Robert Moy

Supplementation with antioxidants and folinic acid for children with Down’s syndrome: randomised controlled trial

Objectives To assess whether supplementation with antioxidants, folinic acid, or both improves the psychomotor and language development of children with Down’s syndrome. Design Randomised controlled trial with two by two factorial design. Setting Children living in the Midlands, Greater London, and the south west of England. Participants 156 infants aged under 7 months with trisomy 21. Intervention Daily oral supplementation with antioxidants (selenium 10 μg, zinc 5 mg, vitamin A 0.9 mg, vitamin E 100 mg, and vitamin C 50 mg), folinic acid (0.1 mg), antioxidants and folinic acid combined, or placebo. Main outcome measures Griffiths developmental quotient and an adapted MacArthur communicative development inventory 18 months after starting supplementation; biochemical markers in blood and urine at age 12 months. Results Children randomised to antioxidant supplements attained similar developmental outcomes to those without antioxidants (mean Griffiths developmental quotient 57.3 v 56.1; adjusted mean difference 1.2 points, 95% confidence interval −2.2 to 4.6). Comparison of children randomised to folinic acid supplements or no folinic acid also showed no significant differences in Griffiths developmental quotient (mean 57.6 v 55.9; adjusted mean difference 1.7, −1.7 to 5.1). No between group differences were seen in the mean numbers of words said or signed: for antioxidants versus none the ratio of means was 0.85 (95% confidence interval 0.6 to 1.2), and for folinic acid versus none it was 1.24 (0.87 to 1.77). No significant differences were found between any of the groups in the biochemical outcomes measured. Adjustment for potential confounders did not appreciably change the results. Conclusions This study provides no evidence to support the use of antioxidant or folinic acid supplements in children with Down’s syndrome. Trial registration Clinical trials NCT00378456.

Successful public health action to reduce the incidence of symptomatic vitamin D deficiency

Background In response to a resurgence of symptomatic cases of vitamin D deficiency in a high-risk predominantly ethnic minority population, a programme of universal rather than targeted vitamin D supplementation was begun with a public awareness campaign about the importance of vitamin D. Objective To evaluate the effectiveness of this programme in reducing case numbers. Methods Cases of symptomatic vitamin D deficiency in children under 5 years resident in a primary care trust catchment area presenting at local hospitals were identified through laboratory records of low vitamin D levels which were cross-checked against medical records to confirm the diagnosis. Comparisons were made of the case incidence rate, level of public knowledge and vitamin supplement uptake rate at the onset of the programme in 2005 and 4 years later. Results The number of cases of symptomatic vitamin D deficiency in those under 5 years fell by 59% (case incidence rate falling from 120/100 000 to 49/100 000) despite the supplement uptake rate rising only to 17%. Public awareness of vitamin D deficiency rose to near universal levels. Conclusions A programme of universal rather than targeted Healthy Start vitamin D supplementation for pregnant and lactating women and young children has led to a substantial decrease in cases of symptomatic vitamin D deficiency in a high-risk population. Supplementation was also started at a younger age than in the national programme. This approach has implications for the delivery of vitamin D supplementation programmes in similar populations.

Designing new UK‐WHO growth charts: implications for health staff use and understanding of charts and growth monitoring

New pre-school UK charts have been produced incorporating the new World Health Organization growth standards based on healthy breastfed infants. This paper describes the process by which the charts and evidence-based instructions were designed and evaluated, and what it revealed about professional understanding of charts and growth monitoring. A multidisciplinary expert group drew on existing literature, new data analyses and parent focus groups as well as two series of chart-plotting workshops for health staff. The first series explored possible design features and general chart understanding. The second evaluated an advanced prototype with instructions, using plotting and interpretation of three separate scenarios on the old charts, compared with the new charts. The first plotting workshops (46 participants) allowed decisions to be made about the exact chart format, but it also revealed widespread confusion about use of adjustment for gestation and the plotting of birthweight. In the second series (78 participants), high levels of plotting inaccuracy were identified on both chart formats, with 64% of respondents making at least one major mistake. Significant neonatal weight loss was poorly recognized. While most participants recognized abnormal and normal growth patterns, 13-20% did not. Many respondents had never received any formal training in chart use. Growth charts are complex clinical tools that are, at present, poorly understood and inconsistently used. The importance of clear guidelines and formal training has now been recognized and translated into supporting educational materials (free to download at http://www.growthcharts.rcpch.ac.uk).

Risk factors for high diarrhoea frequency: a study in rural Zimbabwe

Diarrhoea morbidity data were collected prospectively over 22 months from a cohort of young children living in a deprived community in rural Zimbabwe. Despite the general high prevalence of diarrhoeal disease, there was considerable individual variability in attack rates. Risk factors associated with high diarrhoea frequency were therefore sought by a questionnaire study on feeding, environmental, educational and socio-economic factors. This was supported by observation of living conditions, and water and sanitation facilities. Surprisingly, no association was found between diarrhoeal morbidity and any of these factors, suggesting that other factors such as individual hygiene behaviour or individual susceptibility to diarrhoea may play a role in determining the observed differences in diarrhoea rates in this community.

Nutritional Iron Deficiency in Early Childhood

• The true prevalence of nutritional iron deficiency (ID) in childhood is unclear because of the uncertainty over its definition and the insensitivity of markers of ID.

Anemia is an important finding and is likely to respond to iron therapy

We thank Dr Carron for his comments on our study.1 His main concern was the accuracy of the diagnosis of otitis media. Although it was not explicitly stated in our report, all the children had tympanostomy tubes, which made the diagnosis straightforward because it invariably involved discharge from the tympanostomy tube. Some children had lost their tympanostomy tubes during the follow-up period, but adenoidectomy did not prevent the need for reinsertion of tympanostomy tubes. Dr Carron suggested that children who have had adenoidectomy because of obstructive symptoms should have been included in our study. Such children, however, benefit from adenoidectomy irrespective of middle ear disease, because adenoidectomy will enable normal nasal breathing. Therefore, these children were excluded from our study. Comparisons of such children with our study children with recurrent otitis media would have been difficult, because they have different diseases. In some children, adenoids may be infected chronically and serve as a source of pathogenic bacteria, presumably predisposing to otitis media. This may explain why adenoidectomy was beneficial in earlier studies of children who were mainly older than 4 years and who had previously received tympanostomy tubes2 and in children who suffered from persistent middle ear disease.3,4 It may be presumed that these children had had infections starting from their infancy, which allowed a chronic infection to develop in their adenoids. However, this is entirely hypothetical, and it is quite vague to call adenoidectomy “therapeutic” without gross adenoid enlargement. Dr Carron also questioned what would happen to the child when the tympanostomy tubes fall out and the child is reliant on his or her own ventilation system again. The focus of such a study should involve only those children who have middle ear disease after the initial or even secondary insertion of tympanostomy tubes, as has been evaluated in an earlier study.2 He stated that “tympanostomy tubes are great for preventing ear infections.” This certainly is not an evidence-based fact at all, because the effect of tympanostomy tubes for preventing otitis media is at its best quite modest5 and is not “preventing most ear infections anyway.” Because children who are younger than 4 years and who do not suffer from gross adenoid enlargement comprise the vast majority of children with middle ear infections, it is especially important to evaluate the effect of adenoidectomy in this very population. As our study showed, adenoidectomy failed to produce any additional benefit in preventing otitis media.