Expectant Parents’ Understanding of the Implications and Management of Fever in the Neonate

Objective

We estimated the extent to which Canadian expectant parents would seek medical care in a febrile neonate (age 30 days or less). We also evaluated expectant parents’ knowledge of signs and symptoms of fever in a neonate, and explored the actions Canadian expectant parents would take to optimize the health of their child.

Methods

We conducted a cross-sectional survey of a sample of expectant parents from a large urban center in Canada. We recruited participants from waiting rooms in an obstetrical ultrasound clinic located in an urban tertiary care hospital in Montreal, Canada. We asked participants nine questions about fever in neonates including if, and how, they would seek care for their neonate if they suspected he/she were febrile.

Results

Among the 355 respondents, (response rate 87%) we found that 75% of parents reported that they would take their febrile neonate for immediate medical assessment, with nearly one fifth of the sample reporting that they would not seek medical care. We found no significant associations between the choice to seek medical care and expectant parents socio-demographic characteristics.

Conclusions

Despite universal access to high quality health care in Canada, our study highlights concerning gaps in the knowledge of the care of the febrile infant in one fifth of expectant parents. Physicians and health providers should strive to provide early education to expectant parents about how to recognize signs of fever in the neonate and how best to seek medical care. This may improve neonatal health outcomes in Canada.     

The parental obligation to expand a child's range of open futures when making genetic trait selections for their child

As parents become increasingly able to make genetic trait selections on behalf of their children, they will need ethical guidance in deciding what genetic traits to select. Dena Davis has argued that parents act unethically if they make selections that constrain their child's range of futures. But some selections may expand the child's range of futures. And other selections may shift the child's range of futures, without either constraining or expanding that range. I contend that not only would parents act unethically if they make selections that constrain the range of their child's futures, they would act unethically if they make selections that shift the range of their child's futures, because selections that shift the range of the child's futures would allow parents to over-determine their child's futures. Thus, I contend that parents would act ethically only if they make selections that expand their child's range of futures.     

Compelled organ donation

Along with ethical considerations, compelling an individual to donate organs, tissues, or bodily fluids brings several legal doctrines into conflict. The privacy of one's body is generally considered sacrosanct by American courts, which have upheld a competent adult's right to refuse medical procedures, even in cases when they are necessary to save the life of another. Although medical and legal communities stress “respect for the individual” as being paramount under American jurisprudential principles, the doctrine of “substituted judgment” permits a court to act (for example, by consenting to organ donation) on behalf of an incompetent individual or child. Parents also have the right to cause a child to “donate” an organ, and although a means exists by which the child can refuse, this may not be realistically feasible for young children. The revised Uniform Anatomical Gift Act of 2006, while clarifying issues of who may make organ donation decisions, does not resolve all the practical issues of compelled organ donation for minors.     

Non-accidental injury in children: what we do in Derby.

A scheme for dealing with cases of non-accidental injury in children in the Derby clinical area has been operating since 1971. A stable team of doctors, policemen, and social workers deal with each case. The parents are told at once that battering is suspected, and the police and social services department co-operate closely in establishing the facts, supporting the family, and protecting the child. A psychiatric assessment of the parents may help social workers decide on the long-term care of the child, and the forensic physician is invaluable if the case has to go to court. The team has made three recommendations about prevention and management of these cases: a specialist social service team should be set up to deal with these children and regain the skills and knowledge lost when children''s departments were abolished in 1971; babies should be routinely weighed naked in infant welfare clinics; and juvenile courts should be able to order a psychiatric report on the parents in care proceedings.     

Causes and consequences of increase in child survival rates: ethnoepidemiology among the Hmong of Thailand.

The Hmong "hill tribe" minority in Thailand has much higher exposure to factors usually associated with risk of child mortality (high fertility, low status of women, low education, less use of modern medical care for births, exposure to warfare, economic and physical disruption, and poor hygienic conditions) than the rural ethnic Thai population. Nonetheless, infant mortality has declined from over 120 per 1000 to under 50 per 1000 live births among both these populations in the past 30 years. The reason for the rapid increase in child survival among the Hmong appears to be better access to and more use of modern curative and preventive medical care associated with road construction rather than major changes in social or hygienic conditions. Conventional wisdom suggests that high fertility is both a cause and a consequence of high infant and child mortality and that parents will not reduce fertility until they see that mortality has declined. Most Hmong parents recognize the decline in child mortality and attribute it to better access to modern medical care. Most Hmong parents also say that, if they were starting to have children now, they would want to have fewer children. Fear of child death is infrequently mentioned as a motive for having more children, and the perceived decline in child mortality is rarely mentioned as a reason for reduced fertility. Most Hmong parents explain their desired family size in terms of economic conditions rather than perceived risk of child mortality. Results of this study suggest that fertility and child mortality can vary independently of one another and that major reductions in child mortality can be accomplished without waiting for major social changes (e.g., improved education or status of women) or major reductions in fertility.     

Parents, ADHD and the internet

The objective of this study is to examine the potential impact of using the internet on medical consultations by analysing the attitudes, attributions, and emotional responses of parents who have been informed by specialists that their child does not have attention-deficit hyperactivity disorder (ADHD) and to examine the nature of the feedback they obtained from members of online internet support groups. Over 40,000 messages from the five most popular international internet forums discussing children with ADHD were analysed. Messages from parents who reported that they had seen at least one specialist (e.g. paediatrician, psychiatrist or psychologist) because of their concerns that their child had ADHD were identified. The children included boys and girls with an age range from 2 to 16?years. Of these, we analysed messages where the parents additionally reported that the specialist had excluded a diagnosis of ADHD. Using these criteria, 91 messages from parents who had consulted over 200 different specialists and 398 replies to these messages were identified for content analysis. The replies to concerned parents were analysed to determine whether they were offered impartial advice. A majority of the parents reported that they did not believe the specialist and were unhappy about their child not being diagnosed with ADHD. They expressed dissatisfaction with the professional's opinions and the implication that their child's conduct was caused by their poor parenting skills. Importantly, 87.6?% of the responses that these parents received, from other members of online forums, reinforced the parent's negative attitude towards the professional's judgement. It was generally suggested that the parents should not believe the expert and should seek a further opinion. The use of the internet may encourage "doctor shopping" and mistrust in health services. Medical professionals and others may need to be aware of this, and parents may need more support than is generally offered to be able to accept alternative explanations for their child's behaviour.     

Lessons for health care rationing from the case of child B.

More details have emerged about the child B leukaemia case with the publication of the All England Law Report on the Appeal Court decision. At the time the view was widely held that the controversy might have been avoided if the responsible health authority had consulted the public. The law report reveals, however, that the courts adopted a moral language widely at variance with that of the patient''s doctor. The courts were concerned to support a utilitarian decision procedure based on calculations of the greatest overall good; the doctor was concerned with the best interests of a sick child. The doctor-patient relationship may be damaged when public consideration transforms the issue in this way. Also, the Appeal Court supported a decision which claimed to have "weighed" opposing evaluations, but it excused the health authority from describing how that weighing took place. One of the main criticisms of the utilitarian approach, however, is that weighing of this type is extremely difficult to justify. By its ruling the court has made legal challenge on the grounds of inadequate consultation virtually impossible to substantiate.     

Is There a Case in Favour of Predictive Genetic Testing in Young Children?

Genetic testing technology has brought the ability to predict the onset of diseases many years before symptoms appear and the use of such predictive testing is now widespread. The medical fraternity has met the application of this practice to children with caution. The justification for their predominantly prohibitive stance has revolved around the lack of a readily identifiable medical benefit in the face of potential psychological harms to the child. We argue that predictive testing can have important psychosocial benefits and that the interests of the child have been construed too narrowly. Proponents of a prohibitive stance also argue that testing in childhood breaches the child's future right to make the same decision as an autonomous adult and to maintain this information as confidential. We argue that predictive genetic testing of children is not necessarily a violation of the child's future autonomy. Indeed, in some cases, such testing may facilitate the development of autonomy in the maturing child. We argue that parents are generally best placed to judge what is in their own child's overall interests, and that a parental request for testing after appropriate genetic counselling should be respected unless there is clear evidence that the child will be harmed in an overall sense as a result of testing.     

Parents' experiences discussing pediatric vaccination with healthcare providers: a survey of Canadian naturopathic patients

Background

Parents who choose to selectively vaccinate or avoid vaccination for their children may do so at risk of compromising relations with their family physician or pediatrician. Groups that are associated with reduced rates of pedicatic vaccination, such as parents who access naturopathic care, may be particularly vulnerable to this issue.

Methodology/Principal Findings

In March through September 2010, we administered a 26-item cross-sectional survey to 129 adult patients, all of whom were parents with children ≤16 years of age, presenting for naturopathic care in Ontario, Canada. Ninety-five parents completed the survey (response rate 74%), and only 50.5% (48 of 95) reported that their children had received all recommended vaccines. Most parents (50.5%; 48 of 95) reported feeling pressure to vaccinate from their allopathic physician and, of those who discussed vaccination with their physician, 25.9% (21 of 81) were less comfortable continuing care as a result. Five percent (4 of 81) of respondents were advised by their physician that their children would be refused care if they decided against vaccination. In our adjusted generalized linear model, feeling pressure to vaccinate (odds ratio [OR] = 3.07; 95% confidence interval [CI] = 1.14 to 8.26) or endorsing a naturopathic physician as their most trusted source of information regarding vaccination (OR = 3.57; 95% CI = 1.22 to 10.44) were associated with greater odds of having a partially vaccinated or unvaccinated child. The majority (69.6%; 32 of 46) of parent''s with partially vaccinated or unvaccinated children reported a willingness to re-consider this decision.

Conclusions/Significance

Use of naturopathic care should be explored among parents in order to identify this high-risk group and engage them in discussion regarding pediatric vaccination to encourage evidence-based, shared decision making. Physicians should ensure that discussions regarding vaccination are respectful, even if parents are determined not to vaccinate their children.     

Patients' prerogatives and perceptions of benefit.

Patients today demand more information about their treatment. Doctors, however, seem reluctant to cast aside ingrained habits of paternalism, believing they can best interpret therapeutic choices for their patients. Whether doctors can be more objective and effective than patients in interpreting the "probabilities" of medical evidence is open to question. On the other hand, the exercise of choice by patients may itself have a bearing on the probabilities of outcome. Involving patients more in making therapeutic choices is justified if doctors can present options in an unbiased and effective manner and if the process improves the outcome of the care delivered.     

Can children withhold consent to treatment?

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child''s refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children''s consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice.     

The legal investigation of a decision not to operate on an infant with Down's syndrome and a duodenal atresia: a report from the Netherlands

It is well-known that in the Netherlands it has for several years been possible to carry out voluntary euthanasia quite openly, provided certain strict conditions are fulfilled. This situation has arisen because courts in the Netherlands have decided that doctors who end the lives of their patients under these conditions are in a "conflict of duties" situation, and therefore should not be convicted of any criminal offence. It has, however, not been known what view a Netherlands court might take about life and death decisions concerning patients who are not capable of giving consent -- for example, infants. This report briefly outlines my experience in the case of an infant with Down's syndrome and duodenal atresia -- a blockage of the digestive system that must be operated upon if the infant is to survive. A decision was taken not to operate, and this decision resulted in the Netherlands courts considering whether criminal proceedings were justified.     

Discussion: pre-zygotic rights

Silverman uses Warnock's article "Do human cells have rights?" (Bioethics 1987 Jan; 1(1): 1-14) as the springboard for a brief discussion of decision making in the care of handicapped newborns. He argues that the parents of these children should have a major role in deciding for or against life-prolonging treatment, because they must live with the consequences. Silverman does not find it surprising that, in reaching their decision, parents are inclined to weigh the competing interests of family members, including those of children not yet conceived whose rights are foreclosed by the drain on the family of an existing handicapped child.     

Determining medical fitness to drive: physicians' responsibilities in Canada.

Current legislation indicates that physicians in Canada have a legal responsibility to know which medical conditions may impede driving ability, to detect these conditions in their patients and to discuss with their patients the implications of these conditions. The requirements to report unfit drivers vary among the provinces, and the interpretations of the law vary among the courts; therefore, physicians'' risks of liability are unclear. Physicians may be sued by their patients if they fail to counsel the patients on the dangers of driving associated with certain medications or medical conditions. Physicians may also face legal action by victims of motor vehicle accidents caused by their patients if the court decides that the physicians could have foreseen the danger of their patients'' continuing to drive. Physicians'' legal responsibilities to report patients with certain medical conditions override their ethical responsibilities to keep patients'' medical histories confidential.     

The Doctor-Patient Relationship: A Survey of Attitudes and Practices of Doctors in Singapore

This article reports the results of a survey, by mailed questionnaire, of the attitudes, values and practices of doctors in Singapore with respect to the doctor-patient relationship. Questionnaires were sent to a random sample of 475 doctors (261 general practitioners and 214 medical specialists), out of which 249 (52.4%) valid responses were completed and returned. The survey is the first of its kind in Singapore. Questions were framed around issues of medical paternalism, consent and patient autonomy. As the doctors were exposed to Western ethical concepts in their training, we were not surprised to find that they would mostly allow patients some say in decision-making and keep patients reasonably informed. In respecting patient autonomy, they would usually seek to influence patient choice by persuasion. However, the residual 'Asian-ness' of doctors in Singapore gives rise to some inconsistencies between values and practices. Many doctors still believe that a number of their patients are incapable of rational choice. There is some lack of openness in telling patients the whole truth. When patients choose to refuse treatment, many doctors are prepared to involve family members in making a consensus decision.
Doctors were also asked how they made ethical judgements in the face of dilemmas, and how they would like disputes with patients to be resolved. By and large, the doctors prefer to make their own judgements rather than to rely on rules. They also wish to keep the law courts out of disputes with patients, preferring less public ways of settling disputes.     

Health Seeking Behaviour and Treatment Intentions of Dengue and Fever: A Household Survey of Children and Adults in Venezuela

Background

Dengue in Venezuela is a major public health problem with an increasing incidence of severe cases. Early diagnosis and timely treatment influences the outcome of dengue illness, as delay in care-seeking is significantly associated with complications leading to severe dengue. We aimed to understand patterns of health seeking behaviour (HSB) in individuals exposed to high dengue incidence in order to improve early attendance to health centres.

Methods

Between September 2013 and February 2014 a cross-sectional household survey was performed in Maracay, Venezuela. Intended HSB of adults and children’s parents/guardians was assessed with respect to fever or suspected dengue. Data was collected through structured questionnaires from 105 individuals.

Results

Most individuals felt at risk of dengue and believed it could be a deadly disease. In the case of suspected dengue, the majority (60%) would choose to first seek medical help versus first treating at home, in contrast to 11% in the case of fever. Amongst those who decided to visit a doctor, a suspected dengue infection would prompt them to search medical help earlier than if having only fever (p<0.001). Multivariate analysis modelling showed that the independent factors associated with the intention to firstly visit a doctor versus treating at home in the case of dengue were feeling at risk (OR = 3.29; p = 0.042) and being an adult (as opposed to caring for a child as a parent/guardian; OR = 3.33, p = 0.021), while having had a previous dengue infection (OR = 0.29; p = 0.031) and living in the neighbourhood Caña de Azúcar (OR = 0.28, p = 0.038) were negatively associated with seeking medical care as their first action.

Conclusion

Knowledge of HSB related to dengue is scarce in the Americas, our study attempts to contribute to a better understanding of HSB in this region. Improving early dengue disease recognition and awareness may enhance prompt attendance to medical care in affected populations and thereby reduce mortality and severity of dengue. Especially for those with a previous dengue infection, efforts have to be made to promote prompt health centre attendance.     

The legal assault on physician—patient privilege

Can there be appropriate and just disclosure of medical and therapeutic records, given that such records are defined and acted upon quite differently in the arenas of law and health? Medical and therapeutic records are kept for healing purposes, not as findings of fact for a court. However, Canadian courts increasingly are being asked to disregard privilege between doctor and patient when that patient has reported a sexual assault. The Supreme Court will soon rule in two cases that may change policies and laws and affect Canadian physicians, other health care professionals and hospitals.     

The use of auxiliary courts by the lek-forming White-bearded Manakin Manacus manacus (Aves, Pipridae)

The White-bearded Manakin is a passerine specially noted for elaborate courtship. Each resident male has a cleaned oval court delimited by saplings in leks. No study mentions the use of more than one court by a territorial male during the breeding season. We report the use of auxiliary courts by males in the lowland forest of southeastern Brazil and discuss its probable function in attracting females for mating. Additionally, we experimentally modified a male’s main courts, testing that auxiliary courts serve as alternative display places. Twelve males from four different leks were observed for 145 h. Six males used from one to four auxiliary courts located 1.0 to 8.1 m from their main courts. The males that also used auxiliary courts displayed more than males that used only the main court. Nevertheless, the proportion of female visits per display time indicates that males that used only the main court have greater efficiency in attracting potential mates. Individual males responded differently to the experimental modification of their main courts, but one male avoided the modified court. The use of auxiliary courts may be a strategy adopted mainly by peripheral males to attract females that visit more successful males with central territories on the lek. In the short term, auxiliary courts function as optional display places in cases of loss of the main court. In the long term, the use of auxiliary courts may be involved in the temporal persistence of lek areas.     

When a physician and a clinical ethicist collaborate for better patient care

Bioethics is a relatively new addition to bedside medical care in Arab world which is characterized by a special culture that often makes blind adaptation of western ethics codes and principles; a challenge that has to be faced. To date, the American University of Beirut Medical Center is the only hospital that offers bedside ethics consultations in the Arab Region aiming towards better patient‐centered care. This article tackles the role of the bedside clinical ethics consultant as an active member of the medical team and the impact of such consultations on decision‐making and patient‐centered care. Using the case of a child with multiple medical problems and a futile medical condition, we describe how the collaboration of the medical team and the clinical ethics consultant took a comprehensive approach to accompany and lead the parents and the medical team in their decision‐making process and how the consultations allowed several salient issues to be addressed. This approach proved to be effective in the Arab cultural setting and indeed did lead to better patientcentered care.     

Collaboration between child psychiatry and medical genetics. Genetic diseases with an atypical beginning

When a children psychiatrist, faced to atypical psychological troubles, comes up against difficulties in establishing a precise diagnosis, he may consider a genetic etiology and ask for a genetic consultation. He may encounter many problems when he suggests this specialized consultation to the parents. These have often been prepared for a long time to the necessity of a psychiatric therapy in order to cure their child's troubles. The geneticist's diagnosis will induce the parents and the psychiatrist to have a different look on the child and mostly will set limits to the possibilities of treatment.