Michelle M. Garrison

Systemic Corticosteroids in Infant Bronchiolitis: A Meta-analysis

Objective. To determine whether corticosteroids are efficacious in treating bronchiolitis in hospitalized infants. Methods. Online bibliographic databases (Medline, Embase, and Cochrane Clinical Trials Registry) were searched for: 1) bronchiolitis or respiratory syncytial virus, and 2) corticosteroid or glucocorticoid or steroidal antiinflammatory agents or adrenal cortex hormones. Reference lists from all selected articles were also examined. Randomized, placebo-controlled trials of systemic corticosteroids in treatment of infants hospitalized with bronchiolitis were selected by 2 investigators. Of 12 relevant publications identified in the literature search, 6 met the selection criteria and had relevant data available. Investigators independently extracted data for 3 outcomes: length of stay (LOS), duration of symptoms (DOS), and clinical scores. Results. In the pooled analysis, infants who received corticosteroids had a mean LOS or DOS that was .43 days less than those who received the placebo treatment (95% confidence interval: −.81 to −.05 days). The effect size for mean clinical score was −1.60 (95% confidence interval: −1.92 to −1.28), favoring treatment. Secondary analyses of mean LOS or DOS were performed on 5 trials that had clearly identified methods of randomization, 5 trials that measured LOS, and 4 trials that clearly excluded infants with previous wheezing. The estimates of effect were similar to the primary analysis but were not statistically significant. Conclusions. Combined, published reports of the effect of systemic corticosteroids on the course of bronchiolitis suggest a statistically significant improvement in clinical symptoms, LOS, and DOS.

Modifying Media Content for Preschool Children: A Randomized Controlled Trial

BACKGROUND: Although previous studies have revealed that preschool-aged children imitate both aggression and prosocial behaviors on screen, there have been few population-based studies designed to reduce aggression in preschool-aged children by modifying what they watch. METHODS: We devised a media diet intervention wherein parents were assisted in substituting high quality prosocial and educational programming for aggression-laden programming without trying to reduce total screen time. We conducted a randomized controlled trial of 565 parents of preschool-aged children ages 3 to 5 years recruited from community pediatric practices. Outcomes were derived from the Social Competence and Behavior Evaluation at 6 and 12 months. RESULTS: At 6 months, the overall mean Social Competence and Behavior Evaluation score was 2.11 points better (95% confidence interval [CI]: 0.78–3.44) in the intervention group as compared with the controls, and similar effects were observed for the externalizing subscale (0.68 [95% CI: 0.06–1.30]) and the social competence subscale (1.04 [95% CI: 0.34–1.74]). The effect for the internalizing subscale was in a positive direction but was not statistically significant (0.42 [95% CI: −0.14 to 0.99]). Although the effect sizes did not noticeably decay at 12 months, the effect on the externalizing subscale was no longer statistically significant (P = .05). In a stratified analysis of the effect on the overall scores, low-income boys appeared to derive the greatest benefit (6.48 [95% CI: 1.60–11.37]). CONCLUSIONS: An intervention to reduce exposure to screen violence and increase exposure to prosocial programming can positively impact child behavior.

The Impact of a Healthy Media Use Intervention on Sleep in Preschool Children

BACKGROUND: Although observational studies have consistently reported an association between media use and child sleep problems, it is unclear whether the relationship is causal or if an intervention targeting healthy media use can improve sleep in preschool-aged children. METHODS: We conducted a randomized controlled trial of a healthy media use intervention in families of children aged 3 to 5 years. The intervention encouraged families to replace violent or age-inappropriate media content with quality educational and prosocial content, through an initial home visit and follow-up telephone calls over 6 months. Sleep measures were derived from the Child Sleep Habits Questionnaire and were collected at 6, 12, and 18 months after baseline; repeated-measures regression analyses were used. RESULTS: Among the 565 children analyzed, the most common sleep problem was delayed sleep-onset latency (38%). Children in the intervention group had significantly lower odds of “any sleep problem” at follow-up in the repeated-measures analysis (odds ratio = 0.36; 95% confidence interval: 0.16 to 0.83), with a trend toward a decrease in intervention effect over time (P = .07). Although there was no significant effect modification detected by baseline sleep or behavior problems, gender, or low-income status, there was a trend (P = .096) toward an increased effect among those with high levels of violence exposure at baseline. CONCLUSIONS: The significant effects of a healthy media use intervention on child sleep problems in the context of a randomized controlled trial suggest that the previously reported relationship between media use and child sleep problems is indeed causal in nature.

Outcomes associated with type of intervention and timing in complex pediatric empyema

BACKGROUNDnThe presence of effusion/empyema in pediatric pneumonia can increase treatment complexity by possibly requiring pleural drainage. Currently, no data support the superiority of any drainage modalities in children.nnnMETHODSnWe performed a retrospective cohort study using the Pediatric Health Information System database from 2003 to 2008.nnnRESULTSnA total of 14,936 children were hospitalized with effusion/empyema. Fifty-two percent of children were treated with antibiotics alone. Compared with patients receiving a chest tube, patients receiving antibiotics alone, thoracotomy, and video-assisted thoracoscopic surgery had a shorter length of stay, lower mortality rates, and fewer re-interventions. Delaying drainage by 1 to 3 days was associated with a lower mortality rate, and a delay of more than 7 days was associated with a higher mortality rate.nnnCONCLUSIONSnHalf of all children with effusion/empyema are treated with antibiotics alone with low morbidity and mortality. Initial video-assisted thoracoscopic surgery or thoracotomy had improved outcomes compared with other interventions. Intervention should not be delayed beyond 7 days.

Physical Activity and Beverages in Home- and Center-based Child Care Programs

OBJECTIVEnTo describe and compare obesity prevention practices related to physical activity and beverages in home- and center-based child care programs.nnnMETHODSnA telephone survey of licensed home- and center-based child care programs in Florida, Massachusetts, Michigan, and Washington between October and December 2008.nnnRESULTSnMost programs reported almost universal access to outdoor play areas and staff who frequently engage in and lead physical activities. About half of the programs reported ≤ 60 minutes of outdoor play time per day for preschoolers. Fewer home-based programs offered a variety of fixed and portable play equipment. Over a third of the programs did not have adequate indoor space for all physical activities. Over two thirds of programs offered juice 3 or 4 times per week or more.nnnCONCLUSIONS AND IMPLICATIONSnMany child care programs could increase active opportunities (by increasing outdoor time and providing better spaces for indoor physical activity) and decrease juice provision.

Engagement in “My Child's Asthma”, an interactive web-based pediatric asthma management intervention

PURPOSEnThe Internet is a promising tool for delivering health behavior change programs although such interventions raise questions about participant engagement in this medium. In this study we sought to determine the characteristics of parents who engage in an Internet-based health intervention for their children (with asthma) and to distinguish parents who engage at the prescribed intervals versus those who engage less often.nnnMETHODSnN=283 parents with children who had asthma were recruited and randomized to receive a web-based intervention. Participants filled out six surveys over a 6-month period asking them about demographic and clinical characteristics, outcome expectations and self-efficacy beliefs regarding asthma control for their child, and attitudes about computers and the Internet. Descriptive statistics were used to describe the population and analyze associations.nnnRESULTSnController use and being adherent to this medication as well as positive outcome and self efficacy expectations were associated with increased engagement. Parents who logged on only once reported significantly less frequent use of the Internet than parents who logged on to all sessions.nnnDISCUSSION AND CONCLUSIONnThe results of this study suggest that it is important to find ways to increase engagement in a web-based intervention for parents who are not yet engaging in the recommended behaviors and/or who report less positive outcome and efficacy expectations around asthma management.

Review and special articlePediatric smoking prevention interventions delivered by care providers: A systematic review

OBJECTIVEnTo conduct a systematic review of randomized controlled trials of smoking prevention interventions for youth delivered via medical or dental providers offices.nnnMETHODSnOnline bibliographic databases were searched as of July 2002, and reference lists from review articles and the selected articles were also reviewed for potential studies. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study methods, intervention studied, outcomes measured, and results.nnnRESULTSnThe literature search returned 81 abstracts from MEDLINE and 49 from Cochrane Clinical Trials Registry (CCTR); of these, four articles met the inclusion criteria. Included were two studies conducted in primary care, and one each in dental and orthodontic offices. Only one study demonstrated a significant effect on smoking initiation; in that study, 5.1% of the intervention group and 7.8% of the control group reported smoking at 12-month follow-up (odds ratio= 0.63; 95% confidence interval, 0.44-0.91). None of the studies had follow-up times greater than 3 years.nnnCONCLUSIONSnThere is very limited available evidence demonstrating efficacy of smoking prevention interventions in adolescents conducted in providers offices and no evidence for long-term effectiveness of such interventions.

Parental Cultural Attitudes and Beliefs Regarding Young Children and Television

IMPORTANCEnResearch has shown that preschool-aged children spend considerable time with media, and risks and benefits for cognitive and behavioral outcomes exist depending on what is watched and how it is watched.nnnOBJECTIVEnTo examine the associations among child race/ethnicity, parental beliefs/attitudes about television (TV) and child development, and TV viewing habits of young children, and to assess reasons for existing racial/ethnic disparities in childrens media use.nnnDESIGN, SETTING, AND PARTICIPANTSnParents completed demographic questionnaires, reported on attitudes regarding medias risks and benefits to their children, and completed 1-week media diaries where they recorded all of the programs their children watched. Enrollment was from March 13, 2009, to April 12, 2010. The study was conducted at 2 metropolitan Seattle pediatric clinics and an academic practice network, each serving a diverse population of patients, and involved a community-based sample of 596 parents of children aged 3 to 5 years.nnnMAIN OUTCOMES AND MEASURESnParental beliefs/attitudes regarding screen time and TV viewing habits of young children.nnnRESULTSnOverall, children watched an average (SD) of 462.0 (315.5) minutes of TV per week. African American children watched more TV per week than non-Hispanic white children (mean [SD], 638.0 [450.9] vs 431.0 [282.6] minutes; Pu2009<u2009.01); however, these differences were no longer statistically significant after controlling for attitudes and demographic covariates (eg, family socioeconomic status). It is important to note that socioeconomic status confounded the results for race/ethnicity, and the association between race/ethnicity and media time across the sample was no longer statistically significant after adjusting for family socioeconomic status. However, significant differences were found between parents of ethnically/racially diverse children and parents of non-Hispanic white children regarding the perceived positive effects of TV viewing, even when parental education and family income were taken into account.nnnCONCLUSIONS AND RELEVANCEnDifferences in parental beliefs/attitudes regarding the effects of media on early childhood development may help explain growing racial/ethnic disparities in child media viewing/habits, but more research is needed to understand the cultural nuances of the observed differences.

Health Care Delivery ResearchLearning from a Distance: Effectiveness of Online Spirometry Training in Improving Asthma Care

OBJECTIVEnWe evaluated the effectiveness of a virtually delivered quality improvement (QI) program designed to improve primary care management for children with asthma.nnnMETHODSnThirty-six physicians, nurses, and medical assistants from 14 primary care pediatric practices (7 matched practice pairs) participated in a cluster randomized trial from October 2007 to September 2008. All practices received a spirometer and standard vendor training. A 7-month QI program delivered during the study period included: 1) Spirometry Fundamentals™ CD-ROM, a multimedia tutorial; 2) case-based, interactive webinars led by clinical experts; and 3) an internet-based spirometry quality feedback reporting system. Practice pairs were compared directly to each other, and between-group differences were analyzed with the use of mixed effects regression models. Our main outcome measures were the frequency of spirometry testing, percentage of acceptable quality spirometry tests, asthma severity documentation, and appropriate controller medication prescribing.nnnRESULTSnParticipating practices uploaded a total of 1028 spirometry testing sessions, of which 340 (33.1%) were of acceptable quality. During the 7-month intervention period, there was no difference between intervention and control practices in the frequency of spirometry tests performed. Intervention practices were estimated to have significantly greater odds of conducting tests with acceptable quality compared with matched control practices, adjusting for quality in the baseline period (odds ratio 2.85; 95% confidence interval 1.78-4.56, P < .001). Intervention providers also had significantly greater odds of documenting asthma severity during the intervention period (odds ratio 2.9, 95% confidence interval 1.8-4.5; P < .001). Although use of controller medications among patients with persistent asthma approached 100% for both groups, the proportion of asthma patients labeled as persistent increased from 43% to 62% among intervention practices, and decreased from 57% to 50% among controls (NS).nnnCONCLUSIONSnA multifaceted distance QI program resulted in increased spirometry quality and improved assessment of asthma severity levels. Successful participation in QI programs can occur over distance.

Improving Parental Adherence with Asthma Treatment Guidelines: A Randomized Controlled Trial of an Interactive Website

BACKGROUNDnControllers are underprescribed for children with asthma, and when they are, adherence is suboptimal. We sought to test whether an interactive website grounded in social cognitive theory can improve the dispensing of controller medications and adherence with them where indicated.nnnMETHODSnRandomized controlled trial. Parents of eligible patients were randomized to be prompted to assess their childs asthma each month for 6 months and receive tailored feedback on controller use and adherence strategies. For the next 6 months, participation in the site was optional. Outcomes were assessed at 6 and 12 months.nnnRESULTSnA total of 603 families were enrolled. At baseline, 176 (29%) children had mild-to-severe persistent asthma, whereas 71% of children met criteria for mild intermittent asthma. Among patients who should have been on controllers at baseline but were not, there was no statistically significant increase in controller prescriptions at 6 months (odds ratio [OR] 2.85; 95% confidence interval [95% CI] 0.63-14.04], P = .17). There was a trend to improved adherence with controllers among users at 6 months (OR 1.54, 95% CI 0.90-2.63, P = .10). Among patients who used controller medicine at both baseline and at 6 months, users in the intervention arm had significantly greater adherence than those in control arm at 6 months (OR 1.92; 95% CI 1.05-3.55; P = .02). For patients with persistent asthma at baseline and who were on controller medicine at both time points, patients in the intervention arm had significantly better adherence than those in the control arm at 6 months (OR 3.33; 95% CI 1.20-10.07, P = .01). However, there were no discernible differences at the 12-month assessment.nnnCONCLUSIONnA tailored interactive website shows some benefit in improving controller medication adherence during a period of active intervention.