Using decision analysis to better evaluate pediatric clinical guidelines.

Health Aff (Millwood). 2008 Sep-Oct;27(5):1467-75.

Cohen JT, Neumann PJ.Tufts

Although systematic and explicit, existing evidentiary criteria for clinicalguidelines tend to use study design as a surrogate for evidence quality.Moreover, they do not independently characterize evidence quality and netbenefits and do not systematically evaluate research needs. Decision analysis,which quantifies the range of potential net benefits based on whatever evidenceis available, can augment traditional frameworks. It is particularly useful forpediatric research, where randomized controlled trials are often unavailable and infeasible. Policymakers should incorporate decision analysis into comparativeeffectiveness research and clinical guidelines.

El artículo aún no es accesible a texto completo on-line (es un precoz PubMed - in process), pero el resumen promete.

Physical activity at the government-recommended level and obesity-related health outcomes: a longitudinal study (Early Bird 37)

Arch. Dis. Child. 2008;93;772-777
B S Metcalf, L D Voss, J Hosking, A N Jeffery, T J Wilkin

ABSTRACT
Background: In the UK and USA, government guidelines for childhood physical activity have been set (>60 min/ day at >3 metabolic equivalents of thermogenesis (METs)), and body mass index (BMI) chosen as the outcome measure.
Aim: To determine the extent to which physical activity at the government-recommended intensity is associated with change in body mass/fat and metabolic health in prepubertal
children.
Methods: Non-intervention longitudinal study of 113 boys and 99 girls (born 95/96) recruited from 54 schools. Physical activity (Actigraph accelerometers),changes in body mass (raw and age/gender-standardised BMI), fatness (skin-fold thickness and waist circumference)
and metabolic status (insulin resistance, triglycerides, cholesterol/HDL ratio and blood pressure separately and as a composite metabolic z score) were measured on four annual occasions (5, 6, 7 and 8 years).
Results: Mean physical activity did not change over time in either sex. Averaging the 7-day recordings from four time points rather than one increased the reliability of characterising a child’s activity from 71% to 90%. Some 42% of boys and 11% of girls met the guideline. There
were no associations between physical activity and changes in any measurement of body mass or fatness over time in either sex (eg, BMI standard deviation scores: r=20.02, p=0.76). However, there was a small to moderate inverse association between physical activity and change in composite metabolic score (r=20.19, p,0.01). Mixed effects modelling showed
that the improvement in metabolic score among the more active compared to the less active children was linear with time (20.08 z scores/year, p=0.001).
Conclusions: In children, physical activity above the government-recommended intensity of 3 METs is associated with a progressive improvement in metabolic health but not with a change in BMI or fatness. Girls habitually undertake less physical activity than boys, questioning whether girls in particular should be encouraged to do more, or the recommendations adjusted for girls.

International Trends in Sudden Infant Death Syndrome: Stabilization of Rates Requires Further Action

International Trends in Sudden Infant Death
Syndrome: Stabilization of Rates Requires Further
Action
PEDIATRICS 2008;122( 3): 660-666
Fern R. Hauck, Kawai O. Tanabe.

CONCLUSIONS AND RECOMMENDATIONS
There have been impressive reductions in SIDS deaths around the world. These declines seem to be real and attributable, in large measure, to risk-reduction activities, especially placing infants supine to sleep. However, rates have stabilized in the majority of countries, and in some countries they remain unacceptably high, which highlights the need for risk-reduction activities to be continued, especially in communities with the greatest burden of SIDS. In the United States in 2004, the National Infant Sleep Position Survey revealed that 12.9% of infants were placed prone for sleep. Using the pooled odds ratios from 7 case-control studies conducted in the post–Back to Sleep period for prone sleeping position (6.02), we estimate that 47% of the annual
SIDS deaths in the United States could be attributed to prone sleeping (Appendix).Using a more conservative estimate of an odds ratio of 2.5 (based on 2 studies in the United States), an estimated 27% of SIDS deaths could be attributed to placing infants prone to sleep (Appendix). Thus, working toward eliminating the use of this position has the potential to reduce the number of SIDS deaths in the United States significantly.
Differences in rates and trends are also influenced by diagnostic shifts that have occurred. Consequently, several classifications for SIDS and SUID have been proposed as a way to achieve greater accuracy and consistency in diagnosis within and across countries.
The Nordic countries have been successful in adopting standard criteria to diminish previously identified discrepancies in SIDS rates. It is essential that more widespread consensus on the definition and classification of sudden unexpected death in infancy be achieved so that national and international comparisons are more meaningful. Several initiatives in the United States are
underway to develop a standardized approach, including development by the Centers for Disease Control and Prevention of a national surveillance system for SUIDs that would collect data on modifiable risk factors for SIDS and SUID and on the conduct and quality of the death-scene investigation and autopsy; a standardized classification scheme for cause of death will also be developed In addition, legislation is being considered that would fund this and other related activities, including training for those who investigate infant deaths and certify cause of death.
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