Paul L. P. Brand

Poor inhalation technique, even after inhalation instructions, in children with asthma

The aim of this study was to evaluate the effect of instructions to children with asthma (given by general practitioners or by pharmacy assistants) on how to inhale from metered dose inhalers with spacers (MDI/s) or dry powder inhalers (DPI). We scored inhalation technique of asthmatic children according to criteria defined by the Netherlands Asthma Foundation, and related the performance to the inhalation instructions given. For each inhaler, a number of steps were considered essential for reliable drug delivery. Patients newly referred for asthma were asked to demonstrate their inhalation technique and to fill out a questionnaire on the inhalation instruction received prior to referral. Children participating in a clinical trial, who had received repeated comprehensive inhalation instructions, served as a control group.

Peak flow diaries in childhood asthma are unreliable

BACKGROUND A study was undertaken to investigate the compliance with and accuracy of peak flow diaries in childhood asthma. METHODS Forty asthmatic children (5–16 years) were asked to perform peak flow measurements twice daily for 4 weeks by means of an electronic peak flow meter and to record values in a written diary. Patients and parents were unaware that the device stored the peak flow values on a microchip. In random order, half of the patients were only told that the device allowed for more accurate assessment of peak flow while the other half were told that accurate recording of peak flow was important because the results would be used in guiding adjustments to treatment. Data in the written diary (reported data) were compared with those from the electronic diary (actual data). RESULTS In the entire study population the mean (SD) actual compliance (77.1 (20.5)%) was much lower than the mean reported compliance (95.7 (9.1)%) (95% CI for difference 12.7% to 24.4%) The percentage of correct peak flow entries decreased from 56% to <50% from the first to the last study week (p<0.04), mainly as a result of an increase in self-invented peak flow entries. Results were comparable for both groups. For incorrect peak flow entries the mean difference between written and electronically recorded entries ranged from –72 to 34 l/min per patient. CONCLUSIONS Peak flow diaries kept by asthmatic children are unreliable. Electronic peak flow meters should be used if peak flow monitoring is required in children with asthma.

Allergic rhinitis is associated with poor asthma control in children with asthma

Background Asthma and allergic rhinitis are the two most common chronic disorders in childhood and adolescence. To date, no study has examined the impact of comorbid allergic rhinitis on asthma control in children. Objective To examine the prevalence of allergic rhinitis in children with asthma, and the impact of the disease and its treatment on asthma control. Methods A cross-sectional survey in 203 children with asthma (5–18 years) using validated questionnaires on rhinitis symptoms (stuffy or runny nose outside a cold) and its treatment, and the paediatric Asthma Control Questionnaire (ACQ). Fraction of nitric oxide in exhaled air (FeNO) was measured with a Niox Mino analyser; total and specific IgE levels were assessed by the Immunocap system. Results 157 children (76.2%) had symptoms of allergic rhinitis but only 88 of these (56.1%) had been diagnosed with the condition by a physician. ACQ scores were worse in children with allergic rhinitis than in those without the condition (p=0.012). An ACQ score ≥1.0 (incomplete asthma control) was significantly more likely in children with allergic rhinitis than in those without (OR 2.74, 95% CI 1.28 to 5.91, p=0.0081), also after adjustment for FeNO levels and total serum IgE. After adjustment for nasal corticosteroid therapy, allergic rhinitis was no longer associated with incomplete asthma control (OR 0.72, 95% CI 0.47 to 1.12, p=0.150). Conclusion Allergic rhinitis is common in children with asthma, and has a major impact on asthma control. The authors hypothesise that recognition and treatment of this condition with nasal corticosteroids may improve asthma control in children, but randomised clinical trials are needed to test this hypothesis.

Determinants of correct inhalation technique in children attending a hospital-based asthma clinic.

Many children with asthma use their inhaler device incorrectly even after comprehensive inhalation instruction. The aim of this study was to identify factors associated with correct inhalation technique. Two hundred children with asthma demonstrated their inhalation technique. Patient characteristics and the components of inhalation instructions they had received were compared for children demonstrating a correct or incorrect inhalation technique. In addition, the inhalation technique of 47 newly referred patients was followed‐up prospectively after repeated comprehensive instruction sessions. Seventy‐eight percent of all patients demonstrated a correct inhalation technique. Patients who had received repeated instruction sessions and patients who had previously been asked to demonstrate the use of their inhaler during an instruction session were more likely than other children to demonstrate a correct inhalation technique (p < 0.001 and p= 0.03, respectively). Multiple logistic regression analysis showed that repetition of instructions was significantly associated with a correct inhalation technique (odds ratio (OR) 8.2, 95% CI 3.2–21.5; p < 0.0001) irrespective of type of inhaler used. Demonstration of the inhaler use by the patient was significantly associated with a correct inhalation technique for patients using a metered dose inhaler plus spacer device (OR 3.5,95% CI 1.0–12.6; p= 0.05), but not for patients using a dry powder inhaler (OR 1.6,95% CI 0.4‐6.4; p= 0.54). The number of newly referred patients demonstrating a correct inhalation technique improved from 57.4% to 97.9% after three comprehensive instruction sessions.

International prevalence of recurrent wheezing during the first year of life: variability, treatment patterns and use of health resources

Background Recurrent wheezing (RW) during the first year of life is a major cause of respiratory morbidity worldwide, yet there are no studies on its prevalence at an international level. A study was undertaken to determine the prevalence of RW in infants during their first year of life in affluent and non-affluent localities. Methods This international population-based study was performed in random samples of infants aged 12–15 months from 17 centres in Latin America and Europe. It uses a validated questionnaire answered by parents at the primary care health clinics where infants attend for growth/development monitoring and/or vaccine administration. Results Among the 30 093 infants surveyed, 45.2% (95% CI 44.7% to 45.8%) had at least one episode of wheezing and 20.3% (95% CI 19.8% to 20.7%) had RW. The mean prevalence of RW in Latin American and European centres was 21.4% (95% CI 20.9% to 21.9%) and 15.0% (95% CI 14.0% to 15.9%), respectively (p<0.001). There was significant morbidity associated with RW in terms of severe episodes (59.4%), visits to the emergency department (71.1%) and hospital admissions (26.8%); 46.1% used inhaled corticosteroids. Conclusions The prevalence of RW in infants during the first year of life is high and varies between localities. A significant proportion of infants progress to a more severe condition which results in high use of health resources (visits to emergency department and hospitalisations). The prevalence of RW is lower and less severe in European than in Latin American centres, suggesting there is a higher risk for the disease in developing areas.

Sensitization patterns to food and inhalant allergens in childhood: A comparison of non-sensitized, monosensitized, and polysensitized children

To cite this article: Baatenburg de Jong A, Dikkeschei LD, Brand PLP. Sensitization patterns to food and inhalant allergens in childhood: A comparison of non‐sensitized, monosensitized, and polysensitized children. Pediatr Allergy Immunol 2011; 22: 166–171.

Classification and pharmacological treatment of preschool wheezing: changes since 2008

Since the publication of the European Respiratory Society Task Force report in 2008, significant new evidence has become available on the classification and management of preschool wheezing disorders. In this report, an international consensus group reviews this new evidence and proposes some modifications to the recommendations made in 2008. Specifically, the consensus group acknowledges that wheeze patterns in young children vary over time and with treatment, rendering the distinction between episodic viral wheeze and multiple-trigger wheeze unclear in many patients. Inhaled corticosteroids remain first-line treatment for multiple-trigger wheeze, but may also be considered in patients with episodic viral wheeze with frequent or severe episodes, or when the clinician suspects that interval symptoms are being under reported. Any controller therapy should be viewed as a treatment trial, with scheduled close follow-up to monitor treatment effect. The group recommends discontinuing treatment if there is no benefit and taking favourable natural history into account when making decisions about long-term therapy. Oral corticosteroids are not indicated in mild-to-moderate acute wheeze episodes and should be reserved for severe exacerbations in hospitalised patients. Future research should focus on better clinical and genetic markers, as well as biomarkers, of disease severity. The distinction between episodic viral and multiple-trigger wheeze is unclear in many preschool children http://ow.ly/sKYZF

Differences in management of bronchiolitis between hospitals in The Netherlands

Abstract To study the variation in management of acute bronchiolitis in the Netherlands, a questionnaire on the use of diagnostic and therapeutic procedures and prescription of drugs after discharge was mailed to all 110 hospital-based paediatric practices in the Netherlands. A 100% response rate was achieved. There was a great deal of variation in management of bronchiolitis between respondents. The most commonly applied diagnostic procedures were immunofluorescence staining of nasopharyngeal secretions for respiratory syncytial virus (100% of respondents), blood gas analysis (93%), leucocyte count/differentiation and serum C-reactive protein levels (92%), and chest X-rays (83%). Most respondents used supplemental oxygen (100%) and tube feeding (96%) when needed, and gave nebulized bronchodilators, either as a trial (59%) or in a fixed schedule (33%). Antibiotics for suspected bacterial co-infection were used by 69% of respondents. Corticosteroids were used for severe cases by 35% of respondents; ribavirin was only used in 11% of hospitals for treatment of children from high-risk groups. When children had responded favourably to bronchodilators during admission, these drugs were continued after discharge by 69% of respondents; more than half of these also prescribed inhaled corticosteroids to these children. Conclusion Considerable variation in management of bronchiolitis exists between hospitals in the Netherlands. Several diagnostic and therapeutic approaches are used which are not evidence based, probably reflecting the lack of therapeutic options with proven clinical efficacy for this condition.

High inhaled corticosteroids adherence in childhood asthma : the role of medication beliefs

Our aim was to study determinants of adherence in young asthmatic children over a 3-month period, including the role of parental illness and medication perceptions as determinants of adherence. Consecutive 2–6-yr-old children with asthma, using inhaled corticosteroids (ICS), followed-up at our paediatric asthma clinic (where patients are being extensively trained in self-management, and are followed-up closely) were enrolled. Adherence was measured electronically using a Smartinhaler® and calculated as a percentage of the prescribed dose. We examined the association of adherence to a range of putative determinants, including clinical characteristics and parental perceptions about illness and medication. Median (interquartile range) adherence, measured over 3 months in 93 children, was 92 (76–97)%, and most children had well controlled asthma. 94% of parents expressed the view that giving ICS to their child would protect him/her from becoming worse. Adherence was significantly associated with asthma control and with parental perceptions about medication. The high adherence rate observed in our study was associated with parental perceptions about ICS need. The high perceived need of ICS may probably be ascribed to the organisation of asthma care (with repeated tailored education and close follow-up).

Disseminating educational innovations in health care practice: Training versus social networks

Improvements and innovation in health service organization and delivery have become more and more important due to the gap between knowledge and practice, rising costs, medical errors, and the organization of health care systems. Since training and education is widely used to convey and distribute innovative initiatives, we examined the effect that following an intensive Teach-the-Teacher training had on the dissemination of a new structured competency-based feedback technique of assessing clinical competencies among medical specialists in the Netherlands. We compared this with the effect of the structure of the social network of medical specialists, specifically the network tie strength (strong ties versus weak ties). We measured dissemination of the feedback technique by using a questionnaire filled in by Obstetrics & Gynecology and Pediatrics residents (n=63). Data on network tie strength was gathered with a structured questionnaire given to medical specialists (n=81). Social network analysis was used to compose the required network coefficients. We found a strong effect for network tie strength and no effect for the Teach-the-Teacher training course on the dissemination of the new structured feedback technique. This paper shows the potential that social networks have for disseminating innovations in health service delivery and organization. Further research is needed into the role and structure of social networks on the diffusion of innovations between departments and the various types of innovations involved.