• Home
  • News
  • Calendar
  • About DF/HCC
  • Membership
  • Visitor Center

Member Resources



Pediatrics RSS feed -- current issue

The first evaluation of the economic impact of all vaccines in the routine US childhood immunization schedule assessed the 2001 schedule (excluding pneumococcal conjugate and influenza vaccines) and documented substantial cost savings over the lifetimes of the cohort of children born in 2001.

This report updates our previous evaluation, and estimates the costs and benefits of vaccinating the cohort of children born in 2009. We include vaccines routinely recommended for children in 2009. (Read the full article)

Previous studies have confirmed feasibility of MRI for diagnosis of appendicitis in adults and children. No study has assessed clinical end points when using ultrasound and MRI compared with computed tomography for diagnosis of appendicitis in children.

Radiation-free imaging with ultrasound selectively followed by MRI does not change clinical endpoints compared with CT for diagnosing appendicitis in children, with no difference in time to antibiotic administration, time to appendectomy, negative appendectomy rate, perforation rate, or length of stay. (Read the full article)

Kidney transplantation is the optimal treatment of children with end-stage renal disease. The field of pediatric kidney transplantation has changed over time with regard to immunosuppression, surgical technique, organ allocation policy, and rates of living donor transplantation.

Outcomes after pediatric kidney transplantation in the United States have improved over time, independent of changes in recipient, donor, and transplant characteristics. These improvements were most dramatic within the first posttransplant year and among the most highly sensitized patients. (Read the full article)

The pediatric mental health burden is substantial, with >4 million children meeting criteria for a mental health disorder. Mental health is a key priority for national pediatric inpatient quality measures, but little is known about admitted patients and their diagnoses.

Nationally, nearly 10% of hospitalizations in children >3 years are for primary mental health diagnoses. The most common and costly are depression, bipolar disorder, and psychosis. Fewer free-standing children’s hospitalizations (3%) were for mental health admissions, although diagnostic distributions were similar. (Read the full article)

Recent studies have shown that participating in the Supplemental Nutrition Assistance Program (SNAP) is associated with improved household food security. With the exception of 1 descriptive analysis, studies have not examined how SNAP affects children’s food security.

This article estimates the association between SNAP and children’s food security using the largest, most rigorous national study of food security to date. Given current proposals to reduce program size, this study underscores SNAP’s importance in affecting children’s well-being. (Read the full article)

Motor vehicle crashes, heavy drinking, and drug use are serious, interactive health concerns for the teenage population. Teenage alcohol-impaired driving behaviors are associated with heavy drinking, parenting practices, and exposure to drinking and driving.

Earliness of exposure to alcohol/drug impaired driving (DWI) and early licensure were independent risk factors for teenage DWI. A strong, positive dose-response existed between DWI and amount of prior exposure to DWI in the form of riding with an impaired driver. (Read the full article)

Adolescents and young adults consume a significant amount of health care resources in our current medical system. With the Patient Protection and Affordable Care Act, a much larger number of previously uninsured young adults (aged ≥19) will be covered.

The Military Health System provides valuable information about the health utilization patterns of adolescents and young adults (aged 12–22) with universal insurance and excellent access to care. This information may help us understand the impact of new health care legislation. (Read the full article)

Concussions in youth are a common injury evaluated in the emergency department (ED). Early recognition and active management of this mild traumatic brain injury are important to safe recovery. Tools to assess and manage concussion in the ED are lacking.

Acute Concussion Evaluation tools, modified for ED use, improved reported follow-up with primary care or concussion specialists and adherence to recommendations. Barriers to follow-up remain and the importance of ongoing outpatient management should be stressed. (Read the full article)

After mild traumatic brain injury, most youth recover well. A minority of patients report persistent symptoms, which relate to both injury and noninjury factors. In adult studies, validity test performance is 1 noninjury factor that relates to persistent symptoms.

This is the first pediatric study to demonstrate that validity test failure is associated with increased symptoms after mild traumatic brain injury. The findings suggest that some symptoms conceptualized as injury-related "postconcussive" problems are better explained by exaggeration or feigning. (Read the full article)

Little is known about the epidemiology and pathogenicity of Clostridium difficile infection among children, particularly those aged ≤3 years in whom colonization is common and pathogenicity uncertain.

Young children, 1 to 3 years of age, had the highest Clostridium difficile infection incidence. Considering that clinical presentation, outcomes, and disease severity were similar across age groups, C difficile infection in the youngest age group likely represents true disease and not asymptomatic colonization. (Read the full article)

Approximately 50% of children diagnosed with attention-deficit/hyperactivity disorder (ADHD) at <7 years of age in the community do not meet criteria for ADHD over time. There is a need to examine predictors of diagnostic stability in young children with ADHD.

Predictors of diagnostic stability from early to middle childhood include child’s baseline externalizing and internalizing symptoms, parental history of psychopathology, and socioeconomic status. These predictors may guide treatment planning at the time of ADHD diagnosis. (Read the full article)

Childhood attention-deficit/hyperactivity disorder has been associated with both childhood and adult obesity, whereas treatment with stimulants has been associated with delayed child growth. No longitudinal studies with details about dates of diagnosis, treatment, and duration of stimulant use have been published.

Using electronic health record data, this was the first study to evaluate the independent associations of attention-deficit/hyperactivity disorder diagnosis, stimulant treatment, age at first stimulant use, and duration of stimulant use on longitudinal BMI trajectories throughout childhood and adolescence. (Read the full article)

Many parenting Web sites encourage use of infant "sleep machines" to play ambient noise while infants sleep. Noise recommendations for hospital nurseries suggest a limit of 50 A-weighted dB, whereas occupational standards limit exposure times for noise >85 A-weighted dB.

We measured the maximum sound level outputs of infant sleep machines and found that several devices are capable of producing levels that may be damaging to infant hearing and may be detrimental to auditory development. (Read the full article)

Many children experience the death of a parent during childhood. The long-term consequences of this life event, including school performance, and the importance of the psychosocial circumstances of the home have not been well elucidated in previous studies.

Both maternal and paternal deaths during childhood were associated with lower grades and school failure. Many of the associations (and especially for death due to external causes) were associated with socioeconomic disadvantage and psychosocial problems in the family. (Read the full article)

We previously reported that parents of children enrolled in genomic research made more restrictive data sharing (DS) decisions than adults. The ethics of pediatric DS have been discussed, but reasons for differences in decision-making have not been explored.

We present an empirically based discussion of attitudes toward and preferences for DS obtained from structured interviews of adult patients and parents of pediatric patients enrolled in genomic research studies. Parents expressed more concern about future risks than adult participants. (Read the full article)

Guidelines recommend that primary care physicians provide preventive dental services to young children. Most state Medicaid programs reimburse physicians for providing fluoride varnish. Individual-level studies show that these services are effective in reducing caries-related treatments and costs.

Preventive dental services provided through a North Carolina Medicaid preventive dental program led to a reduction in dental caries among young children statewide. Programs targeting vulnerable populations through medical offices can reduce disparities in oral health among preschool-aged populations. (Read the full article)

Maintaining high levels of measles-mumps-rubella immunization is an important public health priority that has been threatened by discredited claims about the safety of the vaccine. Relatively little is known about what messages are effective in overcoming parental reluctance to vaccinate.

Pro-vaccine messages do not always work as intended. The effectiveness of those messages may vary depending on existing parental attitudes toward vaccines. For some parents, they may actually increase misperceptions or reduce vaccination intention. (Read the full article)

Mobile devices are ubiquitous in children’s lives, but how caregivers and children use them in everyday situations, and how use of devices affects caregiver–child interactions, has not been studied.

In naturalistic mealtime observations, we documented the behavior of many caregivers whose attention was highly absorbed in their mobile devices, with varying child reactions to this absorption. This study raises several hypotheses about mobile device use and caregiver-child interaction. (Read the full article)

Little is known about how thirdhand smoke beliefs are related to smoking and quitting behaviors, and how parental smokers’ thirdhand smoke beliefs influence behaviors to protect children. A previous study suggests thirdhand smoke beliefs are associated with home smoking bans.

This is the first study to show that parents’ beliefs about thirdhand smoke are associated with multiple smoking-related attitudes and behaviors that affect the health of children. (Read the full article)

Although expert consensus and previous literature document the importance of early feeding and activity behaviors and practices in preventing obesity and the risks of early rapid weight gain, few studies have rigorously assessed obesity-related behaviors by caregivers of infants.

This study demonstrates the high prevalence of behaviors thought to increase risk for obesity in a diverse, large sample of parent/2-month-old dyads and finds that many behaviors vary by race and ethnicity, suggesting the potential for culturally tailored interventions. (Read the full article)

Existing literature indicates relationships between BMI, physical activity, sleep patterns, eating behavior, and health-related quality of life in children and adolescents. However, many previous studies have used non–preference-based instruments, which are not suitable for application within economic evaluation.

The Child Health Utility 9D, a new preference-based health-related quality of life instrument for application in economic evaluation in children and adolescents, revealed stronger associations between utilities and sleep patterns or eating behavior than with BMI, physical activity, or sedentary behavior. (Read the full article)

Physical activity interventions aimed at improving body composition in childhood have had limited success and often targeted overweight children. Therefore, the efficacy of physical activity randomized controlled trials in improving body composition among children with varying adiposity levels remains unknown.

This randomized controlled trial demonstrated that a physical activity program designed to meet daily physical activity recommendations can improve cardiorespiratory fitness, decrease total fat mass, and prevent accumulation of central adiposity in a group of children with varying adiposity levels. (Read the full article)

Individuals living in Mediterranean countries have historically had a lower risk of cardiovascular disease. Important changes in diet and lifestyle have taken place in these countries in recent years, and it is unknown how these changes might influence current cardiovascular health.

Fitness and fatness levels indicate that urban adolescents from southern Europe are less healthy than those from central northern Europe. The extent to which these differences might be explained by physical activity, diet, and genetics is analyzed and discussed in this article. (Read the full article)

Resistance exercise is known to have a robust effect on glycemic control and cardiometabolic health among children and adolescents, even in the absence of weight loss.

Normalized strength capacity is associated with lower cardiometabolic risk clustering in boys and girls, even after adjustment for cardiorespiratory fitness, level of physical activity, and BMI. (Read the full article)

Diarrhea still remains as a significant cause of morbidity and mortality. Intervention to reduce this risk are needed. Evidence on the effect of Lactobacillus reuteri DSM 17938 to prevent diarrhea in children is scarce.

In healthy children attending day care centers, daily administration of L reuteri DSM 17938 had a significant effect in reducing episodes and duration of diarrhea and respiratory tract infections, with consequent cost saving for the community. (Read the full article)

Scabies is a frequent cause of consultation and has recently been classified as a neglected disease. The clinical presentation seems to be linked with age, although no specific study has aimed to delineate the clinical spectrum of scabies in infants and children.

Scabies in infants and children has distinct clinical features. This prospective observational study found that infants were more likely to have relapse, nodules, and to present involvement with extremities, face, and scalp, arguing for specific cares in this age group. (Read the full article)

Ceftriaxone at therapeutic doses can lead to renal stone formation.

Renal stone formation with ceftriaxone therapy can result in postrenal acute renal failure in children. The condition can be treated effectively by timely pharmacotherapy or retrograde ureteral catheterization with good prognosis. (Read the full article)

Asthma is a clinical condition treated mostly at primary care community clinics. Epidemics of asthma exacerbation occur annually with return to school after summer vacation and have been reported in many countries, including Israel.

In 82 234 asthmatic children, unscheduled primary care physician visits and drug prescriptions for asthma exacerbations peaked in September after a summer trough, with a lesser peak in late autumn and fluctuations through the winter months. (Read the full article)

The familial nature of vesicoureteral reflux (VUR) is well recognized. Several studies have shown that siblings of children with VUR are at much higher risk for reflux than the general pediatric population with a reported prevalence between 26% and 50%.

There is increased risk of renal cortical abnormalities in siblings with a previous urinary tract infection, siblings with high-grade VUR, and siblings >1 year of age. This information may be useful when counseling parents about the risk of familial VUR. (Read the full article)

Diabetic ketoacidosis (DKA) is a life-threatening condition and often the presenting symptom of newly diagnosed type 1 or type 2 diabetes in youth. SEARCH previously reported that the prevalence of DKA at diagnosis was 25.5% in 2002–2003.

DKA in youth with type 1 diabetes remains a problem, with almost one-third presenting with DKA. Among youth with type 2 diabetes, DKA was less common and decreased by ~10% per year, suggesting improved detection or earlier diagnosis. (Read the full article)

Individuals with DiGeorge syndrome (DGS) have varying degrees of immunodeficiency. All are susceptible to vaccine-preventable infections with serious complications. Although live vaccines are generally contraindicated in this population, limited evidence suggests that they may be effective and safe for select individuals.

Many individuals with DGS received live vaccines despite having a known diagnosis. Adverse events following live immunizations were typically minor and self-limited, suggesting that live vaccines may be considered for patients with DGS who exhibit mild-to-moderate immunosuppression. (Read the full article)

Preterm infants have transiently lowered thyroid hormone levels during the early postnatal period. Past research suggests that low thyroid hormone levels are related to cognitive and developmental deficits in children born preterm.

Contrary to expectations, in this study of children born <30 weeks’ gestation, higher concentrations of free thyroxine over the first 6 weeks of life were associated with poorer cognitive function at 7 years of age. (Read the full article)

Initial studies in children and young adults have identified higher levels of anxiety and lower quality of life scores in patients with implantable cardioverter–defibrillators. Few studies are available looking at the same questions in young patients with pacemakers.

Anxiety is highly prevalent in young patients with ICDs, but the higher rates can be attributed to medical disease severity and age at implantation rather than type of device. Patients with pacemakers have depression and anxiety but at lower rates. (Read the full article)

Physical activity is beneficial to health. Parents are crucial in shaping children’s behaviors, with active mothers appearing to have active children. Little is known about this association in preschool-aged children, or about factors influencing activity in mothers of young children.

Mother-child physical activity levels were positively associated and influenced by temporal and demographic factors. Maternal activity levels were low, and influences differ by activity intensity. Health promotion efforts to increase activity in mothers may also benefit their young children. (Read the full article)

Integrated or collaborative care intervention models have revealed gains in provider care processes and outcomes in adult, child, and adolescent populations with mental health disorders. However optimistic, conclusions are not definitive due to methodologic limitations and a dearth of studies.

This randomized trial provides further evidence for the efficacy of an on-site intervention (Doctor Office Collaborative Care) coordinated by care managers for children's behavior problems. The findings provide support for integrated behavioral health care using novel provider and caregiver outcomes. (Read the full article)

The period of transition from childhood to adulthood and the period immediately after transfer of care is a challenging time for young people with kidney failure.

Young patients with kidney failure cared for exclusively in adult-oriented facilities experience increased rates of avoidable hospitalizations during late adolescence and young adulthood. Avoidable hospitalizations increased among pediatric kidney failure patients during the years immediately after transfer to adult care. (Read the full article)

Prenatal lipid-based nutrient supplementation has been demonstrated to increase birth length. However, the impact of this intervention on infant growth and morbidity is unknown.

Infants from mothers who were given prenatal lipid-based nutrient supplements showed decelerated linear growth. The gain in length at birth related to prenatal lipid-based nutrient supplementation was not sustained during infancy. (Read the full article)

The incidence of Kawasaki disease is increasing in many countries. The only reported Australian incidence (3.4/100 000 <5 years) is almost 20 years old and the current Australian epidemiology and outcomes are unknown.

We analyzed 30 years’ total population hospitalization data from Western Australia. Kawasaki disease incidence increased markedly from 1979 to 2009 and is currently 9.34/100 000 <5 years. The epidemiology and cardiovascular outcomes are similar to other predominantly European-Caucasian populations. (Read the full article)


To evaluate the economic impact of the 2009 routine US childhood immunization schedule, including diphtheria and tetanus toxoids and acellular pertussis, Haemophilus influenzae type b conjugate, inactivated poliovirus, measles/mumps/rubella, hepatitis B, varicella, 7-valent pneumococcal conjugate, hepatitis A, and rotavirus vaccines; influenza vaccine was not included.


Decision analysis was conducted using population-based vaccination coverage, published vaccine efficacies, historical data on disease incidence before vaccination, and disease incidence reported during 2005 to 2009. Costs were estimated using the direct cost and societal (direct and indirect costs) perspectives. Program costs included vaccine, administration, vaccine-associated adverse events, and parent travel and work time lost. All costs were inflated to 2009 dollars, and all costs and benefits in the future were discounted at a 3% annual rate. A hypothetical 2009 US birth cohort of 4 261 494 infants over their lifetime was followed up from birth through death. Net present value (net savings) and benefit-cost ratios of routine childhood immunization were calculated.


Analyses showed that routine childhood immunization among members of the 2009 US birth cohort will prevent ~42 000 early deaths and 20 million cases of disease, with net savings of $13.5 billion in direct costs and $68.8 billion in total societal costs, respectively. The direct and societal benefit-cost ratios for routine childhood vaccination with these 9 vaccines were 3.0 and 10.1.


From both direct cost and societal perspectives, vaccinating children as recommended with these vaccines results in substantial cost savings.


Cross-sectional imaging increases accuracy in diagnosing appendicitis. We hypothesized that a radiation-free imaging pathway of ultrasonography selectively followed by MRI would not change clinical end points compared with computed tomography (CT) for diagnosis of acute appendicitis in children.


We retrospectively reviewed children (<18 years old) who had diagnostic imaging for suspected acute appendicitis between November 2008 and October 2012. Before November 2010 CT was used as the primary imaging modality (group A); subsequently, ultrasonography was the primary imaging modality followed by MRI for equivocal findings (group B). Data collected included time from triage to imaging and treatment and results of imaging and pathology.


Six hundred sixty-two patients had imaging for suspected appendicitis (group A = 265; group B = 397, of which 136 [51%] and 161 [41%], respectively, had positive imaging for appendicitis). Negative appendectomy rate was 2.5% for group A and 1.4% for group B. Perforation rate was similar for both groups. Time from triage to antibiotic administration and operation did not differ between groups A and B. There was higher proportion of positive imaging and appendectomies in group A and thus more negative imaging tests in group B (ultrasonography and MRI), but diagnostic accuracy of the 2 imaging pathways was similar.


In children with suspected acute appendicitis, a radiation-free diagnostic imaging of ultrasonography selectively followed by MRI is feasible and comparable to CT, with no difference in time to antibiotic administration, time to appendectomy, negative appendectomy rate, perforation rate, or length of stay.


To investigate changes in pediatric kidney transplant outcomes over time and potential variations in these changes between the early and late posttransplant periods and across subgroups based on recipient, donor, and transplant characteristics.


Using multiple logistic regression and multivariable Cox models, graft and patient outcomes were analyzed in 17 446 pediatric kidney-only transplants performed in the United States between 1987 and 2012.


Ten-year patient and graft survival rates were 90.5% and 60.2%, respectively, after transplantation in 2001, compared with 77.6% and 46.8% after transplantation in 1987. Primary nonfunction and delayed graft function occurred in 3.3% and 5.3%, respectively, of transplants performed in 2011, compared with 15.4% and 19.7% of those performed in 1987. Adjusted for recipient, donor, and transplant characteristics, these improvements corresponded to a 5% decreased hazard of graft loss, 5% decreased hazard of death, 10% decreased odds of primary nonfunction, and 5% decreased odds of delayed graft function with each more recent year of transplantation. Graft survival improvements were lower in adolescent and female recipients, those receiving pretransplant dialysis, and those with focal segmental glomerulosclerosis. Patient survival improvements were higher in those with elevated peak panel reactive antibody. Both patient and graft survival improvements were most pronounced in the first posttransplant year.


Outcomes after pediatric kidney transplantation have improved dramatically over time for all recipient subgroups, especially for highly sensitized recipients. Most improvement in graft and patient survival has come in the first year after transplantation, highlighting the need for continued progress in long-term outcomes.


Inpatient pediatric mental health is a priority topic for national quality measurement and improvement, but nationally representative data on the patients admitted or their diagnoses are lacking. Our objectives were: to describe pediatric mental health hospitalizations at general medical facilities admitting children nationally; to assess which pediatric mental health diagnoses are frequent and costly at these hospitals; and to examine whether the most frequent diagnoses are similar to those at free-standing children’s hospitals.


We examined all discharges in 2009 for patients aged 3 to 20 years in the nationally representative Kids’ Inpatient Database (KID) and in the Pediatric Health Information System (free-standing children’s hospitals). Main outcomes were frequency of International Classification of Diseases, Ninth Revision, Clinical Modificationdefined mental health diagnostic groupings (primary and nonprimary diagnosis) and, using KID, resource utilization (defined by diagnostic grouping aggregate annual charges).


Nearly 10% of pediatric hospitalizations nationally were for a primary mental health diagnosis, compared with 3% of hospitalizations at free-standing children’s hospitals. Predictors of hospitalizations for a primary mental health problem were older age, male gender, white race, and insurance type. Nationally, the most frequent and costly primary mental health diagnoses were depression (44.1% of all mental health admissions; $1.33 billion), bipolar disorder (18.1%; $702 million), and psychosis (12.1%; $540 million).


We identified the child mental health inpatient diagnoses with the highest frequency and highest costs as depression, bipolar disorder, and psychosis, with substance abuse an important comorbid diagnosis. These diagnoses can be used as priority conditions for pediatric mental health inpatient quality measurement.


This article investigates the association between Supplemental Nutrition Assistance Program (SNAP) participation and child food security by using data from the largest national survey of the food security of SNAP participants to date.


The analysis used a survey of nearly 3000 households with children and a quasi-experimental research design that consisted of 2 sets of comparisons. Using a cross-sectional sample, we compared information collected from SNAP households within days of program entry with information collected from a contemporaneous sample of SNAP households that had participated for ~6 months. Next, by using a longitudinal sample, we compared baseline information collected from new-entrant SNAP households with information from those same households 6 months later. Multivariate logistic regression analysis was used to estimate associations between SNAP and child food security.


SNAP participation was associated with an approximately one-third decrease in the odds of children being food insecure in both samples. In the cross-sectional analysis only, SNAP was also associated with a decrease in the odds of children experiencing severe food insecurity (designated very low food security). Findings were qualitatively robust to different empirical specifications.


After controlling for other possible confounders, we found children in households that had participated in SNAP for 6 months experienced improvements in food security. On the basis of these findings, we conclude SNAP serves a vital role in improving the health and well-being of low-income children by increasing food security. Future research is needed to determine whether specific groups of children experience differential improvements in food security.


To examine the association between driving while alcohol/drug impaired (DWI) and the timing and amount of exposure to others’ alcohol/drug-impaired driving (riding while impaired [RWI]) and driving licensure timing among teenage drivers.


The data were from waves 1, 2, and 3 (W1, W2, and W3, respectively) of the NEXT Generation Study, with longitudinal assessment of a nationally representative sample of 10th graders starting in 2009–2010. Multivariate logistic regression was used for the analyses.


Teenagers exposed to RWI at W1 (adjusted odds ratio [AOR] = 21.12, P < .001), W2 (AOR = 19.97, P < .001), and W3 (AOR = 30.52, P < .001) were substantially more likely to DWI compared with those reporting never RWI. Those who reported RWI at 1 wave (AOR = 10.89, P < .001), 2 waves (AOR = 34.34, P < .001), and all 3 waves (AOR = 127.43, P < .001) were more likely to DWI compared with those who never RWI. Teenagers who reported driving licensure at W1 were more likely to DWI compared with those who were licensed at W3 (AOR = 1.83, P < .05).


The experience of riding in a vehicle with an impaired driver increased the likelihood of future DWI among teenagers after licensure. There was a strong, positive dose-response association between RWI and DWI. Early licensure was an independent risk factor for DWI. The findings suggest that RWI and early licensure could be important prevention targets.


Adolescents and young adults are frequently uninsured (9.0% and 26.4%). Under the Affordable Care Act, the impact of insuring this population on health care utilization is unclear. We examined insurance records from >3.5 million non-pregnancy-related primary care visits in the Military Health System to describe health care utilization patterns among 467 099 non–active duty patients, aged 12 to 22, with access to free health care.


We described association of age and gender with primary care utilization rates, clinic type, and primary and secondary diagnoses.


Adolescents and young adults were seen for 2.63 primary care visits per year. Use of Pediatric Clinics declined with age (51.6% to 1.8%) and increased for Family Medicine (45.5% to 91.1%). The top 3 diagnostic groups in our study were health maintenance (18.3%), health evaluation (17.3%), and respiratory/ear, nose, and throat (15.1%). Age-by-gender interactions had a significant association with health care utilization rates and diagnoses at primary care appointments. For example, the percent of all appointments accounted for by musculoskeletal injuries increased significantly (P < .001) with age for males (10.6%, 12–14 years; 12.8%, 15–18 years; 15.2%, 19–22 years) and decreased for females (10.3%, 9.2%, 7.5%).


Unlike previous studies of adolescents and young adults, we show that this population, especially female young adults, does use health care when it is available and largely free. Extrapolating from our Military Health System data, we expect implementation of the Affordable Care Act will result in an increased demand for health care, particularly in the areas of reproductive health care, respiratory/ear, nose, and throat issues, and routine health maintenance.


Accurate recognition of pediatric concussion in the emergency department (ED) is important to ensure appropriate management for safe recovery. The study objective was to determine whether the Centers for Disease Control and Prevention’s Acute Concussion Evaluation (ACE) tools, modified for ED use, improved patient follow-up and post-injury behaviors.


The original ACE tools (ACE, ACE Care Plan) were modified for ED use via Delphi methodology with an expert panel and implemented in 2 urban pediatric EDs for patients aged 5 to 21 years evaluated within 24 hours of a head injury. Pre- (February 2009 to July 2009) and post- (December 2009 to June 2010) implementation, patient phone surveys were conducted 1, 2, and 4 weeks after ED discharge. Reported rates of patient follow-up and recovery measures were analyzed. ED clinician adherence was assessed.


During the study, 164 patients were enrolled pre-implementation and 190 post-implementation. The mean patient age was 10.6 years (SD, 3.7); 65% were males, 49% were African American, and 46% were Caucasian. Post-implementation, 58% of patients received the modified ACE diagnostic tool and 84% received the modified ACE discharge instructions. Follow-up was improved at all time points (32% vs 61% at week 4; P < .001; odds ratio, 3.4; 95% confidence interval, 2.1–5.4). Post-implementation, parental recall of discharge instructions was significantly increased, patient’s mean total post-concussion symptom score was significantly higher, and report of return to normal activity was significantly longer.


The ACE tools, modified for ED use, were successfully implemented in the pediatric ED. Post-implementation, increased patient follow-up and improved recall of and adherence to ED discharge recommendations was demonstrated.


A minority of pediatric patients who have mild traumatic brain injury (mTBI) report persistent postconcussive symptoms. In adults, failure on validity tests, which help to detect exaggerated or feigned problems, is associated with symptom complaints. No pediatric studies have examined the relationship between validity test performance and symptom report. We hypothesized that children failing a validity test would report significantly more postconcussive symptoms than those passing.


Using a consecutive clinical case series design, we examined 191 patients aged 8 to 17 years seen for neuropsychological evaluation after mTBI. Participants were administered a validity test (Medical Symptom Validity Test; MSVT) and completed a graded symptom scale as part of a neuropsychological battery.


A total of 23 participants (12%) failed the MSVT. The Fail group endorsed significantly more postconcussive symptoms than the Pass group, with a large effect size (P < .001; d = 1.1). MSVT performance remained a robust unique predictor of symptom report even after controlling for other influential factors (eg, female gender, premorbid psychiatric problems).


A subset of children who had persistent complaints after mTBI may be exaggerating or feigning symptoms. If such negative response bias remains undetected, errors in etiologic statements and less than optimal treatment may occur. Because the detection of invalid responding is well established in neuropsychology, clinical neuropsychologists should be incorporated routinely into clinical care for patients who have persistent complaints. To better control for noninjury effects in future pediatric mTBI studies, researchers should add validity tests to neurobehavioral outcome batteries.