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To characterize preschoolers’ daily parent-supervised outdoor play frequency and associated factors.Cross-sectional using data from the Early Childhood Longitudinal Study–Birth Cohort.Nationally representative US sample.Preschool-aged children.Parent-reported outdoor play frequency.The sample size of 8950 represented approximately 4 million children. Sixty percent of mothers worked outside the home, 79% exercised 0 to 3 days per week, and 93% perceived their neighborhood to be safe. Forty-four percent of mothers and 24% of fathers reported taking their child outside to play at least once per day. Fifty-one percent of children were reported to go outside to play at least once per day with either parent. Fifty-eight percent of children who were not in child care went outside daily. A child’s odds of going outside daily were associated with sex (odds ratio [OR] for girls, 0.85;95% CI, 0.75-0.95), having more regular playmates (OR for ≥ 3 playmates, 2.03; 95% CI, 1.72-2.38), mother’s race/ethnicity (OR for Asian, 0.51, 95% CI, 0.43-0.61; black,0.59, 95% CI, 0.49-0.70; Hispanic, 0.80, 95% CI, 0.67-0.95), mother’s employment (OR for full time, 0.70; 95%CI, 0.62-0.81), and parent’s exercise frequency of 4 days or more per week (OR, 1.50; 95% CI, 1.28-1.75). We did not find significant association of outdoor play with child’s time spent watching television, household income, mother’s marital status, or parent’s perceptions of neighborhood safety.About half the preschoolers in this sample did not have even 1 parent-supervised outdoor play opportunity per day. Efforts to increase active outdoor play should especially target children who are girls and nonwhite. Outdoor play opportunities at child care are critical for children of parents who work outside the home.

Objective To determine the effect of asthma controller medication use, choice, and adherence on sleep in children with asthma. Design A case-crossover analysis examining within-subject differences in controller use between time points with and without sleep problems, based on survey data from 3 time points (baseline, 6 months, and 1 year) of a randomized trial. Setting Families were recruited from 2 area practice networks; all assessments were completed by parents online. Participants Children with asthma, aged 2 to 10 years, as identified by asthma-related medical encounters and prescription fills. Main Exposures Parent report of asthma controller medication use (yes/no), type (inhaled corticosteroid or leukotriene inhibitor), and adherence (daily use, nonadherent use, or nonuse). Main Outcome Measures Children's sleep problems, as defined by parent report regarding how often the child had difficulty falling asleep or experienced daytime sleepiness. Results The analysis included 482 children; 82.6% and 75.9% completed the 6-month and 1-year follow-up visits, respectively. Sleep problems were common, with 19.4% of parents at baseline reporting frequent problems with the child falling asleep and 12.1% reporting frequent daytime sleepiness. Compared with children who did not use a controller medication, children had a decreased risk of problems falling asleep during periods with daily controller use (odds ratio [OR], 0.34; 95% confidence interval [CI], 0.13-0.92), with a trend toward an effect in those with nonadherent use (0.47; 0.20-1.12). Any controller use, regardless of adherence, was also associated with decreased odds of daytime sleepiness (OR, 0.69; 95% CI, 0.51-0.94). When controller class was examined, leukotriene inhibitors were associated with significantly decreased odds of problems falling asleep (OR, 0.18; 95% CI, 0.04-0.78), with or without concomitant use of inhaled corticosteroids, but the results for use of inhaled corticosteroids alone were not statistically significant (0.69; 0.32-1.53). Conclusions Controller medications appear to be effective in reducing sleep problems in children with asthma, and leukotriene inhibitor medications may be especially effective in this population.

Objective To examine the differences and trends in pediatric antireflux procedures (ARPs) across individual pediatric hospitals over time. Design Retrospective cohort study. Setting Administrative database containing inpatient records with discharge dates between January 1, 2001, and March 31, 2006. Participants Hospitalized pediatric patients younger than 18 years with primary procedure codes for ARP, appendectomy, pyloromyotomy, and gastrostomy tube placement. The comparisons with admissions for these common procedures were used to identify changes in the incidence of ARP per hospital per year. Main Outcome Measures The ratio of ARPs to appendectomies, pyloromyotomies, gastrostomies, and all 3 procedures combined, in each hospital by year. Results During our study period 13 691 ARPs, 41 441 nonincidental appendectomies, 14 895 pyloromyotomies, and 23 527 gastrostomy tube placements were identified. The average number of ARPs per appendectomy, pyloromyotomy, and gastrostomy tube placement declined annually across free-standing pediatric institutions. When these annual changes are examined within each hospital individually, however, it appears that such changes are not occurring equally, in that some hospitals are performing significantly greater and some significantly fewer ARPs relative to these common procedures. Conclusions The number of ARPs being performed in 36 free-standing children's hospitals is decreasing each year relative to several operations commonly performed at these institutions. Despite this overall annual decrease, there is tremendous variation between individual hospitals in how frequently ARPs are being performed relative to these procedures.

Objective To test the hypothesis that audible television is associated with decreased parent and child interactions. Design Prospective, population-based observational study. Setting Community. Participants Three hundred twenty-nine 2- to 48-month-old children. Main Exposures Audible television. Children wore a digital recorder on random days for up to 24 months. A software program incorporating automatic speech-identification technology processed the recorded file to analyze the sounds the children were exposed to and the sounds they made. Conditional linear regression was used to determine the association between audible television and the outcomes of interest. Outcome Measures Adult word counts, child vocalizations, and child conversational turns. Results Each hour of audible television was associated with significant reductions in age-adjusted z scores for child vocalizations (linear regression coefficient, −0.26; 95% confidence interval [CI], −0.29 to −0.22), vocalization duration (linear regression coefficient, −0.24; 95% CI, −0.27 to −0.20), and conversational turns (linear regression coefficient, −0.22; 95% CI, −0.25 to −0.19). There were also significant reductions in adult female (linear regression coefficient, −636; 95% CI, −812 to −460) and adult male (linear regression coefficient, −134; 95% CI, −263 to −5) word count. Conclusions Audible television is associated with decreased exposure to discernible human adult speech and decreased child vocalizations. These results may explain the association between infant television exposure and delayed language development.

Objective To determine whether an online intervention reduces references to sex and substance abuse on social networking Web sites among at-risk adolescents. Design Randomized controlled intervention trial. Setting www.MySpace.com. Participants Self-described 18- to 20-year-olds with public MySpace profiles who met our criteria for being at risk (N = 190). Intervention Single physician e-mail. Main Outcome Measures Web profiles were evaluated for references to sex and substance use and for security settings before and 3 months after the intervention. Results Of 190 subjects, 58.4% were male. At baseline, 54.2% of subjects referenced sex and 85.3% referenced substance use on their social networking site profiles. The proportion of profiles in which references decreased to 0 was 13.7% in the intervention group vs 5.3% in the control group for sex ( P = .05) and 26.0% vs 22% for substance use ( P = .61). The proportion of profiles set to “private” at follow-up was 10.5% in the intervention group and 7.4% in the control group ( P = .45). The proportion of profiles in which any of these 3 protective changes were made was 42.1% in the intervention group and 29.5% in the control group ( P = .07). Conclusions A brief e-mail intervention using social networking sites shows promise in reducing sexual references in the online profiles of at-risk adolescents. Further study should assess how adolescents view different risk behavior disclosures to promote safe use of the Internet.

Objective To test the hypotheses that block play improves language acquisition and attention. Design Randomized controlled trial. Setting Pediatric clinic. Participants Children aged 1½ to 2½ years. Intervention Distribution of 2 sets of building blocks. Main Outcome Measures Scores on the MacArthur-Bates Communicative Development Inventories, television viewing based on diary data, and the hyperactivity domain of the Child Behavior Checklist. Results Of 220 families approached in the clinic waiting room, 175 (80%) agreed to participate in the study. At least 1 diary was returned from 92 of the 175 families (53%). A total of 140 families (80%) completed exit interviews. Of the children in the intervention group, 52 (59%) had block play reported in their diaries compared with 11 (13%) in the control group ( P P = .07); percentile, 8.4 ( P = .15); low-income sample—raw score, 12.40 ( P = .01); percentile, 14.94 ( P = .03). For attention the results were as follows: entire sample—odds ratio, 0.49 ( P = .29); low-income sample—odds ratio, 0.48 ( P = .26) There were no statistically significant differences with respect to hyperactivity scores. Conclusions Distribution of blocks can lead to improved language development in middle- and low-income children. Further research is warranted.

To determine whether presenting test performance characteristics influences clinical management.Two questionnaire-based, randomized controlled trials.Mailed surveys with 2 clinical vignettes.Randomly selected US pediatricians (N=1502).Vignette-specific, randomly assigned test information: no additional information (control), test characteristics (TC), or TC defined. In the pertussis vignette, the TC group received the direct fluorescent antibody test's sensitivity and specificity, and the TC defined group received the same information with definitions. In the urinalysis vignette, the TC group received the false-positive rate of persistent microhematuria in predicting renal disease, and the TC defined group received a definition of this information.In the pertussis vignette, diagnostic test choice and management of erythromycin therapy and hospital discharge plans. In the urinalysis vignette, serum laboratory testing and nephrology referral plans.Six hundred fifty-three participants (49.5% of those eligible) returned completed surveys. In the pertussis vignette, significantly more of the TC (73%) and TC defined (71%) groups ordered the best-performing test than did controls (21%) (P.001 for both comparisons). Receiving test characteristics did not significantly affect erythromycin therapy or hospital discharge plans (Por=.40). In the urinalysis vignette, the TC defined group referred to nephrology (30%) and checked laboratory tests (88%) significantly more often than did controls (19%, P=.01; 78%, P=.01, respectively), but the TC and control groups' testing and referral plans did not differ significantly (22% vs 19%, P=.36; 75% vs 78%, P=.48, respectively).Providing test performance characteristics influenced certain clinical decisions, sometimes in unexpected ways.

Bullying is a major public health issue, the risk factors for which are poorly understood.To determine whether cognitive stimulation, emotional support, and television viewing at age 4 years are independently associated with being a bully at ages 6 through 11 years.We used multivariate logistic regression, using data from the National Longitudinal Survey of Youth, to adjust for multiple confounding factors.Parental cognitive stimulation and emotional support at age 4 years were each independently protective against bullying, with a significant odds ratio of 0.67 for both variables associated with a 1-SD increase (95% confidence interval, 0.54-0.82 for cognitive stimulation and 0.54-0.84 for emotional support). Each hour of television viewed per day at age 4 years was associated with a significant odds ratio of 1.06 (95% confidence interval, 1.02-1.11) for subsequent bullying. These findings persisted when we controlled for bullying behavior at age 4 years in a subsample of children for whom this measure was available.The early home environment, including cognitive stimulation, emotional support, and exposure to television, has a significant impact on bullying in grade school.

Objective To examine the possible impact of changes in the organization and management of the Medicaid program on hospitalization patterns for children with chronic and nonchronic conditions between January 1, 1991, and December 31, 1998. Design Longitudinal retrospective study of hospitalization patterns of children in 4 strata: Medicaid, non-Medicaid, chronic conditions, and nonchronic conditions. Setting Washington State. Patients Hospital discharge abstract records for all children aged 0 to 17 years profiled into those with and without a chronic condition, Medicaid, and non-Medicaid using a diagnosis-based classification system. Main Outcome Measures Hospitalization and multiple hospitalization rates and length of hospital stay. Results In 1991, hospitalization and multiple hospitalization rates were higher for all Medicaid vs non-Medicaid children. From 1991 to 1998, there was a decrease in the hospitalization and multiple hospitalization rates for Medicaid children only. By 1998, rates for Medicaid children approximated those for non-Medicaid children. This decrease was greater for nonchronically ill children than for chronically ill children. Total hospitalizations in Medicaid children decreased by 4.5%. The mean length of stay in 1991 for all Medicaid hospitalized children was higher than that for non-Medicaid children (6.1 vs 5.1 days). By 1998, the length of stay decreased for both groups (5.7 vs 4.9 days). Conclusion The declines in hospitalization and multiple hospitalization rates observed in Washington State Medicaid children from 1991 to 1998 may be the result of many statewide efforts to increase access and improve management for this population.

Background Although children with developmental delay are known to have increased health care use, it is unclear what proportion of that health care use is related to associated chronic health conditions. Objectives To assess the prevalence of isolated developmental delay and to determine the role of developmental delay in health care use controlling for chronic health conditions. Design Retrospective cohort study using Washington State Medicaid claims records from November 1, 1990, to December 31, 1997, an administrative data set that contains both International Classification of Diseases, Ninth Revision, Clinical Modification codes and billed services. Patients and Setting Children born between November 1, 1990, and December 31, 1992, diagnosed as having developmental delay before the age of 5 years, enrolled in Medicaid within 1 month of birth, and continuously enrolled for at least 12 months. Four control subjects per case were matched on date of birth and duration of continuous enrollment in Medicaid. Main Outcome Measures Visits to physicians, emergency departments, other practitioners, or hospitals by year of life. Results One thousand two hundred forty-two children having developmental delay and 5370 children without developmental delay were included. One percent of those who met study criteria had developmental delay without chronic health conditions and 30% of the children with developmental delay had no associated chronic health conditions. Boys were 1.6 times as likely to have a diagnosis of developmental delay. Developmental delay was independently associated with increased health care use by all 4 measures used. Conclusion Developmental delay increases health care use apart from associated chronic health conditions.

Background: Nonpharmacological and nonsurgical measures are often recommended for gastroesophageal reflux disease (GERD) in infants, despite ambiguous supporting evidence. Objective: To conduct a systematic review of rigorously evaluated nonpharmacological and nonsurgical therapies for GERD in infants. Design/Methods: We searched online bibliographic databases, including MEDLINE, EMBASE, the Cochrane Collaboration and Clinical Trials Database, and alternative medicine databases for the terms gastroesophageal reflux and infants. We selected randomized controlled trials of nonpharmacological and nonsurgical GERD therapies in otherwise healthy infants. Data were extracted from the selected articles regarding reflux, emetic episodes and intraesophageal pH. Results: We identified 43 relevant studies, of which 10 met the selection criteria. These studies examined positioning, pacifier use, and feeding changes. Positioning at a 60° elevation in an infant seat was found to increase reflux compared with the prone position. No significant difference was shown between the flat and head-elevated prone positions. The impact of pacifier use on reflux frequency was equivocal and dependent on infant position. The protein content of formula was not found to affect reflux. Although no study demonstrated a significant reflux-reducing benefit of thickened infant foods compared with placebo, 1 study detected a significant benefit of formula thickened with carob bean gum compared with rice flour (pH4 for 5% vs 8% of time). Another study showed that if supplementing with dextrose 5% water or dextrose 10% water, the lower-osmolality fluid was associated with less reflux. Conclusions: Many conservative measures commonly used to treat GERD in infants have no proven efficacy. Although thickened formulas do not appear to reduce measurable reflux, they may reduce vomiting. Further studies with clinical outcomes are needed to answer questions about efficacy definitively.