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Csonka LL, Tikkakoski A, Vuotari L, Karjalainen J, Lehtimäki L. Relation of changes in peak expiratory flow (PEF) and forced expiratory volume in 1 s (FEV 1) during bronchoconstriction. Clin Physiol Funct Imaging 2024. [PMID: 38923340 DOI: 10.1111/cpf.12898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/27/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
Diagnosis of asthma can be confirmed based on variability in peak expiratory flow (PEF) or changes in forced expiratory volume in 1 s (FEV1) measured with spirometry. Our aim was to use methacholine challenge as a model of induced airway obstruction to assess how well relative changes in PEF reflect airway obstruction in comparison to relative changes in FEV1. We retrospectively studied 878 patients who completed a methacholine challenge test. To assess congruency along with differences between relative changes in FEV1 and PEF during airway obstruction, a regression analysis was performed, and a Bland & Altman plot was constructed. ROC analysis, sensitivity, specificity, positive and negative predictive values and κ-coefficient were used to analyze how decrease in PEF predicts decrease of 10% or 15% in FEV1. The relative change in PEF was on average less than the relative change in FEV1. In the ROC analysis areas under the curve were 0.844 and 0.893 for PEF decrease to predict a 10% and 15% decrease in FEV1, respectively. The agreement between changes in PEF and FEV1 varied from fair to moderate. Airway obstruction detected by change in PEF was false in about 40% of cases when compared to change in FEV1. Change in PEF is not a very accurate measure of airway obstruction when compared to change in FEV1. Replacing peak flow metre with a handheld spirometer might improve diagnostic accuracy of home monitoring in asthma.
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Affiliation(s)
- Leon L Csonka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Tikkakoski
- Department of Clinical Physiology and Nuclear Medicine, Tampere University Hospital, Tampere, Finland
| | - Liisa Vuotari
- Department of Clinical Physiology and Nuclear Medicine, Tampere University Hospital, Tampere, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
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Csonka L, Tikkakoski A, Tikkakoski AP, Karjalainen J, Lehtimäki L. Relation of changes in PEF and FEV1 in exercise challenge in children. Clin Physiol Funct Imaging 2024; 44:179-185. [PMID: 37933772 DOI: 10.1111/cpf.12864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/12/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023]
Abstract
Decrease in forced expiratory volume in one second (FEV1 ) of 10% or 15% in exercise challenge test is considered diagnostic for asthma, but a decrease of 15% in peak expiratory flow (PEF) is recommended as an alternative. Our aim was to assess the accuracy of different PEF cut-off points in comparison to FEV1 . We retrospectively studied 326 free running exercise challenge tests with spirometry in children 6-16 years old. FEV1 and PEF were measured before and 2, 5, 10 and 15 min after exercise. Receiver operating characteristics (ROC) analysis, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and ϰ-coefficient were used to analyse how decrease in PEF predicts decrease of 10% or 15% in FEV1 . In the ROC analysis, areas under the curve were 0.851 (p < 0.001) and 0.921 (p < 0.001) for PEF decrease to predict a 10% and 15% decrease in FEV1 , respectively. The agreement between changes in PEF and FEV1 varied from slight to substantial (ϰ values of 0.199-0.680) depending on the cut-points. Lower cut-off for decrease in PEF had higher sensitivity and NPV, while higher cut-off values had better specificity and PPV. Decrease of 20% and 25% in PEF seemed to be the best cut-offs for detecting 10% and 15% decrease in FEV1 , respectively. Still, a fifth of the positive findings based on PEF were false. Change in PEF is not a precise predictor of change in FEV1 in exercise test. The currently recommended cut-point of 15% decrease in PEF seems to be too low and leads to high false positive rate.
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Affiliation(s)
- Leon Csonka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Tikkakoski
- Department of Clinical Physiology and Nuclear Medicine, Tampere University Hospital, Tampere, Finland
| | - Anna P Tikkakoski
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
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Liu M, Chung JE, Robinson B, Taylor L, Andrewn RA, Li J. A home visit program for low-income African American children with asthma: Caregivers' perception of asthma triggers and a gap in action. J Pediatr Nurs 2022; 67:e79-e84. [PMID: 36328913 DOI: 10.1016/j.pedn.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE The goals are to gauge caregivers' knowledge of at-home asthma triggers and identify the areas on which educational campaigns can focus to alleviate a child's asthma symptoms. DESIGN AND METHODS Families with children with moderate to severe asthmatic symptoms who had been recently hospitalized or in the emergency room were invited to participate in a home visit program. As part of the home visit, caregivers of the asthmatic children were asked a series of questions on asthma triggers and the measures for eliminating the triggers (N = 218). RESULTS Findings show a gap between caregivers' perception of asthma triggers and the actions to mitigate or avoid such triggers. CONCLUSIONS Overall findings show that home environments were suboptimal for the management and control of child asthma conditions. Knowledge about home triggers as well as the actions and efforts by caregivers and landlords to mitigate these was found to be inadequate. Even when caregivers are aware of the presence of at-home triggers, actions to minimize exposure to the trigger do not always follow due to a lack of power, resource, and knowledge. PRACTICE IMPLICATIONS The findings raise the need for additional research to investigate the reasons for the lack of actions, advocacy for low-income families to live in a healthy environment, continued education and empowerment, and patient/caregiver-doctor partnership. Additionally, the provision of community support through community advocacy and training of culturally competent healthcare providers are needed for the successful management of pediatric asthma among African American children.
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Affiliation(s)
- Meirong Liu
- School of Social Work, Howard University, USA
| | | | | | - Lori Taylor
- Respiratory Therapy, University of the District of Columbia, USA
| | | | - Jiang Li
- Department of Electrical Engineering and Computer Science, Howard University, USA
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Aarestrup LK, Hermansen MN, Prahl J, Hansen KS, Chawes BL. Objective confirmation of asthma diagnosis, treatment adherence and patient outcomes in children and adolescents. Acta Paediatr 2022; 111:1220-1229. [PMID: 34905254 DOI: 10.1111/apa.16216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 02/06/2023]
Abstract
AIM The aim of this study was to investigate the diagnostic workup in children with asthma hypothesising that objective confirmation of the diagnosis is associated with improved treatment adherence and patient outcomes. METHODS We reviewed medical records of children aged 5-18 years diagnosed with asthma at the Department of Paediatric and Adolescent Medicine, Herlev-Gentofte Hospital, Denmark, in 2018. Objective confirmation of the diagnosis was based on either (1) lung function, (2) bronchodilator response, (3) bronchial hyperresponsiveness and/or (4) elevated FeNO and was associated with treatment adherence (proportion of days covered, PDC), lung function development and exacerbations during a two-year follow-up period. RESULTS A total of 88 children were included. Asthma was objectively confirmed in 67 (76%). Children with objective confirmation of the diagnosis were more likely to redeem short-acting beta-2-agonist prescriptions: at least once, aOR = 1.3 (95% CI, 1.1-13.1), p = 0.036, and were more adherent to inhaled corticosteroid treatment: PDC>80%, aOR = 10.4 (1.8-201.1), p = 0.033. Further, objective confirmation was associated with improved lung function and reduced bronchodilator response, but not with exacerbations. CONCLUSION Objective confirmation of the asthma diagnosis in children is associated with an increased treatment adherence and improved lung function, which underlines the importance of conducting objective tests in the diagnostic workup in paediatric asthma management.
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Affiliation(s)
- Louise K. Aarestrup
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Mette N. Hermansen
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Julie Prahl
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Kirsten S. Hansen
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- Allergy Clinic Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
| | - Bo L. Chawes
- Department of Paediatric and Adolescent Medicine Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
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Long B, Lentz S, Koyfman A, Gottlieb M. Evaluation and management of the critically ill adult asthmatic in the emergency department setting. Am J Emerg Med 2020; 44:441-451. [PMID: 32222313 DOI: 10.1016/j.ajem.2020.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/08/2020] [Accepted: 03/16/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Asthma is a common reason for presentation to the Emergency Department and is associated with significant morbidity and mortality. While patients may have a relatively benign course, there is a subset of patients who present in a critical state and require emergent management. OBJECTIVE This narrative review provides evidence-based recommendations for the assessment and management of patients with severe asthma. DISCUSSION It is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation. Once the diagnosis is determined, the majority of the assessment is based upon the clinical examination. First line therapies for severe exacerbations include inhaled short-acting beta agonists, inhaled anticholinergics, intravenous steroids, and magnesium. Additional therapies for refractory cases include parenteral epinephrine or terbutaline, helium‑oxygen mixture, and consideration of ketamine. Intravenous fluids should be administered, as many of these patients are dehydrated and at risk for hypotension if they receive positive pressure ventilatory support. Noninvasive positive pressure ventilation may prevent the need for endotracheal intubation. If mechanical ventilation is required, it is important to avoid breath stacking by setting a low respiratory rate and allowing permissive hypercapnia. Patients with severe asthma exacerbations will require intensive care unit admission. CONCLUSIONS This review provides evidence-based recommendations for the assessment and management of severe asthma with a focus on the emergency clinician.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, United States
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Affiliation(s)
- Rebecca Dobra
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Amanda Equi
- Department of Paediatrics, Watford General Hospital, Watford, UK
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Peak Expiratory Flow Rate as a Monitoring Tool in Asthma. Indian J Pediatr 2017; 84:573-574. [PMID: 28612223 DOI: 10.1007/s12098-017-2398-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
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Brigham EP, West NE. Diagnosis of asthma: diagnostic testing. Int Forum Allergy Rhinol 2016; 5 Suppl 1:S27-30. [PMID: 26335833 DOI: 10.1002/alr.21597] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/29/2015] [Accepted: 06/05/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Asthma is a heterogeneous disease, encompassing both atopic and non-atopic phenotypes. Diagnosis of asthma is based on the combined presence of typical symptoms and objective tests of lung function. Objective diagnostic testing consists of 2 components: (1) demonstration of airway obstruction, and (2) documentation of variability in degree of obstruction. METHODS A review of current guidelines and literature was performed regarding diagnostic testing for asthma. RESULTS Spirometry with bronchodilator reversibility testing remains the mainstay of asthma diagnostic testing for children and adults. Repetition of the test over several time points may be necessary to confirm airway obstruction and variability thereof. Repeated peak flow measurement is relatively simple to implement in a clinical and home setting. Bronchial challenge testing is reserved for patients in whom the aforementioned testing has been unrevealing but clinical suspicion remains, though is associated with low specificity. Demonstration of eosinophilic inflammation, via fractional exhaled nitric oxide measurement, or atopy, may be supportive of atopic asthma, though diagnostic utility is limited particularly in nonatopic asthma. All efforts should be made to confirm the diagnosis of asthma in those who are being presumptively treated but have not had objective measurements of variability in the degree of obstruction. CONCLUSION Multiple testing modalities are available for objective confirmation of airway obstruction and variability thereof, consistent with a diagnosis of asthma in the appropriate clinical context. Providers should be aware that both these characteristics may be present in other disease states, and may not be specific to a diagnosis of asthma.
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Affiliation(s)
- Emily P Brigham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Natalie E West
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Rottier BL, Eber E, Hedlin G, Turner S, Wooler E, Mantzourani E, Kulkarni N. Monitoring asthma in childhood: management-related issues. Eur Respir Rev 2016; 24:194-203. [PMID: 26028632 PMCID: PMC9487817 DOI: 10.1183/16000617.00003814] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Management-related issues are an important aspect of monitoring asthma in children in clinical practice. This review summarises the literature on practical aspects of monitoring including adherence to treatment, inhalation technique, ongoing exposure to allergens and irritants, comorbid conditions and side-effects of treatment, as agreed by the European Respiratory Society Task Force on Monitoring Asthma in Childhood. The evidence indicates that it is important to discuss adherence to treatment in a non-confrontational way at every clinic visit, and take into account a patient's illness and medication beliefs. All task force members teach inhalation techniques at least twice when introducing a new inhalation device and then at least annually. Exposure to second-hand tobacco smoke, combustion-derived air pollutants, house dust mites, fungal spores, pollens and pet dander deserve regular attention during follow-up according to most task force members. In addition, allergic rhinitis should be considered as a cause for poor asthma control. Task force members do not screen for gastro-oesophageal reflux and food allergy. Height and weight are generally measured at least annually to identify individuals who are susceptible to adrenal suppression and to calculate body mass index, even though causality between obesity and asthma has not been established. In cases of poor asthma control, before stepping up treatment the above aspects of monitoring deserve closer attention. ERS review summarising and discussing the management-related issues regarding the monitoring of asthma in childhoodhttp://ow.ly/JfjGs
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Affiliation(s)
- Bart L Rottier
- Dept of Pediatric Pulmonology and Allergology, GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ernst Eber
- Respiratory and Allergic Disease Division, Dept of Paediatrics and Adolescence Medicine, Medical University of Graz, Graz, Austria
| | - Gunilla Hedlin
- Dept of Women's and Children's Health and Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Steve Turner
- Dept of Paediatrics, University of Aberdeen, Aberdeen, UK
| | | | - Eva Mantzourani
- Dept of Paediatrics, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Neeta Kulkarni
- Leicestershire Partnership Trust and Dept of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
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Everard ML, Wahn U, Dorsano S, Hossny E, Le Souef P. Asthma education material for children and their families; a global survey of current resources. World Allergy Organ J 2015; 8:35. [PMID: 26681996 PMCID: PMC4677448 DOI: 10.1186/s40413-015-0084-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/18/2015] [Indexed: 12/05/2022] Open
Abstract
One of the keys to high quality paediatric asthma management is the provision of age appropriate information regarding the disease and its management. In order to determine whether the generation of a minimum dataset of information which can be translated into a wide range of languages might be used to assist children and their parents around the world, we undertook a survey of national Member Societies of the World Allergy Organization (WAO) to determine what educational material on asthma for children and their families already exists. A questionnaire was developed using Survey Monkey and distributed in 2014 to 263 representatives of the WAO member Societies from 95 countries. Thirty-three replies were received from thirty-one countries. The survey highlighted a considerable disparity in availability of material among the responding countries, with some countries reporting that information was freely available in hard copy and online and others reporting a lack of suitable material locally. The results highlight the need to develop a core set of simple, clear and consistent age appropriate information that can be easily translated and delivered in a cultural and educationally effective format.
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Affiliation(s)
- Mark L. Everard
- />School of Paediatrics and Child Health, University of Western Australia, TelethonKids Institute, Princess Margaret Hospital for Children, Roberts Road, Subiaco, 6008, Western, Australia
| | - Ulrich Wahn
- />Department of Pediatric Pneumology and Immunology, Charité Humbolt University, Berlin, Germany
| | - Sofia Dorsano
- />World Allergy Organization, International Headquarters, Milwaukee, Wisconsin United States
| | - Elham Hossny
- />Pediatric Allergy and Immunology (PAI) Unit, Children’s Hospital of Ain Shams University, Cairo, Egypt
| | - Peter Le Souef
- />School of Paediatrics and Child Health, University of Western Australia, TelethonKids Institute, Princess Margaret Hospital for Children, Roberts Road, Subiaco, 6008, Western, Australia
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Hamburger R, Berhane Z, Gatto M, Yunghans S, Davis RK, Turchi RM. Evaluation of a statewide medical home program on children and young adults with asthma. J Asthma 2015; 52:940-8. [PMID: 25539026 DOI: 10.3109/02770903.2014.999282] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Asthma, the most common chronic condition among children, accounts for significant healthcare utilization and impact on quality of life. Care coordination in a medical home is considered standard practice, but has not been rigorously evaluated. METHODS We initiated this pilot study of children/young adults with asthma (n = 967), ages: birth to 24 years, receiving care from a subset of pediatric practices (n = 20) participating in the Pennsylvania Medical Home Initiative, Educating Practices in Community-Integrated Care (92 practices statewide). We hypothesized children and youth with asthma receiving care coordination in the context of a formal medical home program would experience favorable associations with healthcare utilization and quality of life measures. RESULTS A total of 9240 care coordination encounters for this cohort of children/youth occurred over 100 days. The average length of care coordination encounter was 20.7 minutes. The most common care coordination activity was referral management (21%) and the care coordinator in the practice most often contacted parent/family and specialists (75%). Children with more severe asthma had more hospitalizations and emergency department (ED) visits than children with less severe asthma. There was a significant decrease in school absences, ED visits and acute care visits for children/youth with asthma with increasing length of time in a medical home program (p < 0.05). CONCLUSION Care coordination for children/youth with asthma is feasible and may yield improvements in healthcare utilization, expenditures and quality of life. Larger-scale implementation of care coordination and medical home models for children/youth with asthma and other diagnoses are warranted.
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Affiliation(s)
- Robert Hamburger
- a Nova Southeastern University College of Osteopathic Medicine , Fort Lauderdale , FL , USA .,b Department of Epidemiology and Biostatistics , School of Public Health, Drexel University , Philadelphia , PA , USA
| | - Zekarias Berhane
- b Department of Epidemiology and Biostatistics , School of Public Health, Drexel University , Philadelphia , PA , USA
| | - Molly Gatto
- c Make-A-Wish Foundation of Philadelphia and Susquehanna Valley , Blue Bell , PA , USA
| | - Suzanne Yunghans
- d Pennsylvania Chapter, American Academy of Pediatrics , Media , PA , USA
| | - Renee K Davis
- e Department of Community Health and Prevention , Maternal and Child Health Working Group, School of Public Health, Drexel University , Philadelphia , PA , USA
| | - Renee M Turchi
- e Department of Community Health and Prevention , Maternal and Child Health Working Group, School of Public Health, Drexel University , Philadelphia , PA , USA .,f Department of Pediatrics , St. Christopher's Hospital for Children , Philadelphia , PA , USA , and.,g Department of Community Health and Prevention , School of Public Health, Drexel University , Philadelphia , PA , USA
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13
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Robberecht MN, Beghin L, Deschildre A, Hue V, Reali L, Plevnik-Vodušek V, Moretto M, Agustsson S, Tockert E, Jäger-Roman E, Deplanque D, Najaf-Zadeh A, Martinot A. Educating Asthmatic Children in European Ambulatory Pediatrics: Facts and Insights. PLoS One 2015; 10:e0129198. [PMID: 26061153 PMCID: PMC4465179 DOI: 10.1371/journal.pone.0129198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 04/15/2015] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to assess the role of European ambulatory pediatricians in caring for asthmatic children, especially in terms of their therapeutic education. We developed a survey that was observational, declarative, retrospective and anonymous in nature. 436 ambulatory pediatricians in Belgium, France, Germany, Italy, Luxembourg and Slovenia were asked to participate in the survey providing information on three children over 6 years old suffering from persistent asthma, who had been followed for at least 6 months. We considered the pediatricians' profile, and their role in the therapeutic education of children. 277 pediatricians (64%) responded: 81% were primary care pediatricians; 46% participated in networks; 4% had specific training in Therapeutic Patient Education; 69% followed more than 5 asthmatic children per month, and over long periods (7 ± 4 years). The profiles of 684 children were assessed. Answers diverged concerning the provision of a Personalized Action Plan (60-88%), training the child to measure and interpret his Peak Expiratory Flow (31-99%), and the prescription of pulmonary function tests during the follow-up programme of consultations (62-97%). Answers converged on pediatricians' perception of their role in teaching children about their condition and its treatment (99%), about inhalation techniques (96%), and in improving the children's ability to take preventive measures when faced with risk situations (97%). This study highlights the role of European pediatricians in caring for asthmatic children, and their lack of training in Therapeutic Patient Education. Programmes and tools are required in order to train ambulatory pediatricians in Therapeutic Patient Education, and such resources should be integrated into primary health care, and harmonized at the European level.
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Affiliation(s)
- Marie Noëlle Robberecht
- European Confederation of Primary Care Pediatricians (ECPCP), 11 quai Général Sarrail, 69006 Lyon, France
- Association Française de Pédiatrie Ambulatoire, pediatric office, 32 avenue Desrousseaux, 59370 Mons-en-Baroeul, France
- * E-mail:
| | - Laurent Beghin
- Centre d’Investigation Clinique -9301-Inserm, CHRU, F-59037 Lille, France
- Inserm U995, IFR 114, Univ Nord de France, F-59037 Lille, France
| | - Antoine Deschildre
- Clinique de Pédiatrie, Hopital Jeanne de Flandre, Av Eugène Avinée, F-59037 Lille, France
| | - Valérie Hue
- Clinique de Pédiatrie, Hopital Jeanne de Flandre, Av Eugène Avinée, F-59037 Lille, France
| | - Laura Reali
- European Confederation of Primary Care Pediatricians (ECPCP), 11 quai Général Sarrail, 69006 Lyon, France
- Associazione Culturale Pediatri, via Montiferru, 6–09070 Narbolia (OR), Italy
| | - Vesna Plevnik-Vodušek
- European Confederation of Primary Care Pediatricians (ECPCP), 11 quai Général Sarrail, 69006 Lyon, France
- Delovna slupina za primarno pediatrijo, Zdravstveni dom velenje Vodnikova 1, 3320 Velenje, Slovenia
| | - Marilena Moretto
- European Confederation of Primary Care Pediatricians (ECPCP), 11 quai Général Sarrail, 69006 Lyon, France
- Pediatric Department Hôpital St Pierre- Université Libre de Bruxelles (ULB)- Rue Haute 322 à 1000, Bruxelles, Belgique
| | - Sigurlaug Agustsson
- European Confederation of Primary Care Pediatricians (ECPCP), 11 quai Général Sarrail, 69006 Lyon, France
- Société Luxembourgeoise de Pédiatrie, Center of Pediatrics, Val Sainte Croix, Luxembourg
| | - Emile Tockert
- European Confederation of Primary Care Pediatricians (ECPCP), 11 quai Général Sarrail, 69006 Lyon, France
- Société Luxembourgeoise de Pédiatrie, Center of Pediatrics, Val Sainte Croix, Luxembourg
| | - Elke Jäger-Roman
- European Confederation of Primary Care Pediatricians (ECPCP), 11 quai Général Sarrail, 69006 Lyon, France
- Berufsverband der Kinder-und Jugendärzte, Köhlerstr. 23, Berlin, Germany
| | | | - Abolfazl Najaf-Zadeh
- Clinique de Pédiatrie, Hopital Jeanne de Flandre, Av Eugène Avinée, F-59037 Lille, France
| | - Alain Martinot
- Clinique de Pédiatrie, Hopital Jeanne de Flandre, Av Eugène Avinée, F-59037 Lille, France
- EA 2694, Université Droit et Santé Lille (UDSL), Univ Lille Nord de France, Lille, France
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Pijnenburg MW, Baraldi E, Brand PLP, Carlsen KH, Eber E, Frischer T, Hedlin G, Kulkarni N, Lex C, Mäkelä MJ, Mantzouranis E, Moeller A, Pavord I, Piacentini G, Price D, Rottier BL, Saglani S, Sly PD, Szefler SJ, Tonia T, Turner S, Wooler E, Lødrup Carlsen KC. Monitoring asthma in children. Eur Respir J 2015; 45:906-25. [PMID: 25745042 DOI: 10.1183/09031936.00088814] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. To reach this goal in children with asthma, ongoing monitoring is essential. While all components of asthma, such as symptoms, lung function, bronchial hyperresponsiveness and inflammation, may exist in various combinations in different individuals, to date there is limited evidence on how to integrate these for optimal monitoring of children with asthma. The aims of this ERS Task Force were to describe the current practise and give an overview of the best available evidence on how to monitor children with asthma. 22 clinical and research experts reviewed the literature. A modified Delphi method and four Task Force meetings were used to reach a consensus. This statement summarises the literature on monitoring children with asthma. Available tools for monitoring children with asthma, such as clinical tools, lung function, bronchial responsiveness and inflammatory markers, are described as are the ways in which they may be used in children with asthma. Management-related issues, comorbidities and environmental factors are summarised. Despite considerable interest in monitoring asthma in children, for many aspects of monitoring asthma in children there is a substantial lack of evidence.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Dept of Paediatrics/Paediatric Respiratory Medicine, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Eugenio Baraldi
- Women's and Children's Health Dept, Unit of Respiratory Medicine and Allergy, University of Padova, Padova, Italy
| | - Paul L P Brand
- Dept of Paediatrics/Princess Amalia Children's Centre, Isala Hospital, Zwolle, The Netherlands UMCG Postgraduate School of Medicine, University Medical Centre and University of Groningen, Groningen, The Netherlands
| | - Kai-Håkon Carlsen
- Dept of Paediatrics, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Ernst Eber
- Respiratory and Allergic Disease Division, Dept of Paediatrics and Adolescence Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Frischer
- Dept of Paediatrics and Paediatric Surgery, Wilhelminenspital, Vienna, Austria
| | - Gunilla Hedlin
- Depart of Women's and Children's Health and Centre for Allergy Research, Karolinska Institutet and Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Neeta Kulkarni
- Leicestershire Partnership Trust and Dept of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Christiane Lex
- Dept of Paediatric Cardiology and Intensive Care Medicine, Division of Pediatric Respiratory Medicine, University Hospital Goettingen, Goettingen, Germany
| | - Mika J Mäkelä
- Skin and Allergy Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Eva Mantzouranis
- Dept of Paediatrics, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ian Pavord
- Dept of Respiratory Medicine, University of Oxford, Oxford, UK
| | - Giorgio Piacentini
- Paediatric Section, Dept of Life and Reproduction Sciences, University of Verona, Verona, Italy
| | - David Price
- Dept of Primary Care Respiratory Medicine, Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Bart L Rottier
- Dept of Pediatric Pulmonology and Allergology, GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sejal Saglani
- Leukocyte Biology and Respiratory Paediatrics, National Heart and Lung Institute, Imperial College London, London, UK
| | - Peter D Sly
- Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Australia
| | - Stanley J Szefler
- Children's Hospital Colorado and University of Colorado Denver School of Medicine, Denver, USA
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Steve Turner
- Dept of Paediatrics, University of Aberdeen, Aberdeen, UK
| | | | - Karin C Lødrup Carlsen
- Dept of Paediatrics, Women and Children's Division, Oslo University Hospital, Oslo, Norway Dept of Paediatrics, Faculty of Medicine, University of Oslo, Oslo, Norway
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Archibald MM, Caine V, Ali S, Hartling L, Scott SD. What is left unsaid: an interpretive description of the information needs of parents of children with asthma. Res Nurs Health 2015; 38:19-28. [PMID: 25557981 DOI: 10.1002/nur.21635] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2014] [Indexed: 11/09/2022]
Abstract
Parents of children with asthma provide the vast majority of day-to-day asthma care. Understanding their information needs is an essential step to provide meaningful and effective family-centered asthma education. To gain insight into the information needs and information deficits of parents of children with asthma, we conducted an interpretive descriptive study to capture the perspectives of 21 parents from diverse backgrounds whose 23 children with asthma had a range of illness trajectories and management scenarios. Parents were purposively sampled from two asthma clinics and one pediatric emergency department in a large urban center in North America. Semi-structured interviews were conducted in 2011-2012. In data analysis, parents' self-identified information needs were distinguished from analysts' interpretations of information deficits. Participants' knowledge did not always reflect time since diagnosis, and information needs and deficits persisted for years. Parents often reported receiving little or no little or no education about asthma and its management. An asthma management information hierarchy was identified, starting with the most foundational, recognizing severity; followed by acute management; prevention versus crisis orientation; and knowing "about" asthma. In the absence of adequate and accurate education, parents' beliefs about the nature of asthma as an acute rather than chronic condition shaped their asthma management decisions and information-seeking behaviors. Information deficits were affected by interactions with health care providers. These parents' pervasive unmet information needs and deficits highlight the need for comprehensive, problem-oriented asthma education.
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Affiliation(s)
- Mandy M Archibald
- PhD Candidate, Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy (ECHA), Avenue 11405 87, Edmonton, T6G 1C9, Alberta, Canada
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16
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Brand PLP, Klok T, Kaptein AA. Using communication skills to improve adherence in children with chronic disease: the adherence equation. Paediatr Respir Rev 2013; 14:219-23. [PMID: 23434178 DOI: 10.1016/j.prrv.2013.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Nonadherence to maintenance medication is common in paediatric chronic conditions. Despite the common belief that nonadherence is therapy-resistant, and the apparent lack of evidence for successful interventions to improve adherence, there is, in fact, a considerable body of evidence suggesting that adherence can be improved by applying specific communicative consultation skills. These can be summarized as the adherence equation: adherence=follow-up+dialogue+barriers and beliefs+empathy and education => concordance. Close follow-up of children with a chronic condition is needed to establish a therapeutic partnership with the family. Teaching self management skills is not a unidirectional process of providing information, but requires a constructive and collaborative dialogue between the medical team and the family. Identifying barriers to adherence can be achieved in a non-confrontational manner, by showing a genuine interest what the patient's views and preferences are. In particular, parental illness perceptions and medication beliefs should be identified, because they are strong drivers of nonadherence. Through empathic evidence-based education, such perceptions and beliefs can be modified. By applying these strategies, concordance between the child's family and the medical team can be achieved, resulting in optimal adherence to the jointly created treatment plan.
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Affiliation(s)
- Paul L P Brand
- Princess Amalia Children's Clinic, Isala klinieken, Zwolle, the Netherlands; UMCG Postgraduate School of Medicine, University Medical Centre Groningen, the Netherlands.
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17
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Abstract
Based on a review of the evidence on the usefulness of monitoring disease outcome parameters in childhood asthma and the author's 20-yr clinical experience in managing childhood asthma, this article provides the clinician with up-to-date recommendations on how to monitor childhood asthma in everyday clinical practice. Monitoring should be focused on patient-centered outcomes, such as exacerbations and impact on sports and play. Composite asthma control measures, although reasonably validated, do not take exacerbations into account and have a short recall window, limiting their usefulness as a routine monitoring tool in clinical practice. Lung function, airways hyperresponsiveness, exhaled nitric oxide, and inflammatory markers in sputum are surrogate end points, of little if any interest to patients. There is no evidence to support their use as a monitoring tool in clinical practice; office spirometry may be used as additional information. Rather than monitoring surrogate end points, clinicians should focus on showing a genuine interest in the impact of asthma on children's daily lives, and building and maintaining a partnership by monitoring those characteristics of asthma which have the biggest impact on children (exacerbations and limitations in sports and play), and adjusting treatment accordingly.
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Affiliation(s)
- Paul L P Brand
- Princess Amalia children's Clinic, Isala klinieken, Zwolle, UMCG Postgraduate School of Medicine, University Medical Centre and University of Groningen, the Netherlands.
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18
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Childhood asthma: considerations for primary care practice and chronic disease management in the village of care. Prim Care 2012; 39:381-91. [PMID: 22608872 DOI: 10.1016/j.pop.2012.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Childhood asthma is at historically high levels, with significant morbidity and mortality. Despite more than two decades of improved understanding of childhood asthma care and the evolution of beneficial medications, widespread control remains poor, leading to suboptimal patient outcomes and quality of life. This lack of control results in excessive emergency department use, hospitalizations, and inappropriate and/or unnecessary costs to the health care system. Advanced practice models that incorporate community-based approaches and services for childhood asthma are needed. Innovative, community-included methods of care to address the burden of childhood asthma may provide examples for care of other chronic diseases.
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Abstract
BACKGROUND While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care or the same education delivered elsewhere. The home setting allows educators to reach populations (such as the economically disadvantaged) that may experience barriers to care (such as lack of transportation) within a familiar environment. OBJECTIVES To perform a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes. We also planned to make the education interventions accessible to readers by summarising the content and components. SEARCH STRATEGY We searched the Cochrane Airways Group Specialised Register of trials, which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearched respiratory journals and meeting abstracts. We also searched the Education Resources Information Center database (ERIC), reference lists of trials and review articles (last search January 2011). SELECTION CRITERIA We included randomised controlled trials of asthma education delivered in the home to children, their caregivers or both. In the first comparison, eligible control groups were provided usual care or the same education delivered outside of the home. For the second comparison, control groups received a less intensive educational intervention delivered in the home. DATA COLLECTION AND ANALYSIS Two authors independently selected the trials, assessed trial quality and extracted the data. We contacted study authors for additional information. We pooled dichotomous data with fixed-effect odds ratio and continuous data with mean difference (MD) using a fixed-effect where possible. MAIN RESULTS A total of 12 studies involving 2342 children were included. Eleven out of 12 trials were conducted in North America, within urban or suburban settings involving vulnerable populations. The studies were overall of good methodological quality. They differed markedly in terms of age, severity of asthma, context and content of the educational intervention leading to substantial clinical heterogeneity. Due to this clinical heterogeneity, we did not pool results for our primary outcome, the number of patients with exacerbations requiring emergency department (ED) visit. The mean number of exacerbations requiring ED visits per person at six months was not significantly different between the home-based intervention and control groups (N = 2 studies; MD 0.04; 95% confidence interval (CI) -0.20 to 0.27). Only one trial contributed to our other primary outcome, exacerbations requiring a course of oral corticosteroids. Hospital admissions also demonstrated wide variation between trials with significant changes in some trials in both directions. Quality of life improved in both education and control groups over time.A table summarising some of the key components of the education programmes is included in the review. AUTHORS' CONCLUSIONS We found inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although education remains a key component of managing asthma in children, advocated in numerous guidelines, this review does not contribute further information on the fundamental content and optimum setting for such educational interventions.
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Affiliation(s)
- Emma J Welsh
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
| | | | - Patricia Li
- Montreal Children's Hospital, McGill University Health CentreDepartment of PediatricsMontrealQCCanada
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20
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McCloud E, Papoutsakis C. A medical nutrition therapy primer for childhood asthma: current and emerging perspectives. ACTA ACUST UNITED AC 2011; 111:1052-64. [PMID: 21703384 DOI: 10.1016/j.jada.2011.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 12/22/2010] [Indexed: 10/18/2022]
Abstract
Asthma is the most common chronic disease in children. Prevalence has increased in the past 2 decades and has reached a plateau of approximately 9% of children in the United States, affecting about 6.7 million children. The increased prevalence of childhood asthma has paralleled the increased prevalence in childhood obesity. Changes in diet have also been implicated in the increased prevalence of asthma, among other risk factors. The main symptoms of asthma (ie, wheezing, coughing, and chest tightness) require medical evaluation and monitoring. The cornerstone of asthma management is medication therapy, frequently consisting of inhaled bronchodilators and corticosteroids and, when needed, therapy of corticosteroids by mouth. As part of the multidisciplinary management of this chronic disease, nutrition assessment and follow-up in childhood asthma is necessary to identify and address relevant nutrition-related problems. These problems can involve food-medication interactions, obesity, gastroesophageal reflux disease, food allergies, and other issues; therefore, individualized medical nutrition therapy is warranted. Finally, counseling to achieve a healthy balanced diet is recommended for overall health and weight management. A recent but small number of descriptive investigations agree that adherence to a Mediterranean dietary pattern can be associated with a decreased risk of current asthma symptoms in children. Although this evidence is promising, food interventions are required to substantiate an evidence-based foundation for medical nutrition therapy in childhood asthma. At this time, there is no known health risk if a Mediterranean diet is adopted.
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Pedersen SE, Hurd SS, Lemanske RF, Becker A, Zar HJ, Sly PD, Soto-Quiroz M, Wong G, Bateman ED. Global strategy for the diagnosis and management of asthma in children 5 years and younger. Pediatr Pulmonol 2011; 46:1-17. [PMID: 20963782 DOI: 10.1002/ppul.21321] [Citation(s) in RCA: 186] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 05/31/2010] [Accepted: 05/31/2010] [Indexed: 12/28/2022]
Abstract
Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits, and hospitalisation. During the past two decades, many scientific advances have improved our understanding of asthma and our ability to manage and control it effectively. However, in children 5 years and younger, the clinical symptoms of asthma are variable and non-specific. Furthermore, neither airflow limitation nor airway inflammation, the main pathologic hallmarks of the condition, can be assessed routinely in this age group. For this reason, to aid in the diagnosis of asthma in young children, a symptoms-only descriptive approach that includes the definition of various wheezing phenotypes has been recommended. In 1993, the Global Initiative for Asthma (GINA) was implemented to develop a network of individuals, organizations, and public health officials to disseminate information about the care of patients with asthma while at the same time assuring a mechanism to incorporate the results of scientific investigations into asthma care. Since then, GINA has developed and regularly revised a Global Strategy for Asthma Management and Prevention. Publications based on the Global Strategy for Asthma Management and Prevention have been translated into many different languages to promote international collaboration and dissemination of information. In this report, Global Strategy for Asthma Management and Prevention in Children 5 Years and Younger, an effort has been made to present the special challenges that must be taken into account in managing asthma in children during the first 5 years of life, including difficulties with diagnosis, the efficacy and safety of drugs and drug delivery systems, and the lack of data on new therapies. Approaches to these issues will vary among populations in the world based on socioeconomic conditions, genetic diversity, cultural beliefs, and differences in healthcare access and delivery. Patients in this age group are often managed by pediatricians and general practitioners routinely faced with a wide variety of issues related to childhood diseases.
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Abstract
Children who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group, with substantial morbidity. The evidence base for management is sparse, and is mostly based on data from studies in children with mild and moderate asthma and on extrapolation of data from studies in adults with severe asthma. In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. The first step is a detailed diagnostic assessment to exclude an alternative diagnosis ("not asthma at all"), followed by a multidisciplinary approach to exclude comorbidities ("asthma plus") and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). In particular, environmental causes of secondary steroid resistance should be identified. An individualised treatment plan should be devised depending on the clinical and pathophysiological characterisation. Licensed therapeutic approaches include high-dose inhaled steroids, the Symbicort maintenance and reliever (SMART) regimen (with budesonide and formoterol fumarate), and anti-IgE therapy. Unlicensed treatments include methotrexate, azathioprine, ciclosporin, and subcutaneous terbutaline infusions. Paediatric data are needed on cytokine-specific monoclonal antibody therapies and bronchial thermoplasty. However, despite the interest in innovative approaches, getting the basics right in children with apparently severe asthma will remain the foundation of management for the foreseeable future.
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Affiliation(s)
- Andrew Bush
- Imperial School of Medicine, National Heart and Lung Institute, Royal Brompton Hospital, London, UK.
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Harver A, Humphries CT, Kotses H. Do asthma patients prefer to monitor symptoms or peak flow? J Asthma 2009; 46:940-3. [PMID: 19905923 DOI: 10.3109/02770900903274475] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We administered a 65-item survey to patients to assess preference of symptoms and peak flow to detect worsening asthma and to collect information about asthma triggers, asthma knowledge sources, and barriers to peak flow meter use. It was completed by 139 asthma patients. Survey responses were comparable for adult and pediatric patients and for those who owned peak flow meters and those who did not. But patients who owned a peak flow meter reported more severe asthma than others. On average, the patients preferred symptoms to peak flow for assessing worsening asthma. It is likely that the preference for symptom over peak flow monitoring was effort related: Patients preferred symptom monitoring because it was the easier of the two to conduct.
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Affiliation(s)
- Andrew Harver
- Department of Public Health Sciences, The University of North Carolina at Charlotte, 9201 University City Blvd., Charlotte, NC 28223-0001, USA.
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Soto-Martínez ME, Avila L, Soto-Quirós ME. [New criteria for the diagnosis and management of asthma in children under 5 years old: GINA Guidelines 2009]. An Pediatr (Barc) 2009; 71:91-4. [PMID: 19608470 DOI: 10.1016/j.anpedi.2009.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 06/29/2009] [Indexed: 11/19/2022] Open
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