Short-term effects of coping skills training in school-age children with type 1 diabetes

Objective:  Little is known about the use of psychosocial interventions in children younger than adolescence with type 1 diabetes (T1D) and their parents. We report preliminary short-term outcomes of a randomized controlled trial of coping skills training (CST) compared with group education (GE) in school-aged children with T1D and their parents.
Methods:  One hundred and eleven children (range = 8–12 yr) with T1D for at least 6 months (3.71 ± 2.91 yr) were randomized to CST (55.6% female (F); 81.5% white (W)) or GE (69.7% F; 90.9% W). Children and parents (n = 87) who completed the intervention, baseline, 1- and 3-month data are included. Children completed measures of self-efficacy, coping, and quality of life; parents completed measures of family functioning (adaptability and cohesion), diabetes-related conflict, parent depression, and parent coping. Metabolic control was assessed with glycosylated hemoglobin A1c. Mixed-model repeated measures anova was used to analyze the data.
Results:  CST and GE group composition was generally comparable. Children had good psychosocial adaptation and metabolic status. CST parents reported significantly more improvement in family adaptability compared with GE parents, and a trend was seen indicating that CST children showed greater improvement in life satisfaction than GE children. Effect sizes for this short-term follow-up period were small, but group participants were receptive to the intervention and reported positive gains.
Conclusions:  In these preliminary results, CST and GE were more similar than different across multiple measure of psychosocial adaptation, although CST showed promising statistical trends for more adaptive family functioning and greater life satisfaction. Longer term follow-up is underway.     

Management of childhood asthma in Western Australia

Aims:   The study aimed to determine how childhood asthma is managed in Western Australia by general practitioners (GPs) and specialist paediatricians.
Methods:   A questionnaire survey was sent to 992 GPs and specialist paediatricians, asking about practice and preferences regarding maintenance management of childhood asthma and treatment of acute asthma. Questions about asthma in infants, pre-school and school-aged children were asked separately.
Results:   The overall response rate was 24.7%, with 188/878 (21.4%) of GPs and 44/62 (71.0%) of paediatricians returning the questionnaire. The decision to start maintenance therapy was generally based on symptom frequency and severity. The first choice for maintenance treatment in all age groups was inhaled corticosteroids (ICS). The second most common treatment varied according to age group, with short-acting β₂-agonist (SBA) preferred for infants, montelukast or short-acting β₂-agonist for pre-schoolers and combination therapy (ICS + long action β₂-agonist) for school-aged children. Objective monitoring of lung function with peak flow or spirometry, was used by 40% of GPs and 59% of paediatricians. Acute asthma was primarily managed with inhaled salbutamol and oral corticosteroids. There were few differences in treatment choice between GPs and paediatricians. Many GPs indicated that they did not treat asthma in infants without specialist consultation.
Conclusions:   These data show good compliance by the minority of GPs responding to the survey and by paediatricians practising in Western Australia with current Australian asthma management guidelines. Major differences in treatment preferences between the groups were not detected.     

达良好控制哮喘患儿停用低剂量吸入性糖皮质激素的临床随访研究

目的 通过随访达良好控制哮喘患儿停用低剂量吸入性糖皮质激素（ICS）后哮喘急性发作情况,以及实验室指标的动态变化,以期为哮喘患儿的长期控制最佳方案提供依据。方法 根据家长意愿,将63例达到良好控制的哮喘患儿分为ICS治疗组（n=35）和停药组（n=28）,进行18个月随访,每3个月进行评估,观察哮喘急性发作情况,并动态监测两组患儿肺功能和呼出气一氧化氮（FeNO）浓度,以及儿童哮喘控制测试（C-ACT）评分等指标进行分析。结果 随访第3、6、9、12个月时,FeNO在两组间比较差异无统计学意义（P > 0.05）;但在随访第15、18个月时,停药组FeNO显著高于治疗组（P < 0.05）。6次随访时点内C-ACT在两组间比较差异无统计学意义（P > 0.05）。随访第3、6、9、12个月时,第1秒用力呼气容积占预计值的百分比（FEV1%）、第1秒用力呼气量占用力肺活量比值（FEV1/FVC%）、最大呼气中期流速占预计值百分比（MMEF%）、最大呼气50%肺活量的瞬间流速（MEF50%）等指标在两组间比较差异无统计学意义（P > 0.05）;但在随访第15、18个月时,治疗组MMEF%、MEF50%显著高于停药组（P < 0.05）。治疗组随访期间有3例（9%）患儿哮喘发作,停药组有8例（29%）患儿哮喘发作,停药组哮喘复发率高于治疗组（P=0.0495）。结论 持续吸入低剂量ICS可维持哮喘患儿肺功能稳定,减少哮喘发作。     

The effects of birthweight and breastfeeding on asthma among children aged 1–5 years

Aim:   Asthma is a major cause of morbidity and mortality among children and has steadily increased in prevalence. The combined effect of birthweight and breastfeeding on childhood asthma remains unclear.
Methods:   In this study, we analysed a nationally representative sample of children aged 1–5 years from the National Health and Nutrition Examination Survey 1999–2002. Logistic regression was performed to examine the hypothesis whether birthweight and breastfeeding are independently associated with the prevalence of asthma after accounting for the complex sampling design. In addition, we sought to describe the relationship between birthweight and childhood asthma and to assess the potentially combined effect between birthweight and breastfeeding on asthma among children aged 1–5 years after considering the possible effects of social and environmental factors.
Results:   We found that birthweight (measured continuously) was inversely and linearly associated with the prevalence of childhood asthma (odds ratio (OR) = 0.80 per 1 kg increase in birthweight, 95% confidence interval (CI): 0.65–0.98). Using a categorical variable, low birthweight (LBW) was positively associated with childhood asthma (OR = 1.28, 95% CI: 0.81–2.68). Furthermore, we detected an interaction between birthweight and breastfeeding on childhood asthma. Breastfeeding had a strong protective effect on asthma among children with high birthweight (OR = 0.14, 95% CI: 0.04–0.43) while it had no significant effect on asthma among children with normal birthweight or LBW.
Conclusions:   The mechanisms underlying these relationships remain uncertain and warrant further explanation.     

Repeatability of the low-dose ACTH test in asthmatic children on inhaled corticosteroids

Aim:  To assess the repeatability of low-dose Synacthen test (LDST) in asthmatic children receiving high-dose fluticasone propionate (FP).
Methods:  Low-dose Synacthen test was performed on 18 children with stable chronic asthma treated with FP at a constant daily dose of ≥500 μg and repeated 1 month later. Repeatability was assessed using the Kappa statistic for categorical variables.
Results:  Fifteen patients had consistent results (either two normal or two abnormal responses) and three patients had inconsistent results (one normal and one abnormal response). The Kappa statistic was 0.56 indicating fair to good agreement between the tests.
Conclusion:  The results of adrenal function testing in patients on inhaled steroids can have major implications for patient management, making it important to use a test with excellent repeatability. The LDST conducted using our protocol does not fulfil this criterion.     

Improving follow-up for children with asthma after an acute Emergency Department visit

OBJECTIVE: To improve follow-up with primary care providers after acute Emergency Department (ED) asthma visits for children from low-income urban families. STUDY DESIGN: A prospective, randomized, controlled trial evaluated combined telephone asthma coaching and monetary incentive. The primary outcome was asthma-planning visits with primary care providers within 15 days of index ED visits. The subjects were urban parents whose children were treated for asthma in the ED and had Medicaid or no insurance. RESULTS: We enrolled 527 parents (264 control and 263 intervention). There was a significant difference ( P < .0001) between the intervention (35.7%) and control (18.9%) groups in the proportion of children who had asthma-planning visits and decreased mean nights/days with asthma symptoms by 4.36 intervention and 3.31 control at 2 weeks. The proportions of children with asthma-planning visits and acute asthma care visits during the 16-day to 6-month period were similar for both groups. CONCLUSIONS: Telephone coaching and a monetary incentive significantly increased the proportion of low-income urban parents who brought their children for asthma-planning visits, and decreased asthma symptoms shortly after asthma ED visits. The intervention did not increase subsequent asthma-planning visits or decrease ED visits or hospitalizations.     

Prospective comparison of child asthma education in the emergency department and at scheduled follow-up consultation]

OBJECTIVES: To assess asthma control in asthmatic children attending the emergency department and to compare it with that for children with scheduled specialist follow-up. POPULATION AND METHODS: Between September 2002 and September 2003, we included asthmatic children aged 6 to 16 years, attending the emergency department (group U) or pulmonology follow-up appointments (group C) at Necker Hospital, Paris, France. We used the Asthma Therapy Assessment Questionnaire (ATAQ), completed by the parents and children aged 10 years and over. RESULTS: We interviewed 156 families and included 144 (92%) in the final analysis (77 in group U). The 2 groups did not differ in age, sex ratio, age at onset and asthma diagnosis and the frequency of asthma attacks. Children in group U received less daily maintenance treatment (P<0.01) but reported more severe asthma (P<0.05). They had also experienced fewer investigations for their asthma (fewer lung function tests P=0.01 and allergy tests P=0.001). The children in group C had better controlled asthma, as assessed by both the children themselves and their parents. They also had fewer problems relating to the behavior, communication and treatment control domains. The assessment of children and parents were similar in all areas except communication. The children considered their communication problems to be more serious than their parents did. Age-related differences were observed, with older children's parents having more difficulties in all domains investigated. CONCLUSION: Clinicians should consider assessing asthma control in children attending the emergency department. There is clearly an opportunity to improve the quality of asthma education for these children. Clinicians could provide children with a written plan of action for asthma attacks and information about daily self-management. Improving communication between children, their parents and doctors should be considered a key educational project.     

Asthma and protracted bronchitis: Who fares better during an acute respiratory infection?

Aim:   Acute respiratory infections (ARI) are common in children, and symptoms range from days to weeks. The aim of this study was to determine if children with asthma have more severe ARI episodes compared with children with protracted bronchitis and controls.
Methods:   Parents prospectively scored their child's next ARI using the Canadian acute respiratory illness and flu scale (CARIFS) and a validated cough diary (on days 1–7, 10 and 14 of illness). Children were age- and season-matched.
Results:   On days 10 and 14 of illness, children with protracted bronchitis had significantly higher median CARIFS when compared with children with asthma and healthy controls. On day 14, the median CARIFS were: asthma = 4.1 (interquartile range (IQR) 4.0), protracted bronchitis = 19.6 (IQR 25.8) and controls = 4.1 (IQR 5.25). The median cough score was significantly different between groups on days 1, 7, 10 and 14 ( P  < 0.001). A significantly higher proportion of children with protracted bronchitis (63%) were still coughing at day 14 in comparison with children with asthma (24%) and healthy controls (26%).
Conclusion:   Children with protracted bronchitis had the most severe ARI symptoms and higher percentage of respiratory morbidity at day 14 in comparison with children with asthma and healthy controls.     

Group discussions with parents have long-term positive effects on the management of asthma with good cost-benefit

AIM: To investigate if an intervention with extra information and support in a group setting to parents of preschool children could improve adherence and clinical outcome. METHODS: This is a controlled, prospective study where the parents of 60 newly diagnosed preschool asthmatic children aged 3 mo-6 y were randomized to either a control group or to an intervention that consisted of four group sessions in close connection with the diagnosis. The basic education on asthma and the written treatment plan were the same in both groups. The outcome measures were questionnaires to the parents and classification of the children according to symptoms and medication. The adherence rate and the burden of asthma were calculated with the help of diaries and weighing of the MDIs used between 12 and 18 mo after inclusion. RESULTS: The follow-up rate was 85% after 18 mo. The parents' presence in the sessions was around 70%, with no gender difference. The parents' view on adherence issues improved significantly in the intervention group. In the control group, 30% had poor adherence compared to 8% in the intervention group (p=0.015). Both the parents and the paediatricians underestimated the number of children with poor adherence. The children in the intervention group had significantly fewer exacerbation days during the last 6 mo-2.1 compared to 3.9 d/child-although they had lower inhaled steroid doses after 18 mo. An economic calculation showed that the intervention was profitable. CONCLUSION: This intervention resulted in an improvement in the parents' view on adherence, in the measured adherence rates and in the clinical outcome.     

Internet survey of childhood asthma and use of inhaled therapy in the home in Japan

Background: The aim of the present study is to undertake a survey of childhood asthma and details of the use of inhaled therapy from mothers with asthmatic children ≤15 years old, using the Internet.
Methods: This study was done on a nationwide scale in Japan during the latter half of July 2001.
Results: Responses were obtained from 748 mothers. Four hundred and three children (53.9%) had been diagnosed with asthma when ≤2 years old and 263 children (35.2%) when 2–5 years old. Three hundred and ninety-seven children (53.1%) were in remission or had mild asthma, 295 children (39.4%) had moderate asthma, and 56 (7.5%) had severe asthma. Of 563 children who required some pharmacological treatment, 266 used inhaled therapy. One hundred and forty-four children used metered-dose inhaler (MDI), 136 used powered nebulizer, and 34 used dry powder inhaler (DPI). Of children treated with inhaled sodium cromoglycate, 63 used MDI, 129 used nebulizer solution and 23 used DPI. Of children treated with inhaled corticosteroids, 43 used MDI and six used DPI. Of children using powered nebulizer, 48 were well satisfied and 76 were slightly satisfied. More than 90% of mothers commented that this form of treatment improved the quality of life both of the asthmatic children and of the family.
Conclusion: Internet survey of childhood asthma is effective, and powered nebulizer therapy may be encouraged more acceptable by infants and young children in the treatment of asthma.     

Pre-school teachers' knowledge, attitudes and practices on childhood developmental and behavioural disorders in Singapore

Aim:   Demands for diagnostic and intervention services in childhood developmental and behavioural disorders (CDABD) have increased in Singapore. With earlier enrolment of some 50 000 children in pre-schools, early childhood educators must be well-versed in normal development (ND) and CDABD, to help detect children with potential difficulties and refer for early diagnosis and intervention.
Methods:   Knowledge, attitudes and practices in ND and CDABD were evaluated among 503 pre-school teachers, most aged 30–44 years. With a median pre-school experience of 6.0 (0.1, 40) years, most had received formal training in early childhood but not special-needs (SN) education.
Results:   A pass rate in knowledge (≥50% total-score) was achieved in 56%, with the overall median total-score of 50 (0, 87)%. In specific blocks on ND, autistic spectrum disorder and attention deficit/hyperactive disorder, pass-rate was achieved in 66%, 68% and 32%, with median block-scores of 56 (0, 100)%, 50 (0, 100)%, 40 (0, 100)% respectively. Results on attitudes and perceptions revealed that most supported mainstream integration and aides in the classroom, agreeing that both the government and parents should pay for such support services. While most felt unequipped, further training interested them, with >90% wanting to and feeling that they could make a difference for these children.
Conclusion:   This study demonstrated educational deficits in CDABD among our pre-school teachers. Yet, most care and want to improve their skills to aid integration and improve SN education, calling for more training and resource support. Necessary changes in policy and resource allocation should occur to allow better-integrated adults of tomorrow.     

Use of over-the-counter medicines for young children in Australia

Aim:   To describe over-the-counter (OTC) medicine use by Australian parents for children aged birth to 24 months; types of medicines used and indications for use.
Methods:   A cross-sectional survey of parents was conducted using a self-administered over-the-counter medicine use questionnaire. A total of 640 questionnaires were distributed to parents of children who attended a hospital outpatient clinic, maternal and child health centre, or a childcare service in Melbourne, Australia.
Results:   A total of 325 questionnaires were completed (50.1%). Of these, 98.2% of parents had reportedly purchased at least one OTC medicine for their child in the previous 12 months. The most commonly purchased medicines were: paracetamol (acetaminophen) (95.9%), choline salicylate (47.3%), ibuprofen (36.4%), and cough and cold products (46.7%). Paracetamol was commonly used for a high temperature (82.4%) and non-specific pain (62.3%). Over 40% of parents had used cough and cold products to treat cold and flu symptoms. Nineteen (6.1%) parents had used OTC medicines to induce sleep or settle their child.
Conclusions:   Most parents had used at least one OTC medicine to manage childhood symptoms. Of concern is that over 40% of parents had used cough and cold products for their young child, despite a lack of evidence surrounding their efficacy. In order to minimise risks associated with OTC medicine use, particularly cough and cold products, health-care providers need to continue the provision of current evidence-based information to parents regarding safe and appropriate use of medicines for their child.     

Cost-effectiveness of routine and group programs for treatment of obese children

Background:  Cost-effectiveness analyses facilitate the allocation of health care resources. The aim of the study was to compare the cost-effectiveness of group treatment, already known to be more effective, with routine counseling in obese children.
Method:  A prospective 6-month intervention assessed family-based group treatment (15 separate sessions for parents and children) and routine counseling (two appointments for children). Children's weights and heights were measured at baseline, at the end of the intervention and at follow up 6 months later, and the changes in weight for height and body mass index standard deviations scores (BMI-SDS) were calculated and used as main outcome measures. The mean costs and effects of the programs were analyzed to produce the incremental cost-effectiveness ratio, which is an estimate of the additional costs per 1% decrease in weight for height or 0.1 decrease in BMI-SDS. Cost-effectiveness analysis was performed from the perspective of the service provider.
Results:  At the end of the intervention, group treatment costs were 1.4-fold (non-calculable 6 months later) when counted per 1% weight for height decrease, and 3.5-fold (2.8-fold 6 months later) when counted per 0.1 BMI-SDS decrease. Incremental cost-effectiveness ratio estimates were €53 when calculated for 1% weight for height decrease, and €266 (€275 6 months later) when calculated for 0.1 BMI-SDS decrease.
Conclusions:  Family-based group treatment is more costly compared with individual routine counseling. Salaries form most of the total costs.     

Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature

Objectives:   To examine withdrawal and limitation of life-sustaining treatment (WLST) in an Australian paediatric intensive care unit (PICU) and to compare this experience with published data from other countries.
Design:   Retrospective chart review and literature review.
Source of Data:   Review of 12 months of patient records from a tertiary Australian children's teaching hospital. Medline search using relevant key words focusing on death and PICU.
Results:   Twenty of 27 deaths (74%) followed either WLST ( n  = 16) or Do Not Resuscitate (DNR) orders ( n  = 4); five children failed cardiopulmonary resuscitation (CPR); and two children were brain-dead. Meetings between the medical team and family were documented for 15 of 16 children (93.8%) before treatment was withdrawn. The average time between withdrawal of life support and death was 13 min. A review of the English-language literature revealed that 18–65% occurring in PICUs worldwide follow WLST and/or institution of DNR orders. Rates were higher (30–65%) in North America and Europe than elsewhere. Most PICU deaths occurred within 3 days of admission. North American and British parents appear to be involved in decisions regarding withdrawal and limitation of treatment more often than parents in other countries.
Conclusions:   Withdrawal and limitation of life-sustaining treatment was more common in an Australian children's hospital ICU than has been reported from other countries. Details of discussion with parents, including the basis for any decision to WLST, were almost always documented in the patient's medical record.     

Randomized controlled trial of asthma education after discharge from an emergency department

OBJECTIVES: To test the hypothesis that reinforcement of the advice given at the time of discharge from the emergency department by telephone consultation would improve asthma outcomes. METHODS: A randomized controlled trial of the parents of 310 children who had been discharged from the emergency department with asthma was undertaken. The parents were randomized to receive either standard care (155 children) or standard care plus education by telephone (155 children) from a trained asthma educator. Symptoms, parental asthma knowledge, parental quality of life and use of asthma action plans and preventer therapy were collected at baseline and 6 months later. The primary measure was days of wheeze in last 3 months; intermediate measures were regular use of preventer medications, possession and use of written asthma action plan, parental asthma knowledge scores and parental quality of life scores. RESULTS: A total of 266 parents (136 intervention) completed the follow-up questionnaires after 6 months. Both groups showed similar symptoms and process measures at baseline, apart from more regular use of preventer medication in the control children. At follow up, the intervention group children were significantly more likely than controls to possess (87.5% vs 72.3%; P = 0.002) a written asthma action plan. Possession of action plans increased from baseline in the intervention group but tended to decrease in the control group. Use of action plans was greater in the intervention group but decreased from baseline in both groups. Both intervention and control groups showed significant decreases in asthma symptoms. CONCLUSIONS: Reinforcement by telephone consultation did not improve the primary outcome of wheeze in the last 3 months. However, it increased the possession and regular use of written asthma action plans in the intervention group.     

Childhood asthma complicated by anxiety: An application of cognitive behavioural therapy

Objective : To identify characteristics within the patient and the environment that might be instrumental in triggering and maintaining an episode of asthma in children whose objective lung function tests suggested a less severe exacerbation than the subjective report and behaviour indicated, and also to investigate the efficacy of a cognitive behavioural intervention, using the paradigm of a panic anxiety disorder.
Methodology : A retrospective investigation of 23 case records and psychosocial histories, focusing on the characteristics of the sample and the number of presentations and admissions before and after the intervention, which is described.
Results : Children aged 10-12 years predominated. A precipitating event triggered a fear that their condition had deteriorated in the context of a growing understanding that asthma in a child could be fatal. A reduction in presentations and admissions post-intervention is shown.
Conclusions : The paradigm of panic disorder is useful to understand the sudden onset of apparent deterioration in the severity of asthma when objective lung function tests do not support the subjective experience.     

Prevalence and predictors of immunization in a health insurance plan in a developing country

Background:  The aim of the present study was to describe rates and predictors of compliance with immunization schedule among children enrolled in the Health Insurance Plan of the American University of Beirut.
Methods:  Charts were reviewed for 774 children, and 154 parents underwent a randomly selected sample survey of demographic characteristics, parental behavior and attitudes, and health-care system variables.
Results:  The overall compliance rate was 49.9%. By age 4 years, 54.6% of children had taken the required vaccines on time. A total of 86% of parents whose children were non-compliant had recall bias. Age of the child (older), incorrect parental perception of immunization status, mother's low education, and use of other health-care facility, were associated with non-compliance.
Conclusions:  Health education about vaccines should be promoted, with an emphasis on high-risk groups. Recall systems and other tools to increase immunization coverage may have an effective role, but in developing countries, aspects such as wide availability of computers and addresses need to be secured before such implementation.     

A home respiratory support programme for children by parents and layperson carers

Aim:   To describe a respiratory support programme for children at home by parents and layperson carers.
Methods:   Analysis of records of children with long-term mechanical respiratory support at home.
Results:   From 1979 to 2008 the programme managed 168 children (median age 7 years, range 3 weeks–19 years) with obstructive sleep apnoea (55, 32%), neuromuscular conditions (42, 25%), tracheo-bronchomalacia (23, 14%), kyphoscoliosis-cerebral palsy (20, 12%), acquired central hypoventilation (8, 5%), congenital central hypoventilation (7, 4%), chronic lung disease or pulmonary hypoplasia (8, 5%), traumatic quadriplegia (3, 2%) and tumour-related quadriplegia (2, 1%). One hundred and sixty-one (96%) were discharged: 73 (46%) remain in the programme; 27 (16%) transferred to adult services, 25 (15%) recovered and 36 (23%) died. Principal modes of therapy were mask continuous positive airway pressure (CPAP) 35%, mask bilevel positive airway pressure 30%, tracheostomy CPAP 20%, tracheostomy mechanical ventilation 8%, phrenic nerve pacing 3%, negative pressure chamber ventilation 2% and nasal tube CPAP 2%. Two unexpected deaths occurred at home: one from accidental tracheostomy decannulation and another unrelated to respiratory support. Average time in the programme was 3.3 years. Parents of 69 children were provided with trained carers. Successful discharge resulted from early recognition of potential to discharge, parental training, recruitment and training of carers, purchase of equipment and secure funding. Seven children were not discharged, two of whom died in the hospital and five are subject to discharge planning.
Conclusion:   Respiratory support of children at home by trained parents and layperson carers is safe and efficient. All modes of respiratory support may be used.