Shared decision-making in adolescent healthcare: a literature review of ethical considerations.

PURPOSE: Adolescence is a period of growing independence and maturity, within the period of legal minority. As parents or guardians are socially and legally responsible for adolescents' medical decisions, shared decision-making in adolescent healthcare could be ethically challenging. This review aims to identify and map the ethical tensions in shared decision-making in adolescent healthcare. METHODS: We systematically searched the literature following the PRISMA guidelines to identify relevant articles, which were analyzed using the review of reasons methodology Strech and Sofaer (J Med Ethics 38(2):121-6, 2012). RESULTS: We included 38 articles which involved adolescents, healthcare professionals and parents as being the main stakeholders. Shared decision-making was influenced not only by individual stakeholders' characteristics, but by tensions between stakeholder dyads. Most studies supported the involvement of the adolescent in decision-making, depending on their life experience, decision-making capacity and clinical condition. CONCLUSIONS: Shared decision-making in adolescent health is receiving increasing attention. However, questions remain on what this concept entails, the roles and involvement of stakeholders and its practical implementation. WHAT IS KNOWN: • Although adolescents wish to be involved in health decisions, shared decision-making in adolescents is underexplored • Adolescent shared decision-making is different from pediatric and adult shared decision-making, and is ethically complex due to the adolescent's growing autonomy What is new: • Adolescent SDM involves three-way interactions between the adolescent, healthcare professional and parents • In adolescent shared decision-making, involving or excluding a stakeholder and sharing or withholding information are ethically value-laden steps • Research is needed to further understand the roles of adolescents' personal value systems, extended or reconstituted families and decision aids in shared decision-making.

Effectiveness of safety netting approaches for acutely ill children: a network meta-analysis.

BACKGROUND: Safety netting advice (SNA) can help in the management of acutely ill children. AIM: Assess the effectiveness of different SNA methods for acutely ill children on antibiotic prescription and consumption. DESIGN AND SETTING: Systematic review and network meta-analysis of randomised controlled trials, non-randomised trials of interventions, and controlled before-after studies in ambulatory care. METHOD: We searched MEDLINE, Embase, Web-Of-Science Core Collection, and Cochrane Central Register of Controlled Trials (22 January 2024). We assessed the risk of bias (RoB) with the Cochrane Tool 2, Revised Cochrane Tool for Cluster-Randomised Trials, and ROBINS-I tool. Certainty of evidence was assessed using the CINeMA approach. We performed sensitivity analyses and network meta-regression. RESULTS: We included 30 studies (20 interventions). Compared to usual care, paper SNA may reduce antibiotic prescribing (OR=0.66 (95%CI: 0.53-0.85), I²=92%, very low certainty; 3 studies, 35,988 participants), especially when combined with oral SNA (OR=0.40 (95%CI: 0.08-2.00), P-score: 0.86), antibiotic consumption (OR=0.39 (95%CI: 0.27-0.58), low RoB; 1 study, 509 participants), and return visits (OR=0.74 , 95%CI 0.63-0.87). Paper SNA without antibiotics may reduce antibiotic consumption compared to paper SNA and delayed antibiotics (OR=0.27 (95%CI: 0.15-0.51, some RoB; 1 study, 206 participants). Video SNA, oral SNA, read-only websites, and web-based modules may increase parental knowledge (ORs 2.23-4.52). Video SNA and web-based modules may improve parental satisfaction (ORs 1.64-4.08). CONCLUSION: Paper SNA (with oral SNA) may reduce antibiotic use and return visits. Video, oral, and online SNA, may improve parental knowledge while video SNA and web-based modules may increase parental satisfaction.

Cycle safe or cycle cool? Adolescents' views on bicycle helmet use and injury prevention campaigns in Belgium.

OBJECTIVES: Although cycling is a healthy, ecological and practical way of transportation, it is not without risk. The effect of bicycle helmets to prevent head injuries on crashing has been extensively investigated. Nonetheless, the overall use of helmets by adolescents remains low. While various interventions to increase helmet use have been adopted, adolescents' perspectives on these interventions have not been extensively explored. In our study, we aim to understand the facilitators and barriers to bicycle helmet use by adolescents and their perspectives on injury prevention campaigns. METHODS: A qualitative methodology was selected. A convenience sample of three schools in Belgium was selected for participation. 12 focus groups were conducted with a total of 84 adolescents aged 12-17 years in the second, third or fourth year of secondary school. RESULTS: Four key themes regarding adolescents' views on safe cycling practices emerged from the analysis: external motivation, internal motivation, factors specific to the helmet and the cycling environment. The main barriers to bicycle helmet use identified by adolescents were peer pressure, appearance and discomfort. The perceived risks of cycling without a helmet among adolescents were low. Mandatory bicycle helmet laws and non-legislative programmes were considered to be an effective strategy by the study participants. Parental strategies, including strict parental rules and parental helmet use, further contributed to wear a bicycle helmet. CONCLUSION: The results of this qualitative study add to the literature by expanding the understanding of motivation for bicycle helmet use and should be considered when designing interventions to promote bicycle helmet use.

The Association of Social Media Use and Eating Behaviour of Belgian Adolescent Girls Diagnosed with Anorexia Nervosa-A Qualitative Approach.

BACKGROUND: Social media have become integral in adolescents' lives, presenting both opportunities and risks, especially concerning psychiatric issues like eating disorders, prevalent in this vulnerable age group. METHODS: This qualitative study employed semi-structured interviews with seven adolescent girls (aged 15-17) diagnosed with eating disorders. Interviews covered seven predefined topics, recorded and transcribed for thematic analysis. RESULTS: Participants identified four key themes: exposure to selective content, biased interpretation, behavioural adaptation, and evolving perspectives during recovery. They highlighted social media's role in exacerbating body dissatisfaction and altering behaviours related to eating disorders. CONCLUSIONS: This research underscores the critical need for awareness and guidance in adolescents' social media use to mitigate negative impacts, emphasizing the potential link between exposure to specific content and cognitive-behavioural changes in those with eating disorders. Further investigation is warranted to deepen our comprehension of these dynamics.

Temporal trends in antibiotic prescribing and serious and nonserious infections in children presenting to general practice: a registry-based longitudinal cohort study of 162 507 individuals.

BACKGROUND: It is crucial to understand the trends in paediatric antibiotic prescribing and serious and nonserious infections to improve antibiotic prescribing practices for children in ambulatory care. OBJECTIVES: Assessing trends in paediatric antibiotic prescribing and infection incidence in general practice from 2002 to 2022. METHODS: In this retrospective cohort study using INTEGO network data from 162 507 patients in Flanders (Belgium), we calculated antibiotic prescribing rates and proportions alongside incidence rates of serious and nonserious infections, stratified by age (0-1, 2-6, 7-12 years) and municipality. We performed autoregressive moving average time-series analyses and seasonality analyses. RESULTS: From 2002 to 2022, antibiotic prescribing rate decreased significantly: 584/1000 person-years (PY) (95% CI 571-597) to 484/1000PY (95% CI 478-491); so did antibiotic overall prescribing proportion: 46.3% (95% CI 45.1-47.6) to 23.3% (95% CI 22.9-23.7) (59.3% amoxicillin and 17.8% broad spectrum). Prescribing proportions dropped significantly for nonserious (45.6% to 20.9%) and increased for serious infections (64.1% to 69.8%). Proportions significantly dropped for acute suppurative otitis media (74.7% to 64.1%), upper respiratory tract infections (44.9% to 16.6%), bronchitis/bronchiolitis (73.6% to 44.1%) and acute tonsillopharyngitis (59.5% to 21.7%), while significantly increasing for pneumonia (65.2% to 80.2%). Nonserious and serious infection incidence rates increased from 785/1000PY and 34.2/1000PY to 1223/1000PY and 64.1/1000PY, respectively. Blood and CRP testing proportions increased significantly. CONCLUSIONS: Antibiotic prescribing in general practice for children declined from 2002 to 2022. Further targeted antibiotic stewardship initiatives are needed to reduce the use of broad-spectrum antibiotics and antibiotic prescribing for conditions such as otitis media and bronchitis/bronchiolitis.

Parenting dimensions and views on adolescent decision making in health care: A cross-national study of Belgian and Dutch parents.

BACKGROUND: The aim of this study was to investigate the link between parenting and parents' perspectives on health-related decision making for adolescents. During adolescence, there is a gradual increase in responsibility and autonomy, which influences parenting behavior and child development. Understanding how parenting is associated with parents' views on medical decision making is crucial in the context of the parent-child-physician triad. This study was the first to explore parenting and parents' views on adolescent health care decision making. We compare Belgian and Dutch parents-two countries selected for their different legal frameworks on medical adolescent decision making. METHOD: An online questionnaire surveyed 984 Belgian and 992 Dutch parents (ages 35-55) with at least one child. Analytical methods included t tests, structural equation modeling, and latent profile analysis. RESULTS: Parents considered adolescents to be competent decision makers at 16.7 years old. Dutch parents granted autonomy at younger ages than Belgian parents. Parents with high behavioral expectations granted autonomy to adolescents at higher ages, while those high in autonomy support and punishment granted autonomy at lower ages. When classifying parents into profiles, we distinguished four types: highly permissive, moderately permissive, moderately restrictive, and highly restrictive groups. The majority of the sample was classified into moderately and highly restrictive profiles. CONCLUSION: The study highlighted the importance of providing parents with education and support on adolescent development and autonomy. Parenting practices that encourage autonomy and support open communication between parents and adolescents may contribute to a more trusting and supportive parent-child context for adolescent medical decision making. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Vitamin D Status in Belgian Children: A Regional Study.

Background: Vitamin D deficiency is the most frequent cause of impaired skeletal growth, and can lead to the development of nutritional rickets. The aim of this study was to evaluate the vitamin D status in a large group of children aged 0-18 years. Methods: We collected laboratory data on vitamin D levels from children who underwent blood sampling between 2014 and 2021. Results: We included 14,887 samples. In this group, 17.7% were vitamin D severely deficient (<12 ng/mL), 25.2% were insufficient (12-20 ng/mL), and another large proportion (28.3%) was borderline (20-30 ng/mL). Sufficient levels (>30 ng/mL) were met in 28.8% of children. We observed no association between gender and vitamin D status (p = 0.132). Adolescents aged 13-18 years (n = 3342) had the highest prevalence of severe vitamin D deficiency (24.9%). Vitamin D levels were higher in summer/autumn compared to winter/spring. Conclusions: Vitamin D deficiency/insufficiency has a high prevalence in children, mostly in children above 7 years of age. Many of these children (over 80%) do not meet the 30 ng/mL sufficiency threshold. It is essential that Belgian Health Authorities are aware of this high prevalence, as the current Belgian recommendation suggests ceasing vitamin D supplementation at the age of six. Additional research is required to investigate the consequences of our findings, and what specific approach is needed to achieve normal vitamin D levels in children aged 0 to 18 years.

Knowledge Gaps and Bridges: The Relationship between the Awareness of General Patient Rights and the Awareness of Minors' Patient Rights in the Netherlands.

The major focus of this research is the level of awareness among Dutch parents of general patient rights in relation to minors' patient rights. Moreover, this study is intended to highlight the most effective strategies to increase the awareness of general and minor patient rights in the Netherlands. A survey was conducted among 1010 Dutch parents aged between 35 and 55 years who had at least one child. In this study, we described the relationship between the knowledge among parents of general patient rights and their understanding of the patient rights of minors. A significant connection was found between the knowledge levels of general patient rights and the knowledge levels of the patient rights of minors (p < 0.05 [95% CI: 0.019-0.183]). While age and sex (male/female) did not appear to be significant confounders in this association, the educational background of the participants may have played a role. This study provides comprehensive insights into the association between the knowledge of general patient rights and the patient rights of minors among Dutch parents. Furthermore, this study points out that there is a need for focused educational interventions to address specific areas of misunderstanding or uncertainty.

Towards an international consensus on safety netting advice for acutely ill children presenting to ambulatory care: a modified e-Delphi procedure.

OBJECTIVE: Develop a consensus on the content and form of safety netting advice (SNA) for parents of acutely ill children. DESIGN: Four-round modified e-Delphi using online questionnaires and feedback among clinical and research experts. SETTING: Ambulatory care in high-income countries. PARTICIPANTS: Forty-one experts from 13 countries: 3 emergency physicians, 15 general practitioners, 4 nurses and 19 paediatricians. RESULTS: The experts defined the content of SNA as advice on the normal, expected disease course of the provisional diagnosis, diagnostic uncertainty, alarm signs that indicate the need for medical help and information on where and how to find such help. Regarding the form of the SNA, the experts agree that a reliable source should give SNA verbally with paper or digital written or video/image resources at every appropriate healthcare encounter in a short and simple empowering fashion, specific to the child's situation and seek confirmatory feedback from parents. CONCLUSIONS: SNA needs to contain advice on the expected disease course, alarm signs and where and how to find help. It should be given verbally with written resources by a reliable healthcare professional or digital platform. Short, simple and specific, SNA needs to empower the parent whose understanding of the advice should be checked. The effectiveness of SNA resources coproduced by parents and experts should be assessed in different settings and those providing SNA require up-to-date and reliable training.

Testing a Home Solution for Preparing Young Children for an Awake MRI: A Promising Smartphone Application.

Thanks to its non-invasive nature and high-resolution imaging capabilities, magnetic resonance imaging (MRI) is a valuable diagnostic tool for pediatric patients. However, the fear and anxiety experienced by young children during MRI scans often result in suboptimal image quality and the need for sedation/anesthesia. This study aimed to evaluate the effect of a smartphone application called COSMO@home to prepare children for MRI scans to reduce the need for sedation or general anesthesia. The COSMO@home app was developed incorporating mini-games and an engaging storyline to prepare children for learning goals related to the MRI procedure. A multicenter study was conducted involving four hospitals in Belgium. Eligible children aged 4-10 years were prepared with the COSMO@home app at home. Baseline, pre-scan, and post-scan questionnaires measured anxiety evolution in two age groups (4-6 years and 7-10 years). Eighty-two children participated in the study, with 95% obtaining high-quality MRI images. The app was well-received by children and parents, with minimal technical difficulties reported. In the 4-6-year-old group (N = 33), there was a significant difference between baseline and pre-scan parent-reported anxiety scores, indicating an increase in anxiety levels prior to the scan. In the 7-10-year-old group (N = 49), no significant differences were observed between baseline and pre-scan parent-reported anxiety scores. Overall, the COSMO@home app proved to be useful in preparing children for MRI scans, with high satisfaction rates and successful image outcomes across different hospitals. The app, combined with minimal face-to-face guidance on the day of the scan, showed the potential to replace or assist traditional face-to-face training methods. This innovative approach has the potential to reduce the need for sedation or general anesthesia during pediatric MRI scans and its associated risks and improve patient experience.

Is blood thicker than water? Perceptions on the role of stepparents in medical decisions among minors.

Alternative family configurations are becoming more prevalent, yet current legislative statutory does not support stepparents in medical decisions for their stepchildren. We investigate opinions of Belgian and Dutch adults regarding inclusion of stepparents in medical decision-making in minors. We make two observations. First, participants wanted stepparents to be involved in cases when medical information had to be shared or informed consent signed. Second, when stepparents object against previously approved medical interventions by a biological parent, respondents were less likely to support stepparents. Participants with stepchildren were likely to favour inclusion of stepparents in decision-making. Overall, our findings indicate that Belgian and Dutch adults view stepparents as potential executive actors in medical decision-making for minors, but not as primary decision-makers. This study is a first step in showing to what extent stepparents could be included in medical information and decision-making regarding stepchildren. We reflect on these findings in light of implications for medical practice and legislative shortcomings.

Challenges of Antibiotic Formulations and Administration in the Treatment of Bloodstream Infections in Children Under Five Admitted to Kisantu Hospital, Democratic Republic of Congo.

Severe bacterial infections in children need prompt, appropriate antibiotic treatment. We report challenges observed within a prospective, cohort study on antibiotic efficacy in non-typhi Salmonella bloodstream infection (NCT04850677) in Kisantu district hospital (Democratic Republic of Congo). Children (aged > 28 days to < 5 years) admitted with suspected bloodstream infection (August 1, 2021 through July 31, 2022) were enrolled and followed until day 3 or discharge for non-typhi Salmonella patients. Antibiotics were administered to 98.4% (1,838/1,867) of children, accounting for 2,296 antibiotic regimens (95.7% intravenous, 4.3% oral). Only 78.3% and 61.8% of children were, respectively, prescribed and administered antibiotics on the admission day. At least one dose was not administered in 3.6% of children, mostly because of mismatch of the four times daily cefotaxime schedule with the twice-daily administration rounds. Inappropriate intravenous administration practices included multidose use, air-venting, and direct injection instead of perfusion. There was inaccurate aliquoting in 18.0% (32/178) of intravenous ciprofloxacin regimens, and thus administered doses were > 16% below the intended dose. Dosing accuracy of oral suspensions was impaired by lack of instructions for reconstitution, volume indicators, and/or dosing devices. Adult-dose tablets were split without/beyond scoring lines in 84.4% (27/32) of tablets. Poor availability and affordability of age-appropriate oral formulations contributed to low proportions of intravenous-to-oral switch (33.3% (79/237) of non-typhi Salmonella patients). Other quality issues included poor packaging, nonhomogeneous suspensions, and unsafe water for reconstitution. In conclusion, poor antibiotic products (no age-appropriate formulations, poor quality and access), processes (delayed prescription/administration, missed doses), and practices (inaccurate doses, [bio]safety risks) must be urgently addressed to improve pediatric antibiotic treatment.

Knowledge of Child Abuse and Neglect among General Practitioners and Pediatricians in Training: A Survey.

Child abuse and neglect is a common, underreported, and worldwide problem. Health care providers play an important role in detecting and reporting this problem. This study examined the knowledge on the clinical signs and mimickers of child abuse among Belgian trainees in family medicine and pediatrics. Participants filled out an anonymous online survey of 15 fictional but realistic cases with either suspicious or non-suspicious signs of abuse or neglect in the context of primary or emergency care. The overall score on all cases, the number of correct answers per case, and the median score were calculated, and the association of the participant's demographic characteristics with their score was examined using regression analysis. A total of 70 participants completed the survey. The overall median score was 73.3% (IQR 20.0%). The suspicious cases were solved more correctly than the non-suspicious cases (median: 85.7% versus 62.5%, p < 0.001). Regression analysis could not reveal a significant association of type and level of education with the performance on the survey. Knowledge of the clinical signs of child maltreatment among pediatricians and general practitioners in training is good, but there is still room for improvement.

Modulation of engineered nanomaterial interactions with organ barriers for enhanced drug transport.

The biomedical use of nanoparticles (NPs) has been the focus of intense research for over a decade. As most NPs are explored as carriers to alter the biodistribution, pharmacokinetics and bioavailability of associated drugs, the delivery of these NPs to the tissues of interest remains an important topic. To date, the majority of NP delivery studies have used tumor models as their tool of interest, and the limitations concerning tumor targeting of systemically administered NPs have been well studied. In recent years, the focus has also shifted to other organs, each presenting their own unique delivery challenges to overcome. In this review, we discuss the recent advances in leveraging NPs to overcome four major biological barriers including the lung mucus, the gastrointestinal mucus, the placental barrier, and the blood-brain barrier. We define the specific properties of these biological barriers, discuss the challenges related to NP transport across them, and provide an overview of recent advances in the field. We discuss the strengths and shortcomings of different strategies to facilitate NP transport across the barriers and highlight some key findings that can stimulate further advances in this field.

Location-specific pathology analysis of the monopodial pulmonary vasculature in a rabbit model of bronchopulmonary dysplasia-A pilot study.

The mammalian pulmonary vasculature consists of functionally and morphologically heterogeneous compartments. When comparing sets of lungs, for example, in disease models or therapeutic interventions, local changes may be masked by the overall heterogeneity of the organ structure. Therefore, alterations taking place only in a sub-compartment may not be detectable by global analysis. In the monopodial lung, the characterization of distinct vessel groups is difficult, due to the asymmetrical branching pattern. In this pilot study, a previously established method to classify segments of the monopodial pulmonary arterial tree into homogeneous groups was employed. To test its suitability for experimental settings, the method was applied to a hyperoxia (HYX, ≥95% oxygen) rabbit model of bronchopulmonary dysplasia and a normoxic control group (NOX, 21% oxygen). The method allowed the identification of morphological differences between the HYX and the NOX groups. Globally visible differences in lumen diameter were pinpointed to specific lung regions. Furthermore, local changes of wall dimension and cell layers in single compartments, that would not have been identifiable in an unfocused analysis of the whole dataset, were found. In conclusion, the described method achieves a higher precision in morphological studies of lung disease models, compared to a common, global analysis approach.

Teacher Preparedness for Medical Emergencies in Belgian Classrooms: Studying Objective and Subjective First-Aid Knowledge.

About one in seven accidents involving children occurs at school. Roughly 70% of these accidents involve children under the age of 12 years. Thus, primary school teachers may be confronted with accidents where first aid could improve the outcome. Despite the importance of first-aid knowledge among teachers, little is known about this topic. To fill this gap, we conducted case-based survey research on the objective and subjective first-aid knowledge of primary school and kindergarten teachers in Flanders, Belgium. An online survey was distributed to primary school and kindergarten teachers. It included 14 hypothetical first-aid scenarios in a primary school context to assess objective knowledge, along with one item to assess subjective knowledge. A total of 361 primary school and kindergarten teachers completed the questionnaire. The participants achieved an average knowledge score of 66%. Those who had completed a first-aid course had significantly higher scores. Knowledge regarding child CPR was amongst the lowest, with only 40% correct answers. Structural equation modeling showed that only previous first-aid training, recent experience with first aid, and subjective first-aid knowledge were linked to teachers' objective first-aid knowledge-particularly for basic first aid. This study shows that completing a first-aid course and completing a refresher course can predict objective first-aid knowledge. We therefore recommend that first-aid training and regular refresher courses should be mandatory in teacher training, given that a large share of teachers may need to apply first aid to a pupil at some point during their career.

Prematurity and Hyperoxia Have Different Effects on Alveolar and Microvascular Lung Development in the Rabbit.

Bronchopulmonary dysplasia (BPD) is a developmental disorder of infants born prematurely, characterized by disrupted alveolarization and microvascular maturation. However, the sequence of alveolar and vascular alterations is currently not fully understood. Therefore, we used a rabbit model to evaluate alveolar and vascular development under preterm birth and hyperoxia, respectively. Pups were born by cesarean section 3 days before term and exposed for 7 days to hyperoxia (95% O2) or normoxia (21% O2). In addition, term-born rabbits were exposed to normoxia for 4 days. Rabbit lungs were fixed by vascular perfusion and prepared for stereological analysis. Normoxic preterm rabbits had a significantly lower number of alveoli than term rabbits. The number of septal capillaries was lower in preterm rabbits but less pronounced than the alveolar reduction. In hyperoxic preterm rabbits, the number of alveoli was similar to that in normoxic preterm animals; however, hyperoxia had a severe additional negative effect on the capillary number. In conclusion, preterm birth had a strong effect on alveolar development, and hyperoxia had a more pronounced effect on capillary development. The data provide a complex picture of the vascular hypothesis of BPD which rather seems to reflect the ambient oxygen concentration than the effect of premature birth.

[What do parents know of patient rights of minors in the Netherlands?] / Wat weten ouders over de patiëntenrechten van kinderen?

INTRODUCTION: In the Netherlands, medical decision-making without parental permission is allowed from the age of 16. The aim of this study was to examine parents' knowledge of this age-based framework to discover potential knowledge gaps that hinder the communication between doctors, parents, and their children. METHODS: Survey-based research was conducted to examine parents' knowledge of the age-based framework that applies to minors in Dutch healthcare. The survey was based on 5 topics: medical diagnosis and treatment, medical advice, reproductive and sexual health services, abortion, and euthanasia. The survey was sent to 1,010 Dutch parents, aged 35-55 years, with at least one child. The data were analysed using SPSS. Percentages and means were calculated. RESULTS: Parental knowledge of the age-based framework varied depending on the topic. CONCLUSION: This study provides insights into parents' current level of knowledge of the age-based framework that applies to minors in Dutch healthcare. This information is useful in the conversation between health care professional, parents, and their children.