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THE NUTRITIONAL PARADOX
Undernutrition and obesity – the nutritional paradox – is becoming more common in countries around the world. This is highlighted in a report by Jafar and colleagues from Pakistan. In two surveys conducted about 10 years apart, the first in 1990–1994 and the second 2004–2005, the percentage of children 5 to 14 years of age who were underweight remained about the same 29.7% and 27.9%. Unfortunately, the percentage of children who were overweight nearly doubled, increasing from 3.0% to 5.7%. In an accompanying perspective, Corvalan, Dangour and Uauy argue that the obesity epidemic has not spared low-income countries, particularly South Asia, as these countries have experienced unparalleled urbanisation and adoption of energy-dense processed foods. Sadly, the twin threats to health as an adult, being malnourished as an infant and obese as an adolescent, are flourishing.
MORE ON OBESITY
Using the Millennium Cohort Study, a research group from UCL Institute of Child Health, provide very granular data about UK regional differences in overweight at 3 years of age. The strength of this analysis is that the investigators were able to adjust for both numerous individual risk factors, such as ethnicity, birthweight, duration of breastfeeding and introduction of solid foods, as well as family level attributes, such as income and maternal highest academic qualifications. Overall, they report that 23% of 13 194 children were overweight or obese. Northern Ireland and Wales topped the list, followed by Scotland and England. There were substantial differences in England by region. The East and South East appear to have the leanest 3-year-olds, and the North East the heaviest.
This report is coupled with a leading article about bariatric surgery to treat childhood obesity. Although the worldwide experience with obesity surgery for adolescents is limited, for the morbidly obese adolescents, it is becoming more common, at least in the US. The little data that are available, suggest that the procedure is safe and very effective. Information from my own institution, generated in 2007 from an electronic medical record, indicate that of 3220 adolescents 12 to 18 years of age, of which 55% were black and 17% of hispanic ethnicity, 3% had a BMI >40 kg/m2 and 7% had a BMI >99th percentile. Both of these cut-offs have been used as possible indications for weight loss surgery (C Lenders et al, personal communication, 2008).
ASSESSING NEW THERAPIES IN CHILDREN
The number of children with serious life-threatening diseases remains small. It makes assessing the effects of new therapies quite difficult; hence, there is a need for more multicentre clinical trials. Nevertheless, when faced with a child with a serious illness we can utilise adult data, and information about the biological basis of a disease, to make informed decisions. In a case-series from Great Ormond Street, Podolskaya and colleagues describe the results of using rituximab, a monoclonal antibody specific for human CD20 that depletes circulating B cells, in 19 children with severe complications of systemic lupus erythematosus. The results are impressive.
See pages 401
ONE PERSON CAN MAKE A DIFFERENCE
The plight of children in some countries is appalling. I continue to give credit to both the Gates Foundation and the Lancet for reviving interest in child global health. The addition of the Buffett dollars to the Gates Foundation—an additional 1–2 billion dollars a year for disbursement—will certainly help us reach the Millennium Development Goals. The question that I often ponder is how a single individual can make a difference in the lives of children. In this issue, Simon Lenton writes of his experience in The Gambia. For the past 5 years, in conjunction with Jole Rider, a Bath-based charity, he has been collecting and distributing bikes in The Gambia. I have met Simon numerous times and felt his fortitude and quiet determination to change the lives of these children. I suspect the simple addition of transportation—bicycles—is creating an environment where children go to school, learn, achieve and improve their lives. We hope to bring you other stories of individual initiatives from around the world.
See pages 439
THIS MONTH IN FETAL & NEONATAL EDITION
Infant mortality is one of the most important “health measures.” It is used to assess and compare healthcare systems, and is often used as a proxy for child well-being. In a provocative study from the UK and Australia, investigators compare infant mortality in Trent Health Region and New South Wales for all births 22 to 31 weeks gestational age in 2000, 2001 and 2002. In part, more ready admission to the NICU in the UK may explain why neonatal mortality is higher in the UK. See page F212
About 1 in 4 newborns in the UK and 1 in 3 in the US are born by caesarean section. The rate continues to increase. Liston and colleagues from Nova Scotia describe neonatal outcomes following 142 971 deliveries, of which 27 263 were caesarean. Pasupathy and Smith, from the Department of Obstetrics and Gynaecology, Cambridge, UK, add their thoughts about this issue. See pages F174 and F176
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