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“But you have to say something”, admonished her jaded crime editor, vexation serving only to enhance both his proptosis and sundowner-crimson cheeks, his long-serving herring-bone jacket and corduroys at breaking point round his girth. These outbursts had become more familiar in the years since the Walmart heist, the desperation for a comparable story inversely proportional to the supply that typified a mid-West town of the ‘Gleaner’s’ population. The investigation had, to her seemed straightforward: a simple case of a milk urn disappearing from the trellis outside the barn. There was no conspiracy theory to disinter, there were no rival cheesemakers, no FBI interference, no state nominee gain. ‘Urchins lifted jug for dare’ ran her headline: “This is what happened – it’s simple, no undercurrents – can’t we just keep it that way?” she implored.
Traditions in zoster: chapter z
Are we finally at the end of the decades-long zoster immune globulin (ZIG) – or acyclovir in immunocompromised children debate? In many countries this has ceased to be an issue: elsewhere it has smouldered. The traditional prevailing (surely a decent slug of intramuscularly injected antibodies is better than an oral antiviral) angle has felt out of touch for some time but, previous work by Jessica Bate and colleagues, has testified to the impossibility of recruiting enough to formally test this in an RCT in the UK alone.1 The issue reached simmering point in 2018 when national stocks of immunoglobulin began to dwindle, but a new analysis of outcomes by treatment Claire Cuerden and colleagues (the PEPtalk group) in the intervening years data looks now to have drawn the line, the low rates of post exposure infections (all of which were mild) being greater with ZIG.
This is observational data, but, given the pragmatic barriers to a trial, the safety of acyclovir, the 50 (yes, fifty!) times greater cost of ZIG, the discomfort of the IM injection and theoretical risk of bleeding from thrombocytopaenia… the scales tip clearly towards simplification. See page 1027
No magic formula
In a provocative analysis of data from the 2015-18 Cambridge Breast Feeding study, Ken Ong and colleagues followed exclusively breast fed (EBF) babies and assessed predictors of continuation or cessation. They found that faster weight gain in the first 2 weeks predicted continuation: each +1 unit gain in weight SD reducing probability of stopping EBF by 5 weeks by 70%. In those receiving EBF for 6 weeks or longer, each weight SD gain between birth and 6 weeks was strongly protective against stopping: OR 0.18; 95% CI 0.05 to 0.63.
Is this partly the result of over adherence to standard growth charts and overmeasurement? We know that weighing too frequently causes false positive alerts2 and, given we know now that normal growth is so variable one has to ask if are we allowing a societal construct of success manacle us? Are we overcomplicating by dint of over frequent measurements? See page 1032
Global health
In the mid-1990s, the WHO launched the seminal Integrated Management of Childhood Illness book, a guide to common acute situations that would be encountered in primary settings principally in low- and middle-income countries. Successive iterations have testified to its impact and usability. There were, however, some overlooked themes: the relatively well child, adolescence and standards for equipment diagnostics and tools and overlooked regions. Europe is one: there are many parts of the continent where adequate primary care is patchy and the new publication of child and adolescent care described by Susanne Carai and colleagues fills a long overdue gap. See page 959
Paediatric emergency medicine
There are no PEM protocols that specifically direct management of febrile young (under 3 months) babies after vaccination. There are arguments for assessing this group differently as 40% develop fever after routine vaccinations: Ana Barreiro-Parado and colleagues quantified the relative outcomes of the post vaccination and non-vaccination fever groups with data from 11 years of the Basque ED collection. None (0%) of the post vaccination group (185) had invasive infection: 1.4% of the non- vaccination group (ca 1350) did. Respective rates for UTI (aseptic method confirmed) were 7% and 20.1% (p<0.001, OR 1.9–5.9).
Doing no harm comes in various forms: missing an IBI is one; subjecting a well baby and family after her first vaccination to admission and lumbar puncture isn’t without downsides too… when a few hours of extra observation might, for most, suffice. See page 993
Keto-Acidosis
We’ve published a great deal of argument(correspondence/evidence from both sides in the diabetic keto-acidosis (DKA) fluid rate debate. Accepting that adverse neurological outcomes are rare (so numbers needed to show a subtle difference in either direction huge), we must conclude that there’s no evidence for a difference. A welcome and well-timed meta-analysis of RCTs of fluid volume and outcome in DKA by Ali Abdalla Hamud einforces this impression. Perhaps time to switch focus to other mechanisms (insulin dose one in the cross-hairs) or even to allow ‘chacun son gout’. See page 1021
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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