ProQuad (Merck), the new combination vaccine, is the latest vaccine to hit the market for varicella. Efficacy and prelicensure studies showed that ProQuad is comparable to administering the vaccines separately, according to Váquez. What makes this vaccine different is that the amount of varicella virus in the MMRV vaccine is about seven times higher than what is in the traditional two-dose vaccine, as a result of the necessary counterbalance needed to combine MMR and varicella vaccines. ProQuad is approved for children aged 1 to 13 years.

Immunization in Infants : Long Needle or Short Needle?

Vaccination with long needles resulted in fewer local reactions.

Little is known about the effect of needle size on vaccine efficacy and side effects. In a randomized clinical trial from the U.K., 696 healthy infants were vaccinated at 2, 3, and 4 months of age using the standard 25-gauge 25-mm-long needle, a slightly thicker one (23 gauge, 25 mm long), or a slightly shorter one (25 gauge, 16 mm long). The infants received a combined diphtheria, tetanus, whole cell pertussis, and Haemophilus influenzae type b vaccine in one leg and a serogroup C meningococcal glycoconjugate vaccine in the other.

Parents maintained diaries on reactions following immunizations. Infants vaccinated with standard-length needles of both gauges experienced significantly fewer local reactions (i.e., swelling, redness, hardness, or tenderness) than infants vaccinated with shorter needles; this difference was not significant at 6 hours postimmunization, but was significant at days 1, 2, and 3. Of 11 infants who were withdrawn from the study because of extensive redness and swelling, 10 had been vaccinated using shorter needles. Immunogenicity, as measured by antibody concentrations to the various antigens at 28 to 42 days after the third dose, was similar in the three groups.

Comment: These results support the American Academy of Pediatrics’ recommendation that infants from 2 to 12 months of age be vaccinated with 7/8-inch (22.2 mm) to 1-inch (25.4 mm) needles. Longer needles appear to elicit fewer local reactions — possibly because, as an editorialist comments, they ensure that vaccines are injected into muscle rather than into subcutaneous tissue.

— Howard Bauchner, MD in Journal Watch Pediatrics and Adolescent Medicine November 8, 2006

OBJECTIVE. The objective of this study was to assess whether computer-stored digital sound recordings can be used to distinguish innocent from pathologic systolic murmurs.

METHODS. Recordings of 55 children aged 1 month to 19 years were made remotely with the use of a digital stethoscope and were e-mailed to a computer in our center for later assessment. Eight-second recordings were made by a physician in 2 to 4 locations on the chest. Three cardiologists who were blinded to the diagnosis reviewed the recordings independently using stethophones to assess the splitting of the second heart sound and whether murmurs were innocent or pathologic. Diagnoses were confirmed with echocardiography.

RESULTS. Seventeen children had innocent murmurs and 38 had pathologic murmurs. For the 3 cardiologists, sensitivity was 0.87 to 1.0, specificity was 0.82 to 0.88, negative predictive value was 0.75 to 1.0, and positive predictive value was 0.93 to 0.95. Assessment of splitting of second heart sound was highly accurate.

CONCLUSIONS. Digital recordings of children’s heart sounds allow reliable differentiation between innocent and pathologic murmurs. Use of this technology may allow remote diagnosis of childhood murmurs and avoid the expense and stress of travel to pediatric cardiology centers for some children. Cardiologists who use recordings should assess their diagnostic accuracy before clinical application. (Pediatrics (December 2006) 118: 2322-2325.)

The pulsed dye laser (PDL), now in its third generation, is the treatment of choice for port wine stains (PWSs). Dramatic, if not total, fading is possible in most patients. What is the chance that a laser-treated PWS will recur? In this retrospective study from the U.K., 110 pediatric patients with PWS treated with the 585-nm PDL were evaluated for lesion reemergence. Of the 110 patients, 16 were excluded from analysis (because of missing records, incomplete treatment, loss to follow-up, or lack of response).

Treatment was stopped when the lesion had faded completely, the patient was happy with the result, or the physician felt that the response was so good that further treatment was not indicated. Reemergence of the PWS necessitating additional PDL treatment occurred in 15 of the 94 patients (16%), 17 to 59 months (mean, 31 months) after the initial PDL series.

Comment: Contrary to initial reports of 100% fading in 100% of patients treated with PDL, total fading is seen in only a minority of patients, and a considerable number of lesions re-darken. This is consistent with the fact that the blood vessels in the PWS-affected skin lack the autonomic innervation that gives blood vessels their tone. Without autonomic nerve support, the vessels become ectatic. Any vessels remaining after PDL treatment, even small, apparently normal vessels, can be expected to dilate over time, leading to re-darkening of the PWS. The rate of recurrence after treatment with the newer PDLs — which have longer pulse durations, higher energy fluences with cooling, and large spot sizes — remains to be determined. Treatment is still worthwhile for most patients, as only a minority of lesions recur, and these recurrent lesions tend to be much lighter than the initial PWS. Retreatment every few years can keep patients free of clinically visible PWSs.

— George J. Hruza, MD Journal Watch Dermatology September 22, 2006

Patterns of Inhaled Antiinflammatory Medication Use in Young Underserved Children With Asthma

CONCLUSIONS. Overreliance on short-acting ß agonist and underuse of inhaled corticosteroid medications was common in this group of young children with persistent asthma. Only one fifth of children obtained sufficient controller medication fills. (Pediatrics, December 2006, 118: 2504-2513)