Failure to Thrive

Failure to thrive is poor physical growth that results when the nutritional demands of young children are not fulfilled. This diagnosis is made when, on serial growth monitoring, the child’s anthropometric parameters such as weight for age and/or height are found to be significantly below the expected values. A detailed evaluation by the treating physician, taking into account physical and psychosocial factors affecting the child’s health is essential for understanding the factors contributing to failure to thrive. The treatment of this entity requires a multidisciplinary approach, correcting the macro and micronutrient deficiency in the child as well as education of parents regarding age-appropriate feeding recommendation for children. In addition, parents need to be apprised of the possible implications of malnutrition on growth and neurodevelopment of the child. Early childhood being a crucial period for growth and development, an early diagnosis and treatment will result in better outcomes in children with failure to thrive.     

Parental perceptions of well-child care visits in an inner-city clinic.

OBJECTIVES: To assess parental perceptions of the importance of well-child care (WCC) in an inner-city clinic and to determine what type and format of information parents would like to obtain at WCC visits. METHODS: A convenience sample of parents accompanying a child aged 12 years or younger attending an inner-city pediatric teaching clinic completed self-administered written surveys. Parents ranked the importance of WCC overall, as well as its various components, using Likert scales. Parents also responded to checklist-style questions to indicate selected topics they would like to receive more information about and the format of information they preferred (written, talking to the physician, or videotapes in the waiting room). RESULTS: A total of 239 parents completed surveys. Overall they believed WCC was important (91% responded "extremely important" or "very important"). The individual WCC components ranked most important by parents were immunizations, growth and development issues, and the opportunity to discuss behavior or other concerns. The topics of information requested most frequently were how to help their child learn healthy eating habits (55%), how to help their child do well in school (53%), and how to keep their child safe outside of their home (49%). Written information was the format most frequently preferred (65%) by parents for receiving information. CONCLUSIONS: Parents of inner-city children consider WCC important. They want to hear about child health-related issues and prefer a written format. This knowledge can guide health care providers and educators during WCC visits and while teaching.     

Accuracy of parental reporting of immunization

This study was undertaken to evaluate the reliability of parental reporting of their children's immunization status. One hundred eight consecutively admitted children to Brookdale University Hospital and Medical Center were sampled during October and November 2001. Review of the immunization record, recording the immunizations documented, and matching it with the parents' report was done for children in whom the parents brought the cards. The primary care physician was contacted to verify the immunization status for children for whom the parents did not bring the card during hospitalization or for whom there was a mismatch between the card and the parents' report. The study included 100 patients (8 were excluded). Forty-nine patients had their immunization cards on admission; 18 brought the cards later during the hospital stay. Of the 100 parents questioned, 98 stated that their children are up to date and 2 stated that their children are missing vaccinations. Of the 98 parents who stated that their children are up to date, 2 were found not to be up to date. Ninety-eight percent of parents were aware of their children's immunization status and were accurate with their reporting. Parents are knowledgable of their children's immunization status (98% parental accuracy) and their statements can be relied on during history-taking. It is important for each child to have a primary care physician.     

How well does the questionnaire for identifying children with chronic conditions identify individual children who have chronic conditions?

BACKGROUND: The Questionnaire for Identifying Children With Chronic Conditions (QuICCC) is an instrument based on a conceptual noncategorical definition that uses parental responses to identify children with chronic conditions for epidemiological purposes. OBJECTIVES: To determine whether the QuICCC is sufficiently valid, sensitive, and specific to be used to identify individual children as having a chronic condition or disability; whether parents are accurate enough that their answers to QuICCC items can be accepted as valid; and what kinds of errors in classification occur when the QuICCC is used to identify children with chronic conditions. METHODS: The sample consisted of 424 children who were patients of 9 physicians in separate practice settings throughout New England. Each physician was briefly trained in the conceptual definition on which the QuICCC is based and then was asked to identify 25 children in his or her practice who met the definition and 25 children who did not meet the definition. The QuICCC was administered to the parents of these children by blinded interviewers via telephone. The QuICCC classification was compared with physician categorization. Discrepant cases were then followed up by asking physicians and parents to answer the original questions a second time. RESULTS: Complete data were available on 379 (89.4%) of 424 children. There was agreement on 89% (kappa = 0.78). The sensitivity was 94%; specificity, 83%; positive predictive value, 86%; and negative predictive value, 92%. Of the 42 discordant cases, 30 parent reports on the QuICCC qualified the child as having a chronic condition when the physician classified the child as being without such a condition. Fewer (n = 12) discrepancies occurred because physicians identified children with chronic conditions that the QuICCC failed to identify. When the questions were readministered at follow-up, physicians corrected errors in rating in 9 cases; mothers changed their answers in 5 instances. In 13 instances the issues were known to both parties and appeared to arise in the "gray zone" or boundary area, where there was disagreement over whether a particular child qualified using the theoretical definition. For 11 children identified as having a chronic condition only by the parent's responses to the QuICCC, physician report appeared to be inaccurate primarily due to the physician's lack of information. In 3 cases where the physician reported the child to have a chronic condition, but the parent did not, the physician appeared to be correct. Follow-up data were incomplete on 1 child. CONCLUSIONS: These data support the validity of parent-generated information for the evaluation of health status. Although these findings should be replicated, this study suggests that the QuICCC may be applicable also as a screening tool for individual child identification, provided that several sources of error are considered.     

When is it permissible to dismiss a family who refuses vaccines? Legal,ethical and public health perspectives

Although immunization is one of the most important health interventions of the 20th century, cases of infectious disease continue to occur. There are parents who refuse immunization for their children, creating a dilemma for the primary care physician who must consider the best interest of the individual child as well as that of the community. Some physicians, when faced with parents who refuse immunization on behalf of their children, choose to dismiss these families from their practice. Given the existing shortage of primary care physicians across Canada, this decision to dismiss families based on vaccine refusal has far-reaching implications. The present article explores this issue in the Canadian context from a legal, ethical and public health perspective.     

Parents’ Experiences with Services and Treatment for Their Children Diagnosed with Cerebral Palsy

ABSTRACT

While there is a considerable body of knowledge investigating the efficacy of constraint-induced movement therapy (CIMT), there is a need for information focusing on parents’ experiences when their children receive these services. This qualitative research study initially explored the experiences of four parents with children who are diagnosed with cerebral palsy (CP) and who participated in CIMT using a group format. Additionally, the richness of the information shared by parents provided insights on other important issues related to family supports when raising a child and the availability of resources for children diagnosed with CP. Response analysis from in-depth interviews with parents resulted in three themes: (a) Everything in my family changed when my child was diagnosed with CP and the support I feel from my family makes all the difference in how I cope. (b) It was so hard to get the information and support that I needed for my child. (c) The group format enhanced CIMT for my child and provided social benefits as well. Findings from this study suggest there are benefits of using CIMT in group formats.     

When and by whom is concern first expressed for children with neuromotor problems?

OBJECTIVE: To describe when and by whom concern is first expressed for children referred to rehabilitation because of neuromotor problems. STUDY DESIGN AND SETTING: We conducted a survey of parents of 92 children (aged 0-6 years) who were on the waiting list for physical or occupational therapy services at rehabilitation centers in Montréal, Québec. We compared age of child at initial concern with who first expressed concern for children who were considered at risk due to their perinatal history of prematurity and those who were not born prematurely but were later diagnosed as having neuromotor problems. INTERVENTION: Parents were interviewed regarding their child's medical history and utilization of health care services. RESULTS: Parents were concerned later than physicians were regarding their child's development (mean difference, 8.2 months; 95% confidence interval [CI], 3.7-12.6 months). There was no significant difference in time of recognition of problems between the premature (10.2 months) and full-term (11.9 months) groups. Even after controlling for risk group, parental concern occurred later than physician concern (beta coefficient, 7.3; 95% CI, 2.5-12.2). The child's age at the time of initial concern was associated with the child's age at referral to rehabilitation (beta coefficient, 0.04; 95% CI, 0.01-0.06). CONCLUSIONS: Early recognition is important if a child is to benefit from early rehabilitation. It may be important to improve primary care screening of children for neuromotor problems and to increase parental awareness regarding normal motor development of their children. Prompt, simultaneous referral to medical evaluation and rehabilitation resources may decrease delays in rehabilitation.     

Education and internationally adopted children: working collaboratively with schools

Families who adopt internationally often need assistance in determining which factors they need to consider when making educational decisions for their child, and they frequently seek guidance from their physician. Understanding how the education system functions, how it differs from the medical system, and how children who have been adopted internationally can succeed in school is important for health care providers, because this information helps parents in making proactive decisions for their children. Internationally adopted children have the best chance of maximizing their learning potential when medical and educational professionals work together to assist families as they plan for their child's education.     

Parents' experiences with services and treatment for their children diagnosed with cerebral palsy

While there is a considerable body of knowledge investigating the efficacy of constraint-induced movement therapy (CIMT), there is a need for information focusing on parents' experiences when their children receive these services. This qualitative research study initially explored the experiences of four parents with children who are diagnosed with cerebral palsy (CP) and who participated in CIMT using a group format. Additionally, the richness of the information shared by parents provided insights on other important issues related to family supports when raising a child and the availability of resources for children diagnosed with CP. Response analysis from in-depth interviews with parents resulted in three themes: (a) Everything in my family changed when my child was diagnosed with CP and the support I feel from my family makes all the difference in how I cope. (b) It was so hard to get the information and support that I needed for my child. (c) The group format enhanced CIMT for my child and provided social benefits as well. Findings from this study suggest there are benefits of using CIMT in group formats.     

The importance of play in promoting healthy child development and maintaining strong parent-child bond: focus on children in poverty

Play is essential to the social, emotional, cognitive, and physical well-being of children beginning in early childhood. It is a natural tool for children to develop resiliency as they learn to cooperate, overcome challenges, and negotiate with others. Play also allows children to be creative. It provides time for parents to be fully engaged with their children, to bond with their children, and to see the world from the perspective of their child. However, children who live in poverty often face socioeconomic obstacles that impede their rights to have playtime, thus affecting their healthy social-emotional development. For children who are underresourced to reach their highest potential, it is essential that parents, educators, and pediatricians recognize the importance of lifelong benefits that children gain from play.     

Adopted children in their adoptive families.

The adoptive process can produce unusual stresses on the child, and biologic and adoptive parents, from prenatal to postnatal life, and through the various phases of physical and pscyhological development. Because of the possibility of these children and their families falling into the "at risk" category with greater potential for psychological and social problems, the pediatrician is of primary importance in diagnosis and counseling. The pediatrician can be of major help in properly diagnosing emotional, behavioral and/or learning problems occurring in adopted children. There must be a thorough evaluation of the child and his family to understand and properly treat symptomatic behavior. The pediatrician can give advice regarding developmental milestones, and especially help the adoptive parents in appreciating their conscious and unconscious attitudes so as to enhance attachment behaviors. Pediatricians are the consultants to whom parents turn for advice regarding the timing of telling about adoption. This advice needs to be individualized according to the specific child's needs. Using a developmental conceptual framework, the pediatrician is in the best position to help the parents and their adopted children with their feelings about societal attitudes and how these can most appropriately be handled. Along this line, the pediatrician can give help and advice when and if the adoptee decides to search for his biologic parents. There is a need to clarify laws which seal the original birth certificate permitting those adoptees who wish to attain a knowledge of potentially related disease processes and an identity with his own genealogical past to do so. This would also allow the adoptee to offer his own children information about their own genetic pool and an awareness of adoption as one of the most valuable and historically significant child rearing practices.     

Childhood obesity

Several conclusions can be drawn on the basis of the research reviewed: Obese children are more likely to become obese adults than are their thinner peers. Parent weight may interact with child weight status in the etiology of adult obesity. Obese children with obese parents are more likely to become obese adults than are obese children with thin parents. The prediction of adult obesity from childhood obesity improves with the age of the child. As the obese child gets older, he or she is more likely to become an obese adult. The inclusion of parents in the treatment process is important for the success of childhood weight control. It may be best to see the parent and child separately in treatment meetings rather than together. Children with thin parents may do better in weight control than children of obese parents. Adherence to exercise is likely to be a problem with obese children, and the choice or design of an exercise program should take these adherence problems into account. Nutritional adequacy of the child's diet should be evaluated both in terms of what the child is eating as well as in terms of the prescribed diet. Likewise, growth of the obese child during dieting should be monitored and should be related to expected height, which can be based on parent height. In summary, childhood obesity is a problem that places a child at great risk for becoming an obese adult. However, a growing body of research has emerged that has identified important risk factors for the development of obesity in children. Likewise, treatment methods have been developed that produce significant and long-lasting effects on childhood weight status. Continued development of treatment methods would be of great potential importance in the prevention and treatment of this prevalent problem.     

Health insurance coverage and physician use among children with disabilities: findings from probability samples in five metropolitan areas

The effect of insurance coverage on physician use for children in the United States who have been identified as disabled by their schools under the provisions of the Education for All Handicapped Children Act (PL 94-142) is examined. The research is based on identically drawn stratified random samples of children from the elementary school special education populations of five large metropolitan school systems. It was found that health insurance coverage was a predictor of whether a disabled child had seen a doctor in the past year even after adjustment for site, family background characteristics, type and severity of childhood disability, and structural access factors (adjusted odds ratio, 1.76, P less than .05); Hispanic children with disabilities were more likely than white children to be without any health insurance (adjusted odds ratio, 3.63; P less than .001), but there was no similar statistically significant difference between blacks and whites; and wide variations persist in scope of insurance payment for care, such that parents of publicly insured children paid out of pocket for only 5% of all physician visits as compared to 30% of visits for the privately insured. Even for children with various low-prevalence disabilities, when privately insured, parents paid out of pocket for 23% of all physician visits. These data help clarify the extent of health insurance coverage among children with disabilities and indicate that insurance remains an important predictor of physician use even though it continues to pay for only certain elements of care.     

First step in obtaining child health care: selecting a physician

To investigate the process by which families identified and selected their children's current physicians, a close-ended questionnaire was administered to 750 families in a mail panel. Of 630 responses (84.0%), 244 had children in the home; 229 (93.9%) identified a regular and current physician for their youngest child. However, parents did not spend much time or energy selecting a physician and rarely explored medical expertise in their decisions. Families averaged 1.2 sources of information consulted per decision; few considered more than two physician choices and infrequently considered alternative types of doctors (pediatricians v family or general practitioners). Selection priorities ranked in order of importance concerned parents' perceptions of their doctors' communication skills, accessibility, and quality as determined by recommendations of friends or physicians. Parents appeared less concerned with issues of cost and convenience. Families selecting pediatricians differed from those selecting family and general practitioners in sources of information used and selection priorities. The survey also identified 84 families who had changed or seriously considered changing the physician who was caring for their youngest child. The most frequent dissatisfaction was the perception that an illness was not being managed adequately, followed by believing that the doctor or staff were rude or unconcerned. Families unhappy with pediatricians expressed different reasons from those unhappy with family or general practitioners. The study results provide insight about the first step in obtaining child health care services, a relatively unexplored area of patient decision making.     

Parental presence during procedures in an emergency room: results from 50 observations

This report describes the physician-parent-child encounter during an invasive medical procedure in a pediatric emergency department. Fifty children underwent venipuncture or intravenous cannulation performed by 22 physicians and 6 nurses. The median age of the children was 12 months. Parents remained with their children during 31 (62%) of the 50 procedures. Parents were more likely to stay if they had previously stayed when this child (P = .05) or another (P = .02) had undergone a procedure. Parental decision to stay was not related to parental age, gender, race, marital status, or level of education, nor to the residents' age, gender, or level of training. Only 43% of the parents who did stay were given that option by the residents, and of those who did not stay 37% reported that physicians asked them to leave. Nonverbal cues by the residents, such as pulling the curtain closed or turning their back toward parents, were noted in 58% of the encounters in which parents did not stay. The residents and nurses indicated that parents should stay with their child for the following procedures: laceration repair, 66%; venipuncture, 58%; intravenous cannulation, 48%; arterial blood sampling, 32%; suprapubic aspiration, 20%; and lumbar puncture, 14%. In the emergency room studied, it appears that for venipuncture and intravenous cannulation, the majority of parents stay with their children. Parental decision to stay or leave is frequently made without discussion with the physician.     

Evaluation and management of children and adolescents with sports-related concussion

Concussions are common sport injuries, and are particularly common among children and adolescents involved in organized sports and recreational activities. Symptoms of concussion can be subtle, and may be overlooked by athletes, coaches/trainers and parents. If a child or youth sustains a concussion, they should immediately be removed from play and assessed by a physician as soon as possible. The athlete should rest from physical and cognitive activities to allow for recovery from concussion. Once symptoms have completely resolved at rest, the athlete can progress through a medically supervised stepwise exertion protocol before being medically cleared to return to play. It is imperative that everyone involved in child and youth sports be aware of the signs and symptoms of concussion so that an accurate and timely diagnosis can be made, and proper evaluation and management instituted. The present position statement replaces the previous document published in 2006.     

Reported versus confirmed wheeze and lung function in early life.

AIMS: To investigate the relation between parentally reported wheeze (unconfirmed), physician confirmed wheeze, and subsequent lung function. METHODS: Children at risk of allergic disease (one parent atopic) were recruited antenatally and followed prospectively from birth. During the first three years of life parents were asked to contact the study team if their child was wheezy. The presence of wheeze was confirmed or not by the primary care or study physician. Respiratory questionnaire and specific airway resistance measurement (sR(aw), body plethysmograph) were completed at age 3 years. RESULTS: A total of 454 children were followed from birth to 3 years of age. One hundred and eighty six (40.9%) of the parents reported their child wheezing in the first three years of life, and in 130 (28.6%) the wheeze was confirmed. A total of 428 children attended the three year clinic review, of whom 274 (64%) successfully carried out lung function tests. There was no significant difference in sR(aw) (kPa.s; geometric mean, 95% CI) between children who had never wheezed (n = 152; 1.03, 1.00 to 1.06) and those with a parentally reported but unconfirmed wheeze (n = 36; 1.02, 0.96 to 1.07, p = 1.00). sR(aw) was significantly higher in children with a physician confirmed wheeze (n = 86; 1.17, 1.11 to 1.22, p < 0.001) compared to those with no history of wheeze or with unconfirmed wheeze. CONCLUSIONS: Children with physician confirmed wheeze have significantly poorer lung function compared to those with parentally reported but unconfirmed and those who have never wheezed. A proportion of parents may have little understanding of what medical professionals mean by the term "wheeze".     

Sporttauglichkeit bei Kindern mit angeborenen Herzfehlern

Children with congenital heart disease also need leisure and sports activities to prevent deficits in psychosocial development. The treating physician involved should therefore encourage these children and their parents; however, on many occasions a clear statement by the pediatric cardiologist as to whether the child should be restricted in physical activity or not would be of great value. A software tool is presented that can be downloaded for free (http://www.dgpk.org) and enables easy generation of a certificate that can be individualized for the child.     

Parental reactions to a child's first febrile convulsion. A follow-up investigation

The severe psychological reactions of most parents to the first febrile convulsions of their child contrast with the doctors' consideration of febrile convulsions as a simple and benign phenomenon. Fifty-two parents whose child had been admitted with febrile convulsions were interviewed about their immediate and long-term reactions. Most of the parents knew little about febrile convulsions before the fit. Parents with previous knowledge of febrile convulsions took more appropriate measures during the fit than parents without such knowledge. Sixty per cent of the parents slept restlessly for some time after the fit, 13% watched their child at night, and 29% had dyspeptic symptoms. Parents of young children should as a routine be offered general information by the family doctor about fever and febrile convulsions. Parents who have watched their child during a fit need specific information in order to avoid long-term reactions.     

Parental Reactions to a Child's First Febrile Convulsion:A Follow-up Investigation

ABSTRACT. The severe psychological reactions of most parents to the first febrile convulsions of their child contrast with the doctors' consideration of febrile convulsions as a simple and benign phenomenon. Fifty-two parents whose child had been admitted with febrile convulsions were interviewed about their immediate and long-term reactions. Most of the parents knew little about febrile convulsions before the fit. Parents with previous knowledge of febrile convulsions took more appropriate measures during the fit than parents without such knowledge. Sixty per cent of the parents slept restlessly for some time after the fit, 13% watched their child at night, and 29% had dyspeptic symptoms. Parents of young children should as a routine be offered general information by the family doctor about fever and febrile convulsions. Parents who have watched their child during a fit need specific information in order to avoid long-term reactions.