Femoral growth lines: bony birthmarks in infants.

OBJECTIVE: During a study of infants who were being examined for antenatal renal dilatation, we noted that many had growth lines in their proximal femur on postnatal radiographs. We decided to determine the prevalence of growth lines in healthy infants. MATERIALS AND METHODS: Voiding cystourethrograms of 791 neonates and infants, 0-6 months old, were reviewed. All who had documented severe illness or no reasonable view of the proximal femur were excluded, resulting in a cohort of 633 healthy infants. Each study was coded for presence or absence of a growth line in the proximal femur, and the distance of the growth line from the metaphyseal edge was measured to the nearest 0.5 mm. Radiographs were obtained on a unit with fixed tube-film distance. Data on the mode of delivery were collected for 136 infants. RESULTS: Of 633 eligible infants, 247 (39%) of 633 had a discernible growth line. The distance of the growth line from the metaphysis, in millimeters, correlated significantly with age in days (r = .81, p < .01). Infants delivered vaginally were more likely to have a growth line than were those born by cesarean delivery (p = .049). CONCLUSION: A growth line in the proximal femur is common in healthy infants. The rate of longitudinal growth of the proximal femoral metaphysis, on radiographs, is approximately 1 mm per 11 days (1 mm per 13 days when corrected for magnification). Approximation of the timing of prenatal and postnatal stressful events that result in a growth disturbance line may be possible.

Chickenpox immunisation in New Zealand.

PREVENTION: The appropriate use of varicella vaccine, effective in the prevention of chickenpox, has been considered by a Ministry of Health Working Party in 1996 and 1997, including discussion at a workshop held in Wellington, 26-27 June 1996. The introduction of varicella vaccine into the routine childhood immunisation schedule was not supported at this stage. The use of the only varicella vaccine for which the Minister of Health has given consent for distribution in New Zealand, Varilrix (SmithKline Beecham Limited), in healthy children aged nine months to 13 years inclusive, was supported. Consent has not been given for the use of Varilrix in immunocompromised people or in adults. This report discusses other groups that could be candidates for vaccination, such as children with deteriorating renal function and susceptible health care workers who regularly come into contact with especially vulnerable patients. In these cases, the vaccine would need to be administered on a named patient basis. The use of Varilrix in immunocompromised people was not supported. SURVEILLANCE: Enhanced surveillance of chickenpox and zoster are required in New Zealand. Adverse reactions to Varilrix should be carefully monitored. OUTBREAK CONTROL: There are insufficient data at present to support the use of Varilrix in outbreak control. The frequency, cost and current management of nosocomial outbreaks should be ascertained. This information may also assist in the decision whether to incorporate a varicella vaccine into the routine childhood immunisation schedule in the future.

Comparison of ceftriaxone and trimethoprim-sulfamethoxazole for acute otitis media. Greater Boston Otitis Media Study Group.

OBJECTIVE: The purpose of this prospective, randomized, single-blind trial was to assess the clinical efficacy of a single intramuscular dose of ceftriaxone compared with 10 days of oral trimethoprim-sulfamethoxazole (TMP-SMZ) in treating acute otitis media (AOM). METHODS: Children aged 3 months through 3 years diagnosed with AOM (signs of acute illness plus evidence of middle-ear effusion) were randomized to treatment with either a single intramuscular dose of ceftriaxone (maximum dose of 50 mg/kg) or 10 days of oral trimethoprim-sulfamethoxazole (8 mg of TMP and 40 mg of SMZ/kg/day in two divided doses). Children were evaluated at scheduled visits on days 3, 14, and 28, and the parents were telephoned on day 5. Children were assessed as cured, improved, or failed on day 3, and as cured or failed on days 14 and 28. Children ill at other times during the study period were, if possible, seen and assessed by the study team. RESULTS: Of 596 children enrolled during the study period, 484 were evaluable. Characteristics of evaluable subjects did not differ significantly by drug. On day 3, 223/241 children in the ceftriaxone group (92.5%) and 231/243 (95.1%) in the TMP-SMZ group were cured or improved. On day 14, 158/197 (80.2%) in the ceftriaxone group and 174/212 (82.1%) in the TMP-SMZ group were cured. On day 28, 108/136 (79.4%) in the ceftriaxone group and 124/155 (80%) in the TMP-SMZ group were cured. Persistence of middle-ear fluid did not differ between groups at day 14 (55% in the ceftriaxone group vs 47% in the TMP-SMZ group; P = .16) or at day 28 (39% vs 43%; P = .48). Pain at the injection site persisting at day 3 occurred in 8.4% of children receiving ceftriaxone. New diarrhea was more common in the ceftriaxone group (23.6% vs 9.2%; P < .001). CONCLUSION: A single intramuscular dose of ceftriaxone is comparable in clinical efficacy to 10 days of oral TMP-SMZ for treatment of AOM.

Serious bacterial infections in febrile infants and children selected for lumbar puncture.

Lumbar puncture (LP) is performed frequently in pediatric emergency departments to diagnose meningitis in infants and young children with fever. Children selected to have LP who do not have meningitis may, however, have other serious bacterial infections. We surveyed lumbar punctures performed in the Boston City Hospital Pediatric Emergency Department and monitored the incidence of meningitis and other serious bacterial infections. Meningitis was diagnosed in 8% of children who underwent LP. An additional 10.5% of children who underwent LP and had normal cerebrospinal fluid had positive cultures of blood (3.1%), urine (4.1%) or stool (3.3%). The decision to perform lumbar puncture identifies children at risk of having not only meningitis but other serious bacterial illnesses. Those children 2 years of age and younger with normal cerebrospinal fluid should be considered for cultures of blood, urine and possibly stool.

Neurocysticercosis in a child with no history of travel outside the continental United States.

We present a case of neurocysticercosis in a 16-month-old girl who had no history of travel outside the continental United States. Immunoblot assays of serum and CSF were both reactive. The patient's father was found to be shedding Taenia ova in his stools, a finding that suggested direct fecal-oral transmission between himself and the patient. Given the possibility of this mode of transmission, the diagnosis of CNS cysticercosis should be considered for patients with compatible clinical presentations even if they do not have obvious risk factors such as travel to an area endemic for the parasite.

Strategies to control recurrent acute otitis media in infants and children.

Recurrent AOM is a plague in many societies. The considerable attendant morbidity is best reduced through extended periods of antimicrobial prophylaxis. Children who are not helped by this intervention and who are experiencing sufficiently severe disease become candidates for surgical management with tympanostomy tubes. Should both strategies fail, then an adenoidectomy should be considered. In every case, the practitioner must weigh the severity of the recurrent illness against the real costs and risks of surgery.

Acoustic reflectometry for assessment of hearing loss in children with middle ear effusion.

We sought associations between acoustic reflectometry and hearing loss in ears with and without middle ear effusion in 137 New Zealand children ages 3 to 16 years. Reflectometry was significantly associated with conductive hearing loss. These associations were present in the entire sample; correlation coefficients varied between 0.31 at 2000 Hz (P less than 0.001) and 0.55 for a three frequency pure tone average (P less than 0.001). The associations persisted for the sample of ears deemed to be filled entirely by effusion; correlation coefficients varied between 0.27 at 4000 Hz (P = 0.026) and 0.47 at 500 Hz (P less than 0.001). Using a reflectivity of 6.0 or greater to detect a three frequency pure tone average loss of 30 dB or more, the sensitivity was 88% and the specificity was 44%. The technique of acoustic reflectometry should be explored and extended to permit rational decisions about management of middle ear effusions.

Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. Greater Boston Otitis Media Study Group.

To determine intellectual and linguistic sequelae of middle ear disease, 207 children were randomly selected from a cohort of 498 followed prospectively from birth until age 7 years. After controlling for confounding variables, estimated time spent with middle ear effusion (MEE) during the first 3 years of life was significantly associated with lower scores on tests of cognitive ability, speech and language, and school performance at age 7 years. The adjusted mean full-scale WISC-R were 113.1 for those with least time with MEE, 107.5 for those with moderate time, and 105.4 for those with most time. Similar significant differences were found for verbal and performance IQ scores. For the Metropolitan Achievement Test, we found that middle ear disease in the first 3 years of life was associated with significantly lower scores in mathematics and reading. Similar differences were found for articulation and use of morphologic markers. After considering time spent with MEE during the first 3 years of life, time spent after age 3 years was not a significant predictor of scores on any of the tests administered.