Faculty Bibliography

OBJECTIVE: To determine whether the 1991 Centers for Disease Control and Prevention lead poisoning prevention guidelines for biannual screening and retesting are feasible among a high-risk population. METHODS: For 632 urban high-risk children aged 9 to 25 months who used a pediatric primary care center between 1989 and 1991, we assessed physician screening practices and the need to increase utilization to meet guidelines for retesting. Analysis also focused on missed opportunities for lead screening. For 425 urban high-risk children who were long-term utilizers of the center, we assessed the need to increase utilization to meet guidelines for biannual screening. RESULTS: Screening was not up to date in 55%, 34%, and 29% of children at ages 9 to 13 months, 14 to 19 months, and 20 to 25 months, respectively. These children had a mean of 2.3, 2.5, and 2.3 missed opportunities during each age period. Among children who had made well-child visits, in 41%, 36%, and 28% of children screening was not up to date at each age period. Between ages 13 and 37 months, 42% of long-term clinic utilizers made sufficient visits to achieve biannual screening. Sixty-five percent of children who were screened made a subsequent visit within 2 to 5 months, at which time retesting could have been performed. CONCLUSIONS: At this primary care center, many high-risk children, including those who had made well-child visits, were not appropriately screened for lead toxic effects. Children not screened had many missed opportunities at all types of visits, including well-child visits. Many children visited frequently enough to achieve biannual screening and retesting without increased numbers of visits if non-well-child visits had been used as opportunities for retesting

BACKGROUND. The Centers for Disease Control and Prevention (CDC) has recommended using a five-item questionnaire at every regular office visit for all children 6 to 72 months of age to identify those at risk of high-dose exposure to lead. OBJECTIVE: To determine how well the questionnaire identifies children with elevated lead levels. RESEARCH DESIGN. Comparison of results of the questionnaire, which is intended to identify children as being low-risk or high-risk for lead poisoning, with children's blood lead levels. SETTING. A pediatric continuity clinic located in a major teaching hospital in Rochester, NY. PATIENTS. A consecutive sample of 476 children aged 6 to 72 months without a prior history of lead poisoning who were seen in the clinic in July and August 1992, and (for those aged < 36 months) or 12 months (for those aged 36 to 72 months). MEASUREMENTS AND MAIN RESULTS. Fingerstick lead samples were obtained from all children, and those > or = 15 micrograms/dL (0.72 mumol/L) were confirmed by subsequent venous lead determinations. Twenty-eight percent had blood lead levels > or = 10 micrograms/dL (0.48 mumol/L), 8% had levels > or = 15 micrograms/dL (0.72 mumol/L), and 5% had lead levels > or = 20 micrograms/dL (0.96 mumol/L). According to responses on the questionnaire, 44% were initially classified as low-risk, and 43% were high-risk. In 13% risk could not be determined because one or more items on the questionnaire had not been answered or were answered equivocally, whereas all other items were answered 'No.' Children for whom risk could not be determined were presumed to be at high risk and were added to that category, resulting in 56% of the study population so designated. The questionnaire was moderately effective in identifying children with elevated lead levels. Seventy percent of children having lead levels > or = 10 micrograms/dL (0.48 mumol/L) and 82% of children having lead levels > or = 15 micrograms/dL (0.72 mumol/L) had been classified as high-risk by the questionnaire. Children classified as low-risk were very unlikely to have elevated lead levels. Eighty-one percent of low-risk children had lead levels < 10 ug/dL, and 97% had lead levels < 15 ul/dL. An abbreviated questionnaire using only the first three items from the CDC questionnaire had almost identical effectiveness. CONCLUSIONS. In this clinical setting, in which children are largely urban, poor, and have a moderate to high risk of developing elevated lead levels, the CDC risk assessment questionnaire is effective in identifying children with elevated lead burdens. However, an abbreviated version of the questionnaire may be as effective as the complete questionnaire. Additional questions should be added to the questionnaire to improve its overall sensitivity, and the questionnaire should be tested in other settings to see if it is effective with children having different environmental exposures to lead

The need for a widely applicable definition of chronic conditions for research, policy, and program development has led to an extensive review of the development of such definitions, the considerations involved in their use, and some recommendations for a new approach. This paper examines some of the methodologic and conceptual issues related to defining and classifying chronic conditions and describes some consequences resulting from decisions made about these issues. While most examples are taken from child health applications, the basic concepts apply to all age groups. The dominant method for identifying and classifying children as having a chronic condition has relied on the presence of an individual health condition of lengthy duration. This condition-specific or 'categorical' approach has increasingly seemed neither pragmatically nor conceptually sound. Thus, the development of a 'generic' approach, which focuses on elements that are shared by many conditions, children, and families, is recommended. Such a definition might reflect the child's functional status or ongoing use of medical services over a specified time period. In addition, it is suggested that conditions be classified based on the experience of individual children, thus emphasizing the tremendous variability in expression of seemingly similar conditions

To be consistent with national health goals and ACOG policies and recommendations, physicians providing prenatal care should encourage breast-feeding whenever possible. The parents' choice to breast- or formula-feed their infant is the consequence of a complex decision. The physician's role is to provide information objectively so that the parents' decision can be made on an informed and factual basis. Clearly, the physician must support parents' decisions. However, the distribution of formula or vouchers in the physician's office during the antepartum period places the physician in the position of advertising or promoting a specific product and of potentially contributing to the failure of some patients to nurse their infants. We urge physicians not to distribute formula or formula vouchers to their pregnant patients, and encourage local and national obstetrics organizations to consider devising and discussing a policy statement discouraging such practices