Paediatric inflammatory multisystem syndrome in Canada: population-based surveillance and role of SARS-CoV-2 linkage.

BACKGROUND: Paediatric inflammatory multisystem syndrome (PIMS) is a rare condition temporally associated with SARS-CoV-2 infection. Using national surveillance data, we compare presenting features and outcomes among children hospitalized with PIMS by SARS-CoV-2 linkage, and identify risk factors for intensive care (ICU). METHODS: Cases were reported to the Canadian Paediatric Surveillance Program by a network of >2800 pediatricians between March 2020 and May 2021. Patients with positive versus negative SARS-CoV-2 linkages were compared, with positive linkage defined as any positive molecular or serologic test or close contact with confirmed COVID-19. ICU risk factors were identified with multivariable modified Poisson regression. RESULTS: We identified 406 children hospitalized with PIMS, including 49.8% with positive SARS-CoV-2 linkages, 26.1% with negative linkages, and 24.1% with unknown linkages. The median age was 5.4 years (IQR 2.5-9.8), 60% were male, and 83% had no comorbidities. Compared to cases with negative linkages, children with positive linkages experienced more cardiac involvement (58.8% vs. 37.4%; p < 0.001), gastrointestinal symptoms (88.6% vs. 63.2%; p < 0.001), and shock (60.9% vs. 16.0%; p < 0.001). Children aged ≥6 years and those with positive linkages were more likely to require ICU. CONCLUSIONS: Although rare, 30% of PIMS hospitalizations required ICU or respiratory/hemodynamic support, particularly those with positive SARS-CoV-2 linkages. IMPACT: We describe 406 children hospitalized with paediatric inflammatory multisystem syndrome (PIMS) using nationwide surveillance data, the largest study of PIMS in Canada to date. Our surveillance case definition of PIMS did not require a history of SARS-CoV-2 exposure, and we therefore describe associations of SARS-CoV-2 linkages on clinical features and outcomes of children with PIMS. Children with positive SARS-CoV-2 linkages were older, had more gastrointestinal and cardiac involvement, and hyperinflammatory laboratory picture. Although PIMS is rare, one-third required admission to intensive care, with the greatest risk amongst those aged ≥6 years and those with a SARS-CoV-2 linkage.

Frequency and characteristics of patient exclusion criteria in Canadian multidisciplinary pain treatment facilities: a cross-sectional study.

PURPOSE: A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs. METHODS: We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures. RESULTS: A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff. CONCLUSIONS: Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.

RéSUMé: OBJECTIF: Une approche multidisciplinaire est recommandée pour les patients souffrant de douleur chronique (DC) complexe. De nombreux centres multidisciplinaires de traitement de la douleur (CMTD) utilisent des critères d'exclusion des patients, mais on ne sait que peu de choses sur leurs caractéristiques. L'objectif de cette étude était de décrire la fréquence et les caractéristiques des critères d'exclusion dans les CMTD publics canadiens. MéTHODE: Nous avons mené une étude transversale dans laquelle nous avons défini un CMTD comme une clinique composée de professionnels de trois disciplines ou plus (y compris au moins une spécialité médicale) et dont les services étaient intégrés à l'établissement. En 2017-2018, nous avons fait parvenir un questionnaire en ligne aux responsables administratifs des CMTD partout au pays. Ils ont été invités à remplir le questionnaire sur les caractéristiques de leurs établissements. Les données ont été analysées à l'aide de statistiques descriptives et de mesures de corrélation. RéSULTATS: Au total, 87 CMTD ont été inclus dans les analyses. La moitié d'entre eux (52 %) ont déclaré utiliser trois critères d'exclusion ou plus. Il n'y avait pas d'association significative entre le nombre de critères d'exclusion et le temps d'attente pour un premier rendez-vous ou le nombre de nouvelles consultations au cours de la dernière année. La fibromyalgie et la migraine étaient les syndromes douloureux les plus fréquemment exclus (10 % et 7 % des CMTD, respectivement). Plus d'un CMTD sur quatre excluait les patients atteints de troubles de santé mentale (30 %) et/ou de troubles liés à l'utilisation de substances (29 %), y compris les CMTD comptant des spécialistes dans leur personnel. CONCLUSION: Les critères d'exclusion des centres multidisciplinaires de traitement de la douleur sont plus susceptibles d'affecter les patients atteints de douleur chronique vivant avec des problèmes de douleur complexes et des vulnérabilités psychosociales. Des efforts au niveau des politiques sont nécessaires pour aider les CMTD canadiens à favoriser un accès équitable à la prise en charge de la douleur.

To sim or not to sim-choosing wisely for procedural skills training in paediatrics.

Objectives: Simulation is a commonly used modality to teach paediatric procedural skills, however, it is resource intensive. Which paediatric skills are best taught using simulation is not known. This study aims to examine what skills to simulate, allowing for the best use of resources in ever expanding curricula. Method: We administered a questionnaire to community and hospitalist general paediatricians in Canada asking them to rate the importance of maintaining competency in each paediatric procedural skill and the frequency with which they perform the skill in their practice. Results: Skills that were rated as highly important and also high frequency were: bag-mask ventilation (BMV), lumbar puncture, neonatal cardiopulmonary resuscitation (CPR), specimen procurement for infectious diseases, immunization, and ear curettage. Skills that were rated as highly important but low frequency were: paediatric CPR, intraosseous needle insertion, neonatal intubation, defibrillation, gathering specimens for evidence of child maltreatment, paediatric intubation, cervical spine immobilization, and oral/nasogastric tube placement. Conclusion: Paediatric procedural skills are rated variably in terms of importance and frequency of use in general paediatric practice. Eight skills of high importance are infrequently performed and should be targeted for teaching via simulation.

Characteristics of children admitted to hospital with acute SARS-CoV-2 infection in Canada in 2020.

BACKGROUND: Risk factors for severe outcomes of SARS-CoV-2 infection are not well established in children. We sought to describe pediatric hospital admissions associated with SARS-CoV-2 infection in Canada and identify risk factors for more severe disease. METHODS: We conducted a national prospective study using the infrastructure of the Canadian Paediatric Surveillance Program (CPSP). Cases involving children who were admitted to hospital with microbiologically confirmed SARS-CoV-2 infection were reported from Apr. 8 to Dec. 31 2020, through weekly online questionnaires distributed to the CPSP network of more than 2800 pediatricians. We categorized hospital admissions as related to COVID-19, incidental, or for social or infection control reasons and determined risk factors for disease severity in hospital. RESULTS: Among 264 hospital admissions involving children with SARS-CoV-2 infection during the 9-month study period, 150 (56.8%) admissions were related to COVID-19 and 100 (37.9%) were incidental infections (admissions for other reasons and found to be positive for SARS-CoV-2 on screening). Infants (37.3%) and adolescents (29.6%) represented most cases. Among hospital admissions related to COVID-19, 52 (34.7%) had critical disease, 42 (28.0%) of whom required any form of respiratory or hemodynamic support, and 59 (39.3%) had at least 1 underlying comorbidity. Children with obesity, chronic neurologic conditions or chronic lung disease other than asthma were more likely to have severe or critical COVID-19. INTERPRETATION: Among children who were admitted to hospital with SARS-CoV-2 infection in Canada during the early COVID-19 pandemic period, incidental SARS-CoV-2 infection was common. In children admitted with acute COVID-19, obesity and neurologic and respiratory comorbidities were associated with more severe disease.

Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures.

Common medical procedures to assess and treat patients can cause significant pain and distress. Clinicians should have a basic approach for minimizing pain and distress in children, particularly for frequently used diagnostic and therapeutic procedures. This statement focuses on infants (excluding care provided in the NICU), children, and youth who are undergoing common, minor but painful medical procedures. Simple, evidence-based strategies for managing pain and distress are reviewed, with guidance for integrating them into clinical practice as an essential part of health care. Health professionals are encouraged to use minimally invasive approaches and, when painful procedures are unavoidable, to combine simple pain and distress-minimizing strategies to improve the patient, parent, and health care provider experience. Health administrators are encouraged to create institutional policies, improve education and access to guidelines, create child- and youth-friendly environments, ensure availability of appropriate staff, equipment and pharmacological agents, and perform quality audits to ensure pain management is optimal.

Caractéristiques des hospitalisations au Canada d'enfants ayant contracté une infection aiguë par le SRAS-CoV-2 en 2020.

CONTEXTE: Les facteurs de risque de complications graves de l'infection par le SRAS-CoV-2 n'ont pas été bien établis chez les enfants. Nous avons voulu décrire les hospitalisations pédiatriques associées au SRAS-CoV-2 au Canada et identifier les facteurs de risque de maladie grave. MÉTHODES: Nous avons procédé à une étude prospective nationale en utilisant l'infrastructure du Programme canadien de surveillance pédiatrique (PCSP). Les hospitalisations d'enfants ayant contracté une infection par le SRAS-CoV-2 confirmée en laboratoire de microbiologie ont été rapportées du 8 avril au 31 décembre 2020 au moyen de questionnaires hebdomadaires en ligne distribués au réseau du PCSP, qui compte plus de 2800 pédiatres. Nous avons catégorisé les hospitalisations comme suit : liées à la COVID-19, infections découvertes fortuitement, ou hospitalisations pour des raisons sociales ou de contrôle des infections, et dégagé les facteurs de risque associés à la gravité de la maladie chez les patients hospitalisés. RÉSULTATS: Sur les 264 hospitalisations d'enfants ayant contracté le SRAS-CoV-2 au cours de la période de l'étude de 9 mois, 150 (56,8 %) ont été associées à la COVID-19 et 100 (37,9 %) étaient des cas découverts fortuitement (admission pour d'autres raisons et découverte fortuite du SRAS-CoV-2 par dépistage positif). Les nourrissons (37,3 %) et les adolescents (29,6 %) représentaient la majorité des cas. Parmi les hospitalisations liées à la COVID-19, 52 patients (34,7 %) étaient atteints d'une forme grave de la maladie, dont 42 (28,0 % des cas liés à la COVID-19) ont eu besoin d'une forme d'assistance respiratoire ou hémodynamique, et 59 (39,3 %) présentaient au moins 1 comorbidité sous-jacente. Les enfants atteints d'obésité, de maladies neurologiques chroniques ou de maladies pulmonaires chroniques, à l'exclusion de l'asthme, étaient plus susceptibles de présenter une forme grave ou critique de la COVID-19. INTERPRÉTATION: Parmi les enfants hospitalisés au Canada chez lesquels on a diagnostiqué une infection par le SRAS-CoV-2 au début de la pandémie de COVID-19, la découverte fortuite du SRAS-CoV-2 a été fréquente. Chez les enfants hospitalisés pour une COVID-19 aiguë, l'obésité et les comorbidités neurologiques et respiratoires ont été associées à une gravité accrue.

Six ways to get a grip on patient and family centered care during the undergraduate medical years.

Patient and family-centered care and patient engagement practices have strong evidence-based links with quality and safety for both patients and health care providers. Expectations for patient and family-centered care have advanced beyond hearing the patient perspective and taking patient wishes into account. A participatory approach including patients as partners in their care journey is expected, but attitudes toward patient and family-centered care remain barriers in practice. As health service organizations shift from a system-centered approach to a patient and family-centered care delivery model, black ice occurs. In this Black Ice article, we present some practical tips for medical educators to improve opportunities for medical students to develop knowledge, attitudes, and skills that support patient and family-centered care.

Le lien entre les soins axés sur le patient et la famille et l'engagement des patients d'un côté et la qualité et la sécurité des soins, tant pour les patients que pour les prestataires de services, de l'autre, a été solidement démontré. Les attentes en matière de soins axés sur le patient et la famille ont évolué et elles ne se limitent plus à recueillir le point de vue du patient et à prendre en considération ses souhaits. On préconise désormais une approche participative faisant intervenir les patients en tant que partenaires dans leur cheminement clinique. Toutefois, certaines attitudes à l'égard des soins axés sur le patient et la famille freinent la mise en pratique d'une telle démarche. Dans les organismes de services de santé, le passage d'une approche centrée sur le système à un modèle de prestation de soins axé sur le patient et la famille constitue un terrain glissant. Nous proposons ici quelques stratégies pratiques pour aider les enseignants en médecine à faciliter l'acquisition par les étudiants des connaissances, des attitudes et des habiletés qui favorisent les soins centrés sur le patient et la famille.

"We survived the pandemic together": The impact of the COVID-19 pandemic on Canadian families living with chronic pain.

Introduction: Pediatric chronic pain is a significant problem in Canada, affecting one in five youth. This study describes the impact of the pandemic on the experiences of Canadian families living with chronic pain through interviews with youth living with chronic pain, parents, and siblings. Methods: Employing a qualitative descriptive design, in-depth semistructured interviews were completed with Canadian youth living with pain, as well as parents and siblings. Participants were not required to be related. Interviews were analyzed using a reflexive thematic analysis approach. Results: Forty-four interviews were completed with 14 parents, 19 youth with chronic pain, and 11 siblings from across the country. Three key themes were developed: (1) absorbing and shifting: the toll of the pandemic on the family system (e.g., loss of coping mechanisms, shifting roles to respond to the pandemic), (2) social ambiguity and abandonment (e.g., social sacrifice and abandonment by the health care system), and (3) building community resilience: familial adaptation to the pandemic (e.g., family cohesion, confidence, and self-management). Discussion/Conclusions: Youth, parents, and siblings reported that the pandemic impacted coping strategies across the family system. These results outline the challenges youth experienced managing their pain and overall health throughout the pandemic and the resilience built within families during this time. Going forward, it would be relevant to examine how racialized and structurally marginalized youth with chronic pain and their families experienced the pandemic. Future research should examine how unexpected benefits of the pandemic (e.g., increased confidence and self-management) may be sustained into the future.

Introduction: La douleur chronique pédiatrique est un problème important au Canada, qui touche un jeune sur cinq. Cette étude décrit les répercussions de la pandémie sur les expériences des familles canadiennes vivant avec la douleur chronique par des entrevues avec des jeunes vivant avec une douleur chronique, des parents et des frères et sœurs.Méthodes: À l'aide d'un devis descriptif qualitatif, des entretiens semi-structurés approfondis ont été réalisés auprès de jeunes Canadiens vivant avec la douleur, leurs parents, et leurs frères et sœurs. Il n'était pas nécessaire que les participants aient un lien familial. Les entretiens ont été analysés à l'aide d'une approche d'analyse thématique réflexive.Résultats: Quarante-quatre entretiens ont été réalisés auprès de 14 parents, 19 jeunes souffrant de douleur chronique et 11 frères et sœurs de tout le pays. Trois thèmes clés ont été abordés : (1) l'absorption et le changement : le coût de la pandémie pour le système familial (p. ex., perte de mécanismes d'adaptation, changement de rôles pour réagir à la pandémie), (2) l'ambiguïté sociale et l'abandon (p. ex., le sacrifice social et l'abandon par le système de soins de santé), et (3) le renforcement de la résilience communautaire : adaptation familiale à la pandémie (p. ex., cohésion familiale, confiance et auto-prise en charge).Discussion/Conclusions: Les jeunes, les parents et les frères et sœurs ont signalé que la pandémie avait eu des répercussions sur les stratégies d'adaptation dans l'ensemble du système familial. Ces résultats décrivent les défis rencontrés par les jeunes pour prendre en charge leur douleur et leur santé globale tout au long de la pandémie, ainsi que la résilience démontrée par les familles pendant cette période. À l'avenir, il serait pertinent d'examiner comment les personnes racialisées et les jeunes structurellement marginalisés souffrant de douleur chronique et leurs familles ont vécu la pandémie.Les recherches futures devraient examiner comment les avantages inattendus de la pandémie (par exemple, une confiance accrue et l'auto-prise en charge) peuvent être maintenus à l'avenir.

Resource use and disease severity of children hospitalized for COVID-19 versus multisystem inflammatory syndrome in children (MIS-C) in Canada.

Background: Direct comparisons of paediatric hospitalizations for acute coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C) can inform health system planning. We describe the absolute and relative hospital burden of acute paediatric COVID-19 and MIS-C in Canada. Methods: This national prospective study was conducted via the Canadian Paediatric Surveillance Program from March 2020-May 2021. Children younger than 18 years old and hospitalized for acute COVID-19 or MIS-C were included in the analysis. Outcomes included supplemental oxygen (low-flow oxygen or high-flow nasal cannula), ventilation (non-invasive or conventional mechanical), vasopressors, paediatric intensive care unit (PICU) admission, or death. Adjusted risk differences (aRD) and 95% confidence intervals (CI) were calculated to identify factors associated with each diagnosis. Results: Overall, we identified 330 children hospitalized for acute COVID-19 (including five deaths) and 208 hospitalized for MIS-C (including zero deaths); PICU admission was required for 49.5% of MIS-C hospitalizations versus 18.2% of acute COVID-19 hospitalizations (aRD 20.3; 95% CI, 9.9-30.8). Resource use differed by age, with children younger than one year hospitalized more often for acute COVID-19 (aRD 43.4% versus MIS-C; 95% CI, 37.7-49.1) and more children 5-11 years hospitalized for MIS-C (aRD 38.9% vs. acute COVID-19; 95% CI, 31.0-46.9). Conclusion: While there were more hospitalizations and deaths from acute paediatric COVID-19, MIS-C cases were more severe, requiring more intensive care and vasopressor support. Our findings suggest that both acute COVID-19 and MIS-C should be considered when assessing the overall burden of severe acute respiratory syndrome coronavirus 2 in hospitalized children.

Perinatal and childhood morbidity and mortality in congenital analbuminemia.

Albumin, a serum transport protein, provides 80% of colloid osmotic pressure. Congenital analbuminemia (CAA) is an autosomal recessive disorder characterized by absence of serum albumin. Fifty cases of CAA have been reported throughout the world; however, little is known about its clinical impact. Most reported cases have few clinical signs and symptoms. Twelve local cases from the northwestern central plains region in Saskatchewan were identified and reviewed to ascertain morbidity and mortality related with CAA. All the cases are from two remote First Nations communities. Cases had frequent hospital admissions and recurrent respiratory tract infections. Placental abnormalities included hydropic placentas, placental infarcts and microcalcifications. One-half of the cases were born preterm and one-quarter were small for their gestational age. There were three mortalities in the case series. The present case series suggests increased morbidity and mortality during infancy in patients with CAA. The long-term risks of CAA in this population are unknown and a longitudinal study is recommended.

L'albumine, une protéine du transport sérique, fournit 80 % de la pression colloïdo-osmotique. L'analbuminémie congénitale (AAC) est un trouble autosomique récessif caractérisé par l'absence d'albumine sérique. Cinquante cas d'AAC ont été signalés dans le monde, mais on ne sait pas grand-chose de ses répercussions cliniques. La plupart des cas déclarés s'associaient à peu de signes et symptômes cliniques. Les chercheurs ont dépisté 12 cas locaux, originaires de la région du nord-ouest des plaines centrales, en Saskatchewan, et les ont analysés afin de déterminer la morbidité et la mortalité liées à l'AAC. Tous les cas provenaient de deux communautés éloignées des Premières nations. Ils étaient souvent hospitalisés et avaient des infections respiratoires récurrentes. Les anomalies placentaires incluaient des placentas hydropiques, des infarctus placentaires et des microcalcifications. La moitié des cas étaient prématurés et le quart d'entre eux étaient petits par rapport à leur âge gestationnel. Trois mortalités ont été constatées. Cette série a démontré une augmentation de la morbidité et de la mortalité pendant l'enfance chez les patients ayant une AAC. On ne connaît pas les risques à long terme de l'AAC au sein de cette population. Une étude longitudinale est recommandée.

Canadian surveillance study of complex regional pain syndrome in children.

ABSTRACT: This study describes the minimum incidence of pediatric complex regional pain syndrome (CRPS), clinical features, and treatments recommended by pediatricians and pain clinics in Canada. Participants in the Canadian Paediatric Surveillance Program reported new cases of CRPS aged 2 to 18 years monthly and completed a detailed case reporting questionnaire from September 2017 to August 2019. Descriptive analysis was completed, and the annual incidence of CRPS by sex and age groupings was estimated. A total of 198 cases were reported to the Canadian Paediatric Surveillance Program, and 168 (84.8%) met the case definition. The minimum Canadian incidence of CRPS is estimated at 1.14/100,000 (95% confidence interval 0.93-1.35/100,000) children per year. Incidence was highest among girls 12 years and older (3.10, 95% confidence interval 2.76-3.44/100,000). The mean age of CRPS diagnosis was 12.2 years (SD = 2.4), with the mean time from symptom onset to diagnosis of 5.6 months (SD = 9.9) and no known inciting event for 19.6% of cases. Most cases had lower limb involvement (79.8%). Nonsteroidal anti-inflammatory drugs (82.7%) and acetaminophen (66.0%) were prescribed more commonly than antiepileptic drugs (52.3%) and antidepressants (32.0%). Referrals most commonly included physical therapy (83.3%) and multidisciplinary pain clinics (72.6%); a small number of patients withdrew from treatment because of pain exacerbation (5.3%). Pain education was recommended for only 65.6% of cases. Treatment variability highlights the need for empiric data to support treatment of pediatric CRPS and development of treatment consensus guidelines.

Experiences of Pediatric Pain Professionals Providing Care during the COVID-19 Pandemic: A Qualitative Study.

Chronic pain affects 1 in 5 youth, many of whom manage their pain using a biopsychosocial approach. The COVID-19 pandemic has impacted the way that healthcare is delivered. As part of a larger program of research, this study aimed to understand the impact of the pandemic on pediatric chronic pain care delivery including impact on patients' outcomes, from the perspective of pediatric healthcare providers. A qualitative descriptive study design was used and 21 healthcare providers from various professional roles, clinical settings, and geographic locations across Canada were interviewed. Using a reflexive thematic analysis approach 3 themes were developed: (1) duality of pandemic impact on youth with chronic pain (i.e., how the pandemic influenced self-management while also exacerbating existing socioeconomic inequalities); (2) changes to the healthcare system and clinical practices (i.e., triaging and access to care); (3) shift to virtual care (i.e., role of institutions and hybrid models of care). These findings outline provider perspectives on the positive and negative impacts of the pandemic on youth with chronic pain and highlight the role of socioeconomic status and access to care in relation to chronic pain management during the pandemic in a high-income country with a publicly funded healthcare system.

Risk factors for severe COVID-19 in hospitalized children in Canada: A national prospective study from March 2020-May 2021.

Background: Children living with chronic comorbid conditions are at increased risk for severe COVID-19, though there is limited evidence regarding the risks associated with specific conditions and which children may benefit from targeted COVID-19 therapies. The objective of this study was to identify factors associated with severe disease among hospitalized children with COVID-19 in Canada. Methods: We conducted a national prospective study on hospitalized children with microbiologically confirmed SARS-CoV-2 infection via the Canadian Paediatric Surveillance Program (CPSP) from April 2020-May 2021. Cases were reported voluntarily by a network of >2800 paediatricians. Hospitalizations were classified as COVID-19-related, incidental infection, or infection control/social admissions. Severe disease (among COVID-19-related hospitalizations only) was defined as disease requiring intensive care, ventilatory or hemodynamic support, select organ system complications, or death. Risk factors for severe disease were identified using multivariable Poisson regression, adjusting for age, sex, concomitant infections, and timing of hospitalization. Findings: We identified 544 children hospitalized with SARS-CoV-2 infection, including 60·7% with COVID-19-related disease and 39·3% with incidental infection or infection control/social admissions. Among COVID-19-related hospitalizations (n=330), the median age was 1·9 years (IQR 0·1-13·3) and 43·0% had chronic comorbid conditions. Severe disease occurred in 29·7% of COVID-19-related hospitalizations (n=98/330 including 60 admitted to intensive care), most frequently among children aged 2-4 years (48·7%) and 12-17 years (41·3%). Comorbid conditions associated with severe disease included pre-existing technology dependence requirements (adjusted risk ratio [aRR] 2·01, 95% confidence interval [CI] 1·37-2·95), body mass index Z-scores ≥3 (aRR 1·90, 95% CI 1·10-3·28), neurologic conditions (e.g. epilepsy and select chromosomal/genetic conditions) (aRR 1·84, 95% CI 1·32-2·57), and pulmonary conditions (e.g. bronchopulmonary dysplasia and uncontrolled asthma) (aRR 1·63, 95% CI 1·12-2·39). Interpretation: While severe outcomes were detected at all ages and among patients with and without comorbidities, neurologic and pulmonary conditions as well as technology dependence were associated with increased risk of severe COVID-19. These findings may help guide vaccination programs and prioritize targeted COVID-19 therapies for children. Funding: Financial support for the CPSP was received from the Public Health Agency of Canada.

Maximizing Opportunities for User-Centered Design in Acute-Care: Introducing the Focal Wall.

Digital health is a promising development in the pursuit of patient centered care. Technological developments, like patient portals, are providing new opportunities for patients to engage in their own healthcare journeys, increasing access to health data and practitioners in many cases. The primary objective of this research is the establishment of an in-patient portal for a new children's hospital through a collaborative design process. This paper details experiences from the first phase of this multi-year project and in particular methodological solutions that have been developed in order to meet the challenges of engaging acute care patients, families, and practitioners in user-centered design within such a demanding context.

Cross-sectional study of pediatric pain prevalence, assessment, and treatment at a Canadian tertiary hospital.

BACKGROUND: Painful experiences are common among hospitalized children. Long-term negative biopsychosocial consequences of undertreated pain are recognized. AIMS: The study benchmarks pain prevalence, assessment, and treatment as first steps to improve pain care in a Canadian tertiary hospital. METHODS: Single-day audits were undertaken on the pediatric ward (PW), pediatric emergency department (ED), and maternal services (MS). Participants (child or caregiver proxy) reported hospital pain experiences in the preceding 24 h; medical records were reviewed for assessment and treatment. RESULTS: Among 84 participants, pain prevalence ranged from 75% to 88%; mean pain intensity ranged from 5.7 to 6.5/10. Prevalence of moderate to severe pain was 78% on PW, 65% in ED, and 55% on MS; needle pokes were the most frequent cause of worst pain. Documentation of pain assessment varied by setting (PW, 93%; ED, 13%; MS, 0%). Documented maximum pain scores were significantly lower compared to participant report (mean difference 4.5/10, SD 3.1, P < 0.0001). A total 29% (6/21) of infants with heel lance or injection received breastfeeding or sucrose, and 29% (7/24) of participants receiving other needle procedures had documented or reported topical lidocaine use. All participants on MS underwent needle procedures. CONCLUSIONS: Pain is experienced commonly by infants and children in PW, ED, and MS. Pain assessment documentation is not routine and underestimates participant report. Evidence-based pain management strategies are underutilized. An institution-wide quality improvement approach is required to address pain care. Pain assessment and needle pain prevention and treatment should be prioritized in these pediatric acute care and newborn care settings.

Contexte: Les expériences douloureuses sont courantes chez les enfants hospitalisés. Les conséquences biopsychosociales négatives à long terme d'une douleur sous-traitée sont reconnues.Objectifs: L'étude compare la prévalence, l'évaluation et le traitement de la douleur comme premières étapes pour améliorer les soins de la douleur dans un hôpital tertiaire canadien.Méthodes: Des audits d'une journée ont été effectués dans les services de pédiatrie (SP), les services d'urgence pédiatrique (SU) et les services maternels (SM). Les participants (enfant ou soignant) ont rapporté des expériences de douleur à l'hôpital au cours des 24 heures précédentes; les dossiers médicaux ont été examinés pour évaluation et traitement.Résultats: Parmi les 84 participants, la prévalence de la douleur variait de 75 % à 88 % ; l'intensité moyenne de la douleur variait de 5,7 à 6,5/10. La prévalence de la douleur modérée à sévère était de 78 % pour les services de pédiatrie, 65 % pour les services d'urgence pédiatrique et 55 % pour les services maternels ; les piqûres étaient la cause la plus fréquente des pires douleurs. La documentation de l'évaluation de la douleur variait selon le contexte (SP 93 % ; SU 13 % ; SM 0 %). Les scores maximaux de douleur documentés étaient significativement inférieurs à ceux rapportés par les participants (différence moyenne 4,5 / 10, SD 3,1, P < 0,0001). Au total, 29 % (6/21) des nourrissons ayant reçu une piqûre au talon ou une injection ont reçu un allaitement ou du saccharose, et 29 % (7/24) des participants recevant d'autres procédures d'injection avaient documenté ou signalé une utilisation topique de lidocaïne. Tous les participants des services maternels ont subi une procédure impliquant une aiguille.Conclusions: La douleur est couramment ressentie par les nourrissons et les enfants dans les services de pédiatrie, les services d'urgence pédiatrique et les services maternels. La documentation relative à l'évaluation de la douleur n'est pas systématique et sous-estime la douleur rapportée par les participants. Les stratégies de prise en charge de la douleur fondées sur des données probantes sont sous-utilisées. Une approche d'amélioration de la qualité à l'échelle de l'établissement est nécessaire pour aborder les soins de la douleur. L'évaluation de la douleur et la prévention et le traitement de la douleur causée par les aiguilles devraient être prioritaires dans ces établissements de soins pédiatriques aigus et de soins aux nouveau-nés.

Learning needs of family physicians, pediatricians, and obstetricians to support breastfeeding and inform physician education.

BACKGROUND: Physicians require breastfeeding education appropriate to their roles. The aim of this survey was to determine physician learning needs and to inform development of breastfeeding education for physicians. METHODS: A cross sectional survey was distributed to family physicians, pediatricians and obstetricians in a tertiary institution. Importance of knowledge to practice and confidence to manage was assessed for 18 learning topics proposed by a multi-specialty physician working group. Descriptive statistics, ANOVA and tests for equality of variances were calculated. Mean values of importance to practice and confidence to manage for each topic suggested learning priorities. RESULTS: The study group included 75 physicians. The most important topics were "informed choice when supporting newborn feeding," "analgesics, antidepressants and other medications while breastfeeding" and "community resources for breastfeeding support." Confidence to manage was lowest for "latch assessment," "what mom can do during pregnancy to promote milk production," and "risk factors for delayed lactogenesis." Preferred learning formats were 15-minute online modules and grand rounds. CONCLUSIONS: Physicians acknowledged the importance of all topics but report lowest confidence to manage latch assessment, prenatal interventions to support lactogenesis and management of delayed lactogenesis. Participants placed relatively low importance on learning about latch assessment despite the central nature of this skill in supporting early breastfeeding.

CONTEXTE: Les médecins ont besoin d'une formation sur l'allaitement adaptée à leur rôle. L'objectif de cette enquête était de contribuer à l'élaboration d'une telle formation en déterminant les besoins d'apprentissage des médecins dans ce domaine. MÉTHODES: Une enquête transversale a été réalisée auprès des médecins de famille, des pédiatres et des obstétriciens dans un établissement tertiaire. L'importance des connaissances pour la pratique et de la confiance envers la prise en charge a été évaluée pour 18 sujets d'apprentissage proposés par un groupe de travail de médecins de diverses spécialités. On a effectué des statistiques descriptives, une analyse de la variance et des tests de l'égalité des variances. Les valeurs moyennes de l'importance pour la pratique et de la confiance dans la prise en charge pour chaque sujet indiquent les priorités d'apprentissage. RÉSULTATS: Le groupe d'étude comprenait 75 médecins. Les sujets les plus importants étaient « le choix éclairé concernant l'alimentation du nouveau-né ¼, « la prise d'analgésiques, d'antidépresseurs et d'autres médicaments pendant l'allaitement ¼ et « les ressources communautaires de soutien à l'allaitement ¼. La confiance dans la prise en charge était la plus faible en ce qui concerne « l'évaluation de la prise du sein ¼, « ce que la mère peut faire pendant la grossesse pour favoriser la production de lait ¼ et « les facteurs de risque associés au retard de la lactogenèse ¼. Les formats d'apprentissage préférés étaient les modules en ligne de 15 minutes et les séances plénières. CONCLUSIONS: Les médecins reconnaissent l'importance de tous les sujets mais ils se disent moins confiants dans leur capacité d'évaluer la prise du sein, de faire les interventions prénatales pour favoriser la lactogenèse et de prendre en charge la lactogenèse retardée. Les participants ont accordé relativement peu d'importance à l'apprentissage de l'évaluation de la prise du sein, malgré l'importance de cette compétence pour soutenir le démarrage précoce de l'allaitement.

Evolution of a community-centred experiential learning module: A mixed-methods approach to promote social accountability and community partnership in undergraduate medical education.

This article was migrated. The article was marked as recommended. Background: Education in social determinants of health (SDH) has become an important part of medical curricula, facilitated increasingly through students' experiential learning with communities. The Community and Workplace Centred Learning Experience (CWCLE) module of the University of Saskatchewan, Canada, intends to integrate and extend second-year medical students' attitudes, skills, and knowledge about SDH and community resources. We aimed to: 1) Solicit students' self-evaluation of their ability to perform module learning objectives, 2) Assess module impact on student attitudes toward SDH, 3) Obtain feedback from community partners and students about their community experiences, and 4) Use feedback to collaboratively develop recommendations to enhance the CWCLE module. Methods: We used a mixed-method approach to combine quantitative data with stories and personal experiences. We developed an online survey for two cohorts of students who had completed the module, soliciting students to self-evaluate their perceived abilities to perform the module's learning objectives and evaluating students' attitudes towards SDH. We invited representatives from community agencies involved in the CWCLE module to participate in focus groups. We also held separate focus groups with students who participated in the online survey to elaborate on their survey comments. Results: In total, 145 students participated in the online survey (response rate=72.5%). Eleven community agency representatives and seven students participated in five focus groups. Our results demonstrate that medical students benefit from community-based experiential learning of SDH and community resources. We trace evaluations and discussions in the ongoing development of this community-based experiential learning module from its initial, primarily medical-school driven designs, towards a substantial involvement of community-based organizations in its operation and continuing redevelopment. Conclusions: Our mixed method offered us a better understanding of module impact and opportunities for improvement. This module evaluation and reform generated opportunities for community partners to influence decisions in medical education and led to a collaborative evolution of a community-centred learning experience. Medical schools should actively engage community partners in teaching behavioural and social components of the curriculum and acknowledge their partners' expertise to promote community engagement and social accountability in medical education.

Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in Canada.

BACKGROUND: Multidisciplinary pain treatment facilities (MPTFs) are considered the optimal settings for the management of chronic pain (CP). This study aimed (1) to determine the distribution of MPTFs across Canada, (2) to document time to access and types of services, and (3) to compare the results to those obtained in 2005-2006. METHODS: This cross-sectional study used the same MPTF definition as in 2005-2006-that is, a clinic staffed with professionals from a minimum of three different disciplines (including at least one medical specialty) and whose services were integrated within the facility. A comprehensive search strategy was used to identify existing MPTFs across Canada. Administrative leads at each MPTF were invited to complete an online questionnaire regarding their facilities. RESULTS: Questionnaires were completed by 104 MPTFs (response rate 79.4%). Few changes were observed in the distribution of MPTFs across Canada compared with 12 years ago. Most (91.3%) are concentrated in large urban cities. Prince Edward Island and the Territories still lack MPTFs. The number of pediatric-only MPTFs has nearly doubled but remains small (n=9). The median wait time for a first appointment in publicly funded MPTFs is about the same as 12 years ago (5.5 vs 6 months). Small but positive changes were also observed. CONCLUSION: Accessibility to public MPTFs continues to be limited in Canada, resulting in lengthy wait times for a first appointment. Community-based MPTFs and virtual care initiatives to distribute pain services into regional and remote communities are needed to provide patients with CP with optimal care.

Partnering For Pain: a Priority Setting Partnership to identify patient-oriented research priorities for pediatric chronic pain in Canada.

BACKGROUND: Chronic pain affects 1-3 million Canadian children and adolescents and their families. The primary objective of the Partnering For Pain project was to collaboratively identify the top 10 research priorities in pediatric chronic pain. METHODS: Partnering For Pain took a patient-oriented research approach and followed a modified James Lind Alliance Priority Setting Partnership (PSP) to identify the top research priorities in pediatric chronic pain according to people with lived experience (patients), family members and health care providers (clinicians). The PSP was completed in 4 phases between May and December 2018: 1) national survey of stakeholders, including those with lived experience with pediatric chronic pain, family members and clinicians who treat children with chronic pain, to gather priorities, 2) data processing, 3) interim prioritization by invited patients, family members and clinicians (former research participants or identified through pediatric chronic pain programs, patient partner organizations and steering committee member networks) and 4) in-person priority-setting workshop involving patients, family members and clinicians identified via steering committee networks and partner organizations, with evaluation of patient engagement. The process was led by a national steering committee of patient and parent partners, researchers and clinicians engaged in codesign, analysis and translation of project findings. RESULTS: In phase 1, 215 Canadians (86 patients [40.0%], 56 family members [26.0%] and 73 clinicians [34.0%]) submitted 540 potential priorities that were developed into 112 unique research questions (phase 2). Of the 112 questions, 63 were rated for importance by 57 participants (19 patients [33%], 17 family members [30%] and 21 clinicians [37%]) in phase 3. In phase 4, 20 participants (6 patients [30%], 6 family members [30%] and 8 clinicians [40%]) discussed the 25 most highly rated questions and reached consensus on the final top 10. INTERPRETATION: The final priorities address pediatric chronic pain prevention, impact and treatment, as well as delivery, access and coordination of care. The priorities reflect a directed and collaborative call to action to improve existing pediatric pain research and care. PLAIN LANGUAGE SUMMARY: Chronic pain affects 1 in 5 children and teens. This means that 1-3 million Canadian youth deal with pain lasting months to years. This pain gets in the way of being active, sleeping, going to school, and getting along with friends and family. Youth with chronic pain and their families are experts on what it's like to live with pain, but, until now, research has not asked what issues they care about most. The goal of the Partnering For Pain project was to develop a list of the 10 most important things we still need to learn about chronic pain during childhood according to people who live with it, their families and health care providers. We did this in 4 steps: 1) a survey with 215 people who shared 540 concerns they have about chronic pain in childhood, 2) turning those concerns into questions that can be answered by research, 3) a survey with 57 people who ranked how important each research question was and 4) an in-person discussion with 20 people who chose the top 10 research priorities. Each step included Canadians who have had chronic pain during childhood, their families and health care providers. The final top 10 list has questions about how to better prevent and care for children and teens with chronic pain. These priorities make sure that future research focuses on what is most important to people who will use it in their everyday lives. Project video: https://youtu.be/wA-RwrFiSPk. Project website: www.partneringforpain.com.

The Interdisciplinary Patient Partner Program: Building Better Health Care Professionals through Mentorship with Patients and Families.

This article was migrated. The article was marked as recommended. Introduction: Patient- and Family Centered Care (PFCC) aims to promote collaborative empowering relationships among patients, families, and health care professionals. Best practice for teaching patient- and family-centred care is unknown. Methods, Results: Patient and Family Advisors were matched with an interdisciplinary group of 2-3 students from medicine, pharmacy, and nursing over a five month period to teach PFCC. Advisors provided their journey in the health care system as a basis for further exploration of the 4 pillars of Patient and Family Centered Care. 28 students and 14 Patient and Family Advisors completed the program. Overall, students and advisors were satisfied with the program. Attitudes toward family centeredness were evaluated on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). Paired samples t-tests were conducted to gauge perceived increases over the program. All items increased significantly with large effect sizes. Discussion: Patient and Family Advisors highlighted the importance of sharing stories and exploring them through dialogue with students as a key factor in the success of the program. The Interdisciplinary Patient Partner Program also reinforced the power of relationship as a learning tool for students. The interdisciplinary nature of this program resulted in additional learning opportunities such as learning about the interdependencies between health care professionals and the importance of an interdisciplinary approach to health care Conclusion: Matching medicine, pharmacy and nursing students with Patient and Family Advisors is an effective way to improve students' understanding of Patient and Family Centered Care.