M.J. Cilleruelo Ortega

Calendario de vacunaciones de la Asociacion Espanola de Pediatria: recomendaciones 2010

The Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP) updates the immunisation schedule every year, taking into account epidemiological data as well as evidence on safety, effectiveness and efficiency of vaccines. The present schedule includes levels of recommendation. We have graded, as routine vaccinations, those that the CAV-AEP consider all children should receive; as recommended those that fit the profile for universal childhood immunisation and would ideally be given to all children, but that can be prioritised according to the resources available for their public funding; and as risk group vaccinations those that specifically target individuals in special situations. Immunisation schedules tend to be dynamic and adaptable to ongoing epidemiological changes. Based on the latest epidemiological trends, CAV-AEP recommends the administration of the first dose of MMR and varicella vaccines at age 12 months, with the second dose at age 2-3 years; the administration of DTaP or Tdap vaccine at age 4-6 years, always followed by another Tdap dose at 11-12 years; and the three meningococcal C scheme at 2 months, 12 months and 12 years of age. It reasserts its recommendation to include vaccination against pneumococcal disease in the routine immunisation schedule. The CAV-AEP believes that the coverage of vaccination against human papillomavirus in girls aged 11-12 years must be increased. Universal vaccination against varicella in the second year of life is an effective strategy, and the immediate public availability of the vaccine is requested in order to guarantee the right of healthy children to be vaccinated. Vaccination against rotavirus is recommended in all infants due to the morbidity and elevated healthcare burden of the virus. The Committee stresses the need to vaccinate population groups considered at risk against influenza and hepatitis A. The recently authorised meningococcal B vaccine has opened a chapter of hope in the prevention of this disease. In anticipation of upcoming national and international studies, the Committee recommends the vaccine for the control of disease outbreaks, and insists on the need to be available in pharmacies. Finally, it emphasises the need to bring incomplete vaccinations up to date following the catch-up immunisation schedule.

Conocimiento sobre el uso de fármacos off-label en Pediatría. Resultados de una encuesta pediátrica nacional 2012-2013 (estudio OL-PED)

INTRODUCTION Off-label drug use is a common practice in paediatrics. The aim of the present study was to estimate the knowledge of Spaniard paediatricians on off-label use. MATERIAL AND METHODS Cross-sectional, multicentre, descriptive and national study from July 2012 to March 2013 using an on-line questionnaire on off-label use in children. An e-mail was sent to paediatricians who were members of the Spanish Association of Paediatrics (AEP) or its Regional or Paediatric Specialties Societies. RESULTS Out of 673 responses were received, 75.1% of Spanish paediatricians knew the meaning of off-label use, 61% of them prescribed medicines outside the conditions authorised in their Summary of Product Characteristics (SPC) and 47% knew of the importance of noting the off-label use in the medical record. However, just under half of paediatricians informed parents, and only 22% wrote it down in the medical record. CONCLUSIONS Most Spanish paediatricians do not meet current regulations regarding off-label use. This regulation demands: justifying the decisions when off-label use is needed, and to write down in the medical record that, at least an oral consent from the parents has been obtained. This study reveals a fact that Spanish paediatricians must change. Meanwhile, it is a priority to continue with the implementation of consensus and clinical guidelines, to obtain more data on the efficacy and safety of off-label drug use in children, and to incorporate them into the SPC.

Infecciones del tracto urinario: sensibilidad antimicrobiana y seguimiento clínico

The initial treatment of the urinary tract infections (UTI) is empirical and it is a priority to determine the antibiotic resistance of most common germs in a population. Furthermore, due to the suspicion of acute pyelonephritis the presence of renal scarring should be ruled out as this may lead to further complications. A retrospective longitudinal study was performed on all children under 14 years diagnosed with UTI from January 1 2009 to December 31 2009. The in vitro susceptibility to the most important urinary pathogens was analysed, along with the presence of scars, and a subsequent follow-up. The most frequently isolated bacteria were E. coli (80%), P. mirabilis (9.7%) and K. pneumoniae (4.2%). In the antibiogram, E coli showed a high sensitivity to fosfomycin (99.1%), cefotaxime (98.2%) cefuroxime (97.3%) and gentamicin (95.6%). The sensitivity obtained against amoxicillin-clavulanate was 83.2%, while that obtained against cotrimoxazole was 78.9%. Post-pyelonephritis scars were found in 19% of patients with febrile UTI, 17% out-patients and 20% of those admitted.

Immunization schedule of the Spanish Association of Pediatrics: 2012 recommendations

The Advisory Committee on Vaccines of the Spanish Association of Pediatrics (CAV-AEP) updates the immunization schedule every year, taking into account epidemiological data as well as evidence on the effectiveness and efficiency of vaccines. The present schedule includes grades of recommendation. We have graded as routine vaccinations those that the CAV-AEP believes all children should receive; as recommended those that fit the profile for universal childhood immunization and would ideally be given to all children, but that can be prioritized according to the resources available for their public funding; and as risk group vaccinations those that specifically target individuals in situations of risk. Immunization schedules tend to be dynamic and adaptable to ongoing epidemiological changes. Nevertheless, the achievement of a unified immunization schedule in all regions of Spain is a top priority for the CAV-AEP. Based on the latest epidemiological trends, the main changes introduced to the schedule are the administration of the first dose of the MMR and the varicella vaccines at age 12 months (12-15 months) and the second dose at age 2-3 years, as well as the administration of the Tdap vaccine at age 4-6 years, always followed by another dose at 11-14 years of age. The CAV-AEP believes that the coverage of vaccination against human papillomavirus in girls aged 11-14 years must increase. It reasserts its recommendation to include vaccination against pneumococcal disease in the routine immunization schedule. Universal vaccination against varicella in the second year of life is an effective strategy and therefore a desirable objective. Vaccination against rotavirus is recommended in all infants due to the morbidity and elevated healthcare burden of the virus. The Committee stresses the need to vaccinate population groups considered at risk against influenza and hepatitis A. Finally, it emphasizes the need to bring incomplete vaccinations up to date following the catch-up immunization schedule.

Exposición a tuberculosis multirresistente: estudio y seguimiento de nueve niños

A world increase in multidrug-resistant tuberculosis (MDR-TB) has been reported over the last few years. A larger number of diagnoses are being seen in Spain, due to the increase of immigration from high endemic TB countries. Articles published on this are anecdotal in children, and there is no clear directives for treatment of MDR-TB, or latent tuberculosis infection (ITBL) or on prophylaxis after exposure to active pulmonary MDR-TB. We present the initial management and progression of nine children after close contact exposure to an Ecuadorian woman diagnosed with active pulmonary TB, resistant to Isoniazid, Rifampicin and Pyrazinamide.

Artritis idiopática juvenil

Juvenile idiopathic arthritis (JIA) is a chronic disease defined by the International League of Associations for Rheumatology (ILAR) criteria as arthritis in one or more joints that begins before the 16th birthday, persists for at least 6 weeks, and excludes all other known conditions. It is the most common rheumatic disease in children and one of the more common chronic illnesses of childhood. The etiology and pathogenesis of JIA is not completely understood, but substantial evidence suggests that the pathogenesis is autoimmune. Outcome studies have underlined the importance of early diagnosis and early aggressive treatment in improving prognosis. Despite this situation, many children with JIA continue to have persistently active arthritis into adulthood. The modern treatment of JIA involves a range of specialists. In recent years, new biologic medications have added significantly to the management of children with JIA.

Documento de consenso sobre etiología, diagnóstico y tratamiento de la sinusitis

The Spanish National Consensus (Spanish Society of Pediatric Infectious Diseases, Spanish Association of Primary Care Pediatrics, Spanish Society of Pediatric Outpatient and Primary Care, Spanish Society of Otorhinolaryngology and Cervical-Facial Pathology) on Sinusitis is presented. Rhinosinusitis is a difficult to diagnose and often unrecognised disease. The document discusses the aetiology, the clinical signs and symptoms, and the diagnostic criteria. A proposal for treatment is made based on the epidemiological situation in our country. Oral amoxicillin is the treatment of choice (80mg/kg/day divided every 8hours). Alternative treatment is proposed in special cases and when amoxicillin is not sufficient. The main complications are reviewed.

Brote de 22 casos de sarampión autóctono en la zona norte de Madrid

After being virtually eradicated in Europe, thousands of cases of measles in the population of Spanish origin have appeared in the last 3 years. We describe the cases diagnosed in the north of Madrid between January and June 2011. A total of 22 cases are reported, 18 of them grouped in 2 outbreaks (2 nurseries). The primary attack rate was 29% in the main outbreak. All cases were in unvaccinated patients (median = 14 months). Genotype D4 was predominant (95%). There was a 45% complication rate and 45% were admitted to hospitals. The Public Health Service recommended isolating cases and vaccinating susceptible contacts in advance. Health Centres established a specific protocol to respond to suspected cases. The Measles vaccination has been brought forward from 15 to 12 months in Madrid. Measles is a re-emerging disease in Europe. The coordinated management between public health and health facilities is essential to limiting outbreaks.

Vacunación frente al meningococo B. Posicionamiento del Comité Asesor de Vacunas de la Asociación Española de Pediatría

Meningococcal invasive disease, including the main clinical presentation forms (sepsis and meningitis), is a severe and potentially lethal infection caused by different serogroups of Neisseria meningitidis. Meningococcal serogroup B is the most prevalent in Europe. Most cases occur in children, with a mortality rate of 10% and a risk of permanent sequelae of 20-30% among survivors. The highest incidence and case fatality rates are observed in healthy children under 2-3 years old, followed by adolescents, although it can occur at any age. With the arrival in Spain of the only available vaccine against meningococcus B, the Advisory Committee on Vaccines of the Spanish Association of Paediatrics has analysed its preventive potential in detail, as well as its peculiar administrative situation in Spain. The purpose of this document is to publish the statement of the Committee as regards this vaccination and the access to it by the Spanish population, taking into account that it has been only authorized for people at risk. The vaccine is available free in the rest of Europe for those who want to acquire it, and in some countries and regions it has been introduced into the systematic immunisation schedules. The Committee considers that Bexsero® has a profile of a vaccine to be included in the official schedules of all the Spanish autonomous communities and insists on the need for it to be available in pharmacies for its administration in all children older than 2 months.

Vacunación frente a la encefalitis centroeuropea o encefalitis transmitida por garrapatas en niños viajeros

En mayo del año 2002 el Ministerio de Sanidad acreditó al Hospital Carlos III como centro de vacunación internacional, con dos consultas: consulta del niño y del adulto viajero. En la consulta pediátrica se evaluaron, sólo en el año 2007, 528 niños con edades comprendidas entre los 15 días y los 16 años. La mitad de los niños viajeros que acudieron a la consulta precisaron quimioprofilaxis antipalúdica y las vacunas más prescritas fueron contra la hepatitis A y la fiebre amarilla. Recientemente, ha surgido la alarma en los medios de comunicación sobre la indicación de vacunar frente a encefalitis centroeuropea a viajeros que van a zonas boscosas de Europa central esta primavera. El Servicio de Pediatría del Hospital Carlos III, como en años anteriores, recomienda: La vacuna frente a la encefalitis centroeuropea transmitida por garrapatas es una vacuna de virus inactivados cultivados en células de embrión de pollo. Se indica en los niños viajeros campistas a zonas boscosas del centro, norte y este de Europa en primavera y verano cuando el viaje tiene una duración superior a 3 semanas. La pauta son 3 dosis administradas con un intervalo de 1-3 meses entre la primera y la segunda (mínimo 15 días) y de 9-12 meses entre la segunda y la tercera. Existe, no obstante, una pauta acelerada: 0,7 y 21 días. En este caso la protección comienza a los 15 días de la segunda dosis. En niños de entre 1 y 11 años se administrará la dosis pediátrica (la mitad de la dosis de adultos) y en los mayores de 11 años, la dosis completa. Se recomienda un recuerdo cada 3-5 años si el niño se mantiene en zona de riesgo. La vacuna está comercializada como FSME-inmun inject. Júnior o Encepur Children dosis pediátrica (jeringa precargada de 0,25 ml) para niños menores de 11 años. Esta vacuna se administra únicamente en los centros de vacunación internacional autorizados por el Ministerio de Sanidad en cada comunidad autónoma. Los países con riesgo elevado de encefalitis centroeuropea son: Alemania, Austria, Bielorrusia, Croacia, Eslovaquia, Eslovenia, Finlandia, Hungría, Lituania, Polonia, Republica Checa, Rusia, Suecia, Suiza y Ucrania. Los países con riesgo bajo de encefalitis centroeuropea son Albania, Bosnia, China, Dinamarca (solo la isla de Bornholm), Francia, Grecia, Italia, Japón, Kazajstán, Moldavia, Mongolia, Noruega, Rumanía y Serbia1. Puede consultarse el mapa de distribución de los casos comunicados a la Organización Mundial de la Salud (OMS)2 (CDC Health Information for Internacional Travel 2008) disponible en http://www.isw-tbe.info/tbe.aspx.