Ambulatory Pediatrics

Vision for Our Journal

Peter G. Szilagyi — 2008-11-01

Under the leadership of James M. Perrin, our journal has grown into one of the top journals in pediatrics, with a focus on improving the health care delivery, health outcomes of children and youth, and education in pediatrics. Readership has grown tremendously, and individual and institutional subscriptions are rising. Most important, the published articles are innovative and significant because investigators are sending excellent work to the journal. The metrics of success, such as readership, number of submissions, impact factor, PubMed citations, and the number of electronic citations are all improving steadily. The success of the first decade of our journal is a tribute to Jim Perrin's leadership.

The Making and the Being of an Academic (Ambulatory) Pediatrician

John M. Leventhal — 2008-10-06

It is a privilege to follow in the footsteps of two Armstrong awardees and Yale colleagues—Paul McCarthy, who is in the audience today, and Dr George Silver, who in 1967 received the very first Armstrong award. George was a health policy expert at the Yale School of Public Health and a tireless advocate for children's health. I also want to mention my special link with C. Henry Kempe, the 1976 awardee, whose talk was about the prevention of child abuse; many years before others, Kempe was wise enough to focus on the prevention of this terrible problem. Kempe labeled and described the “battered child syndrome” in a landmark publication in JAMA in 1962. In so doing, he got American physicians to recognize a disease that had gone mostly undiagnosed and ignored. This work made us all much smarter. He also established and was the first editor of an academic journal focused on child abuse. I had the honor of being the fourth editor of that journal, and if I can accomplish one tenth of what Kempe did in the field of child abuse, I will feel privileged.

A Tribute to Julius B. Richmond, MD

Jonathan P. Winickoff, James M. Perrin — 2008-11-01

Pediatrician and former US surgeon general Julius B. Richmond died on July 27, 2008, of cancer. Dr Richmond was born in 1916 in Chicago and worked on a sheep farm during the Depression. After considering animal husbandry as a career, he ultimately chose people, and he received degrees in physiology and medicine from the University of Chicago in 1939. He spent 2 years at Cook County Hospital and then served in the United States Air Force as a flight surgeon during World War II. His early research, inspired by the US Supreme Court 1954 ruling in Brown v Board of Education, documented the effects of poverty on the psychosocial development of young children, much of it with his long-term collaborator, Bettye Caldwell. He led the 1965 launch and was the first director of Head Start, a program that has helped millions of poor and underserved children since its inception during the Johnson administration.

Arrival

George Estreich — 2008-11-01

We were sitting in the waiting room, among the toys and magazines. I felt—not serene, but expectant. Uncertain. Nancy, the nurse, came to take us back to the exam room. “It'll just be a minute,” she said as she left us. Theresa lifted Laura from her car seat and set her, still sleeping, on the clean paper of the exam table. I got out colored pencils and a notebook for Ellie. We were paging through People and Us when Dr E came in, knocking softly. He closed the door, crossed the room, and turned toward us.

Use of a Web-Based Game to Teach Pediatric Content to Medical Students

Katherine A. Sward, Stephanie Richardson, Jeremy Kendrick, Chris Maloney — 2008-10-06

Objective: The aim of this study was to assess, using a Web-based format, third-year medical students’ pediatric knowledge and perceptions of game playing with faculty facilitation compared with self-study computerized flash cards.Methods: This study used a repeated-measures experimental design with random assignment to a game group or self-study group. Pediatric knowledge was tested using multiple choice exams at baseline, week 6 of the clerkship following a 4-week intervention, and 6 weeks later. Perceptions about game playing and self-study were evaluated using a questionnaire at week 6.Results: The groups did not differ on content mastery, perceptions about content, or time involved in game playing or self-study. Perceptions about game playing versus self-study as a pedagogical method appeared to favor game playing in understanding content (P < .001), perceived help with learning (P < .05), and enjoyment of learning (P < .008). An important difference was increased game group willingness to continue participating in the intervention.Conclusions: Games can be an enjoyable and motivating method for learning pediatric content, enhanced by group interactions, competition, and fun. Computerized, Web-based tools can facilitate access to educational resources and are feasible to apply as an adjunct to teaching clinical medicine.

Why Do Parents Bring Children to the Emergency Department for Nonurgent Conditions? A Qualitative Study

2008-10-06

Objective: Nonurgent conditions account for 58% to 82% of pediatric emergency department (ED) visits, but only 1 preliminary qualitative study has examined reasons why parents bring children to the ED for nonurgent care. The aim of this study was to identify parents’ reasons for choosing the ED over their primary care provider (PCP) for nonurgent pediatric care.Methods: Audiotaped ethnographic interviews in English and Spanish were conducted of parents of children presenting for nonurgent care on weekdays from 8 AM to 4 PM at a children's hospital ED over a 4-week period.Results: For the 31 families interviewed, the mean parental age was 28 years, and mean child age, 3 years. Reasons cited by caregivers for choosing the ED over their child's PCP were long appointment waits, dissatisfaction with the PCP, communication problems (accents and unhelpful staff at PCP), health care provider referral, efficiency, ED resources, convenience, quality of care, and ED expertise with children. Some parents said they would like education on the urgency of pediatric problems.Conclusions: Parents bring their children to the ED for nonurgent care because of problems with their PCP, PCP referral, and perceived advantages to ED care. Although parents report that education on the urgency of pediatric conditions would be helpful, substantial reduction of pediatric nonurgent ED use may require improvements in families’ PCP office access, efficiency, experiences, and appointment scheduling.

Discussion of Maternal Stress During Pediatric Primary Care Visits

Jonathan D. Brown, Lawrence S. Wissow — 2008-10-27

Objective: To determine whether the discussion of maternal stress in pediatric primary care is associated with the mother's satisfaction with her child's provider.Methods: Children ages 5–16 and their mothers (N = 747) were recruited from the waiting rooms of 13 geographically diverse pediatric primary care sites from 2002 to 2005. Directly after the visit, the mother reported her satisfaction with the attention that the provider gave to her and her child's problems and also reported whether the provider understood the problems that she wanted to discuss during the visit. The mother also reported whether the visit included discussion of her “stresses and strains” and the discussion of child mood or behavior.Results: Thirty-five percent of mothers discussed their stresses and strains with their child's provider. The mother was more likely to be “completely” satisfied with the attention that she and her child received from the provider (odds ratio [OR] 2.43, 95% confidence interval [95% CI], 1.43–4.11) and to agree “strongly” that the provider understood the problems she wanted to discuss (OR 1.95, 95% CI, 1.32–2.93) when the visit included the discussion of maternal stress after controlling for the reason for the visit, number of previous visits, provider specialty (family practice or pediatrics), youth mental health status, whether the visit included the discussion of child mood or behavior, and maternal distress measured with a standard screening tool.Conclusions: The mother was more satisfied with her child's primary care provider when maternal stress was discussed during the visit. This finding should somewhat alleviate fears that mothers will react negatively to discussion of their stress during pediatric visits.

Feasibility of Using a Tablet Computer Survey for Parental Assessment of Resident Communication Skills

2008-10-06

Background: The Accreditation Council for Graduate Medical Education recommends using patient surveys for assessing resident competency in interpersonal and communication skills. Despite the existence of several validated patient surveys for communication assessment, no system has been developed for their sustained use in resident assessment.Methods: We developed and pilot tested a system to collect surveys from parents of hospitalized children on the day of discharge. We used a 28-item, tablet computer–based survey that measures individual provider and team communication. The computer displays resident photographs to ensure accurate identification and offers the survey in multiple languages. We assessed parental acceptance of the system by analyzing response rate, as well as reasons for response and nonresponse.Results: Of the 98 eligible parents that were approached, 62 (63%) completed the survey. Only 2 (2%) of the eligible families refused to participate, and only 5 (5%) refused participation because of the survey not being available in a language they were familiar with.Conclusions: Use of a tablet computer parent survey for resident assessment is feasible, with response rates comparable to those of mailed surveys. The low rate of parental refusal indicates our system could be used to attain sufficient numbers of survey responses to help validly measure resident communication skills.

Comparison of Severe Injuries Between Powered and Nonpowered Scooters Among Children Aged 2 to 12 in the United States

Russell Griffin, Chris T. Parks, Loring W. Rue, Gerald McGwin — 2008-10-16

Objective: A substantial increase in the number of nonpowered and powered scooter injuries since 2000 has occurred in the United States. Because of differences in weight and operational speed between scooter types, it is possible that the type and severity of injuries may differ. The purpose of the current study is to compare demographics and injury characteristics between scooter types, focusing on differences in injury severity.Methods: The 2002–2006 National Electronic Injury Surveillance System provided information about individuals aged 2 to 12 years who sought treatment at an emergency department due to powered or nonpowered scooter–related injury in the United States. We defined severe injury as an injury resulting in the hospitalization, staying in the hospital for observation, or transfer of the injured patient. Logistic regression analysis, adjusted for sex, age, and geographic location in which the injury occurred, estimated odds ratios (ORs) and 95% confidence intervals (CI) for the association between scooter type and severe injury.Results: There were an estimated 15 752 and 185 007 injuries related to powered and nonpowered scooters, respectively. Powered scooter–related injuries were over 3 times as likely to be severe (OR 3.57, 95% CI, 1.91–6.65). This association was more prominent among females (OR 5.80, 95% CI, 2.02–16.63) than males (OR 2.90, 95% CI, 1.44–5.82).Conclusion: Data suggest that, compared with nonpowered scooter–related injuries, powered scooter–related injuries are more often severe. This association is stronger among females than males. The higher risk of severe injury due to powered scooter use could result from increases in concussions and hip and lower extremity injuries.

Assisting Primary Care Practices in Using Office Systems to Promote Early Childhood Development

2008-08-26

Objective: The aim of this study was to use family-centered measures to estimate the effect of a collaborative quality improvement program designed to help practices implement systems to promote early childhood development services.Methods: A cohort study was conducted in pediatric and family practices in Vermont and North Carolina. Eighteen collaborative education practices and 17 comparison practices participated in a 12-month program to assist practices in implementing improved systems to provide anticipatory guidance and parental education. The main outcome measures were change over time in parent-reported measures of whether children received each of 4 aspects of recommended care, documentation of developmental and psychosocial screening, and practice-reported care delivery systems.Results: The number of care delivery systems increased from a mean of 12.9 to 19.4 of 27 in collaborative practices and remained the same in comparison practices (P = .0002). The proportion of children with documented developmental and psychosocial screening among intervention practices increased from 78% to 88% (P < .001) and from 22% to 29% (P = .002), respectively. Compared with control practices, there was a trend toward improvement in the proportion of parents who reported receiving at least 3 of 4 areas of care.Conclusion: The learning collaborative was associated with an increase in the number of practice-based systems and tools designed to elicit and address parents’ concerns about their child's behavior and development and a modest improvement in parent-reported measures of the quality of care.

Development and Validation of a Self-Administered Questionnaire to Measure Water Exposures in Children

Marc H. Gorelick, Duke Wagner, Sandra L. McLellan — 2008-10-06

Objective: To develop and validate a questionnaire to measure water exposures in children.Methods: Caregivers of children younger than 18 years old evaluated in a pediatric emergency department completed a self-administered questionnaire with items about the child's exposure to water for drinking (15 items), hygiene (4 items), and recreation (5 items); other beverages (11 items); and other risk factors (11 items). Test-retest reliability was measured by administering the questionnaire to the same respondent within 48 hours. Concurrent validity was measured by having a second caregiver, when available, complete the same questionnaire independently. Agreement of paired responses was calculated by kappa (κ) for categorical variables or Spearman rho (ρ) correlation coefficient along with percentage mean difference for continuous variables.Results: Ninety-four initial surveys were completed (45 subjects with diarrhea). All 94 completed retesting, while 23 had a second independently completed survey. Test-retest reliability (κ or ρ > 0.6) was acceptable for 84% of items, and concurrent agreement was acceptable (κ or ρ > 0.5) for 91% of items.Conclusions: This questionnaire has excellent test-retest and concurrent validity in measuring water exposures and other risk factors for gastrointestinal illness in children.

Association of Bicycling and Childhood Overweight Status

Robert A. Dudas, Michael Crocetti — 2008-10-06

Objectives: Obesity is the most common chronic disease of childhood. Although it is accepted that diet and exercise practices are important, there is little data to discern the contributions of specific activities toward a healthy body weight. We sought to identify associations between bicycling and overweight status and to compare this with other physical activities and dietary practices thought to be protective against overweight status.Methods: We constructed a survey to gather dietary and activity practices in a cross-sectional, convenience sample of 100 children presenting to an urban hospital setting in Baltimore, Maryland. We chose to emphasize bicycling because it is a widely available activity that requires a sustained level of moderate energy expenditure, yet little is known about the relationship of this particular activity with childhood overweight status.Results: The mean age of our population was 11.8 years and 56% were overweight (body mass index >85 percentile). Most (96%) knew how to ride a bike and 80% reported owning a bike. Children who rode a bike just once a week or less were the most likely to be overweight (multivariate-adjusted odds ratio 6.6, 95% confidence interval, 2.1–21). This association was stronger than for all other dietary and activity practices. We found that approximately half of our participants do not eat breakfast, fruits, or vegetables regularly. More than half never ride a bike to school, walk to school, or participate in any organized sport.Conclusions: Riding a bicycle at least 2 or more days during the week is associated with a decreased likelihood of being overweight during childhood.

Author Index

2008-11-01

Subject Index

2008-11-01

Editorial Board

2008-11-01

Ambulatory Pediatrics

Vision for Our Journal

The Making and the Being of an Academic (Ambulatory) Pediatrician

A Tribute to Julius B. Richmond, MD

Arrival

Use of a Web-Based Game to Teach Pediatric Content to Medical Students

Why Do Parents Bring Children to the Emergency Department for Nonurgent Conditions? A Qualitative Study

Discussion of Maternal Stress During Pediatric Primary Care Visits

Feasibility of Using a Tablet Computer Survey for Parental Assessment of Resident Communication Skills

Comparison of Severe Injuries Between Powered and Nonpowered Scooters Among Children Aged 2 to 12 in the United States

Assisting Primary Care Practices in Using Office Systems to Promote Early Childhood Development

Development and Validation of a Self-Administered Questionnaire to Measure Water Exposures in Children

Association of Bicycling and Childhood Overweight Status

Author Index

Subject Index

Editorial Board

Table of Contents