care, health and development Child: Current Literature
bs_bs_banner
doi:10.1111/cch.12259
Current Literature The impact of stopping high-energy oral nutritional supplements on eating behaviour and weight gain. Wright C.M. & Chillingworth A. (2015) Archives of Disease in Childhood, doi:10.1136/archdischild-2014-307564. Background and aims Many children referred to a tertiary feeding clinic are already taking high-energy oral nutritional supplements (HEOS), but these often seem not clinically useful. We undertook a retrospective review of all children on HEOS at the time of referral to the clinic in order to describe their subsequent progress in terms of growth and feeding behaviour. Results A total of 48 children were on HEOS at referral and withdrawal of HEOS was attempted in 38 children, aged median 3.0 years (range 0.7–10 years) who were taking volumes equivalent to two-thirds of total daily energy requirements. The children tended to be very short and slim [median height standard deviation score (SDS) 2.0 (range 5.7 to 1.9); body mass index 2.0 ( 5.1 to 1.9)]. Half had normal neurodevelopment but four (11%) had learning disability and four (11%) severe neurodevelopment problems. By last follow-up after 0.86 (0–2.9) years, 30 (79%) had stopped all feeds. Those who stopped had a mean (SD) change in weight of 0.08 (0.6) SDS (range 0.88 to +1.59). Five children (17%) showed significant catch up weight gain after stopping feeds, of whom three had been referred for weight faltering and possible tube feeding. Improvement in feeding behaviour was documented in 76% (29). Conclusions The use of HEOS in children suppresses appetite for solid food because of energy compensation. In some cases, HEOS may perpetuate or even cause weight faltering. It should not be assumed that failure to respond to HEOS is an indication for tube feeding.
seemed to have no benefit, there was no demonstrable change in growth after withdrawal; in some cases, there was a distinct improvement and, in most cases, a dramatic normalization of family mealtimes. This is a case series so one has to be cautious in drawing conclusions. The cases were a selected group, the children with severe neurodisability who required enteral feeding were not included, and there may have been some self-selection among families who followed the clinic’s recommendations. Nevertheless, this is a useful and important paper on clinical experience. There has been an explosion in the use of supplemental feeding, with large numbers of paediatric dieticians spending much time on monitoring weight and calorie intake, and many primary health workers such as health visitors and general practitioners are prescribing or advising these feeds without any strong evidence of their benefit. The patients described here are at the more severe end of the spectrum but even among these, most did not obtain benefit. The problem clinically is the diagnosis of growth faltering and an understanding of normal growth patterns. This team has published extensively on this in the past, and it is useful to see how they have put their theoretical knowledge into practice. For the rest of us, there is too slavish attention paid to a child’s relative position on a growth chart, their trajectory and an understanding of genetic, congenital and medical factors, which may result in slow but ‘normal’ growth. It is ludicrous; we advise parents against the use of high-calorie sugary drinks, which inhibit normal appetite, then we prescribe high-calorie food supplements, which have the same effect yet are deemed acceptable because they have the imprimatur of a ‘scientific’ formulation. Well done, I am pleased to see this paper. A controlled trial of food supplement withdrawal surely is called for.
Comment: At last! This paper describes the experience of a feeding clinic in managing high-energy supplement feeding for children
Richard Reading
with apparent growth faltering. The approach taken by the feeding team is to try and withdraw these supplemental feeds. A few children with severe neurodisability clearly required supplementation, but the majority of these ultimately moved on to tube feeding. For the rest, high-energy supplements
© 2015 John Wiley & Sons Ltd
Establishing a child rights, health equity and social justicebased practice of pediatrics. Goldhagen J., Mercer R., Robinson G., Duran E., Webb E. & Ehrich J. (2015) The Journal of Pediatrics, 166, 1098–1099.e3. 637
638 Current Literature
The United Nations’ Convention on the Rights of the Child came into force 25 years ago as the first human rights document that focused solely on children.1 The articles of the Convention on the Rights of the Child are concordant with the underlying precepts of paediatrics and public health. Yet, despite ongoing changes in the social-ecology of health, more than a half century of enlightenment as to the relevance of human rights to the health and well-being of children, and rapid advances in social epidemiology and the life course sciences, the principles of human rights, health equity and social justice have not been integrated into health professional training. Comment: This brief article outlines a manifesto for a new approach to child health care. The authors describe a practice of paediatrics called Community, Social and Societal Paediatrics (C-SSP). I am not sure why the hyphen? This is based on principles of children and human rights, equity and justice. They offer four appendices where the body of their proposals sit, and these include basic principles of children’s rights to health, standards and models for the system realizing children’s rights to health, roles and responsibilities of states and professionals, and measuring and evaluating the outcomes of such an approach. It is a complex article despite its short length, perhaps the authors wanted to include much detail they have worked on at length. Each sentence conveys a different concept. This makes it difficult to read at times, but we are reassured that further articles expanding on this introduction will subsequently appear in the journal. I am again struck by how much a child rights approach to realizing children’s health is bound up with a public health approach. The authors imply I think that taking a conventional public health approach is somehow limiting, but in fact, all the principles and practical approaches they describe are fundamentally the same as those embodied in public health. Equally, public health approaches have a great deal to gain from articulating their arguments in a children’s (and human) rights framework. The article does provide a good argument that paediatricians should, at the least, have a working knowledge of what is in the United Nations convention on the rights of the child. I agree with that, it has helped me in complex and ethically challenging situations and is entirely consistent with other ethical and
A randomized, controlled trial of an aerosolized vaccine against measles. Low N., Bavdekar A., Jeyaseelan L., Hirve S., Ramanathan K., Andrews N.J., Shaikh N., Jadi R.S., Rajagopal A., Brown K.E., Brown D., Fink J.B., John O., Scott P., Riveros-Balta A.X., Greco M., Dhere R., Kulkarni P.S. & Henao Restrepo A.M. (2015) New England Journal of Medicine, 372, 1519–1529. Background Aerosolized vaccine can be used as a needle-free method of immunization against measles, a disease that remains a major cause of illness and death. Data on the immunogenicity of aerosolized vaccine against measles in children are inconsistent. Methods We conducted an open-label non-inferiority trial involving children 9.0 to 11.9 months of age in India who were eligible to receive a first dose of measles vaccine. Children were randomly assigned to receive a single dose of vaccine by means of either aerosol inhalation or a subcutaneous injection. The primary end points were seropositivity for antibodies against measles and adverse events 91 days after vaccination. The non-inferiority margin was 5 percentage points. Results A total of 1001 children were assigned to receive aerosolized vaccine, and 1003 children were assigned to receive subcutaneous vaccine; 1956 of all the children (97.6%) were followed to day 91, but outcome data were missing for 331 children because of thawed specimens. In the per-protocol population, data on 1560 of 2004 children (77.8%) could be evaluated. At day 91, a total of 662 of 775 children [85.4%; 95% confidence interval (CI) 82.5 to 88.0] in the aerosol group, as compared with 743 of 785 children (94.6%; 95% CI 92.7 to 96.1) in the subcutaneous group, were seropositive, a difference of 9.2 percentage points (95% CI 12.2 to 6.3). Findings were similar in the full-analysis set [673 of 788 children in the aerosol group (85.4%) and 754 of 796 children in the subcutaneous group (94.7%) were seropositive at day 91, a difference of 9.3 percentage points (95% CI 12.3 to 6.4)] and after multiple imputation of missing results. No serious adverse events were attributable to measles vaccination. Adverse-event profiles were similar in the two groups. Conclusions Aerosolized vaccine against measles was immunogenic, but at the prespecified margin, the aerosolized vaccine was inferior to the subcutaneous vaccine with respect to the rate of seropositivity.
professional obligations and guidance we follow. Comment: This is an important vaccine trial as it might
Richard Reading © 2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 637–640
have heralded a new way of protecting children against
Current Literature 639
measles in resource poor settings. Currently, some countries use aerosolised measles vaccine, Mexico, for example, but the evidence of efficacy is unclear. From my understanding, most of the evidence is in older children, there appears to be a lower rate of seroconversion, and this may be insufficient to induce herd immunity. However, the convenience and acceptability of delivering aerosolised vaccine need to be taken into account as well. The results of this trial suggest that levels of seroprotection are slightly lower for the aerosolized vaccine among the infants (aged 9–12 months) studied in the trial. Although the difference was small, it was significant and may have resulted in reduced herd immunity. The authors discuss whether aerosolized vaccines may still have a place in the
Results Of 4010 children present in both waves, complete data were available for 3629, of whom 233 (6.4%) developed a chronic disabling condition between 6/7 and 10/11 years old. After adjustment for confounding, the children from the lowest income quintile were more than twice as likely to develop a chronic disabling condition as those from the highest income quintile. Onset of a chronic disabling condition was associated with a smaller increase in household income over time but no change in hardship prevalence. Conclusions Family socio-economic disadvantage when children are aged 6/7 years is associated with their development of a chronic disabling condition over the next 4 years and with adverse effects on household income.
wider strategy against measles, for example, to immunize older children and to boost immunity in children already
Comment: Trying to determine causality and direction
vaccinated with an inadequate seroconversion, or where
of effect in studies looking at socio-economic inequalities in
calculations taking into account coverage and rates of
health is extremely difficult. There is rarely any credible
seroconversion suggest that population protection would
experimental evidence, with the possible exception of some
still be higher despite lower efficacy.
natural experiments. Cross-sectional or case-control data
These results are important as they appear to be a
are unable to determine the direction or causal pathway of
relatively unbiased and reliable estimate of efficacy in
any associations, and cohort studies are fraught with
infants, but they are not the end of the story, and further
potential confounding and bias introduced by differential
trials may show that aerosolized vaccine still has a place in a
follow-up. Putting all that to one side, the enduring facts
strategy to protect the population and eradicate measles.
are that there is a strong association between children with chronic disabling conditions and socio-economic
Richard Reading
disadvantage within the family. Possible explanations that have been proposed are that the same process that leads
Socioeconomic disadvantage and onset of childhood chronic disabling conditions: a cohort study. Spencer N. & Strazdins L. (2015) Archives of Disease in Childhood, 100, 317–322.
to one leads to the other (for example, if there is a genetic susceptibility to a disabling condition in a parent, this may result both in reduced earning capacity and a similar disability in the child); that caring for a disabled child imposes extra financial and caring burdens that
Objective The aim of this paper was to study the temporal relationship between socio-economic disadvantage and onset of chronic disabling conditions in childhood. Method Using parent reported data from the longitudinal study of Australian children, we compared children who developed a chronic disabling condition between the ages of 6/7 and 10/11 years without a chronic disabling condition at either age. Logistic regression models assessed association between onset of chronic disabling condition and household income quintiles at 6/7 years, adjusting for confounders. To study the consequences of chronic disabling condition onset for family finances, a linear regression model was fitted on change in household income adjusted for income at 6/7. We compared prevalence of family material hardship in the two groups between 6/7 and 10/11 years old.
reduce a family’s economic resources or that social disadvantage and poverty result in family adversity that then results in childhood disability. An example of the latter explanation might be that poverty leads to poor nutrition, which leads to mental and physical impairments, or that living in a disadvantaged neighbourhood increases the risk of an accidental injury, which then results in physical impairment. This study, despite all the aforementioned caveats, provides support for a combination of the latter two explanations. Poverty and social disadvantage appear to be associated with the subsequent development of a disabling condition, and the development of a disabling condition results in further economic disadvantage. The key to this analysis is the time course, which suggests a causal
© 2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 637–640
640 Current Literature
direction. Other confounding factors have been accounted
ological observational studies can never convincingly
for. The associations are consistent and in a gradient (i.e.
prove causation.
show a dose–response relationship) so there are many criteria for establishing causality, but ultimately epidemi-
© 2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 637–640
Richard Reading
bs_bs_banner
doi:10.1111/cch.12259
Current Literature The impact of stopping high-energy oral nutritional supplements on eating behaviour and weight gain. Wright C.M. & Chillingworth A. (2015) Archives of Disease in Childhood, doi:10.1136/archdischild-2014-307564. Background and aims Many children referred to a tertiary feeding clinic are already taking high-energy oral nutritional supplements (HEOS), but these often seem not clinically useful. We undertook a retrospective review of all children on HEOS at the time of referral to the clinic in order to describe their subsequent progress in terms of growth and feeding behaviour. Results A total of 48 children were on HEOS at referral and withdrawal of HEOS was attempted in 38 children, aged median 3.0 years (range 0.7–10 years) who were taking volumes equivalent to two-thirds of total daily energy requirements. The children tended to be very short and slim [median height standard deviation score (SDS) 2.0 (range 5.7 to 1.9); body mass index 2.0 ( 5.1 to 1.9)]. Half had normal neurodevelopment but four (11%) had learning disability and four (11%) severe neurodevelopment problems. By last follow-up after 0.86 (0–2.9) years, 30 (79%) had stopped all feeds. Those who stopped had a mean (SD) change in weight of 0.08 (0.6) SDS (range 0.88 to +1.59). Five children (17%) showed significant catch up weight gain after stopping feeds, of whom three had been referred for weight faltering and possible tube feeding. Improvement in feeding behaviour was documented in 76% (29). Conclusions The use of HEOS in children suppresses appetite for solid food because of energy compensation. In some cases, HEOS may perpetuate or even cause weight faltering. It should not be assumed that failure to respond to HEOS is an indication for tube feeding.
seemed to have no benefit, there was no demonstrable change in growth after withdrawal; in some cases, there was a distinct improvement and, in most cases, a dramatic normalization of family mealtimes. This is a case series so one has to be cautious in drawing conclusions. The cases were a selected group, the children with severe neurodisability who required enteral feeding were not included, and there may have been some self-selection among families who followed the clinic’s recommendations. Nevertheless, this is a useful and important paper on clinical experience. There has been an explosion in the use of supplemental feeding, with large numbers of paediatric dieticians spending much time on monitoring weight and calorie intake, and many primary health workers such as health visitors and general practitioners are prescribing or advising these feeds without any strong evidence of their benefit. The patients described here are at the more severe end of the spectrum but even among these, most did not obtain benefit. The problem clinically is the diagnosis of growth faltering and an understanding of normal growth patterns. This team has published extensively on this in the past, and it is useful to see how they have put their theoretical knowledge into practice. For the rest of us, there is too slavish attention paid to a child’s relative position on a growth chart, their trajectory and an understanding of genetic, congenital and medical factors, which may result in slow but ‘normal’ growth. It is ludicrous; we advise parents against the use of high-calorie sugary drinks, which inhibit normal appetite, then we prescribe high-calorie food supplements, which have the same effect yet are deemed acceptable because they have the imprimatur of a ‘scientific’ formulation. Well done, I am pleased to see this paper. A controlled trial of food supplement withdrawal surely is called for.
Comment: At last! This paper describes the experience of a feeding clinic in managing high-energy supplement feeding for children
Richard Reading
with apparent growth faltering. The approach taken by the feeding team is to try and withdraw these supplemental feeds. A few children with severe neurodisability clearly required supplementation, but the majority of these ultimately moved on to tube feeding. For the rest, high-energy supplements
© 2015 John Wiley & Sons Ltd
Establishing a child rights, health equity and social justicebased practice of pediatrics. Goldhagen J., Mercer R., Robinson G., Duran E., Webb E. & Ehrich J. (2015) The Journal of Pediatrics, 166, 1098–1099.e3. 637
638 Current Literature
The United Nations’ Convention on the Rights of the Child came into force 25 years ago as the first human rights document that focused solely on children.1 The articles of the Convention on the Rights of the Child are concordant with the underlying precepts of paediatrics and public health. Yet, despite ongoing changes in the social-ecology of health, more than a half century of enlightenment as to the relevance of human rights to the health and well-being of children, and rapid advances in social epidemiology and the life course sciences, the principles of human rights, health equity and social justice have not been integrated into health professional training. Comment: This brief article outlines a manifesto for a new approach to child health care. The authors describe a practice of paediatrics called Community, Social and Societal Paediatrics (C-SSP). I am not sure why the hyphen? This is based on principles of children and human rights, equity and justice. They offer four appendices where the body of their proposals sit, and these include basic principles of children’s rights to health, standards and models for the system realizing children’s rights to health, roles and responsibilities of states and professionals, and measuring and evaluating the outcomes of such an approach. It is a complex article despite its short length, perhaps the authors wanted to include much detail they have worked on at length. Each sentence conveys a different concept. This makes it difficult to read at times, but we are reassured that further articles expanding on this introduction will subsequently appear in the journal. I am again struck by how much a child rights approach to realizing children’s health is bound up with a public health approach. The authors imply I think that taking a conventional public health approach is somehow limiting, but in fact, all the principles and practical approaches they describe are fundamentally the same as those embodied in public health. Equally, public health approaches have a great deal to gain from articulating their arguments in a children’s (and human) rights framework. The article does provide a good argument that paediatricians should, at the least, have a working knowledge of what is in the United Nations convention on the rights of the child. I agree with that, it has helped me in complex and ethically challenging situations and is entirely consistent with other ethical and
A randomized, controlled trial of an aerosolized vaccine against measles. Low N., Bavdekar A., Jeyaseelan L., Hirve S., Ramanathan K., Andrews N.J., Shaikh N., Jadi R.S., Rajagopal A., Brown K.E., Brown D., Fink J.B., John O., Scott P., Riveros-Balta A.X., Greco M., Dhere R., Kulkarni P.S. & Henao Restrepo A.M. (2015) New England Journal of Medicine, 372, 1519–1529. Background Aerosolized vaccine can be used as a needle-free method of immunization against measles, a disease that remains a major cause of illness and death. Data on the immunogenicity of aerosolized vaccine against measles in children are inconsistent. Methods We conducted an open-label non-inferiority trial involving children 9.0 to 11.9 months of age in India who were eligible to receive a first dose of measles vaccine. Children were randomly assigned to receive a single dose of vaccine by means of either aerosol inhalation or a subcutaneous injection. The primary end points were seropositivity for antibodies against measles and adverse events 91 days after vaccination. The non-inferiority margin was 5 percentage points. Results A total of 1001 children were assigned to receive aerosolized vaccine, and 1003 children were assigned to receive subcutaneous vaccine; 1956 of all the children (97.6%) were followed to day 91, but outcome data were missing for 331 children because of thawed specimens. In the per-protocol population, data on 1560 of 2004 children (77.8%) could be evaluated. At day 91, a total of 662 of 775 children [85.4%; 95% confidence interval (CI) 82.5 to 88.0] in the aerosol group, as compared with 743 of 785 children (94.6%; 95% CI 92.7 to 96.1) in the subcutaneous group, were seropositive, a difference of 9.2 percentage points (95% CI 12.2 to 6.3). Findings were similar in the full-analysis set [673 of 788 children in the aerosol group (85.4%) and 754 of 796 children in the subcutaneous group (94.7%) were seropositive at day 91, a difference of 9.3 percentage points (95% CI 12.3 to 6.4)] and after multiple imputation of missing results. No serious adverse events were attributable to measles vaccination. Adverse-event profiles were similar in the two groups. Conclusions Aerosolized vaccine against measles was immunogenic, but at the prespecified margin, the aerosolized vaccine was inferior to the subcutaneous vaccine with respect to the rate of seropositivity.
professional obligations and guidance we follow. Comment: This is an important vaccine trial as it might
Richard Reading © 2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 637–640
have heralded a new way of protecting children against
Current Literature 639
measles in resource poor settings. Currently, some countries use aerosolised measles vaccine, Mexico, for example, but the evidence of efficacy is unclear. From my understanding, most of the evidence is in older children, there appears to be a lower rate of seroconversion, and this may be insufficient to induce herd immunity. However, the convenience and acceptability of delivering aerosolised vaccine need to be taken into account as well. The results of this trial suggest that levels of seroprotection are slightly lower for the aerosolized vaccine among the infants (aged 9–12 months) studied in the trial. Although the difference was small, it was significant and may have resulted in reduced herd immunity. The authors discuss whether aerosolized vaccines may still have a place in the
Results Of 4010 children present in both waves, complete data were available for 3629, of whom 233 (6.4%) developed a chronic disabling condition between 6/7 and 10/11 years old. After adjustment for confounding, the children from the lowest income quintile were more than twice as likely to develop a chronic disabling condition as those from the highest income quintile. Onset of a chronic disabling condition was associated with a smaller increase in household income over time but no change in hardship prevalence. Conclusions Family socio-economic disadvantage when children are aged 6/7 years is associated with their development of a chronic disabling condition over the next 4 years and with adverse effects on household income.
wider strategy against measles, for example, to immunize older children and to boost immunity in children already
Comment: Trying to determine causality and direction
vaccinated with an inadequate seroconversion, or where
of effect in studies looking at socio-economic inequalities in
calculations taking into account coverage and rates of
health is extremely difficult. There is rarely any credible
seroconversion suggest that population protection would
experimental evidence, with the possible exception of some
still be higher despite lower efficacy.
natural experiments. Cross-sectional or case-control data
These results are important as they appear to be a
are unable to determine the direction or causal pathway of
relatively unbiased and reliable estimate of efficacy in
any associations, and cohort studies are fraught with
infants, but they are not the end of the story, and further
potential confounding and bias introduced by differential
trials may show that aerosolized vaccine still has a place in a
follow-up. Putting all that to one side, the enduring facts
strategy to protect the population and eradicate measles.
are that there is a strong association between children with chronic disabling conditions and socio-economic
Richard Reading
disadvantage within the family. Possible explanations that have been proposed are that the same process that leads
Socioeconomic disadvantage and onset of childhood chronic disabling conditions: a cohort study. Spencer N. & Strazdins L. (2015) Archives of Disease in Childhood, 100, 317–322.
to one leads to the other (for example, if there is a genetic susceptibility to a disabling condition in a parent, this may result both in reduced earning capacity and a similar disability in the child); that caring for a disabled child imposes extra financial and caring burdens that
Objective The aim of this paper was to study the temporal relationship between socio-economic disadvantage and onset of chronic disabling conditions in childhood. Method Using parent reported data from the longitudinal study of Australian children, we compared children who developed a chronic disabling condition between the ages of 6/7 and 10/11 years without a chronic disabling condition at either age. Logistic regression models assessed association between onset of chronic disabling condition and household income quintiles at 6/7 years, adjusting for confounders. To study the consequences of chronic disabling condition onset for family finances, a linear regression model was fitted on change in household income adjusted for income at 6/7. We compared prevalence of family material hardship in the two groups between 6/7 and 10/11 years old.
reduce a family’s economic resources or that social disadvantage and poverty result in family adversity that then results in childhood disability. An example of the latter explanation might be that poverty leads to poor nutrition, which leads to mental and physical impairments, or that living in a disadvantaged neighbourhood increases the risk of an accidental injury, which then results in physical impairment. This study, despite all the aforementioned caveats, provides support for a combination of the latter two explanations. Poverty and social disadvantage appear to be associated with the subsequent development of a disabling condition, and the development of a disabling condition results in further economic disadvantage. The key to this analysis is the time course, which suggests a causal
© 2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 637–640
640 Current Literature
direction. Other confounding factors have been accounted
ological observational studies can never convincingly
for. The associations are consistent and in a gradient (i.e.
prove causation.
show a dose–response relationship) so there are many criteria for establishing causality, but ultimately epidemi-
© 2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 637–640
Richard Reading
