Children's drinking water: parental preferences and implications for fluoride exposure.

PURPOSE: The purposes of this study were to: describe children's drinking water sources; determine if any demographic factors are associated with water choice; describe parents' reasons for selecting bottled water; and determine parents' ability to provide enough information about their drinking water for providers to assess children's fluoride exposure. METHODS: Subjects were parents of children 6 months to 15-years-old. A questionnaire was verbally administered in English or Spanish. Chi-square analyses were used to evaluate associations among study variables. RESULTS: Of 194 parents, 134 (69%) gave their children bottled water either exclusively or with tap water. Bottled water use was not significantly associated with the primary source of tap water, parent's education level, or household income. Reasons for giving children bottled water included: fear of contaminants in tap water; taste and/or smell of tap water; and convenience of bottled water. For parents using bottled water, over 65% did not know the brand's fluoride content. CONCLUSIONS: Barriers to an accurate fluoride assessment include frequent bottled water use and parental uncertainty about its fluoride content. By initiating communication with parents and educating them about fluoride sources, health care and dental providers may be able to better evaluate the adequacy of children's fluoride exposure and decide whether fluoride supplementation is necessary.

Parental beliefs about autism: implications for the treating physician.

This study investigated parental beliefs about the etiology, diagnosis, and treatment of autism spectrum disorders. Sixty-two families of affected children completed a questionnaire asking when the parent first noticed developmental or behavioral problems, when they were told the diagnosis, how confident they were about the ability of their child's physician to recognize autism, whether they believed anything specific might have caused their child's autism, and what medications and complementary or alternative therapies they had tried. Two-thirds of parents suspected a specific cause, and three-quarters questioned their physician's ability. Parents who perceived a greater delay in diagnosis or who had tried more different therapies both tended to have less confidence in their physician (p = 0.20 and p = 0.07, respectively). Physicians should inquire about parental beliefs concerning etiology, learn what treatments the children are receiving, perform screening at the 18 month visit, and make referrals for further evaluation as soon as a child begins to exhibit signs suggestive of autism.

Pediatric residents as learners and teachers of evidence-based medicine.

OBJECTIVES: Residents must learn to assess the medical literature and apply it clinically. We designed and implemented a curriculum to support resident acquisition and use of skills required for critical review and clinical application of evidence from the pediatrics literature. The experience provided an opportunity for residents to observe, demonstrate under supervision, and practice evidence-based skills using the "see one, do one, practice many" approach. DESCRIPTION: We revised our residents' evidence-based pediatrics journal club curriculum to provide specific learning objectives to be accomplished by residents during the three years of residency. Curriculum objectives address study design, definition of the research question, characterization of variable type and choices of statistical methods, attention to sample size, diagnostic test characteristics, identification of sources of bias, and generalization and specific application of research findings to our clinical setting. We implemented a three-stage approach to skills learning. First-year residents participate in a monthly journal-club presented by the second-year residents ("see one"). During the second year, residents present noon conferences based on the curriculum objectives. The second-year resident meets with a faculty member to select a journal article for discussion, identify key curriculum objectives illustrated by the study, and choose pertinent clinical epidemiology references. The resulting presentation is given as a noon conference to an audience of residents, students, and faculty ("do one"). During the remainder of residency, residents continue to attend a monthly journal club that equips them with new skills and allows them to take a more meaningful part in the discussions ("practice many"). Curriculum faculty attend the monthly journal club to help direct the discussion of the article to fulfill curriculum objectives. DISCUSSION: Skills are best acquired in an environment which promotes active learning supervised by experts and provides frequent opportunities to practice the skills. Residents have responded positively to our curriculum and have presented high-quality conferences. Evaluation data being collected now (resident self-assessments and evaluations of the experience, faculty assessments of presentations, pre- and post-second year written assessments of knowledge) will inform us if the desired outcomes are being attained. Over the first two years of implementation of this curriculum, we have observed that it takes no more faculty time to supervise resident preparation and presentation than it would for the faculty to prepare and present material concerning similar curriculum objectives in a lecture or conference format. Additional benefits for residents include creating materials for presentation with experienced faculty, making presentations for peer groups, and assuming the role of teacher.

Seizure disorder as a risk factor for gastroesophageal reflux in children with neurodevelopmental disabilities.

The proportion of children with severe neurodevelopmental disabilities, in whom symptoms of gastroesophageal reflux develop after gastrostomy placement, has not been well studied. The medical records of children who received a gastrostomy tube (with or without a simultaneous antireflux procedure) at our institution between 1987 and 1997 were reviewed to identify neurologically related diagnoses at the time of the gastrostomy, diagnostic tests ordered to detect reflux, and dates and reasons for re-admissions within 2 years of discharge. Of 102 patients studied, 37 received a gastrostomy tube alone. Complete follow-up data were available for 30 of these patients, 7 of whom (23%) required subsequent antireflux surgery within 2 years. Patients with a seizure disorder had greater than a 4-fold risk of re-admission for this operation compared with other patients (57% [4/7] vs. 13% [3/23]; P=0.03). In a child with severe neurodevelopmental disability, the existence of a seizure disorder at the time of a gastrostomy operation increases the risk of subsequently requiring an antireflux procedure by a factor of 4.

Breastfeeding education and support services offered to pediatric residents in the US.

OBJECTIVE: The American Academy of Pediatrics (AAP) encourages pediatricians to support the practice of breastfeeding and residency educators to develop formal curricula in breastfeeding education. Few studies, however, describe breastfeeding education or support services currently provided to pediatric residents in the United States. The goals of this study were to investigate breastfeeding training offered during 3-year pediatric residency programs and to describe residency programs' policies and services for residents who breastfeed. METHODS: We conducted a cross-sectional study using a Web-based survey of pediatric program directors regarding breastfeeding education and support services for residents. RESULTS: Seventy percent of program directors (132 of 189) completed the survey, with 77.3% of respondents (n = 102) estimating the amount of breastfeeding education offered to their pediatric residents. Residents are provided with a median total of 9.0 hours of breastfeeding training over 3 years, primarily in continuity clinic and in lectures and rounds with attendings. At the programs' primary teaching hospitals, breastfeeding residents are provided breastfeeding rooms (67.0%), breast pumps (75.3%), and breast milk storage facilities (87.6%). Only 10 programs reported having an official policy to accommodate breastfeeding residents. CONCLUSIONS: Pediatric residents receive approximately 3 hours of breastfeeding training per year. In addition, there is less than universal implementation by residency programs of AAP recommendations for supporting breastfeeding in the workplace. Pediatric residency programs should find ways to improve and assess the quality of breastfeeding education and workplace support to better role model this advocacy standard.

Yield of diagnostic testing in infants who have had an apparent life-threatening event.

OBJECTIVE: Many infants who have experienced an apparent life-threatening event (ALTE) seem normal by the time they reach the hospital. Nevertheless, they typically undergo an extensive evaluation to rule out serious underlying conditions. The purpose of the present investigation was to determine the yield of different diagnostic tests in helping to identify the cause of the ALTE. METHODS: We reviewed test results from a consecutive series of infants who were younger than 12 months and admitted to a tertiary care academic medical center between November 1996 and June 1999 after having experienced a sudden breathing irregularity, color change, or alteration in mental status or muscle tone. For each patient, we noted whether a given test was performed, whether the result was positive, and, if so, whether the test contributed to the diagnosis, that is, suggested or helped establish the cause. We also noted whether the initial history and physical examination contributed information that eventually led to the final diagnosis. RESULTS: A total of 243 patients met the enrollment criteria. Of the 3776 tests ordered, 669 (17.7%) were positive and 224 (5.9%) contributed to the diagnosis. Prompted by findings from the initial clinical assessment, the following tests proved useful in patients who had a contributory history and physical examination: blood counts, chemistries, and cultures; cerebrospinal fluid analysis and cultures; metabolic screening; screening for respiratory pathogens; screening for gastroesophageal reflux; chest radiograph; brain neuroimaging; skeletal survey; electroencephalogram; echocardiogram; and pneumogram. In the remaining patients, who had a noncontributory history and physical examination, only the following tests proved useful: screening for gastroesophageal reflux, urine analysis and culture, brain neuroimaging, chest radiograph, pneumogram, and white blood cell count. Broad evaluations for systemic infections, metabolic diseases, and blood chemistry abnormalities were not productive in these patients. CONCLUSIONS: For many tests used in the evaluation of an ALTE, the likelihood of a positive result is low and the likelihood of a contributory result is even lower. Estimates of diagnostic yield derived from the present investigation can help clinicians maximize the productivity and efficiency of their evaluation.