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Arch Dis Child 2000 Volume 83 No 1
Of couch potatoes and sofa fries
Paediatricians need only use their eyes to learn that youngsters are getting larger. But they may not be aware of other phenomena of malnutrition, which is why this month we publish a major study of US adolescents spanning over 30 years (page 18).
Surprisingly, energy intake fell over the years, although the authors are unsure whether this is a methodological artefact or a reflection of decreased energy expenditure. There was a big fall in the proportion of energy provided from fat and protein but a nearly 17% rise in the proportion provided by carbohydrate. By 1996 only 40% of girls met the recommended dietary intake for iron and only 20% for calcium.
The authors, from Nestlé Research and the University of North Carolina, were able to define what has happened in some detail: the increasing availability of other dairy products did not compensate for the fall in milk drinking; grains increased, but largely in high fat mixtures like pizza, macaroni cheese, and what the authors coyly term “certain ethnic foods”. Teenagers eat less fruit and drink more fruit juice and soft drinks, fewer potatoes and more chips (french fries).
They speculate on what problems might be gestating: low fibre, low anti-oxidants and non-nutrient plant foods may increase future cancer risks; girls turning away from milk may mean they later tend towards osteoporosis; hyperlipidaemia and dental caries are two of the risks of increased risks of fizzy drink consumption.
Leptin to the rescue? Not quite yet
Also, this month, our series on Recent Advances continues with an overview of the genetics of severe childhood obesity, from Farooqi and O'Rahilly in Cambridge (page 31). They note that five single gene disorders have been identified which lead to early onset obesity: the families variously have mutations in leptin, the leptin receptor, one form of the melanocortin receptor, and prohormone convertase 1.
ADC doesn't often permit touting for custom but, as the authors point out, although few patients have so far come to light, the potential clinical implications are enormous. Therefore, we are happy to endorse their offer of assistance in studying severely obese children (BMI more than 4SD above age related mean and onset before 10 years old).
Nature or nurture (again)
We know a lot about the effects on development of significant prematurity and intrauterine malnutrition. We know a lot less about whether term babies are any worse off for being born small for gestational age (SGA).
We report a multicentre Scandinavian cohort study following up 338 term SGA babies with 335 appropriate for gestational age (AGA) controls (page 25). At 5 years old, the SGA babies are a little behind the controls in IQ. However, SGA versus AGA status accounted for a negligible variance in IQ compared with that attributable to maternal abilities and child rearing styles. But smoking was bad for everyone.
Sublime and not so ridiculous
All journal editors look forward to receiving a nice juicy meta-analysis. This month's will help paediatricians decide how much and how long steroids should be used in treating a first episode of nephrotic syndrome (page 45). I detect the usual “more in sorrow than in anger” attitude of the Australian authors as they point out that there are too few studies out there to search and that most are underpowered or too brief, had inadequate allocation concealment, or had been reported in abstract only with the authors shy of expanding the experience etc, etc. Perhaps it is time to have a standard health warning about meta-analyses.
Potential authors who haven't yet taken up residence in some unpopulated corner of Cochrane must not despair. There is still room inADC for a case report. We are not at all keen on rarity for its own sake or the first case of something or other none of us will ever see, unique only for where the unfortunate sufferer happened to come to light. It is a pleasure, however, to publish a report detailing how the simultaneous expression in a child of fructose intolerance and alpha-1 antitrypsin deficiency demanded a novel approach to diagnosis—in this case by molecular genetic techniques (page 72). More please.
Small is beautiful (I think)
Non-UK readers can look away if they wish. For some years the British Paediatric Association and now the RCPCH have agonised about whether or not small NHS hospitals can offer adequate training for future paediatricians or general practitioners.
I admit to shameless bias working as I do in a hospital that is small by anybody's standards. My colleagues and I have had sleepless nights dreaming up what used to be called Liverpool City Council accounting methods to make sure our annual admissions are above the magic figure of 1800. Perhaps we shouldn't have bothered. MacFaul and others have studied admissions to ten hospitals (page 39) and conclude that small units provide adequate experience for common problems. Of course, they cannot offer exposure to rare problems but it turns out that only five hospitals in the country probably can!
MacFaul and colleagues' paper is important but we reject many other papers detailing the processes of NHS care. Disappointed authors, in their letters of appeal, often start with the phrase: “As the journal of the Royal College . . .”.ADC is much more than that: nearly 40% of our subscribers are overseas as are the majority of those who hit our website. Consequently, we were pleased to receive the large US study on diet mentioned above, which will now be reprinted in theWestern Journal of Medicine. What we look for are findings that can teach readers something useful wherever they live and work.