Congenital anomalies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tongue tieD M B Hall, M J Renfrew. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Common problem or old wives’ tale?

The resurgence of interest in breastfeeding has been accompanied by alively debate about the significance

of ‘‘tongue tie’’ or ankyloglossia.Symptoms attributed to tongue tieinclude nipple pain and trauma, diffi-culty in the baby attaching to the breast,frequent feeding, and uncoordinatedsucking. These problems may result inthe mother deciding to terminate breastfeeding prematurely, slow weight gainfor the baby, and even hypernatraemicdehydration. Speech defects have alsobeen attributed to tongue tie. Strongviews have been expressed by manyeminent authors on the subject (box 1).This paper reviews what is known

about tongue movements and the sig-nificance and treatment of tongue tie. Itis based on two literature reviews, oneconducted on behalf of NICE1 2 by one ofus (MR) and updated by furthersearches of published and grey literatureand conference abstracts. The publica-tions reviewed for this paper are sum-marised in table 1.As our review found little high quality

objective evidence, we begin by makingexplicit the personal experience and biaswith which we commenced the review.One of the authors (MR) felt that

tongue tie is an important issue—sheexperienced pain for many weeks whilebreast feeding her first child, whoexhibited features said to be typical oftongue tie, and has since discussed thisissue widely with lactation specialistsand women having similar problems.The other (DH) accepted that ankylo-glossia occurs in dysmorphic infants10

and occasionally in otherwise normalbabies,11 but was sceptical about thehigh prevalence of the condition nowbeing described by several authors.

ANATOMY AND PHYSIOLOGYThe tongue is a highly mobile organmade up of longitudinal, horizontal,vertical, and transverse intrinsic musclebundles. The extrinsic muscles are thefan-like genioglossus which is insertedinto the medial part of the tongue andthe styloglossus and hyoglossus into thelateral portions. The sub-lingual frenu-lum is a fold of mucosa connecting themidline of the inferior surface of thetongue to the floor of the mouth.Tongue tie is the name given to thecondition arising when the frenulum isunusually thick, tight, or short. Thereare many variations and differingdegrees of severity (fig 1).

The movements of the tongue duringinfant feeding have been studied bycine-radiography and more recently byultrasound.12 13 Ultrasound reveals somesimilarities between the movementsmade by the baby when either breastor bottle feeding,14 but also some impor-tant differences.15 The tongue is pro-jected further forward in breastfeeding16 and the human nipple elon-gates during each suck in a way that anartificial teat cannot do.14 During feed-ing, the artificial teat, or the nippletogether with some breast tissue, is heldfully in the mouth with the tonguecovering the lower gum ridge. Thenipple is protected from damage andpain at the back of the baby’s mouth.16

The baby’s lower jaw is then elevated,compressing the artificial teat, or thebreast immediately behind the nipple,while the front of the tongue moves upto aid the expression of milk. In breastfeeding, this is by compression of themilk ducts under the areola. A wave ofupward movement of the medial part ofthe tongue progresses backwards, andthe expression of the milk is furtherfacilitated by negative pressure gener-ated by downward movement of theback of the tongue and the lower jawand, in breast feeding, by the activeexpulsion of milk once the let downoccurs.In coordinated feeding, the sucking,

swallowing and breathing movementsfollow in a 1:1:1 sequence. This cantake several days to become establishedin healthy full term infants. In pre-term infants and in some term infantsa variety of poorly coordinated feed-ing movement patterns are observedand sometimes persist.17 Antenatal

Box 1: Quotes from the past

‘‘In observing a very large series of newborn babies, we have never seen a tongue that had to be clipped’’ (McEnery and Gaines,Chicago,1940)‘‘While tongue tie is not nearly as common as members of the public believe, nevertheless a genuine case is occasionally seen andthe condition is not entirely mythical although surrounded by an aura of superstition and old wives’ tales’’ (Cullum, UK, 1959)‘‘Tongue tie…has been described as a myth of hoary antiquity…but it is probably wrong to suggest that it never causes symptoms.A case is reported in which a tight fraenum ruptured spontaneously during feeding…this baby remained a slow feeder and…(hadnot been) disabled by his tongue tie’’ (Smithells, London, 1959)‘‘Tongue tie is a rare but definite congenital deformity’’ (Browne, London,1959)‘‘Tongue tie is a rare cause of dysarthria, though it is often blamed for slow speech development…most patients who have reallimitation of movement as a result of tongue tie have a history of difficult milk feeding’’ (Ingram, Edinburgh, 1968)‘‘I have never seen feeding difficulties in the first year resulting from tongue tie and I doubt whether it is ever necessary to carry outan operation on it till the age of two or three…There are still doctors who cut the frenulum in the newborn period. This is alwayswrong’’ (Illingworth, Sheffield, 1982)‘‘Tongue tie where the tongue is forked can, very rarely, add to the baby’s difficulties in taking the breast with poor protractility’’(Gunther, UK, 1970)‘‘To some extent tongue tie is normal in every newborn baby and it should rarely interfere with either sucking or later speechdevelopment’’ (Davies et al, UK, 1972)‘‘True tongue tie is a very rare condition. This condition has been over-diagnosed in the past because of the failure to recognisethat the frenum passing from the tongue to the floor of the mouth is normally short in the newborn…Only in infants with severelimitation of the tongue movement and inability to suck is division of the frenum indicated’’ (Turner, Douglas, and Cockburn, UK,1988)

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ultrasound studies show that mouthand tongue movements are alreadywell developed in association withintra-uterine yawning and crying.18 19

HYPOTHESESReview of the literature and expertopinion gave rise to the followinghypotheses:

N Tongue tie is a definable condition

N Tongue tie affects 3–4% of infants

N The tight frenulum prevents theinfant from getting the tongue overthe lower lip and gum ridge andtherefore can cause feeding pro-blems, particularly affecting breastfeeding, leading to pain for themother and poor infant weight gain;it can also affect bottle feeding

N The impact of a tight frenulum variesbetween mother–baby dyads

N A tight frenulum can also causeproblems in older children and adults,involving speech, dental hygiene, lick-ing ice cream, and French kissing

N Division of the frenulum (frenulot-omy) is a low risk effective treatment

N The condition is genetic

CASE DEFINITIONCan tongue tie be defined—and to whatextent do individual observers agree onthe diagnosis? The length of attachmentof the frenulum varies widely. In somebabies it extends to the tip of thetongue. There may be an indentationof the anterior edge, referred to as aheart shaped tongue. The appearance ofthe tongue is not sufficient on its own tomake a diagnosis, as the thickness andelasticity of the frenulum also varywidely and affect the extent to whichnormal tongue movements are inhibited(see fig 1).In four published studies of tongue tie

in babies, the initial selection of possiblecases from thewhole newborn populationwas based only on appearance and wasdone by one individual (Ballard andcolleagues5), or by one individual withconfirmation of positive diagnoses by oneother observer (Messner and colleagues3),or accomplished by providing staff with a

selection of photos (Hogan and collea-gues,4 Ricke and colleagues6). We havenot found any formal data on observeragreement or variation in this process.The method of selection in the study byMasaiti and Kaempf20 is unclear but caseswere probably selected on the basis ofbreast feeding problems. Two authors(Messner,3 Ricke6) aimed to reduce biasby trying to avoid specific mention oftongue tie to mothers but acknowledgethat this was difficult.All authors agreed that function is

more important than appearance andHazelbaker designed an Assessment Toolfor Lingual Frenulum Function(ATLFF).21 Ballard used this tool but didnot examine inter-rater reliability. Ricke etal found that the inter-rater agreementusing the ATLFF was only moderate andthat many infants did not fit in any of thecategories defined by Hazelbaker.

BIRTH PREVALENCE OF TONGUETIEThere is agreement among authors thattongue tie is found in around 3–4% ofbabies, with the exception of Hogan et al

Table 1 Tongue tie; review of literature

Author(s) Number and age group studiedHow cases wereidentified

Type of study andintervention Results

Messner et al3 Examined 1041 newborns. Identified 50TT cases (4.8%). M: F ratio 2.6:1

Screened by onedoctor, confirmed byone colleague

Observational follow up studybut no intervention

30/36 TT cases and 33/36 controlsbreast fed to 2 months (p = 0.29).9 cases and 1 control experiencedbreast feeding difficulties

36 cases of TT enrolled and 36 controlswithout TT

Hogan et al4 Examined 1866 babies. Identified 201 TTcases (10.7% ). M:F ratio 1.6:1. 44% TTcases had problems feeding. 57 TT babiesentered study (40 breast fed and 17 bottlefed)

Photos to assist staff inpostnatal checks

Randomised to immediatefrenulotomy or support bylactation counsellor, at meanage 20 days (3–70), medianage 14 days

TT cases treated by frenulotomy; 27/28marked improvement. Counselled casesmanaged conservatively; 1/29improved

Ballard et al5 Examined 2763 breast fed in-patientbabies and 273 attenders at lactationclinic.

One observer examiningall babies. ATLFF used

123 cases underwentfrenulotomy at age 1–2 days

Latch improved in all, pain scores fellsignificantly

M:F ratio 1.5:1. Identified TT in 3.2%in-patients and 12.8% clinic attenders

Ricke et al6 Examined 3490 babies, identified 148 TTcases (4.24%). M:F ratio 2.3:1.

Nurses assisted byphotos, ATLFF by team

Observational study, nointervention

Mothers of TT babies three times morelikely to give up breast feeding by oneweek; however, 80% TT breast feedingwell at one week. TT and non-TT breastfeeding in equal numbers at 1 month.Mothers with TT babies reporting morepain at one month but not statisticallysignificant. Small numbers so type IIerrors possible

Enrolled 49 TT babies for study with 2matched non-TT breast fed babies ascontrols

Ramsay7 Case series Referrals to paediatricsurgeon

Measured nipple tip to hardsoft palate junction byultrasound, pre- and post-frenulotomy

Distance changed from 7.99 mm to6.49 mm. Milk transfer increased from3.3 to 7.2 ml/min. At least 7 dayinterval between frenulotomy and 2ndmeasurement

Messner andLalakea8

Case series of speech problems: 30children age 1–12

Measured tongueprotrusion and inter-incisal distance

Frenulotomy Speech improved. 25 mothers had triedto breast feed; 21 said no problems

Fernando9 Case series, n >200 Various; majoritypresenting with speechdisorders

Frenulotomy Improved to varying degree. 20% hadhistory of BF problems: 80% did not

TT, tongue tie; ATLFF, Assessment Tool for Lingual Frenulum Function.

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Figure 1 Six examples of babies diagnosed as having tongue tie, showing the variation in the thickness and insertion of the frenulum (reproduced withkind permission from Carolyn Westcott, Princess Anne Hospital, Southampton).

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who report 10.7%. All report a malepreponderance with ratios varying from1.5:1 to 2.6:1.

THE IMPACT OF TONGUE TIEMaternal pain during feeding, some-times accompanied by trauma, anddifficulty in the baby taking the breast,are the main breast feeding problemsattributed to tongue tie.3–6 Attributingpain during breast feeding to tongue tieis not straightforward, however, sincepain is a common problem that canresult from several other causes, includ-ing attachment problems unconnectedwith tongue tie, and infection.16 22–24

Ricke and colleagues6reported that moretongue tied infants than controls werebottle fed at one week but there was nosignificant difference at one month,though attrition meant that numberswere small. Messner et al3 found nodifference in the rate of breast feedingbetween tongue tied infants and con-trols at 2 months but a significantdifference in the numbers of mothersreporting problems with breast feeding.Ramsay7 measured the distance from

nipple tip to the junction of the hardand soft palate by sub-mental ultra-sound. The distance decreased from7.99 mm (¡2.80) to 6.49 mm (¡1.87)seven days after frenulotomy. Thischange, though statistically significant,is small and its practical significance isunknown. The tongue movements weresaid to become ‘‘more normal’’.

VARIATION BETWEEN DYADSHogan and colleagues4 found that morethan half of babies with tongue tie hadno problems breast feeding but couldnot show any correlation between sever-ity of tongue tie and feeding difficulty.This is perhaps surprising, but it may bethat only a small shift in positioning onthe breast is sufficient to eliminate painand improve feeding. Ricke and collea-gues6 reported that 80% of tongue tiedinfants were breast feeding successfullyat one week. It is of interest that in twocase series of older children presentingwith speech difficulties and other pro-blems attributed by the authors totongue tie, 21/25 mothers (Messnerand Lalakea8) and 80% of an unspecifiednumber (Fernando9) who were askedabout breast feeding reported no sig-nificant difficulties.

OTHER PROBLEMSSeveral case series report a range ofother problems in older children asso-ciated with ankyloglossia—speechdefects, difficulty in licking the lips orin kissing, dribbling, etc. These aredifficult to evaluate as the authors donot give details of the catchment popu-lation, referral patterns, or detailedcriteria for inclusion in the series.

INTERVENTIONAll authors agree that frenulotomy inthe newborn is a low risk minorprocedure, performed without anaes-thetic. The presence of the deep lingualvein just lateral to the midline meansthat significant venous bleeding couldoccur if technique is not meticulous butwe found no reports of serious adverseevents. In older children the procedureneeds an anaesthetic and sometimes afrenuloplasty, which carries some risk ofscarring.Ballard and colleagues5 reported a

marked fall in maternal pain scoresafter the procedure. Hogan and collea-gues4 randomised their cases to immedi-ate or delayed intervention and foundthat frenulotomy was much more effec-tive than advice from a lactation coun-sellor. They reported dramatic andrapid, often immediate, improvementafter the procedure in most of theircases; improvement was noted in 95% ofbabies. The measurement of outcomeswas not blinded. The precise criteriafor improvement were not specified.Improvement was not always imm-ediate, but this could be due to theneed for sore nipples to heal or for thebaby to re-learn optimal patterns ofsuckling.In case series of older children and

adults, some striking improvementswere noted after surgery, but many ofthe children showed only gradual ormodest improvement, particularlywhere the articulation of speech wasconcerned; these children often neededcontinuing speech therapy and this wasattributed to the need to un-learnestablished patterns of articulation.9

The absence of any comparison orcontrol cases makes these reportsimpossible to evaluate and we foundno comparative studies or randomisedtrials addressing the role of tongue tie orfrenulotomy in older children.

IS ANKYLOGLOSSIA INHERITED?To define the inheritance of a condition,a robust case definition is needed, buttongue tie varies markedly in severityand is not an all-or-none condition.When an anomaly is identified in anewborn infant, the family searches itscollective memory for other similarcases but, in the case of tongue tie, itwould be impossible to assess thevalidity of that diagnosis in retrospect.None of the studies we reviewed con-sidered these issues and none hadgathered systematic family data acrossa number of families with and withoutthe condition. Notwithstanding thecomments made in several papers, noconclusions can currently be drawnabout family history.

AN OVERVIEWTongue tie is at first glance a minorissue, but from the results of the onlyrandomised controlled trial yet con-ducted, Hogan and colleagues4 suggestthat at least 3% of newborns (57/1866)would benefit from frenulotomy andthat this would increase the rate ofcontinuing breast feeding. Most of theliterature on tongue tie has been inconnection with breast feeding; how-ever, Hogan et al report that of the 57babies in their study who benefitedfrom frenulotomy, 40 were breast fedbut 17 were artificially fed. If they arecorrect, this is a very common congeni-tal anomaly that affects both breast fedand bottle fed babies, and up to 18 000such procedures should be performedeach year in the UK. It is thereforeimportant to ask whether the evidencesupports that rate of intervention and toscrutinise the evidence with a particu-larly critical eye.There were a number of methodolo-

gical problems with most of the studieswe reviewed. These included:

N Inadequate assessment of inter-observer reliability of the initial diag-nosis, the dynamic assessment offeeding and the maternal symptoms

N Ethical and practical difficulties inconcealing the suspected diagnosisfrom the mother, thus potentiallyintroducing a bias by raising theexpectation of breast feeding pro-blems and of improvement fromintervention—this is, however, acommon limitation in most studiesof breast feeding problems

N Poorly defined outcome measures; itis particularly difficult to establish anobjective assessment of improve-ment, when the primary outcomemeasure is reduction in maternalpain during breast feeding

N The dilemma of when to assess andintervene for tongue tie; if done veryearly, before breast feeding is estab-lished, as in the Ballard et al study,improvements may be wronglyattributed to the procedure (becausesuckling efficiency improves over thefirst few days and weeks13), but ifdone later (as in Hogan et al), manymothers may already have sore nip-ples or have given up breast feeding.

CONCLUSIONSWe began this review by stating ourpersonal bias. While DH confesses tostill being somewhat more scepticalthan MR, we are in complete agreementon the following conclusions:

N Individual case histories suggest thatsome babies do have a tight frenulum(tongue tie) which can inhibit breast

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feeding and, in some cases, bottlefeeding as well

N Although frenulotomy is a simple lowrisk procedure, it should be carriedout only by those who have beentrained in the procedure25

N It can be justified only if it is likely tolead to significant improvement inthe comfort and the continuation ofbreast feeding, or of other longerterm problems for the child

N We do not know the true prevalenceof significant tongue tie

N There is no evidence one way or theother about inheritance

N On current evidence, there is nojustification for actively searchingfor tongue tie during routine exam-ination, but when mothers are hav-ing difficulty in breast feeding thisshould be considered as one ofseveral possible causes

N The diagnosis should rest primarilyon observation and analysis of feed-ing difficulties rather than the staticappearance of the tongue

N It may be wise to be particularlycautious in making this diagnosis inthe first two or three days beforelactation is established

N The problem is of sufficient interestand importance to merit furtherstudies of both breast and bottle fedbabies, in which more precise casedefinition, measures of inter-observerreliability of pre- and post-interven-tion assessment, and ultrasound ima-ging are likely to play a key role

N Given the evidence that breast feed-ing has many advantages for bothmother and baby, funding should besought for carefully planned defini-tive studies on the issue.

Arch Dis Child 2005;90:1211–1215.doi: 10.1136/adc.2005.077065

Authors’ affiliations. . . . . . . . . . . . . . . . . . . . . .

D M B Hall, Institute of General Practice andPrimary Care, ScHARR, University of Sheffield,UKM J Renfrew, Mother and Infant ResearchUnit, Department of Health Sciences,University of York, UK

Correspondence to: Prof. D M B Hall, StorrsHouse Farm, Storrs Lane, Sheffield S6 6GY,UK; d.hall@sheffield.ac.uk

Competing interests: none declared

Parental consent was obtained for publicationof the babies in figure 1

REFERENCES1 Renfrew MJ, Dyson L, Wallace LW, et al. The

effectiveness of public health interventions topromote the duration of breastfeeding: asystematic review. London: National Institute forHealth and Clinical Excellence, 2005.

2 Renfrew MJ, Woolridge MW, Ross McGill H.Enabling women to breastfeed. London: TheStationary Office, 2000.

3 Messner AH, Lalakea ML, Aby J, et al.Ankyloglossia: incidence and associated feedingdifficulties. Arch Otolaryngol Head Neck Surg2000;126:36–9.

4 Hogan M, Westcott C, Griffiths M. Randomized,controlled trial of division of tongue tie in infantswith feeding problems. J Paediatr Child Health2005;41:246–50.

5 Ballard JL, Auer CE, Khoury JC. Ankyloglossia:assessment, incidence, and effect of frenuloplastyon the breastfeeding dyad. Pediatrics2002;110:e63.

6 Ricke LA, Baker NJ, Madlon-Kay DJ, et al.Newborn tongue tie: prevalence and effect onbreast-feeding. J Am Board Fam Pract2005;18:1–7.

7 Ramsay DT. Ultrasound imaging of the effect offrenulotomy on breast feeding infants withankyloglossia [abstract]. Paper presented at 12thinternational conference of the InternationalSociety for Research in Human Milk andLactation, Cambridge, UK, 2004.

8 Messner AH, Lalakea ML. The effect ofankyloglossia on speech in children. OtolaryngolHead Neck Surg 2002;127:539–45.

9 Fernando C. Tongue tie—from confusion toclarity. Sydney: Tandem, 1998.

10 Emmanouil-Nikoloussi E, Kerameos-Foroglou C.Congenital syndromes connected with tonguemalformations. Bull Assoc Anat (Nancy)1992;76:67–72.

11 Fitz-Dersorgher R. All tied up. Practising Midwife2003;6:20–3.

12 Bosma JF, Hepburn LG, Josell SD, et al.Ultrasound demonstration of tongue motionsduring suckle feeding. Dev Med Child Neurol1990;32:223–9.

13 Weber F, Woolridge MW, Baum JD. Anultrasonographic study of the organisation ofsucking and swallowing by newborn infants. DevMed Child Neurol 1986;28:19–24.

14 Nowak AJ, Smith WL, Erenberg A.Imaging evaluation of breast-feeding andbottle-feeding systems. J Pediatr1995;126:S130–4.

15 Woolridge MW. The ‘anatomy’ of infant sucking.Midwifery 1986;2(4):164–71.

16 Woolridge MW. Aetiology of sore nipples.Midwifery 1986;2(4):172–6.

17 Bu’Lock F, Woolridge MW, Baum JD.Development of co-ordination of sucking,swallowing and breathing: ultrasound study ofterm and preterm infants. Dev Med Child Neurol1990;32:669–78.

18 Gingras JL, Mitchell EA, Grattan KE. Fetalhomologue of infant crying. Arch Dis Child FetalNeonatal Ed 2005;90:F415–18.

19 Kurjak A, Stanojevic M, Azumendi G, et al. Thepotential of four-dimensional (4D)ultrasonography in the assessment of fetalawareness. J Perinat Med 2005;33:46–53.

20 Masaitis NS, Kaempf JW. Developing afrenotomy policy at one medical center:a case study approach. J Hum Lact1996;12:229–32.

21 Hazelbaker AK. The assessment tool for lingualfrenulum function (ATLFF): use in a lactationconsultant private practice [thesis]. Pasadena,CA: Pacific Oaks College, 1993.

22 Gunther M. Sore nipples: causes and prevention.Lancet 1945;ii:590–3.

23 Amir LH, Pakula S. Nipple pain, mastalgia andcandidiasis in the lactating breast.AustNZJObstetGynaecol 1991;31:378–80.

24 Hamlyn B, Brooker S, Olienkova K, et al. InfantFeeding Survey 2000. London: The StationeryOffice.

25 Ballard J, Chantry C, Howard CR. Guidelines forthe evaluation and management of neonatalankyloglossia and its complications in thebreastfeeding dyad. Academy of BreastfeedingMedicine, 2004. http://www.bfmed.org/protocol/ankyloglossia.pdf. Accessed 21 July2005.

Endocrinology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Children with diabetes benefit fromexerciseJ I Wolfsdorf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Commentary on the paper by Massin et al (see page 1223)

How much physical activity dochildren require to obtain benefi-cial health and behavioural

effects? The recent report concerningthe effects of regular physical activity onhealth and behavioural outcomes in6–18 year old youth recommends that

school age youth should participate dailyin at least 60 minutes of moderate tovigorous physical activity that is devel-opmentally appropriate, enjoyable, andinvolves a variety of activities.1 There isstrong evidence for beneficial effects ofphysical activity on: musculoskeletal and

cardiovascular health, adiposity in over-weight youth, and blood pressure inmildly hypertensive adolescents. Physicalactivity also has a beneficial effect onanxiety, depression, and self-concept. The60 minutes or more of physical activitycan be achieved in a cumulative mannerin school during physical education,recess, intramural sports, and before andafter school programmes.Exercise requires considerable altera-

tions in fuel metabolism and presentsunique challenges for the person withtype 1 diabetes mellitus (T1D).2 Duringthe first 5–10 minutes of moderateintensity exercise, skeletal muscle glyco-gen is the major fuel for workingmuscle. With increasing duration ofexercise, plasma glucose and non-ester-ified fatty acids (NEFA) predominate,and to meet the increased demand for

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fuel, a complex hormonal and auto-nomic response increases hepatic glu-cose production and mobilisation ofNEFA from adipose tissue. Plasmainsulin concentration decreases andlevels of the counter-regulatory hor-mones (adrenaline, noradrenaline, glu-cagon, cortisol, and growth hormone)increase, resulting in enhanced hepaticproduction of new glucose from gluco-neogenic substrates such as lactate andglycerol. Large quantities of the glucosetransporter protein GLUT4 are recruitedto the membrane of contracting muscle,independently of insulin, increasingglucose transport into muscle.3 Thesechanges result in the increased fuelsupply required to match glucose utili-sation by exercising muscle and preventhypoglycaemia. After prolonged exer-cise, liver and muscle glycogen storesare low and hepatic glucose productionis accelerated. Resynthesis of muscleglycogen is, initially, largely a result ofincreased GLUT4 transporter activityand insulin sensitivity.Glucose homoeostasis, which depends

on the balance between tissue glucoseuptake and hepatic glucose release, isinfluenced by the plasma levels ofinsulin and counter-regulatory hor-mones. The normal regulation of insulinsecretion is lost in T1D, and currentmethods of replacing insulin do notpermit patients to mimic precisely theexquisite complexity of the normalphysiological adaptations to exercise.Consequently, the child with T1D fre-quently experiences periods of eitherexcessive or insufficient insulinaemiaduring exercise. When plasma insulinlevels are relatively high, exercise causesblood glucose to decrease, whereaswhen insulin levels are low, and espe-cially if diabetes is poorly controlled,vigorous exercise can aggravate hyper-glycaemia and stimulate ketoacid pro-duction.4 The child whose diabetes is outof control (marked hyperglycaemia withketonuria) should not exercise untilsatisfactory glycaemic control has beenrestored.Exercise acutely lowers the blood

glucose concentration to an extent thatdepends on its intensity and durationand the concurrent level of insulinae-mia.2 In part, this results from acceler-ated insulin absorption from theinjection site owing to increased regio-nal blood flow and the massaging effectof contracting limb musculature.5 Ifexercise is planned, the preceding insu-lin dose should be reduced by 10–20%and the injection given in a site leastlikely to be affected by exercise; forexample, the anterior abdominal wall inthe morning preceding a sports event.Because young children’s physical activ-ities tend to be spontaneous, this advice

is often difficult to implement consis-tently. Extra snacks (for example,10–15 g carbohydrate per 30 minutesof vigorous physical activity dependingon the child’s age) before and, if theexercise is prolonged, during the activityare used to compensate for unplannedbursts of increased energy expenditure.Exercise may be more predictable in

older children and adolescents, andhypoglycaemia can usually be preventedby a combination of anticipatory reduc-tion in the pre-exercise insulin dose or atemporary interruption of basal insulininfusion in patients who use continuoussubcutaneous insulin infusion (CSII)together with supplemental carbohy-drate before, during, and after physicalactivity. The optimal strategy in theindividual child depends on the inten-sity and duration of the physical activityand its timing relative to the child’susual dietary and insulin regimen. Afterprolonged or strenuous exercise in theafternoon or evening, the pre-supper orbedtime dose of intermediate actinginsulin should be reduced by 10–30%(or an equivalent temporary reductionin overnight basal insulin delivery inpatients using CSII). To further reducethe risk of nocturnal or early morninghypoglycaemia caused by the lag effectof exercise,6 7 the bedtime snack shouldbe larger than usual and contain carbo-hydrate, protein, and fat. Frequent over-night blood glucose monitoring isessential until sufficient experience hasbeen obtained to appropriately modifythe evening dose of insulin after exer-cise.In this issue, Massin et al report the

results of an observational study of theamount and intensity of physical exercise,measured by 24 hour monitoring of heartrate, in preschool, school age children,and adolescents with T1D.8 The structureddiabetes education programme at theauthors’ centre includes the recommen-dation to obtain regular physical activity.The message is reinforced by encouragingregular physical exercise at clinic visitsand by attendance at diabetes campwhere children learn about the effects ofdifferent types of physical activity onglycaemia. The study involved a ‘‘snap-shot’’ of the lives of these children on asingle weekday, and it is possible thatsubjects knowing that their physicalactivity was being measured affected theresults. The majority of children withdiabetes receiving care at this centre metthe paediatric recommendations for phy-sical activity and compared favourably totheir non-diabetic peers. The authors alsoobserved a significant inverse associationbetween mean annual glycated haemo-globin and the amount of time spent inlight and moderate physical activity inschool age children.

Despite its limitations, the studysuggests that light and moderate physi-cal activity may be associated withbetter glycaemic control in school agechildren, but not in teenagers. Whatmight explain the difference betweenchildren and teenagers? Diabetes man-agement is even more challenging dur-ing puberty, and glycaemia is typicallyless well controlled than before pubertyand in adulthood. This is attributable toa combination of the endocrinologicalchanges characteristic of puberty9 andless meticulous adherence to diet andinsulin administration.Although physical exercise is compli-

cated for the child with T1D by the needto prevent hypoglycaemia, with properguidance and preparation, participationin exercise can and should be a safe andenjoyable experience. Despite the lack ofcompelling evidence that physical train-ing and exercise per se improve glycae-mic control in children and adolescentswith T1D,10–16 exercise clearly offersmany health and psychological benefitsfor people with and without diabetes. Atleast 60 minutes of moderate to vigorousphysical exercise daily should be acomponent of a comprehensive pro-gramme of diabetes management inchildren. With the increased prevalenceof overweight and obesity in the popu-lation, children and adolescents withT1D may also be overweight or obese.17

For these children, exercise is a criticalcomponent of a weight managementstrategy. Exercise ameliorates risk fac-tors (obesity, hypertension, and hyperli-pidaemia) for cardiovascular disease,18

but equally important, children withdiabetes are likely to benefit from theenjoyment and enhanced feeling of self-worth derived from participation inphysical activity with their peers.

Arch Dis Child 2005;90:1215–1217.doi: 10.1136/adc.2005.082446

Correspondence to: Dr J I Wolfsdorf, Division ofEndocrinology, Children’s Hospital Boston, 300Longwood Avenue, Boston, MA 02115, USA;joseph.wolfsdorf@childrens.harvard.edu

Competing interests: none declared

REFERENCES1 Strong WB, Malina RM, Blimkie CJ, et al.

Evidence based physical activity for school-ageyouth. J Pediatr 2005;146:732–7.

2 Wasserman DH, Zinman B. Exercise inindividuals with IDDM. Diabetes Care1994;17:924–37.

3 Goodyear LJ, Kahn BB. Exercise, glucosetransport, and insulin sensitivity. Annu Rev Med1998;49:235–61.

4 Berger M, Berchtold P, Cuppers HJ, et al.Metabolic and hormonal effects of muscularexercise in juvenile type diabetics. Diabetologia1977;13:355–65.

5 Koivisto VA, Felig P. Effects of leg exercise oninsulin absorption in diabetic patients.N Engl J Med 1978;298:79–83.

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6 MacDonald MJ. Postexercise late-onsethypoglycemia in insulin-dependentdiabetic patients. Diabetes Care 1987;10:584–8.

7 Tsalikian E, Beck R, Chase HP, et al. Impact ofexercise on overnight glycemic control in childrenwith type 1 diabetes (T1DM). Diabetes2005;54(suppl 1):A64.

8 Massin MM, Lebrethon M-C, Rocour D, et al.Patterns of physical activity determined by heartrate monitoring among diabetic children. ArchDis Child 2005;90:1223–6.

9 Dunger DB. Diabetes in puberty. Arch Dis Child1992;67:569–70.

10 Campaigne BN, Gilliam TB, Spencer ML, et al.Effects of a physical activity program onmetabolic control and cardiovascular fitness in

children with insulin-dependent diabetes mellitus.Diabetes Care 1984;7:57–62.

11 Arslanian S, Nixon PA, Becker D, et al. Impact ofphysical fitness and glycemic control on in vivoinsulin action in adolescents with IDDM. DiabetesCare 1990;13:9–15.

12 Sackey AH, Jefferson IG. Physical activity andglycaemic control in children with diabetesmellitus. Diabet Med 1996;13:789–93.

13 Landt KW, Campaigne BN, James FW, et al.Effects of exercise training on insulin sensitivity inadolescents with type I diabetes. Diabetes Care1985;8:461–5.

14 Rowland TW, Swadba LA, Biggs DE, et al.Glycemic control with physical training in insulin-dependent diabetes mellitus. Am J Dis Child1985;139:307–10.

15 Huttunen NP, Lankela SL, Knip M, et al.Effect of once-a-week training program onphysical fitness and metabolic control inchildren with IDDM. Diabetes Care1989;12:737–40.

16 Raile K, Kapellen T, Schweiger A, et al. Physicalactivity and competitive sports in children andadolescents with type 1 diabetes. Diabetes Care1999;22:1904–5.

17 Libman IM, Pietropaolo M, Arslanian SA, et al.Changing prevalence of overweight children andadolescents at onset of insulin-treated diabetes.Diabetes Care 2003;26:2871–5.

18 Austin A, Warty V, Janosky J, et al. Therelationship of physical fitness to lipid andlipoprotein(a) levels in adolescents with IDDM.Diabetes Care 1993;16:421–5.

Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Inter-hospital transport for children andtheir parent(s)R C Tasker. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Commentary on the paper by Davies et al (see page 1270)

Each year, out of a child populationof 10.5 million in England andWales, approximately 10 000 need

treatment in paediatric intensive careunits (PICU).1 Almost half of thesechildren are transported between thereferring hospital and their regionalPICU by a specialist team; currently,the Department of Health recommendsthat parents should not routinely travelwith their sick child in the ambulance.2

So, should we be allowing parents toaccompany their critically ill child dur-ing inter-hospital transport—or shouldthey make their own way? In this issue,the PICU team from Guy’s Hospitalreport their experience of having thechild’s parent accompany them duringinter-hospital transport.3 An emphatic‘‘yes’’ comes from the South ThamesAcute Retrieval Service (STARS) thatcovers the south of England: they still‘‘continue to provide the service’’ andhope that their ‘‘results may informother services that are consideringadopting a similar policy’’.In many respects it has been an error

to have not considered, before now, thequestion of parents accompanying theircritically ill child. Over 10 years ago theAmerican Academy of Pediatrics stated:‘‘it is sometimes beneficial when trans-porting the anxious and sick child tohave a parent accompany him or her inthe transport vehicle’’.4 In our defence,we could cite certain hurdles to pro-gress—concerns about accident insur-ance for passengers, shortage of space inthe ambulance, and staff anxiety

because of the added burden of support-ing relatives during transport.5 Thereality, however, is that the culture hasevolved to exclude parents—we havestreamlined the transport process and itavoids potential parental complications,by not having them there. The report byDavies and colleagues3 reminds us that,like other areas in acute paediatric care,it is time to hear what parents feel andwant, and now do something about it.If we trace the pathway of care from

acute presentation to later transfer tothe PICU, we already know much aboutparents. First, in accident and emer-gency practice there has been growinginterest in letting them stay by theirchild when procedures are performed, orat least giving them the choice about it.For example in the 1980s, Bauchner et alsurveyed 253 parents and found that78% would want to be present shouldtheir child need a blood test or insertionof an intravenous catheter.6 In follow upstudies, the same authors found, first,that parents chose to be present in 31 of50 (62%) such procedures,7 and second,as a consequence, they were lessanxious and more satisfied with theirchild’s care.8 More recently, in a surveyof 400 parents presented with fiveemergency department scenarios, Boieet al found that parents exhibited ahierarchy or order in their preference.9

They were less inclined to be presentwith more invasive procedures, which,in decreasing order, were: venepunc-ture, 97.5%; suturing a laceration, 94%;lumbar puncture, 86.5%; resuscitation

of a conscious child, 80.7%; and resus-citation of an unconscious child, 71.4%.However, irrespective of these prefer-ences, Boie et al found that if a child waslikely to die, most parents would wantto be present. Second, we know thatthere is likely to be a conceptual gapbetween what physicians think is appro-priate for parents to see and whatparents consider is their choice todecide. In the survey by Boie andcolleagues,9 only 6.5% of parents wantedthe attending physician to determinetheir presence by their child. In a similaremergency department study, but thistime surveying 645 emergency staff (306physicians and 339 nurses) on viewsabout six scenarios, Beckman et al foundthat almost half of the physiciansbelieved that they alone (44%) shoulddecide whether parents should be pre-sent.10 This difference in viewpoint—between parents and physicians—is notaltogether unexpected given the culturalhistory of our specialty: there was a timewhen parents were excluded from manyaspects of hospital paediatric care (forexample, bedside visiting for inpatients,peri-operative transfer between theward and the operating theatre, induc-tion of anaesthesia, etc). Now, child andparent centred care is essential to whatwe practice—that is, good medicine inthe context of listening to patients’ andparents’ voices, openness, good commu-nication, and developing a relationshipbased on trust. In essence, what weshould learn from the studies reportedby Boie and colleagues9 and Beckmanand colleagues10 are the reasons under-lying the gap between 6.5% and 44%, inparents and physicians respectively.Third, in children who are critically ill,

transport to a regional PICU is often thenext step after presentation to theemergency room.11 12 Patients may wellhave undergone resuscitation and therecould be significant risk of adverseoutcome. In 1995, Woodward andFleegler (from the Transport Servicesof the Children’s Hospital ofPhiladelphia) had a unique opportunityto survey two groups of parents: a group

PERSPECTIVES 1217

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who had been allowed to accompanytheir child in an ambulance becausethey had made a request to do so eventhough ‘‘this option was not activelyencouraged’’ (n=46), and a group whodid not accompany their child(n=40).13 Eighty six per cent of theseparents felt accompanying their childwas important. Prior to transfer, 74%were either worried or very worriedabout their child’s stability. Only 5% ofparents accompanying their child foundthat doing so made them anxious orvery anxious, whereas 56% of those whodid not accompany their child feltanxious or very anxious (p , 0.05).Finally, 94% of parents would chooseto travel with their child in a futuresimilar circumstance. These findings arenot dissimilar to those found in thesouth of England in 2003. Colville et alsurveyed 233 parents, of whom only 13had been allowed to travel with theirchild in the ambulance: in total, 70% ofthese parents commented on the jour-ney they made to the PICU, oftentravelling alone using their own trans-port.14 A recurring theme in what theparents had to say was their sense ofseparation and the distress this journeycaused them. Three quotations, relayedby the authors, capture the very essenceof what these parents are feeling, andwe should not forget this: ‘‘the worstjourney of our lives’’, ‘‘the worst partwas seeing the ambulance disappearingin the distance’’, and ‘‘for all I knew shewas dying and I wasn’t allowed to bewith her’’. In this issue, the report byDavies and colleagues3 focuses on logis-tics, staff perceptions, and adverseevents—and that is entirely right giventhe newness of this service developmentin the south of England. However,another—albeit less emphasised—keymessage emerges from this work. Theauthors’ interpretation of parental feed-back (presumably compared with pre-vious experience in the south ofEngland13) was that these parents wereless stressed as a consequence of accom-panying their child. These audit dataneed to be followed up with furtherclinical studies. For example, do parentswho travel with their children experi-ence less acute stress disorder? Are theyat less risk of post-traumatic stressdisorder?

Davies et al tell us that their pilotstudy—permitting parents to accom-pany their critically ill child duringinter-hospital transfer—was conductedin response to the distress expressed byparents, and now, because of theirexperience, it has become the estab-lished practice of the STARS team.3

There are at least 14 other regionalPICU transport services in England andWales—how should we respond andmove on? Should we determine whetherthere is national consensus regardinginvolving parents in inter-hospitaltransport—and only act if there is? Thepresent standards of the UnitedKingdom Paediatric Intensive CareSociety (1996 and 2001)12 do not coverthis issue. Rather, they state that it isthe referring hospital that is ‘‘obligatedto provide transport to the Lead Centre(that is, regional PICU) for parents’’.Even in the United States, there did notappear to be consensus among paedia-tric critical care transport team man-agers in 2001.15 Only 63% of teamsallowed parents to accompany theirchild in the ambulance, but the authorsfrom Philadelphia (see also Woodwardand Fleegler13) took the view that‘‘awareness of this issue may help toestablish discussion and guidelinesregarding the role of parents’’. In otherwords, lack of unanimity should notdetract from this potential develop-ment—it merely indicates the extent ofchange in practice that is needed if weare to respond to what parents need.There is now a literature showing thatthe most helpful coping strategy forparents of PICU patients is to allowthem to stay with their child and toempower them.16–18 Inter-hospital trans-port should be no different. However, ifwe cannot extrapolate the conclusion ofthe STARS service to our own regionalpractices, then we should at least look atalternative ways of better supportingparents during the time it takes for themto travel from the accident and emergencydepartment to the regional PICU.

Arch Dis Child 2005;90:1217–1218.doi: 10.1136/adc.2005.077057

Correspondence to: Dr R C Tasker, University ofCambridge School of Clinical Medicine,Department of Paediatrics, Box 116,Addenbrooke’s Hospital, Hills Road,Cambridge CB2 2QQ, UK; rct31@cam.ac.uk

Competing interests: none declared

REFERENCES1 Paediatric Intensive Care Audit Network. Annual

Report 2003–2004, Universities of Leeds,Leicester and Sheffield, May 2005 (ISBN 0 85316254 9).

2 Department of Health. A framework for thefuture: report from the national co-ordinatinggroup on paediatric intensive care to the chiefexecutive of the NHS executive. London: TheStationary Office, 1997.

3 Davies J, Tibby SM, Murdoch IA. Should parentsaccompany critically ill children during inter-hospital transport? Arch Dis Child2005;90:1270–3.

4 American Academy of Pediatrics Taskforce onInterhospital Transport. Guidelines for air andground transport of neonatal and pediatricpatients. Elk Grove Village, IL: The Academy,1993:74.

5 Hill Y. Is there a place for parents in the retrievalof critically sick children? Nursing in Critical Care1999;4:121–7.

6 Bauchner H, Waring C, Vinci R. Pediatricprocedures: do parents want to watch? Pediatrics1989;84:907–8.

7 Bauchner H, Waring C, Vinci R. Parental presenceduring procedures in an emergency room: resultsfrom 50 observations. Pediatrics 1991;87:544–8.

8 Bauchner H, Vinci R, Bak S, et al. Parents andprocedures: a randomized controlled trial.Pediatrics 1996;98:861–7.

9 Boie ET, Moore GP, Brummett C, et al. Do parentswant to be present during invasive proceduresperformed on their children in the emergencydepartment? A survey of 400 parents. Ann EmergMed 1999;34:70–4.

10 Beckman AW, Sloan BK, Moore GP, et al. Shouldparents be present during emergency departmentprocedures on children, and who should make thedecision? A survey of emergency physician andnurse attitudes. Acad Emerg Med 2002;9:154–8.

11 Britto J, Nadel S, Maconochie I, et al. Morbidityand severity of illness during interhospitaltransfer: impact of a specialized paediatricretrieval team. BMJ 1995;311:836–9.

12 Paediatric Intensive Care Society. Standards forpaediatric intensive care, Saldatore Ltd,Hertfordshire, 1996 and 2001.

13 Woodward GA, Fleegler EW. Should parentsaccompany pediatric interfacility groundambulance transports? The parent’s perspective.Pediatr Emerg Care 2000;16:383–90.

14 Colville G, Orr F, Gracey D. ‘‘The worst journeyof our lives’’: parents’ experience of specializedpaediatric retrieval service. Intensive Crit CareNurs 2003;19:103–8.

15 Woodward GA, Fleegler EW. Should parentsaccompany pediatric interfacility groundambulance transports? Results of a nationalsurvey of pediatric transport team managers.Pediatr Emerg Care 2001;17:22–7.

16 Miles MS, Carter MC. Sources of parental stressin pediatric intensive care units. Child Health Care1983;11:65–9.

17 Melynk BM, Alpert-Gillis LJ, Hensel PB, et al.Helping mothers cope with a critically ill child: apilot test of the COPE intervention. Res NursHealth 1997;20:3–14.

18 Melnyk BM, Alpert-Gillis L, Feinstein NF, et al.Creating opportunities for parent empowerment:program effects on the mental health/copingoutcomes of critically ill young children and theirmothers. Pediatrics 2004;116:e597–607.

11th European Forum on Quality Improvement in Health Care

26–28 April 2006, Prague, Czech RepublicFor further information please go to: www.quality.bmjpg.comBook early to benefit from a discounted delegate rate

1218 PERSPECTIVES

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Adverse effects of rapid isotonicsaline infusionNeville et al reported on a randomised con-trolled trial of hypotonic versus isotonic salinefor rehydration of children with gastroenteritis.They found that isotonic saline was superiorwith regards to correction of hyponatraemia.1

The majority of patients in the study received a‘‘rapid replacement protocol’’ which entailedthe infusion of 40 ml/kg of isotonic saline over4 hours in the isotonic saline arm of the study.The authors did not report on important knownadverse effects associated with rapid infusionof isotonic saline which have been reported inprevious randomised controlled trials ofvolume support with isotonic saline versusother fluids.

Rapid isotonic saline infusion predictablyresults in hyperchloraemic acidosis.2 Theacidosis is due to a reduction in the stronganion gap by an excessive rise in plasmachloride as well as excessive renal bicarbo-nate elimination.2 In a randomised controlledtrial with a mixed group of patients under-going major surgery, isotonic saline infusionwas compared to Hartmann’s solution with6% hetastarch and a balanced electrolyte andglucose solution. Two thirds of patients in thesaline group but none in the balanced fluidgroup developed postoperative hyperchlorae-mic metabolic acidosis.3 The hyperchloraemicacidosis was associated with reduced gastricmucosal perfusion on gastric tonometry.

Another double blind randomised controlledtrial of isotonic saline versus lactated Ringer’sin patients undergoing aortic reconstructivesurgery confirmed this result; the acidosisrequired interventions like bicarbonate infu-sion and was associated with the application ofmore blood products.4 Hyperchloraemia wasfound to have profound effects on eicosanoidrelease in renal tissue, leading to vasoconstric-tion and a reduction of the glomerular filtrationrate.5 The increased eicosanoid release may alsoexplain the findings of reduced gastric perfu-sion in hyperchloraemia mentioned above.3

The main adverse effect of saline inducedhyperchloraemic acidosis, however, may bethe action which is taken to correct theabnormality. Acidosis is often seen as areflection of poor organ perfusion and poormyocardial function, and a negative baseexcess may prompt the application of bolusesof more saline containing fluids exacerbatingthe acidosis, the use of blood products,escalation of inotropic support and initiationof ventilatory support.6

The safety of hyperchloraemic acidosis hasnot been established in prospective studiesand in patients with different types of criticalillness. Particularly in critically ill patientswith co-morbidities like renal disease, morephysiological electrolyte solutions (e.g.Ringer’s lactate solution) may be preferableto isotonic saline, and a slow replacementprotocol safer than rapid infusions.

M EisenhutConsultant Paediatrician, Luton & Dunstable Hospital,

Lewsey Road, Luton LU4 0DZ, UK;michael_eisenhut@yahoo.com

doi: 10.1136/adc.2006.100123

Competing interests: none declared

References

1 Neville KA, Verge CF, Rosenberg AR, et al.Isotonic is better than hypotonic saline forintravenous rehydration of children withgastroenteritis: a prospective randomised study.Arch Dis Child 2006;91:226–32.

2 Prough DS, Bidani A. Hyperchloremic metabolicacidosis is a predictable consequence ofintraoperative infusion of 0.9% saline.Anesthesiology 1999;90:1247–9.

3 Wilkes NJ, Woolf R, Mutch M, et al. The effects ofbalanced versus saline-based hetastarch andcrystalloid solutions on acid-base and electrolytestatus and gastric mucosal perfusion in elderlysurgical patients. Anesth Analg2001;93:811–16.

4 Waters JH, Gottlieb A, Schoenwald P, et al. Normalsaline versus lactated Ringer’s solution forintraoperative fluid management in patientsundergoing abdominal aortic aneurysm repair: anoutcome study. Anesth Analg 2001;93:817–22.

5 Bullivant EMA, Wilcox CS, Welch WJ. Intrarenalvasoconstriction during hyperchloremia: role ofthromboxane. Am J Physiol 1989;256:152–7.

6 Brill SA, Stewart TR, Brundage SI, et al. Basedeficit does not predict mortality when secondaryto hyperchloremic acidosis. Shock2002;17:459–62.

LETTER

PostScript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BOOK REVIEW

There are separate sections on preschoolchildren and junior children, covering topicsranging from breast feeding and weaning toexplanations about what constitutes a healthydiet. The advice about managing behaviouraldifficulties around mealtimes is particularlyhelpful, with sections such as ‘‘Tips to avoidbecoming wound up at meal times’’ providingplenty of practical suggestions for families totry. There are also practical suggestions onencouraging physical activity in children andreducing television watching. The issue ofdealing with a child who is already overweightis addressed, emphasising the need to takeaction early, placing this responsibility withinthe family context. There is also helpfulinformation about understanding children’spsychological wellbeing, examining the issueof low self esteem, bullying, and depression.

The final section covers nutrition andhealth problems. Basic nutritional informa-tion is provided to help make sense of thecontents of our food and details what shouldconstitute a healthy well balanced diet. Thereis a well written section on a wide variety ofmedical problems encountered which mayaffect a child’s growth, ranging from cows’milk allergy to cystic fibrosis, and sources offurther information are well referenced.

Overall I felt that this was a well writtenbook, packed full with helpful practical sugges-tions. As a paediatrician, the advice containedwithin the chapters covered many of the foodrelated problems seen in clinic. As a parent Ialso recognised many of the scenarios andremembered many meal times with youngtoddlers which were far from enjoyable! Myone criticism of the book would be the generallayout as I felt this was more in keeping with amedical textbook rather than a manual forparents. I’m not sure whether first impressionsof the book would encourage parents to pick itup. However, this certainly won’t deter mefrom recommending this book. I do feel thiswill be of benefit to all paediatricians to read aswell as GPs, health visitors, school nurses, andof course also parents, especially those dealingwith truculent toddlers!

C Grayson

Weight matters for children

Edited by Rachel Pryke. Oxon: RadcliffeMedical Press Ltd, 2006, £14.95 (US$28(approx.); J22 (approx.)), paperback,pp 215, ISBN 1857757718

It seems impossibleto open a newspa-per or turn on thetelevision withoutthe issue of child-hood obesity beingraised. The govern-ment has set targetsto reduce the inci-dence of childhoodobesity and schoolbased programmeshave been estab-

lished, and yet the number of children whoare obese continues to rise. What seems to belacking and what this book sets out to provideis specific practical guidance for parents tofollow as to what families need to be doing on aday to day basis to ensure children remainhealthy and avoid becoming obese.

The primary focus is on parents and carers,and the author, who is a GP, frequentlydraws on her own experience as a mother togive examples of her own family life, whichhelps give credence to the messages whichrun throughout the book. The issue of choiceis dealt with very well and discusses howimportant it is to give children choice andhow parents can influence children to makethe right choice. Parents are also encouragedto examine their own parenting styles to seehow this influences the behaviour and eatinghabits of their children.

doi: 10.1136/adc.2003.045401corr1

Principi N, Esposito S, Gasparini R, MarchisioP, Crovari P, for the Flu-Flu Study Group.Burden of influenza in healthy children andtheir households. Arch Dis Child 2004;89:1002–7.

This article has been retracted by thepublisher because of significant overlap withPrincipi N, Esposito S, Marchisio P, GaspariniR, Crovari P. Socioeconomic impact of influ-enza on healthy children and their families.Pediatr Infect Dis J 2003;22(Suppl 10):S207–10.

CORRECTIONS

doi: 10.1136/adc.2005.77065corr1

D M B Hall and M J Renfrew. Tongue tie(Arch Dis Child 2005;90:1211–5).

Photographs 1, 2, 4, and 5 in this article arereproduced by kind permission of KayHoover, MEd, IBCLC.

Arch Dis Child 2006;91:797 797

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