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Ovine or ursine?
Human behavioural phenotypes are complex and the debate around relative contribution(s) of genetics, epigenetics and environment (however defined) are likely (however loudly each proponent shouts) insoluble. Chacun à son gout. Whatever our whole exome sequence predicts for us individually, we’re all sculpted. The boundaries society deem reasonable, the practice of peers and family behaviours are certain to modify the expression, even the trajectory of our nucleic acid profile as several studies of monozygotic twins brought up separately testify. So, let’s accept there are some factors we can modify and others not, a notion illustrated literally and metaphorically, by this month’s selection.
It has been a while since COVID-19 featured in the column, but Ermengol Coma and colleagues’ study in Catalonia, Spain has implications for future policy (who knows whether the heirs of Omicron will be benign or unkind?) and potentially public health stance in future non-covid pandemics. The WHO recommended face masks only in children over 12 years old, but many countries interpreted the risks differently. In Spain, for example, school children at 5 years of age were not required to wear masks, while their 6-year-old contemporaries were. The authors’ quasi-randomised controlled study comparing incidence rates is methodologically as good as it gets in this arena, much more robust than ecological analyses. The results may or may not surprise you—read and find out whether your presumptions are confirmed or require a rethink. Either way, you’ll understand why this is this month’s editor’s choice. See page 131
Safer to steer clear?
Over the peak pandemic era, there were dramatic reductions in paediatric emergency presentations worldwide. Some of the change would have been the fall in interindividual viral transmission. RSV, of course disappeared then reappeared with renewed vigour in a naïve population the following summer once the brakes were released. Attributing this as a sole cause, though, seems under-interrogative. Damian Roland and colleagues in the pan-European REPEM network systematically review data from previous, recent pandemics (MERS, SARS, Ebola, Chikungunya, E Coli and H1N1) and find contrasting directions of ‘effect’. Of these, only COVID-19, SARS, MERS (all coronaviruses) and Ebola were temporarily associated with a fall in ED visits. During the other pandemics, visits increased, a difference which is, on the surface, hard to fully explain. The probability that staying away or presenting reflects public health messages so often, by necessity, reflex responses to a new infectious problem but simultaneously, frequently pendular and inconsistent. The source of literature was very strongly high-income country based, an issue that, rightly, gnaws. See page 115
Sharpening the tool
It wasn’t that long ago (September 2000) that the Millennium Development Goals were launched. Central to this joint UN/WHO initiative was the reduction in preventable mortality through intervention in several ‘target areas’, many of which were directly or indirectly relevant to global child health. Though indices of progress were not universally consistent in direction (conflict, sadly, a perennial setback), child (but not neonatal) mortality fell steadily over the subsequent 15 years when the MDGs were replaced by the Sustainable Goals (SDGs). Over the SDG era to date, there has been a subtle, but tangible shift in emphasis beyond survival to the tacit assumption that infancy and early childhood will (for most) be navigated and that quality of life (in its broadest sense) or fulfilment of potential (as the WHO defines health) is the new hard currency. Child development is, arguably, the example par excellence of this change in approach, the literature at least in research settings now making a compelling case for screening for early detection and intervention. But (rhetorically couched) is choosing a validated screening tool enough particularly given the range of criteria to be fulfilled? With this backdrop, Maria Neocleous and colleagues in Liverpool present the findings from their systematic review and analysis of user friendliness of the currently available early child development screening tools, the emphasis being on training provision. There are currently 24 tools in circulation, 18 of which provided enough onsite information to assess training adequacy and accessibility. The majority fell short and with (and this is where altruism seems to have left the building) training costs ranging from zero to $4,000, leads inevitably to question what motivates the more fiscally driven organisations. Are these tools intended for all or simply those with larger accounts? Either way, these figures are hard to reconcile in the context of the ‘information for all’ mantra. See page 103
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.