Faculty Bibliography

OBJECTIVE: To determine whether educational media as actually used by low-income families promotes parent-child cognitive stimulation activities. METHODS: Secondary analysis of the control group of a longitudinal cohort of mother-infant dyads enrolled post-partum in urban public hospital. Educational media exposure (via a 24-hour recall diary) and parent-child activities that may promote cognitive stimulation in the home (using StimQ) were assessed at 6, 14, 24, and 36 months. RESULTS: 149 mother-child dyads; 93.3% Latino. Mean (standard deviation) educational media exposure at 6, 14, 24, and 36 months was: 25 (40), 42 (58), 39 (49), and 39 (50) mins/day. In multilevel model analyses, prior educational media exposure had small positive relationship with subsequent total StimQ (beta=0.11, P=.03), but was non-significant (beta = 0.08, P = .09) after adjusting for confounders (child: age, gender, birth order, non-educational media exposure, language; mother: age, ethnicity, marital status, country of origin, language, depressive symptoms)Educational media did predict small increases in verbal interactions and toy provision (adjusted models, respectively: beta = 0.13, P = .02; beta = 0.11; P = .03). In contrast, more consistent relationships were seen for models of the relationship between prior StimQ (total, verbal interactions and teaching; adjusted models, respectively: beta = 0.20, P = .002; beta = 0.15, P = .006; beta = 0.20, P = .001) and predicted subsequent educational media. CONCLUSIONS: Educational media as used by this sample of low-income families does not promote cognitive stimulation activities important for early child development or activities such as reading and teaching.

OBJECTIVES: To determine whether parents who use a low literacy, pictogram- and photograph-based written asthma action plan have a better understanding of child asthma management compared to parents using a standard plan. METHODS: Randomized controlled study in 2 urban pediatric outpatient clinics. INCLUSION CRITERIA: English/Spanish-speaking parents of 2-12 year old asthmatic children. Parents were randomized to receive a low literacy or standard asthma action plan (American Academy of Allergy, Asthma and Immunology) for a hypothetical patient on controller and rescue medications. A structured questionnaire was used to assess whether there was an error in knowledge of 1)medications to give everyday and when sick, 2)need for spacer use, and 3)appropriate emergency response to give albuterol and seek medical help. Multiple logistic regression analyses performed adjusting for parent age, health literacy (Newest Vital Sign); child asthma severity, medications; site. RESULTS: 217 parents were randomized (109 intervention;108 control). Parents who received the low literacy plan were 1)less likely to make an error in knowledge of medications to take everyday and when sick compared to parents who received the standard plan (63.0 vs. 77.3%, p = 0.03; adjusted odds ratio [AOR] = 0.5[95% CI: 0.2-0.9]) and 2)less likely make an error regarding spacer use (14.0 vs. 51.1%, p<0.001; AOR = 0.1[0.06-0.3]). No difference in error in appropriate emergency response was seen (43.1 vs. 48.1%, p = 0.5). CONCLUSIONS: Use of a low literacy written asthma action plan was associated with better parent understanding of asthma management. Further study is needed to assess whether use of this action plan improves child asthma outcomes.

OBJECTIVE: To describe infant activity at 3 months old and to test the efficacy of a primary care-based child obesity prevention intervention on promoting infant activity in low-income Hispanic families. METHODS: This study was a randomized controlled trial (n = 533) comparing a control group of mother-infant dyads receiving standard prenatal and pediatric primary care with an intervention group receiving "Starting Early," with individual nutrition counseling and nutrition and parenting support groups coordinated with prenatal and pediatric visits. Outcomes included infant activity (tummy time, unrestrained floor time, time in movement-restricting devices). Health literacy was assessed using the Newest Vital Sign. RESULTS: Four hundred fifty-six mothers completed 3-month assessments. Infant activity results were: 82.6% ever practiced tummy time; 32.0% practiced tummy time on the floor; 34.4% reported unrestrained floor time; 56.4% reported >/=1 h/d in movement-restricting devices. Inadequate health literacy was associated with reduced tummy time and unrestrained floor time. The intervention group reported more floor tummy time (OR 2.16, 95% CI 1.44-3.23) and unrestrained floor time (OR 1.69, 95% CI 1.14-2.49) compared to controls. No difference in the time spent in movement-restricting devices was found. CONCLUSIONS: Tummy time and unrestrained floor time were low. Primary care-based obesity prevention programs have potential to promote these activities.

Sleep problems are common, reported by a quarter of parents with children under the age of 5 years, and have been associated with poor behavior, worse school performance, and obesity, in addition to negative secondary effects on maternal and family well-being. Yet, it has been shown that pediatricians do not adequately address sleep in routine well-child visits, and underdiagnose sleep issues. Pediatricians receive little formal training in medical school or in residency regarding sleep medicine. An understanding of the physiology of sleep is critical to a pediatricians ability to effectively and confidently counsel patients about sleep. The biological rhythm of sleep and waking is regulated through both circadian and homeostatic processes. Sleep also has an internal rhythmic organization, or sleep architecture, which includes sleep cycles of REM and NREM sleep. Arousal and sleep (REM and NREM) are active and complex neurophysiologic processes, involving both neural pathway activation and suppression. These physiologic processes change over the life course, especially in the first 5 years. Adequate sleep is often difficult to achieve, yet is considered very important to optimal daily function and behavior in children; thus, understanding optimal sleep duration and patterns is critical for pediatricians. There is little experimental evidence that guides sleep recommendations, rather normative data and expert recommendations. Effective counseling on child sleep must account for the child and parent factors (child temperament, parent-child interaction, and parental affect) and the environmental factors (cultural, geographic, and home environment, especially media exposure) that influence sleep. To promote health and to prevent and manage sleep problems, the American Academy of Pediatrics (AAP) recommends that parents start promoting good sleep hygiene, with a sleep-promoting environment and a bedtime routine in infancy, and throughout childhood. Thus, counseling families on sleep requires an understanding of sleep regulation, physiology, developmental patterns, optimal sleep duration recommendations, and the many factors that influence sleep and sleep hygiene.

OBJECTIVE: Determine maternal and infant characteristics associated with adding cereal into the bottle. DESIGN: Secondary data analysis. PARTICIPANTS: Study participants were immigrant, low-income, urban mother-infant dyads (n = 216; 91% Hispanic, 19% US-born) enrolled in a randomized controlled trial entitled the Bellevue Project for Early Language, Literacy and Education Success. MAIN OUTCOME MEASURES: Maternal characteristics (age, marital status, ethnicity, primary language, country of origin, education, work status, income, depressive symptoms, and concern about infant's future weight) and infant characteristics (gender, first born, and difficult temperament). ANALYSIS: Fisher exact test, chi-square test, and simultaneous multiple logistic regression of significant (P < .05) variables identified in unadjusted analyses. RESULTS: Twenty-seven percent of mothers added cereal into the bottle. After adjusting for confounding variables identified in bivariate analyses, mothers who were single (P = .02), had moderate to severe depressive symptoms (P = .01) and perceived their infant had a difficult temperament (P = .03) were more likely to add cereal into the bottle. Conversely, mothers who expressed concern about their infants becoming overweight were less likely to add cereal (P = .02). CONCLUSIONS AND IMPLICATIONS: Health care providers should screen for adding cereal in infant bottles. Further research is needed to investigate the impact of adding cereal into the bottle on weight trajectories over time. Causal associations also need to be identified to effectively prevent this practice.

OBJECTIVE: Child sleep problems are prevalent and have been linked to poor behavior, worse school performance, and obesity. Low health literacy (HL) is associated with suboptimal parenting practices and worse health outcomes, but the relationship between parent HL and child sleep-related issues is not known. We examined the association between parent HL and child sleep-related issues. DESIGN/METHODS: Cross-sectional analysis of data from caregivers enrolled in a cluster randomized trial of a primary care-based child obesity prevention program in 4 pediatric clinics. Parent HL assessed using the Short Test of Functional HL in Adults. At the 9-month well-child visit, sleep-related factors were assessed: presence of TV in room where child sleeps, regular naptimes and bedtimes (>5 days/week), low daytime and nighttime sleep duration (>1SD below mean based on national data). Adjusted logistic regression analyses performed. RESULTS: 557 caregivers of 9-month olds enrolled (49.7% Hispanic, 26.9% Black, 56.2% <$20K annual income); 49.6% reported having a TV in the room where their child sleeps; 26.6% did not have regular naptimes/bedtimes. Median (IQR) sleep duration was 2.3(1.5-3.0) hours (daytime), 9.0(8.0-10.0) hours (night) (30.2% low daytime; 20.3% low night sleep duration). Children of parents with low HL were more likely to have a bedroom TV (66.7 v. 47.7%, p=0.01; AOR=2.2[95%CI: 1.1-4.3]) and low nighttime sleep (37.0 v. 18.5%, p=0.002; AOR=2.4[1.2-4.8]). CONCLUSIONS: Low parent HL is associated with TV in the bedroom and low night sleep duration. Additional study is needed to further explore these associations and intervention strategies to address child sleep problems.

OBJECTIVE: Asthma is a leading cause of pediatric admissions. While several factors including race have been linked to increased overall asthma morbidity and mortality, few studies have explored factors associated with inpatient asthma outcomes. We examined factors associated with mortality and morbidity in children admitted for asthma. DESIGN/METHODS: Data were obtained from the US Nationwide Inpatient Sample for 2007-2011. Patients 2-18 years old with a primary diagnosis of asthma were included. Predictor variables were sociodemographic and hospital factors and acute/chronic secondary diagnoses. Outcomes were mortality, intubation, length of stay (LOS), and costs. Weighted national estimates were calculated. Multivariable analyses were performed. RESULTS: There were 97,379 (478,546 weighted) asthma admissions. Most patients were male (60.6%); 30% were white, 28% black, and 18% Hispanic. Mortality rate was 0.03%. 0.3% were intubated. Median (IQR) LOS was 2 (1-3) days. Median (IQR) costs were $2760 ($1860-4320). Native American race, older age (13-18 years), and West region were significant independent predictors of mortality. Intubation rate was lower in Hispanic compared to white children (p=0.028). LOS was shorter in Asian compared to white children (p=0.022) but longer in children with public insurance and from low income areas (p <0.001). Average costs were higher in black, Hispanic, and Asian compared to white children (p<0.05). CONCLUSIONS: With the exception of Native Americans, race/ethnicity is not associated with inpatient asthma mortality and has varied effects on morbidity. Recognition of factors associated with increased asthma mortality and morbidity may allow for earlier, more effective treatment and avoidance of complications.

BACKGROUND AND OBJECTIVES: The use of written asthma action plans (WAAPs) has been associated with reduced asthma-related morbidity, but there are concerns about their complexity. We developed a health literacy-informed, pictogram- and photograph-based WAAP and examined whether providers who used it, with no training, would have better asthma counseling quality compared with those who used a standard plan. METHODS: Physicians at 2 academic centers randomized to use a low-literacy or standard action plan (American Academy of Allergy, Asthma and Immunology) to counsel the hypothetical parent of child with moderate persistent asthma (regimen: Flovent 110 mug 2 puffs twice daily, Singulair 5 mg daily, Albuterol 2 puffs every 4 hours as needed). Two blinded raters independently reviewed counseling transcriptions. PRIMARY OUTCOME MEASURES: medication instructions presented with times of day (eg, morning and night vs number of times per day) and inhaler color; spacer use recommended; need for everyday medications, even when sick, addressed; and explicit symptoms used. RESULTS: 119 providers were randomly assigned (61 low literacy, 58 standard). Providers who used the low-literacy plan were more likely to use times of day (eg, Flovent morning and night, 96.7% vs 51.7%, P < .001; odds ratio [OR] = 27.5; 95% confidence interval [CI], 6.1-123.4), recommend spacer use (eg, Albuterol, 83.6% vs 43.1%, P < .001; OR = 6.7; 95% CI, 2.9-15.8), address need for daily medications when sick (93.4% vs 34.5%, P < .001; OR = 27.1; 95% CI, 8.6-85.4), use explicit symptoms (eg, "ribs show when breathing," 54.1% vs 3.4%, P < .001; OR = 33.0; 95% CI, 7.4-147.5). Few mentioned inhaler color. Mean (SD) counseling time was similar (3.9 [2.5] vs 3.8 [2.6] minutes, P = .8). CONCLUSIONS: Use of a low-literacy WAAP improves the quality of asthma counseling by helping providers target key issues by using recommended clear communication principles.

AIM: To establish whether young children watched foreground electronic media or background media that was not aimed at them or was inappropriate for their age. METHODS: We performed a longitudinal analysis of mother-infant dyads participating in a larger parenting study. The primary dependent variable was maternal reports of watching habits from media diaries at 6, 14, 24 and 36 months. Independent variables were child age, programme content and whether the programme was turned on specifically for the child. RESULTS: We analysed 3570 programme exposures in 527 children, mostly from television. Children were significantly more likely to actually watch programmes if they were older, if the content was coded as 'educational young child' or if the parent tuned on the programme specifically so the child could watch it. Children under the age of two were more likely than older children to watch background media that featured age-inappropriate content or had not been turned on for them to watch [30% versus 16% of programmes; AOR = 2.19 (95%CI 1.82-2.65)]. CONCLUSION: Young children under the age of two frequently watch background media that has age-inappropriate content or has not been turned on for them to watch.