Pediatric Telephone Advice: Seattle Hotline Experience

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Sleep Enuresis Discipline Aggression Sibling rivalry Thumb-sucking/pacifier Phobia/fixation Sexual issue Excessive crying Dreams/night terrors Masturbation Separation issues Social Encopresis Hyperactivity Divorce Low self-image Nail biting School problems Shy/cautious Miscellaneous 31 21.1 15 10.6 14 9.9 12 8.5 ii 7.7 9 6.3 6 4.2 6 4.2 S 3.5 4 2.8 4 2.8 4 2.8 4 2.8 3 2.1 2 2.1 2 1.4 2 1.4 2 1.4 2 1.4 2 1.4 2 1.4

Total 142 100.0

814 PEDIATRICS

Vol. 88 No. 4 October

1991

Pediatric

Telephone

Advice:

Seattle

Hotline

Experience

Pediatric hotlines gives parents and interested parties the opportunity to call pediatricians with

questions regarding child health issues. More than

a dozen such hotlines have been held by state

chapters of the American Academy of Pediatrics in all regions of the United States. They were

pro-moted by regional newspapers and generally pre-ceded by feature articles centered on child health

concerns. The first hotline was held in 1987 by

pediatricians in Delaware, District of Columbia,

Maryland, and Virginia in conjunction with the

Washington, DC, chapter of the American

Acad-emy of Pediatrics and the newspaper USA Today.

Seattle-area pediatricians and

The

Seattle Times

sponsored a 1-day, 8-hour hotline in March 1989.

A total of 21 physicians, who volunteered their time,

answered 456 total calls. We report an analysis of the calls documented in the Seattle hotline and discuss possible explanations for the nature and

distribution of calls received. Given these findings, we also discuss their conceivable impact on strate-gies for educating parents within the office practice

and in the community at large.

METHODS

The Seattle hotline was held March 7, 1989, over

an 8-hour period. As noted, 21 pediatricians partic-ipated, working three shifts of 3 hours each. All

pediatricians participating in the hotline were

asked to record incoming calls on phone logs sheets.

Recorded information included age and sex of the

child in question and the relationship of the caller to the child. Questions were categorized by the participating physician as developmental, behav-ional, on medical. Space was available on the log sheet to note specifically the topic of the call ne-ceived. Completed logs were analyzed and all legible entries were included in the final analysis.

RESULTS

A total of 926 calls were received by the switch-board operators during the 8-hour hotline period. Due to phone line restrictions and staffing

limita-tions, the 21 pediatricians participating in the event

were able to answer only 456 of the total calls

Received for publication May 24, 1990; accepted Jun 8, 1990.

Reprint requests to (J.A.W.) Dept of Pediatrics, Children’s

Hospital and Medical Center, P0 Box C-5371, Seattle, WA

98105-0371.

American Academy of Pediatrics.

received. Entry forms for 359 of these 456 were legible and complete enough to analyze.

Broad categorization of recorded calls revealed

78 developmental (22%), 142 behavioral (39%), and

139 medical (39%) questions (see Tables 1 through 3 for specific topics). Developmental questions

cen-tered on two main topics, feeding and toilet

train-ing, comprising 72% of total calls in this category.

Behavioral questions focused on sleep, enunesis, discipline, aggression, sibling rivalry, and

thumb-sucking, constituting more than 60% of these calls.

Medical questions were more widely distributed,

with only upper respiratory symptoms and ear in-fections relatively dominant concerns.

The 10 most frequent topics are listed in Table

4; questions regarding these topics totaled 50% of

all calls received. Of the 10 topics, 8 were behavioral

on developmental in nature. Most calls were

ne-ceived from mothers (>80%) and pertained to chil-dren younger than 6 years of age (80%) (Tables 5 and 6). Only 4% of questions pertained to the

adolescent age range, 11 years of age on olden. There

was a slight predominance of male to female chil-dren (57% vs 43%).

DISCUSSION

Pediatric hotlines provide a forum for examining parental health concerns. Such information is

p0-tentially quite useful, as it provides an opportunity to more cleanly gauge parental perceptions of child health issues and needs. Those perceived needs can then be used to target anticipatory guidance and

educational programs for parents within the office

setting and in the community as a whole.

TABLE 1. Topics of Calls With Behavioral Questions

Topic No. %

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tions

TABLE 3. Topics of Calls With Medical Questions

Topic No. %

Miscellaneous

Upper respiratory tract infection symptoms Ear infections Miscellaneous infections Orthopedic Constipation Immunizations Rash Diarrhea Allergies Colic Chickenpox Asthma Abdominal pain Umbilical hernia Circumcision Diabetes Fever Adenopathy Milk intolerance 34 27.6 16 11.0 13 9.0 9 6.2 8 5.5 8 5.5 6 4.1 6 4.1 S 3.4 S 3.4 4 2.8 4 2.8 3 2.1 3 2.1 3 2.1 3 2.1 3 2.1 2 1.4 2 1.4 2 1.4

Total 139 100.0

TABLE 2. Topics of Calls With Developmental Ques- TABLE 5. Age of Children Who Were Subject of Calls

EXPERIENCE AND REASON 815

Topic No. %

Feeding 28 35.9

Toilet training 21 26.9

Breast-feeding 7 9.0

Miscellaneous S 6.4

Language delay 4 5.2

Car seat 3 3.8

Gross motor delay 3 3.8

General development delay 3 3.8

Return to work 2 2.6

School readiness 2 2.6

Total 78 100.0

TABLE 4. Topics of 10 Mos t Frequent Calls

Topic No. of

Total Calls

Feeding 35 9.7

Sleep 30 8.4

Toilet training 21 5.8

Upper respiratory tract 16 4.4

infection symptoms

Enuresis 15 4.2

Discipline 14 4.0

Ear infections 13 3.6

Aggressive behavior 12 3.3

Sibling rivalry 11 3.1

Thumb-sucking/pacifiers 9 2.5

Total 176 49

To date, no studies have been published in the medical literature analyzing the nature of calls to

pediatric hotlines held around the country.

Pre-vious papers describing telephone calls to pediatric

practices emphasized the phone management of

Age, y No. %

<1 112 31.2

1-S 178 49.6

6-10 54 15.0

11-20 15 4.2

Total 359 100.0

TABLE 6. Caller’s Relation to Child

Relation No. %

Mother 298 Grandmother 27 Father 22 Other 12 83.0 7.5 6.1 3.4

Total 359 100.0

acute illness,’’ the use of protocols on tniage,4#{176} on

analysis of clinic or after-hours calls.7’8 Few studies have described the actual content of calls received in their senies.58 Of these, all found the lange ma-jonity of calls (>75%) related to acute illness on

medically related questions. Such findings

stnik-ingly differ from those of this study.

In the Seattle hotline, the majority ofcalls related

to behavioral on developmental issues. Reported informal results from three other regional pediatric hotlines showed similar issues dominating calls (Kohrt AE, president, Pennsylvania chapter, Amen-ican Academy of Pediatrics, personal communica-tion, September 8, 1989; Katz L, Florida chapter,

American Academy of Pediatrics, written

commu-nication, July 5, 1989; Florida Times- Union, May

23, 1989:C1). The actual explanations for such a

heavy orientation toward behavioral and develop-mental calls may be related to newspaper articles

preceding the event emphasizing “long-range” health concerns. Also, most physician’s offices han-dle questions about acute illness, but few are set up to handle behavioral or developmental concerns.

Direct access to pediatricians rather than office

staff may have affected the orientation of calls. Perhaps the nature of the hotline itself, providing easy and anonymous access to free health care information, selected a population with the

ob-served concerns.

Regardless of the explanation, the large volume of calls in the Seattle series, 926 over the 8-hour hotline period, demonstrates demand for pediatric health advice. One must ask why such a demand

exists, particularly in a community as large and

medically well-staffed as Seattle. Are health care providers failing to meet these needs? Reisingen

and Bines9 noted, for example, in a 1980 study that

pediatricians spend an average 97 seconds on

antic-ipatory guidance with an infant younger than 5

months of age and an average 7 seconds with an

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816 PEDIATRICS Vol. 88 No. 4 October 1991 adolescent. Such results would indicate that phy-sicians’ educational efforts in the office need to be

refocused and intensified. Our present study

mdi-cates that a concentrated educational effort focused on defined, topic-specific behavioral and develop-mental issues in the 0 through 5 range would ad-dress areas of greatest concern.

Parents and caretakers have many questions

ne-ganding child health issues and new methods must

be developed to address these concerns. We, as

physicians, should take note of these issues and use

this information to target anticipatory guidance

efforts within the confines of our own practice

setting, as well as advocate the expansion of efforts to educate parents in the community at large.

JAMES L. TROUTMAN, MD

JEFFREY A. WRIGHT, MD

DONALD L. SHIFRIN, MD

University of Washington

Dept of Pediatrics

Children’s Hospital and Medical Center

Seattle, WA

REFERENCES

1. Greitzer L, Stapleton FB, Wright L, Wedgwood RJ.

Tele-phone assessment of illness by practicing pediatricians. J

Pediatr. 1976;88:880-882

2. Perrin EC, Goodman HC. Telephone management of acute

pediatric illnesses. N EngI J Med. 1978;298:130-135

3. Fosarelli PD. The telephone in pediatric medicine, a review. Clin Pediatr (Phila). 1983;22:293-296

4. Levy JC, Rosekrans J, Lamb GA, Friedman M, Kaplan D,

Strasser P. Development and field testing of protocols for

the management of pediatric telephone calls: protocols for

pediatric telephone calls. Pediatrics. 1979;64:558-563

5. Strasser PH, Levy JC, Lamb GA, Rosekrans J. Controlled

clinical trial of pediatric telephone protocols. Pediatrics. 1979;64:553-557

6. Katz H, Pozen J, Mushlin A!. Quality assessment of a

telephone care system utilizing non-physician personnel. Am J Pub/ic Health. 1978;68:31-37

7. Villarrel SF, Berman 5, Groothius JR, Strange V, Schmitt

BD. Telephone encounters in a university pediatric group. C/in Pediatr (Phi/a). 1983;23:456-458

8. Levy JC, Strasser PH, Lamb GA, et al. Survey of telephone

encounters in three pediatric practice sites. Public Health

Rep. 1980;95:324-328

9. Reisinger KS, Bires JA. Anticipatory guidance in pediatric

practice. Pediatrics. 1980;66:889-892

10. Fulginiti VA. Role of the pediatrician in patient education.

Pediatrics. 1984;74(suppl):914-916

Captopril-Induced

Reversible

Acute

Renal

Failure

in an

Infant

With Coarctation

of

the Aorta

Activation of the nenin-angiotensin system has been implicated in the initiation of hypertension associated with coanctation of the aorta, with so-dium and volume expansion playing a role in main-tenance of the hypertension. Increase in total pe-niphenal resistance induced by the stenosis itself also has received increasing attention in the

etiol-ogy of coanctation and renal vascular

hyperten-sion.’5 To date, angiotensin-converting enzyme

(ACE) inhibitors have been used to lower acutely

blood pressure in patients with coarctation, as well as in “paradoxical” postoperative treatment of hy-pentension.2’6 We recently cared for a small infant

Received for publication Oct 22, 1990; accepted Dec 5, 1990.

Reprint requests to (E. G. W.) Division of Pediatric Nephrology,

Cardinal Glennon Children’s Hospital, St. Louis University,

1465 S Grand Blvd, St. Louis, MO 63104.

with hypertension due to coarctation of the aorta who developed acute renal insufficiency while

ne-ceiving captopnil. Functionally, renal hemodynamic

changes in this child may have been similar to those

postulated in patients with bilateral renal artery

stenosis who have developed acute renal failure

when receiving ACE inhibitors.

CASE REPORT

This patient was a 1.73-kg white female infant born at 33 weeks postconception. She was found to be clinically

hypertensive at birth with diminished pulses in the lower

extremities. Four extremity blood pressures revealed an upper extremity blood pressure of 150 mm Hg systolic and a lower extremity blood pressure of 55 mm Hg systolic. Echocardiogram demonstrated a severe periduc-tal coarctation, small left ventricle, bicuspid aortic valve, and a hypoplastic aortic arch. She was treated medically with furosemide and digoxin; but, due to worsening congestive heart failure, she underwent surgical repair of the periductal coarctation. Severe hypertension, thought to be secondary to the hypoplastic arch, persisted post-operatively despite therapy with propranolol, hydrala-zine, and furosemide. Doppler estimation of the remain-ing gradient contributed by the hypoplastic arch was 34 to 100 mm Hg. Surgical arch repair was considered ex-tremely risky in this 2-kg infant. Due to persisting hy-pertension and congestive heart failure despite continu-ing therapy with furosemide, digoxin, propranolol, and

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1991;88;814

Pediatrics

JAMES L. TROUTMAN, JEFFREY A. WRIGHT and DONALD L. SHIFRIN