Administration of medicines in school: who is responsible?

Increasing adherence to inhaled steroid therapy among schoolchildren: randomized, controlled trial of school-based supervised asthma therapy

OBJECTIVE

We aimed to determine the effectiveness of school-based supervised asthma therapy in improving asthma control. The primary hypothesis was that the supervised-therapy group would have a smaller proportion of children experiencing an episode of poor asthma control each month, compared with those in the usual-care group.

METHODS

Children were eligible if they had physician-diagnosed persistent asthma, the need for daily controller medication, and the ability to use a dry-powder inhaler and a peak flowmeter. The trial used a 2-group, randomized, longitudinal design with a 15-month follow-up period. A total of 290 children from 36 schools were assigned randomly to either school-based, supervised therapy or usual care. Ninety-one percent of the children were black, and 57% were male. The mean age was 11 years (SD: 2.1 years). An episode of poor asthma control was defined as > or =1 of the following each month: (1) an absence from school attributable to respiratory illness/asthma; (2) average use of rescue medication >2 times per week (not including preexercise treatment); or (3) > or =1 red or yellow peak flowmeter reading.

RESULTS

Two hundred forty children completed the study. There were no differences in the likelihood of an episode of poor asthma control between the baseline period and the follow-up period for the usual-care group. For the supervised-therapy group, however, the odds of experiencing an episode of poor asthma control during the baseline period were 1.57 times the odds of experiencing an episode of poor asthma control during the follow-up period. Generalized estimating equation modeling revealed a marginally significant intervention-time period interaction, indicating that children in the supervised-therapy group showed greater improvement in asthma control.

CONCLUSIONS

Supervised asthma therapy improves asthma control. Clinicians who have pediatric patients with asthma with poor outcomes that may be attributable to nonadherence should consider supervised therapy.

Medication management in primary and secondary schools: evaluation of mental health related in-service education in local schools

An increasing number of students are taking medications while they are in school or are under the influence of medication during school hours. In a novel effort, clinical pharmacists and mental health therapists worked together to provide "mini-in-service" educational programs on psychological disorders and medications used to treat these disorders. The purpose of this study was to implement and evaluate the effectiveness of these educational programs presented to school nurses, teachers, school administrators, and other personnel. The study compared participant responses before and after attending a medication in-service session on a psychological disorder and its related medications. Results indicated that in-service education on attention deficit/hyperactivity disorder (ADHD) and depression improved the knowledge and confidence levels of school personnel regarding medications and symptoms. Feedback indicated school personnel wanted longer educational sessions and more information on these disorders and treatments. School nurses working with health professionals can improve education for staff, families, and students about mental health disorders and their treatment.

Survey of administration of medicines to pupils in primary schools within the London area

OBJECTIVE

To examine the policy, administration, and supervision of medicine administration in primary schools within the Greater London area (GLA).

DESIGN

A prospective survey using postal questionnaires sent to 172 randomly selected primary schools within the GLA.

PARTICIPANTS

Head teachers of primary schools.

RESULTS

Some 65% of head teachers replied. Less than 50% of responding head teachers had actually read the national guidelines Supporting Pupils with Medical Needs and only 30% of respondents were aware of other members of staff who had read the document. A total of 95% of respondents followed a policy/procedure in caring for the medical needs of pupils. Over 80% of respondents had staff handling the pupils' medical needs, staff handling access to stored medicines, and prior arrangements for staff training. However, it is worrying that a quarter of the schools did not keep a written record of medicines given to children in schools. The majority of staff with responsibility for medicine administration in schools are support staff. The most encouraging findings were that for the majority of schools with children using the EpiPen and rectal diazepam, there were trained staff to administer these medicines.

CONCLUSIONS

The majority of schools had a policy in place to deal with medicine administration, although further work should be conducted to analyse the content of such policies. It is very important that training is directed at staff responsible for medicine administration and not just at teachers. Most schools were willing to administer rectal diazepam and EpiPen treatment in an emergency.

A literature review to identify interventions to improve the use of medicines in children

BACKGROUND

It is estimated that 200 million prescriptions for children and adolescents were issued in the UK during 2002. Therefore, it is important for the National Service Framework for Children (NSFC) to include advice on managing medicines effectively for children. This literature review was performed at the request of the NSFC Medicines External Working Group in order to provide underpinning evidence in the development of advice on managing medicines.

METHODS

Detabases, websites and conference abstracts were searched systematically to identify information on managing medicines in children in 2003. This article reported the results on medication review, concordance, enhanced medicines access through community pharmacy services and the use of medicines in schools.

RESULTS AND CONCLUSIONS

Although there is little evidence specific to paediatrics, the objectives and rationale of medication review could be expected to apply to chronic diseases in children. Issues such as polypharmacy, wastage, repeat prescriptions and medication problems could be similar. The benefits seen in adults may also occur in children, and medication review may possibly have a role in the management of medicines in children. There is an obvious role for pharmacists in ensuring the safety of over-the-counter medications and provision of information and education to parents, carers and adolescents. Evaluation and provision of necessary education and training to community pharmacists is needed, even in the most basic paediatric issues such as sugar-free medications. The evidence suggests that treatment compliance and adherence are generally lower in children than in adults, particularly in adolescents as they approach independence. Those with learning disabilities and infants are likely to be at risk of non-compliance, although little work has been done in these populations. Children and adolescents need appropriate parental and professional support in taking control of their medication and treatment. The management of medicines in school would appear to be far from ideal. Further research into school-based medicines education and outreach clinics would also be beneficial.

Inadequacy of in-school support for diabetic children

The level of blood glucose control needed to minimize complications in children with diabetes requires frequent blood sugar monitoring and appropriate responses to the information obtained. It is our impression that optimal support for good control is not available in all of the schools our patients attend. The objective of this study was to identify and quantify barriers to good control of diabetes in the school setting, and then use this information to target interventions to improve in-school support for children with diabetes. Two questionnaires were designed based on recommendations of the American Diabetes Association for appropriate in-school support for children with diabetes. Parental perception of in-school resources was addressed in one questionnaire. Forty-seven parents of children with diabetes in our clinic were surveyed. The second questionnaire was mailed to 222 randomly selected schools in our area inquiring about the in-school support available to children with diabetes and the types of educational materials that would be useful for school personnel. Thirty percent of the parents of children with diabetes indicated that the in-school support of their child was insufficient. Sixty-five of the 222 schools surveyed responded. The responses were variable and demonstrated inconsistency and, in some cases, inadequacy of support. A major deficiency noted in 13% of schools was lack of on-site personnel trained in diabetes management skills. From the schools' perspective, however, 50% of schools reported lack of parental communication. The care available for the child with diabetes is highly variable among schools. Targeted educational materials for both school personnel and parents would be useful to improve support for these children.

Parents' perspectives of health-care delivery to their chronically ill children during school

This study sought to identify parents' perspectives about issues relating to the provision of health care to their chronically ill children while they are at school. A survey of parents with school-aged children attending the paediatric subspecialty outpatients clinic in a large teaching hospital was designed to collect both qualitative and quantitative data about this topic. Findings included that 48% (n =161) of parents participating in the study said their child required some form of care or attention while at school. Highest scoring areas of need included supervision of meals (36%), administering insulin (19%), and administering nebulizers/puffers (19%). In addition, 75% of parents with children requiring health care while in school said that special knowledge and skill was required to deliver this care; 56% of these parents did not feel that teachers had the knowledge that would enable them too look after their chronically ill child during school hours.

Teaching teachers about school health emergencies

The passage of laws requiring that all children receive appropriate public education in the least restrictive environment means children with special health care needs who are at increased risk for health emergencies have entered regular public classrooms. Therefore, teachers must deal not only with health emergencies of normal children, but with emergencies of children with special health care needs. The purpose of this study was to evaluate the effectiveness of a nurse-led educational intervention for 324 teachers on their knowledge of and anxiety about management of children having health emergencies. The intervention resulted in increased knowledge and decreased anxiety about emergency response. This study demonstrated the feasibility and value of nurses educating teachers about school emergencies and in placing the individual health care plan into action.

First aid anaphylaxis management in children who were prescribed an epinephrine autoinjector device (EpiPen)

BACKGROUND

Epinephrine for first aid use by parents and other caregivers and in the form of an autoinjector device (EpiPen, Center Laboratories) is often prescribed for children who have had previous anaphylactic reactions. It is not known whether the EpiPen device is used appropriately during subsequent reactions and whether its use is able to prevent the complications of anaphylaxis.

OBJECTIVE

Our purpose was to determine parental knowledge and practice concerning first aid anaphylaxis management, the frequency of recurrent generalized allergic reactions, the first aid measures taken, and the subsequent outcome of these reactions.

METHODS

A retrospective survey was performed with a telephone questionnaire of all children with a history of anaphylaxis who attended a specialist allergy service and were prescribed an EpiPen autoinjector device.

RESULTS

Recurrent generalized allergic reactions occurred with a frequency of 0.98 episodes per patient per year and were more common in those with food compared with insect venom anaphylaxis. The EpiPen device was only used in 29% of recurrent anaphylactic reactions. Parental knowledge was deficient in recognition of the symptoms of anaphylaxis and use of the EpiPen device, and adequate first aid measures were not in place for the majority of children attending school. Those children in whom the EpiPen device was used were less likely to be given epinephrine in hospital and to require subsequent hospital admission.

CONCLUSION

The EpiPen autoinjector device is infrequently used in children with recurrent episodes of anaphylaxis; the reasons for this require further research. It is likely that parents and other caregivers will require continuing education and support in first aid anaphylaxis management. When the EpiPen device is used appropriately, it appears to reduce subsequent morbidity from anaphylaxis.

Parent reported allergy and anaphylaxis in 4173 South Australian children

OBJECTIVES

To determine the prevalence of parent reported allergy and anaphylaxis in a sample of children and to investigate the first aid management of anaphylaxis in the schools and preschools that these children attend.

METHODS

The study sample comprised 4173 South Australian children aged 3-17 years. Information was collected regarding parent-reported allergy and anaphylaxis. All children with known anaphylaxis were contacted and an attempt was made to contact those with reports of allergy to ascertain if these children had anaphylaxis. A telephone questionnaire was used to verify reports of anaphylaxis and determine the cause, severity and school first aid management of anaphylaxis.

RESULTS

The rate of parent reported allergy and anaphylaxis was 7.3 and 0.59 per 100 children, respectively. Two-thirds of children with anaphylaxis did not have emergency medication available at school, an emergency action plan, or a teacher on site able to administer adrenaline for first aid use.

CONCLUSIONS

Children attending preschool or school may have had a past history of anaphylaxis. Arrangements for first aid management of these children while in this environment are often inadequate.