Of the 166 surveyed, 19 participants were excluded because they did not complete the full questionnaire. Therefore, the final number of participants included in the study was 147(88.6%).
Socio-demographic and professional characteristics of the participants are shown in Table 1. Median age was 39(31-46) years and 50.3% were Males. Most of the respondents were pediatricians 77(52.4%) and only 6 (4.1%) were associate consultants. 48.3% of participants reported their current work setting was a primary care center and 51.7% a tertiary care center. Approximately 50% of the participants reported that more than 10 pediatricians’ practice at their centers and 60.5 % reported that there was a pediatric fellowship associated with their centers; Table 1.
In case 1, there were wide variations in the diagnostic procedures recommended by participants (Table 2). The majority of respondents recommended additional laboratory tests to the CBC test; SF and TIBC were the most frequent (70.7%, 51%, respectively) recommended additional tests. However, only 15.6% of the respondents selected the “no other tests necessary” option. Moreover, 2% of respondents suggested blood film as another additional lab test not include in the list.
Amongst the listed oral iron preparation, most (77.6%) of the respondents preferred treatment with ferrous sulfate; previous successful experience was the most (51%) cited reason. In terms of total daily iron dose, the respondents’ recommendations were equally distributed across the three listed choices.
Respondents were asked about total daily elemental iron dose they will recommend based on the degree of anemia severity. If the patient’s Hb was 6.1 g/dl (rather than 8.1 g/dl), 8.8% indicated that they would not change the dose. The majority (47.6%) of the respondents recommended a 6 mg/kg dose, whereas 5.4% would choose a 2-3 mg/dl dose. In case of patient’s Hb was 10.1 g/dl (rather than 8.1 g/dl), 19% indicated they would not change the dosage, whereas the majority (34%) would choose a 2-3 mg/dl dose and 24.5% of the respondents would choose a 4-5 mg/dl dose. In terms of dose frequency, the majority (57.1%) recommended 2 doses (BID) and 34% recommended a once daily dose (QDay).
In regard to recommended course of action for the Hb value below which blood transfusion should definitely be recommended, for well compensated children, wide variability in responses was found. Approximately 38% recommended blood transfusion when Hb value is 6 g/dl, whereas 21% responded that there is no Hb below which they would recommend a blood transfusion. Hb values from 3-5 g/dl were chosen by some respondents in different percentages; 7.5% to 14.3%.
As a continuation of this case scenario, participants were asked whether they will continue oral therapy at the 12th weeks visit if the patient’s hemoglobin is 12.2 g/dL, MCV 78 fL and ferritin 25 ng/mL and his whole cow milk intake is limited. Approximately 31% indicated that they will not continue iron therapy, 36.1% indicated that they will continue iron therapy 1-2 additional month and 25% they recommend continuation for a further 3 months or more, and 4% indicated other continuation periods.
In case scenario 2, majority of respondents recommended treatment with ferrous sulfate (76.2%) divided into two daily doses (62.6%). While 50.3% of respondents reported that patient’s daily dose should be based on weight, 49.7% recommended that dose should be based on number of tablets. For participants who reported that the daily dose will be based on the number of tablets, approximately 42.5% reported that they will choose 1 iron tablet daily, 53.4% reported that they will choose 2-3 iron tablets daily, and 4.1% reported other numbers of tablets. In terms of those who recommended daily dose should be based on the weight, 32.4% recommended a 2-3 mg/kg dose, 58.1% recommended a 4-5 mg/kg dose and 6.7% indicated other doses; Table 3.
In continuation to the case scenario 2, respondents were asked regarding parenteral iron treatment they would recommend in case there is no response to oral iron. Most (42.9%) respondents indicated IV iron dextran. While 32.7% of prefer IV iron saccharate, 13.4% reported that they would continue oral iron therapy. Moreover, 10.9% of respondents specified some other treatments in the free text comment instead of listed options, including seeking the advice of dietitian, refer to hematologist, and admission for observation.
Correct responses on different questions related to diagnosis and management of IDA are represented in table 4. Participants were less likely to consider no other laboratory test necessary beyond CBC 23(15.6%). However, SF had the highest proportion of the preferred lab tests; 71.2%.
Majority of the respondents recognized the appropriate oral iron preparation (87.8%) and related factors that should guide their recommendations of the optimum oral iron preparation; 95%. While the vast majority of participants (99.3%) could properly divide the total daily iron dose, 68% were able to identify the total daily elemental iron dose. Percentages of the correct answers related to which total daily elemental iron dose they would choose if the Hb was 6.1 g/dl or 10.1 g/dl (rather than 8.1 g/dl) were 78.9%, 61.9%, respectively. However, they were less likely to know the Hb value below which they would recommend blood transfusion (33.3%). Approximately 64 % of the participants identified the correct answer associated with continued iron therapy when the patient improved and lab result showed normal Hb, MCV, and ferritin values. For case scenario 2, a high proportion identified the correct oral iron preparation (85%), and only half of them were able to indicate the correct daily dose. However, 58.1% of them had positive knowledge about weight-based dose. While 99.3% of participants could know the correct division of the total daily iron dose, only 32.7% of them identified the optimum parenteral iron treatment.
Differences in overall median scores of correct answers by demographic and professional characteristics are represented in table 5. Overall scores differed significantly by professional qualification (P=0.007) and type of current work setting (P=0.043).
Robust regression analysis for factors associated with overall score is represented in table 6. In univariate analysis, professional qualification and type of current work setting were the only two variables statistically significantly associated with overall score. In the final multivariate analysis model, the only variable that was independently significantly associated with increased overall scores was professional qualification (P=0.017). Score of Pediatric Hematologists was 14.98 times higher than score of GPs (β=14.98, CI 6.81-23.15, P<0.0001). Compared with scores of participants who work in primary care, score of participants who work in tertiary care was 3.63 times higher (β=3.63, CI -0.03-7.28, P 0.05).
Based on findings of the above detailed regression analysis, further analyses were carried out to fully describe differences in scores both in the diagnostic and therapeutic domains questions by professional qualifications and type of current work setting. Consistently, the proportion of those achieved highest score of correct answers were pediatric hematologists, compared with respondents with other professional qualifications. General Practitioners had the lowest proportion. Moreover, participants who work in tertiary care had significantly higher proportion of those achieved highest score of correct answers compared with those who work in primary care.