American Journal of Diseases of Children

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260006001

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.

FREED, GARY L.;KONRAD, THOMAS R.;DEFRIESE, GORDON H.;LOHR, JACOB A.

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260014004pmid: 8427227

Abstract Sir.—Haemophilus influenzae type b (Hib) infection in children is responsible for approximately 12 000 cases of meningitis and 7500 cases of other invasive diseases annually in the United States,1,2 with a mortality rate of 5% in cases of meningitis and as many as 40% of survivors having significant neurologic sequelae.3 On October 4, 1990, the Food and Drug Administration (FDA) permitted one Hib vaccine manufacturer to amend its package insert to claim safety and efficacy for administration at age 2 months.4 The previous recommended age of first administration had been 15 months. The American Academy of Pediatrics (AAP) soon issued a recommendation for first administration to infants at age 2 months. A letter called a Ped-Comm was sent from the AAP to its members in late October 1990 recommending the earlier age for first vaccination, but information on safety or efficacy was not included since References 1. Cochi SL, Broome CV, Hightower AW. Immunization of US children with Hemophilus influenzae type b polysaccharide vaccine: a cost-effectiveness model of strategy assessment . JAMA . 1985:253:521-529.Crossref 2. Broome CV. Epidemiology of Haemophilus influenzae, type b infections in the United States . Pediatr Infect Dis J. 1987;6:779-782.Crossref 3. Feigin RD. Bacterial meningitis beyond the neonatal period . In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Disease . Philadelphia, Pa: WB Saunders Co; 1987:439-477. 4. HHS News . Washington, DC: US Dept of Health and Human Services; (October 4) ,1990:1-3. 5. Centers for Disease Control. Recommendations and Reports . MMWR . 1991;40( (RR) -1):1-7. 6. DiFrancesco E. Manufacturer requests lower age for Hib immunization . Infect Dis Child. 1990;3:10-11. 7. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? N Engl J Med. 1989; 321:1306-1311.Crossref 8. Wilde JA, Pedroni AT. Your liability for vaccine-related injuries . Contemp Pediatr. 1991; 8:51-54. 9. Bauer RA, Wortzel LH. Doctor's choice: the physician and his sources of information about drugs . J Marketing Res. 1966;3:40-47.Crossref 10. Menzel H, Katz E. Social relations and innovation in the medical profession: the epidemiology of a new drug . Public Opinion Q. Winter 1956;19:337-352.Crossref 11. Coleman J, Menzel H, Katz E. Social processes in physicians' adoption of a new drug . J Chronic Dis. 1959;9:1-19.Crossref 12. Williamson PM. The adoption of new drugs by doctors practicing in group and solo practice . Soc Sci Med. 1975;9:233-236.Crossref 13. Becker MH, Stoley PD, Lasagna L. Differential education concerning therapeutics and resultant physician prescribing patterns . J Med Educ. 1972;47:118-127. 14. Coser RL. Authority and decision making in a hospital: a comparative analysis . Am Sociol Rev. 1958;23:56-64.Crossref

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260014002

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables. Abstract The annual meeting of the American Pediatric Society, The Society for Pediatric Research, and The Ambulatory Pediatric Association will be held May 3-6, 1993, at the Sheraton Washington (DC) Hotel. For further information, contact the APS/SPR Association Headquarters, 141 Northwest Point Blvd, PO Box 675, Elk Grove Village, IL 60009-0675; (708) 427-0205; fax (708) 427-1305; or the Ambulatory Pediatric Association, 6728 Old McLean Village, McLean, VA 22101; (703) 556-9222; fax (703) 556-8729.

FULGINITI, VINCENT A.

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260014003

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables. Abstract JAMA and all of the American Medical Association's family of journals, including AJDC, will dedicate all or most of one of their fall 1993 issues to manuscripts devoted to the theme of genetics. This initiative is in recognition of the significant and fast-paced changes that have occurred in our understanding of the molecular basis of heredity and all that stems from that understanding. Forty years ago, James D. Watson and Francis H. C. Crick published their reports unraveling the structure of DNA and revealing it as a double helix. In the intervening decades, sometimes at a dizzying pace, the molecular basis of heredity and developmental biology has been similarly unraveling. It is difficult to believe that today humans are receiving gene therapy in experimental situations with the prospect of reversing genetic defects once thought immutable. In both a tribute to these advances and in prospect of the significant changes in

KWITTKEN, PAMELA L.;ROSEN, SHEA;SWEINBERG, SHARON K.

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260018005pmid: 8427228

Abstract Sir.—The resurgence of childhood measles in the United States has prompted secondary immunization with the measles, mumps, and rubella (MMR) vaccine.1 Immediate allergic reactions to the MMR vaccine, including dyspnea and hypotension, have been documented in egg-allergic individuals.2 Recently, five patients without a history of egg allergy experienced similar reactions, requiring emergency treatment with antihistamines and epinephrine hydrochloride.3 The MMR vaccine contains hydrolyzed gelatin, sorbitol, and neomycin sulfate (25 μg).4 Neomycin is an antibiotic that is known to cause both local and systemic allergic reactions. Our experience with the following patient suggests that hypersensitivity to these additives found in the MMR vaccine, especially neomycin, may be a factor in documented reactions in individuals without egg allergy. Patient Report.—The patient was a 7-year-old white boy who ingested all food products, including eggs, without incident. His medical history was remarkable for mild asthma treated symptomatically with References 1. Committee on Infectious Diseases. Measles. Elk Grove Village, Ill: American Academy of Pediatrics; 1991:308-323. 2. Beck SA, Williams LW, Shirrell MF, Burks W. Egg hypersensitivity and measles-mumpsrubella vaccine administration . Pediatrics . 1991; 88:913-917. 3. Kalet A, Berger DK, Bateman WB, Dubitsky J, Covitz K. Allergic reactions to the MMR vaccine . Pediatrics . 1992;89:168-169. 4. Physicians' Desk Reference . 46th ed. Montvale, NJ: Medical Economics Company Inc; 1992:1494-1496. 5. Fisher AA. Allergic contact dermatitis in early infancy . Cutis . 1985;35:315-316. 6. Goh CL. Anaphylaxis from topical neomycin and bacitracin . Aust J Dermatol. 1986;27: 125-126.Crossref 7. Anderson KE, Hjorth N, Menne T. The baboon syndrome: systemically-induced allergic contact dermatitis . Contact Dermatitis . 1984;10: 97-100.Crossref 8. Ghadially MB, Ramsay C. Gentamicin: systemic exposure to a contact allergen . J Am Acad Dermatol. 1988;18:428-430.Crossref 9. Polak L, Turk JL. Studies on the effect of systemic administration of sensitizers in guinea-pigs with contact sensitivity to inorganic metal compounds . Clin Exp Immunol. 1968;3:253-262. 10. Comaish JS, Cunliffe WJ. Absorption of drugs from varicose ulcers: a cause of anaphylaxis . Br J Clin Prac . 1967;21:97-98. 11. Epstein S, Wenzel FJ. Cross-sensitivity to various 'mycins.' Arch Dermatol. 1962;86:101-112. 12. Pirila V, Rouhunkoski S. On cross-sensitization between neomycin, bacitracin, kanamycin and framycetin . Dermatologica . 1960; 121:335-342.Crossref 13. Schorr WF, Wenzel FJ, Jegedus SI. Cross-sensitivity and aminoglycoside antibiotics . Arch Dermatol. 1973;107:533-539.Crossref 14. Hill DB, Henderson LM, McClain CJ. Osmotic diarrhea induced by sugar-free theophylline solution in critically ill patients . J Parenter Enter Nutr. 1991;15:332-336.Crossref 15. Badiga MS, Jain NK, Casanova C, Pitchumoni CS. Diarrhea in diabetics: the role of sorbitol . J Am Coll Nutr. 1990;9:578-582.Crossref 16. Karrenberg R, Stober HD. The dangers of fructose-sorbitol infusions . Anaesthesiol Reanim . 1990;15:181-187. 17. Keller U. The sugar substitutes fructose and sorbite: an unnecessary risk in parenteral nutrition . Schweiz Med Wochenschr . 1989;119:101-106.

RAO, SREEDHAR P.;TEITLEBAUM, JEFFREY;MILLER, SCOTT T.

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260019007

Abstract In Reply.—We read with interest Dr Özsoylu's comments regarding our report. Our main purpose was to describe another case of aseptic meningitis following IVIG therapy to raise awareness among physicians of this complication. While additional cases continue to be reported by Watson et al and others,1 it seems that aseptic meningitis is still very uncommon and apparently benign. In general, we have been impressed with the rapidity of response and safety of IVIG therapy, and in addition have avoided bone marrow aspiration in most of our patients with ITP; we would feel compelled to do a bone marrow aspiration if we were to use steroid therapy. While the high-dose steroid regimen is reported by Özsoylu et al to have been tolerated very well, we remain concerned about the potential toxic effects of such therapy. A prospective randomized trial comparing these two treatments would be of interest. References 1. Pallares DE, Marshall GS. Acute aseptic meningitis associated with administration of intravenous immune globulin . Am J Pediatr Hematol Oncol. 1992;14:279-281.Crossref

OZSOYLU, SINASI

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260019006pmid: 8489588

Abstract Sir.—Rao et al1 reported the case of a child with immune thrombocytopenic purpura (ITP) in whom unusual aseptic meningitis, with greater than 0.90 neutrophils in cerebrospinal fluid, developed within 36 hours of intravenous immune globulin (IVIG) administration. Although the authors stated that "all reported cases of aseptic meningitis occurred in patients with immune thrombocytopenic purpura," it was also observed in adults2 with ITP who were given different preparations of IVIG in different doses. Although bacterial and viral cultures of cerebrospinal fluid remained negative in those cases (including the authors' patient), this unusual aseptic meningitis could be related to a causative agent (including chemicals) that is not yet known, since the cerebrospinal fluid findings do not fit those of pseudotumor cerebri. Since the prognosis of acute childhood ITP is very favorable, and, when required, the platelet count can be raised above 150×109/L within 3 days in References 1. Rao SP, Teitlebaum J, Miller ST. Intravenous immune globulin and aseptic meningitis . AJDC . 1992;146:539-540. 2. Watson JDG, Gibson J, Joshua DE, kronenberg H. Aseptic meningitis associated with high dose intravenous immunoglobulin therapy . J Neurol Neurosurg Psychiatry . 1991;54:275-276.Crossref 3. Özsoylu Ş, Irken G, Karabent A. High-dose intravenous methylprednisolone for acute Childhood idiopathic thrombocytopenic purpura . Eur J Haematol . 1989;42:431-435.Crossref 4. Özsoylu Ş, Ertürk G. Oral megadose methylprednisolone for childhood acute idiopathic thrombocytopenic purpura (ITP) . Blood . 1991;77:1856-1857. 5. Özsoylu Ş, High dose intravenous methylprednisolone for chronic idiopathic thrombocytopenic purpura . Acta Haematol . 1989;81:112-113.Crossref 6. Manoharan A. Treatment of refractory idiopathic thrombocytopenic purpura in adults . Br J Haematol . 1991;79:143-147.Crossref

BRAYDEN, ROBERT M.

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260020008pmid: 8427229

Abstract Sir.—The article by Dubowitz et al,1 published in the June 1992 issue of AJDC, on child sexual abuse is a thorough description of the multidisciplinary approach to child sexual abuse evaluation. Unfortunately, it fails to help clarify the important distinction between the legal definitions of child sexual abuse and the medical opinion of the same. Behaviors that involve adults and children and result in any sexual stimulation run a spectrum from very brief, perhaps unnoted and perhaps unintended, sexual stimulation to premeditated, coercive exploitation. State laws designate which sexual behaviors are unacceptable or abusive. Assessment of whether behaviors violate these standards is the province of governmental investigative and judicial systems. As such, medical professionals are charged with providing accurate information to judges and juries, who are the legal definers of abuse. To use the verbiage "diagnosis of child sexual abuse" serves to blur the boundary of responsibility for References 1. Dubowitz H, Black M, Harrington D. The diagnosis of child sexual abuse . AJDC . 1992;146: 688-693.

DUBOWITZ, HOWARD;BLACK, MAUREEN;HARRINGTON, DONNA

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260020009

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables. Abstract In Reply.—Brayden raises some interesting issues regarding the diagnosis of sexual abuse. However, it would be a minimalist role for pediatricians to only report the history and physical findings. Indeed, pediatricians (and others) need to interpret the information and make a (perhaps tentative) assessment of the likelihood of abuse to make a report to child protective services. This decision does need to be guided by state law. In addition, child protective services should be interested in the pediatrician's findings and assessment. Few caseworkers, lawyers, or judges are in a position to interpret the physical findings. Although a final decision on the likelihood of abuse may be made by the public agencies, a comprehensive assessment and well-reasoned opinion facilitates this process. The distinction between a medical opinion and a diagnosis appears to be largely semantic. Clearly, if the diagnosis is uncertain, appropriate caution is warranted. In addition to state reporting

BONADIO, WILLIAM A.

1993 American Journal of Diseases of Children

doi: 10.1001/archpedi.1993.02160260021010pmid: 8427230

Abstract Sir.—A 1991 study showed that adjunctive dexamethasone therapy significantly reduced the rate of neurologic sequelae experienced by children with bacterial meningitis.1 The most recent (1991) recommendation by the American Academy of Pediatrics Committee on Infectious Diseases2 was that "dexamethasone therapy be considered only when the diagnosis of bacterial meningitis has been proven or is strongly suspected on the basis of the CSF [cerebrospinal fluid] examination, Gram-stained smear, or antigen test results", and that "dexamethasone should not be used for suspected or proven aseptic or non-bacterial meningitis." The protocol includes initiating dexamethasone prior to administering the initial dose of antibiotics so as to diminish the host inflammatory response to rapid lysis of a large inoculum of bacteria. In most cases, these recommendations place the burden of deciding whether to initiate dexamethasone therapy for suspected bacterial meningitis on the emergency medicine physician, since lumbar puncture is performed and the References 1. Odio C, Faingezicht I, Paris M, McCracken GH. The beneficial effects of dexamethasone therapy for bacterial meningitis . N Engl J Med. 1991;324:1525.Crossref 2. The Committee on Infectious Diseases. Dexamethasone Therapy for Bacterial Meningitis in Infants and Children . 2nd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1991:566-570. 3. Bonadio WA, Bruce R, Barry D, Smith D. Reference values of non-infected cerebrospinal fluid in infants aged 0-8 weeks . Pediatr Infect Dis J. 1992;11:589-591.Crossref 4. Portnoy J, Olson L. Normal cerebrospinal fluid values in children: another look . Pediatrics . 1985;75:484. 5. Sarff L, Platt L, McCracken GH. Cerebrospinal fluid evaluation in neonates: comparison of high-risk infants with and without meningitis . J Pediatr. 1976;88:473-476.Crossref 6. Bonadio WA. The cerebrospinal fluid: physiologic aspects and alterations with bacterial meningitis . Pediatr Infect Dis J 1992;11:423-432.Crossref 7. Izsak I. Pediatric emergency medicine fellowship programs . Pediatr Emerg Care . 1990;6:68.Crossref 8. Waagner DC, Kennedy W, Hoyt M. Lack of adverse effects of dexamethasone therapy in aseptic meningitis . Pediatr Infect Dis J. 1990;9:922.