All mothers should be screened for domestic violence as a marker for potential child abuse. In cases of domestic violence, as many as 77% of children are also being physically abused, most are suffering emotional abuse, and many are being neglected. Universal screening of mothers is an important first step in identifying children who are at risk. Screening mothers in the clinic can start by talking with the mother alone and acknowledging that violence is so common in women's lives that physicians and nurses are now asking all of their patients about this. Simply asking if the mother is in a relationship where she has been physically hurt or where her partner has been very controlling will detect many cases. The physician should ask if she feels safe at home and screen for the presence of unlocked firearms in the home. Women who are in such relationships should be referred to domestic violence services and their children should be screened for possible physical and emotional abuse. (4)
Heightened awareness, improved screening, and prompt detection of abuse will enhance the safety of all children. For further information please contact Dr. Sheets at (913) 588-7339.
Division Chief, Child Sexual Abuse.
Adolescence is a time of rapid growth, during which children gain 50 percent of their adult weight, 50 percent of their skeletal mass, and 20 percent of their adult height. During this period, increased amounts of protein and carbohydrates are needed for growth, as well as folate and B12 for tissue synthesis. Unfortunately, it is also the time of the highest incidence of poor dietary habits, including skipped meals and increased intake of "junk foods". These practices can lead to problems with growth and learning. There is also inadequate ingestion of vegetables and fruits (36% and 28% of recommended daily allowance, respectively) (J Am Diet Assoc., 1998,98(12)). It has been estimated that one fourth of the vegetables consumed by adolescents are in the form of French fries!
While overall nutrition has improved over the last 30 years, the intake of certain minerals has not. The intake of calcium, iron, and zinc remains poor, as does the intake of Vitamins A, B, and C. Adolescents from 9-18 years need 1300 mg of calcium daily, but 80 percent of females and 40 percent of males fail to meet that recommended allowance. The peak absorption of calcium for both males and females is during adolescence. Poor calcium intake during that time can lead to lifelong problems. Osteoporosis is a disease initiated in pediatric age groups by decreased calcium intake and increased phosphorous intake (found in almost all sodas). There are many sources of calcium including dairy products, leafy vegetables, calcium fortified foods such as juices and grains, and dietary supplements.
As with calcium, deficiencies of iron and zinc are also common among adolescents. Inadequate iron intake can lead to anemia and decreased intellectual function. The incidence of iron deficiency in the adolescent population is currently between two and ten percent. The peak incidence of iron deficiency is between the ages of 11 and 14 for males. For females, the peak occurs between the ages of 15 and 19. Good sources of iron include iron-fortified foods, red meats (including liver), eggs, legumes, and nuts. Inadequate consumption of zinc, commonly seen in adolescents, can lead to immunosuppression, anemia, and poor wound healing. Sources of zinc include meats, grains, nuts, and cheese.
With the exception of mineral intake, under-nutrition no longer poses a major public health problem in the United States. The most significant problem facing us today is obesity. The trend towards obesity starts early in life. Thirty-three percent of American adults and 22 percent of adolescents are obese. This is a result of increased dietary fat and lack of exercise. A major factor contributing to adolescent obesity is poor eating habits. A few statistics highlight the problem. Up to 12 percent of adolescents skip breakfast, which can lead to overeating at lunch. Ninety percent of all snacks are "junk" food, and 80 percent of all visits to fast food restaurants are from people under the age of 18. Many factors influence adolescent's eating habits, including family and peers. Perhaps the most important factor is the media. The average teenager has seen 100,000 food-related television commercials, with messages contradictory to health needs.
A few simple recommendations, however, can help your patients eat healthy, complete meals. During adolescence girls need around 2200 Kcal a day and boys need 2500-3000 Kcal a day. Following the "Food Pyramid" will help meet daily needs. Adolescents need 55 percent carbohydrates, 15-20 percent protein. Protein intake can also be calculated according to the adolescent's height: 0.28 g protein per cm for girls, 0.31 g per cm for boys. Fat should make up no more than 30 percent of calories. Dietary fiber can be determined by adding five to the adolescent's age for the grams of fiber per day.
Adolescents need yearly screening for eating disorders and obesity. Tools used to check for these problems should include a history, Body Mass Index (BMI, expressed as kg/m2), and dietary questionnaires. Screening of adolescents is necessary to identify and treat problems that are not yet apparent.
Adolescent nutrition doesn't follow the "Don't ask, don't tell" policy. Talk to adolescents about what they eat. Calcium, iron, and zinc are important but are often overlooked. Utilizing the food pyramid, BMI, and common sense are keys to helping adolescents achieve good nutrition. Remember that good nutritional habits formed during the adolescent years will last a lifetime!
Chief, Division of Adolescent Medicine;
University of Kansas Medical Center.
We have just completed the residency applicant interviews for pediatrics and medicine/pediatrics training programs and look forward to an exciting group of new first year residents.
We are pleased to announce effective July 1, 2001 two pediatric gastroenterologists, Dr. Paul Hyman and Dr. Jose Cocjin, will be available to see patients both at KUMC and some of our outreach sites.
Our Annual Spring CME program, "Mini Symposia: Airway Obstruction and Diabetes/Endocrine Disease" will be held on May 4, 2001. Please mark the date and plan to attend. Registration forms will be mailed soon. If you need additional information, please call 913-588-6339. Hope to see you there.
Sincerely,
Professor and Chair
Several recent studies have demonstrated that primary care physicians and emergency room physicians are missing cases of potentially life-threatening child abuse in the youngest, most vulnerable children. Bruising in infants who are not yet cruising (walking holding onto something), signs of abusive head trauma, and the presence of domestic violence in the home are warning signs of abuse or a high risk situation, which may escalate and threaten the lives and well-being of children in the home. Such injuries and high-risk environments pose diagnostic dilemmas for busy emergency rooms and primary care physicians.
While bruising in toddlers and children is extremely common in the course of normal play, infants who are not yet cruising rarely bruise. In 1990, Wedgewood published a study (1) in which he examined developing motor skills and the presence of accidental bruising. As expected, the number of bruises increased as motor skills developed. Of the 11 children who were not yet cruising, none had bruises.
His study was expanded in 1999 by Sugar, et al (2), who examined bruises in 942 children less than 36 months of age when they presented for well-child care at one of seven practice sites. Bruising was virtually nonexistent in children who were unable to sit alone. Only 2.2% of children who were not yet cruising had any bruises. Most of these bruises were on the lower legs or on the forehead/scalp. The percentage of cruising children with bruises increased to 17.8%. In all age groups, bruises on the face and trunk were rare and bruises on the hands or buttocks were absent.
The presence of bruising in a child who is not yet cruising should raise the suspicion of non-accidental trauma. Even in ambulating children, bruises that are over soft tissue such as the buttocks and cheeks are suspicious. In any age group, patterned bruises should alert the physician to the possibility of abusive injury. Whenever bruises are possibly secondary to child abuse, the clinician should seek alternate explanations such as an accident history and clotting studies (PT/PTT, platelets, and fibrinogen).
Another important group of children whose abusive injuries often go unrecognized are those who have experienced abusive head trauma (AHT) but present with nonspecific signs or symptoms such as irritability or vomiting. Jenny, et al (3), examined 173 children younger than three years old with abusive head injuries. Of these children, 31.2% had been seen by physicians after the AHT and the diagnosis was initially missed. The average delay in diagnosis was seven days with an average of 2.8 physician visits during that delay. More than one-fourth of these children were re-injured during the delay in diagnosis. Of the five children who died during the delay, four might have survived had the diagnosis not been missed. Most of these unrecognized cases of AHT were from intact Caucasian families, were less than six months old, and did not have seizures or respiratory compromise. Most missed cases of AHT were initially diagnosed with gastroenteritis, accidental injury, or possible sepsis. Those infants diagnosed with gastroenteritis had vomiting but no diarrhea.
Suggestions for improving detection of AHT include the following:
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The University of Kansas Medical Center