Get SMART: Teaching Pediatric Residents the 2020 Focused Asthma Updates' Recommendations for Symptom-Based Medication Increases.

Introduction: The 2020 Focused Asthma Updates introduced a paradigm shift in the treatment of asthma that includes symptom-based adjustments to outpatient asthma treatment that vary by age and severity. The length and complexity of the updates have made them challenging to adopt. Methods: We implemented an educational session among pediatric residents to increase their familiarity with, comprehension of, and plans to adopt two evidence-based recommendations introduced in the 2020 Updates for symptom-based therapy. Facilitators led groups of four to six pediatric residents in cased-based discussions during a 30-minute, ambulatory care-based session. One week prior, participants and facilitators received synopses of the 2007 Guidelines for the Diagnosis and Management of Asthma and the 2020 Updates. Facilitators also received a guide and scripts explaining new concepts, providing supporting data, and highlighting learning objectives. Retrospective pre/post surveys assessed participants' familiarity with, comprehension of, and planned adoption of recommendations for intermittent steroids and single maintenance and reliever therapy (SMART) before and after the conference. The surveys also assessed prior exposure to the 2020 Updates and reflections on the educational session. Results: There were 26 participants. Ratings of familiarity, comprehension, and adoption plans regarding the recommendations significantly improved (ps < .001, Wilcoxon signed rank test). The case-based approach was well received, and the material was deemed relevant. Discussion: This educational session significantly increased pediatric residents' familiarity with, comprehension of, and plans to adopt two new evidence-based treatments. Dissemination of this educational session may improve outpatient asthma management.

Screening, Monitoring, and Referral to Treatment for Young Adolescents at an Urban School-Based Health Center.

BACKGROUND: This study describes the experience of implementing a screening, monitoring, and referral to treatment (SMARTT) initiative at an urban middle school school-based health center. METHODS: Retrospective data were collected for adolescents screened with the Pediatric Symptom Checklist-17-Y. At-risk adolescents having unmet health needs were offered a mental health referral, and those that declined a mental health referral were offered a primary care monitoring (PCM) visit with the medical provider. Chi-square analyses were used to evaluate differences in screening and outcomes by age, sex, and race/ethnicity. RESULTS: One out of four adolescents had a positive PSC-17-Y or negative screen with other identified concerns. Approximately half of these at-risk adolescents accepted a mental health referral, and 86% of those who declined agreed to the PCM visit. More than two-thirds of the PCM group did not need continued monitoring and support at follow-up, and 85.4% of youth who had a mental health assessment accepted mental health services. CONCLUSIONS: The SMARTT initiative successfully demonstrated that co-located and integrated mental health services can enhance access and connection to mental health services for at-risk youth. In addition, PCM visits were found to be an effective option for youth who declined mental health referrals.

Reducing HIV/STI Risk Among Adolescents Aged 12 to 14 Years: a Randomized Controlled Trial of Project Prepared.

Despite calls for evidence-based HIV/STI prevention programs for youth aged 12 to 14 transitioning to adolescence, few effective programs exist. In a two-group intent-to-treat randomized trial in the Bronx, NY, 397 participants were randomly assigned to Project Prepared or an attention control, TEEN. Participants completed surveys at baseline, 6 months, and 12 months. Prepared had two components, an 11-session program and a 3-week internship. Content covered sexual risk behavior, social cognitions, gender norms, relationships, and resilience. TEEN built communication skills and had the same intensity and structure as Prepared but no sexual content. In both, boys and girls were trained together in mixed groups of ~ 11 teens. Primary outcomes were HIV knowledge, self-efficacy, condom outcome expectancy, and behavioral intentions. Secondary outcomes were relationship expectations and endorsement of risky gender norms. Generalized estimating equation analyses showed youth randomized to Prepared had significant improvements compared to TEEN at T2 in HIV knowledge, sexual self-efficacy, and outcome expectancy for condom use. At T3, there were significant differences favoring Prepared in outcome expectancy for condom use, sexual self-efficacy, and intention for partner communication about HIV/AIDS or STIs. Analyses by gender showed program effects in both boys (intention to talk to a partner about condom use, abstinence self-efficacy, sexual self-efficacy, and condom outcome expectancy) and girls (gender norms, and abstinence outcome expectancy). Prepared effectively reduced risk in young adolescents. ClinicalTrials.gov ID: NCT01880450, Protocol ID: 2008-551.

Pediatric Hematologists Report Infrequent Prognosis Discussions in the Routine Care of Children with Sickle Cell Disease.

A large proportion of the morbidity and almost all of the mortality of sickle cell disease (SCD) now occurs in adulthood. Children with SCD underuse disease-modifying and curative treatments, in part because of how patients/parents understand SCD morbidity and mortality. Whether practitioners provide prognostic information to families is unknown. We emailed a 31-item survey to 1,149 pediatric hematologist-oncologists and analyzed 96 responses. Most said discussing prognosis would change patient/parent willingness to start hydroxyurea, but fewer actually discuss prognosis when they want to start hydroxyurea (91% vs. 75%, p=.001). Similarly, most said discussing prognosis would change adherence to therapy, but fewer actually discuss prognosis to motivate adherence (78% vs 31%, p<.001). Most (77%) addressed prognosis when the "patient or their parent bring it up." Respondents reporting frequent life expectancy discussions were more likely to report a pathway for such discussions (p=.017). Pediatric hematologists may not conduct prognostic discussions without prompting, although these conversations may be important for shared, informed decision-making.

DBP Evaluations in DBPNet Sites: Is Race/Ethnicity a Significant Factor in Care?

OBJECTIVE: To examine whether there are differences between non-Hispanic white (NHW) and nonwhite (NW) children in referral questions, evaluations, and diagnoses during developmental behavioral pediatrician (DBP) evaluations at academic medical centers and the potential role of socioeconomic factors in any disparities noted. DESIGN/METHODS: This observational study used survey data from 56 DBPs at 12 sites participating in DBPNet. Child race and ethnicity were obtained from DBP report. Mixed-model logistic and linear regression analyses controlling for site, provider, and socioeconomic proxy variables (insurance type, parent education, and language spoken at home) were used to compare groups on referral concerns, evaluation procedures, and diagnoses. RESULTS: Among the patients evaluated, 349 were NHW, 406 were NW (187 Hispanic, 135 black, 58 Asian/Pacific Islander, and 26 other/mixed), and 29 were missing race/ethnicity data. The mean waiting time controlling for site and provider was 20.4 weeks for NHW children and 20.5 weeks for NW children. Reasons for referral were similar in the NWH and NW groups, with only sleep problem concerns being more frequent among NHW children (9.2% vs 3.4% NW, p = 0.01). Patients also had similar evaluations in the 2 groups; the only differences found were that more NHW than NW children had genetic testing (33.1% vs 19.3%, p = 0.02), ophthalmology evaluations (8.7% vs 3.4%, p = 0.03), and psychopharmacologic evaluations (19.1% vs 9.7%, p = 0.008). Numbers and types of diagnoses did not vary by race/ethnicity. CONCLUSION: This study suggests little inequality between NHW and NW children in wait time to care, reasons for referral, workup, or final diagnosis for initial DBP evaluation at these 12 academic DBP centers when socioeconomic factors are considered. Nevertheless, because differences in these related factors may be mechanisms through which racial/ethnic disparities can arise, it will be important to consider them in planning models and care protocols for underserved communities.

The Hybrid Arch Bar Is a Cost-Beneficial Alternative in the Open Treatment of Mandibular Fractures.

Obtaining maxillomandibular fixation (MMF) to achieve fracture reduction and functional occlusion is essential in the management of maxillofacial trauma. The aims of this retrospective review were to compare the total time spent in the operating room (OR) when using the Erich arch bar (EAB) versus the bone anchored hybrid arch bar (HAB) as well as performing a cost-benefit analysis (CBA). The study sample comprised patients older than 18 years who underwent open reduction internal fixation of mandible fractures at two separate institutions over a 5-year period. The primary outcome variable was total surgical time in minutes, defined as the time from incision to the completion of closure. Average operative time was significantly longer for the EAB than for the HAB (186.74 ± 70.73 vs. 135.98 ± 2.69 minutes, p < 0.001). A significant amount of time was saved by using the HAB for unilateral (37.17 ± 13.19 minutes; p = 0.007) and bilateral fractures (55.83 ± 18.89 minutes; p = 0.005). In-depth CBA showed that, for average OR fees of $60 per minute, the HAB produced savings of at least 4.01 and 11.63% of the total cost of surgery for unilateral and bilateral fractures. These results support the hypothesis that the HAB is a time-saving maneuver in the open treatment of mandible fractures. The HAB saves more time in bilateral fracture cases despite the longer overall operative times. This study shows the differential time-saving effect of the HAB regardless of fracture laterality as well as its cost minimization benefit compared with the EAB.

Do Urban Minority Parents and Children Agree on Asthma Symptoms with Exercise, Worries, and Confidence in Disease Management?

OBJECTIVE: Providers commonly rely on parent reports of a child's asthma symptoms; however, children as young as 7 years can report on their own health. Our study compared parent and child reports of asthma symptoms with exercise, worries about developing an asthma attack, and confidence in disease management. METHODS: We recruited children ages 7 to 10 years with asthma from 4 Bronx, NY, schools, as well as their parents. The parents and children completed interview surveys with parallel questions regarding perceived asthma symptoms, asthma-related worries, and confidence in disease management. We used McNemar tests for paired data to compare parent and child responses. RESULTS: We analyzed data for 105 parent-child pairs. Mean child age was 8.5 years (standard deviation, 0.99); 53% were male, and 82% were Hispanic. Children were more likely than their parents to report ever having an exercise-induced asthma attack (85% vs 48%; P < .001) and that they "worry a lot" about developing an asthma attack during exercise (63% vs 45%; P = .01). Children felt more confident about using an inhaler correctly (76% of the children were "very sure" vs 60% of the parents; P = .009) and were more likely to report having an inhaler available in case of an attack (38% of the children were "very sure" vs 20% of the parents; P = .003). CONCLUSIONS: In this school-based sample of urban children with asthma, we found disagreement between parent and child reports of symptoms with exercise, worry about developing an attack, and confidence in medication use. These findings suggest that including child reports during history taking could help providers identify children in need of enhanced asthma management.

Expanded Medicaid dental coverage under the Affordable Care Act: an analysis of Minnesota emergency department visits.

OBJECTIVES: Hospital emergency departments (EDs) function as the safety net for patients with non-traumatic dental conditions (NTDCs). With the implementation of Medicaid expansion under the Affordable Care Act (ACA) many adults became eligible for dental benefits. We examined the impact of "early" Medicaid expansion in Minnesota on ED visits for NTDCs from 2008 (prereform) to 2014 (postreform). METHODS: Data from the State Emergency Department Databases for Minnesota were analyzed for 2 years: 2008 and 2014. All individuals who presented to the ED with a dental problem were identified based on the International Classification of Diseases, Ninth Revision, Clinical Modification with a primary diagnosis of 520.0-529.9. Demographic variables including patient age, gender, and primary payer were examined. RESULTS: Between 2008 and 2014 there was a 18.8 percent increase in the number of all non-dental ED visits and a 9.7 percent decrease in the number of NTDC visits. In that time period, young adults 18-26 years old showed a significant decrease (19.3 percent, P < 0.001) in the number of NTDC visits. CONCLUSIONS: The Minnesota experience suggests that the increase in Medicaid dental benefits through the ACA has significantly decreased NTDC visits, especially among young adults who were eligible for a dependent coverage policy that extends parents' health insurance to age 26. To our knowledge, no previous study has reported on the impact of early Medicaid expansion on the rate of ED use for NTDCs.

Primary Care Providers as Mental Health Counselors: Views from Urban, Minority Adolescents.

OBJECTIVE: To examine urban, minority adolescents' preferences for receiving guidance for mental health (MH) issues from primary care providers (PCPs) or from mental health providers (MHPs). METHODS: Adolescents (13-21 years) from three community clinics and one school-based health center (SBHC) in the Bronx, N.Y. completed anonymous surveys. Characteristics of adolescents who preferred the PCP vs. MHP and adolescents' attitudes about the PCP vs. the MHP were compared. RESULTS: Adolescents (N=135), mean age 16 years, majority Hispanic participated. Although 85% strongly agreed or agreed that their PCP was knowledgeable about MH, 57% preferred to talk to a MHP. Those who preferred the MHP were younger, attend a SBHC, and trust information on MH from a MHP. Those who preferred the PCP were more likely to report feeling comfortable talking to their PCP about MH. CONCLUSIONS: Although the majority preferred a MHP, PCPs appeared to be an acceptable alternative for MH care.

Engaging and sustaining adolescents in community-based participatory research: structuring a youth-friendly community-based participatory research environment.

Community-Based Participatory Research partnerships typically do not include adolescents as full community partners. However, partnering with adolescents can enhance the success and sustainability of adolescent health interventions. We partnered with adolescents to address health disparities in a low-income urban community. In partnering with youth, it is important to consider their developmental stage and needs to better engage and sustain their involvement. We also learned the value of a Youth Development framework and intentionally structuring a youth-friendly Community-Based Participatory Research environment. Finally, we will raise some ethical responsibilities to consider when working with youth partners.

The Adult Roles Models Program: Feasibility, Acceptability, and Initial Outcomes.

We present the feasibility and acceptability of a parent sexuality education program led by peer educators in community settings. We also report the results of an outcome evaluation with 71 parents who were randomized to the intervention or a control group, and surveyed one month prior to and six months after the 4-week intervention. The program was highly feasible and acceptable to participants, and the curriculum was implemented with a high level of fidelity and facilitator quality. Pilot data show promising outcomes for increasing parental knowledge, communication, and monitoring of their adolescent children.

Evaluation of MDI-spacer utilization and technique in caregivers of urban minority children with persistent asthma.

OBJECTIVE: Incorrect Metered-Dose Inhaler (MDI)-spacer technique can result in decreased drug delivery to distal airways and poor asthma outcomes. There is lack of research to examine whether the caregivers utilize proper technique when applying an MDI-spacer delivery system for young minority children with persistent asthma in the United States. The objective of this study was to evaluate MDI-spacer utilization and technique among the caregivers of Bronx minority children with persistent asthma and to determine characteristics associated with correct use. METHODS: We analyzed data from 169 caregivers of urban minority children with persistent asthma (aged 2-9 years). MDI-spacer device technique was assessed using a 10-step checklist derived from the national guidelines, literature and manufacturers' instructions. Based on the median MDI-technique score of six steps demonstrated accurately, caregivers were categorized as correct (seven or more) or incorrect (six or less) users. RESULTS: Of the 169 caregivers, 95% were mothers, mean age 32.3 years (SD 7.6), 56% were unemployed; 74% of the children were Hispanic, 87% had either "not well controlled" or "very poorly controlled" asthma, 92% had a spacer at home and 71% used it "all" or "most" of the time. Only one caregiver correctly demonstrated all 10 steps of the MDI-spacer technique. Child's having one or more asthma-related hospitalizations in the past 12 months and higher caregiver educational level were independent predictors of correct MDI-spacer technique. CONCLUSIONS AND RELEVANCE: The caregivers of urban, minority children with persistent asthma lack proper MDI-spacer technique, suggesting the potential value of both targeted short- and long-term educational interventions.

Social-emotional screening for infants and toddlers in primary care.

BACKGROUND AND OBJECTIVES: Recommendations in pediatrics call for general developmental screening of young children; however, research suggests social-emotional development, in particular, is important as an initial indicator of general well-being versus risk. We aim to describe a program designed to identify the social-emotional status of young children in the pediatric setting by using the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) as a universal screening tool, and to assess the effect of interventions by a colocated psychologist on changes in ASQ:SE scores over time. METHODS: In a prospective cohort design we analyzed scores on ASQ:SE surveys completed on children 6 to 36 months of age, to determine if children were at risk for problems in social-emotional development. The probability of remaining at risk over time was then compared between subjects receiving intervention by the psychologist, and those who declined intervention. Logit specifications were used in multivariate comparisons to control for a set of covariates. RESULTS: Three thousand one hundred and sixty-nine children were screened; 711 (22.4%) scored at or above the risk cutoff. Among the 711 at-risk children, 170 were rescreened. At the time of rescreening, those children who received intervention from the psychologist showed significant improvement on ASQ:SE scores compared with those who declined intervention (P = .01). CONCLUSIONS: Universal social-emotional screening in a busy pediatric practice is challenging. Significant percentages of children can be identified as being at risk for social-emotional problems, and colocation of a psychologist promotes the ability to effectively address young children's social-emotional development within their medical home.

Modifiable risk factors for asthma morbidity in Bronx versus other inner-city children.

BACKGROUND: Bronx children have higher asthma prevalence and asthma morbidity than other US children. OBJECTIVE: To compare risk factors for asthma morbidity present in Bronx children with those of children from other US inner-city areas. METHODS: Cross-sectional, multi-state study of 1772 children ages 5-11 yrs. old with persistent asthma. Parental responses to the Child Asthma Risk Assessment Tool for 265 Bronx children are compared with those of 1507 children from 7 other sites (1 Northeast, 2 South, 2 Midwest, 2 West). RESULTS: Bronx children were significantly more likely to be sensitized to reported aeroallergens in their homes than were children from the other sites (86% vs. 58%; p < .001). More Bronx parents reported household cockroaches (65% v 20%; p < .001), mice (42% v 11%; p < .001), and rats (7% v 3%; p < .001); using a gas stove to heat the home (20% v 9%; p < .001); and visible mold (48% v 25%; p < .001). Bronx parents were more likely to report pessimistic beliefs about controlling asthma (63% v 26%; p < .001) and high parental stress (48% v 37%; p < .01). CONCLUSIONS: Compared with other inner-city children with asthma, Bronx children are more likely to be exposed to household aeroallergens to which they are sensitized and have poor housing conditions. Their parents are more likely to report low expectations for asthma control and high levels of psychological stress. Interventions that address these identified needs may help to reduce the disproportionate burden of asthma morbidity experienced by Bronx children.

Effects of yoga on inner-city children's well-being: a pilot study.

OBJECTIVE: To examine yoga's effects on inner-city children's well-being. METHODS: This pilot study compared fourth- and fifth-grade students at 2 after-school programs in Bronx, New York. One program offered yoga 1 hour per week for 12 weeks (yoga) and the other program (non-yoga) did not. Preintervention and postintervention emotional well-being was assessed by Harter's Global Self-Worth and Physical Appearance subscales, which were the study's primary outcome measures. Secondary outcomes included other measures of emotional well-being assessed by 2 new scales: Perceptions of Physical Health and Yoga Teachings (including Negative Behaviors, Positive Behaviors, and Focusing/relaxation subscales). Preintervention and postintervention, physical wellbeing was assessed by measures of flexibility and balance. Subjective ratings ofyoga's effects on well-being were evaluated by an additional questionnaire completed by the yoga group only. RESULTS: Data were collected from 78% (n=39) and 86.5% (n=32) of potential yoga and non-yoga study enrollees. No differences in baseline demographics were found. Controlling for preintervention well-being differences using analysis of covariance, we found that children in the yoga group had better postintervention Negative Behaviors scores and balance than the non-yoga group (P < .05). The majority of children participating in yoga reported enhanced wellbeing, as reflected by perceived improvements in behaviors directly targeted by yoga (e.g., strength, flexibility, balance). CONCLUSIONS: Although no significant differences were found in the study's primary outcomes (global self-worth and perceptions of physical well-being), children participating in yoga reported using fewer negative behaviors in response to stress and had better balance than a comparison group. Improvements in wellbeing, specifically in behaviors directly targeted by yoga, were reported. These results suggest a possible role of yoga as a preventive intervention as well as a means of improving children's perceived well-being.

Association of functional limitation with health care needs and experiences of children with special health care needs.

OBJECTIVE: The goal was to evaluate whether having a functional limitation was associated with health care needs and experiences of children with special health care needs. METHODS: We used caregivers' responses in the National Survey of Children with Special Health Care Needs (2001). Functional limitation was categorized as severe, some, or no limitation. We performed analyses of the relationships of functional limitation to measures of health care needs and experiences. RESULTS: Children with special health care needs with severe functional limitation were more likely to have received specialized educational services, to have had physician visits, and to have needed health services, compared with those with no limitation. They had significantly greater odds of delayed care, unmet health care and care-coordination needs, referral problems, dissatisfaction, and difficulty using health services, compared with those without limitation. Caregivers of children with special health care needs with severe limitation were twice as likely as those with no limitation to report that providers did not spend enough time, listen carefully, provide needed information, and make family members partners in the child's care. Compared with children with special health care needs without limitation, those with severe limitation had worse health insurance experiences, in terms of insurance coverage, copayments, being able to see needed providers, and problems with health insurance. The impact on families (financial problems, need to provide home care, or need to stop or to cut work) of children with special health care needs with severe functional limitation was much greater than the impact on families of children with special health care needs without limitation. For most measures examined, results for some limitation were between those for severe limitation and no limitation. CONCLUSIONS: Functional limitation is significantly associated with the health care needs and experiences of children with special health care needs.

Asthma risk factor assessment: what are the needs of inner-city families?

BACKGROUND: A complex array of risk factors contributes to sustained high levels of asthma morbidity in inner-city children. OBJECTIVE: To describe risk factors for asthma morbidity in a national sample of inner-city children with persistent asthma. METHODS: This study examined baseline questionnaire results from 1,772 children ages 5 to 11 years old with moderate to severe persistent asthma who enrolled in the Centers for Disease Control and Prevention-funded Inner-City Asthma Intervention between April 2001 and March 2004. Risk for asthma morbidity was assessed in 9 domains using the Child Asthma Risk Assessment Tool. The domains included environmental exposures, parental stress, medication adherence, pessimistic asthma beliefs, smoke exposure, aeroallergen exposure, child psychological well-being, responsibility for medication administration, and medical care. RESULTS: A total of 51% of families demonstrated high risk of asthma morbidity in 3 or more domains. High risk of asthma morbidity was suggested based on household environmental exposures (47.7%), high parental stress (38.5%), poor medication adherence (38.3%), pessimistic asthma beliefs (31.8%), environmental tobacco smoke (24.4%), sensitization to aeroallergens in the home (24.8%), child behavioral or emotional concerns (22.9%), child assigned responsibility for medication administration (21.2%), and poor medical care (20.7%). Allergy testing was completed for 40% of the participating children. Of these children, 61% were exposed to aeroallergens in their home to which they were sensitized. CONCLUSIONS: In this national sample of inner-city children, multiple risk factors for asthma morbidity were identified. Asthma programs that provide multilevel support and intervention are needed to reduce the burden of asthma on inner-city families.

The relationship of depressive symptoms to parenting competence and social support in inner-city mothers of young children.

OBJECTIVE: Despite the high prevalence of maternal depression and its negative consequences for children, many pediatricians fail to identify this problem. Our goal was to determine whether simple questions about parenting competence and the adequacy of maternal social support might be useful to providers in determining which inner-city mothers are likely to be depressed. METHODS: We surveyed a convenience sample of 279 English-speaking mothers of children 6 months to 3 years old prior to a routine visit at an urban, hospital-based general pediatrics clinic. The mothers self-completed the Psychiatric Symptom Index (PSI) and the Parenting Stress Index Sense of Competence subscale, and rated the adequacy of their social support, and provided health and sociodemographic data by face-to-face interview. RESULTS: 41% of mothers had "high" PSI symptom levels and 22% had scores above a criterion that suggests major depressive disorder. In addition, 15% experienced high parenting stress (low competence) and 42% reported little or no social support. High distress was unrelated to a variety of sociodemographic risk factors, but significantly associated with a poor sense of parenting competence (Adj. OR = 3.3, 95% CI = 1.5, 7.0) and inadequate perceived social support (Adj. OR = 2.3, 95% CI = 1.2, 4.4), as well as with having health-related activity limitations (Adj. OR = 3.2, 95% CI = 1.1, 9.0). CONCLUSIONS: Negative ratings of parenting competence, low perceived social support, and presence of health-related activity restrictions can be useful markers of likely depression among inner-city mothers of young children. These factors are often assessed during routine pediatric visits and may be helpful to pediatricians in identifying mothers needing further evaluation or treatment by mental health specialists.

Predicting the need for hospitalization in acute childhood asthma using end-tidal capnography.

OBJECTIVE: To explore the utility of end-tidal capnography for predicting hospitalization in acute childhood asthma. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study of a convenience sample of children 5 to 17 years of age presenting to a pediatric emergency department with an acute asthma exacerbation. Capnography was performed at baseline. The length of the plateau portion of the baseline capnograph waveform was measured in millimeters and divided by the respiratory rate at the time of the measurement to create a ratio. The sensitivity and specificity of the baseline capnography ratio for predicting hospitalization were assessed. MAIN OUTCOME MEASURES: Hospitalization versus discharge from the pediatric emergency department. RESULTS: Thirty-seven patients were enrolled. The hospitalized (n = 12) and discharged (n = 25) groups did not differ in terms of any demographic or baseline characteristics except for pulmonary score and the median baseline capnography ratio. The median ratio was 0.15. Ten (83.3%) of 12 of patients who were hospitalized had a baseline ratio less than 0.15 compared with 8 (32%) of 25 of patients who were discharged from pediatric emergency department (P < 0.05). Controlling for baseline asthma severity, the odds of being hospitalized if the baseline capnography ratio was less than 0.15 were 18.77 (95% confidence interval, 1.91-184.69). CONCLUSION: This pilot study suggests that baseline capnography may be useful as an objective effort-independent tool for identifying children with an asthma exacerbation who are at risk for hospitalization.