Benjamin D. Hoffman

Policy statement - Tobacco use: A pediatric disease

Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobacco-use prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobacco-control measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in tobacco control to promote the health of children, adolescents, and young adults.

Unsafe from the start: serious misuse of car safety seats at newborn discharge

OBJECTIVE To estimate prevalence of car safety seat (CSS) misuse for newborns on hospital discharge; and to identify potential risk and protective factors for CSS misuse. STUDY DESIGN We randomly sampled 291 mother-baby dyads from the newborn unit of an academic health center. Participants completed a survey and designated someone (themselves or another caregiver) to position their newborn in the CSS and install the CSS in their vehicle. Certified child passenger safety technicians assessed positioning and installation using nationally standardized criteria. To examine factors associated with CSS misuse, we used logistic regression to compute ORs and 95% CIs. RESULTS A total of 291 families (81% of those eligible) participated. Nearly all (95%) CSSs were misused, with 1 or more errors in positioning (86%) and/or installation (77%). Serious CSS misuse occurred for 91% of all infants. Frequent misuses included harness and chest clip errors, incorrect recline angle, and seat belt/lower anchor use errors. Families with mothers of color (OR, 6.3; 95% CI, 1.8-21.6), non-English language (OR, 4.9; 95% CI, 1.1-21.2), Medicaid (OR, 10.3; 95% CI, 2.4-44.4), or lower educational level (OR, 4.5; 95% CI, 1.7-12.4) were more likely to misuse CSSs. However, families that worked with a child passenger safety technician before delivery were significantly less likely to misuse their CSSs (OR, 0.1; 95% CI, 0.0-0.4). CONCLUSION Nearly all parents of newborn infants misused CSSs. Resources should be devoted to ensuring families with newborns leave the hospital correctly using their CSS.

Technical report - Secondhand and prenatal tobacco smoke exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.

Pediatrics in the community: integrating community pediatrics into residency training.

1. Beth Rezet, MD 1. Associate Clinical Professor of Pediatrics, Assistant Director Pediatric Residency Training Program, The Childrens Hospital of Philadelphia 2. Benjamin D. Hoffman, MD 1. Associate Professor of Pediatrics, Director, Pediatric Residency Program, University of New Mexico 3. Jeffrey Kaczorowski, MD 1. Director, Community Pediatrics Training Initiative, American Academy of Pediatrics, Associate Professor of Pediatrics, University of Rochester Since 1999, the American Academy of Pediatrics (AAP) has asserted that pediatricians should “reaffirm their role as professionals in the community and prepare themselves for it, just as diligently as they prepare for traditional clinical roles.” (1) Furthermore, as of 2001, the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Pediatrics mandated, “there must be structured educational experiences that prepare residents for the role of advocate for the health of …

Child Passenger Safety: Direction, Selection, Location, Installation

The most significant risk factor for death and serious injury in a car crash is the failure to use a size-appropriate restraint system. Providing accurate car safety seat anticipatory guidance to families is the standard of care. Guiding families on the best car seat for best protection can be done with the four messages, direction, selection, location, and refer, if needed, to community resources for correct installation. Addressing special issues that impact use of a car seat on each and every ride, including challenging behaviors and obesity, will transfer to many other situations. Data support a new recommendation that children stay rear-facing in size-appropriate car seats until they reach the highest weight and height allowed for rear-facing by the manufacturer of the convertible seat. Premature graduation to the next seat type/size/position increases risk of injury. A driver who is distracted by a cell phone, food, or something else, becomes a risk factor for a car crash. State laws may lag behind best practices. Advocacy for stronger laws, better enforcement, and best practices at the local, state, and national levels is a critical role for the pediatric professional community.

Preventing gun injuries in children

Firearms are involved in the injury and death of a large number of children each year from both intentional and unintentional causes. Gun ownership in homes with children is common, and pediatricians should incorporate evidence-based means to discuss firearms and protect children from gun-related injuries and violence. Safe storage of guns, including unloaded guns locked and stored separately from ammunition, can decrease risks to children, and effective tools are available that pediatricians can use in clinical settings to help decrease childrens access to firearms. Furthermore, several community-based interventions led by pediatricians have effectively reduced firearm-related injury risks to children. Educational programs that focus on childrens behavior around guns have not proven effective.

Pediatrics in the Community

1. Beth Rezet, MD 1. Associate Clinical Professor of Pediatrics, Assistant Director Pediatric Residency Training Program, The Childrens Hospital of Philadelphia 2. Benjamin D. Hoffman, MD 1. Associate Professor of Pediatrics, Director, Pediatric Residency Program, University of New Mexico 3. Jeffrey Kaczorowski, MD 1. Director, Community Pediatrics Training Initiative, American Academy of Pediatrics, Associate Professor of Pediatrics, University of Rochester Since 1999, the American Academy of Pediatrics (AAP) has asserted that pediatricians should “reaffirm their role as professionals in the community and prepare themselves for it, just as diligently as they prepare for traditional clinical roles.” (1) Furthermore, as of 2001, the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Pediatrics mandated, “there must be structured educational experiences that prepare residents for the role of advocate for the health of …

Fluoride Supplementation Adherence and Barriers in a Community Without Water Fluoridation

BACKGROUND To prevent early childhood caries, the American Dental Association recommends oral fluoride supplementation for children in communities lacking water fluoridation who are at high caries risk. However, patient adherence to oral fluoride supplementation has not been studied in this population. This study assessed adherence to oral fluoride and barriers to adherence in a community lacking water fluoridation. METHODS A self-administered survey was completed in a systematic sample of 209 parents of children aged 6 months to 4 years, during a primary care visit in an urban academic medical center. Participants reported frequency of administering oral fluoride to their children, as well as agreement or disagreement with proposed barriers to supplementation. Bivariate and multivariate analyses were used to assess adherence with oral supplementation and the association of barriers to supplementation and child receipt of fluoride on the day before. RESULTS More than half of parents either had not or did not know if their child had received fluoride on the day before. Approximately 1 in 4 of parents had given fluoride in 0 of the previous 7 days. Difficulty remembering to give fluoride and agreeing that the child does not need extra fluoride were associated with not receiving fluoride on the day before. CONCLUSIONS Adherence to oral fluoride supplementation in the primary care setting is low. Difficulty remembering to give fluoride daily is the greatest barrier to adherence. Further research on interventions to reduce common barriers is needed to increase fluoride administration and reduce early childhood caries in communities lacking water fluoridation.

Integrating community pediatrics into residency training

1. Beth Rezet, MD 1. Associate Clinical Professor of Pediatrics, Assistant Director Pediatric Residency Training Program, The Childrens Hospital of Philadelphia 2. Benjamin D. Hoffman, MD 1. Associate Professor of Pediatrics, Director, Pediatric Residency Program, University of New Mexico 3. Jeffrey Kaczorowski, MD 1. Director, Community Pediatrics Training Initiative, American Academy of Pediatrics, Associate Professor of Pediatrics, University of Rochester Since 1999, the American Academy of Pediatrics (AAP) has asserted that pediatricians should “reaffirm their role as professionals in the community and prepare themselves for it, just as diligently as they prepare for traditional clinical roles.” (1) Furthermore, as of 2001, the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Pediatrics mandated, “there must be structured educational experiences that prepare residents for the role of advocate for the health of …

Comparison of the effectiveness of hands-on versus online education in child passenger safety

Background Community paediatricians’ knowledge of appropriate child safety seat (CSS) use in vehicles may be inadequate. We compared the effectiveness of hands-on and online education in improving and retaining child passenger safety (CPS) knowledge and skills among paediatric trainees. Methods Paediatric trainees were randomised to receive hands-on skills training versus a 1-hour online module in CPS. CSS knowledge and installation skills were assessed using a validated 10-item/point questionnaire and an assessment tool respectively at baseline and after 6 months. Preintervention and postintervention knowledge improvement and CSS installation skills between groups were assessed using paired t-tests and effect size (d). Results Forty-eight students agreed to participate and were randomised. Thirty-nine completed training (hands-on: 23 and online: 15). At entry, no significant differences in learners’ demographics and prior CPS education existed. Baseline CPS knowledge scores did not differ significantly between groups (p=0.26). Postintervention, both groups demonstrated a significant increase in knowledge scores (hands-on=3.1 (95% CI 2.4 to 3.7), p<0.0001; online=2.6 (95% CI 1.9 to 3.3), p<0.0001), though the pre–post gain in knowledge scores were not significantly different between groups (p=0.35). At follow-up, both groups demonstrated a significant increase in knowledge scores (hands-on=1.8 (95% CI 1.2 to 2.4), p<0.0001; online=1.1 (95% CI 0.7 to 1.6), p<0.0001) with the hands-on group scores significantly better than the online group (p<0.02). The long-term gain in knowledge scores was not significantly different between groups (p=0.12). Baseline CSS installation skill scores did not significantly differ between groups for forward-facing seats (p=0.16) and rear-facing seats (p=0.51). At follow-up, mean CSS installation skill scores significantly increased for the hands-on group (forward-facing seat: 0.8 (95% CI 0.16 to 1.44), p<0.02; rear-facing seat: 1.2 (95% CI 0.6 to 1.7), p<0.001) but not for the online group (forward-facing seat: 0.9 (95% CI −0.08 to 1.9), p=0.07); rear-facing seat: −0.2 (95% CI −1.1 to 0.7), p=0.6). Conclusions Among paediatric trainees, hands-on and online CPS education are both effective in improving long-term CPS knowledge. Long-term installation skills for forward-facing and rear-facing CSS persist for hands-on education but are inconclusive for online education.