Faculty Bibliography

This policy statement offers pediatricians a concise definition of community pediatrics and provides a set of specific recommendations that underscore the critical nature of this important dimension of the profession

BACKGROUND: Dust control is recommended as one of the primary strategies to prevent or control children's exposure to residential lead hazards, but the effect of dust control on children's blood lead levels is poorly understood. OBJECTIVE: To determine the effectiveness of dust control in preventing children's exposure to lead, as measured by blood lead levels, during their peak age of susceptibility. DESIGN: A randomized, controlled trial. SETTING: Rochester, NY. PARTICIPANTS: A total of 275 urban children were randomized at 6 months of age, of whom 246 (90%) were available for the 24-month-old follow-up visit. INTERVENTIONS: Children and their families were randomly assigned to an intervention group (n = 140), which received cleaning equipment and up to eight visits by a dust control advisor, or a control group (n = 135). OUTCOME MEASURES: Geometric mean blood lead levels and prevalence of elevated blood lead levels (ie, >10 microg/dL, 15 microg/dL, and 20 microg/dL). RESULTS: At baseline, children's geometric mean blood lead levels were 2.9 microg/dL (95% confidence interval [CI] = 2.7, 3.1); there were no significant differences in characteristics or lead exposure by group assignment, with the exception of water lead levels. For children in the intervention group, the mean number of visits by a dust control advisor during the 18-month study period was 6.2; 51 (36%) had 4 to 7 visits, and 69 (49%) had 8 visits. At 24 months of age, the geometric mean blood lead was 7.3 microg/dL (95% CI = 6.6, 8.2) for the intervention group and 7.8 microg/dL (95% CI = 6.9, 8. 7) for the control group. The percentage of children with a 24-month blood lead >/=10 microg/dL, >/=15 microg/dL, and >/=20 microg/dL was 31% versus 36%, 12% versus 14%, and 5% versus 7% in the intervention and control groups, respectively. CONCLUSIONS: We conclude that dust control, as performed by families and in the absence of lead hazard controls to reduce ongoing contamination from lead-based paint, is not effective in the primary prevention of childhood lead exposure

OBJECTIVE: We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure. METHODS: Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%). RESULTS: Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02-0.08] or obstetrical (OR, 0.14; 95% CI, 0.08-0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3-110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4-306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7-7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7-4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties. CONCLUSIONS: Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques

OBJECTIVES: As part of their training, pediatric residents provide primary care services to young children, including youngsters who may have elevated blood lead levels. We set out to (1) determine the percentage of pediatric residents who screen children for elevated blood lead levels according to the guidelines of the Centers for Disease Control and Prevention and the American Academy of Pediatrics; (2) assess the likelihood of lead screening by residents based on demographic and practice-setting characteristics; and (3) compare the attitudes of residents who report that they are universal screeners, selective screeners, or nonscreeners. DESIGN: Confidential, cross-sectional survey of a nationally representative sample of pediatric residents conducted as part of the American Academy of Pediatrics 28th Periodic Survey of Fellows. SUBJECTS: One hundred forty-three responding pediatric residents (51% response rate). RESULTS: Seventy-five percent of pediatric residents reported screening all patients aged 9 to 36 months for elevated blood lead levels, 21% reported screening some, and 4% reported screening none. Pediatric residents who cared for patients in urban settings were more likely to report screening patients for elevated blood lead levels than were pediatric residents who cared for patients in suburban or rural settings (100% vs 73%; P < .001) and pediatric residents in the Northeast were more likely to report screening universally than were residents in the rest of the country (93% vs 63%; P < .001). Overall, pediatric residents who reported screening patients universally were more likely to believe that the benefits of screening outweigh the costs than were residents who reported screening patients selectively (67% vs 17%; P < .001). CONCLUSIONS: Most pediatric residents reported that they screened patients for elevated blood lead levels, either universally or selectively. Nevertheless, the screening practices of pediatric resident and their opinions concerning the relative benefits and costs of lead screening largely reflect the areas of the country and the practice settings in which they had their primary care experiences

Childhood lead poisoning is a problem that disproportionately affects impoverished children. Many aspects of affected children's lives may be involved in the prevention and treatment of this disease. Changes in child health services are occurring in the context of fundamental changes of virtually all human services. Managed care changes may alter the sites where children get primary care services, the content of that care, and linkages of medical services to public health, nutrition support, housing, mental health, education, and social services. This article discusses the opportunities and the dangers that managed care changes may pose to the prevention and treatment of childhood lead poisoning

OBJECTIVE: To investigate whether students who are old-for-grade have higher rates of reported behavior problems and to investigate whether this association is independent of having been retained a grade in school. METHODS: Cross-sectional analyses of parental reports from the nationally representative sample of 9079 children ages 7 to 17 years who participated in the Child Health Supplement to the 1988 National Health Interview Survey. Students older than the modal age for their grade were considered old-for-grade, either due to delayed school entry (those without grade retention) or to delayed school progress (with history of grade retention). Behavior problems were defined as scores >90th percentile on a well-utilized, standardized Behavior Problem Index (BPI). RESULTS: Twenty-six percent of 7- to 17-year-old children in the United States are old-for-grade. Being old-for-grade is more common in males (31%), blacks (33%), Hispanics (32%), those living in single-parent households (31%) or poverty (43%), and those with mothers with low educational attainment (42%). Most children (84%) who repeated a grade are old-for-grade, but only 54% of old-for-grade students have been retained. For children who were old-for-grade, 19% of those grade-retained and 12% of those nonretained had extreme BPI scores, and for those not old-for-grade, 17% of grade-retained and 7% of nonretained children had extreme BPI scores. Although rates of extreme BPI scores were consistently lower for children who were neither old-for-grade nor grade-retained, and consistently higher for those with both, these rates increased with age for children who were old-for-grade without being retained. Controlling for multiple potential confounders with logistic regression, both old-for-grade status and grade retention are independently associated with increased rates of behavior problems. Separate logistic regression analyses for blacks and whites showed that these findings pertained only to white children. CONCLUSIONS: Whereas grade retention is associated with increased rates of behavior problems in children and adolescents, simply being older than others in one's class, without having experienced grade retention, is also associated with increased rates of behavior problems, most noticeably among adolescents. These data suggest that there may be latent adverse behavioral outcomes that result from delaying children's school entry