Injury-related emergency department use among people with intellectual and developmental disabilities insured by Medicaid from 2010 to 2016.

OBJECTIVES: Data on non-fatal injuries and visits to the emergency department (ED) for injuries are not readily available. The objective of this paper is to describe injury-related ED visits for people with intellectual and developmental disabilities who are covered by the Medicaid insurance programme. METHODS: We aggregated 2010-2016 Medicaid claims data from eight states. Using these data, we identified individuals with intellectual and developmental disabilities and then determined an all-cause ED visit rate, ED visit due to injury rate and admission from ED due to injury rate. Data were stratified by sex and age group. Results were compared with national rates. RESULTS: Medicaid members with intellectual and developmental disabilities visited EDs at approximately 1.8 times the rate of the general population. The ED visit rate due to injury was approximately 1.5 times that observed in the population overall. When ED visits due to injury data were stratified by age and sex, the largest discrepancy was observed in women ages 45-64, who visited EDs due to injury at a rate 2.1 times that of women of the same age in the general population. The admission rate from ED due to injury increased over the study period most notably in the older age groups. CONCLUSIONS: While rates and patterns of ED utilisation among Medicaid members with intellectual and developmental disabilities vary by age and gender, our findings suggest this group visits the ED due to injury at rates well above the general population.

Racial and Ethnic Differences in Timing of Diagnosis and Clinical Services Received in Duchenne Muscular Dystrophy.

INTRODUCTION: Racial/ethnic differences in diagnostic and treatment services have been identified for a range of health conditions and outcomes. The current study aimed to analyze whether there are racial/ethnic differences in the timing of diagnostic testing and treatments for males with Duchenne muscular dystrophy (DMD). METHODS: Diagnostic and clinical data for male individuals with DMD born during 1990-2010 were analyzed from eight sites (Arizona, Colorado, Georgia, Iowa, Piedmont Region of North Carolina, Western New York, South Carolina, and Utah) of the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet). Seven milestones related to diagnosis/treatment experiences were selected as outcomes. Times to each milestone were estimated and compared by four racial/ethnic groups using Kaplan-Meier estimation and Cox proportional-hazards models. Times between initial evaluation or diagnostic testing and later milestones were also compared by race/ethnicity. RESULTS: We identified 682 males with definite or probable DMD of whom 61.7% were non-Hispanic white, 20.5% Hispanic, 10.6% other, and 7.2% non-Hispanic black. Seven milestone events were studied (initial evaluation, first neurology/neuromuscular visit, diagnosis, corticosteroid treatment first offered, corticosteroid treatment started, first electrocardiogram or echocardiogram, and first pulmonary function test). The first five milestone events occurred at an older age for non-Hispanic black individuals compared to non-Hispanic white individuals. Time to first offering of corticosteroids and initiation of corticosteroid therapy was later for Hispanic individuals compared to non-Hispanic white individuals. When accounting for timing of initial evaluation/diagnosis, offering of corticosteroids continued to occur later, but first pulmonary testing occurred earlier, among Hispanic individuals compared to non-Hispanic whites. No significant delays remained for non-Hispanic black individuals after accounting for later initial evaluation/diagnosis. CONCLUSION: We described racial/ethnic differences in ages at selected diagnostic and treatment milestones. The most notable differences were significant delays for five of seven milestones in non-Hispanic black individuals, which appeared to be attributable to later initial evaluation/diagnosis. Findings for Hispanic individuals were less consistent. Efforts to address barriers to early evaluation and diagnosis for non-Hispanic black children with DMD may promote more timely initiation of recommended disease monitoring and interventions.

Disability, Hospital Care, and Cost: Utilization of Emergency and Inpatient Care by a Cohort of Children with Intellectual and Developmental Disabilities.

OBJECTIVE: To use medical claims data to determine patterns of healthcare utilization in children with intellectual and developmental disabilities, including frequency of service utilization, conditions that require hospital care, and costs. STUDY DESIGN: Medicaid administrative claims from 4 states (Iowa, Massachusetts, New York, and South Carolina) from years 2008-2013 were analyzed, including 108 789 children (75 417 male; 33 372 female) under age 18 years with intellectual and developmental disabilities. Diagnoses included cerebral palsy, autism, fetal alcohol syndrome, Down syndrome/trisomy/autosomal deletions, other genetic conditions, and intellectual disability. Utilization of emergency department (ED) and inpatient hospital services were analyzed for 2012. RESULTS: Children with intellectual and developmental disabilities used both inpatient and ED care at 1.8 times that of the general population. Epilepsy/convulsions was the most frequent reason for hospitalization at 20 times the relative risk of the general population. Other frequent diagnoses requiring hospitalization were mood disorders, pneumonia, paralysis, and asthma. Annual per capita expenses for hospitalization and ED care were 100% higher for children with intellectual and developmental disabilities, compared with the general population ($153 348 562 and $76 654 361, respectively). CONCLUSIONS: Children with intellectual and developmental disabilities utilize significantly more ED and inpatient care than other children, which results in higher annual costs. Recognizing chronic conditions that increase risk for hospital care can provide guidance for developing outpatient care strategies that anticipate common clinical problems in intellectual and developmental disabilities and ensure responsive management before hospital care is needed.

Burden of community-associated Clostridioides difficile infection in southeastern United States: a population-based study.

OBJECTIVES: This cross-sectional population-based study aims to determine overall incidence rate of Clostridioides difficile infection (CDI) in the State of South Carolina and provide an estimated cost of hospitalization due to community-associated CDI (CA-CDI). METHODS: All CDI cases in South Carolina were identified through National Healthcare Safety Network (NHSN) and the South Carolina Infectious Disease and Outbreak Network (SCION) from January 1, 2015 to June 30, 2016, excluding infants < 1 year of age. RESULTS: During the 18-month study period, 10,254 CDI events were identified in South Carolina residents with an overall incidence rate of 139/100,000 person-years. Over one-half of CDI cases were CA-CDI (5192; 51%) with an incidence rate of 71/100,000 person-years. Among patients with CA-CDI, 2127 (41%) required hospitalization with a median length of stay of 5 days. The annual burden of CA-CDI in South Carolina was estimated to be 9282 hospital days and $16,217,295 in hospitalization costs. CONCLUSION: The incidence rate of CA-CDI in South Carolina has surpassed both community-onset healthcare facility associated and hospital-onset CDI combined. The heavy burden of CA-CDI justifies dedication of public health resources to combat CDI in ambulatory settings, through antimicrobial stewardship initiatives.

The effect of steroid treatment on weight in nonambulatory males with Duchenne muscular dystrophy.

To describe the long-term effect of steroid treatment on weight in nonambulatory males with Duchenne Muscular Dystrophy (DMD), we identified 392 males age 7-29 years with 4,512 weights collected after ambulation loss (176 steroid-naïve and 216 treated with steroids ≥6 months) from the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet). Comparisons were made between the weight growth curves for steroid-naïve males with DMD, steroid-treated males with DMD, and the US pediatric male population. Using linear mixed-effects models adjusted for race/ethnicity and birth year, we evaluated the association between weight-for-age and steroid treatment characteristics (age at initiation, dosing interval, cumulative duration, cumulative dose, type). The weight growth curves for steroid-naïve and steroid-treated nonambulatory males with DMD were wider than the US pediatric male growth curves. Mean weight-for-age z scores were lower in both steroid-naïve (mean = -1.3) and steroid-treated (mean = -0.02) nonambulatory males with DMD, compared to the US pediatric male population. Longer treatment duration and greater cumulative dose were significantly associated with lower mean weight-for-age z scores. Providers should consider the effect of steroid treatment on weight when making postambulation treatment decisions for males with DMD.

Fourth-grade children's dietary reporting accuracy by meal component: Results from a validation study that manipulated retention interval and prompts.

We examined reporting accuracy by meal component (beverage, bread, breakfast meat, combination entrée, condiment, dessert, entrée, fruit, vegetable) with validation-study data on 455 fourth-grade children (mean age = 9.92 ± 0.41 years) observed eating school meals and randomized to one of eight dietary recall conditions (two retention intervals [short, long] crossed with four prompts [forward, meal-name, open, reverse]). Accuracy category (match [observed and reported], omission [observed but unreported], intrusion [unobserved but reported]) was a polytomous nominal item response variable. We fit a multilevel cumulative logit model with item variables meal component and serving period (breakfast, lunch) and child variables retention interval, prompt and sex. Significant accuracy category predictors were meal component (p < 0.0003), retention interval (p < 0.0003), meal-component × serving-period (p < 0.0003) and meal-component × retention-interval (p = 0.001). The relationship of meal component and accuracy category was much stronger for lunch than breakfast. For lunch, beverages were matches more often, omissions much less often and intrusions more often than expected under independence; fruits and desserts were omissions more often. For the meal-component × retention-interval interaction, for the short retention interval, beverages were intrusions much more often but combination entrées and condiments were intrusions less often; for the long retention interval, beverages were matches more often and omissions less often but fruits were matches less often. Accuracy for each meal component appeared better with the short than long retention interval. For lunch and for the short retention interval, children's reporting was most accurate for entrée and combination entrée meal components, whereas it was least accurate for vegetable and fruit meal components. Results have implications for conclusions of studies and interventions assessed with dietary recalls obtained from children.

Children's school-breakfast reports and school-lunch reports (in 24-h dietary recalls): conventional and reporting-error-sensitive measures show inconsistent accuracy results for retention interval and breakfast location.

Validation-study data were analysed to investigate retention interval (RI) and prompt effects on the accuracy of fourth-grade children's reports of school-breakfast and school-lunch (in 24-h recalls), and the accuracy of school-breakfast reports by breakfast location (classroom; cafeteria). Randomly selected fourth-grade children at ten schools in four districts were observed eating school-provided breakfast and lunch, and were interviewed under one of eight conditions created by crossing two RIs ('short'--prior-24-hour recall obtained in the afternoon and 'long'--previous-day recall obtained in the morning) with four prompts ('forward'--distant to recent, 'meal name'--breakfast, etc., 'open'--no instructions, and 'reverse'--recent to distant). Each condition had sixty children (half were girls). Of 480 children, 355 and 409 reported meals satisfying criteria for reports of school-breakfast and school-lunch, respectively. For breakfast and lunch separately, a conventional measure--report rate--and reporting-error-sensitive measures--correspondence rate and inflation ratio--were calculated for energy per meal-reporting child. Correspondence rate and inflation ratio--but not report rate--showed better accuracy for school-breakfast and school-lunch reports with the short RI than with the long RI; this pattern was not found for some prompts for each sex. Correspondence rate and inflation ratio showed better school-breakfast report accuracy for the classroom than for cafeteria location for each prompt, but report rate showed the opposite. For each RI, correspondence rate and inflation ratio showed better accuracy for lunch than for breakfast, but report rate showed the opposite. When choosing RI and prompts for recalls, researchers and practitioners should select a short RI to maximise accuracy. Recommendations for prompt selections are less clear. As report rates distort validation-study accuracy conclusions, reporting-error-sensitive measures are recommended.

Effectiveness of Prompts on Fourth-Grade Children's Dietary Recall Accuracy Depends on Retention Interval and Varies by Gender.

BACKGROUND: Dietary recall accuracy is related to retention interval (RI) (i.e., time between to-be-reported meals and the interview), and possibly to prompts. To the best of our knowledge, no study has evaluated their combined effect. OBJECTIVE: The combined influence of RI and prompts on children's recall accuracy was investigated in this study. Two RIs [short (prior-24-h recall obtained in afternoon) and long (previous-day recall obtained in morning)] were crossed with 4 prompts [forward (distant-to-recent), meal-name (breakfast, lunch, etc.), open (no instructions), and reverse (recent-to-distant)], creating 8 conditions. METHODS: Fourth-grade children (n = 480; 50% girls) were randomly selected from consenting children at 10 schools in 4 districts in a southern state during 3 school years (2011-2012, 2012-2013, and 2013-2014). Each child was observed eating school-provided breakfast and lunch, and interviewed one time under 1 of the 8 conditions. Condition assignment was constrained so that each had 60 children (30 girls). Accuracy measures were food-item omission and intrusion rates, and energy correspondence rate and inflation ratio. For each measure, linear models determined effects of RI, prompt, gender, and interactions (2-way, 3-way); race/ethnicity, school year, and district were control variables. RESULTS: RI (P values < 0.015) and prompt (P values < 0.005) were significant for all 4 accuracy measures. RI × prompt (P values < 0.001) was significant for 3 accuracy measures (not intrusion rate). Prompt × gender (P = 0.005) was significant for omission rate. RI × prompt × gender was significant for intrusion rate and inflation ratio (P values < 0.001). For the short vs. long RI across prompts and genders, accuracy was better by 33-50% for each accuracy measure. CONCLUSIONS: To obtain the most accurate recalls possible from children, studies should be designed to use a short rather than long RI. Prompts affect children's recall accuracy, although the effectiveness of different prompts depends on RI and varies by gender: at a short RI, the choice of prompts has little systematic effect on accuracy, whereas at a long RI, reverse prompts may elicit the most accurate recalls.

Hospitalizations and emergency room visits for adolescents and young adults with muscular dystrophy living in South Carolina.

INTRODUCTION: Transitioning from adolescence to adulthood can be problematic for individuals with rare disabilities such as muscular dystrophy (MD). METHODS: We identified a cohort of 220 individuals with MD and 440 matched comparison individuals and measured emergency room (ER) and inpatient (IP) encounters for the years 2000 through 2010, using all-payer hospital discharge uniform billing data. We compared ER and IP use rates for people with and without MD, and for 15-19-year-olds with MD to 20-24-year-olds with MD. RESULTS: ER and IP use rates were significantly higher among individuals with MD than the comparison group. In addition, ER and IP use rates were significantly higher in the 20-24-year age group than in the 15-19-year group. CONCLUSIONS: Additional research is needed to determine whether increased ER and IP use in young adults is attributable to difficulties in healthcare transition versus increased disease severity.

Children's Social Desirability: Effects of Test Assessment Mode.

This study examined a recently developed short version of the Children's Social Desirability (CSD-S) scale with 157 fourth-grade children. Of interest was a) whether one-month test-retest reliability would vary as a function of test assessment mode (interview or classroom), gender, race, SES, and BMI percentile, and b) whether the degree of social desirability would vary as a function of these same variables. The CSD-S scale showed good test-retest reliability for both interview and classroom assessment modes (.85 and .83, respectively). Internal consistency also was good (first interview administration = .84; first classroom administration = .81). Reliability was good and did not vary significantly over assessment mode or any child subgroup variables, suggesting that the CSD-S scale is appropriate for general use. The interview mode elicited significantly more socially desirable answers than did the classroom mode. Social desirability did not differ across child subgroups. Some of these findings were examined, and replicated, on another sample. Thus, the CSD-S scale may be used with diverse groups of children to a) reliably assess a social desirability bias that may systematically bias other self-reports of interest to researchers and b) examine individual differences in degree of social desirability.

Disparities in health care utilization by race among teenagers and young adults with muscular dystrophy.

BACKGROUND: For people with muscular dystrophy (MD) health care access is crucial and utilization is expected to be high. A multidisciplinary approach is needed for optimal management of symptoms of this rare condition. Regular primary care, specialty care, therapy, and medicine use can improve quality of care and reduce need for emergency treatment and hospitalization. We analyzed health insurance and administrative data to test for racial disparities in regular care use among teenagers and young adults with MD. METHODS: We used South Carolina Medicaid and other administrative data for individuals aged 15-24 years to determine annual health care utilization patterns for individuals with MD by race. We studied adolescents and young adults with MD because this age group represents a time when the condition is typically intensifying and the transition from pediatric to adult care is expected. We used Generalized Estimating Equation models to analyze longitudinal utilization data conditional on other factors that may lead to utilization differences. RESULTS: Race is correlated with health care utilization among adolescents and young adults with MD. Blacks have lower overall utilization, and less primary care, therapy, and specialist care use but higher incidence of hospitalization and emergency treatment use compared with whites and also to other races. The most striking disparity was the use of outpatient services. Blacks utilized these services 50% less compared with whites and 70% less compared with others. Even in regression analysis, where we take into account individual unobserved factors and allow clustering at the individual level, these differences remained and were in most cases statistically significant. CONCLUSIONS: Our results indicate that there are differences in health care utilization by race even when individuals have access to the same health care benefits. This means simply offering coverage to individuals with MD may not be sufficient in eliminating health disparities. Future studies will be needed to examine other possible sources of these racial disparities, such as resource awareness, health knowledge, or access barriers such as transportation.

Accuracy and usefulness of ICD-10 death certificate coding for the identification of patients with ALS: results from the South Carolina ALS Surveillance Pilot Project.

The purpose if this study was to investigate the positive predictive value and sensitivity of the ICD-10 code G12.2, which is used to identify patients who have possibly died from ALS. All patients with a motor neuron disease diagnosis code during the study period (2001-2005) were identified using administrative data. South Carolina death certificate data were used to assess the positive predictive value and sensitivity of the ICD-10 code G12.2. Two hundred and seventy known cases of ALS linked to the death certificate data file. G12.2 was coded as either the underlying or contributing cause of death for 229 cases, sensitivity = 85%. There were 318 deaths due to ALS identified by the G12.2 code where a medical record was available for review. Of those, 205 contained information supporting the diagnosis of ALS, positive predictive value = 65%. This evaluation raises questions concerning the validity of using mortality data in forming epidemiological conclusions in this patient population. However, it does appear that mortality data can be used in the development of case-finding algorithms to identify ALS patients through the use of administrative data sets.

How accurate are parental responses concerning their fourth-grade children's school-meal participation, and what is the relationship between children's body mass index and school-meal participation based on parental responses?

BACKGROUND: This article investigated (1) parental response accuracy of fourth-grade children's school-meal participation and whether accuracy differed by children's body mass index (BMI), sex, and race, and (2) the relationship between BMI and school-meal participation (based on parental responses). METHODS: Data were from four cross-sectional studies conducted from fall 1999 to spring 2003 with fourth-grade children from 13 schools total. Consent forms asked parents to report children's usual school-meal participation. As two studies' consent forms did not ask about lunch participation, complete data were available for breakfast on 1,496 children (51% Black; 49% boys) and for lunch on 785 children (46% Black; 48% boys). Researchers compiled nametag records (during meal observations) of meal participation on randomly selected days during children's fourth-grade school year for breakfast (average nametag days across studies: 7-35) and for lunch (average nametag days across studies: 4-10) and categorized participation as "usually" (≥ 50% of days) or "not usually" (< 50% of days). Weight and height were measured. Concerning parental response accuracy, marginal regression was used with agreement between parental responses and nametag records as the dependent variable; independent variables were BMI, age, sex, race, and study. Concerning a relationship between BMI and school-meal participation, marginal regression was used with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, age, sex, race, and study. RESULTS: Concerning breakfast participation and lunch participation, 74% and 92% of parents provided accurate responses, respectively. Parental response accuracy was better for older children for breakfast and lunch participation, and for Black than White children for lunch participation. Usual school-meal participation was significantly related to children's BMI but in opposite directions -- positively for breakfast and inversely for lunch. CONCLUSIONS: Parental response accuracy of children's school-meal participation was moderately high; however, disparate effects for children's age and race warrant caution when relying on parental responses. The BMI results, which showed a relationship between school-meal participation (based on parental responses) and childhood obesity, conflict with results from a recent article that used data from the same four studies and found no significant relationship when participation was based on nametag records compiled for meal observations.

Temporal Association between Influenza Vaccination Coverage and Ambulatory Antibiotic Use in Children.

In this population-based retrospective cohort study, increased influenza vaccination coverage was temporally associated with a reduction in ambulatory antibiotic use in children. After adjustment for yearly vaccine effectiveness, antibiotic prescription rate declined by 3/1000 person-months for each 1% increase in influenza vaccination coverage between 2012 and 2017 in South Carolina (P < 0.001).

Relation of Children's Dietary reporting accuracy to cognitive ability.

A validation study of children's dietary reporting provided an opportunity to investigate whether cognitive ability is a source of systematic error in dietary recalls. From the fall of 2004 through the spring of 2007, fourth-grade children (n = 374) in Columbia, South Carolina, were observed eating school meals and interviewed to obtain 24-hour dietary recalls; subsequently, measures of dietary reporting error were calculated. The common factor extracted from 4 subject-area achievement tests (scores on which were provided by the school district for 362 children) was used as a measure of cognitive ability. For the 325 children who reported school meals that met the criteria to be reports about school meals, as cognitive ability increased, dietary reporting error decreased; the relation between cognitive ability and dietary reporting performance was stronger among girls than among boys. The mean cognitive ability for 37 children who reported no meals that satisfied the criteria for being reports about school meals was significantly lower than that for the 325 children who reported meals that satisfied these criteria. These findings indicate that cognitive ability is a source of systematic error in children's dietary recalls. More generally, the quality of epidemiologic survey data may depend systematically on the cognitive ability of respondents.

Validity of hospital discharge data for identifying cases of amyotrophic lateral sclerosis.

Inpatient hospital encounters and emergency department visits were examined to identify cases of amyotrophic lateral sclerosis (ALS).The ninth edition of the International Classification of Disease, clinical modification (ICD-9-CM) for ALS was confirmed for ALS was confirmed in 93% of inpatient discharges and in 91% of emergency department visits by the diagnostic standard (chart review). Yearly prevalence rates ranged from 2.94 to 3.28 per 100,000 residents. The low calculated prevalence rates suggest that this method of case identification is inadequate and must be combined with other data sets to maximize confirmation of the clinical diagnosis.

Health Service Utilization Patterns Among Medicaid-Insured Adults With Intellectual and Developmental Disabilities: Implications for Access Needs in Outpatient Community-Based Medical Services.

Limited existing evidence suggests that adults with intellectual and developmental disabilities (IDD) experience substantial disparities in numerous areas of health care, including quality ambulatory care. A multistate cohort of adults with IDD was analyzed for patterns of inpatient admissions and emergency department utilization. Utilization was higher (inpatient [RR = 3.2], emergency department visits [RR = 2.6]) for adults with IDD, particularly for ambulatory care-sensitive conditions (eg, urinary tract [RR = 6.6] and respiratory infections [RRs = 5.5-24.7]), and psychiatric conditions (RRs = 5.8-15). Findings underscore the importance of access to ambulatory care skilled in IDD-related needs to recognize and treat ambulatory care-sensitive conditions and to manage chronic medical and mental health conditions.

Clostridioides difficile infection and antibiotic prescription rates in the community: Explaining the gender gap.

In this cross-sectional population-based study, women had significantly higher crude incidence rates of both community-associated Clostridioides difficile infection (CA-CDI) and ambulatory antibiotic prescriptions compared to men in South Carolina in 2015. After adjustments for antibiotic prescription rates, there was no difference in the incidence rates of CA-CDI between the genders.

Voltage gated potassium channel antibodies in amyotrophic lateral sclerosis.

Although overlap exists between the clinical manifestations in patients with acquired peripheral nerve hyperexcitibility and amyotrophic lateral sclerosis (ALS), the presence of VGKC antibodies has not been associated with the development or clinical manifestations of motor neuron disease. We present the finding of elevated potassium channel antibodies in a cohort of patients with ALS and demonstrate a higher number of abnormal titer levels and higher mean titer levels in ALS patients compared to a cohort of patients with peripheral nervous system disorders. These results suggest the possibility of a subset of ALS patients where autoimmunity could play a role in disease development and progression.

Children's body mass index, participation in school meals, and observed energy intake at school meals.

BACKGROUND: Data from a dietary-reporting validation study with fourth-grade children were analyzed to investigate a possible relationship of body mass index (BMI) with daily participation in school meals and observed energy intake at school meals, and whether the relationships differed by breakfast location (classroom; cafeteria). METHODS: Data were collected in 17, 17, and 8 schools during three school years. For the three years, six, six, and seven of the schools had breakfast in the classroom; all other schools had breakfast in the cafeteria. Information about 180 days of school breakfast and school lunch participation during fourth grade for each of 1,571 children (90% Black; 53% girls) was available in electronic administrative records from the school district. Children were weighed and measured, and BMI was calculated. Each of a subset of 465 children (95% Black; 49% girls) was observed eating school breakfast and school lunch on the same day. Mixed-effects regression was conducted with BMI as the dependent variable and school as the random effect; independent variables were breakfast participation, lunch participation, combined participation (breakfast and lunch on the same day), average observed energy intake for breakfast, average observed energy intake for lunch, sex, age, breakfast location, and school year. Analyses were repeated for BMI category (underweight/healthy weight; overweight; obese; severely obese) using pooled ordered logistic regression models that excluded sex and age. RESULTS: Breakfast participation, lunch participation, and combined participation were not significantly associated with BMI or BMI category irrespective of whether the model included observed energy intake at school meals. Observed energy intake at school meals was significantly and positively associated with BMI and BMI category. For the total sample and subset, breakfast location was significantly associated with BMI; average BMI was larger for children with breakfast in the classroom than in the cafeteria. Significantly more kilocalories were observed eaten at breakfast in the classroom than in the cafeteria. CONCLUSIONS: For fourth-grade children, results provide evidence of a positive relationship between BMI and observed energy intake at school meals, and between BMI and school breakfast in the classroom; however, BMI and participation in school meals were not significantly associated.