Pediatric advocacy: Advancement in academic institutions

IMPACT

Children are facing many threats to their health today that require system change at a sweeping level to have real-world impact. Pediatricians are positioned as natural leaders to advocate for these critical community and policy changes. Academic medical center (AMC) leaders recognize the importance of this advocacy and clear steps can be taken to improve the structure to support pediatricians in their advocacy careers through faculty development and promotion, including standardized scholarly measurement of the outcomes.

Academic Careers in Advocacy: Aligning Institutional Values Through Use of an Advocacy Portfolio

Academic children's hospitals must embrace advocacy as a central component of their missions to discover new knowledge and improve the health of the communities and patients they serve. To do so, they must ensure faculty have both the tools and the opportunities to develop and articulate the work of advocacy as an academic endeavor. This can be accomplished by integrating the work of advocacy at the community and policy-change levels into the traditional value systems of academic medicine, especially the promotions process, to establish its legitimacy. Academic pediatric institutions can support this transformation through robust training and professional development programs and establishing opportunities, resources, and leadership positions in advocacy. The adoption of an advocacy portfolio can be used to align these activities and accomplishments to institutional values and promotion. This alignment is crucial to supporting the advocacy work of pediatricians at a time in which community engagement and systems and policy change must be added to professional activities to ensure optimal outcomes for all children.

An Essential Role for Pediatricians: Becoming Child Poverty Change Agents for a Lifetime

Poverty has profound and enduring effects on the health and well-being of children, as well as their subsequent adult health and success. It is essential for pediatricians to work to reduce child poverty and to ameliorate its effects on children. Pediatricians have important and needed tools to do this work: authority/power as physicians, understanding of science and evidence-based approaches, and first-hand, real-life knowledge and love of children and families. These tools need to be applied in partnership with community-based organizations/leaders, educators, human service providers, business leaders, philanthropists, and policymakers. Examples of the effects of pediatricians on the issue of child poverty are seen in Ferguson, Missouri; Denver, Colorado; and Rochester, New York. In addition, national models exist such as the American Academy of Pediatrics Community Pediatrics Training Initiative, which engages numerous pediatric faculty to learn and work together to make changes for children and families who live in poverty and to teach these skills to pediatric trainees. Some key themes/lessons for a pediatrician working to make changes in a community are to bear witness to and recognize injustice for children and families; identify an area of passion; review the evidence and gain expertise on the issue; build relationships and partnerships with community leaders and organizations; and advocate for effective solutions.

Overweight children and adolescents: a risk group for iron deficiency

BACKGROUND

The prevalence of obesity has increased at an epidemic rate, and obesity has become one of the most common health concerns in the United States. A few small studies have noted a possible association between iron deficiency and obesity.

OBJECTIVE

To investigate the association between weight status, as measured by body mass index (BMI), and iron deficiency in a nationally representative sample of children and adolescents.

DESIGN

National Health and Nutrition Examination Survey III (1988-1994) provides cross-sectional data on children 2 to 16 years of age. Recorded measures of iron status included transferrin saturation, free erythrocyte protoporphyrin levels, and serum ferritin levels. Children were considered iron-deficient if any 2 of these values were abnormal for age and gender. With the use of age- and gender-specific BMI percentiles, at risk for overweight was defined as a BMI of > or =85th percentile and <95th percentile, and overweight was defined as a BMI of > or =95th percentile. The prevalence of iron deficiency was compared across weight groups. Logistic regression was used to estimate the association between iron status and overweight, controlling for age, gender, ethnicity, poverty status, and parental education level.

RESULTS

In this sample of 9698 children, 13.7% were at risk for overweight and 10.2% were overweight. Iron deficiency was most prevalent among 12- to 16-year-old subjects (4.7%), followed by 2- to 5-year-old subjects (2.3%) and then 6- to 11-year-old subjects (1.8%). Overweight 2- to 5-year-old subjects (6.2%) and overweight 12- to 16-year-old subjects (9.1%) demonstrated the highest prevalences of iron deficiency. Overall, the prevalence of iron deficiency increased as BMI increased from normal weight to at risk for overweight to overweight (2.1%, 5.3%, and 5.5%, respectively), and iron deficiency was particularly common among adolescents (3.5%, 7.2%, and 9.1%, respectively). In a multivariate regression analysis, children who were at risk for overweight and children who were overweight were approximately twice as likely to be iron-deficient (odds ratio: 2.0; 95% confidence interval: 1.2-3.5; and odds ratio: 2.3; 95% confidence interval: 1.4-3.9; respectively) as were those who were not overweight.

CONCLUSIONS

In this national sample, overweight children demonstrated an increased prevalence of iron deficiency. Given the increasing numbers of overweight children and the known morbidities of iron deficiency, these findings suggest that guidelines for screening for iron deficiency may need to be modified to include children with elevated BMI.

Benefits of a school-based asthma treatment program in the absence of secondhand smoke exposure: results of a randomized clinical trial

BACKGROUND

Daily maintenance medications are recommended for all children with mild persistent to severe persistent asthma; however, poor adherence to these medications is common.

OBJECTIVE

To evaluate the impact of school-based provision of inhaled corticosteroids on asthma severity among urban children with mild persistent to severe persistent asthma.

DESIGN

Children aged 3 to 7 years with mild persistent to severe persistent asthma were identified at the start of the 2000-2001 and 2001-2002 school years in Rochester. Children were assigned randomly to a school-based care group (daily inhaled corticosteroids provided through the school) or a usual-care group (inhaled corticosteroids not given through school).

MAIN OUTCOME MEASURE

Improvement in parent-reported symptom-free days.

RESULTS

Of 242 eligible children, 184 were enrolled from 54 urban schools. Data for 180 children were available. Parents of children in the school-based care group had a greater improvement in quality of life compared with parents of children in the usual-care group (change score, 0.63 vs 0.24; P =.047); also, children in the school-based care group vs the usual-care group missed less school because of asthma (mean total days missed, 6.8 vs 8.8; P =.047) and experienced more symptom-free days during the early winter months (mean days per 2-week period, 9.2 vs 7.3; P =.02). A post hoc analysis revealed that all significant findings were produced by differences among children who were not exposed to secondhand smoke. Furthermore, among children not exposed to smoke, those in the school-based care group vs the usual-care group had more symptom-free days overall (11.5 vs 10.5; P =.046), had fewer days needing rescue medications (1.6 vs 2.3; P =.03), and were less likely to have had 3 or more acute visits for asthma (6 [13%] of 47 children vs 17 [31%] of 54 children; P =.03).

CONCLUSIONS

School-based provision of inhaled corticosteroids significantly improved symptoms, quality of life, and absenteeism among urban children with mild persistent to severe persistent asthma. This effect was seen only among children not exposed to secondhand smoke.

Elevated blood pressure and decreased cognitive function among school-age children and adolescents in the United States

OBJECTIVE

To evaluate the relationship between elevated blood pressure (BP) and cognitive test performance in a nationally representative sample of children. Study design The National Health and Nutrition Examination Survey III provides cross-sectional data for children 6 to 16 years, including BP and cognitive test scores. Elevated BP was defined as systolic or diastolic BP >or=90th percentile. Cognitive tests were compared for children with elevated and normal BP. Linear regression was used to evaluate the relation between elevated BP and decreased test scores.

RESULTS

Among the 5077 children, 3.4% had systolic BP >or=90th percentile and 1.6% diastolic BP >or=90th percentile. Children with elevated systolic BP had lower average scores compared with normotensive children for digit span (7.9 vs 8.7, P=.01), block design (8.6 vs 9.5, P=.03), and mathematics (89.6 vs 93.8, P=.01). Elevated diastolic BP was associated with lower average scores on block design (9.5 vs 11, P=.01). Linear regression showed that elevated systolic BP was independently associated with lower digit span scores (P=.032).

CONCLUSION

Children with elevation of systolic BP are at risk for central nervous system end-organ damage, as manifested by decreased digit span test scores.

A potential pitfall in provider assessments of the quality of asthma control

BACKGROUND

Pediatricians elicit information about asthma control from parents to help formulate management plans. If parents of children with significant asthma symptoms inappropriately indicate good control, physician recommendations may not be optimal. We examined whether a single general question about asthma control might lead to inaccurate assessment of severity.

DESIGN/METHODS

Children 3-7 years of age who met the National Heart, Lung, and Blood Institute (NHLBI) criteria for mild persistent to severe asthma were identified from 40 urban schools. A phone survey of their parents provided demographic information, symptom frequency, medication use, and general interpretation of their child's asthma control. Chi-square analyses compared the parent's general interpretation of control with demographic characteristics and measures of asthma severity.

RESULTS

One hundred sixty of 224 eligible children participated in this study. Seventy-eight percent were described as in good asthma control. General assessment of asthma control did not vary by demographic characteristics. Parents were as likely to describe children with daily asthma symptoms in good control as they were to describe children with less frequent symptoms in good control. Parents were less likely to report good control in children using daily rescue medications when compared with children with less frequent medication use (65% vs 82%, P =.03), but the majority of children in both groups was described as having good control.

CONCLUSIONS

Most parents underestimated the severity of their child's asthma and reported good control with their global assessment. Parents frequently reported good control even when the children had daily asthma symptoms. Pediatricians should ask about specific asthma symptoms during patient encounters because a global question about asthma control likely will result in underestimations of asthma severity.

Providers underestimate symptom severity among urban children with asthma

BACKGROUND

Guidelines recommend that children with mild persistent to severe persistent asthma receive maintenance anti-inflammatory medications. However, providers may not be aware of the severity of their patients' symptoms. The underestimation of severity may contribute to poor adherence to asthma care guidelines.

OBJECTIVES

To describe the use of preventive medications among a group of urban children with mild persistent to severe persistent asthma and to evaluate the degree to which their health care providers are aware of their asthma severity.

DESIGN

Children (ages 4-6 years) from urban schools in Rochester, NY, were eligible if their parents reported mild persistent to severe persistent asthma symptoms. Each child's health care provider was asked to assess the child's asthma severity and use of medications based both on their knowledge of the child and review of the medical record. Parent and provider assessments were compared. Bivariate and regression analyses were used to identify factors associated with concordant classifications of asthma severity.

RESULTS

Ninety children with parent-defined mild persistent to severe persistent asthma participated (64% boys, 67% black, 73% receiving Medicaid). Only 40% of the children were described accurately by their providers as having mild persistent to severe persistent asthma, and only 50% of the total had been prescribed maintenance medications. Thirty-six percent of families reported that their child used maintenance medications daily. In contrast, most of the children who were classified by their provider as having mild persistent to severe persistent asthma were prescribed a maintenance medication (83%), and 58% used them daily. Sociodemographic characteristics and asthma severity were not associated with provider accuracy.

CONCLUSIONS

Most children in this study were not accurately classified by their providers as having mild persistent to severe persistent asthma and had not been prescribed maintenance medications. When providers were aware of their patient's asthma symptoms, most of the children were prescribed maintenance medications. Attempts to improve adherence to asthma guidelines should take into consideration provider underestimations of asthma severity.

School readiness among urban children with asthma

BACKGROUND

Children with chronic illnesses, including asthma, are at risk for school problems. Developmental problems, however, may begin before school entry, and the developmental status of preschool children with asthma has not been evaluated.

OBJECTIVE

To test the hypothesis that urban preschool children with asthma have lower parent-reported developmental scores compared with children without asthma.

METHODS

A comprehensive survey of children beginning kindergarten in 1998 in the urban school system in Rochester, NY, collected parent reports of demographic, medical, and developmental data. We compared children with asthma with and without limitation of activity to children without asthma for motor, language, socioemotional, and school readiness skills and the need for extra help with learning. Linear and logistic regression were used to determine associations between asthma and developmental outcomes.

RESULTS

Among the 1058 children in this sample, 9% had asthma, including 5% with asthma with limitation of activity. After adjustment for multiple potential confounding variables, the children with asthma with limitation had lower scores on school readiness skills compared with children without asthma (2.0 vs 2.5, P <.001). Further, the parents of children with asthma with limitation were substantially more likely (P <.05) to describe them as needing extra help with learning (74% vs 56%; odds ratio, 3.2; 95% confidence interval, 1.5--7.8).

CONCLUSIONS

Urban preschool children with significant asthma had poorer parent-reported school readiness skills and a greater need for extra help with learning compared with children without asthma. This finding suggests that developmental problems for children with asthma may begin before school entry.

Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States

CONTEXT

Iron deficiency anemia in infants can cause developmental problems. However, the relationship between iron status and cognitive achievement in older children is less clear.

OBJECTIVE

To investigate the relationship between iron deficiency and cognitive test scores among a nationally representative sample of school-aged children and adolescents.

DESIGN

The National Health and Nutrition Examination Survey III 1988-1994 provides cross-sectional data for children 6 to 16 years old and contains measures of iron status including transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Children were considered iron-deficient if any 2 of these values were abnormal for age and gender, and standard hemoglobin values were used to detect anemia. Scores from standardized tests were compared for children with normal iron status, iron deficiency without anemia, and iron deficiency with anemia. Logistic regression was used to estimate the association of iron status and below average test scores, controlling for confounding factors.

RESULTS

Among the 5398 children in the sample, 3% were iron-deficient. The prevalence of iron deficiency was highest among adolescent girls (8.7%). Average math scores were lower for children with iron deficiency with and without anemia, compared with children with normal iron status (86.4 and 87.4 vs 93.7). By logistic regression, children with iron deficiency had greater than twice the risk of scoring below average in math than did children with normal iron status (odds ratio: 2.3; 95% confidence interval: 1.1-4.4). This elevated risk was present even for iron-deficient children without anemia (odds ratio: 2.4; 95% confidence interval: 1.1-5.2).

CONCLUSIONS

We demonstrated lower standardized math scores among iron-deficient school-aged children and adolescents, including those with iron deficiency without anemia. Screening for iron deficiency without anemia may be warranted for children at risk.

Five days of whole-bowel irrigation in a case of pediatric iron ingestion

The maximum duration and volume of polyethylene glycol electrolyte solution (PEG-ELS) that can be safely administered during whole-bowel irrigation of the poisoned patient are poorly defined. We present a case of a 33-month-old boy who ingested at least 160 mg/kg elemental iron and received 44.3 L of PEG-ELS (2,953 ml/kg) over 5 days because of the persistence of iron tablets in teh gastrointestinal tract. The child remained clinically well after initiation of PEG-ELS therapy, and further significant iron absorption did not appear to occur. The rectal effluent cleared within 2 days of the start of PEG-ELS therapy despite the persistence of iron in the gastrointestinal tract as shown on radiography. No adverse effects resulted from teh large volume or duration of the PEG-ELS therapy. This is the greatest reported volume of PEG-ELS to be used for whole-bowel irrigation in the treatment of a toxic ingestion.

Spiritual well-being and anxiety in adults diagnosed with cancer

Exploring the theory that anxiety is lower in highly spiritual persons confronting life-threatening illness, this correlational study was conducted with 114 adults who had been diagnosed with cancer. Relationships were measured between spiritual well-being and state-trait anxiety, using the Spiritual Well-Being Scale, which distinguishes between the religious and existential dimensions of spirituality, and the State-Trait Anxiety Inventory, which differentiates between transitory and characteristic anxiety. Efforts were made to identify demographic features of the sample which could influence spirituality and anxiety and their interactions. A consistent inverse relationship (p less than .001) was found between spiritual well-being and state-trait anxiety, regardless of influences of gender, age, marital status, diagnosis, group participation, and length of time since diagnosis. This supports the theory that persons with high levels of spiritual well-being have lower levels of anxiety. Controlled studies now are indicated, with attention to diversity and specificity of ethnic, socioeconomic, and religious backgrounds, as well as cancer type, stage, symptoms, and prognosis. The hospice community is challenged to undertake studies of the spiritual dimension and its healing potential.