Faculty Bibliography

BACKGROUND AND OBJECTIVES: Our objective was to determine the level of adult understanding of dosage instructions for a liquid medication commonly prescribed for children. METHODS: Structured interviews were conducted with 373 adults waiting for an appointment at family medicine clinics serving low-income populations in Shreveport, La; Chicago; and Jackson, Mich, from July 2003-August 2004. Subjects were asked to read a prescription label for amoxicillin and explain how they would take the medication. Correct interpretation was determined by a panel of blinded physician reviewers who coded subjects' verbatim responses. Qualitative methods were used to determine the nature of incorrect responses. RESULTS: Twenty-eight percent of subjects misunderstood medication instructions. The prevalence of misinterpreting instructions among subjects with adequate, marginal, and low literacy was 18%, 34%, and 43%, respectively. Common causes for misunderstanding included problems with dosage measurement (28%; ie, tablespoon instead of teaspoon) and frequency of use (33%; ie, every 3 hours instead of every 6-8 hours). In an adjusted analysis that excluded literacy, African Americans were more likely to misunderstand instructions than Caucasians (adjusted odds ratio [AOR] 1.63, 95% confidence interval [CI]=1.02-2.61). When literacy was included in the model, the effect of race on misunderstanding was reduced and nonsignificant. Inadequate and marginal literacy remained independent predictors of misunderstanding (inadequate--AOR 2.90, 95% CI= 1.41-6.00; marginal--AOR 2.20, 95% CI=1.19-3.97). CONCLUSIONS: Misinterpretation of pediatric liquid medication instructions is common. Limited literacy is a significant risk factor for misunderstanding and could contribute to racial disparities. Instructions should be written in a concise manner and standardized to ensure comprehension

Despite a heightened focus on improving quality, recent studies have suggested that children only receive half of the indicated preventive, acute, or chronic care. Two major areas in need of improvement are chronic illness care and prevention of medical errors. Recently, health literacy has been identified as an important and potentially ameliorable factor for improving quality of care. Studies of adults have documented that lower health literacy is independently associated with poorer understanding of prescriptions and other medical information and worse chronic disease knowledge, self-management behaviors, and clinical outcomes. There is also growing evidence to suggest that health literacy is important in pediatric safety and chronic illness care. Adult studies have suggested that addressing literacy can lead to improved patient knowledge, behaviors, and outcomes. Early studies in the field of pediatrics have shown similar promise. There are significant opportunities to evaluate and demonstrate the importance of health literacy in improving pediatric quality of care. Efforts to address health literacy should be made to apply the 6 Institute of Medicine aims for quality-care that is safe, effective, patient centered, timely, efficient, and equitable. Efforts should also be made to consider the distinct nature of pediatric care and address the '4 D's' unique to child health: the developmental change of children over time; dependency on parents or adults; differential epidemiology of child health; and the different demographic patterns of children and their families

OBJECTIVE: To determine whether maternal literacy level accounts for associations between educational level and the cognitive home environment in low-income families. DESIGN: Analysis of 369 mother-infant dyads participating in a long-term study related to early child development. SETTING: Urban public hospital. PARTICIPANTS: Low-income mothers of 6-month-old infants. MAIN EXPOSURE: Maternal literacy level was assessed using the Woodcock-Johnson III/Bateria III Woodcock-Munoz Tests of Achievement, Letter-Word Identification Test. Maternal educational level was assessed by determining the last grade that had been completed by the mother. MAIN OUTCOME MEASURE: The cognitive home environment (provision of learning materials, verbal responsivity, teaching, and shared reading) was assessed using StimQ, an office-based interview measure. RESULTS: In unadjusted analyses, a maternal literacy level of ninth grade or higher was associated with increases in scores for the overall StimQ and each of 4 subscales, whereas a maternal educational level of ninth grade or higher was associated with increases in scores for the overall StimQ and 3 of 4 subscales. In simultaneous multiple linear regression models including both literacy and educational levels, literacy continued to be associated with scores for the overall StimQ (adjusted mean difference, 3.7; 95% confidence interval, 1.7-5.7) and all subscales except teaching, whereas maternal educational level was no longer significantly associated with scores for the StimQ (1.8; 0.5-4.0) or any of its subscales. CONCLUSIONS: Literacy level may be a more specific indicator of risk than educational level in low-income families. Studies of low-income families should include direct measures of literacy. Pediatricians should develop strategies to identify mothers with low literacy levels and promote parenting behaviors to foster cognitive development in these at-risk families

OBJECTIVE: To evaluate the efficacy of a pictogram-based health literacy intervention to decrease liquid medication administration errors by caregivers of young children. DESIGN: Randomized controlled trial. SETTING: Urban public hospital pediatric emergency department. PARTICIPANTS: Parents and caregivers (N = 245) of children aged 30 days to 8 years who were prescribed liquid medications (daily dose or 'as needed'). INTERVENTION: Medication counseling using plain language, pictogram-based medication instruction sheets. Control subjects received standard medication counseling. OUTCOME MEASURES: Medication knowledge and practice, dosing accuracy, and adherence. RESULTS: Of 245 randomized caregivers, 227 underwent follow-up assessments (intervention group, 113; control group, 114). Of these, 99 were prescribed a daily dose medication, and 158 were prescribed medication taken as needed. Intervention caregivers had fewer errors in observed dosing accuracy (>20% deviation from prescribed dose) compared with caregivers who received routine counseling (daily dose: 5.4% vs 47.8%; absolute risk reduction [ARR], 42.4% [95% confidence interval, 24.0%-57.0%]; number needed to treat [NNT], 2 [2-4]; as needed: 15.6% vs 40.0%; ARR, 24.4% (8.7%-38.8%); NNT, 4 [3-12]). Of intervention caregivers, 9.3% were nonadherent (ie, did not give within 20% of the total prescribed doses) compared with 38.0% of controls (ARR, 28.7% [11.4%-43.7%]; NNT, 3 [2-9]). Improvements were also seen for knowledge of appropriate preparation for both medication types, as well as knowledge of frequency for those prescribed daily dose medications. CONCLUSION: A plain language, pictogram-based intervention used as part of medication counseling resulted in decreased medication dosing errors and improved adherence among multiethnic, low socioeconomic status caregivers whose children were treated at an urban pediatric emergency department. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00537433

OBJECTIVE: To determine whether mothers with plans related to shared reading and baby books in the home at the time of delivery of their newborns would be more likely to engage in shared reading behaviors at age 6 months. METHODS: This was a cohort study with enrollment after birth and follow-up at 6 months in an urban public hospital. Predictors included mothers' attitudes and resources related to shared reading during the postpartum period. Outcomes included mothers' shared reading activities and resources at 6 months, as assessed by the StimQ-READ measure. RESULTS: A total of 173 mother-infant dyads were assessed. In multiple regression analyses adjusting for sociodemographics and maternal depression and literacy, StimQ-READ score at 6 months was increased in association with all 3 postpartum predictors: plans for reading as a strategy for school success (adjusted mean 1.7-point increase in 6-month score; 95% confidence interval [95% CI], 0.3-3.0), plans to read in infancy (3.1-point increase; 95% CI, 1.6-4.6), and having baby books in the home (2.3-point increase; 95% CI, 0.9-3.6). In multiple logistic regression analysis, mothers with 2 or more attitudes and resources had an adjusted odds ratio of 6.2 (95% CI, 2.0-18.9) for having initiated reading at 6 months. CONCLUSIONS: Maternal attitudes and resources in early infancy related to shared reading are important predictors of reading behaviors by 6 months. Cumulative postnatal attitudes and resources are the strongest predictors of later behaviors. Additional research is needed regarding whether guidance about shared reading in early infancy or pregnancy would enhance programs such as Reach Out and Read

OBJECTIVE: Caregivers of young children frequently measure doses of liquid medications incorrectly. Use of nonstandardized dosing instruments and lack of knowledge that dosing is weight-based contribute to dosing errors. We sought to assess whether low caregiver health literacy was associated with these outcomes. METHODS: This was a cross-sectional analysis of caregivers presenting to an urban pediatric emergency room. Dependent variables were caregiver reported use of nonstandardized dosing tools and knowledge of weight-based dosing. The independent variable was caregiver health literacy (Test of Functional Health Literacy in Adults [TOFHLA]). RESULTS: Two hundred ninety-two caregivers were assessed: 23.3% reported use of nonstandardized liquid dosing instruments, and 67.8% were unaware of weight-based dosing. Caregivers who were unaware of weight-based dosing were more likely to use nonstandardized dosing tools (28.3% vs 12.8%; P = .003). In unadjusted analyses, overall health literacy, reading comprehension, and numeracy were all associated with both dependent variables. In analyses adjusting for child age, health care experiences, and caregiver acculturation and education, inadequate/marginal overall health literacy was associated with lack of knowledge of weight-based dosing (adjusted odds ratio [AOR] 2.3; P = .03), whereas lower reading comprehension was associated with both lack of knowledge (AOR 2.0; P = .03) and reported use of nonstandardized instrument (AOR 2.4; P = .007). CONCLUSIONS: Low health literacy, in particular reading comprehension, was associated with reported use of nonstandardized dosing instruments and lack of knowledge regarding weight-based dosing. Both caregiver health literacy and sociodemographic factors should be considered in the design of interventions to prevent medication administration errors

OBJECTIVE: To determine whether the bispectral index (BIS) monitor could be used to guide physicians in titrating propofol to an effective safe level of deep sedation for children undergoing painful medical procedures. DESIGN: Multiphase clinical trial. SETTING: Outpatient treatment center of a university children's hospital. PATIENTS: Pediatric outpatients undergoing painful medical procedures. INTERVENTIONS: Patients were sedated with propofol for the procedures. Patients were monitored with a BIS monitor, and the BIS score was correlated with the patient's clinical level of sedation. The BIS score was then used as a guide to titrate propofol in the last phase of the study. MEASUREMENTS AND MAIN RESULTS: The study consisted of 3 phases. In a chart review of data for 154 children who underwent 212 procedures, propofol was found to be safe and effective, with consistent dosing among the intensivists administering the medication. The children received a mean bolus dose of propofol of 1.56 mg/kg, with a mean total dose of propofol of 0.33 mg/kg per minute for the duration of the procedure. In the second phase, 21 patients ranging in age from 27 weeks to 18 years, with normal neurologic function, were sedated with propofol. An observer who was blinded to the BIS scores recorded clinical levels of sedation and reactivity (with a modified Ramsay scale and reactivity score) every 1 to 3 minutes. Another observer recorded the BIS scores at the same times. A total of 275 data points were collected and evaluated. All data points from the times at which patients were considered to be sedated adequately were used to construct a normal distribution of BIS scores. The mean BIS score was 62. This distribution was used to predict that a maximal BIS score of 47 was needed to ensure adequate sedation for 90% of the population. In the third phase of the study, an algorithm was devised to determine the target BIS score necessary for adequate sedation of 95% of the patients. We chose an initial BIS score of 50 (at which 85% of the patients in phase 2 were sedated) because of the possibility of data from phase 2 being skewed toward oversedation. Propofol was administered by an intensivist in an attempt to maintain the target BIS score. A blinded observer noted the patient's clinical level of sedation. In this group, there were 2 failures, ie, patients were clinically uncomfortable despite a BIS score of < or =50, representing only 90% success. Therefore, with the algorithm, propofol was titrated to sedate the next patients to a BIS score of 45. These patients required a mean bolus dose of 1.47 mg/kg and a mean total dose of 0.51 mg/kg per minute to maintain a BIS score of 45. They awakened in 12.75 minutes. All patients were sedated adequately, all procedures were successful, and no patients experienced complications from the sedation. To eliminate variability in the way propofol was dosed, the next 10 patients were given propofol according to a standardized protocol. These 10 children received an initial bolus of 1 mg/kg, with incremental bolus doses of 0.5 mg/kg per dose (maximum: 20 mg) to achieve and to maintain a BIS score of 45. With this protocol, all patients were sedated adequately and none experienced complications from the sedation. The patients required a mean bolus dose of 2.23 mg/kg and a mean dose of 0.52 mg/kg per minute to maintain a BIS score of 45. The mean time until awakening was 14.9 minutes. Regarding the total dose over time and the time until awakening, there was no statistical significance between this group and the group sedated to a BIS score of 45 without the dosing protocol. CONCLUSION: The BIS monitor can be a useful monitoring guide for the titration of propofol by physicians who are competent in airway and hemodynamic management, to achieve deep sedation for children undergoing painful procedures