DC Child Accident & Safety Blog

One in 100 newborns has a malformed heart. It's the most common birth defect. Now, a federal advisory panel recommends a simple and painless test for all newborns to detect such defects before the babies are released from the hospital.

Pulse oximetry measures the amount of oxygen in the blood via a small light sensor taped to a baby's wrist, hand or foot. It's inexpensive ($5-$10), fast (five minutes) and can detect a life-threatening condition otherwise difficult to find in a physical exam. An infant's cardiovascular system might appear normal in the first few days after birth, even though it continues to mature.

According to WebMD, only two states -- Maryland and New Jersey -- legally mandate the test. Some hospitals elsewhere do it voluntarily, but it's not in widespread use.

The federal panel's advice has been endorsed by the American College of Cardiology, the American Heart Association and the American Academy of Pediatrics.

If you're expecting, and you don't live in Maryland or New Jersey, make sure your hospital knows you want the test to be performed before your bring junior home. The chances of heart problems are low, but it's better know if there is one -- and to address it -- before it presents far from where it can be treated.

It’s parental instinct to want to make a child’s world as safe and normal as possible. And when that world is different from the one most other children live in, parents want to know why.

When a pediatrician’s patient lives in the world of autism, explaining the whys and whats to the parents is particularly daunting. Writing in the New York Times recently, Dr. Perri Klass addressed how she relates to parents of autistic children who want to know the cause and, for prospective parents, how they can reduce the risk for children they’re planning to have.

“[A]lthough there is more research in this area than ever before,” she writes, “it sometimes feels as if it’s getting harder, not easier, to provide answers that do justice to the evidence and also offer practical guidance.”

Autism is a complex disorder that research has shown is driven by both genetic and environmental factors. As Klass describes, “Genes matter, but we usually can’t tell how. Environmental exposures matter, but we usually don’t know which.”

Not much there for parents to work with.

A study of autism in twins showed that fraternal twins were both likely to have the disorder, which seems to compromise the strength of the genetic component (since fraternal twins share fewer genes than identical twins).

A couple of generations ago, when ignorance about all mental disorders was evident far more than common sense, autism was blamed on remote parenting. More recently, a noisy campaign was based on fake science supposedly indicating an association between childhood vaccinations and autism, a theory that has been wholly discredited.

But the genetic influences have been proved scientifically sound, and autism spectrum disorder has been described by the American Psychiatric Association as “among the most heritable of psychiatric disorders.”

This evolution of understanding has led scientists to accept that autism results both from genetic predisposition and from environmental influence. But “environment” is a fluid concept.

As one researcher quoted by Klass put it, it’s “everything that’s not the inherited DNA.” Parents might wonder about the chemical ingredients of the placenta’s soup, about the mother’s nutritional profile, her stress level, about the caustic cleaning products under the sink … They’re all part of a developing fetus’s environment.

According to Klass, “The causal links most strongly supported by research include rubella (measles) infection during pregnancy and prenatal exposure to medications like thalidomide and valproic acid, an anti-seizure drug.” Air pollution and exposure to pesticides have an association with autism, but there’s no evidence of causality.

Phthalates, which are chemicals found in flexible plastic products such as shower curtains and other household furnishings such as carpet and shampoo, can leach out in microscopic amounts and disrupt a variety of developmental processes, including brain development. But, again, they haven’t been shown to be a cause of autism, only as an association with its symptoms.

Bottom line: Autism is a custom-made disorder, and probably the result of several factors.
“So it’s hard — and frustrating — to offer prospective parents advice about avoiding risks we still can’t clearly identify,” Klass observes, “and factors that may differ from family to family.”

You can’t completely sanitize your environment, you can’t turn your uterus into a scientific “clean” room — potential toxins are simply a part life. But Klass does offer prospective parents concerned about autism some advice that’s more a prescription of common sense than a prophylactic:

• Take prenatal vitamins before trying to conceive.


• Ensure your immunizations are up to date.


• Get good prenatal care.


• Discuss the risks and benefits of any medications you take with your doctor.


• Avoid pesticides.


• Don’t microwave food plastic containers.


• Use fragrance-free personal products.

“Still, Klass concludes, “it’s hard to talk about this without terrifying parents. And I wonder if in giving advice about prevention, we risk repeating the errors of the past, making parents feel they’re to blame for a child’s autism because they failed to micromanage an environment full of complex agents with potential to interact with fetal genes in a range of damaging but poorly understood disruptions.”

Do you text while driving? Have a swimming pool at home without a cover? Have a gun in your house?

All sensible questions for pediatricians to ask parents and adolescent patients, looking for ways they can help improve home safety. But the last question, about guns, is now officially off limits for any Florida doctors to ask, thanks to a National Rifle Association campaign that succeeded in persuading the Florida Legislature that the question was too intrusive of privacy.

Having represented grieving parents whose child was killed by an accidental gun discharge at a neighbor's home whom they didn't know had a gun inside, I can relate to the desire of pediatricians to cut the toll of tragic gun deaths by asking parents this simple question. The question is intended to trigger a safety talk about the importance of keeping the gun unloaded and ammunition locked up where kids cannot get to it.

Because when kids are fooling around with a loaded weapon and it goes off, no one can put the bullet back in the gun.

Read more on the gun question from a pediatrician's perspective in a recent New York Times essay.

They grow up so fast, don't they? Some time between graduating middle school and graduating college, an adolescent should also graduate from pediatric to adult medical care. A new clinical report from three organizations recommends that such a transition should be planned in advance.

A successful, well-designed plan reflects the needs of the individual and involves the family and the medical providers on both ends--the ones who treated the kid, and the ones who will treat the adult--in order to develop the patient's ability to assume the responsibilities of self-care.

In preparing young people to be treated as adult patients, pediatricians should have a written policy spelling out the expectations of health-care transition, and they should bring up the subject with parents.

Doctors should develop individual plans jointly with the patients and their parents, ideally by the time the kids are 14, and earlier if they have special needs. The plan should be reviewed regularly by caregivers and parents to ensure updates are made before the transition occurs. And the pediatrician should communicate directly with the new adult health-care providers about the patient's history and needs.

The report offers six steps for parents and providers to effect a smooth transition (that is, as smooth a transition as anything adolescent-related can be).

• 1. Ensure that all young people with special health-care needs have a health-care professional to address them.


• 2. Identify core educational needs related to transition and integrate them into health-care professionals' training and certification requirements.


• 3. Prepare and maintain a current medical summary that is portable.


• 4. Create a written health-care transition plan for each patient by age 14.


• 5. Apply the same primary and preventive-care guidelines to all adolescents and young adults.


• 6. Ensure affordable, continuous health-care insurance for young people with special needs through adolescence and adulthood.

The report, scheduled to appear in the July 1 issue of Pediatrics, discusses a study showing that adult survivors of childhood diseases increasingly seek in-patient care at childrens' hospitals, which suggests that "systemic barriers" thwart the transition of some patients to adult care. But proactive parents in conjunction with enagaged pediatricians can overcome obstacles that would loom larger if left longer.

In comparison with the transition from puberty to sorority, transitioning your kid from pediatrician to the general practitioner is a walk in the parental park.

Children on the public Medicaid program who need to see a doctor for a serious but non-emergency health issue are shunned by many pediatricians' offices when their parents try to get appointments, according to a new study.

Two out of three get rejected entirely, and the average wait time for those who do get an appointment is three weeks longer than kids on private insurance.

This study gives scientific credence to the common hunch that children with public health insurance receive lesser care than those with private insurance.

According to an auditing study published in the New England Journal of Medicine this month, expanded eligibility for Medicaid and the Children's Health Insurance Program (CHIP) has not been accompanied by easier access.

"There's never been a study this comprehensive or this rigorous that actually measured access to specialty care, let alone children's access," said Karin V. Rhodes, M.D., an author of the study and director of emergency care policy research in the department of emergency medicine at the University of Pennsylvania.

Researchers telephoned clinics for medical appointments pretending to be the parent of a child with an urgent problem that wasn't an emergency. Problems included diabetes, seizures, asthma and broken bones. If asked, they said a primary care doctor or emergency department had referred them.

Sixty-six percent of the Medicaid-CHIP callers were denied an appointment versus 11% of privately insured callers.

Among 89 clinics that accepted both types of insurance, the average wait time for Medicaid-CHIP enrollees was 22 days longer than that for privately insured children.

Researchers attributed the disparity to low and delayed Medicaid fees that also were encumbered by red tape. The study, said the New York Times, is one of only a few efforts to measure access to health care among people with Medicaid.

Medicaid supplies coverage to one in five Americans at some point in a given year, and publicly insured patients are poised to find themselves wedged even deeper between the rock of financially strapped states and the hard place of diminishing coverage. As described in another New York Times story, the Obama administration's infusion of billions of dollars into Medicaid during the depths of the recession is expiring, and benefits are being cut for millions of recipients.

In one example from the study, Medicaid paid $99.86 for an office visit for a problem of "moderate severity," compared with $160 from a private insurer. Several doctors said their practices were threatened by accepting too many Medicaid patients, Rhodes reported; specialists said they would be willing to treat more Medicaid patients but the academic medical centers with which they were affiliated pressed them to see more patients with private insurance.

As health-care experts widely acknowledge, the blowback of diminishing resources will be felt elsewhere within the health-care system. Patients whose doctors refuse to accept lower Medicaid payments often turn to hospital emergency rooms for routine as well as urgent care. Other health-care providers--individuals and institutions--often try to recover lost Medicaid revenue with increased charges to privately insured patients.

Those children who get their care through emergency rooms often are sicker than kids with more ready access to the health care system, because their harried parents wait until the child is really, really sick to go to the ER. Their care winds up being more expensive than if the illness was nipped in the bud with earlier care. Thus a vicious cycle is born.

Meantime, the harsh and impossible reality for poor families is: Don't let your kid get sick.

The American Academy of Pediatrics (AAP) has revised its patient safety guidelines to reduce unintended harm to children by the healthcare system.

Noting that national awareness of patient safety risks has grown in this decade, Marlene Miller, MD, and AAP colleagues write in the June issue of Pediatrics that “the depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to uncover a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification.”

As technology evolves and medical advances become increasingly complex, the risk of causing unintentional medical harm has also increased, they write, pointing to studies that show seven failures to prevent a clinically important deterioration per 100 hospitalized children, 100 prescribing errors per 1000 children seen in an emergency room, and three preventable adverse drug events per 100 children seen in pediatric practices.

"The field of pediatric patient safety has matured much in recent years; there are now more robust epidemiology of errors for children, a deep understanding of the concept and measurement of a culture of safety, clear guidance on key elements of patient-safety solutions and introduction of successful pediatric patient-safety solutions," the article says.

"Nonetheless, continued work is needed to infuse these data and concepts into everyday pediatric practice for all clinicians, and special attention should be paid to the training of new clinicians to ensure that the future workforce can exercise all the tenets of pediatric patient safety as part of their everyday work life.

The new AAP patient safety recommendations aim to:

Expand efforts to educate clinicians, ensuring that they can all identify pediatric patient-safety issues and know how to improve them individually and within healthcare systems.

Create a safety culture by challenging all organizations, including small practices, to implement a pediatric patient safety plan that informs, supports and educates using appropriate local examples.

Develop patient-safety metrics for the ambulatory settings, where most children in the U.S. primarily interact with the healthcare system (though most patient safety work to date has been in hospitals).

Develop and support broad-scale pediatric error-reporting systems and analysis of reported events.

Comply with proven best practices for improving pediatric patient safety to enhance pediatric healthcare outcomes.

Target drug safety by advocating for the development of effective and safe pediatric medications and formulations and for withdrawal of medications with unfavorable risk/benefit ratios.

Educate clinicians on strategies to reduce medication errors by ensuring that they maintain access to and proficiency in the use of a comprehensive and current pharmaceutical knowledge base.

Source: Medscape

You can read the full text of the AAP statement here.

The American Academy of Pediatrics has new advice for parents about how to buckle their children in their cars. In a new policy published last month, the AAP advises parents to keep their toddlers in rear-facing car seats until age 2, or until they reach the maximum height and weight for their seat. In addition, it recommends that children ride in a belt-positioning booster seat until they have reached 4’9” and are between 8 and 12 years of age.

Previously, the AAP advised parents to keep infants and toddlers rear-facing up to the limits of the car seat but also set a minimum of age 12 months and 20 pounds, which resulted in many parents turning the seat to face the front of the car when their child celebrated his or her first birthday.

“Parents often look forward to transitioning from one stage to the next, but these transitions should generally be delayed until they’re necessary, when the child fully outgrows the limits for his or her current stage,” said Dennis Durbin, MD, FAAP, lead author of the policy statement and accompanying technical report.

“A rear-facing child safety seat does a better job of supporting the head, neck and spine of infants and toddlers in a crash because it distributes the force of the collision over the entire body,” Durbin said. “For larger children, a forward-facing seat with a harness is safer than a booster, and a belt-positioning booster seat provides better protection than a seat belt alone until the seat belt fits correctly.”

While the death rate of children in motor vehicle crashes dropped by 45% between 1997 and 2009, it is still the leading cause of death for children ages 4 and older. Counting children and teens up to age 21, there are more than 5,000 deaths each year. And for each death, about 18 children require hospitalization and another 400 need medical treatment.

Source: The American Academy of Pediatrics

Small medical clinics sprouting at the back of drug stores, grocery stores and big box outlets stress speedy service, but at what price? According to pediatrician Roy Benaroch, MD, who publishes the online blog The Pediatric Insider, these “McClinics” are the medical equivalent of fast food -- filling but not nourishing.

McClinics offer exactly what children don’t need, Benaroch says. Good pediatric care "looks at the whole child, the whole history, and the whole story. To do a good job I have to review the history, the growth charts, the prior blood pressures, the immunization records, and more. At the retail-based clinic, the encounters are just a quick toss-off: an opportunity for genuinely improving health that’s thrown away.”

Good pediatric care requires good training, Benaroch says, whereas McClinics are staffed by midlevel providers who may have minimal pediatric experience. Children are not the same as adults, and without specific, ongoing, significant pediatric training, the nurses at the local McClinic may not have the skills to adequately assess a child.

Benaroch recently reviewed two cases of children from his own practice who were clearly mishandled by a local McClinic. . One was a child given a vaccine he didn’t need, the other involved treating a urinary tract infection without doing the appropriate testing beforehand.

Benaroch also notes that some clinics offer special cut-rate sports and camp physicals to lure patients away from their primary care physicians for well-checks, even though “the heart of the well-check is to review all current issues, to look at the big picture, to make sure all health-maintenance tests and immunizations are up-to-date.” McClinics, he says, cannot offer that service without a thorough review of past records.

Source: The Pediatric Insider

The use of fetal heart rate monitors lowers the rate of infant mortality, according to a new study. Previous studies were too small to definitively prove the effectiveness of fetal monitoring, and some obstetricians maintained that the technology had been adopted too quickly.

But the new study, which was presented at the Society for Maternal-Fetal Medicine's (SMFM) annual meeting in San Francisco, used data from the 2004 National Birth Cohort to get a large enough sample (1,945,789 singleton births that met the studies inclusion criteria) to gauge its effectiveness.

The study found that in 2004, 88% of singleton pregnancies had fetal heart-rate monitoring and associated the monitoring with significantly lower infant mortality (3.8 per thousand live births without monitoring vs. 3.0 with monitoring), which in turn was mainly driven by a 53% decrease in early neonatal mortality. The decreased risk was associated with both low- and high-risk pregnancies.

Source: Science Daily

You’ll find an abstract of the study here.

The U.S. Consumer Product Safety Commission (CPSC) recently joined three child safety organizations to release "Safe Sleep for Babies," a new crib safety video aimed at helping all new parents avoid suffocation, strangulation and entrapment risks. CPSC also announced three new recalls of dangerous drop-side cribs.

Collaborating with CPSC on the video, which is moderated by TV journalist Joan Lunden, were the American Academy of Pediatrics (AAP), Keeping Babies Safe (KBS) and New York-Presbyterian/Morgan Stanley Children's Hospital.

Meanwhile, CPSC recently recalled nearly 40,000 drop-side cribs due to concerns about “entrapment, suffocation and fall hazards.” More than 34,000 of these were for Heritage Collection 3-in-1 drop-side cribs, which were manufactured in Vietnam and retailed at K-Mart nationwide from February 2007 through October 2008 for about $130.

The remaining recalls were for drop side cribs (a) manufactured in China and sold online at Ababy.com, Babyage and other Web Retailers from December 2004 through January 2009 under the “Longwood Forest” or “Angel Line” label for about $140; and (b) manufactured in the United States and China and sold at Ethan Allen stores from January 2002 through December 2008 for between $550 and $900.

The "Safe Sleep for Babies" video, which aims to educate new and expectant parents and caregivers on crib safety while they are at the hospital or visiting their pediatrician's office, is part of CPSC's Safe Sleep Initiative, a multi-pronged effort aimed at reducing crib deaths and injuries. In addition to this education effort, CPSC's Safe Sleep Initiative includes the development of new crib standards, warnings about drop-side cribs, sleep positioners, and infant slings, and the recall of millions of cribs in the past five years.

CPSC will distribute the video online and through its network of about 100 hospitals nationwide. NewYork-Presbyterian/Morgan Stanley Children's Hospital plans to make the video available to all families as part of their parent education programs, and provide copies to hospitals in the NewYork-Presbyterian Hospital Healthcare System. The American Academy of Pediatrics will promote the video to its 60,000 members and will feature it on AAP's parents-focused website, www.healthychildren.org, where it will be available for download.

Source: Consumer Product Safety Commission
For more information on the crib recalls, go here.
You can view the video here.

Many parents who want to ensure their young child’s safety in a car put them in booster seats. A recent study conducted by the Journal of the American Academy of Pediatrics now confirms what these parents already suspected – namely, that using child safety seats can reduce injuries and deaths in an automobile crash. It also supports the introduction of upgraded child restraint laws for children older than 3.

The study is the first to look at injury rates before and after a state law on booster seats went into effect. In March 2005, the state of New York upgraded its child restraint law to apply to children age 4 to 6. Since the state already had a law mandating child restraints in cars for children age 3 and under, the study compared the percentage of new restraint users in the 4 to 6 group with those in the 3 and under group.

The study found that after the child restraint law was upgraded, the use of boosters increased from 29% to 50%, resulting in an 18% decrease in injuries to children age 4 to 6. Meanwhile, the rates of booster use and injuries in the group age 3 and under remained unchanged.

Child seat laws vary from state to state, though all states mandate restraints for children until they are 3. Child safety experts recommend that, regardless of state law, children under 57 inches (4’9”) should ride in an appropriate restraint until the car’s own seat belts fit safely and comfortably. They also recommend that children under 13 should always ride in the rear of the vehicle.

Source: Consumer Reports Safety Blog
You can view the original study here.

Parents who turn to their child’s pediatrician for health and safety advice may end up hearing recycled parenting myths, a new study reports.

“In some cases, a child’s well-being may be seriously compromised if parents are given misinformation by a pediatrician based on these misconceptions and old wives’ tales,” said Andrew Adesman, M.D., lead investigator of the study and chief of developmental and behavioral pediatrics at the Steven and Alexandra Cohen Children’s Medical Center of New York.

The study was based on a questionnaire sent to a national sample of board-certified primary-care pediatricians and included a mix of 34 myths and 14 true statements. Analysis of more than 1,000 responses indicated that the majority of pediatricians (76 percent) mistakenly endorsed one or more of the parenting myths as being true, and 13 percent got three or more wrong.

Although most of the myths are benign old wives’ tales, Adesman said, there were a “dangerous dozen” health beliefs that reflected outdated parenting beliefs that could pose a risk to a child’s safety or well-being. For example:

• 33 percent said a burn can be treated with an application of ice. Risk: Ice can also cause injury to the skin.

• 33 percent said it is safe to put a baby to sleep on his or her side. Risk: Crib death -- also known as sudden infant death syndrome. (All babies need to sleep on their backs.)

• 5 percent said children can be given an ice bath to treat a fever. Risk: Hypothermia.

• 5 percent said children over age 6 can be given aspirin for a fever. Risk: Reye’s syndrome.

• 5 percent said it’s OK to place a soft object in a child’s mouth during a seizure. Risk: Dental injury to the child, hand injury to the adult.

• 3 percent said babies younger than six months can be given honey. Risk: Botulism poisoning.

Many pediatricians also endorsed less dangerous myths.. For example:

• 15 percent said children should not swim until 30 minutes after eating.

• 17 percent said vitamin C helps ward off colds.

• 16 percent said eating carrots improves a child’s vision.

• 8 percent said eating chocolate causes acne.

• 11 percent said listening to Mozart makes a baby smarter.

• 7 percent said reading in the dark causes visual problems.

• 11 percent said sugar causes hyperactivity.

• 7 percent said sitting too close to the TV damages vision.

• 9 percent said sleeping with a nightlight causes nearsightedness.

Source: Los Altos Town Crier
You can view the complete study here.