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Two-drug antiretroviral treatment of mothers during labour (or starting before labour) and of mothers and infants for 1 week after delivery reduces HIV-1 transmission in the first 6 weeks but has little effect on HIV-1 infection rates by age 18 months (
). But this approach to the problem of mother-to-child transmission may be outdated. A commentator (ibid: 1168–9) suggests that such treatments may induce drug resistance and make later treatment of the mother ineffective. Reductions in cost have made three drug combination treatments feasible for poor countries and in future the best way of preventing transmission may be effective treatment of the mother. Two drug short course regimens may prevent transmission but make orphans of the children.
It has been recognised for a long time that male circumcision may reduce the risk of cervical cancer in female partners. It now seems almost certain that the relevant male factor is penile human papillomavirus (HPV) infection. Data from seven case control studies in five countries (
) have shown that circumcised men are 63% less likely to have penile HPV infection. There was a 58% reduction in risk of cervical cancer in the current partners of circumcised men compared with those of uncircumcised men but only if the male partner reported having had at least six lifetime female sexual partners. Whether all this is a reason to promote routine neonatal circumcision is debatable. Other measures such as promotion of condom use by men with high risk sexual behaviour or the development of HPV vaccination may prove more effective.
Why does the efficacy of BCG vaccination vary so much in different parts of the world? In the UK the protective efficacy of BCG against tuberculosis is up to 80% whereas in Malawi it is not protective. It seems probable that the answer lies in different levels of environmental exposure to mycobacteria. A study of young people in Malawi and the UK (
) has shown that immune responsiveness to mycobacteria (whole blood interferon-γ production after addition of PPD and tuberculin skin reactivity, before BCG vaccination was common in Malawi (61% and 46% positivity for the two tests respectively) but much less common in the UK (22% v 13%). One year after BCG a positive interferon-γ test was recorded in 78% of subjects in Malawi and 83% in the UK but 70% of unvaccinated controls in Malawi and 21% in the UK also had a positive test. The findings with tuberculin skin reactivity were similar. It is concluded that prior exposure to environmental mycobacteria induces immune responsiveness to Mycobacterium tuberculosis and therefore reduces the potential benefit from BCG.
Successful stem cell transplantation corrects the T cell deficiency but not the B cell malfunction of boys with X linked severe combined immunodeficiency. In Paris (
) five boys with this disease were infused with their own CD34+ bone marrow cells after these cells had been transduced with the γc gene using a defective murine leukaemia virus as a vector. Four of the boys had almost normal T cell numbers and function and adequate B cell function up to 30 months after the infusion. The fifth boy had disseminated BCG infection before infusion, did not respond, and received an allogeneic stem cell transplant 8 months later. At least two children have received this gene therapy at Great Ormond Street Hospital, London (
Ibuprofen may cause pulmonary hypertension in preterm babies. A French trial of ibuprofen prophylaxis for patent ductus arteriosus in infants born at less than 28 weeks gestation was stopped prematurely (
) after three infants given ibuprofen developed severe hypoxaemia and pulmonary hypertension. A total of 135 infants had been randomised (1:1) to ibuprofen or placebo. The pulmonary hypertension responded to inhaled nitric oxide.
High risk infants (both parents atopic) who develop recurrent wheezing in the first year have reduced lung function within 2 months of birth. In Manchester (
) 69 term infants had maximum flow at functional residual capacity (V1 max FRC) measured at between 24 and 55 days of age. V1 max FRC adjusted for length was significantly less (1.3 v 2.0 ml/s/cm) in infants who developed recurrent wheeze than in those who did not. The same applied to infants who developed recurrent cough. The reduction in lung function was independent of maternal asthma, maternal mattress housedust mite content, and maternal smoking in pregnancy. Maternal smoking, however, increased the risk of recurrent wheezing in infancy by a factor of 30. There is a balance to be achieved between spoonfeeding people with advice and assuming that most are intelligent enough to work out a great deal for themselves. You might think it quite likely that parents would allow their children to take somewhat greater risks with appropriate safety gear than without safety gear and that is what was found in a telephone interview study in Ontario (
). The conclusion was that there is a “need to communicate to parents that safety gear moderates injury risk but does not necessarily guarantee the prevention of injury”. Well yes, but… Parents’ ratings of the efficacy of safety gear for various activities usually ranged around 3 or 4 points on a six point scale.
When Lucina thinks of preventing child deaths from fire she thinks of smoke alarms but a report from Dallas, Texas (
) has highlighted the importance of fireplay from which, it seems, smoke alarms offer little protection. Between 1991 and 1998 residential fires in Dallas caused 39 deaths and 37 nonfatal injuries in children. Fireplay (mostly children playing with matches or lighters) accounted for 5.4% of all fires but for 32 (42%) of the 76 deaths and injuries to children and 24 (60%) of the 40 deaths or injuries in children under 5 years. Thirteen of 14 deaths in apartment or mobile home fires were associated with fireplay. Publicity about the danger and possibly the development of childproof matches and lighters seem the most likely means of prevention.
Abnormalities of quantity or quality of type 1 procollagen produced by cultured skin fibroblasts are found in some 90% of people known to have osteogenesis imperfecta. In Seattle (
) samples were tested from 262 children for whom a diagnosis of nonaccidental fractures was being considered. A diagnosis of osteogenesis imperfecta was made on the basis of these studies in 11 children. Two hundred and twenty children did not have osteogenesis imperfecta and the results were equivocal for 11 children. Of the 11 children with osteogenesis imperfecta the diagnosis had been made on clinical grounds in six. One hundred and twenty-three children had negative tests and adequate clinical data. Four of these had been thought by referring physicians to have osteogenesis imperfecta, in three cases because of blue sclerae. DNA studies on the 11 equivocal samples did not provide useful information. Which children with suspected non-accidental injury should have these tests remains a matter for debate.