Trends in childhood illness and treatment in Australian general practice, 1971-2001

The epidemiology of superficial Streptococcal A (impetigo and pharyngitis) infections in Australia: A systematic review

BACKGROUND

Streptoccocal A (Strep A, GAS) infections in Australia are responsible for significant morbidity and mortality through both invasive (iGAS) and post-streptococcal (postGAS) diseases as well as preceding superficial (sGAS) skin and throat infection. The burden of iGAS and postGAS are addressed in some jurisdictions by mandatory notification systems; in contrast, the burden of preceding sGAS has no reporting structure, and is less well defined. This review provides valuable, contemporaneous evidence on the epidemiology of sGAS presentations in Australia, informing preventative health projects such as a Streptococcal A vaccine and standardisation of primary care notification.

METHODS AND FINDINGS

MEDLINE, Scopus, EMBASE, Web of Science, Global Health, Cochrane, CINAHL databases and the grey literature were searched for studies from an Australian setting relating to the epidemiology of sGAS infections between 1970 and 2020 inclusive. Extracted data were pooled for relevant population and subgroup analysis. From 5157 titles in the databases combined with 186 grey literature reports and following removal of duplicates, 4889 articles underwent preliminary title screening. The abstract of 519 articles were reviewed with 162 articles identified for full text review, and 38 articles identified for inclusion. The majority of data was collected for impetigo in Aboriginal and Torres Strait Islander populations, remote communities, and in the Northern Territory, Australia. A paucity of data was noted for Aboriginal and Torres Strait Islander people living in urban centres or with pharyngitis. Prevalence estimates have not significantly changed over time. Community estimates of impetigo point prevalence ranged from 5.5-66.1%, with a pooled prevalence of 27.9% [95% CI: 20.0-36.5%]. All studies excepting one included >80% Aboriginal and Torres Strait Islander people and all excepting two were in remote or very remote settings. Observed prevalence of impetigo as diagnosed in healthcare encounters was lower, with a pooled estimate of 10.6% [95% CI: 3.1-21.8%], and a range of 0.1-50.0%. Community prevalence estimates for pharyngitis ranged from 0.2-39.4%, with a pooled estimate of 12.5% [95% CI: 3.5-25.9%], higher than the prevalence of pharyngitis in healthcare encounters; ranging from 1.0-5.0%, and a pooled estimate of 2.0% [95% CI: 1.3-2.8%]. The review was limited by heterogeneity in study design and lack of comparator studies for some populations.

CONCLUSIONS

Superficial Streptococcal A infections contribute to an inequitable burden of disease in Australia and persists despite public health interventions. The burden in community studies is generally higher than in health-services settings, suggesting under-recognition, possible normalisation and missed opportunities for treatment to prevent postGAS. The available, reported epidemiology is heterogeneous. Standardised nation-wide notification for sGAS disease surveillance must be considered in combination with the development of a Communicable Diseases Network of Australia (CDNA) Series of National Guideline (SoNG), to accurately define and address disease burden across populations in Australia.

TRIAL REGISTRATION

This review is registered with PROSPERO. Registration number: CRD42019140440.

Prevalence and determinants of antibiotic exposure in infants: A population-derived Australian birth cohort study

AIM

The aim of this study was to describe antibiotic exposure in Australian infants during the first year of life, focusing on antibiotic class, indication, risk factors associated with exposure and comparison with international counterparts.

METHODS

The Barwon Infant Study is a birth cohort study (n = 1074) with an unselected antenatal sampling frame from a large regional centre in Victoria, Australia. Longitudinal data on infection and medication were collected at 1, 3, 6, 9 and 12 months by parental questionnaire and from general practitioner and hospital records. Predictors of questionnaire non-completion were identified. A total of 660 infants with complete serial data were comprehensively examined. Antibiotic exposure was calculated as (i) antibiotic prescriptions and (ii) antibiotic days-exposed per person-year.

RESULTS

Mean antibiotic prescription rate was 0.92 prescriptions (95% confidence interval (CI), 0.83-1.02) per person-year, with the highest rates in those aged <1 month (1.50 (95% CI, 1.09-1.91) per person-year). A total of 50.0% of infants were exposed to at least one antibiotic in their first year of life. Increasing number of siblings was associated with increased antibiotic exposure. Penicillin with extended spectrum (365 of 661 antibiotic prescriptions, 52.6%) and cephalosporins (12.0%) were the most frequently prescribed antibiotics. One fifth of antibiotics were prescribed for respiratory tract infections and bronchiolitis.

CONCLUSION

Australian infants in this large population-based study are exposed to considerably more antibiotics than the majority of their international counterparts. Interventions aimed at addressing avoidable prescribing by medical practitioners and modifiable risk factors associated with antibiotic exposure may reduce antibiotic use.

Aetiology of febrile pharyngitis in children: Potential of myxovirus resistance protein A (MxA) as a biomarker of viral infection

Objectives

Besides group A streptococcus (GAS), microbial causes of pharyngitis in children are not well known. We aimed to document the viral and bacterial aetiology of pharyngitis and to assess the pathogenic role of viruses by determining the myxovirus resistance protein A (MxA) in the blood as a marker of interferon response.

Methods

In this prospective observational study, throat swabs and blood samples were collected from children (age 1–16 years) presenting to the emergency department with febrile pharyngitis. Microbial cause was sought by bacterial culture, polymerase chain reaction, and serology. Blood MxA level was determined.

Results

A potential pathogen was detected in 88% of 83 patients: GAS alone in 10%, GAS and viruses in 13%, group C or G streptococci alone in 2% and together with viruses in 3%, and viruses alone in 59% of cases. Enteroviruses, rhinoviruses, and adenoviruses were the most frequently detected viruses. Blood MxA levels were higher in children with viral (880 [245–1250] μg/L; median [IQR]) or concomitant GAS-viral (340 [150–710] μg/L) than in those with sole GAS (105 [80–160] μg/L) infections.

Conclusions

Detection of respiratory viruses simultaneously with elevated blood MxA levels supports the causative role of viruses in the majority of children with pharyngitis.

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We evaluated the microbiological aetiology of febrile pharyngitis in 83 children.

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A potential pathogen could be detected in 88% and virus in 76% of patients.

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Blood myxovirus resistance protein A (MxA) levels were elevated in most of the patients with virus finding.

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MxA is a promising biomarker of virus infection.

A multi-centre open-label randomised non-inferiority trial comparing watchful waiting to antibiotic treatment for acute otitis media without perforation in low-risk urban Aboriginal and Torres Strait Islander children (the WATCH trial): study protocol for a randomised controlled trial

Background

Treatment guidelines recommend watchful waiting for children older than 2 years with acute otitis media (AOM) without perforation, unless they are at high risk of complications. The high prevalence of chronic suppurative otitis media (CSOM) in remote Aboriginal and Torres Strait Islander communities leads these children to be classified as high risk. Urban Aboriginal and Torres Strait Islander children are at lower risk of complications, but evidence to support the subsequent recommendation for watchful waiting in this population is lacking.

Methods/Design

This non-inferiority multi-centre randomised controlled trial will determine whether watchful waiting is non-inferior to immediate antibiotics for urban Aboriginal and Torres Strait Islander children with AOM without perforation. Children aged 2 − 16 years with AOM who are considered at low risk for complications will be recruited from six participating urban primary health care services across Australia. We will obtain informed consent from each participant or their guardian. The primary outcome is clinical resolution on day 7 (no pain, no fever of at least 38 °C, no bulging eardrum and no complications of AOM such as perforation or mastoiditis) as assessed by general practitioners or nurse practitioners. Participants and outcome assessors will not be blinded to treatment. With a sample size of 198 children in each arm, we have 80 % power to detect a non-inferiority margin of up to 10 % at a significance level of 5 %, assuming clinical improvement of at least 80 % in both groups. Allowing for a 20 % dropout rate, we aim to recruit 495 children.

We will analyse both by intention-to-treat and per protocol. We will assess the cost- effectiveness of watchful waiting compared to immediate antibiotic prescription. We will also report on the implementation of the trial from the perspectives of parents/carers, health professionals and researchers.

Discussion

The trial will provide evidence for the safety and effectiveness of watchful waiting for the management of AOM in Aboriginal and Torres Strait Islander children living in urban settings who are considered to be at low risk of complications.

Trial registration

The trial is registered with Australia New Zealand Clinical Trials Registry (ACTRN12613001068752). Date of registration: 24 September 2013.

The effect and acceptability of tympanometry and pneumatic otoscopy in general practitioner diagnosis and management of childhood ear disease

BACKGROUND

Tympanometry and pneumatic otoscopy are recommended for diagnosis of otitis media, but are not frequently used by general practitioners (GPs). We examined how, after targeted short training, GP diagnosis and management of childhood ear disease was changed by the addition of these techniques to non-pneumatic otoscopy. We further explored factors influencing the uptake of these techniques.

METHODS

Between 2011 and 2012, we used a crossover experimental design to determine associations between tympanometry and pneumatic otoscopy and the GP diagnosis and management of ear disease in children aged 6 months to 6 years. GPs recorded a diagnosis and management plan after examining ears using non-pneumatic otoscopy, and another after using either tympanometry or pneumatic otoscopy. We compared diagnosis, prescription of oral antibiotics and planned GP follow-up at these two steps between the tympanometry and pneumatic otoscopy groups. We interviewed participants about their views regarding these techniques and analysed these data thematically.

RESULTS

Thirteen GPs recorded 694 ear examinations on 347 children: 347 examinations with non-pneumatic otoscopy; then 196 using tympanometry; and 151 using pneumatic otoscopy. Tympanometry was more likely to be associated with changes in diagnosis (χ (2) = 28.64, df 1, p < 0.001) and planned GP follow-up (χ (2) = 9.24, df 1, p < 0.01) than pneumatic otoscopy. Change in oral antibiotic prescription was no different between the two techniques. GPs preferred tympanometry to pneumatic otoscopy, but cost was a barrier to ongoing use. Pneumatic otoscopy was considered the more difficult skill. GPs were not convinced that the increased detection of middle ear effusion afforded by tympanometry and pneumatic otoscopy resulted in benefit to general practice patients.

CONCLUSION

Tympanometry was more likely than pneumatic otoscopy to change GP diagnoses and follow-up plans of childhood ear disease. Tympanometry may require less training than pneumatic otoscopy. GPs preferred tympanometry due to ease of use and interpretation; however, perceived high cost inhibited their intent to use it in the future. Training, cost and perceived lack of patient benefit are barriers to the use of tympanometry and pneumatic otoscopy in general practice.

Inappropriate prescribing of inhaled corticosteroids: are they being prescribed for respiratory tract infections? A retrospective cohort study

BACKGROUND

Guidelines recommend regular use of inhaled corticosteroid (ICS)-containing medications for all patients with persistent asthma and those with moderate to severe chronic obstructive pulmonary disease. It is important to identify indicators of inappropriate prescribing.

AIMS

To test the hypothesis that ICS are prescribed for the management of respiratory infections in some patients lacking evidence of chronic airways disease.

METHODS

Medication dispensing data were obtained from the Australian national Pharmaceutical Benefits Scheme (PBS) for concessional patients dispensed any respiratory medications during 2008. We identified people dispensed only one ICS-containing medication and no other respiratory medications in a year, who were therefore unlikely to have chronic airways disease, and calculated the proportion who were co-dispensed oral antibiotics.

RESULTS

In 2008, 43.6% of the 115,763 patients who were dispensed one-off ICS were co-dispensed oral antibiotics. Co-dispensing was seasonal, with a large peak in winter months. The most commonly co-dispensed ICS among adults were moderate/high doses of combination therapy, while lower doses of ICS alone were co-dispensed among children. In this cohort, one-off ICS co-dispensed with oral antibiotics cost the government $2.7 million in 2008.

CONCLUSIONS

In Australia, many people who receive one-off prescriptions for ICS-containing medications do not appear to have airways disease. In this context, the high rate of co-dispensing with antibiotics suggests that ICS are often inappropriately prescribed for the management of symptoms of respiratory infection. Interventions are required to improve the quality of prescribing of ICS and the management of respiratory infections in clinical practice.

Children and adolescents as patients in general practice - the reasons for encounter

Background

The SESAM 2 study was performed to estimate consultations of general practitioners. In the recent work we focused on the reasons for encounter of children and adolescents consulting the general practitioner.

Methods

Cross-sectional study with general practices in Saxony (Germany) as setting. Two hundred and seventy of the 2510 (10.8%) Saxon general practitioners agreed to participate and recorded data of 8877 patients. Evaluation of the data was organized by the Saxon Society of General Medicine (SGAM). Cross-sectional data were collected during a one-year period. One day of the week (Monday till Friday) was chosen at random for recording. Data were documented from every tenth patient with personal contact to the practitioner using a standardized report form at either the morning or afternoon consulting hours. Main outcome measures: reasons for encounter, the investigations and treatments performed and also the results of the consultation. Unpublished but publicly available data from the Dutch Transition Project were also analysed.

Results

Eight hundred and five of 8877 patients were aged under 20 years. The mean percentage of children and adolescents in the general practice consultation was 9.1%. The mean number of reasons for encounter per child patient was about 1.5 and did not differ between the age groups. Most consultations were due to respiratory, digestive, skin or general symptoms with typical seasonal variations regarding the most frequent reasons for encounter caused by infectious diseases.

Conclusions

As there is limited access to pediatric specialists, German general practitioners have to deal with children quite frequently. The number of child reasons for encounter is manageable for the general practitioner with an increasing spectrum of reasons for encounter among adolescents. In agreement with other publications most of the young patients consult for respiratory or general symptoms, or require preventive immunization or injection.

Keywords

Children; Adolescents; Reason for encounter; General practice; Primary care

Management of children's psychological problems in general practice 1970-1971, 1990-1991 and 2008-2009

OBJECTIVE

The aim of this study was to examine changes over four decades in children's psychological problems managed in Australian general practice and to describe recent management of these problems.

METHOD

Analysis of GP encounters with children, using data from the BEACH study, an on-going, cross-sectional, national survey of general practice, provides contemporary results. Comparisons with two related studies: 1970-1971 (from published reports), and 1990-1991 (secondary analysis), describe changes over time.

RESULTS

Changes over time: psychological problems accounted for 2% of all children's problems managed in 1971, 1.3% in 1990-1991 and 2.6% in 2008-2009. In 1971, non-organic enuresis accounted for 30% of children's psychological problems but only 2.7% in 2008-2009. Insomnia showed a similar pattern. Between 1990-1991 and 2008-2009, ADHD increased from 0.8% to 14.7%, and from 2000-2001 to 2008-2009, autism spectrum disorders rose from 4.9% to 11%. Current practice: most common psychological problems managed for children less than 18 years were anxiety, depression, intellectual impairment and ADHD. Among children aged 0-5 years, sleep disturbance and intellectual impairment were the main problems, for 6-11 year olds, anxiety and ADHD, and for 12-17 year olds, depression. Boys were significantly more likely to be managed for intellectual impairment, ADHD and autism spectrum disorders than were girls, who were more likely to be managed for depression. The medication rate was low at 19 per 100 psychological problems although higher for depression and ADHD. Referrals were given at a high rate. Counselling was also provided often, except in management of ADHD.

CONCLUSIONS

Access to the three studies allowed consideration of trends over a forty year period, showing the development of newly defined conditions which have replaced childhood diagnoses of past decades. The results demonstrate that GP involvement in children's mental health care management has grown significantly over the past 20 years.

The evidence base for interventions delivered to children in primary care: an overview of cochrane systematic reviews

BACKGROUND

As a first step in developing a framework to evaluate and improve the quality of care of children in primary care there is a need to identify the evidence base underpinning interventions relevant to child health. Our objective was to identify all Cochrane systematic reviews relevant to the management of childhood conditions in primary care and to assess the extent to which Cochrane reviews reflect the burden of childhood illness presenting in primary care.

METHODOLOGY/PRINCIPAL FINDINGS

We used the Cochrane Child Health Field register of child-relevant systematic reviews to complete an overview of Cochrane reviews related to the management of children in primary care. We compared the proportion of systematic reviews with the proportion of consultations in Australia, US, Dutch and UK general practice in children. We identified 396 relevant systematic reviews; 358 included primary studies on children while 251 undertook a meta-analysis. Most reviews (n = 218, 55%) focused on chronic conditions and over half (n = 216, 57%) evaluated drug interventions. Since 2000, the percentage of pediatric primary care relevant reviews only increased by 2% (7% to 9%) compared to 18% (10% to 28%) in all child relevant reviews. Almost a quarter of reviews (n = 78, 23%) were published on asthma treatments which only account for 3-5% of consultations. Conversely, 15-23% of consultations are due to skin conditions yet they represent only 7% (n = 23) of reviews.

CONCLUSIONS/SIGNIFICANCE

Although Cochrane systematic reviews focus on clinical trials and do not provide a comprehensive picture of the evidence base underpinning the management of children in primary care, the mismatch between the focus of the published research and the focus of clinical activity is striking. Clinical trials are an important component of the evidence base and the lack of trial evidence to demonstrate intervention effectiveness in substantial areas of primary care for children should be addressed.

WITHDRAWN: Decongestants and antihistamines for acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is a common and important source of morbidity in children, although the majority of cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit.

OBJECTIVES

To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, symptom resolution, medication side effects, and complications of AOM.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2); MEDLINE (January 2004 to May 2007); and EMBASE (July 2003 to May 2007).

SELECTION CRITERIA

Randomized controlled trials (RCTs) evaluating decongestant or antihistamine treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant.

DATA COLLECTION AND ANALYSIS

The review authors independently evaluated studies for inclusion, performed validity assessments and completed data extraction. Dichotomous data were pooled to generate relative risks; homogeneity was assessed using approximate chi-square tests.

MAIN RESULTS

No new studies were included following this updated search. Fifteen trials involving 2695 people were included. Only the combined decongestant-antihistamine group demonstrated statistically lower rates of persistent AOM at the two week period (fixed relative risk (RR) 0.76; 95% confidence interval (CI) 0.60 to 0.96; number needed to treat (NNT) 10). No benefit was found for early cure rates, symptom resolution, prevention of surgery or other complications. There was a five to eight -fold increased risk of side effects for those receiving an intervention, which reached statistical significance for all decongestant groupings. Validity sub analyses demonstrated that lower quality studies found benefit, while analysis of those studies with higher validity scores found no benefit of treatment.

AUTHORS' CONCLUSIONS

Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant treatment in children with AOM. There was a small statistical benefit from combination medication use but the clinical significance is minimal and study design may be biasing the results. Thus, the routine use of antihistamines for treating AOM in children cannot be recommended.

The nature and impact of collaboration and integrated service delivery for pregnant women, children and families

AIM

This paper explores the impact of models of integrated services for pregnant women, children and families and the nature of collaboration between midwives, child and family health nurses and general practitioners.

BACKGROUND

Increasingly, maternity and child health services are establishing integrated service models to meet the needs of pregnant women, children and families particularly those vulnerable to poor outcomes. Little is known about the nature of collaboration between professionals or the impact of service integration across universal health services.

DESIGN

Discursive paper.

METHODS

A literature search was conducted using a range of databases and combinations of relevant keywords to identify papers reporting the process, and/or outcomes of collaboration and integrated models of care.

RESULTS

There is limited literature describing models of collaboration or reporting outcomes. Several whole-of-government and community-based integrated service models have been trialled with varying success. Effective communication mechanisms and professional relationships and boundaries are key concerns. Liaison positions, multidisciplinary teams and service co-location have been adopted to communicate information, facilitate transition of care from one service or professional to another and to build working relationships.

CONCLUSIONS

Currently, collaboration between universal health services predominantly reflects initiatives to move services from the level of coexistence to models of cooperation and coordination.

RELEVANCE TO CLINICAL PRACTICE

Integrated service models are changing the way professionals are working. Collaboration requires knowledge of the roles and responsibilities of colleagues and skill in communicating effectively with a diverse range of professionals to establish care pathways with referral and feedback mechanisms that generate collegial respect and trust.

Systematic review of clinical trials assessing the effectiveness of ivy leaf (hedera helix) for acute upper respiratory tract infections

Introduction. Among nonantibiotic cough remedies, herbal preparations containing extracts from leaves of ivy (Hedera helix) enjoy great popularity. Objective. A systematic review to assess the effectiveness and tolerability of ivy for acute upper respiratory tract infections (URTIs). Methods. We searched for randomized controlled trials (RCTs), nonrandomized controlled clinical trials and observational studies evaluating the efficacy of ivy preparations for acute URTIs. Study quality was assessed by the Jadad score or the EPHPP tool. Results. 10 eligible studies were identified reporting on 17463 subjects. Studies were heterogeneous in design and conduct; 2 were RCTs. Three studies evaluated a combination of ivy and thyme, 7 studies investigated monopreparations of ivy. Only one RCT (n = 360) investigating an ivy/thyme combination used a placebo control and showed statistically significant superiority in reducing the frequency and duration of cough. All other studies lack a placebo control and show serious methodological flaws. They all conclude that ivy extracts are effective for reducing symptoms of URTI. Conclusion. Although all studies report that ivy extracts are effective to reduce symptoms of URTI, there is no convincing evidence due to serious methodological flaws and lack of placebo controls. The combination of ivy and thyme might be more effective but needs confirmation.

Decongestants and antihistamines for acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is a common and important source of morbidity in children, although the majority of cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit.

OBJECTIVES

To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, symptom resolution, medication side effects, and complications of AOM.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2); MEDLINE (January 2004 to May 2007); and EMBASE (July 2003 to May 2007).

SELECTION CRITERIA

Randomized controlled trials (RCTs) evaluating decongestant or antihistamine treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant.

DATA COLLECTION AND ANALYSIS

The review authors independently evaluated studies for inclusion, performed validity assessments and completed data extraction. Dichotomous data were pooled to generate relative risks; homogeneity was assessed using approximate chi-square tests.

MAIN RESULTS

No new studies were included following this updated search. Fifteen trials involving 2695 people were included. Only the combined decongestant-antihistamine group demonstrated statistically lower rates of persistent AOM at the two week period (fixed relative risk (RR) 0.76; 95% confidence interval (CI) 0.60 to 0.96; number needed to treat (NNT) 10). No benefit was found for early cure rates, symptom resolution, prevention of surgery or other complications. There was a five to eight -fold increased risk of side effects for those receiving an intervention, which reached statistical significance for all decongestant groupings. Validity sub analyses demonstrated that lower quality studies found benefit, while analysis of those studies with higher validity scores found no benefit of treatment.

AUTHORS' CONCLUSIONS

Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant treatment in children with AOM. There was a small statistical benefit from combination medication use but the clinical significance is minimal and study design may be biasing the results. Thus, the routine use of antihistamines for treating AOM in children cannot be recommended.

Burden of acute sore throat and group A streptococcal pharyngitis in school-aged children and their families in Australia

OBJECTIVE

The objective of this study was to determine the incidence, transmission, carriage, and risk factors for group A streptococcal pharyngitis in school-aged children and their families.

METHODS

A 16-month, prospective, family-based cohort study was undertaken from August 2001 through December 2002 in Melbourne, Australia. A total of 202 families (853 people) with at least 1 child aged 3 to 12 years were randomly selected from 3 primary care practices across suburban Melbourne to collect surveillance data for acute group A streptococcal pharyngitis, including serology for index and secondary cases and intermittent carriage data. Cohort retention was 97% for 16 months.

RESULTS

The incidence of acute sore throat, group A streptococcal swab-positive pharyngitis, and serologically confirmed group A streptococcal pharyngitis was 33, 13, and 8 per 100 child-years, respectively, for school-aged children (5-12 years) and 60, 20, and 15 per 100 family-years, respectively. Sore throat was less common in adults than children, but adults with sore throat were as likely as children to have group A streptococcal culture-positive or serologically proven pharyngitis. In families who had a primary case, 43% had at least 1 secondary case, and in family members who were at risk, 13% contracted a secondary case. The spring, summer, and winter carriage rates for children were 13%, 8%, and 16%, respectively, and for adults the rate was 2% across all seasons.

CONCLUSIONS

Group A streptococcal pharyngitis is still common, and the peak incidence occurs in school-aged children. However, the incidence in adults is higher than expected, and the number of secondary cases in families may be an important factor when considering the potential benefits of treatment.

The state of play in the battle against antimicrobial resistance: a general practitioner perspective

This article summarizes personal reflections from the perspective of general practice on developments with regard to antibiotic resistance and the containment of antibiotic prescribing during the lifetime of the Specialist Advisory Committee on Antimicrobial Resistance in England. These reflections concern the entry of antibiotics into the food chain, recent extensions of prescribing responsibilities and developments towards improved surveillance and reduced antibiotic prescribing. A large gap remains between the scientific appreciation of the risks from antimicrobial resistance and effective means to measure it and thereby hopefully control it.

Duration of poverty and child health in the Quebec Longitudinal Study of Child Development: longitudinal analysis of a birth cohort

OBJECTIVES

The objective of this study was to examine the relationship between duration of poverty and the health of preschool children in the Quebec Longitudinal Study of Child Development birth cohort.

METHODS

Data from the Quebec Longitudinal Study of Child Development for 1950 children who were followed annually up to age 3 years were analyzed. Poverty was defined as having an income below the low-income cutoff from Statistics Canada. Five health indicators were examined: asthma attacks, infections, growth delay, a cumulative health-problems index, and maternal perception of the child's health. The association between duration of poverty and child health was explored with logistic regression modeling controlling for child and mother characteristics, including the mother's level of education, social support, and physical violence.

RESULTS

In this birth cohort, 13.7% (268) 3-year-old children from the Quebec Longitudinal Study of Child Development experienced intermittent poverty since birth (1-2 episodes), and another 14.4% (280) experienced chronic poverty (3-4 episodes). Children from families with chronic poverty had more frequent asthma attacks and had a higher cumulative health-problems index score, whereas children with intermittent poverty were more often perceived to be in less than very good health by their mothers. These associations remained statistically significant when controlling for child and mother characteristics. No association was observed between duration of poverty and infections or growth delay.

CONCLUSIONS

Chronic poverty affects a large number of children and has negative consequences for preschool children's health, although universal health care is available. The effects of chronic poverty may vary according to different health indicators and the age of the child.

Antibiotic prescribing in Australian general practice: How has it changed from 1990–91 to 2002–03?

There is increasing evidence that antibiotics have limited value for many respiratory illnesses. This study investigates changes in overall antibiotic prescribing rates, and rates for specific conditions, by Australian general practitioners (GPs) between 1990-91 and 2002-03. This is a comparative study of two cross-sectional surveys of general practice activity, the Australian Morbidity and Treatment Survey (AMTS) 1990-91 and Bettering Evaluation and Care of Health (BEACH) 2002-03. Both studies used random samples of GPs, each providing data about a cluster of patient encounters. Outcome measures are the antibiotic prescribing rate per 100 encounters or per 100 selected problems managed. Between 1990-91 and 2002-03, the overall antibiotic prescribing rate decreased 24.3% from 18.9 prescriptions per 100 encounters to 14.3 (P<0.001). For children, the decrease for acute upper respiratory tract infection (URTI) was from 39.0 per 100 URTI problems to 24.4 (P<0.001), while the antibiotic prescribing rate increased for acute otitis media, decreased for bronchitis/bronchiolitis, and remained unchanged for other respiratory problems analysed. For adults the antibiotic prescribing rate for URTI decreased from 58.2 per 100 URTI problems to 40.0 (P<0.001), increased significantly for sinusitis and remained unchanged for all other respiratory problems. Antibiotic prescribing decreased significantly between 1990-91 and 2002-03 but the decrease was selective. The decline has been more pronounced among children than adults, and particularly for URTI. While the message of educators may be achieving its goal for URTI, other approaches targeting specific respiratory problems may be required to reduce antibiotic prescribing in these areas.

Topical analgesia for acute otitis media

BACKGROUND

Acute otitis media (AOM) is a spontaneously remitting disease for which pain is the most distressing symptom. Antibiotics are now known to have less benefit than previously assumed.

OBJECTIVES

To assess the effectiveness of topical analgesia for AOM.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to May Week 3 2006), EMBASE (1990 to December 2005) and LILACS (1982 to September 2005) without language restriction, and the reference lists of articles. We also contacted manufacturers and authors.

SELECTION CRITERIA

Double-blind randomised or quasi-randomised controlled trials comparing an otic preparation with an analgesic effect (excluding antibiotics) versus placebo or an otic preparation with an analgesic effect (excluding antibiotics) versus any other otic preparation with an analgesic effect, in adults or children presenting at primary care settings with AOM without perforation.

DATA COLLECTION AND ANALYSIS

Potential studies were screened independently and trial quality was assessed by three authors, and differences were resolved by discussion. Data was then independently extracted from the trials selected by two authors. We contacted the authors of three trials to acquire additional information not available in published articles.

MAIN RESULTS

Our searches yielded 356 records; four trials met our criteria. One trial with 54 participants compared treatment with anaesthetic ear drops versus an olive oil placebo immediately at diagnosis. All patients were also given paracetamol. There was a statistically significant pain reduction of 25% in those receiving anaesthetic drops 30 minutes after instillation. Three trials (with one common co-author) compared anaesthetic ear drops with naturopathic herbal ear drops in 274 patients. One of these trials also used antibiotics in both groups. There were statistically significant differences at instillation of drops, or 15 or 30 minutes after the instillation (or both) on one to three days after diagnosis, always favouring the naturopathic group in each trial.

AUTHORS' CONCLUSIONS

The evidence from these four randomised controlled trials, only one of which addresses the most relevant question of primary effectiveness, is insufficient to know whether ear drops are effective or not.

The emergency department as an asthma surveillance tool at the community level: a decline in the burden of pediatric asthma in halifax, Canada

We report pediatric emergency department (PED) asthma visit and inpatient asthma (AS) admission data in our area over a 5-year period. AS visits decreased by 33.9%, AS admissions by 24.6%, both significant compared with the decline in elementary school enrollment. The decrease in asthma visits was due to a decrease in the number of asthmatic patients, not a decline in repeat visits, or use of alternate venues of care. Explanations include a decrease in the burden of disease or an improvement in ambulatory care, but not alternate treatment venues or improvement in acute (PED) care. Readily available, emergency department data are useful in the community surveillance of asthma.

Changing morbidity patterns in children in Dutch general practice: 1987-2001

OBJECTIVES

To examine the presentation and pattern of childhood morbidity in general practice compared with 14 years ago.

METHODS

We used data of all children aged 0-17 years from two cross-sectional surveys performed in 1987 and 2001 in general practice in the Netherlands. The total number of children in the practices participating in these surveys were 86,577 children in 1987 and 82,053 children in 2001. First of all, we compared consultation rates of children in general practice. Secondly, childhood morbidity was assessed by episodes of disease, coded according to the International Classification of Primary Care (ICPC). We compared childhood morbidity in 1987 and 2001 by assessing the distribution of episodes among ICPC chapters stratified by ethnicity, and by comparing incidence rates of most frequently presented diseases.

RESULTS

Childhood consultation rates have decreased from 2.7 visits a year per child in 1987 to 2.1 in 2001. The distribution of episodes among ICPC chapters had also changed. Respiratory problems are still the most frequently presented health problem in children but the proportion has decreased from 25.5% in 1987 to 23.3% in 2001. Skin problems were presented more often (23.0% in 2001 versus 17.8 in 1987), and Western children more often presented with skin problems than with respiratory problems in 2001. Incidence rates of most respiratory diseases have decreased and specific skin diseases (dermatomycosis, impetigo and eczema) were diagnosed more often.

CONCLUSION

In the Netherlands, childhood morbidity has changed. Skin diseases have become more important in general practice and respiratory problems are declining.

Reduction in outpatient antibiotic sales for pre-school children: interrupted time series analysis of weekly antibiotic sales data in Sweden 1992–2002

OBJECTIVES

The aim of this study was to use detailed weekly data on outpatient antibiotic sales for pre-school children in Sweden to test for the significance of trends during 1992-2002. We also report on the special features found in weekly antibiotic data, and how the interrupted time series (ITS) design can adjust for this.

METHODS

Weekly data on the total number of dispensed outpatient antibiotic prescriptions to pre-school children were studied, as well as the individual subgroups commonly used to treat respiratory tract infections in children: narrow-spectrum penicillins, broad-spectrum penicillins and macrolides. In parallel, monthly data of paracetamol sales of paediatric dosages were analysed to reflect trends in symptomatic treatment. An ITS model controlling for seasonality and autocorrelation was used to examine the datasets for significant level and trend shifts.

RESULTS

A significant increase in mean and change in level could be found in the total antibiotic data in 1997, also reflected in broad-spectrum penicillin data where a similar trend break occurred in 1996. For macrolides, a trend break with a decrease in mean was noted in 1996, but no trend breaks were found in narrow-spectrum penicillin data. In contrast to the general decreasing trends in antibiotic sales, the yearly over-the-counter sales of paracetamol in paediatric preparations increased during the same period, with no identified trend breaks.

CONCLUSIONS

The overall decrease in antibiotic sales and increase in paediatric paracetamol sales might suggest that symptomatic treatment in the home has increased, as antibiotics are less commonly prescribed.

The burden of asthma in children: an Australian perspective

The burden of asthma among children is high in Australia compared with many other countries. Recent data show that 14-16% of children report a diagnosis of asthma that remains a problem. Boys, children under the age of 5 years and urban indigenous children experience a greater burden of asthma than other children. More than one-third of children with asthma have sleep disturbance due to the illness and 60% have missed school and/or experienced other restrictions in their activities due to the disease. Despite this, there is continuing evidence of under-utilisation of effective treatment for the disease. Asthma is a major cause of healthcare utilisation among children. Since the early 1990s, there has been a decline in both hospitalisation rates and general practitioner consultation rates for asthma among children. It remains to be seen whether this favourable trend will continue and extend into the adult age range.