I read with interest the recent paper on "Pancreatic dysfunction in severe obesity" by Drake et al where they identified one obese Caucasian adolescent with type II diabetes.[1] All previously reported cases of Type II diabetes in adolescents in the United Kingdom have been amongst ethnic minority groups especially Asian patients.[2][3] I wish to report another case of type II diabetes in a young British Caucasian girl.

AJ presented at the age of 13 years. She was asymptomatic but was referred because a random blood sugar done by the GP was found to be elevated at 12.9mmol/L. She was obese, BMI 36 (>99.6th centile for age), not dysmorphic, no Acanthosis Nigricans, and normotensive. She was known to have undergone valvotomy for pulmonary stenosis but was not on any medication. Her mother had type II diabetes diagnosed at the age of 27 years.

Investigations showed hyperglycaemia with hyperinsulinaemia
Fasting blood sugar: 11.1 mmol/L
Fasting C peptide: 2198 pmol/L
Fasting insulin: 553.0 pmol/L
Fasting Pro-insulin: 177 pmol/l (normal <_10 pmol="pmol" l="l" br="br"/>Islet cell antibody screen was negative
Normal fasting cholesterol and triglycerides
Her pre-meal blood sugar profile during the day was between 7.9 - 14 mmol/L.

Management consisted of encouraging change in lifestyle with emphasis on healthy eating and regular exercise. She continues to receive regular dietary advice. She was started on Metformin 500mg bd. Her blood sugar profile improved. Her current HbA1c after 3 months of therapy is 7.5%.

With increasing prevalence of obesity in all ethnic groups in this country, we may begin to see more cases of type II diabetes amongst the Caucasian population too. Risk factors appear to be the presence of obesity, Acanthosis Nigricans and family history of diabetes. Type I diabetes however, remains the commonest type of diabetes in the paediatric population.

Dr J C Agwu
Consultant Paediatrician
Sandwell Healthcare NHS Trust
West Bromwich B71 4HJ, UK References

(1) Drake AJ, Greenhalgh L, Newbury-Ecob R, et al, Pancreatic dysfunction in severe obesity. Arch Dis Child 2001;84:261-2.

(2) Etisham S, Barnett Y Gm Shaw N J. Type II diabetes Mellitus in UK Children - an energy problem. Diabet Med 2000;17(12):867-71.

(3) Ng GYT, Burren CP. Type II diabetes in adolescence unearthed at the time of registration with the general practitioner (G.P). Practical Diabetes 2000;17:273-4.

Dear Editor:

Stewart-Brown's paper on the compatibility of medical practice in community paediatrics with that in public health[1] is a superlative effort. This is more so as it has come at a time when community paediatrics is being actively discussed by the RCPCH (UK Royal College of Paediatrics and Child Health) for a variety of reasons but, perhaps, most importantly because it does not seem to attract enough specialist registrars.

It can be argued that all paediatricians (just not community paediatricians) can and do play an important role in child advocacy issues at various levels. From the clinical perspective the community paediatric role in immunisation and child health surveillance is the most important.

Trainees in paediatrics need to recognize that child public health is a small (albeit important) role of the community paediatricians. The bulk of community paediatricians are neurodevelopmental specialists. Many have an important role in child protection. Some community paediatricians are developing a behavioural paediatric interest in their clinical practice.

Most districts in the UK need their community paediatricians to look after families with children with disabilities. Some districts (like ours) need them to offer outpatient epilepsy services as well. With increasing prevalence of behavioural problems in children, many community paediatricians have trained (or retrained) themselves to cater to this need. Useful links with child psychiatric and psychology colleagues have been forged. In fact, our counterparts in the US are called developmental and behavioural paediatricians and their core curriculum reflects the depth of training offered for both these domains.[2]

There is no doubt, therefore, that the term “community paediatrics” is a misnomer and may not offer confidence to the budding specialist registrar who may find being a neurologist or an oncologist a better bet. There is increasing specialism within community paediatrics, and the job title needs to reflect that expertise.

It is very possible that a small minority of (community) paediatricians may chose to train with a major public health interest. It may be helpful to know that the American Acdemy of Pediatrics has a section for paediatricians with this interest.[2] The bulk should continue (to train and practice) with a major clinical interest and that should be an important selling point for community paediatrics. Hopefully job titles in the future will reflect the clinical expertise. This will not only help trainees but also purchasers, referers and the families we serve.

This letter is not meant to be in any way critical of Dr Stewart-Brown’s paper which, in fact has highlighted the importance of public health medicine for (community) paediatricians. Health promotion is indeed a skill that can be applicable easily in clinical practice.

Dr Ashok Nathwani
Consultant (Community) Paediatrician
Portsmouth, UK

References

(1) Stewart-Brown S. Is the ethos of medical practice in community paediatrics compatible with that in public health? Arch Dis Child 2000;83:101-3.

(2) Section on Community Pediatrics, American Acdemy of Pediatrics, http://www.aap.org/commpeds/ [accessed 3 Aug 2000].

In response to the short report of Brogan and Raffles.[1]

Although studies on children with petechiae who appear clinically unwell are important, the management of such children should pose few dilemmas in deciding to treat for presumed sepsis. A more challenging group is those with petechiae who appear to be well. We feel this group generates anxiety for clinicians who worry about missing occult or early sepsis.

To address this question, we retrospectively identified from a 1 year period, all children who presented with petechiae to our emergency department.

We wanted to focus in particular on well, afebrile children with petechiae of unknown cause. Therefore, unlike Brogan and Raffles, we excluded those at the time of presentation thought to have clinical sepsis, those with idiopathic thrombocytopaenic purpura or Henoch- Schonlein purpura and those with suspected non-accidental injury. We also excluded febrile children, but unlike Brogan and Raffles, we defined fever as a temperature of 38C or more (in accordance with the study of Mandl et al [2], the largest prospective study to-date on the incidence of sepsis associated with petechiae).

31 well, afebrile children with petechiae were identified. Each had comments in their notes like 'appears well' and the diagnosis for each was 'viral illness', plus or minus mechanical causes for petechiae. In addition, objective criteria such as pulse oximetry, capillary refill time and blood pressure were all normal. Having identified this cohort, we reviewed laboratory data and outcome for each child.

10 children were less than one year, 10 between one and five years and 11 over five years. 19 had blood cultures done - all negative. 9 of these also had meningococcal PCR done - all negative. Of the 12 without blood cultures, 1 had meningococcal PCR done, which was negative. 27 had full blood counts - 3 showed an elevated white cell count and none had low white cell counts. 19 had C-reactive protein measured, 9 of which were elevated. 12 children were admitted - all remained well (despite this 9 were given antibiotics, which were discontinued after 48 hours). 19 were discharged, having received no antibiotics. As far as we are aware, no children subsequently developed clinical sepsis.

The results of our study are in keeping with those of Mandl et al [2], who found the incidence of clinical sepsis amongst (febrile) children with petechiae, who appeared well at the time of presentation, to be nil.

Furthermore, our study shows that management of well children with petechiae is highly variable. Lack of consensus among paediatricians on the management of petechial rashes has been well documented [3]. In our own department, we are considering implementation of the following guidelines for the management of well, afebrile children with petechiae, although we acknowledge that larger prospective studies are required.

1. That such children be observed in the emergency department for 4 to 6 hours and if they remain clinically well and afebrile, discharge without antibiotics would be safe.

2. Laboratory investigation is probably unnecessary, unless indicated to exclude ITP.

Yours sincerely,

Malcolm Jones and Stephen Goldring, formerly SHOs in paediatric A&E, University Hospital, Lewisham

Tina Sajjanhar, Consultant in paediatric A&E, University Hospital, Lewisham

References

(1) The management of fever and petechiae: making sense of rash decisions. Brogan and Raffles, Archives of Disease in Childhood 2000; 83: 506-507

(2) Incidence of bacteraemia in infants and children with fever and petechiae. Mandl et al, The Journal of Pediatrics 1997; vol 131, no.3: 398-404

(3) Evaluation of febrile children with petechial rashes: is there consensus among paediatricians? Nelson et al, The Pediatric Infectious Disease Journal 1998; vol 17, no. 12: 1135-1140

Dear Editor:

Partsch and colleagues speculate that a rise in testicular temperature in infants and young children consequent to the wearing of modern plastic lined disposable nappies [diapers] may have contributed to both the fall in sperm counts and the increase in testicular cancer which have been reported in some countries.[1] In support of this hypothesis Partsche et al refer to reports of rising incidence rates in testicular cancer.[2-6] These studies report increased cancer risk in men born from before 1900 to 1988 diagnosed up to 1988, from 1916 to 1978, before 1970, from 1907 to 1981, and from 1865 to 1975, respectively. None reports incidence of testicular cancer in men who have had the opportunity to wear modern disposable nappies which have only been widely available since the late 1970s. There is some suggestion that the rise in testicular cancer may not be continuing.[7]

There are no data on testicular cancer incidence in men who are likely to have worn modern disposable nappies as the peak age for this disease is the late 20s and the men are simply too young. Similarly, the reports of a declining sperm count do not include any men born after 1975,[8-11] and even the most recent study from Denmark includes men born only before 1978.[12]

There is no way that modern disposable nappies could have contributed to the changes in male gonadal health reported in men observed to date since all studies are of men who were born before they were available.

Partsch et al[1] claim that the scrotal cooling mechanism was often completely abolished in boys wearing modern disposable nappies. This would appear to be over-interpretation of the data they had available, for two reasons. Firstly, they compared 24-hour mean scrotal temperature with spot rectal temperature and were unable to take into account the considerable circadian variation in core temperature in infants.[13] Secondly, they used measurement techniques validated in adults but not in nappy-wearing infants. They have not demonstrated that their methods, which included covering a considerable portion of the scrotal surface with adhesive tape, did not interfere with two aspects of scrotal cooling, ie, evaporation from the skin surface and contraction and relaxation of the scrotal sac. There is the very real possibility that the measurement process itself increased scrotal temperatures in all children.

There are several inconsistencies in the results table (table 1 in the paper by Partsch et al)[1]; for example, the mean temperatures and the calculated difference between temperatures measured with modern plastic lined disposable nappies and cotton nappies can not be reconciled, which the authors may wish to clarify.[1]

Further scientific research is clearly needed to establish the normal range of temperatures in infant testes and the extent to which they may be affected by different types of nappies and also the extent to which any changes may affect testicular health. However, it is clear that modern plastic lined disposable nappies can have played no role in the changes in male gonadal health reported worldwide to date.

References
1. Partsch C-J, Aukamp M and Sippell WG. Scrotal temperature is increased in disposable plastic lined nappies. Arch Dis Child 2000;83:364-8.

2. Adami H, Bergström R, Möhner M, et al. Testicular cancer in nine northern European countries. Int J Cancer 1994;59:33-8.

3. Forman D, Möller H. Testicular cancer. Cancer Surv 1994;19-20:323-41.

4. Hoff Wanderas E, Tretli S, Fossa SD. Trends in incidence of testicular cancer in Norway 1955-1992. Eur J Cancer 1995;31A:2044-8.

5. Weir HK, Marrett LD, Moravan V. Trends in the incidence of testicular germ cell cancer in Ontario by histologic subgroup, 1964-1996. CMAJ 1999;160:201-5.

6. Zheng T, Holford TR, Ma Z, Ward BA, Flannery J, Boyle P. Continuing increase in incidence of germ-cell testis cancer in young adults: experience from Connecticut, USA, 1035-1992. Int J Cancer 1996;65:723-9.

7. Andersen AG, Jensen TK, Carlsen E, et al. High frequency of sub-optimal semen quality in an unselected population of young men Hum Reprod 2000;15:366-72.

8. Auger J, Kunstmann JM, Czyglik F, Jouannet P. Decline in semen quality among fertile men in Paris during the past 20 years. N Engl J Med 1995;332:281-5.

9. Benshushan A, Shoshani O, Paltiel O, Schenker JG, Lewin A. Is there really a decrease in sperm parameters among healthy young men? A survey of sperm donations during 15 years. J Assist Reprod Genet 1997;14:347-53.

10. Carlsen E, Giwercman A, Keiding N, Skakkebaek NE. Evidence for decreasing quality of semen during past 50 years. BMJ 1992;305:609-13.

11. Irvine S, Cawood E, Richardson D, MacDonald E, Aitken J. Evidence of deteriorating semen quality in the United Kingdom: birth cohort study in 577 men in Scotland over 11 years. BMJ 1996;312:467-71.

12. Pharris-Ciurej ND. Cook LS. Weiss NS. Incidence of testicular cancer in the United States: has the epidemic begun to abate?. Am J Epidemiol 1999;150:45-6.

13. Wailoo MP. Petersen SA. Whittaker H. Goodenough P. Sleeping body temperatures in 3-4 month old infants. Arch Dis Child 1989;64:596-9.

Conflict of Interest
I have provided advice on scientific and epidemiological aspects of this study to 2 trade associations which act on behalf of modern plastic lined disposable nappy manufacturers EDANA and AHPMA.