Program Brief: Child Health Research Findings

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Emergency Care/Hospitalization

Current studies are focused on improving emergency department (ED) triage and identifying risk factors for functional limitations in adolescents following major trauma.

Injuries account for nearly one-third of pediatric ED visits.

More than 1.5 million ED visits by children in 2003 were due to injuries, and about $2.3 billion was spent on outpatient injury-related ED visits that year, according to this study. Infants, adolescents, children from very low-income communities, and those from rural areas were more likely than their peers to have an injury-related ED visit. Although patient characteristics were fairly consistent across the Nation, there were some State-to-State variations in admission rates and expected source of payment for injury-related ED visits. Owens, Zodet, Berdahl, et al., Ambul Pediatr 8(4):219-240, 2008 (AHRQ Publication No. 08-R082)* (Intramural).

Researchers examine the efficiency of pediatric endoscopy units.

Researchers looked at time to onset of sedation, procedure time, discharge time, and total time for 134 children who underwent an endoscopic procedure at a pediatric teaching hospital. Half of the children received the two-drug combination of midazolam and fentanyl and the other half received propofol. Although patients given propofol had slightly shorter median times for anesthesia onset than children in the other group, they also had longer procedure times and longer times to discharge. Overall, the time from initiation of anesthesia to release from the hospital was comparable, although earlier studies have shown that patients given propofol are faster in opening their eyes, responding to verbal commands, and orienting themselves. Lightdale, Valim, Newburg, et al., Gastrointest Endosc 67(7):1067-1075 (AHRQ Grant HS13675).

Nearly half of infant hospitalizations are due to infectious diseases.

Using data from AHRQ's Kids Inpatient Database, researchers found that more than 40 percent of infant hospitalizations are caused by infectious diseases, including lower respiratory tract infections (more than half of the admissions) and infections of the kidney, urinary tract, and bladder. Hospitalization rates for infectious diseases were higher for boys and for black and Hispanic infants and lowest for Asian/Pacific islander infants. Hospital stays lasted 3 days and cost $2,235, on average. Yorita, Holman, Sejvar, et al., Pediatrics 121(2):244-252, 2008 (AHRQ Publication No. 08-R049)* (Intramural).

High hospital occupancy rates can affect the care children receive.

Researchers studied claims data (1996-1998) on over 69,000 respiratory and 49,000 non-respiratory pediatric admissions in Pennsylvania and New York to investigate the association between hospital occupancy and admission workload on length of stay for common pediatric diagnoses. They found the effect of admission day occupancy on length of stay was apparent only for children with respiratory conditions and was greatest when the occupancy rate was higher than 60 percent. Lorch, Millman, Zhang, et al., Pediatrics 121, 2008; online at www.pediatrics.org (AHRQ Grant HS09983).

Researchers develop model to predict level of care for pediatric ED patients.

Researchers developed and validated a model, using information available at the time of patient triage, to predict the level of care provided to pediatric emergency patients for use as a severity of illness measure. They included eight predictor variables in the final models: presenting complaint, age, triage acuity category, arrival by EMS, current use of prescription drugs, and three triage vital signs (heart rate, respiratory rate, and temperature). The Revised Pediatric Emergency Assessment Tool (RePEAT) score accurately predicted level of care provided for pediatric emergency patients. Gorelick, Alessandrini, Cronan, and Shults, Acad Emerg Med 14:316-323, 2007 (AHRQ Grant HS11359).

Study finds racial/ethnic differences in hospital admission rates for children.

Researchers examined hospital admission rates for nearly 9,000 children (3,112 white, 3, 288 black, and 2,552 Hispanic) seen at 13 sites and found that the sickest children in all three groups were admitted at similar rates. For children in the two lowest severity-of-illness categories, white youngsters were admitted at 1.5 to 2.0 times the expected rate. The researchers conclude, however, that white children were being overadmitted when not severely ill, while black and Latino children were not being denied essential services. Chamberlain, Joseph, Patel, et al., Pediatrics 119, 2007; online at www.pediatrics.org (AHRQ Grant HS10238).

Color-coded tape helps EMTs calculate the correct dose of medications for children receiving emergency care.

Children age 12 and under in Los Angeles County who suffered prehospital cardiopulmonary arrest and were treated initially by EMTs were three times as likely to receive the correct dose of epinephrine if the EMTs were required to use the Broselow tape to quickly determine medication dosing. The Broselow tape measures a child's height in color zones that correlate with body weight, which helps EMTs to rapidly estimate a child's weight, calculate weight-based drug doses, and choose the correct size of resuscitation equipment. Kaji, GauscheHill, Conrad, et al., Pediatrics 118(4):1493-1500, 2006 (AHRQ HS09166).

EDs staffed with physician residents in training are less effective than non-resident staffed ERs in deciding which children to hospitalize.

Emergency departments staffed with physician residents in training admitted children at a rate nearly 14 times the expected rate compared with nonresident hospitals. These EDs also had far more children returning to the ED within 72 hours after discharge, an indicator that they were discharged from the ED prematurely. Chamberlain, Patel, and Pollack, J Pediatr 149:644-649, 2006 (AHRQ 10238).

Some pediatric offices may not be prepared to provide emergency care.

Pediatric offices occasionally see children with emergencies such as epileptic seizures or asthma-related breathing problems, yet they may not be prepared to treat a critically ill child while waiting for paramedics to arrive. Researchers found that four of eight pediatric offices surveyed did not have the appropriate medications for epileptic seizures, and some lacked the basic supplies necessary to handle respiratory emergencies. Four offices had written guidelines for medical emergencies, but only one office required staff to participate in mock emergency codes. The offices generally treated an average of one child a week who required emergency care or subsequent emergency hospitalization. Santillanes, GauscheHill, and Sosa, Pediatr Emerg Care 22(11):694-698, 2006 (AHRQ HS09166).

Use of a medical home managed care model can reduce ED use among children with special health care needs.

According to this study, a managed care model that emphasizes care coordination and does not include strong financial incentives to limit care use can reduce the use of emergency department care among children with special health care needs. The researchers compared ED use before and after the children joined a managed care plan specially designed for them and found an association between managed care enrollment and a nearly one-fourth drop in ED use. The plan features a medical home approach to create an environment for the more effective management of chronic health problems and facilitate early intervention when those problems become acute, thereby reducing ED use. Pollack, Wheeler, Cowan, and Freed, Med Care 45(2):139-145, 2007 (AHRQ Grant HS10441).

Study finds that use of pediatric hospitalists results in lower costs and shorter hospital stays.

According to this review, the use of pediatric hospitalists results in lower hospital costs and shorter stays for hospitalized children. This approach does not adversely affect the experiences of the referring physician, parent, or hospital housestaff. The researchers reviewed 20 studies and found an average decrease of 10 percent in both cost and length of stay. Data on quality of care were insufficient to draw conclusions. Landrigan, Conway, Edwards, and Srivastava, Pediatrics 117(5):1736-1744, 2006 (AHRQ Grant HS13333).

Children who have surgery for hypoplastic left heart syndrome fare better at more experienced hospitals.

Treatment options for children born with hypoplastic left heart syndome (HLHS)—a congenital anomaly in which the entire left side of the heart is underdeveloped—include palliation shortly after birth, heart transplantation, or comfort care. Researchers examined in-hospital mortality rates for 754 infants with HLHS in 1997 and 880 infants in 2000. In 1997, children undergoing palliation surgery in teaching hospitals were 2.6 times as likely to die as those having surgery at nonteaching hospitals.

By 2000, however, palliation surgery was centralized at teaching hospitals. This centralization, along with medical and surgical advances, was associated with an overall decrease in mortality from 28 to 24 percent. Yet mortality rates continued to approach 50 percent at low-volume hospitals, compared with 19 percent for high-volume hospitals. Berry, Cowley, Hoff, and Srivastava, Pediatrics 117(4):1307-1313, 2006 (AHRQ Grant HS11826).

Children's hospitals are much more likely than general hospitals to diagnose child abuse in severely injured infants.

Researchers examined abuse diagnosis by hospital type for children less than 1 year of age and found that children's hospitals are more than twice as likely as general hospitals to diagnose child abuse in severely injured infants (29 vs. 13 percent, respectively). General hospitals with a children's unit identified more abuse cases (19 percent) than general hospitals without a children's unit but fewer than a children's hospital. Nearly half (49 percent) of the infants studied were admitted to general hospitals, one-fourth were admitted to general hospitals with children's units, and one-fourth were admitted to a children's hospital. Infants treated at children's hospitals tended to be younger, more severely injured, and more likely to have private health insurance than those cared for at general hospitals. Trokel, Wadimmba, Griffith, and Sege, Pediatrics 117(3):722-728, 2006 (AHRQ grant T32 HS00060).

Hospitalization rate for children with cat-scratch disease remains stable.

Despite an increase in cat ownership from 1980 to 2000, the rate of children hospitalized for cat-scratch disease in 2000 was similar to that of the 1980s. Typically, cat-scratch disease is benign and self-limited and is characterized by enlarged lymph nodes and fever. However, atypical cat-scratch disease infections can be accompanied by inflammatory responses that lead to hospitalization. During 2000, there were an estimated 437 hospitalizations for cat-scratch disease in children younger than 18. Hospital stays were as long as 19 days for typical cases and 22 days for atypical cases. The median charge was $6,140, with total annual hospital charges of about $3.5 million. Reynolds, Holman, Curns, et al., Pediatr Infect Dis J 24(8):700-704, 2005 (AHRQ Publication No. 05-R011)* (Intramural).

Children who are in the ICU and have arterial catheters are at elevated risk of dying from blood infections.

Among 168 hospitalized children with positive blood cultures for Candida blood infections, 17 percent died within 1 month of the first positive culture. Children in the pediatric ICU at the time of infection were 6.3 times as likely as other children to die within 30 days, and those with an arterial line were 2.4 times as likely as other children to die within 30 days. The study involved children who were inpatients at one large hospital during the period 1998-2001. Zaoutis, Coffin, Chu, et al., Pediatr Infect Dis J 24(8):736-739, 2005 (AHRQ Grant HS10399).

Limiting use of broad-spectrum antibiotics may reduce life-threatening infections in hospitalized children.

Curtailed use of broad-spectrum cephalosporin antibiotics in children at high risk for Escherichia coli or Klebsiella species infections may reduce the incidence of such infections, according to this study. The researchers used laboratory data from the Children's Hospital of Philadelphia from May 1, 1999 to September 30, 2003 to identify children with bloodstream infections and pinpoint risk factors for such infections. Zaoutis, Goyal, Chu, et al., Pediatrics 115(4):942-949, 2005 (AHRQ grant HS10399).

Postoperative staph infection of a child's chest cavity is a risk factor for bloodstream infection.

Up to 4 percent of children who undergo surgery that involves cutting the breastbone develop infections of the chest cavity. Children who develop postoperative chest cavity infections due to Staphylococcus aureus are much more likely to develop a bloodstream infection than children whose chest cavity infections are caused by other pathogens, according to this study. The researchers studied hospital data on 43 children who developed chest cavity infections after surgery between 1995 and 2003 at one urban children's hospital. Shah, Lautenbach, Long, et al., Pediatr Infect Dis J 24(9):834-837, 2005 (AHRQ Grant HS10399).

Children commonly suffer from bacterial infections after stem cell transplant.

Researchers studied 182 pediatric patients who underwent their first hematopoietic stem cell transplant for cancer and received gut decontamination with antibiotics at one children's hospital from 1999 to 2002. They examined the impact of several factors on infection, including stem cell source, donor, recent bacteremia, and graft versus host disease prophylaxis agents. Overall, 41 percent of patients developed bacterial infections. The majority were Gram-positive cocci, consistent with recent trends in immunocompromised patients. Kersun, Propert, Lautenbach, et al., Pediatr Blood Cancer 45:162-169, 2005 (AHRQ Grant HS10399).

Perforated appendicitis disproportionately affects Medicaid-insured and minority children.

In one-third of children who have appendicitis, the appendix ruptures before surgery, leading to more complications and longer hospital stays. Ruptured appendix usually results from delayed diagnosis and treatment and occurs more often among minority and Medicaid-insured children. Researchers used 1997 data from AHRQ's Kid's Inpatient Database of pediatric hospital discharges from 22 States to determine patient and hospital characteristics associated with perforated appendicitis. Smink, Fishman, Kleinman, and Finkelstein, Pediatrics 115(4):920-925, 2005 (AHRQ Grant T32 HS00063).

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Mental Health

Despite the debilitating nature and prevalence of mental health problems in children, many disorders continue to be underdiagnosed and inadequately treated. AHRQ-funded research focuses on improving delivery of mental health care in primary care practice.

Study provides new evidence linking antidepressants and risk of suicide in children and adolescents.

This study of Medicaid-insured children from all 50 States provides additional evidence that antidepressants boost the risk of suicidal behavior among depressed children and adolescents. It found a two-fold increased risk of suicide attempts among children treated with any type of antidepressant medication. Olfson and Marcus, J Clin Psychiatr 69(3):425-432, 2008 (AHRQ Grant HS16097).

White children are about twice as likely as black and Hispanic children to use stimulant medications.

Stimulant medications are typically prescribed for children with attention deficit/hyperactivity disorder (ADHD), and white children are more likely than children of other races to use them, according to the study. The researchers examined data on stimulant use between 2000 and 2002 among U.S. children aged 5-17. Overall, 5.1 percent of white children compared with 2.8 percent of black and 2.1 percent of Hispanic children were prescribed at least one stimulant medication during the study period. Differences in family or individual characteristics accounted for about 25 percent of the differences between whites and Hispanics but not for the difference between blacks and whites. The source of the remaining differences in children's stimulant use is unclear, note the researchers. Hudson, Miller, and Kirby, Med Care 45(11):1068-1075, 2007 (AHRQ Publication No. 08-R044)* (Intramural).

Youths at highest risk for attempting suicide are severely depressed and have other key stressors.

Researchers examined suicide attempts among 451 ethnically diverse depressed youths aged 12-21 and found that in the previous 6 months, 12 percent of the youths had attempted suicide. Those who had attempted suicide were significantly more likely to be female and to have more severe depression. After controlling for depression severity, only key stressors—a romantic breakup, recent arrest, or assault—remained a significant predictor of suicide attempt, increasing the risk by 58 percent. Fordwood, Asarnow, Huizar, and Reise, J Clin Child Adolesc Psychol 36(3):392-404, 2007 (AHRQ Grant HS09908). See also Olfson and Marcus, J Clin Psychiatry 69(3):425-432, 2008 (AHRQ Grant HS16097).

Use of antidepressants in children decreased in response to regulatory warnings.

Regulatory warnings about the potential for increased suicidal thoughts and behavior in children and adolescents led to fewer prescriptions of antidepressants for these groups in 2004 and 2005, according to this study. The researchers studied antidepressant prescribing among children insured by the Tennessee Medicaid program from January 2002 through December 2003 (before the warning) and January 2004 through September 2005 (after the warning). They found that new users of antidepressants decreased by 33 percent among children and adolescents by 21 months after the warnings. The researchers cite an urgent need for better safety and efficacy data to guide pediatric antidepressant practice. Kurian, Ray, Arbogast, et al., Arch Pediatr Adolesc Med 161(7):690-696, 2007 (AHRQ Grant HS10384).

Pediatric prescriptions for antipsychotic medications increased five-fold from 1995 to 2002.

Using data from two national surveys, researchers found that antipsychotic prescribing increased from 8.6 per 1,000 children ages 2 to 18 in 1995-1996 to 39.4 per 1,000 in 2001-2002. Although prescribing rates were similar for children aged 2 to 12 and 13 to 18, overall prescribing rates were higher for the older children. Two-thirds of prescriptions were for males. Nearly one-third of antipsychotic prescriptions were associated with visits to clinicians other than mental health specialists. Cooper, Arbogast, Ding, et al., Ambulatory Pediatr 6:79-83, 2006 (AHRQ Grant HS10384).

Use of antidepressants among children increased significantly from 1997 to 2002.

Overall use of antidepressants among children increased from 0.9 million children (1.3 percent) in 1997 to 1.4 million children (1.8 percent) in 2002. This increase was driven by a doubling in antidepressant use by adolescents, from 2.1 percent in 1997 to 3.9 percent in 2002, with no change in use among children younger than age 13. This finding is consistent with the higher prevalence of depression in adolescents (about 6 percent) than in younger children (about 2 percent). The increase in antidepressant use was most evident in groups that previously had lower levels of use, such as girls, blacks, and low-income children. Vitiello, Zuvekas, and Norquest, J Am Acad Child Adolesc Psychiatry 45(3):271-279, 2006 (AHRQ Publication No. 06-R037)* (Intramural).

Cognitive behavioral therapy used with antidepressants offers additional benefits to adolescents with depression.

This study involved 152 adolescents aged 12 to 18 with major depressive disorder who were in treatment at an HMO pediatric primary care practice. They were randomly assigned to receive antidepressants alone or antidepressants plus brief cognitive behavioral therapy. Adolescents who received the combination treatment used approximately 20 percent less medication than those who received medication only. The researchers note that these results are consistent with recent studies indicating that depressed youths only reluctantly take antidepressant medication and look for opportunities to discontinue it. Clarke, Debar, Lynch, et al., J Am Acad Child Adolesc Psychiatry 44(9):888-898, 2005 (AHRQ Grants HS10535 and HS13854).

Mental health problems among children who have special health care needs and their caregivers are barriers to care.

The mental health problems of children with special health care needs and their caregivers appear to be barriers to obtaining needed care, according to this study. In a survey of a random sample of 1,088 caregivers in Washington, DC, in 2002, the researchers asked about children's unmet needs, mental health status, and the caregivers' mental health status. Caregivers with symptoms of depression were much more likely than those without depression to report children's unmet needs for hospital and physician care, mental health services, and other types of health care. Most of the children were black and urban, so these findings may differ for children of other races and those living in rural areas. Gaskin and Mitchell, J Ment Health Policy Econ 8:29-35, 2005 (AHRQ grant HS10912).

Despite questions about efficacy and safety, use of atypical antipsychotic drugs in children continues.

Atypical antipsychotic drugs, such as risperidone and clozapine, are approved to treat schizophrenia in adults but not children. Some studies suggest more prevalent and serious side effects in children and adolescents, such as weight gain and sedation. Nevertheless, this study found that nearly one-fourth of children and adolescents with prescription claims for these drugs were aged 9 or younger. Since schizophrenia is seldom diagnosed before adolescence, it is likely that these drugs are being prescribed to treat behavior disorders such as ADHD, conclude the researchers. Curtis, Masselink, Ostbye, et al., Arch Pediatr Adolesc Med 159:362-366, 2005 (AHRQ Grant HS10385).

Improving primary care access to effective treatment for adolescent depression improves outcomes.

This randomized controlled trial involved 418 primary care patients aged 13-21 with depression who were enrolled in managed care and treated between 1999 and 2003. Subjects were randomized to either quality improvement (intervention) or usual care (control). After 6 months, intervention patients reported significantly fewer depressive symptoms than usual care patients, higher quality of life scores, and greater satisfaction with mental health care. Asarnow, Jaycox, Duan, et al., JAMA 293(3):311-319, 2005 (AHRQ Grant HS09908).

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