Faculty Bibliography

OBJECTIVE: To evaluate the relationship between elevated blood pressure (BP) and cognitive test performance in a nationally representative sample of children.Study design The National Health and Nutrition Examination Survey III provides cross-sectional data for children 6 to 16 years, including BP and cognitive test scores. Elevated BP was defined as systolic or diastolic BP >or=90th percentile. Cognitive tests were compared for children with elevated and normal BP. Linear regression was used to evaluate the relation between elevated BP and decreased test scores. RESULTS: Among the 5077 children, 3.4% had systolic BP >or=90th percentile and 1.6% diastolic BP >or=90th percentile. Children with elevated systolic BP had lower average scores compared with normotensive children for digit span (7.9 vs 8.7, P=.01), block design (8.6 vs 9.5, P=.03), and mathematics (89.6 vs 93.8, P=.01). Elevated diastolic BP was associated with lower average scores on block design (9.5 vs 11, P=.01). Linear regression showed that elevated systolic BP was independently associated with lower digit span scores (P=.032). CONCLUSION: Children with elevation of systolic BP are at risk for central nervous system end-organ damage, as manifested by decreased digit span test scores

BACKGROUND: Parental smoking has been associated with increased rates of sudden infant death syndrome, low birth weight, otitis media, asthma, and decreased lung growth. No prior parent surveys have assessed national rates of screening and counseling for parental tobacco use in the context of their child's visit to primary care. OBJECTIVE: To assess and compare rates of pediatrician and family practitioner screening and counseling for parental smoking. Design/Methods. Data were collected by telephone survey of households from July to September 2001. The sample is weighted by race and gender based on 1999 US Census estimates to be representative of the US population. RESULTS: Of 3566 eligible respondents contacted, 3002 (84%) completed surveys; 902 of those were parents who had a child seen by a pediatrician (62%) or family practitioner (38%) in the past year. About half of all parents who visited a pediatrician or family practitioner reported that they had been asked about household member smoking status (52% vs 48%). More parents who visited pediatricians had been asked if they had rules prohibiting smoking in the home than those who visited family practitioners (38% vs 29%). Of 190 (21%) parents who were smokers, fewer than half reported being counseled by either specialty about dangers of second-hand smoke (41% vs 33%) or risks of modeling smoking behavior (31% vs 28%). Similarly, fewer than half of parental smokers received advice to quit (36% vs 45%). CONCLUSION: Overall rates of screening and counseling for parental smoking in pediatric and family practice are low. Despite some differences between specialties, significant opportunities exist to improve tobacco control activities in primary care settings that serve children

BACKGROUND: In adults the metabolic syndrome imposes a substantial risk for type 2 diabetes mellitus and premature coronary heart disease. Even so, no national estimate is currently available of the prevalence of this syndrome in adolescents. OBJECTIVE: To estimate the prevalence and distribution of a metabolic syndrome among adolescents in the United States. DESIGN AND SETTING: Analyses of cross-sectional data obtained from the Third National Health and Nutrition Examination Survey (1988-1994), which was administered to a representative sample of the noninstitutionalized civilian population of the United States. PARTICIPANTS: Male and female respondents aged 12 to 19 years (n = 2430). MAIN OUTCOME MEASURES: The prevalence and distribution of a metabolic syndrome among US adolescents, using the National Cholesterol Education Program (Adult Treatment Panel III) definition modified for age. RESULTS: The overall prevalence of the metabolic syndrome among adolescents aged 12 to 19 years was 4.2%; 6.1% of males and 2.1% of females were affected (P=.01). The syndrome was present in 28.7% of overweight adolescents (body mass index [BMI], >/=95th percentile) compared with 6.8% of at-risk adolescents (BMI, 85th to <95th percentile) and 0.1% of those with a BMI below the 85th percentile (P<.001). Based on population-weighted estimates, approximately 910 000 US adolescents have the metabolic syndrome. CONCLUSIONS: Perhaps 4% of adolescents and nearly 30% of overweight adolescents in the United States meet these criteria for a metabolic syndrome, a constellation of metabolic derangements associated with obesity. These findings may have significant implications for both public health and clinical interventions directed at this high-risk group of mostly overweight young people

OBJECTIVE: A substantial proportion of homes and automobiles serve as settings for environmental tobacco smoke (ETS) exposure, and many public settings that children frequent are still not smoke-free. Tobacco control efforts are attempting to increase smoking bans. The objective of this study was to describe the knowledge, attitudes, and practices of smokers and nonsmokers regarding smoking bans and child ETS exposure in multiple public and private settings and to report changes from 2000-2001. METHODS: Cross-sectional data from the annual Social Climate Survey of Tobacco Control were analyzed for changes in knowledge, attitudes, and practices regarding tobacco. These data were collected via automated, random-digit-dialing telephone surveys that were conducted in the summers of 2000 and 2001. The samples were weighted by race and gender to be representative of the US population. RESULTS: Response rates for eligible adults actually contacted were 1501 (75%) of 1876 in 2000 and 3002 (84%) of 3566 in 2001. The majority of adults, both smokers and nonsmokers, support smoking bans in a wide variety of places. The percentage of all respondents reporting the presence of smoking bans in several public and private places increased from 2000-2001: the household (69%-74%), in the presence of children (84%-88%), convenience stores (68%-74%), fast-food restaurants (52%-58%), and non-fast-food restaurants (25%-28%). Support for smoking bans also increased in shopping malls (71%-75%), fast-food restaurants (77%-80%), and indoor sporting events (78%-80%). There were no significant changes in support for smoking bans in convenience stores, restaurants, or outdoor parks. Adults' knowledge of the harm caused by tobacco was unchanged, with the vast majority of adults recognizing the dangers of exposure to ETS from parental smoking (95%) and exposure to ETS in cars (77%). CONCLUSIONS: Small improvements in adult attitudes and practices regarding children's ETS exposure occurred from 2000-2001. However, a significant number of adults in the United States still report ignorance of the harmful effects of child ETS exposure, and there was no improvement in reported knowledge in this 1-year period. In contrast, a growing majority of smokers and nonsmokers favor restrictions on smoking in public settings, suggesting that states and communities have public support for broad public smoking restriction policies. There are significant roles that pediatricians can play in preventing children's ETS exposure, through both patient and family education and by moving smoking restriction policies forward on their community's agenda

BACKGROUND: Medical care ecology has previously been investigated for adults, but no similar exploration has been made specifically for children. OBJECTIVE: To describe proportions of children receiving care in 6 types of health care setting on a monthly basis and to identify characteristics associated with receipt of care in these settings. METHODS: Nationally representative data from the 1996 Medical Expenditure Panel Survey were used to estimate the number of children per 1000 per month who received care at least once in each type of setting. Multivariate analyses assessed associations between receiving care in various settings and children's sociodemographic factors (age, sex, ethnicity, poverty, parent's education, urban or rural residence, insurance status, and whether or not the child had a usual source of care). RESULTS: Of 1000 children aged 0 to 17 years, on average each month 167 visited a physician's office, 82 a dentist's office, 13 an emergency department, and 8 a hospital-based outpatient clinic. Three were hospitalized and 2 received professional health care in their home. Younger age was associated with increased proportions of children receiving care in all health care settings except dentists' clinics. Poverty, lack of health insurance, black race, and Hispanic ethnicity were associated with decreased receipt of care in physicians' and dentists' offices. Only age (<2 years and 13-17 years) and poverty status were associated with hospitalization (P <.05 for each). Rural residence was not associated with any significant variation in proportions of children receiving care in any setting. Having a usual source of care was associated with increased receipt of care in all settings except hospitals. CONCLUSIONS: The ecology of children's medical care is similar to that of adults in the United States in that a substantial proportion of children receive health care each month, mostly in community-based, outpatient settings. In all settings except emergency departments, receipt of care varies significantly by children's age, race, ethnicity, income, health insurance status, and whether they have a usual source of care

CONTEXT: Dental decay is the most common chronic disease of children and it disproportionately affects those living in poverty, but the reasons for this are not clear. Passive smoking may be a modifiable risk factor for dental caries. OBJECTIVE: To examine the relationship between dental caries and serum cotinine levels. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional data from the Third National Health and Nutrition Examination Survey (1988-1994) of 3531 children aged 4 to 11 years, who had had both dental examinations and a serum cotinine level measurement. MAIN OUTCOME MEASURES: Passive smoking defined as serum cotinine levels of 0.2 to 10 ng/mL and caries defined as decayed (unfilled) or filled tooth surfaces. RESULTS: Twenty-five percent of the children had at least 1 unfilled decayed tooth surface and 33% had at least 1 filled surface. Fifty-three percent had cotinine levels consistent with passive smoking. Elevated cotinine level was significantly associated with both decayed (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.5-2.9) and filled (OR, 1.4; 95% CI, 1.1-1.8) tooth surfaces in deciduous but not in permanent teeth. This relationship persisted after adjusting for age, sex, race, family income, geographic region, frequency of dental visits, and blood lead level. For dental caries in deciduous teeth, the adjusted OR was 1.8 (95% CI, 1.2-2.7) for the risk of decayed surfaces and 1.4 (95% CI, 1.1-2.0) for filled surfaces. We estimated the population attributable risk from passive smoking to be 27% for decayed and 14% for filled tooth surfaces. CONCLUSIONS: There is an association between environmental tobacco smoke and risk of caries among children. Reduction of passive smoking is important not only for the prevention of many medical problems, but also for the promotion of children's dental health

OBJECTIVE: To assess the frequency of clinician-reported delivery of counseling for avoidance of child environmental tobacco smoke (ETS) exposure and tobacco use at periodic well-child visits and at illness visits for asthma and otitis media (OM). METHODS: Combined data from the National Ambulatory Medical Care Survey and the outpatient portion of the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 were analyzed. The frequency of pediatric visits (<or=18 years) that included clinician-reported counseling for tobacco use/exposure prevention was assessed. Diagnosis-specific visits were determined by using International Classification of Diseases, Ninth Revision codes for asthma (493-), OM (381-, 382-), and well-child visits. Bivariate and regression analyses were performed. RESULTS: Of 33 823 ambulatory care visits by children, 1.5% were reported to include delivery of tobacco counseling. Only 4.1% of well-child visits, 4.4% of illness visits for asthma, and 0.3% of illness visits for OM included tobacco counseling. With the use of logistic regression models, adolescent patient visits (13-18 years) were more likely to include delivery of tobacco counseling than younger child visits [OR = 15.8, 95% CI (7.5-33.5)]. Visits by children with Medicaid and those seen by a nurse practitioner or a physician's assistant were also more likely to include tobacco counseling (odds ratio: 1.6; 95% confidence interval: 1.002-2.50; and odds ratio: 3.0; 95% confidence interval: 1.5-6.0, respectively). There were no significant differences in counseling delivery by race, ethnicity, or clinician specialty. CONCLUSIONS: Rates of tobacco counseling at well-child visits and at illness visits for diagnoses directly affected by tobacco use and ETS are extremely low. Significant opportunities exist to improve counseling rates for child ETS exposure and adolescent tobacco use in primary care

CONTEXT: The 1999 surgeon general's report on mental health concluded that insufficient attention to mental health disorders is being paid in children's primary medical care services. This lack of attention has occurred despite considerable attention to this issue in the planning documents of many federal agencies. OBJECTIVE: To assess the extent to which federal agencies' portfolios of funded research grants were consistent with the directives for primary care-based mental health services for children and adolescents featured in their planning documents. DATA SOURCE: A cross-sectional review of the 66 749 abstracts listed in the April 2001 Computer Retrieval of Information on Scientific Projects (CRISP) database of currently funded research grants supported by the US Department of Health and Human Services. Abstracts were rated by whether they targeted primary care, examined behavioral or emotional issues, and examined or modified a facet of primary care. DATA SYNTHESIS: Of the 45 022 research abstracts in the CRISP database, 2720 (6%) contained the words children, adolescents, or youth. Sixty-three abstracts contained work on children, adolescents, or youth in primary care (0.14% of the portfolio). Of these 63 abstracts, only 21 (0.05% of the portfolio) addressed behavioral or emotional issues. Of the 21 projects, only 11 examined aspects of the primary care process. When the distribution of child and adult studies on the treatment of depression within primary care settings was examined, it was found that adults received 15 times the research attention compared with children. CONCLUSION: Even though the importance of primary care as a system for identifying and treating behavioral and emotional problems in children has been recognized for more than 20 years, little attention is being paid to this topic in the research portfolios of the National Institutes of Health and other federal agencies that support research