Five-Phase Replication of Behavioral Health Integration in Pediatric Primary Care.

BACKGROUND AND OBJECTIVES: Because of severe and protracted shortages of pediatric behavioral health (BH) specialists, collaboration between pediatric primary care practitioners (PCPs) and BH specialists has the potential to increase access to BH services by expanding the BH workforce. In a previous study, we demonstrated that phase 1 of a behavioral health integration program (BHIP) enrolling 13 independently owned, community-based pediatric practices was associated with increased access to BH services while averting substantial cost increases and achieving high provider self-efficacy and professional satisfaction. The current study was undertaken to assess whether the initial access findings were replicated over 4 subsequent implementation phases and to explore the practicality of broad dissemination of the BHIP model. METHODS: After phase 1, BHIP was extended over 4 subsequent phases in a stepped-wedge design to 46 additional pediatric practices, for a total cohort of 59 practices (354 PCPs serving >300 000 patients). Program components comprised BH education and consultation and support for integrated practice transformation; these components facilitated on-site BH services by an interprofessional BH team. Outcomes were assessed quarterly, preprogram and postprogram launch. RESULTS: Across combined phases 1 to 5, BHIP was associated with increased primary care access to BH services (screening, psychotherapy, PCP BH visits, psychotropic prescribing) and performed well across 7 standard implementation outcome domains (acceptability, appropriateness, feasibility, fidelity, adoption, penetration, and sustainability). Emergency BH visits and attention-deficit/hyperactivity disorder prescribing were unchanged. CONCLUSIONS: These findings provide further support for the potential of integrated care to increase access to BH services in pediatric primary care.

Vitamin, fluoride, and iron use among US children younger than 12 years of age: results from the Slone Survey 1998-2007.

Pediatric vitamin and mineral supplements are thought to be used commonly in the United States, but details of their use are lacking. Using data from the Slone Survey (a cross-sectional national random-digit-dial medication use survey), this study sought to define the prevalence and patterns of use of supplemental vitamins, fluoride, and iron among US children younger than 12 years of age. Primary statistical analyses involved descriptive statistics and calculation of weighted prevalence of use estimates with 95% confidence intervals. Between February 1998 and April 2007, there were 2,857 children 0 to 11 years of age enrolled from the 48 contiguous United States with weighted prevalence of use of vitamins, iron, and fluoride as the primary outcome. The response rate to the survey was 61%. Overall, 23.1% of children had used a vitamin, fluoride, or iron supplement in the 7 days before the interview, with use being highest among 2- to 5-year-olds. Almost all vitamins and most fluoride and iron were taken in the form of multicomponent products. The most commonly taken specific vitamins were C, D, B-12, B-6, and B-2, each by >20% of children. Overall, 3.3% of study participants took supplemental fluoride and 9.7% took supplemental iron. In conclusion, this study found that almost one-quarter of US children younger than 12 years of age, and 30% of 2-year-olds, use supplemental vitamins, fluoride, and iron in a given week. These data should be combined with what is known about the need for pediatric supplementation with vitamins, fluoride, and iron to help clinicians and policy makers counsel parents about the optimal use of these products.

Effect of monophosphoryl lipid A (MPL) on T-helper cells when administered as an adjuvant with pneumocococcal-CRM197 conjugate vaccine in healthy toddlers.

As new vaccines are developed, novel adjuvants may play an important role in eliciting an effective immune response. We evaluated the safety and adjuvant properties of monophosphoryl lipid A (MPL in 129 healthy toddlers immunized with two doses of nine-valent pneumococcal-CRM(197) protein conjugate vaccine (PCV9) combined with 10, 25, or 50 micro g of MPL with or without alum (AlPO(4)). Vaccine-specific humoral and cell-mediated responses were examined following the second dose of study vaccine. All doses of MPL were well-tolerated and a dose-dependent effect of MPL on specific cellular responses was observed. The 10 micro g MPL dose significantly enhanced CRM(197)-specific T-cell proliferation (P=0.02) and interferon-gamma (INF-gamma) production (P=0.009) compared to responses of controls who received PCV9 with AlPO(4). In contrast, CRM(197)-specific T-cell proliferation and interferon-gamma production of the 50 micro g MPL/AlPO(4) group were decreased when compared to controls although these differences did not reach statistical significance. IL-5 and IL-13 responses after immunization showed a similar pattern with increased production in the 10 micro g MPL group and decreased production in the 50 micro g MPL/AlPO(4) group compared to controls. There were no differences in serum IgG antibody concentrations to the nine vaccine pneumococcal capsular polysaccharides and carrier protein between the MPL-containing and control vaccine groups. These findings demonstrate a dose-dependent effect of MPL on T-helper cell type 1 (TH-1) responses to the carrier protein and also suggest an effect on T-helper cell type 2 (TH-2) responses.