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A 4-year-old boy was admitted to our hospital with abdominal pain, vomiting and weight loss. After a period of diarrhoea, he was now constipated. Micturition was painful but there were no abnormalities in the urine. Blood test showed no signs of infection or elevated liver enzymes. Signs of cholecystitis were seen on abdominal ultrasound, but this diagnosis was ignored because of the low incidence of cholecystitis in children and the absence of abnormal liver enzymes and infection parameters. Other diagnostic investigations were carried out, but no cause could be found for his symptoms. His condition worsened during the hospital stay, and liver enzymes and infection parameters became abnormal. An abdominal laparoscopy was finally performed, and a perforation in the presence of a necrotizing cholecystitis was seen. This case shows that one should never ignore a diagnostic report even if the diagnosis has low prevalence.

Objective: To determine the efficacy of 2 nurse-directed programmes of different intensity for the counselling and follow-up of patients hospitalised for heart failure, compared with standard care by a cardiologist., Design: Multicentre randomised clinical trial (www.trialregister.nl: NCT 98675639)., Method: A total of 1023 patients were randomized after hospitalisation for heart failure to 1 of 3 treatment strategies: standard care provided by a cardiologist, follow-up care from a cardiologist with basic counselling and support by a nurse specialising in heart failure, or follow-up care from a cardiologist with intensive counselling and support by a nurse specialising in heart failure. Primary end points were the time to rehospitalisation due to heart failure or death and the number of days lost to rehospitalisation or death during the 18-month study period. Data were analysed on an intent-to-treat basis., Results: Mean patient age was 71 years, 38% were women, 50% had mild heart failure and 50% had severe heart failure. During the study, 411 patients (40%) were rehospitalised due to heart failure or died from any cause: 42% in the control group, and 41% and 38% in the basic and intensive support groups, respectively (differences not significant). The time to rehospitalisation or death was similar in the 3 groups: hazard ratios for the basic and intensive support groups versus the control group were 0.96 (95% CI: 0.76-1.21; p = 0.73) and 0.93 (95% CI: 0.73-1.17; p = 0.53), respectively. The number of days lost to rehospitalisation or death was 39,960 in the control group; this number was 15% less in the intervention groups, but the difference was not significant. However, there was a trend toward lower mortality in the intervention groups. In all 3 groups, more visits occurred than planned, which may have had a considerable effect on care, notably in the control group., Conclusion: The results of this study indicated that the provision of additional counselling and support by a nurse specialising in heart failure as an adjuvant to intensive follow-up care provided by a cardiologist does not always lead to a reduction in rehospitalisation frequency.

Objective: To estimate the prevalence of parental actions to stop infant crying that may threaten infant health, and to determine specific risk groups regarding these actions., Design: Descriptive., Method: Before their visit to a well-baby clinic in the Netherlands, parents of 3345 infants aged 1-6 months (96.5% response) filled out an anonymous questionnaire on actions that they undertook to stop their child crying., Results: At 6 months, 5.6% (95% confidence interval: 4.2-7.0%) of all the parents reported having smothered, slapped, or shaken their infant at least once because of its crying. The highest risks for detrimental parental actions were run by infants of parents from non-industrialised countries, of parents with no or only a part-time job, and of parents who had judged their infant's crying as excessive., Conclusion: Clinicians should be aware of the observed risk factors for abuse of young children known to cry a lot, in order to help parents to cope with this crying.

Objective: To determine the number of teenage births and abortions in Amsterdam, the Netherlands, in total and according to age and ethnic origin., Design: Retrospective analysis of routinely collected data., Method: Based on data collected from the municipal population register and the abortion clinics in Amsterdam, birth rates, abortion rates and abortion ratios were calculated for the period 1996-1998. The birth rate was the number of live births and the abortion rate the number of abortions per 1000 teenage girls. The abortion ratio was the number of abortions per 100 pregnancies., Results: The average birth rate and abortion rate for the period 1996-1998 were 3.2 and 7.6 for 14- to 16-year-old girls respectively, and 25.0 and 29.5 for 17- to 19-year-old girls respectively. Among 14- to 16-year-old girls 70 pregnancies out of 100 ended in an abortion and among 17- to 19-year-old girls 54 pregnancies out of 100. In both age groups the birth rate for Surinamese, Antillian, Moroccan, Turkish and Ghanian girls was higher than for Dutch girls. There was one exception: Moroccan girls aged 14-16 years did not have a higher birth rate than Dutch girls of the same age. Surinamese, Antillian and Ghanian girls aged 14-16 years and 17-19 years also had a higher abortion rate compared with Dutch girls of the same age. The Turkish and Moroccan girls did not have (much) higher abortion rates. In both age groups the abortion ratio was lowest for Turkish teenagers and highest for Ghanian teenagers. The figures for second-generation immigrant teenagers were more akin to those of the native Dutch girls than those of first-generation immigrants., Conclusion: In Amsterdam unwanted pregnancies were most frequent in Surinamese, Antillian and Ghanian teenage girls. To prevent these pregnancies further research into the (cultural) determinants of sexual behaviour is necessary.

Objective: To investigate the prevalence of breastfeeding amongst infants in Amsterdam prior to and following an active breastfeeding policy that has been operating in Amsterdam since 1993; investigate the link between ethnic origin and breastfeeding and the reasons mothers give for stopping breastfeeding., Design: Retrospective, descriptive study., Method: During the period 1998 to 2000, 1274 mothers in six child health centres in Amsterdam, the Netherlands, were asked about how they had fed their infant, aged 6 to 8 months, from the first week onwards, and their reasons for starting formula feeding. The breastfeeding percentages were compared with a study for the period 1992 to 1993., Results: During the first week of the infant's life, 87% of the mothers gave breastfeeding, and at 25 weeks this figure was 30%. For the period 1998 to 2000, the breastfeeding rate at 15 weeks was higher compared with the period 1992 to 1993, 45.1% as opposed to 36.4%. An increased percentage of breastfed infants were found in each ethnic group studied. More Turkish and Moroccan mothers than Dutch mothers started to breastfeed, and they breastfed for a similar period. Surinam mothers started breastfeeding as often as Dutch mothers, but breastfed for a shorter period. Concern about inadequate milk supply was stated as the most important reason for starting formula feeding (44%). This was also the most important reason stated by each of the ethnic groups, Dutch (139/411; 34%), Surinam (63/129; 49%), Moroccan (70/130; 54%) and Turkish women (42/67; 63%)., Conclusion: An active breastfeeding policy in Amsterdam that has been operating since 1993 has been accompanied by an increase in the number of breastfed infants. This has also been the case in non-Dutch groups. Health programmes should devote greater attention to mothers' concerns about a shortage of milk.

Objective: To examine if in Amsterdam there are social or cultural groups of children with a relatively low vaccination coverage for diphtheria, pertussis, tetanus and poliomyelitis (DPTP) and mumps, measles and rubella (MMR)., Design: Descriptive cross-sectional study., Method: In the Department of Child Health Care of the Municipal Health Service of Amsterdam all 83,217 children aged 2-12 years living in Amsterdam on the 1st of January 2000 were analysed for vaccination and sociodemographic data collected routinely by the Department of Child Health Care. The sociodemographic data concerned sex, year of birth, country of birth of the mother and child, name of the school and postal code of the home address. Schools were grouped by (religious) affiliation on the basis of the Amsterdam school guide 1999/2000. Based on postal codes children were classified by the neighbourhoods in which they were living. Neighbourhoods were grouped by socio-economic status based on data from the Central Bureau for Statistics., Results: The overall vaccination rates of DPTP and MMR were 92.4% and 93.5% respectively. No important variation in vaccination coverage was identified between more and less affluent neighbourhoods. The uptake rate among foreign children was sometimes slightly higher and sometimes slightly lower compared with native children. Especially foreign children born abroad (Surinam, Antilles, Morocco, Turkey) were not fully vaccinated: 70.9% were fully immunized for DPTP, 79.5% for MMR. Children who visited anthroposophical schools were considerably less frequently fully immunized compared with children visiting other schools: for DPTP and MMR 81.0 and 59.9% respectively versus 94.4 en 95.3% for children attending general municipal schools., Conclusion: The vaccination coverage was high in children in Amsterdam. Further improvement of the vaccination uptake might be achieved by a more outreaching attitude to children born abroad, and by more intensely informing sceptical parents about the benefits and (supposed) dangers of vaccinations.

Objective: To investigate whether the prevalence of asthmatic symptoms among children in the Netherlands has changed., Design: Literature study., Method: Investigations into the prevalence of children with asthmatic symptoms were collected from Medline, Embase and various libraries if they had been performed between 1984/'85 and 1994/'95 and had used the so-called WHO or Region list. 23 studies were selected with data on 76,353 elementary school pupils. Linear regression analysis, weighed for the number of children, was used to determine if the proportions of children with asthmatic symptoms had increased over the years., Results: In 10 years the prevalence of recent shortness of breath had increased by 107% (from 4.16 to 8.63%), that of recent wheeze by 16% (from 10.64 to 12.35%), that of recent attacks of breathlessness with wheezing by 17% (from 5.29 to 6.19%), and for chronic cough by 259 (from 1.05 to 3.77%) to 272% (from 3.14 to 11.68%). The prevalence of doctor-diagnosed asthma had increased by 120% (from 2.82 to 6.19%)., Conclusion: There had been a pronounced increase in the percentage of primary schoolchildren with asthmatic symptoms between 1984/'85 and 1994/'95. The prevalence of doctor-diagnosed asthma increased faster then did key symptoms of asthma.

Objective: To examine whether ethnic origin is related to care giving styles relevant to sudden infant death., Design: Prospective/retrospective, descriptive., Method: In six child health care centres in Amsterdam, the Netherlands, data about sleep position, bedclothes and passive smoking of infants aged 1-5 months were collected by face-to-face interviews of mothers visiting these centres between February 1997 and October 1998., Results: Eligible for the study were 1815 infants, 919 boys and 896 girls, mean age 2 months. In Amsterdam 12.5% of infants were usually or sometimes put to sleep in a prone position, 31.0% usually or now and then in a side position (but not in a prone position) and 56.5% usually in a supine position. Prone sleeping position was more frequent among Surinamese infants and less frequent among Moroccan infants compared with Dutch infants. Overall use of a duvet among infants was 22.7%. Use of duvets was higher among allochtonous infants; after controlling for demographic factors this difference was not significant, however. 6.3% of the infants had slept in the previous night with a pillow. Use of a pillow was much more frequent among allochtonous than among autochtonous infants: 13% versus 1.2%. Maternal daily smoking during pregnancy and daily smoking by mothers or others at home at time of interview was found in 15.1% and 25.8% of the infants respectively. Almost no Moroccan mothers smoked during pregnancy (0.4%), while Turkish mothers smoked as much as Dutch mothers (18.5% and 21.6% respectively). No differences in daily smoking at home were found between Surinamese, Moroccan and Dutch families (circa 26%). However, daily smoking at home was much more frequent in Turkish families (43.8%)., Conclusion: Health education about a safe sleeping position, about safe bedclothes and about the dangers of passive smoking is still needed. Education programmes to prevent sudden infant death must take into account ethnic differences in care giving styles. Special attention must be paid to the use of a pillow among allochtonous infants.

Objective: To investigate whether ethnic origin is related to the prevalence of bedwetting among children and how parents handle bedwetters., Design: Descriptive study., Setting: Department of Youth Health Care in Amsterdam, the Netherlands., Method: Parents of children who attended a child health centre in 1992/1993 were interviewed using a questionnaire. A total of 1506 children aged 3-4, 2422 aged 5-6 and 2081 aged 11-12 years participated in the study., Results: The prevalences of bedwetting were 24.6%, 15.7% and 5.4% at 3-4, 5-6 and 11-12 years of age respectively. Moroccan and Turkish 3-4-year-olds wet their beds just as often as Dutch children, Surinamese 3-4-year-olds less often. However, Surinamese, Moroccan and Turkish school children wet their beds more often than their Dutch classmates. For Dutch children the prevalence of bedwetting at the age of 5-6 was clearly lower than at the age of 3-4, in contrast with Surinamese, Moroccan and Turkish children. Non-Dutch bedwetters were rewarded less often for a dry night and punished more often for a wet night than Dutch bedwetters, even at the age of 3-4., Conclusion: Bedwetting by school children still occurs often, and more often among non-Dutch than among Dutch children. Possibly, differences between Dutch and non-Dutch parents in the ways they deal with bedwetting plays a part. Appropriate information and support of (especially non-Dutch) parents of young children can perhaps reduce the prevalence of bedwetting at later ages.

Objective: To determine the causes of death among Amsterdam children dying abroad., Design: Retrospective study., Setting: Department of Youth Health Care in Amsterdam, the Netherlands., Method: Analysis was based on the data bank of the Department of Youth Health Care, which contains the items sex, age and ethnic origin of decreased children as well as time, place and cause of death., Results: A total of 791 Amsterdam children (1 week-14 years old) died during the period 1982-1993. Of these children 98 (12.4%) died outside the Netherlands; of two the place of death was unknown. A relatively large proportion of decreased Turkish and Moroccan children died while abroad, 24.7% and 34.2% respectively. The distribution of causes of death among children dying in the Netherlands differed from children dying abroad. The most important causes abroad were accidents (especially car accidents), infections (especially gastrointestinal infections) and congenital disorders. Children who died of accidents were mainly between 1 and 9 years old. Fatal infections were primarily seen in children 0 years old and of Moroccan origin, and in the period 1982-1985. Children who died of congenital abnormalities were mostly of Moroccan origin., Conclusion: Mortality among Turkish and Moroccan Amsterdam children often occurred outside the Netherlands. Mortality in children visiting foreign countries was mainly the result of preventable causes such as accidents and infections.

Objective: To investigate whether breast feeding is related to family type, family size, maternal education, maternal occupational status and ethnic origin., Design: Descriptive study., Setting: Six child health centres in Amsterdam, the Netherlands., Method: In the period 1992-1993 the feeding practices of 961 children of 3 months were investigated by interviewing their mothers., Results: In Amsterdam 21% of infants were exclusively breast-fed, 15% of infants were breast and formula fed and 64% of infants were exclusively formula fed. After adjustment for potential confounding variables, breast-feeding was associated with mother's educational level and ethnic origin. The breast feeding rate was 49% for mothers with a high education and 26% for mothers with a low education. Among Dutch mothers the frequency of breast-feeding was 37%, and among Surinam, Moroccan and Turkish mothers the frequencies of breast feeding were 16%, 34% and 43% respectively., Conclusion: These results suggest that besides socioeconomic factors cultural factors also play a part in the breast feeding practices of mothers. To promote breast feeding culture-based perceptions with respect to feeding and nursing of infants should be considered.