29.11.06

Vitamin D deficiency: prevention or treatment?

Arch Dis Child. 2006 Dec;91(12):1011-4.
Zipitis CS, Markides GA, Swann IL.Burnley
BACKGROUND: Vitamin D deficiency is a chronic condition which contributes togeneral ill health and seems to be re-emerging in our catchment area sincefunding of vitamin D supplementation by Primary Care Trusts ceased. This studyaims to verify this situation and to assess the cost effectiveness ofreintroducing vitamin D supplementation in the Burnley Health Care NHS Trust.
METHODS: Vitamin D deficient patients presenting between January 1994 and May2005 were identified and data retrospectively collected from their case notes.The cost of treatment and the theoretical cost of primary prevention for theTrust population were calculated using previous and current DoH guidelines.
RESULTS: Fourteen patients were identified, of whom 86% presented in the last 5years and 93% were of Asian origin. The incidence of vitamin D deficiency forour population is 1 in 923 children overall and 1 in 117 in children of Asianorigin. The average cost of treatment for each such child is pound2500, whilethe theoretical cost of prevention of vitamin D deficiency in the Asianpopulation through primary prevention according to COMA guidance is pound2400per case.
CONCLUSIONS: Vitamin D deficiency is re-emerging in our Trust. Theoverwhelming majority of our patients are of Asian origin. The cost of primaryprevention for this high risk population compares favourably both medically andfinancially with treatment of established disease. We suggest that Primary CareTrusts provide funds for vitamin D supplementation of Asian children for atleast the first 2 years of life.

Immunisation of premature infants

Arch Dis Child. 2006 Nov;91(11):929-35.
J Bonhoeffer1, C-A Siegrist2 and P T Heath1
1 St George’s Hospital, London, UK2 University of Geneva, Geneva, Switzerland
ABSTRACT
Premature infants are at increased risk of vaccine preventable infections, but audits have shown that their vaccinations are often delayed. Early protection is desirable. While the evidence base for immunisation of preterm infants is limited, the available data support early immunisation without correction for gestational age. For a number of antigens the antibody response to initial doses may be lower than that of term infants, but protective concentrations are often achieved and memory successfully induced. A 2-3-4 month schedule may be preferable for immunisation of preterm infants in order to achieve protection as early as possible, but an additional dose may be required to achieve persistence of protection. This update focuses on the use of routine childhood vaccines in premature infants.

8.11.06

Nutrition in Toddlers

Nutrition in Toddlers
RICHARD E. ALLEN, M.D., M.P.H., St. Mark’s Family Medicine Residency, Salt Lake City, Utah
ANYA L. MYERS, R.D., M.SC., Chinook Health, Cardston, Alberta
Am Fam Physician 2006;74:1527-32, 1533-4.
Toddlers make a transition from dependent milk-fed infancy to independent feeding and a typical omnivorous diet. This stage is an important time for physicians to monitor growth using growth charts and body mass index and to make recommendations for healthy eating. Fat and cholesterol restriction should be avoided in children younger than two years. After two years of age, fat should account for 30 percent of total daily calories, with an emphasis on polyunsaturated fats. Toddlers should consume milk or other dairy products two or three times daily, and sweetened beverages should be limited to 4 to 6 ounces of 100 percent juice daily. Vitamin D, calcium, and iron should be supplemented in select toddlers, but the routine use of multivitamins is unnecessary. Food from two of the four food groups should be offered for snacks, and meals should be made up of three of the four groups. Parental modeling is important in developing good dietary habits. No evidence exists that early childhood obesity leads to adult obesity, but physicians should monitor body mass index and make recommendations for healthy eating. The fear of obesity must be carefully balanced with the potential for undernutrition in toddlers.

3.11.06

Should Our Well-Child Care System Be Redesigned? A National Survey of Pediatricians

Tumaini Coker, MD, MBAa,b, Lawrence P. Casalino, MD, PhDa,c, G. Caleb Alexander, MD, MSa,d,e and John Lantos, MDa,b,d
OBJECTIVE. The goal was to examine pediatricians' views about whether and how well-child care for children 0 to 5 years of age should be changed.
METHODS. A mail survey of a national random sample of 1000 general pediatricians was performed with a survey instrument that examined pediatricians' attitudes and behaviors toward our current way and an ideal way of providing well-child care. Results were analyzed for the following 3 major domains of change in well-child care: provider type, visit format, and visit location.
RESULTS. Sixty percent (n = 502) of eligible subjects responded to the survey. Nearly all respondents (97%) rated the current US system as excellent or good in providing well-child care. Most pediatricians (85%–91%) reported that they are currently the main providers of anticipatory guidance, developmental screening, and psychosocial screening. However, a majority (54%–60%) reported that, in an ideal system that maximized the effectiveness and efficiency of care, nonphysicians would provide these services. Fewer pediatricians (24%) reported that ideally nonphysicians should provide the physical examination. The majority of respondents (79%–93%) reported that at least some anticipatory guidance, minor acute care, and chronic care services could be conducted through telephone or e-mail communication, and 55% stated that at least some well-child care services should be provided in alternative locations, such as day care centers. In multivariate analysis, support for these changes was distributed widely across pediatricians with varying personal and practice characteristics.
CONCLUSIONS. Although most pediatricians are generally satisfied with our current way of providing well-child care, a majority think that a system that is less reliant on physicians and face-to-face office visits would be a more effective and efficient way to provide care.

1.11.06

Home safety measures and the risk of unintentional injury among young children: a multicentre case–control study

Home safety measures and the risk of unintentional injury among young children: a multicentre case–control study. John C. LeBlanc, I. Barry Pless, W. James King, Harry Bawden, Anne-Claude Bernard-Bonnin, Terry Klassen and Milton Tenenbein.CMAJ • October 10, 2006 • 175(8) | 883

Background: Young children may sustain injuries when exposed to certain hazards in the home. To better understand the relation between several childproofing strategies and the risk of injuries to children in the home, we undertook a multicentre case–control study in which we compared hazards in the homes of children with and without injuries.

Methods: We conducted this case-control study using records from 5 pediatric hospital emergency departments for the 2-year period 1995–1996. The 351 case subjects were children aged 7 years and less who presented with injuries from falls, burns or scalds, ingestions or choking. The matched control subjects were children who presented during the same period with acute non-injury-related conditions. A home visitor, blinded to case-control status, assessed 19 injury hazards at the children's homes.

Results: Hazards found in the homes included baby walkers (21% of homes with infants), no functioning smoke alarm (17% of homes) and no fire extinguisher (51% of homes). Cases did not differ from controls in the mean proportion of home hazards. After controlling for siblings, maternal education and employment, we found that cases differed from controls for 5 hazards: the presence of a baby walker (odds ratio [OR] 9.0, 95% confidence interval [CI] 1.1–71.0), the presence of choking hazards within a child's reach (OR 2.0, 95% CI 1.0–3.7), no child-resistant lids in bathroom (OR 1.6, 95% CI 1.0–2.5), no smoke alarm (OR 3.2, 95% CI 1.4–7.7) and no functioning smoke alarm (OR 1.7, 95% CI 1.0–2.8).

Interpretation: Homes of children with injuries differed from those of children without injuries in the proportions of specific hazards for falls, choking, poisoning and burns, with a striking difference noted for the presence of a baby walker. In addition to counselling parents about specific hazards, clinicians should consider that the presence of some hazards may indicate an increased risk for home injuries beyond those directly related to the hazard found. Families with any home hazard may be candidates for interventions to childproof against other types of home hazards.

Potential impact of newborn screening for cystic fibrosis on child survival: a systematic review and analysis

Potential impact of newborn screening for cystic fibrosis on child survival: a systematic review and analysis.
Grosse SD, Rosenfeld M, Devine OJ, Lai HJ, Farrell PM.
J Pediatr. 2006 Sep;149(3):362-6.
OBJECTIVE: To estimate the population impact of child mortality as a result of cystic fibrosis (CF) potentially preventable by newborn screening. STUDY DESIGN: A systematic literature review of mortality in children with classic CF without meconium ileus (MI) in screened and unscreened cohorts was extended by contacting investigators for unpublished data. In addition, survival in US states with and without newborn screening (NBS) programs for CF was compared using data from the Cystic Fibrosis Foundation Patient Registry (CFFPR). RESULTS: Among non-US studies, CF-related mortality risk to approximately 10 years of age was lower by 5 to 10 per 100 in screened cohorts. Unpublished US data from a trial of NBS for CF indicate no CF-related deaths to 10 years of age in either cohort. CFFPR data suggest improved survival among children with CF born in US states with NBS, with a CF-related mortality difference to 10 years of age between the screened and unscreened groups between 1.5 and 2 per 100 children with CF without MI. CONCLUSION: In addition to improving nutritional outcomes, newborn screening for CF may result in improved child survival. The absolute differential in mortality risk, although modest in size, appears comparable to NBS for certain other genetic disorders.