Optimal Care For Children Research Articles

A survival guide to the children's diabetes clinic

Abstract Over the last 10 years the model of optimal care for children with diabetes has undergone significant changes in the UK. These changes include the introduction of Best Practice Tariff (BPT), the adoption of electronic patient records for diabetes in many centres and other rapidly evolving technology. The changes hope to optimise and standardise care, however they also have had an important impact on the running of diabetes clinics. This review is intended to help prepare healthcare professionals for the complex demands of a modern paediatric diabetes clinic and should help with understanding the multiple facets.

Resource Document: Coordination of Pediatric Emergency Care in EMS Systems

Background: Citing numerous pediatric-specific deficiencies within Emergency Medical Services (EMS) systems, the Institute of Medicine (IOM) recommended that EMS systems appoint a pediatric emergency care coordinator (PECC) to provide oversight of EMS activities related to care of children, to promote the integration of pediatric elements into day-to-day services as well as local and/or regional disaster planning, and to promote pediatric education across all levels of EMS providers. Methods: A systematic review of the literature was undertaken to describe the evidence for pediatric coordination across the emergency care continuum. The search strategy was developed by the investigators in consultation with a medical librarian and conducted in OVID, Medline, PubMed, Embase, Web of Science, and CINAHL databases from January 1, 1983 to January 1, 2016. All research articles that measured a patient-related or system-related outcome associated with pediatric coordination in the setting of emergency care, trauma, or disaster were included. Opinion articles, commentaries, and letters to the editors were excluded. Three investigators independently screened citations in a hierarchical manner and abstracted data. Results: Of 149 identified titles, nine were included in the systematic review. The nine articles included one interventional study, five surveys, and three consensus documents. All articles favored the presence of pediatric coordination. The interventional study demonstrated improved documentation, clinical management, and staff awareness of high priority pediatric areas. Conclusion: The current literature supports the identification of pediatric coordination to facilitate the optimal care of children within EMS systems. In order for EMS systems to provide high quality care to children, pediatric components must be integrated into all aspects of care including day-to-day operations, policies, protocols, available equipment and medications, quality improvement efforts, and disaster planning. This systematic review and resource document serves as the basis for the National Association of EMS Physicians position statement entitled “Physician Oversight of Pediatric Care in Emergency Medical Systems.”

Changes in Optimal Childcare Practices in Kenya: Insights from the 2003, 2008-9 and 2014 Demographic and Health Surveys.

Objective(s)Using nationally representative surveys conducted in Kenya, this study examined optimal health promoting childcare practices in 2003, 2008–9 and 2014. This was undertaken in the context of continuous child health promotion activities conducted by government and non-government organizations throughout Kenya. It was the aim of such activities to increase the prevalence of health promoting childcare practices; to what extent have there been changes in optimal childcare practices in Kenya during the 11-year period under study?MethodsCross-sectional data were obtained from the Kenya Demographic and Health Surveys conducted in 2003, 2008–9 and 2014. Women 15–49 years old with children 0–59 months were interviewed about a range of childcare practices. Logistic regression analysis was used to examine changes in, and correlates of, optimal childcare practices using the 2003, 2008–9 and 2014 data. Samples of 5949, 6079 and 20964 women interviewed in 2003, 2008–9 and 2014 respectively were used in the analysis.ResultsBetween 2003 and 2014, there were increases in all health facility-based childcare practices with major increases observed in seeking medical treatment for diarrhoea and complete child vaccination. Mixed results were observed in home-based care where increases were noted in the use of insecticide treated bed nets, sanitary stool disposal and use of oral rehydration solutions, while decreases were observed in the prevalence of urging more fluid/food during diarrhoea and consumption of a minimum acceptable diet. Logit models showed that area of residence (region), household wealth, maternal education, parity, mother's age, child’s age and pregnancy history were significant determinants of optimal childcare practices across the three surveys.ConclusionsThe study observed variation in the uptake of the recommended optimal childcare practices in Kenya. National, regional and local child health promotion activities, coupled with changes in society and in living conditions between 2003 and 2014, could have influenced uptake of certain recommended childcare practices in Kenya. Decreases in the prevalence of children who were offered same/more fluid/food when they had diarrhea and children who consumed the minimum acceptable diet is alarming and perhaps a red flag to stakeholders who may have focused more on health facility-based care at the expense of home-based care. Concerted efforts are needed to address the consistent inequities in the uptake of the recommended childcare practices. Such efforts should be cognizant of the underlying factors that affect childcare in Kenya, herein defined as region, household wealth, maternal education, parity, mother's age, child’s age and pregnancy history.

Emergency Information Forms for Children With Medical Complexity: A Simulation Study.

Emergency information forms (EIFs) have been proposed to provide critical information for optimal care of children with medical complexity (CMC) during emergencies; however, their impact has not been studied. The objective of this study was to measure the impact and utility of EIFs in simulated scenarios of CMC during medical emergencies. Twenty-four providers (12 junior, 12 experienced) performed 4 simulations of CMC, where access to an EIF was block randomized by group. Scenario-specific critical action checklists and consequential pathways were developed by content experts in simulation and pediatric subspecialists. Scenarios ended when all critical actions were completed or after 10 minutes, whichever came first. Two reviewers independently evaluated the video-recorded performances and calculated scenario-specific critical action scores. Performance in scenarios with and without an EIF was compared with Pearson's χ(2) and Mann-Whitney U tests. Interrater reliability was assessed with intraclass correlation. Each provider rated the utility of EIFs via exit questionnaires. The median critical action score in scenarios with EIFs was 84.2% (95% confidence interval [CI], 71.7%-94.1%) versus 12.5% (95% CI, 10.5%-35.3%) in scenarios without an EIF (P < .001); time to completion of scenarios was shorter (6.9 minutes [interquartile range 5.8-10 minutes] vs 10 minutes), and complication rates were lower (30% [95% CI, 17.4%-46.3%] vs 100% [95% CI, 92.2%-100%]) with EIFs, independent of provider experience. Interrater reliability was excellent (intraclass correlation = 0.979). All providers strongly agreed that EIFs can improve clinical outcomes for CMC. Using simulated scenarios of CMC, providers' performance was superior with an EIF. Clinicians evaluated the utility of EIFs very highly.

Haemostatic disorders in children

Haemorrhagic and thrombotic events occur in both children and adults. The underlying causes are congenital or acquired disorders. In contrast to haemorrhagic disorders, inherited thrombotic disorders nearly exclusively in association with additional external risk factors lead to thrombotic events predominantly during the newborn period and adolescence. It is necessary to be aware of age-specific properties of coagulation in order to correctly interpret clinical and laboratory findings and to provide optimal care for children with haemorrhagic and thrombotic complications.

Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer.

Previous guidelines for the management of thyroid nodules and cancers were geared toward adults. Compared with thyroid neoplasms in adults, however, those in the pediatric population exhibit differences in pathophysiology, clinical presentation, and long-term outcomes. Furthermore, therapy that may be recommended for an adult may not be appropriate for a child who is at low risk for death but at higher risk for long-term harm from overly aggressive treatment. For these reasons, unique guidelines for children and adolescents with thyroid tumors are needed. A task force commissioned by the American Thyroid Association (ATA) developed a series of clinically relevant questions pertaining to the management of children with thyroid nodules and differentiated thyroid cancer (DTC). Using an extensive literature search, primarily focused on studies that included subjects ≤18 years of age, the task force identified and reviewed relevant articles through April 2014. Recommendations were made based upon scientific evidence and expert opinion and were graded using a modified schema from the United States Preventive Services Task Force. These inaugural guidelines provide recommendations for the evaluation and management of thyroid nodules in children and adolescents, including the role and interpretation of ultrasound, fine-needle aspiration cytology, and the management of benign nodules. Recommendations for the evaluation, treatment, and follow-up of children and adolescents with DTC are outlined and include preoperative staging, surgical management, postoperative staging, the role of radioactive iodine therapy, and goals for thyrotropin suppression. Management algorithms are proposed and separate recommendations for papillary and follicular thyroid cancers are provided. In response to our charge as an independent task force appointed by the ATA, we developed recommendations based on scientific evidence and expert opinion for the management of thyroid nodules and DTC in children and adolescents. In our opinion, these represent the current optimal care for children and adolescents with these conditions.

Good death for children with cancer: a qualitative study.

This study aims to explore the characteristics of a good death for children with cancer. A total of 10 pediatric cancer survivors, 10 bereaved family members and 20 medical professionals participated in in-depth interviews. Qualitative content analysis was performed on the transcribed data obtained from semi-structured interviews. Thirteen characteristics including unique and specific for children of a good death were identified: (i) sufficient opportunities to play freely, (ii) peer supporters, (iii) continued access to the patient's usual activities and relationships, (iv) assurance of privacy, (v) respect for the patient's decisions and preferences, (vi) a sense that others acknowledge and respect the patient's childhood, (vii) comfort care to minimize distressing symptoms, (viii) hope, (ix) not aware of the patient's own impending death, (x) constant dignity, (xi) strong family relationships, (xii) no sense of being a burden to family members and (xiii) good relationships with medical staffs. This study identifies important characteristics of a good death for children with cancer. These findings may help medical staffs provide optimal care for children with cancer and their families, enabling them to achieve a good death.

Problems down under

Disorders of sex development (DSD) previously referred to as ‘intersex disorders’ comprise a variety of congenital diseases with anomalies of sex chromosomes, the gonads, the reproductive ducts and the genitalia. I shall illustrate the assessment, investigation and management of a DSD by using a recent case from the Canterbury region. Optimal care for children with DSD requires an experienced multidisciplinary approach, of which the endocrine laboratory is an integral part. A clinical scientist with interest in DSD can advise the multidisciplinary team on interpretation of tests, assay specificities, reference ranges and effective use of small samples. I would like to give examples of how urine steroid profiles are used to diagnose defects of steroid biosynthesis as part of the investigation of DSDs.

186: Trends in Emergency Department Utilization By Children with Mental Health Issues

Pediatric mental health emergencies constitute a significant and growing proportion of overall visits to pediatric emergency departments (PEDs), as demonstrated by American studies. However, there is little published data on the utilization of PEDs by patients with mental health issues in Canada. To describe the trends in utilization of PED resources by mental health patients over the last 10 years at the British Columbia Children's Hospital (BCCH). We primarily reported the number and acuity of mental health related visits, their length of stay (LOS), admission rate and return visits, relative to all PED visits. We conducted a retrospective cohort study of PED visits at BCCH from 2003 to 2012. All visits with chief complaints or discharge diagnosis including terms related to mental health disorders were selected for evaluation. Descriptive statistics were used to summarize our findings. We observed a 38% increase in the number of pediatric mental health presentations compared to a 9% increase in the number of total visits to the PED over the study period. Repeat visits represented a significant proportion of all mental health related visits to the ED. Yearly, 31% to 36% of all mental health related visits were repeated visits, a third of those occurring within 30 days from the index visit. Moreover, while the proportion of visits for mental health concerns triaged to a high acuity level has steadily decreased, the proportion of visits triaged to the mid-acuity level has steadily increased. Mean LOS in the ED for mental health patients increased from 295 min in 2003 to 318 min in 2012. These LOS are significantly longer then for overall visits to the ED (171 min in 2003; 234 min in 2012). We also observed that the number of PED visits for a psychiatric concern resulting in an admission has increased by 50% between 2003 and 2012. Mental health related visits represent a significant and growing burden for the ED at a tertiary care PED. The largest proportion of psychiatric related visits are now triaged to mid-level acuity, possibly reflecting a shortage of community mental health services. These results highlight the need to reassess health resource allocation to ensure optimal care for children affected by mental health illnesses and to consider alternative ways to optimize risk assessment as well as improving the linkage to mental health services upon disposition from the PED.

Considerations in individualizing prophylaxis in patients with haemophilia A

Prophylaxis is considered optimal care for children and adults with severe haemophilia A because of its proven ability to reduce joint and other bleeding episodes. However, a 'one size fits all' approach to prophylaxis is not ideal, potentially leading to over-treatment in some individuals and under-treatment in others. Moreover, a generic plan fails to take into account a patient's lifestyle and personal preferences. This article reviews the factors contributing to bleeding risk and joint damage and uses case studies to illustrate how these contributors can be weighed to individualize the prophylactic regimen, thereby increasing the likelihood of therapeutic success.

Use of the national quality registry to monitor health-related quality of life of children with type 1 diabetes

The management of diabetes is complicated, as treatment affects the everyday life of both children and their families. To enable optimal care for children with type 1 diabetes, it is important to highlight health-related quality of life (HrQoL) as well as medical outcomes to detect psychological problems that otherwise could be missed. The aim was to study HrQoL in children and adolescents with type 1 diabetes dependent on gender, age and co-morbidity and to study the consistency between children's self-reporting and parents' proxy reporting. The cross-sectional data were collected using the questionnaire DISABKIDS Chronic Generic Measure and the DISABKIDS diabetes module. Parents in the proxy report perceived their children's HrQoL to be lower than children themselves. Boys reported their HrQoL to be better than girls. Results show that living with an additional disease has an impact on the HrQoL, which is an important factor to consider in the quality registry. Assessing HrQoL on a routine basis may facilitate detection and discussion of HrQoL-related questions in the national quality registry.

Teaching the psychosocial aspects of pediatric surgery

The optimal care of children with surgical diseases requires acquiring skills in the psychosocial assessment and therapy of children. Developing and implementing a curriculum to teach these concepts to pediatric surgery trainees should result in decreased perioperative stress for the child and improved patient outcomes and family satisfaction.

Investing in the Youngest: The Optimal Child Care Policy

The aim of the paper is to characterize the optimal child care policies (subsidies and state provision), assuming that child care provision affects the child’s future abilities. Public intervention is needed since two sources of economic inefficiency are contemporaneously influential: parents do not properly account for the impact of child care on future generations (human capital externalities) and income tax is distortive, hence labour supply is suboptimal. In an optimal income tax model, altruistic parents provide child care either by providing care at home or by paying for it on the market. If the government is able to observe the amount of domestic care provided by parents, it is optimal to subsidize provision of paid child care if only to correct the human capital externality. If, conversely, it is not possible to observe the amount of domestic care, market-provided child care is subsidized, including for redistributive reasons. In fact, an efficiency case for higher child care subsidies to lower income earners arises. State provision of child care may be desirable when market care purchases cannot be observed at the household level.

OP-028 TRANSCORONARY SEPTAL ALCOHOL ABLATION IN OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY WITH HIGH PRESSURE GRADIENT: UNICENTER SHORT TERM RESULTS

left ventricular wall was noted, where in 28 patients hypertrophy was asymmetric while 14 had concentric hypertrophy of left ventricle. Left ventricular ejection fraction was depressed in the 21 patients, all with signs of heart failure. Patients in cardiac failure received various combinations of diuretics, B-blockers, ACE inhibitors and aspirin. Surgical intervention was not performed to none of them, despite of clinical and echocardiographic indications. Death occurred in 8 patients, in 4 of them shortly after admission, 3 left Kosovo against medical advice and continued examination in Italy and Germany, and the remaining 32 were followed-up for a mean 42 months, with a range from 5 to 115 months. Recovery was noted in 14 patients but still requiring anti-failure medications. Slightly over two-fifths died. Of those with asymmetric form, 45% died, in half of those presenting in infancy, and 89% of those who presented with signs of cardiac failure. Conclusion: Hypertrophic cardiomyopathy manifested often in severe form in our patients, and the response to standard anti-failure therapy was unsatisfactory. The goals of therapy in HCM are symptoms control and prolongation of survival. In summary, randomized clinical trials would be quite valuable to help define optimal care of children with hypertrophic cardiomyopathy. Significant challenges exist, such as various medical combinations in therapy, surgical intervention and heart transplantation.

The American Academy of Pediatrics and Quality Improvement

From the American Academy of Pediatrics, Elk Grove Village, Ill The views expressed in this report are those of the authors and do not necessarily represent those of the USDepartment of Health andHuman Services, the Agency for Healthcare Research and Quality or the American Board of Pediatrics Foundation. The authors declare that they have no conflict of interest. Publication of this article was supported by the Agency for HealthcareResearch andQuality and the American Board of Pediatrics Foundation. Address correspondence to ThomasK.McInerny,MD, FAAP, Department of Pediatrics, Children’s Hospital at Strong, 601ElmwoodAve, Box 777, Rochester, NY 14642 (e-mail: Thomas_McInerny@urmc.rochester.edu).

How can we really improve childcare practices in Nigeria?

Suboptimal care is an important risk factor for undernutrition and disease. Such care includes inappropriate breastfeeding (BF) and child-feeding practices and inadequate immunization and supplementation. Over the past several years, Nigeria has increased the availability of health workers and health facilities. The use of health services has also increased. However, this has not led to an improvement in childcare practices, and certain practices that are mediated through behavior change communication, such as BF, have even declined. This article presents the result of a study that identified potential reasons for the decline in these childcare practices. The study was conducted in a primary health-care center (PHC) in South Eastern Nigeria. A key informant interview was held with the Chief Matron of the PHC. The delivery of nutrition and health information to mothers was observed over a 3-month period, and 107 women completed questionnaires to document their knowledge and practice of appropriate childcare practices. The findings from this study show that both health worker and maternal factors may contribute to less than optimal childcare practices. Health workers had received training in nutrition and health education, but their delivery of information was inconsistent and unstructured. Moreover, many mothers who regularly utilized the PHC services, and were aware of adequate childcare practices, were not adopting the practices. These results underscore the need to improve existing behavior change communication channels, as well as identify the barriers to the utilization of the information provided.

Out of the Skin of Babes: Measuring the Full Impact of Atopic Dermatitis in Infants and Young Children

Valid psychometric instruments should be culturally adapted and refined with use. Neri et al. present an excellent example of this process for the Childhood Atopic Dermatitis Impact Scale. The work emphasizes that psychometric measurement continues to develop and reminds us that optimal care of children with atopic dermatitis requires considering its multidimensional effects on both the children and their families.

Family experience of childhood obliterative bronchiolitis – findings from a UK and Ireland national survey

<h3>Aims</h3> To highlight areas of worry and concern, as well as excellence, and to share results to improve the overall care of children with OB in the UK and Ireland. <h3>Method</h3> Family questionnaire to explore the experiences of families who have a child affected by Obliterative Bronchiolitis (OB). A printed survey including SAE was sent to 29 families, followed up by an on-line reminder. The key areas covered were: diagnosis, treatment and care, support services and sources of information. <h3>Results</h3> There was a 70% return rate to the survey. Of these 43% of families were initially misdiagnosed. Overall findings were of lack of awareness and knowledge amongst some professionals, and lack of information and support for families. Time to diagnosis and quality of ongoing management were particular areas of concern. Breathtakers and the respiratory consultant were seen as the main sources of reliable information. Variations in the level of care nationally were picked up, raising concerns about equity of access to the best standards of care. <h3>Conclusions</h3> Support groups and charities are vitally important for all sufferers of rare diseases. To address the issue of ‘repeating stories’, the information from this survey has been used to develop a route map for the optimal care of children with this condition. This will provide a comprehensive resource for families and professionals planning the care of OB sufferers in the UK.

The Clinical Spectrum of Juvenile Idiopathic Arthritis in a Large Urban Population

Urban populations present particular challenges for medical providers. Patients are extremely diverse, with varied socioeconomic, cultural, and ethnic backgrounds. Physicians caring for children with juvenile idiopathic arthritis must be prepared to interact effectively with many types of families who bring with them varied experiences and expectations. Pediatric rheumatologists should be familiar with patient characteristics that can influence disease outcomes. Access to care is affected by place of residence, referral delays, parental education, and the child’s insurance status. Patients of different ethnic backgrounds vary in their trust of physicians and health systems. Understanding of risk in medical decision making is influenced by ethnicity as well. Adherence also varies by ethnic group, with African American patients reporting lower adherence than Caucasian patients. Issues of doctor– patient communication and use of complementary and alternative medicine are also affected by cultural factors. Especially for physicians working in a large metropolitan area, an understanding of societal factors influencing patient behavior is essential to provide optimal care for children with juvenile idiopathic arthritis.

The role of ICNA in Africa

The role of ICNA in Africa