Correction to: Does specialist physician supply affect pediatric asthma health outcomes?

In the original publication of this article [1], the institutional author's name needs to be revised from The Paediatric Chairs of Canada Mark Bernstein to The Paediatric Chairs of Canada.

Does specialist physician supply affect pediatric asthma health outcomes?

BACKGROUND: Pediatrician and pediatric subspecialist density varies substantially among the various Canadian provinces, as well as among various states in the US. It is unknown whether this variability impacts health outcomes. To study this knowledge gap, we evaluated pediatric asthma admission rates within the 2 Canadian provinces of Manitoba and Saskatchewan, which have similarly sized pediatric populations and substantially different physician densities. METHODS: This was a retrospective cross-sectional cohort study. Health regions defined by the provincial governments, have, in turn, been classified into "peer groups" by Statistics Canada, on the basis of common socio-economic characteristics and socio-demographic determinants of health. To study the relationship between the distribution of the pediatric workforce and health outcomes in Canadian children, asthma admission rates within comparable peer group regions in both provinces were examined by combining multiple national and provincial health databases. We generated physician density maps for general practitioners, and general pediatricians practicing in Manitoba and Saskatchewan in 2011. RESULTS: At the provincial level, Manitoba had 48.6 pediatricians/100,000 child population, compared to 23.5/100,000 in Saskatchewan. There were 3.1 pediatric asthma specialists/100,000 child population in Manitoba and 1.4/100,000 in Saskatchewan. Among peer-group A, the differences were even more striking. A significantly higher number of patients were admitted in Saskatchewan (590.3/100,000 children) compared to Manitoba (309.3/100,000, p < 0.0001). CONCLUSIONS: Saskatchewan, which has a lower pediatrician and pediatric asthma specialist supply, had a higher asthma admission rate than Manitoba. Our data suggest that there is an inverse relationship between asthma admissions and pediatrician and asthma specialist supply.

Screening and referral to identify children at risk for FASD: Search for new methods 2006-2013.

As part of the Canadian Association of Paediatric Health Centres Taskforce on FASD Screening commitment to further pilot, validate and evaluate the multiple components of the Canadian FASD Screening Tool Kit, it was deemed necessary that recent developments and/or improvements in FASD screening were identified and considered. In 2008 a literature review of methods for screening for FASD was published until 2006 and identified five tools which met pre-set criteria. A review of all new papers was published from the period January 2006 until July 1, 2013. Out of 1392 papers, two new screening methods met the inclusion criteria: Clarren et al's new norms for palpebral fissure length by age in Canada; and Breiner et al's extension of the Neurobehavioral Screening Test (NST) to age 4 years. Further work is needed to validate these methods in other settings. 

The maternal drinking history guide: development of a national educational tool.

BACKGROUND: The National Taskforce for the development of screening tools for FASD has identified maternal drinking as a critical area that should be screened. We describe the steps of development and implementation of a knowledge translation program for health care providers. The slide presentation is attached in English and French to allow its maximal use. METHODS: In 2010, the National Taskforce for the development of screening tools for FASD identified maternal drinking as a critical area that should be screened. The systematic review and associated recommendations have been published and were included in the toolkit developed by the Canadian Association of Paediatric Health Centres with funding support from the Public Health Agency of Canada. Effective inquiry of maternal drinking can be conducted at three levels: Primary level, as part of practice-based screening; Level 2 use of structured questionnaires; and Level 3 laboratory-based screening. CONCLUSION: It was acknowledged that most physicians do not ask women of reproductive age questions regarding their drinking habits, and the Taskforce was seriously concerned that even an effective guide may not change practice at the primary level. To that end, the Taskforce developed a three phase Knowledge Translation plan, to ensure that the educational program developed will be optimally effective for Canadian healthcare providers.

Are the career choices of paediatric residents meeting the needs of academic centres in Canada?

BACKGROUND: Responsibility for training paediatric medical subspecialists in Canada lies primarily with the 16 academic paediatric departments. There has been no mechanism to assess whether the number of residents in training will meet the needs of currently vacant positions and/or the predicted vacancies to be created by anticipated faculty retirement in the next five years across the different paediatric medical subspecialties. HYPOTHESIS: At the present time, the training of the paediatric physician is not linked with the current and future needs of the academic centres where the vast majority of these paediatric subspecialists are employed. METHODS: The academic paediatric workforce database of the Paediatric Chairs of Canada (PCC) for the surveys obtained in 2009/2010 were analyzed. Data included the number of physicians working in each subspecialty, the number of physicians 60 years of age or older, as well as the number of residents and their level of training. RESULTS: There are some paediatric subspecialties in which the actual number of trainees exceeds the currently predicted need (eg, cardiology, critical care, hematology-oncology, nephrology, neurology, emergency medicine and genetic-metabolic). On the other hand, for other specialties (eg, adolescent medicine, developmental paediatrics, gastroenterology and neonatology), assuming there is no significant change to selection patterns, an important gap will persist or appear between the need and the available human resources. CONCLUSION: The present analysis was the first attempt to link the clinical orientation of trainees with the needs of the academic centres where the vast majority of these paediatric subspecialists work.

Description of the development and validation of the Canadian Paediatric Trigger Tool.

OBJECTIVE: To describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT). METHODS: Five existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger. RESULTS: Nurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT. CONCLUSIONS: The CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities.

Practising what we preach: A look at healthy active living policy and practice in Canadian paediatric hospitals.

BACKGROUND: In the past 30 years, the rate of obesity has risen considerably among Canadian children. Paediatric hospitals are in a unique position to model healthy environments to Canadian children. OBJECTIVE: To obtain an overview of healthy active living (HAL) policy and practice in Canadian paediatric hospitals. METHODS: Working in partnership with the local Canadian Paediatric Society HAL champions and the Canadian Association of Paediatric Health Centres liaisons, a nationwide survey was conducted in 2006/2007 to identify healthy eating, physical activity and smoking cessation practices in all 16 Canadian paediatric academic hospitals. RESULTS: Policies addressing healthy eating and/or physical activity promotion were present in 50% of hospitals with a greater focus on nutrition. Wellness committees were created in 50% of the hospitals, most of which were recently established. Healthy food options were available in cafeterias, although they were often more expensive. Fast food outlets were present in 75% of hospitals. Although inpatient meals were designed by dietitians, 50% offered less nutritious replacement kids meals (ie, meal substitutions) on request. Options for play available to inpatients and outpatients were primarily sedentary, with screen-based activities and crafts predominating over active play. Physical activity promotion for staff focused on reduced membership fees to fitness centres and classes. CONCLUSION: Canadian paediatric hospitals do not adequately promote HAL for patients and staff. The present study findings suggest further effort is required to create necessary healthy lifestyle modifications in these institutions through Canadian Paediatric Society/Canadian Association of Paediatric Health Centres-led policy development and implementation initiatives. A national-level policy framework is required to regulate interhospital variability in policies and practices.

Experiences with HUS in Canada: what have we learned about childhood HUS in Canada?

Experiences with childhood hemolytic uremic syndrome (HUS) in Canada will focus on the development of the Canadian Pediatric Kidney Disease Research Centre (CPKDRC) and the results of our collaborative research over a 13-year period (1985-1998).

National collaborative: Top five drugs reported as causing harm through medication error in pediatrics.

The Canadian Association of Paediatric Health Centres (CAPHC) and the Institute for Safe Medication Practices Canada (ISMP Canada) are working collaboratively to enhance the safety of pediatric medication use. Eleven CAPHC member organizations submitted data on more than 4,000 medication incidents to ISMP Canada for the period October 2005 to June 2008, 305 of which were reported as resulting in harm. From this, the top five drugs causing harm through medication error and contributing factors to the incidents were identified. In this article, we intend to inform critical care practitioners of the medication incident analyses and the collaborative pediatric patient safety initiatives underway.

Development of Canadian screening tools for fetal alcohol spectrum disorder.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is the most common cause of neurobehavioural handicap in North America. Screening for FASD may facilitate diagnosis and hence management of these children. We present a variety of screening tools for the identification of children at risk for FASD. METHODS: We critically reviewed and evaluated published and practiced methods for their potential of screening suspected cases, their epidemiological characteristics (sensitivity, specificity, positive and negative predictive values) [Phase I], as well as their feasibility [Phase II]. RESULTS: The following five tools were selected for the FASD screening toolkit: screening fatty acid ethyl esters in neonatal meconium, the modified Child Behaviour Checklist, Medicine Wheel tool, Asante Centre Probation Officer Tool, and maternal history of drinking and drug use. CONCLUSIONS: The toolkit for FASD screening aims at screening different populations, from the newborns to youth and at-risk mothers. It is anticipated that the toolkit will facilitate diagnosis of FASD.

A randomized trial of regular standardized telephone contact by a diabetes nurse educator in adolescents with poor diabetes control.

OBJECTIVE: The aim of this study was to determine the effect of regular standardized telephone contact by a diabetes nurse educator (DNE) on metabolic control, treatment compliance, and quality of life in adolescents with poorly controlled type 1 diabetes. METHODS: A single-blinded 6-month randomized controlled trial was used. Participants included 46 of 49 eligible adolescents (13-17 yr) with type 1 diabetes >1-yr duration and hemoglobin A1c (HbA1c) >8.5% for the previous 6 months. Subjects were randomly assigned to 6 months of standard diabetes management or standard care plus weekly telephone contact by a DNE. Telephone conversations included review of events in the adolescents' lives and diabetes education, but the primary focus was on blood glucose results and insulin-dose adjustments. HbA1c, compliance with glucose monitoring, quality of life [Diabetes Quality of Life Scale for Youth (DQOLY)], and family functioning [Family Environment Scale (FES)] were assessed at baseline, and at 3 and 6 months. Posthoc, HbA1c levels were assessed 6 months following study completion. RESULTS: Six months of regular telephone contact by a DNE had no immediate effect on any of the outcome measures. However, posthoc 6 months, HbA1c levels decreased (1% change compared to baseline) in 6/21 of the study group and 0/18 of the control group, while HbA1c increased in 4/21 of study subjects compared to 8/18 of control subjects (p = 0.015). CONCLUSIONS: In contrast to adult studies, regular telephone contact did not lead to immediate improvements in metabolic control in adolescents with poorly controlled type 1 diabetes. However, knowledge and skills gained during the intervention may have had a delayed beneficial effect in these high-risk adolescents.

Changing trends in the referral patterns of pediatric nephrology patients.

This study investigates the changing referral patterns of young patients to a tertiary pediatric nephrology center with a well-defined catchment area over two consecutive 8.5-year periods. We paid special attention to the known increase of obesity and diabetes mellitus in childhood. Demographic data (site of residence, height, weight, gender and renal diagnosis) were collected on 6,154 children aged 0-19 years, referred as in- and outpatients to the Children's Hospital of Eastern Ontario for nephrological work-up. Body mass index (BMI) Z-scores were calculated on the basis of data from the National (USA) Center for Health Statistics (2000). In 6,124 (99.5%) patients a final renal diagnosis could be made, allowing calculation of the incidence of a variety of renal diseases in pediatric patients, data that are not readily available. BMI increased significantly over the years, with a Z-score that rose from a median of +0.20 to +0.32 in the two 8.5-year study periods (p<0.0001). The increase in obesity coincided with a significant increase in the incidence of chronic renal insufficiency (CRI). The combined incidence of CRI and end stage renal disease rose from 0.994 to 2.334 per 100,000 children per year (p=0.0014). This study provides new information on the (changing) pattern of pediatric renal disease over almost two decades. Pediatric renal patients became progressively overweight and showed an increase in the incidence of CRI. This is the first time that this phenomenon, well known in adults, has been observed in the pediatric age group.

The safety and use of short-acting nifedipine in hospitalized hypertensive children.

Recent reports suggest that calcium channel blockers are harmful in the treatment of acute hypertension in adults. However, short-acting nifedipine is an effective and useful medication in pediatric hypertension and is currently utilized for hypertensive emergencies. This study will address these safety concerns in hypertensive children. Medical records (from five Canadian pediatric hospitals) of all pediatric hypertensive hospitalized children who were treated with short-acting nifedipine from January 1995 to December 1998 were retrospectively reviewed for patient demographics, dosing regimen, use of concomitant medications, co-morbid conditions, and presence/absence of minor and serious adverse events. Final data were extracted from 182 patients. Each patient had an average of 2.6 episodes of hypertension in hospital that required treatment, totaling 477 episodes. Within the 477 episodes, 1,162 doses of short-acting nifedipine were administered. The mean dose was 0.22 mg/kg (range 0.043-0.67 mg/kg, median 0.19 mg/kg) with 55.6% (260/468 episodes) receiving the drug via the sublingual route. Hypertension resolved in 85.5% (408/477) of the episodes. There were only 29 of 574 (5.1%) minor adverse events that were definitely or probably related to short-acting nifedipine administration. Two patients experienced a serious adverse event that involved of a reduction in blood pressure of more than 40%, but neither had any symptomatology from the serious adverse event and recovered spontaneously within 2 h. Short-acting nifedipine in hypertensive, hospitalized children appears to be a safe and efficacious medication with minimal side effects.

Canadian Perspectives on Verocytotoxin-Producing Escherichia coli Infection †.

Infection with verocytotoxin-producing Escherichia coli (VTEC) became nationally reportable in 1990. Between 1990 and 1994, the national incidence of reported infections ranged from 3 to 5.3 per 100,000 inhabitants. Most cases are sporadic and are caused by E. coli O157:H7. Recent investigations have identified that, in addition to exposure to undercooked ground beef, contact with cattle, consumption of well water, and exposure to rural environments are important risk factors for VTEC infection. Also, results of case control studies and detection of asymptomatic fecal carriage of E. coli O157:H7 and other VTEC in farm family members and abattoir workers have led to an increasing emphasis on person-to-person spread in the epidemiology of VTEC infection. Controlling E. coli O157:H7 and other VTEC at the farm level may therefore have a broader impact than simply reducing the risk of foodborne VTEC infection. Longitudinal studies on dairy farms have demonstrated that E. coli O157:H7 carriage by cattle at the farm and animal level is often transient, and that cattle, rather than the farm environment, are the major reservoir for this organism on dairy farms. Small herds that are controlled by traditional management practices have the highest risk for VTEC infection. Further studies are likely to result in development of effective strategies to control VTEC at the farm level.