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Sleep quality is vital for healthy development in children. Sleep disorders are prevalent and negatively affect sleep quality. Early identification and appropriate intervention can improve children’s health and quality of life. The current reference standard, polysomnography (PSG) has limitations regarding availability, cost, and access and may not replicate normal sleep patterns in the home. Simple, accurate sleep tests, available for repeated testing should be beneficial in management of sleep disorders. Secondary analysis of PSG data from the prospective multicenter Childhood Adenotonsillectomy Trial (CHAT) to evaluate FDA-cleared cloud-based software (Software-as-a-Medical-Device), which is based on analysis of photoplethysmogram data (PPG; plethysmogram-signal (PLETH) and oxygen saturation data (SpO2)), to automatically generate a novel apnea-hypopnea index (sAHI). sAHI is compared to manually scored AHI from PSG. Significant correlation is observed comparing the software-generated sAHI and manually derived AHI from the in-laboratory PSG-studies (Pearson correlation = 0.954, p

* Abbreviations: COVID-19 — : coronavirus disease 2019 PART — : Pediatricians Against Racism and Trauma We have seen the horrifying cell phone and surveillance video footage of the murder of George Floyd replay again and again in the last few weeks. The aftermath begs the question why this particular murder of a Black man by a police officer has sparked the international response so few have received.1 Scores of other Black men, women, and children have been killed by police since the 2014 murder of Eric Garner in New York City, in which he suffered an illegal chokehold and uttered the devastating refrain “I can’t breathe,” and countless others have been murdered over generations. These cases represent just the tip of the iceberg because these murders happened to be recorded on bystander cell phone video or police webcam capture. Moreover, it is the tip of another iceberg because these cases represent modern-day lynchings. The lynching of Black people in the United States was routine before the “civil rights era,” when there were major legal advances to change the treatment of Black Americans in this country. However, it was not until February 2020 that federal legislation, the Emmett Till Antilynching Act, was passed by the House of Representatives but is still … Address correspondence to Benard P. Dreyer, MD, FAAP, Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, New York University Grossman School of Medicine and Department of Pediatrics, Bellevue Hospital Center, 550 First Ave, New York, NY 10016. E-mail: benard.dreyer{at}nyulangone.org

To describe perinatal and neonatal outcomes in newborns exposed to SARS-CoV-2.A systematic review was conducted by searching PubMed Central, LILACS, and Google Scholar using the keywords 'covid ' AND 'newborn' OR 'child' OR 'infant,' on 18 March 2020, and again on 17 April 2020. One researcher conducted the search and extracted data on demographics, maternal outcomes, diagnostic tests, imaging, and neonatal outcomes.Of 256 publications identified, 20 met inclusion criteria and comprised neonatal outcome data for 222 newborns whose mothers were suspected or confirmed to be SARS-CoV-2 positive perinatally (17 studies) or of newborns referred to hospital with infection/pneumonia (3 studies). Most (12 studies) were case-series reports; all were from China, except three (Australia, Iran, and Spain). Of the 222 newborns, 13 were reported as positive for SARS-CoV-2; most of the studies reported no or mild symptoms and no adverse perinatal outcomes. Two papers among those from newborns who tested positive reported moderate or severe clinical characteristics. Five studies using data on umbilical cord blood, placenta, and/or amniotic fluid reported no positive results. Nine studies reported radiographic imaging, including 5 with images of pneumonia, increased lung marking, thickened texture, or high-density nodular shadow. Minor, non-specific changes in biochemical variables were reported. Studies that tested breast milk reported negative SARS-CoV-2 results.Given the paucity of studies at this time, vertical transmission cannot be confirmed or denied. Current literature does not support abstaining from breastfeeding nor separating mothers and newborns. Further evidence and data collection networks, particularly in the Americas, are needed for establishing definitive guidelines and recommendations.Describir los resultados perinatales y neonatales de los recién nacidos expuestos al SARS-CoV-2.Se realizó una revisión sistemática con búsqueda bibliográfica en PubMed Central, LILACS, y Google Scholar usando las palabras clave ‘covid’ Y ‘newborn’ O ‘child’ O ‘infant’, el 18 de marzo de 2020, y de nuevo el 17 de abril de 2020. Un investigador llevó a cabo la búsqueda y extrajo datos sobre demografía, resultados maternos, pruebas de diagnóstico, imágenes y resultados neonatales.De las 256 publicaciones identificadas, 20 cumplieron los criterios de inclusión y comprendían datos de resultados neonatales de 222 recién nacidos cuyas madres eran casos sospechosos o positivos confirmados de SARS-CoV-2 en el período perinatal (17 estudios) o bien recién nacidos internados en el hospital con infección/neumonía (3 estudios). La mayoría (12 estudios) eran informes de series de casos; todos procedían de China, excepto tres (de Australia, España e Irán). De los 222 recién nacidos, 13 tenían resultados positivos para SARS-CoV-2; en la mayoría de los estudios se informó que los recién nacidos eran asintomáticos o tenían síntomas leves y que no se habían producido resultados perinatales adversos. Entre los estudios con recién nacidos positivos, en dos se informaron características clínicas moderadas o graves. En cinco estudios se analizó la sangre del cordón umbilical, la placenta o el líquido amniótico y no se informaron resultados positivos. En nueve estudios se reportaron imágenes radiográficas, entre ellos cinco con imágenes de neumonía, aumento de la trama pulmonar, textura engrosada u opacidades nodulares de alta densidad. Se informaron alteraciones menores e inespecíficas de los parámetros bioquímicos. En los estudios en que se analizó la leche materna se informaron resultados negativos para el SARS-CoV-2.Dada la escasez de estudios, en este momento no es posible confirmar ni descartar la transmisión vertical. La bibliografía actual no apoya la abstención de la lactancia materna ni la separación de los recién nacidos de sus madres. Se necesitan más evidencia y redes de recolección de datos, en particular en la Región de las América, para establecer directrices y recomendaciones definitivas.Descrever os resultados perinatais e neonatais dos recém-nascidos expostos à SARS-CoV-2.Uma revisão sistemática com pesquisa bibliográfica em PubMed Central, LILACS e Google Scholar foi realizada utilizando as palavras-chave ‘covid’ E (‘newborn’ OU ‘child’ OU ‘infant’) em 18 de março de 2020, e novamente em 17 de abril de 2020 por um pesquisador. Foram analisados dados sobre demografia, resultados maternos, testes de diagnóstico, técnicas de imagem e resultados neonatais.Das 256 publicações identificadas, 20 preenchiam os critérios de inclusão e incluíam dados de resultados neonatais de 222 recém-nascidos cujas mães eram suspeitas ou positivas para a SARS-CoV-2 no período perinatal (17 estudos) ou recém-nascidos internados no hospital com infecção/pneumonia (3 estudos). A maioria (12 estudos) eram relatos de séries de casos; todos, exceto três (Austrália, Irão e Espanha), eram provenientes da China. Dos 222 recém-nascidos, 13 eram positivos para SARS-CoV-2; a maioria dos estudos relatou que os recém-nascidos eram assintomáticos ou tinham sintomas leves e que não foram observados resultados perinatais adversos. Entre os estudos com recém-nascidos positivos, dois descreviam características clínicas moderadas ou graves. O sangue do cordão umbilical, a placenta ou o líquido amniótico foram analisados em cinco estudos, não tendo sido relatados resultados positivos. Imagens radiográficas foram descritas em nove estudos, incluindo cinco com imagens de pneumonia, aumento da trama pulmonar, espessamento da textura ou opacidades nodulares de alta densidade. Foram relatadas alterações menores e não específicas dos parâmetros bioquímicos. Estudos que analisaram leite materno mostraram resultados negativos para SARS-CoV-2.Dada a escassez de estudos, neste momento a transmissão vertical não pode ser confirmada ou excluída. A literatura atual não apoia a abstenção da amamentação ou a separação dos recém-nascidos das suas mães. São necessárias mais provas e mais dados, especialmente na Região das Américas, para estabelecer orientações e recomendações definitivas.

A variety of microcephaly case definitions detect high background prevalence in rural Guatemala, which complicates congenital Zika screening efforts. In addition, gestational age is needed for most screening tools but is usually unknown in low-resource settings. Fenton growth curves, originally designed for use in preterm infants, offer a standardized approach to adjust for unknown gestational age and may improve screening efforts., Background: Congenital microcephaly is the result of a disturbance in early brain development and can have multiple etiologies. Establishing background prevalence of microcephaly in Zika virus (ZIKV)-affected areas is important for improving identification of ZIKV-affected newborns. However, to date, there is limited consistent guidance for the accurate identification of microcephaly in infants of unknown gestational age, a common concern in low- and middle-income countries. Methods: Occipital frontal head circumference (OFC) obtained from infants (0–13 days) of unknown gestational age at enrollment in a pregnancy registry in rural Guatemala from August 2014 to March 2016 were retrospectively reviewed. Trained community health nurses recorded anthropometry in an online database. In April 2015, ZIKV was identified in this population. Gestational age was approximated in 2 ways: presumed term and estimated using z-score of zero for height on modified Fenton growth curves. After which, z-scores for OFC and weight were obtained. Microcephaly and microcephaly background prevalence were estimated using 7 established microcephaly case definitions from national and international organizations and 3 proposed definitions using Fenton growth curves. Independent associations with microcephaly and OFC, including relationship with date of birth, were assessed with prevalence ratios and linear regression. Results: For 296 infants, the mean OFC was 33.1 cm (range, 29.5 to 37 cm) and the mean OFC z-score was −0.68. Depending on case definition, 13 to 125 infants were classified as having microcephaly (background prevalence 439 to 4,223 per 10,000 live births), and 1 to 9 infants were classified as having severe microcephaly (

Background: Determine the usefulness of ear pain anticipatory counseling for young children with public health plans to reduce visits for acute otitis media (AOM) and shift visits from urgent care/emergency department (UC/ED) settings to primary care clinic (PCC) settings. Methods: We documented the AOM visit distribution and incidence rates by setting according to race/ethnicity from the EPIC electronic medical record system for 12 months following the enrollment of eligible 12-15 month old children in a single blind randomized control trial of ear pain counseling. Results: Among the 310 children enrolled in the study, 30.6% of participants had at least 1 AOM visit and 4.5% had 3 or more AOM visits. The overall incidence was 490 AOM visit episodes per 1000 child years with rates of 232 in PCC and 226 in UC/ED settings. The difference in the proportion of Hispanic children with at least 1 AOM visit (33.5% 52/155) compared to Non-Hispanic children (24% 25/106) approached significance (p=0.08). The counseling intervention did not reduce the proportion of children with at least 1 AOM visit (counseling: 29.0%: 45/155; control: 32.3% 50/155 p=0.54); the proportion of children with 3 or more AOM visits (counseling: 5.8%: 9/155; control: 3.2% 5/155 p=0.41); or the AOM visit incidence rates (counseling: 471; control: 510) and did not shift AOM visits from the UC/ED to PCC setting. Conclusions: Anticipatory ear pain counseling in a hospital based PCC serving children enrolled in public plans does not reduce PCC or UC/ED AOM visit incidence rates.

Health plans try to maintain profit margins and limit rising premiums as escalating drug prices, expensive new technologies, and higher physician and hospital expenditures increase health care costs. Rural areas have the additional issue of adverse risk because young, healthier people often move to live in urban areas, leaving an older, sicker population in these communities. Health plan cost-containment strategies include having a narrow network that excludes primary care, specialty, and pediatric subspecialty physicians whose practice patterns and/or high payment rates result in higher costs. When a health plan’s physician network is restricted (narrow), the plan has more leverage to negotiate favorable payments because a high proportion of the patients in a participating physician’s practice are enrolled in the plan. Having a network that has fewer specialists and pediatric subspecialists may also discourage the enrollment of children and adults with chronic and complex conditions when they recognize that their physician does not participate in the plan. When a plan has fewer sick enrollees, it can have lower premium costs, which also encourages enrollment of lower … Address correspondence to Stephen Berman, MD, FAAP, 13199 E Montview Blvd, Suite 310, A090, Aurora, CO 80045. E-mail: stephen.berman{at}childrenscolorado.org

Objective: “Pediatrics in Disasters” (PEDS) is a course designed by the American Academy of Pediatrics to provide disaster preparedness and response training to pediatricians worldwide. China has managed to sustain the course and adapt its content for local needs. China has also experienced several natural disasters since the course’s inception, providing an opportunity to evaluate the impact of courses that took place in Beijing and Sichuan, in 2008-2010.Methods: We used pretesting/post-testing, participant surveys, and in-depth interviews to evaluate whether the course imparted cognitive knowledge, was perceived as useful, and fostered participation in relief efforts and disaster preparedness planning.Results: In Beijing and Sichuan, post-test scores were 16 percent higher than pretest scores. On immediate postcourse surveys, 86 percent of Beijing and Sichuan respondents rated the course as very good or excellent. On 6-month surveys, participants identified emotional impact of disasters, planning/triage, and nutrition as the three most useful course modules. Twelve of 75 (16 percent) of Beijing respondents reported direct involvement in disaster response activities following the course; eight of 12 were first-time responders. Participant interviews revealed a need for more training in providing nutritional and psychological support to disaster victims and to train a more diverse group of individuals in disaster response.Conclusions: PEDS imparts cognitive knowledge and is highly valued by course participants. Emotional impact of disasters, planning/triage, and nutrition modules were perceived as the most relevant modules. Future versions of the course should include additional emphasis on emotional care for disaster victims and should be extended to a broader audience.

We present a local and state phased approach for expanding coverage and improving the health care system for children. During the first phase, state regulatory reforms can be instituted to enhance the ability of Medicaid and State Child Health Insurance Plan (SCHIP) programs to provide measurable, high-quality clinical care that is patient-centered, safe, effective, timely, and efficient. The second phase can implement regulatory and legislative reforms that build program awareness in the community and streamline the enrollment process to maximize the enrollment of eligible uninsured children into a state's Medicaid/SCHIP program. The third phase involves a legislative expansion of income eligibility for SCHIP together with state-financed programs for legal immigrant children and foreign national children. The fourth phase considers legislative reforms to make family coverage more affordable to slow the erosion of employer-sponsored family insurance coverage, especially in small businesses.

BACKGROUND: There are no published studies of hospitalist comanagement of pediatric surgical patients. OBJECTIVES: (1) To describe comanagement activities; (2) to determine the association of hospitalist comanagement with length of stay (LOS) following spinal fusion surgery DESIGN: Retrospective analysis of the surgeons' log. SETTING: Tertiary-care pediatric hospital. PATIENTS: Patients who underwent initial spinal fusion surgery (n = 759) between July 2000 and October 2005. INTERVENTION: Hospitalist pre- and perioperative evaluation and management of medically complex patients (from December 2004 to October 2005). MEASUREMENTS: Log-transformed LOS and trend in LOS by piecewise regression were measured, adjusting for patient covariates and clustering by surgeon. RESULTS: After December 2004, 12% of all spinal fusion surgery patients (14 of 115) were comanaged by a hospitalist. Nine-three percent (13 of 14) of comanaged patients had neuromuscular scoliosis, and comanaged patients represented 37% (13 of 35) of all neuromuscular patients. Mean LOS for all spinal fusion surgeries decreased from 6.5 days (95% CI: 6.2–6.7) to 4.8 days (95% CI: 4.5–5.1) after December 2004. Mean LOS decreased more for neuromuscular patients (8.6 days [95% CI: 8.0– 9.2] to 6.2 days [95% CI: 5.5–6.9]) than for idiopathic patients (5.2 days [95% CI: 5.0–5.4] to 4.1 days [95% CI: 3.9–4.4]). Variability in LOS also decreased significantly for both groups. Prior to hospitalist comanagement, there was no change in adjusted LOS over time. After December 2004, there was a significant decline in average adjusted LOS (neuromuscular slope = −0.23 to −0.31 days/month, P = .0075; idiopathic slope = −0.10 to −0.12 days/month; P = .0007). CONCLUSIONS: The introduction of selective hospitalist comanagement of pediatric spinal fusion surgery patients was associated with significant decreases in LOS and variability in LOS. Journal of Hospital Medicine 2007;2:23–30. © 2007 Society of Hospital Medicine.

OBJECTIVES. Our objective was to determine the following among US pediatricians: (1) perceptions regarding burden of rotavirus disease and need for a vaccine; (2) intentions for recommending a newly licensed rotavirus vaccine; (3) perceived barriers to implementation; and (4) factors associated with plans for vaccine adoption. PATIENTS AND METHODS. A network of 431 pediatricians was recruited from a random sample of American Academy of Pediatrics’ members. The network was designed to be representative of the American Academy of Pediatrics with respect to region of the country, practice type, and practice setting. During January and February 2006, physicians were surveyed by Internet or mail. The survey contained a paragraph summarizing results of the new rotavirus vaccine trial. Respondents were asked about intentions to use the vaccine and anticipated barriers. RESULTS. The survey response rate was 71%. Of the respondents, 52% strongly agreed and 37% somewhat agreed with the need for a rotavirus vaccine. If recommended for routine use, 50% would strongly recommend and 34% would recommend but not strongly; 52% would begin to use within 6 months and 27% from 6 months to 1 year. The top 3 “definite” barriers to implementation included concerns about uniform coverage of vaccine by insurers, lack of adequate reimbursement, and parental reluctance because of withdrawal of previous rotavirus vaccine. In multivariate analysis, factors associated with very likely adoption of the vaccine included perception of a high burden of rotavirus disease and a high level of confidence in prelicensure studies of vaccine safety. The presence of physician concerns about safety of the new vaccine and the perception of parental concerns about vaccine safety in general were negatively associated with adoption. CONCLUSIONS. The majority of pediatricians reported willingness to implement the new rotavirus vaccine, most within 6 months. Major barriers to optimal implementation included provider concerns about reimbursement issues and parental acceptance of the vaccine.

Background. Beginning in 1997 the Colorado Medicaid program de-emphasized managed care and shifted children from enrollment in a health maintenance organization (HMO), which required an enrollee to have an assigned primary care physician, to either the unassigned fee-for-service (UFFS) program in which the enrollee was not required to have a primary care physician (PCP) or to the primary care physician program (PCPP) in which the enrollee was required to select a participating PCP if one was available. The proportion of Medicaid enrollee-months in HMOs dropped from 75.4% in 1997 to 29% in 2003, whereas the proportion of enrollee-months in UFFS programs during this time period increased from 18.6% to 45.6%, and the proportion in the PCPP increased from 5.5% to 25.3%. This shift of children from HMO managed care to the UFFS program provided a natural experiment to assess the impact of not having an assigned PCP on pediatric primary care services. Objective. We sought to assess whether an elective shift of children from Medicaid HMO managed care plans with an assigned PCP to the UFFS program without an assigned PCP restricted access to a primary care medical home, recommended health supervision visits, and age-appropriate immunizations. Methods. Published Colorado Health Plan Employer Data and Information Set (HEDIS) data for 1999–2003 were reviewed to determine if Colorado children enrolled in Medicaid managed care programs with an assigned PCP (HMO and PCPP) compared with the UFFS program were more likely to have any type of visit with a PCP, to have recommended health supervision visits, and to be fully immunized. In the analysis, “HMO total” refers to the average of all children participating in HMO plans. Kaiser Permanente was considered a benchmark because it had the highest immunization rates of all HMOs. “Total Colorado” refers to the average of all children enrolled in Medicaid including the managed care and UFFS options. For 2-year-olds, the 4:3:2:1:1 combination immunization included 4 diphtheria-tetanus-acellular pertussis vaccines, 3 oral poliovirus vaccines or inactivated polio vaccines, 2 hepatitis B vaccines, 1 Haemophilus influenzae type b vaccine, and 1 measles-mumps-rubella vaccine. Results. In 1999 the percentages of children 12 to 24 months of age having any type of visit with a PCP were >80% for the PCPP, Kaiser Permanente, and UFFS programs. However, although the proportion with any visit remained >85% in 2001 for children enrolled in the PCPP and Kaiser Permanente program, the percentage dropped 13.9% to 66.2% for children in the UFFS program. In 2001 the percentage of children with any type of PCP visit enrolled in the UFFS program (66.2%) was significantly lower than the total Colorado (73.6%) as well as the PCPP (85.7%) and Kaiser Permanente program (97.7%). Children 12 to 24 months of age enrolled in the PCPP in 2001 were 1.3 times more likely to have any type of visit with a PCP compared with those enrolled in the UFFS program. Children in the PCPP in 2001, 2002, and 2003 were 1.4, 1.9, and 2.6 times more likely, respectively, to have all 6 of the recommended health supervision visits compared with children enrolled in the UFFS program. Children 3 to 6 years old in the PCPP in 2001, 2002, and 2003 were 1.3, 1.5, and 1.4 times more likely, respectively, to have an annual health supervision visit compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 2-year-old children enrolled in the PCPP were 2.0, 1.4, 1.5, and 1.8 times more likely, respectively, to be up-to-date with 4:3:2:1:1 vaccines compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 adolescents enrolled in the PCPP were 1.8, 1.6, 1.3, and 1.6 times more likely, respectively, to be up-to-date with 2 measles-mumps-rubella vaccines compared with children enrolled in the UFFS program. Conclusions. This study documents the diminishing ability of the Colorado Medicaid program to provide children access to the benefits of a medical home, including visits with PCPs, recommended health supervision visits, and immunizations as care was shifted to the UFFS program from HMO managed care. The high up-to-date immunization rates achieved by Kaiser Permanente suggest that differences in immunization rates reflect the effectiveness of the care processes rather than the characteristics of the Medicaid population.

Within a clinic serving disadvantaged children, 1) to evaluate a multifaceted quality improvement (QI) project to improve immunization (IZ) up-to-date (UTD) rates and 2) to assess the efficacy of IZ reminder/recall performed following QI.A year-long QI project followed by a trial of reminder/recall. QI interventions were targeted at previously identified barriers to IZ and were designed specifically to improve the efficacy of reminder/recall. QI interventions were designed to 1) increase the use of medical record releases to document IZs received elsewhere; 2) improve the accuracy of parental contact information; and 3) reduce missed opportunities by utilizing chart prompts, provider education, and provider reminders. Following QI, we conducted a randomized trial of reminder/recall.UTD rates for 7-11 month olds increased from 21% before the QI project to 52% after (P.0001); rates for 12-18 month olds increased from 16% before QI to 44% after (P.0001); 19-25 month olds 18% before to 33% after (P.001). After QI, an average of 61 records per month were updated with IZs received elsewhere. However, the accuracy of parental contact information worsened (29% unreachable before QI vs 44% after, P.001) and missed opportunities did not improve (8% before vs 6% after, P = not significant [NS]). A subsequent trial of reminder/recall did not increase UTD rates, with 17% of recalled children brought UTD vs 16% of controls (P = NS).Clinic-based QI increased documented UTD rates in a disadvantaged patient population. However, IZ reminder/recall did not further increase UTD rates above the rates achieved by the QI process.

Background Determination of the cause of childhood diarrhea in low- and middle-income countries is complicated by the presence of multiple potential pathogens in stool at the time of illness. Serial multiplex PCR may offer a method to characterize pathogens more likely to clear over time (suggesting a higher likelihood of causality) vs. those that are more typically persistent (suggesting higher likelihood of nonpathogenic colonization). Such determination may have both clinical and epidemiologic utility. Methods Children 6–35 months old with acute non-bloody diarrhea (duration

Background Microcephaly is the result of disturbance in early brain development and has various causes. Zika was identified in Central America in early 2015. Establishing baseline microcephaly rates in areas affected by Zika is important for the assessment of the burden and contribution of Zika to microcephaly in low-resource settings. Methods We undertook a retrospective review of records from a community wellness programme in rural Guatemala where trained community health workers obtained data on weight, length, and head circumference for infants aged 0 to 13 days, enrolled in the programme between August 1, 2014, and March 31, 2016. We estimated gestational age using a Z-score of zero for length on the modified Fenton growth curve. Z-scores for head circumference and weight, adjusted for gestational age and sex, were then calculated. We used univariate logistic regression to test associations between microcephaly and low weight (Z ≤−1), small size for gestational age (weight below 10th percentile for gestational age), and sex. We analysed head circumference Z-scores and microcephaly for changes over time using birth month as well as multiple time-breaks (we compared infants born before versus after April 30, 2015; October 31, 2015; and January 31, 2016) with Student t-tests, and logistic and linear regression. Findings We included 296 infants: mean head circumference Z-score was −0·68 (95% CI −0·78 to −0·58). 20 infants (6·8%) had a head circumference Z-score ≤–2 and were considered to have microcephaly, giving a microcephaly prevalence of 676 per 10 000 livebirths. One infant (0·3%) had a head circumference Z-score ≤–3. Weight ≤–1 SD (OR 4·59 (1·69–12·41, p=0·003) and small for gestational age (6·65, 1·88–23·55, p=0·003) were associated with microcephaly. Sex was not significantly associated with microcephaly. Birth month and time-breaks were not associated with microcephaly nor with head circumference Z score. Interpretation Baseline neonatal microcephaly present in this rural Guatemalan community before and during Guatemala's early Zika epidemic is more than 100 and 300 times higher than baseline rates reported before the Zika virus epidemic in Puerto Rico and Brazil, respectively. Increased microcephaly rate associated with Zika epidemics in other countries was not detectable in our study population, probably because data were collected early in the Zika epidemic. High baseline microcephaly rates have important implications for neonatal screening programmes to identify infants congenitally infected with Zika in low-income countries. Funding The Center for Global Health at the University of Colorado and the Jose Fernando Bolanos Menendez Foundation provided funding for the wellness programme.

The findings of this evaluation document partial success for the PEDS training program to achieve its 3 aims. It will take several years for the dissemination of this program to reach a critical mass of pediatricians and other physicians in many LMICs. Obtaining stronger support from MOHs and other governmental agencies is necessary to achieve this goal. Another additional approach would be to integrate the training into medical school and residency programs.

Objective: To examine effectiveness of immunization recall in an urban pediatric teaching clinic and to identify barriers to recall effectiveness. Design: Randomized, controlled trial. Children aged 5 to 17 months who were not up to date (UTD) with recommended immunizations were identified and assigned to intervention (n = 294) or control groups (n = 309). The intervention consisted of a mailed postcard and up to 4 telephone calls. Two months after intervention, UTD status, visit, and probable missed opportunity rates were assessed. Results: Of the intervention group, 30% could not be reached. In 12-month-old children in the intervention group compared with those in the control group, there was a trend toward higher UTD rates (51% vs 39%, P =.07) and a higher proportion of UTD children receiving immunizations as opposed to getting more complete documentation (25% vs 10%, P =.005). Similar differences between intervention and control children were not seen in the 7-month and 19-month age categories. More children in the intervention group had a health maintenance visit (17% vs 11%, P =.03). Of children in the intervention group who were seen when not UTD, 17 of 24 (71%) of those seen for an illness visit and 5 of 24 (21%) of those seen for health maintenance probably had missed opportunities to be immunized. Conclusions: Recall efforts were partially successful but were undermined by inability to reach the clinic population, poor documentation of immunizations, and missed opportunities. (J Pediatr 2001;139:630–5)

Objective.—To determine increases in immunization up-to-date (UTD) rates at a rural pediatric practice with the sequential addition of records from other sites in a 2-county region. Design/Methods.—UTD rates for children aged 3 months to 35 months (n = 876) were determined for the index practice and then recalculated after sequential addition of records from 1) the other private practice in the region, 2) 7 public primary care sites, and 3) 2 public health clinics in the region. Results.—Adding records from all sites increased documented UTD rates in the index practice from 49% to 64% at 3 months (N = 33, P = 0.025), 50% to 68% at 5 months (N = 38, P = 0.008), 28% to 45% at 7 months (N = 113, P Conclusions.—Regional registries will be valuable tools for immunization delivery if there is an ongoing commitment to effective collection of current and historical immunization data.

We describe neonatal hepatitis B virus (HBV) vaccine policies in Colorado before and after thimerosal recommendations, plans for use of thimerosal-free HBV vaccine, and nurses' awareness of high-risk criteria for HBV vaccination. The results suggest that fewer neonates are receiving HBV vaccine at birth hospitals.

The objective of this study was to document the frequency and timing of otitis media—related visits, audiological consultations, and surgical interventions following a new episode of otitis media. A retrospective descriptive study was performed on a Medicaid administrative database that follows individual patients over time. The study included 14,453 children enrolled in Medicaid during 1991 and 1992 who were 30 months of age or younger and had a “new” episode of otitis media. Among 14,321 patients with an uncomplicated episode of otitis media, there were 10,443 with additional otitis media visits. Audiological testing was performed in 1.134 (10.9%). The testing occurred within 2 months of the onset of otitis media in 52.2% of the children and within 3 months in 66.6%. Physicians referred 400 children (3.8%) to an otolaryngologist; 299 (75%) underwent 1 or more surgical procedures. These surgical interventions included placement of ventilating tubes in 296 children, adenoidectomy in 34 children (all of whom also had placement of ventilating tubes), mastoidectomy in 2 children, and tympanoplasty in 1 child. The proportion of children who underwent surgical placement of ventilating tubes who had prior audiological testing was 174 of 296 (58.8%). The overall surgical rate for ventilating tubes was 2.9%. Among children who underwent surgery, the procedure occurred within 2 months of the onset of otitis media in 21.4% of children. Attempts to rationalize the management of otitis media in early childhood must deal with the difficulties in distinguishing among the otitis media conditions. The findings of this study suggest a need to know whether insertions of ventilating tubes within 3 months after a new episode of otitis media are related to unresponsive or recurrent infections.

Background. Influenza immunization is recommended for adults ≥ 50 years, healthy children 6–59 months and individuals with a chronic medical condition. Objectives. To compare respondents' perceptions of safety of immunization for children and adults both with and without chronic medical conditions. Methods. We surveyed parents of 828 randomly selected healthy children aged 6–21 months of age from 5 pediatric practices in Denver, Colorado between August and October of 2003. Results. The survey response rate was 57% ( n = 472). Although 65% of parents thought influenza immunization was safe for healthy 1 year olds, only 40% considered it safe for 1 year olds with a chronic condition. Similarly, 86% judged it safe in healthy 70 year olds versus 50% in 70 year olds with a chronic condition. Conclusions. Educational efforts to encourage influenza immunization in individuals with chronic illnesses should highlight the message that a chronic medical condition is an indication for immunization and does not confer additional risk of complications from vaccination. Further research is needed to confirm and better understand the observed perception of vulnerability to adverse events of vaccines in those with chronic illness.

Retrospective studies carried out in the 1950s, 1960s, and 1970s suggested an association between otitis media early in life and subsequent developmental impairments in children. Although these stu...

Background. Treatment of otitis media is the most frequent reason for administering antibiotics to children in the United States. However, only limited data are available on medical effectiveness of antibiotic prescribing patterns for otitis media and their associated expenditures or the factors that influence antibiotic prescribing. Methods. The study population consisted of 131 169 children during 1991 and 157 065 children during 1992 who were ≤13 years of age and enrolled in Colorado's fee-for-service Medicaid program. Among these children, 5127 (1991) and 7254 (1992) were enrolled in the cohort treated for a “new” episode of acute otitis media. An analysis using this cohort was performed to document the antibiotics used to treat a new episode of acute otitis media, factors influencing antibiotic selection, and the short-term outcomes of therapy. An analysis using the entire Medicaid population was performed to document the annual use of antibiotics for otitis, the associated antibiotic expenditures, and factors influencing antibiotic selection. Results. In the cohort analysis, office-based physicians prescribed second- and third-generation cephalosporins more often than did physicians in other settings (17% vs 9.7% and 11.8%), whereas hospital clinics prescribed trimethoprim plus sulfamethoxazole more frequently than did office-based physicians (19.2% vs 7.1% and 10.9%). Family physicians prescribed second- and third-generation cephalosporins more often than did pediatricians (16.6% vs 12.3%) but trimethoprim plus sulfamethoxazole and erythromycin plus sulfisoxazole less often than did pediatricians (10.5% vs 17%). The average rate of prescribing a second course of antibiotics within 24 days after initial antibiotic treatment of a new acute otitis media episode was 11.6% when less expensive antibiotics (amoxicillin, trimethoprim plus sulfamethoxazole, or erythromycin plus sulfisoxazole) were prescribed, and 13.2% when more expensive antibiotics (cefaclor, amoxicillin plus clavulanate, or cefixime) were prescribed. The average adverse drug reaction rate was 5.9% when less expensive antibiotics were prescribed, compared with 6.1% when more expensive antibiotics were prescribed. In each of the two study years, amoxicillin accounted for almost half of the total antibiotic fills but only 9% to 10% of the expenditures. Low-cost antibiotics (amoxicillin, trimethoprim plus sulfamethoxazole, and erythromycin plus sulfisoxazole) were prescribed for 66% to 67% of the total fills and accounted for 21% of the total projected expenditures. More expensive antibiotics (cefaclor, cefixime, amoxicillin plus clavulanate) prescribed for 30% of the fills generated 76% to 77% of expenditures. Cefaclor, prescribed for 17% to 18% of the total fills, generated 43% to 45% of total antibiotic expenses. Conclusions. The findings of this study document a preference for amoxicillin as the initial antibiotic for a new episode of acute otitis media. Although there was a wide variation in the selection of antibiotics to treat otitis, the more expensive antibiotics were not associated with better outcomes. This wide variation has important financial implications because of differences in antibiotic costs. Changes in prescribing patterns among initially uncomplicated children that reduce the use of high-cost antibiotics could reduce expenditures substantially without compromising short-term outcomes.

Background Diarrhea is a leading cause of morbidity and mortality in children in low and middle income countries (LMICs). Assessing diarrhea etiology in LMICs is of great importance in order to better develop both therapeutic and public health strategies, but is hampered by the complexity of potential diarrheal pathogens, and diverse methodology needed for pathogen identification Methods Subjects 6 to 35 months old with acute, moderate severity, non-bloody diarrhea were enrolled in a diarrheal treatment trial, conducted at one rural (N = 172) and two urban sites (N = 144) in Guatemala. Diarrheal pathogens were determined in stool by multiplex PCR (FilmArray GI® Biofire) which allows simultaneous identification of 23 bacterial, viral, parasitic pathogens. Descriptive statistics on demographics, pathogen load, and differences in pathogen occurrence by site were performed; differences were assessed with t-test and chi2 test Results Nearly all (96.8%) subjects had pathogens identified, and most had multiple potential pathogens identified (mean pathogen count: 2.7 urban and 4.8 rural; P < 0.001 (Figure 1). Notable pathogen differences were observed between rural and urban populations. Bacteria (particularly E.coli pathotypes and Campylobacter) and protozoa (particularly giardia) were more common in the rural population (Figure2). Viral pathogens were either similar or more common (norovirus; P = 0.04) in the urban population; rotavirus was uncommon in both sites (10 rural and 12 urban cases). A similar pattern of pathogen evolution with patient age was noted in both settings, with a decrease in the relative number of viral and increase in parasitic pathogens (Figure 3). Important demographic and socioeconomic differences between rural and urban were noted: rural subjects had poorer nutritional status, underdeveloped water and sanitation facilities and more domestic animal exposure Conclusion Acute diarrheal episodes in Guatemalan children were associated with a complex spectrum of pathogens when determined by multiplex PCR, with distinct patterns in rural and urban populations. Future studies to precisely determine diarrheal etiologies in LMICs will need to incorporate controls to sort causative organisms from those colonizing the intestine. Disclosures All authors: No reported disclosures.

Objective To examine the relationship between characteristics of the cognitive environment at age 10 to 18 months and vocabulary at age 18 to 30 months. Design Analysis of baseline and follow-up data on 157 families participating in a comparison of 2 anticipatory guidance programs. Setting Children's Hospital outpatient department serving low-income families. Participants Parents of children aged 10 to 18 months at baseline who participated in a follow-up telephone interview at age 18 to 30 months. Main Outcome Measures Three subscales of the StimQ (reading, parental involvement in developmental activities, and parental verbal responsivity [PVR]) and the short form of the MacArthur Communicative Development Inventories. Results Vocabulary score percentiles dropped significantly between baseline and follow-up, with scores for bilingual families showing a greater decrease than those for English speaking–only families. StimQ subscale scores increased with maternal education and increased between baseline and follow-up. Multiple regression analysis showed that baseline variables accounted for 25% of the variance in follow-up vocabulary score percentile, with significant contributions from baseline expressive vocabulary ( P P = .01), and home language ( P = .03) scores. Seventy-seven percent of children with PVR scores less than 4 had follow-up vocabulary scores at or less than the 25th percentile, with an associated likelihood ratio of 4.33. However, 35% of children with a PVR score of 4 also had vocabulary scores less than the 25th percentile at follow-up, with an associated likelihood ratio of 0.67. Conclusions The StimQ is a clinically useful method for assessing early environmental factors that influence vocabulary development. The PVR subscale score was the best StimQ predictor of later vocabulary delay and may be useful in identifying children needing referral for evaluation.

Background Epidermolysis bullosa (EB) is a family of rare, heterogeneous, genetic disorders characterized by fragility of the skin and mucous membranes. Reduced bone mass and fractures have been recognized as complications of generalized forms of EB. Objectives We sought to describe the range and to estimate the prevalence of low bone mass in children with generalized EB, and to identify correlates of low bone mass in this population. Methods This was a prospective, observational study of 24 patients with generalized EB. Each patient completed a history, physical examination, laboratory studies, bone age, and x-rays of the lumbar spine. Those aged 6 years and older underwent dual energy x-ray absorptiometry scans of the lumbar spine. Primary outcomes were areal bone mineral density (aBMD) based on chronologic age, bone age, and adjusted for height Z-score. Descriptive statistics were used to summarize results, and linear regression was used to determine factors associated with low aBMD. Results Mean lumbar spine aBMD Z-scores ± SD were: –2.6 ± 1.4 for chronologic age, –1.7 ± 1.3 for bone age, and –1.0 ± 1.2 after adjusting for height Z-score. aBMD Z-scores were less than or equal to –2 in 64% for chronologic age, 50% for bone age, and 28% after adjusting for height Z-score. aBMD correlated with height Z-score, weight Z-score, extensive blistering, immobility, albumin, hemoglobin, iron, erythrocyte sedimentation rate, and c-reactive protein values. Limitations Small sample size was a limitation. Conclusions Children with severe, generalized recessive dystrophic EB have low aBMD for age. Deficits in aBMD were reduced after adjusting for delayed skeletal maturation and small body size.

* Abbreviations: AAP = : American Academy of Pediatrics • FDA = : Food and Drug Administration • ATSDR = : Agency for Toxic Substances and Disease Registry The American Academy of Pediatrics (AAP) seeks to improve the health and well-being of America's children, in part, by formulating well-designed child health policy statements. The development of child health policy statements should always consider 4 key principles: integrity, credibility, fairness, and responsibility. A recent example of the child health policymaking process of the AAP was the joint statement of the AAP and US Public Health Service on the use of a mercury-containing preservative called thimerosal in vaccines and recommendations for hepatitis B vaccine administration. The perceived need to address the thimerosal issue quickly to provide pediatricians with timely recommendations precluded an extensive inclusive policymaking process. The process used demonstrates that the AAP, the US Public Health Service and other public agencies, and experts from academia can respond quickly and work together in the best interests of our children. This commentary will reflect on how the child health policymaking process of the AAP tried to consider these 4 key principles in its deliberations and understand the possible implications of alternative policy options. The principle of integrity involves the need to gain as complete an understanding of the issue as possible and communicate an unbiased assessment, acknowledging both what is known and not known. The AAP sought to maintain the integrity of the process by presenting the available information to pediatricians in as impartial and intellectually honest way as possible. The AAP became … Address correspondence to Stephen Berman, MD, FAAP, The Children's Hospital, 1056 E 19th Ave, B032, Denver, CO 80218. E-mail: berman.stephen{at}tchden.org

OBJECTIVE: The goal was to describe variable costs to providers of delivering childhood immunizations.METHODS: We documented variable costs (costs that vary with the amount of services rendered), including time spent by pediatric staff members and physicians on immunization-related activities, as well as supply costs and medical waste disposal costs. Ten private pediatric practices in the Denver, Colorado, metropolitan area participated in the study. Among the 7 practices that provided us with payment data, 8 health plans were mentioned by ≥2 practices. There were 37 different agreements between the health plans and practices for vaccine administration payments.RESULTS: The total documented variable cost per injection (excluding vaccine cost) averaged $11.51, calculated from the following categories: nursing time, $1.71; billing services, $2.67; nonroutine services, $1.64; registry use, $0.96; physician time, $4.05; supplies, $0.36; medical waste disposal, $0.12. Nonroutine activities primarily included performing vaccine inventory and ordering, providing vaccination records to requesters, and answering parent telephone questions about vaccinations. With the use of a simulation model to compensate for the small number of participating practices, the calculated total variable cost per injection was $11.83. When 2 vaccines were administered, we compared the sum of the 2 payments with the sum of the 2 variable costs ($23.02). More than one third of the payment agreements (13 of 37 agreements) paid the practices less than the combined variable costs for 2 immunizations.CONCLUSION: This study shows that the variable costs of vaccine administration exceeded reimbursement from some insurers and health plans.

The emergence and rapid spread of walk-in clinics staffed with nurse clinicians in retail stores and shopping malls challenges both medical and nonmedical communities to consider the relative priorities of continuity and the medical home compared with convenience and cost. Continuity of care has 3 dimensions: time, accessibility, and setting. The time dimension refers to having the same pediatrician (or clinician team) care for a child over a considerable period of time, optimally for many years, so that the pediatrician can develop a long-lasting relationship with the child and his or her family. Having continuous care allows for deeper understanding of the past as well as present issues that impact the child's development, health, and well-being. The accessibility dimension refers to ensuring that the family will be able to contact the pediatrician or a member of the coverage team 24 hours a day, 7 days a week, and be able to get needed care promptly in an appropriate medical setting. The setting dimension refers to coordinating care across multiple settings including the hospital, physician outpatient office, school, home health care agency, and, if necessary, hospice program. Continuity of care is important for both pediatric primary and subspecialty care. In several situations a subspecialty pediatrician, such as an oncologist, may provide continuous care and assume the care-coordination responsibilities. For more than 3 decades pediatric residency training programs have attempted to “teach continuity” through the establishment of continuity clinics in which residents care for a panel of patients. Because most residents only attend these clinics 1 or 2 half-days per week, continuity over time tends to be limited to scheduled preventive care and chronic care visits. However, even this limited amount of continuity is being … Address correspondence to Stephen Berman, MD, Children's Hospital, 1056 E 19th Ave, B032, Denver, CO 80218. E-mail: berman.stephen{at}tchden.org

OBJECTIVE. A human papillomavirus vaccine was licensed in June 2006. The vaccine is quadrivalent, protecting against 2 human papillomavirus strains that cause cervical cancer and 2 that cause genital warts. The objective of this study was to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination. METHODS. Between August and October 2005, a cross-sectional survey was administered to a national network of 431 pediatricians. The network was developed from a random sample of American Academy of Pediatrics members and was designed to be representative of the organization’s membership with respect to urban/rural location, practice type, and region. The survey was conducted before human papillomavirus vaccine licensure and therefore focused on a candidate quadrivalent human papillomavirus vaccine and a range of potential vaccination recommendations. The main outcome measure was intention to recommend a quadrivalent human papillomavirus vaccine to young adolescent (10- to 12-year-old) females. RESULTS. Survey response rate was 68%. If endorsed by national health organizations, 46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern. Respondents who believed that other new adolescent immunization recommendations (eg, meningococcal, pertussis) would facilitate human papillomavirus vaccine implementation were more likely to intend to recommend vaccination. CONCLUSIONS. Although a national sample of pediatricians expressed a high level of acceptance of human papillomavirus vaccination in older adolescent females, fewer than one half anticipated giving human papillomavirus vaccine to younger female patients. Provider concerns about parental vaccine acceptance will need to be addressed to optimize human papillomavirus vaccination implementation.

Objectives To assess the frequency and characteristics of missed opportunities for influenza immunization in children with chronic medical conditions and, among unimmunized children in that group, to explore parent-reported reasons for not vaccinating their child. Design Prospective cohort study. Data were obtained from billing and immunization registry databases and telephone interviews of parents. Setting Four pediatric practices in metropolitan Denver, Colo, during the 2002-2003 influenza season. Participants Children aged 6 to 72 months with 1 or more chronic medical conditions. Main Outcome Measure A missed opportunity for influenza immunization, defined as having a billed encounter, being eligible for immunization, and not receiving vaccine. Subjects with asthma were analyzed separately from those with other conditions. Results We identified 926 children with chronic conditions: 820 (89%) with asthma only and 106 (11%) with other conditions. Missed opportunities occurred at 78% of all vaccine-eligible visits for children with asthma and 74% of all visits for children with other conditions. For children with asthma, 92% of vaccine-eligible visits in December and January resulted in a missed opportunity vs 69% in October and November; for children with other conditions, corresponding frequencies were 86% vs 68%, respectively. For children with asthma, 86% of non–well-child visits resulted in a missed opportunity, compared with 62% of well-child visits; similar frequencies were seen among children with other chronic conditions. Parents of unimmunized children reported lack of a physician recommendation and low perceived susceptibility to influenza as the primary reasons for not immunizing their child. Conclusion Missed opportunities contribute significantly to low influenza immunization rates among children with chronic medical conditions.

Two articles in this issue of Pediatrics 1,2 provide additional evidence that our health care system is not functioning appropriately in the private or public sectors and needs to undergo a major transformation that focuses on value: enhancing quality while controlling expenditures. Most children in the United States have either private employer-based (commercial) health insurance or public health insurance through Medicaid or the State Children’s Health Insurance Program. In the private sector, payments for physician services (and other medical services) are determined by market forces with minimal or no government regulation. Payments usually are based on contracts between payers (the health plans) and physicians who deliver the services. Unfortunately, individual and small groups of pediatricians often lack the ability to negotiate with large for-profit health plans effectively. A central tenet of a private health care system is that quality per unit of cost will be maximized by having a competitive market determine the prices of medical services based on supply and demand. Demand should be based on quality per unit of cost, which is value. When the value of a service is high, demand should create a financial incentive to provide the service. How well is this private health care market system working to ensure that children are receiving recommended preventive care and immunization services? This is an important question, because our society benefits from wide-scale immunization; whole communities are protected, including individuals who are not vaccinated. McInerny et al,1 from the American Academy of Pediatrics, published a study in this issue of Pediatrics that addresses this question by examining the relationship in the commercial market between state-level physician payments for primary care services including immunizations with visit rates and up-to-date immunization rates. State-level payments were determined by using the Reden and Anders’ national actuarial database. State-level … Address correspondence to Stephen Berman, MD, FAAP, Children’s Hospital, 1056 E 19th Ave, B032, Denver, CO 80218. E-mail: berman.stephen{at}tchden.org

Background. An Advisory Committee on Immunization Practices policy of encouraging influenza vaccination for healthy 6- to 23-month-old children was in effect during the 2003–2004 influenza season, which was unusually severe in Colorado. We collaborated with 5 pediatric practices to attempt universal influenza immunization in this age group.Objectives. The objectives were (1) to assess the maximal influenza immunization rates that could be achieved for healthy young children in private practice settings, (2) to evaluate the efficacy of registry-based reminder/recall for influenza vaccination, and (3) to describe methods used by private practices to implement the recommendations.Methods. The study was conducted in 5 private pediatric practices in Denver, Colorado, with a common billing system and immunization registry. Although recommendations by the Advisory Committee on Immunization Practices included children who were 6 to 23 months of age at any point during the influenza season, our practices chose not to recall children 22 to 23 months of age, because they would have become >24 months of age during the study period. Therefore, our study population consisted of all healthy children 6 to 21 months of age from the 5 practices (N = 5193), who were randomized to intervention groups (n = 2595) that received up to 3 reminder/recall letters or to control groups (n = 2598) that received usual care. The primary outcome was receipt of ≥1 influenza immunization, as noted either in the immunization registry or in billing data.Results. Immunization rates for ≥1 dose of influenza vaccine for the intervention groups in the 5 practices were 75.9%, 75.4%, 68.1%, 55.6%, and 44.3% at the end of the season. Overall, 62.4% of children in the intervention groups and 58.0% of children in the control groups were immunized (4.4% absolute difference), with absolute differences, compared with control values, ranging from 1.0% to 9.1% according to practice. However, before intensive media coverage of the influenza outbreak began (November 15, 2003), absolute differences, compared with control values, ranged from 5.1% to 15.3% and were 9.6% overall. Before November 15, significant effects of recall were seen for children in the intervention groups, in both the 12- to 21-month age category (10.4% increase over control) and the 6- to 11-month category (8.1% increase over control); at the end of the season, however, significant effects of recall were seen only for the older age group (6.2% increase over control). The rates of receipt of 2 vaccine doses ≥1 month apart for eligible children ranged from 21% to 48% among the practices. Four of the 5 practices held influenza immunization clinics during office hours, evenings, or weekends, and these clinics achieved higher coverage rates.Conclusions. These results demonstrated that, in an epidemic influenza year, private practices were able to immunize the majority of 6- to 21-month-old children in a timely manner. Although media coverage regarding the epidemic blunted the effect of registry-based recall, recall was effective in increasing rates early in the epidemic, especially for children between 1 and 2 years of age. The practices that achieved the highest immunization rates were proactive in planning influenza clinics to handle the extra volume of immunizations required.

Objective. To describe costs to providers of delivering childhood immunizations.Methods. We collected variable costs—costs that vary with the amount of services rendered—including cost of practitioner and staff time and supplies, using a cost accounting method, from 12 practices (4 pediatric practices, 4 family practices, and 4 public health agencies) in rural and urban areas in Colorado. For private practices, we estimated fixed costs—costs that do not vary with the amount of services, eg, rent and insurance). We also collected reimbursement information for vaccinations for private practices.Results. Variable costs per shot (excluding vaccine cost) were $8.15 for pediatric practices, $5.79 for family practices, and $5.41 for public health agencies. Total costs per shot, including fixed costs, were $10.67 for pediatric practices and $7.57 for family practices. Average reimbursement for pediatricians and private family practices was $8.27 and $6.68, respectively. For pediatric practices, average variable costs were barely exceeded by average reimbursement, and reimbursement was 22% less than average total costs. This contrasts with an earlier study of the rural practices investigated here, in which there was a comfortable margin between reimbursement and variable costs.Conclusion. The decline in the ratio of reimbursement to cost for private practices, particularly for pediatric practices, suggests that referral to public agencies by private providers for vaccinations may increase and that if vaccinations are not as frequently provided in the child's medical home, then the currently high childhood immunization rates may be in jeopardy.

Objectives. Despite long-standing recommendations to provide annual influenza vaccination to children with chronic medical conditions, immunization rates are Methods. The study was conducted in 4 private pediatric practices in metropolitan Denver, Colorado, that share a computerized billing system and also participate in an immunization registry. For all children aged 6 to 72 months, registry records were linked with the billing database. Patients with ≥1 encounters for an HRC in the previous 24 months were selected, with HRCs identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Using medical records as the “gold standard,” we reviewed 327 randomly selected records to determine the sensitivity, specificity, and accuracy of billing data for identifying HRCs. For children with an HRC, we then conducted a randomized, controlled trial of reminder/recall for influenza vaccination. The primary outcome of the recall trial was receipt of influenza vaccine.Results. Billing data had a sensitivity of 72% (95% confidence interval [CI]: 48%–95%), specificity of 95% (95% CI: 90%–100%), and overall accuracy of 90% (95% CI: 84%–96%) in determining which children had an HRC. Of the 17 273 patients aged 6 to 72 months, 2007 had ≥1 HRCs (12% overall; range: 9%–14% per practice). Asthma/reactive airways disease accounted for 87% of all HRCs. Reminder/recall significantly increased influenza immunization in children with HRCs, with a vaccination rate of 42% in those recalled, compared with 25% in control subjects. Recalled subjects were more likely to have an office visit (68% vs 60%) and less likely to have a missed opportunity to immunize (28% vs 37%) compared with control subjects.Conclusions. Diagnosis-based billing data accurately identified children who had HRCs and needed annual influenza vaccination, and registry-driven reminder/recall significantly increased influenza immunization in targeted children.

The 2 articles published in this issue of Pediatrics by Gary Freed and his colleagues document the prices that 76 pediatric and family medicine practices in 5 states (California, Georgia, Michigan, New York, and Texas) pay for vaccines and how much they are reimbursed by health plans for purchasing and administering the vaccines.1 In addition, the authors successfully surveyed 385 pediatricians and 251 family physicians (a 60% response rate) throughout the country to better understand their attitudes about vaccine reimbursement, whether they are having any financial difficulties purchasing vaccines, and whether they are seriously considering no longer providing all vaccines in their practices.2 The findings will be reassuring, as well as disturbing, to the nation's vaccine policy makers. The findings are reassuring in that current reimbursement levels are not an imminent threat to the vaccine-delivery system. Pediatricians remain committed to continuing to immunize their patients; only 5% of the pediatricians responded that they are seriously considering whether to continue to provide all recommended vaccines in their practice. Pediatricians provide the majority of infants and young children with primary care services and immunizations. On the other hand, many of the other findings have disturbing implications. First, the survey reveals that payments throughout the country for immunization services often do not cover the full costs of immunizing children, which has the potential to undermine the vaccine-delivery system in the future. Second, the survey results suggest that access to immunization services in rural areas is already eroding as increasing numbers of family physicians decide not to provide immunizations. One in 5 family physicians were seriously considering whether to stop providing all recommended vaccines to privately insured children. Many family physicians were not purchasing newer, more expensive vaccines such as the human papillomavirus (HPV) and meningococcal conjugate (MCV4) vaccines because of high … Address correspondence to Stephen Berman, MD, University of Colorado School of Medicine, Children's Hospital, Department of Pediatrics, 13123 E 16th Ave, B032, Aurora, CO 80045. E-mail: berman.stephen{at}tchden.org

Objective: To provide population-based information about the utilization of ambulatory visits, antibiotic prescriptions, and surgical procedures related to the diagnosis and management of otitis media. Design: A descriptive study in which utilization rates per child and per child-year were calculated. Child-year rates stratified by age were calculated only for children having at least 1 ambulatory visit with a diagnosis of otitis media. Setting: Administrative data from Colorado Medicaid for the 1991 and 1992 calendar years. Patients: All children enrolled in Medicaid who are younger than 13 years and not participating in a prepaid health care plan during the study years (n= 131 169 and n=157 065) were included in the analysis. Results: Approximately 22% of children made at least 1 ambulatory visit with a diagnosis of otitis media, with the peak prevalence (46.8%) occurring between ages 1 and 2 years. Among all children younger than 13 years enrolled in Medicaid, there were 0.5 ambulatory visits for otitis media per child (0.7 ambulatory visits per child-year), with 70% occurring in a physician office setting, 14.8% in a hospital clinic or community health center, and 15.2% in a hospital emergency department. For all children enrolled in Medicaid, the rate of antibiotic courses for otitis media was 0.34 per child (0.48/child-year). Each child with otitis media had an annual average of 1.55 antibiotic courses (1.82 antibiotic courses per child-year). The average ratio of antibiotic courses to ambulatory visits related to otitis media was 65%. There was an annual rate of 12 surgical procedures related to otitis media per 1000 children (16.6/1000 child-years). The peak rate of ventilating tube insertion occurred in children ages 1 to 2 years and for adenoidectomy in children 3 to 6 years. Mastoidectomy rates were low, 92% occurring in children older than 2 years. Conclusions: This study represents preliminary techniques to profile the care of children with otitis media. Our findings support the need to measure volatility of enrollment in an insured population before calculating rates of utilization. Additional research is needed to measure the effects of discontinuous eligibility, access to a regular source of primary care, site of treatment, and physician preferences on the quantity and quality of treatments for otitis media. Arch Pediatr Adolesc Med. 1997;151:407-413

To determine theoretical practice patterns and Medicaid practices in the management of persistent and recurrent otitis media by family physicians and pediatricians in Colorado.Members of the Colorado chapters of the American Academy of Pediatrics and the Colorado Academy of Family Medicine were surveyed with the use of two hypothetical case management scenarios for which they were asked to indicate which International Classification of Diseases, Ninth Revision, Medicaid codes they would use. Physicians were presented with two case scenarios (one involving a persistent asymptomatic middle ear effusion and the second involving recurrent otitis media) and were asked to choose from a variety of management options, including observation, antibiotic therapy, decongestants, corticosteroids, antibiotic prophylaxis, and referral for ventilation tube surgery.Family physicians would have prescribed high-cost antibiotics (amoxicillin plus clavulanate potassium, cefaclor, or cefixime) to treat persistent middle ear effusions twice as often as pediatricians would have (P.002). At the 6-week visit, 50 family physicians (43%) would administer an oral decongestant either alone or in combination with other therapy as compared with 16 (14%) of pediatricians (P.001). Family physicians would refer patients for ventilating tube surgery three times more often than pediatricians at the 9-week visits (P.001). Recurrent episodes of acute otitis media would be managed similarly by both physician groups. Respondents reported a wide variety of International Classification of Diseases, Ninth Revision, coding, often coding persistent effusions as acute otitis or as unspecified otitis media.The findings of this survey document the wide variation in practice patterns for treating children with persistent otitis media and children with recurrent otitis media in Colorado.

The frequency of otitis media is one of a number of factors causing physicians to seek out the most cost-effective clinical strategies for managing the condition. It is estimated that, by the time they reach two years of age, all the children in the United States currently under that age will have had a total of 9.3 million episodes of acute otitis media,1 and that approximately 17 percent of children have three or more episodes during a six-month period.2 Frequent episodes of otitis disrupt child-care arrangements and work schedules and generate parental anxiety and stress. The annual cost of the . . .

Background.Treatment of otitis media in children is associated with substantial expenditures because of its high frequency during childhood. Vaccines against respiratory pathogens causing otitis media are now being developed. Information about otitis media-related medical expenditures will be needed to determine the cost-effectiveness of these preventive interventions.Methods.This study used utilization data from claims to impute otitis media-related expenditures for medical visits, pharmaceuticals, and surgical procedures for 87 057 children 13 years of age and younger who were continuously enrolled in Colorado's fee-for-service Medicaid program during 1992. International Classification of Disease, Ninth Revision diagnostic codes were used to identify visits for otitis media. An antibiotic was considered to have been prescribed to treat otitis media if it was dispensed up to 24 hours before or within 48 hours after a physician encounter showing a diagnosis of otitis media. All tympanostomies, mastoidectomies, and adenoidectomies were assumed to be related to otitis media. Expenditures were imputed from utilization using a Medicaid fee schedule.National expenditures for 1992 to treat otitis media were extrapolated from Colorado's Medicaid data. We adjusted for differences between Colorado and the United States as a whole in terms of price, number, and intensity of services; for differences in reimbursement rates by service between Medicaid and private insurance; and for differences in utilization between Medicaid enrollees and the uninsured. To provide a more current expression of medical expenditures for otitis media, we inflated the 1992 expenditure estimates to 1998 dollars using the Consumer Price Index published by the US Bureau of Labor Statistics.Results.Twenty-eight percent of children experienced at least 1 episode of diagnosed otitis media. The proportion of children with a diagnosis of otitis media was highest (42%–60%) in the 7-month to 36-month age range. The proportion was also higher among white (34.5%) and Hispanic (25.3%) children than among black children (18.5%), as well as among rural (34.5%) compared with urban children (27.2%).Children 19 to 24 months of age incurred the highest total annual expenditures per child with otitis media ($239.68). Expenditures for drugs, visits, and procedures were all highest for this group. The per-patient cost to Medicaid was greater for visits than for drugs or procedures across all age groups.Total per-patient expenditures were higher for males ($174.67) than for females ($154.47) and higher for white children ($176.59) than for Hispanic ($154.12) or black children ($134.44). The differences among the ethnic groups can be attributed almost entirely to differences in expenditures for procedures and drugs. Although mean expenditures per patient varied substantially by some patient characteristics (eg, race), these differences accounted for only a small fraction of the enormous variation in costs per patient.Including children with and without otitis media, age-specific estimated expenditures per child peaked among children 1 ($132.94) and 2 years of age ($88.72). Children 3 to 6 years of age incurred expenditures only one third as great as those incurred by children 1 year of age.Total national expenditures were estimated to have been approximately $4.1 billion in 1992 dollars and $5.3 billion in 1998 dollars. Over 40% of national expenditures to treat otitis media in children younger than 14 years of age were incurred for children between 1 and 3 years of age ($453 per capita in 1992 dollars over these 2 years vs $1027 for all years of age from 2 to 13). Nationally, expenditures for visits remained the largest component of expenditures.Limitations.This study assessed expenditures from the point of view of the health care system; that is, no social costs, such as lost work time, or expenditures not normally covered by insurance, such as those for transportation, were included. The study captured expenditures to treat otitis media during a calendar year and should not be interpreted as the cost to treat episodes of otitis media. Our reported expenditures may have captured only part of an episode straddling 2 calendar years, or, alternatively, they may cover several episodes.The figures reporting 1992 expenditures expressed in 1998 dollars should not be taken as an estimate of 1998 expenditures to treat otitis media. The approach used to adjust the expenditures did not take into account changes in the medical practice environment, such as would occur with a movement of the population from predominantly fee-for-service practice to managed care or the introduction of new treatment practices. It also did not account for changes in insurance status, eg, an increase in the proportion of uninsured children, or for population increases.Most importantly, our estimates of expenditures are based on treatment of otitis media as it was practiced in 1992, before the current practice guidelines were promulgated. The effect of the guidelines on physician practice in 1992 may, however, not have been substantial. In 1998, Christakis and Rivara found that only 50% of pediatricians were aware of the otitis media guidelines, and of these, only 28% believed that they had changed their practice as a result of the guidelines. It is important to remember that our estimates are based on 1992 Medicaid utilization. Given Medicaid's low reimbursement to primary care physicians at that time, doctors would have had little financial incentive to see patients more often than necessary. Thus, insofar as practice guidelines encouraged fewer visits, Medicaid utilization may already reflect close adherence to the practice guidelines.Conclusions.Because 40% of expenditures to treat otitis media are incurred between 1 and 3 years of age, vaccines designed to reduce the incidence of otitis media are most likely to be cost-effective if they can be administered before the child's first birthday.Because visits are the most costly category of service for all payers, otitis media case management guidelines should emphasize reducing unnecessary visits, for instance, by improving physician training in pneumatic otoscopy, which has been shown to be critical to an accurate diagnosis of otitis media, and by scheduling follow-up visits for children who have become asymptomatic 3 to 4 weeks after diagnosis rather than after 10 to 14 days, allowing time for resolution of the middle ear effusion.

A surveillance system for acute lower respiratory tract illnesses was implemented February 1977 in five neighborhood health clinics. Of the 1,229 patients with an illness identified during the 25 months from Feb 1, 1977 to Feb 28, 1979, there were 38 with croup, 451 with tracheobronchitis, 339 with bronchiolitis, and 401 with pneumonia. Forty-two percent of the illnesses occurred in children less than 1 year of age and 66% occurred in children less than 2 years of age. A viral infection was diagnosed in 20% of the patients by viral cultures and/or fourfold rises in complement fixation antibody titers in acute and convalescent sera. A viral agent was identified in 29% of patients with croup, 20% with tracheobronchitis, 22% with bronchiolitis, and 17% with pneumonia. Four viral agents, respiratory syncytial virus (RSV) adenovirus, parainfluenza viruses, and influenza viruses accounted for 94% of the cases associated with a viral infection. RSV was associated with 9% of the cases, adenovirus with 6.8%, parainfluenza with 2.1%, and influenza with 1.3%. These four viral agents had slightly different clinical patterns. The majority of RSV infections were diagnosed in children less than 2 years of age with bronchiolitis or pneumonia. Yearly outbreaks of RSV were noted during periods corresponding to RSV peaks in northern temperate climates. Adenoviral infections occurred most frequently in children between 1 and 5 years of age with tracheobronchitis or pneumonia in association with high fever. Parainfluenza viral infections were usually associated with tracheobronchitis and pneumonia. Influenza infections usually occurred in older children with pneumonia associated with high fever, headache, and myalgias. Bacteremias were identified in four patients with lower respiratory tract infections. Twenty percent of children with moderate or severe malnutrition and an acute respiratory illness were bacteremic. Three of the four children with moderate or severe malnutrition, pneumonia, and fever greater than 38.9°C had a positive blood culture. There were 17 children seen who required hospitalization and three subsequent deaths in this group.