Final report of the FOPE II Education of the Pediatrician Workgroup.

This report from the FOPE II Education of the Pediatrician Workgroup assesses the current status and future trends of pediatric education. The attributes of each level of the education process (undergraduate, residency, fellowship, continuing medical education [CME]) are considered within the framework of lifelong learning. The pediatric education of nonpediatrician providers is carefully considered. The Workgroup proposes and describes a new model for pediatric education that encompasses educational needs assessment, curriculum development and outcomes evaluation. Particular attention is paid to CME, with a review of the strengths and problems of the current system. The proposal for improving CME in the 21st century highlights the need for each pediatrician to have a "CME home," and several models and scenarios are explored. Appendices summarize the results of several surveys conducted on behalf of the Workgroup, and list societal trends and advances in pediatric health care that will influence pediatric education in the future. Pediatrics 2000;106(suppl):1175-1198; pediatric education, educational needs assessment, curriculum development, outcomes evaluation.

Assessing mothers' attitudes about the physician's role in child health promotion.

OBJECTIVE: This study assessed maternal attitudes about the physician's role in child health promotion. METHODS: Home interviews were conducted with 200 Massachusetts mothers (with one child age 2 to 3 years) enrolled in a health maintenance organization. RESULTS: Mothers chose growth and nutrition, physical development, and illness as the most important topics and felt that providers have the ability to prevent problems and to help. Psychosocial and safety issues were less important, although mothers felt susceptible to these issues and believed they greatly affected children's health. CONCLUSIONS: On all issues, mothers believed physicians were more effective in helping families after, not before, problems arose. The Health Belief Model provided insight into attitudes and possible interventions.

Energy expenditure of children and adolescents with severe disabilities: a cerebral palsy model.

Spastic quadriplegic cerebral palsy (SQCP) is a severe disability that is associated with abnormal physical activity, body composition, and food intake and with frequent malnutrition. This study examined the pattern of dietary intake, anthropometry, and energy expenditure in a group of subjects with SQCP aged 2-18 y and a normal control group. The energy expenditure pattern was determined from resting energy expenditure (REE, n = 61 SQCP; n = 37 control group) by using indirect calorimetry and from total energy expenditure (TEE, n = 32 SQCP; n = 32 control group) by using the doubly labeled water method. Physical activity, including the chronic spasticity of SQCP, was estimated from the ratio of TEE to REE. Abnormal growth and body composition were common and dietary intake was markedly overreported in the children with SQCP. Children with SQCP were divided according to body fat stores determined by triceps-skinfold-thickness measurements. The children with low fat stores had a lower REE adjusted for fat-free mass compared with the SQCP and control groups with adequate fat stores. TEE was significantly lower for the SQCP group than for the control group. The ratio of TEE to REE, indicating energy for nonbasal needs, was significantly lower in the SQCP children than in the control group, with the adequately nourished SQCP children having lower ratios than the more poorly nourished SQCP group. The nonbasal energy expenditure, such as for physical activity and spasticity, of children with SQCP was low. The nutrition-related growth failure and abnormal pattern of REE are likely related to inadequate energy intake.

Expectations, goals, and perceived effectiveness of child health supervision: a study of mothers in a pediatric practice.

The purpose of the study was to assess parent expectations and goals in child health supervision and variability by socioeconomic status (SES), family size, social support, and pediatrician. Home interviews were conducted with mothers and their pediatricians were surveyed. Two hundred mothers with at least one child age 2-3 years who see one of five pediatricians in a staff model health maintenance organization were asked to participate. Mothers' and pediatricians' goals in the following seven areas of health supervision were assessed: biomedical, development, behavior, family functioning, safety education, and interpersonal and system interaction. Mothers stated physicians were their main source of parenting information. Assurance of physical health and normal development were more important than discussion of behavioral, family, or safety issues. Mothers of low SES were more likely to feel that physical aspects of health should be the focus and were less interested in psychosocial issues. Physicians stressed interpersonal, safety, and behavioral goals more than mothers. Individual physician responses did not predict the responses of mothers in their practice. Our data suggest either that mothers do not feel that psychosocial and safety issues are the highest priorities in health supervision or that physicians are not effectively reaching mothers on these issues.

Family practice, internal medicine, and pediatrics as partners in the education of generalists.

The generalist of the future will play an integral role in the health care delivery system, yet the three recognized generalist specialties have developed and functioned along largely separate tracks. No matter what form of generalism evolves, family practice, internal medicine, and pediatrics must begin to cooperate and collaborate in developing new graduate medical education programs that are sufficiently flexible to meet whatever emerges in the future. They must devote their energies to working together, rather than competing; to emphasizing those parts of their programs that have similarities; and to sharing their knowledge, skills, attitudes, and perspectives about the care of patients. They must develop training experiences in which residents will obtain maximum contact with a wide variety of problems and patients in many different settings; a substantial portion of such training should be generic and virtually interchangeable among the three specialties. As the health care system evolves, so should these disciplines; they must begin to "train physicians to provide continuing, comprehensive and coordinated medical care to a population undifferentiated by gender, disease or organ system," as urged by the American Boards of Family Practice and Internal Medicine.

Body composition in children with spastic quadriplegic cerebral palsy.

OBJECTIVE: To determine the pattern of body composition and nutritional status in a group of prepubertal children with spastic quadriplegic cerebral palsy (SQCP) compared with healthy control children. STUDY DESIGN: Subjects were enrolled for this cross-sectional study from two tertiary care settings. One hundred thirty-six subjects with SQCP, 2 to 12 years of age, were evaluated by anthropometric measures, or by anthropometric and total body water (TBW) measures (n = 28), with 39 control subjects. RESULTS: Body composition and nutritional status indicators were significantly reduced in children with SQCP. Accretion of fat-free mass with age was smaller for children with SQCP. Calculation of body fat from two skin folds correlated best with measures of fat mass from TBW. CONCLUSION: Malnutrition is common in children with SQCP. Clinically available, serial anthropometric measures enable the clinician to identify malnourished children with SQCP.

Home abatement and blood lead changes in children with class III lead poisoning.

We studied the effect of home abatement on blood lead (PbB) levels in children from central Massachusetts who had not undergone chelation therapy and whose homes were abated between 1987 and 1990, when stricter abatement guidelines were enacted. One hundred and thirty-two children with a mean preabatement PbB of 25.9 micrograms/dL (1.25 mumol/L) were studied: their mean postabatement PbB (up to 1 year later) was 21.1 micrograms/dL (1.02 mumol/L) (P < .001). This reduction correlated with preabatement PbB; 32 of 33 (97%) with preabatement PbB > or = 30 micrograms/dL (> or = 1.45 mumol/L) were lower postabatement, and 64 of 79 (81%) with PbB 20 to 29 micrograms/dL (0.97-1.40 mumol/L) were lower. However, in children with preabatement PbB < 20 micrograms/dL (< 0.97 mumol/L), only seven of 20 (35%) were lower postabatement and, in fact, there was a significant rise in PbB from 16.8 to 19.3 micrograms/dL (0.81 to 0.93 mumol/L) (P = 0.05). Continued improvement in home abatement technology is needed if that strategy is to be effective in achieving the lower PbB levels now mandated in the 1991 Centers for Disease Control guidelines. Primary prevention of the initial blood lead level elevation remains the most desirable strategy.

Nutritional status and growth of children with diplegic or hemiplegic cerebral palsy.

The growth failure and nutritional status were assessed of 154 children with diplegic or hemiplegic cerebral palsy, aged between two and 17.4 years. Linear growth was significantly reduced compared with norms for healthy children. About 30 per cent of the sample were undernourished, indicated by bodyweight or depleted subcutaneous fat stores at the triceps skinfold site. 8 per cent were overly fat by triceps skinfold and 14 per cent overweight by bodyweight. 23 per cent of the children had stunted growth. Children in the youngest age-group were most at risk for poor nutritional status and delayed growth. These findings suggest that children with diplegic or hemiplegic cerebral palsy are at risk for a variety of abnormalities of growth and nutritional status, and that a growth and nutritional assessment should be conducted periodically so that under- or overnutrition can be corrected when identified.

Nutrition-related growth failure of children with quadriplegic cerebral palsy.

Growth failure and nutritional status were evaluated in 142 children with quadriplegic cerebral palsy, aged between two and 18 years. Linear growth was assessed by upper-arm and lower-leg lengths: both means were significantly reduced. Mean bodyweight and triceps skinfold thickness fat stores were reduced to 65 per cent medians and subcapsular skinfold fat stores to 81 per cent median. Muscle stores were the most preserved and reduced to 88 per cent median. Examination of the sample by age-group showed significant reductions in growth and nutrition status indicators, even at two to four years, except for muscle area. To determine the degree to which nutritional status affected linear growth, a set of two-step regression analyses was conducted. The linear growth measures were significantly correlated with the measures of nutritional status.

The flexibility of A-form DNA.

We have determined the rise per base pair and persistence length of A-form DNA in trifluoroethanol solutions for fragments 350-900 base pairs in length that best describe rotational diffusion coefficients determined by transient electric birefringence. The 2.6 A spacing between base pairs found in crystal and fiber A-form structures is preserved in solution. The persistence length is about 1500 A, or about three times longer than for B-form DNA. There is no apparent electrostatic contribution to the persistence length in the salt concentration range 0.2-2.0 mM Na cacodylate. This suggests an even closer association between DNA and its neutralizing counterions than predicted by condensation theory, perhaps due to a sheath of trifluoroethanol excluded water surrounding the A-form helix.

Community ambulation by children with myelomeningocele and high-level paralysis.

It has frequently been noted that high-level paralysis precludes community ambulation for children with myelomeningocele. Of the 87 children in our population with high-level paralysis, however, 45 (52%) did achieve community ambulation by 5 years of age, while 42 (48%) did not. There was no significant difference between these two groups by sex, shunt status, scoliosis, or hip surgery prior to 5 years of age. Among the community ambulating group, there were significantly (p less than 0.001) more children who were not retarded, had received physical therapy for walking, and had compliant parents. We concluded, therefore, that community ambulation is a realistic goal for many children with myelomeningocele and high-level paralysis.

Ventriculitis in newborns with myelomeningocele.

It has frequently been cited that a delay in back closure of beyond age 48 hours in newborns with myelomeningocele is associated with an increased risk of ventriculitis. It has been suggested that antibiotic therapy prior to surgery might minimize this risk. We reviewed our experience with ventriculitis in newborns with myelomeningocele and its relationship to antibiotic usage and time of back closure. Of 186 newborns, ventriculitis developed in 13 (7%), and there was no observed difference by time of back closure, clinical severity of infant at birth, status of myelomeningocele sac at birth, or type of delivery. There was a significant association between antibiotic usage and ventriculitis among the infants with delayed surgery, of which only one (1%) of 73 receiving broad-spectrum antibiotic prophylactic therapy developed ventriculitis compared with five (19%) of the 27 who did not receive antibiotics. Our data support the suggestion that antibiotic treatment is effective in minimizing the risk of ventriculitis among infants with myelomeningocele undergoing surgery after 48 hours of age.