Outpatient management of young febrile infants with urinary tract infections.

OBJECTIVE: Controversy exists regarding the disposition of young febrile infants who present to emergency departments (EDs) with urinary tract infections (UTIs). In a large multicenter cohort of such patients, we aimed to determine the variation in patient disposition and clinical factors independently associated with outpatient management. METHODS: Secondary analysis of a retrospective study of infants 29 to 60 days with fever (≥38.0°C), urinalysis finding, and culture-proven UTIs presenting to 20 North American EDs belonging to the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. We determined independent factors associated with outpatient management. RESULTS: Of 1764 infants with UTIs, 132 (7.5%) were discharged home from the ED. The proportion of infants managed as outpatients varied among sites (0%-20.0%). Of the 132 infants, 29 (22.0%) were subsequently hospitalized after culture results were known, including 5 patients with bacteremia. None of the 107 patients initially discharged from the ED for whom outcomes were known had adverse events (0%; 95% CI, 0%-2.7%). On multivariable regression and generalized estimated equations analyses, only clinical site, presence of upper respiratory tract infection symptoms, absence of vomiting, and having fewer than 10 white blood cells per microliter on cerebrospinal fluid examination were independently associated with discharge from the ED. Clinical site was the factor most highly associated with outpatient management (odds ratio, 8.8; 95% confidence interval, 5.2-15.0). CONCLUSIONS: There is substantial practice variation regarding the disposition of febrile infants 29 to 60 days of age with UTIs. Institutional practice is the strongest predictor of outpatient management. Further evidence is needed to guide the management of non-toxic-appearing young febrile infants with UTIs.

Acute care costs in overweight children: a pediatric urban cohort study.

BACKGROUND: Evidence indicates obese children have increased health care utilization. It is unknown if this is true within the emergency department (ED) setting. Our purpose is to determine if overweight children presenting for emergency care have increased resource utilization over normal weight peers. METHODS: We conducted a retrospective cohort study of children 2 to <18 years old presenting to a pediatric ED in 2007. Overweight was defined as >95th percentile sex-specific weight-for-age, and normal weight was defined as ≤95(th) percentile. We used a subsample validation to compare these study definitions to BMI-based definitions. We compared total billed charges and secondary outcomes of ED length of stay and admission rate using multivariate and logistic regression models. Outcomes were reported for admitted and discharged patients. Four diagnoses were examined for primary and secondary outcomes. RESULTS: Of 32,996 included visits, 6333 (19.2%) were for overweight children. Study definitions correctly classified 98.3% of normal weight children but only 51.3% of overweight children. Overweight children were more likely to be older, black, and publicly insured. Median charges for overweight and normal weight children, whether discharged or admitted, were not different in the adjusted model. Admitted overweight children with asthma and fractures or dislocations had higher median charges than normal weight $4617 (2065-375,669) versus $4177 (1980-37,432, p=0.01) and $9855 (6681-58,546) versus $8137 (1461-52,557, p=0.01), respectively. CONCLUSIONS: Overall acute care costs for overweight children are not different from normal weight children. However, admitted overweight children have disease-specific increased use of resources.

A randomized controlled trial of cast versus splint for distal radial buckle fracture: an evaluation of satisfaction, convenience, and preference.

OBJECTIVES: Buckle fractures are inherently stable and at low risk for displacement. These advantages allow for treatment options that may create confusion for the practitioner. Accepted immobilization methods include circumferential cast, plaster or prefabricated splint, and soft bandaging. Despite mounting evidence for splinting, the questions of pain, preference, satisfaction, and convenience offer a challenge to changing practice. The purposes of this study were (1) to compare cast versus splint for distal radial buckle fractures in terms of parental and patient satisfaction, convenience, and preference and (2) to compare pain reported for cast versus splint. METHODS: We conducted a prospective randomized trial of a convenience sample of patients 2 through 17 years with a radiologically confirmed distal radial buckle fracture. Subjects were randomly assigned to short-arm cast or prefabricated wrist splint. We assessed satisfaction, convenience, preference, and pain in the emergency department and at days 1, 3, 7, and 21 after immobilization. RESULTS: Ninety-four patients were enrolled. Compared with the cast group, those in the splint group reported higher levels of satisfaction, preference, and convenience on 10-point visual analog scale. Although pain scores were higher for those in the splint group, the difference was not statistically significant. CONCLUSIONS: With the exception of pain reported in the emergency department being higher for the splinted group, all other measures, including convenience, satisfaction, and preference, showed a clear trend favoring splints at almost every time period in the study. This study provides additional evidence that splinting is preferable to casting for the treatment of distal radial buckle fractures.

Potential adverse effects of spinal immobilization in children.

OBJECTIVE: The purpose of our study was to describe potential adverse effects associated with spinal immobilization following trauma among children. METHODS: We conducted a prospective cohort study of children presenting to the emergency department (ED) for evaluation following trauma over a 13-month period. Children were eligible if they underwent spinal immobilization prior to physician evaluation or if they met the American College of Surgeons (ACS) guidelines for spinal immobilization but were not immobilized. We compared children who were immobilized with those who were not immobilized for self-reported pain, use of radiography to evaluate the cervical spine, ED length of stay, and ED disposition. We also report the characteristics of the cohort. RESULTS: One hundred seventy-three spine-immobilized children and 112 children who met ACS criteria but were not immobilized were enrolled. There were differences between the two study groups, which included age, mechanism of injury, and proportion transported by emergency medical services. However, the comparison groups had comparable Pediatric Trauma Scores (PTSs) and Glasgow Coma Scale scores (GCSs). Immobilized children had a higher median pain score (3 versus 2) and were more likely to undergo cervical radiography (56.6% versus 13.4%) and be admitted to the hospital (41.6% versus 14.3%). The comparison groups had similar lengths of stay in the ED. CONCLUSION: Despite presenting with comparable PTSs and GCSs, children who underwent spinal immobilization following trauma had a higher degree of self-reported pain, and were much more likely to undergo radiographic cervical spine clearance and be admitted to the hospital than those who were not immobilized. Future studies are warranted to determine whether these differences are related to spinal immobilization or differences in the mechanisms of injury, injury patterns, or other variables.

Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions.

OBJECTIVE: To evaluate the nature, frequency, and predictors of adverse events during the use of propofol by pediatric hospitalists. STUDY DESIGN: We reviewed 1649 charts of patients sedated with propofol by pediatric hospitalists at St Louis Children's Hospital between January 2005 and September 2009. RESULTS: Hospitalists were able to complete 1633 of the 1649 sedations reviewed (99%). Major complications included 2 patients with aspiration and 1 patient intubated to complete the study. We observed a 74% reduction in the number of patients with respiratory events and airway interventions from 2005 to 2009. Predictors of respiratory events were history of snoring (OR, 2.40; 95% CI, 1.52-3.80), American Society of Anesthesiologists (ASA) physical status classification of ASA 3 (OR, 2.30; 95% CI, 1.22-4.33), age >12 years (OR, 4.01; 95% CI, 2.02-7.98), premedication with midazolam (OR, 1.85; 95% CI, 1.15-2.98), and use of adjuvant glycopyrrolate (OR, 4.70; 95% CI, 2.35-9.40). All except ASA 3 status were also predictors for airway intervention. There was a decline in the prevalence of all of these predictors over the study years (P < .05) except for use of glycopyrrolate. CONCLUSION: Our pediatric hospitalists implemented a successful propofol sedation program that realized a 74% reduction in respiratory events and airway interventions between 2005 and 2009. Decreased prevalence of the predictors of adverse events that we identified likely contributed to this reduction.

Clinical outcomes after withdrawal of anti-tumor necrosis factor α therapy in patients with juvenile idiopathic arthritis: a twelve-year experience.

OBJECTIVE: To estimate the length of time to disease flare and the likelihood of achieving clinical remission after discontinuation of treatment with tumor necrosis factor α (TNFα) blockers in patients with juvenile idiopathic arthritis (JIA). METHODS: We conducted a retrospective chart review in a cohort of patients with JIA treated with TNFα inhibitors between January 1, 1998 and November 1, 2009. Demographic information, laboratory data, and medication exposure were extracted using a standardized tool. Outcomes of interest were based on preliminary criteria for remission in JIA. RESULTS: One hundred seventy-one patients with 255 discrete episodes of anti-TNFα treatment were reviewed. The median duration of patient observation was 59.7 months (range 5.8-211.2 months). Among patients in whom disease was inactive after discontinuation of anti-TNFα therapy, 50% had persistently inactive disease at 6 months, and 33% had clinical remission at 12 months. The median duration of anti-TNFα therapy after inactive disease was obtained was 6.1 months (range 0-67.9 months). No significant association was observed between the time to disease flare after cessation of treatment with TNFα antagonists and the length of time from the diagnosis of JIA to the initiation of anti-TNFα therapy, the duration of therapy following the onset of inactive disease, or the total duration of treatment with TNFα antagonists prior to discontinuation. The category of JIA, sex, and age at diagnosis were not associated with the risk of relapse. CONCLUSION: One-third of patients with JIA can successfully undergo withdrawal of treatment with TNFα antagonists and be spared the cost and potential morbidity of treatment for at least 12 months. Further studies are needed to identify factors to accurately identify these patients.

Lung transplantation in children with idiopathic pulmonary arterial hypertension: an 18-year experience.

BACKGROUND: The natural history of idiopathic pulmonary arterial hypertension (IPAH) in patients of all ages is one of relentless progression. For those who fail medical therapy, lung transplantation remains the ultimate palliation. In the USA, IPAH is the second leading indication for lung transplantation in children and first for children 1 to 5 years of age. In this study, we report our 18-year experience with lung transplantation in children with IPAH. METHODS: We performed a retrospective chart review of children with IPAH listed for lung transplant at our center between 1991 and 2009. Our data reflect a total of 26 children ranging in age from 1.6 to 18.9 years. Nineteen were transplanted and 7 died while waiting (27%). The impact of a number of pre-transplant variables on survival was evaluated. RESULTS: Median survival for those transplanted was 5.8 years, with 1- and 5-year survival rates of 95% and 61%, respectively. Survival was independent of pre-transplant considerations such as age, weight, need for intravenous (IV) inotropes, use of IV pulmonary vasodilators, year of transplant and severity of right-sided cardiac pressures. There was 1 hospital death. Compared with the transplanted group, children who died waiting had a significantly higher incidence of supra-systemic right heart pressures (p = 0.02) and hemoptysis (p = 0.01). CONCLUSIONS: Our study is the largest to date to look at outcomes for lung transplantation in children with IPAH. Their median survival compares favorably with that of all pediatric lung transplant recipients, 5.8 years vs 4.5 years, respectively. We did not identify any pre-transplant variables that presaged a poorer outcome. Thus, survival seemed more related to factors that influence long-term outcomes in all transplant recipients such as rejection and infection. Lung transplantation remains a viable option for children with IPAH, especially for those with supra-systemic right heart pressures despite maximal medical therapy.

Camp jump start: effects of a residential summer weight-loss camp for older children and adolescents.

OBJECTIVE: Residential weight-loss camps offer an opportunity for overweight and obese children to lose weight in a medically safe, supervised, supportive environment. The purpose of this report is to describe short-term outcomes in 76 children participating in a 4- or 8-week residential weight-loss camp for children and adolescents. PATIENTS AND METHODS: The camp program enrolled obese 10- to 18-year-old adolescents. The program consisted of structured and nonstructured physical activities and group educational sessions covering nutrition, physical fitness, and self-esteem. A diet plan of 3 balanced meals and 2 snacks per day was prepared under the supervision of a registered dietitian. Participants had height, weight, and blood pressure measured and performed a 1-mile run at maximum effort on an outdoor track. RESULTS: For all campers, statistically significant (P < .0001) reductions were observed for BMI, BMI z score, systolic blood pressure, body weight, and 1-mile run times. Compared with campers in the 4-week session, campers in the 8-week session had greater reductions in BMI, BMI z score, body weight, and systolic blood pressure. Multivariate analysis revealed that gender was a significant predictor for reduction in body weight, BMI, and BMI z score, all of which decreased more in boys than in girls. CONCLUSIONS: This report adds to the evidence that residential weight-loss camps are highly effective in improving measures of health and fitness among overweight and obese children and adolescents. Additional study is needed on the long-term effects of such camps in terms of weight maintenance, behavior change, and metabolic and health outcomes.

Late onset hearing loss: a significant complication of cancer survivors treated with Cisplatin containing chemotherapy regimens.

Cisplatin is a known ototoxic agent and has been associated with late onset hearing loss (LOHL) in children beyond completion of treatment. We completed a retrospective review of 160 patients yielding 59 who received cisplatin and had sufficient data to determine the presence of LOHL. LOHL was defined as a significant change in hearing thresholds 6 months past the last cisplatin therapy. A significant change was defined as a decrease of >15 dB in a frequency from 1 to 8 kHz in either ear, or a decrease of 10 dB at 2 or more frequencies in the same ear, compared with the previously entered audiogram. Hearing loss was classified using the Brock grading system for each ear. Of the 59 patients evaluated, 51% exhibited LOHL. Univariate analysis indicated LOHL was significantly associated with age of diagnosis (P=0.031), diagnosis of medulloblastoma (P=0.035), hearing aids (P=0.010), and cranial radiation (P=0.044), particularly to the posterior fossa (P=0.023). Multivariate analysis revealed only radiation to the posterior fossa (P=0.02) and the use of hearing aids (P=0.01) were significantly associated with LOHL. LOHL is a significant complication in childhood cancer survivors who receive cisplatin. Long-term audiologic monitoring after therapy is needed to identify the affected patients.

Dismal lung transplant outcomes in children with tetralogy of Fallot with pulmonary atresia compared to Eisenmenger syndrome or pulmonary vein stenosis.

BACKGROUND: Certain congenital heart lesions in children can lead to irreversible lung disease thus making lung transplantation a therapeutic option. We retrospectively analyzed our experience with lung transplantation in 32 children with three distinct underlying congenital heart defects: (1) Eisenmenger syndrome (EIS); (2) tetralogy of Fallot with pulmonary atresia (PA); and (3) pulmonary vein stenosis (PVS). METHODS: Pediatric patients <18 years of age with either EIS (n = 7), PA (n = 8) or PVS (n = 17), who underwent lung or heart-lung transplantation, were analyzed. We compared survival rates between the three groups. Pre- and peri-operative variables were also assessed for their effect on outcome. RESULTS: Compared with EIS and PA patients, PVS patients were younger and sicker at the time of transplantation. All EIS and PA patients required either additional intracardiac repairs or a heart transplant at the time of lung transplantation. PA patients had the highest rate of major post-operative complications and in-hospital deaths. Median survival was comparable between EIS (6.1 years) and PVS (6.5 years) patients. Outcomes for PA patients were dramatically worse, with a median survival of only 0.12 year ( approximately 47 days). Needing additional intracardiac surgery or a heart transplant at the time of lung transplantation did not impact survival. The diagnosis of PA itself correlated with a worse outcome. CONCLUSIONS: Outcomes in EIS and PVS patients undergoing lung transplantation compare favorably to that of all pediatric lung transplant recipients (median survival 4.3 years). For PA patients, their underlying pathology appears to make them high-risk candidates for lung transplantation. For the younger and acutely sicker PVS patients, lung transplantation is a viable therapeutic alternative.

Lower airway obstruction is associated with increased morbidity in children with sickle cell disease.

RATIONALE: The association between pulmonary function and morbidity in children with sickle cell disease (SCD) has not been previously evaluated. Our objective was to study the relationship between abnormalities in pulmonary function and morbidity as represented by the rate of hospitalizations for pain or acute chest syndrome (ACS) in children with SCD. METHODS: Results of pulmonary function tests obtained for clinical indications in children ages 6-18 years were classified as lower airway obstruction (forced expiratory volume in 1 sec/forced volume capacity <95% confidence interval adjusted for age, gender, race, and height), restriction (total lung capacity <80% predicted adjusted for gender, age, race, and height), and normal lung function. Incidence rates of pain or ACS were compared between children with lower airway obstruction or restriction and children with normal lung function. RESULTS: A total of 102 children, mean age at evaluation 12.0 years with follow-up of 3.8 years, were included. Children with lower airway obstruction had twice the rate of morbidity compared to children with normal lung function (2.5 vs. 1.2 hospitalizations for pain or ACS per patient-year, P = 0.003) (Risk ratio: 2.0; 95% CI: 1.3-3.3). Children with restriction did not have different rates of future morbidity compared to children with normal lung function (1.4 vs. 1.2 hospitalizations for pain or ACS per patient-year, P = 0.68) (Rate ratio: 1.1; 95% CI: 0.6-2.1). CONCLUSIONS: We conclude that children with SCD who have lower airway obstruction should have increased surveillance for future morbidity.

Brain-derived neurotrophic factor in infants <32 weeks gestational age: correlation with antenatal factors and postnatal outcomes.

Neurotrophins (NTs) play important roles in brain growth and development. Cord blood (CB) brain-derived neurotrophic factor (BDNF) concentrations increase with gestational age but data regarding postnatal changes are limited. We measured BDNF concentrations after birth in 33 preterm infants <32-wk gestation. Serum was collected at birth (CB), at day 2, between day 6 and 10 (D6), at day 30 (D30), and at day 60 (D60). BDNF concentrations fell on D2 (p = 0.03), recovered by D6 (p = 0.10), and continued to rise thereafter at D30 (p = 0.06) and D60 (p = 0.01) compared with CB. CB BDNF concentrations positively correlated with duration of rupture of membranes (r = 0.43, p = 0.04). Antenatal steroids (ANS, p = 0.02), postnatal steroids (PNS, p = 0.04), and retinopathy of prematurity (ROP, p = 0.02) were identified as significant factors in multivariate analyses. The median (25-75th interquartile range) CB BDNF concentrations were higher in infants who received a complete course ANS compared with those who received a partial course [1461 (553-2064) versus 281 (171-536) pg/mL, p = 0.04]. BDNF concentrations negatively correlated with the use of PNS at D30 (r = -0.53, p = 0.002) and at D60 (r = -0.55, p = 0.009). PNS use was associated with reduced concentrations of BDNF at D30 [733 (101-1983) versus 2224 (1677- 4400) pg/mL, p = 0.004] and at D60 [1149 (288-2270) versus 2560 (1337-5166) pg/mL, p = 0.01]. BDNF concentrations on D60 in infants who developed ROP (n = 16) were lower than those who did not develop ROP (n = 7) [1417 (553-2540) versus 3593 (2620-7433) pg/mL, respectively, p = 0.005]. Our data suggests that BDNF concentrations rise beyond the first week of age. BDNF concentrations correlate with factors that influence neurodevelopment outcomes.

Elevated urinary leukotriene E4 levels are associated with hospitalization for pain in children with sickle cell disease.

Cysteinyl leukotrienes (CsyLTs) are inflammatory mediators produced by white blood cells. Leukotriene LTE(4) is the stable metabolite of CsyLTs, which can be measured in urine. We tested two hypotheses among children with sickle cell disease (SCD): (1) baseline urinary LTE(4) levels are elevated in children with SCD when compared with controls; and (2) baseline LTE(4) levels are associated with an increased incidence rate of hospitalization for SCD-related pain. Baseline LTE(4) levels were measured in children with SCD (cases) and children without SCD matched for age and ethnicity (controls). Medical records of cases were reviewed to assess the frequency of hospitalization for pain within 3 years of study entry. LTE(4) levels were obtained in 71 cases and 22 controls. LTE(4) levels were higher in cases compared with controls (median LTE(4): 100 vs. 57 pg/mg creatinine, P < 0.001). After adjustment for age and asthma diagnosis, a greater incidence rate of hospitalization for pain was observed among children with SCD in the highest LTE(4) tertile when compared with the lowest (114 vs. 52 episodes per 100 patient-years, P = 0.038). LTE(4) levels are elevated in children with SCD when compared with controls. LTE(4) levels are associated with an increased rate of hospitalizations for pain.

Physician beliefs and practices regarding the use of hepatitis A vaccine.

BACKGROUND: In 1999, the Centers for Disease Control and Prevention recommended routine vaccination of children against hepatitis A in states, counties, and communities with rates twice the national average or greater. Milwaukee is such a community. OBJECTIVES: To assess physician knowledge, beliefs, and practices regarding hepatitis A disease and hepatitis A vaccine recommendations in Milwaukee. METHODS: A cross-sectional study of 291 Milwaukee pediatricians and family physicians using a self-administered questionnaire. RESULTS: The response rate was 46%. Of physicians responding, 88% were aware that hepatitis A vaccine was recommended for all children in Milwaukee >2 years of age; 61% believed hepatitis A was a significant health problem, with a significant difference between pediatricians and family physicians (74% versus 43%); and 65% stated they offered the vaccine "almost always" or "most of the time" to children between the ages of 2 and 19 years. CONCLUSIONS: More physician education is needed regarding the public health impact of hepatitis A and the value of the vaccine.

Association of adrenal steroids with hypertension and the metabolic syndrome in blacks.

Blacks have a high prevalence of hypertension and adrenal cortical adenomas/hyperplasia. We evaluated the hypothesis that adrenal steroids are associated with hypertension and the metabolic syndrome in blacks. Ambulatory blood pressures, anthropometric measurements, and measurements of plasma renin activity (PRA), aldosterone, fasting lipids, glucose, and insulin were obtained in 397 subjects (46% hypertensive and 50% female) after discontinuing antihypertensive and lipid-lowering medications. Hypertension was defined as average ambulatory blood pressure >130/85 mm Hg. Late-night and early morning salivary cortisol, 24-hour urine-free cortisol, and cortisone excretion were measured in a consecutive subsample of 97 subjects (40% hypertensive and 52% female). Compared with normotensive subjects, hypertensive subjects had greater waist circumference and unfavorable lipid profiles, were more insulin resistant, and had lower PRA and higher plasma aldosterone and both late-night and early morning salivary cortisol concentrations. Twenty-four-hour urine-free cortisol and cortisone did not differ. Overall, ambulatory blood pressure was positively correlated with plasma aldosterone (r=0.22; P<0.0001) and late-night salivary cortisol (r=0.23; P=0.03) and inversely correlated with PRA (r=-0.21; P<0.001). Plasma aldosterone correlated significantly with waist circumference, total cholesterol, triglycerides, insulin, and the insulin-resistance index. Based on Adult Treatment Panel III criteria, 17% of all of the subjects were classified as having the metabolic syndrome. Plasma aldosterone levels, but not PRA, were elevated in subjects with the metabolic syndrome (P=0.0002). The association of aldosterone with blood pressure, waist circumference, and insulin resistance suggests that aldosterone may contribute to obesity-related hypertension in blacks. In addition, we speculate that relatively high aldosterone and low PRA in these hypertensive individuals may reflect a mild variant of primary aldosteronism.

An exploratory study of the cognitive, academic, and behavioral functioning of pediatric cardiothoracic transplant recipients.

CONTEXT: Limited information is available regarding the cognitive, academic, and behavioral outcomes of pediatric cardiothoracic transplant recipients. OBJECTIVE: To examine the cognitive, behavioral, and academic functioning of a group of children who have received heart, heart/lung, or lung transplants. DESIGN, PARTICIPANTS, AND SETTING: An exploratory cross-sectional outcomes study of surviving pediatric cardiothoracic transplant recipients at a Midwestern pediatric hospital. MAIN OUTCOME MEASURES: Transplant recipients completed measures of cognitive and academic functioning. Parents and teachers completed measures of behavioral functioning. Parents and transplant recipients also provided qualitative data regarding their main concerns after transplantation. RESULTS: On measures of cognitive functioning, 46% showed significant delays (> 2 SD below the normative population). Of those eligible for academic testing, 78% fell within the average range (within 1 SD of the normative population) for reading and spelling, and 57% fell within the average range for math. Twenty-seven percent of mothers, 11% of fathers, and 17% of teachers rated subjects as having significant behavioral concerns. Results highlight the need for close contact between transplant teams and school personnel to optimize outcomes. In addition, patients and families may benefit from psychological intervention after transplantation as there are ongoing concerns regarding life expectancy and quality of life.

Perceptions of inner city parents about early behavioral and violence prevention counseling.

OBJECTIVES: (1) Identify how receptive inner city parents of young children are to routine anticipatory guidance about behavior at well child care visits. (2) Determine whether inner city parents correlate early behavior problems with a risk of later behavior problems. (3) Determine whether inner city parents believe that physician-provided anticipatory guidance about behavioral issues and violence prevention can help their child avoid future violence-related problems. METHODS: A convenience sample of parents of children < or =5 years old attending an inner city pediatric teaching clinic were invited to complete a self-administered survey including questions about behavior, parenting, and physician-provided behavior and violence counseling. RESULTS: One hundred and ninety-five participants completed surveys; most were African-American (81%) mothers (92%). In response to T/F questions, 84% of parents responded "False" to "Bad behavior in kids cannot be prevented" (95% CI; 78.8, 89.1), 97% responded "False" to "[Bad behavior in kids] cannot be changed" (95% CI; 94.5, 99.3), and 67% responded "True" to "My child's doctor can help me protect my child from violence" (59.8, 73.6). A majority of parents indicated that doctors should routinely ask about behavior and discuss parenting even if the parent was not worried about their child's behavior. CONCLUSIONS: Inner city parents believe that bad behavior in children can be changed and prevented. They welcome physician-provided guidance about behavior and believe physicians can help their children avoid violence.