Global health: Charges to migrant children’s families

In a hard-hitting salvo, Russell and colleagues argue that recent changes to charging regulations in the NHS, both undermine child health and represent a departure from the founding principles of the organisation. The new rules effectively restrict access to care to an estimated 1 20 000 child migrants in the UK classified as ‘undocumented’ even though many are second generation. The changes include a charge of 150% of the NHS tariff for those unable to prove a regular status and sharing of personal data with the Home Office if payments are not addressed with potential for deportation for failure of payment. In short, the rules contravene the tenet of universal health coverage, a cornerstone of the Sustainable Development Goals. The Royal College of Paediatrics and Child Health (RCPCH) and other medical colleges have called for its suspension. How many of you are aware of this change: how many children might you have seen in today’s clinic with this threat hanging over them? See page 722.

Intergrowth

The new Intergrowth charts were based on the philosophy that basing postnatal growth on standard charts, which were derived by serial cross measurements and aim to replicate the much faster in utero growth is unrealistic. This represents a new, very different way of thinking, is more liberal and ‘allows’ babies to grow at slower rates slower potentially mitigating the future metabolic risks inherent in rapid ‘catch up’ a term that is much misused. The charts were based on longitudinal ex-utero growth in well, breastfed preterm babies. Villar and colleagues describe the philosophical differences between the Intergrowth and traditional charts and the methodologies behind its design all of which are in keeping with the WHO Multicentre Growth Reference Study approaches. It is untenable that the two methods will ever be compared directly in a randomised trial, but the observational data collected over the next few years on cardiovascular markers, morbidity and mortality will tell us much more about the risk-benefit equation we are still struggling to decode. See page 725.

Adolescent health

There are a number wide ranging pieces in this month’s adolescent health section: Koster addresses patterns of prescription use in Dutch teenagers; Knight, chronic fatigue syndrome epidemiology in Australia and Kramer describes the essential information gathering steps as part of the mental health assessment after an overdose. See pages 745, 733, 728.

County lines

I’m not easily shocked but found Glover Williams brilliant piece on the subculture known officially as ‘County Lines’ by the Home Office (and unofficially by a number of euphemisms) very disturbing. The basic premise is that mobile phone lines are used by gangs to infiltrate provincial towns likely to yield profitable drug related ‘business’. Once ‘settled’, they promote, among other drugs, heroin and crack cocaine, through social media and a system that functions on child criminal and sexual exploitation and human trafficking. Typically, gangs take over the homes of vulnerable adults, promise drugs in exchange for letting them use the premises, start a relationship with them or use force or coercion to secure their base. Children entangled in these organisations might show unusual signs or behaviours (an increase in call rates, unexplained injuries and overt sexualization), but, because of fear of reprisal will be reluctant to make any revelations about their persecutors. See page 730.

Transgender young people and fertility

Though puberty ‘blocking’ treatment in young people with gender dysphoria (GD using gonadotrophin analogues is common, the effects on fertility (either through natural conception or gamete harvesting) are unclear. Little is also known about the wishes of dysphoric young people with regards to future children, a deficit Chiniara and colleagues sought to address. They used a questionnaire (previously used to evaluate the same issues in children receiving treatment for cancer) on health and fertility wishes administered to a group (n=79) of patients aged 12 to 18 years at Toronto Children’s hospital. They found the current life priority for YP of eight options was good health and the least important was having children. Anticipated life priorities 10 years from now were ranked similarly.

Parents’ rankings paralleled the YP responses though ranked having children as a higher priority in 10 years for young people assigned female at birth (AFAB) compared with those assigned males at birth. The majority wanted to be a parent in the future, most did not envision having a biological child and most were open to adoption. There was no control group through which to determine the effect size of dysphoria, but one hopes that this group is followed for the next 15 to 20 years in order to capture the social and biological outcomes of most interest. See page 739.

Distress during airway sampling

Few stimuli are as unpleasant as pharyngeal sampling yet it remains one of the cornerstones on which treatment for exacerbations in cystic fibrosis is based. There are two techniques in wide use: the cough swab and nasopharyngeal suctioning. Assuming equal bacteriological yield, the ‘better test’ is that which causes least distress and Doumit and colleagues addressed this sparsely researched are in children attending the Sydney Children’s hospital respiratory service. They used a validated distress score (the Groningen scale) and heart rate and tested both techniques in all children, randomly assigning the order. Interrater reliability was good and the scores for the cough swab unequivocally lower. Given that this is a common procedure and one that continues lifelong, it is hard to think why practice should not switch entirely to the less unpalatable swab: a thought which makes the paper my editor’s choice for the month. See page 806.