Safe MMR vaccination despite neomycin allergy
1
365 Traumatic avulsion of the left common carotid artery I SiR,—Your editorial (Nov 24, p 1287) rightly noted that rupture of the intrathoracic aorta is a common result of road-traffic accidents. Crush injuries can have the same effect, although damage may be unusual and may result from forces other than those generated by acceleration/deceleration. A 14-year-old male cyclist was admitted to hospital after being knocked down by a car that had allegedly reversed over him. He had sustained a closed head injury and fractured right olecranon. The pattern of a tyre tread ran obliquely across his anterior chest wall. An erect chest radiograph showed widening of the mediastinum and changes consistent with contusion of the right lung. Aortography revealed the appearance of an aneurysm near the origin of the left common carotid artery. During emergency surgery, under hypothermic cardiopulmonary bypass, the left common carotid artery was found to be avulsed from the aortic arch for about 75 % of its circumference. Haematoma extended inferiorly around the ascending aorta. Re-implantation of the carotid vessel into the aorta was held to be impossible and an anastomosis to the innominate artery was completed. The defect in the aorta was repaired with a single layer of suture reinforced with ’Teflon’. The patient has recovered. Previous reports of blunt trauma to the major branches of the aorta have related to the innominate and subclavian arteries1,2 and, occasionally, avulsion of the left common carotid and other arteries together.2 Isolated disruption of the left common carotid artery is rare.3-5 Nevertheless, aortography or computed tomography should routinely include examination of the major branches of the aorta. Department of Academic Cardiology, St Mary’s Hospital Medical School, London W2 1NY, UK Wessex Cardiothoracic Unit, Southampton General Hospital, Southhampton, UK R. H. DAVIES N. CONWAY R. K. LAMB 1 Kirsh MM, Orringer MB, Behrendt DM, Mills LJ, Tashian J, Sloan H Management of unusual traumatic ruptures of the aorta Surg Gynecol Obstet 1078, 146: 365-70 2 Faro RS, Monson DO, Weinberg M, Hushang J. Disruption of aortic arch branches due to nonpenetrating chest trauma Arch Surg 1983; 118: 1333-36 3 Schmidt CA, Smith DC Traumatic avulsion of arch vessels in a child, primary repair using hypothermic circulatory arrest (case report). J Trauma 1989, 29: 248-50 4 Perry MO, Snyder WH, Thal ER Carotid artery injuries caused by blunt trauma Ann Surg 1980, 192: 74-77 5. McNab AA, Fabinyi GC, Milne PY Blunt trauma to the carotid artery. Aust N Z J Surg 1988, 58: 651-56 Safe MMR vaccination despite neomycin allergy SIR,-Hypersensitivity to a vaccine constituent is one of the few contraindications to vaccination. The mumps, measles, and rubella vaccine (MMR) sometimes contains small quantities of neomycin or kanamycin and an allergy to either of those constituents is a contraindication to the vaccine. 1 A 3-year-old girl was brought to her general practitioner for MMR vaccination and, on direct questioning by the practice nurse, gave a history of a previous reaction (swelling and erythema) to neomycin-containing ear drops when 18 months of age. She was referred to the paediatric immunisation advice clinic. Before this episode, she had received a full course of diphtheria, pertussis, and tetanus, poliomyelitis, and measles vaccination with no reaction. The girl’s mother has a contact dermatitis to metals and her grandmother has asthma. Although positive prick tests were found to egg, milk, and housedust, a prick test with undiluted MMR vaccine was negative. Patch testing to 25 common contact allergens gave a positive reaction to 20% neomycin sulphate. 0-5 ml MMR vaccine was given intramuscularly. There were no immediate or delayed adverse reactions. The frequency of contact sensitivity to neomycin in children is not accurately known, but estimates vary from to 1 out of 6532 to 25 out of 314 children However, such contact sensitivity should not contraindicate vaccination. The child should be referred to a paediatncian and, where appropriate, further investigations undertaken. Rarely will it be necessary to withhold the vaccine, though in some cases it may be wise for vaccination to be completed in hospital. Since the neomycin solutions given in intradermal tests contain between four and forty times the amount of neomycin as does the MMR vaccine there is little logic in doing intradermal testing. Continuing Care Unit, Clare House, St George’s Hospital, London SW17, UK DAVID ELLIMAN BIBI DHANRAJ 1. Department of Health and Social Security. Immunisation against infectious disease. London: HM Stationery Office, 1990. 2 Leyden JJ, Kligman AM. Contact dermatitis to neomycin sulfate. JAMA 1979; 242: 1276-78. 3 Weston WL, Weston JA, Kinoshita J, et al. Prevalence of positive epicutaneous tests among infants, children, and adolescents. Pediatrics 1986; 78: 1070-74. 4 Rietschel RL. Neomycin sensitivity and the MMR vaccine JAMA 1981; 245: 571. Weight and failure to thrive in infancy SiR,—There is an urgent need for a reproducible definition of failure to thrive, and the consensus lately has been that this should be growth based Edwards and colleagues’ definition,3 being velocity based, is very attractive. However, a continuing retrospective study in Newcastle in which this definition is used has yielded surprising results. The records of all 3418 full-term infants aged 18-30 months who were living in Newcastle on Dec 1, 1989, have been reviewed to obtain routinely collected weight data. For every child one weight was extracted, as available, in each of ten age bands between 1 and 18 months. The weights were converted to Z scores, corrected for skew, with Tanner and Whitehouse data as standard, in a fortran subroutine, and then analysed by SPSS. 70% of children had sufficient weights records to allow the application of Edwards and colleagues’ definition. This method3 uses weights manually plotted onto centile charts, and subsequent growth is compared with a baseline centile position at 4-8 weeks. Failure to thrive was defined as a fall from baseline to below two major centile lines, persisting for at least 1 month. The best approximation to this in our study was a fall of one standard deviation (SD) from the baseline Z score at 4-8 weeks. The proportion of Newcastle children in our study meeting this definition was 34%, a very high figure, indicating that Edward’s definition as thus applied included too many of these children. On looking at the Z score trend for the whole cohort this finding is readily explained (figure). It is clear that the match with the Tanner and Whitehouse standards is very poor, with a mean fall of 0-5 SD between 6 weeks and 1 year of age. This mismatch has been described before,* but its importance in the context of failure to thrive has not previously been appreciated. The data for Tanner and Whitehouse standards were collected in the 1950s and were based on only 80 children.5 Our findings emphasise the urgent need for new growth standards in infancy. Weight standard deviation (Z) scores compared with Tanner and Whitehouse standards. B = at birth.
Transcript of Safe MMR vaccination despite neomycin allergy
365
Traumatic avulsion of the left commoncarotid artery
I
SiR,—Your editorial (Nov 24, p 1287) rightly noted that ruptureof the intrathoracic aorta is a common result of road-traffic
accidents. Crush injuries can have the same effect, although damagemay be unusual and may result from forces other than those
generated by acceleration/deceleration.A 14-year-old male cyclist was admitted to hospital after being
knocked down by a car that had allegedly reversed over him. He hadsustained a closed head injury and fractured right olecranon. Thepattern of a tyre tread ran obliquely across his anterior chest wall.An erect chest radiograph showed widening of the mediastinum andchanges consistent with contusion of the right lung. Aortographyrevealed the appearance of an aneurysm near the origin of the leftcommon carotid artery. During emergency surgery, under
hypothermic cardiopulmonary bypass, the left common carotidartery was found to be avulsed from the aortic arch for about 75 % ofits circumference. Haematoma extended inferiorly around theascending aorta. Re-implantation of the carotid vessel into the aortawas held to be impossible and an anastomosis to the innominateartery was completed. The defect in the aorta was repaired with asingle layer of suture reinforced with ’Teflon’. The patient hasrecovered.
Previous reports of blunt trauma to the major branches of theaorta have related to the innominate and subclavian arteries1,2 and,occasionally, avulsion of the left common carotid and other arteriestogether.2 Isolated disruption of the left common carotid artery israre.3-5 Nevertheless, aortography or computed tomography shouldroutinely include examination of the major branches of the aorta.
Department of Academic Cardiology,St Mary’s Hospital Medical School,London W2 1NY, UK
Wessex Cardiothoracic Unit,Southampton General Hospital,Southhampton, UK
R. H. DAVIES
N. CONWAYR. K. LAMB
1 Kirsh MM, Orringer MB, Behrendt DM, Mills LJ, Tashian J, Sloan H Managementof unusual traumatic ruptures of the aorta Surg Gynecol Obstet 1078, 146: 365-70
2 Faro RS, Monson DO, Weinberg M, Hushang J. Disruption of aortic arch branchesdue to nonpenetrating chest trauma Arch Surg 1983; 118: 1333-36
3 Schmidt CA, Smith DC Traumatic avulsion of arch vessels in a child, primary repairusing hypothermic circulatory arrest (case report). J Trauma 1989, 29: 248-50
4 Perry MO, Snyder WH, Thal ER Carotid artery injuries caused by blunt trauma AnnSurg 1980, 192: 74-77
5. McNab AA, Fabinyi GC, Milne PY Blunt trauma to the carotid artery. Aust N Z JSurg 1988, 58: 651-56
Safe MMR vaccination despite neomycinallergy
SIR,-Hypersensitivity to a vaccine constituent is one of the fewcontraindications to vaccination. The mumps, measles, and rubellavaccine (MMR) sometimes contains small quantities of neomycinor kanamycin and an allergy to either of those constituents is acontraindication to the vaccine. 1
A 3-year-old girl was brought to her general practitioner forMMR vaccination and, on direct questioning by the practice nurse,gave a history of a previous reaction (swelling and erythema) toneomycin-containing ear drops when 18 months of age. She wasreferred to the paediatric immunisation advice clinic. Before thisepisode, she had received a full course of diphtheria, pertussis, andtetanus, poliomyelitis, and measles vaccination with no reaction.The girl’s mother has a contact dermatitis to metals and hergrandmother has asthma. Although positive prick tests were foundto egg, milk, and housedust, a prick test with undiluted MMRvaccine was negative. Patch testing to 25 common contact allergensgave a positive reaction to 20% neomycin sulphate. 0-5 ml MMRvaccine was given intramuscularly. There were no immediate ordelayed adverse reactions.The frequency of contact sensitivity to neomycin in children is
not accurately known, but estimates vary from to 1 out of 6532 to 25out of 314 children However, such contact sensitivity should notcontraindicate vaccination. The child should be referred to apaediatncian and, where appropriate, further investigations
undertaken. Rarely will it be necessary to withhold the vaccine,though in some cases it may be wise for vaccination to be completedin hospital. Since the neomycin solutions given in intradermal testscontain between four and forty times the amount of neomycin asdoes the MMR vaccine there is little logic in doing intradermaltesting.
Continuing Care Unit,Clare House,St George’s Hospital,London SW17, UK
DAVID ELLIMANBIBI DHANRAJ
1. Department of Health and Social Security. Immunisation against infectious disease.London: HM Stationery Office, 1990.
2 Leyden JJ, Kligman AM. Contact dermatitis to neomycin sulfate. JAMA 1979; 242:1276-78.
3 Weston WL, Weston JA, Kinoshita J, et al. Prevalence of positive epicutaneous testsamong infants, children, and adolescents. Pediatrics 1986; 78: 1070-74.
4 Rietschel RL. Neomycin sensitivity and the MMR vaccine JAMA 1981; 245: 571.
Weight and failure to thrive in infancySiR,—There is an urgent need for a reproducible definition of
failure to thrive, and the consensus lately has been that this shouldbe growth based Edwards and colleagues’ definition,3 beingvelocity based, is very attractive. However, a continuingretrospective study in Newcastle in which this definition is used hasyielded surprising results.The records of all 3418 full-term infants aged 18-30 months who
were living in Newcastle on Dec 1, 1989, have been reviewed toobtain routinely collected weight data. For every child one weightwas extracted, as available, in each of ten age bands between 1 and 18months. The weights were converted to Z scores, corrected forskew, with Tanner and Whitehouse data as standard, in a fortransubroutine, and then analysed by SPSS. 70% of children hadsufficient weights records to allow the application of Edwards andcolleagues’ definition. This method3 uses weights manually plottedonto centile charts, and subsequent growth is compared with abaseline centile position at 4-8 weeks. Failure to thrive was definedas a fall from baseline to below two major centile lines, persisting forat least 1 month. The best approximation to this in our study was afall of one standard deviation (SD) from the baseline Z score at 4-8weeks. The proportion of Newcastle children in our study meetingthis definition was 34%, a very high figure, indicating thatEdward’s definition as thus applied included too many of thesechildren.On looking at the Z score trend for the whole cohort this finding is
readily explained (figure). It is clear that the match with the Tannerand Whitehouse standards is very poor, with a mean fall of 0-5 SDbetween 6 weeks and 1 year of age. This mismatch has beendescribed before,* but its importance in the context of failure tothrive has not previously been appreciated. The data for Tannerand Whitehouse standards were collected in the 1950s and werebased on only 80 children.5 Our findings emphasise the urgent needfor new growth standards in infancy.
Weight standard deviation (Z) scores compared with Tannerand Whitehouse standards.
B = at birth.
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