AAP Recommendations on Children in Foster Care

The Committee on Early Childhood, Adoption, and Dependent Care of the American Academy of Pediatrics (AAP) has issued guidelines on health care for young children in foster care. The recommendations appear in the March 2002 issue of Pediatrics.

In the past decade, the number of children in foster care has doubled. On any given day, approximately 500,000 children are in foster care, a 65 percent increase from 10 years ago. Infants and young children make up the fastest-growing group in need of foster care. Most of these children have been abused or neglected because of their parents' substance abuse, extreme poverty, mental illness, homelessness, or human immunodeficiency virus infection.

Children who have been placed in foster care are often in poor health. However, the health care they receive is often compromised by insufficient funding, poor planning, lack of access, long waits for community-based medical and mental-health services, lack of coordination of services, and poor communication among health care and child-welfare professionals. State Medicaid systems rarely cover all of the services these children require, and most children do not undergo a comprehensive developmental or psychologic assessment while they are in foster care.

Physicians can help minimize the trauma of being placed in foster care by improving the child's health and development. Physicians should be prepared to spend more time than usual with children who have been placed in foster care, and they must provide necessary care even when little or no information about the child is available. The physician should try to identify physical, psychosocial, and developmental problems and to help social workers and foster parents determine which types of additional evaluation, care, and community services the child needs.

In addition to these recommendations, the AAP has developed the following guidelines:

• Physicians should help child-welfare administrators, caseworkers, and foster parents implement the Standards for Health Care Services for Children in Out-of-Home Care, the guidelines developed in 1988 by the AAP and the Child Welfare League of America.

• All children entering foster care should have an initial physical examination before or soon after placement to identify acute and chronic conditions that require urgent treatment.

• Within one month of entering foster care, children should receive comprehensive physical, mental health, and developmental evaluations.

• Individual, court-approved, social service case plans should include the results of physical, mental health, and developmental assessments and incorporate the recommendations of health care professionals.

• Physicians and child-welfare agencies should work together to ensure that children in foster care participate in all federal and state entitlement programs for which they are eligible and receive the full range of preventive and therapeutic services needed.

• Child-welfare agencies and health care professionals should implement systems to ensure the efficient transfer of physical and mental health information among professionals who treat children in foster care.

Cervical Cytologic Abnormalities Guidelines

The American Society for Colposcopy and Cervical Pathology (ASCCP) has issued evidence-based guidelines on managing women with cervical cytologic abnormalities. The guidelines appear in the April 24, 2002 issue of the Journal of the American Medical Association.

Each year in the United States, approximately 7 percent of the 50 million women who undergo Papanicolaou (Pap) testing are diagnosed with a cytologic abnormality that requires additional follow-up or evaluation. Identifying which patients are at risk of developing cervical disease is a major public health challenge.

A woman with cervical cytology interpreted as atypical squamous cells (ASC) has a 5 to 17 percent chance of having high-grade precursor cervical intraepithelial neoplasia (CIN) confirmed by biopsy. However, the risk of invasive cervical cancer in a woman with ASC is low. So, although a woman with ASC requires some form of follow-up, physicians should try to prevent unnecessary inconvenience, cost, anxiety, and discomfort.

Management of women with ASC depends on whether the Pap test is subcategorized as “of undetermined significance” (ASCUS) or “cannot exclude high-grade squamous intra-epithelial lesion” (ASCH). Women with ASCUS can be managed with a program of two repeat cytologic tests, immediate colposcopy, or DNA testing for high-risk types of human papillomavirus (HPV). Testing for HPV DNA is the preferred approach when liquid-based cytology is used for screening.

In most cases, the ASCCP recommends that women with ASCH, low-grade squamous intraepithelial lesion, high-grade squamous intraepithelial lesion, and atypical glandular cells be referred for an immediate colposcopy.

AFM Call for Papers, Reviewers

Annals of Family Medicine (AFM) will begin publication in spring 2003, and prospective authors are encouraged to begin preparing papers for submission to the peer-reviewed journal. Manuscripts must be submitted through a Web-based system, which will be available at the Annals Web site,www.annfammed.org. Instructions for authors are available at the site.

Because the quality of the journal is dependent on having highly qualified reviewers, the editorial team is also encouraging physicians wishing to serve as reviewers to register now. The journal will publish original research, methodology, theory, and essays. Physicians interested in becoming a reviewer can find additional information and download a reviewer registration form at the AFM Web site.

Annals, which will be published six times a year, is a collaborative effort of the American Academy of Family Physicians and five other organizations.

FDA Norplant Advisory

The U.S. Food and Drug Administration (FDA) announced in July that Wyeth Pharmaceuticals, the manufacturer of the six-capsule Norplant contraceptive system (levonorgestrel implants), reports that women using the system no longer need to rely on backup contraceptives. In 2000, the company recommended using a backup contraceptive when several lots of product were found to contain lower-than-expected hormone levels, but subsequent testing of the specified lots has confirmed their effectiveness. The FDA also noted that the company, because of product component supply limitations, would no longer distribute Norplant.

The FDA Talk Paper is available atwww.fda.gov/bbs/topics/ANSWERS/2002/ANS01161.html. The text of a letter sent by Wyeth to physicians and patients can be accessed throughwww.fda.gov/medwatch/SAFETY/2002/safety02.htm#norpla.

Expanded WONCA Web Site

The World Organization of Family Doctors, WONCA, has launched its redesigned Web site,www.globalfamilydoctor.com. “Global Family Doctor” contains features about WONCA and its working groups, membership, conferences, publications and research, Internet resources, and interactive education.

The “Daily News Centre” contains Journal Watch and News Briefs, which are updated with 20 new items per week, Disease Alerts, and Clinical Reviews. About 30 family medicine and major general journals are reviewed regularly, and synopses of relevant articles are posted each weekday. Also in the Daily News Centre is the Philosophy in Family Medicine and some features to give light relief such as Medical Mirth and Quotable Quotes.