Child health

Up to 20% of parents report a problem with infant crying or irritability in the first 3 months of life. Crying usually peaks at 6 weeks and abates by 12–16 weeks. For most irritable infants, there is no underlying medical cause. In a minority, the cause is cow’s milk and other food allergy. Only if frequent vomiting (about five times a day) occurs is gastro-oesophageal reflux a likely cause. It is important to assess the mother–infant relationship and maternal fatigue, anxiety and depression. Management of excessive crying includes: explaining babies’ normal crying and sleeping patterns; helping parents help their baby deal with discomfort and distress through a baby-centred approach; helping parents recognise when their baby is tired and apply a consistent approach to settling their baby; encouraging parents to accept help from friends and family, and to simplify household tasks. If they are unable to manage their baby’s crying, admission to a parenting centre (day stay or overnight stay) or local hospital should be arranged.

Harriet Hiscock FRACP, MD, GradDipEpi · Brigid Jordan BSW, PhD

Correction Re: “Prevalence and nature of connexin 26 mutations in children with non-syndromic deafness”, by Hans-Henrik M Dahl, Kerryn Saunders, Therese M Kelly, Amelia H Osborn, Stephen Wilcox, Barbara Cone-Wesson, Julia L Wunderlich, Desiree Du Sart, Maria Kamarinos, Robert J McKinlay Gardner, Shirley Dennehy, Robert Williamson, Neil Vallance, Patricia Mutton (Med J Aust 2001; 175: 191-194). A recent audit of our use of Guthrie cards has shown that the 1000 anonymous Guthrie blood spots used to estimate the connexin 26 carrier incidence in our study were collected in a week selected at random from 1984, and not May 1986 as stated on page 193. (Also, in the Abstract [page 191], the collection year, given as 1986, should read 1984.) This does not affect the study results or our conclusions.

Hans-Henrik M Dahl

An Australian model could be used to get better “evidence” into legal decision-making The UK government is reviewing 258 cases in which a parent was convicted of murder, manslaughter or infanticide. This review follows the overturning of the conviction of one mother for the murder of two of her children, and the collapse of the prosecution case against another mother accused of murdering three of her children. In addition, the cases of thousands of children spirited into care, as they were deemed to be at risk of child abuse, may also be revisited. One of the key issues in these events has been the incorrectness of evidence advanced by an expert medical witness whose estimates of the probability of the occurrence of more than one sudden infant death occurring in a family were grossly incorrect. Both in the UK and Australia, primary care is not particularly well placed to detect cases of child abuse As a consequence of all these developments, UK doctors are now apparently reluctant to sit on child protection committees. A news item in the BMJ reporting this eventually generated 38 rapid online responses, reflecting varied but always strong views on the difficulty of getting the appropriate balance between protecting the child and destroying the family. The foregoing events raise two issues — how do we get better “evidence” into legal decision-making and, realising that we may never get it completely correct, should we have a system that is inclined to accept false positives or false negatives in attribution of guilt in cases of possible child abuse? Taking the issue of evidence first, one of Australia’s better-kept secrets is its excellent system of applying evidence to compensation claims of military veterans — a model which could be adopted elsewhere. The crux of the system is an independent panel that uses sound medical–scientific evidence to determine the causation of injury, disease or death in relation to exposure to military service. Although this does not relate to individual cases, but to the generality of exposure, the success of the program and the principles by which it operates provide a model that may be adapted in other jurisdictions. The independent panel arose from a request in 1994 by the Australian government to the Repatriation Commission. The Commission was asked to prepare, in consultation with veterans’ organisations, legislation to reform the process of decision-making about the causation of disease. The purpose of the reform was to create a more equitable and consistent system for dealing with claims for disability pensions received from Australian veterans and their dependants. One of the outcomes of the legislative reform was the formation of the Repatriation Medical Authority (RMA), an independent statutory authority responsible to the Minister for Veterans’ Affairs (see <www.rma.gov.au/>). The RMA consists of a panel of five practitioners eminent in fields of medical science. Their role is to determine “statements of principles” for any disease, injury or death that could be related to military service, based on sound medical–scientific evidence. The statements of principles state the factors that “must” or “must as a minimum” exist to cause a particular kind of disease, injury or death. The statements of principles also identify what constitutes “sound medical–scientific evidence” for the purpose of applying the relevant standards of proof relating to particular kinds of injury, disease or death affecting veterans: the “reasonable hypothesis” standard and the “reasonable satisfaction” (or “balance of probabilities”) standard. In its modern guise, epidemiology makes attribution of causation a rigorous process, with clear principles to be followed, and there can even be different levels of proof required for decisions from the same database. Acquiring these skills is quite different from the experience of clinical practice and significantly changes the definition of the traditional “expert witness”. The RMA has been externally reviewed and shown to make consistent decisions at its prescribed standards of proof. With such consistency in establishing causal decisions, all plaintiffs can be assured of a standardised level of judgement that does not vary from one expert witness to another. Such a system would not have allowed the error in assigning probabilities that occurred after the deaths of children in the UK. Having mentioned epidemiology, let’s move to the question of false positives or false negatives. Set the bar of suspicion too high, and child abuse will go unpunished. Set it too low, and there will be false accusations, imprisonment and family break-ups. What would be the epidemiological approach to this? First, there is a pressing need for better diagnostic tests. Are social workers and paediatricians trained well enough to identify and differentiate between real and alleged child abuse? Does this training identify the importance of pretest probability (the prevalence) and its influence on false positives and false negatives? While the training should include the relevant clinical, psychosocial, ethical and legal domains, there needs to be some good old-fashioned clinical epidemiology thrown in, to demonstrate that, in situations of low prevalence (as is usually the case with child abuse), the predictive value of a “positive” test is low. Paediatricians, social workers and primary care teams should receive more formal training and undergo some kind of accreditation and review process. Both in the UK and Australia, primary care is not particularly well placed to detect cases of child abuse or early warning signs of infanticide, and there are lost opportunities. Second, can we improve systems for reporting or our monitoring and evaluating services? An overhaul of current processes, development of less cumbersome reporting procedures, and better resourcing, as well as incentives for people to do this work, would be a start. In all this, the role of the media and various lobby groups in whipping up public concern cannot be forgotten — objectivity is difficult enough to achieve without these pressures. There is an obsession with identification and demonisation of paedophilia in Britain, fuelled by the tabloid press with its unhelpful, brutalising effect on complex social issues. But is child abuse less common in Australia? Are the media more, or less, responsible? Are paediatricians and social workers better trained? The Repatriation Medical Authority certainly sets a good example, which could be followed both within Australia and elsewhere for reducing the variability of expert opinion in possible child abuse and other medicolegal cases. Adopting this model in the UK may reduce the uncertainty surrounding child abuse that has transfixed the medical and general community here.

Richard F Heller MD, FRCP, FRACP, FAFPHM · Konrad Jamrozik DPhil, FAFPHM, MFPH · David P Weller MPH, PhD, FRACGP, FAFPHM

Objective: To determine the changes in availability of neonatal intensive care for extremely low birthweight (ELBW) infants, and the consequences of a lack of availability.Design and setting: Population-based cohort study of consecutive ELBW infants born in the state of Victoria during four distinct eras.Participants: All livebirths weighing 500–999 g in Victoria in the calendar years 1979–1980 (n = 351), 1985–1987 (n = 560), 1991–1992 (n = 429), and 1997 (n = 233).Main outcome measures: Changes over time in the proportions of ELBW infants offered intensive care, the proportions that were “outborn” (born outside level 3 perinatal centres), and their survival rates and quality of survival compared with “inborn” infants.Results: The proportions of ELBW infants offered intensive care increased over time and were significantly higher in heavier infants. The proportion of outborn ELBW infants was 30% in 1979–1980, falling to 9% by 1997. The difference in survival rates between inborn and outborn infants widened progressively over time: the survival advantages for inborn infants over outborn infants were 12.0% in 1979–1980, 30.1% in 1985–1987, 36.5% in 1991–1992, and 43.6% in 1997. For survivors, the quality of life was significantly better for inborn infants in two of the four eras.Conclusions: Neonatal intensive care has been increasingly available for ELBW infants in Victoria over the period 1979 to 1997. The gap in survival rates between outborn and inborn infants has widened, and the quality of life of outborn survivors is inferior.

for the Victorian Infant Collaborative Study Group*

Objective: To determine the prevalence and types of deliberate self-harm (DSH) in adolescents, and associated factors.Design: A cross-sectional questionnaire study.Participants and setting: 3757 of 4097 Year 10 and Year 11 students (91.7%) from 14 high schools on the Gold Coast, Queensland, during September 2002.Main outcome measures: DSH behaviour, including descriptions of the last act, psychological symptoms, recent stressors, coping styles, help-seeking behaviour, lifestyle choices, and self-prescribing of medications.Results: 233 students (6.2%) met the criteria for DSH in the previous 12 months, with DSH more prevalent in females than males (OR, 7.5; 95% CI, 5.1–10.9). The main methods were self-cutting (138 respondents; 59.2%) and overdosing with medication (69 respondents; 29.6%). Factors associated with DSH included similar behaviours in friends or family, coping by self-blame, and self-prescribing of medications. Most self-harmers did not seek help before or after their most recent action, with those who did primarily consulting friends.Conclusions: DSH is common in Australian youth, especially in females. Preventive programs should encourage young people to consult health professionals in stressful situations.

Diego De Leo MD, PhD, FRANZCP · Travis S Heller BSc(Hons), BA

Christine B Phillips,* Suzanne Manning† * Senior Lecturer, Academic Unit of General Practice and Community Health, Australian National University Medical School, PO Box 254, Jamison Centre, Jamison, ACT 2614; † Intern, Department of Psychology, Australian National University, Acton, ACT. christine.phillipsATcalvary-act.com.au To the Editor: Since 1999, most asylum seekers in Australia who have been detained and subsequently found to be genuine refugees have been issued temporary protection visas (TPVs). Missing from much of the debate about management of asylum seekers has been the impact of the provisions of TPVs on children. A comparison of the entitlements of refugees on permanent and temporary protection visas is given in Box 1. To estimate the proportion of TPVs issued to children under 18 years of age, we analysed data provided by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA). The denominator population was drawn from data on numbers of temporary and permanent protection visas issued between June 1999 and June 2002.1,2 Numerator data were drawn from information provided by DIMIA on request.3 As shown in Box 2, we found that between October 1999 and June 2002, 23% of all TPVs were issued to children under the age of 18. Some of these children are now over 18 years of age. However, as children born to TPV holders in Australia are also given TPV status, more children will be recruited into this visa category. Australia is a signatory to the UN Convention on the Rights of the Child, which enshrines key rights for children, such as the right to health and safety.4 However, we believe that several of these basic rights are undermined by the lack of provisions afforded to TPV holders: they are prohibited from sponsoring family members, and they have limited access to settlement services for refugees (Box 1). Withholding of family reunion provisions increases the risks for children, as it makes it more likely that parents will take their children with them when they undertake hazardous travel to seek asylum. This is in contrast to the traditional model of families sending an index person, who then sponsors other family members. The lack of a comprehensive settlement package for TPV holders, and the temporary and indeterminate nature of the visas, is likely to compound the psychological distress experienced by both adult and child refugees. Children who have experienced ongoing adversity are vulnerable to developing psychological disorders.5 The children of TPV holders must also live in families where the parents bear an ongoing burden of fear and destabilisation. The effects of TPVs are borne by large numbers of children. There is a need for concerted advocacy by health professionals to ensure that the health consequences of TPVs for children are recognised and addressed. Addendum 13/07/04. While a recent federal government initiative will allow current Temporary Protection Visa holders to apply for permanent Australian residency, we urge ongoing review of refugee visas. 1 Comparison of entitlements of refugees on permanent and temporary protection visas Services funded by the Australian Government Refugees with permanent visas Refugees with temporary protection visas Settlement services Translating and interpreting service Eligible Not eligible Accommodation support Eligible Not eligible Assistance from Migrant Resource Centre Eligible Not eligible Early health and intervention service Eligible Eligible Torture and trauma counselling Eligible Eligible English language tuition Free tuition for adults and children Adults not eligible. Children eligible from July 2002 Family reunion May apply to sponsor family members Not eligible Employment Access to all assistance programs Not eligible except for most basic services Income support Eligible for full range of social security benefits Restricted entitlements Medicare Eligible Eligible Education Primary and secondary education Eligible Eligible Tertiary education Eligible for HECS Must pay upfront fees Travel Right of return if holder travels overseas No right of return if holder leaves country HECS = Higher Education Contribution Scheme. 2 Proportion of temporary protection visa (TPV) holders who were children when visa was granted (1999–2002) Years* No. of TPVs granted No. (%) < 18 years when TPV granted 1999–2000 871 108 (12.4%) 2000–01 4456 907 (20.3%) 2001–02 3196 952 (29.8%) Total 8523 1967 (23.1%) * Financial years.

Christine B Phillips · Suzanne Manning

At least a quarter of primary school children in Australia are overweight or obese; the long-term impacts are likely to include chronic morbidity and loss of life-years. Universal preventive strategies have so far had limited effectiveness, while secondary and tertiary referral services would be overwhelmed if they attempted to systematically manage a problem with such high prevalence. Primary care services could play an important role in secondary prevention of overweight and mild obesity in children. While reports of child obesity research have burgeoned since 1995, effectiveness trials of primary care interventions in primary-school-aged children have been neglected. Randomised controlled trials of a primary care approach, although challenging, are essential to determine whether it does more good than harm.

Melissa A Wake MD, FRACP · Zoë McCallum FRACP

In November 1999, in the United Kingdom, a woman was convicted of the murder of her two infant sons. An appeal against the conviction was dismissed in October 2000, but the conviction was quashed by a second court of appeal in January 2003. Review of the autopsy findings showed that standard procedures had not always been followed, thus limiting verification of the alleged findings. Some potentially important diagnoses and conclusions were also altered over time. This case and its sequelae demonstrate the difficulties that may arise if cases are not fully investigated by pathologists with specific training or experience in paediatric forensic pathology, with all of the results being clearly summarised and discussed in autopsy reports. Trying to clarify findings, diagnoses and circumstances of death at a later stage may simply not be feasible, owing to a wide variety of possibilities other than inflicted injury. This type of case has unfortunately led to mistrust of the medical and legal systems and has made the investigation of such emotive and tragic cases all the harder.

Roger W Byard MD, FRCPath

Objective: To determine the incidence of congenital heart defects (CHD) in Aboriginal and non-Aboriginal infants in Central Australia and to compare this with the incidence elsewhere in Australia.Design and setting: Data on cases were obtained from patient records of the Alice Springs Hospital, Central Australia, the sole referral centre for paediatric and initial cardiac diagnostic services for the region.Participants: Patients with CHD proven by echocardiography reported between 1 January 1993 and 30 June 2000.Main outcome measures: Incidence of CHD using all live births in Central Australia as the denominator.Results: 108 patients with CHD were detected among 6156 live births (incidence, 17.5 per 1000; 95% CI, 14.9–21.7 per 1000); 57 of 2991 were Aboriginal (19.0 per 1000; 95% CI, 14.4–24.6 per 1000) and 51 of 3165 were non-Aboriginal (16.1 per 1000; 95% CI, 12.0–21.1 per 1000). The difference between the two groups was not statistically significant (relative risk, 1.18; 95% CI, 0.81–1.72). CHD incidence in Central Australia was significantly higher than that reported for other parts of Australia (4.3 per 1000 live births in New South Wales and the Australian Capital Territory, 1981–1984; 7.65 and 12 per 1000 total births in Western Australia, 1980–1989, and South Australia, 1993–2000, respectively).Conclusions: The high rates of CHD in Central Australia may partly reflect the high utilisation of echocardiography for assessing minor lesions. However, the incidence of both major and minor types of CHD was significantly higher than previously reported from other regions of Australia. The role of socioenvironmental factors in this high incidence should be explored.

Srinivas Bolisetty FRACP · Ameet Daftary MD · Dan Ewald FAFPHM · Brodie Knight FRACP · Gavin Wheaton FRACP

To the Editor: We read with interest the article by Mitchell et al and the editorial by Cole on comparatively adverse outcomes in adolescents and young adults with cancer.1,2 The improvements in cancer survival, most remarkably demonstrated in children, have failed to similarly benefit older adolescents and young adults, a population with a higher and increasing incidence of cancer.3 Most authors advocate increasing research, networking resources and information, enhancing support for clinical trials and facilitating participation in them. Recently announced funding for a comprehensive cancer-care program for adolescents and young adults at the Peter MacCallum Cancer Institute in Melbourne is a welcome step towards these goals. The specific emotional and psychosocial needs of this age group are also poorly addressed within traditional models of care.4 Patients in this group express strong preference for peer support, opportunities to be cohorted with each other and access to specific support services.4 The short and long term sequelae of cancer, as well as of its treatment, in adolescents and young adults create particular challenges for both healthcare professionals and the broader community. In December 2003, an entire issue of the European Journal of Cancer was dedicated to adolescent oncology — this science, clinical care and the needs of the patient population.5 An important development in the United Kingdom has been the establishment of eight “teenage cancer units” with a comprehensive approach to all aspects of care.6 Preliminary research in Australia and New Zealand by one of our group (J E) highlights gaps in service and support perceived by consumers, concerns yet to be addressed by appropriate policy and funding.7 The paediatric model of care has provided not only excellent survival but also an exemplary family-centred and comprehensive support system. The recent emphasis on the transition process for adolescents with a variety of chronic illnesses has highlighted systemic differences between the paediatric and adult models. Some paediatric oncologists, especially in the United States, have proposed raising the upper age limit for eligibility to childhood cancer units as a solution. A more realistic approach, particularly in Australia, requires establishing specialist facilities operated in partnership between (preferably collocated) adult and paediatric units, with subspecialisation of the multidisciplinary workforce, an age-appropriate environment and peer support from groups like the Australian Organisation for Young People Living with Cancer (CanTeen). This approach is capable of addressing all of the above issues, from better science through to psychosocial expertise appropriately targeted for age. The ideal number and distribution of such centres/partnerships should be guided by the paediatric track record for balancing centralisation and quality with access and family focus.

Les White · Jane Ewing · Anne M Senner · Madeleine King · Belinda Goodenough

To the Editor: It has been claimed that patients are missing out on the most effective current treatments if they are not given an opportunity to enrol in clinical trials. Such statements are misleading and have the potential both to create concern in those without access to trials and to reduce the likelihood of true informed consent for involvement in trials. Trials are, by definition, just that — trials. Treatment in the “innovative” arm(s) may result in worse outcomes. The finding that those involved in trials have a better outcome (eg, 5-year survival) may have numerous explanations. It is unlikely that the innovation is an adequate explanation for the finding — confounding factors such as selection bias, adherence to best current practice, and intensity of monitoring are more likely explanatory factors. Furthermore, it is important to focus on other outcomes of therapeutic endeavour, such as quality of life, and the impact of the illness on other family members. Patients who live some distance away from tertiary referral centres or trial centres may have a greater adverse effect from involvement in a trial than other patients who live close to such centres. Well designed trials are a crucial part of advancing medical therapeutics. However, the recent editorial by Cole1 and the article by Mitchell and colleagues2 in the Journal have been picked up by the news media as demonstrating that only through involvement in clinical trials can patients get best-quality care. It is not surprising that this is the way that the message has been received. The truth is importantly different. It is only through the conduct of clinical trials that best practice can be defined. However, patients anywhere in the country should be able to access current best-practice treatment even if they do not want to be involved in a clinical trial. Encouragement to participate in clinical trials should be based on arguments about the “greater good” and not about issues of quality of care. To use the latter as the basis for argument must be seen as coercion and as unethical.

Alex N Thomson

In reply: Thomson is correct in stating that patients involved in clinical trials have better 5-year survival rates when compared with patients not recruited into clinical trials. There may, as Thomson points out, be numerous possible explanations for this finding. Nonetheless, this improvement in survival is well documented and has been recognised for some time.1 Although it is becoming increasingly important to focus on other therapeutic outcomes, such as quality of life, it is incorrect to assume that involvement in clinical cancer trials equates to impairment of quality of life and an increase in adverse effects. In fact, the primary end-point of numerous clinical cancer trials is improved quality of life.2 We agree with Thomson when he states that patients anywhere in the country should be able to access current best-practice treatment. We agree that best-practice treatment can only be defined through the conduct of clinical trials. Hence, well designed clinical trials are necessary, and indeed crucial, to the advancement of cancer therapy. In the context of adolescents and young adults with cancer, the lower than expected improvement in survival may be explained, in part, by a low rate of participation in clinical trials.3 There is no doubt that participation in late-phase clinical trials provides a “benchmark” and ensures the provision of quality medical care. Rural and regional settings should not, a priori, be a barrier to trial participation. Adequate infrastructure and support should be available for such centres to participate. Greater cooperation between all adult and paediatric clinicians involved in the care of adolescents and young adults with cancer is essential to ensure that the inequity in survival is corrected.

Anne E Mitchell · Deborah L Scarcella · Gemma L Rigutto · David M Ashley · Vicky J Thursfield · Graham G Giles · Maree Sexton

Objective: To assess compliance with current standards of playgrounds where children have sustained a fall-related arm fracture.Design, setting and participants: Between October 2000 and December 2002, a consecutive prospective series of 402 children aged under 13 years who fell from playground equipment and sustained an arm fracture was identified by emergency department staff in five Victorian hospitals. Trained field testers measured playground equipment height, surface type and depth, and surface impact attenuation factors to determine compliance with safety standards.Main outcome measures: Playground compliance with current Australian safety standards.Results: Ninety-eight percent of playgrounds had a recommended type of surface material. The mean surface depth was 11.1 cm (SD, 5.0 cm) and the mean equipment height was 2.04 m (SD, 0.43 m). Although over 85% of playgrounds complied with recommended maximum equipment height and surface impact attenuation characteristics, only 4.7% complied with recommended surface depth.Conclusion: Playgrounds where children have sustained an arm fracture generally comply with all important safety recommendations except surface depth. Playground fall-related arm fracture requires specific countermeasures for prevention, distinct from head injury prevention guidelines.

Shauna Sherker PhD, MSc, BSc · Joan Ozanne-Smith MD, FAFPHM, MPH

Jennifer H Barralet,* Neil R Parker† * Epidemiologist, Communicable Diseases Unit, † Public Health Physician, Darling Downs Public Health Unit, Queensland Health, GPO Box 48, Brisbane, QLD 4001. Neil_ParkerAThealth.qld.gov.au To the Editor: Queensland has a small but increasing number of Q fever notifications in children. This is of concern to public health services in the Darling Downs and south-west Queensland where most Q fever notifications originate (Box). Little is known about Q fever in children, especially in Australia, as the disease is primarily diagnosed in adults following occupational exposure to Coxiella burnetii. Here we report a case series examining clinical presentation, exposure to risk factors and disease outcomes in children. Twenty-one children aged 3–14 years notified with Q fever from the Darling Downs and south-west Queensland in 2001 and 2002 were followed up. In acute cases the febrile illness was similar to that in adults from the same region. The one child with chronic Q fever had no known acute illness and presented with osteomyelitis of the wrist. All the children recovered, although relapsing symptoms were reported in two children and three reported persisting fatigue for 3 months or more after diagnosis. All but one patient reported contact with cattle, sheep or goats (13 lived on a farm and 7 had visited a farm). The single exception reported contact with kangaroos and feral pigs through hunting. Prolonged exposure to animals or the farm environment was not necessary for infection. Twelve of the children had high risk exposure to C. burnetii (contact with animal births, newborn animals, or animal carcasses). With increasing age, exposure of children from rural properties approaches that of their parents as they participate in the same activities. An effective vaccine is available,1 but use in people younger than 15 years is not recommended because of the lack of safety and efficacy data. Although avoidance of high risk situations such as shearing, animal births or on-farm butchering will decrease the chance of infection, these measures may be impractical for rural children. Realising this, some practitioners choose to vaccinate younger children who assist with animal births and butchering. Increasing notifications in children may reflect increased awareness that Q fever is not confined to adults with occupational exposures. Increased awareness leading to recognition of infection would give children access to effective treatment and may contribute to prevention of chronic disease. However, much remains unknown about Q fever in children, including how often the infection is asymptomatic, the spectrum and outcome of disease, and if there are effective preventive strategies. As many rural children cannot avoid potential exposure to Q fever, our study highlights the need for a safe and effective vaccine for children. Q fever notifications in children aged 0–14 years, 1997–2002

Jennifer H Barralet · Neil R Parker

Although some vaccines new to the childhood schedule are not free, they are strongly recommended In September 2003, the National Health and Medical Research Council (NHMRC) approved the new Australian Standard Vaccination Schedule recommended by the Australian Technical Advisory Group on Immunisation (ATAGI) (Box). The schedule includes inactivated poliomyelitis vaccine (IPV), varicella vaccine and seven-valent pneumococcal conjugate vaccine (7vPCV) for infants and young children. Earlier, in late 2002, routine meningococcal C conjugate vaccine was approved and funded for children aged 12 months, together with a cross-sectional catch-up program for young people to the age of 19 years (media release, Senator Kay Patterson, 24 November 2002). For the first time since 1994 — when all vaccines recommended on the schedule were funded for children vaccinated by both private and public providers under the National Immunisation Strategy1 — the childhood schedule recommended by NHMRC contains vaccines (IPV, varicella and 7vPCV) not available free of charge to parents. As well as adding these four vaccines to the childhood program, the NHMRC also approved changes to the pertussis vaccination schedule. Since the diphtheria–tetanus vaccine was replaced by a combined diphtheria–tetanus–acellular pertussis (DTPa) vaccine at 4–5 years in 1995, the peak age of pertussis has progressively risen to 13–18 years.2 Based on recent evidence that three doses of DTPa in the first year of life provide good protection until the age of 6 years,3 it was decided to adjust the schedule so that the fifth dose is now given to adolescents at 15–17 years, using an adult-formulated vaccine (dTpa). This was done by removing the 18-month dose, thus making the 4-year dose the fourth dose. This is not expected to lower preschoolers’ protection from pertussis,4 but should help reduce the number of large local reactions seen when the dose was given at 18 months.5 Inactivated poliomyelitis vaccine was recommended because it does not cause the extremely rare (1 in 2.4 million doses) live-vaccine-associated paralytic polio. The United States has already changed to inactivated vaccine,6 and other countries are considering doing so. The change to this vaccine in Australia may take time, as it is many times more costly than the oral vaccine and has had limited availability. Although various combinations of IPV with diphtheria, tetanus, acellular pertussis, Haemophilus influenzae type b and hepatitis B vaccines are licensed in Australia,7 they are not yet available, as the companies producing them are uncertain of the potential market. In the interim, the Australian Government’s National Immunisation Program will continue to provide free oral live-attenuated poliomyelitis vaccine. In making recommendations about the inclusion of each new vaccine in the childhood vaccination schedule, ATAGI took into account a wide range of factors. These included: vaccine safety and efficacy; the preventable burden of the disease targeted by the vaccine; the ease with which the vaccine could be integrated into the existing schedule; any likely effects on herd immunity, reduction in antibiotic resistance or impact on disease epidemiology; and cost-effectiveness and equity issues. Some of the information used by ATAGI as the basis for its recommendations is contained in the The Australian immunisation handbook (8th edition), while the levels of evidence for the new recommendations are available on the Internet and on CD-ROM.7 NHMRC resolved that the benefits of these vaccines were sufficient for them to be included in the schedule, irrespective of the provision of public funding. These new vaccines are more costly than any previous additions to the vaccination schedule. In the private market, three doses of conjugated pneumococcal vaccine cost far more than $300, one dose of varicella vaccine more than $40 and combinations with IPV more than an extra $18 for the IPV component. At the government level, the total annual cost of adding IPV, varicella vaccine and 7vPCV to the schedule would be about $100 million, and would almost double the current cost of all other childhood vaccines. This is a large expenditure. The cost-effectiveness of these three vaccines in Australia is therefore important.8-10 Changing to IPV (at $14 per dose) is estimated to prevent one case of vaccine-associated paralytic polio every 2–3 years, a cost of $17 million per case averted.8 This must be considered in the context of the maintenance of public confidence in immunisation programs. For varicella vaccine (at $53 per dose), universal vaccination of infants could prevent 450 hospitalisations each year, at a cost of $21 000 per hospitalisation averted, and one death per year, at a cost of $10 million per death averted, over a 30-year period.9 This does not include the out-of-pocket costs to families of a child having varicella, which make vaccination cost-effective in the United States.11 Universal use of 7vPCV (at $90 per dose) could prevent two to three deaths, 13 cases of meningitis, 110 cases of invasive pneumococcal disease, 800 cases of pneumonia and 14 600 cases of otitis media which would otherwise occur annually in each birth cohort of about 240 000 non-Indigenous Australian children by their fifth birthday.10 The cost per death averted and the cost per life-year saved by 7vPCV is estimated to be $5 million and $230 000, respectively.10 This does not take into account the impact of universal 7vPCV on adult pneumococcal disease or pneumococcal antibiotic resistance, as documented in the United States.12 However, these economic data were only part of the many reasons that ATAGI and NHMRC recommended that all children receive these vaccines (see above). Parents should be strongly encouraged by their physicians to have their children vaccinated. Conjugated pneumococcal vaccine is funded for a small group of children with medical conditions placing them at high risk of disease, as well as for Aboriginal and Torres Strait Islander children.7 For some parents the NHMRC recommendation will be sufficient; for others further discussion of the vaccine costs and benefits will be needed. Detailed fact sheets to assist providers and parents are available on the website of the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases <www.ncirs.usyd.edu.au>. Until all recommended vaccines are available free at the point of service, there is a dilemma for the community and for policy makers. The objectives of high childhood vaccine coverage and of equity for children could be at stake. This will be a continuing issue over the next 5–10 years as more new vaccines become available. These include rotavirus vaccine, live attenuated intranasal influenza vaccine, and other live vaccines targeting viral respiratory pathogens. Until now, vaccines have had a very high cost–benefit ratio, often being cost-saving,13 in contrast to many other prophylactic and most curative treatments. We can no longer expect vaccines to be cost-saving, with the increasing cost of the large clinical trials now needed to measure impact on rare diseases and to exclude rare adverse effects. Nevertheless, despite the fall in cost–benefit ratio in absolute terms, the economic benefits of vaccines relative to pharmaceuticals will persist.13 We now need greater public awareness of the current and potential benefits of disease prevention from vaccines, leading to greater public advocacy. Maximal benefit from vaccines can only be obtained by ensuring their availability and use across all age-eligible members of the population. Australian standard vaccination schedule7

Margaret A Burgess MD, FRACP, FAFPHM · Peter B McIntyre FRACP, FAFPHM, PhD

Objectives: To document diagnosis rates of type 2 diabetes mellitus in children and adolescents in Western Australia over the past 12 years, the clinical characteristics of these patients and any comorbidities.Design: Review of a prospectively recorded diabetes database.Setting: Tertiary paediatric referral centre (the only such centre in WA).Patients: All children and adolescents aged < 17 years diagnosed with type 2 diabetes between 1990 and 2002 and managed by Princess Margaret Hospital Diabetes Unit.Main outcome measures: Anthropometric and demographic data; glycohaemoglobin (HbA1c) level; blood pressure; lipid levels; presence of acanthosis nigricans.Results: 43 patients (15 males and 28 females) were diagnosed with type 2 diabetes. Age (SD) at diagnosis was 13.6 (1.8) years. The rate of diagnosis has been progressively increasing (average annual increase in the unadjusted overall rates of type 2 diabetes was 27%). Twenty-three patients (53%) were of Indigenous origin and 18 (42%) resided in rural areas. The mean (SD) HbA1c level at diagnosis was 10.0% (3.2%). Seventy-two per cent of patients had acanthosis nigricans, 59% had hypertension, and 24% had hyperlipidaemia.Conclusions: There has been an increase in the diagnosis rate of type 2 diabetes in children and adolescents in WA. Comorbidities are frequent.

Sarah K McMahon MB BS(Hons) · Aveni Haynes MB BChir · Nirubasini Ratnam BSc(Hons), RN · Maree T Grant RN · Christine L Carne PGRN(Paed) · Timothy W Jones FRACP · Elizabeth A Davis FRACP

Children of parents with mental illness. Personal and clinical perspectives. Vicki Cowling (editor). Melbourne: ACER Press, 2004 (xix + 242 pp). ISBN 0 86431 473 6. It is difficult to believe that only a short time ago parents were routinely vilified when their children developed psychiatric illness. Obvious examples are “the schizophrenogenic mother” and the lack of maternal communication skills that were blamed for the development of autism. Since we have come to understand the biological basis of psychiatric disorders, such blaming concepts appear foolish. On the other hand, people who are or who will become parents may suffer from mental illness. The children of these parents may be affected through genetic inheritance, quality of parenting, family relationships, and psychosocial adversity. The editor, a social worker and psychologist, has estimated that, in 1995, 27 000 Australian children were affected by maternal psychosis alone. Many ill parents parent well, and not all children are affected, but up to two-thirds probably experience negative consequences. Amazingly, the needs of these children have been largely ignored. Cowling has brought together 20 contributors from various disciplines to produce a highly instructive book addressing “coalface” issues for children of mentally ill parents. Four of the contributors had experienced parents suffering from schizophrenia, depression, bipolar disorder and Huntington’s disease. These personal accounts are extraordinarily revealing and I regret that there were not more of them included. The first part of the book provides some vital background information on the genetics, behavioural and psychosocial effects of major psychiatric illnesses. An excellent chapter outlines the possible impact of different illnesses and their symptoms on infants and children of different ages. Different treatments for disorders, as well as preventive interventions, are also outlined. The role of the partner of the mentally ill parent and wider family ramifications are also considered. There is a chapter with advice on how to talk to children and another that examines the impact on adolescents. In a welcome departure from the political correctness of cognitive behaviour therapy, a chapter relates anecdotes from the psychoanalysis of an 11-year-old boy who had been adopted away from his mentally ill mother at the age of 2½. There are other chapters on placing children in out-of-home care and adoption. A highlight of the book is its description of peer-support activities — various ways of organising group therapy for children of parents with mental illness. Group peer support combats isolation, shame and despondency and the benefits of group therapy can be enormous, but are frequently underestimated. In summary, this is a book that provides irreplaceable insights about children whose parents have mental illness. I found most of the book easy to read, highly instructive and often deeply moving. Medical students and doctors should set aside some reading time for this wonderful book. Nicholas A KeksPsychiatrist Box Hill, VIC

Nicholas A Keks

Viral bronchiolitis is the commonest cause of hospital admission in young infants. Respiratory syncytial virus is responsible for most cases of bronchiolitis. Secondary bacterial infection is rare and antibiotics are seldom necessary. Most children with bronchiolitis develop only mild illness and can be managed at home. Infants born prematurely, those with pre-existing cardiac or respiratory disease, and infants in the first three months of life are more likely to need hospital admission. On current evidence, nebulised adrenaline, inhaled and systemic corticosteroids, and inhaled bronchodilators do not have a role in the routine management of infants with bronchiolitis.

Dominic A Fitzgerald MB BS, PhD, FRACP · Henry A Kilham MB BS, FRACP

Kidsnet was established in 1997 at the Children’s Hospital at Westmead as a paediatric telephone triage service. The demand for Kidsnet increased from 18 327 in 1997/98 to 22 844 in 2001/02, with an average of 1669 callers per month. Most callers were able to proceed to seeking care at a more appropriate time and were satisfied with the service provided. The service is highly valued and the advice given perceived to be accurate. Kidsnet has shown that it can play a key role in providing safe advice to families.

Ralph M Hanson FRACP, FACEM, MPH · Bronwyn J Exley RN, GradDip(Paed) · Paul Ngo BSc · Maureen P Fitzpatrick BPhty(Hons), MCogSc · Elizabeth L Petering RN, BN, GradDip(Paed) · Sara J Matthews CNS · Diana Lechner RN · Celeste J Daniels RN, GradDip

Research into adolescent health issues is hampered by absolute requirements for parental consent. Society’s recognition of adolescents’ autonomy and decision-making capacity has been embodied in the legal recognition of the mature minor’s right to make decisions on matters affecting his or her life. Psychological research indicates that young people from 14 years have decision-making capacity. US and UK research ethics guidelines acknowledge the mature-minor principle, but Australian guidelines are out of step with international practice. An absolute requirement for parental consent in Australian research ethics guidelines is potentially unethical if it denies mature adolescents’ autonomy and is a barrier to participation, study validity and improved health outcomes through research findings. There are grounds for considering a mature-minor clause in the National Health and Medical Research Council research ethics guidelines, particularly in the context of youth participation in minimal-risk research.

Lena A Sanci MB BS, PhD, FRACGP · Susan M Sawyer MB BS, MD, FRACP · Penny J Weller BA/LLB, MA, PhD · Lyndal M Bond BA(Hons), MA, PhD · George C Patton MB BS, MD, FRANZCP

Clinical records Patient 1 A 5-month-old girl presented with biphasic stridor (ie, stridor present during inspiration and expiration) and feeding difficulties since birth. The stridor was not related to her position or to her level of wakefulness. Asthma treatment with bronchodilators, inhaled corticosteroids (up to 500 μg/day fluticasone propionate) and courses of oral steroids were prescribed by several doctors from 6 weeks of age for her “noisy breathing”. These treatments did not alter her symptoms. No investigations were undertaken. There was no significant perinatal or other medical history. The child appeared well; she was thriving and her development was appropriate for her age. The biphasic stridor was not associated with wheeze or tachypnoea. She had mild tracheal tug and chest wall recession. Her chest was clear, and the findings from the remainder of the examination were normal. A chest x-ray (CXR) showed a right aortic arch and reduced air–tissue interface at the carina, consistent with tracheomalacia. A barium swallow showed a posterior indentation of the mid-oesophagus, suggestive of a vascular ring (extrinsic compression of the oesophagus and trachea by aberrantly sited blood vessels [Box 1]). Bronchoscopy confirmed these findings and showed significant reflux oesophagitis. A magnetic resonance angiogram confirmed the presence of a vascular ring formed by a double aortic arch, with each arch giving rise to its own common carotid and subclavian arteries. Surgical correction of the compressive vascular band on the trachea 3 days later was uneventful. The proton pump inhibitor omeprazole was prescribed for the reflux oesophagitis, but this proved insufficient. After further hospitalisations for pulmonary aspiration, a fundoplication was performed and a gastrostomy tube inserted. Twelve months later, she remains asymptomatic with normal growth. Patient 2 A 9-week-old girl presented with biphasic stridor and a 3-week history of intermittent central cyanosis associated with feeding. She was noted to have had “noisy breathing” from birth. At age 6 weeks, she had been admitted to another hospital with cough and more prominent biphasic stridor. Her respiratory difficulties were attributed to bronchiolitis caused by respiratory syncytial virus. She required supportive treatment including oxygen for 5 days in hospital. On discharge, she improved, but continued to have very noisy breathing, which was worse when she was active or feeding. She was bottle fed with infant formula and noted to have occasional episodes of transient cyanosis during feeding. On examination, she appeared well and was thriving. She had a moist cough, moderate subcostal recession and audible biphasic stridor. A CXR showed a left, normally sited aortic arch and poor delineation of the distal tracheal air column suggestive of tracheomalacia. A barium swallow (Box 2A) showed significant oesophageal compression anteriorly and posteriorly, consistent with a double aortic arch. A magnetic resonance angiogram (Box 2B) confirmed the presence of the double aortic arch, as well as extrinsic, anterior compression of the distal trachea. Bronchoscopy, performed before surgery to divide the vascular ring, showed mild tracheomalacia. The infant was discharged a week later with reduced stridor and recession. No further episodes of central cyanosis with feeding occurred during the 6-month follow-up period after surgery. Biphasic stridor from birth or early infancy suggests fixed proximal airway obstruction, which may be intra- or extrathoracic. Conversely, variable inspiratory stridor suggests a less severe, extrathoracic, dynamic obstruction. Patients with biphasic stridor (such as that caused by a vascular ring) are often initially misdiagnosed as having asthma because of noisy respirations, although stridor is never a sign of asthma, but rather of proximal airway compromise. Stridor differs from wheeze in that it has a different pitch and harsher sound than the more musical pitch of a wheeze. Stridor is heard predominantly during inspiration. Children with a vascular ring usually present in infancy with non-specific symptoms of dyspnoea, cough, inspiratory or biphasic stridor, and sometimes an expiratory “wheeze” (presumably related to downstream obstruction of the intrathoracic trachea) as well as feeding problems.3-5 A vascular ring occurs when one or more aortic arch abnormalities, with or without a patent ductus arteriosus or ligamentum, produce a ring that completely encircles the trachea and oesophagus, leading to symptoms of tracheal or oesophageal compression6 (Box 1). Differential diagnosesThe differential diagnosis of persistent biphasic stridor in an infant includes severe laryngomalacia, tracheomalacia and, less commonly, vocal cord paresis (causing a hoarse cry), subglottic haemangioma (causing rapidly progressing stridor, sometimes associated with a facial haemangioma) and vascular ring. Laryngomalacia is the most common cause of neonatal inspiratory stridor, but is an unlikely cause of biphasic stridor from birth, unless it is very severe. Stridor in laryngomalacia more commonly occurs after several weeks of age, is usually limited to inspiration and varies with posture and airflow (eg, it is louder with crying). Signs usually gradually resolve without treatment by 12 to 18 months of age.7 Tracheomalacia, a condition characterised by weakness of the tracheal walls and supporting cartilage (localised to the region of external compression by blood vessels), commonly occurs in association with lesions such as a vascular ring and persists for several years until the tracheal cartilage firms. The formation of the ring depends on the preservation or deletion of specific segments of the rudimentary aortic arch complex, or the presence of major arteries with anomalous origins or remnants (eg, ligamentum arteriosum) compressing the trachea and oesophagus. The double aortic arch is the most common form of vascular ring,4 and is characterised by persistence of both embryonic aortic arches, with separate carotid and subclavian arteries originating from each arch. The ascending aorta bifurcates anterior to the trachea to form the aortic arches, and each courses either right or left of the trachea and the oesophagus. The larger of the two arches usually crosses posterior to the oesophagus and unites with the other arch in the posterior mediastinum to form the single descending aorta. This can be seen as a posterior indentation on the mid-oesophagus on a barium swallow (Box 2A). When biphasic stridor is detected in an infant, a chest x-ray (CXR) and a barium swallow are simple initial investigations that together will usually confirm or exclude a vascular ring as the underlying cause.8-10 The CXR may show a right-sided aortic arch, a poorly visualised distal trachea, or another cause for tracheal compression or deviation (eg, a mediastinal mass). A barium swallow may show abnormal indentations on the posterior oesophageal wall. If these abnormalities are detected, referral for more detailed investigations (including bronchoscopy and magnetic resonance angiography) and treatment is appropriate.11,12 Tracheomalacia may occur in isolation, and the diagnosis often relies on the bronchoscopist’s interpretation of the airway calibre and shape at bronchoscopy. ManagementAfter surgical treatment for a vascular ring, it is essential that the child’s parents receive ongoing management advice, as tracheomalacia will persist, and there is therefore an increased risk of severe croup. The child may continue to display noisy breathing for a period of a few months to several years13 and should be followed up until school age. In school-age children, any residual inspiratory flow limitation can be quantified using inspiratory flow volume loops with spirometry. Residual tracheomalacia commonly results in difficulty clearing airway secretions (impaired mucociliary clearance) through the functionally narrowed section of trachea at the site of the previous extrinsic wall compression. This may manifest as a brassy, rattly cough that persists longer than expected after a viral infection. It would be appropriate to consider influenza and pneumococcal vaccination in these children. Lessons from practice Stridor is never a feature of asthma and can be differentiated from wheezing by its predominance during inspiration, its harsher sound and different pitch. Biphasic stridor suggests fixed intra- or extrathoracic proximal airway obstruction. Any infant with biphasic stridor should have a chest x-ray and a barium swallow to detect the presence of a rare congenital anomaly in which aortic arch or large blood vessel abnormalities produce a ring encircling and compressing the trachea and oesophagus. Management of patients with vascular ring must include postoperative advice concerning the ongoing tracheomalacia and the associated risk of croup, as well as possible continuation of noisy breathing and impaired mucociliary clearance, which may prolong a viral-induced, rattly cough. 1: A double aortic arch (as in Patient 1) The simplified anatomy of a double aortic arch, which produces a vascular ring encircling the trachea and oesophagus, causing symptoms of tracheal or oesophageal compression. 2: Investigations for biphasic stridor (Patient 2) 2A: Barium swallow, showing anterior (arrow A) and posterior (arrow B) compression of the oesophagus, together with a posterior bulge (arrow C) caused by a double aortic arch. 2B: Magnetic resonance image, showing the double aortic arch — superior vena cava (A), brachiocephalic vein (B), pulmonary arteries (C, D), prominent left aortic arch (E), and smaller right aortic arch (F).

Sami Spencer · Belinda H Yeoh MB BS · Peter P Van Asperen MD, FRACP · Dominic A Fitzgerald MB BS, PhD, FRACP

Can we solve a riddle by burying an illusion? Over the past 40 years, the prevalence of asthma appeared to rise inexorably in both the developed and the developing world. So the report by Robertson and colleagues in this issue of the Journal (page 273), showing a decline in reported symptoms in children since 1993,1 is to be warmly welcomed. It comes with supporting evidence, in the form of reduced hospital admissions for asthma in Victoria, but also with a catch. The prevalence of reported hay fever and eczema has increased over the same period. Why the prevalence of asthma increased and why it may now be stabilising or declining is baffling. Robertson et al suggest one possibility may be the increased use of daycare facilities. The “hygiene hypothesis” — the inverse relationship between microbial or infection exposure and allergic disease — was first suggested by Gerrard et al while studying allergic disease in the Metis Indian community in Canada.2 Strachan refined this observation from large UK cohorts, in which he found an inverse relation between the number of older siblings and the prevalence of hay fever, but not asthma.3 He emphasised that the link was through atopy to allergic disease. Several studies have subsequently shown reduced asthma prevalence in school-aged children with early daycare attendance. These children tend to show more early wheezing, but less asthma later on. The proposed explanation is that they contract more upper respiratory tract infections from close contact with children, and this leads them to have more early wheezing, but, in turn, protects them from later developing atopy and atopic disease. This explanation seems less likely in the study by Robertson et al, given that the prevalence of hay fever and eczema increased while asthma prevalence decreased. However, one would need to know the atopic status of the children to clarify the issue. The 26% reduction in current wheeze prevalence in Melbourne, while significant, is within the range found in Australia in phase 1 of the International Study of Asthma and Allergies in Childhood (ISAAC) study. For example, in the four Australian centres that took part, there was a 19% difference between the highest and lowest prevalence. For sleep disturbance and speech limitation, this was 40%.4 There is even greater variation in large cities. In Mumbai (Bombay), for example, reported current wheeze varied by more than 100% in different parts of the city. Large cities are not homogeneous, with large variations in many factors that may affect wheezing, such as housing conditions, smoking prevalence, diet and variable access to healthcare. Over time, with gentrification and changes in zoning, factors may vary even in the same narrow geographic location. Robertson et al also note that awareness of asthma in the community is a determinant of the prevalence of reported symptoms. The pool of individuals with a history of symptoms in any population will be larger than the proportion who report symptoms in a defined period. In a resurvey of 700 young adults, all of whom had 4 years previously responded positively to at least one of three asthma questions, only two-thirds reported symptoms. In the first survey, 28% had responded positively to all three questions, and in the second, 29%. However, only 60% were the same individuals.5 Just how large this pool is has recently been clarified, at least in New Zealand. In a 26-year follow-up of a birth cohort in Dunedin, 73% reported wheezing on at least one occasion and 51% on at least two.6 Given that there is likely to be some loss to recall, wheezing at some time between birth and adulthood appears virtually universal. Clearly, most of this wheezing is occasional, trivial, inconsequential, and a normal phenomenon. It is now easy to see how a change in diagnostic and hence societal emphasis on wheezing, as opposed to bronchitis, with attendant changes in treatment, can enhance recall for asthma in cross-sectional surveys. Perhaps this emphasis is now stabilising and the diagnostic label “asthma” is being applied slightly less frequently in Melbourne. The strengths of the ISAAC approach — simple questionnaires requiring minimal funding — allow large-scale international comparisons of children (in fact, this is the only way that such large population studies can be conducted), but interpreting relatively small changes over time in a very asthma-“savvy” environment like Australia is more difficult. Although the ISAAC approach clearly shows that reported asthma symptoms are far more frequent in Australia, New Zealand and the United Kingdom compared with, say, Albania or India (more than 10-fold), smaller differences over relatively short time intervals in individual countries are harder to interpret. In the past 30 years there have been many cross-sectional studies reporting an increase in the prevalence of asthma symptoms over time. In only two has this been accompanied by measures of airway hyperresponsiveness. In the first, in the United Kingdom, Burr et al showed that current asthma symptom reporting had doubled over a 15-year period, but exercise-induced fall in peak expiratory flow rate had not changed.7 In the second, Peat et al showed a doubling of current symptoms and airway hyperresponsiveness, predominantly among atopic children, suggesting an increase in asthma relating to greater allergen exposure.8 There is a real need for the measurement of objective markers over time in similar populations. The advent of easily obtainable markers of airway inflammation, such as exhaled nitric oxide or constituents of breath condensate, may allow population studies of airway inflammation to be quantified and tracked over time. Perhaps it is time to abandon our inconvenient population model of asthma as a disease, just as doctors did for essential hypertension in the 1950s.9 Nature provides no obvious support for asthma and we can neither define nor measure it accurately; indeed, it remains a mystery because it is largely an illusion. The late Geoffrey Rose (Professor of Epidemiology at the London School of Hygiene and Tropical Medicine) suggested that we should seek the answers to “disease” by exploring populations rather than atypical minorities.10 We need to consider applying this concept to airway inflammation. Now that appropriate tools are becoming available, we should measure airway inflammation and airway responses in large populations and explore the environmental and genetic factors that affect the airway at a population level. This might reveal that it is not just the upper end of the distribution of airway inflammation (which we arbitrarily and inconsistently call asthma) that varies by environment, and over time, but the whole distribution. In the meantime, Robertson and colleagues have shown that parent-reported asthma symptoms of young Melbourne children have declined in the past decade. This may or may not be an early signal for a real decline in asthma prevalence. What it does suggest is that asthma prevalence has not increased, which in itself is a welcome observation.

Julian Crane MB BS, FRCP, FRACP

Objective: To determine the change in prevalence of asthma, eczema and allergic rhinitis in Australian schoolchildren between 1993 and 2002.Design: Questionnaire based survey, using the protocol of the International Study of Asthma and Allergy in Childhood.Setting: Metropolitan Melbourne primary schools within a 20 km radius of the GPO in 1993 and 2002.Subjects: All children in school years 1 and 2 (ages 6 and 7) attending a random sample of 84 schools in 1993 and 63 schools in 2002.Main outcome measures: Parent-reported symptoms of atopic disease; treatment for asthma; country of birth.Results: There was a 26% reduction in the 12-month period prevalence of reported wheeze, from 27.2% in 1993 to 20.0% in 2002. The magnitude of reduction was similar for boys (27%) and girls (25%). The 12-month period prevalence of reported eczema increased from 11.1% in 1993 to 17.2% in 2002, and rhinitis increased from 9.7% to 12.7%. There were reductions in the proportion of children attending an emergency department for asthma in the previous year (3.6% to 2.3%), the proportion admitted to hospital (1.7% to 1.1%) and the proportion taking asthma medication (18.5% to 13.4%). Of those who reported frequent wheeze, there was an increase in the proportion taking regular inhaled steroids (34.5% to 40.9%).Conclusion: There has been a significant reduction in the prevalence of reported asthma in Melbourne schoolchildren, whereas the prevalence of eczema and allergic rhinitis has continued to increase.

Colin F Robertson MD, FRACP · Mary F Roberts BAppSci · Johanna H Kappers BNursSci

Objectives: (i) To evaluate the benefits and adverse effects of a Diabetes Day Care Program (DDCP); and (ii) to compare outcomes in two cohorts diagnosed before and after implementing the DDCP (“pre-DDCP” and “post-DDCP”).Design: Outcomes from the pre-DDCP cohort were compared with those of the post-DDCP cohort.Setting: The study was conducted from March 2001 to October 2002 at the Children’s Hospital at Westmead.Participants: The pre-DDCP cohort comprised all children newly diagnosed with type 1 diabetes from March 2000 to November 2000 (n = 49). The post-DDCP cohort were those diagnosed from November 2000 to August 2001 (n = 61).Main outcome measures: Length of stay, adverse events, insulin requirement and glycohaemoglobin (HbA1c) level over the first year after diagnosis were ascertained from medical records. Questionnaires to measure parents’ knowledge of diabetes, emotional adjustment to diabetes, and responsibility for and conflict over specific diabetes management tasks were completed by parents at 6-monthly intervals.Results: Median length of hospital stay decreased from 5.14 days (range, 2–10) to 1.70 days (range, 0–10) (P < 0.001). There were no differences between the two cohorts in insulin requirement at 12 months (pre-DDCP: 0.9 U/kg [95% CI, 0.8–1.0]; post-DDCP: 0.8 U/kg [95% CI, 0.7–0.9]; P = 0.22), HbA1c level at 12 months (pre-DDCP: 8.4% [95% CI, 8.0%–8.9%]; post-DDCP: 8.2% [95% CI, 7.9%–8.5%]; P = 0.37) and adverse events over the first year after diagnosis. Both groups reported similar scores for the parental questionnaires.Conclusions: Ambulatory stabilisation of children with type 1 diabetes provides similar metabolic outcomes for the child, and comparable levels of diabetes knowledge and similar psychosocial outcomes for the family, to inpatient stabilisation programs.

Shubha Srinivasan MB BS, FRACP · Maria E Craig FRACP, PhD · Linda Beeney PhD · Rachel Hayes MND · Nuala Harkin RSCN, APN · Geoffrey R Ambler FRACP, MD · Kim C Donaghue FRACP, PhD · Christopher T Cowell MB, FRACP

Objective: To determine changes in morbidity and management of disease in children in Australian general practice.Design and setting: A comparative study of general practice consultations in children under 15 years, using data from cross-sectional general practice surveys (1990–91 and 2000–01), and a descriptive comparison with a similar study from 1971.Main outcome measures: Relative rates of management (rate/100 general practice encounters) of the most common children’s problems and treatments.Results: Problems with significantly higher management rates in 2000–01 compared with 1990–91 included vaccination (11.1 v 7.6 per 100 encounters in 1990–91) and contact/allergic dermatitis (3.1 v 2.5). Those managed significantly less often in 2000–01 v 1990–91 included acute otitis media (7.7 v 9.4), asthma (5.4 v 8.8), tonsillitis (4.4 v 6.0), acute bronchitis (3.8 v 5.3) and gastroenteritis (1.7 v 2.7). Asthma management rates rose from 2.4% of all problems managed in 1971 to 7.2% in 1990–91, then fell in 2000–01 to 4.6%. More frequent rates of counselling and advice in 2000–01 (28.4% of encounters v 22.9% in 1990–91) were associated with a decrease in rates of prescribing and supply of medication (56.6% of encounters v 64.3% in 1990–91). Antibiotic prescribing declined significantly (from 33.8 per 100 encounters in 1990–91 to 25.2 in 2000–01), as did prescribing of respiratory medications (from 15.5 to 9.9 per 100 encounters), while prescribing of vaccines and systemic corticosteroids doubled (from 9.6 to 18.8 per 100 encounters, and from 0.6 to 1.2, respectively). (All comparisons between 1990–91 and 2000–01 are significant at P < 0.01.)Conclusions: These findings point to the emergence of a generation of Australian children who are generally well vaccinated and are less likely to present to GPs with “traditional” childhood illnesses.

Janice Charles BA, MSc(Med) · Ying Pan MCH · Helena Britt BA, PhD