The frequency distribution of presenting symptoms in children aged six months to six years to primary care

Evaluation of the Double-Tracer Gas Single-Breath Washout Test in a Pediatric Field Study

BACKGROUND

The early life origins of chronic pulmonary diseases are thought to arise in peripheral small airways. Predictors of ventilation inhomogeneity, a proxy of peripheral airway function, are understudied in schoolchildren.

RESEARCH QUESTION

Is the double-tracer gas single-breath washout (DTG-SBW) measurement feasible in a pediatric field study setting? What are the predictors of the DTG-SBW-derived ventilation inhomogeneity estimate in unselected schoolchildren?

STUDY DESIGN AND METHODS

In this prospective cross-sectional field study, a mobile lung function testing unit visited participating schools in Switzerland. We applied DTG-SBW, fraction of exhaled nitric oxide (Feno), and spirometry measurements. The DTG-SBW is based on tidal inhalation of helium and sulfur-hexafluoride, and the phase III slope (SIIIHe-SF6) is derived. We assessed feasibility, repeatability, and associations of SIIIHe-SF6 with the potential predictors of anthropometrics, presence of wheeze (ie, parental report of one or more episode of wheeze in the prior year), Feno, FEV1, and FEV1/FVC.

RESULTS

In 1,782 children, 5,223 DTG-SBW trials were obtained. The DTG-SBW was acceptable in 1,449 children (81.3%); the coefficient of variation was 39.8%. SIIIHe-SF6 was independently but weakly positively associated with age and BMI. In 276 children (21.2%), wheeze was reported. SIIIHe-SF6 was higher by 0.049 g.mol.L-1 in children with wheeze compared with those without and remained associated with wheeze after adjusting for age and BMI in a multivariable linear regression model. SIIIHe-SF6 was not associated with Feno, FEV1, and FEV1/FVC.

INTERPRETATION

The DTG-SBW is feasible in a pediatric field study setting. On the population level, age, body composition, and wheeze are independent predictors of peripheral airway function in unselected schoolchildren. The variation of the DTG-SBW possibly constrains its current applicability on the individual level.

TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03659838; URL: www.

CLINICALTRIALS

gov.

Antipyretic Effect of Oral Dipyrone (Metamizole) Compared to Oral Ibuprofen in febrile Children: A Systematic Review and Meta-Analysis.. [DOI: 10.21203/rs.3.rs-2920290/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background The nonsteroidal anti-inflammatory medication dipyrone (metamizole) is most frequently used as a painkiller as well as an anti - pyretic. Despite the fact that it has been banned in many high-income countries following confirmed studies of fatal agranulocytosis and adverse drug reactions, it is still widely used in various countries of the world. However, the antipyretic therapeutic indications of dipyrone in febrile children are currently unknown, and there is little information on the advantages and disadvantages of using dipyrone in febrile youngsters. In febrile youngsters, we expected that dipyrone's antipyretic effectiveness wouldn't be any more effective than ibuprofen. Therefore, the purpose of this research is to evaluate the effectiveness of oral dipyrone and oral ibuprofen as antipyretics in febrile children. Methods Several databases, including PubMed, Scopus, Web of Science, and Cochrane Library, were searched thoroughly using a pre-established search strategy for potential research. The studies included in this analysis comprised randomized controlled trials that compared the antipyretic effects of oral ibuprofen and oral dipyrone in febrile kids. Data analysis was carried out using Revman 5.4 software. Results Three studies were selected among the 27 publications we discovered to be applicable, and they underwent qualitative and quantitative analysis. The pooled analysis revealed no discernible difference between oral dipyrone and oral ibuprofen in terms of their antipyretic effects (Mean difference (MD) = 0.06; 95% confidence interval (CI): -0.08, 0.20). Conclusion Both oral dipyrone and ibuprofen are effective in reducing high-temperature levels in febrile children without any significant difference.

Therapeutic principles and unmet needs in the treatment of cough in pediatric patients: review and expert survey

BACKGROUND

There are evidence gaps in the management of pediatric cough, particularly for acute pediatric cough. This study had two aims: to identify therapeutic principles and unmet needs in the treatment of cough in pediatric patients (internationally), and to consider the evidence required to address these unmet needs.

METHODS

A MEDLINE/PubMed database search was performed to identify articles describing therapeutic principles in the treatment of pediatric cough. An online survey of international pediatric cough experts was conducted, with questions on the definitions, diagnosis, treatment, and unmet needs in pediatric cough management.

RESULTS

Cough guidelines have differing definitions of pediatric patients (≤12-18 years), acute pediatric cough (< 2-3 weeks), and chronic pediatric cough (> 4-8 weeks). Similarly, among 18 experts surveyed, definitions varied for pediatric patients (≤10-21 years), acute pediatric cough (< 3-5 days to < 6 weeks), and chronic pediatric cough (> 2-8 weeks). Guidelines generally do not recommend over-the-counter or prescription cough medicines in acute pediatric cough, due to lack of evidence. In the expert survey, participants had differing opinions on which medicines were most suitable for treating acute pediatric cough, and noted that effective treatments are lacking for cough-related pain and sleep disruption. Overall, guidelines and experts agreed that chronic pediatric cough requires diagnostic investigations to identify the underlying cough-causing disease and thereby to guide treatment. There are unmet needs for new effective and safe treatments for acute pediatric cough, and for randomized controlled trials of existing treatments. Safety is a particular concern in this vulnerable patient population. There is also a need for better understanding of the causes, phenotypes, and prevalence of pediatric cough, and how this relates to its diagnosis and treatment.

CONCLUSIONS

Whereas pediatric cough guidelines largely align with regard to the diagnosis and treatment of chronic cough, there is limited evidence-based guidance for the management of acute cough. There is a need for harmonization of pediatric cough management, and the development of standard guidelines suitable for all regions and patient circumstances.

Association between Environmental Exposures and Asthma among Children in King Williams Town, South Africa

The study aimed to assess the association between environmental exposure and asthma among children between 3 and 12 years old in King Williams Town, South Africa. A quantitative case-control study was conducted at Grey Hospital to assess the association between environmental exposure and asthma among children who reside in King Williams Town. Of the total 566 study participants, 50.5% (286) had asthma while 49.5% did not. Socio-demographic factors associated with asthma in children were being within the age group 9-12 years (OR 1.74, CI 95% 1.09-2.78) and India ethnicity (OR 0.20, CI 95% 0.08-0.48). Factors associated with asthma were weight within 25-35 kg (OR 1.64, CI 95% 1.11-2.42) and BMI within 15-20 (OR 4.80, CI 95% 2.80-8.22). Environmental risk factors associated with asthma were indoor exposure to tobacco smoke from mothers of the participants (OR 5.45, CI 95% 3.08-9.65) and from fathers (OR 4.37; CI 95% 2.77-6.90). Abstaining from eating seafood appeared to be protective from developing asthma (OR 0.01; CI 95% 0.00-0.05). The study found no significant association between outdoor environmental exposures and childhood asthma. The age of participant, weight, BMI, exposure to environmental tobacco smoke (ETS), and eating seafood had significant correlations with childhood asthma. Strengthening the evaluation of children healthcare and encouraging smoking cessation among parents could reduce exposure to environmental asthma triggers among children.

Characteristics of Pediatric Primary Healthcare Visits in a University-Based Primary Healthcare Center in Saudi Arabia

This study aimed to identify the characteristics of pediatric primary health care (PHC) visits and evaluate the outcomes of patients presenting with complaints along with their referral and consultation capabilities. This was a retrospective medical record-based study. The study population included any pediatric patient (≤14 years old), including females and males, Saudis, and non-Saudis. Research data were gathered for visits from 2016-2021. Sampling was performed using a stratified random sample based on age groups, followed by simple random sampling with proportional allocation to different age groups. The number of pediatric visits included was 1439 (males, 52.2%). The most common age group was toddlers, and 60% of the total sample was from Saudi Arabia. The most common cause of visits was vaccination (32%), followed by general checkups and/or a well-baby visit (25.4%), and fever (11.2%). Approximately 10% of visits needed referral to other subspecialties. Approximately 50% of visits with complaints concerning ophthalmology, cardiology, and surgical intervention were referred to a specialized department. More awareness needs to be raised about the important role of PHC services in the pediatric age group, as it was capable of handling approximately 90% of their cases.

Candidate Biomarkers for the Detection of Serious Infections in Children: A Prospective Clinical Study

Serious bacterial infections (SBI) in children are associated with considerable morbidity and mortality, and their early identification remains challenging. The role of laboratory tests in this setting is still debated, and new biomarkers are needed. This prospective, observational, single-center study aims to evaluate the diagnostic role of blood biomarkers in detecting SBI in children presenting with signs of systemic inflammatory response syndrome (SIRS). A panel of biomarkers was performed, including C-reactive protein (CRP), procalcitonin (PCT), white blood cell count (WBC), absolute neutrophil count (ANC), interleukin (IL)-6, IL-8, IL-10, human terminal complement complex (C5b-9), Plasmalemma-Vesicle-associated protein 1 (PV-1), Intercellular Adhesion Molecule-1 (ICAM-1), and Phospholipase A2 (PLA2). Among 103 patients (median age 2.9 years, 60% males), 39 had a diagnosis of SBI (38%). Significant predictors of SBI were CRP (p = 0.001) and ICAM-1 (p = 0.043). WBC (p = 0.035), ANC (p = 0.012) and ANC/WBC ratio (p = 0.015) were also significantly associated with SBI in children without pre-existing neutropenia. ROC curves, however, revealed suboptimal performance for all variables. Nevertheless, a model that combined CRP and ANC/WBC ratio had more in-depth diagnostic accuracy than either of the two variables. Overall, this study confirms the limited usefulness of blood biomarkers for the early diagnosis of SBI. WBC, ANC, ANC/WBC ratio, CRP, and ICAM-1 showed the best, albeit moderate, diagnostic accuracy.

Randomised comparative trial of the efficacy of paracetamol syrup and dispersible tablets for the treatment of fever in children

Objective

Fever is the most common reason for the presentation of children in the outpatient department. Paracetamol is marketed in different formulations for ease of administration to the paediatric population. These include syrups, dispersible tablets and rectal inserts. Dispersible tablets disintegrate rapidly in liquid and are subsequently taken orally, providing another oral formulation. We determined if there is a difference in the antipyretic efficacy of the syrup and the dispersible formulation of paracetamol, thereby prompting the development of the latter (another oral formulation) for use in children.

Methods

A randomised, controlled, double-blind intervention of a single dose of both formulations was given to febrile children, and their temperatures were documented twice in 30-minute intervals. Temperature changes were compared statistically.

Results

The mean temperatures at recruitment were 38.2 ± 0.5°C and 38.3 ± 0.6°C for the dispersible and syrup group, respectively. There was no significant difference between the temperature changes at T2 (30 minutes) and T3 (60 minutes) between the two study arms. However, the temperature was significantly different at T1 (baseline), T2 and T3 within the dispersible and syrup groups.

Conclusion

The decreasing trend in temperature was similar in both groups. Both preparations produced statistically similar antipyretic effects with no reported adverse drug reaction.

Preschool Wheezing and Gastro-Esophageal Reflux: --Causal or Casual Coincidence? Update from Literature

Gastroesophageal reflux (GER) and wheeze are two common conditions in children. GER has been advocated as a causative factor for explaining recurrent to persistent respiratory symptoms at any age. This association very often means that many children with cough, wheezing, or recurrent respiratory infections receive empirical anti-reflux medications. The causal relationship is still largely discussed. Compared to the large number of studies in infants and adolescents, literature on the relationship between GER and wheeze in preschool children is scarce and inconclusive. The aim of the present narrative review was to summarize what is known so far, and what the literature has proposed in the last 20 years, on the relationship between preschool wheezing and GER. In preschool children with respiratory symptoms there is a high rate of positivity of reflux testing, for this reason pH-MII testing and endoscopy are recommended. Flexible bronchoscopy may be useful to exclude anatomical abnormalities as the cause of wheezing in infancy and preschool years. Several biomarkers, as well as empirical anti-reflux therapy, have been proposed for the diagnosis of GER-related airway diseases, but the conclusions of these studies are controversial or even conflicting. There is a great need for future clinical trials to confirm or rule out the association.

Wheeze and cough measurements at night in children with respiratory symptoms

Background

Nocturnal cough and wheeze are important symptoms when diagnosing any respiratory disease in a child, but objective measurements of these symptoms are not performed.

Methods

The aim of our study was to analyze the use of an automated detection system to assess breath sounds objectively in comparison to cough and wheeze questionnaires and to evaluate its feasibility in clinical practice.

Results

Forty-nine recordings of thirty-nine children were processed (asthma n = 13; cystic fibrosis n = 2; pneumonia n = 5; suspicion of habit cough n = 7; prolonged, recurrent or chronic cough n = 13), and cough and asthma scores were compared to the objective nocturnal recordings. Time for audio-validation of recordings took between 2 and 40 min (mean: 14.22 min, (SD): 10.72). Accuracy of the automated measurement was higher for cough than for wheezing sounds. Nocturnal cough readings but not wheeze readings correlated with some of the corresponding scores.

Conclusion

To our knowledge this is the first study using a new device to assess nocturnal cough and obstructive breath sounds objectively in children with a wide variety of respiratory diseases. The assessment proved user friendly. We obtained additional information on nighttime symptoms, which would otherwise have remained obscure. Further studies to assess possible diagnostic and therapeutic benefits of this device are needed.

Brain Death Secondary to Rocky Mountain Spotted Fever Encephalitis

A two-year-old female presented with acutely altered mental status following eight days of fever and rash. She had been camping at an Indiana campground 11 days prior to the onset of illness and was evaluated twice for her fever and rash prior to admission. Laboratory evaluation on admission revealed thrombocytopenia, hyponatremia, and elevated transaminases. The patient developed diffuse cerebral edema, and despite intensive care, the edema led to brain death from Rocky Mountain spotted fever (RMSF). We present this case to highlight the importance of considering RMSF and other tick-borne illnesses in a child with prolonged fever and rash in a nonendemic area and also the difficulty of diagnosis in early stages of disease. A detailed travel history, evaluation of key laboratory findings (white blood count, platelet count, and transaminases), and close follow-up if rash and fevers persist may help to improve detection of RMSF. If a tick-borne illness such as RMSF is suspected, empiric doxycycline therapy should be started immediately, as lab confirmation may take several days and mortality increases greatly after five days of symptoms.

The Burden Of Visits For Fever At A Paediatric Emergency Room: A Retrospective Study On Patients Presenting At The Cantons Hospital Of Fribourg, A Peripheral Public Hospital Of Switzerland

Introduction

Fever is the chief complaint of up to one-third of all paediatric office visits in many places. The high number of consultations at our emergency department (ED) led us to hypothesise that this increase was due to febrile paediatric patients with lower urgency seeking medical advice.

Methods

We retrospectively analysed the number and characteristics of patients 3 months to 5 years of age consulting for a body temperature of 38.5°C or higher during the 6 winter months of 2011-2012.

Results

Twenty-four percent of all consultations were requested by the patients included in our group. None of the 835 patients had to be hospitalised, 95% of these patients had additional respiratory or gastrointestinal symptoms, 36.7% required antibiotic therapy, and 17.6% (laryngitis and lower respiratory tract infection (RTI)) required temporary respiratory support. A total of 56.2% of patients sought advice outside of the normal working hours.

Conclusion

The majority of patients had fever accompanied by additional symptoms justifying a medical consultation. However, most of these did not require the infrastructure of an ED for their health care problem and probably visited the ED because of the open hours.

Parental Perception of Childhood Anaemia and Efficiency of Instrument Assisted Pallor Detection among Mothers in Southeast Nigeria: A Field Validation Study

Background

Control of anemia can be achieved with early detection of pallor by parents at home. However, most parents lack the capacity to recognize pallor; thus most cases of anaemia are detected during hospital visit due to other symptoms. This study aimed to evaluate parental ability to detect pallor when aided with the anaemia screening tool.

Methods

In the study information on the symptoms of illness and parental knowledge on anaemia. Their ability to detect anaemia aided with the Home-Base anaemia-screen tool (HB-Anae) was compared to the healthcare providers' assessment of pallor. The haemoglobin estimation with the Hb-301 haemoglobinometer was used as the gold standard.

Results

None of the children in their previous illnesses had paleness as a complaint. Few (20.8%) parents knew what anaemia meant. Only 18.3% knew sites on the body where pallor can be detected. Many (55.1%; 304/552) surveyed children were anaemic (Hb<11g/dl) based on HB 301. Majority (88.8%; 270/304) of the parents aided with the HB-Anae were able to detect pallor on the children who were anaemic compared to 95.1% (289/304) detected by healthcare workers unaided, and the difference was not statistically significant (p=0.25).

Conclusion

There was poor knowledge on anaemia among parents. The ability of parents to detect anaemia could be improved with the simple HB-Anae screen tool.

An approach to the child with a wet cough

When children have a wet cough, it suggests the presence of secretions in their airways. This often has an infectious aetiology which is usually a self-limiting viral infection requiring no investigation or treatment. In those with acute wet cough it is, however, important to identify features suggestive of community acquired pneumonia or an inhaled foreign body as these causes require specific management. When there is chronic wet cough, the most common diagnoses are protracted bacterial bronchitis (PBB) and bronchiectasis. The relationship between these two conditions is complex as the development of bronchiectasis manifests as a clinical continuum in which the early features of which are indistinguishable from PBB. It is therefore important to identify PBB and chronic cough endotypes which are associated with an increased risk of bronchiectasis. This article offers a pragmatic approach to the investigation and treatment of children with wet cough. It is hoped this will limit unnecessary investigations whist aiding the prompt diagnosis of conditions needing treatment to reduce symptom burden and prevent further lung damage.

Beliefs, Practices and Health Care Seeking Behavior of Parents Regarding Fever in Children

Background and objectives: Fever in children is one of the most common reasons for seeking medical attention. Parents often have misconceptions about the effects to fever, which leads to inappropriate use of medication and nonurgent visits to emergency departments (ED). The aim of this study was to clarify the beliefs on the effects and management of fever and to identify healthcare seeking patterns among parents of febrile children in Latvia. Materials and Methods: Parents and legal guardians of children attending ED with febrile illness were included in the study. Participants were recruited in Children’s Clinical University Hospital (CCUH) in Riga, and in six regional hospitals in Latvia. Data on beliefs about fever, administration of antipyretics, healthcare-seeking behavior, and experience in communication with health care workers were collected via questionnaire. Results: In total, 355 participants were enrolled: 199 in CCUH and 156 in regional hospitals; 59.2% of participants considered fever itself as indicative of serious illness and 92.8% believed it could raise the child’s body temperature up to a dangerous level. Antipyretics were usually administered at median temperature of 38.0 °C, and the median temperature believed to be dangerous was 39.7 °C; 56.7% of parents usually contacted a doctor within the first 24 h of the illness. Parents who believed that lower temperatures are dangerous to a child were more likely to contact a doctor earlier and out-of-hours; 60.1% of participants had contacted their family doctor prior their visit to ED. Parental evaluation of satisfaction with the information and reassurance provided by the doctors at the hospital was higher than of that provided by their family doctor; 68.2% of participants felt safer when their febrile children were treated at the hospital. Conclusions: Fever itself was regarded as indicative of serious illness and potentially dangerous to the child’s life. These misconceptions lead to inappropriate administration of antipyretics and early-seeking of medical attention, even out-of-hours. Hospital environment was viewed as safer and more reassuring when dealing with febrile illness in children. More emphasis must be placed on parental education on proper management of fever, especially in primary care

Value of parental concern and clinician's gut feeling in recognition of serious bacterial infections: a prospective observational study

Background

Serious bacterial infections (SBI) are a significant cause of mortality worldwide. Parental concern and clinician’s gut feeling that there is something wrong has been associated with increased likelihood of developing SBI in primary care studies. The aim of this study is to assess the diagnostic value of parental concern and gut feeling at the emergency department of a tertiary hospital.

Methods

This prospective observational study included children with fever attending the emergency department of Children’s Clinical University hospital in Riga between October 2017 and July 2018. Data were collected via parental and clinician questionnaires. “Gut feeling” was defined as intuitive feeling that the child may have a serious illness, and “Sense of reassurance” as a feeling that the child has a self-limiting illness. “Parental concern” was defined as impression that this illness is different from previous illnesses. SBI included bacterial meningitis, sepsis, bacteraemia, pneumonia, urinary tract infection, appendicitis, bacterial gastroenteritis, and osteomyelitis. Pearson’s Chi-Squared test or Fisher’s exact test were used to compare the variables between children with and without SBI. Positive likelihood ratio was calculated for “gut feeling”, “sense of reassurance”, and parental concern.

Results

The study included 162 patients aged 2 months to 17.8 years. Forty-six patients were diagnosed with SBI. “Sense of reassurance” expressed by all clinicians was associated with lower likelihood of SBI (positive likelihood ratio 8.8, 95% confidence interval 2.2–34.8). “Gut feeling” was not significantly predictive of the patient being diagnosed with SBI (positive likelihood ratio 3.1, 95% confidence interval 1.9–5.1), The prognostic rule-in value of parental concern was insignificant (positive likelihood ratio 1.4, 95% confidence interval 1.1–1.7).

Conclusion

Sense of reassurance was useful in ruling out SBI. Parental concern was not significantly predictive of SBI.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1591-7) contains supplementary material, which is available to authorized users.

The child with an incessant dry cough

Cough is a forced expulsive manoeuvre, usually against a closed glottis and is associated with a characteristic sound that is easily recognised. It is a protective reflex against aspiration and to clear airway secretions. In children cough is extremely common and when prolonged it is often a cause for concern for parents, resulting in a high proportion of attendances to primary and secondary care. There are many causes of cough which may be divided into productive or non-productive in character. As there are many guidelines for the management of productive or 'wet' cough the focus of this paper will be to discuss some of the main causes, investigations and management options for 'dry' cough. Dry coughing suggests airway irritation and or inflammation (without excessive extra secretion formation) and is predominantly the result of an acute viral respiratory infection that may last up to 3-4 weeks.

Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance

BACKGROUND

Adverse childhood experiences (ACEs) including maltreatment and exposure to household stressors can impact the health of children. Community factors that provide support, friendship and opportunities for development may build children's resilience and protect them against some harmful impacts of ACEs. We examine if a history of ACEs is associated with poor childhood health and school attendance and the extent to which such outcomes are counteracted by community resilience assets.

METHODS

A national (Wales) cross-sectional retrospective survey (n = 2452) using a stratified random probability sampling methodology and including a boost sample (n = 471) of Welsh speakers. Data collection used face-to-face interviews at participants' places of residence. Outcome measures were self-reported poor childhood health, specific conditions (asthma, allergies, headaches, digestive disorders) and school absenteeism.

RESULTS

Prevalence of each common childhood condition, poor childhood health and school absenteeism increased with number of ACEs reported. Childhood community resilience assets (being treated fairly, supportive childhood friends, being given opportunities to use your abilities, access to a trusted adult and having someone to look up to) were independently linked to better outcomes. In those with ≥4 ACEs the presence of all significant resilience assets (vs none) reduced adjusted prevalence of poor childhood health from 59.8 to 21.3%.

CONCLUSIONS

Better prevention of ACEs through the combined actions of public services may reduce levels of common childhood conditions, improve school attendance and help alleviate pressures on public services. Whilst the eradication of ACEs remains unlikely, actions to strengthen community resilience assets may partially offset their immediate harms.

Fever in Children: Pearls and Pitfalls

Fever in children is a common concern for parents and one of the most frequent presenting complaints in emergency department visits, often involving non-pediatric emergency physicians. Although the incidence of serious infections has decreased after the introduction of conjugate vaccines, fever remains a major cause of laboratory investigation and hospital admissions. Furthermore, antipyretics are the most common medications administered to children. We review the epidemiology and measurement of fever, the meaning of fever and associated clinical signs in children of different ages and under special conditions, including fever in children with cognitive impairment, recurrent fevers, and fever of unknown origin. While the majority of febrile children have mild, self-resolving viral illness, a minority may be at risk of life-threatening infections. Clinical assessment differs markedly from adult patients. Hands-off evaluation is paramount for a correct evaluation of breathing, circulation and level of interaction. Laboratory markers and clinical prediction rules provide limited help in identifying children at risk for serious infections; however, clinical examination, prudent utilization of laboratory tests, and post-discharge guidance ("safety netting") remain the cornerstone of safe management of febrile children.

Effectiveness of a cough management algorithm at the transitional phase from acute to chronic cough in Australian children aged <15 years: protocol for a randomised controlled trial

INTRODUCTION

Acute respiratory infections (ARIs) are leading causes of hospitalisation in Australian children and, if recurrent, are associated with increased risk of chronic pulmonary disorders later in life. Chronic (>4 weeks) cough in children following ARI is associated with decreased quality-of-life scores and increased health and societal economic costs. We will determine whether a validated evidence-based cough algorithm, initiated when chronic cough is first diagnosed after presentation with ARI, improves clinical outcomes in children compared with usual care.

METHODS AND ANALYSIS

A multicentre, parallel group, open-label, randomised controlled trial, nested within a prospective cohort study in Southeast Queensland, Australia, is underway. 750 children aged <15 years will be enrolled and followed weekly for 8 weeks after presenting with an ARI with cough. 214 children from this cohort with persistent cough at day 28 will be randomised to either early initiation of a cough management algorithm or usual care (107 per group). Randomisation is stratified by reason for presentation, site and total cough duration at day 28 (<6 and ≥6 weeks). Demographic details, risk factors, clinical histories, examination findings, cost-of-illness data, an anterior nasal swab and parent and child exhaled carbon monoxide levels (when age appropriate) are collected at enrolment. Weekly contacts will collect cough status and cost-of-illness data. Additional nasal swabs are collected at days 28 and 56. The primary outcome is time-to-cough resolution. Secondary outcomes include direct and indirect costs of illness and the predictors of chronic cough postpresentation.

ETHICS AND DISSEMINATION

The Children's Health Queensland (HREC/15/QRCH/15) and the Queensland University of Technology University (1500000132) Research Ethics Committees have approved the study. The study will inform best-practice management of cough in children.

TRIAL REGISTRATION NUMBER

ACTRN12615000132549.

Antitussive activity of the Schisandra chinensis fruit polysaccharide (SCFP-1) in guinea pigs models

ETHNOPHARMACOLOGICAL RELEVANCE

Schisandra chinensis (Turcz.) Baill. (S. chinensis), locally known as "Wuweizi", has been used in the treatment of chronic cough as prescription medications of Traditional Chinese Medicine for thousands of years. However, the components of antitussive activity of S. chinensis and the mechanism are poorly understood.

AIM OF THE STUDY

This study aims to investigate the antitussive activity of polysaccharides extracted from S. chinensis.

MATERIALS AND METHODS

S. chinensis fruit polysaccharide-1 (SCFP-1) was extracted by 95% ethanol and distilled water successively, and then the water extraction was isolated with chromatographic columns. The preliminary characterization of SCFP-1 was analyzed by gel permeation chromatography (GPC), gas chromatography-mass spectrometry (GC-MS) and some other recognized chemical methods. Antitussive potential of SCFP-1 was estimated at dose of 250, 500, and 1000mg/kg respectively by peroral administration in a guinea pigs model with cough hypersensitivity induced by cigarette smoke (Chronic cough model) or acute cough guinea model induced by citric acid (Acute cough model). Also, the time-dependent antitussive effect of SCFP-1 were evaluated with acute cough model, and compared with codeine.

RESULTS

The molecular of SCFP-1 was 3.18×10⁴Da, mainly being composed of glucose and arabinose (66.5% and 29.4%, respectively). Peroral administration of SCFP-1 at 250, 500, and 1000mg/kg showed remarkable suppressive effects respectively on cough in both of chronic cough model and acute cough model. Meanwhile, inflammatory cell in BALF and some typical characteristics of nonspecific airway inflammation in animals exposed to CS was significantly attenuated after pretreatment with SCFP-1. The cough suppression of SCFP-1 (500 mg/kg) stablly lasted during the whole 5 h of time-dependent experiment, while no positive effect was observed after 300 min of oral administration of codeine.

CONCLUSIONS

SCFP-1 is one of the antitussive components of S. chinensis.

A Program of Nurse Management for Unscheduled Consultations of Children With Acute Minor Illnesses in Primary Care

INTRODUCTION

Attention to patients with acute minor illnesses represents a major burden for primary care. Although programs of nurse care for children with acute minor illnesses in primary care started a long time ago, there is limited information about the results of these programs in current practice.

OBJECTIVES

The objective of this study was to assess the feasibility and efficacy of a program of nurse management for unscheduled consultations of children with acute minor illnesses.

METHODS

Observational study of children seeking unscheduled consultations for 16 acute minor illnesses in 284 primary care practices during a 2-year period. The program of nurse management used predefined management algorithms.

FINDINGS

Among 467,160 consultations performed, case resolution was achieved in 65.4%. The remaining 34.6% of cases were not solved by the primary healthcare nurse due to the existence of signs of alarm and were referred to a pediatrician. Return to consultation during a 7-day period for the same reason as the original consultation was only 2.6%.

CONCLUSIONS

A program that uses management algorithms is effective for nurse care management of children with acute minor illnesses in primary care.

CLINICAL RELEVANCE

Application of programs of nurse management for unscheduled consultations for children with acute minor illnesses is feasible and effective.

Workload and management of childhood fever at general practice out-of-hours care: an observational cohort study

OBJECTIVE

Even though childhood fever is mostly self-limiting, children with fever constitute a considerable workload in primary care. Little is known about the number of contacts and management during general practitioners' (GPs) out-of-hours care. We investigated all fever related telephone contacts, consultations, antibiotic prescriptions and paediatric referrals of children during GP out-of-hours care within 1 year.

DESIGN

Observational cohort study.

SETTING AND PATIENTS

We performed an observational cohort study at a large Dutch GP out-of-hours service. Children (<12 years) whose parents contacted the GP out-of-hours service for a fever related illness in 2012 were included.

MAIN OUTCOME MEASURES

Number of contacts and consultations, antibiotic prescription rates and paediatric referral rates.

RESULTS

We observed an average of 14.6 fever related contacts for children per day at GP out-of-hours services, with peaks during winter months. Of 17,170 contacts in 2012, 5343 (31.1%) were fever related and 70.0% resulted in a GP consultation. One in four consultations resulted in an antibiotic prescription. Prescriptions increased by age and referrals to secondary care decreased by age (p<0.001). The majority of parents (89.5%) contacted the out-of-hours service only once during a fever episode (89.5%) and 7.6% of children were referred to secondary care.

CONCLUSIONS

This study shows that childhood fever does account for a large workload at GP out-of-hours services. One in three contacts is fever related and 70% of those febrile children are called in to be assessed by a GP. One in four consultations for childhood fever results in antibiotic prescribing and most consultations are managed in primary care without referral.

Chronic cough in children

Cough is probably the most common cause of seeking medical care in pediatric practice. Most acute cough is caused by infection and usually resolves within less than 4 weeks. If it lasts longer, it is considered chronic and deserves investigation to identify the underlying cause, which can be almost any of a wide variety of illnesses of the respiratory tract and certain extrathoracic conditions. This review provides an optimal approach for diagnosis through a skillful history taking, physical examination, and selection of appropriate tests.

Recurrent wheeze and cough in young children: is it asthma?

A clinical diagnosis of asthma is often considered when a child presents with recurrent cough, wheeze and breathlessness. However, there are many other causes of wheeze in a young child. These range from recurrent viral infections to chronic suppurative lung disease, gastro-oesophageal reflux disease and rare structural abnormalities. Arriving at a diagnosis includes taking into consideration the symptomatology, triggers, atopic features, family history, absence of red flags and therapeutic trial, where indicated.

The development of chronic cough in children following presentation to a tertiary paediatric emergency department with acute respiratory illness: study protocol for a prospective cohort study

Background

Acute respiratory illness, a leading cause of cough in children, accounts for a substantial proportion of childhood morbidity and mortality worldwide. In some children acute cough progresses to chronic cough (>4 weeks duration), impacting on morbidity and decreasing quality of life. Despite the importance of chronic cough as a cause of substantial childhood morbidity and associated economic, family and social costs, data on the prevalence, predictors, aetiology and natural history of the symptom are scarce. This study aims to comprehensively describe the epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children presenting to a tertiary paediatric emergency department.

Methods/design

A prospective cohort study of children aged <15 years attending the Royal Children’s Hospital Emergency Department, Brisbane, for a respiratory illness that includes parent reported cough (wet or dry) as a symptom. The primary objective is to determine the prevalence and predictors of chronic cough (≥4 weeks duration) post presentation with acute respiratory illness. Demographic, epidemiological, risk factor, microbiological and clinical data are completed at enrolment. Subjects complete daily cough dairies and weekly follow-up contacts for 28(±3) days to ascertain cough persistence. Children who continue to cough for 28 days post enrolment are referred to a paediatric respiratory physician for review. Primary analysis will be the proportion of children with persistent cough at day 28(±3). Multivariate analyses will be performed to evaluate variables independently associated with chronic cough at day 28(±3).

Discussion

Our protocol will be the first to comprehensively describe the natural history, epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children. The results will contribute to studies leading to the development of evidence-based clinical guidelines to improve the early detection and management of chronic cough in children during and after acute respiratory illness.