While having some sympathy with Drs Wynne and Speight over the despair that they feel about the containment of child neglect and abuse, the answer surely cannot be the wholesale transfer of children from the frying pan of their own homes (one notes that the West children remained in a way fond of their father despite truly appalling treatment at his hands) to the fire of local authority institutions staffed by paedophiles or unsuitable and stop-gap fostering. The problem is perhaps essentially insoluble, given its nature and the way in which our resources are made available and deployed -as in the case of imprisonment for offenders; and occasional exceptions merely prove statistical rules. But to reduce the numbers of children in such straits may require changes in our whole culture; which may not only be impossible to achieve but might do more harm than good by rescuing the unlucky 10% at the cost of no longer taking the well being of the 90% for granted, as one should be able to do. Nor does the insinuation of best practice necessarily work since it so much depends on the enthusiasm, dedication and idealism of those who have developed it which is usually the kernel of their achievement while what can be described and specified is only the husk.

It is surely unacceptable that in a grossly overpopulated world with over exploited resources and with the availability of effective birth control children are still being born whose parents don't want them, can't provide for them or, instead of rearing them properly, abuse and exploit them - while at the same time we spend a lot of public money on the treatment of infertility. A pseudo Darwinian free for all mitigated by charity is not the answer in that in a struggle for survival the survivors are often damaged without necessarily any culling of the unfit in terms of the qualities that are needed to promote the kind of world we want and strive for; yet we rightly cannot bring ourselves to manage society like an ant heap. It could be that make do and mend is the best way forward; relying on those in the front line - like Drs Wynne and Speight - for guidance on how best to use limited resources.

Yours faithfully

Professor John Davis

Hodge et al(1) draw our attention to the possible association of hypogammaglobulinemia and global lymphopenia with Proteus syndrome. They suggest that this may be secondary to loss of immunoglobulins and lymphocytes into lymphoedematous tissue. We have seen a similar phenomenon in a child with massive cystic hygroma in the neck. Immunological investigations showed persistent severe lymphopenia with low levels of all lymphocyte subsets. Lymphocyte proliferative responses to PHA were normal as were immunoglobulin levels and antibody responses to protein (diphtheria and tetanus toxoid) and polysaccharide (haemophilus b) vaccines. He initially suffered recurrent chest and skin infections and oral candidiasis but this responded well to treatment with prophylactic cotrimoxazole and nystatin mouthwashes. As in their case, we feel we may have been observing peripheral sequestration of circulating lymphocytes in this case and that, as a consequence, the clinical phenotype was milder than one would have expected in a child with similar results but caused by failure of lymphocyte production. We would like to extend their suggestion for immunological investigations in Proteus syndrome to other children with large lymphatic malformations.

1. Hodge D, Misbah SA, Mueller RF, Glass EJ, Chetcuti PAJ. Proteus syndrome and immunodeficiency. Arch Dis Child 2000;82:234-235

I recognise that Drs. Speight and Wynne, wrote an unbalanced article (Is the Children Act failing severely abused and neglected children) to encourage discussion but I expect more respect for evidence in Archives of Disease in Childhood.

I could trade insults based on factual inaccuracies (the Children Act was enacted in 1989 not 1990 and implemented in 1991), selective and inaccurate references and many unsupported statements that largely ignore counter-indicators. But insults would obscure the important point.

The Children Act is framework legislation. It does not dictate practice but sets a framework sufficiently flexible to adapt to new ideas. If evidence shows that removing more children from their relatives will result in greater child protection, the Act will permit such a change in emphasis.

The child protection field lacks reliable evidence about what works, for whom, when and why. Into this vacuum floods completely inconsistent ideology and rhetoric. Practitioners are criticised one week for doing too little, the next for being over reactive.

Would a greater willingness to prosecute parents, intervene in family life and remove children lead to better outcomes for victims of maltreatment? I do not know. I could produce a learned, properly referenced article giving the pros and cons. Can the state parent better than an errant parent? The answer is sometimes 'yes', sometimes 'no'. Evidence from the United States, probably the most interventionist of western developed countries and almost certainly the least effective in protecting children urges caution.

We need less rhetoric and more evidence. The struggle is to find out what works in the protection of children and to encourage the consistent application and re-evaluation of that technology. Arguing whether to remove more or fewer children is pointless. Thinking about what we do when we are responsible for supporting these children is the key. The Children Act encourages reflection and will allow implementation of results, whether they be for or against the views of Drs Speight and Wynne.

Michael Little, Ph.D. Co-director Dartington Social Research Unit, Research Fellow, Chapin Hall Center for Children at The University of Chicago