Lower respiratory tract illness in young children: predictors of disease and health care utilization

Abstract

Lower respiratory tract illness (LRTI) is an important health problem in early childhood. More than half of all infants develop LRTI in the first years of life. LRTI is an important risk factor for asthma. At the age of six, 10-15% still has symptoms of LRTI. Most of the children grow over the symptoms and turn out to have so called 'transient wheezing'. However, in spite of the good prognosis, these children contribute to high health care utilization and costs. Parents are concerned about the illness and the possible consequences. At this moment there is no rational treatment. Antibiotics and inhalation corticosteroids do not seem to be effective and reassurance is maybe the best treatment. Prediction tools that could distinguish between low and high risk infants for LRTI, could contribute to better management. However, until now there is no prediction tool available for use in healthy infants in primary care. The impact on infants, their parents and health care, together with the lack of prediction tools may be considered as two important arguments for a comprehensive study of neonatal risk for clinical relevant LRTI in the first year of life. First we looked into the determinants of health care utilization for LRTI. We showed that besides complaints, child and parental factors play an important role in help-seeking. It seems that a lot of consultations are driven more by parental anxiety and social reasons than rational medical reasons. Parents expect the general practitioners to help them with knowledge and support, to improve their capability to identify minor illness and act adequately. It is an important challenge for primary care to deal with this need for information and reassurance in an efficient way. With regard to informing and supporting care takers of young infants, it is also very important to assess disease severity and prognosis of patients adequately. We showed that symptoms of wheeze and cough have different determinants already in the first year of life. Probably it is useful to ask parents specifically about these complaints. Furthermore we investigated the possibilities of detecting newborns at risk for developing relevant LRTI in the first year of life. We showed that is was possible to specify the overall risk of LRTI of 26% to 12% in low risk infants and to 45% in high risk infants. Although these differences are interesting and relevant for daily practice, our model could only classify 60% of our infants correctly. Extending the neonatal characteristics with clinical data later in life will probably improve prediction. Finally we investigated the management of LRTI in the first year of life. Forty percent of our infants with LRTI received medication (20% antibiotics and 35% corticosteroids). Besides medical reasons, we showed that child, parental and physician factors play an important role in the decision to prescribe. Doctors should be aware of expectations and anxieties of parents and try to discuss these important issues explicitly with them. Better assessment of disease severity and prognosis of infants could also help to inform parent better.