Uninsured immigrant and refugee children presenting to Canadian paediatric emergency departments: Disparities in help-seeking and service delivery

INTRODUCTION:

Access to health care for medically uninsured immigrant and refugee children is a public health concern due to the consequences of delayed or substandard care for child development and health.

OBJECTIVE:

To explore possible differences in help-seeking and service delivery across migratory statuses, institutions and provinces.

METHODS:

A review was undertaken of 2035 emergency files of immigrant, refugee and undocumented children without provincial health care coverage who sought care at three major paediatric hospitals in Montreal (Quebec) and Toronto (Ontario) during 2008 and 2009.

RESULTS:

Refugee claimant children with Interim Federal Health Program benefits consulted for less urgent problems than the overall hospital population, except in one hospital that had a multicultural paediatric ambulatory clinic. Undocumented children and new permanent resident immigrant children within the three-month waiting period for provincial health care coverage were over-represented in the very urgent triage category and presented more often for injuries, trauma and mental health problems than did refugee claimant children.

DISCUSSION/CONCLUSIONS:

Wide interhospital differences suggest that the predicament of limited access to health care of these groups of vulnerable medically uninsured children needs to be addressed through further research to inform policies and develop training.     

Maternal relationship style, paediatric health care use and infant health

OBJECTIVE:

The aim of the current exploratory study was to examine the relationships between maternal relationship style, paediatric health care use and infant health variables in a sample of middle-class and ethnically diverse mother-infant dyads.

METHODS:

An initial cross-sectional cohort study obtained demographic and self-report data on mothers’ relationship styles. As an extension of the original study, infants’ patient files were reviewed for the year following initial recruitment to obtain data regarding the use of paediatric health care services and infant health. The final sample included 64 mothers and their infants.

RESULTS:

Correlational analyses revealed that mothers’ higher endorsement of a dismissive relationship style were associated with fewer acute care visits and fewer reported infant illnesses.

CONCLUSIONS:

Compared with other relationship styles, mothers who highly endorsed a dismissive relationship style tended to use fewer acute paediatric health care services and reported fewer infant health problems. However, further longitudinal research is needed to clarify these relationships.     

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.     

Rare disease surveillance: An international perspective

BACKGROUND:

The International Network of Paediatric Surveillance Units (INoPSU) was established in 1998 and met formally for the first time in Ottawa, Ontario in June 2000.

OBJECTIVES:

To document the methodology and activities of existing national paediatric surveillance units; the formation of INoPSU; the diseases studied by INoPSU members; and the impact of such studies on education, public health and paediatric practice.

METHODS:

Directors of paediatric surveillance units in Australia, Britain, Canada, Germany, the Netherlands, Latvia, Malaysia, Papua New Guinea, New Zealand and Switzerland were asked to provide information on each unit’s affiliations, funding and staffing; the method of case ascertainment, the mailing list and response rates; and diseases studied. Original articles that reported data derived from units were identified by a search of an electronic database (MEDLINE), and additional information was obtained from units’ annual reports.

RESULTS:

Worldwide, 10 units (established from 1986 to 1997), use active national surveillance of more than 8500 clinicians each month to identify cases of rare or uncommon diseases in a childhood population (younger than 15 years of age) of over 47 million (monthly response rate 73% to 98%). By January 1999, units had initiated 147 studies on 103 different conditions, and 63 studies were completed.

CONCLUSION:

INoPSU enhances collaboration among units from four continents, providing a unique opportunity for simultaneous cross-sectional studies of rare diseases in populations with diverse geographical and ethnic characteristics. It facilitates the sharing of ideas regarding current methodology, ethics, the most appropriate means of evaluating units and their potential application.     

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.     

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.     

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.     

Childhood obesity: should primary school children be routinely screened? A systematic review and discussion of the evidence

Background

Population monitoring has been introduced in UK primary schools in an effort to track the growing obesity epidemic. It has been argued that parents should be informed of their child''s results, but is there evidence that moving from monitoring to screening would be effective? We describe what is known about the effectiveness of monitoring and screening for overweight and obesity in primary school children and highlight areas where evidence is lacking and research should be prioritised.

Design

Systematic review with discussion of evidence gaps and future research.

Data sources

Published and unpublished studies (any language) from electronic databases (inception to July 2005), clinical experts, Primary Care Trusts and Strategic Health Authorities, and reference lists of retrieved studies.

Review methods

We included any study that evaluated measures of overweight and obesity as part of a population‐level assessment and excluded studies whose primary outcome measure was prevalence.

Results

There were no trials assessing the effectiveness of monitoring or screening for overweight and obesity. Studies focussed on the diagnostic accuracy of measurements. Information on the attitudes of children, parents and health professionals to monitoring was extremely sparse.

Conclusions

Our review found a lack of data on the potential impact of population monitoring or screening for obesity and more research is indicated. Identification of effective weight reduction strategies for children and clarification of the role of preventative measures are priorities. It is difficult to see how screening to identify individual children can be justified without effective interventions.     

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.     

An examination of the beliefs, attitudes and counselling practices of paediatric oncologists toward physical activity: A provincial survey

BACKGROUND

With an increasing population of childhood cancer survivors and a growing recognition of the long-term effects of diagnosis and treatment, it is imperative that modifiable risk factors for long-term health and disease comorbidity be identified and addressed. Physical activity is one therapy that is gaining credibility in enhancing quality of life and reducing the burden of disease.

OBJECTIVES

To examine the beliefs, attitudes and counselling practices of a group of Alberta-based paediatric oncologists.

METHODS

All Alberta-based physicians with a known specialty in paediatric oncology were approached and asked to complete a onetime, mail-out survey.

RESULTS

All responding physicians regarded both personal exercise and physical activity for childhood cancer survivors as moderately to extremely important. Importantly, one-half of the respondents believed that there is no adverse risk associated with physical activity in this survivor group. While the bulk of physicians report prescribing physical activity, few believe that their patients actually follow these recommendations.

CONCLUSIONS

Responding oncologists acknowledge the importance of physical activity for all survivors; however, future research is needed to better understand how to best promote healthy active living within this group.     

Performance of clinical clerks doing paediatric rotations in a community hospital versus a university hospital

INTRODUCTION

Most clinical clerks (third-year medical students) do their paediatric rotation at the IWK Health Centre, the Dalhousie University-affiliated tertiary care paediatric institution in Halifax, Nova Scotia. Due to limited space, some clerks are sent to community hospitals in the provinces of New Brunswick and Prince Edward Island. These community hospitals are different in terms of the academic environment and the availability of paediatric subspecialty services.

OBJECTIVE

To compare performance of clinical clerks doing paediatric rotations in community hospitals (group I) with those in a university hospital (group II).

METHODS

The end-of-rotation test scores on the 45 single correct answer multiple choice questions and the three 15 min objective structured clinical examinations in group I (n=54) and group II (n=124) for two consecutive academic years were studied. The end-of-rotation comments by the clerks in group I were examined to assess the quality of their experience.

RESULTS

For the two academic years, the cumulative mean ± SD scores for multiple choice questions and objective structured clinical examinations were 82.82±7.47 and 70.82±11.37, respectively, in group I compared with 83.03±7.74 and 69.02±11.23 in group II. There were no significant differences in the results between the two groups. No difference in results was seen when the scores were analyzed separately for each of the academic years. The clerks in group I rated their experience as positive.

CONCLUSIONS

Clerks doing paediatric rotations in community hospitals perform as well and receive similar educational benefits as those at university hospitals. Community hospitals can provide a quality experience for paediatric clerkship training.     

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.     

Physical activity levels in children and adolescents are reduced after the Fontan procedure, independent of exercise capacity, and are associated with lower perceived general health

Objectives

To determine physical activity levels in paediatric patients who underwent the Fontan procedure, and their relationship to functional status and exercise capacity.

Study Design

We studied 147 patients (ages 7–18 years) at a median of 8.1 years after Fontan, as part of the Pediatric Heart Network cross‐sectional study of Fontan survivors. Assessment included medical history, self‐reported physical activity, parent‐completed Child Health Questionnaire (CHQ), cardiopulmonary exercise testing and physical activity level measured by accelerometry (MTI Actigraph).

Results

Measured time spent in moderate and vigorous activity was markedly below normal at all ages, particularly in females, and was not significantly related to self‐reported activity levels, or to maximum Vo₂, Vo₂ at anaerobic threshold or maximum work rate on exercise testing. Lower measured activity levels were significantly related to lower perceived general health but not to self‐esteem, physical functioning, social impact of physical limitations or overall physical or psychosocial health summary scores. Reduced exercise capacity was more strongly related than measured activity levels to lower scores in general health, self‐esteem and physical functioning.

Conclusions

Physical activity levels are reduced after Fontan, independent of exercise capacity, and are associated with lower perceived general health but not other aspects of functional status.     

An urban survey of paediatric environmental health concerns: Perceptions of parents, guardians and health care professionals

OBJECTIVES

To conduct a survey in Edmonton, Alberta, to gather information regarding concerns about the influence of environmental factors on children’s health and to use the information to set an agenda for the resources of the Paediatric Environmental Health Specialty Unit at Misericordia Hospital (Edmonton, Alberta).

METHODS

Two questionnaires with 28 closed-ended questions were developed to examine parents’, guardians’ and health care professionals’ concerns. They comprised items about six environmental factors (air, water and food quality; household supplies; radiation; and waste disposal). Health care professionals were also asked four questions about their knowledge of and their needs in Paediatric Environmental Health. Parents and guardians attending the public health centres and nurses working therein received questionnaires. Physicians were surveyed by e-mail.

RESULTS

After verification, the questionnaire data from 400 parents or guardians and 152 health care professionals were used for analyses. Results from contingency table, Hotelling’s T² and effect size analyses revealed similarities in the levels of concern in both groups, and the results were combined. The greatest concern of both groups was with environmental tobacco smoke, followed by pesticides in water. Concerns about six additional environmental elements were also expressed. The health care professionals showed a high level of concern about the need for resources, specific training and public education regarding paediatric environmental health.

CONCLUSION

A significant level of concern was consistently found between the two groups studied, regardless of professional training. The highest level of concern was with a well-documented topic (ie, environmental tobacco smoke). Less concern associated with decreased documentation calls for increasing the knowledge of society, including health care professionals, to address the adverse effects of environmental factors on children.     

Staphylococcus aureus bloodstream infections in children: A population-based assessment

BACKGROUND:

Although Staphylococcus aureus is a major cause of bloodstream infections, population-based data on these infections in children are limited.

OBJECTIVE:

To describe the epidemiology of S aureus bacteremia in children.

METHODS:

Population-based surveillance for all incident S aureus bacteremias was conducted among children (18 years of age or younger) living in the Calgary Health Region (Alberta) from 2000 to 2006.

RESULTS:

During the seven-year study, 120 S aureus bloodstream infections occurred among 119 patients; 27% were nosocomial, 18% health care associated and 56% community acquired. The annual incidence was 6.5/100,000 population and 0.094/1000 live births. A total of 52% had a significant underlying condition, and this was higher for nosocomial cases. Bone and joint (40%), bacteremia without a focus (33%), and skin and soft tissue infections (15%) were the most common clinical syndromes. Infections due to methicillin-resistant S aureus were uncommon (occurring in one infection) and three patients (2.5%) died.

CONCLUSIONS:

S aureus bacteremia is an important cause of morbidity in the paediatric age group. Underlying medical conditions and implanted devices are important risk factors. Methicillin-resistant S aureus and mortality rates are low.     

Practising what we preach: A look at healthy active living policy and practice in Canadian paediatric hospitals

BACKGROUND:

In the past 30 years, the rate of obesity has risen considerably among Canadian children. Paediatric hospitals are in a unique position to model healthy environments to Canadian children.

OBJECTIVE:

To obtain an overview of healthy active living (HAL) policy and practice in Canadian paediatric hospitals.

METHODS:

Working in partnership with the local Canadian Paediatric Society HAL champions and the Canadian Association of Paediatric Health Centres liaisons, a nationwide survey was conducted in 2006/2007 to identify healthy eating, physical activity and smoking cessation practices in all 16 Canadian paediatric academic hospitals.

RESULTS:

Policies addressing healthy eating and/or physical activity promotion were present in 50% of hospitals with a greater focus on nutrition. Wellness committees were created in 50% of the hospitals, most of which were recently established. Healthy food options were available in cafeterias, although they were often more expensive. Fast food outlets were present in 75% of hospitals. Although inpatient meals were designed by dietitians, 50% offered less nutritious replacement kids meals (ie, meal substitutions) on request. Options for play available to inpatients and outpatients were primarily sedentary, with screen-based activities and crafts predominating over active play. Physical activity promotion for staff focused on reduced membership fees to fitness centres and classes.

CONCLUSION:

Canadian paediatric hospitals do not adequately promote HAL for patients and staff. The present study findings suggest further effort is required to create necessary healthy lifestyle modifications in these institutions through Canadian Paediatric Society/Canadian Association of Paediatric Health Centres-led policy development and implementation initiatives. A national-level policy framework is required to regulate interhospital variability in policies and practices.     

Management of 21-hydroxylase deficiency congenital adrenal hyperplasia: A survey of Canadian paediatric endocrinologists

BACKGROUND

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive disorders. Many issues in the management of CAH in children still remain unresolved.

OBJECTIVE

To assess how children with CAH are treated in Canada.

METHODS

Fifty-nine paediatric endocrinologists and postgraduate trainees from across Canada took part in a survey that evaluated four areas of CAH management: type and dose of glucocorticoid therapy, current use of alternative therapies, monitoring of care, and approach/attitude to prenatal diagnosis and treatment of CAH.

RESULTS AND CONCLUSIONS

The present survey demonstrated that there is general agreement among paediatric endocrinologists in Canada regarding the management of patients with CAH, which includes very little use of newer antiandrogen therapies. The goal remains to be the optimization of currently available therapy to ensure normal growth and sexual maturation without any evidence of glucocorticoid excess or deficiency. Prenatal diagnosis and management is widely, but infrequently, used.     

Prevalence and indications for video recording in the health care setting in North American and British paediatric hospitals

BACKGROUND:

Health care video recording has demonstrated value in education, performance assessment, quality improvement and clinical care.

METHODS:

A survey was administered to paediatric hospitals in Great Britain, Canada and the United States. Heads of departments or delegates from six areas (emergency departments [EDs], operating rooms, paediatric intensive care units [PICUs], neonatal intensive care units [NICUs], simulation centres and neuroepilepsy units) were asked 10 questions about the prevalence, indications and process issues of video recording.

RESULTS:

Seventy hospitals were surveyed, totalling 307 clinical areas. The hospital response rate was 100%; the rate for clinical departments was 65%. Sixty-six hospitals (94%) currently use video recording. Video recording was used in 62 of 68 (91%) operating rooms; 36 of 69 (52%) PICUs; 35 of 67 (52%) NICUs; 12 of 65 (19%) EDs; seven of eight (88%) neuroepilepsy units and 13 of 14 (93%) simulation centres. Education was the most common indication (112 of 204 [55%]). Most sites obtained written consent. Since the introduction of more strict privacy legislation, 11 of 65 (17%) EDs have discontinued video recording.

CONCLUSION:

The present study describes video recording practices in paediatric hospitals in North America and Great Britain. Video recording is primarily used for education and most areas have a consent process.