Depression in chronic fatigue syndrome

Chronic fatigue syndrome (defined as 3 months of disabling fatigue plus at least one additional symptom persisting after routine tests have failed to identify an obvious underlying cause) is common and challenging to manage. More than half of children and young people are bed bound at some stage and miss one academic term. Depression is often seen and can impact on recovery. Bould and colleagues report the results of a cross sectional survey of depression in chronic fatigue syndrome using the Hospital Anxiety and Depression score (HADS) at assessment in a specialist CFS/ME unit. Depression (>9 HADS) was present in 29% of 542 referrals. Using univariate analysis female gender, poor school attendance, level of fatigue, levels of pain and anxiety were risk factors although duration of illness was not. On multivariate analysis the strongest predictor was disease severity with lower levels of disability associated with lower levels of depression. The authors discuss the importance of screening for, assessing and treating depression in chronic fatigue syndrome and that the level of disability (ie, level of functioning) rather than the duration of symptoms is the most important risk factor. See page 425

Cow's milk allergy in infancy

The prevalence of cow's milk allergy is highly variable in different reported series with concerns expressed about under and over diagnosis. Elizur and colleagues take a systemised approach to this by investigating infants with any possible adverse reaction to milk (n=381) from a large prospective cohort (n=13 019) using strict diagnostic criteria including SPT and oral challenge. After the initial evaluation 66 infants were diagnosed with IgE mediated CMA, 36 with food protein induced enterocolitis, 21 with CMP associated rectal bleeding and 15 other symptoms for which CMP could not be excluded as a trigger. CMP allergy was excluded in 243 (by a combination of history, examination, investigation and challenge). The ‘mislabelled’ infants tended to present earlier, have single organ involvement (atopic dermatitis common) and higher maternal and paternal education. The authors emphasise the importance of objectively diagnosing milk allergy. See page 408

Pain in young people with cerebral palsy

Pain is very prevalent in young people with cerebral palsy and associated with lower subjective well being and reduced participation. There are many potential causes including spasms, hip subluxation, contractures, operative sites, therapeutic interventions, assistive devices and gastrostomy tubes. Feeding can be uncomfortable. Functional pain is likely to be at least as common as in the general population. In this issue, Parkinson and colleagues report data on behalf of SPARCLE (Study of participation of children with Cerebral Palsy living in Europe) on the prevalence, site, severity and frequency of pain in young people aged 13–17 by self and parent report. In the study group 75% reported that they had experienced some pain in the last week; moderate to severe in 25%. 40% had experienced leg pains, 34% headache, 26% stomach pains and 45% reported pain during physiotherapy. Girls reported more pain than boys. Pain was more common in the non ambulant and in young people with emotional issues (measured by the strengths and difficulties questionnaire). The authors discuss the importance of assessing pain in young people with cerebral palsy emphasising the multifactorial aetiology and different potential management strategies including recognition of the association between pain and emotional health. This has important implications for the management of young people with cerebral palsy including during transition as the issues are likely to persist into adulthood. See page 434

Changing pattern of coeliac disease

Coeliac disease is common with a prevalence of 1 in 100 in screened populations. Lisa Whyte reports the South Wales experience over almost 28 years during which the incidence has increased considerably mostly as a consequence of the modern diagnostic strategies which include low threshold antibody testing and screening. Children are generally older at diagnosis (increase in median age 4 years, 14 years) and non specific features and a lack of overt gastrointestinal symptoms are now common at presentation with increasing numbers diagnosed through targeted screening. These are challenging cases to manage with compliance often being a major issue and it will be important to assess the long term impact of treatment through high quality prospective studies. See page 405

Poverty, maltreatment and attention deficit hyperactivity disorder

Attention deficit disorder is common affecting many thousands of children with potential adverse health, social and educational outcomes. The aetiology is multifactorial and poorly understood with many potential factors implicated. In an interesting leading article Elspeth Webb separates children for whom the development of ADHD is largely genetically driven from those who have a ‘phenocopy’ of ADHD as a result of adverse early childhood experiences with the prevalence of the latter group being heavily skewed towards children living with poverty and violence. Phenocopy is when individuals exhibit a phenotype that appears identical to that found in others who have a linked genotype but do not possess this genotype themselves. The cross over is described as a third group, that is, those with a high genetic risk exposed to poverty and violence. Other factors (epigenetics) will affect the severity of functional difficulties including for example pre term birth and intrauterine environment. The complexities of these different factors and their interaction and impact on each other is discussed in detail with the strong emphasis on the impact of such factors as domestic violence/child maltreatment and how different subgroups respond to treatments including stimulants. ADHD is common and complex and clearly if we better understand the condition we can better tailor the treatment to the individual sufferer with the potential thereby to improve outcomes longer term. See page 397

In E&P this month

In the regular feature Dermatophile Peter Lio takes us through the differential diagnosis of alopecia—published as a picture multiple choice quiz so you can test yourself and record as CPD. Gregory Skinner outlines how to write a problem solving case—contact him if you want to discuss a submission. There are pharmacy updates—bronchodilators in wheezy under-2-year-olds, pharmacological management of the obese child and the usual selection of excellent Best Practice and How to Use articles.

For our Podcasts (including highlights) visit http://podcasts.bmj.com/journal-adc/