Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition.

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Screening for ventricular shunt function in children with hydrocephalus secondary to meningomyelocele.

OBJECTIVE: To evaluate the current method of using computerized tomographic (CT) scans to screen for ventricular shunt failure in children who have hydrocephalus. DESIGN: Retrospective review of 112 randomly selected charts. PATIENTS: Children diagnosed with infantile hydrocephalus secondary to meningomyelocele, who were treated at the Andrew J. Kirch Developmental Services Center since 1978. RESULTS: One hundred and twelve patients were monitored with CT scans for an average of 12.2 years. There was a total of 2,869 CT scans and an average of 2.1 CT scans per year. Shunt failure was diagnosed 76% of the time by symptoms, 15% by physical findings and 8% by routine CT scans. Sixteen patients had no shunt failure, whereas the remaining 96 had 255 shunt failures. Complications occurred during 30 of the 255 admissions. One child died due to complications directly related to shunt failure. No statistically significant correlations were found between the length of stay or complications and method of diagnosis. CONCLUSIONS: Although children in this study received frequent CT scans, 76% of the episodes of shunt failure were diagnosed because of symptoms. Children admitted to the hospital with symptomatic shunt failure did not have more complications or a longer stay than those diagnosed by routine CT scan. This study suggests that the use of routine CT scans to diagnose shunt failure while patients are asymptomatic does not lead to significantly better medical outcomes and is not cost-effective. However, before routine CT scans are eliminated, a prospective study needs to be conducted that examines outcomes such as cognitive and psychological functioning.

Health status of children with moderate to severe cerebral palsy.

The aim of the study was to evaluate the health of children with cerebral palsy (CP) using a global assessment of quality of life, condition-specific measures, and assessments of health care use. A multicenter population-based cross-sectional survey of 235 children, aged 2 to 18 years, with moderate to severe impairment, was carried out using Gross Motor Function Classification System (GMFCS) levels III (n = 56), IV (n = 55), and V (n = 122). This study group scored significantly below the mean on the Child Health Questionnaire (CHQ) for Pain, General Health, Physical Functioning, and Impact on Parents. These children used more medications than children without CP from a national sample. Fifty-nine children used feeding tubes. Children in GMFCS level V who used a feeding tube had the lowest estimate of mental age, required the most health care resources, used the most medications, had the most respiratory problems, and had the lowest Global Health scores. Children with the most severe motor disability who have feeding tubes are an especially frail group who require numerous health-related resources and treatments. Also, there is a relationship among measures of health status such as the CHQ, functional abilities, use of resources, and mental age, but each appears to measure different aspects of health and well-being and should be used in combination to reflect children's overall health status.

Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition.

BACKGROUND: Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. METHODS: The Constipation Subcommittee of the Clinical Guidelines Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated clinical practice guidelines for the management of pediatric constipation. The Constipation Subcommittee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. RESULTS: The Subcommittee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guidelines provide recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Subcommittee also provided recommendations for management by the pediatric gastroenterologist. CONCLUSIONS: This report, which has been endorsed by the Executive Council of the North American Society for Pediatric Gastroenterology and Nutrition, has been prepared as a general guideline to assist providers of medical care in the evaluation and treatment of constipation in children. It is not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Effects of providing comprehensive ambulatory services to children with chronic conditions.

OBJECTIVE: To document the effects of a comprehensive program of care on the resource utilization and cost of care for children with chronic conditions. DESIGN: Descriptive study of 10715 admissions between 1984 and 1995 with analyses of costs based on charges. Comparisons were made with data from a national consortium of academic medical centers and from a national survey of hospitals. A 2-week survey of staff was conducted to identify their use of time in the care of these patients. PATIENTS: Children aged birth through 18 years meeting International Classification of Diseases, Ninth Revision, Clinical Modification criteria for chronic conditions. Patients with acute conditions were used as controls. INTERVENTION: A program of expanded care funded since 1989 by a regional insurance company. RESULTS: Between 1984 and 1995, mean length of stay for children with chronic conditions decreased from 83.9 to 10.6 days; mean annual admissions decreased from 2796 to 1622. Median hospital inpatient charges, adjusted for cost of living, decreased from $26.1 to $14.6 million. A $77.7 million savings occurred for inpatient care, with total expenditures from the insurance program of $3.6 million (a 21:1 ratio). Almost half the professional activities provided for these children were for services that could not be reimbursed in a fee-for-service model. Median adjusted inpatient charges were lower in Rochester, NY ($8746) than in other academic medical centers ($12773) or in a national survey of hospitals ($12462), and fewer children were readmitted within 30 days in Rochester (12.7%) than in other academic medical centers (15.0%). CONCLUSIONS: An investment of funds by a regional insurance company was associated with reduced costs, admissions, and lengths of stay for children with chronic conditions, and resulted in significant savings for the company. This model may be applicable to other centers.

The child who has severe neurologic impairment.

The formulation of a diagnosis in a child who has neurologic impairment should not (except in extreme circumstances) be made on the basis of a single finding. For example, the presence of delayed milestones, primitive or exaggerated reflexes, abnormal muscle tone, abnormal posture, abnormal neurologic examination, and temporal course should all be used to make the diagnosis of cerebral palsy. Furthermore, because each condition has a spectrum of disabilities from mild to severe involvement, determination of the child's abilities and impairments should be part of the diagnostic process. Because the child lives in a number of different environments, assessment of the child's functional abilities and evaluation of the environments should be made. Finally, evaluations by specialists in physical therapy, occupational therapy, speech therapy, psychology, special education, and nutrition may be necessary to complete the child's diagnosis. The ability to examine the child over a period of time (i.e., continuity of care) allows the practitioner to provide a more accurate prognosis for future development. It also enables easier diagnosis of the child when he or she is acutely ill. This also allows a more trusting relationship to develop with the parent and enhances the ability to influence the psychosocial conditions that affect outcomes. Finally, all these children should have care coordination (case management) (i.e., someone who can ensure that they receive the care they need, without duplication) across all settings, including home, school, hospitals, and ambulatory facilities.

Diagnostic clusters in infants as child health outcomes. Variation among socioeconomic areas in one community.

Objectives were to examine geographic variation in rates of infant hospitalization for diagnostic clusters in Monroe County (Rochester), New York and to assess these clusters as indexes of child health. ICD-9 codes were used to cluster all 7,883 hospitalizations of infants (< 24 months) between 1985 and 1991 on the basis of their avoidability. Environmentally sensitive clusters accounted for 63% of admissions. These clusters included environmental, environmental/constitutional, and other infectious disease. Disparities in morbidity between inner city and suburbs were greatest for the environmental cluster, followed by the environmental/constitutional, and other infectious disease clusters. For the constitutional and quality indicator clusters, differences between inner-city and suburban risk were minimal. Environmental interventions may be more important than improved health services to reducing racial and economic disparities in child health. Analysis of morbidity clusters, ascertained from available administrative data bases and aggregated for small geographic areas, may guide child health policy well.

Helping adolescents who have disabilities negotiate transitions to adulthood.

Adolescents who have disabilities face unique challenges as they progress through the transitions necessary to achieve optimum functioning in adulthood. These youths often need professional assistance to successfully negotiate these important transitions. Our article describes processes for collaborating with these adolescents, their families, and other professionals to facilitate successful transitions to a more healthy, productive, and satisfying adulthood.

Decline of pediatric admissions with Haemophilus influenzae type b in New York State, 1982 through 1993: relation to immunizations.

OBJECTIVES: To evaluate the impact of vaccination for Haemophilus influenzae type b (Hib) on pediatric hospital admissions in New York State, and to identify risk factors in children who continue to be admitted for Hib invasive disease. METHODS: Retrospective review of hospitalizations in New York state from 1982 through 1993 and a survey of immunization records from physician offices in Monroe Country, New York. RESULTS: In 1982, 769 children were admitted to New York state hospitals for Hib-related conditions; by 1993, this had decreased to 133. Significant declines during the study period occurred in the age-adjusted admission rates for Hib meningitis, septicemia, pneumonia, and epiglottitis, but not for arthritis and osteomyelitis. In 1993 alone, 712 admissions, 18 deaths, and 135 episodes of morbidity were avoided. Since 1991, the rates of admissions for Hib-related conditions have remained fairly constant. Minority subjects continue to be twice as likely as white subjects to be admitted for invasive Hib disease (0.44 vs 0.17/100,000). Children living in urban Rochester also are more likely to be admitted and less likely to be completely immunized against Hib (61%) than those living in suburban areas (82%). CONCLUSIONS: Although Hib vaccine has had a major impact on hospital admissions for Hib-related conditions, the goal of completely eliminating Hib disease will require programs targeted at groups at high risk, such as minorities and those living in cities.

Socioeconomic variation in discretionary and mandatory hospitalization of infants: an ecologic analysis.

OBJECTIVES: To examine geographic variation in rates of infant hospitalization for diagnoses classified by type of hospitalization decision in Monroe County (Rochester), New York. METHODS: Study design was cross-sectional and ecologic. International Classification of Diseases (ICD) codes were used to categorize all 7883 hospitalizations for infants (age, <24 months) beyond the newborn period between 1985 and 1991. Postal zip codes defined socioeconomic areas as inner-city, other urban, and suburban for the population at risk. In 1990, inner-city infants included 62% black and 65% Medicaid-covered infants, whereas suburban infants included 3% black and 6% covered by Medicaid. Hospitalization rates were compared among the three socioeconomic areas. RESULTS: Overall hospitalization rate was 50.3 per 1000 child years. Admissions classified as discretionary accounted for 59% of these, followed by those classified as mandatory, 18%; sometime (congenital heart disease, cleft palate), 15%; discretionary surgery (inguinal hernia, tonsillectomy/adenoidectomy), 6%; and unlikely to need admission, 2%. A stepwise, socioeconomic gradient in hospitalization was found, with rates of 38.1, 51.3, and 82.9 per 1000 child-years, respectively, for suburban, other urban, and inner-city areas. Rates for discretionary, unlikely, and mandatory admissions followed this gradient. Using the odds for hospitalization of suburban infants as the base odds, the odds ratio for discretionary hospitalization for inner-city infants was 2.88 (95% confidence interval [CI], 2.69 to 3. 08) and that for mandatory hospitalization was 2.20 (95% CI, 1.94 to 2.49). In multiple regression analysis, low education level of mothers explained 81% of the variance in discretionary hospitalization rate. Although the per capita rate of hospital care of inner-city infants was more than twofold greater than that for suburban infants, potential for reducing this difference is suggested by the fact that discretionary admissions accounted for 78. 9% of this difference, whereas mandatory admissions accounted for 17. 7% of the difference. CONCLUSION: The hospitalization rate for inner-city infants is much greater than that for suburban infants. A substantial portion of the difference, namely that attributable to mandatory admissions, reflected higher rates of serious illness. Differences attributable to discretionary admissions may reflect higher rates of serious illness to some extent, but also appear to reflect less effective health services to a substantial degree.

Ensuring high-quality alternatives while ending pediatric inpatient care as we know it.

Child advocates recognize pediatric hospitalization as an issue of great concern because of the serious morbidity it reflects and the adverse psychosocial effects of inpatient experience on children and families. Accounting for almost 50% of child health care costs, estimated at $49.8 billion in the United States in 1987, pediatric hospitalization also represents a substantial financial burden. Studies of the variation in childhood hospitalization rates among geographic areas, however, suggest a large portion of these hospitalizations are avoidable. In individual level analysis, admitting pediatricians judged 28% of acute, general pediatric hospitalizations to be potentially avoidable had specified alternative services been available. Furthermore, evidence supports the safety of care in alternative settings for selected acute illness episodes. Hospitals share incentives for reducing inpatient services as they join managed care organizations that capitate hospital costs. At a time when health care cost reduction has become a dominant theme in industry and politics, concern seems warranted that cost considerations might prevail over quality considerations in shaping change. The concern of child advocates is heightened by the fact that costs are measured as dollars while measures of quality remain comparatively vague.

Avoidable morbidity in infants. A classification based on diagnoses in administrative databases.

OBJECTIVES: A hierarchical classification for avoidable morbidity in infants was developed based on a conceptual model for causes of morbidity. Experts rated the impact of risk factors and health services on diseases coded according to the International Classification of Diseases, 9th Revision, Classification Modification (ICD-9-CM). An etiologic framework was chosen for the classification because knowledge of etiology often suggests strategies for prevention. Causes of morbidity that cluster on the basis of similar risk factors might be avoided using similar strategies. METHODS: Diseases (346 different diagnoses) were rated by 16 general pediatricians; 12 attributes were considered, including the impact on disease occurrence and on severity of five risk factors, preventive health services, and medical treatment. Raters evaluated the impact of health services, constitutional risk factors, and environmental risk factors without regard for service site (eg, inpatient, emergency department, primary care office). Environmental risk factors categories, including family, social, and physical environments, were rated separately. The impact of health services was rated on prevention, treatment, and complications of care. RESULTS: Only ratings indicating that the impact of a risk factor category was substantial were used for the final classification of 275 diagnoses. Consistent with the multifactorial etiology of many diseases, many diagnoses had ratings indicating substantial impact of multiple risk factors. Five mutually exclusive clusters were derived from the 12 ratings based on factor analysis and recognized strategies for prevention. Ordered by level of avoidability, these clusters were termed vaccine-preventable, health-care quality indicators, environmental, environmental/constitutional, and constitutional. CONCLUSIONS: The usefulness of this classification for policy-oriented epidemiologic and health services research is grounded in the premise that prevention is the cardinal objective of child health policy. Cluster-specific hospitalization rates, ie, rates aggregated for all diagnoses falling in a cluster, might be used for allocating resources to interventions directed at environmental or health service determinants of morbidity. Widespread use of ICD-9-CM codes in hospital discharge and ambulatory databases suggests many potential applications for this classification of morbidity burden in population groups.

Tethered spinal cord: update of an analysis of published articles.

Two hundred and fifteen papers written in English between 1943-1994 addressing the issue of tethered spinal cord (TSC) were reviewed using established criteria for research design. Of 127 articles that were not reviews or case reports, 64% specified the diagnostic criteria used for TSC: only 6% discussed the representativeness of the sample. Observer bias was addressed in 6%: reliability in a mere 5%. Only 16% of the 43 articles dealing with clinical trials used a control group: in no case was it randomly chosen. Only 20% of the 25 articles addressing clinical course/prognosis utilized an inception cohort. A "gold standard" diagnostic test was used in 66% of the 44 studies dealing with the issue, but only 21% employed an independent blind comparison. Critical questions such as: What is the optimal surgery to prevent TSC? What is the optimal technique to repair TSC? Should surgery be performed on all asymptomatic children with TSC? Are changes in the appearance of the spinal cord associated with neurological deterioration? What is the role of TSC in scoliosis? cannot be answered because reliable data to answer them does not exist.

Children with chronic conditions need your help at school.

As they try to make the most of their opportunities at school, children with chronic conditions need a pediatrician's advocacy. Use your knowledge of the illness, the law, and the resources in your community to play an active role.

The role of the pediatrician in caring for children with developmental disabilities: overview.

Pediatricians can help children with developmental disabilities to reach their potential. In addition to the issues relating to direct care outlined above and in the other articles in this issue of Pediatric Annals, clinicians should advocate on a community-wide level. This includes working with neighborhood schools, community health nurses, disease-oriented volunteer groups, and neighborhood agencies to provide access to services, support, and education for children and their families. It also includes championing the cause of children with disabilities with local and state governments. Because of the respect that pediatricians command in the community, they can play a major role in the lives of these children and their families.