Recurrent lower respiratory illnesses among young children in rural Kyrgyzstan: overuse of antibiotics and possible under-diagnosis of asthma. A qualitative FRESH AIR study

Abstract

Lower respiratory tract illnesses (LRT-illnesses) in children under 5 years (U5s) are a leading cause of morbidity, hospitalisations and mortality worldwide, particularly in low-income countries. It is pertinent to understand possible inconsistent management. This study explored perceptions and practices among caregivers and health professionals on recurrent LRT-illnesses in U5s. Semi-structured interviews with 13 caregivers to U5s with recurrent LRT-illnesses and with 22 primary care health professional interviews in two rural provinces in Kyrgyzstan were triangulated. Data were thematically analysed. The majority (8/13) of caregivers described their young children as having recurrent coughing, noisy breathing and respiratory distress of whom several had responded positively to acute salbutamol and/or had been repeatedly hospitalised for LRT-illness. Family stress and financial burdens were significant. The health professionals classified young children with recurrent LRT-illnesses primarily with pneumonia and/or a multitude of bronchitis diagnoses. Broad-spectrum antibiotics and supportive medicine were used repeatedly, prescribed by health professionals or purchased un-prescribed by the caregivers at the pharmacy. The health professionals had never applied the asthma diagnosis to U5s nor had they prescribed inhaled steroids, and none of the interviewed caregivers’ U5s were diagnosed with asthma. Health professionals and caregivers shared a common concern for the children’s recurrent respiratory illnesses developing into a severe chronic pulmonary condition, including asthma. In conclusion, the study identified an inconsistent management of LRT-illnesses in U5s, with exorbitant use of antibiotics and an apparently systemic under-diagnosis of asthma/wheeze. When the diagnosis asthma is not used, the illness is not considered as a long-term condition, requiring preventer/controller medication.

Hospital admission for symptoms exacerbation in 2,075 infants suffering from recurrent asthma-like symptoms (EISL-3 South America)

“…[2][3][4]7,[20][21][22][25][26][27] In this study, 41.5% of infants with recurrent asthma-like symptoms whose parents also reported severe episode and visit ED have not received ICS; similar percentages have been found in previous studies. 21,22,27 According to major guidelines, ICS therapy in preschool children with high risk for asthma is an effective approach for preventing exacerbations and symptom reduction. 27 Recently, in a large sample of infants with asthma-like symptoms, there was a significant reduction in the rate of admission for wheezing after starting with controller therapy.…”

“…2 The authors identified a strong association between the severity of recurrent asthma-like symptoms and admission to hospital for wheezing, suggesting the need to improve the symptoms' severity recognition and medical management because this might prevent visits to ED and admissions in this group of infants, particularly in developing countries. 3,4,6,[19][20][21][22][23][24] In infants with troublesome recurrent asthma-like symptoms and older asthmatic children, there are several treatment-related issues: repeated use of antibiotics, poor inhalation technique and treatment adherence, ICS at low doses, discontinuous use of ICS, among others, will predictably result in poor treatment outcomes. [2][3][4]7,[20][21][22][25][26][27] In this study, 41.5% of infants with recurrent asthma-like symptoms whose parents also reported severe episode and visit ED have not received ICS; similar percentages have been found in previous studies.…”

“…Many of these young children had had several episodes of recurrent wheezing and repeated consultations for wheezing, which should be considered as an alarm signal to improve interventions if we want to avoid exacerbations and subsequent hospitalisations in this group of infants. [2][3][4]7,[20][21][22][23][24]27…”

H2020 funding for respiratory research: scaling up for the prevention and treatment of lung diseases

“…2) The diagnosis and treatment of asthma in children should be tailored as if infectious disease is highly prevalent, asthma is often unknown to healthcare workers and its diagnosis is regularly missed [23,24].…”

Evaluation of rational prescribing in paediatrics

“…Overuse of antibiotics in children has been reported in both high-income 4 and low-income countries. 5 Other examples of inappropriate use of medicines are the widespread use of cough medicines in children 6 and polypharmacy. 7 Polypharmacy is associated with an increased risk of drug toxicity.…”