You pick up the chart to go into the room of your next patient. You note the following:

You pick up the chart to go into the room of You pick up the chart to go into the room of your next patient. You note the following:your next patient. You note the following:– He is an 8 month old maleHe is an 8 month old male– He is here for the first timeHe is here for the first time– His last name sounds “Spanish”His last name sounds “Spanish”– His chief complaint is “here for shots”His chief complaint is “here for shots”

What might you want to check before What might you want to check before going into the room?going into the room?

Role PlayRole Play

Organic FTT (OFTT) describes an infant or Organic FTT (OFTT) describes an infant or toddler who has grown poorly and has a toddler who has grown poorly and has a medical disorder known to interfere with medical disorder known to interfere with

growth, including malabsorptive diseases,growth, including malabsorptive diseases,

genetic syndromes, endocrine disorders, genetic syndromes, endocrine disorders, and neurologic dysfunction. Almost any and neurologic dysfunction. Almost any

chronic medical condition in a young child chronic medical condition in a young child may manifest as poor growth.may manifest as poor growth.

Nonorganic FTT (NOFTT) often has been Nonorganic FTT (NOFTT) often has been used as a diagnosis of exclusion to describe used as a diagnosis of exclusion to describe the child who has grown poorly and has no the child who has grown poorly and has no identified medical condition.identified medical condition.

This framework suggests that NOFTT is This framework suggests that NOFTT is caused by environmental conditions, rather caused by environmental conditions, rather than intrinsic biologic disease.than intrinsic biologic disease.

Multifactorial FTT (or “mixed FTT”) describes Multifactorial FTT (or “mixed FTT”) describes the common situation in which both organic the common situation in which both organic and nonorganic factors are identified as and nonorganic factors are identified as contributing to a child’s poor growth.contributing to a child’s poor growth.

Conditions that put children at risk for poor growth:Conditions that put children at risk for poor growth:

Poverty / Food insecurity. Poverty / Food insecurity.

20% of children younger than 4 years of age are living below the 20% of children younger than 4 years of age are living below the federal poverty line ($18,850 for a family of four in 2004). federal poverty line ($18,850 for a family of four in 2004).

Food insecurity has been documented in 21% of households Food insecurity has been documented in 21% of households having children younger than 3 years of age having children younger than 3 years of age

Food insecurity occurs when the availability of adequate food is Food insecurity occurs when the availability of adequate food is limited or uncertain and often is associated with intermittent limited or uncertain and often is associated with intermittent hunger. hunger.

Other documented risk factors include:Other documented risk factors include:Larger family size Larger family size History of child abuseHistory of child abuse

Pathogenesis of poor growthPathogenesis of poor growthThree principal mechanismsThree principal mechanisms

1)1) Loss of calories through malabsorptionLoss of calories through malabsorption

2)2) Increased caloric expenditure (such as Increased caloric expenditure (such as occurs in hyperthyroidism, congenital heart occurs in hyperthyroidism, congenital heart disease, and chronic pulmonary disease)disease, and chronic pulmonary disease)

3) inadequate intake of calories.3) inadequate intake of calories.

Pediatrics in ReviewJanuary, 2006

KRUGMAN, DUBOWITZ; Am Fam Physician. 2003 Sep 1;68(5):879-884.

KRUGMAN, DUBOWITZ; Am Fam Physician.  2003 Sep 1;68(5):879-884.PART 1

Part 2

In a classic study of hospitalized children with FTT, only 1.4 percent (36 of 2,607 tests) were of diagnostic assistance. Sills RH. Failure to thrive. The role of clinical and laboratory evaluation. Am J Dis Child 1978; 132:967-9.KRUGMAN, DUBOWITZ;

Am Fam Physician. 2003 Sep 1;68(5):879-884.

Common Beliefs and PracticesCommon Beliefs and Practices

Some Hispanic people believe that disease is Some Hispanic people believe that disease is caused by an imbalance between hot and cold caused by an imbalance between hot and cold principlesprinciples

Traditional medicine in most Hispanic countries Traditional medicine in most Hispanic countries has an extensive list of folk remedies. has an extensive list of folk remedies.

Providers may encounter the concept of a Providers may encounter the concept of a bilongo or hex...... bilongo or hex......

The evil eye (mal de ojo) appears in several The evil eye (mal de ojo) appears in several Hispanic cultures. ….It is believed to be brought Hispanic cultures. ….It is believed to be brought on by an admiring look from a person with a on by an admiring look from a person with a strong eye. strong eye.

http://erc.msh.org/mainpage.cfm?file=5.3.0c.htm&module=provider&language=english

Thus, "hot" diseases are treated with "cold" Thus, "hot" diseases are treated with "cold" remedies, and "cold" diseases are treated with remedies, and "cold" diseases are treated with "hot" remedies."hot" remedies.

Hypertension is defined as a hot illness. In 60% Hypertension is defined as a hot illness. In 60% of the cases the etiology is thought to be due to of the cases the etiology is thought to be due to corajescorajes (anger) or (anger) or sustosusto (fear); the remaining (fear); the remaining 40% are felt to be due to "thick blood". Cool 40% are felt to be due to "thick blood". Cool remedies such as bananas and lemon juice are remedies such as bananas and lemon juice are popular as well as teas of passion flowers popular as well as teas of passion flowers ((pasionarapasionara), linden (), linden (tiliatilia), or ), or zapote blancozapote blanco. .

http://www.rice.edu/projects/HispanicHealth/Courses/mod7/mod7.htmlhttp://www.rice.edu/projects/HispanicHealth/Courses/mod7/mod7.html

Key Concepts *Key Concepts *Familia – FamilyFamilia – Family

1- Allow for several family and friends1- Allow for several family and friends

2- Communicate with the group2- Communicate with the group

3- Determine matriarch and patriarch3- Determine matriarch and patriarch

4- Notice if the acculturated children or non-4- Notice if the acculturated children or non-family members are the spokespeople.family members are the spokespeople.

•The following slides are taken from “Quality Health Services for Hispanics: The Cultural Competency Component – HRSA/BPHC/SAMHSA/Office of Minority Health

Respeto – RespectRespeto – Respect

1- Always be respectful1- Always be respectful

2- Explain without condescending2- Explain without condescending

3- Address elders in traditional ways (below 3- Address elders in traditional ways (below eye level if you’re younger).eye level if you’re younger).

4- Be mindful of the parents or elders in the 4- Be mindful of the parents or elders in the room when the acculturated child or a room when the acculturated child or a health mediator is the spokesperson.health mediator is the spokesperson.

HRSA

RespetoRespeto

5- Ask for questions or a description of what 5- Ask for questions or a description of what was first heard and experienced.was first heard and experienced.

6- Indirectly ask personal/private questions 6- Indirectly ask personal/private questions such as alcohol use, mental problems, such as alcohol use, mental problems, violence, stressors, sex, etc.violence, stressors, sex, etc.

7- Ask permission to touch genitalia after 7- Ask permission to touch genitalia after explaining what you are doing and why.explaining what you are doing and why.

HRSA

Personalismo – Personal FamiliarityPersonalismo – Personal Familiarity

1- Respect distal space and touching based on 1- Respect distal space and touching based on familiarity.familiarity.

2- Ask about their life (family, friends, work).2- Ask about their life (family, friends, work).

3- Share your own life stories.3- Share your own life stories.

4- Share pictures.4- Share pictures.

5- Converse with all of the family members.5- Converse with all of the family members.

6- Be respectful of gender, do not give an 6- Be respectful of gender, do not give an impression of being too familiar.impression of being too familiar.

7- Make personal notes in medical records to cue 7- Make personal notes in medical records to cue provider of family names or special events to provider of family names or special events to discuss on the next visit.discuss on the next visit. HRSA

Hispanic families traditionally emphasize Hispanic families traditionally emphasize interdependence over independence and interdependence over independence and cooperation over competition.cooperation over competition.

A few words spoken in Spanish may become A few words spoken in Spanish may become an important cue to people about your an important cue to people about your positive attitudes towards them.positive attitudes towards them.

Personal rather than institutional relationships Personal rather than institutional relationships are important. (are important. (Continuity of care implications)Continuity of care implications)

HRSA

By respecting the patient’s culture and By respecting the patient’s culture and showing personal interest, a health care showing personal interest, a health care provider can expect to win their confianza provider can expect to win their confianza (trust).(trust).

Health care brokers, community outreach Health care brokers, community outreach workers or promotoras can play a key role workers or promotoras can play a key role in establishing trust with a new provider.in establishing trust with a new provider.

HRSA

Integrated Body, Mind and Espiritu Integrated Body, Mind and Espiritu (Spirit)(Spirit)

Health symptomatology often present from the Health symptomatology often present from the mind/body/spirit connection.mind/body/spirit connection.

Mental health problems and life’s stressors Mental health problems and life’s stressors may appear as tight chest pain, shortness of may appear as tight chest pain, shortness of breath, abdominal pain, sweats, chronic or breath, abdominal pain, sweats, chronic or frequent illness.frequent illness.

Sustos – attaques de nervios, penaSustos – attaques de nervios, pena

Mental health problems viewed as a weaknessMental health problems viewed as a weaknessHRSA

KRUGMAN, DUBOWITZ; Am Fam Physician. 2003 Sep 1;68(5):879-884.

Pediatrics in ReviewJanuary, 2006

Definition – Community PediatricsDefinition – Community PediatricsAAP Policy StatementAAP Policy Statement

Pediatrics Vol. 115 No.4 April 2005Pediatrics Vol. 115 No.4 April 2005

The American Academy of Pediatrics (AAP) offersThe American Academy of Pediatrics (AAP) offers

a definition of community pediatrics to remind alla definition of community pediatrics to remind all

pediatricians, generalists and specialists alike, of the pediatricians, generalists and specialists alike, of the profound importance of the profound importance of the community community

dimensiondimension in pediatric practice. Community in pediatric practice. Community pediatrics is all of the following:pediatrics is all of the following:

A perspective that enlarges the pediatrician’s A perspective that enlarges the pediatrician’s focus from one child to focus from one child to

all childrenall children

in the communityin the community

A recognition that A recognition that family, educational, family, educational, social, cultural, spiritual, economic, social, cultural, spiritual, economic, environmental, and political forcesenvironmental, and political forces

act favorably or unfavorably, act favorably or unfavorably,

but always significantly, but always significantly,

on the health on the health

and and

functioningfunctioning

of childrenof children

A synthesis of A synthesis of clinical practiceclinical practice and and public healthpublic health

principlesprinciples directed toward directed toward

providing providing health carehealth care to a given child to a given child

and and

promoting the healthpromoting the health

of all children within the context of the family, of all children within the context of the family, school, and communityschool, and community

A commitment to use a A commitment to use a community’s community’s resourcesresources in in collaborationcollaboration with other with other professionals, agencies, and parentsprofessionals, agencies, and parents to to

achieve optimal accessibility, achieve optimal accessibility, appropriateness, and quality of services appropriateness, and quality of services

for all children and to for all children and to advocateadvocate especially especially for those who for those who lack accesslack access to care to care

because of because of social, cultural, geographic, social, cultural, geographic, or economic conditions or special or economic conditions or special

health care needshealth care needs

An An integral partintegral part of the professional role and of the professional role and duty of the pediatrician.duty of the pediatrician.

…….the major threats to the health.the major threats to the healthof America’s children, the of America’s children, the new morbiditiesnew morbidities, arise, arise

from problems that from problems that cannot be addressed adequatelycannot be addressed adequatelyby the practice model aloneby the practice model alone AAP Policy Statement - April 2005AAP Policy Statement - April 2005

high infant mortality rates high infant mortality rates children with chronic health children with chronic health

care needscare needs ObesityObesity intentional and unintentional intentional and unintentional

injuriesinjuries exposure to lead and other exposure to lead and other

environmental hazards, environmental hazards, substance abusesubstance abuse

behavioral and developmental consequences of inappropriate care and experience

mental health conditions poor school readinessfamily dysfunction sexually transmitted diseasesunwanted pregnancieslack of access to medical homes

Competencies Competencies

Community PediatricsCommunity Pediatrics

1. Delivery of Culturally Effective Care1. Delivery of Culturally Effective Care

Pediatricians must demonstrate interpersonal and Pediatricians must demonstrate interpersonal and communication skills that result in effective information communication skills that result in effective information

exchange with children and familiesexchange with children and families

from all cultural backgrounds and diverse communities.from all cultural backgrounds and diverse communities.

2. Child Advocacy2. Child Advocacy

Pediatricians should advocate for the well-being of Pediatricians should advocate for the well-being of patients, families, and communities; patients, families, and communities;

We must develop advocacy skills to address We must develop advocacy skills to address relevant individual, community, and population relevant individual, community, and population health issues; and understand the legislative health issues; and understand the legislative

process (process (local, state, and federallocal, state, and federal) to address ) to address community and child health issues.community and child health issues.

3. Medical Home3. Medical Home

Pediatricians must be able to Pediatricians must be able to identify and/or identify and/or provide a medical homeprovide a medical home for all children and for all children and

families under their care. families under their care.

As defined by the AAP, the medical home is an As defined by the AAP, the medical home is an approach to providing comprehensive primary approach to providing comprehensive primary

health care services in partnership with families. health care services in partnership with families.

Care received in the medical home is accessible, Care received in the medical home is accessible, continuous, comprehensive, family centered, continuous, comprehensive, family centered, coordinated, compassionate, and culturally coordinated, compassionate, and culturally

effective.effective.

4. Special Populations4. Special Populations

Pediatricians must be able to identify children and Pediatricians must be able to identify children and youth at risk for poor health outcomes and those youth at risk for poor health outcomes and those

with with special health care needsspecial health care needs. . Pediatricians, in concert with other child health Pediatricians, in concert with other child health professionals, must collaboratively develop and professionals, must collaboratively develop and implement management plans that are realistic, implement management plans that are realistic,

family centered, community referenced, family centered, community referenced, nonrestrictive, and effective. nonrestrictive, and effective.

They must have a working knowledge of They must have a working knowledge of specific specific psychosocial issues, legal protections/implications, psychosocial issues, legal protections/implications,

policies, and services provided for these populations policies, and services provided for these populations at the local, state, and federal levels.at the local, state, and federal levels.

5. The Pediatrician as a Consultant, 5. The Pediatrician as a Consultant, Partner, and Collaborative LeaderPartner, and Collaborative Leader

Pediatricians must be able to act as child Pediatricians must be able to act as child health consultantshealth consultants in their communities. in their communities.

Using collaborative skills, they must be able Using collaborative skills, they must be able to work with multidisciplinary teams, to work with multidisciplinary teams,

community members, and representatives community members, and representatives from from schools, child care facilities, and schools, child care facilities, and

legislative bodies.legislative bodies.

6. Educational and Child Care Settings6. Educational and Child Care Settings

Pediatricians must be able to interact with Pediatricians must be able to interact with the staff of the staff of schools and child care schools and child care settingssettings to improve the health and to improve the health and

educational environments for children.educational environments for children.

7. Community and Public Health7. Community and Public Health

Pediatricians must be able to understand and Pediatricians must be able to understand and potentially modify the potentially modify the health determinantshealth determinants affecting affecting

patients and families in the community that they patients and families in the community that they serve. serve.

To effect change in health outcomes, pediatricians To effect change in health outcomes, pediatricians must be able to identify and must be able to identify and mobilize community mobilize community

assets and resources toward preventing illness, assets and resources toward preventing illness, injury, and related morbidity and mortality.injury, and related morbidity and mortality.

EG - disaster preparedness and response:EG - disaster preparedness and response:

Moving Moving

To the To the

Global Global

LevelLevel

Major Causes of Child Death (1998)Major Causes of Child Death (1998)

EIP/WHO

All other (18%)

HIV/AIDS (3%))

Congenital (4%))

Injuries (6%)

Malaria (7%)

Measles (8%)

Diarrhoeal diseases (17%)

Respiratory diseases (17%)

Perinatal (20%)

Total deaths: 10.8 million

Malnutrition is estimated to contribute to around 50% of all childhood deaths.

49% of child deaths

Co-morbidity/Underlying CauseCo-morbidity/Underlying CauseExampleExample

WarWar Disruption Immunization Disruption Immunization ServicesServices

Child with Child with measlesmeasles

DiarrheaDiarrhea && PneumoniaPneumonia

DEATHDEATH

Integrated Management of Integrated Management of Childhood Illnesses (IMCI)Childhood Illnesses (IMCI)

integrated approachintegrated approach aims to reduce death, illness and disability, aims to reduce death, illness and disability,

and to promote improved growth and and to promote improved growth and developmentdevelopment

includes both preventive and curative includes both preventive and curative elements elements

implemented by families, communities and implemented by families, communities and health facilitieshealth facilities

IMCI Addresses Most Causes of IMCI Addresses Most Causes of DeathDeath

PneumoniaPneumonia DiarrheaDiarrhea MeaslesMeasles MalariaMalaria MalnutritionMalnutrition

SepsisSepsis MeningitisMeningitis DehydrationDehydration AnemiaAnemia Ear infectionEar infection HIV/AIDSHIV/AIDS WheezingWheezing Sore throatSore throat

Improving Health Worker Skills, Improving Health Worker Skills,

Community Care, and Health SystemsCommunity Care, and Health Systems

Capacity, structureand functions ofhealth system

Knowledge,Beliefs and skills caretakers

ClinicalAssessmentand treatment by health workers

Per Capita Income and Infant Per Capita Income and Infant MortalityMortality

Per Capita Income and Infant Per Capita Income and Infant MortalityMortality

Megan Brown Children’s Defense Fund Minnesota

Z-Score of less than -2 are classified as malnourished.

Some ReferencesSome References

ThankThank

YouYou