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1.  Paediatric palliative home care in areas of Germany with low population density and long distances: a questionnaire survey with general paediatricians 
BMC Research Notes  2012;5:498.
Background
In 2007, the patient’s right to specialised palliative home care became law in Germany. However, childhood palliative care in territorial states with low patient numbers and long distances requires adapted models to ensure an area-wide maintenance. Actually, general paediatricians are the basic care providers for children and adolescents. They also provide home care. The aim of this study was to improve the knowledge about general paediatrician’s involvement in and contribution to palliative care in children.
Findings
To evaluate the current status of palliative home care provided by general paediatricians and their cooperation with other paediatric palliative care providers, a questionnaire survey was disseminated to general paediatricians in Lower Saxony, a German federal state with nearly eight million inhabitants and a predominantly rural infrastructure. Data analysis was descriptive.
One hundred forty one of 157 included general paediatricians completed the questionnaire (response rate: 89.8%). A total of 792 children and adolescents suffering from life-limiting conditions were cared for by these general paediatricians in 2008. Severe cerebral palsy was the most prevalent diagnosis. Eighty-nine per cent of the general paediatricians stated that they had professional experience with paediatric palliative care.
Collaboration of general paediatricians and other palliative care providers was stated as not well developed. The support by a specialised team including 24-hour on-call duty and the intensification of educational programs were emphasised.
Conclusions
The current regional infrastructure of palliative home care in Lower Saxony can benefit from the establishment of a coordinated network of palliative home care providers.
doi:10.1186/1756-0500-5-498
PMCID: PMC3532334  PMID: 22967691
Children; Palliative care; Paediatrician’s survey; Home care; Network; Prevalence
2.  Accuracy of clinical assessment of heart murmurs by office based (general practice) paediatricians 
Archives of Disease in Childhood  1999;81(5):409-412.
AIM—To determine the diagnostic accuracy of physical examination by office based (general practice) paediatricians in the evaluation of heart murmurs.
DESIGN—Each of 30 office based paediatricians blindly examined a random sample of children with murmurs (43% of which were pathological). Sensitivity and specificity were calculated and were related to paediatricians' characteristics.
RESULTS—Mean (SD) sensitivity was 82 (24)% with a mean specificity of 72 (24)% in differentiating pathological from innocent murmurs, with further investigations requested for 54% of assessments. The addition of a referral strategy would have increased mean sensitivity to 87 (20)% and specificity to 98 (8)%. Diagnostic accuracy was not significantly related to the paediatricians' age, education or practice characteristics, but was related to referral practices and confidence in assessment.
CONCLUSIONS—Diagnostic accuracy of clinical assessment of heart murmurs by office based paediatricians is suboptimal, and educational strategies are needed to improve accuracy and reduce unnecessary referrals and misdiagnosis.


PMCID: PMC1718138  PMID: 10519714
3.  Community paediatricians' counseling patterns and knowledge of recommendations relating to child restraint use in motor vehicles 
Injury Prevention  2004;10(2):103-106.
Background: Road traffic injury is the leading cause of death among Canadian children and youth. Transport Canada recommends four types of child restraint depending on the size of the child, and recent studies have demonstrated the effectiveness of recommended restraint use.
Objectives: To determine community paediatricians' knowledge of Transport Canada recommendations for child restraint use in vehicles, and to examine paediatricians' counseling patterns in relation to child passenger safety.
Methods: A mailed questionnaire survey of all community paediatricians affiliated with the Hospital for Sick Children, Toronto was conducted. A 16 item questionnaire gathered information on knowledge of Transport Canada recommendations for child restraint use, general counseling patterns in relation to child passenger safety, and demographic information.
Results: In total, 60 community paediatricians in active practice were identified. Of these, 48 (80%) responded to the mailed questionnaire. Almost all paediatricians (92%) correctly identified the recommended weight for transition to a forward-facing car seat, whereas fewer paediatricians (63%) correctly identified the recommended weight for transition to a booster seat from a forward-facing car seat, and only one third of paediatricians correctly identified the recommended weight for transition from a booster seat to a seat belt.
Conclusion: Community paediatricians' knowledge of Transport Canada recommendations for child restraint use in vehicles is incomplete. There is a need for such recommendations to be better disseminated to paediatricians and parents so that information on child restraint use is delivered in a clear and consistent manner.
doi:10.1136/ip.2003.004168
PMCID: PMC1730066  PMID: 15066976
4.  Paediatric palliative home care by general paediatricians: a multimethod study on perceived barriers and incentives 
BMC Palliative Care  2010;9:11.
Background
Non-specialist palliative care, as it is delivered by general practitioners, is a basic component of a comprehensive palliative care infrastructure for adult patients with progressive and far advanced disease. Currently palliative care for children and adolescents is recognized as a distinct entity of care, requiring networks of service providers across different settings, including paediatricians working in general practice. In Germany, the medical home care for children and adolescents is to a large extent delivered by general paediatricians working in their own practice. However, these are rarely confronted with children suffering from life-limiting diseases. The aim of this study was therefore to examine potential barriers, incentives, and the professional self-image of general paediatricians with regard to paediatric palliative care.
Methods
Based on qualitative expert interviews, a questionnaire was designed and a survey among general paediatricians in their own practice (n = 293) was undertaken. The survey has been developed and performed in close cooperation with the regional professional association of paediatricians.
Results
The results showed a high disposition on part of the paediatricians to engage in palliative care, and the majority of respondents regarded palliative care as part of their profile. Main barriers for the implementation were time restrictions (40.7%) and financial burden (31.6%), sole responsibility without team support (31.1%), as well as formal requirements such as forms and prescriptions (26.6%). Major facilitations were support by local specialist services such as home care nursing service (83.0%), access to a specialist paediatric palliative care consultation team (82.4%), as well as an option of exchange with colleagues (60.1%).
Conclusions
Altogether, the high commitment to this survey reflects the relevance of the issue for paediatricians working in general practice. Education in basic palliative care competence and communication skills was seen as an important prerequisite for the engagement in paediatric palliative home care. A local network of specialist support on site and a 24/7 on-call service are necessary in order to facilitate the implementation of basic palliative care by paediatricians in their own practice.
doi:10.1186/1472-684X-9-11
PMCID: PMC2902453  PMID: 20525318
5.  Initial evaluation of congenital hypothyroidism: a survey of general paediatricians in East Anglia 
Archives of Disease in Childhood  1997;77(4):339-341.



The practice of general paediatricians in the initial evaluation of congenital hypothyroidism (CHT) was assessed. This was performed by a questionnaire survey of paediatricians in East Anglia of whom 84% responded. Nineteen of 25 clinicians based in seven district hospitals managed children with CHT. The median number of children in the care of each clinician was 4 (range 1-17) and the median number of children attending each hospital was 12 (range 5-23). All except one clinician arranged to confirm the diagnosis with a serum thyroid stimulating hormone concentration and free or total thyroxine. There was variation of opinion on the value of serum triiodothyronine and free triiodothyronine measurements, antibody screening, knee radiographs, and thyroid isotope scans. One clinician sought advice when notified of new children and two expressed the need for an investigation protocol. These findings indicate that most general paediatricians in East Anglia manage only a few children with CHT; the initial diagnosis is appropriately confirmed but they are uncertain about the value of other investigations.


PMCID: PMC1717345  PMID: 9389240
6.  Recurrent abdominal pain in children and adolescents – a survey among paediatricians 
Objective: Little is known about prevalence and usual treatment of childhood and adolescent recurrent abdominal pain (RAP) in outpatient paediatricians’ practice. This study’s primary objective was to acquire insights into the usual paediatricians’ treatment and their estimation of prevalence, age and gender of RAP patients. Further objectives were to assess to which extent family members of patients report similar symptoms, how paediatricians rate the strain of parents of affected children and adolescents and how paediatricians estimate the demand for psychological support.
Methods: Provided by a medical register, 437 outpatient paediatricians received a questionnaire to assess their perception of several psychosomatic problems and disorders including recurrent abdominal pain.
Results: According to paediatricians’ estimation, 15% of all visits are caused by patients with RAP. In 22% of these cases of RAP, at least one family member has similar problems. In about 15% of all RAP cases, parents ask for professional psychological support concerning their children’s issues, whereas 40% of paediatricians wish for psychological support considering this group of patients.
Conclusions: Estimated frequencies and paediatricians’ demands show the need for evidence-based psychological interventions in RAP to support usual medical treatment.
doi:10.3205/psm000071
PMCID: PMC3070435  PMID: 21468324
recurrent abdominal pain; RAP; functional abdominal pain; paediatricians; standard medical care; outpatient practice
7.  Early childhood caries and infant oral health: Paediatricians’ and family physicians’ knowledge, practices and training 
Paediatrics & Child Health  2006;11(3):151-157.
OBJECTIVES
To assess the knowledge of early childhood caries and to examine the current preventive oral health-related practices and training among Canadian paediatricians and family physicians who provide primary care to children younger than three years.
METHODS
A cross-sectional, self-administered survey was mailed to a random sample of 1928 paediatricians and family physicians.
RESULTS
A total of 1044 physicians met the study eligibility criteria, and of those, 537 returned completed surveys, resulting in an overall response rate of 51.4% (237 paediatricians and 300 family physicians). Six questions assessed knowledge of early childhood caries; only 1.8% of paediatricians and 0.7% of family physicians answered all of these questions correctly. In total, 73.9% of paediatricians and 52.4% of family physicians reported visually inspecting children’s teeth; 60.4% and 44.6%, respectively, reported counselling parents or caregivers regarding teething and dental care; 53.2% and 25.6%, respectively, reported assessing children’s risk of developing tooth decay; and 17.9% and 22.3%, respectively, reported receiving no oral health training in medical school or residency. Respondents who felt confident and knowledgeable and who considered their role in promoting oral health as “very important” were significantly more likely to carry out oral health-related practices.
CONCLUSION
Although the majority of paediatricians and family physicians reported including aspects of oral health in children’s well visits, a reported lack of dental knowledge and training appeared to pose barriers, limiting these physicians from playing a more active role in promoting the oral health of children in their practices.
PMCID: PMC2435315  PMID: 19030271
Attitudes; Dental caries; Early childhood caries; Health knowledge; Oral health; Physicians; Practice
8.  Asthma in children: Management practices among paediatricians and family physicians 
Paediatrics & Child Health  2001;6(6):355-360.
OBJECTIVE:
To ascertain the variation in asthma management practices among paediatricians and family physicians to determine how to improve care.
DESIGN:
Questionnaire study of paediatricians and family physicians that focused on the use of beta2-agonists, inhaled corticosteroids, patient asthma education, quantitative measurements of airflow and diagnostic investigations for asthma. Case scenarios were used in the questionnaire.
RESULTS:
The response rate was 66% (415 of 632) among paediatricians and 42% (1156 of 2750) among family physicians. In general, both groups followed consensus guidelines. There were some differences in management practices among paediatricians and family physicians. Paediatricians were more likely to develop an action plan and less likely to use xanthines or inhaled anticholinergic agents. However, family physicians were more likely to use spirometry or home peak expiratory flow rates to make a diagnosis of asthma.
CONCLUSION:
Family physicians and paediatricians require a different focus on educational interventions to improve the care of children with asthma.
PMCID: PMC2804761  PMID: 20084262
Asthma; Children; Management; Professional variation
9.  Why children's rights are central to international child health 
Archives of Disease in Childhood  2007;92(2):176-180.
The UN Convention on the Rights of the Child provides a framework for improving children's lives around the world. It covers both individual child health practice and public health and provides a unique and child‐centred approach to paediatric problems. The Convention applies to most child health problems and the articles are grouped into protection, provision and participation. Examples of the first are the right to protection from abuse, from economic exploitation and from illicit drugs. We examine one particular problem in each of these categories, specifically child labour, services for children with a disability and violence against children. The role of the paedialrician in applying a children's rights approach is discussed. Children's rights are increasingly being accepted around the world but still there is much more rhetoric paid to their value than genuine enforcement. Paediatricians can make a difference to the status of children worldwide by adopting a rights‐based approach.
doi:10.1136/adc.2006.098228
PMCID: PMC2083315  PMID: 17264288
10.  Diagnosing and treating attentional difficulties: a nationwide survey 
Archives of Disease in Childhood  2004;89(10):913-916.
Aims: To ascertain from paediatricians and child psychiatrists their views regarding the aetiology, assessment, and diagnosis of attentional difficulties in children, and the prescribing of stimulant medication for such difficulties.
Methods: Using a questionnaire devised by the authors, 465 paediatricians and 444 child psychiatrists were surveyed.
Results: The overall response rate was 73%. Some 94% of child psychiatrists and 29% of paediatricians routinely dealt with attentional difficulties. Views on aetiology, classification, and diagnosis were varied. More than 60% of both groups were prepared to prescribe stimulant medication without a formal diagnosis being made. Comorbid conduct disorder and the views of other professionals and of parents have an impact on practice.
Conclusions: This survey demonstrates that there is a range of approaches to attentional difficulties by both paediatricians and child psychiatrists.
doi:10.1136/adc.2002.023499
PMCID: PMC1719661  PMID: 15383433
11.  Shared care obesity management in 3-10 year old children: 12 month outcomes of HopSCOTCH randomised trial 
Objective To determine whether general practice surveillance for childhood obesity, followed by obesity management across primary and tertiary care settings using a shared care model, improves body mass index and related outcomes in obese children aged 3-10 years.
Design Randomised controlled trial.
Setting 22 family practices (35 participating general practitioners) and a tertiary weight management service (three paediatricians, two dietitians) in Melbourne, Australia.
Participants Children aged 3-10 years with body mass index above the 95th centile recruited through their general practice between July 2009 and April 2010.
Intervention Children were randomly allocated to one tertiary appointment followed by up to 11 general practice consultations over one year, supported by shared care, web based software (intervention) or “usual care” (control). Researchers collecting outcome measurements, but not participants, were blinded to group assignment.
Main outcome measures Children’s body mass index z score (primary outcome), body fat percentage, waist circumference, physical activity, quality of diet, health related quality of life, self esteem, and body dissatisfaction and parents’ body mass index (all 15 months post-enrolment).
Results 118 (60 intervention, 56 control) children were recruited and 107 (91%) were retained and analysed (56 intervention, 51 control). All retained intervention children attended the tertiary appointment and their general practitioner for at least one (mean 3.5 (SD 2.5, range 1-11)) weight management consultation. At outcome, children in the two trial arms had similar body mass index (adjusted mean difference −0.1 (95% confidence interval −0.7 to 0.5; P=0.7)) and body mass index z score (−0.05 (−0.14 to 0.03); P=0.2). Similarly, no evidence was found of benefit or harm on any secondary outcome. Outcomes varied widely in the combined cohort (mean change in body mass index z score −0.20 (SD 0.25, range −0.97-0.47); 26% of children resolved from obese to overweight and 2% to normal weight.
Conclusions Although feasible, not harmful, and highly rated by both families and general practitioners, the shared care model of primary and tertiary care management did not lead to better body mass index or other outcomes for the intervention group compared with the control group. Improvements in body mass index in both groups highlight the value of untreated controls when determining efficacy.
Trial registration Australian New Zealand Clinical Trials Registry ACTRN12608000055303.
doi:10.1136/bmj.f3092
PMCID: PMC3677741  PMID: 23751902
12.  Attitudes and practice of Children’s Hospital of Eastern Ontario (Ottawa, Ontario) paediatricians and residents toward literacy promotion in Canada 
Paediatrics & Child Health  2011;16(5):e38-e42.
BACKGROUND:
Literacy is a critical health issue in Canada. Paediatricians play an important role in improving literacy skills; however, formal training in literacy education and promotion is not currently part of most Canadian paediatric residency programs.
OBJECTIVE:
To examine the attitudes and practice of paediatricians and residents at the Children’s Hospital of Eastern Ontario (CHEO [Ottawa, Ontario]) toward literacy promotion.
METHODS:
A descriptive, cross-sectional survey of CHEO-affiliated paediatricians, residents and fellows was performed. Survey items addressed demographics, attitudes toward literacy, current practice and previous education/training in literacy education through self-reporting.
RESULTS:
One hundred ninety-seven surveys were distributed, with a response rate of 82%. Ninety-one per cent of respondents reported never having formal training in literacy development and promotion. Seventy-four per cent of respondents believed that low literacy is a significant health issue in Canada; however, only 16% of respondents reported regularly discussing literacy with patients and their families. Thirty-nine per cent of general paediatricians reported discussing literacy with patients and families regularly, compared with 10% of paediatric subspecialists (P<0.01). Seventy-one per cent of respondents believed that literacy education should be a standard part of residency education.
CONCLUSIONS:
While most respondents identified literacy as an important paediatric issue, most paediatricians did not regularly discuss the importance of literacy with their patients. General paediatricians are most likely to discuss literacy. There is a lack of formal education among paediatricians in literacy development and promotion, and the majority of respondents believe that this should be a standard part of paediatric residency training.
PMCID: PMC3115000  PMID: 22547952
Advocacy; Literacy; Medical education; Reading
13.  Signs and symptoms in children with a serious infection: a qualitative study 
BMC Family Practice  2005;6:36.
Background
Early diagnosis of serious infections in children is difficult in general practice, as incidence is low, patients present themselves at an early stage of the disease and diagnostic tools are limited to signs and symptoms from observation, clinical history and physical examination. Little is known which signs and symptoms are important in general practice. With this qualitative study, we aimed to identify possible new important diagnostic variables.
Methods
Semi-structured interviews with parents and physicians of children with a serious infection. We investigated all signs and symptoms that were related to or preceded the diagnosis. The analysis was done according to the grounded theory approach. Participants were recruited in general practice and at the hospital.
Results
18 children who were hospitalised because of a serious infection were included. On average, parents and paediatricians were interviewed 3 days after admittance of the child to hospital, general practitioners between 5 and 8 days after the initial contact.
The most prominent diagnostic signs in seriously ill children were changed behaviour, crying characteristics and the parents' opinion. Children either behaved drowsy or irritable and cried differently, either moaning or an inconsolable, loud crying. The parents found this illness different from previous illnesses, because of the seriousness or duration of the symptoms, or the occurrence of a critical incident. Classical signs, like high fever, petechiae or abnormalities at auscultation were helpful for the diagnosis when they were present, but not helpful when they were absent.
Conclusion
behavioural signs and symptoms were very prominent in children with a serious infection. They will be further assessed for diagnostic accuracy in a subsequent, quantitative diagnostic study.
doi:10.1186/1471-2296-6-36
PMCID: PMC1215482  PMID: 16124874
14.  The care of children in family practice 
The role of the general practitioner in the care of children is described and compared with that of the paediatrician. Several practical problems arising in child care in general practice are described with emphasis on the respiratory tract. A quarter of a century ago, maternity care was the foundation on which general practice was built. Today the care of children is the new base of general practice.
PMCID: PMC2574220  PMID: 7420320
15.  Perception of primary health professionals about Female Genital Mutilation: from healthcare to intercultural competence 
Background
The practice of Female Genital Mutilation (FGM), a deeply-rooted tradition in 28 countries in Sub-Saharan Africa, carries important negative consequences for the health and quality of life of women and children. Migratory movements have brought this harmful traditional practice to our medical offices, with the subsequent conflicts related to how to approach this healthcare problem, involving not only a purely healthcare-related event but also questions of an ethical, cultural identity and human rights nature.
Methods
The aim of this study was to analyse the perceptions, degree of knowledge, attitudes and practices of the primary healthcare professionals in relation to FGM. A transversal, descriptive study was performed with a self-administered questionnaire to family physicians, paediatricians, nurses, midwives and gynaecologists. Trends towards changes in the two periods studied (2001 and 2004) were analysed.
Results
A total of 225 (80%) professionals answered the questionnaire in 2001 and 184 (62%) in 2004. Sixteen percent declared detection of some case in 2004, rising three-fold from the number reported in 2001. Eighteen percent stated that they had no interest in FGM. Less than 40% correctly identified the typology, while less than 30% knew the countries in which the practice is carried out and 82% normally attended patients from these countries.
Conclusion
Female genital mutilations are present in primary healthcare medical offices with paediatricians and gynaecologists having the closest contact with the problem. Preventive measures should be designed as should sensitization to promote stands against these practices.
doi:10.1186/1472-6963-9-11
PMCID: PMC2631456  PMID: 19146694
16.  Low incidence of reactive arthritis in children following a salmonella outbreak 
Annals of the Rheumatic Diseases  2001;60(11):1055-1057.
OBJECTIVES—To assess the incidence of reactive arthritis (ReA) in an outbreak of salmonella infection in a large cohort of children in Germany.
METHODS—A few days after the salmonella outbreak all parents of affected children and all paediatricians and general practitioners in the region were provided with detailed information about the possibility of ReA. Six weeks after the outbreak a telephone call was made to all general practitioners and paediatricians to identify patients with ReA. Ten weeks after the outbreak a questionnaire assessing symptoms of ReA was mailed to all parents, and after a period of 4 months paediatricians and general practitioners were contacted again to search for additional unreported cases of ReA.
RESULTS—Of the 286 children (age range 11 months to 9 years) with diarrhoea and stool cultures positive for Salmonella enteritidis lysotype 8/7, not a single case of arthritis was reported over the 4 month period. However, six children (2%) had arthralgia of various duration (1 day to 6 weeks) with a single recurrence in one child. The joint pattern was oligoarticular and lower limb joints (knee/ankle) were affected exclusively.
CONCLUSION—The incidence of ReA after salmonella infection in children appears to be very low which may be related to differences in the immune response between children and adults.


doi:10.1136/ard.60.11.1055
PMCID: PMC1753416  PMID: 11602478
17.  Specialist approach to childhood asthma: does it exist? 
Twenty six paediatricians and 21 consultant physicians concerned in the care of children with asthma answered a postal questionnaire on various aspects of the management of asthma, attitudes to referral, and the nature of advice given to parents and children. The 47 specialists had considerable differences in opinion for more than half the questions, including the role of allergen skin tests and the use of "breathing exercises." In addition, the paediatricians disagreed with the responses of the non-paediatricians on common issues such as whether to use aminophylline suppositories and whether swimming helps children grow out of asthma. These results have disturbing implications for the advice that specialists give to general practitioners, children, and parents.
PMCID: PMC1548894  PMID: 6409273
18.  Parental questions about developmental coordination disorder: A synopsis of current evidence 
Paediatrics & Child Health  2006;11(8):507-512.
In recent years, knowledge about developmental coordination disorder (DCD) has accumulated very rapidly. Considerable progress has been made in the understanding of DCD, but recent studies have not been compiled in a way that makes them easily accessible to practicing paediatricians. In the present paper, the literature is reviewed and organized around the questions commonly raised by parents of children with DCD when they meet with their paediatrician. Parents express concern and seek information about their child’s movement difficulties. They want to know what causes their child’s lack of coordination and whether DCD is the correct diagnosis. Are other developmental disorders involved? What can they do to help their child’s daily frustrations? The present review addresses frequently asked questions through a critical appraisal of current research literature. Paediatricians who are familiar with the research evidence will be better able to recognize these children and to share information with parents.
PMCID: PMC2528644  PMID: 19030319
Children; Developmental coordination disorder; Movement skill difficulties; Parents
19.  Prevalence and dietetic management of mild gastrointestinal disorders in milk-fed infants 
AIM: To assess the prevalence of mild gastrointestinal disorders in milk-fed infants in paediatric practice, and to evaluate the effectiveness and satisfaction with dietetic treatment.
METHODS: A cross-sectional epidemiological study was first carried out. A total of 285 paediatricians included 3487 children seen during a period of one week. In a second phase an observational, prospective and multicentre study was conducted and 2069 milk-fed infants with mild gastrointestinal disorders (colic, constipation, regurgitation and diarrhoea) were included. There was a baseline visit (start of treatment) and a final visit four weeks later. The effectiveness of the various Novalac formulas, as well as the satisfaction of the parents/tutors and paediatricians with the dietetic treatment were assessed at the final visit.
RESULTS: The prevalence of mild gastrointestinal disorders was 27.8% of all paediatrician consultations (9.2%, 7.8%, 6.1% and 4.6% in relation to colic, constipation, regurgitation and diarrhoea, respectively). The several Novalac adapted milk formulas resolved 88.4% of the mild gastrointestinal disorders. Depending on the type of disorder, differences in response rate were observed. The highest effectiveness was recorded with respect to diarrhoea (92.6%), followed by constipation (91.6%), colic (87.6%) and regurgitation (81%). Overall, 91% of the paediatricians and 88.8% of the parents/tutors were satisfied or very satisfied with the Novalac adapted milk formulas.
CONCLUSION: Mild gastrointestinal disorders show a high prevalence in paediatric practice. The Novalac adapted milk formulas have been shown to be effective in treating mild gastrointestinal disorders in milk-fed infants in the context of routine clinical practice.
doi:10.3748/wjg.14.248
PMCID: PMC2675122  PMID: 18186563
Mild gastrointestinal disorders; Prevalence; Adapted infant formulas; Effectiveness; Satisfaction
20.  Why do paediatricians prescribe antibiotics? Results of an Italian regional project 
BMC Pediatrics  2009;9:69.
Background
To investigate determinants of antibiotic prescription in paediatric care, as a first step of a multilevel intervention to improve prescribing for common respiratory tract infections (RTIs) in a northern Italian region with high antibiotic prescription rate.
Methods
A two-step survey was performed: in phase I, knowledge, and attitudes were explored involving all family and hospital paediatricians of Emilia-Romagna and a sample of parents. In phase II, patient care practices were explored in a stratified random sample of visits, both in hospitals and family physician's clinics; parent expectations were investigated in a sub-sample of these visits.
Results
Out of overall 4352 visits for suspected RTIs, in 38% of children an antibiotic was prescribed. Diagnostic uncertainty was perceived by paediatricians as the most frequent cause of inappropriate prescription (56% of 633 interviewed paediatricians); but, rapid antigen detecting tests was used in case of pharyngitis/pharyngotonsillitis by 36% and 21% of family and hospital paediatricians only. More than 50% of paediatricians affirmed to not adopt a "wait and see strategy" in acute otitis. The perceived parental expectation of antibiotics was not indicated by paediatricians as a crucial determinant of prescription, but this perception was the second factor most strongly associated to prescription (OR = 12.8; 95% CI 10.4 - 15.8), the first being the presence of othorrea. Regarding parents, the most important identified factors, potentially associated to overprescribing, were the lack of knowledge of RTIs and antibiotics (41% of 1029 parents indicated bacteria as a possible cause of common cold), and the propensity to seek medical care for trivial infections (48% of 4352 children accessing ambulatory practice presented only symptoms of common cold).
Conclusion
A wide gap between perceived and real determinants of antibiotic prescription exists. This can promote antibiotic overuse. Inadequate parental knowledge can also induce inappropriate prescription. The value of this study is that it simultaneously explored determinants of antimicrobial prescribing in an entire region involving both professionals and parents.
doi:10.1186/1471-2431-9-69
PMCID: PMC2777860  PMID: 19895678
21.  Adverse events associated with paediatric use of complementary and alternative medicine: Results of a Canadian Paediatric Surveillance Program survey 
Paediatrics & Child Health  2009;14(6):385-387.
BACKGROUND
Despite many studies confirming that the use of complementary and alternative medicine (CAM) by children is common, few have assessed related adverse events.
OBJECTIVE
To conduct a national survey to identify the frequency and severity of adverse events associated with paediatric CAM use.
METHODS
Survey questions were developed based on a review of relevant literature and consultation with content experts. In January 2006, the Canadian Paediatric Surveillance Program distributed the survey to all paediatricians and paediatric subspecialists in active practice in Canada.
RESULTS
Of the 2489 paediatricians who received the survey, 583 (23%) responded. Respondents reported that they asked patients about CAM use 38% of the time and that patients disclosed this information before being questioned only 22% of the time. Forty-two paediatricians (7%) reported seeing adverse events, most commonly involving natural health products, in the previous year. One hundred five paediatricians (18%) reported witnessing cases of delayed diagnosis or treatment (n=488) that they attributed to the use of CAM.
CONCLUSION
While serious adverse events associated with paediatric CAM appear to be rare, delays in diagnosis or treatment seem more common. Given the lack of paediatrician-patient discussion regarding CAM use, our findings may under-represent adverse events. A lack of reported adverse events should not be interpreted as a confirmation of safety. Active surveillance is required to accurately assess the incidence, nature and severity of paediatric CAM-related adverse events. Patient safety demands that paediatricians routinely inquire about the use of CAM.
PMCID: PMC2735381  PMID: 20592974
Adverse effects; Complementary therapies; Health survey; Manipulation; Natural products; Paediatrics; Spinal
22.  Clinicians' knowledge of informed consent 
Journal of Medical Ethics  2007;33(3):181-184.
Objective
To audit doctors' knowledge of informed consent.
Design
10 consent scenarios with “true”, “false”, or “don't know” answers were completed by doctors who care for children at a large district general hospital. These questions tested clinicians' knowledge of who could give consent in different clinical situations.
Setting
Royal United Hospital, Bath, UK.
Results
51 doctors participated (25 paediatricians and 26 other clinicians). Paediatricians scored higher than other clinicians (average correct response 69% v 49%). Only 36% (9/25) of paediatricians and 8% (2/26) of other clinicians realised that the biological father of a child born before 1 December 2003 needed a court order or a parental responsibility agreement to acquire parental responsibility, and thus be able to consent on behalf of his child, if he was not married to the child's mother. Non‐paediatric clinicians were unsure or incorrect when tested on situations where people with parental responsibility do not agree, or where young people (<16 years), who are Fraser competent do not want to consult their parents. Most clinicians did not know that the parents of a 20‐year‐old man with severe learning difficulties are unable to consent to surgery on his behalf, and many non‐paediatricians were unclear on who could give consent when a child lived with foster parents.
Conclusion
Clinicians who obtain consent for the treatment of children need to increase their knowledge on who is able to give informed consent to ensure best (legal and safe) practice.
doi:10.1136/jme.2006.016758
PMCID: PMC2598260  PMID: 17329394
23.  Paediatric Care in General Practice: an Experiment in Collaboration 
British Medical Journal  1969;2(5649):106-108.
A project of joint consultation between a paediatrician and several general practitioners serving a group practice of 15,000 patients has shown that outpatient clinics held at a group-practice centre (when 36 children were seen at 78 consultations over 18 months) reduced the overall work-load, eliminated dual care, and directly benefited the doctors, the children, and their families.
PMCID: PMC1982863  PMID: 5775433
24.  A study of clinical opinion and practice regarding circumcision 
Archives of Disease in Childhood  2000;83(5):393-396.
AIM—To establish clinical opinion regarding appropriate indications for circumcision and to examine actual clinical practice.
METHODS—A questionnaire was sent to all NHS hospital consultants in the Yorkshire region of the UK identified as having a role to play in the management of boys (under 16 years of age) requiring circumcision. Retrospective data on actual clinical practice during a three month study period were also collected via a simple proforma.
RESULTS—Of 153 questionnaires sent, 64 were returned. Responses revealed varying opinions regarding appropriate indications for circumcision within each consultant group, and between paediatricians and surgeons. Surgeons were generally more inclined to recommend circumcision for each of the indications listed in the questionnaire. Analysis of clinical practice revealed that almost two thirds of procedures were carried out for phimosis, and nearly half of these children were under the age of 5years.
CONCLUSION—There are differences in the clinical opinions of surgeons and paediatricians on what constitutes an appropriate indication for circumcision. Paediatricians' opinions are generally more in line with current evidence than those of surgeons, possibly resulting in many unnecessary circumcisions.


doi:10.1136/adc.83.5.393
PMCID: PMC1718533  PMID: 11040144
25.  Paediatric CT scan usage and referrals of children to computed tomography in Germany-a cross-sectional survey of medical practice and awareness of radiation related health risks among physicians 
Background
Computed tomography (CT) is a major source of ionizing radiation exposure in medical diagnostic. Compared to adults, children are supposed to be more susceptible to health risks related to radiation. The purpose of a cross-sectional survey among office-based physicians in Germany was the assessment of medical practice in paediatric CT referrals and to investigate physicians' knowledge of radiation doses and potential health risks of radiation exposure from CT in children.
Methods
A standardized questionnaire was distributed to all paediatricians and surgeons in two defined study areas. Furthermore, the study population included a random sample of general practitioners in the two areas. The questionnaire covered the frequency of referrals for paediatric CT examinations, the medical diagnoses leading to paediatric CT referrals, physicians' knowledge of radiation doses and potential health risks of radiation exposure from CT in children.
Results
A total of 295 (36.4%) physicians responded. 59% of the doctors had not referred a child to CT in the past year, and approximately 30% referred only 1-5 children annually. The most frequent indications for a CT examination in children were trauma or a suspected cancer. 42% of the referrals were related to minor diagnoses or unspecific symptoms. The participants underestimated the radiation exposure due to CT and they overestimated the radiation exposure due to conventional X-ray examinations.
Conclusions
In Germany, the frequency of referrals of children to computed tomography is moderate. The knowledge on the risks from radiation exposure among office-based physicians in our sample varied, but there was a tendency to underestimate potential CT risks. Advanced radiological training might lead to considerable amendments in terms of knowledge and practice of CT referral.
doi:10.1186/1472-6963-12-47
PMCID: PMC3306200  PMID: 22364554

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