A review of randomised controlled trials published in Archives of Disease in Childhood from 1982-96

Success rate of nitrous oxide-oxygen procedural sedation in dental patients: systematic review and meta-analysis

The aim of this systematic review was to determine the success rate of nitrous oxide-oxygen procedural sedation (NOIS) in dentistry. A systematic digital search was conducted for publications or reports of randomized controlled trials evaluating the clinical performance of NOIS. Abstracts of research papers were screened for suitability, and full-text articles were obtained for those who met the inclusion and exclusion criteria accordingly. The quality of the studies was assessed using the revised Cochrane risk-of-bias tool (RoB 2). A total of 19 articles (eight randomized clinical trials with parallel intervention groups and 11 crossover trials), published between May 1988 and August 2019, were finally selected for this review. The studies followed 1293 patients reporting NOIS success rates, with a cumulative mean value of 94.9% (95% CI: 88.8–98.9%). Thirteen trials were conducted on pediatric populations (1098 patients), and the remaining six were conducted on adults (195 patients), with cumulative efficacy rates of 91.9% (95% CI: 82.5–98.1%) and 99.9% (95% CI: 97.7–100.0%), respectively. The difference was statistically significant (P = 0.002). Completion of treatment and Section IV of the Houpt scale were the most used efficacy criteria. Within the limitations of this systematic review, the present study provides important information on the efficacy rate of NOIS. However, further well-designed and well-documented clinical trials are required and there is a need to develop guidelines for standardization of criteria and definition of success in procedural sedation. Currently, completion of treatment is the most used parameter in clinical practice, though many others also do exist at the same time. To maximize NOIS efficacy, clinicians should strictly consider appropriate indications for the procedure.

The uncertain fate of the National Institutes of Health (NIH) pediatric research portfolio

BACKGROUND

The amount of federal dollars allocated to improving the health of our pediatric population can serve as an indicator of the priority placed on child well-being. Although Congress has established novel mechanisms that marginally increase pediatric research funding, the pediatric research portfolio is facing an increasingly uncertain fate.

METHODS

This work examines pediatric, perinatal and pediatric research initiative (PRI) spending using data collected by the NIH that uses the novel research, condition and disease categorization system. Further, this work reports on recent policy developments in pediatric biomedical research and offers recommendations to insulate this portfolio from future uncertainty.

RESULTS

Federal support for pediatric research has declined with average annual growth rates of NIH pediatric spending dropping from 12.8% (FY 1998-2003) to 1.7% (FY 2004-2015). After taking into account Biomedical Research and Development Price Index growth, the pediatric research portfolio's purchasing power has declined by 15.9% (FY 2004-2015).

CONCLUSION

Federal support for pediatric biomedical research has plateaued in nominal terms and declined significantly in real terms. Future congressional action will be necessary to protect gains and to expand the capacity of the pediatric portfolio.

Quality of life in parents of preterm infants in a randomized nutritional intervention trial

BACKGROUND

Being a parent of a very-low birth weight (VLBW, birth weight <1,500 g) infant is challenging because of the numerous complications these infants may encounter, many of which are caused by inadequate nutrition. Whether the burden to the parents increases when their VLBW infant participates in a randomized intervention trial (RCT) and is thus exposed to additional risk is unknown.

OBJECTIVE

To examine parental qualify of life (QoL) and well-being after participation of their VLBW infants in a nutrition RCT.

DESIGN

QoL and symptoms associated with well-being of parents of VLBW infants participating in a nutrition RCT (n=31) and of a reference group (parents of nonparticipating VBLW infants, n=31) were examined. Assessments were performed when their infants were in the neonatal intensive care unit (NICU) (time point T1) and concurrently at 3.5 years of age (time point T2). The parents completed the following questionnaires: Quality of Life Scale, Hospital Anxiety and Depression Scale, Lee Fatigue Scale (LFS), and General Sleeping Disturbance Scale (GSDS).

RESULTS

At T1, the QoL was better among RCT parents (p=0.02). At T2, the RCT parents reported less sleep disturbance symptoms (GSDS) (p=0.03) and more energy (LFS) (p=0.03).

CONCLUSION

The RCT participation of VLBW infants may have improved parental QoL. While in the neonatal unit, symptoms of anxiety and depression were common among all parents. The high incidence of anxiety and depression in parents must be considered in the care of parents in the NICU. Long-term effects of participation seem to be less sleep problems and more energy.

C-reactive protein point-of-care testing in acutely ill children: a mixed methods study in primary care

BACKGROUND

Point-of-care C-reactive protein (CRP) testing of adults with acute respiratory infection in primary care reduces antibiotic prescribing by 22%. The acceptability and impact of CRP testing in children is unknown

OBJECTIVE

To determine the acceptability and impact of CRP testing in acutely ill children.

DESIGN

Mixed methods study comprising an observational cohort with a nested randomised controlled trial and embedded qualitative study.

SUBJECTS AND SETTING

Children presenting with an acute illness to general practice out-of-hours services; children with a temperature ≥38°C were randomised in the nested trial; parents and clinical staff were invited to the qualitative study.

MAIN OUTCOMES

Informed consent rates; parental and staff views on testing.

RESULTS

Consent to involvement in the study was obtained for 200/297 children (67.3%, 95% CI 61.7% to 72.6%); the finger-prick test might have been a contributory factor for 63 of the 97 children declining participation but it was cited as a definite factor in only 10 cases. None of the parents or staff raised concerns about the acceptability of testing, describing the pain caused as minor and transient. General practitioner views on the utility of the CRP test were inconsistent.

CONCLUSIONS

CRP point-of-care testing in children is feasible in primary care and is likely to be acceptable. However, it will not reduce antibiotic prescribing and hospital referrals until general practitioners accept its diagnostic value in children.

TRIAL REGISTRATION NUMBER

ISRCTN 69736109.

Reporting of consent rates in critical care studies: room for improvement

OBJECTIVES

Reporting of consent rates in published articles is important to determine potential sources of bias and validity and generalizability of results. Our objective was to determine the percentage of critical care studies for which the consent rate was reported.

STUDY DESIGN AND SETTING

We reviewed all articles published in eight medical journals in 2013. Studies meeting the following inclusion criteria were selected: (1) randomized controlled trial (RCT) or observational clinical study, (2) study population involving critically ill patients, and (3) part of the study occurring in an intensive care unit.

RESULTS

A total of 1,871 articles were screened of which 156 were included. The consent rate was discernable in 30.8% of articles (48/156, 95% confidence interval: 24.1, 38.4) with a median consent rate of 86.9% (interquartile range, 71.6, 94.1). A statement on Research Ethics Board approval was included in 96.8% of studies. There was a significant difference in reporting of consent rates between RCTs and non-RCTs (58.70% vs. 19.09%, P < 0.0001).

CONCLUSION

Consent rates are reported in less than one-third of critical care studies. We encourage journals to require reporting of consent rates to improve interpretation, validity, and generalizability of critical care study results.

Gastroenteritis Therapies in Developed Countries: Systematic Review and Meta-Analysis

Context

Gastroenteritis remains a leading cause of childhood morbidity.

Objective

Because prior reviews have focused on isolated symptoms and studies conducted in developing countries, this study focused on interventions commonly considered for use in developed countries. Intervention specific, patient-centered outcomes were selected.

Data Sources

MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, trial registries, grey literature, and scientific meetings.

Study Selection

Randomized controlled trials, conducted in developed countries, of children aged <18 years, with gastroenteritis, performed in emergency department or outpatient settings which evaluated oral rehydration therapy (ORT), antiemetics, probiotics or intravenous fluid administration rate.

Data Extraction

The study was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Data were independently extracted by multiple investigators. Analyses employed random effects models.

Results

31 trials (4,444 patients) were included. ORT: Compared with intravenous rehydration, hospitalization (RR 0.80, 95%CI 0.24, 2.71) and emergency department return visits (RR 0.86, 95%CI 0.39, 1.89) were similar. Antiemetics: Fewer children administered an antiemetic required intravenous rehydration (RR 0.40, 95%CI 0.26, 0.60) While the data could not be meta-analyzed, three studies reported that ondansetron administration does increase the frequency of diarrhea. Probiotics: No studies reported on the primary outcome, three studies evaluated hospitalization within 7 days (RR 0.87, 95%CI 0.25, 2.98). Rehydration: No difference in length of stay was identified for rapid vs. standard intravenous or nasogastric rehydration. A single study found that 5% dextrose in normal saline reduced hospitalizations compared with normal saline alone (RR 0.70, 95% CI 0.53, 0.92).

Conclusions

There is a paucity of patient-centered outcome evidence to support many interventions. Since ORT is a low-cost, non-invasive intervention, it should continue to be used. Routine probiotic use cannot be endorsed at this time in outpatient children with gastroenteritis. Despite some evidence that ondansetron administration increases diarrhea frequency, emergency department use leads to reductions in intravenous rehydration and hospitalization. No benefits were associated with ondansetron use following emergency department discharge.

StaR Child Health: developing evidence-based guidance for the design, conduct and reporting of paediatric trials

There has been a huge upsurge in clinical research in children in the last decade, stimulated in England by dedicated research infrastructure and support through the National Institute for Health Research. This infrastructure offering research design, expert review, trial management, research nurse, data support and dedicated facilities enables paediatricians to conduct more and better research. The challenge is how to design and conduct trials that will make a real difference to children's health. Standards for Research (StaR) in Child Health was founded in 2009 to address the paucity and shortcomings of paediatric clinical trials. This global initiative involves methodologists, clinicians, patient advocacy groups and policy makers dedicated to developing practical, evidence-based standards for enhancing the reliability and relevance of paediatric clinical research. In this overview, we highlight the contribution of StaR to this agenda, describe the international context, and suggest how StaR's future plans could be integrated with new and existing support for research.

Randomized controlled trials of antibiotics for neonatal infections: a systematic review

AIMS

Antibiotics are a key resource for the management of infectious diseases in neonatology and their evaluation is particularly challenging. We reviewed medical literature to assess the characteristics and quality of randomized controlled trials on antibiotics in neonatal infections.

METHODS

We performed a systematic search of PubMed, Embase and the Cochrane Library from January 1995 to March 2010. Bibliographies of relevant articles were also hand-searched. We included all randomized controlled trials that involved neonates and evaluated the use of an antibiotic agent in the context of a neonatal infectious disease. Methodological quality was evaluated using the Jadad scale and the Cochrane Risk of Bias Tool. Two reviewers independently assessed studies for inclusion and evaluated methodological quality.

RESULTS

A total of 35 randomized controlled trials were evaluated. The majority were conducted in a single hospital institution, without funding. Median sample size was 63 (34-103) participants. The most frequently evaluated antibiotic was gentamicin. Respectively, 18 (51%) and 17 (49%) trials evaluated the therapeutic or prophylactic use of antibiotics in various neonatal infections. Overall, the methodological quality was poor and did not improve over the years. Risk of bias was high in 66% of the trials.

CONCLUSIONS

Design and reporting of randomized controlled trials of antibacterial agents in neonates should be improved. Nevertheless, the necessity of implementing such trials when antibacterial efficacy has already been established in other age groups may be questioned and different methods of evaluation should be further developed.

A study of consent for participation in a non-therapeutic study in the pediatric intensive care population

OBJECTIVE

To document the legal guardian-related barriers to consent procurement, and their stated reasons for non-participation in a paediatric critical care research study.

STUDY DESIGN

A multicentre, prospective, cohort study.

PARTICIPANTS

Legal guardians of children who participated in a multicentre study on adrenal insufficiency in paediatric critical illness. Data were collected on all consent encounters in the main study.

METHODS

Screening data, reasons for consent not being obtained, paediatric risk of mortality (illness severity) scores and age were collected on all 1707 patients eligible for participation in the Adrenal Insufficiency Study.

RESULTS

The main barriers to approaching legal guardians for consent were lack of availability of the legal guardians (321/1707) and language barriers (84/1707). Legal guardians of 917 patients were approached with an overall consent rate of 42% (range 14-56% across the seven sites). 81% of the 528 legal guardians who declined consent provided an unsolicited reason for refusal. The three most commonly stated reasons were: being overwhelmed (117/429), not wanting anything else done to their child (63/429) and not wanting an additional medication (53/429). In addition, 14.2% cited research-related concerns as the reason for their non-participation.

CONCLUSIONS

Barriers to consent procurement in a non-therapeutic paediatric critical care study appear to occur at many levels with lack of availability of legal guardians, and legal guardians feeling overwhelmed, being the most commonly recorded reasons. Further research into the impact of these findings on the validity and generalisability of the results of such studies is necessary prior to the development and study of future consent models.

Pediatric nephrologists' beliefs regarding randomized controlled trials

BACKGROUND

Pediatrics and pediatric nephrology lag behind adult medicine in producing randomized controlled trials (RCTs). Physician attitudes have been shown to play a significant role in RCT enrollment.

METHODS

We surveyed members of the American Society of Pediatric Nephrology regarding beliefs about RCTs and factors influencing decisions to recommend RCT enrollment. Regression analyses were used to identify the effects of variables on an aggregate score summarizing attitudes toward RCTs.

RESULTS

One hundred thirty replies were received. Sixty-six percent had enrolled patients in RCTs. Respondents in practice for more than 15 years were more likely to have recruited a patient to an RCT than those in practice for less than 5 years. Respondents were more willing to recommend RCT enrollment if the study was multicenter, patients were sicker or had a poorer prognosis, or if the parent or participant received a financial incentive versus the provider. In multiple regression analysis, history of enrolling patients in an RCT was the only significant predictor of higher aggregate RCT-friendly attitude.

CONCLUSIONS

Many pediatric nephrologists have never enrolled a patient in an RCT, particularly those in practice for less than 5 years. Respondents who have not enrolled patients in RCTs have a less RCT-friendly attitude. Provision of improved training and resources might increase participation of junior providers in RCTs.

Pediatric nephrologists' beliefs regarding randomized controlled trials

BACKGROUND

Pediatrics and pediatric nephrology lag behind adult medicine in producing randomized controlled trials (RCTs). Physician attitudes have been shown to play a significant role in RCT enrollment.

METHODS

We surveyed members of the American Society of Pediatric Nephrology regarding beliefs about RCTs and factors influencing decisions to recommend RCT enrollment. Regression analyses were used to identify the effects of variables on an aggregate score summarizing attitudes toward RCTs.

RESULTS

One hundred thirty replies were received. Sixty-six percent had enrolled patients in RCTs. Respondents in practice for more than 15 years were more likely to have recruited a patient to an RCT than those in practice for less than 5 years. Respondents were more willing to recommend RCT enrollment if the study was multicenter, patients were sicker or had a poorer prognosis, or if the parent or participant received a financial incentive versus the provider. In multiple regression analysis, history of enrolling patients in an RCT was the only significant predictor of higher aggregate RCT-friendly attitude.

CONCLUSIONS

Many pediatric nephrologists have never enrolled a patient in an RCT, particularly those in practice for less than 5 years. Respondents who have not enrolled patients in RCTs have a less RCT-friendly attitude. Provision of improved training and resources might increase participation of junior providers in RCTs.

10-year trend in quantity and quality of pediatric randomized controlled trials published in mainland China: 2002-2011

Background

Quality assessment of pediatric randomized controlled trials (RCTs) in China is limited. The aim of this study was to evaluate the quantitative trends and quality indicators of RCTs published in mainland China over a recent 10-year period.

Methods

We individually searched all 17 available pediatric journals published in China from January 1, 2002 to December 30, 2011 to identify RCTs of drug treatment in participants under the age of 18 years. The quality was evaluated according to the Cochrane quality assessment protocol.

Results

Of 1287 journal issues containing 44398 articles, a total of 2.4% (1077/44398) articles were included in the analysis. The proportion of RCTs increased from 0.28% in 2002 to 0.32% in 2011. Individual sample sizes ranged from 10 to 905 participants (median 81 participants); 2.3% of the RCTs were multiple center trials; 63.9% evaluated Western medicine, 32.5% evaluated traditional Chinese medicine; 15% used an adequate method of random sequence generation; and 10.4% used a quasi-random method for randomization. Only 1% of the RCTs reported adequate allocation concealment and 0.6% reported the method of blinding. The follow-up period was from 7 days to 96 months, with a median of 7.5 months. There was incomplete outcome data reported in 8.3%, of which 4.5% (4/89) used intention-to-treat analysis. Only 0.4% of the included trials used adequate random sequence allocation, concealment and blinding. The articles published from 2007 to 2011 revealed an improvement in the randomization method compared with articles published from 2002 to 2006 (from 2.7% to 23.6%, p = 0.000).

Conclusions

In mainland China, the quantity of RCTs did not increase in the pediatric population, and the general quality was relatively poor. Quality improvements were suboptimal in the later 5 years.

Parental perceptions of clinical research in the pediatric emergency department

BACKGROUND

There is a paucity of information about parental perceptions of clinical research in children, particularly in the emergency department (ED) setting.

METHODS

Parents accompanying their child to the ED completed a self-administered survey gauging perceptions of research and willingness to enroll a child in a clinical research study. Factor analysis was used to correlate survey responses into domains representing parents' feeling about participation in a research study. Logistic regression was used to assess the predictors of caregivers' amenability to research participation for their child.

RESULTS

Three hundred eighty-eight parents were enrolled. Most subjects were willing to enroll their child in a study involving follow-up after ED care (87%) and collection of a urine or saliva sample (79% and 81%, respectively) and extant blood (69%). Fewer were amenable to studies that involve an investigational medication (26%) or additional phlebotomy (27%). Overall, more than 90% of parents felt that research was needed to help other children and was conducted in a way that is morally right, and 25% felt that research may compromise their child's confidentiality. Factor analyses yielded 3 factors that accounted for the variance across the survey questions. Patient and parent demographics, including the patient's triage acuity level, were not associated with willingness to participate in research.

CONCLUSIONS

Most parents are amenable to having their child participate in a research study in the ED setting. Most parents share a sense of altruism that research is needed to help children, and this belief is predictive of willingness to participate in a research study.

An evaluation of the impact and costs of three strategies used to recruit acutely unwell young children to a randomised controlled trial in primary care

Background

Recruitment to primary care trials, particularly those involving young children, is known to be difficult. There are limited data available to inform researchers about the effectiveness of different trial recruitment strategies and their associated costs.

Purpose

To describe, evaluate, and investigate the costs of three strategies for recruiting febrile children to a community-based randomised trial of antipyretics.

Methods

The three recruitment strategies used in the trial were termed as follows: (1) ‘local’, where paediatric research nurses stationed in primary care sites invited parents of children to participate; (2) ‘remote’, where clinicians at primary care sites faxed details of potentially eligible children to the trial office; and (3) ‘community’, where parents, responding to trial publicity, directly contacted the trial office when their child was unwell.

Results

Recruitment rates increased in response to the sequential introduction of three recruitment strategies, which were supplemented by additional recruiting staff, flexible staff work patterns, and improved clinician reimbursement schemes. The three strategies yielded different randomisation rates. They also appeared to be interdependent and highly effective together. Strategy-specific costs varied from £297 to £857 per randomised participant and represented approximately 10% of the total trial budget.

Limitations

Because the recruitment strategies were implemented sequentially, it was difficult to measure their independent effects. The cost analysis was performed retrospectively.

Conclusions

Trial recruiter expertise and deployment of several interdependent, illness-specific strategies were key factors in achieving rapid recruitment of young children to a community-based randomised controlled trial (RCT). The ‘remote’ recruitment strategy was shown to be more cost-effective compared to ‘community’ and ‘local’ strategies in the context of this trial. Future trialists should report recruitment costs to facilitate a transparent evaluation of recruitment strategy cost-effectiveness.

Parents' perceptions of their infants' participation in randomized controlled trials

OBJECTIVE

To explore parents' perceptions of their infants' participation in randomized control trials (RCTs) and the implications of the RCT for their infant and themselves.

DESIGN

A qualitative study using semistructured interviews.

SETTING

Participants were identified from neonatal intensive care unit (NICU) clinical registers and from responses to an advertisement put on the website of United Kingdom special care baby charity, BLISS. Interviews were conducted with parents face-to-face in their homes or over the telephone.

PARTICIPANTS

Sixteen parents of 12 infants born prematurely or with complications at full term and who had participated in one of three RCTs while receiving intensive care in one of seven NICUs.

METHODS

Interviews were audio-taped or digitally recorded, transcribed verbatim, and analyzed using systematic thematic analysis using WinMax qualitative software.

RESULTS

Five main themes emerged from the data. The themes were parents' immediate reactions to being approached about RCT enrollment, interactions between parents and clinicians upon the approach of enrollment and during the RCT, making the decision to enroll their infants, implications of the RCT for parents, and effects of the RCT on the infants.

CONCLUSIONS

Clinicians should be encouraged to approach parents about enrollment of their infants in clinical research given that parents reported mostly positive experiences related to this participation. However, appropriate measures should be taken to ensure that the individual needs of parents are being met throughout the entire research process from enrollment to follow-up.

StaR Child Health: developing evidence-based guidance for the design, conduct, and reporting of pediatric trials

Standards for Research in (StaR) Child Health was founded in 2009 to address the paucity and shortcomings of pediatric clinical trials. This initiative involves international experts who are dedicated to developing practical, evidence-based standards to enhance the reliability and relevance of pediatric clinical research. Through a systematic "knowledge to action" plan, StaR Child Health will make efforts to improve and expand the evidence base for child health across the world.

Quality of reporting of neonatal and infant trials in high-impact journals

OBJECTIVES

To perform a systematic review of the quality of reporting for randomized controlled trials (RCTs) with infants and neonates that were published in high-impact journals and to identify RCT characteristics associated with quality of reporting.

METHODS

RCTs that enrolled infants younger than 12 months and were published in 2005-2009 in 6 pediatric or general medical journals were reviewed. Eligible RCTs were evaluated for the presence of 11 quality criteria selected from the Consolidated Standards of Reporting Trials guidelines. The relationships between quality of reporting and key study characteristics were tested with nonparametric statistics.

RESULTS

Two reviewers had very good agreement regarding the eligibility of studies (κ = 0.85) and the presence of quality criteria (κ = 0.82). Among 179 eligible RCTs, reporting of the individual quality criteria varied widely. Only 50% included a flow diagram, but 99% reported the number of study participants. Higher quality of reporting was associated with greater numbers of study participants, publication in a general medical journal, and greater numbers of centers (P < .0001 for each comparison). Geographic region and positive study outcomes were not associated with reporting quality.

CONCLUSIONS

The quality of reporting of infant and neonatal RCTs is inconsistent, particularly in pediatric journals. Therefore, readers cannot assess accurately the validity of many RCT results. Strict adherence to the Consolidated Standards of Reporting Trials guidelines should lead to improved reporting.

The development of medicines for children. Part of a series on Pediatric Pharmacology, guest edited by Gianvincenzo Zuccotti, Emilio Clementi, and Massimo Molteni

The lack of availability of appropriate medicines for children is an extensive and well known problem. As a consequence off label or unlicensed administration of medicinal products in every day paediatric practice is frequent. A variety of obstacles hinder the development of paediatric indications for drugs primarily intended for the adult market. The barriers to proper research on children's drug development include several complex factors, such as the limited commercial interest, lack of suitable infrastructure and competence for conducting paediatric clinical trials, difficulties in trial design, ethical worries and many others. Medicinal products used to treat children should be subjected to ethical research of high quality and be explicitly authorised for use in children as it happens in adults. Conducting adequate clinical trials in children is challenging and demanding. Identification of paediatric medical needs, extrapolation from adult data, modelling and simulation, specific clinical trial methodology are important features in the development of drugs intended for children. Market forces alone have proven insufficient to stimulate adequate research aimed at specific authorisation of medicinal products for the paediatric population, and for that reason, following the US experience, the European Paediatric Regulation has been amended in January 2007 by the European Commission. The objective of the Paediatric Regulation is to improve the development of high quality and ethically researched medicines for children aged 0 to 17 years, to facilitate the availability of information on the use of medicines for children, without subjecting children to unnecessary trials, or delaying the authorisation of medicines for use in adults. The impact of the Paediatric Regulation reflects in an increase in the number of paediatric studies to be performed, even if a significant number of these studies have not started yet. The objective of this review is to describe the main regulatory and scientific features which play a role in the complex issue of paediatric drug development.

The European paediatric legislation: benefits and perspectives

BACKGROUND

The lack of availability of appropriate medicines for children is an extensive and well known problem. Paediatricians and Physicians who take care of the paediatric population are primarily exposed to cope with this negative situation very often as more than half of the children are prescribed off-label or unlicensed medicines.

DISCUSSION

Medicinal products used to treat this population should be subjected to ethical research of high quality and be explicitly authorized for use in children as it happens in adults. For that reason, and following the US experience, the European Paediatric Regulation has been amended in January 2007 by the European Commission. The objective of the Paediatric Regulation is to improve the development of high quality and ethically researched medicines for children aged 0 to 17 years, to facilitate the availability of information on the use of medicines for children, without subjecting children to unnecessary trials, or delaying the authorization of medicines for use in adults.

SUMMARY

The Paediatric Regulation is dramatically changing the regulatory environment for paediatric medicines in Europe and is fuelling an increased number of clinical trials in the paediatric population. Nevertheless, there are some risks and pitfalls that need to be anticipated and controlled in order to ensure that children will ultimately benefit from this European initiative.

Published pediatric randomized drug trials in developing countries, 1996-2002

BACKGROUND

The greatest burden of disease in children lies in the developing world; however, previous reviews have suggested that few randomized controlled trials (RCTs) involving children take place in developing countries. Children in developing countries deserve the same standard of medicines as those in developed countries, i.e. appropriate medications for the specific diseases that occur.

OBJECTIVE

To elucidate published pediatric therapeutic RCTs that have taken place in the developing world and to determine whether they are appropriate for the major diseases occurring there, and to explore their approach to safety monitoring.

METHODS

A previously assembled database of pediatric RCTs published between 1996 and 2002, from journals indexed in MEDLINE, was analyzed. The main country of setting of the RCTs was categorized as having low, medium or high development status according to the Human Development Index (HDI). Articles were read to add the WHO International Classification of Diseases 10th Revision (ICD-10) category of the disease studied, the WHO Collaborating Centre for Drug Statistics Methodology Anatomical Therapeutic Chemical (ATC) classification system category of the main drug therapy studied, the source of funding, and ethical approval to the variables already recorded in the database.

RESULTS

One hundred and fifty-eight (22%) of the 733 RCTs analyzed took place in medium and low HDI (developing) countries. The disease areas studied seemed appropriate, with 89 (56%) of the 158 RCTs studying infectious and parasitic diseases. Ninety-nine (63%) RCTs from developing countries were trials of antiparasitic and anti-infective drugs. Compared with studies from high HDI countries, a significantly lower proportion of articles from medium and low HDI countries mentioned ethical committee or institutional review board approval, and safety monitoring. Only one paper from low and medium HDI countries mentioned the presence of a safety monitoring committee/data safety monitoring board.

CONCLUSIONS

Published pediatric drug RCTs conducted in developing countries appear to study appropriate diseases but the results show that fewer RCTs are undertaken compared with the developed world. The standard of reporting for RCTs from developing countries needs attention to ensure that adequate information can be obtained, especially with regard to safety monitoring.

How do parents experience being asked to enter a child in a randomised controlled trial?

Background

As the number of randomised controlled trials of medicines for children increases, it becomes progressively more important to understand the experiences of parents who are asked to enrol their child in a trial. This paper presents a narrative review of research evidence on parents' experiences of trial recruitment focussing on qualitative research, which allows them to articulate their views in their own words.

Discussion

Parents want to do their best for their children, and socially and legally their role is to care for and protect them yet the complexities of the medical and research context can challenge their fulfilment of this role. Parents are simultaneously responsible for their child and cherish this role yet they are dependent on others when their child becomes sick. They are keen to exercise responsibility for deciding to enter a child in a trial yet can be fearful of making the 'wrong' decision. They make judgements about the threat of the child's condition as well as the risks of the trial yet their interpretations often differ from those of medical and research experts. Individual parents will experience these and other complexities to a greater or lesser degree depending on their personal experiences and values, the medical situation of their child and the nature of the trial. Interactions at the time of trial recruitment offer scope for negotiating these complexities if practitioners have the flexibility to tailor discussions to the needs and situation of individual parents. In this way, parents may be helped to retain a sense that they have acted as good parents to their child whatever decision they make.

Summary

Discussing randomised controlled trials and gaining and providing informed consent is challenging. The unique position of parents in giving proxy consent for their child adds to this challenge. Recognition of the complexities parents face in making decisions about trials suggests lines for future research on the conduct of trials, and ultimately, may help improve the experience of trial recruitment for all parties.

That sinking feeling, again? The state of National Institutes of Health pediatric research funding, fiscal year 1992-2010

This review article examines the National Institutes of Health's (NIH) overall budget and its pediatric research funding across three time periods: predoubling [fiscal year (FY) 1992-1997]; doubling (FY 1998-2003); and postdoubling (FY 2004-2009). The average annual NIH appropriations increased by 5.4%, 13.4%, and 1.3% in each period, respectively. The average annual pediatric research funding (actual grants, contracts, intramural research, and other mechanisms of support) increased much less, by 4.7%, 11.5%, and 0.3% in each period, respectively. Between FY 2004 and FY 2007, the average NIH budget increase has nearly flattened, to only 1.96%. During this period, average pediatric research funding has dropped markedly lower, to 0.57%; estimated FY 2008 pediatric funding is at negative 0.5%. Although pediatric research enjoyed significant benefits of the NIH doubling era, the proportion of the NIH budget devoted to the pediatric research portfolio has declined overall. The most recent period has wiped out the annual gains of the doubling era for both pediatric and overall NIH research funding. We offer recommendations to protect against further erosion of pediatric research funding and to implement several unfulfilled commitments to strengthen the federal pediatric research portfolio in the coming decade.

Making a difference: the clinical research programme for children

High quality paediatric clinical research will ensure that tomorrow's children receive new and better treatments

"Bonne Année", "Gutes Neues Jahr"? Will 2007 be a "Happy New Year" for children's medicines in Europe?

New European legislation has the potential to have an enormous impact on how paediatric medicines are studied and used

An absence of pediatric randomized controlled trials in general medical journals, 1985-2004

OBJECTIVE

There are numerous potential barriers to conducting randomized controlled trials (RCTs) in children. The purpose of this study was to compare the quantity, trends over time, characteristics, and quality of pediatric RCTs published in general medical journals (GMJs) with adult RCTs.

STUDY DESIGN AND SETTING

We conducted an electronic search of adult and pediatric RCTs from 1985-2004 and a manual search of published RCTs in the year 2000 in five high-impact GMJs (New England Journal of Medicine, Journal of the American Medical Association [JAMA], the Lancet, British Medical Journal [BMJ], Canadian Medical Association Journal [CMAJ]). Linear trends were identified and the 1-year sample was analyzed for publication characteristics (location of recruitment, sample size, number of centers, funding sources, and results) and quality scoring (Jadad score, intention-to-treat analysis, and citation frequency since publication).

RESULTS

Adult RCTs increased by 4.71 RCTs/year (95% confidence interval (CI) 3.62-5.80; P<0.001), which was significantly higher (P<0.0001) than pediatric RCTs, which increased by 0.4 RCTs/year (95% CI -0.02 to 0.9; P=0.06). Adult RCTs were more likely to be hospital-based (P=.001) and to involve more centers in multicenter studies (P=0.02). Quality scores were similar, although adult RCTs were cited more frequently (P=0.003).

CONCLUSION

There may be significant barriers to the publication of high-quality pediatric RCTs in GMJs.

Future pharmacologic agents for treatment of heart failure in children

The addition of new agents to the armamentarium of treatment options for heart failure in pediatric patients is exciting and challenging. Administration of these therapies to pediatric patients will require careful scrutiny of the data and skilled application. Developmental changes in drug metabolism, excretion, and distribution are concerning in pediatric patients, and inappropriate evaluation of these parameters can have disastrous results. Manipulation of the neurohormonal pathways in heart failure has been the target of most recently developed pharmacologic agents. Angiotensin receptor blockers (ARBs), aldosterone antagonists, beta-blockers, and natriuretic peptides are seeing increased use in pediatrics. In particular, calcium sensitizing agents represent a new frontier in the treatment of acute decompensated heart failure and may replace traditional inotropic therapies. Endothelin receptor antagonists have shown benefit in the treatment of pulmonary hypertension, but their use in heart failure is still debatable. Vasopressin antagonists, tumor necrosis factor inhibitors, and neutral endopeptidase inhibitors are also targeting aspects of the neurohormonal cascade that are currently not completely understood. The future of pharmacologic therapies will include pharmacogenomic studies on new and preexisting therapies for pediatric heart failure. The education and skill of the practitioner when applying these agents in pediatric heart failure is of utmost importance.

A major new initiative to improve treatment for children

UK Medicines for Children Research Network

Controlled clinical trials in cystic fibrosis — are we doing better?

We have previously reported the time trends, design and interventions in randomised controlled trials (RCTs) in cystic fibrosis (CF) from 1961 through 1997 [Cheng K, Smyth RL, Motley J, O'Hea U, Ashby D, Randomised controlled trials in cystic fibrosis (1966-1997) categorized by time, design, and intervention. Pediatr Pulmonol 2000, 29:1-7.]. We maintain an ongoing register of all RCTs and controlled clinical trials (CCTs) in CF and have noted that in the five years since 1997 there has been a 48% increase in published trials. We aimed to assess whether this increase has been associated with an improvement in design quality. All RCTs and CCTs from 1961-2002 were assessed. Two epochs were then compared, 1961-1997 and 1998-2002. For each trial we recorded the design, participant numbers and the intervention studied. 261 trials in 1998-2002 were compared with 544 trials in 1961-1997. Comparing the two epochs a similar proportion of trials were parallel, double-blind and placebo controlled; also the median number of participants was similar. In the later epoch 25% of trials were multicentre, compared with 11% previously. Whilst this recent increase in clinical trials in CF is welcome, this has not been associated with improvements in quality. The trend for an increasing proportion of trials to be multicentre is encouraging. There are however, still deficiencies in the design of clinical trials in CF.

"It was a snap decision": parental and professional perspectives on the speed of decisions about participation in perinatal randomised controlled trials

For some perinatal trials, parents can be asked to make important decisions about trial participation within limited timeframes in highly stressful circumstances. This qualitative study explores the pace of decision-making for 78 parents associated with one or more of four such trials in the UK. The themes associated with rapid decisions were concern for their baby, reactions to staff, and perceptions of the benefits and risks associated with the trial. Those who took longer to decide whether or not to participate often described similar emotions to those who made rapid decisions, but their slower decisions were because more time was available, they wanted further discussion or they found the decision particularly difficult. The majority of those who made rapid decisions felt that there were no risks associated with the trial in question, in contrast to the majority of those who made slower decisions who felt there were risks. The parents did not appear to view rapid decisions as problematic. Although there was evidence of parental vulnerability in each trial context, they largely felt that they acted swiftly and responsibly in the best interests of their child in accordance with the timeframes that were set for them.

Do weekends or evenings matter in a pediatric intensive care unit?

OBJECTIVE

To assess what independent influence, if any, weekend or evening admission to a pediatric intensive care unit (PICU) staffed 24 hrs/day, 7 days/wk by in-house, board-certified pediatric intensivists might have on mortality.

DESIGN AND PATIENTS

A retrospective study of 5,968 consecutive admissions to the PICU from August 1996 to December 2003 for patients aged 0 days to 21 yrs.

SETTING

A single, 14-bed, multidisciplinary PICU at an academic medical center.

MEASUREMENTS

Standardized mortality ratios of observed-to-predicted mortality were derived with their corresponding p values. Multivariate logistic regression was used to test the independent effect of weekend admission, weekend discharge/death, and evening PICU admission on mortality for the entire sample and, separately, for only emergency admissions, controlling for other significant predictor variables or interaction terms.

RESULTS

Overall, crude mortality was significantly higher on the weekend (weekday, 2.2%; weekend, 5.0% [p = .0000]) and in the evening (day, 2.1%; evening, 3.8% [p = .0004]). Assessing the entire sample using multivariate logistic regression, neither weekend admission (p = .146), weekend discharge/death (p = .348), nor evening PICU admission (p = .711) showed a significant relationship with mortality controlling for other significant factors. Limiting the scope to the emergency admissions subset, neither weekend admission (p = .135), weekend discharge/death (p = .278), nor evening PICU admission (p = .867) were significant predictors of mortality. Weekend and evening admissions differed in important ways from weekday and daytime admissions, making simple comparisons of crude mortality rates inappropriate. Weekend and evening admissions were more likely to be emergency, nonoperative patients; have a lower Pediatric Risk of Mortality III score but have a higher overall predicted mortality risk; and differ in the distributions of patients by primary diagnosis.

CONCLUSIONS

Using multivariate logistic regression to control for important clinical differences, neither weekend admission, weekend discharge/death, nor evening admission had a significant independent effect on mortality risk in the entire sample or for the emergency patient subset. Our findings are consistent with previous work demonstrating the benefit of intensive care units staffed 24 hrs/day, 7-days/wk by in-house, board-certified intensivists.

Barriers to Australian physicians’ and paediatricians’ involvement in randomised controlled trials

OBJECTIVE

To compare attitudes of Australian physicians and paediatricians about treatment and randomised controlled trial (RCT) participation.

DESIGN AND PARTICIPANTS

A cross-sectional survey using the validated "Physician Orientation Profile" (POP), with 250 physicians and 250 paediatricians surveyed.

OUTCOME MEASURES

Five indices - primary allegiance, decision making under uncertainty, professional activities, perceived rewards, and peer-group influence - with scores for each participant ranging along a continuum from clinician-oriented to research-oriented and expressed as a number between 0 and 1.

RESULTS

Overall response rate was 60%, with 135 physicians (54%) and 165 paediatricians (66%) responding. Paediatricians and physicians were similar in their attitudes to RCT participation, being generally clinician-oriented rather than research-oriented and less inclined to participate in RCTs when there is uncertainty about the best treatment. Most assign limited time to research, with 26.9% not currently involved in research and 31.5% having no experience of RCT participation. Doctors perceive few rewards and little peer-group influence regarding trial participation. Independent predictors of favourable attitudes to trial participation (based on POP scores) were the presence of allocated research time (0.37 for no allocated research time v 0.61 for > 70% research time; P < 0.0001), previous experience enrolling a patient in an RCT (0.40 for no experience v 0.46 for experience; P < 0.0001), and articles published in the past 12 months (0.40 for no publications v 0.55 for > 3 publications; P < 0.0001).

CONCLUSIONS

This study highlights the minor importance of research for most Australian physicians. Research plays only a small role in their professional activities, and the importance of research participation is not recognised. They are clinician-oriented in their attitudes to RCT participation. To encourage greater involvement in trials among physicians in Australia, clinical research needs to be restructured in a primarily clinically oriented setting with dedicated research time.

Evidence based medicine in inborn errors of metabolism: Is there any and how to find it

Evidence based medicine (EBM) represents an attempt to assist healthcare providers in basing clinical decisions on the best available evidence. That evidence in the treatment realm usually takes the form of clinical trials (CTs), with the randomized controlled clinical trial (CCT or RCT) being the gold standard. Many specialties such as internal medicine have embraced EBM. Medical geneticists who care for patients with inborn errors of metabolism (IEM) have by and large not benefited from the EBM movement. IEM are rare genetic conditions, many of which are treatable. Therefore, the principles of EBM should be applicable to IEM. Notably, Archibald Cochrane, one of the founders of EBM, suffered from porphyria, an IEM. The principles of EBM as applied to IEM are explored herein. The author hypothesized that EBM has not infiltrated the specialty of medical genetics, that few controlled trials for IEM have been published, and that where CTs have been carried out in IEM they can be difficult to find with electronic bibliographic database searches. To test the hypothesis, MEDLINE searches for CTs were carried out for a few representative IEM. The search results support the hypothesis. In this article, the principles of EBM are introduced and its history reviewed as background information to lay the groundwork for further discussion. Next, the dearth of evidence base in IEM, impediments to the application of EBM to IEM, steps to be taken to improve the evidence base for IEM, and finally strategies to make it easier to find CTs for IEM in database searches are all discussed.

Clinical trials in children

The imperative to undertake randomised trials in children arises from extraordinary advances in basic biomedical sciences, needing a matching commitment to translational research if child health is to reap the benefits from this new knowledge. Unfortunately, many prescribed treatments for children have not been adequately tested in children, sometimes resulting in harmful treatments being given and beneficial treatments being withheld. Government, industry, funding agencies, and clinicians are responsible for research priorities being adult-focused because of the greater burden of disease in adults, coupled with financial and marketing considerations. This bias has meant that the equal rights of children to participate in trials has not always been recognised. This is changing, however, as the need for clinical trials in children has been increasingly recognised by the scientific community and broader public, leading to new legislation in some countries making trials of interventions mandatory in children as well as adults before drug approval is given. Trials in children are more challenging than those in adults. The pool of eligible children entering trials is often small because many conditions are uncommon in children, and the threshold for gaining consent is often higher and more complex because parents have to make decisions about trial participation on behalf of their child. Uncertain about what is best, despite supporting the notion of trials in principle, parents and paediatricians generally opt for the new intervention or for standard care rather than trial participation. In this review, we explore issues relating to trial participation for children and suggest some strategies for improving the conduct of clinical trials involving children.

Perinatal pathology in the context of a clinical trial: attitudes of bereaved parents

BACKGROUND

Interviews with neonatologists in a related study had revealed a degree of discomfort with approaching bereaved parents for postmortem examinations (PMs) and a widespread concern that parents should not be further distressed or feel under pressure to consent.

OBJECTIVE

To report the attitudes of bereaved parents to trial related perinatal PMs, in the light of declining perinatal PM rates and poor levels of participation in pathology studies.

METHODS

A qualitative study was carried out, using semistructured interviews. The study involved 11 interviews with 18 bereaved parents from five UK neonatal units. The parents had consented to the enrolment of their baby in one of two neonatal trials.

RESULTS

The data provide support for the careful approach described by neonatologists in a related study, but also suggest that it may be possible to approach more parents without undermining their wellbeing. The interviews show the variety of reactions to PMs that one would expect, from parents who were clear that they did not want a PM to others who felt that they needed the information from the examination. Between these extremes were parents who were initially discomforted by the idea but who then made the decision to go ahead. Parents who elected to have a PM did so for their own needs, or to contribute to a trial, or for both reasons. The fact that the subject was raised was generally not seen as inappropriate, and none stated that they felt that they were actually pressured into making their decision. The data also suggest that for some parents the degree of caution and selectivity exercised by the neonatologists may not be entirely appropriate. In two cases, consent for the PM was driven by a sense of making an altruistic contribution to research, and, in another two, altruism was expressed in the context of their own desire for information from a PM.

CONCLUSIONS

It is important to determine whether trial related pathology studies are considered by professionals and lay people to be worth while and feasible. If there is support for such studies, the challenge is to develop the means to approach more parents in the most sensitive way.

Randomized controlled trials in pediatric surgery: could we do better?

BACKGROUND/PURPOSE

Randomized controlled trials (RCTs) are accepted as the gold standard for assessing the effectiveness of clinical interventions but are rarely reported in pediatric surgery. Have RCTs submitted to the British Association of Paediatric Surgeons (BAPS) Annual Congress during the last 5 years been adequately designed and large enough to produce a valid result?

METHODS

Abstracts accepted by the Annual BAPS Congress meetings between 1996 and 2000 were examined in collaboration with a senior health services researcher. The quality of the design, methodology, statistical analysis and conclusions, and the adequacy of the sample size were assessed for all identifiable clinical RCTs.

RESULTS

From 760 accepted abstracts, there were only 9 RCTs (1%) of clinical interventions. In only 4 trials was the relevant primary end-point specified at the outset of the study, and none documented the method of randomization. Only one abstract mentioned blinding with respect to the intervention or outcome measure. Sample sizes were inadequate to detect even large clinical differences. To date, only one of these RCTs has been published in an English-language, peer-reviewed journal.

CONCLUSIONS

Clear guidelines exist for the conduct of RCTs, yet compliance with these standards was rarely documented in abstracts of pediatric surgical RCTs presented at BAPS. Sample sizes were inadequate. RCTs in pediatric surgery are difficult to perform, but the specialty would benefit from well-designed, carefully conducted, multicentre, clinical RCTs to advance evidence-based practice.

Research in children

The importance of medical research to the diagnosis and treatment of human diseases is well recognized. The use of human subjects, however, presents complex legal and ethical challenges for the scientific community and for society. The history of research performed on children reveals an especially vulnerable population needing special protection against violation of individual rights and exposure to undue risk. The development of guidelines and policies to protect children as research subjects is reviewed. Special focus is given to the present federal regulations that are intended to provide an ethical context for the performance of pediatric research, including the distinction between therapeutic and nontherapeutic studies. In part, these guidelines represent a return of the pendulum to a more moderate position, after an era of restrictive regulations in reaction to past abuses of children as research subjects. As a result, federal and professional initiatives are bringing renewed focus on the need for rigorous study of childhood development and disease within an appropriate ethical framework.

Meta-analyses involving cross-over trials: methodological issues

BACKGROUND

Meta-analysis of randomized controlled trials (RCTs) is usually based on trials where patients are randomized individually into two different, parallel, treatment groups. This paper concentrates on RCTs of a different design-two-period, two-treatment cross-over trials.

METHODS

The characteristics of these trials are outlined, with detailed examples of methods for analysis for both continuous and binary data. These case studies are then extended into the context of a meta-analysis. The Cochrane Library was surveyed to assess current practice for synthesis.

RESULTS

Methods are described for continuous and binary data for use both when the necessary paired data are given and also when they need to be calculated or imputed, and some suggestions are provided to help people wishing to synthesize data from cross-over trials into meta-analyses. The survey suggested that about 8% of the trials in the Cochrane library were cross-over trials and 18% of the reviews referred to such trials, although there was no consistent approach to their inclusion into the reviews.

CONCLUSIONS

Methods do exist for including valuable information from two-period, two-treatment cross-over trials into quantitative reviews. However, poor reporting of cross-over trials will often impede attempts to perform a meta-analysis using the available methods.