e-Monitoring of Asthma Therapy to Improve Compliance in children (e-MATIC): a randomised controlled trial.

Real-time medication monitoring (RTMM) is a promising tool for improving adherence to inhaled corticosteroids (ICS), but has not been sufficiently tested in children with asthma. We aimed to study the effects of RTMM with short message service (SMS) reminders on adherence to ICS, asthma control, asthma-specific quality of life and asthma exacerbation rate; and to study the associated cost-effectiveness.In a multicentre, randomised controlled trial, children (aged 4-11 years) using ICS were recruited from five outpatient clinics and were given an RTMM device for 12 months. The intervention group also received tailored SMS reminders, sent only when a dose was at risk of omission. Outcome measures were adherence to ICS (RTMM data), asthma control (childhood asthma control test questionnaire), quality of life (paediatric asthma quality of life questionnaire) and asthma exacerbations. Costs were calculated from a healthcare and societal perspective.We included 209 children. Mean adherence was higher in the intervention group: 69.3% versus 57.3% (difference 12.0%, 95% CI 6.7%-17.7%). No differences were found for asthma control, quality of life or asthma exacerbations. Costs were higher in the intervention group, but this difference was not statistically significant.RTMM with tailored SMS reminders improved adherence to ICS, but not asthma control, quality of life or exacerbations in children using ICS for asthma.

Revealing the hidden agency of children in a clinical setting.

BACKGROUND: Interactions with children in clinical settings are often criticized because parents and medical professionals speak for children rather than to them. Such approaches do not take the agency of children into account. OBJECTIVE: First, to examine how children enact agency in a clinical encounter and draw lessons from this to improve health-care practices for children and, second, to explain how looking at agency might help to move the participation agenda forwards. DESIGN: A qualitative study incorporating a range of methods, including participant observation, interviews and focus group discussions. SETTING: Three hospitals in the Netherlands. PARTICIPANTS: Children with diabetes type 1, between 8 and 12 years (n = 30), parents (n = 22) and medical professionals (n = 16). RESULTS: Children do not simply accept the recurrent health education from medical professionals. Instead, they attribute their own personal meaning to their disease and treatment. Drawing from their years of experience with the disease and health care and the image of a passive and vulnerable child, they actively find ways to balance personal goals with medically defined goals. CONCLUSION: Efforts to facilitate child participation should be based on insights into the ways in which children enact agency in the clinical encounter. Our data show that children already participate in health care and that their enactment of agency is based on a practical logic. Understanding of children's current participation and agency is needed to more successfully attune their treatment to their daily lives with diabetes. This is crucial for the success of treatment and the well-being of children.

Vitamin D deficiency among native Dutch and first- and second-generation non-Western immigrants.

UNLABELLED: The aim of this study was to determine the prevalence of 25-hydroxyvitamin D (25(OH)D) deficiency in a hospital-based population of both native Dutch and non-Western immigrants and to investigate the influence of immigrant status on the prevalence of vitamin D deficiency. A cross-sectional survey was conducted among 132 patients (1-18 years of age) visiting the paediatric outpatient department. Serum levels of 25(OH)D were measured using high-performance liquid chromatography. Cut-off levels of 30 and 50 nmol/l for serum 25(OH)D were evaluated. One third of the patients had serum 25(OH)D levels below 30 nmol/l, and half of the study population had serum levels below 50 nmol/l. Non-Western immigrants had an increased risk for vitamin D deficiency compared to their native Dutch peers [25(OH)D of <30 nmol/l, p = 0.03, odds ratio (OR) 3.87 (95 % confidence interval (CI) 1.13-13.29); 25(OH)D of <50 nmol/l, p = 0.02, OR 3.57 (95 % CI 1.26-10.14)] with the highest risk for first-generation non-Western immigrants. CONCLUSION: Vitamin D deficiency in the paediatric population is still a matter of concern in the Netherlands, in particular among first-generation non-Western immigrants. We therefore strongly recommend vitamin D supplementation for all non-Western immigrants, regardless of age, skin type or season. Health-care staff who work with non-Western immigrants should be aware of the prevalence and implications of vitamin D deficiency.

The association of ethnicity with electronically measured adherence to inhaled corticosteroids in children.

PURPOSE: To investigate the association of ethnicity with objectively, electronically measured adherence to inhaled corticosteroids (ICS) in a multicultural population of children with asthma in the city of Amsterdam. METHODS: The study was designed as a prospective, observational multicenter study in which adherence to ICS and potential risk factors for adherence to ICS were measured in a cohort of Moroccan and native Dutch children with asthma. Electronic adherence measurements were performed for 3 months per patient using a Real Time Medication Monitoring (RTMM) system. Ethnicity and other potential risk factors, such as socio-economic status, asthma control and parental medication beliefs, were extracted from medical records or parent interviews. The association between adherence and ethnicity was analysed using multivariate linear regression analysis. RESULTS: A total of 90 children (aged 1-11 years) were included in the study and data of 87 children were used for analysis. Average adherence to ICS was 49.3 %. Native Dutch children showed higher adherence to ICS than Moroccan children (55.9 vs. 42.5 %, respectively; p = 0.044, univariate analysis). After correction for confounders (>3 annual visits to the paediatric outpatient clinic, regular use of a spacer during inhalation), the final regression model showed that ethnicity was independently associated with adherence (p = 0.028). CONCLUSIONS: In our Western European population of inner city children with asthma, poor adherence to ICS was a serious problem, and even somewhat more so in ethnic minorities. Paediatricians involved in asthma treatment should be aware of these cultural differences in medication-taking behaviour, but further studies are needed to elucidate the causal mechanism.

[Burns in children: child abuse or another cause?]. / Brandwonden bij kinderen: kindermishandeling of niet?

Burns are common in children but it is not always clear whether the burn is accidental or not. Child abuse should always be considered. We present two children in which the diagnosis only became clear after admission and further investigation. Patient A, a 15-month-old boy, had a burn on his left shoulder. The burn was assumed suspect in view of the unclear history given by the parents and a possible delay in their seeking help. The patient was ultimately diagnosed with impetigo bullosa and successfully treated with antibiotics. Patient B, a 24-month-old girl, had burns on both feet and her right hand, which were infected as a result of the delay in seeking help. The burns were identified as abuse-related. The child was removed from her mother's care and sent to a foster home. A well-defined work-up should be followed in case of burns in children.

Ethnic diversity outpatient clinic in paediatrics.

BACKGROUND: The health status of chronic sick ethnic minority children in the Netherlands is unequal compared with indigenous Dutch children. In order to optimize the health care for these children a specific patient-oriented clinic in ethnic-cultural diversity: the Mosaic Outpatient Clinic (MOC) was integrated in the general Paediatric Outpatient Departments (POPD) of three hospitals in Amsterdam. METHODS: Feasibility of the MOC, factors influencing the health care process and encountered bottlenecks in health care were studied in ethnic minority children with asthma, diabetes type 1 or metabolic disease originating from Morocco, Turkey and Surinam. Feasibility was determined by the number of patients attended, support from the paediatric medical staff and willingness of the patients to participate. Influences on the health care process comprised parents' level of knowledge of disease, sense of disease severity, level of effort, linguistic skills, health literacy, adherence to treatment and encountered bottlenecks in the health care process. Moreover, the number of admissions and visits to the POPD in the years before, during and after the MOC were analysed. RESULTS: In 2006 a total of 189 ethnic minority children were seen. Integration of the MOC within the general POPD of the hospital is feasible. The ability of the parents to speak and understand Dutch was found to be 58%, functional health literacy was 88%; sufficient knowledge of disease and sense of disease severity were 59% and 67%, respectively. The main bottlenecks in the healthcare process: poor knowledge of disease, limited sense of disease severity and low health literacy in the parents proved to be the best predictors for decreased adherence. After attending the MOC there was a decrease in the number of admissions and visits to the POPD for asthma while the number of visits increased in patients with diabetes and the amount of no-shows decreased in patients with a metabolic disease. CONCLUSION: Integration of a MOC in the general POPD is feasible and appreciated by the parents, provides more insight in the problems ethnic minority children and their parents face and shows promising directions for optimizing adherence in these children.

Antimicrobial susceptibility and serotypes of nasopharyngeal Streptococcus pneumoniae in children with pneumonia and in children attending day-care centres in Fortaleza, Brazil.

The susceptibility of nasopharyngeal Streptococcus pneumoniae to eight antibiotics was studied in 482 children under 5 years of age with community-acquired pneumonia and in 429 healthy pneumococci carriers in Fortaleza, Brazil. Serotyping of strains with pooled and type-specific antisera was also performed. Overall, S. pneumoniae was isolated from 499/911 (55%) children. The carriage rate in children attending day-care centres was higher (72%) than in children with pneumonia (50%) (P<0.001). MIC determination in 441 strains revealed 45% to be intermediate penicillin-resistant and 4% high penicillin-resistant strains. Resistance rates to co-trimoxazole and erythromycin were 42 and 23%, respectively. Serotyping of 211 penicillin-resistant and 58 randomly selected penicillin-susceptible isolates showed that 78% of the strains belonged to paediatric serogroups 6, 14, 19 and 23 (86% of the penicillin-resistant and 51% of the penicillin-susceptible strains, P=0.001). Resistance rates of S. pneumoniae to penicillin and co-trimoxazole in Fortaleza were higher than previously reported in Brazil and associated with paediatric serogroups 6, 14, 19 and 23.

S. pneumoniae isolados da nasofaringe de crianças sadias e com pneumonia: taxa de colonização e suscetibilidade aos antimicrobianos / Nasopharyngeal isolates of S. pneumoniae from healthy carriers and children with pneumonia: colonization rates and antimicrobial susceptibility

Objetivos: comparar as taxas de colonizaçäo e a resistência antimicrobiana de pneumococos em nasofaringe de crianças sadias e com pneumonia. Métodos: estudo de tipo transversal. As crianças sadias foram recrutadas em centros de vacinaçäo (CV) e creches públicas (CP), selecionados aleatoriamente, e aquelas com pneumonia em emergências pediátricas. Foram utilizados swabs flexíveis de alginato para a colheita do material de nasofaringe. O isolamento e a identificaçäo dos pneumococos seguiram procedimentos padronizados. As concentraçöes inibitórias mínimas (CIM) foram determinadas por microdiluiçäo em placas. Resultados: foram estudadas 911 crianças, 429 sadias (60 por cento portadoras de pneumococo, sendo 72 por cento destas recrutadas em CP e 49 por cento em CV) e 482 com pneumonia (50 por cento de portadoras) (p=0,002). De 441 isolados com CIM determinadas, 198 (45 por cento) apresentavam resistência intermediária, e 16 (4 por cento) apresentavam resistência plena à penicilina. As taxas de resistência dos pneumococos isolados de portadores sadios e com pneumonia, respectivamente, foram: penicilina 48 por cento (CV 37 por cento e CP 55 por cento) e 50 por cento (p>0,05); eritromicina: 28 por cento e 19 por cento (p=0,05); cotrimoxazol 81 por cento e 76 por cento (p>0,05); cloranfenicol 6 por cento e 7 por cento (p>0,05), rifampicina 5 por cento e 3 por cento (p>0,05), ceftriaxone 2 e 4 por cento (p>0,05) e vancomicina 0 por cento, para ambos grupos. Foi constatada associaçäo entre as resistências do pneumococo à penicilina, eritromicina e ao cotrimoxazol. Conclusöes: a taxa de portador de pneumococos foi maior em crianças sadias do que naquelas com pneumonia. As resistências dos pneumococos à penicilina e ao cotrimoxazol foram elevadas, sobretudo entre os usuários de creches públicas

[Nasopharyngeal isolates of S. pneumoniae from healthy carriers and children with pneumonia: colonization rates and antimicrobial susceptibility]. / S. pneumoniae isolados da nasofaringe de crianças sadias e com pneumonia: taxa de colonização e suscetibilidade aos antimicrobianos.

OBJECTIVES: To compare colonization rates and antimicrobial resistance of nasopharyngeal pneumococci in healthy carriers and children with pneumonia. METHODS: A cross-sectional study. Healthy subjects of this study were selected from randomly chosen immunization centers and day-care centers, and those with pneumonia were selected in pediatric emergency rooms. Flexible perinasal alginate swabs were employed to collect nasopharyngeal pneumococci specimens. Isolation and identification were performed according to standard procedures. Minimum Inhibitory Concentrations were assessed by microdilution techniques. RESULTS: We studied 911 children, 429 healthy controls (60% of carriers, 72% attending day care centers and 49% recruited in immunization centers) and 482 children with pneumonia (50% of carriers) (P=0.02). The Minimum Inhibitory Concentration of penicillin to 441 isolates detected 198 (45%) of intermediate and 16 (4%) fully resistant pneumococci. Antimicrobial resistance rates of isolates from healthy carriers and children with pneumonia were, respectively: penicillin 48% (37% for immunization centers and 55% for day-care centers) and 50% (P>0.05), erythromycin 28% and 19% (P=0.05); cotrimoxazole 81% and 76% (P>0.05), chloramphenicol 6% and 7% (P>0.05), rifampin 5 and 3% (P>0.05) ceftriaxone 2 and 4% (P>0.05) and vancomycin 0% in both groups. An association among pneumococcal resistance to penicillin, erythromycin and cotrimoxazole was detected. CONCLUSIONS: Pneumococcal carriage rate was higher in healthy children than in children with pneumonia. Penicillin and cotrimoxazole resistance rates were high, especially among those attending day-care centers.