Niños y adolescentes con necesidades especiales de atención en salud: prevalencia hospitalaria y riesgos asociados / Children with special health care needs: prevalence in a pediatric hospital and associated

Background: "Children with special health care needs" (CSHCN) is a novel definition for pediatric patients with chronic diseases, adopted by the Chilean Pediatric Society in 2008. As life expectancy in Chile increases, prevalence of CSHCN is progressively growing, leading to higher health costs. Aim: To describe the epide-miological profile and clinical characteristics of hospitalized CSHCN, and compare the risk assessment of adverse events during hospitalization using two definitions for CSHCN. Patients and Methods: A cohort of hospitalized CSHCN in a Pediatric Center at Santiago, Chile, was followed from September to December 2009. Clinical and demographic data were registered in a database, including admission to intensive care unit (ICU), nosocomial infections and prolonged hospitalization (> 7 days). Incidence ratios for these events were compared between CSHCN and non-CSHCN, and between children attended by three or more health care professionals (CSHCN-3) and non-CSHCN. Results: Nine hundred twenty patients were included (54% male), with a median age 14 months (0-221) and median days of hospitalization 4 days (1-229). Prevalence of CSHCN was 60.8% of hospitalized children. When using CSHCN definition and comparing with non-CSHCN, no excess of risk was documented. On the other hand, prevalence of CSHCN-3 was 19.9%. Compared to non-CSHCN, these patients had a higher risk of ICU admission (relative risk (RR) 1.58; 95% confidence intervals (CI) = 1.22-2.05; p < 0.01), nosocomial infections (RR 2.28; 95% CI = 1.54-3.39; p < 0.001) and prolonged hospitalization (RR 1.99; 95% CI = 1.52-2.60; p < 0.001). Conclusions: One in five hospitalized children met CSHCN-3 definition. These patients had an increased risk of adverse events during their hospitalization compared to non-CSHCN.

Transición de la infancia a la adolecencia: notas para la práctica pediátrica / From childhood to adolescence: notes for the pediatric practice

Con información encontrada en Internet, resultados de investigaciones hechas en Chile en las décadas de 1980 y 1990 y experiencia personal, se analiza la transición desde la infancia a la adolescencia para formular algunas proposiciones. Éstas apuntan a facilitar la transición y prevenir problemas, así como a detectar en forma rápida y mejor, crisis mayores eventuales que pudiesen ocurrir. Se hace énfasis en la ventaja de considerar el entorno general y familiar del individuo; así como en la ventaja de irse preparando para este cambio. Se destacan herramientas potencialmente útiles para estos fines, como las guías anticipatorias y elempleo de actitudes adecuadas. En estas últimas se subraya la importancia de una buena comunicación y del empleo de estilos comunicacionales adecuados por parte de los padres.

The transition from childhood to adolescence is analyzed based on information found in Internet, Chilean research results obtained in the decades of 1980 and 1990 and personal experience. Some guidelines are proposed to make this transition easier and softer as well as to prevent problems or to allow quick and better detection of eventual major crises. Emphasis is made on the advantage of taking into account individual general and family contexts and the convenience of preparedness. Anticipatory guides for parents and children are out lined as potentially useful tools while some practical management attitudes are suggested for preparation. The importance of good communication and advisable parent’s communication styles is emphasized.

Características biológicas y sociales de los menores de un año muertos por neumonía en la Región Metropolitana de Chile, 1995 / Biological and social characteristics of infants who died from pneumonia in the Santiago Metropolitan Region of Chile, 1995

Para determinar las características biológicas, socioculturales y de la atención de salud asociadas con las muertes por neumonía en menores de un año, se realizó un estudio de casos y controles para obtener información cuantitativa mediante un cuestionario semiestructurado a las madres y a 28 médicos jefes de servicios hospitalarios (n = 15) o ambulatorios (n = 13). Los casos se definieron como los menores de un año fallecidos por neumonía en 1995 en la Región Metropolitana de Chile (Santiago). Como controles se seleccionaron 118 niños que sobrevivieron a un ingreso por neumonía en el mismo período y en la misma región, apareados con los casos por edad, mes de hospitalización y comuna de residencia. Además se realizó un estudio cualitativo, consistente en entrevistas en profundidad con las madres de 20 casos y de 5 controles y con 12 informantes clave de los equipos de salud ligados a la atención primaria. De los 149 casos identificados, se estudiaron 113 (75,8%) que fueron divididos en dos grandes grupos: fallecidos en el hospital (69%) y fallecidos en el domicilio (31%). Cerca de dos tercios de las muertes (63,7%) ocurrieron en el primer trimestre. Tanto los casos como los controles tuvieron más riesgo biológico y social que la población chilena en general, aunque hubo diferencias significativas entre ellos. La incidencia de bajo (< 2 500 g) y muy bajo (< 1 500 g) peso al nacer, elevada en ambos grupos en comparación con la de la población en general, fue significativamente mayor en los casos (40,7 y 13,3%, respectivamente) que en los controles (18,8 y 1,7%). Lo mismo ocurrió con la prematuridad (edad gestacional < 37 semanas), que fue particularmente elevada en los fallecidos en el hospital (40,3%, frente a 25,7% en los fallecidos en el domicilio y 17,1% en los controles). Los fallecidos en el hospital también tuvieron 10 veces más afecciones congénitas que los fallecidos en el domicilio y siete veces más que los controles. Según sus madres, más de la mitad (18/35) de los fallecidos en el domicilio no habrían presentado signos de neumonía, lo cual sugiere muerte súbita o por aspiración. En el aspecto socioeconómico, el nivel de vida de los controles fue inferior al de los casos. Durante 1995 o los 6 meses anteriores habían estado cesantes 58,6% de los padres de los casos y 60,3% de los padres de los controles. No hubo diferencias entre los dos grupos con respecto a la percepción de los signos de enfermedad por parte de las madres ni a sus conocimientos sobre la forma de prevenir las neumonías. Entre los médicos encuestados prevaleció la opinión de que el principal factor condicionante de las muertes era la alta frecuencia de problemas biológicos en los fallecidos. En conclusión, los menores de un año fallecidos por neumonía constituyeron dos grupos de tamaño y características diferentes (los fallecidos en el domicilio y los fallecidos en el hospital), que deben ser objeto de estrategias diferentes encaminadas a reducir estas muertes. Es importante efectuar la necropsia en todos los casos para poder determinar si la causa fue la neumonía, el síndrome de muerte súbita del recién nacido o la aspiración de alimentos.

In order to determine the biological, sociocultural, and health-care characteristics associated with deaths from pneumonia among infants, this study used cases and controls to obtain quantitative information from a semistructured questionnaire given to those infants' mothers and to 28 doctors (15 who headed inpatient services and 13 who directed outpatient services). The cases were defined as children under 1 year of age who had died from pneumonia in 1995 in the Metropolitan Region of Chile (Greater Santiago). The controls were 118 children who survived after being hospitalized with pneumonia during the same period in the same area. The two groups were paired by age, month of hospitalization, and community of residence. A qualitative study was also done. It consisted of in-depth interviews with the mothers of 20 cases and of 5 controls and with 12 key informants from primary health care staffs. Of the 149 cases identified, 113 (75.8%) were studied, divided into two major groups: those who had died in the hospital (69%) and those who had died at home (31%). Of the deaths, 63.7% occurred during the first three months after birth. Both the cases and the controls had more biological and social risk than the Chilean population in general, although there were significant differences in risk between the cases and controls. The incidence of both low birthweight (< 2 500 g) and of very low birthweight (< 1 500 g) was higher in the two groups than in the general population and was significantly greater in the cases (40.7% and 13.3%, respectively) than in the controls (18.8% and 1.7%). Prematurity (gestational age < 37 weeks) was especially high among the children who had died in the hospital (40.3%), in contrast to 25.7% for those who had died at home and 17.1% among the controls. Those who had died in the hospital also had 10 times as many congenital disorders as did those who had died at home, and seven times as many as did the controls. According to their mothers, more than half (18/35) of the children who had died at home had not shown signs of pneumonia, which suggests sudden infant death syndrome or death from aspiration of food into the lungs. In terms of socioeconomics, the standard of living of the controls was lower than that of the cases. During 1995 or the second half of 1994, 60.3% of the fathers of the controls had been unemployed, as had 58.6% of the fathers of the cases. There were no differences between the cases and the controls with respect to the mothers' having noticed signs of illness or the mothers' knowledge of how to prevent pneumonia. The surveyed physicians generally believed that the primary cause of the deaths had been the high level of biological problems among those children. Since the group of children who died at home differed in both size and other characteristics from those who died in the hospital, there should be different strategies aimed at reducing deaths in the two groups. It is important to do autopsies in all deaths in order to determine if the cause of death is pneumonia, sudden infant death syndrome, or aspiration of food