How to find and how to read articles in neonatology

The abstract can usually be easily accessed; hopefully it will become clear whether there is a concurrent control group, an adequate sample size, and enough details of methodology to know whether further reading is likely to be worthwhile. The following paragraphs detail some considerations for analysis of a published article.

The journal in which the article is published

Articles published in the highest profile journals are not all worthy of much consideration; they need to be evaluated using the same standards as articles in other journals. As one example, a randomized controlled trial (RCT) of steroids for the prevention of bronchopulmonary dysplasia was published in the New England Journal of Medicine [1], perhaps suggesting ground-breaking findings. However, that study included a total of only 26 patients in three different groups. It showed a significant

Uncontrolled trials are unreliable

Any study which reports the outcome of a group of patients without a control group is suspect. In cardiovascular support, for example, there are numerous examples of reports showing a change in a particular variable, such as renal Doppler findings after a drug infusion that was started [2] in preterm infants on the first day of life. Renal perfusion is known to increase enormously during the first day of life, so without a control group is it unclear whether any changes seen are due to the

Beware of review articles

All review articles should be based on systematic review and synthesis of the literature. Many review articles and book chapters are selective and unreliable, reflecting the author's own preoccupations and a biased interpretation of the published literature. A review article should therefore clearly state how the reference list was assembled, which references are RCTs and systematic reviews, and what attempts were made to ensure that the review is balanced and complete.

The hierarchy of evidence

The idea of a hierarchy of reliable evidence came about as a result of the evidence-based medicine movement. The need to evaluate and summarize published evidence was recognized, and various pyramids have been drawn and published. At the top of such pyramids is the systematic review, a method for analyzing and summarizing all the reliable evidence from RCTs.

Systematic reviews

Several provisos must be considered when determining whether an individual systematic review should be considered to give a reliable answer about the clinical question being asked.The most important of these are the size and quality of the component RCTs, and the possibility of publication bias. Numerous small RCTs can inflate the apparent benefit (or harm) of an intervention. This is particularly the case when negative trials may not be published, either from failure to submit, or rejection of

Systematic reviews are only reliable if they are built on reliable data

There are many systematic reviews, even in the best sources, such as the Cochrane Database, which are based on one or a few small trials of limited research quality. A systematic review based on a few low-quality small trials may have misleading results, and may be overturned by a single high-quality trial. Systematic reviews are also at risk of bias; to be reliable they should be performed according to a predefined protocol, and any deviations from that protocol should be clearly explained. A

Randomized controlled trials

Randomized controlled trials are clearly the bedrock of clinical evidence, and numerous tables have been constructed to evaluate the quality of each trial. A checklist which can be used to evaluate the reliability of both randomized and non-randomized health care interventions has been published and validated [8]. The 27-item checklist is simple to complete and gives a good overview of the methodologic quality of a study. A shorter checklist is freely available and downloadable from the

Clinically important outcomes

Outcomes that are important to infants and their families should be the primary outcomes of interest for clinical trials.

Secondary outcomes and subgroup analyses

The issue of the reliability and importance of secondary outcomes is thorny, but important. It is widely held that secondary outcomes can only be hypothesis generating, not hypothesis confirming. In a strict sense this is true, as a trial is usually designed to answer one question with sufficient power, and with all the procedures aimed at answering that one question. Any data from two groups of patients will have some significant differences between groups if you look hard enough and long

Studies of prognosis

Whenever evaluating a study of prognosis in neonatology it is important to consider how important the outcome is, and why prediction of that outcome may be useful. The characteristics of a prognostic test that make it useful depend on the reason for performing the test. So a test designed to determine future surveillance may require a high sensitivity if the surveillance is affordable and harmless, and/or a high specificity if harm is possible or cost is substantial. Prognostic testing in

Studies of diagnosis

For studies reporting a diagnostic test, comparison with a gold standard is the most important feature to evaluate. For some diagnoses, however, a “gold standard” may be lacking. For example the gold standard for diagnosis of a patent ductus arteriosus (PDA) is the demonstration of ductal flow on echocardiography. However, the definition of a “hemodynamically significant PDA” remains questionable, and there is currently no gold standard to make this diagnosis.As another example, one vitally

Studies of physiology

Many interesting studies of physiology have eventually led to improvements in management. It is important, however, to guard against making clear recommendations based only on physiologic studies. Interventions which seem physiologically justified may not lead to improved outcomes. To return to the example of sepsis, the rapid production of inflammatory mediators, which are associated with clinical signs and with mortality, has led to a series of trials of agents designed to interrupt their

Conclusion

Staying up to date with the neonatal literature is important, and a difficult but not an insurmountable challenge. Ongoing surveillance of the important journals, repeated regular searches using freely available tools, and focussed searches to answer specific questions are complementary approaches. Evaluation of whether or not the published evidence should lead to changes in clinical practice depends on the nature and the quality of the publications. Studies without controls are unreliable, and

Conflict of interest statement

None declared.

Funding sources

None.

     

Parental Information and Behaviors and Provider Practices Related to Tummy Time and Back to Sleep

IntroductionThis exploratory study aimed to discern parental understanding and behaviors, provider practices, and available online information related to infant positioning including “Back to Sleep” and “Tummy Time” (TT) during early infancy.MethodThe study employed three methods of exploration: surveys of 119 mothers of newborns, a focus group of nine health care providers, and an analysis of popular parental Web sites.ResultsNinety percent of the mothers reported receiving information about positioning the infant while asleep. However, only 55% mothers postpartum and 26% at 2 months after birth received information regarding infant positioning during awake time. Providers reported barriers such as lack of time and confusing guidelines to TT education. Parenting Web sites were inconsistent regarding TT initiation and duration information.DiscussionStudy outcomes suggest that, with the implementation of “Back to Sleep” guidelines, there has been a need for parental education about positioning infants during sleep and awake times.     

Genetic testing: when to test and when to refer

Paediatricians care for children with known or suspected genetic conditions and children at risk of genetic disorders based on family history. Paediatricians are expected to help establish the diagnosis of a genetic disorder, coordinate long-term care and serve as a resource for the family. The ever-changing landscape of genetic tests, test methods, and test sensitivity can be daunting to even the most experienced geneticist. Paediatricians need to ask questions addressing the timely use of genetic testing and thereby make decisions about when to test and when to refer.     

Exposure to violence and its relationship to psychopathology in adolescents

OBJECTIVES: This study aimed to establish prevalence of adolescents' exposure to violence and related symptoms in the South African context and to explore relationships between exposure and symptoms. SETTING: Four high schools in Cape Town, South Africa. METHODS: Self report questionnaires were administered to 104 students. Types of violence explored included: witnessing or being a victim of violence perpetrated by someone known to the child or in the home and witnessing or being a victim of violence perpetrated by a stranger. The Harvard Trauma Scale, Beck Depression Inventory, and Zung Self-Rating Anxiety Scale were used to assess potentially related symptoms. RESULTS: The majority of children had been exposed to at least one type of violence, and exposure to the one type of violence was related to the other type. Symptoms of post-traumatic stress disorder and depression appear to be related to most types of exposure to violence, but anxiety symptoms only to exposure to violence perpetrated by someone known to the child or in the home. CONCLUSIONS: Rates of exposure to violence, and related symptoms, were unacceptably high. Symptoms were associated with exposure to violence.     

Contact investigation and genotyping to identify tuberculosis transmission to children

BACKGROUND: Tuberculosis (TB) in young children is an indicator of ongoing community transmission. We examined contact investigations related to pediatric TB, yield for source case identifications and genotypes for relevant Mycobacterium tuberculosis isolates in a low-incidence setting. METHODS: We reviewed public health data for all patients with TB aged <18 years reported to Montreal authorities during 1996 to 2000. M. tuberculosis isolates from patients of all ages were subjected to IS6110-based genotyping, supplemented by spoligotyping, to compare isolates from children and adults during the same years. RESULTS: Sixty-six patients aged <18 years were diagnosed with active TB from 1996 to 2000. Mean age was 11.1 years (standard deviation 6.7 years). Twenty-five children (38%) were Canadian-born, all with at least one foreign-born parent. Nineteen children were diagnosed after contact investigations of known adult cases; 8 underwent no contact investigation. For the remaining 39 children, a total of 616 contacts were identified. The median number of contacts per child was 9 (interquartile range, 6-10). Four hundred eighty-one contacts (78%) underwent tuberculin testing; 188 (39%) were reactors and 186 (39%) began treatment of latent TB. Investigations uncovered 4 probable source cases, all involving parents or other relatives. M. tuberculosis genotyping for 38 children identified up to 14 additional possible source cases; in only one was a possible epidemiologic link evident from public health records. CONCLUSIONS: Among largely foreign-born children with active TB, contact investigations were extensive and often identified latent tuberculosis infection--but rarely source cases. However, genotyping suggested substantial, previously unrecognized transmission to children despite low overall incidence.     

Allergies to fruits and vegetables

Allergic reactions to fruits and vegetables are frequently observed in older children and adolescents. They can result from a primary sensitization to food allergens or from a primary sensitization to inhalant allergens such as pollens or latex. In the case of fruit allergies, the stability of the allergens involved is crucial to the sensitization pathway and in the clinical presentation of the food allergy. Two patients allergic to fruits are presented and discussed in the light of the allergens involved. Patient 1 was a 14 yr-old girl with a grass and olive pollen allergy who developed oropharyngeal symptoms typical of the oral allergy syndrome (OAS) with multiple fruits from taxonomically unrelated families, and who was sensitized to profilin. Patient 2 was an 8 yr-old girl, with no pollen allergies, who developed systemic reactions to peach and apple, and who was sensitized to non-specific lipid transfer proteins (LTP). Profilins are labile allergens present in pollens and foods, and sensitization occurs through the respiratory route to pollen profilin. The cross-reactive IgE antibodies generated can elicit local reactions in the oropharyngeal mucosa (OAS) when exposed to fruit profilins. In contrast, LTPs are a family of stable allergens that resist thermal treatment and enzymatic digestion, and can thus behave as true food allergens inducing primary (non-pollen related) sensitizations and triggering systemic reactions. These two cases represent two distinct patterns of sensitization and clinical expression of fruit allergies that are determined by the panallergens involved (LTPs and profilins) and their intrinsic physicochemical properties. Additionally, these two cases also show the improved diagnostic value of Component Resolved Diagnosis, and strengthen its utility in the routine diagnosis and management of patients.     

Prolonged neonatal jaundice: When to worry and what to do

Neonatal jaundice persisting beyond 14 days of age is a common clinical scenario. The vast majority of affected children have a benign unconjugated hyperbilirubinemia, but included in this clinical presentation is a group of neonates with conjugated hyperbilirubinemia and liver disease. Early identification of liver disease improves the infant’s outcome, especially for those with extrahepatic biliary atresia. The present paper reviews the approach to the neonate with prolonged jaundice, including clinical presentation, when to proceed with initial investigations, timing of referral, further investigations and management, and provides an overview of the more common causes of neonatal cholestatic liver disease.     

Orphaned and vulnerable to infection, undernutrition and early death: increasing threats to infants and children

Infants and young children in Guinea-Bissau who were made motherless had much higher mortality rates than a control group of subjects. Child mortality was higher in rural than urban children and was highest under 2 y of age and within 6 mo of their mothers' deaths. The authors of this study, which appears elsewhere in this issue, suggest that premature weaning may contribute to this excess mortality.

Conclusion: There are many causes of maternal mortality that can lead to motherlessness among infants and children, particularly in developing countries. Multifaceted approaches to the care of these children are needed to lessen their excessive mortality. Paediatricians have a potentially very important role in preventing this burden of childhood ill-health and deaths.     

School Readiness and CNS Maturity: Relation to Psychophysical and Psychosocial Development and to Early School Achievement

ABSTRACT. In randomly selected schools 113 girls and 102 boys were subjected to a School Readiness (SR) test and to a Complex Reaction Time (CRT) measurement at the age of 7. Their psychophysical development, social adjustment and school achievement were assessed by teachers and by means of self-ratings during the first 3 school years. The developmental outcome of the children seemed principally related to CNS-maturity as measured by CRT, and not to the SR test scores. A CNS-dysfunction, indicated by slow CRT, seemed to be an essential handicap during the early school years, impairing particularly the boys' language and motor development and their school achievement and causing feelings of inferiority. This handicap, which is mainly a developmental delay, should thus be taken into consideration when assessing school maturity. Early detection of this handicap might enable us to take preventive measures with regard to these children.