Academic Pediatrics

Overview

2010-01-01

Outcome and Process in Pediatric Education: Does the Whole Equal the Sum of the Parts?

Kenneth B. Roberts — 2009-10-12

It is both an honor and a great personal pleasure to be giving the Miller-Sarkin Lecture at this, the first combined meeting of Council on Medical Student Education in Pediatrics (COMSEP) and the Association of Pediatric Program Directors (APPD). Any opportunity to honor longtime friends and colleagues Steve Miller and Rich Sarkin is an opportunity for which I'm grateful. The other reason for the personal pleasure is that we are here together today at a meeting that has been a long time coming. When I was a residency program director at the University of Massachusetts (UMass), Al Scheiner, the director of medical student education in pediatrics at UMass (and the first newsletter editor of COMSEP), engaged me in student activities. Al and I collaborated to mutual benefit, and I thought every clerkship director and residency program director enjoyed the kind of relationship we had. In 1999, Rich Sarkin, then president of COMSEP, made me aware that I was incorrect: He estimated that there were more programs in which clerkship directors and residency program directors competed than there were programs in which they collaborated. Well, as I thought about it, we do live in somewhat different worlds (). In addition to belonging to different organizations that meet separately, we answer to different accrediting bodies, and our learners answer to different credentialing bodies. Developing a relationship between COMSEP and APPD seemed like an obvious (and productive) way to model collaboration, so I began to lobby the leaders of the organizations for a combined meeting. During the next several years, Ed Zalneraitis and Carol Carraccio established task forces for APPD that paralleled COMSEP's and worked with Bruce Morgenstern to establish collaboration. Steve Miller, Robin Deterding, Bill Raszka, Ed Zalneraitis, Carol Carraccio, Rob McGregor, Ted Sectish, and Susan Guralnick—we are indebted to all of you for this day.

Excellence in Research: Threats From All Directions

Mark A. Schuster — 2010-01-01

Editor's Note: On May 4, 2009, Mark Schuster, MD, PhD, received the Academic Pediatric Association 2009 Research Award. The chair of the APA's Research Committee, Benard Dreyer, MD, introduced Dr Schuster. Following are Dr Schuster's remarks. A slide appeared behind him with the names of his mentors and mentees. This commentary is being published simultaneously in the Journal of Adolescent Health, Volume 46, Number 2 (the February 2010 issue).

How Do We Support Women and Families in Breastfeeding?

Alison Volpe Holmes, Cynthia R. Howard — 2010-01-01

The debate is over about the importance of breastfeeding for health outcomes for women and children in the United States. There is no debate. … The real questions are: How do we support women and families in breastfeeding and exclusively breastfeeding? What can the healthcare system itself do? What is our responsibility? How are we currently supporting it, and how are we currently sabotaging it? What can employers do? What can society in general do? What can policy makers and the government do? That's an ecological approach to answering this question.–David Meyers, MD, FAAFPAgency for Healthcare Research and QualityFirst Annual Summit on Breastfeeding, June 11, 2009

The Exterminator

Daniel R. Taylor — 2010-01-01

I am no longer surprised. The presentations are varied. “I think I have wax in my ear.” “He keeps tugging at his ear.” “I hear a buzzing in my ear.” Sometimes it's the shocked look one of my new pediatric residents gives to me, stating, “I think I see a bug in his ear.” By the end of the third year of their residency, regrettably, this surprised reaction fades as cases of “cockroach ear” become commonplace.

A Randomized Controlled Community-Based Trial to Improve Breastfeeding Rates Among Urban Low-Income Mothers

2009-10-26

Objective: The purpose of this study was to assess whether providing a breastfeeding support team results in higher breastfeeding rates at 6, 12, and 24 weeks postpartum among urban low-income mothers.Methods: Design: A randomized controlled trial with mother-infant dyads recruited from 2 urban hospitals. Participants: Breastfeeding mothers of full-term infants who were eligible for Special Supplemental Nutrition Program for Women, Infants, and Children (n=328) were randomized to intervention (n=168) or usual-care group (n=160). Intervention: The 24-week intervention included hospital visits by a breastfeeding support team, home visits, telephone support, and 24-hour pager access. The usual-care group received standard care. Outcome Measure: Breastfeeding status was assessed by self-report at 6, 12, and 24 weeks postpartum.Results: There were no differences in the sociodemographic characteristics between the groups: 87% were African American, 80% single, and 51% primiparous. Compared with the usual-care group, more women reported breastfeeding in the intervention at 6 weeks postpartum, 66.7% vs 56.9% (odds ratio, 1.71; 95% confidence interval, 1.07–2.76). The difference in rates at 12 weeks postpartum, 49.4% vs 40.6%, and 24 weeks postpartum, 29.2% vs 28.1%, were not statistically significant.Conclusions: The intervention group was more likely to be breastfeeding at 6 weeks postpartum compared with the usual-care group, a time that coincided with the most intensive part of the intervention.

Are 2 Weeks of Daily Breastfeeding Support Insufficient to Overcome the Influences of Formula?

2010-01-01

Objective: To evaluate the effectiveness of proactive telephone breastfeeding support in low-income, primiparous, primarily Latina women on 1) duration and exclusivity of breastfeeding, 2) satisfaction with feeding, 3) rationale for discontinuing breastfeeding and 4) health care utilization.Methods: Randomized controlled trial comparing usual care to 2 weeks of daily telephone calls by nurses by using culturally informed scripted protocols; and qualitative study of focused interviews on a sample of women in the intervention group (n = 40).Results: Breastfeeding duration and exclusivity rates, feeding method satisfaction, and reasons for stopping breastfeeding did not differ significantly between intervention (n = 161) and control (n = 180) groups, with 74% of both breastfeeding at 1 month and 28% and 37%, respectively, at 6 months. Insufficient milk supply was the main reason for stopping in both groups. Intervention infants were less likely to have a sick visit by 1 month (25%) than controls (35%, P = .05). Qualitative interviews revealed that the intervention was informative and helpful, with breastfeeding reported as healthier but harder; formula was a good alternative. Intervention mothers reporting ≤2 supplemental formula feedings on day 4 were more likely than mothers reporting ≥3 supplemental feedings to breastfeed at 1 month (odds ratio 7.7; 95% confidence interval 2.4–24.3).Conclusions: Two weeks of daily telephone support did not increase breastfeeding duration but was associated with a decrease in sick visits in the first month. Early supplementation and the perception of formula as a good alternative to dealing with the breastfeeding difficulties appeared to be factors in failure of the intervention.

Maternal Perceptions of Infant Hunger, Satiety, and Pressuring Feeding Styles in an Urban Latina WIC Population

2009-12-11

Objective: Controlling feeding styles in which parents regulate feeding without responding to child cues have been associated with poor self-regulation of feeding and increased weight, but have not been well studied in infancy. We sought to assess maternal perception of infant feeding cues and pressuring feeding styles in an urban Latina Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) population.Methods: Secondary analysis of a larger study of Latina mothers participating in New York City WIC programs. We examined maternal perception of infant feeding cues and pressuring feeding style. Using logistic regression, we assessed: 1) characteristics associated with perceptions of cues and pressuring to feed, including sociodemographics, breastfeeding, and maternal body mass index; and 2) whether perceptions of cues were associated with pressuring feeding style.Results: We surveyed 368 mothers (84% response rate). Most mothers perceived that babies sense their own satiety. However, 72% believed that infant crying must indicate hunger. Fifty-three percent believed that mothers should always make babies finish the bottle (“pressure to feed”). Pressuring feeding style was associated with foreign maternal country of birth (adjusted odds ratio [AOR] 3.05; 95% confidence interval [CI], 1.66–5.60) and less than a high school education (AOR 1.81; 95% CI, 1.12–2.91). Two perceptions of feeding cues were related to pressuring feeding style: belief that infant crying must indicate hunger (AOR 2.59; 95% CI, 1.52–4.42) and infant hand sucking implies hunger (AOR 1.83; 95% CI, 1.10–3.03).Conclusions: Maternal characteristics influence perception of infant hunger and satiety. Interpretation of feeding cues is associated with pressuring feeding style. Improving responsiveness to infant cues should be a component of early childhood obesity prevention.

Factors Associated with Detection and Receipt of Treatment for Youth with Depression and Anxiety Disorders

2010-01-01

Objective: Anxiety and depression are common among youth and are associated with significant morbidity. Few youth with depression are diagnosed and receive treatment for these disorders. The purpose of this study was to examine the rate of recognition and management among an insured population and the factors associated with evidence of detection among youth.Methods: Structured mental health interviews assessing depression and anxiety diagnoses were completed with a random sample of 581 youth (age range 11–17 years) from an integrated health care system. Administrative data on medical and pharmacy services were used to examine any evidence of detection by the medical system in the prior 12 months.Results: Fifty-one youth met criteria for an anxiety or depressive disorder. Twenty-two percent of these youth with an anxiety or depressive disorder as defined in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition had evidence of detection or treatment. Factors associated with detection and treatment included having diagnosis of a depressive disorder (with or without an anxiety disorder), more depressive symptoms, greater functional impairment, a higher number of primary care visits in the prior year, and higher parent-reported externalizing symptoms. On multivariate analysis, having more depressive symptoms and a higher number of primary care visits were significant predictors of detection and receipt of treatment.Conclusions: The rate of detection and treatment of anxiety and depressive disorders is very low in this age group and suggests a need for increased focus on detection, particularly in light of recent evidence suggesting decreases in diagnosis and treatment among youth following the black box warning regarding antidepressant medications.

Socioeconomic Risk Factors for Mental Health Problems in 4–5-Year-Old Children: Australian Population Study

Elise Davis, Michael G. Sawyer, Sing Kai Lo, Naomi Priest, Melissa Wake — 2010-01-01

Objective: To describe the extent to which parent- and teacher-reported child mental health problems vary by different indicators of socioeconomic status.Methods: Participants were 4–5-year-old children in the Longitudinal Study of Australian Children (LSAC). Parents (N = 4968) and teacher (N = 3245) completed the 3–4-year-old version of Strengths and Difficulties Questionnaire (SDQ). Parents also reported the socioeconomic indicators of income, education, employment, and family composition (1- vs 2-parent families). Logistic regression models were used to predict SDQ total difficulties and each of the 4 SDQ subscales problems, as reported by parents and by teacher, and considered all putative socioeconomic status (SES) predictor variables simultaneously.Results: The proportions of children scoring in the abnormal range varied according to SES indicator and mental health subscale. All of the SES indicators independently predicted parent-reported child mental health problems, although odds ratios were generally small to moderate (1.2 to 2.4), and not all reached statistical significance. Low income and parent education showed larger associations than sole parenthood or unemployment. The pattern for teachers was similar, though less consistent. Behavioral problems showed stronger associations with social disadvantage than emotional problems.Conclusions: Research examining pathways to young children's mental health should include diverse measures of SES, particularly of family income and education. The fact that mental health problems were most strongly associated with parent education and income should be of interest to policy makers because education and income reflect investments in the lives of our participants' parents during their own childhood and adolescence.

Impact of Managed Care on Publicly Insured Children with Special Health Care Needs

Lynne C. Huffman, Gabriel A. Brat, Lisa J. Chamberlain, Paul H. Wise — 2010-01-01

Objective: The aim of this review was to evaluate the impact of managed care on publicly insured children with special health care needs (CSHCN).Methods: We conducted a review of the extant literature. Using a formal computerized search, with search terms reflecting 7 specific outcome categories, we summarized study findings and study quality.Results: We identified 13 peer-reviewed articles that evaluated the impact of Medicaid and State Children's Health Insurance program (SCHIP) Managed Care (MSMC) on health services delivery to populations of CSHCN, with all studies observational in design. Considered in total, the available scientific evidence is varied. Findings concerning care access demonstrate a positive effect of MSMC; findings concerning care utilization were mixed. Little information was identified concerning health care quality, satisfaction, costs, or health status, whereas no study yielded evidence on family impact.Conclusion: The available studies suggest that the evaluated record of MSMC for CSHCN has been mixed, with considerable heterogeneity in the definition of CSHCN, program design, and measured outcomes. These findings suggest caution should be exercised in implementing MSMC for CSHCN and that greater emphasis on health outcomes and cost evaluations is warranted.

Comparing Medical Homes for Children with ADHD and Asthma

Sara L. Toomey, Charles J. Homer, Jonathan A. Finkelstein — 2010-01-01

Objective: The aims of our study were, among children with attention-deficit/hyperactivity disorder (ADHD) compared with children with asthma: 1) to assess characteristics associated with parent report of having a medical home for children with either of these 2 conditions; 2) to determine whether, controlling for these characteristics, the likelihood of having a medical home differs between children with ADHD and asthma; and 3) to identify the specific components of a medical home that are lacking for children with these 2 conditions.Methods: Cross-sectional analysis of the National Survey of Children with Special Health Care Needs, 2005–2006 (NS-CSHCN) was used. The outcome variable was parent report of their child's practice having specific attributes of the medical home. We used multivariate logistic regression to test whether the likelihood of having a medical home and its components differed for children with ADHD in comparison to children with asthma.Results: The NS-CSHCN interviewed parents of 11 674 children with ADHD and 13 517 children with asthma aged between 4 to 17 years. Significantly fewer children with ADHD compared with children with asthma have a medical home (OR [odds ratio] 0.68; P < .001). Specifically, parents reported differences in receiving family-centered (OR 0.79; P < .001) and coordinated care (OR 0.59; P < .001).Conclusion: Parents of children with ADHD report worse performance across key dimensions of primary care compared with parents of children with asthma. For primary care to be optimally effective in addressing the needs of children with ADHD, efforts to significantly strengthen these key dimensions are needed.

Physician and Parent Response to the FDA Advisory About Use of Over-the-Counter Cough and Cold Medications

2009-10-12

Objective: The aim of this study was to assess the likely impact of the US Food and Drug Administration (FDA) advisory not to use over-the-counter (OTC) cough and cold products for children aged <2 years on care provided by pediatricians and parents.Methods: A mailed survey was completed by 105 community pediatricians (53% response rate), and 1265 parents with children aged <12 years completed a self-administered survey while waiting for an office visit.Results: All physicians were aware of the advisory; 75% agreed with it. Fifty-nine percent did not recommend OTC cough and cold products for children aged <2 years before the advisory, and 35% were less likely to do so afterward. Seventy-three percent of parents were aware of the advisory, 70% believed these products relieved symptoms, 68% did not believe they were dangerous, and 74% had them at home. After the advisory, 21% of parents were more likely to request an antibiotic from the doctor. Among the parents, 225 only had children aged <2 years and 695 only had children aged 2 to 11 years; of these parental groups, 53% and 10% of parents, respectively, did not use these products before the advisory, an additional 33% and 28%, respectively, were less likely to do so afterward, and 15% and 61%, respectively, would continue use them.Conclusions: Pediatricians must be prepared for requests from parents for antibiotics and other remedies for symptom relief for their children with colds. As no effective alternatives are available, maybe nontreatment should be promoted.

Practice Characteristics That Influence Nonurgent Pediatric Emergency Department Utilization

2010-01-01

Objective: The goal of this study was to determine what characteristics of a primary care pediatric practice are associated with nonurgent use of the pediatric emergency department (PED).Methods: Primary care practice characteristics were prospectively collected from 33 practices. Nonurgent and urgent visits to the PED for patients from these practices were analyzed retrospectively. A discriminant analysis classification model was used to identify practice characteristics that were associated with nonurgent versus urgent utilization of the PED.Results: Patients in the network of 33 practices accounted for 31 076 visits to the PED during the 12-month study period, 47% of which were classified as nonurgent. Based on the discriminant analysis classification model, discriminant patterns that predict the frequency of nonurgent utilization included the percentage of patients with Medicaid, total available sick slots to see patients per physician, closer distance to the PED, whether or not the nurse triage line notified all on-call physicians of disposition to the PED, whether it is practice policy to accept all walk-in sick visits, and ability of practice to have same-day turnaround of laboratory tests.Conclusions: Nonurgent utilization of the PED by patients in a specific primary care practice can be predicted based on discriminant practice characteristics, several of which may be modifiable. Use of these predictive rules can be used to optimize pediatric services and policy to help mitigate the high volume of PED nonurgent visitation. Focused interventions on practice characteristics of significance may help reduce PED overcrowding and improve continuity of care.

Evidence-Based Diagnosis

Michael J. Steiner — 2010-01-01

This excellent new textbook thoroughly explains all aspects of a reasoned approach to diagnostic decision making. The first section of the book provides an overview of diagnostic testing, with chapters covering the definitions of disease; test reliability and error; and dichotomous test results, including thorough explanations of sensitivity, specificity, likelihood ratios, and appropriate cautions around predictive values. The more complicated chapters of this introductory section include explorations of multilevel and continuous results, sequential testing, and logistic regression as a tool in diagnostic determination. The next section of the book includes chapters on screening tests, prognostic tests, critical appraisal of diagnostic test studies, and a surprisingly thorough discussion of treatment studies. The final chapter of the book explores limitations to the evidence-based approach and to health care in general.

Review Acknowledgment

2010-01-01

We, the editors of Academic Pediatrics sincerely thank the reviewers listed below who generously gave their time to the journal over the past year. Their insightful feedback helps authors improve their scholarship and enables us to provide a quality journal to our readers. We include below all reviewers though mid-November 2009. We sincerely apologize to anyone whose name was accidentally omitted from this list.

Author Index

2010-01-01

Subject Index

2010-01-01

Editorial Board

2010-01-01

Academic Pediatrics

Overview

Outcome and Process in Pediatric Education: Does the Whole Equal the Sum of the Parts?

Excellence in Research: Threats From All Directions

How Do We Support Women and Families in Breastfeeding?

The Exterminator

A Randomized Controlled Community-Based Trial to Improve Breastfeeding Rates Among Urban Low-Income Mothers

Are 2 Weeks of Daily Breastfeeding Support Insufficient to Overcome the Influences of Formula?

Maternal Perceptions of Infant Hunger, Satiety, and Pressuring Feeding Styles in an Urban Latina WIC Population

Factors Associated with Detection and Receipt of Treatment for Youth with Depression and Anxiety Disorders

Socioeconomic Risk Factors for Mental Health Problems in 4–5-Year-Old Children: Australian Population Study

Impact of Managed Care on Publicly Insured Children with Special Health Care Needs

Comparing Medical Homes for Children with ADHD and Asthma

Physician and Parent Response to the FDA Advisory About Use of Over-the-Counter Cough and Cold Medications

Practice Characteristics That Influence Nonurgent Pediatric Emergency Department Utilization

Evidence-Based Diagnosis

Review Acknowledgment

Author Index

Subject Index

Editorial Board

Table of Contents