EBM in practice: paediatrics

Training pediatric clinical pharmacology and therapeutics specialists of the future: the needs, the reality, and opportunities for international networking

In recent years there has been a rapid and marked increase in global recognition of the need for better medicines for children, with various initiatives being implemented at global and regional levels. These exciting developments are matched by recognition of the need to build greater capacity in the field of pediatric clinical pharmacology and therapeutics to help deliver on the promise of better medicines for children. A range of pediatric medicines researchers, educators, clinical therapeutics practitioners, and experts in drug evaluation, regulation, and broader medicines policy are needed on a larger scale, in both developed and developing world settings. The current and likely future training needs to meet these diverse challenges, the current realities of trying to meet such needs, and the opportunities for international networking to help meet future training needs are discussed from a global perspective.

Delivering better medicines to children: need for better integration between the science, the policy, and the practice

We are experiencing an exciting and unprecedented period in the history of children's medicines globally. Milestone developments unfolding in recent years include the formation of the International Alliance for Better Medicines for Children in 2006 and landmark initiatives by the EU, the World Health Assembly (WHA), and the WHO in 2007. However, the challenges of optimizing the development, wider availability, and routine use of effective, safe, and affordable medicines addressing important child health needs are considerable. Each aspect of this continuum has so far received differential attention. Major initiatives in the US and EU have focused on stimulating research into children's medicines, largely driven by drug regulatory reforms, but with important gaps remaining. Many countries are lacking similar reforms, so the benefits of these initiatives are currently not well reflected in the rest of the world. A systematic approach to knowledge translation to improve use of best evidence and deliver quality use of medicines (QUM) to children routinely has also been largely a 'missing link' so far. The WHO's Essential Medicines List for Children and related initiatives are addressing improving children's access to needed medicines. Priority research gaps, especially in the developing world, are also being pursued by the WHO. However, in many countries, including developed nations such as Australia, the policy response to the WHA resolution on 'Better Medicines for Children' has been inconsistent or fragmented. A better integrated overall approach, linking global medicines research efforts to child health needs and actual medicines use is needed. International networking to support the conduct, synthesis, and rapid dissemination of pediatric medicines research will help close knowledge gaps at a global level. Harmonization of pediatric drug regulation will support this goal and facilitate improving access to needed medicines. Increasing research into and dissemination of effective strategies to promote QUM is an essential component to maximize return (in health benefits) on increased investment in medicines research. A greater focus on QUM should also help create demand for better evidence from clinicians. Delivering on the promise of better medicines for children, wherever in the world they may be, depends on achieving successful integration between the science, the policy, and the practice of pediatric medicines.

Incidence, characteristics, and predictive factors for Dysphagia after pediatric traumatic brain injury

OBJECTIVE

(1) To establish an incidence figure for dysphagia in a population of pediatric traumatic brain injury (TBI) cases; (2) to provide descriptive data on the admitting characteristics, patterns of resolution, and outcomes of children with and without dysphagia after TBI; and (3) to identify any factors present at admission that may predict dysphagia.

PARTICIPANTS

A total of 1,145 children consecutively admitted to an acute care setting for traumatic brain injury between July 1995 and July 2000.

MAIN OUTCOME MEASURE

Medical parameters relating to dysphagia based on medical chart review.

RESULTS

(1) Dysphagia incidence figure of 5.3% across all pediatric head injury admissions. Incidence figures of 68% for severe TBI, 15% for moderate TBI, and only 1% for mild brain injury. (2) Statistically significant differences were found between the dysphagic and nondysphagic subgroups on the variables of length of stay, length of ventilation, Glasgow Coma Scale (GCS), computed tomography classification, duration of speech pathology intervention, supplemental feeding duration, duration until initiation of oral intake (DIOF), duration to total oral intake (DTOF), and period of time from the initiation of intake until achievement of total oral intake (DI-TOF). (3) Significant predictive factors for dysphagia included GCS < 8.5 and a ventilation period in excess of 1.5 days.

CONCLUSION

The provision of incidence data and predictive factors for dysphagia will enable clinicians in acute care settings to allocate resources necessary to deal with the predicted number of dysphagia cases in a pediatric population, and assist in predicting patients who are at risk for dysphagia following TBI. Early detection of patients with swallowing dysfunction will be aided by these data, in turn helping to facilitate effective medical and speech pathology intervention via assisting the reduction of medical complications such as aspiration pneumonia.