Brief Reports

Varicella Zoster Immunoglobulin may not Prevent Severe Neonatal Varicella

Source:Reynolds L, et al. Neonatal varicella: Varicella zoster immunoglobulin (VZIG) does not prevent disease. Arch Dis Child Fetal Neonatol Ed 1999;81:69-70.

As many as 50% of infants develop clinical varicella if the mother develops chickenpox four or fewer days before delivery and up to two days after delivery. In these clinically infected newborns, the fatality rate is as high as 31% if no prophylaxis or therapy is given. The use of varicella zoster immunoglobulin (VZIG) can modify the clinical course and usually prevents more serious neonatal disease. However, although decreased, the risk of fatality is not totally eliminated.

Reynolds and associates from the St. Mary’s Hospital Medical School in London describe two Asian newborns with severe neonatal varicella infections. One of the mothers developed chickenpox two days before delivery; the other one day after delivery. Both infants received intramuscular VZIG in the first day of life, but no information concerning further care or follow-up was apparently given to the families or out-of-hospital health care providers. At 10 and 11 days of life, the infants developed severe disease requiring ventilatory support. Intravenous acyclovir was administered for 2-3 weeks. Both babies recovered after a stormy hospital course.

In both of these patients, there was a three-day delay from the onset of symptoms and the institution of antiviral therapy with acyclovir, a delay resulting from an apparent lack of awareness of the high risk of varicella in the infants that is not totally prevented by appropriate therapy with VZIG. The average interval between the onset of the mother’s rash to the baby’s rash in untreated cases is 11 days. However, administration of VZIG to the newborn baby can prolong the incubation period to as long as 30 days.

When a neonate has received VZIG because of maternal perinatal chickenpox, it should be made clear to the parents and health workers that if the baby becomes sick or develops any kind of a rash, the child should be seen and hospitalization for prompt institution of acyclovir therapy should be strongly considered to prevent avoidable morbidity and even mortality. Even the 1997 AAP Red Book is less than definitive on this point. VZIG (125 U) is recommended for infants whose mothers have the onset of varicella from five days before to two days after delivery. Approximately half of these newborns can be expected to develop varicella even if VZIG is administered, but "the disease is often modified. Nevertheless VZIG recipients should be followed closely." —lmb

Varicella-zoster immunoglobulin therapy as prophylaxis for neonatal varicella:

a. is indicated when the mother has the onset of clinical chickenpox two days after delivery.

b. is indicated when the mother has the onset of clinical chickenpox seven days before delivery.

c. invariably prevents severe neonatal varicella.

d. should regularly be supplemented with acyclovir therapy to the infant.

Lead Poisoning in Competitive Shooters

Source: Shannon M. Lead poisoning in adolescents who are competitive marksmen. N Engl J Med 1999;341:852.

Four adolescent girls, 14-16 years of age, were found to have elevated blood lead levels, 18-28 mg/dL. All four girls were competitive marksmen at a single indoor firing range in Boston. None was symptomatic. One girl had an initial blood lead level determined by finger stick to be 100 mg/dL, indicating considerable skin contamination, which was presumably the source of exposure. Environmental exposure ingestion of chips and dust from lead-containing paint is the most common cause of lead poisoning in children. However, exposure can also occur from other sources, including smelters and burning of storage batteries. In older individuals, lead poisoning has been associated with industrial exposure but has also been associated with gun use and has been reported among firearm instructors.1 The sport of competitive shooting is said to be increasingly popular, perhaps because of the concern about personal safety and the publicity and debate about gun use.

Two generations ago, one of the most popular toys of young boys involved melting lead in electric furnaces at home and using the molten lead to cast lead soldiers for play. We have no data concerning plumbism resulting from such a hobby, but I would bet that it was considerable. Although the elevation of blood lead in the adolescent girls was not extreme and no chelation therapy was used, it is increasingly accepted that chronic exposure should be avoided. It is incumbent upon pediatricians to question their adolescent patients about their hobbies. —hap

Elevated blood lead levels in adolescent competitive shooters:

a. are probably related to skin contamination.

b. are probably related to inhalation of lead in the air of the indoor firing ranges.

c. often require chelation therapy.

d. had no precedent in other gun users.

Infrequency of Serious Infections in Infants Younger than 8 Weeks with Otitis Media

Source: Nozicka CA, et al. Otitis media in infants aged 0-8 weeks: Frequency of associated serious bacterial disease. Pediatr Emerg Care 1999;15:252-254.

Nozicka and associates at the children’s hospital of Wisconsin emergency department (ED) in Milwaukee studied 40 nontoxic-appearing small infants with otitis media (OM) confirmed by a pediatric otolaryngologist using a binocular operating microscope. Thirty-eight percent (15/40) had rectal temperatures equal to or greater than 38°C. All infants had typanocentesis with middle ear fluid (MEF) culture and complete sepsis evaluation including CBC, blood culture, catheter urine culture, and lumbar puncture with cerebrospinal fluid (CSF) culture. All infants were treated with parenteral ampicillin and either gentamicin or cefotaxime and admitted to the hospital.

Bacterial pathogens were recovered from the MEF in 25/40 (62.5%) infants, and 15 infants had negative cultures of the MEF. All infants who were afebrile on admission to the ED had negative blood, urine, and CSF cultures. Only two of 15 febrile infants had positive cultures from sites other than the MEF.

Nozicka et al conclude that previously healthy, nontoxic-appearing afebrile, nontoxic infants aged 2-8 weeks of age with otitis media infrequently have an associated serious bacterial infection and the oral antibiotic therapy with close follow-up may be a reasonable therapeutic option. However, infants younger than 2 months of age with OM who are febrile, toxic, or who have signs of systemic illness require a full septic workup and consideration of parenteral antibiotic therapy. —lmb

Neonates with proven otitis media:

a. frequently have bacterial pathogens cultured from middle ear fluid.

b. frequently have bacterial pathogens cultured from other sites than the MEF.

c. have other positive bacterial cultures that are more frequent in febrile/toxic infants.

d. should always be hospitalized for a septic workup and parenteral antibiotics.