Impact of the 7-valent pneumococcal conjugate vaccine on the incidence of childhood pneumonia.

In September 2006, the 7-valent pneumococcal conjugate vaccine (PCV7) was added to the UK immunization programme. We aimed to evaluate the impact of PCV7 on the incidence of all-cause community-acquired pneumonia (CAP) in children. A prospective survey was undertaken in 2008-2009 at 11 hospitals in North East England of children aged 0-16 years with radiologically confirmed pneumonia. Data were compared to those from a similar survey undertaken in the same hospitals in 2001-2002. A total of 542 children were enrolled, of which 74% were aged <5 years. PCV7 uptake was 90∙7%. The incidence of pneumonia was 11∙8/10,000 [95% confidence interval (CI) 10∙9-12∙9], and the hospitalization rate was 9∙9/10,000 (95% CI 9∙0-10∙9). Compared to 2001, there was a 19% (95% CI 8-29) reduction in the rate of CAP in those aged <5 years, and in those <2 years a 33∙1% (95% CI 20-45) reduction in the incidence of CAP and 38∙1% (95% CI 24-50) reduction in hospitalization rates. However, for those unvaccinated aged ≥5 years, there was no difference in the incidence of CAP and hospitalization rate between both surveys. Since 2001, the overall reduction in incidence was 17∙7% (95% CI 8-26) and for hospitalization 18∙5% (95% CI 8-28). For the <5 years age group there was a lower incidence of CAP in PCV7-vaccinated children (25∙2/10,000, 95% CI 22∙6-28∙2) than in those that were not vaccinated (37∙4/10,000, 95% CI 29∙2-47∙1). In conclusion, PCV7 has reduced both incidence and rate of hospitalization of pneumonia in children, particularly in the <2 years age group.

Epidemiology of community-acquired pneumonia in children seen in hospital.

There is little UK data on hospital admission rates for childhood pneumonia, lobar pneumonia, severity or risk factors. From 13 hospitals serving the catchment population, demographic and clinical details were prospectively collected between 2001 and 2002 for children aged 0-15 years, seen by a paediatrician with community-acquired pneumonia (CAP) and consistent chest X-ray changes. From 750 children assessed in hospital, incidence of CAP was 14.4 (95% CI 13.4-15.4)/10,000 children per year and 33.8 (95% CI 31.1-36.7) for <5-year-olds; with an incidence for admission to hospital of 12.2 (95% CI 11.3-13.2) and 28.7 (95% CI 26.2-31.4) respectively. Where ascertainment was confirmed, incidence of CAP assessed in hospital was 16.1 (95% CI 14.9-17.3) and 41.0 (95% CI 37.7-44.5) in the 0-4 years age group, whilst incidence for hospital admission was 13.5 (95% CI 12.4-14.6) and 32 (95% CI 29.1-35.1) respectively. In the <5 years age group incidence of lobar pneumonia was 5.6 (95% CI 4.5-6.8)/10,000 per year and severe disease 19.4 (95% CI 17.4-21.7)/10,000 per year. Risk of severe CAP was significantly increased for those aged <5 years (OR 1.50, 95% CI 1.07-2.11) and with prematurity, OR 4.02 (95% CI 1.16-13.85). It also varied significantly by county of residence. This is a unique insight into the burden of hospital assessments and admissions caused by childhood pneumonia in the United Kingdom and will help inform future preventative strategies.

A scoring system for lung function tests in infants.

Measurements of thoracic gas volume (TGV), airway resistance (Raw), and airway conductance (Gaw) were calculated in a group of 42 normal infants using a whole-body plethysmograph. Maximum expiratory flow at functional residual capacity was measured in a separate group of 108 normal infants. Using data obtained from these infants the following regression equations were calculated: Gaw (L.s-1.cmH2O) = -0.0475 + 0.00164 x length (cm) square root of TGV (mL1/2) = -3.22 + 0.263 x length (cm) VmaxFRC (mL.s-1) = -173 + 5.2 x length (cm). The standard errors of prediction are a measure of the scatter of individual results from the normal population about the true regression line. They were used to define limits of the normal ranges for these tests of lung function, and to develop a scoring system. This approach is preferable to expressing results as percent predicted, which gives no indication of how likely a measurement is to be within normal limits.

Gaviscon and Carobel compared with cisapride in gastro-oesophageal reflux.

We compared the efficacy of the prokinetic agent cisapride with that of Gaviscon (an alginate/alkaline compound) plus Carobel (carob seed flour) in the treatment of gastrooesophageal reflux (GOR). Fifty infants with confirmed GOR received either oral cisapride (0.8 mg/kg/day) or Gaviscon plus Carobel for one month in a randomised, parallel group study. Parental evaluations, diary scores, and 24 hour lower oesophageal pH recordings before and at the end of each treatment were compared. In the cisapride group 14/26 (53%) were considered better by their parents compared with 19/24 (79%) of those who received Gaviscon plus Carobel. Diary scores, range (0.00-1.00), improved in both groups with the median change being greater in the Gaviscon plus Carobel group (-0.21) than the cisapride group (-0.15). Five of 17 pH variables had significantly improved from baseline in infants who had received cisapride compared with 11/17 in those receiving Gaviscon plus Carobel. However, unpaired analysis of diary and pH data showed no significant differences between the two groups. We conclude that first line treatment of GOR with cisapride is no more effective than conventional treatment with Gaviscon plus Carobel.

Variations in results of simultaneous ambulatory esophageal pH monitoring.

Twenty-four-hour esophageal pH monitoring is regarded as the gold standard investigation for gastroesophageal reflux (GER) (1) and the possibility of an "incorrect" answer, false positive or false negative, is only rarely considered (2). However, when a group of infants in this hospital had such pH studies performed on two consecutive days, considerable differences in the results were found (3). This also had been reported from other centers (4-6). It seems likely that most of the differences were due to true "biological" variability in the amount of GER from day to day, but it remains possible that variation in the accuracy of the equipment in detecting acid reflux was also involved.

Gastro-oesophageal reflux and respiratory function in infants with respiratory symptoms.

This study aimed to define the incidence and severity of gastro-oesophageal reflux (GOR), as measured using 24 hour oesophageal pH monitoring, in 38 infants with recurrent respiratory symptoms and to relate these findings to measures of respiratory function. Twenty one infants had a pH under 4 for more than 5% of the time (one definition of abnormal GOR) and nine had GOR exceeding age related normal values. Maximum expiratory flow at functional residual capacity was reduced in 37 infants, airways resistance was raised in 19 infants, and thoracic gas volume was abnormal in 11 infants. There was no association between indices of GOR and measures of lung function whether assessed by correlation or by chi 2 analysis for normal versus abnormal values. However, individual infants appeared to have respiratory symptoms produced by GOR. This suggests that host responsiveness to GOR may be of greater relevance than the amount of GOR.

Reproducibility of 24 hour oesophageal pH studies in infants.

Thirteen infants who had undergone 24 hour oesophageal pH monitoring to diagnose gastro-oesophageal reflux had a second study carried out to see if the results were reproducible. The studies were done without restricting the babies' activities. Appreciable differences were found, the percentage of the total time during which the pH was less than 4 varying by up to 3.7-fold between the two tests. The differences were largely the result of biological rather than technical variability. From these results estimates were made of the reliability of a single diagnostic study and the size of changes that would be necessary to show the effect of treatment. These findings have a considerable impact on the diagnosis of abnormal gastro-oesophageal reflux and its response to treatment whether using 24 hour pH monitoring or any other method of measurement.

Syncope as a presenting feature of hindbrain herniation with syringomyelia.

Syncope is rare as a presenting symptom of syringomyelia. Three cases are described in which syncope brought the patient to hospital and in each case syringomyelia was subsequently diagnosed and treated. The suggestion is made that impaction of hindbrain hernia or the Chiari malformation may be a causative mechanism of loss of consciousness in such cases; the three examples presented all did well after posterior fossa surgery to decompress the hindbrain hernia.