Are we ready for universal school-based asthma screening?: An outcomes evaluation

BACKGROUND: Asthma is the most common chronic condition of childhood and a common reason for school absenteeism and use of school health services. Unrecognized but symptomatic childhood asthma may be adding to this school burden. OBJECTIVE: To evaluate the effectiveness of school-based asthma screening in identifying children at high risk for unrecognized asthma and facilitating new asthma diagnoses. METHODS: A controlled trial of school-based asthma screening using mailed parent surveys and medical record review to estimate outcomes of interest, specifically numbers of new asthma diagnoses. RESULTS: Most parents (80%, N = 5116) responded to the asthma screening survey. About 1 in 5 (19.4%, n = 994) parents reported that their children had previously been diagnosed with asthma or reactive airway disease. Letters recommending further evaluation for symptoms suggestive of possible asthma were sent to the parents of 388 children (7.6% of respondents) without known asthma. About half of parents returned postcards stating their intended reaction to the referral recommendation including 52 parents (13.4% of those referred) who thought no further action was necessary. Parent-initiated physician visits occurred in 45 (11.6%) of the 388 referred children. Overall, there were 57 (0.9%, 57/6401) new physician diagnoses of asthma among the screened children in the 6 months following screening: 16 in the referred group and 41 in the group not referred, including 20 in the group whose parents said they had known that their child had asthma, but had no medical record documentation of an asthma diagnosis. The incident asthma diagnosis rate was 1.2% (34/2906; P =.25) in a comparable control group that did not participate in screening. CONCLUSIONS: School-based asthma screening did not increase the incident rate of asthma diagnoses in this community. Parents participated in the screening process, but the percentage of referred children with follow-up medical visits was low.     

Anorectal malformations and neurospinal dysraphism: is this association a major risk for continence?

Background/purpose  

Anorectal malformations (ARM) are a spectrum of defects ranging from the very minor ones, with an excellent functional prognosis, to those that are more complex, often associated with other anomalies, difficult to manage and with a poor functional outcome. A significant number of these children suffer from fecal and urinary incontinence despite major advances in the management of ARM patients have significantly improved the quality of life. The role of sacrovertebral anomalies/dysraphism (SD) and neurospinal cord anomalies/dysraphism (ND) associated with ARM on the continence of these patients is still controversial. The authors made a review of their experience in a period of 5 years, focusing on the role of neurospinal cord anomalies in patients with ARM.     

Attention‐deficit/hyperactivity disorder: Are we medicating for social disadvantage? (Against)

The functional impairments seen in attention deficit hyperactivity disorder (ADHD) are the result of a complex interplay between biological vulnerability and environmental influences. In children with ADHD from social disadvantaged families the latter often appear to predominate. Stimulant medication is the intervention with the largest demonstrable effect size in decreasing the core symptoms of ADHD, irrespective of social context. However, medication alone will not effectively treat common comorbidities, such as oppositional behaviour, anxiety, or learning disabilities. Nor can medication be expected to diminish major family discord or psychosocial adversity. Stimulant medication is one key therapy modality in children with ADHD. Data on prescribing rates do not support the assertion that there is systematic overprescribing of stimulants in Australia. There is, however, a serious problem with access to family support and appropriate services in schools for children with ADHD. Paediatricians have a responsibility to provide evidence-based medical treatment for children with ADHD (i.e. stimulant medication), while advocating across sectors for services to enhance family resilience and function.     

Canadian medical schools’ preclerkship paediatric clinical skills curricula: How can we improve?

BackgroundLittle is known about how Canadian medical schools teach paediatric clinical skills (history and physical exam) to preclerkship students, or its cost to the institutions.MethodsClinical skills program directors from all 17 Canadian medical schools were contacted to complete a questionnaire focused on teaching methods, and barriers/strengths of their Preclerkship Paediatric Clinical Skills program.ResultsSeventeen schools (100% response rate) participated. Seven schools (41%) do not introduce paediatric clinical skills until the second year of medicine. Half of the schools (53%) dedicate <10 total hours to preclerkship paediatric clinical skills. Fifty-nine per cent have ≤6 total hours of hands-on paediatric patient interaction (real or simulated). Medical students were least likely to be exposed to the infant age group (age 1 to 24 months). Twelve schools (71%) used simulated parent/child dyads. The most significant barriers identified by programs were limited time for sessions and patient availability. We describe one sample medical school’s simulated parent/paediatric patient program where every student has hands-on learning with paediatric patients of all ages (program cost $938/student).DiscussionThis study is the first to summarize Canadian preclerkship paediatric clinical skills programs, among which there is great variability and commonly experienced barriers. Many students are not being exposed to all age groups of paediatric patients before their clerkship years. Medical schools can use this information to strengthen this important and challenging aspect of the curriculum, while being mindful of its fiscal implications.     

Attention‐deficit/hyperactivity disorder: Are we medicating for social disadvantage? (For)

The diagnosis of attention-deficit/hyperactivity disorder (ADHD) is based on well defined criteria, which describe a number of symptoms. It is important to consider the context of the symptoms, in terms of the influence of the child's family and school. Although stimulant medications benefit selected children they may not benefit all children with symptoms of ADHD. The incidence of ADHD increases with social disadvantage. There is a potential danger of using stimulant medication alone to treat children with complex psychosocial problems, associated with social disadvantage, including Aboriginal children. We desperately need better training in the management of ADHD and better access to child psychiatrists.     

Whooping cough: Are health‐care workers putting children at risk?

AIM: To explore the attitudes and knowledge of health-care workers (HCW) towards whooping cough and an adult whooping cough booster for HCW. METHODS: HCW at Fairfield Health Service, who had clinical contact with infants or children, were sent a self-administered questionnaire. RESULTS: Questionnaires were completed by 135 staff, giving a response rate of 74%. Thirty-five per cent were not known to be immunised against whooping cough. Fifty-nine per cent of doctors were known to be immunised, 33% of allied health staff and 28% of nurses. The rates of immunisation between the professional groups were significantly different (chi2 = 8.2 with 2 degrees of freedom; P = 0.017). Thirty-nine per cent of HCW did not know that primary immunisation did not provide lifelong protection. Twenty-seven per cent did not agree that HCW should be offered an adult whooping cough booster. Staff who felt at risk of contracting whooping cough were more likely to recommend that a booster should be offered (OR 2.71; 95% CI 1.22-6.04; P = 0.019). Doctors were less likely to recommend that a booster should be offered (OR 0.36; 95% CI 0.15-0.87; P = 0.028). CONCLUSIONS: HCW have low rates of immunity to whooping cough and misconceptions about whooping cough infection and immunisation. Over a quarter of HCW did not agree that a booster should be offered. An ongoing education programme addressing the attitudes and misconceptions identified in this study is a crucial component of the campaign to increase the uptake of adult whooping cough booster immunisation by HCW.     

Optimizing oxygen therapy for preterm infants at birth: Are we there yet?

Premature infants undergo a complex postnatal adaptation at birth. For last two centuries, oxygen has been integral to respiratory support of preterm infants at birth. Excess oxygen can cause oxidative stress and tissue injury. Preterm infants due to lung immaturity may need oxygen for successful transition at birth. Although, considerable progress has been made in the last 3 decades, optimum oxygen therapy for preterm delivery room resuscitation remains unknown. In this review, we discuss the history and physiology behind oxygen therapy in the delivery room, evaluate current literature, provide practice points and point out knowledge gaps of oxygen therapy in preterm infant at birth.     

Editorial: The search for core symptoms – will this help clinical decision‐making?

Diagnosis is an important component of our clinical roles, and should also lead to particular treatment pathways. The diagnostic process may be challenged by co‐occurring deficits that are neither specific nor universal to the diagnosis under consideration and may well be evident across a range of other clinical conditions. How important is it to refine our instruments so that they measure unique symptoms? Will this alter or improve intervention choices? This Editorial focuses on the extent to which fine tuning diagnostic instruments improves our decisions about treatment, in the context of articles published in this issue of JCPP.