Be sure to appropriately assess the financial status of families that present for care since economicchallenges are a risk for certain diseases and noncompliance with thetreatment plan
Be sure to appropriately assess the financial status of families that present for care since economicchallenges are a risk for certain diseases and noncompliance with thetreatment plan: Excerpt from Avoiding Common Pediatric Errors
Author:
Johann Peterson, MD
What to Do - Gather Appropriate Data
Understanding the social situation and environment of your patients helps
in tailoring the counseling, screening, and preventive services you provide.
Economic status is an important part of this information. Economic status
has been well established as a risk factor for many health conditions. Overall childhood mortality increases with lower incomes, especially mortality
related to trauma (motor vehicle accidents and homicide) and fire. Many
specific sources of morbidity and mortality are also inversely related to family income, and knowing your patient's financial status will allow you to focus
on these known risks with support from clinical evidence.
Poor children are at greater risk for elevated blood lead levels, especially
in the "high-normal" range of 5 to 10 µg/dL. Recall that children with these
blood levels, although below the usual cut-off of 10 µg/dL, still have an increased risk of worse developmental outcomes. These children also have a
higherrisk of iron deficiency, so screeningfor anemia is especiallyimportant.
There is some evidence that anemia per se is not sensitive enough as a screen
for iron deficiency, which by itself seems to be related to impaired cognitive development even in the absence of anemia. Therefore, consider taking
a more careful dietary history with such patients and consider obtaining
protoporphyrin levels as a more sensitive screen for iron deficiency.
Poor children also tend to have more emergency department (ED) visits
for asthma and are more likely to be admitted to the hospital when they do
presenttotheED,whichsuggeststhattheirincreaseduseoftheEDresultsat
leastpartlyfrommoreseverediseasethanchildrenwhoarenotpoor.Children
fromlower-incomehomesarealsomorelikelytodiefromrespiratorydisease.
This understanding of the social elements of health care should motivate you
to be especially thorough in your asthma care. Assure that your poor patients
have backup inhalers and inhalers at school. Consider how much albuterol
they are using and their degree of control. To some patients, using albuterol
a few times per week is "not that much." You may take it for granted that
inhaled steroids offer improved asthma control with minimal and acceptable
adverse effects; however, many families are very reluctant to use inhaled
steroids.
Neuropsychiatric disorders are another area in which poor children
are at an increased risk. For example, a lower-income status confers an increased risk of anxiety disorders among adolescents. Poor children with
autism and related disorders are diagnosed on average almost a year later
than are children from wealthier families. Whether this is because of limited or unstable access to primary care or because they are referred to sub-
specialists later and present in ways that are more difficult to diagnose is
unclear. Whatever the reason, your extra vigilance may help narrow the
gap in autism diagnosis. Choose a brief, validated screening questionnaire
such as the Childhood Autism Test (CHAT) and use it liberally. The school
psychiatry Web site at Massachusetts General Hospital lists other options
(http://www.massgeneral.org/schoolpsychiatry/screening pdd.asp).
Finally, remember that once a diagnosis is made and a treatment plan is
established, families need to purchase the medication and administer it correctly. Refractory conditions that would be expected to resolve or conditions
thatoccurwithfrequentrecurrencesshouldbeconsideredasnoncompliance
until proven otherwise. Treatment escalation will not benefit these patients
if they are unable to afford the medications that you prescribe to treat their
underlying problem.
Suggested Readings
Babin SM, Burkom HS, Holtry RS, et al. Pediatric patient asthma-related emergency department visits and admissions in Washington, DC, from 2001–2004, and associations with air
quality, socio-economic status and age group. Environ Health. 2007;6:9.
Centers for Disease Control and Prevention (CDC). Blood lead levels–United States, 1999–
2002. MMWR Morb Mortal Wkly Rep. 2005;54(20):513–516.
Crowell R, Ferris AM, Wood RJ, et al. Comparative effectiveness of zinc protoporphyrin and hemoglobin concentrations in identifying iron deficiency in a group of
low-income, preschool-aged children: practical implications of recent illness. Pediatrics.
2006;118(1):224–232.
Mandell DS, Novak MM, Zubritsky CD. Factors associated with age of diagnosis among
children with autism spectrum disorders. Pediatrics. 2005;116(6):1480–1286.
SchneiderJM,FujiiML,LampCL,etal.Anemia,irondeficiency,andirondeficiencyanemiain
12-36-mo-old children from low-income families. Am J Clin Nutr. 2005;82(6):1269–1275.
T´ellez-Rojo MM, Bellinger DC, Arroyo-Quiroz C, et al. Longitudinal associations between
blood lead concentrations lower than 10 microg/dL and neurobehavioral development in
environmentally exposed children in Mexico City. Pediatrics. 2006;118(2):e323–e330.
Roberts RE, Roberts CR, Xing Y. Rates of DSM-IV psychiatric disorders among adolescents
in a large metropolitan area. J Psychiatr Res. 2006;41(11):959–967.
Wise PH, Kotelchuck M, Wilson ML, et al. Racial and socioeconomic disparities in childhood
mortality in Boston. N Engl J Med. 1985 8;313(6):360–366.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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