Health Supervision Visit Research Articles

Child Passenger Safety

Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death of children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats for most infants up to 2 years of age; (2) forward-facing car safety seats for most children through 4 years of age; (3) belt-positioning booster seats for most children through 8 years of age; and (4) lap-and-shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health-supervision visit.

Child Passenger Safety

Despite significant reductions in the number of children killed in motor vehicle crashes over the past decade, crashes continue to be the leading cause of death for children 4 years and older. Therefore, the American Academy of Pediatrics continues to recommend inclusion of child passenger safety anticipatory guidance at every health-supervision visit. This technical report provides a summary of the evidence in support of 5 recommendations for best practices to optimize safety in passenger vehicles for children from birth through adolescence that all pediatricians should know and promote in their routine practice. These recommendations are presented in the revised policy statement on child passenger safety in the form of an algorithm that is intended to facilitate their implementation by pediatricians with their patients and families. The algorithm is designed to cover the majority of situations that pediatricians will encounter in practice. In addition, a summary of evidence on a number of additional issues that affect the safety of children in motor vehicles, including the proper use and installation of child restraints, exposure to air bags, travel in pickup trucks, children left in or around vehicles, and the importance of restraint laws, is provided. Finally, this technical report provides pediatricians with a number of resources for additional information to use when providing anticipatory guidance to families.

Ultraviolet Radiation: A Hazard to Children and Adolescents

Ultraviolet radiation (UVR) causes the 3 major forms of skin cancer: basal cell carcinoma; squamous cell carcinoma; and cutaneous malignant melanoma. Public awareness of the risk is not optimal, overall compliance with sun protection is inconsistent, and melanoma rates continue to rise. The risk of skin cancer increases when people overexpose themselves to sun and intentionally expose themselves to artificial sources of UVR. Yet, people continue to sunburn, and teenagers and adults alike remain frequent visitors to tanning parlors. Pediatricians should provide advice about UVR exposure during health-supervision visits and at other relevant times. Advice includes avoiding sunburning, wearing clothing and hats, timing activities (when possible) before or after periods of peak sun exposure, wearing protective sunglasses, and applying and reapplying sunscreen. Advice should be framed in the context of promoting outdoor physical activity. Adolescents should be strongly discouraged from visiting tanning parlors. Sun exposure and vitamin D status are intertwined. Cutaneous vitamin D production requires sunlight exposure, and many factors, such as skin pigmentation, season, and time of day, complicate efficiency of cutaneous vitamin D production that results from sun exposure. Adequate vitamin D is needed for bone health. Accumulating information suggests a beneficial influence of vitamin D on many health conditions. Although vitamin D is available through the diet, supplements, and incidental sun exposure, many children have low vitamin D concentrations. Ensuring vitamin D adequacy while promoting sun-protection strategies will require renewed attention to children's use of dietary and supplemental vitamin D.

US Preventive Services Task Force Vision Screening Recommendations

We commend the recent recommendation by the US Preventative Services Task Force (USPSTF) for vision screening of all children at least once between the ages of 3 and 5 years.1 Amblyopia is the leading cause of monocular visual impairment in US children. Several high-quality, randomized controlled clinical studies have shown that amblyopia treatment is highly successful.2 Early detection is critical, because there is a window for successful treatment. Hence, this recommendation is an important step toward the elimination of a major preventable cause of lifelong visual loss. The USPSTF recommendation is consistent with the American Academy of Pediatrics “Recommendations for Preventive Pediatric Health Care,”3 and Bright Futures Guidelines for Health Supervision of Infants Children and Adolescents ,4 both of which recommend universal screening for vision at the 3-, 4-, and 5-year health supervision visits. Although we support the task force recommendation to provide vision screening for children aged 3 to 5 years, we are concerned about the finding of “insufficient evidence” (I) for screening children under the age of 3. Figure 1 in the recommendation1 notes that current practice for these younger children is “assessment … Address correspondence to Sean P. Donahue, MD, PhD, Departments of Pediatrics, Ophthalmology, and Neurology, Vanderbilt University Medical Center/Vanderbilt Eye Institute, 2311 Pierce Ave, Nashville, TN 37232-8808. E-mail: sean.donahue{at}vanderbilt.edu

Abnormal Head Growth

1. Amy Sniderman, MD 1. Cleveland Clinic Foundation Cleveland, Ohio 1. 1. Baxter PS, 2. Rigby AS, 3. Rotsaert M, 4. Wright I Acquired Microcephaly: Causes, Patterns, Motor and IQ Effects, and Associated Growth Changes . Baxter PS, Rigby AS, Rotsaert M, Wright I. Pediatrics. 2009;124:590–595 [OpenUrl][1][Abstract/FREE Full Text][2] 2. 1. Zitelli BJ, 2. Davies HW Central Nervous System Malformations . Zitelli BJ, Davies HW. In: Atlas of Pediatric Physical Diagnosis. 5th ed.Philadelphia, Pa: Mosby/Elsevier; 2007:575–579 3. Head Circumference for Age Tables, Infants Ages Birth–36 Months- Selected Percentiles . Accessed July 2010at: http://www.cdc.gov/growthcharts/ 4. 1. Vertinsky AT, 2. Barnes PD Macrocephaly, Increased Intracranial Pressure, and Hydrocephalus in the Infant and Young Child . Vertinsky AT, Barnes PD. Top Magn Reson Imaging. 2007;18:31–51 [OpenUrl][3][CrossRef][4][PubMed][5] 5. 1. Ashwal S, 2. Michelson D, 3. Plawner L, 4. Dobyns WB Practice Parameter: Evaluation of the Child With Microcephaly (An Evidence-based Review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society . Ashwal S, Michelson D, Plawner L, Dobyns WB. Neurology. 2009;73:887–897 [OpenUrl][6][Abstract/FREE Full Text][7] Measurement of the head circumference is a routine yet critical part of newborn, infant, and toddler health supervision care. Abnormal head growth may indicate a medical or developmental problem and often leads practitioners to further evaluation. Normal head circumferences in term infants range from 32 to 38 cm. Microcephaly is defined as a head circumference 2 standard deviations (SDs) below the mean for age and sex or roughly less than the 2nd percentile. Conversely, macrocephaly is defined as a head circumference greater than 2 SDs above the mean or greater than the 98th percentile. Bright Futures recommendations state that head circumference measurements should be obtained at each health supervision visit from birth to 24 months of age, but the Centers for Disease Control and Prevention growth charts extend to 36 months. Microcephaly can present as primary or acquired. Causes of primary microcephaly include autosomal dominant and autosomal recessive genetic disorders; trisomy 13, 18, and 21; various syndromes, including Cornelia de Lange syndrome, Smith-Lemli-Opitz syndrome, and Rett syndrome; inborn errors of metabolism; and hypothyroidism. Acquired microcephaly is distinguished by a normal head circumference at birth, followed by development of microcephaly in subsequent months or years, usually due to lack of brain development or growth. Causes of acquired microcephaly include sequelae from stroke, meningitis, or encephalitis; other infections, such as toxoplasmosis, rubella, cytomegalovirus, and herpes; in utero teratogen exposure; and hypoxic-ischemic encephalopathy. One study from England (Baxter PS, et al, 2009) noted three different patterns of head growth in infants … [1]: {openurl}?query=rft.jtitle%253DPediatrics%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2008-2784%26rft_id%253Dinfo%253Apmid%252F19651581%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=124/2/590&atom=%2Fpedsinreview%2F31%2F9%2F382.atom [3]: {openurl}?query=rft.jtitle%253DTopics%2Bin%2Bmagnetic%2Bresonance%2Bimaging%2B%253A%2B%2BTMRI%26rft.stitle%253DTop%2BMagn%2BReson%2BImaging%26rft.aulast%253DVertinsky%26rft.auinit1%253DA.%2BT.%26rft.volume%253D18%26rft.issue%253D1%26rft.spage%253D31%26rft.epage%253D51%26rft.atitle%253DMacrocephaly%252C%2Bincreased%2Bintracranial%2Bpressure%252C%2Band%2Bhydrocephalus%2Bin%2Bthe%2Binfant%2Band%2Byoung%2Bchild.%26rft_id%253Dinfo%253Adoi%252F10.1097%252FRMR.0b013e3180d0a753%26rft_id%253Dinfo%253Apmid%252F17607142%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [4]: /lookup/external-ref?access_num=10.1097/RMR.0b013e3180d0a753&link_type=DOI [5]: /lookup/external-ref?access_num=17607142&link_type=MED&atom=%2Fpedsinreview%2F31%2F9%2F382.atom [6]: {openurl}?query=rft.jtitle%253DNeurology%26rft.stitle%253DNeurology%26rft.issn%253D0028-3878%26rft.aulast%253DAshwal%26rft.auinit1%253DS.%26rft.volume%253D73%26rft.issue%253D11%26rft.spage%253D887%26rft.epage%253D897%26rft.atitle%253DPractice%2BParameter%253A%2BEvaluation%2Bof%2Bthe%2Bchild%2Bwith%2Bmicrocephaly%2B%2528an%2Bevidence-based%2Breview%2529%253A%2BReport%2Bof%2Bthe%2BQuality%2BStandards%2BSubcommittee%2Bof%2Bthe%2BAmerican%2BAcademy%2Bof%2BNeurology%2Band%2Bthe%2BPractice%2BCommittee%2Bof%2Bthe%2BChild%2BNeurology%2BSociety%26rft_id%253Dinfo%253Adoi%252F10.1212%252FWNL.0b013e3181b783f7%26rft_id%253Dinfo%253Apmid%252F19752457%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [7]: /lookup/ijlink?linkType=ABST&journalCode=neurology&resid=73/11/887&atom=%2Fpedsinreview%2F31%2F9%2F382.atom

Developmental Milestones: Motor Development

1. R. Jason Gerber, MD* 2. Timothy Wilks, MD† 3. Christine Erdie-Lalena, MD‡ 1. *Major, USAF, Medical Corps, Developmental & Behavioral Pediatrics Fellow, Madigan Army Medical Center, Joint Base Lewis-McChord, Wash. 2. †LCDR, USN, Medical Corps; Developmental & Behavioral Pediatrics Fellow, Madigan Army Medical Center, Joint Base Lewis-McChord, Wash. 3. ‡Lt Col, USAF, Medical Corps, Program Director, Developmental & Behavioral Pediatrics Fellowship, Madigan Army Medical Center, Joint Base Lewis-McChord, Wash. After completing this article, readers should be able to: 1. Identify the milestones for gross and fine motor development. 2. Recognize the child whose development falls outside of the expected range. 3. Describe the sequences involved in gross and fine motor development. This is the first of three articles on developmental milestones; the second and third articles will appear in the September and November 2010 issues of Pediatrics in Review, respectively . Infancy and childhood are dynamic periods of growth and change. Neurodevelopmental and physical growth proceed in a sequential and predictable pattern that is intrinsically determined. Skills progress from cephalic to caudal; from proximal to distal; and from generalized, stimulus-based reflexes to specific, goal-oriented reactions that become increasingly precise. As one clinician has stated, “infants [and children] are very orderly in their ways; they actually behave [and develop] according to laws that can be explored, discovered, confirmed, reconfirmed, and celebrated.” (1) By convention, these neurodevelopmental “laws” or sequences often are described in terms of the traditional developmental milestones. Milestones provide a framework for observing and monitoring a child over time. According to recent American Academy of Pediatrics and Bright Futures guidelines, pediatricians should incorporate developmental surveillance at every health supervision visit. Surveillance involves analyzing the milestones in the context of a child's history, growth, and physical examination findings to recognize those who may be at risk for developmental delay. A thorough understanding of the normal or typical sequence of development in all domains (gross motor, fine motor, problem-solving, receptive language, expressive language, and social-emotional) allows the clinician to formulate a correct overall impression of a child's true developmental status. However, it …

Characteristics Associated With Low Self-Esteem Among US Adolescents

Low self-esteem in adolescents has been associated with a number of risk and protective factors in previous studies, but results have been mixed. Our objective was to examine characteristics associated with low self-esteem in a large national sample of young adolescents. We conducted a population-based correlational study. A sample of 6522 adolescents aged 12 to 16 years was surveyed by phone as part of a national study of media and substance use. Self-esteem was measured with 3 questions that assessed global self-worth and physical appearance. Multivariate logistic regression was used to examine the relationship between self-esteem and sociodemographics, child personality characteristics,weight status, daily TV time, parenting style, school performance,and team sports participation. Interactions among gender, race, and weight status were examined. In multivariate analysis, female gender, Hispanic race, overweight and obesity, sensation seeking, rebelliousness, and daily TV time were each independently associated with lower self-esteem. Teens of black race, with higher parental responsiveness and demandingness, better school performance, or involvement in team sports were less likely to report low self-esteem. Black females were at lower risk and Hispanic males were at higher risk for low esteem than peers of similar gender of other races. Low self-esteem was associated with a number of modifiable risk factors, including obesity, TV time, team sports participation, school performance, and parenting style, that should be discussed with teens and parents at health supervision visits. Further research examining race and gender-specific factors that serve to moderate risk for poor self-esteem in adolescents is warranted.

Enhancing Pediatric Mental Health Care: Strategies for Preparing a Primary Care Practice

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Toilet Training

Toilet Training

Intimate Partner Violence

Intimate Partner Violence

Discovering Gifted Children in Pediatric Practice

Casey is a first grader who is brought to the pediatrician for consideration of ADHD. His mother is concerned that he is very difficult to focus at home when asked to do anything and gets so distracted at meals that he eats very little. The teachers last year and this year say that Casey is very distracted, always "in a fog" and just can't seem to get his work done. "He's in his own world." His report card has several unsatisfactory marks because of poor completion of work, doing things other than the assignment and talking too much to the kids around him. The parents are very upset as they see their son as very bright. His advanced vocabulary, early reading skills and his extensive knowledge of engines, machines and aircraft were all noted in his medical chart in the past as part of his health supervision visits. He has lots of friends, mostly third graders and plays soccer with moderate success. The paternal grandmother says Casey is just like his dad who is now a biochemical geneticist. He too had a hard time getting his work in as a child and "always talked back" to the teacher. Casey's mother would like him on medication before the Iowa Basics come around. The Vanderbilt rating scales by both teacher and parent are positive for inattention and borderline for hyperactivity. Casey took it upon himself to speak to the principal about how bored he was with the classroom work. She agreed that he could have some special assignments. In the pediatrician's office, Casey is a delightful, verbal, thin boy who has about 100 things to talk about, from train engines to the sports scores, acquired from the television sports channel, to what should be done to "fix" his school. He said he was bored and knew more about volcanoes than the science teacher. He just wanted to get home each day and work on his elaborate train setup. He doesn't seem overly active, distractible, anxious, inattentive or oppositional. Testing by the school psychologist showed him to have an IQ of 138 with an even verbal/performance profile. Sam is a 4-year old whose parents brought him to the local private school for application to kindergarten. The admission requirements consisted of a group "developmental" test, given to groups of 20 youngsters at a time. Sam failed the test. The report said that he was too immature, talked out of turn and generally wasn't ready for the vigorous academic program planned at that school. He asked too many questions and argued with the admissions person. They suggested he might need medication before he attempted school. His parents asked their pediatrician for an opinion on the school report. They asked for a referral for testing as they could not believe their son was a preschool failure. The psychologist reported that his IQ was 142 (verbal 146 and performance 136).

Reformatting the 9-Month Health Supervision Visit to Enhance Developmental, Behavioral and Family Concerns

Dr. McClintock reviewed her schedule for the following week when she observed there were eight health supervision visits in 9 month old children. She recalled that these healthy children, whom she followed since birth, were up-to-date on their immunizations. As she reflected on the visits, it occurred to Dr. McClintock that this might be an ideal opportunity to use the time to assess developmental status and behavioral interactions. She could also ask questions about the families, including childcare arrangements, satisfaction with parenting and marriage relationships. Dr. McClintock considered the best use of the time available in order to have the most meaning to the children and their families. What lines of questioning or what screening tests might be most useful during the 9-month office visit?

Global Developmental Delay in a 10-Month-Old Infant Boy

A 10-month-old boy was seen for the first time for a health supervision visit by a pediatrician. A brief review of the child's medical history did not reveal any specific problems. On physical examination, the pediatrician found an alert, smiling child, but she was surprised by the following observations: unable to sit without support, absent pincer grasp, no audible language, unilateral exotropia, and microcephaly. Expansion of the medical history revealed an uneventful full-term prenatal course and normal vaginal delivery. The mother denied use of alcohol or other drugs/medications during the pregnancy. She did not have a recent history of any infections, unexplained fevers, or high risks for sexually transmitted disease. The baby cried spontaneously and the parents reported no resuscitation efforts. There were early feeding problems associated with a poor suck and gastroesophageal reflux. The parents were healthy and this was their first child. Family history was negative for early problems in child development or any neurological conditions. Parents were high school graduates without any learning problems; they were both employed in retail sales with a steady employment history. The pediatrician then took a second look at the child and discovered truncal hypotonia, extremity hypertonia, tongue protrusion, and a broad mouth. She concluded that the child had a global developmental delay, including delays in motor, language, and social development.

Research and Statistics: Understanding and Identifying Bias in Research Studies

1. Jacky M. Jennings, PhD, MPH* 2. Erica Sibinga, MD* 1. *Assistant Professor of Pediatrics, Division of General Pediatrics & Adolescent Medicine, Johns Hopkins University, Baltimore, Md. You are seeing a healthy 18-year-old patient who is interested in contraception and, specifically, the “Depo shot” or medroxyprogesterone. The information you have gathered from her during your visit and her medical history suggest that she is a good candidate. You take a few minutes out of the visit to review the literature for issues of safety. Most of the articles and reviews suggest that medroxyprogesterone is a good choice for healthy young women, but a recent study shows an association between medroxyprogesterone and the development of hypertension. You look more closely at the study and discover that the young women taking medroxyprogesterone had their vital signs (including blood pressure) checked every 3 months when they came in for the medroxyprogesterone injection. The other women included in the study for comparison only had their vital signs checked every year at annual health supervision visits. You are unclear about whether the study design might have introduced bias and how the bias might affect your reading of the study results. Bias is a major issue in epidemiologic research studies and can lead to inferences that systematically deviate from truth. Bias has been defined as “any systematic error in the design, conduct or analysis of a study that results in a mistaken estimate of an exposure's effect on the risk of disease.” (1 …

Intimate Partner Violence

1. Megan H. Bair-Merritt, MD, MSCE* 1. *Assistant Professor of Pediatrics, Associate Director, Primary Care Fellowship Program, Johns Hopkins School of Medicine, Baltimore, Md. After completing this article, readers should be able to: 1. Describe the prevalence of intimate partner violence and childhood exposure to intimate partner violence. 2. Identify risk factors associated with intimate partner violence. 3. Explain the relationship of child maltreatment in the setting of intimate partner violence. 4. Recognize the impact of intimate partner violence exposure on children's social-emotional and physical health and health-care use. 5. Discuss strategies for screening and responding to intimate partner violence in the pediatric setting. You are seeing a healthy 4-month-old infant for a health supervision visit. As part of a routine social history, you inquire about intimate partner violence (IPV). The infant's mother discloses that her partner frequently yells at her, pushes her, and makes her feel afraid. On additional questioning, she describes the infant as “fussy.” The baby's physical examination findings are unremarkable, but you note that he missed his 2-month visit and is behind on his immunizations. How do you proceed? Family violence and domestic violence often are used synonymously and refer to violence occurring between any family member dyad, including parent-child, intimate partner-intimate partner, or sibling-sibling. IPV refers specifically to violence perpetrated between romantic partners and has been defined by the Family Violence Prevention Fund as “a pattern of purposeful coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation and threats. These behaviors are perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent victim and are aimed at establishing control of one partner over the other.” (1) Over the course of a lifetime, between one fourth …

Teaching Parents Effective Discipline During a Health Supervision Visit

Parents tell us that they want information from pediatricians about how they can enhance the development, behavior, and learning skills of their children. Others are not comfortable asking questions in some of these areas during well-child care (WCC) visits. Some parents may not be aware that guidance in these areas is a major component of (WCC) visits.1,2 To address some of these concerns, innovative parent-education programs designed for traditional (WCC) visits have been promoted to increase knowledge and change parent behaviors in areas of child development, behavior, and learning.3 Examples of these programs are “Reach Out and Read,” previsit computerized screening questionnaires (for parent concerns, developmental milestones, and behavioral profiles), parent and teen group learning (including group WCC), family drawings to enhance communication during visits, and use of a developmental or behavioral theme as a guide for each WCC visit. Providing parents with knowledge about effective discipline of young children is a significant area of focus during WCC visits. Parents want to learn more about discipline.4,5 The American Academy of Pediatrics guidelines on discipline in young children6 and the new Bright Futures 7 guidelines encourage pediatricians to ask about discipline practices during WCC … Address correspondence to Martin T. Stein, MD, 824 Forward St, La Jolla, CA 92037. E-mail: mtstein{at}ucsd.edu

Tobacco-Related Documentation in Pediatric Practice

The goal of this study was to evaluate tobacco-related documentation in children's medical records. A cross-sectional, consecutive sample of 4216 parents at 13 primary care practices was surveyed on demographics, health habits, and smoking status of household members. The medical records of 2085 children from a subsample of 1149 families (all households with smokers and a sample of nonsmoking households) were reviewed for tobacco-related documentation at the first visit to the practice and visits in the 14 months preceding recruitment. Relationships of documentations with visit type, household smoking status, and use of charting prompts were examined. Most children (93%) had > or =1 visit during the reviewed period (77% had a health supervision visit), 23% were aged > or =11 years, 52% were Medicaid/uninsured, and 70% lived with smokers; 30.6% of children had family tobacco use status documented at a first visit to the practice and 15.4% had prenatal tobacco use status documented. Among children with a visit in the reviewed period, 39.3% with a health supervision visit and 9.6% without had a tobacco-related notation at a visit (P < .001). Overall, 15.2% of children living with a smoker had a visit notation indicating that someone in the household smoked. In households with smokers, documentation of household tobacco use status often disagreed with parent survey. Charting prompts significantly increased rates of identification of family tobacco use history and prenatal tobacco use history. Correct identification of household smoking status was absent for most children living with smokers. Improved documentation systems may facilitate tobacco-related surveillance and counseling.

Visual Diagnosis: Two Infants Who Have Skin Lesions That React to Minor Trauma

1. Abdulla Gori, MD* 2. Carlos Torneria, MD* 3. Victoria M. Kelly, MD† 4. Barrett J. Zlotoff, MD† 5. Michael E. Contreras, MD† 1. *Assistant Professor, Pediatrics, Case Western Reserve University, Cleveland, Ohio 2. †Department of Dermatology, University of New Mexico School of Medicine, Albuquerque, NM A 2-year-old girl presents to the outpatient clinic for a routine health supervision visit. She was born at term with congenital hydronephrosis requiring antibiotic prophylaxis. Except for one episode of pyelonephritis during infancy, her past medical history has been uneventful. Growth and development are normal for age. Family history is unremarkable. Routine physical examination reveals a happy, playful, well-developed toddler who has nine skin lesions located on the abdominal wall and back. The lesions range from red to tan to brown and appear as macules, papules, or plaques (Fig. 1). Stroking one of the lesions triggers a wheal and flare reaction at the lesion site (Fig. 2). No respiratory symptoms develop at that time. Findings on the rest of her physical examination are unremarkable. Figure 1. Red to tan to brown abdominal macules and papules. Figure 2. Wheal and flare reaction of skin lesion after stroking. On additional questioning, her parents recall that the skin lesions developed during infancy, gradually increasing in number. They were not concerned because the lesions did not appear to have any associated signs or symptoms. A clinical diagnosis is made. A 5-month-old girl presents to the clinic with a 4-month history of a recurrent “blister” on her left fourth finger. Between episodes of blistering, the finger remains swollen and red. The patient's mother denies any history of a burn or trauma to the finger. She reports that her daughter often sucks on the finger. Despite bandaging, the blistering continues to occur. The infant is otherwise asymptomatic; she has had no febrile episodes or abdominal or respiratory symptoms. The infant was born at term via vaginal delivery without complications. Past medical history and family history are unremarkable. Physical examination reveals a well-nourished infant in no acute distress. Skin examination reveals a 1×2-cm reddish-brown papule with an overlying bulla on the …

Hearing Loss in Children

1. Kimberly A. Gifford, MD* 2. Michael G. Holmes† 3. Henry H. Bernstein, DO* 1. *Department of Pediatrics, Dartmouth Medical School, Children's Hospital at Dartmouth, Lebanon, NH 2. †Dartmouth College, Hanover, NH After completing this article, readers should be able to: 1. Determine the difference between conductive and sensorineural hearing loss. 2. Discuss the congenital and acquired causes of hearing loss. 3. Delineate the most appropriate times for screening, diagnosis, and interventions for hearing loss. 4. List the risk factors for hearing loss in all children. 5. Recognize the need for identification of hearing loss and prompt intervention in all children. ### Case 1 During his routine health supervision visit, a healthy 2-year-old boy is noted to have an isolated speech delay. There is no family history of hearing problems. On questioning about the child's newborn hearing screen, the mother says, “They said something about repeating it, but we were pretty busy, so we never got around to it. Since no one mentioned it again, I didn't think it was important.” The child is referred to audiology and diagnosed with moderate bilateral sensorineural hearing loss. A hearing aid and intensive speech therapy are recommended. ### Case 2 A 4-year-old girl presents for evaluation of behavioral problems. Her parents are worried about attention-deficit disorder. They report that she frequently ignores their requests, does not seem to pay attention, and has trouble following instructions. In addition, she has not outgrown her temper tantrums like other children with whom she plays. She can understand preschool activities when the whole class is doing them, but she has the most difficulty with directions given to her individually. She has had frequent medical visits for acute otitis media. Physical examination reveals tympanic membranes that are retracted, with some scarring bilaterally. In-office tympanometry and audiometry suggest a moderate conductive hearing loss. Due to concerns that her behavioral problems are related to her hearing loss, she is referred to an otolaryngologist for consideration of tympanostomy tube placement. As demonstrated by these cases, childhood hearing loss can be a debilitating condition that …

Health Supervision Visits of Very Young Children: Time Addressing 3 Key Topics

To describe the time and actions on 3 key health topics during health supervision (HS) visits of children aged 0 to 1 years. HS visits were observed at 5 offices. Parents provided demographics and children's measurements were obtained. Using special computer software, visits were observed for frequency and time for growth measurements, charting and interpretations, and for discussions on growth, diet, and safety. A total of 128 visits were analyzed. Almost all children had weight (100%) and height (98%) measured and >80% had weight-for-age and height-for-age plotted. Growth interpretation (weight-for-height) was determined for 1 child. Nearly all visits included discussions of growth (88%), diet (97%), and safety (84%). When a topic was addressed, median times were as follows: growth, 9 seconds; diet, 42 seconds; and safety, 22 seconds. Median time on all 3 topics was 86 seconds. Growth, diet, and safety are frequently, but briefly, discussed at HS visits of young children.