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OBJECTIVE: Seven million US children lack health insurance. Community health workers are effective in insuring uninsured children, and parent mentors (PMs) in improving asthmatic children’s outcomes. It is unknown, however, whether a training program can result in PMs acquiring knowledge/skills to insure uninsured children. The study aim was to determine whether a PM training program results in improved knowledge/skills regarding insuring uninsured minority children. METHODS: Minority parents in a primary-care clinic who already had Medicaid/Children’s Health Insurance Program (CHIP)-covered children were selected as PMs, attending a 2day training session addressing 9 topics. A 33-item pretraining test assessed knowledge/skills regarding Medicaid/CHIP, the application process, and medical homes. A 46-item posttest contained the same 33 pretest items (ordered differently) and 13 Likert-scale questions on training satisfaction. RESULTS: All 15 PMs were female and nonwhite, 60% were unemployed, and the mean annual income was $20,913. After training, overall test scores (0–100 scale) significantly increased, from a mean of 62 (range 39–82) to 88 (range 67–100) (P

CASE Satish is a 3 (1/2)-year-old boy you are seeing in your primary care office for a "sick visit" due to parental concerns about his language development. He is the only child of a couple who immigrated to the United States from India shortly before his birth. He received early intervention services for speech and language delays for a few months before he attained 2 years of age. However, services were discontinued when the family moved back to India for a year. After the family returned to the United States, they lived in a different state for several months before moving again recently to his current home, so he is relatively new to your practice. Satish's mother is concerned not only about his communication skills but also about his attention and social skills. She notes that he often plays alone or in parallel with other children. She was also told by his first pediatrician that Satish had "a limited imagination." His parents feel that he has pretend play, in that he will pretend to get his haircut, talk on the phone, or ride on a train. Satish was born at term without complications. He passed his newborn hearing screen and a repeat hearing test at the age of 2 years. He has had no medical problems and takes a daily multivitamin. His parents are both of Indian descent. Satish's father is an engineer and had a history of being a late talker. His mother graduated from high school and is a homemaker. They are expecting their second child. Satish's developmental history is significant for language delays. He babbled at 6 months but did not have single words until he was 2 years. When he was 2 (1/2) years, he had 2 to 3 word sentences. He responded to his name at 15 months and could follow single step commands by the age of 2 years. Currently, Satish is noted to have difficulty with "back and forth conversation." He sometimes repeats what others are saying.The family speaks Hindi, their native language, exclusively at home. When Satish speaks, he usually speaks in Hindi. His parents describe him as using "odd language" in that he will often mix up his pronouns. Satish is in an English-speaking preschool. His preschool teachers report concerns that he seems to "withdraw into his own world," and does not interact well with the other children. They also report attentional problems and poor eye contact.In the office, Satish makes good eye contact with the examiner and his parents. He looks to his parents for approval when completing a task requested of him. He seems to like an Elmo toy that is in the room but holds it and looks at it closely rather than pretend to do anything with it. You ask him to feed Elmo, and he says, "Feed Elmo." Because it is not clear whether he understands the verbal cues given to him, his parents repeat English directions to him in Hindi several times. He eventually complies but then leaves his chair to explore the room. His parents continue to translate your questions to him with variable results. He becomes increasingly difficult to engage, despite repeated attempts, in both English and Hindi, to attract his attention. Where do you go from here?

Background. Clinical practice guidelines are increasingly being used for a wide variety of medical conditions, but not enough is known about physicians' attitudes and beliefs about guidelines, how often and under what circumstances they are used, and factors associated with their acceptance. Objective. To determine practice guideline attitudes, beliefs, practices, and factors associated with use among a representative national sample of general pediatricians. Study Design. Cross-sectional mail survey. Subjects. Random sample of general pediatrician members of the American Academy of Pediatrics residing in all 50 states and Puerto Rico. Survey Instrument. Twenty-four multiple-choice, Likert scale, yes–no, and open-ended questions about pediatric clinical practice guidelines. Results. From 1088 respondents, 461 specialists were excluded; the remaining 627 general pediatricians were mostly male (61%), white (81%), and in group practice (62%) in a suburban location (48%). Practice guidelines are used by 35% of pediatricians, in part by 44%, and not at all by 21%. Over 100 different practice guidelines are used, most commonly for asthma (77%), hyperbilirubinemia (27%), and otitis media (19%). Common reasons for use of practice guidelines include standardization of care (17%) and helpfulness (10%). Commonly cited problems with practice guidelines include failure to allow for clinical judgment (54%), use in litigation (16%), and limitation of autonomy (5%). In multivariate analysis, the odds of practice guideline use were greater among pediatricians in health maintenance organization practices (odds ratio [OR]: 9.1; 95% confidence interval [CI]: 1.2–68.0) and those who were nonwhite (OR: 2.3; 95% CI: 1.1–4.8), but lower in those with more weekly patient visits (OR: .7; 95% CI: .5–.9). Features most likely to lead to practice guideline use include simplicity (16%), feasibility (12%), and evidence of improved outcomes (10%). Most pediatricians agree that practice guidelines improve outcomes (89%), are motivated by a desire to improve quality (94%), and should not be used in litigation (82%) or disciplinary actions (77%), nor be motivated by a desire to reduce costs (73%). Conclusions. Most general pediatricians use practice guidelines, but no specific guidelines, except those for asthma, are used by >27% of pediatricians. The results of this study suggest that practice guidelines are most likely to be followed if they are simple, flexible, rigorously tested, not used punitively, and are motivated by desires to improve quality, not reduce costs.

OBJECTIVES: This study characterized ethnic disparities for children in demographics, health status, and use of services; explored whether ethnic subgroups (Puerto Rican, Cuban, and Mexican) have additional distinctive differences; and determined whether disparities are explained by differences in family income and parental education. METHODS: Bivariate and multivariate analyses of data on 99,268 children from the 1989-91 National Health Interview Surveys were conducted. RESULTS: Native American, Black, and Hispanic children are poorest (35%, 41% below poverty level vs 10% of Whites), least healthy (66%-74% in excellent or very good health vs 85% of Whites), and have the least well educated parents. Compared with Whites, non-White children average fewer doctor visits and are more likely to have excessive intervals between visits. Hispanic subgroup differences in demographics, health, and use of services equal or surpass differences among major ethnic groups. In multivariate analyses, almost all ethnic group disparities persisted after adjustment for family income, parental education, and other relevant covariates. CONCLUSIONS: Major ethnic groups and subgroups of children differ strikingly in demographics, health, and use of services; subgroup differences are easily overlooked; and most disparities persist even after adjustment for family income and parental education.

49.6 million Americans speak a language other than English at home. Yet many patients who need medical interpreters have no access to them. Dr. Glenn Flores writes that language barriers can have deleterious effects.

Journal of Pediatrics, The - In Press.Proof corrected by the author Available online since mardi 8 avril 2014

Objective. To evaluate the efficacy of b2- agonists in bronchiolitis. Design. Critical review and meta-analysis of random- ized controlled trials of inhaled b2-agonists. Results. Three inpatient and five outpatient studies were identified. Inpatient studies (82 patients) were char- acterized by wide variability in therapeutic regimens and measurement of outcomes. Several problems were iden- tified in the selection and specification of patients, such as failure to assess the prestudy duration of illness or to exclude patients already taking bronchodilators. Meta- analysis was not possible for inpatient trials due to the great variability in study outcomes, timing of outcome assessment, and drug regimens. Results of inpatient tri- als were contradictory: one found significant reductions in the clinical score and a shorter hospital stay with treatment, whereas two others found only significant oxygen desaturations. Outpatient studies (251 patients) examined immediate changes in physiologic measures and clinical scores after two treatments, but have not examined the effects of the longer-term regimen customarily used by clinicians. Meta-analysis revealed that short-term b2-agonist ther- apy had no impact on the hospitalization rate or respira- tory rate, and had a statistically significant but clinically insignificant impact on oxygen saturation and heart rate. The diversity of scoring systems precluded pooling of clinical score data. Conclusions. Despite eight clinical trials, conclusive evidence for the efficacy of b2-agonist therapy for bron- chiolitis remains unavailable. Well-designed inpatient trials are needed. Meta-analysis of outpatient studies does not support the use of b2-agonist therapy for bron- chiolitis, but investigators have not studied the outcomes and the long-term outpatient regimen customarily used by clinicians. Pediatrics 1997;100:233-239; bronchiolitis, b2-agonists, meta-analysis, clinical trials, infants.

Update of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for oral cancer.The USPSTF reviewed the evidence on whether screening for oral cancer reduces morbidity or mortality and on the accuracy of the oral screening examination for identifying oral cancer or potentially malignant disorders that have a high likelihood of progression to oral cancer.This recommendation applies to asymptomatic adults aged 18 years or older who are seen by primary care providers. This recommendation focuses on screening of the oral cavity performed by primary care providers and not dental providers or otolaryngologists.The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults.

Description: Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation on primary care interventions to prevent tobacco use in children and adolescents. Methods: The USPSTF reviewed the evidence on the effectiveness of primary care interventions on the rates of initiation or cessation of tobacco use in children and adolescents and on health outcomes, such as respiratory health, dental and oral health, and adult smoking. The USPSTF also reviewed the evidence on the potential harms of these interventions. Population: This recommendation applies to school-aged children and adolescents. The USPSTF has issued a separate recommendation statement on tobacco use counseling in adults and pregnant women. Recommendation: The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents.

To examine gaps in communication versus documentation of weight-management clinical practices, communication was recorded during primary care visits with 6- to 12-year-old overweight/obese Latino children. Communication/documentation content was coded by 3 reviewers using communication transcripts and health-record documentation. Discrepancies in communication/documentation content codes were resolved through consensus. Bivariate/multivariable analyses examined factors associated with discrepancies in benchmark communication/documentation. Benchmarks were neither communicated nor documented in up to 42% of visits, and communicated but not documented or documented but not communicated in up to 20% of visits. Lowest benchmark performance rates were for laboratory studies (35%) and nutrition/weight-management referrals (42%). In multivariable analysis, overweight (vs obesity) was associated with 1.6 more discrepancies in communication versus documentation ( P = .03). Many weight-management benchmarks are not met, not documented, or performed without being communicated. Enhanced communication with families and documentation in health records may promote lifestyle changes in overweight children and higher quality care for overweight children in primary care.

OBJECTIVE: Adequate vitamin D is essential for skeletal health in developing children. Although excess body weight is associated with risk of vitamin D deficiency, the national prevalence of and risk factors associated with vitamin D deficiency in overweight and obese children are unknown. METHODS: The prevalence of vitamin D deficiency (defined as 25-hydroxyvitamin-D RESULTS: The prevalence of vitamin D deficiency in healthy-weight, overweight, obese, and severely obese children was 21% (20%–22%), 29% (27%–31%), 34% (32%–36%), and 49% (45%–53%), respectively. The prevalence of vitamin D deficiency in severely obese white, Latino, and African-American children was 27% (3%–51%), 52% (36%–68%), and 87% (81%–93%), respectively. Compared with healthy-weight children, overweight, obese, and severely obese children had significantly greater adjusted odds of vitamin D deficiency. Modifiable factors associated with vitamin D deficiency in overweight/obese children were identified. CONCLUSIONS: Vitamin D deficiency is highly prevalent in overweight and obese children. The particularly high prevalence in severely obese and minority children suggests that targeted screening and treatment guidance is needed.

Objectives. We identified factors associated with child bullying in the United States. Methods. We used the 2007 National Survey of Children’s Health to examine associations among child, parent, and community factors and bullying perpetration among children aged 10 to 17 years, using bivariate and stepwise multivariable analyses. Results. African American and Latino children and children living in poverty and who had emotional, developmental, or behavioral (EDB) problems had higher odds of bullying, as did children of parents who felt angry with their child or who felt their child bothered them a lot or was hard to care for; suboptimal maternal mental health was associated with higher bullying odds. Children who always or usually completed homework and had parents who talked with them and met all or most of their friends had lower bullying odds. Conclusions. Assessing children’s EDB problems, maternal mental health, and parental perceptions may identify children at risk for bullying. Parent–child communication, meeting children’s friends, and encouraging children academically were associated with lower bullying odds; these protective factors may be useful in designing preventive interventions.

To examine the association of overweight/obesity with health, health care utilization, and expenditures in a national sample of 10- to 17-year-old children and adolescents.Secondary analysis of 2005 to 2009 Medical Expenditure Panel Survey data (n = 17,224). Outcome measures included suboptimal health, emotional/behavioral problems, health care utilization, and expenditures.Overweight and obese children and adolescents had greater risk of suboptimal health (adjusted risk ratio [ARR], 1.4 and 1.7; P.01), use of prescriptions (ARR, both 1.1; P = .01), and emergency department visits (ARR, 1.2 and 1.1; P = .01); overweight children/adolescents had lower mean out-of-pocket expenditures (∼$100, P.01); and obese children/adolescents had greater risk of emotional/behavioral problems (ARR, 1.2; P.01) and specialist visits (ARR, 1.1; P = .01). The most common specialty referral among obese children/adolescents was psychiatry. Overweight and obesity were not associated with office visits or total expenditures. A greater proportions of children and adolescents with suboptimal health and emotional/behavioral problems had health care expenditures, and those with suboptimal health were more likely to have out-of-pocket expenditures.Pediatric overweight and obesity affect child and adolescent health status, emotional/behavioral problems, and specific domains of health care utilization, but do not appear to be associated with total health care expenditures. Out-of-pocket expenditures are lower among overweight children and adolescents. These findings highlight the need for early intervention in overweight children/adolescents, when health care expenditures may not be greater, and suggest that it may prove useful to pay special attention to the health status and emotional/behavioral problems of overweight and obese children/adolescents in weight-management interventions.

To determine the proportion of abstracts submitted to the 2010 Pediatric Academic Societies (PAS) meeting that were exclusively qualitative, and to examine whether these abstracts were more or less likely than all others to be designated as platform, poster, or publish only.The database of abstracts submitted to the 2010 PAS meeting was searched using qualitative terms. Authors reviewed abstracts to identify exclusively qualitative abstracts. The proportions and mean score ± standard deviation for qualitative abstracts and those designated platform, poster, or publish only were calculated. Student's t test was used to analyze mean differences; pairwise comparisons and odds ratios (ORs) were used to examine differences in the disposition of qualitative versus all other abstracts. The main outcome was the proportion of abstracts designated as platform, poster, or publish only.Of 4057 abstracts, 1.6% used only qualitative methods. Scores for qualitative and all other abstracts were 4.26 ± 0.60 and 3.88 ± 0.92, respectively (P.001). The disposition of qualitative abstracts among platform, poster, and publish only differed from all other abstracts (P = .04). Compared with all others, qualitative abstracts had lower odds of platform presentation (OR 0.36; 95% confidence interval [CI] 0.15-0.91), demonstrated a nonsignificant trend toward publish only (OR 1.6; 95% CI 0.95-2.7), and were equally likely to be posters (OR 1.1; 95% CI 0.65-1.8).Compared with all other abstracts, qualitative abstracts were about 3 times less likely to be chosen for platform presentations; in addition, they demonstrated a trend toward greater odds of publish only. These findings may be the result of inferior quality or an inadequate review process.

The success of primary stroke prevention for children with sickle cell disease (SCD) throughout the United States is unknown. Therefore, we aimed to generate national incidence rates of hospitalization for stroke in children with sickle cell disease (SCD) before and after publication of the Stroke Prevention Trial in Sickle Cell Anemia (STOP trial) in 1998.We performed a retrospective trend analysis of the 1993-2009 Nationwide Inpatient Sample and Kids' Inpatient Databases. Hospitalizations for SCD patients 0-18 years old with stroke were identified by ICD-9CM code. The primary outcome, the trend in annual incidence rate of hospitalization for stroke in children with SCD, was analyzed by linear regression. Incidence rates of hospitalization for stroke before and after 1998 were compared by the Wilcoxon rank-sum test.From 1993 to 2009, 2,024 hospitalizations were identified for stroke. Using the mean annual incidence rate of hospitalization for stroke from 1993 to 1998 as the baseline, the rate decreased from 1993 to 2009 (point estimate = -0.022/100 patient years [95% CI, -0.039, -0.005], P = 0.027). The mean annual incidence rate of hospitalization stroke decreased by 45% from 0.51 per 100 patient years in 1993-1998 to 0.28 per 100 patient years in 1999-2009 (P = 0.008). Total hospital days and charges attributed to stroke also decreased by 45% and 24%, respectively.After publication of the STOP trial and hydroxyurea licensure in 1998, the incidence of hospitalization for stroke in children with SCD decreased across the United States, suggesting that primary stroke prevention has been effective nationwide, but opportunity for improvement remains.

This study examines trends in prevalence and factors associated with bullying perpetration among children 10–17 years old, using the 2003 and 2007 National Survey of Children’s Health. A parent-reported bullying measure and NSCH-designed questions were used to measure factors associated with bullying. The 2003 (n = 48,639) and 2007 (n = 44,152) samples were 51 % male, with mean age of 13.5 (standard deviation 2.3). 23 % of children bullied at least sometimes in 2003 and 15 % bullied in 2007. Parental anger with their child, a child emotional/developmental/behavioral problem, and suboptimal maternal mental health were associated with higher bullying odds in 2003 and 2007, whereas parents talking with their child very/somewhat well, and meeting their child’s friends were associated with lower odds. Between 2003 and 2007, parental anger with their child was associated with increasing bullying odds and parents’ meeting their child’s friends was associated with decreasing odds. Targeting these persistent factors may result in effective bullying-prevention interventions.

Most pediatric research examining health and health care disparities has focused on specific indicators, such as obesity, a usual source of care, unmet needs, delayed care, mental health care receipt, and selected oral health measures (Brown, Wall, and Lazar 1999; Wen 2007; Alexandre, Martins, and Richard 2009; Bethell et al. 2009; Hoilette et al. 2009; Huang et al. 2009; Taichman et al. 2009). Only two studies have comprehensively examined racial/ethnic disparities among children of all ages (Flores and Tomany-Korman 2008a; Flores 2010), but no published studies have comprehensively examined racial/ethnic disparities in health status, access to care, and use of services. A comprehensive examination of adolescent racial/ethnic disparities is crucial for identifying, monitoring, and eliminating disparities. Adolescents 10–17 years old comprise almost 50 percent of the pediatric population, and approximately half of adolescents are racial/ethnic minorities (U.S. Census Bureau a 2011). Latinos are the largest racial/ethnic group of children after whites, followed by African Americans, Asian/Pacific Islanders (APIs), and American Indian/Alaska Natives (AI/ANs) (U.S. Census Bureau 2011). Available studies suggest that there are unique disparities for adolescents (Wen 2007; Van Wie, Blewett, and Davern 2008; Adams et al. 2009; Alexandre, Martins, and Richard 2009). For example, adolescents had higher odds of poorer parent-rated health relative to younger children in a study of U.S. children (Wen 2007). Poor childhood health is associated with lower educational attainment (Haas and Fosse 2008; Jackson 2009) and poor health in adulthood (Case, Fertig, and Paxson 2005). Two studies have examined adolescent disparities in overall health status and a limited number of access-to-care and use-of-services measures (Fox et al. 2007; Mulye et al. 2009). One study examined disparities only among three racial/ethnic groups (whites, Latinos, and African Americans) for 12 indicators of health and health care access and use in two national datasets, and found minority youth were more likely to have poor or fair health (Fox et al. 2007). The other study (Mulye et al. 2009) was a review of multiple data sources, including electronic databases, articles, and reports, with a limited number of nationally representative measures. Additional studies on overweight/obesity, dental caries, discussion of preventive health topics, or mental health services receipt mainly compared whites with Latinos and African Americans or African Americans only (Brown, Wall, and Lazar 1999; Alexandre, Martins, and Richard 2009; Bethell et al. 2009). Nationally representative studies comprehensively examining adolescent disparities in medical and oral health, access to care, and use of services from other racial/ethnic groups, including API, AI/AN, and multiracial youth, are lacking. To understand and reduce racial/ethnic health care disparities among adolescents, disparities must first be identified (Kilbourne et al. 2006). The study aim, therefore, was to identify disparities in 40 health and health care measures in a nationally representative, racially/ethnically diverse sample of adolescents. The study hypothesis was that multiple disparities in medical and oral health, access to care, and use of services would be identified in this nationally representative, racially/ethnically diverse sample of adolescents.

Background Minorities are more prevalent than the general population in the child protection system; however, racial/ ethnic disparities in physical abuse and child protective services interventions are not understood. Methods Bivariate and multivariate analyses evaluated racial/ethnic differences in reported and substantiated physical abuse, physical abuse deaths, and interventions provided in all reported maltreatment from the 2006 National Child Abuse and Neglect Data System. Results In bivariate analyses, African American (25%), Asian/ Pacific Islander (21%), and multiracial children (21%) have a higher prevalence of substantiated physical abuse than whites (20%). Native Americans (0.21%), African Americans (0.15%), Asians/Pacific Islanders (0.12%), and Latinos (0.11%) are more likely to die from physical abuse than whites (0.09%). African Americans have higher odds than whites of reported (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.11-1.14) and substantiated (OR, 1.27; 95% CI, 1.23-1.31) physical abuse. Latinos have higher odds of reported physical abuse (OR, 1.18; 95% CI, 1.16-1.20) and lower odds of substantiated physical abuse (OR, 0.93; 95% CI, 0.90-0.96). Native Americans have lower odds (OR, 0.53; 95% CI, 0.49-0.56) and Asian/ Pacific Islanders higher odds (OR, 1.34; 95% CI, 1.26-1.44) of reported physical abuse vs whites. Latinos have significantly lower odds than whites of receiving support services. Conclusions Compared with whites, African Americans are at increased risk. Latino, Asian/Pacific Islander, and multiracial children have greater odds of reports, and Native Americans have lower odds of reports for physical abuse. Significant disparities exist in interventions provided to minority families. Understanding these disparities has the potential to improve reporting, prevention, and interventions.

Few studies have rigorously evaluated school-based interventions to reduce violence and substance use in high school students, especially Latinos. This study assessed the effects of a school-based program on reducing violence and substance use among primarily Latino high school students.Ninth-grade students at risk for violence and substance use were randomized to intervention or control groups. The intervention was based on an existing program developed for white and African American youth. Data on smoking, alcohol and drug use, fighting, and grades were collected at baseline and 4 and 8 months post enrollment.There were 55 students in the control and 53 in the intervention group; 74% of controls and 78% of intervention students were Latino. There were no significant changes in fighting, smoking, or alcohol or drug use, from baseline to 8-month follow-up, between the intervention and control group. Pre and post grade point average (GPA) decreased from 2.3 at baseline to 1.8 at follow-up (p.01) in the intervention group, with no significant between-group changes in GPA from baseline to follow-up.This school-based program showed no reduction in violence or substance use. The findings suggest that a program targeting non-Latino youth may not be optimal for reducing violence and substance use in Latinos; greater attention to cultural appropriateness and racial/ethnic differences may be needed. There was a decrease in intervention-group GPA but no significant change compared with controls. Further studies of the impact of school-based substance use and violence prevention programs on academics, and the effectiveness of afterschool or community-based programs compared to school-based programs are needed.

Objective To identify factors associated with initiation of the human papillomavirus vaccine series and parental report of a healthcare provider recommendation of the human papillomavirus vaccine in adolescent females. Design Cross-sectional analysis of 2007 National Survey of Children's Health. Participants Parents of 12–17 year-old US adolescent females. Main outcome measures Associations of sociodemographic and healthcare factors with initiation of the human papillomavirus vaccine series and parental report of a healthcare provider recommendation of the human papillomavirus vaccine. Results Data were analyzed for 16,139 adolescent females. Almost 20% of adolescent females initiated the HPV vaccine series. Significantly higher proportions of adolescent females who initiated the human papillomavirus vaccine series vs. those who did not initiate the human papillomavirus vaccine series had a parental report of their healthcare provider recommending the human papillomavirus vaccine (84% vs. 20%). In multivariable analyses, adolescent females who were American Indian/Alaska Native, were multiracial, received the meningococcal vaccine, received the tetanus/tetanus–diphtheria/tetanus–diphtheria–acellular pertussis vaccine, or were poor had higher adjusted odds of initiating the human papillomavirus vaccine series; parental report of a healthcare provider recommendation of the human papillomavirus vaccine was associated with about 18 times the adjusted odds of initiating the human papillomavirus vaccine series. In separate multivariable analyses, adolescent females who were African-American and uninsured had lower adjusted odds of a parental report of a healthcare provider recommendation of the human papillomavirus vaccine. Conclusion Parental report of a healthcare provider recommendation is significantly associated with human papillomavirus vaccine-series initiation. African-American race/ethnicity and uninsurance were associated with lower odds of a parental report of a healthcare provider recommendation of the human papillomavirus vaccine. Routine healthcare provider recommendation of human papillomavirus vaccination might improve adolescent females’ human papillomavirus vaccination rates.

Study objective To compare interpreter errors and their potential consequences in encounters with professional versus ad hoc versus no interpreters. Methods This was a cross-sectional error analysis of audiotaped emergency department (ED) visits during 30 months in the 2 largest pediatric EDs in Massachusetts. Participants were Spanish-speaking limited-English-proficient patients, caregivers, and their interpreters. Outcome measures included interpreter error numbers, types, and potential consequences. Results The 57 encounters included 20 with professional interpreters, 27 with ad hoc interpreters, and 10 with no interpreters; 1,884 interpreter errors were noted, and 18% had potential clinical consequences. The proportion of errors of potential consequence was significantly lower for professional (12%) versus ad hoc (22%) versus no interpreters (20%). Among professional interpreters, previous hours of interpreter training, but not years of experience, were significantly associated with error numbers, types, and potential consequences. The median errors by professional interpreters with greater than or equal to 100 hours of training was significantly lower, at 12, versus 33 for those with fewer than 100 hours of training. Those with greater than or equal to 100 hours of training committed significantly lower proportions of errors of potential consequence overall (2% versus 12%) and in every error category. Conclusion Professional interpreters result in a significantly lower likelihood of errors of potential consequence than ad hoc and no interpreters. Among professional interpreters, hours of previous training, but not years of experience, are associated with error numbers, types, and consequences. These findings suggest that requiring at least 100 hours of training for interpreters might have a major impact on reducing interpreter errors and their consequences in health care while improving quality and patient safety.

OBJECTIVE: To identify risk clusters that are associated with higher or lower risk of new abuse reports (rereports) and substantiated rereports (reabuse) in children who remain in the home after an abuse report. DESIGN: A 5-year prospective cohort study. SETTING: National Survey of Child and Adolescent Well-Being. PARTICIPANTS: Children reported to the child protection system for child abuse. Main Exposure Remaining in the home after an abuse report. Main Outcome Measure Incidence of rereports and reabuse. RESULTS: A total of 2578 children remained in the home following an abuse report, and 44% were rereported within the follow-up period. In bivariate analyses, children with behavior problems (49% vs 38%), caregivers with an abuse history (33% vs 16%) or a child welfare history (38% vs 25%), and families with an annual income lower than $20 000 (70% vs 60%) were more likely to be rereported. Forty-five percent of rereports were substantiated reabuse, but 2 risk clusters had a higher incidence: (1) the cluster with a substantiated index report, having a caregiver without parenting class, non-African American race/ethnicity, and caregiver younger than 41.5 years (54%); and (2) the cluster with a substantiated index report, a caregiver with parenting class, and child age younger than 8.5 years (60%). The lowest risk group for reabuse had a substantiated index report, a caregiver without parenting class, non-African American race/ethnicity, and a caregiver 41.5 years or older (26%). CONCLUSIONS: Among children remaining in the home following an abuse report, specific risk groups have higher and lower incidence of rereports and reabuse. These risk-group categories may be useful to child protection services and others in identifying at-risk children and making decisions about placement and services. Language: en

The objective of this study was to identify factors that may account for the disproportionately high prevalence of suicidal behaviors among Hispanic/Latina youth by examining whether associations of health risk behaviors with suicidal ideation and suicide attempts vary by race/ethnicity among female students. Data from the school-based 2007 national Youth Risk Behavior Survey were analyzed. Analyses were conducted among female students in grades 9 through 12 and included 21 risk behaviors related to unintentional injuries and violence; tobacco use; alcohol and other drug use; sexual behaviors that contribute to unintended pregnancy and sexually transmitted infections, including human immunodeficiency virus; physical activity; obesity and weight control; and perceived health status. With the exception of physical activity behaviors and obesity, all risk behaviors examined were associated with suicidal ideation and suicide attempts. Associations of risk behaviors with suicidal ideation varied by race/ethnicity for 5 of 21 behaviors, and for 0 of 21 behaviors for suicide attempts. Stratified analyses provided little insight into factors that may account for the higher prevalence of suicidal behaviors among Hispanic/Latina female students. These results suggest that the increased risk of suicidal behaviors among Hispanic/Latina female students cannot be accounted for by differential associations with these selected risk behaviors. Other factors, such as family characteristics, acculturation, and the socio-cultural environment, should be examined in future research.

health is critical to assuring national well-being, now and in the future. However, monitoring the status of the health of children and adolescents and understanding the role of various factors in fostering optimal health have proven difficult. Of particular importance is the influence of the availability, use, and quality of health care services, especially for those with life-threatening conditions or special health care needs. Despite the presence of multiple data sets and measures, the United States currently has no national information system that can provide timely, comprehensive, and valid and reliable indicators of health and health care quality for children and adolescents. Although progress has been made in selected areas, the country lacks a comprehensive strategy to make better use of existing resources and identify the need for new indicators and methods.

To estimate national hospitalization rates for invasive pneumococcal disease (IPD) in children with sickle cell disease (SCD) before and after the 2000 licensure of the heptavalent pneumococcal conjugate vaccine (PCV7).We performed a retrospective trend analysis of the 1994-2007 Nationwide Inpatient Sample databases. Hospitalizations involving children with SCD and IPD were identified by ICD-9CM code. The primary outcomes, the annual hospitalization rate for IPD in children with SCD and the proportion of hospitalizations for IPD per 100 total SCD hospitalizations, were analyzed using multivariable linear regression and contingency analysis, respectively.A total of 1,242 hospitalizations for IPD in SCD patients were identified from 1994-2007, with a mortality rate of 2.4%. The national mean annual rate of IPD hospitalization decreased by 65%, from 131.8 cases/year from 1994 to 2000 to 45.5 cases/year from 2001 to 2007 (P = 0.001). The national proportion of hospitalizations for IPD per 100 total SCD hospitalizations decreased from 0.4 to 0.15 (P 0.0001) over the same interval. Following PCV7 licensure, the mean annual cumulative hospital days and cumulative hospital charges decreased nationally by 53% and 36%, respectively.In a national sample, PCV7 licensure is temporally associated with a nearly threefold reduction in IPD hospitalizations in children with SCD.

Latinos are among the most overweight racial/ethnic groups of US children. The study aim was to identify parents' perspectives on healthy eating, physical activity, and weight-management strategies for overweight Latino children. Four focus groups were conducted of Mexican immigrant, Mexican-American, Puerto Rican, and other Latino families with overweight children. Parents were asked 33 questions and sampled four healthy substitutes for traditional Latino foods, including multigrain enchiladas and brown rice. Nineteen parents were interviewed in the focus groups. The children′s median body mass index was 23; 60% had a body mass index ≥95th percentile. Parents identified 22 themes regarding the most important things parents can do to help overweight children lose weight, including encouragement, not making the child feel left out, the whole family eating healthy, and the parent setting a good example. Parents identified 17 themes regarding the most important things overweight children can do to help themselves lose weight, including eating healthier, limiting portion size and second helpings, drinking more water, increased physical activity, decreased screen time, children educating themselves at school, asking parents for help, and participating in interventions that include the whole family. Challenges to getting kids to exercise included expense, time constraints, and neighborhood safety. Parents were open to integrating healthy substitutes into traditional Latino meals/snacks, and found them palatable. One mother stated, "We have to keep our traditional foods, but realize that we can make them more nutritious." Parents reported their children would accept high-fiber foods and low-fat dairy. In designing effective weight-management interventions for overweight Latino children, the study findings may prove useful in identifying healthy, well-accepted foods and beverages; agreeable physical activities; suitable targets for reducing inactivity; and efficacious strategies for enhancing traditional foods and meals so that there is an increased likelihood of healthy diet and weight loss. Parental input on the most important things that children and parents can do to help children lose weight and on challenges faced in trying to get children to exercise might provide valuable guidance in devising effective, evidence-based interventions that are likely to be adhered to.

Objectives To comprehensively assess family services, health, and health care outcomes for US children in kinship care vs foster care. Design A 3-year prospective cohort study. Setting National Survey of Child and Adolescent Well-Being. Participants The sample consisted of 1308 US children entering out-of-home care following reported maltreatment. Main Exposure Kinship care vs foster care. Main Outcome Measures Baseline caregivers' support services and the children's behavioral, mental health, and health service use outcomes 3 years after placement. Results Kinship caregivers were more likely than foster caregivers to have a low socioeconomic status but reported significantly fewer support services (caregiver subsidies, parent training, peer support, and respite care). Kinship care was associated with a lower risk ratio (RR) of continuing behavioral problems (RR = 0.59; 95% confidence interval [CI], 0.41-0.80), low social skills (RR = 0.61; 95% CI, 0.40-0.87), mental health therapy use (RR = 0.45; 95% CI, 0.27-0.73), and psychotropic medication use (RR = 0.46; 95% CI, 0.24-0.82) but higher risk of substance use (RR = 1.88; 95% CI, 0.92-3.20) and pregnancy (RR = 4.78; 95% CI, 1.07-17.11). Conclusions Kinship caregivers received fewer support services than foster caregivers. Children in kinship care fared better with behavioral and social skills problems, mental health therapy use, and psychotropic medication use. Adolescents in kinship care may be at higher risk for substance use and pregnancy.

To determine whether warm-antibody autoimmune hemolytic anemia (AIHA) responds to treatment with intravenous gammaglobulin (IVGG), we conducted separate pilot studies at three institutions enrolling a total of 37 patients. We combined these results with a review of 36 cases of AIHA treated with IVGG reported in the literature. Sixteen clinical variables were examined to determine associations with response to IVGG. Overall, 29 of 73 patients (39.7%) responded to IVGG therapy. Two variables were strongly related to a good response to IVIG: the presence of hepatomegaly (with and without splenomegaly) and a low pre-treatment hemoglobin. A trend towards a better response was observed in the 11 children. Overall, IVGG provided acute benefit in only 1/3 of patients and therefore cannot be recommended as standard therapy for AIHA. It may, however, be useful as adjunctive treatment in selected cases, such as in those with a pre-treatment hemoglobin < 6-7 gm/dl or those with hepatomegaly, and in clinical settings where the toxicity of other treatments may be an important consideration.

OBJECTIVE: The goal was to examine racial/ethnic and language disparities in family-centered care (FCC) and in FCC components for children with special health care needs (CSHCN). METHODS: Bivariate and multivariate logistic regression analyses of data from the 2005–2006 National Survey of CSHCN were performed. RESULTS: A total of 66% of CSHCN with a health visit in the past year received FCC. In adjusted analyses, we found lower odds of FCC for Latino (odds ratio: 0.53 [95% confidence interval: 0.45–0.63]), African-American (odds ratio: 0.60 [95% confidence interval: 0.52–0.69]), and other (odds ratio: 0.58 [95% confidence interval: 0.43–0.78]) children, compared with white children, and for children in households with a non-English primary language (odds ratio: 0.48 [95% confidence interval: 0.36–0.64]), compared with those in households with English as the primary language. These disparities persisted after adjustment for child health (condition severity and emotional, behavioral, and developmental needs), socioeconomic (poverty level, parental education, household composition, and residing in a metropolitan statistical area), and access (insurance type, usual source of care, and having a personal physician) factors. Of these factors, only condition severity was significantly associated with the racial/ethnic disparities; none was significantly associated with the language disparities. Disparities were found for Latino and African-American children and children in households with a non-English primary language for the FCC components of time spent with the provider and sensitivity to the family's values and customs. CONCLUSIONS: Robust FCC racial/ethnic and language disparities exist for CSHCN; initial efforts to address these disparities should focus on increasing provider time and cultural sensitivity.

This technical report reviews and synthesizes the published literature on racial/ethnic disparities in children's health and health care.A systematic review of the literature was conducted for articles published between 1950 and March 2007. Inclusion criteria were peer-reviewed, original research articles in English on racial/ethnic disparities in the health and health care of US children. Search terms used included "child," "disparities," and the Index Medicus terms for each racial/ethnic minority group.Of 781 articles initially reviewed, 111 met inclusion criteria and constituted the final database. Review of the literature revealed that racial/ethnic disparities in children's health and health care are quite extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. Mortality-rate disparities were noted for children in all 4 major US racial/ethnic minority groups, including substantially greater risks than white children of all-cause mortality; death from drowning, from acute lymphoblastic leukemia, and after congenital heart defect surgery; and an earlier median age at death for those with Down syndrome and congenital heart defects. Certain methodologic flaws were commonly observed among excluded studies, including failure to evaluate children separately from adults (22%), combining all nonwhite children into 1 group (9%), and failure to provide a white comparison group (8%). Among studies in the final database, 22% did not perform multivariable or stratified analyses to ensure that disparities persisted after adjustment for potential confounders.Racial/ethnic disparities in children's health and health care are extensive, pervasive, and persistent, and occur across the spectrum of health and health care. Methodologic flaws were identified in how such disparities are sometimes documented and analyzed. Optimal health and health care for all children will require recognition of disparities as pervasive problems, methodologically sound disparities studies, and rigorous evaluation of disparities interventions.

Objective To identify factors associated with fighting among African American, Asian/Pacific Islander, Latino, and white youth, with a focus on family and school connectedness. Methods Subjects were 4010 adolescents (12–17 years old) from the 2003 California Health Interview Survey. Stratified logistic regression examined whether fighting in the past year was associated with various risk and protective factors among African American, Asian/Pacific Islander, Latino, and white youth subsamples. Results Fighting was reported by 27% of African American, 24% of Latino, 16% of white, and 6% of Asian/Pacific Islander youth. Male gender, alcohol use, and smoking were associated with higher odds of fighting among whites and Latinos. Poverty was associated with higher odds of fighting among whites and African Americans, as was depression among Latinos. Higher family support was associated with decreased odds of fighting for white youth. Higher school support was associated with decreased odds of fighting for Latino youth. Conclusions A higher proportion of African American and Latino youth report fighting than do whites and Asians/Pacific Islanders. There is, however, important variation in racial/ethnic disparities in risk and protective factors associated with fighting. Family and school factors may be protective against fighting. Prevention and intervention efforts to decrease youth violence might benefit from tailoring to communities' racial/ethnic composition and paying greater attention to family and community influences on adolescent fighting.

Objective: To evaluate Cooper 12-minute run/walk test (CT12) as a one-time estimate of cardiorespiratory fitness and marker of fitness change compared with treadmill fitness testing in young children with persistent asthma. Design: A cohort of urban children with asthma participated in the asthma and exercise program and a subset completed pre- and postintervention fitness testing. Setting: Treadmill fitness testing was conducted by an exercise physiologist in the fitness laboratory at an academic children's hospital. CT12 was conducted in a college recreation center gymnasium. Participants: Forty-five urban children with persistent asthma aged 7 to 14 years participated in exercise interventions. A subset of 19 children completed pre- and postintervention exercise testing. Interventions: Participants completed a 9-week exercise program where they participated in either swimming or golf 3 days a week for 1 hour. A subset of participants completed fitness testing by 2 methods before and after program completion. Main Outcome Measures: CT12 results (meters), maximal oxygen consumption (JOURNAL/cjspm/04.02/00042752-200907000-00006/ENTITY_OV0312/v/2017-07-27T023525Z/r/image-pngo2max) (mL·kg−1·min−1), and treadmill exercise time (minutes). Results: CT12 and maximal oxygen consumption were moderately correlated (preintervention: 0.55, P = 0.003; postintervention: 0.48, P = 0.04) as one-time measures of fitness. Correlations of the tests as markers of change over time were poor and nonsignificant. Conclusion: In children with asthma, CT12 is a reasonable one-time estimate of fitness but a poor marker of fitness change over time.

BACKGROUND AND OBJECTIVE. Fifty-five million Americans speak a non-English primary language at home, but little is known about health disparities for children in non-English-primary-language households. Our study objective was to examine whether disparities in medical and dental health, access to care, and use of services exist for children in non-English-primary-language households. METHODS. The National Survey of Childhood Health was a telephone survey in 2003–2004 of a nationwide sample of parents of 102 353 children 0 to 17 years old. Disparities in medical and oral health and health care were examined for children in a non-English-primary-language household compared with children in English- primary-language households, both in bivariate analyses and in multivariable analyses that adjusted for 8 covariates (child's age, race/ethnicity, and medical or dental insurance coverage, caregiver's highest educational attainment and employment status, number of children and adults in the household, and poverty status). RESULTS. Children in non-English-primary-language households were significantly more likely than children in English-primary-language households to be poor (42% vs 13%) and Latino or Asian/Pacific Islander. Significantly higher proportions of children in non-English-primary-language households were not in excellent/very good health (43% vs 12%), were overweight/at risk for overweight (48% vs 39%), had teeth in fair/poor condition (27% vs 7%), and were uninsured (27% vs 6%), sporadically insured (20% vs 10%), and lacked dental insurance (39% vs 20%). Children in non-English-primary-language households more often had no usual source of medical care (38% vs 13%), made no medical (27% vs 12%) or preventive dental (14% vs 6%) visits in the previous year, and had problems obtaining specialty care (40% vs 23%). Latino and Asian children in non-English-primary-language households had several unique disparities compared with white children in non-English-primary-language households. Almost all disparities persisted in multivariable analyses. CONCLUSIONS. Compared with children in English-primary-language households, children in non-English-primary-language households experienced multiple disparities in medical and oral health, access to care, and use of services.

Context/Objectives. We surveyed New Jersey (NJ) hospitals to assess current language services and identify policy recommendations on meeting limited English profi - ciency (LEP) patients' needs. Methods . Survey with 37 questions regarding hospital/patient features, interpreter services, and resources/policies needed to provide quality interpreter services. Results . Sixty-seven hospitals responded (55% response rate). Most NJ hospitals have no interpreter services department, 80% provide no staff training on working with interpreters, 31% lack multilingual signs, and 19% offer no written translation services. Only 3% of hospitals have full-time interpreters, a ratio of 1 interpreter:240,748 LEP NJ residents. Most hospitals stated third-party reimbursement for interpreters would be ben- eficial, by reducing costs, adding interpreters, meeting population growth, and improving communication. Conclusions . Most NJ hospitals have no full-time interpreters, interpreter services department, or staff training on working with interpreters, and deficiencies exist in hospital signage and translation services. Most NJ hospitals stated third-party reimburse- ment for interpreter services would be beneficial.

Objective Nonurgent conditions account for 58% to 82% of pediatric emergency department (ED) visits, but only 1 preliminary qualitative study has examined reasons why parents bring children to the ED for nonurgent care. The aim of this study was to identify parents' reasons for choosing the ED over their primary care provider (PCP) for nonurgent pediatric care. Methods Audiotaped ethnographic interviews in English and Spanish were conducted of parents of children presenting for nonurgent care on weekdays from 8 AM to 4 PM at a children's hospital ED over a 4-week period. Results For the 31 families interviewed, the mean parental age was 28 years, and mean child age, 3 years. Reasons cited by caregivers for choosing the ED over their child's PCP were long appointment waits, dissatisfaction with the PCP, communication problems (accents and unhelpful staff at PCP), health care provider referral, efficiency, ED resources, convenience, quality of care, and ED expertise with children. Some parents said they would like education on the urgency of pediatric problems. Conclusions Parents bring their children to the ED for nonurgent care because of problems with their PCP, PCP referral, and perceived advantages to ED care. Although parents report that education on the urgency of pediatric conditions would be helpful, substantial reduction of pediatric nonurgent ED use may require improvements in families' PCP office access, efficiency, experiences, and appointment scheduling.

Objective Several studies have shown that prolonged bottle-feeding is associated with iron deficiency. Mexican-American toddlers are the racial/ethnic group at greatest risk for prolonged bottle-feeding and iron deficiency, yet no studies have examined reasons for prolonged bottle-feeding in Mexican-American toddlers. The objective of this study was to assess infant feeding beliefs, knowledge, and behaviors among Mexican-American parents. Methods Ethnographic interviews were conducted of parents of Mexican-American toddlers 15 to 48 months old at 3 community sites. A 31-question moderator's guide addressed 4 domains: knowledge and cultural beliefs; sources of nutritional information; anticipatory guidance; and suggestions for ways to change infant feeding practices. Interviews were audiotaped, transcribed, and analyzed using grounded theory. Results Thirty-nine parents were interviewed; the mean parental age was 29 years, and mean child age, 2.2 years. Parents cited convenience as a reason for prolonged bottle-feeding, and believed that they should give toddlers as much milk as they want. Many parents lacked essential knowledge regarding infant feeding practices and iron deficiency, including when to stop bottle-feeding, health problems caused by prolonged bottle-feeding, the quantity of milk to give a child >1 year old, and iron deficiency as a complication of prolonged bottle-feeding. Parents reported not receiving enough education from physicians, and they supported educational interventions on healthy infant feeding practices, including refrigerator magnet charts, videos, brochures, and teaching by physicians. Conclusions Parents of Mexican-American toddlers often are unaware of the adverse consequences of prolonged bottle-feeding and developmental problems associated with iron deficiency. Parents supported educational interventions, including videos, brochures, and refrigerator magnet charts on healthy infant feeding practices.

Objectives: Medicaid enrollees disproportionately experience dental disease and difficulties accessing needed dental care. However, little has been documented on the factors associated with the acceptance of new Medicaid patients by dentists, and particularly whether minority dentists are more likely to accept new Medicaid patients. We therefore examined the factors associated with the acceptance of new Medicaid patients by dentists. Methods: We analyzed 2001 data from the Wisconsin Dentist Workforce Survey administered by the Wisconsin Division of Health Care Financing, Bureau of Health Information. We used descriptive statistics and logistic regression analysis to examine the factors associated with the outcome variable. Results: Ninety-four percent of Wisconsin licensed dentists (n = 4,301) responded to the 2001 survey. A significantly higher likelihood of accepting new Medicaid patients was found for racial/ethnic minority dentists (35 versus 19 percent of White dentists) and dentists practicing in large practices (31 versus 16 percent for those in smaller practices). In the multivariable analysis, minority dentists [odds ratio (OR) = 2.06, 95 percent confidence interval (CI) = 1.30, 3.25] and dentists in practices with >3 dentists (OR = 2.25, 95 percent CI = 1.69, 3.00) had significantly greater odds of accepting new Medicaid patients. Conclusions: Racial/ethnic minority dentists are twice as likely as White dentists to accept new Medicaid patients. Dentists in larger practices also are significantly more likely than those in smaller practices to accept new Medicaid patients. These findings suggest that increasing dental workforce diversity to match the diversity of the general US population can potentially improve access to dental care for poor and minority Americans, and may serve as an important force in reducing disparities in dental care.

Discusses the potential of community-based participatory research (CBPR) to reduce the burden of chronic health problems on poor and minority neighborhoods and describes three successful CBPR programs.

Cultural competency leads to higher quality care for asthmatic children, yet it is not known whether asthma educational materials targeting minority children and families are culturally competent. The study objective was to evaluate the cultural competency of printed asthma educational materials targeting minorities in Wisconsin.The Wisconsin Asthma Coalition Disparities Workgroup held a series of meetings to develop, test, and apply a tool for evaluating the cultural competency of asthma educational materials targeting minorities in Wisconsin. The tool consists of seven domains: language, normative cultural values, folk illnesses, parent/patient beliefs, provider practices, visuals, and an overall assessment. Asthma educational materials were obtained from healthcare organizations and clinics. All seven domains were scored using a 5-point Likert scale.Only 17 asthma educational materials targeting minorities exist in Wisconsin: 16 for Latinos, one for Native Americans, none for African Americans, and none for Asians/Pacific Islanders. Overall assessment scores for each material ranged from 1-2 (poor-fair), with a mean+/-SD=1.4+/-0.5. The highest mean domain scores were for language (3.5+/-1.2) and illustrations (3.4+/-1.4); the lowest score was for folk illnesses (1.1+/-0.2), with weaknesses identified for parent/patient beliefs (1.8+/-0.7); provider practices (1.8+/-0.7); and normative cultural values (2.5+/-0.7).The few asthma educational materials targeting minorities that exist in Wisconsin are not culturally competent. More culturally competent asthma educational materials for minorities are needed.

BACKGROUND. Iron deficiency affects 2.4 million US children, and childhood iron-deficiency anemia is associated with behavioral and cognitive delays. Given the detrimental long-term effects and high prevalence of iron deficiency, its prevention in early childhood is an important public health issue.OBJECTIVES. The study objectives were to (1) identify risk factors for iron deficiency in US children 1 to 3 years old, using data from the most recent waves of the National Health and Nutrition Examination Survey IV (1999–2002) and (2) examine risk factors for iron deficiency among Hispanic toddlers, the largest minority group of US children.PATIENTS AND METHODS. Analyses of the National Health and Nutrition Examination Survey IV were performed for a nationally representative sample of US children 1 to 3 years old. Iron-status measures were transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Bivariate and multivariable analyses were performed to identify factors associated with iron deficiency.RESULTS. Among 1641 toddlers, 42% were Hispanic, 28% were white, and 25% were black. The iron deficiency prevalence was 12% among Hispanics versus 6% in whites and 6% in blacks. Iron deficiency prevalence was 20% among those with overweight, 8% for those at risk for overweight, and 7% for normal-weight toddlers. Fourteen percent of toddlers with parents interviewed in a non–English language had iron deficiency versus 7% of toddlers with parents interviewed in English. Five percent of toddlers in day care and 10% of the toddlers not in day care had iron deficiency. Hispanic toddlers were significantly more likely than white and black toddlers to be overweight (16% vs 5% vs 4%) and not in day care (70% vs 50% vs 43%). In multivariable analyses, overweight toddlers and those not in day care had higher odds of iron deficiency.CONCLUSIONS. Toddlers who are overweight and not in day care are at high risk for iron deficiency. Hispanic toddlers are more likely than white and black toddlers to be overweight and not in day care. The higher prevalence of these risk factors among Hispanic toddlers may account for their increased prevalence of iron deficiency.

BACKGROUND. Twenty-three million Americans have limited English proficiency. Language barriers can have major adverse consequences in health care, but little is known about whether pharmacies provide adequate care to patients with limited English proficiency.OBJECTIVES. We sought to evaluate pharmacies' ability to provide non–English-language prescription labels, information packets, and verbal communication, and assess pharmacies' satisfaction with communication with patients who have limited English proficiency.METHODS. We used a cross-sectional, mixed-methods survey of Milwaukee County, Wisconsin, pharmacies. Survey questions addressed sociodemographic and language-service characteristics of pharmacies. A pharmacist or technician at each pharmacy was asked 45 questions by telephone, fax, or mail. The main outcome measures were the ability of pharmacies to provide non–English-language prescription labels, information packets, and verbal communication; and pharmacy satisfaction with communication with patients who have limited English proficiency.RESULTS. Of 175 pharmacies, 73% responded. Forty-seven percent of the pharmacies never/only sometimes can print non–English-language prescription labels, 54% never/only sometimes can prepare non–English-language information packets, and 64% never/only sometimes can verbally communicate in non-English languages. Eleven percent use patients' family members/friends to interpret. Only 55% were satisfied with their communication with patients who have limited English proficiency. In multivariate analyses, community pharmacies had significantly lower odds of being able to verbally communicate in non-English languages, whereas pharmacies using telephone interpreting services had significantly higher odds. Pharmacies' suggestions for improving patient communication included continuing education, producing a chain-wide list of resources, hiring bilingual staff, using telephone interpreters, analyzing translation quality/accuracy of labels and information packets, and adding more languages to pharmacy software.CONCLUSIONS. Approximately half of Milwaukee pharmacies never/only sometimes can provide non–English-language prescription labels or information packets, and approximately two thirds never/only sometimes can verbally communicate in non-English languages. One in 9 pharmacies that verbally communicate in non-English languages use patients' family members/friends to interpret. Almost half of the pharmacies are dissatisfied with their communication with patients who have limited English proficiency. Community pharmacies are less likely and pharmacies using telephone interpreting services are more likely to be able to verbally communicate in non-English languages. Study findings indicate that improvements in pharmacies' communication with patients who have limited English proficiency may result by increasing the quality and number of non-English languages in existing computer programs, hiring bilingual staff, and using telephone interpreting services when in-person interpreters are unavailable.