Early life environment and social determinants of cardiac health in children with congenital heart disease.

Congenital heart disease is a significant cause of infant mortality. Epidemiology and social context play a crucial role in conditioning disease burden and modulating outcomes, while diagnosis and treatment remain resource intensive. This review will address the role of social demographics, environmental exposure, epigenetics and nutrition in the aetiology of congenital heart disease. We then discuss the determinant effect of social factors on the provision and outcomes of care for congenital heart disease and implications for practice. It is our hope that enhanced knowledge of the intersection of social determinants of health and congenital heart disease will facilitate effective preventative strategies at the individual and population levels to optimize heart health outcomes across the life course.

Identification of early childhood caries in primary care settings.

Early childhood caries (ECC) is the most common chronic disease affecting young children in Canada. ECC may lead to pain and infection, compromised general health, decreased quality of life and increased risk for dental caries in primary and permanent teeth. A multidisciplinary approach to prevent and identify dental disease is recommended by dental and medical national organizations. Young children visit primary care providers at regular intervals from an early age. These encounters provide an ideal opportunity for primary care providers to educate clients about their children's oral health and its importance for general health. We designed an office-based oral health screening guide to help primary care providers identify ECC, a dental referral form to facilitate dental care access and an oral health education resource to raise parental awareness. These resources were reviewed and trialled with a small number of primary care providers.

Social pediatrics: weaving horizontal and vertical threads through pediatric residency.

BACKGROUND: Social pediatrics teaches pediatric residents how to understand disease within their patients' social, environmental and political contexts. It's an essential component of pediatric residency training; however there is very little literature that addresses how such a broad-ranging topic can be taught effectively. The aim of this study was to determine and characterize social pediatric education in our pediatric residency training in order to identify strengths and gaps. METHODS: A social pediatrics curriculum map was developed, attending to 3 different dimensions: (1) the intended curriculum as prescribed by the Objectives of Training for Pediatrics of the Royal College of Physicians and Surgeons of Canada (RCPSC), (2) the formal curriculum defined by rotation-specific learning objectives, and (3) the informal/hidden curriculum as reflected in resident and teacher experiences and perceptions. RESULTS: Forty-one social pediatric learning objectives were extracted from the RCPSC Objectives of Training for Pediatrics, most were listed in the Medical Expert (51%) and Health Advocate competencies (24%). Almost all RCPSC social pediatric learning objectives were identified in more than one rotation and/or seminar. Adolescent Medicine (29.2%), Pediatric Ambulatory Medicine (26.2%) and Developmental Pediatrics (25%) listed the highest proportion of social pediatric learning objectives. Four (10%) RCPSC social pediatric objectives were not explicitly named within learning objectives of the formal curriculum. The informal curriculum revealed that both teachers and residents viewed social pediatrics as integral to all clinical encounters. Perceived barriers to teaching and learning of social pediatrics included time constraints, particularly in a tertiary care environment, and the value of social pediatrics relative to medical expert knowledge. CONCLUSIONS: Despite the lack of an explicit thematic presentation of social pediatric learning objectives by the Royal College and residency training program, social pediatric topics are integrated, taught and learned throughout the entire curriculum. Special attention needs to be given to the hidden curriculum and system barriers that may impede social pediatric education.

The breastfeeding paradox: Relevance for household food insecurity.

Mitigating the harmful effects of adverse social conditions is critical to promoting optimal health and development throughout the life course. Many Canadians worry over food access or struggle with household food insecurity. Public policy positions breastfeeding as a step toward eradicating poverty. Breastfeeding fulfills food security criteria by providing the infant access to sufficient, safe and nutritious food that meets dietary needs and food preferences. Unfortunately, a breastfeeding paradox exists where infants of low-income families who would most gain from the health benefits, are least likely to breastfeed. Solving household food insecurity and breastfeeding rates may be best realized at the public policy level. Notably, the health care provider's competencies as medical expert, professional, communicator and advocate are paramount. Our commentary aims to highlight the critical link between breastfeeding and household food insecurity that may provide opportunities to affect clinical practice, public policy and child health outcomes.

We need psychologists!

Paediatricians are more likely than ever to encounter patients with mental health problems on a daily basis. There is a need for investment in proven treatments, such as psychology-based interventions, for children identified with mental health disorders. There are four main arguments supporting the engagement of psychologists for children with mental health problems: there is clear evidence that psychological interventions can effectively treat a wide range of mental health disorders; many parents and children are more open to exploring psychological therapies rather than medication for mental health problems; psychologists are trained and licensed to perform psychoeducational assessments, which can provide invaluable information about a child's learning profile, attention problems and overall intelligence; and behaviour problems in children can be prevented or improved through parent-based interventions. The authors' strongly advocate for the public funding of psychology services - both in collaborative primary care models and in the school setting.

Les pédiatres sont plus susceptibles que jamais de rencontrer quotidiennement des patients qui ont des troubles de santé mentale. L'investissement dans des traitements démontrés s'impose, tels que les interventions de nature psychologique, pour les enfants chez qui on décèle ce type de troubles. Quatre grands arguments appuient l'embauche de psychologues pour les enfants ayant des troubles de santé mentale : les données probantes démontrent clairement que les interventions psychologiques peuvent traiter des troubles de santé mentale très variés, de nombreux parents et enfants sont plus ouverts à explorer des thérapies psychologiques qu'à opter pour la médication dans ce contexte, les psychologues sont formés et détiennent un permis pour effectuer des évaluations psychoéducatives, ce qui peut fournir de l'information précieuse sur le profil d'apprentissage de l'enfant, ses troubles d'attention et son intelligence globale, et il est possible de prévenir ou d'atténuer des troubles de comportement chez les enfants grâce à des interventions des parents. Les auteurs préconisent fortement le financement public de services de psychologie, tant dans le cadre de modèles de soins coopératifs de première ligne qu'en milieu scolaire.

Standard of Care in Pediatrics: Integrating Family-Centred Care and Social Determinants of Health.

In pediatric healthcare, there is a recognized need to address social determinants of health (SDOH) to positively influence child health and development. In addition, family-centred care (FCC) recognizes the value of the family unit in affecting individual patient experiences of illness and care. However, pediatric healthcare that incorporates principles of FCC and SDOH may be interpreted as calling on clinicians to deviate from or add to practices that form an accepted standard of care. This paper explores the legal and ethical considerations of doing so and describes practical responses to these challenging situations.

Food insecurity and hunger: A review of the effects on children's health and behaviour.

Food insecurity and hunger are significant problems in Canada, with millions of Canadians experiencing some level of food insecurity. The purpose of the present article is to review what is currently known about the effects of food insecurity and hunger on children. Longitudinal studies in Canada indicate that hunger is related to poor health outcomes, including a higher risk of depression and suicidal ideation in adolescents, and chronic conditions, particularly asthma. In addition, nutrient deficiencies, such as iron deficiency, are known to impair learning and cause decreased productivity in school-age children, and maternal depressive disorders. School-based nutrition programs and innovations, such as subsidized food (apples, cheese, soy nuts, carrots and broccoli), are an essential immediate need, but long-term solutions lie in adequate incomes for families.

L'insécurité alimentaire et la faim sont de graves problèmes au Canada, car des millions de Canadiens présentent un certain niveau d'insécurité alimentaire. Le présent article vise à analyser ce que l'on sait des effets de l'insécurité alimentaire et de la faim chez les enfants. D'après des études longitudinales au Canada, la faim est liée à une mauvaise santé, y compris un risque plus élevé de dépression et d'idéation suicidaire à l'adolescence, ainsi que de maladies chroniques, notamment l'asthme. En outre, on sait que les carences nutritionnelles, telles que l'anémie ferriprive, nuisent à l'apprentissage et sont responsables d'une diminution de la productivité chez les enfants d'âge scolaire, ainsi que de troubles dépressifs chez les mères. Les programmes et les innovations en milieu scolaire, comme les denrées subventionnées (pommes, fromage, noix de soja, carottes et brocoli) représentent un besoin immédiat essentiel, mais les solutions à long terme dépendent d'un revenu suffisant pour les familles.

Child poverty. Ways forward for the paediatrician: A comprehensive overview of poverty reduction strategies requiring paediatric support.

The harmful effects of child poverty are well documented. Despite this, progress in poverty reduction in Canada has been slow. A significant gap exists between what is known about eradicating poverty and its implementation. Paediatricians can play an important role in bridging this gap by understanding and advancing child poverty reduction. Establishment of a comprehensive national poverty reduction plan is essential to improving progress. The present review identifies the key components of an effective poverty reduction strategy. These elements include effective poverty screening, promoting healthy child development and readiness to learn, ensuring food and housing security, providing extended health care coverage for the uninsured and using place-based solutions and team-level interventions. Specific economic interventions are also reviewed. Addressing the social determinants of health in these ways is crucial to narrowing disparities in wealth and health so that all children in Canada reach their full potential.

Les effets néfastes de la pauvreté des enfants sont bien attestés. Pourtant, les progrès sont lents au Canada en matière de réduction de la pauvreté. Il y a un écart important entre ce que l'on sait sur l'éradication de la pauvreté et ce qui est fait. Les pédiatres peuvent jouer un rôle important pour corriger cet écart s'ils comprennent la pauvreté des enfants et font progresser les mesures de réduction. Il est essentiel de créer un plan national détaillé de réduction de la pauvreté pour améliorer ces progrès. La présente analyse présente les principaux éléments d'une stratégie efficace de réduction de la pauvreté. Ces éléments comprennent un dépistage efficace de la pauvreté, la promotion d'un développement sain de l'enfant et de la préparation à apprendre, l'assurance de la sécurité alimentaire et de la sécurité de logement, l'offre d'une couverture étendue d'assurance-maladie aux non-assurés et l'utilisation de solutions territoriales et d'interventions d'équipes. Des interventions économiques précises sont également examinées. Il est essentiel de se pencher sur les déterminants sociaux de la santé pour réduire les disparités sur le plan de la richesse et de la santé, afin que tous les enfants du Canada réalisent leur plein potentiel.

Recognizing and responding to parental mental health needs: What can we do now?

Early daily interactions in a child's life, frequent and positive, are crucial to optimal human development. The negative effects of maternal depression may include her perception of the child, the child's cognitive development and future antisocial behaviour. Emerging research investigating paternal depression is also concerning. Signs of maternal depression can be observed through either an intrusive or withdrawn maternal-infant interaction. The particular role of poverty, which affects so many Canadian families, is highlighted. Furthermore, the benefits and risks of screening for parental depression are discussed. Approaches available to the physician to address this issue using available resources are outlined.

Des interactions quotidiennes précoces fréquentes et positives dans la vie d'un enfant sont essentielles à son développement optimal. Les effets négatifs de la dépression de la mère peuvent inclure sa perception de l'enfant, le développement cognitif de l'enfant et un comportement antisocial plus tard. Des recherches émergentes sur la dépression du père sont également préoccupantes. Les signes de dépression de la mère peuvent se manifester par une interaction intrusive ou distante avec le nourrisson. Les auteurs soulignent le rôle particulier de la pauvreté, qui touche tant de familles canadiennes. Ils abordent aussi les avantages et les risques du dépistage de la dépression des parents et présentent les approches à la disposition des médecins pour sonder ce problème.

A comparative analysis of early child health and development services and outcomes in countries with different redistributive policies.

BACKGROUND: The social environment is a fundamental determinant of early child development and, in turn, early child development is a determinant of health, well-being, and learning skills across the life course. Redistributive policies aimed at reducing social inequalities, such as a welfare state and labour market policies, have shown a positive association with selected health indicators. In this study, we investigated the influence of redistributive policies specifically on the social environment of early child development in five countries with different political traditions. The objective of this analysis was to highlight similarities and differences in social and health services between the countries and their associations with other health outcomes that can inform better global early child development policies and improve early child health and development. METHODS: Four social determinants of early child development were selected to provide a cross-section of key time periods in a child's life from prenatal to kindergarten. They included: 1) prenatal care, 2) maternal leave, 3) child health care, and 4) child care and early childhood education. We searched international databases and reports (e.g. Organization for Economic Cooperation and Development, World Bank, and UNICEF) to obtain information about early child development policies, services and outcomes. RESULTS: Although a comparative analysis cannot claim causation, our analysis suggests that redistributive policies aimed at reducing social inequalities are associated with a positive influence on the social determinants of early child development. Generous redistributive policies are associated with a higher maternal leave allowance and pay and more preventive child healthcare visits. A decreasing trend in infant mortality, low birth weight rate, and under five mortality rate were observed with an increase in redistributive policies. No clear influence of redistributive policies was observed on breastfeeding and immunization rates. In the analysis of child care and early education, the lack of uniform measures of early child development outcomes was apparent. CONCLUSIONS: This paper provides further support for an association between redistributive policies and early child health and development outcomes, along with the organization of early child health and development services.

Hospital-legal partnership at Toronto Hospital for Sick Children: the first Canadian experience.

Operating a hospital-legal partnership on a pro bono basis positively impacts patients' families by providing legal assistance for non-medical issues that affect the health of their children and their ability to care for their children. This article describes a formative evaluation of the first hospital-legal partnership in Canada, established at The Hospital for Sick Children in Toronto in 2009, which was carried out through file reviews and interviews with staff, lawyers and family members. The early indications of success of this partnership suggest that its use as a template for similar programs at other Canadian healthcare institutions should be considered.

It takes a village: a realist synthesis of social pediatrics program.

OBJECTIVES: To better understand how social pediatric initiatives (SPIs) enact equitable, integrated, embedded approaches with high-needs children and families while facilitating proportionate distribution of health resources. METHODS: The realist review method incorporated the following steps: (1) identifying the review question, (2) formulating the initial theory, (3) searching for primary studies, (4) selecting and appraising study quality, (5) synthesizing relevant data and (6) refining the theory. RESULTS: Our analysis identified four consistent patterns of care that may be effective in social pediatrics: (1) horizontal partnerships based on willingness to share status and power; (2) bridged trust initiated through previously established third party relationships; (3) knowledge support increasing providers' confidence and skills for engaging community; and (4) increasing vulnerable families' self-reliance through empowerment strategies. CONCLUSIONS: This research is unique because it focused on "how" outcomes are achieved and offers insight into the knowledge, skills and philosophical orientation clinicians need to effectively deliver care in SPIs. Research insights offer guidance for organizational leaders with a mandate to address child and youth health inequities and may be applicable to other health initiatives.

Keeping caries at bay in breastfeeding babies.

As an infant grows, human milk may become the substrate for cariogenic bacteria. Here's what to watch for and how to counsel parents.

Time course of juvenile onset recurrent respiratory papillomatosis caused by human papillomavirus.

BACKGROUND: With the recent licensure of a new quadrivalent vaccine, many diseases caused by human papillomavirus (HPV) can now be prevented, including recurrent respiratory papillomatosis (RRP). The purpose of this study was to describe the burden and time course of juvenile onset RRP. METHODS: A retrospective chart review was conducted of children with airway papillomatosis at the Hospital for Sick Children in Toronto, Canada, between 1994 and 2004. Statistical methods included descriptive statistics of the cohort, a repeated events survival model, and nonlinear modeling equations to describe the time course of illness. RESULTS: Nine hundred twenty-six surgical procedures in 67 patients were identified through a review of surgical records. The median age at diagnosis was 3.2 years (range, 0.1-14.8 years) and the most common presenting symptom was hoarseness (75%). Adjuvant pharmacologic therapy (interferon or cidofovir) was used in 13 cases (19%). HPV types 6 or 11 were identified most commonly as the etiologic agent. Nonlinear modeling equations (exponential and quadratic) fit the observed data well, and were superior to linear models. Repeated events survival analysis identified significant prognostic variables: surgeon, adjuvant therapy, and anatomic score. A decision rule is presented that allows the time to next surgery to be predicted based on the previous surgery and the anatomic score. CONCLUSIONS: Most patients have a decelerating rate of debulking surgeries over time, well described by our nonlinear modeling equations. Factors affecting the time course of RRP include: inter-surgeon variability, the extent and severity of papillomas at the time of laryngoscopy, and the use of adjuvant medical therapies.

Acute childhood encephalitis and encephalopathy associated with influenza: a prospective 11-year review.

BACKGROUND: Influenza virus infection has been associated with a variety of neurologic complications. The objective of this study was to evaluate prospectively the role of influenza viruses in acute childhood encephalitis/encephalopathy (ACE). METHODS: All children admitted to the Hospital for Sick Children, Toronto, during an 11-year period with ACE and evidence of acute influenza virus infection were included. Acute influenza virus infection was defined by detection of the organism in the nasopharynx by direct immunofluorescence microscopy or viral culture and/or by a 4-fold or greater rise in complement fixation titer. RESULTS: A total of 311 children with ACE were evaluated; evidence of influenza infection was detected in 7% (22 of 311). Eight were excluded from the main analysis because of evidence implicating other potential pathogens. Eleven of the 14 included subjects were <5 years of age. A respiratory prodrome was documented in 93% of subjects. In 64% neurologic manifestations developed within 5 days of onset of respiratory symptoms. Neuroimaging abnormalities were more common in children <2 years of age. Neurologic sequelae occurred in more than one-half of subjects. CONCLUSIONS: In this prospective registry, influenza virus infection was associated with 5% of ACE cases. The majority of children were <5 years of age and the prevalence of neuroimaging abnormalities was higher in children <2 years of age suggesting that younger children are predisposed to the neurologic complications of influenza. An acute rather than a postinfectious process was suggested by the briefness of the respiratory prodrome in most cases.

Vaccine-strain varicella zoster virus causing recurrent herpes zoster in an immunocompetent 2-year-old.

Varivax III is a live attenuated vaccine against varicella zoster virus (VZV). We report a case of recurrent vaccine-strain herpes zoster in an immunocompetent 2-year-old child. Vaccine-strain VZV was identified through polymerase chain reaction. This report aims to alert physicians that recurrent vaccine-strain herpes zoster can be a rare complication of VZV vaccination in apparently immunocompetent hosts.

Social paediatrics and early child development: Part 1.

Diseases of modernism, rather than infectious diseases and chronic medical conditions, increasingly cause childhood morbidity and mortality. Thus, the goal of enhancing life outcomes for all children has become imperative. Paediatricans may begin with a renewed interest in social paediatrics - the care of the disadvantaged child in Canada, requiring a focus on all the complex factors that impact families and the community. New paediatricians need the tools to impact both social determinants of health and political policies to support health for all. Such interest is as old as the field of paediatrics (social medicine began with the great pathologist, Virchow, in the 1800s). The new neuroscience of experience-based brain and biological development has caught up with the social epidemiology literature. It is now known from both domains that a child's poor developmental and health outcomes are a product of early and ongoing socioeconomic and psychological experiences. In the era of epigenetics, it is now understood that both nature and nurture control the genome. Future paediatricians need to understand the science of experience-based brain development, and the interventions demonstrated to improve life trajectories. A challenge is to connect the traditional population health approach with traditional primary care responsibilities. New and enhanced collaborative interdisciplinary networks with, for example, public health, primary care, community resources, education and justice systems are required.

Pediatric Epstein-Barr virus-associated encephalitis: 10-year review.

Many neurologic manifestations of Epstein-Barr virus (EBV) infection have been documented, including encephalitis, aseptic meningitis, transverse myelitis, and Guillain-Barré syndrome. These manifestations can occur alone or coincidentally with the clinical picture of infectious mononucleosis. Since 1994, The Hospital for Sick Children has maintained a prospective registry of all children admitted with acute encephalitis. This report summarizes all cases of Epstein-Barr virus-associated encephalitis compiled from 1994 to 2003. Twenty-one (6%) of 216 children, median age 13 years (range 3-17 years), in the Encephalitis Registry were identified as having evidence of Epstein-Barr virus infection. This evidence consisted of convincing Epstein-Barr virus serology and/or positive cerebrospinal fluid polymerase chain reaction (PCR). One patient had symptoms of classic infectious mononucleosis; all others had a nonspecific prodrome, including fever (n = 17; 81%) and headache (n = 14; 66%). Slightly less than half (n = 10; 48%) had seizures and often had electroencephalograms showing a slow background (n = 12; 57%). Many demonstrated cerebrospinal fluid pleocytosis (n = 17; 81%), and 71% (n = 15) had abnormal magnetic resonance imaging findings. Two patients died, 2 suffered mild deficits, and 16 were neurologically normal at follow-up. Most patients with Epstein-Barr virus encephalitis do not show typical symptoms of infectious mononucleosis. Establishing a diagnosis of Epstein-Barr virus encephalitis can be difficult, and, consequently, a combination of serologic and molecular techniques should be used when investigating a child with acute encephalitis. Most children make full recoveries, but residual neurologic sequelae and even death can and do occur.