Online First articles may not be available until 00.01 (UK time) Friday.
Press releases Monday 1 September - Friday 5 September 2008
Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://bmj.com).
(1) Young children's fever is reduced for longer by giving ibuprofen first (2) Better guidance urgently needed for doctors in child protection cases, say experts (3) Should nurses replace GPs as frontline providers of primary care?
(1) Young children's fever is reduced for longer by giving ibuprofen first (Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial) http://www.bmj.com/cgi/content/abstract/337/sep02_2/a1302 (Editorial: Antipyretic treatment for feverish young children in primary care) http://www.bmj.com/cgi/content/extract/337/sep02_2/a1409
Children's fever can be kept at bay for longer if they are given ibuprofen first and then paracetamol plus ibuprofen, according to a study published on BMJ.com today.
National guidelines which caution that the drugs should not be used in combination should be reviewed in light of this evidence, say the authors.
Fever is a normal part of childhood illness and affects around 70% of pre-school children every year. Paracetamol and ibuprofen are being increasingly used together in the home, and in healthcare settings for the relief of fever and its symptoms. But the evidence for the effectiveness of the two drugs given together, rather than when used alone, is sparse and conflicting.
Guidelines published last year by the National Institute for Health and Clinical Excellence (NICE) advise the use of either medicine for children unwell or distressed with fever and state that, due to the lack of evidence, they should not be combined or alternated.
A team of researchers from the University of Bristol and the University of the West of England, recruited 156 children aged between six months and six years old who had a temperature between 37.8 and 41 degrees centigrade, due to an illness that could be managed at home. Children were randomised to receive either paracetamol plus ibuprofen, just paracetamol, or just ibuprofen.
The children were recruited from 35 Bristol primary care sites during the two year study.
The parents were advised to give the study medicines for up to 48 hours: paracetamol every 4 to 6 hours (maximum of 4 doses in 24 hours) and ibuprofen every 6 to 8 hours (maximum of 3 doses in 24 hours).
The children's condition was followed up at 24 hours, 48 hours and at day five.
The researchers found that in the first four hours children given both medicines spent an extra 55 minutes less time with fever compared to those given paracetamol alone. But giving two medicines was not markedly better than just giving ibuprofen.
However, over a 24 hour period, children given both medicines experienced 4.4 hours less time with fever than those given just paracetamol, and 2.5 hours less time with fever than those just given ibuprofen.
The researchers say: "Doctors, nurses, pharmacists and parents wanting to use medicines to treat young, unwell children with fever should be advised to use ibuprofen first and to consider the relative benefits and risks of using both medicines over a 24 hour period."
They conclude that the NICE guidance regarding the use of two medicines combined does not need to be so cautious now that there is good evidence of superiority for two drugs over one for increasing time without fever over 24 hours.
In an accompanying editorial, Dr Anthony Harnden from the University of Oxford, says that this trial shows that longer action ibuprofen is the most suitable drug to use for fever in children. He warns that because it is easy for parents to overdose their children [31 children received a drug overdose in this trial], a "more complicated alternating regimen of paracetamol and ibuprofen may be less safe than using either drug alone."
Contact: Caroline Clancy, University of Bristol Press Office Email: caroline.clancy@bristol.ac.uk Editorial: Rachael Davies, BMJ Press Office, London, UKEmail: rdavies@bma.org.uk
(2) Better guidance urgently needed for doctors in child protection cases, say experts (Editorial: Medical law and the protection of children)http://www.bmj.com/cgi/content/extract/337/sep04_2/a1380
Better guidance is urgently needed for doctors in child protection cases to prevent them from being deterred from acting to protect children, says an editorial on bmj.com today.
Writing in response to recent high profile cases such as that of Sir Roy Meadow, which have highlighted "the crisis of confidence" developing between the General Medical Council (GMC) and paediatricians, David Foreman and Juliet Williams call for better guidance to prevent doctors from being deterred from raising concerns about child abuse and to restore confidence in child protection processes.
They point out that the number of complaints against paediatricians related to child abuse work increased by more than 500% between 1995 and 2003.
In addition, since 2003, registrations of children for emotional and sexual abuse have increased while those for physical and sexual abuse have declined. This, they say, suggests that doctors may be avoiding work related to abuse for which more detailed physical examinations are needed.
According to the authors, part of the problem is that there is a basic confusion in doctors' duties regarding child protection. Medical law still states that doctors have a duty of care to both the parent and the child, but current paediatric professional guidance incorrectly applies the Children Act principle that the welfare of the child must be placed over all other considerations. In fact, this only applies to the courts, when they make a decision governed by that Act.
Therefore, in child protection cases, doctors have conflicting duties both to the child and to the parents who may not feel that doctors are acting in their best interests, particularly if they are suspects and if retrospectively no abuse is detected. This situation worsens if the doctor is later required to act as an expert witness in court.
Recent hostile media campaigns have added to the pressure on doctors by making it less likely that the GMC will dismiss high profile cases because its duty is to protect the public and also the reputation of medicine while maintaining public confidence in the profession, say the authors.
So what can be done to reinstate confidence in child protection processes and prevent a reduction in child protection?
The authors call on the GMC and other professional bodies to issue more specific guidance for doctors on how to manage these conflicting duties of care in child protection cases.
They also suggest that complaints against professionals in child protection cases should be subject to independent scrutiny before they are referred to their professional bodies.
To avoid unwarranted public criticism the public also need to be better educated about child protection work, so that the dual role of doctors in these cases is better understood, they conclude.
Contact: David Foreman, Child and Adolescent Mental Health Service, Noble's Hospital, Isle of Man, UK Email: David_Foreman@doctors.net.uk
(3) Should nurses replace GPs as frontline providers of primary care? (Head to head: Should primary care be nurse led?) Yes: http://www.bmj.com/cgi/content/extract/337/sep04_2/a1157 No: http://www.bmj.com/cgi/content/extract/337/sep04_2/a1169
Should nurses be the frontline providers of primary care, taking the place of general practitioners as the first point of patient contact? Two experts debate the issue on bmj.com today.
Nurses can deliver as high quality care as general practitioners in most areas of general practice including preventive health care, the management of long term conditions, and first contact care for people with minor illness, writes Bonnie Sibbald, Professor of health services research at the University of Manchester.
She argues that substituting nurses for doctors has the potential to improve the efficiency of primary health care. Too often GPs provide the same services as nurses and this leads to duplication rather than substitution of care.
In fact, she says, GPs skills would be better used to tackle more complex health problems which have a higher degree of uncertainty about their diagnosis and treatment.
According to Sibbald, general practices in the UK are already aware of the value of nurses to improve the scope and quality of primary care. Over the last twenty years, there has been a rapid expansion in the numbers of practice nurses recruited to meet new service contracts. For instance, nurses now provide immunisations, vaccinations, and cervical screening services and will be a key part of meeting the quality of care targets for people with long term conditions set out in the General Medical Services contract of 2004.
She believes that recent changes to legislation, such as the right for qualified nurses to prescribe licensed medicines, have begun to allow nurses to realise their full potential.
This trend, she concludes, must be followed "to its logical conclusion, acknowledging nurses to be the true frontline providers of primary care"… [while the] "general practitioners' role should evolve to become that of a consultant in primary care receiving referrals from nurses."
But Dr Rhona Knight, a GP from Leicester who has first hand experience in a nurse led practice, argues that nurse led primary care would restrict patient choice and undermine the importance of nurses' unique contribution to primary health care.
She acknowledges that patients report a high level of satisfaction with nurse consultations, but points to evidence that patients prefer to consult with a GP if they think their symptoms are serious.
She points out that GPs' training takes 10 years and that they are hugely experienced in dealing with undifferentiated illness which enables them to be key deliverers and leaders of generalist healthcare. In contrast, she says, advanced nurse training is less developed and recommends a minimum of only 500 indirect or direct supervised hours and the competencies cover "just nine pages".
Currently, she says, a lack of nationally agreed standards means that nurses have varied roles with inconsistent training, knowledge, experience and titles.
Nurses would need increased training and a similar curriculum to GPs to be able to take the lead in dealing with all illnesses, she argues. One solution could be for nurses to take a graduate health science medical course and train to be a GP and be appropriately rewarded for this role, she concludes.
In an accompanying feature, Rebecca Coombes outlines some of the major impediments to senior nurses taking on some medical roles including a lack of professional regulation, low pay, and cultural objections from doctors.
Contacts: Bonnie Sibbald, National Primary Care Research and Development Centre, University of Manchester, UK Email: bonnie@sibbald@manchester.ac.uk Rhona Knight, GP, Leicester, UK Email: rhona.knight@pearlmedical.co.uk Rebecca Coombes, BMJ, Tavistock Square, London, UK Email via: rdavies@bma.org.uk
FOR ACCREDITED JOURNALISTS
Embargoed press releases and articles are available from:
Public Affairs Division, BMA House, Tavistock Square London WC1H 9JR
(contact: pressoffice@bma.org.uk)
and from:
the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
[[$FOOTER]]