The changing clinical presentation of coeliac disease.

BACKGROUND: There has been a growing recognition that coeliac disease is much more common than previously recognised, and this has coincided with the increasingly widespread use of serological testing. AIM: To determine whether the age at presentation and the clinical presentation of coeliac disease have changed with the advent of serological testing. METHODS: A 21-year review of prospectively recorded data on the mode of presentation of biopsy confirmed coeliac disease in a single regional centre. Presenting features over the past 5 years were compared with those of the previous 16 years. Between 1983 and 1989 (inclusive), no serological testing was undertaken; between 1990 and 1998, antigliadin antibody was used with occasional use of antiendomysial antibody and antireticulin antibody. From 1999 onwards, anti-tissue transglutaminase was used. RESULTS: 86 patients were diagnosed over the 21-year period: 50 children between 1999 and 2004 compared with 25 children between 1990 and 1998 and 11 children between 1983 and 1989. The median age at presentation has risen over the years. Gastrointestinal manifestations as presenting features have decreased dramatically. In the past 5 years, almost one in four children with coeliac disease was diagnosed by targeted screening. CONCLUSION: This study reports considerable changes in the presentation of coeliac disease-namely, a decreased proportion presenting with gastrointestinal manifestations and a rise in the number of patients without symptoms picked up by targeted screening. Almost one in four children with coeliac disease is now diagnosed by targeted screening. Most children with coeliac disease remain undiagnosed. Paediatricians and primary care physicians should keep the possibility of coeliac disease in mind and have a low threshold for testing, so that the potential long-term problems associated with untreated coeliac disease can be prevented.

Randomized double-blind controlled trial on the effects on iron status in the first year between a no added iron and standard infant formula received for three months.

UNLABELLED: Recent research has not only questioned the necessity of iron supplementation in human milk substitutes prior to weaning, but also suggested some potential adverse effects. This study investigated the hypothesis that infant formula need not contain added iron in the first 3 mo. Healthy term infants were recruited into a double-blind controlled trial and randomized to receive either a new no added iron formula (New; <0.1 mg Fe 100 ml(-1)) or a standard formula (Standard; 0.5 mg Fe 100 ml(-1)) for the first 3 mo of life. A breastfed reference group was also studied. Iron status was assessed at 3 and 12 mo from heel-prick capillary blood samples evaluated by full blood-count analysis, including reticulocytes and serum ferritin. In total, 149 infants were entered (51 New, 49 Standard, 49 breastfed) with no differences between the groups in gender distribution, birthweight, gestation or numbers completing the study. There were no significant differences between the principal outcome measures: mean values for haemoglobin, mean cell volume and ferritin, between the two formula-fed groups, and the proportion with a haemoglobin level <11 g dl(-1) or ferritin <10 microg l(-1) did not differ. CONCLUSION: The use of a "no added iron" infant formula in place of an iron-fortified formula during the first 3 mo of life did not clinically affect iron status at 3 and 12 mo of age. The universal supplementation of formulae with iron during this initial period needs further consideration.

Maternal cigarette smoking and pregnancy outcome.

Maternal smoking rates in pregnancy have declined, particularly in the non-manual social classes, and perinatal mortality rates have fallen over the last 20 years. We have therefore re-evaluated the relationship between maternal cigarette smoking and pregnancy outcome against this background. A total of 608 stillbirths and 634 infant deaths were identified using the All Wales Perinatal Survey. The cause of death was classified using the clinicopathological system. Maternal smoking rates and social class groupings were compared with those in a cohort of 16047 survivors born to women resident in South Glamorgan. The smoking rate was 37.8% in mothers of babies who died compared with 27.2% in mothers of survivors, an odds ratio (OR) of 1.63 [95% CI 1.44, 1.84]. The OR for unexplained stillbirth was 1.72 [95% CI 1.38, 2.13], placental abruption 2.07 [95% CI 1.29, 3.31], infection 3.70 [95% CI 2.23, 6.13] and sudden infant death syndrome 4.84 [95% CI 3.05, 7.69]. Maternal smoking was not associated with death due to prematurity or a congenital anomaly. Despite changes in smoking habits and the causes of perinatal death, smoking during pregnancy continues to be strongly associated with fetal and infant mortality. It is important that health promotion activities are effective in reducing smoking during pregnancy.

Paediatric resuscitation--by phone.

OBJECTIVE: To ascertain the training and knowledge of paediatric resuscitation amongst all paediatric residents in New Zealand. METHOD: A validated national telephone survey. RESULTS: Interviews were conducted with 96 out of a possible 109 paediatric residents. Most had been qualified less than 5 years and a third had received some training in paediatric resuscitation in the last year. The initial dose of intravenous adrenaline was known by 61% but only 10% knew the recommended ten-fold increase in subsequent doses. Recognition of the importance of cervical spine management in trauma was poor. Correct resuscitation fluids and volumes were selected by 90%, though infusion rates were frequently too slow. Residents with paediatric qualifications and greater experience scored significantly higher. CONCLUSION: Many junior paediatric staff are inadequately prepared for resuscitating children. We believe improved regular training is required and that the introduction of a nation-wide Advanced Paediatric Life Support course, subsequent to the completion of this survey, will lead to improved standards. Its effectiveness needs to be audited.