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WHEN WILL WE EVER LEARN?
Throughout 1999 and 2000 we upset authors by declining to publish papers dealing with cisapride, reasoning that its withdrawal from use by many regulatory agencies relegated it, at least for the time being, to the dustbin of paediatric therapeutics. However, there is always a new lesson to learn. This month we publish the final, final word—with an analysis by Bourke and Drumm of the association (or lack of it) between randomised controlled trials and prescribing the drug to treat gastro-oesophageal reflux.
It is clear that widespread use preceded reliable evidence of efficacy. This is scarcely a first in medical history and doubtlessly not the last. Ten years ago Antman and colleagues used the technique of sequential meta-analysis of trials of treatment for myocardial infarction.1 They showed that review articles in journals and textbooks often failed to mention important advances, delayed recommending effective interventions and continued to quote potentially harmful or ineffective care.
Editors pathetically hope that the peer review process might help. There is an abundant pessimistic literature. A recent example is the finding that when papers destined for two neuroscience journals are each sent to two referees, the likelihood of their agreeing on acceptance or rejection was no better than chance.2
Bourke and Drumm echo our repeated cautions against publishing guidelines which are not transparently and reliably evidence-based. Please tell us if we transgress.See page 71
UPDATING THE MERSEY CP DATABASE
Doctors have learned to be cautious when prognosticating life expectancy for multiply disabled children. Lawyers are another kettle of fish as life expectancy is the largest determinant in calculating the cost of care in clinical negligence claims. Courts in the UK frequently have their attention drawn to the Mersey Cerebral Palsy register, which now contains data on 1942 subjects born between 1966–89. We asked Professor Pharoah and Dr Hutton to provide us with updated information from their database. Where motor disability is severe, they quote a 30 year survival of 42%, with effects of the severity and number of functional disabilities as well as birth weight. We asked Rosenbloom to comment, in the knowledge that many of the children on the register have been under his clinical care (page 90). He comments on his clinical experience of a subgroup of profoundly cognitively impaired children whose life expectancy is severely curtailed. The registry data are presumably not sufficiently detailed to define such a group. Rosenbloom calls for clinicians, statisticians, and epidemiologists to work together to maximise the value of data collection. We are sure the authors would agree.See page 84
LEARNING FROM THE DEVELOPING WORLD (1)
We have been enjoined to include a section in ADC devoted to international child health. Our discussions continue, but the most cogent opposing argument is that the developed world has more to learn from the third world than vice versa, so there is no need to separate the contributions. In a further development of their work in Papua New Guinea, Duke and colleagues from the University of Melbourne, present their findings on 257 neonates and children with hypoxaemia. They point out that the best predictive physical signs in infants and young children were cyanosis, tachypnoea, and poor feeding, but only the first was predictive in newborns. Most importantly they show that hypoxaemia is surprisingly common in sick infants without acute lower respiratory illnesses. The value of pulse oximetry is stressed.
I have always thought that the WHO guidelines on managing acute respiratory infection in the developing world4 are remarkably valuable in teaching paediatric trainees what to do in the UK. This paper only serves to strengthen that conviction.See page 108
LEARNING FROM THE DEVELOPING WORLD (2)
A WHO recommendation not appropriate for the developed world is the first line use of oral co-trimoxazole in treating non-severe (“out-patient”) pneumonia. Cost was the main reason for the recommendation as the drug is much cheaper than betalactams. The CATCHUP study group (this month's best acronym) performed a double blind RCT comparing cotrimoxazole and amoxycillin, after excluding children with severe or very severe pneumonia. The outcomes were no different but there was a disturbingly high failure rate (16–19%). The authors postulate that some failures were due to unwitting inclusion of children with bronchiolitis or other bronchial hyper-reactivity syndromes, but less likely that increasing antibiotic resistance patterns or dosage interval were to blame. The authors conclude that there is no reason to change the current antibiotic guideline but more work is needed on alternative regimes.See page 113