GCF Chan

In this issue, one article describes the intermediate term effect on growth and well being of children affected by the melamine-contaminated dairy products at Zhejiang province in China. At that time, melamine was added to the milk so it interfere the quantitative assessment of the protein in order to mask the effect of dilution. Such malpractice was widely adopted by the dairy farmers in China and eventually the high melamine content led to renal calculi formation in some infants who consumed the contaminated products. Many Chinese children including those in Hong Kong had been taking such dairy products at that time. This incidence ignited a furious public response and in consequence, people lost their faith on local dairy products because even reputable national scale manufacturers were involved. On one hand, it is relieving now to find out that vast majority of the children exposed to such melamine contaminated milk products do not appear to have intermediate term effects. On the other hand, how to prevent similar food safety hazard from recurrence has been hotly debated. The result of such chaos is far beyond the original dimension. A significant proportion of Chinese parents crossed the border to purchase foreign dairy products and led to shortage of formula milk in Hong Kong. Many Hong Kong residents and politicians were quick to react and asked for using legislative measure to tighten the control of food products manufacturing within China. They also imposed a limit on the exportation of foreign formula milk across the border. Does legislation process really solve the problem?

All those of us who are familiar with the situation in China would know that there are already plenty of laws and regulations governing the food safety and medical practice comparing to other parts of the world. But food products safety issues just keep happening. Using medical related legislation as example, Tetracycline and Quinolone derivatives are not allowed to be used for children in China. The initial motive is to protect the children from Tetracycline related side effects such as dental stain or dysplasia or Quinolone related side effects such as abnormal osteogenesis on growing children. However, when medical practice is dictated by law, the previously unforeseen side effects evolve. Now we are facing wide spread Macrolides resistant Mycoplasma in China, children suffer from serious Mycoplasma chest infections can be fatal or develop permanent organ dysfunction for they are not allowed to receive newer generations of Tetracycline or Quinolones, even these are recommended approach for children internationally. Therefore, setting more laws and regulations may lead to unnecessary hindrance and at the same time, does not necessary prevent malpractice to recur.

One of the primary issues of the melamine-contaminated milk product is due to the low and suppressed purchase price set by the big dairy enterprise and the dairy farmers have no bargaining power to refuse. This is further aggravated by the lack of adequate law enforcement at the root level. Even more importantly is the lack of social conscience and personal moral value. These basic ethics have to be taught and emphasize early in life, similar to other essential basic knowledge that we have to acquire. The public has to develop a sense of responsibility for what they are doing. Such cultural change may take time to sublimate into the social practice level and therefore should be implemented as soon as possible.

Another article applies the latest version of American Academy of Pediatrics guideline on managing urinary tract infection of local young children. It is a matter of standardising clinical practice based on existing evidence. Most of us agree that it is a good clinical practice that we update our medical management guidelines regularly based on the emerging evidence. What we believe to be true in the past may not be so in the future. For example, the guidelines of giving antibiotic prophylaxis for rheumatic fever, or for post-splenectomy patients have changed quite significantly in recent years. One important aspect is that while guidelines aim at a standardised practice, but whether it should always be "strictly" followed remains to be discussed. This is particularly true for those opinion-based guidelines. Local experts can modify the guidelines according to their own unique issues. In addition, guidelines have to be revised regularly with time. As we know, new understanding of the disease process and availability of new treatment modalities may affect our approach. Therefore, some allowance should be given to clinical practice when new information evolves and yet guidelines have not been revised on-time. One such example is the management of infantile haemangioma. While observation without treatment used to be the standard practice for most infantile haemangioma, the discovery of Propranolol as a new form of treatment is changing our approach now though new guidelines have not been developed yet.

With the evolution of genetics, obtaining an individual pharmacogenetic profile is now feasible and no longer a myth. When such information is widely available, it will inevitably change our future medical practice. The future drug usage has to consider an individual's tolerance based on genetic data and therefore same dosage should not be uniformly applied to everyone as in the past. Such personalised medicine approach will inevitably impact on standardised therapeutic regimens. Future clinical studies will have to consider individual variance and certain degree of flexibility will have to be allowed.

Therefore, we need rules and regulations in food safety and clinical practice. However, we don't need too much rules and regulations which hinder our progress and new approaches. Whenever food or medical related incidences occur, we should investigate the root causes and try to solve it with the existing umbrella of laws rather than seeking help from setting up new laws instantaneously. Furthermore, both laws and guidelines have to be revised constantly with time to suit the changing environment, culture, epidemiology and technology.