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BACKGROUND AND OBJECTIVES In a previous study of 204 transgender and gender diverse youth in our region, 44% reported being made to feel uncomfortable in the emergency department (ED) because of their gender identity. The objective of our study was to conduct a 2 year quality improvement project to increase affirmed name and pronoun documentation in the pediatric ED. METHODS Using process mapping, we identified 5 key drivers and change ideas. The key driver diagram was updated as interventions were implemented over 3 Plan–Do–Study–Act cycles. Our primary outcome, the percentage of ED visits per month with pronouns documented, was plotted on a run chart with the goal of seeing a 50% increase in form completion from a baseline median of ∼14% over the 2 year study period. RESULTS The frequency of pronoun documentation increased from a baseline median of 13.8% to a median of 47.8%. The most significant increase in pronoun documentation occurred in Plan–Do–Study–Act cycle 3, immediately after ED-wide dissemination of a near-miss case and subsequent call for improvement by ED leadership. Roughly 1.7% of all encounters during the study period involved patients whose pronouns were discordant from the sex listed in their electronic health record. CONCLUSIONS This quality-improvement project increased the frequency of pronoun documentation in the ED. This has the potential to improve the quality of care provided to transgender and gender diverse youth in the ED setting and identify patients who may benefit from receiving a referral to a pediatric gender clinic for additional support.

IMPORTANCE: Currently, there is a lack of consensus in the literature on the association between screen time (eg, television, video games) and children’s behavior problems. OBJECTIVE: To assess the association between the duration of screen time and externalizing and internalizing behavior problems among children 12 years or younger. DATA SOURCES: For this systematic review and meta-analysis, MEDLINE, Embase, and PsycINFO databases were searched for articles published from January 1960 to May 2021. Reference lists were manually searched for additional studies. STUDY SELECTION: Included studies measured screen time (ie, duration) and externalizing or internalizing behavior problems in children 12 years or younger, were observational or experimental (with baseline data), were available in English, and had data that could be transformed into an effect size. Studies conducted during the COVID-19 pandemic were excluded. Of 25 196 nonduplicate articles identified and screened for inclusion, 595 met the selection criteria. DATA EXTRACTION AND SYNTHESIS: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Extracted variables were child age, sex, and socioeconomic status; informants and measurement type for screen time and behavior problems; study publication year; and study design and quality. Data were extracted by 2 independent coders and were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES: The primary outcome was the association of screen time duration with externalizing (eg, aggression, attention deficit/hyperactivity disorder symptoms) and internalizing (eg, depression, anxiety) behaviors or diagnoses. RESULTS: Of the 595 full-text articles assessed for eligibility, 87 studies met all inclusion criteria, comprising 98 independent samples and 159 425 participants (mean [SD] age, 6.07 [2.89] years; 83 246 [51.30%] male). Increased duration of screen time had a small but significant correlation with more externalizing problems (90 samples; r, 0.11; 95% CI, 0.10-0.12) and internalizing problems (43 samples; r, 0.07; 95% CI, 0.05-0.08) in children. Several methodological moderators explained between-study heterogeneity. There was evidence of significant between study heterogeneity (I(2) = 87.80). CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis found small but significant correlations between screen time and children’s behavior problems. Methodological differences across studies likely contributed to the mixed findings in the literature.

Objectives It is critical to understand what children, and in which context, are at risk for high levels of screen use. This study examines whether child temperament interacts with cumulative social risk to predict young children’s screen use and if the results are consistent with differential susceptibility or diathesis-stress models. Methods Data from 1,992 families in Calgary, Alberta (81% White; 47% female; 94% >$40,000 income) from the All Our Families cohort were included. Mothers reported on cumulative social risk (e.g., low income and education, maternal depression) at Results Children high in surgency (i.e., high-intensity pleasure, impulsivity) had greater screen use than children low in surgency as social risk exposure increased. In line with differential susceptibility, children high in surgency also had less screen use than children low in surgency in contexts of low social risk. Children with heightened negative affectivity (i.e., frequent expressions of fear/frustration) had greater screen use as social risk increased, supporting a diathesis-stress model. Conclusions Young children predisposed to high-intensity pleasure seeking and negative affectivity in environments characterized as high in social risk may be prone to greater durations of screen use. Findings suggest that an understanding of social risks and individual characteristics of the child should be considered when promoting healthy digital health habits.

Cardiac complications, particularly myocarditis and pericarditis, have been associated with SARS-CoV-2 (the virus that causes COVID-19) infection (1-3) and mRNA COVID-19 vaccination (2-5). Multisystem inflammatory syndrome (MIS) is a rare but serious complication of SARS-CoV-2 infection with frequent cardiac involvement (6). Using electronic health record (EHR) data from 40 U.S. health care systems during January 1, 2021-January 31, 2022, investigators calculated incidences of cardiac outcomes (myocarditis; myocarditis or pericarditis; and myocarditis, pericarditis, or MIS) among persons aged ≥5 years who had SARS-CoV-2 infection, stratified by sex (male or female) and age group (5-11, 12-17, 18-29, and ≥30 years). Incidences of myocarditis and myocarditis or pericarditis were calculated after first, second, unspecified, or any (first, second, or unspecified) dose of mRNA COVID-19 (BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) vaccines, stratified by sex and age group. Risk ratios (RR) were calculated to compare risk for cardiac outcomes after SARS-CoV-2 infection to that after mRNA COVID-19 vaccination. The incidence of cardiac outcomes after mRNA COVID-19 vaccination was highest for males aged 12-17 years after the second vaccine dose; however, within this demographic group, the risk for cardiac outcomes was 1.8-5.6 times as high after SARS-CoV-2 infection than after the second vaccine dose. The risk for cardiac outcomes was likewise significantly higher after SARS-CoV-2 infection than after first, second, or unspecified dose of mRNA COVID-19 vaccination for all other groups by sex and age (RR 2.2-115.2). These findings support continued use of mRNA COVID-19 vaccines among all eligible persons aged ≥5 years.

Weight control programs for children monitor BMI changes using BMI z-scores that adjust BMI for the sex and age of the child. It is, however, uncertain if BMIz is the best metric for assessing BMI change.To identify which of 6 BMI metrics is optimal for assessing change. We considered a metric to be optimal if its short-term variability was consistent across the entire BMI distribution.285 643 2- to 17-year-olds with BMI measured 3 times over a 10- to 14-month period.We summarized each metric's variability using the within-child standard deviation.Most metrics' initial or mean value correlated with short-term variability (|r| ~ 0.3 to 0.5). The metric for which the within-child variability was largely independent (r = 0.13) of the metric's initial or mean value was the percentage of the 50th expressed on a log scale. However, changes in this metric between the first and last visits were highly (r ≥ 0.97) correlated with changes in %95th and %50th.Log %50 was the metric for which the short-term variability was largely independent of a child's BMI. Changes in log %50th, %95th, and %50th are strongly correlated.

Importance: In-person schooling has been disrupted for most school-aged youth during the COVID-19 pandemic, with low-income, Black, and Hispanic populations most likely to receive fully remote instruction. Disruptions to in-person schooling may have negatively and inequitably affected children's mental health. Objective: To estimate the association between school closures and child mental health outcomes and how it varies across sociodemographic factors. Design, Setting, and Participants: This cross-sectional population-based survey study included a nationally representative sample of US adults aged 18 to 64 years with at least 1 child in the household. The survey was administered between December 2 and December 21, 2020, via web and telephone in English and Spanish. Participants were recruited from the NORC AmeriSpeak panel, an address-based panel with known probability sampling and coverage of 97% of US households. Exposures: Schooling modality (in person, fully remote, or hybrid), household income, age. Main Outcomes and Measures: Child mental health difficulties were measured with the parent-report version of the Strengths and Difficulties Questionnaire, with small, medium, and large effect sizes defined as 1.3-, 3.3-, and 5.2-point differences, respectively. Results: A total of 2324 adults completed the survey. Overall, 1671 respondents (71.9%) were women, 244 (10.5%) were Black, 372 (16.0%) were Hispanic, and 421 (18.1%) had a high school education or less. Children attending school in-person had higher household incomes (mean difference, $9719; 95% CI, $4327 to $15 111; P < .001) and were more likely to be White compared with those attending remotely (366 of 556 [65.8%] vs 597 of 1340 [44.5%]; P < .001). Older children in remote schooling had more mental health difficulties than those attending in-person schooling (standardized effect size, 0.23 [95% CI, 0.07 to 0.39] per year older; P = .006), corresponding to small effect sizes in favor of in-person schooling for older children and very small effect sizes favoring remote schooling for younger children. Children from families with higher income benefitted more from attending schools in-person compared with their peers from families with lower income (B = -0.20 [95% CI, -0.10 to -0.30] per $10 000-increase in annual income; P < .001), although this advantage was not apparent for children attending hybrid school (B = -0.05 [95% CI, -0.16 to 0.06] per $10 000-increase in annual income; P = .34), and directionally lower but not significantly different for children attending remote school (B = -0.12 [95% CI, -0.04 to -0.20] per $10 000-increase in annual income; P < .001). Learning pods fully buffered the associations of hybrid schooling (d = -0.25; 95% CI, -0.47 to -0.04) but not remote schooling (d = 0.04; 95% CI, -0.10 to 0.18) with negative mental health outcomes. Conclusions and Relevance: The findings of this study suggest that older and Black and Hispanic children as well as those from families with lower income who attend school remotely may experience greater impairment to mental health than their younger, White, and higher-income counterparts. Ensuring that all students have access to additional educational and mental health resources must be an important public health priority, met with appropriate funding and workforce augmentation, during and beyond the COVID-19 pandemic.

Background: Children with attention deficit hyperactivity disorder (ADHD) are at increased risk for poor health and obesity. The authors describe obesity-related movement behaviors in children with...

This survey study examines cell phone policies at US middle and high schools, practices of students and faculty, and principals’ attitudes about cell phone use during school.

OBJECTIVE: To evaluate the odds of a behavioral health diagnosis among youth with a difference of sex development (DSD) or congenital adrenal hyperplasia (CAH) compared with matched controls in the PEDSnet database. STUDY DESIGN: All youth with a diagnosis of DSD (n=1,216) or CAH (n=1,647) and at least one outpatient encounter were extracted from the PEDSnet database and propensity-score matched on 8 variables (1:4) to controls (n=4,864 and 6,588, respectively) using multivariable logistic regression. The likelihood of having behavioral health diagnoses was examined using generalized estimating equations. RESULTS: Youth with a DSD had higher odds of a behavioral health diagnosis (OR: 1.7 [95% CI: 1.4, 2.1], p

Organophosphate flame retardants (OPFRs), including Tris (1,3-dichloro-isopropyl) phosphate (TDCPP), triphenyl phosphate (TPP), and isopropylated triphenyl phosphate (ITP), are increasingly used in consumer products because of the recent phase out of polybrominated diphenyl ether (PBDE) flame retardants. OPFRs have been widely detected in adults and have been linked to reproductive and endocrine changes in adult males. Carcinogenicity and damage to immunologic, neurologic and developmental systems have been observed in human cell lines. Young children are especially vulnerable to OPFR exposure, but little is known about exposure levels or exposure risk factors in this population. We examined parent-reported demographic and dietary survey data in relation to OPFR urinary metabolite concentrations in 15- to 18-month old toddlers (n = 41). OPFR metabolites were detected in 100% of subjects. The metabolite of TPP, diphenyl phosphate (DPP) was detected most commonly (100%), with TDCPP metabolite, bis(1,3-dichloro-2-propyl) phosphate (BDCPP), detected in 85-95% of samples, and ITP metabolite, monoisopropylphenyl phenyl phosphate (ip-DPP), detected in 81% of samples (n = 21). Toddlers of mothers earning$10,000 annually had geometric mean DPP concentrations 66% higher (p = 0.05) than toddlers of mothers earning$10,000/year (7.8 ng/mL, 95% CI 5.03, 12.11 and 4.69 ng/mL, 95% CI 3.65-6.04, respectively). While no dietary factors were significantly associated with OPFR metabolite concentrations, results suggested meat and fish consumption may be associated with higher DPP and BDCPP levels while increased dairy and fresh food consumption may be associated with lower DPP, BDCPP, and ip-DPP levels. Research with larger sample sizes and more detailed dietary data is required to confirm these preliminary findings.

Objectives Most parents believe childhood obesity is a problem for society, but not for their own children. We sought to understand whether parents’ risk assessment was skewed by optimism, the tendency to overestimate one’s chances of experiencing positive events. Methods We administered a national web-based survey to 502 parents of 5–12 year old children. Parents reported the chances that (a) their child and (b) “a typical child in their community” would be overweight or obese, and develop hypertension, heart disease, type 2 diabetes, and depression in adulthood. Respondents self-reported demographic and health information, and we obtained demographic and health information about the typical child using zip-code level census and lifestyle data. We used regression models with fixed effects to evaluate whether optimism bias was present in parent predictions of children’s future health outcomes. Results Parents had 40 times lower adjusted odds (OR= .025, p < 0.001, 99% CI: 0.006, 0.100) of predicting that their child (versus a typical child) would be overweight or obese in adulthood. Of the 20% of parents who predicted their child would be overweight in adulthood, 93% predicted the typical child would also be overweight in adulthood. Controlling for health and demographic characteristics, parents estimated that their children’s chances of developing obesity-related co-morbidities would be 12–14 percentage points lower those that of a typical child. Conclusions Parent risk assessment is skewed by optimism, among other characteristics. More accurate risk perception could motivate parents to engage in behavior change.

Current trends suggest that adolescents and young adults typically maintain a social media "portfolio" of several sites including Facebook and Twitter, but little is known regarding how an individual chooses to display risk behaviors across these different sites. The purpose of this study was to investigate college students' displayed alcohol references on both Facebook and Twitter.Among a larger sample of college students from two universities, we identified participants who maintained both Facebook and Twitter profiles. Data collection included evaluation of 5 months of participants' Facebook and Twitter posts for alcohol references, number of social connections (i.e., friends or followers), and number of posts. Phone interviews assessed participants' frequency of Facebook and Twitter use and self-reported alcohol use. Analyses included Fisher's exact test, Wilcoxon matched pair sign test, Friedman rank-sum tests, and logistic regression.Of 112 eligible participants, 94 completed the study. Participants were more likely to display alcohol references on Facebook compared with those on Twitter (76% vs. 34%, p = .02). Participants reported more social connections on Facebook versus Twitter (average 801.2 friends vs. 189.4 followers, p.001) and were more likely to report daily use of Facebook versus Twitter (94.6% vs. 50%, p.001). Current alcohol use was predictive of both Facebook and Twitter displayed alcohol references, but mediators differed in each model.College students were more likely to display alcohol references on Facebook compared with those on Twitter. Understanding these patterns and predictors may inform prevention and intervention efforts directed at particular social media sites.

Importance There is limited information on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and infection among pediatric patients across the United States. Objective To describe testing for SARS-CoV-2 and the epidemiology of infected patients. Design, Setting, and Participants A retrospective cohort study was conducted using electronic health record data from 135 794 patients younger than 25 years who were tested for SARS-CoV-2 from January 1 through September 8, 2020. Data were from PEDSnet, a network of 7 US pediatric health systems, comprising 6.5 million patients primarily from 11 states. Data analysis was performed from September 8 to 24, 2020. Exposure Testing for SARS-CoV-2. Main Outcomes and Measures SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) illness. Results A total of 135 794 pediatric patients (53% male; mean [SD] age, 8.8 [6.7] years; 3% Asian patients, 15% Black patients, 11% Hispanic patients, and 59% White patients; 290 per 10 000 population [range, 155-395 per 10 000 population across health systems]) were tested for SARS-CoV-2, and 5374 (4%) were infected with the virus (12 per 10 000 population [range, 7-16 per 10 000 population]). Compared with White patients, those of Black, Hispanic, and Asian race/ethnicity had lower rates of testing (Black: odds ratio [OR], 0.70 [95% CI, 0.68-0.72]; Hispanic: OR, 0.65 [95% CI, 0.63-0.67]; Asian: OR, 0.60 [95% CI, 0.57-0.63]); however, they were significantly more likely to have positive test results (Black: OR, 2.66 [95% CI, 2.43-2.90]; Hispanic: OR, 3.75 [95% CI, 3.39-4.15]; Asian: OR, 2.04 [95% CI, 1.69-2.48]). Older age (5-11 years: OR, 1.25 [95% CI, 1.13-1.38]; 12-17 years: OR, 1.92 [95% CI, 1.73-2.12]; 18-24 years: OR, 3.51 [95% CI, 3.11-3.97]), public payer (OR, 1.43 [95% CI, 1.31-1.57]), outpatient testing (OR, 2.13 [1.86-2.44]), and emergency department testing (OR, 3.16 [95% CI, 2.72-3.67]) were also associated with increased risk of infection. In univariate analyses, nonmalignant chronic disease was associated with lower likelihood of testing, and preexisting respiratory conditions were associated with lower risk of positive test results (standardized ratio [SR], 0.78 [95% CI, 0.73-0.84]). However, several other diagnosis groups were associated with a higher risk of positive test results: malignant disorders (SR, 1.54 [95% CI, 1.19-1.93]), cardiac disorders (SR, 1.18 [95% CI, 1.05-1.32]), endocrinologic disorders (SR, 1.52 [95% CI, 1.31-1.75]), gastrointestinal disorders (SR, 2.00 [95% CI, 1.04-1.38]), genetic disorders (SR, 1.19 [95% CI, 1.00-1.40]), hematologic disorders (SR, 1.26 [95% CI, 1.06-1.47]), musculoskeletal disorders (SR, 1.18 [95% CI, 1.07-1.30]), mental health disorders (SR, 1.20 [95% CI, 1.10-1.30]), and metabolic disorders (SR, 1.42 [95% CI, 1.24-1.61]). Among the 5374 patients with positive test results, 359 (7%) were hospitalized for respiratory, hypotensive, or COVID-19–specific illness. Of these, 99 (28%) required intensive care unit services, and 33 (9%) required mechanical ventilation. The case fatality rate was 0.2% (8 of 5374). The number of patients with a diagnosis of Kawasaki disease in early 2020 was 40% lower (259 vs 433 and 430) than in 2018 or 2019. Conclusions and Relevance In this large cohort study of US pediatric patients, SARS-CoV-2 infection rates were low, and clinical manifestations were typically mild. Black, Hispanic, and Asian race/ethnicity; adolescence and young adulthood; and nonrespiratory chronic medical conditions were associated with identified infection. Kawasaki disease diagnosis is not an effective proxy for multisystem inflammatory syndrome of childhood.

The aims of this study were to quantify and examine differences in preschoolers&rsquo, indoor and outdoor sedentary time and physical activity intensity at child care using GPS devices and accelerometers. We conducted an observational study of 46 children (mean age 4.5 years, 30 boys, 16 girls) from five child care centers who wore accelerometers and GPS devices around their waists for five days during regular child care hours. GPS signal-to-noise ratios were used to determine indoor vs. outdoor location. Accelerometer data were categorized by activity intensity. Children spent, on average, 24% of child care time outdoors (range 12&ndash, 37% by site), averaging 74 min daily outdoors (range 30&ndash, 119 min), with 54% of children spending &ge, 60 min/day outdoors. Mean accelerometer activity counts were more than twice as high outdoors compared to indoors (345 (95) vs. 159 (38), (p &lt, 0.001)), for girls and boys. Children were significantly less sedentary (51% of time vs. 75%) and engaging in more light (18% vs. 13%) and moderate-to-vigorous (MVPA) (31% vs. 12%) activity when outdoors compared to indoors (p &lt, 0.001). To achieve a minute of MVPA, a preschooler needed to spend 9.1 min indoors vs. 3.8 min outdoors. Every additional 10 min outdoors each day was associated with a 2.9 min increase in MVPA (2.7 min for girls, 3.0 min for boys). Preschool-age children are twice as active and less sedentary when outdoors compared to indoors in child care settings. To help preschoolers achieve MVPA recommendations and likely attain other benefits, one strategy is to increase the amount of time they spend outdoors and further study how best to structure it.

Decades of research supports the health benefits of breastfeeding. Prior studies have shown that hospital discharge bags containing free samples of infant formula are associated with decreased breastfeeding exclusivity. This study aims to determine if receiving a free sample of infant formula in the mail has an impact on breastfeeding duration and exclusivity.This was a cohort study analyzing data from the Infant Feeding Practices Study II. The main outcomes of interest were any breastfeeding through 12 months of age and exclusive breastfeeding through 6 months of age. The main predictor of interest was receipt of a free sample of infant formula in the mail around the time of the infant's birth. Logistic regression models were developed to evaluate the association between the outcomes and predictor of interest at each month.This study included 3,031 infants; mothers of 1,741 (57.4%) received a sample of infant formula in the mail. There was no difference in the likelihood of any breastfeeding at each month among those who received formula in the mail compared with those who did not. There was also no difference in exclusive breastfeeding through 5 months; however, by 6 months of age infants whose mothers received formula in the mail were less likely to be exclusively breastfed (odds ratio = 0.57; 95% confidence interval, 0.37, 0.89).Receiving infant formula in the mail decreases the likelihood of exclusive breastfeeding by 6 months of age while having no impact on the duration of any breastfeeding.

OBJECTIVE: Problematic Internet use (PIU) is an emerging health concern that lacks screening measures validated for use with adolescents and young adults. This study aimed to validate the Problematic and Risky Internet Use Screening Scale (PRIUSS) for use with older adolescents and to increase its clinical utility by determining scoring guidelines and assessing the relationship between PIU and other mental health conditions. METHODS: This cross-sectional survey study took place at a large, public Midwestern university among 330 older adolescents aged 18 to 25 years. Confirmatory factor analysis and Spearman's correlations were used to assess the PRIUSS' structural and construct validity, respectively. A risk-based scoring cutoff was estimated using a Bayesian latent class modeling approach to computing a receiver operating characteristic curve. RESULTS: The confirmatory factor analysis indices for the 3-factor model indicated an acceptable fit (goodness-of-fit index 0.89, root mean square error of approximation 0.07). A cutoff of 25 (sensitivity 0.80, 95% confidence interval [CI] 0.47-0.99; specificity 0.79, 95% CI 0.73-0.84) is proposed for identifying those at risk for PIU. Participants at risk for PIU were at significantly greater odds of also reporting symptoms of attention-deficit/hyperactivity disorder (odds ratio [OR] 2.36 95% CI 1.21-4.62, P =.009), depression (OR 3.25, 95% CI 1.65-6.42, P =.008), and social anxiety (OR 3.77, 95% CI 2.06-6.89, P CONCLUSIONS: The PRIUSS demonstrated validity as a PIU screening instrument for adolescents and young adults. Screening for PIU may also help to identify those at high reciprocal risk for other mental health conditions. Language: en

BACKGROUND AND OBJECTIVES: Physical activity (PA) is important for children’s health and development, yet preschoolers are not meeting PA recommendations. The objective of this study was to examine different PA opportunities at child care and how variation in indoor versus outdoor and free versus teacher-led opportunities relate to children’s PA. METHODS: An observational study of 98 children (mean age 4.5 years, 49% girls) from 10 child care centers. Classrooms were observed for at least 4 full days per center (total 50 days) to categorize time into (1) not an active play opportunity (APO); (2) naptime; (3) APO, outdoor free play; (4) APO, outdoor teacher-led; (5) APO, indoor free play; and (6) APO, indoor teacher-led. Children wore accelerometers during observations. Linear regression models examined the influence of APO categories on moderate-vigorous physical activity (MVPA) and sedentary time. RESULTS: Children’s activity was 73% sedentary, 13% light, and 14% MVPA. For 88% of time children did not have APOs, including 26% time as naptime. On average, 48 minutes per day were APOs (41% sedentary, 18% light, and 41% MVPA), 33 minutes per day were outdoors. The most frequent APO was outdoor free play (8% of time); outdoor teacher-led time was CONCLUSIONS: Preschoolers were presented with significantly fewer than recommended opportunities for PA at child care. More APOs are needed for children to meet recommendations, particularly those that encourage more outdoor time, more teacher-led and child-initiated active play, and flexibility in naptime for preschoolers.

Decades of research supports the health benefits of breastfeeding. Prior research has shown that unsupportive work environments are frequently cited as reasons women abandon breastfeeding early. The objective of this study is to determine if mothers' perceptions of workplace lactation support are associated with job satisfaction.Female employees of Seattle Children's Hospital (SCH) and a large corporation were e-mailed a survey to measure perceptions of workplace lactation support. Women were eligible to participate if they had a child born within the last 5 years. Questions were asked about lactation support across five domains; organization, manager, coworker, time, and physical environment. The main outcome was job satisfaction. Linear regression models were run to evaluate the association between workplace support scores and the outcome of interest.The survey was completed by 420 women at SCH and 131 women at the large corporation (response rate, 47%). Ninety-eight percent of study participants initiated breastfeeding, and most sustained breastfeeding for at least 6 months. Increased total workplace support score was associated with increased job satisfaction at both companies (p0.001). Increased support scores within each domain were independently associated with increased job satisfaction (p values0.005). When all domains were considered together, only manager and coworker supports were significant at SCH (p=0.04), and only time support was significant at the large corporation (p=0.01). The workplace support score was not significantly associated with breastfeeding duration at either institution.Improved lactation support in the workplace may improve new mothers' job satisfaction, which could be beneficial to businesses.

Introduction Amazon’s Mechanical Turk (MTurk) is frequently used to administer health-related surveys and experiments at a low cost, but little is known about its representativeness with regards to health status and behaviors. Methods A cross-sectional survey comprised of questions from the nationally-representative 2014 Behavioral Risk Factor Surveillance System (BRFSS) and 2014 National Health and Nutrition Examination Survey (NHANES) was administered to 591 MTurk workers and 393 masters in 2016. Health status (asthma, depression, BMI, and general health), health behaviors (influenza vaccination, health insurance, smoking, and physical activity), and demographic characteristics of the two MTurk populations (workers and masters) were compared to each other and, using Poisson regression, to a nationally-representative BRFSS and NHANES samples. Results Workers and master demographics were similar. MTurk users were more likely to be aged under 50 years compared to the national sample (86% vs. 55%) and more likely to complete a college degree than the national sample (50% vs. 26%). Adjusting for covariates, MTurk users were less likely to be vaccinated for influenza, to smoke, to have asthma, to self-report being in excellent or very good health, to exercise, and have health insurance but over twice as likely to screen positive for depression relative to a national sample. Results were fairly consistent among different age groups. Conclusions MTurk workers are not a generalizable population with regards to health status and behaviors; deviations did not follow a trend. Appropriate health-related uses for MTurk and ways to improve upon the generalizability of MTurk health studies are proposed.

The goal of this study was to assess biomarkers of exposure to glyphosate and assess potential associations with renal function in children. Glyphosate is used ubiquitously in agriculture worldwide. While previous studies have indicated that glyphosate may have nephrotoxic effects, few have examined potential effects on kidney function in children. We leveraged three cohorts across different phases of child development and measured urinary levels of glyphosate. We evaluated associations of glyphosate with three biomarkers of kidney injury: albuminuria (ACR), neutrophil gelatinase-associated lipocalin (NGAL), and kidney injury marker 1 (KIM-1). Multivariable regression analyses examined associations of glyphosate with kidney injury biomarkers controlling for covariates. We identified glyphosate in 11.1% of the total participants. The herbicide was particularly detected more frequently in the neonate population (30%). Multivariable regression models failed to identify significant associations of log-transformed glyphosate with any of the kidney injury biomarkers, controlling for covariates age, sex, and maternal education. While we confirm detectability of glyphosate in children’s urine at various ages and stages of life, there is no evidence in this study for renal injury in children exposed to low levels of glyphosate. Further studies of larger sample size are indicated to better understand putative deleterious effects of the herbicide after different levels of exposure.

Objective We evaluated the effect of Primary Care Positive Parenting Program (Triple P) training on pediatric residents and the families they serve to test 2 hypotheses: first, training would significantly improve resident skill in identifying and addressing discrete parenting and child behavior problems; and second, parents would report an improvement in their sense of self-efficacy, use of positive discipline strategies, and their child's behavior. Methods Study participants included pediatric residents from 3 community clinics of a pediatric residency program, as well as English-speaking parents of children aged 18 months to 12 years without a diagnosed behavior disorder cared for by study residents. Residents were randomized to receive Primary Care Triple P training either at the beginning or end of the study period. The measured resident outcomes were self-assessed confidence and skills in giving parenting advice. The measured family outcomes were parent sense of self-efficacy, child externalizing behavior, and discipline strategies. Results Primary Care Triple P training had a positive, significant, and persistent impact on residents' parenting consultation skills (mean increase on Parent Consultation Skills Checklist 48.11, 95% confidence interval [CI] 40.07, 57.36). Parents visiting intervention-trained residents demonstrated improved disciplinary practices compared to parents visiting control residents (mean change in Child Discipline Survey 0.322, 95% CI 0.02, 0.71), with stronger differential effects for parents with lower baseline skills (mean Child Discipline Survey change 0.822, 95% CI 0.48, 1.83). No differences were found for child behavior or parenting sense of confidence. Conclusions Training residents in Primary Care Triple P can have a positive impact on consultation skills and parent disciplinary practices. This finding adds strength to the call for increased residency training in behavioral pediatrics.

Early childhood education settings are critical for promoting physical activity (PA) but intervention effects are often small. The aim of this study was to develop, test, and compare two approaches to increasing physical activity among preschoolers at child care centers: one focused on a teacher-led PA curriculum (Active Play!) and the other on increasing outdoor child-initiated free play time (Outdoor Play!). We conducted a matched-pair cluster-randomized study in 10 centers in and around Seattle, WA, USA (n = 97 children, mean age 4.6). Pre- and post-intervention data were collected from observations and accelerometers. At pre-intervention, 19% of Active Play! and 25% of Outdoor Play! children achieved &gt, 120 min/day of PA during child care. The total opportunity for PA increased in both interventions (Active Play! = 11 min/day, Outdoor Play! = 14 min/day), with the largest increase in outdoor child-initiated free playtime (Active Play! = 19 min/day, Outdoor Play! = 24 min/day). No changes in sedentary time, light or moderate- to vigorous-intensity PA (MVPA) were observed in either intervention and there was no difference between interventions in the percentage of children attaining more than 120 min/day of PA. A small (&lt, 3 min/day) relative increase in teacher-led outdoor activity was observed in the Active Play! intervention. Both intervention strategies led to an increase in active play opportunities, predominantly outdoors, but neither was able to substantially increase the intensity and/or duration of children&rsquo, s PA. Future studies are needed to better understand and inform sustainable approaches to increase PA in early learning settings.

Objective To test the hypothesis that salivary cortisol levels respond differently when infants play with blocks compared with watching a digital video disk (DVD). Study design We conducted a randomized experiment in which 8- to 14-month-old infants either watched a DVD or played with blocks for 30 minutes. Serial salivary cortisol measurements were obtained and analyzed, and parental and infant responses and activities were recorded. Results were converted to standardized effect sizes (ESs) for clarity of presentation. Results A total of 49 infants (49% female, mean age 10.6 months) participated in the study. In linear regression analyses, there was a trend toward higher cortisol levels in the block group at the 35-minute collection point (ES = 0.47, P = .08) and significantly higher levels at 45 minutes (ES = 0.56, P = .04); these salivary cortisol levels reflect serum levels approximately 10 and 20 minutes into the activity period, respectively. The results were substantially the same in sensitivity analyses excluding the outliers. Conclusion Viewing by infants of a DVD leads to different neuroendocrine responses than block play in a laboratory setting. The implications of these differences are currently unknown, but may suggest different means of cognitive engagement between interactive play and DVD viewing.

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.

BACKGROUND: Although observational studies have consistently reported an association between media use and child sleep problems, it is unclear whether the relationship is causal or if an intervention targeting healthy media use can improve sleep in preschool-aged children. METHODS: We conducted a randomized controlled trial of a healthy media use intervention in families of children aged 3 to 5 years. The intervention encouraged families to replace violent or age-inappropriate media content with quality educational and prosocial content, through an initial home visit and follow-up telephone calls over 6 months. Sleep measures were derived from the Child Sleep Habits Questionnaire and were collected at 6, 12, and 18 months after baseline; repeated-measures regression analyses were used. RESULTS: Among the 565 children analyzed, the most common sleep problem was delayed sleep-onset latency (38%). Children in the intervention group had significantly lower odds of “any sleep problem” at follow-up in the repeated-measures analysis (odds ratio = 0.36; 95% confidence interval: 0.16 to 0.83), with a trend toward a decrease in intervention effect over time (P = .07). Although there was no significant effect modification detected by baseline sleep or behavior problems, gender, or low-income status, there was a trend (P = .096) toward an increased effect among those with high levels of violence exposure at baseline. CONCLUSIONS: The significant effects of a healthy media use intervention on child sleep problems in the context of a randomized controlled trial suggest that the previously reported relationship between media use and child sleep problems is indeed causal in nature.

Many older adolescents display sexual references on their social networking site profiles; this study investigated whether these references were associated with self-reported sexual intention, sexual experience, or risky sexual behavior. Public Facebook profiles of undergraduate freshmen were identified within 1 large U.S. university Facebook network. Profile owners who displayed sexual references (Displayers) and did not display references (Non-Displayers) were invited to complete surveys. Surveys measured sexual intention, using the Postponing Sexual Intercourse (PSI) scale, and sexual experiences. A higher PSI score was inversely related to intention to initiate sexual intercourse. Of the 118 profiles that met inclusion criteria, 85 profile owners completed surveys. Profile owners were mostly female (56.5%) and Caucasian (67.1%). The mean PSI score for Displayers was 6.5 ± 1.6, and the mean PSI score for Non-Displayers was 10.2 ± 0.6 (p = .02). There were no differences between Displayers and Non-Displayers regarding lifetime prevalence of sexual behavior, number of sexual partners, or frequency of condom use. Display of sexual references on college freshmen's Facebook profiles was positively associated with reporting intention to initiate sexual intercourse. Facebook profiles may present an innovative cultural venue to identify adolescents who are considering sexual activity and may benefit from targeted educational messages.

OBJECTIVE: To measure the association between inpatient bronchiolitis prevalence (IBP) and the delivery of unnecessary tests and treatments to patients hospitalized with bronchiolitis. METHODS: A multicenter, retrospective, cohort study was performed using the Pediatric Hospital Information System database. All patients 2 months to 2 years of age hospitalized with bronchiolitis during 2004–2008 at participating pediatric hospitals were included. Main outcome measures were the probability of receiving potentially unnecessary care for bronchiolitis, including steroids, intravenously administered antibiotics, chest or neck radiographs, and any laboratory tests during hospitalization. RESULTS: During winter months, with each 1% absolute increase in IBP, patients were less likely to receive steroids (incidence rate ratio: 0.968 [95% confidence interval: 0.960–0.976]; P < .001), radiographs (incidence rate ratio: 0.988 [95% confidence interval: 0.984–0.992]; P < .001), and laboratory tests (incidence rate ratio: 0.992 [95% confidence interval: 0.988–0.995]; P < .001). During summer months, similar associations were observed for steroids and radiographs. No association between IBP and antibiotic use was observed during either time period. CONCLUSIONS: The frequency with which several types of unnecessary care were delivered to patients with bronchiolitis seemed to decrease with increasing IBP. This finding suggests that an association exists between contextual information and care delivery during the management of acute illness, and it highlights the importance of such information for delivery of high-quality health care.

In 1999, the American Academy of Pediatrics (AAP) issued a policy statement addressing media use in children. The purpose of that statement was to educate parents about the effects that media—both the amount and the content—may have on children. In one part of that statement, the AAP recommended that “pediatricians should urge parents to avoid television viewing for children under the age of two years.” The wording of the policy specifically discouraged media use in this age group, although it is frequently misquoted by media outlets as no media exposure in this age group. The AAP believed that there were significantly more potential negative effects of media than positive ones for this age group and, thus, advised families to thoughtfully consider media use for infants. This policy statement reaffirms the 1999 statement with respect to media use in infants and children younger than 2 years and provides updated research findings to support it. This statement addresses (1) the lack of evidence supporting educational or developmental benefits for media use by children younger than 2 years, (2) the potential adverse health and developmental effects of media use by children younger than 2 years, and (3) adverse effects of parental media use (background media) on children younger than 2 years.

BACKGROUND: Media use has been shown to negatively affect a child's sleep, especially in the context of evening use or with a television in the child's bedroom. However, little is known about how content choices and adult co-use affect this relationship. OBJECTIVE: To describe the impact of media content, timing, and use behaviors on child sleep. METHODS: These data were collected in the baseline survey and media diary of a randomized controlled trial on media use in children aged 3 to 5 years. Sleep measures were derived from the Children's Sleep Habits Questionnaire. Media diaries captured time, content title, and co-use of television, video-game, and computer usage; titles were coded for ratings, violence, scariness, and pacing. Nested linear regression models were built to examine the impact of timing, content, and co-use on the sleep problem score. RESULTS: On average, children consumed 72.9 minutes of media screen time daily, with 14.1 minutes occurring after 7:00 pm. Eighteen percent of parents reported at least 1 sleep problem; children with a bedroom television consumed more media and were more likely to have a sleep problem. In regression models, each additional hour of evening media use was associated with a significant increase in the sleep problem score (0.743 [95% confidence interval: 0.373–1.114]), as was daytime use with violent content (0.398 [95% confidence interval: 0.121–0.676]). There was a trend toward greater impact of daytime violent use in the context of a bedroom television (P = .098) and in low-income children (P = .07). CONCLUSIONS: Violent content and evening media use were associated with increased sleep problems. However, no such effects were observed with nonviolent daytime media use.

Objective To assess preschoolers' cumulative daily screen time, measure the contributions of the home and the child care setting to this total, and characterize children that are most at risk for excessive screen time. Study design We used data from the Early Childhood Longitudinal Study-Birth Cohort, to calculate daily screen time based on reports by preschooler's parents and care providers. Results The sample size of 8950 represented approximately 4 million children. By preschool age, >80% of children were in some child care. On average, children in this study were exposed to 4.1 hours of screen time daily, including 3.6 hours at home and 0.4 hours in child care. Children in centers had the lowest screen time (3.2 hours) compared with children in parental care only (4.4 hours), home-based care (5.5 hours), and Head Start (4.2 hours). Even when adjusted for relevant covariates, these differences remained significant ( P Conclusions Preschoolers' cumulative screen time exceeds recommendations and most previous estimates. Pediatric clinicians are uniquely positioned to encourage families to discuss screen time with their children's caregivers and to advocate for high quality child care. Efforts to decrease screen time in homes and home-based child care settings are needed.

Objective Characterize and compare care in children with hemangiomas, who do or do not undergo airway procedures. Methods National retrospective cohort study of patients aged 0–18 with hemangiomas, from 33 freestanding United States pediatric hospital discharge records, 2001–2005. The main outcome measures were therapy, readmission and mortality. Results Of 2890 patients diagnosed with hemangiomas, 337 (12%) underwent airway procedures. Most airway procedures were for patients between ages 1 and 11 months. Patients with hemangiomas and airway procedures had more steroid use (80%), increased readmission (30%), and increased mortality (2%) compared to hemangioma patients without airway procedures. Procedures (i.e. laser, open surgery, tracheotomy) and age over 4 months in airway procedure patients were associated with decreased readmission. Increased readmissions were associated with systemic steroid administration. Conclusion Hemangioma patients who undergo airway procedures experience increased medical and surgical therapy compared to those who do not. Readmission is increased in patients with hemangiomas and airway procedures, but surgical intervention and age greater than 4 months decreased readmission.

OBJECTIVE: To test the independent association of adult language input, television viewing, and adult-child conversations on language acquisition among infants and toddlers. METHODS: Two hundred seventy-five families of children aged 2 to 48 months who were representative of the US census were enrolled in a cross-sectional study of the home language environment and child language development (phase 1). Of these, a representative sample of 71 families continued for a longitudinal assessment over 18 months (phase 2). In the cross-sectional sample, language development scores were regressed on adult word count, television viewing, and adult-child conversations, controlling for socioeconomic attributes. In the longitudinal sample, phase 2 language development scores were regressed on phase 1 language development, as well as phase 1 adult word count, television viewing, and adult-child conversations, controlling for socioeconomic attributes. RESULTS: In fully adjusted regressions, the effects of adult word count were significant when included alone but were partially mediated by adult-child conversations. Television viewing when included alone was significant and negative but was fully mediated by the inclusion of adult-child conversations. Adult-child conversations were significant when included alone and retained both significance and magnitude when adult word count and television exposure were included. CONCLUSIONS: Television exposure is not independently associated with child language development when adult-child conversations are controlled. Adult-child conversations are robustly associated with healthy language development. Parents should be encouraged not merely to provide language input to their children through reading or storytelling, but also to engage their children in two-sided conversations.

Neonatal seizures are one of the most common neurological disorders in infants. However, the optimal treatment strategy for neonatal seizures remains controversial and there is little data regarding current treatment of neonatal seizures. In this study we describe the current treatment of neonatal seizures and variation in practice among 31 pediatric hospitals in the United States. We retrospectively identified 6099 infants hospitalized in the first month of life in one of 31 pediatric hospitals participating in the Pediatric Health Information System, with a discharge diagnosis of seizure. As expected, most treated infants received phenobarbital. However, there was significant interhospital variability for all treatments studied including any antiepileptic drug treatment, phenytoin treatment, antiepileptic drug treatment through discharge, number of antiepileptic drugs used, and treatment with pyridoxine (P < .001). These findings highlight the need for rigorous controlled outcome studies to determine optimal therapy for neonatal seizures and devise treatment standards.

To test the hypothesis that children enrolled in Medicaid managed care health plans that provide asthma-specific communication to providers would be more likely to have adequate asthma medication filling.We conducted a historical cohort study of 4498 children (2-17 years old) with moderate-severe asthma in Washington State and Tennessee Medicaid managed care programs from 2000 to 2002. Interviews with health plans were conducted to identify communication strategies health plans used to improve asthma care by providers in the plan. The main outcome measure was guideline-recommended filling of asthma preventer medications.Children in plans that provided specific feedback to providers about asthma quality and notified providers when children had an asthma-related event had the highest mean days plus or minus SE of filling in the 365-day follow-up period (164.6 +/- 13 days) compared with children in plans with neither (135.3 +/- 10.8 days; P.05). In children with the greatest asthma severity, enrollment in a plan with both features was associated with 27.1 additional days of filling (95% CI, 0.7-53.4 days) during the follow-up period.Health plan communication to providers was associated with increased preventer filling in children with moderate-severe asthma in 2 state Medicaid programs.

BACKGROUND In the evaluation of infants with bronchiolitis there is little evidence to support the use of diagnostic testing, particularly complete blood counts (CBCs). However, the extent to which CBCs are ordered in the evaluation of infants with bronchiolitis is unknown. OBJECTIVES (1) To determine institutional variability in ordering of initial and repeat CBCs in infants hospitalized with bronchiolitis; (2) to examine the relationship between proportion of admissions with CBCs and mean hospital charges. METHODS We analyzed the Pediatric Health Information System database, which contains demographic and diagnostic data from 30 U.S. children's hospitals. We restricted our analysis to children less than 12 months old with a primary discharge diagnosis of bronchiolitis and an APR-DRG of bronchiolitis/asthma. We performed multivariate ANOVA to examine variability in initial and repeat CBC ordering across hospitals, controlling for potential confounders. We used stratified logistic regression to determine which factors were associated with repeat CBCs. We examined the relationship between proportion of admissions with CBCs and mean hospital charges using t tests. RESULTS 17,397 children were included in the analysis, and 48.2% had at least 1 CBC, whereas 7.8% had more than 1 CBC. The proportion of admissions with initial (23.2%-70.2%) and repeat (0%-18.6%) CBCs varied significantly across hospitals. Compared to those hospitals with the lowest proportion of admissions with CBCs, hospitals with higher proportions of CBCs had significantly higher mean hospital stay charges. CONCLUSIONS Given the potential downstream medical and financial consequences associated with CBC ordering in evaluation of infants with bronchiolitis, explanations for institutional variation warrant exploration. Journal of Hospital Medicine 2007;2:69–73. © 2007 Society of Hospital Medicine.

Objective To assess how parents perceive long-term risks for developing obesity-related chronic health conditions. Methods A Web-based nationally representative survey was administered to 502 US parents with a 5- to 12-year-old child. Parents reported whether their child was most likely to be at a healthy weight or overweight, and the probability that their child would develop hypertension, heart disease, depression, or type 2 diabetes in adulthood. Responses of parents of children with overweight and obesity were compared to those of healthy-weight children using multivariate models. Results The survey had an overall response rate of 39.2%. The mean (SD) unadjusted parent predicted health risks were 15.4% (17.7%), 11.2% (14.7%), 12.5% (16.2%), and 12.1% (16.1%) for hypertension, heart disease, depression, and diabetes, respectively. Despite underperceiving their child's current body mass index class, parents of children with obesity estimate their children to be at greater risk for obesity-related health conditions than parents of healthy-weight children by 5 to 6 percentage points. Having a family history of a chronic disease, higher quality of care, and older parent age were also significant predictors of estimating higher risk probabilities. Conclusions Despite evidence that parents of children who are overweight may not perceive these children as being overweight, parents unexpectedly estimate greater future risk of weight-related health conditions for these children. Focusing communication about weight on screening for and reducing the risk of weight-related diseases may prove useful in engaging parents and children in weight management.

OBJECTIVE. The purpose of this work was to conduct a systematic review of experimental trials for the effects of television viewing by infants and preschoolers. METHODS. Searches were conducted as of January 2005 on several online bibliographic databases for the disciplines of medicine, psychology, education, and communications. Relevant bibliographies were also reviewed. The article contents were critically evaluated to determine whether they met inclusion criteria. Data were extracted from each included article regarding study methods and results. RESULTS. Twelve controlled trials met all of the criteria for inclusion in this review. All of the studies focused on the effect of television content rather than viewing time. The findings suggest that educational television programs are successful in broadening young children's knowledge, affecting their racial attitudes, and increasing their imaginativeness. There is insufficient experimental evidence for effects of viewing these programs on either children's prosocial behavior or their aggressive behavior. Finally, there is some evidence that viewing cartoons has a negative effect on children's attentional abilities. CONCLUSIONS. A number of gaps remain in the literature. Although the amount of time children spend viewing television raises concern, the studies presented here focus only on content. Despite the fact that infants are the fastest growing television market segment, the controlled trials only include children aged ≥3 years. Finally, the clinical utility of the findings are questionable given that most studies included small group sizes, all took place in nonnaturalistic settings, and all but 1 study only evaluated short-term effects of television viewing.

Background: Providers' interest in satisfying parents may provide an impetus for unnecessary antibiotic use in children. Objectives: To determine (1) whether receipt of antibiotics at a visit for cough and cold symptoms was associated with increased satisfaction and (2) whether nonreceipt of antibiotics at an initial visit but subsequent receipt of antibiotics in the course of the same illness episode was associated with decreased satisfaction. Methods: Prospective cohort study of patients 2–10 years of age presenting to a university-affiliated pediatric clinic with cough and cold symptoms. Parents were enrolled at the index visit and then followed up by phone at least 7 days later (mean time to follow-up, 14.9 days). Satisfaction with the index visit on a 10 point scale was the primary outcome. The primary predictors were whether antibiotics were prescribed at the index visit and, if not, whether they were prescribed since that visit. Linear and median regression were used to adjust for income, child age, parental race and individual provider. Results: A total of 539 parents were enrolled in the study, and 378 (70%) completed follow-up interviews. The mean age of participating children was 4.67 years (SD 2.16). Overall 47% of patients received antibiotics at the index visit, and 8% of those that did not reported receiving them between the index visit and the follow-up assessment. In the regression model, receiving antibiotics at the index visit trended toward being associated with higher satisfactions scores (0.28; P = 0.08). Among those who did not receive antibiotics initially, receiving them subsequently was associated with significantly lower median satisfaction score for the index visit (−3.0; P Conclusions: Receiving antibiotics after an initial visit for cough and cold symptoms at which antibiotics were not prescribed is associated with decreased satisfaction. Use of contingency prescriptions may be an important intervention.

To determine pediatricians' routine screening urinalysis practices.This was a survey of a nationally representative sample of pediatricians practicing in the U.S. regarding their screening urinalysis practices in childhood.Of the 1502 pediatricians sampled, 653 eligible subjects participated, for an estimated response rate of 49.5%. The vast majority of participants (78%) routinely screen asymptomatic children with urinalysis in at least 1 age group. Pediatricians' screening urinalysis practice varies based on age group: 9% screen during infancy (1 year), 60% screen during early childhood (1 up to 5 years), 55% screen during late childhood (5 to 12 years), and 58% screen during adolescence (13 to 20 years). The majority of pediatricians (58%) routinely screen more than 1 age group. Some 38% of the pediatricians surveyed believe that the overall health of children is improved by screening all asymptomatic children with urinalysis.Many pediatricians routinely conduct screening urinalysis during childhood, frequently at ages not recommended by the American Academy of Pediatrics.

This study examined the association between early emotional support provided by parents and child internalizing and externalizing problems, using a nationally representative, longitudinal sample of 1361 children. Parental emotional support was assessed using the Home Observation for the Measurement of the Environment, incorporating both parent report and interviewer observation. We found that, controlling for child externalizing problems at age 6 years, parental emotional support at age 6 years was negatively related to child externalizing problems at age 8 years. A developmental model that assessed the timing of the emergence of this relationship was then analyzed by including parental emotional support at ages 2, 4, and 6 years as predictors of child externalizing problems at age 8 years. The developmental model suggested that less parental emotional support as early as age 2 years is associated with later externalizing problems in children. This study discusses the importance of very early parental emotional support in promoting positive child development. J Dev Behav Pediatr 26:267-275, 2005. Index terms: parenting, emotional support, child internalizing, child externalizing.

Objectives. We know little about the variation in diagnosis and management of bronchiolitis. The objectives of this study were (1) to document variations in treatment and diagnostic approaches, lengths of stay (LOSs), and readmission rates and (2) to determine which potentially modifiable process of care measures are associated with longer LOSs and antibiotic usage. Methods. We used the Pediatric Health Information System, which includes demographic, diagnostic, and detailed patient-level data on 30 large children's hospitals. We examined infants who were younger than 1 year and hospitalized for bronchiolitis (October 2001–September 2003). Multivariate analysis of variance was used to determine whether the variance in the outcomes was hospital related after controlling for other covariates. Linear regression was used to model predictors of increased LOS. Logistic regression was used to model antibiotic usage. Analyses were stratified by age group ( Results. A total of 17397 patients were included in the analysis. The mean LOS was 2.97 days; 72% of patients received chest radiographs, 45% received antibiotics, and 25% received systemic steroids. The mean LOS varied considerably across hospitals (range: 2.40–3.90 days), and hospital remained a significant contributor to LOS variation after controlling for our covariates. Variations in the use of diagnostic tests and medications as well as readmission rates also existed and also remained significant after controlling for covariates. The factors associated with the greatest increases in LOS in the regression analyses included higher severity scores and use of antibiotics, bronchodilators, and corticosteroids. The strongest predictors of antibiotic use in the logistic regression analyses were higher severity scores and receipt of a blood or cerebrospinal fluid culture. Receiving a chest radiograph was a significant predictor of antibiotic use in older but not younger infants. Conclusions. Considerable, unexplained variation exists in the inpatient management of bronchiolitis. The development of national guidelines and controlled trials of new therapies and different management approaches are indicated.

To conduct a population-based survey of television and other media usage in young children to determine (1) total media usage; (2) the proportion of children who have televisions in their bedrooms and who eat breakfast or dinner in front of the television; and (3) predictors of parental concern about the amount of television their child watches.Telephone survey administered to 1454 parents of children11 years old derived from a diverse clinic population.The mean age of the index child was 5.05 years. Mean daily reported child media use was as follows: television (1.45 hours; SD, 1.5); videos (1.1 hours; SD, 1.30); and computer games (0.54 hours; SD, 0.96). Thirty percent of parents reported that their child ate breakfast or dinner in front of the television in the past week, and 22% were concerned about the amount of television that their child watched. In multivariate linear regression, eating breakfast or dinner in front of the television in the past week was associated with increased hours of television viewing (0.38 hours [0.21, 0.54]) and video (0.19 hours [0.04, 0.34]). Having a television in a child's bedroom was associated with increased hours of television (0.25 hours [0.07, 0.43]), video viewing (0.31 hours [0.16, 0.47]), and computer games (0.21 hours [0.10, 0.32]). In general, higher parental education was associated with decreased hours of television and video but not computer games. Older children were 2 to 3 times more likely than younger children to have a television in their bedroom and to have eaten a meal in front of it in the past week. More educated parents were less likely to report that their child had a television in their bedroom and more likely to be concerned about the amount of television their child viewed.Combined video and computer game usage exceeded television usage. Both children of low- and high-income parents are at risk for certain behaviors associated with television usage. Parents whose children watched more television were more likely to be concerned about the amount of television their child viewed.

Objective. To test the hypothesis that late adolescent drinking behavior (ages 17–20) is associated with harmful and binge drinking in early adulthood (ages 30–31). Methods. We used the National Longitudinal Survey of Youth (NLSY), a nationally representative longitudinal data set. We used harmful and binge drinking at ages 17 to 20 to predict harmful and binge drinking at ages 30 to 31, stratifying for gender and controlling for confounders. Results. Data were available on harmful drinking at both the adolescent and the early adult age period for 3790 individuals and on binge drinking for 2387 individuals. Harmful drinking during adolescence was significantly associated with harmful drinking at ages 30 to 31 for men only. Among male adolescents, 14% of harmful drinkers continued harmful drinking at ages 30 to 31, compared with 4% of nonharmful drinkers who became harmful drinkers. In Poisson regression models, binge drinking during adolescence was associated with binge drinking at ages 30 to 31 for both men and women, generating relative risks of 2.3 (95% confidence interval: 1.8–3.0) and 3.0 (95% confidence interval: 2.4–4.8), respectively. Half of binge-drinking male adolescents and one third of binge-drinking female adolescents engaged in binge drinking into early adulthood, compared with 19% for non–binge-drinking male adolescents and 8% of non–binge-drinking female adolescents. Conclusions. Problem drinking during adolescence is associated with problem drinking in early adulthood. Efforts to prevent and treat adolescent problem drinking could have an impact on the progression of alcohol-related disease.

Background Tobacco is the leading cause of death in the United States. The majority of people who smoke begin before age 18. Objective Determine the number of smoking-attributable deaths and years of potential life lost (YPLL) in adults that might be saved through interventions to reduce smoking prevalence among children and adolescents. Methods Calculation of the smoking-attributable mortality and years of potential life lost by age 85 among the cohort of people aged 18 in 2000. Results By age 85, there would be 127,670 smoking-attributable deaths among women and 284,502 deaths among men, for a total 412,172 smoking-attributable deaths in the United States among the cohort of 3,964,704 people aged 18 years alive in 2000. Through large-scale multimedia campaigns and a $1 increase in the price per pack of cigarettes, smoking prevalence could be reduced by 26% and would result in an annual savings of 108,466 lives and 1.6 million YPLL. Conclusions Interventions to decrease smoking prevalence among children and adolescents can have large effects on adult mortality.

Background. Personal digital assistants (PDAs) are being increasingly used in medical practice. Although they have been touted as having the ability to improve efficiency and safety, little is known about pediatricians’ use of and attitudes about PDAs. Objective. Our goals were to 1) determine the percentage of pediatricians using PDAs and computers, 2) determine perceived strengths and weaknesses of PDAs, and 3) explore characteristics associated with beliefs and use. Design/Methods. Pediatricians (2130) were selected randomly from the American Medical Association Physician Masterfile of US-licensed physicians. All participants were mailed a survey along with a prepaid return envelope and a $1 incentive. Up to 3 mailings were sent per participant. Results. Of eligible participants, 63.2% returned a survey. There were no significant differences between respondents and nonrespondents with respect to sex, type of practice, and present employment. Thirty-five percent of respondents currently use PDAs at work, and 40% currently use PDAs for personal use. Of those using PDAs, the most commonly used applications were for drug reference (80%), personal scheduling (67%), and medical calculations (61%). Few pediatricians are currently using PDAs for prescription writing (8%) or billing (4%). Users of PDAs were more likely to be male (adjusted odds ratio [AOR]: 2.29; 95% confidence interval [CI]: 1.64–3.19), in an urban community (AOR: 1.81; 95% CI: 1.30–2.55), in training (AOR: 2.64; 95% CI: 1.58–4.42), not in private practice (AOR: 1.47; 95% CI: 1.03–2.11), and a more recent graduate of medical school (AOR: 1.04 per year; 95% CI: 1.02–1.06). When controlling for covariates, those using PDAs were more likely to believe that PDAs can decrease medical errors (AOR: 2.22; 95% CI: 1.46–3.38) and increase efficiency (AOR: 2.40; 95% CI: 1.56–3.71). When compared with nonusers, users were less likely to view the small screen size (AOR: 0.53; 95% CI: 0.37–0.77) or system speed (AOR: 0.47; 95% CI: 0.26–0.84) as a problem but were significantly more likely to view memory as an issue (AOR: 3.48; 95% CI: 2.30–5.25). Conclusions. More than one third of pediatricians are using PDAs in clinical practice. There seems to be a general consensus among users that they have the potential to improve patient safety and streamline care. Future studies should explore means to utilize their potential.

Objective. To compare the continuity of care experienced by children who are in foster care with that of children who are not in foster care and are covered under Medicaid managed care and Medicaid fee-for-service (FFS).Methods. This retrospective cohort study used Medicaid claims/encounter data from Washington state. A total of 903 children who were in foster care and continuously enrolled in Medicaid for 24 months (1998–1999) were matched by age, gender, and rural/urban residence to 903 Medicaid managed care enrollees and 903 FFS beneficiaries who were not in foster care. Indices of the continuity of primary care experienced were calculated for each patient, and differences in continuity among the cohorts were assessed by running 3 multiple linear regression models for all possible pairings of cohorts, controlling for age, gender, rural/urban residence, and total number of primary care visits.Results. Foster care status was associated with decreased continuity of care relative to nonfoster managed care status (β = −0.12; 95% confidence interval [CI]: −0.15 to −0.09). Nonfoster FFS status was associated with lower continuity than managed care (β = −0.09; 95% CI: −0.12 to −0.06) and slightly higher continuity than foster care status (β = 0.03; 95% CI: 0.01–0.06).Conclusion. Although not dramatically different, continuity seems somewhat lacking for children in foster care. It is unclear to what degree the observed difference is confounded by the managed care/FFS distinction. As the enrollment of children in foster care into managed care plans has been controversial, efforts to promote the consistency of contact with providers while maintaining the flexibility afforded by FFS coverage seem warranted.

OBJECTIVES: Examine prospective associations between parent-reported early childhood self-regulation problems and media exposure (television and video viewing) at 2 years. We hypothesized that children with poor self-regulation would consume more media, possibly as a parent coping strategy. METHODS: We used data from 7450 children in the Early Childhood Longitudinal Study–Birth Cohort. When children were 9 months and 2 years old, parents completed the Infant Toddler Symptom Checklist (ITSC), a validated scale of self-regulation. With daily media use at 2 years as our outcome, we conducted weighted multivariable regression analyses, controlling for child, maternal, and household characteristics. RESULTS: Children watched an average of 2.3 hours per day (SD 1.9) of media at age 2 years. Infants with poor self-regulation (9-month ITSC score ≥3) viewed 0.23 hour per day (95% confidence interval [CI] 0.12–0.35) more media at 2 years compared with those with 9-month ITSC score of 0 to 2; this remained significant in adjusted models (0.15 hour per day [95% CI 0.02–0.28]). Children rated as having persistent self-regulation problems (ITSC ≥3 at both 9 months and 2 years) were even more likely to consume media at age 2 (adjusted β 0.21 hour per day [95% CI 0.03–0.39]; adjusted odds ratio for >2 hours per day 1.40 [95% CI 1.14–1.71]). These associations were slightly stronger in low socioeconomic status and English-speaking households. CONCLUSIONS: Early childhood self-regulation problems are associated with mildly increased media exposure, even after controlling for important confounding variables. Understanding this relationship may provide insight into helping parents reduce their children’s screen time.

Context.The benefits of continuity of pediatric care remain controversial.Objective.To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization.Design.Retrospective cohort study.Setting and Population.We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics.Main Exposure Variable.A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider.Main Outcome Measures.ED utilization and hospitalization.Results.Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20–1.36]) and more likely to be hospitalized (HR: 1.22 [1.09–1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49–1.66]) and to be hospitalized (HR: 1.54 [1.33–1.75]). These risks were even greater for children on Medicaid and those with asthma.Conclusions.Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.

We assessed the reading habits of internists with and without epidemiological training because such information may help guide medical journals as they make changes in how articles are edited and formatted. In a 1998 national self-administered mailed survey of 143 internists with fellowship training in epidemiology and study design and a random sample of 121 internists from the American Medical Association physician master file, we asked about the number of hours spent reading medical journals per week and the percentage of articles for which only the abstract is read. Respondents also were asked which of nine medical journals they subscribe to and read regularly. Of the 399 eligible participants, 264 returned surveys (response rate 66%). Respondents reported spending 4.4 hours per week reading medical journal articles and reported reading only the abstract for 63% of the articles; these findings were similar for internists with and without epidemiology training. Respondents admitted to a reliance on journal editors to provide rigorous and useful information, given the limited time available for critical reading. We conclude that internists, regardless of training in epidemiology, rely heavily on abstracts and prescreening of articles by editors.