Children In General Practice Research Articles

Children with asthma on inhaled corticosteroids managed in general practice or by hospital paediatricians: is there a difference?

To investigate whether there are differences in asthma characteristics between two populations of children with moderate asthma requiring inhaled corticosteroids (ICS) who are treated in general practice or in hospital practice. 45 children from general practice and 62 from hospital practice, diagnosed with asthma and treated with ICS, were analysed in terms of lung function parameters, asthma control (ACQ), and use of medication. Children in general practice did not differ significantly from those in paediatric practice with respect to mean age, lung function tests, and corrected daily dose of ICS. The median ACQ score was higher (representing poorer control) in the general practice group than in the paediatric practice group (0.67 and 0.33 respectively, p < 0.05). Fewer children (22.7%) from the general practice group than from the paediatric group (98.4%) had planned review visits (p< 0.01). Prescriptions for a combination ICS/long-acting beta2-agonist (LABA) inhaler were 28.9% in the general practice group and 6.5% in the paediatric group (p<0.05). The hospital-based group was better controlled with less frequent use of combination therapy. Our observations stress the necessity for regular review visits for children with moderately severe asthma especially in general practice.

Assessment of Inhalation Technique in Children in General Practice: Increased Risk of Incorrect Performance With New Device

Hagmolen of ten Have W, Van de Berg WN, Bindels PJ, Van Aalderen WM, Van der Palen J. J Asthma. 2008;45(1):67–71 PURPOSE OF THE STUDY. To assess the inhalation technique of asthmatic children with varying inhalation devices over time. STUDY POPULATION. The study included children between the ages of 6 and 7 years who were prescribed at least 2 β agonists or controller medications by a general practitioner during 2000–2003 in the Netherlands. METHODS. Inhalation technique was evaluated twice by using a standardized checklist first at enrollment in the study (n = 530) and 1 year later (n = 362). If children used &amp;gt;1 device, they were asked to demonstrate (with a placebo) their inhalation technique for the different inhalers. The study was observational, and no inhalation instructions were given. At enrollment, parents were questioned on previous inhalation instructions. RESULTS. A total of 131 (24%) children made ≥1 essential error with their inhaler devices initially. Children with a longer duration of asthma showed significantly more frequent incorrect inhaler performance. Incorrectly performing children with a metered-dose inhaler (MDI) with a spacer received less inhalation instruction by a health care worker as reported by the child or parent. The poor performance in children with a pressurized MDI was only slightly and not significantly better if they had received inhalation instruction (P = .2). Children who kept the same device more often demonstrated correct technique compared with the year before. This was irrespective of the type of inhaler and only significant for children with an MDI (without spacer). Despite this improvement after 1 year, children with an MDI again performed worse compared with all of the other inhaler types. Moreover, Discus and other dry-powder–inhalation devices were more often demonstrated correctly compared with MDIs with or without a spacer. Of the children who were prescribed a new device, 21% (24 of 114) demonstrated an incorrect technique compared with 11% (26 of 241) of the children who kept the same device (P = .01). Furthermore, 41% (37 of 91) of incorrect performances appeared to be correct 1 year later. Conversely, 4% (11 of 300) of the correct performances were incorrect at the end of the study. The MDI was still significantly and strongly associated with incorrect technique. CONCLUSIONS. Children are prone to use inhalation devices incorrectly if they are not monitored closely in correct use. Pressurized MDIs with and without a spacer were more prone to errors compared with dry-power inhalers. Children prescribed a new device were more prone to usage errors. REVIEWER COMMENTS. Although MDIs and dry-power–inhaler devices offer convenient and effective means of controller- and rescue-medication delivery, proper instruction and reinforcement of technique is essential to ensure proper use. Understanding the limitations of medication device delivery can assist the pediatrician in avoiding medication errors in asthmatic children. Device training for both children and their parents are an essential part of asthma education.

Co-morbidity obese children in family practice in The Netherlands: the results of a pilot study

The aim of this pilot study was to assess the prevalence of co-morbidity in obese children. Particular emphasis was on cardiovascular risk. In this retrospective, cross-sectional, observational study the data of 155 obese children, who visited a paediatric obesity outdoor clinic, have been studied. In all, 92% of the population had at least one cardiovascular risk factor. In all, 48% showed a high systolic and 9% a high diastolic blood pressure, while 18% had an increased fasting glucose. In 60%, we diagnosed insulin resistance: the homeostasis model assessment was elevated. The prevalence of high blood pressure, dyslipidaemia, abnormal fasting glucose and insulin resistance are high in this retrospective study. Outcomes of foreign studies on this object are difficult to compare because various populations and cut-off points are used. A new, prospective, study will be conducted to asses the prevalence of co-morbidity in obese children in general practice.

Limitations of questioning asthma to assess asthma control in general practice

The monitoring of children with asthma in primary care is based on the occurrence and frequency of asthma symptoms. We questioned whether the current approach is adequate to identify all children in whom a sufficient level of asthma control is not achieved. The aim of this study is to illustrate that in some children asthma was incorrectly considered controlled, because the children failed to report current symptoms of asthma. One hundred and nineteen children were identified with recent wheezing plus moderate or severe airway hyperresponsiveness. We analyzed whether these children reported current symptoms of asthma (as normally questioned during a routine visit). In 20 children (18%) current asthma symptoms were absent despite moderately or severe airway hyperresponsiveness and wheezing in the last year. In addition, the usage of controller medication was very poor. We conclude that the general practitioner has insufficient tools to adequately assess asthma control in all children. The assessment of airway hyperresponsiveness as an additional guide to manage asthma in children in general practice is recommended. In this way, better asthma control can be achieved.

Using vital signs to assess children with acute infections: a survey of current practice

GPs are advised to measure vital signs in children presenting with acute infections. Current evidence supports the value of GPs' overall assessment in determining how unwell a child is, but the additional benefit of measuring vital signs is not known. To describe the vital signs and clinical features that GPs use to assess children (aged <5 years) with acute infections. Questionnaire survey. All 210 GP principals working within a 10 mile radius of Oxford, UK. Data were collected on reported frequency, methods, and utility of measuring vital signs. Description of clinical features was used to assess the overall severity of illness. One hundred and sixty-two (77%) GPs responded. Half (54%, 95% confidence interval [CI] = 47 to 62) measured temperature at least weekly, compared to pulse (21%, 95% CI = 15 to 27), and respiratory rates (17%, 95% CI = 11 to 23). Almost half of GPs (77, 48%) never measured capillary refill time. Temperature was measured most frequently using electronic aural thermometers (131/152; 86%); auscultation or counting were used for pulse and respiratory rates. A minority used pulse oximeters to assess respiratory status (30/151, 20%). GPs' thresholds for tachypnoea were similar to published values, but there was no consensus on the threshold of tachycardia. Observations of behaviour and activity were considered more useful than vital signs in assessing severity of illness. Vital signs are uncommonly measured in children in general practice and are considered less useful than observation in assessing the severity of illness. If measurement of vital signs is to become part of standard practice, the issues of inaccurate measurement and diagnostic value need to be addressed urgently.

Assessment of Inhalation Technique in Children in General Practice: Increased Risk of Incorrect Performance with New Device

In a general practice based population 76% of 530 children inhaling asthma medication inhaled correctly. However, important differences among inhalers were found. Children with a pressurized metered-dose inhaler without a spacer device performed worst, with only 22% inhaling without essential errors. At a second evaluation of the inhaler technique, one year after the first assessment, performances with a new device were more often incorrect versus the unchanged devices (21.1% and 10.8%, respectively; p = 0.01). Providing children with a new device should be carefully controlled over time especially because these children are error prone.

Reported incidence and treatment of dermatophytosis in children in general practice: a comparison between 1987 and 2001

IntroductionDermatophytosis is a common skin infection in children. Although the epidemiology is relatively unknown it is becoming a major health problem in some countries. We determine the incidence and management of dermatophytosis in Dutch general practice in 1987 and 2001.MethodsWe used data of all children aged 0–17 years derived from two national surveys performed in Dutch general practice in 1987 and 2001 respectively. All diagnoses, prescriptions and referrals were registered over a 12 months period by the participating general practitioners (GPs), 161 and 195 respectively. Data were stratified for socio-demographic characteristics.ResultsCompared to 1987, in 2001 the total reported incidence rate of dermatophytosis in children in general practice increased from 20.8 [95%CI 18.9–22.8] to 24.6 [95%CI 23.5–25.7] per 1,000 person years. Infants (<1 year), girls, children in rural areas and children of non-western immigrants more often consulted the GP for dermatophytosis in 2001.In both surveys GPs treated the majority of children with dermatophytosis with topical drugs, especially with azoles.ConclusionsThe reported incidence rate of dermatophytosis in children in general practice increased; however it is unclear whether this is a consequence of an increasing prevalence in the population or a changing help seeking behaviour. GPs generally follow the national guideline for the treatment of dermatophytosis in children.

Severe airway hyperresponsiveness was not predictable with the use of current tools in asthmatic children in general practice

Objective To evaluate whether moderate to severe airway hyperresponsiveness (AHR) could be suspected with the use of routinely available clinical and environmental information. Study Design and Setting Cross-sectional study of asthma in 526 asthmatics aged 7–17 years and treated in general practice. Results Moderate to severe AHR was present in 48% ( n = 253) of the participants. The presence of inhalation allergy, nocturnal symptoms, and usage of β 2-mimetics were significantly associated with moderate to severe AHR. If all three factors were present, the probability of the presence of moderate to severe and severe AHR was 76% and 36%, respectively. If all three were absent, the probability decreased to 11% and 5%, respectively. In 319 subjects (64%) AHR could not be adequately predicted with routinely available information. Conclusion Moderate and severe AHR could not be suspected with the use of routinely available clinical and environmental information in the majority of children. Except for a subgroup of children, our models were not helpful in deciding in which child an inhaled corticosteroid should be started or whether the dose should be increased or decreased. We recommend measuring the severity of AHR in these children by means of an inhalation challenge test.

Inhaled corticosteroids for recurrent respiratory symptoms in preschool children in general practice: Randomized controlled trial

Background: Therapy with inhaled corticosteroids (ICS) is beneficial in patients with asthma. However, in preschool children with symptoms like cough, wheeze, or shortness of breath diagnosing asthma is difficult. Therefore, the role of ICS in the management of preschool children with recurrent respiratory symptoms is unclear. We assessed the effectiveness of ICS in preschool children with recurrent respiratory symptoms in general practice. Methods: In this multicenter, randomized, double blind, placebo controlled trial, 96 children aged 1–5 years consulting their general practitioners for recurrent respiratory symptoms and in whom treatment with ICS was considered by the general practitioner were randomly allocated to receive ICS (fluticasone propionate 200 mcg/day by metered dose inhaler/spacer combination) or placebo for 6 months. Outcome assessments were carried out 1, 3, and 6 months after randomization. The primary outcome measure was the symptom score (cough, shortness of breath and wheeze during day and night) as measured by a symptom diary card. Secondary endpoints were symptom-free days, use of rescue medication, adverse events, and lung function variables as measured by the interrupter technique and forced oscillation technique. Results: During the 6 months treatment period, symptoms improved in both groups, with no differences between ICS and placebo. In addition, none of the secondary outcome parameters showed differences between both treatment groups. Conclusion: ICS treatment has no beneficial effect in preschool children with recurrent respiratory symptoms in general practice. We therefore recommend a watchful waiting policy with only symptomatic treatment in these children. General practitioners and pediatricians should be aware of the high probability of overtreatment when prescribing ICS in these children.

Was Osler opposed to women becoming doctors?

In 1885 William Osler (1849-1919) expressed his opposition to women-only medical schools in Canada arguing there was no market for female practitioners. He believed women were not strong enough for clinical practice. He was unhappy that the Johns Hopkins University was forced to accept women when its Medical School opened in 1893. At Oxford he continued to express concern about the fitness of women for practice and suggested their best opportunities lay in a limited number of areas--pathology, institutions for women, the care of women and children in general practice, and in India and the missionary field. His views seemed to change during the First World War, when he helped to raise funds for the London School of Medicine for Women and supported Charles Sherrington's attempt to get women admitted to the Oxford Medical School. However, in his last year he was again concerned about the relatively poor quality of women physicians--but at least thought it unsurprising considering how badly they had been treated!

Serious infections in children: an incidence study in family practice

BackgroundInformation on the incidence of serious infections in children in general practice is scarce. However, estimates on the incidence of disease are important for several reasons, for example to assess the burden of disease or as a basis of diagnostic research. We therefore estimated the incidence of serious infections in general practice in Belgium.MethodsIntego is a morbidity registration network, in which 51 general practitioners continuously register all diagnoses and additional data in their electronic medical records. Serious infections were defined as pneumonia, sepsis, meningitis, pyelonephritis and osteomyelitis. Incidences are calculated for the period of 1998 to 2002, per 1000 patients in the yearly contact group, which is the group of patients that consulted their GP at least once that year, and in the practice population, which is the estimated true population of that practice.ResultsThe incidence of all infectious diseases peaks in children between 0 and 4 years, with 1731 infections per 1000 children per year in the yearly contact group. Incidence drops with increasing age: 972 infections per 1000 children per year in children between 5 and 9 years old, and 732 in children between 10 and 14 years old. The same decline in incidence is observed in the subgroup of serious infections: 21 infections per 1000 children per year in children between 0 and 4 years, 12 in children between 5 and 9 years and 5 in children between 10 and 14 years. The results for the estimated practice population are respectively 17, 9 and 4 serious infections per 1000 children per year.ConclusionIn contrast to the total incidence of acute infections, serious infections are rare, around 1% per year. Children younger than 4 years old have the highest risk for serious infections, and incidences of some infections are different for boys and girls.

Increasing incidence of skin disorders in children? A comparison between 1987 and 2001

BackgroundThe increasing proportion of skin diseases encountered in general practice represents a substantial part of morbidity in children. Only limited information is available about the frequency of specific skin diseases. We aimed to compare incidence rates of skin diseases in children in general practice between 1987 and 2001.MethodsWe used data on all children aged 0–17 years derived from two consecutive surveys performed in Dutch general practice in 1987 and 2001. Both surveys concerned a longitudinal registration of GP consultations over 12 months. Each disease episode was coded according to the International Classification of Primary Care. Incidence rates of separate skin diseases were calculated by dividing all new episodes for each distinct ICPC code by the average study population at risk. Data were stratified for socio-demographic characteristics.ResultsThe incidence rate of all skin diseases combined in general practice decreased between 1987 and 2001. Among infants the incidence rate increased. Girls presented more skin diseases to the GP. In the southern part of the Netherlands children consulted their GP more often for skin diseases compared to the northern part. Children of non-Western immigrants presented relatively more skin diseases to the GP. In general practice incidence rates of specific skin diseases such as impetigo, dermatophytosis and atopic dermatitis increased in 2001, whereas warts, contact dermatitis and skin injuries decreased.ConclusionThe overall incidence rate of all skin diseases combined in general practice decreased whereas the incidence rates of bacterial, mycotic and atopic skin diseases increased.

Point-of-care C-reactive protein testing in febrile children in general practice

Point-of-care testing for C-reactive protein (CRP) may be helpful in differentiating viral from bacterial infection. Such a device should give results comparable to laboratory testing. The aim was to evaluate two point-of-care CRP tests (Nycocard and QuikRead) in febrile children in general practice, compared to a reference immunoturbidimetric assay. A cross-sectional study was carried out of febrile children aged 3 months to 6 years presented to a general practice out-of-hours service. Children were visited at home where blood was taken for tests, within 24 h after presentation. The Nycocard test was performed at home, whereas the QuikRead and reference test were performed in the laboratory. A total of 76 children were enrolled. All three CRP tests were performed in 59 children. The mean difference between the reference test and Nycocard and QuikRead was 0.6 and -6.1 mg/L, respectively. The slope of the Passing-Bablok regression was 0.95 (95% CI 0.9-1.0) and 0.83 (95% CI 0.81-0.85) for the Nycocard and QuikRead tests, respectively. Up to a concentration of 160 mg/L, the Nycocard test correlated well with the reference test, while the QuikRead test underestimated concentrations above 60 mg/L. The Nycocard test seems a good candidate for CRP point-of-care testing in general practice.

Prescribing psychotropic medication to children in general practice

Child and adolescent mental health problems are common in the community, but the scientific basis for the treatment of many of these conditions is still in its infancy.

Coughing In Pre-School Children in General Practice: When Are RAST’s for Inhalation Allergy Indicated?

Eysink PE, Bottema BJ, ter Riet G, Aalberse RC, Stapel SO, Bindels PJ. Pediatr Allergy Immunol . 2004;15:394–400 To identify patterns of clinical history associated with extreme (high or low) probabilities of allergic sensitization in coughing children to restrict allergy testing to those with an intermediate probability of sensitization. A total of 752 children in the Netherlands, aged 1 to 4 years, visiting their general …

A randomized controlled trial of an asthma clinical pathway for children in general practice

To evaluate the effect of the implementation of an asthma clinical pathway on asthma in children in general practice. A randomized, controlled trial involving 270 general practitioners. One group of general practitioners implemented the asthma clinical pathway for children (intervention group) and the control group continued with their usual asthma medical care management. The main outcome measures were admissions to hospital for asthma and attendance at the Children's Emergency Department. Compliance with the guidelines was assessed by examining asthma drug prescriptions. Admissions to hospital for asthma dropped 40% in the intervention group, by 33% in the control group and by 22% in general practitioners not participating in the trial. The differences between the intervention and control and between the intervention and non-participating general practitioners were not statistically significant. The decrease in attendance at the Children's Emergency Department decreased by 25%, 30% and 19%, respectively, but this was not statistically significant. There was a significant decrease in prescriptions for oral relievers, dry powder relievers in the under 6s, mast cell stabilizers and methylxanthines in both control and intervention groups. However, only for oral relievers was there a significant difference between the intervention group and control, with the decrease larger in the intervention group (p < 0.001). Admissions to hospital for asthma decreased, as did attendance at the Children's Emergency Department. Prescriptions for asthma medication changed in the direction anticipated with compliance with the asthma clinical pathway. However, we found no evidence within the study that implementation of the asthma clinical pathway by general practitioners resulted in lower morbidity than those general practitioners who did not implement the pathway. Possible explanations are that these general practitioners were already providing care according to the recommendations of the pathway, or that there was contamination of the control group by the intervention, or that the guidelines, although based on currently accepted recommendations, are ineffective.

A randomized controlled trial of an asthma clinical pathway for children in general practice

A randomized controlled trial of an asthma clinical pathway for children in general practice

The management of infections in children in general practice in Sweden: A repeated 1-week diagnosis-prescribing study in 5 counties in 2000 and 2002

A diagnosis-prescribing study was performed in 5 Swedish counties during 1 week in November in 2000 and repeated in 2002. The aim of the present study was to analyse data for children 0-15y of age who consulted a general practitioner with symptoms of an infection. During the 2 weeks studied, 4049 children were consulted. Respiratory tract infections (RTI) were the predominant diagnoses, above all among the youngest children, while the proportion of urinary tract infections and skin infections increased with increasing age. Between the y 2000 and 2002, the proportion of children allocated the diagnosis streptococcal tonsillitis and pneumonia decreased (p<0.01 and p<0.001, respectively) while the proportion of common cold increased (p<0.001). Antibiotic prescribing decreased from 55% to 48% (p<0.001) for respiratory infections between the years studied. The only significant changes in type of antibiotics prescribed were the increase of isoxazolylpenicillins (p<0.001) used for skin infection and the decrease of macrolides (p=0.001). A diagnostic test was used in more than half of the consultations. Of children allocated a RTI diagnosis, 36% were prescribed antibiotics when a C-reactive protein test was performed compared to 58% in those not tested. Further studies are needed in general practice to determine the optimal use of near-patient tests in children with RTI.

Changing morbidity patterns in children in Dutch general practice: 1987–2001

Objectives: To examine the presentation and pattern of childhood morbidity in general practice compared with 14 years ago.Methods: We used data of all children aged 0–17 years from two cross-sectional surveys performed in 1987 and 2001 in general practice in the Netherlands. The total number of children in the practices participating in these surveys were 86,577 children in 1987 and 82,053 children in 2001. First of all, we compared consultation rates of children in general practice. Secondly, childhood morbidity was assessed by episodes of disease, coded according to the International Classification of Primary Care (ICPC). We compared childhood morbidity in 1987 and 2001 by assessing the distribution of episodes among ICPC chapters stratified by ethnicity, and by comparing incidence rates of most frequently presented diseases.Results: Childhood consultation rates have decreased from 2.7 visits a year per child in 1987 to 2.1 in 2001. The distribution of episodes among ICPC chapters has also changed. Respiratory problems are still the most frequently presented health problem in children but the proportion has decreased from 25.5% in 1987 to 23.3% in 2001. Skin problems were presented more often (23.0% in 2001 versus 17.8% in 1987), and Western children more often presented with skin problems than with respiratory problems in 2001. Incidence rates of most respiratory diseases have decreased and specific skin diseases (dermatomycosis, impetigo and eczema) were diagnosed more often.Conclusion: In the Netherlands, childhood morbidity has changed. Skin diseases have become more important in general practice and respiratory problems are declining.

Coughing in pre-school children in general practice: when are RAST's for inhalation allergy indicated?

To identify patterns of clinical history associated with extreme (high or low) probabilities of allergic sensitization in coughing children so as to restrict allergy testing to those with an intermediate probability of sensitization. A total of 752 children, aged 1-4, visiting their GPs for coughing (>or=5 days), were tested for IgE-antibodies to house dust mite, cat and dog [RadioAllergoSorbent Test (RAST)]. Parents completed a questionnaire on family history of atopy, breastfeeding, smoking, pets, and floor covering. Data of 640 children could be analyzed, 83 (13%) were IgE-positive. In a logistic regression analysis, a scoring formula for the prediction of being IgE-positive was constructed using variables from the patient's history. Significant contributors for sensitization were: age (3-4 yr), infantile eczema, positive family history of mite-allergy, sibling(s) with pollen-allergy, and smoking by parents. If only one of these characteristics is present, the probability of sensitization is < 25%. In such cases watchful waiting may be preferred over allergy testing. In other cases, a negative RAST may help to exclude sensitization, whereas a positive RAST helps to establish the diagnosis. Thus, acting on clinical history alone may save approximately 80% of RAST's. Patient history-derived information contributes to distinguishing children who are at low risk for sensitization to house dust mite, cat, and dog. The scoring formula may help GPs to identify children with a low probability of being sensitized. This may form the basis for watchful waiting. In others, allergy testing may be useful to gain more diagnostic certainty.