Jeffrey Kaczorowski

Elevated blood pressure and decreased cognitive function among school-age children and adolescents in the United States

OBJECTIVE To evaluate the relationship between elevated blood pressure (BP) and cognitive test performance in a nationally representative sample of children. Study design The National Health and Nutrition Examination Survey III provides cross-sectional data for children 6 to 16 years, including BP and cognitive test scores. Elevated BP was defined as systolic or diastolic BP >or=90th percentile. Cognitive tests were compared for children with elevated and normal BP. Linear regression was used to evaluate the relation between elevated BP and decreased test scores. RESULTS Among the 5077 children, 3.4% had systolic BP >or=90th percentile and 1.6% diastolic BP >or=90th percentile. Children with elevated systolic BP had lower average scores compared with normotensive children for digit span (7.9 vs 8.7, P=.01), block design (8.6 vs 9.5, P=.03), and mathematics (89.6 vs 93.8, P=.01). Elevated diastolic BP was associated with lower average scores on block design (9.5 vs 11, P=.01). Linear regression showed that elevated systolic BP was independently associated with lower digit span scores (P=.032). CONCLUSION Children with elevation of systolic BP are at risk for central nervous system end-organ damage, as manifested by decreased digit span test scores.

The Expanding Role of the Pediatrician in Improving Child Health in the 21st Century

Children in the United States increasingly are at risk for health problems that are precipitated or exacerbated by social, community, and environmental factors. Currently, pediatricians are unable to sufficiently address these health conditions without expanding their roles beyond that of providing health care to individual patients. Thus, to improve child health, physicians must work within their communities to identify the needs of the population they serve and take appropriate action to influence the private and public policies that address these needs. Healthy People 2010 establishes a well-supported framework that confronts the social and community factors that affect childrens health and serves as a resource for community-minded pediatricians. In addition to Healthy People 2010, other successful initiatives have been created by pediatricians, and they must be expanded if the pediatric community is to alleviate the social, community, and environmental factors that negatively affect child health.

School Readiness Among Urban Children With Asthma

BACKGROUND Children with chronic illnesses, including asthma, are at risk for school problems. Developmental problems, however, may begin before school entry, and the developmental status of preschool children with asthma has not been evaluated. OBJECTIVE To test the hypothesis that urban preschool children with asthma have lower parent-reported developmental scores compared with children without asthma. METHODS A comprehensive survey of children beginning kindergarten in 1998 in the urban school system in Rochester, NY, collected parent reports of demographic, medical, and developmental data. We compared children with asthma with and without limitation of activity to children without asthma for motor, language, socioemotional, and school readiness skills and the need for extra help with learning. Linear and logistic regression were used to determine associations between asthma and developmental outcomes. RESULTS Among the 1058 children in this sample, 9% had asthma, including 5% with asthma with limitation of activity. After adjustment for multiple potential confounding variables, the children with asthma with limitation had lower scores on school readiness skills compared with children without asthma (2.0 vs 2.5, P <.001). Further, the parents of children with asthma with limitation were substantially more likely (P <.05) to describe them as needing extra help with learning (74% vs 56%; odds ratio, 3.2; 95% confidence interval, 1.5--7.8). CONCLUSIONS Urban preschool children with significant asthma had poorer parent-reported school readiness skills and a greater need for extra help with learning compared with children without asthma. This finding suggests that developmental problems for children with asthma may begin before school entry.

A Potential Pitfall in Provider Assessments of the Quality of Asthma Control

BACKGROUND Pediatricians elicit information about asthma control from parents to help formulate management plans. If parents of children with significant asthma symptoms inappropriately indicate good control, physician recommendations may not be optimal. We examined whether a single general question about asthma control might lead to inaccurate assessment of severity. DESIGN/METHODS Children 3-7 years of age who met the National Heart, Lung, and Blood Institute (NHLBI) criteria for mild persistent to severe asthma were identified from 40 urban schools. A phone survey of their parents provided demographic information, symptom frequency, medication use, and general interpretation of their childs asthma control. Chi-square analyses compared the parents general interpretation of control with demographic characteristics and measures of asthma severity. RESULTS One hundred sixty of 224 eligible children participated in this study. Seventy-eight percent were described as in good asthma control. General assessment of asthma control did not vary by demographic characteristics. Parents were as likely to describe children with daily asthma symptoms in good control as they were to describe children with less frequent symptoms in good control. Parents were less likely to report good control in children using daily rescue medications when compared with children with less frequent medication use (65% vs 82%, P =.03), but the majority of children in both groups was described as having good control. CONCLUSIONS Most parents underestimated the severity of their childs asthma and reported good control with their global assessment. Parents frequently reported good control even when the children had daily asthma symptoms. Pediatricians should ask about specific asthma symptoms during patient encounters because a global question about asthma control likely will result in underestimations of asthma severity.

Five Days of Whole-Bowel Irrigation in a Case of Pediatric Iron Ingestion

The maximum duration and volume of polyethylene glycol electrolyte solution (PEG-ELS) that can be safely administered during whole-bowel irrigation of the poisoned patient are poorly defined. We present a case of a 33-month-old boy who ingested at least 160 mg/kg elemental iron and received 44.3 L of PEG-ELS (2,953 ml/kg) over 5 days because of the persistence of iron tablets in teh gastrointestinal tract. The child remained clinically well after initiation of PEG-ELS therapy, and further significant iron absorption did not appear to occur. The rectal effluent cleared within 2 days of the start of PEG-ELS therapy despite the persistence of iron in the gastrointestinal tract as shown on radiography. No adverse effects resulted from teh large volume or duration of the PEG-ELS therapy. This is the greatest reported volume of PEG-ELS to be used for whole-bowel irrigation in the treatment of a toxic ingestion.

Evaluation of a community-based pediatrics residency rotation using narrative analysis.

Purpose. To evaluate the extent to which a community pediatrics rotation in disadvantaged neighborhoods provided residents with a self-assessed change in knowledge, attitudes, and skills useful for improving the health of children at the community level. Method. All pediatrics and medicine–pediatrics residents at the University of Rochester Medical Center participate in a two-week community-based rotation. At the end of each rotation, residents were asked to write a short essay on what they learned during the experience. An interdisciplinary team conducted a retrospective, qualitative analysis of residents’ essays looking for recurring themes. Essays were also examined for narrative plot elements that would indicate a causal sequence of events indicating some transformation of the learner. Results. Of the 25 essays reviewed, each gave evidence of at least one of three themes: increased knowledge of lives in poverty, renewed enthusiasm for advocacy, and increased skill in making referrals. Although many residents expressed initial skepticism of the value of a community rotation, none noted any negative final impression. The narrative structure of residents’ essays also showed evidence of some transformation of the learner. Conclusions. A community pediatrics rotation can be a successful educational experience for providing residents with knowledge of how pervasive poverty impacts children and families. Reported changes in attitudes and skills require further evaluation to demonstrate that they can be applied in practice.

Education for Community Pediatrics

To have an impact on many of the most vexing child health issues of our era of necessity requires the pediatrician to expand the boundaries of practice well beyond the walls of the clinic or office. Without exception, none of the leading health needs of America’s children will be met without intense community-based work, as well as individual patient/family intervention.1,2 Examples include improving access to health care, ser ving children with special needs (chronically ill and handicapped), modifying the effects of school-related problems, preventing youth and family violence, reducing rates of obesity, and delaying the onset of degenerative diseases. Pediatricians see health problems that are socially determined, but not necessarily linked to low income, such as eating disorders, depression, substance abuse, and motor vehicle injuries. We are also increasingly aware of the effects of disparities in healthcare access and health status among poor children, children of color, and children of new immigrants. Addressing these “non-traditional” issues is a central part of our discipline and our practice.3-6 In community pediatrics, a pediatrician strives to provide services to and advocacy for a population of children in a community regardless of their social status or income to maximize their health and functioning. Community-focused pediatricians provide preventive and curative services and work to understand the determinants and consequences of child health and illness and the effectiveness of services provided. The American Academy of Pediatrics is clear that all pediatricians, generalists and specialists alike, need to practice community pediatrics, defined by all of the following:7

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 …

The Essential Role of Research in Community Pediatrics

Several recommendations in the American Academy of Pediatrics policy statement “The Pediatricians Role in Community Pediatrics” underscore the essential role of research as an agent of change to promote the health and well-being of children. This article provides (1) a framework for thinking about research in community pediatrics, (2) special considerations important in conducting community-level research, (3) an example of community-level research that has significantly decreased mortality in children (prevention of sudden infant death syndrome), (4) an example of a current issue illustrating the importance of community pediatrics research (promotion of school readiness), and (5) a discussion of future directions for research. Many of the leading health problems facing the United States as outlined in Healthy People 2010 are problems that affect children or have their roots in childhood and are likely to be addressed by community-level research and interventions. It seems clear that pediatricians should be learning to participate in, advocate for, and conduct more community pediatrics research.

Pediatrics in the community: community pediatrics training initiative (CPTI).

Our inaugural story for Pediatrics in the Community was in the January 2007 edition of Pediatrics in Review. Dr Robert Haggerty provided the historical rationale for community pediatrics training (CPT) as part of that feature. Now, 1 year later, we asked Dr Jeff Kaczorowski, Director of the CPTI at the American Academy of Pediatrics (AAP), to describe the present and future of CPT. As the stories in this series have shown, some residents are having wonderful community experiences already and making a difference in the lives of children in their communities. The challenge is how to make such experiences available to all pediatric residents and pediatricians.-C. Andrew Aligne, MD, MPH, Section Editor.