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I am delighted to be handing over to a new substantive Editor-in-Chief, Dr Mark Beattie. Mark has been an Associate Editor for ADC for the past 5 years. He is a paediatric gastroenterologist in Southampton, UK, but as well as his specialist work he has retained a significant interest in general paediatrics. He has a prolific research output in spite of a full-time clinical commitment; he is president of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition. He is full of new ideas to improve your journal, and I leave the editorial role in good hands.
Falling violent death rates: a cause to celebrate?
Recent media coverage of some horrific child murders might lead people to conclude that violent child deaths in the UK are becoming more common. Not so. Peter Sidebotham and colleagues from the University of Warwick used data from the UK's Office for National Statistics and the Home Office between 1974 and 2008 to analyse trends. Although the interpretation is complicated by changing definitions, the trend towards improvement is unarguable. The violent death rate for infants in 2008 was about an eighth of what it was in 1974. In other words, about 30 infants lived in 2008 who would have died violently in 1974. The trend for adolescents was less encouraging: it remained stable for girls and increased for boys.
Most violent deaths in younger children are associated with maltreatment by carers. All those who have devoted vast amounts of time and energy to create an elaborate safeguarding structure for vulnerable children would like to think that our efforts have contributed to this improvement. Sidebotham has backed up his mortality observations with a thoughtful review of the role of Serious Case Reviews. These detailed, multidisciplinary inquiries are now obligatory in England and Wales whenever a child dies or is seriously harmed and maltreatment is thought to play a part. The anonymised reports are made public. Consistent themes are identified on what more could have been done to protect these children. Sidebotham argues that we could improve the way these lessons are disseminated, and if these are acted on, can we hope for even fewer violent deaths in the future?
Can coughing cause retinal bleeds?
Violent shaking is an important cause of infant death, and retinal haemorrhages have long been considered pathognomic of this injury. This dogma has been challenged,1 with claims that violent coughing might be responsible. Arguing that the most violent (and hypoxia-inducing) coughing ever seen in infants is due to pertussis, Curcoy and colleagues from Barcelona examined the retinas of 35 infants admitted with definite pertussis. They found no retinal haemorrhages. An on-line rapid response to this article argues controversially that they have by no means shown that retinal haemorrhage cannot have an innocent cause.
‘It tastes horrible…’
No-one could say that our Drug therapy section is dominated by obscure pharmacology: all the articles are of everyday practical use. Faust and colleagues review what all paediatricians know, but clinical guideline-writers frequently ignore, that children do not like some medicines (see page 293). It seems obvious that adherence with oral treatments will be influenced by how it tastes (to a child, not an adult), but foul-tasting medicines are often suggested where palatable ones would do as well. To help with this, Spomer et al have shown how easy it is for young children, even infants, to swallow mini-pills (see page 283). Manufacturers should take note.
The prescribers ‘bible’, the British National Formulary for Children (BNFC), has many merits but may tend to over-simplify: Eyers et al have calculated that its age-related advice for paracetamol dosing may give hugely varied per kilogram dosages. (see page 279). Warren Lenney (see page 277) discusses whether this really matters, and describes how advice will be updated in future editions of the BNFC.
How should our patients assess us?
All doctors in the UK will be subjected to revalidation by the General Medical Council, and inevitably patient and carer views will form part of this. Existing patient feedback methods developed for adult specialties are inappropriate for paediatrics, and so Mary McGraw and colleagues from the RCPCH have developed a feedback tool: they piloted it in a self-selected group and found very positive gradings in all areas. In their analysis they address the sensitive issues of the doctor's gender and ethnicity. This volunteer group is unlikely to contain many poorly-performing doctors, so it remains to be seen how it will work when we all have to ask our patients and their carers to assess us. See page 206
In F&N this month
Some articles in the Fetal and Neonatal edition might interest non-neonatologists. There is reassuring data from Malcolm Battin and colleagues about the effects of corticosteroids given antenatally to mothers on postnatal growth in their babies. Anne Lebihannic and colleagues in France claim that the electroencephalography in very pre-term babies can be predictive of neurological outcomes. Those interested in promoting ‘safety culture’ may find the lessons of papers by Jochen Profit and colleagues can be translated to areas other than neonatal units.