Children's presence in research. A review of online registers

OBJECTIVES

To determine how many online clinical trial registers include paediatric trial data, how much information is provided, ease of searching for paediatric trials and the accessibility of paediatric trial data in general.

METHODS

Medline and Google were searched for mention of clinical trial registers in July 2008. All registers considered to be eligible were evaluated for trial information provided, search options available, and number of trials, both total and paediatric. A meta-analytic weighted average of the presence of paediatric trials was calculated and compared to the percentage of published paediatric trial articles in Medline. The paediatric trials in the registers were searched for in the World Health Organization's International Clinical Trials Registry Platform (ICTRP). All online, freely accessible registers including ongoing trials on different drugs or therapeutic areas, were eligible for review.

RESULTS

Twelve registers were included in the review. All except one provided detailed trial data, while search options varied between registers: seven provided free-text searching, two listed their trials by condition, two provided elaborate search options (age group, condition, study purpose, etc) and one simply listed its trials. Nine of the 12 registers' search facilities made it possible to search for paediatric trials, and these were analysed further: the percentage of paediatric trials in the single registers ranged from 4.8 to 33.3%, and the weighted average was 15% (95% confidence interval 8.2-21.8). The percentage of published, paediatric trial articles was 25%. Of the paediatric trials also searched for in the ICTRP, 66% were found.

CONCLUSIONS

Great difficulty was found in retrieving paediatric trials due to the limited and inadequate search functions of the registers reviewed but, in general, the registers seem to represent fewer paediatric trials than those reported in the literature. The ICTRP portal is important for trial accessibility, but it is still in an initial phase and far from representative of the global research situation, especially in the field of paediatrics.

European paediatric research and children's therapeutic needs. A trial review

AIM

To evaluate the current paediatric therapeutic research situation in Europe with respect to paediatric needs and drug therapies.

METHODS

Data from ongoing and published paediatric drug therapy trials from 2004 to 2007 were evaluated and compared to the European Medicines Agency (EMEA) priority list for studies on paediatric medicinal products. Ongoing trial data from the DEC-net paediatric trial register and published trials from two biomedical databases were used.

RESULTS

In all, 379 trials from the 27 European Union (EU) countries were found (most common country: Italy, 18.2%). The major disease area covered was 'infectious and parasitic diseases' (21.4%). Only four of 25 EMEA priority conditions were addressed, the most common were 'malignant diseases' (18.2% of trials) and 'asthma' (3.2%). A subset of 190 published trials, representing the same four countries that participated in DEC-net (France, Italy, Spain and United Kingdom), was compared to the register's 257 ongoing trials. Some significant differences in disease areas covered were found. Concerning the EMEA priority conditions, the ongoing research addressed more of them.

CONCLUSION

Paediatric research is being carried out in Europe, but this study found a general lack of overlap between therapeutic needs and research. The Paediatric Regulation will hopefully lead to research that is more focused on children's needs.

Off-label use of drugs in Italy: a prospective, observational and multicentre study

The aims of the study were to measure the paediatric, off-label use of drugs in the Italian hospital setting and to reveal areas for priority intervention by investigating the therapeutic indications most involved. Prescriptions given to all children admitted to nine general paediatric hospital wards from December 1998 to February 1999 were analysed. In total, 4265 prescriptions were given to 1461 children, 10 of which were unlicensed and excluded from further analysis. Sixty percent of prescriptions (range between centres: 44-71%) were off-label and concerned 89% of children receiving medications (80-96%). The main drug classes were antibacterials, antiasthmatics and analgesics, and represented 56% of off-label prescriptions. Paracetamol (385 prescriptions) and beclomethasone (339) were the generic substances most often used off-label. The most common off-label categories were dosage/frequency (50% of prescriptions), indication and lack of paediatric licence (7% each). Fifty-four per cent of all indications that led to off-label prescribing involved only respiratory problems, fever, respiratory tract infections and bronchospasm.

CONCLUSIONS

Despite prescription profile differences among centres, off-label use was high everywhere. Immediate action for more rational drug use is necessary and requires not only regulatory intervention but also a more evidence-based, therapeutic approach.

Drug prescribing in out-patient children in Southern Italy

OBJECTIVES

The aim of this study was to investigate and evaluate the prescribing habits of family pediatricians in Southern Italy in order to determine which aspects need to be addressed for a more rational use of drugs in children.

METHODS

An observational prospective study was conducted for a 3-month period in 1998 in which family pediatricians were asked to record information regarding every patient doctor contact on an index day of the week. The information was collected on a specifically designed data collection form and included the reason for the contact, the child's general characteristics, the drugs prescribed, and the purpose for which they were prescribed (therapeutic indication). The data were entered, prescribed drugs were classified according to the International Anatomic-Therapeutic-Chemical Classification system (ATC), and the therapeutic indications were coded using the International Classification of Diseases (ICD-9). Analyses were carried out using the EPI-Info software package and the SPSS statistical analysis program.

RESULTS

A total of 35 pediatricians participated and consulted with 9917 children, prescribing 8805 drugs to 6417 patients under 12 years old. Prescription rates were higher for younger children. In all, 288 different generic substances were prescribed, but the 20 most common made up two-thirds of the prescriptions and would have sufficed to cover almost 70% of all prescription purposes. Two-thirds of prescriptions concerned respiratory system drugs or anti-infectives. Acute pharyngotonsillitis, cough, and acute otitis media were the most common morbidities. Despite the free availability of drugs in the Italian health care system, the families paid for over half their cost mainly due to the incorrect manner in which they were prescribed.

CONCLUSIONS

Although, according to current recommendations, most of the patients' needs could have been taken care of using few drugs, prescriptions involved a wide variety of compounds. Prescription practices did not follow guidelines and were widely "evidence unbased". Prescribing drugs is one of the most frequent interventions in general practice, yet more effort is needed to establish a rational use of drugs in children, as well as in adults.

Mothers as active partners in the prevention of childhood diseases: maternal factors related to immunization status of preschool children in Italy

BACKGROUND

We examined how maternal socio-demographic factors, together with mother's education, knowledge, and perception of immunizations, can affect the uptake of optional vaccinations of preschool children in Italy.

METHODS

Interviews of Italian mothers were performed using a structured questionnaire administered by trained interviewers with no specific medical competence.

RESULTS

A convenience sample of 1,035 mothers were interviewed. Fifty-nine percent of the respondents reported to have had their child immunized with the MMR vaccine and 54% reported to have had their child immunized against pertussis. In logistic regression analysis, three variables were significantly associated with both the immunization outcomes: mother's positive attitude toward immunization (OR = 1.69; IC 1.13-2.52 for pertussis; OR = 1.86, IC 1. 17-2.96 for MMR); mothers' residency in the North of the country (OR = 1.74; IC 1.32-2.30 for pertussis; OR = 1.63, IC 1.18-2.24 for MMR); and mother's receipt of satisfactory information on immunization (OR = 1.67; IC 1.15-2.21 for pertussis; OR = 2.25, IC 1. 47-3.43 for MMR). An immunization performed in recent years (after 1994), probably following the widespread use of acellular vaccine, was the most significant predictor for pertussis immunization (OR = 3.21; IC 2.43-4.24).

CONCLUSIONS

The findings suggest that mothers' attitudes, educational level, and socio-demographic characteristics, as well as socio-economic factors and local health policies, can influence children's immunization uptake. Health promotion, based on a partnership between parents and health professionals, should become a priority in Italian vaccination policies.

Survey of unlicensed and off label drug use in paediatric wards in European countries. European Network for Drug Investigation in Children

OBJECTIVE

To determine the extent of use of unlicensed and off label drugs in children in hospital in five European countries.

DESIGN

Prospective study of drugs administered to children in general paediatric medical wards over four weeks.

SETTING

Children's wards in five hospitals (one each in the United Kingdom, Sweden, Germany, Italy, and the Netherlands).

SUBJECTS

Children aged 4 days to 16 years admitted to general paediatric medical wards.

MAIN OUTCOME MEASURE

Proportion of drugs that were used in an unlicensed or off label manner.

RESULTS

2262 drug prescriptions were administered to 624 children in the five hospitals. Almost half of all drug prescriptions (1036; 46%) were either unlicensed or off label. Of these 1036, 872 were off label and 164 were unlicensed. Over half of the patients (421; 67%) received an unlicensed or off label drug prescription.

CONCLUSIONS

Use of off label or unlicensed drugs to treat children is widespread. This problem is likely to affect children throughout Europe and requires European action.

Parents on the web: risks for quality management of cough in children

BACKGROUND

Health information on the Internet, with respect to common, self-limited childhood illnesses, has been found to be unreliable. Therefore, parents navigating on the Internet risk finding advice that is incomplete or, more importantly, not evidence-based. The importance that a resource such as the Internet as a source of quality health information for consumers should, however, be taken into consideration. For this reason, studies need to be performed regarding the quality of material provided. Various strategies have been proposed that would allow parents to distinguish trustworthy web documents from unreliable ones. One of these strategies is the use of a checklist for the appraisal of web pages based on their technical aspects.

OBJECTIVE

The purpose of this study was to assess the quality of information present on the Internet regarding the home management of cough in children and to examine the applicability of a checklist strategy that would allow consumers to select more trustworthy web pages.

METHODS

The Internet was searched for web pages regarding the home treatment of cough in children with the use of different search engines. Medline and the Cochrane database were searched for available evidence concerning the management of cough in children. Three checklists were created to assess different aspects of the web documents. The first checklist was designed to allow for a technical appraisal of the web pages and was based on components such as the name of the author and references used. The second was constructed to examine the completeness of the health information contained in the documents, such as causes and mechanism of cough, and pharmacological and nonpharmacological treatment. The third checklist assessed the quality of the information by measuring it against a gold standard document. This document was created by combining the policy statement issued by the American Academy of Pediatrics regarding the pharmacological treatment of cough in children with the guide of the World Health Organization on drugs for children. For each checklist, the web page contents were analyzed and quantitative measurements were assigned.

RESULTS

Of the 19 web pages identified, 9 explained the purpose and/or mechanism of cough and 14 the causes. The most frequently mentioned pharmacological treatments were single-ingredient suppressant preparations, followed by single-ingredient expectorants. Dextromethorphan was the most commonly referred to suppressant and guaifenesin the most common expectorant. No documents discouraged the use of suppressants, although 4 of the 10 web documents that addressed expectorants discouraged their use. Sixteen web pages addressed nonpharmacological treatment, 14 of which suggested exposure to a humid environment and/or extra fluid. In most cases, the criteria in the technical appraisal checklist were not present in the web documents; moreover, 2 web pages did not provide any of the items. Regarding content completeness, 3 web pages satisfied all the requirements considered in the checklist and 2 documents did not meet any of the criteria. Of the 3 web pages that scored highest in technical aspect, 2 also supplied complete information. No relationship was found, however, between the technical aspect and the content completeness. Concerning the quality of the health information supplied, 10 pages received a negative score because they contained more incorrect than correct information, and 1 web page received a high score. This document was 1 of the 2 that also scored high in technical aspect and content completeness. No relationship was found, however, among quality of information, technical aspect, and content completeness.

CONCLUSIONS

As the results of this study show, a parent navigating the Internet for information on the home management of cough in children will no doubt find incorrect advice among the search results. (ABSTRACT TRUNCATED)

Mother's knowledge of, attitudes toward, and management of fever in preschool children in Italy

BACKGROUND

We examined mothers' knowledge of, attitudes toward, and management of fever in their children.

METHODS

Interviews of mothers of preschool children were performed using a structured questionnaire administered by interviewers with no specific medical competence.

RESULTS

Of a total of 1,237 mothers who were interviewed, data were analyzed for the 707 mothers who had coped with a febrile episode in their children during the previous month. Of these, 59% were concerned about fever in their children and 17% were very worried. At the onset of fever, 48% of the mothers gave their child an antipyretic and 18% called the physician immediately. In logistic regression analysis, five variables were significantly associated with mothers' concern: the absence of previous information on the management of fever, temperature > 39 degrees C, an only child, mother's low educational level, and mother's residency in the south of Italy. For the request for a physician's visit, of the variables entered, the only explanatory ones were the mother's concern and the absence of previous information on the management of fever.

CONCLUSIONS

These findings suggest that informing mothers on the definition, consequences, and treatment of fever can significantly improve their confidence in managing fever, as reflected by fewer requests for physicians' visits.

Reliability of health information for the public on the World Wide Web: systematic survey of advice on managing fever in children at home

OBJECTIVE

To assess the reliability of healthcare information on the world wide web and therefore how it may help lay people cope with common health problems.

METHODS

Systematic search by means of two search engines, Yahoo and Excite, of parent oriented web pages relating to home management of feverish children. Reliability of information on the web sites was checked by comparison with published guidelines.

MAIN OUTCOME MEASURES

Minimum temperature of child that should be considered as fever, optimal sites for measuring temperature, pharmacological and physical treatment of fever, conditions that may warrant a doctor's visit.

RESULTS

41 web pages were retrieved and considered. 28 web pages gave a temperature above which a child is feverish; 26 pages indicated the optimal site for taking temperature, most recommending rectal measurement; 31 of the 34 pages that mentioned drug treatment recommended paracetamol as an antipyretic; 38 pages recommended non-drug measures, most commonly tepid sponging, dressing lightly, and increasing fluid intake; and 36 pages gave some indication of when a doctor should be called. Only four web pages adhered closely to the main recommendations in the guidelines. The largest deviations were in sponging procedures and how to take a child's temperature, whereas there was a general agreement in the use of paracetamol.

CONCLUSIONS

Only a few web sites provided complete and accurate information for this common and widely discussed condition. This suggests an urgent need to check public oriented healthcare information on the internet for accuracy, completeness, and consistency.