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Transcript of Παιδιατρική | Τόμος 70 • Τεύχος 2 • Μάρτιος - Απρίλιος 2007

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    210 7771 663Fax: 210 7758 354e-mail: [email protected]

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    81 HPV.

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    83 Homocystinuria due to cystathionine -synthase deficiencyS. H. Mudd

    85 Prevention of unintentional injury:relevance to paediatriciansN. Spencer

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    87 Creating a safer Europe for childrenA. J. Nicholson, D. Van Esso, I. Malcic, A. Biver

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    146 Homocystinuria due to cystathionine -synthase deficiency: two sides to thesame coinP. Augoustides-Savvopoulou, H. Ioannou, N. Kozeis, A. Karagiannidou, M. Athanasiou-Metaxa

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    : R. J. Gorlin . .

    70 2 - 2007

    : 3889

    ISSN 0377-2551

    Pediatr Mar-Apr 07 28-03-07 17:22 1

  • Bimonthly Publication ofthe Greek Paediatric Society

    PresidentA. Constantopoulos

    Editorial Board

    Editor-in-ChiefC. Stefanidis

    MembersS. AndronikouP. Augoustides-SavvopoulouA. Vazeou-GerasimidiG. Varlamis. GalanakisL. ThomaidouM. Kanariou. Katsarou-PectasidesA. KattamisS. Kitsiou-Tzeli. PapadopoulouN. PapadopoulosA. Siamopoulou-Mavridou M. Tsolia

    Manuscript Editing

    Greek EditingF. Mavroidi

    English EditingS. Nakou

    Publisher

    K. Griveas

    Publishing Coordinator

    SCIENTIFIC PUBLICATIONS Ltd1 Pierias St. GR - 144 51, MetamorfossiTel.: +30 210 87 78 810 Fax: +30 210 87 78 822

    Owner

    Greek Paediatric Society

    92 Michalakopoulou str.GR - 115 28, AthensTel.: +30 210 7771 140

    +30 210 7771 663Fax: +30 210 7758 354e-mail: [email protected]

    Annual SubscriptionAll foreign countries: US $ 50

    Contentsxi LETTER FROM THE EDITOR-IN-CHIEF

    C. Stefanidis

    CURRENT ISSUE

    81 HPV vaccinationA. Constantopoulos

    EDITORIAL COMMENTARIES

    83 Homocystinuria due to cystathionine -synthase deficiencyS. H. Mudd

    85 Prevention of unintentional injury:relevance to paediatriciansN. Spencer

    REVIEW ARTICLES

    87 Creating a safer Europe for childrenA. J. Nicholson, D. Van Esso, I. Malcic, A. Biver

    93 Safer play for children in playgrounds:barriers and prospectsP. Grigoriou, A. Terzidis, E. Petridou

    ORIGINAL ARTICLES

    97 Atherogenic risk factors in preschoolchildren in Crete A. Kafatos, C. Hatzis, M. Linardakis, D. Athanasopoulos, C. Lionis, E. Balomenaki,A. Kapnisakis, H. Stamataki and Collaborativeresearchers

    107 Thyroid volume, prevalence of subclinicalhypothyroidism and autoimmunity inchildren and adolescentsI. Kaloumenou, L. Duntas, M. Alevizaki, G. Mastorakos, E. Mantzou, A. Antoniou, C. Ladopoulos, C. Mengreli, D. Chiotis, I. Papassotiriou, C. Dacou-Voutetakis

    115 Neurodevelopmental outcome of very lowbirth weight neonates at preschool ageH. Bouza, I. Antoniadou, H. Antonopoulou, M. Anagnostakou, F. Anatolitou, M. Morosini, J. Sarafidou, . Xanthou

    123 Radiofrequency catheter ablation ofaccessory pathways in children: immediateand long-term results J. Papagiannis, G. Kirvassilis, I. Sofianidou, C. Laskari, M. Kiaffas, S. Apostolopoulou, S. Rammos

    135 Use of alternative and complementarytherapy by paediatric oncology patients in GreeceA. Pourtsidis, D. Doganis, M. Baka, M. Varvoutsi,D. Bouhoutsou, P. Xatzi, H. Kosmidis

    141 The epidemiology of chickenpox in school-age children from the prefecture of Attica. Katsafadou, V. Papaevangelou, G. Ferentinos,A. Constantopoulos

    CASE REPORTS

    146 Homocystinuria due to cystathionine -synthase deficiency: two sides to thesame coinP. Augoustides-Savvopoulou, H. Ioannou, N. Kozeis, A. Karagiannidou, M. Athanasiou-Metaxa

    152 Neurocysticercosis in childhood: a case reportM. Theodoridou, V. Vasilopoulou, A. Zisouli, G. Mostrou, V. Syriopoulou

    156 PAEDIATRIC NEWS IN BRIEF

    . Galanakis

    158 CLINICAL QUIZ

    C. Costalos

    159 NEWS FROM THE INTERNET

    Adolescent health websitesN. Papadopoulos

    163 LETTER TO THE EDITOR

    Obituary: R. J. Gorlin C. S. Bartsokas

    PaediatrikiVolume 70 Number 2 March-April 2007

    Pediatr Mar-Apr 07 28-03-07 17:22 3

  • v E EDITORIAL BOARD

    Members of the International Editorial Board

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    Editor-in-ChiefConstantinos Stefanidis, Athens

    Section EditorsStella Andronikou, IoanninaNeonatology

    Persefoni Avgoustides-Savvopoulou, ThessalonikiMetabolic Disorders

    Andriani Vazaiou-Gerasimidi, AthensEndocrinology

    George Varlamis, ThessalonikiCardiology

    Emmanuel Galanakis, HerakleionEthics and Deontology

    Loretta Thomaidou, AthensDevelopmental Pediatrics

    Maria Kanariou, AthensImmunology

    Eustathia Katsarou-Pektasides, AthensNeurology

    Antonis Kattamis, AthensHaematology - ncology

    Sophia Kitsiou-Tzeli, AthensGenetics

    Alexandra Papadopoulou, AthensGastroenterology - Hepatology - Nutrition

    Nicos Papadopoulos, AthensAllergology - Pneumonology

    Antigoni Siamopoulou-Mavridou, IoanninaRheumatology

    Marisa Tsolia, AthensInfectious Diseases

    Alexis Arzimanoglou, Paris, France

    Ellis D. Avner, Milwaukee, USA

    Swati Bhave, New Delhi, India

    Alberto Bissot, Panama, Panama

    David Branski, Jerusalem, Israel

    Francesco Chiarelli, Chieti, Italy

    Chok-Wan Chan, Hong Kong, China

    Denis Daneman, Toronto, Canada

    Jochen Ehrich, Hannover, Germany

    Demetrius Ellis, Pittsburgh, USA

    Yoshikatsu Eto, Tokyo, Japan

    Richard N. Fine, Stony Brook, USA

    Margaret C. Fisher, Philadelphia, USA

    Raif Geha, Boston, USA

    Adenike Grange, Lagos, Nigeria

    Judith G. Hall, Vancouver, Canada

    Patricia Hamilton, London, UK

    Enver Hasanoglu, Ankara, Turkey

    Christer Holmberg, Helsinki, Finland

    Peter Hoyer, Essen, Germany

    Jan Janda, Prague, Czech Republic

    Jan Kimpen, Ultrecht, Netherlands

    Craig B. Langman, Chicago, USA

    John Manis, Boston, USA

    Manuel Moya, Alicante, Spain

    Hugh O'Brodovich, Toronto, Canada

    Ross Petty, Vancouver, Canada

    Willem Proesmans, Leuven, Belgium

    Jose Ramet, Antwerp, Belgium

    Alan Sinaiko, Minneapolis, USA

    Nick J. Spencer, Coventry, UK

    Alfred Tenore, Udine, Italy

    Alkis Togias, Bethesda, USA

    Eva Tsalikian, Iowa City, USA

    Catherine Weil-Olivier, Paris, France

    Max Zach Graz, Austria

    Johannes Zschocke, Heidelberg, Germany

    Pediatr Mar-Apr 07 28-03-07 17:22 5

  • xi EDITORIAL

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    Dear colleagues,

    Thank you for your kind comments on the improvements of the layout and the content of the journal.We would like to inform you that the new members of the Editorial Board are Dr Stella Andronikou(Neonatology), Dr Manolis Galanakis (Medical Ethics), Dr Sophia Kitsiou (Genetics) and Dr LorettaThomaidou (Developmental Pediatrics). These colleagues have long experience in their respective fields andwe believe that they will contribute to the success of the journal. Dr Christos Kostalos and Dr EleniAntonopoulou stepped down from the Editorial Board. We would like to thank them for their contribution.

    The editorial process of the journal is handled electronically since the beginning of this year. All paperscan now be submitted by e-mail. Detailed information about the submission of articles is included in theInstructions to authors of this issue. We would like to emphasize the importance of compliance to thesuggested length of publications. We will be able to publish a larger number of papers if the manuscriptsare shorter. In addition shorter papers are more reader friendly. To save space you will find theInstructions to authors only in the first issue of each year and at the web page of the journal.

    A new section: Paediatric news in brief will start from this issue with comments on recent pediatricarticles. We hope that you will find this section interesting. Educational articles will be included in thenext issues with multiple choice answers. Finally we invite you to send us questions that arise from yourevery day practice. These questions will become the topics of the new section: Ask the expert.

    Warm greetings

    Constantinos StefanidisEditor-in-Chief

    Pediatr Mar-Apr 07 28-03-07 17:22 11

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    The patrol of thePeace, Diana Marcela Cortes,10 years old, ColombiaPartially blind child

    Blind childrenpaint, Anna Laoutari-Gritzala,Athens 2006

    Pediatr Mar-Apr 07 28-03-07 17:23 14

  • xvi ABBREVIATIONS

    Ao

    angstrom angstromcal caloriecm centimetercm2 square centimetercm3 cubic centimeteroC degree Celsiusg gramh hourIU international unitkg kilograml literm metermg milligrammin minutemm millimetermol molen numberNS not significantosm osmolep probabilitySD standard deviationSE standard errorsec secondU unit

    Combining prefixes

    tera- (1012) Tgiga- (109) Gmega- (106) Mkilo- (103) khector- (102) hdeca- (101) dadeci- (10-1) dcenti- (10-2) cmilli- (10-3) mmicro- (10-6) nano- (10-9) npico- (10-12) pfemto- (10-15) fatto- (10-18) a

    Pediatr Mar-Apr 07 28-03-07 17:23 16

  • xviii INSTRUCTIONS TO AUTHORS

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  • xix

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    All authors are cited if they are six or less; if they are 7 or more,the first six are cited, followed by et al.

    Regular edition:Proesmans W. Bartter syndrome and its neonatal variant. Eur

    J Pediatr 1997;156:669-679.

    Supplement issue:Flyvbjerg A. Role of growth hormone, insulin-like growth fac-

    tors (IGFs) and IGF-binding proteins in the renal complicationsof diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19.

    No author:National Institutes of Health Consensus Development Con-

    ference. Neurofibromatosis conference statement. Arch Neurol1988;45:575-578.

    Article type specification:Schreiner GF, Lange L. Ethanol modulation of macrophage in-

    flux in glomerulonephritis [Abstract]. J Am Soc Nephrol 1991;2:562.

    Should antileukotriene therapies be used instead of inhaledcorticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med1998;158:1697-1701.

    Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculi-tis associated with levamisole and circulating autoantibodies [Let-ter]. Arch Dis Child 1996;75:355-356.

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    Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome.In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrol-ogy. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742.

    Book or monograph:Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and

    neck. 3rd ed. New York: Oxford University Press; 1990.

    Publication in a volume of proceedings:Bauer AW. The two definitions of bacterial resistance. In:

    Smith AJ, Rogers CA, eds. Proceedings of the Third InternationalCongress of Chemotherapy; 1962 May 29-31; New York: Interna-tional Society of Chemotherapy; 1963. p. 484-500.

    Doctoral dissertation:Kaplan SJ. Post hospital home health care: the elderlys access

    and utilization [dissertation]. St. Louis (Mo): Washington Univ.;1995.

    . CD-ROMAnderson SC, Poulsen KB. Andersons electronic atlas of

    hematology [CD-ROM]. Philadelphia: Lippincott Williams &Wilkins; 2002.

    IV. ON THE INTERNETArticle in journal

    Abood S. Quality improvement initiative in nursing homes: theANA acts in an advisory role. Am J Nurs [Internet]. 2002 Jun: Web-page: http://www.nursingworld.org/ AJN/2002/june/Wawatch.htm

    MonographFoley KM, Gelband H, editors. Improving palliative care for

    cancer [Monograph, Internet]. Washington: National AcademyPress; 2001. Webpage: http://www.nap.edu/books/0309074029/html

    WebsitesCancer-Pain.org [Webpage, Internet]. New York: Association

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    Pediatr Mar-Apr 07 28-03-07 17:23 19

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    10. Figure titles.

    Cheryl Desjardins, 15 ,

    , -, 2006

    A single Flower, Cheryl Desjardins, 15 years old, CanadaPartially blind child

    Blind childrenpaint, Anna Laoutari-Gritzala,Athens 2006

    xx

    Pediatr Mar-Apr 07 28-03-07 17:23 20

  • 81 CURRENT ISSUE

    A: [email protected]

    Correspondence:Andreas [email protected] of the GreekPaediatric Society

    2007;70:81-82

    HPV

    .

    - (HPV) . , 16 18 70% - -. , HPV - 200. 70-80% - HPV. test -, , - . - test 70-75%. - (- 1). , , - test -, 85-95% -, .

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    1. Anttila A, Ronco G, Clifford G, Bray F, Hakama M, Arbyn M, et al. Cervical cancer screening programmes andpolicies in 18 European countries. Br J Cancer 2004;91:935-941.

    2. van Ballegooijen M, van den Akker-van Marle E, Patnick J, Lynge E, Arbyn M, Anttila A, et al. Overview ofimportant cervical cancer screening process values in European Union (EU) countries, and tentative predictionsof the corresponding effectiveness and cost-effectiveness. Eur J Cancer 2000;36:2177-2188.

    3. Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2002: cancer incidence. Mortality and prevalence worldwide.IARC cancer base no. 5, version 2.0. Lyon (France): IARC Press; 2004.

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    Pediatr Mar-Apr 07 28-03-07 17:23 81

  • . - - . test , . . . - : , - 38,5oC. - 5 . -, -. Gardasil, 24.000 1.071 . - - Gardasil. 4,5-5 10,5 . . -, -, - .

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    82 .

    Paediatriki 2007;70:81-82

    Pediatr Mar-Apr 07 28-03-07 17:23 82

  • Homocystinuria due to cystathionine -synthase deficiency

    S. H. Mudd

    83EDITORIAL COMMENTARY

    Laboratory of MolecularBiology, National Institute of Mental Health

    Correspondence:S. Harvey [email protected] 35, Room 1B100635 Convent DriveBethesda, MD 20892, USA

    2007;70:83-84

    In this issue of Paediatriki Persephone Au-goustides-Savvopoulou and coauthors describetwo cases of cystathionine -synthase (CS) de-ficiency with emphasis on the clinical and meta-bolic identification of such patients, and the factthat proper treatment can help avoid adverse ef-fects of this genetic abnormality (1). This edito-rial attempts to clarify two nomenclatural issuesthat may make reading about this condition dif-ficult for non-specialists, and to expand uponaspects covered only briefly in the article inquestion (1).

    The name of the condition. Homocystinuria(i.e. excessive urinary homocystine) was foundby Nina Carson and coworkers in 1962 amongmentally retarded Northern Irish children andindependently (and virtually simultaneously) byGerritsen and Waisman and by Barber andSpaeth in the United States (2). In 1964 deficientactivity of CS, the enzyme that catalyzes thecondensation of homocysteine with serine,forming cystathionine, was shown to be the un-derlying cause of the homocystinuria in Barberand Spaeths patient (2). For a few years there-after homocystinuria was used as a definitivename of a specific genetic abnormality. Howev-er, in 1969 a patient with excessive urinary ho-mocystine was shown to be unable to convert vi-tamin B12 to its coenzyme forms, methyl-B12 andadenosyl-B12, so that the methyl-B12-dependentmethylation of homocysteine back to methion-ine did not occur normally (3). This defect innow termed cblC (cobalamin C) disorder to dis-tinguish it from other inherited disorders ofcobalamin metabolism. In 1972 a different ho-mocystinuric patient was found to have yet an-other causative metabolic abnormality, severelydeficient activity of 5,10-methylenetetra-hydro-folate reductase (MTHFR), the enzyme thatforms methyltetrahydrofolate, a methyl donorfor methylation of homocysteine (4). [These re-actions are diagrammed in level (2) in Fig. 1 incitation (1)]. It thus became evident that ho-mocystinuria is a metabolic abnormality withmultiple causes, and that, to designate a specificdisease with this abnormality, it is important toname the underlying deficiency. In contrast tothe elevated methionine of CS deficiency, thetwo additional defects just discussed, as well as

    others discovered more recently affecting homo-cysteine remethylation (5), are characterized bylow plasma methionine. A recent report indi-cates the brain damage of MTHFR deficiency isdue to lack of methionine rather than to elevat-ed homocysteine (6). Therefore, establishing theproper cause of a case of homocystinuria be-comes especially important: dietary methioninerestriction is often used beneficially in CS defi-ciency, but is contraindicated in a homocysteineremethylation defect.

    Homocystine, homocysteine, and total homo-cysteine (tHcy). Homocystine is a disulfide withstructure RS-SR (where R=-CH2CH2CH(NH2)COOH, formed in the body from homocysteine,the metabolically active sulfhydryl form, RSH. Inplasma, homocystine greatly exceeds homocys-teine, and even more homocysteine moieties oc-cur as mixed disulfides bound to cysteine (RS-SR) or protein cysteine (RS-S-Protein) (7). Ami-no acid chromatography usually measures ho-mocystine, but to measure the sum of the variousforms in which homocysteine moieties occur,modern methods cleave disulfide bonds, assaythe resulting homocysteine and term it total ho-mocysteine (tHcy) (7).

    The present situation. Based on the experi-ence since 1962, and as described by Au-goustides-Savvopoulou et al (1), CS deficiencyis now known to occur in both B6-responsiveand B6-non-responsive forms, ultimately de-pendent upon the specific mutation(s) in the al-leles encoding CS (8). Untreated, B6-respon-sive individuals develop less severe clinical ab-normalities or manifest them more slowly. Forexample, in a survey including data for 231 B6-responsive patients and the same number of B6-non-responders, the median IQ among respon-ders was 78 versus 64 for non-responders; thechances of having been found to have dislocatedoptic lenses by age 10 years was 55% and 82%for responders and non-responders; of having athromboembolic event by age 15 years, 12% and27%; of having radiologically detectable spinalosteoporosis by age 15, 36% and 64%; and of notsurviving to age 30, 4% and 23% (9). However,there may have been ascertainment bias for thepatients included in that study, because, to be in-cluded, a patient had either to have some clinical

    Pediatr Mar-Apr 07 28-03-07 17:23 83

  • manifestation, to be a family member of a diagnosedpatient, or to have been detected by elevated bloodmethionine at newborn screening. More recent ge-netic screening of newborns in Denmark (10) or Nor-way (11), or of unrelated German control subjects(12) indicates the prevalence of homozygosity for theI278T CS mutation might be as high as 1:20,500,1:104,000 and 1:17,800 live births, in those countries,respectively. Since homozygosity for I278T leads toB6-responsiveness, and because B6-responders areusually missed in newborn screening based upon ele-vated blood methionine concentrations (8), it re-mains possible that some of these patients may re-main clinically normal throughout life, or that theymay be diagnosed only later in life if they present withthromboembolic problems. As illustrated by the re-port of Augoustides-Savvopoulou et al (1), and sup-ported now by a variety of further evidence, treat-ment of responders with pyridoxine and of non-re-sponders by dietary methionine restriction, oftenwith betaine in addition, is clearly beneficial (8,9,13).

    Much progress has been made also for the homo-cystinurias due to remethylation defects. Particularlynoteworthy are: The recent identification of the gene,MMACHC, mutations in which lead to cblC disor-ders (14). The discovery of further cobalamin disor-ders producing functional methionine synthase defi-ciency (cblE and cblG). The cloning of the gene forMTHFR and identification of several mutations in itleading to severely deficient activity of that enzyme.The discovery of the common MTHFR polymor-phism, C677T, that leads to formation of a thermola-bile enzyme and, in individuals with serum folate to-ward the lower end of the reference range, to mild el-evations of plasma tHcy. The current report that anAmish baby shown by genetic screening at birth to behomozygous for a severely inactivating MTHFR mu-tation and treated early with betaine to maintain me-thionine levels has been free of the irreversible mentaland developmental problems that affect other indi-viduals homozygous for the same mutation, buttreated only at older ages (6).

    The situation in Greece. It is of interest to the pre-sent author that, in-so-far as he is aware, the patientsreported by Augoustides-Savvopoulou et al (1) arethe first individuals with homocystinuria due to CSdeficiency identified in Greece. On the current JanKraus CS website (http://www.uchsc.edu/sm/cbs),among the 559 alleles responsible for CS deficiencythe ancestries of which are shown, none is listed as ofGreek origin. Whether the Greek population is un-usually free of inactivating CS mutations, orwhether individuals with such mutations are present,

    awaiting ascertainment and treatment, may pose anintriguing question for the physicians of Greece.

    References1. Augoustides-Savvopoulou P, Ioannou H, Kozeis N, Kara-

    giannidou A, Athanasiou-Metaxa M. Homocystinuria dueto cystathionine b-synthase deficiency: two sides to thesame coin. Paediatriki 2007;70:146-151.

    2. Mudd SH, Finkelstein JD, Irreverre F, Laster L. Homo-cystinuria: an enzymatic defect. Science 1964;143:1443-1445.

    3. Mudd SH, Levy HL, Abeles RH, Jennedy JP Jr. A derange-ment in B12 metabolism leading to homocystinemia, cys-tathioninemia and methylmalonic aciduria. Biochem Bio-phys Res Commun 1969;35:121-126.

    4. Mudd SH, Uhlendorf BW, Freeman JM, Finkelstein JD,Shih VE. Homocystinuria associated with decreasedmethylenetetrahydrofolate reductase activity. BiochemBiophys Res Commun 1972;46:905-912.

    5. Rosenblatt DS, Fenton WA. Inherited disorders of folateand cobalamin transport and metabolism. In: Scriver CR,Beaudet AL, Valle D, Sly WS, Childs B, Kinzler KW, editors.The Metabolic and Molecular Bases of Inherited Disease,8th ed. New York, N.Y.: McGraw-Hill; 2001. p. 3897-3933.

    6. Strauss KA, Morton DH, Puffenberger EG, HendricksonC, Robinson DL, Wagner C, et al. Prevention of brain dis-ease from severe 5,10-methylenetetrahydrofolate reduc-tase deficiency. Mol Genet Metab 2007; in press.

    7. Mudd SH, Finkelstein JD, Refsum H, Ueland PM, Mali-now MR, Lentz SR, et al. Homocysteine and its disulfidederivatives: a suggested consensus terminology. Arte-rioscler Thromb Vasc Biol 2000;20:1704-1706.

    8. Mudd SH, Levy HL, Kraus JP. Disorders of transsulfura-tion. In: Scriver CR, Beaudet AL, Sly WS, Valle D, ChildsB, Kinzler KW, editors. The Metabolic and Molecular Bas-es of Inherited Disease, 8th ed. New York: McGraw-Hill;2001. p. 2007-2056.

    9. Mudd SH, Skovby F, Levy HL, Pettigrew KD, Wilcken B,Pyeritz RE, et al. The natural history of homocystinuriadue to cystathionine beta-synthase deficiency. Am J HumGenet 1985;37:1-31.

    10. Gaustadnes M, Ingerslev J, Rutiger N. Prevalence of con-genital homocystinuria in Denmark. N Engl J Med1999;340:1513.11.

    11. Refsum H, Fredriksen A, Meyer K, Ueland PM, Kase BF.Birth prevalence of homocystinuria. J Pediatr 2004;144:830-832.

    12. Linnebank M, Homberger A, Junker R, Nowak-Goettl U,Harms E, Koch HG. High prevalence of the I278T muta-tion of the human cystathionine beta-synthase detected bya novel screening application. Thromb Haemost 2001;85:986-988.

    13. Yap S, Boers GH, Wilcken B, Wilcken DE, Brenton DP,Lee PJ, et al. Vascular outcome in patients with homo-cystinuria due to cystathionine beta-synthase deficiencytreated chronically: a multicenter observational study. Ar-terioscler Thromb Vasc Biol 2001;21:2080-2085.

    14. Lerner-Ellis JP, Tirone JC, Pawelek PD, Dore C, AtkinsonJL, Watkins D, et al. Identification of the gene responsiblefor methylmalonic aciduria and homocystinuria, cblCtype. Nat Genet 2006;38:93-100.

    84 S. H. Mudd

    Paediatriki 2007;70:83-84

    Pediatr Mar-Apr 07 28-03-07 17:23 84

  • 85EDITORIAL COMMENTARY

    Correspondence:Nicholas [email protected] of WarwickCoventry, UK

    2007;70:85-86

    Prevention of unintentional injury: relevance to paediatricians

    N. Spencer

    Public health importance of unintentionalinjury

    As noted by Nicholson et al in this issue ofthe journal, unintentional injuries are the lead-ing cause of death and disability in Europeanchildren. Globally, it is estimated that by 2020road traffic crashes will have moved from ninthto third in the world disease burden ranking, asmeasured in disability adjusted life years (1).The costs in premature death and disability andthe burden on health and social care services andfamilies are huge. Yet injury prevention com-mands far less attention in most countries thansmoking cessation. The tendency of doctors tofocus on the consequences of injury rather thanprevention contributes to the relatively low pro-file of this major public health issue.

    Contributory factorsEuropean countries that have succeeded in

    providing a relatively safe environment fortheir children with resulting reduction indeaths and disability associated with uninten-tional injury, have done so as a result of a com-bination of legislation, enforcement and publiceducation. Legislation, although necessary, isnot sufficient to protect children. For example,Greece enacted legislation over 20 years ago re-lated to seat belt wearing by children in carsand speed limits on urban roads but continuesto have one of the highest road accident deathrates in the EU (see Nicholson et al, Tables 2and 3). This is likely to be due to limited en-forcement and relatively poor acceptance ofthese measures by the population.

    A key factor in relation to child pedestrianand cyclist injuries is exposure to traffic (2).Children who are exposed to high volumes oftraffic either as pedestrians or cyclists are athigh risk. Poorer children are more likely to beexposed in this way as their parents are lesslikely to own cars (3).

    Effectiveness of preventive interventionsNicholson et als reliance mainly on the re-

    sults of individual studies as evidence of effec-tiveness of preventive interventions to reduceunintentional injury among children leads

    them to slightly overstate the strength of theavailable evidence. Good randomised con-trolled trials in accident prevention are rareand the evidence base tends to be weak. How-ever, there are now a series of Cochrane sys-tematic reviews that report reasonably robustevidence for some preventive interventions.For example, speed enforcement devices suchas cameras are associated with a significant re-duction in crashes (4) and helmets for cyclistssignificantly reduce head and facial injuries (5).The Cochrane reviews highlight the need formore robust studies of injury prevention inter-ventions.

    Relevance to paediatriciansDue to the heavy burden of death and dis-

    ability resulting from unintentional injury,paediatricians are frequently faced with theconsequences. Paediatricians, in common withother doctors, tend to focus on curative, clini-cal interventions at the individual level ratherthan preventive approaches at the populationlevel. Clinical approaches to the consequencesof unintentional injury can relieve suffering butcannot address the fundamental causes. Thus,for paediatricians to make a contribution to re-ducing the burden of unintentional injury, theyneed to focus on preventive interventions at thepopulation level as well as clinical managementof the consequences in individual children.

    How might paediatricians contribute?On matters concerning children, paediatri-

    cians have a powerful voice. We need to learnhow to use this power to change public policyand public perceptions in relation to uninten-tional injury. The individual paediatrician canprovide developmentally appropriate advice toparents and can participate in local groups pro-moting injury prevention strategies. Advocacy isprobably most powerful when undertaken by na-tional paediatric organisations that can commu-nicate directly with policy makers and politi-cians. We, in Europe, can learn from our Ameri-can colleagues in the American Academy of Pe-diatrics who have a long tradition of effectivelobbying on a range of child health related issues.

    Pediatr Mar-Apr 07 28-03-07 17:23 85

  • Paediatricians also have a major potential role inpromoting high quality, robust research to informpreventive strategies. Research of this nature is asimportant as drug trials.

    References1. Murray CJ, Lopez AD. Alternative projections of mortali-

    ty and disability by cause 1990-2020: Global Burden ofDisease Study. Lancet 1997;349:1498-1504.

    2. Sonkin B, Edwards P, Roberts I, Green J. Walking, cyclingand transport safety: an analysis of child road deaths. J RSoc Med 2006;99:402-405.

    3. Edwards P, Roberts I, Green J, Lutchmun S. Deaths frominjury in children and employment status in family: analy-sis of trends in class specific death rates. BMJ 2006;333:119.

    4. Wilson C, Willis C, Hendrikz JK, Bellamy N. Speed en-forcement detection devices for preventing road traffic in-juries. Cochrane Database Syst Rev 2006;2:CD004607.

    5. Thompson DC, Rivara FP, Thompson R. Helmets for pre-venting head and facial injuries in bicyclists. CochraneDatabase Syst Rev 2000;2:CD001855.

    86 N. Spencer

    Paediatriki 2007;70:85-86

    Pediatr Mar-Apr 07 28-03-07 17:23 86

  • 87REVIEW ARTICLE

    2007;70:87-92

    BackgroundInjuries are the leading cause of death and

    disability for children in the European Union(EU). In the EU, for every death from injury,there are 30 hospital admissions and 300emergency department attendances (1). It hasbeen estimated that the overall socio-economicburden of all injuries in Europe is 400 billionEuros annually (i.e. almost 4 times the entire EUbudget).

    The leading causes of injury death for chil-dren (1-14 years old) in the EU include road-re-lated (48%), drowning (11%), intentional in-juries (11%), house fires (5%), high falls (5%),poisonings (2%) and miscellaneous (18%).There has been improvement in all EU memberstates in the reduction of child injury deaths overthe past 20 years (2-5).

    Thus injuries are a neglected problem thathas devastating effects on individuals andhealth budgets. Within the expanded EU, mostof the burden of injuries falls on low and mid-dle-income countries which have undergonegreat changes brought about by transition tomarket-style economies since the 1990s. Chil-dren living in low and middle-income coun-tries are 3.6 times more likely to die from injurythan those in high income countries (Tables 1and 2). High income countries have increasedinjury rates in socioeconomically deprived

    groups and a widening gap between rich andpoor. The increased mortality risk in deprivedgroups applies to most injury types includingdrowning, falls, poisoning, road-related andfire-related injuries.

    Some countries in the EU, such as theNetherlands, United Kingdom and Sweden areamong the safest places in the world and if allcountries were to match their figures, twothirds of the lives lost every year due to injurycould be saved. Countries with low rates of in-jury have invested in safety as a societal respon-sibility. Legislation and enforcement to ensuresafer environments (e.g. road and housing de-sign and the use of safety equipment) and re-duce risk behaviors (e.g. speeding and drivingunder the influence of alcohol) are key changesat a population level (6-8). These measureshave a synergistic effect when coupled with me-dia and educational campaigns. There are dif-ferences that exist in countries throughoutEurope as to how they adopt effective measuresin reducing childhood deaths and serious in-juries (Table 3).

    Road-related injuriesIn the area of road safety, the EU has set a

    target to halve the number of deaths from roadtraffic injuries by 2010.

    Without doubt road-related injuries should

    Accident PreventionWorking Group of theEuropean Academy ofPaediatrics

    Correspondence:Alf [email protected] Lady of Lourdes Hospital,Drogheda, Co. Louth, Ireland

    Creating a safer Europe for children

    A.J. Nicholson, D. Van Esso, I. Malcic, A. Biver

    Abstract: Unintentional injuries are the leading cause of death and disability in European children withroad-related injuries accounting for just under half of all deaths due to injury. There is a steep socialgradient for all serious childhood injuries and children living in low- and middle-income EuropeanUnion (EU) countries are 3.6 times more likely to die from injury than those in high-income countries.Some EU countries (such as Sweden, the Netherlands and the United Kingdom) are among the safestplaces in the world and, if other EU countries were to match their performance, two thirds of lives lostper year due to injury could be saved. Legislation and enforcement to ensure safer environments (e.g.road and housing design and use of safety equipment) and reduction of risk behavior (e.g. speedingand driving under the influence of alcohol) are effective at a population level. Effective evidence-basedinterventions include reduction of speed limits, traffic calming measures, safer car fronts, correctly-fittedchild passenger restraints, bicycle helmets, swimming pool fencing, personal flotation devices, smokedetectors, child-resistant lighters and child-resistant packaging for medicines and household chemicals.Paediatricians across the EU should be aware of the extent of childhood injury deaths and assume agreater advocacy role to aid their prevention.

    Key words: unintentional injury, road-related injuries, drowning, burns and scalds, falls, poisoning, chokingand suffocation.

    Pediatr Mar-Apr 07 28-03-07 17:23 87

  • 88 A.J. Nicholson et al.

    be our first priority as these constitute 48% of all in-jury deaths in the EU. Road-related accidents in-clude child injury deaths to pedestrians, bicyclistsand motor vehicle passengers (9,10).

    A pre-requisite for setting targets is good baselinedata on road-related injuries and this requires eitheran injury surveillance system or some other means ofproviding complete and accurate information on theepidemiology of road-related injuries.

    A great deal of intervention is being done inmost EU countries but there is evidence that morelives could be saved on roads if the following strate-gies were implemented, enforced and taught to thepublic.

    a. The reduction of speed limitsIn the United Kingdom (11), introduction of 20

    mph/hour speed limit zones has resulted in local re-ductions of 48% in child bicycle injuries and a 70%reduction in fatal road accidents involving pedestri-ans. Speed cameras or radar can catch drivers who areexceeding speed limits. Publicizing the presence ofspeed cameras or radar, further increases compliancewith speed laws and substantially reduces road-relat-ed deaths.

    b. Traffic calmingResidential access roads should have speed limits

    of no more than 30 km/hour and design features thatcalm traffic and this has resulted in 60% reductions inroad-related childhood injuries in 30 km/hour zones(Figure 1).

    Pedestrians have twice the risk of injury where theyare not segregated from motor vehicle traffic andstudies in Denmark (12) have shown that segregatedbicycle lanes alongside urban roads reduced deathsamong cyclists by 35%.

    c. Safer car fronts for pedestrians and cyclistsEngineers have known for some time how to

    modify car fronts so that they do less harm to cyclistsand pedestrians and yet no EU country requires thefronts of cars to have a crashworthy design to mini-mize injury to pedestrians. If vehicles were requiredto pass performance tests for vehicle fronts, the annu-al number of deaths and injuries to pedestrians in theEU could fall by 20% (13-16,23).

    d. Child passenger restraintsTo protect occupants, a motor vehicle should be

    designed so that the passenger compartment maintains

    Table 1. Injury deaths for children (0-14 years) in the EU

    Source: WHO 1996-2000 National Sources Average

    Malta* 2.19Sweden* 3.79

    United Kingdom* 4.21Italy* 4.57

    Netherlands* 4.73Finland 5.00

    Germany* 5.34Denmark* 5.40

    Luxembourg 5.96Austria 6.33

    Spain 6.49France* 6.66Ireland* 6.70

    Slovenia* 7.36Belgium* 7.44

    Greece* 7.87Hungary 8.09

    Czech Republic 8.47Portugal 8.95

    Poland* 9.16Slovakia 10.53

    Lithuania 21.01Estonia 22.60

    Latvia 23.51

    0.00 5.00 10.00 15.00 20.00 25.00

    Rates per 100,000 population

    *Some data is missing

    Paediatriki 2007;70:87-92

    Pediatr Mar-Apr 07 28-03-07 17:23 88

  • 89

    its integrity in a crash and there should be restraintsso that occupants do not eject from the vehicle ortumble about inside it, injuring themselves and otheroccupants.

    When used properly, child restraints or car seatshave been shown to have an injury-reducing factorof 90-95% for rear-facing systems and 60% for for-ward-facing systems (17-19,23,24). For children 0-15 months (weight up to 13 kg), rear-facing child re-

    straints optimally distribute any force of impact andthereby reduce sever injuries by 90%. Rear-facingchild restraints should always be placed in the backseat as many vehicles have front airbags. Child pas-senger restraints are shown in Figure 2.

    e. Bicycle helmets Correctly fitted, bicycle helmets reduce the risk of

    head and brain injury by 63-88% (23).

    DrowningDrowning is the second leading of death for chil-

    dren of the EU with more than 70% of the victims be-ing boys and the most vulnerable being 1 to 4 years ofage (21). Prompt resuscitation following immersionis critical to survival and the outcome for most chil-dren with immersion is determined by their status onarrival to the emergency department - medical andpaediatric intensive care appear to have relatively lit-tle impact on outcome. Therefore prevention is thekey to decreasing hospitalisations and deaths fromdrowning. Effective prevention strategies includeswimming pool fencing (22). Other preventive strate-gies include personal flotation systems, swimminglessons, parental supervision and lifeguards.

    1

    0.8

    0.6

    0.4

    0.2

    00 20 40

    Impact speed (km/h)60 80 100

    Pro

    bab

    ilit

    y o

    f d

    eath

    Figure 1. Pedestrian fatality risk as a function of the impact speedof a car.

    Table 2. Road accident deaths for children (0-14 years) in the EU

    Source: WHO 1996-2000 National Sources Average

    Slovakia 0.09Malta* 0.94

    Sweden* 1.56United Kingdom* 1.62

    Czech Republic 1.68Finland 1.84

    Netherlands* 2.03Germany* 2.19

    Austria 2.32Italy* 2.36

    Hungary 2.55Denmark* 2.84

    France* 3.04Slovenia* 3.12Belgium* 3.20

    Luxembourg 3.23Spain 3.32

    Ireland* 3.44Poland* 4.07Greece* 4.14

    Portugal 5.02Lithuania 5.48

    Estonia 5.58Latvia 5.58

    0.00 1.00 2.00 3.00 4.00 5.00 6.00

    Rates per 100,000 population

    *Some data is missing

    2007;70:87-92

    Creating a safer Europe for children

    Pediatr Mar-Apr 07 28-03-07 17:23 89

  • Burns and scaldsSevere burn injuries require multiple hospitalisa-

    tions and lengthy treatment and may result in perma-nent disability and disfigurement. Scalds and contactburns occur predominantly to under 2 year-olds. Agestandardized mortality rates for children (1-14 years ofage) dying through fires in the EU show that the low-est rate is in Italy (0.17 per 100,000) and the highestrate is in Ireland (0.91 per 100,000). Burn and scaldinjuries could be reduced in Europe, if the followingpreventive measures were implemented, enforcedand promoted to the general public:

    Smoke detectors are an effective, reliable and in-expensive devices that provide an early warning andassist in reducing residential fire deaths by 71%(23,24).

    Legislation requiring a safe pre-set temperature(54oC) for all water heaters has proven to be a more ef-fective method of reducing scald burns than educationto encourage parents to turn down water heaters.

    In the USA, fire deaths associated with cigarettelighters dropped by 43% with the adoption of child-resistant designs (14).

    A dramatic 75% reduction in burn unit admissions

    due to sleepwear occurred following the introductionof the Flammable Fabrics Act of 1972 in the USA.

    FallsFalls resulting in severe or fatal injuries are usual-

    ly due to second storey or higher windows. Stair gates have been shown to assist in reducing

    falls downstairs. Absorbent surface material in play-grounds and appropriate height of play equipmentfor various ages provides an improvement in seriousfall injuries. Window bars have shown a 35% decreasein deaths and a 31% decrease in reported falls.

    PoisoningChildren under 2 years of age are especially vulner-

    able and more than 90% of poisonings occur in thehome environment (5). Many common householdproducts can poison children including cleaning sup-plies, alcohol, pesticides, medicines and cosmetics (5).

    Safe storage is an effective means of preventingpoisoning with both medicinal and non-medicinalagents (6).

    Educational strategies aimed at children and par-ents have been associated with increased knowledge

    Table 3. Effective measures in reducing childhood deaths and serious injuries in Europe (Source: updated from Towner and Towner, 2004)

    Bicycle Child safety Seat belt Speed Child resistant Smoke Barrier Children Adoption of No sale ofhelmets seats/ wearing limits - packaging detectors fencing, banned playground fireworks

    for children restraints by children roads pharmaceuticals in home domestic from riding/ standards to childrenin cars in urban swimming driving farm

    areas pools tractors

    Austria 1994 1994 1994 1996 1995 1974

    Belgium 1996 1975 1998 2001 2000Czech Republic 2000 2000 2000 1999 2000 1999 2000Denmark Estonia 2003 2003 2003 2003 2004France 1992 1972 2003 1994Germany 1992 1993 1952 1976 Greece 1999 1977 1962 Hungary 2000 2000 Iceland 1999 1990 1981 1988 1993 Ireland 1993 1994 Italy 1988 1989 1984 1996 Luxembourg 2000 Netherlands 1992 1986 2003* 1997 1995Norway 1979 1990 1997 1996Poland 1997 1997 1997 2002 1997 Portugal 1995 1994 1998 Spain 1999 1992 1974 1990 Sweden 1988 1988 1936 1973 Switzerland 1981 1981 1959 1976 1988United Kingdom 1989 1989 1934 1994 1999 1998 1998 1997

    *: New homes only, : Indicates legislation enacted but year not known , YEAR: Indicates date legislation enacted if known, Blank: Nolegislation measure enacted

    90 A.J. Nicholson et al.

    Paediatriki 2007;70:87-92

    Pediatr Mar-Apr 07 28-03-07 17:23 90

  • 91Creating a safer Europe for children

    2007;70:87-92

    of poison prevention. The compulsory use of child-resistant packaging for aspirin and paracetamol led toa dramatic fall in the number of children admitted to

    hospital as a result of these medications in England,the Netherlands and USA (6).

    Choking and suffocationChoking occurs most commonly on small attrac-

    tive products, including balloons, coins, small toyparts, small food pieces and inedibles in food prod-ucts. Legislative measures to be implemented includeproduct bans (inedibles in foodstuffs, drawstrings onclothing); warning labels on products have reduceddeaths in those countries where this legislation hasbeen enforced (7).

    Socioeconomic deprivation and childhood injuryIn England and Wales, the risk of children dying

    from fire was 16 times greater in the lowest socioeco-nomic group (SEG) compared to the highest (10,11),the risk of pedestrian injuries was 5 times higher inlower SEG and the overall risk of a childhood injurydeath was 3-4 times higher in children of parents inunskilled manual jobs than children whose parentswere skilled non-manual workers (11). In Germany,poorer families were twice as likely to be involved inroad traffic accidents (12).

    Thus, there is a steep social gradient in relation toserious childhood injuries and deaths in most EUcountries.

    The impact of an expanding EUThe childhood injury death rates for the new EU

    countries range from 10.8 per 100,000 in Hungary to38.4 per 100,000 in Latvia. The only country that hasa higher childhood injury death rate than the new EUcountries is Portugal (17.8 per 100,000). Thus thechildhood injury death rate in Latvia is 8 times that inSweden. If the EU is committed to reducing dispari-ties in living standards between its members, seriouscommitments will need to be made to ensure thatchildhood injury deaths will be reduced in candidatecountries as a matter of urgent priority.

    The role of government and legislationAs of June 2001, only the UK and the Netherlands

    have specific targets or specific goals as part of a na-tional health plan aimed at reducing childhood injury(12,13,15). It is clear that, before there can be an inte-grated approach to child safety across the EU, thereneeds to be one within each individual member state.

    Legislation and its enforcement is one of the mosteffective ways to create a safer environment (13).

    Whilst no EU member state has adopted all ten pre-ventive policy measures that were conducted in recentresearch by Towner et al (12), Sweden and Spain do

    Rearward-facing baby seat(For babies up to 13 kg)

    Forward-facing seat (Weight 9-18 kg)

    Booster cushion (Weight 22-36 kg)

    Figure 2. Car seats at different ages.

    Booster seat (Weight 15-25 kg)

    Never put arearward-facingseat in the frontseat if there is a

    passenger airbag!

    Never put arearward-facingseat in the frontseat if there is a

    passenger airbag!

    Pediatr Mar-Apr 07 28-03-07 17:23 91

  • 92 A.J. Nicholson et al.

    Paediatriki 2007;70:87-92

    show commitment to using policy to influence the re-duction of childhood injury by adopting most of themeasures outlined in Table 3. The most common mea-sures are related to motor vehicles and include child re-straints, seat belt wearing and reduced speed limits.The lowest adopted measures include bicycle helmetsand smoke alarms in private residences. Even thoughGermany and the UK introduced mandatory child-re-sistant packaging for medicines 25 years ago, only 4other countries use this proven safety measure. Even insituations where European directives exist, there isgreat variation in how EU member states enact thesedirectives in their bodies of law. Many countries with-in the EU lack even a basic structure for enforcing reg-ulations and standards for consumer products such aschild care articles and toys. Coordination at nationaland European levels is quite deficient.

    The role of EU regulations and standardsThe Treaty of Maastricht has extended significantly

    the authority of the European Commission with re-spect to the protection of the health and safety of Euro-pean citizens. Standards play a key role in regulatingsafety in the EU as they provide technical specificationsfor existing framework legislation. European regula-tions and standards addressing child safety (e.g. child-resistant packaging) are not implemented properly orare not providing the safety measures that are current-ly needed. New directives should be developed at EUlevel for pedestrian and bicycle protection throughsafer car fronts, all under 12 year olds should be pro-tected by child restraint systems in cars, playgroundequipment should meet EU safety standards and Euro-pean regulations should be developed for inedibles infood products, flammability of clothing, cords on chil-drens clothes, cigarette lighter that are child-proof andbuilding code requirements for pool fencing, windowad balcony railings and amusement /riding devices.

    Legislation of injury strategies and its enforcementis one of the most effective ways to create safer envi-ronments.

    References1. World Health Organization. Atlas of mortality in Europe.

    Geneva; 1997.2. Consumer Safety Institute. Deaths and injuries due to ac-

    cidents and violence in the Netherlands 1998-1999. Ams-terdam; 2000.

    3. European Consumer Safety Association. Priorities for con-sumer safety in the European Union. Amsterdam; 2001.

    4. British Medical Journal Publications. Injury Prevention.London; 2001.

    5. European Transport Safety Council. Priorities for EU mo-tor vehicle safety design. Brussels; 2001.

    6. Towner E, Dowswell T, Mackereth C, Jarvis S. What worksin preventing unintentional injuries in children and youngadolescents? NHS. Health Development Agency; 2001.

    7. Harborview Injury Prevention and Research Center /Cochrane Collaboration / systematic review database.University of Washington, Seattle. 2001.

    8. EUROCAPP (European Evaluation of childrens and ado-lescents Accident Prevention Policies) study. Luxem-bourg; 1997.

    9. Petridou E. Injuries from food products containing inedi-bles. Report to the European Parliament. Athens; 1997.

    10. Proceedings on social inequalities and injury risk. JournalInjury Control and Safety Promotion 2001;8:129-210.

    11. UNICEF: A league table of child deaths by injury in richcountries. Florence: Innocenti Report Card, No 2; 2001.

    12. Breen J. Road safety advocacy. BMJ 2004;328:888-890.13. European Association for the coordination of consumer

    representation in standardisation: update on standardisa-tion work in the child safety field. Brussels; 2001.

    14. Warda L, Tenenbein M, Moffatt ME. House fire injuryprevention update. Part 1. A review of risk factors for fataland non-fatal fire injury. Inj Prev 1999;5:145-150.

    15. Plitponkarnpim A, Andersson R, Jansson B, Svanstrom L.Unintentional injury mortality in children: a priority formiddle income countries in the advanced stage of epi-demiological transition. Inj Prev 1999;5:98-103.

    16. Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA,Jarawan E, et al. World report on road traffic injury pre-vention. Geneva: World Health Organization; 2004.

    17. Racioppi F, Eriksson S, Tingvall C, Villaveces A. Preventingroad traffic injury: a public health perspective for Europe.Copenhagen: WHO Regional Office for Europe; 2004.

    18. Cubbin C, Smith GS. Socioeconomic inequalities in in-juries: critical issues in design and analysis. Annu RevPublic Health 2002;23:349-375.

    19. Towner E. Injury and inequalities: bridging the gap. Intl JInj Contr Saf Promot 2005;12:79-84.

    20. Roberts I, Mohan D, Abbasi K. War on the roads. BMJ2002;324:1107-1108.

    21. Risk assessment and target setting in EU transport pro-grammes. Brussels: European Transport Safety Council;2003.

    22. Hobbs A. Safer car fronts for pedestrians and cyclists.Brussels: European Transport Safety Council, February2001. (Presentation to Commission hearing on pedestrianprotection).

    23. Thompson DC, Rivara FP, Thompson RS. Effectiveness ofbicycle helmets in preventing head injuries. A case-controlstudy. JAMA 1996;276:1968-1973.

    24. Zaza S, Sleet DA, Thompson RS, Sosin DM, Bolen JC;Task Force on Community Preventive Services. Reviews ofevidence regarding interventions to increase use of childsafety seats. Am J Prev Med 2001;21 (4 Suppl):31-47.

    Pediatr Mar-Apr 07 28-03-07 17:23 92

  • :

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    Safer play for children in playgrounds: barriers and prospectsP. Grigoriou, A. Terzidis, E. Petridou

    Abstract: Among childhood injuries, those occurring in playgrounds have been recognized as a majorproblem. Each year in the United States, emergency departments treat more than 200,000 childrenaged 14 years and younger for playground-related injuries. Children aged 5 to 9 years have higherrates of emergency department visits for this reason than any other age group. Although common,most playground injuries are not serious enough to cause permanent disability or death. Fatalities areusually the result of asphyxiation secondary to strangulation. Swing accidents have been studiedthrough the European Home and Leisure Accident Surveillance System, and it was concluded that70,000 people are treated every year in emergency departments for swing-related injuries in the Euro-pean Union. While playground-related injuries represent a substantial proportion of childhood injuriesin most developed countries, prevention has always been a sensitive issue, as on the one hand, chil-dren must be allowed to test their skills, while on the other this process should take place in a safe en-vironment. Standards are an essential tool for the prevention of playground injuries. The absence of ap-propriate legislation, inadequate maintenance of facilities, the lack of involvement of medical person-nel, child psychologists, teachers and parents and the huge costs of safety measures complicate the im-plementation and enforcement of standards. Further epidemiological studies focusing on exposure da-ta and the evaluation of prevention strategies will contribute substantially to safer play in playgrounds.

    Key words: Playground injuries, playgrounds standards.

    93 REVIEW ARTICLE

    E ,

    A: [email protected] . 75, .. 11527

    Laboratory of Hygiene andEpidemiology, MedicalSchool, University of Athens

    Correspondence:Eleni [email protected] of Hygiene andEpidemiology Medical School, Universityof Athens 75, Mikras Asias St., 11527, Athens

    2007;70:93-96

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    2. Krohe JR. Beyond playgrounds. The best advice you can givea kid may be: Go play in the street. Illinois Issues 1996;19-26.http://www.lib.niu.edu/ipo/1996/ii960619.html

    3. MacKay M. Playground injuries: recent attempts to beginto address what we dont know. Inj Prev 2003;9:194-196.

    4. Tinsworth D, McDonald J. Special study: Injuries anddeaths associated with childrens playground equipment.United States Consumer Product Safety Commission.Washington (DC), USA; 2001. Webpage: http://www.cp-sc.gov/library/playgrnd.pdf

    5. Phelan KJ, Khoury J, Kalkwarf HJ, Lanphear BP. Trendsand patterns of playground injuries in United States chil-dren and adolescents. Ambul Pediatr 2001;1:227-233.

    6. Preventing playground injuries. Injury Prevention Commit-tee, Canadian Paediatric Society; Paediatrics & Child Health2002;7(4): 255-256. Website: http://www.cps.ca/english/statements/IP/IP02-01.htm

    7. Mulder S, Barrow M, Bay-Neilsen H, Duval C. Swing ac-cidents within the European region. Int J Consumer Safe-ty 1995;2:175-189.

    8. Sibert J, Stone D. Injury prevention in the UK - the Euro-pean dimension. Inj Prev 1998;4 (Suppl): S34-S41.

    9. Petridou E, Sibert J, Dedoukou X, Skalkidis I, Trichopou-los D. Injuries in public and private playgrounds: the rela-tive contribution of structural, equipment and human fac-tors. Acta Paediatr 2002;91:691-697.

    10. Dessypris N, Petridou E, Skalkidis Y, Moustaki M, Kout-selinis A, Trichopoulos D. Countrywide estimation of theburden of injuries in Greece: a limited resources approach.J Cancer Epidemiol Prev 2002;7:123-129.

    11. Norton C, Nixon J, Sibert JR. Playground injuries to chil-dren. Arch Dis Child 2004;89:103-108.

    12. Ball D. Playgrounds: risks, benefits and choices. Contractresearch report. No 426/2002. Health and Safety Execu-tive, UK; 2002.

    Pediatr Mar-Apr 07 28-03-07 17:23 96

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  • 98 . .

    Paediatriki 2007;70:97-106

    central obesity were strongly related to other atherogenic risk factors, namely dyslipidemia. Health andnutrition education addressed to parents, teachers and children should become an urgent national pri-ority.

    Key words: Preschool age, atherogenic risk factors, hypertension, obesity, body mass index, waistcircumference.

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    , , - TCHOL, LDL-C,TCHOL/HDL-C (p>0,05), - TG (p0,05).

    3 .

    7,4% 7,9% (p>0,05). 16,6% 19,5% (p>0,05), 10,8% 9,0% (p>0,05)., 1,3% - GLU .

    4 . - 5,1% 6,9% , (- ) 2,7% (p=0,026).

    5 GLU .

    GLU

    1. 12

    ()

    ()

    TCHOL (mg/dl) 5,1-6,0 169,328,5 (237) 173,230,2 (244) 171,328,4 (481)6,1-7,0 168,325,5 (64) 175,531,5 (48) 171,428,3 (112)

    LDL-C (mg/dl) 5,1-6,0 102,125,8 105,026,6 103,626,26,1-7,0 100,421,4 105,327,5 102,524,2

    HDL-C (mg/dl) 5,1-6,0 57,311,4 57,011,6 57,111,56,1-7,0 57,511,0 59,010,8 58,210,9

    TG (mg/dl) 5,1-6,0 50,418,8* 56,121,9 53,220,66,1-7,0 51,723,8 55,523,1 53,323,4

    TCHOL/HDL-C 5,1-6,0 3,040,65 3,130,73 3,090,696,1-7,0 3,000,56 3,050,70 3,020,62

    GLU (mg/dl) 5,1-6,0 82,18,5** 78,77,9 80,48,46,1-7,0 80,97,5* 78,17,5 79,77,6

    Student t test ( ) * p

  • (p
  • 90 , 3,43 (95% : 1,28-9,17,p=0,014) . 30kg/m2, 2,87 (95% :1,05-7,85, p=0,041) .

    77% 67

    . -

    . 15% 7,7%, - 603 - GLU (>100 mg/dl) 12 . 6% - , 1,4% (8 ) - ( ).

    - , , - - .

    - , . , - 3-17 , , - . , 2,7% 3,7% (19). , - - 4% 5% (20).

    5.

    (mmHg) (mmHg) (kg) (cm) (cm) (kg/m2)

    r (N)*

    GLU 0,162 (299)** 0,050 (299) 0,257 (298)** 0,160 (298)** 0,272 (298)** 0,249 (298)** 0,124 (298)** 0,219 (298)**

    (mg/dl) 0,136 (279)** 0,075 (279) 0,236 (278)** 0,143 (278)** 0,245 (278)** 0,234 (278)** 0,162 (278)** 0,211 (278)**

    TCHOL -0,086 (299) -0,124 (299)** -0,098 (298) -0,097 (298) 0,128 (298)** -0,061 (298) -0,143 (298)** -0,080 (298)(mg/dl) 0,059 (279) 0,057 (279) -0,029 (278) -0,055 (278) -0,055 (278) -0,003 (278) -0,075 (278) -0,016 (278)

    TG 0,130 (298) 0,062 (298) 0,038 (297) 0,060 (297) 0,054 (297) 0,017 (297) 0,129 (297)** 0,066 (297)(mg/dl) 0,040 (278) 0,004 (278) 0,082 (277) -0,081 (277) 0,162 (277)** 0,161 (277)** 0,180 (277)** 0,277 (277)**

    HDL-C -0,096 (299) -0,072 (299) -0,015 (298) -0,065 (298) -0,032 (298) 0,040 (298) -0,121 (298) 0,002 (298)(mg/dl) 0,026 (279) 0,021 (279) -0,090 (278) -0,012 (278) -0,134 (278)** -0,117 (278) -0,172 (278)** -0,139 (278)**

    LDL-C -0,054 (298) -0,090 (298) -0,091 (297) -0,074 (297) -0,126 (297)** -0,076 (297) -0,140 (297)** -0,099 (297)(mg/dl) 0,047 (278) 0,075 (278) 0,011 (277) -0,028 (278) -0,024 (277) 0,032 (277) -0,054 (277) 0,002 (277)

    TCHOL/ 0,013 (299) -0,022 (299) -0,044 (298) 0,004 (298) -0,055 (298) -0,075 (298) -0,012 (298) -0,058 (298)HDL-C 0,031 (279) 0,054 (279) 0,059 (278) -0,028 (278) 0,075 (278) 0,097 (278) 0,091 (278) 0,102 (278)

    * r= Spearman (N= ) ** p-value 95 (-) >95 ( -) 3. : >90 4. : 100 mg/dl 5. HDL :

  • ,

    -

    .

    -

    1982 20%, -

    9-16

    (21). , -

    2002 -

    (40%),

    4,2% 12,7%. , -

    5,5-7

    (One sample Student test: 23 24,4 kg,

    103

    6.

    (mmHg) (mmHg) (kg) (cm) (cm) (kg/m2)

    GLU 50 * 295 94,40,5** 60,90,5 22,40,2** 117,10,3** 54,80,4 16,20,1 0,890,01 0,470,01(mg/dl) 50-90 233 96,30,6 61,80,5 24,20,3 118,40,3 57,60,4 17,20,1 0,900,01 0,490,01

    >90 50 98,71,3 63,21,1 24,10,6 119,50,7 56,40,9 16,80,3 0,880,01 0,470,01TCHOL 170 306 95,70,5 61,50,5 23,60,2 118,30,3 56,70,4 16,80,1 0,900,01** 0,480,01(mg/dl) 171-200 192 95,70,6 61,90,6 22,90,3 117,40,4 55,40,5 16,50,2 0,880,01 0,470,01

    >200 80 94,51,0 60,30,9 23,00,5 117,20,6 55,40,7 16,70,3 0,870,01 0,470,01TG 80 530 95,40,4 61,40,3 23,20,2 117,90,2 55,90,3** 16,60,1** 0,890,01 0,470,01**

    (mg/dl) 81-100 24 98,31,8 62,31,6 24,00,9 117,21,0 57,51,3 17,30,5 0,900,02 0,490,01>100 22 96,71,9 62,31,7 25,50,9 118,71,1 59,71,4 17,90,5 0,910,02 0,500,01

    HDL-C 130 77 94,41,0 59,60,9 22,50,5 116,30,6 54,90,7 16,40,3 0,880,01 0,470,01

    * (50 : 82 / 79, 90 : 91 / 88) ** p-value 0,05 ( ANCOVA: .

    Levene)

    7. (Odds ratio) , -

    (mm Hg) (mm Hg) (cm) (kg/m2)

    >95 * >95 >90 25-30 >30

    Odds ratio [95%] () p-value

    GLU >90 0,65 [0,18-2,27] 0,29 [0,11-0,76] 0,54 [0,16-1,79] 1,70 [0,82-3,54] 1,38 [0,58-3,27](mg/dl) (578) (578) (576) (507) (485)

    TCHOL >200 0,49 [0,11-2,12] 2,00 [0,46-8,67] 0,53 [0,21-1,38] 1,17 [0,63-2,19] 0,68 [0,29-1,56](mg/dl) (578) (578) (576) (507) (485)

    TG >100 0,80 [0,10-6,28] 0,89 [0,11-6,91] 3,43 [1,28-9,17] 1,00 [0,28-3,60] 2,87 [1,05-7,85](mg/dl) (576) (576) (574) 0,014 (505) (483) 0,041

    HDL-C 130 0,43 [0,13-1,47] 1,44 [0,60-3,42] 0,70 [0,29-1,69] 0,81 [0,41-1,62] 0,56 [0,23-1,34](mg/dl) (576) (576) (574) (507) (484)

    # : * : ( )

    2007;70:97-106

    Pediatr Mar-Apr 07 28-03-07 17:23 103

  • p>0,05, ) - 1992-1993 (16,22). , - - 1992-1993 (16,7 16,3 kg/m2 ,p
  • - - . - (16,22,26,27), . - , , - ( ), - (28). , - , - (15% ) , - (5,28).

    , -, , , - -.

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    Friesland. , , - : - . , . - . , - . .. , , - . , , -, ,

    & O - . . , . - /.

    * : , -

    , , , , . : . : -, , -Brie, , , , -, , , , . - : . : - . : - , . : , , .

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