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Arch Dis Child 2000 Volume 83 No 4
Focus on the respiratory tract
Winter is on its way in the northern hemisphere and with it brings the annual misery of respiratory tract infections. This month we present a mini symposium, with eight papers devoted to children's respiratory illness.
The fetus and the ashtray
The ALSPAC study team (page 307) have looked at the relationship between maternal smoking in pregnancy and reported wheeze in offspring. After controlling for postnatal environmental tobacco smoke and demographic risk factors, the team concludes that mothers who smoke in the third trimester, whether a little or a lot, are more likely to have little wheezers. Future studies will look at whether they become big wheezers.
Locking stable doors
The IMpact trial of a monoclonal antibody prophylaxis against respiratory syncytial virus (RSV) infection claimed a relative risk reduction of 55% in the admission rate of immunised high risk infants.1 Clark and colleagues in Liverpool, UK (page 313), found similar RSV admission rates for small babies in their area. They calculated the potential cost saving to the NHS had all these babies been immunised, and balanced it against the cost of vaccine. Their health provider would have spent an extra £315 000–966 000 (US$ 472 500–1 450 000), depending on how many babies had been offered protection. About half of the 68 admissions might have been prevented, but the authors conclude that this would have been insufficient to avoid their opening a “winter pressures” ward.
1 The IMpact-RSV Study Group. Palivizumab, a humanised respiratory syncytial virus monoclonal antibody, reduces hospitalisation from respiratory syncytial virus infection in high-risk infants.Pediatrics1998;102:531–7.
A reason for using antibiotics?
Acute otitis media may coexist with bronchiolitis; indeed a group from Israel (page 317) reports it in 79 of 150 infants, using a US rather than a UK description of bronchiolitis. Contrary to the authors' expectations, the ear infection had no impact on the course of the respiratory illness. This may or may not have been affected by their prompt treatment with antibiotics and tympanocentesis.
And a way of avoiding them
Paediatric trainees (interns and residents) in Nottingham, UK, used to treat 75% of the children admitted with community acquired pneumonia, with intravenous cefotaxime, benzylpenicillin, ampicillin, or flucloxacillin. It was a rare feat to avoid antibiotics at all.
Guidelines were introduced in the hope of rationalisation of prescribing practices by using serology, microbiological culture, and PCR to pin down aetiology and thereby minimise empirical broad spectrum use. A re-audit (page 320) has now shown that 61% of children treated for this disease, rather than 10%, now receive intravenous penicillin, while use of cefotaxime and ampicillin fell from 59% to 18%. Knowing the PCR result encouraged clinicians in their conviction that penicillin and/or a macrolide was initial treatment of choice. Roll on desktop PCR kits.
What! Me wheezy?
An elegant piece of work from Brighton (Sussex, not Beach) has shown that hypoxic asthmatics perceive themselves as less breathless than those not hypoxic (page 325). The message is: after asking the child how they feel, measure oxygen saturation. If you get a nasty surprise, make sure that follow up involves regular home peak flow testing and impress on parents the need for early recourse to medical advice.
But do they inhale?
Jonasson and colleagues in Oslo, Norway (page 330) conducted a clinical trial of an inhaled steroid against placebo in children with mild asthma. Sneakily, they counted up the administered doses from the inhaler devices. As time went on, adherence to medication instructions fell by more than half in two years. The good news was that they were more likely to dump the placebo.
Smoking doesn't just make you wheeze
As an senior house officer at Great Ormond Street a long time ago, I recall admitting an infant whose address was the Soviet Trade Delegation in north London. He was accompanied by a Russian doctor and we spent a pleasant hour discussing our different child care practices. At one point he told me triumphantly that Soviet babies never suffered colic. I was busily unwinding the baby at the time and, to this day, am uncertain whether it was swaddling or ideology that kept them pain free.
Now Reijneveld and others from the Netherlands (page 302) report that if mothers smoke their babies' colic rate doubles. The good news is that the association is less marked if they also breast feed.
Swaddling, meanwhile, may be on the way out but cultural differences remain. This month we report a WHO supported survey on sleep positioning and advice in 489 Eastern European hospitals in countries with infant mortality rates varying from 7 (Slovenia) to 55 (Turkmenistan) deaths per 1000 live births (page 304). Although prone sleeping was rarely practised or recommended, 65% of units placed babies on their side. The next step must be to collect data on actual sleeping position at home and SIDS rates.
Now for something completely different—Goodness, Gracious . . . (Lewis J Lee, 1962)
When we accepted Partsch and colleagues' meticulously performed investigation of scrotal temperature as a function of nappy (diaper) design (page 364), we toyed with it as an end of year conceit. But then we read Hughes' erudite leader on the subject (page 281) and voted it the music of the spheres.
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