A survey study of index food-related allergic reactions and anaphylaxis management

To cite this article: Jacobs TS, Greenhawt MJ, Hauswirth D, Mitchell L, Green TD. A survey study of index food-related allergic reactions and anaphylaxis management. Pediatr Allergy Immunol 2012: 23: 582-589. ABSTRACT: Background: Initial food-allergic reactions are often poorly recognized and under-treated. Methods: Parents of food-allergic children were invited to complete an online questionnaire, designed with Kids with Food Allergies Foundation, about their children's first food-allergic reactions resulting in urgent medical evaluation. Results: Among 1361 reactions, 76% (95% CI 74-79%) were highly likely to represent anaphylaxis based on NIAID/FAAN criteria. Only 34% (95% CI 31-37%) of these were administered epinephrine. In 56% of these, epinephrine was administered by emergency departments; 20% by parents; 9% by paramedics; 8% by primary care physicians; and 6% by urgent care centers. In 26% of these, epinephrine was given within 15?min of the onset of symptoms; 54% within 30?min; 82% within 1?h; and 93% within 2?h. Factors associated with a decreased likelihood of receiving epinephrine for anaphylaxis included age <12?months, milk and egg triggers, and symptoms of abdominal pain and/or diarrhea. Epinephrine was more likely to be given to asthmatic children and children with peanut or tree nut ingestion prior to event. Post-treatment, 42% of reactions likely to represent anaphylaxis were referred to allergists, 34% prescribed and/or given epinephrine auto-injectors, 17% trained to use epinephrine auto-injectors, and 19% given emergency action plans. Of patients treated with epinephrine, only half (47%) were prescribed epinephrine auto-injectors. Conclusions: Only one-third of initial food-allergic reactions with symptoms of anaphylaxis were recognized and treated with epinephrine. Fewer than half of patients were referred to allergists. There is still a need to increase education and awareness about food-induced anaphylaxis.     

Severe food-allergic reactions in children across the UK and Ireland, 1998-2000

Aim: Medical and lay concerns about food allergy are increasing. Whilst food allergy may be becoming more common, fatal reactions to food in childhood are very rare and their rate is not changing. We sought to establish how common severe reactions are. Methods: Prospective survey, 1998 to 2000, of hospital admissions for food-allergic reactions—conducted primarily through the British Paediatric Surveillance Unit, covering the 13 million children in the United Kingdom and Ireland. Results: 229 cases reported by 176 physicians in 133 departments, yielding a rate of 0.89 hospital admissions per 100 000 children per year. Sixty-five per cent were male, 41% were under 4 y and 60% started at home. Main allergens were peanut (21%), tree nuts (16%), cow's milk (10%) and egg (7%). Main symptoms were facial swelling (76%), urticaria (69%), respiratory (66%), shock (13%), gastrointestinal (4%). Fifty-eight cases were severe. Three were fatal, six near fatal, and 8 of these 9 had asthma with wheeze being the life-threatening symptom. Three near-fatal cases received excess intravenous epinephrine. None of the non-fatal reactions resulted in mental or physical impairment. Seven of 171 non-severe and 6/58 severe cases might have had a worse outcome if epinephrine auto-injectors had been unavailable. Six of the severe cases might have benefited if auto-injectors had been more widely prescribed.

Conclusion: In the United Kingdom and Ireland, the incidence of severe reactions is low. The study highlights that: asthma is a strongly significant risk factor for a severe reaction and therefore warrants optimal management; severe wheeze is a prominent feature of severe reactions and warrants optimal management; intravenous epinephrine should be used with great care if needed. Epinephrine auto-injectors do not always prevent death, but our study design and data do not allow a definite statement about whether overall they are beneficial.     

Food-allergic reactions in schools and preschools.

BACKGROUND: Food allergies may affect up to 6% of school-aged children. OBJECTIVES: To conduct a telephone survey to characterize food-allergic reactions in children (defined as those aged 3-19 years in this study) with known food allergies in schools and preschools and to determine mechanisms that are in place to prevent and treat those reactions. DESIGN: The parents of food-allergic children were contacted by telephone and asked about their child's history of food-allergic reactions in school. The schools the children attended were contacted, and the person responsible for the treatment of allergic reactions completed a telephone survey. RESULTS: Of 132 children in the study, 58% reported food-allergic reactions in the past 2 years. Eighteen percent experienced 1 or more reactions in school. The offending food was identified in 34 of 41 reactions, milk being the causative food in 11 (32%); peanut in 10 (29%); egg in 6 (18%); tree nuts in 2 (6%); and soy, wheat, celery, mango, or garlic in 1 (3%) each. In 24 reactions (59%), symptoms were limited to the skin; wheezing occurred in 13 (32%), vomiting and/or diarrhea in 4 (10%), and hypotension in 1 (2%). Also, 15 (36%) of the 41 reactions involved 2 or more organ systems, and 6 (15%) were treated with epinephrine. Fourteen percent of the children did not have a physician's orders for treatment, and 16% did not have any medications available. Of the 80 participating schools, 31 (39%) reported at least 1 food-allergic reaction within the past 2 years and 54 (67%) made at least 1 accommodation for children with a food allergy, such as peanut-free tables, a peanut ban from the classroom, or alternative meals. CONCLUSIONS: It is common for food-allergic children to experience allergic reactions in schools and preschools, with 18% of children having had at least 1 school reaction within the past 2 years. Thirty-six percent of the reactions involved 2 or more organ systems, and 32% involved wheezing. Every effort should be made to prevent, recognize, and appropriately treat food-allergic reactions in schools.     

Management of food allergy in the school setting

Food allergy is estimated to affect approximately 1 in 25 school-aged children and is the most common trigger of anaphylaxis in this age group. School food-allergy management requires strategies to reduce the risk of ingestion of the allergen as well as procedures to recognize and treat allergic reactions and anaphylaxis. The role of the pediatrician or pediatric health care provider may include diagnosing and documenting a potentially life-threatening food allergy, prescribing self-injectable epinephrine, helping the child learn how to store and use the medication in a responsible manner, educating the parents of their responsibility to implement prevention strategies within and outside the home environment, and working with families, schools, and students in developing written plans to reduce the risk of anaphylaxis and to implement emergency treatment in the event of a reaction. This clinical report highlights the role of the pediatrician and pediatric health care provider in managing students with food allergies.     

The US Peanut and Tree Nut Allergy Registry: characteristics of reactions in schools and day care

OBJECTIVE: Severe food-allergic reactions occur in schools, but the features have not been described. STUDY DESIGN: Participants in the US Peanut and Tree Nut Allergy Registry (PAR) who indicated that their child experienced an allergic reaction in school or day care were randomly selected for a telephone interview conducted with a structured questionnaire. RESULTS: Of 4586 participants in the PAR, 750 (16%) indicated a reaction in school or day care, and 100 subjects or parental surrogates described 124 reactions to peanut (115) or tree nuts (9); 64% of the reactions occurred in day care or preschool, and the remainder in elementary school or higher grades. Reactions were reported from ingestion (60%), skin contact/possible ingestion (24%), and inhalation/possible skin contact or ingestion (16%). In the majority of reactions caused by inhalation, concomitant ingestion/skin contact could not be ruled out. Various foods caused reactions by ingestion, but peanut butter craft projects were commonly responsible for the skin contact (44%) or inhalation (41%) reactions. For 90% of reactions, medications were given (86% antihistamines, 28% epinephrine). Epinephrine was given in school by teachers in 4 cases, nurses in 7, and parents or others in the remainder. Treatment delays were attributed to delayed recognition of reactions, calling parents, not following emergency plans, and an unsuccessful attempt to administer epinephrine. CONCLUSIONS: School personnel must be educated to recognize and treat food-allergic reactions. Awareness must be increased to avoid accidental exposures, including exposure from peanut butter craft projects.     

Quality of life of parents and siblings of children with inflammatory bowel disease

BACKGROUND: Few investigators have reported on the quality of life of family members of children with inflammatory bowel disease. Psychological symptoms have been reported in parents and siblings, but the problems that which give rise to these symptoms are seldom examined. In this pilot study, some of the issues that affect the quality of life of parents and siblings of children with inflammatory bowel disease were examined. METHODS: Focus group meetings were held separately with 20 parents and 7 siblings of children with inflammatory bowel disease. The participants were encouraged to identify voluntarily problems related to the disease that affected their lives, and the discussions were tape recorded. Each participant subsequently wrote down the three most important concerns. RESULTS: Thirteen (65%) parents were very concerned about the effect of the disease on the child's future jobs, marriage, independence) and 11 (55%) were worried about problems the ill child was encountering at school. Other issues of most concern to parents included side effects of medication (n = 7), limited job prospects (n = 3), persistent feelings of guilt (n = 3), and restricted family lifestyle (n = 1 ). Most siblings (57%) were concerned about their parents' keeping information about the illness from them, and three (43%) of them were also concerned about others bullying the ill child at school. Other issues of concern to siblings included fear about the disease and treatment (n = 3), parents overprotecting the ill child, and feelings of jealousy (n = 1). CONCLUSION: Families of children with inflammatory bowel disease experience many problems that may affect their quality of life. Resources should be made available to help families with these concerns.     

Familial use of ibuprofen in febrile children: a prospective study in the emergency room of an hospital in Lille]

AIM OF THE STUDY: To assess the place of ibuprofen in the treatment of fever in children. PATIENTS AND METHODS: An anonymous self-questionnaire was submitted to the parents of 156 children aged less than 15 years and 3 months consulting for a fever in a pediatric emergency care unit. Questions related antipyretic drugs availability at home and their administration modality to the febrile child. RESULTS: Acetaminophen (liquid or rectal) was the first drug owned by families (N = 149, 96%). Ibuprofen was owned by 79 families (51%). The antipyretic drug administered as a first intention treatment was acetaminophen in 131 children (77%), ibuprofen in 27 (17%) and aspirin in 6 children (4%). An antipyretic bi-therapy was received by 58 children (35%), nearly always acetaminophen and ibuprofen (N = 48, 87%). The use of a bi-therapy was more frequent when ibuprofen was the first drug used. Children who received an antipyretic bi-therapy as compared to those who received a monotherapy exhibited significantly a higher fever level and long lasting fever period. Antipyretic drugs given to the sick children were prescribed by a physician in more than 90% of cases. CONCLUSION: Ibuprofen was largely used in febrile children. This drug has almost always been prescribed by a physician. However, due to its side effects, ibuprofen should be used only in high and badly tolerated fever that is not altered by a well conducted acetaminophen monotherapy.     

Self-injectable epinephrine for first-aid management of anaphylaxis

Anaphylaxis is a severe, potentially fatal systemic allergic reaction that is rapid in onset and may cause death. Epinephrine is the primary medical therapy, and it must be administered promptly. This clinical report focuses on practical issues concerning the administration of self-injectable epinephrine for first-aid treatment of anaphylaxis in the community. The recommended epinephrine dose for anaphylaxis in children, based primarily on anecdotal evidence, is 0.01 mg/kg, up to 0.30 mg. Intramuscular injection of epinephrine into the lateral thigh (vastus lateralis) is the preferred route for therapy in first-aid treatment. Epinephrine autoinjectors are currently available in only 2 fixed doses: 0.15 and 0.30 mg. On the basis of current, albeit limited, data, it seems reasonable to recommend autoinjectors with 0.15 mg of epinephrine for otherwise healthy young children who weigh 10 to 25 kg (22-55 lb) and autoinjectors with 0.30 mg of epinephrine for those who weigh approximately 25 kg (55 lb) or more; however, specific clinical circumstances must be considered in these decisions. This report also describes several quandaries in regard to management, including the selection of dose, indications for prescribing an autoinjector, and decisions regarding when to inject epinephrine. Effective care for individuals at risk of anaphylaxis requires a comprehensive management approach involving families, allergic children, schools, camps, and other youth organizations. Risk reduction entails confirmation of the trigger, discussion of avoidance of the relevant allergen, a written individualized emergency anaphylaxis action plan, and education of supervising adults with regard to recognition and treatment of anaphylaxis.     

The prevention and management of anaphylaxis

Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause death. The incidence of anaphylaxis is increasing. Clinicians are highly likely to encounter a case during their career, hence they need to be equipped to make a diagnosis through taking a thorough history, mast cell tryptase levels and allergy testing. After confirming the allergen trigger, prevention of anaphylaxis is through avoidance of the allergen, optimal management of co-morbidities such as asthma, desensitization and adjuncts such as anti-IgE therapies. The management of anaphylaxis is different in hospital and community settings, but in both the key emphasis is the prompt administration of adrenaline. Patients therefore need to be empowered to manage potential anaphylactic reactions with training in the use of adrenaline auto-injectors and personalized emergency management plans.     

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income.

OBJECTIVES: To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States. METHODS: Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations. RESULTS: Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children. CONCLUSIONS: While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.     

Prospective comparison of child asthma education in the emergency department and at scheduled follow-up consultation]

OBJECTIVES: To assess asthma control in asthmatic children attending the emergency department and to compare it with that for children with scheduled specialist follow-up. POPULATION AND METHODS: Between September 2002 and September 2003, we included asthmatic children aged 6 to 16 years, attending the emergency department (group U) or pulmonology follow-up appointments (group C) at Necker Hospital, Paris, France. We used the Asthma Therapy Assessment Questionnaire (ATAQ), completed by the parents and children aged 10 years and over. RESULTS: We interviewed 156 families and included 144 (92%) in the final analysis (77 in group U). The 2 groups did not differ in age, sex ratio, age at onset and asthma diagnosis and the frequency of asthma attacks. Children in group U received less daily maintenance treatment (P<0.01) but reported more severe asthma (P<0.05). They had also experienced fewer investigations for their asthma (fewer lung function tests P=0.01 and allergy tests P=0.001). The children in group C had better controlled asthma, as assessed by both the children themselves and their parents. They also had fewer problems relating to the behavior, communication and treatment control domains. The assessment of children and parents were similar in all areas except communication. The children considered their communication problems to be more serious than their parents did. Age-related differences were observed, with older children's parents having more difficulties in all domains investigated. CONCLUSION: Clinicians should consider assessing asthma control in children attending the emergency department. There is clearly an opportunity to improve the quality of asthma education for these children. Clinicians could provide children with a written plan of action for asthma attacks and information about daily self-management. Improving communication between children, their parents and doctors should be considered a key educational project.     

Influence of parental stress and social support on the behavioral adjustment of children with transposition of the great arteries

The joint role of parent stress and social support in the emotional adjustment of children was examined prospectively in a group of children with d-transposition of the great arteries (d-TGA). Questionnaires on parent perceptions of stress and social support were administered when children were 1 and 4 years of age (n = 143-153). Parent ratings of child behavior problems were collected at 4 years (n = 152). The findings indicate a favorable outcome for parents and children with congenital heart disease (CHD). Compared with normative samples, parents experienced less stress and more social support, and they rated children as showing fewer behavior problems. Parents with more stress at both ages reported more behavior problems. Families with less social support reported more stress at both 1 and 4 years. Social support, however, did not moderate the relationship between stress and child behavior problems. Early detection of distressed families may assist in alleviating stress and reducing behavior problems.     

Emergency department utilization patterns and health care needs assessment among parents of Chinese American children in New York City

A limited number of publications have addressed the health care needs of Chinese American children of recently immigrated parents. We administered a Chinese-language survey to parents presenting to an urban pediatric emergency department (PED) in New York City and at community venues. The survey assessed demographics, access to health care, and utilization/expectations of the PED. Emergency Severity Index scores were recorded for emergency department patients. Three hundred fifteen families (54% in the PED) completed the survey. Of those completed in the PED, 79% sought emergency services because of pediatric referral or because their pediatrician's office was closed. Of our sickest patients with an Emergency Severity Index score of 3 or less, 28% of parents felt that the child was somewhat sick or not sick at all. Although the majority of our Chinese American families utilize the emergency department appropriately, 28% of the parents of our sickest patients did not appreciate the degree of illness of their children.     

Examination of long-lasting parental concern after false-positive results of neonatal hearing screening.

OBJECTIVE: To investigate whether false-positive outcomes on neonatal hearing screening cause long-lasting parental concerns. METHODS: A general population of parents whose children had participated in the universal neonatal hearing screening (UNHS) programme were examined. Parents filled out a questionnaire 6 months after UNHS. Outcomes were compared for all parents whose child tested positive or inconclusive in at least one of three tests but afterwards proved not to have hearing impairment (cases, n = 154) and a random sample of parents whose child passed the first test (controls, n = 288). Parental anxiety as measured with the State-Trait Anxiety Inventory (STAI), attitude towards the child (child health rating and experienced problems) and sensitivity to hearing problems were measured. RESULTS: Median STAI score was equal for cases and controls. Parental attitudes toward the child also did not differ. The difference in the proportion of parents who worried about their child's hearing was statistically significant between cases and controls (p = 0.001) and varied with the number of screens; 4% of controls were worried about the child's hearing, as compared to 10% of cases whose children were tested twice, and 15% of cases whose children were tested three times. CONCLUSIONS: False-positive UNHS test results do not cause long-term general parental anxiety. However, 6 months after screening, a considerable proportion of parents continued to experience hearing-specific worries regarding their child.     

The Paediatric Asthma Caregiver's Quality of Life Questionnaire in Swedish parents

With the Paediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), parents grade impaired activities (5 items) and emotional concern (8 items) from 1 to 7 regarding how much their own quality of life (QoL) has been affected by the disease of their child during the last week. The questionnaire was translated into Swedish. To test the feasibility and validity of the Swedish version, 71 asthmatic children and their families were approached. Sixty-one families (86%) participated. The mean age of the children was 8.7 y. Parental grading of symptoms (Spearman's rho = 0.637, p < 0.001), the asthma-specific QoL of the child (rho = 0.359, p = 0.002) and gradings of asthma from medical records (mild asthma median score 6.69, moderate 6.27 and severe 5.12, p = 0.001) were all related to overall PACQLQ scores. The sex of the child, the presence of other diseases related to allergy, peak flow rate (PEFR) and socio-economic level did not affect the scores. Lower scores in the emotional domain were seen in parents of children on steroids (p = 0.049). The distribution of scores was heavily skewed towards the positive end of the scale, leading to limited power to discriminate among parents of children with mild asthma. The instrument had good internal consistency and was well accepted by the parents.     

Promoting healthy weight among elementary school children via a health report card approach

BACKGROUND: As overweight continues to rise among children, schools seek effective and sensitive ways to engage parents in promoting healthy weight. OBJECTIVE: To evaluate a school-based health report card on the family awareness of and concern about the child weight status, plans for weight control, and preventive behaviors. DESIGN: Quasi-experimental field trial with a personalized weight and fitness health report card intervention (PI), a general-information intervention (GI), and a control group (CG). Outcomes were assessed using a postintervention telephone survey, including process and outcome measures. PARTICIPANTS: The intervention included 1396 ethnically diverse students at 4 elementary schools in an urban area. Telephone surveys were completed by 399 families from an evaluation sample of 793.Intervention Families were randomly assigned to the PI, GI, or CG and mailed intervention materials. The CG was mailed GI materials after the survey. MAIN OUTCOME MEASURES: Parent awareness of child weight status, concerns, weight-control plans, and preventive behaviors. Group effects were significantly different by the child's weight status, so results were stratified. RESULTS: Among overweight students, intervention parents were more likely to know their child's weight status (PI, 44%; GI, 41%; CG, 23%) (P =.02). The PI parents planned medical help (PI, 25%; GI, 7%; CG, 9%) (P =.004), dieting activities (PI, 19%; GI and CG, <5 cases) (P =.02) and physical activities (PI, 42%; GI, 27%; CG, 13%) (P<.001) for their overweight children. No group effect on concern or preventive behaviors was detected. Most parents of overweight children who read materials requested annual weight and health information on their child (PI, 91%; GI, 67%). CONCLUSIONS: Among overweight children, the PI was associated with increased parental awareness of their child's weight status. Although parents wanted PI for their children, more research is needed to test this approach on children's self-esteem and plans for weight control.     

Food-induced anaphylaxis: who, what, why, and where?

Food-induced anaphylaxis is a leading cause of anaphylaxis treated in emergency departments and hospitals around the world. Peanuts, tree nuts, fish, and shellfish are the most commonly implicated foods. Food-induced anaphylaxis may occur in any age group and with any food. However, food-induced anaphylaxis fatalities disproportionately affect adolescents and young adults with peanut and tree nut allergy. Individuals who have both IgE-mediated food allergy and asthma are at a higher risk for food-induced anaphylaxis fatality. Delayed administration of epinephrine is also associated with fatal outcome. Often, in fatal reactions, the food allergen is unknowingly ingested away from home, in settings such as restaurants and schools. Although avoidance of food allergens is critical, timely administration of epinephrine is also of great importance in the treatment of food-induced anaphylaxis. Patients, families, and caregivers must be well educated regarding the signs, symptoms and risk factors for anaphylaxis. They must also be counseled on the importance of strict food avoidance of the implicated food allergens, compliance with having self-injectable epinephrine available at all times, and the importance of timely administration of epinephrine, even when cutaneous symptoms are lacking.     

Parental perceptions of barriers to children's participation in organised sport in Australia

Aim: To examine parents' perceptions on how cost, time, travel and the variety of organised sporting activities influence their decisions to allow their child to participate in organised sport; and recent expenditure on sport‐related items for their child. Methods: Computerised assisted telephone interviews survey of 402 parents of children aged 5–17 years old living in New South Wales, Australia. Results: Overall, 63% of children participated in organised sporting activities. Multivariate analysis shows that for parents of 5–12‐year old children, the decision to allow their child to participate in organised sports was strongly influenced by time (P < 0.00). The financial costs associated with a child's participation in organised sports influenced families with lower incomes (p = 0.01) and with girls (p=0.04), while for rural families the option of a wider variety of local sporting activities influenced decisions about their child's participation in organised sport (p=0.05). Footwear/uniforms were the main sporting related expense. Sydney parents were more likely to report sport related expenditures for their child (P < 0.01). Conclusions: Sporting costs, variety and time commitments influenced parents' decisions about their child's participation in organised sport. These factors indicate the need for initiatives to promote access to organised sports through reducing costs and increasing variety, particularly for families with lower incomes and are living in rural and regional areas.     

Use of psychotropic agents in preschool children: associated symptoms,diagnoses, and health care services in a health maintenance organization

BACKGROUND: Recent pharmacoepidemiological reports have contributed to concerns about frequent and perhaps indiscriminate psychopharmacotherapy for very young children. OBJECTIVE: To examine the diagnoses, symptoms, and health care services associated with preschool children receiving psychotropic medication. DESIGN: Population-based pharmacoepidemiological analysis of electronic medical records, paper medical and mental health charts, and pharmacy records from 1997 and 1998. SETTING: A large Pacific Northwest health maintenance organization. PARTICIPANTS: Preschool children receiving psychotropic medication (psychostimulants, antidepressants, neuroleptics, or alpha(2)-adrenergic agonists). MEASURES: Physician-reported mental health diagnoses and related symptoms, functional impairment, family and participant characteristics, and the types and level of associated medical and mental health services. RESULTS: Of 743 preschool children who clinicians identified as having behavioral or emotional problems, 120 (16%) received psychotropic medication; 57 children (48%) were prescribed a stimulant medication only, and 60 (50%) received a diagnosis of attention-deficit/hyperactivity disorder. Most children had substantial psychosocial risk factors, including parents with psychiatric or substance abuse problems (71%; n = 85), documented histories of abuse (29%; n = 35), and out-of-home placement (31%; n = 37). Four of 5 children or families (83%; n = 99) received psychosocial services in addition to pharmacotherapy. On average, children received psychotropic medication at least 6 months after initial identification of a behavioral or mental health problem. CONCLUSIONS: Despite commentary by the popular media about widespread psychopharmacotherapy for very young children, such treatment was only infrequently received in this health plan. Most children receiving psychopharmacotherapy had substantial additional risk factors and were receiving psychosocial services for mental health or behavioral management.