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Sixteen million US children (21%) live in households without consistent access to adequate food. After multiple risk factors are considered, children who live in households that are food insecure, even at the lowest levels, are likely to be sick more often, recover from illness more slowly, and be hospitalized more frequently. Lack of adequate healthy food can impair a child’s ability to concentrate and perform well in school and is linked to higher levels of behavioral and emotional problems from preschool through adolescence. Food insecurity can affect children in any community, not only traditionally underserved ones. Pediatricians can play a central role in screening and identifying children at risk for food insecurity and in connecting families with needed community resources. Pediatricians should also advocate for federal and local policies that support access to adequate healthy food for an active and healthy life for all children and their families.

OBJECTIVEVaccinating all children aged 6 months to 18 years every year has potentially large ramifications for office-based primary care pediatricians. We determined the degree to which pediatricians support routine annual influenza vaccination outside the medical home, especially in school-located mass influenza vaccination clinics.METHODSInternet-based survey sent in May and June 2009 to all 623 currently practicing primary care general pediatricians who were members of the Maryland Chapter of the American Academy of Pediatrics.RESULTSOf those surveyed, 193 (31%) responded. Approximately 67% reported they vaccinated more than half the children in their practice with at least one dose in the 2008–2009 influenza season, and about half anticipated that, in their office, they would not attain ≥75% coverage of all patients older than 5 months of age. Approximately 27% of respondents predicted they would likely have difficulty obtaining sufficient vaccine to cover commercially insured patients, and 32% were likely to have difficulty getting sufficient vaccine to cover Medicaid, underinsured, and uninsured patients because of ordering or distribution problems. Approximately 78% of respondents cited borderline or poor reimbursement for influenza vaccinations, and 53% had unused vaccine at the end of the 2008–2009 influenza season. Ninety-six percent of respondents supported school-located influenza vaccination programs in their community for their patients.CONCLUSIONSThese results indicate awareness by primary care pediatricians in Maryland of the potential difficulties involved in implementing universal influenza vaccinations in their practice and their support of school-located vaccination programs managed by the local health department in their community.

Objective The aim of this study was to examine how prenatal drug exposure (PDE) and caregiving environment relate to cognitive, academic, and behavioral performance at ages 6 and 7. Methods A longitudinal follow-up was conducted of 111 children with PDE and a community cohort of 62 non–drug-exposed children (N = 173). Children completed standardized tests of cognition (Stanford-Binet Intelligence Scales, Fourth Edition [SB-IV]) and academic performance (Wide Range Achievement Test 3). Caregivers completed ratings of child behavior problems (Child Behavior Checklist [CBCL]). Multivariate analyses were conducted, adjusting for gender, prenatal tobacco exposure, number of caregiver placement changes, and 3 caregiver variables assessed at age 7, including depressive symptoms, employment status, and public assistance status. Results After adjusting for perinatal and environmental variables, there were no significant exposure-group differences in cognition, academic performance, or behavior problems. In comparison with males, females had higher scores on overall IQ and 4 of 8 SB-IV subtests, fewer caregiver-reported attention and aggression problems, and higher reading achievement scores. There were no significant gender-by-group interactions. Conclusion When analyses were adjusted for perinatal and environmental variables, most associations between PDE and cognitive-behavioral functioning were attenuated. Regardless of drug exposure history, males performed more poorly than females on multiple cognitive-behavioral indices. Both exposed and nonexposed children were from low-income families and obtained scores substantially below normative expectations.

Objective. To determine the community-wide incidence of missed opportunities to vaccinate, to describe the clinical settings in which they occur, and to estimate the impact of missed opportunities on immunization coverage. Design and Methods. We abstracted outpatient medical records from a random, community-based sample of 2-year-old children whose residence was inner-city Baltimore. The date of each vaccine and the date, diagnoses, and temperature at each visit were collected for 502 children at 98 different provider sites. Main Outcome Measures. Missed opportunities to vaccinate and up-to-date vaccination status. Results. By 24 months of age, 75% of the children had at least one missed opportunity and only 55% were up-to-date for the 4:3:1 series. Missed opportunities occurred at more than one third of eligible visits for each vaccine, including >20% of preventive care visits. Diagnoses commonly associated with missed opportunities were "well child," otitis media, upper respiratory infection, gastroenteritis, skin infection, and resolving illness. If no missed opportunities had occurred, 73% of the children would have been up-to-date by 24 months. Conclusions. Missed opportunities occurred commonly at providers serving inner-city children in Baltimore and represent a major factor in underimmunization. Reduction of missed opportunities by accurate screening at all visits and adherence to the contraindication guidelines is a provider-based, low-cost method to increase immunization coverage.

Lactoferrin has an array of biological activities that include growth, immune modulation, and antimicrobial effects. The aim of this randomized, placebo-controlled, double-blind study was to examine the impact of bovine lactoferrin supplementation in infants.Healthy, formula-fed infants,or =34 weeks' gestation andor =4 weeks of age, enrolled in a pediatric clinic. Infants received either formula supplemented with lactoferrin (850 mg/L) or commercial cow milk-based formula (102 mg/L) for 12 months. Growth parameters and information on gastrointestinal, respiratory, and colic illnesses were collected for the infants' first year. Antibodies to immunizations and hematologic parameters were measured at 9 and 12 months.The lactoferrin-enhanced formula was well tolerated. There were significantly fewer lower respiratory tract illnesses, primarily wheezing, in the 26 lactoferrin-fed (0.15 episodes/y) compared with the 26 regular formula-fed (0.5 episodes/y) infants (P0.05). Significantly higher hematocrit levels at 9 months (37.1% vs 35.4%; P0.05) occurred in the lactoferrin-supplemented group compared with the control formula group.Lactoferrin supplementation was associated with potentially beneficial outcomes such as significantly fewer lower respiratory tract illnesses and higher hematocrits. Larger, more focused studies in infants are warranted.

Identification of children with respiratory viral infections may augment infection-control practices on inpatient units. There are clinical syndromes leading to morbidity among hospitalized children, however, in which a viral etiology of the illness might not be considered.Virus infection rates among 243 children aged1 to 19 years hospitalized between October 1993 and April 1994 with asthma, pneumonia, bronchiolitis, fever, apnea, croup, or respiratory distress were evaluated as part of a University of Maryland Medical Center infection-control protocol. Anonymous data collected included admission diagnoses, age, and virus-identification result.Seventy-one children (29%) had a virus identified, including 19 of 123 (15%) with asthma, 4 of 12 (33%) with pneumonia, 27 of 47 (57%) with bronchiolitis, 13 of 41 (32%) with fever, 4 of 9 (44%) with apnea, 2 of 3 (67%) with croup, and 2 of 8 (25%) with unspecified respiratory distress.This study reinforces the concept that clinicians should consider respiratory viruses for a broad range of diagnoses. This heightened awareness may help reduce the number of nosocomial respiratory viral infections.

To evaluate the effectiveness of pediatric practice consultation in reducing missed-opportunity rates at eight pediatric sites in Baltimore, Maryland. The overarching goal was to decrease the occurrence of missed opportunities from 33% to 15% for the first, second, and third diphtheria and tetanus toxoids and pertussis vaccines during visits at which children were eligible for the vaccines.The effect of an in-office educational program alone at four sites is compared with the educational program and a consultation on office vaccination practices at four matched sites. All eight sites received a small grant ($2,000) to fund practice changes. The medical records of children making visits before and after the interventions were audited to determine missed-opportunity rates. The policies and operations and the knowledge, attitudes, and practices of physicians and nurse practitioners at each site were also assessed.The four education-consultation sites experienced a statistically significant 14% net reduction in the missed-opportunity rate relative to the education-only sites. This positive effect, however, was largely due to an increase in missed opportunities at one education-only site. There was a 10% increase in the missed-opportunity rate among the education-only sites and a 4% decrease among the education-consultation sites; neither change was statistically significant. Two of the three sites that reduced missed opportunities were matched health maintenance organizations (HMOs). Shortly after the interventions, both HMOs implemented tracking and follow-up information systems, which were planned before the interventions.There is no evidence that either the educational program alone or the educational program and consultation combination reduced missed opportunities. The findings suggest that improved tracking and follow-up data systems and vaccination of children at sick visits may reduce missed opportunities.

Objective : To identify perinatal factors that are predictive of disruption in primary caregiving among infants of substance abusing women. Method : A randomized longitudinal cohort study. One hundred and fifty two mother/infant dyads were assessed for evidence of disruption of primary caregiving or neglect during the first 18 months of life, defined by mother's inability to provide care. Data analyzed included neonatal characteristics, urine toxicology at delivery, maternal history of drug use, maternal depression, social support, and social and health history. Results : Sixty-six infants (43.4%) had disruption in their primary care during the first 18 months of their life, 86 infants (56.6%) remained in the care of their mothers. Women who were younger, were heroin users, had two or more children, had other children in foster care, and reported depressive symptoms were least likely to provide ongoing primary care for their infant. Conclusions : Although all infants born to substance abusing women are at a high risk for disruption in the continuity of their primary caregiving, maternal demographic and psychosocial factors present at delivery can predict which infants are likely to experience an early disruption in their primary caregiving. Identifying these families can enable health care providers to monitor them more closely and, when appropriate, encourage support from the extended family.

Objective: Standards for pediatric immunization practices were issued by the Centers for Disease Control and Prevention, Atlanta, Ga, in May 1992. This article provides baseline data on immunization practices related to eight of the standards. Design: Survey of pediatric providers before publication of the standards. Setting: Baltimore, Md. Participants: Forty of the 41 health centers, clinics, and private practices serving children in designated high-risk census tracts participated in the survey. One hundred seventy-three of the 251 eligible physicians and nurse practitioners at the sites responded. Main Outcome Measures: Conformity with the eight standards was measured as a percentage of either sites or physicians and nurse practitioners across the sites. Results: Conformity with the standards varied, ranging from nearly universal conformity with the need to educate parents and guardians about immunizations (standard 5) to less than 3% for simultaneous administration of all vaccine doses when a child is first eligible (standard 8). For most of the standards, considerable variability was found between and within public and private sites. Conclusions: Providers often followed practices that did not conform to the new standards (prior to issuance). Some of the standards are ambiguous and require clarification before they can be fully applied. The impact of the standards on immunization rates and pediatric primary health care has yet to be tested empirically. (Arch Pediatr Adolesc Med. 1994;148:930-935)

Objective. To provide empirical data on immunization coverage and the receipt of preventive health care to inform policy makers' efforts to improve childhood immunization. Design and methods. We surveyed a random sample drawn from a birth cohort of 557 2-year-old children living in the inner-city of Baltimore. Complete information on all their preventive health care visits and immunization status was obtained from medical record audits of their health care providers. Main outcome measures. Age-appropriate immunizations and preventive health care visits. Results. By 3 months of age, nearly 80% made an age-appropriate preventive health visit, but by 7 months of age, less than 40% had a preventive visit that was age-appropriate. In the second year of life, 75% made a preventive health visit between their 12- and 17-month birthdays. The corresponding age-appropriate immunization levels were 71% for DTP1, 39% for DTP3, and 53% for measles-mumps-rubella vaccine. Infants who received their DTP1 on-time were twice as likely to be up-to-date by 24 months of age. Conclusions. Our analyses focus attention on the performance of the primary health care system, especially during the first 6 months of life. Many young infants are underimmunized despite having age-appropriate preventive visits, health insurance coverage through Medicaid, and providers who receive free vaccine from public agencies. Measles vaccination coverage could be improved by initiating measles-mumps-rubella vaccine vaccination, routinely, at 12 months among high risk populations.

Objective. To examine the efficacy of albuterol (0.15 mg/kg per dose) in the management of bronchiolitis. Design. Randomized, double-blind, placebo-controlled outpatient clinical trial utilizing four study groups: nebulized albuterol, nebulized saline, oral albuterol, and oral placebo. Setting. Pediatric emergency department and outpatient clinic at University of Maryland in Baltimore. Patients. Eighty-eight infants (median age 5.5 months) being treated for their first episode of wheezing were randomly assigned to nebulized albuterol (n = 22), nebulized saline (n = 23), oral albuterol (n = 19), oral placebo (n = 24). Interventions. The nebulized groups received two nebulizations 30 minutes apart, whereas the oral groups received one oral dose. Main outcome measures. Respiratory and heart rates, clinical score, oxygen saturation (Spo2), and the infant's state, ie, asleep, awake, or feeding, were recorded at baseline and at 30 and 60 minutes after treatment Results. Randomization produced equivalent groups in terms of demographics and baseline measures. There were no statistically significant differences in any outcomes among the four treatments, except for oral albuterol, which produced an increase in heart rate (15 beats per minute, P = .005). No differences in the need for additional treatment or hospitalization were observed. Change in the state of the infant during the trial had significant effects on respiratory rate and clinical score. Conclusions. Albuterol is as effective as oral placebo in the management of bronchiolitis. Past studies supporting the use of albuterol did not control for effects of change in state of the infant and did not use a truly inactive placebo group. This study underscores the importance of these design components in measuring the efficacy of albuterol in infants.

A resurgence of measles in the past decade has focused attention on the limitations of current immunization programs, particularly for inner-city, low-income populations. As part of a larger study of immunization rates, we discussed perceptions of disease severity and vaccine efficacy, as well as the prioritization of the tasks of parenthood, with 40 parents of infants living in inner-city Baltimore to discover their beliefs about immunization. Vaccines were considered only partly successful; susceptibility to chickenpox after vaccination was repeatedly cited as evidence of vaccine failure. Fever was seen as a primary indicator of illness; thus, vaccines were believed to cause, rather than prevent, illness. Immunization was not considered a high-priority parental responsibility. These findings suggest future interventions be aimed at changing parental perceptions of vaccines as ineffective and of fever after immunization as an indicator of illness. Finally, immunizations should be made easily available, even during clinic visits for a child's illness.