Catherine E. Burns
Pediatric primary care providers use a critical thinking skill set to help them arrive at a diagnosis and to provide efficient, cost-effective care to their patients. Evidence-based practice has become a guiding principle that is consistent with the diagnostic reasoning process: using the best information available as one thinks through the pros and cons of various pathways that emerge along the road from diagnosis to management and problem resolution.
The clinician is typically taught to move from assessment to diagnosis to intervention and, finally, to evaluation in a linear fashion; however, in reality, the practicing clinician considers various diagnoses while conducting the assessment so that data will confirm or refute various possible diagnoses. Sometimes, management strategies also have diagnostic elements—if the plan doesn’t work, then perhaps the diagnosis was wrong. For example, if iron supplementation does not result in raising a low hemoglobin level and further tests were not done initially, then perhaps the problem was not iron-deficiency anemia. Therefore, additional tests must be done to identify another diagnosis. Thus, the use of iron supplementation had diagnostic elements. The problem-solving or diagnostic reasoning process may be linear (i.e., diagnosis generally comes before intervention), but during a given episode the process generally is more convoluted than linear. The clinician also must think on his or her feet with only minimal time for reflection. Delivering primary care to pediatric patients often presents unique diagnostic challenges for healthcare providers.
Evidence-based care is the standard; however, using the best evidence available when assessing and managing patients is not always easy because new information is forever emerging, sometimes validating and sometimes refuting previous “best evidence.” There is also an issue of selecting the best evidence for a particular case. Will the healthcare provider have to generalize data from adults studies to children? Are data from a study of children in another country or involving a different population appropriate to use? Is using a particular diagnostic test essential or optional? Should one consider a new therapy, a drug for example, before best evidence results are available? Which variables, such as race, gender, culture, educational level, age, or family constellation, might make a difference in selecting the best management plan? Will a nationally recognized clinical practice guideline work to the benefit of the patient, given the setting, clinical resources, financial status, and other factors of the client at hand? Has new information emerged that the clinician isn’t yet aware of? Many factors affect the assessment process, conclusions reached, and plans made. Pediatric primary care using the best evidence available may not always be in the best interests of a particular child if the interventions or strategies do not take into consideration the child’s and family’s unique needs, values, and personal preferences.
Content for Pediatric Primary Care: The Three Domains of Healthcare Problems
Pediatric healthcare problems in this book are conceptualized as falling into three domains: diseases, functional and mental health problems, and developmental problems (Burns, 1991a, 1991b, 1992a, 1992b, 2009). These are domains for the content of health care, not the context for care. The disease domain includes physiological problems, which are diagnosed and managed at the organ system and cellular levels. Pneumonia, anemia, traumatic injuries, and acne are all examples of diseases diagnosed and managed at this level. Functional health problems are significant issues in pediatric primary care. Nutrition problems such as obesity, elimination problems such as encopresis and enuresis, and sleep problems all fall into this domain. Cognitive perceptual problems such as attention deficit hyperactivity disorder and mental health/coping problems also fit into this domain. Problems in this domain are considered primarily as concerns involving daily living and managed through changes in those patterns of daily living. That is not to say physiological issues are not involved, often neurological in nature or with genetic components, but they cannot be treated primarily through cellular treatment modalities. Finally, there are problems of the developmental domain. These are problems that affect the child’s developmental trajectory over the long term—issues of motor, language, social, and cognitive development. These problems are just as significant to the child’s well-being as many diseases can be. They must be treated through therapies to modify and promote developmental progression.
This book is organized according to these domains. Units I and II address developmental, functional health, and mental health problems. Unit III concentrates on diseases in all body systems. Depending on the child’s developmental age and chief complaint, the clinician should always ask one or two questions in each of the three domains while focusing major attention on the problem at hand. Examples of ancillary questions might include items such as:
• How is he doing in school? or How is school going? (developmental domain)
• How is breastfeeding going now? (functional health domain)
• Is he sleeping through the night? (functional health domain)
• How is toilet training going? (functional health domain)
• What are your plans after you finish high school? (developmental domain)
• What is her mood like most of the time at home? (mental health domain)
• Is she easy or hard to get along with? (mental health or developmental domain)
• Can she do all the things other kids her age are doing? (developmental domain)
• Have you noticed any problems with his health since he was here last? (disease domain)
Such questions can be interjected in a visit while washing hands or doing the physical examination, while waiting for the parent to undress the child, or during the interview process. The provider should always be scanning or conducting surveillance for emerging problems in all three domains.
Context for Pediatric Primary Care: Complicating Factors
The clinician not only needs to provide evidence-based care as much as possible for problems within one or more of the three domains, but also needs to attend to some complicating factors for each client and family.
Developmental assessment is an absolutely key element to pediatric primary care. It needs to be considered at every step, not only as content, but also as context. Both the physiology and psychology of children change with age, so one cannot parcel off physical ailments, saying that they are physiologically the same as in adults and therefore can be treated similarly. The infant and young child may not present with symptoms that are easily recognizable due to their immature nervous and physiological systems, limited language skills, limited experiences with illness, and social skills that keep them from being cooperative when needed. Diagnosing problems is difficult. Further, management always needs to consider the developmental level of the child, whether it is choosing a medication form that the child will accept, asking the child and family to change health behaviors, or some other element that best practice would expect to be incorporated into a healthcare plan. Additionally, parents develop along with their children, learning new skills to adapt to their child’s forever-emerging new behaviors. Incorporation of developmental factors into daily practice during every pediatric encounter provides the key difference between pediatric experts and those who just provide some care to children.
Another essential factor to consider when providing primary care to children is the child’s family. Children come for care in a dyadic relationship with their parents. Even if they are adolescents, the parent is a ghost in the room if not actually present. The parents are the lens through which the child is seen outside of the examining room, and, even within the room, are providing information about changes from normal behavior or physiology as seen by them. The parents know and provide the history, support the child through the physical examination and other tests, and are the ones who must be educated to care for the child after the clinical visit. Without full cooperation and understanding from those caregiving adults, the health care of the child will fall short of its desired goals. Thus, it is in the best interests of child, parents, and the clinician to use the available parent or caregiver to best advantage, listening to and forming an alliance with that essential member of the healthcare team.
Family-centered care involves more than recognizing the parent as essential to the provision of health care for the child. It also involves recognition that families can have problems at the family systems level in addition to the individual child’s health problems. In this case, family problems become content, not just context. These, too, must be dealt with because an unhealthy family system often negatively affects the health of the child, both physically and psychologically. Some examples of family problems include social isolation, caregiver role strain, alterations in parenting, family communication problems, absent family members, and inadequate healthcare and financial resources. An example of a family problem is given in one of the case studies, a mother of a newborn whose husband is overseas in the military. She not only does not have the support of the absent parent, but also has additional strains due to anxieties about his safety and perhaps financial problems because military families often receive limited income and perhaps loss of income if a reservist has to put a civilian job on hold. Unless this mother can be adequately supported, she will be unable to provide optimal parenting to her new infant. Divorced families, gay and lesbian parents, single parent families, teen parents, and others may have special needs, too. In any case, the pediatric primary care provider needs to assess for potential family problems even though the family may be functioning well and no concerns emerge. Pediatric primary care occurs on two levels, child and family.
Another complicating factor relates to comorbidities. Patients often have several problems to address at a given visit. Which problem should be addressed first? Will the management of one problem compromise the status of a second problem or limit the options for treatment? For instance, a child with allergies may not do well with some antibiotics if she has an infection or suggestions of certain foods for diet management if the child is overweight. Or the child with a mental health problem such as anxiety may have greater difficulty coping with a chronic disease that requires aggressive management such as type 1 diabetes. Of course, adults also experience comorbidity problems. Nevertheless, multiple problems affect the pathways that the provider must navigate to provide optimal care. Care is often nonlinear and convoluted, as stated earlier.
Cultural differences are the norm in the United States and all other parts of the world these days. Values and beliefs, communication styles, language, healthcare practices, understandings of health and illness causes and cures, food preferences and preparation practices, parenting practices, and other aspects of daily life vary among different people. The clinician must incorporate cultural understandings into assessment and management. Again, adding these factors into the recipe for “best practice” care makes it ever more complex!
The Process of Providing Care As Modeled in This Book
The cases in this book reflect the stories of children and their families who are seen in pediatric primary care settings, and were written by a variety of expert clinicians. In each case, they move from symptom analysis to a mental review of all the possible diagnoses that should be considered and gathering of further data to support or refute the various suppositions, gradually narrowing the list down to the diagnosis that best fits the picture presented by the patient.
Management generally involves three pathways: further diagnostic elements, treatment of the specific condition, and then education to prevent subsequent episodes, limit complications, and promote healthy behaviors and understanding of the problem by the patient and family. The clinician should always consider these three elements, although the plan may not include all elements. In primary care settings, the child’s diagnosis is frequently evident from history and physical examination findings alone with no diagnostic testing needed. In some instances, only basic diagnostic tests are required to arrive at a diagnosis or to help determine the management plan. Typically, extensive and/or elaborate additional diagnostic testing is necessary only if the child does not improve or his or her condition worsens. Treatment and education are always required, although sometimes they are delivered over several visits and not all at one time.
Management may also include referrals to other healthcare professionals and then coordination of care across people and/or agencies. Primary care has been defined as comprehensive, continual, and coordinated; however, it is not “solo.” No one healthcare provider can be expected to have all the skills, knowledge, and time to provide total care to patients. Rather, care is initiated in the healthcare setting in which a need is identified. Sometimes the initial provider, be it nurse, nurse practitioner, physician, or physician assistant, can manage the case from beginning to end. However, often referrals are made to specialists in the management of specific disease entities, mental health conditions, education problems, or other aspects of unique healthcare needs. The primary care provider role is envisioned as being comprehensive—all body systems and healthcare needs will be evaluated. It is also viewed as continual—care is provided over the long term for a variety of problems and a familiarity with the client and family will be established. Coordination is the element of taking into consideration all the various elements of care necessary for the child and family, setting priorities, and helping the family navigate various specialty services for the resolution of their healthcare problems in a cost-effective, efficient, supportive manner. Sometimes the care can be delivered within the given time slot on the schedule of patients for the day, but sometimes it involves taking other time for phone calls, preparation of papers for consultations and insurance, and even visits with the family to the school or elsewhere. All this work also requires assessment, making a diagnosis of the functionality of the plan given various healthcare systems, and management that may involve providing access to care rather than specialized therapies. The primary care provider uses teams of experts to support his or her work with patients.
1. Primary care assessment is linear in broad strokes but convoluted along the pathways from symptom analysis to diagnosis to treatment.
2. Evidence-based practice is easy to conceptualize but difficult to execute.
3. Three domains for primary care practice need to be considered as the provider completes a comprehensive assessment of a patient: disease, functional and mental health, and development.
4. A variety of complicating contextual factors makes assessment and management more difficult: developmental issues, family issues, comorbidities, and cultural variables.
5. Management should consider three basic elements: diagnostic, therapeutic, and educational plans, though not all will be necessary for a given patient.
6. Primary care providers need to use other specialists in a variety of healthcare, mental health, and educational fields to support and provide the care necessary to maximize the health of children and families in their practices.
Burns, C. (2009). Child and family health assessment. In C. Burns, A. Dunn, M. Brady, N. Starr, & C. Blosser (Eds.), Pediatric primary care (4th ed., pp. 12–40). St. Louis: Elsevier.
Burns, C. (1992a). A new assessment model and tool for nurse practitioners. Journal of Pediatric Health Care, 6, 73–81.
Burns C. (1992b). Using a comprehensive taxonomy of diagnoses to describe the practice of pediatric nurse practitioners: Findings of a field study. Journal of Pediatric Health Care, 7, 115–121,
Burns, C. (1991a). Development and content validity testing of a comprehensive classification of diagnoses for use by pediatric nurse practitioners. Nursing Diagnosis, 2, 93–104.
Burns, C. (1991b). Parallels between research and diagnosis: The reliability and validity issues of clinical practice. Nursing Practice, 16, 42–50.