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Vaccine problems in proportion
This month we have a mouth watering menu. Our antipodean hors d'oeuvre deals with children who have had a previous adverse reaction to a vaccine. In a previous issue, we provided reasoned advice on the safety of MMR in children with real or presumed egg allergy.1 Oddly, the BMJoffered more cautious and perhaps less practical advice the following week2; unhappily the Lancet had already published a distinctly below the belt assault on this essentially safe vaccine.3 Despite the bad press, most paediatricians consider the frequency of problems with vaccines grossly exaggerated. Thus, we are pleased to provide some balance with details of a South Australian clinic offering advice and immunisation to children who have had a previous adverse event (page 128). Ninety percent were successfully revaccinated, even after reactions such as hypotonia-hyporesponsiveness, or fever and screaming. Only 14 of the 421 revaccinees suffered a significant reaction but with no sequelae. The authors conclude that such a clinic is a valuable component of any comprehensive immunisation programme.
Our choice of main course comprises three papers looking at long (or longish) term effects of childhood illness or assault. A group of community paediatricians from Leeds (UK) report follow up of children determined, 10 years previously, as having been sexually abused (page132). Unsurprisingly the results are ominous: compared with “controls” they were much more likely to suffer subsequent abuse, educational or chronic health problems, and behaviour disturbance. They were more likely to have changed their surname, moved house and school, and become involved with mental health services. Those previously determined as “probably abused” fared no better than those categorised as definite.
This is not the final word: our reviewers (and the authors) take care to point out that the study does not answer the question of the relative negative contributions of the abuse itself and any associated family disruption. They also draw attention to the potential confounding of the controls not being matched socioeconomically.
Another group with worrying outcomes are survivors of bacterial meningitis, 109 of whom were reviewed (out of 158) seven and twelve years after their acute illness. Nearly one third had significant impairment, compared with 5% of controls, while 16% (controls 6%) had one minor impairment—such as, IQ 70–80, educational deficit, or mild to moderate deafness. As expected, acute neurological complications produced greatest risk. The authors have previously published their seven year figures4; thankfully no child deteriorated between the two follow up assessments. They also remind us that their cohort was recruited before HiB vaccine became available.
Is there life after systematic review?
From time to time we receive “quality of life” papers, usually dealing with a specialty clinic cohort. Editorial meetings puzzle long and hard over whether a paper is of sufficient interest when the only original issue is a different indicator chronic illness.
Therefore, we commissioned a team from the child and adolescent psychiatry department at St Mary's Hospital , London, to review published papers on our behalf, with particular attention to psychosocial outcome (page 104).
The authors concentrate initially on the methodological problems they encountered before dealing with described long term effects of a number of conditions. I can't help thinking how frustrating it can be for budding meta-analysts. Perhaps it's time to look at their quality of life?
For those who always choose minestrone, our latest cytokine paper is on offer.
El-Radhi and colleagues (page 159) have looked at T cells and eosinophil function in the blood of children suffering acute exacerbations of asthma before and after oral steroid treatment. They hypothesised that serum sCD25, IL-5, IL-4, and ECP would be higher than that of controls and return to normal with treatment. Although IL-4 let the side down, their hypothesis was broadly supported by their findings. However, even when children had recovered clinically their inflammatory markers remained higher than those of controls. The implication is that the very brief anti-inflammatory treatment generally offered in asthma exacerbations may be overly cautious. One problem for investigators wishing to pursue this line of argument is the ethical issue of repeated blood sampling once children are well.