Spoilt for choice

One of the many pleasure inherent to my job, is seeing papers evolve from submission through the review process, and then appear in print. Writing this column (which I do about 6 weeks before the issues arrive in the post or appear on the website) is, therefore, one of the highpoints of my month. I am invariably spoilt for choice and left with difficult decisions as to what to feature. It has been particularly hard this time, the papers being of such quality and breadth, but exactly the sort of ‘problem’ I enjoy

Every few years, public attention is captured by a story so poignant, that it plays out in the full glare of the public eye. Such exposure is now, of course, heightened by social media, and where in the not-so-distant past, events would be relayed by newspaper or radio the following day, the speed of the internet, inevitably heightens the emotion of those involved. Last summer, the sad case of a young boy with a mitochondrial depletion syndrome became the focus of attention for several weeks. His paediatricians and parents had opposing views on the merits of a trial of a novel treatment and, as the issue could not be resolved internally, the case was referred to the High Courts of Justice and then the European Court of Human Rights. We feature three different but complementary views on the case: a paediatrician’s, Colin Wallis, ( see page 413 ); a medico legal one, Robert Wheeler ( see page 410 ); and a view from outside the UK from Hugo Lagercrantz in Sweden ( see page 409 ). The passage of time, if anything, has made these articulate opinions even more vital and resonant.

After the scars have healed

We’re all aware of the link between burns and environment (in the broadest social sense), but, perhaps less of that between thermal injury and later development. In an elegant data linkage study in New South Wales, Holland and colleagues followed 1,556 children with burns sustained in the early 2000s before school age and 6,200 controls ( see page 444 ). They estimated differences in school performance in years 3, 5 and 7 after extensive adjustment for potential socio-economic confounders with results that were genuinely sobering. Cases performed significantly worse across every domain (reading, writing and numeracy) with a clear dose response relationship, each 10% increase in total body surface area burnt predicting a year 5 scores by 37.0% lower in numeracy and 72 % in writing. The reasons are likely to be complex, involving parental access of health care, disruption to schooling, and self-esteem, but (as the exposure-effect association suggests) may also involve other pathways. Whatever the mechanisms, I will think differently the next time I assess a child with even minor burns. I think you will too.

Predicting chronic pain

Pain and life quality are inextricably linked, and therefore any advance in identifying windows for early intervention should be welcomed. Thompson and colleagues analysed of a cohort of children enrolled in the Childhood Arthritis Prospective Study (principally in the Juvenile Idiopathic group) and assessed the probability of following each of three pain severity trajectories by a range of candidate predictors including function, mood and early use of disease modifying drugs ( see page 437 ). The analysis included 851 children and showed that (counterintuitively) older age at onset, poor function/disability and longer disease duration at baseline were associated with consistently high pain trajectories. This sort of model may well be applicable to other forms of chronic pain, and might form the basis of new and earlier interventions.

HIV and feeding

The WHO recommends exclusive breast feeding (preferentially) or exclusive replacement feeding for the first 6 months after birth for HIV-exposed infants to reduce the not inconsiderable risk of postnatally acquired infection. Mixed feeding (breast and replacement contemporaneously) is now known to increase the risk and should be avoided. However, as a result of social pressure, poor resources, lack of access to safe water and cultural beliefs, adherence can be difficult. Langa’t and colleagues ( see page 470 ) explored these issues qualitatively in Kenya where, in 2013, there were an estimated 13 000 infected babies born to 76 000 infected mothers. They identified similar uncertainties among mothers, and in addition, conflicting advice from healthcare workers, presumably reflecting uncertainty and confusion around feeding and change in recommendations. It is clear that even the most complete ART programme will not fulfil its full potential unless the seemingly straightforward but in reality, socially complex area of infant feeding, is addressed.