Julia A. McMillan, MD

After spending the month of July as attending pediatrician on a general inpatient service, I'm convinced that the medical home is an appropriate concept for the inpatient setting as well, and that inpatient facilities for pediatric patients-at least those in large academic medical centers-must begin to conceive of themselves as being responsible for creating an environment in which those same adjectives apply. 

Children with complex, technology-dependent, chronic conditions increasingly occupy inpatient pediatric units in referral hospitals. They require surgical intervention, including cerebrospinal fluid shunts, gastrostomy and jejunostomy tube placement, debridement of decubitus ulcers, and insertion of central line catheters; their care involves coordination of multiple subspecialties meeting with each other and with family members. 

Children who require extensive care coordination in the inpatient setting are often admitted repeatedly to one hospital. When this is the case, coordination of care among professionals who are familiar with the child and his or her family is possible. Such coordination is not likely to come from physicians, however. The rotating schedules of subspecialists, residents, fellows, and even hospitalists mean that families often have to become acquainted with an entirely new physician team with each admission. 

Other professionals, including nurses, case managers, and social workers, sometimes provide continuity and a familiar face for families, but only if the child is admitted to a particular hospital and unit each time admission is required. One of the advantages of the electronic medical record is that it allows sharing of information among providers, and in some settings, even among institutions. As helpful as that can be, however, it does not replace the personal understanding of a family and a child's past medical and psychosocial history. 

Coordination in the inpatient setting requires coordination with the professionals who will care for patients with complex, chronic needs when they return home. Communication with home care providers, subspecialists, pharmacists, primary care providers, and others who will resume their care of the patient after an inpatient stay involves more than sending copies of discharge summaries. Ensuring that communication occurs with each outpatient provider often is dependent on the conscientiousness of an individual resident or attending. 

Extension of the medical home concept to the inpatient environment will not occur without conscious recognition of its importance by the institutions whose pediatric and surgical subspecialists attract patients with complex medical and surgical needs. Resources, including personnel who establish continuity with families and patients as well as communication with outpatient providers, will be needed. Pediatric hospitalists and nurse practitioners are possible candidates for assuming these responsibilities. The primary care medical home has provided a model; the inpatient medical home is the next logical step.  

Articles

The medical home is a familiar concept to pediatricians. In recent years its definition has been made more formal and more comprehensive, but it is nearly always linked to an environment of primary care in the outpatient setting.

Inpatient medical home model

Vaccines have nearly eliminated invasive 

 type b infection in the United States and significantly diminished the frequency of serious infection because of 

, yet suspicion of UTI in febrile infants remains as important as ever. 

Among febrile infants younger than 12 months with no focal findings, 6.5% of girls and 3.3% of boys will have a UTI. That percentage rises to 8% of febrile girls aged between 12 and 24 months and falls to 1.9% for boys in their second year of life. 

Lacking evidence to assure us otherwise, experts have, in the past, recommended that diagnosis of the first UTI in an infant younger than 24 months should prompt renal and bladder ultrasound examination as well as a voiding cystourethrogram (VCUG), with the intent to provide long-term antibiotic prophylaxis for infants whose VCUG was abnormal. 

New guidelines have now been published in consideration of accumulated evidence that demonstrates that 1) the vast majority of infants who develop their first UTI do not have significant vesicoureteral reflux demonstrable on VCUG, and 2) antibiotic prophylaxis is not beneficial in preventing subsequent UTIs in infants with mild to moderate reflux.

  Kenneth Roberts, MD, lead author of the new guidelines and chair of the American Academy of Pediatrics Subcommittee on Urinary Tract Infection, 2009-2011, has provided a practical discussion in this month's issue of many of the recommendations included in the guidelines. 

There are some aspects of Roberts' article and of the guidelines themselves that should be emphasized: 
1) Accurate diagnosis and appropriate initial therapy are as important as ever. Pediatricians must maintain a high index of suspicion for UTIs in febrile infants, and diagnostic tests should be obtained in a manner that assures accurate interpretation of findings.
2) The recommendations for management apply to uncomplicated, first UTIs in infants with normal anatomy. 

One of the most important functions of a physician is to understand when guidelines do not apply. Although each child is unique, some are more susceptible to certain conditions than are others. It's our job to determine which child is at greater risk and to individualize care for that child.  

 Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in febrile infants. 

 Roberts KB, Charney E, Sweren RJ, et al. Urinary tract infection in infants with unexplained fever: a collaborative study. 

 Bauchner H, Philipp B, Dashefsky B, Klein JO. Prevalence of bacteriuria in febrile children. 

 Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. 

Even in the pre-Prevnar, pre-conjugated Hib vaccine era, urinary tract infection was the most common bacterial infection found in infants who presented with fever without localizing clinical findings.

Urinary tract infections

Mayor Bloomberg was lampooned as acting more like a nanny than a mayor, but the mayor responded that the suggested ban was "purely education," because New Yorkers would still be free to buy super-sized soda if they were willing to buy it in 2 containers. He compared his proposal to other laws instituted during his administration, including banning smoking in public places, outlawing the use of trans fats in restaurants, and requiring chain restaurants to post calorie counts. 

This soft drink controversy is merely the most recent illustration of personal freedoms being weighed against the health of the public. The arguments against Bloomberg's proposal, in addition to those related to personal liberty, highlight the futility of isolating this one (albeit important) contributor to overweight and obesity and raise concerns about what's next (eg, will it be the size of slices of pie or pizza?). 

We have considerable evidence that laws aimed at protecting the public from unhealthful behaviors can have important positive effects. Laws mandating use of bike helmets reduce head injuries; seat belt laws prevent motor vehicle injuries, and the more vigorously those laws are enforced, the more likely seat belts will be used.

Data regarding the effect of smoking ban laws on the incidence of cardiac disease are difficult to interpret because it's not easy to isolate the effect of the ban from other efforts to discourage smoking, but a recent meta-analysis demonstrated significant and growing reductions in acute myocardial infarction related to those bans.

And infants benefit as well. A study from El Paso, Texas, demonstrated that in El Paso, where smoking is banned in public places, preterm births were 23% lower than in Pueblo, where no such ban was in effect.

As pediatricians, we welcome legislation intended to improve the health of children. Some of those laws raise concern that personal liberty is being pushed aside, however good the intention of the legislation. Perhaps New Yorkers, as well as the rest of us, should be allowed to drink as much sugary soda as they like. But if Mayor Bloomberg's proposal does nothing but highlight the adverse health effects of large quantities of empty calories, perhaps he's proven that, sometimes, public officials have to act like nannies to make a point.  

National Highway Traffic Safety Administration. Primary enforcement of seat belt use laws saves lives and reduces injuries. 

									http://www.nhtsa.gov/About+NHTSA/Traffic+Techs/current/Primary+Enforcement+of+Seat+Belt+Use+Laws+Saves+Lives+and+Reduces+Injuries

Lightwood JM, Glantz SA. Declines in acute myocardial infarction after smoke-free laws and individual risk attributable to secondhand smoke. 

Page RL 2nd, Slejko JF, Libby AM. A citywide smoking ban reduced maternal smoking and risk for preterm births: a Colorado natural experiment. 

On May 30, 2012, New York City Mayor Michael Bloomberg caused an early summer commotion when he suggested that New York ban sodas and other sugary drinks in containers of more than 16 ounces sold in outlets other than grocery and convenience stores. Mayor Bloomberg was lampooned as acting more like a nanny than a mayor.

Legislating health

 includes an article, "An Emerging Dyslipidemia: Assessing Future Cardiovascular Risk in Children," that reminds pediatricians that our responsibilities actually extend to prevention of conditions that impair the health and shorten the lifespan of adults. 

Written by Samuel S. Gidding, MD, this article reviews the evidence demonstrating that risk factors for adult cardiac disease can be identified and treated during childhood. 

These efforts were successful enough that about 35 years ago, "new morbidities" captured the attention of pediatrics when it became clear that as a result of improved medical care, prevention efforts, and public health advocacy, psychosocial, behavioral, and developmental concerns had equaled or surpassed physical illness and injury as determinants of well-being. The concerns identified as the new morbidity have certainly not been eliminated, but genetic research, long-term studies, and improved care of children with chronic conditions now enable pediatric care to ameliorate some adult health problems.  

When efforts to prevent adult morbidity involve pharmaceutical treatment of apparently asymptomatic children, however, pediatricians appropriately want to be convinced of both the efficacy and the safety of the intervention. For that reason, recommendations to screen all children for dyslipidemia and to intervene with dietary changes and/or medications when the results suggest risk for later cardiovascular disease have been met with skepticism. 

As Gidding outlines, there is now robust evidence that links genes, environment, and diet in childhood to cardiovascular outcomes in adulthood. The potential that intervention through lifestyle, diet, and, in some cases, medication, may interrupt that link was convincing enough to an expert panel that formal recommendations have now been published.

  With these guidelines, pediatricians are expected to accept responsibility for improving the health of their patients, not until they are 22, but for several decades after that. Next month, Gidding will provide us with an overview of these new lipid management guidelines.  

Is implementation of these guidelines even possible on a large scale? Will implementation of the recommendations of the expert panel really result in longer lives and less morbidity for our current patients? The answers to these questions cannot be known today, but the challenge to identify subclinical conditions in children that will affect their health as adults is one that we will be increasingly asked to accept. It is an opportunity we should embrace.  

Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. 

The American Academy of Pediatrics Web site states that the AAP is "an organization of 60,000 pediatricians committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults."

Author | Julia A. McMillan, MD

Articles

Inpatient medical home model

Urinary tract infections

Legislating health

Pediatrics: It's not just for kids anymore