You pick up the chart to go into the room of your next patient. You note the following:

1. You pick up the chart to go into the room of your next patient. You note the following: • He is an 8 month old male • He is here for the first time • His last name sounds “Spanish” • His chief complaint is “here for shots”

2. What might you want to check before going into the room?

6. Role Play

7. Organic FTT (OFTT) describes an infant or toddler who has grown poorly and has a medical disorder known to interfere with growth, including malabsorptive diseases, genetic syndromes, endocrine disorders, and neurologic dysfunction. Almost any chronic medical condition in a young child may manifest as poor growth.

8. Nonorganic FTT (NOFTT) often has been used as a diagnosis of exclusion to describe the child who has grown poorly and has no identified medical condition. This framework suggests that NOFTT is caused by environmental conditions, rather than intrinsic biologic disease.

9. Multifactorial FTT (or “mixed FTT”) describes the common situation in which both organic and nonorganic factors are identified as contributing to a child’s poor growth.

10. Conditions that put children at risk for poor growth: Poverty / Food insecurity. 20% of children younger than 4 years of age are living below the federal poverty line ($18,850 for a family of four in 2004). Food insecurity has been documented in 21% of households having children younger than 3 years of age Food insecurity occurs when the availability of adequate food is limited or uncertain and often is associated with intermittent hunger. Other documented risk factors include: Larger family size History of child abuse

11. Pathogenesis of poor growthThree principal mechanisms Loss of calories through malabsorption Increased caloric expenditure (such as occurs in hyperthyroidism, congenital heart disease, and chronic pulmonary disease) 3) inadequate intake of calories.

12. Pediatrics in Review January, 2006

13. KRUGMAN, DUBOWITZ; Am Fam Physician. 2003 Sep 1;68(5):879-884.

14. PART 1 KRUGMAN, DUBOWITZ; Am Fam Physician.  2003 Sep 1;68(5):879-884.

15. Part 2 In a classic study of hospitalized children with FTT, only 1.4 percent (36 of 2,607 tests) were of diagnostic assistance. Sills RH. Failure to thrive. The role of clinical and laboratory evaluation. Am J Dis Child 1978; 132:967-9. KRUGMAN, DUBOWITZ; Am Fam Physician. 2003 Sep 1;68(5):879-884.

16. Common Beliefs and Practices • Some Hispanic people believe that disease is caused by an imbalance between hot and cold principles • Traditional medicine in most Hispanic countries has an extensive list of folk remedies. • Providers may encounter the concept of a bilongo or hex...... • The evil eye (mal de ojo) appears in several Hispanic cultures. ….It is believed to be brought on by an admiring look from a person with a strong eye. http://erc.msh.org/mainpage.cfm?file=5.3.0c.htm&module=provider&language=english

17. Thus, "hot" diseases are treated with "cold" remedies, and "cold" diseases are treated with "hot" remedies. • Hypertension is defined as a hot illness. In 60% of the cases the etiology is thought to be due to corajes (anger) or susto (fear); the remaining 40% are felt to be due to "thick blood". Cool remedies such as bananas and lemon juice are popular as well as teas of passion flowers (pasionara), linden (tilia), or zapote blanco. http://www.rice.edu/projects/HispanicHealth/Courses/mod7/mod7.html

18. Key Concepts * Familia – Family 1- Allow for several family and friends 2- Communicate with the group 3- Determine matriarch and patriarch 4- Notice if the acculturated children or non- family members are the spokespeople. • The following slides are taken from “Quality Health Services for Hispanics: The Cultural Competency Component – HRSA/BPHC/SAMHSA/Office of Minority Health

19. Respeto – Respect 1- Always be respectful 2- Explain without condescending 3- Address elders in traditional ways (below eye level if you’re younger). 4- Be mindful of the parents or elders in the room when the acculturated child or a health mediator is the spokesperson. HRSA

20. Respeto 5- Ask for questions or a description of what was first heard and experienced. 6- Indirectly ask personal/private questions such as alcohol use, mental problems, violence, stressors, sex, etc. 7- Ask permission to touch genitalia after explaining what you are doing and why. HRSA

21. Personalismo – Personal Familiarity 1- Respect distal space and touching based on familiarity. 2- Ask about their life (family, friends, work). 3- Share your own life stories. 4- Share pictures. 5- Converse with all of the family members. 6- Be respectful of gender, do not give an impression of being too familiar. 7- Make personal notes in medical records to cue provider of family names or special events to discuss on the next visit. HRSA

22. Hispanic families traditionally emphasize interdependence over independence and cooperation over competition. A few words spoken in Spanish may become an important cue to people about your positive attitudes towards them. Personal rather than institutional relationships are important. (Continuity of care implications) HRSA

23. By respecting the patient’s culture and showing personal interest, a health care provider can expect to win their confianza (trust). Health care brokers, community outreach workers or promotoras can play a key role in establishing trust with a new provider. HRSA

24. Integrated Body, Mind and Espiritu (Spirit) Health symptomatology often present from the mind/body/spirit connection. Mental health problems and life’s stressors may appear as tight chest pain, shortness of breath, abdominal pain, sweats, chronic or frequent illness. Sustos – attaques de nervios, pena Mental health problems viewed as a weakness HRSA

25. KRUGMAN, DUBOWITZ; Am Fam Physician. 2003 Sep 1;68(5):879-884.

26. Pediatrics in Review January, 2006

27. Definition – Community PediatricsAAP Policy StatementPediatrics Vol. 115 No.4 April 2005 The American Academy of Pediatrics (AAP) offers a definition of community pediatrics to remind all pediatricians, generalists and specialists alike, of the profound importance of the community dimension in pediatric practice. Community pediatrics is all of the following:

28. A perspective that enlarges the pediatrician’s focus from one child to all children in the community

29. A recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces act favorably or unfavorably, but always significantly, on the health and functioning of children

30. A synthesis of clinical practice and public health principles directed toward providing health care to a given child and promoting the health of all children within the context of the family, school, and community

31. A commitment to use a community’s resources in collaboration with other professionals, agencies, and parents to achieve optimal accessibility, appropriateness, and quality of services for all children and to advocate especially for those who lack access to care because of social, cultural, geographic, or economic conditions or special health care needs An integral part of the professional role and duty of the pediatrician.

32. ….the major threats to the healthof America’s children, the new morbidities, arisefrom problems that cannot be addressed adequatelyby the practice model aloneAAP Policy Statement - April 2005 high infant mortality rates children with chronic health care needs Obesity intentional and unintentional injuries exposure to lead and other environmental hazards, substance abuse • behavioral and developmental consequences of inappropriate care and experience • mental health conditions • poor school readiness • family dysfunction • sexually transmitted diseases • unwanted pregnancies • lack of access to medical homes

33. Competencies Community Pediatrics

34. 1. Delivery of Culturally Effective Care Pediatricians must demonstrate interpersonal and communication skills that result in effective information exchange with children and families from all cultural backgrounds and diverse communities.

35. 2. Child Advocacy Pediatricians should advocate for the well-being of patients, families, and communities; We must develop advocacy skills to address relevant individual, community, and population health issues; and understand the legislative process (local, state, and federal) to address community and child health issues.

36. 3. Medical Home Pediatricians must be able to identify and/or provide a medical home for all children and families under their care. As defined by the AAP, the medical home is an approach to providing comprehensive primary health care services in partnership with families. Care received in the medical home is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.

37. 4. Special Populations Pediatricians must be able to identify children and youth at risk for poor health outcomes and those with special health care needs. Pediatricians, in concert with other child health professionals, must collaboratively develop and implement management plans that are realistic, family centered, community referenced, nonrestrictive, and effective. They must have a working knowledge of specific psychosocial issues, legal protections/implications, policies, and services provided for these populations at the local, state, and federal levels.

38. 5. The Pediatrician as a Consultant, Partner, and Collaborative Leader Pediatricians must be able to act as child health consultants in their communities. Using collaborative skills, they must be able to work with multidisciplinary teams, community members, and representatives from schools, child care facilities, and legislative bodies.

39. 6. Educational and Child Care Settings Pediatricians must be able to interact with the staff of schools and child care settings to improve the health and educational environments for children.

40. 7. Community and Public Health Pediatricians must be able to understand and potentially modify the health determinants affecting patients and families in the community that they serve. To effect change in health outcomes, pediatricians must be able to identify and mobilize community assets and resources toward preventing illness, injury, and related morbidity and mortality. EG - disaster preparedness and response:

41. Moving To the Global Level

47. Major Causes of Child Death (1998) Total deaths: 10.8 million Perinatal (20%) Respiratory diseases (17%) Diarrhoeal diseases (17%) Measles (8%) 49% of Malaria (7%) child Injuries (6%) deaths Congenital (4%)) HIV/AIDS (3%)) All other (18%) Malnutrition is estimated to contribute to around 50% of all childhood deaths. EIP/WHO

48. Co-morbidity/Underlying Cause Example WarDisruption Immunization Services Child with measles Diarrhea & Pneumonia DEATH

49. Integrated Management of Childhood Illnesses (IMCI) integrated approach aims to reduce death, illness and disability, and to promote improved growth and development includes both preventive and curative elements implemented by families, communities and health facilities

50. IMCI Addresses Most Causes of Death Pneumonia Diarrhea Measles Malaria Malnutrition Sepsis Meningitis Dehydration Anemia Ear infection HIV/AIDS Wheezing Sore throat