Coexistence of social inequalities in undernutrition and obesity in preschool children: population based cross sectional study.

AIMS: To test for the coexistence of social inequalities in undernutrition and obesity in preschool children. METHODS: Retrospective, cross sectional, study of routinely collected data from 74 500 children aged 39-42 months in 1998/99. Main outcome measures were weight, height, sex, and age routinely recorded by health visitors. Body mass index (BMI) standardised for age and sex, relative to UK 1990 reference data, was used to define undernutrition (BMI <2nd centile) and obesity (BMI >95th centile; BMI >98th centile). Social deprivation was assessed as Carstairs deprivation category (1 = most affluent to 7 = most deprived). RESULTS: Both undernutrition (3.3%) and obesity (8.5% above 95th centile; 4.3% above 98th centile) significantly exceeded expected frequencies from UK 1990 reference data. Undernutrition and obesity were significantly more common in the more deprived families. Odds ratios in deprivation category 7 relative to category 1 were 1.51 (95% CI 1.22 to 1.87) for undernutrition (BMI <2nd centile) and 1.30 (95% CI 1.05 to 1.60) for obesity (BMI >98th centile). The cumulative prevalence of under and overnutrition (malnutrition) in the most deprived group was 9.5% compared to 6.9% in the least deprived group. CONCLUSIONS: Undernutrition and obesity are significantly more common than expected in young children and strongly associated with social deprivation. Both undernutrition and obesity have adverse short and long term health effects. Public health strategies need to tackle malnutrition (both undernutrition and obesity) in children and take into consideration the association with social deprivation.     

Coexistence of social inequalities in undernutrition and obesity in preschool children: population based cross sectional study

Aims: To test for the coexistence of social inequalities in undernutrition and obesity in preschool children. Methods: Retrospective, cross sectional, study of routinely collected data from 74 500 children aged 39–42 months in 1998/99. Main outcome measures were weight, height, sex, and age routinely recorded by health visitors. Body mass index (BMI) standardised for age and sex, relative to UK 1990 reference data, was used to define undernutrition (BMI <2nd centile) and obesity (BMI >95th centile; BMI >98th centile). Social deprivation was assessed as Carstairs deprivation category (1 = most affluent to 7 = most deprived). Results: Both undernutrition (3.3%) and obesity (8.5% above 95th centile; 4.3% above 98th centile) significantly exceeded expected frequencies from UK 1990 reference data. Undernutrition and obesity were significantly more common in the more deprived families. Odds ratios in deprivation category 7 relative to category 1 were 1.51 (95% CI 1.22 to 1.87) for undernutrition (BMI <2nd centile) and 1.30 (95% CI 1.05 to 1.60) for obesity (BMI >98th centile). The cumulative prevalence of under and overnutrition (malnutrition) in the most deprived group was 9.5% compared to 6.9% in the least deprived group. Conclusions: Undernutrition and obesity are significantly more common than expected in young children and strongly associated with social deprivation. Both undernutrition and obesity have adverse short and long term health effects. Public health strategies need to tackle malnutrition (both undernutrition and obesity) in children and take into consideration the association with social deprivation.     

What is a normal rate of weight gain in infancy?

We have retrieved weights from the Child Health records of an annual cohort of 3418 full-term children, aged 18–30 months in order to define a lower limit of normality for weight gain for both clinical and research purposes. There was a strong tendency for children at the extremes of the distribution to move inwards towards the average: only 26% of those below the 3rd centile for weight at six weeks were still below it at one year. We describe a method based on conditional standards to correct for this "regression to the mean" and produce a measure of the discrepancy between a child's predicted and actual growth: the "thrive index". The value of the thrive index below which only a minority of children fell provided a lower threshold for normality. While most children below the 3rd centile for weight at 9–24 months of age also had subnormal weight gain, 41 % of those with subnormal weight gain had not fallen below the 3rd centile.     

The influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive): data from a prospective birth cohort.

AIMS: To study the influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive) in the first year of life. METHODS: The Gateshead Millennium Baby Study is a population birth cohort in northeast England studied prospectively from birth, via parental questionnaires and a health check aged 13 months. Data were collected on maternal education, deprivation, eating attitudes, and depression, using the Edinburgh Post Natal Depression Scale (EPDS) at 3 months. Weight gain was assessed using change in weight SD score, conditional on birth weight (Thrive Index); weight faltering was defined as conditional weight gain below the 5th centile. RESULTS: Of 923 eligible infants born at term, 774 (84%) had both weight and questionnaire data. Replicating a previous finding, both the highest and the lowest levels of deprivation were associated with weight faltering; this was independent of the type of milk feeding. No relation was found with maternal educational status. Maternal eating restraint was unrelated to weight gain. Infants of mothers with high depression symptom scores (EPDS >12) had significantly slower weight gain and increased rates of weight faltering up to 4 months (relative risk 2.5), especially if they came from deprived families, but by 12 months they were no different from the remainder of the cohort. CONCLUSIONS: In this setting, social and maternal characteristics had little influence on infants' weight gain, apart from a strong, but transient effect of postnatal depression.     

What is the long term outcome for children who fail to thrive? A systematic review.

AIMS: To ascertain the long term outcomes in children diagnosed as having failure to thrive (FTT). METHODS: Systematic review of cohort studies. Medline, Psychinfo, Embase, Cinahl, Web of Science, Cochrane, and DARE databases were searched for potentially relevant studies. Inclusion criteria: cohort studies or randomised controlled trials in children <2 years old with failure to thrive defined as weight <10th centile or lower centile and/or weight velocity <10th centile, with growth, development, or behaviour measured at 3 years of age or older. RESULTS: Thirteen studies met the inclusion criteria; eight included a comparison group, of which five included children identified in community settings. Two were randomised controlled trials. Attrition rates were 10-30%. Data from population based studies with comparison groups and which reported comparable outcomes in an appropriate form were pooled in a random effects meta-analysis. Four studies report IQ scores at follow up and the pooled standardised mean difference was -0.22 (95% CI -0.41 to -0.03). Two studies reported growth data as standard deviation scores. Their pooled weighted mean difference for weight was -1.24 SDS (95% CI -2.00 to -0.48), and for height -0.87 SDS (95% CI -1.47 to -0.28). No studies corrected for parental height, but two reported that parents of index children were shorter. CONCLUSIONS: The IQ difference (equivalent to approximately 3 IQ points) is of questionable clinical significance. The height and weight differences are larger, but few children were below the 3rd centile at follow up. It is unclear to what extent observed differences reflect causal relations or confounding due to other variables. In the light of these results the aggressive approach to identification and management of failure to thrive needs reassessing.     

Inequalities in cycle helmet use: cross sectional survey in schools in deprived areas of Nottingham

Aims: To describe cycle helmet owning and wearing among children in a deprived area and to investigate the association between helmet ownership and wearing and socioeconomic deprivation. Methods: Cross sectional survey in 28 primary schools in deprived areas of Nottingham; 1061 year 5 schoolchildren were studied. Results: All year 5 children attending school on the day of the survey completed the questionnaire (87% of children registered at participating schools). Children residing in a deprived area were less likely to own a bike and more likely to ride it four days a week or more. Half the children owned a helmet (52%), but only 29% of these always wore their helmet. Children in deprived areas were less likely to own a helmet, but those that owned a helmet were not less likely to always wear one. Family encouragement and parental warning of dangers of not wearing a helmet were associated with increased helmet ownership rates. Family encouragement and best friends wearing a helmet were associated with higher rates of helmet wearing. Conclusions: Programmes aimed at preventing head injury among child cyclists will need to address the inequality in helmet ownership that exists between children residing in deprived and non-deprived areas. Strategies to increase family encouragement to wear a helmet may be useful, as may those recognising the importance of the attitudes and behaviours of peers, such as peer education programmes. Further work is required to assess how exposure to risk of cycling injury varies with deprivation.     

Inequalities in cycle helmet use: cross sectional survey in schools in deprived areas of Nottingham.

AIMS: To describe cycle helmet owning and wearing among children in a deprived area and to investigate the association between helmet ownership and wearing and socioeconomic deprivation. METHODS: Cross sectional survey in 28 primary schools in deprived areas of Nottingham; 1061 year 5 schoolchildren were studied. RESULTS: All year 5 children attending school on the day of the survey completed the questionnaire (87% of children registered at participating schools). Children residing in a deprived area were less likely to own a bike and more likely to ride it four days a week or more. Half the children owned a helmet (52%), but only 29% of these always wore their helmet. Children in deprived areas were less likely to own a helmet, but those that owned a helmet were not less likely to always wear one. Family encouragement and parental warning of dangers of not wearing a helmet were associated with increased helmet ownership rates. Family encouragement and best friends wearing a helmet were associated with higher rates of helmet wearing. CONCLUSIONS: Programmes aimed at preventing head injury among child cyclists will need to address the inequality in helmet ownership that exists between children residing in deprived and non-deprived areas. Strategies to increase family encouragement to wear a helmet may be useful, as may those recognising the importance of the attitudes and behaviours of peers, such as peer education programmes. Further work is required to assess how exposure to risk of cycling injury varies with deprivation.     

Traffic calming policy can reduce inequalities in child pedestrian injuries: database study

OBJECTIVES: To determine whether area wide traffic calming distribution reflects known inequalities in child pedestrian injury rates. To determine whether traffic calming is associated with changes in childhood pedestrian injury rates. DESIGN: Small area ecological study, longitudinal analysis of injury rates with cross sectional analysis of traffic calming and method of travel to school.Settings: Two cities in the United Kingdom. PARTICIPANTS: 4-16 year old children between 1992 and 2000. MAIN OUTCOME MEASURES: Area wide traffic calming distribution by area deprivation status and changes in injury rate/1000. RESULTS: The most deprived fourth of city A had 4.8 times (95% CI 3.71 to 6.22) the number of traffic calming features per 1000 population compared with the most affluent fourth. Injury rates among the most deprived dropped from 9.42 to 5.07 from 1992-94 to 1998-2000 (95% CI for change 2.82 to 5.91). In city B, the traffic calming ratio of the most to least deprived fourth was 1.88 (95% CI 1.46 to 2.42); injury rates in the deprived areas dropped from 8.92 to 7.46 (95% CI for change -0.84 to 3.77). Similar proportions of 9-12 year olds walked to school in both cities. CONCLUSIONS: Area wide traffic calming is associated with absolute reductions in child pedestrian injury rates and reductions in relative inequalities in child pedestrian injury rates.     

The influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive): data from a prospective birth cohort

Aims

To study the influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive) in the first year of life.

Methods

The Gateshead Millennium Baby Study is a population birth cohort in northeast England studied prospectively from birth, via parental questionnaires and a health check aged 13 months. Data were collected on maternal education, deprivation, eating attitudes, and depression, using the Edinburgh Post Natal Depression Scale (EPDS) at 3 months. Weight gain was assessed using change in weight SD score, conditional on birth weight (Thrive Index); weight faltering was defined as conditional weight gain below the 5th centile.

Results

Of 923 eligible infants born at term, 774 (84%) had both weight and questionnaire data. Replicating a previous finding, both the highest and the lowest levels of deprivation were associated with weight faltering; this was independent of the type of milk feeding. No relation was found with maternal educational status. Maternal eating restraint was unrelated to weight gain. Infants of mothers with high depression symptom scores (EPDS >12) had significantly slower weight gain and increased rates of weight faltering up to 4 months (relative risk 2.5), especially if they came from deprived families, but by 12 months they were no different from the remainder of the cohort.

Conclusions

In this setting, social and maternal characteristics had little influence on infants'' weight gain, apart from a strong, but transient effect of postnatal depression.     

Measurement of social inequalities in health and use of health services among children in Northumberland.

Social inequalities in a variety of indicators of child health were measured using a 'small area' geographical method of social classification. Cross sectional analyses of routine child health information and of a population survey of the height of primary school children were used. Social classification was by census enumeration district of residence using the Townsend deprivation score. Over 21,000 children resident in Northumberland born between January 1985 and September 1990, and 9930 children aged 5-8.6 years in Northumberland schools were studied. The following differences between the most deprived 10% of areas and the most affluent 10% of areas were used as outcome measures: the proportion of birth weights less than 2800 g; the proportion of births to teenage mothers; the proportion of 15 month old children not immunised against pertussis; the proportion of infants not screened at 6 weeks of age; the proportion of children not screened at 18 months of age; and the mean height of children in SD scores. Between the most deprived and most affluent areas birth weights less than 2800 g varied from 18 to 11%, the percentage of teenage mothers from 18 to 3%, non-immunised children from 30 to 19%, children not screened at 18 months from 21 to 14%, and mean height from -0.2 SD scores to +0.1 SD scores. The area variation in screening at 6 weeks of age was less, but still poorer in deprived areas. It is concluded that small area methods are effective in showing inequalities in child health, even in a rural area where such methods might be expected to perform less well. Social inequalities in all the aspects of child health measured remain evident.     

Measurement of social inequalities in health and use of health services among children in Northumberland

Social inequalities in a variety of indicators of child health were measured using a 'small area' geographical method of social classification. Cross sectional analyses of routine child health information and of a population survey of the height of primary school children were used. Social classification was by census enumeration district of residence using the Townsend deprivation score. Over 21,000 children resident in Northumberland born between January 1985 and September 1990, and 9930 children aged 5-8.6 years in Northumberland schools were studied. The following differences between the most deprived 10% of areas and the most affluent 10% of areas were used as outcome measures: the proportion of birth weights less than 2800 g; the proportion of births to teenage mothers; the proportion of 15 month old children not immunised against pertussis; the proportion of infants not screened at 6 weeks of age; the proportion of children not screened at 18 months of age; and the mean height of children in SD scores. Between the most deprived and most affluent areas birth weights less than 2800 g varied from 18 to 11%, the percentage of teenage mothers from 18 to 3%, non-immunised children from 30 to 19%, children not screened at 18 months from 21 to 14%, and mean height from -0.2 SD scores to +0.1 SD scores. The area variation in screening at 6 weeks of age was less, but still poorer in deprived areas. It is concluded that small area methods are effective in showing inequalities in child health, even in a rural area where such methods might be expected to perform less well. Social inequalities in all the aspects of child health measured remain evident.     

Inequalities in hospital admission rates for unintentional poisoning in young children

OBJECTIVE: To determine the relationship between deprivation and hospital admission rates for unintentional poisoning, by poisoning agent in children aged 0-4 years. DESIGN: Cross sectional study of routinely collected hospital admissions data. SETTING: East Midlands, UK. PARTICIPANTS: 1469 admissions due to unintentional poisoning over two years. MAIN OUTCOME MEASURE: Hospital admission rates for unintentional poisoning. Incidence rate ratios (IRRs) comparing hospital admission rates for poisoning in the most and least deprived electoral wards. RESULTS: Children in the most deprived wards had admission rates for medicinal poisoning that were 2-3 times higher than those in the least deprived wards (IRR 2.49, 95% CI 1.87 to 3.30). Admission rates for non-medicinal poisoning were about twice as high in the most compared to the least deprived wards (IRR 1.77, 95% CI 1.19 to 2.64). Deprivation gradients were particularly steep for benzodiazepines (IRR 5.63, 95% CI 1.72 to 18.40), antidepressants (IRR 4.58, 95% CI 1.80 to 11.66), cough and cold remedies (IRR 3.93, 95% CI 1.67 to 9.24), and organic solvents (IRR 3.69, 95% CI 1.83 to 7.44). CONCLUSIONS: There are steep deprivation gradients for admissions to hospital for childhood poisoning, with particularly steep gradients for some psychotropic medicines. Interventions to reduce these inequalities should be directed towards areas of greater deprivation.     

Epidemiology of central nervous system tumors in children and young adults (0-29 years), Yorkshire, United Kingdom

The authors describe the incidence and survival of 480 patients diagnosed under 30 years with a CNS tumor in Yorkshire, UK between 1990 and 2001. The effect on survival from deprivation and other prognostic factors was examined. Young adults (aged 15-29) were significantly less likely to develop CNS tumors than children (p = .001), largely because of an excess of medulloblastoma and ependymoma in the pediatric age range. No significant temporal trends in incidence were present apart from young adults with “other CNS” tumors showing an average annual increase of 10.7% (95% CI 1.3-21.0%; p = .03). Young adults had significantly lower survival rates than children (hazard ratio = 1.52, 95%CI 1.10-2.10). The highest risk of death was observed for patients from the most affluent areas. The overall burden of CNS tumors appears to be relatively constant, but the significantly poorer survival for young people needs further rapid investigation.     

Social trends in singleton births and birth weight in Wirral residents, 1990-2001

OBJECTIVE: To examine social trends in the number of singleton births and birth weight in an English health district between 1990 and 2001, using an area based deprivation index. DESIGN: Analysis of routinely collected hospital data. SETTING: Wirral Health District in north west England. PARTICIPANTS: All 48 452 live births to Wirral residents from 1990 to 2001. MAIN OUTCOME MEASURES: Birth numbers, birth weight, and standard deviation score for birth weights for singleton births. Townsend material deprivation scores derived from postcodes. RESULTS: The number of singleton births fell by 28% over the 12 years. The fall in the least deprived Townsend quartile (45%) was more than triple that in the most deprived quartile (gamma = 0.045; 95% confidence interval (CI) = 0.036 to 0.054; p < 0.001). Over the study period, the mean birth weight in the least deprived Townsend quartile was 141 g higher than in the most deprived quartile. There was a highly significant association between the standard deviation score for birth weight and Townsend quartile (tau-b = -0.062; 95% CI = -0.068 to -0.055; p < 0.001). Numbers of low birth weight babies in the least deprived quartile fell disproportionately compared with those from the most deprived quartile (gamma = 0.17; 95% CI = 0.09 to 0.25; p < 0.001). CONCLUSION: The reduction in birth rate in the Wirral was significantly less in the most deprived districts. This was accompanied by related differences in mean birth weight and the number of low birth weight babies, indicating increasing social inequality in birth trends. Previously described social inequity in birth weight and the number of low birth weight babies continues in the north west of England.     

Primary school accident reporting in one education authority.

BACKGROUND: Studies have shown a correlation between increased accident rates and levels of deprivation in the community. School accident reporting is one area where an association might be expected. AIMS: To investigate differences in primary school accident rates in deprived and more affluent wards, in an area managed by one education authority. METHODS: Statistical analysis of accident form returns for 100 primary schools in one education authority in Wales over a two year period, in conjunction with visits to over one third of school sites. RESULTS: Accident report rates from schools in deprived wards were three times higher than those from schools in more affluent wards. School visits showed that this discrepancy was attributable primarily to differences in reporting procedures. One third of schools did not report accidents and approximately half did not keep records of minor accidents. CONCLUSIONS: The association between school accident report rates and deprivation in the community is complex. School accident data from local education authorities may be unreliable for most purposes of collection.     

Primary school accident reporting in one education authority

Background: Studies have shown a correlation between increased accident rates and levels of deprivation in the community. School accident reporting is one area where an association might be expected. Aims: To investigate differences in primary school accident rates in deprived and more affluent wards, in an area managed by one education authority. Methods: Statistical analysis of accident form returns for 100 primary schools in one education authority in Wales over a two year period, in conjunction with visits to over one third of school sites. Results: Accident report rates from schools in deprived wards were three times higher than those from schools in more affluent wards. School visits showed that this discrepancy was attributable primarily to differences in reporting procedures. One third of schools did not report accidents and approximately half did not keep records of minor accidents. Conclusions: The association between school accident report rates and deprivation in the community is complex. School accident data from local education authorities may be unreliable for most purposes of collection.     

EPIDEMIOLOGY OF CENTRAL NERVOUS SYSTEM TUMORS IN CHILDREN AND YOUNG ADULTS (0–29 YEARS), YORKSHIRE,UNITED KINGDOM

The authors describe the incidence and survival of 480 patients diagnosed under 30 years with a CNS tumor in Yorkshire, UK between 1990 and 2001. The effect on survival from deprivation and other prognostic factors was examined. Young adults (aged 15–29) were significantly less likely to develop CNS tumors than children (p =. 001), largely because of an excess of medulloblastoma and ependymoma in the pediatric age range. No significant temporal trends in incidence were present apart from young adults with “other CNS” tumors showing an average annual increase of 10.7% (95% CI 1.3–21.0%; p =. 03). Young adults had significantly lower survival rates than children (hazard ratio = 1.52, 95%CI 1.10–2.10). The highest risk of death was observed for patients from the most affluent areas. The overall burden of CNS tumors appears to be relatively constant, but the significantly poorer survival for young people needs further rapid investigation.     

GROWTH RETARDATION AND DEVELOPMENTAL DELAY AMONGST INNER-CITY CHILDREN

A whole population survey of an inner-city health district (population 130,000) was undertaken in order to study the association between social deprivation and non-organic growth delay in preschool children. Potential cases were identified from health clinic records. Cases comprised white, full-term singletons, whose weight and height lay below the tenth centile at 4 years of age. Allowance was made for parental stature. A comparison group was closely matched for socio-economic conditions, and other salient variables. Case children were comparatively significantly delayed in all areas of their cognitive development. One-third were seriously retarded and likely to require special education.     

Socioeconomic variation in injury in children and older people: a population based study

OBJECTIVES: To compare hospital admission rates for all causes and specific causes of injury in children and the elderly by a measure of economic deprivation. STUDY DESIGN: All emergency admissions for Welsh residents from 1997-99 were located to one of 865 electoral tracts, which were grouped into fifths using a measure of socioeconomic deprivation. Standardised admission rates for all ages and 0-14, 15-75, and 75+ year groups for each quintile were calculated with 95% confidence intervals. RESULTS: There were 90 935 admissions in a population of 2.84 million yielding a crude admission rate of 1601/100 000/year and a standardised rate of 1493/100 000. The ratio of admissions in deprived and affluent areas varied with category of injury and age group. In general, socioeconomic variations in injury rates were much smaller in older people than in children with the exception of pedestrian related injuries where the rates were similar. The largest variations were for injuries sustained in assaults or self inflicted. CONCLUSIONS: The relationship between socioeconomic position and injury varies by cause and age group. This should be considered when developing area based preventive interventions or monitoring the effectiveness of policies to reduce inequalities in injury occurrence.     

The incidence and mortality for meningococcal disease associated with area deprivation: an ecological study of hospital episode statistics.

AIMS: To determine whether incidence, mortality, and case fatality for meningococcal disease (MD) differs by area deprivation, and if this has changed over time. METHODS: The population of children aged less than 5 years with MD was analysed as quintiles of area deprivation scores over two time periods, 1995-99 and 1991-94. Annual age standardised rates were calculated and the association between incidence, mortality, and area deprivation quintiles assessed using Poisson regression and the risk ratios determined. Case fatality was calculated from the odds ratio of mortality by area deprivation score for the two time periods. RESULTS: There were 10,524 cases of MD and 441 deaths (4.2%). Incidence rates were higher for 1995-99 (45.4 per 100,000) compared to 1991-94 (27.4 per 100,000). Mortality rates remained stable over time, indicating a decline in risk of death of around 40%. The incidence rates for the most deprived quintile were around twice those for the most affluent quintile, but this gradient declined over time. A threefold gradient was seen for mortality rates across the top and bottom quintiles, which was constant over time. The odds of mortality did not show a linear pattern, with mortality being lowest in the first and highest in the second and fifth area deprivation quintiles. CONCLUSIONS: These data show that MD incidence and mortality are socially patterned. The determinants of case fatality are more complex and require further investigation.