Chapter 9: Ambulatory & Office Pediatrics

Pediatric ambulatory outpatient services provide children and adolescents with preventive health care and acute and chronic care management services and consultations. In this chapter, special attention is given to the pediatric history and physical examination, normal developmental stages, screening laboratories, and a number of common pediatric issues.

The development of a physician-patient-parent relationship is crucially important if the patient and parent are to effectively confide their concerns. This relationship develops over time, with regular visits, and is facilitated by the continuity of clinicians and other staff members. This clinical relationship is based on trust that develops as a result of several experiences in the context of the office visit. Perhaps the greatest factor facilitating the relationship is for patients or parents to experience advice as valid and effective. Anticipatory guidance should be age-appropriate and timely in order to be most helpful. Important skills include choosing vocabulary that communicates understanding and competence, demonstrating commitment of time and attention to the concern, and showing respect for areas that the patient or parent does not wish to address (assuming that there are no concerns relating to physical or sexual abuse or neglect). Parents and patients expect that their concerns will be managed confidentially and that the clinician understands and sympathizes with those concerns. The effective physician-patient-parent relationship is one of the most satisfying aspects of ambulatory pediatrics.

A unique feature of pediatrics is that the history represents an amalgam of parents’ objective reporting of facts (eg, fever for 4 days), parents’ subjective interpretation of their child’s symptoms (eg, infant crying interpreted by parents as abdominal pain), and for older children their own history of events. Parents and patients may provide a specific and detailed history, or a vague history that necessitates more focused probing. Parents may or may not be able to distinguish whether symptoms are caused by organic illness or a psychological concern. Understanding the family and its hopes for and concerns about the child can help in the process of distinguishing organic, emotional, and/or behavioral conditions, thus minimizing unnecessary testing and intervention.

Although the parents’ concerns need to be understood, it is essential also to obtain as much of the history as possible directly from the patient. Direct histories not only provide firsthand information but also give the child a degree of control over a potentially threatening situation and may reveal important information about the family.

Obtaining a comprehensive pediatric history is time consuming. Many offices provide questionnaires for parents to complete before the clinician sees the child. Data from questionnaires can make an outpatient visit more productive, allowing the physician to address problems in detail while more quickly reviewing areas that are not of concern. Questionnaires may be more productive than face-to-face interviews in revealing sensitive parts of the history. Developmental and mental health screening saves provider time and the results when reviewed with the parent or family member can yield critical information. However, failure to review and assimilate this information prior to the interview may cause a parent or patient to feel that the time and effort have been wasted.

Elements of the history that will be useful over time should be readily accessible in the medical record, including demographic data, a problem list, chronic medications, allergies, and previous hospitalizations. Immunizations, including all data required by the National Childhood Vaccine Injury Act, should also be documented.

The components of a comprehensive pediatric history are listed in Table 9–1. The information should, ideally, be obtained at the first office visit. Items 8 and 9, and a focused review of systems (ROS), are dealt with at each acute or chronic care visit. The entire list should be reviewed and augmented with relevant updates at each health supervision visit.

During the pediatric physical examination, time must be taken to allow the patient to become familiar with the examiner. Interactions and instructions help the child understand what is occurring and what is expected. A gentle, friendly manner and a quiet voice help establish a setting that yields a nonthreatening physical examination. The examiner should take into consideration the need for a quiet child, the extent of trust established, and the possibility of an emotional response (crying!) when deciding the order in which the child’s organ systems are examined. Unpleasant procedures (eg, otoscopic examination) should be deferred until the end of the examination. Whether or not the physician can establish rapport with the child, the process should proceed efficiently and systematically.

Because young children may fear the examination and become fussy, simple inspection is important. For example, the examiner can observe the child’s respiratory rate and work of breathing from across the room (often by having a parent lift the child’s shirt) before moving near the child for the remainder of the examination. During a health supervision visit, observation will provide the examiner with an opportunity to assess development and parent-child interactions.

Clothing should be removed slowly and gently to avoid threatening the child. A parent or the child is usually the best person to do this. Modesty should always be respected, and gown or drapes should be provided. Examinations of adolescents should be chaperoned whenever a pelvic examination or a stressful or painful procedure is performed.

Examination tables are convenient, but a parent’s lap is a comfortable location for a young child. For most purposes, an adequate examination can be conducted on a “table” formed by the parent’s and examiner’s legs as they sit facing each other.

Although a thorough physical examination is important at every age, certain components of the examination may change based on the age of the patient. An astute clinician can detect signs of important clinical conditions in an asymptomatic child. In infancy, for example, physical examination can reveal the presence of craniosynostosis, congenital heart disease, or developmental dysplasia of the hip. Similarly, examination of a toddler may reveal pallor (possible iron-deficiency anemia) or strabismus. The routine examination of an older child or adolescent may reveal scoliosis or acanthosis nigricans (a finding associated with insulin resistance).

One of several timetables for recommended health supervision visits is illustrated in Figure 9–1. (Note: A PDF printable format of this figure is available from the American Academy of Pediatrics [AAP].) The federal Maternal and Child Health Bureau has developed comprehensive health supervision guidelines through their Bright Futures program. In areas where evidence-based information is lacking, expert opinion has been used as the basis for these plans. Recently revised Bright Futures Guidelines emphasizes working collaboratively with families, recognizing the need for attention toward children with special health care needs, gaining cultural competence, and addressing complementary and alternative care, as well as integrating mental health care into the primary care setting. Practitioners should remember that guidelines are not meant to be rigid; services should be individualized according to the child’s needs.

During health supervision visits, the practitioner should review child development and acute and chronic problems, conduct a complete physical examination, order appropriate screening tests, and anticipate future developments. New historical information should be elicited through an interval history. Development should be assessed by parental report and clinician observation. In addition, systematic use of formal parent-directed screening tools, such as the Ages and Stages Questionnaire (ASQ) or the Parents’ Evaluation of Developmental Status (PEDS), is recommended. Growth parameters should be carefully recorded, and weight, length, or height, head circumference (up to age 3), and body mass index (BMI) (for > 2 years) should be plotted and evaluated using established growth charts (see Chapter 3). Vision and hearing should be assessed subjectively at each visit, with objective assessments at intervals beginning after the child is old enough to cooperate with the screening test, usually at 3–4 years of age.

Because fewer than 4% of asymptomatic children have physical findings on routine health maintenance visits, a major portion of the health supervision visit is devoted to anticipatory guidance. This portion of the visit enables the health care provider to address behavioral, developmental, injury prevention, nutritional issues, and school problems; and other age-appropriate issues that will arise before the next well-child visit.

DEVELOPMENTAL & BEHAVIORAL ASSESSMENT

Addressing developmental and behavioral problems is one of the central features of pediatric primary care. The term developmental delay refers to the circumstance in which a child has not demonstrated a developmental skill (such as walking independently) by an age at which the vast majority of normally developing children have accomplished this task. Developmental delays are, in fact, quite common: approximately 18% of children younger than 18 years either have developmental delays or have conditions that place them at risk of developmental delays.

Pediatric practitioners are in a unique position to assess the development of their patients. This developmental assessment should ideally take the form of developmental surveillance, in which a skilled individual monitors development in multiple domains (gross motor, fine motor, language, and personal or social) over time as part of providing routine care. Developmental surveillance includes several key elements: listening to parent concerns, obtaining a developmental history, making careful observations during office visits, periodically screening all infants and children for delays using validated screening tools, recognizing conditions and circumstances that place children at increased risk of delays, and referring children who fail screening tests for further evaluation and intervention.

The prompt recognition of children with developmental delays is important for several reasons. Children with delays can be referred for a wide range of developmental therapies, such as those provided by physical, speech or language, and/or educational therapists. Children with delays, regardless of the cause, make better developmental progress if they receive appropriate developmental therapies than if they do not. Many infants and toddlers younger than 3 years with delays are eligible to receive a range of therapies and other services, often provided in the home, at no cost to families. Children aged 3 years and older with delays are eligible for developmental services through the local school system.

Several parent- and physician-administered developmental screening tools are available and should be utilized in order to more efficiently incorporate this process in the busy well-child care visit. The PEDS, ASQ, and the Child Development Inventories (CDI) are screening tests that rely on parent report. Other screening tools, such as the Denver II screening test, the Early Language Milestone Scale (see Chapter 3, Figure 3–1), and the Bayley Infant Neurodevelopmental Screener, involve the direct observation of a child’s skills by a care provider. All developmental screening tests have their strengths and weaknesses. The Denver II is familiar to many pediatric providers and is widely used. However, whereas the Denver II has relatively high sensitivity for detecting possible developmental delays, the specificity is poorer, and this may lead to the over referral of normal children for further developmental testing.

In addition to general developmental screening, autism-specific screens (such as the Modified Checklist for Autism in Toddlers [MCHAT]) should be administered at the 18- and 24-month health supervision visits.

Regardless of the approach taken to developmental screening, there are a number of important considerations: (1) The range of normal childhood development is broad, and therefore a child with a single missing skill in a single developmental area is less likely to have a significant developmental problem than a child showing multiple delays in several developmental areas (eg, gross motor and language delays); (2) continuity of care is important, because development is best assessed over time; (3) it is beneficial to routinely use formal screening tests to assess development; (4) if developmental delays are detected in primary care, these patients need referral and close follow-up to insure evaluation completion for further testing and likely will benefit from receiving developmentally focused therapies and strategies; and (5) parents appreciate when attention is paid to their child’s development and generally react positively to referrals for appropriate developmental therapies.

Several developmental charts with age-based expectations for normal development are presented in Chapter 3 (see Tables 3–1, 3–2, 3–3), as well as a discussion of the recommended medical and neurodevelopmental evaluation of a child with a suspected developmental disorder.

In addition to developmental issues, pediatric providers are an important source of information and counseling for parents regarding a broad range of behavioral issues. The nature of the behavioral problems, of course, varies with the child’s age. Some common issues raised by parents, discussed in detail in Chapter 3, include colic, feeding disorders, sleep problems, temper tantrums, breath-holding spells, and noncompliance. Behavioral issues in adolescents are discussed in Chapter 4.

GROWTH PARAMETERS

Monitoring appropriate growth is pivotal in ambulatory pediatric practice.

Height, weight, and head circumference are carefully measured at each well-child examination and plotted on age- and sex-specific growth charts. The Centers for Disease Control and Prevention (CDC) recently recommended use of the World Health Organization (WHO) growth standards to monitor growth for infants and children ages 0–2 in the United States, in lieu of its own growth charts. The WHO standards are based on a sample of 8500 babies (from Brazil, Ghana, India, Norway, Oman, and the United States) who were predominantly breast-fed for at least 4 months, still nursing at 1 year and living in nonsmoking households. The methods used to create the CDC growth charts and the WHO growth charts are similar for children aged 2 years and older.

To ensure accurate weight measurements for longitudinal comparisons, infants should be undressed completely and young children should be wearing underpants only. Recumbent length is plotted on the chart until approximately 2 years of age. When the child is old enough to be measured upright, height should be plotted on the charts for ages 2–20 years. Routine measurements of head circumference may cease if circumferential head growth has been steady for the first 2 years of life. However, if a central nervous system (CNS) problem exists or develops, or if the child has growth deficiency, this measurement continues to be useful. Tracking the growth velocity for each of these parameters allows early recognition of deviations from normal.

It is useful to note that in the first year of life, it is common for height and weight measurements to cross over a percentile line. After approximately 18 months, most healthy children tend to follow the curve within one growth channel.

Determination of whether or not a child’s weight falls within a healthy range also relies on growth charts. For children younger than 2 years, the weight-for-length chart is used. For children 2–18 years, a BMI chart is used, which is a measure that correlates well with adiposity- and obesity-related comorbidities. The BMI is calculated as the weight (in kilograms) divided by the squared height (in meters). The BMI is useful for determining obesity (BMI ≥ 95th percentile for age) and overweight (BMI between 85th and 95th percentiles), as well as underweight status (BMI ≤ 5th percentile for age). It must be emphasized that “eyeballing” overweight or underweight is frequently inaccurate and should not substitute for careful evaluation of the data on growth charts.

BLOOD PRESSURE

Blood pressure screening at well-child visits starts at age 3 years. There are some conditions that warrant blood pressure monitoring at an earlier age:

• History of prematurity, very low birth weight, or other neonatal complication requiring intensive care

• Congenital heart disease (repaired or nonrepaired)

• Recurrent urinary tract infections, hematuria, or proteinuria

• Known renal disease or urologic malformations

• Family history of congenital renal disease

• Solid organ transplant

• Malignancy or bone marrow transplant

• Treatment with drugs known to raise blood pressure (steroids, oral contraceptives)

• Other conditions associated with hypertension (neurofibromatosis, tuberous sclerosis, etc)

• Evidence of elevated intracranial pressure

Accurate determination of blood pressure requires proper equipment (stethoscope, manometer and inflation cuff, or an automated system) and a cooperative, seated subject in a quiet room. Although automated blood pressure instruments are widely available and easy to use, blood pressure readings from these devices are typically 5 mm Hg higher for diastolic and 10 mm Hg higher for systolic blood pressure compared with auscultatory techniques. Therefore, the diagnosis of hypertension should not be made on the basis of automated readings alone. Additionally, blood pressure varies by the height and weight of the individual. Consequently, hypertension is diagnosed as a systolic or diastolic blood pressure greater than the 95th percentile based on the age and height percentile of the patient using charts from the AAP Clinical Practice Guidelines (see references).

The width of the inflatable portion of the cuff should be 40%–50% of the circumference of the limb. Overweight children need a larger cuff size to avoid a falsely elevated blood pressure reading. Cuffs that are too narrow will overestimate and those that are too wide will underestimate the true blood pressure. Hypertension should not be diagnosed based on readings at one visit, but rather three separate occasions of documented hypertension are required. Repeated measurements at different visits over time should be tracked using flowcharts in an electronic medical record or equivalent in a paper chart. Children with repeated blood pressure readings from the 90th to the 95th percentile may be classified as having elevated blood pressure. Those with greater than between the 95th and 99th percentile plus 12 mm of Hg are classified as Stage 1 hypertension, and those greater than the 99th percentile plus 12 mm of Hg are termed Stage 2 hypertension. National High Blood Pressure Education Program recommends that all children with blood pressure of greater than or equal to 95% should have a complete blood count (CBC), serum nitrogen, creatinine, electrolytes, lipid panel, glucose, urinalysis, and a renal ultrasound in those with abnormal urinalysis or renal function. Nonpharmacologic interventions include diet, exercise, and weight management. Indications for pharmacologic therapy may include the following:

• Symptomatic hypertension

• Stage 2 hypertension without a clearly modifiable factor (eg, obesity)

• Chronic kidney disease

• Diabetes (types 1 and 2)

• Persistent hypertension despite nonpharmacologic measures

Based on a recent systematic review for US Preventive Services Task Force, it is unclear whether screening for hypertension in children and teens reduces adverse outcomes in adults.

VISION & HEARING SCREENING

Examination of the eyes and an assessment of vision should be performed at every health supervision visit. Eye problems are relatively common in children: refractive errors (including myopia, hyperopia, and astigmatism), amblyopia (loss of visual acuity from cortical suppression of the vision of the eye), and/or strabismus (misalignment of the eyes) occur in 5%–10% of preschoolers. Assessment of vision should include visual inspection of the eyes and eyelids, alignment of eyes, and visual acuity.

Starting at birth, the movement and alignment of the eyes should be assessed and the pupils and red reflexes examined. The red reflex, performed on each pupil individually and then on both eyes simultaneously, is used to detect eye opacities (eg, cataracts or corneal clouding) and retinal abnormalities (eg, retinal detachment or retinoblastoma). By 3 months of age, an infant should be able to track or visually follow a moving object, with both eyes.

Starting after age 3, formal testing of visual acuity should be done if possible. This can be performed in the office with a variety of tests, including the tumbling E chart or picture tests such as Allen cards. In these tests, each eye is tested separately, with the nontested eye completely covered. Credit is given for any line on which the child gets more than 50% correct. Children who are unable to cooperate should be retested, ideally within 6 months, and those who cannot cooperate with repeated attempts should be referred to an ophthalmologist. Because visual acuity improves with age, results of the test are interpreted using the cutoff values in Table 9–2. However, any two-line discrepancy between the two eyes, even within the passing range (eg, 20/20 in one eye, 20/30 in the other in a child aged ≥ 6 years) should be referred to an ophthalmologist.

Throughout childhood, clinicians should screen for undetected strabismus (ocular misalignment). The corneal light reflex test can be used starting at 3 months and the cover test can be used beginning at 6 months to assess for strabismus. The corneal light reflex test, the cover test, and visual acuity test are described further in Chapter 16.

Recommendations for vision screening and indications for referral are listed in Table 9–3. Referral to an ophthalmologist is also recommended for preterm infants for evaluation of retinopathy of prematurity (ROP), as well as children with a family history of amblyopia, strabismus, retinoblastoma, or retinal degeneration. Children with Down syndrome should be referred to an ophthalmologist at 6 months of age given their increased risk for refractive error, strabismus, and cataracts.

Hearing loss, if undetected, can lead to substantial impairments in speech, language, and cognitive development. Because significant bilateral hearing loss is one of the more common major anomalies found at birth, and early detection and intervention of hearing loss leads to better outcomes for children, universal hearing screening is provided to newborns in most parts of the United States. Hearing in infants is assessed using either evoked otoacoustic emissions or auditory brainstem-evoked responses. Because universal newborn hearing screening is sometimes associated with false-positive test results, confirmatory audiology testing is required for abnormal tests.

Informal behavioral testing of hearing, such as observing an infant’s response to a shaken rattle, may be unreliable. In fact, parental concerns about hearing are of greater predictive value than the results of informal tests, and such concerns should be taken seriously. Prior to age 4, infants should be referred to an audiologist for testing if a concern arises. Conventional screening audiometry, in which a child raises her hand when a sound is heard, can be performed starting at age 4. Each ear should be tested at 500, 1000, 2000, and 4000 Hz and referred at threshold levels of greater than 20 dB at any of these frequencies. Any evidence of hearing loss should be substantiated by repeated testing, and if still abnormal, a referral for a formal hearing evaluation should be made.

The AAP periodicity schedule recommends routine hearing screening at 4, 5, 6, 8, and 10 years of age and several times during adolescence. Children with any risk factors for hearing loss should be closely followed and receive more frequent screening. A number of inherited or acquired conditions increase the risk of hearing loss. Sometimes hearing loss can be mistaken for inattention, and so hearing screening should be part of workup for attention problems. Additional details regarding hearing assessment are provided in Chapter 18.

Newborn Screening

Newborn screening involves population-wide testing for metabolic and genetic diseases. It has become an essential component in a public health program that screens over 4 million newborns every year. Blood samples are collected by heel stick from newborns before hospital discharge, and results are usually available within 1 week. Some states routinely repeat blood testing between 7 and 14 days of life, while others recommend it if the child is discharged in less than 24 hours. The state-to-state variation seen in newborn screen panels has begun to diminish as a result of national recommendations. In 2010, the Secretary Advisory Committee on Heritable Disorders in Newborns and Children recommended screening for 32 core conditions with another 26 detectable through differential diagnosis. Most states have adopted these guidelines.

Infants with a positive screening result should receive close follow-up, with additional confirmatory studies performed at a center with experience in doing these tests. Screening tests are usually accurate, but the sensitivity and specificity of a particular screening test must be carefully considered. If symptoms of a disease are present despite a negative result on a screening test, the infant should be tested further. Newborn screening has benefited thousands of infants and their families, preventing and diminishing the morbidity of many diseases. At the same time, the emotional cost of false-positive screening is a continuing challenge. Parents report high levels of stress during the evaluation process. Recommendations for useful resources, given the variability of information on the Internet, and prompt clinical services can help reduce this distress.

Lead Screening

The developing infant and child are at risk of lead poisoning or toxicity because of their propensity to place objects in the mouth and their efficient absorption of this metal. Children with lead toxicity are typically asymptomatic. High blood levels (> 70 mcg/dL) can cause severe health problems such as seizures and coma. Numerous neuropsychological deficits have been associated with increased lead levels. Blood lead levels less than 10 mcg/dL have been correlated with lower intelligence quotients. The primary source of lead exposure in this country remains lead-based paint, even though most of its uses have been banned since 1977. Lead levels have declined nationally from a mean of 16 mcg/dL in 1976 to less than 2 mcg/dL in 2008. However, considerable variation in lead levels exists in different regions of the United States, and a majority of children at risk of lead toxicity are not currently screened. Despite the wide variation in the prevalence of lead toxicity, the CDC recommends universal lead screening for children at ages 1 and 2 and targeted screening for older children living in communities with a high percentage of old housing (> 27% of houses built before 1950) or a high percentage of children with elevated blood lead levels (> 12% of children with levels > 10 mcg/dL). Children enrolled in Medicaid are required to be screened at 12 and 24 months.

Communities with inadequate data regarding local blood lead levels should also undergo universal screening. Caregivers of children between 6 months and 6 years of age may be interviewed by questionnaire about environmental risk factors for lead exposure (Table 9–4), although the data to support the use of this screening are inconclusive. If risk factors are present, a blood lead level should be obtained. A venous blood sample is preferred over a capillary specimen. An elevated capillary (fingerstick) blood sample should always be confirmed by a venous sample. There is no safe level of lead in a child’s blood, but the CDC reference level of 5 mcg/dL should be used to identify children at risk in order to initiate public health actions. The recommended actions can be viewed on the CDC website (see references).

The cognitive development of children with confirmed high blood levels should be evaluated and attempts made to identify the environmental source. Iron deficiency should be treated if present. Chelation of lead is indicated for levels of 45 mcg/dL and higher and is urgently required for levels above 70 mcg/dL. All families should receive education to decrease the risk of lead exposure. With any elevated lead level (> 5 mcg/dL), rescreening should be performed at recommended intervals.

Iron Deficiency

Iron deficiency is the most common nutritional deficiency in the United States. Severe iron deficiency causes anemia, behavioral problems, and cognitive effects, but recent evidence suggests that even iron deficiency without anemia may cause behavioral and cognitive difficulties. Some effects, such as the development of abnormal sleep cycles, may persist even if iron deficiency is corrected in infancy.

Risk factors for iron deficiency include preterm or low-birth-weight births, multiple pregnancy, iron deficiency in the mother, use of nonfortified formula or cow’s milk before age 12 months, and an infant diet that is low in iron-containing foods. Infants and children with chronic illness, restricted diet, or extensive blood loss (such as gastrointestinal bleeding or injury) are at risk for iron deficiency.

Primary prevention of iron deficiency should be achieved through dietary means, including feeding ground up meats and iron-containing cereals by age 6 months, avoiding low-iron formula during infancy, and limiting cow’s milk to 24 oz per day in children aged 1–5 years.

Universal screening for anemia should occur at approximately 12 months of age by obtaining often by obtaining a hemoglobin or hematocrit. Premature and low-birth-weight infants may need testing before 6 months of age.

A full CBC to look at mean corpuscular volume (MCV) can aid in the evaluation. Serum ferritin is a useful test to evaluate iron-deficiency anemia, as it can also pick up iron deficiency in the absence of anemia, and provides more specificity in detecting iron deficiency. Serum ferritin is recommended by the WHO for iron screening. Because ferritin is an acute-phase reactant and can be falsely reassuring in the presence of inflammation, infection, or malignancy, some experts recommend obtaining a concurrent C-reactive protein (CRP) for accurate interpretation of the ferritin level. Elevated lead levels can cause iron-deficiency anemia and should be explored as a cause for at-risk infants and children.

Management of iron deficiency with or without anemia includes treatment doses of 3–6 mg/kg body weight of elemental iron.

Hypercholesterolemia & Hyperlipidemia

Cardiovascular disease is the leading cause of death in the United States, and research has documented that the atherosclerotic process begins in childhood. Genetic factors, diet, and physical activity all play a role in the disease process. Nonfasting lipid screening is recommended universally for children between the ages of 9 and 11. Fasting lipid screening is recommended between the ages of 2 and 8, and ages 12 and 16 if risk factors are present. Diet and weight management strategies are the primary interventions. However, for severe dyslipidemia (LDL ≥ 190 mg/dL), pharmacologic therapy should be considered. However, consideration of pharmacotherapy should be made for severe dyslipidemia (LDL ≥ 190 mg/dL), or at greater than 160 mg/dL if there is a family history of heart disease, and in all patients at greater than 130 mg/dL depending on their level and amount of risk factors.

Tuberculosis

According to the CDC, 9272 cases of tuberculosis (TB) were reported in the United States in 2016. Risk of TB should be assessed at well-child visits, and screening should be based on high-risk status. High risk is defined as contact with a person with known or suspected TB; having symptoms or radiographic findings suggesting TB; birth, residence, or travel to a region with high TB prevalence (Asia, Middle East, Africa, Latin America); contact with a person with AIDS or human immunodeficiency virus (HIV); or contact with a prisoner, migrant farm worker, illicit drug user, or a person who is or has been recently homeless. TB testing can be performed by a skin test or a blood test. The Mantoux test (five tuberculin units of purified protein derivative) is the only recommended skin test. The interferon-gamma release assays (IGRAs) are blood tests that can be useful for patients who have been immunized with bacille Calmette-Guerin (BCG) or for patients who may have difficulty returning for a second appointment to look for skin reaction.

Targeted screening for latent TB for high-risk individuals is the recommended approach based on available evidence. The following screening questions have been validated to determine high-risk status:

1. Was your child born outside the United States? If yes, this question would be followed by: Where was your child born? If the child was born in Africa, Asia, Latin America, or Eastern Europe, a TB testing should be performed.

2. Has your child traveled outside the United States? If yes, this question would be followed by: Where did the child travel, with whom did the child stay, and how long did the child travel? If the child stayed with friends or family members in Africa, Asia, Latin America, or Eastern Europe for more than 1 week cumulatively, TB testing should be performed.

3. Has your child been exposed to anyone with TB disease? If yes, this question should be followed by questions to determine if the person had TB disease or latent TB infection (LTBI), when the exposure occurred, and what the nature of the contact was. If confirmed that the child has been exposed to someone with suspected or known TB disease, TB testing should be performed. If it is determined that a child had contact with a person with TB disease, notify the local health department per local reporting guidelines.

4. Does your child have close contact with a person who has a positive TB test? If yes, go to question 3.

Screening of Adolescent Patients

Adolescents may present with chief complaints that are not the true concern for the visit. Repeating the question “Is there anything else you would like to discuss?” should be considered. Since suicide is a leading cause of morbidity and mortality in this age group, screening with the Pediatric Symptom Checklist for Youth is recommended (https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf).

Testing adolescents for blood cholesterol, TB, and HIV should be offered based on high-risk criteria outlined in this chapter and in Chapter 41. Females should have a screening hematocrit once after the onset of menses. During routine visits, adolescents should be questioned sensitively about risk factors (eg, multiple partners; early onset of sexual activity, including child sexual abuse) and symptoms (eg, genital discharge, infectious lesions, pelvic pain) of sexually transmitted infections (STIs). An annual dipstick urinalysis for leukocytes is recommended for sexually active adolescents. Because STIs are often not symptomatic, urine polymerase chain reaction (PCR) for gonorrhea and chlamydia and screening tests for trichomoniasis should be considered. Current guidelines recommend that the first Papanicolaou (Pap) test should be performed at age 21 years, regardless of onset of sexual activity. A complete pelvic examination should be performed when evaluating lower abdominal pain in an adolescent.

Please see Chapter 4 for additional details on adolescent preventive services.

ANTICIPATORY GUIDANCE

An essential part of the health supervision visit is anticipatory guidance. During this counseling, the clinician directs the parent’s or the older child’s attention to issues that may arise in the future. Guidance must be appropriate to age, focus on concerns expressed by the parent and patient, and address issues in depth rather than run through a number of issues superficially. Both oral and printed materials are used. When selecting written materials, providers should be sensitive to issues of literacy and primary language spoken by the family members. Areas of concern include diet, injury prevention, developmental and behavioral issues, and health promotion.

Smoking Cessation

Deleterious effects of secondhand smoke (SHS) on children’s health are well documented and the AAP has highlighted the importance of tobacco screening and counseling at each pediatric visit. One-third of children live in a home with an adult smoker. The Ask, Advise, and Refer methodology has been shown to be a feasible approach to smoking cessation. Ask families if there is a smoker at home, advise the family about the benefit of cessation for the child, and refer to a formal cessation program if the family member is ready to quit.

Injury Prevention

For children and adolescents aged 1–19 years, unintentional injuries are the number one cause of death. In every age category, males are at higher risk than females for unintentional injury.

Injury prevention counseling is an important component of each health supervision visit and can be reinforced during all visits. Counseling should focus on problems that are frequent and age appropriate. Passive strategies of prevention should be emphasized, because these are more effective than active strategies; for example, placing chemicals out of reach in high, locked cupboards to prevent poisoning will be more effective than instructing parents to watch their children closely.

Informational handouts about home safety, such as The Injury Prevention Program (TIPP; available from the AAP), can be provided in the waiting room. Advice can then be tailored to the specific needs of each family, with reinforcement from age-specific TIPP handouts.

A. Motor Vehicle Injuries

The primary cause of death of children in the United States is motor vehicle injuries. Although the rate of death from this cause is improving, still in 2015, about 35% of children aged 12 years or younger who were killed in motor vehicle accidents were unrestrained.

The type and positioning of safety seats can be confusing. While car seat and booster seat laws differ by state, a recent AAP policy statement describes the best practice recommendations. All infants and toddlers should ride in a rear-facing car safety seat until 2 years of age or until they reach the weight and height limits for convertible car safety seats (usually 35–40 pounds). Infants may ride in infant-only seats (which often have a carrying handle and snap into a base that is secured in the car) until they reach the height and weight limit for that seat, and then transition to a convertible car seat. Once a child reaches 2 years of age (or younger than 2 if outgrown the weight and height limit of a convertible car seat), he or she can be in a forward-facing car safety seat with a harness. The safest scenario is for a child to remain in a car safety seat with a harness as long as possible. Once a child reaches the weight or height limits of a forward-facing seat, he or she may be transitioned to a belt-positioning booster until the vehicle’s lap-and-shoulder belt fits properly (child can sit with his back against the vehicle seat, bend his knees at the edge of the seat, have the belt positioned in the center of the shoulder and across the chest, and have the lap belt touching the thighs). These criteria are generally met once a child reaches height of 4 ft 9 in and is between the ages of 8 and 12 years. All children younger than 13 years should be restrained in the rear seats of the vehicle.

Unfortunately, restraint use shows a decreasing trend with advancing age: children from 1 to 8 years of age use restraints over 90% of the time, but those 8–12 years of age use restraints less than 85% of the time. African-American and Hispanic children use child safety seats less often than white children.

A final motor vehicle risk for health involves the use of portable electronic devices. Using a cell phone while driving is associated with a threefold increase in motor vehicle accidents. Texting while driving poses an even greater danger. All should avoid these risks and adults should model safe practices.

B. Bicycle Injuries

Each year, an average of nearly 400 children die from bicycle crashes, and over 450,000 are treated for bicycle-riding injuries. Over 150,000 children are treated annually in emergency departments for head injuries sustained while riding a bicycle. Many observational studies have shown a decreased risk of head injury with the use of bicycle helmets. Community-based interventions, especially those that provide free helmets, have been shown to increase observed bike helmet wearing. Counseling by physicians in various settings has also been shown to increase bike helmet use. While there is no federal law mandating bicycle helmets, some states have passed legislation requiring bicycle helmets.

C. Skiing and Snowboarding Injuries

Recent studies have suggested that the burden of skiing injuries is high among children, and that children have the highest rate of injury of any age group: approximately 3 injuries per 1000 skier days. Traumatic brain injuries are the leading cause of death for pediatric age skiers. Case-control studies have shown a decrease in head injuries associated with helmet use.

D. Firearm Injuries and Violence Prevention

The United States has a higher rate of firearm-related death than any other industrialized country. For children younger than 15, the death rate from firearm-related injuries is nearly 12 times greater than that of 25 other industrialized nations. Some gun deaths may be accidental, but most are the result of homicide or suicide. A gun in the home doubles the likelihood of a lethal suicide attempt. Although handguns are often kept in homes for protection, a gun is more likely to kill a family member or a friend than an intruder. Adolescents with a history of depression or violence are at higher risk with a gun in the home. The most effective way to prevent firearm injuries is to remove guns from the home. Families who keep firearms at home should lock them in a cabinet or drawer and store ammunition in a separate locked location.

E. Drowning and Near Drowning

Drowning is the leading cause of injury-related death in children ages 1–4 years and the third leading cause of injury-related death in children ages 5–19 years. An estimated 8700 children younger than 20 years old were taken to a hospital emergency department for a drowning event in 2017. Children younger than 1 year are most likely to drown in the bathtub. Buckets filled with water also present a risk of drowning to the older infant or toddler. For children aged 1–4 years, drowning or near drowning occurs most often in swimming pools; and for school-aged children and teens, drowning occurs most often in large bodies of water (eg, swimming pools or open water). Parents should be cautioned that inflatable swimming devices are not a substitution for approved live vests or close supervision and can give a false sense of security. All children should be taught to swim, and recreational swimming should always be supervised. Home pools must be fenced securely, and parents should know how to perform cardiopulmonary resuscitation. A phone should be available near the swimming area. Because drowning is a leading cause of death by injury in children, the AAP has produced a Drowning Prevention “toolkit” for pediatric providers and families (see references).

F. Fire and Burn Injuries

Fires and burns are the leading cause of injury-related deaths in the home. Categories of burn injury include smoke inhalation; flame contact; scalding; and electrical, chemical, and ultraviolet burns. Scalding is the most common type of burn in children. Most scalds involve foods and beverages, but nearly one-fourth of scalds are with tap water, and for that reason it is recommended that hot water heaters be set to a maximum of 120°F. Most fire-related deaths result from smoke inhalation. Smoke detectors can prevent 85% of the injuries and deaths caused by fires in the home. Families should discuss a fire plan with children and practice emergency evacuation from the home.

Sunburn is a common thermal injury and often is not recognized because symptoms of excessive sun exposure usually do not begin until after the skin has been damaged. Repeated sunburn and excessive sun exposure are associated with skin cancers. Prevention of sunburn is best achieved by sun avoidance, particularly during the midday hours of 10 AM to 4 PM. A sunscreen with a minimum sun protection factor (SPF) of 30 that protects against both UVA and UVB rays should be used on sunny and cloudy days to help protect against sunburn. Hats, sunglasses, and long-sleeved swim shirts are also important aspects of safe sun exposure. The safety of sunscreen is not established for infants younger than 6 months; thus, sun avoidance, appropriate clothing, and hats are recommended for this age group. In extreme circumstances in which shade is not available, a minimal amount of sunscreen can be applied to small areas, including the face and back of the hands.

G. Choking

Choking is a leading cause of injury and death in young children. Choking hazards include food and small objects. Children younger than 3 are particularly at risk because they do not have fully coordinated chewing and swallowing, and they are more apt to put small objects in their mouths. Foods that are commonly associated with choking include hot dogs, hard candy, nuts, popcorn, raw vegetables, and chunks of meat, fruit, or cheese. Common nonfood items that pose a risk for choking include coins, latex balloons, button batteries, marbles, small toys, and small toy parts. While being mindful of choking hazards is important, accidents can still occur. Again, parents and caregivers should be trained in CPR and choking first aid.

NUTRITION COUNSELING

Screening for nutritional problems and guidance for age-appropriate dietary choices should be part of every health supervision visit. Overnutrition, undernutrition, and eating disorders can be detected by a careful analysis of dietary and activity patterns interpreted in the context of a child’s growth pattern.

Human milk feeding is species specific and is the preferred method for infant feeding for the first year of life. Pediatricians should assist mother-infant dyads with latch and help manage breast-feeding difficulties in the early newborn period. For exclusively and partially breast-fed infants, vitamin D supplementation should be given. Iron-fortified formula should be used in situations when breast-feeding is contraindicated such as HIV, active untreated TB, galactosemia, and certain medications. As noted in Chapter 11 (Normal Childhood Nutrition & Its Disorders), the positive benefits of continued breast-feeding and breast milk by mothers who have used illicit drugs should be balanced in individual cases against the risk of transmission of such drugs to the infant via the milk. After the first year, breast-feeding may continue or whole cow’s milk can be given because of continued rapid growth and high-energy needs. After 2 years of life, milk with 2% fat or lower may be offered. Baby foods and appropriately prepared table foods should be introduced between 4 and 6 months of age and self-feeding with finger foods encouraged by 7–8 months of age.

When obtaining a dietary history, it is helpful to assess the following: who purchases and prepares food, who feeds the child, whether meals and snacks occur at consistent times and in a consistent setting, whether children are allowed to snack or “graze” between meals, the types and portion sizes of food and drinks provided, the frequency of eating meals in restaurants or eating take-out food, and whether the child eats while watching television.

For children 2 years of age and older, a prudent diet consists of diverse food sources, encourages high-fiber foods (eg, fruits, vegetables, grain products), and limits sodium and fat intake. Since obesity is becoming increasingly prevalent, foods to be avoided or limited include processed foods, sugar-sweetened drinks or soda, and candy. Parents should be gently reminded that they are modeling for a lifetime of eating behaviors in their children, both in terms of the types of foods they provide and the structure of meals (eg, the importance of the family eating together). For additional information on nutritional guidelines, undernutrition, and obesity, see Chapter 11; for eating disorders, see Chapter 6; for adolescent obesity, see Chapter 4.

As of 2009, the Women, Infants, and Children (WIC) food packages reflect the recommendations above and include provision of more fruits and vegetables, whole grains, yogurt and soy products, low-fat milk, and limitations on juice. Breast-feeding mothers receive more food as part of their package, less formula supplementation, and breast-fed infants receive baby food meats as a first food (because of more iron and zinc).

COUNSELING ABOUT TELEVISION & OTHER MEDIA

Screen time and social media have a significant influence on children and adolescents. The average child in the United States watches approximately 3–5 hours of television per day, and this does not include time spent watching movies, playing video games, playing on computers or tablets, accessing the Internet, or using cell phones. Taking into account these other forms of media, current estimates are around 7.5 hours of media exposure per day for average 8- to 18-year-olds. Figure 9–2 shows a breakdown of media exposure by age group.

Having a television set in the bedroom increases daily media exposure and is also associated with sleep disturbances. According to the Kaiser Family Foundation, over 70% of 8- to 19-year-olds have a television in their bedrooms.

Watching television may have both positive and negative effects. Programs directed toward early childhood may increase knowledge and imaginativeness, and may also teach empathy and acceptance of diversity. However, excessive television viewing of programs with inappropriate content has been shown to have negative effects with respect to violence, sexuality, substance abuse, nutrition, social skills, and body self-image. More recent data suggest that excessive viewing in childhood may have a long-lasting negative effect on cognitive development and academic achievement. Clinicians should assess media exposure in their patients and offer parents concrete advice. Screen time for all media, including television, movies, DVDs, video games, computer activities, computers, tablets, the Internet, and cell phones, should be limited. The AAP recommends that 18- to 24-month-old children should not have any screen time (unless it is video chatting), and that children 2–5 years be limited to 1 hour total screen time each day. The television should not be on during mealtimes, night, or naptimes. Parents should themselves watch sensibly, monitor the program content to which their children are exposed, watch programs and discuss interesting content with children, remove television sets from all bedrooms, and encourage alternative activities. Parents should be advised that research consistently shows that exposure to media violence correlates with childhood aggression.

Social networking sites are becoming increasingly popular, and clinicians need to encourage parents to monitor participation and be aware of potential problems with cyberbullying, “Facebook depression,” sexting, and exposure to inappropriate content on sites such as YouTube. Free family media use plans are available through the AAP (www.HealthyChildren.org/MediaUsePlan).

IMMUNIZATIONS

A child’s immunization status should be assessed at every visit and every opportunity should be taken to vaccinate. Even though parents may keep an immunization record, it is critical that providers also keep an accurate record of a child’s immunizations. This information should be written in a prominent location in the paper or electronic chart or kept in an immunization registry.

Despite high overall national immunization coverage levels, areas of under immunization continue to exist in the United States. An understanding of true contraindications (vs “false contraindications”) and a “no missed opportunities” approach to immunization delivery has been shown to successfully increase immunization levels. Therefore, it is important that clinicians screen records and administer required immunizations at all types of visits, not just well child visits, and administer all needed vaccinations simultaneously. Additionally, clinicians should operate reminder or recall systems, in which parents of underimmunized children are prompted by mail, telephone, and text messages (particularly with adolescents) to visit the clinic for immunization. The assessment of clinic-wide immunization levels and feedback of these data to providers have also been shown to increase immunization rates.

Parent refusal of immunizations is an issue in some communities. Because a plethora of incorrect information about vaccine safety and efficacy is on the Internet, it is useful for the provider to direct parents toward reliable sources to help them make an informed decision. A wealth of information for parents and providers about immunizations is available at the National Immunization Program’s Web site (www.cdc.gov/vaccines).

Other Types of General Pediatric Service

ACUTE-CARE VISITS

Acute-care visits account for 30% or more of the general pediatrician’s office visits. Office personnel should determine the reason for the visit and whether it is an emergent situation, obtain a brief synopsis of the child’s symptoms, carefully document vital signs, and list known drug allergies. The clinician should document the events related to the presenting problem and carefully describe them in the medical record. The record should include supporting physical examination data and a diagnosis. Treatments and follow-up instructions must be recorded, including when to return to the office if the problem is not ameliorated. Immunization status should be screened, as previously discussed. Depending on the severity of illness, this may also be an opportunity for age-appropriate health maintenance screenings and anticipatory guidance. This may be particularly true with older school-aged children or adolescents who may be seen more rarely for routine health maintenance visits.

PRENATAL VISITS

Ideally, a couple’s first trip to a physician’s office should take place before the birth of their baby. A prenatal visit goes a long way toward establishing trust and enables a pediatric provider to learn about a family’s expectations, concerns, and fears regarding the anticipated birth. If the infant develops a problem during the newborn period, a provider who has already met the family is in a better position to maintain rapport and communication with the new parents.

In addition to helping establish a relationship between parents and pediatric providers, the prenatal visit can be used to gather information about the parents and the pregnancy, provide information and advice, and identify high-risk situations. A range of information can be provided to parents regarding feeding choices and the benefits of breast-feeding; injury prevention, including sleeping position and the appropriate use of car seats; and techniques for managing colic. Potential high-risk situations that may be identified include mental health issues in the parents, a history of domestic violence, or maternal medical problems that may affect the infant.

SPORTS PHYSICALS

A preparticipation physical examination (PPE) evaluation is a recommended part of every routine well-child and adolescent care visit. Physicians should be recommending exercise and activity to every child, not just those participating in organized sports.

The goal of the sports physical is to identify medical conditions that would make sports participation unsafe, screen for underlying illness through a traditional history and physical, and recognize preexisting injuries or medical problems that have affected previous sports seasons. As part of the history, the particular sport being played or specific exercise activity should be discussed. Different sports have different potentials for injury, and prevention methods will differ. All patients should be asked about previous cardiac, respiratory, musculoskeletal, or neurologic problems associated with activity. Particular attention should be drawn to any suspicion of cardiac syncope, asthma symptoms, past concussions, or history of unilateral organs, such as kidneys or testicles. Anabolic steroid and nutritional supplement discussion should be explored. Any relevant family history of cardiac death younger than age 50 should be documented.

The physical examination starts with vital signs, including accurate blood pressure screening and examination for obesity. Highlights of the examination include a careful respiratory and cardiac examination, looking for evidence of exercise-induced bronchospasm or anatomic heart disease. Electrocardiogram (ECG) or pulmonary function tests can be considered for suspected abnormalities. The skin examination should look for evidence of potentially contagious skin infections like impetigo or molluscum. The musculoskeletal examination should include all major muscle groups, as well as range of motion and stability testing of the neck, back, shoulder, hips, knees, and ankles. Any pain or limitation should prompt consideration of further investigation or therapy.

A few specific conditions bear mentioning during the counseling phase of the sports participation, including the risks and danger of concussions and performance-enhancing drugs. A list of medical conditions that may affect sports participation can be found in the references. Appropriate protective equipment should be encouraged.

CHRONIC DISEASE MANAGEMENT

Chronic disease in pediatrics is defined as illness that has been present for more than 3 months. Around 25% children and 35% adolescents have illnesses that meet the definition of a chronic illness. The most common chronic conditions in pediatric practice include asthma, obesity or overweight, attention-deficit/hyperactivity disorder (ADHD), and allergic diseases, but also include congenital anomalies and other conditions. Many patients with chronic conditions are cared for only by a primary care provider. However, when subspecialist care is required, the primary care provider plays an integral part of the care to deal with the complexity of these conditions, which also includes understanding the child’s growth and development, routine health promotion and anticipatory guidance, evaluating for social issues, advocating for children and their families, and care coordination.

The goal of chronic disease management is to optimize quality of life while minimizing the side effects of treatment interventions. Problem lists should be used to document chronic diagnoses and monitor associated medications. The child and family’s emotional responses to chronic illness should be addressed, and referrals to counselors should be offered if needed. Nutrition and the management of medical devices (eg, catheters, gastrostomy tubes) may need to be addressed, and care coordinated with appropriate specialists.

MEDICAL HOME

The medical home is a concept in which children and their families have an identified, easily accessible primary care provider or group of primary care providers within an office. The AAP has identified seven characteristics of a medical home. The medical home must be (1) accessible, meaning that it must be within the child’s community, physically accessible, and all insurances accepted; (2) family centered, with mutual responsibility and decision-making between the patient or family and medical provider, and the family is recognized as an expert of the child; (3) continuous, in that the same medical professionals provide the continuity of care; (4) comprehensive, with provisions made such that ambulatory and inpatient care are available 24 hours per day, 7 days a week, for 52 weeks of the year; (5) coordinated, with a plan of care developed by the physician and family that is communicated to other providers and agencies as needed; (6) compassionate, meaning that concern is expressed and efforts are made to understand the patient’s and family’s perspective; and (7) culturally effective, in that the cultural background of the patient and family is respected and incorporated into care, and services are provided in the family’s primary language or through a trained medical interpreter.

All children should have a medical home, but it is particularly crucial for children with special health care needs or those with one or more chronic health condition expected to last more than a year. A primary care provider through a medical home should be available for children to assist families with the coordination of consultant recommendations and development of a care plan to implement recommendations.

Parents frequently consult their pediatrician on a large variety of parenting and behavioral health issues. Common topics on which the pediatrician must be comfortable counseling include discipline, temper tantrums, toilet training, biting, and sleep problems.

In addition, there are mental health issues that pediatricians will commonly address in the primary care setting, including ADHD, anxiety, depression, school problems, or family stressors (such as separation, divorce, or remarriage). After assessing the situation, the primary care physician must decide whether the child’s and family’s needs are within his or her area of expertise or whether referral to another professional such as a psychologist or an education specialist would be appropriate.

The pediatrician should know the warning signs of childhood depression and bipolar disorder and have a low threshold for referral of these concerns to the appropriate mental health professional. Ideally, mental health services not provided by the clinician are available in the same setting where physical health services are obtained (see as follows).

Integrated Mental & Behavioral Health in the Primary Care Setting

In the United States, approximately 20% of school-age children suffer from a diagnosable emotional impairment. Prevalence is higher for children living in poor socioeconomic circumstances. About 75% of all children with psychiatric disturbances are seen in primary care settings, and half of all pediatric office visits involve behavioral, psychosocial, or educational concerns.

Child and family concerns routinely manifest in the context of visits with pediatric primary care providers. However, many pediatric providers in community settings do not feel equipped to address the growing mental health and behavioral needs of the populations they serve due to lack of training and perceived lack of support from mental health providers and systems. Parents are most likely to turn to their primary health care provider for information regarding parenting and child development than to another specialist.

Studies have shown that improved detection of mental health conditions is best done when there is a true partnership between clinical providers and families. A small number of clinic settings have moved forward with providing integrated behavior, development, and mental health training for physicians. The Healthy-Steps for Young Children Program provides an example of training pediatric providers and delivering enhanced developmental services in pediatric primary care settings. Families participating in Healthy Steps received more developmental services, were more satisfied with the quality of care provided, were more likely to attend well-child visits and receive vaccinations on time, and were less likely to use severe discipline techniques with their children. Participation in the program also increased the likelihood that mothers at risk for depression would discuss their symptoms with someone in the pediatric setting.

Providing appropriate, efficient, and timely clinical advice over the telephone is a critical element of pediatric primary care in the office setting. An estimated 20%–30% of all clinical care delivered by general pediatric offices is provided by telephone. Telephone calls to and from patients occur both during regular office hours and after the office has closed (termed after-hours), and the personnel and systems in place to handle office-hours versus before- and after-hours calls may differ. In either circumstance, several principles are important: (1) advice is given only by clinicians or other staff with formal medical education (eg, nurse, medical assistant), (2) staff is given additional training in providing telephone care, (3) documentation is made of all pertinent information from calls, (4) standardized protocols covering the most common pediatric symptoms are used, and (5) a physician is always available to handle urgent or difficult calls.

During routine office hours, approximately 20%–25% of all telephone calls to pediatric offices involve clinical matters. Many of these calls, however, are routine in nature, and an experienced nurse within the office can screen calls and provide appropriate advice by telephone. Calls from inexperienced or anxious parents about simple concerns should be answered with understanding and respect. Certain types of calls received during office hours should be promptly transferred to a physician: (1) true emergencies, (2) calls regarding hospitalized patients, (3) calls from other medical professionals, and (4) calls from parents who demand to speak with a physician. Nurses should also seek help from a clinician whenever they are uncertain about how to handle a particular call. When in doubt about the diagnosis or necessary treatment, nurses giving telephone advice should err on the side of having the patient seen in the office.

After-hours telephone answering services are available to many clinicians. Pediatric call centers, although not available in all communities, have certain benefits. Calls are managed using standardized protocols, the call centers are typically staffed by nurses with abundant pediatric experience, the calls are well documented, and call centers often perform ongoing quality assurance. Extensive research on pediatric call centers has revealed a high degree of appropriate referrals to emergency departments, safety in terms of outcomes, parent satisfaction with the process, and savings to the health care system.

In general, after-hours pediatric telephone calls tend to be more serious than calls made during regular office hours. Deciding which patients need to be seen, and how urgently, is the most important aspect of these after-hours telephone “encounters.” Several factors influence this final patient disposition: (1) the age of the patient, (2) the duration and type of symptom, (3) the presence of any underlying chronic condition, (4) whether the child appears “very sick” to the caller, and (5) the anxiety level of the caller. Once all the pertinent medical information is gathered, a decision is made about whether the child should be seen immediately (by ambulance vs car), seen in the office later (today vs tomorrow), or whether the illness can be safely cared for at home. At the end of the call, it should be confirmed that parents understand and feel comfortable with the plan for their child.

The Internet has become a common tool used in pediatric office settings. Information about the practice and providers, the care of common minor problems, scheduling of appointments, insurance issues, prescription refills, and laboratory test results are often available using the web. Pertinent health information, with appropriate permissions and authority, can often be provided via the electronic medical record to other locations such as hospitals and pharmacies. A well-functioning website is now a crucial service of a pediatric practice.

Community pediatrics is “a perspective that enlarges the pediatrician’s focus from one child to all children in the community.” Pediatricians have historically been very involved in supporting and developing services for vulnerable children in their communities. As a group, pediatricians recognize that communities are integral determinants of a child’s health and that the synthesis of public health and personal health principles and practices is important in the practice of community pediatrics. As well, pediatricians have long been committed to working with other professionals in the community and advocating for the needs of all children. For example, pediatricians have been instrumental in the passage of laws requiring car seats and bicycle helmets, as well as expanded health care coverage through State Children’s Health Insurance Program (SCHIP) working with legislators on both local and federal levels.

Advocacy refers to the act of representing or pleading a cause on behalf of another. Pediatricians and other providers who care for children have a responsibility to be a voice for a population who cannot vote or advocate for themselves very effectively. Advocacy can be broken down into three categories: individual (patient-based), community, and legislative (policy-based).

Pediatricians in practice frequently engage in one-on-one advocacy, which may take the form of writing a letter of medical necessity or referring children and families to valuable services and resources. Pediatricians must be familiar with programs in the community. For example, children with special health care needs may be eligible for services typically funded through state health departments and through programs such as those provided based on the Individuals with Disabilities Education Act (IDEA). A variety of community-based immunization programs can provide access to needed immunizations for eligible children. Food and nutrition programs such as the federally funded WIC program provide sources of food at no cost to eligible families. Finally, subsidized preschool and child care services such as the federally funded Head Start program provide preschool programs for qualifying children.

Community advocacy goes beyond the walls of the office or hospital. Pediatricians can become involved with local organizations that help children in the community. Pediatricians and other child advocates can work with community partners to address issues that influence child health. Community advocacy might focus on a particular condition (such as obesity) or environmental factors (such as exposure to violence) or improving health prevention (such as promoting programs to incorporate oral health into well-child visits). Finally, pediatricians can learn about issues that affect children and work to affect change at a local, state, or national level. Physician advocates may write or call their legislators, educate the public and disseminate information by writing letters or opinion pieces, provide expert testimony for legislative committees, or even help draft laws.

Chronic or significant stressors can have a tremendous impact on children, as well as increasing their risk for medical, social, and substance abuse problems later in life. The Adverse Childhood Experiences (ACE) study showed a strongly positive relationship between childhood trauma [abuse (emotional/physical/sexual), household challenges (domestic violence, substance abuse, mental illness, parental separation/divorce, incarcerated family member), and neglect (emotional/physical)] with life-long medical and social problems. When a child experiences chronic stressors, but does not have buffering relationships, toxic stress occurs. Primary care pediatric providers have the opportunity to help families build resiliency by encouraging caregivers to take care of themselves and teaching them how to spend nurturing time with their children. Some families will also benefit from additional supports and resources.

FEVER

General Considerations

Fever is one of the most common reasons for pediatric office visits, emergency department encounters, and after-hours telephone calls. Several different definitions of fever exist, but most experts define fever as a rectal temperature of 38°C (100.4°F) or above. Temperature in pediatric patients can be measured in a variety of manners: rectal (using a mercury or digital thermometer), oral (mercury or digital), axillary (mercury, digital, or liquid crystal strip), forehead (liquid crystal strip), or tympanic (using a device that measures thermal infrared energy from the tympanic membrane). Tympanic measurement of temperature is quick and requires little patient cooperation. Several cautions apply to the use of this technique: tympanic temperatures have been shown to be less accurate in infants younger than 3 months and are subject to false readings if the instrument is not positioned properly or the external ear canal is occluded by wax.

Causes

Fever occurs when there is a rise in the hypothalamic set point in response to endogenously produced pyrogens. Among the broad range of conditions that cause fever are infections, malignancies, autoimmune diseases, metabolic diseases, chronic inflammatory conditions, medications (including immunizations), CNS abnormalities, and exposure to excessive environmental heat. In most settings, the majority of fevers in pediatric patients are caused by self-limiting viral infections. Meta-analysis has not shown and association between teething and fever.

Evaluation and Clinical Findings

A. Initial Evaluation

When evaluating a child with fever, one should elicit from the parents information about the duration of fever, how the temperature was taken, the maximum height of fever documented at home, all associated symptoms, any chronic medical conditions, any medications taken, medication allergies, fluid intake, urine output, exposures and travel, and any additional features of the illness that concern the parents (Table 9–5). In the office, temperature, heart rate, respiratory rate, and blood pressure should be documented, as well as an oxygen saturation if the child has any increased work of breathing. A complete physical examination, including a neurologic examination, should then be performed, with particular attention paid to the child’s degree of toxicity and hydration status. A well-appearing, well-hydrated child with evidence of a routine viral infection can be safely sent home with symptomatic treatment and careful return precautions.

Depending on patient age, presence of underlying conditions, type of infection, and the provider’s assessment of toxicity and hydration, many children with focal bacterial infections can also be treated as outpatients, with appropriate oral antibiotics as discussed in Chapter 42.

B. Fever Without a Focus of Infection

Children who present with fever but without any symptoms or signs of a focal infection are often a diagnostic and management challenge. When assessing a child with fever but no apparent source of infection on examination, the provider needs to carefully consider the likelihood of a serious but “hidden” or occult bacterial infection. With the widespread use of effective vaccines against Haemophilus influenzae type b and Streptococcus pneumoniae, two of the most common causes of invasive bacterial infections in unimmunized children, the incidence of occult bacterial infections has declined. However, vaccines are not 100% effective, and other organisms cause serious occult infections in children; therefore, febrile children will always demand careful evaluation and observation. Appropriate choices for empiric antibiotic therapy of children with fever without focus are discussed in Chapter 39.

Febrile infants 28 days old or younger, because of their likelihood of serious disease, including sepsis, should always be treated conservatively. Hospitalization and parenteral antibiotics should be strongly considered in all circumstances. An initial diagnostic evaluation should include CBC; blood culture; urinalysis; urine culture; and Gram stain, cerebrospinal fluid protein and glucose tests, as well as culture of the cerebrospinal fluid. Consideration should also be given to the possibility of a perinatal herpes simplex virus infection (neonatal herpes is described in more detail in Chapter 40). A chest radiograph should be obtained for any febrile infant with increased work of breathing.

Infants aged 29–60 days are at risk of developing a variety of invasive bacterial infections. Febrile infants without a focus of infection can be divided into those who appear toxic versus nontoxic, and those at low risk versus higher risk of invasive bacterial disease. As with febrile neonates, toxic children in this age group should be admitted to the hospital for parenteral antibiotics and close observation. Viral illness is the most common cause of fever in this age group; if there is evidence of viral disease (upper respiratory infection, bronchiolitis), further workup may not be necessary. Urinary tract infection is the most common bacterial cause of infection in this age group. Nontoxic low-risk infants in this age group are typically treated as outpatients with close follow-up.

In an era of increasing immunization coverage against the most common invasive pneumococcal serotypes, it is difficult to estimate the risk of occult bacteremia in febrile 3- to 36-month-olds with no focus of infection. Nevertheless, when assessing children aged 3–36 months with temperatures of 39°C or higher, urine cultures should be considered in all male children younger than 6 months and in all females younger than 2 years. Chest radiographs should be performed in any child with increased work of breathing and should also be considered in children with high (20,000/mm³) WBC counts but no respiratory symptoms. Depending on the child’s appearance, underlying medical condition, and height of fever, blood cultures should also be obtained. Empiric antibiotic therapy may be considered, particularly for children with temperature of 39°C and WBC count of 15,000/mm³. However, in previously healthy, well-appearing, fully immunized children with reassuring laboratory studies, observation without antibiotics is appropriate.

Treatment

Fever phobia is a term that describes parents’ anxious response to the fevers that all children experience. In a recent study, 91% of caregivers thought that a fever could cause harmful effects. Around 7% of parents thought that if they did not treat the fever, it would keep going higher. Parents need to be reassured that fevers lower than 41.7°C do not cause brain damage. They should be counseled that, although fevers can occasionally cause seizures—in which case their child needs to be seen—febrile seizures are generally harmless and likewise do not cause brain damage.

Several safe and effective medications are available for the treatment of fever. Acetaminophen is indicated in children older than 2 months who have fever of 39°C or are uncomfortable. Acetaminophen is given in a dosage of 15 mg/kg of body weight per dose and can be given every 4 hours. The other widely used antipyretic is ibuprofen, which can be used in children 6 months and older. Ibuprofen is given in a dosage of 10 mg/kg of body weight per dose and can be given every 6 hours. Ibuprofen and acetaminophen are similar in safety and their ability to reduce fever. Aspirin should not be used for treating fever in any child or adolescent, because of its association with the development of Reye syndrome (particularly during infections with varicella and influenza). With all antipyretics, parents should be counseled to be very careful with dosing and frequency of administration as poisoning can be dangerous. Alternating acetaminophen and ibuprofen is not recommended.

GROWTH DEFICIENCY

Growth faltering or growth deficiency—formerly termed failure to thrive—is deceleration of growth velocity, resulting in crossing two major percentile lines on the growth chart. The diagnosis also is warranted if a child younger than 6 months has not grown for 2 consecutive months or if a child older than 6 months has not grown for 3 consecutive months. Growth deficiency occurs in about 8% of children.

Patterns of growth deficiency suggest, but are not specific for, different causes. In type I growth deficiency, the head circumference is preserved and the weight is depressed more than the height. This most common type results from inadequate caloric intake, excessive loss of calories, or inability to use calories peripherally. Most cases of type I deficiencies are the result of poverty, lack of caregiver understanding, poor caregiver-child interaction, abnormal feeding patterns, or a combination of factors. Type II growth deficiency, which is associated with genetically determined short stature, endocrinopathies, constitutional growth delay, heart or renal disease, or various forms of skeletal dysplasias, is characterized by normal head circumference and proportionate diminution of height and weight. In type III growth deficiency, all three parameters of growth—head circumference, weight, and height—are lower than normal. This pattern is associated with CNS abnormalities, chromosomal defects, and in utero or perinatal insults.

Just because an infant crosses a growth percentile does not mean an infant necessarily has a problem. Infants can cross growth curves normally, either “lagging down” or “shooting up.” This crossing of growth percentiles is usually normal if it meets the following criteria: change in body weight and length are symmetrical, the size of the infant parallels the midparental weight and stature, the development remains normal, and a new growth curve is subsequently established, usually around 15 months of age; this also can be seen in the exclusively breast-fed infants at 4–6 months. WHO growth curves are now the standard and are based on children from various countries who were exclusively or primarily breast-fed in the first 4 months of life.

Clinical Findings

A. Initial Evaluation

The history and physical examination will identify the cause of growth reduction in the vast majority of cases (Table 9–6). The physical examination should focus on signs of organic disease or evidence of abuse or neglect: dysmorphic features, skin lesions, neck masses, adventitial breath sounds, heart murmurs, abdominal masses, and neuromuscular tone and strength. Throughout the evaluation, the physician should observe the caregiver-child interaction and the level of family functioning. Developmental screening and laboratory screening tests (CBC, blood urea nitrogen, creatinine, electrolytes, urinalysis, and urine culture) may be useful depending on the history and examination.

B. Further Evaluation

A prospective 3-day diet record should be a standard part of the evaluation. Occasionally, an infant or child may need to be hospitalized to obtain an accurate assessment of intake. This is useful in assessing undernutrition even when organic disease is present. The diet history is evaluated by a dietitian for calories, protein, and micronutrients as well as for the pattern of eating. Additional laboratory tests should be ordered based on the history and physical examination. For example, stool collection for fat determination is indicated if a history of diarrhea suggests malabsorption. Moderate or high amounts of proteinuria should prompt workup for nephrotic syndrome. Vomiting should suggest a gastrointestinal, metabolic, neurologic, infectious, or renal cause. The tempo of evaluation should be based on the severity of symptoms and the magnitude of growth failure.

Treatment

A successful treatment plan addresses the child’s diet and eating patterns, the child’s development, caregiver skills, and any organic disease. High-calorie diets in the form of higher-calorie formula or liquid supplement are often required and frequent monitoring (every 1 or 2 weeks initially) is essential. Acceptable weight gain varies by age (Table 9–7).

Education in nutrition, child development, and behavioral management as well as psychosocial support of the primary caregiver is essential. If family dysfunction is mild, behavior modification and counseling will be useful. Day care may benefit the child by providing a structured environment for all activities, including eating. If family dysfunction is severe, the local department of social services can help provide structure and assistance to the family. Rarely, the child may need to be temporarily or permanently removed from the home. Hospitalization is reserved for management of dehydration, for cases in which home therapy has failed to result in expected growth, for children who show evidence of abuse or willful neglect, for management of an illness that compromises a child’s ability to eat, or for care pending foster home placement.

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