BACKGROUND: Medical record abstraction (MRA) is a commonly used method for data collection in clinical research, but is prone to error, and the influence of quality control (QC) measures is seldom and inconsistently assessed during the course of a study. We employed a novel, standardized MRA-QC framework as part of an ongoing observational study in an effort to control MRA error rates. In order to assess the effectiveness of our framework, we compared our error rates against traditional MRA studies that had not reported using formalized MRA-QC methods. Thus, the objective of this study was to compare the MRA error rates derived from the literature with the error rates found in a study using MRA as the sole method of data collection that employed an MRA-QC framework. METHODS: A comparison of the error rates derived from MRA-centric studies identified as part of a systematic literature review was conducted against those derived from an MRA-centric study that employed an MRA-QC framework to evaluate the effectiveness of the MRA-QC framework. An inverse variance-weighted meta-analytical method with Freeman-Tukey transformation was used to compute pooled effect size for both the MRA studies identified in the literature and the study that implemented the MRA-QC framework. The level of heterogeneity was assessed using the Q-statistic and Higgins and Thompson's I(2) statistic. RESULTS: The overall error rate from the MRA literature was 6.57%. Error rates for the study using our MRA-QC framework were between 1.04% (optimistic, all-field rate) and 2.57% (conservative, populated-field rate), 4.00-5.53% points less than the observed rate from the literature (p < 0.0001). CONCLUSIONS: Review of the literature indicated that the accuracy associated with MRA varied widely across studies. However, our results demonstrate that, with appropriate training and continuous QC, MRA error rates can be significantly controlled during the course of a clinical research study.

IMPORTANCE: The function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown. OBJECTIVE: To evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool. DESIGN, SETTING, AND PARTICIPANTS: This post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks' gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024. EXPOSURE: Opioid treatment for NOWS and the ESC care approach. MAIN OUTCOMES AND MEASURES: For each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics. RESULTS: In the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P < .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P < .001). CONCLUSION AND RELEVANCE: When compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04057820.

BACKGROUND: Several studies have examined the association between IPI and birth outcomes, but few have explored the association between interpregnancy interval (IPI) and postnatal outcomes. OBJECTIVE: We examined the association between IPI and injury-related infant mortality, a leading cause of postneonatal mortality. METHODS: We used 2011-2015 US period-linked birth-infant death vital statistics data to generate a multiyear birth cohort of non-first-born singleton births (N = 9 782 029). IPI was defined as the number of months between a live birth and the start of the pregnancy leading to the next live birth. Causes of death in the first year of life were identified using ICD-10 codes. Hazard ratios (HR) for IPI categories were estimated using Cox proportional hazards models adjusted for birth order, county poverty level, and maternal characteristics (marital status, race/ethnicity, education, age at previous birth). RESULTS: After adjustment, overall infant mortality (48.1 per 10 000 births) was higher for short and long IPIs compared with IPI 18-23 months (reference): <6, aHR 1.61, 95% CI 1.54, 1.68; 6-11, aHR 1.22, 95% CI 1.17, 1.26; and 60+ months, aHR 1.12, 95% CI 1.08, 1.16. In comparison, the risk of injury-related infant mortality (4.4 per 10 000 births) decreased with longer IPIs: <6, aHR 1.77, 95% CI 1.55, 2.01; 6-11, aHR 1.41, 95% CI 1.25, 1.59; 12-17, aHR 1.25, 95% CI 1.10, 1.41; 24-59, aHR 0.78, 95% CI 0.69, 0.87; and 60+ months, aHR 0.55, 95% CI 0.48, 0.62. CONCLUSION: Unlike overall infant mortality, injury-related infant mortality decreased with IPI length. While injury-related deaths are rare, these patterns suggest that the timing between births may be a marker of risk for fatal infant injuries. The first year postpartum may be an ideal time for the delivery of evidence-based injury prevention programmes as well as family planning services.

PURPOSE: Racial disparities in childhood asthma prevalence increased after the 1990s. Obesity, which also varies by race/ethnicity, is an asthma risk factor but its contribution to asthma prevalence disparities is unknown. METHODS: We analyzed nationally representative National Health Examination and Nutrition Survey data for 2-19 year olds with logistic regression and decomposition analyses to assess the contributions of weight status to racial disparities in asthma prevalence, controlling for sex, age, and income status. RESULTS: From 1988-1994 to 2011-2014, asthma prevalence increased more among non-Hispanic black (NHB) (8.4% to 18.0%) than non-Hispanic white (NHW) youth (7.2% to 10.3%). Logistic regression showed that obesity was an asthma risk factor for all groups but that a three-way "weight status-race/ethnicity-time" interaction was not significant. That is, weight status did not modify the race/ethnicity association with asthma over time. In decomposition analyses, weight status had a small contribution to NHB/NHW asthma prevalence disparities but most of the disparity remained unexplained by weight status or other asthma risk factors (sex, age and income status). CONCLUSIONS: NHB youth had a greater asthma prevalence increase from 1988-1994 to 2011-2014 than NHW youth. Most of the racial disparity in asthma prevalence remained unexplained after considering weight status and other characteristics.

INTRODUCTION: The purpose of this study was to evaluate the risk of death during the first year of life due to injury, such as unintentional injury and homicide, by birth order in the U.S. METHODS: Using national birth cohort-linked birth-infant death data (births, 2000-2010; deaths, 2000-2011), risks of infant mortality due to injury in second-, third-, fourth-, and fifth or later-born singleton infants were compared with first-born singleton infants. Risk ratios were estimated using log-binomial models adjusted for maternal age, marital status, race/ethnicity, and education. The statistical analyses were conducted in 2016. RESULTS: Approximately 40%, 32%, 16%, 7%, and 4% of singleton live births were first, second, third, fourth, and fifth or later born, respectively. From 2000 to 2011, a total of 15,866 infants died as a result of injury (approximately 1,442 deaths per year). Compared with first-born infants (2.9 deaths per 10,000 live births), second or later-born infants were at increased risk of infant mortality due to injury (second, 3.6 deaths; third, 4.2 deaths; fourth, 4.8 deaths; fifth or later, 6.4 deaths). The corresponding adjusted risk ratios were as follows: second, 1.84 (95% CI=1.76, 1.91); third, 2.42 (95% CI=2.30, 2.54); fourth, 2.96 (95% CI=2.77, 3.16); and fifth or later, 4.26 (95% CI=3.96, 4.57). CONCLUSIONS: Singleton infants born second or later were at increased risk of mortality due to injury during their first year of life in the U.S. This study's findings highlight the importance of investigating underlying mechanisms behind this increased risk.

Risk of death during the first year of life due to external causes, such as unintentional injury and homicide, may be higher among twins and higher-order multiples than among singletons in the United States. We used national birth cohort linked birth-infant death data (2000-2010) to evaluate the risk of infant mortality due to external causes in multiples versus singletons in the United States. Risk of death from external causes during the study period was 3.6 per 10,000 live births in singletons and 5.1 per 10,000 live births in multiples. Using log-binomial regression, the corresponding unadjusted risk ratio was 1.40 (95% confidence interval (CI): 1.30, 1.50). After adjustment for maternal age, marital status, race/ethnicity, and education, the risk ratio was 1.68 (95% CI: 1.56, 1.81). Infant deaths due to external causes were most likely to occur between 2 and 7 months of age. Applying inverse probability weighting and assuming a hypothetical intervention where no infants were low birth weight, the adjusted controlled direct effect of plurality on infant mortality due to external causes was 1.64 (95% CI: 1.39, 1.97). Twins and higher-order multiples were at greater risk of infant mortality due to external causes, particularly between 2 and 7 months of age, and this risk appeared to be mediated largely by factors other than low-birth-weight status.

To investigate whether receiving US Department of Housing and Urban Development (HUD) housing assistance is associated with improved access to health care, we analyzed data on nondisabled adults ages 18-64 who responded to the 2004-12 National Health Interview Survey that were linked with administrative data from HUD for the period 2002-14. To account for potential selection bias, we compared access to care between respondents who were receiving HUD housing assistance at the time of the survey interview (current recipients) and those who received HUD assistance within twenty-four months of completing the survey interview (future recipients). Receiving assistance was associated with lower uninsurance rates: 31.8 percent of current recipients were uninsured, compared to 37.2 percent of future recipients. Rates of unmet need for health care due to cost were similarly lower for current recipients than for future recipients. No effect of receiving assistance was observed on having a usual source of care. These findings provide evidence that supports the effectiveness of housing assistance in improving health care access.

OBJECTIVES: To examine whether access to housing assistance is associated with better health among low-income adults. METHODS: We used National Health Interview Survey data (1999-2012) linked to US Department of Housing and Urban Development (HUD) administrative records (1999-2014) to examine differences in reported fair or poor health and psychological distress. We used multivariable models to compare those currently receiving HUD housing assistance (public housing, housing choice vouchers, and multifamily housing) with those who will receive housing assistance within 2 years (the average duration of HUD waitlists) to account for selection into HUD assistance. RESULTS: We found reduced odds of fair or poor health for current public housing (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.57, 0.97) and multifamily housing (OR = 0.75; 95% CI = 0.60, 0.95) residents compared with future residents. Public housing residents also had reduced odds of psychological distress (OR = 0.59; 95% CI = 0.40, 0.86). These differences were not mediated by neighborhood-level characteristics, and we did not find any health benefits for current housing choice voucher recipients. CONCLUSIONS: Housing assistance is associated with improved health and psychological well-being for individuals entering public housing and multifamily housing programs. (Am J Public Health. Published online ahead of print February 16, 2017: e1-e8. doi:10.2105/AJPH.2016.303649).

We describe mental health service use by insurance among children aged 4 to 17 with diagnosed attention-deficit/ hyperactivity disorder (ADHD). Using parent reports from 2010-2013 National Health Interview Survey, we estimate the percentage that received services for emotional and behavioral difficulties (EBD): medication, other nonmedication services, and none (neither medication nor other nonmedication services). Among children with diagnosed ADHD, 56.0% had used medication for EBD, 39.8% had contact with a mental health professional, 32.2% had contact with a general doctor about the child's EBD, and 20.4% received special education services for EBD. Medication use was more often reported for privately or publicly insured children than uninsured children (P < .001), and uninsured children more often received no services (P < .001). Publicly insured children were more likely than privately insured children to receive other nonmedication services (P < .001). Less than a third (28.9%) of all children received no services as compared to almost half (48.8%) of uninsured children.

OBJECTIVES: Pressure equalization tube (PET) placement (also referred to as tympanostomy tube placement) is among the most common ambulatory surgical procedures performed on U.S. children. Over twenty years ago, differences by race/ethnicity in the national prevalence of having had PETs placed were documented. Whether these differences persist is unknown. METHODS: We used data from the 2014 National Health Interview Survey to examine the percentage of children 0-17 years of age that have ever undergone PET placement. Unadjusted logistic regression with predictive margins was used to assess the relationship between having received PETs and race/ethnicity, as well as other clinical, socioeconomic, and geographic factors. Multivariable logistic regression was used to determine whether other factors could account for any observed differences by race/ethnicity. RESULTS: Overall, 8.9% of children 0 to 17 years of age had undergone PET surgery. By race/ethnicity, 12.6% of non-Hispanic white children received PETs, which was significantly greater than the 4.8% of non-Hispanic black, 4.4% of Hispanic, and 5.6% of non-Hispanic other/multiple race children that had this surgery (p<0.001 for all comparisons). In multivariable analysis, the adjusted prevalence for non-Hispanic white children (10.8%) was greater than for non-Hispanic black (5.4%) and Hispanic (5.8%) children (p<0.001 for both comparisons). CONCLUSION: Nearly 9% of U.S. children have had PETs placed. Non-Hispanic white children still have a greater prevalence of PET placement compared with non-Hispanic black and Hispanic children. These differences could not be fully explained by other demographic, clinical, socioeconomic, or geographic differences between racial/ethnic groups.

BACKGROUND: Reproductive health disparities may be partly explained by the cumulative effects of chronic stress experienced by socially disadvantaged groups. Although, telomere length (TL) and allostatic load score have each been used as biological markers of stress, the relationship between these two measures is unknown. METHODS: We investigated the association between leucocyte TL and allostatic load score in 1503 non-pregnant women (20-44 years) participating in the National Health and Nutrition Examination Survey, 1999-2002. We constructed six different allostatic load scores using either quartile- or clinical-based cut-points for 14 biomarkers based on previously published methods. We estimated associations between TL and allostatic load scores and component biomarkers using linear regression, also assessing interactions by race/ethnicity. RESULTS: After adjustment for age, longer TL was associated with higher HDL cholesterol and lower C-reactive protein and creatinine clearance; TL was not associated with the other component biomarkers. Shorter TL was associated with higher allostatic load scores for the two clinical cut-point-based scores after adjustment for age, but not the four scores based on quartile cut-points. Significant interactions by race/ethnicity were observed for TL and HbA1c and triglycerides, but not for other component biomarkers or allostatic load scores. CONCLUSIONS: Although TL and allostatic load score are both considered measures of cumulative stress, most component biomarkers and scores using quartile-based cut-points were not associated with TL. In reproductive-aged women, allostatic load scores using clinical-based cut-points were more strongly associated with TL compared with quartile-based scores.

OBJECTIVE: To examine national trends in the receipt of asthma action plans, an intervention recommended by the National Asthma Education and Prevention Program guidelines. STUDY DESIGN: We used data from the sample child component of the National Health Interview Survey from 2002, 2003, 2008, and 2013 to examine the percentage of children 2-17 years of age with asthma (n = 3714) that have ever received an asthma action plan. Bivariate and multivariate (with adjustment for sociodemographic characteristics and asthma outcomes consistent with greater disease severity) logistic regressions were conducted to examine trends from 2002 to 2013 and to examine, with 2013 data only, the relationship between having received an asthma action plan and both sociodemographic characteristics and indicators of asthma severity. RESULTS: The percentage of children with asthma that had ever received an asthma action plan increased from 41.7% in 2002 to 50.7% in 2013 (P < .001 for trend). In 2013, a greater percentage of non-Hispanic black (58.4%) than non-Hispanic white (47.4%) children (P = .028), privately insured (56.2%) vs those with public insurance only (46.3%) (P = .016), and users of inhaled preventive asthma medication vs those that did not (P < .001) had ever received an asthma action plan. Adjusted results were similar. CONCLUSION: The percentage of US children with asthma that had ever received an asthma action plan increased between 2002 and 2013, although one-half had never received an asthma action plan in 2013. Some sociodemographic and asthma severity measures are related to receipt of an asthma action plan.

BACKGROUND: Childhood asthma prevalence doubled from 1980 to 1995 and then increased more slowly from 2001 to 2010. During this second period, racial disparities increased. More recent trends remain to be described. METHODS: We analyzed current asthma prevalence using 2001-2013 National Health Interview Survey data for children ages 0 to 17 years. Logistic regression with quadratic terms was used to test for nonlinear patterns in trends. Differences between demographic subgroups were further assessed with multivariate models controlling for gender, age, poverty status, race/ethnicity, urbanicity, and geographic region. RESULTS: Overall, childhood asthma prevalence increased from 2001 to 2009 followed by a plateau then a decline in 2013. From 2001 to 2013, multivariate logistic regression showed no change in prevalence among non-Hispanic white and Puerto Rican children and those in the Northeast and West; increasing prevalence among 10- to 17-year-olds, poor children, and those living in the South; increasing then plateauing prevalence among 5- to 9-year-olds, near-poor children, and non-Hispanic black children; and increasing then decreasing prevalence among 0- to 4-year-olds, nonpoor, and Mexican children and those in the Midwest. Non-Hispanic black-white disparities stopped increasing, and Puerto Rican children remained with the highest prevalence. CONCLUSIONS: Current asthma prevalence ceased to increase among children in recent years and the non-Hispanic black-white disparity stopped increasing due mainly to plateauing prevalence among non-Hispanic black children.

OBJECTIVES: Children with asthma and allergies-particularly food and/or multiple allergies--are at risk for adverse asthma outcomes. This analysis describes allergy prevalence trends among US children by asthma status. METHODS: We analyzed 2001-2013 National Health Interview Survey data for children aged 0-17 years. We estimated trends for reported respiratory, food, and skin allergy and the percentage of children with one, two, or all three allergy types by asthma status. We estimated unadjusted trends, and among children with asthma, adjusted associations between demographic characteristics and allergy. RESULTS: Prevalence of any allergy increased by 0.3 percentage points annually among children without asthma but not among children with asthma. However, underlying patterns changed among children with asthma: food and skin allergy prevalence increased as did the percentage with all three allergy types. Among children with asthma, risk was higher among younger and non-Hispanic black children for reported skin allergy, among non-Hispanic white children for reported respiratory allergy, and among nonpoor children for food and respiratory allergies. Prevalence of having one allergy type decreased by 0.50 percentage points annually, while the percent with all three types increased 0.2 percentage points annually. Non-poor and non-Hispanic white children with asthma were more likely to have multiple allergy types. CONCLUSIONS: While overall allergy prevalence among children with asthma remained stable, patterns in reported allergy type and number suggested a greater proportion may be at risk of adverse asthma outcomes associated with allergy: food allergy increased as did the percentage with all three allergy types.

BACKGROUND: Children with asthma face higher risk of complications from influenza. Trends in influenza vaccination among children with asthma are unknown. METHODS: We used 2005-2013 National Health Interview Survey data for children 2-17 years of age. We assessed, separately for children with and without asthma, any vaccination ( received August through May) during each of the 2005-2006 through 2012-2013 influenza seasons and, for the 2010-2011 through 2012-2013 seasons only, early vaccination (received August through October). We used April-July interviews each year (n=31,668) to assess vaccination during the previous influenza season. Predictive margins from logistic regression with time as the independent and vaccination status as the dependent variable were used to assess time trends. We also estimated the association between several sociodemographic variables and the likelihood of influenza vaccination. RESULTS: From 2005-2013, among children with asthma, influenza vaccination receipt increased about 3 percentage points per year (p<0.001), reaching 55% in 2012-2013. The percentage of all children with asthma vaccinated by October (early vaccination) was slightly above 30% in 2012-2013. In 2010-2013, adolescents, the uninsured, children of parents with some college education, and those living in the South and West were less likely to be vaccinated. CONCLUSION: The percentage of children 2-17 years of age with asthma receiving influenza vaccination has increased since 2004-2005, reaching approximately 55% in 2012-2013.

OBJECTIVES: To examine national trends in the percentage of children whose usual source of care is at a clinic, health center, or hospital outpatient department (hereafter "clinics") and whether trends differ by sociodemographic subpopulations. STUDY DESIGN: Analysis of serial, cross-sectional, nationally representative in-person household surveys, the 1997-2013 National Health Interview Surveys, was conducted to identify children with a usual source of care (n = 190 571), and the percentage receiving that care in a clinic. We used joinpoint regression to identify changes in linear trends, and logistic regression with predictive margins to obtain per-year changes in percentages, both unadjusted and adjusted for sociodemographic factors. Interaction terms in logistic regressions were used to assess whether trends varied by sociodemographic subgroups. RESULTS: Of all children with a usual source of care, the percentage receiving that care in a clinic declined 0.44 percentage points per year (P < .001) from 22.97% in 1997 to 19.31% in 2002. Thereafter, it increased approximately 0.57 percentage points per year (P < .001), reaching 26.1% in 2013. Trends for some sociodemographic subgroups varied from these overall trends. No changes were observed between 2003 and 2013 for non-Hispanic black and Medicaid/State Children's Health Insurance Program insured children. CONCLUSIONS: This study shows that, although the percentage of children with a usual source of care in a clinic declined between 1997 and 2002, it has steadily increased since that time.

BACKGROUND: National Asthma Education and Prevention Program (NAEPP) guidelines recommend that periodic spirometry be performed in youth with asthma. NAEPP uses different spirometry criteria to define uncontrolled asthma for children (6-11 years) and adolescents (12+ years). OBJECTIVE: To describe differences in spirometry between US children and adolescents with current asthma. METHODS: We examined cross-sectional spirometry data from 453 US youth with current asthma age 6-19 years from the 2007-2010 National Health and Nutrition Examination Surveys. The main outcomes were percentage predicted forced expiratory volume at 1 sec (FEV1%) ≤80 and the ratio of FEV1 to forced vital capacity (FEV1/FVC) ≤0.80. We also examined the prevalence of youth with spirometry values consistent with uncontrolled asthma, using NAEPP age-specific criteria, defined for children aged 6-11 years as FEV1% ≤80 or FEV1/FVC ≤0.80, and for adolescents aged 12-19 years as FEV1% ≤80. RESULTS: Children 6-11 years and adolescents 12-19 years did not differ in prevalence of FEV1% ≤80 (10.1% vs. 9.0%) or FEV1/FVC ≤0.80 (30.6% vs. 29.8%). However, based on the NAEPP age-specific criteria, 33.0% of children 6-11 years and 9.0% of adolescents 12-19 years had spirometry values consistent with uncontrolled asthma (P < 0.001). CONCLUSION: Children 6-11 years and adolescents 12-19 years with current asthma did not differ in the percentage with FEV1% ≤80 or FEV1/FVC ≤0.80. However, the percent of children and adolescents with spirometry values consistent with uncontrolled asthma did differ. The difference appears to stem mainly from the different spirometry criteria for the two age groups.

We examined consumption of different types of infant formula (eg, cow's milk, soy, gentle/lactose-reduced, and specialty) and regular milk among a nationally representative sample of 1864 infants, 0 to 12 months old, from the National Health and Nutrition Examination Survey, 2003-2010. Among the 81% of infants who were fed formula or regular milk, 69% consumed cow's milk formula, 12% consumed soy formula, 5% consumed gentle/ lactose-reduced formulas, 6% consumed specialty formulas, and 13% consumed regular milk products. There were differences by household education and income in the percentage of infants consuming cow's milk formula and regular milk products. The majority of infants in the United States who were fed formula or regular milk consumed cow's milk formula (69%), with lower percentages receiving soy, specialty, gentle/sensitive, or lactose-free/reduced formulas. Contrary to national recommendations, 13% of infants younger than 1 year consumed regular milk, and the percentage varied by household education and income levels.

In 2008, the American Academy of Pediatrics (AAP) revised their recommended minimum daily intake of vitamin D for infants and children to 400 IU.1 This was based on the high prevalence of vitamin D deficiency, persistent incidence of rickets, and historical safety profile of 400 IU daily supplementation in infants and children.1 The AAP recommends that vitamin D supplementation should begin within the first few days of life and continue until the infant is consuming at least 1 liter of vitamin D–fortified formula or milk per day. Breastfed infants are at increased risk of vitamin D deficiency because human milk generally does not contain sufficient vitamin D, while infant formula is fortified to provide approximately 400 IU of vitamin D per liter (at normal dilution).2 Adherence to the revised recommended vitamin D intake guidelines has not been evaluated since enactment. | The objective of our analysis was to evaluate the percentage of US infants meeting the 2008 AAP vitamin D recommendations during 2009 to 2012.

OBJECTIVE: The authors reported use of mental health services among children in the United States between ages six and 11 who were described by their parents as having emotional or behavioral difficulties (EBDs). METHODS: Using data from the 2010-2012 National Health Interview Survey, the authors estimated the national percentage of children ages six to 11 with serious or minor EBDs (N=2,500) who received treatment for their difficulties, including only mental health services other than medication (psychosocial services), only medication, both psychosocial services and medication, and neither type of service. They calculated the percentage of children who received school-based and non-school-based psychosocial services in 2011-2012 and who had unmet need for psychosocial services in 2010-2012. RESULTS: In 2010-2012, 5.8% of U.S. children ages six to 11 had serious EBDs and 17.3% had minor EBDs. Among children with EBDs, 17.8% were receiving both medication and psychosocial services, 28.8% psychosocial services only, 6.8% medication only, and 46.6% neither medication nor psychosocial services. Among children with EBDs in 2011-2012, 18.6% received school-based psychosocial services only, 11.4% non-school-based psychosocial services only, and 17.3% both school- and non-school-based psychosocial services. In 2010-2012, 8.2% of children with EBDs had unmet need for psychosocial services. CONCLUSIONS: School-age children with EBDs received a range of mental health services, but nearly half received neither medication nor psychosocial services. School-based providers played a role in delivering psychosocial services, but parents reported an unmet need for psychosocial services among some children.

OBJECTIVES: Examine the extent to which office-based physicians in the United States receive patient health information necessary to coordinate care across settings and determine whether receipt of information needed to coordinate care is associated with use of health information technology (HIT) (defined by presence or absence of electronic health record system and electronic sharing of information). RESEARCH DESIGN: Cross-sectional study using the 2012 National Electronic Health Records Survey (65% weighted response rate). SUBJECTS: Office-based physicians. MEASURES: Use of HIT and 3 types of patient health information needed to coordinate care. RESULTS: In 2012, 64% of physicians routinely received the results of a patient's consultation with a provider outside of their practice, whereas 46% routinely received a patient's history and reason for a referred consultation from a provider outside of their practice. About 54% of physicians reported routinely receiving a patient's hospital discharge information. In adjusted analysis, significant differences in receiving necessary information were observed by use of HIT. Compared with those not using HIT, a lower percentage of physicians who used an electronic health record system and shared patient health information electronically failed to receive the results of outside consultations or patient's history and reason for a referred consultation. No significant differences were observed for the receipt of hospital discharge information by use of HIT. Among physicians routinely receiving information needed for care coordination, at least 54% of them did not receive the information electronically. CONCLUSIONS: Although a higher percentage of physicians using HIT received patient information necessary for care coordination than those who did not use HIT, more than one third did not routinely receive the needed patient information at all.

BACKGROUND: Racial disparities in childhood asthma have been a long-standing target for intervention, especially disparities in hospitalization and mortality. OBJECTIVES: Describe trends in racial disparities in asthma outcomes using both traditional population-based rates and at-risk rates (based on the estimated number of children with asthma) to account for prevalence differences between race groups. METHODS: Estimates of asthma prevalence and outcomes (emergency department [ED] visits, hospitalizations, and deaths) were calculated from national data for 2001 to 2010 for black and white children. Trends were calculated using weighted loglinear regression, and changes in racial disparities over time were assessed using Joinpoint. RESULTS: Disparities in asthma prevalence between black and white children increased from 2001 to 2010; at the end of this period, black children were twice as likely as white children to have asthma. Population-based rates showed that disparities in asthma outcomes remained stable (ED visits and hospitalizations) or increased (asthma attack prevalence, deaths). In contrast, analysis with at-risk rates, which account for differences in asthma prevalence, showed that disparities in asthma outcomes remained stable (deaths), decreased (ED visits, hospitalizations), or did not exist (asthma attack prevalence). CONCLUSIONS: Using at-risk rates to assess racial disparities in asthma outcomes accounts for prevalence differences between black and white children, and adds another perspective to the population-based examination of asthma disparities. An at-risk rate analysis shows that among children with asthma, there is no disparity for asthma attack prevalence and that progress has been made in decreasing disparities in asthma ED visit and hospitalization rates.

OBJECTIVES: We examined gap length, characteristics associated with gap length, and number of enrollment periods among Medicaid-enrolled children in the United States. METHODS: We linked the 2004 National Health Interview Survey to Medicaid Analytic eXtract files for 1999 through 2008. We examined linkage-eligible children aged 5 to 13 years in the 2004 National Health Interview Survey who disenrolled from Medicaid. We generated Kaplan-Meier curves of time to reenrollment. We used Cox proportional hazards models to assess the effect of sociodemographic variables on time to reenrollment. We compared the percentage of children enrolled 4 or more times across sociodemographic groups. RESULTS: Of children who disenrolled from Medicaid, 35.8%, 47.1%, 63.5%, 70.8%, and 79.1% of children had reenrolled in Medicaid by 6 months, 1, 3, 5, and 10 years, respectively. Children who were younger, poorer, or of minority race/ethnicity or had lower educated parents had shorter gaps in Medicaid and were more likely to have had 4 or more Medicaid enrollment periods. CONCLUSIONS: Nearly half of US children who disenrolled from Medicaid reenrolled within 1 year. Children with traditionally high-risk demographic characteristics had shorter gaps in Medicaid enrollment and were more likely to have more periods of Medicaid enrollment.

We examined mental health-related visits to emergency departments (EDs) among children from 2001 to 2011. We used the National Hospital Ambulatory Medical Care Survey-Emergency Department, 2001-2011 to identify visits of children 6 to 20 years old with a reason-for-visit code or ICD-9-CM diagnosis code reflecting mental health issues. National percentages of total visits, visit counts, and population rates were calculated, overall and by race, age, and sex. Emergency department visits for mental health issues increased from 4.4% of all visits in 2001 to 7.2% in 2011. Counts increased 55 000 visits per year and rates increased from 13.6 visits/1000 population in 2001 to 25.3 visits/1000 in 2011 (P < .01 for all trends). Black children (all ages) had higher visit rates than white children and 13- to 20-year-olds had higher visit rates than children 6 to 12 years old (P < .01 for all comparisons). Differences between groups did not decline over time.

OBJECTIVE: Children and adolescents are known to experience poor health care quality; some groups of children have poorer health care than others. We sought to examine trends over time in health care quality and disparities by race, Hispanic ethnicity, income, insurance, gender, rurality, and special health care needs. METHODS: Source data were extracted from the 2011 National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) database, which contains aggregated data from many government and private sources for the years 2000 through 2009. The NHQR and NHDR approaches to calculating disparities and trends in quality and disparities were used. Within each quality measure with available data, results for demographic subgroups of children characterized by race/ethnicity, income, insurance, residence, special health care need, and gender were compared to those of a reference group to determine whether disparities existed and whether disparities had changed over time. RESULTS: Of 68 measures with data for calculating potential disparities, 50 showed disparities in quality for at least 1 comparison subgroup in the most recent year of data available, while 18 measures showed no such disparities. Of the 50 measures with current disparities, 39 measures had sufficient data to calculate trends. Among the 137 comparisons made within these 39 measures, there was no change in disparities over time for 126 comparisons, 3 comparisons worsened, and 8 comparisons improved. CONCLUSIONS: There was some progress in health care quality and reducing disparities in children's health care quality from 2000 to 2009; opportunities for targeting improvement strategies remain.

OBJECTIVE: Local-area studies demonstrate that preventive asthma medication discontinuation among Medicaid and Children's-Health-Insurance-Program (CHIP) enrolled children leads to adverse outcomes. We assessed time-to-discontinuation for preventive asthma medication and its risk factors among fee-for-service Medicaid/CHIP child beneficiaries. METHODS: National-Health-Interview-Survey participants (1997-2005) with ≥1 Medicaid- or CHIP-paid claims when 2-17 years-old (n=4262) were linked to Medicaid-Analytic-eXtract claims (1999-2008). Multivariate Cox proportional-hazards models to assess time-to-discontinuation (i.e., failing to refill prescriptions <30 days after previous supplies ran out) included demographic factors and medication regimen (inhaled corticosteroids [ICS], long-acting beta2-agonists, leukotriene modifiers, mast cell stabilizers, and monoclonal antibodies). RESULTS: Sixty-three percent discontinued preventive asthma medications by 90 days after the first prescription. Adolescents and toddlers had slightly higher hazards of discontinuation (adjusted hazard ratios [aHR], 1.13; 95% CI, 1.05-1.23; and 1.12; 1.03-1.21, respectively) versus 5-11 year-olds, as did Hispanics (aHR, 1.24; 1.13-1.35) and non-Hispanic blacks (aHR, 1.17; 1.07-1.28) versus non-Hispanic whites, children in households with one adult and ≥3 children (aHR, 1.17; 1.05-1.30) versus multiple adults and ≤2 children, and children with caregivers' educational-attainment ≤12th grade (aHR, 1.11; 1.02-1.20) versus caregivers with some college. Compared to regimens including both ICS and leukotriene modifiers, discontinuation was greater for those on ICS without leukotriene modifiers or on other preventive asthma medications (aHR, 1.67; 1.56-1.80; and 2.23; 1.78-2.80, respectively). CONCLUSION: More than 60% of children enrolled in fee-for-service Medicaid/CHIP discontinued preventive asthma medications by 90 days. Risk was increased for minorities and children from disadvantaged households. Understanding these factors may inform future pediatric asthma guidelines.

We describe the association of screen time in excess of American Academy of Pediatrics recommendations (≤2 h/d) with family television-use policies and regular nonscreen activities among US school-aged children. Data from the 2007 National Survey of Children's Health were used. The sum of minutes spent on television, videos, video games, and recreational computer use was calculated for children 6 to 17 years old. Bivariate and multivariate logistic regression models were used to calculate relative odds of exceeding American Academy of Pediatrics guidelines and of heavy screen use (>4 h/d) for varying family media-use policies and frequency of alternative activities (physical activity and family meals). In all, 49% of school-aged children had screen time >2 h/d and 16% had screen time >4 h/d. Lower frequency of family meals, presence of TV in the bedroom, absence of rules about TV viewing, and less physical activity were associated with both >2 and >4 hours per day of screen time.

OBJECTIVE: The national primary cesarean delivery rate increased until 2004, but after 2004, this rate cannot be tracked using Vital Statistics data. Additionally, it is unknown whether changes in the primary cesarean delivery rate reflect changes in the rate of labor attempts, labor success, or both. Here, using hospital discharge data, we examined national trends in primary cesarean deliveries, labor attempts, and labor success among women without prior cesarean delivery between 1990 and 2010. STUDY DESIGN: This analysis of serial cross-sectional data from the National Hospital Discharge Survey used Joinpoint regression to assess trends over time and logistic regression with marginal effects to identify rates of change over time and adjust for demographic and clinical factors. RESULTS: The primary cesarean delivery rate declined 0.2 percentage points per year (95% confidence interval [CI], 0.1-0.3) between 1990 and 1999, increased 1.0 percentage point per year (95% CI, 0.8-1.2) between 1999 and 2004, and increased 0.3 percentage points (95% CI, 0.1-0.6) per year from 2004 until 2010. Between 1998 and 2005, the rate of labor attempts declined 0.4 percentage points (95% CI, 0.3-0.5) per year. No changes in the labor attempt rate occurred between 2005 and 2010. Labor success rates increased 0.2 percentage points (95% CI, 0.1-0.3) per year between 1990 and 1998 but then declined 0.5 (95% CI, 0.5-0.8) percentage points per year from 1998 to 2010. Adjusted results were similar. CONCLUSION: The primary cesarean delivery rate continued to increase after 2004. Increases in the primary cesarean delivery rate after 2005 were driven by declines in labor success rates.

OBJECTIVE: Given widespread interventions to reduce environmental tobacco smoke (ETS) exposure and improve asthma control, we sought to assess the current impact of ETS exposure on children with asthma. METHODS: We analyzed 2003-2010 data for nonsmoking children aged 6 to 19 years with asthma from the National Health and Nutrition Examination Survey. Outcomes (sleep disturbance, missed school days, health care visits, activity limitation, and wheezing with exercise) were compared between ETS exposed children (serum cotinine levels 0.05 to 10 ng/mL) and unexposed children (<0.05 ng/mL) using ordinal regression adjusted for demographic characteristics. We also assessed whether associations were observable with low ETS exposure levels (0.05 to 1.0 ng/mL). RESULTS: Overall, 53.3% of children aged 6 to 19 years with asthma were ETS exposed. Age-stratified models showed associations between ETS exposure and most adverse outcomes among 6- to 11-year-olds, but not 12- to 19-year-olds. Even ETS exposure associated with low serum cotinine levels was associated with adverse outcomes for 6- to 11-year-olds. Race-stratified models for children aged 6 to 19 years showed an association between ETS exposure and missing school, health care visits, and activity limitation due to wheezing among non-Hispanic white children, and disturbed sleep among non-Hispanic white and Mexican children. Among non-Hispanic black children, there was no elevated risk between ETS exposure and the assessed outcomes: non-Hispanic black children had high rates of adverse outcomes regardless of ETS exposure. CONCLUSIONS: Among children with asthma 6 to 11 years of age, ETS exposure was associated with most adverse outcomes. Even ETS exposure resulting in low serum cotinine levels was associated with risks for young children with asthma.

BACKGROUND: Although national cross-sectional estimates of the percentage of children enrolled in Medicaid are available, the percentage of children enrolled in Medicaid over longer periods of time is unknown. Also, the percentage and characteristics of children who rely on Medicaid throughout childhood, rather than transiently, are unknown. METHODS: We performed a longitudinal examination of Medicaid coverage among children across a 5-year period. Children 0 to 13 years of age in the 2004 National Health Interview Survey file were linked to Medicaid Analytic eXtract files from 2004 to 2008. The percentage of children enrolled in Medicaid at any time during the 5-year observation period and the number of years during which children were enrolled in Medicaid were calculated. Duration of Medicaid enrollment was compared across sociodemographic characteristics by using chi(2) tests. RESULTS: Forty-one percent of all US children were enrolled in Medicaid at least some time during the 5-year period, compared with a single-year estimate of 32.8% in 2004 alone. Of enrolled children, 51.5% were enrolled during all 5 years. Children with lower parental education, with lower household income, of minority race or ethnicity, and in suboptimal health were more likely to be enrolled in Medicaid during all 5 years. CONCLUSIONS: Longitudinal data reveal higher percentages of children with Medicaid insurance than shown by cross-sectional data. Half of children enrolled in Medicaid are enrolled during at least 5 consecutive years, and these children have higher risk sociodemographic profiles.