Children with asthma and nebulizer use: parental asthma self-care practices and beliefs.

We examined demographic characteristics, patterns of medication use, asthma morbidity, and asthma self-management practices and beliefs among inner-city children currently using a nebulizer. We also describe the relationship between asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room visits, hospitalizations, symptom days and nights, and school absences in this group of school-aged children with asthma. More than three-quarters (81%) reported asthma symptoms consistent with mild persistent or greater severity of asthma, and therefore these subjects should be taking AI medications. Another 16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more likely to agree with the belief that children should use asthma medications daily even when the child is not reporting any symptoms.

Effectiveness of a home intervention for perceived child behavioral problems and parenting stress in children with in utero drug exposure.

OBJECTIVE: To determine if a home-based nurse intervention (INT), focusing on parenting education/skills and caregiver emotional support, reduces child behavioral problems and parenting stress in caregivers of in utero drug-exposed children. DESIGN: Randomized clinical trial of a home-based INT. SETTINGS: Two urban hospital newborn nurseries; homes of infants (the term infant is used interchangeably in this study with the term child to denote those from birth to the age of 36 months); and a research clinic in Baltimore, Md. PARTICIPANTS: In utero drug-exposed children and their caregivers (N = 100) were examined when the child was between the ages of 2 and 3 years. Two groups were studied: standard care (SC) (n = 51) and INT (n = 49). INTERVENTION: A home nurse INT consisting of 16 home visits from birth to the age of 18 months to provide caregivers with emotional support and parenting education and to provide health monitoring for the infant. MAIN OUTCOME MEASURES: Scores on the Child Behavior Checklist and the Parenting Stress Index. RESULTS: Significantly more drug-exposed children in the SC group earned t scores indicative of significant emotional or behavioral problems than did children in the INT group on the Child Behavior Checklist Total (16 [31%] vs 7 [14%]; P =.04), Externalizing (19 [37%] vs 8 [16%]; P =.02), and Internalizing (14 [27%] vs. 6 [12%]; P =.05) scales and on the anxiety-depression subscale (16 [31%] vs. 5 [10%]; P =.009). There was a trend (P =.06) in more caregivers of children in the SC group reporting higher parenting distress than caregivers of children in the INT group. CONCLUSIONS: In utero drug-exposed children receiving a home-based nurse INT had significantly fewer behavioral problems than did in utero drug-exposed children receiving SC (P =.04). Furthermore, those caregivers receiving the home-based INT reported a trend toward lower total parenting distress compared with caregivers of children who received SC with no home visits.

Maternal depressive symptoms and emergency department use among inner-city children with asthma.

CONTEXT: Inner-city minority children with asthma use emergency departments (ED) frequently. OBJECTIVE: To examine whether maternal depressive symptoms are associated with ED use. DESIGN, SETTING, AND PATIENTS: Baseline and 6-month surveys were administered to mothers of children with asthma in inner-city Baltimore, Md, and Washington, DC. MAIN OUTCOME MEASURES: Use of the ED at 6-month follow-up was examined. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data. RESULTS: Among mothers, nearly half reported significant levels of depressive symptoms. There were no demographic or asthma-related differences between the children of mothers with high and low depressive symptoms. However, in bivariate analyses, mothers with high depressive symptoms were 40% (prevalence ratio [PR], 1.4; 95% confidence interval [CI], 1.0-3.6; P =.04) more likely to report taking their child to the ED. Mothers aged 30 to 35 years were more than twice as likely (PR, 2.2; 95% CI, 1.9-9.3; P =.001) to report ED use, as were children with high morbidity (PR, 1.9; 95% CI, 1.4-7.1; P =.006). Child age and family income were not predictive of ED use. After controlling for asthma symptoms and mother's age, mothers with depressive symptoms were still 30% more likely to report ED use. CONCLUSIONS: Depression is common among inner-city mothers of children with asthma. Beyond asthma morbidity, maternal age and depressive symptoms are strong predictors of reports of ED visits. Identifying and addressing poor psychological adjustment in mothers may reduce unnecessary ED visits and optimize asthma management among inner-city children.

Nebulizer use in inner-city children with asthma: morbidity, medication use, and asthma management practices.

OBJECTIVE: To assess the frequency of nebulizer use, describe morbidity and patterns of medication administration, and examine the potential relationships between inhaled anti-inflammatory medication administration, asthma morbidity, and asthma management practices in children with asthma using a nebulizer compared with children with asthma not using a nebulizer. RESEARCH DESIGN: A cross-sectional, descriptive survey of previous events. SETTING: Elementary schools and participants' homes in Baltimore, Md, and Washington, DC. PARTICIPANTS: Six hundred eighty-six families of children aged 5 to 12 years with a diagnosis of at least mild, persistent asthma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Asthma morbidity, health care utilization, pattern of asthma medication administration, nebulizer use, and asthma management data were collected by telephone survey administered to caregivers. Nebulizer use was defined as use at least 1 or more days per month during the last 6 months. Of 686 children identified, 231 (33%) reported current nebulizer use. Nebulizer users had significantly increased lifetime hospital admissions, hospitalizations, and emergency department visits in the last 6 months compared with nonnebulizer users. Inhaled corticosteroid administration was low for both groups (nonnebulizer users, 8%; nebulizer users, 15%). In the nebulizer users group, administration of inhaled anti-inflammatory medications was associated with increased asthma morbidity (increased hospitalizations, days and nights with symptoms, and oral steroid use). CONCLUSIONS: Nebulizer use by inner-city children with asthma is higher than anticipated but is not associated with reduced asthma morbidity. This group of high-risk children was undertreated with inhaled corticosteroids for long-term control of asthma despite reports of adequate monitoring by a primary care physician.

Emergency department visits by urban African American children with asthma.

BACKGROUND: Asthma morbidity among African American children has been identified as a significant national health concern. High emergency department use is one index of this morbidity and may reflect disease severity, disease management, and social factors. OBJECTIVE: This study examined the prevalence and correlates of emergency department use and other indices of asthma morbidity among a sample of urban, low-income, African American children. METHODS: Parents of 392 elementary school children with asthma who had consented to participate in an asthma education program were interviewed by phone according to a standardized protocol. RESULTS: Children had a mean of 6.2 days of restricted activity (SD 8.1) and 7.9 symptomatic nights (SD 8.1). The mean number of school days missed because of asthma was 9.7 (SD 13.5). Among children with asthma symptoms in the past 12 months, 73.2% could identify a specific physician or nurse who provided asthma care. For those families without an identified asthma primary care provider, 39.3% received their usual asthma care from the emergency department. A total of 43.6% of the children had been to the emergency department for asthma care without hospitalization in the previous 6 months. Close to 80% of children reported using one or more prescribed asthma medication, and of these only 12% reported using inhaled anti-inflammatory medications. Families of children who had used the emergency department in the prior 6 months reported more asthma symptoms, lower social support, problems paying for health care, and the absence of a hypoallergenic mattress cover and that they had seen a physician for regular asthma care in the past 6 months. CONCLUSIONS: We conclude that asthma management for children in the inner city relies on episodic care and emergency care, that asthma medication management does not conform to current guidelines, and that asthma symptoms resulting in school absences and workdays lost are prevalent.

Sequential neuromotor examination in children with intrauterine cocaine/polydrug exposure.

Data are presented on 157 newborn infants followed sequentially in a randomized home-based nursing-intervention trial for drug-exposed infants with follow up at 3 (N=118), 6 (N=124), and 12 months (N=77). The objectives of this study were to describe the longitudinal neurodevelopmental status of a cohort of children with intrauterine exposure to illicit drugs during their gestation, characterize the evolution of early tone abnormalities in a polydrug-exposed cohort, and determine whether neuromotor outcome is associated with drug-exposure patterns. For analysis, infants were grouped based on maternal drug-use pattern and the presence of drug metabolites in the neonatal drug screen. The sequential neuromotor examination was used at each age to define the neuromotor status of six domains and define categorical classifications as either normal, suspect, or abnormal. Multiple patterns of neuromotor abnormalities were observed during the neonatal period; most resolved over time. Axial hypotonia was a prominent finding in the neonatal period; however, it was infrequent in abnormal examinations at 12 months. Increased lower-extremity tone was a less frequent finding during the neonatal period. Infants whose neonatal urine drug screen was positive for both cocaine and opiates, were more likely than infants with negative urine drug screens, cocaine only, or opiate only drug screen results to have abnormal neuromotor examinations; while positive maternal drug screens for concurrent cocaine and opiate use were associated with peripheral hypertonia. Persistence of increased leg-extensor tone was found in 67% of the abnormal examinations at 12 months. Acquisition of rolling and walking was delayed in the drug-exposed cohort.

Ethical conflicts experienced by certified pediatric nurse practitioners in ambulatory settings.

INTRODUCTION: The purpose of this descriptive study was to (a) identify the types of ethical conflicts and their resolutions reported by a group of certified pediatric nurse practitioners (CPNPs) in their ambulatory practice and (b) to examine demographic, educational, and practice-setting factors associated with these conflicts. METHOD: Five hundred fifty-nine CPNPs, identified by the National Association of Pediatric Nurse Associates and Practitioners, received survey questionnaires in the mail and were asked to participate by describing an ethical conflict in their practice. Questionnaires were completed by 118 CPNPs. Each ethical conflict was analyzed according to a four content analysis classification system to capture multiple relevant meanings. The relationship between types of ethical conflicts and demographic, educational, and practice-setting variables was examined. RESULTS: One third (34%) of the perceived ethical conflicts fell in the child/parent/practitioner relationship category. Most conflicts (31%) were experienced as a moral dilemma where 2 or more clear moral principles apply but they support mutually inconsistent courses of action. Most ethical conflicts (22%) were unresolved. DISCUSSION: Understanding the nature of ethical conflicts that CPNPs are experiencing in ambulatory settings is important. Professional and institutions/agencies need to collaborate on how to initiate appropriate ethics education and consultation for professional staff to recognize, discuss, and resolve ethical conflicts in the workplace.

Home intervention for in utero drug-exposed infants.

Each year in the United States, around 5.5% (or 230,000) infants are born to mothers who used illicit drugs during pregnancy. The untoward effects of in utero drug exposure (IUDE) include significant decreases in birthweight and length and head circumference, prematurity, and developmental problems. Intensive early intervention, including home-based interventions, is recognized as an effective method to improve cognitive development and reduce health problems in these high risk infants and children. Examination of home visit records of 20 IUDE infants during their first year of life revealed frequent health and social problems. Infectious disease symptoms were the most frequent problem encountered in the home during the physical assessment of the infants. Of note was the mothers' lack of basic parenting information (understanding signs of illness, basic nutrition, and infant development) which was then provided by the nurse during each home visit. Of concern was the lack of drug treatment sought by these mothers. Findings support the view that home visiting should be incorporated into the discharge planning of any IUDE infant in order to maintain these infants in the health care system and monitor their safety.

Medications used by children with asthma living in the inner city.

OBJECTIVE: The purpose of the study was to examine medication use reported by families participating in an urban school-based community intervention program and to relate this use to other social and medical variables. DESIGN: The design of the study was a cross-sectional questionnaire survey. SETTING: Patients and their families recruited from elementary schools in a community setting were interviewed between December 1991 and January 1992. PARTICIPANTS: A total of 508 children with asthma were identified by school health records and teacher surveys. Their families confirmed the diagnosis and agreed to enter the study. Questionnaires were completed by 392 families. INTERVENTION: The 392 families participated in a controlled trial of asthma education after providing the data that are the basis of this report. RESULTS: More than half of the children took two or more medications for asthma. Thirty-one percent took theophylline alone or in combination with an adrenergic agent; 11% took some form of daily antiinflammatory medication, either cromolyn (8%) or inhaled steroids (3%). The pattern of medication use related to measures of severity and to regular visits to physicians or nurses. In general, however, children were undermedicated. A total of 78 children (20%) reported no medication or over-the-counter medication use, although 37% reported asthma severe enough to be associated with >/=20 days of school missed per month, and 37% had had an emergency room visit for asthma in the past 6 months. More than half of children >/=9 years old supervised their own medication. CONCLUSIONS: We concluded that undermedication is common in poor children with asthma living in urban areas. Antiinflammatory medications are used less commonly than in the general population, and theophylline is used more often. School children may be likely to supervise their own medication.

Primary care for children with human immunodeficiency virus infection.

Pediatric human immunodeficiency virus (HIV) infection is now the seventh leading cause of death in U.S. children 1 to 14 years of age and the leading cause of death in children 2 to 5 years of age in many U.S. cities. The key to enhancing the quality and duration of life in HIV-infected children is to recognize and diagnose HIV infection as early as possible and to initiate prophylactic and antiretroviral therapies. Most of the medical treatment of these children can be conducted in a primary care setting if (a) primary care practitioners are informed of current treatment regimens and (b) adequate pediatric HIV consultation service is available. This article reviews the primary care of HIV-infected children including early diagnosis, current treatment options, and the complex psychosocial issues associated with caring for these children.

Moving health care education into the community.

The A+ Asthma Club, an educational program developed for elementary school children in inner-city schools, is offered through a series of six sessions during school hours with an additional three booster sessions. This article describes how the program was designed, its theoretical basis, the curriculum and its staffing.

Enhancing the role of community-health workers in research.

With recognition of the importance of meeting the needs of underserved communities and the shift to more primary care-community-health workers need to be part of health teams. Community-health workers, in voluntary and salaried positions, augment the roles of professionals through outreach and community-based work and serve as liaisons between communities and institutions. This article describes the rationale for inclusion of community-health workers in research; their roles and responsibilities; and issues in their selection, training, and supervision. Examples are given from the authors' experience with interventions by nurse and community teams. Inclusion of community-health workers enriches the comprehensiveness of a holistic scientific approach to understanding health in a community.

Social factors associated with behavioral problems in children with asthma.

The objective of this study was to describe the proportion of children with a behavior problem and examine which independent variables are associated with the presence of a behavior problem in a group of 392 inner-city children with asthma. Data on child asthma symptoms, medication use, health-care utilization, and school absences were obtained from the parent during a structured telephone interview. Included in the interview was a measure of behavior problems and social support questions. Children classified with a high level of asthma symptoms were more than twice as likely to experience a behavior problem than children classified with a low level of asthma symptoms (P = 0.002). Use of theophylline medication was not correlated with behavior problems (P = 0.45). Significant variables were low level of social support and high or moderate level of asthma symptoms. We have identified a group of children at risk for behavior problems, specifically in families that lack adequate social and financial resources.

Use of community health workers with inner-city children who have asthma.

Use of community health workers (CHWs) to obtain health, social, and environmental information from African-American inner-city children with asthma was one component of a larger intervention study designed to reduce morbidity in African-American children with asthma. A subset of 140 school-aged children with asthma was recruited and enrolled in a program to receive home visits by CHWs for the purposes of obtaining medical information and teaching basic asthma education to the families. Data obtained by the CHWs revealed low inhaled steroid use, high beta 2 agonist use, frequent emergency-room visits, decreased primary-care visits, and increased allergen and irritant exposure. Appropriately recruited and trained CHWs are effective in obtaining useful medical information from inner-city families with children with asthma and providing basic asthma education in the home.

Home environmental risk factors in urban minority asthmatic children.

Urban minority families with children with asthma often live in homes with allergen and irritant exposures harmful to these children. We enrolled 392 African-American asthmatic children, male and female, aged 5 to 12, from 42 schools in Washington, DC and Baltimore, MD. The project is designed to test the effectiveness of school-based asthma education interventions, community-based asthma health workers' programs, and the combination on these children. Baseline telephone interviews were carried out with the primary home care-givers for demographic data and for environmental home exposures that exacerbated asthma. Exposures stated to cause wheezing in the children were cigarette smoke in 72%, dust in 53%, cats in 34%, dogs in 27%, and roach exposure in 15%. Fifty-six percent of children live with cigarette smoke exposure, 73% of which is from mothers. This was a highly symptomatic group with 44% reporting two or more days per week of restricted activity and 62% reporting two or more episodes of night symptoms per week. Those with mattress covers on beds had significantly fewer emergency department visits in the past 6 months than those without covers. Over one-third of parents reported children taking two bronchodilators without anti-inflammatory agents. Less than 20% were reported using anti-inflammatory medications. Decreasing asthma severity in this population entails the prevention and control of known risk factors in the home environment. Emphasis must be placed on cigarette smoking cessation programs, covering mattresses, and dust and animal dander control. Primary care physicians require education on the role of anti-inflammatory medications.

Prevalence of rotavirus on high-risk fomites in day-care facilities.

STUDY OBJECTIVE: The objective of this study was to determine the prevalence of rotavirus contamination on environmental surfaces in day-care environments, using the polymerase chain reaction technique. DESIGN: High-risk fomites were identified in two day-care centers and sampled biweekly during a 6-month study period. Water samples from water-play tables in each center were also collected during the study period. During an infectious disease outbreak, fomites were sampled from the rooms in which the outbreak occurred. Reverse transcriptase/polymerase chain reaction was carried out for viral detection of rotavirus from the fomites, and standard bacteriologic measures were used to detect bacteria in samples from water-play tables. RESULTS: A total of 96 fomite samples were tested for presence of rotavirus from the two centers, of which 18/96 (19%) tested positive for rotavirus. The timing of the positive samples differed between the two centers. In the center that housed infants, a peak of rotavirus-positive fomites coincided with two enteric outbreaks. Rotavirus contamination was found on the telephone receiver, drinking fountain, water-play table, and toilet handles in both centers. Bacteria in large quantities were also identified in water-play table samples. CONCLUSIONS: Moist surfaces including the telephone, water fountains, and water-play tables are common sources of rotavirus contamination within the day-care environment. Until a safe and affordable drug or vaccine against rotavirus is available for general use, avoidance of rotaviral infections is the most effective method for the prevention of rotavirus gastroenteritis.

Infant health care utilization predicted by pattern of prenatal care.

STUDY OBJECTIVE: The objective of this study was to examine the relationship between patterns of prenatal care and subsequent infant health care use in a sample of inner-city women and their infants. In testing this relationship we controlled for several sociodemographic, economic, and psychological factors. DESIGN: This case-control study examined medical records of 148 infants born to mothers previously enrolled in a 9-month study of prenatal care and use or nonuse of illicit drugs. Cases (N = 62) were defined as infants born to women who first registered for prenatal care after 28 weeks' gestation or completed fewer than four prenatal visits. Controls (N = 86) were all other infants matched by date of birth. Data on maternal health and sociodemographic factors were obtained from a maternal interview and medical record review. Maternal drug use was defined as the use of illicit drugs at any time during the pregnancy based on maternal interview and/or a positive maternal or neonatal urine toxicology screen obtained within 48 hours of delivery. RESULTS: Infants of case mothers had significantly lower birth weight and gestational age, increased number of protective service referrals, and lower completion rate of three or more health supervision visits by 9 months of age. Multiple logistic regression analysis revealed that adequate prenatal care was significantly associated with adequate use of infant health care independent of maternal drug use, educational level, marital status, and number of previous living children. CONCLUSIONS: Patterns of infant health care use can be predicted before birth based on the mother's pattern of prenatal care use.

Prenatal care and drug use in pregnant women.

This case-control study tested the hypothesis that pregnant inner-city women with low utilization of prenatal care are likely to be frequent drug users. Cases registered consecutively for prenatal care at > or = 28 weeks gestation or had < 4 prenatal visits. Controls were matched to cases by date of delivery. 24/81 (30%) cases and 16/128 (12%) controls were frequent drug users (adjusted odds ratio = 2.5; 95% CI, 1.2-5.4). Drug use (P = 0.01) and socioeconomic status (P = 0.001) were significantly correlated with prenatal care utilization. Self-report alone failed to note as many drug users as toxicology screen alone. Both substance use history and toxicology screen are advisable in women with low utilization of prenatal care.

HIV-infected women and infants. Social and health factors impeding utilization of health care.

The utilization of health care by HIV-seropositive pregnant women and their infants was studied in an indigent urban population. Ninety HIV-seropositive women delivered 99 HIV-exposed infants at the Johns Hopkins Hospital from August 1, 1988, to April 1, 1991. Repeat pregnancies occurred in 17 (18.9%) women during the study period. Completion of the primary immunization series by age nine months was the criteria for infant adherence to medical care. Of all infants, 72.9% achieved adequate immunization status by nine months. However, only 41 (45.6%) women reported ever seeking HIV-related health care. Factors associated with maternal adherence with HIV-related health care included HIV status of her infant, maternal drug use, and incarceration. Number of living children, maternal age, educational level, marital status, and repeat pregnancy were not associated with mothers seeking HIV-related health care. Despite low adherence to HIV-related health care in this sample of HIV-seropositive women, the majority of their infants did receive adequate immunizations, one proxy measure of adequate infant health care.