Recent Implications of Intrauterine and Postnatal Rubella

Many new facets of rubella virus infection, both natural and congenital, have been recently exposed. In its intrauterine role, the virus is curiously selective and it is possible that the genes of the fetus are important in determining both the occurrence and severity of infection. The risk to the fetus is highest if infection occurs in early pregnancy, but there is some risk up to 24 weeks gestation. Multiplicity of defects and chronic persistence of fetal infection are characteristic features of congenital rubella infection. The clinical manifestations, diagnosis and management of congenital rubella are discussed, with emphasis on the long term sequelae. Postnatal rubella may be difficult to diagnose, since many cases are subclinical and history is unreliable:— serological diagnosis is therefore critical during pregnancy. Vaccination programmes designed to prevent congenital rubella are evaluated; while these show promise, the ideal vaccine is yet to become available.     

Latex sensitization in spina bifida appears disease-associated

OBJECTIVE: The high prevalence of latex sensitization (up to 80%) in patients with spina bifida (SB) has been attributed to repeated exposure to latex products, whereas disease-associated factors have not been considered. METHODS: We compared children with SB (n = 21) and children with posthemorrhagic or congenital hydrocephalus (PH, n = 32), all of whom had a ventriculoperitoneal shunt since young age. Latex sensitization, number of operations, atopic history, and total IgE levels were evaluated. RESULTS: The following characteristics were recorded: age (SB: 52 months, range 1 to 264 months; PH: 71 months, range 1 to 192 months) and mean number of operations (SB: 2. 09; PH: 2.53). Of the SB group, 43% (9 of 21) showed elevated latex-specific IgE antibodies in contrast to 6% (2 of 32) in the PH group (P <.01). Latex-specific IgE antibodies were detected by 1 year of age, and one surgical operation was sufficient to induce latex-specific IgE-antibody production in patients with SB. CONCLUSIONS: The results suggest that the SB population bears a disease-associated propensity for latex sensitization. Sensitization to latex antigens may occur after the very first contact, arguing for latex avoidance measures from the very beginning of life.     

Tobacco smoke enhances allergic bronchial sensitization in the guinea pig

Passive smoking has been shown to cause increased incidence of lower respiratory tract infection and wheezing in young children and an inceased risk of childhood asthma. To evaluate possible influence of tobacco smoke on allergic bronchial sensitization we exposed guinea pigs to tobacco smoke in 3 concentrations of clean air (control group) for 8 h on 5 consecutive days (median plasma cotinine 5. 0—25. 4—87, 2 ng/l). The animals were sensitized by repeated inhalation with ovalbumin. Histologic examination at the end of exposure revealed reactive epithelial hyperplasia and regenerative changes as well as inflammatory reaction mainly in the lung periphery, and histamine provocation showed increased bronchial reactivity at the end of tobacco smoke exposure. Sensitization was measured by specific bronchial provocation testing using body plethysmographic measurement of compressed air (CA) and specific anti-ovalbumin-antibodies of the IgG₁-subclass in the serum, measured by direct ELISA in ELISA units (EU). The group with the highest tobacco smoke exposure differed significantly in bronchial reactivity on specific bronchial provocation tests (p < 0.005) compared with the control groups and showed elevated unspecific IgG₁-antibody levels indicating enhanced sensitization. We conclude that intensive exposure to tobacco smoke over a short period of 5 d can enhance inhalational allergic sensitization in the guinea pig and might explain the increased incidence of respiratory allergies in child passive smokers.     

Febrile Convulsions in Children, Their Frequency and Prognosis

In a series of 405 children with febrile convulsions, admitted to hospital between 1938 and 1953, 82 per cent had the first attack of febrile convulsions within the first 3 years of life, in most cases about the age of 18 months. Fifty-five per cent were boys.
In 63 per cent of the cases the fever had been caused by acute affections in the upper respiratory tract. — In 12.3 per cent the children were readmitted with febrile convulsions.— Forty per cent of all children under 7 years admitted during a 5-year period were febrile. Every ninth of these had febrile convulsions.
It was possible to follow up 77 per cent of the 405 children. — Sixty‐eight per cent of the children followed up had been in completely good health since their discharge. — Epilepsy had been confirmed in 3.8 per cent. — In 20 per cent of the cases there have been convulsions later on without epilepsy being diagnosed. About half the number of these children have, however, been characterized as nervous. — There have been no convulsions in about 9 per cent of the cases, but various mental difficulties have been present.
In conclusion 7 criteria are mentioned which are of importance in the differential diagnosis between febrile convulsions and epilepsy.     

Latex allergy risk assessment in children and adolescents with type I diabetes mellitus

An increased frequency of allergic reactions to latex has been reported in specific populations with chronic latex exposure. However, relevance of latex allergy to children and adolescents with type I diabetes mellitus (DM1) has not been studied yet. The aim of the studty is to assess latex allergy risk in children and adolescents with DM1. Thirty-nine children with DM1 and 35 controls were enrolled. In a case-control study, we applied to all subjects a standard questionnaire, and specific Immunoglobulin E (IgE) concentrations for latex, common aeroallergens, and food-allergens were measured in serum samples. Latex exposure rates by means of medical procedures, operations, and latex glove usage were not different between DM1 and controls. Symptoms due to latex exposure were not determined in both groups. Three (7.7%) subjects in DM1 tested positive for latex-specific antibodies (LSIE), whereas no subject in controls. Diabetics that tested positive for latex-specific antibodies had the disease for three, 5 and 8 years. Nine (23.1%) of diabetics, and two (5.7%) of controls were atopic (p = 0.04). In our investigation, we found that children and adolescents with DM1 are not a risk group for latex allergy, and LSIE in children with DM1 was not accompanied by symptoms of latex allergy, or, presumably, increased risk of latex anaphylaxis.     

Frequent IgE sensitization to latex, cow's milk, and egg in children with short bowel syndrome

Children with short bowel syndrome (SBS) undergo frequent operations, so they are at risk for sensitizing to latex. There have been isolated reports of sensitization to food in these children. In a cross-sectional study, we assessed sensitization to latex, cow's milk, and egg with skin prick tests (SPT) and serum-specific immunoglobulin E (IgE) in 14 children with SBS. Data were collected about the number of operations with latex devices, serum total IgE, and history of feeding with milk formula. Ten children were sensitized to latex (specific IgE median: 6.7 kU/l, range: 0.5–33). Compared with those non-sensitized, sensitized children had significantly (p < 0.05) higher levels of serum total IgE in z-units (mean rank 3.25 vs. 9.2, respectively), and more operations with latex devices (mean rank 3.75 vs. 9). Eight children were sensitized to cow's milk, one with only positive SPT, the other seven with serum-specific IgE (median: 3.5, range: 0.5–21.1 kU/l), and five to egg (specific IgE median: 0.68, range: 0.58–2.17 kU/l). Except for some isolated days with cow's milk formula, the children had been initially fed with a diet without intact cow's milk proteins. Sensitization to latex, cow's milk, and egg is very frequent in children with SBS. They should be treated in a latex-free environment since the very early stages of the disease, and should be routinely studied regarding food sensitization, as this might contribute as an added factor in the chronic diarrhea of these patients.     

Sensitivity and specificity of different skin prick tests with latex extracts in pediatric patients with suspected natural rubber latex allergy – A cohort study

Skin prick tests (SPT) with latex extracts are commonly used in the diagnostic approach of natural rubber latex (NRL) allergy. Non‐ammoniated latex extracts are commonly utilized for this purpose. There is only one commercially available ammoniated latex extract for both diagnostic and therapeutic purposes. To our knowledge, no direct clinical comparisons have been made so far comparing sensitivity and specificity of different latex extracts in patients with clinically confirmed latex allergy. The objective of this study was to evaluate sensitivity and specificity of non‐ammoniated or ammoniated SPT of latex extracts in children with a clinical history suggestive of NRL allergy. Forty‐two subjects (age 4–15 yr), referred to our Allergy Clinic Center, with suspected clinical signs of NRL allergy were evaluated. Patients were selected according to the following inclusion criteria: pediatric patients of age above 4 yr with a suspected clinical history of urticaria, rhinoconjunctivitis and/or asthma due to sensitization to NRL. A definitive NRL allergy diagnosis was made on the identification of latex‐specific IgE (>0.7 kU/l), positive glove use test and a highly indicative clinical history. NRL allergy was confirmed in 26 (62%) subjects. SPT for latex were performed with three different SPT solutions containing non‐ammoniated NRL extracts (product A: Lofarma SpA, Milan, Italy and product B: Stallergenes, Milan, Italy) or an ammoniated extract (product C: ALK‐Abellò, Madrid, Spain). A positive result was considered as the appearance of a wheal with a diameter >3 mm. In patients with confirmed NRL allergy, wheal mean (s.d.) diameters were 7.3 (2.1) with product C, and 5.7 (2.3) and 4.4 (1.8) with products B and A respectively (p = 0.004 C vs. B and A). Mean wheal diameters were significantly higher for product C in comparison with product B and A (p < 0.04). Sensitivity according to the different products tested was 65% (product A); 81% (product B) and 96% (product C) (p = 0.0084; C vs. A). No difference between the three products was observed regarding diagnostic specificity (94%, 88% and 94%, product A, B and C, respectively). Our study shows that diagnostic sensitivity of different latex extract for SPT could differ. In this particular clinical setting (i.e., children with NRL allergy) ammoniated latex extract shows a higher sensitivity in comparison with non‐ammoniated products. This aspect should be considered in the diagnostic approach in subjects with suspected NRL allergy. In children with clinical confirmed latex allergy, sensitivity and specificity of different commercially available skin prick test could vary. Ammoniated latex extract has shown a higher sensibility in comparison with non‐ammoniated products.     

ELEVATION OF CONGENITAL DEPRESSED FRACTURES OF THE SKULL BY THE VACUUM EXTRACTOR

ABSTRACT. Tan. K. L. (Department of Paediatrics, University of Singapore, Singapore). Elevation of congenital depressed fractures of the skull by the vacuum extractor. Ada Paediatr Scand 63: 562, 1974.—The vacuum extractor has been found to be effective in elevating depressed fractures of the skull, especially those of some duration. Two cases are reported to illustrate this procedure. No ill effects have been encountered.     

Antiglobulin antibody in the sera of contacts of children with leukaemia.

Healthy adults (parents, neighbours, and hospital staff) in close contact with children with leukaemia were found to have a high incidence of positive latex agglutination antiglobulin tests (probably an IgM antiglobulin antibody). This may explain a previous report of a high incidence of IgM anti-EB virus antibodies in parents of leukaemic children, which our results did not confirm (IgM antiglobulin, reacting with IgG anti-EB virus, could have been misinterpreted as IgM anti-EB virus). The antiglobulin antibody probably represents a nonspecific response to an infective agent. Other hospital staff, including those exposed to nonleukaemic children with infections, had a much lower incidence of the antibody, and it may represent a response to the leukaemic process itself, rather than to the infections to which such children are prone. Some leukaemic children have a similar antibody.     

TRACE METAL REQUIREMENTS OF PRETERM INFANTS

Shaw, J.C.L. (Department or Paediatrics, University College, London, U.K.). Trace metal requirements of preterm infants. Acta Paediatr Scand, Suppl. 296: 93, 1982. — The elements zinc, copper, manganese, molybdenum, selenium and chromium are considered to be essential nutrients in man. It is known that they cross the placenta because they are all present in fetal bodies where they are presumably necessary for normal growth and development. Though deficiency of copper, zinc, selenium and chromium have been reported in man only copper and zinc deficiency have been described in premature infants. Typically, the deficiency develops late (between 3–6 months of age), at a time when the concentration in breastmilk is falling and before a mixed diet has been introduced.This late onset, together with data on body composition, suggests that preterm infants are born with stores — albeit small — of copper and zinc, as they are with iron. The stores may be depleted to a variable extent following birth by dietary insufficiency (particularly total parenteral nutrition), malabsorption and diarrhoea. This leads to severe deficiency in some infants and possibly less severe deficiency in many more, which may pass unrecognised because of difficulties in diagnosis. Dietary provision of a trace element should have two purposes. It should be sufficient to prevent the development of a deficiency state, and to provide enough to enable stores to be formed so that deficiency does not immediately occur if the diet is temporarily inadequate. No case of manganese, molybdenum, selenium or chromium deficiency has yet been described in preterm infants, but no systematic search for deficiency of these elements has yet been undertaken.     

Sensitivity and allergy to latex in atopic and non-atopic children

To study the sensitivity and allergy to latex in children, we investigated sera of 306 atopic md 303 non-atopic children (median age 4. 5 years) for specif-ic IgE to latex. In patients with specific IgE to latex, a questionnaire was sent to families and provocation tests were carried out. 60/306 atopic children (20. 8%) and 1/303 non-atopic children (0. 3 %) showed specific IgE to latex in serum. The proportion of atopic. latex-sensitized and provocation positive children was 12/48 (25 %). Specific IgE to latex was significantly higher (p < 0.03) in symptomatic compared to non-symptomatic patients. Specificity of a positive history was 92 %, sensitivity 50 %. Atopic dermati-tis tended to be more prevalent among the 12 provocation positive atopic children (75 %) compared to 36 provocation negative children (58 %). There was a tendency that children of the symptomatic group underwent surgical interventions more frequently compared to non-symptomatic children. In conclusion, latex sensitization and latex allergy seem to have oc-cured more often in atopic children than previously known. Risk factors for the development of a sensitization to latex are atopy and the clinical diagno-sis of atopic dermatitis; risk factors for a clinically manifest allergy to latex are an elevated specific IgE to latex, a positive history upon contact to mate-rial containing latex and probably frequent operations. Provocation tests should be performed to plan avoidance measures in latex-allergic children especially before surgical interventions.     

RELAPSE RATE AFTER CESSATION OF THERAPY IN CHILDHOOD LEUKEMIA

Abstract. Johansen, O. J. & Moe, P. J. (Department of Paediatrics, University of Trondheim, Norway). Relapse rate after cessation of therapy in childhood leukemia. A follow-up report on 277 cases from the five Nordic countries. Acta Paediatr Scand, 69: 663, 1980. —Two hundred and seventy-seven children from the Nordic countries who had their antileukemic therapy stopped before January 1979 were surveyed. The children were in remission when therapy was discontinued. So far 64 (23.1%) have relapsed. Central nervous system (CNS) and testicular leukemia have been a problem, but CNS-prophylaxis has been in common use in the Nordic countries only since 1972–1973. Most of the patients relapsed during the first year after stopping therapy, whereas no patient relapsed later than 4 years after cessation of therapy.     

Latex allergy in patients with myelomeningocele presenting for imaging studies of the urinary tract

Objective. We prospectively surveyed patients with myelomeningocele who presented in our department over a 3-month period to determine the frequency of latex allergy in this population.Materials and methods. A questionnaire assessed history of allergy to latex and attitudes toward and use or avoidance of latex-containing products in both medical and non-medical environments. Results. Surveys were completed by 118 patients (56 boys, 62 girls; mean age 10.4 years, range 0.6–30.9 years). Seventy-two (61 %) had heard of latex allergy and 25 (21 %) reported being allergic to latex. Most allergic patients were performing intermittent self-catheterization (92 %) and tended to be slightly older (mean age 12.7 years) than those not reporting allergy (mean age 9.8 years). Although most reactions were limited to rashes and mucosal irritation, two patients experienced anaphylaxis with severe respiratory symptoms or hypotension or both. No reactions had occurred in the Department of Radiology. While 84 % of patients with previous allergic reactions reported trying to avoid further exposure to latex in the hospital, at home, or in school, only 14 % of non-allergic patients took any special precautions. Conclusion. Allergy to latex is common in patients with myelomeningocele who are examined in our department. We have developed a policy designed to prevent exposure of such patients to latex during imaging studies.     

Influences of maternal cigarette smoking on infant arousability

Since the reduction in the incidence of the prone sleeping position, maternal cigarette smoking has become the strongest modifiable risk factor for Sudden Infant Death Syndrome (SIDS). This risk is dose dependent. Various mechanisms have been postulated to explain the increased risk of SIDS associated with maternal smoking, among these, impairment of arousal from sleep. This paper reviews the effects of maternal smoking on infant arousability from sleep, cardiorespiratory controls and sleep architecture. Infants exposed to maternal smoking have been shown to have both decreased spontaneous and evoked arousability from sleep. Such impairment of arousal has been demonstrated to be associated with changes in control of autonomic cardiac function. Sleep architecture appears not to be altered by smoking. During arousal, heart rate, blood pressure and breathing movements increase, while gross body movements occur to avoid the stimulus. Any impairment in arousability from sleep could occur when infants are exposed to maternal cigarette smoking, and could possibly contribute to the final pathway to SIDS.     

Treatment of neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is suffered by infants withdrawing from substances on which they have become physically dependent after in utero exposure. They may require prolonged treatment and spend weeks or even months in hospital. A wide range of drugs have been used to treat NAS. The efficacy of few, however, have been adequately investigated. Evidence suggests that opioids are the most appropriate, at least in infants exposed to diamorphine or methadone. In all "head to head" trials, diazepam has been shown to be ineffective. Morphine and methadone are currently the most commonly prescribed opioids to treat NAS, but randomised trials have not been undertaken to determine which is the more beneficial. Many infants with NAS have been exposed to multiple substances in utero. Further research is required into whether a single opiate or a multiple drug regimen is the best option for such patients.     

DOWN'S SYNDROME IN SWEDEN An Epidemiological Study of a Three-year Materiral

ABSTRACT. Lindsjö, A. (Department of Drugs, National Board of Health and Welfare, Stnckholm, Sweden). Down's syndrome in Sweden — an epidemiological study of a three-year material. Acta Paediatr Scand, 63: 571, 1974.—A continuous, exact monitoring of the incidence of congenital chromosomal disorders is of great interest for the study of the possible significance of exogenous agents in the origin of various Chromosome aberrations. An investigation of the incidence of Down's syndrome in Sweden has been carried out covering the years 1968–70. The total incidence (1:755) was found to he lower than in earlier Swedish investigations. This is probably due to a reduction in the mean maternal age at childbirth. The earlier, characteristic bimodal distribution of maternal age at the birth of children with Down's syndrome has now been reversed. The age-specific incidences showed significantly higher values for the maternal age groups 2629 and more than 40 years in comparison with two earlier extensive surveys from the United Kingdom and Australia. A higher confirmation efficiency due to reports from cytogenetic laboratories may also possibly have contributed to the higher Swedish figures. From 1971 onward, Down's syndrome will be reported to the Swedish register of congenital malformations, so that changes in the incidence can be continuously observed. The investigation demonstrates the difficulty in comparing incidence figures from different time periods of a disease, the origin of which is dependent on maternal age.     

Natural rubber latex allergy: prevalence and risk factors in patients with spina bifida compared with atopic children and controls

Type 1 allergy against natural rubber latex is an increasing problem in health care workers and children with spina bifida or urogenital malformations. The aim of our study was to evaluate the prevalence of latex IgE antibodies and cross-reacting fruit antibodies in patients with spina bifida compared with atopic and non-atopic controls. Risk factors for sensitization should be determined. Sera of 148 patients with spina bifida and 98 controls (44 with atopy) were screened for IgE antibodies against latex, banana and kiwi by fluorescence enzyme immunoassay (CAP system). Atopies, allergic symptoms after latex contacts and the number of operations were compiled by a questionnaire. Patients with spina bifida developed latex IgE antibodies (≥0.7 kU/l) more frequently (40.5%) than atopic children (11.4%) or healthy controls (1.9%). All 18 symptomatic patients belonged to the spina bifida group and had high values of latex antibodies. The risk for developing latex antibodies increases with the number of operations. There was no difference in the history of atopic diseases and in a screening test of IgE antibodies against inhalative allergens between latex sensitized and not sensitized children with spina bifida. Antibodies against banana were more frequent in the latex sensitized children with spina bifida. (18.3% vs 3.4%, P = 0.002). Conclusion The high prevalence of latex antibodies in children with spina bifida justifies a primary prophylaxis by avoiding latex contacts, especially during anaesthesia and surgery, a correlation between the number of operations and the development of latex antibodies exists. Received: 30 March 1996 and in revised form: 19 March 1997 / Accepted: 20 March 1997     

Prevalence of latex sensitization and allergy in Portuguese children

The prevalence of latex allergy has been increasing not only in risk groups but also in the general population, where it is accepted to average 1%. In children, latex sensitization prevalence studies are scarce and involve different population sampling and allergy testing methods, which makes it difficult to compare across studies. Nevertheless, existing studies point towards a low prevalence of latex allergy in children, which still needs to be confirmed in the Portuguese population. Aiming at studying the prevalence of latex sensitization and allergy in a sample of Portuguese children, we studied 182 children from two different hospital outpatient clinics. A standardized questionnaire focusing on atopic background, previous history and allergic signs or symptoms on exposure to latex or fruits was given to all children and parents. Skin prick testing was performed with a battery of common aeroallergens as well as latex. Serum total IgE, Phadiatop, F x 5E and latex-specific IgE were determined in all children. Specific IgE to latex-crossreacting fruits was determined in latex-sensitized children. Based upon the questionnaire, the prevalence of latex allergy would be 0.5%. The prevalence of latex sensitization would be 3.8%, when based solely upon skin prick testing, and 12.1% (>/=0.35 IU/ml) or 6.6% (>/=0.70 IU/ml) when based singly upon determination of latex-specific IgE. When positive results for either test were considered, the prevalence of latex sensitization was 14.3%. All latex-sensitized children were atopic. Sensitivity to latex-crossreacting foodstuffs was demonstrated in 61.5% of latex-sensitized children (16/26). This study shows that the prevalence of latex allergy and sensitization in Portuguese atopic and non-atopic children, as analysed using various diagnostic methods, is similar to that observed in other countries. In addition, the assessment of latex allergy and sensitization should always include skin prick testing and determination of serum IgE.     

Latex type I sensitization and allergy in children with atopic dermatitis. Evaluation of cross‐reactivity to some foods

Recent studies have demonstrated that allergy to natural rubber latex (NRL) is associated with cross-reactivity to certain foods. The aim of this study was to investigate the prevalence of NRL sensitization and allergy in children with atopic dermatitis (n=74). We also examined cross-reactions between latex and foods, and compared the frequency of suspected latex cross-reacting fruits in children with and without NRL-specific immunoglobulin E (IgE). Twelve of the 74 atopic children studied (16.2%; 95% confidence interval (CI), 8.7–26.6%) had circulating IgE antibodies to latex. These NRL-sensitized children were older and they showed significantly higher total IgE values (p<0.003) when compared with the group of children without NRL sensitization. Of the specific food IgE evaluations, 18.4% (93 out of 505) were positive, and 69.9% were observed in the group of children with latex-specific IgE, most frequently to potato, tomato, sweet pepper, and avocado. An isolated latex-specific IgE response without food-specific IgE was never observed. Exclusively in the latex-positive group, conformity with the report of allergic symptoms after ingestion of food and increased food-specific IgE was found. Twenty children without proven latex sensitization showed increased food-specific IgE, most frequently to potato, banana, and chestnut. Avocado-specific IgE was never determined in this patient group. No significant differences were detected concerning the sensitization to potato, banana, and kiwi between NRL-sensitized children and the group of 20 children without latex-specific IgE. The competitive CAP inhibition using sera from children with specific IgE to both latex and food showed different cross-reactivities between latex and the specific food. A close relationship existed between latex and avocado (median inhibition: 100%), whereas sensitization to latex and kiwi seemed to be independent in our study group (inhibition: <25%). In particular, for potato, cross-reactivity and co-sensitization existed. Our study demonstrated that children with atopic dermatitis are a high-risk group for latex sensitization. Increasing age, additional sensitization to ubiquitous inhaled allergens, and enhanced total serum IgE values seemed to be important variables for latex sensitization and further sensitization to the latex-associated foods. Cross-reactivity and, in some cases, co-sensitization to specific fruits and vegetables, were observed.     

A HYDRAULIC MULTIPLE INTESTINAL BIOPSY APPARATUS FOR INFANTS

ABSTRACT. Meeuwisse, G. W., Lindberg, T. and Blomberg, M. (Departments of Paediatrics of Lund and Malmö, and the Department of Medical Engineering of the Hospital of Lund, University of Lund, Sweden). A hydraulic multiple intestinal biopsy apparatus for infants. Acta Paediatr Scand, 63: 839, 1974.—A small hydraulic multiple-biopsy instrument (Ø 3.8 mm, length 9 mm) for infants and children has been developed. The small size, the small hole in the capsule (Ø 1.65 mm), the possibility to regulate the vacuum by which mucosa is sucked into the capsule, and the flexibility of the tube make it useful even for small infants. 1674 biopsies have been taken on 393 occasions. The failure rate was low, on six occasions the biopsy procedure failed, but a biopsy was obtained on a second attempt. There was one complication: an intestinal perforation.