Análise ética dos impactos da pandemia de COVID-19 na saúde de crianças e adolescentes / An ethical analysis of the impacts of the COVID-19 pandemic on the health of children and adolescents / Análisis ético acerca dos impactos de la pandemia COVID-19 en la salud de niños y adolescentes

A pandemia de COVID-19 trouxe impactos significativos para a vida de crianças e adolescentes em todo o mundo. Considerando esse contexto, o objetivo deste artigo foi examinar como as crianças e os adolescentes no Brasil foram impactados pela pandemia à luz de uma análise ética. Para tanto, uma análise interpretativa de estudos brasileiros sobre a saúde da criança e do adolescente durante a pandemia foi realizada. A tarefa de reconhecer essa dimensão ética é importante para entender como as respostas a situações de crise, tais como a presente situação da pandemia de COVID-19, podem ser moldadas e identificar quais as prioridades de ação de acordo com todas as partes interessadas, situando a criança entre essas partes de interesse. A análise demonstrou que tanto os efeitos diretos quanto os indiretos implicam em processos de tomada de decisão que precisam utilizar e sustentar o direito de participação da criança para que a ação tomada esteja o máximo possível focada nos melhores interesses da criança. Contudo, a realidade brasileira tem demonstrado uma exclusão estrutural das vozes infantis. Recomenda-se que mais estudos sejam conduzidos a fim de aprofundar o conhecimento sobre os melhores interesses das crianças e sua participação nas ações tomadas durante a pandemia

The COVID-19 pandemic has impacted the lives of children and adolescents around the world. This article aims to examine how the pandemic has impacted children and adolescents in Brazil using an ethical analysis. An interpretive analysis of Brazilian studies on child and adolescent health during the pandemic was conducted. The task of recognizing this ethical dimension is important to understand how responses to crisis situations, such as the current situation of the COVID-19 pandemic, can be shaped and where are the priorities for action according to all stakeholders, situating the child between these parts of interest. Our analysis highlighted both direct and indirect effects surrounding the decision-making processes for children in the COVID-19 pandemic reality. These decisional processes must sustain the child's right to participation to ascertain that the action taken is in the child's best interests. However, Brazilian reality has shown a structural exclusion of children's voices in decisions that affect them, particularly related to the effects of the pandemics in their lives. More studies must be conducted to deepen the knowledge about children's best interests and their participation in actions planning during the pandemic

La pandemia de COVID-19 ha afectado las vidas de niños y adolescentes de todo el mundo. Este artículo tiene como objetivo examinar cómo la pandemia ha afectado a los niños y adolescentes en Brasil mediante un análisis ético. Se realizó un análisis interpretativo de los estudios brasileños sobre salud del niño y del adolescente durante la pandemia. La tarea de reconocer esta dimensión ética es importante para entender cómo las respuestas a situaciones de crisis, como la situación actual de la pandemia COVID-19, pueden configurarse y dónde están las prioridades de acción según todos los actores, situando al niño entre estas partes. de interés. Estos procesos de decisión deben sustentar el derecho del niño a la participación para asegurarse de que las medidas tomadas respondan al interés superior del niño. Sin embargo, la realidad brasileña ha mostrado una exclusión estructural de las voces de los niños en las decisiones que los afectan, particularmente en relación con los efectos de las pandemias en sus vidas. Se deben realizar más estudios para profundizar el conocimiento sobre el interés superior de los niños y su participación en la planificación de acciones durante la pandemia

When a Family Seeks to Exclude Residents From Their Child's Care.

A primary goal of our medical education system is to produce physicians qualified to promote health, prevent and treat disease, and relieve suffering. Although some aspects of the practice of medicine can be learned in classrooms, from textbooks, or with simulators, other aspects can only be learned through the direct provision of patient care. Residency programs therefore offer essential educational experiences that support residents' acquisition of knowledge, skills, and professional judgment through the assumption of progressive responsibility under an appropriate level of supervision. Yet, ethical questions can arise when medical education is integrated with patient care. How should we balance the educational needs of residents and the social benefits of medical education against obligations to patients and families? In this article, we present the case of a child whose family requests that residents not be allowed to perform any procedures on their child and then ask experts (a pediatric residency program director, a pediatrics resident, and an ethicist) to comment.

Prevalence and predictors of expulsion in home-based child care settings.

This study explored the prevalence of expulsion in home-based child care (HBCC) settings using a nationally representative sample of HBCC providers from the National Survey of Early Care and Education. In addition to prevalence, enrollment and provider characteristics that predicted expulsion were examined. Although there is increasing awareness of the prevalence of early childhood suspension and expulsion in early care and education settings and the negative effects it has on children's development, few studies have included or focused on HBCC, where many children receive care. This study highlights that many home-based providers, especially listed providers, report that they expelled at least one child within the last year. Significant predictors of expulsion emerged, including enrollment characteristics such as caring for children with disabilities, enrolling more children, and caring for children unrelated to the provider. Provider characteristics, including years of experience, provider education, and provider age, also predicted provider report of expulsion. These results provide insight as to possible strategies that may be effective in reducing expulsion rates in this caregiving context.

Este estudio exploró la prevalencia de expulsión en escenarios de cuidado infantil con base en el hogar usando una muestra nacionalmente representativa de proveedores de cuidado infantil con base en el hogar de la Encuesta Nacional de Cuidado y Educación Temprana. Además de la prevalencia, se examinaron el número de inscripciones y las características del proveedor que predecían la expulsión. A pesar de que aumenta el conocimiento acerca de la prevalencia de la suspensión y expulsión en la temprana niñez en escenarios de cuidado y educación temprana y de los efectos negativos que la misma tiene en el desarrollo de los niños, pocos estudios han incluido o se han enfocado en el cuidado infantil con base en el hogar, donde muchos niños reciben el cuidado. Este estudio subraya el hecho de que muchos proveedores con base en el hogar, especialmente proveedores que son parte de una lista, reportan que ellos expulsaron por lo menos un niño dentro del último año. Surgieron significativos factores de predicción de la expulsión, incluyendo características de la inscripción tales como el cuidar a niños con discapacidades, el inscribir a más niños y el cuidar a niños que no están relacionados con el proveedor. Las características del proveedor, incluyendo los años de experiencia, la educación del proveedor y la edad del proveedor, también predijeron el reporte del proveedor sobre la expulsión. Estos resultados aportan una percepción en cuanto a las posibles estrategias que pudieran ser efectivas para reducir el porcentaje de expulsión en este contexto de prestación de cuidado.

Cette étude a exploré la prévalence de l'expulsion dans les contextes de crèches à domicile / familiales en utilisant une échantillon représentatif de l'Inventaire national américain des crèches et des institutions éducatives appelé National Survey of Early Care and Education. En plus de la prévalence, l'admission et les caractéristiques de l'assistante maternelle prédisant l'expulsion ont été examinées. Bien qu'il y ait une prise de conscience de la prévalence de la suspension et de l'expulsion de la petite enfance dans les contextes de modes de garde de l'enfant ainsi que des effets négatifs que celles-ci peuvent avoir sur le développement de l'enfant, peu d'études ont porté sur les soins en crèches familiales, où beaucoup d'enfants sont accueillis. Cette étude met en évidence le fait que bien des crèches familiales, et surtout celles qui apparaissent sur les listes de crèches, signalent avoir renvoyé au moins un enfant en une année. Des facteurs de prédiction importants ont émergé, y compris les caractéristiques de l'inscription et de l'admission comme le fait de prendre soin d'enfants handicapés, le fait d'accepter plus d'enfants, et le fait de prendre soin de plus d'enfants sans lien avec la crèche. Les compte rendus d'expulsion montrent que les caractéristiques de l'assistante maternelle, y compris les années d'expérience, l'éducation, et l'âge étaient également des facteurs de prédiction d'expulsion. Ces résultats donnent une idée de stratégies possibles qui peuvent s'avérer efficaces pour la réduction des taux d'expulsion dans ce contexte de mode de soin.

Ética e estética do cuidado nos primórdios da vida: reinventando a prática cotidiana com bebês numa unidade de acolhimento / Ethics and aesthetics of care in the early days of life: reinventing everyday practice with babies in a care unit

Esta tese é resultado de uma pesquisa-intervenção realizada na Zona Sul da cidade do Rio de Janeiro, em uma Unidade de Acolhimento para bebês entre 0 e 36 meses. Nesse contexto, analisei a importância de uma ética do cuidado em relação à primeiríssima infância, o que significou incluir no estudo o profissional cuidador e a instituição que une os atores, bebês e adultos. Também investiguei a qualidade do cuidado ofertado aos bebês no berçário desse abrigo municipal, exatamente no momento em que os gestores desejavam realizar uma mudança estrutural na dinâmica do trabalho das educadoras sociais. O estudo constou de três passos metodológicos e práticos. Em primeiro lugar, a modificação paradigmática do modo de cuidar foi sendo construída ao longo do tempo, tendo amparo num coletivo denominado Roda de Conversa, quando se passou a falar sobre os problemas enfrentados no cotidiano, especialmente sobre a relação com os bebês e os familiares. As comunicações foram convergindo no sentido de que o bebê precisava de uma relação de referência que lhe assegurasse uma atenção recíproca e amorosa. A partir da interlocução entre a psicanálise e a abordagem Pikler, foi discutido no trabalho um modelo de intervenção que visava favorecer tanto a constituição psíquica dos bebês quanto o cuidado com o cuidador. Para isso, foi ofertado às educadoras, nesse primeiro momento, o referido espaço de fala onde se processavam as angústias que a atividade de cuidar suscita e onde havia uma mútua apropriação das sutilezas da função que elas exercem. Num segundo momento, a pesquisa passou a ser desenvolvida no berçário da instituição e focou-se, de um lado, na observação das relações cotidianas de cuidado entre adultos e crianças, sendo inspirada no método de observação da psicanalista Esther Bick; de outro, nas narrativas das educadoras que foram selecionadas para serem acompanhadas em profundidade e que participaram de uma conversa com a pesquisadora, ao final de cada observação. Essa última atividade se fundamentou na construção clínica da intervenção a tempo e da abordagem da psicossociologia francesa. Num terceiro momento, a equipe técnica foi entrevistada, de forma aberta e sem um instrumento de condução da fala, sobre as relações internas e externas de cada uma. O objetivo foi compreender de que modo essas pessoas, responsáveis institucionais, viam a dinâmica de seu trabalho e a forma como o exerciam, considerando que as dimensões sociais, individuais, subjetivas, intersubjetivas, conscientes e inconscientes, imaginárias e simbólicas nas instituições produzem efeitos na qualidade do que é produzido. Dessa forma, estão no centro da investigação as relações intersubjetivas e seus efeitos nas relações de cuidado, tendo como eixo teórico os trabalhos desenvolvidos por B. Golse e D. Stern sobre os primórdios da subjetivação, assim como o modelo metapsicológico proposto por Winnicott sobre as relações iniciais cuidador/bebê, a teoria psicanalítica sobre os processos intersubjetivos/grupais, a psicodinâmica do trabalho e a abordagem psicossociológica francesa. Considerando as funções do cuidado como um eixo primordial para o processo de subjetivação dos bebês e para o desenvolvimento da capacidade da educadora de estabelecer vínculos de qualidade com os pequenos, o trabalho destacou as dimensões sensíveis do bebê e do adulto, e a necessidade de as instituições considerarem esses elementos invisíveis como veículo para o processo de humanização de todos. Concluo que esse estudo corrobora para o entendimento de que, para um trabalho de qualidade no âmbito do cuidado com bebês aconteça é fundamental que o cuidador tenha a capacidade de se autorregular emocionalmente e de cuidar de si. Para isso, exemplarmente, nesse tempo da pesquisa, as educadoras e a equipe técnica produziram um espaço para a invenção de si e do mundo ao qual pertencem

This thesis is the result of an intervention research conducted in Zona Sul, the southern part of the city of Rio de Janeiro, in a care unit for babies between 0 and 36 months. In this context, I analyzed the importance of an ethics of care in relation to the very first childhood, which meant to include in the study the professional caregiver and the institution that unites the actors, babies and adults. I also investigated the quality of care offered to the babies in the nursery of this municipal shelter, just at the moment when managers wanted to make a structural change in the work dynamics of social educators. The study consisted of three methodological and practical steps. In the first place, the paradigmatic modification of the way of caring was built over time, taking shelter in a collective called Wheel of Talk when it came to talk about the problems faced in the daily life, especially on the relationship with babies and relatives. The communications were converging in the sense that the baby needed a reference relationship that would ensure mutual and loving attention. From the interplay between psychoanalysis and the Pikler approach, an intervention model was discussed in the work that aimed to favor both the psychic constitution of the babies and the care of the caregiver. To this end, it was offered to the educators, at that first moment, the said space of speech where the anxieties that the activity of caring aroused were processed and where there was a mutual appropriation of the subtleties of the function that they exercised. Secondly, the research began to be developed in the nursery of the institution and focused, on the one hand, on the observation of the daily relations of care between adults and children, being inspired by the method of observation of the psychoanalyst Esther Bick; on the other, in the narratives of the educators who were selected to be followed in depth and who participated in a conversation with the researcher at the end of each observation. This last activity was based on the clinical construction of the intervention in time and the approach of French psychosociology. In a third moment, the technical team was interviewed, openly and without an instrument of speech, on the internal and external relations of each one. The objective was to understand how these people, as institutional leaders, saw the dynamics of their work and how they exercised it, considering that the social, individual, subjective, intersubjective, conscious and unconscious, imaginary and symbolic dimensions in institutions produce effects on quality of what is produced. In this way, intersubjective relations and their effects on care relationships are at the heart of the research, with the work of B. Golse and D. Stern on the origins of subjectivation as the theoretical axis. As was emphasized in the metapsychological model proposed by Winnicott on the initial carer / baby relations, the psychoanalytic theory on intersubjective / group processes, work psychodynamics and the French psycho-sociological approach. Considering the functions of care as a primordial axis for the process of subjectivation of the babies and for the development of the educator's ability to establish quality bonds with the small ones, the work highlighted the sensitive dimensions of the baby and the adult, and the need for the institutions to consider these invisible elements as a vehicle for the humanization process of all. I conclude that this study corroborates the understanding that for a quality work in the field of baby care to happen it is fundamental that the caregiver has the ability to self-regulate emotionally and to take care of itself. For this, in this time of research, the educators and the technical team have produced a space for the invention of themselves and of the world to which they belong.

Dilema éticos en la práctica de la medicina infantil / Ethical dilemas in pediatrics

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Dilemas éticos en la práctica de la medicina infantil / Ethical dilemmas in practice of medicine child

Tras revisar la bibliografía existente en los últimos 20 años se aprecia un déficit de información sobre los conflictos éticos que afectan a los pediatras en su práctica diaria lo que provoca cierto grado de incertidumbre en estos profesionales a la hora de resolver estos problemas. Por este motivo se realizó una búsqueda sistemática en las principales bases de datos encontrando más de 150 artículos relacionados con este asunto, de los que se seleccionaron 80 considerados como los más relevantes. Tras estudiarlos, se encontraron 40 dilemas éticos relacionados con algún principio de solución y que se describen en este artículo. Entre ellos destacan algunos dilemas éticos relacionados con incapacidades, o con cuidados paliativos en medicina infantil, o el dilema del consentimiento informado en este rango de edad

After reviewing the existing bibliography in the last 20 years, we concluded that there is a lack of information regarding the ethical conflicts that affect to pediatrics in their daily practice. It produces certain degree of uncertainty in these professionals at the time of solving these problems. We made a systematic search in the main data bases, finding more than 150 articles related, of which 80 were considered outstanding. After studying them, we have found 40 ethical dilemmas, related to some principle of solution and that we described in this article. Through them we can find such important dilemmas as those related to physical disability, palliative care or consent from children

Physical Activity Experiences and Beliefs Among Single Mothers: A Qualitative Study.

PURPOSE: Single motherhood has been associated with negative health consequences such as depression and cardiovascular disease. Physical activity might reduce these consequences, but little is known about physical activity experiences and beliefs that might inform interventions and programs for single mothers. The present study used social-cognitive theory as a framework to explore physical activity beliefs and experiences among single mothers. METHOD: Single mothers (N = 14) completed a semistructured interview and the International Physical Activity Questionnaire. Participants were categorized into 3 activity levels, and data were analyzed according to these categories. RESULTS: All participants reported barriers to physical activity. Physically active single mothers seemed to be more confident in their ability to overcome these barriers and more likely to plan physical activity in their daily routine, and they more frequently reported having social support compared with low-active single mothers. Across all activity levels, participants focused on the physical outcomes of physical activity participation such as weight loss. CONCLUSIONS: These results provide information that is useful for designing and delivering behavioral interventions for increasing physical activity among single mothers.

El papel del radiólogo ante el niño maltratado. Protocolo de imagen y diagnóstico diferencial / The radiologist's role in child abuse: imaging protocol and differential diagnosis

El maltrato infantil o trauma no accidental es un problema de primer orden a nivel internacional que se calcula afecta a cerca de 12.000 niños/año en España. La existencia de lesiones específicas, así como de hallazgos no congruentes con el trauma referido, hacen que en muchas ocasiones sea el radiólogo el facultativo responsable de dar la voz de alarma sobre el abuso. La tríada formada por hematoma subdural, fracturas metafisarias y fracturas costales posteriores se ha demostrado como muy característica del síndrome del «niño zarandeado». La detección de lesiones agudas y crónicas, o en diferentes estadios de curación, en un mismo paciente es altamente específica de trauma no accidental. Fracturas de huesos largos en pacientes que aún no deambulan también son lesiones de alarma en el diagnóstico del maltrato. Lesiones con alta especificidad para maltrato, como las lesiones metafisarias clásicas o las fracturas costales posteriores, pueden ser difíciles de demostrar radiográficamente y son, de forma habitual, clínicamente ocultas. De acuerdo con los protocolos de la American College of Radiology (ACR), se recomienda que cada extremidad, superior e inferior, sea valorada en tres radiografías distintas. Es importante utilizar sistemas radiográficos de alta resolución con bajo kilovoltaje (50-70 kvp) y miliamperaje adecuado. El estudio mediante seriada esquelética se recomienda en todos los niños menores de 2 años con sospecha de maltrato. La seriada esquelética de seguimiento, en torno a las 2 semanas del estudio inicial, es útil para la detección de nuevas fracturas y para valorar la consolidación de otras, lo que facilita la datación de las lesiones. La lesión craneoencefálica es la principal causa de muerte en el niño maltratado. Pese a que la tomografía computarizada suele ser la primera técnica de neuroimagen en el trauma no accidental, la resonancia magnética craneal aporta una mejor caracterización de los hallazgos presentes en la tomografía así como una mejor estimación de la cronología de la lesiones (AU)

Child abuse or nonaccidental trauma is a major problem worldwide; in Spain, there are about 12,000 victims per year. The detection of specific lesions or findings that are incongruent with the reported mechanism of trauma mean that radiologists are often the physician responsible for sounding the alarm in cases of abuse. The triad consisting of subdural hematoma, metaphyseal fracture, and posterior rib fractures is very characteristic of the battered child syndrome. The finding of acute and chronic lesions in the same patient is highly specific for nonaccidental trauma. Fractures of long bones in patients who have yet begun to walk should also alert to possible child abuse. Lesions that are highly specific for abuse, such as classic metaphyseal fractures or posterior rib fractures, can be difficult to demonstrate radiographically and are usually clinically occult. The American College of Radiology (ACR) protocols recommend obtaining three separate X-rays of each upper and lower limb. It is important to use X-ray systems that give high resolution images with low kilovoltage (50-70 kvp) and appropriate milliamperage. A skeletal survey consisting of a series of images collimated to each body region is recommended for all children under the age of two years in whom abuse is suspected. A follow-up skeletal survey about two weeks after the initial survey is useful for detecting new fractures and for assessing the consolidation of others, which helps in dating the lesions. Head injuries are the leading cause of death in abused children. Although computed tomography is the first neuroimaging technique in nonaccidental trauma, magnetic resonance imaging of the head can better characterize the lesions seen on computed tomography and can help to estimate the age of the lesions (AU)

General practitioners' conflicts of interest, the paramountcy principle and safeguarding children: a psychodynamic contribution.

Wainwright and Gallagher propose that when child protection concerns emerge significant difficulties arise for General Practitioners because of conflicts between the individual interests of children and parents who are their patients and the Paramountcy Principle. From a psychodynamic perspective their analysis does not give sufficient weight to the nature of personal as opposed to interpersonal conflict of a conscious or unconscious nature. When issues of major import arise, ordinary parenting inevitably involves parents in putting their children's needs first if competing possibilities occur. It is an over-simplification to present this as a conflict between the interests of children and parents. Parents' own best interests are served by securing their children's safety and welfare. An appreciation of this is crucial in order to implement child protection procedures appropriately. Errors may occur because the complex emotions and relationships involved lead professionals to experience themselves as potential agents of harm rather than benefit.

Excusable deficiency: staff perceptions of mothering at shelters for abused women.

This study examined how staff members in shelters for abused women perceive the women's mothering and the challenges when working with these mothers. Data were collected through focus group interviews with 30 workers at Israeli shelters for abused women. Findings revealed that workers typically held a "deficit perspective" when describing the residents' mothering skills. Most seemed committed to the notion of empowerment as a guiding framework for intervention with the women and made an effort to facilitate the women's choices and autonomy in spite of the obstacles. The study examined workers' perceptions from personal, professional, and sociocultural perspectives.

Influence of neighbourhood collective efficacy on adolescent sexual behaviour: variation by gender and activity participation.

BACKGROUND: Adolescent sexual engagement is a good proxy measure of health risks in the USA owing to a higher prevalence of risky sexual behaviours among sexually active adolescents and to associated undesirable health outcomes. Neighbourhood collective efficacy is considered a potential social process that may prevent or delay early sexual engagement among adolescents. This study examined whether neighbourhood collective efficacy is associated with adolescent lifetime sexual intercourse and whether the association differs by gender, out-of-school activity participation and race/ethnicity. METHODS: This study is a two-level multilevel analysis of the 2000-01 Wave 1 Los Angeles Family and Neighborhood Survey (L.A.FANS-1) data. Responses of 2671 adults who answered collective efficacy-related questions were used to create a tract-level measure of collective efficacy (65 tracts). The tract-level collective efficacy measure was linked to adolescents 12-17 years old who answered a question on lifetime sexual intercourse (n= 859). Individual and family factors including age, gender, race/ethnicity, parental monitoring, activity participation, family composition and family income were controlled for to estimate neighbourhood effects net of individual and family differences. Interactions of collective efficacy with individual-level covariates were also tested. RESULTS: The protection of collective efficacy against lifetime sexual intercourse was significant only among boys [odds ratio (OR) = 0.67, 95% confidence interval (CI) = 0.47, 0.95]. The effect differed by participation status in out-of-school activities. The influence of collective efficacy was significant only in boys who did not participate in out-of-school activities (OR = 0.46, 95% CI = 0.29, 0.73). The association of collective efficacy with the outcome was similar across racial/ethnic groups including Latino adolescents. CONCLUSIONS: This study indicates the role of neighbourhood collective efficacy in protecting against adolescent sexual engagement with variation by gender and activity participation status. Findings point to the importance of considering specific neighbourhood characteristics and cross-level interactions in developing effective policies and programmes.

Self-injurious behavior and functional analysis: where are the descriptions of participant protections?

This study examined the reporting of participant protections in studies involving functional analysis and self-injurious behavior and published from 1994 through 2008. Results indicated that session termination criteria were rarely reported and other specific participant safeguards were seldom described. The absence of such information in no way indicates that functional analysis procedures were unethical or otherwise inappropriate, although the fact that participants emitted many self-injurious responses in some studies where no protections were described and no rationale for requiring such a large sample of behavior was provided is cause for concern. Future publications would benefit from the inclusion of clear and detailed specifications of participant protections.

Respecting autonomy in young people.

Paediatricians have a duty to protect the life and health of their patients and to respect their autonomy. Usually, there will be no conflict between these duties. Both children and parents want effective care and agree to the medical interventions that that are most likely to provide it. However, when children refuse or resist such interventions, it may be unclear when the duty to protect trumps the duty to respect. This is because children may have differing levels of autonomy, sometimes making them competent to make medical decisions for themselves and at other times not. Further, there may be conflict between the children and their parents in such circumstances. Children may refuse treatments that parents desire or vice versa. Sometimes paediatricians may agree with the child in the face of legal powers of parental guardianship. At other times they may agree with the parents, facing the prospect of forcing treatment on an unwilling child with potentially devastating psychological consequences. This paper will explore this potential ethical and legal minefield by evaluating some practical clinical cases based on the experiences of the primary author. It provides a range of examples of these different types of conflicts, including especially problematic "hard cases" that concern the withdrawal of life-sustaining treatment and child protection. The goal of the article is not simply to morally and legally outline the boundaries of such tensions in paediatric care. It also provides concrete advice about how they should best be resolved in everyday clinical practice.

Medicine vs. prayer: the case of Kara Neumann.

Religious beliefs and the use of complementary and alternative medicine can help or hinder health care and the well being of children, who are often unable to make informed decisions for themselves, but instead, depend on their parents or caregivers to make health care decisions for them. Tragically, this can sometimes result in prolonged suffering and death when parents or caregivers refuse treatment due to their own personal beliefs. This two-part article explores the case of Kara Neumann, an 11-year-old girl who died after her parents denied her medical care in lieu of prayer to cure her "spiritual attack," and the role pediatric nurses can play in educating patients and their families.