Design  Longitudinal prospective randomized intervention.

Setting  An urban academic children's hospital.

Patients  A total of 4246 individuals aged 0 to 21 years from each of 4 participating primary care practices recording an index PED visit from April through December 2005.

Intervention  Follow-up phone call from the primary care practice within 72 hours of the initial PED visit to counsel about the availability of after-hours advice and when to access the PED.

Main Outcome Measures  All subsequent visits to primary care practices, PED, pediatric subspecialists, or for inpatient hospitalization during a 365-day follow-up period. Logistic and ordinary least squares regressions estimated unadjusted and adjusted odds ratios of follow-up visits, controlling for covariates.

Results  Of the 2166 intervention subjects, 816 (37.7%) recorded follow-up PED visits compared with 819 (39.4%) of the 2080 control subjects (P = .26, not significant). The adjusted odds of a follow-up visit being to the PED rather than to another venue was significantly less for intervention than for control subjects (odds ratio, 0.88; confidence interval, 0.82-0.94), indicating decreased intensity of PED use.

Conclusion  Follow-up phone calls from primary care practices after PED visits counseling patients on the use of primary care and emergency services can modulate subsequent care-seeking behavior and decrease future PED use.

Design  Cross-sectional study collating information from national, state, and local trauma systems authorities to create a catalog of verified pediatric trauma centers (PTCs) and self-designated "candidate" trauma centers. Access-to-care calculations were estimated using all US block groups and prior validated methods.

Setting  United States.

Patients  Children in the US younger than 15 years.

Main Outcome Measures  The PTC statuses of hospitals in the United States. Percentages of pediatric populations (by state and population density) having access (by ground or air) within 60 minutes to a PTC.

Results  A total of 170 verified PTCs were identified in 41 states (including the District of Columbia). An estimated 71.5% of pediatric patients were within 60 minutes of a verified PTC by air or ground transport, 43% if ground transportation only was considered. An estimated 17.4 million children did not have access to a PTC within 60 minutes. Access ranged from 22.9% of the population in the most rural areas of the United States to 93.5% in the most urban. The addition of 24 candidate centers increased coverage to 77.4% of the pediatric population being within 60 minutes of a PTC.

Conclusions  Current pediatric trauma resources vary greatly by state and population density, with many children, particularly in rural areas, underserved. A thorough standardized catalog of verified PTCs is necessary to accurately assess pediatric trauma needs now and to optimize future trauma system planning for children.

Design  Cross-sectional survey.

Setting  Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts.

Participants  One hundred ninety-four parents of children with cancer (response rate, 70%) in the first year of cancer treatment.

Main Outcome Measure  The Functional Assessment of Chronic Illness Therapy–Spiritual Well-being sense of meaning subscale.

Results  Principal components analysis of Functional Assessment of Chronic Illness Therapy–Spiritual Well-being sense of meaning subscale responses identified 2 distinct constructs, peace of mind (Cronbach  = .83) and sense of purpose (Cronbach  = .71). Scores ranged from 1 to 5, with 5 representing the strongest sense of peace or purpose. One hundred forty-seven of 181 parents (81%) scored 4 or higher for questions related to sense of purpose (mean [SD] score, 4.4 [0.6]). Only 44 of 185 parents (24%) had scores in the same range for peace of mind (mean [SD] score, 3.2 [0.9]) (P < .001). In a multivariable logistic regression model, parents had higher peace of mind scores when they also reported that they trusted the oncologist's judgment (odds ratio [OR] = 6.65; 95% confidence interval [CI], 1.47-30.02), that the oncologist had disclosed detailed prognostic information (OR = 2.05; 95% CI, 1.14-3.70), and that the oncologist had provided high-quality information about the cancer (OR = 2.54; 95% CI, 1.11-5.79). Peace of mind was not associated with prognosis (OR = 0.74; 95% CI, 0.41-1.32) or time since diagnosis (OR = 1.00; 95% CI, 0.995-1.003).

Conclusions  Physicians may be able to facilitate formulation of peace of mind by giving parents high-quality medical information, including prognostic information, and facilitating parents' trust.

Design  Community cross-sectional data obtained using a cluster sample approach.

Setting  From November 5, 2007, through February 5, 2008, we assessed 13 secondary schools in 4 selected health zones in the Ituri district.

Participants  One thousand forty-six adolescents and young adults aged 13 to 21 years completed a self-report questionnaire.

Main Exposures  War-related traumatic events, posttraumatic stress symptoms, and sociodemographic variables.

Main Outcomes Measures  The Adolescent Complex Emergency Exposure Scale, specifically designed for this region, screened for exposure to potentially traumatic events, and the Impact of Event Scale–Revised measured symptoms of posttraumatic stress consistent with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria.

Results  Among the 477 girls (45.6%) and 569 boys (54.4%) in the study, 95.0% reported at least 1 traumatic event. On average, adolescents were exposed to 4.71 traumatic events, with higher exposure rates reported in boys, older groups, rural and urban areas, and respondents whose mother or father was dead. Of 990 respondents, 52.2% met symptom criteria for posttraumatic stress disorder. Symptom scores were strongly related to cumulative trauma exposure; however, the strength of this relationship differed slightly across living area groups for girls.

Conclusion  Adolescents in the eastern Democratic Republic of Congo are highly exposed to political violence, putting them at a considerable risk—mediated by living area and sex—to develop posttraumatic stress symptoms.

Design  Cross-sectional study.

Setting  Lower Manhattan, New York, New York.

Participants  One hundred two preschool child-mother dyads directly exposed to the World Trade Center attacks.

Exposures  Maternal disorders: 2 (posttraumatic stress disorder [PTSD] and depression), 1 (depression or PTSD), or none.

Main Outcome Measures  Maternal depression and PTSD were self-reported. Child behavioral problems were rated by mothers and teachers using a standardized behavioral checklist. For each informant, we created separate dichotomous variables that indicated whether the child's behavioral problems were severe enough to be clinically significant. We then used an analytic technique (generalized estimating equations) that integrates the child behavioral problem ratings by the mother and teachers to derive a more reliable indicator of clinically significant child behavioral problems.

Results  The rate of clinically significant child behavioral problems increased linearly relative to the number of maternal psychopathologies. The number of maternal psychopathologies was associated with a linear increase in functional impairment. Compared with children of mothers without psychopathologies, children of mothers with depression and PTSD were at greater risk for several clinically significant problems, notably, aggressive behavior (relative risk, 13.0), emotionally reactive behavior (11.2), and somatic complaints (10.5). Boys were more likely to have clinically significant behavior problems than were girls.

Conclusion  Concurrent maternal depression and PTSD was associated with dramatic increases in the rate of clinically significant behavioral problems in preschool children, particularly boys, 3 years after the World Trade Center attacks.

Design  Transmission disequilibrium testing in case mothers and maternal grandparents.

Setting  Previous studies have consistently shown increased frequency of HLA-DR4 in probands with autism and their mothers, but not their fathers. However, this has been documented only in case-control studies and not by a more direct study design to determine whether HLA-DR4 acts in mothers during pregnancy to contribute to autism in their affected offspring.

Participants  We genotyped for HLA-DR alleles in members of 31 families with parents and maternal grandparents. Probands with autism were tested using the Autism Diagnostic Observation Schedule–Western Psychological Services and Autism Diagnostic Interview, Revised. There was 80% power to detect an odds ratio of 3.6. Participants were all families from New Jersey and were similar in number to earlier studies of autism and HLA-DR4.

Outcome Measures  Analysis was by standard transmission disequilibrium testing. As a secondary test we examined the possibility of maternal imprinting.

Results  Significant transmission disequilibrium for HLA-DR4 was seen (odds ratio, 4.67; 95% confidence interval, 1.34-16.24; P = .008) for transmissions from maternal grandparents to mothers of probands, supporting a role for HLA-DR4 as an autism risk factor acting in mothers during pregnancy. Transmission disequilibrium was not seen for HLA-DR4 transmissions from parents to probands or from mothers to probands.

Conclusions  The HLA-DR4 gene may act in mothers of children with autism during pregnancy to contribute to autism in their offspring. Further studies are required to confirm these findings.

Design  Longitudinal cohort study.

Participants  Children retained in kindergarten or first (K/1) grade and third grade, presumably for academic reasons, were followed up through fifth grade.

Main Outcome Measure  Presence or absence of an IEP.

Results  A total of 300 children retained in K/1 and 80 retained in third grade were included in the study. Of the K/1 retainees, 68.9% never received an IEP during the subsequent 4 to 5 years; of the third-grade retainees, 72.3% never received an IEP. Kindergarten/first-grade retainees in the highest quintile for socioeconomic status and those with suburban residence were less likely to receive an IEP than retained children in all other socioeconomic status quintiles (adjusted odds ratio, 0.17; 95% confidence interval, 0.05-0.62) and in rural communities (0.16; 0.06-0.44). Among K/1 retainees with persistently low academic achievement in math and reading, as assessed by standardized testing, 38.2% and 29.7%, respectively, never received an IEP.

Conclusions  Most children retained in K/1 or third grade for academic reasons, including many of those who demonstrated sustained academic difficulties, never received an IEP during elementary school. Further studies are important to elucidate whether retained elementary schoolchildren are being denied their rights to special education services. In the meantime, early-grade retention may provide an opportunity for pediatricians to help families advocate for appropriate special education evaluations for children experiencing school difficulties.

Design  Prospective, population-based observational study.

Setting  Community.

Participants  Three hundred twenty-nine 2- to 48-month-old children.

Main Exposures  Audible television. Children wore a digital recorder on random days for up to 24 months. A software program incorporating automatic speech-identification technology processed the recorded file to analyze the sounds the children were exposed to and the sounds they made. Conditional linear regression was used to determine the association between audible television and the outcomes of interest.

Outcome Measures  Adult word counts, child vocalizations, and child conversational turns.

Results  Each hour of audible television was associated with significant reductions in age-adjusted z scores for child vocalizations (linear regression coefficient, –0.26; 95% confidence interval [CI], –0.29 to –0.22), vocalization duration (linear regression coefficient, –0.24; 95% CI, –0.27 to –0.20), and conversational turns (linear regression coefficient, –0.22; 95% CI, –0.25 to –0.19). There were also significant reductions in adult female (linear regression coefficient, –636; 95% CI, –812 to –460) and adult male (linear regression coefficient, –134; 95% CI, –263 to –5) word count.

Conclusions  Audible television is associated with decreased exposure to discernible human adult speech and decreased child vocalizations. These results may explain the association between infant television exposure and delayed language development.

Design  Ten pediatric clinics were randomly assigned to an intervention (5 clinics) or control group (5 clinics). The proportion of sexually active girls screened for CT was estimated over 18 months (April 2005-September 2006).

Setting  Large health maintenance organization in northern California.

Participants  Pediatric clinics providing urgent care services for adolescent girls aged 14 to 18 years.

Intervention  In the intervention clinics, a team of providers and clinic staff met monthly to redesign their clinic system to improve CT screening during urgent care. Controls received an informational lecture on CT screening.

Main Outcome Measures  Clinic-specific proportions of sexually active adolescent girls screened for CT.

Results  The change over time in clinic-specific CT screening rates in urgent care was significantly greater in the intervention group than in the control group (likelihood ratio, ²₁ = 18.7; P < .001). Between baseline and the fifth intervention period, the proportions of girls screened for CT increased by 15.93% in the intervention group and decreased by 2.13% in the comparison clinics.

Conclusions  The intervention significantly improved the proportion of adolescent girls screened for CT during urgent care. Despite this success, substantial barriers to screen for CT in urgent care remain. Innovative strategies to provide basic information about CT, other sexually transmitted infections, and pregnancy are greatly needed since many teens are never seen for preventive care in a given year.

Design  School survey.

Setting  Postmandatory schools.

Participants  A total of 6790 students (3275 females) aged 16 to 20 years, grouped as adolescents with CHCs (355 females, 354 males) and control peers (2920 females, 3161 males).

Main Exposure  Chronic health condition was defined using a noncategorical approach including adolescents with a chronic disease and/or a physical handicap.

Main Outcome Measures  Sports practice, barriers to sports practice among individuals not practicing any sports, and biological, psychological, socioeducative, and physical activity characteristics.

Results  Males with CHCs were less likely than control males to practice sports, whereas no significant difference was observed for females. Chronically ill youth were significantly more likely to report having a CHC as a barrier for not practicing sports. However, the most frequently reported barrier was preference for other activities for males with CHCs and lack of time for control males and for females with and without CHCs.

Conclusions  Having a CHC seems to influence sports practice among males but not females. We recommend that practitioners dealing with adolescents remember to take into account sports practice as part of the care of young patients with CHCs.

Data Sources  Cochrane Effective Practice and Organisation of Care Group database (January 1966 to April 2006), MEDLINE (January 1966 to April 2006), Cochrane Consumers and Communication Group database (January 1966 to May 2006), and bibliographies of retrieved articles.

Study Selection  Randomized controlled trials, controlled before-after trials, or interrupted time series trials of English-language QI evaluations.

Interventions  Must have included 1 or more QI strategies for the outpatient management of children with asthma.

Main Outcome Measures  Clinical status (eg, spirometric measures); functional status (eg, days lost from school); and health services use (eg, hospital admissions).

Results  Seventy-nine studies met inclusion criteria: 69 included at least some component of patient education, self-monitoring, or self-management; 13 included some component of organizational change; and 7 included provider education. Self-management interventions increased symptom-free days by approximately 10 days/y (P = .02) and reduced school absenteeism by about 0.1 day/mo (P = .03). Interventions of provider education and those that incorporated organizational changes were likely to report improvements in medication use. Quality improvement interventions that provided multiple educational sessions, had longer durations, and used combinations of instructional modalities were more likely to result in improvements for patients than interventions lacking these characteristics.

Conclusions  A variety of QI interventions improve the outcomes and processes of care for children with asthma. Use of similar outcome measures and thorough descriptions of interventions would advance the study of QI for pediatric asthma care.

Design  Retrospective cohort study using the state immunization registry.

Setting  Arizona.

Participants  Arizona children born between February 1 and September 30, 2005, who received their initial DTaP dose during a statewide pertussis outbreak (N = 45 129).

Main Exposures  Children who received at least 1 dose of DTaP on the minimum interval schedule (minimum interval group) compared with children who received all doses of DTaP on the standard childhood and adolescent immunization schedule (standard group).

Outcome Measures  Timing and receipt of 3 doses of the DTaP, IPV, and PCV.

Results  Compared with children in the standard group, children in the minimum interval group were more likely to receive 3 doses of DTaP (relative risk, 1.34; 95% confidence interval, 1.32-1.35), 3 doses of IPV (1.27; 1.25-1.29), and 3 doses of PCV (1.37; 1.35-1.39).

Conclusion  Recommending a minimum interval DTaP schedule during a statewide pertussis outbreak had a positive association with the receipt of IPV and PCV, 2 vaccines normally administered at the same time as DTaP.

Design  Prediction model using data from a retrospective cohort study.

Setting  Published data from 8 states that participated in Active Bacterial Core Surveillance of the Emerging Infections Program Network for pneumococcus before pneumococcal conjugate vaccine introduction (July 1, 1997- June 30, 2000).

Participants  A total of 759 739 live births under surveillance.

Intervention  Estimating the potential benefit of administration of the first dose of the pneumococcal conjugate vaccine at 6 weeks of age instead of 2 months of age.

Main Outcome Measures  Estimation of reduction in the rate of invasive pneumococcal disease in infants 61 to 90 days of age.

Results  The estimated direct effect of the acceleration of administration of the first dose of pneumococcal conjugate vaccine from 2 months to 6 weeks of age when this vaccine was first introduced could have reduced the burden of invasive pneumococcal disease in infants 61 to 90 days of age by 39.9%, 56.0%, and 72.1% for respective vaccine efficacies of 50%, 70%, and 90%. This translates into preventing an estimated 73, 103, and 133 cases of invasive pneumococcal disease per year among approximately 4 112 052 live births in the United States.

Conclusions  The acceleration of administration of the pneumococcal conjugate vaccine from 2 months to 6 weeks of age could reduce the burden of invasive pneumococcal disease among infants. This observation may be important when a new conjugate vaccine becomes available, particularly among populations with prevalent invasive pneumococcal disease from a serotype included in the new vaccine.

Design  Observational study using data from a computerized billing database and an electronic immunization information system.

Setting  Four Denver pediatric practices during the 2003-2004 and 2004-2005 influenza seasons.

Participants  Children aged 24 to 72 months with and without HRCs.

Main Exposure  The vaccine shortage of the 2004-2005 influenza season.

Main Outcome Measures  Proportion of children with and without HRCs who were immunized and the timing of influenza immunization in nonshortage (2003-2004) and shortage (2004-2005) seasons.

Results  In the 2003-2004 season, 770 of 1166 children with HRCs (66.0%) were immunized and, in the 2004-2005 season, 656 of 1053 (62.3%) were immunized. Although vaccination coverage did not significantly decrease for children with HRCs during the 2004-2005 season (P = .07), coverage for healthy children decreased from 43.8% (4435/10 117) to 29.5% (3066/10 387) (P < .001). After the priority group recommendation in October 2004, the practices provided few vaccines to healthy children, whereas children with HRCs continued to receive the vaccine.

Conclusion  Pediatric practices with a system to identify and recall children with HRCs can target these children for receipt of the influenza vaccine and maintain high vaccination coverage, despite a vaccine shortage that may result in decreased vaccine coverage in healthy children.

Design  Descriptive qualitative synthesis of sociocultural studies in 4 countries using iterative theme-based analyses.

Setting  Four developing countries: India, Peru, Uganda, and Vietnam.

Participants  Criterion-based sample of 252 focus-group discussions and 470 in-depth interviews with children, parents, teachers/administrators, health workers/managers, and community/religious leaders. A knowledge, attitudes, and practices survey was administered to 879 children and 875 parents in Vietnam.

Results  We found that vaccine decision-making was primarily done by parents, with children having some role. Understanding of cervical cancer and HPV was limited; however, the gravity of cancer and some symptoms of cervical cancer were recognized. Vaccination and government-sponsored immunization programs were generally supported by respondents. Sentiments toward cervical cancer vaccines were positive, but concerns about quality of delivery, safety, adverse effects, and the effect on fertility were raised. Communities requested comprehensive awareness-raising and health education to address these concerns.

Conclusion  Sociocultural studies help elucidate the complexities of introducing a new vaccine from the perspective of children, parents, and communities. Strategies for introducing the HPV vaccine should address community concerns through effective communication, appropriate delivery, and targeted advocacy to make the program locally relevant.

Design  The US National Immunization Survey.

Participants  Children aged 19 to 35 months living in low-income households who were sampled between 1995 and 2007 (N = 232 318). Low-income households had an annual income that was 133% or less of the federal poverty level, and high-income households had an annual income of 400% or more of the federal poverty level.

Main Outcome Measures  Administration of 4 or more doses of diphtheria, tetanus, pertussis (DTaP-DTP) vaccine; 3 or more doses of polio; 1 or more doses of measles, mumps, rubella (MMR); 3 or more doses of Haemophilus influenzae type b (Hib); 3 or more doses of hepatitis B; and 1 or more doses of varicella vaccines by age 19 months as reported by the children's vaccination providers. Progress in timely coverage was evaluated by tracking changes between consecutive annual birth cohorts born between 1994 and 2004.

Results  Among low-income children, timely vaccination coverage increased significantly between consecutive birth cohorts by an estimated 0.5% for DTaP-DTP, 0.3% for polio, 0.6% for MMR, 1.2% for hepatitis B, and 5.3% for varicella vaccines but did not change significantly for the Hib vaccine. Disparities in timely coverage for low- vs high-income children declined significantly between consecutive birth cohorts by an estimated –0.3% for MMR, –0.3% for hepatitis B, and –0.5% for varicella vaccines, did not change significantly for the polio vaccine, and increased significantly by 0.4% for the DTaP-DTP vaccine.

Conclusions  Disparities in vaccination coverage associated with low household income persist. Further progress in timely vaccination may be achieved by improving health care providers' reminder/recall systems, implementing educational interventions that address barriers to vaccination, and increasing parents' awareness of the Vaccines for Children Program.

Design  Single-center, double-blind, randomized clinical trial.

Setting  Outpatient pediatric clinic in Toronto, Ontario, Canada.

Participants  Healthy infants 2 to 6 months of age undergoing routine immunization.

Interventions  Infants received either their primary DPTaP-Hib vaccine or the PCV first, followed by the other vaccine.

Main Outcome Measures  The primary outcome was infant pain during vaccine injection as assessed by a validated measure, the Modified Behavioral Pain Scale (MBPS), using videotaped recordings of the procedure. In addition, parents rated pain using a 10-cm visual analog scale (VAS). Crying (yes/no) was also measured.

Results  The study was conducted between July 21, 2006, and June 21, 2007. A total of 120 infants participated: 60 received the DPTaP-Hib vaccine first and 60 received the PCV first. Infant characteristics did not differ between groups. Overall mean (SD) pain scores per infant after receiving both vaccine injections were significantly lower when DPTaP-Hib was administered first compared with when PCV was administered first (MBPS score, 7.6 [1.5] vs 8.2 [1.5], P = .037; parent VAS score, 4.2 [2.3] vs 5.6 [2.6], P = .003). When given first, the DPTaP-Hib vaccine caused significantly less pain (P < .001) than the PCV, as assessed by the MBPS, VAS, and crying.

Conclusions  Pain was reduced when the DPTaP-Hib vaccine was administered before the PCV in infants undergoing routine vaccination. We recommend that the order of vaccine injections be the DPTaP-Hib vaccine followed by the PCV.

Trial Registration  clinicaltrials.gov Identifier: NCT00390130

Design  Prospective cross-sectional study, 2001-2006.

Setting  International Adoption Clinic, Rainbow Babies and Children's Hospital, Cleveland, Ohio.

Participants  A total of 465 international adoptees presenting within 180 days of arrival.

Main Exposure  Immunization records of vaccines given.

Outcome Measures  Protective immunity to polio, hepatitis B, tetanus, diphtheria, and measles.

Results  Vaccination records were available for 397 (85.4%) adoptees (mean age, 19.4 months; 65.2% girls). Most children came from Russia (41.7%), China (20.9%), and Guatemala (15.7%). Acute or chronic malnutrition was present in 5.5% and 15.4% of adoptees, respectively. Preadoptive settings were institutional (52%), community-based (14%), or both (34%). Of adoptees with 3 or more tetanus (n = 203) or 3 or more diphtheria (n = 205) vaccinations, 87.2% and 94.6% had protective immunity, respectively. Of adoptees with 3 or more polio vaccinations (n = 216), protective immunity was present in 58.3%, 82.4%, and 51.9% for polio types 1, 2, and 3, respectively. Of adoptees with 2 or more hepatitis B vaccinations (n = 170), 94.1% had protective immunity. A total of 80.8% of adoptees with measles vaccination (n = 99) had protective immunity. Children from China were less likely to have protective immunity than children from Russia (odds ratio, 0.34; 95% confidence interval, 0.17-0.66). Nutritional status had no predictive effect.

Conclusions  The predictive value of immunization records in international adoptees is limited and varies between birth countries. Immunization records should not be accepted as evidence of protective immunity. Parents should be well informed and supported to choose between revaccination or vaccination, based on serologic testing.

Design  Prospective longitudinal cohort study.

Setting  Home and laboratory-based settings in 10 sites across the United States.

Participants  Data were drawn from 1061 children as part of the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development.

Main Exposure  Self-regulatory capacity was measured in 2 behavioral protocols; children participated in a self-control procedure at age 3 years and a delay of gratification procedure at age 5 years.

Main Outcome Measures  Age- and sex-specific body mass index (BMI) z scores were calculated based on measured BMI at 6 points.

Results  Mixed-modeling analyses were used to examine differences in the rate of weight gain over time based on the extent to which children exhibited the ability to self-regulate in the behavioral procedures. Compared with children who showed high self-regulation in both behavioral protocols at ages 3 and 5 years, children who exhibited a compromised ability to self-regulate had the highest BMI z scores at each point and the most rapid gains in BMI z scores over the 9-year period. Effects of pubertal status were also noted for girls.

Conclusion  Self-regulation failure in early childhood may predispose children to excessive weight gain through early adolescence.

Design  Longitudinal prospective study.

Setting  Ten US sites.

Participants  Participants in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development.

Main Exposure  Ability to delay gratification at 4 years, measured as pass or fail on a validated task.

Outcome Measures  Overweight at 11 years, defined as a body mass index greater than or equal to the 85th percentile based on measured weight and height.

Results  Of 805 children, 47% failed the ATDG task. Using multiple logistic regression, children who failed the ATDG task were more likely to be overweight at 11 years (relative risk, 1.29; 95% confidence interval, 1.06-1.58), independent of income to needs ratio. Body mass index z score at 4 years and maternal expectation of child ATDG for food did not alter the association, but maternal weight status reduced the association significantly.

Conclusions  Children with limited ATDG at age 4 years were more likely to be overweight at age 11 years, but the association was at least partially explained by maternal weight status. Further understanding of the association between the child's ATDG and maternal and child weight status may lead to more effective obesity intervention and prevention programs.

Design  Randomized controlled trial.

Setting  Ten intervention and 8 control prevocational secondary schools.

Participants  A total of 1108 adolescents (mean age, 12.7 years).

Intervention  An interdisciplinary program with an adapted curriculum for 11 lessons in biology and physical education and environmental change options.

Main Outcome Measures  Body height and weight, waist circumference, 4 skinfold thickness measurements, and dietary and physical activity behavior data.

Results  Multilevel analyses showed that the intervention remained effective in preventing unfavorable increases in important measures of body composition after 20-month follow-up in girls (biceps skinfold and sum of 4 skinfolds) and boys (triceps, biceps, and subscapular skinfolds). Consumption of sugar-containing beverages was significantly lower in intervention schools both after intervention (boys: –287 mL/d; 95% confidence interval [CI], –527 to –47; girls: –249; –400 to –98) and at 12-month follow-up (boys: –233; –371 to –95; girls: –271; –390 to –153). For boys, screen-viewing behavior was significantly lower in the intervention group after 20 months (–25 min/d; 95% CI, –50 to –0.3). No significant intervention effects on consumption of snacks or active commuting to school were found.

Conclusion  The Dutch Obesity Intervention in Teenagers program resulted in beneficial effects on the sum of skinfold thickness measurements in girls and consumption of sugar-containing beverages in both boys and girls in both the short and long terms.

Design  Secondary analysis of a randomized control trial.

Setting  Intervention classes at a lifestyle laboratory and metabolic measures at the General Clinical Research Center.

Participants  Fifty-four overweight Latino adolescents (mean [SD] age, 15.5 [1] years).

Intervention  Sixteen-week study with 3 groups: control, nutrition, or nutrition plus strength training.

Main Outcome Measures  Body composition by dual-energy x-ray absorptiometry; visceral adipose tissue by magnetic resonance imaging; glucose and insulin incremental area under the curve by oral glucose tolerance test; insulin sensitivity, acute insulin response, and disposition index by intravenous glucose tolerance test; and dietary intake by 3-day records.

Results  Fifty-five percent of all participants decreased added sugar intake (mean decrease, 47 g/d) and 59% increased fiber intake (mean increase, 5 g/d), and percentages were similar in all intervention groups, including controls. Those who decreased added sugar intake had an improvement in glucose incremental area under the curve (–15% vs +3%; P = .049) and insulin incremental area under the curve (–33% vs –9%; P = .02). Those who increased fiber intake had an improvement in body mass index (–2% vs +2%; P = .01) and visceral adipose tissue (–10% vs no change; P = .03).

Conclusions  Individuals who reduced added sugar intake by the equivalent of 1 can of soda per day or increased fiber intake by the equivalent of a cup of beans showed improvements in key risk factors for type 2 diabetes, specifically in insulin secretion and visceral fat. Improvements occurred independent of group assignment and were equally likely to occur in control group participants.

Trial Registration  clinicaltrials.gov Identifier: NCT00697580

Design  A cross-sectional analysis of the National Health and Nutrition Examination Survey data collected by the National Center for Health Statistics.

Setting  Nationally representative samples of US adolescents participating in the National Health and Nutrition Examination Survey during the years 1999-2004.

Participants  A total of 6967 adolescents aged 12 to 19 years.

Main Exposure  Sugar-sweetened beverage consumption and physical activity levels.

Outcome Measures  Glucose and insulin concentrations, a homeostasis model assessment of insulin resistance (HOMA-IR), total, high-density lipoprotein, and low-density lipoprotein cholesterol concentrations, triglyceride concentrations, systolic and diastolic blood pressure, waist circumference, and body mass index (calculated as weight in kilograms divided by height in meters squared) percentile for age and sex.

Results  Multivariate linear regression analyses showed that increased sugar-sweetened beverage intake was independently associated with increased HOMA-IR, systolic blood pressure, waist circumference, and body mass index percentile for age and sex and decreased HDL cholesterol concentrations; alternatively, increased physical activity levels were independently associated with decreased HOMA-IR, low-density lipoprotein cholesterol concentrations, and triglyceride concentrations and increased high-density lipoprotein cholesterol concentrations. Furthermore, low sugar-sweetened beverage intake and high physical activity levels appear to modify each others' effects of decreasing HOMA-IR and triglyceride concentrations and increasing high-density lipoprotein cholesterol concentrations.

Conclusions  Sugar-sweetened beverage intake and physical activity levels are each independently associated with insulin resistance–associated metabolic parameters and anthropometric measurements in adolescents. Moreover, low sugar-sweetened beverage intake and high physical activity levels appear to modify each others' effects on several health-related outcome variables.

Design  Secondary analysis based on nationally representative cross-sectional study.

Setting  Fixed-effect regression analysis of 2 nonconsecutive 24-hour dietary recalls from the 2003-2004 National Health and Nutrition Examination Survey data.

Participants  Children and adolescents 2 to 19 years of age (N = 3098).

Main Exposures  Within-person beverage consumption between 2 surveyed days.

Main Outcome Measures  The association between changes in the consumption of SSBs and other beverages and changes in total energy intake (TEI) of the same individual.

Results  Each additional serving (8 oz) of SSB corresponded to a net increase of 106 kcal/d (P < .001; 95% confidence interval [CI], 91 to 121 kcal/d), holding other beverages constant. Increases were also seen (all P < .001) for each additional serving of whole milk (169 kcal/d; 95% CI, 143 to 195 kcal/d), reduced-fat milk (145 kcal/d; 95% CI, 118 to 171 kcal/d), and 100% juice (123 kcal/d; 95% CI, 90 to 157 kcal/d). No net increases in TEI were seen for water (8 kcal/d; P = .27; 95% CI, –6 to 22 kcal/d) or diet drinks (47 kcal/d; P = .20; 95% CI, –23 to 117 kcal/d). Substituting SSBs with water was associated with a significant decrease in TEI, controlling for intake of other beverages, total beverage and nonbeverages, and fast-food and weekend effects. Each 1% of beverage replacement was associated with 6.6-kcal lower TEI, a reduction not negated by compensatory increases in other food or beverages. We estimate that replacing all SSBs with water could result in an average reduction of 235 kcal/d.

Conclusion  Replacing SSB intake with water is associated with reductions in total calories for all groups studied.

Design  Cross-sectional secondary data analysis.

Setting  Nationally representative sample of US children born in 2001.

Participants  Height and weight were measured in 2005 in approximately 8550 children who participated in the Early Childhood Longitudinal Study, Birth Cohort.

Main Exposure  Racial/ethnic group.

Outcome Measure  Prevalence of obesity, defined as body mass index at or above the 95th percentile for age of the sex-specific Centers for Disease Control and Prevention growth charts.

Results  Obesity prevalence among 4-year-old US children (mean age, 52.3 months) was 18.4% (95% confidence interval [CI], 17.1%-19.8%). Obesity prevalence differed by racial/ethnic group (P < .001): American Indian/Native Alaskan, 31.2% (95% CI, 24.6%-37.8%); Hispanic, 22.0% (95% CI, 19.5%-24.5%); non-Hispanic black, 20.8% (95% CI, 17.8%-23.7%); non-Hispanic white, 15.9% (95% CI, 14.3%-17.5%); and Asian, 12.8% (95% CI, 10.0%-15.6%). All pairwise differences in obesity prevalence between racial/ethnic groups were statistically significant after a Bonferroni adjustment (P < .005) except for those between Hispanic and non-Hispanic black children and between non-Hispanic white and Asian children.

Conclusions  Racial/ethnic disparities in obesity are apparent in 4-year-old US children. The highest prevalence is in American Indian/Native Alaskan children, in whom obesity is twice as common as in non-Hispanic white or Asian children.

Design  Prospective cohort study.

Setting  The multicenter National Heart, Lung and Blood Growth and Health Study with annual examinations from 1987-1988 through 1996-1997.

Participants  One thousand eight hundred ninety girls (983 black and 907 white) aged 9 to 10 years at enrollment.

Main Exposure  Self-reported number of pregnancies and births during adolescence and young adulthood (age, 15-19 years): 311 primiparas (17%), 84 multiparas (4%), 196 nulliparous gravidas (10%), and 1299 nulligravidas (69%).

Outcome Measures  Estimated race-specific changes in body weight, height, body mass index, waist circumference, hip circumference, waist to hip ratio, and percent body fat, defined as the difference between baseline and measurements 9 to 10 years later.

Results  Thirty-one percent of black and 10% of white girls gave birth during adolescence and young adulthood. We found evidence of race by pregnancy interactions (P < .10) for changes in weight, body mass index, hip circumference, and percent body fat. Black primiparas and multiparas, respectively, had smaller decrements in waist to hip ratio (0.019 and 0.023) and greater increments in weight (3.6 and 6.0 kg), body mass index (1.3 and 2.3), waist circumference (3.5 and 5.2 cm), hip circumference (2.1 and 4.0 cm), and percent body fat (3.4% and 4.6%) than black nulligravidas after adjustment for baseline measurements, age, study center, family income, parental education, age at menarche, hours of television and video viewing, and height at visit 9 or 10 in weight models (P < .01). White primiparas had borderline greater increments in waist circumference (2.4 cm) and percent body fat (0.9%) and smaller decrements in waist to hip ratio (0.017) than white nulligravidas (P < .05). Height did not differ by pregnancy status.

Conclusions  Women who give birth during adolescence and young adulthood have substantially greater increments in overall and central adiposity than adolescents who do not experience pregnancy independent of other known correlates of weight gain.

Design  Serial, cross-sectional study.

Setting  Age-eligible children and adolescents with prescription drug benefits managed by CVS Caremark, a pharmacy benefits manager.

Participants  Commercially insured US children and adolescents aged 6 to 18 years. Population size varied by month from approximately 5.3 million to 6 million individuals.

Main Outcome Measure  Monthly prevalence of prescription drug use, measured from September 1, 2004, through June 30, 2007.

Results  The 1-month prevalence of antihypertensive, dyslipidemic, or oral antidiabetic medication or insulin use increased 15.2% from 3.3 per 1000 youths in November 2004 to 3.8 per 1000 youths in June 2007. The 16- to 18-year-olds had the highest prevalence overall, but the greatest rate of increase was found among 6- to 11-year-olds: 18.7% for girls and 17.3% for boys. Among antihypertensive medications, β-blockers had the highest prevalence (1.5 per 1000 youths), followed by angiotensin-converting enzyme inhibitors, diuretics, calcium channel blockers, and angiotensin II receptor blockers. For 6- to 11-year-olds, angiotensin-converting enzyme inhibitor use increased 27.7% among girls and 25.2% among boys. Dyslipidemia therapy, which was dominated by statin use, declined 22.9%.

Conclusions  The increasing use of oral antidiabetic and antihypertensive pharmacotherapy among children and adolescents, especially in the younger age group, indicates either an increased awareness of treatment needs or increased incidence of cardiovascular risk factors typically associated with adult populations. The decrease in treatment of dyslipidemia may reflect the ongoing controversy regarding statin use.

Design  Cross-sectional, US representational National Health and Nutrition Examination Survey from 1999-2006.

Setting  Mobile examination centers conducted by the Centers for Disease Control and Prevention.

Participants  For 1999-2000, 613 adolescents (aged 12-19 years); for 2001-2002, 892 adolescents; for 2003-2004, 857 adolescents; and for 2005-2006, 814 adolescents. Exclusions were pregnancy, taking insulin or diabetic pills, and incomplete measurements.

Main Outcome Measures  Fasting plasma glucose level, triglyceride level, high-density lipoprotein cholesterol level, waist circumference, and systolic and diastolic blood pressures.

Results  Increases in fasting plasma glucose and high-density lipoprotein cholesterol levels and decreases in diastolic blood pressure were observed. Rates of adolescents exceeding cutoff points for fasting plasma glucose levels have increased. Compared with girls, adolescent boys had higher rates exceeding cutoff points for fasting plasma glucose and high-density lipoprotein cholesterol levels. Adolescent girls had higher rates exceeding cutoff points for waist circumference. The prevalence of MetS among adolescents has not changed. No sex differences in MetS prevalence were observed.

Conclusions  Some criteria for MetS have remained stable (triglyceride level and systolic blood pressure) and one has improved for boys (high-density lipoprotein cholesterol level), but waist circumference has increased in girls and the rate of an elevated fasting plasma glucose level has nearly doubled for both boys and girls. Adolescent MetS prevalence has remained stable from 1999-2006.

Design  A complex, multistage, stratified geographic area design for collecting representative data from the noninstitutionalized US population.

Setting  The NHANES, an ongoing surveillance of the nation's health conducted by the Centers for Disease Control and Prevention.

Participants  Two thousand four hundred fifty-six Hispanic, white, and black adolescents aged 12 to 19 years observed in the 2001-2002, 2003-2004, and 2005-2006 NHANES data releases.

Main Outcome Measures  Metabolic syndrome was defined as having 3 or more disorders in the following measurements: waist circumference, blood pressure, fasting triglycerides, high-density lipoprotein serum cholesterol, and glucose.

Results  About half of the participants had at least 1 disordered measurement, with an overall metabolic syndrome prevalence of 8.6% (95% confidence interval, 6.5%-10.6%). Prevalence was higher in males (10.8%) than females (6.1%), and in Hispanic (11.2%) and white (8.9%) individuals than in black individuals (4.0%). In black females, there was a high prevalence of a large waist circumference (23.3%), but no component of metabolic syndrome dominated its diagnosis in black adolescents of either sex. A large waist circumference and high fasting triglyceride and low high-density lipoprotein serum cholesterol concentrations were salient factors in Hispanic and white adolescents of both sexes; high glucose concentrations were prominent among Hispanic and white males.

Conclusion  The low prevalence of metabolic syndrome in black adolescents, in parallel with uniformly low prevalence of all 5 risk factors among those with metabolic syndrome, portend ethnic disparities in the time table for early onset of cardiometabolic disorders.

Data Sources  MEDLINE, CINAHL, the Cochrane Library, EMBASE, POPLINE, and bibliographies of identified articles.

Study Selection  A search for English-language records (from January 1950 through August 2006) containing the Medical Subject Heading terms pacifiers and breastfeeding was conducted, resulting in 1098 reports. Duplicate and irrelevant studies were excluded, yielding 29 studies that fit inclusion criteria for the review (4 randomized controlled trials, 20 cohort studies, and 5 cross-sectional studies). Two independent reviewers abstracted data and scored these studies for quality; disagreements were settled through consensus with a third investigator.

Main Exposure  Pacifier use.

Main Outcome Measures  Breastfeeding duration or exclusivity.

Results  Results from 4 randomized controlled trials revealed no difference in breastfeeding outcomes with different pacifier interventions (pacifier use during tube feeds, pacifier use at any time after delivery, an educational program for mothers emphasizing avoidance of pacifiers, and a UNICEF [United Nations Children’s Fund]/World Health Organization Baby Friendly Hospital environment). Most observational studies reported an association between pacifier use and shortened duration of breastfeeding.

Conclusions  The highest level of evidence does not support an adverse relationship between pacifier use and breastfeeding duration or exclusivity. The association between shortened duration of breastfeeding and pacifier use in observational studies likely reflects a number of other complex factors, such as breastfeeding difficulties or intent to wean. Ongoing quantitative and qualitative research is needed to better understand the relationship between pacifier use and breastfeeding.

Design  Case-control study.

Setting  Cases were identified from medical examiners’/coroners' offices between mid-2003 and mid-2005. Jurisdictions included the states of Maryland and North Carolina, 14 districts (33 counties) in Florida, 3 counties in California, 1 county in Texas, and 1 county in New York.

Participants  Cases were children and adolescents aged 1 to 19 years who died of unintentional drowning. Interviews were conducted with 88 families of children who drowned and 213 matched controls.

Main Exposure  Swimming lessons.

Main Outcome Measure  Death due to unintentional drowning. Drownings that were intentional, of undetermined intent, or that occurred under conditions in which swimming ability was unlikely to impact risk (eg, in ice water or bathtubs) were excluded.

Results  Of the 61 cases in the 1- to 4-year age group, 2 (3%) had participated in formal swimming lessons vs 35 of 134 matched controls (26%) (adjusted odds ratio [OR], 0.12; 95% confidence interval [CI], 0.01-0.97). Among the 27 cases aged 5 to 19 years, 7 (27%) had ever taken formal swimming lessons vs 42 of 79 matched controls (53%) (adjusted OR, 0.36; 95% CI, 0.09-1.51). In adjusted analyses, there was no statistically significant association between informal instruction and drowning risk.

Conclusions  Participation in formal swimming lessons was associated with an 88% reduction in the risk of drowning in the 1- to 4-year-old children, although our estimates were imprecise and 95% CIs included risk reductions ranging from 3% to 99%.

Design  Three-wave longitudinal study.

Setting  Confidential telephone survey.

Participants  Representative US sample of 6522 adolescents aged 10 to 14 years at baseline survey (4309 of whom were never-drinkers at 8 months); subjects were resurveyed at 16 and/or 24 months.

Main Exposures  Ownership of ABM (first assessed at the 8-month survey) and attitudinal susceptibility to alcohol use.

Outcome Measures  Initiation of alcohol use that parents did not know about and binge drinking (≥5 drinks in a row).

Results  Prevalence of ABM ownership ranged from 11% of adolescents (at 8 months) to 20% (at 24 months), which extrapolates to 2.1 to 3.1 million US adolescents, respectively. Clothing and headwear comprised 88% of ABM. Beer brands accounted for 75% of items; 45% of items bore the Budweiser label. Merchandise was obtained primarily from friends and/or family (71%) but was also purchased by the adolescents themselves (24%) at stores. Among never-drinkers, ABM ownership and susceptibility were reciprocally related, each significantly predicting the other during an 8-month period. In turn, we found that ABM ownership and susceptibility predicted both initiation of alcohol use and binge drinking, while controlling for a broad range of covariates.

Conclusions  Alcohol-branded merchandise is widely distributed among US adolescents, who obtain the items one-quarter of the time through direct purchase at retail outlets. Among never-drinkers, ABM ownership is independently associated with susceptibility to as well as with initiation of drinking and binge drinking.

Design  Data were collected as part of a longitudinal study of adolescent health behavior involving 2564 parent/child dyads from northern New England. Parents (n = 2401) were surveyed at wave 2 about movie ratings. Qualitative interviews were conducted with a subset of parents (n = 62) 15 months later.

Setting  Participants were surveyed by telephone.

Participants  Most parents (94.9%; n = 2279) were mothers, 52.5% were younger than 40 years, and 90.6% were white, and children were aged 9 to 15 years.

Main Outcome Measures  Whether cigarette and alcohol use should be included as movie ratings criteria and if movies with cigarette or alcohol use should be rated R.

Results  About 52% (n = 1242) and 66% (n = 1579) of parents believed cigarette or alcohol use, respectively, should be used as movie ratings criteria; 28.9% (n = 693) supported an R rating for movies with smoking and 41.9% (n = 1003) supported R ratings for alcohol. In adjusted models, parents were more likely to support adding cigarette and alcohol use as ratings criteria if they believed the current ratings were not useful, they restricted their children from watching R-rated movies, and they were nondrinkers. Nonsmoking parents were more likely to support an R rating for smoking. Interviews revealed that parents may underestimate the impact of movie smoking and drinking.

Conclusions  Although a majority of parents supported including smoking or drinking in ratings criteria, fewer favored R ratings. Parental support could be a key factor in determining the impact of modifications to the Motion Picture Association of America rating system.

Design  A randomized controlled evaluation of usual care vs 2-year asthma coach intervention.

Setting  An urban children's hospital and the surrounding community.

Participants  A population-based sample of 306 children hospitalized for asthma met the inclusion criteria of being 2 to 8 years of age, of African American ethnicity, and having Medicaid coverage. Of these, 200 were contacted and 191 recruited with commitment to evaluation activities but, in order to assess reach, no commitment to participating in intervention.

Interventions  Coaches reinforced basic asthma education and encouraged key management behaviors through home visits and phone calls tailored to parent's readiness to adopt management practices and emphasizing a nondirective supportive style (cooperative and accepting of feelings and choices).

Outcome Measures  The reach of intervention to parents, contacts with coaches, and rehospitalization over 2 years based on hospital records.

Results  Within 3 months of randomization to the asthma coach group, 89.6% of parents had at least 1 substantive contact with the coach, with an average of 21.1 contacts per parent over the 24-month intervention. The proportion of children rehospitalized was 35 of 96 (36.5%) in the asthma coach group and 55 of 93 (59.1%) in the usual care group (P < .01), controlling for parental education and child age, sex, and hospitalization in the year prior to the index hospitalization. In surveys, parents indicated the importance of the nondirective approach to support.

Conclusions  An asthma coach can reach low-income parents of African American children hospitalized for asthma and reduce rehospitalization among the children.

Design  Prospective cohort study.

Setting  Taitung County, Taiwan.

Participants  All first- and fourth-grade elementary school students and first-year junior high school students screened between September 1, 2005, and June 30, 2007.

Intervention  A 2-level heart disease screening program was undertaken. Level 1 screening included a history questionnaire and phonocardiography and electrocardiography. Level 2 screening consisted of examination by a pediatric cardiologist of all children who had abnormal findings on level 1 screening. A control group comprised children whose level 1 screening results were normal. Children with abnormalities on level 2 screening were referred for a detailed cardiac evaluation.

Main Outcome Measures  Previously unsuspected heart diseases.

Results  Of 25 816 children undergoing the level 1 screening program, 5330 had positive findings, of whom 5235 underwent level 2 screening, along with 1104 children in the control group. The pediatric cardiologist referred 780 children to the hospital for full evaluation, including 18 controls and 114 patients with a previous diagnosis of heart disease. A total of 292 children, including 2 controls, had evidence of heart disease, which was previously unsuspected in 178 (61.0%). Excluding children with a previous diagnosis of heart disease, the sensitivity of the screening program was 82.6%. The specificity and the positive predictive value were 98.3% and 28.6%, respectively.

Conclusion  The 2-level heart disease screening program has good sensitivity and detects asymptomatic but potentially life-threatening heart disease in some children.

Design  Prospective longitudinal study.

Setting  The 1999 kindergarten cohort of the Montreal Longitudinal Preschool Study in Canada.

Participants  Written parental consent was obtained for 181 of the 377 children from intact families at kindergarten exclusively selected for follow-up telephone interviews in the fall of sixth grade, 6 years after the initial assessments. Of these, 163 children had complete data in kindergarten (mean age, 5.5 years) and sixth grade (mean age, 11.5 years) for the key variables in the analyses.

Main Outcome Measure  Self-reported gambling behavior in sixth grade.

Results  A 1-unit increase in kindergarten impulsivity corresponded to a 25% increase in later self-reported child involvement in gambling (SE = .02). This was above and beyond potential child- and family-related confounds, including parental gambling.

Conclusions  Our findings offer insight about how the nature and course of early impulsivity might relate to a significantly higher propensity toward involvement in games of chance in later childhood. It is suggested that developmentally continuous risks associated with early impulsivity place individuals on a risk trajectory toward excessive gambling involvement in adolescence and emerging adulthood.

Design  Prospective birth cohort.

Setting  In-person interview at enrollment as well as in-home interviews during study follow-up.

Participants  Children (N = 3116) enrolled in the Fragile Families and Child Wellbeing Study.

Main Exposures  Maternal report of IPV assessed after the child's birth and at 12 and 36 months. In addition, mothers indicated how many days a week they participated in activities with the child and the amount and type of educational/recreational toys available for the child.

Main Outcome Measure  Maternal report of physician-diagnosed asthma by age 36 months.

Results  Asthma was diagnosed in 19% of children. In adjusted analysis, children of mothers experiencing IPV chronically, compared with those not exposed, had a 2-fold increased risk of developing asthma. In stratified analysis, children of mothers experiencing IPV and low levels of mother-child activities (relative risk, 2.7; 95% confidence interval, 1.6-4.7) had a significant increased risk for asthma. Those exposed to IPV and high levels of mother-child activities had a lower risk for asthma (relative risk, 1.6; 95% confidence interval, 0.9-3.2). A similar buffering effect was noted among children with high numbers of educational/recreational toys.

Conclusions  Intimate partner violence is associated with increased early childhood asthma risk. Maternal ability to maintain positive caregiving processes in this context may buffer the effects of violence on child asthma risk. The best way to promote positive health in toddlers may be to help their mothers.

Design  Patients in the case group and participants in the control group were randomized in a 1:3 ratio.

Setting  The Hospital for Sick Children, Toronto, Ontario, Canada.

Participants  Patients with sickle cell disease and osteomyelitis (case patients) and patients with sickle cell disease and bony, vaso-occlusive crisis (control patients), 18 years or younger.

Main Outcome Measures  Five characteristics (number of painful sites, white blood cell count, swelling of the affected limb[s], and duration of pain and fever before presentation) at the time of presentation to hospital.

Results  Data were analyzed for 31 cases and 93 controls. Compared with controls, cases had more days of pain (5 vs 2 days; odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.4 days) and fever (1 vs 0 day; 1.7; 1.2-2.4 days) before presentation. Cases were also more likely to have swelling of the affected limb(s) (71% vs 17%; OR, 11.8; 95% CI, 4.6%-30.0%) and fewer painful sites (1 vs 2; 0.7; 0.5-1.0). On laboratory evaluation, cases had higher white blood cell counts (18.6 vs 15.6/µL; OR, 1.1; 95% CI, 1.0-1.1/µL). Multivariate logistic regression showed that the significant predictors of osteomyelitis were duration of fever (OR, 1.8; 95% CI, 1.2-2.6) and pain (1.2; 1.0-1.4) before presentation and swelling of the affected limb (8.4; 3.5-20.0). The risk of osteomyelitis was decreased if more than 1 painful site was present (OR, 0.7; 95% CI, 0.5-1.0).

Conclusion  In the clinical scenario of a child with sickle cell disease presenting with bony pain and swelling affecting a single site, with prolonged fever and pain, the physician should consider closer monitoring and investigations to exclude a diagnosis of osteomyelitis.

Design  Randomized controlled trial.

Setting  The University of Kentucky College of Medicine, Lexington.

Participants  A total of 186 third-year medical students.

Intervention  Medical students assigned to the intervention group (n = 95) participated in a 4-hour adolescent medicine workshop using standardized patients to practice interviewing and counseling skills. Medical students assigned to the control group (n = 91) participated in an alternative workshop.

Outcome Measures  Medical student adolescent interviewing and counseling skills were assessed using adolescent standardized patient encounters during the end-of-clerkship examination and during the end of the third-year Clinical Performance Examination. Medical student knowledge was assessed at the end of the clerkship using an open-ended postencounter written exercise and the questions specific to adolescent medicine on the clerkship written examination.

Results  Both groups had comparable baseline characteristics. Medical students in the intervention group scored significantly higher on both measures of clinical skills, the standardized patient stations during the end-of-clerkship examination and the Clinical Performance Examination. Intervention medical students also scored significantly higher on both measures of knowledge, the open-ended postencounter written exercise and the written examination.

Conclusions  A brief adolescent medicine workshop using standardized patients improved medical students' knowledge and skills at the end of a 4-week clerkship, and the improvement in clinical skills persisted at the end of the third year of medical school.

Design  Cluster randomized controlled trial.

Setting  Thirty-nine urban child care centers.

Participants  Eight hundred fifty-four parents and 1010 children aged 4 to 8 years in vehicles leaving centers.

Intervention  We trained 168 staff members at 20 centers to give parents and children messages promoting booster seats and supplied lesson plans, children's activities, and free booster seats.

Main Outcome Measures  Observed booster seat use, "good practice" restraint use, and legal restraint use.

Results  Parents at intervention centers were more likely to report receiving restraint information from the center (adjusted odds ratio [AOR], 4.06; 95% confidence interval [CI], 2.48-6.67), speaking with staff about booster seats (AOR, 3.95; 95% CI, 2.26-6.88), and using fit to decide when to move children into seat belts (AOR, 3.39; 95% CI, 1.91-5.99). Groups did not differ in proportions using booster seats (44% vs 43%; AOR, 1.03; 95% CI, 0.62-1.73), good practice (42% vs 41%; AOR, 1.11; 95% CI, 0.70-1.74), or legal restraints (65% vs 65%; AOR, 0.79; 95% CI, 0.48-1.31). Results were similar for children aged 4 to 5 and 6 to 8 years. All outcomes were significantly less likely among children riding in pickup trucks or with Hispanic or black drivers.

Conclusions  The intervention increased parents' receipt of information from center staff and knowledge about booster seats but not booster seat use. Research is needed to identify methods and messages that will empower center providers to promote booster seats effectively and reach high-risk populations.