Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012.

OBJECTIVE: Neonatal abstinence syndrome (NAS), a postnatal opioid withdrawal syndrome, increased threefold from 2000 to 2009. Since 2009, opioid pain reliever prescriptions and complications increased markedly throughout the United States. Understanding recent changes in NAS and its geographic variability would inform state and local governments in targeting public health responses. STUDY DESIGN: We utilized diagnostic and demographic data for hospital discharges from 2009 to 2012 from the Kids' Inpatient Database and the Nationwide Inpatient Sample. NAS-associated diagnoses were identified utilizing International Classification of Diseases, Ninth Revision, Clinical Modification codes. All analyses were conducted with nationally weighted data. Expenditure data were adjusted to 2012 US dollars. Between-year differences were determined utilizing least squares regression. RESULTS: From 2009 to 2012, NAS incidence increased nationally from 3.4 (95% confidence interval (CI): 3.2 to 3.6) to 5.8 (95% CI 5.5 to 6.1) per 1000 hospital births, reaching a total of 21,732 infants with the diagnosis. Aggregate hospital charges for NAS increased from $732 million to $1.5 billion (P<0.001), with 81% attributed to state Medicaid programs in 2012. NAS incidence varied by geographic census division, with the highest incidence rate (per 1000 hospital births) of 16.2 (95% CI 12.4 to 18.9) in the East South Central Division (Kentucky, Tennessee, Mississippi and Alabama) and the lowest in West South Central Division Oklahoma, Texas, Arkansas and Louisiana 2.6 (95% CI 2.3 to 2.9). CONCLUSION: NAS incidence and hospital charges grew substantially during our study period. This costly public health problem merits a public health approach to alleviate harm to women and children. States, particularly, in areas of the country most affected by the syndrome must continue to pursue primary prevention strategies to limit the effects of opioid pain reliever misuse.

Racial differences in child safety restraint use in Tennessee.

OBJECTIVES: To evaluate the appropriate use of child safety restraints (CSR) in black and white children. DESIGN: Cross sectional, observational study of drivers of children age 0-10 years involving an on-site vehicle and CSR inspection and brief driver interview. RESULTS: Data were obtained on 244 white and 204 black children; results were stratified by race due to effect modification of race on driver restraint use and CSR use. Twenty four percent of black and 13% of white child passengers aged 4-10 years were completely unrestrained (p=0.003). Of the 168 black and 220 white child passengers aged 0-10 years who were restrained, 64% of black and 58% of white children had inappropriate restraint use. Appropriate CSR use was significantly lower in 4-8 year old passengers compared with appropriately restrained children aged <4 years and 9-10 years (p<0.0001 for both black and white child passengers). CONCLUSIONS: Black child passengers and all child passengers aged 4-8 years are at increased risk of being inappropriately restrained. Educational efforts should address specific barriers to booster seat use in these populations.

Corticosteroid prescription filling for children covered by Medicaid following an emergency department visit or a hospitalization for asthma.

OBJECTIVE: To identify predictors of corticosteroid prescription filling following an emergency department (ED) visit or a hospitalization for asthma. DESIGN: A retrospective cohort study. PATIENTS: Tennessee children (defined as those aged 2-17 years in this study) covered by Medicaid were included in the cohort if they had an ED visit or a hospitalization for asthma between July 1, 1995, and December 31, 1997. MAIN OUTCOME MEASURES: Prescriptions filled in the child's name for an oral corticosteroid within 7 days of the latest ED visit or hospitalization for asthma. RESULTS: Of 6035 Tennessee children covered by Medicaid with an ED visit for asthma and of 2102 covered by Medicaid with a hospitalization for asthma during the study period, less than half (44.8% following an ED visit and 55.5% following a hospitalization) had prescriptions filled for oral corticosteroids within 7 days. Factors independently predicting a child's not having an oral corticosteroid prescription filled included older age, black race, and residence in rural regions of the state. Conversely, children with oral corticosteroid prescriptions in the previous 6 months were more likely to have oral corticosteroid prescriptions filled following an ED visit for asthma, and children with more than 3 beta-agonist prescriptions in the previous 6 months were more likely to have oral corticosteroid prescriptions filled following a hospitalization for asthma. CONCLUSIONS: Overall, fewer than half of Tennessee children covered by Medicaid had an oral corticosteroid prescription filled following an ED visit or a hospitalization for asthma. Age, race, and county of residence predicted failure to have a prescription filled. Further study is needed to determine whether variations in corticosteroid prescription filling relate to physician practice, family behavior, or both.

Evaluating medicaid managed care programs for children.

Nearly every state has implemented some form of managed care for Medicaid recipients, partly in response to rapid increases in Medicaid expenditures. The unique features of children's health and the differences among states in the implementation and scope of their Medicaid managed care programs provide child health services researchers many opportunities to identify program features that result in favorable health outcomes and those that are less successful. Key stakeholders with interest in this information include state governments and managed care organizations charged with developing and implementing efficient delivery systems, as well as providers interested in understanding the best mechanisms for delivering care to children. This paper outlines potential approaches to evaluating Medicaid managed care programs for children, focusing on identification of appropriate data sources and selection of quality measures encompassing the structure, processes, and outcomes of health care.

Components of effective youth violence prevention programs for 7- to 14-year-olds.

OBJECTIVE: To classify features of effective violence prevention programs for 7- to 14-year-olds according to children's risk groups and targeted behaviors. DATA SOURCES: Articles published between 1980 and 1999 were identified via electronic databases (MEDLINE, ERIC, PsychINFO) using the key words violence, violence prevention, youth violence, or aggressive behavior. Reference lists were hand-searched for additional publications. STUDY SELECTION: One hundred fifty-three articles were reviewed with a modified scale by one of the principal investigators/authors (W.O.C. or M.L.) and a research assistant (K.F.); the other principal investigator resolved any discrepancies. Articles were included if they reported prevention efforts in 7- to 14-year-olds and compared outcome measures, met requirements for scientific rigor, and reported significant improvements (effect size, >0.1 or P< or =.05). Sixty-seven percent (n = 102) did not meet the inclusion criteria. Of the remaining 51 articles (33%), 38 met requirements for scientific rigor, and 32 articles describing 25 programs reported significant improvements in at least 1 area. RESULTS: Twenty-five programs indicated significant improvements in attitudes, knowledge, or intentions (n = 10) and/or reduction in delinquency rates and violent and/or aggressive behavior (n = 11); significant changes in both types of outcomes were indicated in 4 programs. Most programs (n = 13) targeted older children (aged 11-14 years) and focused on fighting (n = 13) and conflict management (n = 14). Classroom teaching was the most common process (n = 18) used. Few programs (n = 7) involved family intervention. CONCLUSIONS: Although limited in number, effective youth violence prevention programs were identified from current literature. Study findings were compiled into a database outlining effective processes for specific sociodemographic and risk behavior groups that will be helpful to future program planning.

Scurvy presenting as painful gait with bruising in a young boy.

A case of scurvy occurred in an apparently well-nourished 5-year-old boy with normal growth parameters. Only after the diagnosis of scurvy was raised on clinical grounds did we discover the peculiar dietary habits that were responsible for his deficiency of ascorbic acid. His case is a reminder to the clinician that nutritionally based disease may occur in any socioeconomic setting and that nutritional screening remains an important part of every child's general health care.

Changes in continuity of enrollment among high-risk children following implementation of TennCare.

BACKGROUND: TennCare, Tennessee's Medicaid managed care program, was introduced in 1994 with the goals of controlling spending and of improving access to health care. OBJECTIVE: To assess changes in the continuity of enrollment following the implementation of TennCare for 2 groups: infants in the first year of life (defined as persons aged 0-12 months in this study) and children hospitalized with a chronic health condition (defined as persons aged 0-18 years in this study). DESIGN: Retrospective cohort analysis. SETTING AND POPULATION: Infants born during 1992 or 1995 to women enrolled in Medicaid or TennCare and 0- to 18-year-old children enrolled in Medicaid or TennCare who were discharged from a hospital during 1992 or 1995 with a chronic health condition. MAIN OUTCOME MEASURES: For infants, failure to enroll an infant in the first 30 days of life or subsequent gaps in enrollment for 7 days or longer during the first year of life. For children hospitalized with a chronic health condition, any gap in enrollment lasting 7 days or longer by 1 year after discharge from a hospital. RESULTS: There was a reduction in the proportion of infants without continuous enrollment in the first year of life following TennCare (19.4% after vs 25.1% before TennCare; odds ratio, 0.69; 95% confidence interval, 0.67-0.72). Improvements in continuity of enrollment for infants occurred despite an increase in the proportion of infants who were not enrolled in TennCare in the first 30 days of life, even though their mother was enrolled at delivery (14.0% after vs 8.0% before TennCare; odds ratio, 1.86; 95% confidence interval, 1.78-1.96). There was a decrease in the proportion of children hospitalized with a chronic health condition who had subsequent gaps in enrollment by 1 year following discharge from a hospital (14.3% after vs 23.3% before TennCare; odds ratio, 0.52; 95% confidence interval, 0.46-0.59). CONCLUSION: For infants in the first year of life and for children hospitalized with a chronic health condition, implementation of TennCare improved continuity of coverage.

Comparison of perinatal outcomes among TennCare managed care organizations.

OBJECTIVE: To compare perinatal outcomes among the managed care organizations (MCOs) providing care to beneficiaries enrolled in TennCare, Tennessee's capitated Medicaid managed care program. DESIGN: Retrospective cohort analysis. SUBJECTS: Infants born in Tennessee during 1995 to women enrolled in TennCare. PRIMARY OUTCOME MEASURES: Prenatal care use, birth weight (BW), death in the first 60 days of life, and delivery of extremely low BW (<1000 g) infants in hospitals without level 3 neonatal intensive care units. RESULTS: During 1995, 34 402 infants were born to mothers enrolled in TennCare. The MCOs differed widely in the demographic characteristics of their enrollees. In addition, there were small differences in prenatal care utilization, but no differences in BW outcomes among the MCOs. In multivariate analysis, however, infants born to women enrolled in 1 MCO were 2.8 times more likely to die in the first 60 days of life than were infants born to women enrolled in the largest MCO (OR: 2.81; 95% CI: 1.31-6.03). Women enrolled in this same MCO seemed to have a higher proportion of extremely low BW (<1000 g) infants delivering in a hospital lacking a level 3 neonatal intensive care unit (38% vs 20% in the largest MCO). CONCLUSION: The differences among MCOs in early infant death and in the delivery of high-risk infants in hospitals lacking appropriate neonatal facilities suggest that monitoring of care delivery to vulnerable children should include assessment of appropriate use of specialized services.

Early childhood mortality from community-acquired infections.

In this study, the authors identified maternal and child characteristics that were independent predictors of death from infectious diseases acquired in the community and determined if these factors could be used to identify groups of children with excess risk of mortality from infection. A historical cohort study was conducted of children less than 5 years of age between 1985 and 1994 (the study period), who were born in Tennessee, and had complete information on their birth certificates. The primary outcome was death from infection identified from death certificates and confirmed through medical record review. Among the 1,014,976 children less than 5 years of age, who contributed 3,351,568 child-years of follow-up, there were 247 deaths from infections (7.4 deaths from infections per 100,000 child-years). Respiratory infections accounted for approximately one half of the deaths. Children having three or more older siblings or birth weight of less than 1,500 g had a 3-fold and 10-fold increased risk of death from infection, respectively, while children with both characteristics had a nearly 20-fold increased risk that persisted beyond the first year of life. Interventions should be focused on prevention of these infections in vulnerable children. At-risk children should be targeted for careful follow-up and early hospitalization when signs of infection develop.

Prevalence and correlates of blood pressure elevation in children with Guillain-Barré syndrome.

While there have been case reports describing blood pressure elevation in adults and children with Guillain-Barré syndrome (GBS), no previous systematic study has explored the prevalence of hypertension in children with this condition. In a retrospective review, blood pressure elevation was seen in 20 of 30 (66.7%) patients with GBS admitted to a children's hospital during a 10-year period. There was a significant correlation between highest GBS stage and deviation of systolic blood pressure from age- and gender-specific norms (r = 0.93, p < 0.05). Since blood pressure may be markedly elevated in GBS, the clinician caring for a child with this condition should be aware of this complication.

Effects of pediatrician characteristics on management decisions in simulated cases involving apparent life-threatening events.

OBJECTIVES: To study variations in the way pediatricians would evaluate and manage an infant with an apparent life-threatening event. SUBJECTS AND METHODS: A survey was mailed to the chief residents of all pediatric residency training programs in the United States in which respondents were presented with a simulated case and asked how they would manage an infant who had experienced an apparent life-threatening event that did not require resuscitation. The survey also explored each physician's tolerance of uncertainty, knowledge of apparent life-threatening events, experience, fear of litigation, responsiveness to parental demands, and propensity to order tests. MAIN OUTCOME MEASURES: Presumed decisions to prescribe antibiotics and/or order home apnea monitoring in a simulated case of an infant who had experienced an apparent life-threatening event not requiring resuscitation. RESULTS: Logistic regression analysis revealed 2 characteristics that made significant and independent contributions to respondents' presumed decision to prescribe antibiotics: (1) experience with an adverse outcome, and (2) propensity to order diagnostic tests. Presumed decisions to order a home apnea monitor were notably affected by fear of litigation. CONCLUSIONS: These findings suggest that differences in pediatricians' characteristics contribute to variations in care. Efforts to make management more uniform must consider that decisions are influenced by a host of different characteristics and experiences.

New use of anticonvulsant medications among children enrolled in the Tennessee Medicaid Program.

OBJECTIVE: To describe the new use of anticonvulsant medications among children enrolled in the Tennessee Medicaid program. DESIGN: A retrospective cohort study. PATIENTS: New users of anticonvulsant medications in 1992 were identified from the 206,098 children (aged 0-18 years) enrolled continuously for 12 months in the Aid to Families With Dependent Children program or foster care program of Tennessee Medicaid. MAIN OUTCOME MEASURES: New users were categorized according to the diagnosis codes of health care encounters occurring 90 days before to 90 days after the first anticonvulsant prescription was filled as having diagnoses consistent with (1) epilepsy or convulsions, (2) neonatal seizures, (3) central nervous system disease, (4) no epilepsy diagnoses but diagnoses for which anticonvulsants might appropriately be used (jaundice, headaches, or psychiatric disorders), or (5) no diagnoses for which an anticonvulsant might appropriately be used. The children in each group were described according to sociodemographic variables, with logistic regression used to analyze variations in the subsequent filling of anticonvulsant prescriptions. RESULTS: Of 647 children continuously enrolled in the Tennessee Medicaid program who were new anticonvulsant users in 1992, 58% had at least 1 health care encounter coded as epilepsy or convulsions, 2% had a diagnosis of neonatal seizures, 8% had central nervous system diagnoses, 16% had specific nonepilepsy diagnoses (jaundice, headache, or psychiatric diagnoses), and 16% had no diagnoses for which anticonvulsants might appropriately be prescribed. For children with epilepsy diagnoses, white race (P = .002) and undergoing tests (P < .001) were independent predictors of a child filling 6 or more prescriptions in the year following the first prescription CONCLUSIONS: A large proportion of new users of anticonvulsants among children enrolled in the Tennessee Medicaid program received these medications for indications other than epilepsy. For children with epilepsy diagnoses, there was considerable variation in the subsequent filling of prescriptions. Further analysis of these variations in practice will allow for the development of policies that will maximize benefit for children who need anticonvulsant therapy, while diminishing unnecessary exposure to potentially toxic drugs for children who do not.

Use of health care services by inner-city infants in an early discharge program.

OBJECTIVE: To assess the use of health care services by inner-city infants enrolled in an early discharge program who received care in tertiary care children's hospital primary care clinic. DESIGN: Retrospective cohort study. SETTING: Large, metropolitan university hospital and a children's hospital. PATIENTS: Term infants cared for in a single full-term nursery, before and after implementation of a coordinated early discharge program, who received primary care at the children's hospital. INTERVENTION: The coordinated Early Discharge Program was characterized by in-hospital visits by hospital-based coordinating nurses, home visits by nurses from a home nursing agency, and communication with physicians for necessary adjustments in postdischarge care. METHODS: After linking birth hospital records and the children's hospital medical records, a retrospective chart review was performed to obtain maternal demographic information and birth hospital length of stay, as well as the infants' attendance at primary care clinic, immunizations, emergency department visits, and rehospitalization. MAIN OUTCOME MEASURES: Number of primary care visits in the first 3 months of life, completion of one series of immunizations by 3 months of life, and number of emergency department visits and rehospitalization during the first 3 months of life. RESULTS: The early discharge group (n = 253) had a significantly shorter birth hospital length of stay (35 +/- 24 hours, mean +/- SD) when compared with the control group (n = 212) (52 +/- 14 hours). The early discharge group was also younger than the control group at the first primary care visit, with significantly more infants visiting the primary care clinic in the first month of life. There was also a significant difference between the groups in the mean number of emergency department visits (early discharge = .61 visits/patient, control = .79 visits/patient) and the proportion of patients with no emergency department visits during the first 3 months of life (early discharge = 57%, control = 43%). There was no difference between the two groups in the proportion of infants completing one series of immunizations or in the number of infants rehospitalized during the study period. CONCLUSIONS: Coordinated early discharge with home nursing visits for inner-city infants may result in earlier use of primary care services. Furthermore, there is a significant decrease in use of the emergency department during the first 3 months of life, and no increase in rehospitalization.

Increased incidence of severe breastfeeding malnutrition and hypernatremia in a metropolitan area.

OBJECTIVE: To identify common characteristics among infants with breastfeeding malnutrition in a region with an increasing incidence of breastfeeding malnutrition. DESIGN: Retrospective case series. SETTING: A 361-bed regional tertiary care children's hospital in a 1.7 million population metropolitan area. CASE SERIES: five infants with severe breastfeeding malnutrition and hypernatremia admitted to a tertiary care children's hospital over a 5-month period. Retrospective case review: 166 infants admitted between 1990 and 1994 with the diagnosis of dehydration, hypernatremia, or malnutrition. MAIN OUTCOME MEASURES: Maternal characteristics, age at presentation, percent loss from birth weight, serum sodium, average age at birth hospital discharge, neurologic, or cardiovascular complications. RESULTS: Five infants were admitted to a children's hospital over a 5-month period with severe breastfeeding malnutrition and hypernatremia. The average weight loss at time of readmission was 23% (+/- 8%) from birth weight. The average presenting sodium was 186 +/- 19 mmol/L. Three suffered significant complications. From 1990 through 1994, there was a statistically significant (P < .05) annual increase in the number of infants admitted with breastfeeding malnutrition and hypernatremia. CONCLUSIONS: While breastfeeding malnutrition and hypernatremia is not a new problem, this cluster of infants represents an increase in frequency and severity of the problem and could be a consequence of several factors, including inadequate parent education about breastfeeding problems and inadequate strategies for infant follow-up.

Acceleration of onset of collagen-induced arthritis by intra-articular injection of tumour necrosis factor or transforming growth factor-beta.

We examined whether tumour necrosis factor (TNF) or transforming growth factor-beta 1 (TGF-beta 1) could alter the course of collagen-induced arthritis (CIA). Injection of 100 ng TNF or 500 ng TGF-beta 1 into ankle joints of normal rats induced a very limited inflammatory response, observable only upon histological analysis. However, when injected into ankle joints of rats 9 days after immunization with bovine type II collagen (CII), identical doses of TNF or TGF-beta 1 induced a sustained, clinically obvious inflammation and oedema that began within 8 h on average, as compared to 90 h in CII-immunized control rats given no injections or intra-articular injections of buffer. The incidence of arthritis at 2 weeks post-immunization was 100% for TNF-injected hindpaws, compared with 55% for the control groups, a statistically significant difference. In rats passively immunized with a subarthritic dose of affinity purified antibody to rat-CII, intra-articular injection of 100 ng TNF or 500 ng of TGF-beta 1 also induced intense, though transient arthritis. The rapid proinflammatory effects in CIA described in this study and the synergy demonstrated between anti-CII IgG and either cytokine, suggest that these cytokines can participate locally in the pathogenesis of arthritis.