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Arch Dis Child 2001 Volume 84 No 1
How much for a night's sleep?
Cost effectiveness rivals evidence based medicine as a 21st century shibboleth. At least in the UK it is no longer sufficient to show that a treatment works; or even that you only have to treat 978 patients to achieve one success. You must also calculate how great a strain it will prove on the public purse. This month, Morris and colleagues (page 15) look at how much of the NHS treasure chest slips away at the insistent demand of crying or non-sleeping babies. Their answer is £65 million a year. Helpfully, they point out this would employ over 2000 nurses or buy 14 million doses of sildenafil. Educational intervention with families costs an extra £4.13 per interruption-free night, and a behavioural programme costs just 56p (US$1). Most parents would consider this money well spent although the manufacturers of sildenafil may conclude otherwise.*
Squeak, ruttle, and roar
In April 2000, ADC published a paper on what parents understand by the word “wheeze” and how this differed from epidemiologists' definitions.2-1 This month, the authors move on to look at how parents describe breathing noises when presented on video (page 31). Another team from Sheffield interviewed parents of noisily breathing infants and did their best to pin them down by asking where they thought the noise was coming from and to match their child with standard video clips (page 35).
Cane and McKenzie, in London, found that only 59% of parents correctly identified a video-presented wheeze. Many called it “snoring” or even normal. Some used vague terms such as “shallow breaths” or “chesty”. Parents were more accurate in guessing where the noise originated. Overall 30% called wheezing something else and 30 % called something else wheezing.
The Sheffield group, as befits a study team from an area of England with particularly rich language, allowed their interviewees an eclectic range of alternatives including rustle, ruttle, ruckle, rattle, snort, whoop, snuffle, whistle, and squeak. I can only admire the poetic instincts of those parents who referred to their child's breathing as like “a tiger roaring” or “a dirty phone call”. Both groups conclude that parents use the word wheeze inappropriately. There are several messages: clinicians must take great care when taking a history to decide whether parents' use of the word “wheeze” is an erroneous interpretation rather than an objective description. Those designing trials involving patient questionnaires must also be cautious: acceptance for publication may prove difficult unless they validate the terms they use with tools such as video.
No increased asthma in premature babies
It's not often that ADC has the opportunity to publish the results of a 14 year follow up study—virtually 80% of a lifetime for paediatrics. Doyle and colleagues from Victoria, Australia, report such a prospective controlled cohort study of babies weighing under 1500 g at birth (page 40). In this report they concentrate on respiratory status, as 23% of their cohort had bronchopulmonary dysplasia (chronic lung disease of prematurity, CLD). They lost very few to follow up and at age 14 it is heartening that low birth weight babies were clinically indistinguishable from controls in this area. Rates of asthma were similar in the 500–999 g, 1000–1500 g, and over 2499 g groups; no effect was seen on this from CLD.
There were some differences in measurements of airflow but the authors regard these as clinically insignificant at present. However, they speculate that these differences, particularly in those who had CLD, might herald earlier onset of obstructive airways disease in later life. What an unanswerable case for a lifetime's research funding.
Under equipped ambulances
About 15 years ago I was asked by a forward looking ambulance authority to sit on its advisory panel for paramedic training. Ever since, I have been impressed by the enthusiasm and commitment of ambulance paramedics in learning how best to deal with resuscitating children. They have a near insurmountable problem in that they gain far less experience with this age group than with adults.
Gaffney and Johnson from Yorkshire surveyed paramedic trainers throughout the NHS, and asked what equipment they carried and what training they received (page 82). No ambulance trust provided all the equipment items deemed necessary by the researchers. For example, only 29% carried a broad range of different gauge endotracheal tubes and only 46% had paediatric defibrillation paddles. The average time spent on paediatric training varied from nil (12 trusts) to 40 hours, with a median of 5.78 hours. Half failed to provide yearly updates. The authors refer to a study in the US in 1994, which showed similar results.
Directors of paediatric services in UK hospitals might reasonably ask their local ambulance trust how effectively their paramedics would deal with a shocked, cyanosed 2 year old who had inhaled a foreign body.
Grommets, part 1
In the pipeline for publication,ADC has a number of papers on the results of treatment with tympanostomy tubes (grommets). The first of these looks at quality of life measures six and 12 months after the tubes were inserted. No improvements were detectable but the authors speculate on whether there might be subgroups that would show benefit. Another case of “more research needed”.
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