Current status of long term ventilation of children in the United Kingdom: questionnaire survey

ObjectivesTo identify the number and current location of children, aged 0 to 16 years, requiring long term ventilation in the United Kingdom, and to establish their underlying diagnoses and ventilatory needs.DesignPostal questionnaires sent to consultant respiratory paediatricians and all lead clinicians of intensive care and special care baby units in the United Kingdom.SubjectsAll children in the United Kingdom who, when medically stable, continue to need a mechanical aid for breathing.Results141 children requiring long term ventilation were identified from the initial questionnaire. Detailed information was then obtained on 136 children from 30 units. Thirty three children (24%) required continuous positive pressure ventilation by tracheostomy over 24 hours, and 103 received ventilation when asleep by a non-invasive mask (n=62; 46%), tracheostomy (n=32; 24%), or negative pressure ventilation (n=9; 7%). Underlying conditions included neuromuscular disease (n=62; 46%), congenital central hypoventilation syndrome (n=18; 13%), spinal injury (n=16; 12%), craniofacial syndromes (n=9; 7%), bronchopulmonary dysplasia (n=6; 4%), and others (n=25; 18%). 93 children were cared for at home. 43 children remained in hospital because of home circumstances, inadequate funding, or lack of provision of home carers. 96 children were of school age and 43 were attending mainstream school.ConclusionsA significant increase in the number of children requiring long term ventilation in the United Kingdom has occurred over the past decade. Contributing factors include improved technology, developments in paediatric non-invasive ventilatory support, and a change in attitude towards home care. Successful discharge home and return to school is occurring even for severely disabled patients. Funding and home carers are common obstacles to discharge.

Key messages

• The number of children requiring long term ventilatory support has increased substantially in the past 8 years
• Ventilatory support at home is the best option for meeting the child’s psychological needs and enhancing quality of life
• The majority of children dependent on long term ventilation live at home and attend mainstream schools
• A shift of care has occurred from intensive care units to less acute areas

     

Nutritional status and mortality of refugee and resident children in a non-camp setting during conflict: follow up study in Guinea-Bissau

ObjectiveTo study the effects on children of humanitarian aid agencies restricting help to refugee families (internally displaced people).DesignFollow up study of 3 months.SettingPrabis peninsular outside Bissau, the capital of Guinea-Bissau, which has functioned as a refugee area for internally displaced people in the ongoing war, and the study area of the Bandim health project in Bissau.Participants422 children aged 9-23 months in 30 clusters.ResultsDuring the refugee situation all children deteriorated nutritionally, and mortality was high (3.0% in a 6 week period). Rice consumption was higher in families resident in Prabis than in refugees from Bissau but there was no difference in food expenditure. Nutritional status, measured by mid- upper arm circumference, was not associated with rice consumption levels in the family, and the decline in circumference was significantly worse for resident than for refugee children; the mid-upper arm circumference of refugee children increased faster than that of resident children. For resident children, mortality was 4.5 times higher (95% confidence interval 1.1 to 30.0) than for refugee children. Mortality for both resident and refugee children was 7.2 times higher (1.3 to 133.9) during the refugee’s stay in Prabis compared with the period after the departure of the refugees.ConclusionIn a non-camp setting, residents may be more malnourished and have higher mortality than refugees. Major improvements in nutritional status and a reduction in mortality occurred in resident and refugee children as soon as refugees returned home despite the fact that there was no improvement in food availability.

Key messages

• During the war in Guinea-Bissau, most of the population fled from the capital and moved in with relatives, friends, or strangers
• International agencies insisted on only providing help to refugees (internally displaced people)
• During the first month of conflict, there were already profound effects on the nutritional status and mortality of young children
• Food consumption was higher in resident families, but resident children were more malnourished and had higher mortality than refugee children
• Nutritional status and survival improved for both refugee and resident children once the refugees returned to Bissau

     

Persistence of Health Inequalities in Childhood Injury in the UK; A Population-Based Cohort Study of Children under 5

BackgroundInjury is a significant cause of childhood death and can result in substantial long-term disability. Injuries are more common in children from socio-economically deprived families, contributing to health inequalities between the most and least affluent. However, little is known about how the relationship between injuries and deprivation has changed over time in the UK.MethodsWe conducted a cohort study of all children under 5 registered in one of 495 UK general practices that contributed medical data to The Health Improvement Network database between 1990–2009. We estimated the incidence of fractures, burns and poisonings by age, sex, socio-economic group and calendar period and adjusted incidence rate ratios (IRR) comparing the least and most socio-economically deprived areas over time. Estimates of the UK annual burden of injuries and the excess burden attributable to deprivation were derived from incidence rates.ResultsThe cohort of 979,383 children experienced 20,804 fractures, 15,880 burns and 10,155 poisonings, equating to an incidence of 75.8/10,000 person-years (95% confidence interval 74.8–76.9) for fractures, 57.9 (57.0–58.9) for burns and 37.3 (35.6–38.0) for poisonings. Incidence rates decreased over time for burns and poisonings and increased for fractures (p<0.001 test for trend for each injury). They were significantly higher in more deprived households (IRR test for trend p<0.001 for each injury type) and these gradients persisted over time. We estimate that 865 fractures, 3,763 burns and 3,043 poisonings could be prevented each year in the UK if incidence rates could be reduced to those of the most affluent areas.ConclusionsThe incidence of burns and poisonings declined between 1990 and 2009 but increased for fractures. Despite these changes, strong socio-economic inequalities persisted resulting in an estimated 9,000 additional medically-attended injuries per year in under-5s.     

The Effectiveness of Different Interventions to Promote Poison Prevention Behaviours in Households with Children: A Network Meta-Analysis

Background

There is evidence from 2 previous meta-analyses that interventions to promote poison prevention behaviours are effective in increasing a range of poison prevention practices in households with children. The published meta-analyses compared any intervention against a “usual care or no intervention” which potentially limits the usefulness of the analysis to decision makers. We aim to use network meta-analysis to simultaneously evaluate the effectiveness of different interventions to increase prevalence of safe storage of i) Medicines only, ii) Other household products only, iii) Poisons (both medicines and non-medicines), iv) Poisonous plants; and v) Possession of poison control centre (PCC) telephone number in households with children.

Methods

Data on the effectiveness of poison prevention interventions was extracted from primary studies identified in 2 newly-undertaken systematic reviews. Effect estimates were pooled across studies using a random effects network meta-analysis model.

Results

28 of the 47 primary studies identified were included in the analysis. Compared to usual care intervention, the intervention with education and low cost/free equipment elements was most effective in promoting safe storage of medicines (odds ratio 2.51, 95% credible interval 1.01 to 6.00) while interventions with education, low cost/free equipment, home safety inspection and fitting components were most effective in promoting safe storage of other household products (2.52, 1.12 to 7.13), safe storage of poisons (11.10, 1.60 to 141.50) and possession of PCC number (38.82, 2.19 to 687.10). No one intervention package was more effective than the others in promoting safe storage of poisonous plants.

Conclusion

The most effective interventions varied by poison prevention practice, but education alone was not the most effective intervention for any poison prevention practice. Commissioners and providers of poison prevention interventions should tailor the interventions they commission or provide to the poison prevention practices they wish to promote.

Highlights

• Network meta-analysis is useful for comparing multiple injury-prevention interventions.
• More intensive poison prevention interventions were more effective than education alone.
• Education and low cost/free equipment was most effective in promoting safe storage of medicines.
• Education, low cost/free equipment, home safety inspection and fitting was most effective in promoting safe storage of household products and poisons.
• Education, low cost/free equipment and home inspection were most effective in promoting possession of a poison control centre number.
• None of the intervention packages was more effective than the others in promoting safe storage of poisonous plants.

     

Generalising the Cinderella Effect to unintentional childhood fatalities

We investigated whether the repeatedly demonstrated increase in risk of child abuse and infanticide associated with living with a step parent generalized to cases of unintentional childhood fatal injury, the most common cause of death in children across the developed world. Reports were drawn from the Australian National Coroners' Information System (NCIS) on all cases of intentionally (n=32) and unintentionally (n=319) produced fatal injury in children aged under 5 years between 2000 and 2003. Even when using the most conservative possible analytic approach, in which all cases in which family type was unclear were classified as being from an ‘intact biological family’, step children under 5 years of age were found to be at significantly increased risk of unintentional fatal injury of any type, and of drowning in particular. Children from single-parented families were generally not found to be at significantly increased risk of intentional or unintentional fatal injury, while children who lived with neither of their biological parents were at greatest risk overall for fatal injury of any type.     

Email submissions from outside the United Kingdom

ObjectivesTo identify whether psychiatric disturbance in parentally bereaved children and surviving parents is related to service provision.DesignProspective case-control study.SettingTwo adjacent outer London health authorities. Participants45 bereaved families with children aged 2 to 16 years.ResultsParentally bereaved children and surviving parents showed higher than expected levels of psychiatric difficulties. Boys were more affected than girls, and bereaved mothers had more mental health difficulties than bereaved fathers. Levels of psychiatric disturbance in children were higher when parents showed probable psychiatric disorder. Service provision related to the age of the children and the manner of parental death. Children under 5 years of age were less likely to be offered services than older children even though their parents desired it. Children were significantly more likely to be offered services when the parent had committed suicide or when the death was expected. Children least likely to receive service support were those who were not in touch with services before parental death.ConclusionsService provision was not significantly related to parental wishes or to level of psychiatric disturbance in parents or children. There is a role for general practitioners and primary care workers in identifying psychologically distressed surviving parents whose children may be psychiatrically disturbed, and referring them to appropriate services.

Key messages

• Parentally bereaved children show high levels of psychological disturbance, with boys being more vulnerable than girls
• Surviving mothers show more psychiatric morbidity than surviving fathers
• Psychological distress in bereaved parents is associated with psychological difficulties in their children
• Service provision for bereaved children is not determined by mental health difficulties in either parents or children, or by parental wishes; it is influenced only by the manner of parental death and the age of the child
• The mismatch between need and service provision indicates a role for general practitioners and primary care workers in identifying distressed or disturbed families in need of public or voluntary service help

     

Does hospital at home for palliative care facilitate death at home? Randomised controlled trial

ObjectiveTo evaluate the impact on place of death of a hospital at home service for palliative care.DesignPragmatic randomised controlled trial.SettingFormer Cambridge health district.Participants229 patients referred to the hospital at home service; 43 randomised to control group (standard care), 186 randomised to hospital at home.InterventionHospital at home versus standard care.ResultsTwenty five (58%) control patients died at home compared with 124 (67%) patients allocated to hospital at home. This difference was not significant; intention to treat analysis did not show that hospital at home increased the number of deaths at home. Seventy three patients randomised to hospital at home were not admitted to the service. Patients admitted to hospital at home were significantly more likely to die at home (88/113; 78%) than control patients. It is not possible to determine whether this was due to hospital at home itself or other characteristics of the patients admitted to the service. The study attained less statistical power than initially planned.ConclusionIn a locality with good provision of standard community care we could not show that hospital at home allowed more patients to die at home, although neither does the study refute this. Problems relating to recruitment, attrition, and the vulnerability of the patient group make randomised controlled trials in palliative care difficult. While these difficulties have to be recognised they are not insurmountable with the appropriate resourcing and setting.

Key messages

• Terminally ill patients allocated to hospital at home were no more likely to die at home than patients receiving standard care
• Although the subsample of patients actually admitted to hospital at home did show a significant increase in likelihood of dying at home, whether this was due to the service itself or the characteristics of patients admitted to hospital at home could not be determined
• The need to balance ideal research design against the realities of evaluation of palliative care had the effect that the trial achieved less statistical power than originally planned
• Particular problems were that many patients failed to receive the allocated intervention because of the unpredictable nature of terminal illness, inclusion of other service input alongside hospital at home, and the wide range of standard care available
• The trial illustrated problems associated with randomised controlled trials in palliative care, none of which are insurmountable but which require careful consideration and resourcing before future trials are planned

     

Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study

ObjectiveTo compare the safety and efficacy of midazolam given intranasally with diazepam given intravenously in the treatment of children with prolonged febrile seizures.DesignProspective randomised study.SettingPaediatric emergency department in a general hospital.Subjects47 children aged six months to five years with prolonged febrile seizure (at least 10 minutes) during a 12 month period.InterventionsIntranasal midazolam (0.2 mg/kg) and intravenous diazepam (0.3 mg/kg).ResultsIntranasal midazolam and intravenous diazepam were equally effective. Overall, 23 of 26 seizures were controlled with midazolam and 24 out of 26 with diazepam. The mean time from arrival at hospital to starting treatment was significantly shorter in the midazolam group (3.5 (SD 1.8) minutes, 95% confidence interval 3.3 to 3.7) than the diazepam group (5.5 (2.0), 5.3 to 5.7). The mean time to control of seizures was significantly sooner (6.1 (3.6), 6.3 to 6.7) in the midazolam group than the diazepam group (8.0 (0.5), 7.9 to 8.3). No significant side effects were observed in either group.ConclusionSeizures were controlled more quickly with intravenous diazepam than with intranasal midazolam, although midazolam was as safe and effective as diazepam. The overall time to cessation of seizures after arrival at hospital was faster with intranasal midazolam than with intravenous diazepam. The intranasal route can possibly be used not only in medical centres but in general practice and, with appropriate instructions, by families of children with recurrent febrile seizures at home.     

Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992-7

ObjectiveTo determine the relation between morbidity from injury and deprivation for different levels of injury severity and for different injury mechanisms for children aged 0-14 years.DesignCross sectional survey of routinely collected hospital admission data for injury 1992-7.Setting862 electoral wards in Trent Region.Subjects21 587 injury related hospital admissions for children aged 0-4 years and 35 042 admissions for children aged 5-14.ResultsBoth total number of admissions for injury and admissions for injuries of higher severity increased with increasing socioeconomic deprivation. These gradients were more marked for 0-4 year old children than 5-14 year olds. In terms of injury mechanisms, the steepest socioeconomic gradients (where the rate for the fifth of electoral wards with the highest deprivation scores was ⩾3 times that of the fifth with the lowest scores) were for pedestrian injuries (adjusted rate ratio 3.65 (95% confidence interval 2.94 to 4.54)), burns and scalds (adjusted rate ratio 3.49 (2.81 to 4.34)), and poisoning (adjusted rate ratio 2.98 (2.65 to 3.34)).ConclusionThere are steep socioeconomic gradients for injury morbidity including the most common mechanisms of injury. This has implications for targeting injury prevention interventions and resources.

What is already known on this topic?

There is a steep socioeconomic gradient for injury related mortalityThere is conflicting evidence regarding the socioeconomic gradient for injury morbidity, particularly with respect to different injury severity and injury mechanisms

What this study adds

A socioeconomic gradient for injury morbidity exists in children aged <15 years, particularly in those aged <5, which persist for different measures of injury severityThe socioeconomic gradient for injury mechanisms is steepest for pedestrian injuries, burns and scalds, and poisoning, which has implications for targeting injury prevention strategies     

Away-from-home food intake and risk for obesity: examining the influence of context

Objective: This study examined sociodemographic and cultural determinants of away‐from‐home food consumption in two contexts and the influence of frequency of away‐from‐home food consumption on children's dietary intake and parent and child weight status. Methods and Procedures: Parents of children (N = 708) in grades K‐2 were recruited from 13 elementary schools in Southern California. Parents were asked through a questionnaire the frequency with which they eat meals away from home and the restaurant they frequented most often. The height and weight of the parents and their children were measured to calculate BMI. Results: Consuming foods at least once a week from relatives/neighbors/friends (RNF) homes was associated with children's dietary intake and children's risk for obesity. For example, children of parents with weekly or greater RNF food consumption drank more sugar‐sweetened beverages. Parents of families who ate at restaurants at least weekly reported that their children consumed more sugar‐sweetened beverages, more sweet/savory snacks, and less water compared with families who did not frequent restaurants this often. The type of restaurant visited did not affect diet intake or obesity. More acculturated families exhibited less healthy dietary behaviors than less acculturated families. Discussion: Restaurants remain an important setting for preventing child and adult obesity, but other settings outside the home need to be considered in future intervention research. This may especially involve eating in the homes of RNF.     

Habitat heterogeneity and intraguild interactions modify distribution and injury rates in two coexisting genera of damselflies

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Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial

ObjectivesTo assess the effectiveness of a trained district nurse individually prescribing a home based exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.DesignRandomised controlled trial with one year''s follow up.SettingCommunity health service at a New Zealand hospital.Participants240 women and men aged 75 years and older.Intervention121 participants received the exercise programme (exercise group) and 119 received usual care (control group); 90% (211 of 233) completed the trial.ResultsFalls were reduced by 46% (incidence rate ratio 0.54, 95% confidence interval 0.32 to 0.90). Five hospital admissions were due to injuries caused by falls in the control group and none in the exercise group. The programme cost $NZ1803 (£523) (at 1998 prices) per fall prevented for delivering the programme and $NZ155 per fall prevented when hospital costs averted were considered.ConclusionA home exercise programme, previously shown to be successful when delivered by a physiotherapist, was also effective in reducing falls when delivered by a trained nurse from within a home health service. Serious injuries and hospital admissions due to falls were also reduced. The programme was cost effective in participants aged 80 years and older compared with younger participants.

What is already known on this topic

Falls are the costliest type of injury among elderly people, and the healthcare costs increase with frequency of falls and severity of injuriesAn exercise programme delivered by a physiotherapist was successful in reducing falls and moderate injuries in elderly people

What this study adds

An exercise programme to prevent falls in elderly people worked well when delivered by a district nurse from a home health service in the suburbs of a large cityResearchers, public health administrators, and health practitioners can work together to benefit elderly people in the community     

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres

ObjectivesTo assess the effectiveness of trained nurses based in general practices individually prescribing a home exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.DesignControlled trial with one year''s follow up.Setting32 general practices in seven southern New Zealand centres.Participants450 women and men aged 80 years and older.Intervention330 participants received the exercise programme (exercise centres) and 120 received usual care (control centres); 87% (371 of 426) completed the trial.ResultsFalls were reduced by 30% in the exercise centres (incidence rate ratio 0.70, 95% confidence interval 0.59 to 0.84). The programme was equally effective in men and women. The programme cost $NZ418 (£121) (at 1998 prices) per person to deliver for one year or $NZ1519 (£441) per fall prevented. Fewer participants had falls resulting in injuries, but there was no difference in the number who had serious injuries and no difference in hospital costs resulting from falls in exercise centres compared with control centres.ConclusionsAn individually tailored exercise programme, delivered by trained nurses from within general practices, was effective in reducing falls in three different centres. This strategy should be combined with other successful interventions to form part of home programmes to prevent falls in elderly people.

What is already known on this topic

One half of those aged 80 years and older will fall in any one year, often with serious health and social consequencesAn exercise programme delivered by a physiotherapist or trained district nurse was successful in reducing falls and moderate injuries in elderly people

What this study adds

An exercise programme to prevent falls in elderly people can be delivered safely and effectively by trained nurses in general practicesThe nurses obtained results that were consistent with the physiotherapist in the research setting and the district nurse in the accompanying paper     

Mental health problems of homeless children and families: longitudinal study

Objective: To establish the mental health needs of homeless children and families before and after rehousing. Design: Cross sectional, longitudinal study. Setting: City of Birmingham. Subjects: 58 rehoused families with 103 children aged 2-16 years and 21 comparison families of low socioeconomic status in stable housing, with 54 children. Main outcome measures: Children’s mental health problems and level of communication; mothers’ mental health problems and social support one year after rehousing. Results: Mental health problems remained significantly higher in rehoused mothers and their children than in the comparison group (mothers 26% v 5%, P=0.04; children 39% v 11%, P=0.0003). Homeless mothers continued to have significantly less social support at follow up. Mothers with a history of abuse and poor social integration were more likely to have children with persistent mental health problems. Conclusions: Homeless families have a high level of complex needs that cannot be met by conventional health services and arrangements. Local strategies for rapid rehousing into permanent accommodation, effective social support and health care for parents and children, and protection from violence and intimidation should be developed and implemented.

Key messages

• Homeless children and their mothers have a high level of mental health problems
• Homeless families experience many risk factors, such as domestic violence, abuse, and family and social disruption
• In two fifths of children and a quarter of mothers, mental health problems persisted after rehousing
• In contrast with a comparison group of families of low socioeconomic status, a substantial proportion of homeless families remained residentially and socially unstable

     

Bicycle-related injuries: a survey in a pediatric emergency department.

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children''s Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child''s home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.     

Variables associated with the occurrence of Ips beetles,red turpentine beetle and wood borers in live and dead ponderosa pines with post‐fire injury

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Impact of breast feeding on admission for pneumonia during postneonatal period in Brazil: nested case-control study

ObjectiveTo determine whether breast feeding protects infants against pneumonia and whether the protection varies with age.DesignNested case-control study.SettingPelotas, southern Brazil.SubjectsCases were 152 infants aged 28-364 days who had been admitted to hospital for pneumonia. Controls were 2391 cases in a population based case-control study.ResultsInfants who were not being breast fed were 17 times more likely than those being breast fed without formula milk to be admitted to hospital for pneumonia (95% confidence interval 7.7 to 36.0). This relative risk was 61 (19.0 to 195.5) for children under 3 months old, decreasing to 10 (2.8 to 36.2) thereafter. Supplementation with solids was associated with a relative risk of 13.4 (7.6 to 23.5) for all infants and 175 (21.8 to 1405.1) for those under 3 months old.ConclusionBreast feeding protects young children against pneumonia, especially in the first months of life. These results may be used for targeting intervention campaigns at the most vulnerable age groups.

Key messages

• Pneumonia is the leading cause of death in children under 5 years old across the world
• In Brazil infants who were not breast fed were 17 times more likely than those receiving breast milk alone to be admitted for pneumonia
• The relative risk of admission was 61 for children under 3 months of age, decreasing to 10 thereafter
• Supplementation with solids was associated with a relative risk of 13.4 for all infants
• Mothers must be encouraged to breast feed very young infants and be advised of the right time to introduce supplementary foods

     

Association between type 1 diabetes and Haemophilus influenzae type b vaccination: birth cohort study

ObjectivesTo determine the effect of Haemophilus influenzae type b vaccination and its timing on the risk of type 1 diabetes in Finnish children.DesignCumulative incidence and relative risk of type 1 diabetes was compared among three birth cohorts of Finnish children: those born during the 24 months before the H influenzae type b vaccination trial, those in the trial cohort who were vaccinated at 3 months of age and later with a booster vaccine, and those in the trial cohort who were vaccinated at 24 months of age only. The probability of type 1 diabetes was estimated using regression analysis assuming that there were no losses to 10 year follow up and no competing risks.SettingFinland (total population 5 million and annual birth rate 1.3%).Subjects128 936 children born from 1 October 1983 to 1 September 1985, and 116 352 children born from 1 October 1985 to 31 August 1987.ResultsNo statistically significant difference was found at any time during the 10 year follow up in the risk of type 1 diabetes between the children born before the vaccination period and those vaccinated at the age of 24 months only (relative risk 1.01). The difference in the risk between the cohort vaccinated first at the age of 3 months and the cohort vaccinated at the age of 24 months only was not statistically significant either (1.06).ConclusionIt is unlikely that H influenzae type b vaccination or its timing cause type 1 diabetes in children.

Key messages

• The gradual increase in vaccination programmes does not permit any particular one to be pinpointed as being responsible for the increase in type 1 diabetes in Finland
• There is no difference in the risk of type 1 diabetes between children not vaccinated against H influenzae type b and those vaccinated at the age of 24 months only
• The difference in risk between children vaccinated against H influenzae type b at the age of 3 months and those vaccinated at the age of 24 months was not statistically significant
• It is very unlikely that H influenzae type b vaccination or its timing causes type 1 diabetes in Finnish children