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In a leading article Mary Ramsey (Public Health, England) discusses the important and ever relevant topic of measles immunisation and the legacy of low vaccine coverage. The initial focus is to remind/educate the reader of the seriousness of measles infection (150 000 deaths per year worldwide) and the importance and potential success of widespread immunisation. Measles immunisation was introduced in the UK in 1968 (the MMR being introduced in 1988) with high initial coverage (>90%, dramatic fall in cases of measles) until the early 2000s when because of a potential link with autism uptake fell significantly (<80% in under 2's in London, 2003/4). This has since largely recovered (92.4% under 2 years, 2012) but the legacy—discussed at length in the article—is the unvaccinated cohort and the large outbreaks in populations with low coverage in 2006/7 and since then in 2011/2012 a sustained increase in cases of measles (1920 confirmed cases in England, 2012; 1163 in the first 5 months of 2013) with a shift in age group affected towards 10 to 14 year olds. The crucial importance of catch up immunisation is emphasised, supported by the recent MMR catch up programme initiated in the UK.
The article puts the issues with measles immunisation into a clear and focussed historical context with a clear message for action now which is supported by the Royal College of Paediatrics and Child Health who have written to all members urging them to use every opportunity to promote vaccination with their patients and their families. See page 752.
Diagnosing coeliac disease
Screening data suggests a 1% incidence of coeliac disease with only 10–20% being diagnosed in the UK. There are multiple potential presentations including overt gastrointestinal symptoms, no gastrointestinal symptoms and diagnosis as a consequence of screening high risk cases. Murch and colleagues report the new UK guidance highlighting the complexities of presentation, strategies for diagnosis and priorities in management. New diagnostic algorithms include the potential to avoid the biopsy in selected cases in whom serology and HLA type is informative. The authors emphasise however that in most cases biopsy is still required and that gluten free diets should not be started until a definitive diagnostic algorithm has been followed by a specialist in the diagnosis and management of this (very) common condition. See page 806.
Managing self harm
Ten per cent of adolescents will have self harmed by the time they finish secondary school and 10% of the adolescents who engage in self harm will repeat self-harm within a year. Hospital admission is common and engagement with treatment is poor. Ougrin and colleagues report the 24 month outcome of a randomised trial of therapeutic (significantly more detailed/family inclusive) versus usual assessment in adolescents with self harm. 69 adolescents completed the study. 20 reported between 1 and 129 episodes of repeat self harm in the first year, 14 reported between 1 and 144 episodes in the second year. Repeat self harm, as the primary outcome, was equal in both groups (OR 0.69, 95% CI 0.23 to 2.13). Engagement with treatment was better in the therapeutic assessment group. The sample size limits sub group analysis. The findings are nevertheless interesting and important and discussed in an accompanying editorial by David Cottrell who discusses the challenges of engaging young people in treatment after self-harm. See pages 772 and 749.
Nutritional content of commercial weaning foods
We are often asked by parents for advice the introduction of solids, recommended from 6 months, although often given earlier. Commercial weaning foods are used as the first ‘solids’ in two thirds of infants in the UK. Garcia and colleagues describe the types of commercial infant foods available in the UK and report an overview of their taste, texture and nutritional content. 479 products were identified from six suppliers. 79% were ready made ‘spoonable’ foods, 44% were aimed at infants from 4 months and 65% were sweet. Mean energy content per 100 mL of ready-made spoonable feeds was similar to breast milk/commercial formula. The nutrient and energy content of family home made weaning foods (the article includes simple recipes) is significantly higher. The authors conclude that the majority of commercial weaning foods will not serve the intended purpose of enhancing the nutrient density, taste and texture in infants’ diets. Home made weaning solids should be encouraged! See page 793.
Respiratory problems in Down's syndrome
Respiratory disease is a common cause of morbidity and mortality in children with Down's syndrome. Watts and colleagues present a comprehensive overview of the many potential pathologies. The authors include conditions directly related to the respiratory tract including structural problems, airway narrowing, sleep-related breathing disorders and lower respiratory tract disease. The authors also cover diseases of other systems which impact on the respiratory tract including cardiac disease, pulmonary vascular disease and gastrointestinal disorders. The review gives clear and practical recommendations and will aid the reader in the assessment and management of children with Down's syndrome and respiratory symptoms. See page 781.
In E&P this month
We launch ‘Equipped’, a new series of articles on quality improvement with a comprehensive introduction to the subject by the series adviser Robert Klaber. Further articles will follow covering essential aspects of this new specialist area for the busy clinician with practical guidance for implementation. There is also a further article in the recently launched Research in Practice series on ethics and the ethics committee. This is in addition to the usual best practice articles (introduction to immunodeficiency, 15 min consultation on headache in the under 5's), series of pickets, challenging dermatophile and problems solving case.
Finally this month
I would like to pay tribute to Dr Doug Addy, paediatrician, responsible for the Archivist and Lucina series, who has retired from that role. Along with all of our readers I wanted to thank him for his enthusiasm, commitment and engaging style in highlighting articles from the literature of importance and relevance to the readership over many years.