Stuart Logan

Association of common health symptoms with bullying in primary school children

Abstract Objectives: To estimate the prevalence of bullying in primary school children and to examine its association with common symptoms in childhood. Design: Semistructured health interview conducted by school nurses as part of a school medical. Setting: Newham, east London. Subjects: All children in year 4 of school during the academic year 1992-93. Main outcome measures: Reported bullying and common health symptoms. Results: 2962 children (93.1% of those on the school roll) were interviewed (ages 7.6 to 10.0 years). Information about bullying was not recorded for 114 children. 22.4% (95% confidence interval 20.9 to 24.0) of children for whom information was available reported that they had been bullied. There was an association between children reporting being bullied sometimes or more often and reporting not sleeping well (odds ratio 3.6, 2.5 to 5.2), bed wetting (1.7, 1.3 to 2.4), feeling sad (3.6, 1.9 to 6.8), and experiencing more than occasional headaches (2.4, 1.8 to 3.4) and tummy aches (2.4, 1.8 to 3.3). A significant trend for increasing risk of symptoms with increased frequency of bullying was shown for all reported health symptoms (P<0.001). Conclusions: Health professionals seeing primary schoolchildren who present with headaches, tummy ache, feeling sad or very sad, bed wetting, and sleeping difficulties should consider bullying as a possible contributory factor. Key messages Many children report having frequent headaches or tummy aches, that they sleep poorly, wet the bed, or feel sad Children who report these symptoms also report being bullied substantially more often than do their peers Although it is not clear whether the association is causal, health professionals seeing such children should ask about bullying

Risk, causes, and outcomes of visual impairment after loss of vision in the non-amblyopic eye: a population-based study.

BACKGROUND Screening for amblyopia in early childhood is done in many countries to ensure that affected children are detected and treated within the critical period, and achieve a level of vision in their amblyopic eye that would be useful should they lose vision in their non-amblyopic eye later in life. We aimed to investigate the risk, causes, and outcomes of visual impairment attributable to loss of vision in the non-amblyopic eye. METHODS For 24 months from July, 1997, national surveillance was done to identify all individuals in the UK with unilateral amblyopia (acuity worse than 6/12) who had newly acquired vision loss in the non-amblyopic eye, resulting in acuity of worse than 6/12 or visual-field restriction precluding driving. Information about participants was obtained at presentation and 1 year later. Participants were categorised as having socially significant visual impairment, or visual impairment, severe visual impairment, or blindness, in accordance with WHO taxonomy. FINDINGS Of 370 eligible individuals, at presentation 104 (28%) had socially significant visual impairment, 180 (49%) visual impairment, and 86 (23%) severe visual impairment or blindness. The minimum risk of permanent visual impairment by age 95 years was 32.9 (95% CI 29.1-36.9) per 100,000 total population. The projected lifetime risk of vision loss for an individual with amblyopia was at least 1.2% (95% CI 1.1-1.4). Only 36 (35%) of 102 people previously in paid employment were able to continue. INTERPRETATION In the UK, where screening for amblyopia is under review, risk of serious vision loss affecting the non-amblyopic eye and its results are greater than that previously assumed. Thus, in addition to the benefits of improved vision in the amblyopic eye, treatment of amblyopia during childhood is a potentially valuable strategy to prevent incapacitating vision loss later in life.

Disabling Conditions and Registration for Child Abuse and Neglect: A Population-Based Study

Objective. To study the relationship between disabling conditions and registration for child abuse and neglect in a 19-year whole-population birth cohort Setting. West Sussex area of the United Kingdom. Study Design. Retrospective whole-population cohort. Main Outcomes. Child-protection registration, physical abuse, sexual abuse, emotional abuse, and neglect. Population and Participants. Infants born in West Sussex (119729) between January 1983 and December 2001 with complete data including birth weight, gestational age, maternal age, and postal code. Results. Cerebral palsy, speech and language disorder, learning difficulties, conduct disorders, and nonconduct psychological disorders were all significantly associated with child-protection registration before adjustment, and all but cerebral palsy retained significance after adjustment for birth weight, gestational age, and socioeconomic status. Autism and sensory disabilities (vision and hearing) were not associated with an increased risk of child-protection registration. Conduct disorders and moderate/severe learning difficulty were associated with registration in each of the 4 categories after adjustment for socioeconomic status, birth weight, and gestational age. Children with speech and language disorders and mild learning difficulties were at increased risk of physical abuse, emotional abuse, and neglect. Nonconduct psychological disorders were associated with all categories except neglect, and cerebral palsy was associated with all categories except physical abuse and neglect. Conclusions. Children with disabling conditions seem to be at increased risk of registration for child abuse and neglect, although the pattern of registration varies with the specific disabling condition. The strong association with registration noted for conditions such as conduct disorder and learning difficulties is likely to arise, in part, because these conditions share a common etiologic pathway with child abuse and neglect.

Is routine growth monitoring effective? A systematic review of trials

BACKGROUND Growth monitoring consists of routine measurements to detect abnormal growth, combined with some action when this is detected. It aims to improve nutrition, reduce the risk of death or inadequate nutrition, help educate carers, and lead to early referral for conditions manifest by growth disorders. As primary care workers world wide invest time in this activity, evidence for its benefits and harms was sort. INCLUSION CRITERIA Studies: randomised or quasi-randomised controlled trials of growth monitoring. Interventions: regular growth monitoring, combined with some intervention targeted at abnormal growth, compared with controls. Outcomes: anthropometric measures; referrals to primary and specialist care, or community services; maternal knowledge, anxiety, and satisfaction; child morbidity and mortality. COMPARISONS Routine growth monitoring compared with no routine growth monitoring; routine growth monitoring by plotting onto a standard chart compared with monitoring with no chart. SEARCH STRATEGY Cochrane controlled trials register; World Health Organisation and World Bank publications; contact with specialist community paediatricians working in the field. RESULTS Two trials met the inclusion criteria. One compared growth monitoring with no growth monitoring, in a cluster randomised trial nested in a nutritional intervention programme, and detected no difference in nutritional outcomes between the two groups. Another trial compared growth monitoring with and without a standard chart, measuring maternal knowledge of women about nutrition. It showed small numerical differences in test scores. DISCUSSION AND IMPLICATIONS Current policies appear to be based on the opinion that investment in the activity has worthwhile health benefits, and does no harm. No reliable evidence was found to support or refute this.

Screening of newborn infants for cholestatic hepatobiliary disease with tandem mass spectrometry

Abstract Objective: To assess the feasibility of screening for cholestatic hepatobiliary disease and extrahepatic biliary atresia by using tandem mass spectrometry to measure conjugated bile acids in dried blood spots obtained from newborn infants at 7-10 days of age for the Guthrie test. Setting: Three tertiary referral clinics and regional neonatal screening laboratories. Design: Unused blood spots from the Guthrie test were retrieved for infants presenting with cholestatic hepatobiliary disease and from the two cards stored on either side of each card from an index child. Concentrations of conjugated bile acids measured by tandem mass spectrometry in the two groups were compared. Main outcome measures: Concentrations of glycodihydroxycholanoates, glycotrihydroxycholanoates, taurodihydroxycholanoates, and taurotrihydroxycholanoates. Receiver operator curves were plotted to determine which parameter (or combination of parameters) would best predict the cases of cholestatic hepatobiliary disease and extrahepatic biliary atresia. The sensitivity and specificity at a selection of cut off values for each bile acid species and for total bile acid concentrations for the detection of the two conditions were calculated. Results: 218 children with cholestatic hepatobiliary disease were eligible for inclusion in the study. Two children without a final diagnosis and five who presented at <14 days of age were excluded. Usable blood spots were obtained from 177 index children and 708 comparison children. Mean concentrations of all four bile acid species were significantly raised in children with cholestatic hepatobiliary disease and extrahepatic biliary atresia compared with the unaffected children (P<0.0001). Of 177 children with cholestatic hepatobiliary disease, 104 (59%) had a total bile acid concentration >33 μmol/l (97.5th centile value for comparison group). Of the 61 with extrahepatic biliary atresia, 47 (77%) had total bile acid concentrations >33 μmol/l Taurotrihydroxycholanoate and total bile acid concentrations were the best predictors of both conditions. For all cholestatic hepatobiliary disease, a cut off level of total bile acid concentration of 30 μmol/l gave a sensitivity of 62% and a specificity of 96%, while the corresponding values for extrahepatic biliary atresia were 79% and 96%. Conclusion: Most children who present with extrahepatic biliary atresia and other forms of cholestatic hepatobiliary disease have significantly raised concentrations of conjugated bile acids as measured by tandem mass spectrometry at the time when samples are taken for the Guthrie test. Unfortunately the separation between the concentrations in these infants and those in the general population is not sufficient to make mass screening for cholestatic hepatobiliary disease a feasible option with this method alone. Key messages The prognosis of cholestatic hepatobiliary disease in infancy, in particular biliary atresia, is improved by early detection Infants destined to present with cholestatic jaundice in the first few months of life have raised concentrations of bile acids in the blood spots obtained at 7-10 days for current neonatal screening programmes Tandem mass spectrometry can be used to detect this marker of neonatal cholestasis Unfortunately there is too much overlap between bile acid concentrations in infants with cholestasis and those in control infants for this to be used as a single screening test for cholestatic hepatobiliary disease in general and biliary atresia Tandem mass spectrometry is a powerful tool for neonatal screening but every potential application must be carefully assessed

Screening for Down's syndrome: effects, safety, and cost effectiveness of first and second trimester strategies

OBJECTIVE To compare the effects, safety, and cost effectiveness of antenatal screening strategies for Downs syndrome. DESIGN Analysis of incremental cost effectiveness. SETTING United Kingdom. MAIN OUTCOME MEASURES Number of liveborn babies with Downs syndrome, miscarriages due to chorionic villus sampling or amniocentesis, health care costs of screening programme, and additional costs and additional miscarriages per additional affected live birth prevented by adopting a more effective strategy. RESULTS Compared with no screening, the additional cost per additional liveborn baby with Downs syndrome prevented was 22 000 pound sterling for measurement of nuchal translucency. The cost of the integrated test was 51 000 pound sterling compared with measurement of nuchal translucency. All other strategies were more costly and less effective, or cost more per additional affected baby prevented. Depending on the cost of the screening test, the first trimester combined test and the quadruple test would also be cost effective options. CONCLUSIONS The choice of screening strategy should be between the integrated test, first trimester combined test, quadruple test, or nuchal translucency measurement depending on how much service providers are willing to pay, the total budget available, and values on safety. Screening based on maternal age, the second trimester double test, and the first trimester serum test was less effective, less safe, and more costly than these four options.

Prediction of improved vision in the amblyopic eye after visual loss in the non-amblyopic eye

Amblyopia arises from abnormal visual experiences in early childhood. Improved function of the amblyopic eye after visual loss in the non-amblyopic eye could be a model for residual neural plasticity. We aimed to establish the likelihood of, and predictive factors for, this improvement in function. We identified 254 individuals aged 11 years or older with unilateral amblyopia who were visually impaired after loss of vision in their non-amblyopic eye but had no other disorder affecting their amblyopic eye. 25 (10%) of 254 people had improved visual acuity in their amblyopic eye. These findings suggest there is some plasticity in the visual system of a few visually mature individuals with amblyopia, which warrants further study. Children should remain the focus of detection and treatment.

The effectiveness and cost-effectiveness of enzyme and substrate replacement therapies: a longitudinal cohort study of people with lysosomal storage disorders.

OBJECTIVES To determine natural history and estimate effectiveness and cost of enzyme replacement therapy (ERT) and substrate replacement therapy (SRT) for patients with Gaucher disease, Fabry disease, mucopolysaccharidosis type I (MPS I), mucopolysaccharidosis type II (MPS II), Pompe disease and Niemann-Pick type C (NPC) disease. DESIGN Cohort study including prospective and retrospective clinical- and patient-reported data. Age- and gender-adjusted treatment effects were estimated using generalised linear mixed models. Treated patients contributed data before and during treatment. Untreated patients contributed natural history data. SETTING National Specialised Commissioning Group-designated lysosomal storage disorder (LSD) treatment centres in England. PARTICIPANTS Consenting adults and children with a diagnosis of Gaucher disease (n = 272), Fabry disease (n = 499), MPS I (n = 126), MPS II (n = 58), NPC (n = 58) or Pompe disease (n = 93) who had attended a treatment centre in England. INTERVENTIONS ERT and SRT. MAIN OUTCOME MEASURES Clinical outcomes chosen by clinicians to reflect disease progression for each disorder; patient-reported quality-of-life (QoL) data; cost of treatment and patient-reported service-use data; numbers of hospitalisations, outpatient and general practitioner appointments; medication use; data pertaining to associated family/carer costs and QoL impacts. RESULTS Seven hundred and eleven adults and children were recruited. In those with Gaucher disease (n = 175) ERT was associated with improved platelet count, haemoglobin, liver function and reduced risk of enlarged liver or spleen. No association was found between ERT and QoL. In patients with Fabry disease (n = 311) increased time on ERT was associated with small decreases in left ventricular mass and improved glomerular filtration rate, but not with changes in risk of stroke/transient ischaemic attacks or the need for a hearing aid. There was a statistically significant association between duration of ERT use and worsening QoL and fatigue scores. We found no statistical difference in estimates of treatment effectiveness between the two preparations, agalsidase beta (Fabrazyme(®), Genzyme) (n = 127) and agalsidase alpha (Replagal(®), Shire HGT) (n = 91), licensed for this condition. In Pompe disease (n = 77) our data provide some evidence of a beneficial effect on muscle strength and mobility as measured by a 6-minute walk test in adult-onset patients; there were insufficient data from infantile-onset Pompe patients to estimate associations between ERT and outcome. Among subjects with MPS I (n = 68), 42 of the 43 patients with MPS I subtype Hurlers disease had undergone a bone marrow transplant. No significant associations were found between ERT and any outcome measure for the MPS I subtype Scheie disease and heparan sulphate patients. An association between duration of ERT and growth in children was the only statistically significant finding among patients with MPS II (n = 39). There were insufficient data for patients with NPC disease to draw any conclusions regarding the effectiveness of SRT. The current annual cost to the NHS of the different ERTs means that between 3.6 and 17.9 discounted quality-adjusted life-years (QALYs) for adult patients and between 2.6 and 10.5 discounted QALYs for child patients would need to be generated for each year of being on treatment for ERTs to be considered cost-effective by conventional criteria. CONCLUSIONS These data provide further evidence on the effectiveness of ERT in people with LSDs. However, the results need to be interpreted in light of the fact that the data are observational and the relative lack of power due to the small numbers of patients with MPS I, MPS II, Pompe disease and NPC disease. Future work should aim to effectively address the unanswered questions and this will require agreement on a common set of outcome measures and their consistent collection across all treatment centres. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 39. See the HTA programme website for further project information.

What is the long term outcome for children who fail to thrive? A systematic review

Aims: To ascertain the long term outcomes in children diagnosed as having failure to thrive (FTT). Methods: Systematic review of cohort studies. Medline, Psychinfo, Embase, Cinahl, Web of Science, Cochrane, and DARE databases were searched for potentially relevant studies. Inclusion criteria: cohort studies or randomised controlled trials in children <2 years old with failure to thrive defined as weight <10th centile or lower centile and/or weight velocity <10th centile, with growth, development, or behaviour measured at 3 years of age or older. Results: Thirteen studies met the inclusion criteria; eight included a comparison group, of which five included children identified in community settings. Two were randomised controlled trials. Attrition rates were 10–30%. Data from population based studies with comparison groups and which reported comparable outcomes in an appropriate form were pooled in a random effects meta-analysis. Four studies report IQ scores at follow up and the pooled standardised mean difference was −0.22 (95% CI −0.41 to −0.03). Two studies reported growth data as standard deviation scores. Their pooled weighted mean difference for weight was −1.24 SDS (95% CI −2.00 to −0.48), and for height −0.87 SDS (95% CI −1.47 to −0.28). No studies corrected for parental height, but two reported that parents of index children were shorter. Conclusions: The IQ difference (equivalent to ∼3 IQ points) is of questionable clinical significance. The height and weight differences are larger, but few children were below the 3rd centile at follow up. It is unclear to what extent observed differences reflect causal relations or confounding due to other variables. In the light of these results the aggressive approach to identification and management of failure to thrive needs reassessing.

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.