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Treating vitamin D deficiency
Symptomatic vitamin D deficiency is a resurgent condition in the UK, especially in ethnic minority families, although targeted public health measures have had a low uptake and little impact. Moy and colleagues report on the outcome of universal rather than targeted vitamin D supplementation implemented since 2005 in inner city Birmingham offering supplements to all pregnant and lactating mothers and children under age 5 years in line with national recommendations. Case incidence of symptomatic deficiency fell from 120 per 100 000 to 49 per 100 000 and although uptake of supplements increased year on year it only reached 17% despite there being a considerable ‘push’ by the health care team. Interestingly the authors also surveyed public knowledge and awareness of vitamin D and showed a significant increase during the study period with recognition that vitamin D was essential for bone health (79%) and sunlight the main source (85%). It is likely that the reduction in symptomatic vitamin D deficiency seen reflects a combination of increased uptake of supplements and the public and health care professional awareness of the importance of vitamin D over the last few years or perhaps it has just been sunnier! See page 952.
Vitamin D deficiency in cystic fibrosis
Many factors impact on bone health in cystic fibrosis including physical activity, co-morbidities (liver disease, diabetes, chronic inflammation and steroids) and fat soluble vitamin deficiency. The cystic fibrosis trust recommend a target of 75–150 nmol/l for serum 25 hydroxyvitamin D although this is not always straightforward to achieve. Brodie and colleagues report on the vitamin D status of their population with cystic fibrosis (pancreatic insufficient) both pre and post a 5 fold increase in supplementation. Median 25 hydroxy vitamin D level increased from 51.5 to 72 nmol/l with an increase in the percentage achieving the target range from 10 to 51. Of note in a smaller pancreatic sufficient group only 13% had vitamin D levels within the target range. There is no doubt about the importance of vitamin D in cystic fibrosis, what is less clear is the target level to achieve and the dosage required to do so. The authors rightly call for urgent guidance. See page 982.
Epilepsy in infancy
The assessment and management of ‘paroxysmal events’ in infancy can be complex and challenging and regularly needs to be addressed on the general paediatric ward round and in clinic. Alam and colleagues review this in a very practical and focused way with guidance on the specific issues that should be considered during the assessment. These include whether the events are likely to be epileptic (including an impressive table of differential diagnosis), if so the seizure type, whether this is an ‘epileptic syndrome’, investigations required and the prognosis. There is a useful table of the commoner epileptic syndromes and a useful algorithm to aid investigation. The authors discuss the ‘conditions not to be missed’ including metabolic disorders where early intervention can impact significantly on prognosis. The article is practical and helpful and consistent with NICE guidance. Early referral to specialist services is recommended. See page 985.
Eradicating meningococcal disease
Meningococcal disease remains a serious global health threat with a high morbidity and mortality despite advances in modern antibiotics, intensive care and immunisation. 75% of cases occur in under 5's with 500 000 cases per year worldwide with a 10% mortality rate and long term sequelae in 20% of survivors. In this issue Nadel reviews the epidemiology of meningococcal disease, available vaccines and the challenges of immunising against serotype B, which is complex but in the early trial phase and gives the potential for eradication of this devastating condition. See page 993.
Screening for abuse and mental health problems in runaways
The homeless child population (runaways) are particularly vulnerable to physical/sexual abuse and have a high prevalence of mental health problems. In this issue Bhat and colleagues report the use of a modified self screening tool in illiterate runaway adolescent boys (n=119) at an observation home in New Dehli—questionnaires are translated then read out by workers once they have gained the confidence of the boys. The results are quite sobering with high rates of exposure to domestic violence (62%), child labour (87%), substance abuse (59%), physical (72%) and sexual abuse (35%). Mental health problems were evident in 70%. It is likely that these data are similar in other runaway populations where the same methodology could be used to investigate. The work highlights the extreme vulnerability of children, particularly runaways and the need nationally and internationally to at least start to address this issue. See page 947.
In F&N this month
There are two specific articles to highlight. Harvey et al in an interesting and thought-provoking study assess the impact on fathers being present when their baby was resuscitated (most fathers attend the birth of their babies and so will be there if the baby requires resuscitation). Findings were mostly negative with a profound and long term emotional impact including a few who suffered symptoms synonymous with post traumatic stress disorder. It is not clear how often this is recognised and this should alert us perhaps to look for and address this in the post resuscitation discussions and subsequently. The second article addresses the important issue of thrombotic episodes in the high risk pre term infant with potential long term sequelae. In a comprehensive review Bhat et al explore the epidemiology, pathophysiology, risk factors, investigation and management. The authors reflect on the lack of data regarding diagnosis and treatment and call for a register of cases to enable further research to impact on this increasingly common condition.
On a positive note, I am pleased to report that the Fetal and Neonatal edition goes from strength to strength and has an increased page count from this month. This reflects the increase in high quality submissions, commitment of the editorial team and engagement of the readership with the journal.