disease management chap 21 and fever chap 21/23

illness prevention

Prevention of illness and communicable diseases is a significant goal when providing primary health care services for children or managing the care of children with chronic diseases or conditions. Health care providers must be vigilant in their practice settings to prevent or reduce the possibility of exposure to communicable diseases and to control the spread of infectious diseases that are a threat to infants, children, and youth. Using the following guidelines can further the goal of prevention: • All children should be appropriately immunized against vaccine-preventable diseases according to the recommendations of the Advisory Committee on Immunization Practices (ACIP), the AAP, and the American Academy of Family Physicians (AAFP). See Chapter 23 for the recommended immunizations and schedules. • Communicable diseases need to be identified and treated appropriately and reported in a timely fashion to public health departments as required by law. • Develop practice setting policies about the following: segregate infected children from well children as quickly as possible; avoid crowded waiting rooms, shorten waiting times, and minimize sharing of toys; wash hands before and after each patient contact; wipe the body of otoscopes or ophthalmoscopes regularly with alcohol; clean ear curettes after each use or use disposable ones, and disinfect with bleach solution or alcohol or sterilize any nondisposable tool if used between patients or contaminated with blood or other body secretions. • Health practices to prevent or control the spread of infectious disease must be carried out in home care programs, out-of-home child care programs, schools, health care settings, and hospitals. Daycare in a small daycare home is associated with less spread of infectious disease than is daycare provided in larger center. Key practices include the following: Use effective personal hygiene—handwashing procedure should take 40 to 60 seconds (World Health Organization, 2009). Teach parents and children the importance of washing their hands, especially after toileting, blowing their nose, and a before eating. The CDC has excellent materials that can be used with families. Ensure appropriate environmental sanitation— disposing of waste (e.g., blood, urine, feces, vomit, saliva) together with proper cleaning and disinfection of equipment, toys, toilets, eating areas, and diaper-changing surfaces. There should be a regular schedule of cleaning, in addition to cleaning when contaminated. Personnel should be regularly updated regarding blood-borne pathogen guidelines. Reduce respiratory spread of disease—cough into one's sleeve and minimize use of handkerchiefs; cover mouth when sneezing or coughing, dispose of tissue after wiping nose, and wash hands immediately; discourage habits of touching the mouth, nose, and eyes; eliminate passive smoke and provide adequate ventilation. Do not serve raw or undercooked eggs or meats. Promote appropriate handling, preparation, sanitation, and storage of food. Reduce exposure to communicable disease by separating sick children from well children. • Educate youth about the prevention of sexually transmitted infections. • Educate young children and teenagers to not share food, liquids, personal hygiene products, cosmetics, hair coverings, grooming products, or towels with others. • Discourage children from kissing pets and playing in areas of animal fecal contamination (e.g., sandboxes). • Provide preventive health guidance about avoiding secondhand smoke. Caring for Our Children: National Health and Safety Standards: Guidelines for OutofHome Child Care Programs outlines preventive health practices to promote a safe environment for infants and children. It addresses the issues of disease prevention and management in family and group daycare homes and childcare centers (The American Public Health Association and AAP, 2002). In addition, several out-of- home daycare resources are listed in Box 21-3. Preventing and controlling the spread of illness in these group settings are important issues in maintaining health.

chap 23 fever without focus in infants and young children

assessment of child w/ acute fever-careful investigation for a source of infection. Children birth-24 months are at greatest risk for unsuspected occult bacteremia; less common in older than 36 months. Fever without focus- acute febrile illness in which the etiology of the fever is not apparent after careful history and physical examination. fever is defined as a rectal temperature of 100.4° F (38° C) or greater in infants 0 to 90 days old; or greater than 102.2° F (39° C) in infants and children 3 to 36 months old. Since Hib vaccine, this agent has been virtually eliminated as a cause of bacteremia in 3 to 36mths; the S. pneumoniae vaccine is expected to follow a similar trend. Clinical Findings: History included in the history of the illness: • Duration and degree of fever (fever documented at home by reliable caregiver considered accurate) • associated symptoms: Vomiting, diarrhea, respiratory symptoms, rash (especially petechiae or purpura), irritability, inconsolability, change in play activities, lethargy (LOC, poor or absent eye contact or failure to recognize parents or interact with persons or objects in the environment) • known exposures (family illness, contacts with other ill children, daycare contacts) • Recent vaccination • Recent travel history • Past medical history of malignancy, splenectomy, shunt, indwelling catheter, immunologic disorders, recurrent bacterial infections, serious bacterial infection • Neonatal history of complications, prior antibiotics, prior surgeries, hyperbilirubinemia • Chronic illness • Current medications, including antipyretics and antibiotics • Immunization history with Hib, pneumococcal vaccines Assessment: Risk Criteria High risk- • febrile infant younger than 1mth • toxic- appearing neonate, infant, child regardless of age, risk factors, or degree of fever • infant 1 to 3 months of age with a rectal fever of 100.4° F (38° C) or greater • An infant 1 to 3 months of age with a chronic illness or underlying condition with unreliable caretakers, was premature, has a WBC count equal to or > 15,000 or absolute WBC band count of > 1500, or > 5 WBCs per high- power field (hpf) in stool specimen, or catheterized spun urine sediment with > 10 WBC/hpf • Continue with the workup even if an infant less than 3 months of age has otitis media. Low risk: • infant or child 3 to 36 months of age with a fever greater than 102.2° F (39° C), nontoxic appearing with a history of previously being healthy, has nonfocal bacterial infection, and a positive rapid influenza A test. • infant 3 to 6 months of age with rectal temperature greater than 100.4° F (38° C) but less than 102.2° F (39° C) who is not ill appearing • Infant or child 3 to 36 months of age who is mildly ill appearing with rectal temperature greater than 102.2° F (39° C) but <104° F (40° C) and fewer than 15,000 WBCs; stool fewer than 5 WBCs/hpf if diarrhea present; catheterized urinalysis spun sediment of less than 10 WBC/hpf; negative chest x- ray if cough present • Documented immunizations (or lack of) to at least two doses of both Hib and pneumococcal vaccine (HPV7 or HPV13). Diagnostic Studies: negative, low-risk ambulatory workup is characterized by the following laboratory results: • CBC: WBC count less than 15,000/mm3, absolute band count of fewer than 1500 bands/mm3 • Blood culture: No growth in 48 hours (72 hours for those immunocompromised or if fungal infection suspected in neonate) • Catheterized urinalysis: Fewer than 10 WBCs/hpf spun sediment, negative leukocytes and nitrites • Catheterized urine culture: More than 100,000 single pathogen. • When diarrhea is present: Fewer than 5 WBCs/hpf in stool • If cough: Negative chest x-ray • petechiae present: Normal platelet count; still monitor clinically Differential Diagnosis: The differential diagnoses includes upper respiratory tract disease (viral URI, otitis media, and sinusitis); lower respiratory tract disease (bronchiolitis, pneumonia); gastrointestinal disease; musculoskeletal infections (cellulitis, septic arthritis, osteomyelitis); urinary tract infection (esp E. coli); occult bacteremia- other pathogens in children 3 to 36 months of age (immunized with both Hib and pneumococcal vaccine- rate is less than 0.5% of children). Serious bacterial agents are identified in 10% to 15% in previously well neonates with fever and dx of sepsis, meningitis, UTI, enteritis, osteomyelitis, and suppurative arthritis. Other possible illnesses- pyelonephritis (more often in uncircumcised boys, neonates, urinary tract anomalies, and females), otitis media, omphalitis, mastitis, and other skin or soft-tissue infections. age related serious causes bacterial/viral infections: (decreasing order of frequency) Bacteremia/Meningitis: <1 mo Group B streptococcus Escherichia coli (and other enteric gram-negative bacilli) Listeria monocytogenes Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Neisseria meningitidis Salmonella spp. Herpes simplex Enteroviruses 1-3 mo S. pneumoniae Group B streptococcus N. meningitidis Salmonella spp. H. influenzae L. monocytogenes S. aureus Osteoarticular Infections: <1 mo Group B streptococcus S. aureus 1-3 mo S. aureus Group B streptococcus S. pneumoniae Urinary Tract Infection: 0-3 mo E. coli Other enteric gram-negative bacilli Group D streptococcus (including Enterococcus spp.) Management: practice guidelines for the outpatient management of infants and children from 0 to 36 months of age, fever without focus.- management algorithm for specific age groups based upon risk factors: fever >104, no serious underlying conditions, non-toxic, previously well = physical exam- source not identified (or) AOM, skin/soft tissue, bone/joint infx, <3mths old = continue with algorithm. -0-4wks: send to ED, transport based on clinical appearance, needs LP, CBC, blood/urine cx, rapid viral testing. (admit) -1-3mths: CBC w/ diff, cathed U/A, urine/blood cx, stool EP if GI sx, chest xray if resp sx,- (+) results = pneumonia, pyelo, >15,000wbc, stool >5wbc/hpf, urine spun > 10wbc/hpf (send to ED further study/eval) -3-6mths: fever >102.2 or 39c- cathed U/A, (-) nitrite f/u 24hr, check cx. (+) nitrite- CBC, blood cx, and tx: ceftriaxone 50mg/kg once IM, DC and f/u 24hr & check CBC, blood cx, follow UTI guideline if pyelo/UTI dx. -3-36mths: fever >102.2/39c, (no)- stop algorithm, (yes)- CBC/diff, cathed U/A, urine/blood cx, stool EP if GI sx, chest xray if resp sx, U/A nitrite/leukocyte (-) = if wbc >15,000, absolute bands 1500, or other findings +, = tx: cetriaxone & DC f/u 24hrs. nitrite/leukocyte (+) = ceftriaxone 50mg/kg once IM & UTI guideline, DC f/u 24hr in clinic/ED, DC instructions, consider further workup. Additionally: • Fever with petechiae in any-age child who is ill appearing is high risk for a life-threatening bacterial infection; immediate hospitalization and workup are indicated. • Fever with petechiae but in a child who is well appearing: draw a CBC, platelet count, and blood culture; observe for further petechial development (unless coughing/sneezing/emesis); if child continues to be well-appearing and has no further petechiae, manage on an outpatient basis as determined by reason for petechiae. • The higher the WBC count and the greater the absolute number of neutrophils or bands, the greater the risk of bacteremia in a febrile child. alternative management plan for those 3 months and older, in light of the decrease in bacteremia caused by Hib & pneumoniae: • well-appearing and has no foci of infection, no diagnostic testing or empirical use of antibiotics is needed. Instead, rechecked in the clinic in a series of follow-up appointments that allow time for clinical and laboratory evaluations. Laboratory studies and antimicrobial treatment would be prescribed as indicated. *Parents need detailed instructions on signs and symptoms that indicate a worsening illness. Instruct to bring in immediately signs and symptoms appear: change in or new rash; duskiness, cyanosis, or mottling; coolness of extremities; poor feeding or vomiting; irritability; cries with positional changes; difficulty in comforting or arousing; seizure activity (eye rolling or jerking of extremities); or bulging anterior fontanelle. **Careful follow-up must be priority.

pharmacological agents and patient education

Before patients and their parents or caregivers leave the health care setting, they should have a basic understanding about the pharmacological effect of any medication, OTC drug, or medicinal product that is prescribed or recommended. Points of information that should be emphasized include the following: • The purpose of the drug, how much should be given, and the frequency of administration • Instructions about the indications for using a drug that is given on an "as necessary" basis or under specific circumstances (e.g., a rescue plan for the child with asthma whose symptoms are worsening) • Signs or symptoms that indicate that a drug is either effective or not producing the desired effect or effects • Possible drug-drug or drug-nutrient interactions, precautions, or adverse reactions that can occur • Information about drug stability, such as the need for refrigeration or storage and compatibility issues (not exposed to light or mixing with foods or other drugs) • If applicable, any monitoring parameters that are required for safe administration of the drug or to maintain effective therapeutic blood levels • Pregnancy risk factor of a drug (refers to the U.S. Food and Drug Administration's [FDA] A, B, C, D, or X categories that indicate the potential of a systemically absorbed drug causing birth defects) and the need to screen for pregnancy when giving specific drugs to female teenagers • For children who take multiple medications, the importance of always carrying with them an up-to- date list of medications (prescription, OTC, herbal products, vitamins, and minerals), their strengths and dosages, in addition to a list of medications the child cannot take in case of an emergency or if the child is seen by another health care provider • Tips to help parents administer medications that may be difficult to get the child to take (e.g., how to hold an infant or small child when administering a medication) • Some medications can be safely mixed to mask the flavor of unpleasant medications. However, be sure to counsel about any medication that may have untoward interactions with foods or that should be administered on an empty stomach. The following is a listing of liquids or solid foods that may be suggested: chocolate or strawberry syrup, ice cream, applesauce, frozen juice concentrates (orange, grape, lemonade), chocolate pudding, regular or frozen yogurt, and jelly. Other suggestions are to have the child eat peanut butter crackers before taking a medicine, eat part of a flavored ice popsicle before and after taking medications, or chew on ice chips before or after the dose. Be sure to tell parents that they need to check with the pharmacist to determine whether the medication can be taken with food. Return demonstration can be a useful adjunct to evaluate the ability of the parent or child to administer a drug or drugs in the desired fashion. Return demonstration is a desired teaching tool in many situations. Examples of such circumstances include the following: • Administering oral suspensions to infants and young children • Measuring small or exact dosages (e.g., when a syringe is needed to measure amounts) • Giving injectable, intravenous, gastrostomy, or nasogastric tube medications • Instilling ophthalmic drops or ointments or nasal sprays or drops • Using a metered-dose inhaler (MDI), spacers, or inhalation equipment • Ensuring that parents with limited cognitive abilities can safely administer medication to their children • Administering multiple medications to ensure that the correct dose of the correct medication is given (e.g., 3 mL of amoxicillin suspension and 1 mL of metoclopramide syrup and not the reverse)

establishing a medical home

Children with chronic diseases have unique health and psychosocial needs. The health care provider may give care to a child with a rare disease or disorder or be involved with the management of a child with a much more common chronic condition, such as asthma or cerebral palsy. Of note, an increasing number of primary care providers are involved in the specialty care of children with chronic conditions. Each child with a chronic illness deserves a medical home where they, as unique children and families, can receive comprehensive, culturally effective, community-based, family-centered coordinated health care (McAllister et al, 2009). The critical issue in health promotion and disease management for children with special health needs is to ensure an organized and coordinated approach to provide appropriate treatment for the child's specific chronic disease or condition and to ensure that the child's primary health care needs are met. The goal of the medical home should be to: (1) provide family-centered care; (2) provide clear, unbiased information about medical care, management, and community resources; (3) provide all-encompassing primary care that is available on an in-patient and outpatient basis 24 hours a day throughout the year; (4) provide care over an extended period of time that allows for transitions to adult care; (5) provide appropriate referrals to subspecialists and care coordination with the team; (6) maintain a record of pertinent information; (7) interact with educational systems including early intervention programs; and (8) provide developmentally appropriate and culturally competent counseling to ensure optimal outcomes (Medical Home Initiatives for Children With Special Needs Project Advisory Committee, 2008). Health care management for children with special health needs includes: (1) assessing their needs; (2) planning comprehensive health care to provide for physical and psychosocial needs; (3) facilitating and coordinating services; (4) following up and monitoring services given and the child's progress; and (5) empowering the child and family through education, counseling, and support. Addressing issues up front about quality of life should always be part of the assessment process in chronic pediatric illness management. Child and parent perceptions about quality of life issues, such as physical and emotional pain and discomfort, may not be the same as those held by the health care provider. Child, parent, and health care provider may each have different perceptions. It is vitally important to determine how the child and the parent feel —physically, emotionally, and socially—by listening to them and asking for their input, rather than assuming that all is going well based on outward appearances. Health care management of children with chronic disease is about empowering them to live their lives to the fullest potential. Providing quality care requires screening patients with chronic conditions who are at risk for other medical problems. For example, patients with Down syndrome have a 3% to 5% risk for hypothyroidism and should receive yearly screening for thyroid disease (AAP and Committee on Genetics, 2001). Prevention of further disability by ensuring that screening and clinical practice guidelines for chronic disease management are meticulously adhered to is a key component of the medical home. The level or type of involvement in the treatment and management of a child with a specific chronic disease may vary depending on the unique situation of the child and family and the health care provider's subspecialty training and education. Strategies related to fostering the child's psychosocial development should be addressed at each health care encounter. A holistic approach to care is a major tenet of the medical home model. Certain situations may require additional advocacy when children with special needs and their families are in a particularly vulnerable position (e.g., if the parent of a child with special needs loses his or her job or suffers significant illness or injury and cannot adequately provide for the child). Children with chronic conditions do well when family functioning is high and there is positive family adaptation. The philosophy underlying the medical home model is to provide for open communication between parents and providers and to advocate for effectively and efficiently coordinated health care services. Although chronic illnesses are diverse in their severity and effect on the child, certain issues are often common concerns for children with chronic conditions and their families and their health care management. By using a medical home model, members of the health care team can communicate about a variety of issues (Stille, 2009). They include the following: • The high cost of treatment—the potential need for financial assistance • Lack of, or difficulties and barriers in, acquiring health care insurance • Family lifestyle alterations that may be required of parents, siblings, or both, in caring for the child • The need to overcome system barriers that families may face navigating through the maze of agency paperwork • The need for supervised care by multiple health care providers and the frequent lack of coordination of services in providing continuity of care • Unpredictability of the condition and the potential for complications, frequent medical visits, hospitalizations, and death • The desire to be kept informed of their child's condition and progress • Treatments or procedures that may be embarrassing, painful, or time consuming • The developmental effect that chronic disease can have on a child, especially during adolescence and early adulthood (periods of increased vulnerability) • Longevity concerns—ability to live and function independently as an adult, including the need for career and vocational counseling • The level of knowledge parents need about the pharmacological management of pain and the disease process or other therapeutic treatments, including nutritional support for the at-home care of the child • The effect of stress on emotional and psychological well-being of the child and family members—parents or caregivers, siblings, and possibly the extended family support network • Acceptance by peers • Parental striving to successfully normalize their child's life by acknowledging the child's condition and its effect on family lifestyle while actively engaging in accommodations to focus on the child and not the condition • Dealing with feelings (e.g., anger, sorrow) while attempting to cope with chronic illness • Developing advocacy skills for these children to access services through schools, state and community agencies, or special federally sponsored programs • • Securing special illness-related equipment (e.g., movement and mobility aids, such as walkers, wheelchairs, or braces) or acquiring communication aids, such as hearing aids or special computers with voices Finding respite care or transitional care for the dependent adult child • Legal conservatory issues and the concern about who will care for the child as an adult when parents are no longer capable of providing physical care or are deceased Pediatric health care settings should work to establish a medical home with a multidisciplinary team model and care coordination. These teams offer the expertise of many individuals in a united approach. In ideal situations the involvement of a clinical social worker, a community health nurse, or a nurse case manager is important to secure essential community resources for the child and family. Parents or guardians are a crucial part of the team. All team members must remember to respect the knowledge that parents or caregivers have about their child, their child's condition, and how the child is likely to respond physically and emotionally to new therapeutic interventions or treatments, situational changes, or exacerbations of illnesses. Other principles coming out of the medical home model are to: • Develop a database for CSHCN who require additional contact time outside of the typical scheduled time frame for either sick or well visits and be sure to flag their charts. An electronic medical record system may provide a function for this. This will help in scheduling additional visit time and alert the office staff when scheduling visits. • Designate a care coordinator for each special care needs patient and train the staff about the medical home concept.

referrals and consultative services

On many occasions primary care providers identify clinical or behavioral problems that they are uncomfortable with or unprepared to manage. In these instances patients should be referred to other providers for assessment and management. In other situations the primary care provider may wish to continue to manage the patient's care but seek consultation with other experts in the field about particular aspects of the case. Whether the primary care provider refers the patient and family to, or consults with, another health care expert, certain information must be shared with the referral or consultant provider in an organized, logical fashion. Guidelines for presenting this information are as follows: • Give the patient's name, age, tentative or actual diagnosis, and what you want the consultant to do (e.g., "newly diagnosed type 1 DM; needs initial insulin control and diet recommendations"). • In a sentence or two briefly discuss why the patient or family is being referred or the reason that a consultation is being requested. • Give a synopsis of the patient's history, clinical findings, prior management plan, and outcome of treatment if applicable. • Identify any pertinent past medical history, such as chronic illnesses or conditions. • Provide pertinent family, educational, or social information, including insurance coverage if this is problematic. If the primary care provider is referring the patient for problem-focused care, this should be made clear to the referral provider. In addition, the primary care provider and the referral specialist must coordinate their services, being clear on who is responsible for which services (e.g., follow-up testing, monitoring, and treatments); clear communication and shared information between the two providers is essential. The primary care provider should maintain a listing of specialty providers in the local area who take referrals from the primary care provider's work setting. If the provider is employed in a large health maintenance organization, there should be a list of pediatric specialty providers within the organization. The child's insurance coverage is often a major factor in referral, and often prior authorization from an insurance carrier is needed for a referral. Important information to gather about specialty providers includes their specialty or subspecialty practice area, evaluation of their effectiveness (can be an informal notation, such as "great resource person"), and, if applicable, their fees for service (e.g., full fee or sliding scale) and which insurance plans will reimburse for their services. Whether consulting formally or informally with another provider about the care of a particular patient, the primary care provider should present information about the patient, as listed previously, and discuss potential management options. At the end of the consultation, the primary care provider should summarize in the patient's chart the key areas that were discussed and the recommendations that were agreed on. Often overlooked sources of free consultation are state and local public health departments or agencies, health-related professional organizations, and some major medical centers that provide telephone consultation for providers in their service area. Again a notation should be placed in the child's chart if the case is discussed with a consultant in such an agency. Connecting with colleagues on the Internet is another option. Real-time chat sessions and e-mail exchanges are possible sources of consultation; however, information secured from unknown sources or not documented or referenced should be verified for accuracy. When a patient is referred to another provider, the primary care provider must explain the reason for the referral to the child and parent, how the transfer of care will be managed, and when the patient is to return to see the primary care provider. The information should be presented in such a manner as to dispel fears of abandonment or giving up. The bond between the child, the parent, and the primary care provider is a strong relationship that individuals rely on. If the primary care provider plans to seek a consultation, the child and parent should be informed by explaining the need for a second opinion or the desire to collaborate with others to ensure that nothing has been missed. After the consultation parents should be informed about what was decided. Finally, the parent may seek consultation with another health care provider. If so, treat this as the parent's need to collaborate in the child's care and listen to the recommendation by this consultant. Be sure that the consultant's reports are filed in the child's chart.

referral to national and local organizations and resources for chronic medical issues

Parents and their children with specific disease entities or health conditions can benefit from the educational materials, resources, and support that national health organizations provide. Learning to live with a chronic disease or handicapping condition presents a special challenge to families. Most national organizations provide written materials that parents and children can easily understand about the cause, management, and treatment of the particular disease in question. These materials also help parents explain their child's condition to teachers and others. Many of these national organizations can guide parents and children to support groups with other families and children who are similarly challenged and to health professionals and other related groups who specialize in the treatment of a particular disease entity. Likewise these organizations can assist parents in accessing unique services to benefit their children (e.g., enrolling in special camps and sports activities, learning about the various legal rights of children with disabilities or handicapping conditions, and acquiring special adaptive equipment). Many national and local health organizations and foundations provide educational materials and valuable information designed for health professionals about a variety of subjects related to their target population of children. For children with rare disorders, the National Organization for Rare Disorders (NORD) may be able to assist parents and offer information about the child's condition or disease (www.raredisease.org). Often these national organizations can provide up-to-date information about new treatment modalities or management strategies. Health care providers should take advantage of the services that these organizations offer. In addition, every clinical or practice setting should have a listing of local community resources. One can make up a personal local resource guide and keep this information along with a listing of national organizations.

patient education and prevention

Primary care providers' effectiveness is enhanced by their ability to educate children and their families about the prevention of disease and the management of common acute illnesses. The patient-parent educational component of the management plan must be individualized and include the following essential points: • Information about the length of time it can take before the child improves and symptoms wane; description of what the course of the disease or illness is likely to be and signs of improvement • Written information about specific signs and symptoms that indicate worsening of the illness, the need for immediate medical attention or for a return visit sooner than planned (e.g., a newborn with a fever of 100.4° F [38° C]; a child with severe lethargy, tender abdomen, labored breathing, stiff neck, bluish lips, purple "dots" on the skin, severe pain, inability to walk, or fever greater than 104° F [40° C]) • Specific, written instructions about when to return for any necessary follow-up or when to be available for a scheduled telephone conference. With electronic medical records, a recall system should be set up to ensure successful follow-up is completed. If the electronic medical record does not allow for a recall, a clinic tickler file is particularly useful for tracking patients whose diagnostic studies or follow-up appointments are crucial to successful management or treatment. This tickler file can be a simple card ile, divided by months. For example, a card would list the patient's name, date, clinic number, medical problem, and contact information and be placed in the file in the month when follow-up is needed. • Written instructions using key concepts of health literacy to make sure that families truly understand special treatment or therapy, how to use adaptive devices, and how to perform home monitoring tests (see Health Literacy later in this chapter) • Careful instructions about the proper dosing of medication, the potential for the need to switch medications during treatment, and the side effects of both prescription and over-the-counter (OTC) drugs (see Appendix A and Pharmacological Agents and Patient Education later in this chapter) • Issues related to administration of medications at school. All appropriate forms must be completed and school personnel instructed on key issues related to pharmacological therapy. • Specific information about any dietary needs or changes, special hydration needs (i.e., electrolyte solutions or increase in fluid intake), plus any changes in eating patterns that can be expected • The rationale for and procedures involved with diagnostic testing, including laboratory (e.g., blood, urine, or cerebrospinal fluid [CSF] cultures; skin testing; antibody titers; or rapid antigen testing for preliminary diagnosis), radiographic, or imaging tests and the meaning of results • Estimations of the length of time or time frame before laboratory or imaging results are available, especially when there will be long waiting periods (these are particularly frustrating for parents) • Information about the cause, if known, and epidemiology of infectious or noninfectious illnesses or medical conditions, communicability issues, and prevention guidelines, if applicable • Information about prevention and recurrence risk • Determination of impediments that prevent the parent or child from complying with the management plan (e.g., limited financial resources, inability to read, dysfunctional family, transportation problems) and discussion about steps to correct these difficulties • Recognition and discussion of cultural practices and beliefs about illnesses. Discuss the potential benefit or harm from specific folk medicine or complementary and alternative medicine (CAM) practices (including herbal, dietary supplements, or botanical preparations) if used either alone or concurrently with prescribed or OTC medications. • Information for the working parent about resources for sick care in the community that are convenient (accessible) and affordable When discussing the management plan with parent(s) and/or child, sit down and make eye contact with them. It is a sign of respect and should be a standard of care. The parents' or caregivers' understanding of instructions should always be assessed by asking them to repeat what they have been told. By doing this any misunderstandings can be addressed. One of the ways to obtain this feedback is by using the three questions in the "Ask me three" plan (Abrams et al, 2009; Partnership for Clear Health Communication, 2010): • "What is my main problem?" • "What do I need to do?" • "Why is it important for me to do this?" It is important to allow time for the body's natural defense system to fight disease. Premature and excessive pharmacological therapy can result in needless iatrogenic disease and resistance to antimicrobial agents and often confuses the clinical picture. The drug of first choice—the one that is least harmful—should be given time to work. Prematurely changing to a new drug, adding additional drugs, and using more toxic drugs are dangerous practices and can decrease confidence in the provider (Ledford et al, 2010). For the most part, parents are alert to subtle changes in their children, so it is important to listen attentively when parents voice their concerns. A sick child who is medically considered high risk due to physical or social problems merits closer observation and follow-up than does the average thriving child who becomes ill. If the child returns and is not significantly improved or is more symptomatic, the initial evaluation and diagnosis should be revisited by carefully analyzing the symptoms, investigating problems related to compliance or adherence, repeating the physical examination, reviewing likely differential diagnoses, and confirming the diagnosis before deciding on another management plan. Be sure to have the family's current or contact telephone number in case a telephone contact needs to be made regarding the results of diagnostic tests that come back or to monitor the course of the child's condition. The number of infants and young children in group daycare is expanding as the number of women in the workforce increases. This phenomenon creates several issues: • The disease pattern in this cohort of children is often related to group exposure to illnesses. • The issue of multiple caregivers can complicate history taking. It is critical to get as much information as possible from as many sources. When the person bringing the child is not the caregiver, the provider should use the phone to communicate with the actual caregiver. • Sometimes parents express feelings of guilt because they must work and their child is exposed to various communicable illnesses at daycare. Simply explaining that children do get sick during childhood may help relieve stress for parents. With the diversity of dialects spoken in the United States, language issues can be barriers to providing optimal health care. If a practice setting does not have access to an interpreter or native speaker, interpreter services can sometimes be obtained from local telephone services. It is important that both the health care provider and the parent or caretaker can communicate with and understand each other (see Chapter 3). Emergency department (ED) visits are often used for the treatment of minor illnesses by families without insurance or by those whose employment precludes visits to a primary care provider during regular clinic or office hours. Data about ED visits in 2007 revealed that 18.6% of children younger than 15 years of age went to pediatric EDs with the most common reason being fever, cough, and vomiting. There were 121 per 10,000 visits for asthma in children younger than 5 years of age (Niska et al, 2010). Health care providers working in EDs must adhere to illness assessment and management protocols and provide critical documentation outlining their physical examination and diagnostic findings, assessment, and management strategies, including education and needed follow-up.

fever in children

common phenomenon seen in children and is a complex systematic inflammatory response that involves modification of the body's thermoregulatory center (hypothalamus) set point. patho: a result of an alteration in the thermoregulatory center of the preoptic nuclei of the anterior hypothalamus. group of neurons maintain the body temperature, sensitive to cytokine- mediated responses and acute phase reactants, toxins and products of viral or bacterial metabolism. Antigen-antibody complexes and complement components- pyrogens, causing monocytes to activate to become macrophages and other inflammatory cells to release cytokines. Cytokines (critical factor in fever, inflammatory response) release prostaglandin E that raises the thermoregulatory set point. heat production is caused by increased cellular metabolism, involuntary shivering, autonomic responses- vasoconstriction, and behavioral responses- covering oneself. differential diagnosis: infectious and noninfectious cause. viral infections are responsible for most children's. others: bacterial infection, malignancy, reaction to immunizations, and connective tissue disease. Body temperature and measurement of temperature varies, done in several ways. pediatric sources define fever as- a rectal temperature higher than 100.4° F (38° C). Rectal temperature gold standard unless it is contraindicated. more closely approximates body core temperature readings vs. axillary, oral, temporal, tympanic. poorest correlation with core temperature is the axillary method (ranging in error 27.8%-33%). Axillary are recommended in the neonatal period but after this period, the method is not effective, influenced by sweating. oral temperature is more comfortable for 5 years/older and is more accurate than axillary. The results are slower and influenced by tachypnea, hot and cold drinks, exercise, mouth breathing, and thermometer position. tympanic membrane and hypothalamus share the same blood supply from the internal and external carotid arteries, the reading can be affected by poor positioning, cerumen, and otitis media. thermometer tip not securely fitted in the canal, the reading measures the temperature of the ear canal, skin, or cerumen. proper use the reading is rapid, clean, convenient, and risk-free. The newest method, temporal artery route, more studies needed to confirm its accuracy. controversial in children less than 36 months. Physiologically: child's heart rate increases 10 to 15bpm and respiratory rate 3-5bpmfor each elevation of degree centigrade (C). There is a normal diurnal variation- low point between 4 and 8 am and a peak later in the day at 4 to 6 pm. Body temperature also varies by age (younger infants higher temperature), gender, physical activity, and surrounding air temperature. Environmental conditions (swaddling) may produce transient elevated temperatures, necessary to take several readings to verify whether an elevated temperature is due to an environmental or a pathological cause. can be related to an infection but clinical appearance is more accurate way to evaluate a child. Parents with "fever phobia"- need reassurance, may believe that temperatures cause brain damage or, if not treated, will go higher. Cellular damage occur more than 105.8° to 107.6° F (41° to 42° C). Fevers less than 105.8° F (41° C), not associated with brain damage. except for temperatures more than 104° F (40° C), fevers are a body defense mechanism. beneficial effect by enhancing immunological responses-increasing phagocytosis and leukocyte migration, and interfering with viral replication and virulence of some microbes. adverse effects: increased metabolic rate with associated fluid loss, oxygen consumption, and increased caloric needs. can precipitate seizures in up to 5% of susceptible infants and young children. associated symptoms of headache, malaise, anorexia, and irritability are uncomfortable for the child, but overall state of the child is determined by complete history and physical and follow up. treat fevers depending on severity or to provide comfort. Parental concern can be a factor in using an antipyretic. suppressing a fever can also assist in clinical decision-making if irritability, tachypnea, and tachycardia a/w a fever resolve after administration of an antipyretic. However, response to antipyretics are not sole criterion to decide whether patient is bacteremic. Many treat fever to provide comfort to a child and use pharmacological agents when a temperature exceeds 101° F (38.3° C). Some use temp greater than 101.5° F (38.6° C) as their guide. overall appearance determines management. A reduction in fever after antipyretic not the deciding factor of whether a child is sick. clinical appearance of the child after fever reduction is the guiding factor. benign illness and a high fever usually is better (i.e., does not appear as ill), child with serious infection will still appear ill. Since the pneumococcal vaccine, risk of pneumococcal bacteremia has been greatly reduced, particularly in the child from 3 to 36 months- use of a CBC and blood culture in this age group is less likely to reveal information about the cause. *urine cultures should be considered in less than 6mths age, uncircumcised males less than 12mths, and all females less than 24mths with fever of greater than 101° F (38.3° C) for more than 2 days w/o source.

chap 23 fever unknown origin

definition in children is: (1) fever (rectal temperature greater than 101° F [38.3° C] or oral temperature greater than 100° F [37.8° C]) for 2 to 3 weeks or more without an etiology, that includes 3 weeks of outpatient visits, extensive studies, and continued fevers (and) (2) no etiology after 1 week in the hospital. FUO requires provider frequently rethink/reevaluate historical, clinical, laboratory data. atypical presentations of common disorders, notably infections (account for more than one third of cases), or rheumatologic and connective tissue diseases (e.g., juvenile rheumatoid arthritis [JRA], SLE). Few are exotic. In the U.S., most diagnoses of FUO include mononucleosis, EBV, cat- scratch disease (B. henselae), complicated UTIs, and vertebral and pelvic osteomyelitis. Other causes: salmonellosis, TB, rickettsial diseases, syphilis, Lyme disease, prolonged viral infections, CMV, viral hepatitis, coccidioidomycosis, histoplasmosis, malaria, and toxoplasmosis. Less common: tularemia, brucellosis, rat-bite fever, leptospirosis, drug fever, Kawasaki disease, inflammatory bowel disease, and rheumatic fever. Neoplastic conditions and AIDS have symptoms other than just fever. more than 6 months have been reported in those with granulomatosis or autoimmune disease. In children less than 6 years of age, common causes- UTI/pyelonephritis, respiratory illnesses, localized infections (abscess, osteomyelitis), juvenile arthritis (JA), and, rarely, leukemia. In adolescents common causes- TB, inflammatory bowel disease, autoimmune disorders, lymphoma, and those listed for children less than 6 years of age. History: helps distinguish between recurrent fever episodes and those that need further evaluation as an FUO. Recurrent resolve with well periods between them, suggesting an etiology of multiple self- limiting infections. • Careful analysis of s/s, meticulous review of systems, history of the fever pattern, and patient's age. adolescent with low- grade fevers, or whose fever has resolved but who feels ill and is unable to attend school or social activities may have "fatigue of deconditioning" (see below). require the same careful medical evaluation, but rarely serious infection or medical condition. • Past medical history of recurrent infections, surgery, transfusions, and contact with ill individuals • Medication use, OTC and herbal/natural supplements • Family medical history, including autoimmune disease or inflammatory bowel disorder; genetic background • Family pets, pet immunization history, or exposure to wild or other domestic animals • Unusual dietary habits (eating squirrel, rabbit, or unusual animal meat) • History of pica; history of travel (location; travel immunizations; water/food ingested; if returned home with travel souvenirs containing dirt, rocks, or earth-contaminated artifacts) fatigue and deconditioning findings: • Age >12 years • Preillness achievement high (academic and social) • Family expectations high (performance) • Acute febrile illness with onset easily dated • Family and outside attention high • Multiple but vague complaints • Odd complaints (10-second "shooting" pains at multiple sites; 30-second "blindness"; stereotypic, sporadic, brief unilateral tremors, jerks, or "paralysis" lasting <1 minute) • Tiredness, but no daytime sleep (or reversal of daytime and nighttime sleep) • Model of chronic illness in family, recent loss of important person, change in family dynamics • Unusual cooperation and interest during interview and examination (unusual fearfulness and dependency on parent) • Preserved or increased weight • Normal physical and neurologic examination • Normal results of screening laboratory tests Clinical Findings: Physical Examination Special attention to these areas: • Skin: Presence of rashes, lesions, nailfold capillary abnormalities; presence or absence of sweating • Mouth: Note a smooth tongue with absence of fungiform papillae; presence of candidiasis • Throat: Exudate, erythema • Local or generalized lymphadenopathy or hepatosplenomegaly • Joint examination, and palpation of bones for tenderness, swelling • Palpation/percussion of sinus and mastoid areas for tenderness; tap upper teeth • Eye examination noting exudate, palpebral or bulbar conjunctivitis, conjunctival hemorrhages, papillary reaction; ophthalmologic examination fully evaluate for uveitis, chorioretinitis, proptosis • Pelvic examination in adolescent females • Rectal examination and guaiac test • Deep tendon reflexes Laboratory Studies: dependent on a history and physical examination, point to a specific infection or area of suspicion. Studies include: • CBC with differential, ESR (>30 mm/hr needs further evaluation) or CRP (no need for both) • Serologic tests for specific diseases as suggested by history and examination • Blood cultures obtained aerobically (may require serial specimens to rule out different diseases) • Urinalysis plus blood and urine cultures • Mantoux skin test • Chest, sinus, mastoid, and gastrointestinal tract radiographs may be indicated. • Liver chemistries • Serum protein analysis • Heterophil antibody and antinuclear antibody titer in older children Other tests: bone marrow, radionuclide scans, total body CT, MRI, echograms, ultrasounds, or biopsies. Differential Diagnosis: Infectious diseases, collagen-vascular disease (JA, SLE), malignancies, drug fever (ingestion of phenothiazines, antidepressants, atropine, amphetamine, and other anticholinergic medications), nosocomial, HIV-associated illnesses, diabetes insipidus, hyperthyroidism, inflammatory bowel disease, hematoma in a confined space, anhidrotic ectodermal dysplasia, and Münchausen syndrome by proxy. Management: Consider hospitalizing if evidence of systemic illness or failure to thrive, very young, parent(s) anxiety is extreme. Otherwise, should followed up with frequent visits, documented fever pattern, and other specialized tests if screening tests indicate the need or if other physical findings develop. Empiric use of antibiotics should be avoided unless possible disseminated TB.

indicators for assessing severity of illness in peds patients and scoring guide

1. Level of consciousness or quality of cry • Strong cry with normal tone or content and not crying (NL) • Whimpering or sobbing (MI) • Weak or moaning or high pitched cry (SI) 2. Hydration • Skin normal; eyes and mouth moist (NL) • Skin and eyes normal and mouth slightly dry (MI) • Skin doughy or tented and eyes may be sunken; dry eyes and mouth (SI) 3. Color • Pink (NL) • Pale hands, feet, or acrocyanosis (MI) • Pale or blue or ashen gray or mottled (SI) 4. Respiratory status • Normal • Nasal flaring, tachypnea, oxygen saturation of ≤95%, crackles (MI) • Grunting, tachypnea with more than 60 breaths/minute, moderate or severe chest in- drawing (SI) 5. Reaction to stimulation by parent or health care provider (HCP)—how a crying child reacts when held, patted on back, jiggled on lap, or carried • Strong cry and normal tone or content and not crying (NL) • Crying on and off (MI) • Cries continuously or minimal response (SI) 6. Sleep-to-awake or awake-to-sleep state • If awake then stays awake or, if asleep and stimulated, wakens quickly (NL) • Eyes close briefly then awakens or awakens but needs prolonged stimulation (MI) • Not able to arouse or falls to sleep (SI) 7. Response to social cues (being held, kissed, hugged, touched, quietly talked to, or comforted)—for infants 2 months or less use alert ratings • Smiles or alerts (NL) • Either briefly smiles or alerts to cue (MI) • No smile, face anxious, dull look, expressionless, • No smile, face anxious, dull look, expressionless, or no alerting (SI) MI, Moderately impaired; NL, normal; SI, severely impaired.

antipyretics infants and children 12 or younger

Acetaminophen: 10 to 15 mg/kg every 4 to 6 hours PO (not to exceed 5 doses/24 hr); or 10 to 20 mg/kg every 4 to 6 hours per rectal suppository as needed Temperature reduced by 1.8° to 3.6° F (1° to 2° C) within 2 hours; 15 mg/kg/dose as effective as ibuprofen at 10 mg/kg/dose; *drug of choice Ibuprofen: For temperatures <102.5° F (39° C): 5 mg/kg/dose every 6 to 8 hours as needed For temperatures ≥102.5° F (39° C): 10 mg/kg/dose every 6 to 8 hours as needed Use in children 6 months to 12 years; maximum daily dose of 40 mg/kg; temperature stays lower for a longer period of time with ibuprofen vs. acetaminophen. Use with caution if decreased liver function, asthma, or coagulation disorder. Educate: goal of antipyretics is to make the child more comfortable. Acetaminophen and ibuprofen work in the same manner by inhibiting prostaglandin synthesis without affecting the baseline body temperature. Alternating these antipyretics remains a controversial. Because of the lack of clinical evidence and the risk of overdosing, the practice of alternating these drugs is not recommended and is not endorsed by the AAP.

telephone manage,eat of illness telephone triage systems

All primary care providers should ensure that their practice settings have a standardized approach to telephone triage. Triage protocols classify problems into one of several categories. These include life-threatening, emergent, urgent, nonurgent, recurrent, or mildly ill. Protocols may vary slightly, but the major aim is to provide safe advice while avoiding unnecessary visits to an urgent care center or ED. Protocols may use a standardized algorithm in order to obtain history, leading to a patient disposition to manage specific health concerns (Black, 2007). Several excellent resources address telephone triage management of illnesses in children (Briggs, 2006; Poole, 2003; Schmitt, 2010). Telephone triage can also be called telehealth, telephone advice services, telephone consultations, or telenursing. Many insurance companies offer telephone triage services as part of the benefits to the insured to avoid unnecessary ED visits. Patients have reported satisfaction with nurse- run telephone advice services (Mayo et al, 2002), and the safety of such advice using protocols has been documented in the literature (Kempe et al, 2006). A major benefit of telephone triage is to provide convenient access to health care professionals and health care advice. Management-by-telephone protocol in an individual practice setting should accomplish the following objectives: • Allow the telephone triage person to manage ill-child calls safely; prevent harmful triage or recommendations. • Provide a standard of care. • Prevent omissions resulting from forgetfulness or fatigue. • Improve quality of care. The method of interaction, screening questions to ask, expressing concern, and reflective listening are all important points. The individual doing the telephone triage must be receptive to the parent's call, stressing that the call is as important to the provider as it is to the parent. Parents can be anxious and find it difficult to calmly state the problem. Additionally, the triage person needs to be a perceptive, conscientious, and calm individual who carefully listens to the caller; asks questions as dictated by protocol and by judgment; processes the information; determines the correct management protocol to use for a particular situation; gives the necessary instructions to parents; offers comfort and understanding to help the parent manage the illness; and documents the encounter. In addition, all these activities must be performed in a relatively short period of time.

assessment HnP

Careful attention must be given when analyzing the signs and symptoms of a child's illness, including the presentation of clinical findings, the course of the disease process, and its associated manifestations. A clear history of the illness is essential and requires a comprehensive description of any symptom or sign of illness. The physical examination is often a challenge when a young child is ill and uncooperative. Patience is important when examining children who are sick. The sick child should be carefully assessed so that significant physical findings are not missed during a hurried or cursory examination. The parts of the physical examination that are especially bothersome or frightening to a child, based on either historical information, observation, or age factors, should be performed last. Often examining the child on the parent's lap can be helpful in these situations. Repeating parts of the examination or observational reassessment is sometimes useful (e.g., after a febrile child is given acetaminophen and the fever abates). To help assess the severity of illness in infants and young children, careful attention must be given to judging key indicators during the history and the physical examination (Box 21-2). These indicators are an important part of the assessment and judgment when determining management, and include level of consciousness, hydration, color, respiratory status reaction to stimulation, sleep-to-awake or awake-to-sleep state, and response to social cues. The child should be noted to have either a normal (NL), moderately impaired (MI), or severely impaired (SI) response in each of the key areas (McCarthy, 2007; National Institute for Health and Clinical Excellence, 2007).

management acute illness

Chapter 23 identifies specific infectious diseases and assessment criteria for illnesses or problems commonly seen in childhood. It also discusses an overall assessment and management plan for sick, febrile children. In general, with infectious diseases, the age of a child is a significant factor to consider when doing an assessment and creating a management plan. The immune response in infants from birth to 90 days old, for example, is particularly poor because of their immature immune system. Infants and young children are at increased risk for overwhelming bacteremia with any infection. Management of an ill child can include a short stay in an outpatient clinic, private office, or emergency or urgent care department for intravenous hydration, pulmonary therapy, medication, and/or close observation. The neonate between 0 and 28 days is generally hospitalized when the fever is greater than 100.4° F (38° C) because the physical examination cannot always predict serious bacterial infection at this age. Between 1 and 2 months admission depends on the results of diagnostic studies and whether the infant can be adequately followed up within 24 hours (Ishimine, 2007). Administration of ceftriaxone can be considered in these patients on a case-by-case basis. After 2 to 3 months of age and before 3 years of age, admission again depends on history, symptomatology, and laboratory results (e.g., an abnormal chest x-ray). Typically children in this age group have more frequent outpatient management and close follow-up than younger children. Before sending an ill infant or child home from the office (rather than admitting the child to the hospital), the provider must carefully assess the parent's ability to cope with a significantly ill child and recognize signs and symptoms of worsening illness. The plan of care following a sick visit is organized according to diagnostic studies, medications prescribed, education, follow-up, and referrals. Each visit plan needs to consider the patient's or parent's desires, the most appropriate, if any, diagnostic test needed to evaluate the presenting problem, the follow-up needed, and whether referral is needed.

diagnostic studies labs

Chapter 26 contains a detailed discussion of the complete blood count (CBC) and provides insight as to the information that can be gained from a CBC, in addition to indications for ordering this basic laboratory study. discusses the laboratory workup for young children with a fever of undetermined origin. All disease entities or conditions addressed in this text include information about diagnostic studies and laboratory tests. Diagnostic studies and tests can be valuable, but it should be remembered that no diagnostic test is 100% sensitive and specific. False positives and false negatives occur; therefore, these tests are only one part of the entire database. Tests should be ordered only when the results are necessary to guide clinical decision-making.

documentation of telephone calls

Documentation of telephone triage calls and their disposition is an important element in a successful system for managing telephone calls for sick children. A documentation system may be part of the EMR, be a separate log, or a sticky label that is included in the patient's medical record. Written or electronic documentation accurately records the information so that other providers know about a child's problem. Such documentation also ensures a medicolegal defense; a method to review medical records for quality improvement and assurance purposes; an avenue to assist in complaint resolution if parents are upset about the advice given to them; and a tool to use when making follow-up calls to the family. Important items to include in any telephone log are: • Date and time • Patient data—name, age, sex, telephone number—and history of chronic disease or condition • List of medications and their dosage if prescribed by the health care providers • The chief complaint and a brief list of symptoms and signs, including their duration and frequency • Documentation of sleeping pattern; activity level, appetite; and bowel and bladder elimination • Diagnosis or working assessment • Triage category (life-threatening, emergent, etc.) • Instructions given about follow-up • An "other" section for any additional comments that are deemed important information When using telephone protocols in a practice setting, training is essential and ensures consistency in the use of the system. Staff sessions, designed to review the written or electronic documentation, are also useful teaching tools and should be encouraged. Perhaps the most important point to emphasize about the use of any telephone management system is the need to assess the comfort of the parent with the advice given. Parents should be asked at the end of the telephone contact whether they are comfortable with the advice and plan. If the parent is not satisfied or is uneasy about the plan, primary care provider consultation should be an option. Finally, parents should be told to call back if their child's condition worsens or the problem persists too long.

parent and child education

Education should be directed to the guardian and/or parent as well as the child. The families' ability to understand the health plan needs to be considered in designing educational strategies. The severity of the illness or disease and the child's age, maturity, and cognitive level are key factors that determine the child's degree of involvement in self-care activities related to acute illness and chronic disease management. Children should be taught basic health promotion and disease prevention behaviors (e.g., handwashing) from early childhood. Likewise they should be involved in the management of their illness to the fullest extent possible considering their developmental capabilities. Children should be consulted regarding their responsibilities for self-care. The pediatric provider also might be called on to be a liaison with school district personnel about the child's illness or medical condition in order to optimize the child's educational and social experience at school.

family centered cared

Family-centered care is a key concept that should be used to empower the family. Parents who have infants and young children with chronic conditions should be viewed as therapeutic partners in the management plan. Communications with parents should be open and honest. They should be treated with respect and dignity and allowed to vent their emotions and to use coping mechanisms that work for them. Likewise as the older child and adolescent mature, their partnership role emerges. Relapses in adherence behavior are problematic but not unusual in situations involving complex treatment plans. Problems of adherence to the management plan can lead to serious medical complications, increased rates of hospitalization, greater length of hospital stay, and increased health care costs. Therefore, the provider should explore with parents and children what can help them become more adherent using motivational interviewing (Schwartz, 2010; Suarez and Mullins, 2008). Box 21-1 outlines categories and key factors to consider when addressing concerns about adherence. Training in motivational interviewing, in which the interviewer seeks to ascertain the individual's level of readiness to change, is a promising technique to use in situations of less than optimal adherence. The key tenets of motivational interviewing are to establish and express empathy; to provide the choice to change or not; to work with patients and families to identify their own personal treatment goals; to work with resistance; to assist in the removal of barriers to change; to provide eedback; and to advocate for the development of patient self-efficacy.

determining a differential diagnosis

Following the history and physical examination, possible diagnoses need to be generated. The management plan will be the direct result of the working diagnosis and the differential. Diagnostic errors are more common than realized. Elstein (2009) estimated diagnostic error at 15%; Berner and Graber's 2008 review of diagnostic error rate for specific conditions was 10% to 69%. They concluded that the rate of diagnostic error is unacceptably high (Berner and Graber, 2008). The Harvard Medical Practice Study reported a rate of diagnostic error of 17% after reviewing 30,195 records (Leape et al, 1991). It is imperative that providers consider all possibilities to avoid reaching a premature conclusion. Diagnostic errors remain a leading cause of malpractice claims (Berner and Graber, 2008). With increasing time constraints in clinical practice, difficulty in keeping track of patients in large group practices, and the development of the full clinical picture that may only become evident over time, it is important to use every available resource to elucidate difficult diagnoses. Strategies to assist health care providers in overcoming diagnostic errors include improving education, practice, and training and getting feedback on diagnostic errors (Berner and Graber, 2008). Whereas a complete review of the various methods to reduce error is outside the scope of this chapter, an essential point to remember is that reflective practice leads to improvement over time. On a systems level, consulting with or referring difficult patients to a more experienced health care provider or using a computerized diagnostic decision support may be helpful. Data suggest that computerized diagnostic systems may give useful suggestions providing that all symptoms are entered correctly into the database. Internet-based decision support systems, such as DXplain, Gideon, Isabel, Lifecom, and VisualDx, allow providers to consider a wider variety of differential diagnoses and formulate an appropriate plan. Diagnostic decision support systems do not make a diagnosis but provide differentials based on age, gender, geographic area, symptoms, and signs.

emotional support

Helping parents and children more effectively handle the emotional stress associated with a chronic illness and condition is a major focus of care. Key points to be cognizant of include: • The time of diagnosis and periods of exacerbations of illness are viewed as times of crisis and added stress. Chronic sorrow is a phenomenon that involves feelings of sadness, anger, guilt, or failure. Parents of a child with a chronic condition may experience these feelings at various times during their child's life. The term was coined by Olshansky in the 1960s to describe cyclical, recurring feelings of sadness during one's lifetime that are of differing degrees of intensity. It involves grieving without finality. It is not pathological and does not occur uniformly within families (Hobdell, 2004; Roos, 2002; Shepard and Mahon, 2002). • Developing a trusting relationship with these children and their families involves being respectful and accepting of their varied emotional needs. • Engaging parents and their children in the treatment plan is a major and essential task (see Shared Decision-Making earlier). Self-management of their disease whenever possible empowers the child, parents, or both. • Research has demonstrated that more paternal involvement in illness-related support is associated with better family and maternal outcomes in families of children with chronic illness; hence in a two- parent household, participation by both parents in their child's care and health care visits should be encouraged (Gavin and Wysocki, 2006). • Partial or poor adherence to complex treatment regimens should be addressed. Motivational interviewing techniques can be a useful tool. Nonadherence issues should be dealt with in a collaborative, "blame-free" problem-solving approach. • Parents of children with chronic diseases are more likely to think about using, or are using, CAM practices. Respecting their reaching out for additional treatments is important. However, it is not common for parents to reveal this to their conventional pediatric providers, so it is important that the health care provider ask about such practices. Some of these treatments may be harmful or ineffective. (See Chapter 42 for a full discussion on engaging the parents in a discussion about CAM, for being an advocate for the patient, and for becoming a collaborative agent with the family.)

key factors that affect treatment adherence in children and adolescents with acute or chronic diseases.

Illness • Severity of the illness and its predictability • Length of illness and prognosis • Effect of illness on functional and social activities of daily living Management • Complexity of treatment plan • Length of time for each treatment, how often, and for what length of time treatments must continue • Visibility of assistive equipment Family • Support network and size of family • Financial resources; knowledge base and the understanding of illness or condition; overall cognitive skills; communication style • Coping ability and skills; problem-solving skills • Family's belief system and spiritual base Patient • Age • Cognitive, social, and emotional level of development; temperament • Peer group; coping ability healthcare provider and environment • Communication style of health care providers with child, family, and other health care providers; belief in patient empowerment • Organization of clinic or office setting to be child-, teen-, and family-friendly; need for adaptive modifications in their environment • Number of health care providers involved in the child's care; team member collaboration and partnership among themselves and with the family • Open and "blame-free" approach when adherence issues arise an opportunity to interact with others who have experienced many of the same challenges, difficulties, sorrows, and triumphs. The provider must address sibling issues and feelings, such as anger or embarrassment; a sense of being overwhelmed with added responsibilities; or believing they need to be the protector for their brother or sister. These groups can be face-to-face or Internet based depending on patient preferences.

safe prescription writing

In order to prescribe, the provider must take a history and conduct a physical examination as well as document the encounter. Prescriptions should be written in a manner that conveys accurate information to the pharmacist and the patient or parent. The following suggestions are made to ensure safe prescription writing for children (AAP, 2007; Taketomo et al, 2011): • Avoid the use of a terminal 0 to the right of the decimal point (e.g., use 5 rather than 5.0) because the decimal point might not be read correctly and result in 10 times the desired dose (e.g., 3.0 mL can be mistaken for 30 mL). • Place a leading 0 (zero) before fractions less than 1 (one). For example, write 0.3 mL rather than .3 mL, which can be confused with 3 mL if the decimal point is inadvertently missed. • Insert a space between the last number and its units (e.g., 15 mg, not 15mg). Do not place a period after mL or mg when writing a prescription. • Write out dosage units rather than using abbreviations (e.g., milligram or microgram rather than mg or μg) • Never use dangerous abbreviations, such as q.d. or qd (daily), qod (every other day), μg (microgram), or U or u (unit), which may be misinterpreted for q.i.d. or qid (4 times daily) or 0 (zero), respectively. Write out in full the words "daily" or "unit." The abbreviation O.D. means right eye; never use O.D. as an abbreviation for once daily. • Do not use abbreviated drug names such as MS or MTX. • Use the metric system only. • Write legibly. • Make sure that the patient's weight is correct in kilograms and that the weight-based dose does not exceed recommended adult dose. Check all calculations (AAP, 2007). • Make sure to specify exact dosage strength to be used. • Be specific with instructions (e.g., "take 2 tablets each night at bedtime"), avoiding vague instructions (e.g., "take as directed"). • Review the prescription with the parent and/or patient: name of the medication, the reason for its use, and direction for its use. Have the patient or parent repeat information back to you; a return demonstration (see Pharmacological Agents and Patient Education) may be appropriate. • Issue a complete prescription that contains all of the following: Patient's full name, age (date of birth), address, and weight (for infants and young children) Name of the drug, dosage, and strength Instructions if a brand name drug is to be used rather than the generic drug option Total amount or quantity (number of pills, milliliters of liquid) to be dispensed Route of administration (e.g., take by mouth, instill in both ears, insert in rectum, instill in right eye) General instructions to the patient or parent about indications for or the purpose of taking the medication, how frequently, and for how long (e.g., take three times a day until completed, take every 4 to 6 hours as needed for pain for 3 days). Consider writing the times of drug administration with the parents having their input as to times that would work into their schedule. Special instructions to the patient or parent about the drug (e.g., give with food, do not give with dairy products) or other instructions (e.g., translate to the primary language of the parent if English is not spoken or read) Number of refills Instructions to fill with a measuring device or other essential delivery devices (e.g., spacer or nebulizer for an aerosolized medication) The Institute for Safe Medication Practices (ISMP) website is an excellent source of information about error- prone abbreviations (www.ismp.org/Tools/errorproneabbreviations_pdf). In addition, some prescription plans or health care settings may require that a diagnosis and allergies to medication be listed on the prescription form. Do a SCRIPT analysis after you have written a prescription for any medication. This will help the provider review the pharmacological management plan and evaluate whether all five points have been considered and adequately covered. SCRIPT is a useful acronym to remember and stands for the following: • Side effects • Contraindications • Right medication, dosage, frequency, route, and duration • Pediatric considerations • Transmittal of all necessary information on the prescription Write the prescription only in the name of the child being seen. Depending on state law, a health care provider can be charged with a criminal act for writing a prescription in a person's name with insurance when the prescription is meant for someone without insurance (John, 2007). Writing for nonpatients—family and friends—or writing outside one's scope of practice could result in a sanction by the provider's licensing board and should not be done.

pharmacological agents and their use prescriptive authority for NP

Nurse practitioners (NPs) must be knowledgeable about the individual state regulations that govern their prescription-writing privileges. Some states do not use the term prescribe to identify what NPs do when writing medication prescriptions for patients. For example, in California the term furnish is used to describe this activity. The individual state board of registered nursing identifies the terminology to be used for this activity and regulates (either as a single state regulatory entity or jointly with medicine or pharmacology state boards) the activities and procedures related to this particular function. Regulations about prescriptive activity vary from state to state. NPs are legally obliged to follow all state regulations and mandates related to any prescriptive authority granted to them.

prevention of allergic and adverse reactions

Pediatric patients are at increased risk for adverse drug reactions for numerous reasons such as the need for individualized doses based on patient's age, weight, and clinical condition and changing pharmacokinetic parameters at various ages and stages of maturational development. Selecting the appropriate pharmacological agent to adequately treat an illness or condition and minimizing the risk of medication errors are important. Lists of current medications and dosages for prescription and OTC drugs, herbals, dietary supplements, and botanical preparations should be in a standard place in the patient's chart. Allergies to medications, with the identified adverse response, should be highlighted in a place that is easily visible. Advise the parents to have their child wear an Allergy Alert bracelet or necklace if they are subject to a life-threatening allergy (e.g., a severe peanut allergy).

educating parents about how to use the telephone and electronic management systems

Practice settings should have an electronic messaging or telephone call policy about sick calls and should acquaint parents with this policy. The policy should cover basic information about the office protocol for handling calls, requests for advice sent electronically about sick children, or other child-related concerns during office hours such as well-child questions, prescription refills, nighttime (after-hours) calls, and weekend and holiday calls. Who screens calls, when calls are returned (e.g., during the noon hour or from 4 to 5 pm), and after-hours coverage are points to cover in the policy. Likewise, a policy about staff's role in answering electronic messages should be in place. Parents should be encouraged to handle minor illnesses at home without unnecessary calling in for advice. Home instruction sheets for managing fevers (including dosage charts) and common childhood illnesses or books on common pediatric illnesses designed for parents are excellent resources to provide to parents (Schmitt, 2005). Pamphlets can be given to parents at anticipatory guidance visits. In addition, NAPNAP has several handouts that can be accessed from its website, and there is also a parent section on the AAP website, which is an excellent resource. During illness visits, parents should be told what to expect when their child is ill, preparing them for the increasing temperature, vomiting, or diarrhea, in addition to what to do if they occur. Parents need to know what type of situations require a call for emergency medical services or the poison control center. If sick care is necessary after scheduled office hours, parents will need to give the following information about their child: • The main symptoms • Any chronic disease or health problem • Temperature (and route it was taken) • Approximate weight • Names and dosages of current medications • Type of insurance coverage • Preferred name of pharmacy and phone number

Intro to disease management

Respiratory and gastrointestinal infections are the most common illnesses seen in pediatric practice settings and may present as minor or life-threatening acute illnesses (Smith, 2011). Noninfectious diseases can also present as acute or chronic conditions, such as those seen with inflammatory or allergic responses, trauma, malignancies, or autoimmune diseases. This chapter provides an overview of the care of the child with acute or chronic diseases, and moves into a general discussion on assessment, management, and educational approaches of that is consistent with pediatric standards of practice; this may involve telephone triaging. Two areas also deserve special consideration in pediatrics—fever and pain— because these problems can be a part of the clinical presentation.

acute disease and children

The health care provider begins management of an acute illness by getting a clear understanding of the presenting complaint and taking a complete history. The provider must always remember that these two elements, plus an accurate assessment, diagnosis, and successful management plan are contingent on the following six factors: 1. Careful observation of the child 2. Attention to pertinent positive and negative historical and physical findings 3. Knowledge of physiological functions and developmental considerations that vary by age 4. Consideration of the trajectory of the problem over time 5. Use of shared decision making (SDM) in the evaluation and management of the child. This concept is crucial for a successful interaction between the provider and family or child. It depends on input and feedback from the parents or caretakers and, if appropriate, the child. This resulting partnership takes into consideration culture, patient choices, social milieu, and specific patient needs, and, as a result, improves adherence to a management plan (Butz et al, 2007; Fiks et al, 2010) (see Shared Decision-Making). 6. Use of health literacy concepts. It should not be assumed that any medical term used by the parent means the same to providers. For example, a parent's definition of fever may be any temperature greater than 99° F (37.2° C), or wheezing to a parent may in fact be rhonchi. A parent who is told that the management needed for the child's problem is some "tincture of time" may go to the local pharmacy looking for that "medication." Feedback from the family and child needs to be obtained in order to ensure that there is understanding and agreement about the management plan and what was told to the parent about the diagnosis and etiology of the problem if known. When satisfied that these six parameters have been given adequate attention, an action or management plan is formed that is acceptable to the parent or guardian, child, and provider.

steps of an effective triage system

The major difficulty in providing telephone advice is the difficulty of accurately assessing a situation without visual input. The sequence of steps that one must go through in using telephone protocols includes the ability to do all of the following: • Collect data about the symptoms through open-ended and direct questioning. • Identify the problem or main symptom. • Develop a working assessment. • Decide on a triage category for the patient. • Select the correct protocol. • Correctly advise the patient about the course of action. Questions should be asked in an effort to narrow the problem clinically and to assist the parent to be clear and focused. In addition, questions should be clustered by area of concern, should move from most to least serious, and should follow a logical sequence based on initial data obtained. When using protocols, the nurse needs to make sure that each question is asked but can add additional questions if needed. Screening questions that should be asked of parents include the following: • Duration: How long has the problem been present? • Description: Tell me about the problem. What signs and symptoms are present? • Clinical changes: How has the child's behavior or activity level changed (e.g., eating, sleeping, playing, interaction with peers and family members)? • Appetite: Has there been a change in the child's drinking or eating habits? • Elimination: Has there been associated changes in bowel or bladder habits? • Sleep pattern: Has there been a change in the child's normal sleeping habits? • Environmental problems: Has there been any recent exposure, change, or stress in the child's environment? • Cause: What does the parent believe is contributing to or causing this condition? • Management: What has the parent done for the condition, and with what effect? • Feelings: Does the parent feel anxious about how the child is behaving? Keep in mind that protocols are a tool and should not override one's own professional judgment. If the provider feels that the patient needs to be seen despite what the telephone triage advice protocol states, then the patient should be seen. The provider's preference needs to be made clear to those triaging. If the office or clinic is not using a standardized telephone triage reference source (such as that by Schmitt as mentioned above), office protocols should be developed to ensure an effective telephone management system. Office protocols may be prewritten and should be regularly reviewed and modified by the physician or NP. There is also a wide variety of telephone triage programs that are Internet-based and will record the answers as the questions are asked. In the future, telephone advice may be supplemented by Internet webcam via programs like Skype that allow the patient to be viewed by the person giving the advice. Nonemergent calls to a practice about a sick child during the day are usually routed through a telephone receptionist, who can make an appointment, if appropriate, or transfer the call to a triage nurse or primary care provider, who in turn can determine the urgency of the need to see the child, give home care advice, or refer to the primary care provider for care. If home care advice is given, the triage person should use standards of care or telephone advice protocols discussed previously. It is extremely useful to have the triage notes automatically routed to the appropriate primary care provider so that the provider can be alert to any significant issues with the child (e.g., increasing calls indicating exacerbation and poor control of asthma). After-hours or call centers are another avenue that pediatric practices use for handling sick calls after office hours. These centers employ nurses and NPs who use telephone protocols to guide parents in the management of their child's illness until their regular health provider is available. Call centers alleviate the burden of night call and are set up to use telephone protocols and a software program for documentation. It is incumbent on the pediatric health care providers within their practice setting to evaluate whether such a center would effectively meet their standards of care for after-hours management of children.

health literacy

The population of the United States is changing with diverse cultures and languages (see Chapter 3). A cross- sectional study of U.S. parents showed that 28.7% had below-basic to basic health literacy (Yin et al, 2009). In order to deliver high-quality care for both acute and chronic care management that closes health disparity gaps, information must be developed for clients with low health literacy, often in languages other than English. Written instructions and easy-to-read handouts with simple illustrations are useful for parents, caregivers, and children. Simply giving oral or written instructions is not enough; the provider needs to make sure that the receiver understands them. In designing handouts, using plain, conversational language, simple words and short sentences without medical jargon increases comprehension. To obtain the reader's attention, fonts larger than 12 points with bullets, white space between sections to separate ideas, and drawings next to related text facilitate the understanding of the information (Miller, 2001; The Joint Commission, 2007). In addition, avoid using double negatives; consistent word usage avoids confusion, and a table of contents is useful for lengthy handouts (Miller, 2001). Whether a practice setting develops its own instruction sheets or uses information sheets from other resource texts, it is important that the instructions be written in the family's native language and at a reading level appropriate for the individual family. Several different tools assess reading level and ease of readability of material such as a patient handout (e.g., Fog Index, SMOG, Flesch-Kincaid Test). The best tool to estimate reading level is the SMOG, and a level no higher than fifth grade is best for patient materials (Wilson, 2009). A number of books written for the lay public are excellent resources to suggest to parents. The care providers should develop a list of appropriate books and websites to give to parents based on the literacy level and unique characteristics. Select books that offer guidance about common infections of childhood, preventive pediatrics, common behavioral problems, and other frequently encountered pediatric concerns. Each practice setting should have its own list of books and supply of handouts, brochures, pamphlets, and other printed resources to share with families in their practice. The Centers for Disease Control and Prevention (CDC) offers health education information through their "Ounce of Prevention Campaign" that addresses common pediatric infectious diseases and their prevention (www.cdc.gov/ounceofprevention).

shared decision-making

The shared decision-making partnership varies with different situations and requires different levels of involvement from the provider; the goal is to jointly make decisions consistent with the patient's wishes (Kon, 2010). Many parents are interested in helping to make decisions and want support and information in the evaluation of options (Jackson et al, 2008). Other families prefer provider-driven decisions. It is not always possible to have parent or patient input into decisions (e.g., emergency intervention after a life-threatening accident), but some providers assume a paternalistic approach to patients and families in all of their interactions. This approach is one in which the provider tells the family and child about the plan without giving them options. At the other end of the spectrum, all options are presented and discussed with the family or child, and the decision is left up to the family members without any provider input. The shared decision-making approach is somewhere in the middle; the provider, family, and child jointly decide the course of action. A good example of SDM might involve the decision to order diagnostic testing by a primary care provider. The decision needs to consider family, child, and provider preferences because there are many courses of action that can lead to the same end. Parents of a 6-year-old may pressure the provider to order blood work and imaging studies when the diagnosis is clearly primary enuresis and not related to a kidney abnormality. In this situation ordering extensive laboratory and other diagnostic tests would not be the best course of action for the child. Similarly, if the diagnosis appears to be systemic lupus erythematosus, the child would be better served by being referred to a pediatric rheumatologist for confirmation of the initial diagnosis, ordering of laboratory tests, and treatment. The use of SDM is supported by research findings that show improved health outcomes when the family agrees to the management plan (Hirsch et al, 2010; Merenstein et al, 2005). And yet Cox and colleagues' study (2007) showed that passive involvement in decision-making by parents and children is more the norm, occurring in 65% of visits. A recent Cochrane review failed to come to any firm conclusion on how best to encourage professionals to adapt SDM into their practice (Légaré et al, 2010). Shared decision-making is a key point in the management of both acute and chronic illness.

chronic disease in children

The types and characteristics of chronic diseases in children are varied and include a spectrum of rare conditions and genetic or prenatal conditions. Some chronic conditions are not permanent, serious, or obvious, whereas others are irreversible, involve acute exacerbations and remissions, and are readily apparent. The number of children with chronic conditions also varies depending on the definition and methods used to classify a chronic condition (Allen, 2010). Children with special health care needs (CSHCN) are defined as "those who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally" (McPherson et al, 1998, p 138). This definition remains the guiding principle to identify children eligible for federal and state assistance because of their chronic health condition. The need for services, rather than medical diagnosis, is the key factor or criterion that labels a child as having special needs. Using this criterion, about 18% of the pediatric population younger than the age of 18 years has a physical, developmental, behavioral, or emotional condition that requires additional services beyond that required by children generally (Levine, 2011). These children make up nearly 25% of pediatric outpatient visits (Hing et al, 2010). The number of children reaching young adulthood with severe long-term illness continues to grow with advances in medical and surgical technology, requiring more coordinated care (Stille, 2009), and the percentage of children with certain chronic conditions, such as asthma and obesity, is escalating (Wise, 2007). If the definition of a chronic condition is limited to those with conditions lasting or expected to last longer than 3 months and that limit social functioning or recreational activities, then approximately 6% of children have chronic illnesses. These figures do not include children with speech defects, visual and hearing disabilities, chronic ear infections, chronic skin conditions, and dental decay. Approximately 6% to 7% of children experience illness or disability that interferes with the child's usual daily activities (Wise, 2007). There can be great variability in the presentation and the course of illness among children with special needs. They and their families often face a range of problems that are as diverse as the conditions that cause these difficulties. A variety of genetic, congenital, and acquired conditions can lead to permanent or persistent problems that have a significant effect on the child's and family's lifestyle. Health care providers must remember that family members are the ones who bear the major daily burden of care. There are several key points to keep in mind when working with these children and their families: • Integrate clinical practice guidelines as part of the care for patients with special health care needs. These are available at www.guidelines.gov and include guidelines published by the National Association of Pediatric Nurse Practitioners (NAPNAP) and the American Academy of Pediatrics (AAP). • Prevention of special health problems is a primary goal of care and includes the following: Early prenatal care for all pregnant women Genetic counseling as indicated Elimination of environmental triggers or toxins Early identification of the condition or disease is of paramount importance • Early intervention from the time of birth and afterward to prevent secondary psychosocial difficulties is crucial; the developmental aspects of long-term illness must be addressed. • Counseling may be needed for the child and family to handle psychosocial and behavioral problems or to discuss their emotions and feelings. • The child, the family, and school personnel must be consulted to ensure that the child is able to attain realistic developmental milestones. • Appropriate educational support in school is a right. Public Law 94-142, the Education of All Handicapped Children Act of 1975, mandates an appropriate education for all school-age children with developmental disabilities in the least restrictive environment. Public Law 99-457 (1986) provides states with the opportunity to extend benefits of Public Law 94- 142 to children from birth to 2 years old. Prevention of discrimination is a right and is mandated under legislation related to individuals with disabilities. The Americans with Disabilities Act (1990) is a law that provides federal protection in the areas of employment, transportation, public accommodations, and communication for individuals with disabilities. The scope of protection covers both private and public sectors. The Individuals with Disabilities Educational Improvement Act (IDEIA) has been amended several times since the original act was passed to bridge the gap between what children with disabilities learn and what is required in a regular curriculum (IDEA-Public Law 105-17, 1997). It provides for the least restrictive environment for educating all children with disabilities. This act was reauthorized and amended in 2004 and 2008. Section 504 of the Rehabilitation Act of 1973 for students with disabilities in regular education/inclusive settings prevents discrimination and provides safeguards and support for reasonable accommodations in the school settings, such as ramps, use of assistive technology, special seating arrangement, and permission to hand in assignments late due to illness (Sadof and Nazarian, 2007). • Each state has programs (Title V) to assist CSHCN with medical care and to provide links to social services, state vocational rehabilitation programs, and state school-to-work projects. • Social service support is essential to help determine financial eligibility for Supplemental Security Income (SSI) or state program benefits (e.g., Medicaid) for individuals with physical, mental, and developmental disabilities, or specific chronic diseases. • Advocacy for children with chronic conditions and their families includes assisting them to secure coordinated and comprehensive health care and community-based services as needed. • Provision of primary care services—regular health maintenance supervision and anticipatory guidance —must not be overlooked.

tips regarding documentation: patient visit and followup

There are several important rules for the primary care provider to remember regarding documentation when charting. Many malpractice claims against care providers are due to a lack of documentation. The old adage, "If it isn't in writing, then it wasn't done" has been used more than once to find care providers liable and render a judgment in favor of the plaintiff. Good documentation practices include: • Being alert to a complaint or combination of complaints that are red flags for more serious illness (e.g., abdominal or chest pains, headache, syncope). Be sure to note pertinent positive and negative history and physical findings relative to these complaints when charting. • Identifying differential diagnoses and ruling out the worst possible illness first. Be sure to gather enough data to either rule in or out the diagnosis based on history, physical findings, or diagnostic studies. If you put "rule-out" on your assessment, you have to include a management plan to do so (i.e., it cannot be listed as a diagnosis or a differential diagnosis if you don't plan to do anything about "ruling it out"). • Conveying the seriousness of the issue to the family or caretaker if there is the probability of a serious illness and the patient needs to return for additional visits or have diagnostic studies done. Be sure to document that conversation. • Knowing patient or family risk factors and screening for them through diagnostic tests or history. • Ensuring that there is a system in place in the practice setting to follow up and secure the results of diagnostic tests that were ordered. There should be a mechanism to ensure that the test or procedure was done and that the provider was given the results and documented reviewing them. • Following up all abnormal test results. There should be a note placed in the patient's chart that the abnormal results were discussed (and with whom) and the plan of action. • Following up on referrals to other health care professionals or agencies and documenting the recommendations or treatments implemented from these referral sources. • Making sure that results of newborn screenings are in the chart. • Revisiting an unresolved problem until it is resolved. This can be accomplished by: Rescheduling a follow-up examination. Telephone contact with the family to determine if the complaint or illness has been resolved. Chart audits should be a regular part of practice quality improvement. Look for such things as omissions of information, whether problems identified in earlier visits were addressed at subsequent visits until resolved, compliance with routine health maintenance screenings, and adherence to evidence-based practice guidelines.

imaging studies

When deciding whether to order diagnostic imaging studies, the provider should keep the following goals in mind: order only those tests that give the most information for the least money, are the least invasive, are crucial in the establishment of a concrete diagnosis, and are critical elements in the development of the treatment plan. There are several useful points to remember about common imaging tests: • Conventional radiographs Useful diagnostic tools if correctly ordered (e.g., the type of view[s] needed) Least expensive of the imaging tests Readily available • Computed tomography (CT) imaging Best for detecting calcifications and fresh blood; shows greater bone detail than magnetic resonance imaging (MRI) (Smith, 2011) Can be used with contrast material (taken by mouth, rectum, or injected via vein) for special evaluations, such as abnormalities affecting blood vessels; check for allergies to iodine or seafood, kidney disease, or prior reaction to contrast materials Shows relationships well; images can be presented in the frontal, transverse, or sagittal planes or obtained in three-dimensional imaging May require sedation or anesthetic for infants and young children Requires radiation exposure, which increases cancer risk (Brenner and Hall, 2007; Brenner et al, 2001); it is therefore important that CT examinations be performed only when absolutely necessary (Cohen, 2009). Costly • MRI Detects neuronal migrations, soft-tissue lesions, and abnormalities of brain structure, ventricular size, as well as chronic subdural effusions Provides excellent images of soft tissue without exposure to ionizing radiation; MRI shows greater tissue detail than CT (Smith, 2011) Often requires sedation or anesthetic in infants and young children because immobilization is necessary Advanced MRIs include diffusion MRI, magnetization transfer MRI, fluid-attenuated inversion recovery (FLAIR), magnetic resonance angiography, magnetic resonance gated intracranial CSF dynamics (MR-GILD), magnetic resonance spectroscopy, functional MRI (fMRI), real-time MRI, and interventional MRI; usually ordered by specialists Expensive • Ultrasonography Gives two-dimensional images and measurements of internal organ systems; however, air-filled lungs and gas-filled bowel loops are impenetrable to ultrasound With Doppler ultrasound blood flow direction and velocity can be measured; a still picture of the image can be recorded as a permanent record, or sonography can be viewed as the image is being projected onto a video screen Highly dependent on operator skill and experience No sedation required no radiation exposure, noninvasive

prescribing

When prescribing pharmacological agents or recommending OTC drugs, it is important to be knowledgeable of the pharmacodynamics and pharmacokinetics of the drug, the usual dosage, adverse reactions, drug interactions, and the indications and contraindications for its use in children (see Appendix A). The provider must have a clear purpose in mind for using a particular drug and should not prescribe or recommend agents because of pressure from a parent or any other individual. Keep the following points in mind when prescribing drugs or OTC medications: • Lack of compliance or adherence in taking medications can be a major problem. Factors that affect compliance include: The more often a drug must be given per day the greater the chance that a dose or doses will be missed. Drugs that have a bitter or repulsive taste are difficult and sometimes impossible to get a child to take. For an extra cost, some pharmacies sell flavoring products that increase palatability (e.g., FLAVORx). The greater the number of drugs that a child is given, the greater the potential for a drug dose to be missed, drug interactions, or the wrong drug to be taken. Waking a child to take a medication is difficult for parents; prescribe round-the-clock dosing only when it is essential to maintain tight therapeutic drug levels. • Poorly given or inadequate instructions increase the risk that the prescribed agent will be misused. • Children with renal or hepatic dysfunction require dosing adjustments. • Use clinical practice guidelines, if available, to enhance or optimize outcomes for patients. • Be aware of the influence of advertising in prescribing practice. The newest agent may be much more expensive and there may be no evidence that use of the agent leads to better patient outcomes. • Use a decision support system to investigate the possibility of drug interactions and side effects. Such support systems may be part of the electronic medical record (EMR) or can be used via a smart phone application like CheckRx from Skyscape or Epocrates or accessed via an online program, for example, drug interaction checker on Medscape or Epocrates. Be sure to check for interactions between pharmacological agents and any herbal, botanical, or dietary supplements.

guidelines for parent for when to call PCP

When to call immediately for an infant younger than 3 months: Baby has the following symptoms: • Is lethargic (very sleepy or difficult to arouse), has poor color, or appears limp and unresponsive • Has a rectal temperature of 100.4° F (38° C) or higher • Refuses to eat three or four times in a row • repeated bouts of diarrhea or vomiting • Has a labored, wheezing, or grunting breathing longer than half an hour • associated with a rash that looks like bleeding under the skin • Baby's eyes, hands, or feet have a yellow, jaundiced color or the baby develops pumpkin-colored skin • You feel very nervous about your baby's illness or general condition When to call immediately for an older child (child has the following symptoms): • unresponsive, does not make eye contact with you, or has cold and clammy skin that is not associated with vomiting • Looks sicker than usual with a routine illness • illness with a rash that looks like bleeding under the skin (purple blotches or spots) • symptom that you believe to be unusual or frightening; trouble breathing, stiff neck, severe headache, or very high fever When to call immediately after trauma or injury: • Child has struck his or her head and has either lost consciousness, has nausea or vomiting, or complains of severe headache; mental confusion, unbalanced walking, poor coordination, loss of memory, or a discharge coming from one or both ears • There is continued swelling, tenderness, or a strange look to the injured part • Child refuses to use an injured extremity for more than half an hour • deep puncture wound, a cut longer than 0.5 inch, or your child has not received a tetanus shot within the past 5 to 10 years • There is injury to an eye that causes redness, pain, or tearing for more than 15 minutes • bitten by an animal, bite has gone through the skin • You need first aid instructions to control bleeding or other problems • swallowed a toxic or poisonous substance When to call about symptoms: • concerned about how your child looks • Symptoms getting worse or last longer than expected • Fever of more than 101° F (38.3° C) has lasted longer than 24 hours • Cough, cold, sore throat, or runny nose longer than 48 to 72 hours • Vomiting longer than 8 hours or diarrhea longer than 24 hours or when there is blood in the stool or vomit • severe stomach pains lasting longer than 4 hours • Symptom more severe than it has in the past • rash or other problem, and not sure what is causing it • You are not certain whether the child needs to be seen by the health care provider.

chap 23 child presenting with fever

defined as an abnormally elevated body temperature with a temperature of 100.4° F (38° C) per rectum or higher. The normal physiologic hypothalamic set-point is altered by many different agents: neonates- usually the result of congenital infections, those acquired at delivery (late-onset group B streptococcal), acquired in the nursery (esp premature infants), acquired at home (pneumococcal, meningococcal infection), or acquired as a result of anatomic or physiologic dysfunction (renal). fever in children- bacterial and viral infections, vaccines, biologic agents, tissue damage, malignancy, drugs, collagen-vascular disorders, endocrine disorders, inflammatory disorders, and other disease states. Temps higher than 105.8° F (41° C) are rarely of infectious origin but are due to CNS dysfunction (malignant hyperthermia, drug fever, heat stroke). The fever-causing agents produce endogenous pyrogens that reset the hypothalamic center, takes approximately 90 minutes. *Clinically, this means- blood cultures obtained before the fever spikes would have greater bacterial or fungal yield. two situations of invasive bacterial or viral infections that are a particular challenge with neonates, infants, and young children 36 months or younger: fever without a source or focus and fever of unknown origin. objective diagnosis can be reached by completing a careful history, physical examination, and following diagnostic, assessment, and management guidelines based on age, symptoms, estimated risks, associated diseases, and immune status. general epidemiologic points: • infants younger than 3 months, with fever, 70% of causative agents can be identified, viral being 40% to 60%; a workup for bacterial disease is still necessary. • Viruses have a seasonal pattern: RSV and influenza A in winter; enterovirus in summer and fall. • Bacteremia occurs in 5% of previously well infants younger than 3 months. • Prior to pneumococcal vaccine, occult bacteremia (S. pneumoniae, N. meningitidis, and Salmonella) was diagnosed in about 1.5% of nontoxic-appearing children between 3 and 36 months of age who had fever of 102.2° F (>39° C) rectally. More commonly infections in this age group attributed to otitis media, pneumonia, URIs, enteritis, UTIs, osteomyelitis, and meningitis. • Bacteremia can be an occult infection in young infants and children (i.e., nontoxic-appearing patient whose blood culture is positive for a pathogenic organism). • The younger the infant- greater uncertainty about the possibility of a serious bacterial infection, greater need to r/o possibility.

fever management

fever control include: • Nonpharmacological: adequate hydration. reassurance to parents and advice that not all fevers need to be treated. appropriate clothing; do not bundle in additional clothing or coverings. ambient environment temperatures of around 72° F (22° C). Sponge with tepid water for temperatures greater than 104° F (40° C)- stopped if the child starts to shiver. Ice-water baths and alcohol sponging should not be done. • Pharmacological measures: antipyretic agents- Acetaminophen, PO, 10 to 15 mg/kg/dose every 4 to 6 hours, not to exceed five doses in 24 hours; temperature generally is reduced by 1° to 2° C within 2 hours. oral dose of 15 mg/kg/dose, is as effective as ibuprofen at 10 mg/kg/dose. Acetaminophen is the drug of first choice. Ibuprofen in children 6 months to 12 years old: temp less than 102.5° F (39.2° C), 5 mg/kg/dose every 6 to 8 hours; for temp greater than or equal to 102.5° F (39.2° C), 10 mg/kg/dose every 6 to 8 hours max daily dose of 40 mg/kg/day. The duration of fever response with ibuprofen may be longer than with acetaminophen. temperature remains lower for a longer time with ibuprofen. *Naproxen sodium is marketed as a "fever reducer." However, not well studied as antipyretic in children, should not be used.

early education and childcare initiative

www.healthychildcare.org/index.html • Programs for teaching care providers how to administer medications • Quality childcare • Quarterly newsletter for health care providers, teachers, and providers healthy kids, healthy care www.healthykids.us • Parent-friendly information for children • Helps parents talk with providers about providing a safe and healthy home for children national resource center for health and safety in childcare and early education http:/nrckids.org • Goal is to help foster health and safety in out-of-home educational settings child care aware www.childcareaware.org • Helps parent identify childcare resources

general guidelines for parent when calling PCP

• When calling for nonurgent matters, such as well- baby advice, prescription refills, or appointments, call during office hours whenever possible. • When calling for an emergency, tell the receptionist or answering service that your call is an emergency call. • Give the following information on every call: your child's name, age, sex, major problem, and telephone number where you can be reached. • Be ready to give information related to your child's problem as briefly and clearly as possible: What are the signs and symptoms? How long has the problem existed? What have you done for the problem? How did your child respond to what was done? How do you feel about your child's condition? What is your intuition? Is your child getting better or worse? • Be ready to give information about your child's general health. Does your child have any chronic illnesses that need to be considered? Is your child receiving medications for this problem or another problem? Has your child recently received immunizations? Does your child have any allergies? • If you do not talk to your provider directly, before hanging up, ask when your call will most likely be returned. • If you do not receive a return call within a reasonable amount of time, call back to make sure your message was taken correctly. • If your provider decides not to examine your child, before hanging up make sure you determine the following: The most likely cause of your child's condition Which medicines or treatments should be given What signs or symptoms to watch for When you should call back for more advice or to report changes in your child's condition If you do not understand the instructions, ask to have them repeated or call back for clarification. If you are instructed to come to the office or go to an emergency department, make sure you have clear directions on how to get there. If you are too anxious to drive, ask a friend or neighbor to drive or call a taxi. If an ambulance is necessary, the provider may be able to call it for you.