Why should my child have a 'medical home'?

Why is having a “medical home” important for your child? Having one pediatric practitioner or group of practitioners see your child regularly can help identify any patterns of illness and promote a healthy lifestyle, according to the American Academy of Pediatrics.

The AAP made its case this week through a series of policy recommendations that support the concept of the “medical home” for every child. Yesterday, I discussed the AAP’s concerns with families using retail-based clinics instead of pediatrician’s office for their child’s care.  Today, I will take a look at the AAP’s recommendations for preventive care for children and off-label use of drugs in children.

In spite of spending much more on health care per patient than any other nation, the health of Americans is no longer better than other developed nations. One major reason in the opinion of organized medicine in the United States and others is that our system is reactive rather than preventive. Lifestyle issues such as obesity, lack of exercise, inappropriate nutrition and safe sex are not being emphasized to prevent illness before it occurs, and we are reacting with disorganization to illnesses with multiple medical providers not communicating with each other and no one seeing the big picture

The statement on preventative care, makes official what many, but not all, pediatric practitioners have been doing for years. Our practice at Jefferson does special developmental screenings at 9, 18, and 24 months to detect delays in language, social, fine motor and gross motor skills with an emphasis on catching and treating autism as early as possible. These screenings are in addition to the developmental surveillance done at every visit. All this is recommended in the new rules and has been for several years. 

We have been discussing with teenager’s lifestyle issues such as alcohol, drugs, smoking and sexuality and have recently started offering rapid HIV testing to every child over 13.  The new national policy endorses this for every practice (and suggests using a specific set of questions), but does not start HIV testing until age 16. In our practice, we suggest testing for HIV and other sexually acquired diseases even before the child has been seen by the practitioner  or asked about sexual activity so that this testing does not reveals anything to the patient’s family that he or she does not want revealed.

Other changes include depression screening starting at age 11 (and our practice also does maternal depression screening in the first 10 weeks of a child’s life because postpartum depression is so frequent), screening in the well nursery for congenital heart disease (the norm in Pennsylvania since 2011), not doing routine pelvic exams prior to age 21, and screening for cholesterol and other blood fats starting at age 9.

AAP’s statement on the off-label use of drugs in children is also on the issue of proper care of children and the medical home.  Even after the Best Pharmaceuticals for Children Act and the Pediatric Research Equity Act were passed, the majority of medications used in children have not been approved in children, and often have not even had controlled studies done about their efficacy and safety in children. 

The knowledge of what medications are best in children may be limited outside of a medical home. The medical home is where there are experts who know what medication can be used in children. I have seen antibiotics actually not approved in children under 10, such as ciprofloxin or tetracycline, given inappropriately to my patients in urgent situations even from emergency rooms let alone “doc in the box” clinics.

In addition to the clinical problems of limited knowledge of medications in children, this policy statement concentrates on the need for the Federal Drug Administration to further research and get all the medicines routinely used in children, actually approved or disapproved in children.  Unfortunately, no one wants to pay for this research.  In addition, the number of test patients needed to prove safety is sometimes more than the number of pediatric patients that would possibly ever take the drug, so it is not actually possible to do the testing.  This lack of knowledge is a huge stumbling block for best pediatric care.

As these policies suggest, finding a “medical home” can be crucial to your child’s well-being., just as it is in adults.  Having one place which stores and has ready access to all the medical history of a patient, child or not, leads to safer and more effective medical care.

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