On both sides of the Atlantic, withdrawing life-sustaining treatment has received an enormous amount of publicity, mobilising both the public and politicians. Sadly, much of the "debate" has been carried to the courts. In May 2004, the College released the second edition of "Withholding or withdrawing life sustaining treatment in children: a framework for practice" (http://www.rcpch.ac.uk/publications/recent_publications/Witholding.pdf – last accessed April 20, 2005). The document provides a framework to guide management in individual cases. Five conditions are considered: the "brain dead child"; the "permanent vegative" state; the "no chance" situation; the "no purpose" situation; and the "unbearable" situation. As we push the limits of neonatal survival ever lower, and our technological wizardry advances in other areas, we are likely to be increasingly confronted by issues related to withdrawing life-sustaining treatment from children and adolescents.

Morris and colleagues from Birmingham Children’s Hospital are to be congratulated for performing a very valuable service – they have created a new formula for calculating the desired rise in haemoglobin or haematocrit. In a two-phase study, they demonstrated that existing formulae do poorly, and then after deriving their new formula, demonstrated its validity. Their new formula improves the actual predicted post transfusion haemoglobin by approximately 35%. If widely adopted, the Birmingham Formula could improve care and reduce cost by limiting the number of transfusions in children.
See page 724

In the 1980s when a trainee asked me what vaccine to give a particular child I could answer the question. Now I would never consider responding without first reviewing established schedules. Over the past decade, both in the UK and US, the immunisation schedule has become more complicated. Drs Finn and Heath discuss the many intricacies of Haemophilus influenzae, meningococcus group C, and pneumococcal conjugate vaccines. They consider priming doses, boosting, herd immunity, cost, and harmonising European schedules. What have we learned from our experiences? First, there will always be surprises—constant monitoring of immunisation immunogenicity will be necessary. Second, the impact of childhood immunisation on adult disease appears to be far greater than expected. Third, reimmunisation with virtually all vaccines will be necessary – the optimal timing of boosting doses has yet to be determined. Lastly, cost and parental perception of vaccines will impact on our ability to immunise children. With new vaccines like the quadrivalent conjugate meningococcal (provides protection against A, C, Y, and W-135) and human papillomavirus vaccines just about ready for world wide release, the science and politics of vaccines will continue to evolve.
See page 667

Although methicillin resistant Staphylococcus aureus (MRSA) has circulated in hospitals for decades two new concerns have arisen: (1) there is an increase in the number of hospitalised patients who become infected with MRSA; and (2) MRSA has spread to the community. Recent reports from the US indicate that MRSA is often "community-acquired".^1,2 Drs Adedeji and Gray, from Birmingham Children’s Hospital, report the numbers of new cases of MRSA in inpatients and outpatients over a 6 year period. Surprisingly, they found a decline among inpatients from 47 cases to 35 and among outpatients from 25 to 17. These declines occurred despite an increase in patient care activity at the hospital. These results are encouraging, but at odds with reports from other institutions and other countries. I recently completed my ward attending time and cared for two children with community-acquired MRSA – a 3 week old infant with neonatal mastitis and a 12 year old with leg cellulitis. In both cases, the patients responded poorly to initial therapy, had wound cultures that grew MRSA, and required 10 days of parenteral therapy.
See page 720

• Aminoglycosides are commonly used in combination with a betalactam for the treatment of neonatal sepsis. Nestaas and colleagues have analysed 16 trials involving 823 neonates who received an aminoglycoside. They found that extended dosing of aminoglycosides—dosage interval typically 24 hours in term and 26–48 hours in premature infants—is safe and effective.
  
• The use of palivizumab for preterm infants is controversial. There are few data indicating a reduction in mortality, although numerous studies suggest a reduction in hospitalisation rates. However, the "benefit" found in these studies is dependent upon the hospitalisation rates in the "control" groups. Embleton, Harkensee, and Mckean review palivizumab prophylaxis in preterm infants.
  
• The diagnosis of tracheobronchomalacia (TBM) can be difficult. Investigators from Great Ormond Street compare the diagnostic utility of CT and tracheobronchography. Their conclusion – bronchography is a better diagnostic test for TBM than CT.
  

1. Chambers HF. Community-associated MRSA – resistance and virulence coverage. N Eng J Med 2005;352:1485–7.[Free Full Text]
   
2. Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Eng J Med 2005;352:1436–44.[Abstract/Free Full Text]
   

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