News You Can Use

How to draw a Genogram

Don't forget the bubbles - Sun, 11/11/2018 - 21:00
Cite this article as:
Bakhsh, D. How to draw a Genogram, Don't Forget the Bubbles, 2018. Available at:

As a Student Doctor at the University of Queensland, I was offered the opportunity to shadow the Adolescent Team at The Child and Youth Mental Health Service (or CYMHS) at the Queensland Children’s Hospital. This was an amazing opportunity to observe some really important work in two of my special interest areas: Paediatrics and Psychiatry. The attachment really drove home that patients don’t exist in isolation, and how this is particularly true for children. The surrounding family system strongly dictates how well they will fare once they leave the hospital.

As part of this attachment I was asked to prepare and present Genograms for every patient at the weekly Multidisciplinary Team meeting. As I began to interview family members in order to gather the required 3 generations of family history, it became clear to me that a small diagram could represent and quickly convey what would otherwise have taken several pages of text. Genograms provide a wealth of insight at a glance, can help align patients with their most appropriate care, and are relatively easy to draw once you know how. They are a mainstay of Paediatrics for a reason.

When I first came across Genograms as a student, attempting to create one was very confusing and a little overwhelming. There are also surprisingly few reference materials available to aid you along the way. So in order to make this task a little easier for the next student, I put together this little video. I hope you find it useful.

– Daniel Bakhsh, Student Doctor, Doctor of Medicine Program, University of Queensland


The post How to draw a Genogram appeared first on Don't Forget the Bubbles.

Categories: News You Can Use

Screening for heart problems in young athletes

Paediatrics and Child Health - Fri, 11/09/2018 - 00:00
Physical training has several cardiovascular benefits. However, in rare cases, intensive exercise may be associated with sudden cardiac death (SCD). Although rare, SCD is the leading medical cause of death in the young athletes. The incidence rate of SCD is widely debated and largely unknown - the probable incidence range of SCD is between 1 and 2.5 per 100 000 athletes. The American Heart Association (AHA) estimates the prevalence of an underlying cardiovascular disorder in young athletes that predisposes to SCD as 0.3%.
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Growing up with Down Syndrome: Robyn Brady and Tara Coughlan

Don't forget the bubbles - Thu, 11/08/2018 - 21:00
Cite this article as:
DFTB, T. Growing up with Down Syndrome: Robyn Brady and Tara Coughlan, Don't Forget the Bubbles, 2018. Available at:

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from

Robyn Brady is a Staff Specialist at Lady Cilento Children’s Hospital in Brisbane, but for the purpose of this talk she is the proud mother of Maeve and Tara. We’ll let Robyn and Tara tell you of their lives together on their own words but if you want to know more about Sprung!! or donate to this amazing not-for profit collaborative then head over to their website.



Robyn Brady (L) and Tara Coughlan (R)

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. Please embrace the spirit of FOAMed and spread the word.


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Stabbings in kids – when and where?

Don't forget the bubbles - Thu, 11/08/2018 - 12:19
Cite this article as:
Davis, T. Stabbings in kids – when and where?, Don't Forget the Bubbles, 2018. Available at:

You cannot have missed the UK media stories about the increase in stabbings in young people; and the data from hospitals in London supports this. This week saw the publication of an article in BMJ Open sharing data from stabbing presentations to a major trauma centre in London.

Where and when do young people get stabbed, and (perhaps more importantly) how can this information inform our violence reduction strategy?


Vulliamy P, Faulkner M, Kirkwood G, et al. Temporal and geographic patterns of stab injuries in young people: a retrospective cohort study from a UK major trauma centre, BMJ Open 2018;8:e023114. doi: 10.1136/bmjopen-2018-023114


Who were the patients?

This was a retrospective cohort study in a major trauma centre in London. It included all patients under 25 years of age who presented following injury from a knife or other sharp object (and who met the criteria for triggering a trauma team activation).

Patients were excluded if the injuries were due to self-harm or were accidental.

It’s also important to understand some key definitions that the authors used (based on WHO categorisation):

  • childhood – <16 years
  • late adolescence – 16-19 years
  • young adulthood – 20-25 years


What were they looking at?

The authors looked at the time of the incident, geographic location, and the demographics of the patients.


What were the numbers?

During the ten year period (2004-2014) 1824 patients under 25 years of age presented with stab injuries. This group represented 56% of the total number of penetrating injuries.

Perhaps most alarmingly, during the ten year period of this study, the number of presentations increased 25% each year.


Who were the victims?

They comprised of: 9.4% children; 47.2% were in late adolescence; and 43.4% were young adults. Although there were no major differences across the three ages groups, this study did note that in-hospital mortality was higher in the youngest age-group. However, overall mortality was only 2%.

97% were male and 71% of victims lived in the most deprived areas.


Where and when  did the stabbings happen?

In the paediatric age group, there was significant peak in incidents between 1600hrs and 1800hrs (22%) in comparison to the adolescent or young adult groups (11%). Young adults were more likely to be stabbed after midnight.

The authors then did an analysis comparing timings of the incidents on school days versus non-school days. They found that more children were stabbed on a school day and that these incidents tended to happen earlier than on a non-school day. Incidents were more likely to happen within 5km of their home on a school day.

In fact, looking specifically at children,  47% of incidents happened within 5km of their home when they occur on a school day.


What does all this mean?

This data describes the young victims of knife crime in the UK and highlights the fact that children are more at risk of being victims of knife crime after school and near their home. This has important implications on how we can target violence reduction projects.

The authors outline a strategy used in Glasgow to reduce their knife crime rates – their multi-disciplinary approach, supported by the government and the broader community, has led to a large reduction in knife crime. They go on to make some specific suggestions for how to target knife crime in young people given the data obtained from this cohort study:

  • delivering educational interventions in secondary school or even as early as primary school
  • staggered release times from school
  • police presence to act as a deterrent where children are known to congregate after school (transport stations, cafes)
  • using a ‘stop and search’ strategy


This is a hugely important study that hopefully will continue to build on our current efforts to target violence amongst young people.


(COI – Tessa: I work with many of the authors of this paper but had no involvement in the study)

The post Stabbings in kids – when and where? appeared first on Don't Forget the Bubbles.

Categories: News You Can Use

Novel Withdrawal Symptoms of a Neonate Prenatally Exposed to a Fentanyl Analog

Journal of Pediatric Health Care - Thu, 11/08/2018 - 00:00
Neonatal abstinence syndrome (NAS) is a withdrawal syndrome observed in neonates exposed to drugs in utero, typically opioids, which is associated with symptoms affecting the central and autonomic nervous systems and the gastrointestinal system. West Virginia, particularly the southeastern region of the state, has remarkably higher rates of NAS than similar communities. Our facility is increasingly faced with complex cases of NAS caused by in utero exposure to multiple substances. We present a case report of a neonate born to a 25-year-old mother enrolled in a medication-assisted treatment program for substance use disorder who was noncompliant in prenatal care, using multiple substances throughout the pregnancy, including gabapentin and fentanyl.
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Paediatrics and Child Health - Thu, 11/08/2018 - 00:00
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Psychocutaneous disorders in childhood and adolescence

Paediatrics and Child Health - Thu, 11/08/2018 - 00:00
The adverse impact of skin diseases on an individual's physical and emotional well-being is well recognised, particularly in children as it is reflected in their growth and development. Conversely, the psychological and psychosocial issues that a child or young person may face, can manifest as a skin problem. Cutaneous manifestations of an underlying primary psychiatric problem are a poorly recognised entity amongst paediatricians. Limited knowledge and experience in this realm increases diagnostic and management challenges.
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DFTB/ADC Journal Club – The Rules

Don't forget the bubbles - Sun, 11/04/2018 - 21:00
Cite this article as:
Tagg, A. DFTB/ADC Journal Club – The Rules, Don't Forget the Bubbles, 2018. Available at:

We all know that it can take up to 17 years for knowledge to go from benchside to bedside. One of the things we pride ourselves on at DFTB is our ability to cut down this knowledge translation window. We do this in the form of our monthly Bubble Wrap, critical appraisals of key literature and engagement with key thought leaders via Twitter.

Now we are going to try something new – a monthly twitter journal club as a collaboration with Archives of Disease in Childhood.

So what does this mean for you?

The first rule of journal club is… You MUST talk about journal club

Without your involvement a journal club will just be four friends discussing an ADC paper. We can do that in the privacy of our own homes or hospitals. One of the things that we love about DFTB is our worldwide community. Many of us work in places where me might not get the opportunity to take part in a formal journal club so we decided to create one for you. It’s a chance for people from every continent to get together on-line and talk about a paper. But it will only work if YOU join in.


The second rule of journal club is… You MUST talk about journal club

Just like in Chuck Palahniuk’s now seminal book, the second rule is an echo of the first. We are going to announce the ADC paper up for discussion on the website, set a date and will see you there. There will be a focused one hour twitter chat online each month to discuss some of the key points in the paper (using the hashtag #DFTB_JC and moderated by @dftbubbles). You can also talk about journal club in the blog comments, on Twitter or via the Facebook page. At the end of the month we will attempt to collate the discussion points and comments, so if you have ever wanted to see your name in lights, you MUST talk about journal club. Just use this hashtag to make it easier for us all to find.


The third rule of journal club is… One question at a time, fellas.

Each month the JC moderator will put up four key questions, in advance, for you to think about. You might have many more and that is okay. We want to be able to try and impose just a little structure on the proceedings though. When answering a question, try and use the following format…This is the format that the one hour twitter chat will take too.


The fourth rule of journal club is… Use references if you can

It is easy to use anecdata to support an argument. We know you are better than that so try and support your arguments with a reference is you can. Citing the literature is another great way that we can help spread knowledge.


The fifth rule of journal club is… Personal experiences do matter!

Perhaps this seems the antithesis of rule four but it is really important to recognise the lived experiences of those we treat. Sometimes it just needs one patient story to make a difference to how we practice medicine. Just remember that what goes on the internet stays on the internet (forever and ever) so no patient identifying factors please.


The seventh rule of journal club is… Journal club is not just for doctors

We want you all to have the chance to read and contribute – nurses, pharmacists, PAs, paramedics, social workers as well as doctors. We are teaming up with Archives of Disease in Childhood to deliver you the paper in open access format each month. The paper will be made available especially for #DFTB_JC by ADC for your reading pleasure


Osler and the journal club

That master of medicine, Sir William Osler, has been suggested as the originator of the first journal club at McGill University back in 1875. Just like now articles were hidden behind paywalls, physical this time rather than digital, and it was a means of sharing knowledge with like-minded  colleagues.

To read more on the modern evolution of the journal club then take a look at one of the online greats #NephJC:-

Topf JM, Sparks MA, Phelan PJ, Shah N, Lerma EV, Graham-Brown MP, Madariaga H, Iannuzzella F, Rheault MN, Oates T, Jhaveri KD. The evolution of the journal club: from Osler to Twitter. American Journal of Kidney Diseases. 2017 Jun 1;69(6):827-36.


And the seventh and final rule… if this is your first journal club, you have to have fun!

I mean, what is the point otherwise.

So when doe this happen? Our first #DFTB_JC will take place on 25th October at 2000hrs UTC. If you want to figure out when that is where you are then use this time zone calculator.


And what paper will we be discussing? We are going to start up with this one. Your moderator, for this first #DFTB_JC,  will be Tessa Davis.


Snelson E, Ramlakhan S. Which observed behaviours may reassure physicians that a child is not septic? An international Delphi study. Archives of disease in childhood. 2018 Mar 15:archdischild-2017.




The post DFTB/ADC Journal Club – The Rules appeared first on Don't Forget the Bubbles.

Categories: News You Can Use

Hot and shaking truths…

Don't forget the bubbles - Thu, 11/01/2018 - 21:00
Cite this article as:
Craig S, and Roland D. Hot and shaking truths…, Don't Forget the Bubbles, 2018. Available at:

It’s always nice to come across a paper that makes you pause. A paper that challenges, until you read it, what you know to be “true”.

This recent paper by Murata et al. on febrile seizures may just do that.

Murata S, Okasora K, Tanabe T, Ogino M, Yamazaki S, Oba C, Syabana K, Nomura S, Shirasu A, Inoue K, Kashiwagi M. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. 2018 Oct 8:e20181009.

Have you ever really reviewed the literature on febrile seizures? We know everything there is to know don’t we? This has led to a pattern of standard advice handed down by generations of Paediatricians to both parents and their juniors.

These are pretty common. Although they’re frightening, they are rarely dangerous…. We need to ensure we know where the fever is coming from [its nearly always a viral illness] but after a period of observation [to both confirm the diagnosis and allow the parents to recover] we’ll be able to send you home.

“There’s not much we can do to stop them happening… The vast majority of children with seizures and a fever do not go on to develop epilepsy, and they grow out of febrile seizures, often by the age of 5 or 6. If a seizure does happen again, here’s what you do…

This newly published RCT of over 400 children from Japan challenges this near universal approach to febrile seizure advice but before we go through the paper, a little background and context is important.


What is the prognosis for febrile seizures?

A nice review in the BMJ provides the following key points:

  • Up to 1/3 of children will have recurrence of a febrile seizure; most of these occur in the next year.
  • Risk factors for recurrence include family history of febrile seizure, going to child care, and younger age (<18 months) at onset. Also, multiple seizures in the one illness, a “low” fever (<39C), and a shorter duration of fever prior to the seizure increase risk for recurrence.
  • There is a low risk of subsequent epilepsy in simple febrile seizures. However, complex seizures, a family history of epilepsy, and neurodevelopmental impairment increase the risk of unprovoked seizures.


What can be done to prevent seizure recurrence?

While standard advice (often provided on handouts) highlights that “Nothing can be done to prevent a febrile convulsion from occurring.” the evidence, however, is more nuanced.

The most recent Cochrane review on medications to prevent febrile seizures in children found

  • 40 articles describing 30 RCTs
  • 4256 randomised participants.

The following tables provide a very brief overview of the findings of the Cochrane review. Briefly, a tick in a box suggests a benefit of treatment, a cross suggests no benefit, and an empty box means there isn’t any data one way or the other.

Intermittent treatment vs placebo


Continuous treatment vs placebo


There have also been comparisons of continuous phenobarbitone to intermittent rectal/oral diazepam (no difference), and intermittent rectal diazepam to intermittent rectal valproate (no difference).

So – there is a statistical benefit to treatment with intermittent diazepam, intermittent diazepam, or continuous phenobarbitone. However, most children with a febrile seizure don’t have a recurrence. The Cochrane authors estimate that “up to 16 children would have to be treated over a year or two to save just one child a further seizure.”

Importantly, these drugs are not benign. In fact, two studies of children given continuous phenobarbitone demonstrated lower comprehension scores, and around 1/3 of children treated with either barbiturates or benzodiazepines had adverse effects.

Finally, the authors conclude with the suggestion that Parents and families should be supported with adequate contact details of medical services and information on recurrence, first aid management and, most importantly, the benign nature of the phenomenon.


So – what do the guidelines tell us to do?

Interestingly, the same evidence has led to varying guidelines, which seem to depend upon the prevailing medical culture where you practice.

Australians, Canadians and the English appear to accept the inevitability of febrile convulsions:

Australia: “Long term anticonvulsants are not indicated except in rare situations with frequent recurrences.”

Canada: “Pending further research, intermittent prophylactic therapy to prevent recurrent febrile seizures cannot be recommended at this time.”

English: “Providing drug treatment to prevent or manage future seizures may be considered appropriate in some circumstances, such as when the child has a history of prolonged or frequent seizures. However, these circumstances are an indication for urgent admission for specialist assessment and management, including the decision to prescribe drugs to manage or prevent future seizures”


The USA and Ireland suggest that there are occasions where intermittent diazepam might be reasonable.

USA: “…the potential toxicities associated with antiepileptic drugs outweigh the relatively minor risks associated with simple febrile seizures. As such, long-term therapy is not recommended. In situations in which parental anxiety associated with febrile seizures is severe, intermittent oral diazepam at the onset of febrile illness may be effective in preventing recurrence…. Although antipyretics may improve the comfort of the child, they will not prevent febrile seizures.”

Ireland: “There is no evidence that antipyretics influence the recurrence of febrile seizures…. Use of intermittent prophylactic oral or rectal diazepam at the time of illness or fever, may help reduce the risk of recurrent febrile seizures. This should only be prescribed in conjunction with a paediatric specialist…. Continuous prophylactic treatment is now not generally advised for children with febrile convulsions, or at very least is rarely indicated and should be prescribed only by a paediatric specialist.”

Japan’s guidelines seem to propose a lower threshold for treatment. They provide recommendations for when to commence prophylactic diazepam (during a subsequent febrile illness). Listed indications include:

  1. A febrile seizure lasting 15 minutes or longer, or
  2. Repeated febrile seizures and two or more of the following risk factors:
  • Focal or repeated seizures within 24 h
  • Preexisting neurological abnormality or developmental delay
  • Family history of FS or epilepsy
  • Age younger than 12 months
  • Seizure within 1 h after onset of fever
  • Seizure occurring with body temperature less than 38 °C


What did the study tell us?

Please do read the full paper but in summary this prospective, open randomised control trial randomised 219 patients to receive regular per rectal paracetamol (10mg/kg) and 204 to receiving no treatment. The latter group were advised NOT to give further antipyretic medication following arrival in hospital with only 3 patients breaching protocol. The power calculation had been based on same fever episode recurrence rate of 15% which had been derived from a previous study looking at the impact of per rectal diazepem. This is relevant as this ‘study’ recurrence rate is likely to be different than a whole population recurrence rate and therefore reduces the external validity of the findings. Of note 188 patients were excluded from the 794 patients who had a Febrile Convulsion during the study period because they had already received a diazepam suppository to prevent a further seizure.

The recurrence rate was significantly lower in the intervention arm (9.1%) compared to the no treatment group (23.5%) with 7 patients needed to be treated to prevent one febrile seizure


Why is this important?

This study highlights that a common perspective, the fatalistic acceptance of the inevitability of febrile seizure, is not necessarily the only reasonable approach.

Each person does see the world in a different way. There is not a single, unifying, objective truth. We’re all limited by our perspective

 Siri Hustvedt

While there may be numerous reasons why this study may not be applicable in your local practice it does appear that controlling the fever can reduce recurrence rates however uncomfortable it might be to admit this isn’t what we previously believed

However, the interpretation and application of evidence depends on context. For a parent terrified of their child having another seizure, this study (and the evidence for intermittent diazepam) may be compelling. On the other hand, a parent who accepts the low likelihood of an adverse outcome from another seizure may have a more relaxed approach

Once this illness has resolved, we don’t have evidence for the use of paracetamol or ibuprofen to reduce the recurrence of febrile seizures with subsequent febrile illnesses. In fact, there’s pretty good evidence that it won’t help.

In an RCT of 231 children who were followed for two years after their first febrile seizure, antipyretics were found to be ineffective in preventing subsequent seizures, with similar rates for placebo, ibuprofen and paracetamol. So for the parent whose child has a febrile convulsion and then two weeks later spikes a solitary fever – rushing for paracetamol is probably not sage advice.

Usual practice isn’t to withhold paracetamol or ibuprofen in the child who has unpleasant symptoms associated with a febrile illness. Most clinicians recommend treating “as needed” (when the child is grumpy, upset, irritable or lethargic). The control arm, the absence of any treatment,  is not normal practice in many healthcare settings and given you are potentially denying a child a treatment for pain and distress something an ethics committee in an different environment may not approve. A control arm of normal care may have resulted in a different recurrence rate (especially in this population which appears to be proactive in the control of fever) i.e. we don’t really know the difference between regular paracetamol and as needed paracetamol on the incidence of early febrile convulsion recurrence,

Ultimately a 1 in 4 recurrence rate is high and difficult to determine from other population studies and so the external validity of this study in other populations does require further study


The bottom line

There is so much to discuss in this study. However, it’s unlikely that any society that doesn’t normally use per rectal medications will be changing guidance on febrile convulsions any time soon. Also, we don’t know how “as needed” antipyretics compares to “regular” antipyretics for this indication.

It is very unlikely that the differences occurred by chance alone, so the impact of regular antipyretic may well have a short term impact, even though the clinical course of the disease is not changed (i.e. febrile seizures will recur in a significant proportion of children).

The next question is should parents and carers have a right to utilise this evidence (and the existing evidence for diazepam for prevention of seizures in future febrile episodes) in treatment options for their own children?


Want to read more?

Read Casey Parker’s take on paracetamol PR for febrile seizures.

The post Hot and shaking truths… appeared first on Don't Forget the Bubbles.

Categories: News You Can Use

Want to come to DFTB19?

Don't forget the bubbles - Thu, 11/01/2018 - 07:00
Cite this article as:
DFTB, T. Want to come to DFTB19?, Don't Forget the Bubbles, 2018. Available at:

After two years in Australia it is time for the Don’t Forget the Bubbles team to take a journey. Whilst it might be just an underground away for some it is a bit further for some of us. With over 70 pitches from speakers from around the world we have taken our time to curate an amazing program for you all.

You can now head over to and take a look!

We are also excited to announce some new workshops.

Join Mary Freer as she brings her Compassion Revolution to England, or sit in with Ross Fisher and Grace Leo and get better at presenting. Or, if they don’t take your fancy then why not join Ian Summers and friends and learn how to take your sim and debriefing to the next level.

Tickets for all of the workshops and the conference itself are now available at

If you can’t make it, don’t worry, we’ve got you covered. All the talks will be recorded and put out as podcasts after the event.



The post Want to come to DFTB19? appeared first on Don't Forget the Bubbles.

Categories: News You Can Use

Society Page

Journal of Pediatric Health Care - Thu, 11/01/2018 - 00:00
Categories: News You Can Use

The Power of Positive Psychology

Journal of Pediatric Health Care - Thu, 11/01/2018 - 00:00
One of the most popular courses at Yale University is PSCY 157, Psychology and the Good Life, taught by Professor Laurie Santos. Similar to those on other college campuses, the course focuses on self-care and mental health. Students learn about the definitions and evidence-based predictors of happiness along with the attendant myths, and also practice strategies to attain greater optimism and satisfaction in life.
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On Elections, Imposter Syndrome, and Burnout

Journal of Pediatric Health Care - Thu, 11/01/2018 - 00:00
I am going to let you in on a little secret: I am writing this in the midst of a July heat wave and trying to imagine what will be important and salient in November. I see the beginning of the chaos of the holiday season and the onset of flu, rotavirus, and the dreaded respiratory syntactical virus. Elective surgery schedules are exploding as people try to get care scheduled before their deductibles reset on January 1st. And, of course, the midterm elections loom large. By November, many middle childhood and adolescent kids present with new concerns about inattention and school performance, and many in fall sports have signs of overuse injuries.
Categories: News You Can Use

Access to Maternal Mental Health Services: Trends in State Legislation

Journal of Pediatric Health Care - Thu, 11/01/2018 - 00:00
Postpartum depression is the most common but underrecognized medical complication of childbearing, and 10% to 15% of pregnant and postpartum women will experience depression. Currently, only 30.8% of women with postpartum depression are identified, and only 6.3% receive adequate treatment (Cox, Sowa, Meltzer-Brody, & Gaynes, 2016). Given this disparity in detection and treatment, women who suffer maternal mental health disorders need effective health policies to increase access to mental health services.
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NAPNAP Position Statement on Immunizations

Journal of Pediatric Health Care - Thu, 11/01/2018 - 00:00
The National Association of Pediatric Nurse Practitioners (NAPNAP) supports the timely and complete immunization of all infants, children, adolescents, and adults in an attempt to maximize the health and wellbeing of all people. Routine childhood immunizations prevent as many as 3 million deaths per year. In addition, 1.5 million deaths per year could be avoided if global vaccination efforts continue to improve (World Health Organization, 2017).
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Cost–Benefit Analysis of Providing Fluoride Varnish in a Pediatric Primary Care Office

Journal of Pediatric Health Care - Thu, 11/01/2018 - 00:00
The American Academy of Pediatrics and the U.S. Preventive Services Task Force, among others, call for the provision of fluoride varnish in the pediatric primary care setting, but many barriers exist to the implementation of such a service in this setting. Knowledge of costs and benefits is one such barrier.
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