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All infants in the United Kingdom are routinely offered immunization against diphtheria, tetanus, and pertussis (DTP), polio, and Haemophilus influenzae type b (Hib) at 2, 3, and 4 months of [...], Objective. To study the effect of dexamethasone in preterm infants with chronic lung disease (CLD) on antibody response to routine immunization against diphtheria, tetanus, and pertussis (DTP). Methods. Serum samples were obtained before and after immunization with DTP (Trivax-AD) from an unselected cohort of 93 preterm infants in the United Kingdom. Antibodies to diphtheria and tetanus and to 4 pertussis antigens (pertussis toxin, filamentous hemagglutinin, pertactin, and fimbrial agglutinogens 2 + 3) were measured by an enzyme-linked immunosorbent assay. Linear regression models were fitted to the natural log of antibody titers to compare the dexamethasone-treated and -untreated infants adjusting for potential risk factors. Results. Sixty-seven (72%) of 93 infants received dexamethasone. Preimmunization geometric mean titers (GMTs) were comparable in both groups for all antibodies. The rise in GMT after immunization was reduced in the dexamethasone-treated group. Final GMT was significantly lower for tetanus, diphtheria, pertussis toxin, and fimbrial agglutinogens 2 + 3 but not for filamentous hemagglutinin or pertactin. Using the minimum protective titer of 0.01 IU/mL, there was no significant reduction in protection for diphtheria and tetanus in the dexamethasone-treated infants. Using the higher reference titer of 0.1 IU/mL, there was a 16% reduction in protection for diphtheria (95% confidence interval: 3%-27%) and a 9% reduction in protection for tetanus (95% confidence interval: -7% to 20%). Conclusions. The use of dexamethasone for CLD in preterm infants is associated with a reduction in antibody titer to routine immunization against diphtheria and tetanus. Antibody responses to 2 of 4 pertussis antigens are reduced, but the clinical significance of this observation is unclear. Protection against tetanus and diphtheria is not impaired when the lower reference value for protective antibody is used. On the basis of this study of UK preterm infants who were treated with dexamethasone for the management of CLD, we conclude that the current DTP immunization schedule is adequate and do not recommend additional booster protection against tetanus or diphtheria during early infancy. When diphtheria prevalence is increased, however, additional protection should be considered. Pediatrics 2004;113:733-737; preterm, dexamethasone, chronic lung disease, diphtheria, tetanus, pertussis, immunization.

To the Editor.-- In their recent Pediatrics article, Robinson et al(1) suggest that receipt of postnatal steroids impairs antibody response to tetanus and diphtheria immunization, having previously asserted the same [...]

PEDIATRICS 2006;118:e1657-e1666. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2005-2742 Paul Clarke, MB ChB, FRCPCH, MRCP (UK), Simon J. Mitchell, MD, FRCPCH, MRCP, Robert Wynn, MD, MRCP, MRCPath, Shanmuga Sundaram, MBBS, MRCPCH, Valerie Speed, BEd RGN, [...], OBJECTIVE. Preterm infants may be at particular risk from either inadequate or excessive vitamin K prophylaxis. Our goal was to assess vitamin K status and metabolism in preterm infants after 3 regimens of prophylaxis. METHODS. Infants RESULTS. On day 5, serum vitamin [K.sub.1] concentrations in the 3 groups ranged widely (2.9-388.0 ng/mL) but were consistently higher than the adult range (0.15-1.55 ng/mL). Presence of vitamin [K.sub.1] 2,3-epoxide on day 5 was strongly associated with higher vitamin [K.sub.1] bolus doses. Vitamin [K.sub.1] 2,3-epoxide was detected in 7 of 29 and 4 of 29 infants from the groups that received 0.5 mg intramuscularly and 0.2 mg intravenously, respectively, but in none of 32 infants from group that received 0.2 mg intramuscularly. After 2 weeks of full enteral feeding, serum vitamin [K.sub.1] was lower in the infants who received 0.2 mg intravenously compared with the infants in the control group. Three infants from the 0.2-mg groups had undetectable serum vitamin [K.sub.1] as early as the third postnatal week but without any evidence of even mild functional deficiency, as shown by their normal undercarboxylated prothrombin concentrations. CONCLUSIONS. Vitamin [K.sub.1] prophylaxis with 0.2 mg administered intramuscularly maintained adequate vitamin K status of preterm infants until a median age of 25 postnatal days and did not cause early [K.sub.1]O accumulation. In contrast, 0.2 mg administered intravenously and 0.5 mg administered intramuscularly led to [K.sub.1]O accumulation, possibly indicating overload of the immature liver. To protect against late vitamin [K.sub.1] deficiency bleeding, breastfed preterm infants given a 0.2-mg dose of prophylaxis should receive additional supplementation when feeding has been established. KEY WORDS. vitamin deficiency, preterm, prophylaxis, vitamin K, phytomenadione.

An interview with Liz Gardener, a forerunner in the field of water conservation, is presented. She mentions that she began a water education program in Denver Public Schools in Colorado, and the program quickly altered to conservation education. She states that it was easy for her to embrace the idea of not wasting water because she grew up in a family of poor farmers. She says that the 1977 drought concentrated attention on the reality that the population Denver Water served was developing.

Background: Spasticity is a common feature of multiple sclerosis (MS), especially in patients with longstanding illness. Medications that reduce spasticity may also reduce muscle strength, potentially impairing the ability to walk. Patients who do not respond adequately to conventional antispasticity medications need additional treatment options that improve spasticity without causing weakness. Objectives: Assess the relationship between changes in spasticity and muscle strength in lower extremities or mobility, using data from 3 randomized controlled trials (GWMS0106, GWSP0604, SAVANT) of nabiximols vs placebo in patients with spasticity due to MS inadequately controlled by antispasticity medications. Methods: Spasticity was evaluated using the Numerical Rating Scale (NRS) in all 3 trials, muscle strength using Motricity Index (MI) in GWMS0106 and GWSP0604, and mobility using timed 10-Meter Walk Test (10MWT) in GWSP0604 and SAVANT. Adjusted mean differences for change from baseline in outcome measures between nabiximols and placebo are summarized. Pearson correlation analysis was conducted to assess the association between change from baseline in spasticity and change in strength or mobility for nabiximols and placebo groups separately. Results: This analysis included 184 patients from GWMS0106, 241 from GWSP0604, and 106 from SAVANT. The baseline mean (SD) Expanded Disability Status Scale score was 6.0 (1.42) in GWSP0604 and 5.9 (1.1) in SAVANT. In GWMS0106, nabiximols significantly improved mean NRS spasticity score (-0.52 points [95% CI: -1.029, -0.004]; P = .048), without significantly affecting the MI for legs (3.86 [-0.06, 7.78]; P = .054). In GWSP0604, nabiximols significantly improved mean NRS spasticity score from baseline vs placebo (-0.84 [-1.29, -0.40]; P = .0002), without significantly affecting the MI for legs (0.97 [-1.49, 3.42], P = .439) or the 10MWT results (-3.34 [-6.95, 0.26]; P = .069). In SAVANT, nabiximols significantly improved spasticity vs placebo (-1.9 [-2.73, -1.06]; P < .0001), without significantly affecting the 10MWT results (-1.71 [-3.84, 0.44]; P = .11). Pearson correlation coefficients were all under ±0.30 (indicating negligible correlation) for the association between change in NRS and MI and for the association between change in NRS and 10MWT, except for the low positive correlation between NRS and 10MWT in the nabiximols group in SAVANT (0.326). Conclusions: The improvement in spasticity with nabiximols was not accompanied by the muscle weakness often observed with antispasticity medications or by a notable change in preferred walking speed. [ABSTRACT FROM AUTHOR]