid point‐of‐care HIV test (RPOCT) among pregnant women and their midwives.

Design

A retrospective review of 717 notes to determine current HIV screening practices and a cross‐sectional survey using a self‐completed questionnaire for pregnant women and midwives.

Setting

The antenatal clinic (ANC) and postnatal wards (PNW) at a university teaching hospital in the West Midlands.

Participants

486 women attending the ANC or admitted to the PNW during a fortnight in May–June 2006. 72 midwives on the delivery ward completed a second questionnaire.

Results

The questionnaire showed that 90.4% of those offered the standard HIV test accepted it, with 7.2% having at least one risk factor for HIV. Over half of the decliners perceived themselves as not at risk. 85.2% would accept the rapid test, including 35.6% of the decliners. 92.8% of midwives agreed/strongly agreed the RPOCT has a role on the delivery ward and 97.2% would be happy to offer the test with appropriate training and guidance.

Conclusions

Midwives deem the RPOCT to be appropriate for a variety of perinatal settings. It is also acceptable to a clinically significant proportion of those who decline the standard test (21 of 59) and therefore has the potential to increase screening and detection rates. Hence, by allowing early diagnosis and the initiation of antenatal interventions, it could reduce the rate of mother‐to‐child transmission (MTCT) in the UK.     

Fetal growth restriction: relation to growth and obesity at the age of 9 years

Objective

To assess growth patterns of 9‐year‐old children, some of whom had intrauterine growth restriction (IUGR).

Method

75 9‐year‐old children (41 were IUGR infants) were weighed and measured at birth, at 1 year, at 2 years and at 9 years of age. Using general linear models for continuous data, changes in weight z scores were used to quantify growth rate between birth and 9 years of age.

Results

IUGR children were smaller at birth (weight z score –2.1 v 0.2 in normal children; p<0.001) but showed a greater increase in their weight between birth and 9 years (change of weight z score 1.5 v 0.4 in normal children; p = 0.001). At the age of 9 years the weight, height and body mass index (BMI) z scores were lower in IUGR children than the control children (weight z score –0.4 v 0.6, respectively; p<0.001, height z score –0.5 v 0, respectively; p = 0.002, BMI z score −0.2 v 0.7, respectively; p = 0.002). The predictors of these differences were IUGR, birth weight and maternal and paternal heights.

Conclusion

IUGR infants grow faster but remain shorter and lighter than their normal counterparts—that is, they fail to fully catch up by 9 years of age.     

Adrenocortical suppression increases the risk of relapse in nephrotic syndrome

Objective

Children with nephrotic syndrome (NS) are usually treated with long‐term low dose alternate day prednisolone with or without glucocorticoid sparing therapy, such as levamisole or ciclosporin, to maintain remission. The degree of hypothalamic‐pituitary‐adrenal axis (HPA) suppression with such therapeutic strategies has not been studied systematically. HPA suppression could cause a relapse or adrenal crisis.

Study design

To study the risks of HPA suppression, a modified low dose synacthen test (0.5 μg) was administered to 32 patients (22 male,10 female) with a mean age of 9.7 years (range 3.8–17.6 years) with NS receiving long‐term alternate day prednisolone for over 12 months. Twelve patients received alternate day prednisolone, 11 alternate prednisolone+levamisole and nine alternate prednisolone+ciclosporin. All patients were followed up for 3 years and the relapse rate noted.

Results

20/32 (62.5%) patients had a peak serum cortisol concentration of <500 nmol/l, which suggested suboptimal cortisol secretion and possible HPA suppression. 10/12 children in the prednisolone group and 8/11 in the levamisole group had a suboptimal cortisol response compared with 2/9 in the ciclosporin group. During follow‐up, the 20 children who had a suboptimal cortisol response had significantly more relapses (95 relapses) compared to the 12 children with a normal cortisol response who had 24 relapses (p = 0.01).

Conclusions

Children with NS receiving long‐term alternate day prednisolone therapy are at risk of developing HPA suppression and should be evaluated using the modified synacthen test. Children with evidence of HPA suppression are at a greater risk of relapse.     

Sudden infant death syndrome and sleeping position in pre-term and low birth weight infants: an opportunity for targeted intervention

Aims

To determine the combined effects of sudden infant death syndrome (SIDS) risk factors in the sleeping environment for infants who were “small at birth” (pre‐term (<37 weeks), low birth weight (<2500 g), or both).

Methods

A three year population based, case‐control study in five former health regions in England (population 17.7 million) with 325 cases and 1300 controls. Parental interviews were carried out after each death and reference sleep of age matched controls.

Results

Of the SIDS infants, 26% were “small at birth” compared to 8% of the controls. The most common sleeping position was supine, for both controls (69%) and those SIDS infants (48%) born at term or ⩾2500 g, but for “small at birth” SIDS infants the commonest sleeping position was side (48%). The combined effect of the risk associated with being “small at birth” and factors in the infant sleeping environment remained multiplicative despite controlling for possible confounding in the multivariate model. This effect was more than multiplicative for those infants placed to sleep on their side or who shared the bed with parents who habitually smoked, while for those “small at birth” SIDS who slept in a room separate from the parents, the large combined effect showed evidence of a significant interaction. No excess risk was identified from bed sharing with non‐smoking parents for infants born at term or birth weight ⩾2500 g.

Conclusion

The combined effects of SIDS risk factors in the sleeping environment and being pre‐term or low birth weight generate high risks for these infants. Their longer postnatal stay allows an opportunity to target parents and staff with risk reduction messages.     

Severity of meningococcal infections is related to anthropometrical parameters

Background

Invasive meningococcal infections remain an important cause of death in children. In addition, malnutrition has been classically associated with increased severity of infectious diseases. However, in our experience lethal meningococcaemia in clinically malnourished children is extremely rare. Our purpose was to determine whether there is an association between nutritional status and outcome in children with invasive meningococcal infection.

Methods

We carried out an observational study and prospectively determined anthropometrical parameters in 127 children aged 1 month to 4 years with invasive meningococcal infection seen in our inpatient facilities from August 1999 to May 2004. Severity and survival were the clinical end points analysed.

Results

Children with severe disease had higher weight for age (1.02 vs −0.19) and height for age (1.12 vs −0.58) z scores than those with non‐severe disease. Non‐survivors had higher weight for age (0.90 vs −0.16) and height for age (0.73 vs −0.57) z scores than survivors. Clinical and biological variables usually accepted as predictors of high mortality or severity in patients with meningococcal infection were not significantly associated with weight for age and height for age z scores.

Conclusion

In the present prospective series of children with invasive meningococcal disease, severity and death were linked to anthropometrical parameters and seemed to be associated with a very good nutritional status, which confirmed our previous uncontrolled observations.     

An 8 year study of risk factors for SIDS: bed-sharing versus non-bed-sharing

Background

It is unclear if it is safe for babies to bed share with adults. In Ireland 49% of sudden infant death syndrome (SIDS) cases occur when the infant is bed‐sharing with an adult.

Objective

To evaluate the effect of bed‐sharing during the last sleep period on risk factors for SIDS in Irish infants.

Design

An 8 year (1994–2001) population based case control study of 287 SIDS cases and 831 controls matched for date, place of birth, and sleep period. Odds ratios and 95% confidence intervals were calculated by conditional logistic regression.

Results

The risk associated with bed‐sharing was three times greater for infants with low birth weight for gestation (UOR 16.28 v 4.90) and increased fourfold if the combined tog value of clothing and bedding was ⩾10 (UOR 9.68 v 2.34). The unadjusted odds ratio for bed‐sharing was 13.87 (95% CI 9.58 to 20.09) for infants whose mothers smoked and 2.09 (95% CI 0.98 to 4.39) for non‐smokers. Age of death for bed‐sharing and sofa‐sharing infants (12.8 and 8.3 weeks, respectively) was less than for infants not sharing a sleep surface (21.0 weeks, p<0.001) and fewer bed‐sharing cases were found prone (5% v 32%; p = 0.001).

Conclusion

Risk factors for SIDS vary according to the infant''s sleeping environment. The increased risk associated with maternal smoking, high tog value of clothing and bedding, and low z scores of weight for gestation at birth is augmented further by bed‐sharing. These factors should be taken into account when considering sleeping arrangements for young infants.     

Adaptation of the Manchester-Minneapolis Quality of Life instrument for use in the UK population

Introduction

The availability of health‐related quality of life (HRQL) measures that are reliable, valid, brief and comprehensible and appropriate for use with UK children is limited. We report the validation of a HRQL measure suitable for UK use in healthy children, children with chronic disease conditions and socially disadvantaged children.

Patients

A total of 1238 children took part in the study, including healthy children as controls (n = 824) and five exemplar groups: children diagnosed with asthma (n = 87), diabetes (n = 103) or inflammatory bowel disease (IBD; n = 69), children in remission from cancer (n = 68) and children in public care (n = 87).

Methods

In phase I, the Manchester‐Minneapolis Quality of Life instrument (MMQL) Child Form was translated into UK English. In phases II and III, the questionnaire was shortened and validated.

Results

MMQL was anglicised and shortened to five components comprising 29 items. Good internal reliability was found with α reaching at least 0.69 for all subscales. Construct validity was established through moderate correlations with comparable PedsQL subscales (Pearson''s r ranged from 0.38 to 0.58, p<0.01). Discriminant validity was also demonstrated in children with asthma and IBD, children in remission from cancer and children in public care, all of whom reported significantly lower HRQL than healthy children. Children with diabetes showed similar HRQL to their healthy peers. Good reproducibility and moderate responsiveness were demonstrated for the new measure.

Conclusions

The anglicised and shortened MMQL was shown to be valid and reliable and could be a valuable new tool for the assessment of HRQL in children.     

Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries

Introduction

A torn labial frenum is widely regarded as pathognomonic of abuse.

Methods

We systematically reviewed the evidence for this, and to define other intra‐oral injuries found in physical abuse. Nine studies documented abusive torn labial frena in 30 children and 27 were fatally abused: 22 were less than 5 years old. Only a direct blow to the face was substantiated as a mechanism of injury.

Results

Two studies noted accidentally torn labial frena, both from intubation. Abusive intra‐oral injuries were widely distributed to the lips, gums, tongue and palate and included fractures, intrusion and extraction of the dentition, bites and contusions.

Conclusions

Current literature does not support the diagnosis of abuse based on a torn labial frenum in isolation. The intra‐oral hard and soft tissue should be examined in all suspected abuse cases, and a dental opinion sought where abnormalities are found.     

Prevalence rates for constipation and faecal and urinary incontinence

Objective

To evaluate the prevalence rates for constipation and faecal and urinary incontinence in children attending primary care clinics in the United States.

Methods

Retrospective review of case records of all children, 4–17 years of age, seen for at least one health maintenance visit during a 6 month period and followed from birth or within the first 6 months of age in our clinics. We reviewed all charts for constipation, faecal incontinence and urinary incontinence.

Results

We included 482 children in the study, after excluding 39 children with chronic diseases. The prevalence rate for constipation was 22.6% and was similar in boys and girls. The constipation was functional in 18% and acute in 4.6%. The prevalence rate for faecal incontinence (⩾1/week) was 4.4%. The faecal incontinence was associated with constipation in 95% of our children. The prevalence rate for urinary incontinence was 10.5%; 3.3% for daytime only, 1.8% for daytime with night‐time and 5.4% for night‐time urinary incontinence. Faecal and urinary incontinence were significantly more commonly observed in children with constipation than in children without constipation.

Conclusion

The prevalence rates were 22.6% for constipation, 4.4% for faecal incontinence and 10.5% for urinary incontinence in a US primary care clinic. Children with constipation had higher prevalence rates for faecal and urinary incontinence than children without constipation. Boys with constipation had higher rates of faecal incontinence than girls with constipation.     

Tacrolimus ointment does not affect the immediate response to vaccination, the generation of immune memory, or humoral and cell-mediated immunity in children

Background

Concern exists that the prolonged application of immunomodulators to treat atopic dermatitis may cause systemic immunosuppression.

Aims

In a 7‐month, multicentre, randomised, controlled trial, we investigated the equivalence of response to vaccination against meningococcal serogroup C disease with a protein‐conjugate vaccine in children (2–11 years) with moderate to severe atopic dermatitis, by applying either 0.03% tacrolimus ointment (TAC‐O; n = 21) or a hydrocortisone ointment regimen (HC‐O; n = 111).

Methods

TAC‐O was applied twice daily (bid) for 3 weeks, and thereafter daily until clearance. 1% hydrocortisone acetate (HA) for head/neck and 0.1% hydrocortisone butyrate ointment for trunk/limbs was applied bid for 2 weeks; thereafter HA was applied bid to all affected areas. At week 1, patients were vaccinated with protein‐conjugate vaccine against meningococcal serogroup C, and challenged at month 6 with low dose meningococcal polysaccharide vaccine. The control group (44 non‐atopic dermatatits children) received the primary vaccination and challenge dose. Assessments were made at baseline, weeks 1 and 5, and months 6 and 7. The primary end point was the percentage of patients with a serum bactericidal antibody (SBA) titre ⩾8 at the week 5 visit.

Results

The response rate (patients with SBA titre ⩾8) was 97.5% (confidence interval (CI) approximately 97.3 to 100), 99.1% (94.8 to 100) and 97.7% (93.3 to 100) in the TAC‐O, HC‐O and control groups, respectively.

Conclusions

The immune response to vaccination against meningococcal serogroup C in children with atopic dermatitis applying either 0.03% TAC‐O or HC is equivalent. Ointment application does not affect the immediate response to vaccination, generation of immune memory or humoral and cell‐mediated immunity.Atopic dermatitis is a chronic, pruritic, inflammatory skin disease that can seriously affect the health and quality of life of the patient. Intense itching is the predominant symptom and excessive scratching can cause damaging excoriations, erosions and lichenification of the skin.¹ The disease is most common during childhood, with 80–90% of children having onset before 5 years of age,² and is likely to persist into adulthood in those who are severely affected.³ The exact pathogenesis of atopic dermatitis is unknown, but it is recognised that T cell‐mediated reactions⁴ and increased eosinophil levels⁵ are involved in the inflammatory response.Atopic dermatitis usually has a relapsing course, and requires long‐term continuous or intermittent treatment. Emollients provide symptomatic relief by reducing the intense itching and inflammation. However, for the treatment of acute exacerbations, most patients require topical treatment with either corticosteroids or calcineurin inhibitors such as tacrolimus or pimecrolimus. Children with moderate to severe atopic dermatitis have large affected body surface areas, often with open and weeping lesions, and this raises concerns that the prolonged application of topical immunomodulators may cause systemic immunosuppression. Current evidence is that the percutaneous absorption of tacrolimus and pimecrolimus is minimal.^6,7,8,9 Nonetheless, as atopic dermatitis often occurs in young children who are undergoing childhood immunisation programmes, it is important to determine whether topical immunomodulators have an effect on the humoral and cell‐mediated immune response to vaccination.Information about the immune response to vaccination of patients with atopic dermatitis treated with topical immunomodulators is scarce. Several studies, however, have investigated the immune response to vaccination of children with corticosteroid‐dependent asthma. It seems that children receiving short‐term low to moderate daily maintenance doses of systemic corticosteroids can receive live virus vaccines without marked suppression of the antibody response.¹⁰ Hanania et al¹¹ found that children with asthma receiving high‐dose inhaled corticosteroids had a normal response to A antigens of the inactivated influenza vaccine. Other studies on children with asthma found no association between inhaled corticosteroid use and varicella vaccine failure,¹² or an impaired immune response to pneumococcal vaccines.¹³ With regard to children with atopic dermatitis applying topical immunomodulators, Papp et al¹⁴ reported that treating children with 1% pimecrolimus cream for up to 2 years did not affect the seropositivity rates for tetanus, diphtheria, measles or rubella after vaccination. In a small US study of 23 children with atopic dermatitis, the application of 0.03% tacrolimus ointment (TAC‐O) for 7 weeks had no effect on the serological response to pneumococcal polysaccharide vaccine.¹⁵To increase our knowledge of the immune response to vaccination of children with atopic dermatitis treated with topical immunomodulators, we investigated whether the application of a hydrocortisone regimen or 0.03% TAC‐O had any effect on the immune response after vaccination against meningococcal serogroup C disease.     

Effect of meningitis in infancy on school-leaving examination results

Objectives

To determine whether having had meningitis in infancy adversely affects academic achievement at age 16.

Methods

A case–control study in England and Wales of 461 teenagers who had bacterial meningitis in infancy and 289 GP matched controls recruited when the index cases were aged 5. Outcome measures: Comparison between index cases and controls of the type of school attended; the number of GCSE examinations attempted; the number of examinations passed (grades A*–C) and achievement in five key subjects. Assessment of examination results according to the age at which meningitis occurred. The effect of meningitis‐associated disability on GCSE results.

Results

36/461 (7.8%) index cases compared with none of the controls were in special schools. Significantly more index cases (117/461 (25.4%)) than controls (19/289 (6.6%)) did not pass any GCSE examinations. Significantly more index cases (184/385 (47.8%)) than controls (59/232 (25.4%)) attending comprehensive schools failed to achieve the national educational standard of five passes at grade C. Pupils attending comprehensive schools who did not have meningitis‐associated disability also passed significantly fewer GCSE examinations than the controls. The age at which meningitis had occurred was not associated with subsequent academic achievement.

Conclusions

After meningitis in infancy a quarter of survivors failed to pass any GCSE examinations; nearly half of those attending state schools did not attain the national educational standard. “Healthy” survivors of bacterial meningitis in infancy pass significantly fewer GCSE examinations than the controls. All cases of bacterial meningitis in infancy should have a full postinfection assessment and continuing supervision.     

Influenza vaccination options to prevent hospitalization

BACKGROUND:

Vaccination of children against influenza remains a controversial topic despite the substantial morbidity caused by this infection.

OBJECTIVE:

To estimate the effect of three different vaccination strategies on preventing hospitalization due to influenza.

METHODS:

A retrospective chart review was conducted of all children admitted to a tertiary health care centre who tested positive for influenza during three consecutive influenza seasons.

RESULTS:

The final analysis included 208 cases with an age range of five days to 16.1 years. Seventy-six children were considered ‘high-risk’ and 132 were considered ‘previously healthy’. Length of stay (LOS) ranged from one day to 46 days with a mean of 6.3 days. The mean LOS was 8.6 days for children with risk factors and 4.9 days for those without risk factors. The number of preventable influenza admissions was determined over three years and averaged over one year for the three vaccination strategies. A universal strategy of vaccinating all previously healthy and high-risk children over six months of age would have prevented 118 admissions. Using a selective strategy of vaccinating only children over six months of age with risk factors and a third strategy of vaccinating only two- to six-month-old infants would have prevented 58 and 55 admissions, respectively.

CLINICAL IMPLICATION:

Use of the universal vaccination strategy would have prevented over one-half of the influenza admissions, which was over twice that of targeted vaccination. Until the challenges of implementing universal vaccination are fully understood, targeted vaccination remains an acceptable alternative.