Management of Acute Otitis Media by Primary Care Physicians: Trends Since the Release of the 2004 American Academy

of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline Louis Vernacchio, Richard M. Vezina and Allen A. Mitchell Pediatrics 2007;120;281 DOI: 10.1542/peds.2006-3601

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2007 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLE

Management of Acute Otitis Media by Primary Care Physicians: Trends Since the Release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline
Louis Vernacchio, MD, MSc, Richard M. Vezina, MPH, Allen A. Mitchell, MD Slone Epidemiology Center at Boston University, Boston, Massachusetts
The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVES. In 2004, the American Academy of Pediatrics and the American Academy of Family Physicians released a clinical practice guideline on the management of acute otitis media that included endorsement of an observation option for selected cases and recommendations of specic antibiotics. We sought to describe primary care physicians current management of acute otitis media to compare it with the guidelines recommendations and describe trends since 2004. DESIGN. We used a mail survey from March through June 2006 within the Slone Center Ofce-Based Research Network, a national practice-based pediatric research network. RESULTS. The response rate was 299 (62.7%) of 477. The observation option was

www.pediatrics.org/cgi/doi/10.1542/ peds.2006-3601 doi:10.1542/peds.2006-3601

Key Words otitis media, antibiotics, clinical practice guidelines, primary care Abbreviations AOMacute otitis media AAPAmerican Academy of Pediatrics AAFPAmerican Academy of Family Physicians SCORSlone Center Ofce-Based Research
Accepted for publication Mar 22, 2007 Address correspondence to Louis Vernacchio, MD, MSc, Slone Epidemiology Center, 1010 Commonwealth Ave, Boston, MA 02215. Email: lvernacchio@slone.bu.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2007 by the American Academy of Pediatrics

considered reasonable by 83.3%, compared with 88.0% in 2004, and was used in a median of 15% of acute otitis media cases over the previous 3 months. The most common physician-identied barriers to the use of the observation option were parental reluctance (83.5%) and the cost and difculty of follow-up of children who do not improve (30.9%). In terms of antibiotic choices for acute otitis media, agreement with the guidelines antibiotic recommendation for 4 common clinical scenarios was as follows: high-dose amoxicillin for acute otitis media with nonsevere symptoms (57.2%), high-dose amoxicillin-clavulanate for acute otitis media with severe symptoms (12.7%), high-dose amoxicillin-clavulanate for cases that failed to respond to amoxicillin (42.8%), and intramuscular ceftriaxone for cases that failed to respond to treatment with amoxicillin-clavulanate (16.7%). Each of these proportions declined from 2004.
CONCLUSIONS. Most primary care physicians accept the concept of an observation option for acute otitis media but use it only occasionally. Antibiotics prescribed for acute otitis media differ markedly from the guidelines recommendations, and the difference has increased since 2004.

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ESPITE BEING ONE of the most common illnesses for which children are brought to physicians, acute otitis media (AOM) remains a management challenge for primary care providers. This is especially true given 2 important trends in AOM management. First, the concept of initial observation without antibiotic treatment has been adopted as standard practice in some parts of the world1 and has begun to achieve acceptance in the United States as well.26 Second, the widespread emergence of antimicrobial resistance has increased the urgency to reduce antibiotic use and, when antibiotic treatment is chosen, has made the choice of antibiotic more difcult. In May 2004, in response to these issues, the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) jointly issued a clinical practice guideline entitled Diagnosis and Management of Acute Otitis Media.7 The guideline endorsed an observation option for selected children with AOM, specically considering it an option for those 2 years old with nonsevere symptoms or an uncertain diagnosis and for those 6 months to 2 years old with both nonsevere symptoms and an uncertain diagnosis. The guideline also made specic antibiotic recommendations for various common AOM scenarios, including high-dose amoxicillin as rst-line treatment for most children, high-dose amoxicillin-clavulanate as rst-line treatment for children with severe symptoms (moderate-to-severe otalgia or fever of 39C), and various specic antibiotics for those whose conditions failed to respond to rstline treatment. In October 2004, we surveyed the physician-members of the Slone Center Ofce-Based Research (SCOR) Network to determine their familiarity with the guideline and to compare their practices with the guidelines recommendations in several key areas.8 We now describe follow-up survey data from the same group of physicians collected 2 years after the publication of the guideline and 18 months after our initial survey.

Approximately 6 weeks later, we sent a second survey to nonresponders, half by mail and half by fax, determined randomly. After another 6 weeks, we called the ofce of each nonresponder to verify the contact information and faxed a third survey to the ofce. To analyze open-ended responses about barriers to the use of the observation option, 1 investigator (Dr Vernacchio) reviewed the responses and created categories to which he assigned each response; a second investigator (Dr Mitchell) independently assigned each response to a category. When the investigators did not agree or when there were 5 responses in a category, the response was coded as other. Proportions were calculated as the number of each given response divided by the total number of valid responses. Comparisons of proportions between groups were performed by 2 analysis or, when the analysis was limited to responders to both the 2004 and 2006 surveys, by McNemars test for paired observations. Comparison between 2004 and 2006 of the median proportion of cases in which physicians used the observation option was performed by using Wilcoxon signed ranks test. SAS 9 (SAS Institute, Inc, Cary, NC) software was used for all analyses. The study was approved by the Boston University Medical Campus Institutional Review Board. RESULTS Four hundred eighty-nine surveys were mailed; 7 were undeliverable because the physician had relocated and a current address could not be determined, 3 physicians were no longer practicing primary care, and 2 others had retired. Two hundred ninety-nine completed surveys were received, for a response rate of 62.7%. Among the 299 respondents, 207 also responded to our 2004 survey. Nonresponders did not differ signicantly from responders by gender, practice setting, region, or specialty (data not shown). The demographics of the responders are shown in Table 1. Overall, 249 (83.3%) believed the observation option was reasonable for some children with AOM, whereas 50 (16.7%) did not. The proportion who accepted the observation option did not differ signicantly by the physicians gender, region, or membership in AAP and/or AAFP, but it was higher among pediatricians (compared with family physicians), suburban and urban noninner-city practices, and younger physicians (Table 2). Compared with 2004, the overall proportion who accepted the observation option among this group of providers declined somewhat, from 88.0% in 2004 to 83.3% in 2006, although the difference was not statistically signicant (P .1). Among the 204 physicians who responded to this question on both the 2004 and 2006 surveys, the proportion declined from 90.2% to 84.3% (162 accepted the observation option at both time points, 10 did not accept the observation option at

METHODS The SCOR Network is a national practice-based, primary care pediatric research network coordinated by investigators at the Slone Epidemiology Center at Boston University. In March 2006, we mailed surveys to all active physician-members of the network inquiring about their opinions and practices regarding the observation option for AOM and about their preferred choices of antibiotics for 4 common AOM scenarios. The AOM scenarios included the following: AOM with nonsevere symptoms, AOM with severe symptoms, AOM that failed treatment with amoxicillin at 80 to 90 mg/kg per day, and AOM that failed treatment with amoxicillin-clavulanate at 80 to 90 mg/kg per day. (The survey also contained a section on screening practices for type 2 diabetes mellitus in children, the results of which are not presented here.)
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TABLE 1 Characteristics of 299 Physicians Who Responded to the Survey

Characteristics Gender Male Female Specialty Pediatrics Family practice Other Academy membership AAP AAFP Neither Both Year of medical school graduation Before 1970 1970s 1980s 1990s Practice setting Suburban Rural Urban, non-inner city Urban, inner city Region Midwest South Midatlantic West Southwest New England No. (%) 215 (71.9) 84 (28.1) 230 (76.9) 66 (22.1) 3 (1.0) 209 (69.9) 55 (18.4) 34 (11.4) 1 (0.3) 49 (16.4) 113 (37.8) 119 (39.8) 18 (6.0) 155 (51.8) 68 (22.7) 57 (19.1) 19 (6.4) 69 (23.1) 63 (21.1) 56 (18.7) 42 (14.1) 36 (12.0) 33 (11.0)

TABLE 2 Acceptance of the Observation Option According to Physician Characteristics

Factor Gender Male Female Specialtya Pediatrics Family practice AAP and/or AAFP membership Yes No Year of medical school graduation Before 1970 1970s 1980s 1990s Practice setting Suburban Rural Urban, non-inner city Urban, inner city Region Midwest South Midatlantic West Southwest New England
an b Test

n/N (%) 180/215 (83.2) 69/84 (82.1) 199/230 (86.5) 47/66 (71.2) 224/265 (84.5) 25/34 (73.5) 38/49 (77.6) 91/113 (80.5) 102/119 (85.7) 18/18 (100.0) 138/155 (89.0) 48/68 (70.6) 51/57 (89.5) 12/19 (63.2) 57/69 (82.6) 51/63 (81.0) 45/56 (80.4) 34/42 (81.0) 31/36 (86.1) 31/33 (93.9) .7

.003

.1

.03b

.0003

.6

3 with other specialties not included in this analysis. for trend.

both time points, 10 did not accept the observation option in 2004 but accepted it in 2006, and 22 accepted the observation option in 2004 but did not accept it in 2006; P .03). During the 3 months before completing the survey, the physicians reported by using the observation option in a median of 15% of the AOM cases they diagnosed (range: 0%95%; 25th, 75th percentiles: 5%, 30%). For those physicians responding to both surveys, the proportion of cases in which they used the observation option did not signicantly change from 2004 to 2006 (median: 15% in both surveys; P .4). In 2006, 10.7% of the responding physicians used the observation option in half or more of their recent AOM cases. Their preferences for follow-up strategies for children treated with observation are shown in Table 3. We asked 249 responding physicians who accepted the observation option to identify in an open-ended fashion up to 3 barriers to its use in their practices. A total of 161 (64.7%) listed parents reluctance, demand for antibiotics, and/or anxiety about observation as the most important barrier, and 208 (83.5%) listed it as 1 of the 3 most important barriers. Other reported barriers to the use of the observation option are shown in Table 4. For 4 common clinical AOM scenarios for which the AAP/AAFP guideline makes specic antibiotic recom-

TABLE 3 Physicians Preferred Follow-up Strategies for Children With AOM Treated With the Observation Option
Follow-up Strategy Back-up antibiotic prescription given at time of initial diagnosis; parent to ll prescription if child not improved in 4872 h Scheduled follow-up visit in 4872 h Parent to call for phone-in antibiotic prescription if child not improved in 4872 h Parent to bring child back to ofce if child not improved in 4872 h
Column total adds up to 100%, because multiple responses were allowed.

No. (%) 170 (56.9)

126 (42.1) 102 (34.1) 97 (32.4)

mendations, the surveyed physicians were asked which antibiotic they would prescribe; the results, compared with responses from 2004, are shown in the Figure 1. From 2004 to 2006, physicians adherence with the recommended antibiotic choices declined for all 4 scenarios presented. DISCUSSION This survey of a group of US pediatric primary care physicians offers a portrait of the ofce-based management of AOM in 2006 and relates it to the recommendations of the 2004 AAP/AAFP AOM clinical practice guideline. In addition, we compared the current surveys responses with those from a similar survey of the same
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TABLE 4 Physician-Identied Barriers to the Use of the Observation Option for AOM
% Most Important Barrier Parental expectations/demand for antibiotics Cost/time/difculty of follow-up visits Physicians concern about patients AOM-related symptoms (eg, pain, fever) Physicians concern about parents reliability/adherence to treatment plan Legal liability Young age of patient Physicians own habits/previous practices Physicians concern about AOM complications (eg, tympanic membrane rupture, mastoiditis, meningitis) Parent will nd another doctor who will prescribe antibiotics Patient with severe illness/ill appearance Daycare/school regulations Patients history of AOM/recurrent AOM Other
a The

Second Most Important Barrier 20.1 16.5 11.6 4.8 5.2 2.8 3.6 2.4 1.6 1.6 0.8 0.8 11.2

Third Most Important Barrier 12.0 11.2 5.2 3.6 2.0 1.2 2.0 3.6 1.6 0.8 2.0 0.4 9.2

Total (Mentioned as 1 of Top 3 Barriers)a 83.5 30.9 18.5 11.2 8.0 6.8 6.8 6.4 4.4 3.6 3.2 2.0 25.7

64.7 8.4 5.2 3.6 0.8 2.8 1.6 0.8 1.6 1.2 0.4 0.8 7.2

total column does not always equal the sum of the rst 3 columns, because some respondents listed multiple barriers that were placed in the same category.

A
100%
9.7%

B
Other
9.7%

100% 90%
2.4%

90% 80% 70% 60% 50% 40%

68.3% 22.0%

6.6% 6.1%

Other Amoxicillinclavulanate 4045 mg/kg per day

6.0% 4.7% 10.4%

Amoxicillin 4045 mg/kg per day

33.1%

80% 70% 60% 50%

Amoxicillin 4045 mg/kg per day

Amoxicillina 8090 mg/kg per day

57.2%

40% 30% 20% 10% 0%

67.0%

Amoxicillin 8090 mg/kg per day

66.2%

30% 20% 10% 0% 2004 2006

17.9%

Amoxicillinclavulanate a 8090 mg/kg per day

12.7%

2004

2006

C
100%
12.2% Other 11.4% Amoxicillinclavulanate 4045 mg/kg per day Azithromycin

D
100% 90%
7.4% 8.0%

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Re

6.3% 8.3%

21.5%

vie

80% 70%

Cefdinir

30.4%

Co

60% 50%

Re vie w
8.0% 15.2% 35.7%

13.4%

Other Cefuroxime axetil

10.4% 4.7% 16.4%

Azithromycin

51.7%

Amoxicillinclavulanate a 8090 mg /kg per day

py

40%
42.8%

30% 20% 10% 0%

27.7%

Co py
Cefdinir

51.8%

Ceftriaxone IM a

16.7%

2004

2006

2004

2006

FIGURE 1 Antibiotic choices of physicians in 2004 and 2006 for 4 common AOM scenarios. A, AOM with nonsevere symptoms (a P .01 for comparison of 2004 to 2006). B, AOM with severe symptoms (a P .1 for comparison of 2004 to 2006). C, AOM that failed treatment with amoxicillin at 80 to 90 mg/kg per day (a P .05 for comparison of 2004 to 2006). D, AOM that failed treatment with amoxicillin-clavulanate at 80 to 90 mg/kg per day (a P .05 for comparison of 2004 to 2006). The antibiotics shown in bold type are recommended by the 2004 AAP/AAFP guideline on AOM.

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group of providers elded in late 2004, 6 months after the release of the AOM guideline. The current survey, and the 2004 survey to which its results are compared, were performed within the SCOR Network, a national, practice-based, pediatric research network consisting of nearly 500 pediatricians and family physicians. Members of the SCOR Network may not be representative of all US pediatric primary care providers in that they have chosen to be involved in research. However, they do represent a diverse group of ofce-based physicians from 42 US states and a variety of practice and community settings, and thus can provide valuable insights into how the AOM guidelines recommendations are being implemented and which of them are most problematic for primary care providers. As for the possibility of response bias in the survey, the fact that the demographics of responders did not differ signicantly from those of nonresponders is reassuring. Yet, other unmeasured biases could have been associated with response. For example, we consider it likely that physicians who are more familiar with the guideline and/or more inclined to follow its recommendations would also have been more likely to complete the survey. This possibility, combined with the fact that SCOR Network physicians have all agreed to be involved in practice-based research, suggests that our results likely represent a best case scenario in terms of familiarity with and adherence to the guidelines recommendations. In this survey, we found that most of these physicians accept the concept of an observation option for selected children with AOM, but the proportion who accept it has not increased since 2004 and may have decreased slightly. Those who are most accepting of the observation option include pediatricians (as opposed to family physicians), younger physicians, and those practicing in suburban and urban noninner-city locations. Overall, the responding physicians currently use the observation option in 15% of the AOM cases they diagnose, approximately the same proportion as in 2004, but just over 1 in 10 of them are enthusiastic early adopters of observation, using it with at least half of their diagnosed AOM cases. When questioned in an open-ended fashion about barriers to the use of the observation option in their practices, these physicians overwhelmingly pointed to parental reluctance to accept this approach. There is, however, growing evidence that many US parents will accept observation when this option is presented in an appropriate context,5,6,912 thus there is a disconnect between what studies show parents will accept and what physicians think parents will accept. About one third of physicians also cited the time, cost, and general difculty associated with follow-up for children managed initially with observation who do not improve within an acceptable time frame as an important barrier. This concern

may be ameliorated somewhat by the use of a backup antibiotic prescription given to the parent at the time of initial AOM diagnosis, a follow-up strategy demonstrated to be practical in several clinical trials6,9,13,14 and favored by a majority of the responding physicians. This strategy does, however, place more decision-making responsibility in the parents hands and may not be welcomed by or appropriate for all families. This survey also demonstrates signicant discrepancies between the recommendations of the AAP/AAFP guideline and physicians choices of antibiotics to treat AOM. For AOM with nonsevere symptoms, slightly more than half chose the recommended high-dose amoxicillin. Nearly one third opt for standard-dose amoxicillin, a signicant increase from 2004. This trend back to standard-dose amoxicillin for nonsevere disease may represent an awareness of recent data that widespread use of the heptavalent pneumococcal conjugate vaccine has reduced the circulation of penicillin-resistant Streptococcus pneumoniae in some communities.15,16 For AOM with severe symptoms, only 1 of 8 physicians agreed with the recommendation for high-dose amoxicillin-clavulanate, whereas a much larger number chose high-dose amoxicillin. The widespread nonadherence with this recommendation may reect a feeling that the guideline strayed from the evidence that AOM with severe symptoms is more likely because of S pneumoniae (for which the addition of clavulanate is not helpful) than nontypeable Haemophilus inuenzae and Moraxella catarrhalis.17,18 Alternatively, initially prescribing amoxicillin-clavulanate for children with AOM and severe symptoms may leave physicians feeling that they do not have a comfortable second-line option (ie, switching to a different oral antibiotic with no better microbiologic coverage for the likely organisms or giving a painful and expensive daily intramuscular injection of ceftriaxone for 3 consecutive days, as the guideline recommends). For children whose treatment with amoxicillin failed, just under half of the responding physicians chose the recommended amoxicillin-clavulanate, with a substantial and increasing number choosing cefdinir instead. Cefdinirs rise as a second-line agent at the expense of amoxicillin-clavulanate may reect heavy marketing of the drug, more convenient dosing options, and/or a lower risk of diarrhea.19 Finally, for children whose treatment with amoxicillin-clavulanate failed, the majority chose an oral antibiotic alternative (primarily cefdinir or azithromycin, which have inferior or at best equivalent microbiologic coverage to amoxicillin-clavulanate for the likely organisms), whereas only 1 in 6 chose the recommended intramuscular ceftriaxone, suggesting a strong preference for oral over intramuscular administration. We did not ask the surveyed physicians to provide a rationale for their antibiotic choices, thus we can only
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speculate as to their reasons for not following the guidelines recommendations. In addition to the possible reasons cited above, one general possibility for nonadherence is that the physicians are not familiar with the guidelines antibiotic recommendations. However, the widespread dissemination of the AAP/AAFP guideline to the pediatric primary care community after its publication, as well as data from our 2004 survey indicating that 90% read the guideline or summaries of it, argue against this conclusion.8 Nonetheless, previous research demonstrated that casual familiarity with a clinical practice guideline does not necessarily result in putting its specic recommendations into practice, and that may be the case here.20 Also, other pressures, such as pharmaceutical company advertising, ofce stockpiling of free antibiotic samples, and/or parental preferences, may drive antibiotic choices as much or more than expert guidelines, although there is little research to quantify the effects of these inuences. Interestingly, we found that agreement with the guideline on antibiotic choices declined from 2004 to 2006 for all 4 of the surveys AOM scenarios. This fact, combined with the lack of increase in acceptance and use of the observation option from 2004 to 2006, suggests that the impact of the AAP/AAFP guideline has declined, at least among this group of providers. This trend, if real, may reect a waning of the intense publicity (eg, review articles, news reports) that the AOM guideline initially received. It may also represent clinical practice guideline fatigue resulting from a potentially overwhelming number of guidelines directed to pediatric primary care providers in recent years.21,22 Finally, it may signal increasing disillusionment with the recommendations themselves. Based on the results of this survey, what might be done to improve the quality of care for children with AOM? First, for those who advocate increased use of the observation option, the overwhelming perception among physicians that parents are not willing to accept this approach will have to be overcome. Recent success in substantially reducing antibiotic use for uncomplicated upper respiratory infections suggests that such a goal can be achieved through coordinated educational efforts directed at both physicians and the public.23,24 Second, for those concerned about the appropriateness of physicians antibiotic choices for AOM, additional research will be needed to explain the large and increasing gap between physicians choices and the guidelines recommendations. Depending on the results of such research, efforts should be undertaken either to more effectively educate practicing physicians or to modify the guidelines antibiotic recommendations to make them more responsive to new data and to the realities of primary care practice. In the end, even the best evidence-based recommendations serve to improve care only if the clinicians
286 VERNACCHIO et al

charged with their implementation nd them both scientically convincing and clinically practical. In the case of the 2004 AAP/AAFP AOM guideline, the experts still face the substantial challenge of convincing pediatric practitioners that the recommendations represent the best interpretation of the data and of assisting those practitioners in overcoming barriers to their implementation. ACKNOWLEDGMENTS We thank the physician-members of the SCOR Network for participation in the survey. REFERENCES
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BEING A JUNIOR DOCTOR IN NATIONAL HEALTH SERVICE Lindsay Palling graduated with a medical degree from the University of Cambridge in February 2005. Currently working in Nottingham City Hospital, she is waiting for the results of the MTAS job recruitment process due to be made public in Juneto hear whether she still has a job. The form she had to complete left no room for her qualications or professional experience; the only thing selectors judged her on were a series of 150-word answers to nebulous questions. The people who short-listed us didnt see what we had done or where we went to university, so none of our experience helped. No one ever felt that they would do something like this, she says sadly. They say there are jobs for most of us, but they are talking about 6000 losing out. In the old days it would have been people who failed their exams, but now that doesnt seem to count for anything anymore. Palling describes how the MTSA debacle has drained her enthusiasm for the job. I dont feel the same sort of dedication to it now, she says. [This mess] has taken idealism about the job away from all of us. It is now just a job. And not particularly well paid for the hours. People die all the time. It is hard. Dealing with the uncertainty of the recruitment process makes adjusting to other workplace problems ever harder, says Palling. We have had a really bad winter here. Quite a lot of wards closed and we were parking patients in the corridor. There is nowhere to do your job properly. You cant do a proper examination. The insecurity is affecting everyone in the hospital. No one feels their job is safe, she says, but it has also made her aware of how important it is to watch what is happening on a political level. Weve always thought that we should have been focusing on our patients and letting others look after the NHS. We are all so caught up in our daily jobs but we should have been paying more attention to the health reforms all the way through, she says. I just feel so helpless about it all. If I get a job in August I will try and become more involved in politics. I think we all will. It has made us all feel that way.
Brown H. Lancet. May 18, 2007 Editors Note: A real disaster in England! Noted by JFL, MD

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Management of Acute Otitis Media by Primary Care Physicians: Trends Since the Release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline Louis Vernacchio, Richard M. Vezina and Allen A. Mitchell Pediatrics 2007;120;281 DOI: 10.1542/peds.2006-3601
Updated Information & Services References including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/120/2/281.full.ht ml This article cites 22 articles, 15 of which can be accessed free at: http://pediatrics.aappublications.org/content/120/2/281.full.ht ml#ref-list-1 This article has been cited by 10 HighWire-hosted articles: http://pediatrics.aappublications.org/content/120/2/281.full.ht ml#related-urls This article, along with others on similar topics, appears in the following collection(s): Infectious Disease & Immunity http://pediatrics.aappublications.org/cgi/collection/infectious_ disease Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2007 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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