A 1 week old former 36-week-old female was admitted after a possible acute life threatening event. The infant was being bottle fed by her mother. Her father said that she stopped breathing while eating. He had to “shake her” and give her “mouth to mouth” to revive her. The parents disagreed whether there was a color change or not and how long the incident lasted, but both said less than 20 seconds. The mother stated that she had choked before stopping breathing.. She was taken to the local hospital where she had been born. The family became agitated with the emergency room staff because “they didn’t know about babies” and asked to be transferred to the regional children’s hospital. The past medical history showed no prenatal care, and mother was not sure about her last menstrual period. Gestational age was done by Ballard score at birth and was 36 weeks. Patient was the product of a spontaneous vaginal birth and maternal laboratory testing at that time was negative. The infant received a 48 hour course of antibiotics because of preterm birth and some initial temperature instability. Cultures were eventually negative.
The social history was complicated by the low functioning mental capacity of both parents and recent job loss by the father. An older sibling had been voluntarily removed from the home because the parents stated “we couldn’t take care of him.” Both parents smoked. The family lived in a trailer that they rented from a family member. They had adequate clothing, a bassinet that they laid the infant on her back to sleep in, and plenty of formula for the infant and food for themselves. A social evaluation during the birth admission had been completed and the family was voluntarily being followed by the state’s Department of Human Services (DHS). The review of systems was negative.
The pertinent physical exam showed a weight of 2.96 kg (~40%). Head circumference and length were 25%. Repeated Ballard examination was consistent with a 37 week gestation infant and the rest of the examination was normal. The work-up at the outside hospital included a complete blood count, electrolytes, and blood cultures. No urine or cerebrospinal fluid was obtained and no antibiotics were begun. The patient was placed on monitors and had no incidents over the 8 hours between presentation at the outside emergency room and admission to the children’s hospital. Additionally, emergency room personnel noted that the infant fed appropriately without difficulty, slept well and was easy to arouse during the observation. The diagnosis of a premature infant with choking during feeding causing a normal brief cessation of breathing was made. The infant also lived within a family with a difficult social situation.
The patient’s clinical course at the children’s hospital showed that the infant had no adverse events seen by staff or on monitors and acted like a normal infant. She showed no signs of any infectious disease process or other abnormality. An extensive social evaluation was made and revealed that the family had several inappropriate ideas about infant care such as the infant should be able to sit upright by herself and hold her own bottle currently. After parental consent, the children’s hospital social worker contacted the local DHS social worker. Both agreed that the family would benefit from more intensive parental education in the home and supervision of the social situation. A visiting nurse and early intervention specialist from the local schools were to come to the home 5 days a week and the parents appeared grateful for the additional help. The social workers and physicians hoped that the additional services would improve the family’s caregiving abilities, but the professionals in the home could also report if the parents were not improving with their knowledge and care and if the infant was in an unfortunate dangerous situation. The family wanted to return to the children’s hospital for primary care but missed the appointment the next week and children’s hospital social worker contacted the family. They stated they now wanted to receive primary care closer to home and had made an appointment. Again after parental consent, the children’s hospital social worker contacted the local DHS social worker and communicated these new concerns. The local DHS social worker stated that “other concerns” had arisen since the infant’s discharge but he did not have parental consent to give more information. He stated that “additional services” had been arranged for the family and that the new primary care physician was aware of the family’s social concerns. He said that the patient would be followed closely.
Health care providers often view the patient through the medical lens and may not see the full view of all aspects of patients and families lives. Even many who work in community centered locations may not be aware of the breadth of services wanted and needed by families. Medical and community services are diverse in every location and often change as funding becomes available or dries up.
One of the most difficult tasks for a health care provider (and patients and families) is to move to a new location and need to locate and access various services. Health care providers who take care of patients and families from a wide geographical area are at an additional disadvantage as the practitioner often is not aware of the availability or non-availability of local community services. Social work professionals are often available through local hospitals, government agencies, non-profit organizations and schools. Questioning patients and families in the office about the types and quality of the community services they use can be a fountain of information for the health care provider to recommend to other families.
Whether its the local Eskimo tribe providing native food to needy families in their community, a police officer going to the home of a family without a telephone to deliver urgent medical information, a rape crisis nurse who assists a patient, family and the emergency room physician though a sexual assault evaluation, or a service organization that modifies toys for children with disabilities, health care providers need to partner with many different community service providers.
Examples of community service providers:
- Community Based Providers
- Child care professionals
- Churches and spiritual organizations
- Cultural organizations
- Counseling services – substance abuse, domestic violence, financial, legal services
- Crisis intervention – rape, mental health
- Health insurance companies
- Libraries – books and toys
- Respite care
- Youth service organizations – Boy and Girl Scouts, YMCA, Big Brothers/Big Sisters, mentoring programs etc.
- Government Based Providers
- Department of Human Services
- Medicaid/SCHIPP health insurance
- Financial assistance
- Food – Women, Infants and Children program, Food stamps
- Law enforcement
- Legal services
- Parks and recreation services including summer camps
- Health Care Based Providers
- Primary care providers
- Specialty care providers including child maltreatment, dental, developmental disabilities, physical therapy, occupational therapy, speech and language services
- Regional healthcare services – providing care across a region of a state or geographic area
- Rehabilitation and skilled nursing care centers
- Visiting nurses
- In-home health care providers
- Hospice and palliative care providers
- Discharge coordinators – often nurses or social workers
- Medical and non-medical social workers
- Mental health providers
- Complementary and alternative health providers
- Public health clinics
- Free medical clinics
- Transient medical services – urban mobile clinics, immigrant clinics
- School Based Providers
- School based health clinics
- Family centers within schools – often provides a wide variety of counseling and referral services
- Early intervention programs
- Head Start programs
- Special education services
- Disability services
- Alternative schools or programs for troubled youth, or youth with different educational needs
- Food programs
Questions for Further Discussion
1. Choose one of the community service provider groups above and list what local provider you would refer a family to?
2. What other community service providers are not listed above?
- Symptom/Presentation: Apnea
- Specialty: General Pediatrics | Neonatology | Preventive Medicine and Health Maintenance | Social Services
- Age: Premature Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
American Academy of Pediatrics Policy Statement. The Pediatrician’s Role in Community Pediatrics. Pediatrics 1999;103;1304-1306. Available from the Internet at: http://pediatrics.aappublications.org/cgi/reprint/pediatrics;103/6/1304 (rev. 06/1999, cited 9/30/2009).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital