Program Brief: Child Health Research Findings

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Otitis Media/Respiratory Conditions

Otitis media (middle ear infection) is a common childhood illness that affects more than half of children under age 5 each year. Current debate revolves around antibiotic use and the long-term effects of ear infection on functioning, behavioral problems, and parental stress.

Study finds an age inconsistency when guidelines for treating otitis media are followed.

Acute otitis media is the most common bacterial illness in children, and concern is growing about increasing antibiotic resistance by the organisms that cause children's ear infections. This study found that the guidelines for treating otitis media reduce antibiotic use among children younger than age 2 but at a relatively high cost of sick days and parental missed work days. In addition, following the guidelines for children age 2 and younger resulted in 21 to 26 percent less antibiotic use and 13 to 14 percent more sick days, compared with 67 percent less antibiotic use and 4 percent more sick days for children aged 2 to 12 years. Meropol, Glick, and Asch, Pediatrics 121:657-666, 2008 (AHRQ Grant HS10399).

Allergen concentrations are lower than expected in Head Start classrooms.

Researchers examined concentrations of common allergens (mold, cat and dog dander, mouse droppings, cockroach allergens) in dust samples collected in classrooms in 33 Arkansas Head Start centers in spring 2003. They found dog and mouse allergens in all of the facilities, dust mites in 27 facilities, cat allergens in 23 facilities, cockroach allergens in 7 facilities, and mold spores in 31 facilities. They suggest that exposure to low dose allergen concentrations in a preschool setting may play an important role in the development of allergies and asthma in young children. Perry, Vargas, Bufford, et al., Ann Allergy Asthma Immunol 100:358-363, 2008 (AHRQ Grant HS11062).

Strep throat in children is associated with significant economic and noneconomic costs.

Researchers in the Boston area surveyed 135 parents whose children had strep throat and were seen in two pediatric practices between October 1, 2005 and January 25, 2006. On average, children with strep missed nearly 2 days of school and passed along their infection to at least one other family member in 29 percent of families. Nearly half of parents missed an average of 1.8 days of work to care for sick children, and 80 percent of the caregivers were women. When the medical costs and costs for transportation and missed work are extrapolated, the burden of strep throat in the United States is between $224 and $539 million each year. Pfoh, Wessels, Goldmann, and Lee, Pediatrics 121(2):229-234, 2008 (AHRQ Grant HS13808).

Outpatient and hospital visits have risen for Tennessee infants with lower respiratory tract infection.

The number of Medicaid-insured infants in Tennessee who received medical care for bronchiolitis—lower respiratory tract viral infection—rose markedly between 1995 and 2003. During the study period, rates of bronchiolitis visits per 1,000 infant-years were: 238 outpatient visits, 77 ED visits, and 71 hospitalizations. Average annual rates for bronchiolitis visits jumped 41 percent between 1996 and 2003, from 188 visits per 1,000 infant-years in 1996-1997 to 265 visits in 2002-2003. Carroll, Gebretsadik, Griffin, et al., Pediatrics 122:58-64, 2008 (AHRQ Grant HS10384).

Risk of protracted illness may be a barrier to reducing antibiotic use for otitis media.

The author of this study performed a cost-utility analysis to gauge the risks and benefits of withholding antibiotics for otitis media, as recommended by the American Academy of Pediatrics. The study showed that for the benefits of the AAP guideline to at least balance the risks, the parents of a sick child considering foregoing a single antibiotic prescription must be willing to face the possibility that their child could be sick for an estimated 7 hours to 4 days, a prospect that might not be acceptable from the parents' perspective. The author notes that other approaches to reduce antibiotic use—such as wider use of flu vaccine—might be more successful. Meropol, Pediatrics 121:669-673, 2008 (AHRQ Grant HS10399).

Community-wide interventions have some success in reducing antibiotic use among children.

The rapid increase in antibiotic-resistant bacteria is widely believed to result from the high use of antibiotics, especially by young children. The research team tested an antibiotic education intervention in 16 small and large towns during three successive cold and flu seasons (2000-2003) in collaboration with three private insurers and a State Medicaid program. The intervention was aimed primarily at parents of children age 6 and younger and their physicians. The program was responsible for a 4.2 percent decrease in antibiotic prescribing for children 24 to 48 months of age and a 6 percent decline among those 48 to 72 months of age. Finkelstein, Huang, Kleinman, et al., Pediatrics 121(1):15-23, 2008 (AHRQ Grant HS10247).

Study supports use of antibiotics in young children with bilateral otitis media.

Researchers analyzed 1,216 cases of children with otitis media and found that very young children with infections in both ears may need antibiotics to kill the bacteria causing their discomfort. For 70 percent of children with ear infections in both ears, cultures were positive for the presence of bacteria. In contrast, only 57 percent of children with infection in one ear had bacteria present. The researchers suggest that the wait-and-see approach recommended for treating children with ear infections should be set aside for children age 2 and younger who have infection in both ears. McCormick, Chandler, and Chonmaitree, Pediatr Infect Dis J 26(7):583-588, 2007 (AHRQ Grant HS10613).

Some doctors do not follow guidelines for use of tympanostomy tubes.

Researchers reviewed the records of 1,046 children seen for otitis media in five New York City hospitals in 2002 and found that 75 percent of the children had surgery for tympanostomy tube insertion at less than the 42-day mark, and more than 50 percent had surgery after fewer than 77 days of inflammation. Two clinical practice guidelines caution against insertion of ear tubes, particularly before the 90-day mark. These surgeries may indicate overuse of ear tubes, note the researchers, and they may be the result of pressure by parents to help their child who is in pain. Keyhani, Kleinman, Rothschild, et al., Pediatrics 121(1), 2008; online at www.pediatrics.org (AHRQ Grant HS10302).

Smoking in the home leads to ER visits and hospital stays for lung problems in young children.

Smoking inside the home may more than double the risk of a young child having an ED visit and more than triple their risk of a hospitalization for a respiratory condition, according to this study. Researchers examined data on health care use, expenditures, and bed days for 2,759 children aged 4 and younger and linked that data to reports of smoking inside the home. They also found that indoor smoking was costly; it was associated with $117 in additional health care expenditures for each child exposed to indoor smoking, or $415 million in annual health expenditures for young children in the United States. There were no significant effects of living with adult smokers who smoked outside the home. Hill and Liang, Tob Control 17:32-27, 2008 (AHRQ Publication No. 08-R050)* (Intramural).

Rhinoviruses are associated with numerous hospitalizations of children under age 5.

According to this study, rhinoviruses (which are the usual cause of the common cold) are an important cause of childhood hospitalizations for acute respiratory infection, especially among children with a history of asthma or wheezing. In 2000 and 2001, 26 percent of children hospitalized in two States for respiratory symptoms or fever tested positive for rhinovirus infections. Historically, respiratory syncytial virus (RSV) has been regarded as the predominant virus associated with hospital stays for acute respiratory infection in young children. However, this study detected more rhinoviruses (26 percent) than RSV (20 percent) among children younger than age 5. Miller, Lu, Erdman, et al., J Infect Dis 295:773-781, 2007 (AHRQ Grant T32 HS13833).

Children with ear infections may acquire more strains of bacteria if they have been vaccinated for pneumonia.

Researchers enrolled 417 children aged 6 months to 4 years between September 1995 and December 2004 to study the impact of the PCV7 pneumonia vaccine on nasopharyngeal colonization with various types of bacteria. They found that although the pneumonia vaccine reduced the overall incidence of acute otitis media, children with ear infections who had been vaccinated with PCV7 acquired significantly more bacteria types than nonimmunized children. Revai, McCormick, Patel, et al., Pediatrics 117(5):1823-1829, 2006 (AHRQ Grant 10613).

Short hospital stays and pulse oximetry can quickly identify failure of amoxicillin treatment in children with severe pneumonia.

Researchers examined data from a previous trial of orally administered amoxicillin vs. injectable penicillin for the treatment of severe pneumonia in children aged 3 to 59 months. They found that a 12-to 24-hour period of observation in the hospital, ideally with pulse oximetry to measure oxygen saturation, is needed to identify children whose oral amoxicillin treatment has failed and who will need additional treatment. One-fifth of the children in the study needed supplemental oxygen at least once during the first 24 hours of observation. Fu, Ruthazer, Wilson, et al., Pediatrics 118(6), 2006; online at www.pediatrics.org (AHRQ Grant T32 HS00060).

Tympanometry can indicate the probability of middle ear effusion in children under age 3.

Traditionally, clinicians have diagnosed middle ear effusion using an otoscope, but visualizing the eardrum and interpreting findings are problematic using this approach in infants and young children. According to this study, tympanometry is more effective than an otoscope in diagnosing middle ear effusion in very young children. The researchers compared tympanometric findings and otoscopic diagnoses in a diverse sample of 3,686 otherwise healthy children aged 3 or younger. Smith, Paradise, Sabo, et al., Pediatrics 118(1):1-13, 2006 (AHRQ Grant HS07786).

Researchers examine trends in antibiotic use among children.

From 1996 to 2001, children's use of antibiotics sharply declined by 8.5 percent overall and 5.1 percent for respiratory tract infections. This decline followed the launch of several national campaigns to promote the appropriate use of antibiotics. An analysis of data from AHRQ's Medical Expenditure Panel Survey found reductions in use among all subgroups of children. However, the decline in overall antibiotic use for white children was more than double the decline for black or Hispanic children. Miller and Hudson, Med Care 44(5 Suppl):36-44, 2006 (AHRQ Publication No. OM-06-0074, for single copies of the journal)* (Intramural).

Pocket card facilitates shared parent/physician decisionmaking about treatment for acute otitis media.

A simple pocket card has been developed to help physicians and parents work together to decide on the appropriate treatment for a child with acute otitis media (AOM). The pocket card combines a parent's assessment of the child's symptoms (using a scale of facial expressions) with the clinician's assessment of tympanic membrane inflammation and middle ear appearance (using an otoscopy scale) to determine AOM severity. After considering this rating of AOM severity, the child's age, and the presence or absence of other risk factors, the clinician and parent can decide on the appropriate treatment plan. Friedman, McCormick, Pittman, et al., Pediatr Infect Dis J 25(2):101-107, 2006 (AHRQ Grant HS10613).

Four clinical factors can help diagnose pneumonia in children seen in the ER.

This study involved 510 children aged 2 to 59 months who arrived in the emergency department of one Cincinnati hospital during the period 2000-2002. The children presented with a cough and one or more of the following symptoms: labored, rapid, or noisy breathing; chest or abdominal pain; and/or fever; 8.6 percent of children had x-ray evidence of pneumonia. The children who had pneumonia differed from those who did not on four characteristics: older age (20.9 vs. 14.8 months), faster respiratory rate (49.8 vs. 42.7 breaths per minute), lower oxygen saturation (95.5 vs. 97.8), and nasal flaring (22.7 vs. 7.7 percent). Mahabee-Gittens, Grupp-Phelan, Brody, et al., Clin Pediatr 44:427-435, 2005 (AHRQ Grant HS11038).

Parents are more satisfied when doctors prescribe antibiotics for their child's cough or cold symptoms.

Children receive an average of two to three antibiotic prescriptions a year, many of which are unnecessary. Clinicians believe that parents will be more satisfied with their office visit when antibiotics are prescribed, and findings from this study suggest they are right. Researchers interviewed 378 parents of children 2 to 10 years of age who were seen at a pediatric clinic for cough and cold symptoms. Nearly half (47 percent) received antibiotics at the initial visit, and their parents gave higher satisfaction scores (9.25 on a 10 point scale) compared with parents whose children did not receive antibiotics (8.95). When children received antibiotics at a subsequent visit, the parents' scores averaged 7.25, compared with 6.25 for parents of children who did not receive antibiotics. Christakis, Wright, Taylor, and Zimmerman, Pediatr Infect Dis J 24(9):1-4, 2005 (AHRQ Grant HS13195).

Doctors still prescribe antibiotics for over half of children with sore throats.

Prescribing of antibiotics for sore throats—most of which are viral—has declined over the last few years, from 66 percent of visits in 1995 to 54 percent of visits in 2003. Nevertheless, doctors still are ordering antibiotics for more than half of children who have a sore throat. With more than 7 million pediatric visits each year for sore throat, inappropriate use of antibiotics continues to be a serious problem. Linder, Bates, Lee, and Finkelstein, JAMA 294(18):2315-2322, 2005 (AHRQ Grants HS14563 and HS13908).

Researchers compare immediate antibiotic treatment with watchful waiting for nonsevere acute otitis media (AOM) in children.

This study found that immediate antibiotic treatment for nonsevere AOM in children 6 months to 12 years provided superior early results compared with watchful waiting, but results were nearly identical between the two groups at 30 days. The study involved 112 children who were randomized to receive immediate antibiotics (amoxicillin and symptom medication) and 111 children who were randomized to watchful waiting (symptom medication only). Two-thirds of the children in the watchful waiting group completed the study without needing antibiotics. McCormick, Chonmaitree, Pittman, et al., Pediatrics 115(6):1455-1465, 2005 (AHRQ Grant HS10613). See also: Trends in Children's Antibiotic Use: 1996-2001, MEPS Research Findings No. 23 (AHRQ Publication No. 05-0020)* (Intramural).

Few physicians initially try watchful waiting for children with nonsevere acute otitis media.

The investigators surveyed 160 physicians and 2,054 parents of children younger than age 6 in 16 Massachusetts communities about their attitudes toward watchful waiting in children with nonsevere AOM. A majority of physicians reported at least occasional use of watchful waiting, but few used it frequently. For example, 38 percent of physicians treating children aged 2 or older said they never or almost never used watchful waiting, 39 percent reported occasional use, and 6 percent said they used it most of the time. About one-third of parents reported that they would be satisfied if their doctor recommended watchful waiting, 26 percent said they would be neutral, and 40 percent said they would be somewhat or extremely dissatisfied. Finkelstein, Stille, Rifas-Shiman, and Goldmann, Pediatrics 115(6):1466-1473, 2005 (AHRQ Grant HS10247).

Pneumococcal carriage seems to be more prevalent in communities that have more children in day care.

Children often carry the pneumococcal bacteria that can cause pneumonia, ear infections, and other illnesses, but carriage rates differ from one community to another. Factors such as age and number of siblings account for some of the differences, but other factors—such as the proportion of children in a community who attend child care centers—also play a role. In this study, the researchers examined data on asymptomatic children in 16 Massachusetts communities and found that the odds of carriage were two to three times as high for youngsters attending child care centers compared with those were not in child care. Huang, Finkelstein, and Lipsitch, Clin Infect Dis 40:1215-1222, 2005 (AHRQ Grant HS10247).

Use of alcohol-based hand gel may reduce transmission of respiratory illnesses in homes with young children who attend day care.

The researchers analyzed transmission rates for respiratory and gastrointestinal (GI) illnesses among 208 ethnically diverse families with children enrolled in child care who were treated at five suburban practices in the Boston area. A survey of the families revealed that a total of 1,545 respiratory and 360 GI illnesses occurred in the families from November 2000 to May 2001. Of these, 54 percent of the illnesses were brought into the home by children younger than 5. Twenty-two percent of respondents reported use of alcohol-based hand gels, and 33 percent reported always washing their hands after blowing or wiping a nose. After adjusting for education, insurance status, and other factors, the researchers concluded that hand gels had a protective effect against respiratory illness transmission in the home. Lee, Salomon, Friedman, et al., Pediatrics 115(4):852-860, 2005 (AHRQ Grant T32 HS00063).

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Palliative/End-of-Life Care

Palliative care seeks to enhance quality of life for children who are living with life-threatening or terminal conditions, regardless of whether they are being cared for in the hospital, in a hospice facility, or at home. Palliative treatments focus on the relief of symptoms (e.g., nausea, pain, shortness of breath) and conditions such as loneliness and fear that cause distress and detract from the child's enjoyment of life. Research has shown that the palliative care provided to adults may be inappropriate for children. AHRQ research in this area is focusing on identifying strategies to deliver appropriate and effective palliative and end-of-life care for children and adolescents.

Education and experience increase nurses' comfort and confidence in providing palliative care to dying children.

Nurses with more years of nursing experience, more education in palliative care, and a more hopeful attitude are more comfortable and feel more confident in providing palliative care to dying children than other, less experienced nurses. More experienced nurses also find it less difficult to talk about death and dying with children and their families, according to a 2005 survey of 410 nurses at a large, urban children's hospital. Feudtner, Santucci, Feinstein, et al., Pediatrics 119:186-192, 2007 (AHRQ Grant HS00002).

Collaboration between hospital and community-based palliative care providers could improve care for dying children.

Most hospice and home care agencies are oriented toward care for terminally ill adults and are not well-equipped to provide palliative care for children who are dying at home. According to this study, better collaboration between hospital and community palliative care services could improve end-of-life care for these children. The Pediatric Advanced Care Team (PACT) at the Children's Hospital of Philadelphia developed a program that fosters joint ventures between such services in five States. In evaluations of the 5-year-old program, community-based providers felt it had helped them to learn about caring for children with complex chronic conditions and how to talk to families about death and dying, as well as provide grief and bereavement services. Carroll, Santucci, Kang, and Feudtner, Am J Hosp Palliat Care 24(3):191-195, 2007 (AHRQ Grant T32 HS0002).

Children with complex chronic conditions are more likely to die at home than in the hospital.

Nearly one-fourth of U.S. children who died between 1989 and 2003 suffered from a complex chronic condition such as congenital heart disease, cancer, or neuromuscular disease. During that period, there was a shift in the proportion of children dying in the hospital. Researchers cite several reasons for the shift from hospital to home care of terminally ill children. These include technological advances—such as tube feeding and home ventilators—that may allow more medically fragile children to be cared for at home and increased availability of home care and hospice services for children. Feudtner, Feinstein, Satchell, et al., JAMA 297(24):2725-2732 (AHRQ Grant T32 HS00002).

DNRs for terminally ill children may not be honored by public schools.

Researchers surveyed personnel from school districts in 81 U.S. cities about written policies or procedures for student DNRs and compared school policies with relevant State laws from all 50 States and the District of Columbia. Most (80 percent) of the school districts surveyed did not have policies for dealing with student DNRs. Also, 76 percent of those surveyed indicated they either would not honor student DNRs or were uncertain about whether they could honor them. Nineteen school districts reported that they honor student DNRs, but 13 of them have no laws to protect school personnel from civil or criminal liability for withholding CPR. Kimberly, Forte, Carroll, and Feudtner, Am J Bioeth 5(1):59-65, 2005 (AHRQ Grant HS00002).

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Preventive and Developmental Services

The majority of injuries and deaths in children and adolescents are preventable. Although the importance of preventive services has been demonstrated, there still are barriers, flaws, and disparities in the content and delivery of clinical preventive services.

Hospital rates for intussusception declined 25 percent from 1993 to 2004.

Rotavrius is the most common cause of severe gastroenteritis in young children, and a new rotavirus vaccine was introduced in 2006. A previous vaccine was withdrawn in 1999 after it was associated with intussusception in infants. Researchers compared annual intussusception hospitalization rates before and after introduction of the new vaccine, and found that the rates have remained stable since 2000, with about 35 cases per 100,000 infants. They note that the downward trend might reflect a true reduction in the incidence of severe intussusceptions, but it also could reflect changes in medical management that do not require hospitalization. Tate, Simonsen, Viboud, et al., Pediatrics 121, 2008; online at www.pediatrics.org (AHRQ Publication No. 08-R071)* (Intramural).

Hospital admissions for pneumonia have declined for infants immunized with pneumonia vaccine.

Since 2000, U.S. infants have been routinely immunized with a pneumonia vaccine that has markedly reduced hospitalizations for pneumonia related to Streptococcus pneumoniae among children younger than 2 years. By the end of 2004, pneumonia hospital admission rates had declined by 39 percent for children in this age group, representing a decline of about 41,000 admissions in 2004. At the same time, there was no significant change in outpatient visits for pneumonia in this age group, suggesting that the decline in hospital admissions was not due to a shift to outpatient care. Grijalva, Nuorti, Arbogast, et al., Lancet 369:1179-1186, 2007 (AHRQ Grant HS16784).

Pneumonia vaccine has resulted in more childhood infections with some nonvaccine serotypes.

Although the pneumococcal conjugate vaccine has reduced infection with S. pneumoniae serotypes targeted by the vaccine, it has increased infection with some nonvaccine serotypes among children in Massachusetts, according to this study. Some 3 years after the vaccine's introduction, children under age 2 in that State suffered a significant increase in pneumonia due to a multidrug-resistant strain of the NVT 19A, which has emerged as the most frequent cause of invasive pneumococcal disease in Massachusetts. The researchers conclude that the S. pneumonia strains colonizing healthy children in Massachusetts have undergone substantial shifts since the introduction of the vaccine. Pelton, Huot, Finkelstein, et al., Pediatr Infect Dis J 26(6):468-472, 2007 (AHRQ Grant HS10247).

Flu vaccinations increased among childcare staff when free immunizations were offered.

Researchers evaluated the impact of free on-site vaccination on childcare staff vaccination rates during four flu seasons: 2002-2003, 2003-2004, 2005-2006, and 2006-2007. Free on-site vaccinations were offered in the 2003-2004 and 2006-2007 seasons. Vaccination rates among childcare workers were markedly higher in the two intervention seasons (51 percent in 2003-2004, 45 percent in 2006-2007) compared with the other two seasons (28 percent in 2002-2003, 26 percent in 2005-2006). One-third of those vaccinated said they would not have been vaccinated if they had to pay for it. Lee, Thompson, Lautenbach, et al., Infect Control Hosp Epidemiol 29(5):465-467, 2008 (AHRQ Grant HS10399).

Computer kiosks can help parents in urban, low-income communities learn about their children's health.

Researchers examined use of three touchscreen computer kiosks at sites in low-income, urban neighborhoods in Seattle. Each kiosk included 14 modules—10 focused on prevention and safety, and three focused on screening for developmental delay, tuberculosis, and attention deficit hyperactivity disorder. In all, parents completed 1,846 kiosk sessions, with nearly half of the sessions taking place at McDonald's. Although less than half of the parents had graduated from high school and more than one-quarter had never used the Internet, most found the kiosk easy to use and the information easy to understand. Half of the parents said they intended to talk to their child's doctor about what they had learned. Thompson, Lozano, and Christakis, Pediatrics 119:427-434, 2007 (AHRQ Grant HS13302).

Parental visits to preventive health Web sites may enhance preventive care provided to children.

Due to time and other constraints, pediatricians spend less than 10 minutes of well-child visits discussing preventive care. This study found that access to a prevention-focused Web site can prompt parents to bring up prevention topics with their child's provider during well-child visits and also can increase parental and physician adoption of preventive measures. Christakis, Zimmerman, Rivara, and Ebel, Pediatrics 118(3):1157-1166, 2006 (AHRQ Grant HS13302).

Study supports recommendation to extend influenza vaccination to children older than age 2.

Influenza causes significant complications, more hospitalizations, and increases care costs among children older than age 2, according to this study. These findings provide support for the 2006 recommendation by the CDC to expand the group of people who should get annual flu shots to include children aged 24 to 59 months. The researchers estimate that the new guideline would target 80 percent of children who are hospitalized for influenza each year. Ampofo, Gesteland, Bender, et al., Pediatrics 118(6):2409-2417, 2006 (AHRQ Grant HS11826).

A substantial delay in administering the first dose of hepatitis B vaccine may lead to underimmunization of children.

Researchers studied children enrolled in five large U.S. provider groups to evaluate the association between delay in the hepatitis B birth dose and a child's probability of being underimmunized at 24 months. The most substantial decreases in vaccine coverage at 24 months occurred in the two provider groups that delayed the first hepatitis B vaccine dose from birth to 45 days or 6 months of age. Children in these provider groups were about three times as likely to be underimmunized at 24 months of age compared with baseline. Lin, Kleinman, Chan, et al., Pediatrics 6(31), 2006; online at www.pediatrics.org (AHRQ HS00028). (Intramural).

Two studies find low levels of preventive care and suboptimal provision of anticipatory guidance.

Researchers studied 44 private pediatric and family medicine practices in North Carolina and found low levels of preventive care, with substantial variation among practices. Only 39 percent of children received three of four recommended preventive services: immunizations, testing for anemia, tuberculosis testing, and lead screening by age 2. The range among clinics was 2 to 88 percent. On average, physicians spent less than 2.5 minutes of each well-child visit on anticipatory guidance (i.e., counseling parents about child development, injury prevention, nutrition, and other topics). Rosenthal, Lannon, Stuart, et al., Arch Pediatr Adolesc Med 159:456-463, 2005 (AHRQ Grant HS08509).

Altering the vaccination schedule for RotaShield could greatly lower the risk of intussusception.

RotaShield, a vaccine intended to prevent severe rotavirus diarrhea among infants and children, was withdrawn in July 1999 because of a link between the vaccine and intussusception (intestinal obstruction) in vaccinated infants. These researchers found that the incidence of intussusception associated with the first dose of RotaShield increases with age (infants 90 days and older accounted for 80 percent of cases), and that altering the vaccination schedule could markedly reduce the risk. They calculated that a two-dose neonatal vaccination schedule administered at 0-29 days and 30-59 days of age would lead to, at most, a 7 percent increase in the incidence of intussusception above the annual background incidence. Simonsen, Viboud, Elixhauser, et al., J Infect Dis 192:S36-S43, 2005 (AHRQ Publication No. 06-R002)* (Intramural).

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