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The Child-Health Conference Suggestions fo r Organization a n d Procedure UNITED STATES DEPARTMENT OF LABOR CHILDREN’S BUREAU Publication No, 2 6 1 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis rat.« https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis UNITED STATES DEPARTMENT OF LABOR F rances P erkins, Secretary CHILDREN S BUREAU • K atharine F. L enroot, Chief + The Child-Health Conference Suggestions fo r O rganisation and Procedure Bureau Publication No. 261 United States Government Printing Office Washington : 1941 For sale by the Superintendent of Documents, Washington, D. C. - https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis - Price 10 cents https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis CONTENTS Introduction ...................................................................................... Functions o f conference......................................................................... Community responsibility for child h ealth................................................................... Relation o f child-health conference to local and State health departments................ Local situations affecting the organization o f a conference............................................ O r gan izing thb conference ................................................................... In an area having a full-time health department............................................................... In an area having a part-time health department............................................................. In an area having no organized health department................................ .......................... T he conference center .................................................................................... Division o f space in conference center................................................................ Preparation o f conference center........................ Reception and w aiting room ............................................................................ W eighing and measuring room ............................................................................ Physician’s consultation room ................................ R egularity a n d frequency of conferences........................................................... A ppointments for exam inatio n ....................................................................... T he conference staff .................................................................................... The public-health nurse.............................................. The volunteer helpers........................................................................................ The conference physician.................................................................................. The nutritionist.................................................................................................. The dentist................................................................................................... The social w orker......................................................................................... P rocedure for mother and child visiting the conference .............................................. In the reception and w aiting room ......................................................................... In the w eighing and measuring room ........................................................... In the consultation room ................................................................................................ E xaminations , immunizations , and tests needed .................................................................. Medical examinations........................................................................................................ Screening tests for vision and hearing.................................................................................. Urinalysis........................................................................... ; .................................. Dental examination........................................_........................................................ Immunization..................................................................................................................... R ecord forms an d record k eepin g ........................................................................................ A ppendix A .— Suggestions for organization and functions of local conference committee .. A ppendix B.— Sources o f posters...... .................................................................... 2 2 2 ^ 4 5 g _ « g jq 22 24 25 2g 26 28 29 2g 29 31 32 32 33 34 34 34 33 33 33 yj 38 42 m https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis a^f https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis THE CHILD-HEALTH CONFERENCE INTRODUCTION Functions o f Conference The purposes of the child-health conference are to educate parents in better methods of child care and to provide or stimulate the provision of continuous health supervision for all children of the community from birth through school age. Being part of a broad public-health education program, the service of the child-health conference, particularly in rural areas, should be available to all parents whose children are not under the supervision of a private physician. Its function is to keep the well child well and to -promote his best possible state of health. The plan for the accomplishment of these purposes includes: (1) Review of the child’s physical and mental health record and examination of the individual child by a physician at regular intervals; (2) the physician’s conference with the mother, at which he discusses with her all aspects of the child’s health and development, advising her regarding the child’s special needs, including the correction of any abnormal conditions, the solution of behavior problems, and the per formance of accepted immunization procedures; (3) service at the conference by the public-health nurse, and when feasible, although not necessarily at every conference, by nutritionist and dentist; and (4) follow-up service by the public-health nurse and, as needed, by other specialists such as the nutri tionist, social worker, and child psychiatrist, when these workers are available. l https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 2 TH E CH ILD-H EALTH CONFERENCE Community Responsibility fo r Child Health While it is well recognized that the health of the individual child is the responsibility of his parents, parents must have an understanding of the fundamentals of child health in order to discharge that responsibility. In addition to the necessary knowledge they must have access to facilities for the protection and promotion of child health. Many parents have no way to acquire the needed knowledge of child care, nor have they access to the necessary health facilities except by means of provisions made through organized community resources. The organization policy for the child-health conference should be to bring together in a cooperative community under taking the public and private health, education, and welfare agencies that are interested in child health so as to eliminate duplication of expense and to develop unity of service. Relation o f Child-Health Conference to Local and State Health Departments A child-health conference in a district, county, city, or town having a public-health department is developed as part of the local public-health program under the supervision of the local health officer. The State health department can assist also with organization and supervision through the professional staff of its maternal and child-health division and by provision of literature and exhibit material. The local health department or, if there is none, the local organizing group w ill obtain full information on the assistance that is available from the State department of health and take advantage of all it has to offer. Local Situations Affecting the Organization o f a Conference In both rural and urban areas the various community situ ations that need to be considered when establishing a childhealth conference are : A. A district, county, city, or town having a well-developed health department w ith a full-time health officer, which assumes full administrative responsibility for the conference. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS' FOE ORGANIZATION AND PROCEDURE 3 B. A district, county, city, or town having a health department w ith a part-time health officer and a public-health nurse, where a local voluntary agency or group o f individuals takes the initiative in organizing and conducting the conference. C. A district, county, city, or town having no organized health department but having a public-health nurse, where a local voluntary agency or group assumes responsibility for the conference. A county or a community without a -public-health nurse should not attempt to organise a child-health conference. Conferences without public-health-nursing follow-up service are of doubtful value. * https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis O RGAN IZIN G THE CONFERENCE With conditions differing as they do in communities throughout the country, it would be impossible to offer sug gestions for the organization of child-health conferences that would meet the requirements of all situations. It is the purpose of this outline to present the fundamental principles of the organization of a conference with suggestions for working them out in certain situations. The details of organi zation procedures in each locality w ill need to be developed according to the local requirements. A. In a district, county, city, or town having a well-developed health department w ith a full-time health officer, which assumes full administrative responsibility for the conference. A child-health conference in such a community is organized by the health department and conducted under its supervision. As it is a combined public-health, medical, and community undertaking, the cooperation of local physicians and the * support of intelligent, interested, and representative com munity groups and individuals is necessary. To gain such support for their programs many health departments have developed community health councils which serve the needs of child-health conferences as a part of the whole health program. (See appendix A, p. 38.) Where child-health conferences are being established for the first time, the health officer w ill probably wish first to discuss the proposition fully with the local physicians and gain their support for the undertaking. Where there is a community health council the matter would then be taken up with that group for the purpose of discussing the need for the proposed conference, its functions, and the local resources and facilities available for its maintenance and operation. In some cases it may be wise to have a subcommittee of the health coun cil appointed to study the matter and assist the health officer with the details of organization and conduct of the conference. 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 5 In communities where there are pediatricians or physicians giving special attention to pediatrics, their advice w ill be particularly helpful in the planning and their services should be obtained, if possible, to conduct the medical conferences. B. In a district, county, city, or town having a health department w ith a part-time health officer and a public-health nurse, where a local voluntary agency or group of individuals takes the initiative in organizing and conducting the conference. The realization of the need for the conference in such com munities usually originates within the community. Whatever the origin of the initial action, the official county or local health department should be consulted early in the planning, and in turn the health department should give all possible assistance. Where the promotion is done by local groups, the public-health nurse usually provides leadership in organizing the conference, with the local health officer and local physi cians represented on the organizing committee. The State department of health should be consulted regarding the assistance it can give. When the health officer and local physicians are thoroughly familiar with the proposal and have agreed to give their sup port, a meeting of local groups representing the community to be served by the conference may be called for the purpose of discussing the need for the proposed conference, its func tions, and the local resources and facilities available for its maintenance and operation. The nonofficial or voluntary agencies, including the local medical and dental associations, nursing groups, voluntary health and welfare groups, parentteacher associations, men and women’s civic and service clubs, churches, and other organized groups of citizens are invited to participate in the organization meeting. The local board of education should be represented. Local boards that are responsible for the expenditure of public funds for health and welfare are urged to attend, and the economy of providing services for health education and prevention of disease should be called to their attention. A careful inventory is taken of the assistance that can be given by each group represented. 245710°—41----- 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 6 TH E CH ILD-H EALTH CONFERENCE If the group agrees on the desirability of proceeding with the establishment of a conference, an organizing committee is appointed. C. In a district, county, city, or town having no organized health department but having a public-health nurse, where a local vol untary agency or group assumes responsibility for the conference. The procedure here would be similar to that described under B, except that there would be no health officer to assist. It is emphasized that where conferences are being organized by voluntary agencies, there is need for medical counsel all along the way. Before the service is undertaken a local conference Com mittee should be appointed by the sponsoring agency and the cooperation of local physicians should be assured. For a discussion of the organization and functions of the local conference committee see appendix A, p. 38. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis THE CONFERENCE CENTER In planning for a child-health, conference, early consideration should be given to the conference center. In a county or community having an established health center or having available the office of the public-health department, the conference would naturally be held there if it is conveniently located for the majority of mothers who w ill bring their children. In larger communities a location convenient to families of low income is important. Communities of more than 10,000 population w ill need more than one conference center to give adequate service. Certain minimum requirements for the conference are mandatory in even the smallest rural community; in the following pages these requirements w ill he italicized. Beyond this there can be such expansion as funds w ill allow for meet ing further needs and providing additional conveniences. In small communities a centrally located -place is best for the conference center. Where possible, rooms on the ground floor are obtained, with facilities for light, ventilation, heat, running water or convenient water supply, and with windows and doors well screened in warm weather. Safe drinking water and paper cups, and a toilet which is in sanitary condition are essential. There should be no hazard to the safety of small children in or about the building. In a town where mothers w ill walk to the center, a protected space for baby carriages is needed. Division o f Space in Conference Center Many types of quarters are used for conference centers, such as hospitals, schools, libraries, and clubrooms. Space and facilities for the conference w ill vary with the community to be served. When the attendance is too large to allow adequate service in small quarters, this difficulty can be met by holding conferences on two successive days or in two suc cessive weeks, adhering in either event to a definite regular day and hour. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 8 TH E CH ILD -H EALTH CONFERENCE It is desirable to have three rooms: one for a reception and waiting room; one for undressing, weighing, and measuring; and one for the physician’s consultations. Where only two rooms are available, one of these may be divided by screens or a curtain. Similarly when a single large room must be used, some -privacy for history taking, for weighing, and for the examination can be provided by means of screens or curtains. A quiet corner of the waiting room is selected for history taking, arranged so that the mother sits at one side of the nurse’s table with her back to the waiting group; a screen w ill provide further privacy. This same comer can be used for the nurse’s conference with the mother. The rooms used for undressing and examination should be provided with heat and, if possible, with running water, and the room in which immunizations are done must have means for sterilizing equipment. Preparation of Conference Center Well before the time for the conference to open, the rooms are made ready for use. In cold weather the waiting room is kept at a temperature of 70° to 72° F. and the weighing and measuring room and the consultation room at about 74° to 76° F. It is important to arrange ventilation throughout so as to avoid drafts. The nurse w ill make a final inspection of each room and of all equipment to be sure that everything is in its place and ready for use. The conference rooms are made as inviting and attractive as possible. Clean light-colored walls, bright-patterned cur tains, and suitable posters (see appendix B, p. 42) help to accomplish this. Needless to say the rooms are kept clean and in good order at all times. Reception and Waiting Room Room is needed to seat comfortably as many adults and small children as are expected to be present at one time, with space also for a desk and two tables. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 9 Equipment (Essentials are in italic) A desk or writing table for use in taking histories; blotter, pen, ink, pencils, paper clips, and scratch pad. Record file for conference cases. This may be only a box or other small compartment for keeping records. Infant and -preschool record forms. Telephone. A table for exhibit material. Chairs or benches. Several small chairs, a low table, and large washable toys for children. Hooks on the w all for wraps. Clock, w all thermometer, and wastebasket. A blackboard for teaching purposes. Educational Material. Exhibits. Excellent use can be made of good exhibit material, and this phase of the conference service is w orth considerable thought. The material could be made up by local groups under the direction o f the public-health nurse. It might include demonstration material pertaining to both mothers and children. For the baby.—K layette, utensils used in preparing milk formulas, approved infant garments, bath equipment, a miniature baby bed, display of foods for children of various ages. For the child o f preschool age. —Proper clothing, toys, especially home made toys, and appropriate picture books. For the m other—Approved garments for the expectant mother, obstet ric supplies, a miniature obstetric bed, and display o f foods for the expectant mother. To be most effective, an exhibit is limited to a single subject, a new exhibit being shown, if possible, at each conference session. For example, one exhibit might include the utensils used in preparation o f milk formulas; another exhibit might be clothing appropriate to the season, such as winter clothing for the baby and the child o f preschool age, out-of-door play suits, and clothing for the baby’s out-of-door nap in cold weather; or foods needed for an adequate diet during pregnancy or during the pre school age. A ll exhibit materials should be clearly labeled and kept fresh and clean. It is important to make all exhibits practical for the group to be served. Some State health departments have exhibits for loan. P osters—T he best obtainable posters on maternal and child-health subjects should be procured. (For suggestions see appendix B, p. 42.) https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis TH E CH ILD-H EALTH CONFERENCE 10 Literature. A supply o f a ll the literature pertaining to maternal and child health distrib uted by the State department of health should be available. The Children’s Bureau, U. S. Department of Labor, Washington, D. C., w ill supply lists of its publications, some of which can be obtained without charge. These publications are not to be placed where they can be taken indiscriminately; they are given out by the nurse to provide information on specific questions. It is important to have literature printed in the language spoken by groups attending the conference. Play Space for Children. When a very large room is available, a good play space for little children can be made in the center or in one comer o f the room by placing chairs or benches together facing outward. These seats can be used by the mothers if desired. The play space may contain a low table, small chairs, and toys. Noisy toys are best avoided. Where a trained play supervisor is available she could be helpful in demonstrating the proper handling of children. W eighing and M easuring Room It is convenient to have the weighing and measuring room between the waiting room and the physician’s room. A space of about 8 feet by 10 feet is needed, well lighted and ventilated, heated in cold weather, and free from drafts. Equipment (Essentials are in italic). Closet or w all cabinet for supplies. A table about 60 inches by 30 inches, or 2 smaller tables for scales and measuring board. Two tables for the convenience of the mothers in undressing and dressing the babies, or A shelf about 30 inches deep by 48 inches long, w ith ends about 12 inches high, and divided into two equal compartments by a parti tion of the same height. This makes a convenient arrangement for undressing and dressing the baby. Two such shelves would be adequate for both undressing and dressing. Similar cubicles w ith a back the height of the partition can be made by a carpenter to fit over the top of a kitchen table. These have the advantage of being portable. Baby scales. —Balance platform type. Measuring board or stationary tape measure on the table. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 11 Standard platform scales and measuring rod for older children. In case there is no measuring rod on the scales a metal tape line secured straight and flat against the w all w ill serve. It should be attached at a point where there is no molding at the contact angle of w all and floor. A desk or small table for use in recording; pen, ink, pencils, and scratch pad. Clinical thermometer. Four chairs. W all thermometer. Wastebasket or pillowcase on chair back or large paper bag for paper that has been used on the scales. Supplies (Essentials are in italic). Pads about 16 inches by 30 inches for measuring and dressing tables w ith rubber sheeting or oilcloth slip cover for each.1 Several baby blankets for mothers who may come unprepared. Scale paper,2 soft paper towels, or sheets o f tissue paper for baby scales , measuring board, and dressing and undressing tables. Safety pins. Baskets, shopping bags, or large paper bags for carrying clothing while child is undressed. Mothers ordinarily should supply their own. Physician’s Consultation Room Minimum size of room needed is about 6 feet by 8 feet. Good light (natural light if possible) and heat in winter are essential. Equipment (Essentials are in italic). Examining table. A shelf underneath is a convenience. Steel tape measure, otoscope, stethoscope, flashlight, and percussion ham mer if not provided by physician. An extra battery for the flash light should be on hand. Table for trays , and for pen, ink, pencils , laboratory blanks, scratch pad, sample diet lists, leaflets , and literature , and printed or typed instructions for mothers. Posture charts. Samples o f proper shoes for infant and preschool child. Chairs. 1 Made like pillowcasing and left open at both ends. This has the advantage of completely covering the pad and it w ill not slip out o f place on the table. 2 Paper that has been sized so as to be semiresistant to moisture, such as the paper used by retail meat dealers. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 12 TH E CHILD -H EALTH CONFERENCE Blanks for report to family physician or specialist or to clinic if family has no regular physician, on abnormal conditions found on examination. Bowl w ith hot and cold running water. If this is not available, a basin and -pitcher, hot plate for heating water, and pail for waste water. Soap. Closet or w all cabinet w ith lock for supplies. W all thermometer. Wastebasket or large paper bag for waste. Supplies (Essentials are in italic) Pad, or blanket, about 16 inches by 30 inches, for examining table, w ith rubber sheeting or oilcloth slip cover. Scale paper, soft paper towels , or sheets of tissue paper for examining table. Specimen bottles. Tray containing— Small-size tongue depressors. Throat swabs. Glass slides. Gauze sponges in jar. Cotton sponges in jar. Roll 3-inch adhesive tape. Roll sterile 2-inch gauze bandage. Blunt-pointed scissors. Alcohol. Tube o f petroleum jelly. Silver-nitrate pencil. Immunization and venapuncture equipment and supplies: Sterilizer or basin for boiling syringes and needles. Tray containing— Tuberculin-test m aterial? Smallpox vaccine .3 • Diphtheria toxoid .8 Wassermann tubes. Syringes , two 2-cc., marked for %-cc. doses. Syringes , two 2-cc., marked for 0.1-cc. doses, one of which is kept for tuberculin tests only. Syringe, 10-cc. Needles, 1 dozen %-inch 26 or 27 gauge. Needles suitable for venapuncture. Forceps, straight, 8-inch, 2 pairs. Iodine, 3-percent solution. Alcohol or acetone. 8 These must be kept in a refrigerator between conferences. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOE ORGANIZATION AND PROCEDURE 13 Green soap. Cotton. Applicators. Spirits of ammonia. Sterile towels. Tourniquet. (The articles provided for the immunization tray need not be duplicated on the regular tray for the examining table.) Equipment for urinalysis: Test tubes. Test-tube rack. Test-tube holder. Test-tube cleaner. Urinometer. 245710° - 41—3 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 10-percent acetic-acid solution. Blue litmus paper. Red litmus paper. Alcohol lamp. Benedict’s solution, qualitative. REGULARITY AN D FREQUENCY OF CONFERENCES The primary aim of the conference is to provide continuous health supervision for the child. In order to do this it is consid ered that a regular schedule is essential—weekly, biweekly, or monthly, depending on the size of the community and the attendance at the conferences. It is important to set a definite day and hour for the conference—for example, the first and third Wednesdays of each month at 2 p. m.—and adhere to the schedule. When conferences cannot be arranged for through out the year they are planned for as much of the year as is feasible. In some areas annual itinerant conferences are held. Con ferences held as infrequently as this, or even those held twice a year, do not meet the requirements of general health super vision. They do, however, serve to demonstrate the need for and value of such service, and to call the attention of parents to abnormal conditions and give them some information on child care in general. For these reasons they are considered worth while, even though far from adequate. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis APPOINTMENTS FOR EXAM INATION The advantage of appointments for examination is unques tioned and in most places they have been found feasible even in rural areas. When making appointments the hour as well as the day is specified. As a rule it has been found best to schedule new cases and the more urgent cases first. An appointment for a new patient is given for about an hour before the time when the child w ill be seen by the physician. For example, when the conference is scheduled to begin at 2 o’clock, the first appointment would be made for 1 o’clock. This allows time for the child’s history to be recorded and the height, weight, and temperature to be taken, so that no time w ill be lost by the physician between his consultations with mothers. Since taking the history of a new patient, or of several children of one mother, requires considerable time, it is a good plan to schedule ahead of new patients, one or two children who are making revisits. Having all in readiness beforehand gives the public-health nurse more opportunity to be present at the physician’s conference with the mother; her presence is desirable although not always possible. There is a tendency in some communities to make the childhealth conference a social occasion, the mothers congregating early and staying until the last examination has been finished. This custom provides good opportunities for group instruction. It has disadvantages, however, particularly in winter, when colds are prevalent and rooms may be poorly ventilated; but even this situation could be utilized for health education, such as teaching the mothers the needed precautions against trans mission of colds. 15 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis THE CONFERENCE STAFF The minimum conference staff includes the physician, the public-health nurse, and from one to three volunteer helpers to work in the reception room, the weighing and measuring room, and, if desired, the physician’s room. When available and where facilities permit the services of a nutritionist, a dentist, and a social worker, especially in the capacity of advisers and consultants to the medical and nursing staff, add to the completeness of the conference service. These special consultants need not all be present at each conference. When any are present additional room is necessary so as to avoid confusion. The conference staff should keep in mind always that the purpose of the conference is to serve the individual mother and child. To do this best, it must make a ll service as considerate and prompt as possi ble; each mother is made to feel that her individual problems are being given careful consideration and she is given such satisfactory service that she w ill wish to return and w ill influence other mothers to come for similar service. Such things as a friendly reception, assistance in disposing of wraps and in finding a place to sit while waiting, a simple explanation by the nurse of conference procedure and especially of the need for the information asked in taking the history, aid greatly in the psychological preparation of the mothers. Likewise a quiet understanding manner on the part of all conference workers in handling the children not only w ill do much to help overcome apprehension on the part of the children but is an excellent demonstration for the mothers. The Public-Health Nurse The effectiveness of a child-health conference depends in large measure upon the services of the public-health nurse. The quality of her services, in turn, depends upon her qualifi cations for public-health nursing in the field of child health. 16 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTION'S FOR ORGANIZATION AND PROCEDURE 17 In most communities the public-health nurse, because of her acquaintance with many families through her general health services, w ill know of the children in need of conference service and w ill refer the parents to the conference. Because of her knowledge of the health, economic, and social conditions of the family, the public-health nurse can at the time of the conference supplement the information of the doctor. At the same time she can interpret to the parents, in terms of their particular home situation, the medical, dental, and nutritional advice given at the conference and w ill show them how they can put it into practice. Although the efficient management and smooth operation of the conference are a responsibility of the public-health nurse, they are only a part of her larger responsibility of making sure that the educational potentialities of each conference are fully realized for each mother. Efficient management is important because it facilitates the creation and utilization of opportuni ties for teaching by public-health nurses, as well as by other members of the professional staff. The number and types of services performed by the publichealth nurse at the child-health conference are influenced by the physical arrangements of the conference, the number of public-health nurses present, and the number of other types of workers assisting. As the most important services for her to perform are those that contribute most to the educational value of the conference, the duties of the public-health nurse may be summarized as follows: General management of the conference. Taking part o f the histories of newly admitted children. (This may be done in the home before the conference takes place.) Conferring w ith the mother before she sees the physician. Observing signs o f illness o f children as they come to the conference and isolating or excluding them as indicated. Instructing and supervising volunteer aids in the performance of their nonprofessional duties. Carrying on individual or group instruction or demonstrations of exhibit materials for waiting parents. Introducing to the physician the mothers and children w ho come to the conference for the first time. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 18 THE CH ILD-H EALTH CONFERENCE Discussing with, the physician any facts related to the progress being made or to home conditions. Being present, whenever possible, during the physician’s conference w ith the mother. Conferring w ith the mother before she leaves the conference concern ing the recommendations of the physician, to give her an appoint ment for her next visit to the conference, to determine whether or not her questions have been satisfactorily answered, and, if indicated, to make an appointment for a home visit. If indicated, referring parents to other community agencies, such as hospital, clinic, welfare agency, school, or private physician. Participating in joint conferences o f professional staff following the conference to review recommendations and plan jointly for carry ing them out. Seeing that individual service records and activity reports for each conference are complete. Probably the most important function of the public-health nurse is further to interpret medical advice and to give practical help to the parents in carrying it out by means of visits to the home. This type of individualized health service is a neces sary supplement to the service of the child-health conference and an effective method of health teaching. The number of the public-health nurse’s visits to the home and the intervals between them are governed by circumstances such as the intelligence and cooperativeness of the parents, the condition of the child, the economic and social conditions in the home, regularity of attendance at the conference, and the progress being made in carrying out the medical recom mendations. The medical examination at the child-health conference can be regarded as the incentive for continuous health supervision of the child, to which the public-health nurse contributes in other environments and in other ways. The Volunteer Helpers Volunteer helpers not only give valuable service in the con ference by releasing the nurse from the more routine work so that she may confer with individual mothers but widen the interest in and understanding of the work in the community. These helpers are selected for their intelligence, dependa bility, and interest in child-health work. They must he https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 19 impressed with the need for guarding honorably a ll information of a personal nature that is acquired in connection with the conference. It is important that they refrain from giving advice to mothers from their own experience. It would be helpful if volunteers could be found who had had some special training pertinent to the functions of the child-health conference, such as nurses, nutritionists, nursery-school workers, laboratory technicians, social workers, or teachers. It is important to have a sub stitute for each volunteer. The volunteer sta ff is under the direction and supervision of the public-health nurse. Each helper must be individually instructed in the duties she is to perform. Group instruction also may be given and conferences held with the volunteer staff for the purpose of improving individual efficiency and developing teamwork. When possible without hardship, volunteers might wear simple smocks to identify them as members of the conference staff. Superfluous jewelry should not be worn. All volunteers w ill be at the center ready for duty at least half an hour before the conference is scheduled to start. When one cannot be present she w ill arrange to have her substitute attend and w ill notify the nurse in charge. One volunteer may be made responsible for opening the center and seeing that it is properly heated and ventilated before the scheduled time for the conference to start. This duty might be rotated among the volunteers. At the close of a conference each volunteer sees that the equipment in her department is properly cared for; that the paper towels and other waste are disposed of; and that every thing is left in good order. The Conference Physician Choosing the physician is a matter of particular importance. The success of the conference w ill depend to a large extent upon the qualifications of the physician in charge. A pediatrician is chosen when at all possible. When a pediatrician is not available an endeavor is made to procure a physician having special training in child-health work. If no such physician is available in the community, the State health department https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 20 T H E CH ILD -H E ALTH CONFERENCE may be requested to assist an interested local physician to acquire the necessary experience in conference work. It may be possible to enlist the aid of a pediatrician to act as con sultant to the regular conference physician and to conduct demonstration conferences from time to time for local physi cians to observe. It is advantageous to have a pediatrician or a physician who has shown an interest in the public-health phases of pediatrics or in general public health, and who has the confidence of the community. In some areas it w ill be necessary for the health officer to do the work. It is important to have the same physician serve regularly at the conference. A substitute physician also is chosen having the same quali fications, if possible, as the regular conference physician. An agreement is made with the regular -physician that he w ill arrange for the substitute physician to attend the conference when he cannot be present and that he w ill notify the nurse whenever this is necessary. Rotation of conference physicians is not conducive to satis factory service and is done only where there are several quali fied physicians in the community who wish to serve. In this case arrangements are made for each physician to serve for at least 6 months and preferably longer. There should be con tinuity of service of the conference physician and he should be paid a stipulated fee for his services. The fee may be determined by the administrative agency and the local medical society. The Duties of the Conference Physician.4 The physician is the medical director of the conference, and his attitude toward parents and children and the type of service he renders make for the success or failure of the conference. It is important that he be present at the hour appointed for the beginning of the conference; otherwise the consultations and examinations must be hurried and the entire plan of work dis turbed. He w ill wear a washable gown or coat while making exami nations and wash his hands bef ore the examination of each child. The physician reads the child’s record before the child is brought to the consultation room. When mother and child 4 Objectives and Techniques for Conducting Child-Health Conferences, by Amos Christie, M. D., Department o f Pediatrics, University of California, San Francisco. Reprints are avail able without charge from the Children’s Bureau, U. S. Department o f Labor, Washington, D. C. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 21 enter, a kindly greeting helps to put both at ease. It is im portant for the physician to make the mother feel that he is interested in assisting her with her child-care problems. The Medical History. A good medical history is essential, and the physician w ill need to obtain this, although he may assign to the nurse the responsibility of assisting. The value of the advice given by the physician to the mother at the child-health conference probably depends as much upon his obtaining a satisfactory medical history as upon his examination of the child. Aside from obtaining specific data regarding the child’s background, which physician and nurse must know, they w ill find out what the mother considers to he her problems regarding the child and the points on which she wants help. It frequently happens that the physician in charge of the conference is so occupied with the examination of the child and with entering notes on the record that he overlooks giving the mother an opportunity to talk. After the physician has obtained from the mother the desired information on the child s history, it may be a good plan for him to ask the mother: “Now what do you want to tell me?’’, giving her a chance to relieve her mind and at the same time furnish clues for further questions pertinent to the individual case. The physician w ill be careful in his questioning not to suggest the proper answers. The taking of the history offers an excellent opportunity for teaching by both physician and nurse. Getting Acquainted With the Child. With the little child who is attending the conference for the first time and to whom the procedure is new and strange, the physician needs to make friends. If the child is apprehensive, timid, or shy, it may be well not to pay too much attention to him at the start but to talk with the mother regarding the more general phases of the child’s history, perhaps handing a toy to the child and giving him opportunity to orient himself and become more at ease. He should be approached quietly and gently. It strengthens the older child’s confidence in the physician if the physician explains honestly to him any https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 22 THE CHILD-HEALTH CONFERENCE unfamiliar or disagreeable procedure that is necessary. Never tell a child a procedure w ill not hurt if it will. The Physical Examination—Appraisal of the Child.5 6 At least 15 minutes is required for a satisfactory examination of the child and conference with the mother. New cases, of course, w ill require longer. In making the examination it is important to keep in mind the picture of a normal healthy child—not merely the “aver age” but the child who is in an optimal state of health. With a standard of excellence in mind and a knowledge of the fundamentals of nutrition and of mental hygiene, the physician is able to give advice to the parent that w ill help toward the attainment of optimal mental and physical health for each child.7 Both the infant and the older child are completely undressed for the examination and for subsequent inspections. There is probably nothing that w ill so impress the parent as to see the physician make a thorough examination. Time must be taken for details, and the physician should not be nor appear to be hurried. It is well to bear in mind the educational as well as the inherent value of strict adherence to cleanliness throughout the examination and of aseptic technique where this is indicated. The order of procedure in examining a child varies w ith the child’s age and disposition. One cannot proceed in a stereotyped course, as is possible w ith the adult. One must pick and feel one’s w ay, starting generally w ith the things that are not unpleasant and gradually, as the child’s confidence is established, passing on to things that are more unpleasant or more dreaded. The throat is nearly always best left until the last unless there is something still more unpleasant, except in the case o f the older child w ho knows that the ordeal is inevitable and wants it over w ith. (See footnote 6, below.) 6 The Appraisal of the Newborn Infant, by Ethel C. Dunham, M. D., Director, Division of Research in Child Development, Children’s Bureau. Single copies available without charge from the Children’s Bureau, Washington, D. C. 6 Examination of the Child in the Practice of Pediatrics, by Joseph Brenneman, M. D., vol. 1, ch. 19. 7 Signs of Health in Childhood. National Education Association, 1201 Sixteenth Street NW., Washington, D. C. 20 cents per copy. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 23 The general appearance should be noted, alertness, state of nutrition, color of mucous membranes and skin, posture, gait, responsiveness, and activity. A child in good mental health is alert, with a happy expres sion, and is interested in his surroundings. There is a very close relationship between bodily and mental health which cannot be too strongly emphasized. In order to be able to appraise a child’s mental status, the physician must be familiar with the psychological aspects of child development.8 Optimum nutrition is evidenced by smooth, clear, and elastic skin; good color of the mucous membranes; sound teeth; firm but not superfluous subcutaneous fat; muscles that are well developed and firm. To determine the amount and turgor of the fat and muscles the physician should feel the tissues of the upper arm, the abdomen, and the calves or thighs. The mus cles should be felt relaxed as well as under tension. Weight should be suitable to body build. A number of years ago there developed a practice of judging a child’s state of nutrition by comparing his height and weight with tables giving average heights and weights of children of his age. It has been generally accepted that this is not a reliable method of judging nutrition because in the compilation of the heightweight-age tables, no consideration was given to the varia tions in type of body build. For example, a child having a large bony frame might compare favorably in height and weight with the average given in the tables for children of his age, but, having small amounts of muscle and subcutaneous fat, he might be much undernourished. Another child having a small bony frame might weigh considerably less than the average for children of his height and age and yet, having well-developed muscles and subcutaneous fat, he might be in an excellent state of nutrition. For these reasons the heightweight-age relationship should not be the basis of judgment of nutritional state. The picture of the whole child is taken 8 Child Management, Are You Training Your Child To Be Happy?, Habit Clinics for Child Guidance, The Child From One to Six—His Care and Training, pp. 1-5 (Pubs. 143, 202, 135, and 30, Children’s Bureau, U. S. Department of Labor, Washington, D. C .). https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 24 THE CH ILD-H EALTH CONFERENCE into consideration. Satisfactory gain in weight is an important evidence of good nutrition. G ood Posture.— Signs of good posture are— Level shoulders. Flat scapulae. Spine free from abnormal curves. Head held erect w ith chin level. Symmetrical chest, w ith equal expansion on both sides during respiration. Abdomen, protruding slightly in children up to about 5 years of age but in line w ith the chest in older children. Legs neither bowed outward nor w ith knees inclined inward. Inner and outer sides o f ankles equally prominent; the inner not projecting as when the arches o f the feet are weak. Feet strong and flexible; inner borders straight from heel to tip of great toe. The feet are normally flat in the infant and very young child, but the arches should develop after the child begins to w alk. The arches o f some children are normally higher than those of others. Head.— Scalp clean and free from scaling or signs of irritation. The anterior fontanel is usually closed before the child is 15 months old. Eyes are bright and clear, lid slits equal, movements coordinated, and pupils equal. Obvious defects in vision and muscle balance may be detected in the conference. Such cases and those in which any abnormalities are suspected should be referred to an ophthalmologist. (For a discussion of screening tests see p. 34.) Mouth w ith smooth and pink mucous membranes; teeth that are w ell formed, w ell enameled, clean and even, free from cavities or w ith cavities properly filled, w ith good occlusion (the grinding surfaces of the bicuspids and molars meeting directly, the upper incisors and canines slightly overlap ping the lower). This inspection w ill of course not take the place of an examination by a dentist. Tonsils.—Large tonsils are not necessarily abnormal unless they cause obstruction to breathing and swallowing or give evidence of acute or chronic infection. Ears.—Canals clear; drums showing well-defined light reflexes and other landmarks. Obvious hearing defects may be detected in the conference, and such cases and those in which any abnormalities are suspected should be referred to an otologist. (For a discussion of hearing testing see p. 34.) N ose unobstructed, free from discharge, septum in the midline; mucous membrane pink and moist. T hyroid gland.—Not enlarged. Cervical lymph nodes.—Not enlarged or tender on palpation. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOE ORGANIZATION AND PROCEDURE 25 Heart.—Satisfactory examination of the heart can be made only when the child is quiet. The heart rate is normally more rapid in a child than in the adult, and there is greater variability o f rate w ith activity. A mur mur is not necessarily evidence o f a pathological condition, but it is an indication for careful examination and medical supervision. Lungs resonant to percussion and clear to auscultation. Abdomen flat and soft when the child is reclining, w ith no enlargement of the viscera. When the head is lifted the abdominal muscles normally become tense w ithout midline separation or bulging. Likewise, there is normally no bulging in the inguinal region when the child stands or coughs. Umbilicus should be healed and dry when the infant is 3 weeks o f age. There is normally no herniation. Genitals: Female—clean and free from discharge and signs of irritation. M ale —clean, foreskin easily retractible, testicles descended. In addition to the attributes of positive health outlined above, the physician obviously should search for the recog nized evidences of physical abnormality. Many abnormal conditions such as glandular dyscrasias, nutritional disorders, allergic diseases, and mental retardation make their appearance during infancy and early childhood. Their early recognition and advice as to the steps necessary for early correction are important functions of health supervision. See also Examinations, immunizations, and tests needed (p. 34). The Conference With the Mother. The physician’s responsibility does not end with the making of the examination. While it is essential to have the best possible physical examination, this alone does the child no good. If it is to be of value, the mother must be informed of the findings and of better ways of caring for the child so as to -promote his optimal mental and physical health. Mothers of infants and young children need some general principles to guide them in everything they do with or for their children. These include not only matters pertaining to physical health but also principles of mental health. These https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 26 TH E CH ILD-H EALTH CONFERENCE principles need to become part and parcel of health-guidance work. It is not logical that parents receive only medical guidance from the physician, and receive their guidance in forming attitudes and habits of everyday living from a psychol ogist or, as is more usual, from grandmothers and the neigh bors. Emotions and physiological functioning are too closely interrelated to permit this division of responsibility. An important causal factor in producing the “below-par” child is frequently found to be the parents’ inability to cope with either their own emotional disturbances or those of their chil dren. Under these circumstances good health habits cannot be developed. For these reasons, in the best health supervision time and thought w ill be devoted to the psychological aspects of child development as well as to the physical aspects. The physician in making recommendations, particularly with reference to diet, w ill keep in mind the economic status of the family and avoid recommendations which the family w ill be unable to follow. To make effective his advice, the physician needs to have the confidence of mother and child. A kindly attitude and genuine interest in their problems w ill rapidly build confidence. Care needs to be taken not to over burden a mother with too much advice at one time. It is often better to stress one thing at a time and to take up other matters at later visits. Most mothers who come to the childhealth conference are eager to learn better ways of caring for their children and are perfectly capable of making good use of the advice given by the physician. The child may, if desired, be excused from the consultation room during this conference. Care should be taken not to discuss the child’s behavior in his presence. When possible, it is very desirable that the public-health nurse who is responsible for the con ference follow-up service be present, although when the physi cian and nurse have learned to work together the physician’s notes on the child’s record w ill usually give the nurse sufficient information for her conference with the mother. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 27 The physician’s conference with the mother w ill include information on— a. The child’s general condition. b. Any deviations from normal, w ith recommendations for correc c. d. e. f. g. h. tion and referral to a private physician, or to the proper public agency for the family in the low-income group. Every effort should be made to find means for correction. The relationship of daily habits to the health o f the child and the importance o f establishing from the beginning proper habits of— (1 ) Taking food. (5) Exercise and play. (2) Sleep and rest. (6) Emotional control. (3) Elimination. (7) Social habits. (4) Cleanliness. The prevention or overcoming of undesirable habits—thumb sucking, bed wetting, and temper tantrums, masturbation, and so forth, as the need for such information occurs.9 10 The management of breast feeding. The need for proper preparation of food and the addition o f certain foods to the diet at certain ages. It is important for the physi cian to keep in mind the economic status of the family and avoid making recommendations the family w ill be unable to follow. The importance of satisfactory gain in weight. The need for immunization against diphtheria and smallpox for all children and against other diseases in special cases. The physician w ill indicate clearly when the child is to be brought again to the conference. The date w ill be entered on the appointment record and also on a slip which is given to the mother. Printed Material as an Aid to the Physician’s Conference With the Mother. It is very helpful both to the conference staff and to the mothers attending to have approved information and direc tions on certain subjects in printed or mimeographed form. Paper of different colors may be used for different subjects if desired. The purpose of this is to supplement, but not to take the place of, the physician’s or the nurse’s explanation, and to give the mother the material to refer to when necessary. 8 See footnote 8, p. 23. 10 The Psychological Aspects of Pediatric Practice, Benj. Spook, M . D ., and Mabel Huschka, M . D. New York State Committee on M ental Hygiene of the State Charities Aid Association 105 East Twenty-second Street, New York, N. Y . 25 cents. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 28 TH E 0HILD-HE1ALTH CONFERENCE Such instructions are written in very simple terms. Many subjects might be treated in this way, such as— Breast feeding. Food for the nursing mother. Routines for the care of the child at various ages. Preparation of the milk formula. Bathing the baby. Directions for laundering diapers. Sleep, exercise, and play. The need for cod-liver oil and directions for giving it. The need for sunshine and directions for giving sun baths. The care of the baby in summer. Prevention of digestive disturbances. Prevention of colds. The baby’s teeth. Weaning the baby. Bowel and bladder control. The importance of immunization against smallpox and diphtheria. Forming good eating habits. Low-cost nourishing foods. Playthings for the little child. Common communicable diseases. Enuresis. Thumb sucking. Source material on these and other subjects can be obtained from State departments of health, and from the United States Children’s Bureau and the United States Department of Agriculture, Washington, D. C. The Nutritionist A nutritionist can add to the effectiveness of a conference in a number of ways. She may supply simple posters, food models, and other devices for teaching the waiting mothers. She may be able to furnish or to suggest sources of printed material on low-cost foods for families with young children. A nutrition consultant on the State health-department staff can often interest local nutrition workers (county home demonstration agents, home-economics teachers, and others) to give volunteer service at child-health conferences. She can also give them supplementary training for this new activity. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 29 If a nutrition worker in the community can attend confer ences regularly, she can instruct both individuals and groups. If someone is present to entertain the children the mothers are free to listen to a short talk on low-cost foods, preferably accompanied by a demonstration of the preparation of some simple, nourishing dish. If there is no time that can be set aside for teaching the entire group, the nutritionist can carry on a continuous demonstration for small groups of mothers waiting for their turn with the physician. The physician and the dentist w ill find that some mothers need detailed instruction in how to carry out the dietary recommendations noted on the record. Much of this instruc tion w ill be given by the nurse as she explains also other recommendations of the physician and the dentist. A nutri tionist can observe the nurse’s instruction of the mother, so that she may know the points that should be stressed in her staff-education work with nurses. She can also confer with mothers in the presence of the nurse as a demonstration of how to teach them to make the most of the money they have to spend for food. Following the conference, the nutritionist can go over with the nurse special food and budget problems that can be worked on during the nurse’s visits to the homes of families represented at the conference. The Dentist A dentist who has had special training or experience in children’s dentistry and is interested in teaching dental health would contribute to the value of the conference service. In some localities dental hygienists serve in conferences. Con sultation between physician and dentist regarding dental conditions affecting the child’s health is obviously desirable. A separate room or partitioned space is needed for the dentist s work. As equipment he w ill need dental explorers and mirror, which he w ill usually supply, a small sterilizer, paper towels, a small table, and chairs. Plenty of time should be allowed for the dentist to become acquainted with the child. He w ill explain to the mother the need for regular dental supervision, corrective procedures, and prophylactic measures. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 30 THE CHILD-H EALTH CONFERENCE A summary of the dental findings and recommendations is entered on the child’s conference record. The Social Worker The public-health nurse and the physician w ill often find social problems that make it difficult for a mother to care properly for her child. It is important that the services of the local social worker be utilized to the fullest extent in deal ing with these problems. In some instances it would be helpful to ask the local social worker to come to the confer ence from time to time to receive and to give reports and dis cuss these problems with the physician and the nurse. In rural areas, particularly where the functions of the social worker are not fully understood, there would be advantages in introducing her at the conference to families needing help. Plans for assisting the family w ill be made jointly by the public-health nurse and the social worker, and they w ill confer with each other as frequently as seems necessary between the conferences in regard to the families receiving social care. Significant social reports should be summarized on the child’s chart. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis PROCEDURE FOR MOTHER AN D CHILD VISITIN G THE CONFERENCE When a mother attending the conference for the first time is not acquainted with the conference staff, the person in charge of each department w ill be careful to introduce to her the person in charge of the next department when she is re ceived there. In the Reception and Waiting Room a. The hostess, usually a volunteer worker, who has been previously instructed, should be on the alert for signs of obvious illness in infants as they are received. As she greets a mother and perhaps assists her to remove her wraps, she has an opportunity to observe the child for possible signs of illness. If any are noticed, the mother is questioned regarding the child’s condition and is requested to occupy a place apart from others who may be present. The doctor and nurse are notified, and the doctor w ill see the sick child immediately. If the case appears to be of an infectious nature, the child is usually dismissed immediately from the conference. But if conditions are such that the mother is unable to take the child away at the moment every effort is made to isolate the child as completely as possible while arrangements are made for suitable care. The method of providing for isolation w ill be determined by the physician and nurse, depending upon the facilities of the individual center. When a child appears to the hostess to be well, the mother is taken to the admission desk. b. Identification data such as date, names of child and parents, and address are obtained and identification numbers are assigned. In most conferences the person acting as hostess obtains this information. The mother is then referred to the nurse, who takes the part of the history delegated to her unless this has been done at a previous home or office visit. 31 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 32 TH E CH ILD-H EALTH CONFERENCE In the W eighing and M easuring Room There may be a volunteer helper in this room to weigh and measure the children and to enter the weight and height on the record cards. When there is available a volunteer helper who has had nursing training, she might well be assigned to weigh and measure the children. It is a good plan to utilize this opportunity to teach the mother how to weigh and measure her child. The weighing and measuring should be done promptly so that the physician does not have to lose time between examina tions. However, after children are undressed, long waiting, which causes restlessness and apprehension, is to be avoided. To be of value the weight and height must be measured and recorded accurately. Incorrect measurements may be harmful by causing anxiety on account of a supposed failure of the child to grow in height or gain in weight, or by creating a false sense of security in the belief that the child has grown or gained when he has not. Great care should be taken to see that each measurement is correctly taken and correctly re corded. To facilitate this the scales and measuring board should be placed where the light is good. The scales should be checked for balance between weighings. A fresh sheet of scale paper or paper towel is used for each child on the scale pan, on the measuring board, on the plat form scale, and on the undressing and dressing tables. While the child is still on the measuring table it is a good plan to take his temperature. Although single isolated tem perature recordings are of doubtful value in themselves, the taking of the temperature at the conference affords a valuable opportunity to teach the mother this procedure. It certainly should be done if the child appears ill. After being weighed and measured the child is not dressed before the examination but should be adequately covered with the small blanket which the mother brings. The child who walks may put on his shoes after being weighed. The diaper should be replaced on the infant. For children who object to complete undressing, light weight underwear, shorts, bloomers, or sunsuits may be left https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOR ORGANIZATION AND PROCEDURE 33 on. Their weight is negligible. Infants, however, should be entirely undressed for weighing. In the Consultation Room Each child coming to the conference for the first time should be given a complete examination. In places where the appointment system is in use every effort w ill be made to keep to schedule. This w ill call for careful planning and for limiting the number of appointments. If a mother comes in without an appointment, an effort should be made to accom modate her. If she cannot wait, an appointment may be made for a later date and an opportunity given for an interview with the nurse, who w ill consider the advisability of a home visit and perhaps give the mother some appropriate literature. A thorough physical examination of a child, allowing opportunity for the mother’s questions and for discussion and instruction, requires time (15 to 20 minutes) to be effective and should not be hurried. Obviously less time is required for children coming to be weighed, measured, and inspected after having had a recent complete examination. Immunizations or any other procedures which are particu larly unpleasant or painful are best deferred until after the completion of the examination and the conference with the mother. There is real advantage in allowing a crying child time to recover before he is sent back to the weighing room or the reception room. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis EXAM INATIONS, IMMUNIZATIONS. AN D TESTS NEEDED M edical 'Examinations Each child w ill be given a complete examination on his first visit to the conference. The frequency of subsequent examinations w ill depend largely on the needs of the indi vidual child and w ill be determined by the physician. The following schedule represents good practice for com plete examinations:11 During the first year—examination at least once a month. During the second year—examination at least every 3 months. From the second to the sixth year—examination at least every 6 months. Inspections w ith the child undressed and conferences w ith the mother w ill be scheduled between the examinations at intervals depending upon the needs in the individual case. Parents should be informed that an examination is advisable after any illness. The weight and height are taken and recorded at each visit to the conference. Screening Tests fo r Vision a n d Hearing Because they require a special room, special equipment, considerable time, and ordinarily two persons to give them, vision and hearing tests for preschool children at regular conference sessions are not usually considered advisable. However, it is highly desirable that children’s visual and auditory acuity be determined before they enter school; and if proper facilities can be arranged for at the conference center and the tests done by special appointment, they would add to the completeness of the health supervision.1213 11 The Health Supervision Program Your Child Should Have. Leaflet prepared by the American Academy of Pediatrics, 636 Church Street, Evanston, 111. 12 Publications of the National Society for the Prevention of Blindness, 1790 Broadway, New York, N. Y. (these include directions for testing the vision of children of preschool age). Testing the Sight of the Young Child, by Parke Lewis, M . D. (American Medical Association, 535 West Dearborn Street, Chicago, 111.; 10 cents.) 18 Publications of the American Society for the Hard of Hearing, 1537 Thirty-fifth Street NW ., Washington, D. C. (these include suggested hearing tests for children of preschool age). Testing Kindergarten Children W ith the 4-A Audiometer, by Warren H. Gardner, Ph. D. (Reprint No. 468 available from the Volta Bureau, 1537 Thirty-fifth Street N W ., Washington, D. C .). 34 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOE ORGANIZATION AND PROCEDURE 35 In case the examining physician discovers at any time any evidence of impaired vision or hearing he w ill promptly refer the child to a specialist, if possible, for further examination and recommendation as to treatment. Urinalysis It is advisable to make routine examinations of the urine of children who can urinate into a receptacle, in order to detect the presence of albumin or sugar. Laboratory facili ties are necessary in examinaing for urinary-tract infection. D ental Examination Dental examination and advice on the care of teeth by a dentist should be begun after the second year. Immunization Inasmuch as there is considerable difference of opinion as to the immunizing agents to be used, dosage, interval between administrations, and age when immunization should be started, it is suggested that the State department of health be consulted regarding its recommendations. The committee on immunization and therapeutic procedures for acute infectious diseases of the American Academy of Pediatrics has issued a report14 giving information on im munity including technique of tests and dosage of immunising agents. Vaccination against smallpox before the age of 12 months is generally accepted as the best practice. It is recommended that the baby be immunized against diphtheria through the injection of three doses of toxoid at about the age of 9 months. A Schick test about 6 months after the last dose and another about a year after the last dose are advised in order to determine whether protection against the disease is complete or whether another injection is needed. The Schick test should be repeated when the child enters school and again when he enters high school, or at about the ages of 6 and 12. » Copies of the report are available at 10 cents each from C. G. Grulee, M . D., Secretary of the American Academy of Pediatrics, 636 Church Street, Evanston, 111. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 36 TH E CHILD-H EALTH CONFERENCE Some physicians now immunize against diphtheria and tet anus in the same injection. Typhoid immunization is seldom necessary in infancy because of the precautions taken in preparing infants’ food and in sterilizing their drinking water. However, in later child hood, if children are at all likely to come in contact with con taminated water or milk supplies, typhoid vaccine may be indicated. The immunity produced is of limited duration. While the effectiveness of vaccine for protection against whooping cough is not established, the protection that it may afford during early childhood, when the mortality from whoop ing cough is highest, would seem to justify consideration of its use. It is advisable that each child be given a tuberculin test.15 Children having positive tuberculin tests are referred to a physician for further examination and recommendation as to care. A positive test in a young child usually indicates con tact with someone who has active tuberculosis. Every effort should be made to determine the source of infection, which, when discovered, should be reported immediately to the local health department. Routine blood tests for syphilis are being advocated, par ticularly in areas where syphilis is prevalent. State depart ments of health make provision for the treatment of children whose parents cannot pay for this service. « For technique of tuberculin test see report referred to in footnote 14 and Diagnostic Standards, issued by the National Tuberculosis Association, 1790 Broadway, New York, N. Y. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis RECORD FORMS AN D RECORD KEEPING Orderly recording of significant information regarding the child’s health and development and services rendered at the conference is essential for insuring continuity in the child’s care and for the evaluation of accomplishment in the confer ence program. The record system should be flexible enough to permit adaptation to the needs of the area concerned, but as a basic principle the use of the same form is recommended for recording service at the conference and in the home. This procedure promotes the integration of services and lessens clerical work. It is advantageous also to have entered on a single record the findings and recommendations of all professional personnel serving the child in the conference. To be of maximum value, a copy of the preschool health record should be furnished to the school health authorities upon the child’s entrance to school. In addition to the record form relating to the care of the individual child, certain records are essential in connection with administrative reports and arrangements for the confer ence, and in the preparation of summaries of conference attendance. In order to have available at all times information on the children attending the clinic and the dates of their attendance, an attendance-record book is helpful. It can also be used for keeping a record of the appointment dates for visits to the conference. Statistics for monthly or annual reports of conference attendance may be compiled from the information in the attendance-record book. Another plan for assembling this information is to count from the individual case records, at the end of each conference session, the number of infants and preschool children in attendance, the number of new admis sions, and the number of réadmissions. The count is entered on the daily report of the nurse or on a summary sheet relating to service in one or more conference centers. At the end of the month or year the counts relating to each conference session are added for the statistical report. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Appendix A.—SUGGESTIONS FOR ORGANIZATION AND FUNCTIONS OF LOCAL CONFERENCE COMMITTEE The local conference committee is an advisory committee serving the district, county, city, or town health department or the local sponsoring agency or agencies. This committee is selected w ith much care since it w ill be a permanent one. Members are appointed so that their terms of office w ill expire in different years. In appointing the members the health officer or appointing body should give careful consideration to the com munity needs and the background of community life, as w ell as to the qualifications and interests of the individuals selected. Members are chosen who can be expected to attend meetings w ith reasonable regularity. The size of the committee should be governed somewhat by the size of the community to be served, 10 to 12 members probably being adequate for most communities. The district, county, city, or town health officer and public-health nurse are members ex officio. It is important to have on this committee, which is composed of both men and women, representatives of the local medical and dental professions, the public-health-nursing groups and other public-health and public-welfare organizations, the public schools, the local government, hospital adminis tration, church organizations, organizations and clubs interested in com munity improvement or civic service, and parent-teacher associations. It is advantageous to include also a capable businessman on the committee. The officers of the committee include chairman, vice-chairman, and secretary. These persons should be community leaders, preferably w ith some knowledge of and particular interest in public-health work. Counties, districts, cities, or towns having full-time public-health departments may already have public-health committees or councils which have agreed upon policies and standards for child-health conferences appli cable to the whole area. In such places the local conference committee may be a subcommittee of such a public-health committee or it may be an independent committee. It should be informed of the policies adopted by the public-health committee in order that such policies may be discussed and that the plans of the local conference committee may not conflict w ith those policies. The local conference committee meets at regular intervals. It is helpful to the physicians and nurses directly responsible for conducting the confer ence to discuss w ith the committee the progress o f the w ork and questions of policy, equipment, publicity, and so forth. The manner in which the w ork of the conference committee is conducted w ill have much to do w ith the success of the conference. Reports of subcommittees should contain material of interest in addition to the necessary statistical material, and 38 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOB ORGANIZATION AND PROCEDURE 39 there should be opportunity for free discussion by all members o f the committee. Each local cooperating agency or group is kept informed by its representative regarding the w ork of the conference. It is advisable for the committee to hold an annual meeting to which the public is invited. The purpose of this is to acquaint the public w ith the accomplishments o f the child-health program during the year and the committee’s plans for the future, and to stimulate further community interest in the service. Arrangements might be made for a special address on some phase of child health at such a meeting. Appointment and Duties of Subcommittees As need occurs subcommittees may be selected by the chairman of the conference committee in consultation w ith the health officer, or, if the local conference committee is under a voluntary agency, by the chairman of the local committee in consultation w ith the sponsoring agency. Only such subcommittees are appointed as are immediately necessary and w ill be active, and they may be dismissed on the completion of their specific tasks. The subcommittees may include any or all o f the following committees: 1. 2. 3. 4. 5. 6. Medical advisory. Finance. Conference center. Volunteer personnel. Publicity. Transportation. The w ork o f each of these subcommittees also is important and great care should be exercised in the selection of its members. Individuals should be appointed who may be expected to have a sustained interest in the service, who are capable of performing the necessary duties, and who have time to give to the work. It is considered advisable that the public-health nurse in charge of the nursing service of the conference be a member ex officio of each committee. The physician in charge of medical service at the conference w ill be a member of the medical advisory committee. The chair man of the local conference committee w ill be a member ex officio o f the subcommittees. Medical Advisory Committee. The membership o f the medical advisory committee includes the local health officer as an ex officio member and members o f the local medical pro fession, particularly those physicians who are experienced or especially interested in child-health or general public-health work. Where there is a full-time local health officer, he may appoint the medical advisory committee after consultation w ith the local medical profession. In rural areas where there are few physicians all of them may be members o f the committee. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis 40 TH E CHILD-H EALTH CONFERENCE The functions of this committee include advice on the plan and scope of the conference, the medical procedures to be followed, and selection o f physicians to conduct the conferences; advice on medical problems; assist ance in preparation of medical information to be included in publicity; assistance in preparation of subject matter relating to medical problems for all publications prepared locally; interpretation of the w ork of the confer ence to the medical profession and assistance in arranging for public speakers on subjects pertaining to child health. Finance Committee. In communities where the State or local health department does not assume the financial responsibility for the conference, this committee w ill be responsible for estimating the financial needs of the center (the prepara tion of the budget) for the year; for obtaining money to meet the budget requirements; for purchasing the equipment for the conference center; and for paying bills, including rent, incidental to the operation of the center. It is probable that most of the equipment, supplies, and furnishings for the center can be obtained through interested groups and individuals so that little w ill have to be purchased. The finance committee works closely w ith the conference-center com mittee, purchasing as promptly as possible any needed supplies or equipment that the latter committee is unable to provide. Conference-Center Committee. This committee w ill probably be required in the beginning to give a considerable amount of time to its duties. These w ill include cleaning and renovating the rooms in the beginning; considering facilities for heating and water supply; obtaining and installing the furnishings, making the center as attractive as possible but keeping the furnishings simple and of a type that can be cleaned or replaced easily; obtaining the necessary equipment and supplies and arranging them in their places. This committee w ill be responsible for the general housekeeping o f the conference center; it w ill keep informed on the condition o f supplies and see that they are replenished as needed. Committee on Volunteer Personnel. The committee on volunteer personnel, together w ith the public-health nurse, w ill analyze the conference jobs, taking into consideration the number o f public-health nurses available regularly for duty at the confer ence, and w ill determine which places are to be filled by volunteers. The requirements o f each place should be carefully studied and a person should be selected for each place w ho is qualified to fill it. A substitute is chosen for each volunteer. It is important to select volunteers w ho can attend regularly. Volunteers and their substitutes are instructed and trained for their work by the public-health nurse. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis SUGGESTIONS FOE ORGANIZATION AND PROCEDURE 41 Publicity Committee. A t least one member of this committee should be familiar w ith publicity technique. It would be w ell to have a member of the medical advisory committee also on this committee. The services of a representative o f a newspaper, a broadcasting station, or an advertising agency would be helpful if available. The functions of the publicity committee are to inform the general public of the service offered by the conference, its purposes, principles, and progress, and to stimulate public interest in the conference. This may be done through newspapers, radio, and public addresses. The publicity com mittee w ill make arrangements w ith the local newspapers to carry ample notice of conferences. Similar announcements might be made in schools or at local meetings. It is desirable to plan a year-round publicity program, including news paper articles, radio talks, and local addresses by qualified persons on sub jects pertaining to child health and community responsibility for child health. Members of the local medical profession and organizations such as parent-teacher associations, service clubs, farm bureaus, and homeeconomics extension bureaus are often available for this purpose. Transportation Committee. The duty of the committee on transportation w ill be to endeavor to find transportation facilities for parents so situated that they cannot avail themselves of conference service unless some means of transportation is provided. It is w ell to determine as far as possible in advance o f each con ference who w ill need this assistance. Volunteers performing this service carry their own automobile liability insurance and need to be fully informed on State laws regarding such liability. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Appendix B.—SOURCES OF POSTERS C hildren’s Bureau, U. S. Department of Labor, Washington, D. C. Posters on diet for the expectant mother and on posture. Bureau of Home Economics, U. S. Department o f Agriculture, Washing ton, D. C. Charts on nutrition and child feeding. Extension Service, U. S. Department of Agriculture, Washington, D. C. Charts on nutrition. M aternity Center A ssociation, 654 Madison Avenue, New York, N. Y. Posters on prenatal, postpartum, and infant care. A merican M edical A ssociation, Bureau o f Health and Public Instruction, 535 North Dearborn Street, Chicago, 111. Posters on infant and child care. A merican D ental A ssociation, Bureau o f Public Relations, 212 East Superior Street, Chicago, 111. N ational Society for the Prevention of Blindness, 1790 Broadway, New York, N. Y. N ational C hild W elfare Federation, Educational Building, 70 Fifth Avenue, New York, N. Y. Posters on health and mental hygiene, and educational posters for children of preschool age. N ational Safety C ouncil, Educational Division, 1 Park Avenue, New York, N. Y. N ational D airy C ouncil, 11 1 Canal Street, Chicago, 111. Posters on the contribution of dairy products to good nutrition. N ational L ive Stock and M eat Board, 407 South Dearborn Street, Chicago, 111. Posters and charts on nutrition. 42 O https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis
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