Dear Editor

Two reviews of MMR vaccine and egg allergy have recently been published. [1, 2] One appears in the Royal College of Paediatrics and Child Health's own journal (Archives of Diseases in Childhood),[1] the other has been endorsed by the Committee on Infection and Immunisation of the Royal College of Paediatrics and Child Health.[2] The two articles differ in their recommendations of which children should be given MMR under supervision in hospital.

Which of these expert opinions should paediatricians and general practitioners follow? Were the authors of the two articles aware of each others conclusions? Could the editorial boards of the two journals (which have members common to both) not have informed the authors?

These recommendations also differ from Department of Health advice,[3] which also differs from that given by the Health Education Authority.[4] This debate might be settled if a consensus can be agreed and published in the next edition of Immunisation against Infectious Disease.[3]

In the mean time a pragmatic approach is needed. That is to offer MMR under supervision in hospital to children who have had a severe allergic reaction to egg and to children whose general practitioners, practice nurses or parents are unhappy for them to be given MMR elsewhere.

This letter has also been sent to BMJ.

F Andrew I Riordan
Consultant Paediatrician Dept of Child Health
Birmingham Heartlands Hospital
BIRMINGHAM B9 5SS, UK

References

1. Lakshman R, Finn A. MMR vaccine and allergy. Arch Dis Child 2000;82:93-95

2. Khakoo GA, Lack G. Recommendations for using MMR vaccine in children allergic to eggs. BMJ 2000;320:929-932

3. Salisbury DM, Begg NT eds. Immunisation against infectious disease. London: HMSO 1996;38:141

4. Health Education Authority. MMR immunisation factsheet. London: Department of Health 1997:5-6

Dear Editor:

I read with interest the article by Raynor and Rudolf[1] comparing the anthropometric indices of failure to thrive. In the same context, I would like to share the findings of our study which was done to compare the indices used for assessing nutritional status at birth. The indices used were the birth weight, Ponderal index and the CANSCORE (Clinical assessment of nutritional score).

A 20 consecutive newborn infants admitted to the postnatal unit of Sultan Qaboos University Hospital (SQUH), Oman were recruited. The measurements including the birth weight, length, and head circumference, were noted down. Ponderal index was calculated by the formula: Weight (g)/Length (cm)3 and the CANSCORE from the nine signs shown in the table.

Score rated from 4 (best) to 1 (worst). See Reference 4 for details.

Under nutrition was defined accordingly[2-5] that for CANSCORE (<_24 birth="birth" weight="weight" _="_" _3="_3" and="and" ponderal="ponderal" index="index" _2.="_2." p="p"/> Out of 20 neonates, 15 (75%) were noted to have adequate nutritional status, while 5 neonates (25%) were noted to be undernourished, basing on the birth weight, ponderal index and CANSORE. Significant correlation was noted between all the parameters, birth weight with CANSORE, r = 0.76, P = 0.0001, birth weight with ponderal index, r = 0.51, P = 0.013 and ponderal index with CANSORE, r = 0.46, P = 0.031,respectively.

We were able to demonstrate a unique combination of birth weight, ponderal index and canscore in the assessment of nutritional status at birth. We concluded that as good correlation existed between the birth weight, ponderal index and CANSORE, they could be equally used individually to assess the newborn's nutritional status. However, birth weight is the simplest, most objective and least tedious of them.

Dr Shabih Manzar, MRCPCH (Associate), FAAP
Assistant Professor, Department of Pediatrics
King Fahd University Hospital
PO Box 40211
Al-Khobar 31952, Saudi Arabia
Fax & telephone + 966 3 897 6941

References

1. Raynor P, Rudolf MCJ. Anthropometric indices of failure to thrive. Arch Dis Child 2000;82:364-365

2. Roberton NRC. Textbook of Neonatology. 2nd ed. Longman Group UK Limited, Churchill Livingstone, Edinburgh. 1992; p 320

3. Avery GB, Fletcher MA, MacDonald MG . Neonatology: pathophysiology and management of the newborn.4th ed, J.B.Lippincott Company, Philadelphia 1994; 369-398

4. Metcoff J. Clinical assessment of nutritional status at birth. Fetal malnutrition and SGA are not synonymous. Pediatric Clinic North America 1994;41(5):875-891

5. Gomella TL, Cunningham MD, Eyal FG (eds). Neonatology: management, procedures, on-call problems, diseases, drugs. 2nd ed.Appleton & Lange, Norwalk, Connecticut. 1992;362-367.

Dear Editor:

Did Raynor and Rudolf[1] look at height or head circumference as anthropometric predictors of developmental, dietary and eating problems? They measured height in order to calculate the Waterlow method of classifying wasting, and head circumference is easier to measure accurately in the field. Waterlow’s 1973 contribution[2] was to divide the weight-for-age deficits classified by Gomez et al in 1956[3] into two components, stunting (low height for median at that age) and wasting (low weight for median weight at that height). It is the former that is a closer equivalent to the Raynor and Rudolf concept of failure to thrive. Pure stunting represented chronic undernutrition and was of low priority for a centre’s acute intervention which was unlikely to succeed. Stunting has, however, been shown to be strongly associated with developmental delay.[4] Waterlow saw pure wasting, on the other hand, as characteristic of the child who had NOT been failing to thrive, but had suddenly run into an acute shortage of nutrient substrate remediable by acute therapy. Wasting and stunting together obviously make for a yet more severe problem, but using the wasting component only and then showing that it is not a measure of failure to thrive is no achievement. It is depressing when work done on the huge, international, largely tropical, problem of childhood malnutrition is at last imported into western Europe and then so misunderstood.

I also find it strange to assess anthropometric variables as independent in a regression to predict the dependent “problem” of low dietary intake. I see children as having a dietary intake in order to attain stature and mass rather than the other way round.

Finally, “parameters measured” in Table 1 is a contradiction in terms, parameter being a combination of para, not and meter, measure. In parametric statistics parameters are virtual population constants estimated from measurements on samples and in deterministic equations they are also constants. They are confused with variables so often that it is pedantic to complain, but growth is one subject where their meaning needs protection, because if Child 1 grows along the curve W = a1 f(t) + ... and Child 2 grows along the curve W = a2 f(t) + ..., weight (W) and age (t) are variables, measured, and a1 and a2 are parameters characteristic of each child but constant during their growth and calculated, not measured.

I believe Raynor and Rudolf have a valuable data-set and the muddle in the analysis reflects on the editorial process. When the subject is so central to paediatrics and it is published in ADC this matters.

E S COOPER
Department of Paediatrics
Newham General Hospital
Glen Road
London E13, UK

REFERENCES

1. Raynor P, Rudolf MCJ. Anthropometric indices of failure to thrive. Arch Dis Child 2000;82:364-365.

2. Waterlow JC. Note on the assessment and classification of protein-energy malnutrition in children. Lancet 1973;ii:1176-1178.

3. Gomez F, Ramos-Galvon R, Frenk S, et al. Mortality in second and third degree malnutrition. Journal of Tropical Pediatrics. 1956;2:77-83.

4. Grantham-Mcgregor SM, Powell CA, Walker SP, Himes JH. Nutritional supplementation, psychosocial stimulation and mental development of stunted children. Lancet 1991;338:1-5.

The recent article by Christian et al (1) highlights the value of clinical features in assessing the risk of renal scarring and therefore the need for DMSA scan after urinary tract infection (UTI). We recently performed a case note study to assess the recording of fever, malaise, recurrent UTI and urine culture results in children investigated with DMSA scan after UTI. Between April 1996 and October 1997 there were 171 DMSA scans in our hospital that fitted these criteria; 30 case notes could not be traced. There were 105 girls (74%) and 36 boys. Age when UTI was diagnosed ranged from 9 days to 15.3 years, mean 4.2 years (SD 3.2).

Urine culture results were:
UTI (>105 cfu/ml) 82 cases (58%)
contaminant ( <_105 cfu="cfu" ml="ml" _27="_27" cases="cases" _19br="_19br"/> no growth - 21 cases (15%)
no urine culture 11 cases (8%) cases.

There were 17 (12%) cases of definite or probable renal scar none of which followed a sterile or contaminated urine culture. Of the 141 case notes, there was no mention of fever in 48 (34%), and no mention of malaise in 76 (54%). In 69 case notes reviewed there was no mention of previous history of UTI in 14 (20%) cases. Of those with a history of fever 19% (10/53) had an abnormal DMSA scan compared to 10% (4/40) in those without fever. 18% (9/50) of those unwell at the time of UTI had an abnormal scan compared to 13% (2/13) of those not ill.

These data suggest that in a substantial proportion of cases the decision to request a DMSA scan is apparently not influenced by salient clinical features and urine culture results. In this series, it would appear that those children with sterile or contaminated urine cultures should not have had a DMSA scan. This would have saved the cost and burden of 48 scans, 34% of this series, over an 18 month period. It is unlikely that these findings are peculiar to our district.

1. Christian MT, McColl JH, MacKenzie JR, Beattie TJ. Risk assessment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography. Arch Dis Child 2000;82:376-380.