the patterns in Solihull children by sex and age were similar to those described by Dr Sellars and colleagues. ' I also considered rates using total numbers of admissions not related to births. This is an indicator of workload rather than incidence. When rates per 1000 admissions were compared with rates per 1000 population accident related admission rates for the youngest age group were remarkably low when compared with rates per total population. Also, similar patterns seemed to exist for children more than 12 months old when either total population or total non-birth related admissions were used as a denominator. The relatively high rates for all injuries were maintained throughout all age groups, as were the peaks for burns and poisoning. This suggests that the denominator used in child accident related admissions -either rates per head of population or per 1000 total admissions-is
arbitrary. Pre-Korner data on inpatient admissions held in the Hospital Activity Analysis system were assigned to ward of residence. This was useful for small area statistics as estimates of ward population are available from the Office of Population Censuses and Surveys. When the Korner data sets were implemented the postcode of residence became the only small area geographical field available in the regional information system. (Postcode sectors are roughly the same size as wards.) Until the next census, the only way of obtaining postcode sector population data is from the family health services authorities. This depends on the capabilities of the computing staff and availability of software. From my limited experience, these data are impossible to obtain. Bearing this in mind, my data suggest that population rates could be replaced by rates per 1000 admissions not related to births when population data are not easily available. In addition, there may be marker inpatient conditions that could be used as a proxy for total population. I would be interested to know if colleagues have discovered such marker conditions for particular age groups and diagnoses. K S SIDHU
Department of Public Health Medicine, Solihull Health Authority, Solihull B91 3AH 1 Sellars C, Ferguson JA, Goldacre MJ. Occurrence arkd repetition of hospital admissions for accidents in preschool children. BMJ 1991;302:16-9. (5 January.)
Causes of fatal childhood accidents SIR,-We agree with Dr P M Sharples and colleagues that road traffic accidents are the commonest cause of fatal head injuries in childreh.' The distribution of causes, however, is quite different for injuries of different severity.2 In children with head injuries who attend accident departments road accidents are much less common than falls,' but they are more common in children who are admitted to hospital; they dominate only in the minority of injuries that are severe or fatal (table). Dr Sharples and colleagues report a death rate of 5 3 per 100 000 children per
year compared with our report of 4011 per 100 000 attending accident and emergency departments and 400 per 100000 admitted to hospital in Scotland.4 We have noted the similarity between head injuries in hospitals in Scotland and in Cleveland.2 Detailed neuropathology shows different types of brain damage in children and adults, and this also varies with cause of injury.' Intracranial haematomas, the main cause of avoidable death, are only half as common in fatally injured children as in adults. In both age groups intracranial haematomas are only half as common after road accidents as they are after falls or assaults. In examining the problem of potentially preventable death and disability due to head injury in children it is important not to overemphasise the importance of road accidents. BRYAN JENNETT LILIAN MURRAY J H ADAMS STEWART CULLY Institute of Neurological Sciences, Glasgow G5 1 4TF 1 Sharples PM, Storey A, Aynsley-Green A, Eyre JA. Causes of fatal childhood accidents involving head injuries in Northern region, 1979-86. BMJ 1990;301:1193-7. (24 November.) 2 Jennett B, MacMillan R. Epidemiology of head injury. BMJ
1981;282:101-4. 3 Jennett B, Teasdale G. Management of head injuries. Philadelphia: F A Davis, 1981. 4 Brookes M, MacMillan R, Cully S, et al. Head injuries in accident and emergency departments. How different are children from
adults?J7 Epidemnol Community Health 1990;44:147-51. 5 Adams JH, Doyle D, Ford I, et al. Brain damage in fatal nonmissile head injury in relation to age and type of injury. Scott Med3 1989;34:399-401.
An integrated child health
another large group of children-preschool, of school age, and at adolescence-for whom parents, teachers, social workers, and others are looking for the support of doctors who understand the links between health, family dynamics, and developmental and educational progress; who offer continuity of service as the named doctor of the local clinics and schools; and who are intimate with and have the confidence of local caring networks. The children so supported rarely, if ever, have continuity of contact with hospital departments. Where they do the true nature of their difficulties cannot be illuminated by blood tests and body scans. Indeed there is a vogue for the parents of such children to return from hospital visits armed with special diets to explain a range of symptoms, but the internal dynamics between parents, children, schools, and society have never been questioned. The support of such children requires dialogue, partnership, and participation with nurseries, schools, and parents to enhance nurture-not merely the transfer of information. Moreover, such doctors who think and act for children in a community setting do this not just on an individual family basis but in terms of a geographical area in service planning, development, training, audit, and the public health function. Senior paediatricians who view the integrated service merely from the needs of the sick child will miss the whole dimension of developmental, educational, and social paediatrics. Community colleagues already have an unequal voice, because the consultant status envisaged in the courts to aid integration was never realised. The hostility lies in the narrowness of view of hospital paediatricians and the lack of appropriate status for those who give dedicated clinical service and lead to the community child health services.
service
SONYA LEFF
SIR,-Drs D M B Hall and M Prendergast write about the "lack of commitment to" or even "frank hostility" toward integration of child health services.' Perhaps it would be helpful to ask why this should be so? Indeed, it could be argued that the very editorial which has been published itself exacerbates the frank hostility. The team identity elucidated by Drs Hall and Prendergast covers the need for an integrated approach to the admission, management, discharge, and care at home of sick children. They say that hospital doctors themselves, who may see children from more than 100 schools, should directly transfer information to local teachers, social workers, and others. Health visitors are described as "an essential component of primary care services for children," but there is only a throw away reference to community child health doctors, acknowledging their skills in child development, behavioural problems, and child abuse. It needs to be fully recognised that child health community doctors are not employed just to do surveillance checks not covered by general practitioners, nor just for back up work with children under S referred by general practitioners and health visitors. Nor are they only employed in schools to support statemented, fostered and adopted, and protection registered children, important as all this clinical work is. There is
School Clinic, Brighton BN2 2RA 1 Hall DMB, Prendergast M. An integrated child health service.
BMJ 1990;301:1341-2. (15 December.)
Flat feet in children SIR,-Mr G K Rose' and Dr E Ann Welton' assert that early identification of flat feet is essential. Function is more important than form, however, and many people diagnosed as having flat feet have no disability. The diagnosis of flat feet will change in many cases when the simple test described by Dr Welton is used.3 In a recent survey of an unselected group of 18 month old children I found that 14 out of 221 had flat feet according to the great toe extension test.3 Before this test was applied 93% of the children had been diagnosed as having flat feet. I wonder how many young people and adults labelled as having flat feet have acquired social disease. I am sure that most of them have normal function. The Canadian study quoted by Mr Rose4 has an obvious selection bias and cannot be used as scientific proof. The time has come for a prospective trial to see whether children with flat feet become adults with flat feet and whether they have anv disability. This might blow away some of the myths surrounding the subject.
Main causes oj head inlunies in children aged under 15
MELVYN H BROOKS
Karkur,
Cause of injury (No (%))
Children with head injuries*
Attending Scottish accident and emergency departments Admitted to Scottish hospitals Transferred to Glasgow neurosurgical unit With severe injuries in Glasgow neurosurgical unit Who died in Glasgow neurosurgical unit
Total No of children
Road traffic accident
2118 351 295 333 122
191 (9) 81 (23) 127 (43) 250 (75) 87 (71)
*Data for each group of children gathered independently over varying periods.
BMJ
VOLUME 302
26 JANUARY 1991
Israel
Fall
Assault
1207 (57) 193 (55)
127(6) 18 (5) 12 (4) 10 (3) 2 (2)
83 (28) 40 (12) 27 (22)
Rose GK. Flat feet in children. BMJ 1990;301:1330-1. (8 December.) 2 Welton EA. Flat feet in children. BMJ 1990;301:1331. (8 December.) 3 Rose GK, Welton EA, Marshal T. The diagnosisof flat foot in the child. JBoneJointSurg[Br] 1985;67:71-8. 4 Harris RI, Beath T. Army foot survey. An investigation of foot ailments in Canadian soldiers. Ottawa: National Research Council of Canada, 1947.
237
arbitrary. Pre-Korner data on inpatient admissions held in the Hospital Activity Analysis system were assigned to ward of residence. This was useful for small area statistics as estimates of ward population are available from the Office of Population Censuses and Surveys. When the Korner data sets were implemented the postcode of residence became the only small area geographical field available in the regional information system. (Postcode sectors are roughly the same size as wards.) Until the next census, the only way of obtaining postcode sector population data is from the family health services authorities. This depends on the capabilities of the computing staff and availability of software. From my limited experience, these data are impossible to obtain. Bearing this in mind, my data suggest that population rates could be replaced by rates per 1000 admissions not related to births when population data are not easily available. In addition, there may be marker inpatient conditions that could be used as a proxy for total population. I would be interested to know if colleagues have discovered such marker conditions for particular age groups and diagnoses. K S SIDHU
Department of Public Health Medicine, Solihull Health Authority, Solihull B91 3AH 1 Sellars C, Ferguson JA, Goldacre MJ. Occurrence arkd repetition of hospital admissions for accidents in preschool children. BMJ 1991;302:16-9. (5 January.)
Causes of fatal childhood accidents SIR,-We agree with Dr P M Sharples and colleagues that road traffic accidents are the commonest cause of fatal head injuries in childreh.' The distribution of causes, however, is quite different for injuries of different severity.2 In children with head injuries who attend accident departments road accidents are much less common than falls,' but they are more common in children who are admitted to hospital; they dominate only in the minority of injuries that are severe or fatal (table). Dr Sharples and colleagues report a death rate of 5 3 per 100 000 children per
year compared with our report of 4011 per 100 000 attending accident and emergency departments and 400 per 100000 admitted to hospital in Scotland.4 We have noted the similarity between head injuries in hospitals in Scotland and in Cleveland.2 Detailed neuropathology shows different types of brain damage in children and adults, and this also varies with cause of injury.' Intracranial haematomas, the main cause of avoidable death, are only half as common in fatally injured children as in adults. In both age groups intracranial haematomas are only half as common after road accidents as they are after falls or assaults. In examining the problem of potentially preventable death and disability due to head injury in children it is important not to overemphasise the importance of road accidents. BRYAN JENNETT LILIAN MURRAY J H ADAMS STEWART CULLY Institute of Neurological Sciences, Glasgow G5 1 4TF 1 Sharples PM, Storey A, Aynsley-Green A, Eyre JA. Causes of fatal childhood accidents involving head injuries in Northern region, 1979-86. BMJ 1990;301:1193-7. (24 November.) 2 Jennett B, MacMillan R. Epidemiology of head injury. BMJ
1981;282:101-4. 3 Jennett B, Teasdale G. Management of head injuries. Philadelphia: F A Davis, 1981. 4 Brookes M, MacMillan R, Cully S, et al. Head injuries in accident and emergency departments. How different are children from
adults?J7 Epidemnol Community Health 1990;44:147-51. 5 Adams JH, Doyle D, Ford I, et al. Brain damage in fatal nonmissile head injury in relation to age and type of injury. Scott Med3 1989;34:399-401.
An integrated child health
another large group of children-preschool, of school age, and at adolescence-for whom parents, teachers, social workers, and others are looking for the support of doctors who understand the links between health, family dynamics, and developmental and educational progress; who offer continuity of service as the named doctor of the local clinics and schools; and who are intimate with and have the confidence of local caring networks. The children so supported rarely, if ever, have continuity of contact with hospital departments. Where they do the true nature of their difficulties cannot be illuminated by blood tests and body scans. Indeed there is a vogue for the parents of such children to return from hospital visits armed with special diets to explain a range of symptoms, but the internal dynamics between parents, children, schools, and society have never been questioned. The support of such children requires dialogue, partnership, and participation with nurseries, schools, and parents to enhance nurture-not merely the transfer of information. Moreover, such doctors who think and act for children in a community setting do this not just on an individual family basis but in terms of a geographical area in service planning, development, training, audit, and the public health function. Senior paediatricians who view the integrated service merely from the needs of the sick child will miss the whole dimension of developmental, educational, and social paediatrics. Community colleagues already have an unequal voice, because the consultant status envisaged in the courts to aid integration was never realised. The hostility lies in the narrowness of view of hospital paediatricians and the lack of appropriate status for those who give dedicated clinical service and lead to the community child health services.
service
SONYA LEFF
SIR,-Drs D M B Hall and M Prendergast write about the "lack of commitment to" or even "frank hostility" toward integration of child health services.' Perhaps it would be helpful to ask why this should be so? Indeed, it could be argued that the very editorial which has been published itself exacerbates the frank hostility. The team identity elucidated by Drs Hall and Prendergast covers the need for an integrated approach to the admission, management, discharge, and care at home of sick children. They say that hospital doctors themselves, who may see children from more than 100 schools, should directly transfer information to local teachers, social workers, and others. Health visitors are described as "an essential component of primary care services for children," but there is only a throw away reference to community child health doctors, acknowledging their skills in child development, behavioural problems, and child abuse. It needs to be fully recognised that child health community doctors are not employed just to do surveillance checks not covered by general practitioners, nor just for back up work with children under S referred by general practitioners and health visitors. Nor are they only employed in schools to support statemented, fostered and adopted, and protection registered children, important as all this clinical work is. There is
School Clinic, Brighton BN2 2RA 1 Hall DMB, Prendergast M. An integrated child health service.
BMJ 1990;301:1341-2. (15 December.)
Flat feet in children SIR,-Mr G K Rose' and Dr E Ann Welton' assert that early identification of flat feet is essential. Function is more important than form, however, and many people diagnosed as having flat feet have no disability. The diagnosis of flat feet will change in many cases when the simple test described by Dr Welton is used.3 In a recent survey of an unselected group of 18 month old children I found that 14 out of 221 had flat feet according to the great toe extension test.3 Before this test was applied 93% of the children had been diagnosed as having flat feet. I wonder how many young people and adults labelled as having flat feet have acquired social disease. I am sure that most of them have normal function. The Canadian study quoted by Mr Rose4 has an obvious selection bias and cannot be used as scientific proof. The time has come for a prospective trial to see whether children with flat feet become adults with flat feet and whether they have anv disability. This might blow away some of the myths surrounding the subject.
Main causes oj head inlunies in children aged under 15
MELVYN H BROOKS
Karkur,
Cause of injury (No (%))
Children with head injuries*
Attending Scottish accident and emergency departments Admitted to Scottish hospitals Transferred to Glasgow neurosurgical unit With severe injuries in Glasgow neurosurgical unit Who died in Glasgow neurosurgical unit
Total No of children
Road traffic accident
2118 351 295 333 122
191 (9) 81 (23) 127 (43) 250 (75) 87 (71)
*Data for each group of children gathered independently over varying periods.
BMJ
VOLUME 302
26 JANUARY 1991
Israel
Fall
Assault
1207 (57) 193 (55)
127(6) 18 (5) 12 (4) 10 (3) 2 (2)
83 (28) 40 (12) 27 (22)
Rose GK. Flat feet in children. BMJ 1990;301:1330-1. (8 December.) 2 Welton EA. Flat feet in children. BMJ 1990;301:1331. (8 December.) 3 Rose GK, Welton EA, Marshal T. The diagnosisof flat foot in the child. JBoneJointSurg[Br] 1985;67:71-8. 4 Harris RI, Beath T. Army foot survey. An investigation of foot ailments in Canadian soldiers. Ottawa: National Research Council of Canada, 1947.
237
