Outcomes of febrile children presumed to be immunocompetent who present with leukopenia or neutropenia to an ambulatory setting.

UNLABELLED: To determine significant medical outcomes in febrile children presenting to an ambulatory setting with neutropenia and/or leukopenia. METHODS: Retrospective medical record review conducted on febrile patients who had a blood culture drawn, with white blood cell counts less than 5,000/mm3 and/or an absolute neutrophil count less than 1000/mm3. Ninety-one patients were identified; 5 with positive blood culture results, 13 with significant non-oncologic disease, and 3 patients with leukemia who had involvement of 2 or more cell lines. CONCLUSIONS: In the majority of patients, clinical judgment, physical findings, and review of all cell lines of the complete blood cell count identified those with significant disease.

Toxicity of over-the-counter cough and cold medications.

Over-the-counter (OTC) cough and cold medications are marketed widely for relief of common cold symptoms, and yet studies have failed to demonstrate a benefit of these medications for young children. In addition, OTC medications can be associated with significant morbidity and even mortality in both acute overdoses and when administered in correct doses for chronic periods of time. Physicians often do not inquire about OTC medication use, and parents (or other caregivers) often do not perceive OTCs as medications. We present 3 cases of adverse outcomes over a 13-month period-including 1 death-as a result of OTC cough and cold medication use. We explore the toxicities of OTC cough and cold medications, discuss mechanisms of dosing errors, and suggest why physicians should be more vigilant in specifically inquiring about OTCs when evaluating an ill child.

Multisite survey of pediatric residents' continuity experiences: their perceptions of the clinical and educational opportunities.

OBJECTIVES: To survey a large group of residents from different institutions to delineate whether there are significant perceptive differences pertaining to the clinical and educational strengths and weaknesses of their continuity experiences by the 3 types of continuity sites. BACKGROUND: The residency review committee requires a 3-year continuity experience for pediatric residents. Residents receive this experience at a variety of practice sites: hospital-based sites (HBS), community health centers (CHC), and private practices (PP)/health maintenance organizations (HMOs). DESIGN/METHODS: Continuity clinic directors who attended the Ambulatory Pediatric Association Continuity Clinic Special Interest Group at the 1999 annual Pediatric Academic Societies Meeting were invited to participate in this cross-sectional study. Thirty-six agreed and distributed a 60-item questionnaire to their residents at the end of the academic year. The questionnaire addressed quality and quantity of the educational and patient care experiences, overall satisfaction, and future career plans. RESULTS: Of the 1167 categorical residents (71%) who returned the questionnaire, 28% were postgraduate level (PL)-1s, 34% were PL-2s, and 37% were PL-3s. Ninety-four percent of the 36 programs had residents in HBS (n = 807 residents), 58% in CHC (n = 106), and 69% in PP/HMO (n = 254). Compared with other groups, residents in HBS were more likely to report having seen patients more than once, being involved during patients' hospitalizations, taking phone calls from patients, and perceiving that the parents identified them as the primary care provider. HBS and CHC residents felt more autonomous and were more likely to believe that they were advocates for their patients, compared with PP/HMO residents. The number of patients seen per session was greater in PP/HMO, whereas residents in PP/HMO were more likely to perceive that they had received the right amount of exposure to practice management and billing issues and the appropriate amount of nursing and office support. Although numbers of newborn visits were reported as adequate across sites, residents in HBS and CHC believed that they did not see enough adolescents. The majority of residents at all sites agreed that their preceptor was a good role model, was available for questions, and delivered the appropriate amount of teaching and feedback. Approximately two thirds of residents from all sites were satisfied with their experience and believed that it was preparing them for their future career. CONCLUSIONS: All 3 types of continuity sites have both strengths and weaknesses. No single type of continuity site met all expectations for clinical care or training. Most residents at all 3 types of sites reported overall satisfaction and believed that their continuity experience helped to prepare them for future career goals. The residency review committee, in collaboration with pediatric continuity educators, needs to prioritize what constitutes the essential experiences in resident continuity practices and to reemphasize that the ongoing relationship is an important component of the continuity experience.

Outcome of children identified as anemic by routine screening in an inner-city clinic.

BACKGROUND: Children found to be anemic on routine screening by HemoCue, a rapid and relatively inexpensive method of screening for hemoglobin (Hb), are often prescribed iron as a diagnostic tool and potential treatment for presumed iron deficiency anemia (IDA). We questioned this approach given the declining prevalence of IDA and the concomitant relative increase in other causes of anemia. OBJECTIVE: To evaluate the practice of Hb screening for IDA by determining the prevalence of anemia by HemoCue; the proportion of anemic patients treated with iron and followed up; the frequency of repeated Hb testing, additional iron studies, and iron prescriptions; and the 6-month outcomes of treated and untreated anemia. DESIGN: Retrospective cohort study. RESULTS: Of 1358 children aged 9 to 36 months who underwent screening, 343 (25%) had anemia, defined as a Hb level of less than 110 g/L. Outpatient medical records of 334 of the anemic children revealed that 239 (72%) were prescribed iron while 95 (28%) were not prescribed iron at the first visit for anemia. Anemia follow-up rates were low for the prescribed and not prescribed groups: 7% vs 5% returned within 1 month, while 37% vs 42% did not return within 6 months for follow-up. Of the children who were prescribed iron, 107 (71%) of 150 responded to treatment or anemia resolved within 6 months compared with 27 (68%) of 40 not prescribed iron. Children underwent repeated blood testing for measurement of Hb and complete blood cell count, but underwent few iron-specific studies. CONCLUSIONS: Routine screening for IDA by HemoCue followed by a therapeutic trial of iron was problematic because of a high rate of anemia in this predominantly African American population, low follow-up rates, and a high spontaneous resolution rate. Prospective studies are needed to evaluate other screening methods to differentiate IDA from other forms of anemia and to improve compliance and outcome in inner-city children.

Effectiveness of a practice-based intervention to increase vaccination rates and reduce missed opportunities.

BACKGROUND: Although provider feedback and recall/reminder systems have been shown to increase vaccination rates for children, little is known about the effectiveness of less intensive interventions. OBJECTIVE: To determine whether provider prompting at acute care visits in an urban hospital-based outpatient clinic can increase vaccination rates and decrease missed opportunities. DESIGN AND METHODS: Study participants, 3 years or younger, were identified from a managed care organization as receiving primary care at the clinic. Eligibility criteria included 1 or more visits to the clinic without regard to continuity of enrollment. Patients' vaccination records were generated at nursing triage and attached to the encounter sheet. Vaccination and visit data were abstracted from medical records, and comparisons were made between baseline (n = 521) and postintervention (n = 642) groups for up-to-date vaccination rates, missed opportunity rates, and mean numbers of visits. RESULTS: Up-to-date rates at the age of 24 months for 4 diphtheria and tetanus toxoids and pertussis, 3 polio, 1 measles-mumps-rubella, 3 hepatitis B, and 3 Haemophilus influenzae type b vaccines changed from 70% to 78% (P =.07). Up-to-date rates increased significantly to 87% among the subset of children continuously enrolled in the managed care organization and the practice (P<.01). Overall, mean numbers of visits were similar. Missed opportunity rates among children not up-to-date for 4 diphtheria and tetanus toxoids and pertussis, 3 polio, 1 measles-mumps-rubella, 3 hepatitis B, and 3 Haemophilus influenzae type b vaccines at the age of 24 months declined from 65% to 45% (P =.04). Similar trends were noted at the age of 10 months. CONCLUSIONS: In the absence of increased funding, minor changes in standard operating procedures may improve vaccination delivery. Further improvements may require efforts to ensure continuity of provider and plan assignment.

Randomized trial of enhanced anticipatory guidance for injury prevention.

OBJECTIVE: To develop and evaluate an injury prevention anticipatory guidance training program for pediatric residents. DESIGN: Thirty-one residents were randomly assigned to an intervention or control group. Both groups attended a 1-hour seminar about injury prevention and the American Academy of Pediatrics TIPP (The Injury Prevention Program) materials. The intervention group also received 5 hours of experiential instruction on injury prevention content and counseling skills (SAFE Counseling Framework). Families with infants from birth to age 6 months were enrolled in the study (N = 196); they were followed up until the child was aged 12 to 18 months. Data were collected by means of baseline and follow-up interviews, audiotapes of medical visits, parent exit surveys, and home observations. SETTING: A hospital-based continuity clinic that serves families living in low-income, inner-city neighborhoods. OUTCOMES: Physician counseling and parent satisfaction, knowledge, beliefs, and behaviors. RESULTS: Parents seen by physicians in the intervention group received significantly more injury prevention counseling for 5 of the 6 safety practices, and they were significantly more satisfied with the help their physicians provided on safety topics. They were no less satisfied with their physicians' counseling on other anticipatory guidance topics. Parents' knowledge, beliefs, and home safety behaviors did not differ between the 2 groups. CONCLUSIONS: The frequency and impact of pediatric counseling can be enhanced by experiential training that targets specific injury hazards. Because low-income families face many barriers to carrying out the recommended safety practices, supplemental strategies are needed to ensure safer homes.

Effects of lead counseling for children with lead levels > or = 20 microgram/dL: impact on parental knowledge, attitudes, and behavior.

The purpose of this study was to assess parental knowledge, attitudes, and behavior concerning lead reduction counseling. Of 108 children with confirmed venous lead levels > or = 20 microg/dL, 75 (69%) of the parents were interviewed by telephone 6-9 months later. The majority of parents recalled being given specific lead reduction strategies. Knowledge of cleaning interventions was associated with parents who could state the lead level, who perceived a benefit from knowing it was elevated, and whose children were referred to a specialty lead clinic. Recall of nutritional interventions was associated with parents who could state the lead level and whose children were referred to a specialty lead clinic. Although 79% of parents thought that it was beneficial to know their child's lead level was elevated, only 65% reported implementing lead reduction strategies. The majority of parents recalled receiving lead reduction counseling but reported low compliance with lead reduction strategies. Further research is needed to determine the causes of the discrepancy between knowledge and making the behavior changes necessary to comply with lead reduction interventions.

No difference in iron status between children with low and moderate lead exposure.

We compared the iron status between children 11 to 33 months old with confirmed blood lead levels of 20 to 44 microg/dL and demographically similar children with blood lead levels of <10 microg/dL. There were no differences. Laboratory investigation or empirical treatment for iron deficiency is not justified on the basis of moderately elevated blood lead levels alone.

Rehospitalization of children with asthma.

BACKGROUND: Although some children with asthma experience multiple admissions, asthma is considered a preventable cause of hospitalization. OBJECTIVE: To assess whether components of medical histories, ambulatory care prior to hospitalization, or ambulatory care after discharge are associated with repeated hospitalizations for children admitted with asthma. DESIGN: Nested case-control study of a cohort of children hospitalized for asthma, comparing those who were rehospitalized within 1 year with those not rehospitalized. SETTING: Urban pediatric primary care clinic. PARTICIPANTS AND METHODS: Subjects were 119 children, aged 0 to 14 years, who had an inpatient admission with a diagnosis of asthma between July 1, 1993, and June 30, 1995 (index hospitalization). Data sources included medical charts, computerized patient records, and administrative data. Use of health care services was compared among children who were rehospitalized within 1 year of the index admission and those who were not. MAIN OUTCOME MEASURE: Repeated hospitalizations. RESULTS: The proportions of children who received general pediatric, allergy, or pulmonary care in the year prior to the index hospitalization were 86%, 7%, and 8%, respectively. By report, half of all children did not receive prescribed therapies, more than half were exposed to cigarette smoke at home, and one fourth were not up-to-date with immunizations at the time of admission. Thirty-five of the 119 children hospitalized with asthma were subsequently readmitted with asthma within 1 year of the index hospitalization. Children readmitted did not differ from those with a single admission in terms of the above characteristics. However, significantly more children subsequently readmitted had a pulmonary consultation during the index admission (23% vs 4%; P = .001) or in the year following discharge (37% vs 12%; P = .002). In addition, children readmitted were more likely to have other chronic conditions (69% vs 49%; P= .048). CONCLUSION: Among low-income urban children, readmission for asthma is not associated with receipt of prescribed therapies or pediatric care.

The effect of patient reassignment on future continuity in a pediatric resident continuity practice.

BACKGROUND: When residents complete their pediatric training, patients from their continuity practices in academic settings must be reassigned to either a known resident of their selection or an unknown, incoming intern. OBJECTIVES: To determine what antecedent factors were associated with patient reassignment to a known resident of their selection, whether such reassignment was associated with increased health care use, and what factors were associated with continuity with the new resident provider. DESIGN: Nonconcurrent cohort study. SETTING: Hospital-based resident continuity clinic practice. PARTICIPANTS: Patients of residents graduating in June 1993. RESULTS: Seven hundred fifty-eight patients of 18 graduating residents required reassignment: 86 patients (11%) were assigned to a resident colleague, defined as the study group. From the remaining 673 patients who were assigned to unknown, incoming interns, a control group was randomly selected (n = 160), with approximately 2 patients for each study group subject. Looking at antecedent factors, study group patients were more likely to have chronic medical problems and to have seen their graduating resident more often and more recently. Univariate analysis explored the consequent factors of health care use and found that study group patients were more likely to return for a visit and to make more visits with the new provider. Multiple logistic regression analysis demonstrated that being in the study group, younger age at the original encounter with the graduating resident, and a shorter interval since the last visit with the graduating resident were all associated with increased continuity with the new resident. CONCLUSIONS: The method of patient reassignment at a continuity clinic was associated with chronic disease of the patient and regularity of visits with the graduating resident. Increased continuity with a new resident, as determined by multivariate analysis, was associated with the method of reassignment, a younger age at first encounter with the graduating resident, and a shorter interval since the last visit with the graduating resident. This study has implications at ambulatory sites where transitions occur.

Is oral albuterol effective for acute cough in non-asthmatic children?

Fifty-nine non-asthmatic children with acute cough were randomized to receive oral albuterol or placebo for 7 d. There was a similar, rapid rate of resolution of acute cough for the two groups, but more shaking or trembling in those treated with albuterol (5/30 vs 0/29; p = 0.05). In ambulatory children with acute cough who have no history of asthma and a normal chest examination, oral albuterol does not reduce the frequency or duration of cough.

Plasma 5-aminolevulinic acid concentration and lead exposure in children.

The relationship between concentration of 5-aminolevulinic acid in plasma (ALAP) and other biomarkers of lead exposure and effect was investigated in lead-exposed children. We measured ALAP by chemical derivatization and high-performance liquid chromatography with fluorescence detection. The study population consisted of 103 children: 78 from a referral clinic for children with lead poisoning and 25 from a general pediatric clinic. Blood lead concentration (PbB), age, and ALAP were higher in lead clinic subjects than in general clinic subjects. ALAP was significantly correlated with PbB (Spearman r=0.38, P=0.0007) and free erythrocyte protoporphyrin concentration (r=0.41, P=0.0002) in lead clinic subjects. PbB was a significant predictor of ALAP (P=0.0001) by multiple linear regression in all subjects. The average PbB in the 3- to 12-month period prior to blood collection correlated with ALAP to the same degree that current PbB correlated with ALAP. Possible associations between ALAP and adverse health outcomes, particularly neurobehavioral effects, should be investigated in children to assess the predictive value of ALAP for these endpoints.

The impact on families of pediatric resident departure from a continuity clinic practice.

OBJECTIVE: To determine views of parents whose children were reassigned to new resident pediatricians at a continuity clinic because their previous pediatricians had completed residency. DESIGN: Cross-sectional survey. SETTING: Hospital-based resident continuity clinic. PARTICIPANTS: Ninety parents whose pediatricians were graduating were interviewed from June through August 1995. RESULTS: Most parents felt they knew their resident pediatrician well and that the resident knew their child well. Sixty-eight parents (76%) were sad about the transition, 33 (37%) were angry, 30 (33%) felt abandoned, and 6 (7%) were relieved. Three fourths of the parents thought it was very important for the family to be involved in the reassignment process, yet less than one fifth had been asked their opinion. Half of the families were experiencing their second or greater transition. Families undergoing their first, vs second or greater transitions, were more likely to feel they knew the resident well (P = .01), and that the resident knew their child well (P = .04). Despite the transitions, 86 (96%) of families stated they would continue to have their child receive medical care at the current site because they knew their child would receive good care. CONCLUSIONS: Strong physician-patient-parent relationships develop when residents are the pediatric primary care providers. Parents want to be informed regarding transitions. Pediatricians need to be sensitive to the impact of transitions and to negotiate with families in choosing their future pediatrician. These results have implications for other practice sites where physician turnover occurs.

The father's role during infancy. Factors that influence maternal expectations.

OBJECTIVE: To describe factors that influence maternal expectations of the father's role during infancy. RESEARCH DESIGN: Cross-sectional survey. SETTING: Postpartum obstetric ward of an inner-city teaching hospital. SUBJECTS: Mothers who were residents in the inner-city communities that surround the hospital and who were recently delivered of a newborn. SELECTION PROCEDURE: Consecutive sampling from March to May 1992. MEASUREMENTS: Through structured maternal interviews, the father's expected role was measured in terms of accessibility, engagement in child care tasks, and decision-making responsibility. Influences included demographics, the mother's desire for the father's involvement, and her perceptions of his motivation, prenatal support, and ability to parent. RESULTS: Of 226 eligible mothers, 197 (87%) were interviewed. Expectations varied widely. Concerning accessibility, 48% and 18% of the mothers expected to see the father daily and less than weekly, respectively. Concerning engagement, 81% of the mothers expected some paternal involvement; the average mother assumed that the father would participate in one third of child care tasks. Concerning decision-making responsibility, 34% of the mothers expected to share all decisions; 30% expected to share none. In all areas, expectations were positively associated with the mother's desires, the strength of the parents' relationship, and the mother's perceptions of the father's motivation and ability to parent and the father's prenatal involvement (all, P < .001). Expected accessibility and engagement were greater for fathers who worked; expected engagement and decision-making responsibility were greater for fathers without children from other relationships (all, P < .03). CONCLUSIONS: The maternal desire for the father's participation, the strength of the parents' relationship, the mother's perception of the father as a parent, and the father's prenatal involvement are all consistently associated with the maternal expectations of the father's role. The demographic characteristics of either parent are not as strongly or consistently associated with the maternal expectations.

The influence of medroxyprogesterone on the duration of breast-feeding in mothers in an urban community.

OBJECTIVE: To assess the effect of medroxyprogesterone acetate on lactation when it is given immediately post partum. DESIGN: Prospective cohort study with follow-up through 16 weeks post partum. SETTING: Urban teaching hospital in Baltimore, Md. PARTICIPANTS: Consecutive sample (N = 95) of mothers who were delivered of healthy, term newborns, had home telephones, received either medroxyprogesterone or nonhormonal contraception at discharge, and were currently breast-feeding their newborns. MAIN OUTCOME MEASURES: Lactation (duration and frequency) and timing of first introduction of formula were measured by weekly telephone interviews. RESULTS: Maternal characteristics included the mean +/- SD maternal age (24 +/- 5 years), race (90% African American), history of pregnancy (63% multiparous), marital status or relationship (50% married or living with partner), and medical assistance (81% of the recipients received aid). Women who were receiving medroxyprogesterone (n = 43) were older (P < .05) and were more likely to be married (P < .05) compared with those who were receiving nonhormonal contraception (n = 52). No other factors that were likely to influence lactation were significantly different. Groups did not differ in the baseline-planned duration of lactation. Follow-up data were obtained on 90 women (96%). The groups were comparable in the duration of lactation (medroxyprogesterone: 98%, 74%, 55%, 47%, and 42% were breast-feeding at least once per day at 1, 4, 8, 12, and 16 weeks, respectively [median, 10.14 weeks], vs nonhormonal contraception: 86%, 70%, 47%, 36%, and 30%, respectively [median, 6.57 weeks] [P = .19]). The percentage of subjects who were exclusively breast-feeding at these times and the timing of formula introduction also did not differ by group. CONCLUSION: Medroxyprogesterone, when given to mothers in an urban community immediately after delivery, has no detrimental effect on the duration of lactation, frequency of lactation, and timing of introduction of formula within the first 16 weeks post partum.

Outcomes of annual tuberculosis screening by Mantoux test in children considered to be at high risk: results from one urban clinic.

BACKGROUND: In January 1994, the American Academy of Pediatrics recommended that annual screening with the purified protein derivative tuberculin skin test, Mantoux method, be used for tuberculosis screening in high-risk children. This test has a better sensitivity and specificity than the previously used multiple puncture test, and patients need to return for a reading done by palpation by a health care professional. OBJECTIVE: To estimate the prevalence of reactivity to purified protein derivative tuberculin in an urban primary care clinic whose patients meet high-risk criteria and to determine if annual screening is warranted, to determine the adherence to return to the clinic for reading of the skin test, and to describe the characteristics of patients who have tuberculosis infection and disease. RESEARCH DESIGN: Cross-sectional study. SETTING: Inner-city, hospital-based primary care pediatric clinic in Baltimore, MD. SUBJECTS: A total of 1433 consecutive children attending this clinic from March through September, 1994, who were at risk for tuberculosis because of frequent exposure to poor and medically indigent city dwellers. METHODS: The Mantoux test (5TU intradermal injection of purified protein derivative) was administered to children at annual health supervision visits. Patients were tracked to determine those who returned for a reading by a health care professional and find those with a positive Mantoux test. The charts of children with a positive test were reviewed. RESULTS: Five hundred seventy-three (40%) patients returned for a reading by a health care professional. Five patients had a positive Mantoux test, giving a prevalence rate of 0.8% of reactivity to purified protein derivative tuberculin. One child with a positive Mantoux test also had chest radiograph findings consistent with tuberculosis disease but was asymptomatic. CONCLUSIONS: In our city with a low prevalence of disease, children whose only risk factor for tuberculosis was exposure to poor and medically indigent city dwellers did not represent a high-risk group. Our results are supportive of the 1996 American Academy of Pediatrics screening statement that annual screening is not warranted. Sixty percent of children did not return for a reading of the Mantoux test by a health care professional. Alternative strategies that are more convenient for parents are needed to obtain accurate readings by health care professionals when skin testing is deemed necessary.

A randomized controlled trial of prenatal pediatric visits for urban, low-income families.

BACKGROUND: Prenatal pediatric visits have been recommended by the American Academy of Pediatrics to allow the pediatrician to counsel parents on infant care issues, establish a supportive relationship, and provide pediatric practice information to parents. We hypothesized that prenatal pediatric visits would have an impact on breastfeeding decisions, health care behaviors, health care utilization, and the doctor-patient relationship. METHODS: We conducted a randomized controlled trial of prenatal pediatric visits for urban, low-income families to measure the impact on breastfeeding decisions, infant car safety seat use, circumcision, health maintenance, and emergency room visits and the pediatrician's perception that he/she would know the mother better. Pregnant women were recruited prenatally from the obstetrics clinic. Outcomes were measured by maternal interview prenatally and when the infant was 2 months old, in addition to review of the nursery record. Physicians were interviewed after the 2-month visit. Health care utilization was measured by chart review at 7 months. RESULTS: A total of 156 pregnant women were enrolled and randomized, 81 to the intervention group and 75 to the control group. Of mothers who breastfed, 45% in the intervention group changed their mind in favor of breastfeeding after enrollment compared with 14% in the control group. Mothers in the intervention group compared with the control group were more likely to make fewer emergency room visits, 0.58 compared with 1.0. Pediatricians were more likely to think that they knew mothers in the intervention group well, 54% versus 29% in the control group, yet 67% of mothers in both groups agreed their pediatrician knew them well. There were no differences between groups in initiation or duration of breastfeeding at 30 or 60 days, infant car safety seat use, circumcision, or health maintenance visits. CONCLUSIONS: Prenatal pediatric visits have potential impact on a variety of health care outcomes. Among urban, low-income mothers, we found beneficial effects on breastfeeding decisions, a decrease in emergency department visits, and an initial impact on the doctor-patient relationship. We suggest urban practices actively promote prenatal pediatric visits.

Missed opportunities for vaccination and the delivery of preventive care.

OBJECTIVES: To evaluate the relative impact of 2 types of missed opportunities (MOs) for vaccination, acknowledged and unacknowledged, on the immunization status of children at 2 years of age and to measure the delivery of immunizations and health care maintenance (HCM) after these types of MOs. DESIGN: Case-control study. SETTING: A large multispecialty clinic serving primarily a managed care population in Tucson, Ariz. PATIENTS: Charts of 1165 patients, ages 2 to 4 years, were reviewed for immunization status by 2 years of age. Of these patients, 652 had received all of their medical care at the clinic during their first 2 years of life. The 76 patients found to be underimmunized (UI) at 2 years of age and 76 controls, who were fully immunized (FI) by 2 years of age, frequency matched for age, were studied. MAIN OUTCOME MEASURES: The charts were reviewed for the following information: sex, age, immunizations received, HCM visits, sick visits, MOs, and pediatrician-patient interchange regarding immunization status during visits. RESULTS: Of the children who received all their care at the study site, 88% were FI. The mean number of MOs per patient occurring during the first 2 years of life was 5.8 for the UI children and 2.6 for the FI children. Only an unacknowledged MO, defined as a visit when the patient's immunization status was not reviewed, was associated with having a deficient immunization status at 2 years of age (4.6 vs 1.7, P < .001). Acknowledged MOs did not differ between UI and FI children (0.95 vs 0.76, P = .67). Immunizations were received at the subsequent visit (within a month) twice as often following a visit at which the child's deficient immunization status was acknowledged and a plan for follow-up made (P < .001). However, HCM was often not completed at the return visit. Following acknowledged MOs, patients did not return as directed 25% of the time for UI children and 5% of the time for FI children. Only 30% of FI patients completed the number of HCM visits recommended by the American Academy of Pediatrics. CONCLUSIONS: In the population studied, lack of review of the patients' immunization status was the primary cause of MOs to vaccinate. Although patients returned significantly more frequently when informed of their child's deficient immunization status, poor follow-up remained a significant problem in children who were eventually found to be lacking immunizations at 2 years of age.