Child health

Kari A J Jarvinen,* Bradley J McCall,† Clare B Nourse,‡ Joe G McCormack,§ Martyn H Tilse¶ * Senior Public Health Registrar, † Public Health Medical Officer, Communicable Disease Control, Brisbane Southside Public Health Unit, 39 Kessels Road, Coopers Plains, QLD 4108; ‡ Paediatric Infectious Diseases Physician, § Director of Infectious Diseases, ¶ Director of Microbiology, Mater Health Services, South Brisbane, QLD. kari_jarvinenAThealth.qld.gov.au To the Editor: Pertussis continues to be a significant public health problem in Australia. Children aged under 1 year are most at risk from severe, life-threatening complications from the disease.1 Traditionally, erythromycin has been the drug of choice for treatment of cases and prophylaxis in selected contacts. However, its use in neonates is known to carry a risk of infantile hypertrophic pyloric stenosis.1,2 Its propensity to cause QT prolongation and ventricular arrhythmias is also well described.2,3 Both azithromycin and clarithromycin have been recently recommended as suitable alternatives for management of pertussis.2,4 The US Centres for Disease Control now regard azithromycin as the agent of choice for neonates less than 1 month of age.1 There is evidence suggesting azithromycin has less pro-arrhythmic potential than erythromycin or clarithromycin.5,6 Azithromycin does not interact significantly with the hepatic cytochrome P450 system and has less potential for significant drug interactions than other macrolide antibiotics.3,5,6 Azithromycin and clarithromycin also require less frequent administration (1–2 doses per day) and shorter treatment regimens (5–7 days) than erythromycin. In Australia, roxithromycin is the most widely prescribed macrolide antibiotic. However, there are no clinical studies on its effectiveness in pertussis, and in-vitro sensitivity studies suggest it may be inferior to erythromycin. Thus, roxithromycin cannot be recommended in pertussis.4 Updated versions of Australian antibiotic guidelines to be released later this year will recommend azithromycin for pertussis treatment and prophylaxis. However, access to azithromycin for this purpose in Australia is currently limited by the restrictions placed on prescribing through the Pharmaceutical Benefits Scheme (PBS). Azithromycin is currently approved for Chlamydia trachomatis urethritis, cervicitis and trachoma. Pertussis is an approved indication only for the use of 500 mg tablets under the Repatriation PBS. This restriction has important implications for the effective and safe management of pertussis in Australia. Widespread use of newer macrolides in the community is not advisable because of the propensity of macrolides to induce antibiotic resistance, and their greater cost. However, for pertussis infection, Australians need to be able to access agents such as azithromycin. PBS restrictions for this indication need to be revised, for both tablet and liquid formulations.

Kari A J Jarvinen · Bradley J McCall · Clare B Nourse · Joe G McCormack · Martyn H Tilse

Andrew J A Holland,* Frank I Ross,† Patricia Manglick,‡ Fiona E Fahy,§ Daniel T Cass¶ * Associate Professor of Paediatric Surgery and Urology, † Clinical Nurse Consultant, ‡ Scientific Officer, § Clinical Nurse Consultant, ¶ William Dunlop Professor of Paediatric Surgery and Director of Trauma, Department of Academic Surgery, The Children's Hospital at Westmead, University of Sydney, Locked Bay 4001, Westmead, NSW 2145. andrewh3ATchw.edu.au To the Editor: Several studies from Australasia and North America have identified that in up to 24% of children with pedestrian motor vehicle injuries (MVIs) the event occurred in a driveway.1-4 Earlier work from our centre in Sydney and others in Auckland, New Zealand, highlighted prevention as the most effective method for reducing the morbidity and mortality associated with this unique mechanism of injury.2,3,5 With ethics committee approval, we prospectively reviewed injury circumstances in children under 16 years of age presenting with a driveway MVI to our institution over a 3-year period between June 2002 and May 2005. Of 36 children injured in 35 separate driveway MVIs, 26 caregivers agreed to an interview and scene visit. Fifteen patients (58%) were male, with a mean age of 48 months. The majority of events occurred in western and south-western Sydney — a paediatric population centre — in the afternoon (18; 69%) and on a weekday (19; 73%), with a trend for greater frequency at the beginning and end of the working week. In all but two cases, the injury occurred at the child’s home, which was owned by the parents in 13 cases (50%; with a mean occupation period, 47 months) and rented in 10 (38%; mean occupation period, 22 months). The majority of homes (22; 85%) had no separation between the dwelling, external play areas and the driveway. Even when a separation was present, this had been circumvented. Sedans were the most common vehicle involved (18; 69%), with the remainder four-wheel drives (4WDs) or light commercial vehicles, and 22 (85%) were reversing. The vehicle was driven by an adult known to the child in 21 cases, but in four the vehicle was inadvertently set in motion by another child. Box 1 reports parental perception of contributing factors and Box 2 lists injuries sustained, with 23 (89%) children receiving injuries severe enough to warrant hospital admission. There were no deaths. This review indicates that driveway MVIs persist as a common and potentially fatal problem for children in New South Wales, with at least one child injured every month.2 Following our previous study published in 2000, and findings of the NSW Child Death Review Team, campaigns by the Motor Accidents Authority of NSW and others have focused on driveway safety, particularly for young children. This review suggests that further intervention is needed to reduce the frequency of these injuries, either through enhanced application of present strategies or the development of more effective, novel approaches. 1 Parental perception of factors contributing to their child sustaining pedestrian motor vehicle injuries in the driveway Lack of supervision 15 Child playing in parked car 5 Children’s behaviour around cars 5 Negligent driving 2 Excessive speed 2 Hand brake not applied 1 Front house door left open 1 Hurrying when leaving home 1 2 Injuries identified in children sustaining pedestrian motor vehicle injuries in the driveway Head and neck Skull fracture 1 Intracranial haematoma 1 Concussion 2 Retropharyngeal haematoma 1 Torso Hepatic contusion 1 Adrenal haematoma 1 Haemopneumothorax 1 Multiple rib fractures 1 Pelvic fracture 1 Major soft tissue injury 1 Limb Fractures 2 Burns Full thickness 4 Partial thickness 3 Major soft tissue injury 1 Minor soft tissue injury 17

Andrew J A Holland · Frank I Ross · Patricia Manglick · Fiona E Fahy · Daniel T Cass

Objective: To document the population iodine nutritional status in Australian schoolchildren.Design and setting: Cross-sectional survey of schoolchildren aged 8–10 years, based on a one-stage random cluster sample drawn from all Year 4 school classes in government and non-government schools in the five mainland Australian states of New South Wales, Victoria, South Australia, Western Australia and Queensland. The study was conducted between July 2003 and December 2004.Participants: 1709 students from 88 schools (881 boys and 828 girls), representing 85% of the estimated target number of students. The class participation rate was 65%.Main outcome measures: (i) Urinary iodine excretion (UIE) levels (compared with the criteria for the severity of iodine deficiency of the World Health Organization/International Council for the Control of Iodine Deficiency Disorders: iodine replete, UIE ≥ 100 μg/L; mild iodine deficiency, UIE 50–99 μg/L; moderate iodine deficiency, UIE 20–49 μg/L; severe iodine deficiency, UIE < 20 μg/L); (ii) Thyroid volumes measured by ultrasound (compared with new international reference values).Results: Overall, children in mainland Australia are borderline iodine deficient, with a national median UIE of 104 μg/L. On a state basis, NSW and Victorian children are mildly iodine deficient, with median UIE levels of 89 μg/L and 73.5 μg/L, respectively. South Australian children are borderline iodine deficient, with a median UIE of 101 μg/L. Both Queensland and Western Australian children are iodine sufficient, with median UIE levels of 136.5 μg/L and 142.5 μg/L, respectively. Thyroid volumes in Australian schoolchildren are marginally increased compared with international normative data obtained from children living in iodine sufficient countries. There was no significant association between UIE and thyroid volume.Conclusion: Our results confirm the existence of inadequate iodine intake in the Australian population, and we call for the urgent implementation of mandatory iodisation of all edible salt in Australia.

Mu Li PhD · Creswell J Eastman AM, MD, FRACP · Kay V Waite Biological Technicians Certificate · Gary Ma PhD · Karen Byth PhD · Margaret R Zacharin MB BS, FRACP · Duncan J Topliss MD, FRACP · Philip E Harding MB BS, FRACP · John P Walsh PhD, FRACP · Lynley C Ward BS, SRN · Robin H Mortimer MB BS, FRACP · Emily J Mackenzie MB BS · Zelda Doyle MSc(Epidemiology)

Hospitals use appropriate sterilisation to prevent transmission of infection among infants from such items as reusable feeding bottles. But what happens when the sterilisation process results in potential harm to the infant in other ways? We describe an incident in which a wrong sterilisation method resulted in an infant being fed with a shrunken feeding bottle. A full-term male infant weighing 2290 g at birth was prescribed formula feeds for low birthweight and neonatal abstinence syndrome. An agency nurse handed the mother a sterilised 120 mL plastic bottle for formula feeding. It was amazing to see how this small infant managed to take the full 90 mL with each feed, which was twice his daily requirement. The explanation became apparent when the nursing unit manager compared the bottle in question with a new 120 mL bottle. While the older bottle was similar in height and even fitted the same teat, it was narrower than the new bottle (Figure). In fact, when the older bottle was filled to the 120 mL mark on the outside, it held only 50 mL! How had this occurred? Further enquiry established that, before use, this particular bottle, designated as unsuitable for autoclaving by the manufacturer, had mistakenly been autoclaved in the Central Sterile Supply Department (CSSD) instead of being chemically sterilised on the ward. Fortunately, the problem was picked up quickly enough to prevent the infant from getting dehydrated. Sterilisation of feeding bottles can be achieved by thermal or chemical means.1 While some recommend boiling as the preferred option, the use of a sodium hypochlorite solution (eg, Milton, Milton Australia Pty Ltd, Brisbane) is widely accepted by hospitals as a superior form of sterilisation.2 In our hospital, feeding bottles are not normally autoclaved. The only other method of sterilisation at CSSD involves ethylene oxide. This method is felt unsuitable for feeding bottles, given the potential for absorption of ethylene oxide into the plastic. But, every now and then, a bottle finds its way down to CSSD and returns as a slimmer version of its old self. While some types of feeding bottle can be safely autoclaved, this particular range of bottles is unsuitable for autoclaving. We have now replaced the implicated bottles with glass and other autoclave-safe plastic bottles so that this type of incident does not occur again.

Sarah Newton MB BS · Hemant Jain MB BS · Joane Coleman RN · Srinivas Bolisetty FRACP

Henry Ekert Haematologist, Children's Cancer Centre and Department of Haematology, Royal Children's Hospital, PO Box 2096, Brighton North, Melbourne, VIC 3186; and Haematology Advisor, Australian Government Department of Health and Ageing. ekerthenryAToptushome.com.au To the Editor: The editorial on mandatory fortification of flour with folic acid by Maberly and Stanley is subtitled: “The scientific benefit is clear, but translating this into practice requires advocacy”.1 The only benefit that is scientifically clear is the reduction in the incidence of neural tube defects. All the other “benefits” listed by the authors are observational and have occurred in a setting where myriad environmental changes have occurred concurrent with folic acid fortification. To imply that the reduction in the rate of heart attacks and stroke is the result of folic acid fortification is, at best, anecdotal, because it is not supported by any randomised controlled studies, and is an extrapolation from the relationship between reduced homocysteine levels and the incidence of stroke and heart disease. The authors also did not mention the increased incidence of multiple pregnancies that has been observed with folate supplementation (relative risk, 1.02; 95% CI, 0.97–1.07).2 While this represents only a slight increase in the risks associated with the birth process, it should not be ignored when considering perceived risks. It is also possible that in a planned pregnancy where the mother is prescribed folic acid before conception, the additional folate intake from fortified flour may further increase the risk of multiple pregnancy. It seems to me that the editorial was in fact an item of advocacy rather than a dispassionate scientific assessment of the arguments for and against mandatory folic acid fortification. At the very least, if mandatory folic acid fortification is implemented, prospective mothers will have to be made aware of the increased risk of multiple pregnancy and the as yet unknown risk of combining the fortified diet with medically prescribed folic acid.

Henry Ekert

Fiona J Stanley,* Glen F Maberly† * Director, Telethon Institute for Child Health Research, PO Box 855, West Perth, WA 6872. † Professor of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA. fionaATichr.uwa.edu.au In reply: Ekert suggests that in our article advocating for mandatory fortification with folate to reduce neural tube defects,1 we omitted to mention the “increased risk of multiple pregnancies”. He then misquotes the Lumley meta-analysis “(relative risk, 1.02; 95% CI, 0.97–1.07)” — the real relative risk was 1.40 (95% CI, 0.93–2.11). This Cochrane systematic review shows that folate supplementation does not carry a statistically significant risk for multiple births, but confirms the dramatic reduction in neural tube defects.2 Another study, which did suggest an increased risk, did not control for the known increased risk of multiple births following infertility treatments, which could explain the increase observed.3 Ekert suggests that we inform women about this unsubstantiated risk and “the as yet unknown risk” which mandatory fortification might add to “medically prescribed folic acid”. Folic acid is found in leafy green vegetables and in many fruits, nuts and other components of a healthy diet. Tablets are available over the counter. What advice would he give to women about these “risks”? Our evidence is that we are not reaching many women in our society by education and voluntary fortification, and that countries that have fortified their flour have achieved much better reductions in these major defects than we have in Australia. Hence our advocacy. We acknowledge that the evidence for stroke and heart disease reduction is not as solid as that for neural tube defects. However, there is an increasing literature on the protective effects of folate on cardiovascular risk and possible mechanisms.4-8 Hence, with consideration of the proven benefits and the unsubstantiated risks, we will continue to advocate for the mandatory fortification of flour with folate.

Fiona J Stanley · Glen F Maberly

Objective: To evaluate the efficacy of supplementation with zinc and vitamin A in Indigenous children hospitalised with acute lower respiratory infection (ALRI).Design: Randomised controlled, 2-by-2 factorial trial of supplementation with zinc and vitamin A.Setting and participants: 187 Indigenous children aged < 11 years hospitalised with 215 ALRI episodes at Alice Springs Hospital (April 2001 to July 2002).Interventions: Vitamin A was administered on Days 1 and 5 of admission at a dose of 50 000 IU (infants under 12 months), or 100 000 IU; and zinc sulfate was administered daily for 5 days at a daily dose of 20 mg (infants under 12 months) or 40 mg.Main outcome measure: Time to clinical recovery from fever and tachypnoea, duration of hospitalisation, and readmission for ALRI within 120 days.Results: There was no clinical benefit of supplementation with vitamin A, zinc or the two combined, with no significant difference between zinc and no-zinc, vitamin A and no-vitamin A or zinc + vitamin A and placebo groups in time to resolution of fever or tachypnoea, or duration of hospitalisation. Instead, we found increased morbidity; children given zinc had increased risk of readmission for ALRI within 120 days (relative risk, 2.4; 95% CI, 1.003–6.1).Conclusion: This study does not support the use of vitamin A or zinc supplementation in the management of ALRI requiring hospitalisation in Indigenous children living in remote areas. Even in populations with high rates of ALRI and poor living conditions, vitamin A and zinc therapy may not be useful. The effect of supplementation may depend on the prevalence of deficiency of these micronutrients in the population.

Anne B Chang MPHTM, FRACP, PhD · Paul J Torzillo FRACP, FFICM · Peter M Stewart FRCPA · Naomi C Boyce BNurs · Andrew V White FRACP · Gavin R Wheaton FRACP · David M Purdie BSc(Hons), PhD · John Wakerman MB BS, MPH · Patricia C Valery MD, MPH, PhD

We recommend screening all infants whose mothers are HCV antibody-positive Perinatal transmission of hepatitis C virus (HCV) is the main source of newly diagnosed paediatric HCV infections in Australia.1 About 5% of infants born to women who are positive for both HCV antibody and HCV RNA during pregnancy will acquire HCV infection.2 The risk of transmission is increased by HIV coinfection during pregnancy. It is estimated that 1%–2% of women of childbearing age in Australia are infected with HCV.3 Assuming that 75% of these have chronic hepatitis and viraemia in the third trimester of pregnancy, we would expect about 75–100 new cases of vertically acquired childhood HCV infection in Australia per year. However, rates reported from national deidentified laboratory data4 and from the Australian Paediatric Surveillance Unit1 are much lower, suggesting that paediatric HCV infection may be underrecognised in Australia. We thus recommend a more standardised approach to identification and follow-up of infants exposed perinatally to HCV. Why identify infants with HCV infection? Although most HCV-infected children have good health for at least the first two decades of life, HCV-induced chronic liver disease and liver failure have both been reported in childhood.5,6 As it is not possible to predict which children will develop severe liver disease, long-term monitoring of HCV-infected children is needed.6 In addition, children identified as HCV-positive should be offered vaccination against both hepatitis A (after 2 years of age) and hepatitis B. Superinfection of HCV-infected individuals with hepatitis A virus increases the risk of fulminant hepatitis and death, while coinfection with HCV and hepatitis B virus is associated with a higher risk of cirrhosis and hepatocellular carcinoma.7 HCV-infected children with severe hepatic involvement should be offered antiviral therapy. A number of treatments (interferon-alfa, ribavirin and pegylated interferon) successfully eradicate HCV in 40%–80% of HCV-infected adults, depending on the HCV genotype. Although data about their efficacy in childhood are limited, these treatments have been used safely and effectively in children. Identifying Australian children with HCV infection could also allow them access to novel therapies and ongoing international multicentre randomised controlled trials.5 Why is HCV infection underdiagnosed in childhood? Children with HCV infection may not be identified for several reasons: They are unlikely to attract medical attention, as most have no symptoms or signs of liver disease, while a small proportion have mild hepatomegaly.1,5 Consequently, their identification relies on careful follow-up of offspring from at-risk pregnancies. Antenatal HCV screening practices vary widely around the country,8 and therefore many HCV-exposed infants are missed. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommends universal antenatal screening for HCV.8 However, other national bodies recommend selective testing for HCV infection in pregnant woman with identifiable risk factors (eg, intravenous drug use, tattooing, body piercing, needle sharing, or receipt of blood products or invasive procedures overseas or before 1990 in Australia).8,9 Appropriate methods of testing HCV-exposed infants and children are not widely understood, and national guidelines for testing and follow-up of offspring of HCV-infected mothers8,9 are not detailed or widely known to child health care providers. In children aged under 18 months, persistence of maternal antibody complicates the interpretation of HCV antibody tests, while in infants aged under about 2 months qualitative HCV RNA polymerase chain reaction (PCR) testing is insensitive.10 How should we screen for vertically transmitted HCV infection? For diagnosing perinatal HCV infection, the most cost-effective strategy may be to screen offspring of HCV RNA-positive women. However, as HCV RNA levels can fluctuate in pregnancy, and as antenatal HCV screening practices vary, we recommend: Screening all infants born to women who are HCV antibody-positive, using HCV antibody and liver function tests, at 18 months of age or older. If results are negative, then the infant can be safely assumed not to have HCV infection. If antibody results are positive or liver function is abnormal, then the child should be referred to a paediatric gastroenterologist. Testing infants who are considered unlikely to attend for 18-month follow-up, using HCV RNA and liver function tests at 3 months of age, when they are more likely to be receiving local medical care. Those with positive HCV RNA results or abnormal liver function should be referred to a paediatric gastroenterologist. If both tests give negative results, we recommend repeating HCV antibody testing at age 18 months, as both viraemia and transaminitis can be intermittent in HCV infection. HCV RNA testing for the diagnosis of vertically transmitted HCV infection (in isolation) is not an approved item on the current Medicare Benefits Schedule11 and costs about $90 (ie, six times the cost of HCV antibody testing). Testing for HCV should be performed only after pre-test family counselling and with the consent of the infant’s parent(s) or guardians. There is an urgent need to disseminate clinical practice guidelines in Australia for the screening, diagnosis and management of children born to women with HCV infection during pregnancy. Ongoing collection of national data on HCV infection in children is needed to document the scale of this emerging disease in the paediatric population, and the groups of children at risk of infection. Identification and referral of HCV-infected children will allow early initiation of therapy and monitoring of outcomes.

Winita Hardikar PhD, FRACP · Elizabeth J Elliott MD, FRACP · Cheryl A Jones PhD, FRACP

Objectives: To examine whether children’s television viewing may be a useful indicator of risk of obesity-promoting versus healthy eating behaviours, low-level physical activity (PA) and overweight or obesity among children of primary school entry and exit ages.Design: Cross-sectional study, stratified by area-level socioeconomic status.Participants and setting: 1560 children (613 aged 5–6 years [50% boys], and 947 aged 10–12 years [46% boys]) from 24 primary schools in Melbourne, Australia, randomly selected proportionate to school size between 1 November 2002 and 30 December 2003 .Main outcome measures: Parents’ reports of the time their child spends watching television, their participation in organised physical activities (PA), and their food intake; each child’s measured height and weight and their PA levels as assessed by accelerometry for one week.Results: After adjusting for the age and sex of child, the parents’ level of education, clustering by school, and all other health behaviour variables, children who watched television for > 2 h/day were significantly more likely than children who watched television for ≤ 2 h/day to: to have one or more serves/day of high energy drinks (adjusted odds ratio [AOR], 2.31; 95% CI, 1.61–3.32), and to have one or more serves/day of savoury snacks (AOR, 1.50; 95% CI, 1.04–2.17). They were also less likely to have two or more serves/day of fruit (AOR, 0.58; 95% CI, 0.46–0.74), or to participate in any organised PA (AOR, 0.52; 95% CI, 0.34–0.80).Conclusions: Health practitioners in the primary care setting may find that asking whether a child watches television for more than 2 hours daily can be a useful indicator of a child’s risk of poor diet and low physical activity level.

Jo Salmon PhD · Karen J Campbell MPH, PhD · David A Crawford PhD

An infant, born at 35 weeks’ gestation to a woman who sniffed petrol, had a cord blood lead level eight times the accepted limit. Treatment with oral dimercaptosuccinic acid promptly reduced his blood lead levels. To our knowledge, this is the first reported case of congenital lead poisoning secondary to maternal petrol sniffing. We suggest that at-risk pregnancies should be identified, cord blood lead levels tested, and chelation therapy and developmental follow-up offered to affected infants. Clinical recordA 27-year-old Indigenous woman, who had sniffed petrol since childhood, presented for antenatal care during her first pregnancy. At the age of 14 years, she had severe lead encephalopathy that led to chronic neurological deficits, including permanent ataxia and memory impairment. Her serum lead levels at 8 and 35 weeks’ gestation were raised at 1.48 and 2.21 μmol/L, respectively (recommended level, ≤ 0.48 μmol/L1). At 35 weeks’ gestation, she went into spontaneous labour and gave birth vaginally to a boy. The infant’s Apgar score was 9 at both 1 and 5 minutes, and birth weight was 2280 g. He was admitted to the special care nursery because of prematurity, and required nasogastric tube feeding because of poor sucking and general sleepiness. On Day 6, the infant developed temperature instability and diarrhoea, with associated dehydration and metabolic acidosis (Box 1). He was treated with 48 hours of intravenous antibiotics and intravenous fluids. No pathogen was grown from blood cultures, urine or stool. Cord blood lead levels were available on Day 10 and were raised at 3.98 μmol/L. No signs of lead encephalopathy were found on examination: muscle tone and reflexes were normal, and there were no signs of seizure activity. Treatment was begun with oral succimer (dimercaptosuccinic acid [DMSA]) on Day 11, at a dose of 10 mg/kg three times daily for 5 days, followed by 10 mg/kg twice daily for 14 days. No adverse effects of chelation therapy (such as vomiting, diarrhoea, fever, rash, or elevated serum transaminase levels) were noted. The infant’s blood lead levels decreased with succimer treatment (Box 2), liver function results remained in the reference range, and his alertness and feeding improved by the 5th day of treatment. At 28 days of age, the infant was feeding well on formula and weighed 3160 g. He was discharged into foster care, and succimer therapy was ceased on Day 35. His growth and development were monitored. At the age of 12 months, he had global developmental delay, with an overall Denver Developmental level of 6–7 months.2 His blood lead levels at 4, 6 and 9 months of age were at least twice the upper acceptable limit (Box 2), although not at the level at which chelation therapy is recommended (> 2.16 μmol/L).3 DiscussionLead exposure in early childhood has long been known to have significant adverse effects on cognitive development.4,5 The National Health and Medical Research Council recommends that lead levels for all Australians be less than 0.48 μmol/L (10 μg/dL).1 However, intellectual impairment is seen in children with lower blood lead levels, and there may be no safe lower limit.6 Chelation therapy is recommended for any child with blood lead levels of 2.16 μmol/L and over.3 Although chelation therapy in early childhood lowers blood levels, recent studies have not shown significant improvement in cognitive and behavioural measurements compared with untreated children.3,4,7 There are a few case reports of neonatal lead intoxication that occurred from maternal exposure to lead through pica, home renovation, or use of contaminated herbal medications.8-10 Petrol sniffing is a form of substance misuse that is widespread in some Indigenous communities in Australia, and is associated with elevated serum lead levels.11 Changing the available petrol to an unleaded form should theoretically lessen the burden of lead toxicity in petrol sniffers. However, the aromatic hydrocarbons in both forms of petrol still cause considerable acute neurotoxicity,12 and petrol sniffers appear to prefer leaded petrol.13 Infants born to women who sniff petrol are more likely to have a birth weight < 2500 g than the infants of non-sniffers, and to require admission to a neonatal nursery for care, although this may be related to other associated lifestyle factors such as smoking and alcohol use.14 Lead freely crosses the placenta and is found in cord blood, amniotic fluid and fetal tissues.8 Cord blood lead levels are often higher than maternal blood levels,8,10 which might indicate preferential placental transfer,8 or be related to the higher neonatal haematocrit.9 In our patient, the cord blood lead level (3.98 μmol/L) was higher than levels in maternal blood collected 2 days before delivery (2.21 μmol/L). Reported effects of congenital lead exposure include intrauterine growth restriction, long-term cognitive problems, and radiographic abnormalities, such as increased bone density at the metaphyses.8,9 Acute neurotoxicity manifested as encephalopathy and peripheral neuropathy has also been described.10 Chelating agents used in the management of lead poisoning include intravenous sodium calcium edetate (CaNa2EDTA) and oral succimer (DMSA).3 Oral succimer is as effective as parenteral CaNa2EDTA.15 It has been previously reported that oral DMSA therapy has not been effective in the chelation of lead in newborns,10 although it is a proven and safe therapy in older children and adults.4,15 In our infant patient, blood lead level decreased spontaneously by 11% (0.45 μmol/L) during the first 10 days of life. After chelation therapy began, serum lead levels fell by 55% in 9 days. No drug-related side effects were noted in the infant.16 This infant did not show clinical signs of acute encephalopathy. His feeding and alertness improved after the start of chelation, but it is uncertain if this was due to falling lead levels or to the normal maturation of the premature infant. After the completion of therapy, serial blood lead levels showed a slow decline, but remained above the recommended level. This was most likely due to a slow release of bound lead from bone,8 but could also have resulted from ongoing exposure to environmental lead. As in similar cases, the infant had global developmental delay at 12 months of age despite chelation therapy.10 Factors other than lead, including malnutrition, recurrent infections and socioeconomic deprivation, might also have contributed to a poor developmental outcome. Petrol sniffing is a significant problem in some Indigenous communities, and it is likely that more infants will be born with lead exposure. Ideally, women who sniff petrol should be identified early in pregnancy. Interventions that might reduce the burden of fetal lead exposure include stopping further petrol sniffing, and giving calcium supplements to the mother to reduce bone resorption, as mobilisation of lead from maternal bone stores is a significant source of fetal lead exposure.17 Chelation agents are contraindicated in pregnancy, and are used only if maternal lead poisoning is life-threatening.8 Cord blood lead levels should be tested in at-risk infants, and chelation therapy given if levels are levels are over 2.16 μmol/L.3 Affected children are at high risk of neurodevelopmental delay. Follow-up and formal developmental assessment is made difficult in remote Indigenous communities by communication barriers, social and economic deprivation, and geographic isolation. Every effort should be made to offer early intervention services, as well as measures to optimise nutrition and general health. 1 Laboratory results for a neonate with lead poisoning and suspected sepsis Reference range* Day 4 Day 5 10:00 13:00 19:35 07:30 Serum levels Sodium (mmol/L) 133–146 140 140 141.6 140 Potassium (mmol/L) 4.6–6.7 4.9 4.5 4.7 4.8 Urea (mmol/L) 1.1–9.1 3.1 2.8 1.3 Creatinine (μmol/L) 56–146 65 65 43 HCO3 (mmol/L) 18–25 12.5 12.8 14.5 21.3 Venous pH 7.35–7.45 7.17 7.19 7.26 7.35 Base excess (mmol/L) − 4 to + 3 − 17.6 − 17.3 − 14.7 − 3.8 Haemoglobin (g/L) 150–170 179 Blood counts (× 109/L)† White cells 5.0–21.0 7.7 Neutrophils 1.5–10.0 1.6 Platelets 150–350 217 * For preterm infant. † Blood film appeared normal for a preterm infant, with no basophilic stippling of red blood cells. 2 Serial blood lead levels in an infant with lead poisoning * Chelation treatment with dimercaptosuccinic acid was given from Days 11 to 29 at a dose of 10 mg/kg, initially three times daily, reducing to twice daily from Day 16. † Maximum acceptable blood level of lead = 0.48 μmol/L. ‡ Urine lead level was raised at 0.82 μmol/L (maximum acceptable level = 0.02 μmol/L).

Suzanna T Powell FRACP · Srinivas Bolisetty FRACP · Gavin R Wheaton FRACP

A national policy challenges professionals to move beyond their specific field and view young people from a broad holistic perspective Health practitioners specialising in adolescence tend to have some common characteristics. They are passionate about young people. They have a strong community focus. And they tend to view health from a broad perspective that encompasses the links with families, peers and the school or workplace. It is this broad perspective that provides the critical link between discussions about adolescent health and those about youth development. This article begins with a wider focus on positive youth development and then shifts to ask questions in relation to health practice and delivery. In early 2002, the New Zealand Government released the Youth Development Strategy Aotearoa.1 This document was the product of extensive discussions and workshops with a cross-section of young people, youth practitioners and academics with an overseas peer review process. Led by the Ministry of Youth Affairs, the Strategy’s goal was ambitious. It was to provide a common framework that would inform all government policies in relation to young people. The driving question being — what do “we” need to do to support the development of a healthy youth population? Outline of the StrategyTalk of fragmented government policy is common — particularly in relation to young people. For Australia, with its federal and state policy machinery, this reality is likely to be accentuated (see Patton et al).2 The body of research on achieving health gains clearly signals that health outcomes are the result of a complex set of relationships and factors.3 Is it possible to develop a policy framework for one segment of the population, in this case young people, that can encompass this set of complex relationships? These were the bold objectives of the Youth Development Strategy Aotearoa. The Strategy is not a prescriptive list of what youth policies should be. This was intentional. National youth policies are often merely a collation of existing policies that relate to young people. Although this may be informative, it does little to advance a coherent and evidence-based approach that transcends the different policy silos. The challenge is to integrate the various strands of evidence into a single framework that informs discussions about the range of policies that affect young people (eg, health, education and justice policies). To achieve this, the Strategy needed to guide the way policy is constructed in many different areas of government and community life. An essential core of the Strategy is the six interrelated key principles: Youth development is shaped by the “big picture”. Youth development is about young people being connected. Youth development is based on a consistent strengths-based approach. Youth development happens through quality relationships. Youth development is triggered when young people fully parti-cipate. Youth development needs good information. The Box presents a visual summary of the Strategy’s approach. What has New Zealand learnt from this exercise?The process of developing and implementing the Strategy has highlighted a number of issues — both positive and negative — for New Zealand. Having one national framework to inform all youth policies is valuable. It has an ecological approach and is linked with an equivalent strategy for children. Having a dedicated youth development agency (Ministry of Youth Development) that is mandated to promote and monitor the application of the Strategy is critical. The Strategy has informed a number of policy initiatives since its launch, although this is difficult to quantify. The youth transitions policy for young people aged 15–19 years and not in education, training or employment4 drew heavily on the Strategy’s framework and evidence base. Importantly, the Strategy’s existence has helped to promote an integrated approach to young people’s health and development in an explicit way, as opposed to it being a vague ideal. There is still a degree of awareness of the Strategy across the country. As most government policy statements have a relatively short lifespan, this is positive. Four years after the Strategy’s launch, a survey of youth workers showed that 45% are familiar with its main points and a further 26% had heard of it and use the Strategy in their work.5 Other professionals tend to be more aware of their sector-specific policy documents (eg, in education, health, welfare, justice) than a generic youth document. They, like governments, tend to act in silos. On the negative side, there is the ongoing risk that the Strategy will revert to a single sector (or issue) focus. This would see youth development pigeonholed to focus on one aspect of young people’s development, instead of being the glass through which we view all youth policies. Related to this is the risk that the language of youth development and health will revert to a mechanistic, deficit-dominated style. Words and phrases like “holistic” and “social connectedness” are beginning to appear in government documents, frequently with very watered-down meanings. However, this is not altogether bad, as introducing new concepts into government vocabulary is necessary. As is the case with all government policies, gains in one area can be undermined by political pressure to introduce policies and approaches that are not consistent with the Strategy. An example of this interplay in New Zealand is the policies relating to youth offending. There is continual pressure on politicians to take a “get tough” stance on young offenders, despite this approach being at odds with the Strategy and contrary to the evidence that it is detrimental to young people’s development and health.6 Keeping a clear common conceptual framework for the Strategy has been important. Without this, the document risks fragmenting into a collection of policies that relate to young people, each with a different set of assumptions and understandings. It is very hard to achieve integration (or even coordination) of policies for young people without agreement on what is important to support young people’s healthy development. What could Australia learn from the New Zealand experience?There is a risk of overstating the contribution of the Strategy. Many people in the New Zealand health profession are unaware of its existence and possible application to their work. Noting these limitations, the most significant potential gain from this initiative is the challenge it presents to all professionals working with young people. It requires them to lift themselves above the boundaries of their professional context and training to view young people from a broad holistic perspective. In this position, there is no dominant issue or problem that is the focus — rather, the focus is on contributing to the positive healthy development of young people. A related challenge is to integrate insights gained from this wider perspective back into their professional sphere. This can be done by simply using the six principles to ask questions of a health service. For example, How much is your service informed by changes in the wider environment (big picture), such as rising unemployment or media messages? How does your service assist young people to make connections with other groups or agencies that can contribute to their wellbeing? How does your health practice help young people identify their strengths? How do workers in your service build effective relationships with young people? And so on. Feedback received on the Strategy is that its core messages are very simple — mostly common sense. We hope this is not a criticism, but just a reminder that we need not overcomplicate matters and that there is value in simplicity. The youth development approach Reprinted from the Youth Development Strategy Aotearoa.1

David Hanna BA · Sue Bagshaw FAChSM

Promotion of healthy youth development is a worldwide priority that cannot be achieved by parents and families alone. Health professionals must use and advocate for evidence-based strategies that enhance key protective factors in the lives of young people. The United Nations’ Millennium Development Goals create an unprecedented opportunity to partner with professional and youth-led organisations to ensure young people in the most vulnerable settings benefit from this initiative to reduce extreme poverty and threats to health and wellbeing.

Michael D Resnick PhD

Perceptions of young people’s health and wellbeing vary greatly, reflecting differences between disciplines, ideologies and generations. Young people are resilient, adaptable and doing well but, at the same time, are experiencing increased rates of important mental and physical health problems. While some of the contradictions in the evidence can be explained — for example, between measures of life satisfaction and happiness and indicators of psychosocial health — tensions between perspectives remain. We describe briefly a project involving cross-disciplinary synthesis that sought to gain a better understanding of the points of convergence and divergence in the commentaries and evidence on young people’s wellbeing in Australia. The project suggests that, if young people’s situation is to be optimised, there needs to be greater focus in both research and policy on: the “big picture” of the social changes reshaping life today; total health and wellbeing, not just ill health; the “mainstream” of youth, not only those young people who are marginalised and at-risk; and social and cultural resources that are as important to wellbeing as material and economic resources.

Richard M Eckersley BSc(Hons), MScSoc · Ani Wierenga BA(Hons), PhD · Johanna Wyn BA, MA, PhD

The concept of self-management is based on the notion that it will improve wellbeing and strengthen self-determination and participation in health care, while reducing health care utilisation and health costs. Increasing self-management is a desirable goal for the 15%–20% of children and adolescents who have a significant ongoing health care need related to a chronic health condition. Promoting self-management in young people with chronic illness can be difficult for parents and health care practitioners. Doctors can help parents recognise the potentially competing aspects of the parenting role — protecting young people’s health while supporting their growing independence and autonomy. Optimal care may or may not be achievable, depending on a young person’s level of development. As children mature through adolescence, they increasingly want their own voice to be heard, as well as the right to privacy and confidentiality in health care consultations. As well as listening to parents and supporting their roles, doctors should see young people alone for part of the consultation, taking a psychosocial history and carefully maintaining confidentiality.

Susan M Sawyer MB BS, FRACP, MD · Rosalie A Aroni PhD

Community debate about confidential health care for adolescents was triggered recently by the federal government’s proposal to allow parents of teenagers aged 16 years and under access to their children’s Health Insurance Commission data without their consent. Extensive research evidence highlights the importance of confidentiality in promoting young people’s access to health care, particularly for sensitive issues such as mental and sexual health, and substance use. Involving parents is important, but evidence for any benefit from mandatory parental involvement is lacking. The law recognises the rights of mature minors to make decisions about their medical treatment and to receive confidential health care; however, the doctor must weigh up certain factors to assess maturity and ensure that confidentiality around such treatment will be in the young person’s best interests. Evaluation of maturity must take into account characteristics of the young person, gravity of the proposed treatment, family factors, and statutory restrictions.

Lena A Sanci MB BS, PhD, FRACGP · Susan M Sawyer MB BS, MD, FRACP · Dagmar M Haller MD, FMHGen Med(Switz) · George C Patton MB BS, MD, FRANZCP · Melissa S-L Kang MB BS, MCH

Objectives: To identify perceptions of health, health concerns, and health service needs among young people in a suburb of Sydney, New South Wales.Design: Qualitative study using focus groups.Setting: Berowra, a geographically isolated suburb on the outskirts of Sydney, between December 2002 and April 2003.Participants: 40 Berowra residents aged 14–24 years, recruited from two local government high schools (two groups), a local youth drop-in centre (one group), and the community, through advertising at the youth centre, local schools and church groups (one group).Results: Focus group findings were classified into four broad themes. 1: Personal safety is a primary health concern. Berowra needs more recreational facilities to prevent drug and alcohol use related to boredom. 2: Health is more about quality of life than disease and illness. 3: Most health information comes from sources other than health providers. Health education must enable young people to make wise choices for the future. 4: Access to health services is of concern. More education is required on how Medicare works. Young people need to trust their service provider and will only see a doctor if they perceive themselves to be severely ill. Young people value meeting general practitioners in the school and community setting and not just in the doctor’s consulting room.Conclusions: Young people desire a whole lifestyle approach to health rather than the traditional model based on diagnosis and disease. Health information needs to be accessible anonymously, and healthy lifestyles need to be promoted throughout the whole community, using youth workers and sporting leaders as role models.

Carolyn H Kefford MB BS, FACPsychMed · Lyndal J Trevena MB BS(Hons), MPhilPH · Simon M Willcock MB BS(Hons)

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.

S Rachel Skinner PhD, FRACP · Cindy Ng MB BS(Hons), DCH · Ann McDonald MPaed, FRANZCP · Tamara Walters FRANZCOG

Paediatricians could raise parents’ awareness of potential problems with media exposure by asking a few simple questions during consultations “This instrument can teach, it can illuminate; yes, and it can even inspire. But it can do so only to the extent that humans are determined to use it to those ends. Otherwise, it is merely wires and lights in a box.”1 The media cut across virtually every major area of concern that parents and paediatricians have about adolescents — aggressive behaviour and violence, suicide, sex, drugs, obesity and eating disorders, and learning problems.2 Yet, both parents and paediatricians seem to show little understanding of the media’s impact on young people, and to take little time to try to consider the current situation — in which teenagers are inundated with messages in the media that are potentially harmful to their health. Why? My own theory is that parents and paediatricians are just too busy raising and caring for children and adolescents to have much time to watch, listen to, or read much media themselves. Furthermore, on the list of “important things” for parents to fight with teenagers about, their media use ranks near the bottom for most. Parents may also buy into the Hollywood myth that television and movies are merely fantasy entertainment. For paediatricians, it is difficult to have time to talk about the media in a busy office visit when there are so many other, “more important” topics to cover — vaccinations, seat belts, bicycle helmets, proper nutrition. However, the media should rank at the top of all concerns because they can have an impact on so many crucial areas of a teenager’s life, and paediatricians and parents need to realise that the media’s influence begins at a very young age. According to the first wave of the long-term Growing Up in Australia study, infants are already spending nearly 1.5 hours a day watching television, and 4–5-year-olds are spending about a third of their total play time (2.1 hours) watching television.3 In 2002, a study of more than 1000 Australians aged 10–13 years found that median screen time for this age group was up to nearly 4 hours per day (Tim Olds, Associate Professor, School of Health Sciences, University of South Australia, personal communication), and more than half of all Australian children aged 8–18 years have a television set in their own bedroom.4 The latest Kaiser Foundation study found that older children and teenagers spend more than 6 hours a day multi-tasking with a dizzying array of media, ranging from television and video games to the Internet, mobile phones and instant messaging, and iPods.5 What we knowMedia violence: There are more than 1000 studies linking exposure to media violence to real-life aggressive behaviour.6-8 Media violence also leads to desensitisation and to the belief that violence is an acceptable solution to everyday problems. A recent study found an association between viewing media violence at a young age and bullying.9 In fact, the connection between media violence and real-life aggression is nearly as strong as the link between smoking and lung cancer, and stronger than the connections between lead and IQ, homework and achievement, calcium and bone mass, and exposure to asbestos and cancer.2,6 Although much of the research has been done in the United States, an Australian Psychological Association position paper in 200010 and the Royal Australasian College of Physicians in 20044 acknow-ledged the significance of media violence. Teen suicide: Numerous studies in the US and Europe have shown a link between media coverage of suicide and subsequent increases in suicides among teens.11 Sex: Only a handful of studies have examined sexual content in the media and its impact on teenagers, but they all show that there is an impact.12 In the absence of effective sex education, the media have become one of the leading sex educators of children and teens today.12 In the most recent study of nearly 1800 teenagers, teens’ viewing of sexual content led to a doubled risk of earlier sexual initiation.13 In addition, most teenagers have been exposed to pornography online, whether intentionally or inadvertently.14,15 Drugs: Young people view as many as 2000 advertisements annually for beer on television alone in the US, and such ads do have an impact.16,17 Children and teens who view R-rated movies (designated suitable for ages 17 years and older in the US) are three times more likely to begin smoking.18 Obesity and eating disorders: Overweight and obesity are increasing at alarming rates in Australia, with a 2.5-fold rise over the past 20 years.19 Australia now has one of the highest rates of type 2 diabetes in the developed world.20 Numerous studies show that there is probably a causal connection between TV viewing and obesity,2 although the exact reasons remain unclear — might the constant barrage of junk food advertisements21 be contributing? A recent study from the Australian Divisions of General Practice found that there is an average of one junk food advertisement per commercial break in children’s television programming, and that 99% of all food advertisements during children’s TV was for junk food.22 Watching TV also correlates with unhealthy body self-image among young girls and teen girls.12,23 A recent study found a cause-and-effect relationship between the introduction of American TV programs into Fiji and the development of new eating disorders and abnormal body self-image among adolescents there.24 Learning problems: In the first study of its kind to examine this concern, researchers found that hours of television viewed per day at both ages 1 and 2 is associated with attentional problems at age 7.25 What we don’t knowWe don’t know why parents and paediatricians don’t pay more attention to the media’s influence on children and adolescents. During an office visit, how long would it take to ask two simple questions of parents? How much TV (and other media) does your child view each day? Is there a TV set in your child’s bedroom? For children and teens who are aggressive, obese, or who are doing poorly in school, perhaps a more detailed media history could be obtained. The recent report from the Royal Australasian College of Physicians outlines a variety of ways that paediatricians can be more attuned to this issue.4 For example, they can be far more assertive in providing counselling to parents about the impact of media on children, and encourage household rules about media use. They should avoid placing TV sets in their waiting rooms. Paediatricians should also be at the forefront of discussions with filmmakers about depicting cigarette smoking in mainstream movies. Finally, both parents and paediatricians need to lobby governments for more funding for research into the crucial areas of how the media affect children and teens, what can be done to maximise pro-social media and protect against harmful media’s influence, better programming for young people, and more funding for media education campaigns and media education programs in schools. TV, movies, and video games may seem like “harmless entertainment” to adults and to Hollywood, but they exert a potent influence on young people. The question is not whether children and teenagers are learning from the media; it is how much and what are they learning.

Victor C Strasburger MD

Objective: To determine the extent to which comprehensive health screening of adolescents was undertaken in a tertiary inpatient setting.Design and setting: Retrospective review of 100 consecutive medical records of 13–18-year-old adolescents admitted to The Royal Children’s Hospital, Melbourne (first 20 consecutive admissions in 2001 to each of five units — general medicine, adolescent medicine, specialty medicine, general surgery, and specialty surgery).Main outcome measures: Documentation of screening for biomedical (height, weight, pubertal staging, and hepatitis B vaccination) and psychosocial concerns (HEADSS framework categorised into four screening levels — none, incomplete, adequate, thorough). Risks identified and actions taken.Results: Weight was recorded for 98 patients, height for 17, pubertal staging for 12, and hepatitis B vaccination status for nine. Documentation of psychosocial screening was absent from 62 charts, inadequate in 29, thorough in three, and complete in seven charts. Adolescent medicine inpatients were more likely than patients in other units to have any screening of psychosocial risk recorded and more likely to be thoroughly screened (P < 0.005). Screening was more often documented for less sensitive issues (eg, home, tobacco) than higher risk behaviours (eg, illicit drug use) (P = 0.013). When screening identified risks, appropriate action was undertaken in most cases.Conclusions: This study highlights deficiencies in comprehensive health screening in adolescents admitted to a tertiary children’s hospital. These results support the development of more consistent approaches to screening adolescent inpatients.

Michele S M Yeo MB BS, FRACP · Lyndal M Bond MA(AppPsych), PhD · Susan M Sawyer MB BS, FRACP, MD

This state-wide Aboriginal community child health survey, the first of its kind in Australia, describes physical and mental health and their antecedents in Western Australian Aboriginal children and young people. Aboriginal young people had significantly more physical and mental health problems and were more likely to engage in lifestyle risk factors than non-Aboriginal young people. Aboriginal young people tend to be caught up in a cycle of disadvantage that includes family and community factors as well as recent history, facilitating their making less optimal life choices, thereby perpetuating the cycle. A coordinated approach will be required to break this cycle, in which appropriately and sympathetically provided medical attention is necessary but not sufficient.

Eve M Blair PhD · Stephen R Zubrick PhD · Adele H Cox DipAppSci

In Australia, where about 16% of young people are born overseas and 24% are from a non-English-speaking background, adolescent health care is a multicultural challenge. “Cultural competency” involves challenging one’s own cultural assumptions and beliefs, developing empathy for people from other cultures, and applying specific communication and interaction skills in clinical encounters. For health professionals, sensitivity to the cultural, ethnic, linguistic and social diversity among young people helps to avert problems and misunderstandings, improves satisfaction for all concerned and leads to better outcomes. Engaging the family and gaining the trust of parents is critical in treating young people from cultural backgrounds in which participation in health care is a family concern rather than an individual responsibility.

David L Bennett MB BS, FRACP, FSAM · Peter Chown BSc(Psych), MAPS(Hons) · Melissa S-L Kang MB BS, MCH

Dagmar M Haller,* Lena A Sanci,† George C Patton,‡ Susan M Sawyer§ * General Practitioner and PhD Candidate, ‡VicHealth Professor and Director of Adolescent Health Research, §Professor of Adolescent Health, and Director, Centre for Adolescent Health, Murdoch Children's Research Institute and The University of Melbourne, 2 Gatehouse Street, Parkville, VIC 3052. †Senior Lecturer, Department of General Practice, The University of Melbourne, Melbourne, VIC. dagmar.hallerATmcri.edu.au To the Editor: We recently advocated the inclusion of a mature-minor clause in the National Health and Medical Research Council ethics guidelines on teenagers’ participation in research.1 This would allow minors (teenagers younger than 18 years) who show sufficient maturity and understanding to consent to participation in minimal risk research (eg, observational studies and quality assurance studies) without requiring parental consent. This is important in primary care research, as teenagers presenting to general practitioners without an accompanying parent or carer frequently wish their visit to remain confidential. To exclude this group from research would deny them the benefit of potential improvements to their health care as a result of research. As no such data were available in Australia, we sought to document, as part of a larger primary care study of young people’s perspectives on their health problems and their expectations from a GP consultation, the proportion of teenagers aged 16 to 18 years who potentially would not be able to participate because they presented without a parent. We also documented whether, when present, parents would express concern about not being asked to provide consent for their teenaged child to participate. We recruited up to 20 consecutive patients aged 16 to 24 years in each of 26 randomly selected practices throughout Victoria and invited them to participate in an interview on their perspectives on the health problem for which they had come to see the doctor and their expectations from the consultation. Our institutional ethics committee approved inclusion of minors aged 16 to 18 years without parental consent. One of the authors, a GP (D H), obtained consent from participants and conducted the interviews. Results are reported with 95% confidence intervals adjusted for clustering within practices. Of the 501 young people approached, 101 were minors. Five minors (5%; 95% CI, 0.6%–9%) were excluded (too unwell, intellectually disabled or non-English speaking), and another five (5%; 95% CI, 1%–8%) declined participation. Of the 91 minors who consented to participation, 40 (44%; 95% CI, 35%–53%) had come without a parent. Although 37 of the parents of the 51 minors who were accompanied (73%; 95% CI, 59%–86%) went into the GP consulting room with their children, only one was concerned about her child consenting and participating in an interview on his own. Had parental consent been mandatory, nearly half the patients aged 16 to 18 years could not have been included in this primary care study. When present, the overwhelming majority of parents did not disapprove of their children consenting and participating on their own. These findings support the idea that, for low-risk studies in primary care, mature minors should be given the opportunity to consent to participation on their own.

Dagmar M Haller · Lena A Sanci · George C Patton · Susan M Sawyer

Graham D Hocking Child Psychiatrist, 25 High St South, Kew, VIC 3101. ghockinATiprimus.com.au To the Editor: Catto-Smith gives a very good account of the medical management of constipation and soiling in children,1 but fails to mention psychological, interpersonal and social factors in the main part of his article. He does mention “behavioural abnormalities” towards the end, in the section “When to refer”. I think it is generally accepted among paediatricians and child psychiatrists that the problem of constipation and soiling, or encopresis, often has multiple determinants and varied psychological effects on the child and the family. Certainly, the older the child is, the more likely these effects will be present.2 If this condition is to be managed in general practice over a period of “6–12 months”, general practitioners need to be aware of these factors so they can be addressed. Twelve months is a long time in the life of a 5 year old, and in that time pathological patterns can become well established and hard to shift. Most children over 5 years with soiling have developed secondary psychological problems as a result of the soiling.3 At this stage, assessment by a child psychiatrist will often reveal that the child has developed a pathological fantasy world around what they believe is happening inside them. The physical management of constipation and soiling is an essential part of the management no matter what the aetiology, but addressing the psychological interpersonal and social factors is equally important. If these factors are obvious to the GP and are not responding to intervention, the family should be referred to a child psychiatrist. With children over 5 years, the secondary effects have almost always become significant, and I believe that all these families should be referred for assessment. Catto-Smith quotes a 30%–50% relapse rate,1 and “there is evidence that they do not improve on reaching puberty”. This is not my experience with families that have the benefit of a multidisciplinary approach to the disorder.

Graham D Hocking

Anthony G Catto-Smith Director, Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052. tony.cattosmithATrch.org.au In reply: Hocking emphasises secondary behavioural and emotional effects that occur in some children with longstanding faecal soiling. Fortunately, there is good evidence that these tend to resolve with effective multimodal treatment of the constipation.1 The relatively high long-term relapse rate of soiling among children who have been treated in tertiary centres has only recently been recognised,2 but the psychological features of this relapsing group are not well defined. My review was directed toward general practitioners and was as much as possible evidence-based. I am unaware of any good quality evidence to support Hocking’s assertion of the benefits of automatic referral to a child psychiatrist of all children over the age of 5 years with ongoing faecal soiling. Given the beliefs of both myself and Hocking, that constipation and soiling are likely to have multiple determinants and varying psychological effects, it would seem to be appropriate to triage “problem” patients through a general paediatrician, with referral for psychological assistance if deemed appropriate. This is best summed up in my article in the section that Hocking mentions, “When to refer”.3

Anthony G Catto-Smith

Objectives: To determine the incidence of childhood type 1 diabetes mellitus (T1DM) in New South Wales from 1997 to 2002; to compare with previously published rates (1990–1996); and to analyse trends in incidence from 1990 to 2002.Design, setting and participants: Prospective population-based incidence study. Primary ascertainment of incident cases aged < 15 years was from the Australasian Paediatric Endocrine Group NSW children’s diabetes register. Secondary ascertainment was from the National Diabetes Supply Scheme until 1999 and from the Australian Institute of Health and Welfare thereafter. Childhood population data were obtained from the Australian Bureau of Statistics.Main outcome measures: Age-standardised incidence; trends in incidence by calendar year, and sex and age at diagnosis.Results: There were 3260 incident cases (1629 boys, 1631 girls) in the 13 years. Case ascertainment was 99.7% complete using the capture–recapture method. Mean age-standardised incidence per 100 000 person-years was 20.9 (95% CI, 19.9 to 21.9) from 1997 to 2002 compared with 17.8 (95% CI, 17.0 to 18.7) from 1990 to 1996; there was a plateau in incidence between 1997 and 2002. Overall, the incidence increased on average by 2.8% per year (95% CI, 1.9% to 3.8%, P < 0.001) and increased with age, being 12.2 (95% CI, 11.3 to 13.1) in 0–4 year olds; 18.9 (95% CI, 17.8 to 20.0) in 5–9 year olds and 26.7 (95% CI, 25.4 to 28.1) in 10–14 year olds. The increase per year in 0–4 year olds (3.9%) was not significantly higher than in older children. The mean incidence of T1DM was 19.8 (95% CI, 18.8 to 20.7) in girls and 18.8 (95% CI, 17.9 to 19.7) in boys (P = 0.02).Conclusions: The incidence of childhood-onset T1DM has increased significantly in all age groups in NSW since 1990. Resource planning in the management of childhood diabetes in NSW should take these findings into account.

Craig E Taplin MB BS · Maria E Craig PhD, FRACP, MMed(ClinEpid) · Margaret Lloyd RN · Martin Silink AM, MD, FRACP · Neville J Howard FRACP, FRCP · Claire Taylor MB ChB · Patricia Crock FRACP