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OBJECTIVE. We conducted a retrospective cohort study to compare the use of triple therapy versus monotherapy for children and adolescents with perforated appendicitis and to determine whether there has been a transition to monotherapy within the freestanding children's hospitals that contribute to the Pediatric Health Information System database. METHODS. We used the Pediatric Health Information System database, which includes billing and discharge data for 32 children's hospitals in the United States, to examine the trend in antibiotic usage and whether the postappendectomy antibiotic regimen was associated with differences in complication-related readmissions, length of stay, or charges in a population of children and adolescents with ruptured appendicitis and discharge dates between March 1, 1999, and September 30, 2004. Pairwise regression analyses were performed to compare the most common monotherapy regimens with the triple therapy. RESULTS. A total of 8545 patients met the inclusion criteria, of whom 58%, over the entire study period, received the aminoglycoside-based triple antibiotic therapy on postoperative day 1. There was, however, a notable transition over this 6-year period, from 69% to 52% of surgeons using aminoglycoside-based combination therapy. There were no significant differences in the odds of readmission at 30 days except for the group receiving ceftriaxone, which was associated with significantly decreased odds. The subgroup receiving piperacillin/tazobactam monotherapy demonstrated significantly decreased length of stay (-0.90 days) and total hospital charges, and the group receiving cefoxitin demonstrated significantly decreased length of stay (-1.89 days), as well as decreased pharmacy and total hospital charges. CONCLUSIONS. Single-agent antibiotic therapy in the treatment of perforated appendicitis is being used with increasing frequency, is at least equal in efficacy to the traditional aminoglycoside-based combination therapy, and may offer improvements in terms of length of stay, pharmacy charges, and hospital charges. www.pediatrics.org/cgi/doi/10.1542/peds.2006-2040 doi:10.1542/peds.2006-2040 Key Words appendicitis, antibiotics Abbreviations PHIS--Pediatric Health Information System OR--odds ratio CI--confidence interval ICD-9--International Classification of Diseases, Ninth Revision LOS--length of stay ABT--aminoglycoside-based combination therapy, APPROXIMATELY 4 APPENDECTOMIES per 1000 children are performed each year in the United States. Of these cases, 15% to 36% are in the presence of perforation. (1-3) Although intravenous antibiotic [...]

OBJECTIVES. The goals were to evaluate the use of touchscreen computer kiosks, containing only child health-promoting information, in urban, low-income, community settings and to characterize the users of these kiosks. METHODS. Three user-driven touchscreen computer kiosks were placed in low-income urban locations in Seattle, Washington, from March 2005 to October 2005. The locations included a public library, a Department of Motor Vehicles office, and a McDonald's restaurant. Users selected age-appropriate modules with prevention information and screening tools. Users entered the age of the child and were presented with age-appropriate modules. On exiting, users were asked to rate their experience and to provide basic demographic data. RESULTS. In total, there were 1846 kiosk sessions. Almost one half occurred at McDonald's. Seventy-eight percent of users identified themselves as first-time users. Users sought information for children of all ages. Sixty-one percent of first-time users explored 1 module. First-time users were most interested in television/media use (16%), smoke exposure (14%), attention-deficit/hyperactivity disorder screening (12%), and asthma assessment (11%). At-risk children were identified in 52% of sessions. Eighty-seven percent of first-time users who completed the asthma assessment had children whose asthma was uncontrolled. Twenty-eight percent of users responded to el question on the exit survey. Of those, 48% had less than a high school education, and 26% had never used the Internet. Approximately one half found the kiosk easy to use (57%) and the information easy to understand (55%); 66% said there was at least some new information. Fifty-five percent planned to try some of the things they had learned, and 49% intended to talk to their child's doctor about what they had learned. CONCLUSIONS. User-driven computer kiosks were used in community settings to obtain child health information. Users found the kiosks easy to use. Additional study on improving use and understanding the impact is needed., GIVEN THE LIMITED success in promoting prevention via pediatricians' offices, alternative methods for delivering child health promotion information are needed. (1-3) Although recommendations regarding age-appropriate topics to be covered at [...]

OBJECTIVE. The purpose of this work was to conduct a systematic review of experimental trials for the effects of television viewing by infants and preschoolers. METHODS. Searches were conducted as of January 2005 on several online bibliographic databases for the disciplines of medicine, psychology, education, and communications. Relevant bibliographies were also reviewed. The article contents were critically evaluated to determine whether they met inclusion criteria. Data were extracted from each included article regarding study methods and results. RESULTS. Twelve controlled trials met all of the criteria for inclusion in this review. All of the studies focused on the effect of television content rather than viewing time. The findings suggest that educational television programs are successful in broadening young children's knowledge, affecting their racial attitudes, and increasing their imaginativeness. There is insufficient experimental evidence for effects of viewing these programs on either children's prosocial behavior or their aggressive behavior. Finally, there is some evidence that viewing cartoons has a negative effect on children's attentional abilities. CONCLUSIONS. A number of gaps remain in the literature. Although the amount of time children spend viewing television raises concern, the studies presented here focus only on content. Despite the fact that infants are the fastest growing television market segment, the controlled trials only include children aged [greater than or equal to] 3 years. Finally, the clinical utility of the findings are questionable given that most studies included small group sizes, all took place in nonnaturalistic settings, and all but 1 study only evaluated short-term effects of television viewing. Key Words systematic review, television, YOUNG CHILDREN IN the United States watch an astonishing amount of television, spending more time in front of a screen than any other single activity except sleeping. (1,2) The American [...]

BACKGROUND. Innovations to improve the delivery of pediatric preventive care are needed. METHODS. We enrolled children, 0 to 11 years of age, into a factorial, randomized, controlled trial of a tailored, evidence-based, Web site (MyHealthyChild) that provided information on prevention topics before a scheduled well-child visit. There were 2 components of the intervention, namely, parental Web content and provider notification. Parental Web content provided information to parents about prevention topics; provider notification communicated to physicians topics that were of interest to parents. We assigned 887 children randomly to 4 groups (usual care, content only, content and notification, or notification only). Outcomes were determined with telephone follow-up surveys conducted 2 to 4 weeks after the visit. Poisson regression analysis was used to determine the independent effects of each intervention on the number of topics discussed and the number of preventive practices implemented. RESULTS. Parents in the notification/content group and in the notification-only group reported discussing more MyHealthyChild topics with their provider. Parents in the notification/content group and in the content-only group reported implementing more MyHealthyChild topic suggestions (such as use of a safety device). CONCLUSIONS. A Web-based intervention can activate parents to discuss prevention topics with their child's provider. Delivery of tailored content can promote preventive practices. Key Words Internet, prevention, primary care, child health, outcome Abbreviations UWPN--University of Washington Physician Network OR--odds ratio CI--confidence interval IRR--incidence rate ratio, PEDIATRICIANS SPEND Historically, changing provider behavior has proved difficult, especially with respect to preventive health maintenance. (12,13) However, patients themselves can motivate provider behavior changes effectively. (12) Informing patients which [...]

BACKGROUND. The advent of tandem mass spectrometry has made it possible to test newborns for multiple conditions efficiently. It is not known how state newborn screening programs have changed screening practices in response to this technology and how it affects the number of false-positive test results. METHODS. We obtained data from the National Newborn Screening and Genetics Resource Center regarding the screening practices for each of the 50 states, to determine the number of mandated disorders added to state newborn screening panels between 1995 and 2005. Combining these data with reported specificities from the literature and the number of births in each state, we estimated the number of infants who would have received false-positive results through screening with tandem mass spectrometry in 2005. RESULTS. The average state mandated screening for 5 disorders in 1995 (range: 0-8 disorders). Wyoming was the only state that decreased its panel size over the next decade. Kansas and Texas were the only states that did not add disorders to their panels between 1995 and 2005; the average state added 19. Iowa, Minnesota, Mississippi, South Dakota, and Tennessee each added [greater than or equal to] 40 disorders. Assuming that an individual test for a disorder had a specificity of 99.995%, we estimated that ~2575 infants would have received false-positive results through screening with tandem mass spectrometry in 2005. If specificity was assumed to be 99.9%, then the number increased to >51 000. CONCLUSIONS. State newborn screening programs have expanded dramatically in the past decade. Because the benefit of such testing may be unclear in some cases and because the number of infants who may receive false-positive results and may be labeled falsely as having disease is potentially sizeable, a more cautious approach is needed. Key Words newborn screening, metabolic disorders, false positive results, IN THE UNITED States, decisions about newborn screening are made by 50 different state legislatures. Shortly after Massachusetts began a mass voluntary screening program for phenylketonuria in 1962, other states [...]

Objective. Decreased physician participation in Medicaid has been shown to affect adversely timeliness of adult acute care and pediatric specialty care, but it is not clear whether this is the case for newborn follow-up. The objectives of this study were to determine whether there is a difference within clinics in the timeliness of follow-up appointments that are given to newborns with Medicaid compared with newborns with private insurance and to determine whether there is a difference between clinics that do and do not accept Medicaid in the timeliness of appointments that are given for newborn follow-up. Methods. A randomized crossover study was conducted among general pediatric clinics and practices that were identified from the yellow pages and Internet searches of hospitals and health departments in 8 metropolitan areas from September 2003 to March 2004. A simulated parent telephoned clinics to find the earliest available appointment for a 1-day-old infant who needed routine follow-up after discharge that day. Clinics were randomly assigned to receive a first call from a patient with either Medicaid or private insurance; each clinic received the same call at least 3 weeks later with the patient's insurance status reversed. The main outcome measure was whether the appointment was timely ([less than or equal to] 2 days from the day of the call). Results. Of 401 participating clinics, 22% did not accept Medicaid. Among clinics that accepted Medicaid, availability of a timely appointment for a newborn with Medicaid was similar to that for a newborn with private insurance (87% vs 90%, respectively). Appointments that were provided to privately insured newborns were as likely to be timely in clinics that accept Medicaid as in clinics that do not accept Medicaid (89.5% vs 93.4%, respectively). However, providing timely appointments was significantly less likely in clinics that were in high-poverty locations compared with clinics that were not (86.1% vs 92.7%, respectively). Conclusions. Although newborns with Medicaid did not have access to >20% of clinics because of their insurance, among clinics that did accept Medicaid, timeliness of available follow-up was similar for newborns with Medicaid compared with newborns with private insurance and similar between clinics that did and did not accept Medicaid. However, to the extent that care for newborns with Medicaid is concentrated in clinics in high-poverty areas, some newborns with Medicaid may not be able to receive timely appointments. Pediatrics 2005;116:1148-1154; access to health care, insurance, Medicaid, newborn. ABBREVIATIONS. AAP, American Academy of Pediatrics; CI, confidence interval., Children who are covered by Medicaid have decreased access to care compared with those with private insurance, (1-3) and only 67% of pediatricians report that they accept all patients with [...]

Background. Regular sleep schedules are an important part of healthy sleep habits. Although television viewing is associated with altered sleep patterns and sleep disorders among children and adolescents, the effect of television viewing on the sleep patterns of infants and toddlers is not known. Objective. To test the hypothesis that television viewing by infants and toddlers is associated with having irregular naptime and bedtime schedules. Methods. We used data from the National Survey of Early Childhood Health, a nationally representative, cross-sectional study of the health and health care of children 4 to 35 months of age. Our main outcome measures were whether children had irregular naptime and bedtime schedules. Our main predictor was hours of television watched on a daily basis. We performed multivariate logistic regression analyses, adjusting for a variety of factors including demographic information, measures of maternal mental health, and measures of family interactions, to test the independent association of television viewing and irregular naptime and bedtime schedules. Results. Data were available for 2068 children. Thirty-four percent of all children had irregular naptime schedules, and 27% had irregular bedtime schedules. Mean hours of television viewing per day were as follows: 0.9 hours/day (95% confidence interval [CI]: 0.8-1.0 hours/day) for children < 12 months of age, 1.6 hours/day (95% Ch 1.4-1.8 hours/day) for children 12 to 23 months of age, and 2.3 hours/day (95% CI: 2.1-2.5 hours/day) for children 24 to 35 months of age. In our logistic regression model, the number of hours of television watched per day was associated with both an irregular naptime schedule (odds ratio: 1.09; 95% Ch 1.01-1.18) and an irregular bedtime schedule (odds ratio: 1.13; 95% Ch 1.04-1.24). Conclusions. Television viewing among infants and toddlers is associated with irregular sleep schedules. More research is warranted to determine whether this association is causal, television, sleep, prevention, infants, toddlers. ABBREVIATIONS. CI, confidence interval; MHI-5, 5-item Mental Health Inventory., Children in the United States watch >19 hours of television per week. (1) Notably, this viewing begins very early in life and may be increasing, given recent attempts to market [...]

Background. No population-based studies have examined the degree to which practice parameters are followed for urinary tract infections in infants. Objective. To describe the medical care of children in their first year of life after a first urinary tract infection. Methods. Using Washington State Medicaid data, we conducted a retrospective cohort study of children with a urinary tract infection during their first year of life to determine how many of these children received recommended care based on the most recent guidelines from the American Academy of Pediatrics. Recommended care included timely anatomic imaging, timely imaging for reflux, and adequate antimicrobial prophylaxis. Multivariate logistic-regression models were used to evaluate if hospitalization for first urinary tract infection, young age at time of diagnosis, gender, race, primary language of parents, having a managed care plan, and rural location of household residence were associated with recommended care. Results. Less than half of all children diagnosed with a urinary tract infection in their first year of life received the recommended medical care. Children who were hospitalized for their first urinary tract infection were significantly more likely than children who were not hospitalized to receive anatomic imaging (relative risk [RR]: 1.38; 95% confidence interval [CI]: 1.20-1.57) and imaging for reflux (RR: 1.62; 95% CI: 1.34-1.90). Conclusions. There is poor compliance with guideline-recommended care for first urinary tract infections in infants in a Medicaid population. Given the trend toward increased outpatient management of urinary tract infections, increased attention to outpatient imaging may be warranted. Pediatrics 2005;115:1474-1478; urinary tract infections, practice parameters/guidelines, Medicaid, population-based studies. ABBREVIATIONS. ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification; CPT-4, Current Procedural Terminology, Fourth Revision; RR, relative risk; CI, confidence interval., Urinary tract infections are one of the most common acute diseases of childhood, affecting an estimated 6.5% of girls and 3.3% of boys in their first year of life. (1) [...]

Objectives. We know little about the variation in diagnosis and management of bronchiolitis. The objectives of this study were (1) to document variations in treatment and diagnostic approaches, lengths of stay (LOSs), and readmission rates and (2) to determine which potentially modifiable process of care measures are associated with longer LOSs and antibiotic usage. Methods. We used the Pediatric Health Information System, which includes demographic, diagnostic, and detailed patient-level data on 30 large children&apos;s hospitals. We examined infants who were younger than 1 year and hospitalized for bronchiolitis (October 2001-September 2003). Multivariate analysis of variance was used to determine whether the variance in the outcomes was hospital related after controlling for other covariates. Linear regression was used to model predictors of increased LOS. Logistic regression was used to model antibiotic usage. Analyses were stratified by age group ( Results. A total of 17397 patients were included in the analysis. The mean LOS was 2.97 days; 72% of patients received chest radiographs, 45% received antibiotics, and 25% received systemic steroids. The mean LOS varied considerably across hospitals (range: 2.40-3.90 days), and hospital remained a significant contributor to LOS variation after controlling for our covariates. Variations in the use of diagnostic tests and medications as well as readmission rates also existed and also remained significant after controlling for covariates. The factors associated with the greatest increases in LOS in the regression analyses included higher severity scores and use of antibiotics, bronchodilators, and corticosteroids. The strongest predictors of antibiotic use in the logistic regression analyses were higher severity scores and receipt of a blood or cerebrospinal fluid culture. Receiving a chest radiograph was a significant predictor of antibiotic use in older but not younger infants. Conclusions. Considerable, unexplained variation exists in the inpatient management of bronchiolitis. The development of national guidelines and controlled trials of new therapies and different management approaches are indicated. Pediatrics 2005;115:878-884; bronchiolitis, infants, quality of care., ABBREVIATIONS. LOS, length of stay; APR-DRG, All-Patient Refined Diagnosis Related Group; OR, odds ratio; CI, confidence interval. Most commonly caused by respiratory syncytial virus, bronchiolitis is a clinical syndrome characterized [...]

Objectives. To describe the proportion and types of medical errors that are stated to be reported via incident report systems by physicians and nurses who care for pediatric patients and to determine attitudes about potential interventions for increasing error reports. Methods. A survey on use of incident reports to document medical errors was sent to a random sample of 200 physicians and nurses at a large children&apos;s hospital. Items on the survey included proportion of medical errors that were reported, reasons for underreporting medical errors, and attitudes about potential interventions for increasing error reports. In addition, the survey contained scenarios about hypothetical medical errors; the physicians and nurses were asked how likely they were to report each of the events described. Differences in use of incident reports for documenting medical errors between nurses and physicians were assessed with [chi square] tests. Logistic regression was used to determine the association between health care profession type and likelihood of reporting medical errors. Results. A total of 140 surveys were returned, including 74 from physicians and 66 by nurses. Overall, 34.8% of respondents indicated that they had reported Conclusions. Medical errors in pediatric patients are significantly underreported in incident report systems, particularly by physicians. Some types of errors are less likely to be reported than others. Information in incident reports is not a representative sample of errors committed in a children&apos;s hospital. Specific changes in the incident report system could lead to more reporting by physicians and nurses who care for pediatric patients. Pediatrics 2004;114:729-735; medical errors, incident reports., ABBREVIATIONS. CHRMC, Children's Hospital and Regional Medical Center; OR, odds ratio; CI, confidence interval. Medical errors have been defined as a major public health problem in the United States. In [...]

Objective. To test the hypothesis that late adolescent drinking behavior (ages 17-20) is associated with harmful and binge drinking in early adulthood (ages 30-31). Methods. We used the National Longitudinal Survey of Youth (NLSY), a nationally representative longitudinal data set. We used harmful and binge drinking at ages 17 to 20 to predict harmful and binge drinking at ages 30 to 31, stratifying for gender and controlling for confounders. Results. Data were available on harmful drinking at both the adolescent and the early adult age period for 3790 individuals and on binge drinking for 2387 individuals. Harmful drinking during adolescence was significantly associated with harmful drinking at ages 30 to 31 for men only. Among male adolescents, 14% of harmful drinkers continued harmful drinking at ages 30 to 31, compared with 4% of nonharmful drinkers who became harmful drinkers. In Poisson regression models, binge drinking during adolescence was associated with binge drinking at ages 30 to 31 for both men and women, generating relative risks of 2.3 (95% confidence interval: 1.8-3.0) and 3.0 (95% confidence interval: 2.4-4.8), respectively. Half of binge-drinking male adolescents and one third of binge-drinking female adolescents engaged in binge drinking into early adulthood, compared with 19% for non-binge-drinking male adolescents and 8% of non-binge-drinking female adolescents. Conclusions. Problem drinking during adolescence is associated with problem drinking in early adulthood. Efforts to prevent and treat adolescent problem drinking could have an impact on the progression of alcohol-related disease. Pediatrics 2004;114:714-719; harmful drinking, binge drinking, alcohol use, prevention, adolescence., ABBREVIATIONS. NLSY79, National Longitudinal Survey of Youth 1979; RR, relative risk; CI, confidence interval. Alcohol disorders are among the 3 most common psychiatric disorders, with estimates from the National Comorbidity [...]

Objective. Cross-sectional research has suggested that television viewing may be associated with decreased attention spans in children. However, longitudinal data of early television exposure and subsequent attentional problems have been lacking. The objective of this study was to test the hypothesis that early television exposure (at ages 1 and 3) is associated with attentional problems at age 7. Methods. We used the National Longitudinal Survey of Youth, a representative longitudinal data set. Our main outcome was the hyperactivity subscale of the Behavioral Problems Index determined on all participants at age 7. Children who were [greater than or equal to] 1.2 standard deviations above the mean were classified as having attentional problems. Our main predictor was hours of television watched daily at ages 1 and 3 years. Results. Data were available for 1278 children at age 1 and 1345 children at age 3. Ten percent of children had attentional problems at age 7. In a logistic regression model, hours of television viewed per day at both ages 1 and 3 was associated with attentional problems at age 7 (1.09 [1.03-1.15] and 1.09 [1.02-1.16]), respectively. Conclusions. Early television exposure is associated with attentional problems at age 7. Efforts to limit television viewing in early childhood may be warranted, and additional research is needed. Pediatrics 2004;113:708-713; ADHD, television, attentional problems, prevention., Attention-deficit/hyperactivity disorder (ADHD) affects between 4% and 12% of US children and is the most common behavioral disorder of childhood. (1-5) Despite decades of research, there are still significant gaps [...]

Background. We recently found documentation discrepancies in 60% of resident daily-progress notes with respect to patient weight, medications, or vascular lines. To what extent information systems can decrease such discrepancies is unknown. Objective. To determine whether a point-of-care personal digital assistant (PDA)-based patient record and charting system could reduce the number of resident progress-note documentation discrepancies in a neonatal intensive care unit (NICU). Design/Methods. We conducted a before-and-after trial in an academic NICU. Our intervention was a PDA-based patient record and charting system used by all NICU resident physicians over the study period. We analyzed all resident daily-progress notes from 40 randomly selected days over 4 months in both the baseline and intervention periods. Using predefined reference standards, we determined the accuracy of recorded information for patient weights, medications, and vascular lines. Logistic and Poisson regression were used in analyses to control for potential confounding factors. Results. A total of 339 progress notes in the baseline period and 432 progress notes in the intervention period were reviewed. When controlling for covariates in the regression, there were significantly fewer documentation discrepancies of patient weights in notes written by using the PDA system (14.4%-4.4% of notes; odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.15-0.56). When using the PDA system, there were no significant changes in the numbers of notes with documentation discrepancies of medications (27.7%-17.1% of notes; OR: 0.63; 95% CI: 0.35-1.13) or vascular lines (33.6%-36.1% of notes; OR: 1.11; 95% Ch 0.66-1.87). Conclusions. The use of our PDA-based point-of-care patient record and charting system showed a modest benefit in reducing the number of documentation discrepancies in resident daily-progress notes. Further study of PDAs in information systems is warranted before they are widely adopted. Pediatrics 2004;113:450-454; resident, documentation, PDA, NICU. ABBREVIATIONS. IOM, Institute of Medicine; PDA, personal digital assistant; NICU, neonatal intensive care unit; OR, odds ratio., The 1999 report by the Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System, made medical error prevention an important goal of many organizations by reporting [...]

Background. Personal digital assistants (PDAs) are being increasingly used in medical practice. Although they have been touted as having the ability to improve efficiency and safety, little is known about pediatricians&apos; use of and attitudes about PDAs. Objective. Our goals were to 1) determine the percentage of pediatricians using PDAs and computers, 2) determine perceived strengths and weaknesses of PDAs, and 3) explore characteristics associated with beliefs and use. Design/Methods. Pediatricians (2130) were selected randomly from the American Medical Association Physician Masterfile of US-licensed physicians. All participants were mailed a survey along with a prepaid return envelope and a $1 incentive. Up to 3 mailings were sent per participant. Results. Of eligible participants, 63.2% returned a survey. There were no significant differences between respondents and nonrespondents with respect to sex, type of practice, and present employment. Thirty-five percent of respondents currently use PDAs at work, and 40% currently use PDAs for personal use. Of those using PDAs, the most commonly used applications were for drug reference (80%), personal scheduling (67%), and medical calculations (61%). Few pediatricians are currently using PDAs for prescription writing (8%) or billing (4%). Users of PDAs were more likely to be male (adjusted odds ratio [AOR]: 2.29; 95% confidence interval [CI]: 1.64-3.19), in an urban community (AOR: 1.81; 95% Ch 1.30-2.55), in training (AOR: 2.64; 95% CI: 1.58-4.42), not in private practice (AOR: 1.47; 95% Ch 1.03-2.11), and a more recent graduate of medical school (AOR: 1.04 per year; 95% CI: 1.02-1.06). When controlling for covariates, those using PDAs were more likely to believe that PDAs can decrease medical errors (AOR: 2.22; 95% Ch 1.46-3.38) and increase efficiency (AOR: 2.40; 95% CI: 1.56-3.71). When compared with nonusers, users were less likely to view the small screen size (AOR: 0.53; 95% CI: 0.37-0.77) or system speed (AOR: 0.47; 95% Ch 0.26-0.84) as a problem but were significantly more likely to view memory as an issue (AOR: 3.48; 95% Ch 2.30-5.25). Conclusions. More than one third of pediatricians are using PDAs in clinical practice. There seems to be a general consensus among users that they have the potential to improve patient safety and streamline care. Future studies should explore means to utilize their potential. Pediatrics 2004;113:238-242; pediatrician, hand-held, PDA, computer., Portable information technology is increasingly being used in clinical practice. Personal digital assistants (PDAs) have the ability to allow clinicians to enter and access data both remotely and at the [...]

Objective. The validity of research presented at scientific meetings continues to be a concern. Presentations are chosen on the basis of submitted abstracts, which may not contain sufficient information to assess the validity of the research. The objective of this study was to determine 1) the proportion of abstracts presented at the annual Pediatric Academic Society (PAS) meeting that were ultimately published in peer reviewed journals; 2) whether the presentation format of abstracts at the meeting predicts subsequent full publication; and whether the presentation format was related to 3) the time to full publication or 4) the impact factor of the journal in which research is subsequently published. Methods. We assembled a list of all abstracts submitted to the PAS meetings in general pediatrics categories in 1998 and 1999, using both CD-ROM and journal publications. In each year, we chose up to 80 abstracts from each presentation format ("publish only," "poster," "poster symposium," "platform presentation"). We chose either 1) all abstracts in each format or 2) when there were >80 abstracts, a random selection of 80 of them. We assessed each selected abstract for subsequent full publication by searching Medline in March 2003; if published, then we recorded the journal, month, and year of publication. We used logistic and linear regression to determine whether publication, time to publication, and the journal&apos;s impact factor were associated with the abstract&apos;s presentation format. Results. Overall, 44.6% of abstracts presented at the PAS meeting achieved subsequent full publication within 4 to 5 years. There were significant differences between the rates of subsequent full publication of abstracts submitted but not chosen for presentation at the meeting (22.2%) and those that were chosen for presentation in poster sessions (40.0%), poster symposia (44.1%), and platform presentations (53.8%). There were no meaningful differences between the presentation formats in their mean time to publication and their mean journal impact factor. Conclusions. PAS meeting attendees and the press should be cautious when interpreting the presentation format of an abstract as a predictor of either its subsequent publication in a peer-reviewed journal or the impact factor of the journal in which it will appear. Pediatrics 2003;112:1238-1241; pediatrician, abstract, publication, meeting., One of the primary purposes of presenting research at scientific meetings is to disseminate important research findings as soon as possible. However, the validity of research presented at scientific meetings [...]

Context. Medical errors are common and potentially dangerous. Little is known about the role of documentation errors. Objective. To determine the proportion of resident physician progress notes that contained discrepancies, and to identify predictors of such discrepancies. Design/Methods. We conducted a retrospective cross-sectional chart review of resident physician progress notes over 40 random days in a 4-month period in a neonatal intensive care unit. Using predetermined criteria, we compared resident documentation of patient weights, medications, and vascular lines to other sources of information and recorded the numbers of documentation discrepancies. Results. There were discrepancies in 209 (61.7%) notes with respect to weight, vascular lines, or medications. Discrepancies occurred in the documentation of medications in 103 (27.7%) progress notes, of vascular lines in 119 (33.9%) progress notes, and of weights in 45 (13.3%) progress notes. Notes both omitted information regarding medications (18.2%) and vascular lines (13.9%) and documented inaccurate information regarding medications (18.6%) and vascular lines (30.1%). Patients with more medications or vascular lines, and with longer lengths of stay, were significantly more likely to have higher rates of documentation errors. Conclusions. Daily progress notes written by resident physicians in the neonatal intensive care unit often contain inaccurate, or omit pertinent, information. Alternative means or methods of documentation are warranted. Pediatrics 2003;111:976-980; resident, documentation, errors, NICU., ABBREVIATIONS. NICU, neonatal intensive care unit; pm, as needed; IRR, incident rate ratio; CI, confidence interval. Medical errors are reported to be common and potentially dangerous. (1) The Institute of [...]

Context. End-of-life care is an important yet underdeveloped component of pediatric hospital services. Objectives. We sought 1) to describe the demographics of children who die in children&apos;s hospitals, 2) to describe the prevalence of complex chronic conditions (CCCs) among these cases, and 3) to test the hypotheses that cases with a greater number of CCC diagnoses experience longer periods both of mechanical ventilation and of hospitalization before death. Design and Methods. We identified all deaths of patients 0 to 24 years old that occurred in the 60 hospitals contributing discharge data to the National Association of Children&apos;s Hospitals and Related Institutions data consortium for the years 1991, 1994, and 1997. We classified discharge diagnoses into 9 major categories of CCCs (cardiovascular, neuromuscular, malignancy, respiratory, renal, metabolic, gastrointestinal, hematologic/immunologic, and other congenital/genetic). Results. Of the 13 761 deaths identified, 42% had been admitted between 0 and 28 days of life, 18% between 1 and 12 months, 25% between 1 and 9 years, and 15% between 10 and 24 years. Fifty-three percent were white, 20% were black, and 9% were Hispanic. The principal payer was listed as a governmental source for 42% and a private insurance company for 35%. Based on all the discharge diagnoses recorded for each case, 40% had no CCC diagnosis, 44% had diagnoses representing 1 major CCC category, 13% had diagnoses representing 2 CCC categories, and 4% had diagnoses representing 3 or more CCC categories. Among cases that had no CCC diagnoses, the principal diagnoses were related to prematurity and newborn disorders for 32% of these cases, injuries and poisoning for 26%, and an assortment of acute and infectious processes for the remaining 42%. Mechanical ventilation was provided to 66% of neonates, 40% of infants, 36% of children, and 36% of adolescents. Cases with CCCs were more likely than non-CCC cases to have been mechanically ventilated (52% vs 46%), and to have been ventilated longer (mean: 11.7 days for CCC cases vs 4.8 days for non-CCC cases). The median duration of hospitalization was 4 days, while the mean was 16.4 days. After adjustment for age, sex, year, and principal payer, compared with patients with no CCC diagnoses, those with 1 major CCC category had a significantly lower hazard of dying soon after admission (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.57-0.62), those with 2 CCC categories even lower (HR: 0.53; 95% CI: 0.50-0.57), and those with 3 or more CCC categories the lowest hazard of rapid death (HR: 0.51; 95% CI: 0.46-0.57). This trend of diminishing hazard of rapid death was significant across the 3 groups of children with 1 or more CCCs. Conclusions. Children&apos;s hospitals care for a substantial number of dying patients, who differ widely by age and medical conditions. Children who die in the hospital with CCCs are more likely to experience longer periods of mechanical ventilation and hospitalization before death. Pediatrics 2002;109:887-893; palliative care, terminal care, hospice care, hospitalization, mortality, chronic disease., The past decade has seen a surge of interest in how our society and its medical system care for dying patients. (1-5) The pediatric health care community more specifically has [...]

Objective. Childhood diarrhea accounts for substantial morbidity and mortality worldwide. Multiple studies in children have shown that Lactobacillus, administered orally, may have antidiarrheal properties. We conducted a meta-analysis of randomized, controlled studies to assess whether treatment with Lactobacillus improves clinical outcomes in children with acute infectious diarrhea. Methods. Studies were sought in bibliographic databases of traditional biomedical as well as complementary and alternative medicine literature published from 1966 to 2000. Search terms were "competitive inhibition," "diarrhea," "gastroenteritis," "Lactobacillus," "probiotic," "rotavirus," and "yog(h)urt." We included studies that were adequately randomized, blinded, controlled trials in which the treatment group received Lactobacillus and the control group received an adequate placebo and that reported clinical outcome measures of diarrhea intensity. These inclusion criteria were applied by blind review and consensus. The original search yielded 26 studies, 9 of which met the criteria. Multiple observers independently extracted study characteristics and clinical outcomes. Data sufficient to perform meta-analysis of the effect of Lactobacillus on diarrhea duration and diarrhea frequency on day 2 were contained in 7 and 3 of the included studies, respectively. Results. Summary point estimates indicate a reduction in diarrhea duration of 0.7 days (95% confidence interval: 0.3-1.2 days) and a reduction in diarrhea frequency of 1.6 stools on day 2 of treatment (95% confidence interval: 0.7-2.6 fewer stools) in the participants who received Lactobacillus compared with those who received placebo. Details of treatment protocols varied among the studies. A preplanned subanalysis suggests a dose-effect relationship. Conclusion. The results of this meta-analysis suggest that Lactobacillus is safe and effective as a treatment for children with acute infectious diarrhea. Pediatrics 2002; 109:678-684; gastroenteritis, infectious diarrhea, Lactobacillus, meta-analysis, rotavirus. ABBREVIATIONS. ID, acute infectious diarrhea; ORS, oral rehydration solution; CI, confidence interval., Diarrhea is common among children and contributes substantially to pediatric morbidity and mortality worldwide. In the United States, an estimated 21 million to 37 million episodes of diarrhea occur among [...]

Objective. Little is known about factors that influence whether children with chronic conditions die at home. We sought to test whether deaths attributable to underlying complex chronic conditions (CCCs) were increasingly occurring at home and to determine what features were associated with home deaths. Design. A retrospective case series was conducted of all deaths that occurred to children age 0 to 18 years in Washington state from 1980 to 1998 using death certificate data, augmented with 1990 US Census data regarding median household income by zip code in 1989, to determine the site of death. Results. Of the 31 455 deaths identified in infants, children, and adults younger than 25 years, 52% occurred in the hospital, 17.2% occurred at home, 8.5% occurred in the emergency department or during transportation, 0.4% occurred in nursing homes, and 21.7% occurred at other sites. Among children who died as a result of some form of CCC (excluding injury, sudden infant death syndrome, and non-CCC medical conditions), the percentage of cases younger than 1 year who died at home rose slightly from 7.8% in 1980 to 11.6% in 1998, whereas the percentage of older children and young adults who had a CCC and died at home rose substantially from 21% in 1980 to 43% in 1998. Children who had lived in more affluent neighborhoods were more likely to have died at home. Using leukemia-related deaths as a benchmark, deaths as a result of congenital, genetic, neuromuscular, and metabolic conditions and other forms of cancer all were more likely to have occurred at home. Significant variation in the likelihood of home death, not explained by the individual attributes of the cases, also existed across the 39 counties in Washington state. Conclusions. Children who die with underlying CCCs increasingly do so at home. Age at death, specific condition, local area affluence, and the location of home all influence the likelihood of home death. These findings warrant additional study, as they have implications for how we envision pediatric palliative care, hospice, and other supportive services for the future. Pediatrics 2002;109:656-660; location of death, chronic illness, palliative care, end of life care, medical geography. ABBREVIATIONS. CCC, complex chronic condition; ICD-9, International Classification of Diseases, Ninth Revision; AOR, adjusted odds ratio; CI, confidence interval., In the realm of end-of-life care for adults, much emphasis has been placed on where death occurs. During the past few decades, several population-based studies have shown that--despite most patients' [...]

Many pediatricians are familiar with clinical practice guidelines (CPG), but fewer appear to find them helpful or alter their medical practices accordingly. CPGs provide guidelines for treating particular conditions, and are designed to improve patient care and control costs. Researchers surveyed 300 pediatricians about CPGs for elevated blood bilirubin in newborns, fever in infants, ear infections, and preventive care. A majority of doctors were familiar with most of the CPGs, but on average found them only moderately helpful. Younger pediatricians were more likely to use CPGs in practice., Background. The increasing complexity of medical care and a desire to increase quality and control costs have led to growing use of clinical practice guidelines (CPGs). It is unclear how helpful these guidelines are to the practitioners expected to use them. We surveyed pediatricians about their knowledge and impressions of four well-publicized CPGs: the American Academy of Pediatrics&apos; "Practice Parameter for Hyperbilirubinemia in Newborns" (hyperbilirubinemia), "A Guideline for the Management of Febrile Infants" (fever), the Agency for Health Care Policy and Research&apos;s "Guideline for Otitis Media With Effusion" (otitis), and the US Preventive Services Task Force Guide to Clinical Preventive Services preventive care). Objectives. 1) What percentage of practicing pediatricians are aware of these guidelines? 2) How helpful do they find them? 3) What are practitioners&apos; perceived limitations of these guidelines? 4) Have these guidelines affected provider behavior? 5) Are there features of a provider&apos;s training or practice that are associated with changing practice as a result of guidelines? Design. A national survey of 600 pediatricians selected at random from the American Medical Association master file. Results. A total of 300 of 555 eligible participants (54%) returned surveys. Of the respondents, 66% were aware of the hyperbilirubinemia guideline, 64% of the fever guideline, 50% of the otitis guideline, but only 16% knew of the preventive care guidelines. Mean helpfulness scores (1 to 10 scale, where 1 = "not at all helpful" and 10 = "extremely helpful") ranged from 3.67 to 6.67 for the different guidelines. In terms of limitations, 15% to 33% of respondents reported that CPGs were "too cookbook," 6% to 19% reported that they were "too time-consuming," and 4% to 16% reported that they were "too cumbersome." Additional reported limitations were believing that a guideline left no room for personal experience and judgment, concern of increased liability risk, and poor parental acceptance of CPG recommendations. The proportions reporting change in management as a result of a CPG were 28% for the hyperbilirubinemia guideline, 36% for the fever guideline, 19% for the preventive care guidelines, and 28% for the otitis guideline. Mean helpfulness scores reported by nonuniversity-affiliated physicians were significantly higher than those reported by university-affiliated physicians. In a regression model of respondents aware of a particular guideline, more recent graduation from medical school and increased helpfulness scores were associated with guideline-related behavior change. Conclusion. In their present form, CPGs are not perceived as very helpful by most practitioners. More recent medical school graduates and nonuniversity-affiliated physicians are more likely to find them helpful and more likely to change their behavior because of them. Pediatrics 1998;101:825-830; practice guideline, pediatrics, evidence-based medicine, survey., ABBREVIATIONS. CPG, clinical practice guideline; AHCPR, Agency for Health Care Policy and Research; USPSTF, US Preventive Services Task Force; AAP, American Academy of Pediatrics; AMA, American Medical Association. Clinical practice [...]

To the Editor.-- In a recent issue of Pediatrics, Christakis et all reported an association between the number of hours of watching television close to 2 and 4 years and [...]

To the Editor.-- Garrison and Christakis[1] justify their systematic review by pointing at some presumed methodologic shortcomings of our systematic review, published in 1998.[2] In fact, the conclusion of their [...]

A Trade-off Analysis of Routine Newborn Circumcision To the Editor.-- The paper by Dr Christakis et al, is informative and important in presenting the risks associated with newborn circumcision. It [...]

Objectives. Advances in medical technology and public health are changing the causes and patterns of pediatric mortality. To better inform health care planning for dying children, we sought to determine if an increasing proportion of pediatric deaths were attributable to an underlying complex chronic condition (CCC), what the typical age of CCC-associated deaths was, and whether this age was increasing. Design. Population-based retrospective cohort from 1980 to 1997, compiled from Washington State annual censuses and death certificates of children 0 to 18 years old. Main Outcome Measures. For each of 9 categories of CCCs, the counts of death, mortality rates, and ages of death. Results. Nearly one-quarter of the 21 617 child deaths during this period were attributable to a CCC. Death rates for the sudden infant death syndrome (SIDS), CCCs, and all other causes each declined, but less so for CCCs. Among infants who died because of causes other than injury or SIDS, 31% of the remaining deaths were attributable to a CCC in 1980 and 41% by 1997; for deaths in children 1 year of age and older, CCCs were cited in 53% in 1980, versus 58% in 1997. The median age of death for all CCCs was 4 months 9 days, with substantial differences among CCCs. No overall change in the age of death between 1980 to 1997 was found (nonparametric trend test). Conclusions. CCCs account for an increasing proportion of child deaths. The majority of these deaths occur during infancy, but the typical age varies by cause. These findings should help shape the design of support care services offered to children dying with chronic conditions and their families. Pediatrics 2000; 106:205-209; complex chronic conditions, population-based study, pediatric deaths, mortality trends., ABBREVIATIONS. CCC, complex chronic condition; ICD-9, International Classification of Diseases, Ninth Revision; SIDS, sudden infant death syndrome. What kinds of children are likely to require end-of-life care in the future? [...]

Objective: To conduct a systematic review of rigorously evaluated treatments for infant colic. Methods. Online bibliographic databases were searched for the term "colic" in articles classified as clinical trials or randomized controlled trials and conducted in infants. Reference lists from review articles, meta-analyses, and the selected articles were also reviewed for potential studies. The abstracts or full-text articles of 57 relevant studies were examined, of which 22 met the selection criteria. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study methods, intervention studied, outcomes measured, and results. Results. Four of the interventions studied had data of adequate quality and statistically significant numbers needed to treat (NNT): hypoallergenic diet (NNT = 6), soy formula (NNT = 2), reduced stimulation (NNT = 2), and herbal tea (NNT = 3). Conclusions. There are some effective therapies for infant colic, but additional rigorous studies of existing and alternative therapies are needed. Pediatrics 2000; 106:184-190; colic, treatment, infant, systematic review., ABBREVIATIONS. RCTs, randomized controlled trials; NNT, number needed to treat; RR, relative risk; CI, 95% confidence interval. Affecting as many as 16% to 26% of newborn children in the first [...]

To the Editor.-- I read with concern the article by Tarini et al, (1) which focused on estimated false-positive results from expanded newborn screening by tandem mass spectrometry (MS/MS) and [...]

To the Editor.-- We read with interest the article "There Is No Meaningful Relationship Between Television Exposure and Symptoms of Attention-Deficit/Hyperactivity Disorder" (1) by Stevens and Mulsow. The authors contrast [...]