Less anticipatory guidance is associated with more subsequent injury visits among infants

The Injury Prevention Program to Reduce Early Childhood Injuries: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics designed The Injury Prevention Program (TIPP) in 1983 to help pediatricians prevent unintentional injuries, but TIPP's effectiveness has never been formally evaluated. We sought to evaluate the impact of TIPP on reported injuries in the first 2 years of life.

METHODS

We conducted a stratified, cluster-randomized trial at 4 academic medical centers: 2 centers trained their pediatric residents and implemented TIPP screening and counseling materials at all well-child checks (WCCs) for ages 2 to 24 months, and 2 centers implemented obesity prevention. At each WCC, parents reported the number of child injuries since the previous WCC. Proportional odds logistic regression analyses with generalized estimating equation examined the extent to which the number of injuries reported were reduced at TIPP intervention sites compared with control sites, adjusting for baseline child, parent, and household factors.

RESULTS

A total of 781 parent-infant dyads (349 TIPP; 432 control) were enrolled and had sufficient data to qualify for analyses: 51% Hispanic, 28% non-Hispanic Black, and 87% insured by Medicaid. Those at TIPP sites had significant reduction in the adjusted odds of reported injuries compared with non-TIPP sites throughout the follow-up (P = .005), with adjusted odds ratios (95% CI) of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively.

CONCLUSIONS

In this cluster-randomized trial with predominantly low-income, Hispanic, and non-Hispanic Black families, TIPP resulted in a significant reduction in parent-reported injuries. Our study provides evidence for implementing the American Academy of Pediatrics' TIPP in routine well-child care.

Effects of Pediatric Anticipatory Guidance on Mothers of Young Children

Provision of anticipatory guidance to parents during well-child visits is a defining component of pediatric primary care. Using nationally representative data from the 2000 U.S. National Survey of Early Childhood Health, this study addressed the questions of whether, how, and what mothers of children below age 3 with different ethnic/racial background could benefit from anticipatory guidance. Structural equation modeling results showed that across ethnic/racial groups, guidance was directly associated with decreased maternal stress and directly and indirectly associated with effective parenting practices in child development, discipline, and safety. Moreover, guidance was consistently associated with decreased stress (effect size = .159/.123/.252) and increased effective parenting practices in child development (total effect = .090/.179/.296), discipline (total effect = .079/.138/.111), and safety (total effect = .186/.204/.229) in White/Black/Latino groups, respectively. Finally, whereas guidance was directly associated with child safety in all groups, it was indirectly contributed to child development and discipline via maternal stress in the Latino group only.

Anticipatory guidance through DVD

The major purpose of the study was to determine if a 5-minute DVD is an effective method for communicating anticipatory guidance to parents at their child's 4-month well-child visit. A total of 84 caregivers were randomly assigned to receive anticipatory guidance through standard care (written anticipatory guidance handout and free talk) or DVD (DVD format + standard care). Participants completed a brief questionnaire immediately before and after their visit. As anticipated, knowledge scores improved significantly from pre-test to post-test. There was also a significant interaction between format used for anticipatory guidance and time. Specifically, there was greater improvement in knowledge over time for parents in the DVD group as compared with the standard care group. Additionally, the mean knowledge level of those in the DVD group as compared with those in the standard care group trended toward significance. Finally, visit length was shortened by nearly 3 minutes in the DVD group, and close to 100% of all respondents, regardless of anticipatory guidance format, indicated that they were very satisfied with their visit and amount of information learned.

Healthcare providers' knowledge, attitudes and counselling on injury prevention for preschool children in Croatia

Injuries are the leading cause of death for children and young adults in Croatia. Research has indicated that health care providers can be effective in reducing the risk for traumatic injury through anticipatory guidance, but successful guidance requires that providers have injury knowledge and informed safety attitudes. This is the first study in Croatia to identify health care provider's knowledge, attitudes, and practices regarding anticipatory guidance on injury prevention for children. A stratified, random sample of licensed Croatian healthcare providers was mailed a survey, with a response of rate of 39.5 %. Participants included pediatricians, family physicians, gynecologists, each with a focus on primary care, and community nurses. Participants filled out a 15-minute paper-and-pencil survey that tested their knowledge of injury risks and prevention strategies, assessed their safety-prone attitudes, and measured the extent to which they counselled their patients on injury prevention. Pediatricians had the highest knowledge of injury risks and intervention approaches, with an average correct score of six out of ten (significantly higher than all other provider types). Knowledge was highest regarding infant fall risk and lowest for safe sleep positions. Pediatricians and community nurses had the highest safety-prone attitudes. Safety prone attitudes were strongest for transportation safety and weakest for safe sleeping position for all providers. Community nurses reported the highest level of patient counselling, followed by pediatricians. Both factual education and support in translating knowledge into everyday practice are necessary for health care providers. Implementing anticipatory guidance for child safety is a promising approach in Croatia.

Screening in child health: studies of the efficacy and relevance of preventive care practices

BACKGROUND

Pediatric screening enables the prevention or early detection of diseases and developmental disturbances in infancy and childhood. Screening is a standard component of pediatric practice in many countries, but its scientific basis is not well known.

METHODS

The scientific justification for pediatric screening beyond the neonatal period is presented on the basis of a selective review of the literature on some aspects of pediatric screening.

RESULTS

The level of evidence varies highly among pediatric screening interventions and can be difficult to determine because of confounding variables. Parent counseling is associated with improvements in child-raising competence, accident prevention, and reading behavior. The early detection of abnormalities in a child's motor, linguistic, mental, or social development is possible and often leads to effective early interventions. Cyanotic congenital heart defects can be detected with 63% sensitivity and 99.8% specificity; cerebral palsy can be diagnosed with 33% to 100% sensitivity and 52.3% to 100% specificity (different figures from multiple studies). Physical therapy seems to improve some manifestations of cerebral palsy. Motor development at 90 days is correlated with motor development at 57 months (72% sensitivity, 91% specificity). A developmental quotient above 85 in a two-year-old child is correlated with an intelligence quotient above 85 when the child is 7 years old.

CONCLUSION

There is an increasing amount of scientific evidence in favor of pediatric screening. Nonetheless, further epidemiological studies are needed.

Using baby books to increase new mothers' safety practices

OBJECTIVE

To determine whether educational baby books are an effective method for increasing low-income, first-time mothers' safety practices during their child's first 18 months.

METHODS

Primiparous women (n = 167) were randomly assigned to 1 of 3 groups: an educational book group, a noneducational book group, or a no-book group. Home visits and interviews measured safety practices when women were in their third trimester of pregnancy (baseline) and when their children were 2, 4, 6, 9, 12, and 18 months of age.

RESULTS

Women in the educational book group had fewer risks in their homes and exercised more safety practices than the no-book group (- 20% risk reduction; effect size = -.30). When the safety practices involved little time or expense (eg, putting away sharp objects), the educational book group was significantly more likely to engage in these behaviors than the no-book group (40% higher practices; effect size = 0.19) or noneducational book group (27% higher practices; effect size = 0.13). However, no differences were found between groups for behaviors that required high effort in time, money, or hassle (eg, installing latches on cabinets).

CONCLUSIONS

Educational baby books appear to be an easy and low-cost way to increase the safety practices of new mothers, especially if the practices involve little to no time, money, or hassle.

Missed well-child care visits, low continuity of care, and risk of ambulatory care-sensitive hospitalizations in young children

OBJECTIVES

To determine if adherence to the recommended well-child care (WCC) visit schedule, independent of continuity of care (COC), is associated with lower risk of ambulatory care-sensitive hospitalizations (ACSH) and whether this association varies by chronic disease status.

DESIGN

Population-based, retrospective cohort study.

SETTING

Hawaii's largest health plan from 1999 to 2006.

PARTICIPANTS

A total of 36 944 children aged 3.5 years or younger were eligible if they were enrolled prior to 2 months of age, had 4 or more outpatient visits during the study period, and had an enrollment period that overlapped with 1 or more WCC visit interval.

MAIN EXPOSURE

Patients' WCC visit adherence and COC index.

MAIN OUTCOME MEASURE

Risk of ACSH (hazard ratio [HR]).

RESULTS

Overall, 8921 (24%) children had 1 or more chronic disease. The proportion of ACSH among healthy children vs those with 1 or more chronic disease were 3% (n = 751) and 7% (n = 645), respectively. For children with chronic disease, those with the lowest WCC visit adherence (0%-25%) had 1.9 times (HR, 1.9; 95% confidence interval [CI], 1.5-2.5) the risk of ACSH compared with those in the highest category (75%-100%). The risk of ACSH for children with chronic disease who fell into the lowest COC category (0-0.25) was 2.4 times (HR, 2.4; 95% CI, 1.7-3.5) higher than for those who fell into the highest category (0.75-1.0).

CONCLUSIONS

For children with chronic disease, both low WCC visit adherence and COC are independently associated with an increased risk of ACSH. Providing access to a consistent source of primary care appears to be important to this vulnerable population.

Injury prevention in the emergency department: a caregiver's perspective

BACKGROUND

Emergency medicine physicians and their staff care for high-risk injured patients, making the emergency department (ED) an appropriate place to discuss injury prevention (IP).

OBJECTIVE

To determine family receptiveness to and short-term effectiveness of IP information delivery during an ED visit.

METHODS

A cross-sectional survey was conducted in an urban pediatric ED. Caregivers of children younger than 15 years, with any chief complaint, were approached to participate. The survey consisted of caregiver's background, IP information received by their primary care pediatrician, and their wishes for receiving IP information in the ED. At survey completion, participants were given an age-appropriate IP handout. Follow-up phone surveys were made at 2 weeks to determine caregiver satisfaction and any self-reported IP changes made.

RESULTS

Two hundred fifty-one caregivers were approached. Two hundred forty-six (98%) were interested in receiving IP information in the ED, and 217 (86%) consented to participate. Ninety-three percent felt that the ED should provide IP information; 83% believed it should be offered even if it prolonged their ED visit. There was no significant difference among participants with regard to who should provide the information or how it should be provided. One hundred thirty (60%) of 217 completed the follow-up survey. Ninety-seven percent felt that the IP information was useful, and 63% kept the handout in a retrievable place. Twenty-eight percent of caregivers who completed the follow-up survey reported to change their safety behavior as a result of their ED encounter.

CONCLUSIONS

Many families surveyed in an urban pediatric ED wished for IP information in the ED setting. A simple IP intervention in an ED setting may encourage families to practice safer behaviors for their children.