Vaccine-related pain: randomised controlled trial of two injection techniques

Objective

To compare acute pain response during immunisation in infants using a slow standard of care injection technique versus a rapid pragmatic technique.

Design

Randomised controlled trial.

Setting

Single‐centre, urban paediatric primary care practice.

Subjects

Healthy infants 4–6 months of age receiving their routine DPTaP‐Hib immunisation.

Interventions

Standard of care group: slow aspiration prior to injection, slow injection and slow withdrawal. Pragmatic group: no aspiration, rapid injection and rapid withdrawal.

Main outcome measures

Immediate infant pain measured by the Modified Behavior Pain Scale (MBPS), crying and parent/paediatrician visual analogue scale (VAS).

Results

113 infants participated; there were no observed differences in age, birth order or prior analgesic use. Mean MBPS scores (95% confidence interval (CI)) were higher (p<0.001) for the standard group compared to the pragmatic group, 5.6 (5 to 6.3) vs 3.3 (2.6 to 3.9). The standard group was more likely to cry, 47/57 (82%) vs 24/56 (43%), to cry longer, median (interquartile range (IQR)) 14.7 s (8.7–35.6) vs 0 s (0–11.30), and to take longer to have the vaccine injected, median (IQR) 8.8 s (7.9–10.3) vs 0.9 s (0.8–1.1), p<0.001 for all comparisons. The median (IQR) VAS scores by parents and paediatricians were higher for the standard group: VAS parent, 3.5 (1.6–5.5) vs 1.9 (0.1–3.1) and VAS paediatrician, 2.8 (2.0–5.1) vs 1.4 (0.2–2.4). There were no adverse events.

Conclusion

Immunisation using a pragmatic rapid injection technique is less painful than a slow standard of care technique and should be recommended for routine intramuscular immunisations.     

Increasing prevalence of hypospadias in Western Australia, 1980-2000

Objectives

Hypospadias, a common birth defect, has shown widespread variation in reported rates and temporal trends across countries over the last 30 years. The aim of this study was to determine the prevalence and trends of hypospadias in an Australian population.

Design

Population‐based study of all male infants born in Western Australia (WA) between 1980 and 2000 diagnosed with hypospadias and notified to the WA Birth Defects Registry.

Main outcome measures

Prevalence of hypospadias, birth outcome and association with other congenital anomalies, stratified by degree‐of‐severity.

Results

1788 cases of hypospadias were registered in WA in 1980–2000 with an overall prevalence of 34.8 (95% confidence interval (CI): 33.2 to 36.4) cases per 10 000 births. The prevalence increased by 2.0% per annum (95% CI: 1.2% to 2.8%) from 27.9 in 1980 to 43.2 per 10 000 births in 2000 (p<0.001). Hypospadias was mild in 84% of cases, moderate‐severe in 11% and unspecified in 5%, with the number of moderate‐severe hypospadias almost doubling over time (p<0.01). There were 1465 (82%) cases of isolated hypospadias and 323 (18%) had co‐existing anomalies. Infants with co‐existing genital (relative risk (RR) 4.5; 95% CI: 3.3 to 6.1) or non‐genital (RR 1.5; 95% CI: 1.0 to 2.2) anomalies were more likely to have moderate‐severe hypospadias compared with isolated cases.

Conclusion

Hypospadias affects one in 231 births and has been reported to have increased significantly over the last 20 years. Future investigation of the aetiology of hypospadias is important to identify potentially modifiable risk factors and ensure optimal male reproductive health in the future.     

Vitamin K deficiency bleeding in Great Britain and Ireland: British Paediatric Surveillance Unit Surveys, 1993 94 and 2001-02

Objective

To conduct and report monitoring of vitamin K deficiency bleeding (VKDB) in Great Britain and Ireland following the 1988–90 survey (VKDB‐90).

Design

Two 2‐year surveys conducted during 1993–4 (VKDB‐94) and 2001–02 (VKDB‐02).

Setting

Data collected from all consultant paediatricians in Great Britain and Ireland.

Patients

All infants presenting with bleeding resulting from vitamin K (VK) deficiency.

Main outcome measures

Incidence of VKDB, related mortality/morbidity and VK prophylaxis recommended/received, noting predisposing features.

Results

Compared with previous studies, VKDB‐02 found fewer cases of VKDB (RR: 0.27 (95% CI: 0.12 to 0.59), p<0.001) with no deaths, no long‐term morbidity and reduced incidence among those receiving any oral dosing (RR: 0.24 (95% CI: 0.06 to 1.01), p<0.059). Breast‐fed infants accounted for the vast majority of cases. The number receiving no prophylaxis fell consecutively over time: 20 of 27 in VKDB‐90, 10 of 32 in VKDB‐94 and 4 (because of parental refusal) of 7 in VKDB‐02. Seven received one oral dose of VK in VKDB‐90, 16 in VKDB‐94 and none in VKDB‐02. Underlying liver disease was found in six cases in VKDB‐90, 12 in VKDB‐94 and one in VKDB‐02.

Conclusions

In the most recent survey, the incidence of VKDB was about one third that in the two earlier studies. Late onset VKDB remains virtually confined to breast‐fed infants who have received either no VK or just one oral dose. The effectiveness of oral prophylaxis regimens has improved over the last 15 years, but parental refusal of prophylaxis has become more problematic.     

Ethnic and gender differences in body fat in British schoolchildren as measured by DXA

Background

There are known to be ethnic differences in body composition in adults which are related to ethnic differences in adult disease.

Objectives

To evaluate gender and ethnic differences in percentage body fat in British schoolchildren and to compare these differences with classification of obesity using body mass index (BMI) criteria.

Design

A cross‐sectional study of 1251 healthy children and adolescents aged 5–18 years from white, South Asian and African‐Caribbean ethnic groups. Percentage body fat was determined by dual x ray absorptiometry and the subjects classified using BMI criteria for overweight and obesity.

Results

Significant gender differences in percentage body fat were seen, with girls having higher values from the age of 5 years. Girls had 3.8% higher percentage body fat at 5 years of age increasing to 12.9% at 18 years of age. Significant ethnic differences were found, with South Asian girls and boys having the highest percentage body fat from 5 and 7 years of age, respectively. These differences increased with age, being most significant in the teenage years. Although South Asian girls and boys were over‐represented in the group containing children with more than 25% body fat (p<0.0001, χ² test), African‐Caribbean subjects were more likely to be classified as obese using BMI criteria.

Conclusions

There are clear gender and ethnic differences in percentage body fat in British schoolchildren which may relate to known differences in the risk of type 2 diabetes in adolescence and adulthood. BMI criteria for defining overweight and obesity do not accurately identify ethnic differences in body fat.     

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.     

Infant feeding in the second 6 months of life related to iron status: an observational study

Objective

To investigate the relationship between iron status in infancy and type of milk and weaning solids consumed.

Design

An observational cohort study.

Setting

928 term infants from the Avon Longitudinal Study of Parents and Children in 1993–94.

Methods

Haemoglobin and ferritin concentrations at 8 and 12 months were assessed in relation to type and quantity of milk intake at 8 months.

Results

By WHO criteria, 22.7% of the infants were anaemic at 8 months and 18.1% at 12 months. More breast‐ than formula‐fed infants were anaemic at 8 and 12 months. Cows'' milk as the main drink was associated with increased anaemia at 12 months and low ferritin at 8 and 12 months. No association was found between any nutrients and haemoglobin concentrations. Protein and non‐haem iron intakes were positively associated with ferritin concentrations and calcium intake negatively. This effect was more marked in infants being fed cows'' milk. More than 25% of infants in the breast milk and cows'' milk groups and 41% of infants having >6 breast feeds per day had iron intakes below the lower reference nutrient intake. Feeding cows'' milk or formula above 600 ml or >6 breast feeds per day was associated with lower intakes of solids.

Conclusions

Both breast and cows'' milk feeding were associated with higher levels of anaemia. Satisfactory iron intake from solids in later infancy is more likely if formula intake is <600 ml per day and breast feeds are limited to <6 feeds per day. Cows'' milk should be strongly discouraged as a main drink before 12 months.     

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.     

Improvement in screening performance and diagnosis of congenital hypothyroidism in Scotland 1979-2003

Aim

To assess the Scottish newborn screening programme for congenital hypothyroidism from 1994 to 2003 (period 2) for performance and compare with an initial audit covering 1979 to 1993 (period 1).

Design

Performance data—age at blood spot sampling, notification by screening laboratory, start of treatment, and the prevalence of late testing, notification or treatment—were compared, together with the incidence of congenital hypothyroidism.

Results

Comparing data for period 2 with period 1, the mean annual incidence of true congenital hypothyroidism was 1:3655 live births v 1:4363. Median age for Guthrie sampling (all referrals) was 6 v 7 days (p<0.0001). Late sampling (>10 days) had fallen from 10.7% to 7%. For infants requiring repeat sampling before notification, the median (range) interval between initial and final repeat samples was 11 (1 to 52) compared with 14 (3 to 73) days. Median age at notification for true congenital hypothyroidism was 10 v 12 days (p <0.0001). Late notification (>15 days) was justifiable (mild TSH elevation) in 10 of 13 patients in period 2. Median age at start of treatment for true congenital hypothyroidism had improved to 11 days from 13.5 days. For true congenital hypothyroidism, late treatment (>16 days) occurred in 7% of patients compared with 19% (p<0.0001).

Conclusions

There has been an improvement in performance measures for the congenital hypothyroidism screening programme in Scotland. However, late sampling, occurring primarily in inpatients and which is never justified, remains a problem, while the interval between initial and recall sampling is a further source of delay.     

A low cost, colour coded, hand held spring scale accurately categorises birth weight in low resource settings

Aims

To determine the accuracy of a low cost, spring calibrated, hand held scale in classifying newborns into three weight categories (⩾2500 g, 2000–2499 g, <2000 g).

Methods

The test device was compared to a gold standard digital baby scale with precision to 2 g. In Sarlahi district, Nepal, 1890 newborns were eligible for the study. Measurements were collected for both the test device and the digital scale from 1820 (96.3%) newborns.

Results

The overall low birth weight (LBW) prevalence rate for the gold standard digital scale was 28.1% (511/1820). Sensitivity (93.7%) and specificity (97.6%) of the test device was high compared to LBW classifications based on digital weight measurements. Classification of infants into the <2000 g category was 5.0% and 4.7% for the gold standard and test device, respectively. Sensitivity and specificity of the test device in identifying infants <2000 g was 87.8% and 99.6%, respectively. Positive predictive values were high (>91%) for both weight categories

Conclusions

This low cost, simple‐to‐use device classified infants into weight categories with a high degree of consistency and accuracy that exceeds that of surrogate measures. This new device is useful for identifying and targeting life saving interventions for LBW, high risk infants in settings where infants are born in the home and conventional weighing scales are unavailable.     

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.     

High prevalence of vitamin D deficiency in newborn infants of high-risk mothers

Objective

To determine the prevalence of vitamin D deficiency in newborn infants of mothers at risk of vitamin D deficiency because of dark skin or the wearing of concealing clothes (such as a veil) compared with a group presumed not to be at risk. A second aim was to correlate these newborn infants'' vitamin D concentrations with biochemical parameters of vitamin D metabolism and bone turnover at birth.

Design

A prospective study conducted between April 2004 and February 2006 including women delivering during this period and their newborn infants.

Setting

The outpatient clinic of the obstetrics department, Sint Franciscus Gasthuis, Rotterdam, the Netherlands.

Patients

Eighty seven newborn infants of healthy mothers with either dark skin and/or concealing clothing (risk group) or light skin (control group).

Results

We found a significant difference in the prevalence of vitamin D deficiency (25‐hydroxyvitamin D₃ <25 nmol/l) between newborn infants of mothers at risk and those of mothers in the control group (63.3% vs 15.8%; p<0.001). Mean alkaline phosphatase concentrations were significantly higher in the at risk group.

Conclusions

Newborn infants of mothers with dark skin or wearing concealing clothes are at great risk of vitamin D deficiency at birth. The clinical implications are unknown. Further research is necessary to determine the long‐term consequences of maternal and neonatal vitamin D deficiency so that guidelines on vitamin D supplementation during pregnancy can be issued.     

Decline in pneumococcal meningitis after the introduction of the heptavalent-pneumococcal conjugate vaccine in northern France

Background

The impact of the heptavalent‐pneumococcal conjugate vaccine on the incidence of pneumococcal meningitis in Europe has not yet been assessed.

Objective

To determine whether heptavalent‐pneumococcal conjugate vaccine implementation in northern France has resulted in a decrease in the incidence of pneumococcal meningitis in children.

Design

Multicentre retrospective cohort study from 2000 through 2005.

Settings

All paediatric departments of the 18 hospitals in northern France.

Patients

Patients <18 years of age, admitted for laboratory‐confirmed pneumococcal meningitis during the study period, were included.

Interventions

Data were collected from medical files and the microbiological laboratories of each hospital and compared with the regional hospital discharge codes, using a capture–recapture method.

Main outcome measures

The study assessed and compared global and age‐related incidence rates of pneumococcal meningitis in 2001 (pre‐vaccine era) and 2005.

Results

77 cases were found through the capture–recapture method. The incidence rate of pneumococcal meningitis varied from 1.65/100 000 children <18 years in 2001 to 0.80/100 000 children in 2005 (53% reduction, 95% CI 31 to 74; p = 0.08). This has so far been significant only for children <2 years of age (8.9/100 000 in 2001 to 1.8/100 000 in 2005; 82% reduction, 95% CI 52 to 95; p = 0.03).

Conclusion

A decline in pneumococcal meningitis has been observed in infants since heptavalent‐pneumococcal conjugate vaccination began in our area.In the United States, Streptococcus pneumoniae has been considered to be the principal pathogen for bacterial meningitis (47%) since Haemophilus influenzae type b vaccination became widespread during the 1990s and before the implementation of vaccination with the heptavalent‐pneumococcal conjugate vaccine (PCV7, Prevenar).¹ In Western Europe, the mean incidence rate of pneumococcal meningitis has averaged 8.7 cases/100 000 in children <2 years old with incidence rates varying from 3.8 to 14.6/100 000 between countries.² Between 2001 and 2004, the French Bacterial Meningitis Surveillance Network reported that S pneumoniae caused 42% of all cases of bacterial meningitis in children, 70% of these occurring in children <2 years old.³ The case‐fatality rate for this disease is estimated at 8–12% in children and has not dramatically changed for 20 years despite progress in diagnosis and treatment.^1,4 Sequelae occur in 20–35% of cases and include deafness, motor deficits, learning disorders linked with concentration disorders, and memory problems.^5,6PCV7, first approved in the US in 1999, targets the seven serotypes involved most frequently in the invasive pneumococcal diseases of young children.^7,8 Serotypes 6B, 9V, 14, 18C and 23F, all present in this vaccine, account for most cases of pneumococcal meningitis today.⁹ PCV7 received marketing authorisation in Europe in February 2001, was available in France in April 2001 and was recommended in March 2002 for children with a disease at high risk of invasive pneumococcal infections (immunosuppression, sickle cell disease, etc),¹⁰ and children aged 2–24 months with risk factors for pneumococcal infection (ie, children cared for more than 4 h/week with more than two other children, children with breast‐feeding duration <2 months, children with at least two siblings), criteria which covered between 79 and 89% of children <2 years of age.¹¹ The vaccination schedule uses a four‐dose regimen, at 2, 3 and 4 months of age and a booster dose during the second year of life. The impact of the PCV7 on the incidence of meningitis and other invasive pneumococcal diseases has been clearly demonstrated in North America and Australia,^{12,13,14,15,16} whose vaccination schedules are different from those in France.The aim of this study was to determine whether PCV7 implementation in a large area of northern France affected the incidence of pneumococcal meningitis in children.     

Impact of zinc supplementation in children with acute diarrhoea in Turkey

Objective

Zinc deficiency is prevalent in children in developing countries. Supplemental zinc provides therapeutic benefits in diarrhoea. Our aim was to evaluate the effect of daily zinc supplementation for 14 days on diarrhoea duration, severity, and morbidity in children.

Methods

In a randomised, open label non‐placebo controlled trial, we assessed the efficacy of providing zinc sulfate to 6–60 month old children with acute diarrhoea for 2 weeks followed by 3 months of morbidity surveillance. Children were randomly assigned to zinc (n = 150) and control (n = 130) groups and received 15–30 mg elemental zinc daily.

Results

Supplemented children had significantly improved plasma zinc levels by day 14 of therapy. Zinc deficiency was observed in 2.6% of the treatment and 3.3% of the control group. The mean duration of diarrhoea after starting supplementation was 3.02±2 days in the zinc group and 3.67±3.2 days in the control group. There was no significant difference in diarrhoea duration by treatment group (p>0.05). The number of stools after starting supplementation was 5.8±3.7 and 5.1±3.9 on day 1, 2.9±1.6 and 3.0±2.2 on day 2, and 1.8±1.1 and 1.6±0.9 on day 3 in the zinc and control groups, respectively. There was no significant difference in diarrhoea severity by treatment group (p>0.05). No significant effect was found on the incidence and prevalence of diarrhoea in the zinc compared with the control group.

Conclusion

Our data indicate that supplementing children with acute diarrhoea in Turkey with 3 RDA of elemental zinc for 14 days improved neither diarrhoea duration nor severity despite significant increments in plasma zinc.     

Impact of HIV-1 status on the radiological presentation and clinical outcome of children with WHO defined community-acquired severe pneumonia

Aims

We compared the radiological features and outcome of WHO defined severe pneumonia among HIV infected and exposed uninfected children randomised to receive penicillin or oral amoxicillin in Durban, South Africa.

Methods

Of 425 children aged between 3 and 59 months with WHO defined severe pneumonia, 366 had anonymous HIV testing performed. Outcome was assessed by failure to improve at 48 h after enrolment or deterioration within 14 days. Chest radiographs were evaluated according to WHO defined radiological criteria for pneumonia and internationally standardised radiological criteria. Findings were stratified for HIV status.

Results

82 (22.4%) children were HIV infected, 40 (10.9%) were HIV exposed and 244 (66.7%) were HIV uninfected. The day 14 outcome in children <12 months of age was significantly worse in HIV‐1 infected than HIV uninfected children (OR 2.8 (95% CI 1.35 to 3.5), p = 0.002), while HIV‐1 infected and uninfected children aged ⩾12 months had equivalent outcomes. Parental penicillin and oral amoxicillin had equivalent response rates in all HIV groups. According to the WHO radiological classification, children who failed WHO standard antimicrobial treatment had significantly higher “other consolidates/infiltrates” than “endpoints for consolidation” in the HIV infected group (OR 5.45 (95% CI 1.58 to 21.38), p<0.002), while the reverse was true for HIV exposed uninfected children (OR 4.13 (95% CI 0.88 to 20.57), p<0.036).

Conclusions

The WHO standard treatment guideline for severe pneumonia is inadequate for HIV‐1 infected infants. The increased prevalence of “other consolidates/infiltrates” among HIV‐1 infected children who failed standard treatment supports the addition of co‐trimoxazole to WHO standard treatment.The global incidence of acute lower respiratory infections (ALRI) is 154 million new episodes per annum with 7–13% of patients requiring hospitalisation.¹ ALRI causes 1.9 million deaths among children annually, accounting for over a fifth of all deaths in Africa.² The World Health Organization (WHO) response to this burden of disease has been the introduction of standard case management guidelines. The benefit of this intervention in HIV non‐endemic areas was recently shown in a meta‐analysis where pneumonia related mortality among neonates, infants and children between 0 and 4 years of age was reduced by 27%, 27% and 20%, respectively.³ The HIV‐1 epidemic has altered the prevalence, presentation and outcome of ALRI.The role of chest radiographs in the management of children with ALRI has had mixed reviews. Some studies suggest that radiographs help confirm the diagnosis of pneumonia in only 36% of episodes, help change the diagnosis in approximately 20% of cases and result in a change in treatment plan in 34%.^4,5 The chest radiographic features of HIV associated pneumonia in childhood have scarcely been reported. Sivit et al described the radiological features of Pneumocystis jiroveci (carinii) pneumonia in infancy (PCP) and found that a ground glass interstitial appearance with pulmonary air cysts and thoracic air leak syndromes were common.⁶ The WHO has defined radiological criteria to assist in the determination of bacterial pneumonia in their vaccine trials on streptococcal pneumonia.⁷ While several studies have described the aetiology of HIV related pneumonia in children, none have evaluated the differences in radiology and response rates to standard WHO therapy.We therefore performed a prospective nested substudy of a larger international pneumonia study⁸ to define the radiological features on admission and clinical response at day 14 of HIV‐1 infected and exposed children with WHO defined severe pneumonia treated with either oral amoxicillin or injectable penicillin.     

Randomised trial of a parenting intervention during neonatal intensive care

Objective

To evaluate the influence of parenting intervention on maternal responsiveness and infant neurobehavioural development following a very premature birth.

Design

Cluster‐randomised controlled trial, with a crossover design and three‐month washout period.

Setting

Six neonatal intensive care units.

Patients

Infants born <32 weeks'' gestation.

Intervention

The Parent Baby Interaction Programme (PBIP) is a supportive, educational intervention delivered by research nurses in the neonatal intensive care unit, with optional home follow‐up for up to six weeks after discharge.

Main outcome measures

Parenting stress at 3 months adjusted age, as measured by the Parenting Stress Index (PSI). Other outcomes included the Neurobehavioural Assessment of the Preterm Infant (NAPI) and maternal interaction as assessed by the Nursing Child Assessment Teaching Scale (NCATS) and the responsivity subscale for Home Observation for Measurement of the Environment (HOME).

Results

112 infants were recruited in the intervention phases and 121 in the control phases. Mean standardised NAPI scores at 35 weeks did not differ between the PBIP and control groups. Both groups had low but similar NCATS caregiver scores before discharge (36.6 in the PBIP group and 37.4 in control, adjusted mean difference −0.7, 95% CI −2.7 to 1.4). At three months, adjusted age mean PSI scores for the PBIP group were 71.9 compared with 67.1 for controls (adjusted mean difference 3.8, 95% CI −4.7 to 12.4). NCATS scores and HOME responsivity scores were similarly distributed between the groups.

Conclusion

This early, nurse‐delivered, parent‐focused interaction programme intervention had no measurable effects on short‐term infant neurobehavioural function, mother–child interaction or parenting stresses.     

Respiratory infections for which general practitioners consider prescribing an antibiotic: a prospective study

Objective

To determine the viral aetiology of respiratory infections in children presenting to primary care with “more than a simple cold”.

Design

Observational study in 18 Oxfordshire general practices over four winters (2000–01 to 2003–04).

Patients

425 children aged 6 months to 12 years with cough and fever for whom general practitioners considered prescribing an antibiotic.

Methods

Nasopharyngeal aspirate obtained from 408 (96%) children was subjected to PCR for respiratory viruses. Parents completed an illness diary for the duration of illness.

Results

A viral cause of infection was detected in most (77%) children. Clinical symptoms correctly identified the infecting virus in 45% of cases. The duration of illness was short and the time course was very similar for all infecting viruses. One third of children were prescribed an antibiotic (34%), but this made no difference to the rate of parent‐assessed recovery (Kruskal‐Wallis, p = 0.67). About one in five children with influenza who did not receive an antibiotic had persistent fever on day 7 compared to no children receiving antibiotics (p = 0.02); this difference remained after adjustment for severity and other factors and was not seen with other viruses.

Conclusions

Most children receiving antibiotics for respiratory symptoms in general practice have an identifiable viral illness. In routine clinical practice, neither the specific infecting virus nor the use of antibiotics has a significant effect on the time course of illness. Antibiotics may reduce the duration of fever in children with influenza which could reflect an increased risk of secondary bacterial infection for such children.     

Nasopharyngeal aspiration for diagnosis of pulmonary tuberculosis

Background

Confirmation of pulmonary tuberculosis (PTB) in young children is difficult as they seldom expectorate sputum.

Aim

To compare sputa obtained by nasopharyngeal aspiration and by sputum induction for staining and culture of Mycobacterium tuberculosis.

Patients and methods

Patients from Mulago Hospital, Kampala with symptoms suggestive of PTB were considered for inclusion in the study. Those with a positive tuberculin test and/or a chest radiograph compatible with tuberculosis were recruited. Infection with human immunodeficiency virus (HIV) was confirmed by duplicate enzyme‐labelled immunosorbent assay or in children <15 months by polymerase chain reaction (PCR). Direct PCR was undertaken on 82 nasopharyngeal aspirates.

Results

Of 438 patients referred, 94 were recruited over a period of 5 months. Median (range) age was 48 (4–144) months. Of 63 patients tested, 69.8% were infected with HIV. Paired and uncontaminated culture results were available for 88 patients and smear results for 94 patients. Nasopharyngeal aspirates were smear‐positive in 8.5% and culture‐positive in 23.9%. Induced sputa were smear‐positive in 9.6% and culture positive in 21.6%. Overall, 10.6% were smear‐positive, 25.5% were culture‐positive and 26.6% had smear and/or culture confirmed tuberculosis. Direct PCR on nasopharyngeal aspirates had a sensitivity of 62% and specificity of 98% for confirmation of culture‐positive tuberculosis.

Conclusions

Nasopharyngeal aspiration is a useful, safe and low‐technology method for confirmation of PTB and, like sputum induction, can be undertaken in outpatient clinics.     

Is omitting post urinary‐tract‐infection renal ultrasound safe after normal antenatal ultrasound? An observational study

Background

Guidelines recommend obtaining a renal ultrasonogram (RUS) for young children after a first urinary tract infection (UTI).

Objective

The aim of the current study was to assess the concordance of prenatal and post‐UTI RUS findings in children with a first simple UTI.

Methods

This was a prospective study and included all children aged 5 years or younger who were hospitalised with a first simple UTI (determined as clinical response and normalisation of temperature within 48 h on initiation of antibacterial therapy with no complications). Data were collected from each child regarding the results of prenatal and post‐UTI RUS.

Results

Overall, 250 children were included in the study and the results of late‐pregnancy and post‐UTI RUS were available for 84% (n = 209). Complete concordance between the two RUS was demonstrated in 96% (n = 201). The predictive value of normal antenatal to normal post‐UTI RUS was 96% (95% CI: 93% to 99%). These results include four children with mild transient pelvic dilatation. In eight children in whom renal anomalies were demonstrated only in post‐UTI RUS, the influence of these anomalies on the children''s management was negligible.

Conclusions

Prenatal‐RUS have been performed in most children <5 years old hospitalised with a first simple UTI. Concordance with post‐infection tests is very high. Findings which appear only in post‐infectious RUS usually have negligible effects on children''s management. Thus, in such children with normal antenatal RUS omitting post‐UTI RUS could be considered.