Urban Pediatric Clinic Research Articles

A six-year repeated evaluation of computerized clinical decision support system user acceptability

ObjectiveLong-term acceptability among computerized clinical decision support system (CDSS) users in pediatrics is unknown. We examine user acceptance patterns over six years of our continuous computerized CDSS integration and updates. Materials and methodsUsers of Child Health Improvement through Computer Automation (CHICA), a CDSS integrated into clinical workflows and used in several urban pediatric community clinics, completed annual surveys including 11 questions covering user acceptability. We compared responses across years within a single healthcare system and between two healthcare systems. We used logistic regression to assess the odds of a favorable response to each question by survey year, clinic role, part-time status, and frequency of CHICA use. ResultsData came from 380 completed surveys between 2011 and 2016. Responses were significantly more favorable for all but one measure by 2016 (OR range 2.90–12.17, all p < 0.01). Increasing system maturity was associated with improved perceived function of CHICA (OR range 4.24–7.58, p < 0.03). User familiarity was positively associated with perceived CDSS function (OR range 3.44–8.17, p < 0.05) and usability (OR range 9.71–15.89, p < 0.01) opinions. ConclusionWe present a long-term, repeated follow-up of user acceptability of a CDSS. Favorable opinions of the CDSS were more likely in frequent users, physicians and advanced practitioners, and full-time workers. CHICA acceptability increased as it matured and users become more familiar with it. System quality improvement, user support, and patience are important in achieving wide-ranging, sustainable acceptance of CDSS.

Stepped Care Interpersonal Psychotherapy Treatment for Depressed Adolescents: A Pilot Study in Pediatric Clinics.

Adolescents with depression are at risk for negative long-term consequences and recurrence of depression. Many do not receive nor access treatment, especially Latino youth. New treatment approaches are needed. This study examined the feasibility and acceptability of a stepped collaborative care treatment model (SCIPT-A) for adolescents with depression utilizing interpersonal psychotherapy for adolescents (IPT-A) and antidepressant medication (if needed) compared to Enhanced Treatment as Usual (E-TAU) in urban pediatric primary care clinics serving primarily Latino youth. Results suggest the SCIPT-A model is feasible, acceptable and potentially beneficial for urban Latino adolescents. Clinicians delivered the SCIPT-A model with fidelity using supervision successfully implemented in a community setting.

Walk-in Model for Ill Care in an Urban Academic Pediatric Clinic

ObjectivesSince the Institute of Medicine's 2001 charge to reform health care, there has been a focus on the role of the medical home. Access to care in the proper setting and at the proper time is central to health care reform. We aimed to increase the volume of patients receiving care for acute illnesses within the medical home rather than the emergency department or urgent care center from 41% to 60%. MethodsWe used quality improvement methods to create a separate nonemergency care stream in a large academic primary care clinic serving 19,000 patients (90% Medicaid). The pediatric primary care (PPC) walk-in clinic opened in July 2013 with service 4 hours per day and expanded to an all-day clinic in October 2013. Statistical process control methods were used to measure the change over time in the volume of ill patients and visits seen in the PPC walk-in clinic. ResultsAverage weekly walk-in nonemergent ill-care visits increased from 61 to 158 after opening the PPC walk-in clinic. The percentage of nonemergent ill-care visits in the medical home increased from 41% to 45%. Visits during regular clinic hours increased from 55% to 60%. Clinic cycle time remained unchanged. ConclusionsImplementation of a walk-in care stream for acute illness within the medical home has allowed us to provide ill care to a higher proportion of patients, although we have not yet achieved our predicted volume. Matching access to demand is key to successfully meeting patient needs.

Food Allergy and Anxiety and Depression among Ethnic Minority Children and Their Caregivers

To investigate the relationship between food allergy and symptoms of anxiety and depression among ethnic minority, low socioeconomic status (SES) children and their caregivers. Pediatric patients ages 4-12 years with and without food allergy and their caregivers were recruited from urban pediatric outpatient clinics. Statistical analyses were used to examine the prevalence of symptoms of anxiety and depression among patients and their caregivers with and without food allergy, adjusting for asthma. Eighty patients ranging from ages 4 to 12 years, with a mean age of 8.1 years, and their caregivers participated in the study. Food allergy was associated with significantly higher t scores on the Multidimensional Anxiety Scale for Children (MASC) Total (P = .007), MASC Humiliation Rejection, (P = .02) and MASC Social Anxiety (P = .02) among pediatric patients, adjusting for asthma. Food allergy was not associated with child depression symptoms, nor was there a significant difference in anxiety or depression symptoms among caregivers of patients with and without food allergy. Food allergy appears to be associated with increased symptoms of social anxiety and higher levels of anxiety overall, but not depression, in ethnic minority children of lower socioeconomic status. This finding was not due to confounding by asthma. Food allergy was not associated with higher levels of depression or anxiety symptoms among caregivers of pediatric patients with food allergy. Future studies should investigate potential pathways between food allergy and anxiety that may be unique to children in underserved populations, and develop interventions to reduce anxiety in children with food allergy.

Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency

ObjectiveHispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents. MethodsCross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged ≤8 years with health literacy and LEP data (n = 1126). Parents were randomized to 1 of 5 groups that varied by pairing of units of measurement on the label/dosing tool. Each parent measured 9 doses (3 amounts [2.5, 5, 7.5 mL] using 3 tools [2 syringes in 0.2 or 0.5 mL increments, and 1 cup]) in random order. Dependent variable was a dosing error of >20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0–3; adequate = 4–6) and LEP (speaks English less than “very well”). ResultsA total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7–2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1–1.9]). ConclusionsDosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.

Parent Preferences and Perceptions of Milliliters and Teaspoons: Role of Health Literacy and Experience

Background and ObjectivesA recent American Academy of Pediatrics policy statement recommends milliliter-exclusive dosing for pediatric liquid medications. Little is known about parent preferences regarding units, perceptions about moving to milliliters only, and the role of health literacy and prior milliliter-dosing experience. MethodsCross-sectional analysis of data collected as part of a randomized controlled study in 3 urban pediatric clinics (SAFE Rx for Kids study). English- and Spanish-speaking parents (n = 493) of children aged ≤8 years were randomized to 1 of 4 study arms and given labels and dosing tools which varied in label instruction format (text plus pictogram, text only) and units (milliliter only [“mL”], milliliter/teaspoon [“mL”/“tsp”]). Outcomes included teaspoon preference in dosing instructions and perceived difficulty with milliliter-only dosing. The predictor variable was health literacy (Newest Vital Sign; low [0–1], marginal [2–3], adequate [4–6]). The mediating variable was prior milliliter-dosing experience. ResultsOver two-thirds of parents had low or marginal health literacy. The majority (>70%) preferred to use milliliters, perceived milliliter-only dosing to be easy, and had prior milliliter-dosing experience; 11.5% had a teaspoon preference, 18.1% perceived milliliter-only dosing will be difficult, and 17.7% had no prior milliliter-dosing experience. Parents with lower health literacy had a higher odds of having a teaspoon preference (low vs adequate: adjusted odds ratio [AOR] = 2.9 [95% confidence interval [CI] 1.3–6.2]), and greater odds of perceiving difficulty with milliliter-only dosing (low vs adequate: AOR = 13.9 [95% CI 4.8–40.6], marginal vs adequate: AOR = 7.1 [95% CI 2.5–20.4]). Lack of experience with milliliter dosing partially mediated the impact of health literacy. ConclusionsMost parents were comfortable with milliliter-only dosing. Parents with low health literacy were more likely to perceive milliliter-only dosing to be difficult; educational efforts will need to target this group to ensure safe medication use.

Can We Identify Parents Who Do Not Verbally Share Concerns for Their Children's Development?

We aimed to identify characteristics of parents who do not voice developmental concerns when prompted by their children's nurse and/or primary care provider (PCP), despite reporting concerns on parent-completed questionnaires. We reviewed 376 medical records of children seen for a 9-month well-child visit in an urban pediatric clinic between September 2011 and December 2012 for sociodemographic variables hypothesized to affect parents' sharing of developmental concerns: the child's birth order and gender; parents' education level, employment, relationship status, and primary language; and family size and racial/ethnic background. The target population was parents who reported concerns on the Parents' Evaluation of Developmental Status (PEDS), a routinely administered, parent-completed screening questionnaire. We subdivided parents who reported concerns on the PEDS (N = 86) based on whether they voiced developmental concerns when prompted by their children's nurse and/or PCP. Two-sided Fisher's exact tests and logistic regression evaluated the relationship between sociodemographic variables and parents' voicing of developmental concerns. Only parent education approached significance, as parents with less than a high school education (<HS) were more likely to not voice concerns for their children's development than parents with at least a high school degree or equivalent (≥HS) (63% compared to 35%, p = .056). Univariate logistic regression analysis showed that parents with <HS were 3.238 (1.085-9.663, 95% CI, p = .035) times more likely to not verbally share developmental concerns than those with ≥HS. Parents with low educational attainment may be more likely to not verbally share their developmental concerns. For children of such parents, early detection of developmental delay may be strengthened by use of written questionnaires.

Improving Adolescent Preventive Care in an Urban Pediatric Clinic: Capturing Missed Opportunities

PurposeTo increase the proportion of adolescents with Medicaid who receive preventive care services in an urban pediatric clinic. MethodsA quality improvement intervention was implemented at an urban pediatric primary care clinic between November 2013 and October 2014. The intervention systematically “flipped” acute visits into well-care visits for patients ages 12–21 years, when overdue. The primary process measure was the percentage of acute visits expanded to include well-care components out of total eligible opportunities. The primary outcome measure was adolescent well-care (AWC) completion in 2014 versus 2013 and 2012. ResultsAmong 857 adolescents with Medicaid, 124 additional AWC visits were completed by October 2014 compared to 2013 and 71 additional visits compared to 2012. The gap to achieving Healthcare Effectiveness Data and Information Set neutral zone targets for AWC was reduced by 59% compared to 2013 and by 54% compared to 2012. The mean proportion of eligible acute opportunities “flipped” monthly increased from 17% (range: 10%–21%) during the initial 3 months of implementation to 30% (range: 5%–50%) in the last 3 months. ConclusionsSystematically flipping acute visits into well visits resulted in reaching Healthcare Effectiveness Data and Information Set quality targets for AWC, which had not previously been accomplished by this clinic. Incorporating staff and provider feedback strengthened intervention fidelity and buy-in despite time constraints in a busy, urban setting.

Use of a low-literacy written action plan to improve parent understanding of pediatric asthma management: A randomized controlled study

ABSTRACTObjectives: The objective of the study was to determine whether parents who use a low-literacy, pictogram- and photograph-based written asthma action plan (WAAP) have a better understanding of child asthma management compared to parents using a standard plan. Methods: A randomized controlled study was carried out in 2 urban pediatric outpatient clinics. Inclusion criteria were English- and Spanish-speaking parents of 2- to 12-year-old asthmatic children. Parents were randomized to receive a low-literacy or standard asthma action plan (American Academy of Allergy, Asthma and Immunology) for a hypothetical patient on controller and rescue medications. A structured questionnaire was used to assess whether there was an error in knowledge of (1) medications to give everyday and when sick, (2) need for spacer use, and (3) appropriate emergency response to give albuterol and seek medical help. Multiple logistic regression analyses were performed, adjusting for parent age, health literacy (Newest Vital Sign); child asthma severity, medications; and site. Results: 217 parents were randomized (109 intervention and 108 control). Parents who received the low-literacy plan were (1) less likely to make an error in knowledge of medications to take everyday and when sick compared to parents who received the standard plan (63.0 vs. 77.3%, p = 0.03; adjusted odds ratio [AOR] = 0.5[95% confidence interval: 0.2–0.9]) and (2) less likely to make an error regarding spacer use (14.0 vs. 51.1%, p < 0.001; AOR = 0.1 [0.06–0.3]). No difference in error in appropriate emergency response was seen (43.1 vs. 48.1%, p = 0.5). Conclusions: Use of a low-literacy WAAP was associated with better parent understanding of asthma management. Further study is needed to assess whether the use of this action plan improves child asthma outcomes.

Neighborhood and Parental Influences on Diet and Physical Activity Behaviors in Young Low-Income Pediatric Patients.

This study explores the relationship between neighborhood characteristics and caregiver preferences for establishing diet and physical activity behaviors among low-income African American and Hispanic young children (2-5 years). Primary caregivers of young children were recruited from 2 urban pediatric clinics to participate in focus groups (n = 33). Thematic analysis of transcripts identified 3 themes: neighborhood constraints on desired behaviors, caregivers' strategies in response to neighborhoods, and caregivers' sense of agency in the face of neighborhood constraints. This study elucidates the dynamic relationship between neighborhoods and caregiver preferences, their interrelated impacts on establishment of diet and physical activity behaviors among young children, and the important role of caregiver agency in establishing behaviors among young children. To effectively address obesity disparities among young children, primary care behavioral interventions must leverage and support such resilient caregiver responses to neighborhood constraints in order to optimally address racial/ethnic and socioeconomic disparities in obesity among young children.

Maternal Experiences in a Parenting Group Delivered in an Urban General Pediatric Clinic.

Untreated perinatal mood and anxiety disorders can result in impaired maternal-infant interactions. Pediatricians have a unique opportunity to identify and support mothers with mood and anxiety disorders. A parenting intervention, Circle of Security, was delivered in a pediatric clinic targeting women with mood and anxiety disorders. A qualitative assessment of the program's acceptability, participant engagement, and general experiences was conducted. Data collection included medical record abstraction, semistructured psychiatric diagnostic interviews, and semistructured questionnaires. Findings indicate Circle of Security is a feasible and practical approach to providing parenting support to women of young children with mood and anxiety disorders in the pediatric medical home. Additional larger studies will be helpful in tracking outcomes of participating women and infants and in further aiding pediatricians in teaching about attachment and emotions, empowering mothers to talk about their struggles, and ensuring support for mothers in reflecting on their emotions and experiences that affect parenting.

Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment.

Poorly designed labels and packaging are key contributors to medication errors. To identify attributes of labels and dosing tools that could be improved, we examined the extent to which dosing error rates are affected by tool characteristics (ie, type, marking complexity) and discordance between units of measurement on labels and dosing tools; along with differences by health literacy and language. Randomized controlled experiment in 3 urban pediatric clinics. English- or Spanish-speaking parents (n = 2110) of children ≤8 years old were randomly assigned to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. Each parent measured 9 doses of medication (3 amounts [2.5, 5, and 7.5 mL] and 3 tools [1 cup, 2 syringes (0.2- and 0.5-mL increments)]), in random order. Outcome assessed was dosing error (>20% deviation; large error defined as > 2 times the dose). A total of 84.4% of parents made ≥1 dosing error (21.0% ≥1 large error). More errors were seen with cups than syringes (adjusted odds ratio = 4.6; 95% confidence interval, 4.2-5.1) across health literacy and language groups (P < .001 for interactions), especially for smaller doses. No differences in error rates were seen between the 2 syringe types. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used (adjusted odds ratio = 1.2; 95% confidence interval, 1.01-1.4). Recommending oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors.

Teaching About Better Family-Clinician Partnerships in High-Risk Pediatric Asthma Care.

Family–clinician partnership including communication, trust, respect, and power leveling is essential in pediatrics. Our case study illustrates elements supporting/hindering partnership in a high-risk urban pediatric asthma clinic. Data from observation of a 100-minute visit were qualitatively analyzed by applying codes to themes, using family-centered principles. Three key categories emerged from examining interactions and their sequencing: (1) partnership supported, (2) partnership missed, and (3) partnership hindered. Practitioners must become more sensitive to families’ lives and skilled in family-centered care delivery. Clinician education about partnership can help with negotiating workable treatment strategies for complex conditions such as asthma and reduce health disparities.

Parenting and Preschooler TV Viewing in Low-Income Mexican Americans: Development of the Parenting Practices Regarding TV Viewing (PPRTV) Scale.

To develop and test a comprehensive, culturally based measure of parenting practices regarding television (TV) viewing in low-income Mexican-American mothers of preschoolers. Low-income Mexican-American female primary caregivers of preschoolers were recruited in urban safety-net pediatric clinics during the 2013 to 2014 academic year. Items on parenting practices regarding TV viewing were developed from a prior scale, review of the literature, and results from semistructured interviews. Items were administered by phone, and analyses included evaluation of the factor structure and psychometric properties of a 40-item measure of parenting practices regarding TV viewing (PPRTV). Using exploratory factor analysis, a 7-factor model emerged as the best fit for the data representing the following domains of parenting practices: time restriction, behavioral control, instructive practices, coviewing, planful restriction, reactive content restriction, and commercial endorsement. Internal reliabilities were acceptable (Cronbach's alpha >.75). Correlations among the resulting subscales were small to moderate (rs = 0.01-0.43). Subscales were correlated with child TV viewing amounts: time restriction (-0.14, p < .05); behavioral control (0.27, p < .001); coviewing (0.16, p < .01); planful restriction (-0.20, p < .001); and commercial endorsement (0.11, p < .05), which provides support for construct validity. The PPRTV scale measures 7 domains of parenting practices and has good initial reliability and validity. It allows investigators to conduct more in-depth evaluations of the role parents play in socializing young children on TV use. Results of such work will be important to informing the design of interventions aiming to ensure healthy screen media habits in young children.

Content Validity of the Child Nutrition and Physical Activity Screening Tool

The content validity of the Child Nutrition and Physical Activity (CNPA) screening tool was determined. A cross sectional design using survey methods was used to collect input from experts about the CNPA. Experts were asked to evaluate items in each of six CNPA domains for theoretical relevance, clinical significance, clarity in wording, and cohesiveness via email. Eleven experts in pediatric weight management or questionnaire development reviewed the CNPA. Ten of the 11 experts were registered dietitians and nine of the 11 had a PhD. The experts have been in the field from one to 30 years, majority being in the field 20 years. The CNPA consists of 22 items in six domains: dietary behavior, screen time, physical activity, confidence, importance, and perception. Proportion of experts who agreed domain items met criteria was calculated with 50% or more agreeing meeting criteria. Fifty percent and more of the experts agreed that all CNPA domains were theoretically relevant, clinically significant, and were cohesive. Less than 50% of experts agreed that there was clarity in wording in the confidence, importance, and perception CNPA domains. The CNPA may still need changes to increase content validity. This will mean further testing and development need to be done before a valid screening tool is created that can be used by health care providers in an urban pediatric primary care clinic.

Feasibility of Picture-Based Asthma Medication Plans in Urban Pediatric Outpatient Clinics.

Picture-based Asthma Action Plans show promise for overcoming parental literacy barriers and improving child asthma outcomes, but it is uncertain how parents respond to pictures of specific medications, which may be particularly important for improving disease self-management. Thus, we assessed parent attitudes toward an asthma-related picture-based medication plan (PBMP) in an urban academic pediatric clinic and examined attitudes by literacy level. Surveys were administered to a convenience sample of parents of children presenting to an urban pediatric pulmonary clinic for asthma consultation between March and August 2011. The Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) was administered to parents. Parents indicated their level of agreement with 9 statements on the potential usefulness of the PBMP: (1) before being shown a PBMP; and (2) after seeing the doctor. McNemar's tests showed that the proportion of high-literate parents (≥9th grade reading level) who endorsed the potential benefits of the PBMP after the clinical encounter was significantly higher than before the clinical encounter. A high proportion of low-literate parents (<9th grade reading level) consistently endorsed the PBMP before and after the clinical encounter. Among a diverse sample seen in an urban asthma clinic, parents of all literacy levels endorse PBMPs as useful, especially after using them in clinical encounters.

Identification and Clinical Characterization of Children With Benign Ethnic Neutropenia.

Benign ethnic neutropenia (BEN) is an asymptomatic condition reported in adults of African and Middle Eastern descent. The clinical description in children is currently lacking. In our urban outpatient pediatric hematology clinic, the median neutrophil count of children with BEN was lower than previous reports in adults at 893×10 cells/L, but increased with older age. There was an equal male to female ratio and 24% of our BEN children reported ethnicities other than African or Middle Eastern. Children with BEN had a clinical course comparable with other healthy children including otherwise normal blood counts, except for mild anemia.

Health literacy and disease-specific knowledge of caregivers for children with sickle cell disease

ABSTRACTThis study was conducted to measure the health literacy (HL) and disease-specific knowledge (DSK) of caregivers for children with sickle cell disease (SCD) and relate them to their child's health care utilization. The authors conducted a cross-sectional study of caregiver-child dyads attending an urban pediatric sickle cell clinic. Caregivers were administered the Shortened Test of Functional Health Literacy (S-TOFHLA) and a locally developed DSK questionnaire. Retrospective review of the child's electronic medical record (EMR) was performed to determine annual emergency department (ED) visits and hospitalizations. A total of 142 caregiver-child dyads were recruited for the study. Less than 5% of caregivers had limited HL, with less education (P =.03) and primary language other than English (P =.04) being the only risk factors. Although caregiver HL was not associated with ED visits or hospitalizations, surprisingly DSK was. Caregivers with higher DSK scores had children with higher annual rates of ED utilization (P =.002) and hospitalizations (P =.001), and these children were also more likely to be classified as high ED utilizers (≥4 visits per year; P =.01). Further, caregiver adherence to medication and clinic visits was associated with their child's age (P =.01). Although HL and DSK are both constructs that measure basic health understanding, they differently affect caregivers' ability to navigate and understand the health care system of children with chronic illnesses. This study suggests that the DSK/health care utilization relationship may be a more important measure than HL for programs following children with sickle cell disease and could also have applications in other pediatric chronic diseases.

Developmental status of preschool children receiving cART: a descriptive cohort study.

HIV is known to cause neurodevelopmental problems in infants and young children. The impact of HIV on the development of preschool-age children has been less well described. The study was conducted at an urban paediatric HIV clinic in Johannesburg, South Africa. A sample of convenience was used. Sixty-eight medically stable children between the ages of 3 and 5 years were assessed with the Griffiths Scales of Mental Development. Children were excluded from the study if they had severe HIV encephalopathy, which made it impossible for them to participate in the items on the Griffiths Scales of Mental Development. The children had started combination antiretroviral treatment (cART) at a mean age of 8.1 months. The majority of the children were virologically suppressed and did not present with wasting or stunting. Severe overall developmental delay (z-scores < -2SD) was detected in 55.88% of children. Developmental facets related to speech, cognition and perception were the most severely affected. Personal-social development was the least affected with only 13.4% of the children demonstrating severe delay. Despite having early access to cART, children infected with HIV are still at risk for severe developmental delay across a number of facets. Very early initiation of cART may help alleviate this problem. All preschool children infected with HIV should have routine developmental screening.

Breastfeeding among Latino Families in an Urban Pediatric Office Setting.

Objective. To determine the breastfeeding rate of Latino infants at an urban pediatric clinic in the first six months of life and to identify factors associated with breastfeeding. Methods. Investigators conducted a retrospective chart review of infants seen at the clinic in 2014 as part of a mixed methods study. Topics reviewed included demographics, infant health data, and feeding methods at 5 points in time. Bivariate correlations and cross-tabulations explored associations between variables. Results. Most of the mothers (75%) fed their newborns with both breastfeeding and formula (las dos). At 6 months, a majority were formula-fed only (55.9%). Approximately 10% of mothers exclusively breastfed their newborns, and the trend of exclusive breastfeeding remained steady through the 6-month visit. Over time, the number of mothers who exclusively bottle-feed their infants steadily rises. There were no statistical differences among the feeding method groups with regard to birth order of child, number of adults or children in the household, vaccination rate, number of sick visits, or infants' growth. Conclusions. More targeted attention to this population and other immigrant populations with culturally tailored interventions spanning the prenatal to early infancy periods could increase exclusive breastfeeding and ultimately improve child health.