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A CLINICAL RESEARCH NETWORK FOR CHILDREN
Randomised clinical trials are the cornerstone of evidence based medicine and the Cochrane Collaboration. They influence the statements of important professional groups like National Institute for Health and Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN). Professor Ros Smyth, in her leading article, details the development and organisation of the Medicines for Children Research Network (MCRN). The coordinating centre is based in Liverpool, but there are also six regional local research networks. The centre helps coordinate multi-site clinical trials. Numerous clinical studies groups have been established—they are responsible for the development of the MCRN’s research portfolio. The need for the MCRN is highlighted by a short report from the Brompton. They found in a small number of children with cystic fibrosis, cared for at a single-centre, that 8 of 18 children without respiratory systems were positive for bacteria on bronchoalveolar lavage. Should all children with cystic fibrosis, regardless of symptoms, undergo regular bronchoscopy? This question cannot be answered by a single-centre, and likely requires a randomised controlled trial. I suspect that if the MCRN is successful, it will become as well known and important as the British Paediatric Surveillance Unit.
See page 835
ANAEMIA DURING INFANCY
The report by Hopkins and colleagues, from the Avon Longitudinal Study of Parents and Childrens (ALSPAC), confirms other reports about iron deficiency—anaemia remains a persistent problem in infants and the introduction of cow’s milk early in life is associated with anaemia. I have been conducting research in this area for over 10 years—the persistence of this problem, particularly in low-income infants, is disturbing and represents a significant health disparity between rich and poor. We have found that if 6-month-old infants are given multivitamins, regardless of whether the vitamins contain iron or not, they are less likely to be iron deficient at 9 months of age.1Clinicians also need to be aware that infants who are breast-fed for more than 6 months, even though the iron in breast-milk has greater bioavailability than that in formula, may develop anaemia if their diet does not contain adequate sources of iron.
See page 850
IMPROVING ASTHMA CARE
Cohen, Taitz and Jaffe detail the use of various asthma medications between 2000 and 2006. The good news—there has been a 60% decline in the use of bronchodilator syrups. The use of combination inhalers (steroids and long acting β agonists) increased from 2.7% to 25.3%. I applaud the reduction in use of liquid bronchodilators—although the authors point out that the data suggest that despite this decline, more than 100 000 prescriptions were written for these agents in 2006. The guidelines from the British Thoracic Society and SIGN, do not support their use. However, although steroids are clearly recognised as the mainstay of treatment for children and adults with persistent asthma, the use of long acting β agonists is more controversial because of their association with sudden death. In addition, in children less than 5 years of age, defining persistent disease is complicated—many children wheeze 2–3 times a week, but only for a few months of year. It is hard to convince parents (and me) that these children should be on steroids year round—although the use of these agents during peak wheezing season is appropriate.
See page 847
OBESITY: THREE MORE REPORTS
At our biweekly auctions—when we review submitted manuscripts and the comments from peer-review—a regular topic of discussion is the number of submitted articles related to obesity. Should we have a “special” issue on obesity, and then significantly limit obesity-related articles in all other issues? To date we have not pursued this option. First, it is difficult to orchestrate a sufficient number of high-quality submissions within a narrow time frame for a theme issue. Second, since we only publish 12 times per year, a themed issue on obesity may not be of interest to many of our readers. However, with respect to articles on obesity, we will increase our focus on new information; hopefully treatment strategies rather than additional cohort studies about prevalence and risk factors. In this issue, Blair and colleagues from Australia confirm the findings of others—maternal obesity, sedentary lifestyle and television viewing are associated with obesity at 7 years of age. Shaw and others, from Birmingham, report that body fat as determined by dual x ray absorptiometry varies by gender (girls greater than boys) and ethnicity (South Asian and African-Caribbean greater than whites). Lastly, Smith and colleagues from Bristol, in a fascinating study utilising the Avon Longitudinal Study of Parents and Children (ALSPAC) group, found that there was no difference between maternal and paternal body mass index (BMI) and offspring BMI. They argue that if there was a specific maternal intrauterine effect than the maternal-offspring association should be stronger than the paternal-offspring effect.
THIS MONTH IN EDUCATION & PRACTICE EDITION
Harry Baumer provides a succinct synopsis of the recent bronchiolitis guideline from SIGN. He also details how it differs from the recently released American Academy of Pediatrics guidelines on the same subject. See page ep149
Two more problem solving cases are provided – “mummy I want a drink” and “don’t be fooled by meconium”. See pages ep139 and ep135
Best practice and pharmacy update focus on important issues—implementing guidelines and feedback about the BNF for Children (BNFC), rather than specific clinical entities. See pages ep129 and ep144
Helen Williams illuminates the normal kidney. See page ep152