Parents' journey through treatment for their child's obesity: a qualitative study.

BACKGROUND: Treatment for childhood obesity is characterised by patient non-attendance and drop-out, and widespread failure to achieve weight maintenance. Qualitative methods may improve our understanding of patient perceptions and so improve treatment for childhood obesity. AIM: To provide insight into the perceptions of parents of obese children as they "journey" from pre-treatment to end of treatment. METHODS: We used purposive sampling and studied 17 parents of children (mean (SD) age 8.4 (2.1) years) attending 6-month outpatient treatments for obesity (BMI>98th percentile). Parent's perceptions were explored by in-depth interviews, analysed using Framework methods. RESULTS: Parents were characterised as being unaware of their child's weight, in denial or actively seeking treatment. Parents were consistently motivated to enter treatment due to perceived benefits to their child's self-esteem or quality of life, and weight outcomes appeared typically less important. During treatment parents felt there was a lack of support for lifestyle changes outside the clinic, and noted that members of the extended family often undermined or failed to support lifestyle changes. Parents generally felt that treatment should have continued beyond 6 months and that it had provided benefits to their child's well-being, self-esteem and quality of life, and this is what motivated many to remain engaged with treatment. DISCUSSION: This study may help inform future treatments for childhood obesity by providing insights into the aspects of treatment of greatest importance to parents. Future treatments may need to consider providing greater support for lifestyle changes within the extended family, and may need to focus more on psycho-social outcomes.     

Parents' search for evidence-based practice: a personal story

Many clients engage in an intense search for evidence related to the diagnosis, prognosis and intervention options of their (or their dependent's) health condition. A client-based search for evidence poses challenges from a client and clinician perspective and evolves the client-clinician relationship. This paper describes the meaning of searching for health evidence by health-care clients such as parents of hospitalised children through a personal story. I discuss the subjective search for evidence-based health information, interpretation and transfer of information as well as its impact on providers. In order to implement client-centred care and evidence-based practice health care organisations and providers need to take an active role in guiding clients in effective health information-seeking behaviour and to develop mechanisms for processing evidence presented by clients.     

Giving information for a life-threatening diagnosis. Parents' and oncologists' perceptions

We surveyed pediatric oncologists throughout the United States and families of children with acute lymphocytic leukemia diagnosed between 1977 and 1980 at Children's Hospital National Medical Center, Washington, DC, to determine what information is perceived by both parents and physicians as essential to convey during the initial presentation of a life-threatening diagnosis. Both groups considered the following topics critical for discussion at the initial conference: diagnosis and prognosis of disease, explanation of disease process, additional tests needed to confirm and/or supplement the diagnosis, immediate therapeutic plan, and the physician's availability. Additionally, both parents and physicians, with minor variations, agreed about the order in which information about the disease should be conveyed. Although acute lymphocytic leukemia was used as a model, this study suggests guidelines that could be utilized to train residents and guide physicians in crisis-counseling techniques in the presentation to parents of a diagnosis of life-threatening illness in their child.     

Beyond 'tomorrow's doctors': a review of basic medical education in the UK

Basic medical education in the UK has been radically reshaped in the past 15 years, prompted by the General Medical Council who drove, supported and monitored the changes. Central aims of the reform included a reduction in curricular factual content, greater prominence of skills acquisition, eradication of the pre-clinical/clinical divide and a higher profile for community-based teaching and learning. Some of the major developments are outlined, although change continues in other areas. Consequences of the initiative include greater choice in the courses now offered to applicants to medical school, the growth of medical education units within medical schools and greater interest in medical education generally.     

Testicular torsion versus epididymitis: a diagnostic challenge.

Unlike the patient who presents with a potentially acute abdomen, the child or adolescent with a potentially acute scrotum cannot simply be observed. If testicular torsion is present, the testicle must be detorted and orchiopexy performed as soon as possible for fertility to be maintained. Torsion of the appendix testis, however, can usually be managed without surgery. Since the presentations of epididymitis and testicular torsion overlap, it is sometimes difficult to rapidly make the correct diagnosis. Early genitourinary consultation is appropriate in this setting. Any patient in whom testicular torsion is strongly considered should undergo immediate exploratory surgery without diagnostic studies. If the findings overlap, immediate testicular radionuclide scanning should be arranged; alternatively, with experience, Doppler sonography can be carried out. If these radiographic studies cannot be arranged and interpreted within one to two hours, scrotal exploration should be performed. Any patient with an acute scrotal complaint and a negative scan should receive daily follow-up until the symptoms subside. Although our adolescent patient did well, his acute presentation and findings should have warranted immediate exploration. It is only through this aggressive approach that we can continue to increase testicular salvage rates.     

Parents' reactions at 24-48 hrs after a preschool child's head injury.

OBJECTIVES: Our objectives were, first, to compare mothers' and fathers' early reactions (stressors, concerns) to the preschool child's head injury, their perceptions of the child's injury severity, and their social support and mental health; second, to compare families with a child in the pediatric intensive care unit (PICU) vs. general care unit (GCU) on these variables; and third, to describe the relationships between parents' early reactions and perceived and objective injury severity, their social support, and mental health. DESIGN: Analysis of data collected in the hospital 24-48 hrs after the child's admission as part of a longitudinal study of parent and family functioning after a preschool child's head injury. SETTING: Seven tertiary care centers: three free-standing children's hospitals and four comprehensive hospitals. PARTICIPANTS: Participants were 182 mothers and 64 fathers of 183 preschool children (ages 3-6) hospitalized for head injury, half in a PICU. INTERVENTIONS: Data collection. MEASUREMENTS AND MAIN RESULTS: We measured parents' early reactions (stressors, concerns), influenced by parent mental health, social support, and objective and perceived injury severity. Mothers reported more stress than fathers regarding the child's behavior and emotions, communication with staff, and their parental role. Mothers in the PICU group reported more concern about the child's future and more stress regarding the child's appearance, sights and sounds of the unit, and procedures done to the child than mothers in the GCU group. Fathers in the PICU and GCU groups reported similar levels of stress and concern. Mothers' reactions were influenced by objective and perceived injury severity, social support, and psychological distress. Fathers' reactions were influenced by objective injury severity and psychological distress. CONCLUSIONS: Although mother-father couples rated their child's injury severity similarly, mothers experienced more stress than fathers. Social support decreased the stress for mothers but not for fathers. The experience of pediatric head trauma was more stressful for mothers of children in the PICU than mothers of children in the GCU.     

Parents' psychological adjustment in families of children with Spina Bifida: a meta-analysis

Background

Spina Bifida (SB) is the second most common birth defect worldwide. Since the chances of survival in children with severe SB-forms have increased, medical care has shifted its emphasis from life-saving interventions to fostering the quality of life for these children and their families. Little is known, however, about the impact of SB on family adjustment. Reviewers have struggled to synthesize the few contradictory studies available. In this systematic review a new attempt was made to summarize the findings by using meta-analysis and by delimiting the scope of review to one concept of family adjustment: Parents' psychological adjustment. The questions addressed were: (a) do parents of children with SB have more psychological distress than controls? (b) do mothers and fathers differ? and (c) which factors correlate with variations in psychological adjustment?

Methods

PsycInfo, Medline, and reference lists were scanned. Thirty-three relevant studies were identified of which 15 were eligible for meta-analysis.

Results

SB had a negative medium-large effect on parents' psychological adjustment. The effect was more heterogeneous for mothers than for fathers. In the reviewed studies child factors (age, conduct problems, emotional problems, and mental retardation), parent factors (SES, hope, appraised stress, coping, and parenting competence), family factors (family income, partner relationship, and family climate), and environmental factors (social support) were found to be associated with variations in parents' psychological adjustment.

Conclusion

Meta-analysis proved to be helpful in organizing studies. Clinical implications indicate a need to be especially alert to psychological suffering in mothers of children with SB. Future research should increase sample sizes through multi-center collaborations.

     

Parents' interpretations of children's respiratory symptoms on video.

AIMS: To investigate how parents report children's respiratory sounds on video compared to a clinical "gold standard". METHODS: Five clinicians agreed on 10 video clips of children with audible breathing. These responses were the "gold standard". The clips were shown to parents of children: (a) with asthma/wheeze; (b) with other respiratory complaints; (c) without respiratory complaints. Parents were asked what they called the sounds, where they originated, and whether their own child made similar sounds. RESULTS: A total of 190 parents took part. The "correct" labelling of wheeze was 59% (95% confidence interval 52 to 66%) and 47% (95% confidence interval 40 to 54%) for other sounds (stridor, snoring, stertor). Parents were better at locating both sounds than labelling. There were no differences between subject groups. There were more false positive responses to labelling and locating other sounds than for wheeze (27% v 8% and 33% v 10%). CONCLUSION: Parents locate sounds better than describing them. At least 30% of all parents use other words for wheeze and 30% labelled other sounds as "wheeze". This could have important clinical implications.     

Parents' worries about children compared to actual risks.

To investigate the concerns of parents, questionnaires were given to the "first 100" parents waiting for their child's pediatric appointment in four different medical settings. They were asked to rate whether they worry "frequently," "occasionally," or "not at all" about 17 physical health issues, 16 psychosocial problems, 7 possible injuries, 4 instances of victimization, and 4 questions about parents' ability to provide discipline, affection, values and financial support. The response rate was 94%; 89% were completed adequately for analysis. Parental concerns were compared to data from the National Center for Health Statistics about the statistical likelihood of the risks occurring. Ear infections (65%) were the most common health concern, followed by reaction to immunization (57%), common colds (51%), and cancer (50%). The greatest psychosocial concern was about children watching too much television (53%), followed by concerns about the quality of day care (50%). Three-quarters of parents worry about car accidents and 72% worry about abduction of their children. Parents worry significantly about their own contribution to their child's welfare: appropriate discipline (73%), affection (56%), values and being a role model (55%), and financial support (66%). Parents who had not completed high school worried more than parents who had more than a high school education (P less than 0.03).     

Prednisolone versus dexamethasone in croup: a randomised equivalence trial.

BACKGROUND: Croup remains a common respiratory problem presenting to emergency departments. A single oral treatment of oral dexamethasone results in improved outcome. Prednisolone has similar pharmacokinetic properties and has a significant advantage in that it is commercially available in liquid preparations. OBJECTIVE: To ascertain whether a single oral dose of prednisolone was equivalent to a single oral dose of dexamethasone (matched for potency) in children with mild to moderate croup. DESIGN: A double blind, randomised, controlled equivalence trial. SETTING: Tertiary paediatric emergency department. Patients: 133 children aged 3 to 142 months presenting with mild to moderate croup. INTERVENTIONS: Children received either a single oral dose of dexamethasone 0.15 mg/kg or single oral dose of prednisolone 1 mg/kg. Outcome: The main outcome measure was unscheduled re-presentation to medical care as determined by telephone follow up at 7 to 10 days. Croup score, adrenaline (epinephrine) use, time spent in the emergency department, and duration of croup and viral symptoms were secondary outcome measures. RESULTS: Children treated with prednisolone were more likely to re-present: 19 of 65 children (29%) reattended medical care compared with 5 of 68 (7%) from the dexamethasone group. The confidence intervals around this 22% difference in outcome were 8% to 35%, outside the 0% to 7.5% range of equivalence. There were no significant differences in other outcome measures. CONCLUSION: A single oral dose of prednisolone is less effective than a single oral dose of dexamethasone in reducing unscheduled re-presentation to medical care in children with mild to moderate croup.     

Parents' trust in their child's physician: using an adapted Trust in Physician Scale.

OBJECTIVES: To assess the performance of the Pediatric Trust in Physician Scale (Pedi-TiPS) that refers to a child's physician and is a modified version of the Trust in Physician Scale (TiPS), and to explore the association of trust to demographic variables. METHODS: We performed a cross-sectional survey of parents in pediatric specialty and primary care sites. Parents completed an anonymous questionnaire that included the Pedi-TiPS. Our main outcome variable was total Pedi-TiPS score (higher scores = higher trust). Reliability was determined by Cronbach's alpha. Bivariate comparisons and linear regression modeling explored potential associations between demographic variables and total score. RESULTS: Five hundred twenty-six parents completed surveys (73% response rate). The mean total score was 45.4 (SD 6), with good internal consistency (alpha = .84). In bivariate analysis, lower scores were associated with being a father (P = 0.03), older parent age (P = 0.02), private insurance status (P < 0.01), parent education greater than high school (P = 0.04), and not having a child age <3 years (P = 0.03). In a regression model adjusted for other factors, parents who were either African American (P = 0.05), or "other" race (P < 0.01), parents with private insurance (P = 0.02), and parents who had no children <3 years of age (P = 0.04) had lower trust. CONCLUSIONS: The Pedi-TiPS has properties similar to the original instrument. We found associations between trust and demographic factors that should be confirmed with further studies.     

Hypotonic versus isotonic saline in hospitalised children: a systematic review.

BACKGROUND: The traditional recommendations which suggest that hypotonic intravenous (i.v.) maintenance fluids are the solutions of choice in paediatric patients have not been rigorously tested in clinical trials, and may not be appropriate for all children. AIMS: To systematically review the evidence from studies evaluating the safety of administering hypotonic versus isotonic i.v. maintenance fluids in hospitalised children. METHODS: Data sources: Medline (1966-2006), Embase (1980-2006), the Cochrane Library, abstract proceedings, personal files, and reference lists. Studies that compared hypotonic to isotonic maintenance solutions in children were selected. Case reports and studies in neonates or patients with a pre-existing history of hyponatraemia were excluded. RESULTS: Six studies met the selection criteria. A meta-analysis combining these studies showed that hypotonic solutions significantly increased the risk of developing acute hyponatraemia (OR 17.22; 95% CI 8.67 to 34.2), and resulted in greater patient morbidity. CONCLUSIONS: The current practice of prescribing i.v. maintenance fluids in children is based on limited clinical experimental evidence from poorly and differently designed studies, where bias could possibly raise doubt about the results. They do not provide evidence for optimal fluid and electrolyte homoeostasis in hospitalised children. This systematic review indicates potential harm with hypotonic solutions in children, which can be anticipated and avoided with isotonic solutions. No single fluid rate or composition is ideal for all children. However, isotonic or near-isotonic solutions may be more physiological, and therefore a safer choice in the acute phase of illness and perioperative period.