Adverse childhood experiences: Basics for the paediatrician

In 1998, the Centers for Disease Control and Prevention Adverse Childhood Experiences study established the profound effects of early childhood adversity on life course health. The burden of cumulative adversities can affect gene expression, immune system development and condition stress response. A scientific framework provides explanation for numerous childhood and adult health problems and high-risk behaviours that originate in early life. In our review, we discuss adverse childhood experiences, toxic stress, the neurobiological basis and multigenerational and epigenetic transmission of trauma and recognized health implications. Further, we outline building resilience, screening in the clinical setting, primary care interventions, applying trauma-informed care and future directions. We foresee that enhancing knowledge of the far-reaching effects of adverse childhood events will facilitate mitigation of toxic stress, promote child and family resilience and optimize life course health trajectories.

Literacy promotion by health care professionals: A comprehensive biomedical and psychosocial approach

Literacy is the ability to read, write and understand print. Proficiency in literacy is fundamental to social inclusion and strongly linked to health outcomes. Thus, improving literacy is important for lifelong health promotion. Poverty, inadequate hearing, speech and vision and learning disabilities may challenge literacy development. In our review, we explore these topics and suggest recommendations to: Mitigate the Effects of Poverty, Access Comprehensive Medical Assessments, Promote Early Childhood Education and Advocate for Early Intervention and Remediation Programs.

Three hundred babies born to underhoused mothers in Toronto-understanding the problem and how we can help

Little is known about pregnancy in underhoused women, possibly because the number of underhoused mothers with babies in Toronto has been significantly underestimated. Using a novel data collection method, it has been found that there are approximately 300 babies being born each year to underhoused women in Toronto. This finding has significant public health implications, as these women are at increased risk of multiple issues related to physical health, mental health, child protection, poverty and safety. This commentary presents a new data collection strategy, highlights the importance of accurate data collection and offers suggestions for supports for this over-looked population.

The paediatrician and middle childhood parenting

The 'forgotten years' of middle childhood, from age 6 to 12, represent a critical period in child development. Emotional, social and physical development during this time have a lifelong impact on health and adult contributions to society. Mental health conditions have displaced physical illness as the leading childhood disability. Positive parenting can improve child behaviour, prevent early-onset conduct problems and provide a buffer from adverse childhood events resulting in decreased toxic stress and improved health. Medical homes can play a key role in supporting parents with positive parenting skills that are practical, evidence-based and useful in everyday life. Paediatricians need to explore the domains that promote healthy development, including caring environments, fundamental needs and nurturing relationships. Our objective is to promote high-quality positive parenting through middle childhood by identifying opportunities for paediatricians to frame parenting discussions in the context of development, behaviour and safety and to provide access to valuable parenting resources.

The First Step to Helping: Asking About Poverty

BACKGROUND: Canadian children living in poverty are more likely to experience poor health outcomes. Physicians have a unique opportunity to screen for poverty and other social determinants of health (SDOH) in order to intervene early and change their patients' health trajectories. It is well known in the literature to date that addressing SDOH in clinical practice can improve health outcomes, however, significant barriers have been identified that limit a physician’s ability to address these issues. The Child Poverty Assessment Tool (CPAT) was developed by an inter-professional team of physicians, social workers and community child health agency partners to provide healthcare providers with screening questions for the SDOH and resources to address identified SDOH needs. The tool was created to support physicians with links to the community and simple screening approaches to common social issues.

OBJECTIVES: To develop an understanding of physicians' current SDOH screening practices and attitudes to screening for the SDOH in clinical practice; To explore the feasibility, accessibility, and relevance of the CPAT for paediatricians at an academic health science centre.

DESIGN/METHODS: Using a qualitative grounded theory approach, seven consultant academic paediatricians were individually interviewed. The interviews were conducted using a semi-structured interview guide, and were digitally recorded and transcribed verbatim. Two team members independently coded the transcripts for recurrent themes. This project was undertaken as a Quality Improvement project and was conducted with appropriate ethical approval.

RESULTS: Three major themes emerged regarding benefits of screening for SDOH: improved assessment of social issues, increased referrals to community supports and agencies, and appropriate modifications to treatment plans as informed by social issues. In addition to limiting billing models and time constraints, five major themes were identified as challenges to screening for SDOH: lack of knowledge of resources, upsetting family expectations, the physician’s own comfort in asking questions regarding the SDOH, the biomedical model of training, and physicians' understanding of their scope of practice. The CPAT was found to address some, but not all of these challenges.

CONCLUSION: The results from the project elucidated important factors that influence the SDOH screening practices of paediatricians. While a structured tool (i.e. the CPAT) may provide support to physicians conducting screening, systemic and medical cultural barriers exist. Further research is needed to examine the effectiveness of implementing screening tools in clinical practice, and to identify solutions for systemic barriers to screening for poverty in paediatric populations.

Poverty and pediatric palliative care: what can we do?

It has been recognized that families of children with life-limiting health conditions struggle with significant financial demands, yet may not have awareness of resources available to them. Additionally, health care providers may not be aware of the socioeconomic needs of families they care for. This article describes a mixed-methods study examining the content validity and utility for health care providers of a poverty screening tool and companion resource guide for the pediatric palliative care population. The study found high relevance and validity of the tool. Significant barriers to implementing the screening tool in clinical practice were described by participants, including: concerns regarding time required, roles and responsibilities, and discomfort in asking about income. Implications for practice and suggestions for improving the tool are discussed. Screening and attention to the social determinants of health lie within the scope of practice of all health care providers. Social workers can play a leadership role in this work.

Fatal late onset group B streptococcal meningitis following maternal postpartum sepsis

Although maternal screening and the administration of prophylactic intrapartum antibiotics have decreased the incidence of early onset group B streptococcal (GBS) disease in neonates, there is still significant morbidity and mortality as a result of neonatal GBS disease.Maternal GBS infections are not uncommon, but with appropriate therapy there is almost a uniformly good outcome. Little is written about the appropriate management of well infants born to mothers with postpartum GBS sepsis.The question of whether well infants born to mothers with GBS puerperal sepsis should be treated empirically with antibiotics and the lack of literature concerning this issue became apparent when an untreated term infant died of late onset GBS meningitis following maternal puerperal GBS sepsis. We describe this event in the following case presentation.With the current paucity of literature regarding the management of well infants born to mothers with postpartum GBS sepsis, it seems prudent to treat such infants empirically with antibiotics (following a full septic work-up) until this matter has been investigated further.

Social paediatrics and early child development - the practical enhancements: Part 2

Parents have central and critical influence in the health, learning and development of their young children. The physician plays a key role in supporting this role of parents, and there are practical health interventions that practitioners can promote in everyday practice that are coherent with the population-based evidence related to childhood outcomes. Four child development enhancers are recognized - emotional awareness, reading books, appropriate discipline and preschool programs including appropriate play opportunities. The child's physician can give clear messages about why each enhancer is important and what parents can do to use them to create nurturing environments for their children. The present article provides the evidence for these interventions and a series of coordinated physician activities that will enhance the early learning opportunities of the first few years of life, for improved trajectories for health and well being.

Active tuberculosis among adolescents in toronto, Canada: clinical features and delays in diagnosis

There are few studies on tuberculosis (TB) in adolescents. During a 6-year period, 23 adolescents were treated for TB in our center. Most were foreign born. The average time from symptom onset to final diagnosis was 5.2 months. Multifocal and extra pulmonary disease occurred in the majority of patients. Clinicians need greater awareness of the unique features of adolescent TB.

Congenital cytomegalovirus infection. Is there a breakthrough?

QUESTION

My 26-year-old patient is planning her first pregnancy in the coming month. She works in a day-care centre. Recently, two cases of cytomegalovirus (CMV) infection were diagnosed in her class. What tests should she have before and during the pregnancy, and how should I care for her?

ANSWER

Cytomegalovirus infection, the most common congenital viral infection in humans, carries high risk of long-term morbidity and mortality. Seronegative mothers of children in day-care centres are at as high risk of acquiring the infection as day-care workers themselves. The immune status of at-risk patients should be evaluated as pregnancy progresses. Evidence of fetal infection does not necessarily mean fetal disease or damage. With a primary-infected fetus, termination of pregnancy might be discussed with the parents.

Congenital rubella syndrome. How can we do better?

QUESTIONMy 22-year-old patient immigrated to Canada 6 years ago from a country where there are no routine immunizations. She is now at 10 weeks' gestation and was exposed to a child with rubella infection. Her immune status is unknown. Should I give her passive or active immunization? How should I follow her pregnancy? And what should I tell her about the risk for her fetus?ANSWERIf the exposure took place less than 1 week ago, blood should be sent for rubella antibody titre. If results are positive for IgG, she is immune and there is no risk for the fetus. If a patient's immune status is unknown and the time of exposure is uncertain, serum samples for rubella antibodies should be obtained 3 weeks apart. Detection of rubella-specific IgM in a sample will confirm recent infection. Your patient should be counseled about the potential risk for her fetus and referred to high-risk pregnancy clinic for follow up. If seroconversion does not take place, she requires immunization immediately postpartum before discharge from hospital.

Cost of chickenpox in Canada: part I. Cost of uncomplicated cases

OBJECTIVE

The purpose of this study was to assess the direct medical costs and productivity losses associated with uncomplicated chickenpox (no hospitalization) in Canada.

METHODS

A total of 179 otherwise healthy 1- to 9-year-old children with active chickenpox were recruited from schools, day care centers, and physician offices in 5 provinces. Direct medical (physician contacts, medication, and diagnostic tests) and nonmedical (personal expenses including child care) resources expended during the illness were determined by caregiver interview. Productivity losses attributable to the disease were determined by assessing caregiver time lost from work and daily activities. Unit costs for all resources were obtained from sources in 2 provinces, and per-patient treatment costs were determined from the patient, Ministry of Health, and societal perspectives.

RESULTS

From a societal perspective, the per-case cost for children from 1 to 4 years of age and from 5 to 9 years of age was $370.2 and $236.5, respectively. Direct medical costs accounted for 10% of the total costs in both groups. The largest cost driver in patient care was caregiver productivity losses, which amounted to $316.5 in the younger age group and to $182.7 in the older age group. Based on an estimated yearly incidence of 344 656 cases of uncomplicated chickenpox in Canada, the total annual societal burden of the disease can be estimated at $109.2 million, with a cost to the Ministry of Health of $11.2 million.

CONCLUSION

Chickenpox is one of the last common childhood diseases prevalent in Canada, and the uncomplicated disease, despite its rather benign course, imparts a large annual economic burden.

Cost of chickenpox in Canada: part II. Cost of complicated cases and total economic impact. The Immunization Monitoring Program-Active (IMPACT)

OBJECTIVE

Primarily, to determine the direct medical costs and productivity losses associated with complicated chickenpox (hospitalized cases) and, secondarily, to quantify the overall economic burden of chickenpox in Canada.

METHODS

Direct medical resource consumption patterns were determined by chart review of 160 otherwise healthy children and 40 children with leukemia hospitalized for chickenpox. Children were selected from the database of the Immunization Monitoring Program Active (IMPACT), a network of 11 tertiary-care hospitals in Canada that collected information at the time of hospitalization from January 1991 to March 1996. An additional 26 healthy children hospitalized were recruited prospectively by IMPACT. Productivity losses (time lost from work and daily activities) were assessed by caregiver interviews. Treatment costs were determined from the patient, Ministry of Health, and societal perspectives.

RESULTS

The average societal per case cost for complicated chickenpox in healthy children was $7060 and $8398, respectively, from the retrospective and prospective assessments. For children with leukemia, the direct medical cost was estimated at $7228. These costs were combined with a cost established previously for uncomplicated chickenpox. The estimated yearly overall economic impact of chickenpox in Canada was $122.4 million, with $24.0 million attributable to Ministry of Health costs, assuming an estimated yearly incidence of 346 527 cases and a 0.54% rate of hospitalization for healthy children.

CONCLUSIONS

Direct medical costs are the major cost driver in the care of complicated chickenpox. However, in the context of the overall economic burden of the disease, uncomplicated chickenpox is the major cost driver, contributing 89% to the total cost.

The morbidity and mortality of pediatric splenectomy: does prophylaxis make a difference?

PURPOSE

The aim of this study was to analyze the incidence of postsplenectomy sepsis morbidity and mortality after prophylaxis, in comparison with our previous 13-year study (1958 to 1970, inclusive).

METHODS

All patients who had splenectomy at the Hospital for Sick Children, Toronto, between 1971 and 1995, inclusive (to give a minimum of 2 years for follow-up), were reviewed for infection and mortality. The criterion for classifying a patient as "infected" was the recovery of an invading encapsulated organism from the blood culture in a patient admitted to the hospital.

RESULTS

Of the 264 patients studied, 10 had a postsplenectomy infection (3.8%); nine occurred in patients who underwent splenectomy between the ages of 0 and 5 years. Infection took place within 2 +/- 3 years (mean +/- SD) after splenectomy for the immunized patients and 11 +/- 5 days (mean +/- SD) for the nonimmunized children. A significant number of patients were admitted for an apparent respiratory infection, but no serum organisms were isolated. One died of overwhelming sepsis, but the responsible organism was not identified.

CONCLUSION

Although there has not been a decrease in the number of splenectomies performed per year, the incidence of infection and mortality has decreased by 47% and 88%, respectively, with prophylaxis.

Nosocomial infection following cardiovascular surgery: comparison of two periods, 1987 vs. 1992

OBJECTIVE

To evaluate whether changes have occurred at our center in the rate of nosocomial infections and in the infectious organisms consequent to changes in policy and procedure as of 1987.

SETTING

Multidisciplinary pediatric intensive care unit (PICU) in a major tertiary care center.

DESIGN

Prospective comparative study.

PATIENTS

Four-hundred and fifty-five consecutive patients who underwent cardiac surgery within a 10-month period.

INTERVENTIONS

Changes related to antibiotic use and invasive device management were introduced after the 1987 survey. To determine the effect of these changes, all patients undergoing cardiac surgery between July 1991 and April 1992 were followed daily from PICU admission to 2 months after hospital discharge for signs of infection. Each infectious episode was reviewed by the nosocomial infection control committee. A weighted scoring system was used to determine risk.

MEASUREMENTS AND MAIN RESULTS

In the 1987 study, 40 of 310 patients had 78 infections for a nosocomial infection ratio (NIR) of 25.2. Of the 455 patients surveyed in 1992, 72 had 91 episodes of infection. The nosocomially infected patient rate was 15.8 and the NIR was 20. The frequency of wound infection decreased from 7% in 1987 to 4.3% in this study, and no episode of mediastinitis was observed. In the bacteriological spectrum, the absence of candidal infection was significant, and there was a decrease in the proportional frequency of pseudomonas infection from 21% to 15%.

CONCLUSION

The comparison between the two time periods demonstrates that an aggressive approach to managing intravascular catheters and urinary catheters and limiting the use of antibiotics probably affects the spectrum of nosocomial infections.

How long should someone wait after CMV infection to start pregnancy?

QUESTION

One of my patients contracted a primary cytomegalovirus (CMV) infection. What is the recommended waiting time between primary CMV infection and conception, and which tests are valid for determining whether infectivity is over?

ANSWER

Although no data on the proper waiting period between primary CMV infection and conception are available, we suggest waiting until CMV-specific immunoglobulin G antibodies are present (at least 6 months).

Pseudobacteremia due to Pseudomonas fluorescens

Pseudomonas fluorescens was recovered from 62 of 22,270 (0.26%) blood cultures, from 57 patients, over a 22-month period at a pediatric hospital. No illness was attributable to the blood culture isolate. A case-control study identified a significant correlation between the recovery of P. fluorescens in blood culture and concomitant coagulation studies (p less than 0.0001). In all cases blood for coagulation studies had been obtained at the same time as the blood culture. A review of venipuncture technique revealed that occasionally the coagulation study tubes (containing 3.8% sodium citrate) were being inoculated before blood culture bottles. P. fluorescens was subsequently isolated from coagulation tubes and from sodium citrate solutions prepared and dispensed in the hospital for use in coagulation studies. In vitro studies confirmed that sodium citrate solutions supported the growth of P. fluorescens, with preferential growth at 25 degrees C and 4 degrees C. This is the first description of P. fluorescens as a cause of pseudobacteremia. Pseudobacteremia was attributed to cross-contamination of blood cultures following inoculation of contaminated citrated collection tubes.

Q fever: hazard from sheep used in research

The recent recognition that Q fever is endemic in Ontario and the known occupational risk of Q fever to research personnel working with sheep prompted a study to determine the prevalence of antibodies to the causative organism, Coxiella burnetti, in animals and staff at a Toronto animal research institute. Of 37 sheep 34 (92%) were found to be seropositive--that is, to have a titre of complement-fixing antibody to the phase II antigen of 1:8 or greater. Of 331 staff members tested, 18% were found to be seropositive, compared with 0.6% of a random sample of Toronto blood donors. The highest rate of seropositivity, 68%, was in the 28 animal attendants tested. Seropositivity was associated with working with sheep or fetal lamb tissue (p less than 0.0001) and with visiting the animal facility (p less than 0.001). Of the 59 seropositive staff members 63% had had no direct contact with sheep. There were 12 clinically apparent cases of Q fever, 2 of which required admission to hospital. Q fever remains a serious occupational hazard to staff working in research laboratories using sheep, even to those with indirect exposure to infected animals.

The management of central intravenous catheter infections

Catheter-associated infection is a frequent complication in patients with indwelling intravenous catheters used for administration of total parenteral nutrition and/or cancer chemotherapy. Thirty-seven catheter-associated infections in 19 patients were identified in our retrospective survey conducted for the period from January 1, 1982, through December 31, 1982. Fourteen patients were receiving total parenteral nutrition for gastrointestinal disorders, and five were receiving total parenteral nutrition and chemotherapy for underlying malignancy. Coagulase-negative staphylococci were isolated from 65% of catheter-associated bacteremias, as a single species (18 cases) or as one of multiple species (6 cases). Ten of 33 coagulase-negative staphylococcal isolates (30%) were methicillin-resistant. Twenty-one infections (57%) were initially treated with antibiotics administered through the central venous catheter. There were three failures with this treatment; in two cases the catheter was removed because of continued fever and positive blood cultures despite antibiotics, and one patient developed a pyogenic granuloma. The remaining 18 (86%) catheter-associated infections were cured without catheter removal. However, a new infection occurred subsequently in two of these patients. We recommend that vancomycin and an aminoglycoside be the initial empiric therapy for suspected catheter-associated sepsis. Lack of defervescence or continued positive blood cultures for 2 to 4 days despite antibiotics are indications for catheter removal. Otherwise antibiotics should be continued for 14 to 21 days.

Health spa whirlpools: a source of Pseudomonas folliculitis

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