ARTICLE
Discharged on Supplemental Oxygen From an
Emergency Department in Patients With Bronchiolitis
AUTHORS: Sarah Halstead, MD, Genie Roosevelt, MD, MPH,
Sara Deakyne, MPH, and Lalit Bajaj, MD, MPH
Section of Pediatric Emergency Medicine, Department of
Pediatrics, University of Colorado Denver, Children’s Hospital
Colorado, Aurora, Colorado
KEY WORDS
bronchiolitis, oxygen, emergency department
ABBREVIATIONS
CI—confidence interval
O2—oxygen
PCP—primary care provider
PED—pediatric emergency department
RA—room air
www.pediatrics.org/cgi/doi/10.1542/peds.2011-0889
doi:10.1542/peds.2011-0889
Accepted for publication Nov 2, 2011
Address correspondence to Sarah Halstead, MD, Department of
Pediatrics, Section of Pediatric Emergency Medicine, University of
Colorado at Denver, 13123 East 16th Ave, B251, Aurora, CO 80045.
E-mail: sarahmhalstead@gmail.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
PEDIATRICS Volume 129, Number 3, March 2012
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WHAT’S KNOWN ON THIS SUBJECT: Bronchiolitis is the most
common cause for hospital admission in patients aged ,1 year.
Hypoxia is a common reason for admission. Despite a multitude of
studies looking at various treatment strategies, no clear benefit
has been found.
WHAT THIS STUDY ADDS: With oxygen therapy being the main
therapeutic option, home oxygen offers a novel way to manage
bronchiolitis. This study shows that home oxygen is a safe and
effective way to decrease hospital admissions in a select group of
patients.
abstract
BACKGROUND AND OBJECTIVE: Bronchiolitis is the most common rea-
son for hospital admission in patients aged ,1 year. Admissions have
been increasing with hypoxia frequently cited as the determinant.
Home oxygen (O2) has been shown to be feasible, although safety
data are lacking. The objective of this study was to evaluate the
impact of a home O2 clinical care protocol on admission rates in
patients with bronchiolitis from the pediatric emergency department.
METHODS: We performed a retrospective chart review of patients with
bronchiolitis who presented to a children’s hospital pediatric emer-
gency department (altitude 1600 m) between 2005 and 2009. Patients
between the ages of 1 and 18 months were included in the analysis.
Patients requiring baseline O2 were excluded. We calculated the per-
centage of patients discharged on O2 and their readmission rates. We
reviewed charts of patients who were admitted after home O2 for
adverse outcomes. We also compared rates of admission before and
after initiation of the protocol.
RESULTS: In this study, 4194 illnesses were analyzed; 2383 (57%) were
discharged on room air, 649 (15%) were discharged on O2, and 1162
(28%) were admitted. Of those discharged on room air, 4% were
subsequently admitted, and 6% of those discharged on O2 were ad-
mitted. There were no ICU admissions or need for advanced airway
management in those patients discharged on O2. Our overall admis-
sion rates for bronchiolitis dropped from a rate of 40% to 31%.
CONCLUSIONS: Home O2 is an effective way to decrease hospital
admissions in a select group of patients with bronchiolitis. Pediatrics
2012;129:e605–e610
e605
Bronchiolitis is the most common rea-
son for hospital admission in children
,1 year of age.1 It is estimated that
there are .150 000 hospitalizations
a year for bronchiolitis. The primary
reasons for admission include respira-
tory distress, poor feeding, and hypoxia
or the need for supplemental oxygen
(O2). Practitioners are influenced by
small changes in pulse-oximetry data
in the decision to admit patients with
bronchiolitis.2 With the increased use
of pulse-oximetry, patients also remain
in the hospital for supplemental O2 for
longer periods of time3 after other
parameters such as work of breathing
and feeding have returned to normal.4
The American Academy of Pediatrics
recommends that O2 therapy be initi-
ated judiciously when O2 saturations
levels fall below 90% and that the in-
tensity of monitoring O2 saturation lev-
els be reduced as the infant improves.5
With an estimated cost of hospitalization
for bronchiolitis being ∼$500 million
per year in the United States alone,6
the utility of home O2 for bronchiolitis
should be assessed.7–9
Although several studies have focused
on a predetermined pulse-oximetry
cutoff that would be safe for discharge
from the hospital,10–12 only 2 have looked
at discharging patients home on O2.
These 2 studies focused on the feasi-
bility of discharging a low-risk population
on home O2 from a tertiary care pedi-
atric emergency department (PED)13 and
from the inpatient setting.14 Although
there was high caregiver and primary
care physician (PCP) satisfaction, rates
of unscheduled returns and subsequent
admissions were not calculated given
the small sample size.13
Before the winter season of 2005–2006,
a home O2 protocol was introduced at
our institution for the use of home O2
in patients with uncomplicated bron-
chiolitis and hypoxia. Uncomplicated
bronchiolitis was defined as a lower re-
spiratory tract illness associated with
e606 HALSTEAD et al
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wheezing and/or crackles in an other-
wise healthy, well-appearing patient
without evidence of underlying cardio-
pulmonary disease. Hypoxia was defined
as a room air (RA) pulse oximetry of
,88%. We sought to characterize rates
of home O2 use and rates of adverse
outcomes in patients discharged from
the hospital on O2 and to determine the
impact this protocol had on hospital
admission rates for bronchiolitis.
METHODS
We performed a retrospective chart
review of all visits of patients with
bronchiolitis who presented to an ac-
ademic tertiary care children’s hospital
PED as well as 4 of the satellite PEDs
and urgent care centers in our system
(altitude 1600 m) between November 1
and April 30 inclusive for each year
from 2005 to 2009. Patients between
the ages of 1 and 18 months who were
diagnosed with bronchiolitis (Interna-
tional Classification of Diseases, Ninth
Revision codes: 466.1. 466.11, 466.19,
480.1 documented in the electronic
health record) were included in the
analysis. Patients with an underlying
cardiopulmonary disease requiring
baseline O2 were excluded. For patients
with multiple visits, a discrete illness
was defined as new symptoms, and if
unknown, a minimum of 2 weeks be-
tween visits. All charts were analyzed
to determine initial disposition (dis-
charge home on RA, discharge home on
O2, or admit/transfer). For patients
who had extended observation in the
PED, defined as $24 hours, their dis-
position was classified as an admis-
sion. Patients discharged on home O2
were identified through an order in the
chart written for home O2 or a plan in
the note stating that the patient was
discharged from the hospital on O2. A
systematic chart review was per-
formed for all patients who were dis-
charged on RA or home O2 to determine
if they were subsequently admitted. For
patients who were discharged on O2,
we reviewed their charts to determine
reason for admission if subsequently
admitted and if they had any adverse
outcomes including admission to the
ICU and/or need for advanced airway
management defined as the use of
continuous positive airway pressure,
biphasic positive airway pressure, or
endotracheal intubation. Although we
did not have access to all patients’
health records, it is the policy of the
state health department to contact the
facility if an unexpected death occurred.
The home O2 protocol recommends that
patients between the ages of 3 and 18
months (minimum of 48 weeks cor-
rected for preterm birth) who have no
underlying chronic cardiopulmonary
disease be observed in the PED or ur-
gent care center for a minimum of 8
hours on continuous pulse oximetry
with vital signs recorded every 2 hours.
If the patients O2 saturations are $90%
on 0.5 L/minute nasal cannula #O2
while awake, asleep, and feeding; the
patient is able to maintain hydration;
there are no signs of deteriorating re-
spiratory status; and the attending and
caregiver are comfortable with dis-
charge home, they are discharged
from the hospital on O2 with a 24-hour
follow-up arranged with either the PCP
or the PED (if the PCP is unavailable).
The patient is given a small portable O2
tank, and a home health care company
is contacted by our respiratory thera-
pists to deliver additional O2 tanks and
supplies to the families’ homes.
We found that patients between the
ages of 1 and 3 months with bron-
chiolitis were also being discharged
from the hospital on O2. Although the
home O2 protocol is for patients aged 3
to 18 months, we included the 1- to 3-
month-old patients in our analysis.
Demographic and clinical variables
from the PED including age, gender,
insurance, lowest RA O2 saturation, vital
signs, medications given, disposition

(discharge from the hospital on RA,
discharge from the hospital on O2, or
admit/transfer), amount of O2 at dis-
charge from the PED if applicable, sub-
sequent need for admission, and
reasons for subsequent admission and
adverse outcomes in patients discharged
initially on home O2 were abstracted
from the electronic health record onto
a standardized data collection sheet.
The primary outcome measures were
the percentage of patients discharged
from the PED on O2, the rates of sub-
sequent admission, and rates of ad-
verse outcomes for those discharged
on O2. Secondary outcome measures
were reasons for subsequent admis-
sion and cost savings.
Cost data for inpatient stays, PED, and
observation visits were obtained from
the facility’s finance department and
averaged over the study period. Au-
thorization to publish cost data were
given by the chief financial officer. We
also attempted to contact the local
home oxygen company to assess the
cost of home oxygen.
Categorical variables were evaluated
with the x2 test or Fisher exact test.
Continuous variables were analyzed by
using either a Student t test or Wil-
coxon rank sum test. Relative risk and
confidence intervals (CI) of subsequent
admissions were calculated between
patients who were discharged from the
hospital on O2 and patients who were
not discharged on O2 during their ill-
ness. Demographic variables, including
age, gender, and insurance status, were
compared among these groups to en-
sure equal distribution. Data were an-
alyzed by using SAS 9.2 (SAS Institute
Inc, Cary, NC). This study was approved
and informed consent was waived by
the Colorado Multiple Institutional Re-
view Board.
RESULTS
The study included 3983 patients with
4194 discrete illnesses that met the
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ARTICLE
inclusion criteria. Of these, 2383 patient Two patients exceeded the suggested
illnesses (57%) were initially discharged supplemental O2 of 0.5 L/minute, 1 being
from the hospital on RA, 649 (15%) were discharged on 0.75 L/minute and the
discharged on O2, and 1162 (28%) were other on 1 L/minute. Both were during
admitted or transferred to another fa- the first bronchiolitis season after the
cility for admission (Fig 1). Of the 1162 initiation of the home O2 protocol. Nei-
who were initially admitted or trans- ther of these patients was subsequently
ferred, 247 (21%) were not admitted on admitted.
oxygen. Reasons for admission in these Of the 2383 patients who were dis-
patients included, but were not limited charged from the hospital on RA, 90 (4%;
to, age ,3 months, dehydration, and 95% CI 3.1–4.6) were subsequently ad-
need for frequent deep suctioning. The mitted. Of the 649 patients who were
overall mean age of our study pop- discharged on O2, 38 (6%; 95% CI 4.3–
ulation was 7.6 6 4.8 months, 59% were 7.9) were subsequently admitted (P =
boys, and 56% had Medicaid. For those .03; Fig 1). The most common reasons
patients discharged on O2, the mean age for subsequent admission were in-
was 8.9 6 4.4 months, 60% were boys, creased O2 requirement or increased
and 52% had Medicaid (Table 1). For work of breathing (Table 3). There were
patients who were discharged on O2 or no adverse outcomes, including ICU
on RA, those who were subsequently admission or need for advanced air-
admitted were younger than those who way management, defined as the use of
were not (Table 1). continuous positive airway pressure, bi-
The mean lowest RA O2 saturation phasic positive airway pressure, or en-
recorded for those patients discharged dotracheal intubation, in those patients
from the hospital on O2 was 84% with an initially discharged on O2. There were 2
SD of 3%. The mean discharge amount patients initially seen in the PED and
of supplemental O2 was 0.39 L/minute discharged on O2 who were subse-
with an SD of 0.1 L/minute (Table 2). quently admitted for reasons other
FIGURE 1
Disposition of patients diagnosed with bronchiolitis.
TABLE 1 Demographic Characteristics of Study Population
D/C on RA D/C on RA D/C on O2 D/C on O2
Overall (Not Admitted) Then Admitted (Not Admitted) Then Admitted Admit
Illnesses, n (%) 4194 2293 (55) 90 (2) 611 (15) 38 (0.9) 1158 (28)
Mean age, mo (SD) 7.6 (4.8) 7.8 (4.4)a 6.0 (5.0)a 8.9 (4.4)b 7.2 (3.8)b 6.3 (5.1)
Male patient (%) 2497 (59) 1371 (60) 63 (70) 364 (60) 28 (74) 671 (58)
Medicaid (%) 2348 (56) 1340 (58) 54 (60) 319 (52) 22 (58) 613 (55)
D/C, discharged from hospital.
a P , .01: D/C home on RA (not admitted) versus D/C home on RA then admitted.
b P = .03: D/C home on O (not admitted) versus D/C home on O then admitted.
2 2
e607
TABLE 2 Clinical Characteristics of Study Population
D/C on RA
(Not Admitted)
Mean lowest RA 93% (3)a
saturation (SD)
Mean O2 in L/min (SD) 0 0
Mean Initial Vitals
Heart Rate (SD) 154 (20)a
Respiratory Rate (SD) 44 (12)a
Temperature (SD) 98.9 (1.6)d
Medications given in
PED (% patients)
Albuterol 374 (16%)
Racemic epinephr 18 (0.8%)e
Oral steroids 20 (0.9%)
D/C, discharged from hospital; epinephr, epinephrine.
a P , .01: D/C on RA (not admitted) versus D/C on RA then admitted.
b P = .58.
c 247 (21%) were not admitted on O
2.
d P = .02: D/C on RA (not admitted) versus D/C on RA then admitted.
e P = .04 (Fisher exact test): D/C on RA (not admitted) versus D/C on RA then admitted.
than bronchiolitis. One patient had
a ventricular-peritoneal shunt and was
admitted with abdominal pain. On ad-
mission, he was no longer hypoxic, and
his O2 was discontinued. The other was
admitted with pyelonephritis and vomit-
ing oral antibiotics. She required O2 for
1 day in the hospital, with no change in
respiratory status or increase in the
amount of O2, and was discharged on
RA. Both of these patients were ex-
cluded from analysis because their
readmission was not secondary to bron-
chiolitis. There was no statistical differ-
ence in the mean lowest RA saturation
for patients discharged on O2 who were
subsequently admitted (85%) and those
who were not (84%; P = .58). There was
a statistically significant difference in
vital signs (temperature, heart rate,
and respiratory rate) as well as an in-
creased use of racemic epinephrine in
TABLE 3 Reasons for Subsequent Admission
for Patients Discharged From
Hospital on Oxygen
Reasona
Increased O2
Increased work of breathing
Parental concern/compliance
Intravenous fluids for poor oral intake
Problem with home O2
aPatients may have more than 1 reason for subsequent
admission.
period, the mean cost of the combina-
D/C on RA D/C on O2 D/C on O2 Admit tion of a PED visit, observation for a
Then Admitted (Not Admitted) Then Admitted minimum of 8 hours, and 1 follow-up
92% (4)a 84% (3)b 85% (3)b 82% (8)c visit was $1344. This results in a cost
0.39 (0.1) 0.42 (0.2) 0.36 (0.9)c
savings of $1262 per patient. We at-
tempted to contact the main home ox-
165 (21)a 160 (19) 166 (18) 165 (19) ygen provider to assess the cost of
48 (11)a 49 (13) 50 (14) 51 (13)
home oxygen, but they did not respond
99.4 (1.6)d 99.4 (1.6) 99.2 (1.4) 99.5 (1.5)
to our inquiries. We do know, however,
that our Medicaid reimbursement for
16 (18%) 49 (8%) 5 (13%) 253 (22%)
up to a month of home O2 is $90.
3 (3%)e 7 (1%) 1 (3%) 194 (17%)
1 (1%) 2 (0.3%) 0 25 (2%)
DISCUSSION
This is the first study demonstrating
that a home O2 protocol in a select group
of patients with uncomplicated bron-
chiolitis from the PED can be both suc-
cessful and sustainable. With increasing
those patients initially discharged on PED overcrowding and boarding of
RA who were not admitted compared inpatients, the development and evalu-
with those who were discharged on RA ation of outpatient management strat-
and subsequently admitted. However, egies, such as home O2, are imperative.
this difference was not seen in those
Recent literature has highlighted the
initially discharged on O2 (Table 2). Our
increasing hospital burden of bron-
overall admission rate for bronchiolitis
chiolitis admissions in otherwisehealthy
dropped from a historical rate of 40%
infants. Although hospital admissions
(L.B., unpublished data) to 31% over the
have drastically increased,15,16 there
past 4 seasons (Table 4), yielding an
has been no change in mortality rates
absolute reduction of 9%.
from bronchiolitis.17 The most likely
Thirty-five patients between the ages of reasons for this increased rate of ad-
1 and 3 months were discharged on O2. mission for bronchiolitis are depen-
However, during the study period, only dence on pulse-oximetry and lack of
3 of the 35 were subsequently admitted, a proven therapy. Despite a multitude
making it difficult to draw any con- of studies looking at various treatment
clusions from this subgroup of patients. strategies,18–23 no clear benefit has
The 3 who were readmitted did not re- been found. Given the lack of effective
quire ICU admission or advanced airway therapies, there is considerable vari-
management. ability in the management and treat-
For PED patients observed and then ment of bronchiolitis.24 Providers have
discharged on O2, the mean PED length been shown to vary markedly in their
of stay was 10 hours (SD 4.8 hours). The recommendation for admission on the
mean length of stay for a patient with basis of minor differences in pulse-
bronchiolitis admitted to the hospital oximetry values.2 Patients also remain
n = 39 in our institution is 2 days. The mean in the hospital for supplemental O2 af-
19 (59%) cost of a 2-day inpatient hospital stay ter other discharge parameters such
17 (44%) for uncomplicated bronchiolitis over as oral intake and work of breathing
10 (62%) the study period was $2606 (US dol- have been reached.4 With O2 therapy
4 (18%)
2 (10%)
lars). Of note, 40% of these inpatients being the main therapeutic option for
are sent home on oxygen from the in- these patients, home O2 offers a novel
patient setting. Over the same time way to manage bronchiolitis.

e608 HALSTEAD et al
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TABLE 4 Disposition of Patients With Bronchiolitis by Year
2005–2006
Illnesses 917
Initial admit/transfer 301 (33%)
Initial D/C 616 (67%)
D/C RA 508 (55%)
Readmitted 18 (4%)
D/C with O2 108 (12%)
Readmitted 6 (6%)
Absolute 325 (35%)
Admit/transfer (95% CI: 32.4–38.6)
CI, confidence interval; D/C, discharged from hospital.
a P = .03.
Our historical bronchiolitis admission
rate of 40% is similar to other rates
reported in the literature. Mansbach
et al and Corneli et al reported ad-
mission rates of 40% and 43%, re-
spectively.12,18 Our admission rate
dropped from 40% to 31% over the
study period with our home O2 pro-
tocol without any other significant
changes in bronchiolitis care at our
institution. This absolute reduction of
9% corresponds to a relative reduction
of 25%. Although there was statistical
significance (P = .03) between those
patients who were subsequently ad-
mitted after being discharged from the
hospital on RA, and those who were
subsequently admitted after being
discharged on O2 (Table 4), we do not
feel that this change is clinically signif-
icant nor does it outweigh the benefit
of reducing overall hospital admission.
Treatment options for bronchiolitis have
shown little impact on admission rates
and length of stay, but we were able to
have a significant effect on our ad-
mission rate by successfully managing
approximately 15% of all bronchiolitis
patients and 39% of all bronchiolitis
patients with hypoxia (611 of 1564
patients) with home oxygen.
In 2006, bronchiolitis admissions were
estimated to cost more than $500 mil-
lion annually with a mean cost of $3799
per hospitalization, highlighting the need
for initiatives to safely reduce bron-
chiolitis hospitalizations and thereby de-
crease health care costs.6 Some studies
report a mean length of stay of 3 days
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2006–2007 2007–2008
896 1150
251 (28%) 309 (27%)
645 (72%) 841 (73%)
513 (57%) 627 (55%)
17 (3%) 32 (5%)
132 (15%) 214 (19%)
8 (6%) 14 (7%)
276 (31%) 355 (30%)
95% CI: 27.9–33.9) (95% CI: 28.3–33.6)
compared with our mean inpatient
length of stay of 2 days.6,24 If other
institutions were to establish similar
home O2 protocols, especially those
with a longer average length of stay, the
savings could be substantial. In our
previous work, we showed a trend to-
ward fewer missed caregiver work-
days in the group that was sent home
from the PED on O2.13 We were not able
to collect these data for this study. We
were also unable to estimate the “cost”
of the physician time. The total cost
savings of the home oxygen program
over traditional inpatient hospitaliza-
tion is likely substantial, but this study
design does not allow us to calculate
the savings precisely.
Apnea is an important concern in the
management of young infants with
bronchiolitis. It has been shown that
age and previous apnea are the 2 most
likely predictors of apnea.25–27 In a study
of 691 patients admitted with bron-
chiolitis, Willwerth et al found 19 to
have apnea while admitted. The patients
who experienced apnea were ,1 month
old, preterm, and ,48 weeks post-
conception, or had a witnessed apneic
episode at home.27 Per our home O2
protocol, these patients would not be
considered low risk and therefore
would not qualify for home O2. In this
study, we had no patients who were
discharged on O2 who returned with
apnea requiring advanced airway man-
agement. Although we had 35 patients
aged 1 to 3 months who were discharged
on O2 and no adverse outcomes were
ARTICLE
2008–2009 All Seasons
1231 4194
301 (24%) 1162 (28%)
930 (74%) 3032 (72%)
735 (60%) 2383 (57%)
23 (3%) 90 (4%)a(95% CI: 3.1–4.6)
195 (16%) 649 (15%)
10 (5%) 38 (6%)a(95% CI: 4.3–7.9)
334 (26%) 1290 (31%)
(95% CI: 24.5–29.5) (95% CI: 29.4–32.2)
seen in these patients, it is not appro-
priate to draw conclusions from this
group of patients because their age is
outside the protocol limits and the
number of patients in this group is small.
Our study has several limitations. It is
retrospective in nature, and thus we
were unable to identify risk factors in
patients who required subsequent ad-
mission. Although there was a statisti-
cally significant difference in vital signs
as well as in the use of racemic epi-
nephrine in those patients initially
discharged on RA who were or were not
subsequently admitted, this difference
was not seen in those initially dis-
charged on O2 (Table 2). It is therefore
difficult to determine the true signifi-
cance of this finding. We only have ac-
cess to data from our own hospital and
its network locations. Thus, our admis-
sion rates may be an underestimate if
patients were admitted at nonnetwork
locations. This study was performed at
an institution located at an altitude of
1600 m in an area where home O2 is
prevalent for a variety of pediatric con-
ditions, including bronchopulmonary
dysplasia and congenital heart dis-
ease, which may have affected the ease
of establishing a home O2 protocol and
may limit its generalizability. We have
respiratory therapists available in the
PED 24 hours a day, 7 days a week. They
perform home O2 teaching with the
family and arrange for O2 to be delivered
to their home. We also have support
from the PCPs in the community who
have made themselves available to
e609
follow-up with patients within 24 hours
of discharge. They are comfortable
caring for their patients on home O2,
including weaning O2 in an outpatient
setting. Finally, the PED attending
physicians have become comfortable
discharging patients on home O2 be-
cause it has become routine in our
setting and facilitates patients’ disposi-
tion. It is also possible that children with
oxygen saturations ,90% at altitude
differ in severity from those with similar
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 Discharged on Supplemental Oxygen From an Emergency Department in
Patients With Bronchiolitis
Sarah Halstead, Genie Roosevelt, Sara Deakyne and Lalit Bajaj
Pediatrics 2012;129;e605; originally published online February 13, 2012;
DOI: 10.1542/peds.2011-0889
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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 © 2012 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Discharged on Supplemental Oxygen From an Emergency Department in
Patients With Bronchiolitis
Sarah Halstead, Genie Roosevelt, Sara Deakyne and Lalit Bajaj
Pediatrics 2012;129;e605; originally published online February 13, 2012;
DOI: 10.1542/peds.2011-0889

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/129/3/e605.full.html

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 © 2012 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on May 28, 2015