Professor Salazar-De-Sousa,[1] commenting on the recent paper by Høst et al,[2] maintains that recent prospective and randomised clinical studies have shown that
soy protein (SP) is as allergenic as cow's milk (CM) protein citing a review paper[3]; however, the author failed to detail which are these studies.
In 1990 we demonstrated[4] that Eastham et al[5] have shown an antibody response to SPs in...
Professor Salazar-De-Sousa,[1] commenting on the recent paper by Høst et al,[2] maintains that recent prospective and randomised clinical studies have shown that
soy protein (SP) is as allergenic as cow's milk (CM) protein citing a review paper[3]; however, the author failed to detail which are these studies.
In 1990 we demonstrated[4] that Eastham et al[5] have shown an antibody response to SPs in all SP-fed infants that was comparable to that found to CM in CM-fed infants. However, only soy antigenicity was studied,[4] since the authors measured not IgE antibodies but hemagglutinins to soy and to CM, which mainly belong to IgG antibodies.[5] As the
matter remained controversial, I have published a paper with 142 references and 7 tables, encompassing all diverse aspects of SPs.[6]
If Professor Salazar-De-Sousa reads attentively the data shown in the tables of the paper, he shall convince himself that SFs are recommended for the treatment and/or
prevention of food allergy, also following a recent document of the American Academy of Pediatrics.[7] However, we were distressed about the news "against soy formulas" that we read on the literature, such as "soy formulas should not
prescribed to allergic infants, due to the high incidence of
crossreactions with cow milk proteins".[8]
Professor Salazar, however, appears to be really interested in hydrolysate formulas (HFs). We have documented 202 reactions to HFs in a paper, and 41 case-reports in
another. In total 17 cases of shock-anaphylaxis (one every 3.3 years) versus one/22.3 years provoked by SPFs, with a difference of 676%.
ARNALDO CANTANI
University Professor of Pediatrics Professor of Pediatric Allergy and Immunology University of Roma "La Sapienza"
MONICA MICERA University of Roma "La Sapienza"
References
(1) Salazar-De-Sousa J. Dietary products used in infants for treatment and prevention of food allergy [letter]. Arch Dis Child 2000;83:88.
(2) Høst A, Koletzko B, Dreborg S, et al Dietary products used in infants for treatment and prevention of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition
Committee on Nutrition. Arch Dis Child 1999;81:80-4.
(3) Kerner JA. Use of infant formulas in preventing or postponing atopic manifestations. J Pediatr Gastroenterol Nutr 1997;24:442-6.
(4) Cantani A, Ferrara M, Ragno W, Businco L. Efficacy and safety of a soy-protein-formula for feeding
babies with atopic dermatitis and cow's milk hypersensitivity. Eur Rev Med Pharmacol Sci 1990;12:311-18.
(5) Eastham EJ, Lichauco T, Grady MI, Walker WA. Antigenicity of infant formulas: role of immature intestine on protein permeability. J Pediatr 1978;93:561-4.
(6) Cantani A, Lucenti P. Natural history of soy allergy and/or intolerance in children, and clinical use of soy-protein formulas. Pediatr Allergy Immunol 1997;8:59-74.
(7) American Academy of Pediatrics. Committee on Nutrition. Soy protein-based formulas: recommendations for use in infant feeding. Pediatrics 1998;101:148-53.
(8) Guarino A. Commento ai testi. In La allergia alimentare. Milano: Plada, 2000.
I read with great interest a manuscript reported by Hodson et al in
the journal (2000;83:45-51. The authors discussed various corticosteroid
treatment protocols in patients with nephrotic syndrome (NS). They
suggested that children in their first episode of NS should be treated
with prednisone for at least three months with an increase in benefit being
shown for up to seven months of treatment.
I read with great interest a manuscript reported by Hodson et al in
the journal (2000;83:45-51. The authors discussed various corticosteroid
treatment protocols in patients with nephrotic syndrome (NS). They
suggested that children in their first episode of NS should be treated
with prednisone for at least three months with an increase in benefit being
shown for up to seven months of treatment.
We used prednisone (daily 60 mg/m2 for 4 weeks, 45, 30, 20, 5 mg/m2 on
alternate days for 4 weeks, respectively) in the treatment of 7 patients
with NS (Group I) and compared its effect with the high dose
methylprednisolone (HDMP) in a dosage of 30 mg/kg/d for 3 days, 20 mg/kg/d for 4 days, 10 mg/kg/d for a week, perorally, before 9 A.M. in the
treatment of 8 patients with NS (Group II).[1]
The patients were followed-up for a duration of 38 ± 5.5 months (24-68
months) in Group I and 42 ± 5.5 moths (16-72 months) in Group II.
No
significant difference was obtained in the duration of remission between
two groups (p>0.05), while HDMP induced early remission than
prednisone (p<_0.05. the="the" mean="mean" relapse="relapse" rates="rates" were="were" _0.8="_0.8" year="year" in="in" both="both" groups.="groups." we="we" think="think" that="that" oral="oral" hdmp="hdmp" treatment="treatment" may="may" be="be" used="used" of="of" ns="ns" and="and" is="is" more="more" effective="effective" inducing="inducing" early="early" remission="remission" than="than" prednisone.p="prednisone.p"/>
Conclusion, it can be recommended that patients with NS can be treated
with the oral HDMP as an alternative treatment to standart oral
prednisone treatment.
Reference
(1) Mocan H, Erduran E, Karagüzel G. High dose methylprednisolone therapy in nephrotic syndrome. Indian J Pediatr 1999;66:171-4.
Liz Donovan's fascinating article certainly suggests that the big
finger is pointing at her. However, although her calculation is numerically
correct (and how nice to find someone using non-US billions) the reasoning
is a little suspect.
First multiplying the probabilities gives the odds against these
seven rare conditions presenting in the order indicated; her final figure
should be divided by 7...
Liz Donovan's fascinating article certainly suggests that the big
finger is pointing at her. However, although her calculation is numerically
correct (and how nice to find someone using non-US billions) the reasoning
is a little suspect.
First multiplying the probabilities gives the odds against these
seven rare conditions presenting in the order indicated; her final figure
should be divided by 7 (5040) to provide the odds against this specific
selection presenting to her in one year.
Second she has calculated the a priori possibility for events that
have already occurred. Just think of the odds against finding someone with
the name Liz Donovan working as a consultant paediatrician in Portsmouth
in the year 2000 having an article accepted by Archives of Disease in
Childhood!
The report of Hacking et al,[1] of a series of infants with very
early onset interstitial lung disease (ILD) with good prognosis, is of
great clinical interest but sadly represents a lost investigative
opportunity.
Firstly, their statement that percutaneous open lung biopsy
has fewer side effects than open lung biopsy (OLB) is not supported by any
direct comparative trial, and cannot be allow...
The report of Hacking et al,[1] of a series of infants with very
early onset interstitial lung disease (ILD) with good prognosis, is of
great clinical interest but sadly represents a lost investigative
opportunity.
Firstly, their statement that percutaneous open lung biopsy
has fewer side effects than open lung biopsy (OLB) is not supported by any
direct comparative trial, and cannot be allowed to stand. Indeed, the
largest published series using this technique[2] was heavily criticized
both for the number of complications and the often non-diagnostic samples
obtained.[3,4] In contrast OLB is safe,[5] permits direct inspection of
the site of biopsy, and allows the acquisition of specimens large enough
to determine the lung architecture in order more precisely to classify the
different types of paediatric ILD. OLB thus allows appreciation of the
distribution of disease involvement within the acinus, allowing more
precise identification of different histopathological patterns. There is
thus no reason to favour percutaneous biopsy over OLB in skilled hands;
indeed the weight of evidence is in favour of OLB.
Secondly, their
selected nomenclature of paediatric ILD is open to criticism. It is
questionable whether the use of term "idiopathic pulmonary fibrosis" (IPF)
is still appropriate in children. IPF is generally used synonymously with
lone cryptogenic fibrosing alveolitis, which in adults is most often
represented histopathologically by the pattern of "usual interstitial
pneumonia" (UIP). However UIP is rarely if ever seen in children; much
more common are lymphocytic interstitial pneumonia (LIP), desquamative
interstitial pneumonia (DIP), non-specific interstitial pneumonia (NSIP)
and chronic pneumonitis of infancy.[6] Identifying these histological
patterns may point towards specific investigations with regard to
aetiology, and may also provide prognostic and treatment data, and we
consider that it is a pity that this or a similar histopathological
classification was not used in this report.
We suggest that more will be
learned about these rare conditions if diagnostic precision is maximized
by comparison of pre-biopsy computed tomography with properly classified
histological findings.[7] Inter-disciplinary collaboration is needed to
achieve this; and it is unfortunate that more details of imaging and an up
to date classification of histology were not included in an otherwise
informative paper.[1]
Dr Andrew G Nicholson MRCPath DM
Consultant Histopathologist
Dr Andrew Bush MD FRCP FRCPCH
Reader and Honorary Consultant in Paediatric Respirology
References
(1) Hacking D, Smyth R, Shaw N, Kokia G, Carty H, Heaf D. Idiopathic pulmonary fibrosis in infants: good prognosis with conservative management. Arch Dis Child 2000;83:152-7.
(2) Spencer DA, Alton HM, Raafat F, Weller PH. Combined percutaneous lung biopsy and high-resolution computed tomography in the diagnosis and management of lung disease in children. Pediatr Pulmonol 1996;22:111-16.
(3) Bush A. Diagnosis of interstitial lung disease. Pediatr Pulmonol 1996;22:81-2.
(4) Flake AW. Is a CT guided needle better than a knife? Pediatr Pulmonol 1996;22:83-4.
(5) Coren ME. Nicholson AG, Goldstraw P, Rosenthal M, Bush A. Open lung biopsy for diffuse interstitial lung disease in children. Eur Respir Dis 1999;14:817-21.
(6) Nicholson AG, Kim H, Corrin B, Bush A, du Bois RM, Rosenthal M, Sheppard MN. The value of classifying interstitial pneumonitis in childhood according to defined histological patterns. Histopathology 1998;33:203-11.
(7) Copley SJ, Coren M, Nicholson AG, Rubens MB, Bush A, Hansell DM. Diagnostic accuracy of thin-section CT and chest radiography of pediatric interstitial lung disease. AJR 2000;174:549-54.
Our group has been evaluating ways[1] of empowering parents to
promote family centred care in the neonatal intensive care unit.[2] We therefore read with
interest the important article showing parental hope to be more strongly
associated with the health related quality of life (HRQL) than neonatal or
current physical deficits.[3]
Hope is prevalent amongst parents and staff in the neonatal in...
Our group has been evaluating ways[1] of empowering parents to
promote family centred care in the neonatal intensive care unit.[2] We therefore read with
interest the important article showing parental hope to be more strongly
associated with the health related quality of life (HRQL) than neonatal or
current physical deficits.[3]
Hope is prevalent amongst parents and staff in the neonatal intensive
care unit[4] and comes in a spectrum ranging from hope for survival to
hope of a normal outcome. We would like the authors to define what hope
is. It is interesting that hope is not listed in the Mosby’s Dictionary
but hopelessness is: "a state in which an individual sees limited or no
alternatives or personal choices available and is unable to mobilize
energy on his or her own behalf."[5]
The incidence of single parent families in the cohort was 17%. This
is lower than the 50% reported in an earlier study with divorce rate for
families having a child with spina bifida being nine times higher than
that for the local population.[6] We also note that 54% of the 13 to 20
year olds responded to the study. There is a risk of ascertainment bias
as it is possible that those who did not cooperate may have a poorer
outcome.[7]
As important as parental hope is the hope of the child with spina
bifida, the attitude of siblings and the health care givers (including
intervention services and respite care services) both in the neonatal and
post discharge period. For the 13 to 20 year olds it would have been
informative to correlate HRQL with the Miller’s Hope Scale (MHS) of the
children themselves. Do we know what is the earliest age that a child is
able to hope? The authors may also like to discuss why they did not
include parental hope in the first 5 years of life considering the
critical period for infant-parent bonding.[8] What is the incidence of
mental retardation amongst the children and how does it impact on MHS and
HRQL? Is there any significant difference for children born in the
periods of aggressive treatment compared with those born during the period
of selective treatment.
It is possible that parental hope does not improve HRQL in the
child; rather improved HRQL of the child allows parental hope. Thus hope
may be the result rather than the cause of better HRQL.
THHG Koh MA FRCPCH FRACP Senior Staff Specialist in Neonatal
Paediatrics
Collie L RN Neonatal Research Nurse
Budge D RN Neonatal Research Nurse
Regional NICU, Kirwan Hospital
Townsville, Great Barrier Reef Queensland 4817, Australia
This is part of the T.A.P.E. project, funded by The Royal Children's
Hospital Foundation, Brisbane.
References
(1) Koh THHG, Jarvis C. Promoting effective communication in NICU by
audiotaping parents-neonatologist conversations. Int J Clin Pract 1998;52:27-9.
(2) Harrison H. The principles of family-centered neonatal care.
Pediatrics 1993;92:643-50.
(3) Kirpalani HM, Parkin PC, Willan AR, Fehlings DL, Rosenbaum PL,
King D, Van Nie AJ. Quality of life in spina bifida: importance of
parental hope. Arch Dis Child 2000;83:293-7.
(4) Cole FS. Extremely preterm birth--defining the limits of hope.
N Engl J Med 2000;343:429-30.
(5) Mosby’s Dictionary. 3rd Ed, CV Mosby Company St Louis, 1990.
(6) Tew BJ, Laurence KM, Payne H, Rawnsley K. Marital stability
following the birth of a child with spina bifida. Br J Psychiatry 1977;131:79-82.
(7) Tin W, Fritz S, Wariyar U, Hey E. Outcome of very preterm birth:
children reviewed with ease at 2 years differ from those followed up with
difficulty. Arch Dis Child Fetal Neonatal Ed 1998;79:F83-7.
I was dismayed to see your publication of the letter by Dr Sam
regarding the role of lumbar puncture in meningococcal disease.[1]
While fully understanding the need to get as much information as possible,
the benefits of isolating the causative organism need to be weighed
against the risk of causing clinical deterioration in a patient who may
have cardiovascular compromise, and or, raised intracranial pressu...
I was dismayed to see your publication of the letter by Dr Sam
regarding the role of lumbar puncture in meningococcal disease.[1]
While fully understanding the need to get as much information as possible,
the benefits of isolating the causative organism need to be weighed
against the risk of causing clinical deterioration in a patient who may
have cardiovascular compromise, and or, raised intracranial pressure, both
are which are recognised contraindications to lumbar puncture.[2] There
are clear and recognised risks of performing this procedure in such
patients.
The potential benefits of lumbar puncture include making a diagnosis
of meningitis and isolation of the organism for epidemiological and
sensitivity testing.
In the UK the typical haemorrhagic rash of meningococcal infection is
pathognomonic of the disease and should be treated as such prospectively,
until further confirmatory evidence is available. With Polymerase Chain
Reaction (PCR) of meningococcal DNA in blood allowing up to 100%
sensitivity for diagnosis in the first 24 hours of illness,[3] there is
little to be gained from looking for bacteria or cells in the cerebrospinal fluid (CSF).
The antibiotic regimen is no different for either meningococcal
meningitis or septicaemia, with 7 days of a 3rd generation cephalosporin
being the treatment of choice because of improved CSF penetration.[4]
There are no reports of meningococcal resistance to this treatment in the
UK, so performance of a lumbar puncture for bacterial sensitivity testing
appears to be unnecessary.
Prospective therapy while awaiting results of culture or PCR from
blood seems to be a small price to pay in this life-threatening illness.
An analogy could be drawn from the management of epiglottitis. It is
generally accepted that throat swabs should not be taken from children
with epiglottitis until the child’s airway has been protected due to the
risk of clinical deterioration. It is time that textbooks of emergency
paediatrics stated clearly that lumbar punctures on children with a
haemorrhagic rash and clinical signs of meningococcal infection should be
not be carried out until the clinical condition has been stabilised, and
if the procedure will add further valuable information that cannot be
obtained elsewhere.
References
(1) Sam WIC. The role of lumbar puncture in meningococcal disease [letter]. Arch Dis Child 2000;83:370.
(2) Advanced Paediatric life Support, 2nd Edition. The Advanced Life
Support Group. BMJ Publishing Group, London, UK. 1997.
(3) Newcombe J, Cartwright K, Palmer WH, McFadden J. PCR of peripheral
blood for diagnosis of meningococcal disease. J Clin Microbiol
1996;34:1637-40.
(4) Peltola H, Anttila M, Renkonen OV. Randomised comparison of
chloramphenicol, ampicillin, cefotaxime and ceftriaxone for childhood
bacterial meningitis. Finnish Study Group. Lancet 1989;i:1281-7.
Dr Elliman is noted for his careful methodological analysis of vaccination studies,[1] but is not so careful in his recent analysis of physical punishment.[2]
The American Academy of Pediatric's co-sponsored scientific
consensus conference on corporal punishment used a more scientific
approach than the Elliman-Lynch summary. First, it carefully defined
spanking as a subset of corporal punish...
Dr Elliman is noted for his careful methodological analysis of vaccination studies,[1] but is not so careful in his recent analysis of physical punishment.[2]
The American Academy of Pediatric's co-sponsored scientific
consensus conference on corporal punishment used a more scientific
approach than the Elliman-Lynch summary. First, it carefully defined
spanking as a subset of corporal punishment. Second, it incorporated a
range of scientifically validated perspectives into summary statements
that were more balanced than the Elliman-Lynch perspective. Third, it
solicited the first systematic review of child outcomes of nonabusive or
customary physical punishment by parents.[3] An update of that review is due
to be published in December 2000.[4]
Both reviews concluded that non-abusive
smacking had consistently beneficial child outcomes in the most causally
conclusive studies (eg, randomized trials): Both non-compliance and
fighting decreased in 2- to 6-year-olds after non-abusive smacking was used
to back up milder disciplinary tactics, such as reasoning or time out.
Causal evidence of detrimental effects of customary physical punishment
was less conclusive and limited to overly frequent smacking (eg, 3 times weekly for 6- to 9-year-olds). In head-to-head comparisons, the effects of
non-abusive or customary smacking rarely compared unfavorably with any
disciplinary alternative, whereas its effects were significantly better
than 6 alternative disciplinary tactics, mostly in 2- to 6-year-olds.
My updated review considered all 92 studies included in the
unpublished 1999 Gershoff review cited by Elliman and Lynch. Most (76) of
her studies were excluded from my review for reasons that Elliman would
use to discount vaccination studies (eg, inappropriate measures, cross-
sectional designs).
Ellison and Lynch also presented a one-sided summary of Swedish
statistics since their 1979 smacking ban. Additional information on this
issue and other related issues can be found at
http://people.biola.edu/faculty/paulp/. The issues are complex, requiring
the same careful analysis given to concerns about vaccination.
References (1) Bedford H, Elliman D. Concerns about immunisation. BMJ 2000;320:240-3.
(2) Elliman D, Lynch MA. The physical punishment of children. Arch Dis Child 2000;83:196-8.
(3) Larzelere RE. A review of the outcomes of parental use of nonabusive or
customary physical punishment. Pediatrics 1996;98:824-8.
(4) Larzelere RE. Child outcomes of nonabusive and customary physical
punishment by parents: An updated literature review. Clinical Child and
Family Psychology Review 2000;3:199-221.
Nicholson and Bush,[1] in response to our article reporting on a
case series of 11 children presenting with pulmonary interstitial fibrosis
over a 10 year period,[2] suggest that an investigative opportunity has
been missed. We do not agree.
Nicholson and Bush have repeated their previously reported criticism
of percutaneous lung biopsy (PLB)[3] and have suggested that this
technique is p...
Nicholson and Bush,[1] in response to our article reporting on a
case series of 11 children presenting with pulmonary interstitial fibrosis
over a 10 year period,[2] suggest that an investigative opportunity has
been missed. We do not agree.
Nicholson and Bush have repeated their previously reported criticism
of percutaneous lung biopsy (PLB)[3] and have suggested that this
technique is prone both to more complications and to a greater number of
non-diagnostic samples. We have shown that PLB on a series of 9 patients
was adequate for diagnosis in all cases and did not result in
pneumothoraces significant to require thoracocentesis.[4]
In our present
report of 11 patients PLB was not associated with any major complications
and failed to provide a histological diagnosis in only one patient. This
compares favorably to Nicholson and Bush's own report of open lung biopsy
(OLB) in 27 cases[5] where 3 patients experienced significant
complications namely a pneumothorax, a haemothorax and a pleural space
infection. Moreover, 5 previously self ventilating patients required
ventilation following biopsy and 5 patients returned from biopsy with a
chest drain which had been inserted in the course of the procedure. We do
not agree that OLB is superior to PLB.
Nicholson and Bush go on to question the nomenclature of paediatric
idiopathic pulmonary fibrosis and briefly describe the histological
classifications of usual pneumonia (UIP) and desquamative interstitial
pneumonia (DIP) as we did in the introduction to our article. They
suggest the 'these histological patterns may… provide prognostic and
treatment data'. However, the distinction between UIP and DIP is
questioned[6] as they may represent different stages in the same disease
process.[7] [8] In common with previous reports[9] [10] [11] we have
shown that the severity of histological change did not relate to patient's
response to steroids or their eventual outcome.
We agree with Nicholson and Bush when they state that 'diagnostic
precision is maximised by comparison of pre-biopsy computed tomography and
corrected classified histological findings' as this was practised through
out our series. We fear that they have missed the most important aspect
of our report which is that idiopathic pulmonary fibrosis in children has
a diverse natural history and a variable prognosis that can be favourable.
The good prognosis seen in our series is different from previous case
reports indicating a greater than 50% mortality [10].
Doug Hacking
Rosalind Smyth
Nigel Shaw
George Kokai
Helen Carty
David Heaf
References
(1) Andrew Nicholson, Andrew Bush. Methodology for assessing patterns
of interstitial pneumonia in children [eLetters] Arch Dis Child 18 October 2000.
(2) Hacking D, Smyth R, Shaw N, Kokai G, Carty H, Heaf D. Idiopathic
pulmonary fibrosis in infants: good prognosis with conservative
management. Arch Dis Child 2000;83:152-7.
(3) Bush A. Diagnosis of interstitial lung disease. Pediatr Pulmonol
1996;22:81-2.
(4) Smyth R, Carty H, Thomas H, van Velzen D, Heaf D. Diagnosis of
Interstitial
lung disease by a percutaneous lung biopsy sample. Arch Dis Child 1994;70:143-4.
(5) Coren ME, Nicholson AG, Goldstraw P, Rosenthal M, Bush A. Open
lung
biopsy for diffuse interstitial lung disease in children. Eur Respir J
1999;14:817-21.
(6) Fan LL, Langston C. Chronic Interstitial Lung Disease in
Children. Pediatr Pulmonol 1993;16:184-96.
(7) Crystal RG, Fulmer JD, Roberts WC, Moss ML, Line BR, Reynolds HY.
Idiopathic pulmonary fibrosis- clinical, histologic, radiographic,
physiologic, scintigraphic, cytologic and biochemical aspects. Ann Intern Med
1976;85:769-88.
(8) Reynolds HY. Classification, definition, and correlation between
clinical and histologic staging of interstitial lung disesases. Semin
Respir Med 1984;6:1-19.
(9) Kerem E, Bentur L, England S, Resisman J, O'Brodovich K, Bryan A,
Levison H. Sequential Pulmonary function measurements during treatment of
infantile chronic interstitial pneumonitis. J Pediatr 1990;116:61-7.
(10) Osika E, Muller M-H, Boccon-Gibod L, Clement A. Idiopathic
Pulmonary Fibrosis in Infants. Pediatr Pulmonol 1997;23:49-54.
(11) Rudd R, Haslam P, Turner-Warwick M. Cryptogenic Fibrosing
Alveolitis: Relationship of Pulmonary Physiology and BAL to response to
therapy and prognosis. Am Rev Respir Dis 1981;124:1-8.
Two recent reports about hospitalisation for respiratory
syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested
that the introduction of prophylaxis may, potentially, be beneficial in
certain subgroups. We would like to emphasise that the "bigger picture"
also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions
who were RSV...
Two recent reports about hospitalisation for respiratory
syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested
that the introduction of prophylaxis may, potentially, be beneficial in
certain subgroups. We would like to emphasise that the "bigger picture"
also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions
who were RSV positive and had a Cambridge ‘CB’ post code. “At risk”
infants (ie, ex-preterms under 6 months of age or those with
bronchopulmonary dysplasia, BPD, under two years) were identified from the
records of the maternity and neonatal units serving our postal region.
The total cost for admission was calculated using length-of-stay on the
ward (bed-day cost of £255 (approx $380) and in the intensive care unit (bed-day cost
of £1136 (approx $1700). The potential cost of prophylaxis in the community was also
estimated (table).
1998/1999
1999/2000
"Low risk" infants
£93,940
£97,692
"High risk" infants
£10,455
£15,162
Savings in "high risk"
£5,228
£7,581
Prophylaxis costs
£13,1440
£16,1120
£1 approx $1.5 (November 2000 figures)
In the CB post code population, the RSV-related admission rate (95%
confidence interval) from our under 6 month old population was in the
range of 19 to 41 per 1000 (denominator estimated from the number of live
births with a CB post code; personal communication with A Sneedon, Office
for National Statistics, London). In the ex-preterm infants who were
under 6 months the proportion admitted during the two winters (1998/99
and 1999/2000) was 5/51 (9.8%, 95% CI 3.3 to 21.4%) and 4/62 (6.5%, 1.8 to
15.7%) respectively. Supposedly “low risk” infants accounted for 92%
(66/72) and 90% (54/60) of our RSV-related admissions for each winter.
There were no deaths in any of the admissions including the two with BPD.
In the first winter, 10 intensive care bed-days were needed, none in the
“high risk” population. In the second winter such infants used 12 out of
54 intensive care bed-days. Finally, inpatient costs for RSV in “high
risk” infants was about 10% and 15% of total RSV-related hospital costs
for the two winters respectively (table).
Taken together, even if there were potential savings following the
introduction of prophylaxis to specific subgroups, a target population -
arguably equally in need of protection - is being overlooked. In fact, in
our area, the potential effect of introducing prophylaxis would more than
double health authority costs for RSV, with little impact on our socalled
“lowrisk” more major caseload.
Jackie J Buck
Philip Debenham
Robert C Tasker
Department of Paediatrics
University of Cambridge Clinical School
Addenbrooke’s Hospital
Hills Road, Cambridge CB2 2QQ, UK
(1) Thomas M, Bedford-Russell A, Sharland M. Hospitalisation for RSV
infection in ex-preterm infants - implications for use of RSV immune globulin. Arch Dis Child 2000;83:122-7.
(2) Clark SJ, Beresford MW, Subhedar NV, Shaw NJ. Respiratory syncytial virus infection in high risk infants and the potential impact of prophylaxis in a United Kingdom cohort. Arch Dis Child 2000;83:313-16
Two recent reports about hospitalisation for respiratory
syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested
that the introduction of prophylaxis may, potentially, be beneficial in
certain subgroups. We would like to emphasise that the "bigger picture"
also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions
who were RSV...
Two recent reports about hospitalisation for respiratory
syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested
that the introduction of prophylaxis may, potentially, be beneficial in
certain subgroups. We would like to emphasise that the "bigger picture"
also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions
who were RSV positive and had a Cambridge ‘CB’ post code. “At risk”
infants (ie, ex-preterms under 6 months of age or those with
bronchopulmonary dysplasia, BPD, under two years) were identified from the
records of the maternity and neonatal units serving our postal region.
The total cost for admission was calculated using length-of-stay on the
ward (bed-day cost of £255 (approx $380) and in the intensive care unit (bed-day cost
of £1136 (approx $1700). The potential cost of prophylaxis in the community was also
estimated (table).
1998/1999
1999/2000
"Low risk" infants
£93,940
£97,692
"High risk" infants
£10,455
£15,162
Savings in "high risk"
£5,228
£7,581
Prophylaxis costs
£13,1440
£16,1120
£1 approx $1.5 (November 2000 figures)
In the CB post code population, the RSV-related admission rate (95%
confidence interval) from our under 6 month old population was in the
range of 19 to 41 per 1000 (denominator estimated from the number of live
births with a CB post code; personal communication with A Sneedon, Office
for National Statistics, London). In the ex-preterm infants who were
under 6 months the proportion admitted during the two winters (1998/99
and 1999/2000) was 5/51 (9.8%, 95% CI 3.3 to 21.4%) and 4/62 (6.5%, 1.8 to
15.7%) respectively. Supposedly “low risk” infants accounted for 92%
(66/72) and 90% (54/60) of our RSV-related admissions for each winter.
There were no deaths in any of the admissions including the two with BPD.
In the first winter, 10 intensive care bed-days were needed, none in the
“high risk” population. In the second winter such infants used 12 out of
54 intensive care bed-days. Finally, inpatient costs for RSV in “high
risk” infants was about 10% and 15% of total RSV-related hospital costs
for the two winters respectively (table).
Taken together, even if there were potential savings following the
introduction of prophylaxis to specific subgroups, a target population -
arguably equally in need of protection - is being overlooked. In fact, in
our area, the potential effect of introducing prophylaxis would more than
double health authority costs for RSV, with little impact on our socalled
“lowrisk” more major caseload.
Jackie J Buck
Philip Debenham
Robert C Tasker
Department of Paediatrics
University of Cambridge Clinical School
Addenbrooke’s Hospital
Hills Road, Cambridge CB2 2QQ, UK
(1) Thomas M, Bedford-Russell A, Sharland M. Hospitalisation for RSV
infection in ex-preterm infants - implications for use of RSV immune globulin. Arch Dis Child 2000;83:122-7.
(2) Clark SJ, Beresford MW, Subhedar NV, Shaw NJ. Respiratory syncytial virus infection in high risk infants and the potential impact of prophylaxis in a United Kingdom cohort. Arch Dis Child 2000;83:313-16
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Two recent reports about hospitalisation for respiratory syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested that the introduction of prophylaxis may, potentially, be beneficial in certain subgroups. We would like to emphasise that the "bigger picture" also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions who were RSV...
Dear Editor
Two recent reports about hospitalisation for respiratory syncytial virus (RSV) infection in high-risk infants[1, 2] have suggested that the introduction of prophylaxis may, potentially, be beneficial in certain subgroups. We would like to emphasise that the "bigger picture" also warrants further consideration.
During the winters of 1998/99 and 1999/2000 we recorded our admissions who were RSV...
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