Abstract
Objective To explore the prevalence of symptom diagnoses in children in general practice and the management strategies performed by GPs.
Design Retrospective cohort study.
Setting The Netherlands.
Participants Participant data registered in a Dutch practice-based primary care research network (Family Medicine Network [FaMe-Net]).
Main outcome measures All episodes of care with at least 1 contact for a symptom diagnosis in 2018 as well as management strategies within each episode of care including the number and type of diagnostic interventions, therapeutic interventions, and referrals.
Results Overall, 6162 children under 15 years of age and registered with GP practices were included in the cohort. Among them, 2767 (44.9%) had at least 1 contact with their GP for at least 1 symptom diagnosis, and 161 (2.6%) had at least 1 persistent symptom diagnosis. Constipation, wheezing, and weakness were the most commonly found persistent symptoms. For persistent symptom diagnoses, GPs indicated more therapeutic interventions (n=217, 40.1%) compared to diagnostic interventions (n=175, 32.3%) or referrals (n=149, 27.6%).
Conclusion Symptom diagnoses are highly prevalent in children in general practice. Future research should focus on which children are at risk of developing persistent symptom diagnoses and how to manage them.
In general practice, a considerable number of patients present with a wide range of symptoms.1,2 These symptoms may belong to an underlying disease. However, when the relevant diagnostic criteria of a disease are not fulfilled, GPs label these symptoms as symptom diagnoses according to the World Organization of Family Doctors International Classification Committee in the International Classification of Primary Care (ICPC).3 Symptom diagnoses are a commonly used diagnostic category to describe a wide range of symptoms for which patients request care, regardless of cause.3 Because 1 in 2 patients present with a symptom diagnosis, the care of these patients is among the GP’s main tasks.1,2 In order to improve clinical practice and education, Stewart et al suggested focusing on symptom research in family medicine.2 Symptom research would provide evidence-based knowledge that can be implemented in medical education and used to support clinicians in recognizing and managing patients with persistent symptoms in their daily practice.
Caring for patients with persistent symptoms can be a challenge for GPs, especially dealing with the dilemma of whether or not to pursue further diagnostic evaluations and how to manage these symptoms adequately.2,4 As such, the presentation of symptoms and patients’ preferences regarding their care trajectory emerge from a complex interplay between patients and the wider context.5 This is even more problematic in pediatric populations because they depend on their parents to seek health care. Furthermore, literature suggests an association between children’s perception of parental overprotection and the onset of somatic symptoms.6 The early onset and persistence of symptoms seem to be associated with a poor prognosis such as functional impairment, missed school days,7,8 and severe mental illness in adulthood.9 Given the lack of primary care guidelines to support GPs in the care for children with persistent symptom diagnoses, it may sometimes be challenging for GPs to prevent unnecessary harmful interventions. Previous research has shown that, in school-aged Danish children, 1 in 5 has experienced at least 1 bodily symptom over a period of 1 year, as reported by their parents.5 For these symptoms, 1 in 3 seeks care from their GP.7 Symptoms in the pediatric population are similar to those of adults, ranging from transient and mild symptoms to persistent and disabling symptoms. While most of the children seem to present with transient and single symptoms, 1 in 10 children show recurrent and persistent bodily symptoms, as reported by their parents.5 However, these prevalence figures come from parent reports, which are at risk of recall bias. Therefore, this study aims to explore the prevalence of symptom diagnoses in children in general practice and the management strategies used by GPs.
METHODS
We performed a retrospective analysis of an observational study using data registered in the Family Medicine Network (FaMe-Net) database, a large, long-standing, and detailed Dutch primary care data registry.10 The FaMe-Net dataset includes data from electronic medical records in general practice covering 308,000 patient-years and over 2.2 million encounters from 2005 to 2019.10 The data registration validity is high because the network regularly distributes surveys for the purpose of training uniformity in coding between FaMe-Net GPs. Extensive details about the methods and the FaMe-Net database have been published.1
We have included all episodes of care (EoC) with at least 1 contact for a symptom diagnosis in 2018 following the ICPC-2, which are presented in Supplemental Table 1, available from CFPlus.* An EoC is defined as a health problem in a person from the first until the last contact.10 An EoC includes the reason for encounter (the initial presentation of illness), the diagnoses, the interventions (diagnostic interventions, treatment, and referrals), and all contacts therein. The World Organization of Family Doctors International Classification Committee states in the ICPC-2 that health problems should be recorded at the highest level of specificity determined at the time of an encounter.11 Episode-of-care diagnoses may be modified by the GP during the interaction when another diagnosis is more specific to that EoC, such as after performing diagnostic tests or referrals. In this study, we included all children under 15 years in age.3 We included face-to-face contact, contact during outside of regular hours, telephone consultations, and virtual consultations. Based on our earlier research, persistent symptom diagnoses were defined as having an EoC duration of more than 365 days.1 This 1-year threshold emerged from our analysis of symptom duration distributions within the data, complemented by insights gained from discussions with GPs specializing in symptom research and clinical practice.1 However, symptoms may disappear for a period of time and then reoccur. In such cases, GPs typically create a new episode for that specific health problem, but only if there has been a symptom-free period.
We collected GP management strategies within the EoC, including the number of EoCs with at least 1 prescription for medication, and the number and type of diagnostic interventions, therapeutic interventions, and referrals. Management strategies and related ICPC-2 codes are summarized in Supplemental Table 2, available from CFPlus.*
Descriptive statistics were reported to summarize patients’ demographic characteristics, the distribution of symptoms, the duration of symptom diagnosis episodes, and GP management strategies as medians and interquartile ranges (IQRs) or frequencies, as appropriate. Data were analyzed using SPSS, version 25.0. We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for reporting observational cohort studies.12
The Radboud University Medical Center Medical Ethical Committee in Nijmegen, the Netherlands, has approved the use of the FaMe-Net data for scientific research (CMO declaration number: 2020-6871). All patients were informed and gave consent for their participation in the FaMe-Net with the option to opt out. The extraction of the FaMe-Net data is anonymized.
The current study is part of the Encompassing Training in Functional Disorders Across Europe training network, which aims to improve the understanding of mechanisms, diagnosis, treatment, and stigmatization of functional disorders,13 and is preregistered in the Open Science Framework.14
RESULTS
Overall, 6162 children under 15 years of age were included. Among these children, 5019 (81.5%) had at least 1 contact with their GP for health problems in 2018, and 2767 (44.9%) had at least 1 contact with their GP for at least 1 symptom diagnosis. The median age of children receiving a symptom diagnosis for the first time was 5 years (IQR=7 years), and a small majority were male (n=1420, 51.3%). The median number of symptom diagnoses per child was 1 (IQR=1). The median number of contacts for children with nonpersistent symptoms was 1 (IQR=1). Most of these contacts were face-to-face contacts (n=4096, 57.9%) and telephone consultations (n=1870, 26.5%). The types of contact for the nonpersistent symptom diagnosis group are summarized in Table 1. The top 10 symptom diagnoses are summarized in Figure 1. Fever (n=439, 15.9%), cough (n=255, 9.2%), and ear pain (n=184, 6.6%) were the most frequent symptom diagnoses in children. In the nonpersistent symptom diagnosis group, GPs carried out more diagnostic interventions (n=1513, 49.6%) than therapeutic interventions (n=912, 29.9%) or referrals (n=624, 20.5%). Most of these diagnostic interventions included laboratory tests (n=1326, 87.6%). The types of interventions are summarized in Table 2.
Type of contact for the nonpersistent and persistent symptom diagnosis groups
Top 10 symptom diagnoses in general practice (contact year: 2018, study period: 2003 to 2020)
General practitioners’ management strategies for nonpersistent (n=3049) and persistent symptom diagnosis (n=541) (contact year 2018, study period 2003 to 2020)
A total of 161 (2.6%) children could be identified as having a symptom diagnosis that lasted for more than 1 year. Among these children, 158 (98.1%) had only 1 persistent symptom diagnosis and 3 of them (1.9%) had 2 persistent symptom diagnoses. The median number of contacts for the persistent group was 4 (IQR=5). Similar to the nonpersistent symptom diagnosis group, most of the contact types for the persistent symptom diagnosis group included face-to-face contacts (n=586, 67.5%) and telephone consultations (n=223, 25.7%) (Table 1). Constipation (n=24, 14.9%), wheezing (n=13, 8.1%), and weakness (n=11, 6.8%) were the most frequent persistent symptom diagnoses in children. Recurrent symptoms such as epistaxis (n=4, 2.5%) and fever (n=4, 2.5%) were also found in the most frequent persistent symptom diagnoses (Figure 2). The median age of patients receiving a persistent symptom diagnosis for the first time was 8 years (IQR=6 years), and a small majority of the children were female (n=84, 52.2%).
Top persistent symptom diagnoses (>1 y) in general practice (contact year: 2018, study period: 2003 to 2020): Twelve symptoms rather than 10 are displayed because H04—ear discharge, R06—nosebleed or epistaxis, S21—skin texture symptom or complaint, T10—growth delay, and A03—fever were all reported the same number of times.
In the persistent symptom diagnosis group, GPs carried out a higher number of therapeutic interventions (n=217, 40.1%) compared to diagnostic interventions (n=175, 32.3%) or referrals (n=149, 27.5%) (Table 2). Most of the therapeutic interventions were prescriptions (n=202, 93.1%). More than half (n=83, 50.6%) of the persistent symptom episodes resulted in at least 1 medical prescription. Most of the diagnostic interventions were laboratory tests (n=156, 89.1%). In 61.0% (n=100) of the persistent symptom episodes, at least 1 referral was indicated.
DISCUSSION
Symptom diagnoses are highly common in children. In 1 year, almost half of the children had at least 1 contact with their GP for at least 1 persistent symptom diagnosis. Of them, 1 in 20 children presented with a persistent symptom diagnosis. Constipation, wheezing, and weakness are more likely to persist in children. A referral or prescription was made in over half of the persistent symptom diagnosis episodes.
Comparison to previous literature
The prevalence of symptom diagnoses in children in our study was similar to the prevalence of symptom diagnoses in the overall population, including children.1 However, the prevalence of persistent symptom diagnoses is 3 times lower in children compared to the overall population.1 The prevalence of persistent symptom diagnoses in our study was lower than the prevalence reported in school-aged Danish children, where 1 in 5 children had at least 1 bodily symptom over a period of 1 year.5 Of these, 1 in 3 children sought care in general practices.7 Even though the data in these studies were collected through surveys, which might be subject to recall bias, the findings suggest a long course of symptoms before visiting a GP.
Headache and abdominal pain were among the top 10 most frequent persistent symptom diagnoses in children who presented to the GP. Most of the community-based literature in children has focused on pain. For example, a community-based survey in school-aged children found a prevalence of 25% of chronic pain lasting for more than 3 months, highlighting the high prevalence of chronic pain.15 These prevalence rates of chronic pain seem to be higher than the prevalence found in our study. In fact, the researchers focused on the general population presenting with pain for more than 3 months through the use of a survey, whereas in our study we focused on a primary care population that presented with pain for more than 1 year using data from electronic health records.
A systematic review of chronic pain in children found that the prevalence of pain ranged between 4% and 88%, mainly because of inconsistencies in the definitions of pain.16 However, most of the studies included in the systematic review did not meet high-quality criteria.16 Additionally, primary care studies were not included.16
Our study found that constipation, wheezing, and weakness were more likely to persist in children. These symptoms are less studied in community-based literature in children, which might suggest that the distribution of symptoms in general practice is different than in the general population.
In line with the overall population,1 we found that GPs carried out more therapeutic interventions compared to diagnostic interventions and referrals in children having persistent symptom diagnoses. Overall, a referral or prescription were the outcome in over half of the episodes where children had persistent symptom diagnoses. This finding is in line with the primary care guidelines for persistent somatic symptoms in adults, which emphasize the need to start with mild treatment options following the stepped-care approach, and that GPs should be cautious with indicating additional investigation and referrals because this might have a negative impact on health outcomes.17
Strengths and limitations
The main strength of our study is our analysis of data from the FaMe-Net database, which is a validated, longstanding primary care data registry and is representative of the Dutch population in terms of age, sex, and social class.18 That said, while FaMe-Net GPs are trained to code the diagnosis at the highest level of certainty, the possibility that some symptoms are undiagnosed diseases remains valid. Therefore, an evaluation of the morbidity rates of symptom diagnoses through an analysis of a primary care data registry might overestimate real-life prevalence. Nevertheless, our findings are a valid representation of general practice where GPs encounter challenges in making relevant diagnoses.
Practical implication and future research
Although the prevalence of persistent symptom diagnoses in children is low, having persistent symptoms during childhood is a predictor of more presentations of symptoms later in life.7 It is important to identify children at risk of developing persistent symptom diagnoses because the initial management provided by GPs is a key aspect of the prognosis of these symptoms.7 Our study highlights that constipation, wheezing, and weakness are more likely to persist in children. More research is needed to identity children at risk of developing persistent symptoms. Additionally, future studies should explore effective interventions for the management of children with persistent symptoms in general practice. Currently, no primary care guidelines are available to support GPs in the care for children with persistent symptom diagnoses, although Danish primary care guidelines on persistent symptoms devote a section to children. While reassurance and normalization were advised for mild and transient symptoms, no evidence-based guidelines for specific treatment and symptom management were suggested for recurrent and persistent symptoms, with the exception of some recommendations relating to cognitive behavioural therapy.19 Psychological interventions seem to reduce symptom load, disability, and school absence in children with persistent symptoms.20 However, the content of the therapy and precise procedures are not well described in the literature.20
Footnotes
↵* Supplemental Tables 1 and 2 are available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.
Contributors
All authors contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
- Copyright © 2025 the College of Family Physicians of Canada
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