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1.  USING COHORT STUDIES IN LIFECOURSE EPIDEMIOLOGY 
Public health  2012;126(3):190-192.
Summary
The UK Medical Research Council (MRC) Population Health Sciences Research Network is a network of MRC research units and centres that aims to bring together and add value to existing MRC investment in public health, health services and epidemiological research. This symposium held in August 2011 at the World Congress of Epidemiology, Edinburgh, discussed a range of topics including methodology and analytical issues based on a number of examples of cohort studies within the context of lifecourse epidemiology.
doi:10.1016/j.puhe.2011.12.002
PMCID: PMC3685132  PMID: 22325617
Epidemiology; Population science; Cohort studies
2.  Newborn screening for congenital toxoplasmosis: feasible, but benefits are not established 
Archives of Disease in Childhood  2006;91(8):629-631.
Perspective on the paper by Schmidt et al (see page 661)
doi:10.1136/adc.2006.094870
PMCID: PMC2083040  PMID: 16861480
toxoplasma gondii; congenital; neonatal screening; toxoplasmosis
3.  True status of supplement not made clear to reader 
doi:10.1136/adc.2005.078782
PMCID: PMC1720138
4.  The hip trial: psychosocial consequences for mothers of using ultrasound to manage infants with developmental hip dysplasia 
Background: The hip trial aimed to assess clinical effectiveness, economic and psychosocial costs, and benefits of ultrasound imaging (US) compared with conventional clinical assessment alone to guide the management of infants with neonatal hip instability.
Objective: To report on psychosocial consequences for mothers and the developing mother-child relationship of US, and associations between abduction splinting and maternal psychosocial distress.
Design: Multicentre randomised controlled trial.
Setting: Thirty three hospitals in the United Kingdom and Ireland.
Participants, interventions: A total of 629 infants with neonatal hip instability randomised to US examination or clinical assessment alone before treatment decision. Questionnaires were completed by 561 (89%) mothers at 8 weeks and 494 (79%) at 1 year.
Main outcome measures: Anxiety, postnatal depression, parenting stress assessed by standardised questionnaires. Maternal concerns about hip problems were assessed using the Infant hip worries inventory.
Results: At 8 weeks, there were no differences between US and non-US groups of the trial in maternal anxiety (mean difference (MD) –1.2, 95% confidence interval (CI) –3.2 to 0.8), depression (MD 0.0, 95% CI –0.7 to 0.8), parenting stress (MD –1.2, 95% CI –2.8 to 0.4), or other measures. The same pattern was evident at 1 year. In an explanatory analysis, early splinting was associated with increased anxiety at 8 weeks (MD 3.8, 95% CI 1.7 to 5.9) and increased level of hip worries at 8 weeks (MD 6.8, 95% CI 5.6 to 7.9) and 1 year (MD 1.3, 95% CI 0.3 to 2.4).
Conclusions: Although early splinting is associated with maternal anxieties, US is not associated with any increase or reduction in psychosocial effects on mothers. Together with the clinical findings, this suggests that the use of US allows reduction in splinting rates without increased risk of adverse clinical or psychosocial outcomes.
doi:10.1136/adc.2002.025684
PMCID: PMC1721817  PMID: 15613565
6.  Low birth weight for gestation and airway function in infancy: exploring the fetal origins hypothesis 
Thorax  2004;59(1):60-66.
Methods: Airway function was measured using the raised volume technique in healthy white infants of low (⩽10th centile) or appropriate (⩾20th centile) birth weight for gestation and was expressed as forced expiratory volume in 0.4 s (FEV0.4), forced vital capacity (FVC), and the maximal expired flow at 25% of forced vital capacity (MEF25). Infant length and weight, maternal height and weight, maternal report of smoking prenatally and postnatally, and parental occupation were recorded.
Results: Mothers of low birth weight for gestation infants (n = 98) were lighter, shorter, and more likely to smoke and have partners in manual occupations. At 6 weeks their infants remained lighter and shorter than those of appropriate birth weight (n = 136). FEV0.4, FVC, and MEF25 were reduced in infants of low birth weight for gestation, in those whose mothers smoked in pregnancy, or who were in manual occupations. After adjusting for relevant maternal and infant characteristics, infants in the low birth weight for gestation group experienced a mean reduction of 11 ml in FEV0.4 (95% CI 4 to 18; p = 0.002), of 12 ml in FVC (95% CI 4 to 19; p = 0.004), and of 28 ml/s in MEF25 (95% CI 7 to 48; p = 0.03).
Conclusions: Airway function is diminished in early postnatal life as a consequence of a complex causal pathway which includes social disadvantage as indicated by maternal social class, smoking and height, birth weight as a proximal and related consequence of these factors, and genetic predisposition to asthma. Further work is needed to establish the relevance of these findings to subsequent airway growth and development in later infancy and early childhood.
PMCID: PMC1758850  PMID: 14694251
7.  Efficiency of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom 
Archives of Disease in Childhood  2003;88(9):760-766.
Aims: To assess, using a decision model, the efficiency of ultrasound based and clinical screening strategies for developmental dysplasia of the hip.
Methods: The additional cost per additional favourable outcome was compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; addition of static and dynamic ultrasound examination of the hips of all infants (universal ultrasound) or restricted to infants with defined risk factors (selective ultrasound); "no screening" (that is, clinical diagnosis only).
Results: Ultrasound based screening strategies are predicted to be more effective but more costly than clinical screening or no screening. Estimated total costs per 100 000 live births are approximately £4 million for universal ultrasound, £3 million for selective ultrasound, £1 million for clinical screening alone, and £0.4 million for no screening. The relative efficiency of selective ultrasound and clinical screening is poorly differentiated, and depends on how infants are selected for ultrasound as well as the expertise of clinical screening examiners. If training costs less than £20 per child screened, clinical screening alone would be more efficient than selective ultrasound. Relative to no screening, each of the 16 additional favourable outcomes achieved as a result of selective ultrasound costs approximately £0.2 million, while each of the five favourable outcomes achieved through universal ultrasound screening, over and above selective ultrasound, costs approximately £0.3 million.
Conclusions: Policy choice depends on values attached to the different outcomes, willingness to pay to achieve these and total budget.
doi:10.1136/adc.88.9.760
PMCID: PMC1719653  PMID: 12937092
8.  Performance, treatment pathways, and effects of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom 
Archives of Disease in Childhood  2003;88(9):753-759.
Aims: To compare, using a decision model, performance, treatment pathways and effects of different newborn screening strategies for developmental hip dysplasia with no screening.
Methods: Detection rate, radiological absence of subluxation at skeletal maturity and avascular necrosis of the femoral head, as favourable and unfavourable treatment outcomes respectively, were compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; the addition of static and dynamic ultrasound examination of the hips of all infants (universal ultrasound) or restricted to infants with defined risk factors (selective ultrasound); "no screening" (that is, clinical diagnosis only).
Results: Universal or selective ultrasound detects more more affected children (76% and 60% respectively) than clinical screening alone (35%), results in a higher proportion of affected children with favourable treatment outcomes (92% and 88% respectively) than clinical screening alone (78%) or no screening (75%), and the highest proportion of these achieved without recourse to surgery (64% and 79% respectively) compared with clinical screening alone (18%). However, ultrasound based strategies are also associated with the highest number of unfavourable treatment outcomes arising in unaffected children treated following a false positive screening result. The detection rate of clinical screening alone becomes similar to that reported for universal ultrasound when based on studies using experienced examiners (80%) rather than junior medical staff (35%).
Conclusion: From the largely observational data available, ultrasound based screening strategies appear to be most sensitive and effective but are associated with the greatest risk of potential adverse iatrogenic effects arising in unaffected children.
doi:10.1136/adc.88.9.753
PMCID: PMC1719641  PMID: 12937091
10.  Airway function at one year: association with premorbid airway function, wheezing, and maternal smoking 
Thorax  2001;56(9):680-686.
BACKGROUND—Impaired growth and development of the respiratory system during fetal and early postnatal life may have important implications for lung development and later lung health. The aim of this study was to examine the association of diminished premorbid airway function, prior wheezing, and maternal smoking with airway function at 1 year of age.
METHODS—Respiratory function was measured at the end of the first year in 100 of 108 healthy term infants (93%) in whom similar measurements had been undertaken prior to any respiratory illness at 8 weeks. Physician diagnosed wheezing episodes were identified retrospectively from medical records.
RESULTS—At 1 year specific airway conductance during end expiration (sGawEE; /s/kPa) was significantly diminished in those infants with prior wheezing (95% CI wheeze/no wheeze -0.76 to -0.14), mothers who smoked (95% CI smoke/no smoke -0.81 to -0.27), a family history of asthma (95% CI family history/no family history -0.62 to 0.00), or diminished premorbid sGawEE (95% CI -0.13 to -0.43/s/kPa per unit reduction sGawEE at 8 weeks). In a multivariate model only maternal smoking and diminished premorbid sGawEE were independently associated with diminished sGawEE at 1year.
CONCLUSIONS—Diminished airway function at the end of the first year appears to be mediated by impaired airway development during early life as well as by exposure to maternal smoking. These findings are consistent with the hypothesis that, at a population level, diminished premorbid airway function provides the link between wheezing lower respiratory illness and diminished airway function at 1 year. Maternal smoking remains an important and avoidable cause of impaired airway development and function in infancy.


doi:10.1136/thorax.56.9.680
PMCID: PMC1746127  PMID: 11514687
11.  Corticosteroids and ibuprofen in cystic fibrosis 
Thorax  1999;54(7):655.
PMCID: PMC1745514  PMID: 10438308
12.  Prevalence of breastfeeding at four months in general practices in south London. 
BACKGROUND: Successive quinquennial National Infant Feeding Surveys have provided a valuable picture of national and regional variations in infant feeding practices within the United Kingdom. Social variation in breastfeeding has been recognised to be an important source of health inequalities in childhood by the Independent Inquiry into Inequalities in Health Report. AIM: To determine the prevalence of breastfeeding at birth and at four months in a sample of women from urban general practices, its variation between practices, and relation to practice population deprivation scores. To report the timing of introduction of solid feeds. DESIGN OF STUDY: Cross-sectional questionnaire survey based on a random cluster sample. SETTING: Women with infants aged four months in general practices in South London. METHOD: Mode of infant feeding at birth and four months, and time of introduction of solids. Jarman score as a measure of practice population deprivation. Housing tenure, maternal ethnic group, and maternal age at leaving full-time education. RESULTS: Twenty-five general practices were sampled. Median practice Jarman score was 15.0 (interquartile range [IQR] = 12.6-21.9). Responses were received from 1053 out of 1532 mothers approached (69%). Of these, 87% (897) had breastfed at birth, while 59% (609) were still breastfeeding their babies at four months. Mothers in rented accommodation were less likely to breastfeed than owner-occupiers (odds ratio [95% CI] = 0.52 [0.37-0.74]), as were women of white, compared with those of black, ethnic origin (odds ratio [95% CI] = 0.55 [0.36-0.82]). Those who completed up to two years and more than two years education after the age of 16 were 2.94 (95% CI = 1.85-4.66) and 9.25 (95% CI = 6.02-14.21) more likely to breastfeed at four months, respectively, than mothers whose formal education was completed at or before 16 years. Practice-specific rates of breastfeeding ranged from 71% to 100% at birth (median 87%; IQR = 79-93%) and 22% to 83% at four months (median 61%; interquartile range = 47-66%). The intra-practice correlation coefficient for breastfeeding at four months was 0.052 (within-cluster variance = 0.23, between-cluster variance = 0.013). There was no association between breastfeeding at four months and practice-specific Jarman score. Median age of starting solids was 16 weeks (IQR = 15-17 weeks). CONCLUSIONS: Housing tenure, maternal education, and ethnic group are significantly associated with breastfeeding prevalence at four months. Between-practice variation in breastfeeding prevalence is not associated with measures of practice population deprivation, as assessed by Jarman scores. Consideration should be given to including information on maternal ethnic group and housing tenure in future National Infant Feeding Surveys. Current weaning practices fall short of the recommendation of the World Health Assembly.
PMCID: PMC1314024  PMID: 11407048
13.  Epidemiology of visual impairment in Britain 
Archives of Disease in Childhood  1998;78(4):381-386.
PMCID: PMC1717530  PMID: 9623409
14.  Urinary antimony in infancy 
Archives of Disease in Childhood  1997;76(5):432-436.
Accepted 6 January 1997

OBJECTIVE—To determine whether antimony may be detected in the urine during infancy and early childhood and its association with passive exposure to tobacco smoke, as assessed by urinary cotinine.
DESIGN—Analysis of spare aliquots of urine collected from infants participating in studies of respiratory function and passive smoking. Urinary antimony was assayed using inductively coupled plasma mass spectroscopy in 201 urine specimens collected at different ages throughout the first two years of life from 122 term and 26 preterm infants. Urinary cotinine was measured using gas liquid chromatography.
MAIN OUTCOME MEASURE—Urinary antimony concentrations.
RESULTS—Absolute antimony concentrations varied widely between infants, being below the laboratory detection limit of 0.02 µg/l in 7% of samples, below 0.5 µg/l in 90.5%, and above the reference value of 1 µg/l reported for non-occupationally exposed UK populations in 4%. Creatinine standardised antimony values were unrelated to postnatal age or urinary cotinine concentrations and were highest in urine collected from preterm infants within 24 hours of birth (geometric mean (95% confidence interval): 2.3 ng/mg (1.5 to 3.4)).
CONCLUSION—Although antimony is present at very low concentrations in urine during infancy and early childhood, the relevance to health is uncertain. The higher levels found in preterm infants may reflect prematurity or fetal assimilation of antimony. Tobacco is unlikely to be an important source of environmental exposure to antimony during infancy and early childhood.


PMCID: PMC1717201  PMID: 9196360
17.  Validation of the reporting bases of the orthopaedic and paediatric surveillance schemes. 
Archives of Disease in Childhood  1996;75(3):232-236.
BACKGROUND: Nationally representative estimates of treatment rates for congenital dislocation of the hip were required to inform a review of the current United Kingdom screening policy. Cases were ascertained through an active reporting scheme involving orthopaedic surgeons and the existing British Paediatric Association Surveillance Unit (BPASU) scheme. OBJECTIVE: To report the methods used to establish, maintain, and validate the orthopaedic and BPASU schemes. METHODS: Multiple sources were used to develop the orthopaedic reporting base. Surgeons treating children were identified by postal questionnaire. The orthopaedic and paediatric reporting bases were compared to the 1992 manpower census surveys of surgeons and paediatricians. RESULTS: A single source of respondent ascertainment would have missed 12% of the 517 surgeons who treated children. Comparison with the manpower census data suggests the orthopaedic and paediatric reporting bases were 97% and 92% complete. CONCLUSIONS: Multiple sources should be used to establish and maintain a reporting base. Targeting respondents avoids unnecessary contact, saves resources, and may improve compliance. Manpower census data can be used for regular validation of the reporting base.
PMCID: PMC1511714  PMID: 8976664
19.  A national survey of screening for congenital dislocation of the hip. 
Archives of Disease in Childhood  1996;74(5):445-448.
OBJECTIVE: To identify current screening and management practices for congenital dislocation of the hip (CDH), and determine the extent to which ultrasound imaging of the hips is practised throughout the United Kingdom and the Irish Republic. METHODS: Postal questionnaire to paediatricians responsible for the routine neonatal care of infants in all maternity units in the UK and the Irish Republic. RESULTS: Questionnaires were returned for 254 maternity units (92% response rate). By 1994, 69% of maternity units had access to ultrasound imaging of the hips, compared to 14% in 1984. Ultrasound imaging of the hip was not used for universal primary screening, but in 93% of units was undertaken for further assessment of infants with clinically detected hip instability or those identified as being at high risk of CDH, or both. Clinical screening of newborn infants was performed by junior paediatricians, but training with a 'Baby Hippy' hip simulator model was provided in only 37% of units. Treatment of clinically detected hip instability, initiated by an orthopaedic surgeon in 93% of units, varied widely in type and duration. CONCLUSIONS: Ultrasound imaging of the hip is increasingly used in the UK for secondary, rather than primary, screening. Current recommendations are implemented to a variable extent nationally, and the existing wide variation in screening and management for CDH reflects a lack of research evidence to support current screening practices. The effectiveness of screening for CDH needs to be established.
PMCID: PMC1511532  PMID: 8669963
21.  A national survey of nebuliser use. 
Archives of Disease in Childhood  1991;66(11):1351-1353.
Nebuliser drug delivery units were reused in 15% of paediatric wards participating in a national survey, while routine servicing and written information was provided by only half the wards issuing home nebulisers. Written information should be developed as a national resource, and further research on optimal cleaning practices is required.
Images
PMCID: PMC1793299  PMID: 1755652
22.  Recognition and early management of Reye's syndrome. 
Archives of Disease in Childhood  1986;61(7):647-651.
Reye's syndrome continues to be associated with a high mortality. Out of 12 cases treated on our intensive care unit over a four year period, seven died, one suffered minimal cerebral damage, and four were normal. Rapid progression through coma stages and high peak ammonia concentrations worsened prognosis. Reye's syndrome was suspected in only 50% of cases at the referring hospital and resulted in prompt referral to the intensive care unit in only one case. Late referral to the unit was associated with a poor outcome. Sudden neurological deterioration followed diagnostic lumbar puncture in six children. Papilloedema was an unreliable sign of raised intracranial pressure and was absent in all cases. While computed tomography of the brain was useful in providing additional evidence of raised intracranial pressure, this could only be confirmed by direct measurement. Lumbar puncture in the presence of rapidly progressive coma should be deferred until raised intracranial pressure has been excluded. To this end, early admission to a paediatric intensive care unit with facilities for computed tomography and monitoring of intracranial pressure is recommended.
PMCID: PMC1777889  PMID: 3740903
23.  Orofaciodigital syndrome with mesomelic limb shortening. 
Journal of Medical Genetics  1984;21(3):189-192.
Two sisters, the children of first cousin Pakistani Moslem parents, have unusual facies, tongue hamartomata, pre- and postaxial polydactyly, severe talipes, and mesomelic limb shortening associated with tibial dysplasia. Homozygosity for a recessive gene defect is probable. The phenotype resembles, but is distinct from, the orofaciodigital syndromes delineated to date. We suggest that this condition be labelled OFD IV.
Images
PMCID: PMC1049264  PMID: 6748015
25.  Sex and ethnic differences in the waist circumference of 5-year-old children: Findings from the Millennium Cohort Study 
International Journal of Pediatric Obesity  2011;6(2Part2):e196-e198.
We examined sex and ethnic differences in central fatness, as assessed by waist circumference measurements, in 13 590 Millennium Cohort Study 5-year-olds. Measurements were expressed as z-scores based on reference data from the British Standards Institute. The cohort, especially girls, had larger waist circumference measurements than the reference population. Black children had larger waists, and children from other minority ethnic groups had smaller waists than White children. Girls, and Black children, in the United Kingdom are at particular risk for central fatness. Further research is needed to clarify ethnic and other influences on fat distribution, and the health outcomes associated with central fatness.
doi:10.3109/17477166.2010.526224
PMCID: PMC3465805  PMID: 21073404
Children; ethnicity; waist circumference; central fatness

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