The importance of relational care.

P131: Food Handling Practices and Eating Preferences of Child and Adult Care Providers

SPN Position Statement: Transition of Pediatric Patients Into Adult Care

Nutrition and Child Care: A Healthy Head Start

1. Timothy R. Shope, MD, MPH* 1. *Department of Pediatrics, Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA. * Abbreviations: AAP: : American Academy of Pediatrics CFOC3: : Caring for Our Children , 3rd ed ECE: : early care and education RSV: : respiratory syncytial virus Out-of-home care and education are the norms for most young children and lead to increased exposure to infectious diseases. Pediatricians need to be aware of strategies to reduce the risk of infection and guidelines for determining exclusion and return to care for mildly ill children who participate in group care arrangements. After completing this article, readers should be able to: 1. Recognize the risks of infectious diseases in children who participate in early care and education programs. 2. Understand methods for reducing infectious diseases in early care and education settings. 3. Identify which infectious diseases require exclusion from early care and education programs. Two-thirds of children younger than 6 years participate in nonparental out-of-home early education and child care. Demographic trends during the past several decades reflect an increased desire and need to work for men and women who are parents. During the first 2 years of participation, children enrolled in early care and education (ECE) programs experience a higher incidence of respiratory and diarrheal infections, otitis media, and antibiotic-resistant bacteria compared with their peers primarily cared for at home. The types of infection generally reflect common respiratory and gastrointestinal viruses in circulation in the community. However, there are some infectious diseases that can cause outbreaks or clusters of infections in ECE settings. When ill children are excluded from an ECE facility, parents may miss work, lose income, and seek health care services in an effort to return their children to child care. Pediatricians need to be aware of the infectious disease risks of child care attendance and various strategies for reducing them. In addition, pediatricians need to be knowledgeable about rational exclusion and return …

Choices abound for 2013–14 influenza season

Pediatricians have long recognized that social determinants (the circumstances in which children live, learn, and play) influence the health and well-being of children and their families. The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of this broader scope of health care, which encompasses more than simply addressing a child’s medical conditions. Although the vast majority of COVID-19 cases in children have been mild, the secondary effects on the health of children have been profound. Downstream effects of the virus on a family’s social circumstances, including increased food insecurity, housing instability, school closures, and lack of child care, have exacerbated preexisting socioeconomic and racial disparities. Although it has often been overlooked, the need for safe and enriching child care that allows parents to be able to work, particularly for the most vulnerable children in our society, has become more acute over the last several months and requires urgent action.

Big Sister, Big Brother: A Mixed Methods Study on Older Siblings’ Role in Infant and Young Child Feeding and Care in Rural Tanzania (P10-020-19)

In this chapter, the author talks about the importance of geriatric medicine in today’s healthcare environment. The basic tenets of geriatric medicine are reviewed and compared to the field of palliative medicine. A personal example is given on why doing less is often better for the older patient. Another example of an older patient with prostate cancer highlights the importance of a more conservative approach to care in older adults. The chapter closes with descriptions of the geriatric approach to care and the geriatric model of care. These are based on the MedWiseTM Philosophy of Care, developed by a group of geriatricians in the mid 1990s.

Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians

Addressing the Need for New Models of Care for Older Adults Receiving Long-term Dialysis

Introduction In 2014 a CROWN (Croatia, Workability, Nurses) study was conducted in Croatian nurses employed in clinical hospitals to determine general health status, physical and psychosocial health of nurses, prevalence and distribution of hand eczema and musculoskeletal symptoms and their influence on daily functioning. Data for musculoskeletal complaints and daily functioning with nurses employed in child and adult care will be shown. Methods A Nordic standardised questionnaire for evaluation of musculoskeletal complaints accompanied with Lickert scale for self-evaluation of complaints and a Disability of arm, shoulder and hands (DASH) questionnaire for daily functioning, were used for this part of research in 115 nurses from three large clinical hospitals for children and two large clinical centres for adults. In both groups, the analysis of musculoskeletal pain (sites, frequency) and daily functioning will be compared to duration of work experience, number of patients, patients’ weight and nurses’ general health. Results The prevalence rate of musculoskeletal complaints among our cohorts of nurses was 95% in child care, and 98,6% in adult care. Lower back pain and neck pain were the most frequent complaints in both groups. Lower back pain had the highest influence on daily functioning. Other co-morbidity and problems in daily functioning in both groups will be shown. Conclusion The prevalence rate for musculoskeletal complaints in this study was very high, higher then reported in similar other studies. That has confirmed the great need for analysing reasons for such a high prevalence of complaints, and taking actions which will reduce their contributing factors and influence on daily functioning. Although the nurses are highly aware of this problem a need exists for formal training in ergonomics, maintenance of adequate posture and taking micro-breaks in reducing WRMDs.

A 16-year-old boy presents with 3 days of pain on urination and bloody discharge at the end of urination. There is no history of fever, sore throat, rash, bloody diarrhea, trauma, medication intake, recent bladder catheterization, easy bruisability, sexual activity, or sickle cell disease. The family history is negative for hematuria, renal disorders, or deafness.On physical examination, the boy is alert and in no distress. All vital signs are normal. His weight is 92.8 kg (>97th percentile), height is 168 cm (10th percentile), and body mass index is greater than the 95th percentile. The rest of the findings are within normal limits.During initial laboratory investigation, urinalysis shows 10 to 15 eumorphic red blood cells (RBCs)/high power field (hpf), 2 to 5 WBCs/hpf, and a positive test for leukocyte esterase. He is treated with trimethoprim-sulfamethoxazole and asked to return for follow-up.The urine culture as well as gonorrhea and Chlamydia screening tests sent at the initial evaluation are negative. His dysuria persists, and he experiences another episode of gross hematuria. The physical examination findings remain unchanged. A repeat urinalysis shows 30 to 50 eumorphic RBCs/hpf. Serum electrolyte and creatinine concentrations are normal, urine creatinine is 401.7 mg/dL (35,510.3 mcmol/L), urine calcium concentration is 14.4 mg/dL (3.6 mmol/L) (urine calcium-to-creatinine ratio, 0.03), prothombin time is 11.90 seconds, activated partial thromboplastin time is 32.5 seconds, international normalized ratio is 0.98, Hgb is 12.9 g/dL (129 g/L), and platelet count is 275×103/mcL (275×109/L). Serum concentrations of complement C3 and C4 and antistreptolysin A (ASO) titer are normal. An additional study reveals the diagnosis.A 6-week-old girl is brought to the ED for evaluation of poor weight gain. She was born at term by normal vaginal delivery without any complications and went home with her mother. Her birthweight was 3 kg, which is her current weight.On physical examination, the baby's heart rate is 134 beats/min and respiratory rate is 70 breaths/min. She has grunting, intercostal and abdominal retractions, and nasal flaring. Her pedal pulses are delayed and weak. The upper extremity blood pressure is 125/65 mm Hg and the lower extremity blood pressure is 71/53 mm Hg. Her oxygen saturation is 100% in room air. Her heart rate and rhythm are regular. She has a soft grade 1/6 systolic ejection murmur at the apex and right upper sternal border. Capillary refill time is 4 seconds. The lungs are clear to auscultation bilaterally. Her liver is palpable to 2 cm below the right costal margin, and its span is 5 cm.Chest radiography shows cardiomegaly and increased pulmonary vascularity. An ECG shows right ventricular hypertrophy, nonspecific ST-T changes, and sinus tachycardia. Her WBC count is 15.6×103/mcL (15.6×109/L) (28% neutrophils, 59% lymphocytes, 8.2% monocytes, 2.8% eosinophils, 2% basophils), and Hgb is 11.7 g/dL (117 g/L). Urinalysis and serum electrolyte measurements are normal. An imaging study confirms the diagnosis.A 9-year-old boy presents with headaches, neck pain, and vomiting for 2 weeks. His symptoms are worse in the morning and improve during the day. There is no history of fever, abdominal pain, rash, diarrhea, or visual changes.On physical examination, he is afebrile, alert, and oriented. His funduscopic examination reveals bilateral papilledema. His neurologic examination findings otherwise are normal. Skin examination reveals multiple hyperpigmented nevi (Fig. 1). His head CT scan yields normal results. A lumbar puncture (LP) discloses an elevated opening pressure of 44 cm H2O (normal <20 cm H2O). CSF analysis shows 8 WBCs/mcL, 1 RBC/mcL, glucose of 19 mg/dL (1.1 mmol/L) (serum glucose, 91 mg/dL [5.1 mmol/L)]), and protein of 23 mg/dL. No organisms are seen on the Gram stain.His headache worsens over the next day. A repeat LP shows an elevated opening pressure (42 cm H2O) and WBC count (14 cells/mcL). Results of polymerase chain reaction tests for herpes simplex virus and enterovirus as well as a cryptococcal antigen test are negative. An MRI of the brain shows T1 enhancement abutting the meninges in his left frontal lobe and bilateral temporal lobes, findings believed to be consistent with encephalitis.The boy is started on acetazolamide for persistent elevated intracranial pressure, but has only minimal relief. A ventriculoperitoneal shunt is placed due to his persistent intracranial hypertension and need for serial therapeutic LPs. Shunt placement relieves his headache initially, but 6 days later he develops generalized tonic-clonic seizures, right-sided weakness, and aphasia. Head CT shows no abnormality. A repeat MRI and the results of additional CSF studies reveal the diagnosis.Bladder ultrasonography demonstrated a 2.30×1.21×1.39-cm lobulated solid mass arising from the posterolateral wall of the left side of the bladder (Fig. 2). The CT scan did not reveal any intraluminal mass. Diagnostic rigid cystoscopy identified a 3-cm solid mass, and transurethral bladder tumor resection was performed. Pathology confirmed the diagnosis of an inverted papilloma without any infiltration into the muscularis of bladder. Postoperative urine cytology was negative for malignant cells. The boy was followed in the urology clinic with annual cystoscopy for 3 years and had no recurrence of growth.Hematuria in children and adolescents is associated most commonly with renal disease. Microscopic hematuria is defined as more than 5 RBCs/hpf in the sediment of freshly voided urine. Gross hematuria is visible to the naked eye. A careful history should include inquiry for symptoms such as dysuria, frequency, urgency, fever, and flank or abdominal pain. In addition, it is important to ascertain the color of the urine and whether blood was mixed with the entire stream or whether it was terminal hematuria. This patient presented with dysuria and terminal hematuria; the urine culture yielded negative results, making infection an unlikely cause of his symptoms. The lack of abdominal pain and the results of microscopic urinalysis did not support nephrolithiasis, and the normal values for urinary calcium and creatinine excluded hypercalciuria.The absence of sore throat or recent skin infection as well as the presence of normal concentrations for C3, C4, and ASO titer eliminated poststreptococcal glomerulonephritis as the cause for hematuria. Nonstreptococcal glomerulonephritis could be present, but those conditions do not present with terminal hematuria. The normal serum creatinine, hemoglobin, and platelet values ruled out hemolytic-uremic syndrome as well as hemolytic anemia.The family history was negative for renal disease, sickle cell disease or trait, and hearing problems, making a diagnosis of familial conditions such as immunoglobulin A nephropathy, sickle cell disease, and Alport syndrome unlikely as the cause for his hematuria.After exhaustive investigations for the most common causes of blood in the urine, clinicians should consider rare causes of gross hematuria.Inverted transitional cell papilloma is a rare tumor that commonly occurs in the bladder, especially in the trigonal area, but may occur in the renal pelvis and ureter. Inverted papilloma of the urinary bladder is rare in children and occurs more frequently in males than in females, with a peak incidence at 60 to 70 years of age. The papilloma generally presents with painless hematuria and occurs as solitary mucosal nodule or 1- to 3-cm sessile polypoidal lesion.Papillomas can occur as a de novo neoplasm or can develop in patients who have a history of bladder cancer. This patient had a de novo neoplasm called transitional cell papilloma, a tumor that has no nuclear anomalies and is covered with urothelium-like cell layers. The absence of mitosis in the nucleus was consistent with a benign tumor.Tumor resection is the mainstay of therapy. The recurrence rate for these tumors is approximately 50%, with a 10% chance of developing transitional cell carcinoma. Therefore, patients who have this condition require long-term follow up to define the biologic behavior and prognosis for the tumor.The presence of congestive heart failure, delayed and weak pedal pulses, and an increased blood pressure gradient between upper and lower extremities led to the suspicion of coarctation of the aorta. Echocardiography confirmed the diagnosis (Fig. 3).The girl underwent resection of the coarctation and end-to-end anastomosis of the aorta and had a smooth postoperative course. Although her blood pressure improved, it remained mildly elevated, and she was treated with an afterload-reducing agent. Subsequent to surgery, she started feeding without difficulty, gained weight to the 25th percentile, and had no signs of congestive failure.Hypertension is defined as the presence of systolic or diastolic blood pressure or both at or over the 95th percentile for age, sex, and height. Any elevated blood pressure should be investigated thoroughly.Although coarctation often causes hypertension in an infant, other disorders, including renal artery or renal venous thromboses, should be considered as potential causes of hypertension, especially in babies born to mothers who have diabetes mellitus or infants who had indwelling arterial or venous umbilical catheters. Renal artery stenosis and congenital renal anomalies can cause hypertension in the newborn period, and among preterm babies, bronchopulmonary dysplasia also may cause hypertension. Uncommon causes of hypertension in infancy include essential hypertension and disorders of the endocrine system such as thyrotoxicosis and pheochromocytoma.Coarctation of the aorta is a common malformation, accounting for 6% to 8% of all congenital heart defects. Girls who have Turner syndrome are at increased risk, with a prevalence as high as 35%. Most coarctations are juxtaductal (narrowing of the aorta at the point of insertion of the ductus arteriosus). Commonly, restriction occurs just distal to the left subclavian artery and, less often, just proximal to the left subclavian artery. About 85% of patients born with coarctation have bicuspid aortic valve, and 50% of patients have ventricular septal defects. Other lesions such as patent ductus arteriosus, mitral valve stenosis, aortic valve stenosis, tricuspid atresia, d-transposition of the great arteries, primum atrial septal defects, and extracardiac vascular anomalies have been reported.The aortic arch and its branches develop during the sixth to eighth week of gestation. Thoracic coarctation is a manifestation of an abnormality in development of the embryologic left fourth and sixth aortic arches. Two theories have been proposed to explain how coarctation develops. The ductus tissue theory states that coarctation develops as the result of migration of ductal smooth muscle cells into the periductal aorta, with subsequent constriction and narrowing of the aortic lumen. This concept is concordant with the clinical observation that coarctation occurs at the site of ductal insertion and often manifests after ductus closure. However, the ductal tissue theory does not explain adequately aortic coarctation that occurs away from the insertion of the ductus arteriosus, such as in the transverse arch or abdominal aorta.The hemodynamic theory proposes that coarctation develops because of hemodynamic disturbances that reduce the volume of blood flow through the fetal aortic arch.The clinical presentation varies, depending on the age of the patient and severity of the coarctation as well as the presence of other associated cardiac defects. After ductal closure in the neonate, coarctation often presents, as in this patient, with severe congestive heart failure. If the low-output state is severe enough, the patient even may develop hypotension. Neonates may be asymptomatic if the patent ductus arteriosus is open or if the coarctation is not severe.Typical clinical findings in older infants and children who have congenital coarctation of the aorta include upper extremity hypertension, diminished or delayed femoral pulses, and lower or unobtainable arterial blood pressure in the lower extremities. Older infants and children may be asymptomatic or present only with a heart murmur or systemic hypertension. Older children may present with chest pain, cold and thin lower extremities, and claudication of the calf on exercise. Adults usually present with hypertension; if the coarctation is severe, they may develop headaches, epistaxis, heart failure, or aortic dissection. Patients who have coarctation of the aorta have a higher incidence of intracranial aneurysms.Along with careful physical examination, two-dimensional and Doppler transthoracic echocardiography can establish the diagnosis, detect associated cardiac defects, and be useful in postrepair follow-up. If a question of the diagnosis exists after equivocal findings on echocardiography, CT scan or MRI of the chest can define the location and severity of the defect clearly.ECG findings may be normal in the neonate, infant, or adult who has coarctation of the aorta. Right ventricular hypertrophy is seen in the neonate who has severe disease. In older children and adults, left ventricular hypertrophy may be present with increased voltage and ST- and T-wave changes over the left precordial leads. Chest radiographic findings vary with age and severity of the coarctation. For infants who experience heart failure, the chest radiograph usually shows generalized cardiomegaly with increased pulmonary vascular markings due to pulmonary venous congestion. In older children and adults, the heart size may remain normal, but other findings such as rib notching and indentation of the aortic wall at the site of coarctation with pre- and postcoarctation dilation may be seen.After hemodynamically stabilizing the infant who has a critical coarctation, definitive repair can be performed with surgery or occasionally by balloon angioplasty. Surgical repair is the treatment of choice to correct coarctation for infants younger than 6 months of age. Some experts recommend balloon angioplasty to stabilize a neonate or infant who is in critical condition, with definitive repair performed at later date.For infants and children between 6 months and 5 years of age, data are sufficient to recommend balloon angioplasty as an option because the recurrence rate (10% to 15%) and the incidence of aneurysm formation (5% to 7%) are comparable to the results of surgical repair. For children older than 5 years of age (if the child weighs >25 kg), stenting is an option. Complications following either surgery or balloon angioplasty include recoarctation, aortic aneurysm, aortic dissection, and systemic hypertension.The boy's persistent, progressive neuropathology and his history of large, cutaneous, hyperpigmented nevi led to the clinical suspicion of neurocutaneous melanosis (NM). The diagnosis was supported by repeat brain MRI, which revealed increased leptomeningeal enhancement at the areas affected in his previous study (Fig. 4). CSF flow cytometry demonstrated atypical cells that had positive immunostaining for melanocytic markers. He underwent a brain biopsy, which revealed both leptomeningeal and brain parenchymal melanocytic lesions.The boy's weakness improved some over the following weeks, but he continued to have seizures and persistent aphasia. MRI performed 4 months after his previous study showed significant disease progression (Fig. 5). He received chemotherapy and craniospinal radiation. After a brief period of stabilization, his condition deteriorated, and he died 8 months after his initial presentation.NM is a rare, noninheritable, congenital syndrome characterized by large or multiple melanocytic nevi and associated benign or malignant melanocytic tumors of the CNS. Large nevi are at least 20 cm in diameter in older children and adults and greater than 9 cm on the head or greater than 6 cm on the body in infants. Multiple nevi is defined as three or more lesions. Although its pathogenesis is not understood fully, NM generally is believed to result from an error in the embryonal development of the neuroectoderm because the melanoblasts of both the skin and the leptomeninges are believed to originate from neural crest precursor cells. Patients who have NM with malignant CNS lesions must be distinguished from those who have metastatic cutaneous melanoma, which is a different disease process. Biopsies may be necessary to show that the cutaneous lesions in these patients are histologically benign.NM can develop at any age, but neurologic manifestations occur most commonly in the first 2 years after birth, with approximately 50% of the cases presenting in the first postnatal year.The most commonly associated neuropathology is hydrocephalus, which is believed to result from the accumulation of melanocytic cells obstructing CSF flow and reabsorption. Spinal cord involvement also can occur, and a myelopathy or radiculopathy may result. Cranial nerve palsies and mental disturbances such as psychosis also have been described.NM has been reported to occur with other neurocutaneous syndromes (neurofibromatosis and Sturge-Weber syndrome) as well as with posterior fossa malformations such as Dandy-Walker complex. Eight to ten percent of patients who have NM have associated Dandy-Walker malformation, suggesting a common origin of the developmental abnormalities.Two thirds of patients who have NM have large congenital melanocytic nevi (LCMN) and one third have multiple nevi without large lesions. The estimated incidence of LCMN is 1 in 20,000, but only a small percentage of affected patients develops NM. The location of the LCMN seems to be an important factor in NM because patients who do not have posterior midline lesions rarely develop the syndrome.The presenting signs and symptoms of NM include those of increased intracranial pressure: irritability, lethargy, headache, vomiting, neck pain or stiffness, seizures, photophobia, and papilledema. Infants may have a bulging anterior fontanelle or increasing head circumference. Patients who have spinal involvement may present with pain, weakness, and bowel or bladder dysfunction. A small subset of patients does not present with any of the associated neurologic manifestations, despite evidence of leptomeningeal melanosis and, therefore, are completely asymptomatic. These patients, often identified because of MRI scans performed for other reasons, have a much better prognosis.CSF evaluation commonly reveals elevated opening pressures, an elevated protein concentration, and sterile pleocytosis. Melanocytic cells occasionally are visible on microscopic examination of the fluid. A CT scan with contrast may show ventriculomegaly and enhancement of the affected meninges, but MRI with gadolinium contrast is the most sensitive imaging modality for detecting NM. MRI demonstrates gadolinium contrast enhancement of the areas that contain melanocytic proliferation. Neuroradiologists should be informed of the clinical suspicion of NM because the MRI findings may mimic other, more common infectious, inflammatory, and malignant processes.A brain or meningeal biopsy is required to make the definitive diagnosis. Histologic examination reveals an infiltration of melanocytic cells in the leptomeninges. The areas of the brain most commonly involved include the base of the brain; the ventral surface of the pons, medulla, and cerebellum; and the upper cervical or lumbosacral spinal cord. Most patients develop leptomeningeal melanoma, and the initial biopsy may show evidence of malignant transformation.Symptomatic NM, regardless of the presence or absence of malignant transformation, has a very poor prognosis, characterized by progressive neurologic deterioration. For most of the cases reported, death occurred within 3 years of the patient's initial presentation, with approximately 70% dying before the age of 10 years. Patients who have malignant tumors occasionally are given trials of radiation or chemotherapy with limited success. Patients treated with palliative surgical measures, such as ventriculoperitoneal shunt placement to relieve symptoms related to hydrocephalus, have shown transient improvement.

Stent implantation has become standard of care in older children and adults for treatment of branch pulmonary artery stenosis (BPAS) and coarctation aorta (CoAo). There are no stents approved or available for infants that have the potential to be dilated to adult diameters. The Minima stent was designed to fulfill this unmet need. Multicenter, prospective, nonrandomized early feasibility studyevaluating safety and effectiveness of the Minima stent for treatment of BPAS and CoAo. Primary endpoints included: (1) successful deployment across lesion, (2) stenosis relief defined by an increase in angiographic diameter of >50% and (3) freedom from stent explant, embolization or migration at 30 days and 6 months. Between 2/2022 and 5/2022, 10 pts underwent Minima stent implantation with a median age and weight of 9 months (4-43 months) and 7.6 kg (5.1-16.9 kg). Procedural success and predefined stenosis relief was achieved in all cases (CoAo [n = 4], BPAS [n = 6]). Adverse events occurred in 3 pts: transient diminished lower extremity pulse (n = 2), distal stent on-balloon displacement successfully managed in the catheterization suite (n = 1). There were no deaths or major adverse events. All patients were free from stent explant and migration at 30 days and 6 months with no evidence for significant restenosis at latest follow-up. Implantation of the Renata Minima stent was safe and effective for the treatment of BPAS and CoAo in this small cohort of infants and young children during early follow-up. Based on these early results, an expanded study with longer follow-up is warranted.

With aging and family nuclearization, providing care for older adults and children has become a global issue. This study empirically examines the impact of care service supply on household consumption inequality. Data from the China Family Panel Studies are analyzed using the ordinary least squares estimation method. First, childcare and older adult care significantly impact household consumption inequality by 0.23 and 0.35%, respectively. Further, their impacts on household consumption inequalities at different inequality levels show gradually increasing trend. Moreover, significant group heterogeneity is observed in the impact coefficients. Second, under the dual care pressures for childcare and older adult care, the supply of dual-care services significantly affects household consumption inequality by 0.05%. Care service supply has an income effect; that is, the supply of family care services affects household consumption inequality by influencing household income inequality. Policy considerations include improving the precision of social welfare and assistance policies, and enhancing the supply mechanism of care services.

Transition of care in children with chronic disease