Thursday, September 1, 2011
From Medscape Internal Medicine > Medicine Matters Sandra A. Fryhofer, MD Posted: 08/24/2011 Egg-allergic patients can now get flu shots. Here is why it matters. Twenty percent of the US population comes down with influenza every year. So every year people should be vaccinated against it. But until now patients with egg allergy couldn't be vaccinated because chicken eggs are used in making vaccine, and there were theoretical concerns that traces of egg protein could trigger a serious allergic reaction. But the data indicate differently.At least 17 studies of more than 2600 egg-allergic patients showed no serious reactions, including respiratory distress and hypotension. The only reactions were minor, such as hives and mild wheezing. The likeliest reason for this surprising lack of reaction is the tiny amount of leftover egg protein in the vaccine. There is also good news for the healthcare professional who administers flu vaccines. No skin tests are needed. The results aren't predictive, and there is no need to divide the dose. Single-dose studies support giving the entire vaccine dose at one time. There are some special caveats. Egg-allergic patients must get the inactivated flu shot because this is what has been used in studies. They cannot get the nasal flu vaccine. Anyone giving vaccinations should be familiar with egg allergy. After administering the shot, patients should be observed for 30 minutes. The bottom line is that allergy experts have changed their tune. They now say it is safer for egg-allergic patients to get vaccinated than to risk getting the flu.
Posted by Dr Tan Poh Tin at 11:06 PM
From Medscape Pediatrics Alan Greene, MD 08/25/2011 Commentary The earlier edition of the breast-feeding guide was a million-plus bestseller and a major influence on breast-feeding in the 21st century. Launched to coincide with the World Health Organization's (WHO) World Breastfeeding Week, the new edition features a decade of the latest research, including new research on ways that breast-feeding can reduce childhood allergies and childhood obesity, 2 pressing concerns for today's parents and clinicians. Perhaps most useful for parents and clinicians alike are the numerous question and answer sidebars with practical mom-tested solutions to common and not-so-common breast-feeding issues. Consider 3 important facts: Between 2002 and 2009 the C-section rate in the United States rose to an all-time high of 34%, according to a HealthGrades report released earlier this summer. The US Centers for Disease Control and Prevention (CDC) and March of Dimes report that the rate of babies born prematurely is dropping slightly but remains above 12%. In a report published in August 2011, the CDC noted that only a very small minority -- 3.5% -- of hospitals implemented 9 of 10 steps recommended in the WHO/UNICEF Ten Steps of Successful Breastfeeding. More than 40% of babies born in the United States are born in ways that produce special challenges -- and solutions -- to establishing breast-feeding. The odds of these mothers and infants being appropriately supported from the time of delivery are slim. The AAP's updated guide provides much-needed expert advice on best handling this sizeable minority of babies. However, providing a recommendation to purchase a book does not then give the clinician permission to just move on. For women with lower literacy, fewer resources, or just not enough time or inclination to read a book, there are many other resources. The Table provides a number of helpful Websites for both professionals and families. Many of the professional sites offer brochures in English and Spanish that are available for download and perfect for displaying in a waiting room or using for breast-feeding classes. Table: Breast-feeding Resources For Healthcare Professionals For Families Hospital Support for Breastfeeding This is part of the CDC Vital Signs program and provides important data to assist clinicians and hospital administrators in creating a baby-friendly hospital Your Guide to Breastfeeding This is available from the US Department of Health & Human Services (DHHS). This full-color downloadable pdf is available in English, Spanish, and Chinese. Breastfeeding Report Card -- United States, 2011 This report provides a wealth of information including process and outcomes indicators of change. Breastfeeding Answers from La Leche League This guide provides information in 11 languages, includes mother-to-mother forums, and provides online support. AAP Breastfeeding Initiatives This Web site includes breast-feeding guidelines, advocacy materials, and links to other resources. Breastfeeding Hotline This Website includes numerous fact sheets, breast-feeding videos, and links to a helpline with English and Spanish counselors. Although breast-feeding for the first 12 months of life is the best obesity prevention strategy, this is not the reality for many women and infants. With a plethora of preparations on the market, formula-feeding decisions are not as simple as they used to be. The United States Department of Agriculture (USDA) provides information about Infant Formula Feeding as part of their online publication, Infant Nutrition and Feeding: A Guide for Use in the WIC and CSF Programs. The timing and choice of solid food introduction is another important factor. A 2011 study found that starting solids before age 4 months (as is the case with a quarter of infants in the United States) is associated with 6 times the risk for obesity at age 3 years. Beyond this, for decades the top source of solid food calories in the first year has been processed white flour that we call rice cereal. Many parents have been advised to make this a first food for babies despite a lack of scientific evidence for this recommendation.
Posted by Dr Tan Poh Tin at 11:02 PM
Medscape Infectious Diseases > Offit on Vaccines Paul A. Offit, MD Posted: 08/24/2011 Hi. My name is Paul Offit and I'm speaking to you today from the Vaccine Education Center here at The Children's Hospital of Philadelphia. I want to discuss a recent paper from the US Centers for Disease Control and Prevention looking at the effectiveness of the varicella or chickenpox vaccine. The varicella vaccine was first introduced into the United States in 1995. The study authors looked at deaths from varicella during the 5-year period before 1995, specifically from 1990 to 1994, and then they looked at deaths from varicella during the 3-year period from 2005 to 2007. In 2006, there was a second dose recommendation for varicella, but for the most part this is a comparison of a 1-dose vaccine schedule that was initiated in 1995 to look at the death rate before and after the introduction of the vaccine. The researchers found that overall, there was an 88% decline in varicella-related deaths: deaths from pneumonia; deaths from encephalitis; and deaths from overwhelming group A beta-hemolytic streptococcal infections that arose in the blisters caused by varicella. They also found a significant 97% reduction in the number of deaths in children younger than 6 years of age, and a significant 96% reduction in deaths in adults under 50 years of age. What we have learned from this is that, not surprisingly, the varicella vaccine works. Not only did it work in prelicensure trials to show that it was efficacious, but it also has worked in postlicensure effectiveness trials. We can only expect a further decline in deaths now that we have a recommendation for a second dose, initiated in 2006. This should result in another 10-fold reduction in cases and, I think, a virtual elimination of deaths. We should take our hats off to all those who were involved in the development of this lifesaving vaccine.
Posted by Dr Tan Poh Tin at 10:51 PM
From Medscape Medical News Emma Hitt, PhD August 31, 2011 — The first-ever guidelines on the diagnosis and treatment of community-acquired pneumonia (CAP) in infants and children, from the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA), emphasize the importance of immunizations, including a yearly influenza vaccine, to protect children from life-threatening pneumonia. A 13-member panel, led by John S. Bradley, MD, with the Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, in California, authored the new guidelines published online August 30 and to appear in the October 1 issue of Clinical Infectious Diseases. The document presents 92 specific recommendations in all, each with varying levels of evidence. Currently, guidelines exist for the diagnosis and treatment of pneumonia in adults, but in the pediatric setting, bacterial pneumonia often takes a different course, even when caused by the same pathogens. Consequently, there is widespread variability in the treatment of CAP among children. The current document is "designed to provide guidance in the care of otherwise healthy infants and children and addresses practical questions of diagnosis and management of CAP evaluated in outpatient (offices, urgent care clinics, emergency departments) or inpatient settings in the United States," Dr. Bradley and colleagues write. Recommendations for Diagnosis "Diagnostic methods and treatments that work well in adults may be too risky and not have the desired result in children," noted Dr. Bradley in an accompanying written release from the PIDS and IDSA. Regarding diagnosis, the guidelines state that blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP treated in the outpatient setting. "In these cases, there is no need to perform unnecessary medical interventions such as using x-rays (which expose the child to radiation needlessly) or prescribing antibiotics (which kill bacteria, not viruses, and may foster drug-resistant bacteria)," the written release states. However, blood cultures should be performed in children "who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy," the study authors write. Hospitalization Based on Symptoms in Infants The guidelines also recommend that infants 3 to 6 months old with suspected bacterial pneumonia be hospitalized, even if the pneumonia is not confirmed by blood tests. "Blood testing in children often isn't accurate, so physicians need to pay close attention to symptoms, and, if unsure, err on the side of treating," Dr. Bradley indicates. Strong Recommendation for Immunizations All children and adolescents at least 6 months old should be immunized annually with vaccines for influenza virus to prevent CAP, which the study authors state is a strong recommendation, based on high-quality evidence. Parents of children younger than 6 months should be vaccinated against influenza because these children cannot receive the preventive vaccine. Amoxicillin Sufficient for First-Line Therapy In addition, amoxicillin should be used as first-line therapy for bacterial pneumonia, but more powerful antibiotics are not needed. Methicillin-resistant Staphylococcus aureus should be considered as a cause of pneumonia if first-line treatment is unsuccessful. According to the guidelines, overtreatment is a critical concern. Most cases of pneumonia in preschool-aged children are of viral origin and will therefore not develop into life-threatening bacterial pneumonia. Because of the difficulty in studying children, the guidelines all call for more research in several areas. "With these guidelines, we are hopeful that the standard and quality of care children receive for community-acquired pneumonia will be consistent from doctor to doctor — providing much better treatment outcomes," Dr. Bradley indicates. "We’re hopeful that in following these guidelines, physicians and hospitals will collect data and the results can be compared," he notes. "We envision this as the first of many revisions of guidelines to come." Guidelines Meet an Important Unmet Need Carrie Byington, MD, a pediatric infectious disease specialist with the Department of Pediatrics, at the University of Utah School of Medicine in Salt Lake City, notes that these guidelines address a very important unmet need for all practitioners who care for children. "Pneumonia is one of the most common reasons for hospitalization for children in the United States, and there's a huge variation in the care that's delivered to children," she told Medscape Medical News. Dr. Byington is an author on the new guidelines and is vice chair of the American Academy of Pediatrics Committee on Infectious Diseases. "Often the care of children is not evidence based and result in both over- and undertreatment of children and less than ideal outcomes," she said. "This is the first attempt to review all the evidence available in the scientific literature and to provide explicit guidelines for practitioners that could assist them in their decision making for children with pneumonia." Areas of Interest According to Dr. Byington, pediatricians in primary care will probably be most interested in the guidelines for diagnostic testing and the recommendation for antibiotic therapy. Pediatricians in the hospital setting will also be interested in the guidelines for hospitalized children, including diagnostic testing and treatment of complicated pneumonia. "We also really want to stress the prevention of pneumonia through immunization, so there is a large section to the research that demonstrates the importance of this," she said. This study was supported by the IDSA. Some of the study authors have disclosed various financial relationships with Wyeth/Pfizer, Sanofi Pasteur, Pfizer, GlaxoSmithKline, Novartis, Baxter Health Care, Halozyme Therapeutics, Pricara (Ortho-McNeil-Janssen), Rox-888, Venasite, the National Institutes of Health, and/or the Robert Wood Johnson Foundation. Clin Infect Dis. Published online August 30, 2011.
Posted by Dr Tan Poh Tin at 10:17 PM