Program Brief: Child Health Research Findings

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Newborns and Infants

In 2006, 4.5 million babies were born in the United States. AHRQ's current research focuses on improving the babies' health outcomes, promoting breastfeeding, and reducing racial and ethnic disparities in access to care.

Infants born to women with asthma are at increased risk for low birthweight.

Researchers examined data on more than 140,000 pregnancies of women enrolled in Tennessee's Medicaid program from 1995 to 2003 and found that 6.5 percent of the women had asthma. Women with asthma typically delivered babies that were smaller in size for their gestational ages and weighed 1.3 to 2 ounces less than babies born to women who did not have asthma. However, preterm birth, birth defects, and post-delivery hemorrhage of the mother were not associated with maternal asthma. J Allergy Clin Immunol 120(3):625-630, 2007 (AHRQ Grant HS10384).

Many premature infants with chronic lung disease can be safely cared for in the community following NICU discharge.

Premature infants with chronic lung disease (CLD) are prone to frequent respiratory illnesses, feeding difficulties, growth problems, and rehospitalization during infancy. They also are more likely than other infants to experience cognitive, motor, and language and hearing impairment. After neonatal intensive care unit (NICU) discharge, these infants typically receive coordinated care from sophisticated medical centers, yet such centers may not be accessible for some families. This study found that premature infants with CLD can fare just as well after NICU discharge when followup care is provided by community-based providers working with a nurse specialist who coordinates the infant's care and maintains frequent contact with the family. O'Shea, Nageswaran, Hiatt, et al., Pediatrics 119(4), 2007; online at www.pediatrics.org (AHRQ Grant HS07928).

Parental satisfaction with NICU care depends mostly on infant health after discharge.

Researchers surveyed 621 older mothers (predominantly white and well-educated) about their satisfaction with the care their newborns received in the NICUs of 10 hospitals in Massachusetts and California 3 months after the infants were discharged. Results showed that parental satisfaction was related mostly to the infant's health after discharge rather than to NICU treatments or neonatal complications. Mothers were asked about such issues as the NICU staff's emotional support and other care related factors, as well as their child's current health, subsequent care use, and other family characteristics. McCormick, Escobar, Zheng, and Richardson, Pediatrics 121(6):1111-1118, 2008 (AHRQ Grant HS10131).

Report summarizes a new process to nominate and review conditions for newborn screening.

This report summarizes a new process to nominate conditions for review by the Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children. Conditions proposed for newborn screening occur at very low frequency in children but pose serious health risks to those affected. Randomized controlled trials on these conditions are usually sparse or lacking, meaning that new ground rules for weighing evidence are needed. Green, Rinaldo, Brower, et al., Genet Med 9(11):792-796, 2007 (AHRQ Publication No. 08-R030)* (Intramural).

More than 15 percent of newborns with necrotizing enterocolitis do not survive their hospital stay.

Necrotizing enterocolitis (NEC)— infection and inflammation of the intestines—occurred in 1 in every 1,000 live births in 2000, and about one in seven of these infants did not survive hospitalization. Researchers examined data from AHRQ's Kid's database and found that more than 4,500 NEC-related hospitalizations occurred among U.S. newborns in 2000; the rate of NEC was highest among black newborns. The median hospital stay for NEC was 49 days, and the in-hospital fatality rate was 15.2 percent. Holman, Stoll , Curns, et al., Paediatr Perinat Epidemiol 20(6):498-506, 2006 (AHRQ Pub. No. 07-R027)* (Intramural).

Researchers determine risk factors for deadly infection after open-chest surgery in infants and toddlers.

For this study, researchers examined medical records for 224 children aged 7 days to 2 years who underwent median sternotomy (cracking of the breastbone) at a pediatric hospital to determine the risk factors for mediastinitis, a potentially fatal infection. The 43 children who developed the infection shared some common characteristics: many had underlying genetic syndromes or chromosomal abnormalities, a score of four or more on the American Society of Anesthesiologists classification scale, and/or had epicardial pacing wires for more than 3 days. These characteristics may be useful for determining who is at risk for mediastinitis. Kagen, Lautenbach, Bilker, et al., Pediatr Infect Dis J 26(7):613-618, 2007 (AHRQ Grant HS10399).

Bloodstream infection occurred in 6 percent of infants undergoing median sternotomy in one urban hospital.

For this study, 192 patients were randomly selected from those undergoing median sternotomy between January 1, 1995 and December 31, 2003. Ninety-eight of the eligible patients were male, and the median patient age was 5.4 months. Bloodstream infections developed in 12 patients within the first 30 days after surgery. Postoperative mediastinitis and the need for extracorporeal membrane oxygenation were risk factors for bloodstream infection after median sternotomy. Shah, Kagen, Lautenbach, et al., J Thorac Cardiovasc Surg 133(2):435-440, 2007 (AHRQ Grant HS10399).

Management of postoperative pain in newborns found suboptimal in some NICUs.

Researchers found that while management of postoperative pain in neonates is well accepted, the practice is highly variable. They found deficiencies in the assessment and management of postoperative pain in neonates treated at NICUs in 10 hospitals. Physician pain assessment (not postnatal age or surgery type) was the only significant predictor of postsurgical analgesic use. Taylor, Robbins, Gold, et al., Pediatrics 118(4):992-1000, 2006 (AHRQ Grant HS13698).

Overcrowding in the NICU influences early discharge of moderately preterm infants.

Decisions about discharging moderately preterm infants from hospital neonatal intensive care units (NICUs) are based in part on how crowded the units are, according to this study. The researchers found that a moderately preterm infant was 32 percent more likely to be discharged earlier than expected when the unit census was high compared with periods of low NICU census. These findings suggest that unit workload and strains on staff influence clinical decisionmaking. Profit, McCormick, Escobar, et al., Pediatrics 119(2):314-319, 2007 (AHRQ Grants T32 HS00063, HS10131).

Teamwork in the delivery room is closely related to the quality of neonatal resuscitation.

Independent observers viewed recordings of the resuscitation of infants born by cesarean section and assessed compliance with Neonatal Resuscitation Program guidelines. All 132 clinical teams involved in the study exhibited certain teamwork behaviors—communication, management, and leadership—that are correlated with the quality of neonatal resuscitation in the delivery room. Although these correlations do not confirm a causal relationship, they may be used in training providers on how to prevent and manage neonatal resuscitation errors. Thomas, Sexton, Lasky, et al., J Perinatol 26:163-169, 2006 (AHRQ Grant HS11164).

Infants born prematurely at 30-34 weeks gestation may have substantial health problems.

Compared with full-term infants (at least 37 weeks gestation), infants born at 30-34 weeks gestation are more than four times as likely to require assisted ventilation; they also are at greater risk for pneumothorax and meningitis. Within 3 months of hospital discharge, 11 percent of premature infants born at 30-34 weeks gestation were readmitted to the hospital. Hospital readmission was more likely among male infants and those with chronic lung disease. Escobar, McCormick, Zupanic, et al., Arch Dis Child Fetal Neonatal Ed 91(4):F238-F244, 2006 (AHRQ Grant HS10131).

Babies being cared for in the NICU are at risk for misidentification.

According to this study conducted in one neonatal intensive care unit (NICU), nearly half of infants cared for in the NICU on any given day were at risk for misidentification. During one calendar year, there was not a single day without at least one pair of patients at risk for misidentification. Misidentification could result in an infant being given a medication, procedure, or mother's expressed breast milk intended for another infant, perhaps with serious adverse consequences. The most common reasons for misidentification risk were similar appearing medical record numbers, identical surnames, and similar sounding surnames. Gray, Suresh, Ursprung, et al., Pediatrics 117(1):43-47, 2006 (AHRQ Grant HS11583).

Catheterization may not be the best way to diagnose urinary tract infections in feverish infants.

Urinary tract infections (UTIs) are the most common cause of serious bacterial infections in feverish infants younger than 3 months. Most doctors use urethral catheterization to diagnose UTIs in young infants, but its accuracy is only marginally better than bag collection. Also, it is technically difficult, invasive, and painful. In a study of 3,066 infants aged 3 months or younger, catheterization and bag collection demonstrated similar sensitivity, but bag collection had somewhat lower specificity as indicated by more false positives. False positives are of particular concern for doctors who manage UTIs aggressively with routine hospitalization and imaging. Schroeder, Newman, Wasserman, et al., Arch Pediatr Adolesc Med 159:915-922, 2005 (AHRQ Grant HS06485).

Use of broad-spectrum antibiotics during labor is linked to late-onset serious bacterial infections in infants.

Over one-third of women in labor are given antibiotics to prevent the transmission of group B streptococcus (GBS) to their infants. Although use of intrapartum antibiotics (IPA) has been very successful in preventing neonatal GBS infection in the first week of life, this study found a relationship between IPA and the occurrence of late-onset (7 to 90 days after birth) serious bacterial infections. Also, pathogens that caused these late-onset infections were more likely to be resistant to ampicillin if the mother received ampicillin during labor. Thus, penicillin—an antibiotic that treats a narrow range of bacteria—is recommended instead of ampicillin for IPA to prevent GBS. Glasgow, Young, Wallin, et al., Pediatrics 116(3):696-702, 2005 (AHRQ Grant HS11826).

Delayed sternal closure increases the risk of infection in young infants who undergo heart surgery.

Most median sternostomies (cracking open of the rib cage to permit open heart surgery) in infants are performed within the first few weeks of life to correct life-threatening, complex congenital heart disease. Infection of the mid-sternum strikes 1.4 percent of children who undergo this procedure and 3 percent of those who have heart and lung transplant. Delayed sternal closure appears to substantially elevate the risk of infection with Gram-negative bacteria, according to this study. Long, Shah, Lautenbach, et al., Pediatr Infect Dis J 24(4):315-319, 2005 (AHRQ Grant HS10399).

Racial disparities found in survival of very low-birthweight babies.

Researchers analyzed the medical records of more than 74,000 black and white very low-birthweight (VLBW) infants treated at 332 hospitals. Hospitals were defined as minority-serving if more than 35 percent of the VLBW infants they treated were black. They found that far more black infants were treated by minority-serving hospitals than were treated at hospitals where less than 15 percent of infants were black. Both black and white VLBW babies were 28 percent more likely to die at minority-serving hospitals than at other hospitals, even though the hospitals treated similarly ill infants. Morales, Staiger, Horbar, et al., Am J Public Health 95(12):2206-2212, 2005 (AHRQ Grants HS13280 and HS10858).

Study hints at a link between breastfeeding and intelligence.

Researchers examined the relationship between breastfeeding history and 15 indicators of physical health, emotional health, and cognitive ability among 16,903 adolescents, including 2,734 sibling pairs. They found a persistent positive correlation between breastfeeding and cognitive ability; that is, siblings who were breastfed had higher cognitive ability than those who were not. The effect was large enough to matter, and it persisted into adolescence. Evenhouse and Reilly, Health Serv Res 40(6):1781-1802, 2005 (AHRQ Grant HS00086).

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Obesity/Overweight

The increasing number of obese children and adolescents across the Nation has led policymakers to rank it as a critical public health threat. Since the 1970s, the prevalence of obesity has more than doubled for preschool children aged 2-5 years and adolescents aged 12-19 years, and it has more than tripled for children aged 6-11 years. At present, approximately 9 million children over 6 years of age are obese.

Behavior modification programs help obese children manage their weight.

Evidence shows that obese school-age children and teens can lose weight and prevent further weight gain if they participate in medium-to high-intensity behavioral management programs. The evidence shows that after completing weight management programs, obese children weigh between 3 pounds and 23 pounds less, on average, as obese children not involved in such programs. The weight difference is greater among heavier children and children involved in more intensive programs. See Effectiveness of Weight Management Programs in Children and Adolescents (AHRQ Publication No. 08-E014)*

This document is also available online; go to: http://www.ahrq.gov/clinic/tp/chwghttp.htm.

Overweight adolescents with type 2 diabetes underestimate their weight problem, as do their parents.

Over 80 percent of children with type 2 diabetes are overweight or at risk for becoming overweight, and severely overweight adolescents (BMI of 36.4) and their parents tend to underestimate the seriousness of their weight problem, according to this study. Researchers interviewed 104 adolescents (aged 12-20) and their parents about perceptions of the adolescents' weight, diet, and exercise behaviors. While 87 percent of children were overweight (mean of 221 pounds), only 41 percent of parents and 35 percent of adolescents considered them to be very overweight; 40 percent of parents and 55 percent of adolescents with BMIs at or above the 95th percentile considered their weight to be "about right." Skinner, Weinberger, Mulvaney, et al., Diabetes Care 31(2):227-229, 2008 (AHRQ Grant T32 HS00032).

Study of young Head Start children links overweight to worsened asthma.

A study of Head Start children in Arkansas—which has the highest national rate of overweight children— suggests a link between being overweight and worsened asthma in this group of disadvantaged children. The researchers found that 19 percent of the 3-to 5-year-old children with asthma were overweight (body mass index or BMI in the 95th percentile or greater) compared with 11 percent of a national sample of children of the same age and 14 percent of Arkansas preschool children not in Head Start. The researchers suggest that the link between overweight and worsened asthma is an interaction of several factors, including hormonal, mechanical, genetic, and environmental characteristics. Vargas, Perry, Robles, et al., Ann Allergy Asthma Immunol 99:22-28, 2007 (AHRQ Grant HS10062).

Many pediatricians feel they have only limited success in treating children's obesity.

Researchers asked eight pediatricians from diverse practices about how they identify and treat obesity and how they might improve office-based obesity treatment. The pediatricians felt that they identified most overweight children, they followed recommendations to emphasize to children and parents the health problems associated with obesity, advised simple behavior changes, and adapted messages to individual families. Despite these efforts, they often considered their efforts futile and found almost no success. They cited several family barriers to success, including poor home environments where there was little time for exercise and food preparation and lack of family commitment to weight loss. Successful patients typically came to the pediatric office already motivated. Barlow, Richert, and Baker, Child Care Health Dev 33(4):416-423, 2007. See also: Barlow and Chang, Acta Paediatr 96:1360-1364, 2007 (AHRQ Grant HS13901).

Required PE classes and State spending on parks and recreation are linked to increased youth activity.

Physical education requirements and curriculum development are correlated with improved participation by boys and girls in PE, and State spending on parks and recreation is also correlated with more vigorous physical activity by girls and strength building exercise by boys. An additional day of this type of activity was associated with an extra $50 in spending for boys and $21 for girls. The researchers studied the effects of State policies using data on 37,000 high school students across the United States. Cawley, Meyerhoefer, and Newhouse, Contemp Econ Policy 25(4):506-517, 2007 (AHRQ Publication No. 08-R025)* (Intramural).

Pediatricians recognize overweight or obesity in children without using proportional weight curves.

According to this study, pediatricians quickly recognize obesity if a child's body mass index (BMI) is above the 95th percentile. However, they may overlook excess weight in children with a BMI at the 85th to 94th percentile. Doctors in this study were more likely to identify obesity in adolescents than in younger children, but identification was not associated with a child's sex or race, practice setting, insurance type, or visit length. Only 41 percent of growth charts were current, and only 6.1 percent had the BMI plotted. The researchers note that BMI plotting on children's charts may increase recognition in mildly overweight children who could be offered diet and exercise counseling. Barlow, Bobra, Elliott, et al., Obesity 15(1):225-232, 2007 (AHRQ Grant HS13901).

Children's attendance at weight management programs may hinge on convenience for parents.

Researchers studied 157 obese children (mean age of 12 years and mean body mass index of 39.9) and found that one-third did not return for their second monthly visit to a weight management program, and nearly two-thirds did not show up for future visits. Reasons given by parents whose children attended only one or two sessions included distance from home (23 percent) and scheduling conflicts (21 percent). Barlow and Ohlemeyer, Clin Pediatr 45:355-360, 2006 (AHRQ Grant HS13901).

Youths are more likely to be counseled about diet and exercise following a diagnosis of obesity.

The researchers used data from two surveys during the period 1997-2000 involving 39,340 outpatient visits by youths aged 2 to 18. Clinicians diagnosed obesity at less than 1 percent of all visits. Factors associated with diet counseling at well-child visits were a diagnosis of obesity, being seen by pediatricians, ages 2 to 5 years compared with 12 to 18 years, and self-pay compared with private insurance. Factors associated with exercise counseling were similar, but this counseling occurred only half as often in visits by black youths as in visits by white youths. Cook, Weitzman, Auinger, and Barlow, Pediatrics 116(1):112-116, 2005 (AHRQ Grant HS13901).

School-based weight loss/exercise programs found effective for some children in Louisiana.

One-fourth of the 279 Louisiana middle school children enrolled in a school-based weight loss program were overweight or obese. Most of the children enrolled in the program were black and from low-income families. Twenty-eight of the children attended a food and fitness class; the rest of the children participated in a free alternative physical education (PE) class that involved warm-up and stretching exercises, aerobic activities, and a cool-down period. Not all students completed the PE class; those who did ended with lower body mass indexes and a total weight loss of 33.25 pounds. Children in the other group ended with a total weight loss of 6.5 pounds. Edwards, Nurs Clin North Am 40(4):661-669, 2005 (AHRQ Grant HS11834).

DVD for kids and parents focuses on childhood obesity.

AHRQ and FitTV have partnered to produce a fun and interactive DVD for children ages 5 to 9 and their parents. The DVD, Max's Magical Delivery: Fit for Kids, is a 30-minute tool that provides fun ways to incorporate physical activity and healthy foods into the daily lives of children. Copies of the DVD (AHRQ Publication No. 04-0088-DVD) are available from AHRQ.*

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Oral Health

In order to reverse trends of under use and disparities in oral care for children, researchers are studying incentives to improve access to and delivery of care.

Untreated tooth decay continues to be a problem for publicly insured children.

According to this study, children enrolled in public health insurance programs such as Medicaid and SCHIP are nearly twice as likely as other children to have untreated tooth decay. The problem is less severe in children covered by SCHIP than in Medicaid-insured children; SCHIP-enrolled children are 26 percent less likely to suffer from untreated tooth decay than their Medicaid-insured peers. Researchers examined dental health outcomes through oral screening of kindergarten children in the 2000-2001 school year and used Medicaid and SCHIP claims data to determine the extent of untreated dental cavities based on insurance enrollment. Brickhouse, Rozier, and Slade, Am J Public Health 98(5):876-881, 2008 (AHRQ Grant HS11514).

Family income and parental education influence children's use of dental services.

Researchers examined data on 8,983 children from the 2003 Medical Expenditure Panel Survey to determine the role of nondentist providers in referring children aged 2 to 17 to dentists for care. Among the children in the survey, 51 percent had a dental checkup in 2003; 60 percent of the children were from middle or high income families, and 38 percent came from poor, near poor, or low income families. About 50 percent of nondentist providers recommended that children in any income category see a dentist. However, the likelihood of that advice translating into a child seeing a dentist depended on several factors, including family income and parents' education. Chu, Sweis, Guay, and Manski, J Am Dental Assoc 138:1324-1331, 2007 (AHRQ Publication No. 08-R036)* (Intramural).

Number of U.S. children covered by government dental insurance has increased.

About 30 percent of U.S. children and adolescents were covered by government-sponsored dental insurance in 2006, a significant increase from the 18 percent covered in 1996. Researchers analyzed data from AHRQ's Medical Expenditure Panel Survey and found that private dental insurance enrollment remained relatively unchanged during the same period. Much of the increase resulted from SCHIP, which began in 1997, and extensions of Medicaid coverage for dental services. Largely due to expanded government coverage, only 19 percent of U.S. children had no dental coverage in 2006 compared with 29 percent in 1996.

Go to Dental Coverage of Children and Young Adults Under Age 21, United States, 1996 and 2006, MEPS Statistical Brief 221; online at http://www.meps.ahrq.gov/mepsweb/ (Intramural).

Rural children with special health care needs often do not receive needed dental care.

Children with special health care needs (CSHCN) who reside in rural areas are less likely than their urban counterparts to receive needed dental care. An analysis of data on more than 37,000 CSHCN aged 2 and older revealed that children living in rural areas were 17 percent more likely than those living in urban areas to have an unmet need for dental care. The researchers cite two main reasons for this disparity: one, rural parents do not fully appreciate the need for dental care, and two, dental care may be difficult to access for rural families. Skinner, Slifkin, and Mayer, J Rural Health 22(1):36-42, 2006 (AHRQ grant HS13309).

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