the sole ethnic Asian patient. The only moderately deficientpatient was 17 years old, GMFCS level V and an anticonvul-sant user. Comparison of mean vitamin D levels in variousgroups was made by two-tailed unpaired t-testing. Those inthe GMFCS I–III group had a higher mean vitamin D levelthan those in the GMFCS IV–V group; however, the differencewas not significant (P = 0.181). Anticonvulsant users (n = 7)had a lower mean vitamin D level than non-anticonvulsantusers (n = 31); however, the difference again was not signifi-cant (P = 0.287). Patients who had recently travelled to lowerlatitude (n = 4) had a mean vitamin D level, which washigher than the other 34 patients who had not travelled;however, the difference was not significant (P = 0.0726). Thoseaged less than 4 years (n = 10) had a significantly highervitamin D level than the 28 patients aged 4 years or older(P = 0.0492).

Thus our study documents another group of children with asubstantial proportion of vitamin D deficiency, as has been seenpreviously in Victoria.4 Higher GMFCS level did not emerge as aclear independent risk factor for hypovitaminosis D in our study.Patients younger than 4 years with CP appear to be at increasedrisk of hypovitaminosis D compared with older patients withCP. To date there is no well-designed study that explores therelationship between level of physical disability and vitamin Dstatus using a reliable tool such as the GMFCS in a larger cohort.Such a study would ideally control the confounding variables ofseasonal variation, range of latitude and skin tone, as was thecase with our study.

Acknowledgements

The authors would like to thank the patients who were involvedin the study and their families; Paediatric Ambulatory Care UnitStaff, Royal Hobart Hospital; and Lesley Willis for secretarialsupport.

Dr Tyson Ware1,2,3

Dr Charlotte Whitelaw2,3

A/Professor Peter Flett2,3

Dr Venkat Parameswaran2

1Children’s Neuroscience CentreRoyal Children’s Hospital

Melbourne, Victoria2Royal Hobart Hospital

3Calvary Rehabilitation Service (now St Giles Southern Services)Hobart, Tasmania

Australia

References

1 Hewison M. Vitamin D and the immune system: new perspectiveson an old theme. Endocrinol. Metab. Clin. North Am. 2010; 39:365–79.

2 Palisano RJ, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B.Development and reliability of a system to classify gross motorfunction in children with cerebral palsy. Dev. Med. Child Neurol. 1997;39: 214–23.

3 Munns C, Zacharin MR, Rodda CP et al. Prevention and treatmentof infant and childhood vitamin D deficiency in Australia and NewZealand: a consensus statement. Med. J. Aust. 2006; 185:268–72.

4 Greenway A, Zacharin M. Vitamin D status of chronically ill ordisabled children in Victoria. J. Paediatr. Child Health 2003; 39:543–7.

Dear Editor,

PAEDIATRIC GROWTH CHARTS: HOW DO WE USE THEM AND CANWE USE THEM BETTER?

Measurement of growth parameters is a key aspect of paediatriccare.1 The admission of infants or children to a paediatric serviceprovides an opportunity for the measurement of growth param-eters. These measurements should then be reviewed and plottedcorrectly on standard growth charts,2 with intervention asindicated.

We previously conducted a retrospective review of 103 con-secutive admissions in our centre in November 2009 and eluci-dated the completeness of growth measurements and recordingsin these children.3 Although almost all the children had meas-urement of their weight at admission, few had height and nonehad head circumference measured. In addition, growth chartswere present and completed in a minority of the hospitalrecords. Overall, this work demonstrated that opportunitieswere being missed to assess auxological parameters in childrenpresenting to hospital acutely.

Following the presentation of these outcomes to the depart-ment, new guidelines for the assessment of growth parametersat admission were instituted. These included a renewed empha-sis on the importance of growth assessment, educational activi-ties, reminders to measure and record growth and arrangementsfor a standardised location for the growth chart in paediatricmedical notes.

We have recently undertaken a further audit in November2011. The notes of 100 consecutive admissions were reviewed,and the frequency of growth parameter documentation wasassessed, following the previously described methodology.3

Weight was documented in 100% of the hospital notes of thisgroup of children, whereas height was documented in 32%.Head circumference was documented in just 25% of the subsetof children aged less than 2 years. Standard growth charts werepresent in the notes of 40% of children, and in 23% of cases themeasured growth parameters were plotted on these charts, withno inappropriate plotting evident. Interestingly in 13% of caseseither height, weight or both fell below the 3rd centile or above97th centile for age. An appropriate management and follow-upplan was documented in the medical records of each of thesechildren.

These data demonstrate a moderate but encouragingimprovement in the assessment and recording of growth inchildren presenting to this paediatric service. This change inpractice was brought about by presentation of the issue tothe department and highlighting the importance of growth

Conflict of interest: None declared.

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Letters to the Editor

Journal of Paediatrics and Child Health 49 (2013) E348–E354© 2013 The Authors

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assessment, prompting a change in guidelines for admittingdoctors and nurses. Completion of an audit cycle along withongoing educational activities will be important to furtherenhance the assessment of growth in children seen acutely inthis centre. We remind practitioners of the importance of thesecore elements of paediatric practice.

Dr Andrew Dodgshun1,2

Professor Andrew S Day1,2

1Department of PaediatricsChristchurch Hospital

2Department of PaediatricsUniversity of Otago (Christchurch)

Christchurch, New Zealand

References

1 Well Child Tamariki Ora. Chapter 2 Clinical Assessment; Growth. NewZealand Ministry of Health. 2002.

2 Cooney K, Pathak U, Watson A. Infant growth charts. Arch. Dis. Child.1994; 71: 159–60.

3 Ramsden L, Day AS. Growth Charts: how do we use them and can weuse them better? J. Paediatr. Child Health 2012; 48: 22–5.

28 May 2012

Dear Editor,

ENVIRONMENTAL CHANGE AS AN EFFECTIVE TREATMENT OFSEVERE CHILDHOOD OBESITY

Severe childhood obesity has become a serious health-careproblem worldwide. When parental behaviours not only lead toobesity developing but subsequently interfere with its recogni-tion and treatment, the label of ‘psychosocial obesity of earlychildhood’ has previously been adopted,1 with a recent com-mentary calling for increased levels of state intervention to helpthese children.2

Anecdotal reports indicate removal from the familialobesogenic environment can successfully reduce the body massindex (BMI) of an obese child,3 and because of the associatedethical dilemmas, it is unlikely that evidence will ever be gath-ered in any way other than via case reports.

Within the last 5 years, two children have presented to ourhospital with severe obesity of seemingly psychosocial origin(BMI > 99.6th centile, Z scores 4.5). In both cases, considerableconcerns were raised by multiple professionals over the mala-daptive family relationships and refusal to engage with any

services despite intensive multidisciplinary medical, dietetic,psychological and social care input. Escalation of interventionsincluded in-hospital observation and in-house parentingsupport, but as both children continued to gain weight, courtaction was taken and they were placed into foster care. Bothchildren demonstrated rapid and sustained weight loss once intheir new environments (Fig. 1) supporting both the lack oforganic pathology and the argument for a more robust approachto select cases of severe childhood obesity, especially in earlychildhood, including considering the role of neglect1,3 and theuse of substitute parenting.

However, deciding when to take such action remains anextremely difficult decision. When multiple social issues inter-play, it becomes increasingly complicated to separate the con-tribution and significance of each one to the subsequentdevelopment of obesity. A framework suggesting when child-hood obesity becomes a child protection matter3 centres aroundthe consistent failure of the family to engage or change behav-iours, while another group4 advocates the fulfilment of specificcriteria before considering child removal, including a highlikelihood of serious imminent harm with co-morbiditiesalready present, a reasonable chance of effective intervention ifremoved and the lack of alternative options.

Despite an ethical and legal obligation to protect the child,most countries have no specific legal framework or profes-sional intervention criteria for the growing problem of severechildhood obesity. Therefore, decisions need to be based onindividualised multidisciplinary case-based discussions carefullyweighing the health risks and emotional trauma of a neglectfulsituation against the psychological trauma of removing the childfrom their familial environment.

Dr Lucinda C Winckworth1

Dr Michael CorenSt Mary’s Hospital, Imperial College Healthcare NHS Trust

LondonUnited Kingdom

References

1 Christoffel KK, Forsyth BW. Mirror image of environmental deprivation:severe childhood obesity of psychosocial origin. Child Abuse Negl.1989; 13: 249–56.

2 Murtagh L, Ludwig DS. State intervention in life-threatening childhoodobesity. JAMA 2011; 306: 206–7.

3 Viner RM, Roche E, Maguire SA, Nicholls DE. Childhood protection andobesity: framework for practice. BMJ 2010; 341: c3074.

4 Varness T, Allen DB, Carrel AL, Fost N. Childhood obesity and medicalneglect. Pediatrics 2009; 123: 399–406.

1Present address: Chelsea & Westminster Hospital, London, UK.Conflict of interest: None declared.

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Letters to the Editor

Journal of Paediatrics and Child Health 49 (2013) E348–E354© 2013 The AuthorsJournal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

E351