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NEWS FLASH Common Antibiotics May be Best for MethicillinResistant Staphylococcus aureus–Related Infections Penicillin and other antibiotics in the βlactam family work as well as other antibiotics to treat methicillin-resistant Staphylococcus aureus infections in the skin and soft tissue of children and may help prevent further resistance to antibiotic treatment according to a study funded by the Agency for Healthcare Research and Quality. The study, published in the June issue of Pediatrics, compared treatment outcomes for three different antibiotics—β-lactums (which include penicillin, cephalosporins, carbapenems, and monobactams), clindamycin, and trimethoprim-sulfamethoxazole. The study concluded that children treated with clindamycin for skin and soft-tissue infections potentially caused by methicillin-resistant S aureus did not show greater improvement compared with those treated with βlactam therapy. Children treated with trimethoprim-sulfamethoxazole were less likely to show improvement.
CDC Approves Single and Combination Varicella Vaccines The Advisory Committee on Immunization Practices, part of the Centers for Disease Control and Prevention, in June rejected the opinion of most members on a working group by endorsing administration of the varicella vaccine either by itself or in combination with the measlesmumps-rubella vaccine (MMR) in infants. According to a MedPage Today article, “Most members supported separate administrations of the MMR and varicella vaccines because of a lower risk for febrile seizures in the first 2 weeks after receiving the shots. The final E-mail: [email protected]. 1527-3369/09/0904-0325$36.00/0 doi:10.1053/j.nainr.2009.09.002
guidance accepted by ACIP leaves the choice to the clinician.” The working group had based its majority opinion on the results of two tests that indicated the risk of febrile seizure doubled when using the combination vaccine for the first dose, with the risk confined to a window of 5 to 12 days after vaccination. The article said, “The increased risk equates to one additional febrile seizure per approximately 2300 doses administered, according to Nicola Klein, MD, PhD, of Northern California Kaiser Permanente in Oakland. Extrapolating that to the average practice, most pediatricians would see just one additional febrile seizure every 15 years, according to S. Michael Marcy, MD, of the University of California Los Angeles Center for Vaccine Research in Torrance.” Marcy is a working group member, and “he and other committee members expressed concern that a stated preference for separate MMR and varicella vaccines would cause vaccine coverage and, thus, disease prevention to suffer.” Read the full article at www.medpagetoday.com/Pediatrics/Vaccines/14909.
Rotavirus Vaccine Induced Diarrhea in Child with Immune Deficiency An article in The Journal of Allergy and Clinical Immunology examined the first reported case of persistent shedding of the rotavirus vaccine in a patient with severe combined immune deficiency (SCID). The authors reported a case of a 9month-old girl who was examined in the hospital after a history of faltering growth and chronic diarrhea. She had received immunizations according to the recommended schedule, including a rotavirus vaccine administered at 2, 4, and 6 months. After the vaccine at 4 months, the patient developed persistent diarrhea and vomiting with poor weight gain that became worse at 6 months. Tests of her stool samples showed the presence of a rotavirus strain that matched that of the vaccine she had received. After a thorough assessment of her case, the patient was diagnosed with SCID. She was given
a successful transplantation of cord blood at age 11 months, and two and a half months later, no further traces of rotavirus were found in her stool. Because vaccines can present problems for immunosuppressed patients due to potential morbidity and mortality, some are not recommended for these individuals. The fundamental deciding factor is whether the vaccine is believed to carry less risk than exposure to natural infection, as is the case with the rotavirus. Primary immunodeficiencies, such as SCID, are usually diagnosed within the first year of life. Thus, the authors concluded that in this new era of universal rotavirus vaccination, it is important to consider this diagnosis when managing patients with faltering growth and chronic diarrhea.
Refusing Immunizations Increases Kids' Risk of Pertussis Children of parents who refuse vaccines are 23 times more likely to get whooping cough compared with fully immunized children, according to a study led by a vaccine research team at Kaiser Permanente Colorado's Institute for Health Research. The study, which appeared in the June 2009 issue of Pediatrics, was funded by the National Institute of Allergy and Infectious Diseases and is the first study to use electronic health records to look for immunization refusal and possible pertussis infections, making it the most definitive on the risk of vaccine refusal to date. Although most families vaccinate their children, leading to dramatic reductions in several serious childhood illnesses, the number of parents refusing immunizations appears to be increasing in the United States, researchers say. The study findings are important for parents who cite low risk of infection as a reason to choose fewer or no immunizations and for researchers who are concerned that decreased immunization rates could lead to more disease outbreaks across the country.
“This study helps dispel one of the commonly held beliefs among vaccinerefusing parents: that their children are not at risk for vaccine-preventable diseases,” said study lead author Jason Glanz, PhD. “It also shows that the decision to refuse immunizations could have important ramifications for the health of the entire community. Based on our analysis, we found that one in 10 additional whooping cough infections could have been prevented by immunization.” Pertussis, more commonly known as whooping cough, is a highly contagious bacterial disease that causes uncontrollable, violent coughing and can be deadly in infants, especially those less than 2 months of age who are too young to be fully vaccinated. In 1976, there were just over 1000 reported cases of pertussis in the United States; by 2004, it climbed to nearly 26 000 cases. Between 2000 and 2005, 140 US deaths resulted from pertussis. The best way to prevent pertussis is through vaccinations. The childhood vaccine, DTaP, is a three-in-one immunization that protects against diphtheria, pertussis, and tetanus. It is given in a series to children at 2, 4, 6, and 15–18 months, and a booster is given before kindergarten. The DTaP vaccine, like other routine childhood immunizations, has been shown to be more than 98% effective. To assess the risk of DTaP refusal, researchers reviewed the electronic health records of children between the ages of 2 months and 18 years who were members of Kaiser Permanente Colorado between 1996 and 2007. First, investigators confirmed which children had pertussis infections. Next, they verified whether parents had refused some or all vaccines for their children. The researchers found 156 laboratoryconfirmed pertussis cases that met the study's criteria. They compared these cases to four times as many children of the same age and sex who were not infected with pertussis. Based on this analysis, the researchers discovered that children of vaccine refusers were 23 times more likely to be infected with whooping cough than vaccinated children. Read a full release at http://xnet.kp. org/newscenter/pressreleases/nat/2009/ 052609immunization.html.
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Sinus Infections May Cause Toxic Shock in Children University of Colorado researchers say sinus infections may cause more than 20% of all cases of toxic shock syndrome in children, so clinicians treating pediatric patients for toxic shock syndrome should be aware of the risk. According to a Reuters article in June, “‘Prompt imaging studies of the sinuses is mandatory when no apparent cause of toxic shock syndrome is found,’ Dr Kenny Chan of the University of Colorado and the Children's Hospital of Denver, whose study appears in the Archives of Otolaryngology, said in a statement.” The article said that Chan et al analyzed the medical records of 76 children who had toxic shock syndrome between 1983 and 2000 and found 23 also had either acute or chronic sinus infections. “Sinus infections were the primary cause of toxic shock in 21% of the cases, many of which were serious. Ten of the children were admitted to the intensive care unit, four needed drugs to raise their blood pressure, and six needed surgery.” Chan warned, “It is imperative that physicians, particularly those who are providing intensive care to children, recognize that rhinosinusitis can be the sole cause of toxic shock syndrome in children.” Read the article at www.reuters.com/ article/healthNews/idUSTRE55E6RS20090616.
Researchers Create Simplified Chart for Pediatric Hypertension Pediatricians now have a new and simple way to diagnose a serious problem facing children, thanks to David Kaelber, MD, PhD, MPH, a MetroHealth System pediatrician, internist, and chief medical informatics officer and Case Western Reserve University School of Medicine researcher and faculty member. Nearly 75% of cases of hypertension and 90% of cases of prehypertension in children and adolescents go undiagnosed. Kaelber and fellow researchers felt that one of the main reasons for the underdiagnosis may be a result of the complex chart currently used to help
VOLUME 9, NUMBER 4, www.nainr.com
physicians and medical personnel identify high blood pressure in children. So, the team simplified the chart—focusing solely on a child's age and sex—by eliminating the need for a height percentile and reducing the number of values in the blood pressure table from 476 to just 64. The revised chart and accompanying description were published in the June issue of Pediatrics. The American Academy of Pediatrics and the American Heart Association recommend that blood pressure checks be done at all pediatric health care visits (including dental and optometric appointments) for children ages 3 to 18. The current standard chart used by health care providers to evaluate pediatric blood pressure is from the National Heart, Lung, and Blood Institute and includes hundreds of normal and abnormal blood pressure values. To differentiate between normal and abnormal readings, providers need to not only remember the variety of blood pressure ranges but also know the child's height percentile, which can be difficult to verify. In redesigning the chart, Kaelber's team reduced the systolic and diastolic blood pressure cutoff values to one value for girls and one value for boys for each year of life from ages 3 to 18 plus. Researchers used the lower limit of height (fifth percentile) in the abnormal blood pressure range for a given gender and age. Although they note this may incorrectly flag some taller children as being in the abnormal blood pressure range, the researchers predict this number will be small compared with the number of children with prehypertension and hypertension who are identified. Any reading at or above the listed numbers in the chart will indicate a child who needs further evaluation by a physician.
Inherited Risk Factors Increase Odds of Developing Childhood ALL Scientists at St. Jude Children's Research Hospital have identified inherited variations in two genes that account for 37% of childhood acute lymphoblastic leukemia (ALL), including a gene that may help predict drug response. The
findings stem from the first complete search of the human genetic blueprint or genome to look for inherited risk factors for ALL, the most common childhood cancer. Published in Nature Genetics, the work offers the first proof based on a complete survey of the human genome that inheritance plays a role in childhood ALL. Mary Relling, PharmD, St. Jude Pharmaceutical Sciences chair and the paper's senior author, estimated that individuals who inherited variations in genes known as ARID5B or IKZF1 are almost twice as likely to develop ALL as those without the variations. Even then, she said, the risk remains low. ALL strikes roughly one
in every 75 000 Americans; 60% are children and teenagers. Researchers collaborated with colleagues from the Children's Oncology Group, who provided additional cases for genetic analysis. Children's Oncology Group is an international group of medical institutions that cooperate in research studies and clinical trials of childhood cancer treatment. Researchers scanned the genomes of 441 children with ALL and a control group of 17 958 cancer-free individuals for more than 300 000 common genetic variations known as single-nucleotide polymorphisms. The new evidence tying inherited variation to an increased
NEWBORN
risk of developing ALL underscores the need for medications targeting variations in that gene, Relling said. Inherited variations might also influence patient response to chemotherapy, particularly to the drug methotrexate. “We found this same inherited variation also affected accumulation of the drug in leukemia cells. It accumulates better, allowing us to use a lower dose and still cure the leukemia,” Relling explained. “These findings may identify a new marker that could be used to help decide on doses of methotrexate in patients with varying gene status.” For more information, visit www. stjude.org.
& INFANT NURSING REVIEWS, DECEMBER 2009
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CDC Approves Single and Combination Varicella Vaccines The Advisory Committee on Immunization Practices, part of the Centers for Disease Control and Prevention, in June rejected the opinion of most members on a working group by endorsing administration of the varicella vaccine either by itself or in combination with the measlesmumps-rubella vaccine (MMR) in infants. According to a MedPage Today article, “Most members supported separate administrations of the MMR and varicella vaccines because of a lower risk for febrile seizures in the first 2 weeks after receiving the shots. The final E-mail: [email protected]. 1527-3369/09/0904-0325$36.00/0 doi:10.1053/j.nainr.2009.09.002
guidance accepted by ACIP leaves the choice to the clinician.” The working group had based its majority opinion on the results of two tests that indicated the risk of febrile seizure doubled when using the combination vaccine for the first dose, with the risk confined to a window of 5 to 12 days after vaccination. The article said, “The increased risk equates to one additional febrile seizure per approximately 2300 doses administered, according to Nicola Klein, MD, PhD, of Northern California Kaiser Permanente in Oakland. Extrapolating that to the average practice, most pediatricians would see just one additional febrile seizure every 15 years, according to S. Michael Marcy, MD, of the University of California Los Angeles Center for Vaccine Research in Torrance.” Marcy is a working group member, and “he and other committee members expressed concern that a stated preference for separate MMR and varicella vaccines would cause vaccine coverage and, thus, disease prevention to suffer.” Read the full article at www.medpagetoday.com/Pediatrics/Vaccines/14909.
Rotavirus Vaccine Induced Diarrhea in Child with Immune Deficiency An article in The Journal of Allergy and Clinical Immunology examined the first reported case of persistent shedding of the rotavirus vaccine in a patient with severe combined immune deficiency (SCID). The authors reported a case of a 9month-old girl who was examined in the hospital after a history of faltering growth and chronic diarrhea. She had received immunizations according to the recommended schedule, including a rotavirus vaccine administered at 2, 4, and 6 months. After the vaccine at 4 months, the patient developed persistent diarrhea and vomiting with poor weight gain that became worse at 6 months. Tests of her stool samples showed the presence of a rotavirus strain that matched that of the vaccine she had received. After a thorough assessment of her case, the patient was diagnosed with SCID. She was given
a successful transplantation of cord blood at age 11 months, and two and a half months later, no further traces of rotavirus were found in her stool. Because vaccines can present problems for immunosuppressed patients due to potential morbidity and mortality, some are not recommended for these individuals. The fundamental deciding factor is whether the vaccine is believed to carry less risk than exposure to natural infection, as is the case with the rotavirus. Primary immunodeficiencies, such as SCID, are usually diagnosed within the first year of life. Thus, the authors concluded that in this new era of universal rotavirus vaccination, it is important to consider this diagnosis when managing patients with faltering growth and chronic diarrhea.
Refusing Immunizations Increases Kids' Risk of Pertussis Children of parents who refuse vaccines are 23 times more likely to get whooping cough compared with fully immunized children, according to a study led by a vaccine research team at Kaiser Permanente Colorado's Institute for Health Research. The study, which appeared in the June 2009 issue of Pediatrics, was funded by the National Institute of Allergy and Infectious Diseases and is the first study to use electronic health records to look for immunization refusal and possible pertussis infections, making it the most definitive on the risk of vaccine refusal to date. Although most families vaccinate their children, leading to dramatic reductions in several serious childhood illnesses, the number of parents refusing immunizations appears to be increasing in the United States, researchers say. The study findings are important for parents who cite low risk of infection as a reason to choose fewer or no immunizations and for researchers who are concerned that decreased immunization rates could lead to more disease outbreaks across the country.
“This study helps dispel one of the commonly held beliefs among vaccinerefusing parents: that their children are not at risk for vaccine-preventable diseases,” said study lead author Jason Glanz, PhD. “It also shows that the decision to refuse immunizations could have important ramifications for the health of the entire community. Based on our analysis, we found that one in 10 additional whooping cough infections could have been prevented by immunization.” Pertussis, more commonly known as whooping cough, is a highly contagious bacterial disease that causes uncontrollable, violent coughing and can be deadly in infants, especially those less than 2 months of age who are too young to be fully vaccinated. In 1976, there were just over 1000 reported cases of pertussis in the United States; by 2004, it climbed to nearly 26 000 cases. Between 2000 and 2005, 140 US deaths resulted from pertussis. The best way to prevent pertussis is through vaccinations. The childhood vaccine, DTaP, is a three-in-one immunization that protects against diphtheria, pertussis, and tetanus. It is given in a series to children at 2, 4, 6, and 15–18 months, and a booster is given before kindergarten. The DTaP vaccine, like other routine childhood immunizations, has been shown to be more than 98% effective. To assess the risk of DTaP refusal, researchers reviewed the electronic health records of children between the ages of 2 months and 18 years who were members of Kaiser Permanente Colorado between 1996 and 2007. First, investigators confirmed which children had pertussis infections. Next, they verified whether parents had refused some or all vaccines for their children. The researchers found 156 laboratoryconfirmed pertussis cases that met the study's criteria. They compared these cases to four times as many children of the same age and sex who were not infected with pertussis. Based on this analysis, the researchers discovered that children of vaccine refusers were 23 times more likely to be infected with whooping cough than vaccinated children. Read a full release at http://xnet.kp. org/newscenter/pressreleases/nat/2009/ 052609immunization.html.
e14
Sinus Infections May Cause Toxic Shock in Children University of Colorado researchers say sinus infections may cause more than 20% of all cases of toxic shock syndrome in children, so clinicians treating pediatric patients for toxic shock syndrome should be aware of the risk. According to a Reuters article in June, “‘Prompt imaging studies of the sinuses is mandatory when no apparent cause of toxic shock syndrome is found,’ Dr Kenny Chan of the University of Colorado and the Children's Hospital of Denver, whose study appears in the Archives of Otolaryngology, said in a statement.” The article said that Chan et al analyzed the medical records of 76 children who had toxic shock syndrome between 1983 and 2000 and found 23 also had either acute or chronic sinus infections. “Sinus infections were the primary cause of toxic shock in 21% of the cases, many of which were serious. Ten of the children were admitted to the intensive care unit, four needed drugs to raise their blood pressure, and six needed surgery.” Chan warned, “It is imperative that physicians, particularly those who are providing intensive care to children, recognize that rhinosinusitis can be the sole cause of toxic shock syndrome in children.” Read the article at www.reuters.com/ article/healthNews/idUSTRE55E6RS20090616.
Researchers Create Simplified Chart for Pediatric Hypertension Pediatricians now have a new and simple way to diagnose a serious problem facing children, thanks to David Kaelber, MD, PhD, MPH, a MetroHealth System pediatrician, internist, and chief medical informatics officer and Case Western Reserve University School of Medicine researcher and faculty member. Nearly 75% of cases of hypertension and 90% of cases of prehypertension in children and adolescents go undiagnosed. Kaelber and fellow researchers felt that one of the main reasons for the underdiagnosis may be a result of the complex chart currently used to help
VOLUME 9, NUMBER 4, www.nainr.com
physicians and medical personnel identify high blood pressure in children. So, the team simplified the chart—focusing solely on a child's age and sex—by eliminating the need for a height percentile and reducing the number of values in the blood pressure table from 476 to just 64. The revised chart and accompanying description were published in the June issue of Pediatrics. The American Academy of Pediatrics and the American Heart Association recommend that blood pressure checks be done at all pediatric health care visits (including dental and optometric appointments) for children ages 3 to 18. The current standard chart used by health care providers to evaluate pediatric blood pressure is from the National Heart, Lung, and Blood Institute and includes hundreds of normal and abnormal blood pressure values. To differentiate between normal and abnormal readings, providers need to not only remember the variety of blood pressure ranges but also know the child's height percentile, which can be difficult to verify. In redesigning the chart, Kaelber's team reduced the systolic and diastolic blood pressure cutoff values to one value for girls and one value for boys for each year of life from ages 3 to 18 plus. Researchers used the lower limit of height (fifth percentile) in the abnormal blood pressure range for a given gender and age. Although they note this may incorrectly flag some taller children as being in the abnormal blood pressure range, the researchers predict this number will be small compared with the number of children with prehypertension and hypertension who are identified. Any reading at or above the listed numbers in the chart will indicate a child who needs further evaluation by a physician.
Inherited Risk Factors Increase Odds of Developing Childhood ALL Scientists at St. Jude Children's Research Hospital have identified inherited variations in two genes that account for 37% of childhood acute lymphoblastic leukemia (ALL), including a gene that may help predict drug response. The
findings stem from the first complete search of the human genetic blueprint or genome to look for inherited risk factors for ALL, the most common childhood cancer. Published in Nature Genetics, the work offers the first proof based on a complete survey of the human genome that inheritance plays a role in childhood ALL. Mary Relling, PharmD, St. Jude Pharmaceutical Sciences chair and the paper's senior author, estimated that individuals who inherited variations in genes known as ARID5B or IKZF1 are almost twice as likely to develop ALL as those without the variations. Even then, she said, the risk remains low. ALL strikes roughly one
in every 75 000 Americans; 60% are children and teenagers. Researchers collaborated with colleagues from the Children's Oncology Group, who provided additional cases for genetic analysis. Children's Oncology Group is an international group of medical institutions that cooperate in research studies and clinical trials of childhood cancer treatment. Researchers scanned the genomes of 441 children with ALL and a control group of 17 958 cancer-free individuals for more than 300 000 common genetic variations known as single-nucleotide polymorphisms. The new evidence tying inherited variation to an increased
NEWBORN
risk of developing ALL underscores the need for medications targeting variations in that gene, Relling said. Inherited variations might also influence patient response to chemotherapy, particularly to the drug methotrexate. “We found this same inherited variation also affected accumulation of the drug in leukemia cells. It accumulates better, allowing us to use a lower dose and still cure the leukemia,” Relling explained. “These findings may identify a new marker that could be used to help decide on doses of methotrexate in patients with varying gene status.” For more information, visit www. stjude.org.
& INFANT NURSING REVIEWS, DECEMBER 2009
e15