Health and growth status of immigrant and refugee children in Toronto,Ontario: A retrospective chart review

OBJECTIVE:

To describe selected anthropometric and health status variables among immigrant and refugee children ≤6 years of age within an inner city clinic in Toronto, Ontario.

METHODS:

A retrospective chart review of patients born between January 1, 1998 and December 31, 2008, was conducted at a Toronto community health centre serving a primarily immigrant and refugee population. Outcome measures included calculated age-specific percentiles for height and weight, and the prevalence of anemia, iron deficiency, enteric parasites, elevated lead levels, HIV and hepatitis B. Postal codes were collected and used to determine the patient’s neighbourhood income quintile.

RESULTS:

A total of 331 patients, born between January 1, 1998 and December 31, 2008, were identified. Of these, a total of 210 charts were manually reviewed. The prevalence of height-for-age and weight-for-age under the third percentile on the Centers for Disease Control and Prevention Growth Charts were 7.2% and 11.6%, respectively, and 8.4% and 5.0%, respectively, on the WHO Growth Standards Chart. Prevalence rates were also calculated for anemia (22.8%), iron deficiency (53.3%), hepatitis B (2.5%), parasitic infections (33.6%), elevated blood lead levels (4.9%) and HIV (0%). Neighbourhood income quintiles revealed that 46.7% of patients were residing in the lowest (ie, poorest) income quintile neighbourhoods.

CONCLUSION:

These findings reveal a high burden of illness within the population presenting to an immigrant/refugee health clinic, and illustrate the need for further research in this area, as well as increased efforts to ensure appropriate screening within clinics serving a high volume of newcomer patients.     

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.     

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.     

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.     

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.     

Modest treatment effects and high program attrition: The impact of interdisciplinary,individualized care for managing paediatric obesity

BACKGROUND:

There is an urgent need to identify effective weight management interventions in real-world, clinical settings to improve the health of children with obesity.

OBJECTIVES:

To determine the impact of individualized, interdisciplinary care on the weight status of children with obesity; to assess the relationship between clinical interactions and change in participants’ weight status; and to document the degree of program attrition.

METHODS:

A retrospective medical record review of clinical and administrative data from a paediatric weight management clinic in Edmonton, Alberta, was performed, which included data from a group of five- to 18-year-olds (body mass index [BMI] ≥85th percentile) collected from 2008 to 2012. Demographic, anthropometric and attendance data were retrieved from baseline and follow-up at three-, seven- and 11-month timepoints. The primary outcomes were participants’ BMI z-score and change in BMI z-score over time.

RESULTS:

Data from 165 individuals were included. Among those with follow-up anthropometric data, weight stabilization occurred at three (n=127) and seven months (n=84). For individuals with follow-up anthropometric data at 11 months (n=44), BMI z-score tended to decrease over time (−0.05±0.12 units; P=0.06). Program attrition increased over time (23%, 49% and 73% at three-, seven- and 11-month follow-ups, respectively). Between presentation and three-month follow-up, there was an inverse relationship between the number of clinical appointments attended and change in BMI z-score (r= −0.18; P=0.04), an association that became nonsignificant at seven and 11 months (both P>0.05).

CONCLUSION:

An individualized, interdisciplinary weight management intervention led to weight stabilization and a modest weight reduction in children with obesity. Strategies to minimize program attrition are needed to optimize family engagement in care and success in managing paediatric obesity.     

Interobserver variability of croup scoring in clinical practice

BACKGROUND:

Viral laryngotracheobronchitis croup is the most common cause of acute upper airway obstruction in young children. Clinical assessment of children with croup is often performed using ‘croup scores’; however, these scores have not been validated outside of the research setting.

OBJECTIVE:

To determine the reliability of clinical observation items in croup scores in a paediatric emergency department (ED) setting.

DESIGN:

Literature review identified 12 observation items (level of consciousness or mental status, inspiratory breath sounds, air entry, stridor, cough, cyanosis or colour, anxiety or air hunger, retractions and/or flaring, respiratory rate and heart rate, oxygen saturation and respiratory distress); overlapping items were combined, yielding 10 variables. In a prospective cohort study over 13 months, patients presenting with croup were observed independently, and croup scores were assigned by the triage nurse, ED nurse and the ED physician before treatment. Agreement among observers for clinical observations was analysed using Cohen’s quadratic weighted kappa.

SETTING:

University-affiliated, paediatric hospital ED providing primary care to an urban area (population 330,000).

PATIENTS:

Children aged three months to five years presenting with viral croup (preceding history of at least one day of upper respiratory tract symptoms associated with barking cough and/or hoarseness and/or stridor).

RESULTS:

One hundred fifty-eight children meeting inclusion criteria for croup were assessed by three observers within 1 h of each other’s assesments and before treatment. Interobserver agreement among the three observers using weighted kappa was greater than chance for all clinical observation items and ranged from fair to moderate (0.2 to 0.4 and 0.4 to 0.6, respectively).

CONCLUSIONS:

In the busy practice setting of a paediatric ED, substantial interobserver variability exists among health care providers in the measurement of respiratory signs associated with croup in young children. Based on the present study in a practice setting and two research studies, the most reliable items of all of the published items included in croup scoring systems were stridor and retractions.     

A cross-Canada survey of clinical programs for the care of survivors of cancer in childhood and adolescence

BACKGROUND

More than 80% of children who have been recently diagnosed with cancer will survive for five years or more. A majority of these survivors are at risk for developing one or more long-term sequelae of their therapy. Thus, they all require specialized medical care that is focused on their specific risks.

METHODS

A survey of informants from all 17 paediatric cancer programs in Canada was conducted to determine the care offered to survivors of childhood cancer, both during their paediatric and adolescent years, as well as after they transition to adulthood.

RESULTS

Sixteen informants representing all 17 centres responded to the survey by telephone or e-mail. Twelve of the 17 centres (71%) had a formal program or clinic dedicated to the care of survivors during their paediatric and adolescent years, while the remaining centres cared for survivors in their acute care oncology clinics. However, only six of 17 centres (35%) had access to a formal program for survivors once they reach adulthood. Fifteen of the 17 centres (88%) adhered to published long-term follow-up guidelines, and 13 of 17 centres (76%) provided a treatment summary and/or a survivorship care plan to each survivor before their transfer out of paediatric care.

CONCLUSION

Despite the centralization of paediatric oncology care within 17 specialist centres and the availability of universal health care, many Canadian survivors of childhood cancer do not have access to clinics specializing in long-term risk-based survivor care, and this access further decreases once they reach adulthood.     

Psychiatric treatment: A risk factor for obesity?

BACKGROUND:

People with psychiatric diagnoses have increased physical health difficulties.

OBJECTIVES:

To examine the physical growth parameters documented in children receiving psychiatric treatment.

METHODS:

A chart review was performed on consecutive paediatric consultations in 1997 and 1998 on 34 children six to 12 years of age admitted to an intermediate-stay psychiatric inpatient service. Growth parameters of each child were plotted on standard growth curves. The prevalence of obesity (body mass index at or above the 95th percentile), absolute weight at or above the 95th and 50th percentiles, underweight status, tall and short stature, macrocephaly and microcephaly were calculated. The prevalence of atypical findings was compared with the expected prevalence of typical growth parameters in the general population. Risk factors for atypical growth parameters were recorded. An association between weight and specific medication use was explored.

RESULTS:

It was found that 11.8% of the children were obese. It was also found that 23.5% of the children had weight at or above the 95th percentile, 79.3% had weight at or above the 50th percentile, 14.7% had macrocephaly and 79.4% had a head circumference above the 50th percentile; these results were statistically significant. The mean number of psychotropic medications prescribed was 6.4, although there was no significant association between higher weight and current medication type.

CONCLUSIONS:

Children receiving inpatient psychiatric treatment were more likely to have higher weight than typical children. Monitoring growth parameters is an important component of the paediatric care of children with psychiatric diagnoses. Guidelines are required for obesity prevention and intervention in the context of the risk factors experienced by this high risk population.     

Paediatric sleep resources in Canada: The scope of the problem

BACKGROUND:

Sleep-disordered breathing (SDB) is prevalent in children and is associated with significant comorbidity.

OBJECTIVES:

To describe paediatric sleep physician and diagnostic testing resources for SDB in Canadian children.

METHODS:

A 38-item, Internet-based survey was sent to the 32 members of the Canadian Pediatric Sleep Network (CPSN). A shorter telephone survey was administered to all 182 non-CPSN sleep laboratories across Canada.

RESULTS:

Responses were obtained from 29 of 31 (91%) CPSN members and 121 of 182 (66%) non-CPSN sleep facilities. Sixty-seven of 121 (55%) of the responding non-CPSN facilities reported that they see children <18 years of age. Thirty-six of 121 (30%) and 23 of 121 (19%), respectively, see children ≤12 years of age or ≤8 years of age. Marked disparities across provinces/territories were observed, with no practitioners or polysomnography in the Yukon, Northwest Territories, Nunavut, Saskatchewan, New Brunswick, Prince Edward Island, and Newfoundland and Labrador. Alberta has the smallest ratio of children to practitioners (approximately 167,000 to 1) and Ontario has the smallest ratio of children to polysomnograms performed per year (approximately 487,000 to 1). Reported wait times for polysomnography ranged from <1 month, to 1.5 to 2 years. In paediatric tertiary care centres, the number of polysomnograms performed per year ranged from 55 to 700 (median 480) and in other laboratories the range was 400 to 4000 (median 1100).

CONCLUSIONS:

The present study demonstrates a significant lack of resources and services for paediatric SDB care across Canada, with pronounced geographical disparities. Even if only affected children were tested with polysomnography, the authors estimate there are 7.5 times more children with SDB than current testing capacity.     

Fetal Alert Network: An integrated population-based fetal care network �C Linking conception to outcome

BACKGROUND:

Fetal diagnosis and intervention are changing the nature and natural history of many congenital anomalies treated today. Given the small cohort numbers and complexity of many congenital anomalies, an integrated network of accurate and timely information sharing is essential for evidence-based best clinical practice and outcomes.

METHODS:

A prospective, population-based, real-time provincial database was established by a transdisciplinary team of antenatal care providers consisting of five perinatal centres and affiliated paediatric subspecialties providing care.

RESULTS:

Eight hundred thirty-two pregnant women referred for fetal anomalies were registered between April 2, 2005, and March 31, 2006. The women had a mean ± SD age of 30±6.2 years, and approximately 90% of the pregnancies were spontaneously conceived. In addition, more than 90% of the women had no predisposing genetic history. The mean time of initial diagnosis was 21 weeks gestational age, and the mean time of referral was 24.7 weeks gestational age. Approximately 50% of the patients had no antenatal screening. Detailed analysis such as geographical mapping demonstrated regional differences in fetal anomalies prevalence, practice differences and clinical outcomes.

CONCLUSIONS:

Accurate, precise and real-time collection of fetal care and health systems utilization information establishes a new benchmark, and reveals some critical deficiencies such as lack of antenatal care and delayed referral for fetal anomalies in Ontario.     

Evidence-based recommendations for monitoring safety of second-generation antipsychotics in children and youth

BACKGROUND:

The use of antipsychotics, especially second-generation antipsychotics (SGAs), for children with mental health disorders in Canada has increased dramatically over the past five years. These medications have the potential to cause major metabolic and neurological complications with chronic use.

OBJECTIVE:

To synthesize the evidence for specific metabolic and neurological side effects associated with the use of SGAs in children, and provide evidence-based recommendations for the monitoring of these side effects.

METHODS:

A systematic review of controlled clinical trials of SGAs involving children was performed. Recommendations for monitoring SGA safety were made according to a classification scheme based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. When there was inadequate evidence, recommendations were based on consensus and expert opinion. A multidisciplinary consensus group reviewed all relevant evidence and reached consensus on the recommendations.

RESULTS:

The present guidelines provide evidence-based recommendations for monitoring SGA safety. The strength of recommendations for specific physical examination manoeuvres and laboratory tests are provided for each SGA medication at specific time points.

CONCLUSION:

Multiple randomized controlled trials evaluated the efficacy of many of the SGAs in paediatric mental health disorders. These benefits, however, are not without risks – both metabolic and neurological side effects occur in children treated with SGAs. The risk of weight gain, increased body mass index and abnormal lipid levels is greatest with olanzapine, followed by clozapine and quetiapine. The risk of neurological side effects of the treatment is greatest with risperidone, olanzapine and aripiprazole. Appropriate monitoring procedures for adverse effects will improve the quality of care of children treated with these medications.     

Unintentional exposure of young children to camphor and eucalyptus oils

BACKGROUND:

Essential oils, such as camphorated and eucalyptus oils, are volatile oils that can be absorbed by mouth and through the skin; if ingested orally by children, they can be harmful, even life-threatening.

OBJECTIVE:

To determine the frequency of essential oil ingestion among children in Toronto, Ontario.

METHODS:

Charts from December 1995 through March 1997 at the Ontario Regional Poison Information Centre, The Hospital for Sick Children, Toronto were reviewed to collect information on calls about essential oil ingestion, and a search of MEDLINE articles from 1966 to 1998 was conducted using the key words: ‘camphor’, ‘eucalyptus’, ‘paediatric’, and ‘poisoning’.

RESULTS:

Callers to the Poison Information Centre reported that 251 children had ingested an essential oil or product: eucalyptus oil 50 children; camphorated oil 18 children; VapAir (Drug Trading, Canada) vaporizing liquid 93 children; and Vicks VaporRub (Procter & Gamble, Canada) 90 children. The most common symptoms were cough, vomiting and cough associated with vomiting. Two children had seizures but recovered. The MEDLINE search found 18 reports of paediatric ingestion of the oils or oil products. The main symptoms were vomiting, lethargy, coma and seizures. One child died.

CONCLUSION:

Although widely used by health care consumers, essential oils and the products that contain them can be harmful when ingested by children. Further education for parents and other caregivers about the risks involved in exposure to these products is required.     

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).     

Feasibility study on the Model Schools Paediatric Health Initiative pilot project

OBJECTIVES:

To assess the feasibility and efficacy of a school-based health centre (SBHC) established at an inner-city elementary school to help alleviate barriers to accessing health care.

METHODS:

A retrospective chart review of the first year of the SBHC was conducted. Feasibility metrics included the number of children who enrolled at the SBHC. Efficacy metrics included the proportion of enrolled children who attended and received new diagnoses and treatment plans.

RESULTS:

A total of 379 children enrolled at the SBHC and 127 children attended. Of the SBHC users, 74.0% received a new diagnosis and 90.6% received a treatment plan; 79.6% were from families with an annual income <$30,000, and 91.6% were from families whose first language was not English.

CONCLUSION:

The SBHC represents a feasible and efficacious way to enhance the delivery of health care to inner-city children.     

Implementation and evaluation of a simulation curriculum for paediatric residency programs including just-in-time in situ mock codes

OBJECTIVE:

To develop, implement and evaluate a simulation-based acute care curriculum in a paediatric residency program using an integrated and longitudinal approach.

DESIGN:

Curriculum framework consisting of three modular, year-specific courses and longitudinal just-in-time, in situ mock codes.

SETTING:

Paediatric residency program at BC Children’s Hospital, Vancouver, British Columbia.

INTERVENTIONS:

The three year-specific courses focused on the critical first 5 min, complex medical management and crisis resource management, respectively. The just-in-time in situ mock codes simulated the acute deterioration of an existing ward patient, prepared the actual multidisciplinary code team, and primed the surrounding crisis support systems. Each curriculum component was evaluated with surveys using a five-point Likert scale.

RESULTS:

A total of 40 resident surveys were completed after each of the modular courses, and an additional 28 surveys were completed for the overall simulation curriculum. The highest Likert scores were for hands-on skill stations, immersive simulation environment and crisis resource management teaching. Survey results also suggested that just-in-time mock codes were realistic, reinforced learning, and prepared ward teams for patient deterioration.

CONCLUSIONS:

A simulation-based acute care curriculum was successfully integrated into a paediatric residency program. It provides a model for integrating simulation-based learning into other training programs, as well as a model for any hospital that wishes to improve paediatric resuscitation outcomes using just-in-time in situ mock codes.     

Missed opportunities to vaccinate children admitted to a paediatric tertiary hospital

Background

Inequalities in vaccine uptake exist. Studies suggest paediatric inpatients have lower rates of immunisation uptake than the general population. Various UK policies advocate opportunistic immunisation.

Aim

To evaluate practice within a paediatric tertiary hospital in identifying and facilitating vaccination of inpatients who were not fully immunised.

Methods

Case notes for 225 inpatients were examined. Thirty staff of various professions and grades were interviewed. Policies, forms and documents used in the hospital were reviewed.

Results

Immunisation status was recorded for 71% of children admitted, but for 69% of these immunisations were documented as “up‐to‐date” without any further information recorded. At least 20% of inpatients were incompletely immunised, but very little was done to facilitate vaccination. There was no training for staff either in giving advice or in administering vaccines and staff views differed regarding the hospital''s role in immunisations. While there were guidelines for specific groups of patients, there were no general immunisation policies. Incorrect and out‐of‐date immunisation schedules were found on documents.

Conclusions

Opportunities to immunise children continue to be missed by all levels of health care service provision. Tertiary centres have a role to play in supporting primary care services to ensure that these vulnerable children are appropriately immunised. Measures are being taken to address the problems identified in this study and we strongly suspect that other hospitals in the UK ought to be confronting these issues as well.     

Paediatrician office follow-up of common minor fractures

BACKGROUND:

Evidence suggests that minor paediatric fractures can be followed by primary care paediatricians (PCPs).

OBJECTIVES:

To determine PCP opinions, knowledge and perceived barriers to managing minor paediatric fractures in the office.

METHODS:

An online survey was sent between June and September 2013 to all paediatricians who subscribed to the American Academy of Pediatrics PROS-Net Listerv and to those who were registered with the Scott’s Canadian Medical Directory as paediatricians who treated children in a primary care capacity. The primary outcome was the proportion of PCPs who agreed with PCP follow-up of minor paediatric fractures. Secondary outcomes included PCP’s perceived barriers to office follow-up.

RESULTS:

A total of 1752 surveys were sent; 1235 were eligible and 459 (37.2%) responded to the survey. Overall, 296 (69.5% [95% CI 65.2% to 74.0%]) PCPs agreed that minor paediatric fractures could be followed in a PCP office. The most frequently reported barriers were lack of materials to replace immobilization (58.1%), PCP knowledge deficits (44.8%) and a perceived parental preference for an orthopedic surgeon (38.6%). Finally, 58.8% of respondents believed that further education was necessary if PCPs assumed responsibility for follow-up of midshaft clavicle fractures, while 66.5% and 77.1% (P<0.0001) believed this was necessary for distal radius buckle and fibular fractures, respectively.

CONCLUSIONS:

More than two-thirds of responding PCPs in Canada and the United States agreed that minor common paediatric fractures can be followed-up by paediatricians. However, PCPs reported some barriers to this management strategy, including a desire for more education on this topic.