Atopic Dermatitis in Children in the General Population: Baseline Characteristics, Medication Use, and Severity Measures in the Rotterdam Eczema Study.

Background: Real-life data on severity and treatments in children with atopic dermatitis (AD) are needed to evaluate self-management. Objectives: To determine severity and use of topical treatments in children with AD in the general population. Furthermore, we aim to determine agreement and correlation between objective and subjective AD severity measures. Methods: Data were used from the Rotterdam Eczema Study, an observational prospective cohort study with an embedded pragmatic open-label randomized controlled trial. Descriptive statistics were used for baseline characteristics, medication use, and severity. Strength of agreement and correlation were determined using kappa analysis and Pearson correlation. Results: In total, 367 children (mean age 5.7 years) were recruited. The mean eczema area and severity index (EASI) score was 2.1 (±3.2) and mean patient-oriented eczema measure (POEM) score was 10.3 (±6.1). The majority applied emollients on a daily basis (54.9%) and had not used topical corticosteroids (TCSs) over the past week (51%). Based on severity banding of POEM and EASI, 49.9% and 24.9% of the children were undertreated, respectively. No evidence was found for an agreement between EASI and POEM (kappa 0.028, n = 178, P = 0.451). A moderate correlation between POEM, EASI, infants' dermatitis quality of life index, and children's dermatology life quality index was found. POEM showed higher correlation with quality of life (QoL) than EASI. Conclusion: Emollients were used sufficiently in the study population. Based on signs or symptoms, 24.9% and 49.9% of children are undertreated, respectively. POEM scores correlated better with QoL than with EASI scores. We argue that EASI underestimates severity of AD, and treatment based on EASI scores may lead to undertreatment of AD. Treating physicians should be aware of suboptimal use of TCSs.

Teaching medical students to apply deliberate reflection.

PURPOSE: Deliberate reflection on initial diagnosis has been found to repair diagnostic errors. We investigated the effectiveness of teaching students to use deliberate reflection on future cases and whether their usage would depend on their perception of case difficulty. METHOD: One-hundred-nineteen medical students solved cases either with deliberate-reflection or without instructions to reflect. One week later, all participants solved six cases, each with two equally likely diagnoses, but some symptoms in the case were associated with only one of the diagnoses (discriminating features). Participants provided one diagnosis and subsequently wrote down everything they remembered from it. After the first three cases, they were told that the next three would be difficult cases. Reflection was measured by the proportion of discriminating features recalled (overall; related to their provided diagnosis; related to alternative diagnosis). RESULTS: The deliberate-reflection condition recalled more features for the alternative diagnosis than the control condition (p = .013) regardless of described difficulty. They also recalled more features related to their provided diagnosis on the first three cases (p = .004), but on the last three cases (described as difficult), there was no difference. CONCLUSION: Learning deliberate reflection helped students engage in more reflective reasoning when solving future cases.

Perceived adherence and associated barriers to the national atopic dermatitis guideline: A survey among general practitioners.

BACKGROUND: General practitioners (GPs) have an important role in managing patients with atopic dermatitis (AD). Although pivotal, adherence to dermatological guidelines in general practice has not been assessed. OBJECTIVES: To assess GPs' perceived adherence and barriers to the Dutch AD guideline. METHODS: A survey was conducted among 391 GPs in the Netherlands between December 2021 and May 2022. GPs rated their perceived adherence and perceived barriers concerning five key recommendations of the AD guideline, following an existing framework. The correlation between perceived adherence and barriers was investigated using Spearman's rank correlation. RESULTS: A total of 213 GPs (54%) participated. Perceived adherence rates varied across recommendations (43.7% to 98.1%). Lowest adherence was reported for recommendations concerning topical corticosteroids (TCS). Across all recommendations, patient factors (65.6%; SD 11.6) and lack of applicability to specific patient groups (29.5%; SD 10.5) were reported most frequently as barriers. The overall correlation between adherence and barriers was strongest for knowledge (ρ .55; SD .10) and attitude-related factors (range: ρ .40--.62). CONCLUSION: GPs' perceived adherence and barriers vary substantially across recommendations of the AD guideline. In particular, GPs reported lower adherence to recommendations concerning TCS. Next to patient-related factors, strong correlations between adherence perceived by GPs and knowledge and attitude-related barriers suggest the importance of addressing these factors as well to improve adherence.

A systematic review of questionnaires measuring asthma control in children in a primary care population.

Several questionnaires are used to measure asthma control in children. The most appropriate tool for use in primary care is not defined. In this systematic review, we evaluated questionnaires used to measure asthma control in children in primary care and determined their usefulness in asthma management. Searches were performed in the MEDLINE, Embase, Web of Science, Google Scholar and Cochrane databases with end date 24 June 2022. The study population comprised children aged 5-18 years with asthma. Three reviewers independently screened studies and extracted data. The methodological quality of the studies was assessed, using the COSMIN criteria for the measurement properties of health status questionnaires. Studies conducted in primary care were included if a minimum of two questionnaires were compared. Studies in secondary or tertiary care and studies of quality-of-life questionnaires were excluded. Heterogeneity precluded meta-analysis. Five publications were included: four observational studies and one sub-study of a randomized controlled trial. A total of 806 children were included (aged 5-18 years). We evaluated the Asthma Control Test (ACT), childhood Asthma Control Test (c-ACT), Asthma APGAR system, NAEPP criteria and Royal College of Physicians' '3 questions' (RCP3Q). These questionnaires assess different symptoms and domains. The quality of most of the studies was rated 'intermediate' or 'poor'. The majority of the evaluated questionnaires do not show substantial agreement with one another, which makes a comparison challenging. Based on the current review, we suggest that the Asthma APGAR system seems promising as a questionnaire for determining asthma control in children in primary care.

Clinical response to varying pollen exposure in allergic rhinitis in children in The Netherlands.

BACKGROUND: Allergic rhinitis (AR) affects 10-15% of children. Symptoms in seasonal AR are influenced by pollen exposure. Pollen counts vary throughout the pollen season and therefore, symptom severity fluctuates. This study investigates the correlation between pollen concentration and symptom load in children with AR in The Netherlands. METHODS: A secondary analysis was performed in a study determining the most effective treatment for children with seasonal AR. Symptoms were measured during three months in 2013 and 2014 using a daily symptom diary. The pollen concentration was measured with a Hirst type volumetric spore trap sampler. A correlation coefficient was calculated for the correlation between the pollen concentration and the mean daily symptom score. The study protocol was approved by the medical ethical review committee of the Erasmus MC and is incorporated in the International Clinical Trials Registry Platform (EUCTR2012-001,591-11-NL). RESULTS: In 2014, the correlation coefficient for birch pollen concentration and symptom score was 0.423 (p = 0.000). The correlation coefficient for grass pollen concentration and symptom score was 0.413 (p = 0.000) and 0.655 (p = 0.000) in 2013 and 2014, respectively. A delayed correlation between the birch pollen concentration and the symptom scores was seen up to two days after the pollen measurement (0.151, p = 0.031). For grass pollen this effect lasted up to three days after the pollen measurement (0.194, p = 0.000). CONCLUSION: We found comparable correlations between symptom score and pollen concentration as found by EAACI. Birch and grass pollen have an elongated influence on symptom score of several days. This implies patients need to continue on demand medication longer after a measured pollen peak.

General practitioners' explanation and advice on childhood eczema and factors influencing their treatment strategy: A qualitative study.

Background: Atopic dermatitis (AD) is common in children and the majority of children can be treated by the general practitioner (GP). Various factors can influence the GP's treatment strategy and may lead to less effective treatment. The objective is to gain insight into the treatment goal, treatment strategy, explanation and advice given by GPs when dealing with AD in children and to explore which factors play a role in the choice of pharmacological treatment. Methods: Semi-structured interviews in primary care in the Netherlands were audio-recorded and transcribed. All data were analysed according to the six-steps approach of inductive thematic analysis. Results: We interviewed 16 GPs. Treatment goals mainly focussed on the short term. GPs discussed the importance of emollient use and emphasised emollients as the basis of treatment. We found that several factors played a role in prescribing topical corticosteroids (TCS); severity of the AD, age of the child, skin type, corticophobia among parents and GPs, experience of side effects and dermatological experience. GPs reported giving limited advice about the use of TCS and prescribed medication that is not recommended by the guideline. Conclusion: Various factors seem to influence GPs' treatment strategy for AD in children. More attention and education about the use and safety of TCS in children during GP training, continuous medical education, probably improve treatment in line with guidelines and can lead to more confidence and knowledge about TCS among GPs, which ultimately may improve the education and self-management of patients.

[Foreign body ingestion in children]. / Ingestie van corpora aliena bij kinderen.

Foreign body ingestion occurs frequently in children and may lead to severe complications and mortality. In this article, three cases are presented. A 2-year-old boy swallowed a plastic toy helmet. He had no symptoms and physical examination was normal, and the toy was found in the stool within three days. Similarly, a 6-year-old girl swallowed two magnets and was asymptomatic. Physical examination was normal and a radiograph showed a foreign body which had passed the stomach. Due to the location, endoscopic removal by gastroduodenoscopy was not possible and surgical removal unnecessary. The magnets were secreted in the stool within two days. A 10-year-old boy with VACTERL association and psychiatric history, swallowed a button battery. After a delay in presentation, a radiograph showed a button battery mid-esophageal, which was endoscopically removed. He also needed dilatation due to esophageal stenosis. The above cases are all illustrative of the topic covered in the guideline 'Ingestion of foreign bodies in children aged 0-18 years', which was developed on behalf of the Dutch Pediatric Association and published in March 2019.

Protocolled practice nurse-led care for children with asthma in primary care: protocol for a cluster randomised trial.

INTRODUCTION: In children with asthma, daily symptoms and exacerbations have a significant impact on the quality of life of both children and parents. More effective use of asthma medication and, consequently, better asthma control is advocated, since both overtreatment and undertreatment are reported in primary care. Trials in adults suggest that asthma control is better when patients receive a regular medical review. Therefore, protocolled care by the general practitioner may also lead to better asthma control in children. However, such protocolled care by the general practitioner may be time consuming and less feasible. Therefore, this study aims to determine whether protocolled practice nurse-led asthma care for children in primary care provides more effective asthma control than usual care. METHODS AND ANALYSIS: The study will be a cluster-randomised open-label trial with an 18-month follow-up. Practice nurses will be the units of randomisation and children with asthma the units of analysis. It is planned to include 180 children aged 6-12 years. Primary outcome will be average asthma control during the 18-month follow-up measured by the Childhood Asthma Control Test (C-ACT). Secondary outcomes include C-ACT scores at t=3, t=6, t=12 and t=18 months; the frequency and severity of exacerbations; cost-effectiveness; quality of life; satisfaction with delivered care; forced expiratory volume in 1 s and forced expiratory flow at 75% and the association of high symptoms scores at baseline and baseline characteristics. Besides, we will conduct identical measurements in a non-randomised sample of children. ETHICS AND DISSEMINATION: This will be the first trial to evaluate the effectiveness of protocolled practice nurse-led care for children with asthma in primary care. The results may lead to improvements in asthma care for children and can be directly implemented in revisions of asthma guidelines.The study protocol was approved by the Medical Research Ethics Committee of the Erasmus Medical Centre in Rotterdam. TRIAL REGISTRATION: NTR6847.

Different potencies of topical corticosteroids for a better treatment strategy in children with atopic dermatitis (the Rotterdam Eczema study): protocol for an observational cohort study with an embedded randomised open-label controlled trial.

INTRODUCTION: Topical corticosteroids (TCS) of different potencies are the main treatment to control atopic dermatitis (AD). The Dutch guideline on AD for general practitioners (GPs) recommends a stepwise approach in which treatment steps are tailored to the severity of the disease, starting with the lowest possible potency of TCS. However, it remains unclear whether the recommended stepwise approach is most efficient. This randomised open-label controlled trial aims to determine whether a potent TCS is more effective than a low-potency TCS in the initial treatment of children with a moderate flare-up of AD in primary care. In the observational cohort, the overall aim is to determine the frequency, burden and determinants of flare-ups of AD during follow-up. METHODS AND ANALYSIS: The study is an observational cohort study with an embedded pragmatic randomised controlled, open-label trial. Eligible are patients diagnosed with AD (aged 12 weeks to 18 years) who visited the GP for AD or received repeated prescriptions for AD in the previous 12 months; follow-up of the cohort is 1 year. Children are enrolled in the trial if they have a flare-up of AD during follow-up in the cohort. Eligible children are randomised to the intervention group (with a potent TCS once daily) or to the GP guideline group (with a low potency TCS once daily). Primary outcome is the difference in average subjective disease severity over 24 weeks follow-up in the trial, measured with the patient-oriented eczema measure. As secondary outcome, the Eczema Area and Severity Index is measured. ETHICS AND DISSEMINATION: This study tests the hypothesis that immediate treatment with a potent TCS during a flare-up of AD leads to faster and more efficacious results as compared with starting with a TCS with low potency with less overall use of TCS. The study protocol is approved by the Medical Ethics Committee (MEC) of the Erasmus Medical Center Rotterdam, the Netherlands (MEC-2017-328). The results of the study will be published in international peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NTR: 6679; Pre-results.

Challenges in identifying antibiotic resistance targets for point-of-care diagnostics in general practice.

General practitioners stand at the front line of healthcare provision and have a pivotal role in the fight against increasing antibiotic resistance. In this respect, targeted antibiotic prescribing by general practitioners would help reduce the unnecessary use of antibiotics, leading to reduced treatment failures, fewer side-effects for patients and a reduction in the (global) spread of antibiotic resistances. Current 'gold standard' antibiotic resistance detection strategies tend to be slow, taking up to 48 h to obtain a result, although the implementation of point-of-care testing by general practitioners could help achieve the goal of targeted antibiotic prescribing practices. However, deciding on which antibiotic resistances to include in a point-of-care diagnostic is not a trivial task, as outlined in this publication.

Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial.

PURPOSE: Fever is the most common reason for a child to be taken to a physician, yet the level of unwarranted antibiotic prescribing remains high. We aimed to determine the effect on antibiotic prescribing of providing an illness-focused interactive booklet on fever in children to out-of-hours primary care clinicians. METHODS: We conducted a cluster-randomized controlled trial in 20 out-of-hours general practice centers in the Netherlands. Children aged younger than 12 years with fever were included. Family physicians at the 10 intervention sites had access to an illness-focused interactive booklet between November 2015 and June 2016. The primary outcome was antibiotic prescribing during the index consultation. Analysis was performed by fitting 2-level random intercept logistic regression models. RESULTS: The trial took place among 3,518 family physicians and 25,355 children. The booklet was used in 28.5% of 11,945 consultations in the intervention group. Compared with usual care, access to the booklet did not significantly alter antibiotic prescribing during the index consultation (odds ratio = 0.90; 95% CI, 0.79-1.02; prescription rate, 23.5% vs 25.2%; intracluster correlation coefficient = 0.005). In contrast, use of the booklet significantly reduced antibiotic prescribing (odds ratio = 0.83; 95% CI, 0.74-0.94; prescription rate, 21.9% vs 25.2%; intracluster correlation coefficient = 0.002). Children managed by family physicians with access to the booklet were less likely to receive any drug prescription, and parents in the booklet group showed a reduced intention to consult again for similar illnesses. CONCLUSIONS: Benefit of an illness-focused interactive booklet in improving outcomes of childhood fever in out-of-hours primary care was largely restricted to the cases in which family physicians actually used the booklet. Insight into reasons for use and nonuse may inform future interventions of this type.

An illness-focused interactive booklet to optimise management and medication for childhood fever and infections in out-of-hours primary care: study protocol for a cluster randomised trial.

BACKGROUND: Fever is the most common reason for a child to be taken to a general practitioner (GP), especially during out-of-hours care. It is mostly caused by self-limiting infections. However, antibiotic prescription rates remain high, especially during out-of-hours care. Anxiety and lack of knowledge among parents, and perceived pressure to prescribe antibiotics amongst GPs, are important determinants of excessive antibiotic prescriptions. An illness-focused interactive booklet has the potential to improve this by providing parents with information about fever self-management strategies. The aim of this study is to develop and determine the effectiveness of an interactive booklet on management of children presenting with fever at Dutch GP out-of-hours cooperatives. METHODS/DESIGN: We are conducting a cluster randomised controlled trial (RCT) with 20 GP out-of-hours cooperatives randomised to 1 of 2 arms: GP access to the illness-focused interactive booklet or care as usual. GPs working at intervention sites will have access to the booklet, which was developed in a multistage process. It consists of a traffic light system for parents on how to respond to fever-related symptoms, as well as information on natural course of infections, benefits and harms of (antibiotic) medications, self-management strategies and 'safety net' instructions. Children < 12 years of age with parent-reported or physician-measured fever are eligible for inclusion. The primary outcome is antibiotic prescribing during the initial consultation. Secondary outcomes are (intention to) (re)consult, antibiotic prescriptions during re-consultations, referrals, parental satisfaction and reassurance. In 6 months, 20,000 children will be recruited to find a difference in antibiotic prescribing rates of 25% in the control group and 19% in the intervention group. Statistical analysis will be performed using descriptive statistics and by fitting two-level (GP out-of-hours cooperative and patient) random intercept logistic regression models. DISCUSSION: This will be the first and largest cluster RCT evaluating the effectiveness of an illness-focused interactive booklet during GP out-of-hours consultations with febrile children receiving antibiotic prescriptions. It is hypothesised that use of the booklet will result in a reduced number of antibiotic prescriptions, improved parental satisfaction and reduced intention to re-consult. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02594553 . Registered on 26 Oct 2015​, last updated 15 Sept 2016.

C-Reactive Protein Level as Diagnostic Marker in Young Febrile Children Presenting in a General Practice Out-of-Hours Service.

BACKGROUND: It is unclear how well a C-reactive protein (CRP) value predicts a serious infection (SI) in young febrile children in general practice. METHODS: This prospective cohort study with 1-week follow-up included children, aged 3 months to 6 years, presenting with fever to a general practitioner out-of-hours service. We evaluate whether CRP level has predictive value for diagnosing a child at risk for an SI either at presentation or during follow-up. The index test was CRP ≤20 mg/L (rule out an SI) and >80 mg/L (rule in an SI). The reference standard was referral to a pediatric emergency department or diagnosis of an SI. The main outcome measure was CRP value. RESULTS: CRP level was available for 440 children. To rule out an SI, CRP ≤20 mg/L did not change the probability of having no SI (87.5%). CRP >80 mg/L increased the probability of having an SI from 11.4% (pretest probability) to 21.2% (posttest probability). In children without a diagnosis of SI at presentation, CRP could not predict an SI during follow-up (CRP >80 mg/L: positive likelihood ratio, 2.1, 95% confidence interval, 1.3-3.5; CRP ≤20 mg/L: negative likelihood ratio, 0.9, 95% confidence interval, 0.7-1.2). CONCLUSIONS: In general practice CRP has little clinically relevant value in discriminating febrile children in need of medical care from those who are not.

Chair/bedside diagnosis of oral and respiratory tract infections, and identification of antibiotic resistances for personalised monitoring and treatment.

Global healthcare systems are struggling with the enormous burden associated with infectious diseases, as well as the incessant rise of antimicrobial resistance. In order to adequately address these issues, there is an urgent need for rapid and accurate infectious disease diagnostics. The H2020 project DIAGORAS aims at diagnosing oral and respiratory tract infections using a fully integrated, automated and user-friendly platform for physicians' offices, schools, elderly care units, community settings, etc. Oral diseases (periodontitis, dental caries) will be detected via multiplexed, quantitative analysis of salivary markers (bacterial DNA and host response proteins) for early prevention and personalised monitoring. Respiratory Tract Infections will be diagnosed by means of DNA/RNA differentiation so as to identify their bacterial or viral nature. Together with antibiotic resistance screening on the same platform, a more efficient treatment management is expected at the point-of-care. At the heart of DIAGORAS lies a centrifugal microfluidic platform (LabDisk and associated processing device) integrating all components and assays for a fully automated analysis. The project involves an interface with a clinical algorithm for the comprehensive presentation of results to end-users, thereby increasing the platform's clinical utility. DIAGORAS' performance will be validated at clinical settings and compared with gold standards.

Predicting prolonged duration of fever in children: a cohort study in primary care.

BACKGROUND: Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care. AIM: To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms. DESIGN AND SETTING: A prospective cohort study at a GPs' cooperative (GPC) out-of-hours service. METHOD: Children (aged 3 months to 6 years) presenting with fever as stated by the parents were included. Exclusion criteria were no communication in Dutch possible, previous enrolment in the study within 2 weeks, referral to the hospital directly after visiting the GPC, or no informed consent. The main outcome measure was prolonged duration of fever (>3 days) after initial contact. RESULTS: Four-hundred and eighty children were analysed, and the overall risk of prolonged duration was 13% (63/480). Multivariate analysis combined model of patient history and physical examination showed that 'sore throat' (OR 2.8; 95% CI = 1.30 to 6.01) and 'lymph nodes palpable' (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever. The discriminative value of the model was low (AUC 0.64). CRP had no additive value in the prediction of prolonged duration of fever (OR 1.00; 95% CI = 0.99 to 1.01). CONCLUSION: The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted.

Translation of clinical prediction rules for febrile children to primary care practice: an observational cohort study.

BACKGROUND: Clinical prediction rules (CPRs) to identify children with serious infections lack validation in low-prevalence populations, which hampers their implementation in primary care practice. AIM: To evaluate the diagnostic value of published CPRs for febrile children in primary care. DESIGN AND SETTING: Observational cohort study among febrile children (<16 years) who consulted five GP cooperatives (GPCs) in the Netherlands. METHOD: Alarm signs of serious infection and clinical management were extracted from routine clinical practice data and manually recoded with a structured electronic data-entry program. Eight CPRs were selected from literature. CPR-variables were matched with alarm signs and CPRs were applied to the GPC-population. 'Referral to emergency department (ED)' was used as a proxy outcome measure for 'serious infection'. CPR performance was assessed by calibration analyses, sensitivity, specificity, and area under the ROC-curve (ROC-area). RESULTS: A total of 9794 GPC-contacts were eligible, 54% male, median age 2.3 years (interquartile range 1.0-4.6 years) and 8.1% referred to ED. Frequencies of CPR-variables varied from 0.5% (cyanosis, drowsy) to 25% (temperature ≥40°C). Alarm signs frequently included in CPRs were 'ill appearance', 'inconsolable', and 'abnormal circulatory or respiratory signs'. The height of the CPR's predicted risks generally corresponded with being (or not being) referred to the ED in practice. However, calibration-slopes indicated that three CPRs underestimated the risk of serious infection in the GPC-population. Sensitivities ranged from 42% to 54%, specificities from 68% to 89%. ROC-areas ranged from 0.52 to 0.81, with best performance of CPRs for children aged <3 months. CONCLUSION: Published CPRs performed moderately well in the primary out-of-hours care population. Advice is given on how to improve translation of CPRs to primary care practice.

Alarming signs and symptoms in febrile children in primary care: an observational cohort study in The Netherlands.

CONTEXT: Febrile children in primary care have a low risk for serious infection. Although several alarming signs and symptoms are proposed to have predictive value for serious infections, most are based on research in secondary care. The frequency of alarming signs/symptoms has not been established in primary care; however, in this setting differences in occurrence may influence their predictive value for serious infections. OBJECTIVE: To determine the frequency of alarming signs/symptoms in febrile children in primary care. DESIGN: Observational cohort study. Clinical information was registered in a semi-structured way and manually recoded. SETTING: General practitioners' out-of-hours service. SUBJECTS: Face-to-face patient contacts concerning children (aged ≤16 years) with fever were eligible for inclusion. MAIN OUTCOME MEASURES: Frequency of 18 alarming signs and symptoms as reported in the literature. RESULTS: A total of 10,476 patient contacts were included. The frequency of alarming signs/symptoms ranged from n = 1 (ABC instability; <0.1%) to n = 2,207 (vomiting & diarrhea; 21.1%). Of all children, 59.7% had one or more alarming signs and/or symptoms. Several alarming signs/symptoms were poorly registered with the frequency of missing information ranging from 1,347 contacts (temperature >40°C as reported by the parents; 12.9%) to 8,647 contacts (parental concern; 82.5%). CONCLUSION: Although the prevalence of specific alarming signs/symptoms is low in primary care, ≥50% of children have one or more alarming signs/symptoms. There is a need to determine the predictive value of alarming signs/symptoms not only for serious infections in primary care, but as well for increased risk of a complicated course of the illness.