Impact of age and diagnosis on waiting times between important healthcare events among children 0 to 19 years cared for in pediatric units: the Canadian Childhood Cancer Surveillance and Control Program

BACKGROUND: The objectives were to describe and compare waiting times to diagnosis and treatment of children and adolescents who accessed pediatric oncology centers in Canada for healthcare, and to assess the effects and relative contributions of age, sex, and diagnosis to waiting times. METHODS: Waiting times were assessed for 2,365 children (0 to 14 y) and 375 adolescents (15 to 19 y) diagnosed with cancer between 1995 and 2000 inclusive and followed by the Treatment and Outcome Surveillance system of the Canadian Children's Cancer Surveillance and Control Program. Differences were assessed using the chi2 test, Fisher exact test, and Wilcoxon test statistic. RESULTS: Median waiting times between first assessment by treating oncologist or surgeon and definitive diagnostic procedure, and the subsequent interval to first therapeutic event, were 2 days each. Significant variation existed in both periods when stratified by age and diagnosis but not sex. The most significant differences between age groups were eliminated when stratified by diagnosis. INTERPRETATION: This analysis suggests that once they enter the healthcare system, children and adolescents treated in pediatric centers in Canada experience short waiting times to key diagnostic and treatment events. Differences in wait times between the 2 age groups are not clinically significant and can be attributed to the differences in the types of cancer experienced by adolescents compared with children.     

Otitis media in Aboriginal children: The discordance between burden of illness and access to services in rural/remote and urban Australia

Objective:   To compare the burden of otitis media (OM) managed by Aboriginal Medical Service (AMS) practitioners and the availability of specialist ear health services in rural/remote versus urban Australian settings.
Design, Setting and Participants:   We mailed questionnaires to all Australian AMS medical practitioners managing children in December 2006. Questions addressed the frequency of childhood OM cases seen, and the availability and waiting times for audiology; ear, nose and throat (ENT); and hearing-aid services. We compared rural/remote and urban practitioner's responses using the χ² test with clustering adjustments.
Results:   Questionnaires were returned by 63/87 (72%) AMSs and by 131/238 (55%) eligible practitioners. Rural/Remote practitioners reported managing a greater number of children with OM per week than urban practitioners (1 df, P = 0.02) and a larger proportion of the children they managed having OM (1 df, P = 0.009). More rural/remote than urban practitioners reported relevant services were not available locally: audiology (11.1 vs. 0%, P = 0.038), ENT (33.3 vs. 3.9%, P = 0.0004) and hearing-aid provision (37.7 vs. 1.9%, P < 0.0001). More rural/remote practitioners reported audiology waiting times longer than the recommended 3 months (18.3 vs. 1.9%, P = 0.007). Equal proportions reported ENT waiting times longer than the recommended 6 months (13.9 vs. 11.3%, P = 0.7).
Conclusions:   Rural/Remote AMS practitioners manage a greater OM burden than urban AMS practitioners, but affected children have less access to specialist ear health services and longer waiting times. One in five rural/remote Aboriginal children wait longer than recommended for audiology testing, and one in eight Aboriginal children nationwide wait longer than recommended for ENT services.     

Impact of wait time on outcome for inguinal hernia repair in infants

Background  Prolonged surgical wait times are a problem in many health care systems. We used data from two pediatric surgical centers, one Canadian and one American, in order to determine if increased wait times are related to rates of incarceration and adverse outcomes. Methods  Data were collected for children under the age of 2 who presented with an inguinal hernia to either the emergency department or clinic in the two hospitals in 2002 and 2003. Results  Infants in the Canadian center were older at presentation and were more likely to present to the emergency department. Wait time for hernia repair was longer in the Canadian than the American hospital (99 ± 103 vs. 27 ± 53 days, P < 0.001). The incidence of incarceration was higher in the Canadian hospital, and infants in the Canadian center were more likely to have episodes of recurrent incarceration. Emergency department usage was greater in the Canadian hospital both at the time of diagnosis as well as during the waiting period for surgery. Discussion  Prolonged wait time for inguinal hernia repair in infants is associated with a higher rate of incarceration as well as greater usage of emergency department resources. These data are important for those surgeons working in systems with limited resources in which strategies to shorten wait times are necessary.     

Factors influencing child mental health: A state‐wide survey of Victorian children

Aims: This study aims to estimate the prevalence of mental health problems among Victorian children and to investigate factors associated with poorer mental health. Method: Computer‐assisted telephone interviews were undertaken with the parents of 3370 randomly selected Victorian children aged 4 to 12 years. They reported on their child's mental health and special health‐care needs as well as their own mental health, family functioning and a range of community and socio‐demographic variables. Population estimates and odds ratios (OR) were calculated with 95% confidence intervals (95% CI). Results: Overall, 11.6% (95% CI = 10.3–12.9%) of Victorian children were estimated to be at risk of having mental health problems. Factors independently placing children at increased risk of mental health problems that were ‘of concern’ include a child having special health‐care needs (OR = 7.89, 95% CI 5.16 to 12.08), unhealthy family functioning (OR = 3.84, 95% CI 2.19 to 6.74), parental mental health problems (OR = 7.89, 95% CI 5.16 to 12.08), neighbourhood safety (OR = 2.47, 95% CI 1.20 to 5.07) and area of residence (OR = 2.01, 95% CI 1.33 to 3.02). Conclusions: A significant proportion of Victorian children are at some risk of mental health problems. These limited but important predictors of children's mental health reinforce the need for policy solutions that will extend beyond those offered by traditional mental health service systems.     

Use of an occupational therapy motor performance checklist by a school health service: A pilot study

Objective : The aim of this pilot study was to assess whether the School Health Service could play a role in identifying the children in most need of community occupational therapy services.
Methodology : A two-tiered referral system, which incorporated a Motor Performance Checklist (MPC) devised by the authors, was used. This checklist consisted of 12 gross and fine motor items and was administered to 123 children in their first year of school. Comparison was made between parent/teacher referrals alone and the two-tiered referral system as measured against a 'gold standard' test (the Bruininks-Oseretsky Test of Motor Proficiency) in a smaller subgroup.
Results : Results indicated that the two-tiered referral system incorporating the MPC had a sensitivity of 75% and specificity of 95% while the teacher/parent referrals had a sensitivity of 88% but a low specificity of only 41%. There was no significant difference in sensitivity ( z = 0, P < 0.05) but a highly significant difference in specificity ( z = 3.56, P > 0.005) between these two systems.
Conclusions : This two-tiered referral system has the potential to impact significantly on paediatric occupational therapy utilization, service delivery and waiting times in the community health setting.     

Comparison of health status of children using a school-based health center for comprehensive care.

OBJECTIVE: Our objective was to compare health problems and medical coverage of homeless and housed children who used a school-based health center (SBHC) for comprehensive care. METHODS: Medical charts of homeless children (n = 76) and housed children (n = 232) seen for comprehensive care at an SBHC in New York City during the 1998-99 school year were systematically reviewed and compared. RESULTS: Controlled for ethnicity and medical coverage, homeless children were 2.5 times as likely (P <.001) to have health problems and 3 times as likely (P <.001) to have severe health problems as housed children. The most common health problems identified in the homeless population were asthma (33%), vision (13%), mental health (9%), and acute problems (8%). Lack of medical coverage was evident in 58% of homeless children, compared with 15% of housed children (P <.001). CONCLUSION: Study findings identify homeless children as being at increased risk for health problems and lack of medical coverage. These findings support use of an SBHC for comprehensive care by underserved segments of the population and a need for increased vigilance on the part of health care providers caring for homeless children.     

Dental visits by Australian preschool children

OBJECTIVE: To provide population-based data on dental visits in preschool children, to assist in the planning of such services and preventive programs. METHODOLOGY: Dental visits in young children are described and associated factors are investigated using data from the 1995 National Health Survey. RESULTS: Thirty-eight per cent of children aged 3-4 years had ever visited a dental professional with 31% having visited a dental professional in the previous 12 months (total n = 1596). Factors associated with having ever visited a dental professional included age in years (chi2 = 74.16, P < 0.0001), state of residence (chi2 = 25.81, P= 0.0005) and private health insurance (chi2 = 7.96, P= 0.005). Similar factors were associated with visits in last 12 months. Western Australia had the lowest proportion of preschool children aged 3-4 years having ever visited a dental professional (29%) while South Australia had the highest proportion (48%). The major reasons given for dental visits were check-up and fillings. CONCLUSION: Data regarding children not as likely to attend dental services can be used to target services and assist in ensuring preschool children receive appropriate dental care.     

Association between residence location and likelihood of transplantation among pediatric dialysis patients

Samuel SM, Hemmelgarn B, Nettel‐Aguirre A, Foster B, Soo A, Alexander RT, Tonelli M, Pediatric Renal Outcomes Canada Group. Association between residence location and likelihood of transplantation among pediatric dialysis patients. Abstract: Many children with ESRD reside far from a kidney transplant center. It is unknown whether this geographical barrier affects likelihood of transplantation. We used data from a national ESRD database. Patients ≤18 yr old who started renal replacement in nine Canadian provinces during 1992–2007 were followed until death or last contact. Primary outcome was kidney transplantation (living or deceased donor). Distance between nearest pediatric transplant center and each patient’s residence was categorized as: <50, 50 to <150, 150 to <300, and ≥300 km. Using survival analysis, we compared likelihood of transplantation between whites and non‐whites living in various distance categories. Among 728 patients, 52.2% were males and 62.5% were whites. Compared to white children living <50 km from a transplant center, white (HR, 0.73; 95% CI, 0.56–0.95) and non‐white (HR, 0.66; 95% CI, 0.48–0.92) children living ≥300 km away were less likely to receive a transplant. Non‐white children living <50 km away (HR, 0.59; 95% CI 0, 45–0.78) were also less likely to receive a transplant compared to otherwise similar whites living <50 km away. Although equitable access to transplantation by residence location is observed among remote‐dwelling adults with ESRD, white and non‐white children with ESRD living ≥300 km from a transplant center were less likely to receive transplants.     

Oral health care for children – a call for action

Oral health is a fundamental component of overall health. All children and youth should have access to preventive and treatment-based dental care. Canadian children continue to have a high rate of dental disease, and this burden of illness is disproportionately represented by children of lower socioeconomic status, those in Aboriginal communities and new immigrants. In Canada, the proportion of public funding for dental care has been decreasing. This financial pressure has most affected low-income families, who are also less likely to have dental insurance. Publicly funded provincial/territorial dental plans for Canadian children are limited and show significant variability in their coverage. There is sound evidence that preventive dental visits improve oral health and reduce later costs, and good evidence that fluoridation therapy decreases the rate of dental caries, particularly in high-risk populations. Paediatricians and family physicians play an important role in identifying children at high risk for dental disease and in advocating for more comprehensive and universal dental care for children.     

Parental attitudes to digital recording: A paediatric hospital survey

Aim: Digital recording is ubiquitous in the community. Its objectivity, permanence and utility in medical education have led to increasing use in health‐care settings. As participants in this process, the perspectives of families are important to inform practice. We surveyed family members of hospitalized children to evaluate their opinions. Methods: A survey was administered to adults in emergency, operating room or ICU waiting areas at a university‐affiliated paediatric hospital in Toronto. Respondents rated the frequency of digital recording in the community and hospital environments, the acceptability of five clinical indications and of consent discussions. Results: Participants completed 154 surveys (response rate 83%) with median (interquartile range) of 2 (1–2) children. Community use of recording >4 times in the week prior was reported by 47 (31%); 42 (28%) reported no recording. The respondents rated the following indications for digital recording acceptable in the health care research 142 (94%), medical education 140 (93%), quality improvement 140 (92%), patient safety 147 (97%), and clinical care (96%). Within healthcare, consent discussions at different times were rated as acceptable before recording by 99%; after recording by 41%; and with no consent by 17%. Conclusion: We performed the first post‐privacy legislation survey of digital recording in Canadian health care. There is widespread acceptance of digital recording in public spaces and health care; however, respondents preferred to provide consent before recording. Balancing these preferences with the demonstrated advantages of video recording in health care presents challenges for optimal health policy creation. This study provides contemporary data to inform discussions.     

A comparison of sleeping problems in school-age children between rural and urban communities in China

Aim:   To investigate differences in sleeping behaviours in school-age children between urban and rural Chinese communities.
Methods:   Children aged between 6 and 12 years old were selected from rural ( n = 472) and urban communities ( n = 576). Children's sleep habits questionnaire was completed by the parents to assess sleep patterns and sleep problems of the children.
Results:   In the 6–8 and 9–12 years groups, the average sleep time in urban children was shorter than in the children from rural areas (9.0 ± 1.1 vs. 11.3 ± 1.1 h, and 9.2 ± 1.0 vs. 10.2 ± 0.9 h, respectively, all P < 0.01). The rate of abnormal sleep behaviour in the urban and rural cohort was 82.8 and 70.1%, respectively ( P < 0.05). The prevalence of sleep delays in the 6- to 8-year-old children from urban areas was higher than in the rural areas (60.3 vs. 40.3%, P < 0.01). In the urban 9–12 years group, the rate of day-time sleepiness was higher than in the rural group (52.6 vs. 26.8%, P < 0.01), whereas the night waking rate was lower (43.8 vs. 58.6%, P < 0.01). Multivariate logistic regression analysis showed that the location of the residence, mother's age, parent's sleep habits and education levels predict the sleeping problems in these children.
Conclusion:   Children from urban communities appear to have sleeping problems than children from a rural setting. A parent's sleep habits, education levels and the location of children's residence have significant impact on the children's sleep behaviour and habits.     

The Canadian Biliary Atresia Registry: Improving the care of Canadian infants with biliary atresia

Biliary atresia is the most common cause of end-stage liver disease and liver cirrhosis in children, and the leading indication for liver transplantation in the paediatric population. There is no cure for biliary atresia; however, timely diagnosis and early infant age at surgical intervention using the Kasai portoenterostomy optimize the prognosis. Late referral is a significant problem in Canada and elsewhere. There is also a lack of standardized care practices among treating centres in this country. Biliary atresia registries currently exist across Europe, Asia and the United States. They have provided important evidence-based information to initiate changes to biliary atresia care in their countries with improvements in outcome. The Canadian Biliary Atresia Registry was initiated in 2013 for the purpose of identifying best standards of care, enhancing public education, facilitating knowledge translation and advocating for novel national public health policy programs to improve the outcomes of Canadian infants with biliary atresia.     

Maternal Place of Birth,Socioeconomic Characteristics,and Child Health in US-Born Latinx Children in Boston

ObjectiveAmong US-born children of Latina US (USB) and Latina foreign-born mothers (FBM), to determine whether 1) household and child characteristics differ; 2) child health outcomes differ; 3) these differences diminish for children of FBM with longer duration of residence in the United States; and 4) these differences can be explained by food insecurity (FI) or by Supplemental Nutrition Assistance Program (SNAP) participation.MethodsCross-sectional survey of 2145 Latina mothers of publicly insured US-born children 0 to 48 months old in a Boston emergency department (ED) 2004 to 2013. Predictors were FBM versus USBM and duration of residence in the United States. Outcomes were mothers’ report of child health, history of hospitalization, developmental risk, and hospital admission on the day of ED visit. Multivariable logistic regression adjusted for potential confounders and effect modification.ResultsFBM versus USBM households had more household (31% vs 26%) and child (19% vs 11%) FI and lower SNAP participation (44% vs 67%). Children of FBM versus USBM were more likely to be reported in fair/poor versus good/excellent health (adjusted odds ratios 1.9, 95% confidence interval [1.4, 2.6]), with highest odds for children of FBM with shortest duration of residence, and to be admitted to the hospital on the day of the ED visit (adjusted odds ratios 1.7, 95% confidence interval [1.3, 2.2]). SNAP and FI did not fully explain these outcomes.ConclusionWhen providing care and creating public policies, clinicians and policymakers should consider higher rates of food insecurity, lower SNAP participation, and risk for poor health outcomes in Latinx children of FBM.     

The impact of humanoid robot presence in the paediatric emergency department waiting room: A prospective cohort study

BackgroundThe waiting room represents families’ first point of contact with the emergency department (ED). We wished to study if a humanoid robot technology presence in the waiting room would improve satisfaction and decrease anxiety for caregivers in the paediatric ED. MethodsThis observational cohort study was conducted from September to December 2018 at a Canadian paediatric ED. All caregivers and children >11 years in the ED waiting room were eligible. We compared a robotic intervention (RI) to standard of care (SOC) education in the waiting room. The RI was a 5-minute psychoeducational program describing the ED process and flow. Specific days were designated for RI or SOC. An anonymous survey was administered twice, at the same times, on both SOC and RI days. The primary outcomes were (a) caregiver satisfaction with waiting room experience using a 5-point Likert scale; and (b) caregiver-reported anxiety in the waiting room, as measured by the State Trait Anxiety Inventory – State Scale. ResultsSix hundred and thirty-three caregivers participated, with a median age of 37 years (IQR 32 to 42); 80 children participated, with a median age of 15 years (IQR 13 to 16). Caregivers reported greater overall satisfaction in the RI cohort (174/200, 87.0%) compared to the SOC cohort (144/229, 62.9%; P<0.0001). Caregivers also reported lower anxiety in the RI cohort (39.38±11.38) compared to the SOC cohort (42.04±11.99; P=0.009).ConclusionsA humanoid robot-based psycho educational intervention in the paediatric ED waiting room has a positive impact on caregiver satisfaction and anxiety.     

Parents may know best! A pilot study suggests that children of parents who do not have contact with health care professionals before attending the emergency department are triaged as more urgent

OBJECTIVE

To assess the influence of prehospital health care contact on triage acuity.

METHODS

One hundred fifteen families were assigned Canadian Triage and Acuity Scale scores by a paediatric emergency department (ED) physician. Scores of children who had or had not seen a health care professional before attending the ED were compared.

RESULTS

Sixty-two of 72 (86.1%) children without previous health care professional contact, and 30 of 43 (69.8%) children with contact were triaged as ‘urgent’ (P=0.034). Parents with first aid knowledge (29 of 43 [67.4%]) were more likely to have had contact with a health care professional before visiting the ED compared with those with no such knowledge (27 of 72 [37.5%]; P=0.003).

CONCLUSION

Patients without previous health care professional contact were assigned more acute triage categories. Health care professionals may advise families to visit the ED more frequently than necessary, which could contribute to ED congestion. Incorporating a parental estimate of the degree of urgency of their child’s complaint into triage procedures represents an intriguing and challenging possibility.     

Continuous source of care among young underserved children: associated characteristics and use of recommended parenting practices.

OBJECTIVES: The aim of this study was to 1) assess sociodemographic and health characteristics associated with having a continuous source of care (CSOC) among young children and 2) determine the relationship between having a CSOC and use of parenting practices. METHODS: We conducted a prospective, community-based survey of women receiving prenatal care at Philadelphia community health centers. We conducted surveys at the first prenatal visit and at a mean age +/- standard deviation of 3 +/-1, 11 +/- 1, and 24 +/- 2 months postpartum, obtaining information on sociodemographic and health characteristics, child's health care provider, and 6 parenting practices. Group differences were tested between those with and without a CSOC by using the chi-square test for categorical variables and the Student's t test for continuous variables. Logistic regression analysis was conducted to adjust for potential confounding variables. RESULTS: Our sample consisted of 894 mostly young, African American, single women and their children. In the adjusted analysis, mothers of children with a CSOC, when compared with those without a CSOC, were more likely to have a high school education or less, be born in the United States, have a postpartum checkup, have stable child health insurance, and initiate care for their child at a site other than a community-based health center. Use of parenting practices was similar for children with and without a CSOC. CONCLUSIONS: Maternal nativity, postpartum care, child health insurance, and initial site of infant care were associated with CSOC, but infant health characteristics were not. Use of parenting practices did not differ for those with and without a CSOC.     

Comparison of Children Hospitalized With Seasonal Versus Pandemic Influenza A, 2004-2009

BACKGROUND: The extent to which pandemic H1N1 influenza (pH1N1) differed from seasonal influenza remains uncertain. METHODS: By using active surveillance data collected by the Immunization Monitoring Program, Active at 12 Canadian pediatric hospitals, we compared characteristics of hospitalized children with pH1N1 with those with seasonal influenza A. We compared demographics, underlying health status, ICU admission, and mortality during both pandemic waves versus the 2004/2005 through the 2008/2009 seasons; influenza-related complications and hospitalization duration during pH1N1 wave 1 versus the 2004/2005 through the 2008/2009 seasons; and presenting signs and symptoms during both pH1N1 waves versus the 2006/2007 through the 2008/2009 seasons. RESULTS: We identified 1265 pH1N1 cases (351 in wave 1, 914 in wave 2) and 1319 seasonal influenza A cases (816 from 2006/2007 through 2008/2009). Median ages were 4.8 (pH1N1) and 1.7 years (seasonal influenza A); P < .0001. Preexisting asthma was overrepresented in pH1N1 relative to seasonal influenza A (13.8% vs 5.5%; adjusted P < .0001). Symptoms more often associated with pH1N1 wave 1 versus seasonal influenza A were cough, headache, and gastrointestinal symptoms (adjusted P < .01 for each symptom). pH1N1 wave 1 cases were more likely to have radiologically confirmed pneumonia (adjusted odds ratio = 2.1; 95% confidence interval = 1.1-3.8) and longer median length of hospital stay (4 vs 3 days; adjusted P = .003) than seasonal influenza A. Proportions of children requiring intensive care and deaths in both pH1N1 waves (14.6% and 0.6%, respectively) were not significantly different from the seasonal influenza A group (12.7% and 0.5%, respectively). CONCLUSIONS: pH1N1 in children differed from seasonal influenza A in risk factors, clinical presentation, and length of hospital stay, but not ICU admission or mortality.     

Difficulties or mistakes in diagnosing type 1 diabetes in children?—demographic factors influencing delayed diagnosis

Background: Diabetic ketoacidosis (DKA) development in children with new‐onset type 1 diabetes (T1DM) is often the main consequence of delayed diagnosis. The aim of the study was to estimate the frequency of difficulties in T1DM diagnosis and to investigate if and how the demographic factors (gender, patient's age at presentation, family history of T1DM, level of maternal education, place of residence, and health service unit the patient called at) have any influence on diagnostic delays. Subjects and methods: Retrospective analysis of 474 children (243 boys—51.27% and 231 girls ?48.73%) with new‐onset T1DM aged below 17 yr and living in the Pomeranian region of Poland was carried out. The delay in diagnosis was recognized if the patient was not diagnosed on the first visit because of omission, wrong interpretation of main diabetic symptoms, exclusive treatment of additional signs, or concomitant diseases. Results: Difficulties in diagnosing T1DM were found in 67 cases (14.13%) and they are the main cause of DKA development in these children (p = 0.00). Among the examined demographic factors, mainly the patient's age at presentation has a significant influence on diagnostic delays (p = 0.01), especially in children below 2 yr (p = 0.00). Most frequently family doctors were responsible for wrong preliminary diagnosis. Conclusions: Difficulties in diagnosing T1DM are a significant cause of DKA development in children with new‐onset disease. Patient's age at presentation is the main risk factor of delayed diagnosis, especially in children below 2 yr. The increase in awareness among pediatricians concerning the possibility of T1DM development in children is needed.