ARTICLE

Parental Attitudes Toward Varicella Vaccination

James A. Taylor, MD; Robert D. Newman, MD, MPH; for the Puget Sound Pediatric Research Network
Objectives: To evaluate parental health beliefs regarding the varicella vaccine and to identify potential areas for interventions designed to increase immunization against varicella. Setting: Data were collected in the offices of pediatriResults: A total of 598 surveys were completed. Gen-

cians who are members of the Puget Sound Pediatric Research Network, a regional practice-based research group in the Seattle, Wash, area.
Methods: At the time of an office visit, parents were asked

to complete a survey on the varicella vaccine. Respondents indicated level of agreement with 10 health belief statements regarding the immunization using a 6-point Likert scale from completely agree to completely disagree; responses were subsequently transformed to an ordinal scale from 1 to 6, with 6 corresponding to highly positive beliefs. A composite health belief score for each respondent was computed by averaging responses to all statements. Parents also were asked to indicate the level of influence of their childs pediatrician on their decision to use the varicella vaccine.

erally, parents agreed that the vaccine was worthwhile even if the only benefit was preventing a rare complication. Conversely, the majority of parents disagreed that varicella vaccine was worthwhile if the only benefit was preventing lost time from work, and that the immunization was worthwhile even if immunity was not lifelong. Parents who indicated that their childs pediatricians opinion significantly influenced their decision to use the vaccine had higher composite health belief scores than those who indicated less influence (median scores, 4.3 and 4.0, respectively; P .001).
Conclusions: In this sample, parents had more positive health beliefs about the ability of varicella vaccine to prevent rare complications than to save time lost from work. These data also suggest that pediatricians can have an important role in increasing positive health beliefs about the vaccine. These findings may help future interventions to increase the immunization rate against varicella.

Arch Pediatr Adolesc Med. 2000;154:302-306 sity of storing the vaccine at 15C makes handling cumbersome.1 In addition, physicians have not uniformly embraced use of the vaccine. In a previous study,6 we found that fewer than 50% of Washington State pediatricians recommended universal varicella immunization. Adherence to the recommended schedule for providing the vaccination was influenced by previous clinical experience with a serious complication of varicella infection, perceptions about the seriousnessofnaturallyacquiredinfection,and beliefs about the cost-effectiveness of providing the immunization. Given the barriers to immunization and lack of physician endorsement, parental health beliefs might be a major influence on whether a child receives the varicella vaccine. Overall, results of recent studies indicate that parents have generally positive beliefs about immunizations.7,8 There are, however, few data on parental beliefs specifically regarding varicella vaccination. One small survey of 34 parents who elected not to immunize their children against varicella found that reasons for not choosing the vaccine were related to concerns about efficacy, longterm consequences of immunization, and side effects.4

Editors Note: Its nice to see that even though Americans work more hours than any other industrialized nation, at least the mothers dont think maintaining that pace (not missing work) is worth an immunization for their children. Catherine D. DeAngelis, MD

From the Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine (Drs Taylor and Newman), International Health Program, Department of Health Services, University of Washington School of Public Health and Community Medicine (Dr Newman), and Health Alliance International (Dr Newman), Seattle, Wash. A list of the participating members of the Puget Sound Pediatric Research Network appears in the acknowledgments at the end of this article.

ESPITE THE 1995 recommendation,1 immunization against varicella remains far from universal. Results of a 1997 national survey indicated that only 26% of US children between the ages of 19 and 35 months had received the varicella vaccine.2 To design interventions aimed at increasing the proportion of young children who receive vaccination against varicella, it is important to elucidate reasons for this high rate of underimmunization. In general, reasons for underimmunization can be divided into systems barriers, provider policies and beliefs, and parental characteristics and beliefs.3 There are significant barriers to varicella immunization: payment for the vaccine was not initiallycoveredbyMedicaidinsomelocations,4 immunizationagainstvaricellaisnotrequired for school entry in all states,5 and the neces-

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, MAR 2000 302

WWW.ARCHPEDIATRICS.COM

Downloaded from www.archpediatrics.com on November 15, 2010 2000 American Medical Association. All rights reserved.

PARTICIPANTS AND METHODS

The study was conducted by the Puget Sound Pediatric Research Network, a regional practice-based research group in the Seattle area. Approximately 40 practicing pediatricians from 9 offices are members of the Puget Sound Pediatric Research Network. For this study, data were collected in 8 of the 9 offices from October 1997 through March 1998. In each participating practice, parents were asked to complete an anonymous survey on attitudes about the varicella immunization at the time of an office visit. The final sample consisted of 598 completed surveys; 92.3% of respondents were mothers. Among parents who completed the survey, 68.8% indicated that they had graduated from college, and 99.0% were at least high school graduates. The survey focused on 10 health belief statements about the varicella vaccine (Table 1). Topics covered in the statements included potential benefits of the immunization, susceptibility of unvaccinated children, severity of varicella, concerns about side effects and length of immunity, and general statements about immunizations. Parents indicated their level of agreement with each statement using a 6-point Likert scale, with possible responses ranging from completely agree to completely disagree. Parents were also asked how much their decision on whether to vaccinate their child was influenced by their pediatricians opinion. Responses to this question ranged from not at all to strongly; a response of do not know pediatricians opinion was also included. Finally, parents were asked to indicate how much money they would be willing to spend out-of-pocket on the varicella vaccine. Other items on the survey included birth date of child being seen in the office and name of this childs primary pediatrician, whether the child had previously received the varicella immunization, whether any of the respondents children had had varicella in the past, and parental educational level. For the analysis, the Likert scale responses to each health belief statement were converted to an ordinal scale between 1 and 6. A score of 6 corresponded to a response of completely agree for positively worded statements about the varicella vaccine, or a response of completely disagree for negatively worded statements. Thus, higher scores denoted positive health beliefs regarding the varicella immunization. This scoring system allows for comparison of level of agreement with different health belief statements.

A composite varicella vaccine health belief score was computed from each parents responses on the survey by dividing the sum of scores for individual statements by the number of statements for which the parent indicated a level of agreement (because not every parent responded to every statement). Thus, composite health belief scores also ranged from 1 to 6. Composite health belief scores of parents with several different dichotomous characteristics were compared using Mann-Whitney tests. These characteristics included previous experience with a child with varicella (yes or no), varicella vaccine status of child being seen (previously received immunization or not), age of child being seen ( 18 months old or 18 months old), high level of parental education (at least college graduate or less education), willingness to pay for varicella vaccine out-ofpocket ( $50 vs $50), and level of influence by pediatrician in making decision about the vaccine (influence quantified as quite a bit or strongly vs other responses). Puget Sound Pediatric Research Network pediatricians had previously participated in a survey on physician attitudes regarding the varicella vaccine.6 Each respondent indicated whether he or she followed the American Academy of Pediatrics recommendation for varicella vaccination, or had another policy. These responses were linked to the parental surveys based on whom parents identified as their childs primary pediatrician. Using this schema, composite health belief scores of parents whose child received care from a pediatrician who recommended universal varicella vaccination were compared with health belief scores of parents whose childs pediatrician had some other varicella immunization policy. Differences in health belief scores between these 2 groups were assessed with Mann-Whitney tests. In addition, parents were placed in 1 of 4 groups based on the degree of influence by their childs pediatrician on their decision to immunize their child against varicella and this pediatricians varicella vaccine policy. Differences in composite health belief scores between parents in different groups were assessed with analysis of variance. Finally, regression analysis was used to determine whether level of physician influence and/or pediatrician varicella immunization policy were independently associated with composite health belief scores. The study was approved by the Childrens Hospital and Regional Medical Center Institutional Review Board and the University of Washington Human Subjects Committee.

To further evaluate parental attitudes regarding the varicella vaccine, we conducted a survey of parents of children followed by private pediatricians in the Seattle, Wash, area. The survey was designed using a health beliefs model.9 The use of a parental health beliefs model may help to explain utilization of preventive services. With this model, the decision by the parent to use the varicella vaccine, or not, is divided into 5 components: the perceived susceptibility of the child to varicella, the severity of the infection, the perceived benefit of the immunization in preventing disease, barriers to receiving the vaccine, and perceived self-efficacy (the perception that the parent can promote his or her childs health despite obstacles). In addition, we were interested in the effect of their childs pediatrician on these parental beliefs, and the influence of previous experience with the vaccine or natu-

ral infection on attitudes about varicella immunization. Prior to conducting the study, we postulated that parents would have positive beliefs about the vaccine and that pediatricians beliefs would significantly influence parental judgments.
RESULTS

The median age of the 598 children being seen on the day that their parents completed the varicella vaccine survey was 16.8 months (range, 2 days to 16 years 10 months); 45.5% of the children were younger than 18 months. A total of 224 parents responded that at least 1 of their children had previously contracted varicella. However, among 380 study children older than 12 months, only 83 had received the varicella vaccine (22.7% of those
WWW.ARCHPEDIATRICS.COM

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, MAR 2000 303

Downloaded from www.archpediatrics.com on November 15, 2010 2000 American Medical Association. All rights reserved.

whose parents responded either yes or no; 12 parents were unsure whether their child had received the immunization, and 3 parents did not respond to the question). In addition, 124 patients who were older than 12 months had previously had varicella. Thus, among eligible children, the rate of vaccination against varicella was 32.0%. Responses to individual health belief statements regarding the varicella vaccine are summarized in Table 2. Parents agreed that receiving all recommended vaccines was important to their childs health (median score, 6.0; 88.4% of respondents agreed or completely agreed with this statement). Generally, parents agreed that their children were likely to get varicella if not immunized (median score, 5.0), and were not overly concerned about the number of shots that their children were receiving (median score, 5.0). However, parents did not agree that the vaccine was worthwhile if the only benefit was in reducing time lost from work; 57.4% of respondents disagreed or completely disagreed with this statement.
Table 1. Health Belief Statements Regarding the Varicella (Chickenpox) Vaccine
1. The chickenpox vaccine is very effective in preventing chickenpox. 2. The chickenpox vaccine is worthwhile even if the only benefit is to prevent a serious complication that occurs in 1 to 2 of 1000 children with chickenpox. 3. I think that the risks of immunization with the chickenpox vaccine may outweigh the benefits. 4. The chickenpox vaccine is worthwhile even if the only benefit is preventing my child from being uncomfortable if he/she gets the chickenpox. 5. I feel that getting all recommended immunizations (shots) is important to my childs health. 6. My child is very likely to get the chickenpox if she/he does not receive the vaccine. 7. My child may not need the chickenpox vaccine because chickenpox is usually a minor illness. 8. The chickenpox vaccine is worthwhile even if the only benefit is that, in preventing chickenpox my child(ren), I, and/or my spouse will not have to miss work. 9. It is worthwhile for my child to receive the chickenpox vaccine even if it does not provide lifelong immunity to chickenpox for my child. 10. I am uncomfortable with the number of shots my child is receiving.

The distribution of composite varicella vaccine health belief scores among the 598 responding parents is displayed in the Figure. Health belief scores were widely distributed between 1 and 6; the median score was 4.1. Comparisons of composite health belief scores in parents with differing characteristics are shown in Table 3. Parents whose children were younger or had previously received the varicella vaccine had significantly more positive health beliefs than the appropriate comparison groups. In addition, parents who indicated their pediatrician influenced their opinions about the immunization quite a bit or strongly had more positive beliefs about the vaccine than those who stated that their pediatricians opinion was less influential (or unknown). Health beliefs of parents who had at least a college education were similar to those with lower levels of education. Finally, parents who had experienced a child with varicella had significantly less positive health beliefs about the immunization than those who had not had a child with varicella. When asked what the most that they would spend out-of-pocket for their child to receive the varicella vaccine, 56.3% of respondents indicated that the maximal amount was $25 or less, and 81.5% indicated that the most they would spend was $50 or less. Conversely, 7.8% of responding parents indicated that they would be willing to spend $100 or more. Parents who responded that they
100

80

% of Parents

60

40

20

0 1.50 1.75 2.00 2.25 2.50 2.75 3.00 3.25 3.50 3.75 4.00 4.25 4.50 4.75 5.00 5.25 5.50 5.75 6.00

Composite Health Belief Scores

Distribution of composite health belief scores among parents completing survey.

Table 2. Parental Health Beliefs Regarding the Varicella Vaccine*

Statement Vaccine is effective in preventing varicella Vaccine is worthwhile if only benefit is preventing complications in 1-2 of 1000 children with varicella Risks of varicella vaccine outweigh benefits Vaccine is worthwhile if only benefit is preventing discomfort of varicella Getting all immunizations is important to my childs health Child is likely to get varicella if not immunized Varicella vaccine is unnecessary because varicella is minor illness Vaccine is worthwhile if only benefit is preventing time lost from work Vaccine is worthwhile even if immunity is not lifelong I am uncomfortable with number of shots child receives No. of Responses 497 581 518 577 596 575 581 582 582 586 Mean SD Score 4.4 0.9 4.4 1.2 3.6 1.4 3.9 1.4 5.4 1.0 5.0 1.1 3.7 1.4 2.7 1.5 3.3 1.5 4.2 1.3 Median Score 4 5 4 4 6 5 4 2 3 5

*Scoring was as follows: positively worded statements: completely agree = 6, agree = 5, somewhat agree = 4, somewhat disagree = 3, disagree = 2, and completely disagree = 1. For negatively worded statements: completely agree = 1, agree = 2, somewhat agree = 3, somewhat disagree = 4, disagree = 5, and completely disagree = 6. Negatively worded statements.

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, MAR 2000 304

WWW.ARCHPEDIATRICS.COM

Downloaded from www.archpediatrics.com on November 15, 2010 2000 American Medical Association. All rights reserved.

Table 3. Univariate Analysis of Composite Health Belief Score Regarding Varicella Vaccine Among Parents With Different Characteristics
No. of Responses 221 353 102 450 95 468 224 368 272 305 407 185 Median Score 4.3 4.0 4.5 4.1 4.6 4.0 4.0 4.2 4.2 4.1 4.1 4.2

Table 4. Comparison of Parental Composite Health Belief Scores by Level of Influence of Childs Pediatrician on Decision to Use Varicella Vaccine and Policy Regarding the Vaccine
P*
Parents Decision to Pediatrician Give Varicella Vaccine Recommends Median to Child Influenced Varicella Vaccine Composite Quite a Bit or Strongly for All Eligible No. of Health Belief by Pediatrician Children Parents* Score No Yes No Yes No No Yes Yes 211 121 141 99 4.0 4.1 4.0 4.5

Characteristic Pediatricians level of influence At least quite a bit Less influenced Out-of-pocket expenditure Willing to pay $50 Willing to pay $50 Varicella vaccine status Child received vaccine No vaccine Previous varicella experience 1 or more child with varicella No varicella experience Childs age 18 mo 18 mo Parents education College graduate or more Less than college graduate *Mann-Whitney test.

.001

.001

.001

.01

*Data are missing on 24 parents who did not respond to the question about pediatrician influence, 1 parent who did not identify a primary pediatrician, and 1 parent whose childs pediatrician did not complete the physician survey. P .001 by analysis of variance for the 4 groups.

.04

.27

were willing to pay more than $50 for the vaccine had significantly more positive health beliefs about the varicella immunization than those who would spend $50 or less out-of-pocket (median scores, 4.5 and 4.1, respectively; P .001). A total of 30 different physicians were identified as primary pediatricians for the children whose parents completed surveys. One provider, identified as the primary pediatrician for one child, did not complete the physician survey on varicella vaccine. Among the remaining 29 pediatricians, 11 (38%) adhered to the American Academy of Pediatrics recommendation for universal immunization against varicella. Parents whose childs pediatrician recommended universal immunization against varicella had significantly more positive health beliefs than those whose childs pediatrician had another varicella vaccine policy (P .001). These health beliefs were also modified based on how much parents indicated that the pediatrician influenced their decision to immunize their child against varicella (Table 4). Overall, the distribution of health belief scores in the 4 groups was significantly different (P .001). Both level of influence of the pediatrician and the varicella vaccine policy of the childs physician were independently associated with composite health belief scores (P .001 and P = .002, respectively, using regression analysis and adjusting for each characteristic).
COMMENT

Results of a 1993 survey indicated that parents of children followed by private pediatricians in the Seattle area had positive health beliefs regarding immunizations.8 Using techniques similar to those employed for the survey on varicella vaccine, the overall health belief score for immunizations was 4.6 (on a scale of 1-6). This composite score was decreased by very low scores for statements regarding the advisability of providing immunizations to

an ill child. For the majority of the remaining health belief statements, mean scores were greater than 5, with 6 being the highest score possible. Since this survey, the immunization rate in the United States has increased.2,10 Given this, the results of the survey on parental attitudes regarding the varicella vaccine were surprising; we had expected that parents would have quite positive health beliefs. Instead, we found that parental enthusiasm about the immunization was rather weak. It appears that the ubiquitous nature of varicella in childhood may play a role in decreasing the perceived necessity for varicella vaccine. A mean score of 3.7 for the statement, My child may not need the chickenpox vaccine because chickenpox is usually a minor illness, indicates that, overall, respondents are ambivalent about the seriousness of varicella. The finding that parents reporting previous experience with chickenpox in their own child(ren) had less positive health beliefs about varicella vaccine suggests that the disease is seen by many parents as benign, or perhaps as a rite of passage. This may explain the relatively low health belief score (mean, 3.6) for the statement regarding the risks vs benefits of the varicella vaccine. Even for a very safe vaccine, concerns about side effects are magnified when there is a common perception that the illness prevented by the immunization is generally minor. Responses to the survey indicate that parents were concerned about the value of the varicella vaccine if the immunity provided is not lifelong. Whether the parents were responding to the statement about lifelong immunity as a hypothetical situation or had previous knowledge about debate among health professionals over this issue is unknown. In our survey of Washington State pediatricians, concern over the possible lack of lifelong immunity was associated with not recommending universal varicella vaccination.6 Perhaps the most striking finding of the survey was that parents placed little value on the potential of childhood immunization against varicella in preventing time lost from work. The statement, The chickenpox vaccine is worthwhile even if the only benefit is that, in preventing chickenpox in my child(ren), I and/or my spouse will not have to miss work, was the lowest rated health
WWW.ARCHPEDIATRICS.COM

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, MAR 2000 305

Downloaded from www.archpediatrics.com on November 15, 2010 2000 American Medical Association. All rights reserved.

belief statement in the survey. In a study by Lieu et al,11 it was estimated that the mean value of work loss time for parents caring for a child with varicella was $183. Only after the inclusion of the savings from preventing work loss was varicella vaccine found to be cost-effective. However, our results suggest that these potential savings may not be a motivating factor for parents in their decision to immunize their children against varicella. Further, promoting the potential of varicella vaccine to reduce parental work loss may not be an effective strategy to raise the rate of immunization. However, the results of the survey provide insight on interventions that might be beneficial. For example, respondents had positive health beliefs about the ability of the vaccine to prevent complications from varicella, even if they occur in only 1 to 2 of 1000 children with the illness. Perhaps this benefit of the vaccine should be more strongly emphasized in educational materials. We also found that parents of children younger than 18 months had more positive beliefs about the varicella immunization than parents of older children. This finding suggests that it might be more effective to advocate vaccination in infants than to promote immunization in older children. The interaction between how greatly parents are influenced by their childs pediatrician, and the varicella vaccine policy of that pediatrician, is interesting. Parents who indicated that their pediatricians opinion about the vaccine significantly influenced their decision to use the immunization had more positive health beliefs than those who responded that they were less influenced. Since being strongly influenced by the pediatrician was independently associated with composite health belief score after adjusting for physician policy on varicella vaccine, this finding may be more indicative of a general belief in the health care system than a response to any specific information from the pediatrician. However, the converse was also true; regardless of the reported level of influence by the pediatrician, health belief scores were significantly more positive among parents whose childs pediatrician recommended universal immunization against varicella. This suggests that education by physicians might contribute to more positive health beliefs about varicella vaccine. This also underscores the importance of aggressive education to convince pediatricians of the necessity of adopting universal varicella immunization if they are to play a central role in convincing parents. There are several limitations to this study. Health beliefs about varicella vaccine among parents in the Seattle area may not be representative of the United States as a whole, especially given the high educational level of the population included in the survey. Although this area has an overall immunization rate that is higher than the many metropolitan areas in the country, only 13% of children aged 19 to 35 months in King County, Washington, had received the varicella vaccine.2 In addition, since the survey has not been validated, it is not certain if the results accurately reflect health beliefs regarding the varicella immunization. However, composite health belief scores were associated with the maximal amount of money that parents indicated they were will to spend out-of-pocket for the vaccine, providing a measure of validation. Finally, the meaning of our finding that parents of children who had previ-

ously received the varicella vaccine had more positive health beliefs than those who had not immunized their child is unclear. Since the immunization preceded the survey, it may be that the process of vaccination promoted positive health beliefs rather than vice versa. Despite these limitations, our findings suggest that parents have significant reservations about the varicella vaccine. Efforts to change these perceptions may be a key component of interventions designed to increase the proportion of children in the United States who are immunized against varicella. Accepted for publication September 10, 1999. This study was supported by an Immunization Special Projects Award from the Ambulatory Pediatric Association, McLean, Va, and by a National Research Service Award (5-T32-PE1002) from the National Institutes of Health, Bethesda, Md, to the University of Washington School of Medicine. This study was presented, in part, at the 1999 Annual Meeting of the Pediatric Academic Societies, San Francisco, Calif, May 1, 1999. Members of the Puget Sound Pediatric Research Network who participated in this study are as follows: Kathryn DelBecarro, MD, Ann Champoux, MD, Ruth Conn, MD, Ruth Crosby, MD, Steven Dassel, MD, Michele Fang, MD, Richard Joslin, MD, Bob Fukura, MD, Kathryn Koelemay, MD, Carol Lengyel, MD, Ouri Malliris, MD, Ted McMahon, MD, Helen Matthews, MD, Zaiga Phillips, MD, Peggy Sarjeant, MD, Jeffrey Scott, MD, Donald Shifrin, MD, Steve Schlafer, MD, Donna Smith, MD, Jeffrey Steele, MD, Bob Telzrow, MD, Frits vanPaasschen, MD, Lee Vincent, MD, Margaret Wheeler, MD, Cathy Wilkinson, MD, Roberta Winch, MD, Agnes Wong, MD, Cheryl Wright-Wilson, MD, and Kyle Yasuda MD. We thank Virginia Hawkins-Gerde for her help in conducting the study. Reprints: James A. Taylor, MD, Department of Pediatrics, University of Washington, 146 N Canal St, Suite 300, Box 358853, Seattle, WA 98103-8652 (e-mail: uncjat@u.washington.edu).
REFERENCES
1. American Academy of Pediatrics. Recommendations for the use of live attenuated varicella vaccine. Pediatrics. 1995;95:791-796. 2. Centers for Disease Control and Prevention. National, state, and urban area vaccination coverage levels among children aged 19-35 monthsUnited States, 1997. MMWR Morb Mortal Wkly Rep. 1998;47:547-555. 3. Szilagyi PG, Roghmann KJ, Campbell JR, et al. Immunization practices of primary care practitioners and their relation to immunization levels. Arch Pediatr Adolesc Med. 1994;148:158-166. 4. Meine EK, Bailey SR, Drucker DA, Walter E. Varicella vaccination in a primary care pediatric practice. Arch Pediatr Adolesc Med. 1998;152:608-609. 5. Centers for Disease Control and Prevention. State Immunization Requirements 1996-97. Washington, DC: US Government Printing Office; 1998. 6. Newman RD, Taylor JA. Reactions of pediatricians to the recommendation for universal varicella vaccination. Arch Pediatr Adolesc Med. 1998;152:792-796. 7. Strobino D, Keane V, Holt E, Hughart N, Guyer B. Parental attitudes do not explain underimmunization. Pediatrics. 1996;98:1076-1083. 8. Taylor JA, Cufley D. The association between parental health beliefs and immunization status among children followed by private pediatricians. Clin Pediatr. 1996;35:18-22. 9. Cutts FT, Orenstein WA, Bernier RH. Causes of low preschool immunization coverage in the United States. Ann Rev Public Health. 1992;13:385-398. 10. Centers for Disease Control and Prevention. Current trends in vaccination coverage of 2-year-old childrenUnited States, 1993. MMWR Morb Mortal Wkly Rep. 1994;43:705-709. 11. Lieu TA, Black SB, Rieser N, Ray P, Lewis EM, Shinefield HR. The cost of childhood chickenpox: parents perspective. Pediatr Infect Dis J. 1994;13:173-177.

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 154, MAR 2000 306

WWW.ARCHPEDIATRICS.COM

Downloaded from www.archpediatrics.com on November 15, 2010 2000 American Medical Association. All rights reserved.