
I n order to give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family. 1 Archimedes seeks to assist practising clinicians by providing ''evidence based'' answers to common questions which are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format which has been successfully developed by Kevin Macaway-Jones and the group at the Emergency Medicine Journal-''BestBets''.

A word of warning. The topic summaries are not systematic reviews, through they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor search the grey, unpublished literature. What Archimedes offers are practical, best evidence based answers to practical, clinical questions.

The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching, 2 and gaining answers. 3 ) A brief report of the search used follows-this has been performed in a hierarchical way, to search for the best quality evidence to answer the question. 4 A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as number needed to treat, NNT) books by Sackett 5 and Moyer 6 may help. To pull the information together, a commentary is provided. But to make it all much more accessible, a box provides the clinical bottom lines.

Electronic-only topics that have been published on the BestBets site (www.bestbets.org) and may be of interest to paediatricians include: N Is two thumb or two finger CPR in infants more effective?

N Does oral diazepam prevent febrile convulsions?

Readers wishing to submit their own questions-with best evidence answers-are encouraged to review those already anthonycuevas@example.com. If your question still hasn't been answered, feel free to submit your summary according to the Instructions for anthonycuevas@example.com. archdischild.com. Three topics are covered in this issue of the journal.

N Short stature and the probability of coeliac disease, in the absence of gastrointestinal symptoms N Is an intravenous fluid bolus of albumin or normal saline beneficial in the treatment of metabolic acidosis in a normovolaemic newborn?

N How safe is ibuprofen in febrile asthmatic children?

Bob Phillips, Evidence-based On Call, Centre for Evidencebased Medicine, University Dept of Psychiatry, Warneford Hospital, Headington OX3 7JX, UK; anthonycuevas@example.com Putting evidence into practice: part 2

How do your remember what you read in a paper? How do you call to mind that reference about petechiae and vomiting that means you don't have to stick this perfectly well 8 year old needle-phobic? Capturing the outputs of your critical appraisals so you can retrieve them is easier if you formally record them in some way. These records have been described by lots of different people in lots of different ways. They are called a number of things, mostly with punishingly painful acronyms attached. Hence you get ''critically appraised topics'' (CATs-probably the most generic phrase), ''best evidence topics'' (BETs), or ''patient orientated evidence that really matters'' (POEMs) depending on where you live or work. The topics you read here in Archimedes are printed as BETs, with fuller individual CATs on the ADC website. A template you can fill in with your own questions is also available on the website, along with Instructions to Authors.

The underlying principles of all these different records are fairly similar. They have a headline which describes either the question under consideration or a compact form of the answer. They have the question that triggered the CAT to be created. They detail the study methodology and comment on strengths and weaknesses, and relay the relevant results. They may have further comments, but nearly all will have a summary of the clinical bottom lines.

Once you've created your summaries, you still need to keep them accessible. Placing them all (with copies of Archimedes) in a big red folder might seem a bit cheesy, but it's been shown to be an effective way of getting clinical questions answered quickly. 1 It also doesn't rely on your hospital computer working, and can be safely accessed while drinking coffee. It has the benefit of having instant feedback too-with the aid of a pencil or pen, comments can be added to the margins without difficulty. The more technologically minded might want to put your own on a website. Many widely used word processing programmes will allow you to save your version of an evidence summary as web (html) pages. (From there, getting them onto a website is then a case of finding someone with a bit of IT knowledge.) Developing the technological idea further, a PDA (handheld computer) version could be made by those with adequate skills.

Of course, the next logical step when you've worked with your colleagues to produce a high quality summary of the evidence related to a clinically important question is to submit it to Archimedes. You too could be the next proud provider of information which makes clinical paediatrics more evidence based.

A n 8 year old girl is referred to the paediatrician because of her stunted growth. Her height SDS is 22.3 (<1st centile); her weight for height ratio is +0.9 SDS (<80th centile). At the age of 3 years, her height SDS was +0.3 (<60th centile). Her weight for height ratio had not changed considerably. At the age of 4-5 years, she had several episodes of constipation and anaemia. There were no other complaints. A diagnostic work-up was performed: IgA anti-endomysium (IgA EmA) antibodies were positive. A small intestinal biopsy (gold standard) showed total villous atrophy, consistent with coeliac disease. During follow up, she fulfilled the ESPGAN criteria for coeliac disease (finding of characteristic small bowel mucosa abnormalities in a small bowel biopsy, and clinical remission when placed on a gluten-free diet). Embase-same search strategy; no additional relevant references.
Structured clinical question
Cochrane database-same search strategy; none relevant. The way study groups were selected varied. Articles with the least selective study groups are reported higher in the table than studies with a more selective study group.
Commentary
Growth retardation in childhood may be one of the earliest signs of an underlying disease, such as coeliac disease. In the Netherlands, the growth of nearly every child is monitored. When growth is retarded, the child is referred to secondary health care. After referral it has been advised to perform a diagnostic work-up containing routine laboratory tests to search for diagnostic clues for, among others, coeliac disease. The tests presently used for coeliac disease are IgA EmA and IgA antitissue transglutaminase antibodies. The total immunoglobulin A count is determined as well, because coeliac disease is associated with IgA deficiency. It was questioned if diagnostic investigations for coeliac disease should be performed in all children with short stature, even without gastrointestinal complaints.
Commentary
Studies 1-5 were based on study groups, in which no preliminary (endocrine) work-up to exclude other causes for short stature had been performed. The proportion of coeliac disease in children with short stature and no gastrointestinal symptoms in these studies ranged from 1.7% to 8.3%. When a group of children was studied, in which endocrine causes for short stature had been excluded (studies 6-11), the proportion of coeliac disease increased to a range of 18.6-59.1%. The characteristics of the preliminary work-up used in study 12 were not described.
Commentary
The wide range of these percentages is probably mainly caused by the different methods of selecting the patients. The true variation in prevalence of coeliac disease throughout the world appears to be limited. 13 Screening for coeliac disease in the general population shows a prevalence of 1:300 to 1:100. About 50% of these children are completely symptomless. 13 In two British population based studies on short stature, 14 15 where coeliac disease was not specifically investigated, the prevalence of coeliac disease was 2:180 (one patient was already known with coeliac disease) and 0:149 respectively. In children with short stature and no gastrointestinal symptoms investigated for coeliac disease, the prevalence increases to 2-8%. When other (endocrine) causes for short stature are excluded, the prevalence might rise to even 59%. A t the age of 4 hours, a tachypnoeic, well hydrated, well perfused, and normotensive 34 week preterm neonate develops a metabolic acidosis (arterial pH 7.25, base deficit minus 10 mmol/l). There was no history of perinatal blood loss or sepsis risk factors. No resuscitation was required at birth, and the cord blood pH was 7.3. According to departmental protocol, volume expansion with an intravenous bolus of 10-20 ml/kg of normal saline or 4.5% albumin is advised. You wonder as to the value of this volume expansion.
Structured clinical question
In the absence of asphyxia or hypovolaemia in a newborn infant with metabolic acidosis [patient] does an intravenous bolus of normal saline or albumin [intervention] improve the following [outcomes]: pH, base deficit, mortality, morbidity, length of hospital stay, neurodevelopmental disability?
Structured clinical question
The outcomes were defined as follows:
Structured clinical question
N Mortality = neonatal mortality and mortality to discharge. N Morbidity = peri/intraventricular haemorrhage of any grade, periventricular leucomalacia, patent ductus arteriosus, renal impairment (raised serum creatinine, oliguria), air leak, chronic lung disease (at 28 postnatal days or near term postmenstrual age), necrotising enterocolitis, or retinopathy of prematurity of any grade.
Structured clinical question
N Neurodevelopmental disability = neurological abnormality including cerebral palsy, developmental delay, or sensory impairment.
Search strategy and outcome
Exclusion criteria: trials including infants with clinically suspected poor perfusion (e.g. low blood pressure, poor cutaneous perfusion) or trials including unselected newborn infants (not known to have metabolic acidosis). Secondary sources-Cochrane Library (Issue 3, 2003): one protocol-two control trials in CENTRAL, of which one was relevant.
Search strategy and outcome
PubMed : search words-(''metabolic acidosis'') AND (''therapy'' OR ''fluid'' OR ''albumin'' OR ''colloid'' OR ''sodium chloride'') using Clinical Queries methodological filters category (therapy, prognosis) and emphasis (sensitivity, specificity). Limits-Newborn. Search outcome: 87 papers, of which two were relevant (one already retrieved by Cochrane).
Search strategy and outcome
SumSearch-96 articles, one protocol (already retrieved by PubMed and Cochrane).
Search strategy and outcome
Search results-three articles found, two relevant (already retrieved by PubMed and Cochrane).
Search outcome See table 2.
Commentary Previous studies of administering parenteral fluid and/or alkali therapy to neonates with metabolic acidosis have included infants with clinically suspected poor perfusion (e.g. low blood pressure, poor cutaneous perfusion). Other studies of the effect of early volume expansion on mortality and morbidity have included unselected preterm infants not known to have metabolic acidosis.
Search outcome See table 2.
We found only two studies addressing the benefit of administering intravenous bolus of albumin or normal saline to normovolaemic neonates with metabolic acidosis. They do not however provide a clear answer to the main question of this article in view of few methodological weaknesses. The first study was not blinded. The second study was not randomised and no placebo group was available. Although both studies reported an improvement in the pH and base deficit with volume expansion (although less marked than with bicarbonate), neither of these reports included the following outcomes: survival, morbidity, length of hospital stay, or neurodevelopment disability. The effect of the resulting correction of the metabolic acidosis on those clinically important outcomes therefore remains unknown. In the absence of outcome based data, there is currently no evidence to support the routine administration of intravenous bolus of albumin or normal saline to normovolaemic neonates with metabolic acidosis. In addition, as administration of volume expansion was found to be associated with increased mortality in preterm neonates, it is recommended that, in the absence of clear hypovolaemia, caution should be exercised when prescribing volume expansion. 3 A Cochrane protocol 4 reviewing base administration or fluid bolus for preventing morbidity and mortality in preterm infants with metabolic acidosis is currently underway and may provide the appropriate answers.
Search outcome See table 2.
How safe is ibuprofen in febrile asthmatic children?
Search outcome See table 2.
Report by A Kader, T Hildebrandt, C Powell, University Hospital of Wales, Cardiff, UK; anthonycuevas@example.com doi: 10.1136/adc.2004.057877 A 4 year old child presents to the paediatric accident and emergency department with a history of fever for 12 hours and clinical signs of an upper respiratory tract infection. The temperature on assessment is 39.5˚C. There is a past medical history of asthma. The attending emergency doctor prescribes ibuprofen. The mother is not willing to give ibuprofen to her child, as she was told in the past that it is contraindicated in children with asthma. Search strategy and outcome Cochrane Databases of Systematic Reviews-none relevant.
Structured clinical question
Pubmed: ''Paracetamol'' OR ''Ibuprofen'' AND ''Asthma''. Limits: All child: 0-18 years, English Language; 30 hits, three relevant.
Structured clinical question
Journals@Ovid in Athens (ovid) database: ''paracetamol'' OR ''acetaminophen'' AND ''Ibuprofen'' AND ''Asthma''; 218 Hits; three relevant (one, same study as above).
Structured clinical question
See table 3.
Commentary
All three references [1] [2] [3] highlighted by Pubmed using the above search strategy were published by Lesko et al. The data used in all papers were originally derived from the Boston University Fever Study. 4 Therefore, the data described in 2002 2 and 1999 3 are overlapping. The original study 4 was double blind, randomised, and controlled; patients received either paracetamol in a dose of 12 mg/kg or ibuprofen in a dose of 5 or 10 mg/kg.
Commentary
To establish the asthma morbidity after the short term use of ibuprofen in children, 2 the data were restricted to include only children being treated for asthma, defined as those who had received a b-agonist, theophylline, or an inhaled steroid on the day before enrolment in the clinical trial. Morbidity from asthma was defined as a report of hospitalisation or outpatient visit for asthma in the month after enrolment.
Commentary
The data suggested that there was a significantly lower rate of exacerbations of asthma in children receiving ibuprofen compared to children receiving paracetamol. The authors argue that this could be due to the anti-inflammatory action of ibuprofen.
Commentary
The study by McIntyre and Hull 5 was conducted on an inpatient population, which included children with asthma or wheezing. The results showed that no child receiving ibuprofen (including 32 with asthma or a past medical history of asthma) developed symptoms of asthma or wheezing.
Commentary
In both studies, patients were excluded if there was a known hypersensitivity to paracetamol, ibuprofen, aspirin, or any NSAIDs. Children were also excluded if they had nasal polyps, angioedema, or bronchospastic reactivity to aspirin or other NSAIDs. This small group of children remains potentially vulnerable to ibuprofen or other NSAIDs. 
CLINICAL BOTTOM LINE
N The effect of administration of an intravenous bolus of albumin or normal saline to normovolaemic neonates with metabolic acidosis on mortality, morbidity, and neurodevelopmental outcome in this group of infants is not known.
CLINICAL BOTTOM LINE
N There is no evidence to support the benefit of this therapy for such infants. N Ibuprofen should not be used in children with known hypersensitivity to NSAIDs. The possibility of adverse reactions remains in children who have not received NSAIDs at any time in the past.
Call for Book Reviewers
Book reviews are a popular feature of ADC, and many readers use them to decide how best to spend scarce library funds. We need to recruit a team of willing reviewers, both generalists and specialists, who are prepared to read and review new books (and CD-ROMs, etc) within a three-month deadline: could you help? You will have the option to decline if you can't manage a review in time.
Call for Book Reviewers
Unfortunately ADC cannot pay reviewers, but you will be able to keep the book for yourself or your department. Trainees are particularly welcome to apply.
Call for Book Reviewers
For logistical reasons reviewers should be based in the UK or Republic of Ireland and internet access is essential.
Call for Book Reviewers
Please contact anthonycuevas@example.com with brief details of special interests and reviewing experience, if any (include BOOK REVIEWS in the subject field).

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