An illness-focused interactive booklet to optimise management and medication for childhood fever and infections in out-of-hours primary care: Study protocol for a cluster randomised trial

Background: Fever is the most common reason for a child to be taken to a general practitioner (GP), especially during out-of-hours care. It is mostly caused by self-limiting infections. However, antibiotic prescription rates remain high, especially during out-of-hours care. Anxiety and lack of knowledge among parents, and perceived pressure to prescribe antibiotics amongst GPs, are important determinants of excessive antibiotic prescriptions. An illness-focused interactive booklet has the potential to improve this by providing parents with information about fever self-management strategies. The aim of this study is to develop and determine the effectiveness of an interactive booklet on management of children presenting with fever at Dutch GP out-of-hours cooperatives. Methods/design: We are conducting a cluster randomised controlled trial (RCT) with 20 GP out-of-hours cooperatives randomised to 1 of 2 arms: GP access to the illness-focused interactive booklet or care as usual. GPs working at intervention sites will have access to the booklet, which was developed in a multistage process. It consists of a traffic light system for parents on how to respond to fever-related symptoms, as well as information on natural course of infections, benefits and harms of (antibiotic) medications, self-management strategies and 'safety net' instructions. Children < 12 years of age with parent-reported or physician-measured fever are eligible for inclusion. The primary outcome is antibiotic prescribing during the initial consultation. Secondary outcomes are (intention to) (re)consult, antibiotic prescriptions during re-consultations, referrals, parental satisfaction and reassurance. In 6 months, 20,000 children will be recruited to find a difference in antibiotic prescribing rates of 25% in the control group and 19% in the intervention group. Statistical analysis will be performed using descriptive statistics and by fitting two-level (GP out-of-hours cooperative and patient) random intercept logistic regression models. Discussion: This will be the first and largest cluster RCT evaluating the effectiveness of an illness-focused interactive booklet during GP out-of-hours consultations with febrile children receiving antibiotic prescriptions. It is hypothesised that use of the booklet will result in a reduced number of antibiotic prescriptions, improved parental satisfaction and reduced intention to re-consult. Trial registration: ClinicalTrials.gov identifier: NCT02594553. Registered on 26 Oct 2015, last updated 15 Sept 2016

Voor elk kind met koorts een eigen ‘stoplicht’?

Fever in children is very common, and is usually caused by self-limiting upper-respiratory-tract infections. The low incidence of serious infections makes it a challenge to identify children that do have a serious infection and need treatment or observation. The Dutch Society of Paediatrics (NVK) recently presented their guideline for febrile children in secondary care. This is an important, science-based guideline. However, the diagnostic schemes presented, which are based on tests that are not available in primary care, in combination with a different prior chance of serious infections between the primary and secondary care settings make it difficult to translate this guideline to primary care. Nevertheless, the 'traffic light system' presented is a promising potential safety net tool for providing advice for parents in the general practitioner's consultation room. A traffic light system especially developed for primary care should be considered

Parents' knowledge, attitudes, and practice in childhood fever: an internet-based survey

Background Fever in children is common and mostly caused by self-limiting infections. However, the number of (re) consultations in primary care is high, driven by lack of knowledge and fear among parents. These drivers have only been studied in parents when consulting with their sick child. Aim To study knowledge, attitudes, and practice in childhood fever in parents within the general population. Design and setting Internet-based survey of a sample of 1000 parents from the general population of the Netherlands. Method A 26-item cross-sectional survey was conducted of parents with one or more children aged 38 degrees C), 55.2% correctly stated that antibiotics are effective in treating bacterial infections and not viral infections, and 72.0% knew that not every child with a fever needs treatment with antibiotics or paracetamol. When asked to prioritise aspects of a GP's consultation, 53.6% considered physical examination as most important. Obtaining a prescription for antibiotics or antipyretics was considered least important. Conclusion Knowledge, attitudes, and practices concerning childhood fever varied among parents with young children. Parents generally expect thorough physical examination and information, but not a prescription for medication (antibiotics or antipyretics) when consulting with a feverish child. GPs must be aware of these expectations as these provide opportunities to enhance consultations in general and prescription strategies in particular

Childhood fever: a qualitative study on GPs' experiences during out-of-hours care

Background. Fever in children is common and mostly caused by self-limiting infections. However, parents of febrile children often consult in general practice, in particular during out-of-hours care. To improve management, it is important to understand experiences of GPs managing these consultations. Objective. To describe GPs' experiences regarding management of childhood fever during out-of-hours care. Methods. A descriptive qualitative study using purposeful sampling, five focus group discussions were held among 37 GPs. Analysis was based on constant comparative technique using open and axial coding. Results. Main categories were: (i) Workload and general experience; (ii) GPs' perceptions of determinants of consulting behaviour; (iii) Parents' expectations from the GP's point of view; (iv) Antibiotic prescribing decisions; (v) Uncertainty of GPs versus uncertainty of parents and (vi) Information exchange during the consultation. GPs felt management of childhood fever imposes a considerable workload. They perceived a mismatch between parental concerns and their own impression of illness severity, which combined with time-pressure can lead to frustration. Diagnostic uncertainty is driven by low incidences of serious infections and dealing with parental demand for antibiotics is still challenging. Conclusion. Children with a fever account for a high workload during out-of-hours GP care which provides a diagnostic challenge due to the low incidence of serious illnesses and lacking long-term relationship. This can lead to frustration and drives antibiotics prescription rates. Improving information exchange during consultations and in the general public to young parents, could help provide a safety net thereby enhancing self-management, reducing consultations and workload, and subsequent antibiotic prescriptions

Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review

Objective: Patients' knowledge and expectations may influence prescription of antibiotics. Therefore, providing evidence-based information on cause of symptoms, self-management and treatment is essential. However, providing information during consultations is challenging. Patient information leaflets could facilitate consultations by increasing patients' knowledge, decrease unnecessary prescribing of antibiotics and decrease reconsultations for similar illnesses. Our objective was to systematically review effectiveness of information leaflets used for informing patients about common infections during consultations in general practice. Design, setting and participants: We systematically searched PubMed/MEDLINE and EMBASE for studies evaluating information leaflets on common infections in general practice. Two reviewers extracted data and assessed article quality. Primary and secondary outcome measures: Antibiotic use and reconsultation rates. Results: Of 2512 unique records, eight studies were eligible (7 randomised, controlled trials, 1 non-randomised study) accounting for 3407 patients. Study quality varied from reasonable to good. Five studies investigated effects of leaflets during consultations for respiratory tract infections; one concerned conjunctivitis, one urinary tract infections and one gastroenteritis and tonsillitis. Three of four studies presented data on antibiotic use and showed significant reductions of prescriptions in leaflet groups with a relative risk (RR) varying from 0.53 (0.40 to 0.69) to 0.96 (0.83 to 1.11). Effects on reconsultation varied widely. One large study showed lower reconsultation rates (RR 0.70 (0.53 to 0.91), two studies showed no effect, and one study showed increased reconsultation rates (RR 1.53 (1.03 to 2.27)). Studies were too heterogenic to perform a meta-analysis. Conclusions: Patient information leaflets during general practitioners consultations for common infections are promising tools to reduce antibiotic prescriptions. Results on reconsultation rates for similar symptoms vary, with a tendency toward fewer reconsultations when patients are provided with a leaflet. Use of information leaflets in cases of common infections should be encouraged. Their contributing role in multifaceted interventions targeting management of common infections in primary care needs to further exploration

Wel of geen paracetamol bij kinderen met koorts? [Risks and benefits of paracetamol in children with fever]

Worldwide, paracetamol is the most commonly used antipyretic for children and the drug of first choice for reducing fever named in the majority of practice guidelines. However, whether or not it is necessary or desirable to treat fever is questionable. The provision of accurate information on the causes and treatment of fever can decrease the help-seeking behaviour of parents. Paracetamol is both effective and advisable when there is a combination of fever and pain. Fever on its own does not require treatment and doctors should therefore show caution about advising paracetamol for children who have just this symptom. The effect of paracetamol on the general well-being of children with fever on its own has not been unequivocally proven. Treatment with paracetamol for the prevention of febrile convulsions has been proven ineffective. There are indications that inhibiting fever through paracetamol can adversely affect the immune response. The use of paracetamol can produce mild side effects and hepatotoxicity

Symptomatic management of febrile illnesses in children: A systematic review and meta-analysis of parents' knowledge and behaviors and their evolution over time

10.3389/fped.2018.00279Frontiers in Pediatrics627