To study recent trends in the cumulative incidence of visual impairment in childhood over a 15‐year period and to assess progress against WHO goals for prevention.
Design, setting and participants
Data from a population‐based register of visual impairment in southern England were used to estimate cumulative incidence and trends in visual impairment (VI) and severe visual impairment/blindness (SVI/BL) for children born in 1984–1998. Causes were classified by anatomical site(s), timing of insult(s) and whether the visual impairment was potentially preventable or treatable.
Of 691 eligible children, 358 (53%) had VI and 323 (47%) SVI/BL. The cumulative incidence of VI to age 12 years was 7.1 (95% CI 6.4 to 7.8) per 10 000 live births and for SVI/BL was 6.2 (95% CI 5.6 to 6.9); the incidence of both decreased significantly over time. There was an inverse relationship with gestational age and birth weight, although the risk of visual impairment associated with prematurity and low birth weight decreased substantially over time. 55% of children with VI and 77% with SVI/BL had other impairments; the proportion of associated impairments among children with VI decreased over time. 130 (19%) of the children have died, with over half dying before the age of 5.
There is evidence of a temporal decline in the incidence of VI and SVI/BL in births from 1984 to 1998 especially in very preterm and low birthweight infants. Early childhood mortality was high. The causes of visual impairment in UK children are numerous, complex and often part of a wider picture of childhood disability.
A torn labial frenum is widely regarded as pathognomonic of abuse.
We systematically reviewed the evidence for this, and to define other intra‐oral injuries found in physical abuse. Nine studies documented abusive torn labial frena in 30 children and 27 were fatally abused: 22 were less than 5 years old. Only a direct blow to the face was substantiated as a mechanism of injury.
Two studies noted accidentally torn labial frena, both from intubation. Abusive intra‐oral injuries were widely distributed to the lips, gums, tongue and palate and included fractures, intrusion and extraction of the dentition, bites and contusions.
Current literature does not support the diagnosis of abuse based on a torn labial frenum in isolation. The intra‐oral hard and soft tissue should be examined in all suspected abuse cases, and a dental opinion sought where abnormalities are found.
abuse; frenum; intra‐oral injury; torn labial frenum; systematic review
The aim of this study was to assess the clinical significance and prognosis of a prolonged isolated elevation of serum aminotransferases without cholestasis (>3 months) in infants and young children, investigated for a variety of conditions, and to determine a protocol for their follow‐up and investigation.
A combined prospective‐retrospective analysis of apparently healthy babies and young children with isolated elevation of serum aminotransferases of at least 1.5 times above the norm for age which persisted for at least 3 months and whose creatine phosphokinase (CK), gamma glutamyltransferase (GGT), alkaline phosphatase and bilirubin levels remained normal throughout the study duration. The children underwent the following investigations: abdominal ultrasound and infectious, metabolic and/or immunological investigation depending on the duration of the abnormality.
Six children were eliminated following the finding of positive cytomegalovirus (CMV) antigen in the urine. 72 children were investigated (47 males and 25 females). The duration of serum aminotransferases elevation was 3–36 months (average 12.4, median 11.5 months). The initial, maximal and final alanine aminotransferase (ALT) values were 85.5, 140.5 and 39.8 IU/l, respectively. Of seven children who had liver biopsies performed, three (42.8%) were suspected of having a glycogen storage disease which was not confirmed enzymatically. Four biopsies revealed non‐specific histological changes.
Isolated elevation of serum aminotransferases in healthy looking young children is mostly a benign condition that usually resolves within a year. If no pathology is found during routine investigation, these children can be followed conservatively. Liver biopsy does not contribute much to the diagnosis and is probably unnecessary.
Vitamin D deficiency (VDD) is common in immigrant children with increased skin pigmentation living in higher latitudes. We assessed the pattern of and risk factors for VDD in immigrant East African children living in Melbourne (latitude 37°49′ South).
A prospective survey of 232 East African children attending a clinic in Melbourne. Data were collected by questionnaire, medical assessment and laboratory tests.
Low 25‐hydroxyvitamin D (25‐OHD) levels (<50 nmol/l) occurred in 87% of children, and VDD (25‐OHD <25 nmol/l) in 44%. Risk factors included age <5 years, female gender, increased time in Australia, decreased daylight exposure and winter/spring season. Anaemia (20%), vitamin A deficiency (20%) and iron deficiency (19%) were also identified.
Asymptomatic VDD is common in East African immigrant children residing at a temperate latitude. Risk factors for VDD limit endogenous vitamin D production. Screening of immigrant children with increased skin pigmentation for VDD, anaemia, iron and vitamin A deficiency is appropriate. VDD in adolescent females identifies an increased risk of future infants with VDD.
Perspective on the paper by Cameron et al (see page 1062)
Primary ciliary dyskinesia (PCD) is usually inherited as an autosomal recessive disorder and presents with upper and lower respiratory tract infection, and mirror image arrangement in around 50% of cases. Cilia dysfunction is also implicated in a wider spectrum of disease, including polycystic liver and kidney disease, central nervous system problems including retinopathy and hydrocephalus, and biliary atresia. Cilia are complex structures, containing more than 250 proteins; recent studies have begun to locate PCD genes scattered throughout the genome. Screening tests for PCD include nasal nitric oxide and in vivo tests of ciliary motility such as the saccharin test. Specific diagnosis requires examination of cilia by light and electron microscopy, with epithelial culture in doubtful cases. This is only available in supra‐regional centres, recently centrally funded by the National Commissioning Group. Treatment is not evidence based and recommendations are largely extrapolated from cystic fibrosis and other suppurative lung diseases.
Chronic abdominal pain (CAP) is common among schoolchildren, but risk factors for its onset are still largely unknown.
To determine the frequency of onset of CAP in schoolchildren and investigate risk factors for its development.
1411 schoolchildren aged 11–14 years were recruited from schools in North West England. Information was collected on recent pain symptoms and potential risk factors for developing CAP. Participants were followed up 1 and 4 years later and new episodes of CAP were identified.
22% reported new‐onset abdominal pain at 1‐year follow‐up which persisted at 4‐year follow‐up (CAP). CAP was almost three times higher in girls than boys (34% vs 13%; χ2: 26.0; p<0.001). In girls, reporting headache at baseline was the only predictive factor for CAP onset: those reporting headaches experienced a doubling in the risk of symptom onset (relative risk: 2.1; 95% confidence interval: 0.95 to 4.7). In contrast, in boys, development of CAP was independently predicted by daytime tiredness (3.0; 1.2 to 7.6), lack of school enjoyment (2.0; 0.95 to 4.2), adverse psychosocial exposures (2.3; 1.2 to 4.5) and taller stature (1.9; 0.8 to 4.5).
Our results suggest that over 20% of adolescent schoolchildren experience new‐onset non‐self‐limiting abdominal pain over a 1‐year period. Future abdominal pain is predicted by previous somatic symptom reporting in girls and both somatic symptom reporting and psychosocial factors in boys. These risk factors indicate a possible mechanism for understanding the development of CAP, and might have important implications for both primary and secondary preventive strategies.
Children from Indian and Pakistani (South Asian) and black minority groups have relatively high rates of attendance at accident and emergency (A&E) departments and admissions to hospital in the UK. We examine parents' beliefs and management of childhood asthma that possibly contribute to their greater use of hospital services.
Three London hospitals serving multicultural communities with a high proportion of South Asian subjects.
Parent(s) accompanying 150 children aged 3–9 years with asthma attending asthma clinics and A&E departments.
Main outcome measures
White, South Asian and “other” ethnic group parents were compared regarding their children's symptoms and asthma in relation to why their children had developed asthma, use of asthma treatments, views about the prognosis of their children's asthma, and their feelings associated with stigma.
South Asian more often than white parents stated that they did not give preventers to their children (odds ratio (OR) 0.30; 95% confidence interval (CI) 0.12 to 0.75), that most drugs were “addictive” (OR 3.89; 95% CI 1.47 to 10.27), and that medicines could do more harm than good (OR 3.19; 95% CI 1.22 to 8.34). South Asian and “other” ethnic groups were more reluctant to tell others about their children's asthma (OR 0.11; 95% CI 0.01 to 1.06 and OR 0.06; 95% CI 0.01 to 0.65, respectively).
Cultural perspectives related to ethnicity are key factors in the understanding of asthma management. Health staff should give high priority to eliciting parents' beliefs regarding management of their children's asthma.
Multiple definitions of the metabolic syndrome (MS) have been proposed for children, adolescents and adults. The aim of this study was to analyse the variations in the MS prevalence using different definitions and to examine which factors influence the frequency of the MS in childhood and adolescence.
Methods and design
The prevalence of the MS according to eight proposed definitions was studied in 1205 Caucasian overweight children and adolescents aged 4–16 years (mean body mass index (BMI) 27.3 kg/m2, mean age 11.8 years, 46% males, 39% prepubertal). Blood pressure, waist circumference and fasting triglycerides, HDL‐cholesterol, total cholesterol, insulin and glucose concentrations were determined. Overweight was defined according to the International Task Force of Obesity in Childhood. Degree of overweight was calculated as standard deviation score of BMI (SDS‐BMI). Insulin resistance was estimated based on the HOMA model.
The prevalence of the MS varied significantly (p<0.001), being between 6% and 39% depending on the different definitions. Only 2% of the children fulfilled the criteria of the MS in all definitions. Insulin resistance and degree of overweight were associated with the MS. In most definitions, pubertal stage did not influence the occurrence of the MS. In a principal component analysis, total cholesterol, triglycerides and waist circumference showed high final communality estimates.
Since the prevalence of the MS varied widely in overweight children and adolescents depending on the proposed definition used, an internationally accepted uniform definition of the MS is necessary to compare different populations and studies.
To examine the experiences and concerns of young people and their parents regarding the management of medication for asthma or diabetes whilst at school.
Face‐to‐face semi‐structured interviews were conducted with 69 young people aged 8–15 years (43 with asthma and 26 with diabetes) and their parents (138 interviews in total) in their own homes. Respondents were recruited through randomly selected general practice surgeries in contrasting areas in South East England. Interviews were audio‐recorded, transcribed verbatim and analysed using established qualitative analytical procedures.
Young people with asthma and diabetes discussed difficulties regarding access to and use of their medicines at school which may jeopardise optimal condition management. School medicines policies could be a further hindrance. Young people endeavour to find ways to accommodate their medication and condition related needs whilst at school, in an attempt to limit the impact of their condition upon school activities such as sport, school trips and relationships with peers. Parents expressed concern regarding the awareness and levels of support available to their sons/daughters, in particular if a crisis should develop.
In order to ensure optimal care, there is a need for the development of protocols tailored to the needs of young people with different conditions. These should preferably be devised in partnership between the young person, their parents and the school to ensure that the flexibility and support required for optimal management are offered.
To estimate the prevalence of nasopharyngeal (NP) carriage of pneumococcus (Streptococcus pneumoniae) and describe the antibiotic resistance patterns and serotypes in young children attending group day care in London.
Design and subjects
Cross‐sectional survey of attendees at a sample of registered child day care centres (CDCCs) in a London borough.
Urban setting with a socially and culturally diverse population.
Methods and outcomes
19 CDCCs (13% of total) participated between March and November 2003. A single NP swab was required from each child, and parents completed a questionnaire about their child's health and attendance at day care. WHO methodology for pneumococcal carriage studies was followed.
30% of parents consented. 234 swabs were collected from children aged 6 months to 5 years. 53% were boys and 81% were white. 120 children (51%, 95% CI 45% to 58%) carried pneumococci in their nasopharynx. None of the isolates were resistant to penicillin (upper CL 3%). 21 isolates were resistant to erythromycin (17.5%, 95% CI 11% to 25.5%). 68 isolates (57%) were serotypes included in the 7‐valent conjugate vaccine. Non‐white children had a lower prevalence of carriage (27% vs 58%).
Conclusion: The prevalence of pneumococcal NP carriage was high. The penicillin resistance rate is lower than in many other countries and may reflect a decrease in community antibiotic prescribing in the UK. Monitoring circulating serotypes is important in the context of recent changes to the vaccination policy. Further study is required to explore the association with ethnicity and risk factors for antibiotic resistance.
To compare acute pain response during immunisation in infants using a slow standard of care injection technique versus a rapid pragmatic technique.
Randomised controlled trial.
Single‐centre, urban paediatric primary care practice.
Healthy infants 4–6 months of age receiving their routine DPTaP‐Hib immunisation.
Standard of care group: slow aspiration prior to injection, slow injection and slow withdrawal. Pragmatic group: no aspiration, rapid injection and rapid withdrawal.
Main outcome measures
Immediate infant pain measured by the Modified Behavior Pain Scale (MBPS), crying and parent/paediatrician visual analogue scale (VAS).
113 infants participated; there were no observed differences in age, birth order or prior analgesic use. Mean MBPS scores (95% confidence interval (CI)) were higher (p<0.001) for the standard group compared to the pragmatic group, 5.6 (5 to 6.3) vs 3.3 (2.6 to 3.9). The standard group was more likely to cry, 47/57 (82%) vs 24/56 (43%), to cry longer, median (interquartile range (IQR)) 14.7 s (8.7–35.6) vs 0 s (0–11.30), and to take longer to have the vaccine injected, median (IQR) 8.8 s (7.9–10.3) vs 0.9 s (0.8–1.1), p<0.001 for all comparisons. The median (IQR) VAS scores by parents and paediatricians were higher for the standard group: VAS parent, 3.5 (1.6–5.5) vs 1.9 (0.1–3.1) and VAS paediatrician, 2.8 (2.0–5.1) vs 1.4 (0.2–2.4). There were no adverse events.
Immunisation using a pragmatic rapid injection technique is less painful than a slow standard of care technique and should be recommended for routine intramuscular immunisations.
needle aspiration; injection speed; immunisation; pain
We need a clear definition of CFS/ME in children and sample sizes for genetic studies need to be much larger
There is no scientific evidence of a link between bowel disease and/or autism and MMR vaccine. Attainment of a high uptake of the vaccine should be encouraged.
This exploratory study surveyed 418 parents attending a paediatric hospital in order to establish their smoking habits and preparedness to quit. We found that 27% were current smokers, of whom 81% were willing to try and quit in the near future. These and the parent's other responses to a questionnaire will be used to develop a programme of smoking cessation for parents attending a children's hospital.
Facial appearance can be a significant clue in the initial identification of genetic conditions, but their low incidence limits exposure during training and inhibits the development of skills in recognising the facial “gestalt” characteristic of many dysmorphic syndromes. Here we describe the potential of computer‐based models of three‐dimensional (3D) facial morphology to assist in dysmorphology training, in clinical diagnosis and in multidisciplinary studies of phenotype–genotype correlations.
facial dysmorphology; 3D shape models
The harmful effects of ionising radiation are widely acknowledged. It has been reported that young children, particularly girls, have a higher sensitivity to radiation than adults. However, the exact detrimental effects of radiation, particularly at the low doses used in routine diagnostic radiography, are unknown and the subject of much controversy. Computed tomography (CT) accounts for about 9% of all radiological examinations but is responsible for 47% of medical radiation dose. Approximately 11% of CT examinations performed are in the paediatric population, but the long‐term hazards of CT are unknown.
radiation; paediatrics; computed tomography; nuclear medicine; radiography