Practice variation among Dutch paediatricians in palivizumab prescription rates: the importance of parental counselling approach.

AIM: To investigate differences in palivizumab prescription rates between Dutch paediatricians, and the role of parent counselling in this practice variation. METHODS: A retrospective chart review of premature infants <32 weeks of gestation, aged less than six months at the start of the winter season, born between January 2012 and July 2014, in three secondary hospital-based paediatric practices in the Netherlands. RESULTS: We included 208 patients, 133 (64%) of whom received palivizumab. Prescription rates varied considerably between the three hospitals: 8% (6/64), 89% (32/36) and 99% (97/98). A noticeable difference in the way parents were counselled about palivizumab was the use of the number needed to treat (NNT). In the hospital with the lowest prescription rate (8%), an NNT of 20 to prevent one hospitalisation was explicitly discussed with parents. Bronchiolitis-related hospital admissions occurred in 11.3% of patients receiving palivizumab compared to 20.0% in nonimmunised infants (p = 0.086). CONCLUSION: Considerable practice variation exists among Dutch paediatricians regarding palivizumab prescription rates. The counselling method seems to play an important role. Presenting palivizumab prophylaxis as a preference-sensitive decision, combined with the explicit use and explanation of an NNT, leads many parents to refrain from respiratory syncytial virus immunisation.

Healthcare reimbursement costs of children with type 1 diabetes in the Netherlands, a observational nationwide study (Young Dudes-4).

BACKGROUND: Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in children. Studies on costs related to T1DM are scarce and focused primarily on the costs directly related to diabetes. We aimed to investigate both the overall healthcare costs and the more specific costs related to the management of diabetes. METHODS: This is a retrospective and observational, nationwide cohort study of all Dutch children (aged 0-18 years) with T1DM. Data were collected from the national registry for healthcare reimbursement, in which all Dutch insurance companies combine their reimbursement data. In the Netherlands for all Dutch citizens health care is covered by law and all children are treated by hospital-based paediatricians. RESULTS: We analysed 6710 children distributed over 81 hospitals: 475 children in 6 university hospitals and 6235 children in 75 general hospitals. Total reimbursement for all children with T1DM over the period 2009 to 2011 was € 167,494,732 corresponding to an annual mean of € 55,831,577 of total costs and € 8326 euros per child. When comparing small (between 26 and 54 patients), medium (57-84 patients) and large (88-248 patients) general hospitals, costs per patient were highest in the hospitals with the highest number of T1DM patients. The costs for devices, secondary care and pharmaceutics had most impact on total expenditures. Over the study period, there was a slight decrease in per person costs. CONCLUSION: The overall health expenditure of a child with T1DM is more than € 8000 per patient per annum. Given the move towards more device-intensive multidisciplinary care for these patients, the costs of treating T1DM in children are likely to increase further in the coming years.

Double-blind food challenges in children in general paediatric practice: useful and safe, but not without pitfalls.

OBJECTIVE: To describe results of double-blind placebo-controlled food challenges (DBPCFC) with cow's milk, hen's egg, soy, peanut and hazelnut in general paediatric practice. METHODS: Food challenges were performed between January 2006 and June 2011, in children 0-18 years of age, on two half-day hospital admissions with a one-week interval. Tests were performed in a double-blind fashion following a standardised protocol with validated recipes. RESULTS: Overall, 234 food challenges were performed in 209 children: 160 with cow's milk, 35 with peanut, 21 with hen's egg, 11 with hazelnuts, and 7 with soy. In two thirds of the cases, the DBPCFC was negative (cow's milk: 57.5%; peanut: 40.0%; hen's egg: 66.7%, hazelnut: 90.9%, soy: 100%). The only patient characteristic significantly associated with a positive DBPCFC was the presence of symptoms from three different organ systems (p=0.007). Serious systemic allergic reactions with wheeze or anaphylaxis occurred in only two children (0.9%). Symptoms were recorded on 29.3% of placebo days. In 30/137 children with a negative test (22%), symptoms returned when reintroducing the allergen into the diet, mostly (66.7%) transient. Of the 85 tests regarded as positive by the attending physician, 19 (22.4%) did not meet predefined criteria for a positive test. This was particularly common with non-specific symptoms. CONCLUSION: A DBPCFC can be safely performed in a general hospital for a range of food allergens. The test result is negative in most cases except for peanut. Non-specific symptoms may hamper the interpretation of the DBPCFC, increasing the risk of a false-positive result.

Parent misperception of control in childhood/adolescent asthma: the Room to Breathe survey.

The aim of our study was to determine how often asthma control is achieved in children and adolescents, and how asthma affects parents' and children's daily lives. Interviews, including the childhood asthma control test (C-ACT), were conducted with 1,284 parents of asthmatic children (aged 4-15 yrs), as well as with the children themselves (aged 8-15 yrs; n=943), in Canada, Greece, Hungary, the Netherlands, South Africa and the UK. Parents reported mild asthma attacks at least weekly in 11% of children, and serious attacks (requiring oral corticosteroids or hospitalisation) at least annually in 35%. Although 73% of parents described their child's asthma as mild or intermittent, 40% of children/adolescents had C-ACT scores ≤ 19, indicating inadequate control, and only 14.7% achieved complete Global Initiative for Asthma (GINA)-defined control and just 9.2% achieved Scottish Intercollegiate Guidelines Network (SIGN)/British Thoracic Society (BTS)-defined control. Guideline-defined asthma control was significantly less common than well-controlled asthma using the C-ACT (p<0.001). Asthma restricted the child's activities in 39% of families and caused lifestyle changes in 70%. Complete asthma control is uncommon in children worldwide. Guideline-defined control measures appear to be more stringent than those defined by C-ACT or families. Overall, parents underestimate their child's asthma severity and overestimate asthma control. This is a major potential barrier to successful asthma treatment in children.

Facilitators and barriers to a nationwide implementation of competency-based postgraduate medical curricula: a qualitative study.

BACKGROUND: Postgraduate medical education (PGME) curricula are being redesigned across the western world. AIM: This study examined the implementation process (what works where and why) of new competency-based PGME curricula and relevant factors influencing this process. METHODS: In a nationwide project (2006-2010) in the Netherlands, competency-based PGME curricula were implemented for residents in Pediatrics and Obstetrics & Gynecology. The authors conducted 25 semi-structured interviews and used a multi-level theoretical framework to guide coding. RESULTS: The implementation process proved to be highly dynamic, non-linear, and influenced by many factors. These could be divided into attributes of the innovations/adopters, the implementation process, and the organization. The context determined the speed, quality, and direction of the process and how a factor affected the process. CONCLUSIONS: We identified specific features of PGME innovation: the challenge of implementing other competencies than that of the medical expert; the importance of regional implementation strategies and educational support; the balance between training and patient care; and the need for regional inter-organizational networks of hospitals. The authors recommend: design the curriculum with the needs of the users in mind; facilitate knowledge sharing; organize educational support; translate the national curriculum to the local workplace; and promote regional inter-organizational networks between hospitals.

Comorbidities of asthma during childhood: possibly important, yet poorly studied.

Asthma in adults is associated with comorbidities such as obesity, gastro-oesophageal reflux, dysfunctional breathing and mental disorders. Herein, we provide an overview of the current state of evidence on these comorbidities in childhood asthma. The prevalence, known mechanisms and possible treatment options for each comorbid condition will be discussed. Obesity is an increasing health problem in children, but its relationship with asthma remains unclear. Allergic rhinitis is a very common comorbidity in asthma, both in children and in adults, but its effect on childhood asthma severity has not been studied. The prevalence and treatment options of dysfunctional breathing, a known comorbidity in adult asthma, have not yet been studied in paediatric asthma. Food allergies appear to cause more severe reactions in patients with asthma. Depressive disorders are more prevalent in childhood asthma than in healthy children, but seem to be poorly recognised and treated in children. Although gastro-oesophageal reflux is commonly thought to be a comorbid disease complicating asthma, it remains uncertain whether treatment improves asthma control. In conclusion, knowledge of asthma comorbidities in childhood is sparse. Further studies are urgently needed to identify the prevalence, and, more importantly, the effects of these comorbidities and their treatment on the degree of asthma control in children.

Paediatrics in Vienna.

The aim of this article is to describe the paediatric highlights from the 2009 European Respiratory Society Annual Congress in Vienna, Austria. The best abstracts from the seven groups of the Paediatric Assembly (asthma and allergy, respiratory epidemiology, cystic fibrosis, respiratory physiology, respiratory infections and immunology, neonatology and paediatric intensive care, and bronchology) are presented alongside findings from the current literature.

Can sensitization to aeroallergens disappear over time in children with allergic disease?

BACKGROUND: Remittance of aeroallergen sensitization has been shown in population-based studies, but there is a common perception that sensitization to aeroallergens rarely if ever disappears in children with allergic disease. METHODS: We retrospectively reviewed all specific IgE tests carried out in children aged 0-18 years at our hospital laboratory over a 14-year period. Of 3115 children sensitized to one or more aeroallergens, 244 (7.8%) were retested after a mean (SD) period of 45 (28) months at their physician's discretion. RESULTS: Disappearance of sensitization to individual aeroallergens did occur, with remittance rates ranging from 3.1% for house dust mite to 17.5% for cat. However, complete remittance of aeroallergen sensitization was found in only one subject. In up to 35% of cases, remittance of sensitization was offset by the appearance of one or more new aeroallergen sensitizations. Remittance was only observed in children sensitized to multiple allergens (with a median of 3 aeroallergen sensitizations), and their median degree of sensitization was low (median 2.1 kU/L). CONCLUSION: Aeroallergen sensitization can disappear in children with allergic disease, but only in polysensitized individuals. Complete remittance of sensitization to aeroallergens is rare in symptomatic children.

Airway obstruction at time of symptoms prompting use of reliever therapy in children with asthma.

BACKGROUND: In asthma treatment, doses of inhaled corticosteroids are often adapted to symptoms and need for bronchodilators. However, in cross-sectional studies in emergency room settings, lung function and respiratory symptoms are not always concordant. Available longitudinal data are based on written peak flow diaries, which are unreliable. Using home spirometry, we studied prospectively whether mild respiratory symptoms, prompting reliever therapy are accompanied by a clinically relevant drop in lung function in children with asthma. METHODS: For 8 weeks, children with asthma scored symptoms and measured peak expiratory flow (PEF) and forced expiratory volume in 1 sec (FEV(1)) on a home spirometer twice daily. Additional measurements were recorded when respiratory symptoms prompted them to use bronchodilators. RESULTS: The mean difference between symptom free days and at times of symptoms was 6.6% of personal best for PEF (95% CI: 3.2-10.0; p = 0.0004) and 6.0% of predicted for FEV(1) (95% CI: 3.0-9.0; p = 0.0004). There was complete overlap in PEF and FEV(1) distributions between symptom free days and at times of symptoms. CONCLUSIONS: Although statistically significant, the degree of airway narrowing at times of respiratory symptoms, prompting the use of reliever therapy, is highly variable between patients, limiting the usefulness of home spirometry to monitor childhood asthma.

The transient value of classifying preschool wheeze into episodic viral wheeze and multiple trigger wheeze.

BACKGROUND: A recently proposed method for classifying preschool wheeze is to describe it as either episodic (viral) wheeze or multiple trigger wheeze. In research studies, phenotype is generally determined by retrospective questionnaire. AIM: To determine whether recently proposed phenotypes of preschool wheeze are stable over time. METHODS: In all, 132 two to six-year-old children with doctor diagnosed asthma on maintenance inhaled corticosteroids were classified as having episodic (viral) wheeze or multiple trigger wheeze at a screening visit and then followed up at three-monthly intervals for a year. At each follow-up visit, standardized questionnaires were used to determine whether the subjects wheezed only with, or also in the absence of colds. Stability of the phenotypes was assessed at the end of the study. RESULTS: Phenotype as determined by retrospective parental report at the start of the study was not predictive of phenotype during the study year. Phenotypic classification remained the same in 45.9% of children and altered in 54.1% of children. CONCLUSION: When children with preschool wheeze are classified into episodic (viral) wheeze or multiple trigger wheeze based on retrospective questionnaire, the classification is likely to change significantly within a 1-year period.

Reference values for peak flow and FEV1 variation in healthy schoolchildren using home spirometry.

Current reference values for diurnal peak flow variation in healthy children (median 8.2%; 95th percentile 31%) are so high that considerable overlap exists with those of asthmatic children. These values have been obtained using written peak flow diaries, which are unreliable. The aim of the present study was to obtain reliable reference values for the variation in peak flow and forced expiratory volume in one second (FEV(1)) in healthy schoolchildren using home spirometry with electronic data storage. Healthy schoolchildren (n = 204; 100 males) aged 6-16 yrs measured their peak flow and FEV(1) twice daily for 2 weeks using an electronic home spirometer. The variation in peak flow and FEV(1) were calculated as a diurnal amplitude as a percentage of the day's mean. The mean peak flow variation was 6.2% (95th percentile 12.3%) and the mean FEV(1) variation was 5.7% (95th percentile 11.8%). Using home spirometry with electronic data storage, healthy schoolchildren show considerably less peak flow and forced expiratory volume in one second variation than previously reported on the basis of written peak flow diaries. Being the 95th percentiles of the distributions in healthy children, a peak flow variation of 12.3% and an forced expiratory volume in one second variation of 11.8% are suggested as cut-off values for disease when using home spirometry.

Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach.

There is poor agreement on definitions of different phenotypes of preschool wheezing disorders. The present Task Force proposes to use the terms episodic (viral) wheeze to describe children who wheeze intermittently and are well between episodes, and multiple-trigger wheeze for children who wheeze both during and outside discrete episodes. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting beta(2)-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitisation has been established. Maintenance treatment with inhaled corticosteroids is recommended for multiple-trigger wheeze; benefits are often small. Montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Large well-designed randomised controlled trials with clear descriptions of patients are needed to improve the present recommendations on the treatment of these common syndromes.

['Drops for allergy' in children: often applied, but not effective]. / 'Druppeltjes tegen allergie' bij kinderen: vaak toegepast, niet effectief.

The practice of using an 'allergy service', supported by manufacturers of sublingual immunotherapy, should be discouraged for a number of reasons. There is an obvious conflict of interest when an employee from a commercial firm with an interest in allergy treatment is involved in interpreting allergy tests and discussing treatment. Most allergic diseases can be well controlled with drug therapy, without having to resort to immunotherapy. Finally, no good evidence exists to prove clinically relevant effects of sublingual immunotherapy in children with atopic disease. Until results of well-designed studies become available, sublingual immunotherapy in children should not be used.

[Serious concerns regarding research linking cot death with child day care]. / Ernstige bezwaren tegen het onderzoek naar het verband tussen wiegendood en kinderopvang.

A recent case-control study suggests that the risk of sudden infant death syndrome (SIDS) is strongly increased in children attending day care. There are several methodological concerns regarding this study. Problems with the selection of both cases and controls may have inflated the observed odds ratio. A similar overestimation of risk may have occurred because of confounding factors including age and socioeconomic status. The study is restricted to the very few SIDS cases that occur during day care hours, which reduces the statistical power and increases the likelihood of chance findings. Finally, if day care is a genuine risk factor for SIDS, prevalence rates of SIDS should be expected to be lower in countries with long maternity leave periods such as in Scandinavia, but this is not the case. Whether or not day care is a risk factor for SIDS can only be evaluated by further and better designed studies. At present, there is no scientific basis to discourage day care for young children.

[Atopic dermatitis in infants not caused by food allergy]. / Constitutioneel eczeem bij kinderen wordt niet veroorzaakt door voedselallergie.

Food allergy is not the primary cause ofatopic dermatitis. This is illustrated in 3 patients with atopic dermatitis, a girl aged 6 months and 2 boys aged 6 and 7 months, respectively, who were referred to our outpatient clinic for evaluation for possible food allergies. All 3 patients were receiving hypoallergenic formula because their parents or health care providers suspected that the atopic dermatitis was caused by a cows' milk allergy. After sufficient explanation of the causes of atopic dermatitis and thorough clarification and use of topical therapy, a remarkable improvement in the severity of the atopic dermatitis was noted. Only 1 patient was allergic to cows' milk as confirmed by a double-blind, placebo-controlled food challenge, but there was no association with the level of eczema activity. It is a common misconception that food allergies and atopic dermatitis are always causally related. In recent years it has become clear that atopic dermatitis may result from defective skin barrier function, for which topical treatment is essential. Unjustified focus on food allergies as the primary cause ofatopic dermatitis increases the risk of unnecessary elimination diets and malnutrition. Only infants with acute allergic symptoms directly related to ingestion, i.e. urticaria and gastrointestinal symptoms, should be evaluated for food allergies by a double-blind, placebo-controlled food challenge.

[Guideline for imminent preterm birth: insufficient adherence and implementation]. / Richtlijnen bij dreigende vroeggeboorte: onvoldoende afstemming en implementatie.

The guideline for referral to perinatology centres in cases of imminent preterm birth at 24-26 weeks gestation, is poorly adhered to by Dutch gynaecologists. Unfortunately, the guideline can be interpreted in various ways and the reasons for non-adherence remain unclear. In addition, no measures were taken to implement the guideline when it was published. This means that the usefulness of the finding that the guideline is poorly adhered to is limited.

[Increase in orders for specific IgE tests and more positive results in children in 1985-2003]. / Meer aangevraagde tests op specifiek IgE bij kinderen in de loop van 1985-2003 en meer positieve uitslagen.

OBJECTIVE: To describe changes over time in the number of allergy tests for specific IgE ordered and outcomes in children, to help address the question whether the increase in allergies is due to an actual increase in sensitisation or an increase in diagnostic awareness of allergies among physicians. DESIGN: Retrospective and descriptive. METHOD: We reviewed the results of all specific IgE tests performed in our hospital's laboratory for children 0-18 years of age in the period 1985-2003. This included tests ordered by both general practitioners and hospital-based specialists. We analysed trends over time in the number of tests ordered (as an indicator ofdiagnostic awareness) and test results (as an indicator ofsensitisation). RESULTS: Between 1989 and 1995, the annual number of tests ordered increased from 1 per 10,000 children to 95 per 10,000 children and remained stable thereafter. Before 1990, more than 90% of tests were ordered by hospital-based specialists; after 1990, approximately 70% of the tests were ordered by general practitioners (p < 0.001). The proportion of positive tests remained stable at approximately 27% until 1991, after which it increased to more than 45% (p < 0.001). CONCLUSION: The increase in the proportion of positive tests suggests an increase in atopic sensitization between 1985 and 2000 which has stabilized since.

[Treatment of asthma in children: revised international guidelines not suitable for use in the Netherlands]. / Behandeling van astma bij kinderen: herziene internationale richtlijnen niet geschikt voor gebruik in Nederland.

The most recent revision of the Global Initiative for Asthma (GINA) guidelines for the treatment of asthma propose to classify and monitor the disease based on asthma control. This concept is attractive but not evidence based. Based on methodological shortcomings the revised GINA guidelines fail to meet the standards for evidence-based guidelines. Inhaled corticosteroids are and remain the cornerstone of asthma management in children. Extensive explanation to children and their parents, intensive followup, and instruction of and adherence to a correct inhalation technique are key factors in effective treatment of asthma in children.

[Persistent and serious lack of data on chronic disorders in Dutch children]. / Chronisch en ernstig gebrek aan gegevens over chronische aandoeningen bij Nederlandse kinderen.

A recent report summarizes the available knowledge on chronic disorders in children in The Netherlands. There is a striking lack of high-quality data on the prevalence of common disorders such as attention deficit hyperactivity disorder (ADHD), atopic eczema, and abdominal pain. Reliable prevalence figures were available for only 34 out of a total of 284 chronic disorders. These affected a total of 4% of all children in the general population--the real prevalence ofchronic disease in children must be considerably higher. There is an even greater lack of studies on the impact of chronic disorders in childhood on quality of life and social and emotional well-being in later life.

[Anaphylaxis: facts and fallacies]. / Anafylaxie: feiten en fabels.

The diagnosis and management of anaphylaxis is surrounded by many misunderstandings. The diagnosis may be made ifa patient develops respiratory or circulatory symptoms, in addition to skin symptoms, after exposure to a possibly relevant allergen. The most common causes ofanaphylaxis are food allergens, such as peanut and tree nuts, insect stings, and drugs, in particular antibiotics. Many patients with peanut or tree nut allergy show only mild allergic symptoms; only a minority develop anaphylaxis upon exposure. A large local reaction to an insect sting does not constitute insect sting allergy and does not increase the risk of anaphylaxis when stung again. Intramuscular epinephrine is the drug of choice in the treatment of anaphylaxis; antihistaminic agents and corticosteroids are supportive therapeutic agents which should only be considered after epinephrine has been administered. Prevention of recurrence ofanaphylaxis comprises identification and avoidance of the causative allergen, and administration of epinephrine autoinjector when the patient develops suggestive signs of recurrence. When prescribing an epinephrine autoinjector, the patient and all caregivers should be instructed carefully in its correct use; referral to an allergist is recommended.