One hundred forty-two allergic children aged three to 18 years were studied for evaluation of the usefulness of skin testing with influenza vaccine as a means of identifying those children who could be immunized safely despite their allergies to chickens, eggs, or feathers. One hundred twenty-eight children were fully immunized with bivalent influenza A/New Jersey/76-A/Victoria/75 vaccine. Twelve children had positive skin tests and were not immunized, and two developed positive skin tests after their first injection. One child had urticaria 8 hr later, one had a nonspecific reaction, and one had a self-limited erythema multiforme reaction eight days after the second injection. All others tolerated the procedure well. History of sensitivity to eggs was not as reliable an indication of vaccine sensitivity as skin testing with vaccine. A negative result of an intradermal skin test with a 1:100 dilution of the vaccine in saline appeared to be a reliable indicator of allergic subjects who could be immunized against influenza without fear of life-threatening acute allergic reactions.
Although pediatricians usually take great care in accurately calculating medication for their patients, the important processes of measuring and administering the dose are often overlooked. Many of the problems encountered in the administration of tablets and capsules to small children have been overcome by the production of medications in liquid form. However, the advantage gained in the administration of liquid products is often lost because of the inaccuracy of the devices used to measure and administer them. Liquid doses may be inaccurate for several reasons. The measuring devices commonly used today include household spoons, cups, and specific devices provided by pharmaceutical manufacturers to be used with their products. Teaspoons are particularly poor measuring and administering devices. The measured capacity of the teaspoon has been shown to be within the range of 2.5 to 7.8 ml.1,2 In addition, teaspoons are a poor delivery device because they tip easily. Furthermore, the same spoon, when used by different persons, may deliver from 3 to 7 ml.3 Such variations may be related to factors such as pouring the liquids from different-sized bottles, the color of the liquids, and the adequacy of available light. Perhaps the most important factor in measurement is related to the care practiced by the person doing the measuring. Although the American Pharmaceutical Association (in 1902) and the American Medical Association (in 1903) defined the "standard teaspoonful" as 5 ml, this recommendation has not been universally adopted.4 The practice of some pharmaceutical manufacturers of establishing doses in 4-ml and other fractions of a "teaspoon" tends to confuse the prescribing physician when it comes to instructing patients.
Anaphylaxis* is an acute reaction, which may range from mild self-limited symptoms to a grave medical emergency. It is caused by a variety of agents, usually occurs unexpectedly, frequently is iatrogenic, and can be fatal if not treated promptly and appropriately. Every physician's and dentist's office, pediatric outpatient clinic, hospital emergency room, allergy clinic or allergy testing laboratory, and radiology department should be equipped to treat this potential disaster.1 The Committee on Drugs of the American Academy of Pediatrics has reviewed the equipment and procedures necessary to treat this emergency, and offers this guide to physicians. CLINICAL PICTURE Anaphylaxis is usually characterized by the following sequence of signs and symptoms: generalized flush, urticaria, paroxysmal coughing, severe anxiety, dyspnea, wheezing, orthopnea, vomiting, cyanosis, and shock. The sooner symptoms develop after the initiating stimulus the more intense the reaction. Symptoms beginning within 15 minutes after administration of the inciting agent require the most expedient management. The primary cause of death in the child is laryngeal edema. In the adult, cardiac arrhythmais may be superimposed on acute upper airway edema.2 MAJOR CAUSES OF ANAPHYLAXIS Table I lists the most common agents associated with anaphylaxis in children. The severity and acuteness of onset will depend upon both the type of agent and the route of administration. Generally, agents administered parenterally are more apt to result in severe life-threatening or fatal anaphylactic reactions than those ingested orally or administered topically to mucus membranes. Medications administered orally, such as aspirin or penicillin, however, have been associated with fatal reactions so that the oral route cannot be utilized with impunity.
When broad-spectrum antibiotics were first introduced two decades ago for the treatment of acne, justification for such therapy seemed reasonably straightforward, e.g., the suppression of the suppurative inflammatory lesions commonly encountered in acne. As time went on, however, certain observations raised questions concerning the rationale for this form of treatment. First, it became apparent with cumulative clinical experience that the disease could ordinarily be controlled by doses of antibiotics lower than those required to treat bacterial infections. Second, bacteriologic studies disclosed that the only bacteria regularly recoverable from acne lesions were the anaerobic diphtheroid Corynebacterium acnes and aerobic coagulase-negative cocci, predominantly staphylococcus type II; both of these bacteria are known to be normal resident skin organisms.1 Thus, as no reports of controlled studies were then available for assessing the true efficacy of antibiotics used in the treatment of acne, the uneasy suspicion arose that such therapy might be inducing a primarily placebo response. In 1965, Freinkel and her collaborators2 demonstrated that the oral administration of tetracycline, even in doses as small as 250 mg daily, resulted in a significant reduction of the free fatty acid concentration of the lipid (sebum) secreted to the skin surface by the sebaceous glands. This effect could be observed in normal subjects as well as in patients with acne and was entirely reversible on discontinuance of drug. The inflammatory lesions of acne are known to result from disorganization of the follicular epithelium, with consequent liberation of the intrafollicular contents, containing sebum, into the dermis.3
One of the most important concepts in pediatric pharmacology is that exposure to drugs or chemicals may have latent, unforeseen effects on the child later in life. Some of the most dramatic occurrences, other than teratogenesis, are those in which hormonal exposure during the fetal or newborn period alters adult sexual development. However, none of these episodes is more impressive and ominous than that reported by Herbst et al.1 Herbst, an obstetrician at the Massachusetts General Hospital, was intrigued by the presentation of seven patients with adenocarcinoma of the vagina, an extremely rare tumor not previously seen at the hospital. The patients ranged in age from 14 to 22 years and sought medical advice because of vaginal bleeding. Several had benign adenosis, suggesting that the malignant change seen in all was based on a fundamental alteration in the biology of the vaginal epithelium. Six of the patients were treated with radical surgery, and one was treated with wide, local excision. One of the patients died after surgery. In what could serve as a model of a scientifically conducted, epidemiologic study, each of the seven patients, plus an additional patient from another hospital, was matched with four controls born in the same hospital within four days. Thus, the "control" group was chosen in a manner to eliminate many biases of artificially contrived control populations. A wide variety of possible influences in both mothers and offspring were considered, e.g., maternal age, smoking habits, exposure to X-rays, breast-feeding, birth weight, age at menarche, medications during pregnancy, and so forth.
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