Paediatricians’ awareness of,agreement with and use of the new Canadian Physical Activity and Sedentary Behaviour Guidelines for children and youth zero to 17 years of age

OBJECTIVE:

To examine the awareness of, agreement with and use of the new Canadian Physical Activity and Sedentary Behaviour Guidelines for children and youth zero to 17 years of age in a sample of Canadian paediatricians.

METHODS:

The findings are based on responses from 331 paediatricians across Canada who completed an online survey in February 2013. Frequencies were calculated for each question.

RESULTS:

Few paediatricians reported being very familiar with the physical activity (6% for the early years, and 9% for children and youth) or sedentary behaviour guidelines (5% for the early years, children and youth). When made aware of the guidelines, a large percentage strongly agreed or agreed with the physical activity (99% for the early years, and 96% for children and youth) and sedentary behaviour recommendations (96% for the early years, and 94% for children and youth). Of paediatricians who performed well-child visits, 16% and 27% reported almost always making physical activity and sedentary behaviour recommendations, respectively, to parents or caregivers of children in the early years, compared with 37% for both behaviours among children and youth. Thirty-nine per cent (for the early years) and 46% (for children and youth) of paediatricians reported it would be highly feasible to briefly explain the guidelines at a well-child visit. The most common barriers reported for recommending the guidelines were insufficient motivation or support from parents, caregivers or youth, and lack of time.

CONCLUSION:

To increase the use of these new evidence-informed guidelines, strategies are needed to increase paediatricians’ awareness and reduce perceived barriers.     

Childhood overweight and obesity management: A national perspective of primary health care providers' views, practices, perceived barriers and needs

BACKGROUND:

Obesity and overweight in children are an escalating problem in Canada and worldwide. Currently, little is known about the manner in which primary health care providers are responding to Canada’s obesity epidemic.

OBJECTIVE:

To determine the views, practices, challenges/barriers, and needs of a national sample of family physicians (FPs) and community paediatricians (CPs) with respect to paediatric obesity identification and management.

METHODS:

A self-administered questionnaire was mailed to a random sample of 1200 FPs and 1200 CPs across Canada between 2005 and 2006.

RESULTS:

A total of 464 FPs and 396 CPs participated. The majority of practitioners viewed paediatric obesity as an ‘important’/‘very important’ issue. Although the majority reported providing dietary (more than 85%) and exercise (98%) advice to their overweight/obese patients, practitioners’ perceived success rate in treating paediatric obesity was limited (less than 22%). Approximately 30% of FPs and 60% of CPs (P<0.05) used the recommended method to identify paediatric obesity. At least 50% of practitioners indicated that too few government-funded dietitians, a lack of success in controlling paediatric patients’ weight, time constraints and limited training were key barriers to their success. To support efforts to identify or manage paediatric obesity, practitioners identified the need for office tools, patient educational materials and system-level changes.

DISCUSSION:

Canadian primary health care providers are not adequately equipped to deal with the paediatric obesity epidemic. Effective assessment tools and treatment resources, dissemination of clinical practice guidelines, enhanced undergraduate medical education and postgraduate continuing medical education, and system-level changes are urgently needed to address this health problem.     

Incorporating CanMEDS and subspecialty training into paediatric residency programs: Why are we still deficient?

BACKGROUND:

The Royal College of Physician and Surgeons of Canada mandates that paediatric training programs in Canada incorporate subspecialty training and the teaching and evaluation of the seven CanMEDS roles into their curriculum. The literature suggests that newly practicing paediatricians feel inadequately prepared in many subspecialties and CanMEDS roles.

HYPOTHESIS:

That either current training programs underestimate the importance of these areas for future practice, or that residents themselves feel that these areas are less important.

METHOD:

An online survey of Canadian paediatric residents and paediatric residency program directors was conducted to determine their views on various subspecialty areas and CanMEDS roles.

RESULTS:

Fourteen of 16 Canadian paediatric programs participated, and 127 of 486 (26%) paediatric residents completed the survey. Overall, trainees were satisfied with their current training (86%), and 90% believed they would be adequately prepared for independent practice. Forty-six residents (40%) believed training programs place less importance on 10 of the subspecialties that newly practicing paediatricians felt less comfortable with (from a previous study conducted in 2006). However, at least 25% of residents themselves placed less importance on nine of these 10 areas. Residents also place less importance on two CanMEDS competencies which practicing paediatricians felt less comfortable with, including the medical aspects of palliative care (medical expert) and managing an efficient office practice (manager).

CONCLUSIONS:

Residents and programs place less importance on specific areas of paediatric training, thus creating potential deficiencies in graduating paediatricians. Promotion of these topics during training may better prepare residents for future practice.     

Adverse events associated with paediatric use of complementary and alternative medicine: Results of a Canadian Paediatric Surveillance Program survey

BACKGROUND

Despite many studies confirming that the use of complementary and alternative medicine (CAM) by children is common, few have assessed related adverse events.

OBJECTIVE

To conduct a national survey to identify the frequency and severity of adverse events associated with paediatric CAM use.

METHODS

Survey questions were developed based on a review of relevant literature and consultation with content experts. In January 2006, the Canadian Paediatric Surveillance Program distributed the survey to all paediatricians and paediatric subspecialists in active practice in Canada.

RESULTS

Of the 2489 paediatricians who received the survey, 583 (23%) responded. Respondents reported that they asked patients about CAM use 38% of the time and that patients disclosed this information before being questioned only 22% of the time. Forty-two paediatricians (7%) reported seeing adverse events, most commonly involving natural health products, in the previous year. One hundred five paediatricians (18%) reported witnessing cases of delayed diagnosis or treatment (n=488) that they attributed to the use of CAM.

CONCLUSION

While serious adverse events associated with paediatric CAM appear to be rare, delays in diagnosis or treatment seem more common. Given the lack of paediatrician-patient discussion regarding CAM use, our findings may under-represent adverse events. A lack of reported adverse events should not be interpreted as a confirmation of safety. Active surveillance is required to accurately assess the incidence, nature and severity of paediatric CAM-related adverse events. Patient safety demands that paediatricians routinely inquire about the use of CAM.     

Paediatrician human resource planning in Canada: A 10-year follow-up

BACKGROUND

Paediatrician human resource planning in Canada is currently a major concern. The optimal mix of physicians by type of practice and geographical distribution also remains controversial for many groups of physicians.

OBJECTIVE

To compare 10-year trends (1987 to 1997) in paediatric practice with respect to age, sex and percentage of paediatricians practicing tertiary care.

METHODS

Information on the demographics and practice patterns of Canadian paediatricians obtained from national surveys conducted in 1987 and 1997 was examined.

RESULTS

In the 1987 survey, 1960 paediatricians were mailed a questionnaire, and 1352 questionnaires were returned (response rate of 69%). In the 1997 survey, 1706 of 2337 paediatricians returned the completed questionnaire (response rate of 73%). In 1987, 26.2% of paediatricians were women compared with 38.5% in 1997 (P<0.0001). When men and women were combined, 14.5% of paediatricians were in the 25- to 34-year age bracket in 1987, compared with only 9.7% in 1997 (P=0.0002). In 1987, 37.7% of paediatricians reported practicing tertiary care versus 38.7% in 1997 (P=0.61). In addition, tertiary care paediatricians have become more centralized in communities with more than 100,000 people.

CONCLUSIONS

The results confirm that the paediatric workforce is aging, located primarily in large urban areas and shifting toward more women. Shortages of paediatricians, especially in remote and rural areas, continue to be a major concern and show no signs of improvement. The potential impact of these changes on delivery and quality of child-care services in the future needs to be assessed.     

Practical aspects of genetic testing in ambulatory paediatrics and child health care

BACKGROUND:

An overview of practical aspects of genetic testing in ambulatory practice in Canada.

OBJECTIVE:

To provide an overview and practical references for child health specialists and paediatricians on genetic services that can be provided to their patients.

METHODS/RESULTS:

A review and summary of areas of genetic testing options available across Canada.

CONCLUSIONS:

Modern Canadian paediatric practice requires office-based practitioners to fully understand and utilize genetics testing in their offices.     

Physiological referrals for paediatric musculoskeletal complaints: A costly problem that needs to be addressed

BACKGROUND/OBJECTIVE:

Referrals to paediatric orthopedists for physiologically normal conditions consume limited resources and delay care for patients. The goal of the present study was to formally define such referrals and determine their prevalence.

METHODS:

A retrospective review evaluated consecutive referrals to a single tertiary paediatric orthopedic centre over two eight-month periods. Referrals from family physicians and paediatricians were retained for analysis. Physiological referrals were defined as a final orthopedic diagnosis of ‘within physiological norms’; and no scheduled follow up.

RESULTS:

Physiological conditions represented 22.5% of referrals. The type of referring physician did not determine referral quality. Flat foot, intoeing and genu varum/valgum exhibited physiological referral rates that exceeded 40%.

CONCLUSION:

Physiological referrals constitute a large portion of the outpatient paediatric orthopedic practice and represent a substantial unnecessary cost to the Canadian medical system. Future strategies to improve referral quality should target undergraduate and postgraduate musculoskeletal education.     

Early childhood caries and infant oral health: Paediatricians�� and family physicians�� knowledge, practices and training

OBJECTIVES

To assess the knowledge of early childhood caries and to examine the current preventive oral health-related practices and training among Canadian paediatricians and family physicians who provide primary care to children younger than three years.

METHODS

A cross-sectional, self-administered survey was mailed to a random sample of 1928 paediatricians and family physicians.

RESULTS

A total of 1044 physicians met the study eligibility criteria, and of those, 537 returned completed surveys, resulting in an overall response rate of 51.4% (237 paediatricians and 300 family physicians). Six questions assessed knowledge of early childhood caries; only 1.8% of paediatricians and 0.7% of family physicians answered all of these questions correctly. In total, 73.9% of paediatricians and 52.4% of family physicians reported visually inspecting children’s teeth; 60.4% and 44.6%, respectively, reported counselling parents or caregivers regarding teething and dental care; 53.2% and 25.6%, respectively, reported assessing children’s risk of developing tooth decay; and 17.9% and 22.3%, respectively, reported receiving no oral health training in medical school or residency. Respondents who felt confident and knowledgeable and who considered their role in promoting oral health as “very important” were significantly more likely to carry out oral health-related practices.

CONCLUSION

Although the majority of paediatricians and family physicians reported including aspects of oral health in children’s well visits, a reported lack of dental knowledge and training appeared to pose barriers, limiting these physicians from playing a more active role in promoting the oral health of children in their practices.     

Paediatricians�� validation of learning objectives in paediatric cardiology

BACKGROUND

The current objectives for teaching paediatric cardiology to paediatric residents have not been validated and may not be relevant to current paediatric practice.

OBJECTIVES

To validate the cardiology component of the Royal College of Physician and Surgeons of Canada’s objectives for training paediatricians.

METHODS

A questionnaire was sent to practising paediatricians in Atlantic Canada. The questions were based on the Royal College of Physician and Surgeons of Canada’s training objectives. The frequency of problems seen, confidence in assessment and management of problems, and reasons for referral were identified. Clinical vignettes were followed by short questions. The outpatient referrals were reviewed to validate the questionnaire responses.

RESULTS

One hundred fifty-one questionnaires were mailed and the response rate was 60%. Murmurs were the most common problem encountered (92%). Syncope (9%), Kawasaki disease (8%) and chest pain (6%) were less frequently encountered. Paediatricians were confident in assessing and managing problems despite the low frequency of encounters. Less confidence was expressed regarding physical examination skills and interpretation of electrocardiograms. Uncertainty of the diagnosis was the most common reason for patient referral, with parental anxiety and medicolegal concerns accounting for 24% and 7% of referrals, respectively. Syncope with exercise was relatively poorly recognized as a worrisome symptom.

CONCLUSIONS

Most cardiology objectives for general paediatric training remain relevant and appropriate to clinical practice. Physical examination skills, electrocardiogram interpretation and the assessment of syncope need to be emphasized.     

Capacity building for child health: Canadian paediatricians in Uganda

BACKGROUND

For six years, Canadian paediatricians have worked in partnership with their Ugandan colleagues to promote improved child health in southwestern Uganda.

OBJECTIVES

To describe a collaboration between the Mbarara University of Science and Technology and Canadian partners that aims to build local capacity in child health through support of training at university, community and health centre levels.

METHODS

Three low-cost initiatives are now implemented. At the university level, volunteer Canadian paediatricians support Ugandan faculty colleagues through teaching health care trainees at a busy tertiary referral and teaching hospital. In the community, the Healthy Child Project helps Ugandans train local health volunteers who educate mothers and caregivers about child health. At health centres in the Mbarara and Bushenyi Districts, Canadians support a locally initiated outreach program that provides paediatric consultation and continuing medical education for staff at rural health posts.

RESULTS

Ugandans and Canadians have benefited from this collaboration. Hundreds of Ugandan undergraduate and graduate health care trainees, more than 100 community volunteers and numerous local health practitioners have received child health training through one of these three Canadian-supported paediatric initiatives. More than 25 Canadian paediatricians have benefited greatly from their overseas teaching and clinical experience.

CONCLUSIONS

The strength of this collaboration is a shared interest in improving child health in southwestern Uganda. A strong Ugandan-Canadian partnership has built significant child health capacity with great benefit to both partners. These initiatives may serve as a model for other child health providers wishing to support capacity-building initiatives in less developed countries to improve global health.     

Canadian paediatricians’ approaches to managing patients with adverse events following immunization: The role of the Special Immunization Clinic network

BACKGROUND:

When moderate or severe adverse events occur after vaccination, physicians and patients may have concerns about future immunizations. Similar concerns arise in patients with underlying conditions whose risk for adverse events may differ from the general population. The Special Immunization Clinic (SIC) network was established in 2013 at 13 sites in Canada to provide expertise in the clinical evaluation and vaccination of these patients.

OBJECTIVES:

To assess referral patterns for patients with vaccine adverse events or potential vaccine contraindications among paediatricians and to assess the anticipated utilization of an SIC.

METHODS:

A 12-item questionnaire was distributed to paediatricians and subspecialists participating in the Canadian Paediatric Surveillance Program through monthly e-mail and mail contacts.

RESULTS:

The response rate was 24% (586 of 2490). Fifty-three percent of respondents practiced general paediatrics exclusively and 52% reported that they administer vaccines. In the previous 12 months, 26% of respondents had encountered children with challenging adverse events or potential vaccine contraindications in their practice and 29% had received referrals for such patients, including 27% of subspecialists. Overall, 69% of respondents indicated that they would be likely or very likely to refer patients to an SIC, and 34% indicated that they would have referred at least one patient to an SIC in the previous 12 months.

CONCLUSIONS:

Patients who experience challenging adverse events following immunization or potential vaccine contraindications are encountered by paediatricians and subspecialists in all practice settings. The SIC network will be able to respond to a clinical need and support paediatricians in managing these patients.     

Asthma in children: Management practices among paediatricians and family physicians

OBJECTIVE:

To ascertain the variation in asthma management practices among paediatricians and family physicians to determine how to improve care.

DESIGN:

Questionnaire study of paediatricians and family physicians that focused on the use of beta₂-agonists, inhaled corticosteroids, patient asthma education, quantitative measurements of airflow and diagnostic investigations for asthma. Case scenarios were used in the questionnaire.

RESULTS:

The response rate was 66% (415 of 632) among paediatricians and 42% (1156 of 2750) among family physicians. In general, both groups followed consensus guidelines. There were some differences in management practices among paediatricians and family physicians. Paediatricians were more likely to develop an action plan and less likely to use xanthines or inhaled anticholinergic agents. However, family physicians were more likely to use spirometry or home peak expiratory flow rates to make a diagnosis of asthma.

CONCLUSION:

Family physicians and paediatricians require a different focus on educational interventions to improve the care of children with asthma.     

Residents as teachers in Canadian paediatric training programs: A survey of program director and resident perspectives

BACKGROUND:

The importance of the teaching role of residents in medical education is increasingly being recognized. There are little data about how this role is perceived within training programs or how residents develop their teaching skills. The aims of the present study were to explore the perspectives of Canadian paediatric program directors and residents on the teaching role of residents, to determine how teaching skills are developed within these programs, and to identify specific areas that could be targeted to improve resident teaching skills and satisfaction.

METHODS:

Program directors and residents in Canadian paediatric residency programs were surveyed about the scope of teaching performed by residents, resident teaching ability and resources available for skill development.

RESULTS:

Responses were received from 11 of 13 program directors contacted. Nine programs agreed to have their residents surveyed, and 41% of residents in these programs responded. Directors and residents agreed that residents taught the most on general paediatric wards, and that medical students and residents were the most frequent recipients of resident teaching. While 72% of directors reported that instruction in teaching was provided, only 35% of residents indicated that they had received such training. Directors believed that residents needed improvement in providing feedback, while residents wanted help with teaching at the bedside, during rounds and in small groups. Teaching performance was included in rotational evaluations in most programs, but residents were often uncertain of expectations and assessment methods.

CONCLUSION:

There is a general consensus that residents play an important teaching role, especially on the inpatient wards. Residents’ ability to fill this role could be enhanced by clearer communication of expectations, timely and constructive feedback, and targeted training activities with the opportunity to practice learned skills.     

Treating and Reducing Anxiety and Pain in the Paediatric Emergency Department: The TRAPPED survey

BACKGROUND:

Management of children’s pain and anxiety in the emergency department is likely suboptimal.

OBJECTIVE:

To determine the availability of currently used strategies in Canadian paediatric emergency departments.

METHODS:

A cross-sectional survey involving all centres of the Pediatric Emergency Research Canada group was performed. The primary outcome was the availability of specific procedures for pain and anxiety management for children in the emergency department. One person per centre was identified to complete the survey. Data were collected from October 2013 to January 2014 using an electronic survey tool.

RESULTS:

All 15 Pediatric Emergency Research Canada centres agreed to participate. The verbal numerical scale was widely used (80%) to assess pain. One-half of respondents (53%) had access to a child life specialist. The following techniques were available for minor procedures: television as a distraction tool (87% of respondents), topical anesthetic before intravenous needle insertion (73%) and positioning of the child on parent’s lap (60%); most remaining centres reported that these could be easily implemented. Intravenous morphine was available at every centre. Intranasal fentanyl was available (60%) or considered to be easy to implement (33%). Few centres reported availability of clinical guidelines regarding pain for doctors (27%) and nurses (40%); all respondents considered them to be easy to implement.

CONCLUSIONS:

There was wide variation in paediatric pain and anxiety management strategies among tertiary care Canadian emergency departments. Several pain-reduction procedures (distraction, positioning on parent’s lap, topical anesthetic, intranasal administration) were identified that could be easily implemented to address the gap.     

e-Health? Clinical information network interest and impediments in a community paediatric setting

BACKGROUND:

Increased interest in implementing evidence-based medicine in paediatric practice has led to the development of a variety of electronic clinical and decision-making support tools. Electronic medical records and information resources have the potential to improve both the clinical and cost effectiveness of paediatric community practice at the point of care. Barriers to the successful implementation of clinical information Intranet resources include physician attitudes, as well as system and practitioner capabilities.

OBJECTIVE:

To examine Ontario’s community care paediatricians’ electronic information resource needs and interest in accessing the proposed Central West Ontario Pediatric Information Network (CWPIN).

DESIGN:

Cross-sectional, interviewer-facilitated, structured survey.

POPULATION STUDIED:

Paediatricians providing community care in the Central West Ontario Health Region.

MAIN RESULTS:

Three-quarters of regional community paediatricians responded to the survey. Of those surveyed, 98% expressed interest in gaining access to the CWPIN. Computer literacy, suggested by home computer and Internet use rates (88% and 81%, respectively), did not differ significantly by age or sex. Other factors that may affect network use, such as workplace computer use and allied personnel role assignment, differed by sex, indicating potentially greater CWPIN use among male practitioners.

CONCLUSIONS:

Physicians reported an overwhelming interest in gaining access to and using the CWPIN. Disparities in current workplace but not home-based computer use by sex indicate that workplace role allocation, rather than computer literacy, may explain sex differences in CWPIN use rates. Attitudinal and computer proficiency issues did not appear to be obstacles to implementing the clinical information Intranet resource in the region.