Pediatric Ambulatory Clinic Research Articles

Screening for Developmental Delay in the Setting of a Community Pediatric Clinic: A Prospective Assessment of Parent-Report Questionnaires

Our goal for this study was to prospectively test whether parent-completed questionnaires can be effectively used in the setting of a busy ambulatory pediatric clinic to accurately screen for developmental impairments. Specific objectives included (1) assessing the feasibility of using parent-report instruments in the setting of a community pediatric clinic, (2) evaluating the accuracy of 2 available screening tests (the Ages and Stages Questionnaire and Child Development Inventory), and (3) ascertaining if the pediatrician's clinical judgment could be used as a potential modifier. Subjects were recruited from the patient population of a community clinic providing primary ambulatory pediatric care. Subjects without previous developmental delay or concerns noted were contacted at the time of their routine 18-month-old visit. Those subjects who agreed to participate were randomly assigned to 1 of 2 groups and completed either the Ages and Stages Questionnaire or Child Development Inventory. The child's pediatrician also completed a brief questionnaire regarding his or her opinion of the child's development. Those children for whom concerns were identified by either questionnaire underwent additional detailed testing by the Battelle Development Inventory, the "gold standard" for the purposes of this study. An equal number of children scoring within the norms of the screening measures also underwent testing with the Battelle Development Inventory. Of the 356 parents contacted, 317 parents (90%) agreed to participate. Most parents correctly completed the Ages and Stages Questionnaire (81%) and the Child Development Inventory (75%). Predictive values were calculated for the Ages and Stages Questionnaire and the Child Development Inventory (sensitivity: 0.67 and 0.50; specificity: 0.39 and 0.86; positive predictive value: 34% and 50%; negative predictive value: 71% and 86%, respectively). Incorporating the physician's opinion regarding the developmental status of the child did not improve the accuracy of the screening questionnaires. Three important conclusions were reached: (1) parent-completed questionnaires can be feasibly used in the setting of a pediatric clinic; (2) the pediatrician's opinion had little effect in ameliorating the accuracy of either questionnaire; and (3) single-point accuracy of these screening instruments in a community setting did not meet the requisite standard for development screening tests as set by current recommendations. This study raises important questions about how developmental screening can be performed, and we recommend additional research to elucidate a successful screening procedure.

Specialty clinics operating within the framework of an ambulatory pediatric oncology clinic

Specialty clinics operating within the framework of an ambulatory pediatric oncology clinic

Etiologic Evaluation in 247 Children with Global Developmental Delay at Istanbul, Turkey

Developmental delay is a common pediatric problem, having a great number of underlying causal factors. Etiologic diagnosis is important for providing information about pathogenesis, prognosis, recurrence risk and specific medical interventions. The aim of this study was to determine the etiologic yield and spectrum of a consecutive cohort of global developmentally delayed children. This retrospective study included all children younger than 5 years of age with global developmental delay referred to a single university-based ambulatory pediatric neurology clinic for initial evaluation over a 14-month period from January 1997. Diagnostic studies consisted of history, physical examination, electroencephalography and selected investigations including neuroimaging, screening for metabolic disease, karyotype and fragile X testing. In the study 247 patients (136 males) with a mean age of 24.2+/-20.3 months were evaluated. Etiologic diagnosis was determined in 64 per cent of the patients classified under the following categories: perinatal complications (21 per cent), cerebral dysgenesis (18 per cent), chromosomal abnormalities (9 per cent), genetic/dysmorphic syndromes (3 per cent), metabolic disorders (4 per cent), hypothyroidism (4 per cent), neurocutaneous syndromes (3 per cent), intrauterine infection (2 per cent). Etiology was unknown in 36 per cent of the patients. Two laboratory tests (neuroimaging and cytogenetic analysis) together with the history and physical examination were most helpful in determining the etiologic diagnosis. This study suggests that optimal management of global developmentally delayed children and their family should involve a comprehensive evaluation.

Telepediatric surgery: capturing clinical outcomes

Purpose The aim of this study is to compare outcomes and patient characteristics of telehealth vs in-person contacts in pediatric surgery ambulatory care patients. Methods All non-Winnipeg telehealth patients (group 1), non-Winnipeg in-person patients (group 2), and a convenience sample of Winnipeg in-person patients (group 3) seen in the pediatric ambulatory surgical clinic and day surgery by one pediatric surgeon in a tertiary urban (Winnipeg, Manitoba) hospital between April 2002 and June 2003 were analyzed. Results There were 118, 205, and 120 (total, 443) patients and 153, 427, and 246 (total, 826) patient contacts in groups 1, 2, and 3, respectively. Of 826 patient contacts, 272 were day surgery procedures and 554 were consults and follow-ups, of which 27% (n = 152) were seen via telehealth. Of the non-Winnipeg contacts, 33.4% of consults and 51.5% of follow-ups used telehealth. Variations were seen between the telehealth and the 2 in-person groups on average age at contact, patient no-show rates, intraoperative complication rates, and postoperative complication rates. The interval to consult by telehealth decreased significantly during the course of the study. Conclusions This is the first comparative analysis of telehealth outcomes in a population of pediatric surgery ambulatory care patients. Telehealth improves access to pediatric surgical services without untoward clinical outcomes.

Parent Opinions About Universal Influenza Vaccination for Infants and Toddlers

Parent and caregiver opinions on the feasibility of routine influenza vaccinations for infants and toddlers are unknown. To assess among English-speaking caregivers of children aged 6 to 23 months opinions about childhood influenza vaccination and potential knowledge, attitudinal, and demographic factors that might influence such opinions. A structured, interviewer-administered survey of knowledge, attitudes, and beliefs about the influenza vaccine among parents and caregivers of children at the ambulatory pediatric clinic or the pediatric emergency department of a large tertiary care teaching hospital. The dependent measure was respondents' expressed intentions to have their eligible children immunized against influenza in the upcoming season. We interviewed 153 caregivers. One hundred nineteen (78%) expressed intent to immunize. Safety was reported by 70 respondents (46%) as their most important concern, followed by the belief that the influenza vaccine could itself cause influenza (31 respondents, 20%). Respondents who believed that influenza was serious, that the influenza vaccine does not cause disease, or that all babies should be immunized had greater intent to immunize than those who did not (85%, 87%, and 96% vs 66%, 66%, and 49%, respectively). Those who believed that vomiting was a symptom of influenza, who did not name any vaccine adverse effect, or who had high school or lower educational levels also had greater intent to immunize (87%, 89%, and 83% vs 66%, 69%, and 69%, respectively). Knowledge, attitudes, beliefs, and educational levels each had an independent influence on parents' intentions to vaccinate the child, whereas demographic factors other than education did not.

Evaluating Length Of Visit In A Pediatric Ambulatory Teaching Clinic

Evaluating Length Of Visit In A Pediatric Ambulatory Teaching Clinic

Type 2 diabetes mellitus in children: prenatal and early infancy risk factors among native canadians.

Type 2 diabetes mellitus is increasingly being observed among children and youth, including the Native population of Canada. Only one study has investigated prenatal and early infancy risk factors for the disease. A case-control study was conducted; 46 patients younger than 18 years were recruited from the only clinical center for the treatment of diabetes serving the province of Manitoba, and 92 age- and sex-matched controls were recruited from a pediatric ambulatory clinic serving a large Native population in Winnipeg, Manitoba. Information on exposure to prenatal and early infancy risk factors was obtained through questionnaires administered by a Native nurse-interviewer. Multiple logistic regression modeling identified preexisting diabetes (odds ratio [OR], 14.4; 95% confidence interval [CI], 2.86-72.5), gestational diabetes (OR, 4.40; 95% CI, 1.38-14.1), and breastfeeding longer than 12 months (OR, 0.24; 95% CI, 0.13-0.99) as significant independent predictors of diabetic status. Other factors, such as low (<2500 g) and high (>4000 g) birth weight and maternal obesity, were also associated with diabetes in our population, but the elevated risks were not statistically significant. Breastfeeding reduces the risk of type 2 diabetes among Native Canadian children and should be promoted as a potential intervention to control the disease.

A Comparison of MRI and Laparoscopy in Detecting Pelvic Structures in Cases of Vaginal Agenesis

Objective: To determine whether laparoscopy improves detection of uterine structures over MRI in cases of vaginal agenesis. Design: Prospective case series. Setting: Ambulatory pediatric gynecology clinic in a tertiary care children's hospital. Participants: Subjects with vaginal agenesis who had an MRI to detect uterine structures. Main Outcome Measures: A chart review identified subjects with vaginal agenesis who had an MRI to assess müllerian structures. The MRI findings were correlated with physical exam, presenting symptoms, and operative findings. We assessed degree of agreement between laparoscopy and MRI in patients both with and without pelvic pain to determine sensitivity and specificity of MRI in predicting uterine structures confirmed on laparoscopy. Results: Twenty-two subjects with vaginal agenesis were identified and 14 had both an MRI and laparoscopic evaluation. MRI successfully predicted uterine anomalies in six cases (43%) and lack of uterine structures in one case (8%). MRI diagnosis did not correlate with laparoscopic findings in the remaining seven cases (50%). Among subjects presenting with no complaints of pelvic pain (n = 6), three had negative MR imaging but positive laparoscopy. Using laparoscopy as a gold standard, MRI had a sensitivity of 53% for accurately detecting uterine anomalies confirmed on laparoscopy. Conclusion: Laparoscopy improves detection of uterine structures over MRI alone in women with vaginal agenesis.

Impacts of a flood disaster on an ambulatory pediatric clinic population.

Impacts of a flood disaster on an ambulatory pediatric clinic population.

Specialty Clinics Operating Within the Framework of an Ambulatory Pediatric Oncology Clinic

Specialty Clinics Operating Within the Framework of an Ambulatory Pediatric Oncology Clinic

Pharmacy-based evaluation and treatment of minor illnesses in a culturally diverse pediatric clinic.

Among medically underserved immigrant parents, access to nonprescription medicines for home treatment of minor childhood illnesses may be limited by scarce financial resources or language barriers. To design and implement a new clinical service for an urban ambulatory pediatric clinic with a large immigrant population that allows pharmacists to evaluate and to treat children and adolescents aged 6 months to 19 years with minor acute illnesses and to provide bilingual patient education materials. We developed protocols and encounter forms for pharmacist evaluation of 5 pediatric conditions: cough/cold, fever, diaper rash, vomiting/diarrhea, and head lice. We published bilingual patient education materials for these conditions in 8 commonly spoken languages. We assessed safety by thoroughly reviewing the medical records of all patients who returned within 1 week of a pharmacy encounter and by asking parents in a telephone survey to compare services received through the pharmacy and the acute care clinic for treatment of the common cold. During the first year of this pilot program, 191 patients were evaluated and treated, 145 (76%) for cough/cold. Seventy percent of the patients were immigrants. No unexpected or adverse outcomes were detected, although occasional deviations from established protocols were noted. Parent satisfaction with the pharmacy service was high, and similar to that received through the standard acute care clinic. Patients evaluated by pharmacists were more likely to be attended to promptly (< 15-minute wait) and were more likely to receive written information than patients evaluated by physicians for similar conditions. Pharmacist evaluation and treatment of minor pediatric illnesses seems to be both safe and well accepted. Further studies are needed to evaluate the cost-effectiveness of this service in diverse settings. In states that allow pharmacists to have prescriptive authority, pharmacy-based evaluation and treatment may improve access to care for children with minor illnesses.

Hunger in midwestern inner-city young children.

To determine the characteristics of hunger in young children who attend ambulatory pediatric clinics in a midwestern city. Consecutive sample. Ambulatory pediatric clinics of an inner-city teaching hospital. English-speaking caregivers of 2578 children younger than 5 years. Structured survey measures of hunger, family characteristics, assistance program use, child feeding practices, and anthropometrics. In this population, 171 (6.6%) were hungry, and 842 (32.7%) were at risk for hunger. Hunger status was associated with increased age (P<.001), decreased maternal education level (P=.013), maternal nonwhite race (P<.002), a history of homelessness (P<.001), and parental unemployment (P<.001). Hunger status was associated with use of Aid to Families with Dependent Children (P<.001) and food stamps (P<.001) but not with participation in The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Results of anthropometrics indicated that mean growth percentiles were no different between hunger categories. Housing, dietary, and family characteristics are identifiable risk factors for early childhood hunger. Hunger cannot be identified, however, using anthropometrics. It is disconcerting that fewer hungry children and children at risk for hunger participate in WIC compared with other programs. These data suggest the potential for more aggressive identification and intervention at the primary care and social service levels to benefit hungry children.

Handwashing patterns in primary pediatric community clinics.

Handwashing is acknowledged as a critical factor in the prevention of nosocomial infection. Nonetheless, health care personnel often wash their hands inadequately. The purpose of this study was to examine the flora of hands and the frequency of handwashing of physicians working in primary care pediatric community clinics. The fingers of the dominant hand of 55 physicians working in 12 clinics were sampled for bacterial cultures. Only 354/720 (49%) of the expected handwashings by 17 board-certified pediatricians were recorded as having been performed. None of them washed their hands after each contact with an examined child. All physicians' hands were found to be contaminated with microorganisms. Staphylococcus species were isolated from 47 (85.4%) of the physicians' hands. Methicillin-resistant Staphylococcus aureus was found on the hands of 9.1% of the physicians. Such contaminated hands may serve as a potential vector of community-acquired infection with highly resistant organisms. Compliance with handwashing recommendations among these physicians was low. An active educational infection control program must be introduced in ambulatory pediatric community clinics.

Relationship between blood lead and dietary iron intake in preschool children: A cross-sectional study

The relationship between dietary iron intake and blood lead levels in urban preschool children was investigated in a cross-sectional study of 299 children from 9 months to 5 years old. Mothers of children attending the University of Maryland Pediatric Ambulatory Clinic volunteered for the children and themselves to join the study. The data collected included nutritional status, socioeconomic status, medical history, and potential sources of lead exposure. Blood samples from all participants were evaluated for levels of blood lead, serum iron (ferritin), free erythrocyte protoporphyrin, calcium, and hematocrit. The average blood lead level (standard deviation) in the studied population was 11.4 (73) μg/dL. With multiple linear and logistic regression analyses to adjust for covariates, a negative association ( P = 0.03) between blood lead and dietary iron intake was found. This finding is consistent with similar results from experimental studies. It is concluded that there is evidence that higher dietary iron intake is associated with lower blood lead among urban preschool children in the studied population.

Maternal employment and use of pediatric clinic services.

This article explores the relative importance of maternal employment as a determinant of pediatric care utilization using data from a 6-month longitudinal study of pediatric clinic use. This study sample (N = 167) was taken from a population of users of a pediatric ambulatory care clinic of a large urban hospital. The clinic served an inner city with a predominantly low-income, working-class population. Independent variables come from personal interviews conducted with the mothers of the preschoolers and from a 4-week health diary. Data on episodic illness care use were obtained from the children's medical records. Results indicate that children of working mothers made fewer visits to the clinic than children of housewives. Somewhat different factors were associated with clinic use for children with employed mothers as compared with children with nonemployed mothers. Findings from multivariate analyses suggested that mother's employment influenced utilization through its relationship with social support and daily stress. Work outside of the home was associated with greater social support as well as greater daily stress. Both social support and stress predicted utilization. Implications of these findings for future research are discussed.

Improving pediatric appointment keeping with reminders and reduced response requirement.

We evaluated the effectiveness of appointment reminders and a reduced response requirement for improving appointment keeping in a hospital ambulatory pediatric clinic. Participants received mailed and telephoned reminders along with a parking pass that reduced the time and effort required to attend the clinic. A multiple baseline analysis of 5,261 appointments over one fiscal year showed that the intervention increased the percentage of appointments kept and decreased the percentage of appointments broken in the continuity clinics of five pediatric health care providers. Social validation, consumer satisfaction, and cost-effectiveness measures, as well as an interrupted time-series analysis, all support the effectiveness of the intervention.

Clinical pharmacy services in a pediatric ambulatory care clinic

New skills for assembling, working effectively in, and leading teams are needed to prepare the next generation of health professionals who work in outpatient settings.To report on a qualitative analysis conducted with 27 residency primary care training programs that included multiple health professional learners.Twenty-seven focus groups were conducted with family medicine, general internal medicine and general pediatrics faculty, clinic staff, and diverse groups of learners to identify benefits of learning together in ambulatory primary care practices. Independent and consensus open and axial coding techniques applied to focus group field notes with consensus meetings identified emergent themes.Four themes were beneficial: Development of Personal Relationships, Improved Education, Improved Patient Care and Improved Job Satisfaction. Enablers to realizing benefits involved leadership support, co-location of learners and having adequate space for team huddles, which allowed health professionals to collaborate and learn together. Barriers to achieving benefits included top-down leadership approaches, poor communication, and lack of knowledge of roles and professions. Inadequate staffing, space constraints, scheduling challenges and clinic productivity pressures made interprofessional learning difficult.Clinic culture, structures and operations both enable or create barriers to interprofessional learning.

Clinical pharmacy services in a pediatric ambulatory care clinic.

The implementation of pharmacy services in an ambulatory pediatric clinic has met with initial success in acceptance by the medical and nursing staffs, the administrator, and the patient population. Errors in medication dispensing and prescription labeling have decreased, and patient understanding of prescribed therapy has improved. The number of ER visits by clinic patients has been reduced since the implementation of our service. The importance of patients' understanding directions for use and of dispensing medications in childproof containers for the pediatric population cannot be overstressed. A future goal of our service is to expand the pharmacist's clinical role to allow further participation in pharmacokinetics, specialty clinics, teaching, and patient education. Further documentation of the value of such services is essential to the expansion of the pharmacist's role in patient care.

Families at risk of poor parenting: A model for service delivery, assessment, and intervention

The At Risk Parent Child Program is a multidisciplinary network agency designed for the secondary prevention of poor parenting and the extremes of child abuse and neglect. This model system of service delivery emphasizes (1) the coordination of existing community resources to access a target population of families at risk of parenting problems, (2) the provision of multiple special services in a neutral location (ambulatory pediatric clinic), and (3) the importance of intensive individual contact with a clinical professional who serves as primary therapist, social advocate and service coordinator for client families. Identification and assessment of families is best done during prenatal and perinatal periods. Both formal and informal procedures for screening for risk factors are described, and a simple set of at risk criteria for use by hospital nursing staff is provided. Preventive intervention strategies include special medical, psychological, social and developmental services, offered in an inpatient; outpatient, or in-home setting. Matching family needs to modality and setting of treatment is a major program concern. All direct services to at risk families are supplied by professionals employed within existing local agencies (hospital, public health department, state guidance center, and medical school pediatric clinic). Multiple agency involvement allows a broad-based screening capacity which allows thousands of families routine access to program services. The administrative center of the network stands as an independent, community-funded core which coordinates and monitors direct clinical services, and provides local political advocacy for families at risk of parenting problems.

Use of therapeutic play in the ambulatory pediatric hematology clinic

Use of therapeutic play in the ambulatory pediatric hematology clinic