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1.  Gallbladder distension in septic neonates. 
Eight cases of neonatal gallbladder distension are described. Group B streptococcal sepsis (5 infants) of suspected sepsis (3 infants) was present and probably played an aetiological role in the development of a distended gallbladder. Two infants required surgery because of persistent gallbladder enlargement and rising levels of bilirubin. Five responded to vigorous medical management and one died from sepsis and pneumonia. The need for conservative early management is stressed.
PMCID: PMC2863255  PMID: 7039518
2.  Coeliac disease associated with congenital heart disease. 
Six children with congenital heart disease are described in whom poor growth was found to be due to small-bowel villous atrophy; none was in heart failure and only one was severely cyanosed. Growth improved in all 6 on a gluten-free diet. Gluten enteropathy may be more common than is realised in children with congenital heart disease, and jejunal biopsy should be undertaken early in any patient with poor growth and no heart failure to exclude the coexistence of the condition.
PMCID: PMC2863259  PMID: 7065700
3.  Acute infective pericarditis in infancy. 
Infective pericarditis is rare; the characteristic presenting illness in 3 children, each aged under one year, is recorded. Early diagnosis is important since surgical drainage of the pericardium is often necessary in addition to antibiotic therapy. The clinical features may suggest pericarditis, but diagnosis is readily and reliably confirmed by echocardiography.
Images
PMCID: PMC2863268  PMID: 7065699
4.  Evaluation of temperature–pulse centile charts in identifying serious bacterial illness: observational cohort study 
Archives of Disease in Childhood  2011;96(4):368-373.
Background
Distinguishing serious bacterial infection (SBI) from milder/self-limiting infections is often difficult. Interpretation of vital signs is confounded by the effect of temperature on pulse and respiratory rate. Temperature–pulse centile charts have been proposed to improve the predictive value of pulse rate in the clinical assessment of children with suspected SBI.
Objectives
To assess the utility of proposed temperature–pulse centile charts in the clinical assessment of children with suspected SBI.
Study design and participants
The predictive value for SBI of temperature–pulse centile categories, pulse centile categories and Advanced Paediatric Life Support (APLS) defined tachycardia were compared among 1360 children aged 3 months to 10 years presenting with suspected infection to a hospital emergency department (ED) in England; and among 325 children who presented to hospitals in the UK with meningococcal disease.
Main outcome measure
SBI.
Results
Among children presenting to the ED, 55 (4.0%) had SBI. Pulse centile category, but not temperature–pulse centile category, was strongly associated with risk of SBI (p=0.0005 and 0.288, respectively). APLS defined tachycardia was also strongly associated with SBI (OR 2.90 (95% CI 1.60 to 5.26), p=0.0002). Among children with meningococcal disease, higher pulse and temperature–pulse centile categories were both associated with more severe disease (p=0.004 and 0.041, respectively).
Conclusions
Increased pulse rate is an important predictor of SBI, supporting National Institute for Health and Clinical Excellence recommendations that pulse rate be routinely measured in the assessment of febrile children. Temperature–pulse centile charts performed more poorly than pulse alone in this study. Further studies are required to evaluate their utility in monitoring the clinical progress of sick children over time.
doi:10.1136/adc.2010.183129
PMCID: PMC3158667  PMID: 21233079
5.  Home injury risks to young children in Karachi, Pakistan: a pilot study 
Archives of disease in childhood  2013;98(11):881-886.
Objective
To pilot an in-home unintentional injury hazard assessment tool and to quantify potential injury risks for young children in a low-income urban setting.
Methods
Two low-income neighbourhoods in Karachi, Pakistan, were mapped, and families with at least one child between the ages of 12 and 59 months were identified. Using existing available home injury risk information, an in-home injury risk assessment tool was drafted and tailored to the local setting. Home injury assessments were done in June–July 2010 after obtaining informed consent.
Results
Approximately 75.4% of mothers were educated through at least grade 12. The main risks identified were stoves within the reach of the child (n=279, 55.5%), presence of open buckets in the bathroom (n=240, 47.7%) within the reach of the child, and pedestal fans accessible to the child (n=242, 48.1%). In terms of safety equipment, a first-aid box with any basic item was present in 70% of households, but only 4.8% of households had a fire extinguisher in the kitchen.
Conclusions
This was the first time that an in-home, all-unintentional injury risk assessment tool was tailored and applied in the context of a low-income community in Pakistan. There was a significant burden of hazards present in the homes in these communities, representing an important opportunity for injury prevention. This pilot may have future relevance to other LMICs where child injury prevention is a critical need.
doi:10.1136/archdischild-2013-303907
PMCID: PMC4316730  PMID: 23995075
6.  A child an hour: burden of injury deaths among children under 5 in Pakistan 
Archives of disease in childhood  2013;98(11):867-871.
Background
Globally, more than 875 000 children under the age of 18 die due to injury every year. The rate of child injury death is 3.4 times higher in low-income and middle-income countries than in high-income countries.
Objectives
To study injury mortality burden among children under the age of 5 in Pakistan.
Methods
Demographic and Health Survey in Pakistan was conducted from September 2006 until February 2007. It included 95 000 households, out of which 3232 households had death of a child under the age of 5 from January 2005 onwards. The Child Verbal Autopsy Questionnaire (CVAQ) was administered to these households with a response rate of 96%.
Results
For age group 0–5 years, injury was the sixth leading cause of death and was responsible for 2.5% of all deaths (n=73). For age group 1–5 years, injury was found to be the third leading cause of death (11%) after diarrhoea (18%) and pneumonia (17%). The overall under fives mortality rate due to injury was estimated at 39.5 per 100 000 per year in Pakistan. Drowning (22%), road traffic injuries (12%), burns (11%) and falls (10%) were the most common types of injury. The mortality rate was twice as high in rural areas (32 per 100 000; 95% CI 18 to 45), compared to the urban areas (15 per 100 000; 95% CI 0.3 to 29).
Conclusions
Injury is the third leading cause of deaths among children 1–5 in Pakistan. The burden is twice as high in rural areas.
doi:10.1136/archdischild-2013-303654
PMCID: PMC4314940  PMID: 23956258
7.  Sickle cell disease: a neglected chronic disease of increasing global health importance 
Archives of Disease in Childhood  2014;100(1):48-53.
Sickle cell disease (SCD) is a single gene disorder causing a debilitating systemic syndrome characterised by chronic anaemia, acute painful episodes, organ infarction and chronic organ damage and by a significant reduction in life expectancy. The origin of SCD lies in the malarial regions of the tropics where carriers are protected against death from malaria and hence enjoy an evolutionary advantage. More recently, population migration has meant that SCD now has a worldwide distribution and that a substantial number of children are born with the condition in higher-income areas, including large parts of Europe and North and South America. Newborn screening, systematic clinical follow-up and prevention of sepsis and organ damage have led to an increased life expectancy among people with SCD in many such countries; however, in resource-limited settings where the majority continue to be born, most affected children continue to die in early childhood, usually undiagnosed, due to the lack of effective programmes for its early detection and treatment. As new therapies emerge, potentially leading to disease amelioration or cure, it is of paramount importance that the significant burden of SCD in resource-poor countries is properly recognised.
doi:10.1136/archdischild-2013-303773
PMCID: PMC4285890  PMID: 25239949
Haematology; sickle cell disease
8.  Socioeconomic inequalities in parent-reported and teacher-reported psychological well-being 
Archives of Disease in Childhood  2014;100(1):38-41.
Objective
To determine whether there are differences in the social gradient of parent-reported and teacher-reported child psychological well-being.
Design
Secondary data analysis comparing ratings of child psychological well-being (Strengths and Difficulties Questionnaire, SDQ) in the UK Millennium Cohort Study at 7 years by socioeconomic circumstances (SEC). A number of measures of SEC were tested; results are reported for maternal education. From a sample of 13 168 singletons who participated at the age of 7 years, complete data were available for 8207 children.
Results
There was a social gradient in SDQ scores reported by parents and teachers, with ‘borderline/abnormal’ scores more prevalent in children with lower-educated mothers. However, the gradient was more marked in parent report compared with teacher report, and discrepancies between parent and teacher reports were greatest for children from higher SECs.
Conclusions
The social gradient in child psychological well-being, although present, was weaker in teacher report compared with parent report. This may be because children behave differently in school and home settings, or parents and teachers demonstrate reporting bias.
doi:10.1136/archdischild-2014-306288
PMCID: PMC4283625  PMID: 25165074
Socio-economic factors; Child Psychology; Cohort studies; Parent-teacher reports
9.  Assessment of neonatal care in clinical training facilities in Kenya 
Archives of Disease in Childhood  2014;100(1):42-47.
Objective
An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya.
Design
Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data.
Setting
Neonatal units of 22 public hospitals.
Patients
Neonates aged <7 days.
Main outcome measures
Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission.
Results
All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing—for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0–3) and a median score of 6 out of 8 for signs of severe illness (IQR 4–7) were documented. Maternal HIV status was documented in 674/1249 (54%, 95% CI 41.9% to 66.1%) cases. Drug doses exceeded recommendations by >20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively.
Conclusions
Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training.
doi:10.1136/archdischild-2014-306423
PMCID: PMC4283661  PMID: 25138104
Neonatology; Health services research; Measurement; Evidence Based Medicine; Data Collection
10.  Inter-individual variation in midazolam clearance in children 
Archives of Disease in Childhood  2014;100(1):95-100.
Objectives
To determine the extent of inter-individual variation in clearance of midazolam in children and establish which factors are responsible for this variation.
Methods
A systematic literature review was performed to identify papers describing the clearance of midazolam in children. The following databases were searched: Medline, Embase, International Pharmaceutical Abstracts, CINAHL and Cochrane Library. From the papers, the range in plasma clearance and the coefficient of variation (CV) in plasma clearance were determined.
Results
25 articles were identified. Only 13 studies gave the full range of clearance values for individual patients. The CV was greater in critically ill patients (18%–170%) than non-critically ill patients (13%–54%). Inter-individual variation was a major problem in all age groups of critically ill patients. The CV was 72%–106% in preterm neonates, 18%–73% in term neonates, 31%–130% in infants, 21%–170% in children and 47%–150% in adolescents. The mean clearance was higher in children (1.1–16.7 mL/min/kg) than in neonates (0.78–2.5 mL/min/kg).
Conclusions
Large inter-individual variation was seen in midazolam clearance values in critically ill neonates, infants, children and adolescents.
doi:10.1136/archdischild-2013-305720
PMCID: PMC4283666  PMID: 25281734
Pharmacology; General Paediatrics
11.  Agreement between routine and research measurement of infant height and weight 
Archives of Disease in Childhood  2014;100(1):24-29.
In many countries, routine data relating to growth of infants are collected as a means of tracking health and illness up to school age. These have potential to be used in research. For health monitoring and research, data should be accurate and reliable. This study aimed to determine the agreement between length/height and weight measurements from routine infant records and researcher-collected data.
Methods
Height/length and weight at ages 6, 12 and 24 months from the longitudinal UK birth cohort (born in Bradford; n=836–1280) were compared with routine data collected by health visitors within 2 months of the research data (n=104–573 for different comparisons). Data were age adjusted and compared using Bland Altman plots.
Results
There was agreement between data sources, albeit weaker for height than for weight. Routine data tended to underestimate length/height at 6 months (0.5 cm (95% CI −4.0 to 4.9)) and overestimate it at 12 (−0.3 cm (95% CI −0.5 to 4.0)) and 24 months (0.3 cm (95% CI −4.0 to 3.4)). Routine data slightly overestimated weight at all three ages (range −0.04 kg (95% CI −1.2 to 0.9) to −0.04 (95% CI −0.7 to 0.6)). Limits of agreement were wide, particularly for height. Differences were generally random, although routine data tended to underestimate length in taller infants and underestimate weight in lighter infants.
Conclusions
Routine data can provide an accurate and feasible method of data collection for research, though wide limits of agreement between data sources may be observed. Differences could be due to methodological issues; but may relate to variability in clinical practice. Continued provision of appropriate training and assessment is essential for health professionals responsible for collecting routine data.
doi:10.1136/archdischild-2014-305970
PMCID: PMC4283671  PMID: 25266076
Growth; Monitoring; routine data; PCHR; research
12.  Nocturnal oxygen saturation profiles of healthy term infants 
Archives of Disease in Childhood  2014;100(1):18-23.
Objective
Pulse oximetry is used extensively in hospital and home settings to measure arterial oxygen saturation (SpO2). Interpretation of the trend and range of SpO2 values observed in infants is currently limited by a lack of reference ranges using current devices, and may be augmented by development of cumulative frequency (CF) reference-curves. This study aims to provide reference oxygen saturation values from a prospective longitudinal cohort of healthy infants.
Design
Prospective longitudinal cohort study.
Setting
Sleep-laboratory.
Patients
34 healthy term infants were enrolled, and studied at 2 weeks, 3, 6, 12 and 24 months of age (N=30, 25, 27, 26, 20, respectively).
Interventions
Full overnight polysomnography, including 2 s averaging pulse oximetry (Masimo Radical).
Main outcome measurements
Summary SpO2 statistics (mean, median, 5th and 10th percentiles) and SpO2 CF plots were calculated for each recording. CF reference-curves were then generated for each study age. Analyses were repeated with sleep-state stratifications and inclusion of manual artefact removal.
Results
Median nocturnal SpO2 values ranged between 98% and 99% over the first 2 years of life and the CF reference-curves shift right by 1% between 2 weeks and 3 months. CF reference-curves did not change with manual artefact removal during sleep and did not vary between rapid eye movement (REM) and non-REM sleep. Manual artefact removal did significantly change summary statistics and CF reference-curves during wake.
Conclusions
SpO2 CF curves provide an intuitive visual tool for evaluating whether an individual's nocturnal SpO2 distribution falls within the range of healthy age-matched infants, thereby complementing summary statistics in the interpretation of extended oximetry recordings in infants.
doi:10.1136/archdischild-2013-305708
PMCID: PMC4283696  PMID: 25063836
Respiratory; Sleep; Measurement; Technology
13.  Knowledge and skills retention following Emergency Triage, Assessment and Treatment plus Admission course for final year medical students in Rwanda: a longitudinal cohort study 
Archives of disease in childhood  2014;99(11):993-997.
Aim
To determine whether, after the Emergency Triage, Assessment and Treatment plus Admission (ETAT+) course, a comprehensive paediatric life support course, final year medical undergraduates in Rwanda would achieve a high level of knowledge and practical skills and if these were retained. To guide further course development, student feedback was obtained.
Methods
Longitudinal cohort study of knowledge and skills of all final year medical undergraduates at the University of Rwanda in academic year 2011–2012 who attended a 5-day ETAT+ course. Students completed a precourse knowledge test. Knowledge and clinical skills assessments, using standardised marking, were performed immediately postcourse and 3–9 months later. Feedback was obtained using printed questionnaires.
Results
84 students attended the course and re-evaluation. Knowledge test showed a significant improvement, from median 47% to 71% correct answers (p<0.001). For two clinical skills scenarios, 98% passed both scenarios, 37% after a retake, 2% failed both scenarios. Three to nine months later, students were re-evaluated, median score for knowledge test 67%, not significantly different from postcourse (p>0.1). For clinical skills, 74% passed, with 32% requiring a retake, 8% failed after retake, 18% failed both scenarios, a significant deterioration (p<0.0001).
Conclusions
Students performed well on knowledge and skills immediately after a comprehensive ETAT+ course. Knowledge was maintained 3–9 months later. Clinical skills, which require detailed sequential steps, declined, but most were able to perform them satisfactorily after feedback. The course was highly valued, but several short courses and more practical teaching were advocated.
doi:10.1136/archdischild-2014-306078
PMCID: PMC4198299  PMID: 24925893
14.  Knowledge and skills retention following Emergency Triage, Assessment and Treatment plus Admission course for final year medical students in Rwanda: a longitudinal cohort study 
Archives of Disease in Childhood  2014;99(11):993-997.
Aim
To determine whether, after the Emergency Triage, Assessment and Treatment plus Admission (ETAT+) course, a comprehensive paediatric life support course, final year medical undergraduates in Rwanda would achieve a high level of knowledge and practical skills and if these were retained. To guide further course development, student feedback was obtained.
Methods
Longitudinal cohort study of knowledge and skills of all final year medical undergraduates at the University of Rwanda in academic year 2011–2012 who attended a 5-day ETAT+ course. Students completed a precourse knowledge test. Knowledge and clinical skills assessments, using standardised marking, were performed immediately postcourse and 3–9 months later. Feedback was obtained using printed questionnaires.
Results
84 students attended the course and re-evaluation. Knowledge test showed a significant improvement, from median 47% to 71% correct answers (p<0.001). For two clinical skills scenarios, 98% passed both scenarios, 37% after a retake, 2% failed both scenarios. Three to nine months later, students were re-evaluated, median score for knowledge test 67%, not significantly different from postcourse (p>0.1). For clinical skills, 74% passed, with 32% requiring a retake, 8% failed after retake, 18% failed both scenarios, a significant deterioration (p<0.0001).
Conclusions
Students performed well on knowledge and skills immediately after a comprehensive ETAT+ course. Knowledge was maintained 3–9 months later. Clinical skills, which require detailed sequential steps, declined, but most were able to perform them satisfactorily after feedback. The course was highly valued, but several short courses and more practical teaching were advocated.
doi:10.1136/archdischild-2014-306078
PMCID: PMC4198299  PMID: 24925893
Medical Education; Accident & Emergency; Resuscitation; Low income populations; Rwanda
15.  Identifying the best body mass index metric to assess adiposity change in children 
Archives of Disease in Childhood  2014;99(11):1020-1024.
Objective
Although dual-energy X-ray absorptiometry (DEXA) is the preferred method to estimate adiposity, body mass index (BMI) is often used as a proxy. However, the ability of BMI to measure adiposity change among youth is poorly evidenced. This study explored which metrics of BMI change have the highest correlations with different metrics of DEXA change.
Methods
Data were from the Quebec Adipose and Lifestyle Investigation in Youth cohort, a prospective cohort of children (8–10 years at recruitment) from Québec, Canada (n=557). Height and weight were measured by trained nurses at baseline (2008) and follow-up (2010). Metrics of BMI change were raw (ΔBMIkg/m2), adjusted for median BMI (ΔBMIpercentage) and age-sex-adjusted with the Centers for Disease Control and Prevention growth curves expressed as centiles (ΔBMIcentile) or z-scores (ΔBMIz-score). Metrics of DEXA change were raw (total fat mass; ΔFMkg), per cent (ΔFMpercentage), height-adjusted (fat mass index; ΔFMI) and age-sex-adjusted z-scores (ΔFMz-score). Spearman's rank correlations were derived.
Results
Correlations ranged from modest (0.60) to strong (0.86). ΔFMkg correlated most highly with ΔBMIkg/m2 (r = 0.86), ΔFMI with ΔBMIkg/m2 and ΔBMIpercentage (r = 0.83–0.84), ΔFMz-score with ΔBMIz-score (r = 0.78), and ΔFMpercentage with ΔBMIpercentage (r = 0.68). Correlations with ΔBMIcentile were consistently among the lowest.
Conclusions
In 8–10-year-old children, absolute or per cent change in BMI is a good proxy for change in fat mass or FMI, and BMI z-score change is a good proxy for FM z-score change. However change in BMI centile and change in per cent fat mass perform less well and are not recommended.
doi:10.1136/archdischild-2013-305163
PMCID: PMC4215345  PMID: 24842797
17.  Probiotics in the prevention of eczema: a randomised controlled trial 
Archives of Disease in Childhood  2014;99(11):1014-1019.
Objective
To evaluate a multistrain, high-dose probiotic in the prevention of eczema.
Design
A randomised, double-blind, placebo-controlled, parallel group trial.
Settings
Antenatal clinics, research clinic, children at home.
Patients
Pregnant women and their infants.
Interventions
Women from 36 weeks gestation and their infants to age 6 months received daily either the probiotic (Lactobacillus salivarius CUL61, Lactobacillus paracasei CUL08, Bifidobacterium animalis subspecies lactis CUL34 and Bifidobacterium bifidum CUL20; total of 1010 organisms/day) or matching placebo.
Main outcome measure
Diagnosed eczema at age 2 years. Infants were followed up by questionnaire. Clinical examination and skin prick tests to common allergens were done at 6 months and 2 years.
Results
The cumulative frequency of diagnosed eczema at 2 years was similar in the probiotic (73/214, 34.1%) and placebo arms (72/222, 32.4%; OR 1.07, 95% CI 0.72 to 1.6). Among the secondary outcomes, the cumulative frequency of skin prick sensitivity at 2 years was reduced in the probiotic (18/171; 10.5%) compared with the placebo arm (32/173; 18.5%; OR 0.52, 95% CI 0.28 to 0.98). The statistically significant differences between the arms were mainly in sensitisation to cow's milk and hen's egg proteins at 6 months. Atopic eczema occurred in 9/171 (5.3%) children in the probiotic arm and 21/173 (12.1%) in the placebo arm (OR 0.40, 95% CI 0.18 to 0.91).
Conclusions
The study did not provide evidence that the probiotic either prevented eczema during the study or reduced its severity. However, the probiotic seemed to prevent atopic sensitisation to common food allergens and so reduce the incidence of atopic eczema in early childhood.
Trial registration Number
ISRCTN26287422.
doi:10.1136/archdischild-2013-305799
PMCID: PMC4215350  PMID: 24947281
Allergy; Microbiology; Dermatology
18.  New understanding of adolescent brain development; relevance to transitional healthcare for young people with long term conditions 
Archives of disease in childhood  2013;98(11):902-907.
Summary
Whether or not adolescence should be treated as a special period, there is now no doubt that the brain changes much during adolescence. From an evolutionary perspective, the idea of an under developed brain which is not fit for purpose until adulthood is illogical. Rather, the adolescent brain is likely to support the challenges specific to that period of life.
New imaging techniques show unequivocal, striking changes in the white and gray matter which take place between 11 and 25 years of age. There is increased connectivity between brain regions, and increased dopaminergic activity in the pre-frontal cortices, the striatum and limbic system and the pathways linking them. The brain is dynamic, with some areas developing faster and becoming more dominant until other areas catch up.
Plausible mechanisms can be postulated for linking these changes to the cognitive and behavioural features of adolescence. The changing brain may lead to abrupt behavioural change with the attendant risks; but it also produces a brain which is flexible and able to respond quickly and imaginatively. Society sets a context and environment that allows adolescent exuberance and creativity to be bounded and explored in relative safety.
Whilst these changes apply to all young people, in healthcare settings they are especially relevant to young people with long term conditions in the context of their transition to young adult life; such young people need to learn to manage their health condition and their health care providers need to understand how to facilitate this.
doi:10.1136/archdischild-2013-303945
PMCID: PMC4096849  PMID: 23986559
Adolescent health; Transition; Brain development
19.  Relationship between adiposity and cognitive performance in 9-10 year old children in south India 
Archives of disease in childhood  2013;99(2):126-134.
Background
Studies in high-income countries have shown inverse associations between adiposity and cognitive performance in children. We aimed to examine the relationship between adiposity and cognitive function in Indian children.
Methods
At a mean age of 9.7 years, height, weight, triceps and subscapular skinfold thicknesses and waist circumference were recorded for 540 children born in Mysore, India. Body fat percentage was estimated using bio-impedance. Cognitive function was assessed using 3 core tests from the Kaufman Assessment Battery for children-II edition and additional tests measuring learning, short-term memory, reasoning, verbal and visuo-spatial abilities, attention and concentration. Data on the parents’ socio-economic status, education, occupation and income were collected.
Results
According to WHO definitions, 3.5% of the children were overweight/obese (BMI>+1SD) and 27% underweight (BMI<−2SD). Compared to normal children, overweight/obese children scored higher in tests of learning/long-term retrieval, reasoning and verbal ability (unadjusted p<0.05 for all). All the cognitive test scores increased with increase in BMI and skinfold thickness, (unadjusted β=0.10 to 0.20 SD; p<0.05 for all). The effects, though attenuated, remained mainly significant after adjustment for age, sex and socio-economic factors. Similar associations were found for waist circumference and percentage body fat.
Conclusions
In this Indian population, in which obesity was uncommon, greater adiposity predicted higher cognitive ability. These associations were only partly explained by socio-economic factors. Our findings suggest that better nutrition is associated with better cognitive function, and that inverse associations between adiposity and cognitive function in high-income countries reflect confounding by socio-economic factors.
doi:10.1136/archdischild-2013-304478
PMCID: PMC3982043  PMID: 24146284
Adiposity; Children; Cognitive function; India; Birth cohort
20.  Season of Birth in a Nationwide Cohort of Coeliac Disease Patients 
Background and objective
Genetic factors alone cannot explain the risk of developing coeliac disease (CD). Children born in summer months are likely to be weaned and introduced to gluten during winter when viral infections are more frequent. Earlier studies on birth season and CD are limited in sample size and results are contradictory.
Method
Case-control study. We used biopsy reports from all 28 Swedish pathology departments to identify individuals with CD, defined as small intestinal villous atrophy (n=29,096). The government agency Statistics Sweden then identified 144,522 controls matched for gender, age, calendar year and county. Through conditional logistic regression we examined the association between summer birth (March-August) and later CD diagnosis (outcome measure).
Results
Some 54.10% of individuals with CD vs. 52.75% of controls were born in the summer months. Summer birth was hence associated with a small increased risk of later CD (Odds ratio: 1.06; 95%CI=1.03–1.08; p<0.0001). Stratifying CD patients according to age at diagnosis, we found the highest OR in those diagnosed before age 2 years (OR=1.17; 95%CI=1.10–1.26), while summer birth was not associated with a CD diagnosis in later childhood (age 2–18 years: OR=1.02; 95%CI=0.97–1.08), but had a marginal effect on the risk of CD in adulthood (age ≥18years: OR=1.04; 95%CI=1.01–1.07).
Conclusions
In this study, summer birth was associated with an increased risk of later CD, but the excess risk was small, and general infectious disease exposure early in life is unlikely to be a major cause of CD.
doi:10.1136/archdischild-2012-302360
PMCID: PMC3560933  PMID: 23172784
celiac; coeliac; epidemiology; risk factors; seasons; viral infection
21.  IMPROVING ACCESS TO CARE FOR CHILDREN WITH MENTAL DISORDERS: A GLOBAL PERSPECTIVE 
Archives of disease in childhood  2013;98(5):323-327.
Developmental disabilities, emotional disorders, and disruptive behaviour disorders are the leading mental health related causes of the global burden of disease in children aged below ten years. This article aims to address the treatment gap for child mental disorders through synthesizing three bodies of evidence: the global evidence base on the treatment of these priority disorders; the barriers to implementation of this knowledge; and the innovative approaches taken to address these barriers and improve access to care. Our focus is on low resource settings, which are mostly found in low and middle income countries (LMIC). Despite the evidence base on the burden of child mental disorders and their long-term consequences, and the recent mhGAP guidelines which testify to the effectiveness of a range of pharmacological and psychosocial interventions for these disorders, the vast majority of children in LMIC do not have access to these interventions. We identify three major barriers to implementation of efficacious treatments: the lack of evidence on delivery of the treatments; the low levels of detection of child mental disorders; and the shortage of skilled child mental health professionals. The evidence base on implementation, although weak, supports the use of screening measures for detection of probable disorders, coupled with a second stage diagnostic assessment, and the use of non-specialist workers in community and school settings for the delivery of psychosocial interventions. The most viable strategy to address the treatment gap is through empowerment of existing human resources who are most intimately concerned with child care, including parents, through innovative technologies such as mobile health, with the necessary skills for the detection and treatment of child mental disorders.
doi:10.1136/archdischild-2012-302079
PMCID: PMC3672840  PMID: 23476001
22.  Delivery by caesarean section and risk of obesity in preschool age children: a prospective cohort study 
Archives of disease in childhood  2012;97(7):610-616.
Objective
To examine whether delivery by caesarean section is a risk factor for childhood obesity.
Design
Prospective pre-birth cohort study (Project Viva).
Setting
Eight outpatient multi-specialty practices based in the Boston, Massachusetts area.
Participants
We recruited women during early pregnancy between 1999 and 2002, and followed their children after birth. We included 1255 children with body composition measured at 3 years of age.
Main outcome measures
Body mass index (BMI) z-score, obesity (BMI for age and sex ≥ 95th percentile), and sum of triceps + subscapular skinfold thicknesses, at 3 years of age.
Results
284 children (22.6 percent) were delivered by caesarean section. At age 3, 15.7% of children delivered by caesarean section were obese, compared with 7.5% of children born vaginally. In multivariable logistic and linear regression models adjusting for maternal pre-pregnancy BMI, birth weight, and other covariates, birth by caesarean section was associated with a higher odds of obesity at age 3 (OR 2.10, 95%CI 1.36 to 3.23), higher mean BMI z-score (0.20 units, 95% CI 0.07 to 0.33), and higher sum of triceps + subscapular skinfold thicknesses (0.94 mm, 95% CI 0.36 to 1.51).
Conclusions
Infants delivered by caesarean section may be at increased risk of childhood obesity. Further studies are needed to confirm our findings and to explore mechanisms underlying this association.
doi:10.1136/archdischild-2011-301141
PMCID: PMC3784307  PMID: 22623615
23.  Does maternal feeding restriction lead to childhood obesity in a prospective cohort study? 
Archives of disease in childhood  2010;96(3):265-269.
Background
Some studies show that greater parental control over children’s eating habits predicts later obesity, but it is unclear whether parents are reacting to infants who are already overweight.
Objective
To examine the longitudinal association between maternal feeding restriction at age 1 and body mass index (BMI) at age 3 and the extent to which the association is explained by weight for length (WFL) at age 1.
Methods
We studied 837 mother–infant pairs from a prospective cohort study. The main exposure was maternal feeding restriction at age 1, defined as agreeing or strongly agreeing with the following question: “I have to be careful not to feed my child too much.” We ran multivariable linear regression models before and after adjusting for WFL at age 1. All models were adjusted for parental and child sociodemographic characteristics.
Results
100 (12.0%) mothers reported feeding restriction at age 1. Mean (SD) WFL z-score at age 1 was 0.32 (1.01), and BMI z-score at age 3 was 0.43 (1.01). Maternal feeding restriction at age 1 was associated with higher BMI z-score at age 3 before (β 0.26 (95% CI 0.05 to 0.48)) but not after (β 0.00 (95% CI −0.17 to 0.18)) adjusting for WFL z-score at age 1. Each unit of WFL z-score at age 1 was associated with an increment of 0.57 BMI z-score units at age 3 (95% CI 0.51 to 0.62).
Conclusions
We found that maternal feeding restriction was associated with children having a higher BMI at age 3 before, but not after, adjusting for WFL at age 1. One potential reason may be that parents restrict the food intake of infants who are already overweight.
doi:10.1136/adc.2009.175240
PMCID: PMC3703750  PMID: 21081589
24.  Fetal head circumference growth in children with specific language impairment 
Objective
To characterise fetal brain growth in children with specific language impairment (SLI).
Design
A nested case–control study.
Setting
Perth, Western Australia.
Participants
Thirty children meeting criteria for SLI at age 10 years were individually matched with a typically developing comparison child on sex, non-verbal ability, fetal gestational age, maternal age at conception, smoking and alcohol intake during pregnancy.
Main outcome measures
Occipitofrontal head circumference (HC) was measured using ultrasonography at approximately 18 weeks gestation. Femur length provided a measure of fetal length. Occipitofrontal HC was measured at birth and at the 1-year postnatal follow-up using a precise paper tape measure, while crown-heel length acted as an index of body length at both time points. Raw data were transformed to z-scores using reference norms.
Results
The SLI group had a significantly smaller mean HC than the typically developing comparison children at birth, but there was no group difference at 18 weeks gestation or at the 1-year postnatal follow-up. Individual analyses found that 12 SLI children had an HC z-score less than −1 at birth, with three of these cases meeting criteria for microcephaly. There was no group difference in the indices of overall body size at any time point.
Conclusions
Children with SLI are more likely to have a small HC at birth but not at 18 weeks gestation or infancy, suggesting growth asynchrony in brain development during the second half of pregnancy.
doi:10.1136/adc.2009.180331
PMCID: PMC3704335  PMID: 20921240
25.  Mothers’ experiences of bottle-feeding: a systematic review of qualitative and quantitative studies 
Archives of disease in childhood  2009;94(8):596-601.
Objective
Most babies receive at least some formula milk. Variations in formula-feeding practices can have both short- and long-term health consequences. We systematically reviewed the literature on parents’ experiences of bottle-feeding to understand how formula-feeding decisions are made.
Methods
We systematically searched for and appraised relevant English-language papers identified by searching 12 electronic databases, reference lists and related articles and by contacting first authors of included papers. We analysed and synthesised the included studies using a combination of narrative and thematic approaches. Consensus on the final inclusion, interpretation and synthesis of studies was reached across the research team.
Results
Six qualitative studies and 17 quantitative studies (involving 13,263 participants) were included. Despite wide differences in study design, context, focus and quality, several consistent themes emerged. Mothers who bottle-fed their babies experienced negative emotions such as guilt, anger, worry, uncertainty and a sense of failure. Mothers reported receiving little information on bottle-feeding and did not feel empowered to make decisions. Mistakes in preparation of bottle-feeds were common. No studies examined how mothers made decisions about the frequency or quantity of bottle-feeds.
Conclusions
Inadequate information and support for mothers who decide to bottle-feed may put the health of their babies at risk. While it is important to promote breastfeeding, it is also necessary to ensure that the needs of bottle-feeding mothers are met.
doi:10.1136/adc.2008.151910
PMCID: PMC3697301  PMID: 19602520
Infant feeding; formula milk; experiences; qualitative methods; systematic review

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