Assessing the health status of children entering foster care.

OBJECTIVE: Most research on health problems of children in foster care has been cross-sectional, resulting in overselection of children who have been in care long-term and underrepresentation of children who are in care for a short time. METHODOLOGY: This paper reports on the health of a large cohort of children who had complete health examinations at the time of entry into foster care in a middle-size city during a 2-year period. RESULTS: Results indicate that > 90% of the children had an abnormality in at least one body system, 25% failed the vision screen, and 15% failed the hearing screen. The children were also lighter and shorter than the norm. Mental health screening revealed that 75% had a family history of mental illness or drug or alcohol abuse. Of children older than 3 years of age, 15% admitted to or were suspect for suicidal ideation and 7% for homicidal ideation. Of the children younger than 5 years of age, 23% had abnormal or suspect results on developmental screening examinations. At the time of entry into foster care, 12% of the children required an antibiotic. More than half needed urgent or nonurgent referrals for medical services and, for children > 3 years of age, more than half needed urgent or nonurgent referrals for dental and mental health services. Just 12% of the children required only routine follow-up care. CONCLUSIONS: The high prevalence and broad range of health needs of children at the time they enter foster care necessitate the design and implementation of better models of health care delivery for children in foster care.

Alprazolam as an adjunct to propranolol in anxious outpatients with stable angina pectoris.

A double-blind crossover comparison is reported of the effects of alprazolam and placebo on anxiety and angina in 27 ambulatory outpatients with angina pectoris stabilized on propranolol. Alprazolam was shown to be a safe treatment when combined with propranolol in these patients. Patients receiving alprazolam with propranolol reported more improvement on their targeted symptoms than did patients receiving placebo with propranolol. The side effect most often reported was moderate drowsiness or sedation; no unusual side effects emerged. There was no evidence that alprazolam compromised the patients' response to propranolol.

Meeting the nutritional needs of the elderly in the institutional setting.

Meeting the nutritional needs of elderly persons who are living in institutionalized settings is often a great challenge for nutrition practitioners. Part of the challenge is to determine nutritional requirements by appropriately assessing individual needs, and part is to analyze the effects of risk factors that include chronic conditions, intermittent concurrent illnesses, medications, and psychologic state. Another strategy in meeting the nutritional needs of the institutionalized elderly is to set nutritional goals within the constraints imposed by the resources available within the institution. Some of the obstacles to achieving nutrition goals in individuals living in an institution may be closely related to the limits imposed by institutional resources, which may include staffing patterns, finances, and state and federal regulations.

Nutrition and health promotion in older adults.

During recent decades, the concept of health promotion has become a legitimate part of health care because of the aging of the postwar baby boom generation. As this population ages, the potential strain on health care systems will increase because the greatest use of health care services occurs during the last years of life. In older adults there are many correctable health factors that can be assessed through screening protocols. Hypertension, cholesterol, hearing, vision, diabetes, and cancer screening are well integrated into health promotion programs; nutrition promotion programs are not as well integrated. Reluctance to develop health promotion programs for older adults exists because of a perception that they would not follow such plans or change their lifestyles. However, longitudinal studies have shown that health promotion activities extend the number of years of health in older people although the relationship weakens in older age. Changes in diet and exercise patterns are most effective in the prevention of nutrition-related conditions when they are instituted early in life, but positive effects can occur at any age. If nutritional interventions are instituted early, a substantial reduction in health care expenditures may result from a decrease in the incidence or the delayed onset of these conditions. Changes in behaviors (reducing salt and fat intake) were positively associated with a belief that consuming a healthful diet would contribute to better health. The use of a variety of adult education theories and models will enhance behavior changes that lead to more healthful habits and enable a health educator to be successful in effecting change.

Attitudes of academic pediatricians with a specific interest in child abuse toward the spanking of children.

OBJECTIVE: To evaluate the attitudes of academic child abuse professionals toward spanking, the effect of context and mode of administration on their attitudes toward spanking appropriateness, and what they teach residents about spanking. DESIGN: A survey. PARTICIPANTS: Convenience sample of 114 members of the Ambulatory Pediatric Association's Special Interest Group on Child Abuse and Neglect. MAIN OUTCOME MEASURES: Respondents were asked if spanking was an appropriate disciplinary option for children 2, 5, and 8 years of age who refused to go to bed, ran into the streets without looking, or hit a playmate. Respondents also rated the appropriateness of spanking in 6 additional scenarios where the setting in which spanking occurred was varied. Respondent's teaching practices relative to spanking observed during a clinic visit were also elicited. RESULTS: The response rate was 70%; 39% thought spanking was appropriate sometimes. The context and mode of spanking affected the acceptance of spanking. All respondents thought that some response was appropriate when spanking was observed during a continuity clinic visit. However, only 29% of respondents taught residents how to handle such situations. CONCLUSIONS: Most academic child abuse professionals believe that spanking is inappropriate and their beliefs are influenced by the context in which spanking occurs. Little is taught about how to manage spanking observed in a clinical setting.

The impact on families of pediatric resident departure from a continuity clinic practice.

OBJECTIVE: To determine views of parents whose children were reassigned to new resident pediatricians at a continuity clinic because their previous pediatricians had completed residency. DESIGN: Cross-sectional survey. SETTING: Hospital-based resident continuity clinic. PARTICIPANTS: Ninety parents whose pediatricians were graduating were interviewed from June through August 1995. RESULTS: Most parents felt they knew their resident pediatrician well and that the resident knew their child well. Sixty-eight parents (76%) were sad about the transition, 33 (37%) were angry, 30 (33%) felt abandoned, and 6 (7%) were relieved. Three fourths of the parents thought it was very important for the family to be involved in the reassignment process, yet less than one fifth had been asked their opinion. Half of the families were experiencing their second or greater transition. Families undergoing their first, vs second or greater transitions, were more likely to feel they knew the resident well (P = .01), and that the resident knew their child well (P = .04). Despite the transitions, 86 (96%) of families stated they would continue to have their child receive medical care at the current site because they knew their child would receive good care. CONCLUSIONS: Strong physician-patient-parent relationships develop when residents are the pediatric primary care providers. Parents want to be informed regarding transitions. Pediatricians need to be sensitive to the impact of transitions and to negotiate with families in choosing their future pediatrician. These results have implications for other practice sites where physician turnover occurs.

Maternal outcomes of a randomized controlled trial of a community-based support program for families of children with chronic illnesses.

BACKGROUND: Parents of children with chronic illnesses are at high risk for secondary mental health problems, such as anxiety and depression. OBJECTIVE: To evaluate maternal outcomes of a support intervention for families of children with selected chronic illnesses. DESIGN: A randomized controlled clinical trial design with repeated measures 1 year apart. SETTING: A community-based family support intervention linked to subspecialty and general pediatric clinics and practices in a metropolitan area. PARTICIPANTS: A population-based sample of 193 mothers of children aged 7 to 11 years; the children were diagnosed as having diabetes, sickle cell anemia, cystic fibrosis, or moderate to severe asthma. About 15% of the persons contacted refused to participate in the research, and 14% of the families were lost to follow-up. INTERVENTION: The 15-month intervention, the Family-to-Family Network, was designed to enhance mothers' mental health by linking mothers of school-aged children with selected chronic illnesses with mothers of older children with the same condition. The program included telephone contacts, face-to-face visits, and special family events. MAIN OUTCOME MEASURES: Beck Depression Inventory score and the Psychiatric Symptom Index. RESULTS: Maternal anxiety scores for participants in the experimental group decreased during the intervention period for all diagnostic groups and for the total group; scores for the control group increased (F = 5.07, P =.03). In multiple regression analyses, the intervention group was a significant predictor of posttest anxiety scores (P =.03). Effects were greater for mothers with high baseline anxiety (P<.001) and for those who were themselves in poor health (P<.01). CONCLUSIONS: A family support intervention can have beneficial effects on the mental health status of mothers of children with chronic illnesses. This type of intervention can be implemented in diverse pediatric settings.

Nutritional support: formulas and delivery of enteral feeding. I. Enteral formulas.

Hospital malnutrition is a recognized condition that may be treated with a variety of feeding modalities. It is possible to achieve the goal of nutritional repletion with enteral feedings. Enteral feedings can now be prescribed for more types of patients because of our ability to better manipulate nutrition sources and the availability of modules and formulas designed for special use. The lower costs associated with enteral feeding have made it an option when nutritional support is required for a patient who has a functioning gastrointestinal tract.

Nutritional support: formulas and delivery of enteral feeding. II. Delivery systems.

As interest in enteral feeding formulas and techniques grows, the hardware (tubes, bags, pumps) is becoming increasingly sophisticated. Newer materials have eliminated earlier problems with feeding tubes, and different lengths and lumen sizes have made access to the gastrointestinal tract more efficient. Patients can be fed via nasoenteric access or directly via gastrostomy or jejunostomy. Enteral nutrition can be administered safely if a protocol for feeding patients and monitoring them regularly is followed. If done carefully, transitional feedings can also be carried out effectively.

Medical and nutritional aspects of intractable diarrhea.

Diarrhea can be due to at least five pathogenetic mechanisms. Major examples of each are presented to better illustrate each type of diarrhea and to provide a springboard for discussion of the nutritional management of each class of diarrhea. Certainly, specific diseases require specific therapies, such as avoidance of gluten in adult coeliac disease, but the major dietary/nutritional alterations and subsequent treatment are similar for each class of disease. Nowhere in medicine and nutrition is an admonition to the health care team more important and more proper than in the treatment of chronic diarrheas: The feeding of healthy man, as well as the diet of the sick cannot be left to chance, guided by the appetite, or ruled by tradition, but can be safely directed only according to the laws of digestion and metabolism.

Continuing education needs assessment and program development: an alternative approach.

Continuing education has become increasingly important to the professions, including dietetics. There is some concern, however, that continuing education programs too seldom focus on practice-related problems and do not have a large enough impact on daily practice. A research and development endeavor is in progress to create an alternative approach to continuing education programming. Utilizing a process called the Practice Audit Model, this approach brings practitioners (or their representatives) and educators together to develop continuing education programs that focus on learning needs identified through an empirical assessment of practitioner performance.

A profile of clinical dietetics practice in Pennsylvania.

Clinical dietitians in Pennsylvania (N = 185) responded to a survey (based on the practice description developed by the Clinical Dietetics Profession Team of the Continuing Professional Education Development Project) in which they rated time spent on and perceived importance of 11 responsibilities and 120 tasks in their practice. Practitioners spent the most time on responsibilities and tasks that they perceived to be most important. Responsibilities rated high in terms of time spent and importance were nutrition care implementation, nutrition care planning, nutrition assessment, and nutrition care evaluation. Dietitians reported spending a considerable amount of time on activities related to documentation.

Patterns of care: an analysis of the quality of nutritional care routinely provided to elderly hospitalized veterans.

To assess the adequacy of the nutritional care provided, a prospective noninterventional study was carried out on 250 randomly selected patients aged 65 and over who were admitted to a Veterans Administration Hospital. Of this group, 97 patients (39%) were found to be at high risk of having clinically significant protein-energy malnutrition. In 43 cases (17%), an assessment of the patient's nutritional status was not possible because the available data were inadequate. No patient had a diagnosis of malnutrition recorded on the problem list. Only 13 percent of the high-risk patients received some form of nutrition support therapy; 10 (10%) received oral supplements, and four (4%) were started on enteral feedings. Patients who received enteral feedings experienced a high rate of complications resulting from use of the feeding tubes. Over all, none of the high risk study patients received optimal nutrition support therapy. These findings indicate that elderly patients hospitalized in the Veterans Administration hospital in this study are usually not screened appropriately for protein-energy malnutrition, the diagnosis is frequently missed or ignored, and nutrition support therapy is underutilized and often ineffectually managed.

A primate model for enteral nutrition by tube.

To establish an animal model for the controlled study of enteral nutrition by tube, five adult chair-adapted primates (Macaca fasicularis) had gastrostomy and jejunostomy tubes placed for the delivery of a modified protein isolate diet. Following 7 days of postoperative depletion with a hypocaloric infusion of dextrose (20 kcal, 0 g N/kg/day), the animals were repleted for 10 days with tube feedings (124 kcal, 0.73 g N/kg/day). There was no operative mortality or morbidity and each animal demonstrated conversion to anabolism by significant weight gain, positive nitrogen balance, and net protein synthesis as determined by [15N]glycine protein turnover rates. Significant correlation was found between caloric intake and nitrogen balance at the level of nitrogen provided in this diet (r = 0.88, p less than 0.05). This model was found to be well suited for the surgical and nutritional techniques required for the long-term study of enteral nutrition by tube.

Effects of age on nutrient requirements.

The effects of age on nutrient requirements are difficult to quantify for older adults because there is great variability in aging. There are trends in changes that have been identified through longitudinal studies that indicate that, although there is a decrease in energy requirement with advancing age, there is not a parallel decrease in the need for most other nutrients. In fact, protein requirements per kilogram of body weight may increase; increases for certain vitamins may be due to their unique absorptive and metabolic processes that may be affected by chronic conditions. There is little evidence to support changes in mineral needs unless there is an association with the management of a chronic condition. Fluid requirements to prevent dehydration must be addressed in elderly people.

Maternal reports of raising children with chronic illnesses:the prevalence of positive thinking.

OBJECTIVE: To examine maternal reports of the positive impact and potential benefits of a child's chronic health condition. DESIGN AND METHODS: A total of 190 mothers and their children with chronic illnesses, including sickle cell disease, cystic fibrosis, diabetes mellitus, and asthma, were recruited from 12 specialty or general pediatric clinics in Baltimore, Md. Standardized interviews were conducted with the mothers and included demographics, condition-related variables, and positive aspects of raising a child with a chronic condition. RESULTS: Eighty-eight percent of the mothers felt better about themselves by learning to manage their child's chronic condition; 70% felt that their families were stronger because of their child's condition; and 80% felt that their family had benefited in some way from having a child with a chronic illness. Ninety-eight percent of the mothers endorsed at least 1 positive item; 58% endorsed all 3. CONCLUSIONS: Asking mothers about the positive impact on a family of a child's chronic illness captures an important part of the experience of caregiving. Physicians' recognition and encouragement of this positive outlook may help families continue to face the challenges of raising a child with a chronic illness.