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Routinely collected census data can provide important information about health inequalities. Unlike many other countries, Thailand seems to be on the way to achieving the fourth Millennium Development Goal of a two‐thirds reduction in under‐five mortality rate (U5MR) between 1990 and 2015 (Lancet 2007;369:850–5; see also Comment, ibid: 804–6). Data from 1990 and 2000 censuses (corresponding to U5MR reference years of 1984 and 1994) have shown an overall reduction in U5MR of 32% (from 27.4 to 18.7 per 1000 livebirths). Among people in the poorest quintile for socioeconomic status the U5MR fell from 40.8 to 23.0 per 1000 and among people in the richest quintile the fall was from 14.8 to 12.9 per 1000. Thus the gap between rich and poor was reduced by 61% (from 26.0 to 10.1 extra deaths per 1000 children under the age of 5). These reductions in U5MR and in U5MR inequality are in large part attributed to economic growth, reduction in poverty, better insurance coverage, and better and more equitably distributed health services.
Men who were brought up in single‐parent homes more often report having suffered sexual abuse in childhood. Low socioeconomic status also increases the risk of child sexual abuse. Now a study in a high‐risk urban area in Philadelphia (J Epidemiol Community Health 2007; 61:319–25) has shown that the risk in one‐parent families is independent of socioeconomic status. The study included 186 men aged 18–49 years, 110 brought up in two‐parent families and 76 in one‐parent families. A history of childhood sexual abuse was reported by 18/110 vs 22/76 (odds ratio 2.08, p=0.04). Adjustment for childhood socioeconomic status increased the odds ratio to 2.4. Seventy per cent of the abuse to one‐parent‐family boys was by a woman and 70% of the abuse to two‐parent‐family boys was by a man but the abuser was significantly more likely to be a non‐family member for one‐parent‐family boys. Fondling was more common in one‐parent‐family boys and oral sex in two‐parent‐family boys. The precise factors that increase the risk of sexual abuse among boys living in one‐parent families have not yet been delineated.
There is good evidence that zinc supplements given to young children in developing countries reduce morbidity from diarrhoea and pneumonia. The reported effects on mortality have varied, however, and there is a suggestion that zinc supplementation may be less effective in areas of sub‐Saharan Africa with high rates of malaria transmission. Now a large placebo‐controlled trial in Zanzibar, where malaria is rife, (Lancet 2007;369:927–34; see also Comment, ibid: 885–6) has shown an overall, nonsignificant 7% reduction in mortality in children under the age of 4 years given zinc supplements. There was, however, a significant 18% reduction in mortality in children aged 12–48 months. The authors of this paper call for a meta‐analysis of all available data.
Pulsed‐dye laser treatment of port wine stains is effective but there have been few long‐term follow‐up studies. Now a study in Amsterdam (New England Journal of Medicine 2007;356:1235–40) has shown that the stains may become darker again some years after treatment. A total of 51 patients were reassessed at ages 12–42 years, 9.5 years on average after an initial treatment course of five treatments over a period of around 2 years. They had had an additional seven treatments, on average, in the meantime. Objective colour measurements showed that the average colour was darker at the end of the follow‐up period but still lighter than before treatment. Thirty patients (59%) were satisfied with the result. Eighteen (35%) said their stain had become darker since the last treatment, thirty (59%) that it was unchanged, and three (6%) that it was lighter.
In a large UK study of adults and children over the age of 4 years standard treatments with carbamazepine (for partial epilepsy) and valproate (for generalised or unclassifiable epilepsy) have been compared with newer drug treatments (Lancet 2007;369:1000–15 and 1016–26; see also Comment, ibid: 970–1). Carbamazepine was compared with lamotrigine, oxcarbazine, topiramate and gabapentin. Lamotrigine was considered to be the best of the five drugs for partial epilepsy on grounds of clinical effectiveness overall and cost‐effectiveness in adults. Valproate was compared with lamotrigine and topiramate and it was concluded that valproate should remain first‐choice for generalised or unclassifiable epilepsy though its potential toxicity in pregnancy should be borne in mind when treating women of child‐bearing age. The Lancet commentator points to deficiencies in this kind of trial. It cannot allow, for instance, for uncommon adverse events (such as pancreatic or liver disease with valproate), interactions with other drugs or idiosyncrasies of drug administration (such as slower initial dosage increases with carbamazepine to reduce the risk of a rash). The main problem for paediatricians though, seems to be that it is not clear to what extent the overall findings apply to children.
A systematic review of 31 papers on medication errors in paediatric care (Qual Saf Health Care 2007;16:116–26) has shown that about three quarters of the errors occur during administering of the medicines. Overall, medication errors occurred with between 5% and 27% of medication orders. Prescribing errors accounted for up to 37% and dispensing errors for up to 58% of all errors. Documentation was faulty in up to 21% of cases. Recommendations for strategies to reduce medication errors are plentiful but none are based on evidence derived from paediatric practice. This paper lists 26 such recommendations. Its authors call for greater rigour in studies of medication errors in children.
Material micronutrient intake is thought to be an important determinant of fetal growth and 96% of all low birthweight infants are born in developing countries. In Tanzania (New England Journal of Medicine 2007;1423–31) a total of 8468 HIV‐negative women were given iron and folic acid and randomised at 12–27 weeks of pregnancy to daily multivitamin supplements or placebo. There were significant reductions in the multivitamin group in the incidence of low birthweight (7.8% vs 9.4%), small for gestational age infants (10.7% vs 13.6%) and maternal anaemia (haemoglobin <11 g/dl, 19.2% vs 21.8%). The groups did not differ significantly in rates of preterm birth (<37 weeks, 16.9% vs 16.7%) or fetal death (4.3% vs 5.0%). Multivitamin supplements reduced the risks of low birthweight, smallness for gestational age and maternal anaemia, but not of preterm birth or fetal death.