Early childhood caries: current evidence for aetiology and prevention

Background: Despite the fact that it is largely preventable, dental caries (decay) remains one of the most common chronic diseases of early childhood. Dental decay in young children frequently leads to pain and infection necessitating hospitalization for dental extractions under general anaesthesia. Dental problems in early childhood have been shown to be predictive of not only future dental problems but also on growth and cognitive development by interfering with comfort nutrition, concentration and school participation. Objective: To review the current evidence base in relation to the aetiology and prevention of dental caries in preschool-aged children. Methods: A search of MEDLINE, CINALH and Cochrane electronic databases was conducted using a search strategy which restricted the search to randomized controlled trials, meta-analyses, clinical trials, systematic reviews and other quasi-experimental designs. The retrieved studies were then limited to articles including children aged 5 years and under and published in English. The evidence of effectiveness was then summarized by the authors. Conclusions: The review highlighted the complex aetiology of early childhood caries (ECC). Contemporary evidence suggests that potentially effective interventions should occur in the first 2 years of a child's life. Dental attendance before the age of 2 years is uncommon; however, contact with other health professionals is high. Primary care providers who have contact with children well before the age of the first dental visit may be well placed to offer anticipatory advice to reduce the incidence of ECC.

Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight/mild obesity

OBJECTIVES: To reduce gain in body mass index (BMI) in overweight/mildly obese children in the primary care setting.
DESIGN: Randomized controlled trial (RCT) nested within a baseline cross-sectional BMI survey.
SETTING: Twenty nine general practices, Melbourne, Australia.
PARTICIPANTS: (1) BMI survey: 2112 children visiting their general practitioner (GP) April-December 2002; (2) RCT: individually randomized overweight/mildly obese (BMI z-score <3.0) children aged 5 years 0 months-9 years 11 months (82 intervention, 81 control).
INTERVENTION: Four standard GP consultations over 12 weeks, targeting change in nutrition, physical activity and sedentary behaviour, supported by purpose-designed family materials.
MAIN OUTCOME MEASURES: Primary: BMI at 9 and 15 months post-randomization. Secondary: Parent-reported child nutrition, physical activity and health status; child-reported health status, body satisfaction and appearance/self-worth.
RESULTS: Attrition was 10%. The adjusted mean difference (intervention-control) in BMI was -0.2 kg/m(2) (95% CI: -0.6 to 0.1; P=0.25) at 9 months and -0.0 kg/m(2) (95% CI: -0.5 to 0.5; P=1.00) at 15 months. There was a relative improvement in nutrition scores in the intervention arm at both 9 and 15 months. There was weak evidence of an increase in daily physical activity in the intervention arm. Health status and body image were similar in the trial arms.
CONCLUSIONS: This intervention did not result in a sustained BMI reduction, despite the improvement in parent-reported nutrition. Brief individualized solution-focused approaches may not be an effective approach to childhood overweight. Alternatively, this intervention may not have been intensive enough or the GP training may have been insufficient; however, increasing either would have significant cost and resource implications at a population level.

Childhood obesity - a sign of commercial success, but a market failure.

'Obesogenic' products, such as energy dense foods, passive entertainment products, cars, and labour-saving devices, are widely available and heavily promoted. Because they are highly consumed and very profitable, obesity becomes the inevitable consequence of their commercial successes. Contemporary market forces heavily favour behaviours for short-term preferences (i.e. over-consumption and underactivity) over long-term preferences (i.e. healthy weight) and this is especially true for children. Hence, if the market, as the main mechanism for determining choices, results in outcomes, which make our children worse off, as is occurring with childhood obesity, then the market has failed to sustain and promote social and individual goals. This is a serious market failure. In the current obesogenic environment, expecting adults, let alone children, to make food and activity choices in their own best long-term interests is, therefore, demonstrably flawed. We argue that significant government intervention is needed to correct this market failure, as has been done for other major health problems.

VNTR polymorphism of the insulin gene and childhood overweight in a general population

Objective: The VNTR polymorphism 5' of the insulin gene has been related to obesity in a previous study on children with early onset of severe obesity. Our purpose was to analyze the association between this polymorphism and adiposity variability in an unselected population of children and adolescents in northern France.

Research Methods and Procedures: In 293 nuclear families from the Fleurbaix Laventie Ville Santé study, we genotyped the INS VNTR polymorphism in 431 children and adolescents (8 to 18 years of age) and their parents. Overweight was defined according to the international definition in both children and adults. A transmission disequilibrium test in families with an overweight offspring was performed. The prevalence of overweight was compared according to genotype. The effect of the genotype on BMI and waist circumference was tested with a linear regression model, adjusting for age, gender, and Tanner stage.

Results: There was an undertransmission of class III alleles from heterozygous parents to their overweight offspring (p < 0.002). Overweight was associated with class I alleles in children and adolescents (12% I/I, I/III vs. 3% III/III; p < 0.08). Those with a class III/III genotype had a 1 kg/m2 lower mean BMI (p = 0.04) and 3 cm lower waist circumference (p = 0.02) than those bearing one or two class I alleles. No association of adiposity or obesity with class I alleles was found in parents.

Discussion: INS VNTR polymorphism seems to contribute to differences in adiposity level in the general population of children and adolescents.

Cost-effectiveness of dexamphetamine and methylphenidate for the treatment of childhood attention deficit hyperactivity disorder

Objective: To analyze from a health sector perspective the cost-effectiveness of dexamphetamine (DEX) and methylphenidate (MPH) interventions to treat childhood attention deficit hyperactivity disorder (ADHD), compared to current practice.

Method: Children eligible for the interventions are those aged between 4 and 17 years in 2000, who had ADHD and were seeking care for emotional or behavioural problems, but were not receiving stimulant medication. To determine health benefit, a meta-analysis of randomized controlled trials was performed for DEX and MPH, and the effect sizes were translated into utility values. An assessment on second stage filter criteria ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Simulation modelling techniques are used to present a 95% uncertainty interval (UI) around the incremental costeffectiveness ratio (ICER), which is calculated in cost (in A$) per DALY averted.

Results: The ICER for DEX is A$4100/DALY saved (95% UI: negative to A$14 000) and for MPH is A$15 000/DALY saved (95% UI: A$9100-22 000). DEX is more costly than MPH for the government, but much less costly for the patient.

Conclusions: MPH and DEX are cost-effective interventions for childhood ADHD. DEX is more cost-effective than MPH, although if MPH were listed at a lower price on the Pharmaceutical Benefits Scheme it would become more cost-effective. Increased uptake of stimulants for ADHD would require policy change. However, the medication of children and wider availability of stimulants may concern parents and the community.

In dialogue with A.D. Hope: dialogue one: childhood and adolescence

[Alec Derwent Hope, born in Cooma 1907, won a scholarship to University College, Oxford, after majoring in English and Philosophy at Sydney University, and returned to a life of teaching and writing from the ‘thirties. His pre-eminence in literary culture was underpinned by his appointment as Professor of English at University College, Canberra, the forerunner of the Australian National University. His work in poetry, translations, and criticism provoked intense response, never indifference. His first published volumes were the satirical sequence, Dunciad Minimus : An Heroic Poem (1950), and selection of poems, The Wandering Islands (1955); amongst the final volumes were the autobiographical Chance Encounters (1992) and Selected Poems (1992).
Dialogue One was designed to explore what connections can be made between the life of the child and the values engendered in this formative phase and the adult’s creative work and view of the world; an exploration shaped by what might be seen as a relentless irony inherent in his poetry and his other scholarly productions and by Hope’s view that childhood is a place of the sacred and of secrets that are best protected from the limiting force of definition--somehow best kept suspended between the unconscious and the conscious mind to draw from when enacting a poetic vision of life. To that extent, Dialogue One is an attempt to navigate territory that might be seen as Hope’s mindscape and landscape as it emerged in childhood and adolescence.
The following exchange comprises selected excerpts from the transcripts of Ann McCulloch’s videoed interviews in Melbourne 1988, The Dance of Language: The Life and Work of A.D. Hope, as well as from her many conversations with Hope between 1981 and 1996 in Canberra.]

Overweight and obesity from childhood to adulthood: a follow-up of participants in the 1985 Australian Schools Health and Fitness Survey

Objective: To examine overweight and obesity in Australian children followed through to adulthood.

Design and participants: A cohort study of 8498 children aged 7–15 years who participated in the 1985 Australian Schools Health and Fitness Survey; of these, 2208 men and 2363 women completed a follow-up questionnaire at age 24–34 years in 2001–2005.

Main outcome measures: Height and weight were measured in 1985, and self-reported at follow-up. The accuracy of self-reported data was checked in 1185 participants. Overweight and obesity in childhood were defined according to international standard definitions for body mass index (BMI), and, in adulthood, as a BMI of 25–29.9 and ≥ 30 kg/m2, respectively, after correcting for self-report error.

Results: In those with baseline and follow-up data, the prevalence of overweight and obesity in childhood was 8.3% and 1.5% in boys and 9.7% and 1.4% in girls, respectively. At follow-up, the prevalence was 40.1% and 13.0% in men and 19.7% and 11.7% in women. The relative risk (RR) of becoming an obese adult was significantly greater for those who had been obese as children compared with those who had been a healthy weight (RR = 4.7; 95% CI, 3.0–7.2 for boys and RR = 9.2; 95% CI, 6.9–12.3 for girls). The proportion of adult obesity attributable to childhood obesity was 6.4% in males and 12.6% in females.

Conclusion: Obesity in childhood was strongly predictive of obesity in early adulthood, but most obese young adults were a healthy weight as children.