Pandas Are Top of the Charts with Little Girls

There is a strong link between emotional state, stress and asthma exacerbations in children. I've said before now that I encourage children to make up their own photo montages and slide shows to use to shift their mood if they are tired or upset. Well, pandas are at the top of the charts with young girls in recent workshops, courtesy of You Tube. All the cute you can handle and possibly a dollop or two over the top. I've never been a fan of circuses or zoos, but I recognise that there is something about pandas and other young animals that sends the under-6s into transports of delight.



Boys are trickier. However, the Lake District Tourist Board is offering MP3 downloads of soothing sounds to counteract the blues of the clocks going back. The downloads range from the sound of fresh air blowing across England's highest mountain, to a reading of Wordsworth's Daffodils or Cumberland sausage sizzling in a pan. It's the sausages that appeal to the boys, of course.

Once the children are feeling brighter, I usually recommend that they should go outside and play with their friends. But, more and more, I feel that this is completely alien to them. It seems that safety concerns, their parents' working hours, and a host of other reasons mean that these children rarely play outdoors when they are home. It's a pest, because I find that children respond very well to their breathing exercises when they are physically active.

One of the fastest ways to help a young child who is distressed is to listen to them, help them to change their mood, and then encourage them to shake off the physical signs of stress by running around etc. Playing Simon Says indoors, and having a couple of, Simon Says, "Shake like a wobbly jelly" or "Do star jumps" is useful, but not the same.

Most children have excellent, robust health, and, despite all of the dire headlines that distort news coverage, many of them seem to be happy, confident and vibrant. However, every so often, I have a run of children who eat nothing but calorie-dense, nutrient-free food, they take no exercise, they are frequently absent from school, they live in poor-quality housing and have chaotic family lifestyles. Oddly enough, those children can be withdrawn or belligerent, they can be pale and pasty, they can be very unhappy. We can work with the children in the workshops but there may be no adults at home who have the energy or interest to supervise the 'homework'. I really do need to meet an economist who can help me to price up the cost of doing nothing with these children v. the cost of introducing school-based programmes in certain areas.

Influenza Vaccination: What Are the Benefits?

Recently, I've been reading arguments by various experts in newspapers and various web sources that flu vaccination should be universal to provide herd immunity for the vulnerable. I've even even seen the claim that universal provision would be cost-effective as it would reduce the number of hospital admissions and treatment costs for those or normal health who developed complications, and vulnerable people who developed significant complications.

Universal immunization would eliminate a lot of misery and lost work and school days while keeping the virus from spreading to sick or older people (family members, friends or strangers) who might die from it.

And the immunization need not be 100 percent. In medicine, there is a concept is called "herd immunity" — that is, if enough members of a group of animals (including humans) are immunized against a disease, the entire group is more likely to escape infection.

Contrast that glowing call to civic responsibility with the Daily Telegraph's account of a Cochranesque study on the efficacy of flu vaccination that questions its usefulness. The article in based on a fascinating evaluation of the flu vaccination programme in the British Medical Journal: Influenza vaccination: policy versus evidence. Dr. Jefferson is the author, and he reports a systematic review of flu vaccination studies: he criticises them as mostly poor quality and showing evidence of bias.

The large gap between policy and what the data tell us (when rigorously assembled and evaluated) is surprising. The reasons for this situation are not clear and may be complex. The starting point is the potential confusion between influenza and influenza-like illness, when any case of illness resembling influenza is seen as real influenza, especially during peak periods of activity. Some surveillance systems report cases of influenza-like illness as influenza without further explanation. This confusion leads to a gross overestimation of the impact of influenza, unrealistic expectations of the performance of vaccines, and spurious certainty of our ability to predict viral circulation and impact. The consequences are seen in the impractical advice given by public bodies on thresholds of the incidence of influenza-like illness at which influenza specific interventions (antivirals) should be used.

Dr Jefferson argues that vaccination programmes should have verifiable and measurable targets; e.g., reducing the number of cases and deaths and reducing absenteeism from workplaces and school. Remembering Jefferson's comments on the poor quality of many of the studies, and the small numbers of people assessed in some of them, the summary of his findings is as follows:

• Flu vaccination is worthwhile for people with bronchitis.
• Inactivated vaccines reduce the incidence of exacerbations after three to four weeks by 39% in those with chronic obstructive pulmonary disease.
• For infants up to 2 years old, vaccination was no better than placebo; in older children there was little evidence of benefit.
• Although a review of study data suggested that vaccination of all children mimimises transmission to other family members, the weakness of the study design made it impossible to quantify the benefit.
• Jefferson did not find enough evidence of benefit for vaccination for people with chronic chest problems, asthma and cystic fibrosis.
• For healthy adults the evidence indicates that, on average, flu vaccination of the population would prevent 0.1 per cent of a working day lost. Vaccination does not affect hospital stay, time off work, or death from influenza and its complications.
• Combined studies of the elderly showed a variation from no effect to a 60 per cent difference when "all cause mortality" was measured.

With reference to the last, Jefferson writes that:

These findings are both counter-intuitive and implausible as other causes of death are far more prevalent in older people even in the winter months. It is impossible for a vaccine that does not prevent influenza to prevent its complications, including admission to hospital.

Jefferson makes a strong argument for the necessity of high quality randomised control trials.

the inception of a vaccination campaign seems to preclude the assessment of a vaccine through placebo controlled randomised trials on ethical grounds. Far from being unethical, however, such trials are desperately needed and we should invest in them without delay. A further consequence is reliance on non-randomised studies once the campaign is under way. It is debatable whether these can contribute to our understanding of the effectiveness of vaccines. Ultimately non-randomised designs cannot answer questions on the effects of influenza vaccines.

Jefferson concludes that:

The optimistic and confident tone of some predictions of viral circulation and of the impact of inactivated vaccines, which are at odds with the evidence, is striking. The reasons are probably complex and may involve "a messy blend of truth conflicts and conflicts of interest making it difficult to separate factual disputes from value disputes" [22] or a manifestation of optimism bias (an unwarranted belief in the efficacy of interventions).[23]

It is a fascinating paper and will probably generate some controversy. One of the areas for discussion is the claim that the dose in adult flu shots is too low (as discussed in the first referenced piece). It is unquestionable however that Jefferson is correct about the poor quality of the studies that do exist and the need for better, randomised trials.

The BBC carries comments from the Dept. of Health and other interested bodies that emphasise their confidence in the value of flu vaccination, but in the light of Jefferson's analysis, it is difficult to accept the assertion that:

There is good evidence from clinical trials that flu and its more serious effects are prevented by vaccination when you look at the community effect.

Jefferson does not argue that people should forego their influenza jabs: he does argue that we need better quality trials and evidence before we can be confident that the jabs are effective and have cost-benefits.

P.S. - Phillip Gordon has mentioned the comments on this post. For reasons that Blogger alone can fathom - they are split between Haloscan and Blogger comments. To see the Haloscan comments, you need the home page loaded and to scroll down to the post and click on comments. If you came here from the PGR 1:15 link, then the Blogger comments should automatically load with the piece. I can't wait until I'm offered the Blogger Beta option.

For more information about the images used in the illustration, click on it or visit the detail on Flickr.

BBC's More or Less: Diet and Behaviour

BBC Radio 4 has an interesting programme, More or Less that explores the way statistics and numbers are used in newstories. This week's programme included a 10 minute segment on an investigation into diet and behaviour that had been conducted in a UK prison (the first 10 minutes). The host characteristed the study as:

in statistical terms, what looks to us like an exemplary piece of high quality research-reaching a standard almost never seen-and often not possible-in criminological studies.

Tony Plant discussed the Gesch trial in Fish v. Drugs for Children and Criminals, so go there for some comment on the study. Gesch is interviewed on More or Less and makes many interesting points and provides good explanations as to what a double-blind, placebo, randomised, controlled trial is and its implications for designing and running an experiment, and then interpreting the results.

Gesch acknowledged that the prison kitchens provided meals that conform to government nutrititional guidelines. However, he remarked that one of the major issues was that the prisoners had no understanding of vitamins, and could not name the food that contained them: typically, the prisoners made poor food choices by nutritional standards.

Gesch's trial reported a 26% fall in incidents ranging from insolence to violence. The host asked the eminently sensible question, "Is that a reduction from a large figure?", and the answer seems to be, "Yes". Gesch told us that Aylesbury Prison (where the trial took place) had been notorious for its difficult population, with an estimated 16 offences per 1000 man-days. Gesch revealed that the more serious offences, such as violence and theft, were reduced by 37%.

The host makes the point that if these results could be replicated in the general population:

it would be one of the most successful crime-cutting initiatives, by far, ever.

The section ends with an overview of why studies such as this are caught up in a political battle. The Home Office issued a statement that the Prison Service would continue to provide nutritionally acceptable meals with clearly labelled Healthy Options. The host wrly commented that this does not address the issue of how the prisoners could be persuaded to eat them.

Education and poor choices are a recurrent issue in the public debate about nutrition. There is a lot of criticism of government guidelines about nutritional status; the 5-A-Day programme is frequently ridiculed, as was the recent suggestion that the Dept. of Health was in talks with supermarkets to provides classes on how to prepare and eat fruit and vegetables. There is a lot of evidence that nutritional education programmes broaden the awareness of the nutritional message but do not have any impact upon food choices. E.g., more people know that the official recommendation is that they should eat 5 servings of fruit and vegetables a day, but only the minority of people meet that recommended level.

Many parents aspire to providing better nutrition for their children but dislike the perception that they are nagged about it and many feel that they don't have the time to prepare home-cooked meals. In addition, they do not have the emotional energy to argue with children about their food choices and feel that it is not a battle that is worth fighting.

Power-law distribution might argue that it is cheaper to make practical interventions to improve the nutrition of some of the most vulnerable than to manage it through educational initiatives. Malcolm Gladwell discusses power law distribution in an extraordinary essay, Million Dollar Murray: Why problems like homelessness may be easier to solve than to manage. Gladwell discusses power-law distribution and its application to homelessness, environmental pollution etc. Tony Plant has given an overview of it in the context of social care in What is the cost of doing nothing?

In a nutshell, experience in the US has shown that it is cheaper to provide free serviced apartments and medical care to the population of alcoholic homeless people, than to provide the usual patchwork of homeless shelters, social services and unlimited emergency health care for them.

Ignoring the political and moral objections, if the government is concerned about obesity and the current/future health problems associated with a poor diet, would it be more cost-effective to feed children at school in socio-economic areas of high deprivation? Particularly when one compares it to the cost of running health education campaigns that have a negligible impact on behaviour. E.g., more people know about the 5 a day slogan, but a negligible number of people have changed their habits. Or when compared to the LEA costs of accommodating children with emotional and behavioural problems (also linked to poor diet by some researchers).

A number of schools have breakfast clubs. In some areas, most pupils qualify for free school lunches. With the introduction of Kelly hours - how much of a stretch would it be to provide tea/dinner?

I can think of a number of moral and political objections to such a programme but I wonder if the economics would actually justify it?

Why Lawyers Are Sometimes More Effective Than Asthma Specialists

Sadly, and intriguingly, it seems as if inner-city asthma patients may sometimes benefit more from a referral to a lawyer rather than to an asthma specialist. Run-down housing may be dusty, mouldy, rodent-infested, cockroach-infested or damp, and this can make it impossible to derive any benefit from asthma medications. In the past, doctors and social workers wrote repeated letters to landlords but the landlords did not take any action.

In a pioneering and surprisingly effective programme, St. Luke`s-Roosevelt and the New York Legal Assistance Group, joined forces. The hospital paid for an attorney's letter to a landlord that effectively stated: Clean the place up or see me in court.

Researchers reported the findings, so far, from 21 patients, all of whom were complying with the recommended use of inhaled corticosteroids to control inflammation but were still unable to control their asthma. For the 11 patients who had adopted the legal remedy:

• Patients who had previously needed to take emergency courses of oral steroids because of uncontrolled asthma, reduced their use from 18 courses in the year before their apartments were cleaned up, to 2 courses in the year after the clean-up.
• Patients reduced the number of asthma exacerbations that triggered a trip to the hospital emergency department, from 14 trips prior to the legal intervention, to 2 visits after the home-repairs.
• Patients significantly improved their asthma condition as assessed by a popular lung disease scale.

The patients who had refused to allow legal action did not show any improvement in their asthma symptoms.

Unsurprisingly, the researchers reported that when living conditions are severely degraded and make a significant contribution to asthma symptoms, improving those conditions leads to improvements in asthma control. The cost-savings were substantial. The initial letter to the landlord cost $225. This compares favourably with an emergency room visit which costs the hospital about $450 in services; each course of prednisone cost about $345.

Paula Anderson, professor of pulmonary and critical care at the University of Arkansas for Medical Sciences, Little Rock, commented on the study:

While the numbers of patients involved in this study were small and...this is a retrospective study, the results show that patients with asthma cannot get better when they live among irritants and allergens. This study shows how brilliantly practical public health measures can be to correct health problems.

The study is also a small-scale replication of the success of the Harlem Children's Zone who have previously worked with lawyers to deal with the housing problems common in low-income areas that are believed to contribute to asthma attacks in children.

This study is an interesting example of times when medical advisors know that their (sometimes very costly) treatment isn't working because of a patient's housing conditions, but they are unable to do anything about that, despite repeated appeals and letters to the people who can. In this study, a legal letter was cheaper than the medical costs: it would be interesting if the researchers had been able to give an estimate of how much the landlord's repairs to the properties had cost, and contrast that with the medical costs.

For more information about the image used in the illustration click on it or visit the detail on Flickr.

Paediatric Grand Rounds 1:14 Is Up!

Paediatric Grand Rounds 1:14 is up at The Wait and the Wonder. Moreena has done a fine job of pulling these rounds together by foraging and looting for posts that would be of interest to us. Moreena's introduction is interesting and un-nerving and a timely reminder that parents need to remain vigilant and that doctors and nurses should credit parents with an extensive knowledge of what is happening with their child.

There is a rich variety of posts, covering an extensive range of situations.

Clark Bartram is on the look out for hosts for future editions of Paediatric Grand Rounds. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

The next Paediatric Grand Rounds is scheduled for November 5 (Guy Fawkes Night for those of us in the UK!), and will be hosted at Tales from the Womb.

ADHD and School Exclusion: R5's Unhelpful Contribution to the Discussion

The BBC carries an interesting piece on the dilemma that faces parents whose children have been diagnosed with ADHD and who face exclusion from schools that are unable to deal with their medical needs. The piece does not cite a source but uses the common estimate that up to 1 in 20 children have ADHD.

A recent survey by the National Attention Deficit Disorder information and support service found the exclusion rate for children with ADHD was 10 times higher than that of those without.

Some parents have told the BBC they were told to give their children medication or keep them at home, and that they often felt they were being denied a proper education.

The Radio 5 piece about ADHD is interesting and irritating (I particularly object to it being called The High Life as this frames the debate in an unhelpful context).

One maddening abuse of statistics in the programme was the shocking news that almost 50% of children are "denied an education" because they've been excluded because of their ADHD. Well, some of them may be permanently excluded, but not all of them. Some of them are excluded for 1 week or more before being accepted back into school. [Later correction: on listening to the programme again, at around 37:56 the journalists do mention that 40% of children are 'fixed-term' excluded and 11% are permanently excluded. In my own defence, it was easy to miss and there was no mitigation of the rather bleak summary given at the top of the programme.] The other statistically irritating point was the reference to the 90-fold increase in the number of prescriptions: there was no attempt to correlate this with any formalisation of ADHD diagnostic criteria or whether this had happened because doctors had been issued with new guidance.

Early on, the dire warning that ADHD medication can kill was highlighted but there was no attempt to give the number of children who are affected by this and the information that this may be related to a pre-existing heart condition was given later in the programme. I had some sympathy for the argument that we do not understand the long-term impact of prescribing these drugs to children. However, I do feel that it is very alarming for parents to hear these warnings in the absence of any immediate discussion that at least estimates the risk.

As ever, Dr. Timimi was interesting. The other experts and parents put up a defence for the value of the drugs with the usual argument that ADHD is under-diagnosed. However, I was very surprised to hear Linda Shepherd criticise Timimi with the claim that he should base his comments on "scientific fact rather than propaganda". Dr. Gringras did argue that more children would benefit from medication but we were not given enough context to understand his stance. I did like the fact that he couched his support for medication as contingent upon adequate diagnosis with the exclusion of other disorders and agreement with the parents. Unfortunately, from my perspective, he did not discuss his work on sleep disorders and the diagnosis of ADHD in this programme.

There was a claim that prescribing guidelines are being ignored and that parents are not being told about behavioural management techniques or given nutritional advice: drugs are being used as the first treatment option rather than a last resort. I would have liked some indication that there is a published literature that supports the efficacy of these management techniques. I'd have liked an exploration as to whether or not there is access to the necessary support and services in all health regions. It would have been good to have an indication what the scale of provision would need to be for the claimed 400,000 children with the diagnosis and what this would cost. I don't expect parents to be able to estimate such costings, but it is shoddy journalism to make such allegations (no advice on alternative strategies) without discussing what the implications would be for service provision and their costs. The one justification that we had for the claim was Mary Rhodes(?) saying:

To put it bluntly, these guidelines seem to be pointless. Part of the problem is that the alternatives to the drugs simply aren't on offer in some areas. For example, the NHS admitted to us that there's no provision of alternative therapies at all, anywhere, in the whole of Scotland. So parents are resorting to private treatment instead, if they can afford it.

We heard that there was no access at all to alternative therapies in the whole of Scotland but it was unclear what these alternatives were. Maybe I didn't listen properly but I would have liked these alternatives to be outlined. If Timimi discusses alternatives, I assume that he means behavioural strategies but it would be good to have had that confirmed.

I was very annoyed by the piece about the Cactus Clinic (around 17 minutes into the interview): either it was badly edited or the designated speaker was very disappointing. When discussing the Cactus Clinic, it seemed that these other alternatives included nutritional interventions: the diagnosis of these was not detailed in the programme but the clinic website refers to nutritional assessment tests that have little scientific credibility. The website says that their 5 point treatment programme aims to:

• correct nutritional deficiencies/excesses
• reduce heavy metal toxicity
• eliminate food intolerances
• balance blood sugar levels
• supplement essential fatty acids.

The clinic website also refers to creating individual programmes for children with psychological, personal or educational needs, the Caregivers' Skills Programme.

The Cactus Clinic was introduced as offering "pioneering nutritional and behavioural advice"; it was represented by Dr. Dave Woodhouse. I've already referred to the lack of evidence that we were given (annoying, if it was edited out). Dr Woodhouse said:

A nutritional approach does work in terms of the types of minerals that might need a supplement [slightly unclear]. There's a whole host of evidence that zinc is important, Omega 3 is important, magnesium is important, selenium is important. And when we look at the kids we get here, we find that these are a common thread that run through all the children. So, if you have time to go round and look at all this so-called scientific evidence then you will build up a picture that there is a lot of information, there is a lot of research out there that does indicate that a nutritional approach does work.

What "so-called scientific evidence" was he referring to - and where is this evidence that a nutritional approach works? The website refers to "heavy metal toxicity" but there is no information about how this is measured, or how the levels of heavy metals are reduced. The journalist refers to an 80% success rate but we hear nothing about how that was assessed and by whom? Did teachers and psychologists administer some of the standard scales? Did parents and children fill out questionnaires? Enquiring minds definitely need to know.

Why did Dr. Woodhouse refer to the NHS as having "only one approach to managing the condition which they call ADHD"? What does he call it? If he is demurring from the DSM IV criteria, shouldn't the journalist have told us that? If the children who are accepted into the clinic do not have to conform to a standard diagnosis, then how can there be claims about improving children's ADHD symptoms? Dr. Woodhouse claimed that the NHS was failing to provide the multi-modal approach and

9 times out of 10 the only approach that parents are given [they say?] is, "OK, take this medication or don't take this medication.".

Around 25:30 minutes into the interview (post the news and sports break) we are brought back into the discussion with the assertion that it seems as if "the NHS is blinkered to anything other than the medication we've been talking about" and advocates medication as a first line approach.

Unless, I'm mistaken, Dr. Timimi practises in the NHS. Does he not count for the purposes of this discussion of NHS provision? Mary Rhodes again refers to the (private) Cactus Clinic and mentions that they carry out a range of tests for nutritional deficicies (without examining the value or accuracy of these tests or the proof that nutritional deficiencies are relevant). Mary Rhodes then says, "The Dept. of Health told us similar treatments should be available through the NHS". She then refers to the fact that the Dept. did not agree to participate in the programme. Rhodes did not do anything useful like assess whether or not these services are available on the NHS, throughout the UK, by ringing around various health trusts or approaching any of the support groups. We were just informed that the Dept. had not been able to provide figures of expenditure that they had requested, so Mary Rhodes asserted that, "In reality [alternatives] are often just not offered".

I'm sorry to harp on about this, but there was no discussion about the nature or evaluation of these nutritional strategies. I was left with these questions.

• Can nutritional deficiencies be evaluated if we are not told whether they are looking at serological levels, intra-cellular levels etc.?
• Can intolerances and deficiencies be diagnosed reliably using the tests that are described on the clinic's website?
• What level of deficiency is clinically significant?
• Is there any indication that the children have an inadequate diet or a malabsorption problem (in which case - how is this addressed?)?
• Is there any peer-reviewed research that describes the protocol for correcting these deficiences?
• Is there any peer-reviewed research that reports trials in which this supplementation successfully reduced the symptoms of ADHD (ignoring the other related issues of understanding what the clinic understands as ADHD)?

Elsewhere, I have found an interesting overview of the nutritional work done by the Pfeiffer Center. If the researchers for this programme had taken a look at this article, and the others in the thread, they might have been able to ask more critical questions about the nutritional strategy. At the very least, they might have picked up on the obvious point that amidst the unproven claims of behavioural improvement, the clinic was referring to those children who had passed its screening - rather than the standard population of children with ADHD.

There is a cursory discussion of the issue of prescribing ADHD medications to the under-6s that prompts the host to say:

It's curious isn't it? It seems as if doctors can almost do what they want here. Guidelines ignored, licensing rules broken when a child is assessed. All routes leading to medication. With a bit more time and investigation, alternatives could be found, perhaps. Shouldn't the NHS be monitoring the situation more effectively?

We did, predictably, hear from an MP who said that we need "to give parents and families the support they deserve" (for my knee-jerk response to this, see the Hoggart opposites question). Linda Shepherd was allowed to state her view that parents do research the options that are available and to highlight that the drugs make a positive impact on the lives of many people and have been investigated for their safety (albeit, it was probably not her responsibility to answer the earlier charge that we know little about the possible long-term implications of sustained use of the medication). She stressed that "the consequences of not treating the disorder can be very tragic".

When Timimi was asked why the 'alternatives' are not more widely available, it was obvious that he was unleashing a dam in the final part of the programme. Timimi said: that we had been

kinda swept along [with?] basically the drug companies' agenda...We've conceptualised these behaviours as being due to a sort of chemical imbalance or a problem in the development of a child's brain despite the evidence being, very clearly, that there is nothing to back that theory up.

There are no tests for ADHD and so figures like 5% and so on can be plucked out of the air because it just depends on where your definition is-your dividing line is-between the normal and the abnormal.

But in terms of alternatives, there are plenty of alternatives. Partly in terms of the whole cultural approach to this problem. So, for example, I think a lot can be done by turning our gaze away from looking for problems within the individual child towards looking for ways of developing our public health approach. For example, looking at diet and nutrition. Looking at working hours of parents, looking at support for parents. Looking at the problem of missing fathers. Addressing what's going on with school. Addressing bullying. Developing more healthy, active lifestyles. Greater community ownership. Looking at marketing and consumerism and advertising that targets children.

And also with individual children, there are plenty of alternative approaches from behaviour therapy, family therapy, nutritional therapies, various lifestyle interventions and so on. And certainly I've been able to practise like that successfully for many, many years. [31:20]

Timimi is an excellent writer. I understand that it can be difficult to put your viewpoint across on radio programmes for a general audience but he is sufficiently experienced as a public speaker to realise that unleashing a dam of possibilities that could not be discussed was inappropriate. Some of his points seemed a little off-the-wall because he did not put them into context. It would have been far better if he had acknowledged that there were many contributing factors in his experience, and then used the time that he had to give more detail about the interventions that he does use in his own practice of children with ADHD.

A number of listeners had contacted the programme to express their viewpoint that ADHD "doesn't exist". Timimi dealt with by saying that parents who are struggling to cope with their children's very difficult behaviour might feel that such an attitude was an insult or a slight. He then went off at a tangent that probably didn't enlighten the listeners who had expressed that view.

It's not that ADHD doesn't exist. These behaviours do exist. They are a problem. And people need help with them and deserve help with them. The problem is that we think of ADHD as being a result of a biological disorder and because we have this idea that it's a...This is the idea that's being promoted by the drug companies, that's it's due to some sort of chemical imbalance. That then promotes the market for a drug which is believed to, or promoted as, correcting this chemical imbalance. This is the bit that's nonsense. This is the bit that's simply not backed up by the evidence. [32:40]

I do not understand how this was an adequate response to the listeners. Nor why Timimi believes that telling parents they are gulled by drug companies into accepting the notion of a chemical balance, is less insulting to parents who have accepted medication for their children.

One listener questioned what the treatment was for, "other than to make life easier for the parents". Linda Shepherd replied:

The hard work begins for the parents once the medication is given. All of the things that you have tried from when these symptoms first showed themselves-you can then go back and repeat. And you will find that it is easier to work with the child. But you have to be consistent. Medication does not make the child behave. We shouldn't be letting children believe this.

Linda Shepherd says that

It was good of Mr. [sic] Timimi to some back and say...that he didn't think we should be saying, or anybody should be saying, that ADHD doesn't exist. But that's actually what he says. You know, most of his papers call it bio-babble and it doesn't exist. [34:30]

(For a discussion of biobabble, see post 4 in this thread.)

The question of the pressures on the education system had very little coverage within the programme.

Although there's been an increase in the number of children with ADHD, there hasn't been an increase in support or training for teachers. So, as a result, some schools simply aren't equipped to deal with the special needs of these children and are resorting to exclusion rather than dealing with the problem.

Now, this sounded like commonsense, but where were the figures to support these assertions? The 'exlusion expert', Peter Turner, was very upfront about only being able to talk from his own experience and not from any acknowledged research. I was pleased that he objected (albeit mildly, with a, "I'm not sure...") to Mary Rhodes' assertion that schools are "getting rid of these children with ADHD" [35:10]. Peter Turner did make the point that it wasn't ADHD that was leading to the exclusion of children, but the difficult behaviours that may be associated with it. He disagreed with Rhodes' assertions that exclusions are on the increase by saying, "Published statistics tend to suggest not...My personal experience, which is limited to one county, tends to suggest that, actually, they are".

Peter Turner did say that from his experience, exclusion was used as a last resort, and typically children with ADHD are allowed to stay on at school despite behaviour that would have led to the exclusion of children who do not have ADHD. The emphasis for the discussion was on the children who are excluded. It wasn't re-emphasised that 11% of pupils are permanently excluded (as distinct from the headline of 50% of children with ADHD who are excluded, the majority of whom are excluded for a 'fixed-term' that might be very short).

On balance, I don't think that any of the material would have been surprising to most people, particularly not those who already have some experience of ADHD as a parent, teacher, doctor, health worker etc. So, it didn't meet the need of bringing illumination to an informed audience, so how about to a 'not particularly well-informed audience'? Well, no. At no time was anybody asked to describe what appropriate provision of 'alternative options' would look like. E.g., how many specialist places in schools, with what level of support? How many more child psychologists or family workers?

Although Linda Shepherd, the parent who was interviewed throughout the programme, made the point that medication could not be the complete strategy for managing ADHD and there was a need for "a package of support", she wasn't asked to elaborate on this. Nobody, including the MP, was asked to cost their preferred approach. Indeed, MP Annette Brook was allowed to tell us that teachers need more support and continuing professional development without having to tell us how this would be funded, or what changes would need to be made to the educational system to allow smaller classrooms and suitable environments for children with ADHD. I was left wondering if she had any real understanding of the implications for school and classroom management of the "challenging behaviour patterns" that she so blithely discussed. We also had the usual political soundbite of, "Inclusion versus special schools-has the pendulum swung too far?". There was the usual reminder that inclusion is not "a cheap option" and needs to be well-resourced with no indication of how this could be funded or what it would cost.

So, why was this programme broadcast? The content wasn't novel or particularly informative. There wasn't enough space for Timimi to describe his argument as to why ADHD may be a social construct in some cases: at one point he reeled off a shopping list of public health and social issues that may contribute to ADHD in children, each one of which is probably worth its own programme to investigate. Timimi raised his familiar argument about ADHD:

There's an interesting question here as to whether there has been a real rise in these behaviours. Or it's just a change in the meaning that we give to these behaviours that has happened...I suspect there's a bit of both...The more we label children with conditions like ADHD, the more...teachers feel, in some way, these children have now a condition that requires an expert to manage them and lose their ability-even their commonsense ability-to just do the ordinary things to manage these children.

I admire Timimi, but, as with the MP, I did wonder if he had any idea what it is like to try and manage a class of 30 children with perhaps 4 disruptive children, who may or may not have a diagnosis of ADHD. Timimi was careful enough to decry others who seemed to insult or slight parents, but seemed ready to slight and insult the goodwill and competence of teachers.

There wasn't enough space for researchers or parents who disagree with Timimi to argue their position fully. I thought that the discussion of 'alternatives' was badly limited by the exclusion of the well-documented correlation of ADHD and sleep disorders: albeit, with the caveat that correlation can never imply causation.

Inevitably, there will be some transcription errors, but I have done my best to transcribe the relevant parts of the programme as faithfully as I could. Inevitably, any emphases are mine, but I did try to capture the speech cadence of the speaker. Timings are approximate and mostly appear in [].

Pneumonia and Asthma in the Developing World Plus Antibiotic Resistance

Mike the Mad Biologist has written an interesting piece, It's The Acute Respiratory Infections, Stupid!. He discusses a Lancet report on the devastating impact of pneumonia on children in the developing world. I was not aware that:

Pneumonia kills more children than any other illness, more than AIDS, malaria, and measles combined... More than 2 million children under 5 years of age die from pneumonia each year, accounting for almost one in five under-5 deaths worldwide.

It's was an odd time to read this piece because this week I have been looking at the increase of asthma prevalence in countries on the continent of Africa. Most of the countries in Africa do not have access to the pharmaceutical treatments that are the gold standard for asthma care in the West. Looking at another tangent, there has been a lot of discussion this year about reports of people with chronic asthma who have had bronchoscopies that reveal the presence of Mycoplasma pneumoniae and Chlamydia pneumoniae in the lungs. In addition, there seems to have been an upswing in the incidence of HIV-related opportunistic infections such as Pneumocystis carinii.

Mike has also written a good piece on antibiotic resistance. The post is notable for some powerful imagery in a comment (borrowed from an unattributed comment):

This is the image they gave us in pharmacy school:

The antibiotic is like a guy with a machine gun standing in a pitch-black room full of 1,000,000 bad guys, firing wildly. Say every clip of ammunition (every tablet) kills 90% of the villains.

So, after tablet #1, there are 900,000 dead bad guys and 100,000 left alive.

After tablet #2, 10,000 left alive

After #3, only 1,000 left alive.

So it's no wonder you feel better after 3 tablets. But the 1000 guys left are the wiliest and strongest ones. If antibiotic resistant bugs are going to develop, they will be decendants of those 1000. Also, to really get rid of the infection, you need to expend a LOT of ammunition on the last couple of bad guys.

That is one of the best descriptions that I have seen: I've managed to track down the source because I intend to use it in the future, with attribution.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

Lack of Sleep Linked to Obesity in Children

I recently discussed Dr. Taheri's cult status in playgrounds for his stance that children need more sleep, and that lack of sleep is linked to hormonal disturbances that increase the consumption of sugary and starchy foods and therefore contribute to weight gain. Dr. Taheri and his researchers are back in the news with the claim that the government should take sleep-deprivation as seriously as diet and exercise in the the public health battle against obesity.

there is increasing evidence that short sleep duration results in metabolic changes that may contribute to the development of obesity, insulin resistance, diabetes and cardiovascular disease...

The relationship between short sleep duration and obesity seems to be more robust in children in whom there is a linear-dose relationship between shorter sleep and increased body weight.

Taheri reports the striking finding that

short sleep duration at an early age of 30 months predicts obesity at age 7 years...sleep loss at a young age may considerably alter the hypothalmic mechanisms that regulate appetite and energy expenditure.

Another one of the studies that Taheri highlights is the finding that

as little as 2-3 nights of sleep restriction in young adults can have profound effects on metabolic hormones.

Taheri discusses the many variables that are entangled in the correlation of obesity and sleep deprivation.

Sleep duration may alter the balance between energy intake and energy expenditure by affecting both sides of the equation. Sleep deprivation results in fatigue and excessive daytime sleepiness. Could this fatigue contribute to reduced daytime physical activity, which many believe is a major contributor to the current obesity pandemic? One study found that about 40% of 12-16-year-olds in their survey reported waking up tired; this could have a serious adverse effect on daily physical activity.

Taheri discusses several of the hormonal changes that have been reported in studies. He suggests that

[h]ormonal changes could contribute to selection of calorie-dense food, excessive food intake, changes in energy expenditure and insulin resistance.

Unsurprisingly, Taheri proposes that some of the sleep problems that are regularly found in children and adolescents may be linked to increased television viewing and computer games, and use of the internet and mobile phones-particularly where these are available in the bedroom. Taheri acknowledges that sleep is not the substantive solution to the "obesity pandemic" but argues that it should be taken seriously because "even small changes in energy balance are beneficial". Because of the impossibility of conducting a placebo-controlled or blinded study, Taheri suggests that the research that we have to date would suggest that a strategy to prevent obesity in children should

[promote] a healthy diet, physical activity and adequate sleep.

Dr. Taheri argues that both parents and children need more education about the importance of sleep. He has written a review* of studies that examine the correlation of sleep deprivation and excess bodyfat. Taheri offers 14 tips to improve the sleep of children and teens.

General tips for children and teenagers

• Ensure a regular bedtime routine
• Set regular bedtimes and wake-up times
• Ensure a quiet, dark, relaxing bedroom that's not too hot or too cold
• Children's beds should be comfortable and only used for sleeping (e.g., no TV watching or listening to music or extensive reading)
• Children should be physically active, but not within a few hours of bedtime
• Remove TVs, computers, playstations, telephones and gadgets from children's bedrooms
• Avoid large meals near bedtime.

Specific tips for teenagers

• Avoid caffeinated drinks after lunchtime
• Avoid nicotine, alcohol, and drugs
• Avoid activities that may be mentally stimulating around bedtime (e.g., intense studying, text messaging, and playing video games)
• Reinforce the sleep-wake cycle:
  • Reduce exposure to bright light in the evening
  • Ensure exposure to bright light after waking up in the morning
• Allow teenagers to sleep in at the weekends , but not by more than two or three hours or it will disrupt the sleep schedule
• Do not stay up all night even at the weekend as it may disrupt the sleep schedule.

Taheri, S. The link between short sleep duration and obesity: we should recommend more sleep to prevent obesity. Archives of Disease in Childhood, November 2006; vol 91: pp 881-884.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

Paediatric Grand Rounds Wants Your Post, Please

Yes, it is out with the begging bowl, as I shamelessly rattle the post collection bag and ask you for your contributions to Paediatric Grand Rounds 1:14. As you can see from the magazine cover, we are open to conventional and more off-beat topics.

The next edition of the PGR will be hosted by Moreena at The Wait and the Wonder. Moreena asks that you send submissions to moreenaATgmailDOTcom by 10pm on the 21st.

Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

For more information about the image used in the illustration (from Tedsblog), click on it or visit the detail on Flickr.

Parents And Their Influence On Their Children's Health

The blogging PC David Copperfield is having his book serialised in the Daily Mail. Reading an extract about an visit to parents who reported a missing child, I had my head in my hands.

After years as a police officer, I have long given up expecting people to act in a certain way — women to behave with decorum, parents to look after their children.

Take a call I had recently. 'A 12-year-old girl has been missing for a few days,' said my radio. 'Please attend the address.' I tried to get the details from her mum and mum's partner but this was a bit difficult over the noise of daytime television.

I wasn't getting anywhere so I set off. My first call was to the girl's school — and there she was. I returned to the house — some 800 yards from the school. 'She's at school, she's fine,' I said. 'That's no good,' said her mum, one eye on the TV. 'I want her back here.'

'How about nipping up there to see her yourself?'

'I haven't got a car', she replied.

'Well, the school is only up the road. You could walk.'

'I'm registered disabled. Look,' she continued, as though speaking to an idiot. 'She could be out there being abused right now. I want her back here. It's your responsibility if she gets abused.'

She shut the door in my face. I collected the girl and brought her home. 'Could you please ensure she doesn't run off in the future?' I asked.

'No,' said her mum. 'I can't do nothing about it. I'm not stopping in all night.'

'But you're registered disabled,' I said. 'Where are you going?'

'Out.'

'So if she goes again will you call the police?'

'Yes, it's your responsibility.'

Next time you get burgled, you know where to find me: I'll be out looking for children whose parents can't be bothered to look for them themselves.

When I run the Breath Spa workshops, I ask that at least one adult (preferably a parent) attends with the child. I have been known to be very annoyed if a child attends without any adults.

Sometimes, it is a grandparent who brings a child to the workshops. There have been occasions when it has been what would best be described as the step-aunt (a woman who lived with a brother of the new partner) who has brought along a child. It is lovely that some adults care so much for the children who come into their circle but it is difficult to work with children when I have no contact with the adults with whom they reside. (What is it about chaotic circumstances that brings out the most stilted and convoluted language to describe them?)

I need to be able to talk to the adults who spend most time with the children to discover how much the children are exposed to tobacco smoke. I need accurate reports about the children's sleeping habits and how they respond to emotional stresses. I need to be able to enlist the adults in supervising the exercises of young children and encouraging them. There may be some changes to the bedtime routine or the bedroom that can not be made by the child alone.

I'm fortunate enough that UnLtd meets the costs of room hire and travel when we run workshops. I'm sometimes asked why we don't run the workshops with organisations like Sure Start: well, I'd like to, but the discussions with the organisations usually break down because we need to have at least one of the parents present when we run the workshops and we're not in the position where we can meet the travel expenses of all of the workshop attendees or provide a meal.

So, although it might be advisable for children to be on the lowest amount of medication to manage their symptoms (where relevant), handling the practicalities can be beyond the means of some parents. Sometimes, the medication seems like a simpler solution, but where there are chaotic or difficult family circumstances, it is not unusual for there to be problems in managing the medication or adjusting it in-line with peak flow readings or symptoms.

For a number of reasons, I am coming to the conclusion that programmes such as Breath Spa are best offered as part of the extended school day. It is still not practical to make changes to the bedtime routine etc. but at least the children would be able to do their various exercises in a supervised manner. And then I catch the thought and wonder if it is appropriate for other people to usurp the responsibilities of parents. And then I read bleak summaries like that of 'PC Copperfield':

Round these parts, love for one's children is articulated at high volume, to save turning off the television, and it's usually peppered with expletives.

It's a love that has quite defined limits though: insufficient to warrant meals at regular times and without chips, for example, but at the same time effusive enough to ensure the provision of great quantities of designer sportswear.

I wonder how social fabric can survive the nagging of parents and the assumption that they either don't care about the well-being of their children are lack the skills to care for them.

For more information about the images used in the illustration, click on it or visit the detail on Flickr.

The Duvet Diet: The Importance of Sleep Quality

When The Times ran an article provocatively entitled The Duvet Diet I feared that it was going to be one of those puff pieces for a magnetised mattress pulling the fat from your body while you slept under the thermogenic stimulus of an essential-oils-impregnated-duvet. So, I was both abashed and relieved that the article stressed that sleep is essential to our physical, cognitive and emotional well-being: and that it has a profound impact on our metabolism and physiology.

Dr. Taheri of the University of Bristol is probably even now attaining cult status in playgrounds for his advice that children should be allowed to sleep uninterrupted (he wisely doesn't get into the argument of when the bedtime should be). Dr. Taheri is particularly interested in whether the sharp increase in teenage obesity is related to the fact that teenagers biologically need so much more sleep than modern lifestyles allow them to have. The article quotes Dr. Taheri:

How much sleep we have affects our IQ, our suicide risk, our chance of substance abuse and our weight...If we don’t take it seriously, we will pay the consequences.

Update October 19, Dr. Taheri has published a review of studies that link sleep deprivation and excess bodyfat in children and teenagers. He suggests some tips to improve that quantity of sleep although he does not address the quality of sleep or sleep-disordered breathing in this review.

A bald summary of the theoretical underpinning of the Duvet Diet is that lack of sleep affects the hormones that influence appetite: so, for some people

less sleep=hormone disruption=greater appetite=weight gain

Several hormones contribute to the rise in appetite. The stress hormone, cortisol, is probably the best-known of these. Cortisol levels follow a fluctuating rhythm throughout the day. Cortisol levels peak somewhere between late-morning and noon: thereafter they fall, and should reach low levels before falling asleep. There is some speculation that there is a substantial fall in cortisol levels between 2 and 4 a.m. that is linked to the number of asthma exacerbations that happen between midnight and 8 a.m.. However, the mechanism of nocturnal exacerbation of asthma is not clearcut: there are probably multiple (perhaps synergistic) factors that make a contribution.

Eve Van Cauter has reported studies that show short sleep duration in young, healthy men is associated with decreased leptin levels, increased ghrelin levels, and increased hunger and appetite, and cortisol disturbances that influence the ability to cope with stress and also promote the laying down of a personal duvet of body fat. An interesting speculation here is that sleep apnoea is typically found in middle-aged, overweight men who have increased their collar-size (implying more body fat around the neck): if sleep disordered breathing (SDB) has been present for some time, it may have contributed to the weight gain, as well as being exacerbated by that weight gain. A similar hypothetical vicious circle may be present in morbidly obese children with SDB.

There is a lot of evidence that highlights the importance of sleep's contribution to allostasis and therefore, wellbeing. Salvador Minuchin famously remarked that "behavioral events among family members can be measured in the bloodstream of other family members".* It seems as if that could also be adapted to "behavioural events among family members can be measured in the diagnoses of other family members". The Times carried a summary of El-Sheik's research into sleep quality in children. The more that children are exposed to parental conflicts, the worse they sleep. And, the worse children sleep, the more likely they are to be tired when awake, have difficulty focusing and be irritable and badly behaved. These are some of the behaviours that could make a contribution to a diagnosis of hyperactivity behaviour or ADHD. The tiredness-related behaviours would also mean that the children fulfil the diagnostic requirement of ADHD to have the behaviour documented in a variety of settings. And, as the children would be tired for most of the day, I think that that criterion would be met. Children with ADHD may have SDB as a separate issue, but there is increasing speculation that some of the children with SDB have been mis-diagnosed with ADHD or hyperactivity behaviour.

Recent sleep research in both adults and children shows that sleep quality has a tremendous impact on physical and emotional well-being and on our cognitive performance. The effects of poor sleep quality go beyond feelings of fatigue; they are said to encompass raised blood pressure, metabolic changes linked to metabolic syndrome, increased likelihood of diabetes etc.

Lack of sleep is a common complaint. So is the sense that sleep wasn't satisfying. Tony Plant of the Happystance Project runs workshops for carers. He observes that carers often report that they have difficulty sleeping. Many of them talk about their hypervigilance. And some of them have the raised blood pressure, raised heart rate, eating habits and even fat deposits around their middles that accompany this. Behavioural hypervigilance has strong physiological correlates that can have other impacts on health. The hypervigilance seems to be not only grounded in the need to listen out for or watch for significant changes in the person for whom they care but also in the social circumstances that go along with caring: financial problems, the benefit/allowance system, difficulties with socialising and relationships with other family members.

One of the interesting predictions of allostasis is that raised blood pressure is related to hypervigilance, and that this can influence the foods to which people are attracted.* One of the contributions to raised blood pressure is the retention of sodium and water by the kidneys. Because hypervigilance is persistent, the body anticipates a continuing need for sodium and can increase the attraction to salty foodstuffs. When there is a perceived need for extra sodium, the body seems to assume that there will be a future demand for fuel. It's plausible that hypervigilance is linked to cravings for foodstuffs like fats and carbohydrates. van Cauter's research frequently reports that her sleep-deprived subjects crave carbohydrates: in the UK, crisps a.k.a. chips, are among the most popular snackfoods and offer salt, fat and carbohydrates-I just thought that might be relevant.

It is possible to argue that hypervigilance and sleep disturbance influence what people eat. And what we eat has its own impact on our health. Adults frequently wish that children ate more healthily (regardless of their own example). The Guardian carries the summary of a US study that reports:

Children consume nearly as many calories as are in a packet of crisps with every hour they spend watching television...Watching TV also encourages children to eat more junk foods, particularly soft drinks and takeaway fast food, the researchers found.

The article quotes one of the researchers as saying:

children and youth are encouraged to watch what they eat, many youth seem to eat what they watch.

It looks like allostasis would make all of these findings part of the same vicious circle of dysregulation. For the present, it does look like a Duvet Diet of adequate sleep and good nutrition might be of importance to establishing a firm foundation for children's health. Poor sleep quality and its plausible contribution to inactivity and poor food choices may mean that the foundation of good health is gradually eroded and may collapse over time.


*These examples are taken from Principles of allostasis: optimal design, predictive regulation, pathophysiology and rational therapeutics (pdf file) by Peter Sterling, in Allostasis, Homeostasis and the Costs of Adaptation, (ed) J. Schulkin. CUP. 2004.

This post is reproduced from an earlier one as I am still convalescing my shoulder.

For more information about the images used in the illustrations, click on them to see the detail about the contributors on Flickr (where they are from Flickr-the cartoon isn't)..

I'd Do Anything For My Children, Except...

Simon Hoggart was so tired of hearing public figures make vacuous statements that he introduced the 'opposite test'. When somebody makes a claim, you should ask yourself, "Would anyone, in any circumstances, ever say the opposite?". My version of this has always been that people only tell you things that you would never be able to work out from your own experience of them (e.g., "I have a great sense of humour", "I'm firm but fair", [insert your own phrase]).

Parents frequently say, "I'd do anything for my children". Too many times, however, I feel that there is a silent 'except' or 'but' that excludes whatever I am discussing with the parents, such as smoking in the house. I recently worked with a 10 year old girl who presented with symptoms of exercise-induced asthma whenever she went on a cross-country run (a weekly event at her school) but not when she swam or participated in other sports. Interestingly enough, the parents had been referred to us because Anita (not her real name) had a paradoxical response to the bronchodilators that she had tried. It was such a problem at school that the mother had been called to the school several times to tend to Anita after a run: either the mother had to attend or the girl would be taken to hospital.

Both Anita and her parents also reported that she was a restless sleeper, who woke several times a night, was typically tired in the morning and snored at a disturbing volume. We made some recommendations about the sleep routine and practised some breathing exercises with Anita as well as reinforcing the message that she should breathe through her nose whenever possible. The sleeping problems resolved quickly and her quality of sleep improved enormously: both Anita and her parents were very pleased.

But...The EIA and cross-country running were a different matter. We discussed the problems with her GP and PE teacher and made recommendations to Anita and her family about practising some breathing techniques while exercising. We needed to start this off with running for short distances and then build on this so that they were interval training while running. The parents didn't want her to practise unaccompanied and said that they would go out running with her. They made it sound as if they agreed that this would happen and that it was a reasonable request. But when we phoned for the one week follow-up, the daughter told us that her parents had refused to get up and run with her before school and were too tired to run with her after school.

We spoke with the parents who said that they would make more of an effort for the next week but felt that the previous days had been "too wet" to go out running. Anita then had a lively discussion with her parents about how they could possibly have known what the weather was like when they were in bed and refusing to get up, but we shall gloss over that.

We pointed out we wanted Anita to start out running at 60% of her capacity for 5 minutes, followed by a fast walk for 10 minutes. We suggested that if the weather was really too foul (but again, this is the UK - and what do people expect in Autumn?) then Anita could practise running up the stairs for 2-3 minutes, and then follow it up with some fast indoor walking (like Leslie Sansone).

We asked for daily updates on the breathing exercises, the quality of sleep and the running. We received the first two but there was an ominous silence about the running. When we made the second week follow-up, there had been no attempt to practise the running. We didn't expect Anita to take responsibility for making sure that she did the running practice but the parents just repeated their commitment to help her.

Parents can have so many time commmitments that it is hard to press them when they are under pressure elsewhere. We could only reiterate that they should practise on the stairs if the weather was unsuitable for running outside and that they should think about taking up something like the Sansone routines. Neither of these happened. In the end, we worked out a compromise with the PE teacher who agreed that Anita could practise the interval running around her school's playing fields while her class was on a cross-country run. It was a workable compromise but Anita hated being left behind.

Anita then started running around the playing field on several days a week with her friends and made good progress. Anita can now run for 3 miles and has not had another episode of asthma. This could so easily have not worked had it not been for Anita's dedication and the support of her PE teacher and GP.

For more information about the images used in the illustration, click on it or visit the detail on Flickr.

When Is A Priority Not A Priority: The Underfunding of Research into Allergic Diseases

European health researchers and experts are concerned that allergic diseases have been omitted from the health priorities of a european research programme despite some very startling statistics that indicate the burden of allergic diseases.

Allergic diseases are taking lives daily and creating huge financial costs. According to the World Health Organization, asthma kills someone in Europe every hour...One child in three is allergic today and by 2015, half of the European population may be suffering from one or more allergic condition...

Estimates have put the financial costs of allergic diseases in Europe at up to 100 billion Euros per year...The personal costs fall particularly heavily on families. Parental fears of a serious attack create anxiety, and even with mild allergies family activities may be limited. Children miss days at school and abstain from sport and other recreational activities. Breathing problems and skin rashes can also harm the self-image of young children, adults and especially teenagers.

It is a very puzzling decision. I was recently told about a very interesting researcher who had studied the link between food allergies and asthma. However, the employment opportunities available after her research led her to shift her research to the compariatively well-funded, hot topic of obesity.

We don't have enough specialist allergy facilities in the NHS and much of the privately available allergy and intolerance testing is of dubious value. In 2003, the RCP reported that Britain has the highest prevalence of allergy in Europe and among the highest in the world. The recent claims that we are less than ten years away from a treatment for food allergies must seem hollow with the news of the lack of this research support. Unless research is supported, the only (wholly unsatisfactory) option that people have is to experiment to identify their own suspected foodstuffs etc. (which can be dangerous and where significant allergy is suspected, should only be done in an appropriate clinical setting) and then to practise avoidance and carry rescue medication.

For more information about the images used in the illustration, click on it or visit the detail on Flickr.