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Early in this decade I sensed a renewed interest in child global health. The commitment to improve the well‐being of children living around the world has been fuelled by numerous factors, including the HIV epidemic, the remarkable leadership and content of the Lancet, as reflected both by its various commissioned series on neonatal and child health as well as its original research reports, and the resources of the Gates Foundation, which have now doubled because of the Buffet gift. Over the past 2–3 years, the focus has expanded from infectious diseases in sub‐Saharan Africa, particularly HIV disease, to other issues, such as neurocognitive development, and to other areas of the world, including Asia and Latin America. In this issue, there is a report from Pakistan, with an accompanying perspective by Zulfi Bhutta, which compares standard versus double dose amoxicillin for non‐severe pneumonia in children. At least in this area of the world, there appears to be no difference in failures and relapses. Professor Bhutta touches on many of the complex decisions in managing acute respiratory infections in children in the developing world, including, appropriate diagnosis, the lack of microbiological confirmation, appropriate end‐points of care, and local bacterial resistance patterns. These issues are not likely to be resolved in the near future, hence, the importance of preventive strategies, including sustained exclusive breast‐feeding, reducing micronutrient deficiencies such as zinc and Vitamin A, and the provision of appropriate immunisations, particularly pneumococcal conjugate vaccine. I am hopeful that within the next five years many of the indicators of child health will begin to improve.
See pages 286 and 291
Whenever possible, recommendations for screening, or the treatment of common diseases, should be based upon high quality evidence. Why? Well in the case of screening – the process of identification, case‐finding, treatment – is complicated and fraught with potential biases. In addition, screening often focuses on large numbers of patients, and can have enormous implications. With respect to common diseases, such as hypertension, or congestive heart failure, once again, evidence based guidelines (and care) can reduce variation, improve quality of care and hopefully avoid inappropriate testing and use of expensive therapies. However, when dealing with uncommon diseases—for example, meningococcal disease, which causes about 1400 laboratory‐confirmed cases each year in England and Wales, we must blend the art of medicine with available evidence. Pollard and colleagues are to be congratulated for accomplishing such a task. In their updated alogorithm for the early management of meningococcal disease in children, they justify, using the available but limited evidence, most of their recommendations. They acknowledge if recommendations are based upon studies in adults rather than children. Does an alogorithm such as the one developed by Pollard and colleagues have a place in a profession increasingly searching for the “right” answers? Unequivocally yes. We continue to lack data for many of the important clinical decisions in paediatrics. Algorithms such as the one developed by the Oxford group, are an excellent starting point for educating our colleagues, providing care and developing much needed clinical trials.
See page 283
Each year we receive between 5 and 10 papers that report new reference standards. Some we publish, some we do not. How do we decide? First and foremost the references must be derived from a large non‐referral population, with children of different ages and sex. Second, the analytical technique and presentation of the data must meet rigorous statistical standards. Lastly, the standards must be important—that is, reflect a significant problem that is relevant to many children. In this issue we present new blood pressure centiles for Great Britain. The standards are derived from over 22000 children who participated in seven nationally representative surveys conducted in the 1990s, just at the beginning of the obesity epidemic. In an accompanying perspective, Stranges and Cappuccio discuss the many strengths of this report and its importance given the concern about a developing hypertension epidemic. Unfortunately, like many other reference standards, race and ethnicity are not reflected in these new centiles. Regardless, they should lead to the early detection of high blood pressure in children.
See pages 288 and 298
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