Pediatric Health Care Professionals Research Articles

Ethical responsibilities of European children's teams facing the resurgent COVID-19 pandemic.

The COrona VIrus Disease 2019 (COVID-19) pandemic is posing an unprecedented challenge to healthcare systems around the globe. Europe has been struggling for 1 year now, and despite some encouraging progress (above all, the beginning of vaccination), the second wave is ongoing. Even though children are less affected than adults, the COVID-19 pandemic—and in particular the measures to counter it—is having a considerable impact on the paediatric healthcare setting. It is, therefore, the duty of paediatric teams in Europe to prepare for the challenges ahead. We wish to contribute to this necessary preparedness in two ways: firstly, by assessing the direct and indirect impact of the pandemic on children and on the paediatric setting; secondly, and more importantly, by identifying the various responsibilities of paediatric healthcare professionals, in light of established ethical principles. Only abiding by these responsibilities will it be possible to ensure that ill children and their families are properly supported even in these difficult times and to grant that decisions about children’s healthcare remain morally justified and lawful. What is Known:• The COVID-19 outbreak is posing an unprecedented challenge to healthcare systems around the globe• Despite the children are less affected than adults, the COVID-19 pandemic is having a huge impact also on paediatric settingWhat is New:• The COVID-19 pandemic lays out specific responsibilities of paediatric professionals towards our pa-tients, society and ourselves• The paediatric teams in Europe should assess the direct and indirect impact of the pandemic on the chil-dren and on the paediatric settings, ensuring consistency between centres and across regions in Europe

Provider Perspectives of Necessary Factors in Sickle Cell Disease Health Care Transition: Results from an Online Survey

Introduction: Survivorship of children with sickle cell disease (SCD) has substantially increased due to the advent of medical advances, such as sepsis prevention (prophylactic penicillin) and exposure to disease-modifying therapies (chronic transfusion and hydroxyurea). Despite greater longevity in SCD, the period surrounding the transition from pediatric to adult care has the highest prevalence of undesirable outcomes: youth aged 18-30 years are at high risk for mortality and high rates of healthcare utilization, resulting in increased healthcare costs. As such, health care transition programs have been created to prepare patients with SCD for adult-centered care and subsequently, improve health outcomes. However, few programs have been evaluated for effectiveness in achieving optimal health outcomes in SCD in part because of a lack of identifiable predictors and outcomes.Objective: To identify factors necessary for successful health care transition, as judged by pediatric and adult healthcare professionals involved with the SCD population.Method: Individuals who provide clinical care for or conduct clinical research with patients with SCD were eligible to participate in the survey and were collectively defined as providers. Providers were recruited online through nationally recognized professional societies, SCD provider contact lists and in person at a national SCD conference. Links to an online survey, administered via Qualtrics software, were distributed to potential participants. The survey included demographic questions and a list of 36 transition factors, including disease knowledge, self-management behaviors, and independent living skills. Participants were asked to rate the level of importance of each factor in helping a patient with SCD successfully transition from pediatric to adult care on a scale from 1 (not important) to 10 (very important). They were then asked to select five of the 36 factors they believed were most necessary for a successful transition, ranking them from 1 (highest) to 5 (lowest). Descriptive statistics were conducted to determine the top ratings and rankings. A two-way MANOVA was conducted to examine whether the top ratings were different according to provider gender and occupation.Results: The sample included 258 providers (74% female, 65% White). The majority were hematologists (41%); 38% were other medical staff (e.g., nurse, midlevel providers, other physicians) and 21% were non-medical staff (e.g., psychologist, social worker, researchers). The transition factor ratings (scale 1 to 10) ranged from 5.82-9.62 (M=8.05, SD=1.74). The factors with the highest ratings included: Knows how to take medications (M=9.62, SD=0.82), Explains/communicates medical needs to medical personnel (M=9.50, SD=0.93), Knows when to seek medical assistance if home management fails (M=9.32, SD=1.12), and Knows how to manage pain episodes (M=9.31, SD=1.18). These same four factors also were ranked as the top five most relevant factors: Knows how to manage pain episodes (N=138, 53%, M=2.59, SD=1.30), Explains/communicates medical needs to medical personnel (N=115, 45%, M=2.54, SD=1.38), Knows how to take medications (N=135, 52%, M=2.67, SD=1.31), Knows when to seek medical assistance if home management fails (N=102, 40%, M=2.97, SD=1.46). Knows medical history (N=100, 39%, M=2.57, SD=1.35) was the fifth most relevant factor. Multivariate results indicated a trend toward hematologists giving lower ratings compared to other medical and non-medical professionals, F (8, 486) = 1.91, p = .057.Conclusions: Our findings reveal the importance of attainment of disease knowledge and self-management skills for optimal transition from pediatric to adult care. Interventions and programming designed to prepare adolescents for transition should target these areas. Furthermore, disease knowledge and self-management skills may be meaningful predictors when evaluating transition outcomes and the effectiveness of transition programs during and after the health care transition process. Our data also indicated differences in provider ratings by profession, demonstrating the value of incorporating a variety of perspectives in assessing transitioning needs. Such efforts are essential to improve health outcomes and quality of care for patients with SCD transitioning to adult care. DisclosuresPorter:NHLBI: Research Funding.

Taking Paediatrics Abroad: Working with low- and middle-income countries in a global pandemic.

Children and young people around the world face challenges to their health and wellbeing. In particular, in low‐ and middle‐income countries they experience a higher burden of disease, exacerbated by global inequity limiting access to quality health care. According to the inverse care law, the availability of quality health care varies inversely to the need of the population, and hardworking health‐care professionals in under‐resourced countries may face impediments to continued education or subspecialty training. In line with the Sustainable Development Goals, collaborations have been developed between high‐income and low‐ and‐middle‐income countries to address global disparities in health. These collaborations face challenges of high financial costs, difficulties creating long‐term sustainable change, and with the emergence of the COVID‐19 pandemic, border closures preventing fly‐in volunteers. In this paper, we describe the development of an innovative, paediatric‐specific model of care for training and support between high‐ and low‐income countries – Taking Paediatrics Abroad Ltd. Taking Paediatrics Abroad supports the development of mutually beneficial relationships between Australian paediatric health‐care professionals and paediatric health‐care professionals in developing countries and remote, underserved Australian Aboriginal communities. Since May 2020, there have been over 100 sessions covering a vast array of paediatric specialties. This article explores Taking Paediatrics Abroad's model of care, its implementation and challenges, and opportunities for the future.

Eyes Open, Ears On: Supporting Hearing Technology Use in Children with Hearing Loss

Eyes Open, Ears On: Supporting Hearing Technology Use in Children with Hearing Loss

R8. Pediatric Health Care Professionals’ Knowledge and Perceptions of Essential Oil Use

R8. Pediatric Health Care Professionals’ Knowledge and Perceptions of Essential Oil Use

Improving hospitalization in children and adolescents through animal assisted interventions (AAIS): A systematic review

IntroductionAnimal Assisted Interventions (AAIs) are increasingly introduced in pediatric care settings as a mean to promote the physical, mental, and emotional well-being of hospitalized children and adolescents and the humanization of the hospital environment.ObjectivesThe aim of this work was to review published studies implementing AAIs in hospital settings and to assess their effectiveness in reducing stress and pain, ameliorating social behavior, quality of life, and mood in pediatric patients. Reviewed interventions were also evaluated for their effects on caregiver’s stress and burden, as well as on perception of the work environment in hospital staff.MethodsStudies were systematically searched using PubMed, Scopus, ProQuest and Web of Science databases in accordance with PRISMA guidelines. The search was aimed at identifying studies examining the effects of AAIs on behavioral and physiological response to stress in children and adolescents (0-18 years) formally admitted to a hospital for a stay, as well as in those undergoing a visit for treatments or medical examinations.ResultsOf 350 studies screened, 17 were eligible for inclusion. Most of them focused on stress, pain and anxiety reduction in pediatric patients, and used both physiological parameters and behavioral observations/scales. The vast majority of the studies employed dogs. Results show the potential of AAIs to reduce anxiety and behavioral distress in pediatric patients, while acting on physiological measures associated with arousal.ConclusionsAlthough further studies of better quality are still needed, the findings of this review may have implications for clinical practices suggesting appropriate planning of AAIs by pediatric healthcare professionals.

The effects of facility dogs on burnout, job-related well-being, and mental health in paediatric hospital professionals.

To examine the effect of working with a facility dog on paediatric healthcare professionals' work-related burnout, job perceptions and mental health. Due to their roles caring for ill children and distressed families, paediatric healthcare professionals often experience substantial depression and burnout. According to prior research, facility dogs in children's hospitals may provide significant benefits to paediatric patients. However, their potential effects on healthcare professionals have been minimally explored. A cross-sectional design was used in adherence to the STROBE checklist. Among 130 participants, n=65 paediatric healthcare professionals working with a facility dog were compared to n=65 control participants matched on age, gender identity, job position category and pet ownership. Hierarchical regression assessed the effect of working with a facility dog on standardised self-report measures of work-related burnout, job perceptions and mental health. For work-related burnout, working with a facility dog was associated with higher perceived personal accomplishment, but had no effect on emotional exhaustion. With respect to job perceptions, working with a facility dog was associated with more positive job descriptions and lower intention to quit, but not with perceptions about co-workers or workplace social support. Finally, in relation to mental health, working with a facility dog was associated with more positive emotions, better perceived mental health and less depression, but had no effect on anxiety. Findings suggest that facility dogs may be related to several benefits for healthcare professionals' work-related burnout, job perceptions and mental health, but that they do not influence all components of these areas. The present research functions to inform personnel in paediatric hospitals with existing facility dog programmes on the scope of their effects, in addition to shaping the expectations of hospitals considering the addition of a facility dog programme.

P0684 / #1685: EXPERIENCE OF HANDLING PEDIATRIC CARDIOPULMONARY RESUSCITATION AMONG PEDIATRIC HEALTH CARE PERSONNEL FOLLOWING ADVANCED LIFE SUPPORT TRAINING: A QUESTIONNAIRE BASED STUDY

Aims & Objectives: Despite regular advanced life support courses, literature has shown that pediatric healthcare personnel remain hesitant to perform lifesaving resuscitation maneuvers. This study was designed to compare the experience and ease of handling cardiopulmonary resuscitation (CPR) after advanced life support (ALS) training between personals trained less then 6 months with more than 12 months ago. Methods:Design: Prospective observational study (January 2019- December 2019). Setting: Questionnaire based study in department of pediatrics. Participants: Pediatric residents and nursing staff. Outcome: i) Experience and ease of handling CPR ii) Comparison between group-A (ALS trained less than 6 months ago) and group-B (ALS trained more than 12 months ago) Results: Total 102 participants (89 residents and 13 nurses) were studied with equal gender distribution (50 male and 52 female). Group-A had 45 participants and group-B had 57. In Group-A, 25; 55% participated in CPR for at least 10 times versus 52; 91.3% in Group B (p=0.01). Very few participated in CPR as a team leader in both the group 11 (24.4%) versus 45 (79%) respectively. Both the groups were familiar with defibrillator 88 (86%) but only 21 (46%) in group-A and 48 (84%) in group-B had used defibrillator at least once (p=0.01). Most of them felt difficulty in handling defibrillator. Conclusions: Leadership quality and confidence in conducting the CPR and handling the defibrillator during CPR was lacking in pediatric healthcare professionals. This emphasizes the need of regular simulation sessions besides ALS courses

P0082 / #337: BARRIERS TO DELIVERING ENTERAL NUTRITION IN PICUS: A SURVEY AND NEW QUALITY IMPROVEMENT TOOL

Aims & Objectives: To develop a pediatric quality improvement instrument for enteral nutrition (EN) delivery in critically ill children and to explore the perceived barriers by pediatric intensive care healthcare professionals (HCP) (nurses, dieticians and physicians) across the world. Methods: Cross-sectional online survey to PICU HCP across the world containing 25 items Results: 920 pediatric intensive care professionals responded from 57 countries; 477/920 (52%) nurses, 407/920 (44%) physicians and 36/920 (4%) dieticians. Sixty-two percent had more than five years PICU experience and 49% worked in general PICUs, with 35% working in combined cardiac and general PICUs. There were also significant differences in 14 perceived barriers when comparing continents. Across all continents, the biggest perceived barrier was enteral feeds being withheld for procedures and operating department visits, and this was the highest perceived barrier in Southern America. Other top perceived barriers were: none or not enough dietitian coverage on weekends or evenings, and not enough time dedicated to education and training on how to optimally feed patients. Conclusions: This is the largest survey that has explored perceived barriers to the delivery of enteral nutrition across the world by HCP. Many perceived barriers to enteral feeding remain in PICUs internationally. These barriers relate to organisational and staff factors as well as clinical patient factors. Whether the barrier is real or not, if clinicians believe these, then this still inhibits the delivery of enteral nutrition. Further education to improve awareness of the existing evidence and facilitate the implementation of best evidence into local unit guidelines is required.

P0444 / #698: IDENTIFYING EXPERIENCES, ATTITUDES AND PRACTICES AROUND THE LIMITATION OF TREATMENT AGREEMENT (LOTA) DECISIONS AMONG PAEDIATRIC PROFESSIONALS IN THE YORKSHIRE AND HUMBER REGION, UK.

Aims & Objectives: Aims: To identify the learning needs of the paediatric professionals in the Yorkshire and Humber region, UK with regards to having the end of life care discussions and documentation of limitation of treatment agreements. Objectives: To investigate the opinions of paediatric health professionals, both doctors and nurses, as to when it is appropriate to have a discussion regarding end of life decisions and limitation of treatment agreements with parents of children with known life-limiting and life-threatening conditions. Methods: We collected the opinions of paediatric health care professionals (doctors from all grades, and nurses) using a questionnaire and clinical vignettes through an online survey website, Survey Monkey. Results: Survey results collected from a varied group of participants showed that even though participants felt the LOTA should be discussed and family’s views should be sought and documented during three clinical vignettes, in their experiences, these discussions are happening much less frequently. Also, most participants didn’t feel comfortable having these discussions. Conclusions: Survey results collected from a varied group of participants showed that even though participants felt the LOTA should be discussed and family’s views should be sought and documented during three clinical vignettes, in their experiences, these discussions are happening much less frequently. Also, most participants didn’t feel comfortable having these discussions.

Generational Empathy: An Approach for Addressing Generational Differences.

Generational differences result in conscious and unconscious biases that affect day-to-day interactions among professionals in the field of pediatrics. From the millennial trainee to the baby boomer seasoned clinician educator, including the three authors of this article, who span three generations, all are guilty to some extent. Pediatricians are not alone. In fact, some of them may even be in “exalted” company: > “They [Young People] have exalted notions because they have not been humbled by life or learned its necessary limitations; moreover, their hopeful disposition makes them think themselves equal to great things, and that means having exalted notions. They would always rather do noble deeds than useful ones. Their lives are regulated more by moral feeling than by reasoning. All their mistakes are in the direction of doing things excessively and vehemently.” > > Aristotle1 Every day, multidisciplinary teams of pediatric health care professionals converge in a clinical setting, hoping to create a psychologically healthy workplace where all generations feel included and valued in patient care discussions. Nonetheless, although health care team members in the field of pediatrics intentionally work to remedy the generational differences that arise between parents and their children, generational comparisons persist. We all are products of our own generational upbringings and the events that shaped our own lives, which, in turn, lead to perceptions about other generations that may or may not be true. We then may treat others … Address correspondence to Christian D. Pulcini, MD, MPH, MEd, Department of Surgery and Pediatrics, The Robert Larner College of Medicine, The University of Vermont and The University of Vermont Children’s Hospital, 111 Colchester Avenue, Burlington, Vermont 05401. E-mail: christian.pulcini{at}uvm.edu

Medical Child Abuse: Essentials for Pediatric Health Care Providers.

Medical child abuse (MCA) is a rare but potentially deadly variant of child maltreatment. MCA results in unnecessary health care for a child because of a caregiver's exaggeration, fabrication, or induction of physical and/or psychological symptoms of illness. These unnecessary health care interventions result in a morbidity rate of 100% in the form of complications and disabilities and a mortality rate as high as 9%. Although MCA is relatively rare, it is estimated that pediatric health care professionals, including pediatric nurse practitioners, will most likely encounter at least one MCA victim in the course of their career. This continuing education article will discuss MCA in terms of definition and features, epidemiology, perpetrators, variants in presentation, consequences, and implications for practice.

Human Flourishing in Adolescents with Cancer: Experiences of Pediatric Oncology Health Care Professionals

PurposeThis study explores human flourishing (HF) in adolescents with cancer (AC) as witnessed by their health care providers, and it develops a list of critical attributes associated with HF to describe the positive outcomes witnessed. Design and MethodsOur study used a qualitative descriptive design incorporating data from an open-ended electronic survey and semi-structured individual interviews with 17 pediatric oncology health care providers. ResultsWe found 3 major themes (positive forward motion, connectedness, and self-character) representing 11 critical attributes of human flourishing in AC: (1) initiative and enterprise, (2) positivity and evocativeness, (3) tranquility and maturity, (4) perseverance and tenacity, (5) compassion and empathy, (6) social engagement and connection, (7) wisdom and translation into life, (8) supportive background, (9) self-awareness and self-agency, (10) transcendence and full potential, and (11) meaning-making. ConclusionsUnderstanding the concept of HF as it applies to the needs of AC is a step toward establishing it as a comprehensive health care goal and toward developing care provider guidelines for its promotion. Practice ImplicationsGiven the attributes of HF in AC, nurses can consider HF as an ultimate nursing care outcome and should focus on goals of care beyond disease treatment and symptoms mitigation when providing care for this population. Holistic, individualized assessment, timely care during each phase of treatment, and developmentally tailored intervention should be provided.

COVID-19 Pandemic Impact and Response in Canadian Pediatric Chronic Pain Care: A National Survey of Medical Directors and Pain Professionals

ABSTRACT Background: The COVID-19 pandemic presents one of the greatest threats to pediatric pain care seen in generations. Due to public health restrictions, many pediatric pain clinics halted in-person appointments, delaying and disrupting access to care. There is no existing research on the impacts of COVID-19 on pediatric chronic pain care in Canada or the challenges experienced by health care professionals and pain clinics. Aims: The aim of this study was to evaluate the impact of COVID-19 on Canadian pediatric chronic pain care by documenting how health care professionals provided care during the first six months of the pandemic. Methods: Two Canadian online cross-sectional surveys were conducted: one among Canadian pediatric pain clinic directors (Study 1) and another among multidisciplinary pediatric pain health care professionals (Study 2). Results: Responses from 13/13 Canadian pediatric pain clinics/rehabilitation programs indicated that all clinics provided virtual care during the pandemic. No significant changes were reported on the frequency of appointment requests. Most clinics reported no perceived change in patient pain levels (n = 9/13, 69%) or occurrence of pain flares (n = 10/13, 77%). Results from 151 individual health care professionals indicated that the majority (90%) of non–emergency department respondents were providing virtual care. The main challenges of virtual care included technological barriers, financial concerns, infrastructure and logistics, privacy, and clinical challenges. Conclusions: This study documented the impact of the COVID-19 pandemic on pediatric chronic pain care in Canada and highlighted the rapid shift to using virtual solutions. Simultaneously, respondents outlined current challenges and potential solutions to consider in the development of virtual care guidelines and policy in Canada.

Challenges to delivering family‐centred care during the Coronavirus pandemic: Voices of Italian paediatric intensive care unit nurses

Challenges to delivering family‐centred care during the Coronavirus pandemic: Voices of Italian paediatric intensive care unit nurses

Impact of deliberate practice on evidence-based medicine attitudes and behaviours of health care professionals.

IntroductionAlthough evidence-based medicine (EBM) teaching activities may improve short-term EBM knowledge and skills, they have little long-term impact on learners’ EBM attitudes and behaviour. This study examined the effects of learning EBM through stand-alone workshops or various forms of deliberate EBM practice.MethodsWe assessed EBM attitudes and behaviour with the evidence based practice inventory questionnaire, in paediatric health care professionals who had only participated in a stand-alone EBM workshop (controls), participants with a completed PhD in clinical research (PhDs), those who had completed part of their paediatric residency at a department (Isala Hospital) which systematically implemented EBM in its clinical and teaching activities (former Isala residents), and a reference group of paediatric professionals currently employed at Isala’s paediatric department (current Isala participants).ResultsCompared to controls (n = 16), current Isala participants (n = 13) reported more positive EBM attitudes (p < 0.01), gave more priority to using EBM in decision making (p = 0.001) and reported more EBM behaviour (p = 0.007). PhDs (n = 20) gave more priority to using EBM in medical decision making (p < 0.001) and reported more EBM behaviour than controls (p = 0.016).DiscussionHealth care professionals exposed to deliberate practice of EBM, either in the daily routines of their department or by completing a PhD in clinical research, view EBM as more useful and are more likely to use it in decision making than their peers who only followed a standard EBM workshop. These findings support the use of deliberate practice as the basis for postgraduate EBM educational activities.

COVID-19 threat and frontline paediatric care professionals.

COVID-19 threat and frontline paediatric care professionals.

Current transition management of adolescents and young adults with allergy and asthma: a European survey

BackgroundTransition from parent-delivered to self-management is a vulnerable time for adolescents and young adults (AYA) with allergy and asthma. There is currently no European guideline available for healthcare professionals (HCPs) on transition of these patients and local/national protocols are also mostly lacking.MethodsEuropean HCPs working with AYA with allergy and asthma were invited to complete an online survey assessing challenges of working with these patients, current transition practices and access to specific healthcare resources.ResultsA total of 1179 responses from 41 European countries were collected. Most HCPs (86%) reported a lack of a transition guideline and a lack of a transition process (20% paediatric HCPs, 50% of adult HCPs, 56% HCP seeing all ages). Nearly half (48%) acknowledged a lack of an established feedback system between paediatric and adult medical services. Many respondents never routinely asked about mental health issues such as self-harm or depression and are not confident in asking about self-harm (66.6%), sexuality (64%) and depression (43.6%). The majority of HCPs (76%) had not received specific training in the care of AYA although 87% agreed that transition was important for AYA with allergy and asthma.ConclusionAlthough there was agreement that transition is important for AYA with allergy and asthma, there are crucial limitations and variations in the current provision of transition services across Europe. Standardisation of AYA management and specific training are required. This should improve management and continuity of care during adolescence and into adulthood to achieve the best healthcare outcomes.

A national guideline for youth-friendly health services developed by chronically ill young people and health care professionals- a Delphi study.

Significant variation in cultural and socio-economic factors across different countries means that modification of existing guidelines for youth-friendly health services are needed. Furthermore, including the views and perspectives of young people in developing health services add significant value. The aim of this study was to develop a national guideline for youth-friendly health services using the Delphi method. We invited young people with chronic conditions, managers of paediatric, psychiatric and relevant adult departments and health care professionals with experience and interest in adolescent medicine to participate. The initial list of elements was constructed based on international guidelines and systematic reviews. The study consisted of three electronic questionnaire rounds assessing relevance, importance and whether the elements were essential/very important, respectively. We used 70% agreement as cut-off. More than 70% of participants agreed that onlyone element was essential: 'Young people should be actively involved in decisions about their treatment and encouraged and supported to ask questions about their illness and treatment'. Additionally, 18 elements reached more than 70% agreement, when the 'essential' was combined with the 'very important' category. We grouped these 19 elements into five themes: 1) staff competences and workflow, 2) developmentally appropriate communication, 3) focus on youth life, including mental health 4) youth participation and shared decisions, and 5) autonomy and transitional care. This guideline for a youth-friendly health care system may serve as inspiration for concrete changes, both locally and internationally, as it was developed together by young people, staff, and management.

Management and Referral Patterns in Pediatric Atopic Dermatitis: A Survey of Pediatric Healthcare Professionals

Background: The incidence of pediatric atopic dermatitis (AD) has continued to increase worldwide and pediatric healthcare providers (PHPs) are typically the initial healthcare provider tasked with management of this disease. The consequences of inadequately managed AD and misdiagnosed food allergies are devastating for patients and their families, and the financial burden associated with these scenarios can be overwhelming. Objective: To assess the management and referral patterns of pediatric AD patients by PHPs in the Jacksonville, Florida (FL) area. Methods: An online electronic survey was distributed to 70 PHPs using Survey Monkey©. Data was collected over a 6-week period. The survey yielded a sample size of 28. Results: Most participants were physicians (92.8%), with an average of 21.75 years in practice. Just over half (53%) of PHPs were aware of the American Academy of Dermatology (AAD) Guidelines of care for the management of AD. Dermatologists were the initial referral choice for AD management in 2/3, while 1/3 indicated preference for an allergist. Diet alteration was used by 14.3% as an initial AD management step and 35.7% tried elimination diets prior to referral to an allergist. Referral to specialists were low with 75% PHPs referring &lt;25 % of their AD patients to dermatology. Conclusion: With the number of outpatient AD visits increasing amongst PHPs, knowledge of management guidelines, in-depth understanding of appropriate use and limitations of elimination diets and food allergen testing, and referral to specialists suitable for management of this cutaneous disorder are imperative, but found to be highly variable.