Acute ketosis is an important physiological mechanism to prevent irreversible neurological damage from hypoglycaemia during starvation, and represents a significant metabolic stress. A cohort of children adapt to relatively short periods of reduced caloric intake by generating large quantities of ketone bodies. When excessive, the gastrointestinal symptoms of starvation ketosis such as nausea and pain may create a vicious cycle that delays spontaneous resolution. The presence of ketones can be dismissed as a normal feature of childhood metabolism, sometimes even when extreme. A broader understanding of this process under the banner of ‘accelerated starvation of childhood’ is helpful for clinicians managing acute illness in children. We advocate that children less than 7 years of age with a history suggestive of accelerated starvation of childhood should be screened by emergency clinicians for ketosis using a simple and cheap bedside capillary test, even if glucose levels are greater than 2.6 mmol/L. Identification and appropriate management of ketosis may alleviate the distressing gastrointestinal symptoms associated with many minor illnesses, and potentially prevent hypoglycaemia in some children. Appropriate advice to carers may be helpful to prevent further episodes. Illustrative case examples from our own practice are provided.

Egg allergy preventionThe mistaken belief that you could prevent peanut allergy by withholding peanuts from infants was turned on its head when studies showed the opposite. Now a Japanese group has shown that early introduction of egg is associated with far less egg allergy.1 Children aged 4-5 months with eczema, and consequent high risk of food allergy, who had never been given egg, were randomised to be given heated egg powder or placebo. The egg was started at age 6 months at a low dose (50 mg daily), increased to 250 mg daily from 9 to 12 months. At age 12 months, the incidence of egg allergy was assessed clinically through oral food challenge. The calculated sample size was 150, but the researchers stopped the study after 100 children had been challenged, because 9% of the eggs exposed but 38% of the placebo children had developed diagnosed egg allergy (risk ratio = 0.22, 95% confidence interval 0.08-0.60, P = 0.001). The only difference in adverse events between groups was that 6 of 60 children in the egg group but none of the placebo group were admitted to hospital; P = 0Á022). The novel aspects of this study are the use of heated egg in powder form and the gradual increase in dose. The proportion of all babies who survived without neurodevelopmental impairment increased from 16 to 20%. While these differences were statistically significant, for a parent deciding about resuscitation or intensive care, the message is that just over a third will survive and half the survivors will have major neuro-developmental impairment. The study could not examine lesser degrees of impairment in the 'normal' survivors. The mortality for 22-week gestation infants did not change across the three-time periods (98, 95 and 97%), and only 9 (1.2%) of 749 22-weekers survived without neuro-developmental impairment. Kaiser et al. also examined the use of ICS in pre-school children with EVW. Intermittent ICS -that is, high-dose ICS given at onset of viral upper respiratory tract infection symptoms for 7-10 days -is beneficial when compared to placebo (number needed to treat = 6), with one severe exacerbation (as defined by need for oral corticosteroids) prevented for every six children treated (Fig. 1), 1 and is equivalent to regular ICS in this subgroup. This approach is an attractive therapeutic option as it has the potential to reduce systemic steroid exposure as well as hospital presentations. At present, the optimal dose of intermittent ICS is unknown as the dose varied across the studies included in the meta-analysis and in most cases was greater than the licensed dose for this age group, if licensed at all. 4 We believe that this study has highlighted intermittent ICS as a potential therapeutic option in pre-school children with EVW, and anticipate that further studies will inform translation to clinical practice if a safe and effective dose can be identified. Reference Reference References

Anorexia nervosa (AN) is an eating disorder associated with a number of cardiac complications. Certain cardiac conduction abnormalities are also frequent in young athletes, including both firstand second-degree atrioventricular (AV) blocks. 1,2 We present the case of a 15-year-old girl with a background of athleticism and new diagnosis of AN (restricting subtype), who had first-degree and two types of second-degree heart block (Mobitz type I 'Wenckebach' and 2:1 AV block). The second-degree heart block significantly improved with weight restoration, suggesting that weight loss was a component of the aetiology.

Background: The ECOS observational study was a long term, multicentre, observational study that looked at assessing the level of adherence to paediatric patients’ prescribed recombinant GH (r-hGH) Saizen (somatropin) via the Easypod® electromechanical auto-injector device, and to then further analyse possible clinical and socioeconomic factors that influence adherence. Aim: To evaluate and compare Australian adherence rates of r-hGH compared with existing global data. Method: Adherence data was determined directly from data downloaded from each Easypod device, while standard baseline and outcomes measures were obtained directly from patient medical notes including socioeconomic, demographic, auxological and diagnostic data. Patients were included on the basis of eligibility for subsidised hGH - diagnoses included growth hormone deficiency (GHD), (sub-analysed as prior GH exposure and GH-naive), small for gestation age, those with chronic renal insufficiency and girls with Turner syndrome. The following data was collected on all patients with a complete data set (CAS): (CAS: Easypod start date documented, no gap in injection data of more than a week, and height documented at baseline and 1 year after the start of easypod). Results: Globally 2417 patients were analysed and, within this, 1203 met the complete data set analysis set (CAS) and were further analysed. The Australian cohort consisted of 28 patients of whom 19 had a complete CAS. This included patients with both GHD (n = 13) and Turner syndrome (n = 6). The median adherence rate was 98.4% at 1 year and 92.6% at 4 years. There was a positive correlation between adherence and change in height (cms), r = 0.739 p = 0.0061 and adherence and height velocity (cms), r = 0.664 p = 0.023, for patients with GHD The greatest response was seen in the GH-naïve dataset. 13 patients had a medium change at 1-year SDS >0.5, indicating an equal to greater positive response. Conclusion: The Australian data from the ECOS study provides additional information regarding adherence to Growth Hormone therapy and growth outcomes. Electronic monitoring potentially provides clinicians an early opportunity to address adherence in a timely manner to promote maximum outcomes.