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.     

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.     

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.     

Principles of managing children with asthma in the emergency department

INTRODUCTION

Paediatric asthma exacerbations comprise a significant portion of emergency department (ED) visits and hospitalizations. Recognition of diagnostic symptoms and signs, and timely use of appropriate medications may reduce the need of hospitalizations and the impact of this disease on the lives of children and their families.

OBJECTIVE

To review the pathophysiology of asthma, the current recommendations for conventional medical treatment in the ED, the controversies surrounding adjunct therapies, and the importance of discharge planning and follow-up.

CONCLUSIONS

Paediatric asthma exacerbations may be successfully treated in the ED with the use of appropriate inhaled and systemic medications.     

Mothers' beliefs about analgesia during childhood immunization

BACKGROUND:

Immunization injections are the most common painful medical procedures experienced during childhood, yet there is a discrepancy between recommendations for the effective use of topical anesthetics to reduce vaccine injection pain and actual practice.

OBJECTIVE:

To improve our understanding of mothers’ experiences and practices regarding their children’s routine immunizations.

METHOD:

Adopting an interpretive, naturalistic paradigm, semi-structured interviews were conducted with 15 mothers to examine their perceptions and experiences of their children’s immunization pain and pain management.

RESULTS:

The findings demonstrated three main themes: attitudes toward immunization pain, immunization pain management and physicians as sources of information. Participants described feeling distressed while their children were being immunized, but most managed these difficulties by focusing on the benefits of immunization and by minimizing or justifying the pain. All of the participants used non-pharmacological techniques to manage immunization injection pain. Few mothers were aware of the availability of topical anesthetics. When participants did use pharmacological analgesic approaches, oral analgesics were most likely to be used for prophylaxis and treatment of fever, and participants were unaware of evidence-based approaches to managing pain. Participants viewed their physicians as trusted sources of information, and the majority said that they would likely use a topical anesthetic in the future if recommended or approved by their physician.

CONCLUSION:

The present findings provide direction for future knowledge translation activities to enhance the knowledge of mothers and clinicians regarding pain during immunization injections and its effective management.     

Oral-steroid sparing effect of inhaled fluticasone propionate in children with steroid-dependent asthma

OBJECTIVE:

To evaluate the oral steroid-sparing effect of inhaled fluticasone propionate (FP) in eight children with steroid-dependent asthma.

DESIGN AND SETTING :

Treatment protocol study at a tertiary pulmonary care centre at a children’s hospital.

PATIENTS:

Eight children with severe persistent steroid dependent asthma (mean age 11.6 years [range 10 to 13 years], mean duration of asthma 8.37 years [range three to 11 years]) were enrolled in the study.

MEASUREMENTS:

Inhaled FP 880 μg/day (two puffs of 220 μg/puff, two times a day) was added to the children’s asthma treatment, and attempts were made to reduce the dose of oral steroids by 20% every two weeks over a six-month period. After this six-month period, in the patients responding to inhaled FP, the dose of inhaled FP was reduced to 440 μg/day (two puffs of 110 μg/puff, two times a day) for the next six months. The mean percentage predicted values for forced expiratory volume in 1 s (FEV₁) and maximal mid-expiratory flow rate (FEF_25%–75%) were compared during the first month, at two to six months, and at seven to 12 month intervals before and after starting FP. The number of asthma exacerbations, emergency room visits, hospital admissions and number of school days lost were also compared.

RESULTS:

Within three months of starting inhaled FP, the mean alternate-day oral steroid dose decreased from 38 mg to 2.5 mg. In addition, six patients (66%) were able to discontinue the use of oral steroids. There was significant improvement in the number of mean emergency room visits per patient (P=0.016), mean asthma exacerbations per patient (P=0.016), mean hospital admissions per patient (P=0.016) and mean number of school days lost per patient (P=0.004) while patients were receiving high dose inhaled FP compared with oral steroids. There was no deterioration of any of the above mentioned parameters during the six month period when the dose of inhaled FP was reduced. The mean FEV₁ and FEF_25%–75% during the two- to six-month and seven- to 12-month periods showed significant improvement, while the patients were receiving FP compared with oral steroids (P<0.05 for both parameters for both time periods).

CONCLUSIONS:

High dose inhaled FP 880 μg/day has an important oral steroid-sparing effect. After oral steroids are tapered, patients maintain adequate control of asthma with low dose inhaled FP. These findings suggest that FP may control asthma better than oral steroids.     

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.     

A survey of the management of newborns with severe hemophilia in Canada

OBJECTIVE

To determine the practice patterns of Canadian hematologists and neonatologists/paediatricians who care for newborns with hemophilia, with regard to vitamin K administration, use of empirical clotting factor replacement therapy, neuroimaging and timing of hematology consultation.

METHODS:

Hematologists and neonatologists/paediatricians, identified from membership lists of Canadian professional organizations, were provided electronic and/or paper versions of the survey instrument. Questions were posed in the context of specific clinical scenarios. Differences in response proportions between groups were compared for selected questions.

RESULTS:

There were 171 respondents among 616 eligible persons who were sent the survey; 58 respondents had recent experience managing a newborn with hemophilia. There was a consensus not to provide empirical treatment to well newborns after uncomplicated deliveries, to provide empirical treatment to symptomatic newborns and to obtain neuroimaging for symptomatic newborns. Systematic differences between hematologists and neonatologists/paediatricians existed with regard to the timing of hematology consultation when the diagnosis of hemophilia had not been confirmed antenatally, the route of vitamin K administration for newborns with hemophilia and the choice of product to use for empirical treatment of a symptomatic newborn.

CONCLUSIONS:

The observed lack of consensus regarding important management decisions indicates a need for ongoing research in the care of newborns with hemophilia. Systematic differences between hematologists and neonatologists/paediatricians suggest a role for improved communication and collaboration between these two groups of practitioners.     

Knowledge of paediatric concussion among front-line primary care providers

OBJECTIVE:

To assess the knowledge of paediatric concussion diagnosis and management among front-line primary care providers.

METHODS:

Experts from the Concussions Ontario Diagnosis and Early Education Working Group developed a 34-item survey incorporating case vignettes with the collaboration of experts in medical education. Electronic surveys were distributed via FluidSurveys using a modified version of Dillman’s tailored design method. The survey was distributed to five Ontario professional associations. The target participants were front-line health care providers (family physicians, emergency medicine physicians, general paediatricians, nurse practitioners and physician assistants) in Ontario; only providers who diagnose and/or manage paediatric concussions were eligible to participate.

RESULTS:

The survey was fully completed by 577 health care providers who treat paediatric concussion. Of the respondents, 78% (95% CI 74% to 81%) reported diagnosing ≥5 concussions annually. Physicians and nonphysicians equally recognized concussion (90% [95% CI 86% to 92%]; 85% [95% CI 77% to 90%], respectively). Only 37% (95% CI 32% to 41%) of physicians correctly applied graduated return to play guidelines. Return to learn recommendations were also insufficient: 53% (95% CI 49% to 58%) neglected to recommend school absence and 40% (95% CI (35% to 44%) did not recommend schoolwork accommodations. Only 26% (95% CI 22% to 30%) of physicians reported regular use of concussion scoring scales.

CONCLUSIONS:

Considerable gaps in knowledge exist in front-line primary care providers with inadequate application of graduated return to play and return to learn following concussion, as demonstrated by the present broad population-based survey. Consistent application of best evidence-based management using comprehensive guidelines may help to reduce the impact of concussion and persistent postconcussive problems in children and adolescents.     

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.     

Early neonatal discharge guidelines: Have we dropped the ball?

OBJECTIVES:

To determine patterns of follow-up and prenatal education by family physicians and to assess whether practice patterns comply with the 1996 Canadian Paediatric Society/Society of Obstetricians and Gynecologists of Canada (CPS/SOGC) guidelines for early neonatal discharge.

DESIGN:

Mail survey.

SETTING:

A community of 300,000 people who were served exclusively for obstetrical care by a tertiary care hospital that performs 5000 deliveries per year and provides an early discharge program (EDP).

PARTICIPANTS:

Family physicians who provide prenatal and/or newborn care.

MAIN OUTCOME MEASURES:

The timing of neonatal follow-up and parental teaching by family physicians.

RESULTS:

Thirty-two per cent of the respondents scheduled their first postnatal visits two or more weeks after early discharge. There was no significant difference (P=0.7) in scheduling of follow-up for babies who were part of an EDP compared with those who were not. Fewer than 20% of physician respondents provided antenatal education in preparation for early discharge.

CONCLUSIONS:

The 1996 CPS/SOGC guidelines for physician follow-up after early neonatal discharge and for anticipatory parental education are not being followed consistently; however, these guidelines were disseminated without reinforcement. Until further study supports a change in practice guidelines, appropriate implementation strategies must be employed to ensure compliance.     

Paediatric primary care quality and accessibility: Parents�� perspective

OBJECTIVE

To measure parents’ satisfaction with paediatric primary care quality and accessibility.

BACKGROUND

High-quality paediatric primary care is a cornerstone of efforts to improve health outcomes and access to care, as well as to control health care spending. A strong primary care infrastructure is related to improved health outcomes, including an improved mortality rate.

METHODS

A cross-sectional survey using the Parents’ Perception of Primary Care questionnaire and evidence-based items from the Rourke Baby Record were used to measure parents’ satisfaction.

RESULTS

Of 200 questionnaires sent, 130 were returned. The mean number of children per family was 1.7±0.8 (mean ± SD). Sixty-six per cent of children received their primary care from general practitioners, 19% received their primary care from paediatricians, and 15% had no regular physician and identified other professionals (community nurses, midwives or chiropractors) as their primary care providers. Parents were questioned about their child’s hearing in 66% of cases. Only 41% of parents received guidance about breastfeeding, 37% about adequate sleeping position, 17% about the dangers of second-hand smoke and 16% about car safety seats. The level of satisfaction with communication, contextual knowledge and coordination of care was higher for families followed by general practitioners and paediatricians than for families followed by nonphysicians. According to the Parents’ Perception of Primary Care scores, the overall satisfaction with primary care was higher for care given by general practitioners and paediatricians than for care given by midwives or chiropractors, and intermediate when given by nurses.

CONCLUSION

In this survey, the majority of children received their primary care from physicians, most commonly general practitioners. Parents’ overall satisfaction regarding their infant’s primary health care was higher when it was delivered by physicians than by alternative health care providers. Evidence-based guidance recommendations were rarely followed.     

Paediatricians’ awareness of children’s oral health: Knowledge,training, attitudes and practices among Turkish paediatricians

BACKGROUND:

In Turkey, 74.1% of children between three and six years of age develop dental caries.

OBJECTIVE:

To assess the depth of oral health and dental knowledge among paediatricians in Turkey, to determine their level of oral health education and to determine factors that were associated with higher knowledge scores.

METHODS:

A cross-sectional survey of demographics that assessed the participants’ knowledge of oral and dental health, attitudes regarding oral health during well-child visits and opinions regarding infant oral health care visits was conducted. The outcome variables were the proportions of paediatricians who adhered to good clinical practice guidelines, recommended dental visits for children younger than one year of age, and having a knowledge score >50%.

RESULTS:

The participant characteristics that were significantly associated with a greater mean number of correct answers were female sex, good clinical practice, confidence in detecting dental caries and the presence of a dentistry department in their hospital (P=0.001, P<0.001, P<0.001 and P=0.02, respectively). Only 13.9% of paediatricians referred children younger than one year of age to a dentist. After adjusting for the level of oral health education received during residency training, sex and having children, only the knowledge score was significantly associated with referring patients younger than one year of age to a dentist (P=0.01).

CONCLUSIONS:

Some paediatricians’ knowledge was found to be associated with practices that were in accordance with professional society recommendations. The lack of dental knowledge and training in residency limits the paediatricians’ role in promoting children’s oral health in daily practice.     

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.     

Determining the benefits and objectives of a child health residency program for Canadian rural family physicians: An international qualitative research study

OBJECTIVES:

To clarify the need for an advanced child health training program for Canadian rural family physicians, and to determine the key learning objectives to enable graduates to become community leaders in child and youth health care.

DESIGN:

Qualitative educational research study.

Setting:

Canada and Australia.

METHODS:

To gather data, the authors carried out semistructured interviews and focus groups with child care consultants, Canadian rural family physicians, child patients and parents, family medicine residents and Australian rural family physicians. Standards of qualitative methodology were applied to identify themes and subthemes.

RESULTS:

It was determined that a family medicine child health program would provide the following benefits: enhanced care by family physicians, improved access to child care, increased attractiveness of family medicine as a career and reduced ‘specialty burden’.Five key learning objectives for graduates were identified: the ability to provide child-centred care, to care for acutely or critically ill children, to care for children with complex needs, to recognize and act on ‘red flags’, and to provide behavioural and mental health care.The Australian general practitioners confirmed that their training provided most of these benefits, and enabled them to achieve the objectives identified.

CONCLUSION:

The present study showed that multiple stakeholders believed that advanced training in child health for rural family physicians would provide better care for children. The study also identified key learning objectives for the program. The present research led to the establishment of a Family Medicine Child Health Residency Program (www.familymedicineuwo.ca/PostGrad/PGY3/ChildHealth.aspx) at The University of Western Ontario (London, Ontario).     

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.