Current Literature
cch_1145748..751On-time vaccine receipt in the first year does not adversely affect neuropsychological outcomes.
Smith M. J. & Woods C. R. (2010)Pediatrics,125, 1134–1141. Originally published online 24 May 2010; DOI: 10.1542/ peds.2009-2489.
Objectives To determine whether children who received rec-ommended vaccines on time during the first year of life had different neuropsychological outcomes at 7–10 years of age as compared with children with delayed receipt or non-receipt of these vaccines.
Methods Publicly available data, including age at vaccination, from a previous VaccineSafety Datalink study of thimerosal exposure and 42 neuropsychological outcomes were analysed. Vaccine receipt was defined as timely when each vaccine was received within 30 days of the recommended age. Associations between timeliness and each outcome were tested in univariate analyses. Multivariable regression models were constructed for further assessment of the impact of timeliness on neuropsycho-logical outcomes after adjustment for potential confounders. Secondary analyses were performed on a subset of children with the highest and lowest vaccine exposures during the first 7 months of life.
Results Timely vaccination was associated with better perfor-mance on 12 outcomes in univariate testing and remained asso-ciated with better performance for two outcomes in multivariable analyses. No statistically significant differences favoured delayed receipt. In secondary analyses, children with the greatest vaccine exposure during the first 7 months of life performed better than children with the least vaccine exposure on 15 outcomes in univariate testing; these differences did not persist in multivariable analyses. No statistically significant dif-ferences favoured the less vaccinated children.
Conclusion Timely vaccination during infancy has no adverse effect on neuropsychological outcomes 7–10 years later. These data may reassure parents who are concerned that children receive too many vaccines too soon.
This article adds further evidence to the safety of the current immunization programme with multiple vaccines in the first year of life. It is a well-designed study and the authors point out that residual confounding from socio-economic and educa-tional factors may still influence the results, nevertheless the marginal benefits seen in the timely vaccinated group make the
possibility of an adverse effect of multiple vaccinations extremely unlikely.
Of course, those fundamentally opposed to immunization will point out various theoretical caveats, but for the vast major-ity of parents, a study like this, which compares neurodevelop-mental outcome at 7–10 years of age and shows the same results for those vaccinated on schedule as for those not, will be reassuring.
Richard Reading
Why children die: avoidable factors associated with child deaths.
Pearson G. A., Ward-Platt M., Harnden A. & Kelly D. (2010)
Archives of Disease in Childhood. Early online publication 8 June 2010; DOI: 10.1136/adc.2009.177071.
Aim To describe the avoidable factors associated with child deaths identified by a confidential enquiry.
Method In the Centre for Maternal and Child Enquiries con-fidential enquiry, a sample (13%) of cases was subjected to case note review by multidisciplinary panels attempting to identify avoidable factors associated with the deaths. Cases were selected blindly but in equal numbers from predetermined age bands and participating regions. The anonymized records were reviewed in regions remote to where the child lived and died. Panel composition, conduct and reporting were standardized.
Results One hundred and nineteen of 126 cases reviewed by enquiry panels had sufficient information to determine avoid-able factors. These cases were comparavoid-able with the whole dataset in terms of sex and causes of death. Thirty-one (26%) of 119 had avoidable factors that were predominantly related to individuals or agencies with a direct responsibility to the child. Fifty-one (43%) of 119 were defined as potentially avoidable. In all, 130 factors were considered in relation to these 82 cases, and 64% of the factors were healthcare-related. Avoidable factors were more likely where life-limiting illness was not present. Recurring avoidable factors included failure to recognize serious illness at the point of presentation and death occurring in children who had been lost to follow-up.
Conclusion Child Death Overview Panels now have the
responsibility to review child deaths using similar methods but relying upon data forms rather than the case record. Analysis of contributory factors on a national scale has the potential to
Child:
care, health and development
Current Literature
doi:10.1111/j.1365-2214.2010.01145.x© 2010 Blackwell Publishing Ltd
improve understanding of why children die and indicate strat-egies to reduce child mortality.
This paper demonstrates the potential value of child death review panels. In this study, careful examination of case notes in a research-oriented standardized way was carried out so the outcome of the deliberations might be slightly different to those of a death review panel. For instance, the authors point out that local familiarity with cases, other professionals and agency structures may influence conclusions. Similarly these research-ers had access to the detailed case notes while review panels only have a structured pro forma. However, this in itself, and the medical constitution of the review teams, may have influenced the study findings, skewing the avoidable factors to medical and healthcare-related factors.
However, these minor quibbles aside, the public health value of such dispassionate case reviews is substantial. While all pro-fessionals strive to avoid child death, in reality it is a relatively uncommon occurrence. Analysis on this scale can provide useful lessons about healthcare, safety practices, and local and national political advocacy.
Richard Reading Mortality from 1 to 16–18 years in bilateral cerebral palsy. Baird G., Allen E., Scrutton D., Knight A., McNee A., Will E. & Elbourne D. (2010)Archives of Disease in Childhood. Online first published June 2010; DOI: 10.1136/ adc.2009.172841.
Objective To ascertain mortality from 1 to 18 years, and pre-dictors of mortality.
Design Long-term follow-up of population cohort born
1989–1992.
Setting Births in South East Thames Region.
Patients Three hundred and forty-six children with bilateral cerebral palsy (CP).
Interventions Not applicable.
Main outcome measures Mortality; predictors of mortality.
Results Ninety-eight per cent of the cohort were traced. Sixty-one of 340 (17.9%) had died by ages of 16–18 years at a steady mortality. The main predictive factor was severity of impair-ment of functional ability [hazard ratio 5.7, 95% CI 2.1–15.0 for poor hand manipulation; 6.8 (1.9–23.9) for severe communica-tion problems].
Conclusions Although there were deaths throughout the child-hood and teenage years, the majority of children with bilateral CP are likely to survive to adulthood, especially if they do not have major functional impairment at 2 years. This confirms findings of other studies of children with CP.
This is a short report that describes mortality in a relatively recent cohort of young adults with cerebral palsy followed up from 1
year of age. The results confirm previous knowledge. Children with poor hand manipulation ability and severely impaired com-municative ability had the highest mortality with fewer than 50% still alive by 18 years. The important findings of this study are the apparent influence of bulbar impairment on causes of mortality, and the complications of gastrostomy, which led to death for some. Swallowing and its disorders remain a significant problem for children with cerebral palsy, gastrostomy has altered the outcome but poses problems of its own.
Richard Reading
Long-term outcome after neonatal hypoxic-ischaemic encephalopathy.
De Vries L. S. & Jongmans M. J. (2010)Archives of Disease in Childhood. Fetal and Neonatal Edition,95, F220–F224. DOI: 10.1136/adc.2008.148205.
Outcome of full-term infants with neonatal encephalopathy of hypoxic-ischaemic origin is often assessed in infancy or early childhood and data on outcome in childhood and adolescence are limited. Magnetic resonance imaging performed in the neo-natal period has made a huge contribution to recognition of different patterns of injury. These different patterns of injury are related to the severity of later motor and cognitive disabili-ties. Long-term follow-up shows that cognitive and memory difficulties may follow even in children without motor deficits. It is therefore recommended to perform follow-up assessment into childhood in children with and without adverse neurologi-cal outcome in early infancy.
Neonatal encephalopathy continues to occur with much the same frequency as before despite advances in perinatal investi-gation and care. The recent trials using cooling for neuropro-tection are encouraging but even the most optimistic reading of the results suggests relatively modest improvements in outcome. This review describes the increasing understanding of the long-term consequences of neonatal encephalopathy. The mild cases continue to have a good overall prognosis, the severe cases still have a poor prognosis; however, the data reviewed here show that the prognosis for moderate cases is more mixed. While relatively few go on to have an obvious severe neurological dis-ability such as cerebral palsy or severe cognitive impairment, many of them have more subtle neuromotor, educational and behavioural deficits. Early magnetic resonance imaging findings are partially predictive but we do need to be aware of these consequences in all babies with clinical evidence of moderate neonatal encephalopathy. These findings do not mean manda-tory paediatric follow-up of all these babies, but a heightened awareness that neuropsychological problems may present at any time into middle childhood.
Richard Reading
Current Literature 749
Motivational interviewing.
Rollnick S., Butler C. C., Kinnersley P., Gregory J. & Mash B. (2010)BMJ,340, c1900.
Simply giving patients advice to change is often unrewarding and ineffective. Motivational interviewing uses a guiding style to engage with patients, clarify their strengths and aspirations, evoke their own motivations for change and promote autonomy of decision making. You can learn motivational interviewing in three steps: practise a guiding rather than directing style; develop strategies to elicit the patient’s own motivation to change; and refine your listening skills and respond by encour-aging change talk from the patient. Motivational interviewing has been shown to promote behaviour change in various health-care settings and can improve the doctor–patient relationship and the efficiency of the consultation.
Motivational interviewing is a development of counselling skills in which the object is to help clients or patients change problematic behaviour. It has been used to good effect in the management of drug-misusing neglectful parents in conjunc-tion with legally based contracts administered through family drug courts. This article describes various other applications for changing health-related behaviour. What is interesting about this article is that the techniques are fairly straightfor-ward. Obviously, you can not learn a technique simply be reading an article, but knowing the basis is a good start, and some of the techniques described could easily be used in routine clinical encounters with good effect. The article describes the difference between the directing style (i.e. ‘this is not doing you any good so you should change it’) and the guiding style as used in motivational interviewing (i.e. ‘let’s have a look at this problem from your point of view and see if we can suggest any way that might make it easier for you to change’). As with so many interpersonal skills, listening is the key to this and responding sensitively and appropriately. Worth a read, if only to know what people are talking about when they describe motivational interviewing.
Richard Reading
Autism spectrum disorder: diagnosis and management. O’Hare A. (2009)Archives of Disease in Childhood. Education and Practice Edition,94, 161–168. DOI: 10.1136/
adc.2008.150490.
Autism spectrum disorders are of high prevalence and have a potentially complex range of presentations within the core impaired domains of social communication, reciprocal social interaction, imaginary thought and restricted and repetitive behaviours. Paediatricians need to recognize the possibility of these conditions among the high-risk populations of children
with whom they work. This includes those presenting in the preschool years to child development clinics with delayed acqui-sition of language or general development delay or those pre-senting in the school years with co-ordination, academic, peer interaction and behavioural difficulties. In addition, paediatri-cians are essential members of the multidisciplinary teams charged with specialist assessment and their clinical history and examination can direct investigations for aetiology. This is a fast moving field with a challenging range of ‘grey evidence’ causes and interventions. The approaches to managing these areas of work are discussed with an emphasis on recognition, important features in the history and clinical examination to aid differen-tial diagnosis and investigations, interpreting the ‘grey evidence’ and understanding intervention and prognosis.
This is an excellent review of the field of autistic spectrum disorders. It is published in the education and practice section of the journal, which seems entirely appropriate as it would be equally valuable to a fresh trainee or as an update to a grizzled old regular like me. It is heavily based on the Scottish Intercol-legiate Guideline SIGN 98 on autistic spectrum disorders, the advantage of this being that much of the evidence cited has been independently peer reviewed and rated for quality. Recognition of autistic disorders in preschool- and school-aged children is covered, as is diagnosis, investigations, genetics and manage-ment. Various checklists, screening questions and indicators of the different aspects of social communication are reviewed. There is a useful section on some of the less mainstream views on aetiology and treatment, and a good discussion on interven-tions – effective and not proven. The emphasis throughout the article is on practical help for the clinician.
Richard Reading
Human papillomavirus and survival of patients with oropharyngeal cancer.
Anh K. K., Harris J., Wheeler R., Weber R., Rosenthal D. I., Phuc F. N.-T., Westra W. H., Chung C. H., Jordan R. C., Lu C., Kim H., Axelrod R., Silverman C. C., Redmond K. P. & Gillison M. L. (2010)New England Journal of Medicine. Published online first http://www.nejm.org June 7, 2010 (10.1056/NEJMoa0912217).
Background Oropharyngeal squamous-cell carcinomas
caused by human papillomavirus (HPV) are associated with favourable survival, but the independent prognostic signifi-cance of tumour HPV status remains unknown.
Methods We performed a retrospective analysis of the associa-tion between tumour HPV status and survival among patients with stage III or IV oropharyngeal squamous-cell carcinoma
750 Current Literature
who were enrolled in a randomized trial comparing accelerated-fractionation radiotherapy (with acceleration by means of con-comitant boost radiotherapy) with standard-fractionation radiotherapy, each combined with cisplatin therapy, in patients with squamous-cell carcinoma of the head and neck. Proportional-hazards models were used to compare the risk of death among patients with HPV-positive cancer and those with HPV-negative cancer.
Results The median follow-up period was 4.8 years. The 3-year rate of overall survival was similar in the group receiving accelerated-fractionation radiotherapy and the group receiving standard-fractionation radiotherapy (70.3% vs. 64.3%;P=0.18;
hazard ratio for death with accelerated-fractionation radio-therapy, 0.90; 95% confidence interval, 0.72–1.13), as were the rates of high-grade acute and late toxic events. A total of 63.8% of patients with oropharyngeal cancer (206 of 323) had HPV-positive tumours; these patients had better 3-year rates of overall survival (82.4% vs. 57.1% among patients with HPV-negative tumours;P <0.001 by the log–rank test) and, after adjustment for age, race, tumour and nodal stage, tobacco expo-sure, and treatment assignment, had a 58% reduction in the risk of death (hazard ratio, 0.42; 95% confidence interval, 0.27– 0.66). The risk of death significantly increased with each
additional pack-year of tobacco smoking. Using recursive-partitioning analysis, we classified our patients as having a low, intermediate or high risk of death on the basis of four factors: HPV status, pack-years of tobacco smoking, tumour stage and nodal stage.
Conclusions Tumour HPV status is a strong and independent prognostic factor for survival among patients with oropharyn-geal cancer.
This is an unusual article to direct you to, but the intriguing and relevant paper is the accompanying editorial [Lowy D. R. & Munger K. Prognostic implications of HPV in oropharyngeal cancer. New England Journal of Medicine, published online first at http://www.nejm.org June 7, 2010 (10.1056/ NEJMe1003607)], which discusses the results of this trial and comments that, notwithstanding the better progress of the patients with HPV-positive oropharyngeal cancer from those who are HPV negative, 90% are associated with HPV type 16, a further 5% with type 18, both of which are covered by the quadrivalent HPV vaccine. Note that only type 16 is covered by the current UK vaccine. Although relatively rare, oropharyngeal squamous-cell carcinoma may change the health economic ben-efits of the current HPV vaccine strategy to a different vaccine and possibly to include boys.
Richard Reading
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