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The article presents a study which assessed how parents' confidence in childhood vaccines changed during the COVID-19 pandemic. Topics include data used in the study, trends in the percentage of parents who strongly agreed or agreed with statements presented about childhood vaccines, and the important role of pediatricians in addressing parents' concerns about childhood vaccines.

OBJECTIVE. Streptococcus pneumoniae is an important cause of otitis media in children. In this study we estimated the effect of routine childhood immunization with heptavalent pneumococcal conjugate vaccine on frequent otitis media (3 episodes in 6 months or 4 episodes in 1 year) and pressure-equalizing tube insertions. PATIENTS AND METHODS. The study population included all children who were enrolled at birth in TennCare or selected upstate New York commercial insurance plans as of July 1998 and continuously followed until 5 years old, loss of health plan enrollment, study outcome, or end of the study. We compared the risk of developing frequent otitis media or having pressure-equalizing tube insertion for 4 birth cohorts (1998-1999, 1999-2000, 2000-2001, and 2001-2002) by using Cox regression analysis. We used data from the National Immunization Survey to estimate the heptavalent pneumococca] conjugate vaccine uptake for children in these 4 birth cohorts in Tennessee and New York. RESULTS. The proportion of children in Tennessee and New York who received at least 3 doses of heptavalent pneumococcal conjugate vaccine by 2 years of age increased from [less than or equal to] 1% for the 1998-1999 birth cohort to ~75% for the 2000-2001 birth cohort. By age 2 years, 29% of Tennessee and New York children born in 2000-2001 had developed frequent otitis media, and 6% of each of these birth cohorts had pressure-equalizing tubes inserted. Comparing the 2000-2001 birth cohort to the 1998-1999 birth cohort, frequent otitis media declined by 17 % and 28%, and pressure-equalizing tube insertions declined by 16% and 23% for Tennessee and New York children, respectively. For the 2000-2001 to the 2001-2002 birth cohort, frequent otitis media and pressure-equalizing tubes remained stable in New York but increased in Tennessee. CONCLUSIONS. After heptavalent pneumococcal conjugate vaccine introduction, children were less likely to develop frequent otitis media or have pressure-equalizing tube insertions. Key Words otitis media, pressure-equalizing tubes, middle ear ventilation tubes, tympanostomy tubes, epidemiology, pneumococcal conjugate vaccine, Streptococcus pneumoniae is an important cause of otitis media, a common childhood illness that has resulted in an estimated $5.3 billion annually in direct medical costs across the United States. [...]

Pediatric professionals are being asked to provide an increasing array of services during well-child visits, including screening for psychosocial and family issues that may directly or indirectly affect their pediatric patients. One such service is routine screening for postpartum depression at pediatric visits. Postpartum depression is an example of a parental condition that can have serious negative effects for the child. Because it is a maternal condition, it raises a host of ethical and legal questions about the boundaries of pediatric care and the pediatric provider's responsibility and liability. In this article we discuss the ethical and legal considerations of, and outline the risks of screening or not screening for, postpartum depression at pediatric visits. We make recommendations for pediatric provider education and for the roles of national professional organizations in guiding the process of defining the boundaries of pediatric care. Key Words postpartum depression, screening tools. well-child care, WHEN A PEDIATRICIAN or pediatric health care provider walks into an examination room for a well-child visit, who is the patient? It is the child, of course, but within the [...]

BACKGROUND. Pneumococcal conjugate vaccine immunization recommendations were rapidly implemented by primary care providers. Before the recommendations, concern was expressed that adding pneumococcal conjugate vaccine might result in delays in other vaccinations or preventive services. OBJECTIVES. The study objectives were to measure whether incorporation of pneumococcal conjugate vaccine by primary care providers delayed other vaccinations or added primary health care visits. DESIGN AND METHODS. In 2 counties surrounding Rochester and Nashville, we reviewed a representative sample of primary care charts for children born before and after licensure of pneumococcal conjugate vaccine. Receipt of vaccinations and health care visits were compared for the 2 age-matched cohorts. RESULTS. We reviewed 1459 records from Rochester and 1857 records from Nashville. The pre--pneumococcal conjugate vaccine and post-pneumococcal conjugate vaccine cohorts had similar demographic characteristics. The median age for receipt of any vaccination was not older for the postvaccine cohort than for the prevaccine cohort in either community. The percentage of children up-to-date for vaccinations by 18 months for postvaccine versus prevaccine cohorts was similar in Rochester (72% in each cohort) and in Nashville (58% postvaccine and 65% prevaccine). The number of well-child care visits or other health care visits during the first 18 months of life was not statistically different between the 2 cohorts. CONCLUSIONS. Implementation of pneumococcal conjugate vaccine was not associated with delays in other childhood vaccinations or more primary care visits. Key Words conjugate pneumococcal vaccination, PCV7, vaccination practices Abbreviations PCV7--pneumococcal conjugate vaccine WCC--well-child care, THE PACE OF new national recommendations for childhood vaccinations has accelerated over the past 2 decades, with revised recommendations for established vaccines, such as polio, (1) influenza, (2,3) and measles-mumps-rubella, [...]

BACKGROUND. Uninsured children with asthma are known to face barriers to asthma care, but little is known about the impact of health insurance on asthma care. OBJECTIVES. We sought to assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with asthma. DESIGN. Parents of a stratified random sample of new enrollees in New York's SCHIP were interviewed by telephone shortly after enrollment (baseline, n = 2644 [74% of eligible children]) and 1 year later (follow-up, n = 2310 [87%]). Asthma was defined by parent report using questions based on National Heart, Lung, and Blood Institute criteria. A comparison group (n = 401) who enrolled in SCHIP 1 year later was interviewed as a test for secular trends. MAIN OUTCOME MEASURES. Access (having a usual source of care [USC], unmet health needs, problems receiving acute asthma care), asthma-related medical visits, quality (continuity of care at the USC, problems receiving chronic asthma care, use of antiinflammatory medications), and asthma outcomes (change in asthma care or severity) were the main outcome measures used. Bivariate and multivariate analyses compared measures at baseline (year before SCHIP) versus follow-up (year during SCHIP). RESULTS. Three-hundred eighty-three children (14%) had asthma at baseline, and 364 had asthma at follow-up (16%). No secular trends were detected between the baseline study group and the comparison group. After enrollment in SCHIP, improvements were noted in access: lacking a USC (decrease from 5% to 1%), unmet health needs (48% to 21%), and problems getting to the USC for asthma (13 to 4%). Children had fewer asthma-related attacks and medical visits after SCHIP (mean number of attacks: 9.5 to 3.8: mean number of asthma visits: 3.0 to 1.5; hospitalizations: 11% to 3%). Quality of asthma care improved for general measures (most/all visits to USC: 53% to 94%; mean rating of provider: 7.9 to 8.8 of 10) and asthma-specific measures (problems getting to the USC for asthma care when child was well: 13% to 1%). More than two thirds of the parents at follow-up reported that both quality of asthma care and asthma severity were "better or much better" than at baseline, generally because of insurance coverage or lower costs of medications and medical care. CONCLUSIONS. Enrollment in New York's SCHIP was associated with improvements in access to asthma care, quality of asthma care, and asthma-specific outcomes. These findings suggest that health insurance improves the health of children with asthma. Key Words SCHIP, health insurance, children, asthma Abbreviations NHLBI--National Heart, Lung, and Blood Institute SCHIP--State Children's Health Insurance Program FPL--federal poverty level USC--usual source of care ED--emergency department, ASTHMA IS THE most prevalent chronic medical condition of childhood (1,2) and affects >6 million US children annually (3) with substantial morbidity (4-6) and cost. (7) Low-income and minority children [...]

Objective. To determine the population impact of pneumococcal conjugate vaccine (PCV) on pneumococcal-related diseases, including pneumonia and otitis media. Methods. Using administrative data from Tennessee Medicaid and 3 commercial insurance plans in upstate New York, we measured annual rates of medical visits for pneumococcal-related diseases (pneumococcal and nonspecific pneumonia and invasive disease; otitis media) and pneumococcal-unrelated diseases (other acute respiratory illnesses). Disease rates before (1995-2000 in Tennessee; 1998-2000 in New York) and after (2000-2002) PCV licensure were calculated for children aged Results. In 2001-2002, there were 67 380 and 9485 child-years of observation for Tennessee and New York children aged Conclusions. Adding PCV to the childhood immunization schedule was associated with a 10-fold greater reduction in pneumonia and a 100-fold greater reduction in otitis media than the previously reported reduction in culture-confirmed invasive pneumococcal diseases of 1.3 episodes per 1000 children aged, ABBREVIATIONS. PCV, pneumococcal conjugate vaccine; CI, confidence interval; ICD-9, International Classification of Diseases, 9th Revision; ED, emergency department. Streptococcus pneumoniae is the leading bacterial cause of meningitis, bacteremia, pneumonia, and [...]

Objective. Respiratory syncytial virus (RSV), influenza virus, and parainfluenza viruses (PIV) cause significant morbidity in young children. Although only influenza virus infection and illness is currently vaccine-preventable, vaccines are under development for RSV and PIV. We established a prospective, active population-based surveillance network to provide precise estimates of hospitalization rates for viral acute respiratory illness (ARI) in young children and to measure the potential impact of enhanced vaccine usage on these rates. Methods. Prospective, active population-based surveillance was conducted in young children who were hospitalized for ARI from October 1, 2000, to September 30, 2001, in Monroe County, New York (Rochester area) and Davidson County, Tennessee (Nashville area). Eligible children younger than 5 years were those who resided in surveillance counties and were hospitalized for febrile or acute respiratory illness. Viral culture and polymerase chain reaction identified viruses from nasal and throat samples obtained from all surveillance children. We measured population-based rates of hospitalization for RSV, influenza virus, and PIV as well as demographic, clinical, and risk factor assessment for each virus. Results. Of 812 eligible hospital admissions, 592 (73%) children were enrolled. Of the enrolled children, RSV was identified in 20%, influenza in 3%, PIV in 7%, other respiratory viruses in 36%, and no detectable virus in 39%. Population-based rates of ARI hospitalizations in children younger than 5 years were 18 per 1000. Viruspositive hospitalization rates per 1000 children were 3.5 for RSV, 1.2 for PIV, and 0.6 for influenza virus. Younger age (particularly Conclusions. This study confirms that children younger than 5 years and particularly children younger than 1 year have a high burden of hospitalization from RSV, influenza, and PIV. The enhanced use of influenza vaccine and the development of RSV and PIV vaccines have the potential to reduce markedly the pediatric morbidity from ARIs. Pediatrics 2004;113:1758-1764; influenza, RSV, parainfluenza, population-based, hospitalizations., ABBREVIATIONS. ARI, acute respiratory illness; RSV, respiratory syncytial virus; PIV, parainfluenza virus; RT-PCR, reverse transcription polymerase chain reaction; NVSN, New Vaccine Surveillance Network; CDC, Centers for Disease Control and Prevention. [...]

Objective. To assess 1) the feasibility of universal postpartum depression screening during well-child visits in the first year of life, 2) the prevalence of postpartum depressive symptoms among mothers who attend first-year well-child visits, 3) detection of postpartum depressive symptoms in a pediatric clinic before and after universal screening at each first-year well-child visit, and 4) social work referrals before and after universal screening. Methods. The practice instituted universal screening for postpartum depressive symptoms during first-year well-child visits using the Edinburgh Postnatal Depression Scale (EPDS). We randomly selected 110 infant medical records before (cohort 1) and 110 after (cohort 2) screening was initiated. Measures included demographics, notation of depression or depressive symptoms in the well-child visit note, and referral for depression. EPDS scores were collected for cohort 2 only. Before-after comparisons were made for detection of depression or depressive symptoms and mental health referrals. Results. The EPDS was included in the medical record in 46% of well-child visits. Eighty-eight percent of these forms were completed. Twenty-one percent of completed EPDS forms had scores [greater than or equal to] 10, and 27% of women who completed the EPDS had scores [greater than or equal to] 10 sometime during the postpartum year. There was a significant increase in documentation of depressive symptoms with the EPDS after initiation of universal screening (1.6% of visits [cohort 1] vs 8.5% [cohort 2]). Social work referrals for mental health reasons increased significantly (0.2% of visits [cohort 1] to 3.6% [cohort 2]). Conclusions. Women with high levels of postpartum depressive symptoms are common in an urban population and can be detected at well-child visits throughout the first postpartum year by pediatricians using a standardized screening tool. Because screening for depression during well-child visits is feasible using a standardized screening instrument, pediatricians can play an active role in early detection and referral for postpartum depression. Pediatrics 2004;113:551-558; postpartum depression, maternal depression, screening, detection. ABBREVIATIONS. EPDS, Edinburgh Postnatal Depression Scale; SD, standard deviation., Healthy People 2010 identifies depression as 1 of 10 leading public health concerns in the United States. (1) Pediatricians have become increasingly concerned about maternal depression (2-4) because of the [...]

Objective. To estimate the additional number of visits to primary care practices that would be required to deliver universal influenza vaccination to 6-to 23-month-old children. Methods. Children who were covered by commercial and Medicaid managed care plans (70% of children in the region; >8000 children in each of 3 consecutive influenza seasons) in the 6-county region surrounding and including Rochester, New York, were studied. An analysis was conducted of insurance claims for visits (well-child care [WCC]; all other visits) to primary care practices during 3 consecutive influenza vaccination seasons (1998-2001). We determined the proportion of children who made I or 2 visits during the potential influenza vaccination period, simulating several possible lengths of time available for influenza vaccination (2, 3, 4, or 5 months). We measured the proportion of children who were vaccinated during each influenza vaccination period. The added visit burden was defined as the number of additional visits that would be required to vaccinate all children, simulating 2 scenarios: 1) administering influenza vaccination only during WCC visits and 2) considering all visits as opportunities for influenza vaccination. Results. Results were similar for each influenza season. Considering a 3-month influenza vaccination window and assuming that no opportunities were missed, if only WCC visits were used for influenza vaccination, then 74% of 6- to 23-month-olds would require at least 1 additional visit for vaccination--39% would require 1 additional visit and 35%, would require 2 additional visits. If all visits to the practice were used for influenza vaccination during the 3-month window, then 46% would require at least 1 additional visit--34% would require 1 additional visit and 12% would require 2 additional visits. Longer vaccination periods would require fewer additional visits; eg, if a 4-month period were available, then 54% of children would require 1 or 2 additional visits if only WCC visits were used and 29% would require 1 or 2 additional visits if all visits were used for influenza vaccinations. Younger children (eg, 6- to 11-month-olds) would require fewer additional visits than older children (12- to 23-month-olds) because younger children already have more visits to primary care practices. Conclusions. Implementation of universal influenza vaccination will result in a substantial increased burden to primary care practices in terms of additional visits for influenza vaccination. Practice-level strategies to minimize the additional burden include 1) using all visits (not just WCC visits) as opportunities for vaccination, 2) providing influenza vaccination for the maximum possible time period by starting to vaccinate as early as possible and continuing to vaccinate as late as possible, and 3) implementing short and efficient vaccination-only visits to accommodate the many additional visits to the practice. Pediatrics 2003;112:821-828; universal child influenza vaccination, visit burden, pediatric primary care., ABBREVIATIONS. ACIP, Advisory Committee on Immunization Practices; VFC, Vaccines for Children Program; AAP, American Academy of Pediatrics; ICD-9, International Classification of Diseases, Ninth Revision; WCC, well-child care. Influenza virus causes [...]

OBJECTIVES: Assess the degree to which US parents are likely to have their children get coronavirus disease 2019 (COVID-19) vaccines and identify parental concerns about the vaccines. METHODS: In February 2021 to March 2021, we surveyed parent members of a nationally representative probability-based Internet panel of ~9000 adults regarding their intent to have their children receive a COVID-19 vaccination, perceptions of COVID-19 vaccines for children, and trust in sources of information about COVID-19 vaccines for children. We used descriptive and multivariate analyses to evaluate parent-stated likelihood of having their children get a COVID-19 vaccine and to assess the association between likelihood of child COVID-19 vaccination and child age, parent demographics, and parental perceptions about COVID-19 vaccines. RESULTS: Altogether, 1745 parents responded (87% of eligible parents, 3759 children). Likelihood of child COVID-19 vaccination was as follows: very likely (28%), somewhat likely (18%), somewhat unlikely (9%), very unlikely (33%), and unsure (12%). The stated likelihood of child vaccination was greater among parents of older children (P < .001) as well as among parents who had a bachelor's degree or higher education (P < .001), had already received or were likely to receive a COVID-19 vaccine (P < .001), or had Democratic affiliation (P < .001); variations existed by race and ethnicity (P = .04). Parental concerns centered around vaccine safety and side effects. A key trusted source of information about COVID-19 vaccines for children was the child's doctor. CONCLUSIONS: Less than one-half of US participants report that they are likely to have their child receive a COVID-19 vaccine. Pediatric health care providers have a major role in promoting and giving COVID-19 vaccination for children. [ABSTRACT FROM AUTHOR]

Professional recommendations for universal blood lead screening may not be followed by all pediatricians. Researchers surveyed 734 primary care pediatricians belonging to the American Academy of Pediatrics (AAP) to study their attitudes toward universal screening for blood lead concentrations. Fifty-three percent of pediatricians said they screened all their patients aged nine to 36 months, and most of these doctors used a sensitive blood lead test. Another 39% of pediatricians selectively screened children with risk factors for elevated blood lead levels. Most doctors concurred with the AAP's new lower acceptable blood lead levels., Objectives. In 1991, the Centers for Disease Control and Prevention (CDC) decreased the blood lead level of concern to 10 [mu]g/dL (0.48 [mu]mol/L) and recommended universal screening. Because these guidelines continue to provoke controversy, we conducted a study to: 1) estimate the proportion of pediatricians who are members of the American Academy of Pediatrics (AAP) who report screening for elevated blood lead levels; 2) describe their clinical practices regarding screening for elevated blood lead levels; 3) compare attitudes of universal screeners, selective screeners, and nonscreeners; and 4) identify characteristics of pediatricians who universally screen. Design. Confidential, cross-sectional survey of a nationally representative random sample of 1610 pediatricians conducted through the AAP Periodic Survey. Subjects. The study included 1035 responders (64% response rate). Analysis was limited to the 734 pediatricians who provide well-child care (de, primary-care pediatricians). Results. Fifty-three percent of pediatricians reported screening all their patients aged 9 to 36 months, 39% reported screening some, and 8% reported screening none. Among those who screen, 96% use a blood lead assay. The primary risk factors for which selective screeners screen are: history of pica (94%); living in an older home with recent renovations (92%); living in an older home with peeling paint (93%); and having a sibling who had an elevated blood lead level (88%). Among primary-care pediatricians, 73% agree that blood lead levels [greater than or equal to]10 [mu]g/dL should be considered elevated, and 16% disagree. However, 89% of primary-care pediatricians believe that epidemiologic studies should be performed to determine which communities have high proportions of children with elevated blood lead levels, and 34% of primary-care pediatricians believe that the costs of screening exceed the benefits. Conclusions. Three years after the Centers for Disease Control and Prevention issued new guidelines for the management of elevated blood lead levels, a slight majority of primary-care pediatricians in the United States who are members of the AAP report that they universally screen their appropriately aged patients, while most of the remaining pediatricians report screening high-risk patients. Many pediatricians may want additional guidance about circumstances under which selective screening should be considered. Pediatrics 1996; 98:372-377; elevated blood lead levels, screening., ABBREVIATIONS, CDC, Centers for Disease Control and Prevention; AAP, American Academy of Pediatrics; US, United States. In 1991, responding to increased evidence of adverse effects due to low-dose exposure to [...]

Quality of care and doctor's philosophy toward hospital admissions appear to affect hospital admission rates for asthmatic children. Hospitalization rates for children with asthma in Boston exceed admission rates in Rochester, New York threefold. Boston children were half as likely to have received inhaled corticosteroids, cromolyn, or inhaled beta-agonist therapy. They were two-tenths as likely to receive oral corticosteroids. One-third of hospitalized Boston children were less severely ill compared with 20% of Rochester children., Background. Hospitalization rates for childhood asthma are three times as high in Boston, Massachusetts, as in Rochester, New York; New Haven, Connecticut, rates are intermediate. We undertook this study to determine how care for children admitted for asthma varies across these communities. Methods. We performed a community-wide retrospective chart review. We reviewed a random sample of all asthma hospitalizations, from 1988 to 1990, of children 2 to 12 years old living in these communities (n = 614). Abstracted data included demographics, illness severity, and treatment before admission. Results. Compared with Rochester children, Boston children were less likely to have received maintenance preventive therapy (inhaled corticosteroids or cromolyn [odds ratio (OR), 0.4 (0.2, 0.9)]), acute "rescue" therapy (oral corticosteroids [OR, 0.2 (0.1, 0.4)]), or inhaled beta-agonist therapy [OR, .5 0.3, 1.0)]. A larger proportion of admitted asthmatic patients in Boston (34%) were in the least severely ill group--oxygen saturation 95% or above--compared with patients in Rochester (20%). Conclusions. The quality of ambulatory care, including choice of preventive therapies and thresholds for admission, likely plays a key role in determining community hospitalization rates for chronic conditions such as childhood asthma. Pediatrics 1996;98:18-23; asthma, children, quality of care., ABBREVIATION. OR, odds ratio. Rates of hospitalization for childhood asthma have increased dramatically over the past 10 years, such that asthma is the most common discharge diagnosis among children.[1] We [...]

Pediatricians and family physicians may be able to improve vaccination rates by adhering to current immunization guidelines such as simultaneous immunizations, immunizing children during acute illness visits as well as well child visits, developing tracking systems for underimmunized children, and by lowering vaccination costs. A survey of 746 members of the American Academy of Pediatrics and 429 members of the American Academy of Family Medicine found that pediatricians were slightly more likely than family physicians to vaccinate during follow-up and acute illness visits and to use tracking systems, and were less likely to think cost was a barrier to immunizations. Physicians from both groups who worked with underimmunized groups of children and physicians who had graduated from medical school more recently followed immunization guidelines more closely than did older physicians and solo practitioners., Objective. To assess current practices and attitudes among pediatricians and family physicians across the United States regarding immunizations. Design. Survey of a random sample of pediatricians and family physicians. Subjects. Fellows of the American Academy of Pediatrics (N=746) and American Academy of Family Medicine (N=429). Survey topics. General immunization practices (eg, types of visits during which vaccinations are provided, mechanisms to identify undervaccinated children); and opinions about perceived barriers to immunizations, acceptance of alternative sites for immunizations, and possible immunization requirements for Medicaid and The Special Supplemental Food Program for Women, Infants, and Children (WIC). Results. Pediatricians and family physicians (combined) reported the following immunizing children during acute illness visits (28%), follow-up visits (90%), and chronic illness visits (77%); using computer or reminder files to identify undervaccinated children (13%); and simultaneously administering four vaccines (diphtheria-tetanus-pertussis, oral poliovaccine, measles, mumps, and rubella and Haemophilus influenzae type b) to an eligible 18-month-old child (66%). Physicians perceived the following as barriers to immunizations: missed preventive visits (40%), vaccine costs 24%), lack of insurance coverage (24%), inability to track undervaccinated patients (22%), incomplete immunization records (12%), and missed vaccination opportunities (12%). Physicians agreed with offering vaccinations during hospitalizations (51%,) or emergency department visits (30%), and with immunization requirements for continued eligibility for Medicaid (66%) or WIC (64%). Pediatricians were more likely to vaccinate during chronic illness and follow-up visits, and were more likely to use systems to track undervaccinated children (P < .05); however, most immunization practices and attitudes of pediatrician and family physicians were similar. Physicians who graduated from medical school more recently and those in high-risk urban practices were more likely to vaccinate during acute illness visits, provide simultaneous vaccinations, and favor vaccinations in hospital settings. Conclusions. Vaccination rates might be improved by closer adherence to current immunization guidelines regarding vaccinations during all encounters and simultaneous vaccinations, by developing systems to identify undervaccinated children, and by reducing patient costs for vaccinations. Current immunizations practices fall short of the immunization guidelines; changes in individual practice styles will be required to conform with these standards. Pediatrics 1994;94:517-523; immunizations, vaccination rates, undervaccination, practice standards.

The Centers for Disease Control and Prevention (CDC) risk assessment questionnaire appears to be effective in identifying children at risk for lead poisoning. Researchers tested and surveyed 476 children aged six to 72 months to evaluate the CDC questionnaire. Eighty-two percent of children with lead levels of 15 micrograms per deciliter (microg/dL) were identified as being high risk and 97% of those with levels less than 15 microg/dL were classified as low risk by the questionnaire. Children identified as high risk by the questionnaire were 1.8 times more likely to have elevated lead levels than children identified as low risk. Children who lived in older homes with chipped or peeling paint had between 1.4 and 1.6 greater risk of having lead levels higher than 10 and 15 microg/dL. Those having siblings or friends with lead poisoning were between 1.9 and 2.4 times more likely to have blood lead levels of 10 or greater., Background. The Centers for Disease Control and Prevention (CDC) has recommended using a five-item questionnaire at every regular office visit f or all children 6 to 72 months of age to identify those at risk of high-dose exposure to lead. Objective. To determine how well the questionnaire identifies children with elevated lead levels. Research design. Comparison of results of the questionnaire, which is intended to identify children as being low-risk or high-risk for lead poisoning, with children&apos;s blood lead levels. Setting. A pediatric continuity clinic located in a major teaching hospital in Rochester, NY. Patients. A consecutive sample of 476 children aged 6 to 72 months without a prior history of lead poisoning who were seen in the clinic in July and August 1992, and who had not had a lead screen in the previous 6 months (for those aged

Visits to the emergency department appear to predict undervaccination, even among children with access to primary medical care. The goal of having 90% of US two-year-olds up-to-date on vaccinations has not yet been achieved, and in some cities the vaccination rates among two-year-olds are as low as 10% to 45%. Vaccination rates were compared between 583 preschool children who visited the emergency room and 583 children of the same age with the same primary care provider. Overall, 137 pairs of children attended a hospital-based clinic for primary care, 172 pairs attended a neighborhood health center and 274 pairs attended private practices. While emergency room patients were more likely to be undervaccinated, the difference in vaccination rates was most pronounced among patients who went to private practitioners for primary care. This finding suggests primary care providers should alter their practice to improve vaccination rates., The purpose of this study was to determine (1) whether preschool-age patients who utilize the emergency department (ED) are undervaccinated compared with patients having the same primary care provider and (2) whether reducing missed vaccination opportunities in the primary care office can potentially reduce the differences in undervaccination between the groups. This retrospective cohort study involved two groups: 583 ED patients, aged 4 to 48 months, who had primary care providers; and 583 control subjects randomly selected from primary care sites and matched according to date of birth and primary care site. The major outcome variable was the point prevalence of undervaccination, defined as more than 60 days past due for a vaccine at the time of the ED visit, and for control subjects, at the time of their matched patient&apos;s ED visit. Demographic variables, vaccination history, presence of chronic illness, and office utilization history were abstracted from office charts. The mean age of all patients was 20.0 months. Emergency department patients were more likely to be boys (61% vs 50%) and had more chronic illness, but did not differ racially from those in the control group. Primary care sites included a hospital-based clinic (n = 137), neigh-borhood health centers (n = 172), and private practices (n = 274). The undervaccination rates by primary provider type were for (1) hospital clinic ED patients 21.1%, control subjects 19.7%; (2) neighborhood health center ED patients 29.1%, control subjects 22.7%; and (3) private practice ED patients 26.6%, control subjects 14.9%. Over-all, the odds ratio of ED patients&apos; being undervaccinated compared with control subjects was 1.8 (95% confidence interval 1.3 to 2.5). This association was strongest for private practice patients (odds ratio 2.45, 95% confidence interval 1.5 to 4.2), but not significant for hospital clinic or neighborhood health center patients. Emergency department patients had previously missed more vaccination opportunities in the office than had control subjects (25% vs 16% of office visits). Taking advantage of missed vaccination opportunities would have greatly reduced undervaccination differences between ED patients and their controls. An ED visit is a marker for undervaccination, even for children who have primary care providers. These data support efforts to reach out to ED patients with interventions designed to increase their vaccination rates. Interventions in primary care offices, however, are likely to be the most effective. Pediatrics 1993; 91:605-611; immunization, undervaccination, missed vaccination opportunities, emergency department utilization, primary care utilization.

Many preschool children may not be vaccinated because of missed opportunities at a checkup or follow-up visit. A missed opportunity is failure of their physician or other health care professionals to identify them as needing a vaccination. A study surveyed the vaccination rate among 1,124 children between nine and 32 months old who were patients at several types of medical care settings, including an HMO, a rural health center, a suburban medical practice and an urban medical practice. The percentage of children who were not vaccinated when they should have been ranged from 4% to 63%, and was greater than 20% at most of the practices. Many of the children were not vaccinated because of a missed opportunity at a checkup or at a follow-up visit. Children with Medicaid or no health insurance were more likely to be missed than those with private health insurance., To determine the rate of childhood undervaccination, rate and types of missed opportunities (MOs) for vaccinations, and the contribution of MOs to the undervaccination of preschool-age children, the authors conducted a retrospective medical chart review in seven primary care settings in the Rochester, NY, area: a hospital clinic, a neighborhood health center, a groupmodel health maintenance organization, an urban group practice, a suburban group practice, a rural health center, and a rural private practice. The random sample included 1124 children having birth dates between March 15, 1988, and September 15, 1989. The main outcome measures were cumulative undervaccination rate, defined as the proportion of patients from each practice who were ever >60 days past-due for a vaccination by 12, 18, or 24 months of age; undervaccination time, defined as the median number of months during which children were undervaccinated; number of MOs; visit types and conditions associated with the MOs; and the duration of undervaccination time attributable to MOs. The cumulative undervaccination rate by 12 months was at least 20% in each practice except for the suburban practice, where it was 4%. The frequency of MOs varied from a high of 1.8 MO per patient per year at the rural private practice to a low of 0.3 MO per patient per year at the suburban practice. More than one quarter of MOs occurred during either health supervision or follow-up visits in all practices. In 28% of visits during which an MO occurred, patients had no fever or acute illness. The impact of MOs was twice as great for children having Medicaid or no health insurance as for children covered by private insurance. Missed opportunities contributed 13% of the total undervaccination time in the suburban practice, 27% in the clinic, and more than 40% in the ether practices. It is concluded that missed opportunities for vaccination occur frequently and contribute significantly to the undervaccination of preschool children. The effect of MOs is greatest in practices serving impoverished children. Reducing MOs would substantially improve the vaccination levels of preschool-age children. Pediatrics 1993;91:1-7; preschool children, vaccination, immunization.

BACKGROUND: Although autodialer centralized reminder and recall (C-R/R) from state immunization information systems (IISs) has been shown to raise childhood vaccination rates, its impact on human papillomavirus (HPV) vaccination rates is unclear. METHODS: In a 4-arm pragmatic randomized controlled trial across 2 states, we randomly selected practices representative of the specialty (pediatrics, family medicine, and health center) where children received care. Within each practice, patients 11 to 17.9 years old who had not completed their HPV vaccine series (NY: N = 30 616 in 123 practices; CO: N = 31 502 in 80 practices) were randomly assigned to receive 0, 1, 2, or 3 IIS C-R/R autodialer messages per vaccine dose. We assessed HPV vaccine receipt via the IIS, calculated intervention costs, and compared HPV vaccine series initiation and completion rates across study arms. RESULTS: In New York, HPV vaccine initiation rates ranged from 37.0% to 37.4%, and completion rates were between 29.1% and 30.1%, with no significant differences across study arms. In Colorado, HPV vaccine initiation rates ranged from 31.2% to 33.5% and were slightly higher for 1 reminder compared with none, but vaccine completion rates, ranging from 27.0% to 27.8%, were similar. On adjusted analyses in Colorado, vaccine initiation rates were slightly higher for 1 and 3 C-R/R messages (adjusted risk ratios 1.07 and 1.04, respectively); completion rates were slightly higher for 1 and 3 C-R/R messages (adjusted risk ratios 1.02 and 1.03, respectively). CONCLUSIONS: IIS-based C-R/R for HPV vaccination did not improve HPV vaccination rates in New York and increased vaccination rates slightly in Colorado. [ABSTRACT FROM AUTHOR]

Context. Iron deficiency anemia in infants can cause developmental problems. However, the relationship between iron status and cognitive achievement in older children is less clear. Objective. To investigate the relationship between iron deficiency and cognitive test scores among a nationally representative sample of school-aged children and adolescents. Design. The National Health and Nutrition Examination Survey III 1988-1994 provides cross-sectional data for children 6 to 16 years old and contains measures of iron status including transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Children were considered iron-deficient if any 2 of these values were abnormal for age and gender, and standard hemoglobin values were used to detect anemia. Scores from standardized tests were compared for children with normal iron status, iron deficiency without anemia, and iron deficiency with anemia. Logistic regression was used to estimate the association of iron status and below average test scores, controlling for confounding factors. Results. Among the 5398 children in the sample, 3% were iron-deficient. The prevalence of iron deficiency was highest among adolescent girls (8.7%). Average math scores were lower for children with iron deficiency with and without anemia, compared with children with normal iron status (86.4 and 87.4 vs 93.7). By logistic regression, children with iron deficiency had greater than twice the risk of scoring below average in math than did children with normal iron status (odds ratio: 2.3; 95% confidence interval: 1.1-4.4). This elevated risk was present even for iron-deficient children without anemia (odds ratio: 2.4; 95% confidence interval: 1.1-5.2). Conclusions. We demonstrated lower standardized math scores among iron-deficient school-aged children and adolescents, including those with iron deficiency without anemia. Screening for iron deficiency without anemia may be warranted for children at risk. Pediatrics 2001;107:1381-1386; iron deficiency, anemia, cognition, math, children, adolescence., ABBREVIATION. NHANES, National Health and Nutrition Examination Survey. Iron deficiency is the most prevalent hematologic disorder in childhood.[1] Infants from 9 to 24 months of age may develop dietary iron [...]

Objective. Nearly 14% of children in the United States are uninsured. We compared the prevalence of psychosocial problems and mental health services received by insured and uninsured children in primary care practices. Methods. The Child Behavior Study was a cohort study conducted by Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network. Four hundred one primary care clinicians enrolled an average sample of 55 consecutive children (4-15 years old) per clinician. Results. Of the 13 401 visits to clinicians with 3 or more uninsured patients, 12 518 were by insured children (93.4%) and 883 were by uninsured children (6.6%). A higher percentage of adolescents, Hispanic children, those with unmarried parents, and those with less educated parents were uninsured. According to clinicians, uninsured children and insured children had similar rates of psychosocial problems (19%) and severe psychosocial problems (2%). For children with a clinician-identified psychosocial problem, we found no differences in clinician-reported counseling, medication use, or referral to mental health professionals. Conclusions. Among children served in primary care practices, uninsured children have similar prevalence of clinician-identified psychosocial and mental health problems compared with insured children. Within their practices, clinicians managed uninsured children much the same way as insured children. Pediatrics 2000;106:930-936; psychosocial problems, uninsured children, pediatrics, family medicine, primary care., Uninsured Children With Psychosocial Problems: Primary Care Management ABBREVIATIONS. CBS, Child Behavior Study; PROS, Pediatric Research in Office Settings; ASPN, Ambulatory Sentinel Practice Network; WRen, Wisconsin Research Network; MAFPRN, Minnesota [...]

To the Editor.-- I read with interest the article entitled "Socioeconomic Variation in Asthma Hospitalization" in the June 1999 issue of Pediatrics electronics pages (URL: http://www.pediatrics.org/cgi/content/ full/103/6/e75). It has occurred [...]

Evaluation of a Health Insurance Program for Low-Income Children: Implications for SCHIP and Health Care Reform Sponsored by The David and Lucile Packard Foundation 687 ABSTRACT. Evaluation of Children's Health [...]

The State Child Health Insurance Program (SCHIP) can improve the care of poor children, according to an evaluation of the program that served as its model. The Child Health Plus (CHPlus) program was implemented in New York State in 1991. A survey of 2,126 children who enrolled in CHPlus in 1992-1993 found a significant reduction in the number of children who did not have a regular health care provider. The reduction was greatest in New York City. Visits to a primary care provider increased and use of public health clinics decreased. No parent was dissatisfied with the care provided under CHPlus., Background. The State Child Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991, New York State implemented Child Health Plus (CHPlus), a health insurance program that became a model for SCHIP. Objective. To examine changes in access to care, utilization of services, and quality of care among children enrolled in CHPlus. Design. A pre-post design was used to evaluate the health care experiences of children in the year before enrollment in CHPlus and during the year after CHPlus enrollment. Setting. New York State, stratified into 4 regions: New York City, urban counties around New York City, upstate urban counties, and upstate rural counties. Participants. A total of 2126 children (0-12.99 years of age) who enrolled in CHPlus in 1992-1993. Data Collection. Parents were interviewed by telephone, and primary care medical charts were reviewed for 694 children (0-3.99 years of age). Analysis. Access, utilization, and quality of care measures for each child were compared for the year before and the year after CHPlus enrollment, controlling for age, geographic region, previous insurance coverage, and CHPlus plan type (indemnity or managed care). Results. Enrollment in CHPlus was associated with fewer children lacking a medical home (5% before CHPlus vs 1% during CHPlus), with the greatest change occurring in New York City (11% vs 1%), where access before CHPlus was lowest. CHPlus was also associated with increased primary care visits: by 25% for preventive visits, by 52% for acute visits, and by 42% for total visits. The number of specialists seen during CHPlus was more than twice as high than before CHPlus. CHPlus was not associated with changes in emergency department utilization, although hospitalizations, which were not covered by CHPlus, were 36% lower during CHPlus coverage. Use of public health departments for immunizations declined by 64%, with more immunizations delivered in the medical home during CHPlus coverage. One third of parents reported improved quality of health care for their child as a result of CHPlus, and virtually none noted worse quality of care. Conclusions. This statewide health insurance program for low-income children was associated with improved access, utilization, and quality of care, suggesting that SCHIP has the potential to improve health care for low-income American children. Pediatrics 2000;105:363-371; Child Health Plus, uninsured, underinsured, health insurance, access, utilization, quality of care, State Child Health Insurance Program., ABBREVIATIONS. SCHIP, State Child Health Insurance Program; CHPlus, Child Health Plus, ED, emergency department; HMO, health maintenance organization. The State Child Health Insurance Program (SCHIP),[1] enacted in 1997 with passage [...]

Many children with asthma are not receiving adequate therapy, as recommended by national guidelines. In a study of 1,025 children with asthma whose parents participated in the National Health and Nutrition Examination Survey (NHANES), only 26% of those with moderate to severe asthma were being treated according to the guidelines. Only 32% of children who were hospitalized for asthma were being treated according to the guidelines. Poor Hispanic children were least likely to be treated according to the guidelines., Objective. Childhood asthma morbidity and mortality are increasing despite improvements in asthma therapy. We hypothesized that a substantial number of children with moderate to severe asthma are not taking the maintenance medications recommended by national guidelines. The objective of this study was to describe medication use among US children with asthma and determine risk factors for inadequate therapy. Methods. The National Health and Nutrition Examination Survey (NHANES) III 1988-1994 provided cross-sectional, parent-reported data for children 2 months to 16 years of age. Analysis focused on children with moderate to severe asthma (defined as having any hospitalization for wheezing, [is greater than or equal to] 2 acute visits for wheezing, or [is greater than or equal to] 3 episodes of wheezing over the past year). We defined these children as adequately treated if they had taken a maintenance medication (inhaled corticosteroid, cromolyn, or theophylline) during the past month. Demographic variables were analyzed for independent associations with inadequacy of therapy. The statistical analysis used SUDAAN software to account for the complex sampling design. Results. A total of 1025 children (9.4%) had physician-diagnosed asthma. Of those with moderate to severe asthma (n = 524), only 26% had taken a maintenance medication during the past month. Even among children with 2 or more hospitalizations over the previous year, only 32% had taken maintenance medications. In a logistic regression analysis, factors significantly associated with inadequate therapy included: age [is less than or equal to] 5 years, Medicaid insurance, and Spanish language. Children surveyed after 1991, when national guidelines for asthma management became available, were no more likely to have taken maintenance medications than children surveyed before 1991. Conclusion. Most children with moderate to severe asthma in this nationally representative sample, including those with multiple hospitalizations, did not receive adequate asthma therapy. These children may incur avoidable morbidity. Young children, poor children, and children from Spanish-speaking families appear to be at particularly high risk for inadequate therapy. Pediatrics 2000;105:272-276; asthma, children, maintenance medications, poverty, guidelines., Inadequate Therapy for Asthma Among Children in the United States ABBREVIATIONS. NHANES, National Health and Nutrition Examination Survey; OR, odds ratio; CI, 95% confidence interval. Asthma is the most common [...]

It appears that doctors in Monroe County, New York are only admitting children with severe asthma to the hospital. This would explain why hospitalization rates remain the same year after year even though asthma has gotten more severe. In Monroe County between 1991 and 1995, the annual hospitalization rate for childhood asthma remained the same. However, hospital admissions for severe asthma increased 270% and hospital admissions for mild asthma fell 50%. Hospitalizations for severe asthma accounted for 60% of the admissions in 1995 compared to 31% in 1991. Mild asthma dropped from 14.1% of admissions to 4.7% of admissions., Background. Asthma morbidity and mortality has increased substantially in recent years, but asthma hospitalization rates among many geographic and sociodemographic groups have remained stable. Observations on asthma hospitalization rates and severity of acute episodes might provide valuable insight into the functioning of the health care system during this period of health care reform. Objective. To analyze changes between 1991 and 1995 in childhood asthma hospitalization rates and severity of acute episodes. Design and Methods. All 29 329 hospitalizations, including 2028 for asthma, for the 198 893 children ([is less than] 19 years of age) in Monroe County (Rochester), New York, were studied during this 5-year period. Severity was determined by hospital record review on a 22% random sample. Using the worst oxygen saturation (Sa[O.sub.2]) during the first 24 hours of hospitalization as the primary index of severity, episodes were categorized as mild (0 to [is greater than or equal to] 95), moderate (90 to 94), or severe ([is less than] 90). Results. Hospitalization rates are expressed as hospitalizations per 1000 child-years. The overall asthma hospitalization rate was 2.04 (95% confidence interval, 1.952.13). The overall annual asthma hospitalization rate remained relatively stable from 1991 (1.90) to 1995 (2.31), whereas the hospitalization rates for severe asthma rose 270%--from 0.57 to 1.55--during this period. Simultaneously, the hospitalization rates for mild asthma decreased from 0.26 to 0.12. As a proportion of all asthma hospitalizations between 1991 and 1995, severe episodes increased from 31.5% to 60.4%; conversely, mild episodes decreased from 14.1% to 4.7%. Conclusions. Severity increased significantly among children hospitalized for asthma while the overall asthma hospitalization rate remained stable. It seems that the health care system in this community has responded to an increase in severity of asthma by raising the severity threshold for admission. Pediatrics 1999;104:454-462; asthma, secular variation, hospitalization, children, severity, outcomes, oxygen saturation., ABBREVIATIONS. Sa[O.sub.2], oxygen saturation; ED, emergency department; CI, confidence interval. Several recent studies determined that annual childhood asthma hospitalization rates have stabilized among many geographic areas[1,2] and sociodemographic groups[2,3] suggesting [...]