Search

Background Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees. Objective Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees. Methods Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors. Results Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed “environment” or “environmental” in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences. Conclusions The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.

Background: Urinary tract infections (UTIs) are the most common serious bacterial infection in young febrile infants, and the urinalysis (UA) is an accurate screening test for emergency department (ED) evaluation. Precise estimates of risk of concomitant bacteremia and/or bacterial meningitis (invasive bacterial infections; IBI) in febrile infants ≤ 60 days have been based on presence of UTIs rather than positive UAs, and lack large prospective study. Objective: We sought to determine the prevalence of IBIs in febrile infants 0-28 …

Study objective To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN). Methods We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia. Results Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections ( E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis. Conclusion The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

From the Departments of Pediatrics and Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY The author declares that she has no conflict of interest. Address correspondence to Ellen F. Crain, MD, PhD, Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, J1W20, Bronx, NY 10461 (e-mail: ellenfcrain@gmail.com). Received for publication September 19, 2013; accepted September 19, 2013.

OBJECTIVE To determine whether emergency departments (EDs) at pediatric emergency medicine (PEM) fellowship training institutions have a departmental policy regarding the evaluation and management of febrile infants and if reported policies are based on published guidelines (PGs). METHODS A 32-item telephone survey was administered to PEM fellowship directors (FDs). Departmental demographics and criteria used to evaluate febrile infants were collected. Scenarios were presented regarding the evaluation and management of low-risk febrile infants. Reported consistency among ED attending physicians at the same institution was also assessed. RESULTS The response rate was 83% (53 of 64). Fifty-one percent (26 of 53) of FDs reported the existence of a departmental policy regarding the evaluation of febrile infants. Of those who have a departmental policy, 19% (5 of 26) stated that it was one of the PGs. The FDs who reported the existence of a departmental policy were significantly more likely to report consistent management by all ED attending physicians in their department compared with those without a departmental policy (81% vs 19%, P < 0.05). The most frequent age and temperature cutoff for a mandatory sepsis evaluation were 28 days (45%, 28 of 53) and 100.4°F (66%, 35 of 53). The FDs reported a lack of consistency among ED attending physicians at the same institution regarding age and temperature (66% and 17% of the time, respectively). Eighty-five percent (45 of 53) of FDs reported that a new guideline is needed. CONCLUSIONS Nearly one half of EDs at PEM fellowship training institutions are reported not to have a departmental policy regarding the management of febrile infants, and departmental policies rarely conform to any of the PGs. There is substantial interdepartmental and intradepartmental practice variability regarding the management of febrile infants and a strong consensus regarding the need for a new guideline.

The purpose of this study was to evaluate the effectiveness of the probiotic Lactobacillus GG (LGG) in reducing the duration of acute infectious diarrhea in the pediatric emergency department.We conducted a double-blind, randomized controlled trial of children 6 months to 6 years presenting to the pediatric emergency department with a complaint of diarrhea. Patients were randomized to receive either placebo or LGG powder twice daily for 5 days. With each dose, parents recorded the stool history in a home diary and were followed up daily by a blinded researcher. Groups were compared in terms of time to normal stool and number of diarrheal stools.Of 155 patients enrolled, 129 completed the study: 63 in the LGG group and 66 in the placebo group. There was no significant difference in the median (interquartile range) time to normal stool (LGG: 60 hours [37-111] vs placebo: 74 hours [43-120]; P = 0.37) or the number of diarrheal stools (LGG: 5.0 [1-10] vs placebo: 6.5 [2-14]; P = 0.19). Among children who presented with more than 2 days of diarrhea, the LGG group returned to normal stool earlier (LGG: 51 hours [32-78] vs placebo: 74 hours [45-120]; P = 0.02), had fewer episodes of diarrheal stools (LGG: 3.5 [1.0-7.5] vs placebo: 7 [3.0-16.3]; P = 0.02), and were 2.2 times more likely to return to normal stool (95% confidence interval, 1.3-3.9; P = 0.01) compared with children in the placebo group.Lactobacillus GG may reduce the duration of acute diarrheal illness among children presenting with more than 2 days of symptoms.

The objective was to determine whether a 3-question version of the Edinburgh Postpartum Depression Scale (EPDS) performs as well as the full EPDS in screening for postpartum depression in a pediatric emergency department (PED).Mothers of infants younger than 6 months presenting to an urban PED were enrolled. After the PED encounter, mothers were asked about demographics, health problems, insurance status, social support, food and housing security, and 3 questions from the EPDS. Mothers then completed the full EPDS. The primary outcome was the score on the full EPDS. Agreement between the 3 questions and the full EPDS for screening positive was measured. Test performance characteristics for screening positive with the 3 questions were calculated. Logistic regression determined the association between sociodemographic characteristics and screening positive. Provider impression of maternal depressive symptoms was recorded.Of 195 mothers enrolled, 23% screened positive using the EPDS; 34% screened positive using the 3 questions (κ = 0.74). Compared with the EPDS, sensitivity of the 3 questions was 100%. Number of children younger than 5 years at home and having food and housing concerns were associated with screening positive. Of 44 mothers who screened positive on the full EPDS, providers identified 14 (32%) as having depressive symptoms or possibly being depressed.Three questions from the EPDS performed similarly to the full EPDS in screening for postpartum depressive symptoms in a PED. Future studies are needed to confirm these findings and examine whether screening improves maternal and child health outcomes and quality-of-life concerns.

To explore the utility of two measures, Risk for Nonadherence (RN) and Admitted Nonadherence (AN), developed in a national sample of children with chronic asthma, for predicting short-term morbidity among children following a pediatric emergency department (PED) visit for acute asthma and to compare verbal and self-completion of these measures.Prospective cohort study of children 3 to 11 years of age presenting to a PED with an acute asthma exacerbation. Caretakers were randomized to self-completion of a questionnaire assessing RN and AN or to verbally respond to the same questionnaire administered by a research assistant. Five asthma morbidity indicators were collected at 2, 4, and 8 weeks following discharge from the PED.One hundred fifty-four patients were enrolled. There were no significant differences in asthma severity, RN, or AN, or the number of items missing on questionnaires between the self-completion and verbal administration groups. Patients with a RN score4 had an adjusted odds of 3.67 (95% confidence interval [CI] 1.57-8.58) for waking2 nights due to asthma symptoms. The adjusted odds of patients with any AN to report needing4 days of rescue asthma medication was 3.16 (95% CI 1.37-7.26).RN and AN were both associated with morbidity indices following an acute asthma exacerbation and can identify children at risk for increased short-term morbidity regardless of the method of questionnaire administration. Assessment of RN and AN by self-administered questionnaire during an ED visit for asthma maybe feasible.

Background: Osteopathic physicians believe that the birthing process causes cranial dysfunction that may be manifested in somatic symptoms, one of which is excessive crying of infancy. Cra...

Efforts to enroll inner-city asthmatic children into continuity care after a pediatric emergency department (PED) visit are frequently unsuccessful. Providing parents with documentation of their child's allergic status and how this can be used to tailor an asthma management plan may improve adherence to scheduled continuity appointments.To determine whether skin testing children during PED visits for wheezing and providing parents with skin test results improves adherence to follow-up visits.A convenience sample of children aged 2 to 12 years with asthma who presented to the PED with wheezing were eligible. Enrolled children were randomized to group 1 (no skin test) or group 2 (skin test). At discharge, both groups scheduled asthma clinic appointments for within 1 week. Children in group 2 underwent skin testing with standard allergens, and parents were given documentation of skin test results. Adherence was assessed by computer confirmation of the patient's asthma clinic visit.Seventy-seven children were enrolled: 39 in group 1 and 38 in group 2. The mean age was 7 years; 69% had mild intermittent asthma. Twenty-four percent of children (9 of 38) in group 1 vs 46% (17 of 37) in group 2 were followed up in the asthma clinic (P.05). Children in group 2 were 2.6 (95% confidence interval, 1.02-6.65) times more likely to keep appointments compared with children in group 1.Parents who receive evidence in the PED of their child's allergic status and probable relationship to the child's asthma are more likely to adhere to scheduled continuity visits.

OBJECTIVE. This study compared parental adherence to delayed antibiotic therapy for acute otitis media with and without a written prescription in a pediatric emergency department. PATIENTS AND METHODS. Children aged 2 to 12 years who met criteria for delayed antibiotic treatment were randomly assigned to observation therapy with or without a prescription. Patients randomly assigned to observation therapy without prescription were instructed to seek follow-up care if symptoms persisted for 2 to 3 days. Patients assigned to observation therapy with a prescription were discharged with an antibiotic prescription, and instructed to fill it if their child's symptoms persisted 2 to 3 days. A research assistant who was blinded to group assignment called parents 7 to 10 days after the visit to assess adherence to observation therapy. RESULTS. Of 117 children assigned to the observation therapy group, 100 completed follow-up; of 115 assigned to the observation therapy with a prescription group, 106 completed follow-up. In the observation therapy group, 87 parents reported no antibiotic use within the 3-day observation period compared with 66 parents in the prescription group. During the entire study period, 81% of the observation therapy group reported no use of antibiotics compared with 53% in the prescription group. These groups did not differ in satisfaction with the visit; 91% and 95% were very or extremely satisfied, respectively. No complications were reported. CONCLUSIONS. Observation therapy with and without a prescription were both well accepted by parents of children diagnosed with acute otitis media in an urban pediatric emergency department. Adherence to delayed antibiotic therapy was better for those not offered a prescription. These data suggest that, in the pediatric emergency department setting, observation therapy reduces antibiotic use without compromising satisfaction with the visit.

Background Evidence is mounting that environmental exposures contribute to causation of disease in children. Yet few pediatricians are trained to diagnose, treat, or prevent disease of environmental origin. Objectives To develop a cadre of future leaders in pediatric environmental health (PEH), the Ambulatory Pediatric Association (APA) launched a new 3-year fellowship in 2001—the world’s first formal training program in PEH. Sites were established at Boston Children’s Hospital, Mount Sinai School of Medicine, George Washington University, University of Cincinnati, and University of Washington. Fellows are trained in epidemiology, biostatistics, toxicology, risk assessment, and preventive medicine. They gain clinical experience in environmental pediatrics and mentored training in clinical research, policy development, and evidence-based advocacy. Thirteen fellows have graduated. Two sites have secured follow-on federal funding to enable them to continue PEH training. Discussion To assess objectively the program’s success in preparing fellows for leadership careers in PEH, we conducted a mailed survey in 2006 with follow-up in 2007. Conclusions Fifteen (88%) of 17 fellows and graduates participated; program directors provided information on the remaining two. Nine graduates are pursuing full-time academic careers, and two have leadership positions in governmental and environmental organizations. Ten have published one or more first-authored papers. Seven graduates are principal investigators on federal or foundation grants. The strongest predictors of academic success are remaining affiliated with the fellowship training site and devoting < 20% of fellowship time to clinical practice. Conclusion The APA fellowship program is proving successful in preparing pediatricians for leadership careers in PEH.

Purpose To investigate the association between a child's preprocedural state anxiety and the success of sedation. Methods A consecutive sample of children aged 2 through17 years requiring sedation for a procedure was enrolled. Pain, preprocedural anxiety (range, 0-9), and success of sedation (10 = most successful) were measured. Results Fifty-nine patients were enrolled. The median age was 7 years. The median anxiety score was 1.0 (interquartile ratio, 0-3). Pain and anxiety were weakly correlated ( r = .21, P > .10). The mean sedation score was 7.8 (±2.2). Preprocedural anxiety and successful sedation were inversely correlated ( r = −0.31, P = .002). Sedation was successful in 81% of children with anxiety scores below the median and 52% with anxiety scores above the median ( P = .02). Children with low anxiety were 3.8 times more likely to be successfully sedated (95% confidence interval, 1.19-12.14). Conclusion Our data suggest that preprocedural state anxiety is associated with the success of sedation in children.

BACKGROUND. Disadvantaged urban children with asthma depend heavily on emergency departments (EDs) for episodic care. We hypothesized that among an urban population of children with asthma, higher spatial accessibility to primary care pediatric services would be associated with (1) more scheduled primary care visits for asthma, (2) better longitudinal asthma management, and (3) fewer unscheduled visits for asthma care. METHODS. We enrolled children aged 12 months to 17 years, inclusive, who sought acute asthma care in an urban pediatric ED. Eligibility criteria included a history of unscheduled visits for asthma in the previous year. We collected comprehensive data on each participant's asthma medical management and prior health care utilization. In addition, we calculated each participant's spatial accessibility to primary care pediatric services, reported as a provider-to-population ratio at their place of residence. Patients then were stratified by their spatial accessibility to care and compared with respect to measures of medical management and health care utilization. RESULTS. Among the 411 eligible participants, the spatial accessibility of primary care ranged from 7.4 to 350.2 full-time pediatric providers per 100000 children CONCLUSIONS. Within this highly urban, largely disadvantaged and minority population of children with chronic asthma, patients with higher spatial accessibility to primary care services made significantly more scheduled visits for asthma care.

BACKGROUND. Current guidelines for asthma management emphasize the control of environmental irritants and allergens within the home. Understanding the prevalence of indoor home exposures within such a population may be important for any emergency department (ED) program that seeks to improve the quality of its asthma care and patient education.OBJECTIVE. We sought to determine the prevalence of indoor home exposures in a cohort of children with moderate to severe asthma who were treated in an urban pediatric ED and to correlate these exposures with household income, prior asthma morbidity, health care utilization, and quality of life (QoL).METHODS. We enrolled a cohort of children with chronic asthma who were 12 months through 17 years of age and who had at least one other unscheduled visit for asthma within the previous 6 months. Trained research assistants interviewed the children’s parent or guardian regarding the prevalence of home exposures to environmental tobacco smoke (ETS) and common allergens. In addition, data were collected on each patient’s prior asthma history, morbidity, health care utilization, medication use, and QoL.RESULTS. Of the 488 eligible children enrolled, 60.0% were 3 ED visits in the previous 12 months. Home exposure to ETS and potential allergens was high. Exposure to cockroach allergen was significantly associated with household income. Coexistence of exposures was common: significantly more patients reporting ETS exposure also reported exposure to cockroach allergen and mold than those not reporting ETS exposure. Poorer QoL was significantly associated with cockroach exposure, although this effect was limited to those also exposed to ETS. Higher rates of unscheduled health care utilization and persistent asthma symptoms were not associated with exposures.CONCLUSION. Additional investigation is necessary to clarify the role of exposure-avoidance measures as a component of ED-based interventions for asthma care.

Objective: To re-evaluate the Philadelphia protocol and the Rochester criteria for identifying infants at low risk for serious bacterial illness (SBI) in a new population. Methods: The authors prospectively enrolled infants 56 days of age or younger with rectal temperatures greater than 100.6°F. Physicians assigned an overall impression of sepsis and objectively scored each infant using the Infant Observation Score. Following a history and physical examination, a complete sepsis evaluation was performed. Infants were considered to have SBI if their blood, urine, cerebrospinal fluid, or stool cultures grew pathogenic bacteria. Infants were assigned to high- and low-risk groups for SBI according to the Philadelphia protocol and the Rochester criteria by a single investigator blinded to the final culture results. The test performance parameters of the Philadelphia protocol and the Rochester criteria in this population were compared with those reported from previous validation studies. Results: One hundred eighty-one infants were assigned to risk groups using the Philadelphia protocol, and 259 infants using the Rochester criteria. In this population, the negative predictive value (NPV) of the Philadelphia protocol was 97.1% (95% confidence interval [95% CI] = 85.1% to 99.8%), compared with 99.7% in the original report, and the NPV of the Rochester criteria was 97.3% (95% CI = 90.5% to 99.2%), compared with a prior report of 98.9%. Conclusions: The Philadelphia protocol and the Rochester criteria maintained their previously reported NPVs when applied to a new population of febrile infants. These data illustrate the usefulness of retesting clinical decision rules in new populations prior to their universal acceptance.

OBJECTIVE The objective of this study was to compare admission rates and medical interventions among children whose caregivers called their child's primary care provider (PCP) before taking an ambulance to the pediatric emergency department (PED) versus those who did not. METHODS This was a prospective cohort study of patients brought to an urban, public hospital PED via emergency medical system (EMS). Children were included if the caregiver called 911 to have them transported via EMS and was present in the PED. The main variable was whether the child's PCP was called before EMS utilization. Study outcomes were medical interventions, such as intravenous line insertion or laboratory tests, and hospital admission. χ Test and logistic regression were used to evaluate the relationship of the main variable to the study outcomes. RESULTS Six hundred fourteen patients met inclusion criteria and were enrolled. Five hundred eighty-five patients (95.3%) were reported to have a PCP. Seventy-four caregivers (12.1%) called their child's PCP before calling EMS. Two hundred seventy-seven patients (45.1%) had medical interventions performed; of these, 42 (15.2%) called their PCP (P = 0.03). Forty-two patients (6.8%) were admitted; among these, 14 (33.3%) called their PCP (P < 0.01). Adjusting for triage level, patients whose caregiver called the PCP before calling EMS were 3.2 times (95% confidence interval, 1.9-5.2 times) more likely to be admitted and 1.7 times (95% confidence interval, 1.1-2.9 times) more likely to have a medical intervention compared with patients whose caregivers did not call their child's PCP. CONCLUSIONS Children were more likely to be admitted or require a medical intervention if their caregiver called their PCP before calling EMS. The availability of a PCP for telephone triage may help to optimize EMS utilization.

To describe the circumstances and injuries associated with nonmotorized scooter-related trauma and to assess parental and child awareness and use of safety equipment.All children18 years of age presenting to an urban pediatric emergency department during a 15-month period with a nonmotorized scooter-related injury were identified. Data were collected by chart review or a detailed survey conducted by the treating clinician.There were 101 children with a total of 159 injuries. The mean age was 8.7 years; 70% were male. Most injuries involved the head/face/neck (30.8%), upper extremities (31.3%), and lower extremities (30.3%). Fifty-two percent (51.5%) of all injuries sustained were contusions, 32.7% fractures, 17.8% lacerations, 9.9% sprains, and 5.9% oral injuries. A total of 6 patients were admitted to the hospital, 1 to the intensive care unit. Data from surveys (n = 63) revealed that most injuries resulted from striking a stationary hazard (36.5%) or spontaneously losing balance (28.6%). Although 71.4% of all parents were aware of scooter safety precautions and 66.7% reported that their child had access to safety equipment, only 15.9% of patients were wearing any equipment. Fractures were more common in childrenor=8 years (P = 0.03); head and facial injuries were more common in children8 years (P = 0.001).Scooter-related injuries result in substantial morbidity. Although injured patients and their parents report awareness of scooter safety equipment, few injured children wear their equipment.

Objective. To test whether obesity is associated with decreased peak expiratory flow rates (PEFR), increased asthma symptoms, and increased health service use. Design/Methods. Secondary analysis of data from a cross-sectional convenience sample. Setting. Emergency departments (EDs) and primary care clinics in 8 inner-city areas in 7 cities. Participants. One thousand three hundred twenty-two children aged 4 to 9 years with asthma. Measures. Obesity was defined as a body mass index (BMI, weight/height2) >95th percentile. Nonobese children were those with a BMI between the 5th and 95th percentile. Underweight children with a BMI Results. Obese (n = 249) and nonobese (n = 1073) children did not differ in terms of age, gender, family income, passive smoke exposure, caretaker's mental health, and skin test reactivity to indoor allergens. Obese children were more often Latino (28% vs 17%) and, in the 3 months before the baseline interview, were more likely to have used oral steroids (30% vs 24%). There were no differences between groups in terms of baseline PEFR scores. During the 9 months after baseline assessment, the obese group had a higher mean number of days of wheeze per 2-week period (4.0 vs 3.4), and a greater proportion of obese individuals had unscheduled ED visits (39% vs 31%). There were no differences between the groups in terms of frequency of hospitalization, or in nocturnal awakening. Conclusions. In our sample of inner-city children with asthma, obese children used more medicine, wheezed more, and a greater proportion had unscheduled ED visits than the nonobese children.

Acetaminophen and ibuprofen are two of the most commonly used medications in children. It is our experience that parents often misdose these medications. Misdosing may lead to unintended toxicity or inadequate symptomatic improvement. There are limited data on the extent of misdosing of these antipyretics. We sought to determine the prevalence of and risk factors for inaccurate dosing by parents seeking care for their children in the emergency department (ED).A cross-sectional observational study was performed in an urban academic pediatric ED. Two hundred patients 10 years of age and younger who were given a known dose of acetaminophen or ibuprofen in the 24 hours prior to the ED visit were enrolled. The treating physician completed a questionnaire for each patient. Caregivers were asked about quantity and frequency of antipyretic use prior to the ED visit, the source of information used to determine dosage, and which factor (eg, age, sex, height, weight, height of fever, severity of illness) they considered most important in determining the correct dosage of medication. Doses of 10 to 15 mg/kg for acetaminophen and 5 to 10 mg/kg for ibuprofen were considered accurate.Overall, 51% of patients received an inaccurate dose of medication, including 62% of patients given acetaminophen and 26% of patients given ibuprofen. Infants1 year old were more likely to receive an inaccurate dose (RR 1.40, P0.04, 95% CI = 1.06-1.86). Caregivers who stated that medication dosage was based on weight were less likely to give an inaccurate dose of medication (RR 0.71, P0.03, 95% CI = 0.52-0.97).Over half of the caregivers surveyed gave an inaccurate dose of acetaminophen or ibuprofen, particularly to infants. Caregivers who reported that antipyretic dosage was based on weight were less likely to misdose medication, suggesting a valuable role for patient education.

We examined the 12-month prevalence of asthma and wheezing among U.S. children and compared the illness-related burden of children who wheezed with and without an asthma diagnosis. Data were obtained in a cross-sectional telephone survey that tested the performance of a health interview designed to identify children with chronic health conditions. Respondents were 712 primary caretakers of 1388 children under 18 years old in a national probability sample selected by random-digit dialing. Although 51 children identified with asthma and wheezing had more episodes, sleep disturbances, and attacks that limited speech, and received more medical treatment for wheezing than 69 children with wheezing alone, the "undiagnosed" children appeared to be only somewhat less affected by their wheezing. Repeat episodes and burden experienced by children with wheezing alone suggest that the asthma prevalence may be underestimated if based only on the diagnostic label.

The objective of this study was to describe perceptions of asthma care, morbidity, and health service utilization by parents of children with asthma presenting to an inner-city emergency department (ED). A cross-sectional survey was conducted in an urban pediatric ED, with a convenience sample of 466 parents of children receiving asthma treatment during a consecutive 6-week period in late fall 1995. Parents completed a 30-item survey including sociodemographic data, source of primary medical care and asthma care for their child, selected measures of access to care, and medications used by their child in the week prior to the ED visit. Perceived quality of asthma care was measured by six items (summary score = 0-6) reported to have been performed by the child's asthma doctor: discussion of home peak flow monitoring, child-specific triggers, dogs/cats, smoke, postexacerbation calling instructions, and provision of a written asthma management plan. Functional morbidity was measured by nights of poor sleep, days of cough, and school days missed due to asthma in the previous month. Among 325 patients with previously diagnosed asthma, 308 (97%) were reported to have a source of primary medical care. Of these, 126 respondents identified their primary care provider as the child's usual source of asthma care, while 158 identified the ED as the usual source. The groups did not differ by insurance status, ethnicity, or mean age of the child. Thirty-nine percent of children with the same provider for primary and asthma care compared with 15% of children reported to receive their asthma care predominantly in the ED had used inhaled steroids or cromolyn in the week prior to the ED visit (p < .0001). Children with the same provider for primary and asthma care had a higher mean quality score than children receiving asthma care in the ED (3.7 vs. 2.8, p < 0.0001), but there was no relationship between source of asthma care and functional morbidity. The ED remains the usual source of asthma care for many inner-city children. Among parents surveyed in the ED, there was a significant relationship between source of usual asthma care and quality of care, but a relationship between usual source of asthma care and functional morbidity could not be identified.

Previous research has demonstrated a significant reciprocal relationship between psychosocial factors and asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated both asthma-specific and non-specific psychosocial variables, including asthma knowledge beliefs and management behavior, caregiver and child adjustment, life stress, and social support. This article presents these psychosocial characteristics in 1,528 4–9-year-old asthmatic urban children and their caretakers. Caretakers demonstrated considerable asthma knowledge, averaging 84% correct responses on the Asthma Information Quiz. However, respondents provided less than one helpful response for each hypothetical problem situation involving asthma care, and most respondents had more than one undesirable response, indicating a potentially dangerous or maladaptive action. Both adults and children reported multiple caretakers responsible for asthma management (adult report: average 3.4, including the child); in addition, children rated their responsibility for self-care significantly higher than did adults. Scores on the Child Behavior Checklist indicated increased problems compared to normative samples (57.3 vs. 50, respectively), and 35% of children met the criteria for problems of clinical severity. On the Brief Symptom Inventory, adults reported elevated levels of psychological distress (56.02 vs norm of 50); 50% of caretakers had symptoms of clinical severity. Caretakers also experienced an average of 8.13 undesirable life events in the 12 months preceding the baseline interview. These findings suggest that limited asthma problem-solving skills, multiple asthma managers, child and adult adjustment problems, and high levels of life stress are significant concerns for this group and may place the inner-city children in this study population at increased risk for problems related to adherence to asthma management regimens and for asthma morbidity. Pediatr. Pulmonol. 1997;24:263–276. © 1997 Wiley-Liss, Inc.

Asthma morbidity has increased dramatically in the past decade, especially among poor and minority children in the inner cities. The National Cooperative Inner-City Asthma Study (NCICAS) is a multicenter study designed to determine factors that contribute to asthma morbidity in children in the inner cities. A total of 1,528 children with asthma, ages 4 to 9 years old, were enrolled in a broad-based epidemiologic investigation of factors which were thought to be related to asthma morbidity. Baseline assessment included morbidity, allergy evaluation, adherence and access to care, home visits, and pulmonary function. Interval assessments were conducted at 3, 6, and 9 months after the baseline evaluations. Over the one-year period, 83% of the children had no hospitalizations and 3.6% had two or more. The children averaged 3 to 3.5 days of wheeze for each of the four two-week recall periods. The pattern of skin test sensitivity differed from other populations in that positive reactions to cockroach were higher (35%) and positive reactions to house dust mite were lower (31%). Caretakers reported smoking in 39% of households of children with asthma, and cotinine/creatinine ratios exceeded 30 ng/mg in 48% of the sample. High exposure (> 40 ppb) to nitrogen dioxide was found in 24% of homes. Although the majority of children had insurance coverage, 53% of study participants found it difficult to get follow-up asthma care. The data demonstrate that symptoms are frequent but do not result in hospitalization in the majority of children. These data indicate a number of areas which are potential contributors to the asthma morbidity in this population, such as environmental factors, lack of access to care, and adherence to treatment. Interventions to reduce asthma morbidity are more likely to be successful if they address the many different asthma risks found in the inner cities.

The National Cooperative Inner-City Asthma Study (NCICAS) was established to identify and then intervene on those factors which are related to asthma morbidity among children in the inner-city. This paper describes the design and methods of the broad-based initial Phase I epidemiologic investigation. Eight research centers enrolled 1,528 children, 4 to 9 years of age, from English- or Spanish-speaking families, all of whom resided in major metropolitan inner-city areas. The protocol included an eligibility assessment and an extensive baseline visit, during which symptom data, such as wheezing, lost sleep, changes in activities of daily living, inpatient admissions, and emergency department and clinic visits were collected. A comprehensive medical history for each child was taken and adherence to the medical regimen was assessed. Access, as well as barriers, to the medical system were addressed by a series of questions including the location, availability, and consistency of treatment for asthma attacks, follow-up care, and primary care. The psychological health of the caretaker and of the child was also measured. Asthma knowledge of the child and caretaker was determined. Sensitization to allergens was assessed by skin-prick allergen testing and exposure to cigarette smoke and the home environment were assessed by questionnaire. For more than a third of the families, in-home visits were conducted with dust sample allergen collection and documentation of the home environment, such as the presence of pets and evidence of smoking, mildew, and roaches. Urine specimens were collected to measure passive smoke exposure by cotinine assays, blood samples were drawn for banking, and children age 6 to 9 years were given spirometric lung function assessment. At 3, 6 and 9 months following the baseline assessment, telephone interviews were conducted to ask about the child's symptoms, unscheduled emergency department or clinic visits, and hospitalizations. At this time, peak flow measurements with 2-week diary symptom records were collected.

Importance Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns (“RNA biosignatures”) in response to infections may provide an alternative diagnostic approach. Objective To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections. Design, Setting, and Participants Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38 ° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type. Exposure RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections. Main Outcomes and Measures Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores. Results Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections—including 32 with bacteremia and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43). Conclusions and Relevance In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with and without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.

Objective To describe the beliefs and preferences of pediatric surgeons regarding the emergent nature of nonperforated appendicitis. Methods An electronic mailing was sent to all 1052 members of the American Pediatric Surgical Association (APSA) inviting participation in a 26-item survey, which was administered by Survey Monkey (www.surveymonkey.com). Chi-square and Mann-Whitney tests were used for bivariate analysis. Spearman's rho was used for nonparametric correlation. Results Four hundred eighty-four pediatric surgeons (46%) responded to the survey. Few respondents (4%) considered nonperforated appendicitis to be a surgical emergency. A minority (14%) would come in from home to perform an overnight appendectomy. Most (92%) believe that postponing overnight appendectomy until daytime does not result in a clinically significant increase in perforation. Respondents endorsed surgeon fatigue (56%) and limited operating room availability (56%) most often among factors that would make them more likely to postpone surgery. Sixty-eight percent reported no departmental guideline regarding delay of overnight appendectomy. Conclusions Most pediatric surgeons in our study believe nonperforated appendicitis is not a surgical emergency and prefer to postpone overnight appendectomy.

Clinical Manual of Emergency Pediatrics, 5th edition, is a concise, portable handbook summarizing the wide range of conditions encountered in pediatric emergency departments. As children with acute problems often receive care in private offices and clinics, it is equally relevant for pediatricians, emergency medicine physicians, family practitioners and internists. The 5th edition of this hugely successful resource is the leading book of its kind for several reasons: • Clear, concise guidance is given for patient evaluation and follow-up and explicit indications for admission • Every chapter is organized in a standard format, making it very easy for a reader to locate critical information rapidly • A dedicated 'Special Considerations' chapter addresses difficult problems such as the crying infant and the cross-cultural encounter Numerous new topics are included, making Clinical Manual of Emergency Pediatrics, 5th edition an invaluable resource for any physician working in acute care settings where children are seen.

Objective To identify a population of children at low risk for bacterial conjunctivitis on the basis of history and physical examination findings. Design Prospective observational cohort study. Setting Urban pediatric emergency department. Participants Children aged 6 months to 17 years with conjunctival erythema, eye discharge, or both. The exclusion criteria were eye trauma, exposure to a noxious chemical, contact lens use, and antibiotic drug use in the past 5 days. Interventions Clinicians completed a checklist of signs and symptoms and collected a conjunctival swab for bacterial culture. Main Outcome Measures The χ 2 test, the Mann-Whitney test, and logistic regression were used to create a prediction model for a negative bacterial culture. Results Of 368 patients enrolled, 194 (52.7%) were males. The median patient age was 3 years (interquartile range, 1-5 years). Conjunctival cultures were negative in 130 patients (35.3%). Age 6 years or older, presentation in April through November, no or watery discharge, and no glued eye in the morning were the clinical factors found to be independently associated with a negative conjunctival culture. If 3 factors were present, 76.4% (95% confidence interval, 63.6%-85.6%) of patients had a negative culture. If all 4 factors were present, 92.3% (95% confidence interval, 66.1%-98.2%) of patients had a negative culture. Conclusion The combination of 4 clinical factors may enable clinicians to identify children at low risk for bacterial conjunctivitis and may reduce routine antibiotic drug administration.

To examine attitudes toward the use of oral rehydration therapy (ORT) by pediatric emergency medicine physicians before and after being given recent data that might affect their practice and to see if there is a difference in responses based upon year of graduation from medical school.A national survey of all members of the American Academy of Pediatrics' Section on Emergency Medicine was conducted. Respondents were asked about their use of ORT for mild, moderate, and severe dehydration, and then presented with data refuting the concern for longer emergency department length of stay with ORT. Participants were then asked about their knowledge of, agreement with, and reaction to these data. Demographic information, such as board eligibility and year of graduation from medical school, was also obtained. The graduates were plotted on a distribution curve by year of graduation, and the group was split into thirds.The response rate was 59%. Before being presented with new data, earlier medical school graduates used ORT 86% for mild and 33% for moderate dehydration, whereas recent graduates used ORT 95% for mild dehydration and 55% for moderate dehydration. Overall, only 23% of physicians were familiar with the new data, but 80% agreed with the new data, and 83% would now incorporate ORT into their practice. Although the earliest graduates were as familiar with the new data as recent graduates (24% vs. 19%), they were less likely to agree with the new data (74% vs. 90%) and to incorporate ORT into practice (75% vs. 92%).When pediatric emergency medicine physicians are presented with data refuting the perceived barrier of prolonged time for the use of ORT, more practitioners reported that they would use ORT for mild to moderate dehydration. However, a substantial number, especially those who graduated medical school earliest, would maintain their current practice. Additional barriers need to be explored.

Objective The purpose of the study was to determine if bedside ultrasound (US) and perception of wound foreign bodies (FBs) are useful screening tools for detecting wound FBs in children. Methods Prospective consecutive sample of children aged 18 years or younger presenting to a pediatric emergency department with wounds considered by the pediatric emergency department attending physician to be at risk for FBs was enrolled. Patients were asked if they had FB sensation in their wound(s). A bedside US of each wound was performed by the pediatric emergency department attending physician. A radiograph of each wound was obtained and interpreted by a radiologist blinded to US results and patient perception. Wound FBs were defined by the removal of a FB. The utilities of US and US with FB perception were compared with radiography for screening for wound FBs. Differences in performance characteristics among the 3 modalities were assessed using Fisher exact test. Results One hundred thirty-one wounds were studied in 105 patients. FBs were identified in 12 wounds (9.2%). A subanalysis was performed on patients able to answer questions regarding their perception of wound FBs. There were no significant differences in the test performance characteristics of bedside US alone compared with radiography for detecting wound FBs. Except for specificity, there were no significant differences in the test performance characteristics of bedside US combined with perception compared with radiography for detecting wound FBs. Conclusions Bedside US is comparable to the performance of radiography interpreted by an attending pediatric radiologist. Bedside US alone or combined with patient perception may be an adequate initial screening tool for detecting wound FBs.

Because environmental health problems are complex and require specialty training, the Ambulatory Pediatric Association initiated a 3-year postgraduate fellowship in Pediatric Environmental Health.To develop competencies for the specialty of Pediatric Environmental Health and appropriate measures (performance indicators) for the achievement of these competencies.The President of the Ambulatory Pediatric Association appointed a 6-member Fellowship Oversight Committee to guide the development of the Fellowship Program and to draft competencies for fellows in Pediatric Environmental Health. The Committee developed a list of proposed competencies for graduates of Pediatric Environmental Health fellowships. These were skills identified as very important for a specialist to have for minimal competency in the practice of pediatric environmental health.Twenty-seven Pediatric Environmental Health competencies are proposed. The competencies are presented from 3 separate perspectives: academic, individual patient care, and community advocacy. Each competency has a list of suggested performance indicators.These competencies are intended to assist in structuring the training experience, achieving consensus with respect to expectations of fellows and faculty, providing opportunities for fellows to assess their own needs or gaps in training, and identifying the expertise of fellowship graduates to potential employers.

Physicians report several barriers to the use of oral rehydration therapy (ORT) for dehydration in children due to acute gastroenteritis.To compare ORT with intravenous therapy for the treatment of moderate dehydration in children with acute gastroenteritis and to determine whether the factors reported as barriers to the use of ORT would be substantiated in practice.Randomized controlled trial in an urban pediatric emergency department. Children with moderate dehydration due to acute gastroenteritis were randomly assigned to ORT (group 1) or intravenous therapy (group 2). The primary outcome was length of stay in the emergency department. Secondary outcomes included hospital admission rate, staff time, relapse after discharge from the hospital, and parental satisfaction. Two days after discharge, parents were surveyed by telephone to assess the relapse and their satisfaction with the visit.Eighteen patients were enrolled in group 1 and 16 in group 2. The mean length of stay in group 1 was 225 vs 358 minutes in group 2 (P.01). Mean staff time was 35.8 minutes in group 1 compared with 65 minutes in group 2 (P =.03). Three patients failed ORT and required intravenous therapy. Two patients (11%) in group 1 vs 4 (25 %) in group 2 required admission to the hospital (P =.20). No patients relapsed after being discharged from the hospital. Fourteen parents (77%) in group 1 compared with 6 (37.5%) in group 2 reported that they were highly satisfied with all aspects of the visit (P =.01).Reported barriers to ORT were not supported by our data. Moreover, ORT performed better than intravenous therapy on all measured outcomes.

Objective: Single-center studies have reported varying relapse rates after treatment of patients with acute asthma. We determined the relapse rate after emergency department (ED) treatment in a cohort of children. Design: This was a prospective inception cohort study performed during 1997-1998. Setting: The study was performed in 44 EDs including both general and pediatric centers. Patients: Children (n = 1184) aged 2 to 17 years who had been admitted to EDs, with acute asthma restricted to 881 patients discharged from the ED. Main results: Two weeks after discharge, families were telephoned to determine relapse. Follow-up data were available for 762 (86%) of the children with a 10% incidence of relapse. On univariate analysis several factors were associated with relapse including current medications and markers of asthma severity. On multivariate analysis the factors associated with relapse were age (OR 1.4 per 5-year increase), use of second-line asthma medications (OR 3.7), exposure to cigarette smoke (OR 0.5), and ED visits within the past year (OR 1.2 per 5 ED visits). Conclusions: The incidence of relapse among children is lower than that observed among adults and varies with age. Other risk factors such as frequent ED visits are likely markers of chronic asthma severity. Further research should focus on ways to decrease the relapse rate among patients at high risk. (J Pediatr 2001;138:318-24)

Objective: To evaluate a family-focused asthma intervention designed for inner-city children 5 to 11 years old with moderate to severe asthma. Study design: Randomized, multisite, controlled trial to minimize symptom days (wheeze, loss of sleep, reduction in play activity) measured by a 2-week recall assessed at 2-month intervals over a 2-year follow-up period. The intervention was tailored to each family’s individual asthma risk profile assessed at baseline. Results: Averaged over the first 12 months, participants in the intervention group (n = 515) reported 3.51 symptom days in the 2 weeks before each follow-up interview compared with 4.06 symptom days for the control group (n = 518), a difference of 0.55 (95% CI, 0.18 to 0.92, P = .004). The reduction among children with severe asthma was approximately 3 times greater (1.54 d/2 wk). More children in the control group (18.9%) were hospitalized during the intervention compared with children in the intervention group (14.8%), a decrease of 4.19% (CI, –8.75 to 0.36, P = .071). These improvements were maintained in the intervention group during the second year of follow-up, during which they did not have access to the asthma counselor. Conclusions: We demonstrated that an individually tailored, multifaceted intervention carried out by Masters-level social workers trained in asthma management can reduce asthma symptoms among children in the inner city. (J Pediatr 1999;135:332-8)

The National Asthma Education and Prevention Program NAEPP Guidelines include recommendations for history-taking and discharge planning during an asthma visit, but there are no tools to measure performance. The objectives of this study were to define and operationalize key elements of history-taking and discharge planning, to develop a tool for measuring these elements, and to evaluate the quality of history-taking and discharge planning in the emergency department (ED) during visits for asthma using the new tool. Expert opinion and extensive literature review were used to develop a 13-item checklist containing items that should be documented during history-taking and provided during discharge planning for an ED visit for an acute asthma exacerbation by children. A convenience sample of 90 pediatric emergency medicine physicians and allergists rated each item in the checklist. The checklist was used to score audiotapes of asthma visits in the ED. Subjects were 154 parents of asthmatic children aged 4-9 years seeking care in nine inner-city EDs affiliated with asthma centers participating in the National Cooperative Inner-City Asthma Study and the physician/providers who delivered care. Seven of the 13 items on the checklist were rated as required to be performed by more than 90% of the allergist/pediatric emergency medicine physicians. Only 10% of the 154 visits included all seven of the highly rated items, whereas 19% of the visits included three or fewer. Only 7 of the 13 items (54%) were performed in more than 50% of the visits, and 4 items were performed in fewer than 25% of visits. Based on expert ratings, the checklist for measuring elements of history-taking and discharge planning during asthma visits appears to have considerable face validity. In the visits studied, the overall performance of these elements was low. Interventions to improve performance on the checklist might lead to improved care for children with asthma who frequent the ED.

To define the risk and identify predictors of single and multiple recurrent febrile seizures.Children (n = 428) with first febrile seizures were prospectively identified and followed for 2 or more years. Parents were interviewed soon after their children's first febrile seizure and were called every 3 months to ascertain recurrent febrile seizures. Medical records of first and recurrent seizures were reviewed for additional information.A total of 136 children (31.8%) experienced recurrent seizures: 73 (17.1%) had only 1 recurrence, 38 (8.9%) had 2 recurrences, and 25 (5.8%) had 3 or more recurrences. Young age at onset, a history of febrile seizures in a first-degree relative, low degree of fever while in the emergency department, and a brief duration between the onset of fever and the initial seizure were strong independent predictors of recurrent febrile seizures. With these 4 factors combined, it is possible to define groups of children having very high and very low probabilities of having any recurrences (70% vs20%), having 2 or more recurrences (60% vs10%), and having 3 or more recurrence (12% vs about 0%). In children who had at least 1 recurrence, age at the time of the first recurrence and a family history of epilepsy were predictors of subsequent recurrences.In children who have had a first febrile seizure, recurrences are common. The risk for 1 or more recurrences can be meaningfully predicted at the time of the initial febrile seizure with a combination of the 4 factors identified in this study.

To evaluate whether providing a spacer device and a single, brief demonstration regarding its proper use would result in earlier resolution of asthma symptoms, improved school attendance, and decreased frequency of unscheduled medical visits for asthma among children receiving noncontinuous care in an urban emergency department (ED).Randomized controlled trial.Urban hospital pediatric ED.Eighty-four children with the chief complaint of asthma.Children were enrolled in the ED at the time of an asthma attack and randomly assigned to one of two treatment groups. The spacer group received an inhaled beta-agonist at discharge from the ED with a spacer device. The control group received inhaled or oral beta-agonists without a spacer device. Both groups received other medications at the discretion of the evaluating physician who was not the interviewer in any case. A baseline questionnaire was completed and follow-up by telephone was done at 1 week, and 2, 4, and 6 months after enrollment.The spacer group reported significantly earlier resolution of wheezing (0 days vs 2 days, p0.01) at the 2- and 4-month follow-up assessments. They reported significantly fewer days of cough after an asthma attack at 2 months (1 day vs 3 days, p0.01) and 4 months (0 days vs 3 days, p0.01). The spacer group missed significantly fewer days of school following an asthma attack at 2 and 4 months (0 days vs 2 days, p = 0.05). There was no difference between the two groups on any outcome measures at the 1-week and 6-month follow-up assessments.Introducing a spacer device to patients in a busy, inner-city pediatric ED is an effective and efficient intervention that improves the functioning of asthmatic children in terms of resolution of cough and wheeze and school absenteeism.

Febrile seizures occur in about 2 to 4 percent of all children, approximately one third of whom will have recurrent febrile seizures. Little is known about predictors of recurrence.In this prospective study, we identified 347 children (1 month to 10 years of age) who presented with a first febrile seizure at one of four pediatric emergency departments. Information about these children was collected from medical records and interviews with the parents, and the children were followed for a median of 20 months to ascertain whether febrile seizures recurred.Recurrent febrile seizures occurred in 94 of the 347 children (27 percent) with a cumulative risk of 25 percent at one year and 30 percent at two years. The duration of fever before the initial seizure was associated with the risk of recurrence at one year: for fever lasting less than 1 hour, the risk of recurrence was 44 percent; for fever lasting 1 to 24 hours, 23 percent; and for fever lasting more than 24 hours, 13 percent (P less than 0.001). With each degree of increase in temperature (in degrees Fahrenheit), from 101 degrees F (38.3 degrees C) to greater than or equal to 105 degrees F (40.6 degrees C), the risk of recurrence at one year declined, from 35 percent to 30, 26, 20, and 13 percent (P for trend = 0.024). An age of less than 18 months and a family history of febrile seizures were also associated with an increased risk of recurrence. A family history of epilepsy, complex febrile seizures, and neurodevelopmental abnormalities did not increase the risk of recurrent febrile seizures.A shorter duration of fever before the initial febrile seizure and a lower temperature are associated with an increased risk of recurrence in children who have febrile seizures.

We are pleased to announce that the Ambulatory Pediatric Association journal will move to a 6 times a year publication, Ambulatory Pediatrics , as of January 2001. Ambulatory Pediatrics will provide a forum for interesting and cutting-edge work in academic general pediatrics. Ambulatory Pediatrics will focus on the education of pediatricians, child health services research, emergency medicine, research methodology, complementary and alternative medicine, child health policy, and adolescent medicine. Ambulatory Pediatrics builds on the success …

Objective To determine if an emergency department–based asthma follow-up clinic could improve outcomes within a high-morbidity pediatric population. Design Prospective, randomized clinical trial with 6 months of follow-up. Setting Emergency department of an urban pediatric medical center. Participants Convenience sample of 488 patients aged 12 months to 17 years, inclusive, with prior physician-diagnosed asthma and 1 or more other unscheduled visits in the previous 6 months and/or 1 or more hospitalizations in the prior 12 months. Intervention Single follow-up clinic visit focusing on 3 domains: asthma self-monitoring and management, environmental modification and trigger control, and linkages and referrals to ongoing care. Main Outcome Measures The primary outcome measure was unscheduled visits for acute asthma care. Secondary outcomes included compliance with a medical plan and asthma quality of life. Analysis was by intention to treat with adjustment for baseline differences. Results Of those randomized to the clinic visit, 172 (70.5%) of 244 attended. The intervention group had significantly fewer mean unscheduled visits for asthma care during follow-up (1.39 vs 2.34; relative risk [RR] = 0.60 [95% confidence interval (CI), 0.46-0.77]). At 6 months, significantly more patients in the intervention group reported use of inhaled corticosteroids in the prior 2 days (49.3% vs 26.5%; RR = 2.03 [95% CI, 1.57-2.62]), no limitation in daytime quality of life (43.8% vs 34.4%; RR = 1.36 [95% CI, 1.06-1.73]), and no functional limitations in quality of life (49.8% vs 40.8%; RR = 1.33 [95% CI, 1.08-1.63]). Conclusion Attendance in the follow-up clinic was high. The intervention decreased subsequent unscheduled health care use while improving compliance and quality of life.

Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004;351:1068–80. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Q In inner city children with atopic asthma, is a multifaceted, home based, environmental intervention (HBEI) effective for improving asthma related outcomes? Clinical impact ratings Paediatrics ★★★★★★☆ Respirology ★★★★★★☆ Immunology ★★★★★☆☆ Allergy and Immunology ★★★★★☆☆ ### ![Graphic][5] Design: randomised controlled trial. ### ![Graphic][6] Allocation: {concealed*}†. ### ![Graphic][7] Blinding: blinded (clinical outcome assessors).* ### ![Graphic][8] Follow up period: 1 year of intervention followed by a 1 year observational period. ### ![Graphic][9] Setting: 7 major cities in the US. ### ![Graphic][10] Patients: 937 children 5–11 years of age (mean age 7.7 y, 63% boys) with atopic asthma who were residents of census tracts in which ⩾20% of the households had incomes below the federal poverty level. Children were also required to have had ⩾1 asthma related hospital admission or 2 unscheduled, asthma related visits to the clinic or emergency department during the previous 6 months and a positive skin test in response to ⩾1 of 11 indoor allergens. ### ![Graphic][11] Intervention: a 1 year … [1]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.aulast%253DMorgan%26rft.auinit1%253DW.%2BJ.%26rft.volume%253D351%26rft.issue%253D11%26rft.spage%253D1068%26rft.epage%253D1080%26rft.atitle%253DResults%2Bof%2Ba%2BHome-Based%2BEnvironmental%2BIntervention%2Bamong%2BUrban%2BChildren%2Bwith%2BAsthma%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJMoa032097%26rft_id%253Dinfo%253Apmid%252F15356304%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1056/NEJMoa032097&link_type=DOI [3]: /lookup/external-ref?access_num=15356304&link_type=MED&atom=%2Febmed%2F10%2F2%2F51.atom [4]: /lookup/external-ref?access_num=000223733900006&link_type=ISI [5]: /embed/inline-graphic-1.gif [6]: /embed/inline-graphic-2.gif [7]: /embed/inline-graphic-3.gif [8]: /embed/inline-graphic-4.gif [9]: /embed/inline-graphic-5.gif [10]: /embed/inline-graphic-6.gif [11]: /embed/inline-graphic-7.gif

Objectives. Morbidity from asthma among children is one of the most important US health concerns. This study examines the relationship of baseline nonadherence to subsequent asthma morbidity among inner-city children.Methods. A multisite, prospective, longitudinal panel study was conducted of 1199 children who were aged 4 to 9 years and had asthma and their caregivers, most of whom were parents, in emergency departments and clinics at 8 research centers in 7 US metropolitan inner-city areas. Nine morbidity indicators were collected at 3, 6, and 9 months after baseline, including hospitalizations, unscheduled visits, days of wheeze/cough, and days of reduced activities.Results. Children whose caregivers scored high on a new measure, Admitted Nonadherence, experienced significantly worse morbidity on 8 of the 9 measures. Children who scored high on a new Risk for Nonadherence measure experienced significantly worse morbidity on all 9 morbidity measures. Multiple and logistic regressions found that the adherence measures had independent significant effects on morbidity. Combining the measures improved estimates of morbidity: children whose caregivers were poor on either adherence measure had worse morbidity than those with good adherence on both, eg, rate of hospitalization was twice as high, they missed more than twice as much school, had poorer overall functioning, and experienced more days of wheezing and more restricted days of activity.Conclusions. Risk for Nonadherence and Admitted Nonadherence independently and jointly predicted subsequent asthma morbidity. Targeting risks for nonadherence may be an effective intervention strategy. Most risks can be controlled by physicians through reducing the complexity of asthma regimens, communicating effectively with caregivers about medication use, and correcting family misconceptions about asthma medication side effects.

Poor access to care has been frequently mentioned as a possible cause for the rapid increase in asthma morbidity among children of the inner-city. For a sample of 1528 inner city children ages 4 to 9, the NCICAS project conducted an extensive assessment including more than 150 questions concerning health care access. This assessment included a wide range of access factors which could potentially be related to asthma morbidity. Using global measures, access to care appeared to be quite high with approximately 95% reporting that they had a usual place for attack and/or follow-up care. However, several specific elements of access were related to the children's asthma morbidity. Those access issues were; 1) having a place to call about the child's asthma problems; 2) finding it hard to get asthma attack care; 3) finding it hard to get follow-up care; 4) having to pay for medical costs; 5) having difficulty getting appointments for care. Responses to these five items were combined into an `access index' (AI) which was verified in a split sample canonical analysis. As expected, dividing the children into high and low AI groups revealed that those children with high access had fewer unscheduled and emergency room visits over a one year follow-up (p

Objectives: To determine whether US emergency department care for pediatric asthma conforms to the National Institutes of Health guidelines and whether the guidelines are likely to be adopted in clinical practice. Design: Mail survey conducted from January to April 1992, and stratified by hospital type (children's, public, and community). Settings: Emergency departments of US hospitals. Participants: Simple stratified random sample of emergency department directors from 376 sampled hospitals. Measurements: Self-reported data on emergency department pediatric asthma care, and knowledge and attitudes about the National Institutes of Health guidelines. Data are reported as mean (±SE). Results: Sixty-eight percent of the surveyed emergency department directors responded. During 1991, there were an estimated 1.6 million visits for pediatric asthma care. Asthma accounted for 16.9% (±9.0%) of all pediatric emergency department visits. Only 2.1% (±1.0%) reported the use of written protocols or guidelines, with significant variation by hospital type. Sixty-seven percent (±3.0%) reported the use of pulse oximetry. Eighty percent reported the use of β-agonists by inhalation as the initial treatment. Only 44.7% (±2.9%) reported the use of steroids if there was a poor response to the initial treatment. An estimated 45.5% (±3.9%) of respondents had heard of the guidelines at the time of this survey; approximately 24% reported that they had read the guidelines. Most respondents reported that the guidelines were credible, clear and concise, and likely to be adopted in their emergency department. Conclusions: These data suggest that reported pediatric asthma care in US emergency departments differs substantially from the National Institutes of Health guidelines, with considerable variation by hospital type. The guidelines appear to provide an acceptable tool for emergency departments to use in assessing their pediatric asthma care. However, in light of the lack of evidence that the guidelines will improve outcomes, the impact of national guideline adoption remains unclear. (Arch Pediatr Adolesc Med. 1995;149:893-901)

Maslow's humanistic model of cognition would suggest that the most thoughtful physicians have acquired more than conceptual skills; they also have learned to get a direct, preconceptual sense of how the patient is feeling through personal interactions with the patient. To explore this possibility, we asked 5 highly regarded attending pediatricians, as well as some pediatricians still in training (14 interns and 9 residents), to report all their thoughts and feelings as they conducted their usual evaluations of children under the age of two years brought to an emergency room with a chief complaint of fever. The findings generally indicated that the attending physicians did make the greatest effort to form preconceptual impressions of the children through warm and personal interactions with them. A second, questionnaire study indicated that as students and physicians-in-training gain experience, they increasingly appreciate the preconceptual, interpersonal approach of the advanced attending pediatrician.