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1. Michael Weitzman, MD* 1. *Department of Pediatrics and Environmental Medicine, New York University Grossman School of Medicine, and Department of Global Public Health, New York University College of Global Public Health, New York, NY Social issues are among the most common and important influences on children’s physical and mental health, on how they develop and function, with consequences both during childhood and across the entire life span. In a widening spiral, children’s health problems in their turn may themselves result in social consequences that have further health-related effects. Pediatricians, other child health professionals, teachers and psychologists, and especially parents and other family members regularly encounter numerous social forces that affect a child’s health. For any particular child, some are noticed and others go unrecognized; some are acted on, others are not. Many, such as family and poverty, have been known about for some time. Others, such as racism, have only recently been widely recognized or fully acknowledged. Still others, such as relatively new digital technologies (eg, computers, tablets, and smartphones), as well as social media, exert strong influences on child attitudes and behavior; although many of their effects are recognized, others are still poorly understood. Still newer ones, particularly the social isolation, homeschooling, and increased screen time resulting from the coronavirus disease 2019 (COVID-19) pandemic, are only now emerging. The concept of adverse childhood experiences and the development of a scale to measure some such experiences are more than 20 years old. The scale consists of 10 items, most relating to early experiences in the child’s family: physical, sexual, or emotional abuse; neglect; and exposure to mental illness, substance abuse, incarceration, discord, or divorce. Research clearly demonstrates how frequently children encounter such experiences and the wide array of adverse health consequences associated with them, many the result of biologic changes involving inflammatory and neuro-endocrine responses. Sixty percent of all children in the …

1. Nan Jiang, PhD* 2. Lily Lee†,§ 3. Judith T. Zelikoff, PhD‡ 4. Michael Weitzman, MD†,‡,¶,** 1. *Department of Population Health, 2. †Department of Pediatrics, 3. ‡Department of Environmental Medicine, School of Medicine, New York University, New York, NY 4. ¶College of Global Public Health, New York University, New York, NY 5. §Brooklyn College, Brooklyn, NY 6. **NYU Abu Dhabi Public Health Research Center, Abu Dhabi, United Arab Emirates 1. 1. Lauterstein D, 2. Hoshino R, 3. Gordon T, 4. Watkins BX, 5. Weitzman M, 6. Zelikoff J The Changing Face of Tobacco Use Among United States Youth. Lauterstein D, Hoshino R, Gordon T, Watkins BX, Weitzman M, Zelikoff J. Curr Drug Abuse Rev. 2014;7(1):29–43 [OpenUrl][1][CrossRef][2][PubMed][3] 2. 1. Nguyen KH, 2. Tong VT, 3. Marynak KL, 4. King BA US Adults' Perceptions of the Harmful Effects during Pregnancy of Using Electronic Vapor Products Versus Smoking Cigarettes, Styles Survey, 2015. Nguyen KH, Tong VT, Marynak KL, King BA. Prev Chronic Dis. 2016;13:E175 [OpenUrl][4] 3. 1. McGrath-Morrow SA, 2. Hayashi M, 3. Aherrera A, 4. et al. The Effects of Electronic Cigarette Emissions on Systemic Cotinine Levels, Weight and Postnatal Lung Growth in Neonatal Mice. McGrath-Morrow SA, Hayashi M, Aherrera A, et al. PLoS One. 2015;10(2):e0118344 [OpenUrl][5][CrossRef][6][PubMed][7] The emergence of electronic cigarettes (e-cigarettes) as devices touted to be helpful in the cessation or reduction of smoking has prompted many concerns about the prevalence and consequences of their use during pregnancy. Both pregnant women and health-care providers are poorly informed or misinformed about the potential health risks associated with e-cigarettes, which has profound consequences on clinical conversations about the product. Unfortunately, the scientific literature has not yet caught up with the rise in e-cigarette use. The safety of e-cigarettes to the mother and fetus is largely unknown, with a handful of human studies finding minimal health effects. In large part, concerns about e-cigarettes have been the result of the adverse health effects associated with nicotine during pregnancy, which include low birthweight, abnormal corpus callosum, and alterations in appetite, attention, and cognition. Although the health consequences of e-cigarette use during pregnancy remain poorly understood, it is imperative that health-care providers are well equipped to initiate conversations about e-cigarette use with pregnant women and women of childbearing age to discourage use during pregnancy as an aid to quitting smoking. E-cigarettes are the most commonly used, newly developed electronic nicotine delivery systems. They are battery-powered vaporizers that heat a liquid solution (typically containing nicotine, glycerol, propylene glycol, flavorings, and other additives) to deliver an aerosol for user inhalation with the intention of imitating conventional cigarettes. Since their introduction to the US market in 2007, e-cigarette use has increased rapidly among youths and adults. E-cigarettes are widely advertised and often are promoted as less harmful alternatives to cigarettes and also as effective smoking cessation tools, which has considerable … [1]: {openurl}?query=rft.jtitle%253DCurr%2BDrug%2BAbuse%2BRev%26rft.volume%253D7%26rft.spage%253D29%26rft_id%253Dinfo%253Adoi%252F10.2174%252F1874473707666141015220110%26rft_id%253Dinfo%253Apmid%252F25323124%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.2174/1874473707666141015220110&link_type=DOI [3]: /lookup/external-ref?access_num=25323124&link_type=MED&atom=%2Fpedsinreview%2F39%2F3%2F156.atom [4]: {openurl}?query=rft.jtitle%253DPrev%2BChronic%2BDis%26rft.volume%253D13%26rft.spage%253DE175%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [5]: {openurl}?query=rft.jtitle%253DPLoS%2BOne%26rft.volume%253D10%26rft.spage%253De0118344%26rft_id%253Dinfo%253Adoi%252F10.1371%252Fjournal.pone.0118344%26rft_id%253Dinfo%253Apmid%252F25706869%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [6]: /lookup/external-ref?access_num=10.1371/journal.pone.0118344&link_type=DOI [7]: /lookup/external-ref?access_num=25706869&link_type=MED&atom=%2Fpedsinreview%2F39%2F3%2F156.atom

1. Lily Lee*,† 2. Jenni A. Shearston‡,§ 3. Michael Weitzman, MD*,‡ 1. *Department of Pediatrics, New York University School of Medicine, New York, NY. 2. ‡College of Global Public Health, New York University, New York, NY. 3. †Brooklyn College, City University of New York, New York, NY. 4. §Department of Population Health, New York University School of Medicine, New York, NY. 1. 1. Drummond MB, 2. Upson D Electronic Cigarettes: Potential Harms and Benefits. Drummond MB, Upson D. Ann Am Thorac Soc. 2014;11(2):236–242. doi: 10.1513/AnnalsATS.201311-391FR. [OpenUrl][1][CrossRef][2][PubMed][3] 2. 1. Lauterstein D, 2. Hoshino R, 3. Gordon T, 4. Watkins B, 5. Weitzman M, 6. Zelikoff J The Changing Face of Tobacco Use Among United States Youth. Lauterstein D, Hoshino R, Gordon T, Watkins B, Weitzman M, Zelikoff J. Curr Drug Abuse Rev. 2014;7(1): 29–43. [OpenUrl][4][CrossRef][5][PubMed][6] 3. 1. Maziak W, 2. Jawad M, 3. Jawad S, 4. Ward KD, 5. Eissenberg T, 6. Asfar T Interventions for Waterpipe Smoking Cessation. Maziak W, Jawad M, Jawad S, Ward KD, Eissenberg T, Asfar T. Cochrane Database Syst Rev. 2015 Jul 31;7:CD005549. doi: 0.1002/14651858.CD005549.pub3. Almost all cigarette use in the United States begins during adolescence, and about 3 of every 4 adolescent smokers continue to smoke into adulthood. Although overall cigarette consumption in the United States has decreased by 33% in the last decade, overall tobacco use among middle and high school students has demonstrated little to no decline. The United States has witnessed an increase in the use of new, so-called alternative tobacco products (ATPs). The many types of ATPs vary from the more popular smoked products such as electronic cigarettes (e-cigarettes) and hookahs (also known as water-pipes or narghile) to smokeless products such as snus. These ATPs are believed by the public and adolescents to be less harmful, less addictive, and more stylish than cigarettes. They are being promoted as and perceived by adolescents, the general public, and health care clinicians as safer alternatives to traditional cigarettes. Many in the public health community fear that, in the absence of widespread awareness and regulatory policies, ATPs will encourage adolescents to start smoking and, thus, undermine a decades-long campaign to “denormalize” smoking. Rates of past 30-day use of e-cigarettes among middle and high school students tripled from 2013 to 2014, after doubling the year before. From 2010 to 2014, the percentage of high school seniors who used hookahs in the last year increased from 17% to 23%. In 2014, for the first time, e-cigarettes were reported to be the most commonly used tobacco product by high school students (13.4%), ahead of both hookahs … [1]: {openurl}?query=rft.jtitle%253DAnn%2BAm%2BThorac%2BSoc%26rft.volume%253D11%26rft.spage%253D236%26rft_id%253Dinfo%253Adoi%252F10.1513%252FAnnalsATS.201311-391FR%26rft_id%253Dinfo%253Apmid%252F24575993%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1513/AnnalsATS.201311-391FR&link_type=DOI [3]: /lookup/external-ref?access_num=24575993&link_type=MED&atom=%2Fpedsinreview%2F37%2F7%2F310.atom [4]: {openurl}?query=rft.jtitle%253DCurr%2BDrug%2BAbuse%2BRev%26rft.volume%253D7%26rft.spage%253D29%26rft_id%253Dinfo%253Adoi%252F10.2174%252F1874473707666141015220110%26rft_id%253Dinfo%253Apmid%252F25323124%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [5]: /lookup/external-ref?access_num=10.2174/1874473707666141015220110&link_type=DOI [6]: /lookup/external-ref?access_num=25323124&link_type=MED&atom=%2Fpedsinreview%2F37%2F7%2F310.atom

Background Approximately one in 285 children will be diagnosed with cancer before reaching their 20th birthday. While both oncologists and parents report a preference that these children die at home rather than in a hospital, there are limited data exploring this issue in depth. Procedure We performed a retrospective analysis of national-level data from 1999 to 2011 from the National Center for Health Statistics “Underlying Cause of Death” database. Characteristics investigated included sex, race, age, ethnicity, cancer type, geographic location, and population density where the child lived. Results Of the 2,130 children with a death attributable to neoplasm in 2011, 37.6% (95% CI, 35.5–39.6%) died at home compared to 36.9% (95% CI, 35.0–38.8%) in 1999. In 2011, there were statistically significant racial differences between white, black, and Hispanic children across nearly every age group, with white children consistently most likely to die at home. Children of non-Hispanic origin were significantly more likely to die at home than Hispanic children (40.3% vs. 29.3%, P

BACKGROUND: Light smoking, consuming a few cigarettes daily, and intermittent, or nondaily, smoking patterns are increasingly common but carry health risks comparable to heavier smoking patterns. Nearly all smokers begin smoking as adolescents, who are at risk for developing these smoking patterns. Previous research suggests that smokers underestimate the risks associated with smoking. The extent to which adolescents perceive light and intermittent smoking as harmful has not been previously assessed. METHODS: Data from 24 658 US adolescents sampled by the 2012 National Youth Tobacco Survey, a national, school-based, cross-sectional survey, were examined. Cross-tabulations and multivariate ordered probit regression models were constructed to describe correlates of US adolescents’ perception of light and intermittent smoking. RESULTS: Although most adolescents (88.0%; 95% confidence interval [CI], 87.2% to 88.8%) reported beliefs that a heavier smoking pattern is very harmful, only 64.3% (95% CI; 63.2% to 65.3%) and 33.3% (95% CI; 32.0% to 34.6%) reported that light and intermittent smoking, respectively, are very harmful. Conversely, nearly one-quarter of US adolescents believed intermittent smoking causes little or no harm. Males, younger adolescents, Hispanics, and non-Hispanic blacks were more likely than their peers to view light and intermittent smoking patterns as less harmful. Those who were already light or intermittent smokers, those who used other tobacco products, and those who had a family member who used tobacco were also less likely to view their smoking patterns as harmful. CONCLUSIONS: Misconceptions about the safety of light and intermittent smoking are widespread among US adolescents. Significant public health attention is needed to redress these misperceptions.

This article summarizes the presentation of the 2017 Howland Award to Michael Weitzman, MD, at the Annual Pediatric Academic Society Meetings. It summarizes the remarkable advances in understanding the effects and pathways of exposure of the two most common and pernicious of our nation’s child environmental exposures, namely lead and tobacco. It also summarizes the profound effect of the translation of these findings into prudent and effective clinical and public health policies such that exposure to both has dramatically decreased over the past 40 years due to the tenacious activities of pediatricians, other child-related professionals, government agencies at all levels, and the American Academy of Pediatrics. Research and clinical activities, although essential, were not sufficient to produce these successes, but required extensive mentoring to produce a generation of academic pediatricians capable of conducting the requisite research, and extensive advocacy by pediatricians and others to overcome the formidable inertia and outright opposition to efforts to protect our children from these exposures. Moreover, the article highlights that both of these environmental exposures have roots in social and environmental injustice and neither is solved, and that there is no safe level of exposure to either of these toxicants.

The purpose of this review is to examine the rapidly expanding literature regarding the effects of prenatal tobacco and postnatal secondhand smoke (SHS) exposure on child health and development. Mechanisms of SHS exposure are reviewed, including critical periods during which exposure to tobacco products appears to be particularly harmful to the developing fetus and child. The biological, biochemical, and neurologic effects of the small fraction of identified components of SHS are described. Research describing these adverse effects of both in utero and childhood exposure is reviewed, including findings from both animal models and humans. The following adverse physical outcomes are discussed: sudden infant death syndrome, low birth weight, decreased head circumference, respiratory infections, otitis media, asthma, childhood cancer, hearing loss, dental caries, and the metabolic syndrome. In addition, the association between the following adverse cognitive and behavioral outcomes and such exposures is described: conduct disorder, attention-deficit/hyperactivity disorder, poor academic achievement, and cognitive impairment. The evidence supporting the adverse effects of SHS exposure is extensive yet rapidly expanding due to improving technology and increased awareness of this profound public health problem. The growing use of alternative tobacco products, such as hookahs (a.k.a. waterpipes), and the scant literature on possible effects from prenatal and secondhand smoke exposure from these products are also discussed. A review of the current knowledge of this important subject has implications for future research as well as public policy and clinical practice.

Objective Questions persist as to which dimensions of child mental health are most associated with parental mental health status and if these associations differ by parental gender. We assessed associations between parental psychological distress and children's mental health. Methods Pooled data from the 2001, 2002, and 2004 National Health Interview Surveys (NHIS), a nationally representative, cross-sectional survey of US children aged 4 to 17 (n = 21,314), were used. Multivariate logistic regression was performed assessing associations between parental psychological distress, measured by the Kessler 6 scale, and the extended-form Strengths and Difficulties Questionnaire (SDQ) scales. Results Logistic regression demonstrated associations between parental psychological distress and increased likelihood of child mental health problems. Children aged 4 to 11 were more likely to have mental health problems if they had a psychologically distressed father (odds ratio [OR] 7.5, 95% confidence interval [CI] 2.3–24.3) or mother (OR 6.7, 95% CI 2.7–16.7). Children aged 12 to 17 with a psychologically distressed father (OR 4.53, 95% CI 1.18–17.47) or mother (OR 3.90, 95% CI 1.34–11.37) were also more likely than those without to have mental health problems. In parents of both genders, associations existed between parental psychological distress, and abnormal emotional symptoms in younger children, conduct disorder in older children, and hyperactivity in children of all ages. Conclusions Parental psychological distress appears similarly associated with adverse child mental health outcomes, regardless of parental gender. These findings corroborate limited prior research and demonstrate that associations between child mental health and parental mental illness are similar in magnitude for fathers and mothers.

Youth indoor tanning rates remain high despite the potential for increased melanoma risk. No previous study has assessed the prevalence of unhealthy weight control behaviors in both male and female adolescent indoor tanning users using a nationally representative survey.Pooled data on high school students from the 2009 and 2011 Youth Risk Behavior Survey were used (n = 26,951). Multivariate logistic regression was used to assess associations between the recent indoor tanning use and recently doing the following to lose weight: fasting for more than 24 hours; taking a pill, powder, or liquid without a doctor's consent; and vomiting or taking a laxative.Pooled data showed 23.3% of females reported indoor tanning within the past year; 6.5% of males did so as well. Adjusted multivariate results show that females who indoor tan were, on average, more likely to have fasted (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0-1.5), taken a pill, powder, or liquid (OR, 2.4; 95% CI, 1.9-3.0), and vomited or taken a laxative to lose weight (OR, 1.4; 95% CI, 1.1-1.7) within the past 30 days than those who did not. Males who indoor tanned within the past year were, on average, more likely to have fasted (OR, 2.3; 95% CI, 1.7-3.1), taken a pill, powder, or liquid (OR, 4.4; 95% CI, 3.3-6.0), and vomited or taken a laxative to lose weight (OR, 7.1; 95% CI, 4.4-11.4) within the past 30 days.Significant associations between indoor tanning use and unhealthy weight control behaviors exist for both male and female adolescents, with a stronger association observed among males.

BACKGROUND: Electronic cigarettes (e-cigarettes) are now the most commonly used tobacco product among US youth. The extent to which perceptions of e-cigarettes’ harm and addictiveness differ from those of other products remains unknown, as does whether these perceptions have changed over time. METHODS: Data from the 2012 and 2014 National Youth Tobacco Survey, a repeated cross-sectional survey of grade 6 to 12 students, were used. Cross-tabulations and logistic regression models were used to describe correlates of perceptions of harm and addictiveness of e-cigarettes, cigars, and smokeless tobacco compared with cigarettes. Trends in perceptions of e-cigarettes’ harm among different demographic groups were also assessed. RESULTS: In 2014, 73.0% believed that e-cigarettes were less harmful than cigarettes, compared with 20.2% for smokeless tobacco and 25.8% for cigars. By comparison, 47.1% believed that e-cigarettes were less addictive than cigarettes, compared with only 14.0% for smokeless tobacco and 31.5% for cigars. Use of each product was associated with a perception of decreased harm and addictiveness in adjusted analyses, as was being male, being a non-Hispanic white, and residing with a household member who used that product. Between 2012 and 2014, increasing numbers of US youth thought they were able to assess the relative harm of e-cigarettes and increasingly believed that e-cigarettes are less harmful than cigarettes. CONCLUSIONS: Most US youth view e-cigarettes as less harmful and addictive than cigarettes. Far fewer think similarly about cigars and smokeless tobacco. Increases in e-cigarettes’ perceived safety mirrors rapid increases observed in their use. Perceived safety correlates with use of each tobacco product.

Extensive research shows maternal depression to be associated with poorer child outcomes, and characteristics of these mothers have been described. Recent research describes associations of paternal depressive symptoms and child behavioral and emotional outcomes, but characteristics of these fathers have not been investigated. This study describes characteristics of fathers with depressive symptoms in the USA. Utilizing data from 7,247 fathers and mothers living in households with children aged 5-17 years who participated in the Medical Expenditure Panel Survey 2004-2006, the Patient Health Questionnaire-2 was used to assess parental depressive symptoms, the Short Form-12 was used to examine paternal and maternal physical health, the Columbia Impairment Scale was used to measure child behavioral or emotional problems, and the Children with Special Health Care Needs Screener was used to identify children with special health care needs. In multivariate analyses, poverty (AOR 1.52; 95% CI 1.05-2.22), maternal depressive symptoms (AOR 5.77; 95% CI 4.18-7.95), living with a child with special health care needs (AOR 1.42, 95% CI 1.04-1.94), poor paternal physical health (AOR 3.31; 95% CI 2.50-4.38) and paternal unemployment (AOR 6.49; 95% CI 4.12-10.22) were independently associated with increased rates of paternal depressive symptoms. These are the first data that demonstrate that poverty, paternal physical health problems, having a child with special health care needs, maternal depressive symptoms, and paternal unemployment are independently associated with paternal depressive symptoms, with paternal unemployment associated with the highest rates of such problems.

BACKGROUND: The negative effects of maternal mental health problems on child health are well documented. In contrast, there is a profound paucity of information about paternal mental health's association with child health. OBJECTIVE: To investigate the association of paternal mental health problems and depressive symptoms and children's emotional or behavioral problems. METHODS: We analyzed Medical Expenditure Panel Survey data, which included a representative sample of US children (N = 21 993) aged 5 to 17 years and their mothers and fathers. The main outcome measure was child emotional or behavioral problems assessed by using the Columbia Impairment Scale. RESULTS: Paternal depressive symptoms, as assessed using the Patient Health Questionnaire–2, and mental health problems, more generally, assessed by using the Short-Form 12 Scale, were independently associated with increased rates of child emotional or behavioral problems even after controlling for numerous potential confounders including maternal depressive symptoms and other mental health problems. The adjusted odds ratio (aOR) for emotional or behavioral problems among children of fathers with depressive symptoms was 1.72 (95% confidence interval [CI]: 1.33–2.23) and the aOR associated with abnormal paternal scores on the mental component scale of the Short-Form 12 was 1.33 (95% CI: 1.10–1.62) for those within 1 SD below average and 1.48 (95% CI: 1.20–1.84) for those >1 SD below average. CONCLUSIONS: To the best of our knowledge, this is the first study to use a representative US sample to demonstrate that living with fathers with depressive symptoms and other mental health problems is independently associated with increased rates of emotional or behavioral problems of children.

Context: Although maternal smoking has been associated with child emotional and behavioral problems, to our knowledge, no study has evaluated the association between overall household smoking and such problems. Objectives: To investigate whether children who live with smokers are more likely than children who do not live with smokers to have emotional or behavioral problems and to explore this association in households with nonsmoking mothers. Design, Setting, and Participants: Nationally representative data from the 2000 to 2004 medical expenditure panel surveys, involving 30,668 children aged 5 to 17 years, were used. Associations between child emotional or behavioral problems and household smoking, and child, maternal, and family characteristics were examined. SUDAAN software was used to adjust for complex sampling design. Main Outcome Measures: Overall score on the Columbia Impairment Scale, a 13-item parent-report measure of child emotional or behavioral functioning (range, 0-52, ≥16 indicates a child with such problems). Results: Children in smoking versus nonsmoking households were significantly more likely to have behavioral problems (17.39% vs 9.29%, p < .001). After adjusting for all covariates, male sex, older age of child, younger age of mother, unmarried mother, maternal depression, and below average maternal physical and mental health, each were independently associated with increased likelihood of emotional and behavioral problems, as was the presence of one or more adult smokers in the household (adjusted odds ratio 1.42; 95% confidence interval: 1.26-1.60). The odds of Columbia Impairment Scale score ≥16 increased with increasing number of smokers in the household, even among children whose mothers did not smoke. Conclusion: Children living with smokers are at increased risk for emotional or behavioral problems, and rates of such problems increase with increasing numbers of smokers in the household, even in the absence of maternal smoking.

To review the recent scientific literature examining the association of prenatal tobacco and postnatal secondhand smoke exposure and child neurodevelopment.Low birth weight and decreased in-utero brain growth are two of multiple potential etiologic pathways proposed as mediating the effects of prenatal tobacco smoke exposure on child neurodevelopment. These negative effects of prenatal exposure have been consistently demonstrated in animal models, and in humans have been found as early as the newborn period. The literature on both prenatal and postnatal exposure is remarkably consistent in showing associations with increased rates of behavior problems, including irritability, oppositional defiant behavior, conduct disorders and attention deficit hyperactivity disorder. A more rudimentary literature also suggests deficits in intelligence quotient. Recent studies have focused on elucidating the complex interaction among tobacco exposure, genetics and environmental factors. Questions still remain about the relative roles of prenatal vs. postnatal exposure and the potential role of genetic and social confounders, limiting the ability to infer a causal nature to these associations at this time. The consistency of findings across studies is, however, highly suggestive of a causal relationship between environmental tobacco exposure and adverse behavioral and cognitive outcomes in children.Prenatal tobacco and postnatal secondhand smoke exposure is consistently associated with problems in multiple domains of children's neurodevelopment and behavior.

OBJECTIVE. We sought to determine whether there is evidence of a causal link between exposure to tobacco promotion and the initiation of tobacco use by children.METHODS. We conducted a structured search in Medline, PsycINFO, and ABI/INFORM Global to identify relevant empirical research. The literature was examined against the Hill epidemiologic criteria for determining causality.RESULTS. (1) Children are exposed to tobacco promotion before the initiation of tobacco use; (2) exposure increases the risk for initiation; (3) there is a dose-response relationship, with greater exposure resulting in higher risk; (4) the increased risk is robust; it is observed with various study methods, in multiple populations, and with various forms of promotion and persists after controlling for other factors; (5) scientifically plausible mechanisms whereby promotion could influence initiation exist; and (6) no explanation other than causality can account for the evidence.CONCLUSIONS. Promotions foster positive attitudes, beliefs, and expectations regarding tobacco use. This fosters intentions to use and increases the likelihood of initiation. Greater exposure to promotion leads to higher risk. This is seen in diverse cultures and persists when other risk factors, such as socioeconomic status or parental and peer smoking, are controlled. Causality is the only plausible scientific explanation for the observed data. The evidence satisfies the Hill criteria, indicating that exposure to tobacco promotion causes children to initiate tobacco use.

OBJECTIVE. To determine whether the processes through which parenting practices, maternal depression, neighborhood, and chronic poverty affect child behavioral problems are similar or different in minority and nonminority children in the United States.METHODS. Data from 884 white, 538 black, and 404 Latino families with children who were 6 to 9 years of age in the National Longitudinal Survey of Youth were analyzed. The outcome, child behavioral problems, was measured using the Behavior Problems Index externalizing and internalizing subscales. The effects of chronic poverty, neighborhood, maternal depression, and parenting on the outcome were analyzed using multigroup structural equation modeling.RESULTS. Chronic poverty affected child behavioral problems indirectly through the other variables, and parenting practices had direct effects in each racial/ethnic group. The effects of maternal depression were partially mediated through parenting in the white and Latino samples but were direct and unmediated through parenting practices in the black sample. Neighborhood effects were present in the white and black samples but were not significant for the Latino sample.CONCLUSIONS. Chronic poverty, neighborhood, maternal depression, and parenting practices have effects on child behavioral problems in white, black, and Latino children, but the processes and mechanisms through which they exert their effects differ among the groups. The differences may be related to social stratification mechanisms as well as sociocultural differences in family and childrearing practices.

To evaluate factors that independently predict counseling for diet, exercise, sexually transmitted diseases (STDs), pregnancy, smoking, and injuries at adolescent well visits, and compare these rates to the frequency of counseling at adolescent acute visits.The 1997-2000 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys were combined for patients aged 11-21 years. Acute visits were identified by ICD-9 code for: sexual health, obesity, asthma, injury, and well care. Bivariate analyses were used to determine differences in relevant counseling provided at acute visits compared with well visits. Logistic regression was used to assess factors that predict counseling on each of the above topics at well adolescent visits.Of 23,378 adolescent ambulatory visits, 1508 (6.5%) were for well care. Only 0.8% of visits were for obesity, 3.7% for sexual health, 2.6% for asthma, and 13% for injuries. Counseling was more frequent at acute than well visits for diet (72% vs. 28%), exercise (52% vs. 23%), human immunodeficiency virus/sexually transmitted diseases (HIV/STD; 14% vs. 6.2%), and family planning (FP) (24% vs. 10%), (all p values.05). Pediatric clinicians were more likely than other specialists to provide counseling for diet (OR 2.3), HIV/STD (OR 2.7), FP (OR 2.9), tobacco use (OR 2.8), and injury prevention (OR 4.7). Blacks received less exercise counseling than Whites (OR 0.4), and counseling about sensitive issues (STDs, family planning) occurred more often in older adolescents (OR 1.3).Despite recommendations, more counseling occurs at acute rather than well visits, and still does not reach all those adolescents in need. There remains much room for improvement in physicians' adherence to national guidelines for adolescent care.

Objective. To examine clinician-reported diagnosis of obesity and frequency of blood pressure assessment and diet and exercise counseling during ambulatory visits made by children and adolescents.Methods. The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey 1997 to 2000 were combined for visits to clinicians of 2- to 18-year-olds. Well-child visits (WCVs) were examined for frequencies of obesity diagnosis, blood pressure screening, and diet and exercise counseling in relation to patient and clinician characteristics. Multivariate models examined the relationship of patient and visit characteristics with diet and exercise counseling.Results. Of the 32 930 ambulatory visits made by 2- to 18-year-olds in 1997–2000, obesity was diagnosed at 0.78% of all visits and 0.93% of WCVs. Blood pressure assessment was reported in 61.1% of WCVs with obesity diagnosis compared with 43.9% of WCVs without obesity diagnosis. WCVs with obesity diagnosis had higher diet counseling rates (88.4% vs 35.7%) and higher exercise counseling rates (69.2% vs 18.6%). Diet counseling was reported for 88.4% and exercise counseling was reported for 69.2% of visits with an obesity diagnosis compared with 35.7% and 18.6% during WCVs without a diagnosis of obesity. In multivariate analyses, factors associated with diet counseling at WCVs were diagnosis of obesity (odds ratio [OR]: 12.9; 95% confidence interval [CI]: 3.0–55.3), being seen by pediatricians (OR: 2.5; 95% CI: 1.6–3.9), 2- to 5-year-olds compared with 12- to 18-year-olds (OR: 0.7; 95% CI: 0.5–1.0), and self-pay compared with private insurance visits (OR: 0.6; 95% CI: 0.4–0.9). Associations with exercise counseling were similar to those for diet counseling, but exercise counseling occurred less frequently in visits by black youths compared with white youths (OR: 0.5; 95% CI: 0.3–0.8).Conclusions. Clinicians may overlook obesity during WCVs. Programs to increase obesity diagnosis could improve diet and exercise counseling rates, but even with diagnosis of obesity, significant opportunities for screening and intervention are missed.

Background. Smokers who use cessation medications when they attempt to quit double their like- lihood of success. No prior survey has assessed the ac- ceptability to parents of receiving smoking cessation medication prescriptions in the context of their child's primary care visits. Objective. To assess acceptability to parents of receiv- ing smoking cessation medication prescriptions and to compare that with the reported rate of actually receiving smoking cessation medication prescriptions in the con- text of the child's health care visit. Methods. Data were collected through a national ran- dom-digit dial telephone survey of households from July to September 2003. The sample was weighted according to race and gender, on the basis of the 2002 US Census, to be representative of the US population. Results. Of 3990 eligible respondents contacted, 3010 (75%) completed surveys; 1027 (34%) of those were par- ents. Of those parents, 211 (21%) were self-identified smokers. One half would consider using a smoking ces- sation medication and, of those, 85% said that it would be acceptable if the child's doctor prescribed or recom- mended it to them. In contrast, of the 143 smoking par- ents who accompanied their child to the doctor, only 15% had pharmacotherapy recommended and only 8% re- ceived a prescription for a smoking cessation medication. These results did not vary according to parent age, gen- der, race, or child age. Conclusions. Child health care clinicians have low rates of recommending and prescribing cessation thera- pies that have proved effective in other settings. The recommendation or provision of cessation medications would be acceptable to the majority of parents in the context of their child's health care visit. Pediatrics 2005; 115:1013-1017; smoking, tobacco, pediatrics, family prac

Background. The prevalence of obesity has increased at an epidemic rate, and obesity has become one of the most common health concerns in the United States. A few small studies have noted a possible association between iron deficiency and obesity. Objective. To investigate the association between weight status, as measured by body mass index (BMI), and iron deficiency in a nationally representative sample of children and adolescents. Design. National Health and Nutrition Examination Survey III (1988–1994) provides cross-sectional data on children 2 to 16 years of age. Recorded measures of iron status included transferrin saturation, free erythrocyte protoporphyrin levels, and serum ferritin levels. Children were considered iron-deficient if any 2 of these values were abnormal for age and gender. With the use of age- and gender-specific BMI percentiles, at risk for overweight was defined as a BMI of ≥85th percentile and Results. In this sample of 9698 children, 13.7% were at risk for overweight and 10.2% were overweight. Iron deficiency was most prevalent among 12- to 16-year-old subjects (4.7%), followed by 2- to 5-year-old subjects (2.3%) and then 6- to 11-year-old subjects (1.8%). Overweight 2- to 5-year-old subjects (6.2%) and overweight 12- to 16-year-old subjects (9.1%) demonstrated the highest prevalences of iron deficiency. Overall, the prevalence of iron deficiency increased as BMI increased from normal weight to at risk for overweight to overweight (2.1%, 5.3%, and 5.5%, respectively), and iron deficiency was particularly common among adolescents (3.5%, 7.2%, and 9.1%, respectively). In a multivariate regression analysis, children who were at risk for overweight and children who were overweight were approximately twice as likely to be iron-deficient (odds ratio: 2.0; 95% confidence interval: 1.2–3.5; and odds ratio: 2.3; 95% confidence interval: 1.4–3.9; respectively) as were those who were not overweight. Conclusions. In this national sample, overweight children demonstrated an increased prevalence of iron deficiency. Given the increasing numbers of overweight children and the known morbidities of iron deficiency, these findings suggest that guidelines for screening for iron deficiency may need to be modified to include children with elevated BMI.

Children’s exposure to tobacco constituents during fetal development and via environmental tobacco smoke (ETS) exposure is perhaps the most ubiquitous and hazardous of children’s environmental exposures. A large literature links both prenatal maternal smoking and children’s ETS exposure to decreased lung growth and increased rates of respiratory tract infections, otitis media, and childhood asthma, with the severity of these problems increasing with increased exposure. Sudden infant death syndrome, behavioral problems, neurocognitive decrements, and increased rates of adolescent smoking also are associated with such exposures. Studies of each of these problems suggest independent effects of both pre- and postnatal exposure for each, with the respiratory risk associated with parental smoking seeming to be greatest during fetal development and the first several years of life.

In the preface1 to this supplement, we pointed out that pediatricians and other clinicians have made major contributions to the discovery of environmental toxicants. Many acute illnesses that are caused by high exposures to some toxicants are clinically diagnosable or at least are commonly in the differential diagnosis, eg, organophosphate poisoning, infant botulism, acute lead encephalopathy, carbon monoxide poisoning, acrodynia, hypervitaminosis A and some cases of aplastic anemia, convulsions, asthma, respiratory distress, methemoglobinemia, Reyes syndrome, kernicterus, and many of the recognizable syndromes that result from exposures to teratogenic drugs and chemicals. In contrast to the obvious effects of high exposures to environmental toxicants, there is less information and less certainty concerning the magnitude of the contribution of many low exposures of environmental toxicants to morbidity, mortality, and subtle alterations in children as well as adults or how the effects of these exposures vary with age or chronicity of exposure. We also informed the readership that we were going to address the issue of environmental toxicology from both a clinical and a toxicologic viewpoint. Very low exposures to environmental toxicants may lead to diseases that resemble many common illnesses that have other causes, or they may lead to decrements in functioning that are subtle or nonspecific. It is an almost insurmountable task for individual practitioners to conclude a cause-and-effect relationship from low exposures to environmental toxicants among patients in the physician’s patient population. Only well-planned, sophisticated epidemiologic and animal studies can answer the questions that pertain to the toxicity of low-level exposures to environmental toxicants, given that not all individuals will be affected equally, if at all, at any particular level of exposure. Many of the previous multi-authored compendia that have been published by groups of scientists have been unified in their conclusions that environmental toxicants are a very serious … Reprint requests to (R.L.B.) Rm 308, R/A, Alfred I. duPont Hospital for Children, Box 269, Wilmington, DE 19899. E-mail rbrent{at}nemours.org

There is realistic concern about the impact of environmental influences on the health of human populations. First, exposure to environmental agents continues despite successes in reducing exposures to known toxicants such as lead, polychlorinated biphenyls (PCBs) and tobacco smoke. Second, there has been increasing concern about the cause of autism and other neurodevelopmental problems and hypotheses that environmental influences may play a role in the prevalence of these and other such childhood and adult conditions as asthma and obesity. Third, many other conditions are directly or indirectly related to environmental influences and are preventable, such as injuries, untoward consequences of alcohol, suicide, drug addiction, and gun-related deaths. There have been numerous publications since the 1970s of symposia, proceedings, monographs, and articles dealing with the increased susceptibility of the embryo, infant, and child to environmental toxicants,1–17 reflecting a greater level of concern about embryonic and childhood exposures. Indeed, great deal of attention has been paid to the vulnerability of the embryo and the fetus to environmental chemicals, drugs, and physical agents. In fact, the publication edited by Miller1 was primarily devoted to exposures to the embryo and the fetus. Because the embryo and the child are growing and their tissues and organs are differentiating, deleterious effects may occur at lower exposures to some chemicals, drugs, and physical agents and produce more severe effects than those seen in adults. In fact, some effects may not occur in adults. Thus, maximal permissible exposures (MPEs) for some environmental chemicals should be lower for the embryo and the child. It is important to note that children and adolescents have better recuperative capacities than adults for many toxic agents, and, similarly, appropriate drug dosages may be lower or higher on a mg/kg or surface area basis in children than in adults to … Reprint requests to (R.L.B.) Rm 308, R/A, Alfred I. duPont Hospital for Children, Box 269, Wilmington, DE 19899. E-mail: rbrent{at}nemours.org

Pediatricians are fully aware of the major environmental causes of observable childhood morbidity and mortality (Table 1). It is also important for pediatricians to be aware of the variety of parental concerns regarding exposures to environmental chemicals. During their training and practice, one of their tasks is to counsel and educate parents on how to reduce or prevent the more common environmental risks (Table 1), but they have to be knowledgeable about the presence of environmental chemical and physical toxicants and the emerging literature on potential effects of low-level exposures of these agents to answer patients’ questions and provide reassurance or warnings about the valid risks of some of these toxicants. This article focuses on areas of counseling for which the pediatrician can feel assured that we have sufficient information so that attention to these issues and concerns will improve child health. Some of the material in this article can be found in more detail in the excellent Handbook of Pediatric Environmental Health .1 We have also used a format for categorizing children’s environmental risks in various age categories that was used by Napier2 in Chapter 13 of Juberg’s text on environmental chemicals.2 View this table: TABLE 1. Leading Causes of Death for Different Age Groups There has been some very good news concerning population exposures to environmental toxicants published by the Centers for Disease Control and Prevention (CDC) in 2003.3 The report indicated that there has been “encouraging signs that levels of lead, pesticides, and other chemicals in the body generally have declined over the past decade or so.”3 The report included 27 substances that included lead, mercury, cadmium, other metals, metabolites of organophosphorous pesticides, cotinine, phthalates, polycyclic aromatic hydrocarbons, dioxins, furans, coplanar polychlorinated biphenyls, noncoplanar polychlorinated biphenyls, phytoestrogens, selected organophosphate pesticides, carbamate pesticides, herbicides, pest repellants, and disinfectants. … Reprint requests to (R.L.B.) Rm 308, R/A, Alfred I. duPont Hospital for Children, Box 269, Wilmington, DE 19899. E-mail rbrent{at}nemours.org

Objective To evaluate the relationship between elevated blood pressure (BP) and cognitive test performance in a nationally representative sample of children. Study design The National Health and Nutrition Examination Survey III provides cross-sectional data for children 6 to 16 years, including BP and cognitive test scores. Elevated BP was defined as systolic or diastolic BP ≥90th percentile. Cognitive tests were compared for children with elevated and normal BP. Linear regression was used to evaluate the relation between elevated BP and decreased test scores. Results Among the 5077 children, 3.4% had systolic BP ≥90th percentile and 1.6% diastolic BP ≥90th percentile. Children with elevated systolic BP had lower average scores compared with normotensive children for digit span (7.9 vs 8.7, P = .01), block design (8.6 vs 9.5, P = .03), and mathematics (89.6 vs 93.8, P = .01). Elevated diastolic BP was associated with lower average scores on block design (9.5 vs 11, P = .01). Linear regression showed that elevated systolic BP was independently associated with lower digit span scores (P = .032). Conclusion Children with elevation of systolic BP are at risk for central nervous system end-organ damage, as manifested by decreased digit span test scores.

Background. Medical care ecology has previously been investigated for adults, but no similar exploration has been made specifically for children. Objective. To describe proportions of children receiving care in 6 types of health care setting on a monthly basis and to identify characteristics associated with receipt of care in these settings. Methods. Nationally representative data from the 1996 Medical Expenditure Panel Survey were used to estimate the number of children per 1000 per month who received care at least once in each type of setting. Multivariate analyses assessed associations between receiving care in various settings and children’s sociodemographic factors (age, sex, ethnicity, poverty, parent’s education, urban or rural residence, insurance status, and whether or not the child had a usual source of care). Results. Of 1000 children aged 0 to 17 years, on average each month 167 visited a physician’s office, 82 a dentist’s office, 13 an emergency department, and 8 a hospital-based outpatient clinic. Three were hospitalized and 2 received professional health care in their home. Younger age was associated with increased proportions of children receiving care in all health care settings except dentists’ clinics. Poverty, lack of health insurance, black race, and Hispanic ethnicity were associated with decreased receipt of care in physicians’ and dentists’ offices. Only age ( Conclusions. The ecology of children’s medical care is similar to that of adults in the United States in that a substantial proportion of children receive health care each month, mostly in community-based, outpatient settings. In all settings except emergency departments, receipt of care varies significantly by children’s age, race, ethnicity, income, health insurance status, and whether they have a usual source of care.

Pediatricians have an important role to play in the advancement of child health research and should be encouraged and supported to pursue research activities. Education and training in child health research should be part of every level of pediatric training. Continuing education and access to research advisors should be available to practitioners and academic faculty. Recommendations to promote additional research education and support at all levels of pediatric training, from premedical to continuing medical education, as well as suggestions for means to increase support and mentorship for research activities, are outlined in this statement.

Disparities in children's oral health are an important and solvable health problem in the United States today. Many parts of the dental and public health communities are actively engaged in efforts aimed at addressing these disparities. Much progress has been made in explicating the issues, developing the scientific and clinical knowledge base needed for primary prevention and treatment, and beginning the development of new training and community-based approaches. But much more is still needed, and there is a great deal that the pediatric community can do to help.

The intent of this statement is to inform practitioners about the special health care needs and vulnerabilities of immigrant children and their families and to suggest clinical approaches to various aspects of their care. Immigrant children and their families, a large and diverse population group, have numerous risks to physical health and functioning and may be unfamiliar with our health care services. They often face many barriers to care, and their special risks and needs may not be familiar or readily apparent to many health care providers. Recently enacted federal welfare and immigration reform measures may increase the vulnerability of this population by limiting its access to health and social services. For multiple ethical and medical reasons, the American Academy of Pediatrics has historically opposed, and continues to oppose, denying needed services to any child residing within the borders of the United States.

Children are exposed to heavy metals, since they occur naturally in the environment and levels of some are raised by pollution. Both lead and mercury are neurotoxic and there is a risk of developmental problems following exposure. High levels of exposure by either metal can cause mental retardation, and lower levels of exposure may cause cognitive and behavioral changes. The lowest level of lead exposure believed to adversely affect neurodevelopment has steadily decreased, and the current blood lead level considered safe is 10 μg/dl or less. Children are exposed to chronic low levels of inorganic mercury from dental amalgams and of methylmercury when they eat fish or fish products. Both mercury vapor and methylmercury cross the placental and blood–brain barriers and at high exposures cause brain damage. No safe level for mercury vapor or methylmercury exposure has been definitely established, but a peak maternal hair level of ≥10 ppm following methylmercury exposure is presently thought to present about a 5% risk of cognitive impairment. This level can be readily achieved by eating fish regularly. Determining the lowest level of heavy metal exposure associated with any degree of alteration in children's cognition or behavior presents a difficult research challenge. MRDD Research Reviews 1997;3:239–245. © 1997 Wiley-Liss, Inc.

The connection between housing and health is well established. Physical, chemical, and biological aspects of the child's home, such as cleanliness, moisture, pests, noise, accessibility, injury risks, and other forms of housing environmental quality, all have the potential to influence multiple aspects of the health and development of children. Basic sanitation, reduced household crowding, other improvements in housing and expanded, and improved housing regulations have led to advances in children's health. For example, lead poisoning prevention policies have profoundly reduced childhood lead exposure in the United States. This and many other successes highlight the health benefits for families, particularly children, by targeting interventions that reduce or eliminate harmful exposures in the home. Additionally, parental mental health problems, food insecurity, domestic violence, and the presence of guns in children's homes all are largely experienced by children in their homes, which are not as yet considered part of the Healthy Homes agenda. There is a large movement and now a regulatory structure being put in place for healthy housing, which is becoming closely wedded with environmental health, public health, and the practice of pediatrics. The importance of homes in children's lives, history of healthy homes, asthma, and exposures to lead, carbon monoxide, secondhand/thirdhand smoke, radon, allergy triggers is discussed, as well as how changes in ambient temperature, increased humidity, poor ventilation, water quality, infectious diseases, housing structure, guns, electronic media, family structure, and domestic violence all affect children's health.

Objectives. In 1991, the Centers for Disease Control and Prevention (CDC) decreased the blood lead level of concern to 10 µg/dL (0.48 µmol/L) and recommended universal screening. Because these guidelines continue to provoke controversy, we conducted a study to:1) estimate the proportion of pediatricians who are members of the American Academy of Pediatrics (AAP) who report screening for elevated blood lead levels; 2) describe their clinical practices regarding screening for elevated blood lead levels; 3) compare attitudes of universal screeners, selective screeners, and nonscreeners; and 4) identify characteristics of pediatricians who universally screen. Design. Confidential, cross-sectional survey of a nationally representative random sample of 1610 pediatricians conducted through the AAP Periodic Survey. Subjects. The study included 1035 responders (64% response rate). Analysis was limited to the 734 pediatricians who provide well-child care (ie, primary-care pediatricians). Results. Fifty-three percent of pediatricians reported screening all their patients aged 9 to 36 months, 39% reported screening some, and 8% reported screening none. Among those who screen, 96% use a blood lead assay. The primary risk factors for which selective screeners screen are: history of pica (94%); living in an older home with recent renovations (92%); living in an older home with peeling paint (93%); and having a sibling who had an elevated blood lead level (88%). Among primary-care pediatricians, 73% agree that blood lead levels ≥10 µg/dL should be considered elevated, and 16% disagree. However, 89% of primary-care pediatricians believe that epidemiologic studies should be performed to determine which communities have high proportions of children with elevated blood lead levels, and 34% of primary-care pediatricians believe that the costs of screening exceed the benefits. Conclusions. Three years after the Centers for Disease Control and Prevention issued new guidelines for the management of elevated blood lead levels, a slight majority of primary-care pediatricians in the United States who are members of the AAP report that they universally screen their appropriately aged patients, while most of the remaining pediatricians report screening high-risk patients. Many pediatricians may want additional guidance about circumstances under which selective screening should be considered.

Nationally representative historical trends in neonatal infantile hemangioma (IH) diagnosis have not been previously assessed. Using the National Hospital Discharge Survey (NHDS), trends in IH diagnoses were assessed according to race and sex. Findings confirmed prior research that female and white newborns are more likely to be diagnosed with IH, and a statistically significant increase in IH diagnoses was observed in white, but not in nonwhite, infants.

Numerous studies have investigated the deleterious effects of maternal depression on child outcomes. Knowledge of characteristics of these mothers is incomplete, as most studies utilize small samples or limit investigation to the postpartum period. Utilizing data from a nationally representative sample of 7,211 fathers and mothers living in households with children aged 5–17 years who participated in the Medical Expenditure Panel Survey (MEPS) 2004–2006, the Patient Health Questionnaire-2 (PHQ-2) was used to assess parental depressive symptoms, the Short Form-12 (SF-12) was used to examine paternal and maternal physical health, and the Columbia Impairment Scale was used to measure child behavioral or emotional problems. In multivariate analyses, maternal unemployment (AOR 1.76, 95 % CI 1.31–2.35); living with smokers (AOR 1.82, 95 % CI 1.12–2.94); poor maternal physical health (AOR 2.31; 95 % CI 1.81–2.94); living with children with behavioral or emotional problems (AOR 2.95, 95 % CI 2.30–3.96); and paternal depressive symptoms (AOR 5.11, 95 % CI 1.97–13.25) each were independently associated with increased rates of maternal depressive symptoms. This paper is the first we are aware of to use a nationally representative sample to investigate characteristics associated with maternal depressive symptoms and found that maternal unemployment, living with smokers, poor maternal physical health, having children with behavioral or emotional problems, and paternal depressive symptoms are each independently associated with maternal depressive symptoms. In these data, paternal depressive symptoms are associated with the greatest risk of mothers exhibiting depressive symptoms, a finding that we believe has never before been shown.

Objective. Recognizing the concerns about the use of local anesthesia in neonatal circumcision, a painful procedure usually performed without analgesia or anesthesia, we undertook a study of acetaminophen for pain management of this procedure. Design. A prospective, randomized, double-blind, placebo-controlled, clinical trial of acetaminophen analgesia in 44 healthy full-term neonates undergoing circumcision was conducted. Beginning 2 hours before Gomco circumcision, neonates received either acetaminophen (15 mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15 mL/kg per dose) every 6 hours for 24 hours. Neonates were monitored intraoperatively for changes in heart rate, respiratory rate, and crying time. Postoperative pain was assessed at 30, 60, 90, 120, 360 minutes, and 24 hours using a standardized postoperative comfort scoring system. Feeding behavior was also assessed before and after circumcision by nursing observation. Results. Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences observed between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores (P < .05). Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acetaminophen did not seem to influence this deterioration. Conclusions. This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the immediate postoperative period.

Background. Despite increasing concerns regarding school readiness, little is known about child health correlates of early school failure among the general child population. The results of this study, conducted to investigate health and social factors associated with early grade retention in a nationally representative sample of children in the United States, are reported here. Design. Analyses of data derived from interviews with parents of 9996 children ages 7 to 17 years who participated in the Child Health Supplement to the 1988 National Health Interview Survey. Main Outcome Measures. History of repeating kindergarten or first grade. Results. Nationally, 7.6% of children repeated kindergarten or first grade. In a logistic regression model, factors independently associated with increased risk of grade retention were: poverty [Odds Ratio (OR) 1.7, 95% confidence interval (CI) 1.4, 2.1], male gender (OR 1.5, CI 1.3, 1.9), low maternal education (OR 1.4, CI 1.1, 1.8); deafness (OR 1.9, CI 1.4, 2.6), speech defects (OR 1.7, CI 1.1, 2.6), low birth weight (OR 1.6, CI 1.2, 2.2), enuresis (OR 1.6, CI 1.1, 2.2), and exposure to household smoking (OR 1.4, CI 1.1, 1.7). High maternal education (OR 0.6 CI 0.4, 0.9) and residence with both biological parents at age 6 years (OR 0.7, CI 0.6, 0.9) were independently associated with a decreased risk of retention. Recurrent otitis media, black race, and low maternal age, although associated with early grade retention in bivariate analyses, were not independently associated with grade retention in a model that controls for these other factors and for the age cohort of the child. Although omitted from the above predictive model because of uncertainty about its temporal relation to early grade retention in this dataset, behavior problems at the time of interview have a strong independent association (OR 1.9, CI 1.5, 2.5) with prior early retention. Conclusions. This is the first study that uses national data to investigate how health and social factors individually and collectively contribute to early grade retention. It demonstrates that early retention is common, that a number of extremely common child health problems are independently associated with it, and that the magnitude of the heightened risk associated with these problems is similar to that of many of the well-recognized and difficult to change family and social risk factors for early retention. The successful implementations of Pub L 99-457 (The Education for All Handicapped Children Act Amendments of 1986) services in communities nationwide, and the improvement in the educational performance of large numbers of children will be facilitated by pediatricians' advocacy and surveillance for problems that place children at risk for educational failure, and by effective referral to and collaboration with nonpediatric child and family services.

Background. The Centers for Disease Control and Prevention (CDC) has recommended using a five-item questionnaire at every regular office visit for all children 6 to 72 months of age to identify those at risk of high-dose exposure to lead. Objective. To determine how well the questionnaire identifies children with elevated lead levels. Research design. Comparison of results of the questionnaire, which is intended to identify children as being low-risk or high-risk for lead poisoning, with children's blood lead levels. Setting. A pediatric continuity clinic located in a major teaching hospital in Rochester, NY. Patients. A consecutive sample of 476 children aged 6 to 72 months without a prior history of lead poisoning who were seen in the clinic in July and August 1992, and who had not had a lead screen in the previous 6 months (for those aged Measurements and main results. Fingerstick lead samples were obtained from all children, and those ≥15 µg/dL (0.72 µmol/L) were confirmed by subsequent venous lead determinations. Twenty-eight percent had blood lead levels ≥10 µg/dL (0.48 µmol/L), 8% had levels ≥15 µg/dL (0.72 µmol/L), and 5% had lead levels ≥20 µg/dL (0.96 µmol/L). According to responses on the questionnaire, 44% were initially classified as low-risk, and 43% were high-risk. In 13% risk could not be determined because one or more items on the questionnaire had not been answered or were answered equivocally, whereas all other items were answered "No." Children for whom risk could not be determined were presumed to be at high risk and were added to that category, resulting in 56% of the study population so designated. The questionnaire was moderately effective in identifying children with elevated lead levels. Seventy percent of children having lead levels ≥10 µg/dL (0.48 µmol/L) and 82% of children having lead levels ≥15 µg/dL (0.72 ≥mol/L) had been classified as high-risk by the questionnaire. Children classified as low-risk were very unlikely to have elevated lead levels. Eighty-one percent of low-risk children had lead levels Conclusions. In this clinical setting, in which children are largely urban, poor, and have a moderate to high risk of developing elevated lead levels, the CDC risk assessment questionnaire is effective in identifying children with elevated lead burdens. However, an abbreviated version of the questionnaire may be as effective as the complete questionnaire. Additional questions should be added to the questionnaire to improve its overall sensitivity, and the questionnaire should be tested in other settings to see if it is effective with children having different environmental exposures to lead.

The need for a widely applicable definition of chronic conditions for research, policy, and program development has led to an extensive review of the development of such definitions, the considerations involved in their use, and some recommendations for a new approach. This paper examines some of the methodologic and conceptual issues related to defining and classifying chronic conditions and describes some consequences resulting from decisions made about these issues. While most examples are taken from child health applications, the basic concepts apply to all age groups. The dominant method for identifying and classifying children as having a chronic condition has relied on the presence of an individual health condition of lengthy duration. This condition-specific or "categorical" approach has increasingly seemed neither pragmatically nor conceptually sound. Thus, the development of a "generic" approach, which focuses on elements that are shared by many conditions, children, and families, is recommended. Such a definition might reflect the child's functional status or ongoing use of medical services over a specified time period. In addition, it is suggested that conditions be classified based on the experience of individual children, thus emphasizing the tremendous variability in expression of seemingly similar conditions.

Secondhand smoke is one of the most common toxic environmental exposures to children, and maternal health problems also have substantial negative effects on children. We are unaware of any studies examining the association of living with smokers and maternal health. To investigate whether non-smoking mothers who live with smokers have worse physical and mental health than non-smoking mothers who live in homes without smokers. Nationally representative data from the 2000–2004 Medical Expenditure Panel Survey were used. The health of non-smoking mothers with children

OBJECTIVE. Smoking behavior is strongly influenced by the social environment. More information is needed about how the composition of households with children is associated with adult smoking behavior so that more effective interventions to reduce children's secondhand smoke exposure can be devised and implemented.METHODS. Using data from the Medical Expenditure Panel Survey 2000–2004, we conducted cross-sectional analyses to assess how adult smoking behavior is associated with household characteristics, including the number of adults and smokers present, the relationship of the child to the head of household, and relationships between adult members of the household.RESULTS. More than one third (34.4%) of children lived with ≥1 adult smoker. Almost half (49.4%) of poor children lived with a smoker, and they were more likely to live with multiple smokers compared with those who lived at >400% of the federal poverty level (21.2% vs 7.8%). Approximately 5 million children lived in households headed by an adult other than their parent, and they were significantly more likely to live with smokers: 53.4% of children who lived in their grandparents' homes and 46.2% of children in homes of other adults lived with at least 1 adult smoker, compared with 33.3% who lived in their parents' home. A total of 59.4% of all children who lived with a smoker had a smoking mother, and 56.7% of those children lived with ≥2 smokers, whereas only 17.0% of children whose mother did not smoke had smoking adults in the home.CONCLUSIONS. These findings demonstrate the significant influence of household composition on children's likelihood to live in homes with adult smokers.

The solid waste crisis is currently receiving extensive publicity in the lay press and increasing attention from the government (Newsweek. November 27, 1989:76; Council for Solid Waste Solutions, Washington, DC, unpublished data).1-3 The United States has the highest per capita rate of solid waste production among industrialized nations, more than three pounds per person each day, resulting in 160 million tons of solid waste each year (Newsweek. November 27, 1989). Disposable diapers contribute significantly to this problem and have, in fact, become a symbol of the solid waste crisis.4-6 Marketing surveys estimate that 80% of infants in the United States use disposable diapers.7,8

Purpose Some have suggested that the criteria for weight loss surgery in adolescents be stricter than those currently recommended for adults by the National Institutes of Health (NIH). The aim of the current study is to define the characteristics of adolescents who meet NIH consensus criteria for bariatric surgery in adults to determine their level of morbidity. Materials and Methods Using the Medical Expenditure Panel Survey 2000-2004, children designated as meeting NIH criteria were 13 to 17 years of age with (1) a body mass index ≥40 or (2) a body mass index >35, and one or more comorbidity. We contrasted surgery candidates with noncandidates. We examined items that comprise a screener for identifying children with special health care needs. The Columbia Impairment Scale (CIS) was used to assess child functioning. Results There were 134 children identified as candidates for bariatric surgery and 4736 noncandidates in the same age range. Candidates were more likely to have special health care needs (36% vs 23%) and more likely to have a CIS above 16 (34% vs 16%). Candidates for weight loss surgery were 2.36 times as likely to have a CIS score of 16 or higher and 1.87 times as likely to be identified as a child with special health care needs ( P ≤ .001). Conclusions We conclude that adolescents who meet NIH consensus criteria for weight loss surgery in adults require specialized health services and have functional impairment. Thus, we advocate the use of the standard adult criteria defined by the NIH as the initial screening requirements so that enhanced access to weight loss surgery for morbidly obese adolescents may be achieved.

According to a substantial literature, passive smoking by children is associated with an increased incidence of lower respiratory illness and diminished pulmonary function. The relationship between passive smoking and childhood asthma, however, is not clear. Data from the Child Health Supplement to the 1981 National Health Interview Survey were analyzed with information about 4331 children aged 0 to 5 years to study the relationship between maternal smoking and (1) the prevalence of childhood asthma, (1) the likelihood of taking asthma medication, (3) the age of onset of children's asthma, and (4) the number of hospitalizations among children with and without asthma. An odds ratio for asthma of 2.1 was shown by multivariate logistic regressions among children whose mothers smoke 0.5 packs of cigarettes or more per day compared with children of nonsmokers (P = .001). In similar analyses maternal smoking of 0.5 packs per day was identified as an independent risk for children's use of asthma medications (odds ratio 4.6, P = .0006) and for asthma developing in the first year of life (odds ratio 2.6, P = .0006). Maternal smoking is also associated with increased numbers of hospitalizations by its association with an increased risk of asthma as well as by contributing to hospitalizations independently of a child having asthma. Among children with asthma, however, maternal smoking is not associated with increased numbers of hospitalizations. It was concluded that maternal smoking is associated with higher rates of asthma, an increased likelihood of using asthma medications, and an earlier onset of the disease. These findings have implications for renewed efforts to discourage smoking in families, especially during pregnancy and the first 5 years of children's lives.

BACKGROUND. Iron deficiency affects 2.4 million US children, and childhood iron-deficiency anemia is associated with behavioral and cognitive delays. Given the detrimental long-term effects and high prevalence of iron deficiency, its prevention in early childhood is an important public health issue.OBJECTIVES. The study objectives were to (1) identify risk factors for iron deficiency in US children 1 to 3 years old, using data from the most recent waves of the National Health and Nutrition Examination Survey IV (1999–2002) and (2) examine risk factors for iron deficiency among Hispanic toddlers, the largest minority group of US children.PATIENTS AND METHODS. Analyses of the National Health and Nutrition Examination Survey IV were performed for a nationally representative sample of US children 1 to 3 years old. Iron-status measures were transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Bivariate and multivariable analyses were performed to identify factors associated with iron deficiency.RESULTS. Among 1641 toddlers, 42% were Hispanic, 28% were white, and 25% were black. The iron deficiency prevalence was 12% among Hispanics versus 6% in whites and 6% in blacks. Iron deficiency prevalence was 20% among those with overweight, 8% for those at risk for overweight, and 7% for normal-weight toddlers. Fourteen percent of toddlers with parents interviewed in a non–English language had iron deficiency versus 7% of toddlers with parents interviewed in English. Five percent of toddlers in day care and 10% of the toddlers not in day care had iron deficiency. Hispanic toddlers were significantly more likely than white and black toddlers to be overweight (16% vs 5% vs 4%) and not in day care (70% vs 50% vs 43%). In multivariable analyses, overweight toddlers and those not in day care had higher odds of iron deficiency.CONCLUSIONS. Toddlers who are overweight and not in day care are at high risk for iron deficiency. Hispanic toddlers are more likely than white and black toddlers to be overweight and not in day care. The higher prevalence of these risk factors among Hispanic toddlers may account for their increased prevalence of iron deficiency.

Tobacco dependence, responsible for ∼4 million annual deaths worldwide, is considered to be a “pediatric disease.” The smoking epidemic is spreading rapidly in developing countries. Factors contributing to youth smoking in developing countries include cultural traditions, tobacco's easy accessibility and moderate pricing, peer and family influences, and tobacco companies' advertisements and promotional activities. Secondhand tobacco smoke exposure is a substantial problem that causes increased rates of pneumonia, otitis media, asthma, and other short- and long-term pediatric conditions. Parental tobacco use results in children's deprivation of essential needs such as nutrition and education. In this article we review contemporary evidence with respect to the etiology of nicotine dependence among youth, the forms of youth tobacco products worldwide, global youth tobacco-control efforts to date, medical education efforts, and child health care clinicians' special role in youth tobacco-control strategies. In addition, we provide a review of currently available funding opportunities for development and implementation of youth tobacco-control programs.

Both maternal smoking and depression are common and can adversely impact child health and functioning, yet few studies have explored their co-occurrence among mothers.To determine the prevalence and associations of depression and smoking among mothers in the United States.Random-digit-dial national telephone survey of 1530 households conducted in 2002. Respondents were asked about their sociodemographic characteristics, smoking status, and their children's receipt of Medicaid. A validated 3-item depression screen was administered. Bivariate and multiple regression analyses for maternal smoking and a positive depression screen were performed.National sample.Seven hundred two mothers with children aged less than 19 years living in their homes.The response rate was 61%. Among mothers, 24.3% were smokers, 24.4% had a positive depression screen, 8.1% had both, and 40.6% were smokers and/or had a positive depression screen. All rates were greater among mothers whose children receive Medicaid (37.6%, 47.5%, 20.6%, and 64.5%) than those whose children do not receive Medicaid (21.1%, 19.0%, 4.8%, and 35.3%) (P.001) for each. In multivariate analyses, maternal smoking was independently associated with a 70% increased risk of depressive symptoms (odds radio, 1.7; 95% confidence interval, 1.1-2.6).This study highlights both the frequency and the co-occurrence of maternal smoking and maternal depressive symptoms, two negative influences on children's health and development, as well as their increased prevalence among mothers whose children receive Medicaid, thereby highlighting the economic disparities associated with both. These findings have significant implications for our nation's children, health care clinicians, and health care payers.