Rourke Baby Record 2000. Collaboration in action.
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Canada↗
Biomedical subjects
D G Leduc
Publications and source records attributed to D G Leduc.
Parents' versus physicians' values for clinical outcomes in young febrile children.
OBJECTIVE: To compare how parents and physicians value potential clinical outcomes in young children who have a fever but no focus of bacterial infection. METHODS: Cross-sectional study of 100 parents of well children aged 3 to 24 months, 61 parents of febrile children aged 3 to 24 months, and 56 attending staff physicians working in a children's hospital emergency department. A pretested visual analog scale was used to assess values on a 0-to-1 scale (where 0 is the value of the worst possible outcome, and 1 is the value for the best) for 22 scenarios, grouped in three categories according to severity. Based on the three or four common attributes comprising the scenarios in a given group, each respondent's value function was estimated statistically based on multiattribute utility theory. RESULTS: For outcomes in group 1 (rapidly resolving viral infection with one or more diagnostic tests), no significant group differences were observed. For outcomes in groups 2 (acute infections without long-term sequelae) and 3 (long-term sequelae of urinary tract infection or bacterial meningitis), parents of well children and parents of febrile children had values that were similar to each other but significantly lower than physicians' values for pneumonia with delayed diagnosis, false-positive diagnosis of urinary tract infection, viral meningitis, and unilateral hearing loss. For bacterial meningitis with or without delay, however, the reverse pattern was observed; physicians' values were lower than parents'. In arriving at their judgment for group 2 and 3 scenarios, parents gave significantly greater weight to attributes involving the pain and discomfort of diagnostic tests and to diagnostic error, whereas physicians gave significantly greater weight to attributes involving both short- and long-term morbidity and long-term worry and inconvenience. Parents were significantly more likely to be risk-seeking in the way they weighted the attributes comprising group 2 and 3 scenarios than physicians, ie, they were more willing to risk rare but severe morbidity to avoid the short-term adverse effects of testing. CONCLUSIONS: Parents and physicians show fundamental value differences concerning diagnostic testing, diagnostic error, and short- and long-term morbidity; these differences have important implications for diagnostic decision making in the young febrile child.
Attitude of Health Personnel↗
Risks and benefits of paracetamol antipyresis in young children with fever of presumed viral origin.
To examine whether antipyretic therapy in young children is associated with potential risks (interference with enhanced host defences at febrile temperatures) or benefits (improved comfort and behaviour), a randomised, double-blind, placebo-controlled trial of paracetamol was conducted among 225 children 6 months to 6 years of age who presented with acute (less than or equal to 4 days) fever (greater than or equal to 38 degrees C per rectum) without evident bacterial focus of infection. Parents were asked to give paracetamol liquid 10-15 mg/kg or placebo every 4 h as needed for fever and to avoid bathing, sponging, or other pharmacological agents. Parents kept temperature and symptom diaries and recorded changes in child comfort and behaviour according to a pretested, 5-category Likert-type questionnaire 1-2 h after every dose. There were no significant differences between treated and placebo groups in mean duration of subsequent fever (34.7 vs 36.1 h) or other symptoms (72.9 vs 71.7 h). Paracetamol-treated children were more likely to be rated by their parents as having at least a 1-category improvement in activity (38 vs 11%; p = 0.005) and alertness (33 vs 12%; p = 0.036) but no significant differences were noted in mood, comfort, appetite, or fluid intake. That overall improvement in behaviour and comfort with paracetamol was not impressive is underscored by the inaccuracy of parents' "guess" at the end of the trial as to which agent their child had received-45% correct guesses for paracetamol and 52% for placebo. The data suggest that the clinically relevant hazards and benefits of paracetamol antipyresis have been exaggerated.
Acetaminophen↗
Carrying as colic "therapy": a randomized controlled trial.
In healthy infants, crying behavior is reduced significantly by "supplemental" carrying; that is, increased carrying throughout the day in addition to that which occurs during feeding and in response to crying. To determine whether the recommendation to increase carrying would be effective as a therapy for colic, 66 mothers of infants 4 weeks of age or less who came to their pediatricians with complaints of crying problems ("colic") were randomized to receive standard pediatric advice (standard group) or standard advice plus the recommendation to increase supplemental carrying by 50% (supplemental group). Overall, the supplemental group carried their infants 6.1 hours/d throughout the intervention period, an increase of 2.2 hours/d (56%) more than that provided by the standard group. Despite this significant increase in carrying, there was no difference between groups in the duration or frequency of crying, fussing, or cry/fuss at any time throughout the intervention period. When the greatest treatment effect was expected at 6 weeks, the supplemental group infants cried only 3 minutes less per day (95% confidence interval: 37 minutes less to 32 minutes more per day). We conclude that, compared with standard pediatric advice to be "responsive," supplemental carrying does not reduce crying and fussing behavior further in infants who have colic. In marked contrast to healthy infants, this apparent resistance to increased carrying may indicate an important difference in state regulation and control in infants with colic.
Colic↗
Parents' vs physicians' utilities (values) for clinical outcomes in potentially bacteremic children.
Our previous analyses of decision strategies in children 3-24 months with acute-onset fever greater than or equal to 39 degrees C and no evident bacterial focus of infection indicated that the risks of routine blood cultures (the unnecessary hospitalization and treatment of children who clear their bacteremia spontaneously) outweigh its benefits (the prevention of a few cases with major infectious sequelae). Because those analyses were based on parents' values for beneficial and adverse clinical outcomes, we wished to examine whether those values differed in physicians and, if so, whether the differences were sufficient to change the results of the decision analysis. Using a pre-tested linear analog utility (value) scale, we evaluated eight potential clinical outcomes in potentially bacteremic children by surveying 121 parents of healthy 3-24-month-old children attending a private pediatric group practice and 57 attending physicians of a tertiary-care children's hospital emergency room. Utilities were based on a 0-1 normalization, where 0 is the utility of the worst outcome (meningitis or other major bacterial infection, plus venipuncture), and 1 the utility of the best outcome (complete recovery without venipuncture or hospitalization), and were analyzed using a recently developed statistical model of utility. The majority of parents and physicians combined the imputed components of the outcomes (disease, pain of venipuncture, and stress of hospitalization) in a nonlinear fashion. Parents assigned substantially lower utility (i.e. greater disutility) to venipuncture, minor infection, and hospitalization than did physicians, and these utilities were even lower in parents with other children at home.(ABSTRACT TRUNCATED AT 250 WORDS)
Attitude of Health Personnel↗
Frequency, severity and risk factors for adverse drug reactions in adult out-patients: a prospective study.
To provide information on the frequency of adverse drug reactions in ambulatory patients we used intensive telephone surveillance to detect suspected reactions in 1026 patients seen at an internal medicine group practice over a 1-year period. Two hundred and ninety-two suspected reactions were detected. The majority of suspected reactions were mild, causing predominantly worry or discomfort. We used a published algorithm to assess the suspected reactions for drug causation with the following results: 40 (14%) unlikely; 193 (66%) possible; 56 (19%) probable; and 3 (1%) definite. The rate of probable or definite reactions was 49/1026 (5%) per patient and 58/3330 (2%) per drug course. Surprisingly, neither the age of the patient nor the number of other drugs he was taking modified the risk of a reaction to an individual newly-started drug. Our data suggest that fear of adverse reaction should not usually be a major factor in therapeutic decision making for an ambulatory patient even when the patient is old or already on multiple drugs.
Adolescent↗
Adverse drug reactions in general pediatric outpatients.
We used a recently developed diagnostic adverse drug reaction (ADR) algorithm and an intensive telephone surveillance program to monitor all courses of prescription and nonprescription drug therapy in a general pediatric group practice for 1 year. A total of 3181 different children visited the practice during the year and received 4244 separate courses of drug therapy. Adverse symptoms were noted in 473 (11.1%) of these courses of therapy. Of 534 total adverse symptoms, however, only 24 scored as definite and 176 as probable ADRs. The main ADRs noted were antibiotic-associated gastrointestinal complaints and rashes, and various manifestations of CNS stimulation with bronchodilators. Sociodemographic variables significantly associated with the risk of a definite or probable ADR were socioeconomic status (P less than 0.0001), ethnic origin (P = 0.0015), and age (P less than 0.05). Treatment-related risk factors included treatment by a practitioner outside the study practice (usually during nonoffice hours) (P less than 0.001) and administration of a dosage above the range recommended by the manufacturer (P less than 0.001). Half the ADRs were judged as inconsequential by the children's parents, and most of the remainder resulted in only minor morbidity. Half were judged to be highly or probably preventable. Our results suggest that ADRs do not occur commonly in general pediatric outpatients and that most are mild and self-limited.
Adolescent↗
Determinants of weight and adiposity in the first year of life.
To overcome methodologic defects (failure to control for confounding factors, univariate statistical analyses) in previous studies of etiologic determinants of childhood adiposity, we carried out a prospective cohort study of 462 healthy, full-term infants observed from birth to 12 months. Postpartum, we obtained sociodemographic data and administered two recently validated scales of maternal attitudes toward feeding and infant body habitus. Parental heights and weights and infant feeding variables were determined by interview, and at 6 and 12 months we measured height and weight and triceps, subscapular, and suprailiac skinfolds. Multiple regression analysis was used to determine independently predictive factors for weight, body mass index (BMI = weight/height), and the sum of the three skinfold measurements. Birth weight, sex, age at introduction of solid, and duration of breast-feeding were all significant predictors of weight at 12 months (r2 = 0.296, P less than 0.0001). Significant determinants for BMI included birth weight, duration of breast-feeding, sex, and IBH (r2 = 0.125, P less than 0.0001); those for total skinfold were age at introduction of solid foods and birth weight (r2 = 0.038, P = 0.002). Similar results were obtained at 6 months, although slightly less of the variance was explained. We conclude that the ability to predict which babies will be heavy or obese during the first year is limited. Breast-feeding and delayed introduction of solid foods do offer some protective effect, however, and thus efforts to encourage these practices may be reaping some benefit.
Adult↗
Infant determinants of childhood weight and adiposity.
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Aging↗
Antibiotic-associated gastrointestinal symptoms in general pediatric outpatients.
As part of an intensive program of surveillance for adverse drug reactions in general pediatric outpatients, 2,714 courses of oral antibiotic therapy were monitored for the occurrence of gastrointestinal (GI) adverse drug reactions. Using a recently developed algorithm to establish a causal link between drugs and adverse symptoms, the risks of diarrheal or upper GI tract adverse drug reactions were found to vary considerably with different antimicrobial agents and, for several agents, according to the administered dosage. For diarrhea, the risk was lowest with sulfasoxazole and trimethoprim/sulfamethoxazole and was highest with cloxacillin. A significant dose-response effect was found with both amoxicillin and trimethoprim/sulfamethoxazole. For upper GI tract adverse drug reactions, the risk was again lowest with sulfasoxazole and trimethoprim/sulfamethoxazole and was highest with erythromycin. Knowledge of the risks of gastrointestinal adverse drug reactions with different agents and different doses should be clinically helpful in assessing risks and benefits when oral antibiotics are prescribed for children.
Ambulatory Care↗
Effect of formula supplementation in the hospital on the duration of breast-feeding: a controlled clinical trial.
To avoid methodologic pitfalls in previous observational studies linking formula supplementation in the hospital to early discontinuation of breast-feeding, a controlled clinical trial of restricted supplementation was conducted. In a pretrial sample of 621 newborns, a comparison of two "well-baby" nurseries found no differences in either hospital supplementation practices or the proportion of infants still being breast-fed at 4 or 9 weeks postpartum. Restriction of supplementation in one of the nurseries for the trial period (n = 781) did not result in higher breast-feeding rates at 4 or 9 weeks. There was, however, a slightly greater mean percent of birth weight lost in the restricted group (6.0% v 5.1%; P less than .001). In examining the control group for evidence of an "observational" association, it was found that infants still breast-feeding at 4 or 9 weeks were far more likely to have been unsupplemented than those no longer being breast-fed. It thus appears that formula supplementation in the hospital is a marker, rather than a cause, of breast-feeding difficulty.
Adult↗
Parental fever phobia and its correlates.
Parents of 202 young febrile children were surveyed about their knowledge, attitudes, and fears concerning fever and its treatment. Forty-eight percent of the parents considered temperatures less than 38.0 degrees C to be "fevers", 43% felt that temperatures less than 40.0 degrees C could be dangerous to a child, 21% favored treatment for fevers less than 38.0 degrees C, and 15% believed that, left untreated, temperature could rise to 42.0 degrees C or higher. Fifty-three percent advocated waking a febrile child at night to administer antipyretic therapy. Young age of the child was associated with a preference for use of acetaminophen over aspirin and, unexpectedly, with a higher parental threshold for consideration of fever. The higher their child's temperature at the time they were questioned, the higher the minimum temperature that parents considered a cause for concern. Surprisingly, higher socioeconomic status was not associated with a lesser degree of fever phobia. In fact, parents of higher socioeconomic status were more concerned about the risks of brain damage or seizures as sequelae of fever than were parents of lower socioeconomic status. It is concluded that undue fear and overly aggressive treatment of fever are epidemic among parents of infants and young children, even among the highly educated and well-to-do. Considerable effort will be required on the part of pediatricians and other child health workers to reeducate these parents about the definition, consequences, and appropriate treatment of fever.
Attitude to Health↗
Maternal psychological determinants of infant obesity. Development and testing of two new instruments.
We have developed and tested two instruments to measure psychological factors that may affect infant feeding and thus "confound" the relationship between feeding and subsequent obesity. The Maternal Preconceptions of Ideal Infant Body Habitus (IBH) consists of 4 drawings of 9-month-olds exhibiting a range of body habiti from quite lean to very chubby; new mothers are asked to rank the 4 in order of preference for their new baby. The Maternal Feeding Attitudes (MFA) ia a 10-item questionnaire addressing the new mother's food "pushiness". Both the IBH and the MFA produced high test-retest intraclass correlation coefficients (RI's): 0.92 and 0.95, respectively. Significant inverse correlations were found between the IBH and both maternal age (r = -0.38; p = 0.004) and the Green SES index (r = -0.28; p = 0.025), indicating that older, higher-SES mothers prefer leaner infants. Breast-feeding mothers had significantly lower mean IBH scores than did formula-feeding mothers (p = 0.029). The MFA, by contrast, was not associated with any of these variables. We conclude that maternal adiposity preference and feeding attitudes can be reliably measured. Owing to their possible associations with infant obesity and its determinants, we suggest that these factors be included in future studies in this domain.
Adult↗
Pediatricians and general practitioners: a comparison of the management of children with febrile illness.
To assess the relative competence of pediatricians and general practitioners in managing febrile illnesses in childhood, a prospective study was undertaken of 259 children less than 10 years of age seen consecutively at the emergency room of a children's hospital and a general hospital. Both groups of patients were similar in demographic characteristics, age, sex, presenting complaints, and height and duration of fever. Of the 148 patients entered in the study at children's hospital and the 111 at general hospital, 90% and 94%, respectively, were interviewed by telephone within two weeks of their emergency room visit to determine outcomes based on duration of the acute illness episode and further physician contacts or admissions to hospital. Although no significant differences in the measured outcomes of febrile illnesses seen by pediatricians or general practitioners were found, a trend in favor of those cared for by pediatricians was discernible with respect to two key measures: unresolved symptoms at one week (8.3% vs 12.5%) and subsequent hospitalization (0.8% vs 3.0%). The overall frequency of laboratory use and antibiotic prescriptions was the same in both groups; however, significant differences were noted in the type of laboratory test used: general practitioners ordered three times more roentgenograms than pediatricians and one fifth the number of microbiologic tests. Larger prospective studies are needed to test how these findings may be generalized in view of their importance for quality assurance in the primary care of children.
Anti-Bacterial Agents↗
Determinants of weight and adiposity in early childhood.
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Body Weight↗