Acute care and antibiotic seeking for upper respiratory tract infections for children in day care: parental knowledge and day care center policies

BACKGROUND: Children who attend day care are high consumers of antibiotics. Studies suggest that physicians prescribe unnecessary antibiotics for upper respiratory tract infections (URIs) for children who attend day care on the basis of perceived pressure from parents and/or day care centers. OBJECTIVE: To determine both parental and day care-level predictors of acute care and antibiotic seeking for children who attend day care. METHODS: We conducted a day care center-based cross-sectional survey of parents and day care center staff. Two hundred eleven parents of children attending 36 day care centers in Massachusetts completed a survey. Day care center staff completed a separate survey addressing their day care center's policies for ill children. RESULTS: Few parents reported day care staff pressure to seek care from a physician (3.9%) or antibiotics (1.9%). In multivariate models, higher parental knowledge about URIs was related to decreased acute care seeking for 3 upper respiratory symptoms (clear rhinorrhea, green rhinorrhea, and cough) in the absence of fever (odds ratios and 95% confidence intervals: 0.45 [0.31-0.65], 0.66 [0.52-0.85], and 0.57 [0.45-0.72], respectively). Parent-reported acute care seeking was not related to a day care center's polices for exclusion or physician clearance for these illnesses. Similar results were also found for the parental belief that antibiotics expedite return to day care for these symptoms. CONCLUSION: Although it has been suggested that inappropriate day care center policies for exclusion motivate parental acute care and antibiotic seeking, this study suggests that parental knowledge is a more important predictor of these reported behaviors than are day care center policies.     

Ruling out the need for antibiotics: are we sending the right message?

OBJECTIVES: To examine the relationships among physician-parent communication practices, physicians' perceptions of parental expectations for antibiotic treatment, and inappropriate antibiotic prescribing for viral upper respiratory tract infections. DESIGN: Cross-sectional study of pediatric encounters motivated by cold symptoms between October 1, 2000, and June 30, 2001. Each encounter was videotaped. Physicians completed a postvisit survey that measured whether they perceived the parent as expecting antibiotics. Coded communication variables were merged with survey variables. Multivariate analyses identified key predictors of parent-physician communication practices, physician perceptions of parents' expectations for antibiotics, and inappropriate antibiotic prescribing for viral conditions. SETTING: Twenty-seven pediatric practices in Los Angeles, Calif. PARTICIPANTS: Thirty-eight pediatricians and 522 consecutively approached parents of children with cold symptoms. MAIN OUTCOME MEASURES: Physicians' perceptions of parental expectations for antibiotics, inappropriate antibiotic prescribing, and parental questioning of nonantibiotic treatments. RESULTS: Physicians were 20.2% more likely to perceive parents as expecting antibiotics when they questioned the physician's treatment plan (P = .004; 95% confidence interval, 6.3%-34.0%). When physicians perceived parents as expecting antibiotics, they were 31.7% more likely to inappropriately prescribe them (P<.001; 95% confidence interval, 16.0%-47.3%). Parents were 24.0% more likely to question the treatment plan when the physician ruled out the need for antibiotics (P = .004; 95% confidence interval, 7.7%-40.3%). CONCLUSIONS: Parental questioning of the treatment plan increases physicians' perceptions that antibiotics are expected and thus increases inappropriate antibiotic prescribing. Treatment plans that focus on what can be done to make a child feel better, rather than on what is not needed, ie, antibiotics, may decrease inappropriate antibiotic prescribing.     

Patient,physician, and nurse satisfaction with antibiotics

To prospectively evaluate patient (parent), physician, and nurse satisfaction with antibiotics, 12,102 children in 661 pediatric study centers throughout the United States with infections to be treated on an outpatient basis were followed with questionnaires completed by parents and with interviews of patients and their parents. Comprehensive surveys were also completed by participating pediatricians and their nursing staffs of which 11,913 (98.4%) contained adequate information for inclusion in an analysis. Data were combined and analyzed using standard statistical methods. Loracarbef was perceived as being superior to other antibiotics based on cost, palatability, and dosing intervals. Few differences were seen among most antibiotics based on treatment outcome or adverse events. All antibiotics studied offered acceptable efficacy and were well tolerated as judged by physicians, nurses, parents, and children. Slight differences might result in increased compliance for some patients.     

Communicating medical bad news: parents' experiences and preferences.

Parents (N = 189) of children enrolled in 15 developmental day care centers completed questionnaires that examined the experience of being told bad news and elicited preferences for physician behavior in a hypothetical situation (communicating the diagnosis of Down syndrome). Parents, in comparison with their experiences, preferred (p < 0.001) more communication of information and feelings by their physician. Their strongest preferences were for physicians to show caring (97%), to allow parents to talk (95%), and to allow parents to show their own feelings (93%). They wanted physicians to share information (90%) and to be highly confident (89%). Most parents (87%) desired parent-to-parent referral, but only a few (19%) were referred. We conclude that there is a difference between what parents experience and what they desire in physicians who communicate bad news. Physicians control the interaction and are highly confident, but parents especially value physicians who show caring and allow parents to talk and share their feelings.     

How Much Explanation Is Enough? A Study of Parent Requests for Information and Physician Responses

OBJECTIVE: To examine the relationship between doctor-parent communication patterns and parents' perceptions that they were listened to by the doctor. DESIGN: Cross-sectional, clinic-based survey. Before the visit, parents were asked about the strength of their desires/preferences for being listened to; after the visit, they were asked if their desires were fulfilled and to rate their satisfaction with care. Encounters were audiotaped, transcribed, and coded for parent requests for information and action and physician responses to those requests. Coding was performed using an adapted version of the Taxonomy of Requests by Patients (TORP). Physician responses to parental requests for information were coded as brief, moderate, or prolonged fulfillment or as partially fulfilled, ignored, or denied. SETTING: Two private pediatric practices, 1 community based and 1 university based. PARTICIPANTS: Ten of 13 eligible physicians (participation rate, 77%) and 306 of 356 eligible parents (participation rate, 86%) who sought care for their children's respiratory illnesses. Parents were invited to participate if they spoke and read English and if their child was 2-10 years old, had a chief complaint of cold symptoms, and was seeing one of the participating physicians. Complete data were obtained for 287 doctor-parent encounters (94%). RESULTS: Before the visit, 74% of parents reported that they considered it necessary for the physician to listen to their ideas about their child's illness. Among these parents, 62% (n = 130) reported after the visit that the physician had listened to their ideas. As the proportion of moderate-length responses to parent requests for information increased, parents were significantly more likely to report being listened to (P <.05). Multivariate results indicated a 59% probability of parents reporting that they were listened to when given moderate-length responses, 45% when given brief responses, 39% when given prolonged responses, and 12% when requests for information were only partially fulfilled, ignored, or denied. The length of response to parent requests for information was not related to overall parent satisfaction. CONCLUSIONS: Parents who received moderate-length answers to their questions were most likely to report that they were listened to. Although it is assumed that lengthier, in-depth explanations result in higher satisfaction, this study suggests that more doctor talk does not necessarily constitute better communication.     

Parents, physicians, and antibiotic use

BACKGROUND: Emergence of resistant bacterial pathogens has increased concerns about antibiotic prescribing patterns. Parent expectations and pressure may influence these patterns. OBJECTIVE: To understand how parents influence the prescribing patterns of physicians and what strategies physicians believe are important if we are going to reduce inappropriate use of oral antimicrobial agents. DESIGNS AND METHODS: One thousand pediatricians who are members of the American Academy of Pediatrics were asked to complete a semi-structured questionnaire. The physicians were chosen randomly by the American Academy of Pediatrics. RESULTS: Nine hundred fifteen pediatricians were eligible and 610 surveys were analyzable, for a response rate of 67%. The majority of respondents were male (56%), worked in a group practice (51%), saw an average of 114 patients per week and were in practice for 14 years. Forty percent of the pediatricians indicated that 10 or more times in the past month a parent had requested an antibiotic when the physician did not feel it was indicated. Forty-eight percent reported that parents always, most of the time, or often pressure them to prescribe antibiotics when their children are ill but antibiotics are not indicated. In follow-up questions, approximately one-third of physicians reported they occasionally or more frequently comply with these requests. Seventy-eight percent felt that educating parents would be the single most important program for reducing inappropriate oral antibiotic use and 54% indicated that parental pressure, in contrast to concerns about legal liability (12%) or need to be efficient in practice (19%), contributed most to inappropriate use of oral antibiotics. CONCLUSIONS: Pediatricians acknowledge prescribing antimicrobial agents when they are not indicated. Pediatricians believe educating parents is necessary to promote the judicious use of antimicrobial agents.     

Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention

A brief educational intervention to promote effective communication between physicians, children, and parents during pediatric office visits was designed and tested. A randomized clinical trial involving 141 children (5- to 15-year-olds) tested the effectiveness of the intervention to improve the process and outcome of medical care. The intervention was contained in three brief videotapes (one each for parents, physicians, and patients) and in accompanying written materials. Materials were designed to build skills and motivation for increased child competence and participation during pediatric medical visits. Control subjects saw health education videotapes and received materials comparable in length with those of experimental subjects. Postintervention medical visit process was analyzed using videotapes of visits. Visit outcomes, assessed with standardized instruments and interviews, included children's rapport with physicians, children's anxiety, children's preference for an active health role, children's recall of information, parents' satisfaction with the medical visit, and physician satisfaction. Results indicated that physicians in the intervention group, compared with their counterparts in the control group, more often included children in discussions of medical recommendations (50% vs 29%, t = 2.39, P less than .05); that children in the intervention group, compared with control children, recalled more medication recommendations (77% vs 47%, P less than .01) and reported greater satisfaction and preference for an active health role; and that the intervention and control groups did not differ in parent satisfaction, physician satisfaction, or child anxiety. The results suggest that a brief educational intervention administered during waiting room time can positively impact physician-child rapport and children's preference for an active role in health and their acquisition of medical information.     

Identification of resident and attending physicians: do parents know who is caring for their hospitalized child?

OBJECTIVE: Correct identification of a physician or resident is an essential first step in developing a good relationship between physicians, patients, and their families. However, many parents are unfamiliar with the individuals responsible for their children's care. This study was conducted to determine how often parents/guardians of hospitalized children could identify the residents and attending physicians caring for their children and what factors they considered important in physician identification. METHODS: This was a cross-sectional study with a convenience sample of the parents/guardians of hospitalized pediatric patients admitted to a university teaching hospital over a 2-month period; we used a self-administered, confidential questionnaire. RESULTS: Subjects were 144 parents/guardians of hospitalized children (100% of subjects asked to participate, 19.3% of all hospitalized children); parents had the following characteristics: mean age, 30 years; 51% Caucasian, 43% African American; 82% female. Physician identification was 76% for attending physicians and 73% for residents. The factors rated as most important to parents were physician introduction (50%-76%), prior relationship (27%-13%), wearing of a white coat (2%-8%), wearing of a name tag (4%-10%), and wearing of a stethoscope (0%-2%). Physician introduction was ranked higher for first hospitalizations. Subsequent hospitalizations increased identification of attending physicians but not residents. CONCLUSIONS: This study indicates that up to a quarter of parents could not identify the physician responsible for their children's care during a hospitalization. Improving physician identification may enhance other aspects of physician-family communication.     

Children's and parents' visual perception of physicians.

The purpose of this study is to evaluate the child's and parents' visual perception of physicians. To do this, 50 children and their parents were asked which physician they preferred, when shown eight pairs of photographs. Four characteristics were tested twice, white coat versus no white coat, smile versus stern face, cartoon posters versus no posters, and standing versus stooping. We found that both children and parents preferred the smiling physician and the physician with cartoon posters on the wall. Surprisingly 54% of children preferred the physician in the white coat, whereas only 35% of parents preferred the white coat. Sixty-eight percent of children also preferred the standing physician compared with only 41% of parents. There was little correlation between the parent's and child's answers. The results did not differ significantly with age, gender, or number of hospitalizations. In conclusion our study did not confirm the popular belief that children are afraid of physicians in white coats, although children did strongly prefer physicians who smiled and those with cartoon posters on the wall.     

Bottled, filtered, and tap water use in Latino and non-Latino children

OBJECTIVES: To describe bottled, filtered, and tap water consumption and fluoride use among pediatric patients; to analyze differences between ethnic and socioeconomic groups; and to describe the frequency of physician-parent discussions regarding water consumption. DESIGN: Convenience sample survey. SETTING: An urban public health clinic. PARTICIPANTS: Parents attending a public health clinic. OUTCOME MEASURES: The primary outcome measure was the prevalence of tap, filtered, and bottled water use. The secondary outcome measures were supplemental fluoride use and the percentage of patients reporting discussions of water consumption with their physician. RESULTS: A total of 216 parents (80.5% Latino and 19.5% non-Latino) completed the survey. Of the parents, 30.1% never drank tap water and 41.2% never gave it to their children. Latino parents were less likely than non-Latino parents to drink tap water (odds ratio, 0.26; 95% confidence interval, 0.10-0.67) and less likely to give tap water to their children (odds ratio, 0.32; 95% confidence interval, 0.15-0.70). More Latinos believed that tap water would make them sick (odds ratio, 5.63; 95% confidence interval, 2.17-14.54). Approximately 40% of children who never drank tap water were not receiving fluoride supplements. Of the lowest-income families (相似文献   

Community physician's role in case management of children with chronic illnesses

There is general agreement that case management should be provided to children with chronic illnesses, yet it is not clear who should provide this service. A survey of physicians and parents of children with chronic illnesses was conducted to evaluate the practice and views of pediatricians and compare their assessments with those of parents. Surveys were mailed to 360 physicians and 519 families with response rates of 39% and 63%, respectively. The majority of physicians (74%) thought that the primary care physician should provide case management. When compared with parents, physicians underestimated the parental need for information about the child's diagnosis (8% vs 52%, P less than .001), treatments (3% vs 54%, P less than .01), and prognosis (30% vs 78%, P less than .01). They also overestimated parental needs for information regarding financial aid (70% vs 58%, P less than .01), vocations (78% vs 54%, P less than .01), and insurance (62% vs 51%, P less than .05). Four services ranked by need by parents in the top 10 were not ranked in the top 10 by physicians. Rural physicians noted that services were more difficult to obtain than did those in nonrural areas. The physicians surveyed made several recommendations for steps that could be implemented to facilitate their role as case managers. If primary care physicians are to be effective case managers, alterations in the current system of care will be required including continuing education related to chronic illness, information about community resources, reimbursement for the time required to perform case management, and better communication between physician and parents.     

Anticipatory guidance: what information do parents receive? What information do they want?

OBJECTIVE: To determine whether parents are receiving anticipatory guidance, whether they could use more information on anticipatory guidance topics, and how receipt of anticipatory guidance relates to satisfaction with care. DESIGN AND SAMPLE: Analysis of data from a telephone interview of 2017 respondents between July 1995 and January 1996. A stratified random-digit dialing design was used to obtain a nationally representative sample of parents with children between 0 and 3 years old. MAIN OUTCOME MEASURES: Discussions with a physician or nurse about 6 anticipatory guidance topics and whether parents could use more information on these topics. Willingness of parents to pay extra to discuss these topics and receive additional care. Ratings of how well clinicians provide health care. RESULTS: The percentage of parents who had not discussed each subject with a clinician varied by topic: newborn care (< 3 months old), 38%; crying, 65%; sleep patterns, 59%; encouraging learning, 77%; discipline (ages 6-36 months), 75%; and toilet training (ages 18-36 months), 66%. Thirty-seven percent of parents had not discussed any of these topics. Among parents who had not discussed a particular issue, the percentage who reported that they could use more information ranged from 22% for both newborn care and crying to 55% for encouraging learning; similar percentages who had discussed the topics could also use more information. Parents who had discussed more of these topics with a clinician were more likely to report excellent care. Parents who could use more information on a larger number of topics were much more willing to pay for additional care. CONCLUSIONS: Although anticipatory guidance is considered an important component of well-child care, the majority of parents reported that they had not discussed most standard topics with a clinician. Many parents could use more information on these topics. Effort is required to provide parents with the information they need to take good care of their children. Arch Pediatr Adolesc Med. 2000;154:1191-1198.     

Computer-based documentation: effect on parent and physician satisfaction during a pediatric health maintenance encounter

OBJECTIVE: To investigate the impact of a computer-based documentation (CBD) tool on parent and physician satisfaction with a pediatric health maintenance encounter. DESIGN: The project used a preintervention and postintervention design. The preintervention group visits used paper-based forms for data entry, whereas the postintervention visits used CBD. At the conclusion of each encounter, both the physician and the parent completed a survey that assessed their perceptions of the encounter's quality. SETTING: Urban hospital-based pediatric teaching clinic. PARTICIPANTS: Parents and physicians of children 18 months and younger. MAIN OUTCOME MEASURES: Parent and physician satisfaction with 7 components of a health maintenance encounter (interim history, social history, anticipatory guidance, developmental assessment, physical examination, assessment, and plan). RESULTS: There was no change in overall parent or physician satisfaction in the areas of communication or physician helpfulness. Physicians using CBD were less likely to agree that they provided clear explanations but were also less likely to agree that they "acted bossy during the visit." There was no correlation between physician and parent satisfaction or between physician satisfaction and pattern of CBD use. However, there was a strong correlation between physicians' satisfaction and the extent to which they found CBD helpful (Spearman rho = 0.29, P<.001). CONCLUSIONS: The introduction of CBD into the health maintenance encounter did not affect measured aspects of parent or physician satisfaction; these results support its continued use in that setting.     

How pediatricians counsel parents when no "best-choice" management exists: lessons to be learned from hypoplastic left heart syndrome

BACKGROUND: Hypoplastic left heart syndrome (HLHS) is a life-threatening congenital cardiac defect. Three mutually exclusive management options exist: the Norwood palliative procedure, cardiac transplantation, and comfort care without surgical intervention. OBJECTIVES: To assess which management options are presented to parents of infants with HLHS, and to determine what factors influence physicians' recommendations. DESIGN: Cross-sectional survey. SETTING: Fourteen of the largest pediatric cardiac surgery centers in the United States. PARTICIPANTS: Attending physicians in neonatology, cardiology, critical care practice, and cardiac surgery. INTERVENTION: A survey was distributed asking physicians what options they present to parents of infants with HLHS and what their recommendations are in general, as well as physician perceptions of HLHS outcomes and demographic information. MAIN OUTCOME MEASURES: Which options physicians discuss and which they recommend. RESULTS: Of 454 eligible physicians 257 (57%) responded to the survey, of which 110 make treatment recommendations to parents. Neonatologists were least likely to recommend surgery. Physicians who recommend surgery recommend procedures performed at their own institution over those performed elsewhere (odds ratio, 2.80; 95% confidence interval, 2.24-3.51). Twenty-six percent of physicians do not discuss nonsurgical management, and 25% of those at centers that do not perform cardiac transplantation do not discuss this option. The recommendations physicians make to parents are poorly associated with their predictions of postoperative outcomes. CONCLUSIONS: Physician recommendations to parents are poorly associated with their estimates of outcomes, and some physicians recommend the treatment preferred at their own institution over other options even when they predict better outcomes from another approach. Further, many physicians do not disclose all reasonable management options to parents of infants with HLHS. These findings raise doubts as to whether parents are given adequate information to make truly informed decisions.     

Prenatal Diagnosis of Hypoplastic Left Heart Syndrome: Impact of Counseling Patterns on Parental Perceptions and Decisions Regarding Termination of Pregnancy

An online survey for parents of children with congenital heart disease (CHD) was developed to study parents?? experiences at the time of diagnosis. The survey was distributed to online support groups. A total of 841 responses from parents of children with CHD were received during a 4-week period. The current study examined those respondents (211 [25?%]) who reported their child??s diagnosis as hypoplastic left heart syndrome (HLHS). Among these, 138 (65?%) reported receiving the diagnosis prenatally. 32?% of those receiving a prenatal diagnosis reported that after they declined to terminate the pregnancy, termination was mentioned again by their physicians. Parents who had termination mentioned again after their initial decline reported significantly lower optimism regarding their child??s life expectancy than those who did not have it mentioned again (66 vs. 94?%, p?<?0.001); were more likely to interpret the term ??rare?? to mean ??little or no chance of survival?? (34 vs. 13?%, p?=?0.01); and were more likely to change pediatric cardiologists (PCs) (43 vs. 12?%, p?<?0.001). Similarly, 22?% of respondents receiving a prenatal diagnosis reported feeling pressure to terminate the pregnancy by the PC. Those who felt pressure to terminate reported lower optimism about their child??s life expectancy than respondents who did not feel pressure (48 vs. 88?%, p?<?0.001) and were more likely to choose a new PC (48 vs. 17?%, p?<?0.001). In our cohort of parents, when termination of pregnancy was mentioned after the parents declined it, or if the parents felt pressure to terminate, the parents perceived a lower chance of survival, felt less optimistic about their child??s life expectancy, and were more likely to choose another PC for long-term follow-up care. Our study could not determine whether repeated discussions of the possibility for termination of pregnancy independently impacts parental optimism regarding prognosis or whether those who counsel with repeated discussions of termination tend to have more guarded notions of the prognosis of children with HLHS. Further study is warranted to identify the implications of counseling patterns on parental perceptions and decisions regarding termination of pregnancy.     

How well does the questionnaire for identifying children with chronic conditions identify individual children who have chronic conditions?

BACKGROUND: The Questionnaire for Identifying Children With Chronic Conditions (QuICCC) is an instrument based on a conceptual noncategorical definition that uses parental responses to identify children with chronic conditions for epidemiological purposes. OBJECTIVES: To determine whether the QuICCC is sufficiently valid, sensitive, and specific to be used to identify individual children as having a chronic condition or disability; whether parents are accurate enough that their answers to QuICCC items can be accepted as valid; and what kinds of errors in classification occur when the QuICCC is used to identify children with chronic conditions. METHODS: The sample consisted of 424 children who were patients of 9 physicians in separate practice settings throughout New England. Each physician was briefly trained in the conceptual definition on which the QuICCC is based and then was asked to identify 25 children in his or her practice who met the definition and 25 children who did not meet the definition. The QuICCC was administered to the parents of these children by blinded interviewers via telephone. The QuICCC classification was compared with physician categorization. Discrepant cases were then followed up by asking physicians and parents to answer the original questions a second time. RESULTS: Complete data were available on 379 (89.4%) of 424 children. There was agreement on 89% (kappa = 0.78). The sensitivity was 94%; specificity, 83%; positive predictive value, 86%; and negative predictive value, 92%. Of the 42 discordant cases, 30 parent reports on the QuICCC qualified the child as having a chronic condition when the physician classified the child as being without such a condition. Fewer (n = 12) discrepancies occurred because physicians identified children with chronic conditions that the QuICCC failed to identify. When the questions were readministered at follow-up, physicians corrected errors in rating in 9 cases; mothers changed their answers in 5 instances. In 13 instances the issues were known to both parties and appeared to arise in the "gray zone" or boundary area, where there was disagreement over whether a particular child qualified using the theoretical definition. For 11 children identified as having a chronic condition only by the parent's responses to the QuICCC, physician report appeared to be inaccurate primarily due to the physician's lack of information. In 3 cases where the physician reported the child to have a chronic condition, but the parent did not, the physician appeared to be correct. Follow-up data were incomplete on 1 child. CONCLUSIONS: These data support the validity of parent-generated information for the evaluation of health status. Although these findings should be replicated, this study suggests that the QuICCC may be applicable also as a screening tool for individual child identification, provided that several sources of error are considered.     

Physician experience with family presence during cardiopulmonary resuscitation in children.

OBJECTIVE: Family presence during cardiopulmonary resuscitation in children is an emerging practice. Although many hospitals allow this practice, there is scant research on physician attitudes and opinions and on physician views about training for resident physicians. DESIGN: Survey method. SETTING: University and community settings. PATIENTS: We randomly selected 1,200 pediatric critical care and emergency medicine providers from professional association mailing lists. INTERVENTION: The providers were mailed up to two written surveys and two reminder cards. The survey consisted of 40 multiple-choice and short-answer questions about demographics, past experiences, and opinions on pediatric family presence. MEASUREMENTS AND RESULTS: Of 1,200 surveys mailed, 521 were completed (43.4%) and 73 (6.1%) respondents returned the form declining to participate. More than 99% of respondents were physicians. Four hundred and thirty-three respondents (83%) reported participation in pediatric resuscitation with family members present, with a mean of 15 episodes ever and three episodes within the last year. Of those who had ever participated, more than half thought it was helpful for the family, and two thirds believed that parents wanted the option. Ninety-three percent would allow family presence in some situations. Seventy-four percent believed family presence would be stressful for a resident physician, but nearly 80% believed that residents working with children should be educated in this area. CONCLUSIONS: Family presence during cardiopulmonary resuscitation in children is not an uncommon experience for health care providers. Most respondents had resuscitated a child with family members present. The majority thought that presence was helpful to parents and that residents should be trained in this practice.