Focus group parental opinions regarding treatment with topical corticosteroids on children with atopic dermatitis.

INTRODUCTION AND OBJECTIVES: Atopic dermatitis is common among children of 0-5 years old. Treatment consists of emollients and topical corticosteroids. Due to corticophobia, however, adherence to topical corticosteroids is low. Our aim was to find factors that influence opinions about topical corticosteroids among parents of children with atopic dermatitis. METHODS: A qualitative focus group study in secondary care with parents of children with atopic dermatitis. Questions concerned opinions, attitude, sources of information, and the use of topical corticosteroids. RESULTS: The parents indicated that they lack knowledge about the working mechanism and side effects of topical corticosteroids. Dermatologists and paediatricians emphasise the beneficial effects, whereas other healthcare workers and lay people often express a negative attitude. CONCLUSIONS: This study gives a complete overview of factors influencing adherence. Treatment with topical corticosteroids can be improved by better informing parents about the working mechanisms, the use, and how to reduce the dose. Healthcare professionals need to be aware of the consequences of their negative attitude concerning topical corticosteroids.

Antibiotic use during pregnancy and asthma in preschool children: the influence of confounding.

BACKGROUND: A recent study suggested that early-life intestinal microbiota may play an important role in the development of childhood asthma, indicating that antibiotics taken during early life or in late pregnancy may be associated with childhood asthma. OBJECTIVE: This study aims to assess the association between prenatal antibiotic use and asthma in preschool children using data from the prescription database IADB.nl. To assess the influence of potential confounding, we conducted both a case-sibling and a case-control study and compared the results. METHODS: We conducted a case-sibling study in which 1228 children with asthma were compared to 1228 siblings without asthma, using data from the prescription database IADB.nl. In addition, a case-control study was conducted. Asthma in preschool children was defined as ≥ 3 prescriptions for anti-asthma medication within a year before the fifth birthday. Conditional logistic regression was used to estimate crude and adjusted odds ratios (aORs). RESULTS: In both the case-sibling and case-control analysis, the use of antibiotics in the third trimester of pregnancy was associated with an increased risk of asthma in preschool children (aOR 1.37; 95% CI 1.02-1.83 and aOR 1.40; 95% CI 1.15-1.47). Time-trend analyses showed that results were not influenced by a time trend in antibiotic exposure. A significant association between exposure to antibiotics in any trimester of pregnancy and the development of asthma in preschool children was observed in the case-control analysis only (aOR 1.46; 95% CI 1.34-1.59). CONCLUSION: Antibiotic use in the third trimester of pregnancy was associated with a small increased risk of asthma in preschool children. This association was robust to time-invariant confounding or exposure time trends, further supporting the important role for early-life intestinal microbiota in the development of childhood asthma.

Identification of Dutch children diagnosed with atopic diseases using prescription data: a validation study.

PURPOSE: The aim of this study is to validate medication proxies for the identification of children diagnosed with atopic disorders that can be applied in various types of epidemiological research. METHODS: Records of 7439 children, aged between 0 and 10 years, in the period 2001 until 2010, were retrieved from the Registration Network Groningen database, a general practitioners database in the north-eastern part of the Netherlands. The sensitivity and positive predictive value (PPV) of 22 medication proxies for the identification of children diagnosed with atopic disorders (asthma, atopic dermatitis, and allergic rhinitis) were computed using the registered diagnoses as gold standards. In addition, different capture periods (1 year, half year, and length of study period) for the detection of prescriptions were tested for all the medication proxies. RESULTS: The highest PPV (0.84, 95 % CI 0.81-0.87) in combination with a sufficient sensitivity value (0.54, 95 % CI 0.50-0.57) for the identification of children diagnosed with asthma was yielded for the medication proxy, ≥2 prescriptions for anti-asthma medication within 1 year, including 1 inhaled steroid. PPV and sensitivity were even higher in the age group 6-10 years. The proxies designed for the identification of children diagnosed with atopic dermatitis and allergic rhinitis yielded only high PPVs (≥0.75) in combination with low sensitivity values (≤0.22). Altering the capture period for the detection of prescriptions to half a year or the length of the study period only affected sensitivity values. CONCLUSION: Children diagnosed with asthma can be identified reliably with a range of medication proxies. The use of prescription data for the identification of children diagnosed with atopic dermatitis and allergic rhinitis is questionable.

An explorative study of school performance and antipsychotic medication.

BACKGROUND: Antipsychotic therapy can reduce severe symptoms of psychiatric disorders, however, data on school performance among children on such treatment are lacking. The objective was to explore school performance among children using antipsychotic drugs at the end of primary education. METHODS: A cross-sectional study was conducted using the University Groningen pharmacy database linked to academic achievement scores at the end of primary school (Dutch Cito-test) obtained from Statistics Netherlands. Mean Cito-test scores and standard deviations were obtained for children on antipsychotic therapy and reference children, and statistically compared using analyses of covariance. In addition, differences in subgroups as boys versus girls, ethnicity, household income, and late starters (start date within 12 months of the Cito-test) versus early starters (start date > 12 months before the Cito-test) were tested. RESULTS: In all, data from 7994 children could be linked to Cito-test scores. At the time of the Cito-test, 45 (0.6 %) were on treatment with antipsychotics. Children using antipsychotics scored on average 3.6 points lower than the reference peer group (534.5 ± 9.5). Scores were different across gender and levels of household income (p < 0.05). Scores of early starters were significantly higher than starters within 12 months (533.7 ± 1.7 vs. 524.1 ± 2.6). CONCLUSION: This first exploration showed that children on antipsychotic treatment have lower school performance compared to the reference peer group at the end of primary school. This was most noticeable for girls, but early starters were less affected than later starters. Due to the observational cross-sectional nature of this study, no causality can be inferred, but the results indicate that school performance should be closely monitored and causes of underperformance despite treatment warrants more research.

Prenatal exposure to acid-suppressive drugs and the risk of allergic diseases in the offspring: a cohort study.

BACKGROUND: Recent studies reported increased risks for the development of asthma in children after prenatal exposure to acid-suppressive drugs. As a result of common pathogenesis, associations could also be present for other allergic diseases. METHODS: Using the prescription database IADB.nl, we conducted a cohort study amongst 33 536 children in the Netherlands, with a maximum follow-up of 8 years. Maternal exposure was defined as ≥1 dispensed prescription for proton pump inhibitors (PPIs) and/or Histamine 2-antagonists (H2As) during pregnancy. Children were considered to have a drug-treated allergic disease if they received either ≥2 prescriptions for dermal (atopic dermatitis), inhaled (asthma) or nasal (allergic rhinitis) steroids within a 12-month period. Clustered Cox proportional hazard regression was used to estimate crude and adjusted hazard ratios (aHR) with 95% confidence intervals (95% CI). RESULTS: The aHR for the development of any allergic disease was 1.37 (95% CI: 1.14-1.66) for children exposed to PPIs or H2As. Prenatal exposure to PPIs and/or H2As was associated with atopic dermatitis, asthma and allergic rhinitis with aHRs of 1.32 (95% CI 1.06-1.64), 1.57 (95% CI 1.20-2.05) and 2.40 (95% CI 1.42-4.04), respectively. The aHR for the development of two or more (aHR 2.13 95% CI: 1.43-3.19) and three allergic diseases (aHR 5.18 95% CI: 2.16-12.42) were even more elevated after prenatal exposure to PPIs or H2As. CONCLUSION: Prenatal exposure to PPIs and H2As appeared associated with an increased risk for the development of atopic dermatitis, asthma and allergic rhinitis in the offspring, especially with the development of multiple allergic diseases. Because our study has limitations inherent to observational studies, prospective studies are now warranted to confirm our findings.

[Spontaneous loss of permanent teeth in children is never innocent]. / Spontaan verlies van een blijvend gebitselement op kinderleeftijd is nooist onschuldig.

A 13-year-old patient spontaneously lost tooth 47. In addition, he had for several weeks experienced numbness of the lower lip and the chin on the right side, fatigue, weakness, loss of appetite, and weight loss. After extensive investigation he seemed to be suffering from a Burkitt lymphoma. Spontaneous loss of permanent teeth in children has an extensive differential diagnosis. Dentists should be familiar with this differential diagnosis as all possible diagnoses are related to serious pathologies. The differential diagnosis includes infectious, metabolic, naplastic, and odontogenic causes. Systematic history taking, physical examination and laboratory investigations will lead to a proper diagnosis.

Antiepileptic drug utilization in children from 1997-2005--a study from the Netherlands.

OBJECTIVE: To investigate the utilization of antiepileptic drugs (AEDs) in Dutch children and compare this with guidelines on the treatment of epilepsy in children. METHOD: From the Dutch Interaction Database (IADB.nl) we selected children aged 0-19 years who received at least one prescription for an AED (ATC-code beginning with N03A) between 1997 and 2005. We calculated cumulative incidences and prevalences per 1000 children per year, stratified by age-category, sex and type of AED, and the total number of months each patient received at least one prescription of AEDs, and we counted the number of person-months and AEDs prescribed. For each AED, proportions of person-months were calculated for mono- and combination therapy. Kaplan-Meier survival analysis was used to analyse the duration of AED use, stratified by sex. RESULTS: The overall prevalence of the prescription of AEDs to children was constant at approximately 4.0 per 1000 children during the years of the study. The overall cumulative incidence from 1997-2005 was 0.67 per 1000 children. When stratified by age category or sex, there were no relevant differences in incidence or prevalence. Valproic acid was the most frequently prescribed drug, followed by carbamazepine and lamotrigine. In 20.3% of all person-months, patients received combination therapy; of these, 34.2% received combination therapy for 3 person-months or less. The older AEDs were prescribed more often as monotherapy than combination therapy, in contrast with the newer AEDs, for which the opposite was true. The 50% survival probability (= time period when 50% of children had stopped using AEDs) was around 2 years, with a significantly lower discontinuation of treatment for girls than boys (P = 0.04). CONCLUSION: The overall cumulative incidence of AEDs was determined to be 0.67 per 1000 children, and the prevalence 4.0 per 1000 children. The most frequently prescribed drug is valproic acid, followed by carbamazepine and lamotrigine. The prescribing of AEDs seems to be in conformity with the overall recommendations of the guidelines on the treatment of epilepsy in children.

Hypertrichosis as a side effect of inhaled steroids in children.

Three spontaneous reports of patients in whom a relationship between hypertrichosis and inhaled corticosteroids (ICS) was suspected, were reported to Lareb, The Netherlands Pharmacovigilance Center. We sought evidence for and against a causal relationship between hypertrichosis and ICS in children. The relationship between hypertrichosis and ICS was studied mathematically by assessing the Reporting Odds Ratio (ROR) and by determining the Naranjo Score (NS). We also studied the reports sent to the Pharmacovigilance Database of the Uppsala Monitoring Centre (UMC) of the WHO and reviewed the literature. In the Dutch children, the ROR between hypertrichosis and ICS was 14.6 (95%CI 3.6-59.5), the NS was 4. In the database of the UMC 20 more reports on hypertrichosis and ICS were found, contributing to the results of the Dutch database. Taken together, 11 boys and 12 girls were involved with a mean age of 7 years (range 1-17). The time between the start of ICS and the occurrence of hypertrichosis varied between 1 month and 3 years. Besides the hypertrichosis, growth retardation was found in 5 children and adrenal suppression in 12. In 12 children the outcome after cessation was reported: in 6 children the hypertrichosis improved, whilst in 6 it did not. We found sufficient evidence to support the suspicion that hypertrichosis might be a true adverse effect of ICS. We found no simple dose-effect relationship but obviously there is an individual susceptibility. After cessation of ICS the exaggerated hair growth will not disappear in all children. Hypertrichosis may be a useful clinical pointer to exogenous steroid excess.

Screening infants with an isolated single umbilical artery for renal anomalies: nonsense?

BACKGROUND: Presently there is no consensus regarding the extent of workup required in newborns who present with an isolated single umbilical artery (SUA). Because of the association with silent renal anomalies, some studies advise to perform renal ultrasonography in infants born with an isolated SUA. AIMS: To decide whether screening (performing a renal ultrasound and in case of abnormalities on the ultrasound performing a micturating cystourethrogram) infants with an isolated SUA is justified by evaluating the prevalence of clinically relevant renal abnormalities. STUDY DESIGN: Retrospective descriptive study. SUBJECTS: Live-born infants with SUA detected by physical examination born between January 1st, 1997 and February 1st, 2005, in a tertiary care university hospital. OUTCOME MEASURES: Renal anomalies detected by renal ultrasonography and a micturating cystourethrogram in infants with abnormalities on renal ultrasound. RESULTS: We included 52 live-born infants with an isolated SUA. Renal ultrasonography was performed in 92.3% of these 52 infants. In this group, abnormalities were found in 5 infants (10.4 %) on renal ultrasound. A relative subpelvine stenosis was detected in 1 infant, the other abnormalities on renal ultrasound were mild hydronephrosis without further consequences. CONCLUSION: Our data suggest that it is not necessary to screen for renal anomalies in infants with a single umbilical artery without other anomalies seen at physical examination.

[Urethrovaginal reflux as a cause of urinary incontinence in girls]. / Urethrovaginale reflux als oorzaak van urine-incontinentie bij meisjes.

Examination of an 11-year-old girl with unintentional urine loss revealed that during micturition, urine was flowing into the vagina. Physiotherapy, aimed at normalization of micturition, was successful. Urinary incontinence is a common problem in school-age children. It can have a lot of different causes, but an anatomical cause is rarely found in isolated daytime incontinence. Often, urethrovaginal reflux is the cause of this urinary incontinence in girls. Good history taking and a specific bladder diary are enough to obtain the diagnosis, radiological investigations are not necessary. The problem is easily resolved by proper instruction on voiding by a qualified physiotherapist.

[When the treatment in children with asthma fails: first other reasons should be sought before prescribing more medication]. / Wanneer de behandeling van kinderen met astma faalt: eerst op zoek naar een verklaring alvorens meer medicatie voor te schrijven.

In 4 children with asthma symptoms increased. A 13-year-old girl suffered shortness of breath from fear of a man who was making indecent advances; an 8-year-old girl was allergic to the new cat at home; a 6-year-old boy was not inhaling the medication properly; and a 6-year-old girl had tracheomalacia and a vascular ring. After the appropriate treatment policy was implemented, the symptoms reduced or the extra doses of medication were no longer needed. If the treatment of asthma in children is unsuccessful, then therapy compliance and inhalation technique should be assessed first. After that causes of failure can be excluded. Only when this has been done can the dosage of inhalation corticosteroids be increased or other medicines added to the medication therapy.

Late neurological, cognitive and behavioural sequelae of prenatal exposure to coumarins: a pilot study.

Neurological, cognitive and behavioural development were assessed in a group of 21, 8- to 10-year old children whose mothers took coumarins during pregnancy. Findings were compared with those in a group of 17 control children. The study was performed to test whether it is feasible to carry out a reliable retrospective study of late effects of prenatal exposure to coumarins. This turned out to be the case. In this small pilot study, no statistical significant differences were found between the study and control group, nevertheless a few findings were remarkable. One child showed severe neurological abnormalities, which may be due to prenatal exposure to oral anticoagulants. The children with the lowest scores on the neurological assessment and the lowest IQ-scores, were found in the exposed group. Obviously, the number of children in this study is too small to conclude if there has been definite effects from coumarin, but these results indicate that a large follow-up study is required. In the present paper, we have shown that such a study is feasible.

Splenic epithelial cysts and splenomegaly: diagnosis and management.

Splenomegaly is a common problem. In the absence of systemic illness or malignancy splenic cysts must be considered, especially the epithelial variety. For large cysts total splenectomy has long been recommended. Recognition of the risk of an overwhelming postsplenectomy infection (OPSI), especially in children, has led to spleen conserving surgery. We describe the use of an absorbable Vicryl net after partial splenectomy with total cystectomy in the management of splenic epithelial cysts.

Fishing for a diagnosis.

A family with primary infertility and two members with mental retardation and subtle facial dysmorphism is described. In the two retarded persons chromosomal rearrangements (partial monosomy of chromosome 5 and partial trisomy of chromosome 7) were detected. One member of the family had died with major congenital malformations. Her fibroblasts had been stored and her chromosomes showed the inverse pattern (partial trisomy of chromosome 5 and partial monosomy of chromosome 7). It appeared that in familial mental retardation with or without congenital malformations FISH-techniques should be used to detect submicroscopic chromosomal aberrations, which are not detectable by routine chromosome studies.

[A child whose parents denied her psychiatric care]. / Een kind aan wie de ouders psychiatrische zorg ontzegden.

A 15-year-old girl was admitted because of an abdominal tumour and inability to eat. History revealed that after an accident at 9 years of age she increasingly developed medically unexplained signs and symptoms (e.g. tunnel vision with blindness, paralysis and loss of sensitivity below the umbilicus, periods of diminished consciousness). No somatic explanation could be found; the parents rejected psychiatric examination. Upon physical examination the patient's weight's was far below the third percentile (32 kg) and the tumour appeared to be the lumbar spine, palpable through the abdominal wall. Following tube feeding and behavioural therapy the girl gained weight and the tumour disappeared. No cause for the underweight was found. Conversion disorder was diagnosed. However, the parents strongly refused to accept this diagnosis; they lodged complaints with various bodies and made further treatment and counseling impossible. Children with psychological problems who were treated as having a somatic disorder by their mothers have been described before. The outcome can be lethal. Children showing unexplained signs and symptoms whose parents strongly refuse psychiatric care will be seriously jeopardised in terms of their somatic and psychological development. Physicians should identify this situation at an early stage.

[Risks of diazepam in newborn infants]. / Risico's van diazepam bij pasgeborenen.

In children there is a good effect of diazepam on convulsions after intravenous or rectal administration. This is not the case in neonates. We describe a newborn to whom diazepam was given because of a convulsion and who exhibited serious side effects: coma, hypotonia and feeding difficulties. We point out the risks of using diazepam in neonates.

[Sport drinks: not a suitable rehydration solution for children]. / Sportdrank: geen rehydratievloeistof voor kinderen.

A two-months-old male infant with gastroenteritis had been given a sports drink (Aquarius) by the general practitioner as a treatment for dehydration and was referred because of ongoing vomiting and weight loss. The child recovered after reinstitution of normal bottle-feeding and administration of a regular oral rehydration solution (ORS). The sports drink was analysed and found to contain less salt than ORS. As a result, the salt:sugar ratio was not optimal. Sports drinks are therefore contraindicated in the treatment of dehydration in children.

[Near asphyxiation of a neonate due to miconazole oral gel]. / Bijna-verstikking van een zuigeling door miconazol orale gel.

A 17-day-old female infant with thrush was almost asphyxiated by miconazole oral gel that had been applied to the nipples of her mother's breasts. The infant recovered after her mother had removed the gel from her mouth. Thrush is most often self-limiting and medical treatment is usually unnecessary. When treatment is indicated, miconazole oral gel or nystatin can be given. To obtain a therapeutic effect, long-term contact with the oral mucosa is needed and therefore the oral gel is viscous. Small amounts of the gel should be applied to the oral mucosa. When prescribing miconazole oral gel, instructions should be given regarding the mode of administration and the risk of respiratory tract obstruction should be pointed out.