Abstract
Although the prevalence of smoking in the U.S. population has decreased, smoke exposure of infants and young children remains painfully common. The Surgeon General's report notes that there is no safe level of tobacco smoke exposure for a pregnant woman, her fetus, or newborn. 1 Although many women stop smoking with pregnancy, relapse after delivery is common. Given the prevalence and adverse impact of in utero and postnatal smoking, tobacco dependence treatment of the parent and caregivers needs to be an important part of fetal and neonatal care. However, it is frequently omitted from obstetric care and rarely included as part of neonatal care (as the infant is the patient, not the parent or caregiver). Adams et al. review the importance of tobacco smoke exposure for the fetus and newborn and their experience with implementing a tobacco counseling and treatment program for parents implemented as part of neonatal care. The conclusion—“This dismissal of our role in preventive health care and active intervention for pregnant women and their infants is intolerable in a society that values women and their pregnancies that produce our future generations of children”—calls us to action. 2 Those of us responsible for the healthcare of infants need to address their second-hand smoke exposure. As parents and caregivers are often the largest contributor to their infant's smoke exposure, counseling and treatment of parental tobacco dependence needs to become an important part of neonatal care. Research is urgently needed to find the best ways to incorporate parental tobacco dependence treatment into neonatal care.
Gerald et al. demonstrate that school policies to allow access to quick relief medication for children with asthma often fall short. Analysis of data collected from 290 children with asthma recruited in 2005 from 36 elementary schools in Jefferson County, Alabama, for participation in a clinical trial found that only 14% had a short-acting beta agonist for quick relief of asthma symptoms readily available at school. Not one had a full asthma action plan. 3 Although a single county and 6 years ago, I suspect if we were to survey children with asthma in most school systems today, most would probably show similar challenges. There continues with much to be done to make our schools asthma friendly.
A random sample survey of U.S. pediatricians examined decision making about pediatric asthma using a series of standardized vignettes, with each vignette differing by a parameter of interest, which were determined from qualitative analysis of results from focus groups of patients and providers. Consistent with current asthma guidelines, frequent symptoms were associated with worse assessments of asthma control; frequency of symptoms, medication intensity, and prior hospitalization were associated with assessments of greater asthma severity. The parameter of “bother” is not part of guideline based assessments (yet). However, report of greater bother in the vignettes was associated with assessment of worse control. Decisions to step up therapy were based on assessments of control. However, decisions to step down therapy were based on assessments of both control and severity (with pediatricians being more hesitant to step down therapy on a patient with more severe asthma even if well controlled). 4 Understanding how we make decisions is important, and optimally this understanding should influence guideline development.
Respiratory Syncytial Virus (RSV) infections usually occur in annual epidemics that generally start in the late fall, peak in the winter, and end by early spring. RSV infection causes close to 100,000 hospitalizations annually among infants <1 year old. 5 Premature infants are at greater risk than otherwise healthy infants. A retrospective medical records review of patients hospitalized with RSV in Austin, Texas, compared patients hospitalized for RSV in the “off season” (May to September) to the remainder of the year (October to April). They found that during the off season, a greater proportion of RSV admissions to the hospital were among premature infants and those with a history of a prior NICU stay than during the epidemic season. 6 In short, during the summer, RSV tended to focus on the more vulnerable to a greater extent than the winter. What could cause this difference? What could make the otherwise healthy infant more vulnerable to RSV in the winter than the summer? Associations between disease severity and viral load have been demonstrated: 7 viral load should be greater in the winter epidemic season than the summer off season, thus differentially impacting the most vulnerable in the summer. Perhaps viral co-infection is a factor. Studies of viral co-detection in RSV illness (two or more viruses detected at the time of RSV illness) have yielded conflicting results. 8 Perhaps it is not concurrent co-infection but sequential co-infection, so by the time the RSV infection hits a prior viral infection has been cleared but the damage to the respiratory epithelium has not. These findings suggest that a greater understanding of the biology of severe RSV infection may be gained by understanding how the winter has a greater impact on equalizing risk between the more and the less vulnerable.
Olivier et al. report on the mechanism of protein polymerization that may explain reduced allergenicity in some dairy products compared to native cow's milk proteins. The authors studied a cohort of 22 symptomatic children allergic to cow's milk by examining levels of serum-specific IgE to Bos d 5 (beta-lactoglobulin). A matched control group tolerant to cow's milk with undetectable specific IgE to Bos d 5 was used for comparison. Skin prick testing showed a significant reduction in skin test reactivity to polymerized bovine whey beta-lactoglobulin compared to native protein in Bos d 5 sensitized children. 9 Polymerization with transglutaminase is a food engineering process used for some dairy products such as cheese and yogurt, and this finding could explain why some children who are allergic to milk may tolerate these products. However, it is worth noting that two children in the cohort had positive skin tests to the polymerized lactoglobulin protein but were negative to the native protein. Therefore, an oral challenge protocol may be useful to define further the clinical relevance of the skin test results in selected circumstances.
We hope that you find these contents valuable. Thank you for your continued interest, and we look forward to your future contributions to the journal. Information for authors, as well as the complete table of contents for the journal, can be found at www.liebertpub.com/ped.