Adolescent medicine subspecialty workforce: Insights from Canada.

Objectives: Adolescent Medicine (AM) in Canada has undergone significant growth since being accredited by the Royal College of Physicians and Surgeons of Canada (RCPSC) in May 2007. A deeper understanding of the workforce is needed in order to identify current gaps, to improve clinical care and scholarly endeavors, and to inform future developments. Methods: This is the first AM workforce survey administered in Canada and included 39 multiple-choice and 3 open-ended questions. Descriptive statistics were calculated, and thematic analysis was used for open-ended questions. Results: We identified 62 AM specialists from across Canada. The overall response was 97% (60/62). Most AM specialists were women (39/53, 74%), Caucasian (38/53, 72%), between 30 and 39 years old (22/53, 42%), and completed their subspecialty training in either Toronto (24/48, 50%) or Montreal (12/48, 25%). Nearly half of participants worked in either the Toronto, Ontario (13/49, 27%) or Montreal, Quebec (10/49, 20%). Nearly all participants (46/49, 94%) practiced in large urban population centres and were based in academic health science centres. The primary clinical areas of focus included eating disorders (25/51, 49%) and mental health (9/51, 18%). Almost all participants were satisfied with their career choice (41/50, 82%). Two-thirds of the participants (31/48, 65%) believed that there was an insufficient number of AM specialists in Canada. Conclusions: Highlighting current characteristics of the AM subspecialty will help government and academic policymakers in understanding the workforce available to care for Canadian adolescents and the need to develop training programs and policies to address gaps and shortages.

Incidence and Age- and Sex-Specific Differences in the Clinical Presentation of Children and Adolescents With Avoidant Restrictive Food Intake Disorder.

Importance: To our knowledge, this is the first pediatric surveillance study of children and adolescents with avoidant restrictive food intake disorder (ARFID). Objectives: To examine the incidence and age- and sex-specific differences in the clinical presentation of ARFID in children and adolescents in Canada. Design, Setting, and Participants: In this cross-sectional study, patients with ARFID were identified through the Canadian Paediatric Surveillance Program by surveying 2700 Canadian pediatricians monthly from January 1, 2016, to December 31, 2017. Main Outcomes and Measures: The incidence of ARFID in Canadian children (5-18 years of age) and age- and sex-specific clinical characteristics at presentation. Results: In total, 207 children and adolescents (mean [SD] age, 13.1 [3.2] years; 127 [61.4%] female) were included in this study. The incidence of ARFID in children 5 to 18 years of age was 2.02 (95% CI, 1.76-2.31) per 100 000 patients. Older children and adolescents were more likely to endorse eating too little (5-9 years of age: 76.7%; 95% CI, 58%-88.6; 10-14 years of age: 90.9%; 95% CI, 84.6%-94.8%; 15-18 years of age: 95.6%; 95% CI, 83.6%-98.9%; P = .02), have a loss of appetite (5-9 years of age: 53.3%; 95% CI, 35.4%-70.4%; 10-14 years of age: 74.2%; 95% CI, 66.0%-81.0%; 15-18 years of age: 80.0%; 95% CI, 65.5%-89.4%; P = .03), be medically compromised (mean body mass index z score: 10-14 vs 5-9 years of age: -1.31; 95% CI, -2.0 to -0.6; 15-18 vs 5-9 years of age: -1.35; 95% CI, -2.2 to -0.5; 15-18 vs 10-14 years of age: -0.04; 95% CI, -0.6 to 0.5; P < .001; mean percentage of treatment goal weight: 10-14 vs 5-9 years of age: -8.6; 95% CI, -14.3 to -2.9; 15-18 vs 5-9 years of age: -9.8; 95% CI, -16.3 to -3.3; 15-18 vs 10-14 years of age: -1.2; 95% CI, -5.8 to 3.4; P < .001; mean heart rate (beats per min): 10-14 vs 5-9 years of age: -10; 95% CI, -21.9 to 1.9; 15-18 vs 5-9 years of age: -19.7; 95% CI, -33.1 to -6.2; 15-18 vs 10-14 years of age: -9.7; 95% CI, -18.7 to -0.7; P = .002), have higher rates of anxiety (5-9 years of age: 26.7%; 95% CI, 13.7-45.4; 10-14 years of age: 52.3%; 95% CI, 43.7%-60.7%; 15-18 years of age: 53.3%; 95% CI, 38.6%-67.5%; P = .03) and depression (5-9 years of age: 0%; 10-14 years of age: 6.8%; 95% CI, 3.6%-12.7%; 15-18 years of age: 26.7%; 95% CI, 15.7%-41.6%; P < .001), and be more likely to be hospitalized (5-9 years of age: 13.3%; 95% CI, 5.0%-31.1%; 10-14 years of age: 41.7%; 95% CI, 33.5%-50.3%; 15-18 years of age: 55.6%; 95% CI, 40.7%-69.5%; P = .001). Younger children were more likely to endorse lack of interest in food (5-9 years of age: 56.7%; 95% CI, 38.4%-73.2%; 10-14 years of age: 75.0%; 95% CI, 66.8%-81.7%; 15-18 years of age: 57.8%; 95% CI, 42.8%-71.4%; P = .03), avoidance of certain foods (5-9 years of age: 90.0%; 95% CI, 72.6%-96.8%; 10-14 years of age: 69.7%; 95% CI, 61.3%-77.0%; 15-18 years of age: 62.2%; 95% CI, 47.2%-75.3%; P = .03), and refusal based on sensory characteristics (5-9 years of age: 66.7%; 95% CI, 47.9%-81.3%; 10-14 years of age: 38.6%; 95% CI, 30.7%-47.3%; 15-18 years of age: 22.2%; 95% CI, 12.3%-36.9%; P < .001). Eating but not enough was more common in girls (75.0%; 95% CI, 64.1%-83.4%) vs boys (68.5%; 95% CI, 59.8%-76.1; P = .04), and boys had a higher rate of refusal based on sensory characteristics (51.2%; 95% CI, 40.2%-62.2%) compared with girls (31.5%; 95% CI, 23.9%-40.2%; P = .007). Conclusions and Relevance: This study suggests that ARFID is a relatively common eating disorder and is associated with important age- and sex- specific clinical characteristics that may help in early recognition and timely treatment of the presenting symptoms.

The tired teen: A review of the assessment and management of the adolescent with sleepiness and fatigue.

The symptoms of sleepiness and fatigue are frequently encountered when caring for adolescents. Up to 40% of healthy teens experience regular sleepiness, defined as an increased tendency to fall asleep. Fatigue is the perception of low energy following normal activity and is reported by up to 30% of well teens. Chronic fatigue syndrome is an unusual syndrome with severe fatigue accompanied by other physical and neurological symptoms. A thorough assessment is required for all teens with sleepiness and fatigue; however, a treatable underlying medical condition is rarely found. Most fatigue and sleepiness in teens is attributable to lifestyle issues, notably too little time spent sleeping. Physicians are in a position to screen for, assess and manage these common conditions in teens.

Accreditation of Adolescent Medicine as a pediatric sub-specialty: the Canadian experience and lessons learned.

The Royal College of Physicians and Surgeons of Canada (Royal College) has an extensive process for recognizing new specialties and subspecialties. Among other requirements, the process requests that the applicants demonstrate that sufficient scientific breadth and depth exists within the proposed field, that a unique field of clinical practice exists, and that there is a societal need for individuals with this distinct area of specialization. In 2004, a group of adolescent medicine specialists from across Canada started the application process for the field to become an accredited pediatric subspecialty. A 3-year process was undertaken to demonstrate the need for accreditation of this new and emerging discipline. In 2007, Adolescent Medicine became the 63rd discipline and a sub-specialty of Pediatrics. This paper provides an overview of the process that led to the accreditation of Adolescent Medicine by the Royal College and offers insights into the lessons learned from this Canadian experience.

Use of gastrostomy tubes in children and adolescents with eating disorders and related illnesses.

PURPOSE: The aim of this case series was to describe five youths with psychiatric illnesses who underwent feeding tube placement as part of their treatment. METHODS: The database of a Canadian academic tertiary care eating disorder program was used to identify patients with feeding tubes. RESULTS: Five patients with feeding tubes were identified in the database of more than 600 patients. Of the five patients, two had anorexia nervosa and three suffered from food refusal as a result of a psychiatric illness unrelated to body image issues. For each patient, the tube was placed only after standard methods of treatment had failed, including repeated hospitalizations and in two cases, residential treatment. The primary goal of placing the tube was to allow for outpatient management of the patient. In all five cases, the healthy weight was restored, and four of the five patients experienced a significant improvement in independent eating behavior. Four of the five patients were found to have had their tube removed when this article was being written. None of the patients required further hospitalizations and no serious relapses were found to have occurred. CONCLUSION: This case series demonstrates that gastrostomy tube feeding can be an effective intervention to allow patients with eating disorders to be treated as outpatients. The limitations of this study include the small study size, the retrospective nature of the study, and the short follow-up after tube removal. Further study is needed to evaluate the psychological effects of enterostomy feeds in patients and their families.