E. Melinda Mahabee-Gittens

Identifying Children with Pneumonia in the Emergency Department

Emergency physicians need to clinically differentiate children with and without radiographic evidence of pneumonia. In this prospective cohort study of 510 patients 2 to 59 months of age presenting with symptoms of lower respiratory tract infection, 100% were evaluated with chest radiography and 44 (8.6%) had pneumonia on chest radiography. With use of multivariate analysis, the adjusted odds ratio (AOR) and 95% confidence intervals (CI) of the clinical findings significantly associated with focal infiltrates were age older than 12 months (AOR 1.4, CI 1.1-1.9), RR 50 or greater (AOR 3.5, CI 1.6-7.5), oxygen saturation 96% or less (AOR 4.6, CI 2.3-9.2), and nasal flaring (AOR 2.2 CI 1.2-4.0) in patients 12 months of age or younger. The combination of age older than 12 months, RR 50 or greater, oxygen saturation 96% or less, and in children under age 12 months, nasal flaring, can be used in determining which young children with lower respiratory tract infection symptoms have radiographic pneumonia.

Common medical terms defined by parents: are we speaking the same language?

Objectives: Physicians often assume that a patient understands frequently utilized medical words and patient management may be based on these assumptions. The objective of this study was to determine the publics definition of regularly used medical terminology. Methods: A cross-sectional convenience survey was conducted for guardians of children presenting to an urban pediatric emergency department. The orally completed, open-ended questionnaire included parental demographic information and their definition of eleven commonly used medical terms. The words chosen represent common chief complaints given in our emergency department. Definitions were grouped, and a concordance rate of 75% was chosen to consider responses similar. Results: One hundred twenty-two guardians completed the survey (89% parents, 88% female, and 55% high school graduates). Caregivers agreed on the definitions of diarrhea, constipation, dehydration, fever, and seizure. However, diarrhea and constipation were mainly defined by either stool consistency or frequency, not both. Dehydration was appropriately defined as lack of body fluids (92%), but many parents had difficulty identifying more than one sign of dehydration. Fever was thought to be an elevated body temperature (76%), yet 69% felt that a temperature less than 100.5°F was considered a fever. Most respondents did not know the definitions of meningitis (70%), lethargy (64%), and virus (40%). Conclusions: Although commonly used in everyday conversation, there seems to be a large disparity between a caregivers perception and the actual definition of medical terms. More precise communication may help both parties to understand the true situation.

A smoking cessation intervention plus proactive quitline referral in the pediatric emergency department: A pilot study

The prevalence of adult tobacco users who utilize the emergency department as patients or parents is disproportionately higher than the national average rates of tobacco use. Thus, it is advised that the emergency department be utilized as a venue for providing tobacco cessation counseling to adult tobacco users. Using a randomized control trial design, this pilot study evaluated the effect of a brief tobacco cessation intervention for tobacco using parents of children brought to a pediatric emergency department. Participants received either usual care or a brief tobacco cessation intervention based on the first 2 of the 5As of the Clinical Practice Guidelines and fax referral to the Quitline. The primary outcome was self-reported repeated point prevalence of tobacco use at 6 weeks and 3 months following the intervention. Secondary aims included number of quit attempts, increases in readiness to quit, comparisons of participants who were successfully retained, and contact rates by Quitline counselors. At 3-month follow-up, compared to the Usual Care Control group, intervention participants were more likely to have made at least one quit attempt (59% vs. 34%; p<.01), be seriously thinking about quitting (68% vs. 37%; p<.001), and have higher Ladder scores (6.2 vs. 5.3; p<.05). Study personnel were able to contact 68% and 52%, respectively, of participants at 6-week and 3-month follow-up. Quitline counselors were unable to reach 54% of participants. Our results reveal increased intentions to quit and trends toward quitting, however we experienced difficulties with participant retention. Suggestions for improvements in point prevalence and retention are given.

Dog bite prevention: an assessment of child knowledge

OBJECTIVES To determine what children know about preventing dog bites and to identify parental desires for dog bite prevention education. STUDY DESIGN This cross-sectional study sampled 5- to 15-year-olds and their parents/guardians presenting to a pediatric emergency department with nonurgent complaints or dog bites. The parent/guardian-child pairs completed surveys and knowledge-based simulated scenario tests developed on the basis of American Academy of Pediatrics and Centers for Disease Control and Prevention dog bite prevention recommendations. Regression analyses modeled knowledge test scores and probability of passing; a passing score was ≥11 of 14 questions. RESULTS Of 300 parent/guardian-child pairs, 43% of children failed the knowledge test. Older children had higher odds of passing the knowledge test than younger children, as did children with white parents vs those with nonwhite parents. No associations were found between knowledge scores and other sociodemographic or experiential factors. More than 70% of children had never received dog bite prevention education, although 88% of parents desired it. CONCLUSIONS Dog bites are preventable injures that disproportionately affect children. Dog bite prevention knowledge in our sample was poor, particularly among younger children and children with nonwhite parents. Formal dog bite prevention education is warranted and welcomed by a majority of parents.

A Randomized Clinical Trial of a Web-Based Tobacco Cessation Education Program

OBJECTIVES: We report the results of a randomized clinical trial of a 3-hour, web-based, tobacco cessation education program, the Web-Based Respiratory Education About Tobacco and Health (WeBREATHe) program, for practicing pediatric respiratory therapists (RTs), registered nurses (RNs), and nurse practitioners (NPs). METHODS: Two hundred fifteen RTs (n = 40), RNs (n = 163), and NPs (n = 12) employed at the Children’s Hospital of Philadelphia and the Children’s Hospital, University of Colorado at Denver, participated in this study. All study activities were completed online. After consenting, participants were randomly assigned to either the training (intervention) or delayed training (control) condition. The training condition consisted of a 3-hour continuing education unit course plus ongoing online resources. Participants were assessed at baseline, 1 week, and 3 months after enrollment. RESULTS: Participants in the training condition were more likely to increase their tobacco cessation intervention behaviors than their delayed training counterparts (F[1, 213] = 32.03, P < .001). Training participants showed significantly greater levels of advise (F[1, 213] = 7.22, P < .001); assess (F[1, 213] = 19.56, P < .001); and particularly assist/arrange (F[1213] = 35.52, P < .001). In addition, training condition participants rated the program highly on measures of consumer satisfaction. CONCLUSIONS: The WeBREATHe program is the first evidence-based education program in tobacco cessation designed specifically for pediatric RTs, RNs, and NPs. Engagement in WeBREATHe increased participants’ tobacco cessation-related behaviors.

A Smoking Cessation Intervention for Low-Income Smokers in the ED

BACKGROUND There is a high prevalence of smoking among caregivers who bring their children to the pediatric emergency department (PED) and even higher rates of tobacco smoke exposure (TSE) and related morbidity among their children. The PED visit presents an opportunity to intervene with caregivers, but it is unknown whether they are more likely to quit if their child has a TSE-related illness. We sought to examine a PED-based smoking cessation intervention and compare outcomes based on childrens TSE-related illness. METHODS A single-arm, prospective trial, with baseline, 3, and 6 month assessments was used in this study. Caregivers whose child had either a TSE-related (n=100) or non-TSE-related illness (n=100) were given a brief intervention consisting of counseling, referral to the Quitline, and free nicotine replacement therapy. RESULTS Participants were 91.5% female, 50.5% African American, 100% Medicaid recipients, 30.8 years old, child age mean of 5.5 years, 90% highly nicotine dependent, and 60.3% and 75.8% allowed smoking in the home and car, respectively. At follow-up (65% retention), 80% reported quit attempts at 3 months and 89% between 3 and 6 months. There were significant decreases in number of cigarettes smoked, time to first cigarette, and smoking in the home and car. Quit rates were 12.2% at 3 months, 14.6% at 6 months, and 7.3% at both time points (50% biochemically confirmed). There were no significant differences in outcomes based on childrens illness. CONCLUSIONS A brief PED-based smoking cessation intervention resulted in quit attempts and successful quits. However, the presence of a TSE-related illness did not result in different cessation outcomes.

Continued importance of family factors in youth smoking behavior.

INTRODUCTION Although it is known that levels of family factors (FF) such as parental monitoring and parent-adolescent connectedness vary during adolescence, it is unknown which factors remain protective, preventing smoking initiation, in youth of differing racial/ethnic groups. Using a longitudinal, nationally representative sample, we examined which FF protect against smoking initiation in White, Black, and Hispanic youth. METHODS A total of 3,473 parent-nonsmoking youth dyads from Round 1 (T1) of the National Survey of Parents and Youth were followed to Round 3 (T2). Youth smoking status at T2 was assessed as the primary outcome. We examined changes in FF (T2 - T1) and the protection afforded by these factors at T1 and T2 for smoking initiation, both by race/ethnicity and overall. RESULTS There were statistically significant decreases in levels of protective FF from T1 to T2 across all racial/ethnic groups; however, FF levels were higher in never-smokers compared with smoking initiators at both T1 and T2 (p < .05). Separate models by race/ethnicity showed the protective effect of increased perceived punishment in all racial/ethnic groups and protection against initiation by increased parental monitoring in Black and Hispanic youth. Overall, higher parental monitoring at T1 was associated with decreased odds of smoking initiation (33%); decreased parental monitoring and perceived punishment from T1 to T2 were associated with increased odds of smoking initiation (55% and 17%, respectively). CONCLUSIONS Smoking prevention interventions should encourage parents to both enforce consistent consequences of smoking behavior, and continue monitoring, especially in minority groups.

The Role of Family Influences on Adolescent Smoking in Different Racial/Ethnic Groups

INTRODUCTION Although differing levels of family influences may explain some of the varying racial/ethnic trends in adolescent smoking behavior, clarification of which influences are protective against smoking may aid in the development of future ethnic-specific smoking prevention interventions. We sought to identify and compare the association of family influences on adolescent smoking among Black, Hispanic, and White adolescents in a cross-sectional national sample. METHODS Data from 6,426 parent-child dyads from Round 1 of the National Survey of Parents and Youth were analyzed. The association of family influences with ever-smokers and recent smokers was evaluated. Multinomial logistic regression using SUDAAN software was used. RESULTS While all measures of family influences except for parent-adolescent activities and intention to monitor were significantly protective against recent smoking and ever smoking among Whites, ethnic-specific family influence predictors of smoking were found in Blacks and Hispanics. Higher parental monitoring, higher intention to monitor, and higher connectedness were protective among Hispanics, while higher parental punishment and favorable attitude toward monitoring were protective against smoking among Blacks. For family influences significantly associated with protection against smoking, consistently greater protection was afforded against recent smoking than against ever smoking. CONCLUSIONS Higher levels of family influences are protective against smoking among all racial/ethnic groups. There are consistencies in family influences on youth smoking; however, there may be specific family influences that should be differentially emphasized within racial/ethnic groups in order to protect against smoking behavior. Our results offer insight for designing strategies for preventing smoking in youth of different racial/ethnic backgrounds.

Missed opportunities to intervene with caregivers of young children highly exposed to secondhand tobacco smoke.

Kruse and Rigotti (2014) conducted a study to assess the feasibility of implementing screening for secondhand tobacco smoke exposure (SHSe) in hospitalized adult and pediatric patients at Massachusetts General Hospital. The authors found that routine screening was feasible, and that 3.8% of admitted non-smoking children were exposed to secondhand tobacco smoke in the home or car; SHSe was more common in children who were Medicaid recipients or admitted with asthma. As the authors and others suggest, findings likely under-represent the prevalence of secondhand smoke (Prochaska et al., 2013) as caregivers may not feel comfortable revealing the level of their childs SHSe. An investigation of SHSe admission screening in children by Wilson and colleagues indicates that the majority of smoke-exposed children were not identified on the basis of admission screenings (Wilson et al., 2012). A study at our institution (Howrylak et al., 2014), indicated that among caregivers who reported no SHSe, 69.9% had detectable salivary cotinine. Our recent research findings indicate a high rate of SHSe in young, low-income children who presented to the pediatric emergency department (PED) with respiratory-related illnesses. This research was part of a larger study conducted from November 2013 to July 2014 to assess the effect of a smoking cessation intervention on caregivers who presented to the PED at Cincinnati Childrens Hospital Medical Center with their children. Caregivers completed a brief tobacco survey and an assessment of their childrens SHSe. As part of this study, we biochemically assessed for SHSe with 16 children via salivary cotinine assays (Salivettes; Salimetrics, Inc., State College, PA). Cotinine was measured using the enzyme-linked immunosorbent assay technique with a limit of detection of 1.0 ng/ml. Based on prior studies (Butz et al., 2011; Kumar et al., 2008), children with a cotinine value of >1 ng/ml were classified as exposed to SHS. In our study, the mean age (SD) of children was 2.26 (1.73) years; 94% were female; 44% were Non-Hispanic, African American, 56% were White; 100% had Medicaid. The top three chief complaints were cough, difficulty breathing, and cold symptoms. Cotinine levels ranged from 1.0 ng/ml. SHSe was documented in the patients record by a clinician 75% of the time, although this may have been assessed on a previous visit. Of those children who did not have SHSe documented in their record, 75% had a detectable level of cotinine. Among the four children whose caregivers reported no tobacco exposure in the home or car, 100% had detectable salivary cotinine. Of the children with reported exposure either in the home or car, 91.7% had detectable salivary cotinine. Our results provide additional evidence to support the universal screening of children, not only in the in-patient setting, as recommended by Kruse and Rigotti, but also in the PED. All pediatric healthcare visits represent an underutilized opportunity to identify and intervene with caregivers to reduce their childs SHSe. Unfortunately, as in previous studies, our findings demonstrate that caregivers fail to accurately report their childs level of SHSe. Therefore, efficient biochemical testing of SHSe exposure is necessary to identify those caregivers and their children who do not self-report exposure. In addition, biochemical testing for SHSe may provide a teachable moment through which to motivate caregivers who smoke to quit.

An Emergency Department Intervention to Increase Parent-Child Tobacco Communication: A Pilot Study

ABSTRACT We conducted a randomized trial of parents and their 9-to 16-year-old children to pilot test an emergency department (ED)-based intervention designed to increase parent-child tobacco communication. Intervention group (IG) parents received verbal/written instructions on how to relay anti-tobacco messages to their children; control group (CG) parents received no specific instructions. Of the 540 subjects, 268 (49.6%) were randomized to the IG; both groups were similar at baseline. At one-month follow-up, IG children were more likely to report that they would definitely not smoke in the next 6 months (96.3% and 88.4%, p = 0.01), that there were an increased number of: child-initiated tobacco conversations (F(1,386) = 5.7, p = 0.02), times parents talked to them about: refusing cigarettes (F(1,380) = 7.6, p = 0.006), and reasons not to smoke (F(1,377) = 6.0, p = 0.015). Our pilot study has shown increases in parent-child tobacco communication after an ED-based intervention, suggesting that the ED may be an appropriate setting to encourage parent-child tobacco communication.