Prescribing for persistent cough in children

RESPIRATORY

MEDICINE

(1998)

Prescribing

92,

638-641

for persistent

cough in children

A. PICCIOTTO”, M. HUBBARD”, P. STURDY+, J. NAISH+ AND S. A. MCKENZIE* ‘Queen Elizabeth Hospital for Children, Royal Hospitals Tmsf, Hackney Road, London E2 SPS, U.K. ‘Department of General Practice and Primary Care, St Bavtkolomew’s and the Royal London School of Medicine and Dentistry, Queen Mary and Westfield College, Mile End Road, London EI 4NS, U.K. To identify the medications general practitioners consider for the treatment of persistent isolated cough, we undertook a postal questionnaire survey of a sample of general practitioners in east London. Fewer than 10% indicated that they never prescribed for such cough. About 70% sometimes considered antibiotics and/or bronchodilators in all age groups. Inhaled steroids and cromoglycate were considered by about 30% of prescribers for infants compared with over 60% for older age groups. As yet there is no evidence that medication is beneficial for persistent isolated cough. The role of asthma drugs for children with this symptom needs to be evaluated so that we can better identify those who are likely to benefit. RESPIR MED.

(1998)

i.

92, 638-641

Introduction

Methods

Isolated persistent cough is a common symptom in children but to date there is no evidence from rigorous clinical trials that medication is of value. Of parents answering a questionnaire about children’s respiratory symptoms, 9% thought their child coughed more than other children (1) and many such children are diagnosed as having asthma. Recent reports suggest that clinical and epidemiological aspects of persistent cough in childhood differ from asthma in childhood (2,3). The British Thoracic Society’sguidelines state ‘criteria for defining asthma in the presence of chronic or recurrent cough have not been adequately defined’ and recommend a trial of asthma treatment in children with chronic cough (4). Reporting of children’s cough by parents is poorly validated by audiotape recording (5,6). Thus, a diagnosis of asthma based on parents’ reporting is possibly unreliable. Asthma treatment for isolated persistent cough with no other evidence of reversible airway diseaseneeds to be evaluated. The purpose of this study was to identify which drugs general practitioners in east London are considering prescribing for persistent cough. We were particularly interested to know what asthma drugs were being considered for which age groups.

A postal questionnaire defined persistent cough. This was either cough on more than three occasions in 6 months without runny nose or eyes, no fever and no other symptoms, or cough for more than 3 weeks as the only symptom or sign. It asked about prescribing of antibiotics, cough linctus, bronchodilators, inhaled steroids, cromoglycate, other drugs and no medication for age-groups < 1, 1-4, 559 and lo-14 years. One of three unambiguous responses could be selected for each drug in each age-group: ‘always’, ‘sometimes’ or ‘never’. A reason could be given for the choice and there were two open questions, one about other approaches to management and the other about clinical features which would suggest that a child with persistent cough had asthma. A total of 120 general practitioners were selected randomly from 360 names on the City and East London General Practice Database. This number was chosen so that with a minimum response rate of 65% the percentages of general practitioners prescribing each drug category would be identified within * 10% (95% confidence limits). Analyses were undertaken on SSPS-PC. Findings are expressed as percentages with 95% confidence intervals. Using x2 testing, comparisons between age-groups for each drug were made for each of the response categories ‘always’, ‘ sometimes’ and ‘never’ and similarly comparisons were made between drugs for each age group for each response category. Significant differences (PcO.05) are reported.

Received

1 July

1997

and

accepted

in revised

form

27 October

1997.

Correspondence should be addressed to: S. A. McKenzie, Elizabeth Hospital for Children, Royal Hospitals Trust, Road, London E2 SPS, U.K. 0954.6111/98/040638+04

$12.00/O

Queen Hackney

0

1998

W. B. SAUNDERS

COMPANY

LTD

PRESCRIBING

No treatment

Inhaled

FIG.

steroids

Cough linctus

Bronchodilators

Cromoglycate

BETWEEN

AGE

GROUPS

Bronchodilators were ‘always’ considered more frequently for children over 5 years than for infants (P=O,O3). The reply of ‘sometimes’ to cough linctus prescribing was significantly greater for children in the older age groups than in infants (PcO.05). The difference was more marked for inhaled corticosteroids (P
BETWEEN

639

95% confidence

DRUG5

For the infants, more respondents replied that they ‘never’ prescribed inhaled steroids, cromoglycate or cough linctus than other medications (P
COMPARISONS (FIG. 1)

84; error bars indicate

COMPARISONS

Eighty-four questionnaires were returned representing a response rate of 70%. Five more returns were blank. Figure 1 shows the choice of medication by age-group but excludes the ‘other drugs’ category where the majority (65-85% according to age-group) gave no response. Depending on the age category, only one to four of the 84 respondents (I 5%; 0.3-9.7%) replied that they never prescribed. Only 14-16 (~20%; 9.626.7%) never considered prescribing antibiotics.

IN CHILDREN

Antibiotics

1. Prescribing considerations for persistent cough (number of respondents,
Results

FOR PERSISTENT COUGH

FOR

CHOICE

OF DRUG

At least one reason for their choice of drug was given by 63% (54/84) respondents. Parental pressure was the reason for 13 respondents prescribing cough linctus and 11 prescribing antibiotics to infants. Seventeen indicated that they prescribed asthma drugs as a trial of therapy. In the l-4 year age-group; concern about asthma was mentioned by 32 respondents and by 21 in each of the older groups. OTHER COUGH

APPROACHES

TO MANAGEMENT

OF

This open question was replied to by 87% (73/84) with a range of answers. The most frequent consideration was

640

A. PICCIOTTO

ET AL

investigation for allergy and asthma (30173) and advice about possible environmental triggers, including cigarette smoke (15173). Other treatments included steam (six), humidifier (five), saline nose-drops (four), steroid nosedrops (two), oral steroids (two), theophylline (two), ipratropium, anti-histamine, gargle, honey and homeopathy. WHAT MADE RESPONDENTS CONSIDER ASTHMA IN PERSISTENT COUGH? The most frequent answer to this question was a family history of atopic disease (43/73). Exercise-induced symptoms or night-time symptoms were mentioned by 40173.

Discussion We chose to circulate a sample of general practitioners so that we could discover within * 10% of the sample for each drug category which medications they say they are prescribing. This study provides no information about the frequency or quantities of medications prescribed. There is no way of finding out from routinely collected prescribing data what is prescribed for a specific condition in specific age groups (7) and so we could not have validated information about prescribing frequency had we asked about it. We designed our questionnaire to obtain information only about prescribing considerations. We deliberately chose the term ‘sometimes’ recognizing that this could represent a prescribing frequency from a minority to a majority of occasions. It is also true that family doctors in other areas and especially in other countries may have different considerations. The response rate to the questionnaire was surprisingly high (70%). General practitioners can be swamped with questionnaires (8) and our successmay reflect the brevity and design of ours (9). Some fields were not completed. Possibly some responders ignored categories where they did not prescribe. Non-responding was most frequent for the field ‘other’ and this would support this assumption. Most replies were for antibiotics and bronchodilators. The majority said they prescribed something for persistent cough in the absence of other symptoms. It is acknowledged that antibiotics are of no value for isolated cough (9,lO). If parents expect antibiotics then a diagnosis of acute bronchitis may be made and antibiotics prescribed (11,12), although this may not be the whole story (13). Prescribing ineffective antitussives for cough has been restricted but cough linctus may still be a cheap placebo. Several of those who gave a reason for prescribing a particular drug mentioned parental pressure. Perhaps the results of this study could be used as a starting point for local audit. It has been suggested that asthma is likely in only a minority of children with persistent nocturnal cough (14). Isolated cough is more likely to be associated with environmental factors whereas a diagnosis of asthma is more likely to be associated with a personal or family history of atopy

(1). Indeed, the respondents in our study indicated that many were giving advice about environmental factors to families whose children coughed and considered family history in the diagnosis of asthma. However, on present evidence there is little to support the diagnosis of asthma in most persistent coughers. Certainly asthmatics cough recurrently or chronically but those with cough-variant asthma have some evidence of airways obstruction (15). It is rarely possible to demonstrate this in pre-school children without special lung function testing. Many children and their parents may not perceive wheeziness. A trial of bronchodilators seemsreasonable in the first instance. In our study, 18% of our sample of general practitioners said that they always prescribed bronchodilators in the two older agegroups. Very few said that they never prescribed asthma drugs. Several respondents indicated that they would investigate for allergy and reversibility of airways obstruction. Undoubtedly some children with persistent cough have asthma and it is encouraging that this approach is being considered. However, controlled studies are needed to evaluate the place of asthma drugs for this common symptom. How can children who are likely to benefit best be identified? Otherwise these drugs could replace antibiotics as prescribed medication for non-specific recurrent or chronic respiratory symptoms. Defining the role of asthma drugs and targeting inappropriate prescribing of other drugs should be a priority for the cost-effective management of persistent cough in children.

Acknowledgements We are grateful to participating general practitioners and to Glaxo Wellcome who funded the project.

References 1. Kelly YJ, Brabin BJ, Milligan PJM, Reid JA, Heaf D, Pearson MG. The clinical significance of cough in the diagnosis of asthma in the community. Arch Dis Child 1996; 75: 489-493. 2. Wright AL, Holberg CJ, Morgan WJ, Taussig LM, Halonen M, Martinez FD. Recurrent cough in childhood and its relation to asthma. Am J Crit Care Med 1996; 153: 1259-1265. 3. Seear M, Wensley D. Chronic cough and wheeze in children: do they all have asthma? Eur Respiv J 1997; 10: 342-345. 4. British Thoracic Society. The British Guidelines on Asthma Management. Thorax 1997; 52: (Suppl. 1). 5. Falconer A, Oldman C, Helms P. Poor agreement between reported and recorded nocturnal cough in asthma. Ped Pulmonol 1993; 15: 209-I 1. 6. Thomson A, Pratt C, Simpson H. Nocturnal cough in asthma. Arch Dis Child 1987; 62: 1001&1004. 7. Sturdy P, Naish J, Griffiths C. Setting standards of prescribing performance. Br J Gen Pvact 1996; 46: 375-376 (letter).

PRESCRIBING

8. MacPherson I, Bisset A. Not another questionnaire: eliciting the views of general practitioners. Fam Pratt 1995; 12: 335-338. 9. Myerson S. Improving the response rates in primary care research. Some methods used in a survey on stress in general practice since the new contract (1990). Fam Pratt 1993; 10: 3422346. 10. Gonzales R, Sande M. What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet 1995; 345: 665. Il. Cornford CS, Morgan M, Ridsdale L. Why do mothers consult when their children cough? Fan? Pratt 1993; 10: 193-196.

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12. Vinson DC, Lutz LJ. The effect of parental expectations on treatment of children with a cough: a report from ASPN. J Fan? Pratt 1993; 37: 23327. 13. Britten N. Patients’ demands for prescriptions in primary care. Br Med J 1995; 310: 108441085. 14. Ninan TK, MacDonald L, Russell G. Persistent nocturnal cough in childhood: a population based study. Arch Dis Child 1995; 13: 403407. 15. Ellul-Micallef R. Effect of terbutaline sulphate on chronic ‘allergic’ cough. Br Med J 1983; 287: 940-943.