Faculty Bibliography

OBJECTIVE: To examine clinician-reported diagnosis of obesity and frequency of blood pressure assessment and diet and exercise counseling during ambulatory visits made by children and adolescents. METHODS: The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey 1997 to 2000 were combined for visits to clinicians of 2- to 18-year-olds. Well-child visits (WCVs) were examined for frequencies of obesity diagnosis, blood pressure screening, and diet and exercise counseling in relation to patient and clinician characteristics. Multivariate models examined the relationship of patient and visit characteristics with diet and exercise counseling. RESULTS: Of the 32 930 ambulatory visits made by 2- to 18-year-olds in 1997-2000, obesity was diagnosed at 0.78% of all visits and 0.93% of WCVs. Blood pressure assessment was reported in 61.1% of WCVs with obesity diagnosis compared with 43.9% of WCVs without obesity diagnosis. WCVs with obesity diagnosis had higher diet counseling rates (88.4% vs 35.7%) and higher exercise counseling rates (69.2% vs 18.6%). Diet counseling was reported for 88.4% and exercise counseling was reported for 69.2% of visits with an obesity diagnosis compared with 35.7% and 18.6% during WCVs without a diagnosis of obesity. In multivariate analyses, factors associated with diet counseling at WCVs were diagnosis of obesity (odds ratio [OR]: 12.9; 95% confidence interval [CI]: 3.0-55.3), being seen by pediatricians (OR: 2.5; 95% CI: 1.6-3.9), 2- to 5-year-olds compared with 12- to 18-year-olds (OR: 0.7; 95% CI: 0.5-1.0), and self-pay compared with private insurance visits (OR: 0.6; 95% CI: 0.4-0.9). Associations with exercise counseling were similar to those for diet counseling, but exercise counseling occurred less frequently in visits by black youths compared with white youths (OR: 0.5; 95% CI: 0.3-0.8). CONCLUSIONS: Clinicians may overlook obesity during WCVs. Programs to increase obesity diagnosis could improve diet and exercise counseling rates, but even with diagnosis of obesity, significant opportunities for screening and intervention are missed

BACKGROUND: Smokers who use cessation medications when they attempt to quit double their likelihood of success. No prior survey has assessed the acceptability to parents of receiving smoking cessation medication prescriptions in the context of their child's primary care visits. OBJECTIVE: To assess acceptability to parents of receiving smoking cessation medication prescriptions and to compare that with the reported rate of actually receiving smoking cessation medication prescriptions in the context of the child's health care visit. METHODS: Data were collected through a national random-digit dial telephone survey of households from July to September 2003. The sample was weighted according to race and gender, on the basis of the 2002 US Census, to be representative of the US population. RESULTS: Of 3990 eligible respondents contacted, 3010 (75%) completed surveys; 1027 (34%) of those were parents. Of those parents, 211 (21%) were self-identified smokers. One half would consider using a smoking cessation medication and, of those, 85% said that it would be acceptable if the child's doctor prescribed or recommended it to them. In contrast, of the 143 smoking parents who accompanied their child to the doctor, only 15% had pharmacotherapy recommended and only 8% received a prescription for a smoking cessation medication. These results did not vary according to parent age, gender, race, or child age. CONCLUSIONS: Child health care clinicians have low rates of recommending and prescribing cessation therapies that have proved effective in other settings. The recommendation or provision of cessation medications would be acceptable to the majority of parents in the context of their child's health care visit

Parental tobacco use is a serious health issue for all family members. Child health care clinicians are in a unique and important position to address parental smoking because of the regular, multiple contacts with parents and the harmful health consequences to their patients. This article synthesizes the current evidence-based interventions for treatment of adults and applies them to the problem of addressing parental smoking in the context of the child health care setting. Brief interventions are effective, and complementary strategies such as quitlines will improve the chances of parental smoking cessation. Adopting the 5 A's framework strategy (ask, advise, assess, assist, and arrange) gives each parent the maximum chance of quitting. Within this framework, specific recommendations are made for child health care settings and clinicians. Ongoing research will help determine how best to implement parental smoking-cessation strategies more widely in a variety of child health care settings

Despite substantial asthma prevalence and morbidity, children from Spanish-speaking families are at high risk of inadequate maintenance therapy. The reasons for this remain unclear. The objective of this study was to compare patterns of asthma morbidity and access to care of children with asthma from Spanish-speaking and English-speaking families. Cross-sectional data from a nationally representative sample of children with asthma 2-17 years of age were analyzed from the 1999 National Health Interview Survey, conducted in both English and Spanish, with the preferred language identified at the time of the interview. Among the 1,228 children with asthma (physician-diagnosed asthma by parent report), 66 (3%) were from Spanish-speaking families and 1,162 (97%) were from English-speaking families. In a logistic regression model adjusting for gender, insurance, poverty (above or below the federal poverty level, based on reported family income and the U.S. Poverty Threshold produced annually by the Census Bureau), and race/ethnicity, children with asthma from Spanish-speaking families were one-third less likely to have a usual health care provider (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.1-0.8) than children with asthma from English-speaking families. Latino ethnicity was not independently associated with diminished continuity of care. These data indicate that children with asthma from Spanish-speaking families are less likely to experience continuity of health care than their counterparts from English-speaking families. Differences in continuity of care may contribute to inadequate asthma maintenance therapy among these children