Chest physiotherapy in paediatric patients hospitalised with community-acquired pneumonia: a randomised clinical trial.
Chest physiotherapy has been used to treat children hospitalised with pneumonia with no clear scientific evidence to support a beneficial effect. The objective of the current study was to evaluate the efficacy of chest physiotherapy as an adjuvant treatment in children hospitalised with acute community-acquired pneumonia.
Children (aged 1–12 years) with a clinical and confirmed radiological diagnosis of pneumonia sequentially admitted to a tertiary children hospital were eligible for this study. Participants were randomly selected to receive a standardised respiratory physiotherapy (positioning, thoracic vibration, thoracic compression, positive expiratory pressure, breathing exercises and forced exhalation with the glottis open or ‘huffing’) three times daily in the ‘intervention group’ or a non-mandatory request to breathe deeply, expectorate the sputum and maintain a lateral body position once a day in the ‘control group’. The primary outcomes were reduction in respiratory rate and severity score (respiratory rate, recession, fever, oxygen saturation and chest x-ray) from baseline to discharge. Secondary outcome was duration of hospitalisation.
In all, 72 patients were randomly allocated to the intervention (n=35) or control (n=37) groups. There were no differences at admission on severity of pneumonia between groups. Respiratory rate and severity score significant decreased between admission to discharge within each group; however, there were no differences when comparing groups. Also, there was no significant difference in duration of hospitalisation between the control and intervention groups (6 vs. 8 days, p=0.11, respectively).
This clinical trial suggests that, in children hospitalised with moderate community-acquired pneumonia, chest physiotherapy did not have clinical benefits in comparison to control group.
Arch Dis Child 2012;97:967-971 doi:10.1136/archdischild-2012-302279
Janice Luisa Lukrafka1, et al
Department of Physiotherapy, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brasil
Department of Social Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil
Department of Pediatrics, School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
Department of Radiology, School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
Department of Statistics, Mathematics Institute, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
Departments of Pediatrics and Family Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child.
Some breastfed infants with atopic eczema benefit from elimination of cow milk, egg, or other antigens from their mother's diet. Maternal dietary antigens are also known to cross the placenta.
To assess the effects of prescribing an antigen avoidance diet during pregnancy or lactation, or both, on maternal and infant nutrition and on the prevention or treatment of atopic disease in the child.
We searched the Cochrane Pregnancy and Childbirth Group`s Trials Register (6 July 2012).
All randomized or quasi-randomized comparisons of maternal dietary antigen avoidance prescribed to pregnant or lactating women. We excluded trials of multimodal interventions that included manipulation of the infant's diet other than breast milk or of non-dietary aspects of the infant's environment.
DATA COLLECTION AND ANALYSIS:
We extracted data from published reports, supplemented by additional information received from the trialists we contacted.
The evidence from five trials, involving 952 participants, does not suggest a protective effect of maternal dietary antigen avoidance during pregnancy on the incidence of atopic eczema during the first 18 months of life. Data on allergic rhinitis or conjunctivitis, or both, and urticaria are limited to a single trial each and are insufficient to draw meaningful inferences. Longer-term atopic outcomes have not been reported. The restricted diet during pregnancy was associated with a slightly but statistically significantly lower mean gestational weight gain, a non-significantly higher risk of preterm birth, and a non-significant reduction in mean birthweight.The evidence from two trials, involving 523 participants, did not observe a significant protective effect of maternal antigen avoidance during lactation on the incidence of atopic eczema during the first 18 months or on positive skin-prick tests to cow milk, egg, or peanut antigen at one, two, or seven years.One crossover trial involving 17 lactating mothers of infants with established atopic eczema found that maternal dietary antigen avoidance was associated with a non-significant reduction in eczema severity.
Prescription of an antigen avoidance diet to a high-risk woman during pregnancy is unlikely to reduce substantially her child's risk of atopic diseases, and such a diet may adversely affect maternal or fetal nutrition, or both. Prescription of an antigen avoidance diet to a high-risk woman during lactation may reduce her child's risk of developing atopic eczema, but better trials are needed. Dietary antigen avoidance by lactating mothers of infants with atopic eczema may reduce the severity of the eczema, but larger trials are needed.
Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev. 2012 Sep 12;9:CD000133. (Review) PMID: 22972039
Reducing Intake of Sugar Sweetened Beverages Reduces Weight Gain in Children.
Interventions aimed at replacing sugar-sweetened beverages with sugar-free drinks reduced weight gain in normal-weight and obese or overweight children and adolescents. Sugar-sweetened beverages are a substantial source of caloric intake in children. Two randomized studies examined the effect of reducing sugar-sweetened beverages on weight gain in children and adolescents. In the first study, researchersrandomized 641 normal-weight Dutch schoolchildren (age range, 4 years 10 months to 11 years 11 months) who regularly drank sugary drinks to receive one can (8 ounces) per day of either a sugar-sweetened, noncarbonated beverage (104 kcal/day) or a similar-tasting, noncaloric, artificially sweetened beverage for 18 months.
At the end of the study, children in the sugar-free group gained significantly less weight and body fat than those in the sugar group (mean weight gain, 6.35 kg vs. 7.37 kg).
In the second study, researchers in Boston randomized 224 overweight and obese adolescents who regularly consumed sugar-sweetened drinks to receive home delivery of bottled water and diet beverages every 2 weeks for 1 year, along with monthly motivational telephone calls with parents and three check-in visits. The intervention group also received written messages by mail with instructions to drink the delivered beverages and not drink sugar-sweetened drinks. The control group received supermarket gift cards. At 1 year, consumption of sugar-sweetened beverages in the intervention group declined to nearly zero and was significantly less than in the control group. Gains in body-mass index (BMI) were significantly smaller in the intervention group at 1 year but not at 2 years.
However, the intervention resulted in significantly smaller gains in BMI and body weight at both 1 and 2 years among Hispanic adolescents.
Although the results of these two studies are not surprising, they demonstrate that reducing intake of sugar-sweetened beverages can reduce weight gain in normal-weight and obese or overweight children and adolescents. Furthermore, in the adolescent intervention trial, providing education and healthier alternative beverages for 1 year had continued dietary effects at 2 years in some adolescents.
- F. Bruder Stapleton, MD
Published in Journal Watch Pediatrics and Adolescent Medicine September 26, 2012 Citation(s): de Ruyter JC et al.
A trial of sugar-free or sugar-sweetened beverages and body weight in children.
N Engl J Med 2012 Sep 21; [e-pub ahead of print]. () Ebbeling CB et al.
A randomized trial of sugar-sweetened beverages and adolescent body weight. N Engl J Med 2012 Sep 21; [e-pub ahead of print]. ()
Effect of Inhaled Glucocorticoids in Childhood on Adult Height.
EXTRACT FROM NEW ENGLAND JOURNAL OF MEDICINE
H. William Kelly, Pharm. D., Alice L. Sternberg, Sc.M., Rachel Lescher, M.D., Anne L. Fuhlbrigge, M.D., Paul Williams, M.D., Robert S. Zeiger, M.D., Ph.D., Hengameh H. Raissy, Pharm. D., Mark L. Van Natta, M.H.S., James Tonascia, Ph.D., and Robert C. Strunk, M.D. for the CAMP Research Group.
We all know that use of inhaled corticosteroids can suppress linear growth. It has been suggested that the latter effect is transient and that growth recovers after the ICS use has stopped with no ultimate effect on adult height. This nice study is a long term follow up of kids from an RCT of 400mcg beclomethasone vs placebo in asthma. It demonstrated the previously known deceleration in growth during treatment but also that this effect persisted so that the ICS group had a highly significantly lower adult height (allowing for several identified confounders). The effect on adult height was relatively small (mean 1.2cm) but not trivial and effects in an individual child might be larger. The effect was also significantly related to dose/kg. There is no doubt that some children with bad persistent asthma benefit greatly from the use of ICS but we have seen a strong trend towards overuse (especially in intermittent wheezers) and lack of dose titration/reduction. It is clear that ICS should be used for the right indications, in the smallest effective dose and with regular review with attempts at dose reduction/cessation.
The use of inhaled glucocorticoids for persistent asthma causes a temporary reduction in growth velocity in prepubertal children. The resulting decrease in attained height 1 to 4 years after the initiation of inhaled glucocorticoids is thought not to decrease attained adult height.
We measured adult height in 943 of 1041 participants (90.6%) in the Childhood Asthma Management Program; adult height was determined at a mean (±SD) age of 24.9±2.7 years. Starting at the age of 5 to 13 years, the participants had been randomly assigned to receive 400 μg of budesonide, 16 mg of nedocromil, or placebo daily for 4 to 6 years. We calculated differences in adult height for each active treatment group, as compared with placebo, using multiple linear regression with adjustment for demographic characteristics, asthma features, and height at trial entry.
Mean adult height was 1.2 cm lower (95% confidence interval [CI], −1.9 to −0.5) in the budesonide group than in the placebo group (P=0.001) and was 0.2 cm lower (95% CI, −0.9 to 0.5) in the nedocromil group than in the placebo group (P=0.61). A larger daily dose of inhaled glucocorticoid in the first 2 years was associated with a lower adult height (−0.1 cm for each microgram per kilogram of body weight) (P=0.007). The reduction in adult height in the budesonide group as compared with the placebo group was similar to that seen after 2 years of treatment (−1.3 cm; 95% CI, −1.7 to −0.9). During the first 2 years, decreased growth velocity in the budesonide group occurred primarily in prepubertal participants.
The initial decrease in attained height associated with the use of inhaled glucocorticoids in prepubertal children persisted as a reduction in adult height, although the decrease was not progressive or cumulative.
The full article is available here.
Randomised controlled trial of amoxicillin clavulanate in
children with chronic wet cough.
Despite guideline recommendations, there are no published randomised controlled trial data on the efficacy of antibiotics for chronic wet cough in children. The majority of children with chronic wet cough have protracted bacterial bronchitis (PBB), a recognised condition in multiple national guidelines. The authors conducted a parallel 1:1 placebo randomised controlled trial to test the hypothesis that a 2-week course of amoxicillin clavulanate is efficacious in the treatment of children with chronic wet cough.
50 children (median age 1.9 years, IQR 0.9-5.1) with chronic (>3 weeks) wet cough were randomised to 2 weeks of twice daily oral amoxicillin clavulanate (22.5 mg/kg/dose) or placebo. The primary outcome was "cough resolution" defined as a >75% reduction in the validated verbal category descriptive cough score within 14 days of treatment compared with baseline scores, or cessation of cough for >3 days. In selected children, flexible bronchoscopy and bronchoalveolar lavage (BAL) were undertaken at baseline.
Cough resolution rates (48%) were significantly higher in children who received amoxicillin clavulanate compared with those who received placebo (16%), p=0.016. The observed difference between proportions was 0.32 (95% CI 0.08 to 0.56). Post treatment, median verbal category descriptive score in the amoxicillin clavulanate group of 0.5 (IQR 0.0-2.0) was significantly lower than in the placebo group, 2.25 (IQR 1.15-2.9) (p=0.02). Pre-treatment BAL data were consistent with PBB in the majority of children, with no significant difference between groups.
A 2-week course of amoxicillin clavulanate will achieve cough resolution in a significant number of children with chronic wet cough. BAL data support the diagnosis of PBB in the majority of these children.
Marchant J, Masters IB, Champion A, et al. Thorax.
2012 Aug;67(8):689-93. Epub 2012 May 24. (Original)
CLINICAL TRIAL NUMBER: ACTRN 12605000533695.
Combination Nasal Steroid–Antihistamine Is More Effective Than Either Agent Alone
For patients with allergic rhinitis, twice-daily azelastine plus fluticasone cut nasal symptoms.
Intranasal steroids are the most effective pharmacologic treatment for seasonal allergic rhinitis (SAR), but they can take several days to take effect, and some patients don't achieve full relief of symptoms. Add-on oral antihistamines or montelukast (Singulair) do not add much benefit.
In three separate trials, researchers randomised 3398 adolescent and adult patients with moderate-to-severe SAR (without regard to previous SAR therapies) to twice-daily azelastine (an intranasal antihistamine), fluticasone propionate, the combination of the two, or placebo for 2 weeks during the allergy season; all treatments were administered as one spray twice daily to preserve blinding. The studies were sponsored by a company that manufactures azelastine and the investigational combination product. The onset of action for combination therapy was 30 minutes. On all study days, combination-therapy recipients showed significantly greater improvement in morning and evening total nasal symptom scores than did patients who received azelastine or fluticasone individually; all active treatments were significantly better than placebo.
For patients with moderate-to-severe SAR that is uncontrolled on nasal steroids alone, the treatment of choice should be a combination intranasal steroid and intranasal antihistamine. For patients with severe symptoms, the combination could be started as first-line therapy, but azelastine has a bitter taste, and two different sprays increase treatment cost and complexity. (A combination product is not yet available commercially.) We don't know if the combination is superior to intranasal steroids alone when used for longer than 2 weeks, but it is worth a try in patients with uncontrolled chronic symptoms.
David Coghlan Comment
I tend to use oral antihistamine first line (ARIA Guide) and if not controlling add a nasal steroid and tend to work well together. Note nasal azelastine has bitter taste and thus will reduce compliance. Oral antihistamine and intranasal steroid acceptable to most particularly availability of once daily nasal sprays.
Article by David J. Amrol, M.D.
Washington State Declares Whooping Cough Epidemic
Washington state is experiencing a pertussis epidemic, with 1284 cases reported through early May, the New York Times reports. At this point last year, the state had only 128 cases. This is the most in at least 30 years, and state health officials suspect it represents only about a fifth of the true number of cases. Most victims are between age 8 and 12 years.
Potentially compounding the outbreak, Washington has the highest exemption rate in the U.S. for childhood immunizations. Some 6.2% of kindergarteners last year had parent-signed exemptions for one or more vaccines, according to a CDC study. Most pertussis patients in the current outbreak had received early childhood immunizations.
The worldwide incidence of whooping cough (pertussis) has been estimated at 48.5 million cases and nearly 295,000 deaths per year. In low-income countries, the case-fatality rate among infants may be as high as 4%. Much of the morbidity of whooping cough in children and adults is due to the effects of the paroxysmal cough. Cough treatments proposed include corticosteroids, beta 2-adrenergic agonists, pertussis-specific immunoglobulin, antihistamines and possibly leukotriene receptor antagonists (LTRAs).
To assess the effectiveness and safety of interventions to reduce the severity of paroxysmal cough in whooping cough in children and adults.
We updated searches of the Cochrane Central Register of Controlled Trials (CENTRAL Issue 2, 2012), which contains the Cochrane Acute Respiratory Infections Group`s Specialised Register, the Database of Abstracts of Reviews of Effects (DARE Issue 2, 2012) accessed from The Cochrane Library, MEDLINE (1950 to January 2012), EMBASE (1980 to January 2012), AMED (1985 to January 2012), CINAHL (1980 to January 2012) and LILACS (January 2012). We searched Current Controlled Trials to identify trials in progress.
We selected randomised controlled trials (RCTs) and quasi-RCTs of any intervention (excluding antibiotics and vaccines) to suppress the cough in whooping cough.
DATA COLLECTION AND ANALYSIS
Two review authors (SB, MT) independently selected trials, extracted data and assessed the quality of each trial for this review in 2009. Two review authors (SB, KW) independently reviewed additional studies identified by the updated search in 2012. The primary outcome was frequency of paroxysms of coughing. Secondary outcomes were frequency of vomiting, frequency of whoop, frequency of cyanosis (turning blue), development of serious complications, mortality from any cause, side effects due to medication, admission to hospital and duration of hospital stay.
Ten trials were included of varying sample sizes (N = 9 to 135) from high-income countries. Study quality was generally poor. Included studies did not show a statistically significant benefit for any of the interventions. Only six trials including a total of 196 participants reported data in sufficient detail for analysis. Diphenhydramine did not change coughing episodes; the mean difference (MD) of coughing spells per 24 hours was 1.9; 95% confidence interval (CI) - 4.7 to 8.5. One study on pertussis immunoglobulin reported a possible mean reduction of -3.1 whoops per 24 hours (95% CI -6.2 to 0.02) but no change in hospital stay (MD -0.7 days; 95% CI -3.8 to 2.4). Dexamethasone did not show a clear decrease in length of hospital stay (MD -3.5 days; 95% CI -15.3 to 8.4) and salbutamol showed no change in coughing paroxysms per 24 hours (MD -0.2; 95% CI -4.1 to 3.7). Only one trial comparing pertussis immunoglobulin versus placebo reported data on adverse events: 4.3% in the treatment group (rash) versus 5.3% in the placebo group (loose stools, pain and swelling at injection site).
There is insufficient evidence to draw conclusions about the effectiveness of interventions for the cough in whooping cough.
 Published in the Journal Watch Infectious Diseases, May 2, 2012.
Bettiol S, Wang K, Thompson MJ, et al. Symptomatic treatment of the cough in whooping cough. Cochrane Database Syst Rev. 2012 May 16;5:CD003257.
Amoxicillin v's Azithromycin
During a five-day course of azithromycin, patients had a small, increased risk of sudden cardiac death compared with those receiving amoxicillin or no antibiotics, in an observational study .
The small, heightened risk was greater among patients with the most baseline cardiovascular risk factors. Although the study tried to account for differences in patients receiving Amoxicillin v's Azithromycin, some deaths may be explained by differences in illness severity, an outside expert suggests.
This was discussed with our group in NCH, Tallaght where we use Azithromycin for many indications: In the article it says "The macrolide antibiotics erythromycin and clarithromycin can increase the risks of serious ventricular arrhythmias and sudden cardiac death, but only recently have reports suggested that this is also true for azithromycin".
My understanding of this is Azithromycin might increase risk, but the same is true of all the macrolides. The patients that are put on Azithromycin thrice weekly are CF patients or patients that get recurrent chest infections, they are more likely to have underlying medical conditions predisposing them to increased risk of cardiac death. So like the article says, its hard to say that these deaths were due to the drug alone. I think there might be an issue if azithromycin is used for lung prophylaxis and erythromycin is used as a pro-kinetic in the same patient. The reason for the increase in the usage of azithromycin is as follows. Azithromycin is less likely than the other macrolides to interact with other drugs. It has better compliance due to once daily dosing, shorter treatment duration and better side effect profile.
It is well absorbed. For the treatment of Pertussis in babies < 1 month old, azithromycin is the preferred agent. Erythromycin is not recommended because of concerns it may cause infantile hypertrophic pyloric stenosis and clarithromycin is not recommended due to the lack of safety data in this age group.
 The study is published in the May 17, 2012 issue of the New England Journal of Medicine.
Zhang L, Prietsch SO, Axelsson I, et al. Acellular vaccines for preventing whooping cough in children. Cochrane Database Syst. Rev. 2012 Mar 14;3:CD001478.
How Risk Factors for SIDS Have Changed Since the Back-to-Sleep Campaign.
A higher percentage of cases are now associated with side sleep position and bed-sharing, and prone position still accounts for 30% of cases.
Although the rate of sudden infant death syndrome (SIDS) in the U.S. has declined more than 50% since the start of the 1994 Back-to-Sleep campaign, the rate has plateaued and SIDS remains the leading cause of postnatal infant mortality. To determine residual risk factors for SIDS, researchers conducted detailed case studies of 568 SIDS deaths from 1991 to 2008 in San Diego County, California. Risks were considered either intrinsic (gestational age at birth <37 weeks, black race, prenatal exposure to alcohol or cigarette smoking) or extrinsic (prone or side sleep position, bed-sharing, over-bundling, covered head, upper respiratory tract infection).
The SIDS rate in the county declined from 1.34 per 1000 births in 1991 to 0.64 per 1000 births in 2008. The percentage of cases found in the prone position declined from 84% to 49%, the percentage found in the side sleep position increased from 7% to 17%, and the percentage of infants bed-sharing at the time of death increased from 19% to 38% (especially among infants younger than 2 months). Although most SIDS cases continue to occur in infants aged 2 to 4 months, the percentage of infants younger than 2 months and older than 4 months increased slightly, as did the percentage of premature infants. The percentage of cases associated with upper respiratory tract infections decreased from 47% to 25%. At least one risk factor was identified in 99% of cases; most (57%) had at least two extrinsic and one intrinsic risk factor. Only 5% of cases did not have an identified intrinsic risk factor.
Thirty percent of infants with sudden infant death syndrome still are found in the prone position, and the percentage of infants placed or found in the side sleep position accounts for an increasing proportion of cases. The side sleep position is not a safe alternative: The authors report that nearly half of SIDS infants placed on their side for sleep are found prone at the time of death. Bed-sharing is also an important risk factor, particularly in children younger than 2 months.
F. Bruder Stapleton, MD Published in Journal Watch Pediatrics and Adolescent Medicine April 25, 2012.
Rotavirus vaccines associated with increased risk of intussusception.
Previous rotavirus vaccines were associated with increased risk of intussusception. As yet they are not part of our routine national schedule. New work suggests some efficacy but only a 50% reduction in risk of all diarrhoea.
Rotavirus results in more diarrhoea-related deaths in children less than five years of age than any other single agent in low- and middle-income countries. It is also a common cause of diarrhoea-related hospital admissions in high-income countries. The World Health Organization (WHO) recommends that all children should be vaccinated with a monovalent rotavirus vaccine (RV1; Rotarix, GlaxoSmithKline Biologicals) or a pentavalent rotavirus vaccine (RV5; RotaTeq, Merck & Co., Inc.), with a stronger recommendation for countries where deaths due to diarrhoea comprise more than 10% of all deaths. Lanzhou lamb rotavirus vaccine (LLR; Lanzhou Institute of Biomedical Products) is used in China only.
To evaluate rotavirus vaccines approved for use (RV1, RV5, and LLR) for preventing rotavirus diarrhoea. Secondary objectives were to evaluate the efficacy of rotavirus vaccines on all-cause diarrhoea, hospital admission, death, and safety profiles.
For this update, we searched MEDLINE (via PubMed) in October 2011, and in June 2011 we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (published in The Cochrane Library 2011, Issue 2), , EMBASE, LILACS, and BIOSIS. We also searched the ICTRP (28 June 2011) and checked reference lists of identified studies.
We selected randomized controlled trials in children comparing rotavirus vaccines approved for use with placebo, no intervention, or another vaccine.
DATA COLLECTION AND ANALYSIS:
Two authors independently assessed trial eligibility, extracted data, and assessed risk of bias. They combined dichotomous data using the risk ratio (RR) and 95% confidence intervals (CI) and used GRADE to evaluate evidence quality, which was reflected as follows: high quality (``vaccine prevents...``); moderate quality (``vaccine probably prevents...``); or low quality (``vaccine may prevent...``).
Forty-three trials, including nine new trials for this update, met the inclusion criteria and enrolled 190,551 participants. Thirty-one trials assessed RV1, and 12 trials evaluated RV5. We did not find any trials assessing LLR. In children aged less than one year, RV1, compared to placebo, probably prevents 70% of all cases of rotavirus diarrhoea (RR 0.30, 95% CI 0.18 to 0.50; seven trials, 12,130 participants; moderate-quality evidence), and 80% of severe rotavirus diarrhoea cases (RR 0.20, 95% CI 0.11 to 0.35; seven trials, 35,004 participants; moderate-quality evidence). Similarly, RV5 prevents 73% of all rotavirus diarrhoea cases (RR 0.27, 95% CI 0.22 to 0.33; four trials, 7614 participants; high-quality evidence), and 77% of severe rotavirus diarrhoea cases (RR 0.23, 95% CI 0.08 to 0.71; three trials, 6953 participants; high-quality evidence). Both vaccines prevent over 80% of rotavirus diarrhoea cases that require hospitalization.
For all-cause diarrhoea, based on two multi-centered trials from South Africa, Malawi, and Europe, RV1 may reduce severe cases by 42% (RR 0.58, 95% CI 0.40 to 0.84; two trials, 8291 participants; low--quality evidence). Also, based on one trial from Finland, RV5 may reduce severe cases by 72% (RR 0.28, 95% CI 0.16 to 0.48; one trial, 1029 participants; low-quality evidence).During the second year of life, compared to placebo, RV1 probably prevents 70% of all cases of rotavirus diarrhoea of any severity (RR 0.30, 95% CI 0.21 to 0.43; six trials, 8041 participants; moderate-quality evidence), and 84% of severe rotavirus diarrhoea cases (RR 0.16, 95% CI 0.12 to 0.21; eight trials, 32,854 participants; moderate-quality evidence). RV5 prevents 49% of all rotavirus diarrhoea cases of any severity (RR 0.51, 95% CI 0.36 to 0.72; four trials, 9784 participants; high-quality evidence), and 56% of severe rotavirus diarrhoea cases (RR 0.44, 95% CI 0.22 to 0.88; four trials, 9783 participants; high-quality evidence). For all-cause diarrhoea, RV1 probably reduces severe cases by 51% (RR 0.49, 95% CI 0.40 to 0.60; two trials, 6269 participants; moderate-quality evidence), and RV5 showed no difference with placebo (three trials, 8533 participants).Reported serious adverse events (including intussusception) after vaccination were measured in 95,178 children for RV1 and 77,480 for RV5, with no difference between the vaccines.
RV1 and RV5 vaccines are effective in preventing rotavirus diarrhoea. These data support the WHO`s global vaccine recommendation. The potential for reduced vaccine efficacy in low-income countries needs to be investigated. No increased risk of intussusception was detected, but surveillance monitoring studies are probably advisable in countries introducing the vaccine nationally.
Published in AAP (American Academy of Paediatrics) Guideline 2011
Nosocomial Measles Outbreak
Nosocomial Measles Outbreak Measles, contracted in a hospital emergency department, affected both unimmunized and previously vaccinated individuals. In the U.S., most cases of measles are imported from endemic areas where immunization rates are low. On March 28, 2009, a physician reported a measles case involving an unvaccinated 23-month-old boy in Pennsylvania. Subsequently, five additional individuals with measles — including the source patient — were identified.
All six individuals had been in the same hospital emergency department (ED) on March 10. The source patient was a 10-year-old boy with unknown vaccination history who had moved to the U.S. from India 2 days before being evaluated in the ED for a rash. The infection was transmitted to the examining physician in the ED (who had a history of measles vaccination), to the index patient and family members who had accompanied him to the ED (his brother and father) for treatment of an unrelated problem, and to an 11-month-old infant who had been examined in the same ED.
The index patient and his brother were unvaccinated by parental choice; the 11-month-old was too young for vaccination. All cases manifested within 18 days of the ED exposure. Diagnosis was established by detection of antimeasles IgM antibodies in the patients' serum.
In the U.S., measles vaccination is almost ubiquitous; coverage is sufficient to provide herd immunity, and endogenous cases are very rare. Unfortunately, some parents — because of religious beliefs or, more often, because of the now-rampant antivaccination propaganda — refuse to immunize their children, thereby exposing themselves and others to preventable illness. Transmission to the previously vaccinated physician raises several issues. Certainly, hospitals should maintain immunity records for all staff. However, to judge by his history, this physician should have been immune. Given the huge expense engendered by this tiny outbreak, requiring serologic proof of immunity in healthcare workers would seem to be cost-effective.
— Stephen G. Baum, MD
Published in Journal Watch Infectious Diseases February 1, 2012
Febrile infants aged 30 to 90 days with positive Urinalyses require Lumbar Puncture.
Despite the authors' conclusion that lumbar puncture is not needed, this study failed to show lower risk for meningitis in febrile infants with urinary tract infections. In a retrospective study of infants aged 30 to 90 days who presented to a tertiary paediatric emergency department with fever 38°C and who received a full septic work-up, researchers assessed the need for lumbar puncture to rule out meningitis in infants with positive urinalysis. Excluded were infants born before 35 weeks' gestation, those with chronic underlying medical conditions, and those who received antibiotics prior to culture. Positive urinalysis was defined as presence of at least one of the following criteria: positive leukocyte esterase, positive nitrites, or >10 white blood cells per high-power field.
Of 392 infants enrolled from 2001 to 2005, 57 had positive urinalyses. Of four infants with culture-proven meningitis, only one (age, 71 days) had a positive urinalysis. This patient's urine, blood, and cerebrospinal fluid cultures grew Escherichia coli. A positive urinalysis yielded a 98% negative predictive value for meningitis. Although the authors recommend "judicious clinical judgment", they conclude that routine lumbar puncture might not be required for febrile infants aged 30 to 90 days with positive urinalyses.
Conclusion: Of the 335 patients with negative urinalyses in this study, 3 (0.9%) had meningitis, and, of the 57 patients with positive urinalyses, 1 (1.8%) had meningitis. The negative predictive value was high simply because the prevalence of meningitis was low. As delineated in the Rochester criteria, a positive urinalysis places an infant in the high-risk category and necessitates lumbar puncture.