Knowledge and beliefs about guidelines for exclusion of ill children from child care.

BACKGROUND: The American Academy of Pediatrics published national child care illness exclusion guidelines in 1992 and 2002. To our knowledge, no published studies have examined child care providers', parents', and pediatricians' knowledge or beliefs about these guidelines. OBJECTIVE: To compare parents', pediatricians', and center-based child care providers' (CCPs) knowledge and beliefs about exclusion guidelines. DESIGN: Cross-sectional survey conducted in 2000 of 80 CCPs, 142 parents, and 36 pediatricians in Baltimore City. Main outcome measures included familiarity with and knowledge of exclusion guidelines and beliefs about exclusion effectiveness among these groups. RESULTS: Response rates were 58% for parents, 59% for pediatricians, 85% for CCPs. Sixteen percent of child care providers (CCPs), 39% of parents, and 53% of pediatricians had not seen any written exclusion guidelines. Compared with national guidelines for 12 common symptoms, responses from CCPs and parents indicated overexclusion, while pediatricians indicated underexclusion. The groups scored similarly in number of correct answers on knowledge items (CCPs 63%, parents 64%, pediatricians 61%, P = .44). More CCPs and parents than pediatricians believed that exclusion effectively controlled infection spread and that sick children should be excluded because they spread disease, would be more comfortable, and recover faster at home (P < .001). CONCLUSIONS: This survey found CCPs, parents, and pediatricians all failed to recognize how national guidelines recommended managing 4 out of 10 common conditions on average. CCPs were more likely than pediatricians to believe that exclusion was warranted to control infection or for the child's personal needs.     

Psychosomatic disorders in children: An emerging challenge to health care in Japan

BACKGROUND: Japan has been witnessing a considerable rise in the number of children presenting with psychosomatic disorders. Thus, there is a mounting demand for pediatricians to be trained in the caring of children with psychosomatic disorders. METHOD: A questionnaire based-survey was conducted to investigate the average number of working hours for the first year (Postgraduate Year 1 (PGY1)) pediatric residents at Keio University Hospital. The same survey was conducted retrospectively with doctors with at least 10 years of experience in child health care. Another survey was conducted at our 27 affiliated hospitals with respect to the number of outpatients and patients presenting with psychosomatic disorders. RESULTS: The survey showed that, in the ward for preschool and school-age children, PGY1 residents spent on average 78.9 h per week. Time required for care of psychosomatic disorders was more than 30% of the total amount of time allotted for information acquisition, interviews and consultations, as well as conferences and discussions. There was virtually no time spent on the care for psychosomatic disorders in our pediatric residency program 10 years ago. It is an implication of the survey that the apparent number of patients with psychosomatic problems is not dependent on the size or location of the hospital. CONCLUSION: General pediatricians will be spending more time than ever before in the caring of children with psychosomatic disorders. Moreover, pediatricians trained for child health care for psychosomatic disorders are short of supply or non-existent, even in the major affiliated hospitals.     

The pediatrician and child death: integration of palliative care in the pediatric intensive care unit

Palliative care is essential in the pediatric intensive care unit (PICU). Because of the mortality rates and the presence of life-threatening conditions in children admitted to the PICU, pediatricians must be prepared to provide palliative care independently of cure-directed therapies. The present article reviews certain issues, including the decision-making process in the PICU, psychosocial needs and susceptibility to burnout among PICU staff, and the emotions and attitudes of the staff when a child dies. We provide some guidelines on how to act when a child dies, how to meet with parents after the child's death and how to follow-up parental bereavement. Strategies that can help PICU pediatricians to cope with the numerous loses they experience are suggested.     

Psychosocial health issues in pediatric practices: parents' knowledge and concerns

Parents' general knowledge of child development and the demographic factors associated with that knowledge were studied. A questionnaire was completed by 230 parents of patients from three quite different pediatric practices in the south-central United States. Chi square analysis was used as the major statistical technique. Results indicated that age, educational level, and income were associated with level of child development knowledge. Parents reported the sources and educational techniques that were most helpful to them in the past and present. The majority (81%) of the questions that parents wished to direct to pediatricians, given sufficient time, were concerned with psycho- social issues. It appears that the pediatric practice is a logical means of providing information to parents about their children's health concerns, both behavioral and physical. These results emphasize the importance of training pediatricians in behavioral issues and in improving their communication skills. The results are presented to help pediatricians select the anticipatory guidance and educational techniques that might be provided to parents through the pediatric practice.     

Listening carefully. Improving communication about behavior and development. Recognizing parental concerns

A simple checklist was developed for completion by parents prior to their regular meetings with their pediatricians for health supervision. Its efficacy in improving communication between pediatricians and parents about behavioral and developmental concerns was evaluated. Without the checklist, 30 percent of parents' concerns were discussed. More items overall, and more items that were concerns of the parent, were discussed with the use of the checklist than without it (p less than 0.05). An intermediate but statistically significant effect was observed even when the pediatrician did not see the completed checklist (43% of concerns were discussed); this effect was increased when he did (53% of concerns discussed). There were marked differences among pediatricians in the number of concerns that were discussed both with and without use of the checklist. Items regarding patterns of family life and child care, death or illness, siblings, and other stresses of modern families were frequently indicated as concerns on the checklist but were less frequently discussed. The data demonstrate the effectiveness of a simple and efficient method to improve communication about childrens' behavior and development between their parents and their pediatricians.     

Developmental intervention: a pediatric clinical review

We have attempted to review developmental intervention for pediatricians in a way that is of clinical relevance to primary care pediatricians. In so doing, we chose not to evaluate certain topics such as therapeutic intervention for handicapped children or center-based educational programs because these have been adequately addressed elsewhere. It is clear that pediatricians have a unique and important role to play in developmental intervention for the following reasons: pediatricians have easy and routinely accepted access to infants and families in the prenatal, perinatal, and preschool periods: pediatricians possess a socially accepted role of authority; and pediatricians can integrate understanding of the child's health and developmental status within the context of the family and social environment to make clinical interpretation regarding the child's developmental status and prognosis. Pediatricians are thus in the best position to convince parents of their impact on their child's development. The following general roles have been identified for pediatricians. First, pediatricians should be aware of the child's biologic status and family environmental situation and the relative degree of risk for developmental problems. This clinical awareness, in combination with the use of appropriate screening instruments of the child's development and family environment, will allow clinical judgment regarding the frequency and type of child health supervision, the need for further diagnostic evaluation, and the need for referral to intervention programs and other resources. Second, the pediatrician should develop an approach for developmental intervention for all children, whatever their degree of biological risk. This review of medical, educational, and psychological literature demonstrate the following recurring important themes as goals for primary intervention: Improve parental understanding of normal child development and developmental expectations. Assist parent's understanding of the individual developmental characteristics and temperamental style of their child. Promote parental sensitivity to the social nature of infant behaviors. Encourage parent responsiveness to the social behaviors. Improve parental feelings of confidence and competence to affect their child's development. Pediatricians can be influential in supporting structural changes that can have beneficial effects on children's development. Support of humanization of obstetric and nursery practices, and the increased use of child health supervision to parents in groups are examples of such efforts.(ABSTRACT TRUNCATED AT 400 WORDS)     

Analysis of child abuse cases admitted in pediatric service in Japan II. Backgrounds of child abuse in non-low birth-weight infants

Child abuse of 126 non-low birth-weight (non-LBW) cases reported front pediatric clinics of major hospitals in Japan in 1986 were examined. Compared to LBW infants abused children's medical problems were few (25.4%) but the presence of step-parents and a history of rearing outside the home were evident (41.3%). The abuse of a child with medical problems by real parents showed similar characteristics to abuse of LBW, occurring at 0–1 and 4 years and two types of abuser's problems were apparent; one problem was the lack of child rearing ability and the other was the inability to cope with the stress involved in child rearing. In abuse of a child by step-parents, most abusers expressed emotional problems with their abused children. Child abuse by a real parent following a period of non-home care occurred soon after the child returned home, and abusers complained that the abused child did not take to its real parents. Abuse of a child without medical problems by real parents occurred at or around birth and indicated a poor ability to rear a child due to parental problems or low tolerance to cope with child rearing. Abuse both of a child and siblings by real parents implied a deficiency of understanding and inability in child rearing due to parental problems that may have resulted in abuse of the children at 0–1 year. It seems that two processes are critical in non-LBW child abuse as well as LBW child abuse. Namely, an inability of parents to raise children and an inability to cope with the problem of their children, especially as a result of communication problems. It is important to detect risk factors for disturbing parent-child communication at an early stage and attempt to improve it.     

Shortage of pediatricians in Japan: A longitudinal analysis using physicians' survey data

Background:  Currently, there is a shortage of hospital pediatricians in Japan. In the present study, using data from the Survey of Physicians, Dentists, and Pharmacists in Japan, we analyzed the dynamics and distribution of pediatricians, using a time series approach.
Methods:  The total number of pediatricians, the ratios of hospital-working and female pediatricians, their mean age and geographic distribution in 1974, 1984, 1994, and 2004 were determined. The dynamics of pediatricians were analyzed by identifying the annual number of physicians participating in and withdrawing from pediatrics, and by following up withdrawal rates from pediatrics and movement rates from hospitals. The withdrawal rates of male and female pediatricians registered in 1992, 1994, and 1996 were also analyzed.
Results:  The number of pediatricians per 10 000 children increased from 1.9 to 7.4 between 1974 and 2004. The percentage of women among pediatricians was significantly higher than that of women among all physicians in 2004 ( P < 0.01). The numbers of physicians who withdrew from pediatrics increased from the periods 1985–1994 to 1995–2004. Younger pediatricians tended to leave pediatrics earlier than elder pediatricians. There were no differences in the withdrawal rates of pediatricians between men and women registered in 1992, 1994, and 1996.
Conclusions:  It is anticipated that the number of pediatricians in Japan will decrease in the near future unless practical strategies are implemented to improve the early withdrawal of younger pediatricians and the current working conditions of female pediatricians.     

Lessons on health promotion from Japanese early childhood development

Early childhood development (ECD) has received increasing attention in both developed and developing countries since the 1990s. In Japan, ECD facilities have pursued integrated practices of education and health care to provide appropriate services to promote children’s welfare. This ECD approach appears to embody objectives of health promotion in young children. Therefore, information about Japanese practices may help to support ECD in other countries, especially developing countries. In this context, the present study discussed the potential application of health‐related ECD practices in Japan for developing countries by reviewing an outline of Japanese ECD, along with a case study describing practices in ECD facilities in Japan. We identified four main points: (i) distinct legal grounds including a legal basis for allocating health specialists; (ii) outlines of activities based on national standards and flexible practices at the facility level; (iii) teachers’ attitudes that respect children’s initiative, and explicit and independent activities embedded in children’s daily lives that reflect the child’s developmental status; and (iv) various useful practices to enhance the effect of health‐related activities, such as cooperation with parents, lesson study and hoiku‐ (teachers) conference. As these practices are based on the Japanese context, it is essential to consider both the Japanese context and potential risks of transplanting such concepts, to enable optimum use of these lessons in other countries.     

Parent expectations and comfort with discussion of normal childhood sexuality and sexual abuse prevention during office visits.

BACKGROUND: The American Academy of Pediatrics recommends that pediatricians provide anticipatory guidance about sexual development and sexual abuse prevention. OBJECTIVE: To examine parents' expectations, comfort level, and experience discussing sexual development and sexual abuse prevention with pediatricians. METHODS: A consecutive sample of parents presenting for care at 9 pediatric offices completed a self-administered survey. The survey included demographic information and questions related to parents' expectations, past experience, and comfort discussing normal childhood sexuality and sexual abuse prevention with their children's provider. Analyses examined relationships with parental recall of provider discussion about these topics and demographic characteristics. RESULTS: Of the 605 parents offered participation, 536 responses (89%) were analyzed. Respondents were 83% mothers, 62% white, 23% Hispanic, 7% African American, 6% Asian, 2% "other," and 65% college graduates. Nearly all respondents (98%) indicated pediatricians should discuss normal sexuality, and 96% indicated physicians should discuss sexual abuse prevention. Most parents (77%) indicated both the parent and the doctor are responsible for introducing these topics. Over 90% of parents reported that they were comfortable discussing these topics. Only 45% of respondents reported their child's pediatrician had discussed normal sexuality, and 29% had discussed sexual abuse prevention. Logistic regression modeling found the highest rates of discussion for normal sexuality were among parents with older children and the highest rates of discussion for child sexual abuse prevention topics were for mothers and those with older children. CONCLUSIONS: Pediatricians can discuss normal sexuality and sexual abuse prevention without fear of alienating parents.     

Identification of violence in the home: pediatric and parental reports

OBJECTIVES: To compare the rates of domestic violence reported by mothers with those identified by physicians, to compare the rates of harsh discipline practices reported by mothers with the rates of abuse identified by physicians, and to examine the relationship between reported domestic violence and harsh discipline practices. DESIGNS: Interviews with parents and pediatricians to compare pediatric detection of domestic violence and child abuse with parental reports of domestic violence and harsh discipline practices. SETTING: Community-based pediatric practices in the 13-town greater New Haven, Conn, area. PARTICIPANTS: Of the 23 practices invited, 19 agreed to participate. Of the 2,006 parents of eligible 4- to 8-year-olds asked to participate, 1,886 (94%) completed the Child Behavior' Checklist. Of those invited into the interview portion, 1,148 (83%) completed the 90-minute in-person interview. MAIN OUTCOME MEASURES: Percentages of cases of domestic violence identified by pediatricians and reported by mothers. Percentages of cases of child abuse detected by pediatricians and percentages of mothers reporting that they have hit their children and left a mark. RESULTS: Pediatricians detected domestic violence in 0.3% of the cases, but parents reported domestic violence in 4.2% kappa= 0.106 [95% confidence interval, -0.007 to 0.219]). Pediatricians identified physical abuse of children in 0.5% of the cases, while mothers reported hitting their children and leaving a mark in 21.6% (kappa = 0.003 [95% confidence interval, -0.018 to 0.024]). Mothers reporting domestic violence were significantly more likely to report hitting hard enough to leave a mark (relative risk, 1.6 ([95% confidence interval, 1.09-2.38]) compared with those not reporting domestic violence. Physicians identifying domestic violence were not significantly more likely to report child abuse than those not identifying domestic violence. CONCLUSIONS: Parents report more cases of violence than pediatricians detect. Pediatricians should ask parents directly about domestic violence and harsh discipline.     

How are Immigrant Children in Sweden Faring? Mean Income,Affluence and Poverty Since the 1980s

This article presents new research on income-based child indicators for immigrant children from 17 different national backgrounds and children of parents born in Sweden observed during the 3-year periods 1983–85, 1995–97 and 2008–10. This research examines mean household income, representation at the top of the income distribution and relative poverty differ for immigrant children from the corresponding levels among children with native born parents. Most of the analysis is concentrated on the second generation of immigrant children. It is shown that the relative position of immigrant children deteriorated between 1983–85 and 1995–97 when the labour market situation of immigrant parents weakened more than among native born parents. Changes thereafter were more complex. Children born in Sweden to parents from Denmark, Norway or Germany were as likely as children of native born parents to be observed at the top of the income distribution in contrast to children of parents from countries with middle or low human development. Poverty rates among immigrant children were higher among all categories of immigrant children in 2008–10 than among children of native born parents. These cross origin differences in income-based child indicators can be attributed to the reasons and qualifications parents had when they entered Sweden and the number of years since their immigration. A majority of children living in Sweden that are classified as poor in 2008–10 were immigrant children of various categories.     

Pediatric and MCH training in Japan: JICA training program in the National Children's Hospital

The experience of the training program for overseas doctors in the National Children's Hospital during 8 years is described. The program was supported by the Japan International Cooperation Agency (JICA) and the objectives of the training course are to provide doctors from developing countries with a better understanding of diagnosis and treatment as specialized pediatricians and pediatric surgeons and to introduce recent medical techniques and equipment for child care. From 1984 to 1993, 37 doctors from 22 developing countries of Asia, Middle and South America and Africa have attended this program. There were 22 pediatricians, 14 pediatric surgeons and one dentist. The outline of this group training program and problems with the course are discussed.     

Child maltreatment 2002: Recognition, reporting and risk

BACKGROUND: Child abuse is a major cause of morbidity and mortality in the USA and in all other countries which have studied its incidence. It is the second leading cause of death of children in the USA. To decrease the incidence of child abuse and improve the welfare of children there must be international efforts to recognize, and report child abuse and to decrease those risk factors, which place children in jeopardy. In the USA, reports of child maltreatment have decreased each year since 1994 after nearly two decades of increase. The increase was associated with the passage of laws that mandated reporting child maltreatment and increased recognition of maltreatment. RESULTS: Several theories have been proposed to explain the decrease. These include: improved economy with decreased caretaker stress and more vulnerable children in day-care, imprisonment of offenders, treatment of victims to prevent reactive abuse, decreased use of corporal punishment, earlier recognition and reporting, prevention programs including home visitors and less corporal punishment in schools. If early recognition is to occur there must be clearly defined and uniform laws that define abuse and the significant consequences to mandated reporters for failure to report. The laws must be concise, understandable and contain medically based definitions of abuse. A bruise should be considered a significant injury. The use of an instrument on a child, for any reason should be reportable as abusive. Society must be taught that a child's head and its contents are particularly susceptible to trauma. Heads should not be slapped, shaken, or struck. The purpose of a report of suspect maltreatment should be to obtain services for families. Without proper services, abuse will reoccur and victims will become victimizers. Any sexual act, including pornography, involving a child who is unable to give consent constitutes reportable sexual abuse. Recognition of what constitutes abuse would be simplified if all countries adopted laws that forbid corporal punishment in schools and homes. Parenting education, which offers alternatives to the use of corporal punishment and anger and stress management skills, should be universal and begun in preschool. In the older child, topics would include conflict management tactics, mate selection, child development, child health, and pregnancy planning. DISCUSSION: Professional knowledge of child maltreatment is inadequate. This multidisciplinary topic must be incorporated into the undergraduate and graduate curricula in medicine and other professions dealing with children. Child victims are unable to represent themselves. In most other childhood diseases the parents rise up in arms to lobby for their children's rights and raise money for research, professional education and clinical services. In child maltreatment, government and private organizations must take on this task. The valuable resources of Federal Public Health Services become available when child maltreatment is declared to be a disease. Other countries should emulate countries that have eliminated corporal punishment of children. Countries that do not protect children from maltreatment including the ravages of war must be seen as perpetrators of child maltreatment and answerable to the international community. One may adhere to the adage that one is not one's brother's keeper. This should never be applied to children. As the world's most precious resource, we must be the keepers of all children.     

Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey.

OBJECTIVE: Childhood psychosocial problems have profound effects on development, functioning, and long-term mental health. The pediatrician is often the only health professional who regularly comes in contact with young children, and it is recommended that health care supervision should include care of behavioral and emotional issues. However, it is unknown whether pediatricians believe they should be responsible for this aspect of care. Our objective was to report the proportion of physicians who agree that pediatricians should be responsible for identifying, treating/managing, and referring a range of behavioral issues in their practices, and to examine the personal physician and practice characteristics associated with agreeing that pediatricians should be responsible for treating/managing 7 behavioral issues. METHODS: The 59th Periodic Survey of members of the American Academy of Pediatrics was sent to a random sample of 1600 members. The data that are presented are based on the responses of 659 members in current practice and no longer in training who completed the attitude questions. RESULTS: More than 80% of respondents agreed that pediatricians should be responsible for identification, especially for attention-deficit/hyperactivity disorder (ADHD), eating disorders, child depression, child substance abuse, and behavior problems. In contrast, only 59% agreed that pediatricians were responsible for identifying learning problems. Seventy percent thought that pediatricians should treat/manage ADHD; but for other conditions, most thought that their responsibility should be to refer. Few factors were consistently associated with higher odds of agreement that pediatricians should be responsible for treating/managing these problems, except for not spending their professional time exclusively in general pediatrics. CONCLUSIONS: These data suggest that pediatricians think that they should identify patients for mental health issues, but less than one-third agreed that it is their responsibility to treat/manage such problems, except for children with ADHD. Those not working exclusively in general pediatrics were more likely to agree that pediatricians should be responsible for treating and managing children's mental health problems.     

Stage-related behavioural problems in the 1-4 year old child: Parental expectations in a child development unit referral group compared with a control group

Abstract Behavioural problems in preschool (1-4 years) children are a common cause of referral to health services. Parents of children presenting to the child development unit with behavioural problems ( n = 18) were compared with a control group ( n = 45). A questionnaire was utilized to examine the parents'expectations of the children's behaviours.
As might be expected, the parents of children presenting to the Unit rated their children as having more difficult behaviours. These parents had unrealistic expectations, particularly for the 'negative'behaviours (disobedience, temper tantrums, defiance and whinging). However, they were able to anticipate normal age-related difficulties in some problem areas (dawdling during mealtimes, masturbating, not sharing toys and being jealous of one's siblings).
Counselling should address the issue of matching the expectations of parents with the individual rates of development of their children.     

Addressing ethical issues in everyday practice

In primary-care practice, just as in critical care, ethical dilemmas challenge pediatricians to make choices in the best interests of their patients. Parents are important to the growth and development of children and have broad responsibility for making virtually all decisions regarding nutrition, clothing, housing, education, religion, and medical care. Society's deference to parental choice promotes the value of family integrity, ensures the availability of an identifiable decision maker, and acknowledges the legitimate role parents play in shaping their child's development. However, pediatricians have obligations to assess and advocate for the best interests of their patients. This requires that physicians reach out to their patients and take the time to listen to children and to involve them in their own care. The proper role of a child in planning care depends less on chronologic age than on developmental and personal capacity. Even young children have a keen awareness of their own clinical situations and options and should be involved as best as is possible in decision making. All decision making for children should be collaborative among patients, parents, and professionals. A situation including an involved child, an informed parent, and a caring and compassionate caregiver working collaboratively is most likely to result in optimal decisions for pediatric patients. Bartholome concluded in 1995 that pediatricians should respect children for the persons they are in the process of becoming by being willing to assist them to participate to the extent of their capacity in making decisions about their health. Combining that view with fostering respect for the strongly held beliefs and values of parents is the direction pediatricians should travel to make decisions in the best interests of children.     

Patterns of disease among children: A simple and versatile measure of child health in communities

Objective : To derive an indicator of community child health that is simple, stable, cost-effective and suitable for small communities.
Methodology : Discharge diagnoses of children have been tabulated for hospitals in Australia and other countries and from an Aboriginal community, for up to 40 years. The differences in ratios between main diagnostic groups relate to the child health status in the community.
Results : As we pass from 'developing' to 'developed' conditions, the proportion of different diagnoses changes with a relative decrease in gastroenteritis and a relative increase in respiratory and other diseases. These changes parallel changes in infant mortality rates and child growth that are independent indicators of community child health.
Conclusions : The ratios of diagnoses of hospital discharges, the 'disease pyramid' is a reliable, valid and cost-effective way of measuring child health in a community while avoiding many of the uncertainties of conventional disease-specific and age-specific discharge rate statistics.     

Child rearing in Japan: Current trends and problems

Abstract Loyalty to one's extended family, a well-known Japanese tradition, has broken down following World War II. Child rearing in Japan, therefore, has been changing gradually and clearly. Traditionally, child rearing was taught to young mothers by the grandmothers. However, recently young couples are no longer living with their parents. Therefore, there are no advisers nor consultants available at home for their child rearing. Commercialism has certainly invaded the field of child rearing, including too many guidebooks and even baby-sitting companies. Children's lives have become much more competitive, busy and unnatural in comparison with those of20–30 years ago. This might be one cause of the increased incidence of bullying, school phobia and psychological disorders in children.     

Environmental risks in childhood

Differences between children and adults with respect to exposure rates, absorption of chemicals, metabolism, and organ development make children uniquely vulnerable to environmental hazards. Moreover, biology does not exist outside of the social life of the child. At least two important implications flow from these findings. First, pediatricians must pay closer attention to the conditions of childhood and the specific details of a child's life in attempting a complete understanding of childhood diseases, particularly their sources in environmental and social conditions. At a minimum, pediatricians must inquire more carefully about environmental exposures and children's complaints in order to make accurate diagnoses. Perhaps equally critical, pediatricians must engage in more aggressive prevention efforts. While they often try to prevent exposure by educating parents about keeping household chemicals away from young children, they might likewise consider that the information they possess about children's special vulnerability to environmental risks could usefully inform political and social decisions to protect children from those risks. This includes, for example, supporting air pollution standards that are protective of children and advocating for stricter controls for certain chemicals to reduce health risks for this vulnerable group.