Diseases and disorders in pediatrics

Health problems most frequently seen in adolescent patients include eating disorders (anorexia nervosa and bulimia nervosa), obesity, and injury-related problems. Accidents are the leading cause of death and injury in adolescence, and suicide is also a leading cause of death (second for ages 10 to 14 and third for ages 15 to 19, according to the CDC). All healthcare personnel should be on the alert for indicators of suicide, including the following:

• Signs of depression, such as headaches, abdominal discomfort, anorexia, fatigue, aggressiveness, drug or alcohol abuse, and sexual promiscuity
• Verbal statements that hint at the adolescent’s intention to commit suicide; talking about dying
• Actions such as giving away prized objects, withdrawing from social groups, suddenly changing normal behavior patterns, or writing a suicide note

This patient population can be challenging to work with, but it can also be rewarding as you help the adolescent patient handle the hurdles of becoming a healthy adult.

Patient coaching

Unintentional injuries are the leading cause of death and disability in children in the United States. Injuries cause more childhood deaths than all diseases combined. The primary causes of childhood injuries are the following:

• Motor vehicle accidents
• Drowning
• Burns
• Falls
• Poisoning
• Aspiration with airway obstruction
• Firearm accidents

Childhood injuries are linked to the child’s growth and development level and usually are preventable. Young children are totally dependent on caregivers to keep them safe, so constant supervision and a childproof environment are essential for this age group. Older children need to be aware of health hazards and should be encouraged to protect themselves from injury (e.g., they should use bike helmets, protective padding when skateboarding, seat belts, and so on). The highest incidence of accidental injuries is seen in children under age 9, but as children grow older, the percentage of deaths from injuries increases. In the United States, more than 9000 children die each year - about 25 deaths a day - from injuries. Healthcare workers play a major role in injury prevention. The medical assistant is responsible for making sure the ambulatory care office is safe, and parents are educated about potential hazards.

Legal and ethical issues

The Child Abuse Prevention and Treatment Act (CAPTA) sets the federal framework: to receive federal funding, each state must have a law requiring certain people to report suspected child abuse and neglect. Healthcare workers, teachers, and social workers are mandated reporters in nearly every state, and in about 17 states every person who suspects that a child is being neglected, abused, or exploited must report it to the proper authority. The agency records the report and, when the report is credible, initiates an investigation promptly - there is no threshold number of reports required before an investigation begins.

Most states accept anonymous reports, although some require mandated reporters, such as healthcare workers, to give their names. A reporter’s identity is kept confidential and is not given to the child’s parent or guardian. A reporter who makes a good-faith report is also protected under the law from any liability for reporting suspicions of child abuse.

If the medical assistant suspects a child is a victim of abuse, neglect, or exploitation, she or he should consult with the provider immediately. In most states, the medical assistant and the provider can make separate reports to the authorities.

State law note: CAPTA sets the federal minimum, but the specifics of mandatory reporting - who must report, the timeline, and whether the medical assistant reports independently of the provider - are defined by each state’s statutes. State and local reporting protocols should be outlined in the office procedures manual.

Signs of child abuse

Obvious signs

Scenario: Conflicting accounts of an injury

A parent brings a 4-year-old in with a fractured arm and says the child fell off a chair. When asked separately, the child gives a different account of how the injury happened, and the office’s records show several previous emergency department visits for this same child’s injuries.

Conflicting stories between parent and child, combined with a pattern of repeated injury visits, are classic warning signs of possible abuse. The medical assistant’s correct response is to consult the provider immediately and follow the office’s reporting protocol - not to confront the family or investigate further.

Examination findings

• Trauma to the nervous system
• Internal abdominal pain
• Discolorations/bruising on the buttocks, back, and abdomen
• Elbow, wrist, and shoulder dislocations

Changes in child’s behavior

• Too eager to please the parent
• Overly passive and too compliant
• Aggressive and demanding
• Parenting the parent (role reversal)
• Delays in the normal growth and development patterns
• Erratic school attendance

Physical indicators

• Poor hygiene
• Malnutrition
• Obvious dental neglect
• Neglected well-baby procedures (e.g., immunizations)

Patient-centered care

In a pediatric practice, the child usually is joined by one or both parents during visits to the provider. Parents need reinforcement, praise, and understanding in dealing with the health and welfare of their children. Provide parents with information to help them understand their children’s behavior and improve their parenting skills. Understanding the normal behavioral characteristics of a particular developmental stage may increase the parents’ confidence and reinforce expectations for the child.

The waiting room is an ideal place for parent education. Use the space and resources available to provide up-to-date information on child health issues and on local resources for support and assistance. If the provider has pamphlets available, discuss them with the parents. Answer questions when possible or alert the provider so that questions can be answered during the office visit. Every opportunity should be taken to teach parents about sound healthcare. Because so many ambulatory care visits involve infectious disorders, educating children and parents on the following infection control measures may reduce the spread of disease:

• Children should cover their mouth with a disposable tissue when they cough or cough into their bent arm rather than their hands.
• A tissue should be used only once and then immediately thrown away.
• Children should not be allowed to share toys they have put in their mouths.
• After a child has discarded a toy that was in their mouth, it should be placed in a bin for dirty toys that are out of the reach of others. Wash and disinfect these toys before allowing children to play with them again.
• Make sure all children and adults follow good handwashing practices. Have pump hand sanitizers available throughout the office.

Professional behaviors

Working as a medical assistant in a busy pediatric practice can be challenging: you’re managing both a child who may be frightened and a caregiver who is often stressed. Stay professional under pressure by using active listening with parents, communicating with the child at an age-appropriate level, and managing your time so the workload stays organized.