Virtual family-centered rounds: a quality improvement initiative to adapt inpatient care during COVID-19 using a human-centred participatory design approach.

BACKGROUND: Family-centered rounds (FCR) are fundamental to pediatric inpatient care. During the COVID-19 pandemic, we aimed to design and implement a virtual family-centered rounds (vFCR) process that allowed continuation of inpatient rounds while following physical distancing guidelines and preserving personal protective equipment (PPE). METHODS: A multidisciplinary team developed the vFCR process using a participatory design approach. From April through July 2020, quality improvement methods were used to iteratively evaluate and improve the process. Outcome measures included satisfaction, perceived effectiveness, and perceived usefulness of vFCR. Data were collected via questionnaire distributed to patients, families, staff and medical staff, and analyzed using descriptive statistics and content analysis. Virtual auditors monitored time per patient round and transition time between patients as balancing measures. RESULTS: Seventy-four percent (51/69) of health care providers surveyed and 79% (26/33) of patients and families were satisfied or very satisfied with vFCR. Eighty eight percent (61/69) of health care providers and 88% (29/33) of patients and families felt vFCR were useful. Audits revealed an average vFCR duration of 8.4 min (SD = 3.9) for a single patient round and transition time between patients averaged 2.9 min (SD = 2.6). CONCLUSION: Virtual family-centered rounds are an acceptable alternative to in-person FCR in a pandemic scenario, yielding high levels of stakeholder satisfaction and support. We believe vFCR are a useful method to support inpatient rounds, physical distancing, and preservation of PPE that may also be valuable beyond the pandemic. A rigorous process evaluation of vFCR is underway.

Unintentional cannabis exposures in children pre- and post-legalization: A retrospective review from a Canadian paediatric hospital.

Objectives: Canada legalized recreational cannabis in October 2018. Cannabis is increasingly available in numerous forms-especially edibles-that make children vulnerable to unintentional intoxication. We sought to: determine the frequency of visits due to cannabis intoxication pre- and post-legalization; characterize the clinical features and circumstances of cannabis intoxication in the paediatric population; and create greater awareness among healthcare providers about this issue. Methods: We performed a retrospective chart review of Emergency Department visits at the Children's Hospital of Eastern Ontario (Ottawa, ON) between March 2013 and September 2020. Inclusion criteria were: age <18 years; unintentional cannabis ingestion, identified by ICD-10 codes T40.7 and X42. We assessed basic demographics, clinical signs and symptoms, exposure details, investigations, and patient disposition. Results: A total of 37 patients (22 male) met inclusion criteria, mean age 5.9±3.8 years. Most visits (32; 86%) occurred in the 2-year period after legalization. Altered levels of consciousness, lethargy/somnolence, tachycardia, and vomiting were the most common presenting signs and symptoms. The majority of exposures were to edibles (28; 76%) in the home setting (30; 81%). Poison control and child protective services were involved in 19 (51%) and 22 (59%) of cases, respectively. Twelve patients (32%) required admission to the hospital, the majority of whom stayed <24 h. Conclusions: Our data confirm increased paediatric hospital visits related to unintentional cannabis exposures post-legalization. Consideration of this clinical presentation is critical for acute care providers. Advocacy for safe storage strategies and appropriate enforcement of marketing/packaging legislation are imperative for public health policymakers.

Caring for children and youth from Canada's military families.

Introduction: The lives of Canada's military families are characterized by persistent stressors that can play a role in the health and development of children and youth. Military families are cared for by civilian physicians who may not be aware of this unique experience and risk. Our study sought to explore the knowledge and experiences of paediatricians providing care to Canadian Armed Forces (CAF) families. Methods: A 14-item survey was disseminated electronically by the Canadian Paediatric Surveillance Program (CPSP) to all 2799 Canadian paediatricians and paediatric specialists registered with the CPSP. Questions were focused on: knowledge of CAF families; the impact of the military on family care; confidence in providing care to CAF families; and training/education needs. Results: A total of 774 (28%) completed surveys were received. Approximately one third of respondents incorrectly believed that CAF families receive services from the federal military healthcare system. Nearly one quarter did not feel that identifying for military status informed patient care. Over half of respondents do not feel adequately prepared to provide care to CAF families. Discussion: Findings from this exploratory study suggest that additional resources and training would benefit the care of CAF families. Conclusion: CAF families experience a collection of risk factors that may negatively affect their health and access to services. The survey findings provide evidence of a need to further military literacy amongst Canadian paediatricians and provide direction for the development of enhanced resources and supports.

2020 edition of the Rourke Baby Record: What is new in preventive care of children up to 5 years of age?

OBJECTIVE: To update primary care providers practising well-child and well-baby clinical care on the evidence that contributed to the recommendations of the 2020 edition of the Rourke Baby Record (RBR). QUALITY OF EVIDENCE: Pediatric preventive care literature was searched from June 2016 to May 2019, primary research studies were reviewed and critically appraised using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, and recommendations were updated where there was support from the literature. MAIN MESSAGE: Notable changes in the 2020 edition of the RBR include the recommendations to limit or avoid consumption of highly processed foods high in dietary sodium, to ensure safe sleep (healthy infants should sleep on their backs and on a firm surface for every sleep, and should sleep in a crib, cradle, or bassinette in the parents' room for the first 6 months of life), to not swaddle infants after they attempt to roll, to inquire about food insecurity, to encourage parents to read and sing to infants and children, to limit screen time for children younger than 2 years of age (although it is accepted for videocalling), to educate parents on risks and harms associated with e-cigarettes and cannabis, to avoid pesticide use, to wash all fruits and vegetables that cannot be peeled, to be aware of the new Canadian Caries Risk Assessment Tool, to note new red flags for cerebral palsy and neurodevelopmental problems, and to pay attention to updated high-risk groups for lead and anemia screening. CONCLUSION: The RBR endeavours to guide clinicians in providing evidence-informed primary care to Canadian children. The revisions are rigorously considered and are based on appraisal of a growing, albeit still limited, evidence base for pediatric preventive care.

Adrenal suppression from exogenous glucocorticoids: Recognizing risk factors and preventing morbidity.

Adrenal suppression (AS), a potential side effect of glucocorticoid therapy (including inhaled corticosteroids), can be associated with significant morbidity and even death. In Canada, adrenal crisis secondary to AS continues to be reported in children. Being aware of symptoms associated with AS, understanding the risk factors for developing this condition, and familiarity with potential strategies to reduce risks associated with AS, are essential starting points for any clinician prescribing glucocorticoids.

Procedural skill needs for Canadian paediatricians: A national profile.

Background and Objectives: Procedural practice by paediatricians in Canada is evolving. Little empirical information is available on the procedural competencies required of general paediatricians. Accordingly, the aim of this study was to conduct a needs assessment of Canadian general paediatricians to identify procedural skills required for practice, with the goal of informing post-graduate and continuing medical education. Methods: A survey was sent to paediatricians through the Canadian Paediatric Surveillance Program (CPSP) (www.cpsp.cps.ca/surveillance). In addition to demographic information about practice type and location, participants were asked to indicate the frequency with which they performed each of 32 pre-selected procedures and whether each procedure was considered essential to their practice. Results: The survey response rate was 33.2% (938/2,822). Data from participants who primarily practice general paediatrics were analyzed (n=481). Of these, 71.0% reported performing procedures. The most frequently performed procedures were: bag-valve-mask ventilation of an infant, lumbar puncture, and ear curettage, being performed monthly by 40.8%, 34.1%, and 27.7% of paediatricians, respectively. The procedures performed by most paediatricians were also those found most essential to practice, with a few exceptions. Respondents performed infant airway procedures with greater frequency and rated them more essential when compared to the same skill performed on children. We found a negative correlation between procedures being performed and difficulty maintaining proficiency in a skill. Conclusions: This report of experiences from Canadian general paediatricians suggests a wide variability in the frequency of procedural performance. It helps establish priorities for post-graduate and continuing professional medical education curricula in the era of competency-based medical education.

The 2020 Rourke Baby Record release: A time for reflection and looking forward.

The Rourke Baby Record (RBR) is a health supervision guide for providing care and anticipatory guidance to children aged 0 to 5 years in Canada. First developed in 1979, it has been revised regularly to ensure that it remains current and evidence-informed. The RBR has a longstanding relationship with the Canadian Paediatric Society (CPS), and relies on this organization for its expertise to inform the RBR guide's content. The 2020 edition of the RBR includes many recommendations based on evidence provided in current CPS position statements. The RBR Working Group is planning to develop app-based resources and an adapted RBR for clinical care provision in this challenging pandemic time to ensure that Canadian infants and children continue to receive high-quality care.

Growth curves: The experiences of Canadian paediatricians in their first 5 years of independent practice.

OBJECTIVES: Completing training is a rite of passage common to all physicians, yet our knowledge of the components in postgraduate paediatric education that equip learners for successful transition to practice is limited. In order to optimally design training programs, it is critical to develop a better sense of what early career paediatricians (ECPs) experience as they navigate this time of transition. METHODS: We created and distributed a 23-question survey via e-mail to 481 Canadian ECPs in September 2017, specifically to those who received Royal College certification in 2011 or later. Survey responses were obtained confidentially through an online platform (Survey Monkey). Descriptive statistics and thematic analysis were used to analyze responses to closed-ended and free text questions, respectively. RESULTS: Response rate was 42% with nearly 70% of the respondents self-identifying as general paediatricians. Factors facilitating transition to practice included: dedicated mentorship; supportive new colleagues and workplace environment; and ease of finding work. Identified challenges included: billing, finances, and practice management; adjusting to a different scope of practice and learning local resources; managing comfort level; and achieving work-life balance. Nearly half of the respondents expressed interest in mentoring new ECP colleagues. CONCLUSIONS: Our findings suggest that ECPs find clear value in mentorship, but desire further support to adapt to new practice contexts and activities. As a result, we must consider strategies in both individual programs and nationally that effectively prepare learners prior to transition and align with needs in the first years of independent practice.

Caring for children and youth from Canadian military families: Special considerations.

Military families experience a number of life stressors, such as frequent geographical moves, long periods of separation within the family, geographic isolation from extended family support systems and deployments to high-risk areas of the world. While children and youth in military families experience all the same developmental and motivational trajectories as their civilian counterparts, they must also contend with more unusual developmental pressures and stressors placed on them by the unique demands of military life. The effects of the military life on families and children are beginning to be recognized and characterized more fully. Understanding the unique concerns of children and youth from military families and mobilizing specific resources to support them are critical for meeting the health care needs of this population.

Édition 2020 du Relevé postnatal Rourke: Quoi de neuf en soins préventifs des enfants jusqu'à 5 ans?

OBJECTIF: Renseigner les fournisseurs de soins de première ligne qui dispensent des soins de médecine préventive durant l'enfance quant aux données ayant servi de fondement aux recommandations de l'édition 2020 du Relevé postnatal Rourke (RBR). QUALITÉ DES DONNÉES: Une recherche a effectuée parmi les publications sur les soins préventifs en pédiatrie entre les mois de juin 2016 et mai 2019, les principales études de recherche ont été revues et rigoureusement évaluées à l'aide de la méthode GRADE (Grading of Recommendations Assessment, Development and Evaluation) et les recommandations ont été actualisées là où les publications étayaient des changements. MESSAGE PRINCIPAL: Les changements notables de l'édition 2020 du RBR sont les recommandations de limiter ou d'éviter les aliments très transformés et riches en sodium alimentaire, de veiller au sommeil sécuritaire (les nourrissons en bonne santé doivent dormir sur le dos et sur une surface rigide à tous les dodos, et ils doivent dormir dans un moïse, un berceau ou une couchette dans la chambre des parents pendant les 6 premiers mois de vie), de ne pas emmailloter les nourrissons après qu'ils aient tenté de se retourner, de s'informer de l'insécurité alimentaire, d'encourager les parents à lire et à chanter aux nourrissons et aux enfants, de limiter le temps que les enfants de moins de 2 ans passent devant un écran (bien que ce soit accepté pour les appels vidéo), de renseigner les parents sur les risques et les torts associés aux cigarettes électroniques et au cannabis, d'éviter les pesticides, de laver tous les fruits et légumes ne pouvant être pelés, de connaître l'existence du nouvel Outil national d'évaluation du risque de caries, de noter les nouveaux symptômes alarmants de paralysie cérébrale et de problèmes neurodéveloppementaux et de porter attention aux nouveaux groupes à risque élevé pour le dépistage du plomb et de l'anémie. CONCLUSION: Le RBR s'efforce de guider les cliniciens pour leur permettre de dispenser des soins de première ligne factuels aux enfants canadiens. Les révisions sont rigoureusement étudiées, et sont basées sur l'évaluation d'une base de données probantes croissante, quoique toujours limitée, sur les soins préventifs en pédiatrie.

Ankyloglossia and breastfeeding.

Ankyloglossia ('tongue-tie') is a relatively common congenital anomaly characterized by an abnormally short lingual frenulum, which may restrict tongue tip mobility. There is considerable controversy regarding its diagnosis, clinical significance and management, and there is wide variation in practice in this regard. Most infants with ankyloglossia are asymptomatic and do not exhibit feeding problems. Based on available evidence, frenotomy cannot be recommended for all infants with ankyloglossia. There may be an association between ankyloglossia and significant breastfeeding difficulties in some infants. This subset of infants may benefit from frenotomy (the surgical division of the lingual frenulum). When an association between significant tongue-tie and major breastfeeding problems is clearly identified and surgical intervention is deemed to be necessary, frenotomy should be performed by a clinician experienced with the procedure and using appropriate analgesia. More definitive recommendations regarding the management of tongue-tie in infants await clear diagnostic criteria and appropriately designed trials.

L'ankyloglossie est une anomalie congénitale relativement courante caractérisée par un frein lingual anormalement court, qui peut restreindre la mobilité de la langue. Une énorme controverse en entoure le diagnostic, la signification clinique et la prise en charge, et les pratiques varient considérablement à cet égard. La plupart des nourrissons ayant une ankyloglossie sont asymptomatiques et n'ont pas de problèmes pour se nourrir. D'après les données probantes, on ne peut pas recommander la frénotomie pour tous les nourrissons ayant une ankyloglossie. Chez certains nourrissons, on peut constater une association entre l'ankyloglossie et certains problèmes d'allaitement. Ce sous-groupe de nourrissons peut tirer profit de la frénotomie (la division chirurgicale du frein de la langue). Lorsqu'une association entre une ankyloglossie marquée et de graves troubles d'allaitement est clairement établie et qu'une intervention chirurgicale est jugée nécessaire, un clinicien habitué à la frénotomie doit effectuer l'intervention et utiliser l'analgésie convenable. Pour faire des recommandations plus définitives sur la prise en charge de l'ankyloglossie chez les nourrissons, il faudra attendre des critères diagnostiques clairs et des essais cliniques bien conçus.

Examining the educational value of a CanMEDS roles framework in pediatric morbidity and mortality rounds.

BACKGROUND: In order to determine whether the CanMEDS roles could be helpful in solidifying knowledge during clinical training, we examined quality of care issues identified during morbidity and mortality (M&M) rounds. METHODS: During the M&M rounds, following the case presentation, there was a pause and attendees were asked to identify quality of care issues that were present in the case. The attendees were assigned to a CanMEDS prompted group or non-prompted group. Following the rounds, the issues were identified, coded according to CanMEDS role, and compared between groups. RESULTS: A total of 111 individuals identified a total of 350 issues; 57 individuals were in the CanMEDS-prompted group and 54 were in the unprompted group. The mean number of issues identified was significantly higher in the CanMEDS-prompted group compared to the unprompted group (3.7 versus 2.6, p = 0.039). There were significantly more issues raised in the prompted group for the roles of communicator, collaborator, scholar and professional. CONCLUSIONS: Using CanMEDS roles as prompts, attendees at M&M rounds identify more quality of care issues than if not given a prompt. Use of the CanMEDS framework may assist learners to consolidate the linkage between expected training objectives and the complexities of clinical practice.

Oral health care for children - a call for action.

Oral health is a fundamental component of overall health. All children and youth should have access to preventive and treatment-based dental care. Canadian children continue to have a high rate of dental disease, and this burden of illness is disproportionately represented by children of lower socioeconomic status, those in Aboriginal communities and new immigrants. In Canada, the proportion of public funding for dental care has been decreasing. This financial pressure has most affected low-income families, who are also less likely to have dental insurance. Publicly funded provincial/territorial dental plans for Canadian children are limited and show significant variability in their coverage. There is sound evidence that preventive dental visits improve oral health and reduce later costs, and good evidence that fluoridation therapy decreases the rate of dental caries, particularly in high-risk populations. Paediatricians and family physicians play an important role in identifying children at high risk for dental disease and in advocating for more comprehensive and universal dental care for children.

La santé buccodentaire est un élément fondamental de la santé globale. Tous les enfants et les adolescents devraient avoir accès à des soins dentaires préventifs et thérapeutiques. Les enfants canadiens continuent de présenter un taux élevé de maladie dentaire, et ce fardeau est représenté de manière disproportionnée chez les enfants provenant de familles défavorises, de communautés autochtones ou de familles de nouveaux arrivants. Au Canada, la proportion du financement gouvernemental affectée aux soins dentaires est à la baisse. Cette pression financière touche surtout les familles à faible revenu, qui sont également moins susceptibles de disposer d'une assurance dentaire. Les régimes d'assurance dentaire financés par les gouvernements provinciaux et territoriaux à l'intention des enfants canadiens sont limités et offrent une protection très variable. Selon des données probantes solides, les visites préventives chez le dentiste améliorent la santé buccodentaire et réduisent les frais subséquents, et selon de bonnes données probantes, la fluorothérapie réduit le taux de caries dentaires, particulièrement dans les populations à haut risque. Les pédiatres et les médecins de famille contribuent énormément à déterminer quels enfants sont très vulnérables à une maladie dentaire et à prôner des soins dentaires plus complets et plus universels pour les enfants.

Community-acquired lobar pneumonia in children in the era of universal 7-valent pneumococcal vaccination: a review of clinical presentations and antimicrobial treatment from a Canadian pediatric hospital.

BACKGROUND: Community-acquired pneumonia (CAP) is a common cause of pediatric admission to hospital. The objectives of this study were twofold: 1) to describe the clinical characteristics of CAP in children admitted to a tertiary care pediatric hospital in the pneumococcal vaccination era and, 2) to examine the antimicrobial selection in hospital and on discharge. METHODS: A retrospective review of healthy immunocompetent children admitted to a tertiary pediatric hospital from January 2007 to December 2008 with clinical features consistent with pneumonia and a radiographically-confirmed consolidation was performed. Clinical, microbiological and antimicrobial data were collected. RESULTS: One hundred and thirty-five hospitalized children with pneumonia were evaluated. Mean age at admission was 4.8 years (range 0-17 years). Two thirds of patients had been seen by a physician in the 24 hours prior to presentation; 56 (41.5%) were on antimicrobials at admission. 52 (38.5%) of patients developed an effusion, and 22/52 (42.3%) had pleural fluid sampled. Of 117 children who had specimens (blood/pleural fluid) cultured, 9 (7.7%) had pathogens identified (7 Streptococcus pneumoniae, 1 Group A Streptococcus, and 1 Rhodococcus). 55% of patients received 2 or more antimicrobials in hospital. Cephalosporins were given to 130 patients (96.1%) in hospital. Only 21/126 patients (16.7%) were discharged on amoxicillin. The median length of stay was 3 days (IQR 2-4) for those without effusion and 9 (IQR 5-13) for those with effusion. No deaths were related to pneumonia. CONCLUSIONS: This study provides comprehensive data on the clinical characteristics of hospitalized children with CAP in the pneumococcal 7-valent vaccine era. Empiric antimicrobial choice at our institution is variable, highlighting a need for heightened antimicrobial stewardship.

Guide de pratique clinique fondé sur des données probantes pour l'examen périodique de la vue chez les enfants de 0 à 5 ans au Canada.

CONTEXTE: Étant donné que les maladies oculaires avant l'âge de 5 ans sont courantes, une certaine forme de dépistage des troubles de la vision devrait être effectuée chez les enfants avant qu'ils ne fréquentent l'école primaire. Cependant, l'absence de recommandations nationales cohérentes crée de la confusion chez les patients, les professionnels des soins oculovisuels et les gouvernements. MéTHODES: L'objectif de ce document est de fournir des recommandations quant aux types d'examens oculaires à pratiquer chez les enfants en bonne santé de 0 à 5 ans ainsi que sur le moment et la périodicité de tels examens. Une recension des écrits a produit 403 articles. Un comité d'experts multidisciplinaire (composé de deux optométristes, d'un ophtalmologiste effectuant des examens complets de la vue, d'un ophtalmologiste pratiquant en pédiatrie, d'un médecin de famille et d'un pédiatre) a établi de façon indépendante les articles jugés essentiels à la question clinique. Les articles se prêtant à un classement [n = 16] ont ensuite été soumis à une évaluation critique indépendante par un groupe externe, lequel a fourni un profil « GRADE ¼ des articles à utiliser et leur a attribué une cote. RECOMMANDATIONS: En plus du dépistage de routine effectué par les professionnels de première ligne, un examen complet de la vue mené par un professionnel possédant l'expertise nécessaire à la détection des facteurs de risque de l'amblyopie (comme un ophtalmologiste ou un optométriste) est requis durant la petite enfance. Les conclusions confirment l'importance de la détection précoce de l'amblyopie avant 36 mois et au plus tard 48 mois par le dépistage assorti d'au moins un examen complet de la vue avant l'âge de 5 ans. CONCLUSIONS: Le dépistage de la vue effectué chez les bébés et les enfants par les fournisseurs de soins de première ligne au cours des consultations de routine et des vaccinations périodiques est un élément essentiel de la détection des maladies oculaires. Toutefois, le potentiel de détection précoce est limité et un examen oculovisuel complet est également recommandé avant que l'enfant n'entre à l'école. Si l'amblyopie, le strabisme ou une autre pathologie oculaire est détecté ou soupçonné, et que le problème dépasse le champ de compétences du professionnel qui examine le patient, celui-ci peut être dirigé vers le spécialiste approprié, ce qui permet d'amorcer le traitement en temps opportun.

Evidence-based clinical practice guidelines for the periodic eye examination in children aged 0-5 years in Canada.

BACKGROUND: As eye disease before age 5 years is common, some form of vision screening should be performed on children before attending primary school. However, the lack of consistent national recommendations creates confusion for patients, eye care professionals, and governments alike. METHODS: The objective of this document is to provide guidance on the recommended timing, intervals, and types of ocular assessments for healthy children aged 0-5 years. A literature search yielded 403 articles. A multidisciplinary expert committee (comprising 2 optometrists, a comprehensive ophthalmologist, a pediatric ophthalmologist, a family physician, and a pediatrician) independently determined those articles deemed to be key to the clinical question. Articles that were gradable (n = 16) were then submitted for independent critical appraisal by an external review group, which provided a Grading of Recommendations Assessment, Development and Evaluation profile of the reviewed articles to use for assigning a grade of evidence. RECOMMENDATIONS: In addition to routine screening by a primary health care professional, a comprehensive eye examination by an individual with the expertise to detect risk factors for amblyopia-such as an ophthalmologist or optometrist-is required in early childhood. The findings support the importance of early detection of amblyopia before 36 months and no later than 48 months of age via screening with at least 1 comprehensive eye examination before age 5 years. CONCLUSIONS: Vision screening performed by primary health care providers during routine well-baby/child visits and scheduled vaccinations is an essential part of the detection of ocular disease. However, this early detection potential is limited, and a full oculovisual assessment is also recommended before the child entering the school system. If amblyopia, strabismus, or other eye pathology is detected or suspected that is beyond the scope of the eye care professional examining the patient, a referral to the appropriate specialist can be made, allowing treatment to be initiated in a timely fashion.

Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children.

Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.