How Good is the Evidence?
For the present issue of the Hong Kong Journal of Paediatrics, we do not have a specific theme, but instead a variety of reviews and original papers. As in any clinical journal, our aim is to present to our readers some evidence which they may find useful in their daily practice.
We are grateful to Prof PI Lee and Prof CY Lee from National Taiwan University for contributing an annotation on the recent epidemic of enterovirus infection in Taiwan.1 Approximately 90,000 enterovirus infections were reported from sentinel physicians, with 314 children hospitalised and 55 of them died. This epidemic in Taiwan and the recent influenza H5N1 outbreak in Hong Kong surely bring home the message that infectious diseases are far from being eradicated in the more developed societies, they only take a different form.
Dr DJ Atherton has given us a thorough review on infantile haemangiomas,2 which are of relatively high prevalence of 1-3% during neonatal period and about 10% by end of first year of life. Lesions of such high prevalence definitely demand attention from most of us and because of its high visibility and sometimes rather distressing, parents will surely demand treatment, hoping for immediate cure. Careful chartings of the natural history of these lesions in fact dictate some lesions should receive no more than expectant management, with lots of explanation for parents, while for some lesions, "therapeutic nihilism" is definitely wrong, an aggressive approach is warranted. Dr. Atherton has indeed shared with us his valuable experience, illustrated by first class clinical pictures.
Nutrition is the cornerstone of child health practice, especially infant nutrition. Dr WWK Koo et al's review of infant nutrition is comprehensive and at the same time practical.3 Colleagues will find many useful recommendations from Dr Koo, backed by an extensive reference list. In contrast, Dr VYH Yu has focused on one aspect of infant nutrition, that is the addition of nucleotides in infant formula.4 Since human milk contains more nucleotides than bovine milk and based on the belief that human milk is the "gold standard", nucleotides supplemented infant formulas have been introduced. However Dr. Yu demonstrated in his critical analysis of the published data that the evidence for clinically beneficial effects of nucleotide-supplemented infant formulas was rather thin. Moreover he drew our attention to the "substitution game", that is using a laboratory outcome measure to substitute for a clinical outcome measure in some of the published randomised clinical trials. Dr Yu's article is a prime example of how to practise evidence-based child health.
Neonatal intensive care medicine has always been exciting and generating controversies and surprises, sometimes quite shocking. For example after years of use of diuretics in preterm babies with intraventricular hemorrhage, in the hope of reducing the chance of hydrocephalus and hence neurological deficits, only a recent randomised controlled trial has demonstrated the treated group of babies may have a worse neurological outcome.5 As Dr WA Silverman argued elegantly in his book, "Where's the Evidence?", that "therapy must always be seen as a sword with at least two edges".6 We have to be critical in our clinical practice, to be based on evidence as much as possible. Therefore it is important for local neonatologists, and indeed all child health care workers, not only to know but to practise evidence-based child health ( 坐言起行 ) To generate locally relevant data should be part of our role. Cohort study as that reported by Dr BCC Lam et al will be a useful first step, pointing to future directions of study.7 Dr KY Chan et al also reported their screening programme for deafness among high risk neonates, challenging at the same time the cost-effectiveness of the present screening programme.8
Paediatric cardiology has reached new heights again and two groups of paediatric cardiologists reported their valuable experience in interventional catheterisation in closing patent ductus arteriosus, taking over the role of cardiac surgeons.9,10 Indeed paediatric cardiologists, in the eyes of general paediatricians, seem to work more like surgeons than internists. Collaboration among hospitals in providing intensive treatment across regions, such as that in paediatric cardiology, will depend on high-quality patient transport system. Dr YF Cheung et al reported the audit of such a system and the team's effort has to be commended.11
Professor Haycock in the 25th C Elaine Field Lecture gave us a comprehensive update on the management of steroid sensitive nephrotic syndrome,12 which all paediatricians should know and feel at ease to treat. Only difficult cases need attention of paediatric nephrologists. We have introduced a Postgraduate Column, under which Dr DKK Ng reviewed inborn errors of metabolism in neonates, admittedly a very difficult area.13 He also reported a brief survey of such diseases in Hong Kong.
With all these wide-ranging reviews and reports, we sincerely hope you enjoy reading your Journal.
1. Lee PI, Lee CY. Epidemic of Severe Enterovirus 71 Infection in Taiwan. HK J Paediatr (New Series) 1998;3:87-8.
2. Atherton DJ. Infantile Haemangiomas: A review. HK J Paediatr (New Series) 1998;3:89-102.
3. Koo WWK, Raju NV, Tan-Laxa MA. Infant Nutrition. HK J Paediatr (New Series) 1998;3:103-21.
4. Yu VYH. Nucleotides in Infant Formula - Evidence for Clinically Beneficial Effects? HK J Paediatr (New Series) 1998;3:122-6.
5. International PHVD Drug Trial Group. International randomised controlled trial of acetazolamide and furosemide in post-haemorrhage ventricular dilatation in infancy. Lancet 1998;352:433-40.
6. Silverman WA. Where's the Evidence? Debate in Modern Medicine. Oxford University Press, Oxford 1998.
7. Lam BCC, Wong KY, Ng YK, Leung CW, Hui SF, Yeung CY Retinopathy of Prematurity: Incidence and Perinatal Risk Factors. HK J Paediatr (New Series) 1998;3:127-30.
8. Chan KY, Lee F, Chow CB, Shek CC, Mak R. Early Screening and Identification of Deafness of High Risk Neonates. HK J Paediatr (New Series) 1998;3:131-5.
9. Ng YM, Wong DML, Chan KC, Lun KS, Lee SH, Gob TH. Transcatheter Closure of Patent Ductus Arteriosus using Gianturco Coils and Ballon Wedge Catheter Method: Experience in Queen Elizabeth Hospital. HK J Paediatr (New Series) 1998;3:136-40.
10. Cheung YE, Leung MP, Chau KT. Transcatheter Coil Occlusion of Native and Residual Arterial Ducts. HK J Paediatr (New Series) 1998;3:141-6.
11. Cheung YE, Leung MP, Chau KT, Hung KW, Cheung MH. Audit of Paediatric Cardiac Patient Transport. HK J Paediatr (New Series) 1998;3:147-53.
12. Haycock GB. Management of Steroid Sensitive Nephrotic Syndrome. HK J Paediatr (New Series) 1998;3:154-7.
13. Ng DKK. Inborn Errors of Metabolism in Neonates. HK J Paediatr (New Series) 1998;3:158-66.
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