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1.  A low cost, colour coded, hand held spring scale accurately categorises birth weight in low resource settings 
Archives of disease in childhood  2006;91(5):410-413.
To determine the accuracy of a low cost, spring calibrated, hand held scale in classifying newborns into three weight categories (>2500 g, 2000−2499 g, ,2000 g).
The test device was compared to a gold standard digital baby scale with precision to 2 g. In Sarlahi district, Nepal, 1890 newborns were eligible for the study. Measurements were collected for both the test device and the digital scale from 1820 (96.3%) newborns.
The overall low birth weight (LBW) prevalence rate for the gold standard digital scale was 28.1% (511/1820). Sensitivity (93.7%) and specificity (97.6%) of the test device was high compared to LBW classifications based on digital weight measurements. Classification of infants into the ,2000 g category was 5.0% and 4.7% for the gold standard and test device, respectively. Sensitivity and specificity of the test device in identifying infants ,2000 g was 87.8% and 99.6%, respectively. Positive predictive values were high (.91%) for both weight categories
This low cost, simple-to-use device classified infants into weight categories with a high degree of consistency and accuracy that exceeds that of surrogate measures. This new device is useful for identifying and targeting life saving interventions for LBW, high risk infants in settings where infants are born in the home and conventional weighing scales are unavailable.
PMCID: PMC2082743  PMID: 16464960
2.  Blood pressure centiles for Great Britain 
Archives of Disease in Childhood  2006;92(4):298-303.
To produce representative cross-sectional blood pressure reference centiles for children and young people living in Great Britain.
Analysis of blood pressure data from seven nationally representative surveys: Health Surveys for England 1995–8, Scottish Health Surveys 1995 and 1998, and National Diet & Nutrition Survey 1997.
Blood pressure was measured using the Dinamap 8100 with the same protocol throughout. Weight and height were also measured. Data for 11 364 males and 11 537 females aged 4–23 years were included in the analysis, after excluding 0.3% missing or outlying data. Centiles were derived for systolic, diastolic, mean arterial and pulse pressure using the lambda-mu-sigma (LMS) equations method.
Blood pressure in the two sexes was similar in childhood, rising progressively with age and more rapidly during puberty. Systolic pressure rose faster and was appreciably higher in adult men than in adult women. After adjustment for age, blood pressure was related more to weight than height, the effect being stronger for systolic blood pressure. Pulse pressure peaked at 18 years in males and 16 years in females.
These centiles increase our knowledge of blood pressure norms in contemporary British children and young people. High blood pressure for age should be defined as blood pressure above the 98th centile, and high-normal blood pressure for age as blood pressure between the 91st and 98th centiles. The centiles identify children and young people with increased blood pressure, and will be of benefit to both clinical practice and research.
PMCID: PMC2083671  PMID: 16905566
3.  Improving infant sleep and maternal mental health: a cluster randomised trial 
Archives of Disease in Childhood  2006;92(11):952-958.
To determine whether a community‐delivered intervention targeting infant sleep problems improves infant sleep and maternal well‐being and to report the costs of this approach to the healthcare system.
Cluster randomised trial.
49 Maternal and Child Health (MCH) centres (clusters) in Melbourne, Australia.
328 mothers reporting an infant sleep problem at 7 months recruited during October–November 2003.
Behavioural strategies delivered over individual structured MCH consultations versus usual care.
Main outcome measures
Maternal report of infant sleep problem, depression symptoms (Edinburgh Postnatal Depression Scale (EPDS)), and SF‐12 mental and physical health scores when infants were 10 and 12 months old. Costs included MCH sleep consultations, other healthcare services and intervention costs.
Prevalence of infant sleep problems was lower in the intervention than control group at 10 months (56% vs 68%; adjusted OR 0.58 (95% CI: 0.36 to 0.94)) and 12 months (39% vs 55%; adjusted OR 0.50 (0.31 to 0.80)). EPDS scores indicated less depression at 10 months (adjusted mean difference −1.4 (−2.3 to −0.4) and 12 months (−1.7 (−2.6 to −0.7)). SF‐12 mental health scores indicated better health at 10 months (adjusted mean difference 3.7 (1.5 to 5.8)) and 12 months (3.9 (1.8 to 6.1)). Total mean costs including intervention design, delivery and use of non‐MCH nurse services were £96.93 and £116.79 per intervention and control family, respectively.
Implementing this sleep intervention may lead to health gains for infants and mothers and resource savings for the healthcare system.
Trial registration
Current Controlled Trial Registry, number ISRCTN48752250 (registered November 2004).
PMCID: PMC2083609  PMID: 17158146
4.  Bronchoscopy following diagnosis with cystic fibrosis 
Archives of Disease in Childhood  2006;92(10):898-899.
We recently changed our practice to perform bronchoscopy following diagnosis with cystic fibrosis. On a retrospective review of 25 children, Pseudomonas aeruginosa was detected in bronchoalveolar lavage for the first time in five children (20%) and Staphylococcus aureus in four (16%). Lavage culture was positive in eight of 18 children without respiratory symptoms. This highlights the potential of bronchoscopy following diagnosis, even in asymptomatic children.
PMCID: PMC2083238  PMID: 17088336
5.  Investigation of unexplained infant deaths in Jerusalem, Israel 1996–2003 
Archives of Disease in Childhood  2006;92(8):697-699.
Sudden infant death syndrome (SIDS) is a diagnosis of exclusion that may be assigned only after investigations including a forensic autopsy are performed to exclude possible organic and environmental causes of death. Israeli society is influenced by the Jewish and Islamic faiths, which permit autopsy only under selected circumstances. Against this background, we carried out a study to determine what examinations are performed to investigate unexplained infant deaths in Jerusalem, Israel.
We examined hospital, Ministry of Health and Ministry of Interior records of unexplained infant deaths in the Jerusalem district from the years 1996–2003.
Ninety six cases were identified from all sources. Forty nine (51%) infants were brought to a hospital at or near the time of death. Studies to determine the cause of death were performed in 54% of cases for which medical records were available for review. These studies included bacterial cultures (44%), skeletal surveys (12%), computerised tomography (3%) and metabolic studies (3%). Only one forensic autopsy was performed, and in no instance was the death site examined by medical personnel. There was a high rate of retrospective review by district health physicians. The most frequently assigned cause of death was SIDS.
: The capacity of public health officials and forensic pathologists to investigate unexplained infant deaths is strongly affected by the legal, religious and political milieu in which they work. Efforts should be made to develop socially acceptable methods of improving the quality of infant death investigations in Jerusalem.
PMCID: PMC2083878  PMID: 17074788
sudden infant death syndrome; autopsy; forensic investigation; religion
6.  Pyridoxine‐dependent seizures in Dutch patients: diagnosis by elevated urinary alpha‐aminoadipic semialdehyde levels 
Archives of Disease in Childhood  2006;92(8):687-689.
Pyridoxine‐dependent seizures (PDS) is a rare, autosomal recessively inherited disorder. Recently α‐aminoadipic semialdehyde (α‐AASA) dehydrogenase deficiency was identified as a major cause of PDS, which causes accumulation of both α‐AASA and pipecolic acid (PA) in body fluids.
We studied urinary and plasma α‐AASA and PA levels in 12 Dutch clinically diagnosed patients with PDS.
α‐AASA was elevated in both urine and plasma in 10 patients. In these patients plasma PA levels were also elevated but urinary PA levels were normal.
In all patients with clinically definite PDS, and in most patients with probable or possible PDS, the clinical diagnosis of PDS could be confirmed at the metabolite level. Non‐invasive urinary screening for α‐AASA accumulation provides a reliable tool to diagnose PDS and can save these patients from the classical and potentially dangerous pyridoxine withdrawal test to prove PDS.
PMCID: PMC2083882  PMID: 17088338
7.  Nasopharyngeal aspiration for diagnosis of pulmonary tuberculosis 
Archives of Disease in Childhood  2006;92(8):693-696.
Confirmation of pulmonary tuberculosis (PTB) in young children is difficult as they seldom expectorate sputum.
To compare sputa obtained by nasopharyngeal aspiration and by sputum induction for staining and culture of Mycobacterium tuberculosis.
Patients and methods
Patients from Mulago Hospital, Kampala with symptoms suggestive of PTB were considered for inclusion in the study. Those with a positive tuberculin test and/or a chest radiograph compatible with tuberculosis were recruited. Infection with human immunodeficiency virus (HIV) was confirmed by duplicate enzyme‐labelled immunosorbent assay or in children <15 months by polymerase chain reaction (PCR). Direct PCR was undertaken on 82 nasopharyngeal aspirates.
Of 438 patients referred, 94 were recruited over a period of 5 months. Median (range) age was 48 (4–144) months. Of 63 patients tested, 69.8% were infected with HIV. Paired and uncontaminated culture results were available for 88 patients and smear results for 94 patients. Nasopharyngeal aspirates were smear‐positive in 8.5% and culture‐positive in 23.9%. Induced sputa were smear‐positive in 9.6% and culture positive in 21.6%. Overall, 10.6% were smear‐positive, 25.5% were culture‐positive and 26.6% had smear and/or culture confirmed tuberculosis. Direct PCR on nasopharyngeal aspirates had a sensitivity of 62% and specificity of 98% for confirmation of culture‐positive tuberculosis.
Nasopharyngeal aspiration is a useful, safe and low‐technology method for confirmation of PTB and, like sputum induction, can be undertaken in outpatient clinics.
PMCID: PMC2083896  PMID: 17185437
nasopharyngeal aspirates; diagnosis; tuberculosis
8.  Assessing the population impact of low rates of breast feeding on asthma, coeliac disease and obesity: the use of a new statistical method 
Archives of Disease in Childhood  2006;92(6):483-485.
Lack of breast feeding has been reported to be associated with a number of chronic childhood disorders.
To use a recently described measure, the population impact number of eliminating a risk factor over a time period (PIN‐ER‐t), to quantify the burden of low rates of breast feeding in a UK population of babies born in 2002 with regard to asthma, coeliac disease and obesity.
We performed literature searches for systematic reviews with meta‐analyses that had investigated the association between breast feeding and asthma, coeliac disease and obesity. Based on these data, and published data on the prevalence of breast feeding and the prevalence of the disorders, we calculated PIN‐ER‐t and estimated the number of cases of each disorder which could be prevented by eliminating “no breast feeding” as a risk factor.
In the population of the 596 122 babies born in England and Wales in 2002, the number of cases of asthma, coeliac disease and obesity that could be prevented over 7–9 years if “no breast feeding” as a risk factor was eliminated were 33 100 (95% CI 17 710 to 47 543), 2655 (95% CI 1937 to 3343) and 13639 (95% CI 7838 to 19308), respectively.
The population burden of low breast feeding rates is high with regard to these chronic disorders. The use of PIN‐ER‐t allows the population burden of low breast feeding rates to be quantified and communicated in a way that will make it easier for both the general public and decision makers to understand.
PMCID: PMC2066141  PMID: 16840504
breast feeding; chronic disorders; population burden; PIN‐ER‐t
9.  Live viral vaccines in a DiGeorge syndrome patient 
Archives of Disease in Childhood  2006;92(6):519-520.
We report a case of pneumonia in a 13 month old male child with partial DiGeorge syndrome who died after inadvertently receiving live viral vaccines. Although live viral vaccines have been used safely in some children with DiGeorge syndrome, there are insufficient data to recommend their routine use in those with severe immunodeficiency.
PMCID: PMC2066142  PMID: 16798784
DiGeorge syndrome; vaccine; viral
10.  Prevalence rates for constipation and faecal and urinary incontinence 
Archives of Disease in Childhood  2006;92(6):486-489.
To evaluate the prevalence rates for constipation and faecal and urinary incontinence in children attending primary care clinics in the United States.
Retrospective review of case records of all children, 4–17 years of age, seen for at least one health maintenance visit during a 6 month period and followed from birth or within the first 6 months of age in our clinics. We reviewed all charts for constipation, faecal incontinence and urinary incontinence.
We included 482 children in the study, after excluding 39 children with chronic diseases. The prevalence rate for constipation was 22.6% and was similar in boys and girls. The constipation was functional in 18% and acute in 4.6%. The prevalence rate for faecal incontinence (⩾1/week) was 4.4%. The faecal incontinence was associated with constipation in 95% of our children. The prevalence rate for urinary incontinence was 10.5%; 3.3% for daytime only, 1.8% for daytime with night‐time and 5.4% for night‐time urinary incontinence. Faecal and urinary incontinence were significantly more commonly observed in children with constipation than in children without constipation.
The prevalence rates were 22.6% for constipation, 4.4% for faecal incontinence and 10.5% for urinary incontinence in a US primary care clinic. Children with constipation had higher prevalence rates for faecal and urinary incontinence than children without constipation. Boys with constipation had higher rates of faecal incontinence than girls with constipation.
PMCID: PMC2066162  PMID: 16857698
functional constipation; acute constipation; faecal incontinence; daytime urinary incontinence; night‐time urinary incontinence
11.  Fluid therapy for children: facts, fashions and questions 
Archives of Disease in Childhood  2006;92(6):546-550.
Fluid therapy restores circulation by expanding extracellular fluid. However, a dispute has arisen regarding the nature of intravenous therapy for acutely ill children following the development of acute hyponatraemia from overuse of hypotonic saline.
The foundation on which correct maintenance fluid therapy is built is examined and the difference between maintenance fluid therapy and restoration or replenishment fluid therapy for reduction in extracellular fluid volume is delineated. Changing practices and the basic physiology of extracellular fluid are discussed. Some propose changing the definition of “maintenance therapy” and recommend isotonic saline be used as maintenance and restoration therapy in undefined amounts leading to excess intravenous sodium chloride intake.
Intravenous fluid therapy for children with volume depletion should first restore extracellular volume with measured infusions of isotonic saline followed by defined, appropriate maintenance therapy to replace physiological losses according to principles established 50 years ago.
PMCID: PMC2066164  PMID: 17175577
12.  Should paediatric central lines be aspirated before use? 
Archives of Disease in Childhood  2006;92(6):517-518.
As blood clots commonly occur in the lumens of paediatric haemodialysis central‐venous lines, they must be routinely aspirated before use to prevent pulmonary emboli. The smaller diameter lines used for parenteral nutrition and cancer chemotherapy are seldom managed this way. We looked for clots formed when children undergoing cancer chemotherapy had their heparin‐locked central lines accessed, and compared with the lines of children undergoing haemodialysis. Patients undergoing haemodialysis had clots aspirated on 83% of occasions, and each child had clots at least once. Clots also occurred in the smaller lines, but they were less frequent (64%, p = 0.01), and had a lower median weight than those in dialysis lines (14.1 v 25.2 mg, p = 0.01). When small diameter central lines are used without initial aspiration, small pulmonary emboli are likely to occur, but are unlikely to be individually clinically important. Daily use, as with long‐term parenteral nutrition, might result in >3 g of clot being embolised annually. Consideration should be given to aspirating all paediatric central lines before use.
PMCID: PMC2066167  PMID: 17068071
13.  Beyond counting cases: public health impacts of national Paediatric Surveillance Units 
Archives of Disease in Childhood  2006;92(6):527-533.
Paediatric Surveillance Units (PSUs) have been established in 14 countries and facilitate national, prospective, active surveillance for a range of conditions, with monthly reporting by child health specialists. The International Network of Paediatric Surveillance Units (INoPSU) was established in 1998 and facilitates international collaboration among member PSUs and allows for sharing of resources, simultaneous data collection and hence comparison of data from different geographical regions. The impact of data collected by PSUs, both individually and collectively as members of INoPSU, on public health outcomes, clinical care and research is described.
PMCID: PMC2066170  PMID: 17158859
child health; paediatrics; population surveillance; public health; rare diseases
14.  Reference chart for relative weight change to detect hypernatraemic dehydration 
Archives of Disease in Childhood  2006;92(6):490-494.
The validity of the rule of thumb that infants may have a weight loss of 10% in the first days after birth is unknown. We assessed the validity of this and other rules to detect breast‐fed infants with hypernatraemic dehydration.
A reference chart for relative weight change was constructed by the LMS method. The reference group was obtained by a retrospective cohort study.
1544 healthy, exclusively breast‐fed infants with 3075 weight measurements born in the Netherlands and 83 cases of breast‐fed infants with hypernatraemic dehydration obtained from literature.
The rule of thumb had a sensitivity of 90.4%, a specificity of 98.3% and a positive predictive value of 3.7%. Referring infants if their weight change is below −2.5 SDS (0.6th centile) in the reference chart in the first week of life and using the rule of thumb in the second week had a sensitivity of 85.5%, a specificity of 99.4% and a positive predictive value of 9.2%.
The rule of thumb is likely to produce too many false positive results, assuming that for screening purposes the specificity needs to be high. A chart for relative weight change can be helpful to detect infants with hypernatraemic dehydration.
PMCID: PMC2066175  PMID: 16880225
breast feeding; weight loss; growth monitoring; infancy; hypernatraemic dehydration
15.  Quality of life and congenital heart defects: comparing parent and professional values 
Archives of Disease in Childhood  2006;92(5):388-393.
To compare preferences obtained from health professionals with those from parents for the longer‐term health outcomes of children with congenital heart defects.
Cardiology conference; hospital.
109 paediatric cardiology professionals (72% female, median age 38 years) and 106 parents of children with congenital heart defects (82% female, median age 37 years).
Eight health state descriptions, for cardiac and neurological disability resulting from congenital heart defects, were developed and presented with a self‐administered anonymous questionnaire. Respondents were asked to rank health state descriptions from best to worst, score each health state using a visual analog scale and mark death on this scale.
Health professionals and parents agreed in the order of ranking health states from best to worst. Both groups assigned the lowest scores to health states with severe neurological disability. Scores did not differ significantly by age, sex or whether the respondent was in the health professional or parent group. Of all respondents, 8% (17) scored at least one health state description worse than death.
Parents and health professionals place similar values on the quality of life outcomes of children with congenital heart defects. Both are more averse to health states describing worse neurological than cardiac disability. Improving our understanding of the relative importance of different outcomes to children and families is an important basis for sharing decisions about clinical care. The views of young people with congenital heart defects should be an important focus for future enquiry into health outcomes.
PMCID: PMC2083724  PMID: 16737999
16.  Quantifying how tests reduce diagnostic uncertainty 
Archives of Disease in Childhood  2006;92(5):404-408.
Diagnostic tests are commonly evaluated from sensitivity and specificity, which are robust and independent of prevalence, but clinically not intuitive. Many clinicians prefer to use positive and negative predictive values (PPV and NPV), but they are frequently applied as if they are independent of prevalence, whereas this may make an important difference.
Methods and results
We present graphs that allow easy reference to appropriate values and demonstrate that PPV and NPV are not independent of prevalence. PPV and NPV figures reflect the prior probability of the case having a positive diagnosis, estimated clinically from the history, examination and other results, as well as the impact of the test result. To avoid the common error of allowing for prior probability twice, and to interpret the impact of the test result alone, we present graphs of the proportionate reduction in uncertainty score (PRU), calculated from sensitivity, specificity and prevalence. These plots show the extent to which either a positive or negative test result affects the remaining degree of uncertainty about a diagnosis in either direction, according to likely clinical prevalence.
PRU plots demonstrate the discriminatory value of tests more clearly than sensitivity and specificity from which they are derived, and should be published alongside them.
PMCID: PMC2083733  PMID: 17158858
17.  Surgical management of inflammatory bowel disease 
Archives of Disease in Childhood  2006;92(4):312-316.
To evaluate the outcome and morbidity after major surgical interventions for inflammatory bowel disease (IBD).
Retrospective case note analysis of 227 children referred to a tertiary referral centre between 1994 and 2002 for treatment of IBD.
26 of 125 children with Crohn's disease (21%) required surgical management. 13 with disease proximal to the left colon underwent limited segmental resections and primary anastomosis, without significant morbidity. Primary surgery for 13 children with disease distal to the transverse colon included 6 subtotal‐colectomies or panprocto‐colectomies. All seven children undergoing conservative segmental resections (three with primary anastomosis, four with stoma formation), required further colonic resection or defunctioning stoma formation. All three children undergoing primary anastomosis developed a leak or fistula formation. 22 of 102 children with ulcerative colitis (22%) required surgery. Definitive procedures (n = 17) included J‐pouch ileoanal anastomosis (n = 11), ileorectal anastomosis (n = 2), straight ileoanal anastomosis (n = 3), and proctectomy/ileostomy (n = 1). Five children await restorative surgery after subtotal colectomy. Median daily stool frequency after J‐pouch surgery was 5 (range 3–15), and 10 of 11 children reported full daytime continence. All three children with straight ileoanal anastomosis had unacceptable stool frequency and remain diverted.
The complication rate after resectional surgery for IBD was 57% for Crohn's disease, and 31% for ulcerative colitis. In children with Crohn's disease, limited resection with primary anastomosis is safe proximal to the left colon. Where surgery is indicated for disease distal to the transverse colon, subtotal or panproctocolectomy is indicated, and an anastomosis should be avoided. Children with ulcerative colitis had a good functional outcome after J‐pouch reconstruction. However, the overall failure rate of attempted reconstructive surgery was 24%, largely owing to the poor results of straight ileoanal anastomosis.
PMCID: PMC2083695  PMID: 16670116
18.  Comparison of standard versus double dose of amoxicillin in the treatment of non‐severe pneumonia in children aged 2–59 months: a multi‐centre, double blind, randomised controlled trial in Pakistan 
Archives of Disease in Childhood  2006;92(4):291-297.
WHO pneumonia case management guidelines recommend oral amoxicillin as first line treatment for non‐severe pneumonia. Increasing treatment failure rates have been reported over a period of time, which could possibly be due to increasing minimum inhibitory concentrations of Streptococcus pneumoniae and Haemophilus influenzae for amoxicillin. Microbiological data show that this resistance can be overcome by increasing amoxicillin dosage. Based on this data, we examined whether we can improve the clinical outcome in non‐severe pneumonia by doubling the dose of amoxicillin.
A double blind randomised controlled trial was conducted in the outpatient departments of four large hospitals in Pakistan. Children aged 2–59 months with non‐severe pneumonia were randomised to receive either standard (45 mg/kg/day) or double dose (90 mg/kg/day) oral amoxicillin for 3 days and then followed up for 14 days. Final outcome was treatment failure by day 5.
From September 2003 to June 2004, 876 children completed the study. 437 were randomised to standard and 439 to double dose oral amoxicillin. 20 (4.5%) children in the standard and 25 (5.7%) in the double dose group had therapy failure by day 5. Including the relapses, by day 14 there were 26 (5.9%) cumulative therapy failures with standard and 35 (7.9%) with double dose amoxicillin. These differences were not statistically significant (p = 0.55 and p = 0.29, respectively).
Clinical outcome in children aged 2–59 months with non‐severe pneumonia is the same with standard and double dose oral amoxicillin. Non‐severe pneumonia can be treated effectively and safely with a 3 day course of a standard dose.
PMCID: PMC2083693  PMID: 16547082
19.  An evaluation of Medline published paediatric audits from 1966 to 1999 
Archives of Disease in Childhood  2006;92(4):309-311.
To evaluate the quality of paediatric audits from 1966 to 1999.
A Medline search was performed using the MeSH terms audit, child, paediatric (and pediatric). Predefined core elements of audit were used as inclusion criteria for entry of an article into this study. These criteria were as follows: (1) an article deals with a healthcare topic; (2) a standard is predefined; (3) actual practice is evaluated; (4) actual practice is compared with the standard. The fifth criterion of audit, dissemination of information and reaudit, was not an inclusion criterion, as it was not used in the early years covered by this study. Empirical grading of standards was used.
The search yielded 442 articles, of which 303 (100%) were related to paediatric healthcare and were reviewed. Standards were defined in 115 (38%) articles. Audit against the standard was performed in 92 (30.4%) articles, of which 42 (45.6%) were published before, and 50 (54.3%) after, 1990. 18 (5.9%) articles were re‐audited: 6 (14.3%) were published before, and 12 (24%) after, 1990. Of the 188 paediatric studies rejected, 119 (63.3%) described practice observations.
Many articles in paediatrics are published as “audits”, but they do not contain the core elements of audit. Although audit is a potentially valuable tool in clinical medicine, the publication of poor‐quality audits may lead to the decline of the audit concept. Suggestions on ways to improve the quality of published audits are made.
PMCID: PMC2083691  PMID: 16738000
20.  Intravenous pamidronate treatment of infants with severe osteogenesis imperfecta 
Archives of Disease in Childhood  2006;92(4):332-338.
Children with the severe forms of osteogenesis imperfecta have in several studies been treated with intravenous pamidronate, but there are only few reports of the effect of early treatment.
To evaluate the effect of treatment started in infancy.
In a prospective observational study, with a historic control group, intravenous disodium pamidronate (APD) was given as monthly infusions to 11 children with osteogenesis imperfecta aged 3–13 (median 3.6) months, who had severe osteogenesis imperfecta with congenital bowing of the femora and vertebral compression fractures.
During treatment of children aged between 3 and 6 (median 4.5) years, dual‐energy x ray absorptiometry measurements of the lumbar spine showed a gradual increase in bone density. Bone metabolism parameters in serum (alkaline phosphatase, osteocalcin, procollagen 1 carboxy‐terminal peptide, collagen 1 teleopeptide) and in urine (deoxypyridinoline) indicated a decrease in bone turnover. An improvement of mobility was seen and at the latest recording, at the age of 3.3–6.5 (median 4.8) years, the children could all walk. Vertebral remodelling was seen, with increased vertebral height, and no child developed scoliosis, kyphosis or basilar impression. All children required femoral intramedullar rods for fractures, and five needed tibial rodding for extreme curvatures that prevented functional standing and walking. No adverse effects were seen on growth, fracture healing or blood chemistry.
APD is an efficient symptomatic treatment for infants with severe osteogenesis imperfecta, but additional orthopaedic surgery is often needed. Early treatment may prevent scoliosis and basilar impression. Long‐term follow‐up is important.
PMCID: PMC2083683  PMID: 17114205
21.  C‐reactive protein is elevated in the offspring of parents with essential hypertension 
Archives of Disease in Childhood  2006;92(4):304-308.
Hypertension is a risk factor for cardiovascular disease (CVD). Studies in adults have shown that high sensitivity C‐reactive protein (CRP) levels are associated with increased risk of CVD and essential hypertension (EHT). Genetic background is widely accepted as a risk factor for CVD. The aim of the present study was to analyse the association of high sensitivity CRP levels with other cardiovascular risk factors in children and young adults with at least one parent with EHT.
Fifty one healthy children and young adults (28 boys) with at least one parent with hypertension and 69 (41 boys) whose parents did not have hypertension were recruited prospectively from primary care centres. High sensitivity CRP, fasting lipid profile, blood pressure (BP) and anthropometric variables were obtained for all participants.
CRP values were higher in the study group than in controls (logCRP mean difference: −0.69; 95% confidence interval: −1.05 to −0.33), even when differences were adjusted for age, gender, body mass index (BMI) and triglyceride levels (p = 0.01). No differences were observed in BP values between groups. In the study group, 35.3% of the participants had a CRP level ⩾1 mg/l compared to 14.5% in the control group (p = 0.009). CRP showed a significant correlation with body weight (rho = 0.28, p = 0.04), BMI (rho = 0.32; p = 0.02) and ponderosity index (rho = 0.28; p<0.05).
CRP is significantly higher in the offspring of parents with EHT. A significant positive relationship exists between BMI and serum CRP levels in this high risk group of children and young adults.
PMCID: PMC2083666  PMID: 17158147
22.  Blood pressure centiles for Great Britain 
Archives of Disease in Childhood  2006;92(4):298-303.
To produce representative cross‐sectional blood pressure reference centiles for children and young people living in Great Britain.
Analysis of blood pressure data from seven nationally representative surveys: Health Surveys for England 1995–8, Scottish Health Surveys 1995 and 1998, and National Diet & Nutrition Survey 1997.
Blood pressure was measured using the Dinamap 8100 with the same protocol throughout. Weight and height were also measured. Data for 11 364 males and 11 537 females aged 4–23 years were included in the analysis, after excluding 0.3% missing or outlying data. Centiles were derived for systolic, diastolic, mean arterial and pulse pressure using the latent moderated structural (LMS) equations method.
Blood pressure in the two sexes was similar in childhood, rising progressively with age and more rapidly during puberty. Systolic pressure rose faster and was appreciably higher in adult men than in adult women. After adjustment for age, blood pressure was related more to weight than height, the effect being stronger for systolic blood pressure. Pulse pressure peaked at 18 years in males and 16 years in females.
These centiles increase our knowledge of blood pressure norms in contemporary British children and young people. High blood pressure for age should be defined as blood pressure above the 98th centile, and high‐normal blood pressure for age as blood pressure between the 91st and 98th centiles. The centiles identify children and young people with increased blood pressure, and will be of benefit to both clinical practice and research.
PMCID: PMC2083671  PMID: 16905566
23.  Prevalence of asthma among schoolchildren in Patras, Greece: four questionnaire surveys during 1978–2003 
Archives of Disease in Childhood  2006;92(3):209-212.
The prevalence of asthma and wheezing has risen during the past four decades. Recent reports suggest that the “asthma epidemic” has reached a plateau.
To examine further trends in the prevalence of childhood diagnosed asthma and wheezing in an urban environment in Greece.
A population‐based cross‐sectional parental questionnaire survey was repeated among third‐grade and fourth‐grade school children (8–10 years) of public primary schools in 2003 in the city of Patras, Greece, by using methods identical to that of surveys conducted in 1978 (completed questionnaires, n = 3003), 1991 (n = 2417) and 1998 (n = 3076).
2725 questionnaires were completed in the 2003 survey. The prevalence rates of current asthma and/or wheezing in 1978, 1991, 1998 and 2003 were 1.5%, 4.6%, 6% and 6.9%, respectively (p for trend <0.001). The lifetime prevalence of asthma and/or wheezing in the three more recent surveys was 8%, 9.6% and 12.4%, respectively (p for trend <0.001). The male:female ratios of current asthma and/or wheezing in the four surveys were 1.14:1, 1.15:1, 1.16:1 and 1.22:1, respectively. The proportion of those with wheezing diagnosed with asthma has increased during the study period, more so among non‐current children with asthma.
Our findings show a continuous increase in the prevalence of asthma and wheezing among preadolescent children in Patras, Greece, over 25 years, albeit at a decelerating rate. There seems to be a true increase in wheezing, despite some diagnostic transfer, particularly among younger children. The male predominance of the disease has persisted in the population of this study.
PMCID: PMC2083439  PMID: 17095554
24.  Effects of dietary management of phenylketonuria on long‐term cognitive outcome 
Archives of Disease in Childhood  2006;92(3):213-218.
Phenylketonuria (PKU) is associated with dopaminergic depletion in the dorsolateral prefrontal cortex and abnormalities of myelination. Both mechanisms may lead to deficits in cognitive functioning. Studies of cognitive outcome in children treated with PKU at an early stage have suggested that there are benefits in remaining on diet into adolescence.
To assess the nature and extent of any cognitive deficits in adults treated at an early stage with PKU who had discontinued their diets in adolescence.
25 patients (aged 18–38 years) who were diagnosed early and had discontinued their diets in adolescence were compared with 25 adults (aged 18–38 years) with PKU on continuous diet, and with a healthy control group (n = 45).
The groups differed significantly on accuracy (p = 0.007) and speed (p = 0.001) of performance on an n‐back working memory task and on speed of performance (p = 0.001) on a flanker inhibitory task, but not on flanker accuracy, object alternation learning or perceptual judgement tasks (all p>0.05). The off‐diet group performed significantly below the on‐diet group on n‐back accuracy (p = 0.007) and flanker speed (p = 0.05), and significantly below the control group on n‐back speed (p = 0.002) and flanker speed (p = 0.001).
The findings suggest that although discontinuing diet in adolescence appears disadvantageous compared with remaining on continuous diet, any deficits are relatively subtle.
PMCID: PMC2083434  PMID: 17068073
25.  Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation 
Archives of Disease in Childhood  2006;92(3):229-233.
To evaluate the effectiveness and cost effectiveness of an intensive home visiting programme in improving outcomes for vulnerable families.
Multicentre randomised controlled trial in which eligible women were allocated to receive home visiting (n = 67) or standard services (n = 64). Incremental cost analysis.
40 general practitioner practices across 2 counties in the UK.
131 vulnerable pregnant women.
Selected health visitors were trained in the Family Partnership Model to provide a weekly home visiting service from 6 months antenatally to 12 months postnatally.
Main outcome measures
Mother–child interaction, maternal psychological health attitudes and behaviour, infant functioning and development, and risk of neglect or abuse.
At 12 months, differences favouring the home‐visited group were observed on an independent assessment of maternal sensitivity (p<0.04) and infant cooperativeness (p<0.02). No differences were identified on any other measures. A non‐significant increase in the likelihood of intervention group infants being the subject of child protection proceedings, or being removed from the home, and one death in the control group were found. The mean incremental cost per infant of the home visiting intervention was £3246 (bootstrapped 95% CI for the difference £1645–4803).
This intervention may have the potential to improve parenting and increase the identification of infants at risk of abuse and neglect in vulnerable families. Further investigation is needed, along with long‐term follow‐up to assess possible sleeper effects.
PMCID: PMC2083433  PMID: 17068074

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