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It is unknown whether racial/ethnic disparities exist in surgical utilization for children. The aim, therefore, was to evaluate the odds of surgery among children in the US by race/ethnicity to test the hypothesis that minority children have less surgery.Cross-sectional data were analyzed on children 0-18 years old from the 1999 to 2018 National Health Interview Survey, a large, nationally representative survey. The primary outcome was odds of surgery in the prior 12 months for non Latino African-American, Asian, and Latino children, compared with non Latino White children, after adjustment for relevant covariates. The National Surgical Quality Improvement Program Pediatric Dataset was used to analyze the odds of emergent/urgent surgery by race/ethnicity.Data for 219,098 children were analyzed, of whom 10,644 (4.9%) received surgery. After adjustment for relevant covariates, African-American (AOR, 0.54; 95% CI, 0.50-0.59), Asian (AOR, 0.39; 95% CI, 0.33-0.46), and Latino (AOR, 0.62; 95% CI, 0.57-0.67) children had lower odds of surgery than White children. Latino children were more likely to require emergent or urgent surgery (AOR, 1.71; 95% CI, 1.68-1.74).Latino, African-American, and Asian children have significantly lower adjusted odds of having surgery than White children in America, and Latino children were more likely to have emergent or urgent surgery. These racial/ethnic differences in surgery may reflect disparities in healthcare access which should be addressed through further research, ongoing monitoring, targeted interventions, and quality-improvement efforts.II.Prognosis study.

Background Child maltreatment causes substantial numbers of injuries and deaths, but not enough is known about social determinants of health (SDH) as risk factors. The aim of this study was to conduct a systematic review of the association of SDH with child maltreatment. Methods Five data sources (PubMed, Web of Science Core Collection, SCOPUS, JSTORE, and the Social Intervention Research and Evaluation Network Evidence Library) were searched for studies examining the following SDH: poverty, parental educational attainment, housing instability, food insecurity, uninsurance, access to healthcare, and transportation. Studies were selected and coded using the PICOS statement. Results The search identified 3441 studies; 33 were included in the final database. All SDH categories were significantly associated with child maltreatment, except that there were no studies on transportation or healthcare. The greatest number of studies were found for poverty (n = 29), followed by housing instability (13), parental educational attainment (8), food insecurity (1), and uninsurance (1). Conclusions SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment. These findings suggest an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism. Impact SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment. No prior published systematic review, to our knowledge, has examined the spectrum of SDH with respect to their associations with child maltreatment. These findings suggest an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism.

BACKGROUND The COVID-19 pandemic exposed significant vulnerabilities of traditional in-person recruitment methodology in the context of limited access to clinical facilities. Remote recruitment is a potential solution, but its yield and efficiency are unknown. OBJECTIVE This study aimed to determine remote recruitment and enrollment rates for a pilot feasibility trial of an electronic monitoring device (EMD) for asthma in the pediatric population. METHODS Children aged 4-18 years with persistent asthma receiving inhaler medications compatible with an EMD were screened for enrollment in a feasibility and acceptability trial. The emergency department (ED) and inpatient wards were identified as initial in-person recruitment locations prior to the pandemic. Owing to the COVID-19 pandemic, recruitment sites transitioned from exclusive ED or inpatient enrollment to outpatient primary care or pulmonary clinics in an attempt to increase enrollment rates. Study staff called families to determine their interest in the study. Patient age, race and ethnicity, insurance, contact attempts, and reasons for enrollment or refusal were recorded. e-Consent was obtained through the REDCap database, and baseline surveys were administered by telephone. RESULTS Since November 2019, the study staff reached 147 out of 278 (52.3%) eligible families by telephone. In total, 37 (13%) families contacted were enrolled in the study. It took the study staff a mean of 2 attempts to reach individuals for initial enrollment but a mean of 4 additional attempts to complete consent forms. Of the families approached, 47% were Hispanic or Latino, 26.5% were Black or African American, 24.5% were White, and 2% were Asian. Among patients approached, 20% Asian, 16% White, 14.5% Hispanic or Latino, and 12% Black patients were enrolled in the study. CONCLUSIONS Telephone recruitment had a low yield across all racial and ethnic groups, averaging approximately 1 successful enrollment per 8 candidates approached. A substantial number of contacts was required to obtain e-consent forms and complete survey questionnaires after participants agreement to enroll. The study findings suggest that when there are barriers to in-person recruitment, remote recruitment is a feasible alternative, but the yield is relatively low, and enrollment requires persistent, repeated follow-up contact.

Background The aim of this study was to evaluate the process of implementing video remote interpreting (VRI) in a hospital already using in-person and over-the-phone interpreting (OPI), including the impact on utilization of language services, efficiency, and costs, as well as implementation challenges. Methods A prospective program-evaluation design was used. From 2012 to 2017, 165 VRI carts and iPads were rolled out in clinics, inpatient wards, and the emergency department. Each area was supported for six weeks with training and problem-solving issues. Additional VRI rollouts occurred in groups, every two to four months. Outcomes were assessed using utilization and observation/interview data. Results Postimplementation, 50,611 VRI encounters occurred for a total of 556,938 interpretation minutes. OPI decreased by 37.5%. Mean wait time for language services fell from 60 to 5 minutes. Rapid VRI uptake (> 10,000 VRI minutes in Year 1) occurred in clinics previously lacking access to in-person interpreters. VRI was associated with in-person interpreters having more time for professional development activities and with five promotions. Implementation challenges included initial resistance to VRI use, device connectivity problems, and six months’ lead-in time to establish proper VRI use. Challenges were overcome through ongoing education, dialogue, and implementation rounds. Conclusion After overcoming initial challenges, VRI implementation, as part of provision of comprehensive language services, can potentially yield several benefits, including immediate extensive use, decreased OPI, reduced wait times for language services, rapid uptake in clinics previously lacking in-person interpreter access, and increased average minutes per encounter by in-person interpreters.

In Latin America, violence is a major public health issue causing many families to flee to the United States to seek safety. Current US immigration policies fail to address why families are forced to depart their home country or the needs of families once arriving in the United States. This article identifies root causes of family displacement, examines the insufficient protections for children in families during US immigration processing, and provides practice and policy recommendations on how to transform the US immigration system so that it is more humane for children and families forcibly displaced by violence.

Background The COVID-19 pandemic exposed significant vulnerabilities of traditional in-person recruitment methodology in the context of limited access to clinical facilities. Remote recruitment is a potential solution, but its yield and efficiency are unknown. Objective This study aimed to determine remote recruitment and enrollment rates for a pilot feasibility trial of an electronic monitoring device (EMD) for asthma in the pediatric population. Methods Children aged 4-18 years with persistent asthma receiving inhaler medications compatible with an EMD were screened for enrollment in a feasibility and acceptability trial. The emergency department (ED) and inpatient wards were identified as initial in-person recruitment locations prior to the pandemic. Owing to the COVID-19 pandemic, recruitment sites transitioned from exclusive ED or inpatient enrollment to outpatient primary care or pulmonary clinics in an attempt to increase enrollment rates. Study staff called families to determine their interest in the study. Patient age, race and ethnicity, insurance, contact attempts, and reasons for enrollment or refusal were recorded. e-Consent was obtained through the REDCap database, and baseline surveys were administered by telephone. Results Since November 2019, the study staff reached 147 out of 278 (52.3%) eligible families by telephone. In total, 37 (13%) families contacted were enrolled in the study. It took the study staff a mean of 2 attempts to reach individuals for initial enrollment but a mean of 4 additional attempts to complete consent forms. Of the families approached, 47% were Hispanic or Latino, 26.5% were Black or African American, 24.5% were White, and 2% were Asian. Among patients approached, 20% Asian, 16% White, 14.5% Hispanic or Latino, and 12% Black patients were enrolled in the study. Conclusions Telephone recruitment had a low yield across all racial and ethnic groups, averaging approximately 1 successful enrollment per 8 candidates approached. A substantial number of contacts was required to obtain e-consent forms and complete survey questionnaires after participants agreement to enroll. The study findings suggest that when there are barriers to in-person recruitment, remote recruitment is a feasible alternative, but the yield is relatively low, and enrollment requires persistent, repeated follow-up contact. Conflicts of Interest None declared.

Objective To systematically review the literature on pediatric asthma readmission risk factors. Study design We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk. Results Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4). Conclusions Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions. Trial registration CRD42018107601.

Objective To identify and contrast risk factors for six-month pediatric asthma readmissions using traditional models (Cox proportional-hazards and logistic regression) and artificial neural-network modeling. Methods This retrospective cohort study of the 2013 Nationwide Readmissions Database included children 5 to 18 years old with a primary diagnosis of asthma. The primary outcome was time to asthma readmission in the Cox model, and readmission within 180 days in logistic regression. A basic neural network construction with 2 hidden layers and multiple replications considered all dataset variables and potential variable interactions to predict 180-day readmissions. Logistic regression and neural-network models were compared on area-under-the receiver-operating curve. Results Of 18,489 pediatric asthma hospitalizations, 1858 were readmitted within 180 days. In Cox and logistic models, longer index length of stay, public insurance, and nonwinter index admission seasons were associated with readmission risk, whereas micropolitan county was protective. In neural-network modeling, 9 factors were significantly associated with readmissions. Four overlapped with the Cox model (nonwinter-month admission, long length of stay, public insurance, and micropolitan hospitals), whereas 5 were unique (age, hospital bed number, teaching-hospital status, weekend index admission, and complex chronic conditions). The area under the curve was 0.592 for logistic regression and 0.637 for the neural network. Conclusions Different methods can produce different readmission models. Relying on traditional modeling alone overlooks key readmission risk factors and complex factor interactions identified by neural networks.

Non-adherence to medication is common Current methods of assessing adherence are inaccurate. Electronic monitoring devices (EMDs) may more accurately assess adherence, but are not currently used in practice. The design, methods, and participant baseline characteristics are described for a pilot trial of the effects of an EMD on asthma medication adherence in a pediatric population. This was a pilot, randomized, controlled trial of children with persistent asthma managed with daily inhaled corticosteroids (ICS). Seventy-five children were randomized 2:1 to receive either two EMDs (one for ICS and one for rescue) linked via Bluetooth to a mobile application (app) or standard of care (controls). EMDs recorded dates and times of inhaler actuations and the app sent daily medication reminders to participants. Controls were provided standard care. Medication adherence was measured using pharmacy refill records and self-report, whereas EMD data were used to measure adherence in the intervention group. Secondary outcomes included asthma control, pulmonary function, and quality of life. Results One hundred sixty children were screened for eligibility, with 123 individuals excluded. Seventy-five children were enrolled, with 25 allocated to the control group and 50 to the intervention. The mean age of participants is 12 years old (±2.9), with equal proportions of male and female children; 45% are Latinx and 19% African-American; 77% report Medicaid or CHIP coverage. Half of participants have moderate persistent asthma and 48% had marginally controlled asthma at time of enrollment. There were no significant inter-group differences in baseline sociodemographic characteristics. Conclusion This pilot successfully reached target populations and met recruitment and enrollment goals. It is addressing an important knowledge gap by evaluating the effects of an EMD with a mobile app on adherence rates, findings which could prove useful in determining whether routine use of EMDs in clinical practice help children achieve better asthma control and outcomes. Clinical Trials.gov NCT03734861.

KP, a 2.5-year-old infant with cachexia, recently was admitted to our hospital. A year ago, the hospitalist team treated her for sequelae of Zika virus exposure: microcephaly, central diabetes insipidus, and failure to thrive. Sadly, here she was again, weighing less than her discharge weight when she was 18 months old. Her standardized weight for age had plummeted from an already poor −2.5 to an abysmal −5.5. How had our medical system failed this child? KP’s mother had dual US and Dominican citizenship, but was homeless and lacking many social supports in the United States. When her medically complex child was born, her social safety net collapsed. She realized she could not continue to bounce around between homes with such a medically fragile child. She had applied for Section 8 housing but had no idea when it would be approved, so she did the only thing that seemed reasonable: move back to the Dominican Republic to live with her parents. She ran out of desmopressin acetate (DDAVP) for her child in 3 months. She was forced to replace her child’s prescribed formula with powdered milk. She was hospitalized multiple times for aspiration pneumonia. KP returned to the United States with her mother, malnourished and weak, when their housing voucher was approved. Her health had dramatically declined, all because of housing insecurity and other key social determinants of health (SDOH). SDOH are “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”1 There is some variability in opinion on what constitutes the SDOH roster, but the determinants generally include economic stability, education, social and community context, health and health care, neighborhood and built environment, limited English proficiency, immigration status, transportation barriers, racism and bias, household …

OBJECTIVES The goal of this study was to evaluate trends in medical claim submissions for limited ultrasound studies performed (1) during emergency department (ED) encounters and (2) by ED providers compared to radiologists. METHODS We conducted a retrospective, descriptive study using medical claims data from Medica Health Plans from January 1, 2011 to December 31, 2015. Current procedural terminology codes were abstracted for limited ultrasound applications performed during an ED visit and further stratified by studies performed by ED providers compared with radiologists. We excluded claims for which we could not determine provider specialty. RESULTS We identified 42,576 encounters with limited US claims, of which, 32,666 were submitted by ED providers (N = 9649) or radiologists (N = 23,017). Among ED providers, there was a significant linear increase in the annual number of claims for retroperitoneal (P

Latinos have the highest US childhood uninsurance rate of any race/ethnicity, but little is known about effective ways to eliminate this disparity. We evaluated the effects of parent mentors-Latino parents with children covered by Medicaid or the Children's Health Insurance Program-on insuring Latino children in a randomized, controlled, community-based trial of 155 uninsured children conducted in the period 2011-15. Parent mentors were trained to assist families in getting insurance coverage, accessing health care, and addressing social determinants of health. We found that parent mentors were more effective than traditional methods in insuring children (95 percent versus 69 percent), achieving faster coverage and greater parental satisfaction, reducing unmet health care needs, providing children with primary care providers, and improving the quality of well-child and subspecialty care. Children in the parent-mentor group had higher quality of overall and specialty care, lower out-of-pocket spending, and higher rates of coverage two years after the end of the intervention (100 percent versus 70 percent). Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities.

This study aimed to examine the associations of parental monitoring and violent peers with violence among Latino youth, and whether these associations varied by acculturation. 133 adolescents were surveyed. Associations between parental monitoring, peer violence, and physical and non-physical violence were examined using bivariate and multivariable negative binomial regression. Multivariable analysis was stratified by age and acculturation. A path model examined whether peer violence mediated the relationship between parental monitoring and youth violence. Stratified analysis demonstrated that peer violence increased the risk of physical (RR = 1.24; 95% CI 1.02–1.20) and non-physical violence (RR = 1.32; 95% CI 1.08–1.62) for high-acculturated youth, whereas parental monitoring was protective for low-acculturated youth (physical RR = 0.88; 95% CI 0.78–0.99; non-physical RR = 0.80; 95% CI 0.68–0.93). In path analysis, low parental monitoring increased risk of involvement with violent peers, which was associated with increased risk of youth violence. Interventions may benefit from focusing on parental monitoring, peer violence, and tailoring by acculturation.

Asian American adolescents have been reported to have the lowest amount of communication with health care providers regarding sexual health topics (sexual activity, contraception, sexually transmitted infections, and pregnancy prevention). This study identified Asian American adolescents’ attitudes/beliefs regarding how health care providers can be most helpful in communicating about sexual health topics. Twenty participants revealed the following information: (a) confidentiality concerns resulted in lying to health care providers about sexual histories or refusing hormonal contraception, (b) a general lack of knowledge regarding sexual health topics, and (c) a hesitancy to discuss sexual histories with Asian American health care providers. Asian American adolescents expressed a need for privacy from parents regarding their sexual behaviors, and want health care providers to initiate conversations and provide information about sexual health topics.

To examine parental perspectives/rankings of the most important weight-management clinical practices and to determine whether preferences/rankings differ when parents disagree that their child is overweight.We performed mixed-methods analysis of a 32-question survey of parents of 2- to 18-year-old overweight children assessing parental agreement that their child is overweight, the single most important thing providers can do to improve weight status, ranking American Academy of Pediatrics-recommended clinical practices, and preferred follow-up interval. Four independent reviewers analyzed open-response data to identify qualitative themes/subthemes. Multivariable analyses examined parental rankings, preferred follow-up interval, and differences by agreement with their child's overweight assessment.Thirty-six percent of 219 children were overweight, 42% obese, and 22% severely obese; 16% of parents disagreed with their child's overweight assessment. Qualitative analysis of the most important practice to help overweight children yielded 10 themes; unique to parents disagreeing with their children's overweight assessments was "change weight-status assessments." After adjustment, the 3 highest-ranked clinical practices included, "check for weight-related problems," "review growth chart," and "recommend general dietary changes" (all P.01); parents disagreeing with their children's overweight assessments ranked "review growth chart" as less important and ranked "reducing screen time" and "general activity changes" as more important. The mean preferred weight-management follow-up interval (10-12 weeks) did not differ by agreement with children's overweight assessments.Parents prefer weight-management strategies that prioritize evaluating weight-related problems, growth-chart review, and regular follow-up. Parents who disagree that their child is overweight want changes in how overweight is assessed. Using parent-preferred weight-management strategies may prove useful in improving child weight status.

INTRODUCTION: This study used clinical practice data to determine whether recommended weight management clinician behaviors are associated with weight status improvement in children aged 6–12 years with overweight/obesity. METHODS: Electronic health record (EHR) data (2009–2014) from 52 clinics were utilized. Weight status was examined from one visit to the next as dichotomous improvement (versus worsening/no change) and change in percentage overweight (above sex-/age-specific BMI(95)). The primary predictor was a clinician behavior variable denoting attention to high BMI alone or with assessment of medical risk/comorbidities and was defined using combinations of diagnostic codes and EHR orders. Covariates included time between visits and medications associated with weight gain/loss. Adjusted multilevel regression models examined association of the clinician behavior variable with weight status improvement. Analyses were conducted from 2015–2018. RESULTS: Children (N=7,205) had a mean age of 8.9 years; 45.5% were overweight, 54.5% obese, and 81.1% publicly insured. For 62% of overweight children, and 38%, 21%, and 11% of those in obesity classes 1–3, respectively, no attention to high BMI/medical risk assessment at any visit was identified. Children with evidence of clinician attention to high BMI alone and who underwent medical risk assessment had significantly greater AOR of improvement in percentage of BMI(95) and percentage of BMI(95) change: BMI alone, AOR=1.2 (p0.05); BMI/medical risk, AOR=1.2 and β= −0.5 (both p

Background Multiple studies have demonstrated thalidomide’s efficacy in numerous indications. Its use is controversial in the adult population, and in paediatrics the lack of experience makes it even more debatable. Purpose To describe the case of a paediatric patient with recurrent aphthous stomatitis (RAS) resistant to the usual treatments and evaluate the efficacy/safety of the use of thalidomide (off-label). Material and methods Retrospective observational study of a paediatric patient with RAS who does not respond to conventional treatments (oral treatments: prednisone 30 mg q.d., colchicine 0.5 mg q.d. and topical treatments: viscous lidocaine 2% t.i.d. and clobetasol propionate t.i.d.). Treatment protocol: ascending doses of thalidomide from 50 mg q.d. to 50 mg t.i.d. (oral suspension). Variables studied: population group, clinical situation, treatment possibilities for RAS and uses of thalidomide in children. The information was obtained from a review of the medical record and an exhaustive bibliographic search. Results The presence of oral ulcers compromised the patient’s life quality and, due to the ineffectiveness of conventional treatments, with prior legal guardians’ authorisation, treatment with thalidomide was started. The aphasic episodes decreased in frequency of appearance and severity. The observed adverse effects were drowsiness, hand tremor and pain in the extremities. After 15 months of successful treatment, neutropaenia (0.9 × 10.3/μL, reference values 2.2–7.5 × 10.3/μL) triggered its discontinuation. After 4 months, the patient recovered from the adverse effects but the aphasic episodes continued, so treatment with colchicine 0.5 mg/24 hour and prednisone was started during acute episodes. Conclusion The use of thalidomide in RAS had an excellent result in the reduction of the oral ulcers, however the development of adverse effects lead to the immediate suspension of the treatment. A strict and periodic monitoring of the patients becomes crucial in the paediatric population with this treatment. Reference and/or Acknowledgements 1. Yang CS, Kim C, Antaya RJ. Review of thalidomide use in the paediatric population. J Am Acad Dermatol2015;72:703–711. No conflict of interest

Adolescent fighting affects 25% of youth, with the highest rates among African-Americans and Latinos but little is known about parental views on youth fighting. The purpose of this study was to examine African-American and Latino parents’ perspectives on adolescent fighting and methods to prevent fighting. We conducted four focus groups with parents of African-American and Latino urban adolescents. Focus groups were stratified by race/ethnicity and fighting status. Groups were audiotaped, transcribed, and analyzed by three independent coders using thematic content analysis. Seventy-six percent of the 17 participants were female. Latino parents condoned fighting only as a last resort, and taught children about consequences of fighting, emotional regulation, and non-violent conflict-resolution strategies. African-American parents endorsed teaching non-violent strategies, but expressed some doubts about their effectiveness. African-American parents also suggested corporal punishment, but acknowledged that this may not be an optimal long-term strategy. Positive role modeling and involvement by teachers and other adults were cited as having important roles in fighting prevention. Suggested interventions included teaching adolescents non-violent conflict-resolution skills, anger management, and alternatives to fighting. Parents recommended that violence prevention programs incorporate the experiences of former fighters and be tailored to community needs. Study findings suggest that youth violence-prevention programs may benefit from addressing parental attitudes towards fighting and parent-child communication about fighting, teaching adolescents non-violent conflict-resolution skills, and tailoring programs by race/ethnicity. Promoting positive modeling and involvement by teachers and other adults also may be beneficial.

Background Few effective community-based interventions exist for early childhood obesity. Parent mentors have been successful as an intervention for other conditions, but have not been used in childhood obesity. We designed an intervention for early childhood obesity using parent mentors and a positive outlier approach to assess potential efficacy, feasibility, and acceptability. Methods This trial enrolled obese (≥ 95th BMI percentile for age and gender) 2–5-year-old children in a Head Start program and their parents, with allocation to either parent mentors trained in positively deviant behaviors regarding childhood obesity, or community health workers delivering health education on obesity-related behaviors. The primary outcome is body mass index z-score change at the six-month follow-up assessment. Secondary outcomes include feeding behaviors and practices, health-related quality of life, dietary intake, and participation levels. Results We enrolled three parent mentors and 60 parent–child dyads. The population is 100% Hispanic; 44% of parents speak Spanish as their primary language and 45% were not high-school graduates. Children had a reported median vegetable and fruit intake of 0.3 and 1.1 cups per day, respectively, at baseline, and a median daily screen time of three hours. There was no intergroup difference in quality-of-life scores at baseline. Retention has been high, at 90% in three months. Conclusions In this randomized trial of the effects of parent mentors on early childhood obesity, parent–child dyads from an underserved, Hispanic population were successfully enrolled through a partnership with a Head Start organization, with a high retention rate.

Summary Objective The objective of this study was to determine whether parental preferences regarding primary care weight-management strategies differ by child age, gender, overweight severity, race/ethnicity or parental agreement that their child is overweight. Methods A survey was administered to parents of 2- to 18-year-old children who are overweight at an academic primary-care clinic regarding perception of child overweight, helpful/harmfulness of having the child present during weight discussions, and dietary-advice preferences. Multivariable analyses examined factors associated with preferred weight-management strategies, after adjustment for parent/child characteristics. Results Eighty-three per cent of parents agreed that a child's presence during weight discussions is helpful/very helpful, 74% that paediatricians should prescribe specific diets, and 55% preferred specific vs. general dietary advice only (N = 219). In multivariable analyses, characteristics associated with helpfulness of child presence included older child age (vs. 2–5 year olds, 6–11 year olds: odds ratio [OR], 4.6; 95% CI, 1.3–16; 12- to 18-year-olds: OR, 23; 95% CI, 4–136), male gender (OR, 5.0; 95% CI, 1.7–10) and obesity (vs. overweight: OR, 2.8; 95% CI, 1.7–12). Characteristics associated with preferring specific diets included Latino race/ethnicity (OR, 5.3; 95% CI, 3–12), older age (vs. 2–5 year olds, 6–11 year olds: OR, 2.8; 95% CI, 1.1–7; 12–18 year olds: OR, 3.7; 95% CI, 1.5–10) and agreement that the child is overweight (OR, 2.3; 95% CI, 1.1–5) and, for specific dietary advice, older age (vs. 2–5 year olds: OR, 2.3; 95% CI, 1.1–5) and agreement that the child is overweight (OR, 2.1; 95% CI, 1.2–4). Conclusions Findings suggest that weight-management strategies tailored to child age, gender, overweight severity, race/ethnicity and parental agreement that their child is overweight may prove useful in improving child weight status.

We examined parental preferences in raising Spanish/English bilingual children. We identified factors influencing their decisions, and the strategies used to promote bilingualism. Focus groups were conducted with Spanish-primary-language parents of children 3 to 7 years old. These groups were audiotaped and transcribed. Three reviewers independently analyzed transcripts for themes using margin-coding and grounded theory; disagreements were resolved by consensus. Thirteen Spanish-primary-language parents participated in two focus groups. The results show that parents wanted their children to be bilingual. Parents also stated that the benefits of bilingualism included better career opportunities, and preservation of culture and native language. Family members, schools, and prior parental experiences influenced the parents’ decisions to raise bilingual children. Parents preferred English-only school classes and to teach Spanish at home. Strategies identified for raising bilingual children included reading bilingual books and having children speak only Spanish at home. Schools and pediatricians are used as resources.

The study purpose was to use recursive partitioning analysis (RPA) to identify factors that, when clustered, are associated with a high prevalence of pregnancy involvement among US adolescent males. The National Survey of Family Growth is a nationally representative survey of individuals 15-44 years old. RPA was done for the 2002 and 2006-2010 cycles to identify factors which, when combined, identify adolescent males with the highest prevalence of pregnancy involvement. Pregnancy-involvement prevalence among adolescent males was 6 %. Two clusters of adolescent males have the highest pregnancy-involvement prevalence, at 84-87 %. In RPA, the highest pregnancy-involvement prevalence (87 %) was seen in adolescent males who ever HIV tested, had4 lifetime sexual partners, reported less than an almost certain chance of feeling less physical pleasure with condom use, had an educational attainment of11th grade, and had ≤2 sexual partners in the past 12 months. Adolescent males who ever HIV tested, had4 lifetime sexual partners, reported less than an almost certain chance of feeling less physical pleasure with condom use, had an educational attainment ≥11th grade, were17 years old, and had their first contraceptive education ≥10th grade, had a pregnancy-involvement prevalence of 84 %. Pregnancy-prevention efforts among adolescent males who have been involved in a pregnancy may need to target risk factors identified in clusters with the highest pregnancy prevalence to prevent subsequent pregnancies in these adolescent males and improve their future outcomes.

Background & objectives Six million US children have no health insurance, and substantial racial/ethnic disparities exist. The design, methods, and baseline characteristics are described for Kids' H ealth Insurance by E ducating L ots of P arents (Kids' HELP), the first randomized, clinical trial of the effectiveness of Parent Mentors (PMs) in insuring uninsured minority children. Methods & research design Latino and African-American children eligible for but not enrolled in Medicaid/CHIP were randomized to PMs, or a control group receiving traditional Medicaid/CHIP outreach. PMs are experienced parents with ≥ 1 Medicaid/CHIP-covered children. PMs received two days of training, and provide intervention families with information on Medicaid/CHIP eligibility, assistance with application submission, and help maintaining coverage. Primary outcomes include obtaining health insurance, time interval to obtain coverage, and parental satisfaction. A blinded assessor contacts subjects monthly for one year to monitor outcomes. Results Of 49,361 candidates screened, 329 fulfilled eligibility criteria and were randomized. The mean age is seven years for children and 32 years for caregivers; 2/3 are Latino, 1/3 are African-American, and the mean annual family income is $21,857. Half of caregivers were unaware that their uninsured child is Medicaid/CHIP eligible, and 95% of uninsured children had prior insurance. Fifteen PMs completed two-day training sessions. All PMs are female and minority, 60% are unemployed, and the mean annual family income is $20,913. Post-PM-training, overall knowledge/skills test scores significantly increased, and 100% reported being very satisfied/satisfied with the training. Conclusions Kids' HELP successfully reached target populations, met participant enrollment goals, and recruited and trained PMs.

Objective To identify risk factors for fighting, factors that protect against fighting, and strategies to prevent fighting, among adolescents who fight and those uninvolved in fighting. Methods Focus groups were conducted with middle and high school students, stratified by fighting (fighter/nonfighter) status, race/ethnicity, and gender. Groups were audiotaped, transcribed, and analyzed using margin coding and thematic content analysis. Themes were independently identified by 3 coders; disagreements were resolved by consensus. Results The 65 participants in the 12 focus groups were 13 to 17 years old. Reasons for fighting include self-defense, to gain/maintain respect, or anger; having goals for the future is protective. Nonfighters state that their parents condone fighting only when physically attacked and that they teach adolescents strategies to avoid fighting. Fighters describe mixed messages from parents, and pro-fighting attitudes and modeling of aggressive behavior among some family members. Nonfighters avoid fighting by ignoring insults or walking away. Fighters feel unable to use nonviolent conflict-resolution methods effectively. Peers may instigate or encourage fights. Suggested prevention strategies include anger-management and conflict-resolution programs, relationships with caring adults, and physicians counseling youth about the consequences of fighting. Conclusions Nonfighters use various strategies to avoid fighting, whereas fighters are aware of few alternatives to fighting. Conflicting parental messages about fighting may enhance the likelihood of fighting. Physicians can counsel youth about the negative consequences of fighting. Interventions that teach anger management and conflict resolution, promote adolescent self-efficacy for using nonviolent strategies, and address parental attitudes about fighting may be effective in preventing fighting.

Historically, research examining health status disparities between members in different socioeconomic status and racial/ethnic groups often focused on adults and the concurrent lifestyle factors that might explain health differentials. Recent years have witnessed an explosion of interest in the developmental origins of adult health and disease, and life course-oriented research has proliferated across the social, biological, and health sciences. This chapter describes how an integrated life course health development framework can be applied to advance our understanding of the dynamic and multilevel processes contributing to health disparities across lifetimes and even generations. Examples of recent research that has examined health status disparities from a life course perspective are provided, and research gaps and challenges are reviewed. The chapter concludes with a set of recommendations for a more strategic and responsive life course-informed research agenda that not only can fill in gaps in current knowledge, but also pave the way for the translation of this knowledge into improvement in practice, programs, and policy aimed at alleviating health disparities.

* Abbreviations: ACE — : adverse childhood event ICE — : US Immigration and Customs Enforcement An undocumented immigrant father drops off his 12-year-old daughter at school in Los Angeles. Moments later, 2 black, unmarked vehicles surround his car a few blocks from the school. US Immigration and Customs Enforcement (ICE) agents arrest him while his 13-year-old daughter watches from his car; she can be heard sobbing while she films a cell phone video of the arrest that later goes viral.1 An undocumented Guatemalan mother of 4 children, including 1 with cerebral palsy, faces deportation after 24 years as a Connecticut housecleaner and seeks sanctuary in a church with her 9-year-old daughter by her side.2 One day after his mother’s ICE arrest, an undocumented Ecuadorian high school senior in New York is taken into custody by ICE hours before his senior prom.3 While waiting at his school bus stop, an undocumented Salvadorian high school senior in North Carolina is arrested and handcuffed by armed ICE agents as schoolmates watch from the bus; he is detained for 5 months and misses graduation.4,5 Another undocumented North Carolina high school senior (who crossed the border as an unaccompanied … Address correspondence to Glenn Flores, MD, FAAP, Connecticut Children’s Medical Center, 282 Washington St, Hartford, CT, 06106. E-mail: gflores{at}connecticutchildrens.org

Background: More than 48% of U.S. children are racial/ethnic minorities, 21% are poor, and 6% are uninsured. It is unclear, however, what methods are most effective for identifying and engaging community partners in study enrollment of these children in high-risk communities. Objective: Evaluate a new methodological approach to the screening, identification, and intervention study enrollment of uninsured minority children. Methods: We developed, implemented, and evaluated a methodological approach consisting of four components: (1) identify communities with the highest proportions of low-income minority families with uninsured children, (2) hire minority research staff responsible for community engagement and data collection, (3) implement and evaluate a parent mentor (PM) intervention built on community partnerships and which creates jobs, and (4) successfully execute the research by engaging appropriate community partners. Results: PMs were successfully recruited (n = 15) and trained (test scores significantly improved). Large numbers (n = 97) of appropriate, diverse community partners were engaged. The most productive community partners for recruitment were schools and childcare establishments, community-based organizations, discount and niche stores, supermarkets, and churches. Community partnerships resulted in 49,631 candidate participants screened and 329 enrolled in the study. The intervention was highly successful, with PMs significantly more effective and faster than traditional outreach/enrollment in insuring uninsured minority children, sustaining coverage, improving care access, reducing out-of-pocket costs, and achieving parental satisfaction and care quality, while saving $6,045 per child insured per year. Conclusions: This innovative, community-based methodology is highly effective, and could prove useful for community-based interventions targeting a variety of childhood and adult health, health-care, and equity issues.

Background Of the 4.8 million uninsured children in America, 62–72% are eligible for but not enrolled in Medicaid or CHIP. Not enough is known, however, about the impact of health insurance on outcomes and costs for previously uninsured children, which has never been examined prospectively. Methods This prospective observational study of uninsured Medicaid/CHIP-eligible minority children compared children obtaining coverage vs. those remaining uninsured. Subjects were recruited at 97 community sites, and 11 outcomes monitored monthly for 1 year. Results In this sample of 237 children, those obtaining coverage were significantly (P 6 months at baseline were associated with remaining uninsured for the entire year. In multivariable analysis, children who had been uninsured for >6 months at baseline (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.4–10.3) and African-American children (OR, 2.8; 95% CI, 1.1–7.3) had significantly higher odds of remaining uninsured for the entire year. Insurance saved $2886/insured child/year, with mean healthcare costs = $5155/uninsured vs. $2269/insured child (P = .04). Conclusions Providing health insurance to Medicaid/CHIP-eligible uninsured children improves health, healthcare access and quality, and parental satisfaction; reduces unmet needs and out-of-pocket costs; and saves $2886/insured child/year. African-American children and those who have been uninsured for >6 months are at greatest risk for remaining uninsured. Extrapolation of the savings realized by insuring uninsured, Medicaid/CHIP-eligible children suggests that America potentially could save $8.7–$10.1 billion annually by providing health insurance to all Medicaid/CHIP-eligible uninsured children.

Objective To examine the perspectives of youth on factors that influence mental health service use after aging out of foster care. Methods Focus groups were conducted with youth with a history of mental health needs and previous service use who had aged out of foster care. Questions were informed by the Health Belief Model and addressed 4 domains: youth perceptions of the "threat of mental health problems," treatment benefits versus barriers to accessing mental health services, self-efficacy, and "cues to action." Data were analyzed using a modified grounded-theory approach. Results Youth (N = 28) reported ongoing mental health problems affecting their functioning; however, they articulated variable levels of reliance on formal mental health treatment versus their own ability to resolve these problems without treatment. Past mental health service experiences influenced whether youth viewed treatment options as beneficial. Youth identified limited self-efficacy and insufficient psychosocial supports "cueing action" during their transition out of foster care. Barriers to accessing mental health services included difficulties obtaining health insurance, finding a mental health provider, scheduling appointments, and transportation. Conclusions Youths' perceptions of their mental health needs, self-efficacy, psychosocial supports during transition, and access barriers influence mental health service use after aging out of foster care. Results suggest that strategies are needed to 1) help youth and clinicians negotiate shared understanding of mental health treatment needs and options, 2) incorporate mental health into transition planning, and 3) address insurance and other systemic barriers to accessing mental health services after aging out of foster care.

OBJECTIVE: To examine pediatrician weight-management communication with overweight Latino children and their parents and whether communication differs by pediatrician-patient language congruency. METHODS: Mixed-methods analysis of video-recorded primary care visits with overweight 6- to 12-year-old children. Three independent reviewers used video/transcript data to identify American Academy of Pediatrics–recommended communication content and establish communication themes/subthemes. Language incongruence (LI) was defined as pediatrician limited Spanish proficiency combined with parent limited English proficiency (LEP). Bivariate analyses examined associations of LI with communication content/themes. RESULTS: The mean child age ( N = 26) was 9.5 years old; 81% were obese. Sixty-two percent of parents had LEP. Twenty-seven percent of pediatricians were Spanish-proficient. An interpreter was used in 25% of LI visits. Major themes for how pediatricians communicate overweight included BMI, weight, obese, chubby, and no communication (which only occurred in LI visits). The pediatrician communicated child overweight in 81% of visits, a weight-management plan in 50%, a culturally relevant dietary recommendation in 42%, a recommendation for a follow-up visit in 65%, and nutrition referral in 50%. Growth charts were used in 62% of visits but significantly less often in LI (13%) versus language-congruent (83%) visits ( P CONCLUSIONS: Many overweight Latino children do not receive direct communication of overweight, culturally sensitive dietary advice, or follow-up visits. LI is associated with a lower likelihood of growth chart use. During primary care visits with overweight Latino children, special attention should be paid to directly communicating child overweight, formulating culturally sensitive weight-management plans, and follow-up. With LEP families, vigilance is needed in providing a trained interpreter and using growth charts.

To identify factors associated with a positive pregnancy attitude among sexually active US teen females.Secondary database analysis of the National Survey of Family Growth.Adolescent females 15-19 years old.Nationally representative sample.Bivariate and multivariable analyses were performed of the 2002 and 2006-08 cycles to examine whether sociodemographic factors, contraceptive history, sexual education and behavior history, medical services history, and family and sexual attitudes were associated with a positive pregnancy attitude among sexually active teen females.Among the 975 sexually active US adolescent females surveyed, 15% reported a positive pregnancy attitude. Compared with adolescent females with a negative pregnancy attitude, those females with a positive pregnancy attitude were significantly (P.05) more likely to have public insurance (43% vs 20%), to be poor (33% vs 10%), to have reached menarche at an earlier age (12 years old vs 13 years old), ever have HIV tested (35% vs 23%), but less likely to have ever been forced to have sex (1% vs 10%). In multivariable analyses, Latino race/ethnicity was associated with triple the odds, and African-American double the odds, of a positive pregnancy attitude. Older age of menarche and higher family income were associated with reduced odds of a positive pregnancy attitude.One in 7 sexually active US adolescent females had a positive pregnancy attitude. Minority race/ethnicity was associated with greater odds of a positive pregnancy attitude, whereas older age of menarche and a higher family income were associated with lower odds of a positive pregnancy attitude. Assessing pregnancy attitudes for these groups of adolescent females might prove useful to decrease adolescent pregnancy rates.

To identify parental perspectives regarding weight-management strategies for school-age children, focus groups were conducted of parents of overweight and obese (body mass index ≥ 85th percentile) 6-12-year-old children recruited from primary-care clinics. Questions focused on the role of the primary-care provider, effective components of weight-management strategies and feasibility of specific dietary strategies. Focus groups were recorded, transcribed and analysed using margin coding and grounded theory. Six focus groups were held. The mean age (in years) for parents was 32, and for children, eight; 44% of participants were Latino, 33%, African-American and 23%, white. Parents' recommendations on the primary-care provider's role in weight management included monitoring weight, providing guidance regarding health risks and lifestyle changes, consistent follow-up and using discretion during weight discussions. Weight-management components identified as key included emphasising healthy lifestyles and enjoyment, small changes to routines and parental role modelling. Parents prefer guidance regarding healthy dietary practices rather than specific weight-loss diets, but identified principles that could enhance the acceptability of these diets. For dietary guidance to be feasible, parents recommended easy-to-follow instructions and emphasising servings over counting calories. Effective weight-management strategies identified by parents include primary-care provider engagement in weight management, simple instructions regarding healthy lifestyle changes, parental involvement and deemphasising specific weight-loss diets. These findings may prove useful in developing primary-care weight-management strategies for children that maximise parental acceptance.

BACKGROUND AND OBJECTIVES: Access to appropriate language services is critical for ensuring patient safety and reducing the impact of language barriers. This study compared language services use by US pediatricians in 2004 and 2010 and examined variation in use in 2010 by pediatrician, practice, and state characteristics. METHODS: We used data from 2 national surveys of pediatricians (2004: n = 698; 2010: n = 683). Analysis was limited to postresidency pediatricians with patients with limited English proficiency (LEP). Pediatricians reported use of ≥1 communication methods with LEP patients: bilingual family member, staff, physician, formal interpreter (professional, telephone), and primary-language written materials. Bivariate analyses examined 2004 to 2010 changes in methods used, and 2010 use by characteristics of pediatricians (age, sex, ethnicity), practices (type, location, patient demographics), and states (LEP population, Latino population growth, Medicaid/Children’s Health Insurance Program language services reimbursement). Multivariate logistic regression was performed to determine adjusted odds of use of each method. RESULTS: Most pediatricians reported using family members to communicate with LEP patients and families, but there was a decrease from 2004 to 2010 (69.6%, 57.1%, P < .01). A higher percentage of pediatricians reported formal interpreter use (professional and/or telephone) in 2010 (55.8%) than in 2004 (49.7%, P < .05); the increase was primarily attributable to increased telephone interpreter use (28.2%, 37.8%, P < .01). Pediatricians in states with reimbursement had twice the odds of formal interpreter use versus those in nonreimbursing states (odds ratio 2.34; 95% confidence interval 1.24–4.40). CONCLUSIONS: US pediatricians’ use of appropriate language services has only modestly improved since 2004. Expanding language services reimbursement may increase formal interpreter use. * Abbreviations: AAP — : American Academy of Pediatrics CHIP — : Children’s Health Insurance Program CLAS standards — : National Standards for Culturally and Linguistically Appropriate Services LEP — : limited English proficiency

Objective:The goal of this study was to identify the proportion of dehydration-related ambulatory care–sensitive condition hospitalizations, the reasons why these hospitalizations were preventable, and factors associated with preventability.Methods:A cross-sectional survey of primary care providers (PCPs), inpatient attending physicians, and parents was conducted in a consecutive series of children with ambulatory care–sensitive conditions admitted to an urban hospital over 14 months.Results:Eighty-five children were diagnosed with dehydration. Their mean age was 1.6 years; most had public (74%) or no (17%) insurance, and were nonwhite (91%). The proportion of hospitalizations assessed as preventable varied from 12% for agreement among all 3 sources to 45% for any source. Parents identified inadequate prevention (50%), poor self-education (34%), and poor quality of care (38%) as key factors. PCPs identified parents providing insufficient home rehydration (33%), not visiting the clinic (25%), and not calling earlier (16%) as reasons. Inpatient attending physicians cited home rehydration (40%), delays in seeking care (40%), and lacking a PCP (20%) as contributors. Physicians (PCPs and inpatient attending physicians) were more likely than parents to describe the admission as inappropriate (75% vs 67% vs 0%; P < .01). Parental dissatisfaction with their child’s PCP and a history of avoiding primary care due to costs or insurance problems were associated with significantly higher odds of preventable hospitalization.Conclusions:Up to 45% of dehydration-related hospitalizations may be preventable. Inadequate parental education by physicians, insufficient home rehydration, deferring clinic visits, insurance and cost barriers, inappropriate admissions, poor quality of care, and parental dissatisfaction with PCPs are the reasons that these hospitalizations might have been prevented.

Background: Childhood overweight is a substantial public-health problem, but little is known about predictors of early childhood overweight. Objective: We aimed to identify factors—alone and in combination— that predict kindergarten overweight. Design: We analyzed nationally representative data from the Early Childhood Longitudinal Study-Birth Cohort, a longitudinal cohort study of 6800 children followed from birth through kindergarten. Multivariable logistic regression and recursive partitioning analysis (RPA) were performed to identify individual and clusters of parental, prenatal/pregnancy, infant, and toddler factors predicting kindergarten overweight. The main outcome was kindergarten overweight [body mass index (BMI) $85th percentile, which includes obesity]. Results: The prevalence of kindergarten overweight was 32%. By using combinations (derived from 131 factors) of a weight-for-length or BMI $85th percentile at earlier ages, race/ethnicity, a maternal gestational diabetes history, birth weight, and ages at solid-food introduction and the child pulling to a stand, the RPA identified 6 groups with a particularly high prevalence of kindergarten overweight (56– 100%) and 2 groups with a particularly low prevalence (11–15%). An especially high prevalence was noted for children with a $85th BMI percentile at preschool age (77%) and in children with a $85th BMI percentile at 2 y old, for white children whose mother had gestational diabetes (100%), and for minority children with a birth weight ,2695.5 g and who pulled themselves to a stand at ,7.5 mo old (89%). Conclusion: Clusters of parental, prenatal/pregnancy, infant, and toddler factors can be used to predict which children are at particularly high and low risk of becoming overweight kindergartners. Am J Clin Nutr doi: 10.3945/ajcn.112.052019.