Evidence based pediatrics - part 1 ppt

EVIDENCE-BASED PEDIATRICS EVIDENCE-BASED PEDIATRICS William Feldman, MD, FRCPC Professor Emeritus of Pediatrics University of Toronto Editor, Annals of the Royal College of Physicians and Surgeons of Canada Ottawa, Canada 2000 B.C. Decker Inc. Hamilton • London • Saint Louis United States B.C. Decker Inc. P.O. Box 785 Lewiston, NY USA Tel: 905-522-7017/1-800-568-7281 Fax: 905-522-7839 e-mail: info@bcdecker.com Canada B.C. Decker Inc. 4 Hughson Street South P.O. Box 620, L.C.D. 1 Hamilton, Ontario, Canada L8N 3K7 Tel: 905-522-7017; 1-800-568-7281 Fax: 905-522-7839 e-mail: info@bcdecker.com Japan Igaku-Shoin Ltd. Foreign Publications Department 3-24-17 Hongo, Bunkyo-ku, Tokyo 113-8719, Japan Tel: 3 3817 5676 Fax: 3 3815 6776 e-mail: fmbook@ba2.so-net.or.jp South America Ernesto Reichmann, Distribuidora De Livros Ltda. Rua Coronel Marques 335-Tatuape, 03440-000 Sao Paulo-SP-Brazil Tel/Fax: 011-218-2122 U.K., Europe, Scandinavia, Middle East Blackwell Science Ltd. 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No part of this publication may be reproduced, stored in a retrieval system, or trans- mitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. 00 01 02 03 / PC / 6 5 4 3 2 1 ISBN 1-55009-087-9 Printed in Canada Sales and Distribution Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and prac- tice at the time of publication. However, since research and regulation constantly change clinical stan- dards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Adelle Roberta Atkinson, RN, BSc, MD, FRCPC, FAAP Fellow, Division of Immunology and Allergy The Hospital for Sick Children Toronto, Canada Carol S. Camfield, MD, FRCPC IWK Grace Health Centre Professor of Pediatrics Department of Pediatrics Dalhousie University Medical School Halifax, Canada Peter R. Camfield, MD, FRCPC IWK Grace Health Centre Professor and Chair, Department of Pediatrics Dalhousie University Medical School Halifax, Canada H. Dele Davies, MD, MSc, FRCPC Director, Child Health Research Unit Alberta Children’s Hospital Associate Professor Departments of Pediatrics, Microbiology and Infectious Diseases and Community Health University of Calgary Calgary, Canada Paul T. Dick, MDCM, MSc, FRCPC Pediatrician, Division of Pediatric Medicine The Hospital for Sick Children Assistant Professor of Pediatrics University of Toronto Toronto, Canada J.M. Dooley, MBBCh, FRCPC Division of Pediatric Neurology IWK-Grace Health Centre Associate Professor, Department of Pediatrics Dalhousie University Halifax, Canada Darcy L. Fehlings, MD, MSc, FRCPC Hospital for Sick Children Bloorview MacMillan Centre Assistant Professor in Pediatrics University of Toronto Toronto, Canada Brian M. Feldman, MD, MSc, FRCPC Staff Rheumatologist The Hospital for Sick Children Clinical Chief, Arthritis Team Bloorview MacMillan Centre Assistant Professor University of Toronto Toronto, Canada Mark E. Feldman, MD, FRCPC Chief of Pediatrics St. Joseph’s Health Centre Assistant Professor University of Toronto Toronto, Canada William Feldman, MD, FRCPC Professor Emeritus of Pediatrics University of Toronto Editor, Annals of the Royal College of Physicians and Surgeons of Canada Ottawa, Canada Contributors  Norma Goggin, MBBCh, MRCP Lecturer in Ambulatory Paediatrics, Department of Child Health Royal Free and University College Medical School University College London Royal Free Hospital London, United Kingdom Ronald Gold, MD, MPH, FRCPC Honorary Consultant The Hospital for Sick Children Professor Emeritus of Pediatrics Faculty of Medicine University of Toronto Toronto, Canada Eudice Goldberg, MD, FRCPC Head, Division of Adolescent Medicine The Hospital for Sick Children Associate Professor of Pediatrics Department of Pediatrics Faculty of Medicine University of Toronto Toronto, Canada K.E. Gordon, MD, MS, FRCPC Division of Pediatric Neurology IWK-Grace Health Centre Associate Professor, Department of Pediatrics Dalhousie University Halifax, Canada Saul Greenberg, MD, FRCPC Staff Physician The Hospital for Sick Children Associate Professor University of Toronto Toronto, Canada R. I. Hilliard, MD, EdD, FRCPC Division of Pediatric Medicine The Hospital for Sick Children Professor of Pediatrics University of Toronto Toronto, Canada Moshe Ipp, MBBCh, FRCPC, FAAP The Hospital for Sick Children Associate Professor University of Toronto Toronto, Canada Sheila J. Jacobson, MBBCh Division of Pediatric Medicine The Hospital for Sick Children Assistant Professor in Pediatrics University of Toronto Toronto, Canada Debra K. Katzman, MD, FRCPC Medical Director, The Eating Disorder Program The Hospital for Sick Children Associate Professor of Pediatrics Department of Pediatrics University of Toronto Toronto, Ontario Kevin B. Laupland, MD, FRCPC Division of Infectious Diseases Alberta Children’s Hospital Fellow, Infectious Diseases and Critical Care University of Calgary Calgary, Canada Katherine A. Leonard, MD, FRCPC Adolescent Health Service North York General Hospital Pediatric Department/Teen Clinic Centenary Health Centre North York, Canada Brian W. McCrindle, MD, MPH, FRCPC Staff Cardiologist The Hospital for Sick Children Associate Professor of Pediatrics University of Toronto Toronto, Canada vi Evidence-Based Pediatrics Golda Milo-Manson, MD, MHSc, FRCPC Developmental Pediatrician Bloorview-MacMillan Centre The Hospital for Sick Children North York General Hospital Assistant Professor University of Toronto Toronto, Canada Michael E.K. Moffatt, MSc, FRCPC Health Sciences Centre Professor and Head, Department of Pediatrics and Child Health University of Manitoba Winnipeg, Canada Arne Ohlsson, MD, MSc, FRCPC Director, Evidence Based Neonatal Care and Outcomes Research Staff Neonatologist Mount Sinai Hospital Professor, Departments of Pediatrics, Obstetrics and Gynecology, and Public Health Sciences University of Toronto Toronto, Canada Patricia C. Parkin, MD, FRCPC Associate Professor Department of Pediatrics University of Toronto Faculty of Medicine Head, Division of Pediatric Medicine Hospital for Sick Children Toronto, Canada Hema Patel, MD, MSc, FRCPC Ambulatory Care Pediatrician The Montreal Children’s Hospital Assistant Professor in Pediatrics McGill University Montreal, Canada Norman R. Saunders, MD, FRCPC Associate Professor in Pediatrics University of Toronto Toronto, Canada Vibhuti Shah, MD, MRCP(UK) Department of Newborn and Developmental Pediatrics Research Fellow in Neonatology Sunnybrook and Women’s College Health Sciences Centre Toronto, Canada Amir Shanon, MD, MPA Director, Department of Medical Professionals Ministry of Health Tel Aviv, Israel Michelle Kiran Shouldice, MSc, MD, FRCPC Section Head, Pediatric Outpatient Consultation The Hospital for Sick Children Assistant Professor University of Toronto Toronto, Canada Michael B.H. Smith, MBBCh, FRCPC Division Head in Pediatric Medicine Physician Leader Acute and Chronic Care IWK Grace Health Centre Assistant Professor in Pediatrics Dalhousie University Halifax, Canada Lynne J. Warda, MD, FRCPC Pediatric Emergency Physician Children’s Hospital, Winnipeg Medical Director, IMPACT—The Injury Prevention Centre of Children’s Hospital, Winnipeg Assistant Professor, Department of Pediatrics and Child Health University of Manitoba Winnipeg, Canada Contributors vii This book is dedicated to infants, children, and adolescents, and to the physicians who care for them. The recipients and providers of health care all benefit when the care is evidence based. Preface  Appropriate medical care for infants and children has three components. The first consists of the clinical skills of the practitioner to provide the preventive, diagnostic, and therapeu- tic interventions that are required to maintain health and to solve clinical problems. The sec- ond component is the practitioner’s awareness of the need to ascertain the patients’ and parents’ knowledge of the nature of the problem and their values regarding how it should be solved. The third component, and by no means the least important, is the practitioner’s determination that all interventions—preventive, diagnostic, therapeutic, and rehabilita- tive—should only be offered when the evidence that the intervention does more good than harm has been thoroughly reviewed. The purpose of this book is to provide the physicians and nurses who care for infants and children with the best available evidence regarding the benefit/risk ratios underlying their interventions. To quote those who have made the concept of “evidence-based medicine” recognized throughout the world: “ evidence-based medicine involves the integration of our clinical expertise, and our patients’ values, with the best available research evidence.” 1 As the editor of Evidence-Based Pediatrics, I was faced with a number of challenges. The first was the choice of topics and problems to be included in the book. Because the likeliest readers are those engaged in the frontline provision of child health care, I decided that the emphasis would be on the most prevalent problems that pediatricians, family physicians, and nurses would face in day-to-day practice. Although only a few rare conditions are discussed, the “red flags” that should alert the practitioner that a rare or serious condition may be causing the child’s problems, are high- lighted throughout the book. The second challenge was the choice of authors. Having practiced as a primary care pedi- atrician, a subspecialist, and mainly as a general consultant pediatrician, I was aware that pediatricians in all three categories have valuable perspectives regarding child health care. I chose, therefore, not to select chapter writers on the basis of whether they were primary-care pediatricians, general consultants, or subspecialists, but rather on the basis of their clinical expertise and their knowledge and practice of evidence-based pediatrics. Thus, some of the authors are in busy primary care practices, some are hospital-based general consultants, and some are subspecialists. Finally, the challenge of how to evaluate the quality of the evidence and the strength of the recommendations required careful consideration. I chose the system of evaluation of evi- dence used by the Canadian Task Force on the Periodic Health Examination. 2 A similar sys- tem has also been used by the U.S. Preventive Services Task Force. 3 In this system (Table 1), the highest quality (level I) of evidence is that obtained from properly conducted random- ized controlled trials (RCTs), and the lowest level (level III) is that derived from opinions of authorities or expert committees, or from descriptive studies. An “A” recommendation, usu- ally based on level I evidence, advises the practitioner to perform the intervention because the benefit/risk ratio is clearly high. A “C” recommendation advises the practitioner that the evidence either to use or not use a particular intervention is poor. An “E” recommendation advises that the intervention should not be used, either because the evidence is good that the maneuver is ineffective or is actually harmful. The “B” and “D” recommendations are based on “fair” evidence that the maneuver should (B) or should not (D) be performed. This system of grading the evidence and recommendations was chosen because it has been widely used throughout North America for at least 20 years and appears to be well understood and accepted. In correspondence with a colleague, who practices and teaches Family Medicine, the system is described as having “real clinical utility as a way to summa- rize evidence. I know of no other that is better or more transparent.”As he states,“In my dis- cussions with practicing family doctors, they have often said that they really want the bottom line. What they mean is that at the community level, they need to know concisely and in a timely fashion (without having to search out the original studies) what they should do with the patient in the office. Having “A”,“B”, “C”, etc. is helpful and straightforward.” 4 I hope the readers of this book will find the evidence and the recommendations concise, timely, helpful, and straightforward. William Feldman, MD, FRCPC QUALITY OF EVIDENCE I: Evidence obtained from at least one properly randomized controlled trial. II-1: Evidence obtained from well-designed controlled trials without randomization II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category. III: Opinions of respected authorities, based on clinical experience, descriptive stud- ies or reports of expert committees. CLASSIFICATION OF RECOMMENDATIONS A: There is good evidence to support the recommendation that the intervention be performed. B: There is fair evidence to support the recommendation that the intervention be performed. C: There is poor evidence regarding the value or harm of the intervention; recom- mendations may be made on other grounds. D: There is fair evidence to support the recommendation that the intervention not be performed. E: There is good evidence to support the recommendation that the intervention not be performed. REFERENCES 1. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence-based medicine: What it is and what it isn’t. BMJ 1996;312:71–2. 2. The Canadian Guide to Clinical Preventive Health Care. The Canadian Task Force on the Peri- odic Health Examination. Canada Communication Group Publishing, Ottawa, 1994. 3. Guide to Clinical Preventive Services, Second Edition. Report of the U.S. Preventive Services Task Force, William and Wilkins Publishers, USA, 1996. 4. McIsaac, Warren, MD. personal communication. May 1999. x Evidence-Based Pediatrics Contents  Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix 1. Problems of the Newborn: Prevention and Management . . . . . . . . . . . . . . . . . . . . . . .1 Vibhuti Shah, MD, MRCP, Arne Ohlsson, MD, MSc, FRCPC 2. Health Maintenance Visits: a Critical Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Norman R. Saunders, MD, FRCPC, Michelle Shouldice, MSc, MD, FRCPC 3. Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Ronald Gold, MD, MPH, FRCPC 4. Nutrition Problems in Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 R.I. Hilliard, MD, EdD, FRCPC 5. Acute Rhinitis and Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Michael B.H. Smith, MBBCh, FRCPC 6. Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 Moshe Ipp, MBBCh, FRCPC, FAAP 7. Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123 Patricia Parkin, MDM FRCPC, Norma Goggin, MBBCh, MRCP 8. Pneumonia and Bronchilotis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155 Kevin B. Laupland, MD, FRCPC, H. Dele Davies, MD, MSc, FRCPC 9. Croup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177 Mark Elliott Feldman, MD, FRCPC 10. Common Cardiovascular Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191 Brian W. McCrindle, MD, MPH, FRCPC 11. Abdominal Pain in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213 Hema Patel, MD, MSc, FRCPC 12. Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229 Peter Camfield, MD, FRCPC, Carol Camfield, MD, FRCPC 13. Headaches in Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243 J.M. Dooley, MBBCh, FRCPC, K.E. Gordon, MD, MS, FRCPC 14. Injury Prevention: Effectiveness of Primary Care Interventions . . . . . . . . . . . . . . . .267 Lynne J. Warda, MD, FRCPC 15. Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283 Amir Shanon, MD, MPA 16. Screening for Anemia in Infants and Toddlers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293 Michael E.K. Moffatt, MD, MSc, FRCPC [...]... Health Care 19 96 ;1: 16 5-9 55 American Academy of Pediatrics Committee on Fetus and Newborn Hospital stay for healthy term newborns Pediatrics 19 95;96:78 8-9 0 56 Neifert MR The optimization of breast-feeding in the perinatal period Clin Perinatol 19 98;25:30 3-2 6 57 The Australian College of Pediatrics Policy statement on breastfeeding J Pediatr Child Health 19 98;34: 41 2-3 14 Evidence- Based Pediatrics 58... Scand J Caring Sci 19 87 ;1: 5 1- 8 71 Waldenström U, Sundelin C, Lindmark G Early and late discharge after hospital birth Health of mother and infant in the postpartum period Upsala J Med Sci 19 87;92:30 1- 1 4 72 Annas GJ Women and children first N Engl J Med 19 95;333 :16 4 7-5 1 73 Carty EM, Bradley CF A randomised, controlled evaluation of early postpartum hospital discharge Birth 19 90 ;17 :19 9-2 04 74 Waldenström... statistics — 19 97 Pediatrics 19 98 ;10 2 :13 3 3-4 9 4 Joseph KS, Kramer MS Recent trends in Canadian infant mortality rates: effect of changes in registration of live newborns weighing less than 500 g Can Med Assoc J 19 96 ;15 5 :10 4 7-5 2 5 Joseph KS, Kramer MS, Marcoux S, et al Determinants of preterm birth rates in Canada from 19 81 through 19 83 and from 19 92 through 19 94 N Engl J Med 19 98;339 :14 3 4-9 6 Kramer... after birth [abstract] Pediatr Res 19 99;45:350A 12 Evidence- Based Pediatrics 17 Canadian Task Force on the Periodic Health Examination Periodic health examination, 19 92, update 4 Prophylaxis for gonococcal and chlamydial ophthalmia neonatorum Can Med Assoc J 19 92 ;14 7 :14 4 9-5 4 18 Crede CSR Die Verhutung der Augenentzundung der Neugeborenen Arch Gyn 18 81; 18:36 7-7 0 19 Lund RJ, Kibel MA, Knight GJ, van... first three months of life in 18 4 cases of phenylketonuria Arch Dis Child 19 70;45: 5 -1 2 30 Williamson ML, Koch R, Azen C, Chang C Correlates of intelligence test results in treated phenylketonuric children Pediatrics 19 81; 68 :16 1- 7 31 Azen CG, Koch R, Friedman EG, et al Intellectual development in 12 -year old children treated for phenylketonuria Am J Dis Child 19 91; 145:3 5-9 32 Koch R, Yusin M, Fishler... of Oman: 19 99 Muscat, Oman: Unicef/Ministry of Health Sultanate of Oman [in press] 64 Fetus and Newborn Committee, CPS Neonatal circumcision revisited Can Med Assoc J 19 96 ;15 4:76 9-8 0 65 American Academy of Pediatrics Task force on Circumcision Circumcision policy statement Pediatrics 19 99 ;10 3:68 6-9 3 66 Anonymous Trends in length of stay for hospital deliveries — United States, 19 7 0 -1 992 MMWR 19 95;44:335–7... screening J Pediatr 19 92 ;12 1:58 1- 4 38 Van Vliet G Neonatal hypothyroidism: treatment and outcome Thyroid 19 99;9:7 9-8 4 39 Lawrence RA Breastfeeding: a guide for the medical profession St Louis: Mosby; 19 99 40 Wang YS, Wu SY The effect of exclusive breastfeeding on the development and incidence of infection in infants J Human Lactation 19 96 ;12 :2 7-3 0 41 Brandt KA, Andrews CM, Kvale J Mother-infant interaction... this study, the group with 10 scheduled visits ultimately averaged only 7.89 well-baby visits, whereas the five-visit group averaged 6 .19 well-baby visits in the first 2 years18 (Table 2 1) A prenatal visit is often felt to be useful, particularly for first-time parents Several objectives can be served by this meeting, particularly, promoting the physician-patient relation- Table 2 1 Frequency of Health Maintenance... Engl J Med 19 88; 318 :65 3-5 7 23 Hammerschlag MR, Cummings C, Roblin PM, et al Efficacy of neonatal ocular prophylaxis for the prevention of chlamydial and gonococcal conjunctivitis N Engl J Med 19 89;320:76 9-7 2 24 Isenberg SJ, Apt L, Yoshimori R, et al Povidone-iodine for ophthalmia neonatorum prophylaxis Am J Ophthalmol 19 94 ;11 8:70 1- 6 25 Isenberg SJ, Apt L, Wood M A controlled trial of povidone-iodine as... breast-feeding 6 Evidence- Based Pediatrics Table 1 3 “Ten Steps to Successful Breast-Feeding” 1 Have a written breast-feeding policy that is routinely communicated to all health care staff 2 Train all health-care staff in the skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breast-feeding 4 Help mothers initiate breast feeding within 1 hour . PA 19 442 Tel: 61 0-8 2 7 -1 640 Fax: 61 0-8 2 7 -1 6 71 B.C. Decker Inc. 4 Hughson Street South P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 90 5-5 2 2-7 017 ; 1- 8 0 0-5 6 8-7 2 81 Fax: 90 5-5 2 2-7 839 E-mail:. 90 5-5 2 2-7 017 ; 1- 8 0 0-5 6 8-7 2 81 Fax: 90 5-5 2 2-7 839 e-mail: info@bcdecker.com Japan Igaku-Shoin Ltd. Foreign Publications Department 3-2 4 -1 7 Hongo, Bunkyo-ku, Tokyo 11 3-8 719 , Japan Tel: 3 3 817 5676 Fax: 3 3 815 . 90 5-5 2 2-7 017 / 1- 8 0 0-5 6 8-7 2 81 Fax: 90 5-5 2 2-7 839 e-mail: info@bcdecker.com Canada B.C. Decker Inc. 4 Hughson Street South P.O. Box 620, L.C.D. 1 Hamilton, Ontario, Canada L8N 3K7 Tel: 90 5-5 2 2-7 017 ;