Milestones

Like many words with an implicit sense of drama, ‘milestones’ has become something of an overused term, a ‘millstone’, if you will. There are occasions, though, where it is fully justified and, by chance, this month’s issue describes events and studies to which the epithet can rightly be applied. I therefore make no apology in risking cliché on this occasion

The end of formula milk advertising in Archives

In 1981, the WHO and Unicef launched the International Code of Marketing of Breastmilk Substitutes, guidance aimed to ban advertising of these products to the public. It stipulated that all milks that may replace breastmilk in the first 3 years of life, including infant formula, follow-on formula, specialist products and milks marketed for toddlers, as well as foods marketed for children under 6 months old, be known as ‘substitutes’. It was hoped that the ban would be upheld by law globally, but, the anticipated changes failed to materialise. Though the UK restricts marketing of infant formula to the general public, it allows advertising of specialist products to be marketed to health professionals providing the information is scientific and factual in the view of the advertiser.

After lengthy (and courageous) discussions between the BMJ journals and RCPCH, the conclusion was reached that this arrangement was in conflict with breastfeeding promotion. As a result, the BMJ, Archives and related journals and the RCPCH will no longer carry advertisements or accept payment from the companies. This will be expensive as losses of funding are inevitable. Though existing contracts will be honoured, the final adverts will appear later this year while the RCPCH examines ways of supporting paediatricians with regards to information regarding specialist milks for children with intestinal dysfunction and allergy.

Read the BMJ editorial on: https://www.bmj.com/content/364/bmj.l1200… AND the RCPCH statement on: https://www.rcpch.ac.uk/news-events/news/rcpch-statement-relationship-formula-milk-companies

Fluids in septic shock

In 2011, the New England Journal of Medicine published the landmark ‘FEAST’ study. This trial challenged existing dogma in terms of fluid bolus volumes in febrile children in Sub Saharan Africa with incipient shock. Children were randomised to an initial, ‘traditional’ bolus of 20 mL/ kg of either 0.9% saline or albumin or to a no bolus control limb. To generalised surprise and consternation, the results robustly demonstrated excess mortality in the higher volume group. Later secondary analyses showed that the excess deaths were largely due to cardiogenic shock, across all categories, though the pathological pathways were unclear. Unsurprisingly, there was a period of resistance in non Low and Middle Income emergency care settings partly on the basis of potential non-generalisability and for some years the question remained tantalisingly unanswered.

Eventually, to the immense credit of the UK NIHR, a pilot, phase two study, fluids in septic shock (FISH) was launched. This multicentre pilot, tested the feasibility of a potential future full scale trial on randomising children to the low or standard volume bolus after an initial 20 mL/kg load. The findings were salutary on two levels. First, adherence was variable suggesting inherent belief in individual previous practice. Second, the number of children eligible was much lower than expected, a reflection of the success of vaccination programme particularly with respect to the conjugate pneumonoccal, meningococcal B and (though not new) haemophilus B programme. Where does this now leave us? Inwald’s paper and the editorial by Kath Maitland, principal investigator of the FEAST study provide detail.  See pages 427 and 409.

Achieving consensus: RCPCH guidance

No one could be unaware or immune to the tensions generated by any of the recent high profile media cases in which paediatricians and parents fundamentally disagreed and, in of which, recourse to the courts was required. Mike Linney’s piece for the Royal College of Paediatrics and Child Heath and Paediatric Intensive Care Society was catalysed by these cases and suggests means of reaching a consensus in decision making in life limiting illness. The guidance is underpinned by the need for communication and includes the following tenets: avoidance of giving (to parents) inappropriate expectations, early use of palliative care teams, the recognition of parental and practitioner stress, the assignation of a lead consultant and use of ethical, legal services and mediation services.  See page 414.

Global health: climate change

To do justice to the effects (direct and indirect) of climate change to children from physical harm to infectious disease to nutritional risk to economic underproductivity, would take several volumes. Despite the magnitude of the task, there are simple practical and philosophical measures that we can incorporate into our daily lives which at scale will (not might) make a difference. Zulfi Bhutta’s editorial (explains how you might adopt these.  See page 418.

Voices

From the outset, I was determined that children’s views and thoughts, literal and metaphorical, would be afforded a place in the journal. This was one of the principles on which Robert Scott-Jupp’s Voices section was based. Other than ‘Voices from children’, there are three spokes, ‘history’, ‘controversies’ and ‘literature’ all of which are now running.

This month sees the first of the children’s and young person’s Voices: these are written by the young person or parent, are peer-reviewed, but, in the spirit of maintaining the authenticity of the original experience. All are anonymous to maintain confidentiality unless a child has died, or is aged over 18 years at the time of submission and have given autonomous consent. The first (and eponymous) piece, ‘all about George’ appears on page 489.