Current Care Guidelines had no immediate effects on antitussive prescriptions to Finnish children

Cough is a common symptom in children and a major cause of outpatient visits. As a child's cough can cause anxiety, interfere sleep and impact quality of life, parents tend to bring children to the doctor to relieve their symptoms. Once commonly used, antitussives are no longer recommended due to inefficiency and potential for severe side effects.1 The national guidelines have impacted clinical practice, as the use of racemic adrenaline for bronchiolitis has been decreased,2 although it is unknown whether the new Current Care Guidelines (CCG) publications have altered prescribing patterns for antitussives for children.3 To address this knowledge gap, we aimed to explore whether the new CCG in 2014 altered antitussive prescription rates. Herein, we reviewed 1661 paediatric (ages 0–15 years) outpatient records for lower respiratory tract infections, based on the International Disease Classification, 10th Revision codes J11 Influenza, J18 Pneumonia, J20 Acute bronchitis, J21 Acute bronchiolitis and obstructive bronchitis and J22 Unspecified acute lower respiratory infection. Of these records, 737 visits occurred in November and December, 2012 and 2013 (ie before the CCG publication on lower respiratory tract infections) and 924 identified post-publication, in November and December in 2014 and 2015. Outpatient visit data were collected from several different institutes, in varying numbers before and after the CCG publications: primary healthcare emergency department Acuta Tampere n = 120 and n = 137, respectively; Tampere University Hospital´s paediatric emergency department n = 255 and n = 364; City of Tampere primary healthcare outpatient clinics n = 72 and n = 133, private outpatient clinic Terveystalo Pirkanmaa n = 138 and n = 119; and in private outpatient clinic Terveystalo Kymenlaakso n = 152 and n = 171, respectively. Institutes reporting no antitussive prescriptions both before and after the release of the CCG were excluded from the subgroup analysis. We manually searched patient records for prescriptions of any antitussive medicines, using Anatomical Therapeutic Chemical (ATC) Classification System codes R05FA02, R05CB06, R05CB01, R05FA02, R05DA01 and R05CB02. Statistical significance of the differences between variables was calculated by chi-square test or Mann-Whitney U test as appropriate, with p < 0.05 considered statistically significant. Data were analysed using SPSS 20 software (SPSS. Inc.). Overall, 8.5% (63/737) of paediatric patients with a co-morbid lower respiratory tract infection received antitussive medication before the CCG publication. Corresponding numbers after the publication were 9.7% (90/924), representing no decrease in the antitussive prescription rates. Among children under 24 months old 2.1% and 1.1% of patients received antitussives before and after the CCG publication, respectively (p = 0.303). With consideration to types of institutes, in primary healthcare emergency department, 5.8% and 13.1% of patients received antitussives before and after the CCG publication, respectively (p = 0.049). In contrast, there was no change (no decrease) in antitussive prescription rates before vs. after the publication, in private outpatient clinics or primary healthcare outpatient clinics. In Tampere University Hospital´s paediatric emergency department, there were no patients who received antitussives before or after the publication of the CCG (Table 1). The mean ages of the children, who received and who did not receive antitussives, were 7.76 and 4.89 years, respectively (p < 0.05). With consideration to sex distribution, boys represented 60.1% of all patients who received and 58.3% who did not receive antitussives (p = 0.677). The present study shows that the new CCG in 2014 has had no rapid effect on antitussive prescription rates among Finnish children with lower respiratory tract infections, with comparable rates noted before and after the changes (8.5% vs 9.7%, respectively). Antitussives were prescribed both in private and public health care, with the exception of Tampere University Hospital´s paediatric emergency department, where antitussives were not used even before the publication of the CCG. There is a long history of using medicines for paediatric cough. However, antitussives are now contraindicated for young children due to serious side effects.1 The CCG are very clear against all use of antitussives. Although antitussives should be avoided, parents who have previously perceived prescription antitussives to be effective in relieving cough may be eager to apply for some medicines also for common cold. Our study provides evidence that changes in CCG have not rapidly altered antitussive prescribing rates for children. It remains to be elucidated whether the lack of change in prescribing, despite the change in recommendations, has contributed to the rise of SABA prescriptions, as was seen in Finland, and to a lesser extent, in Sweden.4 The prescriptions of antitussives for children under 24 months old was rare but still occurred. This study is novel, as we describe the effect of guideline changes in practice. The major strength of this study is that the patient records were obtained from all levels of Finnish health care: primary health care, tertiary health care, emergency departments and private clinics. We are unaware of similar broad level studies describing the impact of guideline changes. The present study has also some limitations. First, this study was conducted mainly in Tampere University Hospital Residential Area. Tampere is the third-largest city in Finland and the largest inland centre in the Nordic countries, but this study does not necessarily depict the impacts of guidelines in other areas. However, one private clinic included in the study was in the Helsinki University Hospital Residential Area but remained also on stable level with antitussive treatments after the new CCG. Second, this study described the impact of guideline changes soon after the release of CCG. It remains to be seen whether dissemination, and uptake, of these recommendations will be implemented over time. In conclusion, there was no decrease in antitussive treatments among paediatric patients suffering from lower respiratory tract infection after the CCG publication favouring not to use antitussives for cough in children. Further studies are needed to show whether the better impact of the guidelines can be measured after a longer period of time. The authors do not have any additional affiliations, financial agreements, other involvement with any company, or any potential conflict of interest.

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