Office-based counseling for unintentional injury prevention

Unintentional injuries are the leading cause of death for children older than 1 year. Pediatricians should include unintentional injury prevention as a major component of anticipatory guidance for infants, children, and adolescents. The content of injury-prevention counseling varies for infants, preschool-aged children, school-aged children, and adolescents. This report provides guidance on the content of unintentional injury-prevention counseling for each of those age groups.     

Predicting clinician injury prevention counseling for young children

BACKGROUND: Injury is the primary cause of morbidity and mortality in children and an important topic for counseling. OBJECTIVE: To describe and explain clinicians' reported counseling behavior during the well-child examinations for children aged 5 years and younger on the following 4 injury prevention topics: motor vehicle crashes, toxic ingestion, drowning, and firearm injuries. METHODS: A random sample of 465 pediatricians, family physicians, and pediatric nurse practitioners in an urban setting received mailed questionnaires; 325 (69.9%) responded. Multivariate logistic regression predicting counseling on each injury prevention topic was performed. RESULTS: Most reported discussing motor vehicle occupant protection (66.2%) and toxic ingestion prevention (62.1%) during the well-child examination. Only 31.8% stated they counseled on drowning prevention and 15.7%, on firearm injury prevention. Knowledge of injury mortality and morbidity rates was not associated with counseling. For most topics, female respondents were more likely to counsel than male respondents (motor vehicle crash odds ratio [OR], 2.24 [P = .03]; toxic ingestion OR, 1.82 [P = .05]; drowning OR, 1.97 [P = .04]). Health maintenance organization settings predicted injury prevention counseling for most topics (motor vehicle crash OR, 2.52 [P = .04]; toxic ingestion OR, 2.77 [P = .01]; firearm injury OR, 2.97 [P = .001]). Clinicians placing lower importance on counseling were less likely to counsel on drowning and firearm injury (drowning OR, 0.73 [P = .006]; firearm injury OR, 0.58 [P<.001]). CONCLUSIONS: Clinicians' knowledge of local injury epidemiology did not influence their counseling on these topics. Clinicians and their patients might benefit by using programs such as The Injury Prevention Program to help them standardize their approach to injury prevention counseling during the routine well-child examination.     

The importance of pediatric injury prevention to trauma care

Injury is currently the primary cause of death and disability in children. The field of injury consists of treatment and prevention. This article describes why prevention is the most important component of trauma care for the reduction of injury morbidity and mortality. The recognized prevention strategies are the “3 Es” of education, engineering, and enforcement. A comprehensive injury prevention program should include multiple strategies that have been shown to be effective in well-designed evaluations. The emergency medicine physician has a number of opportunities through clinical practice, education, and research to be effectively involved in injury prevention.     

Liquid-crystal thermometer use in pediatric office counseling about tap water burn prevention

Tap water scald burns are an important topic of injury prevention in pediatricians' offices. Consecutive pediatric clinic clients, randomized to two groups, received an informational pamphlet, a one-minute discussion about tap water safety, and a baseline questionnaire. The first group also received a liquid-crystal thermometer for testing maximum hot tap water temperature. One month later in a follow-up telephone interview (n = 503), the impact of the added thermometer on knowledge regarding scalding, temperature testing, and thermostat lowering was assessed. Approximately 80% of each group read the pamphlet. Reading the pamphlet was associated with greater temperature testing in the thermometer (T) group but not in the pamphlet only (P) group. Temperatures were checked by 46.4% of the T group but by only 23.0% of the P group (P less than .001). In the households in which the reported water temperature exceeded 54.4 degrees C (130 degrees F) and the water heater was accessible, 77.3% reported lowering the setting, independent of receiving the thermometer. The reliability of self-reported water temperature was assessed after 1 year by home visits. The use of relevant facilitating devices, such as a liquid-crystal thermometer, in-office anticipatory guidance efforts may increase behavioral compliance.     

Barriers to effective pediatric asthma care.

Although progress has been made in understanding the pathophysiology of asthma and identifying key features of quality asthma care, the prevalence of childhood asthma remains high. Barriers to effective asthma care that currently exist include the persistence of environmental risk factors, disparities in care that stem from poverty and cultural differences, and inconsistencies in the quality of asthma care provided by clinicians. Pediatric nurse practitioners at Yale New Haven Children's Hospital have actively implemented the recommended guidelines for asthma care and addressed causes for some of the disparities in asthma health care. Two major initiatives are described: the Asthma Care Coordination Project at Yale New Haven Hospital Pediatric Primary Care Center, and the establishment of an Asthma Outreach Program. Recommended resources and Web sites for the practitioner are also provided.     

Barriers to ideal outcomes after pediatric liver transplantation

Long‐term survival for children who undergo LT is now the rule rather than the exception. However, a focus on the outcome of patient or graft survival rates alone provides an incomplete and limited view of life for patients who undergo LT as an infant, child, or teen. The paradigm has now appropriately shifted to opportunities focused on our overarching goals of “surviving and thriving” with long‐term allograft health, freedom of complications from long‐term immunosuppression, self‐reported well‐being, and global functional health. Experts within the liver transplant community highlight clinical gaps and potential barriers at each of the pretransplant, intra‐operative, early‐, medium‐, and long‐term post‐transplant stages toward these broader mandates. Strategies including clinical research, innovation, and quality improvement targeting both traditional as well as PRO are outlined and, if successfully leveraged and conducted, would improve outcomes for recipients of pediatric LT.     

Genetic counseling in pediatric practice

Genetic counseling can be incorporated into pediatric practice with relative ease. The pediatrician committed to caring for the “whole child” can ill-afford to overlook the medical and psychosocial impact of genetic disorders on his patients, their families and society at large. This article briefly reviews the rapidly growing field of genetic counseling as applied to pediatric practice. Clues to diagnosis and the principles involved in counseling and risk estimation based on accumulated data and personal experience are presented.     

Barriers to pediatric referral in managed care systems.

Anecdotal evidence suggests that children's access to pediatric subspecialty and inpatient care is hampered by referral barriers imposed by managed care systems. To identify such barriers and determine how they affect the referral process, a sample of American Academy of Pediatrics Fellows (n = 1598) was surveyed. The response rate was 79.1% (n = 1264). Of those pediatricians in direct patient care (n = 956), 71.4% participated in a managed care plan. Pediatricians referred patients in managed care systems somewhat less frequently than in traditional pay systems: 8.7% and 6.9% referred managed care patients to subspecialists and inpatient care, respectively, less often. More than 20% and 10% of pediatricians with patients in managed care systems had at least one referral to subspecialist care and inpatient care, respectively, denied in the previous year. Pediatricians experienced more barriers in preferred provider organizations than in health maintenance organizations. These data suggest that utilization management programs, such as those used in managed care systems, may limit necessary access to pediatric subspecialty and inpatient care.     

Barriers to senior centre implementation of falls prevention programmes

This study examined the prevalence of senior centres providing multi-component falls prevention education and the perceived barriers in implementing this education. A telephone interview was conducted in 2006 with 500 senior centres nationwide. Centre directors were asked about the types of multi-component falls prevention education offered (ie, balance exercise classes, medication management, home safety information) and barriers to offering this education. Seventy percent of senior centres offered balance exercise classes, 68% offered medication management and 53% provided home safety information. Thirty-two percent offered all three components. Lack of staff, time and staff not feeling they had sufficient knowledge to deliver falls prevention education were the leading barriers to providing multi-component education. Senior centres provide components of effective falls prevention education and, while some may not address all components of a multifaceted programme, many have existing resources that may be adapted for translation of evidence-based programmes.     

Legal approaches to injury prevention

Injury prevention can be achieved, but it will require a fundamental reexamination of our approach to injury causation. We must learn to examine the manufacturing and marketing practices of companies that produce the products associated with children's injuries, for these are the real culprits in our national childhood injury plague. Most importantly, we must learn to demand from industry that it take injury prevention seriously. If it refuses to do so it must face the consequences before the American system of justice. Legal advocacy can be a valuable tool in this effort. The legal system provides the means to pierce the corporate veil of secrecy and to learn how and why products are made of hazardous design. Under the light of public scrutiny, culprit companies can be made to pay the price for producing hazardous products. Only in this manner will industry be given the incentive to increase product safety.     

Developmental approach to injury prevention

Children's developmentally diverse temperament, motivation, and competencies, when viewed through the lens of the agent-host-environment model, help us understand the child's contribution to the occurrence of injury. Pediatricians can use this information to individualize their safety counseling.     

Barriers to access in pediatric living‐donor liver transplantation

Children receiving a LDLT have superior post‐transplant outcomes, but this procedure is only used for 10% of transplant recipients. Better understanding about barriers toward LDLT and the sociodemographic characteristics that influence these underlying mechanisms would help to inform strategies to increase its use. We conducted an online, anonymous survey of parents/caregivers for children awaiting, or have received, a liver transplant regarding their knowledge and attitudes about LDLT. The survey was completed by 217 respondents. While 97% of respondents understood an individual could donate a portion of their liver, only 72% knew the steps in evaluation, and 69% understood the donor surgery was covered by the recipient's insurance. Individuals with public insurance were less likely than those with private insurance to know the steps for LDLT evaluation (44% vs 82%; P < 0.001). Respondents with public insurance were less likely to know someone that had been a living donor (44% vs 56%; P = 0.005) as were individuals without a college degree (64% vs 85%; P = 0.007). Nearly all respondents generally trusted their healthcare team. Among respondents, 82% believed they were well‐informed about LDLT but individuals with public insurance were significantly less likely to feel well‐informed (67% vs 87%; P = 0.03) and to understand how donor surgery might impact donor work/time off (44% vs 81%; P = 0.001). Substantial gaps exist in parental understanding about LDLT, including its evaluation, potential benefits, and complications. Greater emphasis on addressing these barriers, especially to individuals with fewer resources, will be helpful to expand the use of LDLT.