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Objective. A total of 20% of sudden infant death syndrome (SIDS) cases in the 1990s occurred in child care settings. This is much higher than the 8% expected from Census Bureau data. Factors that were associated with child care SIDS included older age; white race; older, more educated mothers; and unaccustomed prone position. Since these findings, much emphasis has been placed on promoting a safe sleep environment in child care. The objectives of this study were to determine the proportion of SIDS occurring in child care in 2001 and to assess risk factors for SIDS in child care. Methods. We conducted a retrospective review of all SIDS deaths that occurred in 2001 in 13 US states. Information regarding demographics, SIDS risk factors, and child care arrangements were collected and analyzed. Deaths that occurred in child care were compared with deaths that occurred during parental care. Results. Of 480 deaths, 79 (16.5%) occurred in child care settings. Of these child care deaths, 36.7% occurred in family child care homes, 17.7% occurred in child care centers, 21.3% occurred in relative care, and 17.7% occurred with a nanny/babysitter at home. Infants in child care were more likely to be older and to die between the hours of 8 AM and 4 PM and less likely to be exposed to secondhand smoke. There was no difference in usual, found, or placed sleep position between child care and home deaths. Approximately one half of the infants who died of SIDS in both settings were found prone, and 20% of deaths in both settings were among infants who were unaccustomed to prone sleep. Conclusions. The proportion of SIDS deaths in child care has declined slightly but still remains high at 16.5%. Infants in child care are no more likely to be placed or found prone and no more likely to be on an unsafe sleep surface. Educational efforts with child care providers have been effective and should be expanded to unregulated child care providers. In addition, there may be other, yet-unidentified factors in child care that place infants in those settings at higher risk for SIDS. sudden infant death syndrome, risk reduction, intervention, child care, sleep position. ABBREVIATION. SIDS, sudden infant death syndrome., Since 1992, when the American Academy of Pediatrics endorsed the nonprone sleep position for healthy infants, (1) the percentage of infants who are placed prone for sleep has decreased from [...]

Objective. To develop and validate a second-generation severity-of-illness score that is applicable to pediatric emergency patients. The Pediatric Risk of Admission (PRISA) score was developed in a single hospital and was recalibrated and validated in 2, previous, small studies from academic pediatric hospitals. This study was performed to develop and validate a score in a larger sample of diverse hospitals. Methods. Emergency departments (EDs) were block randomly selected as part of a study on ED quality on the basis of 3 care characteristics: annual patient volume (high or low compared with national median), presence or absence of a pediatric emergency medicine subspecialist, and presence or absence of residents. Patients were selected randomly on the basis of daily arrival logs. Medical records were photocopied, and abstracted data included demographic, historical, physiologic, and therapeutic information. The total sample was randomly divided into a 75% development sample and a 25% validation sample. Univariate and multivariate analyses were used to model the risk of mandatory admission, admissions for which preidentified, inpatient medical resources were used. The resulting multiple logistic regression model coefficients were converted to integer scores. Calibration (Hosmer-Lemeshow goodness of fit) and discrimination (area under the ROC curve) were used to measure performance. As a measure of construct validity, proportions of patients in ordered risk intervals were correlated with the outcomes of admission, mandatory admission, and ICU admission. Results. Sixteen EDs enrolled 11 664 patients. Mean patient age ([+ or -] SD) was 6.8 [+ or -] 5.8 years, and 53% were male. Nine percent arrived by emergency medical services, and 6.9% were admitted. The most common diagnoses were minor injuries, otitis media, and fever. The multivariate analysis yielded a score with 7 historical variables, 8 physiologic variables, 1 therapy (oxygen) term, and 1 interaction term. Calibration was excellent. In the development sample, 442 mandatory admissions were predicted and 442 were observed (total [chi square] = 2.275), and in the validation sample, 136.6 were predicted and 145 were observed ([chi square] = 8.575). The area under the receiver operator characteristic curve was 0.82 [+ or -] 0.01 (SE) in the development sample and 0.77 [+ or -] 0.02 in the validation sample. In ordered predicted risk intervals, the proportion of patients with admissions, mandatory admissions, and ICU admissions increased in a linear manner. Conclusions. The second-generation PRISA II score for pediatric ED patients has been developed and validated in a large sample of diverse hospitals. Performance characteristics indicate that PRISA II will be useful for institutional comparisons, benchmarking, and controlling for severity of illness when enrolling patients in clinical trials. Pediatrics 2005;115:388-395; emergency medicine, health services research, severity-of-illness index., ABBREVIATIONS. ED, emergency department; PRISA, Pediatric Risk of Admission; PEM, pediatric emergency medicine; ROC, receiver operator characteristic. Specific components of the Emergency Medical Services system and the Emergency Medical Services-Children [...]

Characteristics of hospital quality may not be related to quality of care in pediatric intensive care units (ICUs). Researchers studied 16 pediatric ICUs that had different quality-of-care factors. The size of the ICU, unit coordination, medical school teaching status of the hospital housing the ICU, and specialist status were the quality factors assessed in terms of patient death rates. Results revealed 5415 admissions to pediatric ICUs and 248 ICU deaths. Patients treated in an ICU located within a teaching hospital were 1.79 times more likely to die than patients treated in an ICU not located in a teaching hospital. Children who were treated in an ICU that was staffed with a pediatric intensivist were 1.54 times more likely to survive than children treated in an ICU that did not have a pediatric intensivist on staff. Unit coordination and ICU size were not significantly related to patients' survival., Objective.--To determine the importance of the following care factors previously associated with hospital quality on survival from pediatric intensive care: size of the intensive care unit (ICU), medical school teaching status of the hospital housing the ICU, specialist status (pediatric intensivist), and unit coordination. Design.--After a national survey, consecutive case series were collected at 16 sites randomly selected to represent unique combinations of quality-of-care factors. Setting.--Pediatric ICUs. Patients.--Consecutive admissions to each site. Main Outcome Measure.--Patient mortality adjusted for physiologic status, diagnosis, and other mortality risk factors. Results.--There were 5415 pediatric ICU admissions and 248 ICU deaths. The ICUs differed significantly with respect to descriptive variables, including mortality (range, 2.2% to 16.4%). Analysis of risk-adjusted mortality indicated that the hospital teaching status and the presence of a pediatric intensivist were significantly associated with a patient's chance of survival. The probability of patient survival after hospitalization in an ICU located in a teaching hospital was decreased (relative odds of dying, 1.79; 95% confidence interval [CI], 1.23 to 2.61; P=.002). In contrast, the probability of patient survival after hospitalization in an ICU with a pediatric intensivist was improved (relative odds of dying, 0.65; 95% CI, 0.44 to 0.95; P=.027). Post hoc analysis indicated that the higher severity-adjusted mortality in teaching hospitals may be explained by the presence of residents caring for ICU patients. Conclusion.--Characteristics indicative of the best overall hospital quality may not be associated, or may be negatively associated, with quality of care in specialized care areas, including the pediatric ICU. (JAMA. 1994;272:941-946)

Smoking patterns, including the number of cigarette smokers and the number of people stopping and starting smoking, were analyzed in terms of gender and race by the National Health Interview Surveys from 1974 to 1985. Smoking is considered to be the most preventable cause of premature death in the United States. Great effort has been made by public health professionals to decrease cigarette smoking in the last 25 years. The number men smoking has decreased linearly each year to 33.5 percent in 1985. Smoking by women decreased to 27.6 percent during the same period. Fewer men started smoking during the period, while the number of women starting to smoke remained the same. However, more women than men stopped smoking during the period. Smoking by whites and blacks decreased to 29.6 and 35.6 percent, respectively. Overall, fewer blacks than whites started smoking between 1974 and 1985. The prevalence of smoking has decreased for men and women, both black and white, although more slowly in women. A reduction in the number of people starting smoking, rather than the amount of those quitting the habit, is mostly responsible for the convergence of smoking patterns of men and women., Trends in the prevalence, initiation, and cessation of cigarette smoking are reported for the US population using weighted and age-standardized data from seven National Health Interview Surveys (1974 to 1985). The decline in prevalence was linear, with the prevalence for men decreasing at 0.91 percentage points per year to 33.5% in 1985 and the prevalence for women decreasing at 0.33 percentage points per year to 27.6% in 1985. For whites the rate of decline (percentage points per year) was 0.57, to 29.4% in 1985, and for blacks the decline was 0.67, to 35.6% in 1985. Smoking cessation increased among all gender-race groups from 1974 to 1985, with the yearly rate of increase (in percentage points per year) about equivalent for blacks (0.75 and whites (.77), while it was higher in women (0.90 than in men (0.67). Smoking initiation decreased among young men (-1.03), while it remained about the same in young women (+0.11). Initiation decreased at a more rapid rate in blacks (-1.02) than in whites (-0.35). We conclude that smoking prevalence is decreasing across all race-gender groups, although at a slower rate for women than men, and that differences in initiation, more than cessation, are primarily responsible for the converging of smoking prevalence rates among men and women.

OBJECTIVE. Racial/ethnic disparities in health care delivery have been well described, but little is known about such disparities for children who seek emergency care. The objective of this study was to test the hypothesis that severity-adjusted emergency department pediatric admission rates are associated with race/ethnicity. METHODS. Secondary analyses were conducted of an established database of 16 emergency departments that participated in a national study to validate the Pediatric Risk of Admission II score, which is used to measure severity of illness. Patients were randomly selected by the coordinating center from daily emergency department visit logs. Crude and severity-adjusted admission rates were compared among the 3 most common races/ethnicities: white, black, and Hispanic. Adjusted admission rates were calculated by using the standardized admission ratio, which was calculated by dividing the observed admissions by the predicted admissions, when predicted was calculated from the Pediatric Risk of Admission II score. RESULTS. After exclusion of 3 sites that recorded race/ethnicity in CONCLUSIONS. There are differences in both crude and adjusted admission rates between white and black/Hispanic patients. The results are more consistent with high rates of discretionary admissions for white patients with low illness severity than with underadmitting severely ill black or Hispanic patients. KEY WORDS. health services research, health care delivery, disparities, health care quality. PEDIATRICS 2007;119:e1319-e1324, URL: www.pediatrics.org/cgi/doi/10.1542/peds.2006-2309

Objective. Traditionally, delivery room management of extremely low birth weight (ELBW) infants consisted of immediate intubation and mechanical ventilation. There have been recent reports of success using nasal prongs continuous positive airway pressure (NCPAP) in this population. Data on the partial pressure of carbon dioxide (PC[O.sub.2]) in spontaneously breathing ELBW infants is very limited. The objective of this study was to determine the trend of the average PC[O.sub.2] in the spontaneously breathing ELBW infants, while on NCPAP, during the first week of life and to determine whether a brief period of mechanical ventilation affects the PC[O.sub.2] levels after extubation. Methods. This is a retrospective cohort study of infants who had birth weights 48 hours and treated mainly with mechanical ventilation during the first week of life. Results. Sixty-two ELBW infants were included in this study: 24 infants in group 1, 19 infants in group 2, and 19 infants in group 3. There was no significant difference between the average PC[O.sub.2] levels of group 1 and group 2 during the first week of life. The daily PC[O.sub.2] level during the first week of life for infants who were breathing spontaneously on NCPAP had a mean value of 39.73 [+ or -] 1.78 mm Hg. There was no difference between the daily average minimum PC[O.sub.2] levels among the 3 groups. Group 3, however, had significantly higher maximum PC[O.sub.2] levels compared with the first 2 groups during days 2 through 7 of life. Conclusions. Daily average PC[O.sub.2] levels in the spontaneously breathing ELBW infants during the first week of life remains at approximately 40 mm Hg. These levels seem to be unaffected by an initial brief period of mechanical ventilation. Infants who are treated with longer periods of mechanical ventilation have higher daily maximum PC[O.sub.2] levels during the first week of life. Additional studies are required to detect neurodevelopmental outcomes of these 3 groups. Pediatrics 2003;112:e208-e211. URL: http://www.pediatrics.org/cgi/content/full/112/3/e208; nasal CPAP, extremely low birth weight infants, carbon dioxide, chronic lung disease.