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中华妇幼临床医学杂志(电子版)

Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition) ›› 2024, Vol. 20 ›› Issue (04): 420 -430. doi: 10.3877/cma.j.issn.1673-5250.2024.04.009

Original Article

Survey on current status of knowledge-attitudes-practices of clinical diagnosis and treatment of infant cow's milk protein allergy among pediatricians and analysis of its influencing factors

Yini Wang1, Fan Yang1,†(), Mei Tang1, Yun Xiang1, Jinhui Wu1, Hong Luo1   

  1. 1.Department of Child Health Care，Key Laboratory of Birth Defects and Related Diseases of Women and Children（Sichuan University），Ministry of Education，West China Second University Hospital，Sichuan University，Chengdu 610041，Sichuan Province，China
  • Received:2024-04-02 Revised:2024-06-12 Published:2024-08-01
  • Corresponding author: Fan Yang
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Objective

To investigate the current status and influencing factors of knowledgeattitudes-practices （K-A-P）among pediatricians regarding the clinical diagnosis and treatment of infant cow's milk protein allergy （CMPA）.

Methods

A total of 546 pediatricians from medical institutions at various levels in Sichuan Province from November to December 2022 were selected as survey subjects by convenient sampling method.A self-designed questionnaire on K-A-P Regarding the Clinical Diagnosis andTreatment of Infant CMPA was administered to these pediatricians.Independent-samples t test or one-way ANOVA were used for univariate analysis of influencing factors of K-A-P scores of clinical diagnosis and treatment of infant CMPA，and multiple linear stepwise regression analysis was used for multivariate analysis.This study complied with the requirements of the HelsinkiDeclaration of the WorldMedical Association

Results

①A total of 554 questionnaires were collected，of which 546 were valid，with a valid questionnaire collection rate of 98.6%.②The scores of K-A-P dimensions of clinical diagnosis and treatment of infant CMPA were （13.3±3.2）points， （27.5±3.6）points，and （51.7±9.8）points，respectively.In the K dimension，there were 8 items with a wrong answer rate of＞50%.The lowest score in the A dimension was for the reverse question "Avoiding milk and eggs during maternal pregnancy reduces the incidence of allergic diseases in offspring"，with 31.9%（174/546）respondents choosing"strongly agree or agree".In the P dimension，34.2%（187/546）respondents"sometimes，occasionally，or never"followed CMPA-related guidelines for the home-based"gradual introduction of milk proteins"in children with mild to moderate non-immunoglobulin（Ig）E mediated CMPA.③Univariate analysis showed that the highest educational level，professional title，hospital level，and department were potential influencing factors for scores of K dimension of clinical diagnosis and treatment of infant CMPA （P ＜0.05）；hospital level and department were potential influencing factors for scores of A dimension （P＜0.05）；professional title，working lifetime，hospital level，and department were potential influencing factors for scores of P dimension （P ＜0.05）.④Multivariate analysis revealed that the regression equations for K-A-P scores of clinical diagnosis and treatment of infant CMPA were y K =13.087+1.612 dep1+2.208 dep2-4.113 dep3，y A=27.697+0.895 dep1+1.770 dep2，y P=51.970+2.623 dep1+5.904 dep2，and y K，y A，and y P represented the scores of respective dimensions，and dep1，dep2，dep3 represented child healthcare department，pediatric gastroenterology department，and otolaryngology department，respectively.Conclusions The current K-A-P levels of pediatricians in the management of infant CMPA are insufficient，which are manifested in misconceptions about knowledge，lack of confidence in attitudes and insufficiently standardized behaviors.The department where the pediatrician works is a common influencing factor on the scores of K-A-P dimensions of the clinical diagnosis and treatment of CMPA in infants.The communication and unification between different specialties is very n ecessary.Targeted training and communication for pediatricians in relevant departments will help improve the K-A-P level and standardize diagnosis and treatment behaviors of CMPA.

Key words: Cow's milk protein allergy, Food hypersensitivity, Practice patterns，physicians', Knowledge, Attitude, Behavior, Pediatricians
表1 本研究546名被调查者一般资料比较［例数（%）］
项目 构成比
性别
男 86（15.8）
女 460（84.2）
年龄（岁）
≥20～30 73（13.4）
≥30～40 236（43.2）
≥40～50 163（29.8）
≥50～60 67（12.3）
≥60 7（1.3）
最高学历
大专及以下 37（6.8）
本科 374（68.5）
硕士 119（21.8）
最高学历
博士及以上 119（21.8）
职称
初级 132（24.2）
中级 229（41.9）
副高级 135（24.7）
正高级 50（9.2）
工作年限（年）
＜5 79（14.4）
≥5～10 120（22.0）
≥10～15 118（21.6）
≥15～20 67（12.3）
≥20 162（29.7）
所在医院等级
一级及以下 55（10.1）
二级 75（13.7）
三级 416（76.2）
所在科室
儿童保健科 227（41.6）
小儿消化科 30（5.5）
皮肤科 6（1.1）
耳鼻喉科 4（0.7）
儿童内科 244（44.7）
全科 35（6.4）
表2 本研究546名被调查者CMPA 诊疗相关K 维度中回答错误率排名前8位的条目及回答错误率［例数（%）］
CMPA诊疗相关K维度条目 回答错误率
CMPA全程膳食回避时间原则上不能＜3个月 478（87.5）
CMPA发病机制 417（76.4）
CMPA婴儿在辅食添加时应回避八大常见致敏食物（鸡蛋、大豆、小麦、鱼、虾等带壳海鲜、坚果、花生等） 371（67.9）
对有FA阳性病史婴儿可诊断为FA 343（62.8）
伴血便的CMPA患儿应被诊断为重度CMPA 329（60.3）
IgG参与介导FA 328（60.1）
伴严重湿疹的CMPA患儿应被诊断为重度CMPA 304（55.7）
人工或混合喂养儿被诊断为CMPA后，可使用部分水解奶粉继续喂养 275（50.4）
表3 本研究546名被调查者对婴幼儿CMPA 临床诊疗的K-A-P维度得分最高的3个条目及其得分（分，±s）
不同维度条目 得分
K维度
CMPA诊断的金标准 0.94±0.24
人工或混合喂养儿被诊断为重度CMPA后，首选氨基酸奶粉喂养 0.93±0.26
皮肤点刺试验结果呈阴性时提示无FA 0.90±0.30
A维度
CMPA早期诊断及正确治疗，有利于减轻疾病对患儿生长发育的影响 4.68±0.60
CMPA的管理需要根据患儿具体情况，考虑由儿童保健科、消化科、皮肤科、耳鼻咽喉科及呼吸科多学科协作 4.50±0.71
未准确识别CMPA可能增加医疗风险，甚至可能引发医疗纠纷 4.38±0.74
P维度
详细采集可疑CMPA患儿的变态反应史 4.32±0.78
详细采集可疑CMPA患儿的家族史 4.29±0.82
指导CMPA患儿的家长在购买食品和营养补充剂前，应先仔细阅读产品标签 4.08±0.90
表4 本研究546名被调查者对婴幼儿CMPA临床诊疗的K-A-P维度得分最低的3个条目及其得分［分，M（Q1，Q3）或±s］
不同维度条目 得分
K维度
CMPA全程膳食回避时间原则上不能＜3个月 0（0，0）
CMPA发病机制 0（0，0）
CMPA婴儿在辅食添加时应回避八大常见致敏食物（鸡蛋、大豆、小麦、鱼、虾等带壳海鲜、坚果、花生等） 0（0，1）
A维度
母亲孕期回避牛奶和鸡蛋，会降低子代变态反应性疾病发生率 2（3，4）
清楚重度与轻、中度CMPA判断标准 3.55±0.87
有足够的知识储备来指导CMPA患儿的诊疗及随访 3.63±0.84
P维度
依据CMPA相关指南指导轻、中度非IgE介导的CMPA患儿在家庭中进行“牛奶蛋白梯度引入” 3.78±1.01
要求母乳喂养的CMPA患儿家长记录母亲的每日饮食 3.79±1.09
要求家长记录CMPA患儿每日饮食 3.84±1.05
表5 不同特征被调查者婴幼儿CMPA 临床诊疗的K-A-P维度得分比较（分，±s）
不同特征被调查者 例数 K维度 A维度 P维度
得分 统计量 P值 得分 统计量 P值 得分 统计量 P值
性别 t=-1.30 0.195 t=1.12 0.262 t=0.35 0.727
男 86 12.9±3.3 27.9±3.4 52.0±9.8
女 460 13.4±3.2 27.4±3.7 51.6±9.7
年龄（岁） F=1.50 0.201 F=1.38 0.239 F=2.13 0.076
≥20～30 73 12.9±2.9 26.8±4.1 50.8±9.6
≥30～40 236 13.2±3.2 27.5±3.8 50.6±10.6
≥40～50 163 13.7±2.9 27.4±3.3 53.1±8.7
≥50～60 67 13.5±3.8 28.2±3.5 53.0±8.8
≥60 7 11.6±4.2 28.6±3.7 53.1±8.5
最高学历 F=4.18 0.006 F=0.60 0.642 F=2.32 0.074
大专及以下 37 12.4±3.8 26.9±3.3 52.0±8.8
本科 374 13.2±3.2 27.5±3.7 51.0±9.8
硕士 119 13.7±3.0 27.7±3.8 53.5±9.9
博士及以上 16 15.4±2.9 28.0±2.9 54.1±9.4
职称 F=7.05 ＜0.001 F=2.14 0.094 F=3.10 0.026
初级 132 12.3±3.1 27.2±3.9 51.1±9.8
中级 229 13.4±3.2 27.3±3.7 50.7±10.3
副高级 135 13.8±3.1 27.8±3.1 53.1±8.1
正高级 50 14.3±3.0 28.5±4.1 54.2±10.4
工作年限（年） F=0.39 0.817 F=1.31 0.266 F=3.02 0.018
＜5 79 13.0±2.7 26.9±4.1 51.6±9.8
≥5～10 120 13.4±3.3 27.1±3.5 49.5±10.2
≥10～15 118 13.3±3.3 27.8±3.9 51.5±10.9
≥15～20 67 13.2±3.0 27.7±3.4 51.3±8.5
≥20 162 13.5±3.4 27.8±3.4 53.5±8.7
所在医院等级 F=6.35 0.002 F=5.84 0.003 F=4.10 0.017
一级及以下 55 12.1±3.6 26.3±4.1 48.8±11.4
二级 75 12.8±3.0 26.8±3.6 50.2±9.9
三级 416 13.6±3.1 27.8±3.5 52.3±9.4
所在科室 F=10.68 ＜0.001 F=3.75 0.002 F=6.08 ＜0.001
儿童保健科 227 14.0±3.4 27.9±3.7 52.9±9.0
小儿消化科 30 15.3±2.6 29.4±3.2 57.6±7.1
皮肤科 6 12.7±2.4 25.8±3.7 44.0±11.5
耳鼻喉科 4 8.8±2.2 28.3±5.0 48.0±15.5
儿童内科 244 12.9±2.7 27.2±3.5 50.7±9.7
全科 35 11.2±3.6 26.2±4.0 47.2±12.3
表6 被调查者婴幼儿CMPA 临床诊疗的K-A-P维度得分影响因素的多重线性逐步回归分析及多重共线性诊断结果
自变量 非标准化 标准化偏回归系数 t值 P值 非标准化偏回归系数95%CI 多重共线性诊断
偏回归系数 标准误 容忍度 VIF
K维度得分
常数项 13.087 0.210 — 62.23 ＜0.001 12.675～13.499 - -
学历（vs本科及以上）
大专及以下 -0.865 0.505 -0.068 -1.71 0.087 -1.855～0.125 0.918 1.089
所在医院等级（vs三级）
一级及以下 -0.919 0.523 -0.087 -1.76 0.080 -1.943～0.105 0.596 1.677
二级 -0.414 0.363 -0.045 -1.14 0.255 -1.125～0.711 0.947 1.056
所在科室（vs儿童内科）
儿童保健科 1.612 0.274 0.249 5.88 ＜0.001 1.075～2.149 0.810 1.235
小儿消化科 2.208 0.557 0.158 3.97 ＜0.001 1.117～3.299 0.919 1.088
皮肤科 -0.289 1.194 -0.009 -0.24 0.809 1.117～3.299 0.955 1.047
耳鼻喉科 -4.113 1.451 -0.110 -2.84 0.005 -6.953～-1.273 0.967 1.034
全科 -0.396 0.665 -0.030 -0.60 0.552 -1.698～0.906 0.557 1.796
A维度得分
常数项 27.697 0.261 — 106.31 ＜0.001 27.016～28.378 - -
所在医院等级（vs三级）
一级及以下 -1.018 0.648 -0.084 -1.57 0.117 -2.287～0.251 0.596 1.677
二级 -0.718 0.450 -0.068 -1.60 0.111 -1.600～0.164 0.947 1.056
所在科室（vs儿童内科）
儿童保健科 0.895 0.340 0.121 2.64 0.009 0.229～1.561 0.810 1.235
小儿消化科 1.770 0.690 0.111 2.57 0.011 0.454～3.086 0.919 1.088
皮肤科 -0.819 1.479 -0.023 -0.55 0.580 -3.718～2.080 0.955 1.047
耳鼻喉科 1.620 1.797 0.038 0.90 0.368 -1.907～5.147 0.967 1.034
全科 0.527 0.824 0.035 0.64 0.523 -1.079～2.133 0.557 1.796
P维度得分
常数项 51.970 0.698 — 74.50 ＜0.001 50.597～53.343 - -
所在医院等级（vs三级）
一级及以下 -1.391 1.736 -0.043 -0.80 0.423 -4.798～2.016 0.596 1.677
二级 -1.514 1.204 -0.054 -1.26 0.209 -3.876～0.848 0.947 1.056
所在科室（vs儿童内科）
儿童保健科 2.623 0.910 0.133 2.88 0.004 0.838～4.408 0.810 1.235
小儿消化科 5.904 1.846 0.138 3.20 0.001 2.290～9.518 0.919 1.088
皮肤科 -5.274 3.960 -0.056 -1.33 0.183 -13.034～2.486 0.955 1.047
耳鼻喉科 -1.132 4.812 -0.010 -0.24 0.814 -10.557～8.293 0.967 1.034
全科 -0.690 2.207 -0.017 -0.31 0.755 -5.010～3.630 0.557 1.796
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