Pediatrics_Nelson

Pediatrics_Nelson. The Profession of Karen J. Marcdante and Benjamin S. Siegel POPULATION AND CULTURE: THE CARE OF CHILDREN IN SOCIETY Health care professionals need to appreciate the interactionsbetween medical conditions and social, economic, and environmental influences associated with the provision of pediatriccare. New technologies and treatments help improve morbidity,mortality, and the quality of life for children and their families,but the costs may exacerbate disparities in medical care. Thechallenge for pediatricians is to deliver care that is socially equitable; integrates psychosocial, cultural, and ethical issues intopractice; and ensures that health care is available to all children.


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Pediatrics_Nelson. Many challenges affect children’s health outcomes. These include access to health care; health disparities; supporting their social, cognitive, and emotional lives in the context of families and communities; and addressing environmental factors, especially poverty. Early experiences and environmental stresses interact with the genetic predisposition of every child and, ultimately, may lead to the development of diseases seen in adulthood. Thus, pediatricians have the unique opportunity to address not only acute and chronic illnesses but also the aforementioned issues and toxic stressors to promote wellness and health maintenance in children.


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Pediatrics_Nelson. Many scientific advances have an impact on the growing role of pediatricians. Incorporating the use of newer genetic technologies allows the diagnosis of diseases at the molecular level, aids in the selection of medications and therapies, and provides information on the prognosis of some diseases. Prenatal diagnosis and newborn screening improve the accuracy of early diagnosis of a variety of conditions, allowing for earlier treatment even when a cure is impossible. Functional magnetic resonance imaging allows a greater understanding of psychiatric and neurologic problems, such as dyslexia and attention-deficit/hyperactivity disorder.


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Pediatrics_Nelson. Challenges persist with the incidence and prevalence ofchronic illness having increased in recent decades. Chronic illness is now the most common reason for hospital admissions among children (excluding trauma and newborn admissions). From middle school and beyond, mental illness is the main non–childbirth-related reason for hospitalization amongchildren. Pediatricians must also address the increasing concern about environmental toxins and the prevalence of physical, emotional, and sexual abuse, as well as violence. Since the September 11, 2001, destruction of the World Trade Centerin New York City, fear of terrorism in the United States hasincreased the level of anxiety for many families and children.


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Pediatrics_Nelson. To address these ongoing challenges, pediatricians must practice as part of a health care team. Many pediatricians already practice collaboratively with psychiatrists, psychologists, nurses, and social workers. Team composition can change, depending on location and patient needs. Although school health and school-based health clinics have improved access and outcomes for many common childhood and adolescent conditions, the shortage of available general pediatricians and family physicians has led to the development of retail medical facilities in pharmacies and retail stores.


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Pediatrics_Nelson. Childhood antecedents of adult health conditions, such as alcoholism, depression, obesity, hypertension, and hyperlipidemias, are increasingly being recognized. Maternal health status can affect the fetus. Infants who are a smaller size and relatively underweight at birth because of maternal malnutrition have increased rates of coronary heart disease, stroke, type 2 diabetes mellitus, obesity, metabolic syndrome, and osteoporosis in later life. Because of improved neonatal care, a greater percentage of preterm, low birth weight, or very low birth weight newborns survive, increasing the number of children with chronic medical conditions and developmental delays with lifelong implications.


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Pediatrics_Nelson. Complex health, economic, and psychosocial challenges greatly influence the well-being and health outcomes of children. National reports from the Centers for Disease Control andPrevention (CDC) (e.g., http://www.cdc.gov/nchs/data/hus/ hus11.pdf#102 ) provide information about many of these issues.Some of the key issues include the following: • Health insurance coverage. In 2010 over eight million children in the United States had no health insurance coverage. In addition, 10 to 20 million were underinsured. Many children, despite public sector insurance, do not receive recommended immunizations. Although Medicaid and the State Children’s Health Insurance Program covered more than 42 million children in 2010 who otherwise would not have health care access, over a million U.S. children are unable to get needed medical care because their families cannot afford it.


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Pediatrics_Nelson. Prenatal and perinatal care. Ten to 25% of women do not receive prenatal care during the first trimester. In addition, a significant percentage of women continue to smoke, use illicit drugs, and consume alcohol during pregnancy. Preterm births. The incidence of preterm births (<37 weeks) peaked in 2006 and has been slowly declining (11.99% in 2010). However, the 2010 rates of low birth weight infants (≤2500 g [8.15% of all births]) and very low birth weight infants (≤1500 g [1.45% of all births]) are essentially unchanged since 2006. Birth rate in adolescents. The national birth rate among adolescents has been steadily dropping since 1990, reaching its lowest rate (34.2 per 1000) for 15to 19-yearold adolescents in 2010.


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Pediatrics_Nelson. Birth rate in adolescents. The national birth rate among adolescents has been steadily dropping since 1990, reaching its lowest rate (34.2 per 1000) for 15to 19-yearold adolescents in 2010. Adolescent abortions. In 2009 nearly 800,000 abortions were reported to the CDC, a continued decline over the last decade. Adolescents from 15 to 19 years of age accounted for 15.5% of abortions. Approximately 60% of sexually active adolescents report using effective contraception. Infant mortality. Although infant mortality rates have declined since 1960, the disparity among the ethnic groups persists. In 2011 the overall infant mortality rate was 6.05 per 1000 live births with a rate per 1000 live births of 5.05 for non-Hispanic whites, 5.27 for Hispanic infants, and 11.42 for black infants. In 2008 the United States ranked thirty-first in infant mortality. Marked variations in infant mortality exist by state with highest mortality rates in the South and Midwest.


Pediatrics_Nelson

Pediatrics_Nelson. Initiation and maintenance of breastfeeding. Seventy-seven percent of women initiate breastfeeding following the birth of their infants. Breastfeeding rates vary by ethnicity (higher rates in non-Hispanic whites and Hispanic mothers) and education (highest in women with a bachelor’s degree or higher). Only 47% of women continue breastfeeding for 6 months, with about 25% continuing at 12 months. Cause of death in U.S. children. The overall causes of death in all children (1 to 24 years of age) in the United States in 2010, in order of frequency, were accidents (unintentional injuries), assaults (homicide), suicide, malignant neoplasms, and congenital malformations (Table 1-1). There was a slight improvement in the rate of death from all causes.


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Pediatrics_Nelson. Hospital admissions for children and adolescents. In 2010 2.4% of children were admitted to a hospital at least once. Respiratory illnesses (asthma, pneumonia, and bronchitis/bronchiolitis) and injury are the causes of over 28% of hospitalization in children under 18 years of age. Mental illness is the most common cause of admissions for children 13 to 17 years of age. Significant adolescent health challenges: substance use and abuse. There is considerable substance use and abuse in U.S. high school students. Forty-six percent of high school students reported having tried cigarettes in 2009. In 2011 nearly 71% of high school students reported having had at least one drink; 21.9% admitted to more


Pediatrics_Nelson

Pediatrics_Nelson. Table 1-1 Causes of Death by Age in the United States, 2005 AGE GROUP (YR) CAUSES OF DEATH IN ORDER OF FREQUENCY 1–4 Unintentional injuries (accidents) Congenital malformations, deformations, and chromosomal abnormalities Homicide Malignant neoplasms Diseases of the heart 5–14 Unintentional injuries (accidents) Malignant neoplasms Congenital malformations, deformations, and chromosomal abnormalities Homicide Diseases of the heart 15–24 Unintentional injuries (accidents) Homicide Suicide Malignant neoplasms Diseases of the heart From Centers for Disease Control and Prevention: Health, United States, 2011: With special feature on socioeconomic status and health (website). http://www.cdc.gov/nchs/data/hus/hus11.pdf#102 than five drinks on one day in the previous month, and 8.2% admitted to driving after drinking. Nearly 40% of high school students have tried marijuana; 11.4%, inhalants; 6.8%, cocaine; 3.8 %, methamphetamine; 2.9%, heroin; and 2%, injectables.


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Pediatrics_Nelson. • Children in foster care. Currently there are about 400,000 children in the foster care system. Approximately 25,000 of these children must leave the child welfare system each year. Of those who leave, 25% to 50% experience homelessness and/or joblessness and will not graduate from high school. These children have a high incidence of mental health problems, substance abuse, and early pregnancy for females with an increased likelihood of having a low birth weight baby. Obesity. The prevalence of obesity continues to increase. The prevalence of overweight children 6 to 19 years of age has increased more than fourfold from 4% in 1965 to over 18% in 2010. Currently it is estimated that 32% of children 2 to 19 years of age are overweight or obese. An estimated 300,000 deaths a year and at least $147 billion in health care costs are associated with the 68% of Americans who are overweight or obese.


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Pediatrics_Nelson. Sedentary lifestyle. Among 6 to 11 year olds, 62% do not engage in recommended amounts of moderate or vigorous physical activity. Nearly 40% spend more than 2 hours of screen time (television/videos) per school day. Motor vehicle accidents and injuries. In 2009, 1314 children 14 years of age or younger died in motor vehicle crashes, and 179,000 were injured. Other causes of childhood injury included drowning, child abuse, and poisonings. The estimated cost of all unintentional childhood injuries is nearly $300 billion per year in the United States. Child maltreatment. Although there has been a slow decline in the prevalence of child maltreatment, there were over 760,000 reported cases of abuse in 2009. The majority (71%) of children were neglected; 16% suffered physical abuse, and nearly 9% were victims of sexual abuse.


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Pediatrics_Nelson. Current social and economic stress on the U.S. population. There are considerable societal stresses affecting the physical and mental health of children, including rising unemployment associated with the economic slowdown, financial turmoil, and political unrest. Millions of families have lost their homes or are at risk for losing their homes after defaulting on mortgage payments. Toxic stress in childhood leading to adult health challenges. The growing understanding of the interrelationship between biologic and developmental stresses, environmental exposure, and the genetic potential of patients is helping us recognize the adverse impact of toxic stressors on health and well-being. Pediatricians must screen for and act upon factors that promote or hinder early development to provide the best opportunity for long-term health.


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Pediatrics_Nelson. Military deployment and children. Current armed conflicts and political unrest have affected millions of adults and their children. There are an estimated 1.5 million active duty and National Guard/Reserve servicemen and women, parents to over a million children. An estimated 31% of troops returning from armed conflicts have a mental health condition (alcoholism, depression, and posttraumatic stress disorder) or report having experienced a traumatic brain injury. Their children are affected by these morbidities as well as by the psychological impact of deployment on children of all ages. Child maltreatment is more prevalent in families of U.S.-enlisted soldiers during combat deployment than in nondeployed soldiers.


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Pediatrics_Nelson. Health disparities are the differences that remain after taking into account patients’ needs, preferences, and the availability of health care. Social conditions, social inequity, discrimination, social stress, language barriers, and poverty are antecedents to and associated causes of health disparities. The disparities in infant mortality relate to poor access to prenatal care during pregnancy and the lack of access and appropriate heath services for women, such as preventive services, family planning, and appropriate nutrition and health care, throughout their life span. Infant mortality increases as the mother’s level of education decreases. Children from poor families are less likely to be immunized at 4 years of age and less likely to receive dental care. Rates of hospital admission are higher for people who live in low-income areas.


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Pediatrics_Nelson. Children from poor families are less likely to be immunized at 4 years of age and less likely to receive dental care. Rates of hospital admission are higher for people who live in low-income areas. Children of ethnic minorities and children from poor families are less likely to have physician office or hospital outpatient visits and more likely to have hospital emergency department visits. Children with Medicaid/public coverage are less likely to be in excellent health than children with private health insurance. Access to care for children is easier for whites and for children of higher income families than for minority and low-income families. CHANGING MORBIDITY: THE SOCIAL/ EMOTIONAL ASPECTS OF PEDIATRIC PRACTICE


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Pediatrics_Nelson. CHANGING MORBIDITY: THE SOCIAL/ EMOTIONAL ASPECTS OF PEDIATRIC PRACTICE Changing morbidity reflects the relationship among environmental, social, emotional, and developmental issues; child health status; and outcome. These observations are based on significant interactions of biopsychosocial influences on health and illness, such as school problems, learning disabilities, and attention problems; child and adolescent mood and anxiety disorders; adolescent suicide and homicide; firearms in the home; school violence; effects of media violence, obesity, and sexual activity; and substance use and abuse by adolescents.


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Pediatrics_Nelson. Currently 20% to 25% of children are estimated to have some mental health problems; 5% to 6% of these problems are severe. Unfortunately it is estimated that pediatricians identify only 50% of mental health problems. The overall prevalence of psychosocial dysfunction of preschool and school-age children is 10% and 13%, respectively. Children from poor families are twice as likely to have psychosocial problems than children from higher income families. Nationwide, there is a lack of adequate mental health services for children.


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Pediatrics_Nelson. Important influences on children’s health, in addition to poverty, include homelessness, single-parent families, parental divorce, domestic violence, both parents working, and inadequate child care. Related pediatric challenges include improving the quality of health care, social justice, equality in health care access, and improving the public health system. For adolescents, there are special concerns about sexuality, sexual orientation, pregnancy, substance use and abuse, violence, depression, and suicide.


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Pediatrics_Nelson. Culture is an active, dynamic, and complex process of the way people interact and behave in the world. Culture encompasses the concepts, beliefs, values (including nurturing of children), and standards of behavior, language, and dress attributable to people that give order to their experiences in the world, offer sense and purpose to their interactions with others, and provide meaning for their lives. The growing diversity of the United States requires that health care workers make an attempt to understand the impact of health, illness, and treatment on the patient and family from their perspective. This requires open-ended questions, such as: “What worries (concerns) you the most about your child’s illness?” and “What do you think has caused your child’s illness?” These can facilitate a discussion of parents’ thoughts and feelings about the illness and its causes. Addressing concepts and beliefs about how one interacts with health professionals as well as the family’s spiritual and


Pediatrics_Nelson

Pediatrics_Nelson. discussion of parents’ thoughts and feelings about the illness and its causes. Addressing concepts and beliefs about how one interacts with health professionals as well as the family’s spiritual and religious approach to health and health care from a cultural perspective allows the pediatrician, patient, and family to incorporate differences in perspectives, values, or beliefs into the care plan. Significant conflicts may arise because religious or cultural practices may lead to the possibility of child abuse and neglect. In this circumstance, the pediatrician is required by law to report the suspected child abuse and neglect to the appropriate social service authorities (see Chapter 22).


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Pediatrics_Nelson. Complementary and alternative medicine (CAM) practices constitute a part of the broad cultural perspective. Therapeutic modalities for CAM include biochemical, lifestyle, biomechanical, and bioenergetic treatments, as well as homeopathy. It is estimated that 20% to 30% of all children and 50% to 75% of adolescents use CAM. Of children with chronic illness, 30% to 70% use CAM therapies, especially for asthma and cystic fibrosis. Only 30% to 60% of children and families tell their physicians about their use of CAM. Some modalities may be effective, whereas others may be ineffective or even dangerous. Society provides a profession with economic, political, and social rewards. Professions have specialized knowledge and the potential to maintain a monopoly on power and control, remaining relatively autonomous. The profession’s autonomy can be limited by societal needs. A profession exists as long as it fulfills its responsibilities for the social good.


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Pediatrics_Nelson. Today the activities of medical professionals are subject to explicit public rules of accountability. Governmental and other authorities grant limited autonomy to the professional organizations and their membership. City and municipal government departments of public health establish and implement health standards and regulations. At the state level, boards of registration in medicine establish the criteria for obtaining and revoking medical licenses. The federal government regulates the standards of services, including Medicare, Medicaid, and the Food and Drug Administration. The Department of Health and Human Services regulates physician behavior in conducting research with the goal of protecting human subjects. The Health Care Quality Improvement Act of 1986 authorized the federal government to establish the National Practitioner Data Bank, which contains information about physicians (and other health care practitioners) who have been disciplined by a state licensing board,


Pediatrics_Nelson

Pediatrics_Nelson. government to establish the National Practitioner Data Bank, which contains information about physicians (and other health care practitioners) who have been disciplined by a state licensing board, professional society, hospital, or health plan or named in medical malpractice judgments or settlements. Hospitals are required to review information in this data bank every 2 years as part of clinician recredentialing. There are accrediting agencies for medical schools, such as the Liaison Committee on Medical Education (LCME), and postgraduate training, such as the Accreditation Council for Graduate Medical Education (ACGME). The ACGME includes committees that review subspecialty training programs.


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Pediatrics_Nelson. Historically the most privileged professions have depended on their legitimacy for serving the public interest. The public trust of physicians is based on the physician’s commitment to altruism. Many medical schools include variations on the traditional Hippocratic Oath as part of the commencement ceremonies as a recognition of a physician’s responsibility to put the interest of others ahead of self-interest.


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Pediatrics_Nelson. The core of professionalism is embedded in the daily healingwork of the physician and encompassed in the patient-physicianrelationship. Professionalism includes an appreciation for the cultural and religious/spiritual health beliefs of the patient,incorporating the ethical and moral values of the profession andthe moral values of the patient. Unfortunately, the inappropriateactions of a few practicing physicians, physician investigators,and physicians in positions of power in the corporate world have created a societal demand to punish those involved andhave led to the erosion of respect for the medical profession. The American Academy of Pediatrics (AAP), the American Board of Pediatrics (ABP), the American Board of Internal Medicine, the LCME, the Medical School Objectives Project of the Association of American Medical Colleges, and the ACGME Outcome Project have called for increasing attention to professionalism in the practice of medicine and in the education of physicians.


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Pediatrics_Nelson. The ABP adopted professional standards in 2000, and the AAP updated the policy statement and technical report on Professionalism in 2007, as follows: Honesty/integrity is the consistent regard for the highest standards of behavior and the refusal to violate one’s personal and professional codes. Maintaining integrity requires awareness of situations that may result in conflict of interest or that may result in personal gain at the expense of the best interest of the patient. Reliability/responsibility includes accountability to one’s patients and their families, to society to ensure that the public’s needs are addressed, and to the profession to ensure that the ethical precepts of practice are upheld. Inherent in this responsibility is reliability in completing assigned duties or fulfilling commitments. There also must be a willingness to accept responsibility for errors.


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Pediatrics_Nelson. for others is the essence of humanism. The pediatrician must treat all persons with respect and regard for their individual worth and dignity; be aware of emotional, personal, family, and cultural influences on a patient’s well being, rights, and choices of medical care; and respect appropriate patient confidentiality. Compassion/empathy is a crucial component of medical practice. The pediatrician must listen attentively, respond humanely to the concerns of patients and family members, and provide appropriate empathy for and relief of pain, discomfort, and anxiety as part of daily practice. Self-improvement is the pursuit of and commitment to providing the highest quality of health care through lifelong learning and education. The pediatrician must seek to learn from errors and aspire to excellence through self-evaluation and acceptance of the critiques of others.


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Pediatrics_Nelson. Self-awareness/knowledge of limits includes recognition of the need for guidance and supervision when faced with new or complex responsibilities. The pediatrician also must be insightful regarding the impact of his or her behavior on others and cognizant of appropriate professional boundaries. Communication/collaboration is crucial to providing the best care for patients. Pediatricians must work cooperatively and communicate effectively with patients and their families and with all health care providers involved in the care of their patients. Altruism/advocacy refers to unselfish regard for and devotion to the welfare of others. It is a key element of professionalism. Self-interest or the interests of other parties should not interfere with the care of one’s patients and their families.


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Pediatrics_Nelson. The ethics of health care and medical decision making relies on values to determine what kinds of decisions are best or appropriate for all. Sometimes ethical decision making in medical care is a matter of choosing the least harmful option among many adverse alternatives. In the day-to-day practice of medicine, although all clinical encounters may have an ethical component, major ethical challenges are infrequent.


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Pediatrics_Nelson. The legal system defines the minimal standards of behavior required of physicians and the rest of society through the legislative, regulatory, and judicial systems. Laws exist to provide for social order and adjudicate disputes, not to address ethical concerns. The laws support the principle of confidentiality for teenagers who are competent to decide about such issues. Using the concept of limited confidentiality, parents, teenagers, and the pediatrician may all agree to openly discuss serious health challenges, such as suicidal ideation and pregnancy. This reinforces the long-term goal of supporting the autonomy and identity of the teenager while encouraging appropriate conversations with parents.


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Pediatrics_Nelson. Ethical problems derive from value differences amongpatients, families, and clinicians about choices and options in the provision of health care. Resolving these value differences involves several important ethical principles. Autonomy, which is based on the principle of respect for persons, means that competent adult patients can make choices about health care that they perceive to be in their best interests, after being appropriately informed about their particular health condition and the risks and benefits of alternatives of diagnostic tests and treatments. Paternalism challenges the principle of autonomy and involves the clinician deciding what is best for the patient, based on how much information is provided. Paternalism, under certain circumstances (e.g., when a patient has a life-threatening medical condition or a significant psychiatric disorder and is threatening self or others), may be more appropriate than autonomy. Weighing the values of autonomy and paternalism can


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Pediatrics_Nelson. life-threatening medical condition or a significant psychiatric disorder and is threatening self or others), may be more appropriate than autonomy. Weighing the values of autonomy and paternalism can challenge the clinician.


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Pediatrics_Nelson. Other important ethical principles are those of beneficence (doing good), nonmaleficence (doing no harm or as little harm as possible), and justice (the values involved in the equality of the distribution of goods, services, benefits, and burdens to the individual, family, or society). End-of-life decision making must address quality of life and suffering in the provision of palliative and hospice care (see Chapter 4). ETHICAL PRINCIPLES RELATED TO INFANTS, CHILDREN, AND ADOLESCENTS


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Pediatrics_Nelson. ETHICAL PRINCIPLES RELATED TO INFANTS, CHILDREN, AND ADOLESCENTS Children vary from being totally dependent on parents or guardians to meet their health care needs to being more independent. Infants and young children do not have the capacity for making medical decisions. Paternalism by parents and pediatricians in these circumstances is appropriate. Adolescents (<18 years of age), if competent, have the legal right to make medical decisions for themselves. Children 8 to 9 years old can understand how the body works and the meaning of certain procedures; by age 14 to 15, young adolescents may be considered autonomous through the process of being designated a mature or emancipated minor or by having certain medical conditions. It is ethical for pediatricians to involve children in the decision-making process with information appropriate to their capacity to understand. The process of obtaining the assent of a child is consistent with this goal.


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Pediatrics_Nelson. The principle of shared decision making is appropriate, but the process may be limited because of issues of confidentiality in the provision of medical care. A parent’s concern about the side effects of immunization raises a conflict between the need to protect and support the health of the individual and the public with the rights of the individual and involves ethical issues of distributive justice in regard to the costs and distribution of the vaccinations and responsibility for side effects. All competent patients of an age defined legally by each state (usually ≥18 years of age) are considered autonomous with regard to their health decisions. To have the capacity to decide, patients must meet the following requirements: Understand the nature of the medical interventions and procedures, understand the risks and benefits of these interventions, and be able to communicate their decision.


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Pediatrics_Nelson. Understand the nature of the medical interventions and procedures, understand the risks and benefits of these interventions, and be able to communicate their decision. Reason, deliberate, and weigh the risks and benefits using their understanding about the implications of the decision on their own welfare. Apply a set of personal values to the decision-makingprocess and show an awareness of the possible conflicts ordifferences in values as applied to the decisions to be made. These requirements need to be placed within the context of medical care and applied to each case with its unique characteristics. Most young children are not able to meet the requirementsfor competency and need others, usually the parent, to makedecisions for them. Legally parents are given great discretion inmaking decisions for their children. This discretion is legally limited when there is child abuse and neglect, which triggers a further legal process in determining the best interests of the child.


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Pediatrics_Nelson. It is important to become familiar with state law becausestate law, not federal law, determines when an adolescent can consent to medical care and when parents may access confidential adolescent medical information. The Health Insurance Portability and Accountability Act (HIPAA) of 1996,which became effective in 2003, requires a minimal standardof confidentiality protection. The law confers less confidentiality protection to minors than to adults. It is the pediatrician’sresponsibility to inform minors of their confidentiality rightsand help them exercise these rights under the HIPAA regulations. Under special circumstances, nonautonomous adolescents are granted the legal right to consent under state law when they are considered mature or emancipated minors or because of certain public health considerations, as follows:


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Pediatrics_Nelson. Mature minors. Some states have legally recognized that many adolescents age 14 and older can meet the cognitive criteria and emotional maturity for competence and may decide independently. The Supreme Court has decided that pregnant, mature minors have the constitutional right to make decisions about abortion without parental consent. Although many state legislatures require parental notification, pregnant adolescents wishing to have an abortion do not have to seek parental consent. The state must provide a judicial procedure to facilitate this decision making for adolescents.


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Pediatrics_Nelson. Emancipated minors. Children who are legally emancipated from parental control may seek medical treatment without parental consent. The definition varies from state to state but generally includes children who have graduated from high school, are members of the armed forces, married, pregnant, runaways, are parents, live apart from their parents, and are financially independent or declared emancipated by a court. Interests of the state (public health). State legislatures have concluded that minors with certain medical conditions, such as sexually transmitted infections and other contagious diseases, pregnancy (including prevention with the use of birth control), certain mental illnesses, and drug and alcohol abuse, may seek treatment for these conditions autonomously. States have an interest in limiting the spread of disease that may endanger the public health and in eliminating barriers to access for the treatment of certain conditions.


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Pediatrics_Nelson. From an ethical perspective, clinicians should engage children and adolescents, based on their developmental capacity, in discussions about medical plans so that they have a good understanding of the nature of the treatments and alternatives, the side effects, and expected outcomes. There should be an assessment of the patient’s understanding of the clinical situation, how the patient is responding, and the factors that may influence the patient’s decisions. Pediatricians should always listen to and appreciate patients’ requests for confidentiality and their hopes and wishes. The ultimate goal is to help nourish children’s capacity to become as autonomous as is appropriate to their developmental stage.


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Pediatrics_Nelson. Confidentiality is crucial to the provision of medicalcare and is an important part of the basis for a trusting patient-family-physician relationship. Confidentiality meansthat information about a patient should not be shared withoutconsent. If confidentiality is broken, patients may experiencegreat harm and may not seek needed medical care. See Chapter67 for a discussion of confidentiality in the care of adolescents.


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Pediatrics_Nelson. The goal of screening is to identify diseases when there is no clinically identifiable risk factor for disease. Screening should take place only when there is a treatment available or when a diagnosis would benefit the child. Testing usually is performed when there is some clinically identifiable risk factor. Genetic testing and screening present special problems because test results have important implications. Some genetic screening (sickle cell anemia or cystic fibrosis) may reveal a carrier state, which may lead to choices about reproduction or create financial, psychosocial, and interpersonal problems (e.g., guilt, shame, social stigma, and discrimination in insurance and jobs). Collaboration with, or referral to, a clinical geneticist is appropriate in helping the family with the complex issues of genetic counseling when a genetic disorder is detected or likely to be detected.


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Pediatrics_Nelson. Newborn screening should not be used as a surrogate for parental testing. Examples of diseases that can be diagnosed by genetic screening, even though the manifestations of the disease process do not appear until later in life, are polycystic kidney disease; Huntington disease; certain cancers, such as breast cancer in some ethnic populations; and hemochromatosis. Parents may pressure the pediatrician to order genetic tests when the child is still young, for the parents’ purposes. Testing for these disorders should be delayed until the child has the capacity for informed consent or assent and is competent to make decisions, unless there is a direct benefit to the child at the time of testing.


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Pediatrics_Nelson. The pediatrician is required to act in the best interests of the child, even when religious tenets may interfere with the health and well-being of the child. When an infant or child whose parents have a religious prohibition against a blood transfusion needs a transfusion to save his or her life, the courts always have intervened to allow a transfusion. In contrast, parents with strong religious beliefs under some state laws may refuse immunizations for their children. However, state governments can mandate immunizations for all children during disease outbreaks or epidemics. By requiring immunization of all, including individuals who object on religious grounds, the state government is using the principle of distributive justice,which states that all members of society must share in the burdens and the benefits to have a just society. Children as Human Subjects in Research


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Pediatrics_Nelson. Children as Human Subjects in Research The goal of research is to develop new and generalized knowledge. Parents may give informed permission for children to participate in research under certain conditions. Children cannot give consent but may assent or dissent to research protocols. Special federal regulations have been developed to protect child and adolescent participants in human investigation. These regulations provide additional safeguards beyond the safeguards provided for adult participants in research, while still providing the opportunity for children to benefit from the scientific advances of research. Many parents with seriously ill children hope that the research protocol will have a direct benefit for their particular child. The greatest challenge for researchers is to be clear with parents that research is not treatment. This fact should be addressed as sensitively and compassionately as possible.


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Pediatrics_Nelson. The death of a child is one of life’s most difficult experiences. The palliative care approach to a child’s medical care should be instituted when medical diagnosis, intervention, and treatment cannot reasonably be expected to affect the imminence of death. In these circumstances, the goals of care focus on improving the quality of life, maintaining dignity, and ameliorating the suffering of the seriously ill child. Central to this approach is the willingness of clinicians to look beyond the traditional medical goals of curing disease and preserving life. They need to look toward enhancing the life of the child and working with family members and close friends when the child’s needs are no longer met by curative goals. High-quality palliative care is an expected standard at the end of life.


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Pediatrics_Nelson. Palliative care in pediatrics is not simply end-of-life care.There are conditions where death is not predictably imminent,and a child’s needs are best met by the palliative care approach.Children needing palliative care have been described as havingconditions that fall into four basic groups, based on the goal oftreatment. These include conditions of the following scenarios: A cure is possible, but failure is not uncommon (e.g., cancer with a poor prognosis). Long-term treatment is provided with a goal of maintaining quality of life (e.g., cystic fibrosis). Treatment that is exclusively palliative after the diagnosis of a progressive condition is made (e.g., trisomy 13 syndrome). Treatments are available for severe, nonprogressive disability in patients who are vulnerable to health complications (e.g., severe spastic quadriparesis with difficulty in controlling symptoms).


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Pediatrics_Nelson. Treatments are available for severe, nonprogressive disability in patients who are vulnerable to health complications (e.g., severe spastic quadriparesis with difficulty in controlling symptoms). These conditions present different timelines and different models of medical intervention. Yet they all share the need to attend to concrete elements, which affect the quality of a child’s death, mediated by medical, psychosocial, cultural, and spiritual concerns.


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Pediatrics_Nelson. The sudden death of a child also requires elements of the palliative care approach, although conditions do not allow for the full spectrum of involvement. Many of these deaths involve emergency medicine caregivers and first responders in the field, and they may involve dramatic situations where no relationship may exist between caregivers and the bereaved family. Families who have not had time to prepare for the tragedy of an unexpected death require considerable support. Palliative care can make important contributions to the endof-life and bereavement issues that families face in these circumstances. This may become complicated in circumstances where the cause of the death must be fully explored. The need to investigate the possibility of child abuse or neglect subjects the family to intense scrutiny and may create guilt and anger directed at the medical team.


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Pediatrics_Nelson. Palliative treatment is directed toward the relief of symptomsas well as assistance with anticipated adaptations that maycause distress and diminish the quality of life of the dying child.Elements of palliative care include pain management; expertise with feeding and nutritional issues at the end of life; and management of symptoms, such as minimizing nausea and vomiting, bowel obstruction, labored breathing, and fatigue.Psychological elements of palliative care have a profound importance and include sensitivity to bereavement, a developmentalperspective of a child’s understanding of death, clarification ofthe goals of care, and ethical issues. Curative care and palliativecare can coexist; aggressive pain medication may be providedwhile curative treatment is continued in the hopes of a remission or improved health status. Palliative care is delivered with amultidisciplinary approach, giving a broad range of expertise topatients and families as well as providing a supportive networkfor


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Pediatrics_Nelson. or improved health status. Palliative care is delivered with amultidisciplinary approach, giving a broad range of expertise topatients and families as well as providing a supportive networkfor the caregivers. Caregivers involved may be pediatricians,nurses, mental health professionals, social workers, and pastors.


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Pediatrics_Nelson. A model of integrated palliative care rests on the following principles:


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Pediatrics_Nelson. Article I. Respect for the dignity of patients and families. The clinician should respect and listen to patient and family goals, preferences, and choices. School-age children can articulate preferences about how they wish to be treated. Adolescents, by the age of 14, can engage in decision making (see Section 12). The pediatrician should assist the patient and the family in understanding the diagnosis, treatment options, and prognosis; help clarify the goals of care; promote informed choices; allow for the free flow of information; and listen to and discuss the social-emotional concerns. Advanced care (advance directives) should be instituted with the child and parents, allowing discussions about what they would like as treatment options as the end of life nears. Differences of opinion between the family and the pediatrician should be addressed by identifying the multiple perspectives, reflecting on possible conflicts, and altruistically coming to agreements that validate the patient


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Pediatrics_Nelson. the family and the pediatrician should be addressed by identifying the multiple perspectives, reflecting on possible conflicts, and altruistically coming to agreements that validate the patient and family perspectives, yet reflect sound practice. Hospital ethics committees and consultation services are important resources for the pediatrician and family members.


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Pediatrics_Nelson. Article II. Access to comprehensive and compassionatepalliative care. The clinician should address the physicalsymptoms, comfort, and functional capacity, with specialattention to pain and other symptoms associated with thedying process, and respond empathically to the psychologicaldistress and human suffering, providing treatment options.Respite should be available at any time during the illness toallow the family caregivers to rest and renew. Article III. Use of interdisciplinary resources. Because of the complexity of care, no one clinician can provide all of the needed services. The team members may include primary and subspecialty physicians, nurses in the hospital/facility or for home visits, the pain management team, psychologists, social workers, pastoral ministers, schoolteachers, friends of the family, and peers of the child. The child and family should be in a position to decide who should know what during all phases of the illness process.


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Pediatrics_Nelson. Article IV. Acknowledgment and support provisions for caregivers. The death of a child is difficult to accept and understand. The primary caregivers of the child, family, and friends need opportunities to address their own emotional concerns. Siblings of the child who is dying react emotionally and cognitively, based on their developmental level. Team meetings to address thoughts and feelings of team members are crucial. Soon after the death of the child, the care team should review the experience with the parents and family and share their reactions and feelings. Institutional support may include time to attend funerals, counseling for the staff, opportunities for families to return to the hospital, and scheduled ceremonies to commemorate the death of the child. Article V. Commitment to quality improvement of palliative care through research and education.


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Pediatrics_Nelson. Article V. Commitment to quality improvement of palliative care through research and education. Hospitals should develop support systems and staff to monitor the quality of care continually, assess the need for appropriate resources, and evaluate the responses of the patient and family members to the treatment program. Issues often arise over less than completely successful attempts to control the dying child’s symptoms or differences between physicians and family members in the timing of the realization that death is imminent. Consensus results in better palliative care from the medical and psychosocial perspective.


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Pediatrics_Nelson. Hospice care is a treatment program for the end of life, providing the range of palliative care services by an interdisciplinary team, including specialists in the bereavement and end-of-life process. Typically, the hospice program uses the adult Medicare model, requiring a prognosis of death within 6 months and the cessation of curative efforts for children to receive hospice services. Recently some states have developed alternative pediatric models where curative efforts may continue while the higher level of coordinated end-of-life services may be applied.


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Pediatrics_Nelson. Bereavement refers to the process of psychological and spiritual accommodation to death on the part of the child and the child’s family. Grief has been defined as the emotional response caused by a loss, including pain, distress, and physical and emotional suffering. It is a normal adaptive human response to death. Palliative care attends to the grief reaction. Assessing the coping resources and vulnerabilities of the affected family before death takes place is central to the palliative care approach. Parental grief is recognized as being more intense and sustained than other types of grief. Most parents work through their grief. Complicated grief, a pathologic manifestation of continued and disabling grief, is rare. Parents who share their problems with others during the child’s illness, who have had access to psychological support during the last month of their child’s life, and who have had closure sessions with the attending staff, are more likely to resolve their grief.


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Pediatrics_Nelson. A particularly difficult issue for parents is whether to talk with their child about the child’s imminent death. Although evidence suggests that sharing accurate and truthful information with a dying child is beneficial, each individual case presents its own complexities, based on the child’s age, cognitive development, disease, timeline of disease, and parental psychological state. Parents are more likely to regret not talking with their child about death than having done so. Among those who did not talk with their child about death, parents who sensed their child was aware of imminent death, parents of older children, and mothers more than fathers were more likely to feel regretful. COGNITIVE ISSUES IN CHILDREN AND ADOLESCENTS: UNDERSTANDING DEATH AND DYING


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Pediatrics_Nelson. COGNITIVE ISSUES IN CHILDREN AND ADOLESCENTS: UNDERSTANDING DEATH AND DYING The pediatrician should communicate with children aboutwhat is happening to them, while respecting the cultural andpersonal preferences of the family. A developmental understanding of children’s concepts of health and illness helpsframe the discussion with children and can help parentsunderstand how their child is grappling with the situation.Piaget’s theories of cognitive development, which help illustrate children’s concepts of death and disease, are categorizedas sensorimotor, preoperational, concrete operations, and formal operations.


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Pediatrics_Nelson. For very young children, up to 2 years of age (sensorimotor), death is seen as a separation, and there is probably no concept of death. The associated behaviors in grieving children of this age usually include protesting and difficulty of attachment to other adults. The degree of difficulty depends on the availability of other nurturing people with whom the child has had a good previous attachment. Children from 3 to 5 years of age (preoperational) (sometimes called the magic years) have trouble grasping the meaning of the illness and the permanence of the death. Their language skills at this age make understanding their moods and behavior difficult. Because of a developing sense of guilt, death may be viewed as punishment. If a child previously wished a younger sibling to have died, the death may be seen psychologically as being caused by the child’s wishful thinking. They can feel overwhelmed when confronted with the strong emotional reactions of their parents.


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Pediatrics_Nelson. In children ages 6 to 11 years of age (late preoperational to concrete operational), the finality of death gradually comes to be understood. Magical thinking gives way to a need for detailed information to gain a sense of control. Older children in this range have a strong need to control their emotions by compartmentalizing and intellectualizing. In adolescents (≥12 years of age) (formal operations), death is a reality and is seen as universal and irreversible. Adolescents handle death issues at the abstract or philosophical level and can be realistic. They may also avoid emotional expression and information, instead relying on anger or disdain. Adolescents can discuss withholding treatments. Their wishes, hopes, and fears should be attended to and respected. CULTURAL, RELIGIOUS, AND SPIRITUAL CONCERNS ABOUT PALLIATIVE CARE AND END-OF-LIFE DECISIONS


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Pediatrics_Nelson. Understanding the family’s religious/spiritual or cultural beliefs and values about death and dying can help the pediatrician work with the family to integrate these beliefs, values, and practices into the palliative care plan. Cultures vary regarding the roles family members have, the site of treatment for dying people, and the preparation of the body. Some ethnic groups expect the clinical team to speak with the oldest family member or to only the head of the family outside of the patient’s presence. Some families involve the entire extended family in decision making. For some families, dying at home can bring the family bad luck, whereas others believe that the patient’s spirit will become lost if the death occurs in the hospital. In some traditions, the health care team cleans and prepares the body, whereas, in others, family members prefer to complete this ritual. Religious/spiritual or cultural practices may include prayer, anointing, laying on of the hands, an exorcism ceremony


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Pediatrics_Nelson. the body, whereas, in others, family members prefer to complete this ritual. Religious/spiritual or cultural practices may include prayer, anointing, laying on of the hands, an exorcism ceremony to undo a curse, amulets, and other religious objects placed on the child or at the bedside. Families differ in the idea of organ donation and the acceptance of autopsy. Decisions, rituals, and withholding of palliative or lifesaving procedures that could harm the child or are not in the best interests of the child should be addressed. Quality palliative care attends to this complexity and helps parents and families through the death of a child while honoring the familial, cultural, and spiritual values.


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Pediatrics_Nelson. Before speaking with a child about death, the caregiver should assess the child’s age, experience, and level of development; the child’s understanding and involvement in end-of-life decision making; the parents’ emotional acceptance of death; their coping strategies; and their philosophical, spiritual, and cultural views of death. These may change over time, and the use of open-ended questions to repeatedly assess these areas contributes to the end-of-life process. The care of a dying child can create ethical dilemmas involving autonomy, beneficence (doing good), nonmaleficence (doing no harm), truth telling, confidentiality, or the physician’s duty. It is extremely difficult for parents to know when the burdens of continued medical care are no longer appropriate for their child. The beliefs and values of what constitutes quality of life, when life ceases to be worth living, and religious/spiritual, cultural, and philosophical beliefs may differ between families and health care


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Pediatrics_Nelson. beliefs and values of what constitutes quality of life, when life ceases to be worth living, and religious/spiritual, cultural, and philosophical beliefs may differ between families and health care workers. The most important ethical principle is what is in the best interest of the child as determined through the process of shared decision making, informed permission/ consent from the parents, and assent from the child. Sensitive and meaningful communication with the family, in their own terms, is essential. The physician, patient, and family must negotiate the goals of continued medical treatment while recognizing the burdens and benefits of the medical intervention plan. There is no ethical or legal difference between withholding treatment and withdrawing treatment, although many parents and physicians see the latter as more challenging. Family members and the patient should agree about what are appropriate do not resuscitate (also called DNR) orders. Foregoing some measures does


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Pediatrics_Nelson. and physicians see the latter as more challenging. Family members and the patient should agree about what are appropriate do not resuscitate (also called DNR) orders. Foregoing some measures does not preclude other measures being implemented, based on the needs and wishes of the patient and family. When there are serious differences among parents, children, and physicians on these matters, the physician may consult with the hospital ethics committee or, as a last resort, turn to the legal system by filing a report about potential abuse or neglect.


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Pediatrics_Nelson. American Academy of Pediatrics: Committee on Bioethics Fallat ME, Glover J: Professionalism in pediatrics: statement of principles, Pediatrics 120(4):895–897, 2007 American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family Health: The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care, Pediatrics 108(5):1227–1230, 2001 Bloom B, Cohen RA: Summary health statistics for U.S. children: National health interview survey, 2006, National Center for Health Statistics, Vital Health Stat 10(234):1–79, 2007 Flores G, Tomany-Korman SC: Racial and ethnic disparities in medical and dental health, access to care, and use of health services in US children, Pediatrics 121(2):e286–e298, 2008 Gluckman PD, Hanson MA, Cooper C, et al.: Effect of in utero and early-life considerations on adult health and disease, N Engl J Med 359(1):61–73, Hamilton BE, Martin JA, Ventura SJ: Births: preliminary data for 2006, Natl


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Pediatrics_Nelson. Hamilton BE, Martin JA, Ventura SJ: Births: preliminary data for 2006, Natl Vital Stat Rep 56(7):1–18, 2007 . National Center for Health Statistics: Health, United States, 2007: with chart-book on trends in the health of Americans, Hyattsville, MD, 2007. David A. Levine 2 The frequent office visits for health maintenance in the first 2 years of life are more than physicals. Although a somatic history and physical examination are important parts of each visit, many other issues are discussed, including nutrition, behavior, development, safety, and anticipatory guidance. Disorders of growth and development are often associatedwith chronic or severe illness or may be the only symptom ofparental neglect or abuse. Although normal growth and development does not eliminate a serious or chronic illness, in general, itsupports a judgment that a child is healthy except for acute, oftenbenign, illnesses that do not affect growth and development.


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Pediatrics_Nelson. The processes of growth and development are intertwined. However, it is convenient to refer to growth as the increase in size and development as an increase in function of processesrelated to body and mind. Being familiar with normal patternsof growth and development allows those practitioners whocare for children to recognize and manage abnormal variations. The genetic makeup and the physical, emotional, and socialenvironment of the individual determine how a child grows anddevelops throughout childhood. One goal of pediatrics is to helpeach child achieve his or her individual potential through periodically monitoring and screening for the normal progressionor abnormalities of growth and development. The AmericanAcademy of Pediatrics recommends routine office visits in thefirst week of life (depending on timing of nursery discharge) at 2weeks; at 1, 2, 4, 6, 9, 12, 15, and 18 months; at 2, 2½, and3 years;then annually through adolescence/young adulthood (Fig. 9-1).


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Pediatrics_Nelson. Deviations in growth patterns may be nonspecific or may be important indicators of serious and chronic medical disorders. An accurate measurement of length/height, weight, and head circumference should be obtained at every health supervision visit and compared with statistical norms on growth charts. Table 5-1 summarizes several convenient benchmarks to evaluate normal growth. Serial measurements are much more useful than single measurements to detect deviations from a particular growth pattern, even if the value remains within statistically defined normal limits (percentiles). Following the trend helps define whether growth is within acceptable limits or warrants further evaluation.


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Pediatrics_Nelson. Growth is assessed by plotting accurate measurements on growth charts and comparing each set of measurements withprevious measurements obtained at health visits. Please seeexamples in Figures 5-1 to 5-4. Complete charts can be found at www.cdc.gov/growthcharts/who_charts.htm for birth to 2 years and www.cdc.gov/growthcharts for 2 to 20 years. The body massindex is defined as body weight in kilograms divided by height inmeters squared; it is used to classify adiposity and is recommendedas a screening tool for children and adolescents to identify thoseoverweight or at risk for being overweight (see Chapter 29).


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Pediatrics_Nelson. Normal growth patterns have spurts and plateaus, so some shifting on percentile graphs can be expected. Large shifts in percentiles warrant attention, as do large discrepancies in height, weight, and head circumference percentiles. When caloric intake is inadequate, the weight percentile falls first, then the height, and the head circumference is last. Caloric intake may be poor as a result of inadequate feeding or because the child is not receiving adequate attention and stimulation (nonorganic failure to thrive [see Chapter 21]). Caloric intake also may be inadequate because of increased caloric needs. Children with chronic illnesses, such as heart failure or cystic fibrosis, may require a significantly higher caloric intake to sustain growth. An increasing weight percentile in the face of a falling height percentile suggests hypothyroidism. Head circumference may be disproportionately


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Pediatrics_Nelson. Weight loss in first few days: 5%–10% of birth weight Return to birth weight: 7–10 days of age Double birth weight: 4–5 months Triple birth weight: 1 year Daily weight gain: 20–30 g for first 3–4 months 15–20 g for rest of the first year Average length: 20 in. at birth, 30 in. at 1 year At age 4 years, the average child is double birth length or 40 in. Average HC: 35 cm at birth (13.5 in.) HC increases: 1 cm per month for first year (2 cm per month for first 3 months, then slower) Birth to 24 months: Boys Length-for-age and Weight-for-age percentiles Figure 5-1 Length-by-age and weight-by-age percentiles for boys, birth to 2 years of age. Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion. (From Centers for Disease Control and Prevention: WHO Child Growth Standards, Atlanta, Ga, 2009. Available at http://www.cdc.gov/growthcharts/who_charts.htm


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Pediatrics_Nelson. Figure 5-2 Head circumference and weight-by-length percentiles for boys, birth to 2 years of age. Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion. (From Centers for Disease Control and Prevention: WHO Child Growth Standards, Atlanta, Ga, 2009. Available at http://www.cdc.gov/growthcharts/who_charts.htm 2to20 years: Girls StatureWeight-for-age percentiles Figure 5-3 Stature-for-age and weight-for-age percentiles for girls, 2 to 20 years of age. Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion. (From Centers for Disease Control and Prevention, Atlanta, Ga, 2001. Available at http://www.cdc.gov/ 2to20years:Girls Body mass index-for-agepercentiles


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Pediatrics_Nelson. Figure 5-4 Body mass index–for-age percentiles for girls, 2 to 20 years of age. Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion. (From Centers for Disease Control and Prevention Atlanta, Ga, 2001. Available at http://www.cdc.gov/ large when there is familial megalocephaly, hydrocephalus, or merely catch-up growth in a neurologically normal premature infant. A child is considered microcephalic if the head circumference is less than the third percentile, even if length and weight measurements also are proportionately low. Serial measurements of head circumference are crucial during infancy, a period of rapid brain development, and should be plotted regularly until the child is 2 years of age. Any suspicion of abnormal growth warrants at least a close follow-up, further evaluation, or both. Available @ StudentConsult.com


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Pediatrics_Nelson. Available @ StudentConsult.com The most common reasons for deviant measurements are technical (i.e., faulty equipment and human errors). Repeating a deviant measurement is the first step. Separate growth charts are available and should be used for very low birth weight infants (weight <1500 g) and for those with Turner syndrome, Down syndrome, achondroplasia, and various other dysmorphology syndromes. Variability in body proportions occurs from fetal to adultlife. Newborns’ heads are significantly larger in proportion tothe rest of their body. This difference gradually disappears.Certain growth disturbances result in characteristic changesin the proportional sizes of the trunk, extremities, and head.Patterns requiring further assessment are summarized inTable 6-1.


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Pediatrics_Nelson. Evaluating a child over time, coupled with a careful history and physical examination, helps determine whether the growth pattern is normal or abnormal. Parental heights may be useful when deciding whether to proceed with a further evaluation. Children, in general, follow their parents’ growth pattern, although there are many exceptions. For a girl, midparental height is calculated as follows: −2.5 2 For a boy, midparental height is calculated as follows: +2.5 2 Actual growth depends on too many variables to makean accurate prediction from midparental height determination for every child. The growth pattern of a child with lowweight, length, and head circumference is commonly associated with familial short stature (see Chapter 173). Thesechildren are genetically normal but are smaller than most Discrepant percentiles (e.g., weight 5th, length 5th, head circumference 50th, or other discrepancies)


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Pediatrics_Nelson. Discrepant percentiles (e.g., weight 5th, length 5th, head circumference 50th, or other discrepancies) Caloric insufficiency Midparental heights Thyroid hormone Growth factors, growth hormone testing Evaluation of pubertal children. A child who, by age, is preadolescent or adolescentand who starts puberty later than others may have the normal variant called constitutional short stature (see Chapter173); careful examination for abnormalities of pubertaldevelopment should be done, although most are normal. Anevaluation for primary amenorrhea should be consideredfor any female adolescent who has not reached menarche by15 years or has not done so within 3 years of thelarche. Lackof breast development by age 13 years also should be evaluated (see Chapter 174).


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Pediatrics_Nelson. Starting out in high growth percentiles, many children assumea lower percentile between 6 and 18 months until they matchtheir genetic programming, then grow along new, lower percentiles. They usually do not decrease more than two major percentiles and have normal developmental, behavioral, and physicalexaminations. These children with catch-down growth should be followed closely, but no further evaluation is warranted.


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Pediatrics_Nelson. Infants born small for gestational age, or prematurely, ingestmore breast milk or formula and, unless there are complicationsthat require extra calories, usually exhibit catch-up growth in the first 6 months. These infants should be fed on demand and provided as much as they want unless they are vomiting (notjust spitting up [see Chapter 128]). Some may benefit from ahigher caloric content formula. Many psychosocial risk factorsthat may have led to being born small or early may contributeto nonorganic failure to thrive (see Chapter 21). Converselyinfants who recover from being low birth weight or prematurehave an increased risk of developing childhood obesity.


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Pediatrics_Nelson. Growth of the nervous system is most rapid in the first 2 years, correlating with increasing physical, emotional, behavioral, and cognitive development. There is again rapid change during adolescence. Osseous maturation (bone age) is determined from radiographs on the basis of the number and size of calcified epiphyseal centers; the size, shape, density, and sharpness of outline of the ends of bones; and the distance separating the epiphyseal center from the zone of provisional calcification. Parallel to the changes in the developing brain (i.e., cognition, language, behavior) are changes in the physical development of the body.


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Pediatrics_Nelson. Parallel to the changes in the developing brain (i.e., cognition, language, behavior) are changes in the physical development of the body. Observation of any asymmetric movement or altered muscle tone and function may indicate a significant central nervous system abnormality or a nerve palsy resulting from the delivery and requires further evaluation. Primitive neonatal reflexes are unique in the newborn period and can further elucidate or eliminate concerns over asymmetric function. The most important reflexes to assess during the newborn period are as follows: The Moro reflex is elicited by allowing the infant’s head to gently move back suddenly (from a few inches off of the mattress onto the examiner’s hand), resulting in a startle, then abduction and upward movement of the arms followed by adduction and flexion. The legs respond with flexion.


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Pediatrics_Nelson. The rooting reflex is elicited by touching the corner of the infant’s mouth, resulting in lowering of the lower lip on the same side with tongue movement toward the stimulus. The face also turns toward the stimulus. The sucking reflex occurs with almost any object placed in the newborn’s mouth. The infant responds with vigorous sucking. The sucking reflex is replaced later by voluntary sucking. The grasp reflex occurs when placing an object, such as a finger, onto the infant’s palm (palmar grasp) or sole (plantar grasp). The infant responds by flexing fingers or curling the toes. The asymmetric tonic neck reflex is elicited by placing the infant supine and turning the head to the side. This placement results in ipsilateral extension of the arm and the leg into a “fencing” position. The contralateral side flexes as well.


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Pediatrics_Nelson. A delay in the expected disappearance of the reflexes may also warrant an evaluation of the central nervous system.See Sections 11 and 26 for additional information on the newborn period. With the development of gross motor skills, the infant is first able to control his or her posture, then proximal musculature, and, last, distal musculature. As the infant progresses through these stages, the parents may notice orthopedic deformities (see Chapters 202 and 203). The infant also may have deformities that are related to intrauterine positioning. Physical examination should indicate whether the deformity is fixed or can be moved passively into the proper position. When a joint held in an abnormal fashion can be moved passively into the proper position, there is a high likelihood of resolving with the progression of gross motor development. Fixed deformities warrant immediate pediatric orthopedic consultation (see Section 26).


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Pediatrics_Nelson. Evaluation of vision and ocular movements is important to prevent the serious outcome of strabismus. The cover test and light reflex should be performed at early health maintenance visits; interventions after age 2 decrease the chance of preserving binocular vision or normal visual acuity (see Chapter 179).


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Pediatrics_Nelson. Older school-age children who begin to participate in competitive sports should have a comprehensive sports history and physical examination, including a careful evaluation of the cardiovascular system. The American Academy of Pediatrics 4th edition sports preparticipation form is excellent for documenting cardiovascular and other risks. The patient and parent should complete the history form and be interviewed to assess cardiovascular risk. Any history of heart disease or a murmur must be referred for evaluation by a pediatric cardiologist. A child with a history of dyspnea or chest pain on exertion, irregular heart rate (i.e., skipped beats, palpitations), or syncope should also be referred to a pediatric cardiologist. A family history of a primary (immediate family) or secondary (immediate family’s immediate family) atherosclerotic disease (myocardial infarction or cerebrovascular disease) before 50 years of age or sudden unexplained death at any age requires additional assessment.


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Pediatrics_Nelson. Children interested in contact sports should be assessed for special vulnerabilities. Similarly vision should be assessed as a crucial part of the evaluation before participation in sports. Adolescents need annual comprehensive health assessments to ensure progression through puberty without major problems (see Chapters 67 and 68). Sexual maturity is an important issue in adolescents. All adolescents should be assessed to monitor progression through sexual maturity rating stages (see Chapter 67). Other issues in physical development include scoliosis, obesity, and trauma (see Chapters 29 and 203). Most scoliosis is mild and requires only observation for progression. Obesity may first manifest during childhood and is an issue for many adolescents.


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Pediatrics_Nelson. The use of milestones to assess development focuses on discrete behaviors that the clinician can observe or accept as present by parental report. This approach is based on comparing the patient’s behavior with that of many normal children whose behaviors evolve in a uniform sequence within specific age ranges (see Chapter 8). The development of the neuromuscular system, similar to that of other organ systems, is determined first by genetic endowment and then molded by environmental influences.


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Pediatrics_Nelson. Although a sequence of specific, easily measured behaviors can adequately represent some areas of development (gross motor, fine motor, and language), other areas, particularly social and emotional development, are not as easy to assess. Easily measured developmental milestones are well established through age 6 years only. Other types of assessment (e.g., intelligence tests, school performance, and personality profiles) that expand the developmental milestone approach are available for older children but generally require time and expertise in administration and interpretation. The terms bonding and attachment describe the affective relationships between parents and infants. Bonding occurs shortly after birth and reflects the feelings of the parents toward the newborn (unidirectional). Attachment involves reciprocal feelings between parent and infant and develops gradually over the first year.


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Pediatrics_Nelson. Attachment of infants outside of the newborn period is crucial for optimal development. Infants who receive extra attention, such as parents responding immediately to any crying or fussiness, show less crying and fussiness at the end of the first year. Stranger anxiety develops between 9 and 18 months of age, when infants normally become insecure about separation from the primary caregiver. The infant’s new motor skills and attraction to novelty may lead to headlong plunges into new adventures that result in fright or pain followed by frantic efforts to find and cling to the primary caregiver. The result is dramatic swings from stubborn independence to clinging dependence that can be frustrating and confusing to parents. With secure attachment, this period of ambivalence may be shorter and less tumultuous.


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Pediatrics_Nelson. Toddlers build on attachment and begin developing autonomy that allows separation from parents. In times of stress, toddlers often cling to their parents, but in their usual activities they may be actively separated. Ages 2 to 3 years are a time of major accomplishments in fine motor skills, social skills, cognitive skills, and language skills. The dependency of infancy yields to developing independence and the “I can do it myself ” age. Limit setting is essential to a balance of the child’s emerging independence.


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Pediatrics_Nelson. There is a growing body of evidence that notes that children who are in high quality early learning environments are more prepared to succeed in school. Every dollar invested in early childhood education may save taxpayers up to 13 dollars in future costs. These children commit fewer crimes and are better prepared to enter the workforce after school. Early Head Start (less than 3 years), Head Start (3 to 4 years), and prekindergarten programs (4 to 5 years) all demonstrate better educational attainment, although the earlier the start, the better the results. Readiness for preschool depends on the development of autonomy and the ability of the parent and the child to separate for hours at a time. Preschool experiences help children develop socialization skills; improve language; increase skill building in areas such as colors, numbers, and letters; and increase problem solving (puzzles).


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Pediatrics_Nelson. Readiness for school (kindergarten) requires emotionalmaturity, peer group and individual social skills, cognitive abilities, and fine and gross motor skills (Table 7-1). Other issuesinclude chronologic age and gender. Children tend to do betterin kindergarten if their fifth birthday is at least 4 to 6 monthsbefore the beginning of school. Girls usually are ready earlierthan boys. If the child is in less than the average developmentalrange, he or she should not be forced into early kindergarten.Holding a child back for reasons of developmental delay, inthe false hope that the child will catch up, can also lead to difficulties. The child should enroll on schedule, and educational planning should be initiated to address any deficiencies. Physicians should be able to identify children at risk for school difficulties, such as those who have developmental delays or physical disabilities. These children may require specialized school services.


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Pediatrics_Nelson. Some define adolescence as 10 to 25 years of age but adolescenceis perhaps better characterized by the developmental stages(early, middle, and late adolescence) that all teens must negotiate to develop into healthy, functional adults. Different behavioral and developmental issues characterize each stage. The ageat which each issue manifests and the importance of these issuesvary widely among individuals, as do the rates of cognitive, psychosexual, psychosocial, and physical development. During early adolescence, attention is focused on the present and on the peer group. Concerns are primarily related Ease of separation of the child from the parent Speech development and articulation Understanding of and ability to follow complex directions Specific pre-academic skills Knowledge of colors Counts to 10 Knows age, first and last names, address, and phone number Ability to copy shapes


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Pediatrics_Nelson. Knowledge of colors Counts to 10 Knows age, first and last names, address, and phone number Ability to copy shapes Motor skills Stand on one foot, skip, and catch a bounced ball Dresses and undresses without assistance Does the child play well with other children? Does the child separate well, such as a child playing in the backyard alone with occasional monitoring by the parent? Does the child show interest in books, letters, and numbers? Can the child sustain attention to quiet activities? How frequent are toilet-training accidents? to the body’s physical changes and normality. Strivings for independence are ambivalent. These young adolescents are difficult to interview because they often respond with short, clipped conversation and may have little insight. They are just becoming accustomed to abstract thinking.


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Pediatrics_Nelson. Middle adolescence can be a difficult time for adolescents and the adults who have contact with them. Cognitive processes are more sophisticated. Through abstract thinking, middle adolescents can experiment with ideas, consider things as they might be, develop insight, and reflect on their own feelings and the feelings of others. As they mature, these adolescents focus on issues of identity not limited solely to the physical aspects of their body. They explore their parents’ and culture’s values, sometimes by expressing the contrary side of the dominant value. Many middle adolescents explore these values in their minds only; others do so by challenging their parents’ authority. Many engage in high-risk behaviors, including unprotected sexual intercourse, substance abuse, or dangerous driving. The strivings of middle adolescents for independence, limit testing, and need for autonomy often distress their families, teachers, or other authority figures. These adolescents are at higher


Pediatrics_Nelson

Pediatrics_Nelson. The strivings of middle adolescents for independence, limit testing, and need for autonomy often distress their families, teachers, or other authority figures. These adolescents are at higher risk for morbidity and mortality from accidents, homicide, or suicide.


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Pediatrics_Nelson. Late adolescence usually is marked by formal operational thinking, including thoughts about the future (e.g., educational, vocational, and sexual). Late adolescents are usually more committed to their sexual partners than are middle adolescents. Unresolved separation anxiety from previous developmental stages may emerge, at this time, as the young person begins to move physically away from the family of origin to college or vocational school, a job, or military service.


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Pediatrics_Nelson. Child behavior is determined by heredity and by the environment. Behavioral theory postulates that behavior is primarily a product of external environmental determinants and that manipulation of the environmental antecedents and consequences of behavior can be used to modify maladaptive behavior and to increase desirable behavior (operant conditioning). The four major methods of operant conditioning are positive reinforcement, negative reinforcement, extinction, and punishment. Many common behavioral problems of children can be ameliorated by these methods.


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Pediatrics_Nelson. Positive reinforcement increases the frequency of a behavior by following the behavior with a favorable event (e.g., praising a child for excellent school performance). Negative reinforcement usually decreases the frequency of a behavior by removal, cessation, or avoidance of an unpleasant event. Conversely sometimes this reinforcement may occur unintentionally, increasing the frequency of an undesirable behavior. For example, a toddler may purposely try to stick a pencil in a light socket to obtain attention, whether it be positive or negative. Extinction occurs when there is a decrease in the frequency of a previously reinforced behavior because the reinforcement is withheld. Extinction is the principle behind the common advice to ignore behavior such as crying at bedtime or temper tantrums, which parents may unwittingly reinforce through attention and comforting. Punishment decreases the frequency of a behavior through unpleasant consequences.


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Pediatrics_Nelson. Positive reinforcement is more effective than punishment. Punishment is more effective when combined with positive reinforcement. A toddler who draws on the wall with a crayon may be punished, but he or she learns much quicker when positive reinforcement is given for the proper use of the crayon—on paper, not the wall. Interrupting and modifying behaviors are discussed in detail in Section 3. Significant individual differences exist within the normal development of temperament (behavioral style). Temperament must be appreciated because, if an expected pattern of behavior is too narrowly defined, normal behavior may be inappropriately labeled as abnormal or pathologic. Three common constellations of temperamental characteristics are as follows: 1.


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Pediatrics_Nelson. The easy child (about 40% of children) is characterized by regularity of biologic functions (consistent, predictable times for eating, sleeping, and elimination), a positive approach to new stimuli, high adaptability to change, mild or moderate intensity in responses, and a positive mood. 2. The difficult child (about 10%) is characterized by irregularity of biologic functions, negative withdrawal from new stimuli, poor adaptability, intense responses, and a negative mood. 3. The slow to warm up child (about 15%) is characterized by a low activity level, withdrawal from new stimuli, slow adaptability, mild intensity in responses, and a somewhat negative mood. The remaining children have more mixed temperaments. The individual temperament of a child has important implications for parenting and for the advice a pediatrician may give in anticipatory guidance or behavioral problem counseling.


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Pediatrics_Nelson. Although, to some degree, temperament may be hardwired (nature) in each child, the environment (nurture) inwhich the child grows has a strong effect on the child’s adjustment. Social and cultural factors can have marked effects on the child through differences in parenting style, educational approaches, and behavioral expectations. Developmental and behavioral problems are more common than any category of problems in pediatrics, except acute infections and trauma. In 2008 15% of children ages 3 to 7 had a developmental disability, and others had behavioral disabilities. As many as 25% of children have serious psychosocial problems. Parents often neglect to mention these problems because they think the physician is uninterested or cannot help. It is necessary to monitor development and screen for the presence of these problems at health supervision visits, particularly in the years before preschool or early childhood learning center enrollment.


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Pediatrics_Nelson. Development surveillance, done at every office visit, is an informal process comparing skill levels to lists of milestones. If suspicion of developmental or behavioral issues recurs, further evaluation is warranted (Table 8-1). Surveillance does not have a standard, and screening tests are necessary.


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Pediatrics_Nelson. Developmental screening involves the use of standardized screening tests to identify children who require further diagnostic assessment. The American Academy of Pediatrics recommends the use of validated standardized screening tools at three of the health maintenance visits: 9 months, 18 months, and 30 months. Clinics and offices that serve a higher risk patient population (children living in poverty) often perform a screening test at every health maintenance visit. A child who fails to pass a developmental screening test requires more comprehensive evaluation but does not necessarily have a delay; definitive testing must confirm. Developmental evaluations for children with suspected delays and intervention services for children with diagnosed disabilities are available free to families. A combination of U.S. state and federal funds provides these services.


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Pediatrics_Nelson. Screening tests can be categorized as general screening teststhat cover all behavioral domains or as targeted screens thatfocus on one area of development. Some may be administered in the office by professionals, and others may be completed athome (or in a waiting room) by parents. Good developmental/behavioral screening instruments have a sensitivity of 70% to80% in detecting suspected problems and a specificity of 70% to80% in detecting normal development. Although 30% of children screened may be over-referred for definitive developmentaltesting, this group also includes children whose skills are belowaverage and who may benefit from testing that may help addressrelative developmental deficits. The 20% to 30% of children whohave disabilities that are not detected by the single administration of a screening instrument are likely to be identified onrepeat screening at subsequent health maintenance visits.


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Pediatrics_Nelson. 2 mo Lifts shoulder while prone Tracks past midline Smiles responsively Cooing Searches for sound with eyes 6 mo Sits alone Transfers object hand to Feeds self Babbles hand Holds bottle 15 mo Walks backward Scribbles Uses spoon and fork Says three to six words Stacks two blocks Helps in housework Follows commands Mo, Month; sec, second; wk, week; yr, year. Chapter 8 u Disorders of Development 17 The Denver Developmental Screening Test II was the norms across subgroups and cultures. The Denver II is a use-classic test used by general pediatricians (Figs. 8-1 and 8-2). ful screening instrument, but it cannot assess adequately the The Denver II assesses the development of children from birth complexities of socioemotional development. Children with to 6 years of age in the following four domains: suspect or untestable scores must be followed carefully. 1. Personal-social The pediatrician asks questions (items labeled with an “R” 2.


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Pediatrics_Nelson. 1. Personal-social The pediatrician asks questions (items labeled with an “R” 2. Fine motor–adaptive may be asked of parents to document the task “by report”) 3. Language or directly observes behaviors. On the scoring sheet, a line is 4. Gross motor drawn at the child’s chronologic age. Tasks that are entirely to The advantage of this test is that it teaches developmen-the left of the line that the child has not accomplished are contal milestones when administered. Items on the Denver II sidered delayed. If the test instructions are not followed accuare carefully selected for their reliability and consistency of rately or if items are omitted, the validity of the test becomes Examiner: Name: DDM, INC. 1-800-419-4729 Date: Birthdate: CATALOG #2115 ID No.: Percent of children passing 2550 75 90 (Check boxes for 1st, 2nd, or 3rd test) ©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds ©1978 W. K. Frankenburg ©2009 Wilhelmine R. Frankenburg


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Pediatrics_Nelson. Percent of children passing 2550 75 90 (Check boxes for 1st, 2nd, or 3rd test) ©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds ©1978 W. K. Frankenburg ©2009 Wilhelmine R. Frankenburg Figure 8-1 Scoring form for Denver II. (From Frankenburg WK: Denver I Training Manual. ©1967, 1970 William K. Frankenburg and Josiah B. Dodds; 1975, 1976, 1978 William K. Frankenburg; 1990, 1992 William K. Frankenburg and Josiah B. Dodds; © 2009 Wilhelmine R. Frankenburg -Contact DDM, Inc. 1-800-419-4729 or Info@denverii.com.)


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Pediatrics_Nelson. Figure 8-2 Instructions for the Denver II. Numbers are coded to a scoring form (see Fig. 8-1). “Abnormal” is defined as two or more delays (failure of an item passed by 90% at that age) in two or more categories or two or more delays in one category with one other category having one delay and an age line that does not intersect one item that is passed. (From Frankenburg WK: Denver I Training Manual. ©1967, 1970 William K. Frankenburg and Josiah B. Dodds; 1975, 1976, 1978 William K. Frankenburg; 1990, 1992 William K. Frankenburg and Josiah B. Dodds; © 2009 Wilhelmine R. Frankenburg Contact DDM, Inc. 1-800-419-4729 or Info@denverii.com.) worse. To assist physicians in using the Denver II, the scoring of development. Parent-reported screens have good validity sheet also features a table to document confounding behaviors, compared to office-based screening measures. such as interest, fearfulness, or an apparent short attention span. Autism screening is recommended for all children at 18


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Pediatrics_Nelson. document confounding behaviors, compared to office-based screening measures. such as interest, fearfulness, or an apparent short attention span. Autism screening is recommended for all children at 18 Repeat screening at subsequent health maintenance visits often to 24 months of age. Although there are several tools, many detects abnormalities that a single screen was unable to detect. pediatricians use the Modified Checklist for Autism in Tod-


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Pediatrics_Nelson. Other developmental screening tools include parentdlers (M-CHAT). M-CHAT is an office-based questionnaire completed Ages and Stages Questionnaires (also milestone that asks parents about 23 typical behaviors, some of which driven), and Parents’ Evaluation of Developmental Status. The are more predictive than others for autism or other pervasive latter is a simple, 10-item questionnaire that parents complete developmental disorders. If the child demonstrates more than at office visits based on concerns with function and progression two predictive or three total behaviors, further assessment with an interview algorithm is indicated to distinguish normal variant behaviors from those children needing a referral for definitive testing. The test is freely distributed on the Internet (see Chapter 20).


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Pediatrics_Nelson. Language screening correlates best with cognitive development in the early years. Table 8-2 provides some rules of thumb for language development that focus on speech production (expressive language). Although expressive language is the most obvious language element, the most dramatic changes in language development in the first years involve recognition and understanding (receptive language).


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Pediatrics_Nelson. Whenever there is a speech and/or language delay, a hearing deficit must be considered. The implementation of universal newborn hearing screening detects many, if not most, of these children in the newborn period, and appropriate early intervention services may be provided. Conditions that present a high risk of an associated hearing deficit are listed in Table 8-3. Dysfluency (stuttering) is common in a 3and 4-year-old child. Unless the dysfluency is severe, is accompanied by tics or unusual posturing, or occurs after 4 years of age, parents should be counseled that it is normal and transient and to accept it calmly and patiently.


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Pediatrics_Nelson. After the child’s sixth birthday and until adolescence, developmental assessment is initially done by inquiring about school performance (academic achievement and behavior). Inquiring about concerns raised by teachers or other adults who care for the child (after-school program counselor, coach, religious leader) is prudent. Formal developmental testing of these older children is beyond the scope of the primary care pediatrician. Nonetheless the health care provider should be the coordinator of the testing and evaluation performed by other specialists (e.g., psychologists, psychiatrists, developmental pediatricians, and educational professionals). Ignorance of the environmental influences on child behavior may result in ineffective or inappropriate management


Pediatrics_Nelson

Pediatrics_Nelson. Ignorance of the environmental influences on child behavior may result in ineffective or inappropriate management Congenital hearing loss in first cousin or closer relative Bilirubin level of ≥20 mg/dL Congenital rubella or other nonbacterial intrauterine infection Defects in the ear, nose, or throat Birth weight of ≤1500 g Multiple apneic episodes Exchange transfusion Meningitis Five-minute Apgar score of ≤5 Persistent fetal circulation (primary pulmonary hypertension) Treatment with ototoxic drugs (e.g., aminoglycosides and loop Health (past and current) Developmental status Temperament (e.g., difficult, slow to warm up) Coping mechanisms Misinterpretations of stage-related behaviors Mismatch of parental expectations and characteristics of child Mismatch of personality style between parent and child Parental characteristics (e.g., depression, lack of interest, rejection,


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Pediatrics_Nelson. Stress (e.g., marital discord, unemployment, personal loss) Support (e.g., emotional, material, informational, child care) Poverty Racism (or both). Table 8-4 lists some contextual factors that should be considered in the etiology of a child’s behavioral or developmental problem.


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Pediatrics_Nelson. Building rapport with the parents and the child is a prerequisite for obtaining the often sensitive information thatis essential for understanding a behavioral or developmentalissue. Rapport usually can be established quickly if the parents sense that the clinician respects them and is genuinelyinterested in listening to their concerns. The clinician develops rapport with the child by engaging the child in developmentally appropriate conversation or play, perhaps providingtoys while interviewing the parents, and being sensitive to thefears the child may have. Too often the child is ignored until itis time for the physical examination. Similar to their parents,children feel more comfortable if they are greeted by name and involved in pleasant interactions before they are askedsensitive questions or threatened with examinations. Youngchildren can be engaged in conversation on the parent’s lap,which provides security and places the child at the eye levelof the examiner.


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Pediatrics_Nelson. With adolescents emphasis should be placed on building a physician-patient relationship that is distinct fromthe relationship with the parents. The parents should not beexcluded; however the adolescent should have the opportunity to express concerns to and ask questions of the physician in confidence. Two intertwined issues must be taken into consideration—consent and confidentiality. Althoughlaws vary from state to state, in general, adolescents whoare able to give informed consent (i.e., mature minors) mayconsent to visits and care related to high-risk behaviors (i.e.,substance abuse; sexual health, including prevention, detection, and treatment of sexually transmitted infections; and pregnancy). Most states support the physician who wishesthe visit to be confidential. Physicians should become familiar with the governing law in the state where they practice (see www.guttmacher.org/statecenter/updates/index.html ). Providing confidentiality is crucial, allowing for optimal