No abstract

We read with interest the recent paper by Tan et al.1 examining daily versus depot (stoss) vitamin D therapy in Aboriginal children. We commend the authors in conducting a randomized control trial addressing a clinically relevant topic. However, we do have some concerns regarding the study design, conclusions, and clinical applicability of their findings.Firstly, the study interventions differ significantly from contemporaneous 2 or current consensus guidelines. 3 In the treatment algorithm a repeat dose of stoss vitamin D was planned at 6 weeks if the serum vitamin D was still low. It is unclear if this planned repeat stoss dose at 6 weeks was in fact administered as the first follow-up was 4-6 months after commencing therapy. In combination with potentially inadequate stoss therapy, daily vitamin D dosing was significantly higher than recommended in the recent Australian consensus guidelines, 3 particularly as given for a 4-to 6-month period prior to assessment. This raises the possibility that the increased efficacy of daily dosing may be secondary to sub-therapeutic depot dosing and excessive daily dosing. It is important to note that even with potentially inadequate stoss therapy there was a rise in serum vitamin D levels in children available for follow-up.We also have concerns that the conclusions made are not statistically valid. The authors calculated a sample size of 20 patients per group, which unfortunately was not achieved. Inadequate patient recruitment and considerable loss to follow-up resulted in an underpowered study. Only 6 of 37 patients were analysed at the final time point. Broad confidence intervals in reported mean increase in serum vitamin D demonstrate imprecision as a result of the small sample size.Applicability to our population is challenging as the basic definitions of vitamin D deficiency do not correlate with consensus guidelines. 2,3 In this study, patients with a level <78 nmol/L were recruited. Current Australian guidelines define deficiency as <50 nmol/L; only 9 (21%) of the 43 participants would meet this definition. We do acknowledge there is ongoing debate regarding what is a normal level of vitamin D in children. Finally, as discussed by the authors, it may be difficult to extrapolate these results to the broader Aboriginal community as the study only sampled from hospital inpatients. This group of children are more likely to have health and environmental issues affecting their vitamin D levels, and may not reflect Aboriginal children in the community.

Forensic investigations into suspected inflicted injury of children can distress children and their parents. Forensic paediatricians and paediatric social workers have the unenviable role of investigating the possible causes of injury, assessing families' psychosocial circumstances and making recommendations to statutory child protection authorities which are likely to have long-lasting impacts. Diagnostic accuracy is paramount.We present the case of a 2-month-old baby referred for forensic medical assessment in relation to suspected bruising that repeated skin examinations over time revealed to be a reticular vascular malformation.