Differences In Child Outcomes Research Articles

Child and Family Outcomes and Experiences Related to Family-Centered Care Interventions for Hospitalized Pediatric Patients: A Systematic Review.

Family-centered care (FCC) is the recommended model for pediatric inpatient care. Our overall aim was to conduct a narrative synthesis of the contemporary published research on the effectiveness of FCC interventions for pediatric inpatients. Our specific objective was to critique studies of inpatient pediatric FCC interventions that evaluated child or parent outcomes. We searched five databases (Pubmed, CINAHL, Embase, PsychInfo, and Web of Science) for peer-reviewed research published from 1 January 2017 to 6 February 2024. Independent reviewers evaluated each study based on pre-specified inclusion and exclusion criteria, then extracted and narratively synthesized the data. We found 16 studies of 15 interventions conducted in six countries. The studies were quantitative (n = 11), qualitative (n = 3), and mixed methods (n = 2), with most designs being of low to moderate quality based on a modified Mixed-Methods Appraisal Tool. Interventions included family-centered rounds, parent-focused health information technology, education, patient navigation, parent-peer support, partnership, and parent participation in caregiving. Most studies found significant improvements in parents' well-being, knowledge, and participation, as well as decreased stress and anxiety with the FCC interventions compared to usual care. One study found no differences in child outcomes (infant feeding, length of stay) between usual care and a parent-participation intervention. Although FCC interventions led to many improved outcomes for parents, there were few well-designed comparison studies using validated tools and well-defined interventions. Higher quality research is needed to promote greater uptake and sustainability of FCC interventions globally.

'School-based screen-and-treat': An effective blueprint for expediating access to care in children experiencing PTSD following disasters.

While 5%-10% of children exposed to natural disasters develop PTSD, few children access support. This paper reports on the proactive 'screen-and-treat' approach deployed following devastating floods in Queensland, Australia, in 2011 and presents results for children in the Lockyer Valley (the most impacted community). Open treatment study (2011-2012) within a government-funded post-disaster service response. One hundred and fifty children (7-12 years) completed pencil-and-paper screening (PTSD, anxiety and depression) at school. Eighty children endorsing either clinical levels of PTSD, or moderate levels of PTSD and clinical levels of either anxiety or depression, and their parents, completed a structured diagnostic interview. Forty-eight children were offered a free trauma-focused CBT intervention. The parents of 19 children accepted this offer. Most clinicians were clinical psychology trainees from local universities. All measures were repeated at post-treatment, 6- and 12-month follow-up. Note: The term 'parents' is used to refer to the wide variety of people serving as a child's primary caregiver. Pre-treatment, all children met diagnostic criteria for full (N = 17) or sub-clinical PTSD. By post-treatment, 10.5% met criteria for PTSD, with 0% meeting criteria at the 12-month follow-up. The incidence of anxiety and depressive disorders also reduced significantly. There were no differences in outcomes for children seen by trainees compared to experienced clinicians. A school-based screen-and-treat approach offers potential as a means of identifying and treating children following natural disaster exposure. However, engagement of families at the outset, and when offering intervention was challenging. Postgraduate trainees represent an effective potential workforce in a post-disaster environment.

Passive Range of Motion for Conservative Management of Brachial Plexus Birth Injury: A Survey of Expert Therapists

Brachial plexus birth injury (BPBI) occurs in almost 1/1000 live births potentially resulting in lifelong upper extremity weakness and joint contracture. Early referral and initiation of passive range of motion (PROM) are recommended but there is no standard of care to guide treatment. A descriptive survey study design was used to target occupational and physical therapists who work in brachial plexus clinics to identify current practices for early therapeutic intervention. With 26 respondents, therapists recommend initiating PROM by 4 wks of life performed at every diaper change. Seventy-four percent of therapists report differences in outcomes for children whose caregivers are more adherent, however, there was no significant relationship between frequency of PROM and outcomes. More outcome research is needed to identify an optimal frequency and duration, examine the efficacy of methods for parent education, and identify training methods to facilitate adherence.

Impacts of the beginning education: early childcare at home (BEECH) program for family child care providers and young children

This study evaluated the effectiveness of the Beginning Education: Early Childcare at Home (BEECH) intervention for family childcare providers and young children (infants, toddlers, and preschoolers). BEECH emphasizes the use of responsive caregiving practices that can be embedded in daily routines and interactions. Family child care providers (n = 154) were randomized to one of 3 conditions: BEECH (n = 54), BEECH+ (n = 45), or control (n = 55). Providers assigned to the BEECH and BEECH+ conditions received access to an online course and they attended in-person trainings; BEECH+ providers received additional coaching support. Approximately 5 children per family child care provider were included in the study, resulting in a total of 643 children (157 infants, 258 toddlers, and 228 preschoolers). Results showed that family child care providers who participated in the BEECH intervention (regardless of condition) showed significant improvements on the Teacher Behaviors Rating Scale's total score, classroom sensitivity, and oral language use domains relative to the control group. BEECH and BEECH+ groups demonstrated similar improvements in provider-level outcomes, suggesting few to no differences between the two instantiations. Finally, there were limited significant differences in child outcomes between the intervention and control groups.

Measurement matters: An individual differences examination of family socioeconomic factors, latent dimensions of children’s experiences, and resting state functional brain connectivity in the ABCD sample

The variation in experiences between high and low-socioeconomic status contexts are posited to play a crucial role in shaping the developing brain and may explain differences in child outcomes. Yet, examinations of SES and brain development have largely been limited to distal proxies of these experiences (e.g., income comparisons). The current study sought to disentangle the effects of multiple socioeconomic indices and dimensions of more proximal experiences on resting-state functional connectivity (rsFC) in a sample of 7834 youth (aged 9–10 years) from the Adolescent Brain Cognitive Development (ABCD) study. We applied moderated nonlinear factor analysis (MNLFA) to establish measurement invariance among three latent environmental dimensions of experience (material/economic deprivation, caregiver social support, and psychosocial threat). Results revealed measurement biases as a function of child age, sex, racial group, family income, and parental education, which were statistically adjusted in the final MNLFA scores. Mixed-effects models demonstrated that socioeconomic indices and psychosocial threat differentially predicted variation in frontolimbic networks, and threat statistically moderated the association between income and connectivity between the dorsal and ventral attention networks. Findings illuminate the importance of reducing measurement biases to gain a more socioculturally-valid understanding of the complex and nuanced links between socioeconomic context, children’s experiences, and neurodevelopment.

Outcomes of Pediatric Patients With Sepsis Related to Staphylococcus aureus and Methicillin-Resistant Staphylococcus aureus Infections Requiring Extracorporeal Life Support: An ELSO Database Study.

Background: Extracorporeal membrane oxygenation (ECMO) is increasingly utilized for pediatric sepsis unresponsive to steroids and inotropic support. Outcomes of children with sepsis are influenced by the type of pathogen causing their illness.Objective: To determine if the outcomes of children with Staphylococcus aureus sepsis receiving ECMO differed according to microbial sensitivity (Methicillin-resistant Staphylococcus aureus [MRSA] vs. Methicillin-sensitive Staphylococcus aureus [MSSA]).Methods: Retrospective case-matched cohort study of children (0–<18 years) with Staphylococcus aureus sepsis reported to the ELSO registry from more than 995 centers. Inclusion criteria were age 0–18 years, laboratory diagnosis of Staphylococcal infection, clinical diagnosis of sepsis, and ECMO deployment. Exclusion criteria were no laboratory diagnosis of Staphylococcal infection. We compared patient demographics, pre-ECMO management and outcomes of those with MRSA vs. MSSA using Chi-Square test, with independent samples t-test used to test to compare continuous variables.Results: In our study cohort of 308 patients, 160 (52%) had MSSA and 148 (48%) MRSA with an overall survival rate of 41.5%. There were no differences in the age group (p = 0.76), gender distribution (p = 0.1) or racial distribution (p = 0.58) between the two groups. P value for racial distribution should be 0.058. There were 91 (56.8%) deaths in the MSSA group and 89 (60.1%) deaths (p = 0.56) in the MRSA group. Duration on ECMO (p = 0.085) and the time from intubation to ECMO (p = 0.37) were also similar in the two groups. Survival with MSSA sepsis and MRSA sepsis did not improve significantly over the 20 years evaluated despite an increase in ECMO utilization.Conclusion: In this multi-center retrospective study, there were no differences in outcomes for children receiving ECMO support with Staphylococcus aureus sepsis according to microbial methicillin sensitivity. There was no significant increase in survival among patients with MRSA and MSSA infections receiving ECMO in the last 20 years.

Prenatal methadone exposure and child developmental outcomes in 2-year-old children.

To examine the developmental outcomes of children born to opioid-dependent females enrolled in methadone maintenance and identify pre- and postnatal factors that place these children at developmental risk. Ninety-nine methadone-maintained females and their 100 infants (42 females, 58 males, mean gestational age 38.8wks) were recruited during pregnancy/at birth and studied to age 2years alongside a regionally representative comparison group of 108 non-methadone-maintained females and their 110 infants (62 females, 48 males, mean gestational age 39.2wks). Information about perinatal exposure was collected from medical records, maternal urine and infant meconium toxicological analysis, maternal interviews (at birth and at 18mo), and a home visit (at 18mo). At age 2years, child neuromotor function, cognition, language, and emotional/behavioral dysregulation were assessed. Opioid-exposed children achieved lower motor, cognitive, and language scores and had poorer self, emotional, eating/feeding, and sensory processing regulation than unexposed children. After adjustment for maternal education and other substance use in pregnancy, between-group differences in child motor, cognitive, and overall dysregulation remained. Postnatal parental and family factors explained a further 40% to 52% of between-group differences in child outcomes. These children and families are extremely high-risk and need antenatal and postnatal support. Children exposed to opioids during pregnancy have pervasive developmental difficulties by age 2years. These challenges are largely explained by adverse pregnancy and socio-environmental exposures, emphasizing the importance of specialist prenatal care and postnatal intervention support. What this paper adds Children born to opioid-dependent females are at high risk of pervasive developmental problems. These problems span a range of functional domains, including motor, cognitive, language, and behavioral/emotional dysregulation. Contributing factors include other adverse pregnancy exposures, postnatal environmental factors, and the direct effects of prenatal opioid exposure.

Identifying patterns of physical activity and screen time parenting practices and associations with preschool children's physical activity and adiposity.

Although physical activity and screen time parenting practices influence children's behaviors, little work has examined how these practices work in combination. The purpose of this study was to identify patterns of physical activity and screen time parenting practices, and examine differences in preschool children's physical activity, sedentary behavior, and adiposity among the identified patterns. Data were collected in 2009-2012 from 319 parent-child dyads enrolled in a randomized trial testing a parent-focused obesity prevention intervention. At baseline, physical activity and screen time parenting practices were assessed using a validated self-report survey. Children's physical activity and sedentary behavior were measured using accelerometers and child anthropometrics were objectively measured. Latent profile analyses identified patterns of physical activity and screen time parenting practices. Differences in child outcomes were tested among the identified classes. Three parent classes were identified: Rewarders (n=165), Activity Supportive (n=98), and Screen Time Permissive (n=56). Rewarder parents were characterized by the highest scores on using physical activity and screen time to reward or control children's behavior. Activity Supportive parents generally had the highest scores on practices to promote physical activity, while Screen Time Permissive parents had the highest scores on practices facilitating screen time. There were no differences in the mean child physical activity, sedentary behavior or BMI z-score among the three classes. Findings revealed distinct classes of parents that could provide modifiable targets for family-based physical activity promotion, but more work is needed examining the influence of these patterns longitudinally and in different populations.

Parents' School Involvement in Kindergarten Predicting Child Outcomes at First Grade and Third Grade

Using the Early Childhood Longitudinal Study, Kindergarten Class of 2010–11 (ECLS-K:2011; N = 18,170), the present study aimed to identify latent classes of parents’ school involvement in kindergarten and whether the latent classes of parents’ school involvement would be differentially related to children’s academic achievement and social-emotional behavioral outcomes at first grade and third grade. Latent class analysis showed three classes: School Involvement, Low Involvement, and School Contact. Parents classified as School Involvement had higher probabilities in attending school events, such as back-to-school nights and parent–teacher conferences, but not school governance. Parents classified as Low Involvement had lower probabilities in all the indicators of school involvement. Parents classified as School Contact had higher probabilities in being contacted by teachers regarding their children’s behaviors and school performance. Few significant differences in child outcomes across the three classes persisted throughout first grade and third grade. Future research and implications are discussed.

Randomized Trial of a Computer-Assisted Intervention for Children With Autism in Schools

Computer-assisted interventions (CAIs) are popular for educating children with autism, but their effectiveness is not well established. This study evaluated the effectiveness of 1 CAI designed to improve children's language, cognitive, and academic skills, TeachTown: Basics, in a large urban school district. Teachers (n= 59) in autism support classrooms and their consented students in kindergarten through second grade (n= 154) were randomized to TeachTown: Basics or waitlist control. Child outcome was measured at baseline and after 1 academic year using the Bracken Basic Concepts Scale-Receptive and Expressive versions and the Differential Ability Scales, Second Edition (DAS-II). Random effects regression models that included clustering of time within students and students within classrooms were used to test whether the change over time in each outcome differed between groups. There were no statistically significant differences in outcomes for children who received TeachTown: Basics or treatment as usual. Increased time spent using TeachTown: Basics was associated with worse receptive language outcomes for children in the experimental group after 1 academic year. However, there was no association between minutes spent using TeachTown and changes in expressive language or DAS-II score. Despite growing enthusiasm for CAIs in autism treatment, the present findings indicate that CAI might not be effective at improving language and cognitive outcomes for children with autism spectrum disorder. The decision to implement CAIs in schools should be carefully balanced against the evidence for effectiveness of these programs. Schools might be better served by investing in treatment strategies with established evidence. RCT of TeachTown in Autism Support Classrooms: Innovation and Exnovation; https://clinicaltrials.gov/; NCT02695693.

Are grandparents a blessing or a burden? Multigenerational coresidence and child-related spending

Economic investments in children may represent a powerful mechanism to explain differences in child outcomes across family types. Unfortunately, evidence on child-related spending across family structures remains poorly understood. Using the Consumer Expenditure Survey (1996–2015), this study is the first to investigate patterns of child-related spending in an increasingly common type of extended family household: multigenerational households, in which children reside with at least one parent and grandparent. This study also contributes to a growing literature giving primacy to parents' socioeconomic disadvantage as moderating the association between multigenerational relationships and child well-being. Results indicate that, when compared to similar two-generation households, multigenerational households are associated with increased spending on education and with decreased spending on child care. Differences in child-related spending between multigenerational and two-generation households differ according to parents' income and relationship status. Overall, living with grandparents represents an adaptive strategy that helps low-income or single parents invest more money in their children's education, hobbies and activities, and to save on the costs of child care.

Treatment of preschool children presenting to the emergency department with wheeze with azithromycin: A placebo-controlled randomized trial.

BackgroundAntibiotics are frequently used to treat wheezing children. Macrolides may be effective in treating bronchiolitis and asthma.MethodWe completed a prospective, double-blinded, randomized placebo-control trial of azithromycin among pre-school children (12 to 60 months of age) presenting to the emergency department with wheeze. Patients were randomized to receive either five days of azithromycin or placebo. Primary outcome was time to resolution of respiratory symptoms after treatment initiation. Secondary outcomes included the number of days children used a Short-Acting Beta-Agonists during the 21 day follow-up and time to disease exacerbation during the following six months (unscheduled health care visit or treatment with an oral corticosteroid for acute respiratory symptoms).ResultsOf the 300 wheezing children recruited, 222 and 169 were analyzed for the primary and secondary outcomes, respectively. The treatment groups had similar demographics and clinical parameters at baseline. Median time to resolution of respiratory symptoms was four days for both treatment arms (interquartile range (IQR) 3,6; p = 0.28). Median number of days of Short-Acting Beta-Agonist use among those who received azithromycin was four and a half days (IQR 2, 7) and five days (IQR 2, 9; p = 0.22) among those who received placebo. Participants who received azithromycin had a 0.91 hazard ratio for time to six-month exacerbation compared to placebo (95% CI 0.61, 1.36, p = 0.65). A pre-determined subgroup analysis showed no differences in outcomes for children with their first or repeat episode of wheezing. There was no significant difference in the proportion of participants experiencing an adverse event.ConclusionAzithromycin neither reduced duration of respiratory symptoms nor time to respiratory exacerbation in the following six months after treatment among wheezing preschool children presenting to an emergency department. There was no significant effect among children with either first-time or prior wheezing.

Using Linked Administrative Data to Examine the Educational Outcomes of Children in Care in Manitoba

ABSTRACT&#x0D; ObjectivesManitoba has one of the highest rates of children in out-of-home care in the world. Our aims were to: 1) describe characteristics of children in care; 2) determine differences in educational outcomes for children in care, children receiving in-home protection services and children not involved with child welfare; and, 3) identify factors contributing to educational success for children in care.&#x0D; ApproachPopulation-level administrative data from the Population Health Research Data Repository at the Manitoba Centre for Health Policy, were used. Several data sources were linked together at an individual level: child welfare services (e.g., in care, in-home services; hospital birth records (e.g., birth weight, gestational age); health status (e.g., from hospitalizations, physician visits); family risk factors (e.g., maternal prenatal smoking and/or drinking, maternal education); family characteristics (e.g., number of children in family, receipt of income assistance); education assessments at kindergarten, grades 3, 7, 8, 9 and 12. Children in care from 1998 onward were included. Number of children analyzed differed depending on the educational outcome examined: e.g., analyses at kindergarten include 1,893 children in care, 4,229 children receiving in-home services, and 32,280 children not involved with child welfare services; for high school completion these numbers were 11,234, 40,671, and 162,265 respectively. Multivariate regressions identified characteristics associated with educational outcomes for children in care.&#x0D; ResultsOver one-third of children in care first entered care as infants, and of those, close to half were apprehended at birth. 5.5% of children in Manitoba spent some time in care before their 15th birthday, with an almost tenfold difference for Indigenous (16.6%) and non-Indigenous (1.7%) children. Across the range of educational outcomes, children in care did more poorly than children receiving in-home services, who in turn did more poorly than children with no child welfare involvement. For example, only 33.4% of children in care completed high school compared to 66.8% of children receiving in-home services and 89.3% of children with no child welfare involvement. Adjusting covariates reduced differences but all remained statistically significant. Factors associated with positive outcomes for children in care differed depending on the outcome and included measures like poverty (at Kindergarten, p&lt;0.05; at high school, p&lt;0.0001) and total number of care placements (at Kindergarten, p&lt;0.05; at grade 9, p&lt;0.01).&#x0D; ConclusionsChildren in care are at risk of experiencing poor educational outcomes, from school entry onwards. Identifying factors associated with educational success for children in care can inform policy and program development.

Communication outcomes of children with hearing loss enrolled in programs implementing different educational approaches: A systematic review

Following the diagnosis of hearing loss in a child, parents are required to make a number of important decisions, including the type of educational approach to adopt in intervention. Many professionals hold strong biases about the various educational approaches, which can make it difficult for parents to make informed decisions. A systematic review was conducted to address two main aims. First, to examine the communication outcomes of children with hearing loss enrolled in programs that follow an auditory-oral, auditory-verbal, total communication, simultaneous communication, or a bilingual–bicultural approach. Second, to investigate whether there are differences in outcomes for children enrolled in different programs. A systematic search of peer-reviewed journal articles published in English between 2000 and 2014 was conducted in five electronic databases. Additional articles were identified by perusing the reference lists of selected papers. A total of 835 records were retrieved through the systematic search. After screening of full-text papers, 14 articles reporting on 10 studies were selected for inclusion in the review and assessed with a critical appraisal tool. Data synthesis indicated that communication outcomes in children with hearing loss are highly variable, and evidence regarding the impact of different educational approaches on outcomes is inconclusive. It is important that professionals talk to parents about the uncertainties related to child outcomes, as well as discuss the possible advantages and disadvantages of each educational approach. The review highlights the need to make recommendations for educational approach based on the needs and goals of individual families, rather than being influenced by ideologies.

Breastfeeding and maternal alcohol use: Prevalence and effects on child outcomes and fetal alcohol spectrum disorders.

Determine any effects that maternal alcohol consumption during the breastfeeding period has on child outcomes. Population-based samples of children with fetal alcohol spectrum disorders (FASD), normally-developing children, and their mothers were analyzed for differences in child outcomes. Ninety percent (90%) of mothers breastfed for an average of 19.9 months. Of mothers who drank postpartum and breastfed (MDPB), 47% breastfed for 12 months or more. In case control analyses, children of MDPB were significantly lighter, had lower verbal IQ scores, and more anomalies in comparisons controlling for prenatal alcohol exposure and final FASD diagnosis. Utilizing a stepwise logistic regression model adjusting for nine confounders of prenatal drinking and other maternal risks, MDPB were 6.4 times more likely to have a child with FASD than breastfeeding mothers who abstained from alcohol while breastfeeding. Alcohol use during the period of breastfeeding was found to significantly compromise a child's development.

Migrant children and migrants' children: Nativity differences in school enrollment in Mexico and the United States.

BACKGROUNDThe growing prevalence of migrant children in diverse contexts requires a reconsideration of the intergenerational consequences of migration. To understand how migration and duration of residence are associated with children’s schooling, we need more comparative work that can point to the similarities and differences in outcomes for children across contexts.OBJECTIVEThis paper addresses the importance of nativity and duration of residence for children’s school enrollment on both sides of a binational migration system: The United States and Mexico. The analyses are designed to determine whether duration of residence has a similar association with school enrollment across these different settings.METHODSThe analyses are based on nationally representative household data from the 2010 Mexican Census and the 2006–2010 American Community Survey. Logistic regression models compare school enrollment patterns of Mexican and U.S.-born children of Mexican origin in the United States and those of Mexican and U.S.-born children in Mexico. Interactions for nativity/duration of residence and age are also included.RESULTSThe results demonstrate that, adjusting for household resources and household-level migration experience, Mexican-born children in the United States and U.S.-born children in Mexico, particularly those who arrived recently, lag behind in school enrollment. These differences are most pronounced at older ages.CONCLUSIONSThe comparisons across migration contexts point to greater school attrition and non-enrollment among older, recent migrant youth, regardless of the context. The interactions suggest that recent migration is associated with lower schooling for youth who engage in migration at older ages in both the United States and Mexico.

Do Factors Other than SES Explain Differences in Child Outcomes Between Children of Teenage and Older Mothers for Off-Reserve First Nations Children?

This study used data from the Aboriginal Children’s Survey (ACS) to explore differences in behavioural outcomes for First Nations children born to teen and older mothers living off-reserve in Canada. Of particular interest was an examination of socio-economic and contextual influences, and their contributions to differences in child outcomes. Findings from this study demonstrate that off-reserve First Nations children born to teen mothers (aged 12 - 19 years when they started childbearing) had poorer behavioural outcomes compared to off-reserve First Nations children born to older mothers (aged 25 and over when they started childbearing). These differences were found for emotional symptoms, inattention and hyperactivity, and conduct disorder scores, but not for prosocial behaviours. Contextual factors differed for children born to teen mothers as compared to older mothers, but parenting behaviors and the number of people involved in raising the child was similar for both groups. While differences in the behaviour of children born to teen mothers are often attributed to poorer socio-economic conditions, this study demonstrates that other contextual factors (e.g., breastfeeding, social support, screen time, residential mobility) may be as important as socio-economic factors in their contribution to the behavioural outcomes of children of teen mothers.

Reply to Tamma &amp; Cosgrove and Esposito

TO THE EDITOR—We are grateful for the comments of Drs Tamma and Cosgrove [1] on the issue of duration of therapy, particularly as it impacts antibiotic exposure in the child and the community. Greater antibiotic exposure is associated with greater antimicrobial resistance and also adds to costs and toxicities of therapy. This particular issue prompted considerable discussion within the writing group. However, with no scientific evidence in children from randomized controlled trials or even high-quality observational studies conducted in North American centers, the extrapolated data from community-acquired pneumonia (CAP) in adults, well-reviewed by Tamma and Cosgrove, was not felt to be of sufficient relevance to make these recommendations for children. Although children may have fewer comorbid conditions than adults, our guidelines do review the many other differences, including the relative immune incompetence in preschool-aged children compared with adults, as well as the role of viral coinfections. Differences in outcomes for children compared with adults with urinary tract infections highlight the challenges of extrapolating adult treatment protocols to children [2]. However, we certainly agree with the critical importance of this issue and included it as one of our research priorities, as provided in our Table 10: “Develop clinical trial designs that can provide information on the lowest effective antimicrobial dose for the shortest duration of therapy to decrease the development of antimicrobial resistance and the risk of antimicrobial toxicity.” Although the guidelines are unable to address the duration of antibiotic therapy based on adequate evidence, they do emphasize the importance of viral infection as a cause of pneumonia in the preschool-aged child and state that “antimicrobial therapy is not routinely required for preschool-aged children with CAP, because viral pathogens are responsible for the great majority of clinical disease.” We believe that if this recommendation is followed, it will significantly decrease the use of inappropriate antimicrobials in children and is well aligned with the goals expressed by Drs Tamma and Cosgrove. We also thank Dr Esposito for her letter citing 8 concerns regarding the Executive Summary of the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America clinical practice guidelines on the management of CAP in children >3 months [3, 4]. In her review of the Executive Summary, she may have overlooked the reference (p 618) to the full-text electronic article for the guidelines that provides a detailed description of the methods, background, and, most important, the Evidence Summaries that support each recommendation. The comments and questions she raises are all addressed within the full text that is available online (doi: 10.1093/cid/cir531).

Non-cognitive child outcomes and universal high quality child care

Exploiting a rich panel data child survey merged with administrative records along with a pseudo-experiment generating variation in the take-up of preschool across municipalities, we provide evidence of the effects on non-cognitive child outcomes of participating in large scale publicly provided universal preschool programs and family day care vis-à-vis home care. We find that, compared to home care, being enrolled in preschool at age three does not lead to significant differences in child outcomes at age seven no matter the gender or the mother's level of education. Family day care, on the other hand, seems to significantly deteriorate outcomes for boys whose mothers have a lower level of education. Finally, longer hours in non-parental care lead to poorer child outcomes.

Ethnic Variation in the Association Between Family Structures and Practices on Child Outcomes at 36 Months: Results From Early Head Start

Research Findings: This study analyzed data from the Early Head Start Research and Evaluation Study (EHSRES) to examine whether the association between family structural characteristics (maternal education, number of parents, employment status, and number of children), parenting practices (sensitive and negative parenting, cognitively stimulating home environment, authoritarian parenting), and children's outcomes (receptive language, cognitive development, and problem behaviors) differ across ethnicity. A sample of 2,777 low-income families included 39% European Americans/Whites, 36% African Americans, and 25% Hispanics. Results indicated ethnic differences in some family structural characteristics, parenting practices, and child outcomes. With the exception of employment status, there was limited evidence that ethnic differences in family structural characteristics were related to differences in child outcomes. Though there were also ethnic differences in parenting practices, there was no evidence that ethnicity moderated the relation between parenting practices and children's language, cognitive, and behavioral outcomes at 36 months. Practice or Policy: The implication of this study is the need to foster and focus on positive parenting practices, rather than negatives ones, because of their importance to children's language, cognitive development, and behavior management. Ethnic differences may matter, but they may not in the face of other stressors such as economic fears, job instability, health concerns, and neighborhood safety.