Child Abuse While at Portsmouth (1976)

Allegations of Medical Neglect: Checking the Facts

Bruce J. McIntosh, M.D. Co-Interim Statewide Medical Director Child Protection Team System Bruce J. McIntosh, M.D. Workshop Moderator

. Received M.D. degree from the University of Florida College of Medicine (1970) . Completed residencies in Pediatrics at the Yale-New Haven Medical Center and the Navy Regional Medical Center, Portsmouth, Virginia . Began working in the field of child abuse while at Portsmouth (1976) . Certified by the American Board of Pediatrics in the sub-specialty of Child Abuse Pediatrics . Presently serving as Co-Interim Statewide Child Protection Team Medical Director Investigating Allegations Objectives of Workshop

. Define and describe the Medical Complex Child and the challenges such children present for their families

. Provide basic medical information on specific medical conditions commonly resulting in reports of medical neglect

. Introduce the use of disease-specific checklists to assist in gathering information about families’ understanding of their child’s medical condition and in identifying potential barriers to successful management of the child in the home

. Assist you in enabling these children to remain safely in their homes while eliminating recidivism, i.e., repeated reports on the same child Evaluating Allegations of Medical Neglect Schedule

Topic Speaker ___ Time Allocation

Introduction McIntosh 5 minutes The Medically Complex Child Elliott 35 minutes Diabetes Shapiro 15 minutes Failure to Thrive Shapiro 15 minutes

Break 15 minutes

Asthma Dully 15 minutes Eczema Dully 15 minutes Dental Problems McIntosh 15 minutes Obesity Pena 15 minutes Summation McIntosh 5 minutes Medical Neglect Definition

. The failure to provide or the failure to allow needed care as recommended by a health care practitioner for a physical injury, illness, medical condition, or impairment, or

. The failure to seek timely and appropriate medical care for a serious health problem that a reasonable person would have recognized as requiring professional medical attention.

Definition from the American Academy of Pediatrics and SB 1666 pages 24 & 25. Medical Neglect Exceptions

 Medical neglect does not occur:  If the parent or legal guardian of the child has made reasonable attempts to obtain necessary health care services or the immediate health condition giving rise to the allegation of neglect is a known and expected complication of the child’s diagnosis or treatment, and  The recommended care offers limited net benefit to the child and the morbidity of other side effects of the treatment may be considered to be greater than the anticipated benefit; or  The parent or legal guardian received conflicting medical recommendations for treatment from multiple practitioners and did not follow all recommendations.

Definition from the American Academy of Pediatrics and SB 1666 pages 24 & 25. Investigating Allegations DCF CPI-CPT Partnership

. Investigating allegations of medical neglect requires a close partnership between DCF and the CPT . Disease-specific checklists have been developed to enable you, the CPI, to gather essential information in the home regarding the family’s understanding of their child’s problem, possession and use of home treatments and access to care . Use of these checklists will help the CPT to help you to identify barriers to home successful management and to develop strategies for addressing them . The goal is to keep these children safely in their own homes whenever possible, while eliminating repeated calls on the same children for the same problems Anne M. Elliott, M.D. The Medically Complex Child

. Attended medical school at the Southern Illinois School of Medicine . Completed residency in Pediatrics at the Medical College of Virginia . Completed fellowship in Pediatric Hematology- Oncology at Children’s Mercy Hospital in Kansas City, Missouri . Has just completed a fellowship in Pediatric Hospice and Palliative Care at the University of Florida - Jacksonville Medically Complex Children: What can a Checklist Tell You?

Anne Elliott, M.D. Hospice & Palliative Medicine Physician Community PedsCare Associate Medical Director What is Medical Complexity?

“Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. “ -- Maternal & Child Health Bureau Division of Services for Children with Special Health Care Needs Medical Complexity What That May Look Like… Medical Complexity and Neglect

“Complex and chronic medical conditions are a risk factor for both the occurrence and the reporting of medical neglect. Chronic diseases impose a higher demand for care on families and increase their contact with the medical system. Similarly, disease processes with high severity raise the probability of bad outcome from even small departures of prescribed care. Thus, chronic, complex, and unstable medical conditions create many more opportunities for medical neglect to occur, for harms to be actualized, for the outcomes of neglect to be severe, and for these harms to be recognized by medical providers” - Pediatric Annals 2014 Medical Complexity and Neglect

Translation When a child: • has a General Pediatrician and 6 or more Subspecialists • has multiple medical diagnoses • takes 5 or more medications • has multiple pieces of home medical equipment which may include life-sustaining technology • requires home nursing care • requires specialized transport It is easy for things to go very wrong leading to serious adverse outcomes. Medical Complexity What Does It Take to Help? Medical Complexity Variety of Barriers

 Knowledge  Psychosocial  Financial  Access to services/equipment  Home nursing, therapy, daycare, education  Provider availability  Medical, nutritional, mobility equipment  Transport - AAP 2007 Medical Complexity Helping Families

 Medically complex children are cared for by a complex and often confusing medical system  Primary care physicians are key  Medical home Medical Complexity Knowledge Barriers

 Lack of understanding of:  What diagnoses the child has  What providers help with each condition  Why medications or equipment are prescribed  Reason for ongoing follow-up  Important concerning signs/symptoms  Possible poor outcomes if not addressed  Alternative caregivers also need to understand this information! Medical Complexity Start with the Basics

 Step one: understanding what and who

 Facilitates prompt contact to physician for concerns and follow-up regarding ongoing needs Medical Complexity Psychosocial Barriers

 Lack of order in family’s life may impair ability to respond appropriately to medical needs  Siblings’ needs  Parents caring for parents  Work & school schedules  Mental illness can impact parent’s ability to care for the child  Can be chronic or acute  Substance Abuse Medical Complexity Simple Questions Open Doors…

 Identifying who may lead to insight into the home life of the family

 Sometimes the answers and following conversation may surprise you… Medical Complexity Additional Help and Support Medical Complexity Care Management

 Reduces unmet healthcare needs  Improves quality of life  Increases family’s understanding of child’s condition  Reduces caregiving burden  Improves outpatient physician visits  Decreases hospital admissions by 26-59%  Decreases ED visits by 18-55% - JG Berry 2015 Medical Complexity Care Management

 Primary Care Physician  Insurance care coordinator Eg. CMS  Medicaid Waiver Programs Eg. Partners-in-Care: Together For Kids Medical Complexity Financial Barriers

 Costs:  Medications  Doctors/Therapists  Hospital Stays  Insurance  Equipment  Supplies  Transportation  Car modifications?  Loss of income  Missed-work  Reduced Hours/Quit Medical Complexity Financial Assistance

 Do they have insurance?  Do they qualify for secondary coverage?  Additional supports?  SSI?  Medicaid Waiver programs?  Transitioning preparation – APD application  Address any correctable No’s! Medical Complexity Early Intervention

 Neural circuits are the most “flexible” in the first 3 years of life  The brain is strengthened by positive early experiences  These combined mean that early intervention may help promote the best long-term outcomes for children both physically and mentally  Early Steps program  Provides in-home therapy services to qualified children Medical Complexity Programs

 School attendance  Individualized Education Plan is needed for the majority of medically complex children attending school  Therapies provided in-school  Socialization for child  Hospice & palliative care support programs  PIC:TFK  Local hospital-based programs Medical Complexity Access to Services

 Medically complex children are 4 times more likely to have 3 or more unmet needs as compared to other children  Parents may be unaware of available services  Insurance or financial barriers to services may exist Medical Complexity Variety of Services Needed

 Equipment, therapy, home-nursing, etc…  Inability to appropriately identify providers or needed services may be an indicator of a knowledge gap or even medical neglect Medical Complexity Therapy and Equipment

 Prescribed in order to promote optimal care and quality of life  Certain deficits may lead to life-threatening conditions  Others may lead to poorly managed pain or other symptoms Medical Complexity Transportation Barriers

 Multiple studies site lack of transportation as a leading reason for missed appointments  Additional reasons include lack of child-care for siblings or long-distance to provider  Specialized vehicles or transport may be necessary  Medicaid transport:  Requires advance booking (1-3 days)  Often won’t allow siblings Medical Complexity An Ounce of Prevention…

 Loss of power, water, or communication can have devastating effects for MCC  Power-dependent technology  Inability to tolerate extreme temperatures  Fire response  Safe rescue or medical response  Home oxygen  Emergency Evacuation  Specialized transport and shelter for duration of event  Plan on what supplies/medications Medical Complexity Assessment as an Opportunity

 For education  For identification of and insight into barriers to child’s care  For setting goals to improve child’s care and parent’s ability to meet their needs Thank You! Sandra Shapiro, ARNP Diabetes and FTT

. Received her bachelors degree in nursing from the University of Florida – Jacksonville . Received Master of Science in Nursing degree and later Family Nurse Practitioner certification from the University of North Florida . Has worked as a medical provider at the First Coast Child Protection Team in Jacksonville since 2011 Using the Diabetes Checklist to Investigate Allegations of Neglect

Sandy Shapiro, MSN, ARNP, CNL Advanced Registered Nurse Practitioner Child Protection Team What Is Diabetes?

. Pancreas makes insulin . Diabetes is when the pancreas makes no, low, or bad insulin . The insulin is the “key” to open the door to the body’s cells from the blood to allow the glucose/sugar into the cell . If there is no “key,” the glucose/sugar in the blood rises How Insulin Works Important To Know Glucose Meter Readings

Normal level of glucose (sugar) in blood 70-120 Daily Glucose/Insulin Levels (Normal) Blood Sugar after Eating Normal, Pre-Diabetic, Diabetic Diabetes Checklist Assessing Family’s Basic Diabetes Knowledge Causes of Elevated Blood Glucose

. Not taking medicine

. Eating too much

. Illness

. Stress

. Decreased activity

. Opposite for low blood glucose Short-term Complications of Uncontrolled Blood Sugars

Hypoglycemia (Low) Hyperglycemia (High) Confusion, Dizzy, Shaky, Headache Increased Thirst Irritable

Sweating, Pale, Trembling, Weak, Anxious Increased Urination

SEVERE: Increased Hunger (stealing food) Poor coordination, concentration Nausea/Vomiting/Stomach pains

Passing out, Seizure Diabetic Ketoacidosis (DKA) Coma Coma 5-10 % of deaths are related to low BG Death

If a caregiver isn’t trained, and finds the child passed out, bigger problems can occur. Diabetic Ketoacidosis (DKA)

. https://www.youtube.com/watch?v=J6ggrlhAi NQ . Life-threatening complication of elevated blood sugars (hospital emergency) . Cells have no glucose, so they break down fats for energy which produces ketones (blood acid). Ketones spill over into the urine. . Body goes into shock . Brain swelling → coma → ventilator . Cognitive impairment . Risk for blood clot and aspiration . Cardiac arrhythmia Long-term Complications of Elevated Blood Glucose Diabetes Checklist Blood Glucose Meter and Hemoglobin A1C

Hemoglobin A1C Blood Glucose vs. Hemoglobin A1c What Does Each Measure?

. Hemoglobin A1c (HgbA1c, or A1C): a test that measures the amount of glycosylated (sugary) hemoglobin in a person’s blood. The test is used to screen and test for diabetes (both types) and to estimate blood sugar control over a 3 month period.

Blood Glucose (BG) Hemoglobin A1c (HbA1c) Tells you glucose level at that moment Tells you 3 month average of glucose Short term blood sugar level Long term blood sugar

Can check at home with glucometer Must go to clinic to check Hemoglobin A1C Measure of Glucose Over Time

When the family reports that they are taking the insulin, yet the A1C remains elevated, what do you think the doctor is going to do? Diabetes Checklist Counting Carbohydrates and Calculating Insulin Insulin Types

. Long acting (treats valley) . Lantus or Levemir . Taken at night . Short acting (treats peaks): . Humalog, Novolog . Regular . Apidra . Lispro . Taken with meals . Measured in units

This is why they check their blood sugars 4 times per day – each meal and before bed Insulin Long Acting

. Long Acting (treats valleys) . The long-acting insulin is a fixed dose once a day (usually @ night) . Starts within 3-4 hours, stays in body for 24 hours . Brings the baseline level down . Example: Lantus 18 units injection (subcutaneous) at night Insulin Short Acting

. Short Acting (treats peaks) . Has two parts to it . Eating: Insulin to carbohydrate (CHO) ratio . Reading: Equation based upon meter value . Starts within 20 minutes, stays in body 3-5 hours . Works to chase down the glucose that is consumed . Example:1 unit for every 70 points above 100 and 1 unit for every 15 grams of CHO CONFUSED?

Algebra is not even taught until 6th grade (advanced math classes). Comprehension of it may be years later. Consider child’s age. How Much Insulin? Short Acting Insulin Calculation

Example: Humalog to CHO (carbohydrate) ratio of 1:15 grams for breakfast, 1:8 grams for lunch and dinner and Humalog 1:70 over 100

*Endocrinologists have Diabetic Educators (typically nurses) that spend a lot of time reviewing insulin with the family. Example of Calculations Calculate Insulin & Count Carbohydrates

. PART 1: . PART 2: . 1 unit for every 70 points above . 1 unit for every 15 grams of 100 carbohydrates (CHO) for . (Meter reading-100) breakfast . 70 . Wheat toast 14 . Blood glucose at breakfast grams . . is 310 on glucometer Orange 12 grams . . (310-100) ÷ 70 = ~ 3 units 1 c skim milk 12 grams . Fruit Loops +25 grams . Total 63 grams . 63 ÷ 15 = ~ 4 units

Total Short Acting Insulin = 3 units + 4 units = 7 units Carbohydrates (CHO) How to Read a Label Diabetes Checklist Calculating Insulin and Counting Carbohydrates

Diabetes Checklist Assess Diabetes Supplies Glucose Meter, Test Strips, Lancets

Glucose meter Test strips Lancets or needles to check (Check Expiration) (Date/Time, # times/day) the blood

Alcohol Pads Diabetes Checklist Insulin Assessing Diabetes Supplies

OR WITH

Insulin pens Insulin vial Insulin needles

Check expiration dates. Most are 28-35 days from date of opening. Diabetes Checklist Assess Diabetes Supplies Ketone Strips and Glucagon

Urine/ketone test strips (when meter reads Glucagon HIGH or symptoms of (when meter reads LOW and can’t high glucose levels) drink/eat) Diabetes Checklist

How often? Have the Child Demonstrate Takes Less than 1 Minute

. 1. Place test strip into blood glucose machine

. 2. Wipes finger with alcohol and pricks finger

. 3. Wipes away initial blood

. 4. Puts blood on test strip

. 5. Checks glucose

. 6. Performs calculations

. 7. Draws up/dials appropriate amount of insulin

. 8. Administers to self (abdomen, thigh or upper arms) More Questions to Ask Child/Family Not on Checklist…Yet

. What is your sick plan? . When are you supposed to call the doctor or clinic? . Usually if meter reads “HIGH” or “LOW” and can’t correct on own at home . Ketones in urine . Barriers to care including transportation, electricity . Hospitalizations/ER visits . How many times have you been to the hospital for high blood sugars? . Have you ever been admitted for DKA (how many times and where)

Using the Checklist to Evaluate Allegations of Failure to Thrive

Sandy Shapiro, MSN, ARNP, CNL Advanced Registered Nurse Practitioner First Coast Child Protection Team Failure to Thrive Definition

. A symptom that describes a particular problem, rather than a diagnosis . Growth failure, or more specifically, failure to gain weight appropriately . A wide variety of medical problems and psychosocial stressors can contribute to FTT . The underlying cause is always “insufficient usable nutrition” aka not enough calories to meet his body’s needs Failure to Thrive Effects

. Persistent short stature . Immune deficiency: severe and prolonged infections . Permanent damage to various parts of the brain and central nervous system . Cognitive function is below normal in ½ of children with FTT, more likely to have behavior problems and learning difficulties . Developmental Delays . Higher cortisol levels which may affect behavioral responses . Can lead to further decreased intake . Affects every system in the body

Early identification and expeditious treatment of FTT may help to prevent long-term developmental deficits Failure to Thrive Parental Factors

. Abuse

. Neglect

. Poverty

. Ignorance/poor parenting skills

. Unusual nutritional beliefs

. Parental emotional disorders

. Substance abuse or other psychopathology

. Poor breast feeding related to many causes Parental Factors Poor Parenting Skills Results in Developmental Delays

. Mother provided inconsistent history . Child was admitted to hospital . Gained 50-60 grams/day while in hospital (catch up = 13 grams/day) . Follow up at CPT, child had lost weight since discharge from hospital Failure to Thrive Checklist The Basics

Prematurity will affect growth

Helpful to bring 24-72 hour diet log CPT will ask for current height, weight and date taken to assess growth Diet Log Time, Food and Drink, Amount

Time Food/Amt Drink/Amt Comments Mon 7 AM 2 oz rice 3 oz plain Wet diaper cereal; 4 oz water* pears 9 AM 6 oz** formula Wet/BM diaper

12 PM 4 oz carrots 8 oz formula Napped 12-230 2:30 PM 8 oz formula 5 PM ½ c Spaghetti 4 oz formula Loved it! & Sauce

7 PM 6 oz formula 7:30 bedtime Tues 2 AM 4 oz formula *Include plain water **If making a 6 ounce bottle (6 ounce water, 3 scoops) and level rises to 7.5 ounces, it’s still a 6 ounce bottle Daily Weight Gain for Expected Age Not Catch-up Weight

. BACK TO BIRTH WEIGHT BY 2-3 WEEKS . 26 to 31 g/day (1 ounce/day) for those 0 to 3 months . 17 to 18 g/day (0.5-1 ounce/day) for those 3 to 6 months . BIRTH WEIGHT SHOULD BE DOUBLED BY 6 MONTHS . 12 to 13 g/day (0.5 ounce/day) for those 6 to 9 months . 9 to 13 g/day for those 9 to 12 months . BIRTH WEIGHT SHOULD TRIPLE BY 12 MONTHS . 7 to 9 g/day for those 1 to 3 years . 3 years to puberty: 5-7 pounds and 2-3 inches per year . Parental Factor Abuse/Severe Neglect Parental Factor Abuse Parental Factor Postpartum Depression Parental Factor Postpartum Depression

. Give Mom Permission to Express Feelings . “How are you feeling?” . “How are things going with your family?” . “Are you getting enough rest?” . “Are you enjoying your baby?” . “It must be hard to have a baby who… . Cries so much . Sleeps so little . Is so difficult to feed, etc…” . “How does that make you feel?” . “Do you find yourself in tears over nothing?” CAGE Questionnaire Screen for Alcoholism (and Drugs)

. Have you ever felt you needed to Cut down on your drinking? . Have people Annoyed you by criticizing your drinking? . Have you ever felt Guilty about drinking? . Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

. Answering “Yes” to 2 or more is interpreted as likely has an alcohol problem (it is not definitive). Parental Factor Neglect and Substance Abuse

Bottle-mouth

Child is camouflaged in clothing Parental Factor Breast Feeding - Checklist

Every 2-4 hours while awake. May need to wake baby at night

Clicking sound

Great way to quantify feeds

Can call maternity ward at hospital Parental Factor Breast Feeding Problems/Medical Issue?

. Low milk supply/low calorie milk . Baby sleeping at breast . Painful breast (latching pain, infections) . Clogged ducts . Mother dehydrated . Mother taking certain medications . Decrease supply . Pass into breast milk causing weight loss . Medical issues, surgeries . Misleading cues to hunger/satiation Parental Factor Poor Breast Feeding

2.5-month-old Birth weight: 7 lb, 0.2 oz

Height: 21.75 inches (< 1st percentile) Weight: 7 pounds, 14.5 ounces (< 1st percentile) Wt-for-length: < 1st percentile HC: 14.25 inches (5th percentile) Parental Factor Poor Breast Feeding Preparing Formula Assessing Technique Parental Factor Improper Technique Diluting Breast Milk The Dangers of Dilution Child Factor How Much is Getting In? Child Factor How Much is Coming Out? Liquid Diet: Juice and Low-Calorie Drinks #1 Cause of FTT in Toddlers

. Can cause nutrient losses by fructose and sorbitol mal-absorption (diarrhea) . Is filling to the child and they do not eat . Low calorie . “She won’t drink anything else…she’s picky” . Remind them who the parent is

Extra low/no-calories What Should They Drink? No More Juice

. Infants: Formula (assess if putting rice cereal in bottle) . Whole Milk (16-24 ounces per day or 2-3 bottles) . Mostly for ages 12-24 months . Can add chocolate or strawberry syrup . Pediasure ~ $1 per bottle . Without DHA is more tolerable . Carnation Instant Breakfast (cheaper if not premixed) What Should They Eat? Adding Calories to Diet

. Dairy: cheese, butter, sour cream, heavy cream, ranch dressing, whipped cream (can add to eggs, potatoes, fruit) . Peanut butter (> 1 year) . Oils such as mayonnaise or vegetable/olive oils (can sauté veggies) . Pot pies and gravy How They Should Eat and Drink Altering Environment

. Feeding Schedule & Environment . Solids before liquids . Three meals and three snacks 2-3 hours apart . No “grazing” or walking around with sippy cup . Avoid junk foods (no protein) . Minimize distractions Child Factor Excessive Juice Intake

17 pounds, 5 ounces 20 pounds, 3 ounces Home Assessment Use with Checklist

. Current height and weight – does child appear of appropriate size for age (should observe without clothes) . Avoid decimals in infants (x pounds, y ounces) . 1.5 hours is not 1 hour, 50 minutes . 2.8 feet is not 2 feet, 8 inches . 10.4 pounds is not 10 pounds, 4 ounces . Parental heights, any extremely short family members . Juice intake . Special needs of child Home Assessment Use with Checklist

. Identify food insecurity . “In the past month, was there any day when you or anyone in your family went hungry because you did not have enough money for food?” . Diluting formula to make it last? . Check laundry for signs of vomiting . Check clothing size, question the following: . 2-year-old wearing size 9 months . 7-year-old wearing a size 4T Failure to Thrive Medical Evaluation and Treatment

. Primary Care Physician . Medical specialists as indicated . Nutritionist . Social Workers . Speech Therapy . Occupational Therapy . Physical Therapy

Careaga MG and Kerner JA. A Gastroenterologist’s Approach to Failure to Thrive. Pediatric Annals 29:558-67, 2000. Caseworker Evaluation and Treatment Team Approach Necessary: Parent Involvement

. Important to try to establish a therapeutic alliance with the parent . Multiple resources may be needed Recurrent or . Regular medical checkups to follow persistent weight weight . WIC and Food Stamps loss, in the absence . Parenting Skills Training of a medical issue, . Supportive counseling or psychiatric care may necessitate . Protective supervision removal of the child . High Risk Newborn, Healthy Start from the home . Daycare . Child Find or Early Steps

15-Minute Break

We will resume promptly in 15 minutes. Asthma: Using Checklists to Identify Causes of Poor Control

Bruce J. McIntosh, M.D. Co-Interim Statewide Medical Director Child Protection Team What is Asthma ? Understanding the Problem

. Asthma is a chronic lung disorder that can make breathing difficult. . Asthma causes inflammation, swelling, and narrowing of the airways (bronchial tubes). . Chronically inflamed bronchial tubes become very sensitive to inhaled allergens, irritants, and other triggers (colds, pollution, pollen, dust & dust mites, fires, extreme temperatures, exercise, etc.) . There are intermittent asthma attacks, or exacerbations, that can be prevented. What is Asthma ? Understanding the Problem

Airway in Person Normal Airway with Asthma

Muscle

Lining Swelling

Tight Muscles Mucous Symptoms of Asthma Some Mild, Some Severe

. Persistent coughing . Trouble speaking . Rapid breathing . Trouble walking . Chest tightness . Trouble with chores . Chest aching . Sweating . Wheezing . Chest/neck pulling in . Trouble sleeping . Shoulders hunched . Fatigue over . Stomach ache . Confusion . Restricted activity . Anxiety, panic How Common is Asthma? Very

• One in 10 Florida children have asthma. • Females, African Americans, Puerto Ricans, and children under 10 have the highest rates of E.R. visits and hospitalizations. • 89,181 E.R. visits in Florida (2011). • 29,776 hospitalizations in Florida (2011). • 10.5 million missed school days (2008) • 14.2 million missed work days (CDC 2008) • Nationally, 9 Americans die of asthma everyday Neglect of Asthma Who Gets Reported ?

. Parents presenting to . Parents who delay E.D. frequently intervention when attack . Parents of child recently occurs hospitalized and back in . Parents who do not want the E.D. an asthma action plan . Parents of child in . Parents who do not hospital repeatedly provide controller med . Parents overusing . Parents not working with a rescue inhaler primary care provider . Parents who let the meds run out Asthma Neglect Checklist Access to Care? Asthma Medications Families Often Confused About Them

• Two basically different types of medications commonly used • Rescue Medications: Used to treat asthma attacks

• Albuterol (Ventolin, Proventil, Proair)

• Levalbuterol (Xopenex) • Controller Medications: Used to prevent attacks in patients with frequent or severe ones

• Fluticasone (Flovent)

• Budesonide (Pulmicort) • Confusion over usage is common cause of poor control Asthma Neglect Checklist Availability and Knowledge of Medications Who Needs Daily Controller Rx? Any Child with Symptoms More Than Twice a Week Asthma Neglect Checklist Availability and Knowledge of Medications Treatment of Asthma Families Often Use Inhalers Incorrectly Treatment of Asthma Families Often Use Inhalers Incorrectly Treatment of Asthma Children Must Use Spacer Devices Asthma Neglect Checklist Availability and Knowledge of Medications Spacer Device Easy Home-Made One

Cut a hole slightly larger than the mouthpiece of the inhaler in the bottom of a plastic water bottle. Treatment of Asthma Spacers Can Be Used for Infants Treatment of Asthma Nebulizers Asthma Neglect Checklist Availability and Knowledge of Medications Predicting Attacks to Prevent Them Peak Flow Measurements Predicting Attacks to Prevent Them Peak Flow Measurements Asthma Neglect Checklist Staying Ahead of Attacks Asthma Action Plans Being Prepared to Handle Attacks Asthma Neglect Checklist Attack Prevention and Early Intervention To Avoid Attacks Avoid Triggers Asthma Neglect Checklist Clean, Asthma-Safe Home Environment Asthma Neglect Checklist Clean, Asthma-Safe Home Environment Asthma Management Top Mistakes – What Can We Correct ?

. No asthma action plan . Stopping meds . No chamber with MDI . No primary care . No controller MDI relationship . Smoke and clutter . Outside in extreme . Sleeping with pet outdoor conditions . . Stuffed animals Unfamiliar with triggers and symptoms . Ignoring symptoms . Not including the school . Delaying treatment nurse . Windows open . Unproven, alternative treatments Goals of Asthma Management Physician Will Work with Family *

• Infrequent symptoms needing treatment • No Emergency Room or other unscheduled doctor’s visits • Able to play and exercise normally • Able to go to school or work • Able to sleep without interruption by symptoms • Peak flows at or near personal best * If Given a Chance Eczema: Using Checklists to Identify Causes of Poor Control

Bruce J. McIntosh, M.D. Co-Interim Statewide Medical Director Child Protection Team What is Eczema? Also Known as Atopic Dermatitis

. The most common chronic skin disorder in infants and children . Compromises the skin’s ability to protect the body from the environment . Inflamed, itchy red rashes that are frequently complicated by . Skin breakdown . Bacterial infections . Viral infections . Fungal infections What Does Eczema Look Like? Typical Findings - Associated with Itching Effects of Eczema Hard on the Child and Family

. A condition that tends to run in families

. Not contagious

. Extremely uncomfortable, sometimes painful

. Huge disturbances of sleep - child & parent

. Affects school, sports, work, daily activities

. Affects relationships (anxiety, embarrassment)

. Can result in isolation, poor sense of worth Atopic Dermatitis Checklist Evaluating Access to Care Eczema/Atopic Dermatitis Routine Treatment to Prevent Trouble

. May use skin cleanser instead of bathing most days . Bathe in tepid (not hot, not cold, just in between) water . No soap or only mild soap, only on dirty places . Pat dry after, NO RUBBING . Apply moisturizer to normal skin right away . Apply steroid ointments to reddened areas twice daily . Apply moisturizer to flared areas after absorption of steroid cream . Give oral antihistamines for itching Atopic Dermatitis Checklist What Is the Family Doing About It? What Can Eczema Look Like? When Infected, It Flares What Can Eczema Look Like? When Poorly Controlled, It Gets Infected Atopic Dermatitis Checklist How Bad Is It? Eczema Triggers Things That Cause Flares

. Heat, sweat for some; cold & dry for others . House dust mites, pet fur, pollen, molds . For some: egg, milk, peanut, soy and wheat . Secondary bacterial or viral infection . Wool, acrylic, nylon, coarse feeling fabrics . Tobacco smoke . Fragrances in soap, shampoo, detergents, fabric softeners, dryer sheets . Stress, repeated water exposure without moisturizing, hot water, sauna, rubbing Atopic Dermatitis Checklist Does the Family Know What Makes It Worse? Oral Antihistamines Important to Control Itching

. Non-sedating during the daytime . Zyrtec (cetirizine) . Atarax (hydroxyzine) . Sedating preferred at nighttime . Benadryl (diphenhydramine) . Doxepin . They are not addictive . Scratching/itching will defeat all other efforts if not treated. Other Eczema Treatments As Directed by Physician

. Non-steroid creams/ointments include Elidel and Protopic, apply at first sign of redness . Bleach baths to control staph skin bacteria . Soak for 10 minutes, then rinse clear . Pat dry, apply emollients and steroids . Wet Wraps . Gather ointments, warm water in basin, gauze for wrapping, “Daddy socks” . Apply ointments, warm damp gauze wrappings, put dry layer over, sleep overnight . Antibiotics when flares become infected Atopic Dermatitis Checklist Medications and Obstacles Eczema Management Take-Away Messages

. Eczema is a chronic, long-term skin condition . There is no cure, only control . Control treatments must be on-going to prevent flare ups . If families slack off on treatment when the skin looks good, flare ups will soon follow . While mild eczema can be managed with simple home measures, more serious eczema will require the involvement of a physician . DCF and CPT involvement will include insuring the child gets to a physician and that the family understands and follows through on treatment plan . Identifying obstacles to successful management early on will prevent recidivism in affected families Emmanuel Peña, D.O. Obesity

. Received Masters Degree in Cellular Biology from Columbia University . Received Doctor of Osteopathy degree from the New York College of Osteopathic Medicine . Completed his residency in Pediatrics at the University of Florida College of Medicine – Jacksonville . Is presently the only Fellow in the State of Florida being trained in the sub-specialty of Child Abuse Pediatrics Obesity: Using Checklist to Identify Causes of Poor Weight Management

Emmanuel Peña, D.O.,F.A.A.P Child Abuse Pediatrics Fellow First Coast Child Protection Team Obesity What is it?

 Obesity - having too much body fat

 Overweight - weighing too much. Weight may come from muscle, bone, fat, and/or body water

 Both terms indicate a person's weight is greater than what is considered healthy for his or her height Obesity How Do We Measure It?

 Body mass index (BMI) combines weight-for- height to classify overweight and obesity (> 2- years of age) BMI How Is It Used? Obesity Understanding the Problem

 In 2012 – 35% of adults in the U.S. were obese and 68.6 % were overweight or obese  Approximately 17% of children and teenagers (ages 2 to 19) were obese and 31.8 % were either overweight or obese  At least 2.8 million people each year die from complications of being overweight or obese Obesity Understanding the Problem

Childhood obesity is one of the most serious public health challenges of the 21st century Comorbidities It Is Not “Just Excess Skin” Outcomes It Is Not “Just Excess Skin”

 Individual:  Suboptimal quality of life – starting during childhood  Poor socialization  Psychopathology  Early Death  Societal . Poor socialization . Psychopathology . Decreased productivity . Medical cost Nutritional Neglect Who Gets Reported?

 Parents who have failed to follow nutritional recommendations for their morbidly obese child

 Chronically obese child with: . Elevated liver enzymes . High blood pressure . Poorly controlled asthma . Several comorbidities Obesity - Neglect Checklist Access to Care? Weight Management Checklist Access to Care?

 Dynamics of the relationship with medical provider – Essential to long-term monitoring

 Awareness of severity of problem

 Engagement with nutritional modifications

 Barriers in access to care Weight Management Checklist Activities of Daily Living Weight Management Checklist Activities of Daily Living

 Social and psychological implications  Needed for successful/healthy adulthood  Depression, self-esteem, bullying, fears  Social impact – hygiene, feeling liked/accepted  Assessment of comorbidities  Joint pain  Trouble breathing – unable to engage in sports  Chest pain – heart disease Weight Management Checklist Family Awareness of the Problem Weight Management Checklist Family Awareness of the Problem

 Parents’ level of engagement in management  Identify potential risky beliefs/practices  Assessing physical comorbidities  Respiratory symptoms while at “rest”  Adult-like diagnosis – severity  Adherence to nutritional recommendations (parents’ side of story)  Other medical conditions that parents perceive as more important Weight Management Interventions Potentially Unsafe for Children Weight Management Appropriate Interventions Weight Management Checklist Family Dynamics – Impact of Services Weight Management Checklist Family Dynamics – Impact of Services

 Pivotal in choosing appropriate interventions  Detects intrinsic family perceptions that may be a barrier to interventions/services  Must be discussed during multidisciplinary meetings  May weigh heavily in the decision to remove in emergent cases Weight Management Checklist Consistent Monitoring Weight Management Checklist Caloric Intake Weight Management Checklist Caloric Intake

 May help identify significant caloric intake problems early in the process  Interventions may be implemented more gradually/efficiently – increase “buy-in”  Weight management in children is primarily addressed with reduction in caloric intake Weight Management Checklist Food Desert? Weight Management Checklist Food Desert?

 More than 29 million Americans live in “food deserts”  Could be a contributing factor in the case  Only CPI can provide this information  The family may not realize this places them at a disadvantage Weight Management Checklist Nutritional Literacy Weight Management Checklist Nutritional Literacy

 Assess how much teaching is needed  Determine the urgency in getting a Registered Dietician (RD) involved with the family  Duration of RD monitoring needed Weight Management Checklist Finances Weight Management Checklist Finances

 Assess spectrum of financial possibilities  Excess food intake by choice  Unhealthy diets because of food insecurity Weight Management in Children Multidisciplinary Approach

 Use the checklist & CPT to guide your investigation early in the process  The child and family need ALL of us  Multidisciplinary staffing should be a default  Lifestyle modification is the cornerstone to long-term weight management Dental Neglect: What, Why and What to Do

Bruce J. McIntosh, M.D. Co-Interim Statewide Medical Director Child Protection Team System Dental Neglect Presentation Objectives

. Define Dental Neglect

. Explain how dental cavities develop and their potential complications

. Discuss use of a checklist to assess the family’s dental knowledge and practices

. Provide information on how to assist families in accessing dental care Dental Neglect: Definition American Academy of Pediatric Dentistry

. Dental neglect is the willful failure of a parent or guardian to seek or follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection. . Active Neglect: Intentional failure of parents or guardians to fulfill their care-giving responsibilities. . Passive Neglect: Unintentional failure of parents or guardians to fullfill their care-giving responsibilities because of lack of knowledge, illness, infirmity, finances or lack of awareness of available community resource. . Self Neglect: A person’s inability to provide for his or her own needs because of a physical, mental or developmental disability.

American Academy of Pediatric Dentistry, Child Abuse Committee: Definitions, Oral Health Policies and Clinical Guidelines. Definition of Dental Neglect, 2008. Dental Neglect What Does It Look Like? Dental Neglect What Does It Look Like? Dental Neglect Checklist Access to Care? Dental

Cavity Anatomy

“Gum Boil” Periapical Abscess Dental Neglect What Can Happen?

Dental Abscess (“Gum Boil”) Preventing Tooth Decay Tooth Brushing Guidelines

. Brushing should begin as soon as baby teeth start coming in. . The enamel of baby teeth is thinner than that of adult teeth and so more susceptible to decay. . Brush teeth twice a day with a soft-bristled brush and a fluoride-containing toothpaste. . Tooth brushes should be replaced every 3 - 4 months or when frayed.

Source: Mouth Healthy Website of the American Dental Association. Dental Neglect Checklist Knowledge Base of Child and Family Baby Bottle Rules Important for Preventing Decay

. Never put the bottle in bed with the baby . Never prop a bottle . Plan to discontinue the bottle at one year of age . Never let the child carry his/her bottle around Baby Bottle Rules Important Anticipatory Guidance Sippy Cups and Tooth Decay Carrying One Leads to Cavities

. Acids produced by bacteria after sugar intake persist for 20 to 40 minutes. . Frequency of sugar ingestion is more important than quantity. . Saliva helps buffer acidity

Safe pH = Acidity Zone

Danger Zone

6 7 8 9 10 11 12 Bottle Breakfast1 Snack Sippy Cup Sippy Cup Lunch Dental Neglect Checklist Eating and Drinking Habits

Yes No N/A Dental Neglect What Can Happen?

Periapical Abscess Dental Neglect What Does It Look Like? Dental Neglect What Can Happen?

Periapical Abscess Dental Neglect What Can Happen?

Brain Dental Neglect Risk Factors – Rarely Just One

. Lack of perceived value of dental health . Parental ignorance . Family isolation . Parental impairment by drugs or alcohol . Lack of finances . Inability of parents to establish a Dental Home for the child

Rhea M. Haugseth, DMD. Dental Health. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. Carole Jenny editor, Elsevier Sanunders Publisher, 2011, page 544. Dental Neglect Special Needs Patients

. Medically complex children are at special risk for dental neglect . Care givers may be overwhelmed by the many aspects of special care required . Even conscientious care givers may have difficulty providing good home dental care . Insuring access to good dental care services is an important part of management

Rhea M. Haugseth, DMD. Dental Health. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. Carole Jenny editor, Elsevier Sanunders Publisher, 2011, page 545. Dental Neglect When Do We Get Involved?

. Untreated caries only get worse, never better. Small cavities become big ones and can lead to abscesses. . “Once a health care provider has identified the dental caries and has made recommendations to the parent or guardian concerning the treatment needed, the child should be carefully followed to make sure the dental treatment is completed . . .” . “If the parent fails to comply with treatment, the health care provider should consider reporting the case to the appropriate child protective agency.”

Rhea M. Haugseth, DMD. Dental Health. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. Carole Jenny editor, Elsevier Sanunders Publisher, 2011, page 544. Dental Neglect Interventions

. Educate family on importance of dental health . Help family obtain insurance or enroll in Medicaid . Refer for substance abuse or mental health treatment . Address other identified obstacles to parental compliance with needed care for child . Assist family in identifying a dental care provider

“Public”

“Low Cost Dental Care”

List of Free or Low Cost Dental Care Resources by County Florida Dental Association floridadental.org Florida Dental Association floridadental.org Resources What’s Available in Belle Glade, Florida?

Palm Beach County

St. Mary’s Free Clinic

Physical Address: 1200 E. Main St., Pahokee, FL 33476 • Office Contact Number: 561.924.0184 • Fax Number: 561.994.3931

Locations Served: Western Palm Beach County, including Pahokee, Belle Glade, Canal Point and South Bay Dental Services:

Comprehensive Dental Care: exams, X-rays, prophylaxis, fluoride, sealants, composites, extractions, root canal, periodontal therapy, and removable prosthetics Resources “Project Dentists Care”

. “Project: Dentists Care” is the FDA-supported access-to-care program for underserved Floridians. It is operated and funded by the Florida Dental Association Foundation. . Online resource list last updated September 5, 2014 . If nothing available in your area or agency listed no longer in service, contact Florida Dental Association Foundation at (800) 877-9922 Interventions for Dental Neglect Summary

. Use Dental Neglect Checklist to gather information on . Family’s attitudes and practices related to dental health . Family’s access to dental care . Share information on prevention of tooth decay . As needed, assist family in enrolling in Medicaid and locating a dental care provider . Take appropriate steps to insure family follows up with plan Evaluating Allegations of Medical Neglect What We’ve Covered

Topic Speaker ___ Time Allocation

Introduction McIntosh 5 minutes The Medically Complex Child Eliott 35 minutes Diabetes Shapiro 15 minutes Failure to Thrive Shapiro 15 minutes

Break 15 minutes

Asthma McIntosh 15 minutes Eczema McIntosh 15 minutes Obesity Pena 15 minutes Dental Problems McIntosh 15 minutes Summation McIntosh 5 minutes Investigating Allegations Summation

. Medically Complex Children and children with chronic medical conditions present many challenges for their families

. With appropriate family education and support, most such children can remain safely in their homes

. Disease-specific checklists are available to assist you in gathering information about families’ understanding of their child’s medical condition and identifying potential barriers to successful management of the child in the home

. These medical conditions are all chronic, and neglect will typically have continued over time. Most families will need continuing monitoring by community support services. Checklists for Evaluating Allegations These Are DCF Forms

. Available to download with the link below:

http://centerforchildwelfare.fmhi.usf.edu/Training/MedNeglect.shtml Rick Scott State of Florida Governor Department of Children and Families Mike Carroll Secretary

Weight Management Checklist

Child’s Name: Number: Date:

Medical Provider Information What is the name and phone number of your child’s Pediatrician, Family Doctor or Clinic? When is your child’s next appointment with his/her Pediatrician, Family Doctor or Clinic? If your child has seen a dietician or weight management specialist, what is the name and phone number of the specialist or clinic? When is your child’s next appointment with the dietician or weight management specialist? Do you expect to have trouble getting to your child’s No Yes Reason: next appointment? If so, why?

Weight Management Questions Yes No N/A Activities of Daily Living 1. Is the child’s weight impairing his/her ability to walk comfortably? 2. Does the child refuse to go to school because of his/her weight? 3. Is the child unable to have an active lifestyle because of his/her weight? 4. Is the child’s ability to play with other children being affected by his/her weight? 5. Is the child’s cleanliness affected by his/her weight? 6. Does the child have self-esteem issues because of his/her weight? 7. Is the child being bullied because of his/her weight? 8. Is there threat of a serious medical complication because of the child’s weight?* Known Medical Condition(s): 1. Do you know what your child weighs currently? 2. Does your child snore, or has a diagnosis of sleep apnea? * 3. Does your child have a medical diagnosis that has been directly caused by excess weight? (e.g. high blood pressure, liver disease, diabetes) * 4. Has the family sought medical care for the child’s weight? 5. Have medical interventions been implemented to manage his/her weight? 6. Has the family failed to follow medical recommendations to manage the child’s weight? 7. Does the child have any medical diagnosis unrelated to weight? Family Dynamics 1. Are other family members in the household overweight or obese? 2. Does the family consider the child's weight a health problem? 3. Is being “big” part of the family’s identity? 4. Has anyone in your family died at a younger age (less than 50) because of complications related to obesity (e.g. heart attack, stroke)? 5. Does the family prefer to drink juice/soda instead of water, when thirsty?

Mission: Work in Partnership with Local Communities to Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and Advance Personal and Family Recovery and Resiliency

Home Environment 1. Does the family have a bathroom scale to monitor the child's weight consistently? 2. Does the family understand that the child should not spend more than 2 hours of screen time (TV and video games) per day, maximum? 3. Has the family tried to use any type of diet or physical activity regimen to address the child’s excess weight? 4. Look in the pantry and refrigerator. Do they contain a good selection of healthy foods? (e.g., fruits and vegetables) 5. Do the pantry and refrigerator contain a selection of unhealthy foods (e.g., cookies, chips, snack, cakes and soda)? 6. Can the family give examples of what healthy food choices are? 7. Can the family afford healthy food choices? 8. Can the family easily get to a store that sells produce and healthy fruits and vegetables? 9. Does the family feel comfortable reading food labels? 10. Can the adults in the home count calories? 11. Does the child, or an older sibling, consistently prepare their meals? 12. Does the family have access to a safe playground, or an affordable gym? 13. Have adults in the family ever met with a nutrition specialist? 14. Has the family ever bought over-the-counter products for weight management? 15. Has the family ever had to worry about having enough to eat?

Potential Obstacles for Successful Management/ Comments:

Obesity Checklist – Version 1.0 of August 13, 2015 2

Rick Scott State of Florida Governor Department of Children and Families Mike Carroll Secretary

Date: ______

Medically Complex Child – Intake

Child’s Name: DOB: Intake # PCP: ______Diagnoses: ______Specialists: ______

People who live in the home:

Insurance Company Case Manager Phone # Primary Secondary SSI: Medicaid Waiver Program: ☐ Date Applied: ______☐ Date Applied: ______☐ Date Approved: ______☐ Date Approved: ______

Programs Name/Location Phone# Effective N/A Dates Early Intervention School: Teacher: Hospice/Palliative Care

Medically Complex Child Intake Checklist Version 1.0 Page 1 of 2

DME Provider Mobility Provider Physical Therapy _____x/week Occupational Therapy _____x/week Speech Therapy _____x/week Communication Equipment Home Nursing _____hr/day *DME = Durable Medical Equipment

Transportation ☐ Self ☐ Medicaid ☐ Medical Transport

Handicap sticker: Transport Co:

Parental Understanding Assessment Yes No Special Circumstance Notification

Does family know or have written down this Electric Co ☐ Sent, Date: ______information? Are they able to tell you the next Fire Dept: ☐ Sent, Date: ______appointments? Have there been any missed appointments? Telephone Co: ☐ Sent, Date: ______Any hospitalizations? Water Co: ☐ Sent, Date: ______Home nursing no-shows? Disaster Plan: ☐ Sent, Date: ______

Potential Challenges for Successful Home Management:

Medically Complex Child Intake Checklist Version 1.0 Page 2 of 2

Rick Scott State of Florida Governor Department of Children and Families Mike Carroll Secretary

Date: ______

Medically Complex Child – Follow-up Name: DOB: Intake # PCP: ______

Updates: New/Changes in? Yes No Notes if yes: N/A Diagnoses Specialists People in the Home Address Insurance SSI Updates Medicaid Waiver Early Intervention Program School Hospice/Palliative Program DME Provider Mobility Provider PT/OT/ST Provider/Frequency Communication Equipment Home Nursing Disaster Plan Problems with: Yes No Notes if yes: N/A Medications Home RN No-shows Getting supplies Broken/Outgrown Equipment Missed Appointments Electricity/Water Housing Additional Comments: ______

**If significant changes – use intake form to document new status; May use back of form for additional notes.

Medically Complex Child Follow-Up Form Version 1.0

Failure to Thrive - Breastfeeding Child Child’s Name: Intake # Date: Question Response Ask the mother how she feels the feedings are going. How often is the mother breast feeding, i.e., how long is it between breast feedings? How many feedings is the baby getting it 24 hours? It should be 8-12. How many minutes is the baby spending on each breast? Usually 10-20 minutes a side is enough. Doses the mother stop to burp the baby from time to time as she is feeding? Does the baby spit up more than just a little with burps? Does the baby spit up much after and between feedings? Does the baby sleep through the night or wake up for feedings? If awakening, how often? How many wet diapers is the baby having? After the third or fourth day, babies getting enough breast milk have 6-8 wet cloth diapers (5-6 wet disposable diapers) per day. How many bowel movements is the baby having? Most young babies getting enough breast milk will have at least 2 to 5 bowel movements every 24 hours for the first several months. Can the mother hear the baby swallowing when he/she nurses? Is the mother pumping breast milk? If so, how much does she get? If pumping, is the mother freezing extra milk? (Check freezer) Has a lactation consultant been involved?

Is the baby enrolled in WIC?

Is the mother supplementing with formula? (See Failure to Thrive- Bottle Feeding list for details.) How much formula does the baby get in a 24-hour period?

What is the baby’s weight at the most recent visit?

What is the Pediatrician or Family Physician’s name and phone number? Has the Pediatrician or Family Physician expressed any concerns or diagnosed any medical conditions? If so, what condition? Does the baby get any solid food, i.e., baby food, jar food or table food? How much food (e.g., how many jars) has the baby had in the last 24 hours Request baby’s regular doctor’s medical records

Arrange CPT appointment

Are there any signs or symptoms of Post-Partum Depression such as crying, insomnia, poor appetite, confusion, excessive preoccupation with child’s health, feelings of hopelessness, loss of interest in things usually enjoyed, poor concentration or mood swings? (Maternal Depression is a very common cause of poor weight gain in young infants.)

Potential Obstacles for Successful Management/ Comments:

2 FTT – Breast Feeding Child Checklist – Version 1.0 of August 10, 2015

Rick Scott State of Florida Governor Department of Children and Families Mike Carroll Secretary

Failure to Thrive - Bottle-Feeding Child Child’s Name: Intake# Date: Question Response Have the parent demonstrate for you how they make a bottle of formula:  Powder: 2 oz water per scoop of powder  Liquid Concentrate: Mix equal parts concentrated formula with water  Ready to Feed: Do not add any water Bottle should be filled only to appropriate mark, not to top. Check ability to do the math for the size of bottles in use Check the bottles and nipples. Does formula come out of the nipples easily, or are the holes too small or blocked? Is the formula preparation area clean? Watch a feeding: If the baby in over 4-6 months old and has been started on solid food (jar or “baby food”) the solid food should be offered first and then the bottle. How much is consumed? Burping: How often? Are there large spit-ups or vomiting? Ask about naps during the day and sleeping at night. Does the baby sleep through feeding times? Who else feeds child and when? Does that person give information to parent on how much was consumed with every episode of care? What was the baby’s birth weight? What is the Pediatrician’s or Family Physician’s name and phone number? Has the child’s doctor expressed any concerns about the child or diagnosed him/her with any medical conditions? Are there any signs or symptoms of Post-Partum Depression such as crying, insomnia, poor appetite, confusion, excessive preoccupation with child’s health, feelings of hopelessness, loss of interest, poor concentration or mood swings? Request baby’s regular doctor’s medical records Request WIC records Arrange CPT appointment

Potential Obstacles for Successful Management/ Comments:

FTT – Bottle Feeding Checklist, Version 1.0 or August 10, 2015

Eczema Management Checklist

Child’s Name: Number: Date:

Medical Provider Information What is the name and phone number of your child’s Pediatrician, Family Doctor or Clinic? When is your child’s next appointment with his/her Pediatrician, Family Doctor or Clinic? What is the name and phone number of the Dermatologist/Skin Specialist caring for your child? When is your child’s next appointment with the Dermatologist/Skin Specialist? Do you expect to have trouble getting to your child’s next No Yes Reason: appointment? If so, why?

Eczema Management Questions Reason for Importance Yes No N/A Signs and Symptoms of Severity Is the child frequently scratching, pinching, These are signs of poorly controlled eczema. twisting, poking or rubbing his/her skin? Has he/she been rubbing his/her skin on linens or surfaces? Does the child have trouble sleeping or awaken This is a sign of poorly controlled eczema. at night or from naps because of itching? Has the child seemed self-conscious about This is a common bad side effect of poorly his/her skin? controlled eczema. Is the child’s ability to socialize with other This is a common bad social side effect of children being affected by his/her eczema? poorly controlled eczema. Have unsolicited comments, advice and stares This is a common embarrassing side effect of become noticeable? poorly controlled eczema. Is eczema, or are eczema treatments, increasing This is a reason to do what’s necessary to the family’s stress? make it better. Basic Skin Care Does the family understand that soaps, bubble Families may make the mistake of bathing the baths and detergents make eczema worse? child with strong soap, thinking that that will make the eczema better, when in fact it will make it worse. Ask doctor about mild soaps. Does the family understand that hot water/ Bathes are good for moisturizing the skin, but heat/sweating worsen eczema? Baths/showers hot water causes the skin to itch more, and should only be warm or tepid, twice daily. 10-20 the scratching makes the rash worse. min. each. Is there an understanding that any rubbing, Rubbing and scratching make the rash worse. scrubbing, or scratching will make the eczema flare (get worse)? No vigorous cloth cleansing. Only pat dry after bathing, no towel rubbing. Does the caregiver apply moisturizer The moisturizer seals the water from the bath immediately after bathing while the skin is still into the skin. damp?

Mission: Work in Partnership with Local Communities to Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and Advance Personal and Family Recovery and Resiliency Is there a clean bathtub (shower) and care-area A dirty tub and contaminated skin care for him/her? Have the child and caregiver show products will lead to infections. The tub all his/her stuff. Check for expired or visibly should be cleaned, and contaminated contaminated, unclean-appearing creams. supplies replaced. Record on a separate piece of paper all It will help the medical personnel who moisturizers, products, creams, ointments, evaluate the child to know what the family is medications in use. actually using. Triggers Does the family understand rubbing can lead to Eczema has been called “the itch that rashes”. itching, which leads to scratching and more In other words, the itch causes the rash, not rubbing with more itching, which flares eczema? the other way around. This is a cycle that CAN be interrupted. Have they any food-related triggers? Sometimes egg, peanut, soy, wheat or milk can flare eczema. Have they noticed any clothing triggers? Scratchy fabrics like wool are bad. Tight clothes and areas of binding such as with elastic. Nickel in belts, snaps and jewelry is famous for causing rashes. Has an allergy evaluation been recommended? If yes, did they go? Note name, Location and phone number in next box. Medications Has the family had difficulty obtaining If they can’t get the medications, the prescribed medications because of lack of medications can’t work. This would identify a money or insurance denials? problem that must be solved. Does the caregiver give the child antihistamine, It is very important to control the itching in by mouth every day? order to stop the itch-scratch cycle. The family should ask the doctor for a prescription if they don’t have one. Is the caregiver using a prescribed steroid or Steroids help fight the inflammation, but steroid-sparing creams on the red, thickened using lots of moisturizer will decrease the skin and moisturizer on normal skin? amount of steroids needed. If there has been burning from steroid creams, If this is a problem, the family can ask the does the caregiver know the same medications doctor for a prescription for an ointment. can instead be supplied as ointments? Have they heard of Elidel or Protopic? If they These are very effective in treating severe were previously prescribed, were there eczema, but they’re expensive, so it may take difficulties obtaining? special effort to obtain them. Does the family have an Eczema Flare Action This is a detailed set of instructions for what Plan? Do they know that they should call the to do when eczema suddenly gets much doctor when the eczema suddenly gets worse? worse. They should ask the doctor for one. Potential Obstacles to Successful Management/Comments:

Eczema Management Checklist Version 1.0 2

Rick Scott State of Florida Governor Department of Children and Families Mike Carroll Secretary

Diabetes Checklist Child's Name: Intake# Date: Blood Glucose Meter Use: Yes No N/A Can the family show you how to use the Blood Glucose Monitor correctly? Are the correct date and time set? Is the meter used only by the child and by anyone else? Does the meter’s history show 4 BG checks per day (may have separate school meter). Keeping a log book is recommended but may not be used. Are blood glucose test strips (in date) and lancets available? Insulin: Are unopened pens and/or vials kept in refrigerator, and are they within expiration date? Do pens and/or vials in current use have date they expire written on them, that is one month after initial use? They may be kept either in refrigerator or at room temperature. Other supplies: Pen needles or syringes for vials? Is there a Glucagon Emergency Kit (within the date listed on back) Are there Ketone test strips (within date) If on an oral medication, is the pill count consistent with regular use? Does Family Have Knowledge of the Following? Do they have contact numbers of Endocrinologist office/Diabetes Center? Do they know the date of next Endocrinology appointment? Do they have the pharmacy and/or medical supply company number? Do they know when they last gave the school supplies for the child? (Should be monthly for insulin.) Do they know the child’s recent blood glucose readings and insulin doses? – (Child must be supervised at home and at school) Do they know how to count carbohydrates accurately? They may use book, app, computer or handouts. What is the plan for how this is being done for school lunches/snacks? Can they describe the signs and symptoms of low blood glucose, how to treat them, including when to use glucagon and how to mix it? Can they describe the signs and symptoms of a high blood glucose and when and how to test for ketones? Can they describe how to dose insulin using calculations or fixed doses? Do they have plan for a responsible person supervising blood glucose checks and insulin doses before all meals and bedtime? Child should also be supervised for snacks after school. Potential Obstacles for Successful Management/ Comments:

Diabetes Checklist Version 1.0 Diabetes Chesklist

Dental Neglect Management Checklist

Child’s Name Number Date

Dental Care Provider Information What is the name and phone number of your child’s Dentist or Clinic? Have you been told that your child has serious Yes No Don’t Know dental decay that must be treated? Is there a treatment plan for your child’s dental Yes No Reason: problem? If not, why not? When is your child’s next dental appointment?

Do you expect to have trouble getting to your No Yes Reason: child’s next dental appointment? If so, why?

Dental Care Questions Reason for Importance Yes No N/A Tooth Brushing Does the family indicate that they Many families don’t think baby teeth understand that dental health are important since they eventually (including the baby teeth) is important? fall out. If there is an infant in the home, does Good dental health habits starts the family understand that they should early. Many children have tooth start brushing his/her teeth as soon as decay before they are two years old. the first tooth appears? Does the child have his/her own Without a toothbrush, good dental toothbrush? health is impossible. Toothbrushes should not be shared. Is there a fluoride-containing Toothpaste is important. Fluoride toothpaste in the bathroom? makes tooth enamel stronger. If old enough, can the child A child who can’t show you how it’s demonstrate to you how he/she done is not being taught good dental brushes his/her teeth? care habits. How often does the child brush his/her Teeth should be at least twice a day. teeth? If old enough, ask the child, not The child should rinse his/her mouth the parent. with water if brushing not possible. Good Eating Habits for Dental Health Does the family know that they should The infant or child who sleeps with a never put a bottle or sippy cup of milk cup or bottle continually bathes or juice in the crib or bed with and his/her teeth in sugar, a very infant or child? common cause of severe tooth decay.

Mission: Work in Partnership with Local Communities to Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and Advance Personal and Family Recovery and Resiliency If there is an infant in the home, does Propped bottles are important risk the family know that they should factors for tooth decay, choking and always hold the infant while giving a failure to thrive. bottle and never prop a bottle? If there is an infant in the home, does Weaning from bottle to cup helps the family know that they should start prevent dental caries. The goal is to teaching him/her to drink from a cup have the child off the bottle by 12 when he/she can sit well without months of age or shortly thereafter. support, typically around 9 months? Does the family know that toddlers Toddlers who carry around sippy should be given a cup or juice box only cups, bottles and juice boxes take at meal or snack time and should not frequent sips and bathe their teeth in carry one around? sugar all day, leading to tooth decay. Check the pantry and refrigerator. Are Children left to their own devices will healthy foods like fruits, vegetables, often eat candy, sugary cereals and and dairy products available? snacks and drink lots of sugary juice. Does the family know that children Children drink juice more for its should be limited to 4-6 ounces of juice sweet taste than thirst. Those who a day? They can have all the water they drink a lot of juice don’t drink as want when thirsty. much milk as they need. This can cause tooth decay and poor growth.

Lists of free and low-cost dental care services can be found at floridadental.org or by calling the Florida Dental Association Foundation at (800) 877-9922.

Possible Obstacles to Successful Management of Dental Problems:

Dental Neglect Checklist – Version 1.0 of August 10, 2015

Rick Scott State of Florida Governor Department of Children and Families Mike Carroll Secretary

Asthma Management Checklist

Child’s Name: Number: Date:

Medical Provider Information What is the name and phone number of your child’s Pediatrician, Family Doctor or Clinic? When is your child’s next appointment with his/her Pediatrician, Family Doctor or Clinic? What is the name and phone number of the Asthma Specialist caring for your child? When is your child’s next appointment with the Asthma Specialist? Do you expect to have trouble getting to your child’s next No Yes Reason: appointment? If so, why?

Asthma Management Questions Reason for Importance Yes No N/A Medications and Equipment Can the parent or child show you the child’s Many brand names including ProAir,Ventolin, “rescue” inhaler (MDI = Metered Dose Inhaler)? Proventil and Xopenex . Can the parent or child tell you what it’s for? This is for use when the child has an asthma attack. Can the parent or child show you the child’s Many brands including Flovent, “controller” inhaler? Symbicort, QVar and Pulmicort. Can the parent or child explain what the These medications prevent attacks and must controller inhaler is used for and how often it is be used every day, once or twice a day used? depending on the medication. A very common cause of poor asthma control is failure to use this “controller” inhaler regularly. Does the child have a “spacer” device to use Children have trouble taking a deep breath with the inhalers? and squirting an inhaler at the same time. Spacers help to insure that the whole dose of medication gets into the child’s lungs. If the child uses a nebulizer machine, does The child should have his/her own machine so he/she have his/her own, or is it borrowed? it is always readily available. If the child has a nebulizer, does the family know When a child is having a bad attack, their that when the child is very “tight” the nebulizer lungs will be too “tight” to allow them to take is better than the inhaler? and hold a full dose of rescue medicine from an inhaler. If the child uses a nebulizer for a controller Children who stop early do not get a full dose medicine, does he or she finish the whole dose? and won’t stay well. If the child is over 6, does he/she have a Peak Peak flow measurements can help identify Flow Meter? asthma attacks in their early stages so treatment can start early If the child has a Peak Flow Meter, can he/she Just having it isn’t enough. There should be a show you how it is used? record of measurements. If the child has a Peak Flow Meter, can the Numbers in the green zone mean the child is family explain to you what the green, yellow and doing well, the yellow zone starting to get red zones mean? sick, the red zone sick.

Mission: Work in Partnership with Local Communities to Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and Advance Personal and Family Recovery and Resiliency Did the child receive a flu shot during the past or Children with asthma often get very sick and present fall or winter? sometimes die of the flu. They need to be protected by flu shot every year. The flu shot cannot give the child the flu. Can the parent or child show you the child’s An Asthma Action Plan tells what should be Asthma Action Plan? done if the child starts having asthma symptoms like cough or trouble breathing. It should be provided by the child’s doctor. Does the school have a copy of the child’s Lots of attacks happen at school. The school Asthma Action Plan and a rescue inhaler for the needs to know what to do and have a rescue child? inhaler. Does the family understand that a child with a 169 children under 15 died from asthma in bad asthma attack can die in minutes? 2011. Home Environment Does anyone smoke in the home, car or day Cigarette smoke makes asthma worse. The care? home should be smoke-free. That includes family and visitors Regardless of the answer to the above question, Families may deny smoking inside but still do does the home smell of cigarette or cigar it. smoke? Are there any warm-blooded pets in the home, Animal hair and dander often make asthma e.g. , dogs and cats? symptoms worse. They should stay outside, or at least never be allowed in the child’s room. Has the family noticed anything is the home that Some children are sensitive to household seems to make the child’s symptoms worse? chemicals (cleaners, pesticides, etc.) and other things. Does the heating/cooling system in the home These should be replaced every 3 months. have filters? Does the child’s mattress have a zip-up plastic Dust mites are tiny insects that live in cover to keep allergy-causing dust from mattresses and are a common cause of escaping? allergies and asthma.

Does the child have a ‘hypoallergenic” pillow, or Feather pillows are a common cause of a dust-proof cover on a regular or foam pillow? asthma and allergies. Dacron fiber “hypoallergenic” pillows are cheap. Does the child sleep with stuffed animals? These produce and collect dust. The number should be kept to a minimum. Let them “take turns” sleeping with the child. Choose washable ones. What kind of floor covering is in the child’s Bare floors are best, mopped regularly. bedroom? (Wall-to-wall carpet is very dusty.) Throw rugs should be washed regularly. Are there curtains or blinds in the child’s These collect dust and need to be washed or bedroom? vacuumed regularly. Is there a musty smell in the home or signs of Many children are allergic to mold. Cleaning water damage or standing water? up the sources will often improve asthma symptoms. Is there a dehumidifier in the child’s room? Keeping the relative humidity below 45% can help control mold and dust mites. Possible Obstacles to Successful Home Management of Asthma:

Asthma Checklist – Version 1.0 of August 10, 2015 2