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Background Guidelines recommend preventive medications for all children with persistent asthma, yet young urban children often receive inadequate therapy. This may occur in part because primary care providers are unaware of the severity of their patients’ symptoms. Objective To determine whether systematic school-based asthma screening, coupled with primary care provider notification of asthma severity, will prompt providers to take preventive medication action (prescribe a new preventive medication or change a current dose). Design Children aged 3 to 7 years with mild persistent to severe persistent asthma were identified at the start of the 2002-2003 school year in Rochester. Children were assigned randomly to a provider notification group (child’s primary care provider notified of asthma severity) or a control group (provider not notified of severity). Primary care providers of children in the provider notification group were sent a facsimile indicating the child’s symptoms and recommending medication action based on national criteria. Interviewers blinded to the child’s group assignment called parents 3 to 6 months later to determine if preventive actions were taken. Results Of 164 eligible children with mild persistent or more severe asthma, 151 (92.1%) were enrolled. Children in the provider notification group were not more likely to receive a preventive medication action than were children in the control group (21.9% vs 26.0%; P = .57). Additional preventive measures, including encouraging compliance with medications (33.3% vs 31.3%; P = .85), recommending environmental modifications (39.3% vs 42.4%; P = .86), and referrals for specialty care (6.6% vs 6.0%; P > .99), also did not differ between the provider notification and control groups. At the end of the study, 52.4% of children in both groups with no medication changes were still experiencing persistent symptoms. Conclusions School-based asthma screening identified many symptomatic children in need of medication modification. Provider notification, however, did not improve preventive care. Findings suggest that more powerful interventions are needed to make systematic asthma screening effective.

Background Daily maintenance medications are recommended for all children with mild persistent to severe persistent asthma; however, poor adherence to these medications is common. Objective To evaluate the impact of school-based provision of inhaled corticosteroids on asthma severity among urban children with mild persistent to severe persistent asthma. Design Children aged 3 to 7 years with mild persistent to severe persistent asthma were identified at the start of the 2000-2001 and 2001-2002 school years in Rochester. Children were assigned randomly to a school-based care group (daily inhaled corticosteroids provided through the school) or a usual-care group (inhaled corticosteroids not given through school). Main Outcome Measure Improvement in parent-reported symptom-free days. Results Of 242 eligible children, 184 were enrolled from 54 urban schools. Data for 180 children were available. Parents of children in the school-based care group had a greater improvement in quality of life compared with parents of children in the usual-care group (change score, 0.63 vs 0.24;P= .047); also, children in the school-based care group vs the usual-care group missed less school because of asthma (mean total days missed, 6.8 vs 8.8;P= .047) and experienced more symptom-free days during the early winter months (mean days per 2-week period, 9.2 vs 7.3;P= .02). A post hoc analysis revealed that all significant findings were produced by differences among children who were not exposed to secondhand smoke. Furthermore, among children not exposed to smoke, those in the school-based care group vs the usual-care group had more symptom-free days overall (11.5 vs 10.5;P= .046), had fewer days needing rescue medications (1.6 vs 2.3;P= .03), and were less likely to have had 3 or more acute visits for asthma (6 [13%] of 47 children vs 17 [31%] of 54 children;P= .03). Conclusions School-based provision of inhaled corticosteroids significantly improved symptoms, quality of life, and absenteeism among urban children with mild persistent to severe persistent asthma. This effect was seen only among children not exposed to secondhand smoke.

Drs Derauf and Derauf make an important point. The reduction of missed immunization opportunities is a very cost-effective way to deal with low vaccination rates in our cities, and the portable record might overcome one of the major obstacles to using immunization opportunities, namely, lack of immunization status information at the medical encounter. As suggested, the effectiveness of the portable record might be vastly improved by making it more attractive through use of baby pictures. Complimentary ideas include the use of reminder stickers on these cards for the next appointment and expanding the cards into "baby passports" that include developmental data and other screening information.

Asthma Admission Threshold has Risen to Maintain Stable Hospitalization Rates Despite Increasing Severity • 542

Child advocates recognize pediatric hospitalization as an issue of great concern because of the serious morbidity it reflects and the adverse psychosocial effects of inpatient experience on children and families. Accounting for almost 50% of child health care costs, estimated at $49.8 billion in the United States in 1987, pediatric hospitalization also represents a substantial financial burden. Studies of the variation in childhood hospitalization rates among geographic areas, however, suggest a large portion of these hospitalizations are avoidable. In individual level analysis, admitting pediatricians judged 28% of acute, general pediatric hospitalizations to be potentially avoidable had specified alternative services been available. Furthermore, evidence supports the safety of care in alternative settings for selected acute illness episodes. Hospitals share incentives for reducing inpatient services as they join managed care organizations that capitate hospital costs. At a time when health care cost reduction has become a dominant theme in industry and politics, concern seems warranted that cost considerations might prevail over quality considerations in shaping change. The concern of child advocates is heightened by the fact that costs are measured as dollars while measures of quality remain comparatively vague.

The ability of children with cyanotic breath-holding spells to respond to anger or frustration by voluntary breath-holding for prolonged periods (often to the point of precipitating hypoxic seizure activity) suggested the hypothesis that such children may have a less powerful urge to breathe in the presence of hypoxia and/or hypercapnia than children who do not have breath-holding spells. Because ventilatory chemosensitivity is difficult to measure in infants and young children, this hypothesis was tested indirectly by measuring the ventilatory responses to hyperoxic progressive hypercapnia and to isocapnic progressive hypoxia of seven individuals who had a history of cyanotic breath-holding spells in infancy and 17 control subjects. The mean values for sensitivity to hypoxia and to hypercapnia were not significantly different between the two groups, and the responses of the majority of the subjects with cyanotic breath-holding spells were clearly within the normal range. There were fewer individuals with high-normal ventilatory responses among the subjects with cyanotic breath-holding spells. Although children with cyanotic breath-holding spells may have decreased ventilatory chemosensitivity transiently during infancy or may differ from other children in some other aspect of the control of breathing, the pathogenesis of infantile cyanotic breath-holding spells does not involve a permanently blunted sensitivity to hypercapnia or hypoxia.

A historical cohort study was performed in order to assess the hypothesis that even mild bronchiolitis in infancy is a predictor of wheezing later in childhood. Subjects who had experienced bronchiolitis and a matched control group were compared in terms of reported wheezing 8 years later. A highly significant difference was found between the bronchiolitis group and the control group in terms of current wheezing (P < .0001, relative risk 3.24). This difference was maintained after adjusting for many potentially confounding variables including family history of allergy and other allergic manifestations in the child. Results suggested that 13.6% of a normal practice population in the age range 6 to 9 years currently wheeze, but that 44.1% of children who experienced bronchiolitis currently wheeze. Based on the incidence of bronchiolitis (4.27/100 children in their first 2 years of life) and the relative odds for wheezing derived from a logistic regression model including variables that measured passive smoking, genetic tendency to wheeze, and bronchiolitis, calculations of attributable risk suggested that wheezing in 9.4% of the population of children who currently wheeze was attributable to bronchiolitis.

The impact of a required preceptorship program was measured by comparing the perceptions of senior medical students who would have elected the preceptorship rotation had it not been required (the elective group) and those who participated only to fulfill the requirement (the required group). The main difference between the two groups before the preceptorship was the elective group's career preference for family medicine and the required group's preference for an internal medicine subspecialty. The preceptorship had no impact for either group on inclinations toward other specialties, preferred practice setting, or assessment of practice location determinants. Both groups, however, perceived an increase in knowledge of primary care practice and confidence in relevant clinical skills following the preceptorship. These results are used to support the value of a required preceptorship program.

The possibility that controllable environmental factors such as passive smoking and non-breast feeding contribute substantially to wheezing has implications for prevention. Effects of passive smoking and non-breast feeding on wheezing in children aged 6 to 10 years were explored in a historical cohort study of 223 children. Family history of respiratory allergy or asthma, male sex, maternal smoking, and non-breast feeding were significantly associated (p less than 0.05) with wheezing in bivariate analysis. In multivariate loglinear analyses, predictors of wheezing included non-breast feeding (p = 0.05, odds ration = 2.1), male sex (p less than 0.03, odds ratio = 3.1), and family history of respiratory allergy (p less than 0.03, odds ratio = 2.6). In a second model, predictors included an interaction of maternal smoking and family history (p less than 0.005, odds ratio = 4.6) in addition to male sex and family history of respiratory allergy. In further exploration based on tabular analysis, maternal smoking appeared to increase wheezing among children in whom the family history of respiratory allergy was positive (p less than 0.001). Among children in whom the family history of respiratory allergy was negative, non-breast feeding appeared to increase wheezing (p = 0.01). Promotion of breast feeding and reduction of maternal smoking might reduce childhood wheezing.

Concern about the long-term sequelae of bronchiolitis has been raised through studies of children hospitalized for bronchiolitis, but the long-term sequelae of mild bronchiolitis have not been studied. We assessed the hypothesis that 25 children with mild bronchiolitis (index subjects) were at greater risk for abnormalities of pulmonary function or airway reactivity to cold air between the ages of 8 and 12 years than were randomly selected, matched controls. There were no consistent differences in pulmonary function or airway reactivity between index and control groups. Airway hyperreactivity was found in five control subjects and three index subjects, and all children with symptomatic asthma were identified by cold air challenge. Our data suggest that children with a history of mild bronchiolitis are not at increased risk between ages 8 and 12 years for airway hyperreactivity or for abnormalities in pulmonary function.

A group of 153 children (51 with a history of bronchiolitis and 102 matched controls) were evaluated in a historical cohort study at a mean age of 8 years and again at 13 years to test the primary hypothesis that mild bronchiolitis, far more common than severe (hospitalized) bronchiolitis, predicts wheezing. A secondary hypothesis was that passive smoking also predicts wheezing. Many potentially confounding variables such as family history of asthma were controlled in analyses. Analysis at 13 years produced results that were not anticipated from previous analysis of interviews at age 8. Although mild bronchiolitis was a powerful predictor of wheezing at age 8 years, it was no longer a strong predictor of wheezing at age 13 in either bivariate or multivariate analysis. Although epidemiologic studies, by their nature, cannot prove causality, findings are consistent with the hypothesis that sequelae often follow mild bronchiolitis but diminish during childhood. Maternal smoking was a powerful predictor of wheezing at age 13 in bivariate analysis (Kendall's Tau B = 0.19, P less than 0.01) and in multivariate analysis (odds ratio = 2.67, P less than 0.01). In children at highest risk for wheezing, males with a family history of asthma, multivariate analysis suggested that maternal smoking is associated with an increase in wheezing from 36% to 60%. We conclude that passive smoking, previously identified as a risk factor in this population for both bronchiolitis in infancy and wheezing at age 8, is a risk factor for wheezing-associated morbidity throughout the childhood years.

The epidemiologic patterns and the economic impact of acute lower respiratory tract illness (LRTI) in children under age two were studied using data collected from November 1, 1971-August 30, 1975 in a suburban pediatric practice in Monroe County, New York. LRTI was responsible for 23 illness episodes per 100 child-years among children in their first two years of life. This indicates that a cohort of 100 children might be anticipated to have 46 LRTI episodes from birth until their second birthday. The majority of episodes correlated with the presence of four viruses in the community, most commonly respiratory syncytial virus. The minimal, estimated direct cost of LRTI in the first two years of life based on 1984 cost data was equivalent to $35.14 for every child and was comprised of hospitalization cost ($19.68) and ambulatory care cost ($15.46). Hospitalization costs attributable to LRTI comprised at least 2.5 per cent of all hospitalization costs in this age group. Immunization against the four most common respiratory viruses, at a reasonable cost per child immunized, would appear to be cost beneficial.

Context. —Interest in home-visitation services as a way of improving maternal and child outcomes has grown out of the favorable results of a trial in semirural New York. The findings have not been replicated in other populations. Objective. —To test the effect of prenatal and infancy home visits by nurses on pregnancy-induced hypertension, preterm delivery, and low birth weight; on children's injuries, immunizations, mental development, and behavioral problems; and on maternal life course. Design. —Randomized controlled trial. Setting. —Public system of obstetric care in Memphis, Tenn. Participants. —A total of 1139 primarily African-American women at less than 29 weeks' gestation, with no previous live births, and with at least 2 sociodemographic risk characteristics (unmarried, Intervention. —Nurses made an average of 7 (range, 0-18) home visits during pregnancy and 26 (range, 0-71) visits from birth to the children's second birthdays. Main Outcome Measures. —Pregnancy-induced hypertension, preterm delivery, low birth weight, children's injuries, ingestions, and immunizations abstracted from medical records; mothers' reports of children's behavioral problems; tests of children's mental development; mothers' reports of subsequent pregnancy, educational achievement, and labor-force participation; and use of welfare derived from state records. Main Results. —In contrast to counterparts assigned to the comparison condition, fewer women visited by nurses during pregnancy had pregnancy-induced hypertension (13% vs 20%; P =.009). During the first 2 years after delivery, women visited by nurses during pregnancy and the first 2 years of the child's life had fewer health care encounters for children in which injuries or ingestions were detected (0.43 vs 0.55; P =.05); days that children were hospitalized with injuries or ingestions (0.03 vs 0.16; P P =.006). There were no program effects on preterm delivery or low birth weight; children's immunization rates, mental development, or behavioral problems; or mothers' education and employment. Conclusion. —This program of home visitation by nurses can reduce pregnancyinduced hypertension, childhood injuries, and subsequent pregnancies among low-income women with no previous live births.

Bronchiolitis is a common lower respiratory tract illness in infants and has substantial acute morbidity and sequelae. To identify risk factors for bronchiolitis, a case-control study was conducted in which 53 subjects who had bronchiolitis were matched with two controls who had no bronchiolitis in infancy. In multivariate analysis, direct effects of passive smoking and older siblings achieved statistical significance. Family history of asthma appeared to interact with older siblings. Among subjects without a family history of asthma, statistically significant predictors proved to be older siblings (odds ratio, 2.31) and passive smoking (odds ratio, 3.87). Among subjects with a family history of asthma, older siblings proved to be an even stronger predictor (odds ratio, 46.81), while the odds ratio for passive smoking did not change much (odds ratio, 4.03). The combined presence of older siblings and passive smoking yielded an odds ratio of 8.94 among subjects without a family history of asthma and 181.67 among subjects with a family history of asthma. Analysis provided risk estimates that were particularly high for certain groups. Among infants with a family history of asthma, 49% who have an older sibling may develop bronchiolitis. If they are also exposed to cigarette smoke, almost 80% may develop bronchiolitis. Among infants without a family history of asthma, bronchiolitis may develop in 46% of infants if there is both an older sibling and exposure to smoke. Exposure of infants to cigarette smoke might diminish more rapidly if clinicians and parents were aware of such high risks. Efforts to reduce morbidity from bronchiolitis in infants might best be directed at the reduction of smoking in families with previous children, particularly if there is a family history of asthma, and at methods that protect infants from respiratory virus carried by siblings.

• A historical cohort study was conducted to measure lower respiratory tract illness (LRTI) up to nine years following mild bronchiolitis and to discover attributes that predict an increased risk for LRTI in childhood. The hypothesis assessed was that the occurrence of bronchiolitis predicts LRTI following the second birthday (childhood LRTI) after adjusting for potentially confounding variables such as a family history of respiratory allergy. Fifty-three children (index subjects) who were seen for bronchiolitis at a suburban community pediatric practice were compared on the basis of childhood LRTI with a control group of 159 children. Chart review, when children were a mean of 8 years old, determined the frequency of childhood LRTI. The mean frequency of childhood LRTI was greater in index subjects than in control subjects (1.62 vs 0.98). This difference remained after adjusting for potentially confounding variables. The yearly occurrence of any LRTI was significantly more common in index subjects through the third year of life (38% vs 15%). A tendency for a more common occurrence of any LRTI was noted through the fifth year (25% vs 16%), but not thereafter. Further analysis of index subjects disclosed that only those who experienced a subsequent LRTI before the second birthday were at an increased risk for the development of childhood LRTI. ( AJDC 1985;139:625-631)

The etymology of bronchiolitis suggests specific histologic findings, and formal recognition of this meaning has been given (American College of Chest Physicians—American Thoracic Society Joint Committee, 1975). Yet, in practice, this label is applied on the basis of clinical findings alone, and diagnostic criteria vary widely. Cardinal among these findings is wheezing, which is a clinical sign associated not with unique, but with various histologic changes. Use of one term to describe both a specific histopathologic entity and a loosely defined clinical syndrome invites obfuscation. In the case of bronchiolitis, it may contribute to the controversy that surrounds this syndrome. I attempt to highlight controversies in the use of this term, to identify their origins, and to suggest principles on which they may be resolved. In selected areas, a resolution is suggested. According to one observer (McIntosh 1 ): Clinicians who care for small children all know what [bronchiolitis] means: an

In Reply.— We appreciate the comments of Welliver regarding our recent article. His primary concerns relate to the issue of causality, particularly the methodology of establishing a causal relationship. These concerns are addressed in our article (Pediatrics 1984;74:1-10) as follows: Although a historical cohort study cannot, by its nature, prove causality, this study's findings are consistent with the hypothesis that bronchiolitis is a causal factor in wheezing. One may speculate that there is a latent factor accounting for the observed bronchiolitis-wheezing association (possibly a genetic factor common both to children who develop bronchiolitis and to children who wheeze during middle childhood years) that is measured by none of the methods employed in this study.