Child health

Objectives: To describe the prevalence of markers of growth, chronic and infectious disease in peripubertal Aboriginal children living in the Darwin Health Region in the "Top End" of the Northern Territory, and to compare prevalence between children living in urban and remote areas.Design: Cross-sectional survey nested in a prospective birth cohort.Subjects: 482 children living in the region who were recruited at birth (Jan 1987 to Mar 1990) and were followed up between 1998 and 2001, when aged 8–14 years.Main outcome measures: Selected parameters of growth and nutrition, infectious disease and potential markers of chronic adult disease were compared between children living at follow-up in suburban situations in Darwin–Palmerston (urban) and those living in rural communities with an Aboriginal council (remote).Results: Remote children were shorter than urban children (mean height, 141.7 v 146.3 cm; P < 0.001), lighter (median weight, 30.3 v 37.1 kg; P < 0.001) and had lower body mass index (median, 15.3 v 17.9 kg/m2; P < 0.001) and haemoglobin level (mean, 125.1 v 130.9 g/L; P < 0.001). Some potential markers of adult chronic disease were higher in urban than remote children: systolic blood pressure (mean, 109.6 v 106.2 mmHg; P = 0.004), and levels of total cholesterol (4.3 v 4.0 mmol/L; P < 0.001), high-density lipoprotein cholesterol (mean, 1.4 v 1.2 mmol/L; P < 0.001) and insulin (median, 7 v 4 mU/L; P = 0.007). Diastolic blood pressure, levels of red cell folate, serum glucose and low-density lipoprotein cholesterol, and urinary albumin–creatinine ratio did not differ by location. The prevalence of visible infections was also higher in remote than urban children (P < 0.05).Conclusion: As some markers of health differ between peripubertal Aboriginal children living in urban areas and those in remote areas, results of surveys in remote areas cannot be generalised to urban Aboriginal populations.

Dorothy E M Mackerras MPH, PhD · Alison Reid MSc · Susan M Sayers FRACP, PhD · Gurmeet R Singh MD · Kathryn A Flynn BNurs · Ingrid K Bucens FRACP

To the Editor: The article on the risks of baby walkers by Thompson is welcome.1 However, he used a broad definition of "serious" (ie, those children who required admission to hospital). Readers should be aware that some of these accidents cause major disfiguring injuries with life-long consequences. Burns sustained as a result of being in a baby walker are more extensive and deeper than those of the average patient admitted to our Burns Unit. In the 5 years to July 2000, 24 patients were admitted to the Burns Unit at The Children's Hospital at Westmead (the NSW State Paediatric Burn Referral Unit) with burns as a result of being in a baby walker. As baby walkers are used by children before they can walk, all were 13 months old or younger (range, 6–13 months), whereas only 15% of all admissions are under one year. In the same 5-year period, 178 patients were under 12 months, with the number rising to 246 if those under 13 months are also included. Only one of the group with burns from using a baby walker was older than 12 months, and only by a day. (Ironically, he was burnt while playing in a baby walker that he had been given for his birthday the day before.) The baby-walker burns were extensive — the largest burn covered 48% of the body surface, with the average being 17%. Deep burns were more common than average, 19 of the 24 children needed grafting (80%) versus only 50% of all admissions. Grafting means that the burns are deep enough to cause permanent scarring. Eight of the 24 required admission to the intensive care unit. Of the 24 children, 21 had scald burns, mostly due to the child being able to reach a cord, tablecloth or container; two had contact burns because the child could reach out to a hot stove; and one sustained a flame burn, because the child moved close to a parent starting a fire with flammable fluid. Thus, the danger results from the child being able to reach higher and move faster than expected. No improvement has been evident in the last 2 years. From July 2000 to June 2002, seven more children were admitted with burns caused by baby walkers: six spill scalds (four water and two oil) and one contact burn (iron pulled down). This helps confirm Thompson's contention that regulations (introduced in September 2000) will not stop baby-walker injuries. Apart from the danger of severe injury, baby walkers impede normal balanced muscle development and so are deleterious to every child who uses one. Apart from being a child-minding device, they have only potential for harm. Now that Thompson has shown that the "safety standards" do not protect children from injury, it is time for them to be banned altogether.

Hugh C O Martin

To the Editor: Thompson's report highlighting the danger of baby walkers and the applicability of the proposed Australian mandatory standard is welcome.1 However, we have some concerns with the statement that the injury data used in the analysis are "largely representative of such events in the major proportion of metropolitan Australia". The only data sources used were the South Australian Department of Human Services Injury Surveillance System and the original Victorian Injury Surveillance System. Equivalent data from Queensland, although readily available, were not used. An analysis of 177 baby-walker injuries recorded in the Queensland Injury Surveillance Information System (ISIS) for the period 1989–1994 shows that only 9% of injuries were not stability related, and that 73% were associated with steps and stairs. Among the cases admitted to hospital, only one was not related to stability or falls down steps or stairs. Examination of more recent Queensland injury surveillance data, although not directly comparable, reveals a similar pattern. These results, which appear to contradict the findings of Thompson, are not altogether surprising considering the differences in architectural styles between Queensland, with its high-set houses with verandahs and wooden steps, which present quite a different injury-prevention challenge to the style of housing more common in Adelaide and Melbourne. The introduction of a baby-walker standard to address the problem of stability and falls down steps and stairs would thus appear worthwhile in this setting. However, we accept that, in other parts of Australia, baby-walker-related injuries may be less amenable to prevention through this intervention. It is also of concern that the new standard is being promoted by the Commonwealth as able to prevent stair-related baby-walker injuries. In reality, this is not the case: a recent study by the US Consumer Product Safety Commission found that 15% of stair-related injuries involved the new-style walkers.2 Furthermore, introduction of the standard, and its ensuing publicity, may result in an increase in use of baby walkers, along with a perception that they are now safe. This has the potential to increase baby-walker injuries. It is our belief that, in this particular case, it may be better to keep publicity very low key. Finally, use of baby walkers has also been associated with a delay in normal physical development.3 For all these reasons we would continue to advocate that the use of baby walkers be actively discouraged.

Richard L Hockey · Rob Pitt

To the Editor: The article by Thompson recommended that baby walkers be banned.1 He described various injuries caused by baby walkers: An 8-month-old baby in a walker pulled the cord of a deep fryer and was splashed by oil, sustaining full-thickness burns to chest, abdomen and upper arms. A 10-month-old baby in a walker sustained severe finger laceration when a fly-screen door slammed shut. It is suggested that baby walkers allow babies to reach hazards, such as heaters, ashtrays, hot drinks, etc. However, all of these injuries result from lack of supervision. In any case, within a couple of months these babies will be standing and then walking and, without supervision, exactly the same injuries may occur. Most injuries in infants are related to an unsafe environment or inadequate supervision. One aspect that Thompson does not mention is walkers for disabled children. Does he recommend that these be banned? For infants and young children with severe disabilities, a walker is their only means of locomotion.

Donald D Beard

Physical signs of child abuse. Christopher J Hobbs and Jayne M Wynne. London: W B Saunders, 2001 ($271.15, 401 pp). ISBN 0 70202582 8. This is the second edition in five years of this rather expensive atlas by two reputable British paediatricians who specialise in the investigation and management of child maltreatment. It is a distressing catalogue of the injuries deliberately inflicted by caregivers on children and young people. The book covers the full spectrum of child abuse as well as providing over 300 pages of photographs (with up to five photographs per page). It provides good guidance on conducting physical examinations, colposcopy and photography. The authors emphasise that the diagnosis and management of abuse requires an interdisciplinary approach, where different professionals and systems bring together different pieces of the jigsaw. There are sections and subsections that cover each type of abuse and its differential diagnosis, and each section starts with a brief overview of the salient points. The contents of many of these sections are in note form (as if they have been made up from teaching slides which were orally expanded). This can be occasionally confusing — for example, under a section on retinal haemorrhages is a dot point “vaginal birth (30%)”. It is unclear if this refers to the proportion of vaginal births having this abnormality, or whether it refers to the fact that only 30% of retinal haemorrhages occurred in infants born vaginally. References for some of these assertions would also have been helpful. Nevertheless, the format is clear and user-friendly. I do have a number of criticisms. The book is somewhat unevenly balanced with head and abdominal injuries sharing a chapter, while superficial integumental injuries are divided among four chapters and burns among three. There are occasional typographic errors, and some references are misspelled. Some of the advice given is not consistent with best evidence for practice in teaching hospitals — for example, CT scans are a more sensitive investigation for head injury than plain skull x-rays, and the role of radioisotopic bone scans as the initial approach to screening for skeletal injuries is underemphasised. The authors note the value of digital photography for exchanging images electronically. In Australia, this advice is problematic, as digital images have been ruled out for evidentiary purposes owing to the ease with which they can be manipulated. Despite these reservations, and considering the fact that the authors are going to produce a complementary slide set (presumably on CD-ROM), I believe that access to this reference book would be helpful to many. It is particularly suitable for those training as general and community paediatricians and for those working in hospitals with a large paediatric patient load. Graham V VimpaniPaediatrician Child, Adolescent and Family Health Services Wallsend, NSW

Graham V Vimpani

Even eight hours after a campfire has been extinguished with sand, it retains sufficient heat to cause a full-thickness burn with contact of one second. Because extinguishing with sand disguises the danger, this is a particular hazard for children. The only safe way to extinguish a campfire is with water.

John F Fraser MRCP, FJFICM · Kelvin L Choo MB BS, FRACS · Roy M Kimble FRCS, FRACS · David Sutch

Objective: To identify the adequacy of first aid care following minor burns in children.Design: Prospective case series.Setting: Emergency Department and Acute Wound Clinic, the Children's Hospital at Westmead (CHW), Sydney.Participants: 109 children who presented with minor burns (10% body surface area or less) to CHW over the five months from 2 November 1998 to 23 March 1999.Main outcome measures: Comparison of the adequacy of first aid delivered by parents and carers, general practitioners, local hospitals, and CHW.Results: Burns included scalds, contact, flame, chemical or electrical burns. Adequate initial first aid had been given by parents or carers in only 24 of 109 cases (22%). The 85 children who presented to medical care after inadequate initial first aid was given by parents or carers included 14 of 14 (100%) who had presented to their general practitioner (GP), 22 of 31 (71%) who had presented to their local hospital, 22 of 38 (58%) who had presented to CHW, and 2 of 2 (100%) who had had first contact with other health professionals.Conclusions: This study shows that there is a need to educate parents and health professionals regarding appropriate first aid for burns.

Rebecca A McCormack MB BS(Hons), RN, GradDipMid · Erik R La Hei MB BS, FRACS · Hugh C O Martin MB BS, FRACS, FRCS

Background: In 1941, a Sydney ophthalmologist, Norman McAlister Gregg, correctly identified the link between congenital cataracts in infants and maternal rubella early in pregnancy. Fifty of Gregg's subjects with congenital rubella, born in 1939–1944, were reviewed in 1967 and again in 1991. We reviewed this cohort in 2000–2001, 60 years after their intrauterine infection.Methods: The subjects underwent full clinical assessment, plus pathology tests, an ophthalmological and cardiological review (including electrocardiography and echocardiography) and HLA histocompatibility testing.Results: Since they were first seen in 1967, 10 have died (cardiovascular causes [4], malignant disease [4], AIDS [1], and hepatitis C-related cirrhosis [1]). All surviving men came for review (19) and 13 women (eight women declined). Echocardiography showed mild aortic valve sclerosis in 68%. The prevalence of diabetes (22%), thyroid disorders (19%), early menopause (73%) and osteoporosis (12.5%) was increased compared with the Australian population; 41% had undetectable levels of rubella antibodies. The frequency of HLA-A1 (44%) and HLA-B8 (34%) antigens was increased, and the haplotype HLA-A1, B8, DR3, said to be highly associated with many autoimmune conditions, was present in 25%.Conclusions: This cohort of people with congenital rubella has illuminated our understanding of viral teratogenesis.

Jill M Forrest MD BS · Fiona M Turnbull MB, ChB · Gary F Sholler MB BS, FRACP · Richard E Hawker MB BS, FRACP · Frank J Martin FRANZCO, FRACS · Margaret A Burgess MD, FRACP · Trevor T Doran MSc, PhD

Current controversy about diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) reflects the divergence between developmental and non-developmental approaches. While there is growing evidence for biological vulnerabilities associated with ADHD, we believe that environmental factors, including early problems in parental attachment, are also important in determining the type and timing of deficit that a child develops, the risk to academic and social performance and eventual outcome. We warn against labelling children with ADHD simply because they fulfil the cross-sectional diagnostic symptom criteria of the Diagnostic and statistical manual of mental disorders — 4th edition (DSM-IV). We advocate an integrated biopsychosocial approach to diagnosis and management with a thorough developmental assessment to identify developmental factors, such as deficits in early attachment, contributing to the presentation.

George Halasz MRCPsych, FRANZCP · Alasdair L A Vance MD, FRANZCP

Ted Stuckey epitomised "quiet achievement". Born on 15 June 1908, he grew up in Inverell, in northern New South Wales, where he was dux of his school. Later, as a medical student living at St Andrew's College, Sydney University, he excelled academically and in sport. He represented the College in rowing, and played hockey for the College, the University, and a combined Australian universities' team. After doing his residency at the Royal Prince Alfred Hospital and the Royal Alexandra Hospital for Children (RAHC), Ted married Joan Vowell and moved into general practice in Scone, NSW. While working in this practice he obtained his Master of Surgery degree. Ted returned to Sydney in 1939 to become a paediatric surgeon, and was appointed Honorary Relieving Assistant Surgeon at RAHC. When war intervened, he joined the Field Ambulance Service. He served until late 1944 in Queensland, then New Guinea, becoming second-in-charge of the 111th Casualty Clearing Station and attaining the rank of Major. From 1945, as Honorary Assistant Surgeon at RAHC, Ted and his colleagues did pioneering work in cardiothoracic and abdominal surgery. Ted's brother Doug was also part of the Congenital Heart Disease team that was involved in the early development of cardiac catheterisation and angiocardiography. In 1948, Ted gained his Fellowship of the Royal Australasian College of Surgeons. In 1958 he was awarded a Fulbright scholarship to study at Harvard Medical School. From 1958 to 1966 he lectured in paediatric surgery at the University of Sydney. He continued at RAHC as an Honorary Consultant Surgeon until 1973. In later years, Ted adopted a more relaxed lifestyle, doing sessional work with the Commonwealth Health Department until 1988 and Surgical Assistant work until 1994 (then aged 86!). Ted was a founding member of the Medical Benefits Fund in 1945 and served on its Council until 1971. He was also heavily involved with the Australian Medical Association. He was a member (1953–1966) and president (1961–1962) of the NSW Branch Council; a member of the AMA Federal Council (1964–1966); Assistant General Secretary, then Deputy Secretary General (1966–1972); and Secretary General (1972–1973). He was made a Fellow of the AMA in 1964. He was secretary of the AMA/benefit fund working party, which produced a plan for a voluntary health insurance scheme that was largely adopted by the federal government and introduced in 1970. He was also a member of the Medical Benefits Schedule Advisory Committee. Although deeply committed to his profession, Ted remained a devoted husband and father to his five children. Over the years, he built for his family a swimming pool, a terraced garden with a badminton court, and three unique folding caravans in which he loved to take them on camping holidays. Ted died on 7 June 2002 of acute renal failure.

Michael EV Stuckey MB BS FRCS FRACS

Significant perinatal distress and depression affects 14% of women, producing short and long term consequences for the family. This suggests that measures for early detection are important, and non-identification of these women may exacerbate difficulties. Screening provides an opportunity to access large numbers of women and facilitate pathways to best-practice care. A valid, reliable, ...

Anne E Buist MD, FRANZCP · Jeannette Milgrom PhD, FAPS · Bryanne E W Barnett MD, FRANZCP · Sherryl Pope PhD · John T Condon MD, FRANZCP · David A Ellwood MA, DPhil, FRACOG, FRANZCOG · Phillip M Boyce MD, FRANZCP · Marie-Paule V Austin MD, FRANZCP · Barbara A Hayes DNSc, FRCNA

While we have learnt much of the molecular and immunological basis of childhood asthma and treatment has changed dramatically, the impact on lifestyle, especially in early childhood, has not moved forward as rapidly. This is predominantly due to the difficulty of collecting objective data on the very young. To understand the causes of asthma and improve outcomes, with particular emphasis on primary prevention, it is ...

Craig M Mellis MD, MPH · Louis I Landau MD, FRACP

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Louis I Landau MD FRACP

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Peter N Le Souëf MD FRACP

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Colin F Robertson MD, FRACP

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Karen O McKay LLB, PhD · James C Hogg MD, PhD

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Gary P Anderson PhD

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David Isaacs MD, FRACP, FRCPCH · Preeti Joshi PhD, FRACP

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Andrew S Kemp PhD, FRACP

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Stephen M Stick MD, PhD, FRACP

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Richard L Henry MD, FRACP

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Stephen M Stick MD, PhD, FRACP

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Sandra D Anderson PhD, DSc

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Peter P Van Asperen MD, FRACP

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Gary P Anderson PhD