To relate the changing epidemiology of childhood to current patterns of pediatric practice in the United States, a critical literature review and selected analyses of national datasets, including the National Health Interview Survey, the National Hospital Discharge Survey, and National Vital Statistics System, were conducted. Trends over the past several decades suggest that the incidence of serious acute illness in children has fallen while the prevalence of chronic disease has risen. These trends have resulted in a growing concentration of serious childhood morbidity and mortality into chronic disorders. Current pediatric practice structures appear to be poorly suited to meet the growing demands of chronic disease in children and likely will require major reform in organization, financing, and training.

Despite their high levels of poverty and less access to health care, children in immigrant families have better than expected health outcomes compared with children in nonimmigrant families. However, this observation has not been confirmed in children with chronic illness. The objective of this study was to determine whether children with asthma in immigrant families have better than expected health status than children with asthma in nonimmigrant families.

Objective: The objectives of this study were to characterize (1) families' cumulative burden of health-related social problems regarding access to health care, housing, food security, income security, and intimate partner violence; (2) families' experiences regarding screening and referral for social problems; and (3) parental acceptability of screening and referral.

Methods: We surveyed 205 parents of children who were 0 to 6 years of age and attended 2 urban pediatric clinics for a well-child visit using a self-administered, computer-based questionnaire. The questionnaire included previously validated questions about health-related social problems and new questions about screening and referral in the past 12 months.

Results: A total of 205 (79%) of 260 eligible families participated. Eighty-two percent of families reported > or = 1 health-related social problem; 54% experienced problems in > or = 2 social domains. Families experienced similar types and frequencies of problems despite demographic differences between clinics. One third of families reported no screening in any domain in the previous 12 months. Of 205 families, 143 (70%) identified at least 1 need for a referral; 101 (49%) expressed > or = 1 unmet referral need. Of families who reported receiving referrals, 115 referrals were received by 79 families; of the referrals made, 63% (73 of 115) led to contact with the referral agency, and 82% (60 of 73) of the referral agencies were considered helpful. A computer-based system in a pediatrician's office for future screening and referral for health-related social problems was deemed acceptable by 92% of parents.

Conclusions: Urban children and families reported a significant burden of health-related social problems yet infrequent pediatric screening or referral for these problems. Of families who reported receiving referrals, a majority contacted the recommended agencies and found them helpful. This study also demonstrates the feasibility of using a computer-based questionnaire to identify health-related social problems in a routine outpatient clinic setting.

Objective: We sought to identify characteristics of pediatricians that were associated with identification or management (referral and/or treatment) of mothers with depression.

Methods: A cross-sectional survey was mailed to a random sample of 1600 of the 50,818 US nonretired members of the American Academy of Pediatrics. Overall, 832 responded, with 745 responses from nontrainee members. The 662 fellow nontrainee members who engaged in direct patient care and completed information on identifying, referring, and treating maternal depression were included in the analyses.

Results: A total of 511 of 662 respondents reported identifying maternal depression; of those who reported identifying maternal depression, 421 indicated they referred and 29 that they treated maternal depression in their practices. Pediatricians who are older, work in practices that provide child mental health services, see primarily (> or = 75%) white patients, use > or = 1 method to address maternal depression, agree that pediatricians should be responsible for identifying maternal depression, think that maternal depression has an extreme effect on children's mental health, and are attitudinally more inclined to identify or manage maternal depression had significantly higher odds of reporting identification of maternal depression. Positive correlates of identification and management of maternal depression included practicing in the Midwest, using > or = 1 method to address maternal depression, working in a practice that provides child mental health services, thinking that caregiving problems attributable to maternal health have an extreme effect on children's physical health, having attitudes that are more inclined to identify and to manage maternal depression, and usually inquiring about symptoms routinely to identify maternal depression.

Conclusions: Pediatricians' practice characteristics and attitudes are associated with their identification and management of mothers with depression.

Context: Child psychosocial issues and maternal depression are underidentified and undertreated, but we know surprisingly little about the barriers to identification and treatment of these problems by primary care pediatricians.

Objectives: The purpose of this work was to determine whether (1) perceived barriers to care for children's psychosocial issues and maternal depression aggregate into patient, physician, and organizational domains, (2) barrier domains are distinct for mothers and children, and (3) physician, patient, and practice/organizational characteristics are associated with different barrier domains for children and mothers.

Methods: We conducted a cross-sectional survey of the 50,818 US nonretired members of the American Academy of Pediatrics. Of a random sample of 1600 members, 832 (745 nontrainee members) responded. This was a mailed 8-page survey with no patients and no intervention. We measured physician assessment of barriers to providing psychosocial care for children's psychosocial problems and maternal depression.

Results: Pediatricians frequently endorse the lack of time to treat mental health problems (77.0%) and long waiting periods to see mental health providers (74.0%) as the most important barriers to the identification and treatment of children's psychosocial problems. For maternal depression, pediatricians most often endorsed lack of training in treatment (74.5%) and lack of time to treat (64.3%) as important barriers. Pediatricians' reports of barriers clustered into physician and organizational domains. Physician domains were distinct for children and mothers, but organizational domains were not. Several physician and practice characteristics are significantly associated with the 4 barrier scales, and different characteristics (eg, sociodemographic, attitudinal, and practice features) were related to each barrier area.

Conclusions: Pediatricians endorse a wide range of barriers with respect to the diagnosis and treatment of children's mental health problems and maternal depression. The specificity of factors relating to various barrier areas suggests that overcoming barriers to the identification and treatment of child mental health problems and maternal depression in primary care pediatrics is likely to require a multifaceted approach that spans organizational, physician, and patient issues. In addition, comprehensive interventions will likely require social marketing approaches designed to engage diverse audiences of clinicians and their patients to participate.

OBJECTIVE. To develop a set of quality indicators for the neurodevelopmental follow-up care of very low birth weight (VLBW; <1500 g) children.

METHODS. We reviewed the scientific literature on predictors of neurodevelopmental outcomes for VLBW children and the clinical practice guidelines relevant to their care after hospital discharge. An expert panel with members nominated by the American Academy of Pediatrics, the National Institute of Child Health and Human Development, the Vermont Oxford Network, and the California Children's Service was convened. We used a modified Delphi method to evaluate and select the quality-of-care indicators.

RESULTS. The panel recommended a total of 70 indicators in 5 postdischarge follow-up areas: general care; physical health; vision, hearing, speech, and language; developmental and behavioral assessment; and psychosocial issues. Of these, 58 (83%) indicators were in preventive care, 5 (7%) were in acute care, and 7 (10%) were in chronic care.

CONCLUSION. The quality indicators cover follow-up care for VLBW infants with various medical conditions. Given the elevated rates of long-term neurodevelopmental disabilities and the potential impact of poor health care, this new set of indicators provides an opportunity to assess and monitor the quality of follow-up care with the ultimate aim of improving the quality of care for this high-risk population.

In this paper, we examine the effect of maternal education on the health of young children by using a large sample of adopted children from China. As adopted children are genetically unrelated to the nurturing parents, the educational effect on them is most likely to be the nurturing effect. We find that the mother's education is an important determinant of the health of adopted children even after we control for income, the number of siblings, health environments, and other socioeconomic variables. Moreover, the effect of the mother's education on the adoptee sample is similar to that on the own birth sample, which suggests that the main effect of the mother's education on child health is in post-natal nurturing. Our work provides new evidence to the general literature that examines the determinants of health and that examines the intergenerational immobility of socioeconomic status.

Objective: Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born.

Design: We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level).

Results: The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (2 points). Similar patterns were observed in 1500- to 2499-g newborns.

Conclusions: The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.

Objective: To compare and contrast proposed definitions of metabolic syndrome in pediatrics, and to determine prevalence of metabolic syndrome in preadolescent females when applying different criteria.

Study Design: A literature review on definitions of metabolic syndrome and cardiovascular "risk factor clustering" in children and adolescents published in the past decade. Pediatric definitions of metabolic syndrome were then applied to a community-based study of 261 black preadolescent females (Girls Health Enrichment MultiSite studies [GEMS]) and a school-based, cross-sectional study of 240 ethnically-diverse preadolescent females (Girls Activity, Movement and Environmental Strategy [GAMES]) who had a baseline physical examination and fasting morning blood sample.

Results: Agreement among pediatric definitions of metabolic syndrome was poor. The prevalence of MS and cardiovascular risk factor clustering ranged from 0.4% to 23.0% for GEMS and 2.0% to 24.6% for GAMES with definitions adapted from the National Cholesterol Education Program Adult Treatment Panel III, and 0% to 15.3% for GEMS and 0.4% to 15.8% for GAMES using modified criteria from the World Health Organization.

Conclusions: The prevalence of metabolic syndrome in preadolescent girls varies widely because of disagreement among proposed definitions of metabolic syndrome in pediatrics. Further investigation is needed to determine which metabolic factors and their respective cut points should be used to identify children at risk for development of clinical disease.

Objective: To examine children's screen media exposure and requests for advertised toys and food/drinks.

Design: Prospective cohort study.

Setting: Twelve elementary schools in northern California.

Participants: Eight hundred twenty-seven third grade children participated at baseline; 386 students in 6 schools were followed up for 20 months.

Intervention: None.

Main Outcome Measures: Child self-reported requests for advertised toys and foods/drinks.

ResultsAt baseline, children's screen media time was significantly associated with concurrent requests for advertised toys (Spearman r = 0.15 [TV viewing] and r = 0.20 [total screen time]; both P.001) and foods/drinks (Spearman r = 0.16 [TV viewing] and r = 0.18 [total screen time]; both P.001). In prospective analysis, children's screen media time at baseline was significantly associated with their mean number of toy requests 7 to 20 months later (Spearman r = 0.21 [TV viewing] and r = 0.24 [total screen time]; both P.001) and foods/drinks requests (Spearman r = 0.14 [TV viewing] and r = 0.16 [total screen time]; both P.01). After adjusting for baseline requests and sociodemographic variables, the relationship between screen media exposure and future requests for advertised foods/drinks remained significant for total TV viewing and total screen media exposure. The relationship with future requests for toys remained significant for total screen media exposure.

Conclusions: Screen media exposure is a prospective risk factor for children's requests for advertised products. Future experimental studies on children's health- and consumer-related outcomes are warranted.