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Gonzalez Garay AG, Reveiz L, Velasco Hidalgo L, Solis Galicia C. Ambroxol for women at risk of preterm birth for preventing neonatal respiratory distress syndrome. Cochrane Database Syst Rev 2014; 2014:CD009708. [PMID: 25361381 PMCID: PMC10542093 DOI: 10.1002/14651858.cd009708.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Respiratory distress syndrome (RDS) is caused by a deficiency of pulmonary surfactant (an active agent that keeps pulmonary alveoli open and facilitates the entry of air to the lungs, thus improving the oxygenation of the newborn).A number of interventions such as pulmonary surfactant and prenatal corticosteroids are used to prevent RDS. Ambroxol has been studied as a potential agent to prevent RDS, but effectiveness and safety has yet to be evaluated. OBJECTIVES To evaluate the efficacy and safety of giving ambroxol to pregnant women who are at risk of preterm birth, for preventing neonatal RDS. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 November 2013), CENTRAL (The Cochrane Library 2013, Issue 11),Embase (1988 to November 2013), MEDLINE (PubMed 1970 to November 2013), LILACS (1982 to November 2013), the WHO International Clinical Trials Registry Platform (ICTRP) (November 2013) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing the administration of ambroxol given to pregnant women at risk of preterm birth versus placebo, antenatal corticosteroids (betamethasone or dexamethasone), or no treatment.We did not identify any trials comparing ambroxol with dexamethasone (corticosteroid) in this review. Nor did we identify any trials comparing ambroxol combined with corticosteroid versus corticosteroid alone, or placebo/no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS We included 14 studies (in 18 trial reports), involving 1047 pregnant women at risk of preterm birth with 1077 newborns. However, three of the included studies did not report on this review's outcomes of interest. We carried out two main comparisons: ambroxol versus antenatal corticosteroids (betamethasone); and ambroxol versus placebo or no treatment. Seven RCTs provided data for our comparison of ambroxol versus corticosteroid (betamethasone) and two trials contributed data to our comparison of ambroxol compared to placebo or no treatment.The included studies were generally judged as having either 'low' risk of bias or 'unclear' risk of bias (because the trial reports provided insufficient details about methods of sequence generation, allocation concealment and blinding). Primary outcomesThere was no clear evidence of a difference in the incidence of RDS among newborns born to women who received ambroxol when compared to newborns of women who were given the corticosteroid, betamethasone (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.59 to 1.07, seven RCTs, 728 women/758 newborns, moderate quality evidence) or placebo/no treatment (average RR 0.74; 95% CI 0.46 to 1.20, two studies, 204 women/204 newborns,T2= 0.07; I(2)= 53%, low-quality evidence). Results were imprecise and consistent with appreciable benefit as well as negligible effect.Similarly, there was no clear evidence of a difference in the rates of perinatal mortality between the group of women who received ambroxol and women in the corticosteroid (betamethasone) group (RR 0.51, 95% CI 0.23 to 1.12, six studies, 648 women/657 newborns, moderate quality evidence) or the placebo/no treatment group (RR 0.61; 95% CI 0.19 to 1.98, one study, 116 women/116 newborns, low-quality evidence).In terms of maternal adverse effects, there was no clear differences (in nausea or vomiting) between those women who received ambroxol compared to either those women who received corticosteroids (betamethasone) (average RR 3.45; 95% CI 0.34 to 35.51, three studies, 305 women, T(2)= 2.82; I(2)= 67%, very low-quality evidence), or women who received placebo or no treatment (RR 1.79; 95% CI 0.45 to 7.13, one study, 116 women, low-quality evidence). No other adverse effects (e.g. diarrhoea, gastric irritation and headache) were reported in the included studies. Secondary outcomesFor the review's secondary outcomes, none of the included studies reported on the incidence of bronchopulmonary dysplasia, periventricular haemorrhage, necrotising enterocolitis or rate of maternal mortality.One small trial (involving 88 women) comparing ambroxol with placebo or no treatment, reported no difference between groups in terms of the need for mechanical ventilation in the neonate (RR 0.94; 95% CI 0.73 to 1.21, 88 women/88 babies, low-quality evidence) or the administration of pulmonary surfactant (RR 1.19; 95% CI 0.61 to 2.30, one RCT, 88 women/88 babies, low-quality evidence). AUTHORS' CONCLUSIONS This review is based on very low to moderate quality evidence from 14 small trials (many are published in the form of conference abstracts with minimal methodological details provided). There is insufficient evidence to support or refute the practice of giving ambroxol to women at risk of preterm birth for preventing neonatal RDS, perinatal mortality and adverse effects. More research is needed in order to fully evaluate the benefits and risks of this intervention.
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Affiliation(s)
- Alejandro G Gonzalez Garay
- Instituto Nacional de PediatriaMethodology Research Unit/NeonatologyInsurgentes Sur 3700 ‐ CCol. Insurgentes Cuicuilco, CoyoacanMexico CityDistrito FederalMexico04530
| | - Ludovic Reveiz
- Pan American Health OrganizationKnowledge Management, Bioethics and Research DepartmentWashingtonDCUSA
| | - Liliana Velasco Hidalgo
- Instituto Nacional de PediatriaPediatric OncologyInsurgentes Sur 3700‐CCol. Insurgentes Cuicuilco, CoyoacanMexico CityDistrito FederalMexico04530
| | - Cecilia Solis Galicia
- Instituto Nacional de Pediatria (Cochrane Mexico)Scientitic Information and DocumentationInsurgentes Sur 3700‐CMexico CityDistrito FederalMexico04530
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Alauzet F, Banide MC, Pailhes C, Blanc S, Montaudié I, Piccini-Bailly C, Berlioz-Baudoin M, Bégassat M, Albertini M, Giovannini-Chami L. [Acute cough in infants: impact of national guidelines on medical practices in a French department]. Arch Pediatr 2014; 21:461-8. [PMID: 24721414 DOI: 10.1016/j.arcped.2014.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 12/09/2013] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
Abstract
CONTEXT AND AIM Guidelines have been published regularly since 2010 by the ANSM (the Health Products Safety Agency) advising against antitussive drugs for infants because of their inefficacy and their side effects (convulsions, respiratory congestion). Antihistamines, mucolytics, and terpene-based suppositories have theoretically disappeared from infant pharmacopoeia. We assessed the degree of compliance with these guidelines on the part of health professionals. MATERIALS AND METHODS From June 2012 to August 2012, 198 general practitioners and 44 pediatricians were assessed in the Alpes-Maritimes department of France by means of questionnaires. At the same time, an analysis of medical prescriptions was sought from the Regional Directorate of Medical Services (RDMS) of the PACA-Corse region Health Insurance. RESULTS The rate of noncompliance with the contraindications was 14.9% (17.7% general practitioners and 2.3% pediatricians). The RDMS study showed a slight decrease in prescriptions for antitussives not recommended from 2011 to 2012: -21% for pediatricians, -15.5% for generalist physicians. CONCLUSION Continued educational and informative campaigns are therefore needed to stop medical prescriptions of cough medicines for infants, which should also involve parents.
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Affiliation(s)
- F Alauzet
- Médecine pédiatrique, pneumo-allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU Lenval, 57, avenue de la Californie, 06200 Nice, France.
| | - M-C Banide
- Direction régionale du service médical de PACA-Corse, 195, boulevard Chave, 13392 Marseille cedex 5, France
| | - C Pailhes
- Direction régionale du service médical de PACA-Corse, 195, boulevard Chave, 13392 Marseille cedex 5, France
| | - S Blanc
- Médecine pédiatrique, pneumo-allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU Lenval, 57, avenue de la Californie, 06200 Nice, France
| | - I Montaudié
- Urgences pédiatriques, pneumo-allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU Lenval, 57, avenue de la Californie, 06200 Nice, France
| | - C Piccini-Bailly
- Urgences pédiatriques, pneumo-allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU Lenval, 57, avenue de la Californie, 06200 Nice, France
| | - M Berlioz-Baudoin
- Médecine pédiatrique, pneumo-allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU Lenval, 57, avenue de la Californie, 06200 Nice, France
| | - M Bégassat
- Médecine pédiatrique, pneumo-allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU Lenval, 57, avenue de la Californie, 06200 Nice, France
| | - M Albertini
- Médecine pédiatrique, pneumo-allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU Lenval, 57, avenue de la Californie, 06200 Nice, France
| | - L Giovannini-Chami
- Médecine pédiatrique, pneumo-allergologie pédiatrique, hôpitaux pédiatriques de Nice, CHU Lenval, 57, avenue de la Californie, 06200 Nice, France
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Chalumeau M, Duijvestijn YCM. Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease. Cochrane Database Syst Rev 2013:CD003124. [PMID: 23728642 DOI: 10.1002/14651858.cd003124.pub4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acetylcysteine and carbocysteine are the most commonly prescribed mucolytic drugs in Brazil and many European and African countries. To our knowledge, no systematic review has been published on their efficacy and safety for acute upper and lower respiratory tract infections (RTIs) in children without chronic broncho-pulmonary disease. OBJECTIVES The objective was to assess the efficacy and safety and to establish a benefit-risk ratio of acetylcysteine and carbocysteine as symptomatic treatments for acute upper and lower RTIs in paediatric patients without chronic broncho-pulmonary disease. SEARCH METHODS We searched CENTRAL (2013, Issue 2), MEDLINE (1966 to February week 3, 2013), EMBASE (1980 to March 2013), Micromedex (2010), Pascal (1987 to 2004) and Science Citation Index (1974 to March 2013). SELECTION CRITERIA To study efficacy, we used randomised controlled trials (RCTs) comparing the use of acetylcysteine or carbocysteine versus placebo, either alone or as an add-on therapy. To study safety, we used trials comparing acetylcysteine or carbocysteine versus active treatment or no treatment and case reports. DATA COLLECTION AND ANALYSIS In this review update two review authors (YD, MC), with help from a colleague, extracted data and assessed trial quality. We performed a subgroup analysis of children younger than two years of age. MAIN RESULTS We included six trials involving 497 participants to study efficacy. They showed some benefit (e.g. reduction of cough at day seven) from mucolytic agents, although differences were of little clinical relevance. No conclusion was drawn about the subgroup of infants younger than two years because data were unavailable. Thirty-four studies, including the previous six trials involving 2064 children, were eligible to study safety. Overall safety was good but very few data were available to evaluate safety in infants younger than two years. However, 59 cases of paradoxically increased bronchorrhoea observed in infants were reported to the French pharmacovigilance system. AUTHORS' CONCLUSIONS The results have to be interpreted with caution because they are based on a limited number of participants included in studies whose methodological quality is questionable. Acetylcysteine and carbocysteine seem to have a limited efficacy and appear to be safe in children older than two years. These results should take into consideration the fact that acetylcysteine and carbocysteine are prescribed for self limiting diseases (for example, acute cough, bronchitis). Given strong concerns about safety, these drugs should only be used for acute upper and lower RTIs in the context of a RCT with regards to children younger than two years.
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Affiliation(s)
- Martin Chalumeau
- INSERM U953 and Department of Pediatrics, Necker Hospital, AP-HP and Paris Descartes University, Paris, France.
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Mallet P, Mourdi N, Dubus JC, Bavoux F, Boyer-Gervoise MJ, Jean-Pastor MJ, Chalumeau M. Respiratory paradoxical adverse drug reactions associated with acetylcysteine and carbocysteine systemic use in paediatric patients: a national survey. PLoS One 2011; 6:e22792. [PMID: 21818391 PMCID: PMC3144941 DOI: 10.1371/journal.pone.0022792] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 06/29/2011] [Indexed: 11/30/2022] Open
Abstract
Objective To report pediatric cases of paradoxical respiratory adverse drug reactions (ADRs) after exposure to oral mucolytic drugs (carbocysteine, acetylcysteine) that led to the withdrawal of licenses for these drugs for infants in France and then Italy. Design The study followed the recommendations of the European guidelines of pharmacovigilance for medicines used in the paediatric population. Setting Cases voluntarily reported by physicians from 1989 to 2008 were identified in the national French pharmacovigilance public database and in drug company databases. Patients The definition of paradoxical respiratory ADRs was based on the literature. Exposure to mucolytic drugs was arbitrarily defined as having received mucolytic drugs for at least 2 days (>200 mg) and at least until the day before the first signs of the suspected ADR. Results The non-exclusive paradoxical respiratory ADRs reported in 59 paediatric patients (median age 5 months, range 3 weeks to 34 months, 98% younger than 2 years old) were increased bronchorrhea or mucus vomiting (n = 27), worsening of respiratory distress during respiratory tract infection (n = 35), dyspnoea (n = 18), cough aggravation or prolongation (n = 11), and bronchospasm (n = 1). Fifty-one (86%) children required hospitalization or extended hospitalization because of the ADR; one patient died of pulmonary oedema after mucus vomiting. Conclusion Parents, physicians, pharmacists, and drug regulatory agencies should know that the benefit risk ratio of mucolytic drugs is at least null and most probably negative in infants according to available evidence.
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Affiliation(s)
- Pauline Mallet
- Department of pediatrics, Necker-Enfants Malades hospital, Université Paris Descartes, Assistance Publique – Hôpitaux de Paris, Paris, France
- Regional Pharmacovigilance Center and Department of Clinical Pharmacology, Cochin Saint Vincent de Paul Hospital, Université Paris Descartes, Assistance Publique – Hôpitaux de Paris, Paris, France
| | | | - Jean-Christophe Dubus
- Unité de Pneumologie et Médecine Infantile, CNRS URMITE 6236, CHU Timone-Enfants, Marseille, France
| | - Françoise Bavoux
- Regional Pharmacovigilance Center and Department of Clinical Pharmacology, Cochin Saint Vincent de Paul Hospital, Université Paris Descartes, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Marie-José Boyer-Gervoise
- Regional Pharmacovigilance Center, Salvator Hospital, Assistance Publique – Hôpitaux de Marseille, Marseille, France
| | - Marie-Josèphe Jean-Pastor
- Regional Pharmacovigilance Center, Salvator Hospital, Assistance Publique – Hôpitaux de Marseille, Marseille, France
| | - Martin Chalumeau
- Department of pediatrics, Necker-Enfants Malades hospital, Université Paris Descartes, Assistance Publique – Hôpitaux de Paris, Paris, France
- Inserm U953, Saint-Vincent-de-Paul hospital, Paris, France
- * E-mail:
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Chéron G, Patteau G, Nouyrigat V. Bronchiolite del lattante. EMC - URGENZE 2011. [PMCID: PMC7149004 DOI: 10.1016/s1286-9341(11)70664-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
La bronchiolite è un’infezione virale stagionale delle vie respiratorie basse del lattante. Il suo agente causale principale è il virus respiratorio sinciziale. La comparsa di un distress respiratorio è legata all’intensità della risposta infiammatoria delle vie aeree. Benché si tratti di una malattia frequente, le cause della suscettibilità dei lattanti a questa infezione non sono conosciute. La diagnosi è clinica. Il trattamento è sintomatico in assenza di misure specifiche. I rapporti a medio e a lungo termine di un primo episodio di bronchiolite con le recidive e con l’asma non sono spiegati. Essi potrebbero dipendere dalla natura del virus in causa al momento del primo episodio e da fattori genetici individuali.
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Duijvestijn YCM, Mourdi N, Smucny J, Pons G, Chalumeau M. Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease. Cochrane Database Syst Rev 2009:CD003124. [PMID: 19160217 DOI: 10.1002/14651858.cd003124.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acetylcysteine and carbocysteine are the most commonly prescribed mucolytic drugs in many European countries. To our knowledge, no systematic review has been published on their efficacy and safety for acute upper and lower respiratory tract infections (ARTIs) in children without chronic broncho-pulmonary disease. OBJECTIVES The objective was to assess the efficacy and safety and to establish a benefit-risk ratio of acetylcysteine and carbocysteine as symptomatic treatments for ARTIs in children without chronic broncho-pulmonary disease. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 4) which contains the Acute Respiratory Infections (ARI) Group's Specialized Register, MEDLINE (1966 to 2008), EMBASE (1980 to 2008); Micromedex (2008), Pascal (1987 to 2004), and Science Citation Index (1974 to 2008). SELECTION CRITERIA To study efficacy, we used randomised controlled trials (RCTs) comparing the use of acetylcysteine or carbocysteine versus placebo either alone or as an add-on therapy.To study safety, we also used trials comparing the use of acetylcysteine or carbocysteine versus active treatment or no treatment and case reports. DATA COLLECTION AND ANALYSIS At least two review authors extracted data and assessed trial quality. We performed a subgroup analysis of children younger than two years of age. MAIN RESULTS Six trials involving 497 participants were included to study efficacy. They showed some benefit from mucolytic agents, although differences were of little clinical relevance. No conclusion was drawn about the subgroup of infants younger than two years because the data were unavailable. Thirty-four studies including the previous six trials involving 2064 children were eligible to study safety. Overall safety was good but very few data were available to evaluate safety in infants younger than two years. However, 48 cases of paradoxically increased bronchorrhoea observed in infants were reported to the French pharmacovigilance system. AUTHORS' CONCLUSIONS The results of this review have to be interpreted with caution because it was based on a limited number of participants included in studies whose methodological quality is questionable. Acetylcysteine and carbocysteine seem to have a limited efficacy and appear to be safe in children older than two years. These results should take into consideration the fact that acetylcysteine and carbocysteine are prescribed for self-limiting diseases (for example, acute cough, bronchitis). Regarding children younger than two years, given concerns about safety, these drugs should only be used for ARTIs in the context of an RCT.
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Affiliation(s)
- Yvonne C M Duijvestijn
- Department of Paediatrics (119), Medical Centre Alkmaar, Wilhelminalaan 12, Alkmaar, Netherlands, 1815 JD.
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Sanz EJ, Hernández MA, Ratchina S, Stratchounsky L, Peiré MA, Lapeyre Mestre M, Horen B, Kriska M, Krajnakova H, Momcheva H, Encheva D, Martínez-Mir I, Palop V. Prescribers' indications for drugs in childhood: a survey of five European countries (Spain, France, Bulgaria, Slovakia and Russia). Acta Paediatr 2005; 94:1784-90. [PMID: 16421040 DOI: 10.1111/j.1651-2227.2005.tb01854.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Indication-based, in comparison to diagnoses-based, drug utilization studies in children are scarce in the literature. AIM To determine the adequacy of the prescriber's indications for specific drug treatments compared to the current literature in five different European countries; and to show the possibilities of performing indication-based drug utilization studies. DESIGN a descriptive, cross-sectional, international study. PATIENTS AND METHODS Randomly selected sample of 12,264 paediatric outpatients seen in consultation rooms attended by paediatricians or general practitioners. Data on patient demographics, diagnoses, and pharmacological treatment, with therapeutic indications for each drug, were collected in pre-designed forms. Diagnoses and indications were coded using the ICD-9 and drugs according to the ATC classifications. RESULTS Indications were registered for every drug prescribed in all locations. Antibiotic indications considered incorrect (common cold, upper respiratory tract infections, viral infections, general symptoms or "not specified") accounted from 24.1% of the total antibiotics prescribed in Tenerife to 67.4% in Slovakia. Incorrect indication of first-choice antibiotics prescribed in acute otitis media and tonsillitis ranged from 28.9% of total antibiotics use in Russia to 75.4% in Tenerife. Correct antibiotic indications ranged from 23.4% of total antibiotics used in Slovakia to 65.7% in Tenerife. Aspirin use in febrile viral conditions was detected mainly in Toulouse and Russia. CONCLUSION The main areas for improvement detected were high use of mucolytics, prescription of aspirin in potential or established viral infections, overuse of antibiotics and identification of specific patterns of incorrect antibiotic prescription and clinical entities associated with each location.
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Affiliation(s)
- Emilio J Sanz
- Department of Clinical Pharmacology, School of Medicine, University of La Laguna, La Laguna, Tenerife, Spain.
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Bocquet A, Chalumeau M, Bollotte D, Escano G, Langue J, Virey B. Comparaison des prescriptions des pédiatres et des médecins généralistes : une étude en population en Franche-Comté sur la base de données de la caisse régionale d'assurance maladie. Arch Pediatr 2005; 12:1688-96. [PMID: 16102954 DOI: 10.1016/j.arcped.2005.06.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2005] [Accepted: 06/14/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare the medical management of children by private pediatricians or by general practitioners. POPULATION AND METHODS A retrospective cohort study analyzed information from the automated database of the Regional Health Insurance Fund for salaried workers in Franche-Comté from January 2001 through December 2002 and compared the mean rates of prescriptions in the populations seen only by general practitioners or mainly by pediatricians. RESULTS Analysis concerned 1 535 208 visits (office and home). Management by pediatricians was associated with 25% fewer consultations and 6% fewer hospitalizations. Pediatricians also wrote 25% fewer prescriptions for drugs, 17% fewer for laboratory tests, and 42% fewer for speech and language therapy. Children seen by pediatricians took antibiotics much less often (penicillin: -24%; cephalosporins: -74%; macrolides: -53%) as well as half as many corticoids and NSAIDs. Their vaccination coverage was more complete (31% more hepatitis B vaccines, 7% more MMR), as was prevention against rickets and cavities (twice the rate of vitamin D and fluoride prescriptions). The population followed mainly by pediatricians included 25% more children with a chronic disease. CONCLUSION General practitioners and pediatricians appear to differ significantly in their management of children. Other studies that can take into account such confounding factors as health status are needed to confirm these results.
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Affiliation(s)
- A Bocquet
- Association française de pédiatrie ambulatoire, 1, rue Auguste-Rodin, 25000 Besançon, France.
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