What Serotypes Cause the Most Group B Streptococcal Disease?

Patient Presentation
A 30-minute old, 39 2/7 week gestation female was admitted to the newborn nursery. The past medical history showed she was born to a G2P1 now 2, 28 year old mother who had received appropriate prenatal care. Her pregnancy had been complicated by group B streptococcus (GBS) positive vaginal colonization, but negative for GBS bacturia. She had rupture of membranes 7 hours prior to vaginal delivery and had received 2 doses of ampicillin at 6.5 and 3 hours prior to delivery. She had no intrapartum fever. Apgars were 8 and 9. The family history showed some diabetes and heart disease. The 2.5 year old sibling had a normal birth and delivery.

The pertinent physical exam showed a healthy female who was 3.163 kg (50%), head circumference of 35 cm (65%) and length 49 cm (50%) and the Ballard assessment was 39 weeks gestation. Her vital signs were normal without tachypnea or temperature instability. Her examination was normal. The diagnosis of a healthy female with a mother who was GBS positive was made. The infant was admitted to the newborn nursery and had a screening laboratory evaluation that showed normal complete blood count, C-reactive protein of < 0.5 mg/dl and erythrocyte sedimentation rate of 5 mm/hr. The infant was not started on antibiotics as the mother had been treated within 4 hours of delivery with antibiotics and the screening labs were normal as was her physical examination and vital signs. The infant’s clinical course over the next 2 days was normal with a mildly increased bilirubin of 6.8 mg/dl at discharge. Her repeat screening laboratory testing at 24 hours was also normal and she was discharged home. At followup on day of life 4 the infant was doing well. Her transcutaneous bilirubin was 9.6 mg/dl and her weight was only decreased by 7% from her birthweight. Her mother’s breast milk had come in and the infant was feeding vigorously.

Discussion
Streptococcus agalactiae or Lancefield Group B streptococcus (GBS) was first described in 1887 and the first neonatal cases were described in the early 1960s. GBS can cause infections in all age groups but pregnant women and infants share most of the burden of the disease. GBS asymptomatically colonizes the genital and gastrointestinal tracts of pregnant women (15-40%). GBS is then transmitted vertically to infants generally after the rupture of fetal membranes or onset of labor. It is estimated that 50% of infants born to GBS+ mothers become colonized and 1% have invasive disease. Recurrent infections do occur in about 1-6% of patients.

For infants, the GBS disease is classified by age of onset:

  • Early onset (EOGBS)
    • Occurs from day 0-day 6 of life
    • 60-70% of cases of disease
    • Greatest risk in first 24 hours of life, especially the first 12 hours of life
    • Caused by vertical transmission
    • Risk factors include: maternal GBS colonization (most important factor), maternal GBS bacturia, male gender, black race, prolonged rupture of membranes, prematurity, intrapartum fever, low maternal GBS antibodies, previous infant with EOGBS
    • Usually presents with sepsis, pneumonia, or meningitis. Death occurs in 2-20% depending on risk factors.
  • Late onset (LOGBS)
    • Occurs from 7 -89 days of life
    • Cause is vertical transmission most often but also nosocomial or community contacts
    • Risk factors include maternal GBS colonization, male sex, black race, twin with LOBGBS, prematurity and infants born to HIV+ mothers.
    • Usually presents with bactermia, meningitis, bone/joint infections, or cellulitis/adenitis. Death occurs in 1-6% depending on risk factors.
  • Late, late onset
    • > 90 days of life
    • More common in < 28 week premature infants or those with an immunodeficiency
    • Cause is from maternal, familial or community contact, usually not vertical transmission.
    • Usually presents with fever without a source, bone/joint infections, skin and soft tissue infections.

Intrapartum antibiotics (IAP) have been shown to reduce the risk of delivering an infant with GBS disease. Guidelines from the American Academy of Pediatrics and other organizations help clinicians to evaluate an individual infant’s risk factors to determine if and when screening laboratories should be obtained and repeated, when and if prophylactic antibiotics should be started and which antibiotics to use, evaluation of an infant suspected to have sepsis, and duration of antibiotic therapy for those suspected or proven to have GBS disease. See To Learn More below.

Learning Point
GBS has a capsular polysaccharide antigen which is the major virulence factor and which helps the organism to counteract host defense mechanisms. The serotypes of GBS are divided into 10 different types based on this capsular polysaccharide antigen. They are Ia, Ib, II, III, IV, V, VI, VII, VIII and IX.

  • While all serotypes can cause neonatal disease, in the US and Europe the invasive serotypes are mainly Ia, IB, II, III and V.
  • Most frequent serotypes from all data sources are III(48.9%), Ia, (22.9%), V (9.1%), Ib (7%) and II (6.2%).
  • LOGBS and neonatal meningitis are associated most often with III.
  • EOGBS is associated most often with Ia, II, III, and V.

Maternal GBS vaccines are being developed. A recent cost-effectiveness analysis of using maternal vaccination (trivalent with serotypes Ia, Ib and III) along with IAP found that while vaccination would cost ~$362.7 million the cost savings would be $43.5 million. This $43.5 million may be comparable to other recently approved vaccines for children and adolescents in the US.

Questions for Further Discussion
1. How are practices for maternal intrapartum screening and antibiotics different in middle or low income countries?
2. What are GBS disease manifestations for postpartum women?
3. What prophylactic antibiotics are usually given for infants exposed to GBS?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Infections and Pregnancy and Streptococcal Infections.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Edmond KM, Kortsalioudaki C, Scott S, Schrag SJ, Zaidi AK, Cousens S, Heath PT. Group B streptococcal disease in infants aged younger than 3 months: systematic review and meta-analysis. Lancet. 2012 Feb 11;379(9815):547-56.

Le Doare K, Heath PT. An overview of global GBS epidemiology. Vaccine. 2013 Aug 28;31 Suppl 4:D7-12.

Ohlsson A1, Shah VS. Intrapartum antibiotics for known maternal Group B streptococcal colonization.Cochrane Database Syst Rev. 2014 Jun 10;6:CD007467. doi: 10.1002/14651858.CD007467.pub4.

Caffrey Osvald E, Prentice P. NICE clinical guideline: antibiotics for the prevention and treatment of early-onset neonatal infection. Arch Dis Child Educ Pract Ed. 2014 Jun;99(3):98-100.

Puopolo KM, Baker CJ. Group B Streptococcal Infection in Neonates and Young Infants. Up To Date.
(rev. 8/10/15, cited 11/19/2015).

Nuccitelli A, Rinaudo CD, Maione D. Group B Streptococcus vaccine: state of the art. Ther Adv Vaccines. 2015 May;3(3):76-90.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Are Current Treatments for Postpartum Depression?

Patient Presentation
A 12-day-old male came to clinic for his 2 week health maintenance examination. He was doing well according to his mother who was breastfeeding every 2-4 hours and was having numerous wet and stool-filled diapers. Previously he had been monitored closely during the first few days of life for hyperbilirubinemia but did not require hospitalization or treatment. His skin color looked better by her report. The mother appeared sad during the interview and was crying when she said that her mother had left the day before after helping out with the baby. The mother’s Patient Health Questionnaire-2 score was 3.

The past medical history showed the product of a 39 weeks gestation born to a 23 year old G1P1 married female who had no problems during the pregnancy or delivery. The family history was non-contributory. The social history showed a family who had recently moved to the area for the father’s new business job. He had returned to work several days ago. The mother did not know other people in the area yet. The pertinent physical exam showed an alert male with minimal jaundice around his face. His weight was 3.578 kg which was 130 grams above birth weight. His length and head circumference were around the 50%. The rest of his examination was normal with a well-healing circumcision. A transdermal bilirubin was 7.8 mg/dl.

The diagnosis of a healthy newborn male was made. The physician discussed with the mother how obviously she wasn’t feeling very well about life. The mother was able to verbalize that she felt exhausted, sad, and overwhelmed. “My husband is gone all day and I don’t really know anybody else that I can talk to,” she said. The pediatrician offered to have the mother referred to the obstetrical psychological clinic but the mother refused, however she was willing to talk with the clinic social worker. The social worker helped the mother work out some strategies for getting some rest and doing her own self-care along with taking care of the baby. The social worker phone number was given to the mother and a followup was arranged for 1 week later.

The patient’s clinical course found that the mother returned with the infant for a rash 3 days later that turned out to be erythema toxicum, but during that visit the mother endorsed feeling worse despite having support from her husband. The PHQ-2 was now 4. She again refused referral to the psychological clinic but did meet with the social worker again. At 3 weeks of life the infant was physically doing well, but the mother continued to have postpartum depressive symptoms and again had a PHQ-2 score of 4. She did allow referral to the obstetrical psychological clinic, which initiated cognitive behavioral therapy. At 6 weeks of life, the infant was still doing well, and the mother was doing somewhat better. She felt that having someone on a regular basis to talk with was helpful, and “the social worker is so helpful in knowing where to go in the community and just to talk to,” she said. With each subsequent visit the mother seemed somewhat better and she continued her therapy for 4 months.

Discussion
Postpartum depression affects 10 to 20% of women after delivery, but less than half of these women are detected. Postpartum depression is defined as major depressive episodes with symptom onset during pregnancy or in the first four weeks following delivery. There is recognition that symptoms may begin later after delivery but the mother would not be diagnosed with PPD.

PPD is distinct from postpartum blues which occur in 50 to 80% of new mothers. They occur within 1 to 2 days of delivery and resolve within 10-14 days of delivery. Symptoms include anxiety, depression, irritability, tearfulness, poor sleep, and appetite. Postpartum psychosis is a rare but extremely serious condition that occurs within 1 to 4 weeks after delivery and carries a high risk of infanticide and maternal suicide. Symptoms include “…delusions, hallucinations, severe and rapid mood swings, sleep disturbances, and obsessive preoccupation about the baby.” Women who experience termination or loss of pregnancy or neonatal death may also have bereavement and experience symptoms such as grief, poor appetite and sleep which may look like PPD.

Risk factors for PPD include: previous depression including PPD, anxiety, relationship problems with partner, inadequate or absent home support, ongoing life stresses, low socioeconomic status, adolescent mother, preterm delivery, substance abuse (alcohol, tobacco, other medications or illicit drugs), and possibly depressive symptoms when taking oral contraceptives or premenstrual dysphoric disorder. Fathers are at risk for depression if their partner has PPD.

Common screening tests for PPD are the Edinburgh Postnatal Depression Scale (EPDS) which has 10 items and takes 10-15 minutes to complete. Items are scored 0-3 with a cut-off of = or > 13 for identification of possible PPD. The PHQ-9 (Patient Health Questionnaire-9) has 9 items which are scored 0-3 with a cut-off of = or > 10. A 10th question is used if any of the first 9 are positive and asks how difficult the symptoms are for the patient to do their work, activities of daily living and getting along with others. The PHQ-2 is a shortened version of PHQ-9 using its first 2 items. A cut-off of = or > 3 for further evaluation is used. The 2 questions rate symptomatic emotions in the past 2 weeks and the items are having “little interest or pleasure in doing things” and “feeling down, depressed or hopeless.” Ratings are by the number of days the symptoms occur with 0 = no days, 1 = several days, 2 = more than half the days and 3 = nearly every day.

The use of antidepressant medications for PPD has increased to over 7% in 2008. A recent Cochrane Review said that its review was the limited by small number of studies and little information about important outcomes. It notes, “There was insufficient evidence to conclude whether, and for whom, antidepressant or psychological/psychosocial treatments are more effective, or whether some antidepressants are more effective or better tolerated than others. There was also inadequate evidence on whether the benefits of antidepressants persists beyond eight weeks or whether they have short- or long term adverse affects on breast-feeding infants.”

A 2014 summary of antidepressant use in pregnant and postpartum women found that research showed

  • “…[M]odestly elevated risk of clinically recognized spontaneous abortion”
  • Limited data on fetal death but probably no association with maternal antidepressant use
  • Selective serotonin reuptake inhibitors (SSRIs) did not appear to be major teratogens with the exception of paroxetine that has been associated with cardiovascular malformations
  • Preterm births occurring at a higher rate
  • Data on fetal growth is mixed
  • Small or no association with persistent pulmonary hypertension of the newborn
  • Associated with neonatal behavioral syndrome with SSRI exposure most often reported with fluoxetine, paroxetine and venlafaxine.
    Neonatal behavior syndrome includes symptoms of “…irritability, jitteriness, trouble feeding, tremor, agitation, hypotonia, hyperreflexia, respiratory distress, seizures, vomiting, excessive crying.”

Learning Point
PPD treatment depends on several factors including severity, patient preference, breastfeeding practices, response to previous treatment, co-morbidities and other risk factors and local mental health services availability. Mild PPD usually are patients who meet diagnostic criteria and who are able to overcome the negative impacts with extra effort. Moderate PPD are patients who cannot overcome the impacts with extra effort but are not incapacitated. Severe PPD are patients that are incapacitated by the symptoms.

  • Patients with mild to moderate PPD usually start with cognitive behavioral therapy or interpersonal therapy.
  • Patients with moderate to severe PPD who are not breastfeeding often are prescribed antidepressant medication with or without psychotherapy. Psychotherapy alone can be used but because of the increased risks requires close tracking of patient symptoms. In patients who are not improving or worsening, antidepressant medication is often a higher priority.
  • Patient with moderate to severe PPD who are breastfeeding often are prescribed prescribed antidepressant medication with or without psychotherapy. Psychotherapy alone can be used but because of the increased risks requires close tracking of patient symptoms. In patients who are not improving or worsening, antidepressant medication is often a higher priority or if depressive symptoms are severe to begin with.
  • For patients who have psychotic symptoms, hospitalization, antipsychotic medications and/or electroconvulsive therapy is needed.

Choice of antidepressant depends on the risk factors above but may be influenced by the mother’s own response to previously used antidepressants or family members response to these medications.

Mothers also need other supports such as parenting support, case management, community support groups and access to access meet physical needs such as food, clothing or shelter.
Other types of counseling may be needed depending on patient needs and availability including group therapy, couples therapy, non-directive counseling and community supports.

Questions for Further Discussion
1. What resources do you use to check for possible medication warnings for use during pregnancy or breastfeeding?
2. What local resources do you have for treatment of postpartum depression?
3. How do you treat major depressive disorder?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Postpartum Depression

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Liberto TL. Screening for depression and help-seeking in postpartum women during well-baby pediatric visits: an integrated review. J Pediatr Health Care. 2012 Mar;26(2):109-17.

Bobo WV, Yawn BP. Concise review for physicians and other clinicians: postpartum depression. Mayo Clin Proc. 2014 Jun;89(6):835-44.

Molyneaux E, Howard LM, McGeown HR, Karia AM, Trevillion K. Antidepressant treatment for postnatal depression. Cochrane Database Syst Rev. 2014 Sep 11;9:CD002018.

Yonkers KA, Blackwell KA, Glover J, Forray A. Antidepressant use in pregnant and postpartum women. Annu Rev Clin Psychol. 2014;10:369-92.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Factors Influence Linear Growth After Transplantation?

Patient Presentation
A 12-year-old male came to clinic for his health supervision visit. He had a history of living related donor renal transplant at age 10 after a few years of peritoneal dialysis. He was doing well in school and activities. His parents were very happy with his overall health. They expressed concerns about him starting into puberty because of the potential risks for non-adherence with his immunosuppressive medications and also with his growth. The family history showed a predicted mid-parental height between 25-50%.

The pertinent physical exam showed a male with normal vital signs including blood pressure. His height was 10%-25% and weight was 50% and tracking. His abdomen showed several scars and his kidney was palpable without pain/tenderness. He was Tanner 1 for pubertal growth. The diagnosis of a healthy male with a renal transplant was made. The pediatrician discussed that his current height was not significantly different than his predicted height but agreed that seeing endocrinology to discuss potential growth hormone use would be appropriate after the parents said that the nephrologist had suggested an appointment. The pediatrician also talked with the family about supporting their child’s independence over the next few years including medication management. “This is a common concern for families dealing with chronic illnesses. The nephrology team, along with me are here to help you. There are also psychologists who can work with him, and also with you on ways to successfully parent him during adolescence. Just let us know if you think you need help and we’re going to ask about it too,” the pediatrician offered.

Discussion
Growth is a defining characteristic of children. Children are expected to have normal height, weight and head circumference growth velocities for their specific age. A review of mid-parental height determination and other growth parameters can be found here.

For children with chronic illness and organ dysfunction or failure, their bodies cannot be expected to continue to have normal growth and therefore these children often have failure of normal growth for any and all of the growth parameters. For children facing organ failure or high risk or relapsed cancers, organ transplantation can be life-saving, but is not without its own problems including neurocognitive abnormalities, psychosocial dysfunction, endocrine abnormalities, bone abnormalities, primary or secondary malignancy, increased risk of infections and growth abnormalities.

While evaluation of weight and head circumferences are important, many studies have focused on outcomes of final height in children who have undergone transplantation.

Learning Point
Linear growth following organ transplantation appears to be influenced by the following:

  • Genetic potential – mid-parental height should be assessed as obviously this determines target height for the individual.
  • Reasons for the transplant – underlying disorders may change the expected target height, for example certain genetic diseases have short stature and therefore the final height would be less than predicted by mid-parental height. The primary diagnosis is often an important predictor.
  • Organ transplanted – specific organ, and solid organ versus hematopoietic transplant
  • Status before transplant – patients who are more ill (i.e. have spent more time in hospital, have poorer transplanted organ function, have other organ disease) tend to have less catch-up growth however age appears to also influence this. If the child has better height at transplant they tend to have better height after transplant.
  • Age at transplant – younger children often have poorer growth before transplant but have greater catch-up growth than older children and teens
  • Pubertal growth spurt – this appears to play an important role in attainment of final height for patients with transplant as it does for children without them. Some patients have growth hormone deficiency because of their treatment and exogenous growth hormone is sometimes used to assist general linear growth and pubertal growth.
  • Graft function after transplant – patients whose grafts function well (i.e. good overall function and few rejection episodes) tend to have better final heights. Secondary renal or bone dysfunction tends to cause poor final heights.
  • Corticosteroid use – corticosteroid use basically causes poor linear growth. Smaller amounts of corticosteroid tends to improve linear growth.

Overall, final height potentially is improved with smaller amounts of corticosteroids, excellent nutritional support, control of other complications such as rejection or secondary organ dysfunction, and the potential use of growth hormone. All of these can be hard to balance when treating the patient and family. Side effects of immunosuppressive medications can be found here.

Questions for Further Discussion
1. What are risk factors for poor linear growth for patients with chronic diseases and cancer?
2. What type of followup care do patients who have had transplantation need?
3. What type of followup care do adult patients who are survivors of pediatric cancer need?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Organ Transplantation, Kidney Transplantation and Puberty.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Perkins JL, Kunin-Batson AS, Youngren NM, et.al. Long-term follow-up of children who underwent hematopoeitic cell transplant (HCT) for AML or ALL at less than 3 years of age. Pediatr Blood Cancer. 2007 Dec;49(7):958-63.

Laster ML, Fine RN. Growth following solid organ transplantation in childhood. Pediatr Transplant. 2014 Mar;18(2):134-41.

Kerkar N, Danialifar T. Changing definitions of successful outcomes in pediatric liver transplantation. Curr Opin Organ Transplant. 2014 Oct;19(5):480-5.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Are Risk Factors for Latex Allergy?

Patient Presentation
A 4-year-old male came to clinic for his health supervision visit. He had a history of lumbar meningomyelocoele not requiring a ventriculoperitoneal shunt. He had a wheelchair for mobility but otherwise was developmentally appropriate and was verbally a precocious child. The past medical history was significant for repair of the meningomyelocoele after birth. He had a history of several urinary tract infections but generally had no problems with his clean intermittent bladder catheterization. The family history was non-contributory. As the physician was preparing to examine the child the mother asked to see the box of gloves. “I know that these are probably latex-free, but better to always check. He’s not latex allergic now and I want to keep it that way,” she said as she double-checked the box confirming they were latex-free.

The pertinent physical exam showed a happy boy sitting in his wheelchair. Vital signs were normal with weight and head circumference trending at the 25%.
His examination was notable for a well-healed scar on his lumbo-sacral area. He had small legs without muscle tone or sensation. The diagnosis of a healthy 4 year old with meningomyelocoele was made. He was current with his immunizations except for seasonal influenza. The physician also confirmed that the live attenuated vaccine did not contain latex.

Discussion
Latex comes from the Hevea brasiliensis plants. There are multiple potentially allergenic polypeptides within the plant’s fluid called Heb b 1-13. True sensitizers are Heb b 1, 5 and 6. Heb b 8 and 12 are cross-reacting proteins.

The type of the latex product and how it is prepared makes a difference in exposure to the latex allergens. Certain extruded latex products such as catheters and rubber stoppers have higher concentrations of true sensitizer allergens. Products made from molds such as gloves have higher concentrations of potential allergens than latex made in sheets such as such as dental dams. Use of powder substances in gloves also increases latex allergen exposure. Cross reactivity with certain foods is called latex-fruit syndrome and includes apples, avocado, chestnuts, banana, kiwi, tomato, bell pepper and carrot. Ficus trees also have some cross-reactivity.

Diagnosis of latex sensitivity and true allergy in the US is usually made by skin prick test conducted in a clinical setting by an allergist. Treatment can include various immunotherapies with the assistance of an allergist. Indications for allergy testing can be found here.

Avoidance of latex products is the best option but it’s difficult to do as latex products are all around us in our environment including clothing (undergarments, socks, bathing suits), sports equipment (balls, grips, masks), condoms, rubber bands or erasers, carpet backing, etc.. In the medical areas, latex in gloves is the one most people think about but other products include the rubber used in stethoscope tubing, rubber hammers, multiple-use vials, syringes, bulb syringes, tourniquets, catheters, bandages, electrodes, heat/cold wraps, impermeable bedding, anesthesia circuits, CPR supplies such as masks and mannequins, surgical clothing, etc. In dentistry, dental dams and orthodontic elastic bands commonly come to mind, but also filling and impression materials may contain it. A list of consumer products that potentially contain latex and some alternatives can be found here.

Questions useful in eliciting a history of latex sensitization or allergy include asking about reactions when exposed to latex balloons or dental dams for dental procedures.

Learning Point
Latex hypersensitivity is about 0.3-4% of the pediatric population. Subpopulations though can be as high as 71%. The highest risk is for patients with spina bifida.

Risk factors for latex allergy and sensitization include:

  • Occupation
    • Food preparation workers
    • Housekeeping personnel
    • Gardener
    • Hairdressers
    • Healthcare workers – surgeon, nursing, laboratory worker, technician, etc. Latex positivity is up to 12% of healthcare workers
    • Others with exposure to frequent gloving
  • Patients who are frequently instrumented or have multiple (N > 5) surgeries
    • Spina bifida – these patients appear to have more sensitization than other similarly exposed patients
    • Urological abnormalities
    • Congenital heart disease
    • Hydrocephaleus
    • Tracheoesophageal fistula
    • Other congenital malformations
  • Having atopy – 1% of atopic children have latex allergy

Questions for Further Discussion
1. What are the 4 types of allergic hypersensitivity?
2. What steps should be taken if a child with latex allergy comes to the clinic or is admitted to the hospital?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Latex Allergy

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Latex Allergy Association. Consumer Products. Available from the Internet at http://latexallergyresources.org/consumer-products (cited 210/26/15).

Sampathi V, Lerman J. Case scenario: perioperative latex allergy in children. Anesthesiology. 2011 Mar;114(3):673-80.

Lucas JS, du Toit G, Lloyd K, Sinnott L, Forster D, Austin M, Clark C, Tuthill D, Brathwaite N, Warner J; Science and Research Department, Royal College of Paediatrics and Child Health. The RCPCH care pathway for children with latex allergies: an evidence- and consensus-based national approach. Arch Dis Child. 2011 Nov;96 Suppl 2:i30-3.

Nettis E, Delle Donne P, Di Leo E, Fantini P, Passalacqua G, Bernardini R, Canonica GW, Ferrannini A, Vacca A. Latex immunotherapy: state of the art. Ann Allergy Asthma Immunol. 2012 Sep;109(3):160-5.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital