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Investigates the BILOG computer program's ability to recover known item parameters for different numbers of items, examinees, and variances of the prior distributions of discrimination parameters for the two-parameter logistic item-response theory model. For samples of at least 250 examinees and 15 items, simulation results support using BILOG. (SLD)

Purpose: Interpreting the rapidly changing speech skills of young children recovering from neurological injury is difficult because developmental expectations are generally available only at relatively lengthy intervals (e.g., 6 or [...]

Developmental outcomes after early or delayed insertion of tympanostomy tubes in children at six years of age are assessed. In otherwise healthy children younger than three years of age who have persistent middle-ear effusion within the duration of effusion, prompt insertion of tympanostomy tubes does not improve developmental outcomes at six years of age.

Background. Stair falls are common among young children and are also common false histories in cases of child abuse. When a child presents with a femur fracture and a stair-fall history, a judgment of plausibility must be made. A lack of objective injury and biomechanical data makes plausibility determination more difficult. Our objective was to characterize key features associated with femur fractures from reported stair falls, to develop a model for assessing injury plausibility (IP). Methods. Children 2 to 36 months of age who presented with a femur fracture from a reported stair fall were studied prospectively. Detailed history recording, examinations, fracture characterization, and injury scene analyses were conducted, and biomechanical measures associated with injury prediction were calculated. With our proposed IP model, all cases were then scored for the detail of history, biomechanical compatibility of fracture morphologic features, time to seeking care, and presence of other injuries. Results. Twenty-nine children were diagnosed with a femur fracture resulting from a reported stair fall. The IP model made a clear distinction between 2 groups, designated plausible and suspicious. Significant differences were observed for the detail of history, biomechanical compatibility of fracture, time to seeking care, presence of other injuries, and total IP scores. In the plausible group, the minimal linear momentum associated with a transverse fracture was almost 10-fold greater than that for spiral or buckle fracture types. Conclusions. This study adds new information to the current body of knowledge regarding injury biomechanics and fractures among children. The IP model provides an objective means of assessing plausibility of reported stair-fall-related femur fractures and identifies key characteristics to facilitate decision-making. Pediatrics 2005; 115:1712-1722; femur fracture, child abuse, stair fail biomechanics. ABBREVIATIONS. CML, classic metaphyseal lesion; IP, injury plausibility; CT, computed tomographic; HQS, history quality scale; CPT, child protection team., Stair falls are a common occurrence among young children and are also a common false history in cases of child abuse. When a young child or infant presents with a [...]

Objective. In a long-term, prospective study, we set out to determine whether otitis media in the first 3 years of life persisting for periods currently considered developmentally threatening actually results in later impairments of children's cognitive, language, speech, or psychosocial development; whether prompt insertion of tympanostomy tubes prevents or lessens any such impairments; and whether, irrespective of causality, associations exist between persistent early-life otitis media and later developmental impairments. This report describes findings in study participants at the age of 4 years. Methods. We enrolled 6350 healthy infants from 2 to 61 days of age at urban hospitals and 2 small-town/rural and 4 suburban private pediatric practices. We regularly evaluated the children for the presence of middle-ear effusion (MEE) throughout their first 3 years of life by pneumatic otoscopy, supplemented by tympanometry; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated children for otitis media according to specified guidelines. In the clinical trial component of the study, we randomly assigned 429 children who met specified minimum criteria regarding the persistence of MEE to undergo tympanostomy tube insertion either promptly or after a defined extended period if MEE remained present. In the associational component of the study, we selected a representative sample of 241 children who ranged from having no MEE to having MEE the cumulative duration of which fell just short of meeting randomization criteria for the clinical trial. In 397 (92.5%) of the children in the clinical trial and in 234 (97.1%) of the children in the representative sample, we assessed cognitive, language, speech, and psychosocial development at the age of 4 years, using formal tests, conversational samples, and parent questionnaires. Results. In children in the randomized clinical trial, there were no statistically significant differences in mean ([+ or -] standard deviation) scores (higher denotes more favorable) favoring the early-treatment group over the late-treatment group on the General Cognitive Index of the McCarthy Scales of Children's Abilities (97 [+ or -] 14 and 98 [+ or -] 14, respectively); the Peabody Picture Vocabulary Test-Revised, a measure of receptive language (90 [+ or -] 15 vs 92 [+ or -] 16); the Nonword Repetition Test, a measure of phonological memory (66 [+ or -] 12 vs 70 [+ or -] 12); the Number of Different Words, a measure of word diversity (150 [+ or -] 34 vs 150 [+ or -] 31); the Mean Length of Utterance in Morphemes, a measure of sentence length and grammatical complexity (3.4 [+ or -] 0.8 vs 3.4 [+ or -] 0.7); or the Percentage of Consonants Correct-Revised, a measure of speech-sound production (92 [+ or -] 5 vs 93 [+ or -] 5). There were also no significant differences in ratings (higher denotes less favorable) on the Parenting Stress Index-Short Form (Total Stress scores: 68 [+ or -] 18 vs 65 [+ or -] 17) or the Child Behavior Checklist (Total Problem T scores: 50 [+ or -] 10 vs 49 [+ or -] 10). In the associational component of the study, correlations between the children's durations of MEE and their developmental outcomes were generally weak and, in most instances, nonsignificant. Exceptions, after adjustment for sociodemographic variables and for hearing thresholds at the time of developmental testing, consisted of a significant negative correlation between children's cumulative durations of MEE in their first 3 years of life and scores on the McCarthy Verbal subscale, and significant positive correlations between durations of MEE and scores on 2 measures of parent-child stress. The percentage of variance in these scores explained by time with MEE beyond that explained by sociodemographic variables ranged from 1.6% to 3.3%. In both the randomized clinical trial and the associational component, sociodemographic variables seemed to be the most important factors influencing developmental outcomes, and in both components, the results at 4 years of age were consistent with the results that had been obtained at 3 years of age. Conclusions. In otherwise healthy children who are younger than 3 years and have persistent MEE within the duration limits that we studied, prompt insertion of tympanostomy tubes does not measurably improve developmental outcomes at 4 years of age. In such children, persistent MEE within the duration limits that we studied is negligibly associated with and probably does not affect developmental outcomes at 4 years of age. otitis media, middle-ear effusion, tympanostomy tube insertion, language, speech, cognition, parent-child stress, behavior, development., ABBREVIATIONS. OME, otitis media with effusion; MEE, middle-ear effusion; dB HL, decibels hearing level; SD, standard deviation; CBCL, Child Behavior Checklist; PSI-SF, Parenting Stress Index-Short Form. Two important, unresolved questions [...]

The use of tympanostomy tubes in young children with and ear infection called otitis media does not necessarily lead to improved developmental outcomes. This was the conclusion of researchers who followed 429 children with chronic otitis media who received tympanostomy tubes immediately or up to nine months later.

The present study was designed to determine whether 4 measures of children's spontaneous speech and language differed according to the educational level of the children's mothers. Spontaneous language samples from 240 three-year-old children were analyzed to determine mean length of utterance in morphemes (MLUm), number of different words (NDW), total number of words (TNW), and percentage of consonants correct (PCC). A norm-referenced, knowledge-dependent measure of language comprehension, the Peabody Picture Vocabulary Test-Revised (PPVT-R), was also included for purposes of comparison with the spontaneous measures. Three levels of maternal education were compared: less than high school graduate, high school graduate, and college graduate. Trend analyses showed statistically significant linear trends across educational levels for MLUm, NDW, TNW, and PPVT-R; the trend for PCC was not significant. The relationship of maternal education and other sociodemographic variables to measures of children's language should be examined before using such measures to identify children with language disorders. Keywords: child language disorders, child language development, child language assessment, test bias, maternal education

A physical exam may be all that is needed to rule out adenoid obstruction in children if symptoms such as mouth breathing and nasal voice are absent. Researchers compared physician ratings of the degree of obstruction as well as physician evaluations of X-rays of the head in 1,033 children. There was strong agreement among physicians when symptoms were obvious or completely absent. However, intermediate levels of symptoms were harder to diagnose without X-rays. X-rays may not be necessary if the child has no symptoms., Objective. As part of a comprehensive study of indications for tonsillectomy and adenoidectomy, we investigated the reliability of standardized clinical assessments and standardized roentgenographic assessments of adenoidal obstruction of the nasopharynx, and the degree of correlation between clinical assessments and roentgenographic assessments. Methods. We rated the degree of patients' mouth breathing and patients' speech hyponasality on a 4-point scale (none = 1, mild = 2; moderate = 3; marked = 4), we averaged the ratings for each child to obtain a Nasal Obstruction Index, and we determined levels of interobserver agreement concerning the ratings. We classified lateral soft-tissue roentgenograms of the nasopharynx, based on assessments of adenoid size and of nasopharyngeal airway patency, as showing either no obstruction, borderline obstruction, or obstruction, and we determined levels of inter- and intraobserver agreement concerning the classifications. Finally, we determined correlations in individual patients between clinical ratings and roentgenographic ratings of nasal/nasopharyngeal obstruction, and calculated the predictive values of clinical ratings based on roentgenographic ratings as the gold standard. Results. In sets of paired examinations, weighted [Kappa] values for interobserver agreement concerning mouth breathing (total, 235 children) and speech hyponasality (total, 648 children) ranged from 0.84 to 0.91. The value for interobserver agreement concerning roentgenographic assessment of nasopharyngeal airway status (207 children) was 0.92, and for intraobserver agreement (191 children) 0.88. The Kendall's [Tau] b value for concordance between Nasal Obstruction Index values and roentgenographic ratings (1033 children) was 0.51. Nasal Obstruction Index values at the lower and upper extremes--ie, 1.0 and [is greater than or equal to] 3.5, respectively--were highly predictive of concordant roentgenographic ratings. Conclusions. We conclude that standardized clinical ratings of the degree of children's mouth breathing and speech hyponasality provide reliable and reasonably valid assessments of the presence and degree of adenoidal obstruction of the nasopharyngeal airway. These clinical assessments are particularly valid at the extremes of either marked obstruction or no obstruction. Clinical assessment alone may be insufficient to establish the presence of adenoidal obstruction, but clinical assessment alone when findings are unequivocally negative can suffice to rule out adenoidal obstruction with a high degree of confidence. Pediatrics 1998;101:979-986; adenoidal obstruction, nasal obstruction, nasopharyngeal airway, clinical assessment, roentgenographic assessment, mouth breathing, speech hyponasality, diagnostic reliability, diagnostic validity., ABBREVIATION. AN, adenoidal-nasopharyngeal. Chronic nasal obstruction attributable to large adenoids is a common condition of childhood. However, in our experience few children with nasal obstruction complain about or admit to [...]

Two case-based modules to teach medical students about immunization appear to be effective. The modules were created by the CDC and the Association of Teachers of Preventive Medicine after a survey revealed that only 47% of all medical schools offer a comprehensive immunization curriculum. The modules are part of the Teaching Immunization for Medical Education, or TIME, project. One uses problem-based learning and the other a multistation clinical teaching scenario. Both were tested by 1,122 medical students and residents and were highly rated by both., Context. -- Vaccines are underused in the United States, resulting in needless morbidity. Many experts have concluded that clinician education is critical to increasing the nation's vaccination rates. Objective. -- To develop and evaluate case-based curricular materials on immunizations that promote preventive medicine skills. Design. -- Before-and-after trial of an educational intervention. Setting and Participants. -- Medical schools and primary care residency programs from 20 institutions across the United States participated in the Teaching Immunization for Medical Education (TIME) project. Intervention. -- A multidisciplinary team developed learning objectives, abstracted clinical cases, and created case-based modules that use contextual learning and small-group interaction to solve clinical and public health problems. The case-based methods are multistation clinical teaching scenarios (MCTS) and problem-based learning (PBL). Main Outcome Measures. -- Knowledge gained by learners from pretest to posttest and the overall ratings of the sessions by learners and facilitators based on evaluation questionnaires. Results. -- Pretest and posttest results were obtained on a total of 1122 learners for all modules combined. For the MCTS method, mean scores increased from the 10-item pretest to the posttest by 3.1 items for measles, 3.8 for influenza, 1.8 for hepatitis B, 3.9 for pertussis, 1.9 for adult vaccination, 1.9 for childhood vaccination, and 2.6 for Haemophilus influenzae type b (P[is less than].01 for each). For the PBL method, mean scores increased by 3.4 items for measles, 3.3 for influenza, 2.6 for hepatitis B, and 2.5 for pertussis (P[is less than].01 for each). Most learners (MCTS, 98%; PBL, 89%) and most facilitators (MCTS, 97%; PBL, 100%) rated the sessions overall as very good or good. Conclusions. -- Use of TIME modules increases knowledge about immunizations, an essential step to improving vaccination practices of future clinicians. Given the realities of decreased faculty time and budgets, educators face major challenges in developing case-based curricula that prepare learners for the 21st century. Nationally tested libraries of cases such as the TIME modules address this dilemma.

The frequency of middle ear infections may be higher than previously thought. Significant risk factors appear to be race, socioeconomic status, and exposure to larger numbers of children. Doctors closely monitored ear infection frequency among 2253 infants from socioeconomically diverse families until they were two years of age. Twenty percent of these children had ear infections before age one and 16.6% had ear infections between age one and two. Children who were black, male, living in cities, on Medicaid, or exposed to a large number of children or family smokers experienced more days with ear infections., Objective. As part of a long-term study of possible effects of early-life otitis media on speech, language, cognitive, and psychosocial development, we set out to delineate the occurrence and course of otitis media during the first 2 years of life in a sociodemographically diverse population of infants, and to identify related risk factors. Methods. We enrolled healthy infants by age 2 months who presented for primary care at one of two urban hospitals or one of two small town/rural and four suburban private pediatric practices. We intensively monitored the infants' middle-ear status by pneumatic otoscopy, supplemented by tympanometry, throughout their first 2 years of life; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated infants for otitis media according to specified guidelines. Results. We followed 2253 infants until age 2 years. The proportions developing [is greater than or equal to] 1 episode of middle-ear effusion (MEE) between age 61 days (the starting point for data analysis) and ages 6, 12, and 24 months, respectively, were 47.8%, 78.9%, and 91.1%. Overall, the mean cumulative proportion of days with MEE was 20.4% in the first year of life and 16.6% in the second year of life. Tympanostomy-tube placement was performed on 1.8% and 4.2% of the infants during the first and second years of life, respectively. By every measure, the occurrence of MEE was highest among urban infants and lowest among suburban infants; these differences were greatest in the earliest months of life. Overall, unadjusted mean cumulative proportions of days with MEE were higher among boys than girls, higher among black than white infants, and higher among Medicaid than private health insurance enrollees. Cumulative proportions of days with MEE varied directly with the number of smokers in the household and with the number of other children to whom infants were exposed, whether at home or in day care, and varied inversely with birth weight, maternal age, level of maternal education, a socioeconomic index, and duration of breastfeeding. After adjustment, using multivariate analysis, the only variables that each remained independently and significantly related to the cumulative proportion of days with MEE were: during the first year of life, study site grouping, sex, the socioeconomic index, breastfeeding for [is greater than or equal to] 4 months, the number of smokers in the household, and an index rating the degree of exposure to other children at home or in day care; and during the second year of life, sex, the socioeconomic index, and the child exposure index. The duration of breastfeeding and the degree of exposure to tobacco smoke contributed little to the explained variance; most was attributable to differences in the socioeconomic index and the child exposure index. Conclusions. Contrary to findings in many previous reports, the prevalence of otitis media during the first 2 years of life among lower-socioeconomic-status black infants appears to be as high as, if not higher than among lower-socioeconomic-status white infants, and certainly higher than among middle-class white infants. Among middle-class white infants the prevalence may also be higher than commonly assumed. The most important sociodemographic risk factors for otitis media appear to be low socioeconomic status and repeated exposure to large numbers of other children, whether at home or in day care. Pediatrics 1997;99:318-333; otitis media, middle-ear effusion, prevalence, risk factors, epidemiology, sociodemographic factors, critical review., ABBREVIATION. MEE, middle-ear effusion. Otitis media is, next to the common cold, the most commonly diagnosed and probably the most prevalent illness in United States children, with its peak incidence [...]