Free Download Burns Pediatric Primary Care 7Th Edition Dawn Lee Garzon Full Chapter PDF
Free Download Burns Pediatric Primary Care 7Th Edition Dawn Lee Garzon Full Chapter PDF
Free Download Burns Pediatric Primary Care 7Th Edition Dawn Lee Garzon Full Chapter PDF
Health Status of Chldren: Global and Natonal Injury Preventon and Chld Maltreatment,
Perspectves,
Key Concepts, Assessments, and Management
Unque Issues n Pedatrcs, of Chldren Wth Acute or Chronc Dsease, 9
Genetcs and Genomcs: The Bascs for Chld Prescrbng Medcatons n Pedatrcs,
Health,
Complementary Medcne n Pedatrc Prmary
Envronment and Chld Health, Care Wth an Introducton to Functonal
Medcne,
Chld and Famly Assessment, 9
Pedatrc Pan and Fever Management, 9
Cultural Consderatons for Pedatrc Prmary
Care, 9 Pernatal Condtons, 0
Chldren wth Specal Health Care Needs, 0 Neurodevelopmental, Behavoral, and Mental
Health Dsorders,
Prncples of Developmental Management of
Chldren, Infectous Dseases,
9 Developmental Management of Newborns, Congental and Inherted Dsorders,
0 Developmental Management of Infants, 9 Atopc, Rheumatc, and Immunodeicency
Dsorders, 0
Developmental Management of Early
Chldhood, 09 Dermatologc Dsorders,
Developmental Management of Mddle Eye Dsorders,
Chldhood, 9
Ear and Hearng Dsorders,
Developmental Management of Adolescents
and Young Adults, Respratory Dsorders,
SEVENTH EDITION
Editors
Professor
School of Nursing
California State University Long Beach Associate Editor
Long Beach, California
Mary Dirks, DNP, RN, ARNP, CPNP-PC,
Nan M. Gaylord PhD, RN, CPNP-PC, FAANP
PMHS, FAANP, FAAN
Clinical Professor and Assistant Dean for Graduate Practice
Professor Programs
College of Nursing College of Nursing
University of Tennessee University of Iowa
Knoxville, Tennessee Iowa City, Iowa
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
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Previous editions copyrighted 2017, 2013, 2009, 2004, 2000, and 1996.
Printed in Canada
v
Contributors
Sandra Ann Banta-Wright, PhD, RN, NNP-BC Cynthia Marie Claytor, RN, MSN, PNP, FNP-C, CCRN
Assistant Clinical Professor Graduate Nursing Faculty
Pediatric Nurse Practitioner Program Azusa Pacific University
Oregon Health & Science University Azusa, California
Portland, Oregon
Daniel J. Crawford, DNP, RN, CPNP-PC, CNE
Jennifer Bevacqua, RN, MS, CPNP-AC, CPNP-PC DNP Program Director
Instructor, Pediatric Nurse Practitioner Program Clinical Assistant Professor
Oregon Health & Science University Edson College of Nursing and Health Innovation
Portland, Oregon Arizona State University
Phoenix, Arizona
Tami B. Bland, DNP, PNP-PC
Clinical Assistant Professor Sandra Daack-Hirsch, PhD, RN, FAAN
College of Nursing Associate Professor
University of Tennessee, Knoxville PhD Program Director
Knoxville, Tennessee College of Nursing
The University of Iowa
Catherine Blosser, MPA, HA, RN, PNP Iowa City, Iowa
Pediatric Nurse Practitioner, Retired
Multnomah County Health Department Renée Lynne Davis, DNP, APRN, CPNP-PC
Portland, Oregon Assistant Professor
School of Nursing
Cris Ann Bowman-Harvey, RN, MSN, CPNP-PC, CPNP-AC Saint Louis University
Emergency Department St. Louis, Missouri
Children’s Hospital Colorado Dr. Norman Pediatrics
Aurora, Colorado Belleville, Illinois
Faculty
Department of Pediatrics Sara De Golier, BSN, MS, CPNP
University of Colorado Emergency Department
Denver, Colorado Children’s Hospital Colorado
Aurora, Colorado
Eliza Buyers, MD
Adolescent Gynecologist and Clinical Medical Director Ardys M. Dunn, PhD, RN, PNP
Pediatric and Adolescent Gynecology Associate Professor, Emeritus
Children’s Hospital Colorado School of Nursing
Senior Instructor University of Portland
Department of Obstetrics and Gynecology Portland, Oregon
University of Colorado Professor, Retired
Aurora, Colorado School of Nursing
Samuel Merritt College
Jennifer Chauvin, MA, BSN, RN-BC Oakland, California
DNP Candidate,
College of Nursing Terea Giannetta, DNP, RN, CPNP, FAANP
Washington State University Vancouver Chief NP
Vancouver, Washington Hematology
Valley Children’s Hospital/Children’s Hospital Central California
Donald L. Chi, DDS, PhD Madera, California
Associate Professor Professor, Emeritus
Oral Health Sciences School of Nursing
University of Washington California State University, Fresno
Seattle, Washington Fresno, California
vii
viii Contributors
Valerie Griffin, DNP, PPCNP-BC, FNP-BC, PMHS, FAANP Sharon Norman, DNP, RN, CPNP, CNS, CCRN
Assistant Clinical Professor School of Nursing
Director FNP Program Oregon Health & Science University
Southern Illinois University Edwardsville Portland, Oregon
Edwardsville, Illinois Randall Children’s Hospital-Legacy Emanuel
Portland, Oregon
Emily Gutierrez, DNP, C-PNP, PMHS, IFM-CP
Practice Owner Catherine O’Keefe, DNP, CPNP-PC
Neuronutrition Associates Adjunct Associate Professor, Emerita
Austin, Texas College of Nursing
Adjunct Faculty Creighton University
School of Nursing Omaha, Nebraska
Johns Hopkins University
Baltimore, Texas Sarah Obermeyer, PhD, CNM, WHNP, IBCLC
Assistant Professor
Susan Hines, RN, BSN, MSN, CPNP School of Nursing
Pediatric Pulmonary Medicine Azusa Pacific University
Children’s Hospital Colorado Azusa, California
Aurora, Colorado
Adebloa M. Olarewaju, RN, MS, CPNP-PC
Jennifer Michele Huson, MS, RN, CPNP, CNS Pediatric Nurse Practitioner
Nurse Practitioner Otolaryngology—Head and Neck Surgery
Pediatric Intensive Care UC Davis Medical Center
Children’s Hospital Los Angeles Sacramento, California
Los Angeles, California
Jaime Panton, DNP, MSN, BSN, CPNP-AC/PC
Belinda James-Petersen, BS, MS, DNP, CPNP-PC Assistant Professor
Pediatric Gastroenterology School of Nursing
Children’s Hospital of The King’s Daughters Columbia University
Norfolk, Virginia New York, New York
Rita Marie John, EdD, DNP, CPNP, PMHS, FAANP Michele Polfuss, PhD, BSN, MSN, RN, CPNP-AC/PC
Special Lecturer Consultant Associate Professor
Former PNP Program Director College of Nursing
Columbia University School of Nursing University of Wisconsin—Milwaukee
Hillsborough, New Jersey Joint Research Chair in the Nursing of Children
Nursing Research Department
Victoria Keeton, MS, RN, CPNP, CNS Children’s Hospital of Wisconsin
Clinical Professor Milwaukee, Wisconsin
School of Nursing Department of Family Care Nursing
University of California San Francisco Sarah Elizabeth Romer, DNP, FNP
Pediatric Nurse Practitioner Assistant Professor
Children’s Health Center Adolescent Medicine, Pediatrics
Zuckerberg San Francisco General Hospital and Trauma Center University of Colorado Denver School of Medicine
San Francisco, California Medical Director
BC4U Clinic
Michelle McGarry, MSN, RN, CPNP, CUNP, FAANP Children’s Hospital Colorado
Certified Pediatric and Urology Nurse Practitioner/Program Aurora, Colorado
Director/President
Pediatric Effective Elimination Program Clinic and Counseling, Ruth K. Rosenblum, DNP, RN, PNP-BC, CNS
PC Associate Professor
Highlands Ranch, Colorado DNP Program Co-Coordinator
The Valley Foundation School of Nursing at San Jose State
Jennifer Newcombe, MSN, PCNS-BC, CPNP-PC/AC University
Nurse Practitioner San Jose, California
Pediatric Cardiothoracic Surgery American Nurses Association/California Board of
Loma Linda Children’s Hospital Directory–Secretary
Assistant Professor
School of Nursing
Loma Linda University
Loma Linda, California
Contributors ix
We would like to thank the previous edition contributors for their efforts in the Sixth Edition and whose work and
ideas influenced this edition’s content:
Denise A. Hall, BS, CMPE Ann M. Petersen-Smith, PhD, APRN, CPNP-PC, CPNP-AC
Practice Administrator Assistant Professor
Advanced Pediatrics Associates College of Nursing
Aurora, Colorado University of Colorado Anschutz Medical Campus
Associate Clinical Professor
Anna Marie Hefner, PhD, RN, CPNP School of Medicine
Associate Professor University of Colorado Anschutz Medical Campus
Azusa Pacific University Aurora, Colorado
Upland, California
Mary Rummell, MN, RN, CNS, CPNP, FAHA
Clinical Nurse Specialist
Pamela J. Hellings, RN, PhD, CPNP-R
Professor, Emeritus The Knight Cardiovascular Institute, Cardiac Services
Oregon Health & Science University
Oregon Health & Science University
Portland, Oregon
Portland, Oregon
Isabelle Soulé, PhD, RN
Susan Hines, RN, MSN, CPNP
Human Resources for Health Rwanda
Pediatric Nurse Practitioner University of Maryland
Sleep Medicine Baltimore, Maryland
Children’s Hospital Colorado
Aurora, Colorado Robert D. Steiner, MD
Executive Director
Julie Martchenke, RN, MSN, CPNP Marshfield Clinic Research Foundation;
Pediatric Cardiology Nurse Practitioner Professor of Pediatrics
Oregon Health & Science University University of Wisconsin
Portland, Oregon Marshfield, Wisconsin
Michelle McGarry, MSN, RN, CPNP, CUNP Ohnmar K. Tut, BDS, MPhil
Certified Pediatric and Urology Nurse Practitioner/Program Adjunct Senior Research Fellow
Director/Owner Griffith University
Pediatric Effective Elimination Program Clinic & Consulting, Program Consultant Investigator
PC HRSA Oral Health Workforce Activities—FSM
Highlands Ranch, Colorado Brisbane, Queensland, Australia
Affiliate Instructor
Peter M. Milgrom, DDS University of Washington
Professor of Oral Health Sciences and Pediatric Dentistry Seattle, Washington
Adjunct Professor of Health Services
Director Yvonne K. Yousey, RN, CPNP, PhD
Northwest Center to Reduce Oral Health Disparities Pediatric Nurse Practitioner
University of Washington Kids First Health Care
Seattle, Washington Commerce City, Colorado
Contributors xi
Reviewers
Brent Banasik, PhD Emily Souder, MD
Scientist Assistant Professor of Pediatrics
Chemistry Drexel University College of Medicine
Banasik Consulting Group Attending Physician
Seattle, Washington Section of Infectious Diseases
St. Christopher’s Hospital for Children,
Philadelphia, Pennsylvania
Preface
We are delighted to introduce the seventh edition and updated (Chapter 3), environmental issues that impact health (Chapter
title of Burns’ Pediatric Primary Care. With the retirement of three 4), children with special healthcare needs (Chapter 7), develop-
of the initial authors of this book, the team believed it was time mental management of newborns (Chapter 9), immunizations
to alter the title to call it what it is commonly referred to by those (Chapter 22), injury prevention and child maltreatment (Chap-
who love it and use it. Changes to this edition were made to ensure ter 24), perinatal disorders (Chapter 19), and developmental,
the contemporary relevance of topics and to support the educa- behavioral, and mental health promotion (Chapter 30).
tional needs of those in pediatric primary care. The editorial team • Unit 3 was redesigned to include typical developmental health
consists of actively practicing pediatric nurse practitioners who issues and to emphasize health promotion and health protec-
understand the contemporary challenges and complexity of the tion. The first section includes developmental, behavioral,
primary care health care system. Each of the contributing authors and mental health promotion. The second section covers the
of the chapters are experts in their fields. As always, every chapter biophysical domains of nutrition, breastfeeding, elimination,
has been thoroughly updated. physical activity and sports, sleep, and sexuality. The final sec-
This book was initially developed more than 20 years ago as a tion focuses on health protection in the areas of dental health,
resource for advanced practice nurses who were providing primary injury and child maltreatment prevention, and immunizations.
health care to infants, children, and adolescents. Currently, pedi- • Unit 4 was redesigned to include management of common
atric nurse practitioners (PNPs) and family nurse practitioners diseases and disorders. This section no longer includes devel-
(FNPs) are the primary audience. However, physicians, physician opmentally typical conditions and instead focuses on health
assistants, and nurses who care for children in a variety of set- restoration. Developmentally typical conditions and issues were
tings also find this book to be a valuable resource. This is the only relocated to Unit 3. The initial chapter in this unit details prin-
nurse practitioner (NP) editorial team and NP-focused pediatric ciples of pediatric disease management common to all ages.
primary care text on the market. • All other chapters have been updated and redesigned to reflect
Burns’ Pediatric Primary Care emphasizes health promotion, the highest level of contemporary evidence including Healthy
disease prevention, and problem management from the primary People 2020 (Healthy People, 2019) and the new edition of
care provider’s point of view. Each chapter introduces key con- Bright Futures (Hagan et al., 2017).
cepts, provides an evidence-based and theoretical care foundation, • We expanded the use of algorithms to streamline the decision
and includes a discussion of the identification and management of making for clinicians.
symptoms or conditions of specific disease entities. Experienced
clinicians can simply jump to the topic or diagnosis in ques- Organization of the Book
tion while the novice can read the chapter for immersion into
the topic. Additional resources for each chapter include websites Children are a special population. Pediatric healthcare requires
to access organizations and printed materials that may be useful unique perspective grounded in a fundamental understandings
for clinicians and their patients and families. of the complexities of child development, unique epidemiologic
Special Features of the Seventh Edition health influences, varied social determinants and environmental
Some features of the seventh edition about which we are par- influences of health, and each child’s unique genetic influences.
ticularly excited include the following: These themes are carried throughout this book.
• NEW! This edition includes a significant content reorganiza- The book is organized into four major sections—Pediatric Pri-
tion. We made this change to reflect current understanding of mary Care Foundations, Management of Development, Pediat-
the continuum of health and illness and to ensure that the flow ric Health Promotion and Protection, and Disease Management.
and classification of information is intuitive to students and Each chapter follows the same format. Standards and guidelines
providers. for care are highlighted, relevant child development is described,
• NEW! Because of the evolving clarity of the primary care ver- the physiologic and assessment parameters are discussed, man-
sus acute care roles, this edition now solely focuses on primary agement strategies are identified, and management of common
care management and the role of referral and consultation for problems is presented in a problem-oriented format. The scope of
acute care issues. practice of the primary care provider is always emphasized with
• NEW! Pediatric primary care providers see patients with a wide appropriate referral and consultation points identified.
range of issues and health complexities. In order to reflect the It is our hope that this book continues in the tradition of the
depth and breadth of this role, nine new chapters were cre- prior editions by supporting the primary care provider with the
ated. These include: a chapter on unique issues in pediatrics highest quality, evidence-based care strategies to foster improved
(Chapter 1), an overview of genetic and genomic concepts health and wellness of children and their families.
xiii
Acknowledgments
A book of this size and complexity cannot be completed with- • To my parents who first loved, supported, and encouraged me.
out considerable help—the work of the chapter authors who To my husband, Mark, who loved me second and continues to
researched, wrote, and revised content; the consultation and love, support, and encourage me in all my professional endeav-
review of experts in various specialties who critiqued drafts and ors. To my children, Curtis and Leah, who make life fun and
provided important perspectives and guidance; and the essential will continue to do so with their own children. Nan Gaylord
technical support from those who managed the production of the • To my children and their children and their children who,
manuscript and the final product. We are particularly grateful to along with children everywhere, are the living messages we
Laura Goodrich, Sharon Corell, and Sandra Clark at Elsevier for send to a time we will not see. Here’s hoping we have done well
their tireless support and advocacy during the development of this by them. Martha Driessnack
book. • The health of our nation’s children is our most important
resource. My hope is that this edition will contribute to that
Our Thanks to Family and Friends critical mission of improving the health and well-being of our
children and families. Further, to my ever-patient husband
• To my husband and greatest champion, Jeff, who always sup- who has sustained and bolstered me through the work on this
ports me and encourages me while giving me a safe place to edition! Karen Duderstadt
recover and just be; to my amazing daughters, Rachel and Eliz- • With sincere gratitude and love to my amazing husband,
abeth, who give my life meaning; to the students, parents, and Chuck, for his endless support and understanding during
families who make me a better person; and to Amy DiMaggio, extended time dedicated toward my work on this edition.
friends, and family for loving me and giving me wings. Dawn Thanks be to God for all my blessings, my parents for prepar-
Lee Garzon Maaks ing me well for life’s journey, and my children, Taylor and Jack,
• Aloha and mahalo to my Jon, Jonah, and AnnaMei. I am ever my pride and joy. Mary Dirks
grateful for the joy you bring to my life as well as your support
of my time with “the book.” Likewise, I am ever thankful for References
Denise and my APA colleagues who give me the flexibility and
challenge to work hand in hand to provide model pediatric Hagan JF, Shaw JS, Duncan PM: Bright Futures: guidelines for health
care. Nancy Barber Starr supervision of infants, children, and adolescent, ed 4, Elk Grove
• With deep appreciation for the circle of love and support from Village, IL, 2017, American Academy of Pediatrics.
my dear family and friends who are always there surrounding Healthy People 2020 (2019). Available at https://www.healthypeople.
gov. Accessed March 30, 2019.
me with warmth, laughter, and joy. Margaret A. Brady
xiv
Contents
xv
xvi Contents
1
Health Status of Children:
Global and National
Perspectives
KAREN G. DUDERSTADT
T
he health of all children is interconnected worldwide, and and violence (UNICEF, 2017). Immigrant children have increased
the health status of all children must be viewed with a global health and educational needs that impact the health and well-being
lens. Whether considering pandemic infectious diseases or of communities; many of these communities have fragile healthcare
global migration, inequities in the health status of children glob- systems. The United Nations Convention on the Rights of Children
ally and nationally are largely determined by common biosocial (UNCRC) charter was established 25 years ago and declares the
factors affecting health. Biosocial circumstances, or social determi- minimum entitlements and freedoms for children globally, including
nants of child health, are shaped by economics, social policies, and the right to the best possible health (UNICEF, 2017a). The charter
politics in each region and country. There is a social gradient in is founded on the principle of respect for the dignity and worth of
health that runs from the top to bottom of the socioeconomic spec- each individual, regardless of race, color, gender, language, religion,
trum globally. Therefore the social gradient in health means that opinions, origins, wealth, birth status, or ability. Immigrant children
health inequities affect low-, middle-, and high-income countries have the right to be protected under this charter (Box 1.1).
(World Health Organization [WHO], 2018). Significant progress Health equity is the absence of unfair or remediable differ-
has been made in reducing childhood morbidity and mortality. ences in health services and health outcomes among populations
However, a sustained effort is required globally and nationally to (WHO, 2016). Addressing health equity globally requires bold
build better health systems to continue to positively impact child goals, political will with broad fiscal support, and a commitment
health outcomes. The framework of the United Nations Millen- within low-resource countries to prioritize the health of children
nium Development Goals (United Nations Development Program and families as a primary goal.
[UNDP], 2015) and Healthy People 2020 (U.S. Department of
Health and Human Services [HHS] Office of Disease Prevention
and Health Promotion [ODPHP], 2018) goals set the mark for Progress on the Millennium Development
improving child health status. Goals
This chapter presents an overview of the global health status
of children, current health inequities, the progress achieved in The United Nations (UN) Millennium Development Goals,
the Millennium Development Goals and Healthy People 2020 adopted in 2000 with a deadline of 2015, produced the most
targets, and the factors currently affecting the health of children successful movement in history by the UN to reduce child pov-
in the United States, including food and housing insecurity. The erty globally (UNDP, 2015). The achievements are the result
chapter also discusses the important role pediatric healthcare pro- of the collaborations between governments, international com-
viders have in advocating for polices that foster health equity and munities, civil societies, and private corporations. Although the
access to quality healthcare services for all children and families. UNDP acknowledges shortfalls that remain, significant progress
has been made globally in the 30 developing countries targeted.
Global Health Status of Children Although the rate of child mortality globally remains high, the
global under-5 mortality rate declined by more than half, from 90
Thirty-one million children younger than 20 years old are part of deaths per 1000 live births in 1990 to 43 deaths per 1000 births
the international migration of populations across continents (United in 2015 (UNDP, 2015). The neonatal mortality rate fell to 19 per
Nations International Children’s Emergency Fund [UNICEF], 1000 live births in 2016 from 37 per 1000 births in 1990. The
2017). Among the world’s refugees are an estimated 10 million highest rates of infant mortality occurred in two countries—39%
children, who have been forcibly displaced from their home coun- of newborn deaths occurred in southern Asia and 38% in sub-
try, and 17 million more who have been displaced due to conflict Saharan Africa. Half of all newborn deaths occurred in just five
1
2 UNIT I Influences on Child Health and Child Health Assessment
• Fig 1.1 United Nations Development Program (UNDP) Sustainable Development Goals for 2030.
(United Nations Development Program: the millennium development goals report 2015. UNDP. http://www.
undp.org/content/undp/en/home/librarypage/mdg/the-millennium-development-goals-report-2015.html.
Accessed September 10, 2018.)
Sustainable development
and climate change
Energy 13 Democratization
4
10 7 Rich–poor gap
Peace and conflict
9 8
Education Health issues
• Fig 1.2 Fifteen Global Challenges Facing Humanity. IT, Information technology. (From http://107.
22.164.43/millennium/challeng.html.)
Most concerning among the child health indicators is the per- age- and gender-specific growth charts. The rate of obesity among
centage of overweight and obese children. Seventeen percent of adolescent males and females 12 to 19 years of age is currently
children 2 to 19 years of age are obese, defined as a body mass 20.5% and has continued to rise over the past decade. Although
index (BMI) greater than the 95th percentile for age on the BMI rates of obesity among children and youth in the United States
4 UNIT I Influences on Child Health and Child Health Assessment
remain the highest among the high-income countries, surveillance Despite many government food assistance programs in the
studies show that the rate of overweight and obesity has stabi- United States, nearly one in five children in the United States
lized among 2 to 5 year olds at 8.9% and the prevalence is less lives in a food-insecure household. Children who are food inse-
than the Healthy People 2020 goal of 9.4% in early childhood cure are more likely to have poorer general health, higher rates
(Ogden et al., 2015). Obese and overweight children and youth of hospitalization, and increased incidence of overweight, asthma,
are more at risk for developing adult health problems, including and anemia and to experience more behavioral problems. Factors
heart disease, type 2 diabetes, metabolic syndrome, stroke, and other than income impact whether a household is food insecure.
osteoarthritis. Of all the child health indicators, overweight and Maternal education, single-parent households, intimate partner
obesity significantly affect the cost of providing healthcare services violence, and parental substance abuse also contribute to food
in the United States. insecurity. Children living in households where the mother is
moderately to severely depressed have a 50% to 80% increased
risk of food insecurity (Gundersen and Ziliak, 2015).
Food and Housing Insecurity and Effect on Three-quarters of children spend some portion of the pre-
Children’s Health school years being cared for outside of the home. Depending on
child care arrangements, the care can contribute to or ameliorate
Hunger and undernutrition are often associated with food inse- the effects of food insecurity for children. Young children who
curity, which exists when populations do not have physical attend a preschool or child care center have lower food insecurity,
and economic access to sufficient, safe, nutritious, and cultur- whereas children cared for at home by an unrelated adult are at
ally acceptable food to meet nutritional needs. Food insecurity higher risk for food insecurity (Gundersen and Ziliak, 2015). The
occurs in impoverished populations in developing countries and Supplemental Nutritional Assistance Program (SNAP), the Spe-
in industrialized nations, particularly among migrant popula- cial Supplemental Nutrition Program for Women, Infants, and
tions. Children affected by migration and family separation are Children (WIC), and the School Breakfast Program (SBP) are
at risk for food insecurity and are vulnerable to further health federally funded programs with the purpose to combat childhood
consequences, including exposure to exploitation and child hunger. The average monthly WIC benefit for families is $43.
trafficking. Growing evidence about climate change indicates Recent WIC data indicate the proportion of infant-prescribed
the dramatic effect on food crops that has led to food distribu- formula declined over the past decade. This may reflect the trend
tion issues globally, which is one of the primary contributors to of increased rates of breastfeeding in the United States reported in
the migration patterns and food insecurity (Fig 1.3). Globally, 2016 (Patlan and Mendelson, 2018).
undernutrition is an important determinant of maternal and Children living in poverty are also significantly affected by
child health and accounts for 45% of all child deaths in children the affordable and adequate housing crisis in the United States,
younger than 5 years of age (UN, 2015). Low rates of breast- particularly immigrant children and families living in large
feeding remain a problem in developed and developing nations. metropolitan areas. Approximately 21% of persons experienc-
Children who are exclusively breastfed for the first 6 months ing homelessness in the United States are children (OHCHR,
of life are 14 times more likely to survive than nonbreastfed 2017). Although many children are reportedly experiencing
infants. sheltered homelessness, this lack of family financial stability, the
Health effects
Temperature-related
illness and death
Regional weather
changes
• Contamination
pathway
Air pollution-related
health effects
• Transmission
Climate
• Heat waves dynamics Water- and food-borne
change • Extreme weather • Food diseases
• Temperature availability
• Precipitation • Migration Vector- and rodent-borne
diseases
Psychological effects
Adaptation
measures Malnutrition
Research
limited housing supply in inner cities, and the high eviction rates indicators address social determinants of health. However, the tar-
negatively impact the education and physical and mental health gets often fall significantly below what is required to decrease the
of children. economic inequalities between communities and neighborhoods.
Some communities are addressing social determinants of health
Addressing Children’s Health in the United through connecting community safety and healthy child devel-
opment and advocating for system, policy, and practice change
States (Prevention Institute, 2017). Exposure to neighborhood violence
impacts children, and safer communities can promote social-emo-
Healthy People 2020 tional development for young children. Safe communities offer
The Healthy People 2020 goals for children include foci specific to public places for children to play and community safety promotes
early and middle childhood and adolescents, social determinants economic development. Policies of community safety and early
of health in childhood, health-related quality of life for children, childhood development intersect and impact determinants of the
and specific disparities in child health to improve healthcare ser- sociocultural environment, physical/built environment, and edu-
vices and health outcomes. With increased proportions of chil- cational/economic environment (Prevention Institute, 2017). Fig
dren with developmental delays, Healthy People 2020 focuses on 1.4 illustrates a framework to help communities better understand
objectives to increase the percentage of children younger than 2 and address the inequities that contribute to violence and how
years old who receive early intervention services for developmen- early experiences influence development over the life course.
tal disabilities and to increase the proportion of children entering
kindergarten with school readiness in all five domains of healthy
development—physical health and well-being; social emotional Adverse Childhood Events and Impact on
development; approaches to learning; language development and Child Health Outcomes
communication; and cognitive development. The objectives set
benchmarks to increase the percentage of young children who are There is growing evidence about the disruptive impact of toxic
screened for autism and other developmental delays at 18 and 24 stress on biologic mechanisms that impact childhood develop-
months of age (National Center on Birth Defects and Develop- ment. Early adverse stress is linked to later impairments in learn-
mental Disabilities, Centers for Disease Control and Prevention ing, behavior, and physical and mental well-being (American
[CDC], 2015). Academy of Pediatrics [AAP], 2014; Shonkoff et al, 2012). Toxic
Reports indicate Healthy People 2020 objectives have been stress results from strong or frequent and prolonged activation of
achieved in many areas. The United States surpassed the overall the body’s stress response systems in the absence of the protec-
goal of a 10% reduction in infant and youth mortality in almost tion of a supportive, adult relationship (Shonkoff et al, 2012). The
all age groups, averting 1200 child deaths in 2015 (Kahn et al., adversity can occur as single, acute, or chronic event in the child’s
2018). Infectious diseases among children in the United States— environment, such as emotional or physical abuse or neglect, inti-
Haemophilus influenzae B, hepatitis B, group B streptococcal and mate partner violence, war, maternal depression, parental sepa-
pneumococcal infections, and meningococcal disease—declined, ration or divorce, and parental incarceration (Box 1.2). Adverse
meeting or exceeding the Healthy People 2020 targets and indi- childhood events (ACEs) occur across all income groups, but 58%
cating movement toward the 2020 objectives for completion of of children with ACEs live in homes with incomes less than 200%
the vaccine series across age groups (National Center for Health of the federal poverty level (FPL). African-American children are
Statistics [NCHS], 2016). disproportionately affected by ACEs—6 out of 10 African-Amer-
Healthy People 2020 objectives also address the need for ican children have experienced ACEs and represent 17.4% of all
increasing the proportion of practicing primary care providers, children in the United States with ACEs (Bethell et al., 2017).
including nurse practitioners, to improve access to quality health- Emotional abuse is the most commonly reported ACE, followed
care services. An integrated workforce can provide appropriate by parental separation or divorce, and household substance abuse
evidence-based clinical preventive services to reduce overall health (Merrick et al., 2018).
care costs, as well as improve access and facilitate communica- Toxic stress in childhood has implications that carry over into
tion and continuity of care for children and families. Approaches adulthood. Evidence suggests that the results of the prolonged
to health care must be interprofessional and must consider the and altered biologic mechanisms lead to increased risk of chronic
biosocial factors in the delivery of health care to achieve child health conditions in adulthood, including obesity, heart disease,
health outcomes beyond those of the biomedical dynamics of dis- alcoholism, and substance abuse (Shonkoff et al., 2012). A child
ease (Holmes et al., 2014). The ODPHP advisory committee is who has experienced ACEs is also more likely to engage in high-
building the Healthy People 2030 objectives on the foundational risk behavior, such as the initiation of early sexual activity and
principles, mission, and overarching goals of the Healthy People adolescent pregnancy. Limiting the impact of ACEs through effec-
2020 framework. tive interventions that strengthen communities and families and
protect young children from the disruptive effects of toxic stress is
critical to improve health outcomes throughout the life course for
Social Determinants of Health and Health Equity future generations (Merrick et al., 2018).
The social determinants of health result in unequal and unavoid-
able differences in health status within communities and between Child Health and Access to Care
communities. Individuals are affected by economic, social, and
environmental factors in their communities. Social determinants Child heath is fundamental to overall child development, and
of health recognize that home, school, workplace, neighborhoods, children with health insurance are more likely to have a regular
and access to health care are significant contributors to child source of care and access to preventive healthcare services. Nation-
health outcomes. Many of the Healthy People 2020 leading health ally, there has been significant progress over the past decade on
6 UNIT I Influences on Child Health and Child Health Assessment
tural Drivers
Struc People
• Social networks & trust
• Participation & willingness
Community to act for the common good
• Norms & culture
Place
People Place • What’s sold & how it is promoted
• Look, feel & safety
• Parks & open space
• Getting around
• Housing
Equitable • Air, water, soil
Opportunity • Arts & cultural expression
Equitable Opportunity
• Education
• Living wages & local wealth
• Fig 1.4 Tool for Health and Resilience in Vulnerable Environments (THRIVE) Clusters and Factors
Impacting Early Child Development. (Prevention Institute & Center for Study of Social Policy; Cradle to
community: a focus on community safety and health child development; 2017:1–47. http://preventionin-
stitute.org/sites/default/files/publications/PI_Cradle to Community_121317_0.pdf. Accessed October 12,
2018.)
and developmental screening services; lack of provider education National Center on Birth Defects and Developmental Disabilities. Cen-
in current strategies to identify child development, emotional, ters for Disease Control and Prevention (CDC). Community report
and behavioral problems; and lack of community referral sources on autism. 2014 (PDF online). www.cdc.gov/ncbddd/autism/states/
to assist children, adolescents, and families. These issues have led comm_report_autism_2014.pdf Accessed October 10, 2018.
National Center for Health Statistics (NCHS). Chapter 23: Immuniza-
to inconsistent quality of preventive healthcare services affecting
tion and Infectious Diseases. Hyattsville, MD: Healthy People 2020
children and families. Midcourse Review; 2016.
Much of the basis for primary care practice is not yet evidence Office of United Nations High Commissioner for Human Rights
based. Primary care would benefit from stronger scientific clini- (OHCHR): Statement on Visit to the USA, Philip Alston, UN Spe-
cal research that could strengthen primary care principles and cial Rapporteur on extreme poverty and human rights. 2017:1–13.
prevention. Lack of funding and infrastructure to support such https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?
primary care clinical research stands in sharp contrast to the orga- NewsID=22533&LangID=E. Accessed on September 12, 2018.
nized commitment and emphasis on advancing knowledge in dis- Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of Obesity
ease entities and treatment options. This gap provides an area of Among Adults and Youth: United States. 2011-2014. NCHS Data Brief.
research open to pediatric nurse researchers and other pediatric no. 219. Hyattsville, MD; 2015.
Patlan KL, Mendelson M. WIC Participant and Program Characteristics
healthcare providers trained in clinical research. Increased evi-
2016: Food Package Report. Prepared by Insight Policy Research Alex-
dence in the primary healthcare domain would help to move the andria, VA: U.S. Department of Agriculture, Food and Nutrition
public dialogue toward a greater focus on primary prevention and Service, Project Officer: Anthony Panzera; 2018. Available online
away from a disease-focused healthcare system. at: www.fns.usda.gov/research-and-analysis. Accessed on October 26.
2018.
Prevention Institute & Center for Study of Social Policy. Cradle to com-
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2
Unique Issues in Pediatrics
MARTHA DRIESSNACK
T
his chapter focuses on some of the unique issues that especially as children’s cognitive and executive function matures.
inform pediatric primary care, beginning with the inher- Parents are clearly authorities and caregivers, but they are not sur-
ent challenges of providing patient-centered care when the rogates. Pediatric providers need to seek out children’s voices and
focus of care is a two-generation or dual patient. This introduction encourage children’s participation in care and health-related deci-
is followed by a brief discussion of contemporary contexts and sions over time.
theories that influence how we view children, as well as how the
continued use of a developmental lens, although important, cre- Looking Through a Developmental Lens
ates challenges. Also highlighted is the importance of early invest-
ment in lifelong health, with a particular focus on a child’s first How children are viewed influences how primary care pro-
1000 days, adverse childhood experiences (ACEs), and household viders (PCPs) interact with them. If children are seen only as
and health literacy. The final section is a reminder that transition- works in progress using a deficit-based, developmental lens,
ing from a pediatric to an adult primary care system is critical for they are regarded as human becomings, rather than as human
all children, but especially for adolescents and young adults with beings (Driessnack, 2005). Children are not seen as agents in
chronic physical and medical conditions. their own right, human beings who are capable of influencing
their learning and others. Instead, our understanding of chil-
Two-Generation or Dual Patient dren and childhood is left to reports from adult surrogates.
Although pediatric PCPs embrace the concept that every child
One of the unique challenges in pediatrics is the two-generation is considered within the context of family, it does not mean that
or dual patient. Although the primary focus in pediatrics is the parents’ perspectives are preferred or take precedence over the
child, each child and/or adolescent comes with at least one parent child’s when health-related decision-making and plans of care
or caregiver, if not three or four, and cannot be seen or cared for are being considered.
without this context. Taking time to understand and work with Past dominance of deficit-based, stage theories as the lens
parents is paramount in pediatric primary care, but it is distinct through which children are primarily viewed is being chal-
from patient- and family-centered care (PFCC). In PFCC, provid- lenged, replaced with a call for a more balanced understanding.
ers acknowledge the patient’s ultimate control over health-related This shift in understanding parallels the emerging emphasis on
decisions, while acknowledging that these decisions are contex- patient-centered care and shared decision-making. Although
tualized within each patient’s broader life experiences and family. being patient-centered has some inherent challenges in pediatrics,
The challenge of using a pure PFCC model in pediatric primary it is a reminder to advocate for the voices of children, which too
care is that there is not one patient, but two, and while the child is often are absent from health-related decision-making and plans of
the focus, the parent is considered the authority in terms of deci- care. New tools and approaches are needed that access children’s
sions (Eichner, 2012). voices based on children’s cognitive strengths and abilities. In the
For pediatric providers, one of the greatest challenges is how to past, clinicians and researchers have relied on adult-developed
access, acknowledge, and include the child’s voice, which is often and adult-centered tools and approaches, which have been
lost and/or overridden in healthcare. This tendency to lose track adapted for use with children by adding pictures and/or simpler
of and/or override children’s voices is rooted in the long-standing language. There is increasing realization that data from adapted,
tradition of seeing children using deficit-based or developmental adult-centered tools have not adequately captured the voices and/
lenses. Using these lenses there is a presumption of decisional inca- or experiences of children, giving rise to national movements,
pacity in the patient and therefore deference to parental authority. such as No More Hand-Me-Down Research and Nothing About Me
This view is contrasted to how the patient is seen in adult health- Without Me.
care, where there is a presumption of decisional capacity in the Understanding how children develop from conception through
patient, with familial insight serving as adjunctive. adolescence is foundational in pediatric primary care. Although
All health care providers are obligated to provide beneficial a number of major theories have informed the study of child
care to the patient. For adults this means the patient’s needs development over the past century, there are a few that have been
and wishes take priority. In pediatrics, balancing the needs and resurrected, or borrowed from other disciplines, to examine the
wishes within the context of the dual patient continues to give impact of modern societal contexts, rapid advances in science, and
rise to some of the most difficult and challenging care decisions, expanding worlds of media and technology (Table 2.1).
8
CHAPTER 2 Unique Issues in Pediatrics 9
»Mutta kun olette löytänyt hänet», kysyi hän, »niin mitä aiotte
tehdä hänelle?»
Ja Martigny? Ken hän oli? Missä suhteessa hän oli näihin naisiin?
Että rikos oli huolellisesti suunniteltu, sitä en voinut epäillä; ja se oli
suoritettu hämmästyttävällä taitavuudella. Ei näkynyt mitään
epäröimistä noissa lujissa katseissa, ei mitään kahden vaiheella
olemista, ei mitään neuvottomuutta, vaan sen sijaan melkein
pirullista toiminnan kylmäverisyyttä, joka ilmaisi voimaa ja tottumusta
sellaisissa asioissa. Epäilemättä se oli Martigny, joka oli punonut
salajuonen ja myöskin toteuttanut sen. Ja kuinka uskaliaasti! Hän ei
ollut pelännyt olla läsnä tutkinnossa, kuten ei myöskään lähestyä
minua ja keskustella kanssani asiasta. Suutuksissa itseeni, kun olin
kiinnittänyt niin vähän huomiota siihen, koetin muistella
keskustelumme yksityiskohtia. Hän oli kysynyt, muistelin, mitä
tapahtuisi neiti Holladaylle, jos hänet huomattaisiin syylliseksi.
Hänelle oli siis tärkeätä pelastaa hänet. Hän oli — niin, nyt käsitin
sen! — kirjoittanut kirjeen, joka pelasti hänet; hän oli antautunut
vaaraan tulla ilmi saadaksensa hänet vapaaksi!
Niin, ja sitten oli vielä eräs toinen asia, jota minun oli varottava.
Mikä esti häntä niin pian kuin tuli maihin sähköttämästä
rikostovereilleen ja kehoittamasta heitä pakenemaan? Taikka
myöskin hän voi odottaa ja vakoilla meitä, kunnes näkisi, että he
todellakin olivat vaarassa. Oli miten oli, joka tapauksessa he voisivat
helposti paeta; neiti Kemball oli ollut oikeassa muistuttaessaan, että
meidän ainoa toivomme onnistumisesta oli siinä, että yllättäisimme
heidät valmistautumattomina. Jospa vain voisin hänet eksyttää,
pettää hänet, vakuuttaa hänelle, ettei hän ollut missään vaarassa!
Leijonan pesässä
»Oli vain sattuma, että sain tietää teidän olevan laivassa», selitin
istuutuessani. »Oletteko jo parempi?»
»Niin, en ole ollut ylhäällä koko aikana, aina matkan alusta asti.
Enkä nousekaan, ennenkuin tulemme Hovreen huomenna.»
»Mutta te, herra Lester», sanoi hän, »mistä johtuu, että te olette
myös matkalla Ranskaan? En tiennyt, että te tulisitte —»
»Vai niin?»
»Niin, ja eräs mies nimeltä Bethuny taikka Bethune taikka jotakin
sellaista. Mutta en kiinnittänyt paljon huomiotani häneen — hänellä
ei oikeastaan ole asiassa mitään tekemistä. Hän ei edes
matkustanut naisten mukana. Samana päivänä, kun lähdin ulos
tiedusteluilleni sai hän halvauskohtauksen jossakin kadulla ja vietiin
sairaalaan, niin lähellä kuolemaa, että oli epätietoista vieläkö hän
lainkaan tointuisi. Niin että hän on poissa pelistä. Jourdainit kertoivat
minulle, että naiset olivat matkustaneet Ranskaan.»
Minä nyökäytin.
»Ei, jos käyttää poliisin apua», sanoi hän. »Ehkäpä siinä piankin
onnistuisitte, jos pyytäisitte poliisia auttamaan teitä.»
»Ah», sanoi hän hiljaa, ja vielä kerran »ah! Niin, näyttääpä vähän
ihmeelliseltä! Mutta jos olisitte odottanut kirjettä, niin ehkä —»
»Niin, enkö ole vielä puhunut sitä teille? Herra Royce, nuorempi
päällikköni, on mukanani — hän on ollut vähän heikko, ja hänen
myöskin tarvitsee levätä.»
»Meille olisi suuri ilo, jos saisimme tulla», vastasin, vaikka tiesin
hyvin, että tarjousta ei tultaisi koskaan käyttämään. »Olette hyvin
ystävällinen.»
»Ei», väitti hän vastaan; »ei!» Mutta hänen äänensä oli melkein
kuulumaton.
»Oikeuksistanne?»
»Hyvästi, herra Lester», sanoi ääni, joka oli tullut minulle hyvin
rakkaaksi. »Odotan kiihkeästi saavamme vielä tavata!»
»Samaa voin minä sanoa», vastasin, ja tunsin kuinka kasvoni
helottivat.
»Se oli ystävällisesti sanottu, neiti Kemball!»
»Ja suoraan sanoen, herra Lester», lisäsi tohtori, »olen iloinen kun
pääsin hänestä. Oli onni, ettei hän kuollut matkalla. Mielipiteeni
mukaan ei hänellä ole kauan elonaikaa jäljellä.»
»Kaksikymmentä kilometriä.»
*****