KEEPING IT CLEAN
================

* Harvey Marcovitch

This journal continues to be fascinated by the hygiene hypothesis—that is, that insufficient exposure to infection in early childhood might predispose towards later asthma and atopy. Two related papers from the ALSPAC study group in Bristol, UK explore this further. The first details hygiene practices for a large number of UK babies and produces the counter-intuitive result that mothers of lower socio-educational status keep their babies cleaner. One reason might be their greater use of chemical household products. The companion paper looks at associations between hygiene at 15 months and atopy by 3.5 years. The results support the hypothesis so it might well be that too sterile an environment is harmful. Recalling his own parental practices, the editor now understands a little better why his offspring did not inherit his asthma.

**See pages [26](http://adc.bmj.com/lookup/volpage/87/26) and [30](http://adc.bmj.com/lookup/volpage/87/30)** 

## THE TWO WORLDS OF IMMUNISATION

Every paediatrician in the developed world dealing with acutely sick children knows what a difference HiB vaccine has made, with potentially fatal diseases such as epiglottitis and Haemophilus meningitis almost wiped out. Meanwhile the public at large and the chattering classes in particular take this spectacular achievement for granted and fret over highly theoretical and unlikely ill effects of mumps-measles-rubella vaccine.

This month we invited researchers at the forefront of vaccine research in the UK to enlighten us on how long it will be before the meningococcus is consigned to the dustbin of history; and how, with prudence, we might start to prescribe the newly licensed (in Europe) conjugate 7-valent pneumococcal vaccine.

Their reports are encouraging. It is not fantasy to look forward to a future in which primary bacterial sepsis becomes a rare reason for hospital attendance. When the time comes, as it surely must, when all infants will receive vaccines ?ial sepsis and meningitis, we will no more need to agonise over how aggressively to investigate and treat the febrile infant.

But what may seem startlingly obvious to our readers looks quite different from other perspectives. Many patients and parents now seek to inform themselves using the world wide web as their prime resource. My own experience with print and television journalists is that they, too, favour this quick and dirty method of enquiry. Simon Chapman and colleagues from Sydney University's department of public health searched 7 leading search engines using the keywords “vaccination” and “immunisation”. Nearly half of the websites they uncovered (and all top ten on [www.google.com](http://www.google.com)) were devoted to anti-vaccination propaganda, with allegations of deaths, conspiracies, incompetence, avarice, and persecution of “brave” rebel doctors.

When advising parents anxious about vaccines, Chapman advises doctors to do their best to inform them of the work that goes on to address issues of vaccine safety. He also suggests discerning families should beware of websites which have highly emotive content, claims of conspiracy, references to privately published material or news items and claims of secret knowledge.

**See pages [13](http://adc.bmj.com/lookup/volpage/87/13), [18](http://adc.bmj.com/lookup/volpage/87/18) and [22](http://adc.bmj.com/lookup/volpage/87/22)** 

## LESSON FROM A DEVELOPING COUNTRY

Poddar and colleagues from Chandigarh, India describe 67 children with fulminant liver failure due to hepatotropic viruses. Normally we are reluctant to publish purely observational studies, unless the disease described is exceptionally rare. However, we were impressed by the authors' assertion that, in the West, we can no longer study the natural history of this condition because of the availability of transplantation. Bad prognostic factors included gastrointestinal bleeding, more severe encephalopathy and spontaneous bacterial peritonitis. Poddar advises ascitic fluid analysis in all cases.

**See page [54](http://adc.bmj.com/lookup/volpage/87/54)** 

## LESSON FROM THE PAST (UPDATED)

Older readers may recall the days when infantile hypertrophic pyloric stenosis (PS) was not exclusively a surgical condition. A paper this month quotes in its reference list an *ADC* paper from 1955, in which Dr Beryl Corner (surely by far the most senior fellow of the RCPCH) described the use of methyl scopolamine nitrate as a treatment, a method still used in the UK in the early 1970s.

Dr Kawahara and colleagues from Osaka, Japan, now report treating 19 infants with PS using intravenous atropine infusions. All but 2 escaped surgery and subsequently attained a normal pyloric muscle thickness. The authors call for a randomised controlled trial. It is not likely that the challenge will be taken up in Europe or the US, where expert surgery is immediately available - but more remote countries might be interested. Long term follow up will be important. Some time ago I saw a patient said to have been treated successfully with atropine for PS as an infant. Later in childhood she developed a trichobezoar related to her yen for munching on her woollen clothes; her thickened pyloric canal contained a peptic ulcer.

**See page [71](http://adc.bmj.com/lookup/volpage/87/71)** 

## EUREKA!

Archimedes, our evidence based problem solving section, is proving very popular if feedback is to be believed. Given that trainees and residents often complain about the lack of opportunity to undertake research, we think this section provides them with a great opportunity. The trick is to describe a common and important clinical scenario and pose a structured question that arises from it. You then find a friend or two and undertake a search strategy for published evidence from which the question can be answered. You then tell us the clinical bottom line. It can be useful, fun, can make you sound knowledgeable on ward rounds and gets you into print. What more can a young paediatrician ask for. Potential authors should contact Archimedes editor, Dr Bob Phillips at bob.phillips{at}doctors.org.uk .

**See page [77](http://adc.bmj.com/lookup/volpage/87/77)**