Main Text:
To the Editor,
The prevalence of food allergy (FA) is increasing in the United
States1 and it is estimated that 8-10% of all
children and 6% of children between 0 and 2 years of age have a
FA.2,3 Recent publications have highlighted clinical
practice deficits, including the inappropriate treatment of
anaphylaxis4 and the lack of implementation of peanut
feeding guidelines by primary care clinicians.5Although pediatricians are frontline providers for infants
(<12 months) and toddlers (12-35 months) with FA, the
Accreditation Council for Graduate Medical Education (ACGME) does not
require a pediatric allergy curriculum as part of pediatric residency
training.
We set out to explore the educational needs, attitudes, and satisfaction
of the pediatric residents (PR) at MassGeneral Hospital forChildren (MGHf C) in Boston, MA. Our main objective was to
investigate sources of information PR use to gain knowledge about
infant/toddler FA and their comfort evaluating, diagnosing, treating,
managing, and counseling patients and their families regarding
infant/toddler FA and anaphylaxis.
A needs assessment survey was developed by pediatric clinicians,
including a pediatric allergist. The survey instrument consisted of
twelve questions exploring the following topics: FA training prior to
residency, resources utilized for information, comfort evaluating and
managing FA, comfort diagnosing and treating anaphylaxis, comfort
counseling families about a variety of FA topics, satisfaction with
current resident training opportunities (if present), and level of
postgraduate training. Using best practices in survey design, cognitive
interviewing was performed with a panel of pediatric clinicians to
ensure face validity and the survey was updated iteratively to
incorporate recommended changes. The final survey instrument was deemed
to meaningfully cover the appropriate topics, to be easy to understand,
and to be of manageable length.
The anonymous survey was administered via Research Electronic Data
Capture (REDCap). A survey link and three follow-up emails were sent to
the population of 64 pediatric and pediatric/internal medicine residents
at MGHf C. The study was exempted by the MassGeneral Brigham Human
Research Office. Results are presented using descriptive and inferential
statistics. Analyses were conducted in Stata/IC Version 16.1 (StataCorp:
College Station, Texas) and two-sided p- values of less than α =
0.05 were considered statistically significant.
A total of 51 PR completed the needs assessment survey, representing a
79.7% response rate and a 100.0% completion rate. 37.3% (19) of the
respondents were postgraduate year 1 (PGY-1), 29.4% (15) were PGY-2,
27.4% (14) were PGY-3, and 5.9% (3) were PGY-4.
Prior to residency entry, only 5.9% of PR received formal training
regarding infant/toddler FA. During residency, 31.4% (16) received
lectures, workshops, or simulations and 70.6% (36) reported feeling
dissatisfied with the current resident training opportunities concerning
this topic.
The most commonly reported sources for information regarding
infant/toddler FA and anaphylaxis included outpatient pediatric
clinicians (i.e., community pediatricians) (72.5%, 37), other pediatric
residents (58.8%, 30), and Emergency Department clinicians (52.9%,
28). However, when asked about their single most informative resource,
outpatient pediatric clinicians (29.4%, 15), allergy electives (15.7%,
8), and allergy-trained clinicians (i.e., staff allergists) (15.7%, 8)
were reported in that order (Figure 1).
The majority of PR felt uncomfortable evaluating (76.5%, 39) and
managing (86.3%, 44) infant/toddler FA. However, 68.6% (35) of PR felt
comfortable diagnosing and treating infant/toddler anaphylaxis,
respectively.
When examining factors that may contribute to PR’s clinical comfort, we
found a strong association between formal engagement with
allergy-trained clinicians, defined as the completion of an allergy
elective and/or the utilization of staff allergy-trained clinicians when
in need of allergy-related advice, and comfort treating infant/toddler
anaphylaxis. After adjusting for years of postgraduate training, PR who
had formal engagement with allergy-trained clinicians had 8.27 times the
odds (OR = 8.27; 95% C.I. 1.16-59.01; p -value = 0.035) of
feeling comfortable treating infant/toddler anaphylaxis as compared to
PR who did not.
Our study identified several educational deficiencies, including a lack
of, and dissatisfaction with, training opportunities and a lack of
comfort evaluating, managing, and counseling families about FA topics.
However, we also showed that formal engagement with allergy-trained
clinicians was strongly associated with increased comfort treating
anaphylaxis.
This study demonstrates several gaps regarding PR’s sources of
information and comfort with infant/toddler FA and anaphylaxis. The
majority of PR enter residency without training in infant/toddler FA and
anaphylaxis. Residents then, in the absence of a standard allergy
curriculum, seek information about infant/toddler FA and anaphylaxis
from multiple sources – many of whom are not allergists. When presented
with lectures, workshops, and simulation experiences about FA, PR are
largely dissatisfied with them. Furthermore, the top three resources
utilized for information about infant/toddler FA and anaphylaxis did not
include allergy experiences, despite PR reporting that two of the top
three single most informative resources were allergy electives and
allergy-trained clinicians. Overall, these findings suggest that the
design and implementation of a standard curriculum, while emphasizing
engagement with pediatric allergists, may present improved educational
opportunities.
This study was designed to be descriptive; therefore, we did not conduct
a power analysis and sample size calculation prospectively. However,
this analysis illuminates the need for an allergy medicine curriculum
emphasizing engagement with allergy-trained clinicians among pediatric
residents at MGHf C. While not generalizable beyond our setting,
we have been successfully funded by The Allergists’ Foundation of the
American College of Allergy, Asthma, & Immunology to expand this
educational needs assessment nationally to determine if the findings at
our institution are generalizable to pediatric residents as a whole
within the United States. Furthermore, this needs assessment
purposefully focused on attitudes, satisfaction, and comfort measured
through self-report. Future studies might focus on direct measures of
residents’ clinical proficiency and how PR apply FA and anaphylaxis
knowledge on their own.
This study is the first to examine pediatric residents’ knowledge
sources and comfort evaluating, diagnosing, treating, managing, and
counseling families regarding infant/toddler FA and anaphylaxis and adds
to the literature in several ways. First, we examined a population of
pediatric and pediatric/internal medicine residents, whereas the
existing literature has focused on other
populations.6-8 Second, we explored where PR seek
information about infant/toddler FA and anaphylaxis. These findings
support the need for a national needs assessment which may guide the
design and implementation of a standard pediatric allergy curriculum for
all pediatric residency programs.
Acknowledgements: We are grateful to the MassGeneral Hospital for Children pediatric residents who voluntarily participated in
this study. We also thank Mharlove Andre for her support during the
preparation of this manuscript.
Impact Statement: Although pediatric residents are frontline
providers for infants and toddlers with food allergy, they may lack
comfort evaluating, managing, and counseling families about food allergy
topics. Formal engagement with allergy-trained clinicians may improve
pediatric residents’ comfort treating allergic conditions.