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OBJECTIVES. Primary care clinicians participating in the Child Abuse Reporting Experience Study did not report all suspected physical child abuse to child protective services. This evaluation of study data seeks (1) to identify factors clinicians weighed when deciding whether to report injuries they suspected might have been caused by child abuse; (2) to describe clinicians’ management strategies for children with injuries from suspected child abuse that were not reported; and (3) to describe how clinicians explained not reporting high-suspicion injuries. METHODS. From the 434 pediatric primary care clinicians who participated in the Child Abuse Reporting Experience Study and who indicated they had provided care for a child with an injury they perceived as suspicious, a subsample of 75 of 81 clinicians completed a telephone interview. Interviewees included 36 clinicians who suspected child abuse but did not report the injury to child protective services (12 with high suspicion and 24 with some suspicion) and 39 who reported the suspicious injury. Interviews were analyzed for major themes and subthemes, including decision-making regarding reporting of suspected physical child abuse to child protective services and alternative management strategies. RESULTS. Four major themes emerged regarding the clinicians’ reporting decisions, that is, familiarity with the family, reference to elements of the case history, use of available resources, and perception of expected outcomes of reporting to child protective services. When they did not report, clinicians planned alternative management strategies, including active or informal case follow-up management. When interviewed, some clinicians modified their original opinion that an injury was likely or very likely caused by abuse, to explain why they did not report to child protective services. CONCLUSIONS. Decisions about reporting to child protective services are guided by injury circumstances and history, knowledge of and experiences with the family, consultation with others, and previous experiences with child protective services.

OBJECTIVES. We assessed adverse events, including oculorespiratory syndrome, following influenza immunization during the first year of a publicly-funded program for infants, toddlers and their household members in Canada.METHODS. Parents bringing infants and toddlers for influenza immunization to clinics in Quebec or British Columbia consented to structured telephone interview 5 to 10 days later. One adult provided information for all household members. Symptom experience commencing before and after immunization was assessed. Non-immunized persons also served as a comparison group for immunized household members.RESULTS. Sample included 690 immunized infants and toddlers and 1801 household members, 1374 immunized. Only fussiness, fever, decreased appetite, drowsiness, and nasal congestion/coryza were reported for >5% of infants/ toddlers within 72 hours of immunization, but only arm discomfort was reported among >5% of immunized household contacts. In multivariate analysis, muscle ache was the only systemic symptom reported more often by immunized household members compared to non-immunized persons. Oculorespiratory symptoms were infrequent and there was no difference between immunized and non-immunized household members in their report. Less than 1% of adults required time off work because of adverse events following influenza immunization in the household. Less than 2% of subjects experiencing an adverse event following influenza immunization were considered unlikely to be vaccinated again.CONCLUSION. Influenza vaccine is well-tolerated by infants, toddlers and their household members. Post-marketing observational designs are an expedient way to assess adverse events following influenza immunization. These methods should be established and rehearsed annually in preparation for a pandemic.

OBJECTIVE. To report the duration of breastfeeding among a population of Australian women and to identify factors that are associated with the duration of full breastfeeding to 6 months and any breastfeeding to 12 months. METHODS. Participants were 587 women who were recruited from 2 maternity hospitals in Perth and completed a baseline questionnaire just before or shortly after discharge from the hospital. Women were followed up by telephone interview at 4, 10, 16, 22, 32, 40, and 52 weeks postpartum. Data collected included sociodemographic, biomedical, hospital-related, and psychosocial factors associated with the initiation and the duration of breastfeeding. Cox's proportional hazards model was used to identify factors that were associated with the risk for discontinuing full breastfeeding before 6 months and any breastfeeding before 12 months. RESULTS. At 6 months of age, fewer than one half of infants were receiving any breast milk (45.9%), and only 12% were being fully breastfed. By 12 months, only 19.2% of infants were still receiving any breast milk. Breastfeeding duration was independently, positively associated with maternal infant feeding attitudes and negatively associated with breastfeeding difficulties in the first 4 weeks, maternal smoking, introduction of a pacifier, and early return to work. CONCLUSIONS. Relatively few women achieved the international recommendations for duration of full and overall breastfeeding. Women should receive anticipatory guidance while still in the hospital on how to prevent or manage common breastfeeding difficulties and should be discouraged from introducing a pacifier before 10 weeks, if at all. Improved maternity leave provisions and more flexible working conditions may help women to remain at home with their infants longer and/or to combine successfully breastfeeding with employment outside the home.

Objective. Infants and toddlers with disabilities in the United States and their families are eligible for early intervention services under Part C of the Individuals With Disabilities Education Act. The purpose of this study was to assess family outcomes at the end of early intervention (near the child’s third birthday). Methods. A nationally representative sample of 2586 parents in 20 states completed a 40-minute telephone interview on or near their child’s third birthday. This article summarizes data related to perceived family outcomes at the end of early intervention. Results. At the end of early intervention, most parents felt competent in caring for their children, advocating for services, and gaining access to formal and informal supports. They also were generally optimistic about the future. Most (82%) parents believed that their family was better off as a result of early intervention. Parents were somewhat less positive in their perceived ability to deal with their child’s behavior problems or gain access to community resources, and lower family outcome scores were found for parents of minority children, children with health problems, and children who were living with a single adult. Conclusion. Results suggest that Part C early intervention provides important supports for families of young children with disabilities. The findings reinforce the need for experimental research to identify factors that are most likely to lead to successful outcomes for all families. In the meantime, early identification and expeditious referral are important so that maximum benefit can be realized for children with disabilities and their families.

Objective. The gender gap describing the apparent differences in male and female reports of firearm-ownership and -storage habits has never been evaluated among individuals who live in the same household. Thus, the objective of this study was to examine the level of agreement on household firearms and storage practices among cohabiting partners.Methods. Data for this investigation came from follow-up telephone interviews of participants who underwent a randomized, controlled trial to test the effect of home-safety counseling, including firearm safety, on behavior change. Baseline interviews were conducted at a level 1 pediatric emergency department in North Carolina with adults who took a child or adolescent who was under his or her care to a pediatric emergency department. Follow-up interviews were conducted via telephone at 18 months after intervention with participants who reported household firearms at baseline. Participants then were asked whether their partners could be contacted for a separate telephone interview. The measured outcomes were number and type of household firearms and firearm-storage practices. The strength of agreement between partners' reported firearm-ownership and -storage practices was measured with the κ statistic.Results. Seventy-six partner–respondent pairs completed the study (62% response rate). Most initial respondents were white (89%), female (76%), and college graduates (52%); the median age was 37. There were no same-gender partners, and 91% reported that they were spouses. There was not perfect agreement among male and female partners with regard to the presence of household firearms. More men (80%) reported the presence of household firearms than did women (72%; κ = .64). The discordance between partner pairs regarding the number of household firearms and type was poor to fair (κ = .35 and .34, respectively). Although similar proportions of men and women reported storing any household firearms loaded (10%) and storing all household firearms locked up (63% men and 62% women), the κ values demonstrated only moderate agreement (κ = .56–.60). Most men (88%) and women (83%) reported that firearm storage was the husband's responsibility; 82% of men compared with 17% of women reported that they personally owned all of the firearms.Conclusions. A gender gap does exist in the reporting of firearm ownership with regard to the number and type of firearms owned. There are also differences in reported firearm-storage practices, which are likely related to the finding that men were reported to be the primary owner of firearms in most households as well as the person more commonly responsible for firearm storage. Firearm-safety counseling should include male partners in the history-taking process to improve knowledge about the presence and storage patterns of household firearms.

Background. Elimination of racial and ethnic disparities in health has become a major national goal. The State Children’s Health Insurance Program (SCHIP) has the potential to reduce disparities among the children who enroll if they exhibit the same disparities that have been documented in previous studies of low-income children. To determine the potential impact of SCHIP on racial and ethnic disparities, it is critical to assess baseline levels of health disparities among children enrolling in SCHIP.Objective. To use data from the Child Health Insurance Research Initiative (CHIRI) to 1) describe the sociodemographic profile of new enrollees in SCHIP in Alabama, Florida, Kansas, and New York; 2) determine if there were differences in health insurance and health care experiences among white, black, and Hispanic SCHIP enrollees before enrollment in SCHIP; and 3) explore whether race or ethnicity, controlled for other factors, affected pre-SCHIP access to health coverage and health care.Setting. SCHIP programs in Alabama, Florida, Kansas, and New York, which together include 26% of SCHIP enrollees nationwide.Design. Telephone interview (mailed survey in Alabama) about the child’s health, health insurance, and health care experiences conducted shortly after SCHIP enrollment to assess experience during the time period before SCHIP.Sample. New SCHIP enrollees (0–17.9 years old in Alabama, Kansas, and New York and 11.5–17.9 years old in Florida). Stratified sampling was performed in Kansas and New York, with results weighted to reflect statewide populations of new SCHIP enrollees.Measures. Sociodemographic characteristics including income, education, employment, and other characteristics of the child and the family, race and ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic [any race]), prior health insurance, health care access and utilization, and health status.Analyses. Bivariate analyses were used to compare baseline measures upon enrollment for white, black, and Hispanic SCHIP enrollees. Multivariate analyses were performed to assess health status and health care access measures (prior insurance, presence of a usual source of care (USC), and use of preventive care), controlling for demographic factors described above. Weighted analyses (where appropriate) were performed by using SPSS, STATA, or SUDAAN.Results. Racial and ethnic composition varied across the SCHIP cohorts studied, with black and Hispanic children comprising the following proportion of enrollees, respectively: Alabama, 33% and Conclusions. SCHIP is enrolling substantial numbers of racial and ethnic minority children. There are baseline racial and ethnic disparities among new enrollees in SCHIP, with black and Hispanic children faring worse than white children on many sociodemographic and health system measures, and there are differences among states in the prevalence and magnitude of these disparities. After controlling for sociodemographic factors, these disparities persisted.Implications for Monitoring and Improving SCHIP. SCHIP has the potential to play a critical role in efforts to eliminate racial and ethnic disparities in health among the children it serves. However, study findings indicate that programmatic efforts are necessary to ensure that disparities are not perpetuated. Program effectiveness and outcomes should be monitored by race and ethnicity to ensure equity in access, use, and outcomes across all racial and ethnic groups. Assessing the health characteristics and needs of new SCHIP enrollees can provide a benchmark for evaluating the program’s impact on eliminating racial and ethnic disparities in health and inform service delivery enhancements.

Objectives. Recurrent abdominal pain (RAP) affects up to 15% of children. A biopsychosocial approach to the treatment of children with RAP has been proposed as an alternative to the traditional medical model. The aim of this study was to examine whether the parental conceptual model of illness is a factor in the long-term outcome of children with severe RAP.Methods. The study was undertaken in 2 parts: 1) a review of the medical and psychiatric records (including Child Behavior Checklist [CBCL]) of all children with RAP of sufficient severity to necessitate hospitalization during a 5-year period and 2) a structured telephone interview to collect information on ongoing abdominal pain, other somatic symptoms, school attendance, and the parents’ opinion as to the cause of the child’s pain.Results. Twenty-eight of 30 children who were identified were available for follow-up. Twenty-three (82%) were tertiary referrals from other pediatric services, and 20 had pain for >6 months. On admission 7 (25%) of 28 had a depressive disorder, and 8 (29%) had an anxiety/depressive disorder. Twenty-one of 28 parents completed the CBCL, and on analysis of the CBCL, 11 (52%) children had scores in the clinical range (>65). At follow-up (mean: 3.56 years; standard deviation: 1.59), 14 (50%) of 28 continued to complain of pain. These children also complained of multiple other somatic complaints and had repeated school absences. Only 1 (7%) of 14 parents of children with ongoing pain believed that there was a psychological cause for their child’s pain, whereas 11 (78%) of 14 parents of the children who had recovered believed that the cause was attributable to psychological factors (odds ratio: 47.67; 95% confidence interval: 3.56–1511.6).Conclusions. The acceptance by parents of a biopsychosocial model of illness is important for the resolution of recurrent abdominal pain in children.

OBJECTIVE: We describe methods used in the Year 6 Follow-Up (Y6FU) of children who participated in the Infant Feeding Practices Study II (IFPSII). This study consists of a questionnaire administered 6 years after the IFPSII to characterize the health, development, and diet quality of the children. METHODS: The Y6FU sample was a subset of those who participated in IFPSII. The IFPSII participants were drawn from a national consumer opinion panel; neither the IFPSII nor the Y6FU sample is nationally representative. The Y6FU sampling frame included all qualified participants who answered at least the first postnatal questionnaire. One questionnaire was administered by mail in 2012, and nonrespondents were contacted for a telephone interview. Survey topics included measures of health, development, diet, physical activity, screen time, and family medical history. We attempted to contact 2958 mothers and obtained completed questionnaires from 1542, a response rate of 52.1%. We conducted 2 sample evaluations, 1 comparing respondents and nonrespondents on data from IFPSII and the other comparing Y6FU respondents with 6-year-old participants in the National Survey of Children’s Health. RESULTS: Y6FU mothers are more likely to be white, married, older, and of higher education and income than both nonresponders and nationally representative mothers. Comparisons also revealed health-related differences and similarities. CONCLUSIONS: Although not nationally representative, the Y6FU provides a valuable database because of its wide coverage of diet and health issues and its unique ability to link early feeding patterns with outcomes at age 6 years.

Context. Our center developed the technique of preimplantation genetic diagnosis (PGD) by sequential polar body removal (PBR) for the diagnosis of Mendelian disorders and aneuploidies. This study examines the obstetric and neonatal outcome of the first 109 live births after PGD by PBR. Objective. To determine if there were any observable effects of PGD by PBR on perinatal morbidity and mortality, birth defects, and growth parameters. Design. Data on perinatal outcome were gathered for the first 109 infants by parental reporting and confirmed by telephone interview and chart review when indicated. In infants >6 months old, a follow-up telephone interview was performed establishing the developmental milestones attained by the child. Setting. A research center conducting an institutional review board-approved research protocol in PGD. Patients. All patients who had PGD by PBR who had clinical pregnancies. Main Outcome Measures. Gestational age, mode of delivery, perinatal mortality, birth weight, birth length, the presence of birth defects, and developmental milestones. Results. There was no significant decrease in birth length or weight, or the frequency of small for gestational age infants. No specific pattern of birth defects was observed. Conclusion. Thus far, there are no observable detrimental effects of PGD by PBR on children born after the procedure.

Objective. To determine the risk of significant injury associated with premature graduation of young (2- to 5-year-old) children to seat belts from child restraint systems (CRS). Background. Advocates recommend use of child safety seats for children younger than age 4 and booster seats for children age 4 and older. Despite these recommendations, many children are prematurely taken out of these child restraints and placed in seat belts. Although data exist to support the use of child restraints over nonrestraint, no real-world data exist to evaluate the risk of significant injury associated with premature use of seat belts. Design/Methods. Partners for Child Passenger Safety includes a child-focused crash surveillance system based on a representative sample of children ages 0 to 15 years in crashes involving 1990 and newer vehicles reported to State Farm Insurance Companies in 15 states and the District of Columbia. Driver reports of crash circumstances and parent reports of child occupant injury were collected via telephone interview using validated surveys. Results were weighted based on sampling frequencies to represent the entire population. Results. Between December 1, 1998, and November 30, 1999, 2077 children aged 2 to 5 years were included and were weighted to represent 13 853 children. Among these young children, 98% were restrained, but nearly 40% of these children were restrained in seat belts. Compared with children in CRS, children in seat belts were more likely to suffer a significant injury (relative risk: 3.5; 95% confidence interval: [2.4, 5.2]). Children in seat belts were at particular risk of significant head injuries (relative risk: 4.2; 95% confidence interval: [2.6, 6.7]) when compared with children in CRS. Conclusions. Premature graduation of young children from CRS to seat belts puts them at greatly increased risk of injury in crashes. A major benefit of CRS is a reduction in head injuries, potentially attributable to a reduction in the amount of head excursion in a crash.

Background. Previous studies demonstrated that constipation and painful defecation are associated with stool toileting refusal (STR), but whether they are the result of STR or occur before this behavior is not known.Objective. To determine whether constipation and painful defecation occur as a result of STR or occur before STR.Methods. Three hundred eighty children between 17 and 19 months of age participated in a prospective longitudinal study of toilet training. Children were monitored with telephone interviews every 2 to 3 months until the completion of daytime toilet training. Information obtained in follow-up interviews included parents' reports on the presence and frequency of hard bowel movements, painful defecation, and child toilet training behaviors. Children were defined as completing daytime toilet training when they were experiencing Results. The mean age at the completion of daytime toilet training was 36.8 ± 6.1 months (range: 22–54 months). Ninety-three children (24.4%) developed STR. Parents of children who developed STR, in comparison with the rest of the sample, were more likely to report that the child had experienced hard bowel movements (67.7% vs 50.9%), frequent hard bowel movements (29.0% vs 14.3%), and painful defecation (41.9% vs 27.9%). Of the children who experienced both STR and hard bowel movements, 93.4% demonstrated constipation before the onset of STR. In that group, parents reported hard bowel movements at almost one-half of all follow-up telephone interviews before the onset of STR. Of the children who experienced both STR and painful defecation, 74.4% experienced the first episode of painful defecation before the onset of STR. Children with frequent hard bowel movements demonstrated a longer duration of STR (9.0 ± 6.5 vs 4.8 ± 3.0 months).Conclusions. When hard bowel movements or painful defecation is associated with STR, the first episode of constipation usually occurs before the STR. The fact that hard bowel movements frequently occur before the onset of STR suggests that for many of these children constipation is a chronic problem that is not being treated effectively. Therefore, hard bowel movements and painful defecation are factors that potentially contribute to the STR and for the majority of children are not caused solely by the STR behavior. Additional studies are needed to determine whether earlier and more effective treatment of constipation could decrease the incidence of STR.

To determine and delineate breastfeeding barriers faced by women in the State of Qatar. A total of 360 mothers were contacted for a telephone interview to fill in a survey of 25 simple questions. Mothers of children born between the period of January 1, 2012 and December 31, 2012 in the State of Qatar were contacted. 207 mothers agreed to be interviewed (response rate 57.5%).Four out of 10 mothers (n=144) did not answer the phone, while 8 mothers (2.2%) answered the phone …

To determine if experienced primary care physicians are more likely to reach correct decisions on the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family practice to evaluate three pediatric patients via a telephone interview with a simulated mother and to decide whether each patient needed to be seen that evening. Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P < .05) or injured (P < .01); however, less than half obtained histories considered adequate to rule out potential serious illnesses. Faculty did better than either residents or private practitioners in managing a severely dehydrated child; 100% of the faculty, but less than 60% of the residents or private practitioners, chose to see the patient promptly (P < .001). More than one third of all residents and private practitioners reached inappropriate management decisions despite obtaining information that should have altered their decisions. In these simulations, experience in private practice was not associated with improved telephone management of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all three simulations, attainment of the correct decision appeared to be determined not by the number or type of questions asked, but rather by the physician's interpretation of the information collected.

OBJECTIVE: Although studies have begun to explore the impact of the current wars on child well-being, none have examined how children are doing across social, emotional, and academic domains. In this study, we describe the health and well-being of children from military families from the perspectives of the child and nondeployed parent. We also assessed the experience of deployment for children and how it varies according to deployment length and military service component. PARTICIPANTS AND METHODS. Data from a computer-assisted telephone interview with military children, aged 11 to 17 years, and nondeployed caregivers (n = 1507) were used to assess child well-being and difficulties with deployment. Multivariate regression analyses assessed the association between family characteristics, deployment histories, and child outcomes. RESULTS: After controlling for family and service-member characteristics, children in this study had more emotional difficulties compared with national samples. Older youth and girls of all ages reported significantly more school-, family-, and peer-related difficulties with parental deployment (P < .01). Length of parental deployment and poorer nondeployed caregiver mental health were significantly associated with a greater number of challenges for children both during deployment and deployed-parent reintegration (P < .01). Family characteristics (eg, living in rented housing) were also associated with difficulties with deployment. CONCLUSIONS: Families that experienced more total months of parental deployment may benefit from targeted support to deal with stressors that emerge over time. Also, families in which caregivers experience poorer mental health may benefit from programs that support the caregiver and child.

OBJECTIVES: We sought to determine joint outcomes relative to impact level of athletic participation among school-aged children who had hemophilia and were taking prophylactic factor replacement, as well as to investigate prognostic factors for joint outcomes. METHODS: School-aged boys with severe hemophilia A or B at a single center were included in the study. Clinical data on baseline joint status, BMI, hemophilia treatment, bleeding episodes, joint assessments, athletic participation, and injuries were retrospectively reviewed. Data on athletic participation were supplemented, when incomplete in the medical record, via structured telephone interview. RESULTS: Among 37 children with severe hemophilia A or B receiving factor prophylaxis, 73% participated in high-impact activities, whereas 27% participated in exclusively low-impact activities. The frequency of joint hemorrhages and new injuries did not appreciably differ between high- and low-impact athletics. In most instances, children developed CONCLUSIONS: In the setting of regular prophylaxis and adult coaching and supervision, significant bleeding complications were uncommon and level of impact of athletic participation was not a prognostic factor for joint outcomes. Athletic participation with appropriate supervision and precautions should be encouraged in children with hemophilia receiving prophylaxis, given potential health benefits in an increasingly overweight pediatric population.

OBJECTIVE. The purpose of this work was to examine factors related to perceived impact of early intervention on children with disabilities and their families. METHODS. A nationally representative sample of ∼2100 parents completed a 40-minute telephone interview near their child's third birthday. Structural equation modeling examined the relationships between 3 support variables (quality of child services, quality of family services, and family/community support) and 2 outcomes at 36 months (impact on child and impact on family) and determined whether these relationships were mediated by 2 perceptual variables (optimism and confidence in parenting) or moderated by 5 demographic variables (poverty, maternal education, ethnicity, age of initial Individual Family Service Plan, and health at 36 months). RESULTS. Perceived impact of early intervention on both child and family were significantly related to each other. The quality of child services was related to impact on the child but not on the family. The quality of family services was related to both child and family impact. Informal support was not related to perceived impact on children or families but was strongly related to confidence in parenting and optimism. Neither optimism nor confidence in parenting mediated the relationships between services or supports and perceived impact. Minority families and families of children with poor health reported lower quality of services, but these characteristics did not moderate the relationships between services and perceived impact on the child. However, both poverty status and minority status were associated with perceptions of impact on the family. CONCLUSIONS. Findings reinforce the role of high-quality services in maximizing perceived impact. They also highlight the important role of informal support in promoting optimism and confidence in parenting. Poverty status, minority status, and poor health of the child are salient factors in predicting lower perceived quality of and benefit from services.

Objectives. To examine the intermediate-term outcome of children with syncope and its relationship to tilt test. Design. This was a retrospective study of 45 children. In 20, the tilt test was negative. Follow-up with respect to the recurrence of syncope was obtained via chart review, a mailed questionnaire, or telephone interview. Results. Follow-up data were available on 15 children whose tilt test was negative and on all 25 tilt-test positive children. Recurrent syncope was significantly greater in the positive-tilt children (13 of 25) than the negative-tilt children (2 of 15). There was no difference between the syncope-free group and the recurrent syncope group or between the tilt-positive and tilt-negative groups with respect to age at initial syncope, duration of symptoms, age at tilt test, and duration of follow-up. Children with a positive tilt test and those with recurrent syncope had more syncopal episodes before their evaluation than either the group with a negative tilt test or the group with no recurrent syncope, respectively. Conclusions. Syncope may recur after either a negative or a positive tilt test. The recurrence rate, however, is higher for the tilt-positive children.

OBJECTIVES. Asthma is one of the more common reasons for children's visits to the emergency departments (EDs). Many studies show that the level of asthma care and self-management in children before an ED visit for asthma is often inadequate; however, most of these studies have been conducted in the inner cities of large urban areas. Our objectives were to describe asthma care and management in children treated for asthma in 3 EDs located in an urban, suburban, or rural setting.METHODS. We studied a prospective patient cohort consisting of children aged 2 to 17 years who presented with an acute asthma exacerbation at 3 EDs in western Michigan. An in-person questionnaire was administered to the parent or guardian during the ED visit. Information was collected on demographics; asthma history; usual asthma care; frequency of symptoms during the last 4 weeks; current asthma treatment, management, and control; and past emergency asthma care. A telephone interview conducted 2 weeks after the ED visit obtained follow-up information. The 8 quality indicators of asthma care and management were defined based on recommendations from national guidelines.RESULTS. Of 197 children, 70% were enrolled at the urban site, 18% at the suburban site, and 12% at the rural site. The average age was 7.9 years; 60% were male, and 33% were black. At presentation, nearly half (46%) of the children had mild intermittent asthma, 20% had mild persistent asthma, 15% had moderate persistent asthma, and 19% had severe persistent asthma. One quarter of the children had been hospitalized for asthma, and two thirds had at least 1 previous ED visit in the past year. At least 94% had health insurance coverage and 95% reported having a primary care provider.Less than half of the children had attended at least 2 scheduled asthma appointments with their regular asthma care provider in the past year. Although only 5% of the subjects reported that the ED was their only source of asthma care, at least 30% reported that they always went directly to the ED when they needed urgent asthma care. Only 3 in 5 children possessed either a spacer or a peak-flow meter, whereas ∼2 in 5 reported having a written asthma action plan. Among those with persistent asthma, there was considerable evidence of undertreatment, with 36% not on either an inhaled corticosteroid or a suitable long-term control medication. Only 20% completed a visit with their regular asthma care provider within 1 week of their ED visit.CONCLUSIONS. Despite very high levels of health care coverage and access to primary care, the overall quality of asthma care and management fell well short of that recommended by national guidelines.

Objective. To measure parents’ and other adults’ values for preventing disease associated with pneumococcal infection and to evaluate how including these values changes the economic appraisal of pneumococcal conjugate vaccine.Methods. Data on preferences and willingness to pay to reduce risk of illness were collected for 6 illnesses that are preventable by pneumococcal conjugate vaccine (simple otitis media, complex otitis media, moderate pneumonia, severe pneumonia, bacteremia, and meningitis) and 1 vaccine-related adverse event (fever and fussiness after vaccine). Interviews were conducted with 2 groups of respondents: 1) parents of children who had experienced 1 or more of the outcomes described in the survey (n = 101) and 2) a US community sample (n = 109). The 30-minute telephone interview used modified time trade-off questions and willingness-to-pay questions. Values from the interview were incorporated in an existing decision-analytic model that simulated the cost-effectiveness and cost-benefit of pneumococcal conjugate vaccine in a hypothetical cohort of newborns.Results. Among parents, the median amount of time that respondents said that they would be willing to trade to avoid diseases ranged from 0 days for otitis media to 1 year for severe pneumonia and 2 years for meningitis. Among the US community sample, the median amounts of time traded were higher, ranging from 7 days for otitis media to 3 years for meningitis. Median willingness-to-pay amounts varied from $100 to prevent 1 episode of otitis media and $500 to reduce the risk of meningitis from 21 in 100 000 to 6 in 100 000 and were similar between parents and community members. Incorporating time trade-off amounts into the existing economic model for pneumococcal conjugate vaccine resulted in cost-effectiveness ratios Conclusions. Both parents and community members assign relatively high values to preventing meningitis, pneumonia, and complex otitis media. When the value of preventing pneumococcal diseases is incorporated into economic analyses, pneumococcal conjugate vaccine has a cost-effectiveness ratio in the range of other widely used health interventions.

Objectives. Follow-up with a primary care provider (PCP) is recommended after an emergency department (ED) visit for asthma to assess clinical status and develop a management plan to improve future care. However, previous ED-based studies of urban children with asthma have reported low follow-up rates. The objective of this study was to determine whether scheduling an appointment at the time of an ED visit improves PCP follow-up for urban children. A secondary goal was to assess the effect of this intervention on short-term health outcomes and the use of recommended preventive controller medications. Methods. This randomized trial enrolled a convenience sample of children who were 2 to 18 years old and discharged after treatment for acute asthma in an urban children’s hospital ED. Both intervention and control subjects were instructed to follow up with their PCP within 3 to 5 days. Study staff assisted intervention subjects to call their PCP from the ED and schedule an appointment. When follow-up could not be scheduled, assistance continued after ED discharge by telephone until an appointment date was confirmed. Study outcomes included PCP visits, asthma-related morbidity, and daily use of preventive medication 4 weeks after the ED visit. Outcomes were assessed by telephone interview and confirmed by PCP record review. Results. A total of 278 eligible subjects were enrolled over 8 months; intervention and control groups were similar by demographic variables and PCP type as well as by asthma history, symptoms, and previous medication use. Only 38% of subjects reported using a daily controller medication, although 70% described persistent asthma symptoms for which these are recommended. For the intervention group, follow-up appointments were successfully obtained during the ED visit for 24% of subjects; when unsuccessful, a median of 3 telephone calls (range: 1–14) were needed to confirm that an appointment had been scheduled. During the 4 weeks after the ED visit, intervention subjects were more likely than controls to follow up with their PCP (64% vs 46%; relative probability for follow-up: 1.4; 95% confidence interval: 1.1–1.7). Study groups did not differ in return ED visits, missed school or work, or the percentage reporting daily use of a controller medication (58% vs 54%) 4 weeks after the ED visit. The median time to the next PCP visit was shorter among intervention subjects (13 vs 54 days). Conclusions. Scheduling an appointment after an ED visit increased the likelihood that urban children with asthma would follow up with a PCP. An appointment could not be obtained during the ED visit for most children. Other interventions are needed to improve linkage between ED and primary care for asthma and to improve the use of controller medications.

UM Sahiner, E Civelek, A Tuncer. Int Arch Allergy Immunol. 2011;156(2):224–230 Chronic spontaneous urticaria (CSU) in childhood is infrequent, and information about the disease is limited. The study investigated its etiologic factors, natural course, and predictors of prognosis. All children aged 18 years or younger in a cohort from Turkey who were diagnosed with CSU during during an 8-year period. Retrospective analysis of the medical records of these patients was performed, and the final outcomes were queried via a telephone interview. One hundred patients (male/female …

van Gent R, de Meer G, Rovers MM, Kimpen JL, van der Ent CK, van Essen LE. Arch Dis Child. 2008;93(3):236–238 PURPOSE OF THE STUDY. To assess the willingness of parents of children with possible asthma to visit their general practitioner (GP). STUDY POPULATION. A cross-sectional group of 130 Dutch children aged 7 to 10 years with possible asthma were studied. METHODS. Participating parents completed the International Study of Asthma and Allergies in Childhood questionnaire. A child was considered to have “diagnosed asthma” if a doctor had diagnosed him or her with asthma in the preceding 12 months. A child was considered to have “possible asthma” if the child had (1) no physician-diagnosed asthma in the preceding 12 months, (2) asthma symptoms in the preceding 12 months, and (3) either reversible airway obstruction or bronchial hyperreactivity. Parents of children with possible asthma were sent a letter recommending further medical evaluation by their GP. The GP received a letter with the results of the questionnaire and lung-function tests. A research nurse contacted parents to conduct a telephone interview regarding adherence to recommendations. RESULTS. A total of 2745 children were invited to participate in the study, and 1758 children participated. Eighty-one (5%) children were diagnosed with asthma and 130 (8%) had a possible diagnosis of asthma, which represented the study population. A follow-up interview was completed for 114 children (88%). Sixty-two percent of the children visited a doctor, and 38% of the parents refused to visit the GP. The main reason for parents not visiting a GP was absence or mildness of symptoms. Most of the parents stated that they would visit a GP if symptoms worsened. CONCLUSIONS. Two thirds of the children with undiagnosed asthma visited their GP. Willingness to follow-up the recommendations was greater for children with more severe airway reversibility and if the mother was less well educated. REVIEWER COMMENTS. Asthma screening in children relies on parental recognition of asthma symptoms. The authors pointed out that parents often underrecognize symptoms of asthma in their child. However, when confronted with information of a possible asthma diagnosis, the majority of parents sought advice from their GP. Asthma screening programs can be a useful tool for helping children with undiagnosed asthma to seek professional care.

Lozano PA, Finkelstein JA, Hecht J, et al. Arch Pediatr Adolesc Med. 2003;157:81–88 To describe the use of asthma medications and the disease burden among children with persistent asthma and to estimate asthma control. A total of 638 children (3–15 years of age) with persistent asthma, drawn from private insurance claims and pharmacy databases, who were recruited for the Pediatric Asthma Care Patient Outcomes Research Team II study from 42 primary care practices in 3 urban locales were studied. A single telephone interview with parents of eligible children was used to assess 1) classes …

Objective. Government agencies and national organizations recommend that physicians counsel their child and adolescent patients about preventive health topics. Using data from a national survey, we describe the counseling patterns of pediatricians in regard to 9 recommended preventive health topics.Methodology. Between October 1998 and April 1999, information was collected from 907 of 1760 primary care pediatricians randomly selected from a nationally representative sample. Through either a telephone interview or a mail survey, pediatricians were asked how frequently in the past month they counseled about 9 preventive health topics during the well-care visits or routine check-ups of their patients. Pediatricians answered questions regarding their patients aged 2 to 5, 6 to 12, and 13 to 18 years.Results. Over 80% of the pediatricians counseled about 1 or more recommended preventive health topics during the well-care visits or routine check-ups of their patients. As compared with pediatricians who did not counsel about any topic, pediatricians who counseled were significantly more likely to be female and spend longer amounts of time with their patients during these visits. The frequency with which specific preventive health topics were discussed varied with the topic and the age of the patient.Conclusion. Most pediatricians routinely counsel about some, but not all, recommended preventive health topics. An understanding of why pediatricians selectively counsel about specific topics is needed.

Objectives. To determine whether there was an increased rate of later developmental delay in school-aged children who presented as infants with deformational plagiocephaly without obvious signs of delay at the time of initial evaluation. Methods. A retrospective medical record review of 254 patients evaluated at the Craniofacial Center of the Children's Hospital and Regional Medical Center in Seattle, Washington, from 1980 through 1991 was completed. Consenting patient families were interviewed via telelphone to determine what, if any, special medical or educational problems had occurred for the children who had had plagiocephaly in infancy or their siblings with normal head shapes. Results. A total of 181 families from the medical record review could be notified about the study and 63 families agreed to participate in a telephone interview. The sample of participants for the telephone interview was random to and representative of the group as a whole. The families reported that 25 of the 63 children (39.7%) with persistent deformational plagiocephaly had received special help in primary school including: special education assistance, physical therapy, occupational therapy, speech therapy generally through an Individual Education Plan. Only 7 of 91 siblings (7.7%), serving as controls, required similar services (χ2 = 21.24). Delays could not be specifically anticipated at the time of the diagnosis of deformational plagiocephaly from any simple set of factors including treatment with helmet therapy, although effected males with reported uterine constraint were at the highest risk for subsequent school problems. Conclusions. Infants with deformational plagiocephaly comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. There is a need for additional research on the long-term developmental problems in infants with deformational plagiocephaly. plagiocephaly, facial asymmetry, torticollis, developmental delay.

Objective.To identify and characterize health care system factors that contribute to successful breastfeeding in the early postpartum period.Study Design.A prospective 8-week cohort study of 522 women at five area hospitals who had a vaginal delivery of a healthy, full-term single child and who intended to breastfeed. Mothers and infants had free access to each other for breastfeeding during the hospital stay. Data were obtained through chart review and surveys. In-person postpartum interviews in the hospital and 4- and 8-week telephone interviews were used to determine participants' perceptions of breastfeeding support by hospital personnel, home visit nurses, and family and friends. The hospital in-person interview with each mother was conducted before discharge to confirm maternal interest and intent to breastfeed. Questions were asked regarding breastfeeding information and support provided by medical and nursing personnel. Mothers were asked to rate the quality of information, as well as the degree of support they received for breastfeeding. Mothers also were asked to rate their hospital breastfeeding experience. A second interview was conducted by telephone 4 weeks after birth. The focus of this interview was to ascertain the rating of their breastfeeding experience, the quality of their interactions with health care professionals, and whether supplemental formula was being provided to the infant. If supplemental formula was being provided, the mothers were asked to quantify the volume and frequency of supplementation. A final telephone interview was conducted when the infants were 8 weeks of age. This interview determined the continuance or cessation of breastfeeding and information about formula supplementation, as in the 4-week interview. Mothers were given a journal and asked to note all telephone calls, clinic visits, and home nurse visits that related to breastfeeding issues and concerns. Demographic data examined included maternal age, marital status, highest level of education reached, race, employment, insurance coverage, and length of stay in the hospital. Pregnancy characteristics included prenatal care, parity, and gravity. Infant characteristics included gestational age and birth weight. Other factors examined included maternal rating of the support received from the infant's father for the decision to breastfeed, the time the infant spent in the mother's hospital room, and whether the infant was breastfed in the delivery room.Results.The women were mostly white (90%), educated (82% had some college education), married, older (mean maternal age of 29.3 years), and insured (92% commercial). The primary outcome of interest was success at breastfeeding. Success was determined based on each mother's initial estimate of the planned duration of breastfeeding. Of the participants, 76% breastfed successfully for at least as long as they had initially planned. Seventeen percent of the mothers had stopped breastfeeding at the time of the 4-week interview, and 29% had stopped by the 8-week interview. Of the infants' fathers, 97% were reported by the mothers to be supportive of the decision to breastfeed. Once discharged, 98% of mothers expected to have help with the household chores. Eighty percent rated their hospital breastfeeding experience as good or very good. However, only 56% rated hospital breastfeeding support as good or very good, and only 44% spoke with a lactation consultant while in the hospital. Of those who spoke with the lactation consultant, 85% felt more confident afterward. Hospital nurses talked with 82% of women, and 97% of these found this helpful. Seventy-four percent reported receiving a home nursing visit after discharge, and of these, 82% found it helpful. Successful mothers were significantly more likely to report that the visiting nurse watched them breastfeed and asked how it was going. Mothers were more likely to call or visit family and friends with concerns about breastfeeding than other possible sources of support. Calls to family or friends to discuss breastfeeding problems were made by 181 mothers (34.7%). Other calls were to the lactation consultant (16.5%), pediatrician (8.8%), obstetrician or midwife (8.2%), breastfeeding support group (5.9%), and birth hospital (2.5%). Factors significantly associated with breastfeeding success were maternal graduate education (OR: 3.20), appraisal of the breastfeeding experience while in the hospital (OR: 1.49), and age (OR: 1.06). When only mothers who had a home nurse visit were included in the model, maternal graduate education (OR: 3.66), appraisal of hospital breastfeeding experience (OR: 1.42), and maternal rating of the home nurse visit (OR: 1.71) were significantly associated with successful breastfeeding.Conclusion.Health system support of breastfeeding women during their hospital stay and early postdischarge period is an important factor in their success. Hospitals should monitor closely the actual quality and quantity of care provided by clinical support personnel and measure their impact on the outcomes on an ongoing basis.

We conducted a retrospective study by telephone interview (10 to 22 months later) of 26 families who had experienced a perinatal death. Six of 26 mothers had a prolonged grief reaction (12 to 20 months). Those mothers with a surviving twin or subsequent pregnancy less than five months following the death were at higher risk for a prolonged grieving period than were those without subsequent pregnancy or one more than six months later. Half of the families obtained information about the cause of death and risk of recurrence only during hospitalization; subsequent contact, weeks to months later, provided additional information for the other half. Twenty-two of 26 mothers met predetermined criteria for having an adequate understanding of cause of death and risk of recurrence; four of 26 knew neither. Sixty percent of the mothers who had adequate understanding and who had no prolonged grief response felt totally dissatisfied or only partially satisfied with the information they received and the way they received it. Follow-tip contact by phone or in person increased understanding significantly; mothers who had had in-person follow-up were more likely to be satisfied with the information they received.