Home schooled children: a pediatric perspective.

To explore the attitudes and self-assessed knowledge of pediatricians regarding home schooling and determine whether practices provide preventive services typically rendered by the school system, we surveyed pediatricians in Wisconsin and Maryland (high versus low rates of home schooling, respectively). Of the 598 (53%) responding, only 18% supported home schooling. They judged home-schooled children to perform at an average (58%) or below average (12%) level on standardized tests and regarded them to be less mature than their peers (51%). These opinions differ from studies published in the educational literature. Many practitioners do not perform routine vision (18%) or hearing (83%) screens or monitor for overdue immunizations (71%). As pediatricians and child advocates, we need to become more knowledgeable about home schooling and provide preventive services for these children.

Family member knowledge of children's medical problems: the need for universal application of an emergency data set.

OBJECTIVE: Advances in medical care have led to a growing population of special needs children who are at risk for suboptimal care when they present to a physician with no previous knowledge of their medical history. This risk may be amplified in the emergency department setting when time-sensitive interventions must be initiated without immediate access to consultants or past records. Our purpose in this study was to evaluate caretakers' knowledge of their children's chronic medical problems and their ability to relate this knowledge to unfamiliar health care providers. METHODS: Caretaker/child pairs presenting for specialty visits were surveyed. Questions focused on knowledge of the child's illness, medicine regime, and how to contact the specialist. Chart review confirmed responses of caretakers and provided sociodemographic information. Descriptive statistics and chi2 were used in data analysis. RESULTS: Of the 49 caretakers interviewed, 85% were parents, 53% were African-American, and 43% were Caucasian. One-half of the group received medical assistance. The mean age of the children was 55 months. Responses showed that 53% of caretakers were unable to provide their children's specific diagnoses. Of these, one half could provide a lay diagnosis whereas the remaining one half could only identify the organ system involved or that there was a problem. For children on medications, 29% of caretakers could not provide an accurate list. Name of the subspecialist and phone number of the subspecialty clinic was unknown by 25% of caretakers. No child wore medical identification jewelry. CONCLUSIONS: Caretakers are not always able to accurately relay vital information on their child's essential medical needs, a problem that may be compounded in emergency situations. The use of some form of independent identification and information set is needed to assure proper treatment of children with special health care needs encountering an unfamiliar health care provider.

Follow-up: who does it and how do they do it?

Follow-up appointments and phone contact after discharge are important components of the emergency department (ED) encounter. We surveyed ED directors at hospitals with accredited pediatric residency programs to determine mechanisms for follow-up 1) to chart progression of illness (POI), 2) for positive laboratory or x-ray results, and 3) for specific illness such as child abuse, burns, and complex wounds. One hundred thirty-five of 207 program directors responded (65%). To follow POI, 54% of EDs use the ED itself, and 59% send patients to community physicians. Of those that use community physicians, 24% do not notify the physician to expect a follow-up visit, and 27% do not send a copy of the ED chart to a physician's office. To follow POI, 20% of EDs have no formal mechanism for telephone follow-up. Sixteen percent keep no record of phone contact. For follow-up of positive laboratory tests or x-rays, results are better; only 4 and 5%, respectively, do not keep records of phone contact. Eleven percent of EDs have no mechanism for follow-up of child abuse. Mechanisms for follow-up of children seen in the ED are variable. We have identified deficiencies in the following areas: 1) lack of communication with the physician to provide follow-up, 2) lack of documentation regarding subsequent patient contacts for POI and positive test results, and 3) lack of resources to follow victims of child abuse. These deficiencies have potential implications regarding optimal patient outcome.

Follow-up: who needs it?

The ability of pediatric residents to appropriately assign patients to receive follow-up has not previously been studied. We independently reviewed 1693 consecutive charts of patients presenting to the pediatric emergency department. The authors agreed with 60 of the 82 resident-assigned follow-ups and identified 99 patients who should have been assigned to receive follow-up but were not (missed follow-ups). When compared with the group appropriately assigned to receive follow-up care, the missed follow-up group was similar in sex, type of insurance, and time of presentation but tended to be younger and was significantly different in terms of mean temperature and health care provider. In regard to the latter, the missed follow-up group had a lower mean temperature and more often had an identifiable routine health care provider. Young age and respiratory difficulty were the factors contributing most to the authors' assignment as a missed follow-up. Specific formal teaching directed at the appropriate use of follow-up for outpatients should be incorporated into pediatric residency training curricula.

Combined iron deficiency and lead poisoning in children. Effect on FEP levels.

Concern for the concomitant occurrence of iron deficiency and elevated blood lead in children is raised by animal studies documenting increased gastrointestinal lead absorption in the presence of iron deficiency. An elevation in free erythrocyte protoporphyrin (FEP) above 35 mg/dl is seen with both iron deficiency and lead toxicity. To determine whether the degree of elevation in FEP is useful in predicting which children with elevated blood lead levels have concomitant iron deficiency, 109 children suspected of having an elevated lead burden were studied. A complete blood count, reticulocyte count, FEP, lead, and ferritin were measured on each child. The effect of the independent variables, lead and iron status, both alone and in combination, on the dependent variable, FEP, was analyzed through a linear regression model. Lead status alone accounted for 42 percent of the explained variance in FEP, and the lead-iron interaction increased the explained variance by only an additional 1 percent. Screening for iron deficiency in children with elevated blood lead should continue to be based on dietary and socioeconomic risk factors and not on degree of elevation in FEP.

Chronic disease: effect on health cognition and health locus of control.

An assessment of health cognition and health locus of control (HLOC) was obtained in 85 healthy and 81 chronically ill children, using instruments adapted from Piaget's work and standard HLOC measures. A relationship between HLOC and compliance was sought in a subset of children with spina bifida taught self-catheterization. Evidence of the developmental nature of health cognition and HLOC was documented. Contrary to the effect of experience in formal learning, experience with chronic disease did not alter developmental progression in these health-related areas. Our results suggest that in communicating with children about illness, the pediatrician's approach should not be altered by an appearance of superficial sophistication that some children may acquire as part of their experience with chronic disease.