Why children's rights are central to international child health.

The UN Convention on the Rights of the Child provides a framework for improving children's lives around the world. It covers both individual child health practice and public health and provides a unique and child-centred approach to paediatric problems. The Convention applies to most child health problems and the articles are grouped into protection, provision and participation. Examples of the first are the right to protection from abuse, from economic exploitation and from illicit drugs. We examine one particular problem in each of these categories, specifically child labour, services for children with a disability and violence against children. The role of the paedialrician in applying a children's rights approach is discussed. Children's rights are increasingly being accepted around the world but still there is much more rhetoric paid to their value than genuine enforcement. Paediatricians can make a difference to the status of children worldwide by adopting a rights-based approach.

The view from the horizon: strategic partnerships of public health, academic medical centers, and managed care.

The organization and operation of public health departments must change if they are to participate in the evolving health system. Strategic partnerships with academic medicine, academic medical centers, and managed care organizations offer an opportunity to establish and sustain these new roles. A rationale for collaboration and description of the assets each organization contributes to the partnership is described. The experience of the authors in developing such strategic partnerships and other examples from across the country is presented.

Computer reminders improve on-time immunization rates.

OBJECTIVES: This study examines the effectiveness of computer-generated telephone reminders in improving infants receiving on-time immunizations. A computer called parents at home, reminded them of their child's visit, and asked if they could keep the appointment. If parents either canceled or failed to honor the appointment, the computer called back a few days later and asked them to reschedule. METHODS: A medical assistant recruited 124 consecutive mothers to receive automated computer reminders. These mothers' infants were younger than 6 months, were being seen at an outpatient clinic for a first visit, and were patients of three attending physicians and three nurse practitioners. These infants were compared to 89 infants from the same clinic, in the same age range, who were being seen for the first time during the same period by the same providers but not contacted by the medical assistant. Subjects were selected from mothers who brought their infants for their first visit in an outpatient urban clinic that serves predominantly minority clients. A research assistant reviewed patients' medical records and collected the infants' birthday, mothers' age, race, source of payments, and the immunization record of the infants. Immunization was considered to be late if, at the time of the first visit, it was more than 30 days past due for any of the recommended immunizations of the American Academy of Pediatrics, except for Hepatitis B vaccine which was not recommended at the time of the study. The dependent variable was on-time immunization. The independent variables were age of the mother at baseline, age of the child at baseline, and membership in either the comparison or the experimental group. Chi-square tests and logistic regression were used to analyze the data. RESULTS: The participation rate for appointments for the experimental group was 82%, as compared to a 69% overall participation rate for the clinic providers. The on-time immunization rate for experimental subjects was 67.8%, whereas the comparison group had an on-time immunization rate of 43.4% (differences were significant at alpha levels less than 0.01). CONCLUSIONS: Computerized reminders sent to the parents led to an increase in participation rate at the clinic and an increase in on-time immunization for their infants.

Attitude of medical students to future practice characteristics.

In November 1990, 14.5% of the 271 medical students of the Gonder College of Medical Science (G.C.M.S.), Gonder, Ethiopia, were of peasant background. Only 10.2% of the 271 expressed willingness to serve for more than two years in the rural areas after graduation, and, of those not willing, a higher proportion (15.5%) were from the main towns than from rural areas (1.2%). Specialty choice of senior students showed obstetrics-gynaecology, other specialties such as dermatology, internal medicine and surgery as the most preferred career goals. In addition, 67.2% of the students agreed that there is a greater need for physicians in rural than urban settings, agreement being six times more frequent by Clinical Year I students than interns (referent group). Among twelve personal and professional variables suggested, continuing education, schools for children, and private practice were considered better in urban than in rural areas. The study has important implications for medical education.

Supraglottitis in three young infants.

Three case histories of young infants with supraglottitis are presented. At this age, supraglottitis rarely occurs. Atypical features, as compared to older children, include a viral prodrome, lack of fever, stomatitis, and negative blood cultures. Although viral supraglottitis has been previously reported, this is the first report of epiglottitis associated with parainfluenza virus.

Anthrax in Ethiopia.

Twenty-seven patients with cutaneous anthrax were identified over a three-year period at Gondar College of Medical Sciences in North Central Ethiopia. Nine patients who delayed seeking medical care presented with severe symptoms and three patients died. Eighteen patients were clustered within four families in which an attack rate of 32% occurred. Ninety-three percent of patients could trace their disease to exposure to the products of a specific diseased animal. Characteristics of anthrax in Ethiopia include a known exposure to diseased animals, occurrence within families, frequent treatment by local healers, and high morbidity and mortality.

Cricoarytenoiditis as a cause of acute airway obstruction in children.

A 4-1/2-year-old girl with a one-year history of juvenile rheumatoid arthritis was admitted with severe respiratory distress requiring endotracheal intubation. Arthritis of the cricoarytenoid joint was diagnosed and she responded well to intubation and high-dose steroids. Although well described in adults, this is only the third case report of a child afflicted with arthritis of the cricoarytenoid joint.

Parental perception of urgency and utilization of pediatric emergency services.

Emergency Room utilization has increased dramatically in recent years. Parental perception of urgency may be one factor that influences utilization of pediatric emergency services, yet little is understood about factors influencing this perception. The goal of this study was to determine if the perception of urgency is a critical factor in the decision of a parent to seek care in an emergency room, if demographic and access factors influence parental perception of urgency, and whether there is agreement of urgency rating by parent and physician. One hundred and one parents were interviewed to determine background demographic and access factors and perception of urgency. Physician and parental urgency was evaluated on a 5 level scale. Chi-square analysis was used to determine association between demographic and access factors and parental urgency ratings. Pearson product moment correlation was used to determine agreement between parent and physician urgency ratings. The majority of visits were acknowledged by both parents and physicians to be non-emergent. Fourteen (13.9%) and 10 (9.9%) of parents and physicians rated the visits as emergent (levels 1 and 2) while 65 (64.4%) parents and 76 (75.3%) physicians rated the visits as nonemergent. No association between demographic or access variables and parental perception of urgency was demonstrated.

Apnea of infancy. Approach to evaluation and management.

The sudden, silent, unobserved death during sleep of an apparently healthy infant strikes about 8,500 children each year in this country. Once called crib death, sudden infant death syndrome (SIDS) has left a trail of grieving parents and baffled pathologists who could find no specific cause at autopsy. One current theory links apnea of infancy to this mystery killer. In the first article of this series on pediatric problems, Dr Goldhagen, who directs an infant apnea evaluation program in Minneapolis, discusses a practical approach to identifying and managing children at risk for apnea of infancy and offers suggestions on the use of cardiorespiratory monitoring in the hospital and in the home.

Croup: pathogenesis and management.

Croup syndromes are common in children, most frequently being infectious in origin. Children present with a slow progression of inspiratory and expiratory stridor and a croupy, "barking seal" cough. Children are variably febrile and with progression of disease, exhaustion, agitation, cyanosis and air hunger may develop. The evaluation of the patient must focus on the degree of respiratory distress and associated findings. Epiglottitis and foreign body aspiration must be excluded. Management is primarily dependent upon administration of humidified air. Children with moderate to severe croup benefit from racemic epinephrine and steroids. Admission is indicated in children with stridor at rest, evidence of exhaustion, toxicity or respiratory distress. Active airway intervention is rarely required but may be life saving if obstruction develops.

Teenage pregnancy in perspective.

In an effort to provide the clinician with suggestions for preventive and remedial approaches to adolescent pregnancy, the nature, medical, social, economic, and psychological aspects of the problem are reviewed and discussed. While the rate of adolescent pregnancy is declining, there are more than 560,000 deliveries to teenagers annually. Medical risks are significantly diminished by early and comprehensive prenatal care. The major complications continue to be social and economic. Lower I.Q.s in offspring of adolescent mothers have been reported. Failure to complete high school significantly increases the risk of unemployment, trapping the premature parent and her offspring in a web of poverty. A lack of a sense of future and viable alternatives may legitimize the option of motherhood in the minds of many adolescent girls. Furthermore, an ignorance and a denial of sexuality combined with the developmental imperatives of experimentation and rebellion place the adolescent at high risk for pregnancy.

PIP: The nature, medical, social, economic and psychological aspects of the problem of adolescent pregnancy are reviewed and discussed in an attempt to provide the clinician with suggestions for preventive and remedial approaches. Despite the fact that the rate of adolescent pregnancy is declining, there are more than 560,000 deliveries to teenagers annually in the United States. Early and comprehensive prenatal care significantly cuts down the medical risks. The major complications continue to be social and economic. A Johns Hopkins Child Development Study, which followed 4600 pregnant women and their offspring over a 12-year period, revealed that those children born to mothers initially 16 years of age or younger had lower intelligence quotient performances than the children of older women. Failure to complete high school has been found to significantly increase the risk of unemployment, trapping the premature parent and her child in a web of poverty. Among the most significant determinants of childhood pregnancy are the number of years the individual has been sexually active and whether or not she has used contraception. An ignorance and a denial of sexuality along with the developmental imperatives of experimentation and rebellion place the adolescent at high risk for pregnancy.