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Are children who were delivered by forceps more likely to get acute otitis media? The question was asked by a mother at a clinic in Mallorca. A subsequent retrospective analysis of clinic data (

) showed an increase in incidence of acute otitis media among toddlers who had had a forceps delivery. Non-operative vaginal delivery, vacuum extraction, and caesarean section were each followed by a 30% incidence of acute otitis media in the second year of life whereas the incidence after forceps delivery was 40%. The mother’s suggestion is supported by not proved.

Heat-shock proteins promote immune responses and children with juvenile idiopathic arthritis (JIA) whose T cells react to autologous heat-shock protein 60 (HSP60) tend to do better. It might be possible to develop immunotherapy to promote this T cell reactivity, particularly for children with oligoarticular JIA. Before this can happen, however, it will be necessary to identify specific HSP60 epitopes involved in JIA. Researchers in Holland, Italy, and the USA (

) used computer algorithms to identify eight potentially relevant epitopes. They assessed the T cell responses induced by each of these epitopes in peripheral blood mononuclear cells of 33 patients with polyarticular JIA, 24 with oligoarticular JIA, 27 healthy controls, and 20 disease controls (with type I diabetes). Five of the eight HSP60 epitopes induced T cell proliferation and interleukin 10 production in the mononuclear cells of patients with JIA but not controls. The responses to these five epitopes were potentially of benefit in patients with oligoarticular JIA. HSP60-peptide immunotherapy might be feasible for some patients with JIA.

Panels of experts have drawn up a new definition and classification of cerebral palsy (

) and vigorous discussion is expected and wanted. The classification is based on motor abnormalities, associated impairments, anatomical and tomographic or MRI findings, and causation and timing. The proposed definition refers to “disturbances” rather than “defects or lesions” in the developing brain and it is suggested in the editorial that this could increase the number of children with a diagnosis of cerebral palsy by a factor of between 25 and 45, and include up to 9% of children.

In Lucknow, India tuberculous meningitis was milder and the outcome better if the child had a BCG scar (

). Of 150 consecutive children, 54 had a BCG scar. Compared with the other 96, these children were less likely to have a depressed conscious level (69% vs 85%) or focal neurological signs (20% vs 40%). Mean Glasgow Coma Scale scores were 10.2 vs 8.8 and CSF white cell counts 211 vs 141 x 106/l. A normal outcome or only mild sequelae occurred in 54% vs 35%.

Over a 2 year period beginning on 1 March 2001 20 children with injury to abdominal viscera considered due to abuse were identified via the British Paediatric Surveillance Unit (BPSU) and 164 with abdominal injuries due to road traffic accidents (112) or falls (52) were identified via the Trauma Audit and Research Network (

). The abused children were younger (mean age 3.7 years vs 9.7 years (road traffic accidents) or 10.4 years (falls); 16 of the 20 abused children and 17 of the other 164 were under 5 years old. The estimated incidence of abdominal injury due to abuse was 0.9 cases per million children per year for children aged 0–14 years and 2.3 per million for children younger than 5 years. Seventeen abused children had other injuries due to abuse but five had no abdominal skin bruising. The intraabdominal trauma in abused children included injuries to small bowel (10), stomach (1), liver (7), spleen (6), pancreas (2), and kidney (2). Six children in the abused group died and four of these had associated head injuries. The authors of this paper conclude that special consideration needs to be given to the cause of small bowel injuries especially if the explanation given is a minor fall and the child is less than 5 years old.

Oral polio virus vaccine induces herd immunity because the live vaccine virus spreads to unvaccinated children. Now a reanalysis of data from a trial in Bangladesh (

) has shown that killed oral cholera vaccines protect both recipients and nonrecipients provided that vaccine coverage is high enough. In baris with low vaccine coverage (<28%) the risk of cholera in women or children during the year after receipt of vaccine or placebo was 2.7 cases per 1000 population among vaccine recipients and 7.0 cases per 1000 population among placebo recipients. In baris with high vaccine coverage (>51%) the corresponding risks were 1.3 and 1.5 cases per 1000 population. The protective efficacy of the vaccine ranged from 52% to 67% in baris in the first four quintiles for vaccine coverage. Among baris in the fifth quintile the protective effect of the vaccine was no longer significantly different between vaccine and placebo recipients (protective efficacy 14%, 95% CI –111 to 64%). It is suggested that the vaccines protect unvaccinated people by reducing the load of cholera vibrios in the environment.

An intermittent divergent squint (exotropia) often increases with distance fixation. An increase in ocular deviation with near fixation is less common and may be associated with neurological disorders. A study at the Arkansas Children’s Hospital, (

) included 29 children aged 3 to 17 years whose external deviation increased with near fixation (study group) and 37 children aged 3 to 14 years whose deviation was the same or greater with distance fixation (control group). Conditions such as developmental delay, cerebral palsy, attention deficit disorder, and history of intracranial haemorrhage were more common in the study group. Altogether 19 of the 29 study group patients and seven of the 37 control group patients had neurological abnormalities. The authors of this paper suggest that intermittent exotropia that increases with near fixation may be a “soft” sign of neurological disease.

Spontaneous resolution in infancy is the outcome in almost all (96%) of the 20% of neonates who have epiphora. For those whose epiphora does not resolve of its own probing is usually successful. The few children who still have the problem after probing present a more difficult technical challenge. At the Birmingham Children’s Hospital (

) endonasal intubation and endonasal dacryocystorhinostomy (DCR) have been performed by a joint ophthalmology/ear, nose, and throat team. For congenital nasolacrimal duct obstruction with persistent epiphora after two technically successful probing procedures the success rate was 73% (or 89% if the children lost to follow up were all cured). For acquired obstruction the success rate was 57%. Seventeen of the 64 children with congenital nasolacrimal duct obstruction had associated conditions including Down’s syndrome (6) and midfacial dysmorphism and/or cleft (6). The success rate in these children was 82%.

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