A developmental approach to pediatric environmental health.

Children cannot be considered "little adults" in the field of environmental medicine. There are differences in exposures, pathways of absorption, tissue distribution, ability to biotransform or eliminate chemicals from the body, and responses to chemical and radiation. The differences vary with the developmental stages of the child. Children all respond differently to environmental toxicants. Knowledge, although rapidly increasing, is still incomplete regarding the impact of the environment on children. As health care providers, prevention is an ally but must be approached differently at each stage of a child's life.

Parental opinions regarding poliomyelitis immunizations.

The successful eradication of poliomyelitis in the United States has primarily been due to the use of oral poliovirus vaccine (OPV). However, because of the risk of vaccine-associated paralytic poliomyelitis with OPV, the use of inactivated poliovirus vaccine (IPV) has become the accepted option. We performed a cross-sectional survey of parents of children less than 18 months of age to determine parental preference regarding poliomyelitis vaccine options. Parents were asked questions about their knowledge regarding poliomyelitis and available vaccines. Parents were also given information about the risks and benefits of the 3 immunization options (all OPV, all IPV, and sequential IPV/OPV) and then asked to choose among the 3 schedules. We distributed 146 questionnaires, with an 88% response rate. Parents were, on average, 22 years old and had 12 years of education. Fifty-eight percent of parents thought that decisions regarding vaccine choices should be made by the physician and caregiver together. However, when given the choice, 41 % could not decide among the different vaccine options. One quarter (25%) chose the all OPV, 13% the all IPV, and 21% the sequential IPV/OPV schedule. Older parents were more likely to choose the all IPV schedule (p=0.042). There was no correlation with the parental level of education. More studies are required to determine if further education will empower urban parents to be more active participants in the medical decision process.

Pediatric residents buckle up: a child safety seat training program for pediatric residents.

OBJECTIVES: To assess the effectiveness of supervised installation of child safety seats (CSSs) as a teaching tool for pediatric residents and to evaluate acceptance of this hands-on learning experience. METHODS: Pediatric residents were divided into an intervention group and a control group. All residents completed an initial questionnaire regarding knowledge about CSS use. The intervention group listened to a CSS lecture, viewed a video, and installed CSSs under the supervision of certified CSS technicians. The control group received no intervention. A second questionnaire was administered to all residents. We compared the knowledge gained since the initial questionnaire. The intervention group answered questions regarding their acceptance of this learning experience. RESULTS: Sixty-one residents participated in the study. Most residents had never installed a CSS and felt uncomfortable with their CSS knowledge. The percentage of the intervention group that received a passing score for knowledge increased from 3% initially to 97% on the posttest (P <.001). There was no change in the passing rate of the control group. The intervention group rated the CSS installation session as extremely helpful. CONCLUSION: A hands-on educational program can be an effective, well-accepted method for increasing pediatric residents' knowledge about CSS use.

Pediatric residency as preparation for primary care practice.

OBJECTIVES: To assess the effectiveness of pediatric residency training as preparation for primary care and make recommendations for improving residency training. METHOD: Two surveys were sent to graduate of the pediatric residency at the University of Colorado from 1984 to 1991. The first survey requested information about practice patterns and ratings of preparedness in 45 areas important for primary care. The second survey requested ratings of importance for increasing training time in 25 areas judged as inadequate in the first survey. RESULTS: Of 147 surveys mailed, 103 graduates responded and rated themselves as less than adequately trained in 25 of 45 areas selected for relevance to primary care. Graduates of the primary care track rated themselves as significantly better trained than graduates of nonprimary care tracks in 10 of 45 areas; nonprimary care graduates had higher ratings in 2 of 45 areas. The second survey (completed by 70 of the 103 initial responders) indicated that the top 5 areas needing increased time in residency training were, in descending order, orthopedics, developmental and behavioral problems, learning disability, attention-deficit hyperactivity disorder, and school difficulty. Graduates of the primary care track rated themselves as adequately trained in developmental and behavioral problems and attention-deficit hyperactivity disorder, but they and nonprimary care graduates felt inadequately prepared in the other 3 areas. CONCLUSION: Implications of these results change with different content areas, suggesting the need to improve training for all residents in some areas and extending to all residents some of the curriculum already implemented in the primary care track.

The accuracy of a lead questionnaire in predicting elevated pediatric blood lead levels.

OBJECTIVES: To determine the prevalence of elevated blood lead levels and to evaluate the accuracy of a lead screening questionnaire in a western United States urban inner-city pediatric population. DESIGN: A convenience sample of children between the ages of 6 months and 6 years seen for a well-child visit were enrolled. Venous blood lead levels were measured and a lead screening questionnaire was completed. SETTING: The primary care clinics of the 10 community health centers of the city and county of Denver, Colorado. Approximately 85% of children receiving services are below the 150% poverty level and 54% are insured through the state's Medicaid program. SUBJECTS: A total of 2978 children seen for a well-child visit from February 1993 to January 1994. MAIN OUTCOME MEASURES: The prevalence of elevated blood lead levels and the operating characteristics of both the Centers for Disease Control and Prevention lead screening questionnaire and the complete questionnaire used in Denver, using venous blood lead levels as the criterion standard. RESULTS: The mean blood lead level was 0.20 mumol/L (4.19 micrograms/dL). Eighty-five children had blood lead levels of 0.48 mumol/L (10 micrograms/dL), representing 2.9% of the study group (95% confidence interval [CI], 2.3-3.5). Only 0.3% of the cohort had blood lead levels greater than 0.96 mumol/L (20 micrograms/dL). The sensitivity, specificity, and positive predictive value of the Centers for Disease Control and Prevention questionnaire was 57%, 51%, and 3%, respectively. The sensitivity, specificity, and positive predictive value of the complete questionnaire was 59.7%, 36%, and 2.6%, respectively. The marginal cost of identifying a child with a blood lead level greater than 0.96 mumol/L (20 micrograms/dL) was $4925. CONCLUSIONS: Few of the low-income children in this study had blood lead levels greater than 0.48 mumol/L (10 micrograms/dL). The questionnaire did little better than chance at predicting the presence or absence of elevated blood lead levels and cannot replace a blood lead level test for childhood lead screening in this community.

Missed opportunities in preventive pediatric health care. Immunizations or well-child care visits?

OBJECTIVE: To determine the percentage of patients in a large pediatric practice in compliance with national recommendations regarding immunizations and well-child care visits. RESEARCH DESIGN: Chart review. Point estimates with 95% confidence intervals were determined for reviewed charts in compliance with recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention and schedule of well-child care visits, screening, and anticipatory guidance recommended by the American Academy of Pediatrics (AAP). SETTING: A large, multisite urban public pediatric practice. PATIENTS: Three hundred eighty-six infants and children (aged 0 to 60 months) who had a total of 7595 patient visits. SELECTION PROCEDURE: A random sample of charts. RESULTS: There was a large discrepancy in compliance for patients aged 0 to 23 months in ACIP-recommended immunizations (90.5% +/- 3.9%) vs AAP-recommended well-child care visits (37.6% +/- 6.4%) and for patients aged 24 to 60 months in ACIP-recommended immunizations (87.8% +/- 5.1%) vs AAP-recommended well-child care visits (31.0% +/- 7.1%). CONCLUSIONS: The data suggest that immunization alone does not ensure that children will receive all aspects of preventive care, raising questions about the practicality of the current AAP recommendations for preventive pediatric health care.

Evaluation of developmental/behavioral training in primary care.

Primary care and regular track residents in one pediatric program were compared with respect to knowledge, perceived level of competence, and attitudes relative to developmental and behavioral pediatrics from beginning to end of the residency. Measures of knowledge and self-perception of competence showed a common pattern characterized by (1) no differences between primary care and regular track residents on entry into the program, (2) significant progress in both groups over the period of the residency, (3) significantly greater progress by primary care residents. Ratings regarding relevance of developmental and behavioral issues for pediatric practice showed that ratings of relevance were significantly higher at the beginning of the residency among primary care residents and remained higher throughout.

The hospital nurse practitioner in pediatrics. A new expanded role for staff nurses.

The Hospital Nurse Practitioner Program in Pediatrics at the University of Colorado Health Sciences Center, Denver, prepared staff nurses for a new and expanded role as health care providers in hospital settings. With the use of their increased skills and greater decision-making responsibilities, hospital nurse practitioners admitted patients to the hospital, assessed both the initial clinical status and subsequent changes in the patient's condition, wrote relevant orders, performed a variety of technical procedures (including many previously reserved to house staff and other physicians), ordered and interpreted laboratory studies, counseled patients and families, discharged patients, and provided other traditional nurse practitioner skills. Hospital nurse practitioners had an improved collaborative relationship with physicians. This program showed that hospital nurse practitioners can be as significant in affecting the health care that patients receive on the general units of hospitals, as are nurse practitioners who deliver care and services to ambulatory patients.