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The field of pediatrics in Europe is characterized by the diversities, variations, and heterogeneities of child health care services provided in 53 European countries with more than 200 million children below 18 years of age. Managing the health care of infants, children, and adolescents in Europe requires balancing clinical aims, research findings, and socioeconomic goals within a typical environment characterized by cultural and economic complexity and large disparity in availability, affordability, and accessibility of pediatric care. Since its foundation in 1976, the European Paediatric Association-Union of National European Paediatric Societies and Associations has worked to improve both medical care of all children and cooperation of their caretakers in Europe. Such a report has been conceived in the strong belief that broadening of the intellectual basis of the European Paediatric Association-Union of National European Paediatric Societies and Associations and creating a multidisciplinary society will be necessary to reduce fragmentation of pediatrics and tackle the legal, economic, and organizational challenges of child health care in Europe. [ABSTRACT FROM AUTHOR]

Background: We aimed to determine the knowledge and attitudes of Turkish pediatricians concerning vitamin D supplement., Methods: The study was planned cross-sectional to be carried out between April-May 2015 in Turkey. A questionnaire form that determined the participants' opinions and practices concerning vitamin D supplement was completed via face-to-face interview., Results: A total of 107 pediatricians (49.3%) and 110 pediatric residents (50.7%) participated in the study. Of the physicians, 85.2% recommended vitamin D supplement for all infants and children regardless of diet, 13.4% recommended for the infants which are solely breastfed. Vitamin D supplement is recommended at a dose of 400 IU/day by 88.8% of pediatricians and by 90% of pediatric residents. Of the pediatricians and pediatric residents, 72% and 68.2%, respectively commence vitamin D supplement when the newborn is 15 days old. The rates of recommending vitamin D supplement until the age of one and two years were higher among pediatricians (48.6% and 41.1%, respectively) than pediatric residents (40.9% and 32.7%, respectively). The rate of starting vitamin D supplement for fontanelle closure was significantly higher among pediatric residents (15.5%) than pediatricians (3.7%) (p = 0.002). It was determined that the rate of prescribing vitamin D supplement until fontanelle closure was higher among pediatric residents (18.2%) than pediatricians (0.9%)., Conclusions: The present study suggest that the knowledge of pediatricians about recommendation of vitamin D needs to be enhanced by education programs in addition to free vitamin D supplement provided by the Ministry of Health.

Correct use of a child safety seat (CSS) can reduce the risk of fatal motor vehicle crash-related injury by up to 71%; however, misuse rates for CSS are as high as 70%. We recruited 189 caregivers at 2 large suburban pediatric office practices; 94 in the intervention group and 95 in the control group. All participants completed a baseline survey and received a CSS safety brochure. Intervention participants had their CSS installation checked at enrollment by a certified child passenger safety (CPS) technician. Follow-up was conducted 4 months post enrollment. Intervention group participants had a 21.3% reduction in critical misuse at follow-up, whereas control participants critical misuse rate at follow-up was identical to the intervention group at baseline. A consult with a certified CPS technician, at the time of a routine visit to the pediatrician, resulted in a reduction in CSS misuse rates.

Background: Few studies have investigated pediatrician attitudes about providing primary medical care for children with special health care needs. The objective of this study was to determine pediatrician perspectives on their comfort level in providing care and on where the medical home should be for children with chronic medical and developmental conditions., Methods: Survey of pediatricians in California in 2014. Pediatricians were randomized to receive surveys featuring either a case of a child with a chronic medical (neurofibromatosis) or a developmental condition (autism). They were then asked about their comfort level in providing primary care for the child. We developed logistic regression models to adjust for practice and provider factors, and availability of family social resources., Results: The survey response rate was 50.2%. Primary care pediatricians expressed more comfort than nonprimary care pediatricians in providing a medical home for a child with chronic medical or developmental condition (range, 84%-92% comfortable vs 58%-79% comfortable), respectively. All pediatricians expressed more comfort providing care for a child with autism than neurofibromatosis. Nearly all primary care pediatricians (90%) believed that the medical home should be in pediatric primary care practice. Pediatrician comfort in becoming a medical home was higher when the family had more social resources., Conclusions: Most pediatricians endorse that the medical home for children with special health care needs be in the primary care setting. Improving access to subspecialty care and providing resources, such as case management, to address family social complexity might raise pediatrician comfort in providing primary care to children with medical and developmental conditions., (Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Although pediatric asthma continues to be a highly studied disease, data to suggest clear strategies to decrease asthma related revisits or readmissions is lacking. The purpose of our study was to assess the effect of emergency department (ED) direct dispensing of beta-agonist metered dose inhalers on pediatric asthma ED revisit and readmission rates., Methods: We conducted a retrospective cohort study of pediatric patients discharged from the pediatric ED with a diagnosis of asthma. Our primary outcome measured the rate of asthma revisits to the ED or admissions to the hospital within 28 days. Logistic regression analysis was used to assess ED beta-agonist MDI dispensing and revisit and/or readmission as the outcome., Results: A total of 853 patients met eligibility for inclusion in the study, with 657 enrolled in the Baseline group and 196 enrolled in the ED-MDI group. The Baseline group experienced a revisit and readmission rate of 7.0% (46/657) versus 2.6% (5/196) in the ED-MDI group, (p = 0.026). ED direct dispensing of MDIs was found to be independently associated with a decreased risk of revisit or readmission (odds ratio 0.37; 95% confidence interval 0.14-0.95)., Conclusions: In our study, ED direct dispensing of beta-agonist MDIs resulted in a reduction in 28-day revisit and readmission to the hospital. Further studies should be performed to evaluate the economic impact of reducing these revisits and readmissions against the costs of maintaining a dispensing program. Our findings may support modification of asthma programs to include dispensing MDIs from the emergency department.

Objective: To evaluate the potential impact of a concussion management education program on community-practicing pediatricians., Study Design: We prospectively surveyed 210 pediatricians before and 18 months after participation in an evidence-based, concussion education program. Pediatricians were part of a network of 38 clinically integrated practices in metro-Atlanta. Participation was mandatory for at least 1 pediatrician in each practice. We assessed pediatricians' self-reported concussion knowledge, use of guidelines, and comfort level, as well as self-reported referral patterns for computed tomography (CT) and/or emergency department (ED) evaluation of children who sustained concussion., Results: Based on responses from 120 pediatricians participating in the 2 surveys and intervention (response rate, 57.1%), the program had significant positive effects from pre- to postintervention on knowledge of concussions (-0.26 to 0.56 on -3 to +1 scale; P < .001), guideline use (0.73-.06 on 0-6 scale; P < .01), and comfort level in managing concussions (3.76-4.16 on 1-5 scale; P < .01). Posteducation, pediatricians were significantly less likely to self-report referral for CT (1.64-1.07; P < .001) and CT/ED (4.73-3.97; P < .01), but not ED referral alone (3.07-3.09; P = ns)., Conclusions: Adoption of a multifaceted, evidence-based, education program translated into a positive modification of self-reported practice behavior for youth concussion case management. Given the surging demand for community-based youth concussion care, this program can serve as a model for improving the quality of pediatric concussion management., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Context: Palliative sedation is a means of relieving intractable symptoms at the end of life, however, guidelines about its use lack consistency. In addition, ethical concerns persist around the practice. There are reports of palliative sedation in the pediatric literature, which highlight various institutional perspectives., Objectives: This survey of 4786 pediatric providers sought to describe their knowledge of and current practices around pediatric palliative sedation., Methods: Our survey was administered to pediatricians who care for children at the end of life. The survey assessed agreement with a definition of palliative sedation, as well as thoughts about its alignment with aggressive symptom management. Bivariate analyses using χ 2 and analysis of variance were calculated to determine the relationship between responses to closed-ended questions. Open-ended responses were thematically coded by the investigators and reviewed for agreement., Results: Nearly half (48.6%) of the respondents indicated that the stated definition of palliative sedation "completely" reflected their own views. Respondents were split when asked if they viewed any difference between palliative sedation and aggressive symptom management: Yes (46%) versus No (54%). Open-ended responses revealed specifics about the nature of variation in interpretation., Conclusions: Responses point to ambiguity surrounding the concept of palliative sedation. Pediatricians were concerned with a decreased level of consciousness as the goal of palliative sedation. Respondents were split on whether they view palliative sedation as a distinct entity or as one broad continuum of care, equivalent to aggressive symptom management. Institutional-based policies are essential to clarify acceptable practice, enable open communication, and promote further research.

Previous research has demonstrated high satisfaction and perceived relevance of Project DOCC (Delivery of Chronic Care), a parent led curriculum in developmental disabilities, across a sample of medical residents., Aims: The influence of such a training program on the clinical practices and professional activities of these residents once they are established in their careers as physicians, however, has not been studied; this was the aim of the present study., Methods: An anonymous follow-up survey was designed and disseminated to physicians who participated in Project DOCC during their one-month developmental disabilities rotation as part of their pediatrics or medicine/pediatric residency between 2002 and 2010. Fifty-eight physicians completed the survey., Results: The findings suggest that participation in a parent led curriculum during medical residency had a lasting impact on physicians' relationships with families. Specifically, a majority of the physicians espoused a family-centered approach to care, a sensitivity to the interactional effect that caring for a Child with Special Health Care Needs (CSHCN) has on family members, the need for physicians to have a prominent role in community resource coordination, and the importance of an integrated approach to health care provision., Conclusions: Use of a parent led curriculum as a means to increase the provision of family-centered care by physicians is supported., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background & Aims: Functional constipation (FC) is a common childhood problem often related to pelvic floor muscle dysfunction. We compared the effectiveness of pelvic physiotherapy (PPT) vs standard medical care (SMC) in children with FC., Methods: We performed a multicenter randomized controlled trial of 53 children (age, 5-16 y) with FC according to the Rome III criteria, at hospitals in The Netherlands from December 2009 to May 2014. Group allocation was concealed using a central computer system. SMC consisted of education, toilet training, and laxatives (n = 26), whereas PPT included SMC plus specific physiotherapeutic interventions (n = 27). Results were obtained from written reports from the subjects' pediatricians and parents. The primary outcome was absence of FC, according to Rome III criteria, after a 6-month follow-up period. Secondary outcomes were global perceived effect (range, 1-9; success was defined as a score ≥ 8), numeric rating scales assessing quality of life (parent and child; scale, 1-10), and the strengths and difficulties questionnaire (SDQ)., Results: Treatment was effective for 92.3% of the children receiving PPT and for 63.0% of the children receiving SMC (adjusted odds ratio for success of PPT, 11.7; 95% confidence interval, 1.8-78.3) (P = .011). Significantly more children undergoing PPT stopped using laxatives (adjusted odds ratio, 6.5; 95% confidence interval, 1.6-26.4) (P = .009). Treatment success (based on global perceived effect) was achieved for 88.5% of subjects receiving PPT vs 33.3% of subjects receiving SMC) (P < .001). PPT also produced larger adjusted mean differences, before vs after treatment, in numeric rating scales to assess quality of life: an increase of 1.8 points for parents (P = .047) and 2.0 points for children (P = .028). Results from the SDQ did not differ significantly between groups (P = .78)., Conclusions: In a randomized controlled trial of children with FC, PPT was more effective than SMC on all outcomes measured, with the exception of findings from the SDQ. PPT should be considered as a treatment option for FC in children 5-16 years old. Dutch Clinical Trial Registration no: NL30551.068.09., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Pediatricians have an important role in early identification and prevention of oral health, but they reported lack of knowledge in this field., Aim: the aim of the study is to evaluate the knowledge and attitudes of Lebanese pediatricians regarding children's oral health., Materials and Methods: A cross sectional study including 100 Lebanese pediatricians was performed. They answered 21 questions. Three variables were taken into consideration: The number of years in practice, the place and type of practice., Results: 73.6% of pediatricians with more than 5 years in practice, 63.5% of pediatricians with an exclusive private practice and 74.7% of pediatricians working in cities/big villages believe that a child is able to brush properly his teeth before the age of 5 years. Only 27.6% of pediatricians with more than 5 years in practice, or working in cities/big villages and 12.7% of those having an exclusive private practice admit that white and black spots are signs of affected teeth., Discussion: Majority of our pediatricians reported that bottle feeding is associated with early childhood caries. They do not believe that the maternal milk can harm the baby's teeth. Concerning the transmission from mother to child of the bacteria responsible for dental caries, the reported percentages were not statistically different in relation to pediatricians' years of experience, type and place of practice. Pediatricians who are academically affiliated were more likely to report that fluoride is safe compared to those practicing in the private sector (P = 0,012). The majority believe that there is a relation between systematic manifestation such as fever and eruption of primary teeth., Conclusion: The Lebanese pediatricians have an acceptable level of knowledge in children's oral health, but should be better informed and motivated toward dental and oral issues., How to Cite This Article: Nassif N, Noueiri B, Bacho R, Kassak K. Awareness of Lebanese Pediatricians regarding Children's Oral Health. Int J Clin Pediatr Dent 2017;10(1):82-88., Competing Interests: Source of support: Nil Conflict of interest: None

Objective: To assess the knowledge, attitude, and practice of pediatricians regarding pediatric liquid medicaments (PLMs) and its effect on dental health., Materials and Methods: A convenience sample of 103 pediatricians was asked to answer a questionnaire., Results: A total number of 87 pediatricians completed the questionnaires. They considered age and body weight of the child (58%), cost of the medicine (40%), and pharmaceutical company (37%) to be relevant while prescribing. Eighty-eight percent of pediatricians knew that the PLM was sweet in nature. Sixty-seven percent of pediatricians stated that pH of PLM is responsible for deleterious effect on teeth. Seventy-two percent of pediatricians were aware of hidden sugars present in PLM. Only 48% of pediatricians were aware of availability of sugar-free medicine. Seventy percent of pediatricians were of the opinion that sugar-free medicine is not as sweet as sugar-containing medicines and is more expensive (65%)., Conclusion: Knowledge, attitude, and practice of pediatricians regarding PLMs and its effect on dental health were not satisfactory., Competing Interests: There are no conflicts of interest.

Background: Of the available treatment options for attention-deficit/hyperactivity disorder (ADHD), the use of medications remains the most controversial and it is often difficult for parents to make decisions about treatment. Provision of relevant, reliable information about treatment during consultations may help address parents' concerns about treatment options. Question prompt lists are structured lists of disease and treatment-specific questions intended for use by patients during consultations to encourage communication with clinicians. They may prove useful in empowering parents to ask questions during consultations and to make informed decisions about treatments for ADHD., Objectives: To evaluate the acceptability and usefulness of a question prompt list (QPL) for attention-deficit/hyperactivity disorder (ADHD) during consultations between parents of diagnosed children and their pediatricians., Methods: Parents of children recently diagnosed with ADHD (n = 17) received a copy of the QPL 7 days before their child's appointment and completed questionnaires before and after their consultations to elicit: satisfaction with the consultation and QPL; situational anxiety levels; achievement of decision-making and information preferences. Pediatricians (n = 3) completed questionnaires after each consultation to determine the impact of the QPL on consultation flow and to ascertain their willingness to incorporate the QPL into their practice., Results: All parents reported that the QPL helped them to ask more questions, was easy to understand and would be useful to them in future. After receiving the QPL and seeing the pediatrician, parents' anxiety decreased significantly. All described their decision-making roles as 'just right' and were satisfied with the information obtained during their consultations. All pediatricians agreed that the QPL was helpful for parents, made communication easier, and helped parents to initiate discussion about difficult topics. The QPL was not found to impede flow of the consultation. All agreed QPL provision was feasible as part of routine clinical care., Conclusions: The QPL received strong support from parents and pediatricians and may be a useful tool in facilitating communication and shared decision-making in this setting. The findings warrant further investigation in a larger randomized controlled study., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Rheumatology laboratory tests are often inappropriately ordered in situations for which they are of low diagnostic utility. We surveyed pediatricians to investigate reasons for ordering these tests. The response rate was 15.3% (93/609). The most commonly ordered tests were antinuclear antibody (ANA), anti-double-stranded DNA (dsDNA) antibody, and rheumatoid factor (RF). Of the 89% (83/93) who ordered an ANA, 86% ordered it for correct/possibly correct reasons; of the 73% (68/93) who ordered RF, 80% did so for correct/possibly correct reasons; and among the 59% (54/92) who had ordered anti-dsDNA antibody, 34% ordered it for correct reasons. A positive relationship was seen between years since residency completion and correct use of ANA. However, positive associations were not seen between measures of pediatric rheumatology experience and correct use of other tests. Interventions are needed to improve pediatricians' utilization of rheumatology tests.

This study was conducted to survey US pediatric specialists about administration of respiratory syncytial virus (RSV) immunoprophylaxis, communication patterns among physicians and parents, and barriers to access. Separate surveys were sent to neonatologists, pediatricians, pediatric pulmonologists, and pediatric cardiologists. Most physicians (≥93.5%) routinely recommended immunoprophylaxis to high-risk children. Most respondents (≥71.8%) reported that >50.0% of eligible infants and young children received each monthly dose throughout the RSV season, with the first dose most commonly administered before discharge from the birth hospitalization. To ensure receipt of subsequent doses, specialists frequently scheduled a follow-up visit at the end of the current appointment. All specialists reported insurance denials as the biggest obstacle to the administration of immunoprophylaxis to high-risk children. These findings may be used to improve adherence to immunoprophylaxis by enhancing education and physician-parent communications about severe RSV disease prevention, and by reducing known barriers to use of this preventive therapy., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Pierre Wong has served on a medical advisory board for AstraZeneca. Joseph Domachowske has received grants and consulting fees from AstraZeneca. Deborah Friedman has served on the speakers’ bureau and advisory board for and has received travel expenses from MedImmune/AstraZeneca. Michael Marcus has served on the speakers’ bureau for MedImmune. Iqra Syed’s and Shelagh Szabo’s employer, ICON plc, was paid for services related to the study design and data analysis of this study. William La Via, Kimmie McLaurin, and Veena Kumar are employees of AstraZeneca and may hold stock or stock options. Prabhu Parimi and Daniel Garcia have no conflicts of interest to disclose., (© The Author(s) 2016.)

Objective: To analyze the perception of pediatric guidelines by mothers at the time of consultation in private offices, in order to know how they assimilate, process and use the information received from the pediatricians., Methods: Data collection was carried out by a questionnaire sent to participants by A total of 200 mothers from a virtual community in social networks participated in the research. The answers were transcribed using the Discourse of the Collective Subject method. The analyses were supported by the research qualitative perspective, from the viewpoint of the social representation theory., Results: Three categories were obtained through data analysis: (1) assessing the pediatric guidelines (2) confronting theory and practice and (3) developing a critical view of the pediatric guidelines. These categories have elucidated that the level of knowledge of pediatric issues by mothers and their ability to use them when making decisions about the care of their babies, have a direct association between following or not the pediatric guidelines., Conclusions: The mother's decision on following the pediatrician's recommendations depends on two main factors: (a) certification of the updated and proven recommendations, according to the official health agencies; (b) support and recognition by the pediatrician of the maternal empowerment during the follow-up process. The mothers' practice of accessing knowledge through social networks hinders the pediatric monitoring., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2015 Sociedade de Pediatria de São Paulo. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background: Secondhand smoke (SHS) exposure of children due to parental tobacco use is a particularly prevalent health issue and is associated with adverse health outcomes. Following the US Clinical Practice guidelines, pediatricians in the United States deliver 5A's (ask, advise, assess, assist, and arrange) counseling to smoking parents which has proven to be effective. We examined Chinese pediatricians' adherence to the clinical practice guidelines for smoking cessation (i.e. 5A's counseling practices) with smoking parents, and identified factors associated with these practices., Methods: A cross-sectional paper-and-pencil survey of pediatricians was conducted in twelve conveniently selected southern Chinese hospitals. Factors associated with any of the 5A's smoking cessation counseling practices were identified by logistic regression., Results: Of respondents (504/550), only 26 % routinely provided 5A's smoking cessation counseling to smoking parents. More than 80 % of pediatricians didn't receive formal training in smoking cessation and had not read China smoking cessation guidelines; 24 % reported being "very confident" in discussing smoking or SHS reduction with parents. Pediatricians who had never smoked (OR: 2.29, CI:1.02-5.12), received training in smoking cessation (OR: 2.50, CI:1.40-4.48), had read China smoking cessation guidelines (OR: 2.17, CI:1.10-4.26), and felt very (OR: 7.12, CI:2.45-20.70) or somewhat (OR: 3.05, CI:1.11-8.37) confident in delivering cessation counseling were more likely to practice 5A's. Pediatricians who reported "it is hard to find a time to talk with parents" (OR: 0.32, CI: 0.11-0.92) or "lack of a standard of care requiring pediatricians to provide smoking cessation or SHS exposure reduction intervention" (OR: 0.45, CI: 0.21-0.98) as a barrier were less likely to follow the 5A's guidelines., Conclusions: Smoking cessation counseling to address parental smoking is infrequent among Chinese pediatricians. There is a need to develop and test intervention strategies to improve the delivery of 5A's smoking cessation counseling to parental smokers.

This study was conducted to assess the perception of US pediatric specialists of respiratory syncytial virus (RSV) disease risk and determine their clinical practices regarding immunoprophylaxis for high-risk children. Separate surveys were sent to neonatologists, pediatricians, pediatric pulmonologists, and pediatric cardiologists. Data were collected using structured questions requiring quantitative responses. Most neonatologists and pediatricians (>82.7%) reported a high clinical need for RSV immunoprophylaxis in preterm infants <32 weeks' gestational age. Pediatric pulmonologists and pediatric cardiologists suggested that health conditions indicative of chronic lung disease of prematurity and hemodynamically significant congenital heart disease, respectively, confer eligibility for RSV immunoprophylaxis. Agreement with the changes in the 2014 American Academy of Pediatrics guidance for RSV immunoprophylaxis was mixed among respondents from the 4 specialties. Survey findings may provide a basis to improve education about risk for severe RSV disease and evaluate changes in physician use of RSV immunoprophylaxis based on the 2014 guidance., (© The Author(s) 2015.)

Objective: The etonogestrel (ENG) contraceptive implant is the most effective reversible contraceptive method. Uptake remains limited in adolescents, a population at high risk for unintended pregnancy. The objectives of this study were to determine the 12-month discontinuation rate of the ENG implant among adolescents in an outpatient setting and to characterize risk factors for discontinuation., Study Design: A retrospective chart review identified adolescent females aged 12 to 22years who received the ENG implant in one pediatric institution between January 1, 2011, and April 15, 2014. Patients were categorized into ENG discontinuers (removed prior to 12months) and ENG continuers (continued for ≥12months). Associations between demographic, clinical and postplacement characteristics with ENG discontinuation category were assessed with t tests, χ(2)/Fisher's Exact Tests and backwards stepwise logistic regression., Results: Of the 750 patients who had an ENG implant inserted, 77 (10.3%) had the device removed prior to 12months of use. The mean length of implant use for those who discontinued was 7.5months. Problematic bleeding was the most commonly cited reason for discontinuation. Older age at time of insertion, history of pregnancy and ≥1 medical visit for implant concerns (not including removal) were independently predictive (p<.01) of method discontinuation., Conclusion: The vast majority of adolescents continued the ENG implant at 12months, making it an excellent contraceptive choice for adolescents within the outpatient pediatric setting. Greater efforts should be made to increase its use by pediatric providers., Implications: The ENG implant is an excellent contraceptive option for adolescents in the outpatient pediatric setting., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Annamaria Staiano and Erasmo Miele speak to Francesca Lake, Managing Editor: Following the presentation of the results from an Italian trial on the treatment of infantile colic through the combination of herbal agents and probiotics, Annamaria Staiano (Professor of Paediatrics) and Erasmo Miele (Assistant Professor of Paediatrics; both Naples University, Italy) discuss childhood gastrointestinal disorders. With an introduction to the topic written by Staiano, Miele proceeds to further discuss the topic., Competing Interests: Financial & competing interests disclosure A Staiano and E Miele have received a grant from DMK baby exclusively for a speech during the 7th European Pediatric GI Motility Meeting (October 2015, Naples, Italy). In that context they were asked to participate in an interview to publish in an international journal. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.

This case series study evaluated the feasibility and acceptability of a behavioral/cognitive psychological intervention in a pediatric primary health care setting during standard well-baby visits. The aim of the intervention was to support caregivers' sensitivity and mentalization in order to promote infant mental health (IMH). Four neonates from birth to 8 months were consecutively enrolled to test a short video-feedback intervention (Primary Care - Video Intervention Therapy, an adaptation of George Downing's Video Intervention Therapy to primary care) conducted by a pediatrician. The 5 min interaction recording and the video-feedback session were performed during the same well-baby visit and in the same pediatrician's office where the physical examination was conducted. During the study period, six video-feedback sessions were performed for each baby at different ages (1, 2, 3, 4, 6, 8 months). A series of different interactional situations were filmed and discussed: touch, cry, affective matching, descriptive language, feeding, separation and autonomy. The intervention was easily accepted and much appreciated by all four families enrolled. This study aimed to answer a dilemma which pediatric providers generally face: if the provider wishes to respond not only to physical but also IMH issues, how on a practical level can this be done? This case series study indicates that Primary Care - Video Intervention Therapy can be a promising new tool for such a purpose.

Pediatricians must recognize and respond to adolescents with social skills deficits because they are at heightened risk for mental health disorders, peer victimization, and social isolation. The aim of this project was to describe a group of adolescent children at the time of enrollment into social skills treatment. Ninety participants with neurodevelopmental weaknesses or disorders, to include high-functioning autism spectrum disorder, participated. Results showed that adolescents referred for social skills deficits had communication weaknesses and concerns in everyday social reciprocal behavior. They rarely hosted get-togethers with same-aged peers and were not often invited by same-aged peers to get-togethers. Twenty-nine percent of participants reported that they were victims of bullying, and more than half of participants reported clinically significant ostracism experiences. Results are discussed in terms of the pediatrician's role in the prevention, identification, and treatment of social skills deficits in light of recent research showing brain neuroplasticity extending into adolescence., (© The Author(s) 2015.)

Background: Telehealth offers strategies to improve access to subspecialty care for children in rural communities. Rural pediatrician experiences and preferences regarding the use of these telehealth strategies for children's subspecialty care needs are not known. We elicited rural pediatrician experiences and preferences regarding different pediatric subspecialty telehealth strategies., Materials and Methods: Seventeen semistructured telephone interviews were conducted with rural pediatricians from 17 states within the United States. Interviewees were recruited by e-mails to a pediatric rural health listserv and to rural pediatricians identified through snowball sampling. Themes were identified through thematic analysis of interview transcripts. Institutional Review Board approval was obtained., Results: Rural pediatricians identified several telehealth strategies to improve access to subspecialty care, including physician access hotlines, remote electronic medical record access, electronic messaging systems, live video telemedicine, and telehealth triage systems. Rural pediatricians provided recommendations for optimizing the utility of each of these strategies based on their experiences with different systems. Rural pediatricians preferred specific telehealth strategies for specific clinical contexts, resulting in a proposed framework describing the complementary role of different telehealth strategies for pediatric subspecialty care. Finally, rural pediatricians identified additional benefits associated with the use of telehealth strategies and described a desire for telehealth systems that enhanced (rather than replaced) personal relationships between rural pediatricians and subspecialists., Conclusions: Rural pediatricians described complementary roles for different subspecialty care telehealth strategies. Additionally, rural pediatricians provided recommendations for optimizing individual telehealth strategies. Input from rural pediatricians will be crucial for optimizing specific telehealth strategies and designing effective telehealth systems.

Background: Pediatricians are physicians trained to provide comprehensive nonsurgical health care for children, but parents may consult other specialists when seeking medical help for their children. This study was designed to analyze the role of pediatricians and the changes in the patterns of ambulatory visits among different specialties for children under the age of 18 years in Taiwan during the past 13 years., Methods: Data on ambulatory visits of children aged 0-17 years from 1999 to 2011 were retrieved from the National Health Insurance Research Database. The physician's specialty, level of the hospital, year of visit, age of the patient, and diagnoses of each ambulatory visit were analyzed. Four of the most commonly visited specialties-pediatrics, otolaryngology, family medicine, and internal medicine-were compared. The yearly trend of ambulatory visits to different specialties, difference in various age groups, influence of hospital levels, and the top 10 diagnoses were analyzed., Results: A total of 1,618,033 ambulatory visits were identified and enrolled into our study. A comparison of the proportions of ambulatory visits between 1999-2003 and 2007-2011 showed that the proportions of visits increased from 27.1 ± 1.3% to 35.4 ± 1.0% for pediatricians, decreased from 32.8 ± 1.8% to 17.0 ± 0.8% for family physicians, and did not change for otolaryngologists and internal medicine physicians. Specifically, pediatricians were visited more often if the children were younger, or if the health-care facility (level of hospital) was either a medical center or a regional hospital. Upper respiratory tract infection was the top diagnosis, followed by acute bronchitis, and acute and chronic tonsillitis., Conclusions: The role of pediatricians in children's ambulatory care increased in importance from 1999 to 2011 in Taiwan. However, approximately two thirds of children sought ambulatory medical help from nonpediatric physicians. Thus, it is important to educate and encourage parents to visit pediatricians if their children require medical help., (Copyright © 2014. Published by Elsevier B.V.)

Background: The aim of this study was to assess the effectiveness of professional training in bereavement care., Method: We mailed a questionnaire to 554 Japanese pediatricians. It asked about demographic characteristics, personal support experiences, professional training, psychological distress, recognition of high risk after a child's death, and eight items relating to awareness in bereavement care. We divided the subjects into two groups based on the presence or absence of professional training and compared them on the basis of each item (χ(2) test), and conducted logistic regression analysis., Results: Of the 239 respondents, 193 (80.8%) had performed bereavement care. The final number included in the analysis was 175, after excluding responses with missing data. A total of 46 respondents (26.3%) had attended bereavement care training. The subjects who had had training were more likely to recognize those at high risk for poor psychological recovery, have information about support groups, have a desire to study bereavement care, and understand the necessity of cooperation with mental health specialists., Conclusion: Many pediatricians had personally provided support for the bereaved. On logistic analysis, it was considered that four factors (recognition of high risk for poor recovery, information about support, desire to study, and cooperation with professionals) were significantly associated with the professional training. There were no significant differences, however, in psychological distress, helplessness, and fatigue. Training programs related to stress management must be improved for pediatricians who feel high levels of psychological distress., (© 2015 Japan Pediatric Society.)

Background: Secondhand Smoke (SHS) exposure is a leading cause of childhood illness and premature death. Pediatricians play an important role in helping parents to quit smoking and reducing children's SHS exposure. This study examined Chinese pediatricians' attitudes and practices regarding children's exposure to SHS and clinical efforts against SHS exposure., Methods: A cross-sectional survey of pediatricians was conducted in thirteen conveniently selected hospitals in southern China, during September to December 2013. Five hundred and four pediatricians completed self-administered questionnaires with a response rate of 92%. χ² tests were used to compare categorical variables differences between smokers and non-smokers and other categorical variables., Results: Pediatricians thought that the key barriers to encouraging parents to quit smoking were: lack of professional training (94%), lack of time (84%), resistance to discussions about smoking (77%). 94% of the pediatricians agreed that smoking in enclosed public places should be prohibited and more than 70% agreed that smoking should not be allowed in any indoor places and in cars. Most of the pediatricians thought that their current knowledge on helping people to quit smoking and SHS exposure reduction counseling was insufficient., Conclusions: Many Chinese pediatricians did not have adequate knowledge about smoking and SHS, and many lacked confidence about giving cessation or SHS exposure reduction counseling to smoking parents. Lack of professional training and time were the most important barriers to help parents quit smoking among the Chinese pediatricians. Intensified efforts are called for to provide the necessary professional training and increase pediatricians' participation in the training.

Numerous malformations can affect the anterior part of the neck presenting at birth as a real diagnostic challenge for the pediatrician or the primary care physician who initially evaluate the baby. Congenital midline cervical cleft represents a rare defect of the midline neck, which is sometimes wrongly diagnosed as a thyroglossal duct anomaly, dermoid cyst, branchial cleft anomaly or "birthmark". A prompt clinical diagnosis and surgical treatment during early infancy are essential to ensure both functional and aesthetic outcome. We report a case of a female neonate with a midline cervical cleft diagnosed immediately after birth. The main features of other congenital anomalies of the anterior neck are also discussed referring to their embryologic origin., (© 2014 Japanese Teratology Society.)

Background: Pediatricians play an important role in promoting smoking cessation among the parents of young children as more behavioral counseling and cessation treatment are made available in the Chinese healthcare system. However, beliefs about the effectiveness of these interventions can influence pediatricians' recommendations to their patients. This study examined pediatricians' beliefs regarding effectiveness of counseling and medications for smoking cessation., Methods: A cross-sectional survey of pediatricians was conducted in thirteen conveniently selected southern Chinese hospitals, during September to December 2013. A self-administered questionnaire was used for data collection. We used chi square tests and multinomial logistic regression analysis to identify factors associated with beliefs regarding effectiveness of counseling and medications for smoking cessation., Results: Beliefs of the respondents (504/550; 92% response rate) were divided regarding the effectiveness of counseling and medications for smoking cessation. Sixty percent believed that physician counseling is effective for smoking cessation; 53% believed pharmacological products (or medications) are effective. Factors that were associated with positive beliefs towards the effectiveness of counseling included: believing about the professional responsibility to discuss smoking cessation, being confident in discussing smoking cessation or SHS exposure reduction with patients' parents, believing that health professionals should routinely ask about their patients smoking habits, believing that health professionals should routinely advise their smoking patients to quit smoking, possessing adequate knowledge in quitting smoking, and being able to assess smokers different stages of readiness to quit. Most of the above factors were also associated with the belief that medication is effective for smoking cessation., Conclusions: A substantial proportion of Chinese pediatricians believed that cessation counseling and medications are not effective, which is not supported by current evidence in the field. Several factors including individual, practice level and health system level characteristics were associated with their belief. Training efforts are needed to influence pediatricians' beliefs regarding the effectiveness of cessation counseling and medications.

This study aimed to evaluate the attitude of pediatricians toward the use of complementary and Traditional Medicine (TM) on children in Muscat, Oman. A cross-sectional survey was performed using a self-completed questionnaire during the year 2012. A total of 67 pediatricians, comprising of 30 males (44.8%) and 37 females (55.2%) participated in the study. The majority of the studied group (83.5%) was of the opinion that most types of complementary and TM are not safe for children, except spiritual healing, to which 53.7% considered as safe. About one third (29.9%) of the participants reported that they might recommend complementary and TM for sick children in the future. Almost half the participants (52.2%) acknowledged personal use of complementary and TM in the past and 67.2% reported that their family members used these medicines. Herbal therapy was found to be the most commonly used method (38.9%) followed by spiritual (33.9%), cautery (20.2%) and Curucoma (15.7%). Other methods, which include; acupuncture, bone healing and Chinese healing were also found to be in use but in rare manner. Knowledge level of TM and complementary medicine of most of the doctors was found to be low but one third of them acknowledged that they may recommend these treatments to their patients in future. Therefore, training pediatricians on the types, benefits and side effects of complementary and TM is recommended.

Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health., (Copyright © 2014 by the American Academy of Pediatrics.)

Objective: This study was intended to assess the knowledge, attitude and practice of pediatricians and pharmacists about sugar free medications (SFMs) and their impact on oral health., Materials and Methods: Self-administered close ended questionnaire was handed out to all pediatricians and pharmacists in five tertiary hospitals in Riyadh (King Khalid University Hospital, King Saud Medical City, King Fahad Medical City, Prince Sultan Medical Military City, Security Forces Hospital) to investigate the knowledge, attitude and practice concerning SFMs., Results: Eighty-five pediatricians and 77 pharmacists participated in this study. The results showed that pediatricians and pharmacists have a good knowledge, but negative attitude toward SFMs. Only (5.9%) of pediatricians had formal undergraduate training which is significantly lower than pharmacists (15.6%) (p = 0.04). One-third of pediatricans and pharmacists prescribe or dispense SFMs. The most influencing factors toward prescription (pediatrician) of SFMs was the medical status of the patient (70.6%), while the most influencing factor of dispensing (pharmacists) SFMs was the availability in the pharmacy (64.9%). Two-third of pediatricians (67%) guide the parents about the risk associated with sugar-containing medications (SCMs) which is significantly higher than pharmacists (p < 0.0001). Also, 53% of pediatricians recommend oral hygiene instructions when prescribing SCMs which is also significantly higher than pharmacists (p = 0.0 02)., Conclusion: There is a considerable knowledge about SFMs and its impact on dental caries, among pediatricians and pharmacists participated in this study. However, their attitude toward prescribing or dispensing SFMs was not positive and may be linked to the gap in knowledge. Further training and education of healthcare providers regarding the use of SFMs and its negative impact on dental caries has to be reiterated.

Background: Professional guidelines and state Medicaid policies encourage pediatricians to provide oral health screening, anticipatory guidance, and fluoride varnish application to young patients. Because oral health activities are becoming more common in medical offices, the objective of this study was to assess pediatricians' attitudes and practices related to oral health and examine changes since 2008., Methods: As part of the 2012 Periodic Survey of Fellows, a random sample of 1638 members of the American Academy of Pediatrics was surveyed on their participation in oral health promotion activities. Univariate statistics were used to examine pediatricians' attitudes, practices, and barriers related to screening, risk assessment, counseling, and topical fluoride application among patients from birth to 3 years of age. Bivariate statistics were used to examine changes since 2008., Results: Analyses were limited to 402 pediatricians who provided preventive care (51% of all respondents). Most respondents supported providing oral health activities in medical offices, but fewer reported engaging in these activities with most patients. Significantly more respondents agreed they should apply fluoride varnish (2008, 19%; 2012, 41%), but only 7% report doing so with >75% of patients. Although significantly more respondents reported receiving oral health training, limited time, lack of training and billing remain barriers to delivering these services., Conclusions: Pediatricians continue to have widespread support for, but less direct involvement with oral health activities in clinical practice. Existing methods of training should be examined to identify methods effective at increasing pediatricians' participation in oral health activities., (Published by Elsevier Inc.)

Objective: Assessment of asthma control in children by physicians, patients and their parents was compared, assuming parents may underestimate symptoms in asthmatic children and exploring whether physicians tend to agree with them., Design: Asthma control perception was assessed in 4- to 11-year-old asthmatic children and their parents, using C-ACT, during 2011-2012. Pediatric pulmonologists used GINA guidelines for their assessment; pediatricians, not having spirometry, used the information given in addition to physical examination. The C-ACT scores given by the children and their parents were further analyzed separately, and compared with their physicians' assessment. Statistical methods, which also measured possible influence of different variables, included kappa, Chi-square, linear-by-linear association, McNemar test and logistic regression., Patient Selection: The study comprised 354 parents and children aged 4-11 years with moderate-severe asthma; 129 (36.4%) were treated by 23 pediatricians; 225 (63.6%) by 11 pediatric pulmonologists., Results: The C-ACT was generally found valid in assessing asthma control (P < 0.001; κ 0.529; CI 0.441, 0.617) and showed that in 229/354 (53%) of children the asthma was uncontrolled. Nevertheless, of the 229 children who indicated their asthma was uncontrolled, 124 (54.1%) of their parents (κ 0.245; CI 0.15, 0.34) and 96 (41.9%) of their physicians believed it to be controlled (κ 0.331; 0.24, 0.43). Comparing the physician-child discordance vis-à-vis the parents, the significant difference was when 96/229 children (41.9%) and 34/126 parents (27.0%) indicated the asthma was uncontrolled while the physician determined it controlled (OR 1.95; 1.19, 3.24). There were no significant differences between pediatric pulmonologists and pediatricians., Conclusions: In addition to increasing awareness of parents to symptoms in their asthmatic children, physicians should question the child appropriately, as well as using the children's responses to C-ACT as an information source for properly assessing asthma control., (© 2013 Wiley Periodicals, Inc.)

Objectives: In 2013, the American Academy of Pediatrics published a policy statement calling for pediatricians to be informed about the need for specific pediatric medical necessity language because children deserve "the intent embedded in Medicaid." This study aims to explore the definitions and determinations of medical necessity in Medicaid Managed Care (MMC), document the relevant language used throughout Medicaid, and investigate whether the federal standard of medical necessity for children is replicated in related state documents., Methods: We conducted a desk review of state statutes, model MMC contracts, and 2 provider manuals per state, for 33 states with a full-risk MMC model., Results: The federal "to correct and ameliorate" standard was replicated in 100% of state regulations, 72% of MMC model contracts (n = 13 of 18 MMC model contracts available online), and 54% of provider manuals (n = 30 of 56 available and sampled online). Only 9 states had an explicit "preventive" pediatric medical necessity standard in their state regulations that exemplified "the intent imbedded in Medicaid.", Conclusions: The federal medical necessity standard for children is not replicated consistently within MMC programs from the state, to health plans, to network providers. Although the majority of the documents reviewed included the standard, the presence of the standard decreased by almost half between state-level and network-provider-level regulations. Having a single, explicitly defined pediatric medical necessity definition replicated at all levels of the health system would reduce confusion and increase the ability of pediatricians to apply the standard more uniformly., (Copyright © 2014 by the American Academy of Pediatrics.)

The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report., (Copyright © 2014 by the American Academy of Pediatrics.)

The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have collaborated to identify practices and principles to guide the care of children, families, and staff in the challenging and uncommon event of the death of a child in the emergency department in this policy statement and in an accompanying technical report., (Copyright © 2014 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.)

Background: No information exists on how the knowledge or the practice of pediatricians regarding anaphylaxis episodes vary with episode severity. The aim of this study was to assess and compare pediatrician knowledge on the management of mild and severe anaphylaxis using clinical scenarios and to determine factors that affect their decisions., Methods: A questionnaire consisting of eight questions on the diagnosis and management of anaphylaxis was distributed at two national congresses. A uniform answer box including possible response choices was given below each question, and respondents were asked to check the answers that they thought appropriate. The management of mild and severe anaphylaxis was examined using two clinical case scenarios involving initial treatment, monitoring, and discharge recommendations., Results: Four hundred and ten questionnaires were analyzed. The percentage of pediatricians who correctly answered all questions on the management of mild and severe anaphylaxis scenarios was 11.3% and 3.2%, respectively. Pediatricians did significantly better with initial treatment, but they were less knowledgeable with respect to observation time and discharge criteria in the mild anaphylaxis case scenario compared with the severe one (both P < 0.001). Multiple logistic regression analysis identified only working in an emergency department or intensive care unit as significantly predicting correct diagnosis of anaphylaxis among pediatricians (P = 0.01, 95% confidence interval: 0.11-0.57). No pediatrician-related factors predicted physician knowledge on the management of anaphylaxis., Conclusions: Pediatricians have difficulty with different steps in managing mild and severe anaphylaxis. Their deficiencies in management may result in failure to prevent recurrences of mild anaphylaxis and may increase mortality in severe anaphylaxis., (© 2013 The Authors. Pediatrics International © 2013 Japan Pediatric Society.)

Study Objective: This study examined documented treatment recommendations provided for sleep disorders and sleep problems in pediatric primary care, the persistence of sleep problems and sleep disorders in children and adolescents, and the relationship between sleep issues and health care utilization., Methods: In-depth chart review of pediatric primary care patient visits (n = 750 patients) from 2007 through 2010., Results: Only 26 children (5.2% of those with a sleep disorder/ problem) received a treatment recommendation, with half of these recommendations behavioral in nature. Sleep disorders and sleep problems were highly persistent across time for up to a third of children. Children with sleep disorders had significantly more sick visits/calls (mean = 8.84, 95% CI 7.77-9.90) than children without a sleep disorder (mean = 6.34, 95% CI 5.56-7.12)., Conclusions: Very few children or adolescents were found to have documented treatment recommendations or referrals for diagnosed sleep disorders or sleep problems. In addition, given that sleep disorders and sleep problems are highly persistent, as well as result in more sick visits/calls, it is important that pediatric primary care providers screen for and identify these issues across development. Furthermore, it is essential to provide health care providers with more education and support on sleep disorders and sleep problems in pediatric primary care.

Aim: In this study, it was aimed to evaluate the levels of knowledge and approaches related with child abuse and neglect in pediatricians and practitioners who have a significant role in recognition and prevention of child abuse and neglect., Material and Methods: Two hundred residents of pediatrics and 100 pediatricians working in university and education and research hospitals in the center of Ankara province and 250 practicioners working in primary health care centers were included in the study. A scale composed of five parts including history, physical examination, radiology, risk groups and symptoms was prepared to determine the level of knowledge of physician related with child abuse and neglect. The correct answers given to the questions included in the scale were added and knowledge scores for the subscales and the total score were calculated. Approval was obtained from Ankara University, Medical Faculty Ethics Committee for the study. The data were evaluated using Mann-Whitney U and Kruskal Wallis test., Results: A total of 550 physicians (339 female and 221 male) were included in the study. The mean total knowledge score related with child abuse and neglect was found to be 12.4±4.5 in residents of pediatrics, 13.7±2.8 in pediatricians and 13.6±2.8 in practitioners. The level of knowledge was found to be significantly higher in women, married physicians, physicians who received education before and after graduation, physician who confronted with cases of abuse or suspicious abuse and made a legal notice., Conclusion: In the light of these findings, child abuse and neglect should be included in education programs before and after graduation for physicians who have a key role in the subject of child abuse and neglect.

The American Academy of Pediatrics and its Section on Oral Health have developed this clinical report for pediatricians and primary care physicians regarding the diagnosis, evaluation, and management of dental trauma in children aged 1 to 21 years. This report was developed through a comprehensive search and analysis of the medical and dental literature and expert consensus. Guidelines published and updated by the International Association of Dental Traumatology (www.dentaltraumaguide.com) are an excellent resource for both dental and nondental health care providers.

This opinion paper provides perspectives from a pediatrician about diagnostic challenges in caring for children. This essay shares personal experiences and lessons learned from a pediatric hospitalist about caring for children and making errors in diagnosis. This piece offers guidance about how to teach medical learners key concepts about error in diagnosis with underscoring the importance of developing critical thinking skills. Finally, the author offers tips from the literature about how physicians and other care providers can reorganize their own thinking (metacognition) to address their clinical practice.