A large meta-analysis concludes omega-3 fatty acid supplementation is modestly effective in treating ADHD, overcoming “considerable confusion and controversy” around the issue, according to the authors.

Ten trials involving 699 children were included in the meta-analysis. It found the effect of the supplementation was modest compared with other pharmacotherapies but may be worthwhile because of the “benign side-effect profile” and low cost.

The results come immediately following Australian data showing parents of children with ADHD are reluctant to start treatment with psychostimulants and try many other alternatives before and after diagnosis (Journal of Paediatrics and Child Health 2011; 47:512-517).

The latest study, published in the Journal of the American Academy of Child & Adolescent Psychiatry, found higher doses of eicosapentaenoic acid (EPA) within omega-3 fatty acids supplements were significantly associated with increased efficacy.

The efficacy of supplementation was the same whether used as a monotherapy or as augmentation with psychostimulants or other pharmacotherapies.

“These results reporting a significant benefit of omega-3 supplementation stand in contrast to the conclusions of most individual trials included in the meta-analysis,” the authors wrote. It remained unclear why supplementation with EPA might improve ADHD symptoms, whereas supplementation with docosahexaenoic acid (DHA) might not to the same degree, the authors wrote.

J Am Ac Child Adoles Psych 2011; doi:10.1016/j.jaac.2011.06.008.

In ankyloglossia, the sublingual frenulum is unusually thick, tight or short

Dr Justin Roche takes a look at the problem of ankyloglossia in infants and examines the benefits of frenotomy for both mother and baby.

Historically, the presence of a labial frenulum resulted in its division immediately after birth, usually by the attending midwife. The need for this practice came into question in the 1940s and 1950s, in part brought about by the rise in popularity of bottle feeding.

The textbooks and literature from this period, and for many years after, record this change in approach. Indeed, the 14th edition of Nelson’s Textbook of Pediatrics, which was published in 1992, stated that frenotomy was unnecessary.

The controversy continues to this day in medical circles. In 2007, the Canadian Paediatric Society reaffirmed its 2002 position statement, saying that ankyloglossia requires “no intervention beyond parental education and reassurance”.

Difference of opinion
There is also a difference in opinion, depending upon the training of health professionals. In a Canadian and American survey, some 69 per cent of lactation consultants, 30 per cent of ENT surgeons and just 10 per cent of paediatricians agreed with a statement that ankyloglossia was associated with feeding problems.

Over the last 15 years, there has been an ever-growing body of evidence to support the impact that ankyloglossia has on feeding and its management.

There has been an Interventional Procedure Guidance written by the National Institute for Health and Clinical Excellence (NICE). Evidence for the benefits of breastfeeding has also been well documented during this time.

These include reduced infant infection rates, reduced risk of diabetes, atopy, obesity and hypertension, as well as improved IQ scores and it aids maternal-infant bonding.

I have a personal interest in ankyloglossia because three of my six children required frenotomy in order to facilitate breastfeeding. As a result of my experiences over the last 12 years, I now provide a frenotomy service.

What is ankyloglossia?
The tongue is a highly mobile organ comprised of horizontal, longitudinal, vertical and transverse intrinsic muscles and the extrinsic muscles of the genoglossus, styloglossus and hyoglossus. The sub-lingual frenulum is a mucosal fold connecting the midline of the inferior surface of the tongue to the floor of the mouth.

Tongue tie, or ankyloglossia, is the condition whereby the sublingual frenulum is unusually thick, tight or short.

The published literature shows a variation in the incidence of between 4 per cent and 10 per cent, with a male preponderance of 2.5:1. The variation in incidence may be explained by a difference in definition between the studies. There are two systems of classification in use in the literature.

The first system grades the ankyloglossia on appearance alone and has four types, ranging from Type 1 with a frenulum that extends to the tip of the tongue, to Type 4 where only the posterior portion of the tongue is involved.

The Type 4 is often easier to feel, by sweeping an index finger under the tongue, than it is to visualise, unless the tongue is elevated with both index fingers. This latter type is often referred to as a posterior tongue tie.

The other classification system is the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF). This has five appearance items and seven function items to try and identify those infants who may experience feeding difficulties.

This tool has only moderate inter-observer correlation and has been commented on as not being practical for use in a busy clinic setting.

In practice, the appearance does not predict whether there will be feeding difficulties. There are many children who have a frenulum that extends to the tip of their tongue who are able to breastfeed without difficulty. Equally, there are children who have a barely discernable posterior tongue tie who have great difficulty feeding. There is a complex interplay between the anatomy and function of the infant’s tongue and the anatomy of the mother’s breast. If there are feeding problems, as outlined in the table (left), and a tongue frenulum is present, then assessment by a lactation consultant and referral for frenotomy should be considered.

‘Chewing’ of the nipple
In order to breastfeed, an infant needs to be able to project their tongue beyond the lower gum margin during sucking. Movements of the posterior portion of the tongue then generate a vacuum, which in turn draws milk from the nipple. Failure to get the tongue over the lower gum results in the phasic bite reflex or ‘chewing’ of the nipple.

This causes trauma and pain for the mother. Often, bottle feeding is successful because ‘chewing’ on the teat can produce sufficient milk flow but for some infants, it is not possible to achieve this or only if the bottle is held in a very precise way.

Treatment options
Medical management in the form of lactation support may enable some of these babies to feed effectively by using alternate positions to the cradle position, such as the ‘clutch’ or ‘football’ hold, to help optimise latch. Mothers may also need to express in order to maintain their milk supply and give the expressed milk via a supplementary feeder, cup or bottle. Alternatively, the lingual frenulum can be divided (frenotomy).

'Most babies cry briefly during the procedure, often starting when the tongue is lifted with no discernable increase during division. Some babies will sleep through the whole procedure. Most infants have settled by the time they are unwrapped and returned to their parent’s arms'

In terms of who should have a frenotomy, the first thing is to establish that the feeding difficulties are in keeping with ankyloglossia. Then an examination of the oral cavity is undertaken to establish if a lingual frenulum is present. Other cranio-facial anomalies, such as cleft palate or Pierre-Robin sequence, should be excluded.

Typically, it takes three-to-five days to establish breastfeeding. Therefore, frenotomy should not be performed prior to 72 hours of age, unless there is very marked symptomatology. Whilst it is not necessary to look for a lingual frenulum on routine newborn examinations, this should be done in cases of mothers who, despite lactation support, are experiencing feeding difficulties beyond 72 hours.

For the procedure itself, the infant is wrapped in a sheet to keep their arms secure. The infant’s shoulders are held by an assistant with their head supported between the assistant’s wrists.

The tongue is lifted with the left index finger and the lower lip retracted by the left thumb. The frenulum is then divided using sterile blunt-tipped iris/Metzenbaum scissors. No anaesthesia is necessary.

Complete division of the frenulum is confirmed by a sweep of the right index finger and a gauze swab applied to the area to aid haemostasis. The infant is then returned to the mother to complete a feed before discharge.

Most babies cry briefly during the procedure, often starting when the tongue is lifted with no discernable increase during division. Some babies will sleep through the whole procedure. Most infants have settled by the time they are unwrapped and returned to their parent’s arms. In my experience, they have all settled once they have completed a feed. For the children from six-to-12 months, 15mg/kg of paracetamol is given before the procedure.

What are the complications?
There is usually, but not always, a small amount of bleeding. This typically would be a few drops of blood and only occasionally up to a teaspoonful. Secondary bleeding is not a problem. The area of division heals rapidly and requires no specific care. There is a very small risk (<1:1000) of infection, which can be managed with oral antibiotics and without negative impact on feeding.

With regard to whether the procedure is effective, there are a number of studies demonstrating the efficacy of frenotomy, including two randomised controlled trials (RCTs).

More effective
Hogan et al (2005) randomised between frenotomy and intensive lactation support. Of those in the frenotomy group, some 27 of 28 experienced reduced nipple pain and improved breastfeeding at one week, compared with one of 29 in the control group. After 48 hours, those in the control group were offered frenotomy, of whom 28 accepted and 27 benefited. Frenotomy was concluded to be significantly more effective than intensive lactation support.

In July 2011, Buryk et al published their RCT, with the control group having a ‘sham frenectomy’. A significant placebo effect was seen for nipple pain, but the frenotomy group had a further significant improvement in nipple pain over the control group. Breastfeeding scores significantly improved for the frenotomy group alone.

So, are there other benefits to frenotomy? There is evidence that division of ankyloglossia beyond infancy has benefits to articulation of speech and dental hygiene. However, there are no data to support or refute benefits in these areas for division in infancy at present.

Summary
In summary, ankyloglossia is a well-recognised cause of feeding problems in infancy, particularly breastfeeding, which has a safe, effective and acceptable form of treatment. In the future, I hope that this will be offered in more centres as a clinic-based procedure and I would welcome any debate in this regard.

References available on request.

• Dr Justin Roche, Consultant Paediatrician with special interest in Community Child Health, South Tipperary General Hospital, Clonmel
• Dr Roche will speak at a seminar on tongue tie and its impact on breastfeeding, which takes place at All Hallows Conference Centre, Drumcondra, Dublin 9, on September 3.

To book a place at the seminar, visit www.breastfeedingsupport.ie or call Nicola O’Byrne on 086 231 2679.

'It is imperative that appropriate support for this population is provided in the community and that decreasing the length of stay (LOS) does not result in increased readmissions'

Niamh Hegarty, Marguerite Fitzgibbon, Dr Elaine Neary, Dr Niazy Al Assaf and Prof Tom Clarke advise on how best to ensure that a comprehensive and systematic discharge plan is provided for neonatal infants.

The demands on obstetric and neonatal services have increased with Ireland’s current high birth rate. Neonatal care has improved dramatically over the last decade and advances in antenatal care have led to increased antenatal in-utero transfers of high-risk pregnancies to tertiary centres.

There has been a gradual reduction in the threshold gestation for viability of pre-term infants, with improved survival rates for premature infants, especially very low birthweight infants. These vulnerable patients often have a complicated medical course, with high rates of morbidity and associated prolonged stay in hospital.

Often parents will ask the question, “When is my child expected to go home?” The simple answer in the past usually was, “About the time your baby was due to be born.”

However, the decision of when to discharge an infant following a significant period in the neonatal intensive care unit (NICU) is complicated and dependent upon several factors, namely the physiologic maturity and stability of the infant, the competency of the parents or other care givers and the support network available following discharge.

Bed management has become an increasingly important reality for both obstetric and neonatal services. If we are to continue to aggressively manage high-risk infants, then we must have adequate resources to manage the associated disabilities which may arise in this group, and to provide adequate support to families and carers. Worldwide initiatives are ongoing with the aim to reduce length of stay for this cohort of infants.

The advantages of a shortened length of stay include cost effectiveness, the fact that they are better for the family unit in terms of bonding and less travelling, and decreased exposure to hospital-acquired morbidity, particularly hospital-acquired infection.

Comprehensive and systematic discharge planning of the infant from the time of admission is should be an integral part of management. Factors that affect the infant’s readiness for discharge include medical, social and institutional factors.

The American Academy of Paediatrics (2008) has prepared guidelines on discharge criteria for this population. These guidelines advise the classification of high-risk infants into four categories:
1) the pre-term infant;
2) the infant with special healthcare needs;
3) the infant at risk because of social issues; and
4) the infant with anticipated early death.

The issues of deciding when discharge is appropriate, defining the special needs for follow-up care and the process of detailed discharge planning are addressed as they apply in general to all four categories; in addition, special attention will need to be directed to the particular issues presented by the four specific categories.

Pre-term infants
Pre-term and low birthweight infants who required neonatal intensive care experience a much higher rate of hospital readmission and death within the first year of life compared with healthy term infants (Lamarche-Vadel, A et al 2004; Smith, VC et al 2004). Preparing families for discharge and the provision of parental education are important components of the discharge process and fundamental in ensuring a seamless transition for all involved in the discharge process.

In the Rotunda Hospital, a discharge planning algorithm has been developed to document acquisition of all essential criteria pre discharge. The aim of the tool was to create a successful discharge plan that would ensure that specific interventions needed by a particular infant are applied at the optimal point in the discharge process.

Healthcare professionals need guidance in assessing readiness for discharge and planning subsequent care. It is imperative that appropriate support for this population is provided in the community and that decreasing the length of stay (LOS) does not result in increased readmissions.

Developments in neonatal intensive care, and associated decrease in complications (e.g. decrease in pneumothorax), have been associated with a reduction in length of stay.

A number of more recent quality improvement initiatives, for example improved infection-control guidelines and the introduction of probiotics with enteral feeds, are reducing LOS further.

Streamlining process
Organisation and streamlining of the discharge planning process within different hospitals will significantly affect the length of stay. Heightening awareness of discharge planning can only serve to improve this aspect of the care to this population. Nationwide guidelines would allow for transition of care between neonatal units and should improve outcomes, particularly in terms of family satisfaction.

The American Academy of Paediatrics (2006) have recommended potentially better practices (PBPs), designed to integrate organisational, clinical and operational processes to ensure optimal discharge planning from admission through follow up into the community (see figure). Discharge planning needs to be facilitated by all members of the multidisciplinary team.

Discharge co-ordinator
A dedicated neonatal discharge co-ordinator is a valuable, cost-effective asset; this post can be full time or part time, depending on the size of the unit. However, most hospitals can implement discharge planning processes within existing allocated resources.

There is no doubt that newborn infants and their families will benefit from this process, leading to a shorter length of stay.

References on request.

• Niamh Hegarty, Clinical Skills Facilitator, Neonatal Unit; Marguerite Fitzgibbon, Neonatal Discharge Co-ordinator; Dr Elaine Neary, Specialist Registrar Paediatrics; Dr Niazy Al Assaf, Locum Consultant Neonatologist; and Prof Tom Clarke, Consultant Neonatologist. Neonatal Intensive Care Unit, Rotunda Hospital, Dublin 1.

Evidence-based and/or potentially better practices in discharge planning*

• Discharge planning sheet (a comprehensive assessment and evaluation record at the infant’s bed space);
• Maintain consistent medical and nursing care plans for individual patients;
• ‘Plan for the day, the stay and the way’ to discharge – consider the discharge planning process every day from admission;
• Provide parent(s), or other caregivers, with educational material and resources;
• Use continuous quality improvement tools and processes to assure parent/caregiver and staff satisfaction;
• Audit and improve infant transfers and interactions with public health nurses and family doctors;
• The allocation of a dedicated social worker to the neonatal unit (full or part-time, depending on size of unit) for assessment of needs and resources of family, and co-ordination of family support services;
• Provide specific case management to high-risk patients;
• Establish a philosophy for parental role development;
• Develop a discharge philosophy and criteria for the neonatal unit.

* Adapted from No Place like Home — NICU Discharge Planning and Length of Stay from Vermont Oxford Network NIC/Q 2000 project (Pediatrics, 2006).

Teenagers with type I diabetes who get depressed are likely to have worse control of their glucose levels, a US study finds, leading the authors to call for screening and prevention of depression in adolescents with type I diabetes.

Interestingly, the researchers found teens who started off with good blood-glucose monitoring were resistant to the effect of depression on glucose control.

A total of 145 adolescents had their depressive symptoms, HbA1c levels and blood glucose monitoring documented once at baseline and again six months later.

On average, HbA1c would change half a percentage point if an adolescent’s depression increased by five points on the Children’s Depression Inventory.

HbA1c levels changed more for children who started off with worse blood-glucose monitoring. There was a “synergistic effect” with depressive symptoms and HbA1c control, such that depressive symptoms accelerated the increase of HbA1c values over time.

“This suggests that targeting sustained adherence to [blood-glucose monitoring] would be the primary tool to prevent worsening glycaemic control for those already achieving optimal glycaemic control, followed closely by maintaining a low level of depressive symptoms,” the study authors wrote in Pediatric Diabetes.

The authors backed systematic screening of depressive symptoms, as well as glucose monitoring and HbA1c levels. They said annual evaluation of depression “appears to be a good first step” and prevention strategies may be the best method of intervention.

“A collection of these screening, prevention, and intervention strategies should put adolescents with type 1 diabetes in the best position for optimal diabetes management and control.”

Pediatric Diabetes 2011; doi: 10.1111/j.1399-5448.2011.00771.x

Children with serious illnesses may be better off out of earshot when doctors are breaking stressful news about them to their parents, the authors of a new study suggest.

The study, which comprised interviews with 53 socio-economically diverse parents (33 mothers) of children being treated for acute lymphoblastic leukaemia, showed that most regarded the informational content and emotional tone of consultations as a threat to their children.

Issues such as prognosis, adverse results and certain medical procedures were identified as being particularly difficult to discuss in front of the child. Both the benefits and difficulties of the child’s presence were conveyed by the parents, although difficulties were more common.

For instance, having the child present conveyed “respect for children”, some parents said. However, whereas only 25 parents identified at least one benefit of having their child present, 36 identified at least one difficulty, including leaving children frightened or confused. Mothers, in particular, reported being distracted by the child’s presence.

Many parents said they avoided asking the physician certain questions in front of their child and that they had to “grab the physician for a quick chat” when alone to clarify their queries. Others said they found doctors reluctant to meet separately and “most seemed to doubt their entitlement to such an option”.

The study authors noted this might be linked to the moral emphasis staff placed on open communication with children. They also noted that parents identified a “sequencing” of information — at diagnosis physicians routinely conveyed the “news” to parents separately and before they talked to the children (in line with recommendations), while later, the onus seemed to shift to the parents to initiate separate consultations.

Whilst acknowledging the complexity of the picture, the authors concluded it would be in each child’s interest for physicians to explore with parents how they wanted significant information conveyed.

Pediatrics 2011; doi:10.1542/peds.2010-2402. http://pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2402v1.

A study of 125 severely obese adolescents awaiting bariatric surgery has found that relatively few had an actual eating-disorder pathology, but those that did were at greatest risk for other problems such as depression.

Eating-disorder pathology was observed among just 15 per cent of the cohort, and these youth were at risk of having high levels of depressive and anxiety symptoms, total problems, family conflict and low quality of life. However, just 23 per cent of these adolescents reported any current psychiatric treatment.

The study identified three distinct subgroups in the cohort: those with an ‘eating pathology’, who had high levels of eating-disorders and other psychopathology; those with ‘low psychopathy’ who had the fewest psychosocial problems; and those with ‘non-specific psychopathology’ who had intermediate scores on measures of psychopathology.

International Journal of Pediatric Obesity 2011; doi:10.3109/17477166.2010.545411

Proton pump inhibitors (PPIs), in common use for gastric reflux symptoms in babies, are ineffective in this age group, concludes a new review.

The review of 12 studies of almost 900 children aged 0-17 noted the paucity of evidence to support the current widespread prescribing of PPIs in infants, as well as in older children.

Although some guidelines recommend considering anti-secretory treatments for distressed infants or for children and adolescents with heartburn, the authors noted the evidence to support this had been “extrapolated from adult studies”.

Furthermore, clinical recovery with PPIs “may be ascribed to a placebo reaction or physiologic symptom resolution over time”.

The review found that for reducing GORD symptoms in infants, PPIs were not effective in two studies, equally effective in two studies compared with placebo, and more effective in just one study compared with hydrolysed formula. Placebo-controlled trials in older children were lacking.

For gastric acidity in infants and children, PPIs were more effective compared with placebo, alginates or ranitidine in four studies. Although PPIs were well tolerated, “they may increase susceptibility to acute gastroenteritis and community-acquired pneumonia, respiratory infections, gastric polyps and bacterial overgrowth”.

Co-author Dr Taher Omari, from the Women and Children’s Hospital in Adelaide, said “the weight of evidence suggests that these drugs are not very effective in infants with GORD”.

Pediatrics 2011; 127:925-935

In the second of a two-part series, Dr Kevin Connolly writes that too many children are still dying annually from vaccine-preventable diseases and renewed vaccination campaign efforts are needed, especially in developing countries.

Control of infectious diseases by better sanitation, cleaner drinking water and vaccination has had a major impact on mortality rates in all countries. Targeted vaccination campaigns have helped reduce global measles deaths from an estimated 733,000 in 2000 to 164,000 in 2008.

Cumulatively, approximately 12.7 million measles deaths were averted.

When the Global Polio Eradication Initiative (GPEI) was launched in 1988, over 125 countries were endemic for the disease, with an estimated 350,000 children paralysed each year. Polio cases have since decreased by over 99 per cent, to 946 reported cases in 2010.

In that year, more than two billion children were immunised with the polio vaccine in 122 countries. This prevented five million cases of paralysis and 250,000 paediatric deaths. However, more than two million children under the age of five die each year from vaccine-preventable diseases.

Over 90 per cent of these deaths occur in the world’s poorest countries. Pneumonia causes approximately 30 per cent of these deaths and is the leading killer of children under five.

Dr Kevin Connolly

About 40 per cent of pneumonias are caused by the pneumococcus. Diarrhoeal diseases cause more than 1.7 million deaths in children under fives; rotavirus is the most common cause of severe diarrhoeal disease.

Risks of complacency
Many people assume that since certain diseases rarely occur, they no longer pose a threat. This and other misperceptions have led to a decline in vaccination coverage, with a resurgence of diseases such as measles, rubella, pertussis and diphtheria. In 1985, when the measles vaccine was introduced to the Irish schedule, some 9,903 measles cases were reported, declining to 201 cases in 1987.

However, despite the routine immunisation programme, further major outbreaks have occurred in 1989 (1,248 cases), 1993 (4,328 cases) and 2000 (1,603 cases). Most of the cases were in the unimmunised.

Rates of diphtheria, pertussis and measles greatly increased after the break-up of the Soviet Union as vaccines became less available. Cases of diphtheria reached epidemic levels by 1995 and there were over 4,000 deaths during the outbreak. A rubella epidemic in 1991 among the Amish in Pennsylvania, who had low immunisation rates, led to 95 pregnant women getting rubella, nine miscarriages and 11 cases of congenital rubella syndrome.

Another threat is the importation of disease from endemic to disease-free countries. This happened with measles introduced to the US in the past few years, and polio into the European region last year.

Why eliminate polio and measles?
Polio and measles can be eradicated because:

• They only affect people – there is no animal reservoir;
• Safe, effective vaccines exists;
• Immunity is life-long;
• The virus can only survive for a very short time in the environment.

Economic modeling studies have demonstrated both the financial and humanitarian benefits of eradication.

http://www.who.int/entity/mediacentre/contacts/en/

Measles is a serious disease, and among the world’s most contagious diseases. In higher-income countries, the mortality rate is around one per thousand. In endemic areas in sub-Saharan Africa, the mortality rate often rises to 10 per cent. The fatality rate in children in complex emergencies is as high as 20 per cent to 30 per cent.

In an unvaccinated population, one case can infect 15 people. Prior to the introduction of the measles vaccine, most people were infected by the age of 15. Because it is so contagious, it will continue to circulate where large numbers of susceptible persons gather, even with high vaccination-rates. In order to halt transmission and eradicate measles, a vaccine uptake rate of over 95 per cent is required.

Despite this progress, over 440 children die each day from this completely preventable infection. Unless vaccination efforts are sustained, there may be a global resurgence in measles deaths. Financial support to the Measles Initiative decreased from US$ 150 million in 2007 to just over US$ 50 million in 2009. Many priority countries are facing funding gaps for their immunisation programmes.

Projections are that, without supplementary immunisation activities in these countries, approximately 1.7 million measles-related deaths could occur between 2011 and 2014.

Why have we still got polio?
Only four countries (Afghanistan, India, Nigeria and Pakistan) remain polio-endemic. However, as long as one person remains infected, children in all countries are at risk of contracting polio. In 2009-2010, some 23 previously polio-free countries were re-infected due to imports of the virus. These included Angola, Chad, Congo, Senegal, the Russian Federation, Tajikistan and Turkmenistan.

In India, poor sanitation facilitates spread of the virus, and malnutrition and chronic diarrhoea reduce the immune response of the vaccine.

Devastating floods overwhelmed Pakistan in August and September last year. More than 600,000 homes were damaged, and 18 million people affected. Relief work focused on providing safe drinking water, food and shelter, and rebuilding infrastructure to cope with a cholera outbreak.

Polio immunisation activities were postponed, resulting in 113 polio cases (up to November 2010). Pakistan had more cases than the three remaining polio-endemic countries (India, Afghanistan and Nigeria) combined. While childhood immunisation coverage in Pakistan has increased substantially since 1990, some children are significantly less likely to benefit than others. Children from the poorest 20 per cent of households are three times more likely than those from the wealthiest 20 per cent to be unimmunized with DPT3. Rural children are 1.4 times more likely than urban children to be unimmunised.

In Afghanistan war, lack of access to every child and low awareness among families are the major obstacles towards eradication. The conflict has posed major problems for vaccine administration, creating an environment of fear and limiting access for vaccination teams in conflict-affected areas. Millions of Afghan refugees live in Pakistan and tens of thousands of people move across the 2,400km border every day.

In northern Nigeria in 2003-4, Muslim religious leaders boycotted the vaccine as a Western plot to sterilise children. The resulting 12-month suspension of immunisation caused a rapid outbreak of disease. Polio spread to 24 countries across west and central Africa and in the Horn of Africa. During 2005, a total of one thousand polio cases (54 per cent of the global total of 1,856) were reported from countries with outbreaks caused by importation, more than from the six remaining polio-endemic countries.

Continuing transmission in northern India resulted in spread to Lebanon, Angola and to Nepal. In 2010, the first polio importation into the European Region since the region was declared polio-free in 2002 resulted in 476 confirmed cases.

What is being done to eradicate polio?
The polio programme has already cost nearly $9 billion, and requires $750 million each year. Bill Gates recently pledged $102 million to eradication; Abu Dhabi pledged $50 million to vaccinating children in Afghanistan and Pakistan against polio and other diseases; Rotary International, which has already given more than $1 billion to polio eradication, pledged an additional $200 million.

In 2010, some 40 per cent of the total budget was allocated to operational costs, which vary greatly between and within countries. For example, in India costs are low (~12 cent per child in 2011) as high population density allows a single health or communication initiative to reach large swathes of the population. The average operational cost to reach one child with vaccine during one round of immunisation activities is ~15 cent per child.

In 2010, more than two billion children were immunised with polio vaccine in 122 countries. This has prevented five million cases of paralysis and 250,000 paediatric deaths.

In October 2010, some 15 African countries launched a synchronised mass immunisation campaign to reach 72 million children with polio vaccine.

A total of 290,000 vaccinators were mobilised to deliver oral polio vaccine (OPV) to every child under five in areas considered at highest risk of polio transmission. In Nigeria, where religious leaders are now supporting vaccination, the number of cases dropped to 21 last year, from 388 in 2009.

Across India, only 42 cases were recorded in 2010, a drop of 94 per cent from the year before. It is the lowest number ever recorded. During immunisation drives, vaccinators go to schools, train stations, bus depots and roadside nomadic enclaves.

The vaccinators are often female so that mothers will trust them with their children.

Health workers give zinc and oral rehydration solution to stop diarrhoea and help children absorb the vaccine. Nearly airtight monitoring means virtually no child is missed, even in the most remote of villages. In just five days last month, 2.5 million workers visited 68 million homes to inoculate 172 million children.

In Afghanistan, four nationwide house-to-house vaccination campaigns reached almost 7.5 million children in the first half of 2009. This particular campaign targeted 1.2 million children under age five in conflict-affected districts. More than 15,000 health workers went door-to-door in eight provinces. A three-day nationwide polio immunisation campaign in October 2010 targeted 7.8 million children in all 34 provinces. Every person who crosses the Afghanistan-Tajikistan border is given OPV.

Even with these efforts, roughly 100,000 Afghan children cannot be reached with vaccinations due to security concerns.

Selected references:
Food and Agriculture Organization, Economic and Social Dept. “The State of Food Insecurity in the World 2005: Eradicating World Hunger — Key to Achieving the Millennium Development Goals”. Food and Agriculture Organization of the United Nations, 2005.
Progress for Children: Achieving the MDGs with Equity (No. 9). UNESCO, Sept. 2010 MMWR, April 02, 1999 / 48(12); 241-243
WHO Fact sheet N°288 March 2005 Immunization against diseases of public health importance.
WHO Polio Global Eradication Initiative, 2010-2012.

• Dr Kevin Connolly became Portiuncula Hospital’s first-ever consultant paediatrician in 1978. He served in that role until his retirement last summer.

‘Every year, 1.4 million children die from vaccine-preventable diseases before they reach the age of five years’

In the first of a two-part series, Dr Kevin Connolly stresses the benefits of comprehensive immunisation programmes in terms of the human cost and financial savings.

Vaccines are widely and routinely administered around the world, based on the principle that it is better to keep people well than to treat them when they become ill. They prevent illness and death, and reduce spread of disease. They thus save money that can be used for other health services.

They can also eradicate diseases. According to one study, the standard childhood immunisation series prevents approximately 10.5 million cases of infectious illness a year.

Infectious diseases have been among the leading causes of illness and death throughout history. However, from the mid-19th Century, deaths from these diseases have reduced significantly throughout the developed world. This decline is due to improved sanitation, provision of clean water, better education and immunisation.

In 1971, Abdel Omran proposed the theory of an ‘epidemiologic transition’ to account for the improvement. He suggested that societies progress through three stages of disease: ‘the age of pestilence and famine’ (high, fluctuating mortality rates, life expectancy <30 years); ‘the age of receding pandemics’ (life expectancy >50 years; persistent heavy burden from infectious diseases); and the ‘age of degenerative and man-made diseases’, during which life expectancy increases further, the burden of infectious disease decreases, and cancer and cardiovascular disease become more prevalent.

Ireland has moved to the third stage. Unfortunately, low-income countries remain in the second stage. Current estimates show that infectious diseases are the main cause of death in these countries, accounting for >25 per cent of deaths worldwide, and over 40 per cent of deaths in developing countries, significantly more than in developed countries. Physical, developmental and economic damage from infectious diseases show a similar or greater persisting difference between the two worlds. However, in the WHO’s European region, vaccine-preventable diseases continue to kill an estimated 32,000 children every year.

There has been some progress in low-income countries. Worldwide, child deaths fell from almost 13 million in 1990 to 8.8 million in 2008. Much of the reduction results from adoption of basic interventions such as early and exclusive breastfeeding, immunisation, vitamin A supplementation, and insecticide-treated bed nets to prevent malaria.

As a result of immunisation, the lives of an estimated 2.5 million children under five years of age are saved each year. Nevertheless, vaccine-preventable diseases continue to cause illness, disability and death. Every year, 1.4 million children die from vaccine-preventable diseases before they reach the age of five years. An additional 600,000 people die from the consequences of hepatitis B infection acquired during childhood every year.
Developing world
A child in the developing world is 10 times more likely to die from a vaccine-preventable disease than a child in the Western world. An estimated 30 million children each year still lack proper vaccination. The burden of vaccine-preventable diseases varies by country, partly because of differences in vaccine distribution and access to care, but also because of geography, climate, crowding, nutritional status, travel and genetic differences that affect disease severity.

The highest rates of child mortality continue to be found in sub-Saharan Africa. In 2008, one in seven children there died before their fifth birthday.

While mortality rates and causes of death provide important data, there are other factors that need to be considered in measuring the burdens of disease. These include decreased worker productivity and gross national product. For example, evidence links poor growth, school absenteeism, decreased cognitive function and physical development to a number of nutritional and environmental exposures, and to infectious diseases in low-income countries.

It has been considered that wealth is the main determinant of health, through better nutrition, medical care, public health infrastructure and education, but this relationship has recently been reversed (‘health drives wealth’). Four factors affecting this relationship have been described:

1)  Healthier populations have higher productivity because of cognitive, physical and emotional improvements;
2)  People in healthier populations have higher life expectancies, which results in stronger incentives to improve personal development through education because they need to plan for a longer survival, and healthier children have higher school attendance, higher cognitive function and increased productivity;
3) Investment in physical capital occurs in healthier populations because life expectancy creates a need to save for retirement, which requires increased investment and results in more opportunities for foreign investment;
(4) The ‘Demographic Dividend’ has been described as a transient but significant boost to the economy associated with declines in infant mortality and fertility.
Immunisation is considered among the most cost-effective of health investments. There is a well-defined target group; contact with the health system occurs only at the time of delivery; and vaccination does not require any major change of lifestyle.

The WHO has prioritised immunisation for seven reasons:
1)    Immunisation saves lives — more than 3 million lives are saved each year by vaccines;
2)    Immunisation is a basic human right;
3)    Outbreaks of vaccine-preventable diseases pose a constant and serious threat;
4)    Communicable diseases still kill;
5)    Vaccine-preventable diseases can be controlled and eliminated;
6)    Immunisation is very cost-effective; and
7)    Children’s health depends on systems that provide safe, effective, inexpensive immunisation.

Childhood diseases
The Expanded Programme on Immunisation (EPI), targeting six vaccine-preventable diseases of childhood, (tuberculosis, polio, diphtheria, tetanus, pertussis and measles) was launched in 1974. At that time, less than 5 per cent of the world’s children were immunised during their first year of life against these six diseases.

Today, nearly 80 per cent of children receive these vaccinations. The programme has been expanded to include other vaccinations such as hepatitis B, Hib, rubella and yellow fever. The Bill & Melinda Gates foundation has donated US$1.5 billion in this area.

Melinda and Bill Gates receiving Honorary Degrees from Cambridge University in 2009

In the past decade, an estimated 8 million children died from pneumococcal pneumonia or meningitis, and 5 million children died from rotavirus gastroenteritis. The introduction of vaccines against these two diseases can save the lives of 1 million children per year. Savings of US$1.5 billion annually will result from completing the eradication of polio.

In the mid-1990s, vaccines to provide coverage for tuberculosis, polio, diphtheria, tetanus, pertussis and measles cost about US$1 per child. Inclusion of vaccines for hepatitis B and Hib raises the vaccine and administration costs to bet-ween US$20-40 per child.

Vaccination costs
In a study of 11 western European countries, the cost per person of measles vaccination, including indirect costs, varied from 17 cent to 97 cent. The cost of treatment of each measles case was estimated to be between €209 and €480. Sustained, high immunisation rates should thus be seen as an investment, not a cost.

Malaria, TB and HIV are responsible for more than 5 million deaths each year, and all are potentially preventable by vaccines. Rapid scientific progress suggests that an effective vaccine is likely to be available for at least one of these diseases in the next decade. The Global Fund to Fight AIDS, Tuberculosis and Malaria is an international financing institution that invests the world’s money to save lives. To date, it has committed US$21.7 billion in 150 countries to support large-scale prevention, treatment and care programs against the three diseases.

In 1999, major international development partners involved in immunisation, including the WHO, UNICEF and the World Bank, joined the Bill & Melinda Gates and Rockefeller Foundations, the vaccine industry and non-governmental organisations to create the Global Alliance for Vaccines and Immunisation (GAVI).

Its aims are:
i)   To increase access to new and under-used vaccines in the world’s poorest countries;
ii)  To improve access to basic immunisation services; and
iii) To accelerate research and development of new vaccines and delivery technology.

The Alliance has helped to prevent an estimated 3.4 million deaths since 2000. More than 100 million infants are immunised each year. Priority is given to about 40 nations where routine immunisation coverage is lowest, and to the districts within those countries where children are least protected.

These priority nations range from Indonesia and Sudan to India and Afghanistan. Ireland has committed US$42 million in direct funding (2002-2014).

It is a major challenge for low-income countries to find ways to introduce more expensive vaccines such as hepatitis B and Hib, which can greatly increase the costs of national immunisation programmes.

With many new vaccines expected to be available in the near future, issues of financing and financial sustainability will become ever more important. Because low-income countries often have little ability to pay, manufacturers give priority to providing vaccines for higher-income markets, where their investments can be recouped more quickly.

A new approach to financing immunisation, which could help millions of children receive pneumococcal vaccines, began in 2010. It is called an Advance Market Commitment (AMC).
Under the AMC, the Gates Foundation and five governments (Italy, Canada, Norway, Russia and the UK) have committed $1.5 billion to purchase pneumococcal vaccines. This commitment gives vaccine-makers an incentive to invest in developing and producing vaccines on a large scale. Low-income countries can then purchase the vaccines at guaranteed prices they can afford. Manufacturers make a commitment to supply a share of the total forecast of 200 million doses annually for 10 years.

The AMC provides a directly proportional share of the $1.5 billion. For instance, if a manufacturer supplies 100 million doses, it is entitled to receive $750 million.

This initiative could help save up to 7 million lives in 20 years. Once the model has been validated, a similar approach is planned for future vaccines against diseases like malaria, tuberculosis and HIV. When world leaders adopted the Millennium Declaration in 2000, they produced an unprecedented international contract, a pledge to create a more peaceful, tolerant and equitable world in which the special needs of children, women and the vulnerable can be met.

The Millennium Develop-ment Goals (MDGs) are a practical manifestation of the Declaration’s aspiration to reduce inequity in human development among nations and peoples by 2015.

The past decade has seen considerable progress towards the goals of reducing poverty and hunger, combating disease and mortality, promoting gender equality, expanding education, ensuring safe drinking water and basic sanitation and building a global partnership for development.

These initiatives add momentum to the push toward the Millennium Development Goals adopted by world leaders in 2000. Reaching MDG 4 — a two-thirds reduction in the 1990 under-five mortality rate by 2015 — would avert 5.4 million child deaths annually.

‘Those with severe growth faltering, chronic diarrhoea or blood in the stool warrant immediate referral’

Soya infant formula is not the first-line option in the management of suspected cow’s milk allergy (CMA). I often field phone calls from the mothers saying, “I was told to put the baby on soya formula. He’s a bit better, but he’s still not right”.
The easy availability of soya formula in the supermarket often means that a health professional may not be consulted and many infants end up on soya formula as a result. Soya formula has its necessary use in the management of infants with galactosaemia, but it is not for those with symptoms ranging from colic to reflux to eczema. Hospitals are not exempt from the use of soya formula, either. So why should it not be used as a first line?

Read on.

Differentiating the infant with cow’s milk allergy can be difficult. CMA is not always a given certainty in the infant covered in nasty eczema. In fact, quite often the infant who refuses to feed and is fighting the bottle/breast may be suffering from the consequences of CMA. Remember, you cannot always see what is going on inside. Immune reactions do not always show themselves on the outside.

So, is the infant sitting in front of you in a busy surgery cow’s-milk allergic or not? While rare in the exclusively breastfed population (0.5 per cent), it does occur and can be missed. However, in Ireland, exclusively breastfed infants are in a minority, with the bulk of them being ‘topped up’ or completely formula-fed. It is estimated that CMA affects between 2.5 per cent and 7 per cent of European infants. In 2009, some 74,728 births were recorded in Ireland, so CMA could have been seen in approximately 1,500-5,600 of them.

Multiple formulas
The mothers of many of these infants present with stories of trying multiple infant formulas, swapping and changing every few days with the same refrain — “my baby is not right”. In addition, they are often the ‘frequent flyers’ of general practice, with high levels of parental stress and an infant termed ‘colicky’.

Severe CMA is impossible to miss. Infants with severe systemic reactions, such as anaphylaxis or difficulty breathing, are thankfully rare and will usually present to the emergency department. Those with severe growth faltering, chronic diarrhoea or blood in the stool warrant immediate referral to a paediatric specialist for advice and management.

The majority of these infants will require an elemental formula such as Neocate (SHS), as well as a milk-protein-free diet until they grow out of the problem. Some never do. As these infants grow into children, they should be under the care of paediatric service, with dietetic access to ensure appropriate dietary management.

In day-to-day clinical practice, you should be suspicious of mild-to-moderate CMA in any infant presenting with one or more of the following:

• Gastrointestinal: frequent vomiting or regurgitation, diarrhoea or constipation, blood in the stool, iron deficiency anaemia;
• Dermatological: atopic dermatitis, urticaria unrelated to acute illness or drug ingestion, reported swelling of the lips or eyes (angioedema);
• Respiratory: runny nose, chronic cough or wheeze unrelated to infection;
• General: persistent distress or colic, infant not willing or difficult to feed.

Always remember the key is in the history; take time to listen to the parent(s) and do not put it down to colic, especially where there is a parental history of asthma, hay fever or eczema.

So, you are suspicious that the infant with the dry skin, loose stools and parentally described extreme periods of being inconsolable, crying after bottle feeding, could have CMA. What can you do? Recommend soya or extensively hydrolysed (eHF) or elemental formula? Or should you just refer for paediatric review at the nearest hospital and let it be sorted out there?

You may not have access to skin-prick testing (SPT) or Specific IgE to diagnose this infant, but remember, that will only diagnose those with IgE-mediated CMA and not those with non-IgE mediated CMA. As a dietician in a hospital that does not currently use SPT, it takes an average of three-to-four weeks for specific IgE results to come through.

Primary-care management
Simple, first-line management is elimination of what you think is the problem — cow’s-milk protein. There is no reason why this cannot be done in primary care. So, what advice can you give?

Breast-feeding mother: advise the mother to remove all sources of cow’s-milk protein from her diet for a minimum of a two-week period. Do not forget about the need for a suitable calcium supplementation for the mother. Review within the two weeks. If there is improvement, re-introduction should re-trigger symptoms in the CMA infant.

Advise the mother to remain on a cow’s-milk-protein-free diet and supplement with calcium. If the mother wishes to introduce a formula, advice on the use of an extensively hydrolysed formula (eHF) such as Nutramigen or Aptamil Pepti should be given.

These are formulas where the protein source has been broken down to peptides. Available eHFs vary in protein source, allergenicity, palatability, fat source, novel substrates and presence of lactose.

Hypoallergenic formula
Formula-fed infant: the trial of a hypoallergenic formula is central to both diagnosis as well as management. eHF (Nutramigen/Aptamil Pepti) is a cost-effective means of diagnosis and is generally well tolerated in the bulk of infants. A minimum of two weeks is recommended and for those with little improvement within this period, a trial of elemental formula/amino acid formula (AAF) such as Neocate is warranted.

It is important to explain to parents that persistence is the key in getting infants to drink these formulas, as often this is the first hurdle to overcome. Infants will naturally prefer breast/standard infant formula, as hypoallergenic formulas by nature tend to be bitter-tasting. However, the innate drive of thirst and hunger will overcome this.

When it comes to introducing solids to the infant’s diet, these also need to be milk-free and it is advised that infants remain cow’s-milk-free for at least six months or until they are approximately 9-12 months of age.

All infants and young children would benefit from review by a dietician with experience in dealing with CMA and referral for paediatrician assessment, as food allergy is part of the allergic march and for some, it can progress to the development of asthma/hay fever. Not all infants and children need referral to a paediatric allergist and can be managed effectively by local hospitals by staff with a knowledge and understanding of allergic disease.

Soya formula
So, why have I not mentioned soya formula before now? Well, in the management of CMA, it is not a first-line option. Soy is not hypoallergenic. Adverse reactions to soy have been reported in 10 per cent to 35 per cent of infants with CMA, regardless of whether or not they were positive or negative for specific IgE antibodies for cow’s milk protein.

Moreover, soy formulations contain high concentrations of phytate, aluminium and phyto-oestrogens (isoflavones), which may have undesired effects and are best avoided in infants less than six months. So, as a dietician, do I use soya in the diet of young infants and children? Well yes, I do, but generally after six months of age and in small amounts in those that tolerate it.

Many do not — hence why soya is not suitable as a first-line management in the treatment of suspected CMA.

Neither is goat’s milk an infant drink. It is an Irish phenomenon that is banned in most of Europe. This product is available on the Irish market and given its cross-reactivity, it is an anaphylactic risk for CMA-allergic infants and young children, as well as being unsuitable on a nutritional perspective as an infant formula.

So, if you think an infant has CMA, do not fear it. A trial of hypoallergenic formula is not only practical, but diagnostic. However, do not forget to monitor the infant as there are other differential diagnoses. When the above advice is not working, or you are not sure, then refer for paediatric specialist review.

References on request.

Deborah Griffin is a Senior Paediatric & Neonatal Dietitian in Waterford Regional Hospital