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A Quebec Village Street, Winter Clarence Alphonse Gagnon
27 Nov 2013 12:00 am
The hardy souls who enjoy snow sports in the north, cavorting in the spindrift, can well relate to Robert
Louis Stevenson’s sense of winter in his poem Winter-Time: “The cold wind burns my face, and blows/Its
frosty pepper up my nose.” (Stevenson RL. A Child’s Garden of Verses. New York, NY; Simon & Schuster
Books for Young Readers; 1999:40.) For Canadian painter Clarence Alphonse Gagnon (1881-1942),
despite sojourns to warmer realms, he loved best his native land of Quebec, and for him, a low mercury
reading was immaterial. With crayon-colored palette, he narrated his nostalgia for the old ways of
Québécois life, often pictured set against a snowy backdrop.
2-year infant and maternal outcomes investigating nicotine-replacement therapy for
smoking cessation in pregnancy from the SNAP trial: a randomised controlled trial
30 Nov 2013 12:02 pm
Publication date: 29 November 2013
Source:The Lancet, Volume 382, Supplement 3
Author(s): Sue Cooper , Jaspal Taggar , Sarah Lewis , Neil Marlow , Anne Dickinson , Rachel Whitemore ,
Tim Coleman
Background Nicotine-replacement therapy (NRT) is widely prescribed for smoking cessation in pregnancy,
despite little evidence for its effectiveness and safety; the expert consensus is that NRT should be safer
than smoking for the unborn infant. SNAP, a placebo randomised controlled trial comparing nicotine
patches with placebo in pregnant smokers, found that NRT doubled cessation rates initially, but at delivery,
no statistically significant effects were seen on either maternal smoking or birth outcomes. We report
secondary outcomes from SNAP, comparing effects of NRT and placebo on infant development and
respiratory problems and on maternal smoking 2 years after delivery. Methods Participants were aged 16–
50 years, of 12–24 weeks' gestation, smoked five or more cigarettes daily, and were recruited in seven
English antenatal hospital settings. Internet randomisation ensured 15 mg/16 h nicotine patch or placebo
were randomly allocated in a 1:1 ratio. Apart from those with documented fetal deaths, all women were
eligible for follow-up until their infants were aged 2 years; participants and those undertaking follow-up were
masked to treatment allocation throughout the study. Outcomes were obtained by questionnaire (PQ2) sent
to participants, which asked about maternal smoking and infant health and used items from the ages and
stages questionnaire (ASQ-3) to assess infants' development. If participants did not respond, their general
practitioner was sent a questionnaire (HPQ) to assess infant development instead. Of the secondary
outcomes recorded at 2 years, the primary outcome was infant survival with no impairment, a composite of
normal scores for all ASQ-3 domains plus no reported problems in remaining PQ2 items or HPQ responses.
Singleton livebirth data were used for primary analysis of infant outcomes. Intention-to-treat analyses were
done; for smoking outcomes, non-responders were assumed to be smokers, and for infant outcomes,
complete case analyses were done with multiple imputations to explore the effect of missing data. Findings
1050 women (mean age 26 years [SD 6·2], mean gestation 16 weeks [3·5]) were randomly assigned but 14
had fetal deaths and no birth details were obtained for 14. From the remaining 1022 women, we obtained
questionnaires at 2 years for 900 (88%; 448 NRT, 452 placebo). 12 women had twins, leaving 1010
singleton infants (mean birthweight 3·2 kg [SD 0·6]), of which we obtained outcome data for 891 (445 NRT,
446 placebo). 323 (73%) singleton infants in the NRT group survived with no impairment compared with
290 (65%) in the placebo group (odds ratio [OR] 1·4, 95% CI 1·05–1·86; p=0·023). There was no difference
in infants' reported respiratory symptoms between NRT and placebo groups: 132 (30%) in the NRT group
and 111 (25%) in the placebo group (OR 1·3, 95% CI 0·97–1·74; p=0·083). Of the 1050 trial participants, 15
(3%) of 521 allocated NRT and nine (2%) of 529 allocated placebo abstained from smoking since a quit
date set in pregnancy (OR 1·7, 95% CI 0·74–3·94; p=0·20). Interpretation Findings suggest that, at age 2
years, NRT used for smoking cessation in pregnancy results in better infant outcomes than with placebo.
Thus, a smoking cessation intervention delivered in pregnancy could affect infant outcomes. We speculate
that reported effects were caused by small changes in maternal smoking behaviour. Funding The National
Institute for Health Research Health Technology Assessment.
50 Years Ago in The Journal of Pediatrics: Autoimmune Disorders of Endocrine Glands
01 Dec 2013 12:00 am
Solomon IL, Blizzard RM. J Pediatr 1963;63:1021-33 In their insightful article, Solomon and Blizzard
reviewed data that substantiated Witebsky's postulates pointing to autoimmunity in 3 endocrine diseases:
Hashimoto's thyroiditis, Addison's disease, and male infertility. They correctly hypothesized that additional
‘idiopathic’ endocrine disorders would have a similar autoimmune etiology including diabetes,
hypoparathyroidism, panhypopituitarism, and ovarian failure.
50 Years Ago in The Journal of Pediatrics: Iron Metabolism in Premature Infants: I.
Absorption and Utilization of Iron as Measured by Isotope Studies
01 Dec 2013 12:00 am
Gorten MK, Hepner R, Workman JB. J Pediatr 1963;63:1063-1071 The modern era of neonatology began
with mechanical ventilation of infants in the early 1970s, yet premature infants survived long before and
were perceived as nutritionally at risk. In the 1960s, investigators recognized that preterm infants were at
risk for postnatal iron deficiency due to low fetal endowment and rapid postnatal growth. Techniques using
radioisotopes to assess gastrointestinal iron absorption and red cell distribution were available.
50 Years Ago in The Journal of Pediatrics: Quality of Medical Care: A Problem
01 Dec 2013 12:00 am
Eagle JF. J Pediatr 1963;63:1151-7 Even 50 years before the bleak picture outlined in 1963 by Eagle, the
quality of healthcare in the US had been a point of candid debate and uncertainty that was mostly neglected
by health professionals. Attention began with 2 reports in the 1910s: the Report to the Carnegie Foundation
from Abraham Flexner, encouraged by the American Medical Association, and the report from Ernest
Codman at Boston's Massachusetts General Hospital, in which the deplorable state of medical schools and
hospitals was described and the urgent need for change emphasized. Although the former report had a
greater public impact, the latter led the American College of Surgeons to establish the Hospital
Standardization Program in 1917, which eventually gave birth in 1952 to the Joint Commission on
Accreditation of Hospitals when the American College of Physicians, American Hospital Association, and
Canadian Medical Association joined this effort.
50 Years Ago in The Journal of Pediatrics: The Effect of Breathing 40 Per Cent Oxygen on
the Arterial Blood Gas Tension of Babies With Bronchiolitis
01 Dec 2013 12:00 am
Reynolds EOR. J Pediatr 1963:63:1135 Reynolds documents the therapeutic benefit of relatively low
concentrations of supplemental oxygen in 10 infants with bronchiolitis. The newsworthiness of this report is
difficult to appreciate 50 years later, but clinically useful machines that could measure the partial pressure of
oxygen in blood had been introduced only in the mid-1950s, and the effects of oxygen in infants with
respiratory distress were not well defined. After documenting that the average alveolar-arterial oxygen
gradient in his subjects was approximately 10 times normal, Reynolds demonstrated that 40% face-mask
oxygen was able to increase the partial pressure of oxygen in arterial blood from 40s and 50s to over 100.
Moreover, the maneuver did not impede the exhalation of carbon dioxide. Using deductive reasoning based
on his own and others' observations, he concluded that most of the hypoxia in this entity was the result of
ventilation–perfusion mismatching, which has proved to be largely correct.
50 Years Ago in The Journal of Pediatrics: The Use of Serum Creatine Phosphokinase and
Other Serum Enzymes in the Diagnosis of Progressive Muscular Dystrophy
01 Dec 2013 12:00 am
Swaiman KF, Sandler B. J Pediatr 1963;63:1116-9 Swaiman and Sandler proposed that creatine
phosphokinase (CPK) measurement was a superior test to aid in early diagnosis of muscular dystrophy
compared with other markers, including aldolase, lactic dehydrogenase, glutamic oxaloacetic transaminase,
and glutamic pyruvic transaminase. Serum analysis of 200 patients demonstrated that young individuals
with Duchenne muscular dystrophy had increased levels of all enzymes, but CPK was most significantly
and reliably elevated.
50 Years Ago in The Journal of Pediatrics: The XXXXY Syndrome: A Report of a Case and
Review of the Literature
01 Dec 2013 12:00 am
Scherz RG, Roeckel IE. J Pediatr 1963; 63:1093-8 The XXXXY syndrome, which had recently been defined
by karyotype, was considered quite rare (frequency unknown at this time). The authors described a 17month-old boy and compared and contrasted his findings with those of 8 other patients previously reported.
As is quite common in the “new” description of a syndrome, virtually all of the subjects had almost all of the
findings. Those signs and symptoms striking in this boy and the others reported included: severe
developmental delay, hypoplastic genitalia, and multiple skeletal anomalies, especially radio-ulnar
synostoses. Some of the features were consistent with Down syndrome and the authors distinguished
between the two syndromes noting some similarities in the facies.
A legal analysis of advertising of unhealthy foods to children: a case for regulatory reform?
30 Nov 2013 12:02 pm
Publication date: 29 November 2013
Source:The Lancet, Volume 382, Supplement 3
Author(s): Colin Mitchell
Background Growing calls for restrictions on marketing of unhealthy food and drink to children over recent
years have culminated in the development of a set of global recommendations by WHO to limit the power of
food advertising and reduce children's overall exposure to promotion of unhealthy food and drink. There is
also increasing criticism from health advocates in the UK and elsewhere on the effectiveness of existing
regulation and the continued reliance on self-regulation of advertising over state-led regulation. We aimed
to map the legal framework of regulation of food advertising to children in the European Union (EU) and UK
and examine it for gaps in coverage of foods, ages, channels, and techniques; and to assess strengths and
weaknesses of the regulatory regimen by principles of better regulation and aspects of regulatory theory, to
develop implications for reform. Methods Relevant law and regulation was identified by legal research
techniques. Analysis of the framework included close textual consideration of legislation and other
regulations. Published work and reports were searched for commentary on the effectiveness of the
regulation. Broader assessment of the regulatory regimen was by analysis for compliance with principles of
better regulation and aspects of regulatory theory. Findings The EU framework of regulation sets some
minimum standards for the protection of children from unhealthy marketing, including limits on false health
claims, misleading statements, and direct encouragement of children to buy food or pester others to do so.
However, the EU's approach is potentially weakened by the exemption from regulation of exaggerated
statements, the failure to allow member states to develop stronger regulation for food labelling, and the
encouragement of voluntary self-regulation over state-led action in broadcast media. The UK has adopted
some strong restrictions of unhealthy (high in fat, salt, or sugar) food and drink marketing in broadcast
media but has not adopted a strategic approach to reduce unhealthy marketing to children more widely. The
UK Government has endorsed the development of ambiguous and uncertain codes, with interpretation—
even of health consequences—left to the self-regulatory agency. This factor has led to a complex and
incoherent system. Moreover, many forms of advertising and marketing are left uncovered by industry-led
self-regulation, creating gaps that ignore the nature of modern integrated marketing. UK regulation does not
meet the UK Government's own standards of good regulation and the central players, UK Government
sanctioned co-regulatory and self-regulatory industries, are also missing key qualities that may be
necessary to secure legitimacy in the eyes of both public health advocates and the public. Interpretation
Gaps and inconsistencies in the regulatory framework suggest that there is a clear case for reform of
existing industry-led regulation of advertising to children. However, much study of regulation suggests that
there is no binary distinction between state-led regulation and self-regulation. Instead, there are a range of
positions between the two. The state is able to influence self-regulators by indirect means; for example, the
oversight of industry codes by other regulators or the development of competing regulatory bodies.
Advocacy that highlights the flaws in self-regulation is justified. However, theoretical approaches, such as
systems-theoretical views of regulation suggest that an indirect approach might be more likely to succeed
than attempts to end self-regulation, and more desirable than piecemeal adjustments that are likely to only
displace, rather than reduce, unhealthy advertising to children. Funding None.
Active Versus Passive Cooling During Neonatal Transport
01 Nov 2013 03:01 pm
Cooling infants with hypoxic-ischemic encephalopathy shortly after birth improves survival and
neurodevelopmental outcome. The optimal way to cool infants during transfer to regional NICUs is unclear.
Data from a regional neonatal transfer team, using first passive and subsequently active cooling for these
infants, suggest that active cooling results in improved thermal control and a reduction in stabilization time.
(Read the full article)
Alcohol marketing in televised English professional football: a frequency analysis
30 Nov 2013 12:02 pm
Publication date: 29 November 2013
Source:The Lancet, Volume 382, Supplement 3
Author(s): Jean Adams , Andy Graham
Background Worldwide, almost 4% of deaths are attributable to alcohol. In the UK, there continues to be a
rise in alcohol-related hospital admissions. Alcohol is marketed through an integrated mix of strategies,
including TV, radio, and print advertising; point-of-sale promotions; new media approaches such as
advergames (ie, advertising in video games); and sponsorship of cultural and sporting events. Systematic
review evidence confirms that alcohol marketing increases the likelihood that young people will start to use
alcohol and will drink more if they already do so. Association football (referred to as football) is a globally
popular spectator sport across all age groups. Little previous research has quantified the full range of
alcohol marketing within televised sport and there has been no such research for football or within the UK.
We assessed the frequency of alcohol marketing in televised top-class English professional football
matches. Methods A purposive sample of six broadcasts of televised top-class English club football
matches broadcast in January and February, 2012, were identified and recorded. The sample was selected
to represent the full range of competitions that teams take part in, as well as broadcasts on different days
and at different times of day. A customised coding framework was used to identify and categorise all verbal
and visual alcohol references, as well as all formal alcohol commercials in the broadcasts. A random two
matches were double coded. Findings The six broadcasts consisted of 1101 broadcast minutes in total, and
one match each from the Barclay's Premier League, nPower Championship, UEFA (Union of European
Football Associations) Champion's League, UEFA Europa League, Budweiser FA (Football Association)
Cup, and Carling League Cup. The mean UK television audience for these broadcasts was 2·52 million (SD
1·53 million), with a mean of 9·5% (2·2) of the audience being aged younger than 18 years. Double coding
revealed discrepancies in the presence of only two visual alcohol references (of 521 in the double-coded
broadcasts). Visual references to alcohol were common (mean 111·3 per h, 95% CI 106·6–116·1). Nearly
all these references were to beer and they were mainly depictions of simple logos or other branding found
on pitch-side advertising hoardings; on the pitch before or after matches; or on-screen around replays,
substitutions, and score updates. Verbal alcohol references were much less common (mean 1·7 per h, 95%
CI 1·2–2·5) and most of these were related to sponsorship of specific competitions. 17 alcohol commercials
were included in the broadcasts, accounting for less than 1% of total broadcast time. Interpretation Because
a purposive sample of only six broadcasts was included, these results are not necessarily generalisable to
all televised English football matches. Nor was any attempt made to assess the effect of the marketing
identified on alcohol-related intentions or behaviour. The relative effects of different types of alcohol
marketing, and how these vary across population groups, remains unclear. In the UK, alcohol marketing is
subject to industry self-regulation with a focus on not appealing directly to children; not encouraging
overconsumption; and not associating alcohol with social or sexual success, irresponsible behaviour, or
illegal drugs. This approach to regulation fails to reflect the nature of alcohol marketing in contemporary
televised sport in which most marketing is constant repetition of simple logos. Further development of
regulation to represent the alcohol marketing environment is justified. Restriction of all alcohol sports
sponsorship, as seen for tobacco, may be warranted. Funding None.
Anticoagulant Treatment With Rivaroxaban in Severe Protein S Deficiency
01 Nov 2013 03:01 pm
We report a case of a 6-year-old girl with severe protein S deficiency due to a homozygous mutation and
recurrent episodes of skin necrosis. She developed purpura fulminans at birth and a catheter-related
venous thrombosis complicated by massive pulmonary embolism at the sixth day of life. Long-term oral
anticoagulant therapy with a vitamin K-antagonist was started with a therapeutic range of the international
normalized ratio of prothrombin time between 2.0 and 3.0. Unfortunately, this common range was not
sufficient because recurrent episodes of warfarin-induced skin necrosis developed if the international
normalized ratio was <4.0. Vitamin K antagonists decrease plasma level of vitamin K–dependent
coagulation proteins, including the natural anticoagulant protein C. In our patient, the hypercoagulable state
due to warfarin-induced reduction of protein C, other than severe protein S deficiency, outweighed the
anticoagulant efficacy of the inhibition of procoagulant factors II, VII, IX, and X. The switch of anticoagulant
therapy from warfarin to rivaroxaban, a direct inhibitor of activated factor X that does not inhibit other
vitamin K–dependent proteins, resulted in the disappearance of skin necrosis at 1 year of follow-up.
Rivaroxaban may be considered as a valid anticoagulant alternative in patients with severe inherited protein
S deficiency and warfarin-induced skin necrosis.
Apnea in Children Hospitalized With Bronchiolitis
01 Nov 2013 03:01 pm
Apnea is a life-threatening complication of bronchiolitis and has been associated with younger age,
prematurity, and a parental report of apnea. Apnea is classically attributed to the respiratory syncytial virus,
but little is known about the role of other viruses.
Among hospitalized children, low or high respiratory rates or low oxygen saturation on presentation were
associated with subsequent apnea in the hospital. Several bronchiolitis pathogens were associated with
apnea, with similar apnea risk across the major viral pathogens. (Read the full article)
Approval and Perceived Impact of Duty Hour Regulations: Survey of Pediatric Program
Directors
01 Nov 2013 03:01 pm
Several studies have been published evaluating the impact of 2011 Accreditation Council for Graduate
Medical Education duty hour regulations. Although resident quality of life may be improved, it appears that
resident education and patient care may be worse.
This is the first study to evaluate pediatric program director approval of 2011 Accreditation Council for
Graduate Medical Education Common Program Requirements and the perceived impact of the regulations
on patient care, resident education, and quality of life. (Read the full article)
Association of Constipation and Fecal Incontinence With Attention-Deficit/Hyperactivity
Disorder
01 Nov 2013 03:01 pm
Several studies have shown that behavioral problems can be associated with defecation and voiding
disorders, although few studies have looked directly at a link between a diagnosis of attentiondeficit/hyperactivity disorder (ADHD) and constipation or fecal incontinence.
We identified an increased risk for both constipation and fecal incontinence in children with ADHD. In
patients with concomitant ADHD and defecation disorders, more aggressive medical and behavioral
treatment of the constipation or fecal incontinence may be warranted. (Read the full article)
Association of Hospital and Provider Types on Sickle Cell Disease Outcomes
01 Nov 2013 03:01 pm
As more children with sickle cell disease survive into adulthood, they are increasingly hospitalized in both
children’s and general hospitals and managed by different provider specialists. But it is unknown if hospital
type and provider specialty affect patient outcomes.
Using a large national administrative dataset, this study revealed that general hospitals were associated
with higher rates of intubation and longer lengths of stay compared with children’s hospitals for adolescents
and young adults with SCD admitted with acute chest syndrome. (Read the full article)
Asymptomatic DNAemia Heralds CMV-Associated NEC: Case Report, Review, and
Rationale for Preemption
01 Nov 2013 03:01 pm
Human cytomegalovirus (CMV) infection may be acquired in very low birth weight and extremely low birth
weight (ELBW) infants from breast milk. The clinical relevance of such infections is uncertain. There is no
consensus on whether screening breast milk for CMV, freezing/pasteurizing milk before feeding, or
performing virological monitoring on at-risk infants is warranted. We describe an ELBW infant who acquired
CMV postnatally from breast milk and developed CMV sepsis syndrome and clinical evidence of necrotizing
enterocolitis (NEC) at ~5 weeks of age. The availability of serial dried blood spots from day of life (DOL) 4 to
21, coincidentally obtained for a metabolic study, provided the novel opportunity to retrospectively test for
and quantify the magnitude of CMV DNAemia. DNAemia was present for several weeks before the onset of
severe CMV disease, first being noted on DOL 18 and increasing in magnitude daily to 4.8
log10 genomes/mL on DOL 21, approximately 8 days before the onset of abdominal distension and 15 days
before the onset of CMV sepsis syndrome and NEC. After surgical resection, supportive care, and
ganciclovir therapy, the infant recovered. This case underscores the importance of including CMV infection
in the differential diagnosis of sepsis and NEC in premature infants. This case also suggests the value of
prospective virological monitoring in at-risk low birth weight and ELBW infants. Future studies should
examine the potential utility of preemptive monitoring for, and possibly treatment of, CMV DNAemia in
premature infants, which may herald the onset of serious disease.
Athlete Endorsements in Food Marketing
01 Nov 2013 03:01 pm
Food marketing can lead to increases in food intake, purchase intentions, and brand preferences. Food
companies use athlete endorsements as 1 form of food marketing. One study revealed that parents
perceive athlete-endorsed food products as healthier than nonendorsed products.
This study assessed the (1) prevalence of athlete endorsements of food, (2) nutritional profile of foods
endorsed by athletes, and (3) youth exposure to athlete endorsements of foods. This study reveals that
adolescents saw more athlete-endorsement food commercials than adults. (Read the full article)
Authors' Response: Re: My Concerns About the American Academy of Pediatrics Clinical
Report on "Motor Delays: Early Identification and Evaluation"
01 Nov 2013 03:01 pm
Authorship criteria
01 Dec 2013 12:00 am
The Journal's leadership looks to organizations such as the Committee on Publication Ethics (COPE) and
International Committee of Medical Journal Editors (ICMJE) for guidance when developing editorial policies
and procedures. Until recently, the three conditions of authorship outlined in ICMJE's “Uniform
Requirements for Manuscripts Submitted to Biomedical Journals”
(http://www.icmje.org./ethical_1author.html) have served as The Journal's guidelines for authorship. In
August 2013, ICMJE updated these requirements, now called “Recommendations for the Conduct,
Reporting, Editing, and Publication of Scholarly Work in Medical Journals” (ie, “ICMJE Recommendations”)
(http://www.icmje.org/icmje-recommendations.pdf). The most notable change in ICMJE Recommendations
is in regard to authorship criteria.
Autoimmune Lymphoproliferative Syndrome Misdiagnosed as Hemophagocytic
Lymphohistiocytosis
01 Nov 2013 03:01 pm
Autoimmune lymphoproliferative syndrome (ALPS) is a rare inherited disorder of apoptosis, most commonly
due to mutations in the FAS (TNFRSF6) gene. It presents with chronic lymphadenopathy, splenomegaly,
and symptomatic multilineage cytopenias in an otherwise healthy child. Unfortunately, these clinical findings
are also noted in other childhood lymphoproliferative conditions, such as leukemia, lymphoma, and
hemophagocytic lymphohistiocytosis, which can confound the diagnosis. This report describes a 6-year-old
girl with symptoms misdiagnosed as hemophagocytic lymphohistiocytosis and treated with chemotherapy
before the recognition that her symptoms and laboratory values were consistent with a
somatic FAS mutation leading to ALPS. This case should alert pediatricians to include ALPS in the
differential diagnosis of a child with lymphadenopathy, splenomegaly, and cytopenias; obtain discriminating
screening laboratory biomarkers, such as serum vitamin B-12 and ferritin levels; and, in the setting of a
highly suspicious clinical scenario for ALPS, pursue testing for somatic FAS mutations when germ-line
mutation testing is negative.
Avoiding Endotracheal Ventilation to Prevent Bronchopulmonary Dysplasia: A Metaanalysis
01 Nov 2013 03:01 pm
BACKGROUND AND OBJECTIVE:
Mechanical ventilation via an endotracheal tube is a risk factor for bronchopulmonary dysplasia (BPD), one
of the most common morbidities of very preterm infants. Our objective was to investigate the effect that
strategies to avoid endotracheal mechanical ventilation (eMV) have on the incidence of BPD in preterm
infants <30 weeks’ gestational age (GA).
METHODS:
In February 2013, we searched the databases Medline, Embase, and the Cochrane Central Register of
Controlled Trials. Study selection criteria included randomized controlled trials published in peer-reviewed
journals since the year 2000 that compared preterm infants <30 weeks’ GA treated by using a strategy
aimed at avoiding eMV with a control group in which mechanical ventilation via an endotracheal tube was
performed at an earlier stage. Data were extracted and analyzed by using the standard methods of the
Cochrane Neonatal Review Group. The authors independently assessed study eligibility and risk of bias,
extracted data and calculated odds ratios and 95% confidence intervals, employing RevMan version 5.1.6.
RESULTS:
We identified 7 trials that included a total of 3289 infants. The combined odds ratio (95% confidence
interval) of death or BPD was 0.83 (0.71–0.96). The number needed to treat was 35. The study results were
remarkably homogeneous. Avoiding eMV had no influence on the incidence of severe intraventricular
hemorrhage.
CONCLUSIONS:
Strategies aimed at avoiding eMV in infants <30 weeks’ GA have a small but significant beneficial impact on
preventing BPD.
Best Practices for Sports Medicine Management for Secondary Schools and Colleges
01 Nov 2013 03:01 pm
Bronchoscopy With N-Acetylcysteine Lavage in Severe Respiratory Failure From Pertussis
Infection
01 Nov 2013 03:01 pm
Pertussis is an illness that causes significant morbidity and mortality, especially in infants younger than 3
months old. In the most severe cases, it can cause pneumonia, respiratory failure, acute respiratory distress
syndrome, pulmonary hypertension, and death. There are reports of using rescue extracorporeal membrane
oxygenation (ECMO) as a rescue therapy. However, the mortality of ECMO with pertussis is higher than
with other causes of pediatric respiratory failure. We report here the case of a 2-month-old boy with severe
respiratory failure and pulmonary hypertension who satisfied ECMO criteria but was successfully treated
with repeated bronchoscopy with instillation of N-acetylcysteine. Our patient’s respiratory failure was
refractory to multiple therapies that have shown benefit in pediatric hypoxemic respiratory failure, including
open lung strategies, prone positioning, intratracheal surfactant, and inhaled nitric oxide. Although
pulmonary hypertension is a key factor in most cases of fatal pertussis, the adverse effects of hyperinflation
and air leaks were more important in this patient’s clinical course. Because bronchiolar obstruction from
inflammatory, mucous, and airway epithelial debris can be seen in severe pertussis, a regimen of repeated
therapeutic bronchoscopy was initiated, and thick, inspissated secretions were retrieved. The patient’s
airway obstruction gradually resolved, and he eventually recovered with minimal sequelae.
Central Line Maintenance Bundles and CLABSIs in Ambulatory Oncology Patients
01 Nov 2013 03:01 pm
OBJECTIVE:
Pediatric oncology patients are frequently managed with central lines as outpatients, and these lines confer
significant morbidity in this immune-compromised population. We aimed to investigate whether a
multidisciplinary, central line maintenance care bundle reduces central line–associated bloodstream
infections (CLABSIs) and bacteremias in ambulatory pediatric oncology patients.
METHODS:
We conducted an interrupted time-series study of a maintenance bundle concerning all areas of central line
care. Each of 3 target groups (clinic staff, homecare agency nurses, and patient families) (1) received
training on the bundle and its importance, (2) had their practice audited, and (3) were shown CLABSI rates
through graphs, in-service training, and bulletin boards. CLABSI and bacteremia person-time incidence
rates were collected for 23 months before and 24 months after beginning the intervention and were
compared by using a Poisson regression model.
RESULTS:
The mean CLABSI rate decreased by 48% from 0.63 CLABSIs per 1000 central line days at baseline to
0.32 CLABSIs per 1000 central line days during the intervention period (P = .005). The mean bacteremia
rate decreased by 54% from 1.27 bacteremias per 1000 central line days at baseline to 0.59 bacteremias
per 1000 central line days during the intervention period (P < .001).
CONCLUSIONS:
Implementation of a multidisciplinary, central line maintenance care bundle significantly reduced CLABSI
and bacteremia person-time incidence rates in ambulatory pediatric oncology patients with central lines.
Further research is needed to determine if maintenance care bundles reduce ambulatory CLABSIs and
bacteremia in other adult and pediatric populations.
Changes in Bedtime Schedules and Behavioral Difficulties in 7 Year Old Children
01 Nov 2013 03:01 pm
Links between clinically diagnosed sleep problems and adverse behavioral outcomes are well documented.
However, in nonclinical populations, causal links between disrupted sleep and the development of
behavioral difficulties are far from clear.
Seven-year-old children with nonregular bedtimes had more behavioral difficulties than children who had
regular bedtimes. There were clear dose–response relationships, and the effects of not having regular
bedtimes appeared to be reversible. (Read the full article)
Characteristics of 5-year-olds who catch up with the combined measles, mumps, and
rubella vaccine: findings from a contemporary UK cohort
30 Nov 2013 12:02 pm
Publication date: 29 November 2013
Source:The Lancet, Volume 382, Supplement 3
Author(s): Anna Pearce , Mario Cortina-Borja , Miranda Mindlin , Helen Bedford
Background The national measles, mumps, and rubella (MMR) catch-up programme, launched in April,
2013, aims to increase vaccine uptake in groups with low immunisation rates. Cover of Vaccination
Evaluated Rapidly (COVER) provides routine data for monitoring of national and local immunisation
coverage; however, records are not held at the individual level and cannot be used to examine vaccine
catch up or individual-level characteristics associated with uptake. We examined predictors of catch up with
MMR in a contemporary cohort of children targeted by the catch-up programme. Methods We used data
from the most recent UK cohort, the Millennium Cohort Study (MCS). Families of children born in the UK in
2000–02 were contacted via opt-out letters; data were collected from 18 818 children, of whom 18 296 were
singletons. At ages 3 and 5 years, participants were followed up by letter, telephone (when possible), and a
visit. 12 989 (71%) singleton children from the initial cohort responded to all three sweeps. We analysed
data for 751 (6%) children who were unimmunised with the MMR at age 3 years. We estimated unadjusted
risk ratios (RRs) and 95% CIs for partial (received one MMR) and full (two MMRs) catch up by age 5 years
(baseline: remaining unimmunised) according to various social, economic, and demographic characteristics
and reasons reported by parents for not immunising their child at age 3 years. Significantly associated
variables in univariable analyses (p&lt;0·10) were entered into multivariable models for partial and full catch
up, by a forward stepwise technique. Findings 440 of 751 children (60·3%, 95% CI 56·2–64·3) remained
unvaccinated; 127 (16·1%, 13·3–19·3) partially and 184 (23·6%, 20·1–27·5) fully caught up. In multivariable
models, children from families who did not speak English at home were nearly five times more likely to
partially catch up than were children living in homes where only English was spoken (RR 4·68, 95% CI
3·63–6·03); full catch up was also more likely in this group (1·90, 1·08–3·32). Children were more likely to
fully catch up if they were from Pakistani or Bangladeshi (2·40, 1·38–4·18) or other ethnic origins (1·88,
1·08–3·29) compared with if they were white British; living in socially rented accommodation compared with
owner occupiers (1·86, 1·34–2·56); and living outside compared with inside London (1·95, 1·32–2·89). Full
catch up was less likely if parents reported medical reasons (RR 0·43, 95% CI 0·25–0·74) or a conscious
decision (0·33, 0·23–0·48) for not immunising at age 3 years (compared with practical reasons).
Interpretation Parents of children who partially or fully caught up with MMR experienced practical barriers to
receiving immunisation (such as missing an appointment) and were from ethnic minority or disadvantaged
groups. Time to uptake could be minimised in these families by reducing practical barriers—eg, by providing
information in community languages and offering vaccination in alternative settings. Families who continued
to reject MMR were from more advantaged backgrounds and made a conscious decision to not immunise
early on. Families should be given opportunities to discuss concerns with health professionals, who in turn
should be trained for effective communication about immunisation. Our findings refer to a period with high
parental concerns around the safety of the vaccine and low incidence of measles. Predictors of catch up in
families with young children might differ during times of measles outbreaks. Still, professionals striving to
increase MMR uptake should consider these findings in light of the characteristics of their local populations.
Funding The Centre for Paediatric Epidemiology and Biostatistics is supported in part by the MRC in its
capacity as the MRC Centre of Epidemiology for Child Health. Research at the UCL Institute of Child Health
and Great Ormond Street Hospital for Children receives a proportion of the funding from the Department of
Health's NIHR Biomedical Research Centres funding scheme. AP is funded by a MRC fellowship.
Childhood Anemia at High Altitude: Risk Factors for Poor Outcomes in Severe Pneumonia
01 Nov 2013 03:01 pm
Pneumonia is the leading cause of death in young children worldwide. Anemia, widely prevalent globally, is
not routinely assessed when treating pneumonia. The effect of anemia and high altitude on outcome of
pneumonia is not well described.
Anemia at high altitude increases the risk of poor outcome with severe pneumonia. Children with severe
pneumonia at high altitude present with more severe hypoxemia and have a longer time to recovery than
children at low altitude. (Read the full article)
Children, Adolescents, and the Media
01 Nov 2013 03:01 pm
Media, from television to the "new media" (including cell phones, iPads, and social media), are a dominant
force in children’s lives. Although television is still the predominant medium for children and adolescents,
new technologies are increasingly popular. The American Academy of Pediatrics continues to be concerned
by evidence about the potential harmful effects of media messages and images; however, important
positive and prosocial effects of media use should also be recognized. Pediatricians are encouraged to take
a media history and ask 2 media questions at every well-child visit: How much recreational screen time
does your child or teenager consume daily? Is there a television set or Internet-connected device in the
child’s bedroom? Parents are encouraged to establish a family home use plan for all media. Media
influences on children and teenagers should be recognized by schools, policymakers, product advertisers,
and entertainment producers.
China relaxes its one-child policy
30 Nov 2013 12:02 pm
Publication date: 30 November–6 December 2013
Source:The Lancet, Volume 382, Issue 9907
Author(s): Yadan Ouyang
Clinical Utility of the Colorado Learning Difficulties Questionnaire
01 Nov 2013 03:01 pm
Caregiver behavioral symptom ratings are frequently used to assist in diagnosing childhood behavioral
disorders. Although behavioral disorders are highly comorbid with learning disabilities (LDs), little work has
examined the utility of caregiver ratings of learning concerns for screening of comorbid LD.
The validity of a time- and cost-efficient caregiver rating of academic concerns (Colorado Learning
Difficulties Questionnaire) was examined. The screening measure accurately predicted children without LD,
suggesting that the absence of parent-reported difficulties may be adequate to rule out overt LD. (Read the
full article)
Cognitive Behavior Therapy for Pediatric Functional Abdominal Pain: A Randomized
Controlled Trial
01 Nov 2013 03:01 pm
Pediatric functional abdominal pain is common and costly. Cognitive behavior therapy (CBT) is a promising
treatment for these complaints, but solid evidence for its effectiveness is lacking.
This randomized controlled trial shows that CBT reduces abdominal pain in 60% of children 1 year after
treatment. Six sessions of CBT delivered by trained master’s students in psychology were equally effective
as 6 visits to an experienced pediatrician. (Read the full article)
Cognitive-Behavioral Therapy for Anxiety in Children With High-Functioning Autism: A
Meta-analysis
01 Nov 2013 03:01 pm
BACKGROUND:
Anxiety is a common and impairing problem in children and adolescents with autism spectrum disorder
(ASD). There is emerging evidence that cognitive-behavioral therapy (CBT) could reduce anxiety in children
with high-functioning ASD.
OBJECTIVE:
To systematically review the evidence of using CBT to treat anxiety in children and adolescents with ASD.
Methods for this review were registered with PROSPERO (CRD42012002722).
METHODS:
We included randomized controlled trials published in English in peer-reviewed journals comparing CBT
with another treatment, no treatment control, or waitlist control. Two authors independently screened 396
records obtained from database searches and hand searched relevant journals. Two authors independently
extracted and reconciled all data used in analyses from study reports.
RESULTS:
Eight studies involving 469 participants (252 treatment, 217 comparison) met our inclusion criteria and were
included in meta-analyses. Overall effect sizes for clinician- and parent-rated outcome measures of anxiety
across all studies were d = 1.19 and d= 1.21, respectively. Five studies that included child self-report
yielded an average d = 0.68 across self-reported anxiety.
CONCLUSIONS:
Parent ratings and clinician ratings of anxiety are sensitive to detecting treatment change with CBT for
anxiety relative to waitlist and treatment-as-usual control conditions in children with high-functioning ASD.
Clinical studies are needed to evaluate CBT for anxiety against attention control conditions in samples of
children with ASD that are well characterized with regard to ASD diagnosis and co-occurring anxiety
symptoms.
Complementary and Conventional Medicine Use Among Youth With Recurrent Headaches
01 Nov 2013 03:01 pm
Use of complementary and alternative medicine (CAM) is increasingly common among American youth;
however, information on use of CAM among youth with recurrent headache (HA) is limited.
Youth across a range of chronic conditions experience HA. These youth are more likely to use CAM. Use
and expenditures for conventional medical care, and increased difficulties in activity and functioning are
greater for youth with HA who use CAM. (Read the full article)
Condom Use by Adolescents
01 Nov 2013 03:01 pm
Rates of sexual activity, pregnancies, and births among adolescents have continued to decline during the
past decade to historic lows. Despite these positive trends, many adolescents remain at risk for unintended
pregnancy and sexually transmitted infections (STIs). This policy statement has been developed to assist
the pediatrician in understanding and supporting the use of condoms by their patients to prevent unintended
pregnancies and STIs and address barriers to their use. When used consistently and correctly, male latex
condoms reduce the risk of pregnancy and many STIs, including HIV. Since the last policy statement
published 12 years ago, there is an increased evidence base supporting the protection provided by
condoms against STIs. Rates of acquisition of STIs/HIV among adolescents remain unacceptably high.
Interventions that increase availability or accessibility to condoms are most efficacious when combined with
additional individual, small-group, or community-level activities that include messages about safer sex.
Continued research is needed to inform public health interventions for adolescents that increase the
consistent and correct use of condoms and promote dual protection of condoms for STI prevention with
other effective methods of contraception.
Conflicts Between Religious or Spiritual Beliefs and Pediatric Care: Informed Refusal,
Exemptions, and Public Funding
01 Nov 2013 03:01 pm
Although respect for parents’ decision-making authority is an important principle, pediatricians should report
suspected cases of medical neglect, and the state should, at times, intervene to require medical treatment
of children. Some parents’ reasons for refusing medical treatment are based on their religious or spiritual
beliefs. In cases in which treatment is likely to prevent death or serious disability or relieve severe pain,
children’s health and future autonomy should be protected. Because religious exemptions to child abuse
and neglect laws do not equally protect all children and may harm some children by causing confusion
about the duty to provide medical treatment, these exemptions should be repealed. Furthermore, public
health care funds should not cover alternative unproven religious or spiritual healing practices. Such
payments may inappropriately legitimize these practices as appropriate medical treatment.
Correction
01 Dec 2013 12:00 am
In the article, “Relationships between Maternal Ethnicity, Gestational Age, Birth Weight, Weight Gain, and
Severe Retinopathy of Prematurity,” by Husain et al, J Pediatr 2013;163:67-72, the authors inadvertently left
out a plus sign in the formula on page 70. The correct formula is:
Early Feeding and Risk of Celiac Disease in a Prospective Birth Cohort
01 Nov 2013 03:01 pm
Lower risk of early celiac disease (CD) has been observed with breastfeeding and low dose of gluten at
introduction. Gluten introduction before 4 or after 6 months has been associated with increased risk. For CD
diagnosed after 2 years, the association is unclear.
Gluten introduction delayed to >6 months as well as breastfeeding >12 months was associated with a
modest increase in CD in this first population-based birth cohort study, and gluten introduction under
continued breastfeeding was not protective. (Read the full article)
Effect of Palivizumab Prophylaxis on Subsequent Recurrent Wheezing in Preterm Infants
01 Nov 2013 03:01 pm
Palivizumab prophylaxis prevents respiratory syncytial virus lower respiratory tract infection. An association
between respiratory syncytial virus infection and subsequent recurrent wheezing has been suggested by
many studies. Only a few studies conducted from Europe and North America have addressed this causal
association.
In a prospective, multicenter, case-control study of 440 children with high follow-up rate of 98.4%,
palivizumab prophylaxis administered to preterm Japanese infants (33–35 weeks’ gestational age) in their
first respiratory season reduced the incidence of subsequent recurrent wheezing up to 3 years. (Read the
full article)
Effect of Thalidomide on Clinical Remission in Children and Adolescents With Refractory
Crohn Disease A Randomized Clinical Trial
27 Nov 2013 12:00 am
Importance
Pediatric-onset Crohn disease is more aggressive than adult-onset disease, has high rates of resistance to
existing drugs, and can lead to permanent impairments. Few trials have evaluated new drugs for refractory
Crohn disease in children.
Objective
To determine whether thalidomide is effective in inducing remission in refractory pediatric Crohn disease.
Design, Setting, and Patients
Multicenter, double-blind, placebo-controlled, randomized clinical trial of 56 children with active Crohn
disease despite immunosuppressive treatment, conducted August 2008–September 2012 in 6 pediatric
tertiary care centers in Italy.
Interventions
Thalidomide, 1.5 to 2.5 mg/kg per day, or placebo once daily for 8 weeks. In an open-label extension,
nonresponders to placebo received thalidomide for an additional 8 weeks. All responders continued to
receive thalidomide for an additional minimum 52 weeks.
Main Outcomes and Measures
Primary outcomes were clinical remission at week 8, measured by Pediatric Crohn Disease Activity Index
(PCDAI) score and reduction in PCDAI by ≥25% or ≥75% at weeks 4 and 8. Primary outcomes during the
open-label follow-up were clinical remission and 75% response.
Results
Twenty-eight children were randomized to thalidomide and 26 to placebo. Clinical remission was achieved
by significantly more children treated with thalidomide (13/28 [46.4%] vs 3/26 [11.5%]; risk ratio [RR], 4.0
[95% CI, 1.2-12.5]; P = .01; number needed to treat [NNT], 2.86). Responses were not different at 4 weeks,
but greater improvement was observed at 8 weeks in the thalidomide group (75% response, 13/28 [46.4%]
vs 3/26 [11.5%]; RR, 4.0 [95% CI, 1.2-12.5]; NNT = 2.86; P = .01; and 25% response, 18/28 [64.2%] vs 8/26
[30.8%]; RR, 2.1 [95% CI, 1.1-3.9]; NNT = 2.99; P = .01). Of the nonresponders to placebo who began
receiving thalidomide, 11 of 21 (52.4%) subsequently reached remission at week 8 (RR, 4.5 [95% CI, 1.414.1]; NNT = 2.45; P = .01). Overall, 31 of 49 children treated with thalidomide (63.3%) achieved clinical
remission, and 32 of 49 (65.3%) achieved 75% response. Mean duration of clinical remission in the
thalidomide group was 181.1 weeks (95% CI, 144.53-217.76) vs 6.3 weeks (95% CI, 3.51-9.15) in the
placebo group (P < .001). Cumulative incidence of severe adverse events was 2.1 per 1000 patient-weeks,
with peripheral neuropathy the most frequent severe adverse event.
Conclusions and Relevance
In children and adolescents with refractory Crohn disease, thalidomide compared with placebo resulted in
improved clinical remission at 8 weeks of treatment and longer-term maintenance of remission in an openlabel follow-up. These findings require replication to definitively determine clinical utility of this treatment.
Trial Registration
clinicaltrials.gov Identifier: NCT00720538
End-Stage Kidney Disease After Pediatric Nonrenal Solid Organ Transplantation
01 Nov 2013 03:01 pm
End-stage kidney disease (ESKD) causes significant morbidity and mortality after solid organ
transplantation. Adults commonly develop advanced kidney disease, particularly after liver and intestinal
transplantation. Previous pediatric studies have not compared the relative incidence of ESKD by organ
type.
This national cohort study shows the highest risk of ESKD among pediatric lung and intestinal transplant
recipients, reflecting unique organ-specific causes of kidney injury. Our findings have implications for
screening for and treating early kidney disease in transplant recipients. (Read the full article)
Estimating glomerular filtration rate
01 Dec 2013 12:00 am
For decades, serum creatinine has been used as a widely available surrogate for glomerular filtration rate
(GFR). Formal determinations of actual GFR are rarely obtained in clinical practice.
Estimation of the quality of life effect of seasonal influenza infection in the UK with the
internet-based Flusurvey cohort: an observational cohort study
30 Nov 2013 12:02 pm
Publication date: 29 November 2013
Source:The Lancet, Volume 382, Supplement 3
Author(s): Anton Camacho , Ken Eames , Alma Adler , Sebastian Funk , John Edmunds
Background Despite the public health effect of seasonal influenza in the UK, population-wide estimates of
the quality-adjusted life-year (QALY) loss associated with influenza do not exist. Such estimates are needed
to quantify the overall disease burden, compare it with other diseases, and assess the cost-effectiveness of
control measures. Since 2009, the Flusurvey—an internet-based community surveillance system for
influenza-like illness—has been operating in the UK. UK residents are recruited through print and broadcast
media, social media, and word of mouth. There were about 6000 registered participants during the 2012–13
season, during which we used the Flusurvey cohort to measure QALY loss associated with illness. Methods
Each week, participants were asked to report any symptoms and their health status. Participants were
asked to score their health status on a scale of 0–100 (0 representing the worst health imaginable and 100
the best); this method has provided estimates of QALY loss that are consistent with those obtained with the
more traditional EQ-5D during the 2009 influenza pandemic. The analysis presented is based on
participants who completed the health score at least once when symptomatic and at least once when free of
symptoms, allowing the effect of illness on quality of life to be measured in individuals. Results were
stratified by age group (0–17, 18–44, 45–64, and ≥65 years) and by severity of symptoms (acute respiratory
infection [ARI] and influenza-like illness [ILI]; appendix ). Findings Illness lasted longer for cases of ILI
(median 9 days, IQR 6–15) than for ARI (6 days, 4–10) and increased somewhat with age ( appendix ). The
median baseline health score, reported when individuals were free from symptoms, was 90 (IQR 83–95).
Individuals with ILI reported low health scores (median 60, IQR 43–75; 1837 episodes); a small reduction
was reported by those with ARI (80, 70–85; 1297 episodes). The scores were similar in different age
groups. The mean loss of quality-adjusted life was about 2·0 days (SD 2·5) for ILI cases (median 1·1 days,
IQR 0·5–2·6) and 0·6 days (SD 0·9) for ARI cases (median 0·3 days, IQR 0·1–0·7). The quality-adjusted
life-day (QALD) loss was thus over three times higher for ILI than for ARI. The mean estimated ILI QALD
loss was close to that estimated for influenza during the 2009 influenza pandemic (2·0 vs 2·7 days). QALD
loss increased with age for both ARI and ILI ( appendix ) and was significantly higher in individuals
experiencing fever (p&lt;0·0001). There was weak evidence for an increase of QALD loss in smokers
(p=0·07) but no association with being in a risk group (p=0·15) or being vaccinated (p=0·73). Interpretation
This internet-based approach opens the way for standardised and refined measure of the public health
effect of seasonal influenza and other respiratory infections in the UK and elsewhere. However, the study
has limitations: it was a non-random, self-selecting sample, in which children were under-represented, and
the self-reported symptoms were not validated by a medical practitioner. Funding The Flusurvey is funded
by Epiwork as part of the EU Seventh Framework Programme. AC and SF are both funded by a Medical
Research Council Career Development Award in Biostatistics. KE is funded by a Career Development
Fellowship supported by the National Institute for Health Research. The views expressed in this publication
are those of the authors and not necessarily those of the funders.
Evidence of Improved Milk Intake After Frenotomy: A Case Report
01 Nov 2013 03:01 pm
Ankyloglossia (tongue tie) is a well-recognized cause of breastfeeding difficulties and, if untreated, can
cause maternal nipple pain and trauma, ineffective feeding, and poor infant weight gain. In some cases, this
condition will result in a downregulation of the maternal milk supply. Milk-production measurements (24hour) for a breastfeeding infant with ankyloglossia revealed the ineffective feeding of the infant (78 mL/24
hours), and a low milk supply (350 mL/24 hours) was diagnosed. Appropriate management increased milk
supply (1254 mL/24 hours) but not infant milk intake (190 mL/24 hours). Test weighing convincingly
revealed the efficacy of frenotomy, increasing breastfeeding milk transfer from 190 to 810 mL/24 hours.
Postfrenotomy, breastfeeding almost completely replaced bottle-feeding of expressed breast milk. This
case study confirms that ankyloglossia may reduce maternal milk supply and that frenotomy can improve
milk removal by the infant. Milk-production measurements (24-hour) provided the evidence to confirm these
findings.
Excessive Antibiotic Prescribing for Sore Throat and Acute Bronchitis Remains Common
27 Nov 2013 12:00 am
Many physicians continue to overprescribe antibiotics to patients with a sore throat or acute bronchitis
despite a lack of benefit for most cases, according to research presented in October at IDWeek 2013, a
joint meeting of the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology
of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Experimental Treatment for Batten Disease Shows Promise
27 Nov 2013 12:00 am
A compound has shown promise as a potential treatment for Batten disease, a rare neurodegenerative
disorder, in cell and mice studies, according to a study funded by the Eunice Shriver Kennedy National
Institute of Child Health and Human Development.
Facing Persistent Challenges in Pediatric Decision-Making: New Hastings Center
Guidelines
01 Nov 2013 03:01 pm
Fetal Growth and Childhood Cancer: A Population-Based Study
01 Nov 2013 03:01 pm
The etiology of childhood cancers is largely unknown. However, excessive fetal growth has been
associated with some childhood cancers. One of the most consistent findings is that high birth weight is
associated with an increased risk of childhood leukemia.
Examining large, population-based birth and cancer registry data from 4 Nordic countries, high birth weight
was the most strongly associated with risk of many childhood cancers among several measures of fetal
growth that have not previously been extensively assessed. (Read the full article)
Fundamental Movement Skill Interventions in Youth: A Systematic Review and Metaanalysis
01 Nov 2013 03:01 pm
BACKGROUND:
Fundamental movement skill (FMS) proficiency is positively associated with physical activity and fitness
levels. The objective of this study was to systematically review evidence for the benefits of FMS
interventions targeting youth.
METHODS:
A search with no date restrictions was conducted across 7 databases. Studies included any school-, home-,
or community-based intervention for typically developing youth with clear intent to improve FMS proficiency
and that reported statistical analysis of FMS competence at both preintervention and at least 1 other
postintervention time point. Study designs included randomized controlled trials (RCTs) using experimental
and quasi-experimental designs and single group pre-post trials. Risk of bias was independently assessed
by 2 reviewers.
RESULTS:
Twenty-two articles (6 RCTs, 13 quasi-experimental trials, 3 pre-post trials) describing 19 interventions
were included. All but 1 intervention were evaluated in primary/elementary schools. All studies reported
significant intervention effects for ≥1 FMS. Meta-analyses revealed large effect sizes for overall gross motor
proficiency (standardized mean difference [SMD] = 1.42, 95% confidence interval [CI] 0.68–2.16, Z=
3.77, P < .0002) and locomotor skill competency (SMD = 1.42, 95% CI 0.56–2.27, Z= 3.25, P = .001). A
medium effect size for object control skill competency was observed (SMD = 0.63, 95% CI 0.28–0.98, Z =
3.53, P = .0004). Many studies scored poorly for risk of bias items.
CONCLUSIONS:
School- and community-based programs that include developmentally appropriate FMS learning
experiences delivered by physical education specialists or highly trained classroom teachers significantly
improve FMS proficiency in youth.
Growth in Duchenne muscular dystrophy
01 Dec 2013 12:00 am
In the past few years, there has been a proliferation of growth charts specific for children with certain
conditions, often genetic. These are helpful in separating growth abnormalities related to the underlying
condition from others that may be treatable or show evidence of comorbid disturbances.
Guiding Principles for Managed Care Arrangements for the Health Care of Newborns,
Infants, Children, Adolescents, and Young Adults
01 Nov 2013 03:01 pm
By including the precepts of primary care and the medical home in the delivery of services, managed care
can be effective in increasing access to a full range of health care services and clinicians. A carefully
designed and administered managed care plan can minimize patient under- and overutilization of services,
as well as enhance quality of care. Therefore, the American Academy of Pediatrics urges the use of the key
principles outlined in this statement in designing and implementing managed care programs for newborns,
infants, children, adolescents, and young adults to maximize the positive potential of managed care for
pediatrics. These principles include the following:
Gunshot Injuries in Children Served by Emergency Services
01 Nov 2013 03:01 pm
Gunshot injuries are an important cause of preventable injury and mortality in children, with emergency
services often providing the initial care for patients. However, there is little recent population-based
research to guide public health, injury prevention, and health policy efforts.
Gunshot injuries are uncommon in children, but cause greater injury severity, need for major surgery,
mortality, and costs compared with other injury mechanisms. There is also large variation in the populationadjusted incidence of pediatric gunshot injuries between regions. (Read the full article)
Have contractual changes in primary care affected unplanned short stay childhood
admissions in England? National time trends study 2001–11
30 Nov 2013 12:02 pm
Publication date: 29 November 2013
Source:The Lancet, Volume 382, Supplement 3
Author(s): Elizabeth Cecil , Alex Bottle , Mike Sharland , Sonia Saxena
Background Short-stay unplanned hospital admissions in children have much increased over the past
decade everywhere. Timely primary care prevents unplanned admissions into hospital and short stays
admissions can be regarded as a proxy indicator of conditions that could be dealt with in primary care. In
April, 2004, major changes in primary care occurred across England, with the introduction of the new
general practitioner (GP) contract. Out-of-hours health provision ceased to be the responsibility of GPs, and
alternative services introduced to compensate were unpopular with patients. In-hours health-care provision
also altered; the introduction of financial incentives for chronic disease management, having been aimed at
adults, altered the availability of GP appointments for children. Reduced access to primary care in and out
of hours could have delayed health seeking and potentially driven parents to use emergency care. We
investigated the effect of these changes on children. Methods We applied a segmented population-based
time trends study design, using Hospital Episode Statistics data, in children aged 0–14 years who were
admitted in England between April 1, 2001, and March 31, 2004, and between April 1, 2004, and March 31,
2011. The outcome measures were age-specific unplanned admission rates for total and very short stays
(same day discharge). The unit of analysis was middle super output area and we applied a generalised
estimating equations model, adjusting for deprivation and autocorrelation. Indicator variables modelled a
step change at and a trend change after service changes in April, 2004. Interaction coefficients estimated
the effect modification of age on the baseline trend and point of intervention. Findings Age-standardised
rates increased by 15% between 2001–02 and 2010–11, from 64·7 (95% CI 64·6–64·9) to 74·3 (74·2–74·5)
unplanned admissions per 1000 children. Segmented trends analysis showed a 1% step change (rate ratio
[RR] 1·01, 95% CI 1·01–1·02) in the adjusted rate of all-cause unplanned admissions after the introduction
of GP service changes in April, 2004, above the baseline trend of a 1% yearly increase in previous years
(1·01, 1·01–1·01). The steepest age-specific baseline trends were in children aged less than 1 year,
decreasing across older age bands (2% yearly increase in children under 1 year vs 1% in those aged 1–4
years). The largest step change in unplanned admission rates in 2004 was 5% in children aged 10–14
years (RR 1·05, 95% CI 1·04–1·07). Increases have been driven by very short stay rates, a yearly increase
of 5% (1·05, 1·05–1·06) and a 4% step change (1·04, 1·03–1·05) in children aged under 15 years. The
effect in 2004 ranged from no effect in children under 1 year (1·00, 0·99–1·01) to a 7% step change in
children aged 5–9 years (1·07, 1·05–1·09). Interpretation We noted a 5% increase in the rate of children
admitted and discharged on the same day, coinciding with major reorganisation in primary care in 2004.
The increase has not been uniform across age groups in children. Alternative explanations for the large
increases in 2004 include the introduction of a 4-h waiting target in English emergency departments;
changes in population demographics with European Union expansion; and the introduction of payment by
results in English hospitals. There are limitations to routine hospital activity data and the observational study
design allows only description of associations between exposure and outcome. However, Hospital Episode
Statistics has been shown to be a useful method for exploring the effect of national policy change. Funding
This study is part of a National Institute for Health Research research project.
Health Outcomes Associated With Transition From Pediatric to Adult Cystic Fibrosis Care
01 Nov 2013 03:01 pm
Transition from pediatric to adult care is often reported to be unsuccessful. Little evidential research has
examined the actual proportion of youth in pediatric versus adult care or impact on health status outcomes
after transferring from pediatric to adult care.
Our article extends the literature by providing health transition outcome data, something that has been
recognized as a critical gap to developing evidence-based programming and health care transition policy.
(Read the full article)
Higher-Hazard, No Benefit Research Involving Children: Parental Perspectives
01 Nov 2013 03:01 pm
Higher-hazard, no-benefit research involving children may be approved by local institutional review boards
only when the protocol enrolls children with the medical condition under study. The ethics of this distinction
have been debated, but parental opinions have not been explored.
We found that parental opinions support federal regulations. We discuss parental motivations for and
against research participation and the extent to which enrolling a child in higher-hazard, no-benefit research
reflects appropriate surrogate decision-making. (Read the full article)
Hypospadias and Residential Proximity to Pesticide Applications
01 Nov 2013 03:01 pm
Some studies suggest a contribution of environmental exposures such as pesticides to risk of hypospadias,
whereas others do not. One of the challenges that has limited current knowledge is the lack of detailed
exposure data.
This study examined a more detailed assessment of exposure to pesticides than previous studies.
Exposure assignments, whether to groups of chemicals, specific chemicals, or a composite involving a
number of chemicals, showed a general lack of association with hypospadias. (Read the full article)
Impact of a Routine Two-Dose Varicella Vaccination Program on Varicella Epidemiology
01 Nov 2013 03:01 pm
The 1-dose childhood varicella vaccination program in the United States resulted in dramatic declines in
varicella incidence, hospitalizations, and deaths. There is little information on the impact of the 2006
recommendation for 2-dose varicella vaccination of children on varicella epidemiology.
In the first 5 years of the 2-dose varicella vaccination program, declines in varicella incidence were seen in
all age groups, including infants who are not eligible for varicella vaccination, providing evidence of the
benefit of high population immunity. (Read the full article)
Improving Depression Screening for Adolescents With Type 1 Diabetes
01 Nov 2013 03:01 pm
OBJECTIVE:
Depression is common among adolescents, but rates increase significantly in the presence of chronic
health conditions. Outpatient screening for depression is recommended but rarely formally conducted due
to barriers of implementation.
METHODS:
To provide a model for depression screening of youth with chronic health conditions, a standard process
using a self-administered electronic version of the Children’s Depression Inventory (CDI) was developed.
Quality improvement methodology and traditional analytic approaches were used to test the feasibility and
outcomes of routine screening in patients 13 to 17 years of age with type 1 diabetes.
RESULTS:
Of the 528 eligible adolescents, 509 (96%) received at least 1 depression screen during the first year. The
process was tested and refined in over 1200 patient encounters, which resulted in an increase in
depression screening rates from <5% to a median of 85% over the initial 12 months. Both patients and staff
reported acceptance of screening on qualitative surveys. Elevated CDI scores (≥16) were found in 8% of
the sample; moderate scores (10–15) in 12% of the sample. Low risk scores were found in 80% of the
sample. Higher CDI scores correlated with lower blood glucose monitoring frequency and higher
hemoglobin A1c, confirming the link between more depression symptoms and poorer diabetes management
and control. Suicidal ideation was endorsed in 7% of the population.
CONCLUSIONS:
Systematic depression screening in adolescents with type 1 diabetes can be reliably implemented with
clinically significant results. A systematic approach, such as described in this study, can serve as a model
for other chronic health conditions.
Infant Hospitalizations for Pertussis Before and After Tdap Recommendations for
Adolescents
01 Nov 2013 03:01 pm
Pertussis rates are on the rise in the United States. Infants often require hospitalization for pertussis.
Vaccination can change hospitalization patterns for vaccine-preventable diseases. It is unknown if
vaccinating adolescents for pertussis (recommended in 2006) might change infant hospitalization utilization.
Universal vaccination policy among adolescents against pertussis appears to have been effective in 3 of the
4 years we examined postvaccination. Further vaccination efforts among adolescents and adults are
needed to prevent infantile hospitalization on a more consistent basis. (Read the full article)
Influenza-Associated Pediatric Deaths in the United States, 2004-2012
01 Nov 2013 03:01 pm
Influenza-associated deaths in children occur every year among children of all ages. Young children and
those with high-risk medical conditions are at higher risk of influenza-related complications.
This study describes influenza-associated pediatric deaths over 8 influenza seasons in the United States
and compares characteristics of deaths in children with high-risk medical conditions with those in children
without high-risk medical conditions. (Read the full article)
Information for Readers
01 Dec 2013 12:00 am
Masthead
01 Dec 2013 12:00 am
Maternal Influence on Child HPA Axis: A Prospective Study of Cortisol Levels in Hair
01 Nov 2013 03:01 pm
Stress affects health of children, potentially persisting as a trajectory into adulthood. Earlier biological
markers assess only momentary stress, making it difficult to investigate stress over longer periods of time.
Cortisol in hair is a new biomarker of prolonged stress.
Mother and child hair cortisol association suggests a heritable part or maternal calibration. Cortisol output
gradually stabilizes, has a stable trait, and is positively correlated to birth weight. Hair cortisol is a promising
noninvasive biomarker of prolonged stress, especially applicable for children. (Read the full article)
Maternal Prenatal Weight Gain and Autism Spectrum Disorders
01 Nov 2013 03:01 pm
Previous studies have found links between prepregnancy BMI and/or pregnancy weight gain and autism
spectrum disorders (ASD) risk. Several contributing factors to BMI and pregnancy weight gain (ie,
prematurity, advanced maternal age, parental education, and parity) overlap with established ASD risk
factors.
This study identifies an association between ASD risk and prenatal weight gain, but not prepregnancy BMI,
and accounts for important confounding variables excluded in previous analyses. It provides the first withinmother comparison of these factors by including unaffected sibling controls. (Read the full article)
Measles in Children Vaccinated With 2 Doses of MMR
01 Nov 2013 03:01 pm
School outbreak investigation in Quebec, Canada suggested that adolescents previously vaccinated with 2
doses of measles vaccine beginning at 12 months of age were at greater measles risk than those whose
first dose was given at ≥15 months of age.
Greater measles risk among earlier first-of-2-dose vaccine recipients was replicated as a generalized
provincial finding during the 2011 epidemic in Quebec, Canada. The mechanism remains unknown, but the
findings warrant additional evaluation in the context of measles elimination efforts. (Read the full article)
Microbial Contamination of Human Milk Purchased Via the Internet
01 Nov 2013 03:01 pm
Sharing human milk between those with an abundant supply and those seeking milk for their child may be
growing in popularity, facilitated by Web sites recently established to link providers and recipients.
This study documents the potential for human milk shared via the Internet to cause infectious disease by
estimating the extent of microbial contamination among samples purchased via a leading Internet Web site.
(Read the full article)
My Concerns About the AAP Clinical Report on "Motor Delays: Early Identification and
Evaluation"
01 Nov 2013 03:01 pm
Narrow Vs Broad-spectrum Antimicrobial Therapy for Children Hospitalized With
Pneumonia
01 Nov 2013 03:01 pm
Recent guidelines for the management of childhood pneumonia recommend narrow-spectrum antimicrobial
agents (eg, ampicillin) for most children; however, few studies have directly compared the effectiveness of
narrow-spectrum agents to the broader spectrum third-generation cephalosporins commonly used among
children hospitalized with pneumonia.
By using data from 43 children’s hospitals in the United States, we demonstrate equivalent outcomes and
costs for children hospitalized with pneumonia and treated empirically with either narrow(ampicillin/penicillin) or broad-spectrum (ceftriaxone/cefotaxime) antimicrobial therapy. (Read the full article)
Neonatal ECMO Study of Temperature (NEST): A Randomized Controlled Trial
01 Nov 2013 03:01 pm
Although providing improved survival for infants with very severe cardiorespiratory problems, the use of
neonatal extracorporeal membrane oxygenation has high rates of disability in survivors. Mild hypothermia
has been shown to limit brain injury in a range of patient groups, including newborns.
Infants who received extracorporeal membrane oxygenation and mild hypothermia did not show an
improved neurodevelopmental outcome, and nonsignificant trends in the data suggested a small adverse
effect. Use of hypothermia in other potential patient groups should be thoroughly tested. (Read the full
article)
Neonatal Resuscitation Guidelines versus the Reality of the Delivery Room
01 Dec 2013 12:00 am
The key to successful neonatal resuscitation is to establish effective ventilation of the newborn lungs in a
timely manner. The neonatal resuscitation algorithm was designed to help focus medical providers on initial
steps to promote initiation of spontaneous breathing and then rapid assessment as to a newborn's success
in taking effective breaths. If the infant is not breathing, is gasping, or has an inadequate heart rate despite
providing warmth, opening the airway, and stimulation by rubbing the back, effective positive pressure
ventilation must be initiated by the provider. Ventilation is judged to be effective once the heart rate is
stabilized above 100 beats per minute.
Nocardia brasiliensis Infection Mimicking Juvenile Idiopathic Arthritis in a 4-Year-Old Girl
01 Nov 2013 03:01 pm
Nocardia are ubiquitous environmental saprophytes that cause pneumonia and disseminated disease in
immunocompromised patients. They can also cause localized cutaneous and soft tissue infections in
healthy people after direct percutaneous inoculation. Nocardia arthritis is rare in both forms of the disease.
Here we present the first published case of a child with septic arthritis caused by N brasiliensis. Importantly,
this otherwise well 4-year-old girl had no known history of trauma but presented with transient cutaneous
lesions and a 6-week history of arthritis involving the right fourth digit proximal interphalangeal joint without
accompanying fever or raised systemic inflammatory markers. She received a diagnosis of juvenile
idiopathic arthritis and underwent antiinflammatory and immunosuppressant therapy. After 2 months she
developed frank septic arthritis, which necessitated a surgical joint washout, from which an intraoperative
swab grew N brasiliensis. The patient received 6 months of high-dose trimethoprim–sulfamethoxazole and
remains well more than 4 years after treatment. This unusual case highlights the importance of considering
an indolent infection from slow-growing organisms, including Nocardia, when diagnosing the oligoarthritis
subtype of juvenile idiopathic arthritis. This is especially relevant when a single joint is involved and
response to antiinflammatory therapy is suboptimal because antiinflammatory agents may mask evolving
signs of infection.
Nonmedical Prescription Opioid and Sedative Use Among Adolescents in the Emergency
Department
01 Nov 2013 03:01 pm
Unintentional overdose and emergency department visits secondary to nonmedical use of prescription
drugs are on the rise with peak age of onset in midadolescence for these risk behaviors. Also, risk
behaviors, such as substance use and violence, tend to cluster.
Approximately 1 in 10 adolescents or young adults using the emergency department endorse nonmedical
prescription opioid or sedative use in the past year. Rates of current opioid or sedative prescriptions are low
among this group. (Read the full article)
Novel cross-sectoral linkage of routine health and education data at an all-Scotland level: a
feasibility study
30 Nov 2013 12:02 pm
Publication date: 29 November 2013
Source:The Lancet, Volume 382, Supplement 3
Author(s): Rachael Wood , David Clark , Albert King , Daniel Mackay , Jill Pell
Background Analysis of routine data provides an efficient way of exploring health risks and outcomes. We
aimed to undertake the first Scotland-wide linkage of children's health and education data to show the
feasibility of such cross-sectoral linkage for research. Methods We undertook a data linkage study of
children in Scottish schools between 2006–07 and 2011–12. The main datasets were the annual Scottish
Government pupil census, which contains Scottish candidate numbers (SCNs; unique identifier used on
education records) and personal identifiers for children in publicly funded schools; and the Community
Health Index (CHI) database held by NHS National Services Scotland (NSS), which contains CHI numbers
(unique identifier used on health records) and identifiers for patients registered with a GP. Restricted pupil
identifiers available for linkage in the pupil census (date of birth, sex, home postcode) were matched
against patient identifiers held on the CHI database by a bespoke version of NSS's in-house medical record
linkage software (previously validated). A best match CHI and additional possible (rival) CHIs were
identified for each pupil and assigned probabilistic scores suggesting the amount of agreement between
identifiers. Links were then partitioned into categories depending on scores. Links within specified
categories (best match CHI with exact agreement on all identifiers or with postcode differing by one
character only, and nearest rival CHI with lower score) were regarded as secure, and best match CHIs were
accepted. Two methods of linkage were explored: linking identifiers from each year's pupil census
separately (A) and combining all the available pupil identifier data from each census into one record per
pupil and then linking the combined records (B). Two quality checks were undertaken to assess whether
accepted CHIs were correct. Pupil names are available in pupil census records, but the government is
unable to share these for linkage purposes. NSS therefore returned SCNs and full names from the best
matching CHI records to the government. The government then used name-matching algorithms to
compare these with the names in the pupil census. The Scottish Qualifications Agency provided SCNs and
full pupil identifiers (including names) for the subset of children registered for Scottish examinations. NSS
ran these data through their established probabilistic matching algorithms and the CHI numbers obtained
were compared with those from the pupil census linkage. The SCN–CHI key resulting from the linkage was
used to construct an anonymised analysis dataset including children's delivery records and their educational
attendance, needs, and attainment records. This dataset was used to explore educational outcomes for
children with different birth presentations and delivery modes to assess its utility in answering research
questions. The results are reported elsewhere. Findings Using linkage method A, an acceptable CHI
number could be found for 607 115 (86·3%) of 703 500 children in the 2006–07 census, increasing to
623 396 (92·9%) of 671 264 in 2011–12. Comparable figures using method B were 655 429 of 703 500
(93·2%) in 2006–07 and 638 011 of 671 264 (95·0%) in 2011–12. Linkage method B was therefore
regarded as preferable. Using linkage method B, both quality checks suggested that over 99% of the
accepted CHIs were indeed correct for children in the 2006–07 and 2011–12 censuses. Interpretation
Routine health and education data in Scotland can be linked to an acceptable quality for public health
research purposes, despite the absence of names available for linkage within education datasets. This
finding opens up the potential for a range of policy-relevant life-course research drawing on routine data
from different sectors. Funding Scottish Collaboration for Public Health Research and Policy (
https://www.scphrp.ac.uk/node/264 ).
Off-Label Topical Calcineurin Inhibitor Use in Children
01 Nov 2013 03:01 pm
In January 2006, a public health advisory and boxed warning for long-term safety and the risk of
malignancies and a medication guide were issued for topical calcineurin inhibitors, tacrolimus and
pimecrolimus.
Evaluation of off-label use of topical calcineurin inhibitors in children before and after regulatory action by
the Food and Drug Administration is important to understand the impact of regulatory action. (Read the full
article)
Opting in to Online Professionalism: Social Media and Pediatrics
01 Nov 2013 03:01 pm
Parent Health and Functioning 13 Months After Infant or Child NICU/PICU Death
01 Nov 2013 03:01 pm
Research has focused on primarily white parents, months to years after their infant/child or adult child died
of cancer, accidental injury, sudden infant death syndrome, or suicide. Many parents experience depression
and/or posttraumatic stress disorder and greater risk for some physical health problems.
Data on hospitalizations, changes in and management of chronic conditions, complexity of medication
regimens, depression, and posttraumatic stress disorder were collected over 13 months from 249 Hispanic,
black, and white parents in 188 families who experienced an infant/child NICU/PICU death. (Read the full
article)
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