Small Geographic Area Variations in Prescription Drug Use
BACKGROUND: Despite the frequency of pediatric prescribing little is known about practice differences across small geographic regions and payer type (Medicaid and commercial).
OBJECTIVE: The goal of this research was to quantify variation in prescription drug use among northern New England children.
METHODS: Northern New England, all-payer administrative data (2007–2010) permitted study of prescriptions for 949 821 children ages 0 to 17 years (1.75 million person-years [PYs]; 54% Medicaid, 46% commercial). Age- and gender adjusted overall and drug group–specific prescription use was quantified according to payer type (Medicaid or commercial) and within payer type across 69 hospital service areas (HSAs). We measured prescription fills per PY (rate) and annual, mean percentage of the population with any drug group–specific fills (prevalence).
RESULTS: Overall mean annual prescriptions per PY were 3.4 (commercial) and 5.5 (Medicaid). Generally, these payer type differences were smaller than HSA-level variation within payer type. HSA-level rates of attention-deficit/hyperactivity disorder drug use (5th–95th percentile) varied twofold in Medicaid and more than twofold in commercially insured children; HSA-level antidepressant use varied more than twofold within each payer type. Antacid use varied threefold across HSAs and was highest in infants where commercial use paradoxically exceeded Medicaid. Prevalence of drug use varied as much as rates across HSAs.
CONCLUSIONS: Prescription use was higher among Medicaid-insured than commercially insured children. Regional variation generally exceeded payer type differences, especially for drugs used in situations of diagnostic and therapeutic uncertainty. Efforts should advance best pediatric prescribing discussions and shared decision-making.
To determine prevalence and correlates of need and unmet need for care coordination in a national sample of children with mental health conditions.
Using data from the 2007 National Survey of Children’s Health, we identified children aged 2 to 17 years with ≥1 mental health condition (attention-deficit/hyperactivity disorder, anxiety disorder, conduct disorder, or depression) who had received ≥2 types of preventive or subspecialty health services in the past year. We defined 2 outcome measures of interest: (1) prevalence of need for care coordination; and (2) prevalence of unmet need for care coordination in those with a need. Logistic regression models were used to estimate associations of clinical, sociodemographic, parent psychosocial, and health care characteristics with the outcome measures.
In our sample (N = 7501, representing an estimated 5 750 000 children), the prevalence of having any need for care coordination was 43.2%. Among parents reporting a need for care coordination, the prevalence of unmet need was 41.2%. Higher risk of unmet need for care coordination was associated with child anxiety disorder, parenting stress, lower income, and public or no insurance. Parents reporting social support and receipt of family-centered care had a lower risk of unmet need for care coordination.
Approximately 40% of parents of children with mental health conditions who reported a need for care coordination also reported that their need was unmet. Delivery of family-centered care and enhancing family supports may help to reduce unmet need for care coordination in this vulnerable population.
Hospitalizations Due to Firearm Injuries in Children and Adolescents
BACKGROUND AND OBJECTIVE:
Despite recent national attention on deaths from firearms, little information exists about children and adolescents who are hospitalized for firearm injuries. The objective was to determine the national frequency of firearm-related hospitalizations in the United States in children, compare rates by cause and demographics, and describe hospitalized cases.
We used the 2009 Kids’ Inpatient Database to identify hospitalizations from firearm-related injuries in young people <20 years of age; International Classification of Diseases, Ninth Revision, Clinical Modification, and external-cause-of injury codes were used to categorize the injuries and the causes as follows: assault, suicide attempt, unintentional, or undetermined. Incidences were calculated by using the weighted number of cases and the intercensal population. Risk ratios compared incidences.
In 2009, 7391 (95% confidence interval [CI]: 6523–8259) hospitalizations were due to firearm-related injuries. The hospitalization rate was 8.87 (95% CI: 7.83–9.92) per 100 000 persons <20 years of age. Hospitalizations due to assaults were most frequent (n = 4559) and suicide attempts were least frequent (n = 270). Of all hospitalizations, 89.2% occurred in males; the hospitalization rate for males was 15.22 per 100 000 (95% CI: 13.41–17.03) and for females was 1.93 (95% CI: 1.66–2.20). The rate for black males was 44.77 (95% CI: 36.69–52.85), a rate more than 10 times that for white males. Rates were highest for those aged 15 to 19 years (27.94; 95% CI: 24.42–31.46). Deaths in the hospital occurred in 453 (6.1%); of those hospitalized after suicide attempts, 35.1% died.
On average, 20 US children and adolescents were hospitalized each day in 2009 due to firearm injuries. Public health efforts are needed to reduce this common source of childhood injury.
Gun Violence Trends in Movies (PDF)
Many scientific studies have shown that the mere presence of guns can increase aggression, an effect dubbed the “weapons effect.” The current research examines a potential source of the weapons effect: guns depicted in top-selling films.
Trained coders identified the presence of violence in each 5-minute film segment for one-half of the top 30 films since 1950 and the presence of guns in violent segments since 1985, the first full year the PG-13 rating (age 13+) was used. PG-13–rated films are among the top-selling films and are especially attractive to youth.
Results found that violence in films has more than doubled since 1950, and gun violence in PG-13–rated films has more than tripled since 1985. When the PG-13 rating was introduced, these films contained about as much gun violence as G (general audiences) and PG (parental guidance suggested for young children) films. Since 2009, PG-13–rated films have contained as much or more violence as R-rated films (age 17+) films.
Even if youth do not use guns, these findings suggest that they are exposed to increasing gun violence in top-selling films. By including guns in violent scenes, film producers may be strengthening the weapons effect and providing youth with scripts for using guns. These findings are concerning because many scientific studies have shown that violent films can increase aggression. Violent films are also now easily accessible to youth (eg, on the Internet and cable). This research suggests that the presence of weapons in films might amplify the effects of violent films on aggression.
Nonmedical prescription opiate use (NPOU) and nonmedical prescription sedative use (NPSU) are serious public health concerns. The objectives of this study were to determine the prevalence and emergency department (ED) visit characteristics and other correlates associated with past-year NPOU and NPSU among adolescents and young adults using the ED.
Participants aged 14 to 20 presenting to the ED at the University of Michigan Medical Center between September 2010 and September 2011 were systematically recruited. A computerized self-report screening survey with validated items measuring past-year NPOU, NPSU, substance use, and violence was delivered to participants, and a retrospective chart review was performed.
Of the 2135 participants (86.0% response rate), 222 (10.4%) reported either NPOU or NPSU. Among the 185 (8.7%) participants that reported NPOU, 14.6% had a current home prescription for an opioid and among the 115 (5.4%) with NPSU, 12.3% had a current home prescription for a sedative. After controlling for demographics (age, gender, race, public assistance), correlates of NPOU or NPSU included other substance use, and drinking and driving or riding with a drinking driver. Additional correlates of NPOU included receiving an intravenous opioid in the ED and for NPSU, dating violence, presenting to the ED for a noninjury complaint, and previous ED visit in the past year.
Nearly 1 in 10 young people who use the ED for care report NPOU or NPSU, and only 12.3% and 14.6% report having current home prescriptions for sedatives and opioids. The ED represents a key location for screening and intervention efforts.
Spanking and Child Development Across the First Decade of Life
To examine the prevalence of maternal and paternal spanking of children at 3 and 5 years of age and the associations between spanking and children’s externalizing behavior and receptive vocabulary through age 9.
The Fragile Families and Child Well-Being Study, a longitudinal birth cohort study of children in 20 medium to large US cities, was used. Parental reports of spanking were assessed at age 3 and 5, along with child externalizing behavior and receptive vocabulary at age 9 (N = 1933). The data set also included an extensive set of child and family controls (including earlier measures of the child outcomes).
Overall, 57% of mothers and 40% of fathers engaged in spanking when children were age 3, and 52% of mothers and 33% of fathers engaged in spanking at age 5. Maternal spanking at age 5, even at low levels, was associated with higher levels of child externalizing behavior at age 9, even after an array of risks and earlier child behavior were controlled for. Father’s high-frequency spanking at age 5 was associated with lower child receptive vocabulary scores at age 9.
Spanking remains a typical rearing experience for American children. These results demonstrate negative effects of spanking on child behavioral and cognitive development in a longitudinal sample from birth through 9 years of age.
Childhood and adolescent melanoma is rare but has been increasing. To gain insight into possible reasons underlying this observation, we analyzed trends in melanoma incidence diagnosed between the ages of 0 and 19 years among US whites by gender, stage, age at diagnosis, and primary site. We also investigated incidence trends by UV-B exposure levels.
By using Surveillance, Epidemiology, and End Results (SEER) program data (1973–2009), we calculated age-adjusted incidence rates (IRs), annual percent changes, and 95% confidence intervals for each category of interest. Incidence trends were also evaluated by using joinpoint and local regression models. SEER registries were categorized with respect to low or high UV-B radiation exposure.
From 1973 through 2009, 1230 children of white race were diagnosed with malignant melanoma. Overall, pediatric melanoma increased by an average of 2% per year (95% confidence interval, 1.4%–2.7%). Girls, 15- to 19-year-olds, and individuals with low UV-B exposure had significantly higher IRs than boys, younger children, and those living in SEER registries categorized as high UV-B. Over the study period, boys experienced increased IRs for melanoma on the face and trunk, and females on the lower limbs and hip. The only decreased incidence trend we observed was among 15- to 19-year-olds in the high UV-B exposure group from 1985 through 2009. Local regression curves indicated similar patterns.
These results may help elucidate possible risk factors for adolescent melanoma, but additional individual-level studies will be necessary to determine the reasons for increasing incidence trends.
OBJECTIVE: To examine food-related parenting practices (pressure-to-eat and food restriction) among mothers and fathers of adolescents and associations with adolescent weight status within a large population-based sample of racially/ethnically and socioeconomically diverse parent-adolescent pairs.
METHODS: Adolescents (N = 2231; 14.4 years old [SD = 2.0]) and their parents (N = 3431) participated in 2 coordinated population-based studies designed to examine factors associated with weight status and weight-related behaviors in adolescents. Adolescents completed anthropometric measurements and surveys at school. Parents (or other caregivers) completed questionnaires via mail or phone.
RESULTS: Findings suggest that the use of controlling food-related parenting practices, including pressure-to-eat and restriction, is common among parents of adolescents. Mean restriction levels were significantly higher among parents of overweight and obese adolescents compared with nonoverweight adolescents. However, levels of pressure-to-eat were significantly higher among nonoverweight adolescents. Results indicate that fathers are more likely than mothers to engage in pressure-to-eat behaviors and boys are more likely than girls to be on the receiving end of parental pressure-to-eat. Parental report of restriction did not differ significantly by parent or adolescent gender. No significant interactions by race/ethnicity or socioeconomic status were seen in the relationship between restriction or pressure-to-eat and adolescent weight status.
CONCLUSIONS: Given that there is accumulating evidence for the detrimental effects of controlling feeding practices on children’s ability to self-regulate energy intake, these findings suggest that parents should be educated and empowered through anticipatory guidance to encourage moderation rather than overconsumption and emphasize healthful food choices rather than restrictive eating patterns.
The Effects of Music Therapy on Vital Signs, Feeding, and Sleep in Premature Infants (PDF)
OBJECTIVES: Recorded music risks overstimulation in NICUs. The live elements of music such as rhythm, breath, and parent-preferred lullabies may affect physiologic function (eg, heart and respiratory rates, O2 saturation levels, and activity levels) and developmental function (eg, sleep, feeding behavior, and weight gain) in premature infants.
METHODS: A randomized clinical multisite trial of 272 premature infants aged ≥32 weeks with respiratory distress syndrome, clinical sepsis, and/or SGA (small for gestational age) served as their own controls in 11 NICUs. Infants received 3 interventions per week within a 2-week period, when data of physiologic and developmental domains were collected before, during, and after the interventions or no interventions and daily during a 2-week period.
RESULTS: Three live music interventions showed changes in heart rate interactive with time. Lower heart rates occurred during the lullaby (P < .001) and rhythm intervention (P = .04). Sucking behavior showed differences with rhythm sound interventions (P = .03). Entrained breath sounds rendered lower heart rates after the intervention (P = .04) and differences in sleep patterns (P < .001). Caloric intake (P = .01) and sucking behavior (P = .02) were higher with parent-preferred lullabies. Music decreased parental stress perception (P < .001).
CONCLUSIONS: The informed, intentional therapeutic use of live sound and parent-preferred lullabies applied by a certified music therapist can influence cardiac and respiratory function. Entrained with a premature infant’s observed vital signs, sound and lullaby may improve feeding behaviors and sucking patterns and may increase prolonged periods of quiet–alert states. Parent-preferred lullabies, sung live, can enhance bonding, thus decreasing the stress parents associate with premature infant care.
OBJECTIVES: This study had 2 objectives: Our first objective was to provide the first evidence of developmental trends in victimization rates for lesbian, gay, and bisexual (LGB)- and heterosexual-identified youth, both in absolute and relative terms, and to examine differences by gender. Our second objective was to examine links between victimization, sexual identity, and later emotional distress.
METHODS: Data are from a nationally representative prospective cohort study of youth in England were collected annually between 2004 and 2010. Our final analytic dataset includes 4135 participants with data at all 7 waves; 4.5% (n = 187) identified as LGB. Analyses included hierarchical linear modeling, propensity score matching, and structural equation modeling.
RESULTS: LGB victimization rates decreased in absolute terms. However, trends in relative rates were more nuanced: Gay/bisexual-identified boys became more likely to be victimized compared with heterosexual-identified boys (wave 1: odds ratio [OR] = 1.78, P = .011; wave 7: OR = 3.95, P = .001), whereas relative rates among girls approached parity (wave 1: OR = 1.95, P = .001; wave 7: OR = 1.18, P = .689), suggesting different LGB–heterosexual relative victimization rate trends for boys and girls. Early victimization and emotional distress explained about 50% of later LGB–heterosexual emotional distress disparities for both boys and girls (each P < .015).
CONCLUSIONS: Victimization of LGB youth decreases in absolute, but not necessarily relative, terms. The findings suggest that addressing LGB victimization during adolescence is critical to reducing LGB–heterosexual emotional distress disparities but additional support may be necessary to fully eliminate these disparities.
To test Music Marker Theory (MMT) positing that early adolescents’ preferences for nonmainstream types of popular music indicate concurrent and later minor delinquency.
MMT was tested in a 4-year longitudinal study (n = 309).
The results showed that early fans of different types of rock (eg, rock, heavy metal, gothic, punk), African American music (rhythm and blues, hip-hop), and electronic dance music (trance, techno/ hardhouse) showed elevated minor delinquency concurrently and longitudinally. Preferring conventional pop (chart pop) or highbrow music (classic music, jazz), in contrast, was not related to or was negatively related to minor delinquency.
Early music preferences emerged as more powerful indicators of later delinquency rather than early delinquency, indicating that music choice is a strong marker of later problem behavior. The mechanisms through which music preferences are linked to minor delinquency are discussed within the framework of MMT. Pediatrics 2013;131:1–10
The US market for organic foods has grown from $3.5 billion in 1996 to $28.6 billion in 2010, according to the Organic Trade Association. Organic products are now sold in specialty stores and conventional supermarkets. Organic products contain numerous marketing claims and terms, only some of which are standardized and regulated.
In terms of health advantages, organic diets have been convincingly demonstrated to expose consumers to fewer pesticides associated with human disease. Organic farming has been demonstrated to have less environmental impact than conventional approaches. However, current evidence does not support any meaningful nutritional benefits or deficits from eating organic compared with conventionally grown foods, and there are no well-powered human studies that directly demonstrate health benefits or disease protection as a result of consuming an organic diet. Studies also have not demonstrated any detrimental or disease-promoting effects from an organic diet. Although organic foods regularly command a significant price premium, well-designed farming studies demonstrate that costs can be competitive and yields comparable to those of conventional farming techniques. Pediatricians should incorporate this evidence when discussing the health and environmental impact of organic foods and organic farming while continuing to encourage all patients and their families to attain optimal nutrition and dietary variety consistent with the US Department of Agriculture’s MyPlate recommendations.
This clinical report reviews the health and environmental issues related to organic food production and consumption. It defines the term “organic,” reviews organic food-labeling standards, describes organic and conventional farming practices, and explores the cost and environmental implications of organic production techniques. It examines the evidence available on nutritional quality and production contaminants in conventionally produced and organic foods. Finally, this report provides guidance for pediatricians to assist them in advising their patients regarding organic and conventionally produced food choices.
Over the last 30 years, cheerleading has increased dramatically in popularity and has evolved from leading the crowd in cheers at sporting events into a competitive, year-round sport involving complex acrobatic stunts and tumbling. Consequently, cheerleading injuries have steadily increased over the years in both number and severity. Sprains and strains to the lower extremities are the most common injuries. Although the overall injury rate remains relatively low, cheerleading has accounted for approximately 66% of all catastrophic injuries in high school girl athletes over the past 25 years. Risk factors for injuries in cheerleading include higher BMI, previous injury, cheering on harder surfaces, performing stunts, and supervision by a coach with low level of training and experience. This policy statement describes the epidemiology of cheerleading injuries and provides recommendations for injury prevention.
OBJECTIVE: US parents were surveyed to determine the amount of background television that their children are exposed to as well as to isolate demographic factors associated with increased exposure to background television. After this, we ask how certain home media practices are linked to children’s background television exposure.
METHODS: US parents/caregivers (N = 1454) with 1 child between the ages of 8 months and 8 years participated in this study. A nationally representative telephone survey was conducted. Parents were asked to report on their child’s exposure to background television via a 24-hour time diary. Parents were also asked to report relevant home media behaviors related to their child: bedroom television ownership, number of televisions in the home, and how often a television was on in the home.
RESULTS: The average US child was exposed to 232.2 minutes of background television on a typical day. With the use of multiple regression analysis, we found that younger children and African American children were exposed to more background television. Leaving the television on while no one is viewing and children’s bedroom television ownership were associated with increased background television exposure.
CONCLUSIONS: Although recent research has shown the negative consequences associated with background television, this study provides the first nationally representative estimates of that exposure. The amount of exposure for the average child is startling. This study offers practitioners potential pathways to reduce exposure.
BACKGROUND AND OBJECTIVE: Herd immunity is an important benefit of childhood immunization, but it is unknown if the concept of benefit to others influences parents’ decisions to immunize their children. Our objective was to determine if the concept of “benefit to others” has been found in the literature to influence parents’ motivation for childhood immunization.
METHODS: We systematically searched Medline through October 2010 for articles on parental/guardian decision-making regarding child immunization. Studies were included if they presented original work, elicited responses from parents/guardians of children <18 years old, and addressed vaccinating children for the benefit of others.
RESULTS: The search yielded 5876 titles; 91 articles were identified for full review. Twenty-nine studies met inclusion criteria. Seventeen studies identified benefit to others as 1 among several motivating factors for immunization by using interviews or focus groups. Nine studies included the concept of benefit to others in surveys but did not rank its relative importance. In 3 studies, the importance of benefit to others was ranked relative to other motivating factors. One to six percent of parents ranked benefit to others as their primary reason to vaccinate their children, and 37% of parents ranked benefit to others as their second most important factor in decision-making.
CONCLUSIONS: There appears to be some parental willingness to immunize children for the benefit of others, but its relative importance as a motivator is largely unknown. Further work is needed to explore this concept as a possible motivational tool for increasing childhood immunization uptake.
BACKGROUND AND OBJECTIVE: Many individuals with autism spectrum disorders (ASDs) are approaching adolescence and young adulthood; interventions to assist these individuals with vocational skills are not well understood. This study systematically reviewed evidence regarding vocational interventions for individuals with ASD between the ages of 13 and 30 years.
METHODS: The Medline, PsycINFO, and ERIC databases (1980–December 2011) and reference lists of included articles were searched. Two reviewers independently assessed each study against predetermined inclusion/exclusion criteria. Two reviewers independently extracted data regarding participant and intervention characteristics, assessment techniques, and outcomes, and assigned overall quality and strength of evidence ratings based on predetermined criteria.
RESULTS: Five studies were identified; all were of poor quality and all focused on on-the-job supports as the employment/vocational intervention. Short-term studies reported that supported employment was associated with improvements in quality of life (1 study), ASD symptoms (1 study), and cognitive functioning (1 study). Three studies reported that interventions increased rates of employment for young adults with ASD.
CONCLUSIONS: Few studies have been conducted to assess vocational interventions for adolescents and young adults with ASD. As such, there is very little evidence available for specific vocational treatment approaches as individuals transition to adulthood. All studies of vocational approaches were of poor quality, which may reflect the recent emergence of this area of research. Individual studies suggest that vocational programs may increase employment success for some; however, our ability to understand the overall benefit of supported employment programs is limited given the existing research.