Cow's Milk Intolerance Research Articles

Exploring the links between necrotizing enterocolitis and cow's milk protein allergy in preterm infants: a narrative review.

A broad range of allergic disorders and intolerance are associated with cow's milk protein in the infant diet. Allergy and intolerance to cow's milk proteins are commonly recognized in the healthy term infant, and the prevalence cow's milk protein intolerance (CMPI) varies widely but 5 challenge confirmed studies free from selection bias ranged from 1.9%-4.9%. These disorders are classified by the presence of IgE, non-IgE or T-cell-mediated signaling. Additionally, the severity of these adverse food reactions can range from mild gastrointestinal symptoms to severe sepsis-like episodes, as in the case of food protein-induced enterocolitis syndrome (FPIES). Food protein-induced intolerance in the healthy young infant lies in stark contrast to enterocolitis that typically occurs in the preterm neonate. Necrotizing enterocolitis (NEC) is a distinct progressive disease process, usually characterized by a high mortality rate, with a risk of death from 30% to 50%. While its exact etiology is unclear, its main triggers include formula (cow's milk protein), hypoxia, perfusion-related issues, and unregulated inflammation in the premature intestine. The distinction between NEC and cow's milk protein intolerance is difficult to discern in some cases. In the late preterm population, infants with colitis can have both NEC and cow's milk intolerance on the differential. In infants with multiple episodes of mild NEC, cow's milk protein intolerance may be the underlying diagnosis. In this review, we compare the pathophysiological characteristics, diagnosis and treatment of disorders of cow's milk protein intolerance with the entity of preterm NEC. This review highlights similarities in both entities and may inspire future cross-disciplinary research.

Effect of Cow's-milk-free diet on chronic constipation in children; A randomized clinical trial.

Background:Cow’s milk intolerance can lead to chronic constipation in children. The present study seeks to determine the effect of cow’s milk-free diet (CMFD) on chronic constipation in children who are not responding to laxatives.Methods:Seventy children suffering from chronic constipation (described as the Rome III criteria) were enrolled in an open-label randomized clinical study. Each group included 35 children aged 4-14 years treated with laxatives for at least three months with no improvements. The intervention group received CMFD plus calcium supplements for four weeks and the control group did not have any restrictions in consuming cow’s milk and dairy products. Also, both groups received polyethylene glycol (PEG; 1 gr/kg/day) and high-fiber foods (at least 10 gr/day) for four weeks. Responsiveness was described as a reduction in symptoms and signs according to the Rome III criteria after four weeks.Results:After four weeks, 25 (71.4%) children in the CMFD group responded to the treatment compared to four (11.4%) children in the control group (P<0.001). Significant differences were found between the CMFD and control groups in terms of the seven Rome III criteria post-intervention; history of large stools (25% vs. 53.6%), large fecal mass in the rectum during examination (17.1% vs. 50%), history of painful defecation (18.2% vs. 55.6%), history of retentive posturing (10% vs. 46%), ≥1 episode/week of incontinence (25 % vs. 50%, P=0.001), ≤ 2 defecations/week (17.4% vs. 52.3%) and history of thick stool with toilet obstruction (22.2% vs. 52.3%)Conclusion:This study showed that children with functional constipation with no response to laxatives could benefit from a cow’s milk-free and dairy-free diet.

Expanding the phenotype of thrombocytopenia absent radius syndrome with hypospadias

Rare genetic diseases and syndromes may appear with unique features in some patients. In genetically-solved cases, this situation indicates a phenotypic expansion of the syndrome with additional features (i.e. the disease-associated gene gives rise to unusual clinical presentation). However, this situation can also hide a multilocus pathogenic variation that cannot be solved genetically except by a massive sequencing approach, such as exome sequencing. Here we describe the case of a child with bilateral radial aplasia, transient thrombocytopenia and anemia, cow's milk intolerance, hypospadias, facial dysmorphism, mild hypothyroidism and umbilical and inguinal hernia.Bilaterally absent radius, presence of thumbs and low platelet count are pathognomonic of thrombocytopenia absent radius (TAR) syndrome, but the child also showed other features beyond those reported in the literature. Since various diseases resembling the proband’s phenotype required differential diagnosis, clinical exome sequencing was performed. The results showed compound heterozygous mutations in the RBM8A gene, confirming the suspicion of TAR syndrome. A truncating heterozygous variant in the DUOX2 gene, known to be associated with transient thyroid dyshormonogenesis type 6 (TDH6), was also detected and may explain the proband's mild hypothyroidism.

Cow's milk exclusion in young children: Parents motives, sources of information and perception of their child's eating behaviours

AbstractResearch has assessed the diets of young children that follow a diet that excludes cow's milk. However, there is insufficient information about why parents decide to exclude cow's milk, where they obtain nutritional information, and their child's eating behaviours. This is important as the prevalence of cow's milk allergy is increasingly common in children, alongside a growing preference for plant-based diets. The purpose of this research was firstly to explore why parents exclude cow's milk from their child's diets and if this is due to recommendations from a health care professional. Secondly, to understand where parents source information to enable them to provide a healthy diet for their child. Finally, to explore parent's opinions of their child's eating behaviours.Thirty parents of children aged 1–3 years who exclude cow's milk and 20 parents of children who did not follow a restricted diet completed an online questionnaire. The questionnaire comprised of three blocks of questions. The first asked about the parents, the second pertained to the child. If they excluded cow's milk they were asked why they made this decision and who advised them. Parents were also asked where they source nutrition information for their child. The final block of questions consisted of the Child Eating Behaviour Questionnaire.Parents reported excluding cow's milk due to cow's milk allergy (60%), lactose or milk intolerance (10%), suspected allergy or intolerance (27%) or personal choice (3%). When asked “Who advised you to remove cow's milk from your child's diet?” the majority responded that it was their own decision (35%), followed by GP advice (24%). The most common sources of nutrition information for parents of children that exclude cow's milk came from parenting webpages (21%), and social media (19%), whilst those on an unrestricted diet obtained information from health visitors (24%) and parenting webpages (19%). There were no differences in eating behaviours between children that excluded cow's milk and children that did not except for satiety responsiveness (p = 0.014), which was greater in the cow's milk exclusion group.This preliminary data indicates that many parents exclude cow's milk from their child's diets based on their own advice. Where parents of children on an unrestricted diet sourced nutrition information from their health visitor, few parents of children who exclude cow's milk used this source of support (7%).

Preoperative liquid gastric emptying rate does not predict outcome after fundoplication

Aim of the studyPreoperative gastric emptying (GE) rate in patients with gastrointestinal reflux disease (GERD) was evaluated as a predictor of outcome after antireflux surgery. Methods and patientsGE was assessed using radionuclide scintigraphy and a standardized meal with cow's milk. GE half time (T1/2), patient demographics and GERD symptoms including vomiting (>4days/week), retching (>4days/week), prolonged feeding time (>3h/day), and discomfort after meals were recorded pre- and postoperatively. A standardized follow-up included a 24-h pH-monitoring and an upper gastrointestinal contrast study. Of 74 patients undergoing Nissen fundoplication between 2003 and 2009, 35 underwent a preoperative GE study. The remaining 39 patients were not examined owing to volume intolerance, cow's milk intolerance or allergy, inability to lie still, or parents refusing participation. Main resultsMedian age at fundoplication was 4.9 [range 1.1–15.4] years, and follow-up time was median 4.3 [1.9–8.9] years. GERD recurred in 7 (20%) patients. Preoperative T1/2 in the seven patients with recurrent GERD was median 45 [21–87] min compared to 44 [16–121] min in the 28 patients without recurrent GERD (p=0.92). There was no significant difference between the one third of patients with the slowest GE [T1/2 54–121min] and the remaining patients [T1/2 16–49min] regarding GERD recurrence or postoperative vomiting, retching, prolonged feeding time, or discomfort after meals. ConclusionPreoperative GE rate did not predict outcome after antireflux surgery, as slow GE was not associated with recurrent GERD or postoperative troublesome symptoms such as vomiting, retching, or meal discomfort.

Fifteen-minute consultation on the healthy child: breast feeding

Despite extensive evidence about the benefits of breast feeding for both infants and mothers, breastfeeding rates in the UK remain low. Most infants presenting with feeding issues are otherwise well...

Association of childhood attention-deficit/hyperactivity disorder with atopic diseases and skin infections? A matched case-control study using the General Practice Research Database

BackgroundData to support the hypothesis of a relationship between attention-deficit/hyperactivity disorder (ADHD) and allergies are conflicting. ObjectiveTo assess whether children with ADHD are more likely to have a history of atopic disorders, skin infections, and medical prescriptions than children without ADHD. MethodsWe conducted a nested case-control study among boys using the UK General Practice Research Database (GPRD). Cases were defined as children with first-time diagnosis of ADHD who were treated with methylphenidate. Four controls who had neither ADHD nor ADHD drug prescriptions in their medical records were matched to each case on age and general practice. ResultsWe identified 884 boys with a first-time diagnosis of drug-treated ADHD and 3,536 controls. The independent odds ratios adjusted for age and presence of low birth weight or preterm delivery were 1.4 (95% confidence interval [CI], 1.2-1.7; P < .001) for a medical history of asthma, 1.5 (95% CI, 1.3-1.9; P < .001) for impetigo, and 1.5 (95% CI, 1.3-1.7; P < .001) for any antihistamine drug prescriptions. Other exposures that were more common in cases than controls, though not independently, were cow's milk intolerance and any prescription from the drug categories antiasthmatics, respiratory corticosteroids, topical steroids, antibacterials, or antifungals. ConclusionDespite possible limitations inherent to observational studies, this study lends support to the emerging evidence that childhood ADHD is associated with atopic diseases and impetigo. Further interdisciplinary research is needed to understand the underlying mechanisms and to evaluate targeted preventive, diagnostic, and therapeutic interventions.

Herpes simplex primo‐infection in an immunocompetent host with eosinophilic esophagitis

Eosinophilic esophagitis and herpes simplex esophagitis are separately well-described entities, but their simultaneous occurrence may pose a special challenge to the clinician, especially regarding the optimal therapeutic approach. The following case report describes a patient with a history of cow's milk and dairy products intolerance, but without an underlying immunologic defect, in whom eosinophilic esophagitis was diagnosed in the course of primary herpes simplex virus 1 (HSV1) infection that clinically presented as herpes labialis and severe esophagitis. The diagnosis was confirmed by a polymerase chain reaction from cytological brush and by immunohistochemical staining that detected the presence of HSV1 DNA in esophageal mucosa, and histologically by persistent eosinophil-predominant inflammation, typical of eosinophilic esophagitis. Despite severe clinical presentation, the HSV1 infection was self-limited. After a directed elimination diet was introduced, the clinical course was favorable, without the need for antiviral therapy.

Five Years Experience of Clostridium difficile Infection in Children at a UK Tertiary Hospital: Proposed Criteria for Diagnosis and Management

Background Clostridium difficile infection (CDI) is associated with significant morbidity and mortality in adults. There is increasing evidence of the pathogenic role of C. difficile in the paediatric population. We sought to ascertain the clinical presentation and severity of CDI in children at our institution and develop criteria to aid management.MethodsClinical data was retrospectively collected from all children (0–16 yrs) with a positive C. difficile toxin result over a 5-year period. National adult guidelines were used to assess the severity and management of CDI.ResultsSeventy-five patients were included with a mean age of 2.97 years. Forty-nine were hospital onset, 22 community onset and 4 healthcare-associated. The most common co-morbidity among the hospital onset infections was malignancy. Gastrointestinal conditions were most common among community onset infections. Fifty-five cases (73.3%) had received antibiotics in the preceding month, 7 (9.3%) had cow’s milk intolerance and 9 (12%) had co-infection with another gut pathogen. According to national adult guidelines 57 cases (76%) were categorised as severe. Thirty cases received oral metronidazole, two patients required intensive care and one patient had a sub-total colectomy for pseudomembranous colitis. No mortality was observed.DiscussionWe confirm the association of paediatric CDI with co-morbidities such as haematological and solid organ malignancies, recent antibiotic use and hospitalisation. We observed an association between cows milk protein intolerance and C. difficile. The use of adult criteria overestimated severity of disease in this cohort, as most cases experienced a mild course of illness with low morbidity and no mortality. This indicates that adult scoring criteria are not useful in guiding management and we propose specific criteria for children.

A case of galactosemia misdiagnosed as cow’s milk intolerance

We report on a female patient affected by galactosemia in whom the diagnosis was obscured by the concomitant presence of manifestations suggesting a cow’s milk intolerance. This case exemplifies the problems in reaching a correct diagnosis in patients with metabolic diseases.

Aceitação sensorial e caracterização de frozen yogurt de leite de cabra com adição de cultura probiótica e prebiótico

O leite de cabra é recomendado para pessoas intolerantes ao leite de vaca e/ou portadoras de desordens gastrintestinais. frozen yogurt elaborado a partir de iogurte de leite de cabra foi acrescido de 1% de prebiótico (inulina), 0,25% de cultura starter (Streptococcus thermophilus e Lactobacillus bulgaricus) e 0,25% de cultura probiótica (Bifidobacterium animalis e Lactobacillus acidophilus) para verificar seu potencial probiótico (após sete e 120 dias de armazenamento), sua qualidade físico-química e sua aceitação sensorial. Durante a estocagem, houve redução de células viáveis da flora microbiana, principalmente dos probióticos. Ainda assim, o produto apresenta potencialidade probiótica pela soma de B. animalis e L. acidophilus atingir o mínimo desejável até o fim do armazenamento. Os valores de extrato seco total (26,6±0,2%), proteína (3,0±0,2), gordura (2,6±0,1%), pH (5,5±0,01) e ácido láctico (0,2±0,01%) encontram-se semelhantes aos relatados em outros trabalhos para o mesmo produto. A avaliação sensorial foi realizada por 50 provadores não treinados em teste com escala hedônica de sete níveis e intenção de compra. O produto recebeu bons escores para aparência global, cor, aroma e sabor; já textura e sabor residual obtiveram menores índices de aceitação. Na intenção de compra, 61% dos avaliadores declararam que comprariam o produto, contra 39% que não comprariam. Nessas condições, demonstra-se a viabilidade de elaboração de frozen yogurt de leite caprino acrescido de pre- e probióticos.

A new formula based on almond milk for management of cow milk intolerance and food allergies

Background. Food allergies in Western countries are notably growing, for a different stimulation on immunologic system different from the past and from the developing countries.

Évaluation d'une nouvelle technique de dosage des immunoglobulines spécifiques E des protéines du lait de vache

Topics Diagnosis of cow's milk intolerance (CMI) is founded upon assay of specific IgE against cow's milk proteins whose ImmunoCap technic from pharmacia diagnostics (Phadia) allows to quantify from 0.1 KUA/l. We retrospectively studied the advantages of this extent of the scale of concentrations with regard to that traditionally scale restricted at 0.35 kUA/l and we verified the forecasted threshold of 0.1 kUA/l. Material and methods We selected 68 serums from 63 children, 32 with CMI confirmed, 12 with probable CMI and 19 controls. Anti alpha lactalbumin, beta lactoglobulin and casein IgE had been measured for every sample on UniCap 100, with a couple of dosage protocols: the usual one which allowed to quantify IgE from 0.35 to 100 kUA/l and the new one with a scale of calibration fit for quantify from 0.1 kUA/l. Results The threshold of this new protocol had been determined on 0.1 kUA/l for the three allergens. The two protocols were well correlated. For 21 among 68 samples (31%), the new calibration permitted to calculate concentrations with specific IgE but it was obtained < 0.35 KUA/l with the old one. These samples correspond with 10 confirmed CMI, 3 probable CMI, 7 controls, among which 5 isolated gastro oesophageal reflux GER. Conclusion Results of this study showed us that the new IgE dosage protocol can be a rearlier diagnosis tool of a cow's milk sensitization. Prospective study is needed to confirm. We asked about possible link between sensitization and GER.

Autistic enterocolitis: is it a histopathological entity?—reply

A series of studies in children with pervasive developmental disorder and gastrointestinal symptoms has reported the presence of a subtle mucosal inflammation, immunohistochemical abnormalities of structure and cellular infiltrate, pro‐inflammatory lymphocyte cytokine profiles, and functional intestinal abnormalities. MacDonald and Domizio question the existence of the mucosal lesion. In contrast, independent replication of the original findings has come from Europe, and North and South America; the data are presented. The willingness of the authors to attribute any mucosal changes to chronic constipation relies heavily on what appears to be a misinterpretation of data that is confounded by the association between cow's milk intolerance and constipation in children. A re‐challenge effect on intestinal symptoms and a biological gradient of mucosal inflammation is evident for an alternative environmental exposure in some children. Application of the research tools and methods that have been developed to examine the pathogenesis of inflammatory bowel disease should be applied to the investigation of affected children in order to further advance our understanding and treatment of this lesion.

Chiropractic Management of Cow's Milk Protein Intolerance in Infants With Sleep Dysfunction Syndrome: A Therapeutic Trial

Objective In addition to the more usual cutaneous, gastrointestinal, and respiratory problems, infants with cow's milk intolerance (CMI) may present with a disturbed sleep pattern. Frustrated mothers may turn to their doctor of chiropractic for assistance. This pilot study shows how a therapeutic trial may offer a realistic, noninvasive approach to the chiropractic management of infants with this clinical problem. Methods A pilot study to describe the presentation and treatment of infants presenting with disturbed sleep patterns to a chiropractic clinic was undertaken. Infants fulfilling a clinical screening protocol for CMI were selected for a therapeutic trial. The sleep behavior of subjects was monitored over a 4-week period during which they were managed by dietary change and a high-impulse, low-amplitude whole-of-body chiropractic management protocol. Results Fifty-nine infants presented with disturbed sleep. Of these, 19 met the clinical criteria used to establish the diagnosis CMI. The mothers of breast-fed infants were counseled on how to implement a dairy-free diet, and those infants who were artificially fed were changed from cow's milk–based formulae to either a partially or wholly hydrolyzed formula. Fourteen achieved a stable sleep pattern within the study period. In 5 instances, the sleep pattern remained problematic, but other clinical evidence of hypersensitivity reactions attributable to CMI disappeared. By the end of the study, no subject had demonstrable evidence of either biomechanical derangement or functional neurologic imbalance. Conclusion CMI should be considered as a possibility in infants with disturbed sleep patterns who present for chiropractic care. This study describes how a therapeutic trial involving dietary modification, parental counseling, and comprehensive chiropractic care may offer a noninvasive approach to excluding and/or managing this condition. Further research is required before definitive recommendations can be made.

Iron deficiency in childhood and adolescence: Retrospective review

Two hundred and thirty-eight subjects of both sexes, age range 7.5 months–16 years, with iron deficiency (ID), were included in a retrospective review of ID causes, to determine the best treatment. Inadequate iron intake was the cause of ID or iron deficiency anemia (IDA) in 59 subjects from the first months of life to adolescence. Blood loss linked to cow's milk intolerance was the cause of ID or IDA in 37 younger children. Meckel's diverticulum (MD) (6 cases), reflux esophagitis (RE) (10 cases), some drugs such as acetyl salicylic acid (11 cases) induced bleeding with ID or IDA in children and adolescents. In pubertal females with ID or IDA, polymenorrhea was observed in 16 cases. Coelic disease (CD) (37 cases), Helicobacter pylori infection (HPI) (39 cases), association of HPI and CD (8 cases), enteromonas infection (15 cases), determining particularly malabsorption, were causes of ID or IDA in patients of a wide age range, unresponsive to iron therapy.Our findings show that iron replacement therapy was not always required and should not be prescribed until the diagnosis is certain.

Sommeil et nutrition chez le nourrisson et le jeune enfant

In infants, sleep/wake rhythms and the feeding pattern are closely related. Establishing stable night sleep depends on time givers. The decrease and later suppression of night feeds are part of the process. Breast fed infants keep waking up at night later than bottle fed peers, and they are fed more frequently during the nocturnal waking occasions. After the age of six months, night awaking is likely induced by environmental factors (sleep conditioning, night eating syndrome, sharing the parents’ bed, absence of limits) rather than by the composition of the mother's milk. Cow's milk intolerance as well as some dietary mistakes (low fat intake, excessive protein intake, low or high feed volumes) can induce true insomnias in infants.

Chronic constipation and food intolerance: A model of proctitis causing constipation

ObjectiveChronic constipation in children can be linked to cow's milk intolerance (CMI) but the existence of a food intolerance-dependent proctitis is still debated. The aim of this study was to evaluate the histologic data in patients with food intolerance-related constipation.Material and methodsFifty-two consecutive patients (22 M, median age 4 years) with chronic constipation unresponsive to common treatment were enrolled. All patients were put on a cow's milk-free diet for 4 weeks and those uncured on this diet underwent a subsequent 4-week period of oligoantigenic diet. In the patients cured on elimination diet, a subsequent double-blind food challenge was performed to confirm the diagnosis of food intolerance. At entry to the study, routine hemato-chemical and immunologic assays, rectoscopy, and histologic study of the rectal mucosa were performed. In the patients cured on elimination diet, rectal histology was repeated when they were cured.ResultsTwenty-four patients were found to be suffering from CMI and 6 from multiple food intolerance. These patients had a normal stool frequency on elimination diet, while constipation reappeared on food challenge. The condition of the remaining 22 patients did not improve on elimination diet. The patients with food intolerance showed a significantly higher frequency of erosions of the mucosa, number of intraepithelial lymphocytes and eosinophils, and number of eosinophils in the lamina propria. Study of the rectal mucus gel layer showed that the food-intolerant patients had a significantly lower thickness than the other subjects studied. In the food intolerant patients, histologic abnormalities disappeared on elimination diet, when the patients were well.ConclusionsFood intolerance-related constipation is characterized by proctitis with eosinophil infiltrate of the rectal mucosa. A reduced mucus gel layer can be considered a contributory factor in the pathogenesis of the constipation.

233 Faecal Calprotectin Levels At Two Months of Age in Healthy Infants and in Infants with Atopic and Gastrointestinal Disorders

Background: Recently the mielomonocytic calcium-binding protein calprotectin has been proposed as sensible marker in faeces for gastrointestinal inflammation, but there are only a few studies about this topic in infancy. The aim of the study was determining normal faecal calprotectin levels in healthy infants during the first 3 months of life and comparing differences between healthy infants and those with atopic diseases, gastroesophageal reflux or severe colic. Methods: Between September 2003 and January 2004 stools samples of 21 healthy infants (mean age 58±24 days) and 14 infants with atopic diseases (atopic dermatitis, cow's milk intolerance) and/or severe infantile colic and/or gastroesophageal reflux (mean age 59±19.1 days) diagnosed by clinical examination and laboratoristic analysis were collected at our Department. Exclusion criteria were infections and intake of anti-inflammatory drugs. Stool samples were stored at –20°C until they were analysed. Faecal calprotectin levels were detected using a quantitative ELISA (Calprest, Eurospital SpA, Trieste, Italy). The study protocol was approved by the hospital's ethic commette and parents gave written consent to inclusion of their infants in the study. Statistical analysis was performed using Student's t-test. A value of p<0.05 was used for statistical significance. Results: Calprotectin levels in healthy infants were significantly lower than those in infants with the detected diseases (157.9±86.9 mg/kg vs 770.1±287.4 mg/kg, p=0.000). No differences were found in relation to the kind of feeding (breast-fed: 408.4±327.2, formula-fed: 349.3±338.4; p=0.627). The two groups were equivalent for age (healthy infants: 58.3±23.6 days, infants with disorders: 58.7±19.1 days; p=0.958) and for gender (healthy infants: M/F=12/9, infants with disorders: M/F=6/8). Conclusion: It is well known that faecal calprotectin levels in infants during the first months of life are higher than in healthy adults and show a wide interindividual and age-dipendent variation. Surprisingly, contrary to previous published data, we have not found any difference between breast-fed and formula-fed infants. Anyway, our finding suggests that this marker might be useful not only to detect bowel inflammation, but also to identify gut involvement related to atopy. Alterations in calprotectin levels may be associated with specific disorders in infancy such as atopic dermatitis, cow's milk intolerance, severe infantile colic and gastroesophageal reflux. Fund of scientific research: MURST 60%.

Forfar &amp; Arneil's Textbook of Pediatrics: 6th edition

Take, for example, single umbilical artery. A distinguished retired paediatrician telephoned me, concerned about his grandfetus which had been found through antenatal scanning to be one umbilical artery short. I scrutinized the index of the new Forfar & Arneil (FA try artery— no. Try the index of the current Nelson Textbook (same publishing stable, cheaper, American)—yes, on p. 528, a concise informative paragraph. Try Google—nearly 1300 citations, reproducible instantly on my printer and no heavy book to balance on the knees. The moral? The talents of editors and contributors might be put to better use in more contemporary information transfer. In F&A the shape of things to come is indicated by a disc behind the front cover. So how is it for me? I have used the new FA this wayward index again) of coeliac disease; and cow's milk intolerance and constipation may be linked in the absence of atopy. Enuresis is discussed more informatively under nephrology than under psychiatry, from which it should have been blue pencilled. My main beef, however, is with this book's two-dimensional context of child life and health—a weakness common to most textbooks. The three principal elements to clinical paediatric practice are diagnosis, treatment and population medicine, all within a whole child/family framework. Though management of defined conditions and the public health of paediatrics are dealt with soundly, the real challenge to the personal physician is unravelling the cause of symptoms and relieving those which defy diagnostic classification, including the whole fascinating (and evidence-limited) spectrum of functional illness, and those which do not remit when the disease thought to cause them is treated 'successfully'. The excellent short chapter on pain management makes a good start in this respect: now for breathlessness, dizziness—and fatigue. I thank the families of McIntosh, Helms and Smyth for loaning them to this project and salute them on the result. The style and content are even and they have largely succeeded in avoiding overlap. Do not baulk at its cost: at just over £1 per contributor you are getting a bargain (and a largely British one, despite the American spelling). This 6th edition was born (4.5 kg) just 5 years after the 5th, and the life expectancy of its knowledge base may prove even shorter. In what form the 7th will be presented I leave you, dear reader, to guess.