National Center for Education in Maternal and Child Health

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September 21, 2001

1. National Child Health Day 2001

2. AAP Recommends Banning Infant Walkers

3. Study Cites Pediatricians' Reasons for Nonadherence to Asthma Guidelines

4. NIMH Offers Suggestions for Helping Children and Adolescents Cope with Violence and Disasters

5. Communitywide Intervention Improves Delivery of Preventive Services to Children

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1. NATIONAL CHILD HEALTH DAY 2001 -- Monday, October 1 -- is fast approaching. This year's theme is All Aboard the 2010 Express: A 10-Year Action Plan to Achieve Community-Based Service Systems for Children and Youth with Special Health Care Needs and Their Families. Promotional materials, fact sheets, and Just for Kids activities and games can be ordered by calling (888) 434-4624, or (703) 356-1964 in the Washington, DC, area, or by visiting the Maternal and Child Health Bureau Web site at <http://mchb.hrsa.gov/html/expresshome.htm>.

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2. AAP RECOMMENDS BANNING INFANT WALKERS

"The American Academy of Pediatrics [AAP] recommends a ban on the manufacture and sale of mobile infant walkers," according to a statement from the AAP Committee on Injury and Poison Prevention in the September issue of Pediatrics. The AAP recommendations are based on data that "indicate a considerable risk of major and minor injury and even death from the use of walkers." The National Electronic Injury Surveillance System (NEISS) estimates that 8,800 children younger than 15 months were treated in hospital emergency departments in 1999 for injuries received while in mobile infant walkers. Additional studies show that most injuries come from falls, either from the walker or with the infant remaining in the walker. Stairs are implicated in 75% to 96% of injuries and in almost all severe injuries.

Prevention and awareness measures such as warning labels, adult supervision, stair gates, and product redesigns have had varying success in discouraging infant walker use and in reducing walker-related injuries. The mandatory standard in effect since 1971 primarily addresses injuries to fingers and toes caused by pinching or shearing in the walker frame and by the collapse of the walker. The more serious problem of falls and tip-overs is addressed by the voluntary standard, with which not all manufacturers comply. The voluntary standard states that walkers manufactured after June 30, 1997, be wider than a 36-inch doorway or have a braking system to stop the walker if one or more wheels drop off the riding surface.

The AAP recommendations include the following:

• Banning the manufacture and sale of mobile infant walkers;
• Choosing a walker (if a parent insists on using one) that is in compliance with the performance standards of ASTM F977-96 to prevent the infant from falling down stairs;
• Encouraging community programs to properly dispose of walkers;
• Promoting the use of stationary activity centers as safer alternatives; and
• Monitoring the compliance of walker manufacturers with the voluntary standard ASTM F977-96.

AAP maintains, "Beyond parental impressions that infants seem happier in walkers, it does not appear that any real benefits of using a walker can be found to balance the considerable risk of injury."

AAP Committee on Injury and Poison Prevention. 2001. Injuries associated with infant walkers. Pediatrics 108(3):790-792.

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3. STUDY CITES PEDIATRICIANS' REASONS FOR NONADHERENCE TO ASTHMA GUIDELINES

Researchers have found that it is crucial for physicians to adhere to the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines to translate evidence-based recommendations into improved outcomes for asthma patients. Poor adherence, however, is well documented. The purpose of a study published in the September issue of the Archives of Pediatrics and Adolescent Medicine was to identify barriers to physician adherence to the NHLBI asthma guidelines.

The authors surveyed a national random sample of primary care pediatricians about adherence to four NHLBI guideline components: 1) prescription of daily inhaled corticosteroids to patients with daily asthma symptoms, 2) instruction of daily peak flow meter use to patients with daily asthma symptoms, 3) screening asthma patients for smoking and counseling for smoking cessation, and 4) screening the parents of patients with asthma for smoking and counseling for smoking cessation.

The authors found that most pediatricians are aware of the guidelines and have access to them. The study indicates that multiple factors such as lack of agreement, poor self-efficacy, lack of outcome expectancy, and practice-related barriers are associated with poor guideline adherence. However, different components of the guidelines are associated with specific barriers to adherence.

The authors suggest that their findings have implications for selecting methods for improving practice. In conclusion, they state, "This study reinforces the need for multiple interventions for overall adherence and tailored interventions to address characteristic barriers of each guideline component."

Cabana MD, Rand CS, Becher OJ, et al. 2001. Reasons for pediatrician nonadherence to asthma guidelines. Archives of Pediatrics and Adolescent Medicine 155:1057-1062.

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4. NIMH OFFERS SUGGESTIONS FOR HELPING CHILDREN AND ADOLESCENTS COPE WITH VIOLENCE AND DISASTERS

"Helping young people avoid or overcome emotional problems in the wake of violence or disaster is one of the most important challenges a parent, teacher, or mental health professional can face," states the National Institute of Mental Health (NIMH) in a report published this spring. School shootings, natural disasters, plane crashes, and violence make children vulnerable to long-term psychiatric trauma, including post-traumatic stress disorder (PTSD) and depression.

Reactions to trauma include the following:

• Children who are 5 years of age or younger may exhibit a fear of separation from their parents, crying, whimpering, immobility and/or aimless motion, and regressive behaviors such as thumbsucking and bedwetting.
• Children who are 6-11 years old may show extreme withdrawal, disruptive behavior, an inability to pay attention, refusal to attend school, and nightmares. Children at this age may also complain of stomachache or other bodily symptoms that have no medical basis. Feelings of guilt and emotional numbing may be exhibited.
• Adolescents between the ages of 12 and 17 may exhibit behaviors much like those of adults, including flashbacks, nightmares, avoidance of reminders of the traumatic event, depression, problems with peers, antisocial behaviors, physical complaints, and school avoidance or academic decline. Adolescents may also feel guilt over failing to prevent injuries, and some adolescents may harbor fantasies of revenge.

NIMH recommendations for helping children and adolescents who have experienced psychiatric trauma include the following:

Protect them from onlookers and media covering the event.

• Lead them away from the site.
• Stay with them until initial stabilization occurs.
• Encourage them to express their feelings without judging.
• Reassure them that they are loved.
• Reassure them that the traumatic event was not their fault.
• Take care of yourself so you can take care of them.

Parents, particularly mothers of young children, should be aware that their responses to violence or disaster strongly influence their children's ability to recover.

The report states, "Most children and adolescents, if given support . . . will recover almost completely from the fear and anxiety caused by a traumatic experience within a few weeks. However, some children and adolescents will need more help perhaps over a longer period of time in order to heal." The report contains a list of resources to assist parents in finding a mental health professional who can help their child or adolescent cope with trauma.

National Institute of Mental Health. 2001. Helping children and adolescents cope with violence and disasters. Available at <http://www.nimh.nih.gov/publicat/violence.cfm>.

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5. COMMUNITYWIDE INTERVENTION IMPROVES DELIVERY OF PREVENTIVE SERVICES TO CHILDREN

"System-level interventions hold promise to improve the effectiveness and outcomes of care for children," state the authors of a study published in the September issue of Pediatrics. The objective of the study of low-income pregnant mothers and their infants, primary care practices, and departments of health and mental health in one North Carolina county was to promote change in the process of care delivery at the family, practice, and community levels.

The system-level approach addresses the need for more effective organization of preventive services within primary care practices and more coordination between practices and community-based agencies. Interventions, selected on the basis of efficacy, involved strategies to build capacity and effectiveness and to avoid adding resources in any single site by increasing coordination of existing resources.

A number of positive effects were observed at all three levels of intervention:

• Policy-level changes in the state and community resulted in lasting changes in the organization and financing of care, which, in turn, enabled changes in clinical services to occur.
• Researchers were able to engage multiple practice organizations, reduce duplication, and improve the coordination of care.
• Changes in the process of preventive services delivery were noted in participating practices.
• Outcomes of the family-level intervention (home visiting) were comparable to the outcomes of previous randomized trials of the intervention, which indicated that home visiting had immediate and enduring effects in improving the quality of the caregiving environment, improving maternal life course development, reducing dependence on government programs, and decreasing childhood injury.

The authors concluded that future programs must be measured by their impact on the health of all children in a community, not just the children enrolled in a particular medical care plan or practice. They state, "The results of this study suggest that tiered, interrelated interventions directed at an entire population of children in a community are feasible. . . . The next steps are to determine who is responsible for system-wide improvement, and what resources are required to achieve the gains in child health and development that are possible."

Margolis PA, Stevens R, Bordley WC, et al. 2001. From concept to application: The impact of a community-wide intervention to improve the delivery of preventive services to children. Pediatrics 108(3):1-10.

Available online at <http://www.pediatrics.org/cgi/reprint/108/3/e42>

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MCH Alert © 2001 by National Center for Education in Maternal and Child Health and Georgetown University. MCH Alert is produced by the National Center for Education in Maternal and Child Health under its cooperative agreement (MCU-119301) with the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. The Maternal and Child Health Bureau reserves a royalty-free, nonexclusive, and irrevocable right to use the work for federal purposes and to authorize others to use the work for federal purposes.

Permission is given to forward MCH Alert to individual colleagues. For all other uses, requests for permission to duplicate and use all or part of the information contained in this publication should be sent to MCH Alert Editor, National Center for Education in Maternal and Child Health, at mchalert@ncemch.org.

The editors welcome your submissions, suggestions, and questions. Please contact us at the address below.

EDITOR: Tracy Lopez

CONTRIBUTING EDITOR: Beth DeFrancis

COPY EDITOR: Gayle Young

FOUNDING EDITOR: Laura Kavanagh

National Center for Education in Maternal and Child Health
Georgetown University

2000 15th Street North, Suite 701
Arlington, VA 22201
(703) 524-7802
(703) 524-9335 (fax)
E-mail: mchalert@ncemch.org
Web site: <http://www.ncemch.org>

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