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Objective: To determine predictors of influenza virus vaccination status in children who are hospitalized during the influenza season., Methods: A cross-sectional study was conducted among children who were hospitalized with fever between 6 months and 3 years of age or with respiratory symptoms between 6 months and 18 years of age. The 1999 to 2000 influenza vaccination status of hospitalized children and potential factors that influence decisions to vaccinate were obtained from a questionnaire administered to parents/guardians., Results: Influenza vaccination rates for hospitalized children with and without high-risk medical conditions were 31% and 14%, respectively. For both groups of children, the vaccination status was strongly influenced by recommendations from physicians. More than 70% of children were vaccinated if a physician had recommended the influenza vaccine, whereas only 3% were vaccinated if a physician had not. Lack of awareness that children can receive the influenza vaccine was a commonly cited reason for nonvaccination., Conclusions: A minority of hospitalized children with high-risk conditions had received the influenza vaccine. However, parents' recalling that a clinician had recommended the vaccine had a positive impact on the vaccination status of children.

The American Academy of Pediatrics and its members are committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults. In response to a 1999 Institute of Medicine report on building a safer health system, a set of principles was established to guide the profession in designing a health care system that maximizes quality of care and minimizes medical errors through identification and resolution. This set of principles provides direction on setting up processes to identify and learn from errors, developing performance standards and expectations for safety, and promoting leadership and knowledge.

Objective: To compare perinatal outcomes among the managed care organizations (MCOs) providing care to beneficiaries enrolled in TennCare, Tennessee's capitated Medicaid managed care program., Design: Retrospective cohort analysis., Subjects: Infants born in Tennessee during 1995 to women enrolled in TennCare., Primary Outcome Measures: Prenatal care use, birth weight (BW), death in the first 60 days of life, and delivery of extremely low BW (<1000 g) infants in hospitals without level 3 neonatal intensive care units., Results: During 1995, 34 402 infants were born to mothers enrolled in TennCare. The MCOs differed widely in the demographic characteristics of their enrollees. In addition, there were small differences in prenatal care utilization, but no differences in BW outcomes among the MCOs. In multivariate analysis, however, infants born to women enrolled in 1 MCO were 2.8 times more likely to die in the first 60 days of life than were infants born to women enrolled in the largest MCO (OR: 2.81; 95% CI: 1.31-6.03). Women enrolled in this same MCO seemed to have a higher proportion of extremely low BW (<1000 g) infants delivering in a hospital lacking a level 3 neonatal intensive care unit (38% vs 20% in the largest MCO)., Conclusion: The differences among MCOs in early infant death and in the delivery of high-risk infants in hospitals lacking appropriate neonatal facilities suggest that monitoring of care delivery to vulnerable children should include assessment of appropriate use of specialized services.

Objectives: To identify sociodemographic predictors of infant injury mortality and to compare trends in injury mortality rates for high- and low-risk US infants from 1985 to 1991., Design: Historical cohort. SETTING/STUDY PARTICIPANTS: The National Center for Health Statistics linked US infants (<1 year) born from 1985 to 1991 with death certificates., Main Outcome Measures: Multivariate regression was used to identify sociodemographic factors associated with injury mortality. The adjusted relative risks (RRs) of maternal age, education, marital status, number of other children, and infant birth weight were used to categorize infants into risk groups. We compared trends in injury rates for the highest and lowest risk groups., Results: There were 5963 injury deaths and 18.6 million infant years or 32.1 injury deaths per 100 000 infant years. Highest risk infants were born to mothers who were younger than 20 years compared with older than 30 years (RR, 3.25; 95% CI, 2.92-3.63), had less than a high school education compared with a college education (RR, 2.22; 95% CI, 1.95-2.53), had more than 2 other children compared with no other children (RR, 3.15; 95% CI, 2.88-3.45), were unmarried (RR, 1.67; 95% CI, 1.57-1.78), or had birth weights 2500 g (RR, 3.36; 95% CI, 2.94-3.84). Infants in the highest risk group (21.0% of the population) had a >10-fold increased risk of injury mortality compared with the lowest risk group (18.1% of the population) and there was no evidence that this disparity was narrowing., Conclusions: Sociodemographic predictors of infant injury mortality include maternal age, education, number of other children, marital status, and infant birth weight. Based on these factors, 1 in 5 infants in the United States can be identified at birth as having a >10-fold increased risk of injury mortality compared with infants in lowest risk group. Programs to reduce injuries in these high-risk groups are urgently needed.

Background: In the United States in 1994, fires claimed 3.75 lives per 100 000 child years and accounted for 17.3% of all injury deaths in children <5 years of age., Objectives: To conduct a historical cohort study that uses maternal demographic characteristics to identify young children at high risk of fire-related deaths, thus defining appropriate targets for prevention programs., Methods: The cohort consisted of children born to mothers who resided in the state of Tennessee between 1980 and 1995. Information was obtained by linking birth certificates, 1990 census data, and death certificates. Children were eligible for the study if they were <5 years of age at any time within the study period and if key study variables were present (99.2% of births). Birth certificates provided information on maternal characteristics including age, race, education, previous live births, use of prenatal care, and residence (in standard metropolitan statistical area). Child characteristics included gender, gestational age, and birth type (singleton/multiple gestation). Neighborhood income was estimated by linking the mother's address at the time of birth to the 1990 census (block group mean per capita income). The study outcome was a fire resulting in at least one fatality (fatal fire event) during the study period, identified from death certificates (coded E880 through E889 in the International Classification of Diseases, 9th rev). We calculated the fatal fire event rate corresponding to each stratum of maternal/child characteristics. We assessed the independent association between each characteristic and the risk of a fatal fire event from a Poisson regression multivariate analysis., Results: During the study period, 1 428 694 children contributed 5 415 213 child years to the cohort: there were 270 deaths from fire (4.99 deaths per 100 000 child years) and 231 fatal fire events. In the multivariate analysis, factors associated with greater than a threefold increase in fatal fire events included maternal education, age, and number of other children. Compared with children whose mothers had a college education, children whose mothers had less than a high school education had 19.4 times (95% confidence interval [CI], 2.6-142.4) an increased risk of a fatal fire event. Children whose mothers had more than two other children had 6.1 times (95% CI, 3.8-9.8) an increased risk of a fatal fire event compared with children whose mothers had no other children. Children of mothers <20 years of age had 3.9 times (95% CI, 2.2-7.1) increased risk of a fatal fire event compared with children whose mothers were >/=30 years old. Although both maternal neighborhood income and race were associated strongly with increased rates of fatal fire events in the univariate analysis, this association did not persist in the multivariate analysis. Other factors that were associated with increased risk of fatal fire events in the multivariate analysis were male gender and having a mother who was unmarried or who had delayed prenatal care. The three factors associated most strongly with fire mortality were combined to create a risk score based on maternal education (>/=16 years, 0 points; 13 to 15 years, 1 point; 12 years, 2 points; <12 years, 3 points); age (>/=30 years, 0 points; 25 to 29 years, 1 point; 20 to 24 years, 2 points; <20 years, 3 points); and number of other children (none, 0 points; one, 1 point; two, 2 points; three or more, 3 points). The lowest-risk group (score <3) included 19% of the population and had 0.19 fatal fire events per 100 000 child years. In contrast, highest-risk children (score >7) comprised 1.5% of the population and had 28.6 fatal fire events per 100 000 child years, 150 times higher than low-risk children. Children with risk scores >5 contributed 26% of child years but experienced 68% of all fatal fire events. If the fatal fire event rate for all children had been equal to that of the low-risk group (risk score <3), then 95% of deaths from

Objective: To assess parents' knowledge and opinions about immunizations and immunization practices before and after introduction of vaccine information pamphlets., Research Design: Telephone questionnaire administered to parents whose children received immunizations in the preceding week., Setting: Six private pediatric practices in Nashville area and resident continuity clinic at Vanderbilt University Medical Center., Participants: Parents whose children were scheduled to receive immunizations were asked to participate. Interviews were completed with 177 parents whose children received immunizations before and 156 parents after pamphlets were introduced. These two groups of parents had similar demographic characteristics., Results: Parents who received vaccine information pamphlets learned more about vaccines (2.38 facts/parent after vs 1.18/parent before vaccine information pamphlets, z = -6.28, P < .0001) and were more eager to obtain immunizations for their children (76% vs 38%, chi 2 = 47.24, P < .001). Receipt of pamphlets did not make parents significantly more likely to report side effects from vaccines (63% after vs 55% before, NS) but tended to make them less likely to turn to non health care providers for information (58% after vs 69% before, chi 2 = 3.73, P = .06). Parents who received pamphlets, however, said more often that they received too much information (20% vs 4%, chi 2 = 14.9, P < .001)., Conclusions: Vaccine information pamphlets enhanced parents' knowledge and acceptance of immunizations. There is room for further improvement.

Promethazine, available by prescription only since its introduction in 1946, has been widely used for pediatric patients because of its antihistaminic, antiemetic, and sedative properties. Recently, it's makers have sought Federal Drug Administration approval to introduce two liquid over the counter allergy/cold/cough products containing promethazine as an active ingredient. Although millions of doses have been administered, promethazine use has not been free of risk. Promethazine has been reported to cause significant sedation, agitation, hallucinations, seizures, dystonic reactions, and possibly apparent life-threatening events or sudden infant death syndrome. The impact of these relatively uncommon adverse reactions on children would be minimal if parents would use over the counter promethazine only for appropriate indications and only in children greater than 2 years of age. However, according to results of research evaluating the use of various over the counter medications by families for their children, promethazine will be used inappropriately. Both its over the counter status, implying a certain margin of safety, and its formulation as a syrup, providing ease of administration, should increase its use in all age groups including that by children less than 2 years of age who may be most vulnerable to the adverse reactions associated with the drug's use.

We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P less than .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

A surplus of general pediatricians has been predicted for 1990. This surplus could provide both opportunity and need for practitioners to identify areas of maternal concern that might guide expansion of marketable physician services. For this purpose, maternal concerns were assessed by interviewing 207 mothers seeking care in private pediatric offices. Only 30% of mothers were most worried about their child's physical health. The remaining 70% were most concerned about problems falling into six categories of parenting, behavior, and development (psychosocial concerns): personality/social development, discipline, mental development, mother-child interaction time, adjustment to divorce and other life changes, and adolescent transition. Although the majority of these concerns conceivably could be handled in private offices, only 28% of these mothers had discussed their greater psychosocial concern with their pediatrician. A search for explanations of this failure to communicate indicated mothers often were not aware that their pediatrician could help, or they questioned his ability or interest in assisting them. Characteristics that correlated significantly with communication were higher family socioeconomic levels, and greater physician self-perceived ability and interest in these psychosocial problems. Parenting, behavior, and development concerns represent an opportunity for expanding services if some of these obstacles can be overcome.

Nine infants with apparent life-threatening events that occurred as a result of poisoning by a caretaker are described. These episodes were characterized by apnea plus some combination of color change, choking or gagging, and abnormal muscle tone. Five of the infants responded to vigorous stimulation, and four required cardiopulmonary resuscitation. Most poisonings (seven infants) were detected by a urine drug screen. Medications detected included acetaminophen, amphetamine, benzodiazepines (two infants), cocaine, codeine, meperidine (two infants), Methadone, phenobarbital, and phenothiazines (three infants). Four infants received two or more drugs. Most perpetrators of the poisonings were mothers (seven) and five of the parents admitted administering the various agents. Reasons for the poisonings included an apparent attempt to harm an infant, the need to sedate a fussy infant, or a gross misunderstanding of the potential risk of various agents to infants. Because no history of drug administration was elicited at the time of hospital admission, six infants might have been discharged with a diagnosis of apnea of infancy had not an attempt been made to investigate the possibility of poisoning. These cases suggest that poisoning by a caretaker should be added to the differential diagnosis of any infant brought to medical attention because of an apparent life-threatening event and that urine drug screening should be considered in the evaluation.

To investigate the process by which families identified and selected their children's current physicians, a close-ended questionnaire was administered to 750 families in a mail panel. Of 630 responses (84.0%), 244 had children in the home; 229 (93.9%) identified a regular and current physician for their youngest child. However, parents did not spend much time or energy selecting a physician and rarely explored medical expertise in their decisions. Families averaged 1.2 sources of information consulted per decision; few considered more than two physician choices and infrequently considered alternative types of doctors (pediatricians v family or general practitioners). Selection priorities ranked in order of importance concerned parents' perceptions of their doctors' communication skills, accessibility, and quality as determined by recommendations of friends or physicians. Parents appeared less concerned with issues of cost and convenience. Families selecting pediatricians differed from those selecting family and general practitioners in sources of information used and selection priorities. The survey also identified 84 families who had changed or seriously considered changing the physician who was caring for their youngest child. The most frequent dissatisfaction was the perception that an illness was not being managed adequately, followed by believing that the doctor or staff were rude or unconcerned. Families unhappy with pediatricians expressed different reasons from those unhappy with family or general practitioners. The study results provide insight about the first step in obtaining child health care services, a relatively unexplored area of patient decision making.