How has your child’s
health care been going this past year?

This could be a difficult question to answer if you’re not
sure what you should expect. For example, do you expect a prescription
medication to relieve congestion or coughing for a particular episode of
illness, or do you expect a treatment plan to reduce recurring symptoms so that
your child and you miss less school and work days throughout the year?
According to the United States Agency for Health Care
Research and Quality (AHCRQ), you should expect both the right treatment at the
right time, as well as an ongoing partnership to manage your children’s health
conditions or problems.
The Right Treatment at the Right Time
Despite the fact that physicians’ guidelines for the
management of common childhood conditions have been developed based upon
scientific evidence and concomitant expert consensus, our children are not
receiving this state-of-the-art care.
According to the most recent member survey of the American
Academy of Pediatrics (AAP), the majority of general pediatricians are not
incorporating clinical practice guidelines into their practices. And studies
show that pediatricians who see more patients use guidelines less. Many
physicians have responded to modern health care financing mechanisms by setting
"productivity" goals that call for seeing a greater number of
patients in a given time frame. But, contrary to popular opinion, managed care
does not force physicians to abandon their professional integrity.
Instead, scientific and health services research offer
specific findings about how pediatricians are not keeping up with advancements
in medical knowledge and practice. The first five things your pediatrician
won’t tell you pertain to these gaps between state-of-the-art and actual
pediatric practice:
1. The National Institutes of Health updated the Guidelines
for the Diagnosis and Management of Asthma in 1997. Contrary to guidelines
recommendations:
* Pediatricians and family physicians do not conduct the
recommended tests to confirm a diagnosis of asthma in school-age children.
* Pediatricians and family physicians do not evaluate
symptom combinations as recommended to diagnose childhood asthma.
* And, although
written treatment plans have been shown to reduce the odds of hospitalization
for asthma, half the primary care doctors don't use them.
2. Antibiotics are still being prescribed inappropriately
for colds, upper respiratory tract infections and bronchitis in infants and
young children, according to a study conducted by Harvard Medical School.
In another study, the following medical decision and
practice errors were documented:
· 69% of physicians considered green or yellow nasal
discharge a diagnostic indicator for sinusitis. It is normal for the mucus to
get thick and change from clear to yellow or green during a viral cold.
· 86% prescribed antibiotics for bronchitis, regardless of
cough duration. Bronchitis is a viral infection. Antibiotics do not kill
viruses. A prolonged cough indicates further diagnostic assessment is warranted
to consider other conditions such as asthma or infection.
· 42% prescribed antibiotics for the common cold. The common
cold is caused by viruses. Antibiotics do not kill viruses.
3. Over-diagnosing middle ear infections and inappropriate
treatment results in the overuse and misuse of antibiotics and, consequently,
increased drug resistance. A child treated with unnecessary antibiotics may
develop a bacterial infection that is resistant to that antibiotic, and may
require hospitalization. Sometimes, there is no treatment for an antibiotic
resistant bacterial infection.
Despite recommendations detailed in the Agency for Health
Care Quality and Research’s Practice Guideline for Managing Otitis Media With
Effusion in Young Children, studies found that variations exist among
physicians regarding when to refer patients for surgery (tube placement). Some
refer later than recommended, and put the child at risk for hearing loss with
associated poor expressive language skills, difficulty paying attention, and
reading delays.
4. Physicians are not following current standards of
practice for the treatment of gastroenteritis (diarrhea) and dehydration,
according to the AAP’s Practice Guideline for The Management of Acute
Gastroenteritis in Young Children. The following practice variations from
current standards of care for oral rehydration (fluid replacement) therapy have
been identified in the recent medical literature:
· Using oral rehydration solutions for children who are not
dehydrated or only mildly dehydrated. These children do not need oral
rehydration solutions.
· Administering intravenous rehydration fluids to children
who are moderately dehydrated. These children's care should be managed with
oral rehydration solutions.
· Withholding oral rehydration solutions or other feeding
for children with vomiting. Instead, these children need adequate fluids and
nutrition.
5. A study comparing contamination rates of urine specimens
obtained by "clean-voided" bag method versus catheterization found
that the inaccuracies of bag urine culture result in risks that outweigh the
benefits. Yet, contrary to the AAP Practice Guideline for The Diagnosis,
Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile
Infants and Young Children, pediatricians are still collecting bag specimens
for culture, largely due to a lack of training and experience for doing
catheterization.
An Ongoing Partnership to Manage Your Child’s Health
Problems
Physician leaders advocate redesigning the way physicians
practice so that a parent-provider partnership is the driving force behind each
child’s health care. However, pediatricians’ resistance to change results in
their adherence to the status quo. This reduces the likelihood of your
pediatrician telling you the next five things about the continuity of care and
collaboration that you should expect from your child’s healthcare:
6. It is your pediatrician’s professional obligation to
follow-up on past health problems.
7. Your pediatrician should understand how any health
problem your child has affects her and your family’s day-to-day life.
8. Your pediatrician should effectively teach you how to
manage your child’s condition at home.
9. You have a right to be involved as much as you want in
decisions about your child’s health care.
10. It should not be a problem getting your child’s
physician to agree with you on the best way to manage your child’s health
condition or problem.

What Can Parents Do?
Parents can take the following actions:
· Get informed about your child’s condition, whether she has
the common cold, allergies, asthma or any other condition,
· Keep a symptom diary to communicate the type, frequency
and duration of your child’s symptoms,
· Target goals you want to achieve, such as optimal symptom
reduction to enable your child to enjoy his regular activities, and
· Prompt your pediatrician for information on how to achieve
these goals and ask for a management plan that provides detailed instructions
for home care.
A practical and medically sound way to accomplish this is to
use two traditional tools of medicine: the patient symptom history and the
treatment or, management, plan.
Parents can keep a diary of their child’s symptoms to provide their pediatrician with information necessary for accurate diagnosis. For some conditions, such as allergies or asthma, professionally-developed management or, action, https://pediatriccare.solutions.aap.org/Pediatric-Care.aspx offers health care information, patient symptom diaries and management plans for you to print and use in partnership with your child’s physician or nurse practitioner. Another useful site for pediatric health care information is the AAP’s site: www.aap.org.
The information and tools available at https://pediatriccare.solutions.aap.org/Pediatric-Care.aspx have been developed based upon published scientific
evidence and corresponding medical
expert consensus about optimal pediatric care. Their use can help you better
prepare for your pediatric office visit, make yourself heard, and activate
state-of-the-art clinical practice guidelines for your child.
Expect nothing less.
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