Jill J. Fussell

Increasing Prevalence of Medically Complex Children in US Hospitals

OBJECTIVE: In this study we used national data to determine changes in the prevalence of hospital admissions for medically complex children over a 15-year period. PATIENTS AND METHODS: Data from the Nationwide Inpatient Sample, a component of the Healthcare Cost and Utilization Project, was analyzed in 3-year increments from 1991 to 2005 to determine national trends in rates of hospitalization of children aged 8 days to 4 years with chronic conditions. Discharge diagnoses from the Nationwide Inpatient Sample were grouped into 9 categories of complex chronic conditions (CCCs). Hospitalization rates for each of the 9 CCC categories were studied both individually and in combination. Trends of children hospitalized with 2 specific disorders, cerebral palsy (CP) and bronchopulmonary dysplasia, with additional diagnoses in more than 1 CCC category were also examined. RESULTS: Hospitalization rates of children with diagnoses in more than 1 CCC category increased from 83.7 per 100 000 (1991–1993) to 166 per 100 000 (2003–2005) (P[r] < .001). The hospitalization rate of children with CP plus more than 1 CCC diagnosis increased from 7.1 to 10.4 per 100 000 (P = .002), whereas the hospitalization rates of children with bronchopulmonary dysplasia plus more than 1 CCC diagnosis increased from 9.8 to 23.9 per 100 000 (P < .001). CONCLUSIONS: Consistent increases in hospitalization rates were noted among children with diagnoses in multiple CCC categories, whereas hospitalization rates of children with CP alone have remained stable. The relative medical complexity of hospitalized pediatric patients has increased over the past 15 years.

Metabolic imbalance associated with methylation dysregulation and oxidative damage in children with autism.

Oxidative stress and abnormal DNA methylation have been implicated in the pathophysiology of autism. We investigated the dynamics of an integrated metabolic pathway essential for cellular antioxidant and methylation capacity in 68 children with autism, 54 age-matched control children and 40 unaffected siblings. The metabolic profile of unaffected siblings differed significantly from case siblings but not from controls. Oxidative protein/DNA damage and DNA hypomethylation (epigenetic alteration) were found in autistic children but not paired siblings or controls. These data indicate that the deficit in antioxidant and methylation capacity is specific for autism and may promote cellular damage and altered epigenetic gene expression. Further, these results suggest a plausible mechanism by which pro-oxidant environmental stressors may modulate genetic predisposition to autism.

Care of Adolescent Parents and Their Children

Teen pregnancy and parenting remain an important public health issue in the United States and the world, and many children live with their adolescent parents alone or as part of an extended family. A significant proportion of teen parents reside with their family of origin, significantly affecting the multigenerational family structure. Repeated births to teen parents are also common. This clinical report updates a previous policy statement on care of the adolescent parent and their children and addresses medical and psychosocial risks specific to this population. Challenges unique to teen parents and their children are reviewed, along with suggestions for the pediatrician on models for intervention and care.

Comprehensive Health Evaluation of the Newly Adopted Child

Children who join families through the process of adoption often have multiple health care needs. After placement in an adoptive home, it is essential that these children have a timely comprehensive health evaluation. This evaluation should include a review of all available medical records and a complete physical examination. Evaluation should also include diagnostic testing based on the findings from the history and physical examination as well as the risks presented by the child’s previous living conditions. Age-appropriate screens should be performed, including, for example, newborn screening panels, hearing, vision, dental, and formal behavioral/developmental screens. The comprehensive assessment can occur at the time of the initial visit to the physician after adoptive placement or can take place over several visits. Adopted children should be referred to other medical specialists as deemed appropriate. The Section on Adoption and Foster Care is a resource within the American Academy of Pediatrics for physicians providing care for children who are being adopted.

Toileting Concerns, Parenting Stress, and Behavior Problems in Children with Special Health Care Needs

This study examined the relationship between toileting concerns, behavior problems, and parenting stress in parents of children with special health care needs (CSHCN). Participants included parents of 99 males and 71 females aged 4 to 12 years with neural tube defects (NTD), developmental-behavioral disabilities (DBD), or history of perinatal intraventricular hemorrhage (IVH). Parents completed the Achenbach Child Behavior Checklist (CBCL) and the Parenting Stress Index-Short Form (PSI-SF). Parents expressing toileting concerns on the CBCL reported significantly more personal distress and more externalizing problems versus those with continent children. Variation within subsamples suggested that expectations based on nature of disability may be a factor in parent adjustment. Direct assessment and intervention of toileting issues should be a high priority in secondary stress prevention with CSHCN and their families.

Social Outcomes Associated With Media Viewing Habits of Low-Income Preschool Children

Research Findings: The purpose of this study was to examine the relationship between preschool childrens social outcomes in the classroom (including hyperactivity, aggression, and social skills) and their media viewing habits (including the amount of television they watch and whether they watch videos/movies that are rated as inappropriate for young children). The participants were 92 low-income pre-kindergarten-age children for whom we obtained parent reports of media viewing habits and teacher reports of classroom behavior. The results suggested that viewing of inappropriate content was associated with higher hyperactivity and aggression scores and a lower social skills rating, whereas the amount of viewing was not related to these classroom outcomes. Policy: There has been a great deal of focus on how both the amount and content of television viewed affects social development in middle and later childhood. These studies have helped influence the development of guidelines for parents of young children to limit media viewing. The findings from the present study suggest that school personnel and others should monitor the content of what preschoolers are watching and should educate parents about the potential impact of media viewing on childrens classroom behavior.

Health Care of Youth Aging Out of Foster Care

Youth transitioning out of foster care face significant medical and mental health care needs. Unfortunately, these youth rarely receive the services they need because of lack of health insurance. Through many policies and programs, the federal government has taken steps to support older youth in foster care and those aging out. The Fostering Connections to Success and Increasing Adoptions Act of 2008 (Pub L No. 110-354) requires states to work with youth to develop a transition plan that addresses issues such as health insurance. In addition, beginning in 2014, the Patient Protection and Affordable Care Act of 2010 (Pub L No. 111-148) makes youth aging out of foster care eligible for Medicaid coverage until age 26 years, regardless of income. Pediatricians can support youth aging out of foster care by working collaboratively with the child welfare agency in their state to ensure that the ongoing health needs of transitioning youth are met.

Triple Risk: Do Difficult Temperament and Family Conflict Increase the Likelihood of Behavioral Maladjustment in Children Born Low Birth Weight and Preterm?

OBJECTIVE This study examined the impact of family conflict on internalizing and externalizing behavior at age 8 for children born low birth weight (LBW) and preterm (PT), with specific attention to the moderating role of early temperament. METHODS The sample included 728 families enrolled in the longitudinal study of the Infant Health and Development Program. The study relied on maternal reports of child temperament at age 1, family conflict at age 6(1/2) years and 8 years, and child behavior at age 8 years. RESULTS Children exposed to high levels of family conflict had more internalizing problems. Child temperament assessed in infancy moderated the impact of family conflict on externalizing but not internalizing problem behavior. DISCUSSION LBW/PT children with a difficult temperament are more at risk for poor developmental outcomes, such as externalizing behavior problems, when exposed to family conflict than children with a less difficult temperament.

Incorporating the ACGME Educational Competencies Into Morbidity and Mortality Review Conferences

Background: The Accreditation Council for Graduate Medical Education (ACGME) mandates that residents be trained in six core educational competencies. Practice-based learning and improvement (PBLI), one of the six competencies, is defined as the investigation and evaluation of ones own patient care. Morbidity and Mortality Conference, a frequently used venue to review the clinical outcome of hospitalized patients, provides the opportunity to teach and assess PBLI. Description: We report an approach to Morbidity and Mortality Conference that includes a systematic analysis of the ACGME core competencies and their application to a clinical case, a regular review of the factors that defines high-quality patient care, and a focused discussion of the PBLI competency. Evaluation: Preliminary data indicate that our residents preferred this revised method for conducting Morbidity and Mortality Conference. Conclusion: Our adaptation to Morbidity and Mortality Conference provides a systematic review of the core competencies and their relevance to clinical decision making, with the ultimate goal of improving patient care.

Parenting: linking impacts of interpartner conflict to preschool children's social behavior.

Family conflict is known to have detrimental impacts on the social development of young children. An important issue in counseling parents and the development of intervention for children is the extent to which other family environmental conditions are the path through which conflict impacts childrens development. This study examined two maternal parenting behaviors (harsh discipline and warmth) that may alter the impact of interpartner conflict on child social development and behavior in a large (n = 440 girls, n = 451 boys) sample of ethnically diverse, low-income families of preschool children. Interpartner conflict was associated with poorer child social development and behavior problems. This study found that interpartner conflict increased harsh discipline, which resulted in poorer child social development. This study, however, found no evidence that interpartner conflict impacted child development through its impact on maternal warmth in that mothers experiencing conflict did not alter the level of warm parenting practices. These findings suggest that, when encountering families experiencing interpartner conflict, clinicians should not only direct families to interventions to lessen family conflict but also counsel them on the mechanism (harsh discipline) by which children are impacted by the conflict.