Family Practice Vol. 19, No. 3, 242-246
© Oxford University Press 2002
Original Paper |
The impact of recurrent throat infection on children and their families
a Department of Epidemiology and Public Health and
b Department of Statistics, University of Newcastle upon Tyne and
c Plymouth Postgraduate Medical School, UK.
Denise Howel, Department of Epidemiology and Public Health, The Medical School, Framlington Place, University of Newcastle upon Tyne, Newcastle upon Tyne, UK.
Howel D, Webster S, Hayes J, Barton A and Donaldson L. The impact of recurrent throat infection on children and their families. Family Practice 2002; 19: 242–246.
Received 14 May 2001; Revised 6 September 2001; Accepted 7 January 2002.
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Abstract |
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Background. Recurrent throat problems in children are common and have an impact on the family. The appropriateness of surgery will depend on both clinical and social factors.
Objectives. The aim of this study was to assess the impact on the whole family when a child is suffering from recurrent throat problems, and investigate related parental attitudes.
Methods. A total of 1190 parents of children in northern England for whom tonsillectomy or adeno-tonsillectomy was a possible treatment option were sent a questionnaire covering social and clinical issues such as children's symptoms, the impact on family life and parental attitudes.
Results. The majority of children had experienced more than four episodes in the previous year, had their sleep affected and time off school. Most parents were worried and reported disruption to the family, including taking time off work and cross-infection. Parental disruption, worry and eagerness for surgery were significantly associated with the duration of episodes of throat problems and the number of episodes in the previous year, but not with duration of tonsillitis. Time off school, or parental time off work was significantly associated with parental worry and disruption, but not with eagerness for surgery.
Conclusion. This work highlights the impact of recurrent throat problems and related parental attitudes, and will aid in striking a balance between clinical requirements and the needs and wishes of the family.
Keywords. Child, family, quality of life, tonsillectomy, tonsillitis.
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Introduction |
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A child with a recurrent or chronic medical condition can have an impact on the whole family. As well as the child's discomfort, there is the possibility of social, emotional and financial impact on family members.1–3 Recurrent throat problems in children present frequently in general practice, and may well lead to referral to ear, nose and throat (ENT) clinics. A GP needs to be aware of the spectrum of non-medical pressures experienced by the family, to develop a shared understanding of what constitutes a successful outcome and to give appropriate advice. The present work was part of a larger study of the impact of clinical guidelines on the appropriateness of decisions to carry out tonsillectomy (with or without adenoidectomy) by ENT surgeons.4 This paper describes the impact of their child's illness on family life and investigates the characteristics of the child and family that are associated with parental worry, disruption and eagerness for surgery.
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Methods |
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The study was carried out during 1994–1995 in four ENT surgical departments within three districts in northern England (Cleveland, Cumbria and Sunderland), covering a mixture of rural and urban areas. Information was collected on successive patients in the clinics operated by the ENT surgeons. Data collection took place in two phases (before and after the introduction of clinical guidelines to ENT surgeons) in each of the three districts. Children aged 0–14 years, attending any of the regular ENT surgery clinics during the study periods, were eligible for the study, if they were judged, prior to consultation, to have been referred for throat-related problems, or problems for which tonsillectomy was a possible treatment option.
The parent or guardian of each eligible child was sent a questionnaire that elicited information about throat problems suffered by the child and aspects of the impact on the child and their family. Surgeons were asked to report the perceived eagerness of the parents or accompanying adults for surgery, and other questions which are not dealt with here. Both questionnaires were piloted for ease of use and face validity for 2 months (n = 40), and there was a further pilot of a revised version for 1 month (n = 23). Five-point scales were used to describe the level of disruption caused by the child's throat problems, the extent to which parents or guardians were worried about their child, and their eagerness for surgery. The labelling of the scales is shown in Table 2
. Further details of the study design are given elsewhere.4 Statistical analysis was by simple descriptive statistics and logistic regression that adjusted for the cluster sampling of subjects (within combinations of district and phase of study). The logistic regression investigated associations between the measures of impact on the child and family and each of the three parental outcomes (worry, disruption and eagerness). The local research ethical committees granted ethical permission for the study.
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Results |
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A total of 1190 children were eligible for the study: 971 completed parent questionnaires were received, giving a response rate of 81.5%. Of these, 959 children had reported problems with tonsillitis or other throat-related problems, and they formed the basis for the results described in this paper. Forty-nine per cent of the children were boys, and their age distribution was 0–2 years 3%, 3–5 years 40%, 6–8 years 28%, 9–11 years 15% and 12–14 years 14%. There was little variation in these characteristics between each district and phase of the study, and study periods were balanced across the seasons of the year. The distribution of age and sex and the clinical decision reached were similar for those children whose parents had and had not returned the parental questionnaire.
Table 1 describes the impact of self-reported tonsillitis on the study children. About half the children had experienced 4–8 episodes in the year before the clinic appointment, with a minority having many more. The duration of these symptoms varied between 2 months and nearly 11 years; most commonly 1–2 years. Individual episodes usually lasted >2 days, and often >5 days, while 15% of parents reported that their offspring had the symptoms almost constantly. Children's sleep was affected in most cases: the most frequent problems were snoring and breathing difficulties, with around a quarter of the parents mentioning each of these. Forty per cent of school-age children missed school every time the symptoms arose, and most of the remainder missed school sometimes. They were most frequently absent from school between 1 and 3 weeks in the last year, but often even more than that.
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The effect on the family of having a child with throat problems is illustrated in Table 2
. About half of the parents said that they had had to take time off work to look after the child at some stage, when the child had throat problems. Some parents gave more details of work and childcare problems. The most common problems were difficulty in arranging the time off and/or finding a replacement, followed by inflexible working hours, loss of earnings or holiday entitlement, having to rely on others to look after the child, and a few had given up work to look after their child. In ~50% of subjects, there had been cross-infection with family members. In one-third of the cases, siblings had been infected in the past year, as had a similar proportion of their mothers: fewer fathers and grandparents had been infected. When asked for any further comments on their child's illness, recurrent issues were the effect that the child's snoring and restless sleep had on the rest of the family, worry that the child's education had suffered, and eating difficulties or weight loss. The three main parental outcomes were worry, disruption and eagerness for surgery, all measured on a 1–5 scale. The majority of parents were quite worried by their child's tonsillitis, although 2% said they were not worried at all; there were similar distributions for the level of disruption to child and family, and desire for surgery. There was little correlation between the three parental attitudes, suggesting they were measuring different aspects of parental feelings (rank correlation between worry and eagerness = 0.22, between disruption and eagerness = 0.19, between worry and disruption = 0.60). For instance, some parents who reported little worry or disruption still expressed a strong desire for surgery. The association between worry and disruption was stronger, but there were some parents who were very worried, but reported little disruption.
Table 3 illustrates the associations between three parental outcomes (worry, disruption and eagerness for surgery) and aspects of the impact on child and family. Parents were more likely to be very worried (a score of 4 or 5 on a scale of 1–5) if the duration of a typical episode of tonsillitis was longer: rising from ~50% for episodes lasting up to 4 days, to 86% for those who had tonsillitis almost constantly. They were also more likely to be very worried if the number of episodes in the last year was higher, if their child had missed more time from school in the past year with throat problems, and if parents had to take time off work more often. More parents reported that there was considerable disruption (a score of 4 or 5 on a scale of 1–5), if a typical episode was longer, if episodes were more frequent, if their child had been absent from school for longer and if they had always taken time off work. More parents were eager for surgery (a score of 4 or 5 on a scale of 1–5) if a typical episode was longer and if episodes were more frequent. There were no statistically significant associations with the remaining factors.
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Table 4
illustrates the association between parental worry or eagerness for surgery, and whether other family members had been treated for similar throat problems in the past. The first grouping of categories shows that a slightly higher proportion of parents were eager for surgery in families where parents or siblings previously had been treated by surgery. The second grouping investigates whether parental attitudes varied with the family member having surgery or not. There were no statistically significant associations, though the width of the confidence intervals indicates that some estimates are imprecise.
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Discussion |
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It is important for GPs to appreciate the extent of personal and domestic impact when a child suffers recurrent throat infections, and this survey has revealed that it can often be considerable in children who have been referred to hospital. The label of tonsillitis may not be appropriate for all cases, but the symptom duration and frequency, absences from school as well as all children being referred to ENT by their GP, indicate a level of severity commensurate with tonsillitis. There are no other published studies on the impact of recurrent throat infections or tonsillitis, but types of impacts on family members similar to those observed in this study have been reported elsewhere in children with recurrent and chronic diseases.1,2,5
As might be expected, more parents were worried or experienced disruption if their child missed school, particularly for long periods, or if they had to take time off work. However, there was no significant association between these school or work absences and the parents' eagerness for surgery. The number of years a child had tonsillitis seemed to be less important to parents than school or work absences or, more importantly, the length and severity of individual episodes. School absence can affect academic performance, and frequent short absences are generally more harmful than an occasional long one.1 A child's illness can involve financial costs from loss of earnings, transport to surgeries and providing childcare. Serious financial costs can occur if carers have to reduce hours or give up work altogether.1,2 A few parents in this study had given up their job to care for their child; slightly more said that the loss of pay was a problem. A larger number reported difficulties in getting time off work when necessary, because their working times were inflexible. This financial impact on parents was also reflected in other studies of the costs of childhood illnesses, where the major cost was that of lost earnings rather than medical costs.3,6
Given the degree of discomfort for the child, and disruption for the rest of the family, it is scarcely surprising that parents seek a definitive solution. Tonsillectomy is a possible treatment option for recurrent throat infection, and preliminary work suggested that some surgeons would consider social impacts along with clinical symptoms when deciding whether to list a child for surgery. Little has been published on the factors associated with parental pressure for tonsillectomy. However, one study suggested that mothers are more enthusiastic for tonsillectomy if a sibling or parent had undergone it before.7 We found slightly more eagerness for surgery if a parent or sibling had been treated by surgery in the past, but no indication of whether this association was stronger for parents or siblings. However, the relatively small numbers in some of the subgroups led to imprecise estimates of association.
Recurrent tonsillitis is the most common indication for tonsillectomy in children. For many years, there has been much debate over the severity and duration of pre-existing disease that are required before the benefit of tonsillectomy outweighs the risk of surgery. Few adequately designed random control trials have addressed this problem. Paradise and colleagues have produced some of the most respected findings on the efficacy of tonsillectomy in children, but these studies concentrate on children with severe recurrent tonsillitis.8,9 A recent review found that trials and studies have shown that children who met the criteria for surgery have reduced incidence of throat infection in the years following tonsillectomy.10 There is little evidence from clinical trials that it reduces the number of lost schooldays, though a recent audit of tonsillectomy patients reported that 80% had no time off school or work in the year after surgery, and 15% had taken less time off.11 More research is needed into the efficacy of tonsillectomy as a treatment for recurrent throat infections that cause persistent disruption to family life and educational attainment, but that do not, in themselves, cause a threat to a child's health.
Since the criteria for and effectiveness of tonsillectomy currently are unclear, the decisions whether to refer and/or operate are not clear-cut. It is the difficult task of the family doctor to balance clinical requirements against an appreciation of the pain, discomfort and family disruption throat problems may cause. Given the growing evidence that patients want to share in decision making, particularly when the condition is not life-threatening,12 and that this can help to manage demand,13 it is important to be aware of patient views. Family doctors need to be aware not only of the domestic disruption recurrent tonsillitis creates, but also factors that lead to anxiety and eagerness for surgery among parents. Forearmed with this information, they will have a deeper understanding of patients' problems and the solutions they may prefer.
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13
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