Background Neonatal intensive care requires adequate numbers of trained neonatal nurses to provide safe, effective care; but existing research into the relation between nurse numbers and the care needs of babies is over ten years old. Since then, the preterm population and treatment practices have changed considerably.

Aims To validate the dependency categories of the British Association of Perinatal Medicine (BAPM, 2001) and to revalidate the Northern Region categories (NR, 1993) in relation to contemporary nursing workload. Setting Three tertiary neonatal intensive care services in England.

Methods Direct observations by trained observers captured nursing activity around each baby every ten minutes. Time spent on each nursing activity was related to the dependency category of the baby and the grade of the nurse.

Results Both scales detected differences between categories. Discrimination between individual categories was improved when nasal continuous positive airway pressure (nCPAP) was distinguished from ventilation and combined with BAPM2/NRA.. On this revised four point scale babies in BAPM1/NRA occupied nursing time for a median of 56 minutes per hour ( IQR 48-70); those on nCPAP or BAPM2/NRB for 36 minutes , (27-42); those in BAPM3/NRC for 20-22 minutes, (15-33); and those in BAPM4/NRD for 31-32 minutes (24-36). The NR scale was easier to apply and had greater interobserver agreement (98.5%) than the BAPM scale (93%). All categories attracted more time compared to 1993.

Conclusions Both scales predict average nursing workload. A revised categorisation which separates nCPAP from ventilation is more robust and practical. Nursing time attracted in all categories has increased since 1993.

Stroke and cerebrovascular disorders are important causes of morbidity and mortality in children, already amongst the top 10 causes of childhood death and probably increasing in prevalence. Acute treatment of stroke syndromes in adults is now evidence-based. Paediatric stroke syndromes are very much less common and the differential diagnosis is very wide but the individual health resource implications are much greater because of the life long treatment costs in survivors. Recognition and consultation with a paediatric neurologist should be rapid so that children can benefit from regional services with emergency neurological, neuroradiological and neurosurgical intervention and paediatric intensive care.

This review focuses on the epidemiology, presentation, differential diagnosis, generic/specific emergency management and prognosis of acute stroke in children. Its aim is to educate and guide management by general paediatricians and to emphasise the importance of local guidelines for the initial investigation and treatment and appropriate transfer of these children.

Background: In the UK and US, Government guidelines for childhood physical activity have been set (≥60mins/day at ≥3 METs), and BMI chosen as the outcome measure.

Aim: To determine the extent to which physical activity at the Government-recommended intensity is associated with change in body mass/fat and metabolic health in pre-pubertal children.

Methods: Non-intervention longitudinal study of 113 boys and 99 girls (born 1995/96) recruited from 54 schools. Physical activity (MTI accelerometers), changes in body mass (raw and age/gender-standardized BMI), fatness (skin-fold thickness and waist circumference) and metabolic status (insulin resistance, triglycerides, cholesterol/HDL ratio and blood pressure - separately and combined as a composite metabolic score) were measured on four annual occasions (5, 6, 7 and 8y).

Results: Mean physical activity did not change over time in either sex. Averaging the seven-day recordings from four time-points rather than one increased the reliability of characterising a child's activity from 71% to 90%. Some 42% of boys and 11% of girls met the guideline. There were no associations between physical activity and changes in any measure of body mass or fatness over time in either sex (e.g. BMI-SDS: r=-0.02 p=0.76). However, there was a small-to-moderate inverse association between physical activity and change in composite metabolic score (r=-0.19, p<0.01). Mixed effects modeling showed that the improvement in metabolic score among the more active compared to the less active children was linear with time (-0.08 z-scores/year, p=0.001).

Conclusions: In children, physical activity above the Government-recommended intensity of 3 METs is associated with a progressive improvement in metabolic health, but not with a change in BMI or fatness (though direction of causality is not certain). Girls habitually undertake less physical activity than boys - questioning whether girls in particular should be encouraged to do more, or the recommendations adjusted for girls.

Introduction: Several autopsy protocols have been suggested for investigating sudden unexpected deaths in infancy (SUDI). The aim of this study is to provide data on the utility of such post-mortem investigations from a large paediatric autopsy series in order to inform future policy.

Methods: Retrospective analysis of >1,500 consecutive post-mortem examinations carried out by specialist paediatric pathologists at a single centre during a 10-year period according to a common autopsy protocol that included the use of detailed ancillary investigations. SUDI was defined as the sudden unexpected death of an infant aged 7 to 365 days. All data capture and cause of death classification were carried out according to defined criteria.

Results: Of 1,516 paediatric post-mortem examinations, 546 presented as SUDI. In 202 infants (37%) death was explained by the autopsy findings. The other 344 cases (63%) remained unexplained. Of the explained deaths, over half (58%) were infective, most commonly due to pneumonia (22%). The component of the post-mortem examination which primarily determined the final cause of death was histological examination in 92 infants (46%), macroscopic examination in 61 (30%), microbiological investigations in 38 (19%), and clinical history in 10 (5%).

Conclusion: This constitutes the largest single-institution autopsy study of SUDI. Ten years on from the CESDI SUDI studies, the ascertainment of a cause of death at autopsy has improved. However, with almost two thirds of SUDI remaining unexplained, alternative and/or additional diagnostic techniques are required to further improve detection rates of identifiable causes of death at autopsy.

The recently published UNICEF review of child well-being [1] concluded that children in the UK had the worst level of well-being of the 21 Organisation for Economic Co-operation and Development (OECD) countries. The review ranked countries on 6 dimensions of well-being - material well-being, health and safety, educational well-being, family and peer relationships, behaviours and risks, and subjective well-being.

Each dimension was informed by 3 components themselves made up of a variable number of indicators. For example, the 3 components of the material well-being dimension were relative income poverty, households without jobs and reported deprivation. Relative income poverty was represented by percentage of children living in homes with equivalent incomes less than 50% of the national median, households without jobs by percentage of children in households without an employed adult, and reported deprivation by percentage of children reporting low family affluence, percentage reporting few educational resources, and percentage reporting fewer than 10 books in the home. Z scores were calculated for each indicator based on data from each country and then averaged to give an average z score for each component. These in turn were averaged to give an average z score for each of the six dimensions.

Rationale: Increasing survival at extremely low gestation is associated with very high rates of bronchopulmonary dysplasia, but is rarely quantified.

Objectives: To identify respiratory morbidity and risk factors in the EPICure cohort over the first 6 years.

Methods: 308 babies born at ≤25 weeks of gestation in 1995 were followed up at 30m and 6y of age. Respiratory outcome was evaluated using clinical assessment and parental questionnaire and peak expiratory flow (PEF) at 6y.

Results: Of this population 74% received supplemental oxygen at 36 weeks PMA and 36% were discharged with supplemental oxygen which continued for a median of 2.5 months (75 percentile: 8.5m). 236 children were followed to 6 years. Respiratory symptoms and use of medication were more prevalent at 30mo and 6y in children with bronchopulmonary dysplasia (BPD) compared to those without. Children without BPD (n=56) were not significantly different from their classmates but had consistently higher prevalence. Symptoms, need for hospital admission and medication use had declined between 30m and 6y. 200 index children completed three peak expiratory flow measures; PEF was lower than in classmates (mean adjusted difference: 39 l/min (95%CI 30; 47)), lowest in children discharged home in oxygen and those with BPD. Gestational age, BPD, maternal smoking at home and in pregnancy were independent risk factors for symptoms but BPD the only independent associate of PEF.

Conclusion: Extremely preterm children have a continuum of poor respiratory health over the first 6 years, which is exacerbated by smoking in pregnancy and in the home.

Objective: To describe the recent trends in demographic, clinical or microbiological characteristics and outcome of treatment of paediatric cases.

Design: National Surveillance Study

Setting: England and Wales

Patients: All children under the age of 16 years reported with tuberculosis to the national enhanced surveillance system between 1999 and 2006 were included. Main outcome measures: Proportions, and rates of disease, by demographic characteristics, site of disease, diagnostic delay, culture confirmation, species, drug susceptibility and treatment outcome.

Results: There were 3563 cases of tuberculosis in children reported between 1999 and 2006. The incidence rate remained stable around 4.3 per 100,000 (95% CI 4.1-4.4). Patients born outside the UK had a tuberculosis rate higher than UK born children (37 per 100,000 vs 2.5 per 100,000) and this rate increased over the period. Rates in the black African ethnic group were highest at 88 per 100,000. 60% of children had pulmonary disease, the commonest presentation, however, only 948 (27%) had culture confirmed tuberculosis. The median time to diagnosis from onset of symptoms is 37 days (IQR 12 - 89). The proportion of cases with rifampicin, isoniazid and multi drug resistant isolates was 2.4%, 9.3% and 2.3% respectively. 88% of children completed treatment and less than 1% died.

Conclusions: Overall rates of tuberculosis in children have remained stable with the majority completing treatment. Rates are, however, highest in the non-UK born, particularly in certain ethnic minority groups. Levels of drug resistance are also high.

Fever is a very common complaint in children and is the single most common non-trauma-related reason for a visit to the emergency department.1 Parents are concerned about fever and it's potential complications, but what knowledge do they have about fever and it's management at home? The biological value of fever (i.e. whether it is beneficial or harmful) is disputed and it is being vigorously treated with the belief of preventing its complications. The practice of alternating antipyretics has become widespread at home and on paediatric wards; is this practice supported by evidence and are there complications as a result? There is still a significant contrast between the current concept and practice, and the scientific evidence. Why is that the case in such a common complaint like fever?

In severely immunocompromized patients, the diagnosis of viral infections relies on PCR/RT-PCR-based methods. The availability of these modern diagnostic tools contributes to a timely diagnosis, and leads to an increasing knowledge about the epidemiology and the clinical spectrum of common and emerging viral pathogens in this highly susceptible population. Not only after stem cell transplantation but also during conventional chemotherapy viral infections may result in life threatening disease in pediatric cancer patients.

Often, clinical symptoms are a consequence of endogenous reactivation of latent viral infection. Many of these viruses are easily transmitted between patients, relatives and health care workers. Prolonged symptomatic and asymptomatic viral shedding is a common feature in pediatric cancer patients.

Thus, it is necessary to implement strategies for the prevention and control of these communicable pathogens in the hospital and in the outpatient clinic. Although no randomized controlled studies are available for pediatric cancer patients, physicians should be aware of potential treatment options since early treatment may prevent a complicated or fatal outcome and shorten the period of contagiosity.

Children with suspected type 1 diabetes mellitus (T1DM) should have same day referral to a paediatric diabetes team.

99 children (54 male, median age 10.5 years (range 0.9 -15.9)) were diagnosed with T1DM at our hospital between Jan 2004 and June 2007. 27(27.2%) presented in diabetic ketoacidosis (DKA). 37(37.3%) required hospital admission; the rest had ambulatory management.

In 21(21.2%) diagnosis was delayed > 24 hours (median 3.0 days (range 1 - 14)), due to: missed diagnosis at local hospital (4) or by GP (7); arranging fasting blood glucose (9); outpatient appointment requested via fax (1). Children with delayed diagnosis presented more frequently in DKA (52.3% vs. 20.5%, p <0.01), with a higher mean presenting HbA1c (12.3% vs. 10.9%, p <0.05).

There was no difference in age and sex between the delayed diagnosis and immediate referral groups. Healthcare providers need to be aware of the importance of immediate referral of newly diagnosed T1DM in children.

Objective: To evaluate the prevalence of chronic constipation (CC) in unselected children, its association with atopy, and the efficacy of a cow's milk protein (CMP) elimination diet on refractory constipation.

Study Design: The study was conducted by 6 primary care pediatricians, serving a population of 5113 children aged birth through 12 years, but only 2068 of them were 6 months-6 years. During a three month period, prevalence of CC was determined for the entire study population, ages 0-12 years. In the second part of the study, all patients aged 6 months to 6 years with chronic constipation, and age and sex matched controls, were evaluated for atopy. and its association with CC. A questionnaire was completed including personal and family history of atopy and bowel movement characteristics. Patients were tested for atopy by specific serum IgE and/or skin-prick tests. Constipated patients, refractory to osmotic laxatives, underwent a 4-week CMP elimination diet.

Results: 91 (1.8 %) had CC, and 69 (3.3%) of the 6 months-6 years age-group fell into the atopy study age range. All 69 constipated children (mean age + SD: 34.9 + 18.0 months) and 69 controls completed the questionnaire. Twelve of 69 constipated children (17.3 %) and 13 of 69 control children (18.8 %) had a diagnosis of atopy. Eleven of 69 (15.9%) constipated children were refractory to constipation treatment, and 3 (27.3%) of these had atopy. The 4 week trial of dietary elimination did not result in improvement in any of these 11 children.

Conclusions: In our study group, prevalence of atopy among children with CC is similar to that in the general population. Refractoriness of chronic constipation does not seem to be related to cow's milk allergy.

It is rare for paediatric palliative medicine physicians to have to break news of a diagnosis of a life-limiting condition (LLC). Usually that has been done weeks or months before. It is much commoner for us to be faced with the question: "how long?" Clearly it is a question that cannot be answered with certainty, and yet a great deal may depend on it. While palliative care (PC) should ideally be available from diagnosis, the need for 'active' practical PC intervention will fluctuate during the course of a child's illness. For most children this will last months or years; often decades. Typically, there will be several periods during which death seems likely before the final terminal episode, particularly among children with non-malignant LLC. Optimal management of all these episodes depends on anticipating the child’s needs in order for timely interventions - or withdrawal of interventions - to be considered. This consideration in turn depends on recognising that such an episode has begun. Providing adequate PC critically depends on making a diagnosis of dying. In this article, we will consider why it is important to make a 'diagnosis of dying', briefly review some of the tools available to help, and examine some of the evidence from published literature in children and adults.

Forty years have passed since medical professionals in the United States were first required to report all cases of suspected child abuse to state child protective service agencies. Despite the passage of time, many cases of severe child physical abuse remain hidden.

Healthcare professionals may not recognize common syndromes of child abuse, or, has been demonstrated in recent studies, may recognize the possibility of abuse but decide not to report the case to the state agencies.

Rethinking the types of training we provide, the relationship between medical professionals and state agencies, and re-training medical and child protection professionals may be required to further improve the recognition and care of abused children.

Background: Evaluation of children with fever without localizing signs (FWLS) is largely unchanged in the United States since 1993 despite reduced invasive disease after Haemophilus influenzae type b conjugate vaccine and conjugate Pneumococcal vaccine (PCV7). PCV7 is now recommended in the United Kingdom for children under 2 years, and new NICE guidelines have been issued for managing feverish children in the UK in anticipation of PCV7's efficacy. We compared rates of bacterial infections in children 3-36 months with FWLS in the pre- and post-PCV7 eras to define current trends and evaluate the guidelines that exist.

Methods: We identified all pediatric blood cultures performed in the emergency department in the years pre- and post-PCV7. We subsequently identified all children 3-36 months with FWLS and reviewed their medical records.

Results: We identified 148 patients with FWLS in the pre-PCV7 period and 275 patients post-PCV7. There were 17 positive cultures pre-PCV7: 10 pathogens and 7 contaminants. Post-PCV7, there were 14 positive cultures, but only 1 pathogen. This represented a 94.6% decrease overall (p=0.009), and a 100% decrease in Streptococcus pneumoniae. Rates of UTIs were unchanged (6.8% vs. 7.6%) and UTIs are now the most prevalent bacterial infection in this group. Over 50% of patients still received empiric antibiotics.

Conclusions: Based on our data, the emphasis in management of children with FWLS should be on diagnosing UTI. Guidelines for evaluating children with FWLS in countries using PCV7 should emulate the NICE model and reflect the trends identified in this study.

Bronchiolitis is the commonest reason for hospital admission in infancy and the most frequent cause of acute respiratory failure in children admitted to paediatric intensive care units in the UK and North America.

The respiratory syncytial virus accounts for most cases of bronchiolitis, however, new virus isolation techniques have led to the discovery of previously unrecognised viruses including the human metapneumovirus and bocavirus which also play a significant role. The main developments in bronchiolitis management in recent years relate to the use of immunoprophylaxis; a number of other therapies such as the use of heliox are currently being investigated.

Supportive therapy remains the mainstay of management with limited or no evidence of benefit for most other pharmacological treatments. This article summarises the current understanding of the different bronchiolitis phenotypes with a brief description of outcomes and a review of the evidence for the various therapeutic interventions.

Objective: To identify trainers, senior house officers (SHOs) and their nursing colleagues perceptions of learning on a neonatal unit.

Design: Three questionnaires were administered to staff on the neonatal intensive care unit. One asked consultants about activities that trainees are exposed to, a second explored the views of other permanent staff regarding the value of the educational activities available for trainees, and a third explored the perception of the SHOs of their learning experiences.

Setting: Regional neonatal intensive care unit.

Results: Permanent clinical staff felt that the consultant ward round, emergency management, protected teaching, practical procedures and informal discussion were the most valuable learning experiences. SHOs felt that consultant and hand-over ward rounds were important and formal protected teaching less so.

Conclusion: A mismatch of perception of learning experiences was identified in the department. These mismatches can be addressed by acknowledging the importance of when the trainees perceive they may learn best and improving the learning experience in situations where they do not.

Limited clinical evidence plus much biochemical analysis suggests that carbonated drinks, such as cola (whether "flat" or otherwise) should not be recommended for oral rehydration in children with acute viral gastroenteritis. Parents and carers should be discouraged from using "flat" fizzy drinks for this purpose.

Phaeochromocytoma are a rare clinical entity in children. Contrary to traditional teaching which suggested that 10% of phaeochromocytomas are 'familial', advances in molecular genetics have revealed an identifiable germ line mutation in up to 59% (27/48) of apparently sporadic phaeochromocytomas presenting at 18 years or younger and in 70% of those presenting before 10 years of age. The inherited predisposition may be attributable to a germ line mutation in the Von Hippel Lindau (VHL) gene; the genes encoding for the subunits B and D of succinate dehydrogenase (SDHB and SDHD); the RET proto-oncogene predisposing to Multiple Endocrine Neoplasia Type 2 (MEN2) or the Neurofibromatosis Type 1 (NF1) gene.1 Of these, the Von Hipplel Lindau gene is the most commonly mutated gene in children presenting with a phaeochromocytoma. Referral to Clinical Genetics is recommended for genetic counselling prior to gene testing and investigation of the wider family. This review provides guidance on the aetiology, investigation, management, histopathology, genetics and follow-up of children with a phaeochromocytoma.

The many parasomnias now officially described often occur in young patients. They are at risk of being confused with each other if their characteristic features are not well known and if they are not carefully assessed, mainly clinically. Accurate diagnosis is essential for choice of treatment which varies considerably for different parasomnias. These points are illustrated mainly by reference to arousal disorders (including sleepwalking and sleep terrors) and the other parasomnias, such as nightmares and sleep-related epilepsies, from which they must be distinguished.

Background: Malnutrition underlies 50% of paediatric morbidity and mortality in sub-Saharan Africa. It is important to look for underlying causes of the malnutrition and some clinicians have assumed that the presence of a pericardial effusion indicates underlying TB. We wished to see how common pericardial effusions are in malnourished children and how their presence or size is related to peripheral oedema or the type of malnutrition of the child, HIV status or to underlying TB.

Methods: We prospectively studied a cohort of children at a regional nutritional rehabilitation unit in Malawi. Echocardiography on admission and follow up four weeks later was performed. During this interval children received therapeutic feeding and any other required medical care. The children were grouped into group 1 (marasmus), group 2 (marasmus with TB), group 3 (marasmic kwashiorkor), group 4 (marasmic kwashiorkor with TB), group 5 (kwashiorkor) and group 6 (kwashiorkor with TB).

Results: Of the 89 children who were enrolled, 28 were marasmic, (8 also had TB), 29 had marasmic kwashiorkor, (6 with TB) and 32 had kwashiorkor (4 with TB). In all the children who had a PE, its size was greatest at presentation. The overall reduction in PE size after four weeks of nutritional therapy was significant (2.9 mm change, range 0 - 8.4 mm, p = 0.002). The greatest change in PE size was in the children with most peripheral oedema compared to those with no oedema (2.7 mm v 1.0 mm, p = 0.017).

Conclusions: In severely malnourished children pericardial effusions are common, larger in children with peripheral oedema and respond to nutritional therapy alone.

Objective:To report 8 years data from a UK-wide audit of acute wheeze/ asthma management in children carried out annually since 1998.

Design: Paediatricians were invited to complete a simple form based on British Thoracic Society (BTS) asthma guidelines for any child over 1 year admitted with acute wheeze/ asthma each November from 1998-2005. Information was collected about patient demographics; initial hospital severity assessment; in-hospital treatment; education and emergency planning; discharge treatment and follow-up.

Results: In total, data on 9429 admissions were available, with between 53 and 67 centres participating each year. The majority of children were under 5 (median age 3 years). Virtually all were treated with bronchodilators while around 90% received systemic steroids. Vital signs (pulse and respiratory rate) and oxygen saturation on admission remained stable over the audit period. Yet, the proportion of admissions given bronchodilators exclusively by spacer increased from 7% to 44% between 1998 and 2005. The proportion discharged with written asthma plans increased from 24% to 41%. Wide variations were noted between centres in children receiving chest x-rays and written asthma plans. Children admitted under the care of a respiratory specialist were more likely to have documentation of being given written asthma information, being given a written asthma plan and having their inhaler device technique checked than if under the care of a general paediatrician.

Conclusions: In many areas, hospital treatment closely followed published guidance. However, some important deficiencies were noted and variations remain. As well as monitoring guideline implementation, national audit can highlight opportunities for research and improving care locally and nationally.

Objective: To investigate the importance of stratification by risk factors in computing the probability of a second SIDS in a family.

Design:Simulation Study

Background:The fact that a baby dies suddenly and unexpectedly means that there is a raised probability that the baby's family have risk factors associated with Sudden Infant Death Syndrome (SIDS). Thus one cannot consider the risk of a subsequent death to be that of the general population. The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI)6 identified three major social risk factors: smoking, age<27 and parity>1, and unemployed/unwaged as major risk factors. It gave estimates of risk for families with different numbers of these risk factors. We investigate whether it is reasonable to assume that, conditional on these risk factors, the risk of a second event is independent of the risk of the first and as a consequence one can square the risks to get the risk of two SIDS in a family. We have used CESDI data to estimate the probability of a second SID in a family under different plausible scenarios of the prevalence of the risk factors. We have applied the model to make predictions in the Care of Next Infant (CONI) study7.

Results: The model gave plausible predictions. The CONI study observed 18 second SIDS. Our model predicted 14 (95% prediction interval 1 to 21).

Conclusion: When considering the risk of a subsequent SIDS in a family one should always take into account the known risk factors. If all risks have been identified, then conditional on these risks, the risk of two events is the product of the individual risks However for a given family we cannot quantify the magnitude of the increased risk because of other possible risk factors not accounted for in the model.

Objectives:In a population based study of tuberous sclerosis (TSC), we sought firstly to identify the number of patients who have presented with symptomatic giant cell astrocytomas (GCAs) and secondly, within a subset of this population, to identify the number who would be diagnosed with GCAs on predetermined radiological criteria.

Methods: Individuals with TSC in Wessex (a geographical region of England) were identified and their medical history determined. A subset of individuals were invited to have a cranial MRI if they did not have a history of a symptomatic GCA and if they were likely to tolerate having cranial imaging without a general anaesthetic. Scans were performed according to a standard protocol on a single scanner and were reported blindly by a neuroradiologist.

Results: 179 individuals were identified with TSC. Ten of the 179 individuals had a history of treatment for a symptomatic GCA. 41 individuals had a cranial MRI. Thirty-nine had subependymal nodules of whom 24 (59%) had at least one (maximum 11) which enhanced with gadolinium. In seven individuals (17%) the lesion was greater than 1cm and all of these lesions enhanced.

Conclusions: In this study, the proportion of those with TSC who had a history of symptomatic GCA was 5.6%. In the subset without such a history, who underwent imaging, the number diagnosed as having a GCA on radiological criteria was much higher (59% enhanced and 17% were greater than 1cm in size). Screening for giant cell astrocytomas (performing scans on asymptomatic individuals with TSC) would, therefore, identify large numbers of patients who had not presented with symptoms. This finding leads us to recommend that screening should not be undertaken.

In tuberous sclerosis, the protein products of the TSC1 and TSC2 genes, hamartin and tuberin, act together in regulating the P13 kinase-Akt-mTOR-S6 kinase cell growth pathway. This finding raises the possibility that drugs could substitute for the role of the hamartin-tuberin complex in this pathway and thereby ameliorate some aspects of the disease in affected individuals. One such drug, rapamycin, is currently beginning evaluation.

Mutations are still only found in two thirds of affected individuals and a negative mutation screen should not be taken as evidence of absence of the disease. The need for detailed clinical examination and investigation remains paramount, especially in evaluating parents.

Seizures in the first 5 years of life, but particularly in the first year, including infantile spasms, require urgent intervention. We do not advocate screening but we do suggest urgent evaluation for possible raised intracranial pressure secondary to giant cell astrocytomas and for bleeding from renal angiomyolipomas where preserving renal function is a priority.

Objective: To develop and evaluate 'Families for Health' - a new community based family intervention for childhood obesity.

Design: Programme development, pilot study and evaluation using intention-to-treat analysis.

Setting: Coventry, England

Participants: 27 overweight or obese children aged 7-13 years (18 girls, 9 boys) and their parents, from 21 families.

Intervention: 'Families for Health' is a 12 week programme with parallel groups for parents and children, addressing parenting, lifestyle change and social & emotional development.

Main Outcome Measures: Primary: change in baseline BMI z-score at end of programme (3 months) and 9 month follow-up. Attendance, drop-out, parents' perception of programme, child's quality of life and self esteem, parental mental health, parent-child relationships and lifestyle changes were also measured.

Results: Attendance rate was 62%, with 18 of the 27 (67%) children completing the programme. For the 22 children with follow-up data (including 4 drop-outs), BMI z-score was reduced by -0.18 (95%CI -0.30 to -0.05) at end of programme and by -0.21 (-0.35 to -0.07) at 9 months. Statistically significant improvements were observed in children’s quality of life and lifestyle (reduced sedentary behaviour, increased steps and reduced exposure to unhealthy foods), child-parent relationships and parents’ mental health. Fruit and vegetable consumption, participation in moderate/vigorous exercise and children’s self-esteem did not change significantly. Topics on parenting skills, activity and food were rated as helpful and were used with confidence by the majority of parents.

Conclusions: Families for Health is a promising new childhood obesity intervention. Definitive evaluation of its clinical effectiveness by randomised controlled trial is now required.

Objective: To investigate the relationship between primary immunisation status and MMR uptake

Design: Nationally representative, Millennium Cohort Study

Setting: Children born in the UK, 2000-2002 Participants: 14,578 children with immunisation data

Main outcome measures: MMR status at 3 years, defined as "immunised with MMR", "immunised with at least one single antigen vaccine", and "unimmunised"

Results: 88.6% of children had been immunised with MMR, 5.2% had received at least one of the single antigen vaccines and 6.1% were unimmunised against measles, mumps and rubella at age 3 years. Children who were unimmunised with the primary vaccines at ages 9 months (1.2%, n=168) and at three years (0.4%. n=67) were 13 (95% confidence interval: 10.8, 14.7) and 17 (14.6, 19.7) times more likely to be unimmunised against measles, mumps and rubella, compared with children who were fully immunised. They were also more likely to be immunised with at least one of the single antigen vaccines with risk ratios (RR) of 2.8 (1.2, 6.1) and 4.3 (1.8, 10.1). Similar but smaller associations were observed if children were partially immunised with the primary vaccines at 9 months (3.5%, n=504) and three years (3.6%, n=522) with risk ratios of 4.0 (3.2, 4.9) and 5.2 (4.2, 6.1) for no MMR immunisation, and 2.0 (1.1, 3.6) and 1.6 (1.1, 2.5) for single antigen vaccine use.

Conclusion: Children who remain unimmunised with primary vaccines are also more likely not to receive MMR. More work is needed to determine how best to target this group.

Objective: To study the immunogenicity and reactogenicity of a combined Haemophilus influenzae type b and Neisseria meningitidis serogroup C tetanus toxoid conjugate vaccine (Hib-MenC-TT), when administered as a booster dose in combination with a measles, mumps and rubella vaccine (MMR).

Design: A phase 3 open randomised controlled trial.

Setting: One centre in Oxford, UK and nine centres in Poland

Subjects: 12-15 month old healthy children

Interventions: In the primary stage of the study 500 healthy, 6-12 week old infants were randomised in a 3:1 ratio to receive Hib-MenC-TT + DTPa-IPV or MenC-CRM197 vaccine + DTPa-IPV-Hib. In the booster stage 476 of participants, 190 in the UK and 286 in Poland, were vaccinated with Hib-MenC-TT and MMR.

Main outcome measures: The proportion of children with protective serum antibody levels against MenC and Hib, 6 weeks following a Hib-MenC-TT booster dose.

Results: The co-primary objectives were met: the Hib-MenC-TT booster dose induced protective antibody titres in children who were vaccinated with a combination of Hib-MenC-TT + DTPa-IPV or MenC-CRM197 + DTPa-IPV-Hib at 2, 3 and 4 months of age. 94.8% (LL 95%CI 92.4) of participants had rSBA-MenC ≥1:128 and 100% (LL 95%CI 99.2) achieved anti-PRP concentrations ≥1.0µg/ml. The percentage of toddlers with a post boost rSBA-MenC of 1:128 was significantly higher after priming with Hib-MenC-TT (97.7%) than after MenC-CRM197 (86%) (difference: 11.7%; 95%CI 6.2 to 19.4).

Conclusion: The waning antibody titres against Hib and MenC following primary immunisation can be boosted to protective levels by administering a dose of the Hib-MenC-TT vaccine at 12-15 months of age, supporting the recent introduction of this vaccine in the UK immunisation schedule to sustain protection of children against Hib and MenC disease. Trial registration: Clinical trials.gov, NCT00258700. Study ID: 103974.

Mucopolysaccharidosis type 1 (MPS1) is an autosomal recessive disorder with severe, moderate and mild phenotypes, Hurler, Hurler-Scheie and Scheie syndromes. We estimated incidence (2001-2006) and prevalence (2002 census) of MPS1 in the Irish Republic (ROI), using population data, database and chart review of all live MPS1 patients attending two specialized centres. Patient genotypes, ethnicity, province of origin, age at diagnosis and presenting features were recorded.

Thirty-one patients (14 females, 17 males) were alive, 27 of whom were <15 years. 26 patients had Hurler syndrome, four had Hurler-Scheie and one had Scheie syndrome, the birth incidence was 1 in 26,206 births and a carrier frequency of 1 in 81. Of note, 19/26 (73%) Hurler patients were Irish Travellers. Amongst Irish Travellers the incidence was 1 in 371 with a carrier frequency of 1 in 10. This is the highest recorded incidence worldwide. Given the morbidity and mortality associated with delayed treatment we recommend targeted newborn screening for this population.

Aims: The purpose of this study was to assess the vitamin D status of children with renal disease attending the outpatient clinics of our tertiary nephrology centre, allowing us to determine the prevalence of vitamin D deficiency and study its relationship with glomerular filtration rate and serum PTH concentration.

Methods: 90 boys and 53 girls: 99 White Caucasians, 38 of South Asian origin and 6 of other ethnic groups were enrolled into the study. 18 were on dialysis (15 peritoneal dialysis and 3 haemodialysis) and 61 had functioning renal transplants (19 with reduced GFR), 18 had chronic renal failure and 46 had a variety of renal disorders with normal renal function. Serum/plasma concentrations of 25(OH)D, 1,25(OH)2D, PTH, creatinine, calcium, phosphate and alkaline phosphatase were measured. Patients with serum 25(OH)D concentrations less than 25 nmol/l were considered to be deficient and 25-50 nmol/l as insufficient.

Results: 26% of all patients were 25(OH)D deficient and a further 32% insufficient. The prevalence in South Asians was higher (87% deficient/insufficient) than in White Caucasians (46% deficient/insufficient, p<0.0001). In children with reduced GFR who were not on dialysis 25(OH)D levels of less than 50 nmol/l was associated with a high PTH in 90% of cases compared to only 50% in those with normal vitamin D concentrations (p=0.013).

Conclusion: A high proportion of renal patients were vitamin D deficient/insufficient particularly children of South Asian origin. High PTH values in the setting of reduced GFR might be due to vitamin D deficiency and should lead to estimation of serum 25(OH)D concentration.

It is widely recognised that health care in Cuba is at a high level and that child health, in particular, is excellent1. This is illustrated by data from the World Health Organization (WHO) in its report World Health Statistics 20072 and UNICEF in its report The State of the World's Children 20063. Table 1 shows mortality rates for neonates, infants and children under the age of 5 (U5MR) for Cuba and three of its nearest neighbours who all have a higher standard of living as well as the UK and the USA.

Background and aims: The optimal dose of thyroxine (T4) in congenital hypothyroidism (CH) during infancy is controversial. Higher doses lead to improvement in cognitive scores, but have been linked to later behavioural difficulties. We have examined the effects of initial T4 dosage on somatic growth - a putative surrogate marker of overtreatment.

Methods: 314 CH children (214 girls, 100 boys) were analysed according to initial daily dose of T4: Group 1 (25 µgg, n=152), Group 2 (30-40µgg, n=63) and Group 3 (50 µgg , n=99). Thyroid function and weight, length and occipito-frontal head circumference (OFC) SDS were compared at 3, 6, 12, 18, 24 and 36 months of age. Linear growth SDS was compared between the three groups using a regression adjustment model at 12 and 18 months of age using birth weight and 3 month data as baselines. Thyroid function was also compared at diagnosis (T0), and 7-21 days after the start of treatment (T1).

Results: At T1 median TSH for Groups 1, 2 and 3 was 58, 29 and 4.1 mU/L respectively (p <0.001), Group 3 values remaining significantly lower at 3 and 6 months. Median fT4 was within or just above the reference range in all groups at T1, but 7.4% of Group 1 had values < 9 pmol/L compared with 5.1% and 0% for Groups 2 and 3 respectively. At 3 months weight, length and OFC SDS values were -0.39, -0.35, 0.09; -0.30, -0.47, 0.32; and -0.03, -0.13, 0.18 for Groups 1, 2 and 3 respectively, indicating relatively large OFC in all infants. A regression adjustment model showed no significant difference in growth rate from baseline and 12 or 18 months of age between the three groups.

Conclusion: An initial T4 dose of 50 µgg daily normalises thyroid function several months earlier than lower dose regimes, with no evidence of sustained somatic overgrowth between 3 months and 3 years.

Magnetic resonance (MR) imaging plays a key role in the management of many childhood tumours. There is increasing interest in extending these investigations to MR techniques that give information on tumour biology in vivo.

Magnetic resonance spectroscopy (MRS) is one such method which provides information on tissue biochemistry. Promising results have been obtained from many preclinical and clinical studies leading to an expectation that MRS will play a valuable clinical role. However, the role of MRS is not yet well defined and there is a paucity of data from multi-centre clinical trials.

In this review we concentrate on MRS in paediatric oncology, providing some general guidance on current applications and outlining areas which need to be developed further.

Objective: to investigate visual function pre- and post surgery in children with single suture non-syndromic craniosynostosis

Design: twenty nine infants (12 with sagittal synostosis, 10 with trigonocephaly and 7 with anterior plagiocephaly) were longitudinally evaluated using a battery of tests assessing various aspects of visual function, including ocular behaviour, acuity, visual fields and fixation shift. All infants were assessed before surgery and 2, 6 and 12 months after surgery.

Results: before surgery only 16% of infants had completely normal visual function, while on the assessment performed 12 months after surgery the number with normal results on all the tests raised to 65%. The only abnormalities found 12 months after surgical correction were mainly found on abnormal oculomotor behaviour in infants with plagiocephaly.

Conclusion: abnormalities of visual function are not frequent in infants with non syndromic craniosynostosis who underwent surgical correction. Approximately half of the patients had some visual abnormalities before surgery, that subsequently improved, showing a delayed visual maturation rather than persistent abnormalities.

Clinical bottom line

1. Aggression and/or hostility can be associated with ADHD (Grade B).

2. Present evidence does not suggest aggression/hostility with atomoxetine compared with methylphenidate or placebo, although it can not be completed ruled out (Grade A).

Although various measures can be used to describe the benefits and harms of treatments, not all of these clearly show the benefits or otherwise of treatments in a clinically useful way. Relative risk and relative risk reduction are commonly used to describe the results of studies but they are of limited clinical usefulness as they do not take baseline risks into account and tend to exaggerate the results of studies. Absolute risk measures such as the number needed to treat (NNT) and the number needed to harm (NNH) allow risk to be expressed in a much more clinically relevant way. The absolute risk measures reflect baseline risk and more accurately give an idea about the magnitude of the treatment effect.

However, because they vary according to the baseline risk of the population, they are of limited generalisability, and the published NNT of a treatment in one population cannot be directly applied to another population with a different baseline risk. There are, however, a number of simple methods which can allow us to estimate NNT's or NNH's for our own patients based on published data. The benefits of a treatment (expressed as the NNT) and the harms of the treatment (expressed as the NNH) can be combined into a single ratio called the likelihood of being helped or harmed (LHH). LHH can be adjusted for individual patients by taking account of their own values and unique circumstances.

Objective: We estimated the prevalence of metabolic syndrome (MS) in adolescents using the new International Diabetes Federation (IDF) paediatric definition and compared this with prevalence estimated using the IDF adult definition and five other previously published definitions.

Design: Cross-sectional survey in the prospective general population-based Northern Finland Birth Cohort 1986 (NFBC 1986) at age 16 years.

Setting: Birth cohort in Finland.

Participants: 5665 adolescents (2862 males and 2803 females) clinically examined in 2001-2002.

Main outcome measures: The prevalence of MS using different definitions.

Results: The overall prevalence of MS using the IDF paediatric definition was 2.4% (95% confidence interval (CI) 2.0 to 2.8%) at the age of 16 years. Using the IDF adult definition the overall prevalence was lower, 1.7% (CI 1.3 to 2.0%, European cut-offs for waist circumference) and 1.0% (CI 0.7 to 1.3%, North American cut-offs).

Conclusion: In 16-year old adolescents, the paediatric IDF definition rendered a higher prevalence estimate than the adult definition.

It has been suggested that young children regulate their daily energy intake very closely with highly stable day-to-day total energy intake. This hypothesis was developed on the basis of an experimental study of 15 children aged 26 to 62 months, which reported a within-subject coefficient of variation (CV) in daily energy intake of 10.4%.

We tested the hypothesis that free-living energy intakes were highly stable on a day-to-day basis in a sample of free-living young children from Glasgow, Scotland. In 101 children (47 boys) aged 2.6-6.8 years, energy intake was measured using multiple-pass 24-hour recalls. Within-subject CV was 19.2% which was significantly higher than the 10.4% reported by Birch and colleagues (p<0.0001). In addition, we identified four other studies on free-living children with within-subject CV's ranging from 16.1-28.7%. This evidence indicates that young children show a wide intra-individual variation in day-to-day regulation of energy intake in a free-living environment.

Background: UK child health promotion guidelines expect health visitors to assess family needs before age 4 months and offer targeted care on that basis thereafter. We have used data from an intensive family support programme to assess how accurately family needs can be predicted at this stage.

Design: Population based cohort of 1202 families with new babies receiving intensive health visiting programme. Analysis of routinely recorded data.

Setting: Starting Well project, Glasgow, UK.

Predictors: Health visitor rating of family needs.

Main outcome measures:Families receiving high visiting rates or referred to social work.

Results: 302 families were rated high need at some point, but only 143 (47%) of these had been identified by age 4 months. Visiting rates in the first year for those initially rated high need were nearly double those for the remainder, but around 2/3 of those with high contact rates and those referred to social work were not initially rated high need. Six family characteristics (no income, baby born preterm, multiple pregnancy, South Asian, prior social work/ criminal justice involvement, either parent in care as a child) were identified as the commonest or strongest predictors of contact rates; 1003 (83%) families had one of these characteristics and/or lived in a highly deprived area and this included 228 (93%) of those with high contact rates and 157 (96%) of those referred to social work.

Conclusions: Most families at risk will not be identified on an individual basis in the early weeks; a majority of families in deprived areas will need continued input if the most vulnerable families are to be reliably identified.

Objective: Sudden Infant Death Syndrome (SIDS) is associated with prone sleeping and circulatory failure has been hypothesised as a factor in the fatal event. We aimed to determine the effect of prone sleeping on heart rate (HR) and blood pressure (BP) control over the first 6 mo of life.

Subjects: Term infants (N=20) were studied longitudinally at 2-4 wk, 2-3 mo and 5-6 mo with daytime polysomnography.

Main outcome measures:A photoplethysmographic cuff (FinometerTM) on the infant's wrist measured (MAP), systolic (SAP), diastolic (DAP) arterial pressure and HR during quiet sleep (QS) and active sleep (AS) in both the supine and prone positions.

Results: BP in QS was lower compared to AS (by 3-9 mmHg) in both positions and at all three ages (p<0.05). At 2-3 mo a change from supine to prone in QS induced a fall in SAP (6 mmHg, p<0.05) and a rise in HR (4 bpm, p<0.05). An overall effect of PNA on BP was identified (ANOVA) with MAP and DAP consistently averaging less (by 1-9 mmHg) at 2-3 mo in both sleep states and sleeping positions compared with both other ages.

Conclusions: Infant BP is modified by sleep state and sleeping position. A tendency for BP to fall in the prone position appears to be prevented by elevated HR, except at 2-3 mo in QS. An uncompensated fall in BP in the prone position at 2-3 mo (when SIDS risk is greatest) could increase the possibility of circulatory failure and SIDS in vulnerable infants.

Background: Childhood obesity is a serious health problem worldwide with a prevalence rising to epidemic proportions. Television viewing is suspected as an important contributor and along with food advertisements significantly influence children’s unhealthy dietary habits, purchaserequests and adiposity.

Objectives: to examine the exposure of Bulgarian children to television food advertising and to make a content analysis of the food/beverage advertisements during children’s TV programs.

Design: 41.5 hours of children's television programming on three national networks were videotaped. All recorded food advertisements were evaluated to identify the marketing strategies used for the stimulation of children’s purchase requests.

Results: Food/beverage advertisements accounted for 124 (33.4%) of all commercials, with 96.8% being for unhealthy foods. 57% of them were aimed specifically at children as the most advertised products were salty/sweetened snacks and cereals, sweets, soft drinks/carbohydrate juices and salty foods, with no fruit or vegetable commercials. Food advertisements used more themes of adventure, animation, music and gifts to attract children's attention and gave information based on the product's taste, physical qualities, novelty, presence of premiums/prizes. Of all food/beverage advertisements, 27.4% contained health-related information about the products; 3/4 of the advertisements were shot with young normal-weight actors with a good/healthy appearance.

Conclusion:Almost all recorded food advertisements do not support the Bulgarian dietary recommendations for healthy and balanced eating. More activities to reduce the unhealthy food promotion to children are mandatory as restrictions by type of advertised food, target group or limits on the advertisements' account and times shown, as well as parental/self-regulation.

The aim of this study was to ascertain whether Health Care Professionals (HCPs) are able to accurately identify overweight and obese children by observation alone. Eighty HCPs were asked to view photographs of thirty-three children, and assign each into one of six categories, ranging from "very underweight" to "obese". The HCPs' categorisation was compared with the children's degree of adiposity based on conventional clinical criteria for BMI.

The HCPs were found to be generally poor at assessing the weight status of the children, and in particular tended to underestimate overweight and obesity in children. This study suggests that it is not appropriate to rely on informal assessment to identify obesity, and highlights the need for HCPs to be aware of their lack of accuracy in this regard.

Background: A false positive sweat test in patients with deficiency of glucose-6-phosphate-1-dehydrogenase (EC 1.1.1.49; G6PD) is repeatedly reported.

Methods: Sweat chloride or conductivity was measured in eleven patients with G6PD deficiency.

Results:Mean chloride level (n=8, median age 9.2 years, range 1.9-48.5) was 18.8 ±9.6 mmol/l and, mean sodium level 26.0 ±10.0 mmol/l respectively, and mean conductivity (n=3, median age 6.6 years, range 1.9-40.5) was 34.3 ±6.5 mmol/l.

Conclusion: In sweat of 11 patients with G6PD deficiency we did not find any abnormality. The reason for alleged false positive sweat test in patients with G6PD deficiency is not known and we were unable to identify any original reference. It appears that tables of putative false positive sweat tests in several disease states have been directly "copied and pasted" from one paper or textbook to another without verifying the original literature, a phenomenon one can call "chain citation".

Malnutrition and growth deficiency are common in neurologically impaired children. Gastrostomy placement has been shown to result in significant catch up growth, improved health of the child and reduction in family stress; its cost effectiveness has not been investigated.

Costs related to gastrostomy placement are estimated here from a prospective controlled study of children referred to a tertiary paediatric centre in UK. Costs of inpatient stay, medication, tests, general practitioner consultations, community health care, equipment, and parents' indirect costs, were estimated at baseline and follow up. Costs of the different types of gastrostomy surgery are given.

Results for both time periods were available for 54 of the 76 children recruited to the study. Five day food diaries were kept at baseline and follow up. Costs of food increased slightly but not significantly post surgery from £33 to £40 [44 to 54, 65 to 78 USD$] per week. Variation in cost between cases was considerable but the mean net cost difference of £20.80 (CI -£43.79 to £85.35) [28 (CI -59 to 115), 41 USD$ (CI -86 to 167USD$)] per week per child including for food and surgery, was also not significant. Community service costs were significantly lower post surgery.

Few parents reported personal costs at either time point, although many had reduced or stopped paid work to care for the child. As gastrostomy placement for these children resulted in significant clinical benefit at no significant extra cost, it is concluded that the procedure is cost effective.

Objective: to examine twhether the inverse association between birth weight and blood pressure varies by skin pigmentation and/or related genotypes Study design: we followed-up 671 children from a predominantly Caucasian birth cohort to adolescence (mean age 14.4; SD 0.64).

Methods: Data on birthweight, socioeconomic status, maternal antenatal smoking, adolescent blood pressure and polymorphisms of candidate genes were obtained and analysed by multiple linear regression.

Results: an increase in birth weight of one kilogram was associated with a not statistically significant difference in adolescent systolic blood pressure of -0.53 mm Hg (95% CI -1.72 to 0.66mm Hg) per 1kg after adjustment for child age and cohort entry criteria. The inverse birth weight-systolic blood pressure association was stronger for those with darker skin (≥ 2% melanin) (P=0.02), for those with more copies of the C allele of corticotropin-releasing hormone (CRH) + T1273C (P=0.06), and for those with more copies of the short (≤ 236bp) form of the 11β-HSD2 {CA} n repeat microsatellite (P=0.03).

Conclusions: These findings add to the evidence that cortisol-related pathways may account for at least part of the observed birth weight-blood pressure associations.

Aim: To ascertain the frequency of significant ano-genital signs, at medical examination following an allegation of sexual abuse, in relation to the timing of the examination.

Method:A case series of 331 children, who were referred by the police or social services for examination following an allegation of child sexual abuse or suspicion of this, over a three and a half year period in a defined geographical area.

Results: Two hundred and fifty seven children alleged penetrative abuse of whom 114 were seen within seven days of the abuse. Twenty three children alleged penetrative anal abuse within the last 7 days; thirteen of these had abnormal findings (56.5%) compared with 9 (18%) of the 50 children seen more than seven days after anal abuse. Ninety two girls alleged penetrative vaginal abuse within the previous seven days and of these 46 (50%) had abnormal findings compared with 31 (30.7%) of the 101 girls seen more than seven days after the alleged abuse. In addition 33 girls seen within seven days had other signs associated with probable assault. Abnormal findings were commoner in post pubertal girls.

Conclusion: Pubertal and post-pubertal girls are more likely to have significant genital signs if they are examined within seven days of the last episode of sexual abuse. Our findings suggest that abnormal anal signs are more likely to be present in the acute phase. This study indicates that children should be examined as soon as possible following a referral. This will have implications for clinical practice. Regardless of the lack of accurate history it will always be important to examine the child as soon as possible after disclosure.

The paper describes the setting up of a database of children with autism spectrum disorder (ASD) in the north east of England. Best practice has been followed including involvement of parents in planning and implementation at all stages, oversight by a multi-agency group, management by a multidisciplinary steering group, and independent administration of the database. From a potential listing of 986 children with ASD aged 3 to 12 years, the parents of 511 have so far responded (51.8%) although response rate varies considerably by local authority. Data checking has shown the information to be valid, and case ascertainment broadly representative. The uses to which data are being put, and the continuing challenges, are outlined.

There is no known cure for Crohn's disease (CD), but a better understanding of the evidence base of both established treatments (such as enteral nutrition, corticosteroids, 5-aminosalicylates, immunosuppressive agents) and emerging novel treatments (such as the anti-tumour necrosis factor- (anti-TNF-) agents, infliximab and adalimumab) provide opportunities to improve and maintain the quality of life of children with the disease.

This article provides an overview of the evidence base of current medical treatments that are used to induce and maintain remission in CD. Exclusive enteral nutrition is recommended as the first line treatment for the induction of remission in paediatric CD. Corticosteroids are also effective for inducing remission but may be associated with significant adverse events. Patients with chronically active CD may benefit from immunosuppressive agents such as azathioprine and methotrexate.

Infliximab is effective for inducing remission in patients who continue to have significant active disease despite the use of conventional treatments. Adalimumab may be indicated for patients who develop severe allergic reaction to infliximab or those who initially respond to infliximab but subsequently lose their response. Treatments that have been shown to be effective for the maintenance of remission include azathioprine, methotrexate, infliximab, and adalimumab.

Recent evidence also suggest that long term enteral nutritional supplementation with patients taking about half of their daily calorie requirements as enteral nutrition may be an effective strategy for the maintenance of remission in CD. The available evidence does not support the use of corticosteroids or 5-aminosalicylates as maintenance therapy for CD.

Background: Selective mutism (SM) now acknowledged as an anxiety condition, tends to be a poorly understood, highly complex and vastly under-recognised clinical entity. Children with SM are a vulnerable group as the condition is not the remit of any one professional group. This inevitably leads to delay in formal diagnosis and management. There is a lack of systematic research on which to base guidelines for management

Aim: To develop, agree and validate key principles underlying the management of SM through a consensus process involving international experts, in order to create a local care pathway.

Methods: A local multi agency consultation process developed 11 statements which were felt to be the key principles underpinning a potential care pathway for managing SM. Thirteen recognised experts from North America, Europe and Australia participated in a modified Delphi process involving two rounds using a Likert-scale and free commentary. Both quantitative and qualitative analyses were used in the validation or revision of the statements at each stage.

Results: Response rates were 100% for Round 1 and 84.6% for Round 2. Despite the differing professional backgrounds and service contexts, by successive revision and/or revalidation of statements it was possible to arrive at a consensus about key principles relating to early recognition, assessment and intervention

The agreed key principles are presented together with the resulting local care pathway.

Conclusion:Through a Delphi process, agreement was reached by a multidisciplinary group of professionals on key principles that underpin the timely identification, assessment and management of children with SM. These include the potential for staff in school/preschool settings to identify SM and that intervention programmes should generally be based in these settings. Children with SM should receive assessment for possible coexisting disorders, whether developmental, emotional or behavioural and additional specific intervention given for these. Agreement was reached as to what constitutes clinical progress, intervals for monitoring progress, criteria for referral onwards for multidisciplinary specialist assessment and role of SSRI medication. A consensus methodology has been successfully used to compensate for the lack of evidence base and harness the expertise of a relatively small number of experienced professionals in order to provide a basis for the future development of services.

For most surgical procedures and clinical interventions on children who lack the capacity to consent, a single consent from a person with parental responsibility for the child will suffice, provided it is given voluntarily, and is informed by proper disclosure.

Objective: Varicella vaccination was introduced at the end of 1999 into the Uruguayan immunisation schedule for children 12 months of age. Varilrix^TM (Oka strain; GlaxoSmithKline Biologicals) has been the only vaccine used since then and coverage has been estimated to exceed 90% since the start of the universal varicella vaccination program. We assessed the impact of the Uruguayan varicella vaccination program through 2005, six years after its introduction.

Methods: Information on hospitalisations was collected from the main paediatric referral hospital and information on medical consultations for varicella was collected from two private health insurance systems in Montevideo. The proportion of hospitalisations due to varicella and proportion of ambulatory visits for varicella since introduction of the vaccine were compared between 1999-2005 and 1997-1999 in the following age groups: < 1 year, 1-4 years, 5-9 years and 10-14 years.

Results: By 2005, the proportion of hospitalisations due to varicella among children was reduced by 81% overall and by 63%, 94%, 73%, and 62% in the < 1, 1-4, 5-9 and 10-14 years age groups, respectively. The incidence of ambulatory visits for varicella among children was reduced by 87% overall and by 80%, 97%, 81%, and 65% in the < 1, 1-4, 5-9 and 10-14 years age groups, respectively.

Conclusions: The burden of varicella has decreased substantially in Uruguayan children since the introduction of varicella vaccination, including those groups outside the recommended vaccination age. It is expected to decrease further as more cohorts of children are vaccinated and herd immunity increases.

Objective: To determine which aspects of socio-economic status (SES) measured at birth and 9/10 years are associated with body composition at ages 9/10 years.

Design: Mixed longitudinal cohort

Setting: Johannesburg-Soweto South Africa

Participants: A sub-sample of the Birth to Twenty (Bt20) cohort (n=281) with data on birthweight, height, weight, fat and lean tissue (whole body DXA), and birth and 9/10 years SES measures.

Main Outcome Measures: Linear regression was used to estimate the influence of birth and ages 9/10 years SES measures on three outcomes; fat mass index (FMI) (Fat Mass (Kg)/height(m)4), lean mass index (LMI) (lean mass (Kg)/height(m)2), and BMI at ages 9/10 years controlling for sex, age, birthweight and pubertal status.

Results: Compared to the lowest SES tertile, being in the highest birth SES tertile was associated with increased LMI at 9/10 years (β = 0.43, SE = 0.21 for White and Black children and β = 0.50, SE = 0.23 for Black children only), whereas children in the high SES tertile at 9/10 years had increased FMI (β = 0.46, SE = 0.22 for White and Black children and β = 0.65, SE = 0.23 for Black children only). SES at birth and 9/10 years accounted for 8 and 6% of the variance in FMI and BMI respectively (Black children).

Conclusions: These findings underline the importance of examining SES across childhood ages when assessing nutrition inequalities. Results emphasise the need to consider lean and fat mass as well as BMI when studying SES and body composition in children.

Background: Some victims of sudden infant death syndrome (SIDS) are found with their heads covered with bedclothes but the significance is uncertain. The aim of this review is to describe the prevalence of head covering, the magnitude of the risk and how the suggested causal mechanisms fit with current epidemiological evidence.

Methods: Systematic review of population-based age-matched controlled studies.

Results: Controlled observations of head covering for the final sleep were found in ten studies. The pooled prevalence in SIDS victims was 24.6% [95% CI: 22.3-27.1%] compared to 3.2% [95% CI: 2.7-3.8%] amongst the controls. The pooled univariate odds ratio (OR) was 9.6 [95% CI: 7.9-11.7] and the pooled adjusted OR from studies mainly conducted after the fall in SIDS rate was 16.9 [95% CI: 12.6-22.7]. The risk varied in strength but was significant across all studies. In a quarter of cases and controls head covering had occurred at least once previously (pooled adjusted OR=1.1 [95% CI: 0.9-1.4]). The population attributable risk (27.1% [95% CI: 24.7%-29.4%]) suggests avoiding head covering might reduce SIDS deaths by more than a quarter.

Conclusions: The epidemiological evidence does not fully support postulated causal mechanisms such as hypoxia, hypercapnoea and thermal stress, but neither does it support the idea that head covering is part of some terminal struggle. Head covering is a major modifiable risk factor associated with SIDS deaths and parental advice to avoid these circumstances should be emphasised.

Atopic eczema is a common condition, affecting as many as 15-20% of school age children, with 1-2% of children with the condition being severely affected. It commonly begins in early childhood, when it can be particularly severe. Whilst most children with atopic eczema are treated in primary care, backed up by dermatologists, paediatricians need a degree of competence in managing the condition and should know when to refer for a specialist dermatological opinion.

Objective: To evaluate the incidence and characteristics of torticollis, plagiocephaly, and facial asymmetry in normal newborn infants.

Design: One hundred and two healthy newborn infants were examined prospectively during their birth hospitalization for torticollis with neck range of motion (ROM) assessment, and for facial, mandibular, and cranial asymmetry by photographic analysis.

Results: Seventy-three percent of newborns had one or more asymmetry: torticollis (16%), asymmetry of the mandible (13%), facial asymmetry (42%), and asymmetry of the head (61%). Torticollis was associated with maternal report of having been "stuck" in one intrauterine position for more than 6 weeks prior to delivery. Moderate facial asymmetry was associated with a longer second stage of labor, forceps delivery, a bigger baby, and birth trauma. Moderate cranial and mandibular asymmetries were associated with birth trauma. Ten percent of newborns had more than one significant asymmetry.

Conclusions:Asymmetries of the head and neck are very common in normal newborns, and sixteen (16%) of 102 study newborns were found to have torticollis. Such newborns, especially if they sleep supine, are thought to be at risk of developing deformational posterior plagiocephaly. Identification of affected infants may allow early implementation of positioning recommendations or physical therapy to prevent the secondary craniofacial deformations that are part of an increasingly common phenomenon.

In 2005, I wrote about the new UK National Patient Safety Agency (NPSA) [1]. However, patient safety is about much more than a government agency; it is about a huge cultural change in how doctors practise.

Two anecdotal case studies may be of interest. In October 2007 the US Department of Justice fined British Petroleum $50m relating to the Texas City refinery explosion in 2005 which killed 15 people and injured 170.

In November 2006 I spent a week with the oil company Shell on an attachment organised by the National School of Government. I wanted exposure to an industrial environment where, like paediatrics, safety is crucial and where things can go wrong very quickly. I retain three memorable images from my arrival at Shell, none of which were the 'rocket science' I anticipated of the high-tech petroleum industry.

The car from the airport could park at Shell only by reversing into the parking space - accidents happen when drivers reverse out after work in the evening darkness. On entering the building and climbing the stairs, I was politely told I had to hold the stair rail. This behaviour would not come as second nature on a North Sea oil rig if not insisted upon ashore. My cup of coffee had to be covered with a lid if I wanted to carry it around the office with me.

Objective: To investigate the outcome for children hospitalised with radiologically confirmed community acquired pneumonia (CAP)

Design: Controlled Follow-up Study Setting: Community based in Newcastle upon Tyne, North Tyneside and Northumberland schools

Patients: 103 cases of radiologically confirmed CAP a median of 5.6 years (range 4.4-7.4) after admission to Newcastle General Hospital, matched for sex and school class to a mean of 2 controls (n = 248)

Interventions: A respiratory questionnaire, clinical examination and spirometry measurements. Main Outcome Measures: Multiple regression was used to describe associations between explanatory variables, including CAP, and outcome variables: forced expiratory volume in one second percent predicted (FEV1%), forced vital capacity in one second percent predicted (FVC%), persistent cough, doctor diagnosis of asthma and abnormal chest shape.

Results: Cases were 2.4 times more likely (95% CI: 1.02, 5.77, p=0.046) to have persistent cough and 5.5. more likely to have an abnormal chest shape (95% CI: 1.65, 18.28, p=0.005). Cases of an atopic parent had a 7.0% deficit in FEV1% (95% CI: -10.5, -3.2, p<0.001) and a 4.4% deficit in FVC% (95% CI: -8.0, -0.78, p=0.017) but were not at increased risk of subsequent asthma. Cases of a non-atopic parent were at increased risk of subsequent asthma (OR 4.8, 95% CI: 1.43, 16.34, p=0.011) but not of deficit in lung function.

Conclusions: CAP requiring admission to hospital is associated with deficits in lung function and persistent respiratory symptoms. This has implications for follow-up for which recommendations are currently lacking. Parental atopy may be a determinant of outcome.

Objective: To investigate the association of adiposity measures with blood pressure (BP) in Chinese children and adolescents.

Design: A cross - sectional study.

Participants: A total of 1330 males and 1170 females aged 6-18 years from a rural population based cohort of twins studied between 1998-2000 in Anhui, China.

Outcome Measures: Adiposity measures included body mass