Assessing the Need to Hospitalize Children: Pediatric Appropriateness Evaluation Protocol Bernard E. Kreger and Joseph D.

Restuccia Pediatrics 1989;84;242

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/84/2/242

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 1989 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Assessing the Need to Hospitalize Children: Pediatric Appropriateness Evaluation Protocol

Bernard E. Kreger, MD, MPH, and Joseph D. Restuccia, DPH
University University

From the Health Care Research Unit, Section Hospital, and the Evans Memorial Department School of Medicine, Boston, Massachusetts

of General of Clinical

Internal Medicine, Research, Boston

ABSTRACT. Rapidly cessitated use review

the appropriateness

increasing hospital costs have neof hospitalized patients to improve

(medical

necessity) of hospital use. of the Pediatric Appropriateness Evaluation Protocol, an objective, criteria-based instrument intended to assist physicians and use reviewers in making decisions regarding appropriateness of

The development

and testing

pediatric

hospital

admissions
1989;84:242-247;

and days protocol.

of care,
use,

are depediat-

scribed. Pediatrics nc appropriateness

hospital

evaluation

Health Care Review Unit and elsewhere, its validity and reliability have been confirmed. The AEP is now a major instrument used by hospitals, HMOs, peer review organizations, Medicaid agencies, and private insurers to screen cases concurrently for physician advisor review and to profile retrospectively provider practice patterns.1 The AEP was designed originally to apply only
to adult patients hospitalized in medical and surgical services in acute care institutions. We thought

ABBREVIATIONS. EMPSRO, Eastern

Organization.

AEP, Appropriateness Evaluation Protocol; Massachusetts Professional Services Review

that different criteria might be needed to monitor pediatric, obstetric, and psychiatric inpatient care,
as well as various sorts oflong-term or chronic care,

including rehabilitation services. Medicaid, for a method to evaluate pediatric care,

the primary impetus for the development

looking provided
of a pe-

For many years, those who provide, administer, and pay for health care in the United States have recognized the need for a valid and reliable method of assessing the use of hospital beds. Criteria based on diagnoses have proven burdensome, both because of their sheer number and because of medical advances that result in frequent changes in preferred treatment modalities for particular diagnoses. Instead, the Appropriateness Evaluation Protocol (AEP), developed during the past decade by the Boston University Health Care Research Unit, has met the demands of the health care systern in providing useful, objective generic criteria for assessing the appropriateness (medical necessity) of hospitalization in an acute care facility. In

diatric AEP. In this article, the iterative process of the design and testing of this instrument are described, in particular, the modifications to the original criteria to tailor them to the special problems encountered in the hospitalization of children.

METHOD
The first step in evolving the pediatric AEP was the application of the standard (adult) AEP criteria
to children. It had already been determined through

several

trials

conducted

by

researchers

at

the

our validation studies that approximately 95% of truly appropriate use of acute beds by adults would be identified by these AEP criteria: thus, only approximately 5% of these truly appropriate cases would require special mention (called overrides in AEP parlance) because no criteria were satisfled. In addition, groups that were using AEP since
its inception had reported back to us that they tried

Received Reprint

for publication Jun requests to (J.D.R.)

10, 1988; accepted Sep 2, 1988. 720 Harrison Aye, Suite 1102, Copyright 1989 by the

Boston,

MA 02118.

PEDIATRICS (ISSN 0031 4005). American Academy of Pediatrics.

applying adult criteria to the pediatric inpatients and found them useful. We, therefore, enlisted the help of the Quality Assurance Unit of Childrens Hospital Medical Center, Boston, for a formal test

242

HOSPITALIZATION

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EVALUATION

of applicability of the Pediatric An independent

recently discharged

as the first step in the development AEP. review of 50 medical records

patients was done by two nurse

of

reviewers trained in AEP and experienced in pediatric care. Besides applying the adult AEP criteria, the nurses provided detailed documentation of deficiencies in the application of the criteria to these pediatric patients. The deficiencies in the AEP adult instrument identified through this review were codified and discussed with pediatricians from both Massachusetts and elsewhere. Exact phraseology for new criteria and modifications of existing criteria were arrived at by consensus. The changes to existing criteria consisted primarily of different physiologic values indicative of a sufficiently severe illness in a child not to warrant commonly hospital-

criteria and instructions for their application were made by Health Care Review Unit researchers with the assistance of clinical consultants. The third step in the development process involved field trials. A small trial addressed the question: Does the Pediatric AEP work as well for community hospitals as it does in academic centers and teaching hospitals. For this preliminary trial,
50 records from each of two community hospitals

were reviewed independently by a physician and a nurse reviewer. No additional problems were found involving the instrument or the instructions. However, a much larger trial was necessary both to ensure the generalizability of this finding and to
establish a baseline appropriateness level with

ization.
atrics

The
clinical

new

criteria
situations

consisted Based AEP

of special on this new

pedifound

which to tions. To that

sional

compare end, the

subsequent Eastern

pediatric Massachusetts

applicaProfes(EMPSRO)

Services

Review

Organization

among criteria,
for

adult inpatients. a new pediatric

was created.

instruction

set of manual

agreed to assist us, after AEP criteria by EMPSRO

indicated that the criteria

review of the Pediatric member pediatricians

had sufficient validity to

reviewers

changes characterize the pediatrics version of the AEP (Appendix 1): (1) The instrument applies to children 6 months of age and older, with physiologic measurements taken at admission such as BP, pulse, and various laboratory test results being stratified according to subgroup of age.

The

following

warrant organize Boston

setts. In

a large field trial. EMPSRO then helped field testing in 24 hospitals in the greater area and 2 hospitals in western Massachueach hospital, 100% of all Medicaid pa-

(Originally, the young as 2 years

subsequent use

instrument of age, but

that the

included children it was confirmed

may be

as with
used

instrument represents

with
as an

even

younger

infants.
criterion

(2) Hematocrit

<30%
a child in

admission

potential trouble, usually with leukemia or its treatment. (3) Need for lumbar puncture was added, to allow for those locales where such a procedure is impractical on an outpatient basis. (4) Special pediatrics situations, often a combination of medical and social problems, were added to the admission criteria: failure of (or history of noncompliance with) outpatient therapy, documented or suspected child abuse, or need for special observation (as in failure to thrive). (5) For day of care criteria, applicable to any day during a hospital stay other than the days of admission and discharge, additions were made to allow inpatient performance of gastrointestinal endoscopy and traction for major orthopedics problems.

tients aged 2 to 15 years discharged during a 6month period in 1983 (February to July or March to August) were sampled, a total of 793 patients. After receiving training in use of the pediatric AEP from Health Care Review Unit staff, EMPSRO nurse reviewers applied the pediatric AEP to the time of admission and to the day before discharge. For admissions lasting only 1 day, no day of care criteria were applicable. When an admission or day was found to be inappropriate at the acute hospital level, the reviewer identified the probable cause of inappropriateness with the assistance of the AEP Reasons List (see Appendix 2). To assess reliability, 143 patients from 3 of the study hospitals were rereviewed by a second nurse reviewer.

RESULTS
In the reliability study, 93.7 and 88.4% agreement was found among reviewers in terms of appropriateness decisions regarding admissions and days of care, respectively. The K statistic was applied to determine the extent to which this agreement differed from the agreement occurring by random chance.2 A K of 0.68 (P < .0001) for admissions and 0.46 (P < .0001) for days indicated that agreement was not due to chance alone and was sufficiently great for the pediatric AEP to be used as either a screening instrument in use review of individual

Two nurse reviewers who were already trained in AEP application then used the new criteria and instructions to assess a set of 1200 pediatrics records at New England Medical Center Hospital, Boston. They provided documentation regarding applicability of the criteria and adequacy of the wording of the criteria and the instruction manual. Where indicated, additional wording changes to the

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243

patients or as an instrument to assess rates of appropriateness among groups

as was the case in this study.

accurately of patients,

considered
.0055).

inappropriate

(6.6%

vs

12.8%,

Of the 26 hospitals in the field trial, 14 had fewer than 25 sample patients during the 6-month period reviewed. The total study sample consisted of 793 patient admissions and 648 days of care (ie, there were 145 one-day stays). Mean length of stay was
4.6 days, with a range of 1 to 49 days. Mean age

For day of care, objective inappropriateness were less for girls than for boys (11.4% and least for ages 6 to 11 years compared
5 years and 12 to 15 years (11.3% diagnoses inpatient vs 16.8%). The 10 most common 19% inappropriate penultimate

rates vs 14.5%) with 2 to

12.2% and had 0% to days, with

was 7.5 years; 55% were male. By objective criteria, 10.5% ofpatient were judged inappropriate, with a range
24.1% among the 12 hospitals at which

admissions of 2.4%
there

to
had

been at least 25 admissions. For day of care, the objective inappropriateness rate was 13.3% among the same hospitals, ranging from 3.5% to 24.7%. The application of override options resulted in reduction of these rates to 5.8% (0% to 17.1%) for
admissions and 9.4% (0% to 22.5%) for days of

pneumonia, acute appendicitis, concussion, and fracture of radius and ulna all greater than 14%. At the end of a childs hospital stay, those who had a procedure were more likely to be inappropriately there (15.2% vs 10.2%), but not significantly so. Finally, the reason cited most frequently for inappropriate admission was that the patient required no institutional care and could be treated as an outpatient. Similarly, inappropriate days of care were most commonly attributed to the lack of need for continuing institutional care.

care. As had been the case in the development of the Adult Medical/Surgical AEP, when we analyzed the use of overrides, we found only a few situations that were considered suitable to warrant additions to objective criteria. These additions were accomplished by expanding definitions of existing admission criteria in posttrial versions of the Pediatric

COMMENT
The extensive experience gained in the design and implementation of the Adult Medical/Surgical AEP tended to facilitate the development of the pediatric version. The process was made especially easy because of the success some AEP users had had evaluating pediatrics hospitalizations using the
adult criteria. Thus, the pediatric AEP grew out of

AEP rather than creating totally new ones. In the main, though, the differences between objective conclusions and those made through the use of overrides reflected incorrect use of the override option. The misuse often occurred because of the confusion of relatively inexperienced reviewers between reasons for inappropriate hospitalization and medical need for hospitalization: for example, using an override to conclude that a patient requiring outpatient services that could not be scheduled conveniently was appropriately hospitalized rather than using the reason, Patient admitted for diagnosis and/or treatment because it was not possible

an already validated and reliable instrument to which necessary and appropriate adjustments were made. The trial application of this version proceeded along lines similar to those involved in the original adult version and encountered similar problems.
Namely, the EMPSRO reviewers, who were rela-

tively inexperienced in using the AEP in general, made reviewing errors mainly by misuse of the override option, wherein a reason for inappropriateness was used as a justification for hospitalization

to be scheduled on an outpatient basis to indicate why the patient was hospitalized despite not having a need for acute hospitalization. It was therefore judged that the data from the use of objective criteria alone provide the most accurate picture of patterns of inappropriateness. The inappropriate admission rate was 9.8% for boys and 10.8% for girls. It was smallest for ages 6 to 11 compared with 2 to 5 and 12 to 15 (8.6% vs
11.2% statistically and 12.3%). significant None of these at the differences .05 level. was Among

instead of an explanation of the reason for the hospitalization despite its being medically inappropriate. With sufficient further training, AEP users
both in the United States and abroad have found

that this gradually

Thus, unless the

most common of errors disappears, although not

to prohibit has use of the reviewer demonstrated

in application always totally.

override proper option use

it is best

<

through consult
use rates

formal reliability a physician advisor

override.

tests or is required to obtain approval to find inappropriateness

appreciably

to for

the 10 most frequent of inappropriateness monia, gastroenteritis,

associated with the ness. If the hospital

discharge diagnoses, the range was 0% to 19.2%, with pneuand cellulitis and abscess
largest rates stay included of inappropriatea procedure, the

of the

It was than
sults

not

surprising for adults.

for childrens

hospitalizations

less

those
from

The

difference
of built-in

probably
care givers

reat

the

presence

childs

admission

was

significantly

less

likely

to be

home

for almost

all children,

whereas

many

adults,

244

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especially the elderly, this regard. Yet, at reasons for inappropriate

are inconveniently least in this initial admissions Children,

solitary trial, and days

in the of are

3. Acute 4. Acute
5.
6.

loss loss

Persistent
38.3#{176}C

of sight or hearing of ability to move body part fever (37.8#{176}C [100#{176}F] orally

or
days

care seem to echo those chosen priate hospitalization of adults. admitted to receive diagnostic
attention at a level easily

to explain and/or for

inapprotoo,

[101#{176}F]

rectally)

for more

than

10

Active
Wound Severe

bleeding
dehiscence electrolyte/acid or evisceration base abnormality (any

therapeutic
as outpatients;

7. 8.

achieved hospital. report, Hospitals

of

and

children

ready

medically

discharge
Kemper, and Clinics,

are
of the de-

the following a. Na <123

Na
b.

values): mEqjL,
mEqJL

nevertheless Finally, University

kept in the in an interesting of Wisconsin

>156

K <2.5

mEqJL,
mEqjL

K >5.6

scribed
that

a pediatrics
included several

adaptation
of the changes

of the days with

adult

AEP
The

we made.3

c. CO2 combining power normal) <20 mEciJL,

(unless

chronically

ab-

proportion ofinappropriate not be compared directly

number of reasons: the age

found, 21.4%, canour results for a

of Kempers 18 years AEP; of pop-

CO2 combining
normal)
d. 9. 10.

power
mEqjL
arterial

(unless

chronically

ab-

>36

range to

ulation
in day both was

extended
directions

beyond
(2 from to the

that
days analysis

in our patient whereas applied and

sample
age);

Arterial Hematocrit
Pulse rate
(optimally

pH <7.30, <30%
greater
a sleeping

pH >7.45
the following
<12 years

or less than
pulse for

ranges
old):

Kemper day
care some

reviewed
omitted

the day of discharge,

in the

that
for 1-

6 2-6

months-2 years
years

years minus 1 day of age, 80-100/mm; of age 70-200/mm;

of age, outside years 60-180/mm; following minus 1 ranges:

stays,
criteria

Kemper from
units

seemed
time were

to have
of

day
again,

of
a

7-11
12

admission, evaluated

years
values

of age, 50-140/mm

deviation
special

AEP
that

procedure;

patients
in our study

in

11.

BP

6 months-2

day of age, 70-100/40mm

mm where this

were not considered in hers. It would apply our pediatric AEP to the 6-month old population described by Kemper,
admission and day of care criteria,

be useful to to 15-yearwith both

what rate
12.
13.

85 mm Hg; 2-6 years of age,

7-11
12

75-125/40-90
80-130/45-90 puncture,

Hg
Hgprocedure is to

years

of age,

to see

years

of age, 90-200/60-120

mmHg basis responding

of inappropriate use would result. would be to find inappropriateness what we described in our trials.

Our expectation rates closer

Need

for lumbar

to

not done routinely on an outpatient Any of the following conditions not

outpatient
ment:

(including

emergency

room)

manage-

IMPLICATIONS
With children as with adults, medical resources can be put to better, more effective use without sacrificing health. Indeed, the extremely technical
facilities of todays acute care hospitals should be
14.

a. Seizures
b.

Cardiac

arrhythmia
asthma or croup

c. Bronchial

d. Dehydration e. Encopresis (for cleanout) f. Other physiologic problem

Special pediatric problems

more successfully used when they and their personnel can concentrate on the care of those who really need them, undiluted by the presence of even 10% or 15% of patients who are inappropriately there. The pediatric AEP should help identify areas for improvement not only for individual institutions but for the pediatric hospital system as a whole. APPENDIX 1: PEDIATRIC EVALUATION PROTOCOL CRITERIA A. Severity
1. Sudden sponsiveness) 2. Acute or

a. Child

abuse

b. Noncompliance

with necessary

therapeutic
monitoring in cases

reg-

imen c. Need for special observation or close of behavior, including calorie intake
failure to thrive

of

B. Intensity
1.

of Service
or procedure scheduled within 24 hours

Surgery

APPROPRIATENESS (AEP) ADMISSION

of Illness
onset

Criteria
of unconsciousness or disorientation sensory,

2.

necessitating a. General or regional anesthesia or b. Use of equipment, facilities, or procedure able only in a hospital Treatment in an intensive care unit
Vital sign monitoring every 2 hours or more

avail-

(coma
motor,

or unre-

3.

often

(may
circulatory,
4.

include

telemetry

or bedside

cardiac

monitor)

progressive

or respiratory pacitate the

breathe, urinate,

embarrassment patient (inability

etc)

sufficient to incato move, feed,

IV medications and/or fluid replacement (does not include tube feedings) 5. Chemotherapeutic agents that require continuous observation for life-threatening toxic reaction

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245

6. IM antibiotics 7. Intermittent every 8 hours

at least
or continuous

every

8 hours
respirator use at least

4.

Fever
reason

at

least
than

38.30C
fever

(1010F)
if patient

rectally
was

(at
admitted 1 hour

least
for

37.8#{176}C [100#{176}F]orally), other 5. Coma-unresponsiveness 6. Acute

for at least

confusional
and alcohol hematologic

state,

including

withdrawal

from
neutro-

PEDIATRIC B. Medical

AEP DAY OF CARE CRITERIA Services

in operating room preoperative that day

drugs
7. Acute

disorders-significant

1. Procedure 2. Procedure day,

penia, in operating room

consultation

anemia,

thrombocytopenia,
or thrombocytosis-yielding acute neurologic

leukocytosis,
signs

eror

scheduled

the

next
or 8.

ythrocytosis, symptoms Progressive

necessitating

difficulties

evaluation 3. Cardiac catheterization 4. Angiography that day

5.

that

day

APPENDIX that day

that
procedure tap,

2: REASONS

LIST

Biopsy

of internal

organ

6. Thoracentesis 7. Invasive CNS lumbar 8. 9. 10. 11. puncture,

or paracentesis
diagnostic cysternal

day
that ventricular day (eg, tap,

For

pneumoencephalography)
Gastrointestinal

endoscopy

that

day

Inappropriate Admission needed diagnosis and/or treatment that can be done on an outpatient basis 2. Patient admitted for diagnostic testing and/or treatment because patient lives too great a distance
1. Any from basis 3. a hospital for it to be done on an outpatient

Any test requiring strict dietary control for the duration of the diet New or experimental treatment requiring frequent dose adjustments with direct medical supervision
Close medical monitoring by a doctor at least three

Patient
because outpatient
testing

admitted

for diagnosis

and/or

treatment

it was not possible basis (although,

and needs treatment could

to be scheduled on an aside from scheduling,

have care, been but done at a level on an

times daily record)

12. B. Postoperative

(observations
day Support for any

must

be documented
described

in
in 4.

outpatient
procedure Patient

basis)
institutional

less

numbers
Nursing/Life 1. Respiratory

1 or 3 to 8 above
Services

than an acute care hospital-general (unspecified) 5. Patient needs care in a chronic disease hospital
6. 8. 9. Patient Premature needs needs care care admission in a skilled in a nonskilled (eg, on Friday nursing nursing for facility facility 7. Patient

care-intermittent or continuous respirator use and/or inhalation therapy (with chest physical therapy, intermittent positive pressure breathing) at least three times daily, isoetharine hydrochloride (Bronkosol) with oxygen, Oxyhoods, oxygen tents

a proce-

For

dure scheduled for the following Other-specify Inappropriate Day of Care

Monday)

2.

Parenteral

therapy-intermittent

or continuous
(electrolytes, at least every 30

A. For

patients

who

need

continued
scheduling
scheduling

hospital
of operative
of tests

stay

for
pro-

IV fluid with any supplementation protein, medications) 3. Continuous vital sign monitoring, minutes for at least 4 hours 4. IM and/or subcutaneous injections
daily 5. 6.

medical reasons 20. Problem in hospital cedure

21. Problem in hospital

or nonop-

at least

twice
22.

erative
Premature

procedure
admission

Intake
Major tubes,

and/or
surgical t tubes,
for

output

measurement
care (eg, chest drains)
or congenital

23. 24.
25.

Patient
lems

bumped
due
not in

because

of operating
problem
of diagnostic

room prob(ie, procetest or

wound and drainage Hemovacs, Penrose

fractures, dislocations,

Delay
dures Delay

to 40-hour

week

7. Traction 8. C. A.

deformities Close medical monitoring times daily with doctors

Condition reviewed the day

done on weekend) receiving results

by nurse orders
for the bowels,

at least

three 29.

Patient (Being 1. Inability

consultation treatment Other-specify

needed

to direct

further

evaluation/

before

day not

of care) attributable

B. For patients

to void

or move

to

neurologic reviewed

disorder-usually within 2 days

a postoperative before the day of

problem
Being

who do not need continued for medical reasons 1. Hospital or physician responsibility a. Failure to write discharge orders
b. Failure to initiate timely hospital

hospital

stay

discharge

care
2. Transfusion 3. Ventricular due to blood loss fibrillation or ECG as stated in progress

planning c. Overly conservative evidence of acute note or in ECG

tient d. No by physician documented plan

medical
for

management
active treatment

of paof

ischemia,

report

evaluation

of patient

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HOSPITALIZATION

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EVALUATION

e. Other-specify
2. Patient b. or family responsibility

a. Lack of family

for home

care
care space at

Family unprepared for patients home c. Patient/family rejection of available appropriate alternate facility
responsibilities

3.

d. Other-specify Environmental
a. Patient
kept until

from

unhealthy

environment-patient
becomes acceptable or

environment

alternative facility found b. Patient is convalescing from an illness,

anticipated
facility would

evaluation protocol and the standardized medreview instrument. Final Report, Health Care Financing Administration grant 18-C-98582/5-01 and 02. Detroit, MI, September 1987 4. Rishpon 5, Lubacsh 5, Epstein LM. Reliability of a method of determining the necessity for hospital days in Israel. Med Care. 1986;24:279-282 5. Wakefield DG, Pfaller MA, Hammons GT, et al. Use of the appropriateness evaluation protocol for estimating incremental costs associated with nosocomial infections. Med Care. 1987;25:481-488 6. Restuccia JD, Payne SMC, Lenhart GM, et al. Assessing the appropriateness of hospital utilization to improve efficiency and competitive position. Health Care Manage Rev.
1987;13:17-27

and it is

that

his/her
than

stay

in an alternative facility nonfacility-based care)

be less

72 hours

c. Unavailability of alternative d. Unavailability of alternative treatment (eg, home health e. Other-specify

JD, Kreger BE, Gertman PM, et al. The approof hospital use in Massachusetts. Health Care Finan Rev. 1986;8:47-53 8. Restuccia JD, Gertman PM, Dayno SJ, et al. A comparative analysis of appropriateness of hospital use. Health Aff. 1984;3:130-138 9. Studnicki J, Stevens CE. The impact of a cybernetic control system on inappropriate admissions. Quality Rev Bull.
1984;304-311

7. Restuccia priateness

REFERENCES 1. Gertman PM, Restuccia JD. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care. 1981;19:855-870 2. Siu AL, Sonnenberg FA, Manning WG, et al. Inappropriate use of hospitals in a randomized trial of health plans: N EngI J Med. 1986;315:1259-1266 3. Strumwasser I, Paranjpe NV. Estimate of non-acute hospitalization: a comparative analysis of the appropriateness

10. Payne SMC. Identifying and managing inappropriate hospital utilization. Health Serv Res. 1987;22:709-769 11. Restuccia JD, Payne SMC, Welge CH, et al. Reducing inappropriate use of inpatient medical/surgical and pediatnc services. Report on Health Care Financing Administration contract 18-C-98317/1-02. Boston, MA: Health Care Research Unit, Boston University Medical Center, March 1986 12. Cohen JA. A coefficient of agreement for nominal scales. Educ Psychol Measure. 1960;20:37-46 13. Kemper KJ. Medical inappropriate use in a pediatric population. N Engl J Med. 1988;318:1033-1037

ENDURING

FAMILIES

AT

RISK

A divorce-prone society is producing its first and women so anxious about attachment and enduring families is imperiled.

generation love that

of young adults, men their ability to create

Submitted

by Student

From 1989.

Wallerstein

JS. Children

after

divorce:

wounds

that

dont

heal.

The New

York

Times;

Jan

22,

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247

Assessing the Need to Hospitalize Children: Pediatric Appropriateness Evaluation Protocol Bernard E. Kreger and Joseph D. Restuccia Pediatrics 1989;84;242
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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 1989 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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