Objectives. 1) To describe the asthma morbidity, primary care practices, and asthma home management of inner-city children with asthma; 2) to determine the responses of parental caretakers to asthma exacerbations in their child; and 3) to compare these responses to the recommendations of the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines for home management of acute exacerbations of asthma.
Design and Methods. A 64-item telephone survey was administered between July 1996 and June 1997 to 220 parental caretakers of 2- to 12-year-old children who had been hospitalized with asthma at an inner-city medical center from January, 1995 to February, 1996. Sociodemographics, primary care practices, asthma morbidity, and asthma home management were assessed. Parents were asked what they would do if their child “began wheezing and breathing faster than usual.”
Results. Morbidity measures indicated that there were an average of 2.5 ± 4.5 emergency department visits for asthma in the last 6 months, 1.6 ± 2.2 hospitalizations for asthma in the last 12 months, and 18.1 ± 17.9 asthma-related school absences in the previous school year. Most, but not all, of the families had primary care providers and most had phone access to them. Half of the families (51%) reported having been given a written asthma action plan. Only 30% of families with children age 5 years and older had peak flow meters. In contrast, almost all families (97%) had equipment for inhalation of β-agonists. Only 39% of the 181 children with persistent symptoms were receiving daily antiinflammatory agents as recommended in the guidelines of the NHLBI. In response to the scenario of an acute exacerbation of asthma, no one mentioned that they would refer to a written plan, only 1 caretaker would measure peak flow and 36% would give β-agonists. Two percent would give oral steroids initially, and 1 additional person would do so if wheezing continued 40 minutes later. Only 4% responded that they would contact their clinician. Reports of actual practice differed from the scenario responses in that more people began β-agonists and oral steroids in response to an exacerbation in the past 6 months than said they would in response to the scenario.
Conclusion. In this population of previously hospitalized inner-city children with asthma, the NHLBI guidelines for the home management of asthma exacerbations are not being followed. Interventions are needed to affect both clinician and caretaker practices.
- inner city
- standard of care
- peak flow
- oral steroids
- access to care
- antiinflammatory agents
Asthma is a major cause of childhood morbidity, affecting 4.8 million children in the United States.1 It is the most common reason for hospitalization and for school absence in children with chronic medical conditions.2 Asthma is disproportionately prevalent in the inner city,3 and its prevalence and associated morbidity are increasing.4,,5 In the Bronx, NY, the 12-month period prevalence rate of asthma in children has been estimated to be 8.6%, twice the national rate,4 and asthma hospitalization and mortality rates continue to climb.6
Efforts to understand the particularly high asthma morbidity in the inner city have looked at environmental factors such as poor housing stock, cockroach exposure, overcrowding, pollutants, and the impact of poverty. Recent studies have suggested that another factor affecting morbidity may be the current standard of care for inner-city children with asthma.7–9
Partnerships between clinicians and caretakers of children with asthma are considered an important component of asthma management. The dynamic nature of asthma, with waxing and waning symptoms, requires ongoing assessment of symptoms and modification of the treatment plan as needed. Clinicians must work with families to help them develop asthma management skills by providing them with appropriate resources and by teaching them to recognize asthma symptoms and to follow appropriate treatment plans. At home, caretakers assume the front line in responding to asthma exacerbations.
Guidelines for asthma management were developed in 199110and revised in 199711 by the National Heart, Lung, and Blood Institute (NHLBI). The NHLBI recommendations for the home management of asthma exacerbations include: 1) having a written asthma action plan with information on what to do at home, when to call the clinician, and when to seek emergency care; 2) use of peak flow meters (for children 5 years and older) to assess the severity of an attack and monitor response to therapy; 3) initiation of inhaled β-agonists; 4) initiation of oral steroids for an incomplete response to therapy with β-agonists; and 5) prompt communication with the child's clinician about any serious deterioration in symptoms and/or peak flow or decreased responsiveness to inhaled β-agonists.
The objectives of this study were: 1) to describe the primary care practices, morbidity, and home management by parental caretakers of inner-city children; 2) to determine responses of parental caretakers to a scenario describing an asthma exacerbation in their child; and 3) to compare these responses to selected recommendations of the NHLBI asthma guidelines.
Study participants were 220 parental caretakers of 2- to 12-year-old children with asthma-related hospitalizations who were recruited as part of a randomized controlled trial to evaluate the effectiveness of the Asthma Passport Program, a primary care-based asthma educational intervention. Baseline data obtained at enrollment were used to compare reported home management of asthma exacerbations and caretakers' responses to vignettes of an asthma exacerbation with the recommendations of the NHLBI guidelines.
Recruitment occurred at a municipal hospital that serves a predominantly inner-city, low-income patient population. Names of 2- to 12-year-old children who had asthma-related hospitalizations from January, 1995 to September, 1996 were obtained from the hospital medical records database. Children with other chronic illnesses affecting the lungs were excluded. In addition, children whose caretakers were not English- and/or Spanish-speaking residents of the Bronx were excluded. As a result of the requirement of the intervention study, all families had to be interested in receiving their child's medical care at our outpatient clinic and not be prohibited from attending our clinic based on participation in a health maintenance organization (HMO) or managed care group that was not accepted by our institution. All had to be willing to receive care from a health care provider participating in the longitudinal study.
All potentially eligible families were mailed information regarding the study and a consent form approved by our Institutional Review Board together with a stamped, self-addressed return envelope. Approximately 1 week after sending the letter, trained research assistants contacted families by phone to screen for eligibility. Of 947 potentially eligible study participants, 591 (62%) were successfully contacted and screened for eligibility. Reasons for not screening families included incorrect or disconnected telephone numbers (48% and 34%, respectfully), no listed phone number (10%), or no response (8%). Of the 591 contacted, 318 met eligibility requirements. The remainder were excluded for the following reasons: 5 had other chronic illness affecting the lungs (eg, pulmonary tuberculosis and bronchopulmonary dysplasia); 98 belonged to an HMO or managed care group not accepted by our institution; 93 did not want to attend our hospital-based outpatient program; 20 were already enrolled in another asthma study; 1 had a sibling already enrolled in the study; 2 had parents unable to complete the telephone survey (1 deaf, 1 mentally ill); and 53 had ongoing relationships with clinicians who were not participating in our study. Of the 318 eligible respondents, 220 (69%) agreed to participate in the longitudinal study (Table 1). All 220 who consented to the study completed the baseline interview. The average time from the last hospitalization to the interview was 7.5 months (range, 0–21 months).
Baseline study data were obtained by 30-minute telephone interviews between July, 1996 and June, 1997 by research assistants trained in questionnaire administration. Caretakers were given the option of being interviewed in English or Spanish and were paid $10 for the interview. Spanish was the language used for 19.6% of the interviews.
The data collection instrument was the Asthma Self-management Awareness Program Questionnaire, a new 64-item questionnaire developed by the authors for this study. It includes four domains: sociodemographics, primary care practices, asthma morbidity, and asthma home management. The Spanish language version was created by translation and back translation into English by two native Spanish speakers. Assessment of primary care practices included whether the caretaker had a regular doctor for the child, telephone access to the doctor, the frequency of primary care visits, and the usual place of care. Asthma morbidity was assessed using symptom days during the last 4 weeks, emergency department (ED) visits during the last 6 months, and hospitalizations and school absences because of asthma during the last 12 months. Home management questions assessed availability of appropriate equipment for inhalation of β-agonists, ie, metered-dose inhalers with spacer devices or nebulizer machines; peak flow meters for home monitoring; use of asthma medications in the last 4 weeks; and exposure to asthma triggers in the home environment.
Medical terminology was translated into simple language. For example, information regarding written asthma home management plans was obtained by asking, “Did your doctor write down for you what to do at home to take care of your child's asthma?” Medication use was assessed by asking open-ended questions regarding use of pumps, nebulizer machines, and so forth. Steroids, cromolyn sodium, and nedocromil were classified as antiinflammatory agents.
Families were also asked to respond to the following scenario of an acute exacerbation of asthma, “If your child began wheezing and breathing faster than usual what would you do?” Those who would give medication at home were subsequently asked what they would do if 20 minutes and 40 minutes later, the child felt better, but was still wheezing and breathing a little harder than usual. The scenarios were pilot tested on a small sample of parents of children with asthma. Open-ended responses to the scenario were categorized and compared with the five selected recommendations of the NHLBI guidelines discussed earlier. Some responses were precoded and listed on the questionnaire, others were written in by the research assistant and coded and confirmed by two of the authors working independently. Actual management of asthma exacerbations was also assessed using historical reports of medication use in response to asthma exacerbations in the last 6 months. Asthma exacerbations were referred to as “asthma attacks” and defined as “episodes of coughing, wheezing or difficulty breathing.”
Asthma severity was determined by applying the 1997 NHLBI criteria for persistent asthma based on symptom days. We extrapolated from the NHLBI use of symptom days per week to symptom days per month and in keeping with the guidelines used symptom nights per month. Children with either 9 or more days per month and/or 3 or more nights per month with asthma symptoms were categorized as having persistent asthma; whereas, those with less frequent symptoms were categorized as having mild intermittent asthma.
All data analyses were conducted using SPSS/PC+ Version 5.0.12 The analyses we report were primarily descriptive in nature. We have provided summary statistics for the study variables as appropriate (including means, standard deviations, and percentages). Bivariate analyses were conducted to examine whether child and/or caretaker characteristics, health service variables, or severity of illness were related to process measures (eg, use of written plans, peak flow meters, etc). Differences between the groups were evaluated using: 1) cross tabulation and χ2 tests for categorical dependent variables (eg, sex, ethnicity, insurance status); and 2) one-way analysis of variance for continuous variables (eg, age).
The caretakers were overwhelmingly mothers (92%); the remainder were fathers (1%), grandparents (2%), and foster parents (5%). The caretakers were primarily Hispanic (42.3% Puerto Rican, 17% other), 33% black (25.5% African-American, 7.7% West Indian, 0.5% other), 1.4% white, and 6.8% other. Additional characteristics of the caretakers and children are included in Table 1.
Table 2 shows the baseline asthma morbidity, measured by ED visits, hospitalizations, school absences, and asthma symptom days in the last 4 weeks.
Primary Care Practices
We first looked at caretakers' usual source of care for their child, whether they had an established relationship with a primary care provider, and if they thought they would be able to contact their clinician by phone in the event of an asthma exacerbation. Seventy-eight percent could identify a primary care provider, and of these families, 84% reported phone access to the clinician. The usual source of care for the children was: 51% outpatient clinic, 25% private doctor, 9% no usual source of care, and 4% an ED. The children averaged 3.1 visits to their clinicians in the last 6 months (median = 2; range, 0–52) including 1.9 visits with asthma symptoms (median = 1; range, 0–52).
Table 3 provides information regarding the availability of written management plans and equipment for asthma home management. Half of the families (51%) reported having been given a written plan, and of these families, 67% reported that they still had the plan, leaving 34% of families with written plans. Home peak flow meters were reported by 30% of families with children ages 5 years and older, ie, those who are old enough to use them. Almost all families (97%) had equipment for inhalation of β-agonists (metered-dose inhalers and/or nebulizers).
Background information on the use of prophylactic asthma medicines was also obtained. We found that 35% of families reported giving daily antiinflammatory medications; of these, 83% gave cromolyn sodium alone. Using the 1997 NHLBI criteria, we identified a subset of children with persistent asthma for whom the guidelines recommend starting or increasing antiinflammatory agents. In our sample, 82% of the children (n = 181) met the criteria. Of these children, 70 (39%) were receiving antiinflammatory agents and 111 (61%) were not. Of the 70 symptomatic children receiving antiinflammatory agents, 50 (71%) were receiving cromolyn sodium alone, and 20 (29%) were receiving an inhaled steroid with or without cromolyn sodium.
Potential asthma triggers in the home environment were assessed. The majority of families lacked zippered pillows (79%) and mattress covers (68%), and had dust (69%) and cockroaches (56%) at home. Other potential triggers included drapes (46%) and rugs (30%). There were smokers in 32% of the households. Mold, cats, and dogs were each present in ∼10% of homes.
Responses to the scenario of an acute exacerbation of asthma were compared with five selected recommendations of the NHLBI asthma guidelines that include: written asthma action plans, peak flow meters, β-agonists, oral steroids for incomplete response to therapy, and contacting the clinician. In response to the scenario of an acute exacerbation of asthma, no one mentioned that they would refer to a written plan. For the children 5 years and older, who could use a peak flow meter (n = 143), only one person reported that she would measure peak flow. In terms of medication use, the majority of families (57%) would not give medication and would go directly to the ED, 36% would give β-agonists, and 7% would do nothing or give an inappropriate medication. Oral steroids would be given initially by 2% (n = 6) and by one additional person if wheezing continued 40 minutes later. Only 4% responded that they would contact their clinicians.
Table 4 shows a comparison of the scenario responses and actual practice, as assessed by retrospective report, with the five selected recommendations of the NHLBI Guidelines. Caretakers whose child had at least one asthma exacerbation during the last 6 months were asked to recall what medications they had given in response to an asthma exacerbation at home during the last 6 months. There were 189 caretakers (86%) whose child had at least one attack during the preceding 6-month period. These children had an average of 7.3 ± 14.7 (median = 3.0) asthma exacerbations in the last 6 months. In contrast to the responses to the scenario, of those caretakers whose child had a recent attack, 75% reported that they had given β-agonists and 26% reported giving prednisone. Only 11% reported that they did not attempt home treatment and went directly to the ED.
We examined whether child and/or caretaker characteristics, health service variables, or severity of illness were related to three of the five NHLBI recommendations: 1) having a written management plan, 2) use of peak flow meters among children older than 5 years, and 3) caretaker's use of β-agonists in response to the scenario presented in the interview. The other two recommendations, initiation of steroids after incomplete response and calling the doctor during an exacerbation, occurred too infrequently as replies to the scenario to be evaluated in this manner.
We found there were fewer caretakers with less than a high school education among the 112 respondents who said they had received written plans than among the 108 caretakers who reported that they had not (35% vs 51%, P < .02). However, none of the other sociodemographic characteristics we examined (child age and sex, caretaker ethnicity, insurance status, public assistance) differed significantly between these two groups. Moreover, none of the sociodemographic characteristics differed between families of children >5 years of age who reported that they either did (n = 41) or did not (n = 102) have peak flow meters at home.
Families with and without written plans also did not differ in whether the children had intermittent or persistent asthma symptoms based on the 1997 NHLBI criteria (used in our study as the indicator of illness severity), whether the parents could identify a primary care provider, and whether they knew how to reach their clinicians when their children were symptomatic. However, we found that the families who said their children attended our hospital-based clinic were more likely to have written plans (n = 99, 59%) than families whose children went to other clinics or health stations (n = 37, 38%) or to private doctors (n = 55, 38%). Surprisingly, we found that 55% of the 20 families who said they had no usual source of care and 7 of 9 (78%) who went to the ED for their care reported that they had been given a written asthma plan by a doctor. Neither severity of symptoms nor any health services characteristics differed between families of children >5 years of age with and without peak flow meters at home.
We also compared the 80 families who responded to the scenario by saying that they would treat an asthma exacerbation at home using β-agonists with the 139 families who said they would go directly to the ED, do nothing, or would give an inappropriate medication. We found that those who would give β-agonists did not differ from those who would not in regard to any child or caretaker demographic characteristic, the usual source of care, being able to identify a primary care provider, or knowing how to reach that provider in the event of an exacerbation. There also was not a significant difference in the proportion of children with intermittent (rather than persistent) symptoms among families who would give β-agonists compared with those who would not (20% vs 16%). Furthermore, having a written plan and/or a peak flow meter were not related to whether caretakers said they would treat at home with β-agonists.
We compared the scenario responses to retrospective data that was available for the 188 families whose child had had an asthma attack in the last 6 months. Of these families, there were 69 who would give β-agonists in response to the scenario. Almost all these families, 63 of 69 (91%), reported that they had given β-agonists in the last 6 months in response to an asthma exacerbation. In contrast, when we compared the 119 families who responded to the scenario by saying that they would go directly to the ED, do nothing, or give an inappropriate medication, 92 of 119 (75%) said that they had given β-agonists in response to an attack. Differences between the responses of the two groups were statistically significant (P < .02).
In this study, we focused on home management of asthma exacerbations by caretakers of inner-city children who had had asthma-related hospitalizations during the past 2 years. We found that in response to a scenario of an acute exacerbation of asthma, most caretakers reported that they would take their child directly to the ED without attempting home management as recommended in the NHLBI guidelines. Although almost all families reported having equipment for β-agonist administration, few have other resources for asthma management recommended by the guidelines, including peak flow meters or written management plans.
Parental adherence to the guidelines is, in part, a reflection of the care they receive from their physician. This study took place between July, 1996 and June, 1997, 5 years after the initial publication of national asthma guidelines, and yet, the guidelines have not been fully adopted. The guidelines are a valuable resource; however, their length and complexity may interfere with accessibility and ready adaptation by busy clinicians. Furthermore, clinicians' familiarity with the guidelines is not enough. Teaching the contents of the guidelines to families requires repeated exposures to the material and incremental learning. Pulmonologists and allergists may be more familiar with the guidelines. However, with the high prevalence of asthma in the inner city it is doubtful that these specialists can be available to all inner-city families with asthma to the extent that primary care providers can. We are currently evaluating an educational intervention, The Asthma Passport Program, which aims to increase primary care providers' familiarity with the asthma guidelines.
In the inner city, implementation of the guidelines is particularly difficult. Asthma teaching takes time and is difficult to accomplish in a busy clinic setting when other medical and psychosocial issues may predominate. In addition, reliance on episodic care and ED visits in the inner city interferes with the development of partnerships between clinicians and caretakers and limits opportunities for asthma education.
Partnerships between health care providers and caretakers are considered to be an important component of asthma management. The majority of our families were able to identify a particular individual as their child's primary care provider, but few, if any, of our families reported that they would attempt to contact their clinician during an exacerbation. Barriers to calling do not seem to be lack of access to a phone or not knowing how to call because the majority of our families had access to phones and knew how to call; yet only 4% would call in response to the scenario. In a recent study of a program for life-threatening asthma, delayed care and lack of communication with caregivers was identified as a primary treatment problem.13 Set instructions on when to call, and on the home use of peak flow meters, may help parents by providing them with objective information on when to call their clinicians. Further work is necessary to identify barriers to calling.
Peak flow meters are recognized as an important component of home management. Interventions using peak flow meters in conjunction with a comprehensive asthma program have shown significant improvements in lung function, symptoms, and medication use.14,,15 The failure to have criteria to observe for improvement after giving medicines has been associated with increased ED use for asthma.16 Parents can use peak flow monitoring to help estimate the severity of an exacerbation and the child's response to inhaled β-agonists.17 Providing families with peak flow meters can also give them more of a sense of control and facilitate proper communication by phone. Only a small percentage of families reported having been given peak flow meters, and only one study participant spontaneously reported that she would use it to monitor the severity of an exacerbation or response to treatment.
Written asthma action plans with instructions on when to change the medication plan and when to call for help are also recommended in the asthma guidelines. In the inner city, low literacy rates and limited English skills may interfere with the use of written asthma action plans. Having standardized, easy-to-understand plans that are readily available may be helpful. Clinicians may be uncomfortable trying to write out clear instructions for a variable illness that requires constant reassessment. Clinicians also have to feel comfortable with the skills and judgment of the families. For example, for clinicians to provide families with prednisone for home use, they must trust that the families will use it appropriately and contact them for guidance.
Initiation of oral steroids is recommended for incomplete response to therapy. Oral steroids are an important part of the armamentarium for controlling asthma exacerbations. Appropriate use of prednisone can reduce symptom days and decrease the need for hospitalizations. Few of our families would give oral steroids in response to the initial scenario or if wheezing continued 20 minutes and 40 minutes after treatment. Early initiation of oral steroids by caretakers may help to reduce asthma morbidity.
Other important aspects of home management include the use of prophylactic medication. In our sample, more children should be receiving prophylactic medications than are currently receiving them. Other reports in the literature have documented an overreliance on β-agonists and underuse of antiinflammatories.18 We cannot determine, based on these data, the relative contributions of underrecognition of symptoms and undertreatment on the part of the clinician and of failure on the part of the caretaker to adhere to a suggested treatment plan.
Reduction of asthma triggers is also an area for improvement. Economic factors may limit a family's ability to move from dusty and cockroach-infested areas or from shared homes where other family members smoke or have pets. The majority of our families reported the presence of dust and of cockroaches.
There were several limitations to this study. One is that we used a hypothetical scenario. Studies by Kolbe et al19,,20 have demonstrated the value of using scenarios in asthma studies to explore the gap between knowledge about treatment and actual practice. We were able to compare responses to the scenario with retrospective data we collected on what families had done at home in the last 6 months.
Actual practice did differ from the reported responses to the scenario. More people began β-agonists and oral steroids at home in the last 6 months for asthma exacerbations than said they would in response to the scenario. There are two possibilities we can speculate regarding the discrepancy between actual practice and response to our scenario. The first is that families initiate treatment at home rather than go to the ED although they think that going to the ED would be the right thing to do. It would be reasonable to think that many families try home treatments, including β-agonists, before seeking medical care, in hope of avoiding an unnecessary trip to the ED. The other possibility for the discrepancy is that the respiratory distress described in the scenario was perceived by the families to be more severe than actual attacks they had treated at home, so they were more aggressive in seeking emergency care. Regardless of the interpretation, it seems that many families are in fact attempting to treat asthma attacks at home. β-agonist use for asthma exacerbations, in the absence of asthma action plans, peak flow meters, and without contacting a clinician may be less effective and delay appropriate care.
We do not know how well our findings generalize to other inner-city children. Our sample is composed exclusively of previously hospitalized children; thus, it may not represent the population at large, but rather a subset of families with poorer outpatient management skills or more severe asthma. In addition, we restricted our study to English and Spanish speakers and excluded families belonging to outside HMO or managed care groups because they could not be randomized to the intervention for the longitudinal study. Furthermore, we chose families who were interested in receiving outpatient care for their child in a public hospital's primary care clinic. It may be that families who already attend this clinic differ from other families. Those who are willing to make a shift in their care to attend this clinic may also have less well established connections with their current care providers and perceive a need for change and improvement.
This analysis of the home management of asthma exacerbations by inner-city families suggests that the home management practices in this population of inner-city children do not conform to the recommendations of the NHLBI asthma guidelines. Families must be better prepared to respond to asthma exacerbations in their children. Specific areas for strengthening were identified including increasing the distribution and use of written asthma action plans and peak flow meters, and increasing phone contact with clinicians during asthma exacerbations. Whereas administration of β-agonists and, at times, oral steroids are appropriate responses to asthma exacerbations, administration of rescue medications must be incorporated into a comprehensive treatment plan. Further work is needed to develop interventions to affect both clinician and caretaker treatment practices.
This work was supported by a grant from the Fan Fox and Leslie R. Samuels Foundation.
The authors wish to acknowledge Mo Katz, of the Fan Fox and Leslie R. Samuels Foundation, for his personal support of the project up until his death in 1997. We also thank Laurie Bauman, PhD; Ellen Crain, MD, PhD; and Nora Esteban-Cruciani, MD, for their help with the questionnaire construction and Ivette Perez and Tracey Pusey for research assistance. Finally, we thank the families for their participation and the New York City Health and Hospitals Corporation for its cooperation.
- Received February 23, 1998.
- Accepted August 5, 1998.
Reprint requests to (K.L.W.) Department of Pediatrics, Albert Einstein College of Medicine/Montefiore Medical Center, 1621 Eastchester Rd, Bronx, NY 10461.
Portions of this study were presented at the 37th Annual Meeting of the Ambulatory Pediatric Association, Washington, DC, May 3, 1997.
- NHLBI =
- National Heart, Lung, and Blood Institute •
- HMO =
- health maintenance organization •
- ED =
- emergency department
- Adams PF,
- Marano MA
- Taylor WR,
- Newacheck P
- Crain EK,
- Weiss K,
- Bijur P,
- Hersh M,
- Carr W,
- Zeitel L,
- Weiss K
- Homer CJ,
- Szilagyi P,
- Rodewald L,
- et al.
- Evans D,
- Mellins R,
- Lobach K,
- et al.
- Halfon N,
- Newachek PW
- ↵National Asthma Education and Prevention Program. Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma. Publication 91–3042. Bethesda, MD: National Institutes of Health; 1991
- ↵National Asthma Education and Prevention Program. Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health Publication; 1997
- ↵Norusis MJ. SPSS/PC+ Version 5.0. Chicago, IL: SPSS, Inc; 1992
- Sherman JM,
- Capen CL
- Beasley R,
- Cushley M,
- Holgate ST
- Lloyd BW,
- Ali MH
- Copyright © 1999 American Academy of Pediatrics