Showing papers in "JAMA Pediatrics in 2001"

Television watching, energy intake, and obesity in US children: results from the third National Health and Nutrition Examination Survey, 1988-1994.

Abstract: Objectives To examine the relationship between television watching, energy intake, physical activity, and obesity status in US boys and girls, aged 8 to 16 years. Methods We used a nationally representative cross-sectional survey with an in-person interview and a medical examination, which included measurements of height and weight, daily hours of television watching, weekly participation in physical activity, and a dietary interview. Between 1988 and 1994, the Third National Health and Nutrition Examination Survey collected data on 4069 children. Mexican Americans and non-Hispanic blacks were oversampled to produce reliable estimates for these groups. Results The prevalence of obesity is lowest among children watching 1 or fewer hours of television a day, and highest among those watching 4 or more hours of television a day. Girls engaged in less physical activity and consumed fewer joules per day than boys. A higher percentage of non-Hispanic white boys reported participating in physical activity 5 or more times per week than any other race/ethnic and sex group. Television watching was positively associated with obesity among girls, even after controlling for age, race/ethnicity, family income, weekly physical activity, and energy intake. Conclusions As the prevalence of overweight increases, the need to reduce sedentary behaviors and to promote a more active lifestyle becomes essential. Clinicians and public health interventionists should encourage active lifestyles to balance the energy intake of children.

A Physical Activity Screening Measure for Use With Adolescents in Primary Care

Abstract: Objective: To develop a reliable and valid physical activity screening measure for use with adolescents in primary care settings. Study Designs We conducted 2 studies to evaluate the test-retest reliability and concurrent validity of 6 single-item and 3 composite measures of physical activity. Modifications were based on the findings of the 2 studies, and a best measure was evaluated in study 3. Accelerometer data served as the criterion standard for tests of validity. Results: In study 1 (N=250; mean age, 15 years; 56% female; 36% white), reports on the composite measures were most reliable. In study 2 (N = 57; mean age, 14 years; 65% female; 37% white), 6 of the 9 screening measures correlated significantly with accelerometer data. Subjects, however, had great difficulty reporting bouts of activity and distinguishing between intensity levels. Instead, we developed a single measure assessing accumulation of 60 minutes of moderate to vigorous physical activity. Evaluated in study 3 (N=148; mean age, 12 years; 65% female; 27% white), the measure was reliable (intraclass correlation, 0.77) and correlated significantly (r=0.40, P<.001) with accelerometer data. Correct classification (63%), sensitivity (71%), and false-positive rates (40%) were reasonable. Conclusion: The moderate to vigorous physical activity screening measure is recommended for clinical practice with adolescents.

Consensus Statement for the Prevention and Management of Pain in the Newborn

Abstract: Objective To develop evidence-based guidelines for preventing or treating neonatal pain and its adverse consequences. Compared with older children and adults, neonates are more sensitive to pain and vulnerable to its long-term effects. Despite the clinical importance of neonatal pain, current medical practices continue to expose infants to repetitive, acute, or prolonged pain. Design Experts representing several different countries, professional disciplines, and practice settings used systematic reviews, data synthesis, and open discussion to develop a consensus on clinical practices that were supported by published evidence or were commonly used, the latter based on extrapolation of evidence from older age groups. A practical format was used to describe the analgesic management for specific invasive procedures and for ongoing pain in neonates. Results Recognition of the sources of pain and routine assessments of neonatal pain should dictate the avoidance of recurrent painful stimuli and the use of specific environmental, behavioral, and pharmacological interventions. Individualized care plans and analgesic protocols for specific clinical situations, patients, and health care settings can be developed from these guidelines. By clearly outlining areas where evidence is not available, these guidelines may also stimulate further research. To use the recommended therapeutic approaches, clinicians must be familiar with their adverse effects and the potential for drug interactions. Conclusion Management of pain must be considered an important component of the health care provided to all neonates, regardless of their gestational age or severity of illness.

Psychosocial correlates of physical activity in healthy children.

Abstract: Background Understanding the determinants of physical activity in children is critical for the treatment and prevention of childhood obesity. Social-cognitive theory has been used to understand behavioral patterns in children. Objectives To explore the relationship between health beliefs, self-efficacy, social support, and sedentary activities and physical activity levels in children and to examine the relationship between physical activity and children's self-esteem. Methods Ninety-two children aged 10 to 16 years completed the study. Physical activity was monitored for 1 week with a motion detector (Actitrac; IM Systems, Baltimore, Md). Moderate-level activity and high-level activity were defined based on the results of treadmill testing. Health beliefs, self-efficacy, social influences, and time spent in sedentary behaviors were determined through questionnaires. Self-esteem was measured using the Piers-Harris Children's Self-Concept Scale. Chronic anxiety was measured with the Revised Children's Manifest Anxiety Scale. Results There was a significant decline in physical activity levels between ages 10 and 16 years, particularly in girls. Preteen girls spent approximately 35% more time in low- and high-level activity than did teenage girls (P Conclusions Children and adolescents are largely sedentary. Correlates of high- and low-level physical activity are different. Time spent on sedentary activities is inversely correlated with moderate-level activity, while self-efficacy and social influences are positively correlated with more intense physical activity. In addition, increased high-level physical activity is an important component in the development of self-esteem in children.

Adolescent cybersurfing for health information: a new resource that crosses barriers.

Abstract: Objective To examine adolescents' use of and attitudes toward accessing health information through the Internet. Design Cross-sectional, school-based survey. Participants A socioeconomically and ethnically diverse sample of 412 suburban New York 10th graders (mean [SD] age, 15.8 [0.68] years). Main Outcome Measures Accessing the Internet for health information. Results Half (49%) of the sampled adolescents had used the Internet to get health information. Topics most often explored through the Internet included sexually transmitted diseases; diet, fitness, and exercise; and sexual behaviors. Adolescents found Internet information to be of high value (using a composite gauging worth, trustworthiness, use, and relevance), with no significant differences related to sex, ethnicity, or mother's education. When considering 11 separate health topics, girls found it more valuable to have information on birth control, diet and nutrition, exercise, physical abuse, sexual abuse, and dating violence. Only for alternative medicine were there differences by ethnicity, and there were no differences based on mother's education for the value of having specific health information available through the Internet. Conclusion For adolescents, the Internet is an accessed and valued information source on a range of sensitive health issues.

Children in food-insufficient, low-income families: prevalence, health, and nutrition status.

Abstract: Objective To examine characteristics of US children living in food-insufficient households and to compare food and nutrient intakes, physical inactivity, and overweight and underweight status of children in food-insufficient households with those in food-sufficient households. Design Cross-sectional, nationally representative sample of children and households from the Continuing Survey of Food Intakes by Individuals, from 1994 to 1996. Participants A group of 3790 households, including 5669 children (ages 0-17 years). Main Outcome Measure(s) Estimates of food insufficiency for children were based on the reported adequacy of their households, described as "often don't have enough to eat" or "sometimes don't have enough to eat." Nutrient consumption was based on two 24-hour dietary recalls from in-person interviews. Results Three percent of all households with children, and 7.5% of low-income families with children experienced food insufficiency. Several demographic and characteristic differences were observed between the food-sufficient and food-insufficient low-income groups. Children of low-income families, either food-sufficient or food-insufficient, had similar macronutrient and micronutrient intake, reported exercise, television watching, and percentage of overweight and underweight. When compared with the higher-income food-sufficient households, children in the low-income food-insufficient households consumed fewer calories ( P = .05) and total carbohydrates ( P = .004), but had a higher cholesterol intake ( P = .02). The low-income food-insufficient group included more overweight children ( P = .04), consumed less fruits ( P = .04), and spent more time watching television ( P = .02). Conclusions While not different from low-income families who do not report food insufficiency, low-income families with food insufficiency had children who differed from high-income families in several nutrition and anthropometric measures. Clinicians should be aware of the possible effects of poverty and lack of access to food on child health and nutrition status. The long-term effects of these are not yet known.

Low family income and food insufficiency in relation to overweight in US children: is there a paradox?

Abstract: Objectives To investigate associations between family income, food insufficiency, and being overweight in US children aged 2 to 7 and 8 to 16 years, to discuss mechanisms that may explain these associations, and to propose design and data requirements for further research that could effectively examine this issue. Methods Data from the Third National Health and Nutrition Examination Survey were analyzed. Children were classified as food insufficient if the family respondents reported that their family sometimes or often did not get enough food to eat. The prevalence of overweight was compared by family income category and food sufficiency status within age-, sex-, and race-ethnic–specific groups. Odds ratios for food insufficiency are reported, adjusted for family income and other potential confounding factors. Results Among older non-Hispanic white children, children in families with low income were significantly more likely to be overweight than children in families with high income. There were no significant differences by family income for younger non-Hispanic white children, non-Hispanic black children, or Mexican American children. After adjusting for confounding variables, there were no differences in overweight by food sufficiency status, except that younger food-insufficient girls were less likely to be overweight, and non-Hispanic white older food-insufficient girls were more likely to be overweight than food-sufficient girls ( P Conclusion Further research to evaluate whether food insecurity causes overweight in American children requires longitudinal quantitative and in-depth qualitative methods.

Secondary Sexual Characteristics in Boys: Estimates From the National Health and Nutrition Examination Survey III, 1988-1994

Abstract: Background Descriptive data on pubertal stages for a representative population of racially and ethnically diverse boys in the United States have not been published to our knowledge. Objective To determine at what ages boys in the United States reach each of the 5 sexual maturity stages for genital and pubic hair growth. Design and Setting Cross-sectional survey from the National Health and Nutrition Examination Survey III (NHANES III), 1988-1994. Participants A population-based sample of 2114 boys aged 8 to 19 years representing 16 575 753 boys according to NHANES III sampling strategies. The sample included white, African American, and Mexican American boys. Main Outcome Measures Sexual maturity stages for genital maturation and pubic hair growth. Results The median (equivalent mean) ages at stage 2 for pubic hair development of white, African American, and Mexican American boys were 12.0 (95% confidence interval [CI], 11.7-12.3), 11.2 (95% CI, 10.9-11.4), and 12.3 (95% CI, 12.1-12.6) years, respectively, and at stage 2 for genital growth were 10.1 (95% CI, 9.6-10.6), 9.5 (95% CI, 8.9-10.0), and 10.4 (95% CI, 9.6-11.1) years, respectively. All 3 groups were significantly taller and heavier than boys in previous NHANES reports and showed earlier genital maturation and pubic hair growth than previous studies based on Tanner staging. Statistically significant differences among the 3 racial/ethnic groups were found in the median ages of onset of pubic hair growth and genital development at stage 5 with and without controlling for height and weight, indicating an earlier age of attainment for the African American boys. Conclusions The median (mean) ages at the onset of genital and pubic hair growth were younger than in past studies. Additional studies are required to further evaluate these findings and to explore the public health implications.

The readability of pediatric patient education materials on the World Wide Web.

Abstract: Background Literacy is a national and international problem. Studies have shown the readability of adult and pediatric patient education materials to be too high for average adults. Materials should be written at the 8th-grade level or lower. Objective To determine the general readability of pediatric patient education materials designed for adults on the World Wide Web (WWW). Materials and Methods GeneralPediatrics.com (http://www.generalpediatrics.com) is a digital library serving the medical information needs of pediatric health care providers, patients, and families. Documents from 100 different authoritative Web sites designed for laypersons were evaluated using a built-in computer software readability formula (Flesch Reading Ease and Flesch-Kincaid reading levels) and hand calculation methods (Fry Formula and SMOG methods). Analysis of variance and pairedttests determined significance. Results Eighty-nine documents constituted the final sample; they covered a wide spectrum of pediatric topics. The overall Flesch Reading Ease score was 57.0. The overall mean Fry Formula was 12.0 (12th grade, 0 months of schooling) and SMOG was 12.2. The overall Flesch-Kincaid grade level was significantly lower (P Conclusions Pediatric patient education materials on the WWW are not written at an appropriate reading level for the average adult. We propose that a practical reading level and how it was determined be included on all patient education materials on the WWW for general guidance in material selection. We discuss suggestions for improved readability of patient education materials.

Reasons for pediatrician nonadherence to asthma guidelines.

Abstract: Background The 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines include recommendations on how to improve the quality of care for asthma. Objective To identify barriers to physician adherence to the NHLBI guidelines. Design Cross-sectional survey. Participants A national random sample of 829 primary care pediatricians. Main Outcome Measures Self-reported adherence to 4 components of the NHLBI guidelines (steroid prescription, instructing peak flow meter use, screening and counseling patients with asthma for smoking, and screening and counseling parents for smoking). We also collected information on physician demographics, practice characteristics, and possible barriers to adherence. We defined adherence as following a guideline component more than 90% of the time. Results The response rate was 55% (456/829). Most of the responding pediatricians were aware of the guidelines (88%) and reported having access to a copy of the guidelines (81%). Self-reported rates of adherence were between 39% and 53% for the guideline components. After controlling for demographics and other barriers, we found that nonadherence was associated with specific barriers for each guideline component: for corticosteroid prescription, lack of agreement (odds ratio [OR], 6.8; 95% confidence interval [CI], 3.2-14.4); for peak flow meter use, lack of self-efficacy (OR, 3.4; 95% CI, 1.9-6.1) and lack of outcome expectancy (OR, 4.7; 95% CI, 2.5-8.9); and for screening and counseling of patients and parents for smoking, lack of self-efficacy (OR, 3.8; 95% CI, 1.7-6.2 and OR, 2.8; 95% CI, 1.3-5.9, respectively). Conclusions Although pediatricians in this sample were aware of the NHLBI guidelines, a variety of barriers precluded their successful use. To improve NHLBI guideline adherence, tailored interventions that address the barriers characteristic of a given guideline component need to be implemented.

Environmental influences, physical activity, and weight status in 8- to 16-year-olds.

Abstract: Objective To assess the association between vigorous physical activity, participation on sport teams and in exercise programs, television watching, family environment, and weight status in youth. Design Cross-sectional data from the Third National Health and Nutrition Examination Survey. Participants A group of 2791 youth between the ages of 8 and 16 years who were enrolled in the Third National Health and Nutrition Examination Survey. Main Outcome Measures Overweight was defined using age- and sex-specific 85th percentile of body mass index using Center for Disease Control and Prevention growth charts. Results Both males and females who had an overweight mother and or father were more likely to be overweight compared with youth who did not have an overweight parent. Females who watched 4 or more hours of television were more likely to be overweight than those who watched less than 4 hours. Males and 14- to 16-year-old females who participated in sport team and exercise programs were less likely to be overweight than their counterparts who did not participate. Also, females with larger families and males from families with higher family incomes were less likely to be overweight. Conclusions These results suggest that family environment is associated with overweight in youth and that sport and exercise program participants are less like to be overweight and that, for females, increased television watching is related to overweight.

Exposure to Violence: Psychological and Academic Correlates in Child Witnesses

Abstract: Background Inner-city children are frequently exposed to violence; however, there are few data regarding the psychological and academic correlates of such exposure in young children at school entry. Objectives To document exposure to violence in inner-city children aged 7 years; assess their feelings of distress; and evaluate the relationships of exposure to violence with school performance, behavior, and self-esteem. Setting A study center in an inner-city hospital. Participants One hundred nineteen inner-city children evaluated at age 7 years; 119 caregivers (biological and foster). Design As part of a longitudinal study, children were administered the following by a masked examiner: Things I Have Seen and Heard (TISH) to assess exposure to violence; Levonn, a cartoon-based interview for assessing children's distress symptoms; and the Culture-Free Self-Esteem Inventory, Second Edition. School performance was assessed by school reports and child behavior by the Child Behavior Checklist (CBCL), the Parent Report Form, and the Teacher Report Form. Caregivers for children were administered the parent report version of the Checklist of Children's Distress Symptoms (CCDS-PRV) as well as the CBCL Parent Report Form. Main Outcome Measures Exposure to violence (TISH); feelings of distress (Levonn); school performance; behavior (CBCL Parent Report Form and CBCL Teacher Report Form); and self-esteem (Culture-Free Self-Esteem Inventory). Results We found that these children were frequently exposed to violence. For example, 75% had heard gun shots, 60% had seen drug deals, 18% had seen a dead body outside, and 10% had seen a shooting or stabbing in the home (TISH). Many showed signs of depression and anxiety; eg, 61% worried some or a lot of the time that they might get killed or die and 19% sometimes wished they were dead (Levonn). Higher exposure to violence (TISH Total Violence score) was correlated with higher Levonn composite scores for depression and anxiety and with lower self-esteem ( P ≤.04), and was also associated with lower grade point average and more days of school absence ( P ≤.02). Caregiver assessment of child anxiety correlated poorly with child report of anxiety ( P = .58). Conclusions Young inner-city children have a high exposure to violence by age 7 years; many show signs of distress that frequently are not recognized by caregivers. Further, higher exposure to violence in children correlates with poorer performance in school, symptoms of anxiety and depression, and lower self-esteem.

Parent Expectations for Antibiotics, Physician-Parent Communication, and Satisfaction

Abstract: Objectives: To explore how parents communicate their preferences for antibiotics to their child’s physician and to examine whether physicians can communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit. Design: Previsit survey of parents, audiotaping of the study encounters, and a postvisit survey of parents and physicians.

How Can Information Technology Improve Patient Safety and Reduce Medication Errors in Children's Health Care?

Abstract: Background Medication errors are common, costly, and injurious to patients. Objective To review the role of information technology in decreasing pediatric medication errors in both inpatient and outpatient settings. Design We performed a literature review of current information technology interventions. Results Several types of information technology will likely reduce the frequency of medication errors, although insufficient data exists for many technologies, and most available data come from adult settings. Computerized physician order entry with decision support substantially decreases the frequency of serious inpatient medication errors in adults. Certain other inpatient information technologies may be beneficial even though less evidence is currently available. These include computerized medication administration records, robots, automated pharmacy systems, bar coding, "smart" intravenous devices, and computerized discharge prescriptions and instructions. In the outpatient setting, where adherence is especially important, personalized Web pages and World Wide Web–based information have substantial potential. Conclusions Medication errors are an important problem in pediatrics. Information technology interventions have great potential for reducing the frequency of errors. The magnitude of benefits may be even greater in pediatrics than in adult medicine because of the need for weight-based dosing. Further development, application, evaluation, and dissemination of pediatric-specific information technology interventions are essential.

Health Effects Related to Environmental Tobacco Smoke Exposure in Children in the United States: Data From the Third National Health and Nutrition Examination Survey

Abstract: Objective: To determine the effects of prenatal and postnatal smoke exposure on the respiratory health of children in the United States. Design: Nationally representative cross-sectional survey, including questionnaire information, mea- surements of serum cotinine (a metabolite of nicotine), and pulmonary function measurement, of 5400 US children. Results: We observed effects of ETS exposure in all age groups, although the effects varied between age groups. Among all children significant effects associated with high cotinine levels were for wheezing apart from cold in the past year (odds ratio (OR), 1.8; 95% confidence interval (CI), 1.1-2.8); 6 or more days of school absence in the past year (OR, 2.0; 95% CI, 1.4-2.8); and lung function decre- ments in the forced expiratory volume in 1 second (mean change, ˛1.8%; 95% CI, ˛3.2% to ˛0.4%) and the maxi- mal midexpiratory flow (mean change, ˛5.9%; 95% CI, ˛8.1% to ˛3.4%). Although current and ever asthma were not significantly associated with high cotinine levels in the overall group (OR, 1.5; 95% CI, 0.8-2.7, and OR, 1.3; 95% CI, 0.8-2.2, respectively), they were increased signifi- cantly among 4- to 6-year-old children (OR, 5.3; 95% CI, 2.2-12.7, and OR, 2.3; 95% CI, 1.1-5.1, respectively). Conclusions: We investigated recent ETS exposures as important predictors of respiratory health outcomes in children 4 years and older. Environmental tobacco smoke exposure affects children of all ages, although the exact effects may vary between age groups. Arch Pediatr Adolesc Med. 2001;155:36-41

Food-Allergic Reactions in Schools and Preschools

Abstract: Background Food allergies may affect up to 6% of school-aged children. Objectives To conduct a telephone survey to characterize food-allergic reactions in children (defined as those aged 3-19 years in this study) with known food allergies in schools and preschools and to determine mechanisms that are in place to prevent and treat those reactions. Design The parents of food-allergic children were contacted by telephone and asked about their child's history of food-allergic reactions in school. The schools the children attended were contacted, and the person responsible for the treatment of allergic reactions completed a telephone survey. Results Of 132 children in the study, 58% reported food-allergic reactions in the past 2 years. Eighteen percent experienced 1 or more reactions in school. The offending food was identified in 34 of 41 reactions, milk being the causative food in 11 (32%); peanut in 10 (29%); egg in 6 (18%); tree nuts in 2 (6%); and soy, wheat, celery, mango, or garlic in 1 (3%) each. In 24 reactions (59%), symptoms were limited to the skin; wheezing occurred in 13 (32%), vomiting and/or diarrhea in 4 (10%), and hypotension in 1 (2%). Also, 15 (36%) of the 41 reactions involved 2 or more organ systems, and 6 (15%) were treated with epinephrine. Fourteen percent of the children did not have a physician's orders for treatment, and 16% did not have any medications available. Of the 80 participating schools, 31 (39%) reported at least 1 food-allergic reaction within the past 2 years and 54 (67%) made at least 1 accommodation for children with a food allergy, such as peanut-free tables, a peanut ban from the classroom, or alternative meals. Conclusions It is common for food-allergic children to experience allergic reactions in schools and preschools, with 18% of children having had at least 1 school reaction within the past 2 years. Thirty-six percent of the reactions involved 2 or more organ systems, and 32% involved wheezing. Every effort should be made to prevent, recognize, and appropriately treat food-allergic reactions in schools.

Effects of Reducing Children's Television and Video Game Use on Aggressive Behavior: A Randomized Controlled Trial

Abstract: Context The relationship between exposure to aggression in the media and children's aggressive behavior is well documented. However, few potential solutions have been evaluated. Objective To assess the effects of reducing television, videotape, and video game use on aggressive behavior and perceptions of a mean and scary world. Design Randomized, controlled, school-based trial. Setting Two sociodemographically and scholastically matched public elementary schools in San Jose, Calif. Participants Third- and fourth-grade students (mean age, 8.9 years) and their parents or guardians. Intervention Children in one elementary school received an 18-lesson, 6-month classroom curriculum to reduce television, videotape, and video game use. Main Outcome Measures In September (preintervention) and April (postintervention) of a single school year, children rated their peers' aggressive behavior and reported their perceptions of the world as a mean and scary place. A 60% random sample of children were observed for physical and verbal aggression on the playground. Parents were interviewed by telephone and reported aggressive and delinquent behaviors on the child behavior checklist. The primary outcome measure was peer ratings of aggressive behavior. Results Compared with controls, children in the intervention group had statistically significant decreases in peer ratings of aggression (adjusted mean difference, −2.4%; 95% confidence interval [CI], −4.6 to −0.2; P = .03) and observed verbal aggression (adjusted mean difference, −0.10 act per minute per child; 95% CI, −0.18 to −0.03; P = .01). Differences in observed physical aggression, parent reports of aggressive behavior, and perceptions of a mean and scary world were not statistically significant but favored the intervention group. Conclusions An intervention to reduce television, videotape, and video game use decreases aggressive behavior in elementary schoolchildren. These findings support the causal influences of these media on aggression and the potential benefits of reducing children's media use.

Comparison of auscultatory and oscillometric blood pressures.

Abstract: Objective To study the differences in blood pressure readings between the auscultatory and oscillometric (Dinamap model 8100; Critikon, Tampa, Fla) methods Design Survey of 2 blood pressure instruments Setting Public schools Participants Seven thousand two hundred eight schoolchildren aged 5 through 17 years Main Outcome Measure Blood pressure levels Results For all children combined , Dinamap systolic pressure readings were 10 mm Hg higher (95% confidence interval, −4 to 24 mm Hg) than the auscultatory systolic pressure readings Dinamap diastolic pressure readings were 5 mm Hg higher (95% confidence interval, −14 to 23 mm Hg) than the auscultatory Korotkoff phase V diastolic pressure readings Conclusion These findings preclude the interchange of readings by the 2 methods Caution must be exercised in the diagnosis of hypertension when an automated device is used

Primary care services promoting optimal child development from birth to age 3 years: review of the literature.

Abstract: Objective To examine the evidence base for primary health care services promoting the optimal development of typically developing children aged birth to 3 years. Data Sources Peer-reviewed publications addressing clinical evaluations of primary care services from the MEDLINE and PsychINFO databases. Study Selection Criteria for selection were as follows: (1) publication between 1979 and 1999; (2) evaluation of efficacy or effectiveness of education, intervention, and care coordination services or validation of assessment approaches; (3) services applicable to an office practice setting; (4) target population including children aged birth to 3 years; and (5) publication in English. Data Extraction A total of 312 publications were abstracted and reviewed by both of us; 47 were selected for inclusion. Data Synthesis Assessments of parental concerns and psychosocial risk factors using validated approaches seem to be more accurate in identifying developmental problems than clinicians' appraisals. In general, study results support the efficacy of (1) primary care educational efforts toward promoting optimal parent-child interaction, parents' understanding of child temperament, book-sharing activities, and approaches to healthy sleep habits and (2) office interventions such as counseling for the management of excessive infant crying and sleep problems. Conclusions The literature suggests that many primary care activities promoting the optimal development of children are efficacious. Evaluations of developmental assessment and services in primary care should be expanded in depth and breadth. The implications for clinical practice, training, and health care policy are discussed.

A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents.

Abstract: Background Most adolescents do not meet national recommendations for nutrition and physical activity. However, no studies of physical activity and nutrition interventions for adolescents conducted in health care settings have been published. The present study was an initial evaluation of the PACE+ (Patient-centered Assessment and Counseling for Exercise plus Nutrition) program, delivered in primary care settings. Participants Adolescents aged 11 to 18 years (N = 117) were recruited from 4 pediatric and adolescent medicine outpatient clinics. Participants' mean (SD) age was 14.1 (2.0) years, 37% were girls, and 43% were ethnic minorities. Intervention Behavioral targets were moderate physical activity, vigorous physical activity, fat intake, and fruit and vegetable intake. All patients completed a computerized assessment, created tailored action plans to change behavior, and discussed the plans with their health care provider. Patients were then randomly assigned to receive no further contact or 1 of 3 extended interventions: mail only, infrequent telephone and mail, or frequent telephone and mail. Measures Brief, validated, self-report measures of target behaviors were collected at baseline and 4 months later. Results All outcomes except vigorous physical activity improved over time, but adolescents who received the extended interventions did not have better 4-month outcomes than those who received only the computer and provider counseling components. Adolescents who targeted a behavior tended to improve more than those who did not target the behavior, except for those who targeted vigorous physical activity. Conclusions A primary care–based interactive health communication intervention to improve physical activity and dietary behaviors among adolescents is feasible. Controlled experimental research is needed to determine whether this intervention is efficacious in changing behaviors in the short- and long-term.

Maternal depressive symptoms and emergency department use among inner-city children with asthma

Abstract: Context Inner-city minority children with asthma use emergency departments (ED) frequently. Objective To examine whether maternal depressive symptoms are associated with ED use. Design, Setting, and Patients Baseline and 6-month surveys were administered to mothers of children with asthma in inner-city Baltimore, Md, and Washington, DC. Main Outcome Measures Use of the ED at 6-month follow-up was examined. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data. Results Among mothers, nearly half reported significant levels of depressive symptoms. There were no demographic or asthma-related differences between the children of mothers with high and low depressive symptoms. However, in bivariate analyses, mothers with high depressive symptoms were 40% (prevalence ratio [PR], 1.4; 95% confidence interval [CI], 1.0-3.6;P= .04) more likely to report taking their child to the ED. Mothers aged 30 to 35 years were more than twice as likely (PR, 2.2; 95% CI, 1.9-9.3;P= .001) to report ED use, as were children with high morbidity (PR, 1.9; 95% CI, 1.4-7.1;P= .006). Child age and family income were not predictive of ED use. After controlling for asthma symptoms and mother's age, mothers with depressive symptoms were still 30% more likely to report ED use. Conclusions Depression is common among inner-city mothers of children with asthma. Beyond asthma morbidity, maternal age and depressive symptoms are strong predictors of reports of ED visits. Identifying and addressing poor psychological adjustment in mothers may reduce unnecessary ED visits and optimize asthma management among inner-city children.

The relationship between lead exposure and homicide.

Abstract: Results: Negative binomial regression was used to examine the relationship between air lead concentrations and the incidence of homicide across counties in the United States (N=3111). After adjusting for sociologic confounding factors and 9 measures of air pollution, the only indictor of air pollution found to be associated with homicide rates was air lead concentration. Across all counties, estimated air lead concentrations ranged from 0 to 0.17 µg/m 3 . The adjusted results suggest that the difference between the highest and lowest level of estimated air lead is associated with a homicide incidence rate ratio of 4.12 (95% confidence interval, 1.02-16.61). Conclusion: The results of this study support recent findings that there is an association between lead exposure and violent behavior. Arch Pediatr Adolesc Med. 2001;155:579-582

Assessing diagnostic accuracy and tympanocentesis skills in the management of otitis media.

Abstract: Background The distinction between acute suppurative otitis media (AOM) and otitis media with effusion (OME) is important for antibiotic treatment decisions. Tympanocentesis may be useful in the diagnosis of AOM in selected patients. Objectives To assess physician accuracy in diagnosing AOM and OME from physical examination findings and technical competence in performing tympanocentesis. Design and Subjects Five hundred fourteen pediatricians and 188 otolaryngologists viewed 9 different videotaped pneumatic otoscopic examinations of tympanic membranes during a continuing medical education course. Diagnostic differentiation of AOM, OME, and a normal tympanic membrane was ascertained. An infant mannequin model was used to assess the technical proficiency of performing tympanocentesis on artificial tympanic membranes. Results Overall, the average correct diagnosis by pediatricians was 50% (range, 25%-73%) and by otolaryngologists was 73% (range, 48%-88%). Pediatricians and otolaryngologists correctly recognized the absence of normality 89% to 100% and 93% to 100% of the time, respectively, but overdiagnosed AOM in 7% to 53% (mean, 27%) and in 3% to 23% (mean, 10%) of examinations. Performance of tympanocentesis was optimally performed by 89% of otolaryngologists and by 83% of pediatricians. Conclusions The use of video-presented examinations to assess diagnostic ability suggests that AOM and OME may be misdiagnosed often. Interactive continuing medical education courses with simulation technology may enhance skills and improve diagnostic accuracy and treatment paradigms.

Are overreferrals on developmental screening tests really a problem

Abstract: Background Developmental screening tests, even those meeting standards for screening test accuracy, produce numerous false-positive results for 15% to 30% of children. This is thought to produce unnecessary referrals for diagnostic testing or special services and increase the cost of screening programs. Objectives To explore whether children who pass screening tests differ in important ways from those who do not and to determine whether children overreferred for testing benefit from the scrutiny of diagnostic testing and treatment planning. Methods Subjects were a national sample of 512 parents and their children (age range of the children, 7 months to 8 years) who participated in validation studies of various screening tests. Psychological examiners adhering to standardized directions obtained informed consent and administered at least 2 developmental screening measures (the Brigance Screens, the Battelle Developmental Inventory Screening Test, the Denver-II, and the Parents' Evaluations of Developmental Status) and a concurrent battery of diagnostic measures, including tests of intelligence, language, and academic achievement (for children aged 2½ years and older). The performance on diagnostic measures of children who failed screening but were not found to have a disability (false positives) was compared with that of children who passed screening and did not have a disability on diagnostic testing (true negatives). Results Children with false-positive scores performed significantly ( P P Conclusions Children overreferred for diagnostic testing by developmental screens perform substantially lower than children with true-negative scores on measures of intelligence, language, and academic achievement—the 3 best predictors of school success. These children also carry more psychosocial risk factors, such as limited parental education and minority status. Thus, children with false-positive screening results are an at-risk group for whom diagnostic testing may not be an unnecessary expense but rather a beneficial and needed service that can help focus intervention efforts. Although such testing will not indicate a need for special education placement, it can be useful in identifying children's needs for other programs known to improve language, cognitive, and academic skills, such as Head Start, Title I services, tutoring, private speech-language therapy, and quality day care.

Exposure to Violence and Associated Health-Risk Behaviors Among Adolescent Girls

Abstract: Objective To examine the relationship between exposure to violence and health-risk behaviors. Design Cross-sectional survey. Setting University-based outpatient family planning clinic. Patients Sexually active adolescent girls younger than 18 years (N = 517) who presented for contraceptive care. Main Outcome Measures Prevalence of witnessing or experiencing violence and the associations with health-risk behaviors, including high-risk sexual behaviors, substance use, and self-injury. Results Compared with adolescents who had not been exposed to violence, those who had only witnessed violence were 2 to 3 times more likely to report using tobacco and marijuana, drinking alcohol or using drugs before sex, and having intercourse with a partner who had multiple partners. Those who had experienced, but not witnessed violence were at increased risk of these same behaviors and were 2 to 4 times more likely than those who had neither witnessed nor experienced violence to report early initiation of intercourse, intercourse with strangers, multiple partners, or partners with multiple partners, tobacco, alcohol and drug use, or to have positive test results for a sexually transmitted disease. Individuals who had both witnessed and experienced violence demonstrated the greatest risk of adverse health behaviors. These adolescents demonstrated 3 to 6 times greater risk of suicidal ideation (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.2-4.0) or suicide attempts (OR, 4.5; 95% CI, 2.2-9.4), self-injury (OR, 5.8; 95% CI, 2.6-12.9), and use of drugs before intercourse (OR, 6.2; 95% CI, 3.0-12.9) than those who had neither witnessed nor experienced violence. Conclusions Adolescents exposed to violence are at increased risk of multiple adverse health behaviors. Programs designed to improve health outcomes should target this high-risk group.

Impact of low birth weight on early childhood asthma in the United States.

Abstract: Objective To estimate the independent contribution of birth weight to asthma prevalence among children younger than 4 years in the United States and to compare the magnitude of its effect on asthma between African American and white children. Design Cross-sectional analysis using the 1988 National Maternal-Infant Health Survey and 1991 Longitudinal Follow-up Survey. Setting United States. Patients Eight thousand seventy-one subjects, selected from a randomized, systematic population-based sample and weighted to be nationally representative, who completed both initial and longitudinal follow-up surveys and reported information on asthma diagnosis. Main Outcome Measures Birth weight and other sociodemographic factors linked to birth outcome were analyzed for independent association with physician-diagnosed asthma by age 3 years. Results The prevalence of asthma varied by birth weight category: 6.7% in children 2500 g or more at birth, 10.9% in children 1500 to 2499 g at birth, and 21.9% in children less than 1500 g at birth (very low birth weight [VLBW]) ( P white , 3.1 (95% CI, 2.2-4.3) and OR African American , 2.5 (95% CI, 2.0-3.3). The prevalence of VLBW, however, was tripled in African American compared with white children (1.8% vs 0.6%). Conclusions These data confirm findings of other studies that identify a strong independent association between low birth weight and asthma. For this 1988 national birth cohort, an estimated 4000 excess asthma cases were attributable to birth weight less than 2500 g. Although the strength of the independent association between VLBW and asthma was smaller in the African American population, the substantially increased prevalence of VLBW in this community may contribute to the disproportionately increased prevalence of asthma among African American children.

Child health status and parental employment.

Abstract: Objective To understand the relationship between several measures of child health status and the employment of parents. Design A cross-sectional study using 1994 National Health Interview Survey on Disability data. Participants A nationally representative sample of children and their parents. Outcome Measures Maternal and paternal employment (measured separately). Intervention We use a series of logistic regression models with maternal and paternal employment as the dependent variables and the health status of the child with the poorest health status in the family as the primary independent variable. Models additionally include sociodemographic correlates of employment. Results Having a child with poor health status, as measured by general reported health, hospitalizations, activity limitations, and chronic condition or disability status, is associated with reduced employment of mothers and fathers. For example, the odds ratios of being employed for having a child with an activity limitation are 0.75 for mothers (95% confidence interval, 0.67-0.85) and 0.66 for fathers (95% confidence interval, 0.53-0.82). Conclusions Having a child with poor health status is associated with reduced maternal and paternal employment. Further studies are needed to determine whether poor child health status causes reductions in parental labor force participation. If such a causal relationship exists, it has important implications for social policy, employment policy, and clinical anticipatory guidance.

Reliability of the urinalysis for predicting urinary tract infections in young febrile children.

Abstract: Background Urinary tract infections (UTIs) are a common source of bacterial infection among young febrile children. Clinical variables affecting the sensitivity of the urinalysis (UA) as a screen for UTI have not been previously investigated. The limited sensitivity of the UA for detecting a UTI requires that a urine culture be obtained in some children regardless of the UA result; however, a proper urine culture requires an invasive procedure, so the criteria for its use should be optimized. Objectives To determine how the sensitivity of the standard UA as a screening test for UTI varies with age, and to determine the clinical situation that necessitates the collection of a urine culture regardless of the UA result. Methods Retrospective medical record review of patients younger than 2 years with fever (≥38°C) seen in the emergency department during a period of 65 months. All urine cultures were reviewed for the collection method, isolates, and colony counts. A UA result was considered positive if the presence of 1 of the following was detected: leukocyte esterase, nitrite, or pyuria (≥5 white blood cells per high power field). Patients who had a paired UA and urine culture were used to calculate the sensitivity, specificity, and likelihood ratios of the UA. The prevalence of UTIs was also subcategorized by age, race, sex, and fever. Results Medical records of 37 450 febrile children younger than 2 years were reviewed. Forty-four percent were girls. Median age and temperature were 10.6 months and 38.8°C. A total of 11 089 patients (30%) had urine cultures obtained. The sensitivity of the UA was 82% (95% confidence interval [CI], 79%-84%) and did not vary by age subgroups. The specificity of UA was 92% (95% CI, 91%-92%). The likelihood ratios for a positive UA and negative UA were 10.6 (95% CI, 10.0-11.2) and 0.19 (95% CI, 0.18-0.20), respectively. Prevalence of UTI was 2.1% overall (2.9% for girls and 1.5% for boys, respectively). Among girls, the prevalence of UTI was 5.0% in white patients, 2.1% in Hispanic patients, and 1.0% in black patients. Among boys, the prevalence was 2.2% in Hispanic patients, 1.4% in white patients, and 0.8% in black patients. Higher prevalence was also seen among patients with a temperature at or above 39°C compared with those whose temperature was between 38.0°C and 38.9°C. The greatest prevalence of UTI (13%) was found among white girls younger than 6 months with a temperature at or greater than 39°C. The posttest probability of a UTI in the presence of a negative UA can be calculated using the negative likelihood ratio and the patient-specific prevalence of UTI. When the prevalence of UTI is 2%, 1 UA among 250 will produce a false-negative test result. Conclusions The sensitivity of the standard UA is 82% (95% CI, 79%-84%) and does not vary with age in febrile children younger than 2 years. The prevalence of UTI varies by age, race, sex, and temperature. A negative likelihood ratio and estimates of prevalence can be used to calculate the risk of missing a UTI due to a false-negative UA result.

Identification and management of psychosocial problems by preventive Child health care

Abstract: Objectives: To assess the degree to which physicians and nurses working in preventive child health care (child health professionals [CHPs]) identify and manage psychosocial problems in children, and to determine its association with parent-reported behavioral and emotional problems, sociodemographic factors, and general and mental health history of children. Design: The CHPs examined the child and interviewed parents and child during their routine health assessments. The parents completed the Child Behavior Checklist. Setting: Nineteen child health care services across the Netherlands, serving nearly all school-aged children routinely. Subjects: Of 4970 children aged 5 through 15 years, eligible for a routine health assessment, 4480 (90.1%) participated. Main Outcome Measures: Identification and management of psychosocial problems by CHPs. Results: In 25% of all children, CHPs identified 1 or more psychosocial problems. One in 5 identified children were referred for further diagnosis and treatment. Identification of psychosocial problems and subsequent referral were 6 times more likely in children with serious parent-reported problem behavior according to the Child Behavior Checklist total problem score (8% of total sample). However, CHPs identified no psychosocial problems in 43% of these children and therefore undertook no action. Other child factors associated with CHPs' identification and referral were past treatment for psychosocial problems, life events, and academic problems. After adjustment for these, sociodemographic characteristics did not predict referral. Conclusions: The CHPs identify psychosocial problems in school-aged children frequently and undertake actions for most of them. Screening for psychosocial problems may be a promising option to reduce these problems, but accurate identification should be enhanced.

Pediatric Stimulant and Selective Serotonin Reuptake Inhibitor Prescription Trends: 1992 to 1998

Abstract: Background Presciption trends have key implications for costs, outcomes, and research, yet few data exist on pediatric selective serotonin reuptake inhibitor (SSRI) trends and associations with stimulant trends. Objective To describe prescription trends for stimulants, SSRIs, and combination prescriptions by age, sex, and race. Methods Retrospective population-based analysis of North Carolina Medicaid prescription claims files. Participants North Carolina Medicaid recipients, 1992 through 1998, aged 1 to 19 years. The population ranged from 342 333 children in 1992 to 581 088 in 1998. Main Outcome Measures Annual number of prescriptions, patients filling a prescription claim, and prescription prevalence for stimulants and SSRIs. Results The number of children and adolescents who received stimulants increased from 6407 (24 584 claims) in 1992 to 27 951 (135 057 claims) in 1998. The number of SSRI recipients increased from 510 children (1326 claims) in 1992 to 6984 children (25 392 claims) in 1998. Prescription prevalence in school-aged children 6 to 14 years increased from 4.4% to 9.5% for stimulants during the study period, and from 0.2% to 1.5% for SSRIs. In 1998, stimulant prescription prevalence was highest for white school-aged males (18.3%) vs black females (3.4%) and SSRI prescription prevalence was highest for white school-aged males (2.8%) vs black females (0.6%). Combination pharmacotherapy also increased during 1992 through 1998. Conclusions Prevalence of stimulant and SSRI medications has increased during the 1990s, with prescription prevalence in North Carolina Medicaid youth higher than previously reported. Age, sex, and racial differences are apparent and call for further attention. Combination pharmacotherapy also has growing importance.