Matilde Irigoyen

Exposure and Use of Mobile Media Devices by Young Children.

BACKGROUND AND OBJECTIVES: Research on children’s use of mobile media devices lags behind its adoption. The objective of this study was to examine young children’s exposure to and use of mobile media devices. METHODS: Cross-sectional study of 350 children aged 6 months to 4 years seen October to November 2014 at a pediatric clinic in an urban, low-income, minority community. The survey was adapted from Common Sense Media’s 2013 nationwide survey. RESULTS: Most households had television (97%), tablets (83%), and smartphones (77%). At age 4, half the children had their own television and three-fourths their own mobile device. Almost all children (96.6%) used mobile devices, and most started using before age 1. Parents gave children devices when doing house chores (70%), to keep them calm (65%), and at bedtime (29%). At age 2, most children used a device daily and spent comparable screen time on television and mobile devices. Most 3- and 4-year-olds used devices without help, and one-third engaged in media multitasking. Content delivery applications such as YouTube and Netflix were popular. Child ownership of device, age at first use, and daily use were not associated with ethnicity or parent education. CONCLUSIONS: Young children in an urban, low-income, minority community had almost universal exposure to mobile devices, and most had their own device by age 4. The patterns of use suggest early adoption, frequent and independent use, and media multitasking. Studies are urgently needed to update recommendations for families and providers on the use of mobile media by young children.

An Individualized Intervention to Improve Asthma Management Among Urban Latino and African-American Families

We hypothesized that an educational intervention based on a readiness model would lead to improved health outcomes among patients with asthma. Within a randomized control design in an urban Latino and African-American community, we conducted an intensive three-month pediatric intervention. A Family Coordinator provided patient education based on a readiness-to-learn model, and facilitated improved interactions between the patient and the doctor. Family education addressed the most basic learning needs of patients with asthma by improving their perception of asthma symptom persistence using asthma diaries and peak flow measures. The physician intervention focused clinicians’ attention on patients’ diary records and peak flow measures, and encouraged physicians to use stepped action plans. Patients were also tested for allergic sensitization and provided strategies to reduce contact with allergens and other asthma triggers. The results showed significant improvements by intervention group families on measures of knowledge, health beliefs, self-efficacy, self- regulatory skill, and adherence; decreases in symptom persistence and activity restriction; and increased prescription of anti-inflammatory medication by the physicians of the intervention group families.

Use of personal digital assistants to enhance educational evaluation in a primary care clerkship

Experiences of students using optically scanned cards were compared with those of students using personal digital assistants (PDAs) to log patient encounters in a primary care clerkship. From April to September 2001, students were offered the option of using a PDA in lieu of scanned cards to track clinical encounters. Data obtained from PDA users were compared with those previously obtained from scanned card users. Verbal and written feedback was obtained from all students. Of the 71 students invited to participate, 21 (30%) owned a PDA, and of these, 20 agreed to participate. Eighteen students completed the pilot. One student was unable to participate owing to software installation problems; another student lost data because of improper back-up. Students using the PDAs recorded more encounters per rotation and had fewer missing data when compared with students who used scanned card. Additionally, feedback from students suggested that PDAs offered other important educational benefits.

Influenza vaccine coverage and missed opportunities among inner-city children aged 6 to 23 months: 2000-2005.

OBJECTIVE. In 2002, the Advisory Committee on Immunization Practices recommended universal influenza vaccination of 6- to 23-month-olds. Little is known about coverage and missed opportunities for influenza vaccination at inner-city practices. The objective of this study was to assess the 2000–2001 to 2004–2005 coverage and the prevalence of missed opportunities for influenza vaccination among inner-city children. METHODS. We conducted a retrospective review for the 2000–2001 to 2004–2005 influenza seasons at a practice network in New York City. The study population included 5 annual cohorts of 6- to 29-month olds as of March 31 of each year with ≥1 visit to the network in the previous 12 months (n = 7063). Immunization data were obtained from the network registry and the New York Citywide Immunization Registry. Coverage levels were estimated for 1 dose (partial) and 2 doses (full). Missed opportunities were assessed for visits within each influenza season. RESULTS. Coverage rose steadily throughout the 5 years (full: 1.6% to 23.7%; partial: 1.5% to 18.1%). The relationship between year and coverage was linear. Missed opportunities occurred in 82% of visits and were more common for first (89%) than for repeat doses (38%). Missed opportunities per child per season decreased from 2.9 to 2.0 during the study period. CONCLUSIONS. Influenza vaccine coverage among 6- to 23-month-olds at inner-city practices increased steadily from 2000–2001 through 2004–2005, and the prevalence of missed opportunities per child decreased. However, coverage remained suboptimal, with most of children not vaccinated or undervaccinated. Missed opportunities were major contributors to low coverage.

Change in parental reasons for use of an urban pediatric emergency department in the past decade.

Objective: To assess changes over the past decade in parental reasons associated with nonurgent visits to pediatric emergency departments (PEDs) during regular primary care office hours. Methods: Secondary analysis of cross-sectional surveys of families of children younger than 3 years visiting a PED in a low-socioeconomic area in New York City conducted in 1997 and 2006. We performed multivariable analyses to assess differences in parental reported reasons for PED use over the period, controlling for sociodemographic factors. Results: Most children (95.6%) had a usual source of care across both periods. Compared with those seen in 1997, children seen in 2006 were far less likely to be brought to the PED during regular primary care office hours for parental perceived urgency (adjusted odds ratio [AOR], 0.076; 95% confidence interval [CI], 0.024-0.24; P < 0.001). At the same time, these children were more likely to be brought to the PED for limited access to their usual source of care (AOR, 3.35; 95% CI, 1.24-9.02; P < 0.05) and greater trust in the medical expertise of the PED (AOR, 5.95 95% CI, 1.20-29.45; P < 0.05). Conclusions: Over the last decade, despite the presence of a usual source of care, a greater number of parents report visiting this urban PED during regular office hours for reasons unrelated to parental perceived urgency. Limited access to care and greater trust in the medical expertise available in PEDs have played important roles. Approaches to decreasing nonurgent visits must take into account all of these factors.

Relationships of dietary fat consumption to serum total and low-density lipoprotein cholesterol in hispanic preschool children☆

BACKGROUND Studies of the relationship between dietary fat intake and serum lipids in young children have yielded inconclusive results. We studied this relationship in 108 Hispanic children ages 4-5 years. METHODS Four 24-hr recalls approximately 3 months apart and two Willett semiquantitative food frequency questionnaires approximately 6 months apart were obtained by interviewing the childrens mothers. Diet measures were averaged for the multiple administrations of each of these instruments. RESULTS Based on the 24-hr recalls, children in the highest tertile of total fat consumption (36.2% of total calories) compared with the lowest tertile (30.2% of total calories) had mean total serum cholesterol of 4.32 mmol/liter (167 mg/dl) vs 3.91 mmol/liter (151 mg/d) (test for linear trend across tertiles, P less than 0.05) and mean low-density lipoprotein cholesterol of 2.74 mmol/liter (106 mg/dl) vs 2.29 mmol/liter (89 mg/dl) (test for linear trend, P less than 0.01). Children in the highest tertile of saturated fat consumption (14.6% of total calories) compared with the lowest tertile (11.2% of total calories) had mean total serum cholesterol of 4.39 mmol/liter (170 mg/dl) vs 3.97 mmol/liter (154 mg/dl) (test for linear trend, P less than 0.05) and mean low-density lipoprotein cholesterol of 2.80 mmol/liter (108 mg/dl) vs 2.35 mmol/liter (91 mg/dl) (test for linear trend, P less than 0.01). These relationships remained significant when calorie-adjusted nutrient intakes were examined and after adjustment in multiple linear regression models for age, sex, and body mass index, with the exception of the association of calorie-adjusted total fat with total serum cholesterol level (P = 0.07). Similar results were obtained using the Willett questionnaires. CONCLUSIONS These findings indicate that dietary fat, particularly saturated fat consumption, is an important correlate of blood lipid levels in preschool children. These are also the first reported data indicating that the Willett questionnaire, as a method for measuring the atherogenic components of diet, has criterion-related validity in young children.

Early Continuity of Care and Immunization Coverage

OBJECTIVE We examined the relationship between early and exclusive continuity of care at the initial source of care and immunization coverage. METHODS We used a cohort study design with 641 randomly selected children initiating care before 3 months and making 2 or more visits to an inner-city practice network. We used 2 complementary data sources: medical records and the New York City Department of Health Citywide Immunization Registry. Immunization measures were cumulative age appropriate and up-to-date at 18 months (UTD18). RESULTS There was a gradual attrition from the initial source of care. By 18 months, less than half the children (46%) remained in care. Regardless of continuity, nearly half (42%) had used other immunization providers. The initial source of care contributed most immunizations (89%-94%); however, across all levels of continuity, children who also used other providers had higher immunization rates. We found a threshold effect of continuity beginning at 12 months: children in care from 12 to 14 months were 17.5 times more likely to be UTD18 than those in care less than 6 months. Each additional period in care increased the time remaining current with immunizations. Among children UTD18, 88% were in care at 11 months compared with 38% among those not UTD18, a 50% difference. CONCLUSIONS Continuity of care at the initial source of care had a significant and lasting impact on immunization coverage, even if not used exclusively. Interventions promoting continued use of the medical home over the first 2 years of life may help improve immunization coverage.

Failure of family history to predict high blood cholesterol among hispanic preschool children

Recommendations for screening children for high blood cholesterol remain controversial. The American Academy of Pediatrics, the American Heart Association, and the National Institutes of Health (NIH) Consensus Conference have recommended targeted screening of children with positive family history. We examined data from a sample of 108 Hispanic preschool children and their families to test targeted screening strategies. Thirty-seven children (34.3%) had total cholesterol levels of greater than or equal to 4.40 mmole/liter (170 mg/dl). Using the American Academy of Pediatrics definition of family history, sensitivity (proportion of those with high blood cholesterol with positive family history) was 0.57 (95% confidence interval, 0.40 to 0.73) and accuracy (overall proportion correctly classified) was 0.58 (0.48 to 0.68). Using the American Heart Association and NIH Consensus Conference definition of family history, sensitivity was 0.46 (0.30 to 0.63) and accuracy was 0.62 (0.52 to 0.71). Classification of children based on the mothers total cholesterol level of greater than or equal to 5.17 mmole/liter (200 mg/dl), the mothers low-density lipoprotein cholesterol level of greater than or equal to 4.14 mmole/liter (160 mg/dl), the mothers low-density lipoprotein cholesterol level of greater than or equal to 3.36 mmole/liter (130 mg/dl), or the childs own body mass index greater than or equal to 75th percentile was less sensitive and no more accurate. These findings indicate that current recommendations as well as other potential strategies for targeted cholesterol screening in young children have serious shortcomings and lend support to universal cholesterol screening in childhood.

Community-Provider Partnerships to Reduce Immunization Disparities: Field Report From Northern Manhattan

In 1996 we launched a community-provider partnership to raise immunization coverage for children aged younger than 3 years in Northern Manhattan, New York City. The partnership was aimed at fostering provider knowledge and accountability, practice improvements, and community outreach. By 1999 the partnership included 26 practices and 20 community groups. Between 1996 and 1999, immunization coverage rates increased in Northern Manhattan 5 times faster than in New York City and 8 times faster than in the United States (respectively, 3.4% vs 0.4% [t = 6.05, p < 0.001] and vs 0.6% [t = 5.65, p < 0.001]). The coverage rate for Northern Manhattan stayed constant through 2000, although it declined during this period for the United States and New York City. We attribute the success at reducing the gap to the effectiveness of our partnership.

Learning primary care in medical school: does specialty or geographic location of the teaching site make a difference?

PURPOSE The Liaison Committee on Medical Education mandates a core curriculum in primary care but does not specify its content or structure. In this study, we explored the question of whether primary care specialty or geographic location affects student learning and satisfaction. METHODS From 1994 to 1996, 294 third-year medical students at one medical school in New York state were randomly assigned to multiple teaching sites for a required 5-week primary care clerkship. Independent predictor variables were primary care specialty of the preceptor (family medicine, medicine, pediatrics, or joint medicine and pediatrics) and geographic location of the site (urban, suburban, rural). Outcome measures included four areas of student satisfaction, one of patient volume, and two of student performance. RESULTS Primary care specialty had no detectable association with the outcome measures, except for a lower rating of patient diversity in pediatric experiences (P <0.001). Geographic location of the site had a significant association with all measures of student satisfaction and patient volume (all P values <0.001). Students at rural sites rated the experience more highly and saw on average 15 more patients per rotation. Ratings of student satisfaction remained high after adjusting for patient volume. Primary care specialty and geographic location did not influence student performance in the clerkship or scores on standardized patient examination. CONCLUSIONS Rural geographic location of teaching site, but not primary care specialty, was associated with higher student satisfaction. However, higher student satisfaction ratings did not correspond to better student performance. Provided that all sites meet the screening criteria for inclusion in a teaching program, these findings support the continued development of high-quality, heterogeneous, interdisciplinary, primary care experiences.