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Arch Dis Child. 2007 September; 92(9): 830.
PMCID: PMC2084019

Lucina

Routine infant vaccination with the seven‐valent pneumococcal conjugate vaccine was introduced in the USA in 2002. National sample data for the years 1997–99 and 2001–04 (Lancet 2007;369:1179–86; see also Comment, ibid: 1144–5) have shown the extent of the decline in hospital admissions of young children for pneumonia since then. Among children less than 2 years old hospital admissions for pneumonia of any cause fell by 39% by 2004. The vaccine prevented about 41 000 such hospital admissions in 2004 and admissions for pneumococcal pneumonia fell by 65%. Reductions of 17–18% in admissions of older children for pneumonia of any cause did not reach statistical significance but there was a significant 26% reduction among young adults aged 18–39 years, attributed to a herd immunity effect of the vaccine. As a control measure it was noted that hospital admissions for dehydration did not change during the study period.

In the UK neonatal screening for cystic fibrosis could be cost‐saving. Data from the UK cystic fibrosis database were analysed and yearly treatment costs analysed for 184 patients diagnosed by neonatal screening and 950 patients diagnosed clinically in 2002 (Lancet 2007;369:1187–95; see also Comment: ibid: 1146–7). Median and mean yearly costs were significantly lower in the neonatal screening group (US $352 and $7228) than in the clinically diagnosed group (US $2442 and $12 008). Limiting the latter group to patients diagnosed after the age of 2 months and diagnosable with a 31 cystic fibrosis transmembrane regulator (CFTR) mutation assay the cost savings from newborn screening were $3 397 344 (mean) and $947 032 (median). The estimated cost of adding cystic fibrosis screening to the UK national screening programme was $2 971 551.

Blood transfusion has, in the past, been used liberally for sick, anaemic patients but a more conservative policy may save costs without risk to patients. A study reported in 1999 showed that a liberal transfusion strategy did not improve outcomes for adults in intensive care when compared with a restrictive strategy and the restrictive strategy halved the amount of blood used. Now a study in children (New England Journal of Medicine 2007;356:1609–19; see also editorial, ibid: 1667–9) has provided similar results. A total of 637 stable, critically ill children with haemoglobin concentrations <9.5 g/dl (mean age 38 months) were randomised in the intensive care unit to a restrictive strategy (red cell transfusion at haemoglobin concentrations of [less-than-or-eq, slant]7 g/dl) or a liberal strategy (transfusion at [less-than-or-eq, slant]9.5 g/dl). New or progressive multiple organ dysfunction developed in 12% of children in each group and 14 children in each group died. There were 301 transfusions in the restrictive strategy group and 542 in the liberal strategy group.

Inherited deficiency of glycosylphosphatidylinositol (GPI) was first described in 2006 as an autosomal recessive condition that presents in infancy with splanchnic vein thromboses and seizures. There are theoretical reasons why sodium phenylbutyrate should counter the deficiency and now (New England Journal of Medicine 2007;356:1641–7) a child with this condition has been treated with remarkable success. At the age of 2 years the child had hepatic vein thrombosis and the Budd‐Chiari syndrome. She developed absence seizures at the age of 4 years and subsequently generalised tonic‐clonic seizures. The diagnosis of inherited GPI deficiency was made by flow‐cytometric analysis of GPI expression on blood cells when she was 9 years old. At the age of 14 years she was having multiple absence seizures and about five tonic‐clonic seizures each day and was treated with lamotrigine, levetiracetam, topiramate and clobazam. She was generally hypotonic, drooling, very drowsy, unable to feed herself and confined to a wheelchair. She was treated with sodium phenylbutyrate and at the same time sodium valproate was added to her treatment and levetiracetam, clobazam and lamotrigine were withdrawn. The complex biochemical abnormalities of the condition were reversed and there was a remarkable clinical improvement. She became seizure‐free within 2 weeks and was able to walk, interact and feed herself. It is not possible to say how much the changes in her standard antiepileptic treatment contributed to her improvement but it seems likely that the sodium phenylbutyrate was the main and specific factor.

In the UK and in the Netherlands in the late 1990s some 10–20% of orchidopexies were performed at or after the age of 13 years. Now national registry data from Sweden (New England Journal of Medicine 2007;356:1835–41) have shown that the risk of testicular cancer increases considerably if orchidopexy is left until after puberty. Among 16 983 men who had undergone orchidopexy for undescended testis between 1964 and 1999 a diagnosis of testicular cancer was made, during a mean follow‐up of 12.4 years, in 56. The standardised incidence ratio for testicular cancer was 2.23 among men who had orchidopexy before the age of 13 years and 5.40 among men who had later orchidopexy. For orchidopexy at ages 0–6, 7–9 and 10–12 years the ratio was 2.02, 2.35 and 2.27 respectively, and for orchidopexy at ages 13–15 and 16‐–19 years it was 5.06 and 6.24 respectively. The proportion of orchidopexies performed at [gt-or-equal, slanted]13 years fell gradually from 27% in the late 1960s to 5% in the late 1980s. In 2005 it was about 6%. From these data it is calculated that treatment of 69 boys before rather than at or after the age of 13 years would prevent one case of testicular cancer before the age of 55 years.

Children in America are more and more receiving a diagnosis of bipolar disorder according to a report in New Scientist (19 May 2007, pp 6–7 and Editorial p 3). This diagnosis was made for 13 in every 100 000 children in 1996 and 73 in 100 000 in 2004, and it is reported that bipolar disorder increased from 10% to 40% of all psychiatric diagnoses in children. It is not clear whether the increase is due to changes in classification, diagnosis of cases previously unrecognised or misdiagnosis. The writer of the editorial refers to “the trend of viewing everyday behavioural difficulties as a medical problem” and “a pharmaceutical industry that encourages drugs to be taken up for a broader range of disorders and by new patient groups”. The diagnosis has been made in very young children and there is concern about the appropriateness of the diagnosis and about the potential toxicity of some of the drugs used in treatment. It has even been suggested that drugs used to treat conditions such as attention deficit hyperactivity disorder (ADHD) might precipitate bipolar symptoms in some children. The New Scientist states bluntly that the diagnosis and treatment of bipolar disorder in American children is in a mess and the mess needs to be sorted out, quickly. In the time‐honoured phrase, “more data are needed”.


Articles from Archives of Disease in Childhood are provided here courtesy of BMJ Group