Exposure to antibiotics in the first 24 months of life and neurocognitive outcomes at 11 years of age.

RATIONALE: Antibiotics are commonly prescribed for infants. In addition to increasing concern about antibiotic resistance, there is a concern about the potential negative impact of antibiotics on the gut microbiota and health and development outcomes. OBJECTIVE: The aim of this study was to investigate the association between early life antibiotic exposure and later neurocognitive outcomes. METHODS: Participants were infants born to mothers enrolled in the probiotics study. The initial study was designed to evaluate the effect of two different probiotics on allergy outcomes in childhood. Antibiotic exposure was based on parent report and categorised according to the following timing of the first exposure: 0-6 months, 6-12 months, 12-24 months or not at all. At 11 years of age, children's neurocognitive outcomes were assessed using psychologist-administered, parent-report and self-report measures. The relationship between the timing of antibiotic exposure and neurocognitive outcomes was examined using regression models. RESULTS: Of the 474 participants initially enrolled, 342 (72%) children had a neurocognitive assessment at 11 years of age. After adjustment for mode of delivery, probiotic treatment group assignment, income and breastfeeding, children who had received antibiotics in the first 6 months of life had significantly lower overall cognitive and verbal comprehension abilities, increased risk of problems with metacognition, executive function, impulsivity, hyperactivity, attention-deficit hyperactivity disorder, anxiety and emotional problems. CONCLUSIONS: These results provide further evidence that early exposure to antibiotics may be associated with detrimental neurodevelopmental outcomes.

Differential modification of genetic susceptibility to childhood eczema by two probiotics.

BACKGROUND: In a double-blind, randomized, placebo-controlled birth cohort, we have recently shown a beneficial effect of Lactobacillus rhamnosus HN001 (HN001) for the prevention of eczema in children through to 6 years of age but no effect of Bifidobacterium animalis subsp lactis HN019 (HN019). OBJECTIVE: Among this cohort of children, we aim to investigate whether these probiotics could modify the expression of genetic predisposition to eczema conferred by genetic variation in susceptibility genes. METHODS: Thirty-three eczema susceptibility SNPs (in eleven genes) were genotyped in 331 children of European ancestry. RESULTS: Children who carried a genetic variant that put them at a high risk of developing eczema were less likely to develop eczema if they had been randomized to the HN001 intervention group compared to those in the placebo group. HN019 was also able to protect against the effects of some SNPs. As well as modifying genetic susceptibility to childhood eczema, HN001 was also found to modify genetic susceptibility to eczema severity and atopy risk. CONCLUSION AND CLINICAL RELEVANCE: This is the first study to show an effect of a probiotic on reducing eczema risk amongst those with particular eczema-associated genotypes. Our findings suggest that Lactobacillus rhamnosus HN001 may be particularly effective in preventing eczema in children with specific high-risk genotypes.

Early supplementation with Lactobacillus rhamnosus HN001 reduces eczema prevalence to 6 years: does it also reduce atopic sensitization?

BACKGROUND: The role of probiotics in prevention of allergic disease is still not clear; efficacy may depend on the timing, dose, duration, and specific probiotic used. Using a double-blind randomized placebo-controlled trial (Australian New Zealand Clinical Trials Registry: ACTRN12607000518460), we have shown that in a high-risk birth cohort, maternal supplementation from 35 weeks gestation until 6 months if breastfeeding and infant supplementation from birth until 2 years with Lactobacillus rhamnosus HN001 (HN001) (6 × 10(9) cfu/day) halved the cumulative prevalence of eczema at 2 and 4 years. Bifidobacterium animalis subsp lactis HN019 (HN019) (9 × 10(9) cfu/day) had no significant effect. OBJECTIVE: To determine whether differences in effects of HN001 and HN019 on eczema persist to age 6 years, and to investigate effects on sensitization. METHODS: Standard procedures were used to assess eczema (The UK Working Party's Criteria), eczema severity (SCORAD), atopic sensitization [skin prick tests (SPT), total and specific IgE] and standard questions used for asthma, wheeze, and rhinoconjunctivitis. RESULTS: HN001 was associated with significantly lower cumulative prevalence of eczema (HR = 0.56, 95% CI 0.39-0.80), SCORAD ≥ 10 (HR = 0.69, 0.49-0.98) and SPT sensitization (HR = 0.69, 95% CI 0.48-0.99). The point prevalence of eczema (RR = 0.66, 95% CI 0.44-1.00), SCORAD ≥ 10 (RR = 0.62, 95% CI 0.38-1.01) and SPT sensitization (RR = 0.72, 95% CI 0.53-1.00) were also reduced among children taking HN001. HN019 had no significant effect on any outcome. CONCLUSION AND CLINICAL RELEVANCE: This study provides evidence for the efficacy of the probiotic L. rhamnosus HN001 in preventing the development of eczema and possibly also atopic sensitization in high risk infants to age 6 years. The absence of a similar effect for HN019 indicates that benefits may be species specific.

A protective effect of Lactobacillus rhamnosus HN001 against eczema in the first 2 years of life persists to age 4 years.

BACKGROUND: Using a double blind randomized placebo-controlled trial (Australian New Zealand Clinical Trials Registry: ACTRN12607000518460), we have shown that in a high risk birth cohort, maternal supplementation from 35 weeks gestation until 6 months if breastfeeding and infant supplementation until 2 years with Lactobacillus rhamnosus HN001 (HN001) (6 × 10(9) cfu/day) halved the cumulative prevalence of eczema by age 2 years. Bifidobacterium animalis subsp lactis HN019 (HN019) (9 × 10(9) cfu/day) had no effect. OBJECTIVE: The aim of this study was to investigate the associations of HN001 and HN019 with allergic disease and atopic sensitization among these children at age 4 years, 2 years after stopping probiotic supplementation. METHODS: The presence (UK Working Party's Diagnostic Criteria) and severity SCORing Atopic Dermatitis (SCORAD) of eczema and atopy (skin prick tests) and parent-reported symptoms of asthma and rhinoconjunctivitis were assessed using standard protocols and questions. RESULTS: Four-hundred and seventy-four infants were eligible at birth of whom 425 (90%) participated in this follow-up. The cumulative prevalence of eczema by 4 years (Hazard ratio (HR) 0.57 (95% CI 0.39-0.83)) and prevalence of rhinoconjunctivitis at 4 years (Relative risk 0.38 (95% CI 0.18-0.83)) were significantly reduced in the children taking HN001; there were also nonsignificant reductions in the cumulative prevalence of SCORAD ≥ 10 (HR 0.74 (95% CI 0.52-1.05), wheeze (HR 0.79 (95% CI 0.59-1.07)) and atopic sensitization (HR = 0.72 (95% CI 0.48-1.06)). HN019 did not affect the prevalence of any outcome. CONCLUSIONS AND CLINICAL RELEVANCE: This study showed that the protective effect of HN001 against eczema, when given for the first 2 years of life only, extended to at least 4 years of age. This, together with our findings for a protective effect against rhinoconjunctivitis, suggests that this probiotic might be an appropriate preventative intervention for high risk infants.

Supplementation with Lactobacillus rhamnosus or Bifidobacterium lactis probiotics in pregnancy increases cord blood interferon-gamma and breast milk transforming growth factor-beta and immunoglobin A detection.

BACKGROUND: This study explored the effects of maternal probiotic supplementation on immune markers in cord blood (CB) and breast milk. METHODS: CB plasma and breast milk samples were collected from a cohort of women who had received daily supplements of either 6 x 10(9) CFU/day Lactobacillus rhamnosus HN001 (n=34), 9 x 10(9) CFU/day Bifidobacterium lactis HN019 (n=35) or a placebo (n=36) beginning 2-5 weeks before delivery and continuing for 6 months in lactating women. CB plasma and breast milk (collected at 3-7 days, 3 months and 6 months postpartum) were assayed for cytokines (IL-13, IFN-gamma, IL-6, TNF-alpha, IL-10, TGF-beta1) and sCD14. Breast milk samples were also assayed for total IgA. RESULTS: Neonates of mothers who received a probiotic had higher CB IFN-gamma levels (P=0.026), and a higher proportion had detectable blood IFN-gamma levels, compared with the placebo group (P=0.034), although levels were undetectable in many infants. While this pattern was evident for both probiotics, when examined separately only the L. rhamnosus HN001 group showed statistically significant higher IFN-gamma levels (P=0.030) compared with the placebo group. TGF-beta1 levels were higher in early breast milk (week 1) from the probiotic groups (P=0.028). This was evident for the B. lactis HN019 group (P=0.041) with a parallel trend in the L. rhamnosus HN001 group (P=0.075). Similar patterns were seen for breast milk IgA, which was more readily detected in breast milk from both the B. lactis HN019 (P=0.008) and the L. rhamnosus HN001 group (P=0.011). Neonatal plasma sCD14 levels were lower in the B. lactis HN019 group compared with the placebo group (P=0.041). CONCLUSION: The findings suggest that supplementation with probiotics in pregnancy has the potential to influence fetal immune parameters as well as immunomodulatory factors in breast milk.

Idiopathic intracranial hypertension presenting as hemiplegic migraine.

UNLABELLED: A 14-y-old girl presented with a 2 h history of left hemiplegia preceded by mild left-sided sensory disturbance. She had experienced migraines for several years and there was a strong family history of migraine, including hemiplegic migraine in one of her sisters. Her hemiplegia and headache responded to sumatriptan but her headache and vomiting subsequently returned. She was found to have intracranial hypertension and developed papilloedema and paracentral scotomas. Further history revealed she had been taking minocycline for acne. CONCLUSION: An association between hemiplegic migraine and pseudotumour cerebri has not previously been reported. There may be a case for examining patients with pseudotumour cerebri for the calcium channel mutation (CACNA1A).

Classical Kawasaki disease in a neonate.

A case is reported of classical Kawasaki disease in an infant younger than 2 weeks of age. Echocardiography detected a coronary artery aneurysm on the fifth day of the illness. Administration of intravenous gamma globulin resulted in rapid improvement. Kawasaki disease is rare in neonates, but it may follow a rapid and severe course.

A case of kernicterus in New Zealand: a predictable tragedy?

A case of neonatal kernicterus due to glucose-6-phosphate dehydrogenase deficiency (G6PD) is described. Diagnosis was delayed as the primary healthcare attendant had no knowledge of this condition and its potential to cause rapidly escalating levels of bilirubin and as she was reassured by the lack of signs of systemic illness or anaemia. The baby has been left deaf, blind, intellectually handicapped, epileptic and paralysed due to athetoid cerebral palsy. The re-organization of perinatal care in New Zealand, which has led to neonates sometimes being managed solely by primary healthcare attendants with minimal training in paediatrics may have increased the risk of a late diagnosis of potentially devastating diseases such as this.

Haemophilus influenzae type b cellulitis.

Five cases of cellulitis due to H influenzae type b in children are described. Cellulitis due to H influenzae type b should be treated in hospital using parenteral antibiotics in appropriate dosage to cross the blood brain barrier; it is recommended a lumbar puncture is performed in all cases of cellulitis in under two year olds, both to exclude meningitis and to allow the giving of steroids immediately prior to starting the first dose of antibiotics. Index cases and close contacts should be offered chemoprophylaxis to prevent spread of the organism. It seems likely that a vaccine against H influenzae b, effective in under two year olds, will become available in the next few years.

Viral and bacterial infection in childhood: the value of C reactive protein.

In 199 children with acute infections admitted to an acute general paediatric ward, the serum C reactive protein (CRP) level, using a simple latex agglutination kit, was compared with standard haematological parameters in distinguishing children with viral and bacterial infections. CRP levels proved superior to any haematological parameters singly or in combination in distinguishing these groups. A CRP level of 1:4 identified all but 13% of children with viral infections and excluded all but 15% of children with bacterial infections. The sensitivity of the test was 87%, the specificity 85%. The positive and negative predictive values were 95% and 74% respectively. Combined haematology, using total white cell count, total neutrophil count and percentage neutrophils, misclassified 26% of patients. CRP estimation could potentially help reduce unnecessary antibiotic prescription and shorten hospitalisation in febrile children. Its use in a general practice setting deserves further study.

Rett syndrome: case reports and review.

Rett syndrome consists of a progressive encephalopathy and psychomotor deterioration in young females who have appeared clinically normal until between six and eighteen months of age. The syndrome has incidence similar to that of phenylketonuria and autism in females. It has been widely recognised only since 1983. After six months of age head growth decelerates associated eventually with severe dementia, and autism, apraxia, stereotypic "hand washing" movements and loss of previously acquired skills occurs. Supportive symptoms may include breathing dysfunction, seizures, EEG abnormalities, and growth retardation. Occurrence indicates sporadic new mutations as a cause. The case histories of two patients diagnosed in New Zealand are described.

Results of a mass screening program for colorectal cancer.

Following a series of educational newscasts about colorectal cancer that were aired on a local television news program, stool guaiac slide kits were distributed on request to 72,000 persons in Memphis. One or more slides were positive In 1310 (6%) of the 23,000 kits returned. Of the 1310 individuals with positive cultures, 597 (45%) saw a physician for further evaluation. Sixty-five of these persons received inadequate evaluations. Of the 532 individuals (90%) who received adequate evaluations, 154 (26%) had no evidence of pathology that would account for occult blood. Of the remaining 443 persons, 26 were found to have colorectal cancer, and 20 of these 26 persons were found to have surgically amenable lesions (Dukes' stages A through B2). In addition, 67 potentially precancerous polyps were found. Mass screening for colorectal cancer using guaiac slide tests, coupled with patient compliance for a screening protocol and adequate follow-up evaluation, has the potential to identify and treat early colorectal cancer.