Trends in hospitalization for childhood asthma in Finland in 1996-2004.

AIM: To discuss trends based on data on all asthma-related admissions of children under 15 years of age. METHODS: retrospective analysis of records of the Finnish National Research and Development Centre for Welfare and Health in 1996-2004. The analysis was stratified for age. RESULTS: Out of the total of 23,715 such admissions, 66.8% involved boys. The number of all admissions for boys aged 0-under 3 years declined by 42.7% (relative to the child population) between 1996 and 2004, that for boys aged 3-under 5 years by 55.1% and that for boys aged 5-under 15 years by 59.0%, the figures for the corresponding age groups of girls being 53.0, 48.7 and 66.1%, respectively. The overall rate of first admissions for asthma among children (relative to population) declined by 36.8% during that period. CONCLUSIONS. The hospitalization of children for asthma has declined in Finland in recent times in all age and both sex groups. This favourable development coincides with the systematically programmed national shift into effective anti-inflammatory therapy in the paediatric age groups.

Confirmed primary HHV-6 infection in children with suspected encephalitis.

HHV-6 infection has been associated with neurological symptoms in children. Two variants of human herpes virus 6, HHV-6A and HHV-6B, have been identified. Their role in neurological infections is poorly understood. We studied 53 children with suspected encephalitis for HHV-6A (strain GS) and HHV-6B (strain Z29) antibodies using an indirect immunofluorescence test. Primary infection was separated from past infection by an IgG-avidity test. The identified primary infections were studied for HHV-6 specific DNA by PCR. Forty-one children of 53 had IgG antibodies to HHV-6. Six children had low avidity of HHV-6 IgG antibodies indicating acute primary infection; four to type A, one to B, and one to both types. By serology, HHV-6 viral etiology was suggested in 6/53 (11.3%) of cases. One of the six patients with primary infection had HHV-6 DNA in serum and two in CSF. The children with primary HHV-6 infection were significantly younger than the whole series, 2.3 years vs. 6.4 years. We conclude that primary HHV-6 infection appears to be an important associated or causative agent in neurological infections of young children, and it can be confirmed from a single serum specimen using the IgG-avidity test.

Childhood bacterial meningitis: initial symptoms and signs related to age, and reasons for consulting a physician.

The relationship of symptoms and signs to age and the reasons for consulting a physician were analyzed in 110 cases of culture-proven childhood bacterial meningitis. H. influenzae caused 74, meningococci 28, pneumococci 6 and streptococci 2 of the cases. Apart from fever (present in 94%), the most common symptoms according to age were as follows: 1-5 months: irritability (85%), 6-11 months: impaired consciousness (79%), 12 months or more: vomiting (82%) and neck rigidity (78%). Absence of neck rigidity at diagnosis was associated with young age (less than 12 months, P less than 0.001) and, in older children, to a short duration of symptoms (P less than 0.01) but not to the degree of CSF pleocytosis. Symptoms of meningitis caused by H. influenzae differed from those of meningococcal meningitis. Meningitis should be suspected in irritable or lethargic febrile children despite absence of neck rigidity. Fever and vomiting were the most frequent reasons for consulting a physician (60% and 31%, respectively). Despite the frequency and alarming character of irritability, impaired consciousness and neck rigidity, their presence led infrequently to a consultation (6%, 22% and 3%, respectively). Parental ignorance of such symptoms or of their importance may cause treatment delay, despite readily available medical services.

Invasive haemophilus influenzae and meningococcal infections in Finland. A climatic, epidemiologic and clinical approach.

A nationwide epidemiological survey on invasive (blood and/or CSF culture positive) Haemophilus influenzae (HI) and meningococcal infections was performed in Finland in 1976-1980. The mean annual incidence of HI infection was 3.4/100,000 inhabitants (813 cases) vs. 2.0/100,000 (469 cases) of meningococcal infection. HI infections showed no geographical predilection, but meningococcal disease, mainly of group B, was more common in northern than in southern Finland (p less than 0.005). Meningitis accounted for 61% of the HI and 91% of the meningococcal infections. The overall fatality rates were 3.1% and 7.9%, respectively. Children accounted for 94% of the HI and 59% of the meningococcal cases. The overall annual incidence of bacterial meningitis in children (less than 15 years) was 19/100,000; in children less than 5 years it was 52/100,000. HI was the most common (62%) causative agent, followed by meningococci (18%) and pneumococci (5%). The fatality rate was 4%. Major neurological sequelae were found in 5%, minor ones in 16%. It was calculated that 42% of the cases of meningitis could have been prevented by vaccines now available on the market. Vaccines now under field investigation may increase the preventability to about 65%.

Multivariate prognostication in bacterial meningitis of childhood.

A multivariate method for prognosticating the outcome of bacterial meningitis was computerized on the basis of initial clinical and laboratory data in 123 patients. The model, based on likelihood ratios, is simple and rapid. At the time of diagnosis, it predicted the outcome correctly in 104/123 cases (85%) in the basic group and in 67/98 independent controls (68%). The sensitivity of the method in predicting death or mild to severe neurological sequelae was 83% in both groups. The predictive value of a calculated good prognosis was 94% in the basic group and 97% in the control group, and that of a calculated poor prognosis was 63% and 26%, respectively. The predictive system can be used for rapid assessment of prognosis in individual patients and for comparisons between groups.

Recurrent meningitis due to pneumococci and non-typable Haemophilus influenzae in a child with a Mondini malformation.

An eight-year-old boy with a congenital inner ear malformation and recurrent otitis media had three episodes of bacteriologically confirmed meningitis within seven months. The first episode was caused by pneumococci, the other two by non-typable Haemophilus influenzae. All episodes were characterized by an abrupt onset. The CSF cultures were positive within 0.5 to 12 hours after the onset of symptoms. Despite misleading laboratory studies, surgical exploration revealed a CSF fistula associated to the inner ear anomaly. No further episodes occurred after the fistula was closed. Careful roentgenographic evaluation, including recently introduced special computed tomography (CT) methods, is indicated in recurrent meningitis. In addition, such evaluations should be considered even after the first episode, when special clinical features suggest a CSF fistula. Such features include an extremely rapid onset and detection of common non-invasive bacteria as causative agents, as illustrated by the present case.

Cerebrospinal fluid white cell, glucose and protein changes during the treatment of Haemophilus influenzae meningitis.

298 cerebrospinal fluid (CSF) samples obtained from 116 children with ongoing Haemophilus influenzae meningitis were analyzed in order to determine the kinetics of the white blood cell (WBC) count and the glucose and protein concentrations--parameters for which there are no "reference values" available for the convalescence period of meningitis. The values determined during the first 10 days of treatment are presented as percentile distribution graphs. CSF WBC counts increased slightly for the first 24 h but declined thereafter without reaching, however, the normal value (less than or equal to 5/microliter) within 10 days in the majority of cases. Low CSF glucose concentrations usually increased to a normal or almost normal level within 48 h. CSF protein concentrations declined steadily throughout the treatment. Extremely high CSF WBC or low CSF glucose concentrations suggested neurological complications or treatment failure. The value of sequentially determined CSF WBC, glucose and protein in monitoring recovery from H. influenzae meningitis is, however, so vague that routine spinal taps do not seem indicated after CSF has become sterilized.

Serum C-reactive protein as detector of pretreated childhood bacterial meningitis.

Serum C-reactive protein (CRP) levels were measured at presentation to the hospital in 15 children with proven bacterial meningitis (BM) pretreated with antibiotics. CRP exceeded the upper normal limit of 19 mg/l in all cases; the mean value was 195 mg/l (range, 55 to 375 mg/l). On the other hand, CRP levels were normal in 12 patients with viral meningitis or meningoencephalitis. Rapid determination of serum CRP should be performed whenever BM is suspected.

Primary diagnosis in a life-threatening childhood infection. A nationwide study on bacterial meningitis.

The accuracy of primary diagnosis made by general practitioners and paediatric house officers was assessed from a nationwide series of 130 Finnish children with bacterial meningitis. Meningitis was diagnosed at the first medical examination in 76 (58%) of the cases (32/70, 46% at physician's office versus 44/60 (73%) in hospital emergency rooms; p less than 0.005). In 44 cases (34%), there was a time lapse (mean, 1.7 days) between the first examination and the diagnosis of bacterial meningitis. In 30 of them, no findings suggestive of bacterial meningitis were present during the initial examination, whereas a definite or probable iatrogenic diagnostic delay occurred in 14 cases (11%). One of the latter children died and 2 recovered with major neurological handicaps. The overall mortality rate was 5/130 (4%) and the frequency of neurological sequelae was 28/130 (22%). The existence of potentially avoidable diagnostic delay in childhood bacterial meningitis was confirmed. Means of avoiding such potentially disastrous delay were discussed briefly.

White blood cell count, erythrocyte sedimentation rate and serum C-reactive protein in meningitis: magnitude of the response related to bacterial species.

White blood cell count (WBC), erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) were determined upon diagnosis of 61 children with bacterial meningitis in order to compare the responses evoked by different bacteria. The age of the patients and the duration of their symptoms were similar in all groups. WBC and ESR corresponded significantly with the bacterial species. The mean WBC in Haemophilus influenzae (n = 44), meningococcal (n = 11) and pneumococcal (n = 6) infection were 14,605/microliters 19,391/microliters and 23,833/microliters, respectively (for H. influenzae and pneumococci p less than 0.001). The mean ESR varied from 58 mm/h (meningococci) to 100 mm/h (pneumococci) (p less than 0.025). CRP was the test least influenced by the nature of the bacteria. The characteristics of CRP suggest its superiority over WBC and ESR as a detector of bacteremic infections. WBC is unsuitable for screening of systemic H. influenzae disease.

C-reactive protein as a detector of organic complications during recovery from childhood purulent meningitis.

Twenty-eight bacteriologically proved episodes of purulent meningitis in 27 infants and children were monitored prospectively with sequential determinations of serum C-reactive protein. Except in one rapidly fatal case, all the patients showed decreasing CRP values for about 1 week. In five patients the CRP values than returned to a high level (P less than 0.001). Each of these patients developed an organic complication (subdural effusions in three, transient widening of the ventricles in one, purulent arthritis with osteomyelitis in one). Except for one infant with sensorineural hearing loss, which probably had developed early in the course of meningitis, no permanent sequelae were found in the patients with uncomplicated courses. One infant later had a relapse of Escherichia coli meningitis, reflected in a sharp increase of CRP. We conclude that sequential CRP measurements may be performed routinely to detect potential complications at an early stage of bacterial meningitis.

Rotavirus infection in a neonatal unit.

The role of rotavirus as a cause of a mild diarrhoeal outbreak among newborns was studied in a small neonatal unit. Thirty-two newborns and 31 controls were tested with a new latex agglutination method (Rotalex) for detection of rotavirus antigen. Thirteen infants in the study group (41%) and one control (3%) excreted rotavirus antigen in their stools (p less than 0.005). The infection was usually mild or asymptomatic, but one critically ill premature infant had severe diarrhoeal symptoms requiring intravenous fluid replacement during antigen excretion. Spontaneous cessation of the epidemic took place when the number of infants at the ward was very small. This finding suggests that closure of a ward is useful for control of neonatal rotavirus infection.