Comparison of oral amoxicillin and intravenous benzyl penicillin for community acquired pneumonia in children (PIVOT trial): a multicentre pragmatic randomised controlled equivalence trial.

OBJECTIVE: To ascertain whether therapeutic equivalence exists for the treatment of paediatric community acquired pneumonia by the oral and intravenous (IV) routes. METHODS: A multicentre pragmatic randomised controlled non-blinded equivalence trial was undertaken in eight paediatric centres in England (district general and tertiary hospitals). Equivalence was defined as no more than a 20% difference between treatments of the proportion meeting the primary outcome measure at any time. 246 children who required admission to hospital and had fever, respiratory symptoms or signs and radiologically confirmed pneumonia were included in the study. Exclusion criteria were wheeze, oxygen saturations <85% in air, shock requiring >20 ml/kg fluid resuscitation, immunodeficiency, pleural effusion at presentation requiring drainage, chronic lung condition (excluding asthma), penicillin allergy and age <6 months. The patients were randomised to receive oral amoxicillin for 7 days (n = 126) or IV benzyl penicillin (n = 120). Children in the IV group were changed to oral amoxicillin after a median of six IV doses and received 7 days of antibiotics in total. The predefined primary outcome measure was time for the temperature to be <38 degrees C for 24 continuous hours and oxygen requirement to cease. Secondary outcomes were time in hospital, complications, duration of oxygen requirement and time to resolution of illness. RESULTS: Oral amoxicillin and IV benzyl penicillin were shown to be equivalent. Median time for temperature to settle was 1.3 days in both groups (p<0.001 for equivalence). Three children in the oral group were changed to IV antibiotics and seven children in the IV group were changed to different IV antibiotics. Median time to complete resolution of symptoms was 9 days in both groups. CONCLUSION: Oral amoxicillin is effective for most children admitted to hospital with pneumonia (all but those with the most severe disease who were excluded from this study). Prior to this study, the British Thoracic Society guidelines on childhood pneumonia could not draw on evidence to address this issue. This will spare children and their families the trauma and pain of cannulation, and children will spend less time in hospital.

Changing trends in sex specific prevalence rates for childhood asthma, eczema, and hay fever.

Numerous surveys of school-aged children have shown increasing asthma prevalence with a less publicized but noticeable change in the male to female ratio. We sought to confirm this change in the sex ratio in four questionnaire-based surveys and investigate possible explanations. Identical questionnaire surveys were performed in 1989 (n=3,390), 1994 (n=4,047), 1999 (n=3,540) and 2004 (n=1,920) in school-children aged 9-11 years. Over these 15 years the male to female ratio (M:F) significantly narrowed for wheeze (1.34 to 0.98:1 P < 0.0002), for asthma (1.74 to 1.02:1 P < 0.0001), for eczema (1.42:1 to 0.81:1 P < 0.0001) and for hay fever (1.46 to 0.93:1 P < 0.0001). The diagnosis of asthma in children with wheeze was more commonly made in boys in 1989 relative risk RR 1.32 (1.12, 1.56), even in those with accompanying eczema and/or hay fever RR 1.20 (0.99, 1.45). By 2004 this sex bias in diagnosis was no longer present, RR 1.01 (0.91, 1.12) for wheeze and 1.02 (0.85, 1.21) for those with wheeze and eczema and/or hay fever. From 1989 to 2004 no significant difference in sex distribution changes between older and younger children occurred, making secular trends in the onset of puberty in females an unlikely contributory factor. The disappearance of the bias to diagnose asthma in symptomatic males but not in females may be partly responsible for the narrowing of the sex ratio, but other factors such as those enhancing the expression of asthma and atopy in females may also be implicated.

Knowledge and exposure to complementary and alternative medicine in paediatric doctors: a questionnaire survey.

BACKGROUND: Complementary and alternative medicines are increasingly used by the general population. A survey was conducted to ascertain the knowledge of Complementary and Alternative Medicines (CAMs) amongst paediatric physicians, and whether seniority increases the likelihood of its use being considered in consultations, or of families discussing it. METHODS: Anonymous survey of general paediatric doctors in a large inner-city district general hospital (DGH) and tertiary children's centre (TC) using a questionnaire. Statistical analysis was calculated using Minitab. RESULTS: 43/49 (88%) questionnaires were returned correctly. 13 (30%, CI 17 - 46%) doctors had personally used CAMs. 24 (56%, CI 40 - 71%) of their families had used CAMs. 13 (30%, CI 17 - 46%) had received formal CAMs education. 21 (49%, CI 40 - 71%) could name a total of 5 types of CAMs. Consultants were significantly more likely to ask about CAM use than middle-grades and juniors (p < 0.05, CI 48 - 93%, 35 - 90%, 8 - 33% respectively) and have had a clinical encounter where they felt it was significant. 32 (74%, CI 59 - 86%) of the clinicians had been asked about CAMs. 33 (77%, CI 61 - 88%) of doctors had successful CAM use reported to them, and 20 (47%, CI 31 - 62%) had failure of CAMs reported to them. CONCLUSION: CAM use is relatively common in paediatric doctors and their families. They have received little formal CAMs education. Consultants were more likely than juniors to ask about CAM use and have had a clinical encounter where it played a significant part. Around half of all doctors irrespective of grade have been asked about CAMs in a clinical encounter.

Criteria for a specialist paediatric asthma clinic.

Childhood asthma is insufficiently controlled in a large number of patients, highlighting the need for improved provision of paediatric asthma care. This paper presents consensus criteria for a paediatric asthma clinic. These are intended to provide a basis for the delivery of asthma care to children in primary and secondary care clinics.

Hospital-based surveillance to estimate the burden of rotavirus gastroenteritis among European children younger than 5 years of age.

OBJECTIVES: Rotavirus is the leading cause of acute gastroenteritis requiring hospitalization in young children. Data on the burden of rotavirus gastroenteritis are needed to guide recommendations for rotavirus vaccine use. This study was undertaken to estimate the burden of rotavirus gastroenteritis in European children <5 years of age. METHODS: This prospective, study was conducted in 12 hospitals in France, Germany, Italy, Spain, and the United Kingdom. A sample of all children aged <5 years presenting to emergency departments or hospitalized because of community-acquired acute gastroenteritis was enrolled for parental interview and stool collection. Acute gastroenteritis was defined as diarrhea (>/=3 loose stools per 24 hours) for <14 days. Rotavirus was detected by enzyme-linked immunosorbent assay and typed by reverse-transcriptase polymerase chain reaction. RESULTS: Between February 2005 and August 2006, 3734 children with community-acquired acute gastroenteritis were recruited and retained for analysis (55.9% via the emergency department, 41.8% hospitalized). Of the 2928 community-acquired acute gastroenteritis cases for which stool samples were available, 43.4% were rotavirus-positive by enzyme-linked immunosorbent assay (32.8% emergency department, 56.2% hospitalized). Of these rotavirus gastroenteritis cases 80.9% occurred in children aged <2 years and 15.9% among infants aged <6 months. Acute gastroenteritis was more severe in rotavirus-positive subjects (Vesikari score >/= 11 in 53.3% compared with 31.0% of rotavirus-negative subjects). All 1271 rotavirus-positive strains were genotyped (G1P[8]: 40.3%; G9P[8]: 31.2%; G4P[8]: 13.5%; G3P[8]: 7.1%). CONCLUSIONS: Rotavirus gastroenteritis places high demands on European health care systems, accounting for 56.2% of hospitalizations and 32.8% of emergency department visits because of community-acquired acute gastroenteritis in children aged <5 years. Most community-acquired rotavirus gastroenteritis occurs in children aged <2 years, and a high proportion occurs in infants aged <6 months. Cases were also observed among very young infants <2 months of age. Rotavirus vaccination is expected to have a major impact in reducing morbidity and the pressure on hospital services in Europe.

A comparison of virus-associated and multi-trigger wheeze in school children.

To examine differences between virus-associated wheeze and wheeze associated with other triggers (multi-trigger wheeze) in elementary school children, we performed a cross-sectional school-based questionnaire study of 5,998 children mainly 7 to 12 years of age, with outliers 6 and 13 years of age. Using parent-completed questionnaires, we identified 522 children who wheezed only during upper respiratory tract infections (virus-associated wheeze), 1,186 children who wheezed on other occasions (multi-trigger wheeze), and 4,290 children with no wheeze. In comparison with children who had multi-trigger wheeze, children with virus-associated wheeze were more likely to be male, to be younger, and to have less frequent wheezy episodes. They were less likely to have night cough, shortness of breath or chest tightness, to have a personal or parental history of atopic disorders, to have a diagnosis of asthma, or to be receiving asthma treatment. Both types of wheeze were associated with social deprivation, a relationship that persisted after controlling for family smoking. Virus-associated wheeze is a common but diminishing problem in this age group, and the differences between virus-associated wheeze and multi-trigger wheeze already noted in pre-school children persist in this older age group.

Brittle asthma.

Asthma is recognised as a heterogeneous disease and, within this heterogeneity, brittle asthma is identified as a distinct phenotype. Two types of brittle asthma have been recognised in adults: type 1, showing more than 40% diurnal variability in PEF rate on most days over long periods and type 2, with acute severe attacks on a background of apparently good asthma control. The exact incidence of these phenotypes in adults is unknown but both seem to carry an increased risk of death and considerable morbidity. Adults with brittle asthma are generally atopic, with a high degree of psychosocial morbidity. This phenotype has not been recognised to the same degree in children, although we believe that such children exist and probably present the same management problems as their adult counterparts. The management of brittle asthma is, as for all patients with complex disease, holistic, with the removal of important causal factors ensuring compliance and providing adequate education. Steroid therapy remains the mainstay of treatment but the balance has to be struck between the benefits and side-effects of both inhaled and oral corticosteroids. Continuous subcutaneous terbutaline has been shown to be effective in controlling PEF variability but there are side effects and it must be used with due caution.