A Growing Concern: The Prevalence of Self-Medication in Pediatric Healthcare in India

Self-medication, the practice of using medications without a valid prescription based on self-diagnosed symptoms, has become a global phenomenon, with a significant presence in developing nations like India. This inclination often arises from the desire to reduce healthcare costs and save time, though it carries inherent risks, including serious adverse effects and the potential masking of chronic disease symptoms. In India, the prevalence of self-medication varies widely, with factors such as media-driven advertisements, positive attitudes, and financial constraints contributing to its adoption, especially among lower- and middle-income families. The pediatric population in India is witnessing a notable increase in self-medication practices, driven by a mix of affordability, convenience, and limited awareness among parents. The risks associated with self-medication in pediatric healthcare are diverse, posing threats to developing immune systems and metabolisms in children. Antibiotic misuse further exacerbates concerns about antibiotic resistance, a global health crisis. Understanding the root causes of self-medication, including restricted healthcare access and societal pressures, is crucial for developing effective interventions. To address this issue comprehensively, a multifaceted approach is essential, emphasizing the need for widespread educational initiatives targeting healthcare literacy. Concurrently, reinforcing regulatory measures to monitor over-the-counter medication sales and conducting public awareness campaigns can deter unauthorized dispensing and promote responsible healthcare practices. Collaborative efforts involving healthcare providers, government bodies, pharmaceutical companies, and educational institutions are imperative to champion policies prioritizing children's health. It is a collective responsibility to ensure access to proper healthcare as an inherent right for every child in India. Urgent action is necessary to address the rising prevalence of self-medication, securing the well-being of the younger generation and paving the way for a healthier and more resilient future.

Prenatal vitamin B12 status and cognitive functioning in children at 4 years of age: The ECLIPSES Study

Maternal vitamin B12 deficiency has been associated with disturbed cognitive functioning in offspring at different ages during childhood. However, this association has not been explored in pre-school-age children. The objective of this study was to examine the association between maternal vitamin B12 levels at the beginning and end of pregnancy and cognitive functioning in their children at 4 years of age. This longitudinal prospective study included a subsample of pregnant women and their children aged 4 years (n = 249) who participated in the ECLIPSES Study conducted in the province of Tarragona, Spain, from 2013 to 2017. Maternal vitamin B12 concentrations were determined in the first and third trimesters, and sociodemographic, nutritional and psychological data were collected. The children's cognitive functioning was assessed using the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV) and subtests of the Neuropsychological Assessment of Development (NEPSY-II). The multivariable models showed a significant relationship between vitamin B12 and the working memory index in the first trimester of the pregnancy but not in the third trimester. Children of mothers in the second vitamin B12 level tertile (314-413 pg/mL) (β = 6.468, 95% confidence interval [CI]: = 2.054, 10.882, p = 0.004) and third vitamin B12 level tertile (≥414 pg/mL) (β = 4.703, 95% CI: = 0.292, 9.114, p = 0.037) scored higher in the working memory index of the WPPSI-IV than the children of mothers with vitamin B12 levels in the first tertile (<314 pg/mL). Maintaining an adequate level of maternal vitamin B12 during early pregnancy contributes to improved performance in childhood working memory at 4 years of age.

Neighborhood context and children's health care utilization and health outcomes: a comprehensive descriptive analysis of national survey data

While child health and health care disparities arising from unequal distribution of resources are well documented, a nationally representative inventory of health and well-being for children across the spectrum of opportunity is lacking. Using the nationally representative sample of children from pooled 2013-2017 Medical Expenditure Panel Survey data linked to the census-tract-level Child Opportunity Index 2.0, a composite measure of neighborhood health, education, and socioeconomic conditions, we describe US children's socioeconomic characteristics, health care utilization and expenditures across the spectrum of child neighborhood opportunity levels. We found that neighborhood level of child opportunity was associated with almost all of children's health status, health care utilization, expenditures, access to care, and satisfaction with care outcomes. Children living in lower-opportunity neighborhoods had the highest rates of poor physical and mental health status and fewest ambulatory care visits but accounted for the highest share of emergency department visits. Their parents were also least likely to report having positive experiences with health care, good communication with providers, and easy access to care. Our findings underscore the myriad harms to children of gaps in health, education, and financial resources at the community level and provide targets for public investments to improve child-focused outcomes.

Parental resources and heritability as factors shaping children's health. An analysis of twins' self-rated health using TwinLife

We assess the relative and joint contributions of genetic and environmental factors on health during childhood and assume that parental resources are part of the environmental factors shaping children's health. We discuss theoretical background and empirical evidence concerning the effects of parental resources and heritability on children's health. Based on these findings we formulate six hypotheses guiding our empirical analysis, using data from TwinLife, a nationally representative sample of same sex twin pairs in Germany. We analyze self-rated health of 1,584 twin pairs aged 4-18. We did find strong support for the idea that parental resources influence children's health: household income and fathers' education consistently show positive effects. In contrast to our expectation, we did not find that genetic factors influence the health of well-off children less than the health of children living in families with lower SES. We also did not find that the genetic influence on health increases during childhood and adolescence. On the contrary our results indicate that the role played by genetic factors diminishes whereas environmental factors gain importance for health of children while growing up. This finding is good news for those interested in improving health chances of children from lower SES backgrounds because it demonstrates the malleability of children's health.

Comparative study of the relationship between pregnancy and childbirth factors and autism in healthy children and children with autism

BACKGROUND

Autism is a group of developmental disorders of the nervous system, the main manifestations of which are defects in social interactions and communication, as well as repetitive behaviors and limited interests. The etiology of autism is not limited to a single factor. Therefore, the aim of this study was to compare the relationship between pregnancy and childbirth factors and autism in healthy children and children with autism.

MATERIALS AND METHODS

The present study was a cross-sectional study that was performed on 200 children in Isfahan in 2021. The instrument in this study was a researcher-made questionnaire. The collected data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 22 software.

RESULTS

The results of data analysis between the two groups with Mann-Whitney U test showed that there was a significant relationship between maternal age at delivery, father's age at delivery, gestational age at delivery, interval between pregnancies, and the length of hospital stay (P ≤ 0.05). Also, the results of data analysis with Chi-squared test showed that there is a significant relationship between the two groups in terms of economic status, place of residence, multiple pregnancies, neonatal sex, and disease in infancy (P ≤ 0.05).

CONCLUSION

The results of this study showed that economic status, place of residence, multiple pregnancies, sex of the baby, and disease in infancy can be effective factors for this disease. According to the results of the study, by considering the factors related to autism, many cases can be adjusted and corrected as much as possible before attempting to conceive.

Anticipated impacts of climate change on women's health: A background primer

Due to human activities, atmospheric greenhouse gas levels have increased dramatically, leading to an increase in the global mean surface temperature by 1.1° Celsius. Unless we can achieve a significant reduction in emissions, the global mean surface temperature will continue to rise to a dangerous level. Adverse outcomes of this warming will include extreme weather events, a deterioration of food, water and air quality, decreased food security, and an increase in vector-borne infectious disease. Political and economic instability as well as mass population migration will result in reduced access to healthcare resources. Mitigation of and adaptation to climate change will be key determinants of humanity's survival in the face of this existential crisis. Women will be more adversely affected by climate change than men, and pregnant persons will be particularly vulnerable. Particular differential impacts on women include higher heat and particulate-related morbidity and mortality; pregnancy risks including preterm birth, fetal growth lag, hypertensive disorders; and mental health impacts. To prepare for the climate crisis, it  is imperative for women's healthcare providers to assist their patients through political advocacy, provide family planning services, and focus on nutrition and lifestyle counseling.

A Feasibility Study to Examine Clinical Variables of Childhood Malnutrition in Guatemala

Introduction: Guatemala is the country with the highest rate of malnutrition in Latin America and fifth highest worldwide. The objective of this pilot study was to determine the feasibility of examining clinical variables of malnutrition among a subset of children at a Guatemalan Nutrition Rehabilitation Center (NRC). Methods: The study was conducted using a secondary dataset of children admitted and discharged at the NRC in 2018. A total of 42 cases were reviewed. The 12 clinical variables were age, gender, height, weight, nutrition status, referral, diet, secondary diagnoses, medications, supplements, discharge disposition, and time-to-discharge. Results: The two major findings were (a) the lack of access to height and weight at discharge and (b) the inability to verify time-to-recovery. Mean age of participants was 23 months (SD = 12.9). All children were discharged home; median time-to-discharge was 48 days. The Kaplan-Meier analyses indicated that children <2 had slower time-to-discharge (51 days), compared to those older than age 2 (32 days); though not statistically significant. Conclusion: Findings of this study provide valuable data to inform ways NRC leadership can better report child health outcomes. International community-academic partnership could contribute to understanding malnutrition and time-to-recovery.

The influence of home and environmental characteristics on 5-18 years old children's health during the COVID-19 pandemic: A cross-sectional study in Iran

Background

The coronavirus disease (COVID-19) pandemic has dramatically changed the health and wellbeing of children. Therefore, this study aimed to investigate the relationship between the home environment and the environmental characteristics on 5-18 years old children health in Iran.

Method

An online survey was conducted among parents of children aged 5 to 18 living in large cities in Iran in 2021. The statistical population of this cross-sectional study was 500 people. In this survey, questionnaires on the quality of the home environment, exterior and interior landscapes of homes, and the Child Health Questionnaire (CHQ) were used to investigate the relationship between the home environment and environmental characteristics on 5-18 years old children health during the COVID-19 pandemic. The t-test and analysis of variance were used in SPSS 24, and the structural equation modeling (SEM) was utilized in AMOS 24 for analyzing the data.

Results

The average age of respondents was 37.13 ± 7.20, and that of children was 11.57 ± 3.47. 73.02% of the families were covered by insurance, and 74.08% of them lived in the metropolis. In addition, 65.04% of the families complied with the restrictions of the quarantine period. A share of 31% of the families live in villas, and 55% paid more attention to cleaning their homes during the COVID-19 pandemic than before. A positive and significant statistical relationship (β = 0.414, p < 0.001) was observed between the residence environment and child health. Thus, explained 17.5% of variations in child health.

Conclusion

The results showed that the children who lived in homes with an exterior landscape in nature had better health. In addition, the 5-18 years old children whose home landscape was a garden, compared to the other two groups (yard, balcony), had better health. Gardens are a potential source of health and not necessarily replaced by other natural environments, thus providing them along with green space is one of the crucial issues that should be considered.

Trend analysis of mortality rates and causes of death in children under 5 years of age in Xuzhou, China from 2016 to 2020

Objectives

To analyze the trends in mortality and causes of death among children under 5 years of age in Xuzhou, China between 2016 and 2020, in order to protect children's health and provide a basis for formulating child survival, development, and protection strategies.

Methods

A population-based epidemiological study was conducted. Data were obtained from the Xuzhou Center for Disease Control Prevention. We input the data into the excel database and analyzed with SPSS20.0.

Results

There were 1,949 children under 5 years of age died in Xuzhou, The number of deaths from 2016 to 2020 were 573 (29.40%), 577 (29.60%), 371 (19.04%), 334 (17.14%), and 94 (4.82%) respectively, mortality in children showed a downward trend. The number of deaths was relatively high in January (195 cases, 10.01%), February (190 cases, 9.75%), and May (180 cases, 9.24%), while was relatively small in July (147 cases, 7.54%), August (139 cases, 7.13%), and September (118 cases, 6.05%). The leading causes of death (COD) in children under 5 years of age were neonatal suffocation and hypoxia (323 cases, 16.57%). Pizhou (528 cases, 27.09%) showed the highest number of deaths in children under 5 years of age in China, and the Kaifa (25 cases, 1.28%) zone showed the lowest death toll.

Conclusions

Our research suggested that the current strategies for reducing child mortality should prioritize the actions on neonatal deaths and conduct targeted interventions for the main cause.

[HOSPITAL MORBIDITY OF CHILDREN IN THE CITY OF MOSCOW DURING THE COVID-19 PANDEMIC]

The article presents information on trends in hospital morbidity of child population in Moscow, as well as morbidity of children in the first year of life. Authors used population data and information from Form No. 14 of the Federal statistical observational study "Information on the activities of the medical organization departments providing inpatient medical care" between 2014 and 2021.In addition to the general indexes, the article presents categories of diseases that were significantly affected by changes in the lifestyle of children during the COVID-19 pandemic. Significant fluctuations in the incidence of infectious diseases are worth noting as they are certainly related to both fragmentations in groups of children during the pandemic, and proper nutrition, which led to positive changes in hospital morbidity due to gastrointestinal disorders. Changes in education, social isolation, better control over hygiene by the government, society and parents has led to unprecedented positive dynamics in morbidity rates of certain diseases. It is worth noting that the COVID-19 infection during pregnancy didn't lead to expected high increases in morbidity rates associated with diseases in the perinatal period.In addition to hospital morbidity, the article presents data on mortality in 24-hour inpatient facilities, as well as changes in the proportion of emergency admissions of patients under 18 to Moscow state hospitals.

The influence of outdoor play spaces in urban parks on children's social anxiety

Urban green spaces are critical to the healthy development of children's social interactions and activities. However, the relationship between urban green spaces for children's activities and the alleviation of children's social anxiety remains unclear. In this study, we aimed to explore the link between spatial characteristics and social anxiety in children. To explore the coupling relationships among green space, play space, and social anxiety, an assessment of children's play spaces and levels of social anxiety was performed using self-reported data, OpenStreetMap captured the characteristic indicators of urban parks, and the ArcGIS and SPSS softwares were used for the mathematical analysis. The results showed that (1) both the NDVI and 10-min accessibility were significantly negatively related to children's social anxiety; (2) the diversity of service facilities, surfacing materials, and the attractiveness and challenge of the environment were negatively related to children's social anxiety; (3) there were significant differences between activity types and social anxiety. These results provide design references and a theoretical basis for improving the benefits of urban green space on children's health and wellbeing.

Exploring the Effects of the COVID-19 Pandemic on the Children and Families Cared for by Pediatric-Focused Advanced Practice Registered Nurses

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has significantly affected children and families. The study purpose was to better understand the perceptions of pediatric-focused advanced practice registered nurses (P-APRNs) on the impact of COVID-19 on patients and practice.

METHOD

A 25-item electronic survey including Likert scales, multiple choice , and open-ended questions was sent by e-mail to electronic mailing list of the National Association of Pediatric Nurse Practitioners.

RESULTS

Responses (N = 109) reflect the magnitude of challenges affecting child physical health, mental health, parental stress, and social determinants of health. P-APRNs expect greater refusal of the COVID-19 vaccine compared with other vaccines. Telehealth use continues at an increased rate and greater resources are needed to support clinical practice.

DISCUSSION

The COVID-19 pandemic has transformed the lives of children, families, and P-APRN practice. These findings reflect challenges and opportunities moving forward. P-APRNs are well-prepared to lead change to support better and more equitable outcomes for all.

Lifecourse factors associated with flourishing among US children aged 1-5 years

AIM

This study aimed to examine the association between lifecourse factors and flourishing among children ages 1-5 years.

STUDY DESIGN

Using data from the combined 2016 and 2017 National Survey of Children's Health (N = 18 007 children aged 1-5 years), flourishing was defined as parent-reported child's affection, resilience, curiosity about learning, and affect. Multivariable logistic regression modelled the associations between lifecourse factors and flourishing. These factors were identified according to the lifecourse health development model.

RESULTS

Approximately 63% of children aged 1-5 years were flourishing. Children who were female (vs. male, adjusted prevalence ratio [APR]: 1.06, 95% confidence interval [CI]: 1.00-1.11), White, non-Hispanic (vs. Black, non-Hispanic, APR: 1.13, 95% CI: 1.01-1.26), not having a special health care need (vs. special health care need, APR: 1.15, 95% CI: 1.03-1.26), not having an emotional, developmental or behavioural disorder (EBD) (vs.

EBD, APR

1.66, 95% CI:1.23-2.10), spoke English at home (vs. other language, APR: 1.30, 95% CI: 1.06-1.54), parents received emotional social support (vs. no emotional social support, APR: 1.11, 95% CI: 1.01-1.21) and who lived in a supportive neighbourhood (vs. not in supportive neighbourhood, APR: 1.12, 95% CI:1.05-1.18) were more likely to flourish. Children from households within 0%-99% of the federal poverty level (APR: 0.89, 95% CI: 0.79-0.98) were less likely to be flourishing compared with their counterparts from households within 400% of the federal poverty level.

CONCLUSIONS

Findings indicate that several lifecourse factors are associated with young children's flourishing, including being female, White, non-Hispanic, not having a special health care need or EBD, English as a primary language, parents receiving emotional social support, having neighbourhood support and a lower household income. Our findings promote the continuation of programmes supporting diverse and low-income children's families and communities such as home visiting and Head Start, which provide avenues for bolstering children's health and development across the lifespan.

Pediatric Chemical Exposure: Opportunities for Prevention

Over the past 50 years, the use of artificial chemicals in products has increased exponentially. Most of these chemicals were not tested for safety before widespread use, and the impacts of exposures are just now being realized. Children are especially vulnerable to the health impacts of chemical exposures, and these exposures are now known to be an important component of rising rates of diseases such as asthma, some cancers, and neurodevelopmental disorders in children. This article reviews the impacts of chemical exposures on children's health, common chemicals children may be exposed to and their health impacts, and how advanced practice registered nurses can assess for exposures, provide anticipatory guidance, and engage in advocacy in support of a healthier environment.

Climate Change and Health of Children: Our Borrowed Future

Children are disproportionately vulnerable to the impacts of climate change because of physiological, developmental, behavioral, and social factors. In addition, they are likely to bear the consequences of these impacts over their life course. This paper reviews the health impacts of climate change on children's health, highlights specific vulnerabilities and offers recommendations to pediatric health care professionals for mitigation, adaptation, policy, and personal interventions to address our changing climate. Health care professionals can help families in mitigation and adaptation strategies to reduce their risk from climate change.

Changes in parental smoking behavior and children's health status in Chile

Studies on parental smoking behavior have mostly been conducted for developed countries and show that current parental smoking is negatively associated with children's current health. Using four waves of a Chilean longitudinal survey (Encuesta de Protección Social), we estimate probit and ordinary least squares models relating parents' self-report of their children's current health status to several covariates, including current parental smoking status and change (transitions) in parental smoking status across the waves of the survey. The data were collected in the years 2004, 2006, 2009, and 2015. The working sample includes 25,052 observations. The study revealed that parents' self-report of their children's current health status is strongly associated with current and past parental smoking status. Parents who smoke have an increased 11.17% probability of reporting that their children are in fair, poor, or very poor health status, when compared to non-smoking parents. The effect is stronger if the smoker is the mother, and it is exacerbated if she is less educated or unemployed/inactive. In addition, quitting smoking has a significant positive effect on children's reported health status, which is greater if the mother quits smoking. Cessation among mothers who are unemployed or inactive is also associated with a more positive assessment of their children's health status. The findings suggest that cessation programs may have health benefits not only for smoking parents, but also for their children. Improving coverage or establishing a national cessation program may have important present and future effects on population health and well-being.

Prospective Cohort Study on the Effect of an Intervention to Reduce Household Air Pollution Among Sudanese Women and Children

BACKGROUND

Exposure to household air pollution through the burning of biomass fuels is a global health concern and can lead to negative health outcomes such as asthma and lung disease.

OBJECTIVES

The goal of this four-year study was to determine whether an intervention to reduce household air pollution (HAP) which included health education and a new well-ventilated cooking location would reduce exposure to HAP, lower carbon monoxide (CO) levels and improve the health of women and children in Port Sudan, Sudan.

METHODS

In 2016, 115 women of low socioeconomic status and their children were invited to participate in the study at two women's centers. One hundred and eleven women consented to participate and were divided into study and control groups on the basis of home ownership. Women who owned their homes learned about the adverse effects of HAP and a well-ventilated outside cooking location (rakoobah) was provided. Control women did not receive HAP education or a rakoobah. Questionnaires were used to assess the effect of education and a new well-ventilated cooking location for a group of Sudanese women who cook with biomass fuels. CO-oximetry was performed. Each year from 2017-2019, the questionnaires and CO-oximetry were repeated.

RESULTS

Sixty-five women and 33 children were assigned to the study group and 46 women and 19 children were assigned to the control group in 2016. Women were enrolled in 2016 with CO levels of 17.8% and 17.4%, respectively. One year later some of the study group women had lower CO levels and others higher, while the CO levels of the controls were stable. An intensive HAP education program was started for the study group women. By 2019, the last study year, the CO levels of both the study and control group women had dropped to normal levels of 2.9% and 3.1%, respectively. Control group women may have benefited from the HAP education and modeled behavior of those in the study group.

CONCLUSIONS

The health impact of the change in cooking location was unclear, yet both groups reported fewer health care visits in 2019. Education and an outside cooking location resulted in lower CO levels of Sudanese women and children.

PARTICIPANT CONSENT

Obtained.

ETHICS APPROVAL

The study was approved by the Penn State Milton S. Hershey Medical Center Institutional Review Board and the Ethics Committee of the Red Sea University Faculty of Medicine located in Port Sudan, Sudan.

COMPETING INTERESTS

The authors declare no competing financial interests.

Dynamics of Parental Opioid Use and Children's Health and Well-Being: An Integrative Systems Mapping Approach

The seemingly intractable opioid epidemic compels researchers, the media, and families to better understand the causes and effects of this complex and evolving public health crisis. The effects of this crisis on people using opioids, maternal prenatal opioid exposure, and neonatal abstinence syndrome are well-documented, but less is known about the impact of caregivers' opioid use on children's health and well-being. One challenge to understanding the effects of parental opioid use disorder (OUD) on child and adolescent outcomes is the numerous interrelated pathways in which a child's health and well-being can be impacted. To better understand these dynamic relationships, we applied a systems mapping approach to visualize complex patterns and interactions between pathways and potential leverage points for interventions. Specifically, we developed a causal loop diagram system map to elucidate the complex and interconnected relationships between parental OUD, social determinants of health at the family and socio-environmental levels, family strengths, social supports, and possible adverse impacts on children's physical and mental health and risks for future substance misuse. The goals of this research are to (1) identify factors and dynamics that contribute to the relationship between parental OUD and children's health and well-being and (2) illustrate how systems mapping as a tool can aid in understanding the complex factors and dynamics of the system(s) that influence the well-being of children and their parents or primary caregivers.

The impact of rotavirus vaccination in the prevalence of gastroenteritis and comorbidities among children after suboptimal rotavirus vaccines implementation in Taiwan: A population-based study

In Taiwan, rotavirus vaccination was implemented in 2006 in the private sector. The population-based impact of rotavirus vaccination on gastroenteritis and comorbidities of children remains under-investigated.We analyzed the annual prevalence of rotavirus-related disease, including gastroenteritis, convulsions, epilepsy, type I diabetes mellitus, intussusception, and biliary atresia among children under 5 years of age. Data were collected from Taiwan's National Health Insurance Research Database, a nationwide population-based database. A 16-year retrospective cohort study was conducted between 2000 and 2015.Among children <5 years of age, the prevalence of gastroenteritis decreased after 2012 (44,259.69 per 100 thousands) and remained lower through 2015 (39,931.11per 100 thousands, P < .001). The prevalence of convulsions rose steadily and significantly from 2007 (775.90 per 100 thousands) to 2015 (962.17 per 100 thousands, P < .001). The prevalence of epilepsy decreased significantly until reaching a nadir in 2013 (from 501.56 to 293.53 per 100 thousands, P < .001). The prevalence of biliary atresia tended upward, and surged suddenly in 2007 with a peak in 2013 (18.74 per 100 thousands). Among infants (<1 year of age) from 2000 to 2015, the prevalence of gastroenteritis declined steadily, and more rapidly after 2007 (22,513 to 17,285 per 100 thousands).In Taiwan, after introducing rotavirus vaccination, gastroenteritis in young children decreased, especially in infancy. However, gastroenteritis is still common in children, given other emerging pathogens. Our results highlight the impact of rotavirus vaccines on children's health in Taiwan and provide indications for future preventive medicine and healthcare strategies in children.

Effects of an Intervention to Promote Physical Activity and Reduce Sedentary Time in Disadvantaged Children: Randomized Trial

BACKGROUND

In our society, children are particularly vulnerable to physical inactivity and excessive sedentary time (ST). The aim of this study was to evaluate the effectiveness of a school-based intervention designed to promote physical activity (PA) and reduce ST in 6- to 10-years-old children from a disadvantaged neighborhood.

METHODS

The first intervention of this randomized trial was carried out in School 1 in 2017/2018 and 2018/2019, School 2 benefited from the same intervention in 2018/2019. Baseline assessments were realized using accelerometers prior to the intervention (T1-T2), after the first intervention (T3) and after the second intervention (T4). School-based actions targeted children, parents, teachers, physical, and organizational environment of school and politics. The chi-square test of independence was used to analyze the evolution of the moderate and vigorous physical activity (MVPA) and ST.

RESULTS

For School 1, an increase in the percentage of very active children (over 40 minutes MVPA/day) and of having a very low ST (less 240 minutes/day) (p = .00) was found. No further evolution was revealed during the intervention (T2-T3) and 1 year after (T3-T4). For School 2, similar effects on PA and ST were found at T3 (p < .05).

CONCLUSIONS

Positive effects occurred before the intervention in each school and then remained stable.

Health Impact of Environmental Tobacco Smoke in the Horne

Environmental tobacco smoke (ETS) can be a major constituent of air pollution in indoor environments, including the home. Regulation on smoking in the workplace and public places has made the home the dominant unregulated source of ETS, with important potential impacts on children. Between 40% and 60% of cbildren in the United Kingdom are exposed to ETS in the home. Many experimental and human and studies have investigated the adverse health effects of ETS. Substantial evidence shows that in adults ETS is associated with increased risk of chronic respiratory illness, including lung cancer, nasal cancer, and cardiovascular disease. In children, ETS increases the risk of sudden infant death syndrome, middle ear disease, lower respiratory tract illness, prevalence of wheeze and cough, and exacerbates asthma. Although banning smoking in the home would be the optimal reduction strategy, several barrier and ventilation methods can be effective. Nevertheless, such methods are not always practical or acceptable, particularly when social pressures contribute to a lack of support for ETS control in the home. Smoking cessation interventions have bad limited success. Research is needed to explore the barriers to adopting ETS risk-reducing behaviors.

A Qualitative Exploration of Parental Perceptions Regarding Children's Sun Exposure, Sun Protection, and Sunburn

Sun protection among children is of utmost importance since sunburn in early life is a major risk factor for skin cancer development. Because parents play a vital role in enhancing sun safety among children, this study explored parental perceptions concerning sun exposure, sun protection behaviors, and sunburn in children. Additionally, the context in which children experience sunburn in order to assist the development, optimization, and targeting of sun safety interventions for parents is revealed. A qualitative study design, using a semi-structured interview guide addressing several themes (e.g., sun exposure, sun protection, and sunburn experiences), was used. Data were collected in the Netherlands in the fall of 2019. Parents were recruited via purposive sampling at schools, youth services centers, and social media. Execution, transcription, and coding of the interviews was done by two researchers, using the qualitative analyzing program Nvivo (interrater reliability of d = 0.84). In total, 26 interviews were performed (n = 17 mothers, n = 17 daughters, aged between 4 and 11 years). Parental perceptions and recall of their child's lifetime sunburn were frequent, even though all parents reported using at least one sun protection measure during sun exposure situations and parents seemed often unaware of their child's sunburn. Moreover, parents reported an overreliance on sunscreen, often failing to adequately protect their children's skin. Water-related activities, a lack of shade, and misconceptions regarding UV-index were often related to sunburn. In addition, unexpected sun exposure or longer exposure duration than initially planned were reported as challenging situations. The majority of parents had positive perceptions regarding tanned skin for both themselves as for children. This study provides directions for skin cancer prevention efforts targeted at both parents and their children. Since a lack of knowledge regarding sufficient sun protection measures and sunburn occurrence in various situations was reported, educational efforts are warranted. Additionally, focusing on clothing, shade-seeking, and adequate sunscreen use is recommended to increase children's sun safety. By intervening in the physical environment as well (e.g., providing shady areas), sun protection barriers can be reduced. Lastly, the general positive attitude toward tanned skin evident in this study is certainly worthy of attention in future interventions.

Exposure to indoor and outdoor air pollution from solid fuel combustion and respiratory outcomes in children in developed countries: a systematic review and meta-analysis

Epidemiological studies have shown a positive association between exposure to outdoor and indoor solid fuel combustion and adverse health effects. We reviewed the epidemiological evidence from Europe, North America, Australia and New Zealand on the association between outdoor and indoor exposure to solid fuel combustion and respiratory outcomes in children. We performed a systematic review and meta-analysis. Pooled relative risks (RRs) and 95% confidence intervals (CI) were calculated using random-effects models. We identified 74 articles. Due to limited evidence on other exposures and outcomes, we performed meta-analyses on the association between indoor wood burning exposure and respiratory outcomes. The RR for the highest vs the lowest category of indoor wood exposure was 0.90 (95% CI 0.77-1.05) considering asthma as an outcome. The corresponding pooled RRs for lower respiratory infection (LRI) and upper respiratory infection (URI) were 1.11 (95% CI 0.88, 1.41) and 1.11 (95% CI 0.85, 1.44) respectively. No association was found between indoor wood burning exposure and risk of wheeze and cough. Inconsistent and limited results were found considering the relationship between indoor wood burning exposure and other respiratory outcomes (rhinitis and hay fever, influenza) as well as indoor coal burning exposure and respiratory outcomes in children. Results from epidemiological studies that evaluated the relationship between the exposure to outdoor emissions derived from indoor combustion of solid fuels are too limited to allow firm conclusions. We found no association between indoor wood burning exposure and risk of asthma. A slight, but not significant, increased risk of LRI and URI was identified, although the available evidence is limited. Epidemiological studies evaluating the relationship between indoor coal burning exposure and respiratory outcomes, as well as, studies considering exposure to outdoor solid fuels, are too limited to draw any firm conclusions.

Parental beliefs and willingness to pay for reduction in their child's asthma symptoms: A joint estimation approach

Many aspects of asthma-in particular the relationship between beliefs, averting behaviors, and symptoms-are not directly observable from market data. An approach that combines observable market data with nonmarket valuation to gather data on unobservable aspects of the illness can improve efforts to quantify the burden of asthma if it accounts for the endogeneity in the system. Such approaches are used in the valuation of recreation but have not been widely used to value the burden of a chronic illness. We estimate parents' willingness to pay (WTP) to reduce their child's asthma symptoms using a three-equation model that combines revealed preference, contingent valuation, and burden of asthma, increasing the efficiency of estimation and correcting for endogeneity. WTP for a device that reduces a child's asthma symptoms by 50% is $125/month (s.d. $20). Parents' valuations are driven by beliefs about asthma and by their degree of worry about asthma between episodes. There is a nonlinear relationship between the number of days with symptoms and WTP per symptom day. The experience of living with asthma affects families' responses to a contingent valuation scenario, because it influences willingness to spend money to manage the illness and their subjective perceptions and beliefs about the illness itself.

A systematic review of strategies to increase drinking-water access and consumption among 0- to 5-year-olds

The objective of this study is to identify promising strategies for improving drinking-water access and consumption among children aged 0 to 5 years. MEDLINE/PubMed, Embase, ERIC, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched in this review. Studies included peer-reviewed, full-text studies from high-income countries, published in English between January 1, 2000, and January 12, 2018, that evaluated interventions to increase water access or consumption in children aged 0 to 5 years. Twenty-five studies met inclusion criteria; 19 used an effective intervention strategy to increase water access or water consumption. Three studies addressed both water access and consumption. Frequently used strategies included policy and practice changes, increasing water access and convenience, and education, training, or social support for caregivers. Studies were of fair methodological quality (average score: 18.8 of 26) for randomized studies and of moderate quality (5.1 of 9) for non-randomized studies. To date, few high-quality studies with objectively measured outcomes have clearly demonstrated strategies that may influence water intake and consumption among young children aged 0 to 5 years.

Complementary and integrative health methods used for the treatment of oral mucositis in children with cancer in Turkey

PURPOSE

We aimed to determine the complementary and integrative health (CIH) methods used by parents to treat oral mucositis in their children who have cancer.

DESIGN AND METHODS

In this multicenter, cross-sectional study, data for the study were collected via the demographic form and CIH form for oral mucositis. The data collection tools were filled out by the researchers during the face-to-face interviews. The parents (N = 302) of children with cancer who had undergone at least one round of chemotherapy were included in this study.

RESULTS

According to the parents' statements, oral mucositis developed in 91.1% of the children with cancer, and CIH was used in 50.9% of them to treat its side effects. Parents stated that to deal with the oral mucositis, they mainly used black mulberry (41.5%), carbonate (15.2%), and honey (11.6%). Some of the parents (51.8%) used CIH for their children without informing their healthcare providers.

PRACTICE IMPLICATIONS

The majority of healthcare providers were unaware of the parents' use of CIH for their children's oral mucositis treatment. Parents' opinions of these methods, of which the side effects and potential interactions with chemotherapeutic agents are not precisely known, and their use by parents for their children's oral mucositis should be evaluated by healthcare providers.

Examining Household Changes in Produce Purchases Among New Parents

OBJECTIVE

To measure whether parenthood is associated with changes in produce purchasing behavior, overall and stratified by income.

DESIGN

Retrospective examination of retail grocery purchases in the Nielsen Consumer Panel, a nationally representative sample of US households, 2007-2015.

PARTICIPANTS AND SETTING

A total of 21,939 households in the US, aged 25-49 years, observed ≤ 8 years; 508 households initiated parenthood during the study period.

MAIN OUTCOME MEASURE

Percentage of household grocery budget spent on produce each year.

ANALYSIS

Difference-in-differences design was used to measure change in the percentage of the grocery budget spent on produce after becoming a parent, relative to households that did not become parents, overall and stratified by income level. Ordinary least-squares regressions was used to adjust for confounders.

RESULTS

Percentage of the grocery budget spent on produce increased by 1.7 percentage points (15.7%) after initiating parenthood. Among higher-income households, produce purchases increased by 1.9 percentage points; no detectable change was found among low-income households.

CONCLUSIONS AND IMPLICATIONS

Initiation of parenthood increased grocery expenditures on produce. Because new parenthood is a critical time in a person's life, this behavior change could create the opportunity for interventions with long-term effects. However, heterogeneous impacts by income indicated that lower-income households need more support and reveal 1 mechanism for income-related disparities in childhood nutrition.

Health care access and glycemic control in youth and young adults with type 1 and type 2 diabetes in South Carolina

Affordability and geographic accessibility are key health care access characteristics. We used data from 481 youth and young adults (YYA) with diabetes (389 type 1, 92 type 2) to understand the association between health care access and glycemic control as measured by HbA1c values. In multivariate models, YYA with state or federal health insurance had HbA1c percentage values 0.68 higher (P = 0.0025) than the privately insured, and those without insurance 1.34 higher (P < 0.0001). Not having a routine diabetes care provider was associated with a 0.51 higher HbA1c (P = 0.048) compared to having specialist care, but HbA1c did not differ significantly (P = 0.069) between primary vs specialty care. Distance to utilized provider was not associated with HbA1c among YYA with a provider (P = 0.11). These findings underscore the central role of health insurance and indicate a need to better understand the root causes of poorer glycemic control in YYA with state/federal insurance.

Economic sanctions and child HIV

Approximately 1.8 million children under age 15 were living with HIV. This study is the first to empirically examine the impact of sanctions on children's new HIV infection and AIDS-related death rates. Using sanction and HIV/AIDS data that are available for 71 developing countries from 1990 to 2012, this study reveals that sanctions increase children's new HIV infection and their AIDS-related death rates. This study increases understanding about the consequences of sanctions, especially their effect on a marginalized population and is in line with previous literature. The significant impacts of sanctions on children's HIV/AIDS suggest that the leader in a country targeted by sanctions needs to consider extending programs to respond to children's HIV/AIDS both during sanctioning and after it is lifted.

Prenatal lead exposure and elevated blood pressure in children

Growing evidence suggests that environmental exposures can influence blood pressure over the course of a lifetime. Exposure to toxic metals, such as lead (Pb) and arsenic (As), has been associated with increased blood pressure in adults, but few studies have examined the impacts of in utero and early life toxic metals exposure on blood pressure in childhood. As subclinical vascular changes are thought to begin early in life, it is possible that in utero toxic metals exposure may play a role in blood pressure homeostasis. In the ongoing New Hampshire Birth Cohort Study, we investigated whether in utero exposure to Pb and As was associated with measures of blood pressure in a total of 323 young children (mean age 5.5 years, SD 0.4). Pb and As were measured in maternal toenail samples collected at ~28 weeks gestation (n = 257) and/or 6 weeks postpartum (n = 285), which represent exposures ~6 to 12 months prior to collection and therefore reflect the early prenatal and late prenatal exposures, respectively. Five measurements of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were averaged for each child using a standardized technique. In linear regression analyses, where log2-transformed prenatal toenail Pb and As were modeled jointly and adjusted for child age, sex, height, weight and maternal smoking during pregnancy, we observed that a doubling of maternal prenatal toenail Pb was associated with statistically significant increases in child SBP (β: 0.58 mm Hg, 95% CI: 0.05, 1.11). We did not observe any association of prenatal or postpartum As, or postpartum Pb, with SBP or DBP. Exploratory sex-stratified analyses suggest that associations of prenatal Pb with BP may be stronger among boys (SBP β: 0.72 mm Hg: 95% CI: -0.01, 1.44; DBP β: 0.37; 95% CI: -0.09, 0.84), compared to girls (SBP β: 0.48 mm Hg: 95% CI: -0.31, 1.26; DBP β: -0.05; 95% CI: -0.52, 0.41), though tests for interaction did not reach statistical significance (p-interaction SBP = 0.059; DBP = 0.057). Our preliminary results suggest that in utero toxic metals exposures may be associated with early life increases in blood pressure in children, which could have consequences for long-term health.

A systematic review of strategies to reduce sugar-sweetened beverage consumption among 0-year to 5-year olds

OBJECTIVE

The objective of this study is to summarize evidence for strategies designed to reduce sugar-sweetened beverage (SSB) consumption among children aged 0 to 5 years.

DATA SOURCES

PubMed, Web of Science, EMBASE, CINAHL, ERIC, Cab Abstracts and the Cochrane Central Register of Controlled Trials are the electronic databases searched in this systematic review.

STUDY SELECTION

Each included study evaluated an intervention to reduce SSB consumption in children aged 0 to 5 years, was conducted in a high-income country and was published between 1 January 2000 and 15 December 2017.

DATA SYNTHESIS

Twenty-seven studies met the inclusion criteria. The primary intervention settings were healthcare (n = 11), preschool/daycare (n = 4), home (n = 3), community venues (n = 3) and other settings (n = 6). Overarching strategies which successfully reduced SSB consumption included (i) in-person individual education, (ii) in-person group education, (iii) passive education (e.g. pamphlets), (iv) use of technology, (v) training for childcare/healthcare providers and (vi) changes to the physical access of beverages. Studies were of moderate methodological quality (average score of 20.7/29.0 for randomized studies; 3.1/9.0 for non-randomized studies).

CONCLUSIONS

Evidence suggests that interventions successful at reducing SSB consumption among 0-year to 5-year olds often focused on vulnerable populations, were conducted in preschool/daycare settings, specifically targeted only SSBs or only oral hygiene, included multiple intervention strategies and had higher intervention intensity/contact time.

Current State of Child Health in Rural America: How Context Shapes Children's Health

PURPOSE

Children's health is influenced by the context in which they live. We provide a descriptive essay on the status of children in rural America to highlight features of the rural environment that may affect health.

DESCRIPTION

We compiled information concerning components of the rural environment that may contribute to health outcomes. Areas addressed include the economic characteristics, provider availability, uniquely rural health risks, health services use, and health outcomes among rural children.

ASSESSMENT

Nearly 12 million children live in the rural United States. Rural counties are economically disadvantaged, leading to higher rates of poverty among rural versus urban children. Rural and urban children are approximately equally likely to be insured, but Medicaid insures a higher proportion of children in rural areas. While generally similar in health, rural children are more likely to be overweight or obese than urban children. Rural parents are less likely to report that their children received preventive medical or oral health visits than urban parents. Rural children are more likely to die than their urban peers, largely due to unintentional injury.

CONCLUSION

Improving rural children's health will require both increased public health surveillance and research that creates solutions appropriate for rural environments, where health care professionals may be in short supply. Most importantly, solutions must be multisectoral, engaging education, economic development, and other community perspectives as well as health care.

A Systematic Review of Children's Environmental Health in Brazil

In the region of the Americas, approximately 100,000 children under the age of 5 years die each year due to environmental hazards. Brazil, due to its large size and wide range of environmental challenges, presents numerous hazards to children's health. The aim of this study was to systematically review the scientific literature that describes children's exposures to environmental pollutants in Brazil and their effects on Brazilian children's health. A systematic review of the scientific literature was performed without language restrictions and time of publication (years). The literature search was conducted in the following key resources: PubMed (MEDLINE), Scopus and Web of Science with the MeSH Terms: Environmental exposure AND Brazil (filters: Human, Child [birth to 18 years] and Affiliation Author). The Virtual Health Library was also employed to access the databases Scielo and Lilacs. The search strategy was [DeCS Terms]: Child OR adolescent AND Environmental exposure AND Brazil. Health effects in children associated with exposure to environmental pollutants in Brazil were reported in 74 studies, during the period between 1995 and 2015. The most frequently cited effect was hospital admission for respiratory causes including wheezing, asthma, and pneumonia among children living in areas with high concentrations of air pollutants. A broad spectrum of other health effects possibly linked to pollutants also was found such as prematurity, low birth weight, congenital abnormality (cryptorchidism, hypospadia, micropenis), poor performance in tests of psychomotor and mental development, and behavioral problems. Exposure to pesticides in utero and postnatally was associated with a high risk for leukemia in children <2 years old. These results show that there is a need in Brazil for stricter monitoring of pollutant emissions and for health surveillance programs especially among vulnerable populations such as pregnant women and young children.

Parental attitudes toward pediatric use of complementary/alternative medicine in Turkey

PURPOSE

This study was conducted to determine the pediatric usage of complementary/alternative medicine (CAM) by parents in Turkey, the incidence of using these methods, and the factors affecting their use.

DESIGN AND METHODS

The sectional and relational design of the study included a sample of 497 parents who took children for treatment at the Maternity and Children's Hospital in Giresun, Turkey. Data for the study were collected via the Personal Information Form and the Evaluation Form for Complementary/Alternative Treatment Use. The data collection tools were filled out by the researchers during the face-to-face interviews. Data obtained from the study were analyzed by Pearson chi-square, Fisher-Freeman-Halton and Fisher's exact (posthoc Bonferroni) tests and Z-test.

RESULTS

It was determined that 97.7% of the parents had used at least one CAM method. Moreover, the parents had used CAM methods mostly for respiratory complaints. The CAM methods were most commonly used for the symptoms of fever, diarrhea, and cough. It was observed that the most commonly used alternative methods in the past were vitamin/mineral remedies, cold treatments, and hodja (Islamic teacher) consultations, while the most common alternative methods currently used are massage, music, and cold treatment. In addition, the differences found between CAM users in terms of sociodemographic characteristics were not statistically significant.

PRACTICE IMPLICATIONS

It is crucial for nurses to learn the characteristics of the health/disease treatments used by those with whom they work in order to increase the efficiency of the service they provide. Thus, it was recommended that nurses should be knowledgeable and aware of the benefits/side effects, treatment methods, and contraindications of CAM.

Disparities in Health Care Quality among Asian Children with Special Health Care Needs

There is a dearth of information on the quality of health care for Asian American children and particularly Asian children with special health care needs (CSHCN). The goal of this article was to determine whether there were disparities in quality of health care for Asian CSHCN, whose experiences have not been studied. Data were derived from the 2009-2010 National Survey of Children with Special Health Care Needs (ns = 355 non-Hispanic Asian children and 4,343 non-Hispanic white CSHCN). Bivariate and multivariate logistic regression analyses were conducted to examine the relationship between racial identity (that is, non-Hispanic white and non-Hispanic Asian) and quality of health care. Racial disparities in quality of health care were substantial between Asian and white CSHCN in 2009-2010. Asian parents were significantly less likely than white parents to report that their health care provider provided the specific information they needed, helped them feel like a partner in their child's care, and was sensitive to the family's values and customs. The development and testing of specific, targeted policy and practice interventions to reduce disparities in health care quality for these children are urgently needed.

Welfare Reform and Children's Health

This study investigates the effect of the Temporary Aid to Needy Families (TANF) program on children's health outcomes using data from the Survey of Income and Program Participation over the period 1994 to 2005. The TANF policies have been credited with increased employment for single mothers and a dramatic drop in welfare caseload. Our results show that these policies also had a significant effect on various measures of children's medical utilization among low-income families. These health measures include a rating of the child's health status reported by the parents, the number of times that parents consulted a doctor, and the number of nights that the child stayed in a hospital. We compare the overall changes of health status and medical utilization for children with working and nonworking mothers. We find that the child's health status as reported by the parents is affected by the maternal employment status.

HIV testing and retention in care of infants born to HIV- infected women enrolled in 'Option B+', Thyolo, Malawi

Prevention of mother-to-child transmission 'Option B+' originated in Malawi in 2011 to prevent new infections in infants exposed to the human immunodeficiency virus (HIV). We assessed 12-month programme retention and HIV testing uptake among infants born to HIV-infected mothers from September 2011 to June 2012 in Thyolo District Hospital. Of 513 infants, 368 (71.7%) remained in care at 12 months. Altogether, 412 (80.3%) underwent HIV DNA polymerase chain reaction testing, with 267 (52.0%) tested at 6-12 weeks, and 255 (49.7%) underwent rapid HIV testing, with 144 (28.1%) tested at 12 months. Eighty-eight (17.2%) infants had both tests as scheduled. Measures are needed to improve adherence to national testing protocols.

Features of the built environment related to physical activity friendliness and children's obesity and other risk factors

OBJECTIVES

We investigated the relationships among environmental features of physical activity friendliness, socioeconomic indicators, and prevalence of obesity (BMI status), central adiposity (waist circumference, waist-height ratio), and hypertension.

DESIGN AND SAMPLE

The design was cross-sectional; the study was correlational. The sample was 911 kindergarteners through sixth graders from three schools in an urban school district residing in 13 designated neighborhoods.

MEASURES

Data from walking environmental community audits, census data for socioeconomic indicators, body mass index, waist circumference, waist-height ratio, and blood pressure were analyzed. A modified Alfonzo's Hierarchy of Walking Needs model was the conceptual framework for environmental features (i.e., accessibility, safety, comfort, and pleasurability) related to physical activity.

RESULTS

Accessibility was significantly and negatively correlated with prevalence of obesity and with prevalence of a waist-height ratio >0.50. When neighborhood education was controlled, and when both neighborhood education and poverty were controlled with partial correlational analysis, comfort features of a walking environment were significantly and positively related to prevalence of obesity. When poverty was controlled with partial correlation, accessibility was significantly and negatively correlated with prevalence of waist-height ratio >0.50.

CONCLUSIONS

The built environment merits further research to promote physical activity and stem the obesity epidemic in children. Our approach can be a useful framework for future research.

Estimating children's exposure to toxic elements in contaminated toys and children's jewelry via saliva mobilization

Children's potential for exposure to potentially toxic elements in contaminated jewelry and toys via mouth contact has not yet been fully evaluated. Various toys and jewelry (metallic toys and jewelry [MJ], plastic toys, toys with paint or coating, and brittle/pliable toys; n = 32) were tested using the saliva extraction (mouthing) compartment of the DIN and RIVM bioaccessibility protocols to assess As, Ba, Cd, Cr, Cu, Mn, Ni, Pb, Sb, and Se mobilization via saliva. Total concentrations of As, Cd, Cu, Ni, Pb, and Sb were found elevated in analyzed samples. Four metals were mobilized to saliva from 16 MJ in significant quantities (>1 μg for highly toxic Cd and Pb, >10 μg for Cu and Ni). Bioaccessible concentrations and hazard index values for Cd exceeded limit values, for young children between 6 mo- and 3 yr-old and according to both protocols. Total and bioaccessible metal concentrations were different and not always correlated, encouraging the use of bioaccessibility for more accurate hazard assessments. Bioaccessibility increased with increasing extraction time. Overall, the risk from exposure to toxic elements via mouthing was high only for Cd and for MJ. Further research on children's exposure to toxic elements following ingestion of toy or jewelry material is recommended.

Pediatric collaborative networks for quality improvement and research

Despite efforts of individual clinicians, pediatric practices, and institutions to remedy continuing deficiencies in pediatric safety and health care quality, multiple gaps and disparities exist. Most pediatric diseases are rare; thus, few practices or centers care for sufficient numbers of children, particularly in subspecialties, to achieve large and representative sample sizes, and substantial between-site variation in care and outcomes persists. Pediatric collaborative improvement networks are multi-site clinical networks that allow practice-based teams to learn from one another, test changes to improve quality, and use their collective experience and data to understand, implement, and spread what works in practice. The model was initially developed in 2002 by an American Board of Pediatrics Workgroup to accelerate the translation of evidence into practice, improve care and outcomes for children, and to serve as the gold standard for the performance in practice component of Maintenance of Certification requirements. Many features of an improvement network derive from the Institute for Healthcare Improvement's collaborative improvement model Breakthrough Series, including focus on a high-impact condition or topic; providing support from clinical content and quality improvement experts; using the Model for Improvement to set aims, use data for feedback, and test changes iteratively; providing infrastructure support for data collection, analysis and reporting, and quality improvement coaching; activities to enhance collaboration; and participation of multidisciplinary teams from multiple sites. In addition, they typically include a population registry of the children receiving care for the improvement topic of interest. These registries provide large and representative study samples with high-quality data that can be used to generate information and evidence, as well as to inform clinical decision making. In addition to quality improvement, networks serve as large-scale health system laboratories, providing the social, scientific, and technical infrastructure and data for multiple types of research. Statewide, regional, and national pediatric collaborative networks have demonstrated improvements in primary care practice as well as care for chronic pediatric diseases (eg, asthma, cystic fibrosis, inflammatory bowel disease, congenital heart disease), perinatal care, and patient safety (eg, central line-associated blood stream infections, adverse medication events, surgical site infections); many have documented improved outcomes. Challenges to spreading the improvement network model exist, including the need for the identification of stable funding sources. However, these barriers can be overcome, allowing the benefits of improved care and outcomes to spread to additional clinical and safety topics and care processes for the nation's children.

Elevated mercury levels in pregnant woman linked to skin cream from Mexico

Mercury exposure during pregnancy can have serious health effects for a developing fetus including impacting the child's neurologic and cognitive development. Through biomonitoring in a low-income Latina population in California, we identified a patient with high levels of mercury and traced the source to face creams purchased in a pharmacy in Mexico.