Statistics from Altmetric.com
Pragmatism is generally taken to mean ‘practical’, a means of operation which is both user and subject friendly. We are all bound to an extent by pragmatism as this defines the world we inhabit, simultaneously adhering to certain rules (or etiquette) of engagement and execution. So what defines a ‘pragmatic study’? I’d argue that this is a pleasingly flexible term, the common denominator being it is neither unwieldy nor unpalatable and, probably, inexpensive. By dint of these qualities a practice becomes sustainable, a feature common to this month’s choices.
Global child health
Pouletty and colleagues compared detection rates of antibiotic treatable forms of diarrhoea in children returning from the tropics to France with standard culture and multiplex PCR. Though numbers were small, detection was not only faster (results on the same day) but the PCR more sensitive both in terms of identifying co-infection and illness requiring specific treatment. Though the vast majority of cases of gastroenteritis require only supportive treatment, those with shigella, symptomatic campylobacter and cholera do warrant antibiotics. A test capable of diagnosing and treating these children earlier can only be of benefit to both them and their contacts. See page 141.
In contrast, Olita and colleagues assessed a peri-partum quality improvement initiative in Papua New Guinea, the aim of which was to minimise antibiotic use in a region with high bacterial drug resistance rates. They adopted a watch and wait approach in high risk babies (prolonged rupture of membranes) who had received a single dose (either intrapartum or immediately post delivery). If well, babies were discharged at 48 hours of advice. Rates of infection were reassuringly low, most were simply cutaneous (and, therefore, unlikely to have been related to early rupture of membranes) and there were no deaths. See page 115.
Illness chronicity and happiness
An area that continues to intrigue is health related quality of life (HLQoL) in children with congenital heart disease (CHD) and Reiner et al’s study and Klaassen’s editorial adds to the burgeoning literature. They compared QoL scores using the validated KINDL tool in 514 German children with a range of cardiac defects compared self-reported QoL scores with a group of control children assessed as part of the normative validation. The mean scores in the cardiac children were both significantly higher (after correction 2.3-point (P<0.001)), consistently greater by sex and age band and, most interestingly by severity of underlying lesion. The children with CHD (unlike their healthy peers) retained QoL through puberty. How do we interpret this? The authors suggest that social support, family environment, peer and school dyamics, a sense of coherence and early learning of coping strategies might. They also propose that a feeling of less pressure might explain their relatively higher scores. Do the differences found mean a clinically important difference? No one knows, but the direction of effect has to be seen positively. See pages 105 and 124 .
In one of a two part series on fabricated or induced illness (FII), as well as marking the 40th anniversary of Meadow’s first use of the term Munchhausen’s by proxy, Murtagh describes the difficult gestation, childhood and adolescence this heterogenous entity has endured. Nothing better illustrates the sensitivities around the area more than the multiplicity of synonyms: preferred terms in the US, for example include ‘paediatric condition falsification’, ‘medical child abuse’ and ‘caregiver fabricated illness in a child’. The diagnostic and statistical manual of mental disorders (DSM-5) now uses the term ‘Factitious disorder imposed on another’ implying that carer behaviour involves deception, though the line between this phenotype and multiple ‘symptomatology’ due to caregiver anxiety is a fine one. See page 110 .
Resuscitation: weight estimated
One of the many additive stresses in a resuscitation situation is the estimation of weight on which to base drug and defibrillation doses and endotracheal tube sizes. Despite the numerous formulae in circulation, children continue to defy attempts to conform… In a pragmatic study to address this Marlow et al used a simulated setting to compare four types of validation: two forms of the Advanced Paediatric Life System calculation, a best guess and a simple table. The methods were comparable (for children over 1 year) in terms of validity, but the table faster (and one assumes, easier) to use. There’s a historical twist here: tables fell out of vogue in the 1980s as formulae were felt to be somehow ‘better’. Sometimes, however, ease and the removal of additional stress trumps other factors. See page 121 .
Moderation is everything
In a compelling piece mixing history, physiology and trial data, Martin and Peters examine the potential disadvantages in over liberal use of the ‘universal panacea’ oxygen. This piece was the subject of a recent podcast (https://soundcloud.com/bmjpodcasts/might-children-rust-what-are-the-risks-of-supplemental-oxygen-in-acute-illness?in=bmjpodcasts/sets/adc-podcast) and is my editor’s choice for the month. See page 106 .
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.