Sleep problems and sleep disorders in pediatric primary care: treatment recommendations, persistence, and health care utilization

STUDY OBJECTIVE

This study examined documented treatment recommendations provided for sleep disorders and sleep problems in pediatric primary care, the persistence of sleep problems and sleep disorders in children and adolescents, and the relationship between sleep issues and health care utilization.

METHODS

In-depth chart review of pediatric primary care patient visits (n = 750 patients) from 2007 through 2010.

RESULTS

Only 26 children (5.2% of those with a sleep disorder/ problem) received a treatment recommendation, with half of these recommendations behavioral in nature. Sleep disorders and sleep problems were highly persistent across time for up to a third of children. Children with sleep disorders had significantly more sick visits/calls (mean = 8.84, 95% CI 7.77-9.90) than children without a sleep disorder (mean = 6.34, 95% CI 5.56-7.12).

CONCLUSIONS

Very few children or adolescents were found to have documented treatment recommendations or referrals for diagnosed sleep disorders or sleep problems. In addition, given that sleep disorders and sleep problems are highly persistent, as well as result in more sick visits/calls, it is important that pediatric primary care providers screen for and identify these issues across development. Furthermore, it is essential to provide health care providers with more education and support on sleep disorders and sleep problems in pediatric primary care.

Comparison of the levels of knowledge and approaches in relation with child abuse and neglect in residents of pediatrics, pediatricians and practitioners working in the province of Ankara

AIM

In this study, it was aimed to evaluate the levels of knowledge and approaches related with child abuse and neglect in pediatricians and practitioners who have a significant role in recognition and prevention of child abuse and neglect.

MATERIAL AND METHODS

Two hundred residents of pediatrics and 100 pediatricians working in university and education and research hospitals in the center of Ankara province and 250 practicioners working in primary health care centers were included in the study. A scale composed of five parts including history, physical examination, radiology, risk groups and symptoms was prepared to determine the level of knowledge of physician related with child abuse and neglect. The correct answers given to the questions included in the scale were added and knowledge scores for the subscales and the total score were calculated. Approval was obtained from Ankara University, Medical Faculty Ethics Committee for the study. The data were evaluated using Mann-Whitney U and Kruskal Wallis test.

RESULTS

A total of 550 physicians (339 female and 221 male) were included in the study. The mean total knowledge score related with child abuse and neglect was found to be 12.4±4.5 in residents of pediatrics, 13.7±2.8 in pediatricians and 13.6±2.8 in practitioners. The level of knowledge was found to be significantly higher in women, married physicians, physicians who received education before and after graduation, physician who confronted with cases of abuse or suspicious abuse and made a legal notice.

CONCLUSION

In the light of these findings, child abuse and neglect should be included in education programs before and after graduation for physicians who have a key role in the subject of child abuse and neglect.

Management of dental trauma in a primary care setting

The American Academy of Pediatrics and its Section on Oral Health have developed this clinical report for pediatricians and primary care physicians regarding the diagnosis, evaluation, and management of dental trauma in children aged 1 to 21 years. This report was developed through a comprehensive search and analysis of the medical and dental literature and expert consensus. Guidelines published and updated by the International Association of Dental Traumatology (www.dentaltraumaguide.com) are an excellent resource for both dental and nondental health care providers.

Perspectives from a pediatrician about diagnostic errors

This opinion paper provides perspectives from a pediatrician about diagnostic challenges in caring for children. This essay shares personal experiences and lessons learned from a pediatric hospitalist about caring for children and making errors in diagnosis. This piece offers guidance about how to teach medical learners key concepts about error in diagnosis with underscoring the importance of developing critical thinking skills. Finally, the author offers tips from the literature about how physicians and other care providers can reorganize their own thinking (metacognition) to address their clinical practice.

Widening disparity in the geographic distribution of pediatricians in Japan

BACKGROUND

The shortage of physicians in Japan is a serious concern, particularly in specialties like pediatrics. The purpose of this study was to investigate recent changes in the geographic distribution of pediatricians and the factors underlying this change.

METHODS

We investigated the numerical changes in the pediatrician workforce (2002 to 2007) per 100,000 of the population under the age of 15 years in 369 secondary medical areas throughout Japan, using attributive variables such as population size, social and economic status, and pediatric service delivery. We performed principal component analysis and multiple regression analysis.

RESULTS

We obtained two principal components: one that reflected the degree of urbanization and another that reflected the volume of pediatric service delivery. Only the first component score was positively correlated with an increased pediatrician workforce per 100,000 of the population under the age of 15 years. We classified the secondary medical areas into four groups using component scores. The increase in pediatrician workforce during this period was primarily absorbed into the two groups with higher levels of urbanization, whereas the two rural groups exhibited little increase. Pediatricians aged 50 to 59 years increased in all four groups, whereas pediatricians aged 30 to 39 years decreased in the two rural groups and increased in the two urban groups.

CONCLUSIONS

The trends of the pediatrician workforce increase generally kept pace with urbanization, but were not associated with the original pediatrician workforce supply. The geographic distribution of pediatricians showed rapid concentration in urban areas. This trend was particularly pronounced among female pediatricians and those aged 30 to 39 years. Given that aging pediatricians in rural areas are not being replaced by younger doctors, these areas will likely face new crises when senior physicians retire.

Pediatrician-led motivational interviewing to treat overweight children: an RCT

OBJECTIVE

The aim of this study was to evaluate the effect of family pediatrician-led motivational interviews (MIs) on BMI of overweight (85th ≥ BMI percentile ≥ 95 th) children aged 4 to 7 years.

METHODS

All the family pediatricians working in Reggio Emilia Province (Italy) were invited to participate in the study; 95% accepted. Specific training was provided. Parents were asked to participate in the trial if they recognized their child as overweight. Children were individually randomly assigned to MIs or usual care. All children were invited for a baseline and a 12-month visit to assess BMI and lifestyle behaviors. The usual care group received an information leaflet, and the intervention group received 5 MI family meetings. The primary outcome was the individual variation of BMI, assessed by pediatricians unblinded to treatment groups.

RESULTS

Of 419 eligible families, 372 (89%) participated; 187 children were randomized to MIs and 185 to the usual care group. Ninety-five percent of the children attended the 12-month visit. The average BMI increased by 0.49 and 0.79 during the intervention in the MI and control groups, respectively (difference: -0.30; P = .007). MI had no effect in boys or in children whose mothers had a low educational level. Positive changes in parent-reported lifestyle behaviors occurred more frequently in the MI group than in the control group.

CONCLUSIONS

The pediatrician-led MI was overall effective in controlling BMI in these overweight children aged 4 to 7 years, even though no effect was observed in male children or when the mother's education level was low.

Play and video effects on mood and procedure behaviors in school-aged children visiting the pediatrician

This study examines how different types of activities, including medical play, typical play, and videos, affect the mood and behaviors of children visiting a pediatric office. Seventy-two school-aged children visiting a pediatrician's office were randomly assigned to 1 of 4 groups: medical play, medical information video, typical play, and nonmedical information video control. Children completed a mood self-report measure and their behaviors were recorded during triage by nurses. The medical information video improved the school-aged children's mood. Children in the medical information video displayed less difficult behaviors during procedures than the medical play group. The findings suggest that providing information about medical equipment through a video of a child engaging in medical play may benefit children visiting the pediatrician.

Enhancing pediatric workforce diversity and providing culturally effective pediatric care: implications for practice, education, and policy making

This policy statement serves to combine and update 2 previously independent but overlapping statements from the American Academy of Pediatrics (AAP) on culturally effective health care (CEHC) and workforce diversity. The AAP has long recognized that with the ever-increasing diversity of the pediatric population in the United States, the health of all children depends on the ability of all pediatricians to practice culturally effective care. CEHC can be defined as the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions, leading to optimal health outcomes. The AAP believes that CEHC is a critical social value and that the knowledge and skills necessary for providing CEHC can be taught and acquired through focused curricula across the spectrum of lifelong learning. This statement also addresses workforce diversity, health disparities, and affirmative action. The discussion of diversity is broadened to include not only race, ethnicity, and language but also cultural attributes such as gender, religious beliefs, sexual orientation, and disability, which may affect the quality of health care. The AAP believes that efforts must be supported through health policy and advocacy initiatives to promote the delivery of CEHC and to overcome educational, organizational, and other barriers to improving workforce diversity.

Current Australian pediatric practice in the assessment and treatment of ADHD

OBJECTIVE

To study the characteristics of children diagnosed with attention-deficit/hyperactivity disorder (ADHD) in Australia, and the assessment and management practices of their pediatricians.

METHODS

A 2-week practice audit was conducted in a large representative sample of Australian general/community pediatricians. Pediatricians completed an audit form for all patients seen. Demographic details, diagnoses, treatments, and referrals made were recorded for each consultation.

RESULTS

A total of 199 pediatricians completed the audit (response rate 66%). There were 1528 consultations with patients with ADHD. Eighty percent of the subjects were male, and mean age at diagnosis was 9.1 years (range 3-19 years). Most patients (60%) had 1 or more comorbidity identified, although the reported rates of anxiety (8%) and oppositional defiant disorder (15%) were lower than expected. Patients with ADHD were more likely than patients with other diagnoses to be seen in private practice settings (76% vs. 65%; P < .001). Children with ADHD were referred to numerous services at diagnosis, most commonly psychology (32%). Stimulant medication or atomoxetine was prescribed for 40% at initial diagnosis and 80% at continuing consultation. Overall, methylphenidate was the most common medication prescribed (63%), with a minority prescribed dexamphetamine, atomoxetine, or clonidine. Eighteen percent were prescribed 2 or more medications. Medication prescription was predicted by age but not by gender or socioeconomic status.

CONCLUSIONS

ADHD is the most frequent diagnosis seen by Australian pediatricians, with some patients being seen into early adult life. Comorbidities appear to be inconsistently identified, with some possibly underdiagnosed. Older children are more likely to be prescribed medication.

Scope of practice issues in the delivery of pediatric health care

The American Academy of Pediatrics (AAP) believes that optimal pediatric health care depends on a team-based approach with supervision by a physician leader, preferably a pediatrician. The pediatrician, here defined to include not only pediatric generalists but all pediatric medical subspecialists, all surgical specialists, and internal medicine/pediatric physicians, is uniquely qualified to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all practice settings. The AAP recognizes the valuable contributions of nonphysician clinicians, including nurse practitioners and physician assistants, in delivering optimal pediatric care. However, the expansion of the scope of practice of nonphysician pediatric clinicians raises critical public policy and child health advocacy concerns. Pediatricians should serve as advocates for optimal pediatric care in state legislatures, public policy forums, and the media and should pursue opportunities to resolve scope of practice conflicts outside state legislatures. The AAP affirms the importance of appropriate documentation and standards in pediatric education, training, skills, clinical competencies, examination, regulation, and patient care to ensure safety and quality health care for all infants, children, adolescents, and young adults.

Providing care for children and adolescents facing homelessness and housing insecurity

Child health and housing security are closely intertwined, and children without homes are more likely to suffer from chronic disease, hunger, and malnutrition than are children with homes. Homeless children and youth often have significant psychosocial development issues, and their education is frequently interrupted. Given the overall effects that homelessness can have on a child's health and potential, it is important for pediatricians to recognize the factors that lead to homelessness, understand the ways that homelessness and its causes can lead to poor health outcomes, and when possible, help children and families mitigate some of the effects of homelessness. Through practice change, partnership with community resources, awareness, and advocacy, pediatricians can help optimize the health and well-being of children affected by homelessness.

The effect of the children's health insurance program on pediatricians' work hours

OBJECTIVE

Our study examines changes in physicians' work hours in response to a coverage expansion.

METHODS

We use as a natural experiment the Children's Health Insurance Program (CHIP), which was established in 1997 and significantly expanded children's eligibility for public health insurance coverage. The magnitude of the CHIP expansion varied across states and over time, allowing its effects to be identified using a state-year fixed effects model. We focus on pediatricians, and we measure their self-reported work hours using multiple waves (pre- and post-CHIP) of the physician survey component of the Community Tracking Study. To address endogeneity concerns, we instrument for CHIP enrollment using key program features (income eligibility cutoffs and waiting times).

RESULTS

We find a large negative relationship between the magnitude of a state's CHIP expansion and trends in pediatricians' work hours. This relationship could be due to key supply-side features of CHIP, including relatively low provider reimbursements and heavy use of managed care tools.

Evaluation of active and passive recruitment methods used in randomized controlled trials targeting pediatric obesity

OBJECTIVE

Evaluate enrollment numbers, randomization rates, costs, and cost-effectiveness of active versus passive recruitment methods for parent-child dyads into two pediatric obesity intervention trials.

METHODS

Recruitment methods were categorized into active (pediatrician referral and targeted mailings, with participants identified by researcher/health care provider) versus passive methods (newspaper, bus, internet, television, and earning statements; fairs/community centers/schools; and word of mouth; with participants self-identified). Numbers of enrolled and randomized families and costs/recruitment method were monitored throughout the 22-month recruitment period. Costs (in USD) per recruitment method included staff time, mileage, and targeted costs of each method.

RESULTS

A total of 940 families were referred or made contact, with 164 families randomized (child: 7.2+/-1.6 years, 2.27+/-0.61 standardized body mass index [zBMI], 86.6% obese, 61.7% female, 83.5% Caucasian; parent: 38.0+/-5.8 years, 32.9+/-8.4 BMI, 55.2% obese, 92.7% female, 89.6% caucasian). Pediatrician referral, followed by targeted mailings, produced the largest number of enrolled and randomized families (both methods combined producing 87.2% of randomized families). Passive recruitment methods yielded better retention from enrollment to randomization (p<0.05), but produced few families (21 in total). Approximately $91,000 was spent on recruitment, with cost per randomized family at $554.77. Pediatrician referral was the most cost-effective method, $145.95/randomized family, but yielded only 91 randomized families over 22-months of continuous recruitment.

CONCLUSION

Pediatrician referral and targeted mailings, which are active recruitment methods, were the most successful strategies. However, recruitment demanded significant resources. Successful recruitment for pediatric trials should use several strategies.

CLINICAL TRIALS REGISTRATION

NCT00259324, NCT00200265.

The breastfeeding mother and the pediatrician

An estimated 70% of mothers in the United States initiate breastfeeding annually. Mothers often discuss breastfeeding problems with their infant's pediatrician. Pediatricians may feel unsure about their role when assisting the nonpatient, breastfeeding mother. By having practical solutions and support systems in place to anticipate and tend to breastfeeding mothers' needs, pediatricians can be instrumental in preventing early weaning. The purpose of this article is to provide practical suggestions to outpatient-based pediatric health care providers when assisting the breastfeeding dyad.

Effective strategies for HPV vaccine delivery: the views of pediatricians

PURPOSE

Pediatricians will play a critical role in human papillomavirus (HPV) vaccine delivery. The objectives of this research were to examine pediatricians' views about key issues related to HPV vaccine delivery and identify their strategies for effective vaccine delivery.

METHODS

A diverse sample of practicing pediatricians was recruited from a three-state region using a purposeful sampling strategy. Participants completed in-depth, semi-structured interviews. Qualitative data were analyzed using framework analysis.

RESULTS

The mean age of the 31 participants was 47 years (range 30-78 years), and 17 (55%) were female. In all, 18 were white, nine (29%) black, and four (13%) Latino. Participants noted that cultural issues, including a family's religious and ethnic background, were important considerations when recommending an HPV vaccine. Almost all participants believed that vaccination should be universal rather than targeted, but opinions regarding legislative mandates for vaccination varied. Those in favor of mandates cited their potential to maximize the public health impact of immunization, while those opposed noted that HPV is not transmitted casually and were concerned about limited data on the long-term safety and efficacy of HPV vaccines. Pediatricians noted that specific strategies for effective vaccine delivery would be needed for an STI vaccine targeted toward adolescents, especially considering the poor public understanding of HPV. These included provision of HPV vaccines in alternative settings, guidance for pediatricians as to how to address parental concerns, and specific educational initiatives.

CONCLUSIONS

The views of pediatricians, who have extensive experience administering vaccines to children and adolescents, will be valuable as HPV vaccine delivery strategies are designed.