Article Text
Abstract
Background Safe assessment of severe underweight in children is important but experience suggests a frequent lack of understanding. Here we sought evidence from a wide spectrum of trainees.
Methods Cross-sectional telephone survey of an on-call middle-grade paediatric doctor in hospitals providing acute inpatient general paediatric care in England and Wales.
Results Response rate was 100%. Only 50% identified BMI as the appropriate measure for underweight in children. Most did not identify any clinical cardiovascular complications of severe underweight. Only 13% identified corrected QT time (QTc) as an important ECG finding. Knowledge of the refeeding syndrome was poor with 20% unable to define it at all, 21% able to identify some clinical features and 57% aware of potential phosphate abnormalities.
Conclusions Knowledge base among middle-grades doctors in England and Wales on this topic is worryingly poor, particularly in relation to several life-threatening features. Existing and new training approaches should recognise this.
- General Paediatrics
- Growth
- Health Service
- Measurement
- Paediatric Practice
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What is already known on this topic
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Children and young people with potentially life-threatening levels of underweight, for example secondary to eating disorders, may present to paediatricians.
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Recognising concerning clinical features of underweight is important, as is an ability to monitor for the refeeding syndrome.
What this study adds
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Many middle-grade doctors did not identify important cardiovascular risks associated with underweight, including ECG findings.
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There is a need for increased emphasis of underweight and its acute complications in paediatric training and those delivering services.
Introduction
Competencies for the assessment and management of malnutrition in children are recognised as important for paediatricians1 but emphasis in training predominantly focuses upon early childhood. In high-income countries, eating disorders (EDs) are important causes of underweight in children and adolescents, potentially causing life-threatening illness that can present acutely to paediatricians and require urgent admission and management.2 The ability to effectively recognise, assess and treat potentially life-threatening levels of underweight is therefore important, as is knowledge of the acute clinical and biochemical complications of reintroduction of nutrition (eg, the refeeding syndrome). Despite this, knowledge and confidence among paediatricians in the UK on this topic anecdotally appear poor.3 To investigate levels of awareness and identify training needs we conducted a telephone survey of an on-call general paediatric middle-grade doctor (ST3 onwards) in each hospital in England and Wales providing inpatient general paediatric acute care.
Methodology
National Health Service (NHS) hospitals providing inpatient general acute paediatric care in England and Wales were identified through a systematic search of all hospitals on the NHS Choices website, confirmed via trust websites or switchboards. One on-call middle-grade doctor was then contacted from each hospital via switchboards at predicted less busy times (09:30–12:30 or 13:30–16:00 weekdays) over a 7-week period, January–March 2012. Verbal consent was obtained and a brief questionnaire was delivered to participants to assess knowledge of important aspects of acute management of severe levels of underweight. Questions and model answers were based on the recently published consensus Junior MARSIPAN report providing guidelines on the acute management of children and adolescents with EDs.3 Participants were also questioned on their choice of measurement to define underweight in (i) infants and (ii) older children and adolescents (designed in part as a quasi-control question to test knowledge in an area where paediatric training is less equivocal, as well as an introductory question on a topic expected to be less threatening). Representativeness of our sample was gauged by asking participants how many doctors participated on the middle-grade on-call rota in their hospital.
Calls were scripted, piloted and refined using local paediatric trainees before final application, and then all calls were carried out by a single researcher (CC). Overall, 10% of calls were observed by a second researcher (LH) to ensure fidelity. On-call doctors were given the option of a call-back if too busy; this was not offered if the subject of the questionnaire had already been revealed, to prevent prepreparation. In such cases, or where a doctor declined participation, hospitals were recontacted later and a different doctor surveyed. R&D approval in our own institution was obtained and procedure followed. Ethics advice was sought from the chair of the local Ethics committee who deemed that this survey was exempt from formal review because it was purely a survey of NHS staff (ie, without patient involvement).
Results
An on-call middle-grade doctor was surveyed in every one of the 177 hospitals identified (100% response rate). In all, 82% of participants were surveyed at first contact, 18% at an agreed call-back time. In all, 54% of participants were male. Overall, 76% were in an ST training post; 5% were consultants working on a middle-grade rota. Median training grade was specialty training grade 5 (IQR 3). Median number of years working in paediatrics was 7 (IQR 5). Estimated total number of doctors participating in general paediatric on-call middle-grade rotas in England and Wales was 1411, implying that approximately 13% of doctors were surveyed.
A total of 175 participants (98.9%) said they would use weight to decide if an infant was failing to thrive (55.9% specified using centiles). In all, 89 (50.3%) said they would use body mass index (BMI) to decide if an older children or adolescent was underweight for age (20.3% specified using BMI centile or %median-BMI). Table 1 summarises proportions of appropriate responses to questions about clinical assessment of severe underweight and refeeding syndrome.
A total of 145 (81.9%) indicated they had previous experience with caring for a child or young person with an ED in their work. In all, 160 (90.4%) participants were in agreement that they required further training in the acute management of EDs.
Overall, 126 (71.2%) said they thought the methodology was acceptable. There was no difference in proportions of participants finding the methodology acceptable between those answering at first contact versus call-back (X2 p=0.98).
Discussion
Our study reveals a low level of knowledge of important clinical features of paediatric patients presenting with severe underweight, despite the majority of trainees having previous experience of managing paediatric patients with EDs. Knowledge was especially low regarding the potentially fatal signs suggesting cardiovascular compromise and prolonged QTc. Knowledge of important specific complications of the refeeding syndrome was also low. Only half of participants identified BMI to define underweight in older children or adolescents, with only 20% identifying a need to adjust for centiles or %median BMI. BMI centiles (or z-scores) are now an internationally recognised standard for defining both underweight and overweight in children,4 with -3SD having high specificity for medical instability.2 Medical instability can however occur at any BMI threshold with weight loss, and thus knowledge and ability to recognise clinical features of underweight in children with weight loss are important. Middle-grade doctors should have access to more senior consultant support as well as dietetic support from a broader multi-disciplinary team, especially when commencing nutrition. They are however likely to be the first senior paediatric doctors to initially lead assessment of such patients at presentation, particularly out of routine hours; thus, their knowledge base is critical.
We believe this is the first cross-sectional cold-call survey used to assess acute clinical knowledge in paediatric doctors, allowing a rare assessment of ‘working knowledge’ on this topic. Our methodology was reported to be acceptable to the majority of participants although more frequent future use would be unacceptable and a potential distraction to patient care. Participants were expected to provide answers on the spot, which may have affected the quality of their responses. However, a lack of significant difference in performance between those surveyed immediately versus at agreed call-backs times suggests this was not the case (data not shown). Verifying the estimated figure of 1411 middle-grade doctors working in general paediatrics is difficult. Royal College of Paediatrics and Child Health data from 2011 identifies 2559 trainees working in paediatrics >ST 2 level in England and Wales.5 However, these data include subspecialty trainees, not just general paediatric doctors, and only registered trainees, therefore likely excluding those in non-training posts. A higher than expected proportion of men were surveyed in our study relative to the known proportion of female paediatric doctors in England and Wales (approximately 70% of registered paediatric trainees are female).5 This may represent a higher proportion of women working part time leading to selection bias.
Our study identifies a safety issue which needs addressing by further training. Key opportunities within the existing framework should not be missed. Many participants identified a previous experience of an inpatient with an ED, highlighting the importance for case-based discussion. Acute resuscitation courses could include severe underweight in their curricula. Trainees and trainers can access the Junior MARSIPAN guidelines online via the Royal College of Psychiatrists website.3 Two published reviews in Archives of Diseases in Childhood are also available.6 ,7 Engagement with The Adolescent Health e-project (which contains a specific training section on EDs) would also be valuable. Moreover, both trainers and trainees should recognise the specific importance of identifying the physical complications of severe underweight as found in children and young people with EDs.
Acknowledgments
The authors would like to thank the doctors who participated in the survey, in particular Drs Billy White, Alex Brightwell and Emri Basatemur, for support in piloting the questionnaire. Thanks also to Dr Eirini Koutoumanou of the UCL Institute of Child Health for statistical support and advice.
Footnotes
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Contributors LDH conceived the study and the methodology. RMV, REK, CC and DEN contributed to the development of the methodology. CC collected the data (with LDH observing for fidelity). PJW supervised CC in a student attachment which involved the study. LDH and CC performed the analyses together. LDH wrote the first draft. All authors contributed to the final submitted manuscript.
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Competing interests None.
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Ethics approval Ethics advice was sought from the chair of the local Ethics committee who deemed that this survey was exempt from formal review because it was purely a survey of NHS staff (ie, without patient involvement). Local R&D approval was obtained and protocol observed.
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Provenance and review Not commissioned; externally peer reviewed.
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Data sharing statement Data collected are mostly presented here. Additional data are freely available at request from the authors.