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All UK general paediatricians will be familiar with the following letter: “Dear Doctor, This child is due for mumps–measles–rubella vaccine but eggs bring him out in a rash and his parents are anxious; could you carry out the immunisation on the ward?”
Advice from standard texts such as theBritish National Formulary, the UK Department of Health Green Book, and the American Academy of Pediatrics Red Book are inconsistent; manufacturers' product inserts have varied over the years. With the aim of providing evidence based practical guidance on the subject, ADC commissioned Lakshman and Finn from the Sheffield Institute for Vaccine Studies, to produce information that our readers could follow and safely pass on to their colleagues in primary care (page 93).
Their answer to the quoted letter would seem to be straightforward: egg allergy is not what really counts. Rather, all vaccinations—not just that with MMR—must be carried out in settings with equipment and personnel to deal with anaphylaxis. All general practice surgeries and immunisation clinics, please copy.
Tilt tables—more than a Georgian aesthetic
Many paediatricians must have been puzzled as to why a child might lose consciousness after breath-holding or a reflex anoxic seizure (pallid syncope) despite extremely brief duration, no evidence for a Valsalva manoeuvre and, sometimes, no obvious major fall in pulse rate. Sung and colleagues from Hong Kong (page 154) have used transcranial Doppler to investigate cerebral blood flow: when they used a tilt table to test children prone to vasovagal syncope and compare them with controls, they found impaired cerebral autoregulation in the former. This was independent of changes in pulse and blood pressure. If, as they suggest, this may be the prime mechanism causing symptoms in such children then there are other groups in whom this technique might be profitably used—for example, infants who suffer acute life threatening events or who are regarded as at risk of SIDS.
Don't throw out the Baby Check with the bathwater
Another piece of the SIDS jigsaw has been found by the CESDI SUDI study group, whose population base is 470 000 babies born over three years to a population of 17.7 million. The group has a paper in press in Pediatrics (Leach CEA, Blair PP, Fleming PJ, et al. Sudden unexpected deaths in infancy: similarities and differences in the epidemiology of SIDS and explained deaths) which compares babies who die suddenly and unexpectedly, with and without a subsequently determined cause. In this month's ADC (page 98), using the same database, the research team relates the immediate premorbid clinical features of an event to the score that might have been calculated at the time by applying the Cambridge Baby Check questionnaire (Morley CJ, Thornton AJ, Cole TJ, et al. Baby Check: a scoring system to grade the severity of acute systemic illness in babies under 6 months old. Arch Dis Child1991;66:100–5).
The conclusion is that Baby Check has the potential to help identify seriously ill babies at risk of sudden death, and it is time to revisit the question of including it in personal child health records. The next step, of course, would be to persuade parents to use it in the way its authors intended rather than just as a general item of interesting, and often reassuring, information.
New College guidelines on research ethics
Ethics are far from immutable. Recent months have shown a great change in what parents, the media, and the profession accept as reasonable. The public inquiry at Bristol has widened the debate well beyond the capabilities of particular cardiac surgeons and whistleblowing. Issues have come to the forefront about how to gain genuine consent before embarking on clinical research, especially where the newborn are concerned. Readers outside the UK might not be aware of the media furore when it was disclosed that many National Health Service morbid anatomy departments were storing whole organs long after postmortem examinations had been concluded. Under such circumstances, practitioners can do worse than to fall back on guidelines and protocols.
This month we are pleased to publish the Royal College of Paediatrics and Child Health's latest guidelines for the ethical conduct of medical research involving children (page 177). These replace those issued in 1992; they emphasise the importance and value of ethical research and the fundamental differences that may exist at times between the interests of children and adults. The previously perceived ambiguity about the degree of risk involved in venepuncture has been resolved and the importance of properly informedconsent, rather than the acquiescence ofassent, emphasised. The guidelines conclude by stating that “researchers who observe high standards will continue to enjoy public support and cooperation”.
We advise all those who intend to submit papers toADC to read this paper carefully and to do their utmost to apply its recommendations. In recent years, the editors have spent more and more time discussing the ethical nature (or otherwise) of submitted papers. However good the science, we will continue to reject papers if we believe ethical considerations have not been thoroughly handled. These guidelines will inform our decisions in future.
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