Physicians' reliance on specialists, therapists, and vendors when prescribing therapies and durable medical equipment for children with special health care needs.

OBJECTIVES: Physicians who care for children with special (health care) needs (CWSN) often must prescribe therapies and/or specialized, durable medical equipment (DME). Given this responsibility and the increasing scrutiny of prescribing practices by various oversight agencies, understanding the extent to which pediatricians rely on their own expertise when prescribing therapies and DME is an important area of research. METHODS: As part of an ongoing investigation of physician preparedness for and practice in prescribing therapies, DME, or procedures for CWSN, we mailed surveys to practicing pediatricians in each of 2 states-Ohio and Mississippi-and to a senior resident at all identified pediatric residency-training programs. The surveys polled recipients as to who they would rely on themselves-specialists, therapists or vendors-to make prescription decisions for a variety of therapies and DME of increasing complexity. We report results as proportions of returned and completed questionnaires. Comparisons among the 3 groups (pediatricians from Ohio and Mississippi and residents) were made with the use of chi(2) analysis. RESULTS: For some categories of therapy and DME, physicians and residents reported that they would take an active role in prescription decisions, and their reliance on specialty consultation increased appropriately with the increasing complexity of the device or therapy. However, respondents generally seemed to share responsibility rather than rely on themselves as sole decision makers for most categories; fewer than one fourth took sole responsibility. Reliance on nonphysician health care providers was evident for all categories; in some cases, up to half of the respondents would allow therapists to take over these decisions, and a small but significant percentage of physicians would entrust DME prescription decisions to vendors alone. CONCLUSIONS: Our findings indicate that many practicing pediatricians and those in training may be unwilling to assume sole responsibility in prescribing and managing therapies and DME for CWSN. Although the number who would rely on consultation with specialists is somewhat reassuring, we found that a significant percentage would turn to nonphysician health care providers and even vendors to make these decisions in some cases, raising liability implications, conflict-of-interest issues, and quality-of-care issues. To protect themselves and their patients from fraud and inappropriate prescriptions and medical management, pediatricians must become increasingly conscientious about complying with American Medical Association guidelines and federal and state laws regarding initiation and supervision of therapies and DME. We offer some recommendations that may help to address this problem.

Protective helmets for children with special health care needs.

An illustrative case of a second traumatic brain injury in the same child raises the issue of the criteria by which protective helmets for disabled children should be prescribed. There is a dearth of data substantiating criteria for helmet prescription for special needs children and assessing potential adverse side effects of routinely wearing a helmet. Further studies seem warranted to determine whether protective helmets truly reduce the frequency and severity of secondary trauma and whether there are adverse effects that outweigh benefits.

Unrestricted riding in pickup truck cargo beds poses significant hazards.

Individuals riding in the beds of pickup trucks face significant risks of debilitating injury or death, yet Mississippi currently has no legislation restricting ridership in truck beds. Data collection on accidents involving truck bed passengers indicates that children make up the majority of victims. Such accidents impose a heavy burden on society in terms of both medical expenses and impaired quality of life for the victims.

Training of pediatricians in care of physical disabilities in children with special health needs: results of a two-state survey of practicing pediatricians and national resident training programs.

OBJECTIVE: One goal of the American Academy of Pediatrics' Future of Pediatric Education II Project is to establish guidelines in training physicians to care for children with special health care needs (CWSN). Assessment of current practices in prescribing therapies and devices is necessary to meet this goal. Although much has been written about CWSN, there is a paucity of literature describing pediatricians' preparedness in prescribing such therapies and devices to children with physical disabilities. In an effort to assess physician preparedness, we surveyed pediatric residents nationwide and practicing pediatricians from 2 states, 1 urban and 1 rural. METHODS. A questionnaire aimed at identifying areas of concern regarding preparedness of physicians in practice and in training was prepared and mailed to prospective participants in Ohio and Mississippi. After follow-up mailings to nonresponders, approximately 59% responded. Summary statistics were reported as proportions with 95% confidence intervals. RESULTS: Among those polled, >70% reported no training in prescribing certain durable medical equipment and over 50% reported no training in prescribing certain therapies. In addition, at least 20% reported no training in treating some of the more common childhood physical disabilities. Nearly three fourths of the respondents indicated that they did not believe that they were adequately prepared to take an active role in prescribing therapies and durable medical equipment. Fewer respondents believed that they should be the sole providers of these therapies and durable medical equipment. CONCLUSIONS: The results of the survey indicate a lack of specific training and physician confidence in prescribing therapies and devices to CWSN, establishing the necessity of expanding training programs to better ensure quality health care for special needs children. Although additional ongoing research is necessary to fully evaluate the preparedness of physicians in caring for CWSN, this survey does help to identify areas of physician training that require improvement to provide quality health care for CWSN.

Hyperpyrexia associated with sustained muscle contractions: an alternative diagnosis to central fever.

Muscle activity is the principal source of body heat production, and elevated core body temperatures may occur in healthy exercising persons. Hyperpyrexia from sustained tonic muscle contractions can also occur in a number of pathological conditions. The present case of hyperpyrexia associated with dystonic posturing and sustained muscle contraction in a child with encephalopathy illustrates the importance of recognizing muscular activity in the generation of fever of unknown origin following central nervous system injury. The pathophysiology, clinical features, and management of this uncommon cause of fever are discussed.

Undiagnosed spinal cord injuries in brain-injured children.

Four children with brain injury were later found to have coexisting spinal cord injury (SCI). Findings that warrant investigation for coexisting SCI include a dermatome pattern sensory loss; absence of movement and reflexes in either both arms or both legs with preservation in the remaining extremities; flaccidity; absence of sacral reflexes; diaphragmatic breathing without use of accessory respiratory muscles; bradycardia with hypotension; autonomic hyperreflexia; poikilothermia; unexplained urinary retention; history of neck pain; unexplained ileus; priapism; and the presence of clonus in an unconscious patient without decerebrate rigidity. If any of the above are present, the spine should be stabilized until either further diagnostic studies confirm SCI with treatment instituted or serial neurologic examinations confirm the absence of SCI.

Interference of oral phenytoin absorption by enteral tube feedings.

The medical records of 11 brain-injured patients, simultaneously on enteral tube feeding and phenytoin, were retrospectively reviewed for evidence of interference of phenytoin absorption. One case demonstrated no interference. Three cases suggested depression of serum phenytoin levels by enteral formula, but the contribution of other factors could not be ruled out. Seven cases did appear to reflect a direct alteration of phenytoin levels by enteral formula. To achieve adequate serum phenytoin levels, patients may need (1) large oral phenytoin doses above that recommended while on continuous enteral feedings, (2) administration of oral phenytoin between intermittent enteral feedings, or (3) a choice of alternative anticonvulsants which have been shown to be unaffected by enteral formula.

Spinal cord injury associated with all-terrain vehicle accidents.

Five instances of three-wheeler, all-terrain vehicle accidents resulting in spinal cord injury are presented. Age range of victims was from 7 to 18 years. Of the five cases of spinal cord injury, three resulted in quadriplegia and two in paraplegia. Reports of all-terrain vehicle accidents in childhood from the US Consumer Product Safety Committee are also reviewed. Concerns are raised about the need for further data gathering about instances and types of injuries from these types of vehicles and the safety of use in all ages of children for these heavy, potentially high-speed vehicles.