• Respiratory distress syndrome
• Non-invasive ventilation

Deciding when sufficient evidence has accumulated for a new therapy to become the ‘standard of care’ is a trade-off between absolute certainty obtained from myriads of trials and insufficient ‘proof.’ In developing countries, the financial and technical resources needed to make new therapies widely available further complicate this balance. Moreover, expensive, large-scale trials are often conducted in industrialised countries. Can the evidence provided by these studies inform treatment selection in resource-limited settings? Or, are ‘local’ studies always necessary? Decisions to adopt new therapies in developing countries should be determined individually, but the underlying clinical and methodological questions that influence these decisions are likely similar. We suggest they include: What is the burden of disease treated by the new therapy? What is the strength of all available evidence for both efficacy and harm? Are there relevant differences between the studies conducted in developed versus developing countries? Finally, is use of the new therapy in resource-limited settings feasible?

Martin et al1 report an important systematic review of studies evaluating bubble continuous positive airway pressure (CPAP) for the treatment of neonatal respiratory distress in resource-limited countries. The authors conclude ‘bubble CPAP is a promising intervention which reduces the need for high cost mechanical ventilators… however there is need for more research into the impact of bubble CPAP on neonatal mortality and into effective implementation methods...’ An implication is made that further prospective trials in resource-limited settings are needed. We respectfully emphasise that if CPAP remains an experimental therapy …