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Typhoid fever commonly affects young children in endemic areas and antibiotic resistance is increasing (in a large epidemic in Tajikistan in 1996–98 over 90% of the organisms were multidrug resistant and 82% were ciprofloxacin resistant). The development of an effective conjugate vaccine could, therefore, hardly come at a more opportune time. In Vietnam (New England Journal of Medicine2001; 344:1263–9, see also editorial Ibid: 1322–3) a randomised, placebo-controlled trial included over 11 000 children aged 2–5 years. Two doses of the vaccine (Vi capsular polysaccharide antigen conjugated with a non–toxic recombinantPseudomonas aeruginosa exotoxin A) provided 91.5% protection against blood culture confirmed typhoid fever. In all children tested, the second dose of the vaccine caused at least a tenfold increase in antibody titre.
Anxiety disorders are said to be the most common kind of psychiatric disorder to affect children but the best way of treating them is uncertain. In a placebo controlled trial at five US academic centres (New England Journal of Medicine2001;344:1279–85, see also editorial, Ibid: 1326–7) a clinically significant response to 8 weeks of treatment occurred in 76% of 6–17 year old children randomised to fluvoxamine (a selective serotonin-reuptake inhibitor) and 29% of controls. The editorialist, though, suggests that cognitive behavioural therapy could be the best initial treatment.
A multicentre trial involving 12–33 month old inner city American children with moderate lead poisoning (blood lead concentrations 1.0–2.1 μmol/L (20–44 μg/dl)) (New England Journal of Medicine 2001;344:1421–6) showed no difference on tests of neuropsychological development after 36 months of follow up between those treated with an oral lead chelating agent (succimer (dimercaptosuccinic acid)) and those treated with placebo. The most sensible thing to do about lead poisoning, say editorialists (ibid: 1470–1), is to stop rearing children in houses with lead paint.
Systemic cyclosporin is effective treatment for severe atopic dermatitis but the drug does not penetrate the epidermis and is therefore ineffective when applied topically. Two drugs, ascomycin and tacrolimus, which have mechanisms of action similar to cyclosporin (they inhibit the production of Th1 and Th2 cytokines by inhibiting calcineurin-induced T-cell activation) are active topically and are undergoing clinical trials. The first study of ascomycin (SDZ ASM 981) in children (British Journal of Dermatology 2001; 144:781–7) has shown little systemic absorption of the drug when given twice daily for three weeks to ten 1 to 4 year old children with atopic dermatitis (23–69% body surface area affected). Clinical response was promising and the treatment was well tolerated. An editorialist (Ibid: 679–81) predicts that the use of these drugs (they are not yet licensed) “will signal the end of the topical glucocorticosteroid era”.
In children with severe neurological impairment, severe gastro-oesophageal reflux may recur after fundoplication and gastrostomy. The operation of total oesophagogastric dissociation with Roux-en-Y oesophagojejunostomy and non-refluxing feeding gastrostomy was proposed as an alternative procedure in 1997. Now surgeons in Rome (Journal of Pediatric Surgery 2001;36:677–80) have reported better results (better postoperative nutrition, fewer respiratory infections, and better quality of life) in 14 children after the dissociation procedure compared with 12 children after fundoplication.
Does a lot of lead in the air make people kill people? This strange proposition has received some support from an ecological study involving all 3111 contiguous counties in the USA (Archives of Pediatrics and Adolescent Medicine 2001;155:579–82). Murder was found to be four times more common in counties with the highest air lead concentrations compared with counties with the lowest concentrations. Other air pollutants were not reliably associated with homicide rates but there must be other potential confounding factors, though it does give a new slant to the expression “filling ‘em full of lead”.
In Guinea-Bissau (American Journal of Clinical Nutrition 2001;73:968–74) children under 3 years old with persistent (2 weeks or more) diarrhoea were randomly assigned to dietary management (a home made gruel containing millet, egg, banana, margarine, and sugar plus vitamin and mineral supplements) or control groups. The treatment group gained significantly more weight during the intervention period (mean duration 17 days) and at 6 months they had put on more weight and grown in length more than the control group.
Paediatric dermatologists at seven US centres (Archives of Dermatology 2001;137: 630–6) diagnosed kwashiorkor in 12 children aged 1–22 months over a period of 9 years. Nutritional ignorance, parentally suspected milk intolerance, and food faddism were the main causative factors. Oedema and the characteristic desquamating rash (“flaky paint dermati-tis”) are the chief clinical clues to the diagnosis.
In the Austrian State of Tyrol (International Journal of Pediatric Otorhinolarynology2001;59:23–8) the introduction of universal newborn hearing screening resulted in a 40% increase in the number of children whose hearing impairment was detected early (in the first 6 months). For children with moderate hearing loss the increase in early detection was almost 50%.
A case control study in Montreal (American Journal of Epidemiology 2001;153:653–8) has confirmed that having siblings and attending day care before the age of 1 year both reduce the risk of asthma at age 3–4 years. Breastfeeding had no effect. The findings are taken to support the hypothesis that early childhood infections may protect against asthma.
Mometasone furoate is a glucocorticoid with high local potency and low systemic availability. A study of 733 patients (adults and children over 11 years old) at 60 centres in 20 countries (Annals of Allergy, Asthma, and Immunology2001;86:397–404) has shown that, in the treatment of moderate persistent asthma, dry powder inhaler treatment with mometasone furoate 200 μg twice daily is similar in effect to fluticasone propionate by Diskhaler 250 μg twice daily.
Viral infection, particularly with adenovirus, may increase the risk of transplant failure after heart transplantation in children. In the USA (New England Journal of Medicine2001;344;1498–503) 149 children had 553 endomyocardial biopsy samples examined as part of investigation for possible rejection and coronary vasculopathy. Forty-eight samples from 34 children were positive for viral DNA (adenovirus in 30 samples). An adverse cardiac event occurred within 3 months after 85% of positive biopsies and 34% of negative biopsies. The finding of viral DNA increased the odds of graft loss more than sixfold.
In Boston, Massachusetts, six adults with severe haemophilia A were treated with gene therapy (New England Journal of Medicine 2001;344:1735–42). They were given back (by laparoscopic injection into the omentum) their own skin fibroblasts transfected with a plasmid containing sequences of the factor VIII gene. Plasma factor VIII activity rose in four of the six, with some clinical improvement. There were no complications and factor VIII inhibitors were not induced.