Journals RSS : Gourt

Celebration at the Maasai Girls School in Southwest Kenya, April 2009 [About the Cover]

About This Journal [About This Journal]

This Month in Archives of Pediatrics & Adolescent Medicine [This Month in Archives of Pediatrics & Adolescent Medicine]

Too Beautiful for Suicide [On My Mind]

Antibacterial Medication Use During Pregnancy and Risk of Birth Defects: National Birth Defects Prevention Study [Article]

Objective To estimate the association between antibacterial medications and selected birth defects. Design, Setting, and Participants Population-based, multisite, case-control study of women who had pregnancies affected by 1 of more than 30 eligible major birth defects identified via birth defect surveillance programs in 10 states (n = 13 155) and control women randomly selected from the same geographical regions (n = 4941). Main Exposure Reported maternal use of antibacterials (1 month before pregnancy through the end of the first trimester). Main Outcome Measure Odds ratios (ORs) measuring the association between antibacterial use and selected birth defects adjusted for potential confounders. Results The reported use of antibacterials increased during pregnancy, peaking during the third month. Sulfonamides were associated with anencephaly (adjusted OR [AOR] = 3.4; 95% confidence interval [CI], 1.3-8.8), hypoplastic left heart syndrome (AOR = 3.2; 95% CI, 1.3-7.6), coarctation of the aorta (AOR = 2.7; 95% CI, 1.3-5.6), choanal atresia (AOR = 8.0; 95% CI, 2.7-23.5), transverse limb deficiency (AOR = 2.5; 95% CI, 1.0-5.9), and diaphragmatic hernia (AOR = 2.4; 95% CI, 1.1-5.4). Nitrofurantoins were associated with anophthalmia or microphthalmos (AOR = 3.7; 95% CI, 1.1-12.2), hypoplastic left heart syndrome (AOR = 4.2; 95% CI, 1.9-9.1), atrial septal defects (AOR = 1.9; 95% CI, 1.1-3.4), and cleft lip with cleft palate (AOR = 2.1; 95% CI, 1.2-3.9). Other antibacterial agents that showed associations included erythromycins (2 defects), penicillins (1 defect), cephalosporins (1 defect), and quinolones (1 defect). Conclusions Reassuringly, penicillins, erythromycins, and cephalosporins, although used commonly by pregnant women, were not associated with many birth defects. Sulfonamides and nitrofurantoins were associated with several birth defects, indicating a need for additional scrutiny.

Parental Views on Withdrawing Life-Sustaining Therapies in Critically Ill Children [Article]

Objective To broaden existing knowledge of pediatric end-of-life decision making by exploring factors described by parents of patients in the pediatric intensive care unit (PICU) as important/influential if they were to consider withdrawing life-sustaining therapies. Design Quantitative and qualitative analysis of semi-structured one-on-one interviews. Setting The PICUs at 2 tertiary care hospitals. Participants English- or Spanish-speaking parents who were older than 17 years and whose child was admitted to the PICU for more than 24 hours to up to 1 week. Intervention Semi-structured one-on-one interviews. Results Forty of 70 parents (57%) interviewed said they could imagine a situation in which they would consider withdrawing life-sustaining therapies. When asked if specific factors might influence their decision making, 64% of parents said they would consider withdrawing life-sustaining therapies if their child were suffering; 51% would make such a decision based on quality-of-life considerations; 43% acknowledged the influence of physician-estimated prognosis in their decision; and 7% said financial burden would affect their consideration. Qualitative analysis of their subsequent comments identified 9 factors influential to parents when considering withdrawing life-sustaining therapies: quality of life, suffering, ineffective treatments, faith, time, financial considerations, general rejection of withdrawing life-sustaining therapies, mistrust/doubt toward physicians, and reliance on self/intuition. Conclusion Parents describe a broad range of views regarding possible consideration of withdrawing life-sustaining therapies for their children and what factors might influence such a decision.

Estimating the Risk of Food Stamp Use and Impoverishment During Childhood [Article]

Objective To estimate the lifetime risk that an American child will reside in a household receiving food stamps and, as a result, will encounter poverty and a heightened exposure to food insecurity. Design Thirty years of longitudinal data from the Panel Study of Income Dynamics survey data set. Setting Nationally representative sample of the US population. Participants Approximately 90 000 childhood years of information are pooled together to create a series of life tables that span the ages of 1 to 20 years. Main Outcome Measure Self-reporting measure of whether survey households received the Food Stamp Program during the prior year. Results Between the ages of 1 to 20 years, nearly half (49.2%) of all American children will, at some point, reside in a household that receives food stamps. Households in need of the program use it for relatively short periods but are also likely to return to the program at several points during the childhood years. Race, parental education, and head of household's marital status exert a strong influence on the proportion of children residing in a food stamp household. Conclusions American children are at a high risk of encountering a spell during which their families are in poverty and food insecure as indicated through their use of food stamps. Such events have the potential to seriously jeopardize a child's overall health.

Case-control Study of a Gastroschisis Cluster in Nevada [Article]

Objective To identify potential risk factors associated with a sudden increase in gastroschisis cases in northern Nevada. Design Case-control study. Setting Medical centers and a pregnancy care center in Reno, Nevada. Participants Participants (n = 14) were women who gave birth to infants with gastroschisis at either of the 2 medical centers in Reno, Nevada, from April 5, 2007, through April 4, 2008. Controls (n = 57) were selected from the same pregnancy center providing perinatal care to the cases and were matched 4:1 to the case mothers by maternal date of birth within 1 year. Main Exposures Environmental exposures and illnesses during pregnancy. Outcome Measures Association of gastroschisis with illnesses, medications, or environmental exposures. Results Gastroschisis was associated with the use of methamphetamine (odds ratio [OR], 7.15; 95% confidence interval [CI], 1.35-37.99) or any vasoconstrictive recreational drug (methamphetamine, amphetamine, cocaine, ecstasy) (OR, 4.46; 95% CI, 1.21-16.44) before pregnancy. When we limited self-reported illnesses to those occurring during the first trimester of pregnancy, chest colds (OR, 16.77; 95% CI, 1.88-150.27) and sore throats (OR, 12.72; 95% CI, 1.32-122.52) were associated with gastroschisis. Conclusions These findings add strength to the hypothesis that use of methamphetamine and related drugs is a risk factor for gastroschisis and raise questions about the risks associated with infections.

A Randomized Trial of Nebulized 3% Hypertonic Saline With Epinephrine in the Treatment of Acute Bronchiolitis in the Emergency Department [Article]

Objective To determine whether nebulized 3% hypertonic saline with epinephrine is more effective than nebulized 0.9% saline with epinephrine in the treatment of bronchiolitis in the emergency department. Design Randomized, double-blind, controlled trial. Setting Single-center urban pediatric emergency department. Participants Infants younger than 12 months with mild to moderate bronchiolitis. Interventions Patients were randomized to receive nebulized racemic epinephrine in either hypertonic or normal saline. Outcome Measures The primary outcome measure was the change in respiratory distress, as measured by the Respiratory Assessment Change Score (RACS) from baseline to 120 minutes. The change in oxygen saturation was also determined. Secondary outcome measures included the rates of hospital admission and return to the emergency department. Results Forty-six patients were enrolled and evaluated. The 2 study groups had similar baseline characteristics. The RACS from baseline to 120 minutes demonstrated no improvement in respiratory distress in the hypertonic saline group compared with the normal saline control group. The change in oxygen saturation in the hypertonic saline group was not significant when compared with the control group. Rates of admission and return to the emergency department were not different between the 2 groups. Conclusions In the treatment of acute bronchiolitis, hypertonic saline and epinephrine did not improve clinical outcome any more than normal saline and epinephrine in the emergency setting. This differs from previously published results of outpatient and inpatient populations and merits further evaluation. Trial Registration isrctn.org Identifier: ISRCTN66632312

Physical Activity Opportunities Associated With Fitness and Weight Status Among Adolescents in Low-Income Communities [Article]

Objective To identify physical activity opportunities linked to fitness and weight status among adolescents in low-income communities. Design, Setting, and Participants Cross-sectional, ecological analysis of 9268 seventh- and ninth-grade students in 19 public schools participating in The California Endowment's Healthy Eating Active Communities program. Main Outcome Measures Cardiorespiratory fitness (mile time) and body mass index. Independent variables included students' perceptions and behaviors related to daily physical activity opportunities, assessed via anonymous survey. Ecological analysis was used to link survey data with fitness and body mass index data within each school. Linear regression identified associations between youths' perceptions/behaviors and fitness/body mass index. Results As the proportion of students reporting enjoying physical education, walking to school, and spending 20 minutes or longer in exercise during physical education increased from 0% to 100%, mile time decreased overall (–2.7 minutes; P = .03), mile time decreased among seventh graders (–3.3 minutes; P = .02), and body mass index z scores decreased among ninth graders (–0.7; P = .045), respectively. Each additional day students reported being active on school grounds outside school hours was associated with decreased mile time (–0.5 minute; P = .02). Active transport to school was associated with poorer weight status and greater odds of purchasing food while in transit (odds ratio = 1.5; P < .001). Conclusions Physical education is a valuable policy opportunity to improve student health. Promoting active transport may improve fitness but must be done in conjunction with community partnerships to improve the food environment in the vicinity of schools. Promoting the use of school grounds outside school hours (such as after-school programs) should also be prioritized in response to youth obesity.

Obesity in the Transition to Adulthood: Predictions Across Race/Ethnicity, Immigrant Generation, and Sex [Article]

Objective To trace how racial/ethnic and immigrant disparities in body mass index (BMI) change over time as adolescents (age, 11-19 years) transition to young adulthood (age, 20-28 years). Design We used growth curve modeling to estimate the pattern of change in BMI from adolescence through the transition to adulthood. Setting All participants in the study were residents of the United States enrolled in junior high school or high school during the 1994-1995 school year. Participants More than 20 000 adolescents from nationally representative data interviewed at wave I (1994-1995) and followed up in wave II (1996) and III (2001-2002) of the National Longitudinal Study of Adolescent Health when the sample was in early adulthood. Main Exposures Race/ethnicity, immigrant generation, and sex. Outcome Measure Body mass index. Results Findings indicate significant differences in both the level and change in BMI across age by sex, race/ethnicity, and immigrant generation. Females, second- and third-generation immigrants, and Hispanic and black individuals experience more rapidly increasing BMIs from adolescence into young adulthood. Increases in BMI are relatively lower for males, first-generation immigrants, and white and Asian individuals. Conclusion Disparities in BMI and prevalence of overweight and obesity widen with age as adolescents leave home and begin independent lives as young adults in their 20s.

Lipid Profile in Portuguese Obese Children and Adolescents: Interaction of Apolipoprotein E Polymorphism With Adiponectin Levels [Article]

Objective To evaluate how the lipid profile associates with apolipoprotein (apo) E gene polymorphism, plasma adiponectin level, and body mass index (BMI) z score in Portuguese youth. Design Transversal cohort study. Setting Hospital de São João and Hospital de Crianças Maria Pia, Porto, Portugal, between May 2006 and March 2007. Participants One hundred thirty-eight obese children and adolescents (62 boys; mean age, 10.8 years [range, 4-16 years]). Participants were grouped according to (1) apo E polymorphism: presence of the apo E alleles 2 or 4 in E2 (n = 11) and E4 (n = 31) carriers, respectively, or as E3/E3 (n = 94) (carriers of E2/E4 [n = 2] were excluded from apo E analysis because they carry both alleles) and (2) BMI z score: group 1, BMI z score less than 2 (n = 31); group 2, BMI z score of 2 or more and less than 2.5 (n = 65); and group 3, BMI z score of 2.5 or more (n = 42). Main Outcome Measures Lipid variable comparisons between apo E polymorphism and BMI z score groups and influence of BMI z score and adiponectin level, adjusted for apo E polymorphism, on total cholesterol to high-density lipoprotein cholesterol and apo A-I to apo B ratios. Results E4 carriers presented with a worse lipid profile when compared with E2 and E3/E3 carriers. There was also a clear risk of worsening for the group with the highest BMI z score. Apolipoprotein E polymorphism, BMI z score, and adiponectin level were significantly associated with total cholesterol to high-density lipoprotein cholesterol (standardized β coefficient = 0.283, 0.354, and –0.292, respectively; P < .001 for all) and apo A-I to apo B (standardized β coefficient = –0.372, –0.284, and 0.327, respectively; P < .001 for all) ratios. Conclusion Our data suggest a more atherogenic lipid profile for some apo E genotypes and for increasing BMI z score, whereas adiponectin level seems to play a protective role.

Television Exposure as a Risk Factor for Aggressive Behavior Among 3-Year-Old Children [Article]

Objective To examine associations of child television (TV) exposure and household TV use with aggressive behavior among 3-year-old children while controlling for demographic characteristics and risk and protective factors for aggression. Design The Fragile Families and Child Wellbeing Study, a prospective cohort study. Setting Data collected at home and by telephone from parents of children born from 1998 to 2000 from 20 cities. Participants Mothers who completed a 36-month in-home survey and met inclusion criteria (n = 3128). Main Exposure Direct child TV exposure and household TV use were the primary explanatory variables. Additional risk factors included neighborhood disorder and maternal factors like depression. Outcome Measures Childhood aggression was assessed with the Child Behavior Checklist/2-3. Multivariate linear regression models were used to examine associations between TV measures, additional risk factors, and childhood aggression. Results Children who were spanked in the past month (β = 1.24, P < .001), lived in a disorderly neighborhood (β = 2.07, P < .001), and had a mother reporting depression (β = 0.92, P < .001) and parenting stress (β = 0.16, P < .001) were significantly more likely to exhibit aggressive behavior. Direct child TV exposure (β = 0.16, P < .001) and household TV use (β = 0.09, P < .001) were also significantly associated with childhood aggression, even when controlling for other factors. Conclusions Three-year-old children exposed to more TV, both directly and indirectly, are at increased risk for exhibiting aggressive behavior. Further research is essential to determine whether pediatric recommendations concerning TV and children should include limits for general household TV use.

Effect of Early Intervention on 8-Year Growth Status of Low-Birth-Weight Preterm Infants [Article]

Objective To examine the impact of early educational experience at age 8 years on child growth status. The Infant Health and Development Program has shown positive impacts to age 8 years on intelligence and adaptive functioning of larger preterm infants. Design Randomized controlled trial. Setting Home and center based. Participants Three hundred seventy-seven intervention (INT) and 608 nonintervention (NI) children, stratified by birth-weight categories 2001 to 2500 g and 2000 g or less. Intervention Educational intervention from nursery discharge until age 3 years. Main Outcome Measures Eight-year weight, height, head circumference, and body mass index. Results Complete data were available for 313 INT children and 491 NI children. Adjusting for child birth weight, birth-weight category, treatment group x birth-weight category interaction, sex, race, and Neonatal Health Index; maternal education and preconception weight; and site, the INT children at age 8 years were significantly taller (127.6 vs 126.6 cm; P = .02) and had a larger head circumference (52.5 vs 52.1 cm; P < .001) than the NI children. The prevalence of both overweight (9%) and underweight (4.5%) was the same in both treatment groups. Lighter low-birth-weight INT children had greater 8-year weight (28.0 vs 26.8 kg; P = .02), larger head circumference (52.6 vs 52.1 cm; P < .001), and larger height (127.6 vs 126.5 cm; P = .05) compared with their counterparts in the NI group. Conclusion Low-birth-weight preterm children, specifically the lighter low-birth-weight group, who received the Infant Health and Development Program educational intervention were heavier and taller and had greater head circumference compared with NI children in the same birth-weight category.

Transcutaneous Bilirubin Nomograms: A Systematic Review of Population Differences and Analysis of Bilirubin Kinetics [Review Article]

Objectives To compare available nomograms in the literature defining trends in bilirubin levels across populations with different risk factor profiles and to study a mathematical bilirubin kinetics model describing the natural course of jaundice and the bilirubin rate of rise needed to cross percentile curves. Data Sources We searched PubMed for publications between March 1999 and March 2009 that created transcutaneous nomograms. We performed the same search among abstracts presented in the past 2 years at meetings of the Pediatric Academic Societies or the European Society for Paediatric Research. Study Selection Inclusion criteria were gestational age of at least 35 weeks among study subjects, the use of an electronic transcutaneous bilirubinometer, and creation of a nomogram based on hour-specific bilirubin values. Four articles met the selection criteria. Data Extraction Jaundice risk factors were analyzed, and raw data were analyzed using nonlinear regression to describe trends in bilirubin levels and kinetics. The bilirubin exaggerated rate of rise needed to cross percentile curves was calculated. Data Synthesis Significant differences in bilirubin values exist across populations, and there is substantial variability in rates of rise. Hispanic neonates demonstrate higher rates of rise and later plateaus. Bilirubin rates of rise tend to plateau and become null (equilibrium between bilirubin production and elimination) at about 96 hours of life. Rates of rise needed to cross percentile curves decrease over time but are lower (approximately 0.11 mg/dL/h [to convert bilirubin level to micromoles per liter, multiply by 17.104]) in the first 48 hours of life than previously thought. Conclusions Transcutaneous bilirubin levels plateau and then decrease after about 96 hours of life in healthy neonates, with some differences across populations. A bilirubin rate of rise higher than in the previous period implies that bilirubin production exceeds elimination and indicates high risk for subsequent hyperbilirubinemia in neonates.

Picture of the Month--Quiz Case [Special Feature]

Picture of the Month--Diagnosis [Special Feature]

Children of the Recession [Editorial]

The Ethics of Hematopoietic Stem Cell Donation by Minors [The Pediatric Forum]

The Ethics of Hematopoietic Stem Cell Donation by Minors--Reply [The Pediatric Forum]

Actual vs Preferred Sources of Human Papillomavirus Information Among Black, White, and Hispanic Parents [The Pediatric Forum]

Take Me Home: Protecting America's Vulnerable Children and Families [Book Reviews and Other Media]

Bronchiolitis and Respiratory Syncytial Virus [Advice for Patients]

Cortical Visual Impairment

Injuries and Chronic Conditions of the Knee in Young Athletes

Screening for Genitourinary Abnormalities in Adolescent Males

Care of the Child Assisted by Technology

Index of Suspicion

Clarification

Visual Diagnosis: Sepsis, Respiratory Distress, and a Persistent Right Lung Opacification in a Newborn

Adolescent Consent and Confidentiality

Adoption of Rotavirus Vaccination by Pediatricians and Family Medicine Physicians in the United States

OBJECTIVES: The goals were to assess, among pediatricians and family medicine physicians, (1) rates of offering the vaccine in their office; (2) knowledge of Advisory Committee on Immunization Practices recommendations; (3) barriers to use; and (4) factors associated with offering the vaccine. METHODS: Surveys of pediatricians and family medicine physicians were conducted in August to October 2007. RESULTS: Response rates were 84% for pediatricians and 79% for family medicine physicians (N = 623). Proportions routinely offering the vaccine were 85% of pediatricians and 45% of family medicine physicians (P < .0001); 70% of pediatricians and 22% of family medicine strongly recommended the vaccine (P < .0001). Sixty-two percent of pediatricians and 32% of family medicine physicians (P < .0001) knew the age by which all 3 doses should be completed. Definite barriers to vaccine use included reported lack of coverage by insurance companies (family medicine physicians: 22%; pediatricians: 19%; not significant), costs of purchasing vaccine (family medicine physicians: 22%; pediatricians: 17%; not significant), lack of adequate reimbursement (family medicine physicians: 18%; pediatricians: 15%; not significant), concerns about safety (family medicine physicians: 25%; pediatricians: 9%; P < .0001), and concerns about adding another vaccine to the schedule (family medicine physicians: 22%; pediatricians: 5%; P < .0001). CONCLUSIONS: Rates of offering the new rotavirus vaccine are high among pediatricians but <50% among family medicine physicians. Both specialties identified financial barriers to use of the vaccine, but family medicine physicians had significantly more concerns about safety and about adding another vaccine to the vaccination schedule.

Can Association Between Preterm Birth and Autism be Explained by Maternal or Neonatal Morbidity?

OBJECTIVE: We examined whether an association between preterm birth and risk of autistic disorders could be explained by pregnancy complications or neonatal morbidity. METHODS: This Swedish, population-based, case-control study included 1216 case subjects with autistic disorders who were born between 1987 and 2002 and 6080 control subjects who were matched with respect to gender, birth year, and birth hospital. We assessed associations between gestational age and autistic disorders and adjusted for maternal, birth, and neonatal characteristics. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Compared with infants born at term, the unadjusted ORs for autistic disorders among very and moderately preterm infants were 2.05 [95% CI: 1.26–3.34] and 1.55 [95% CI: 1.22–1.96], respectively. When we controlled for maternal, pregnancy, and birth characteristics, ORs were reduced to 1.48 [95% CI: 0.77–2.84] and 1.33 [95% CI: 0.98–1.81], respectively. When we also controlled for neonatal complications, ORs were 0.98 [95% CI: 0.45–2.16] and 1.25 [95% CI: 0.90–1.75], respectively. Reductions in risks of autistic disorders related to preterm birth were primarily attributable to preeclampsia, small-for-gestational age birth, congenital malformations, low Apgar scores at 5 minutes, and intracranial bleeding, cerebral edema, or seizures in the neonatal period. Neonatal hypoglycemia, respiratory distress, and neonatal jaundice were associated with increased risk of autistic disorders for term but not preterm infants. CONCLUSION: The increased risk of autistic disorders related to preterm birth is mediated primarily by prenatal and neonatal complications that occur more commonly among preterm infants.

Prospective, Observational Study of Outcomes in Neonates With Severe Thrombocytopenia

OBJECTIVE: A cross-sectional, observational study of outcomes for neonates with severe neonatal thrombocytopenia (SNT; platelet count of <60 x 109 platelets per L) was performed to examine hemorrhage and use of platelet transfusions. METHODS: Neonates who were admitted to 7 NICUs and developed SNT were enrolled for daily data collection. RESULTS: Among 3652 neonatal admissions, 194 neonates (5%) developed SNT. The median gestational age of 169 enrolled neonates was 27 weeks (interquartile range [IQR]: 24–32 weeks), and the median birth weight was 822 g (IQR: 670–1300 g). Platelet count nadirs were <20 x 109, 20 to 39 x 109, and 40 to 59 x 109 platelets per L for 58 (34%), 64 (39%), and 47 (28%) of all enrolled infants, respectively. During the study, 31 infants (18%) had no recorded hemorrhage, 123 (73%) developed minor hemorrhage, and 15 (9%) developed major hemorrhage. Thirteen (87%) of 15 episodes of major hemorrhage occurred in neonates with gestational ages of <28 weeks. Platelet transfusions (n = 415) were administered to 116 infants (69%); for 338 (81%) transfusions, the main recorded reason was low platelet count. Transfusions increased the platelet count from a median of 27 x 109 platelets per L (IQR: 19–36 x 109 platelets per L) to 79 x 109 platelets per L (IQR: 47.5–127 x 109 platelets per L). CONCLUSIONS: Although one third of neonates enrolled in this study developed thrombocytopenia of <20 x 109 platelets per L, 91% did not develop major hemorrhage. Most platelet transfusions were given to neonates with thrombocytopenia with no bleeding or minor bleeding only.

Prenatal Corticosteroid Prophylaxis for Women Delivering at Late Preterm Gestation

OBJECTIVE: We studied patterns of prenatal corticosteroid use, respiratory distress syndrome, and associated mortality rates to assess the congruence between knowledge and clinical practice related to such prophylaxis. METHODS: We used data on all live births in the United States (for the years 1989–1991, 1995–1997, and 2002–2004) and Nova Scotia, Canada (for the years 1988–2007). Gestational age-specific temporal trends in infant deaths resulting from respiratory distress syndrome were quantified in the United States, and gestational age-specific temporal trends in corticosteroid use and morbidity (respiratory distress syndrome and intraventricular hemorrhage) were quantified in Nova Scotia. RESULTS: In the United States, infant deaths associated with respiratory distress syndrome decreased by 48% (95% confidence interval: 46%–50%) from 1989–1991 to 1995–1997 and then decreased by another 18% (95% confidence interval: 15%–22%) by 2002–2004. The latter mortality reduction was evident at 28 to 32 weeks but not 33 to 36 weeks of gestation. Corticosteroid use at 28 to 32 weeks was high in Nova Scotia and increased from 30.7% in 1988–1989 to 50.0% in 1996–1997 and to 52.9% in 2006–2007, whereas rates of use at 33 to 36 weeks were much lower (eg, 6.7%, 17.0%, and 15.7% at 34 weeks in the 3 periods). Increased corticosteroid use at 33 and 34 weeks was estimated to reduce respiratory distress syndrome substantially. CONCLUSION: Addressing the knowledge-practice gap in corticosteroid use at 33 to 34 weeks should reduce infant morbidity and mortality rates.

Improved Adherence and Outcomes for Pediatric Liver Transplant Recipients by Using Text Messaging

OBJECTIVE: The goal was to improve immunosuppressant adherence for pediatric patients with orthotopic liver transplants by using text messaging (TM). METHODS: A prospective study of sending TM reminders to the primary medication administrator (patient or caregiver) for pediatric transplant recipients was performed. Patient records were reviewed, comparing the year before and the year of the study. The SD of serum tacrolimus levels was used as an indicator of adherence. RESULTS: Forty-one patients provided consent. The median age was 15 years (range: 1–27 years), and the median age at the time of transplantation was 2 years (range: 4 months to 23 years). Fourteen patients (34%) were male. In 29 of 41 cases, the medications were self-administered by the patient. The mean duration of study was 13 ± 1.5 months. Twenty-two patients were receiving 1 immunosuppressant, 14 were receiving 2, and 5 were receiving 3. Thirteen patients (37%) stopped the study after 4 months. The mean tacrolimus level SD decreased from 3.46 µg/L before the study to 1.37 µg/L (P < .005). The number of immunosuppressants taken and patient self/caregiver medication administration did not significantly affect the results. The number of acute cellular rejection episodes decreased from 12 to 2 during the study. Risk factors for rejection were older age (17.67 vs 13.28 years) and administration of >1 immunosuppressant. CONCLUSION: We observed significant improvement in medication adherence and a reduction in rejection episodes with TM reminders for pediatric recipients of liver transplants.

Does Measuring the Changes in TcB Value Offer Better Prediction of Hyperbilirubinemia in Healthy Neonates?

OBJECTIVE: We evaluated the diagnostic value of changes in transcutaneous bilirubin (TcB) levels for prediction of subsequent hyperbilirubinemia in healthy term and late-preterm neonates. METHODS: Neonates at 35 weeks of gestation were enrolled in a prospective study. Two TcB determinations were performed for all enrolled neonates (N = 358). The first assessment (TcB1) was performed at 24 ± 6 hours of age, followed by a second (TcB2) ≥12 hours later. Changes in TcB levels were calculated. TcB values were plotted on an hour-specific serum bilirubin nomogram, and risk zones were recorded. Of the 358 neonates enrolled, 325 neonates (91%) were monitored for hyperbilirubinemia until 5 days of age. RESULTS: The mean ages of TcB1 and TcB2 estimations were 23 ± 4 hours and 42 ± 4 hours, respectively. A total of 14.9% of neonates (48 of 325 neonates) developed hyperbilirubinemia by 5 days of age. The sensitivity, specificity, and positive and negative likelihood ratios for prediction of subsequent hyperbilirubinemia for TcB1 (zone >2, >75th percentile) were 80.4%, 58.0%, 1.9, and 0.34; those for TcB2 (zone >2, >75th percentile) were 82.6%, 79.0%, 4.0, and 0.22; and those for the change in TcB levels (>0.18 mg/dL per hour, >75th percentile) were 82.5%, 82.9%, 4.8, and 0.21, respectively. Gestational age, TcB risk zone, and change in TcB levels were found to be independent predictors of subsequent hyperbilirubinemia. CONCLUSIONS: Single TcB measurements at 30 to 48 hours predict hyperbilirubinemia with a reasonably high degree of accuracy. Changes in TcB levels do not offer any added clinical benefit.

Recombinant Human Hyaluronidase-Enabled Subcutaneous Pediatric Rehydration

OBJECTIVES: The Increased Flow Utilizing Subcutaneously-Enabled (INFUSE)-Pediatric Rehydration Study was designed to assess efficacy, safety, and clinical utility of recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous rehydration in children 2 months to 10 years of age. METHODS: Patients with mild/moderate dehydration requiring parenteral treatment in US emergency departments were eligible for this phase IV, multicenter, single-arm study. They received subcutaneous injection of 1 mL rHuPH20 (150 U), followed by subcutaneous infusion of 20 mL/kg isotonic fluid over the first hour. Subcutaneous rehydration was continued as needed for up to 72 hours. Rehydration was deemed successful if it was attributed by the investigator primarily to subcutaneous fluid infusion and the child was discharged without requiring an alternative method of rehydration. RESULTS: Efficacy was evaluated in 51 patients (mean age: 1.9 years; mean weight: 11.2 kg). Initial subcutaneous catheter placement was achieved with 1 attempt for 46/51 (90.2%) of patients. Rehydration was successful for 43/51 (84.3%) of patients. Five patients (9.8%) were hospitalized but deemed to be rehydrated primarily through subcutaneous therapy, for a total of 48/51 (94.1%) of patients. No treatment-related systemic adverse events were reported, but 1 serious adverse event occurred (cellulitis at infusion site). Investigators found the procedure easy to perform for 96% of patients (49/51 patients), and 90% of parents (43/48 parents) were satisfied or very satisfied. CONCLUSIONS: rHuPH20-facilitated subcutaneous hydration seems to be safe and effective for young children with mild/moderate dehydration. Subcutaneous access is achieved easily, and the procedure is well accepted by clinicians and parents.

Complex Multifactorial Nature of Significant Hyperbilirubinemia in Neonates

OBJECTIVE: To determine whether glucose-6-phosphate dehydrogenase (G6PD), uridine-diphosphoglucuronosyltransferase 1A1 (UGT1A1), and hepatic solute carrier organic anion transporter 1B1 (SLCO1B1) gene variants occur at greater frequency in neonates with significant hyperbilirubinemia. METHODS: Infants with gestational ages of ≥37 weeks and ages of <7 days were studied. Case subjects had ≥1 bilirubin level above the 95th percentile (high-risk zone), whereas control subjects had bilirubin levels of <40th percentile (low-risk zone) at study entry. RESULTS: A total of 153 case subjects (median bilirubin level: 15.7 mg/dL) and 299 control subjects (median bilirubin level: 4.6 mg/dL) were evaluated. There were no statistical differences in the frequencies of G6PD, UGT1A1, and SCLO1B1 gene variants between case and control subjects (G6PD: 5.2% vs 3.3%; UGT1A1: 14.4% vs 9.4%; SLCO1B1: 73.2% vs 73.6%). However, coexpression of the G6PD African A– mutation with UGT1A1 and/or SLCO1B1 variants was seen more frequently for case subjects. Case subjects more often demonstrated ≥2 factors contributing to hyperbilirubinemia, including ABO blood group heterospecificity in which the mother had blood group O (47.7% vs 11.4%), positive direct Coombs test results (33.3% vs 4%), sibling treated with phototherapy (16.3% vs 5.4%), maternal circulating blood group antibodies (10.5 vs 0.7%), maternal diabetes mellitus (13.1% vs 6.4%), and maternal East Asian ethnicity (6.5% vs 1.3%). CONCLUSIONS: Clinical contributors to hyperbilirubinemia were identified more frequently for case subjects but individually G6PD, UGT1A1, and SLCO1B1 variants were not. Coexpression of the G6PD African A– mutation with UGT1A1 and SLCO1B1 variants was seen more often for case subjects.

Intimate Partner Violence and Death Among Infants and Children in India

OBJECTIVE: The goal was to test the association between maternal intimate partner violence (IPV) victimization and child death. METHODS: Information was collected regarding 39096 children <60 months of age in the nationally representative 2005–2006 National Family Health Survey of India. The exposures were maternal reports of physical, sexual, psychological, and any IPV. Outcomes included infant (0 to <12 months), older child (12 to <60 months), and any child (0 to <60 months) deaths. RESULTS: Maternal experience of physical IPV was associated with increased mortality rates among all children (risk ratio [RR]: 1.21 [95% confidence interval [CI]: 1.13–1.30]), infants (RR: 1.24 [95% CI: 1.01–1.53]), and older children (RR: 1.25 [95% CI: 1.00–1.56]). Sexual and psychological IPV were less strongly associated with child death. The associations between maternal IPV and death did not differ according to the child's gender. CONCLUSION: The robust association between exposure to household IPV and infant and child death could be attributable to the mother's inability to care for her child, psychological stress associated with witnessing violence, and the use of maternal violence victimization as a proxy for child violence victimization.

Audio-Recorded Guided Imagery Treatment Reduces Functional Abdominal Pain in Children: A Pilot Study

OBJECTIVE: This study was designed to develop and to test a home-based, guided imagery treatment protocol, using audio and video recordings, that is easy for health care professionals and patients to use, is inexpensive, and is applicable to a wide range of health care settings. METHODS: Thirty-four children, 6 to 15 years of age, with a physician diagnosis of functional abdominal pain were assigned randomly to receive 2 months of standard medical care with or without home-based, guided imagery treatment. Children who received only standard medical care initially received guided imagery treatment after 2 months. Children were monitored for 6 months after completion of guided imagery treatment. RESULTS: All treatment materials were reported to be self-explanatory, enjoyable, and easy to understand and to use. The compliance rate was 98.5%. In an intention-to-treat analysis, 63.1% of children in the guided imagery treatment group were treatment responders, compared with 26.7% in the standard medical care–only group (P = .03; number needed to treat: 3). Per-protocol analysis showed similar results (73.3% vs 28.6% responders). When the children in the standard medical care group also received guided imagery treatment, 61.5% became treatment responders. Treatment effects were maintained for 6 months (62.5% responders). CONCLUSION: Guided imagery treatment plus medical care was superior to standard medical care only for the treatment of abdominal pain, and treatment effects were sustained over a long period.

Acute Heart Failure Syndromes in the Pediatric Emergency Department

OBJECTIVE: The objectives of this study were to (1) describe the clinical presentation of acute heart failure syndromes (AHFS) in the pediatric emergency department (ED) and (2) determine the physician treatment regimens and outcomes in the same population. METHODS: This was a cross-sectional study of patients who presented with AHFS to the ED at our institution from January 2003 to October 2006. We defined AHFS as "the gradual or rapid deterioration in heart failure signs and symptoms resulting in a need for urgent therapy." Patients were included when they had documented signs or symptoms of HF attributable to ventricular dysfunction. Patients were excluded when they were older than 21 years or had HF symptoms that were attributable to left-to-right intracardiac shunting or left-sided obstructive lesions. All eligible ED patient visits were adjudicated by a pediatric HF specialist. RESULTS: Fifty-seven patient visits to the ED met inclusion criteria. There was a significant difference in time from arrival to treatment with a diuretic when the therapy was started in the ED rather than in the inpatient units. Median time to initiation of a vasoactive agent was significantly less for patients whose infusions were started in the ED compared with the ICU. Two patients died in the ED, and overall mortality or need for mechanical circulatory support for hospitalized patients was 18% (n = 10). CONCLUSIONS: These data yield important insight into the clinical features and initial treatment of children who present with AHFS in the ED and may allow for improved recognition and treatment of this clinical syndrome.

Using BMI to Determine Cardiovascular Risk in Childhood: How Do the BMI Cutoffs Fare?

OBJECTIVE: Although adverse health outcomes are increased among children with BMI above the 85th (overweight) and 95th (obese) percentiles, previous studies have not clearly defined the BMI percentile at which adverse health outcomes begin to increase. We examined whether the existing BMI percentile cutoffs are optimal for defining increased risk for dyslipidemia, dysglycemia, and hypertension. METHODS: This was a cross-sectional analysis of the National Health and Nutrition Examination Survey from 2001 to 2006. Studied were 8216 children aged 6 to 17 years, representative of the US population. BMI was calculated by using measured height and weight and converted to percentiles for age in months and gender. Outcome measures (dyslipidemia, dysglycemia, and hypertension) were based on laboratory and physical examination results; these were analyzed as both continuous and categorical outcomes. RESULTS: Significant increases for total cholesterol values and prevalence of abnormal cholesterol begin at the 80th percentile. Significant increases in glycohemoglobin values and prevalence of abnormal values begin at the 99th percentile. Consistent significant increases in the prevalence of high or borderline systolic blood pressure begin at the 90th percentile. CONCLUSIONS: Intervening for overweight children and their health requires clinical interventions that target the right children. On the basis of our data, a judicious approach to screening could include consideration of lipid screening for children beginning at the 80th percentile but for dysglycemia at the 99th percentile. Current definitions of overweight and obese may be more useful for general recognition of potential health problems and discussions with parents and children about the need to address childhood obesity.

Exploring the Relationship Among Weight, Race, and Sexual Behaviors Among Girls

OBJECTIVE: The relationship between weight and sexual behavior among adolescents is poorly understood. We examined this relationship in a nationally representative sample of high school girls. METHODS: We performed a cross-sectional analysis of self-reported data from 7193 high school girls who completed the 2005 Youth Risk Behavior Surveillance survey. We used multivariate logistic regression to examine associations among 3 weight indices (BMI calculated from self-reported weight and height, perceived weight, and weight misperception) and 6 sexual behaviors (ever had vaginal sex; sex before age 13; ≥4 sexual partners; and alcohol, condom, and oral contraceptive use at last sex) adjusting for age, race/ethnicity, and a history of intimate partner violence. RESULTS: There were no differences in the likelihood of ever having sex on the basis of BMI or weight perception accuracy; however, girls who perceived themselves as overweight were less likely to have ever had sex. Among sexually active girls, those who had low BMI and perceived themselves as overweight or had overweight misperceptions were less likely to report condom use at last sex. Sexually active girls who perceived themselves as overweight were also more likely to have had sex before age 13. Associations between the 3 weight indices and sexual risk behaviors varied across racial/ethnic groups. CONCLUSIONS: Sexual risk behaviors may be more common among girls who are underweight or perceive themselves (accurately or not) to be overweight and vary by racial/ethnic group. This suggests that girls at weight extremes and those from different racial backgrounds may have unique sexual health education and prevention needs.

Heel-Lancing in Newborns: Behavioral and Spectral Analysis Assessment of Pain Control Methods

OBJECTIVE: Pain experience can alter clinical outcome, brain development, and subsequent behavior in newborns, primarily in preterm infants. The aims of this study were (1) to evaluate several simple, commonly used methods for pain control in newborns and (2) to evaluate the concordance between behavioral and autonomic cardiac reactivity to pain in term neonates during heel-lancing. METHODS: A prospective study was conducted of 180 term newborn infants who were undergoing heel-lancing for routine neonatal screening of phenylketonuria and hypothyroidism. Newborns were assigned to 6 groups: (1) control (no pain relief intervention); (2) nonnutritive sucking; (3) holding by mother; (4) oral glucose solution; (5) oral formula feeding; or (6) breastfeeding. Outcome measures included the Neonatal Facial Coding System score; cry duration; and autonomic variables obtained from spectral analysis of heart rate variability before, during, and after heel-lancing. RESULTS: Infants with no pain control showed the highest pain manifestation compared with newborns to whom pain control was provided. Infants who breastfed or received an oral formula showed the lowest increase in heart rate (21 and 23 beats per minute, respectively, vs 36; P < .01), lowest neonatal facial score (2.3 and 2.9, respectively, vs 7.1; P < .001), lowest cry duration (5 and 13 seconds, respectively, vs 49; P < .001), and lowest decrease in parasympathetic tone (–2 and –2.4, respectively, vs 1.2; P < .02) compared with the other groups. CONCLUSIONS: Any method of pain control is better than none. Feeding and breastfeeding during heel-lancing were found to be the most effective methods of pain relief.

Asthma Morbidity Among Children Evaluated by Asthma Case Detection

OBJECTIVE: Population-based asthma detection is a potential strategy to reduce asthma morbidity in children; however, the burden of respiratory symptoms and health care use among children identified by case detection is not well known. METHODS: Data come from a school-based asthma case detection validation study of 3539 children. Respiratory symptoms, emergency department (ED) visits, and hospitalizations were assessed by questionnaire for children whose case detection result and physician study diagnosis agreed. RESULTS: Physician evaluation of 530 case detection results yielded 420 cases of agreement (168 children with previously diagnosed asthma, 39 with undiagnosed asthma, and 213 without asthma). Children with previously diagnosed asthma were more likely to be male (P < .0001). No differences in severity were observed in children with previously and undiagnosed asthma (P = .31). Children with undiagnosed asthma reported less frequent daytime and nighttime symptoms than children with previously diagnosed asthma but more than those without asthma (P < .0001). The proportion of children with at least 1 respiratory-related ED visit in the past year was 32%, 3%, and 3% for those with previously diagnosed, undiagnosed, and no asthma, respectively (P < .0001). The proportion with at least 1 respiratory-related hospitalization was 8%, 0%, and 0%, respectively (P < .0001). There were no differences in nonrespiratory ED visits (P = .93). CONCLUSIONS: Despite similar physician-rated severity, children with undiagnosed asthma reported significantly less frequent respiratory symptoms and health care use than children with previously diagnosed asthma. These findings suggest that the potential health gains from case detection may be smaller than expected.

Neurobehavior in Term, Small-for-Gestational Age Infants With Normal Placental Function

OBJECTIVE: The goal was to evaluate the neurobehavioral outcomes of term, small-for-gestational age (SGA) newborns with normal placental function. METHODS: A cohort of consecutive term SGA newborns with normal prenatal umbilical artery Doppler ultrasound findings was created and compared with a group of term infants with size appropriate for gestational age, who were sampled from our general neonatal population. Neonatal behavior was evaluated at corrected age of 40 ± 1 weeks with the Neonatal Behavioral Assessment Scale. The effect of the study group on each Neonatal Behavioral Assessment Scale area was adjusted, through multivariate analysis of covariance, for smoking during pregnancy, maternal BMI, socioeconomic level, onset of labor, mode of delivery, use of epidural anesthetic medication, gestational age at delivery, postnatal age (in days) at evaluation, and gender. RESULTS: A total of 202 newborns (102 SGA and 100 appropriate for gestational age) were included. All of the neurobehavioral areas studied were poorer in the SGA group, with significance for attention, habituation, motor, social-interactive, and regulation of state. The average mean differences in scores between the study groups were 0.77 (95% confidence interval: 0.38–1. 14) for attention, 0.64 (95% confidence interval: 0.13–1.14) for habituation, 0.52 (95% confidence interval: 0.31–0.74) for motor, 0.95 (95% confidence interval: 0.54–1.37) for social-interactive, and 0.68 (95% confidence interval: 0.23–1.13) for regulation of state. These differences remained significant after adjustment for potential confounders. CONCLUSION: Term SGA newborns with no signs of placental insufficiency had poorer neurobehavioral competencies, which suggests delayed neurologic maturation.

Parent- Versus Child-Reported Functional Health Status After the Fontan Procedure

OBJECTIVE: We sought to compare perceptions of functional health status between children who had undergone a Fontan procedure and their parents. METHODS: Fontan procedure survivors 10 to 18 years of age were included in the study if the child completed the Child Health Questionnaire (CHQ) and the parent completed the parent form to assess the child's functional health status. Comparisons were made between raw domain scores for the parent- and child-completed CHQs. RESULTS: Between March 2003 and April 2004, 1078 Fontan survivors were screened. Of the 546 eligible and consented patients, 354 were 10–18 years of age and 328 parent/child pairs completed the CHQs. Parents reported significantly lower scores (worse functioning) for their children than the children reported for themselves in the domains of physical functioning (P < .01), impact on school or activities from emotional and behavioral problems (P < .01), impact on school or activities from physical health issues (P < .01), general behavior (P < .01), mental health (P < .01), self-esteem (P < .01), and general health perceptions (P < .01). No significant differences were noted for the domains of bodily pain, family cohesiveness, or family activities. For the physical functioning domain, factors contributing to lower scores for parent versus child reports included pulmonary artery anomalies and fenestration at the time of the Fontan operation. Lower parent-reported scores also were associated with more noncardiac health problems in the child. CONCLUSIONS: Parents' perceptions of the functional health status of their children after the Fontan procedure were worse than the children's perceptions.

Dosing of Porcine Surfactant: Effect on Kinetics and Gas Exchange in Respiratory Distress Syndrome

OBJECTIVE: The goal was to study exogenous surfactant disaturated phosphatidylcholine (DSPC) kinetics in preterm infants with respiratory distress syndrome (RDS) who were treated with 100 or 200 mg/kg porcine surfactant. METHODS: Sixty-one preterm infants with RDS undergoing mechanical ventilation received, within 24 hours after birth, 100 mg/kg (N = 40) or 200 mg/kg (N = 21) porcine surfactant mixed with [U-13C]dipalmitoylphosphatidylcholine. Clinical and respiratory parameters were recorded, and DSPC half-life and pool size and endogenous DSPC synthesis rate were calculated. RESULTS: Clinical characteristics and short-term outcomes did not differ between groups. In the 100 mg/kg group, 28 infants (70%) received a second dose after 25 ± 11 hours and 9 (22.5%) a third dose after 41 ± 11 hours; in the 200 mg/kg group, 6 infants (28.6%) received a second dose after 33 ± 8 hours and 1 a third dose. The DSPC half-life was longer in the 200 mg/kg group (first dose: 32 ± 19 vs 15 ± 15 hours [P = .002]; second dose: 43 ± 32 vs 21 ± 13 hours [P = .025]). DSPC synthesis rates and pool sizes before the first and second doses did not differ between the groups. The 200 mg/kg group exhibited a greater reduction in the oxygenation index than did the 100 mg/kg group after the first (P = .009) and second (P = .018) doses. CONCLUSIONS: Porcine surfactant given to preterm infants with RDS at a dose of 200 mg/kg resulted in a longer DSPC half-life, fewer retreatments, and better oxygenation index values.

The Brains of Very Preterm Newborns in Clinically Stable Condition May Be Hyperoxygenated

OBJECTIVE: The objective was to compare cerebral oxygenation in preterm newborns with that in healthy term newborns. METHODS: Forty-six preterm newborns with gestational ages of <33 weeks and 25 healthy term newborns were included. The cerebral tissue oxygenation index (c-TOI) was measured by using near-infrared spectroscopy in clinical steady state on the first day of life (median age: 19.2 hours). The mean gestational ages and birth weights in the 2 groups were 29.1 ± 2.6 weeks versus 39.7 ± 1.3 weeks and 1307 ± 437 g versus 3484 ± 346 g, respectively. Three preterm infants needed mechanical ventilation and 11 received inotropic drugs. Later, 3 preterm infants developed intraventricular hemorrhage and 2 infants died. All term infants were healthy newborns recruited in the maternity ward. RESULTS: There was a significant difference in c-TOI (preterm: 78.6% [95% confidence interval: 76.9%–80.3%]; term: 74.7% [95% confidence interval: 72.3%–77.1%]). Preterm newborns had significantly lower fractional tissue oxygen extraction, which suggests lower oxygen extraction in this group. There was no significant correlation between head size and c-TOI. The mean peripheral oxygen saturation was 95% in both groups. The median blood Pco2 for the preterm infants was 6.1 kPa (range: 3.4–7.3 kPa). CONCLUSIONS: Cerebral oxygenation on the first day of life was higher in a group of relatively healthy, very preterm infants in stable condition, compared with healthy term newborns. Slightly elevated blood Pco2 could be the explanation. Prematurity itself does not seem to dispose preterm infants to global cerebral hypoxia.

Structural Correlates of Preterm Birth in the Adolescent Brain

OBJECTIVE: The Stockholm Neonatal Project involves a prospective, cross-sectional, population-based, cohort monitored for 12 to 17 years after birth; it was started with the aim of investigating the long-term structural correlates of preterm birth and comparing findings with reports on similar cohorts. METHODS: High-resolution anatomic and diffusion tensor imaging data measuring diffusion in 30 directions were collected by using a 1.5-T MRI scanner. A total of 143 adolescents (12.18–17.7 years of age) participated in the study, including 74 formerly preterm infants with birth weights of ≤1500 g (range: 645–1486 g) and 69 term control subjects. The 2 groups were well matched with respect to demographic and socioeconomic data. The anatomic MRI data were used for calculation of total brain volumes and voxelwise comparison of gray matter (GM) volumes. The diffusion tensor imaging data were used for voxelwise comparison of white matter (WM) microstructural integrity. RESULTS: The formerly preterm individuals possessed 8.8% smaller GM volume and 9.4% smaller WM volume. The GM and WM volumes of individuals depended on gestational age and birth weight. The reduction in GM could be attributed bilaterally to the temporal lobes, central, prefrontal, orbitofrontal, and parietal cortices, caudate nuclei, hippocampi, and thalami. Lower fractional anisotropy was observed in the posterior corpus callosum, fornix, and external capsules. CONCLUSIONS: Although preterm birth was found to be a risk factor regarding long-term structural brain development, the outcome was milder than in previous reports. This may be attributable to differences in social structure and neonatal care practices.

Disaster Preparedness in Pediatric Type 1 Diabetes Mellitus

OBJECTIVE: The goal was to assess emergency preparedness among families caring for children with type 1 diabetes mellitus. METHODS: A total of 115 English-speaking families caring for children with type 1 diabetes mellitus who were attending the diabetes clinic at Texas Children's Hospital agreed to a questionnaire study designed to ascertain their level of preparedness for a disaster or emergency. The study was conducted from June through September 2008 and ended just before Hurricane Ike made landfall. RESULTS: Families were better prepared for self-management of diabetes, compared with general disaster preparedness. Sixty-two percent of the families were generally unprepared for a major disaster. For self-management of diabetes specifically, however, 75% of families had adequate supplies to maintain care for 3 days. Families in higher and moderate socioeconomic status strata were better equipped for an emergency (P < .002). Preparedness was found to be independent of age, gender, ethnicity, and previous experience of a disaster. CONCLUSION: Disaster preparedness still lags in families of lower socioeconomic status.

High-Dose Cysteine Administration Does Not Increase Synthesis of the Antioxidant Glutathione Preterm Infants

OBJECTIVE: Our aim was to evaluate whether administration of additional cysteine is safe and stimulates glutathione synthesis in preterm infants in early life. METHODS: We conducted a prospective, randomized, clinical trial with infants with birth weights of <1500 g (N = 20). The infants were assigned randomly to receive either a standard dose (45 mg/kg per day) or a high dose (81 mg/kg per day) of cysteine. Intakes of other amino acids were similar, providing a total protein intake of 2.4 g/kg per day in both groups. We recorded base requirements in the first 6 days of life. On postnatal day 2, we conducted a stable isotope study to determine glutathione concentrations and synthesis rates in erythrocytes. RESULTS: Base requirements were higher in the high-dose cysteine group on days 3, 4, and 5. Despite an 80% increase in cysteine intake, plasma cystine concentrations did not increase. Glutathione concentrations and synthesis rates did not increase with additional cysteine administration. CONCLUSIONS: Administration of a high dose of cysteine (81 mg/kg per day) to preterm infants seems clinically safe but does not stimulate glutathione synthesis, compared with a lower dose (45 mg/kg per day). Further research is required to determine whether there is significant benefit associated with cysteine supplementation.

Short Nighttime Sleep-Duration and Hyperactivity Trajectories in Early Childhood

OBJECTIVES: Our objectives were to investigate the developmental trajectories of nighttime sleep duration and hyperactivity over the preschool years and to identify the risk factors associated with short nighttime sleep duration and high hyperactivity scores. DESIGN, SETTING, AND PARTICIPANTS: Nighttime sleep duration and hyperactivity were measured yearly by questionnaires administered to mothers of 2057 children from age 1.5 to 5 years. Developmental trajectories of nighttime sleep duration and hyperactivity throughout early childhood were analyzed to determine interassociations. A multinomial logistic regression was performed to determine which factors among selected child, maternal, and family characteristics and parental practices surrounding sleep periods in early childhood were associated with short nighttime sleep duration and high hyperactivity scores. RESULTS: The trajectories of nighttime sleep duration and hyperactivity were significantly associated. The odds ratio (OR) of reporting short nighttime sleep duration was 5.1 for highly hyperactive children (confidence interval [CI]: 3.2–7.9), whereas the OR of reporting high hyperactivity scores was 4.2 for persistently short sleepers (CI: 2.7–6.6). The risk factors for reporting short nighttime sleep duration and high hyperactivity scores were (1) being a boy, (2) having insufficient household income, (3) having a mother with a low education, and (4) being comforted outside the bed after a nocturnal awakening at 1.5 years of age. CONCLUSIONS: The risk of short nighttime sleep duration in highly hyperactive children is greater than the risk of high hyperactivity scores in short sleepers. Preventive interventions that target boys living in adverse familial conditions could be used to address these concomitant behavioral problems.

The Effect of Weekend and Holiday Sleep Compensation on Childhood Overweight and Obesity

OBJECTIVES: A growing trend in childhood sleep habits is to compensate for the weekday sleep deficit by longer weekend and holiday sleep duration. We aimed to investigate the effect of weekend/holiday sleep compensation in relation to childhood overweight and obesity. METHODS: This is a community-based cross-sectional study with 5159 children (49.6% boys), mean age of 9.25 years (SD: 1.78), from 13 primary schools in Hong Kong. Data on sleep patterns, lifestyle, body weight, and height of children were obtained from questionnaires. Sleep durations during weekdays, weekends, and holidays were predictor variables. BMI z scores and obesity/overweight status were the outcome measures. RESULTS: Children slept significantly longer during holidays (mean [SD]: 10.20 (0.92) hours) and weekends (school terms) (10.07 [0.93] hours) than during school weekdays (9.18 [0.95] hours). Children with shorter sleep duration had higher BMI z scores regardless of the sleep parameters used in the analysis. Among children who slept <8 hours during weekdays, those children who did not compensate for their sleep deficit during weekends or holidays had significantly increased risk of overweight/obesity compared with those children with sleep compensation (odds ratios: 2.59 [95% confidence interval: 1.22–5.48] and 2.32 [95% confidence interval: 1.00–5.53], respectively). CONCLUSIONS: There was a prominent difference in sleep duration between weekdays and weekends/holidays among school children. Short sleep duration was associated with higher BMI, but compensation of sleep during weekends/holidays may partly ameliorate the risk of childhood overweight/obesity. Further prospective and interventional study is needed to delineate the risk-benefit effect of these increasingly common sleep habits among children and adolescents.

Interinstitutional Variation in Prediction of Death by SNAP-II and SNAPPE-II Among Extremely Preterm Infants

BACKGROUND: Illness severity scores predict death among infants admitted to NICUs. We know of no study limited to a population defined by an extremely low gestational age. METHODS: A total of 1467 infants born before the 28th postmenstrual week at 14 institutions were given Score for Neonatal Acute Physiology II (SNAP-II) and Score for Neonatal Acute Physiology Perinatal Extension II (SNAPPE-II) values based on data collected within the first 12 postnatal hours. All deaths in the intensive care nursery were identified. RESULTS: The rate of death before postnatal day 28 was 13% (interinstitutional range: 7%–20%), whereas the overall mortality rate was 18% (8%–31%). SNAP-II values, SNAPPE-II values, and mortality rates tended to decrease with increasing gestational age. Even within gestational age strata, however, the risk of death decreased with decreasing SNAP-II and SNAPPE-II values. The positive predictive values of most SNAP-II and SNAPPE-II cutoff levels were close to 30%. In general, institutions' mortality rates increased with the proportions of infants whose SNAP-II values were ≥30. CONCLUSION: The physiologic instability in the first 12 postnatal hours that is identified by illness severity scores conveys information about the risk of death among infants at the lowest gestational ages.

Recommendations for Screening, Monitoring, and Referral of Pediatric Chronic Hepatitis B

Most children with chronic hepatitis B virus infection (persistent hepatitis B surface antigen–positive for >6 months) are asymptomatic and do not generally require treatment. These children are, however, at increased risk for severe complications later in life, including advanced liver disease and liver cancer. On November 11, 2008, the Hepatitis B Foundation, a nonprofit research and disease advocacy organization, convened a panel of nationally recognized North American pediatric liver specialists to consider and recommend an approach for the screening, monitoring, initial management, and referral of children with chronic hepatitis B. The panel developed recommendations to provide guidance to practitioners on determining what additional tests to conduct, how often to monitor on the basis of test results, and when to refer to a pediatric liver specialist to build a partnership between the practitioner and liver specialist to enhance the success of management of children with this lifelong infection.

Hyponatremia in Preterm Neonates: Not a Benign Condition

Secondhand and Prenatal Tobacco Smoke Exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.

Tobacco as a Substance of Abuse

Tobacco use is the leading preventable cause of morbidity and death in the United States. Because 80% to 90% of adult smokers began during adolescence, and two thirds became regular, daily smokers before they reached 19 years of age, tobacco use may be viewed as a pediatric disease. Every year in the United States, approximately 1.4 million children younger than 18 years start smoking, and many of them will die prematurely from a smoking-related disease. Moreover, there is recent evidence that adolescents report symptoms of tobacco dependence early in the smoking process, even before becoming daily smokers. The prevalence of tobacco use is higher among teenagers and young adults than among older adult populations. The critical role of pediatricians in helping to reduce tobacco use and addiction and secondhand tobacco-smoke exposure in the pediatric population includes education and prevention, screening and detection, and treatment and referral.

Athletic Participation in Severe Hemophilia: Bleeding and Joint Outcomes in Children on Prophylaxis

OBJECTIVES: We sought to determine joint outcomes relative to impact level of athletic participation among school-aged children who had hemophilia and were taking prophylactic factor replacement, as well as to investigate prognostic factors for joint outcomes. METHODS: School-aged boys with severe hemophilia A or B at a single center were included in the study. Clinical data on baseline joint status, BMI, hemophilia treatment, bleeding episodes, joint assessments, athletic participation, and injuries were retrospectively reviewed. Data on athletic participation were supplemented, when incomplete in the medical record, via structured telephone interview. RESULTS: Among 37 children with severe hemophilia A or B receiving factor prophylaxis, 73% participated in high-impact activities, whereas 27% participated in exclusively low-impact activities. The frequency of joint hemorrhages and new injuries did not appreciably differ between high- and low-impact athletics. In most instances, children developed <1 bleed or injury per season. A new target joint developed in 1 (3%) child. Sixteen percent of children met established BMI criteria for overweight, and 3% were obese. In logistic regression analyses with adjustment for prophylaxis frequency, level of athletic participation was not a significant prognostic factor for joint hemorrhage. CONCLUSIONS: In the setting of regular prophylaxis and adult coaching and supervision, significant bleeding complications were uncommon and level of impact of athletic participation was not a prognostic factor for joint outcomes. Athletic participation with appropriate supervision and precautions should be encouraged in children with hemophilia receiving prophylaxis, given potential health benefits in an increasingly overweight pediatric population.

Progress in Ensuring Adequate Health Insurance for Children With Special Health Care Needs

OBJECTIVE: This article reports findings from the 2005–2006 National Survey of Children With Special Health Care Needs (NS-CSHCN) regarding the extent to which CSHCN have access to public or private health insurance that meets their needs. METHODS: The HRSA Maternal and Child Health Bureau's health insurance core outcome was measured on the basis of whether a child had public or private coverage at the time of survey; continuity of coverage during the previous 12 months; and adequacy of coverage. Bivariate and multivariate statistical methods were used to assess independent predictors of respondents who met the health insurance core outcome and the impact of meeting the core outcome on measures of access and financial burden. Comparisons with a referent sample of children who did and did not have special needs and were included in the 2001 NS-CSHCN are also presented. RESULTS: A total of 62.0% of CSHCN nationally met the health insurance core outcome in 2005–2006, up from 59.6% in 2001. Disparities by ethnicity and income remain, but some have narrowed, especially for Hispanic CSHCN. Children who did not meet the health insurance core outcome were more likely to have unmet needs and their families to experience financial problems. CSHCN were more likely to be insured than children without special needs but less likely to be adequately insured. CONCLUSIONS: Results of the survey demonstrate that although a growing number of CSHCN have continuous and adequate health insurance, additional effort is needed to improve the adequacy of that insurance, particularly for children in vulnerable subpopulations.

Effectiveness of Belt Positioning Booster Seats: An Updated Assessment

OBJECTIVE: The objective of this study was to provide an updated estimate of the effectiveness of belt-positioning booster (BPB) seats compared with seat belts alone in reducing the risk for injury for children aged 4 to 8 years. METHODS: Data were collected from a longitudinal study of children who were involved in crashes in 16 states and the District of Columbia from December 1, 1998, to November 30, 2007, with data collected via insurance claims records and a validated telephone survey. The study sample included children who were aged 4 to 8 years, seated in the rear rows of the vehicle, and restrained by either a seat belt or a BPB seat. Multivariable logistic regression was used to determine the odds of injury for those in BPB seats versus those in seat belts. Effects of crash direction and booster seat type were also explored. RESULTS: Complete interview data were obtained on 7151 children in 6591 crashes representing an estimated 120646 children in 116503 crashes in the study population. The adjusted relative risk for injury to children in BPB seats compared with those in seat belts was 0.55. CONCLUSIONS: This study reconfirms previous reports that BPB seats reduce the risk for injury in children aged 4 through 8 years. On the basis of these analyses, parents, pediatricians, and health educators should continue to recommend as best practice the use of BPB seats once a child outgrows a harness-based child restraint until he or she is at least 8 years of age.

Young Driver Education Programs That Build Resilience Have Potential to Reduce Road Crashes

OBJECTIVE: The research aimed to explore associations between participation in 2 education programs for school-based learner drivers and subsequent road traffic offenses and crashes among a large cohort of newly licensed drivers. METHODS: DRIVE is a prospective cohort study of 20822 first-year drivers aged 17 to 24 in New South Wales (NSW), Australia. Participants completed a detailed questionnaire and consented to data linkage in 2003–2004. Questionnaire items included year of participation in 2 specific education programs: a 1-day workshop-only program focusing on driving risks ("driver-focused") and a whole-of-community program also including a 1-day workshop but also longer term follow-up activities and a broader focus on reducing risk-taking and building resilience ("resilience-focused"). Survey data were subsequently linked to police-reported crash and offense data for 1996–2005. Poisson regression models that adjusted for multiple confounders were created to explore offenses and crashes as a driver (dichotomized as 0 vs ≥1) after program participation. RESULTS: Offenses did not differ between groups; however, whereas the driver-focused program was not associated with reduced crash risk, the resilience-focused program was associated with a 44% reduced relative risk for crash (0.56 [95% confidence interval: 0.34–0.93]). CONCLUSIONS: The large effect size observed and complementary findings from a comparable randomized, controlled trial in the United States suggest programs that focus more generally on reducing risks and building resilience have the potential to reduce crashes. A large, representative, randomized, controlled trial is urgently needed to confirm road safety benefits and ensure evidence-based spending and practitioner recommendations in this field.

Snacking in Children: The Role of Urban Corner Stores

OBJECTIVE: Childhood obesity is higher among ethnic minorities. One reason may be the limited access to affordable, healthy options. The disparate prevalence of urban corner stores in low-income and high-minority communities has been well documented. There are no data, however, on what children purchase in these environments before and after school. The purpose of this study was to document the nature of children's purchases in corner stores proximal to their schools. METHODS: This was an observational study from January to June 2008. Participants were children in grades 4 through 6 from 10 urban K-8 schools with ≥50% of students eligible for free or reduced-price meals. A total of 833 intercept surveys of children's purchases were conducted outside 24 corner stores before and after school. The main outcomes were type and energy content of items purchased. RESULTS: The most frequently purchased items were energy-dense, low-nutritive foods and beverages, such as chips, candy, and sugar-sweetened beverages. Students spent $1.07 ± 0.93 on 2.1 ± 1.3 items (1.6 ± 1.1 food items and 0.5 ± 0.6 beverage items) per purchase. The total number of calories purchased per trip was 1497.7 ± 1219.3 kJ (356.6 ± 290.3 kcal). More calories came from foods than from beverages. CONCLUSIONS: Purchases made in corner stores contribute significantly to energy intake among urban school children. Obesity prevention efforts, as well as broader efforts to enhance dietary quality among children in urban settings, should include corner store environments proximal to schools.

Secondhand Tobacco Smoke Exposure Among Children and Adolescents: United States, 2003-2006

OBJECTIVE: The implementation of policies that prohibit tobacco smoking in public places has resulted in a significant reduction in secondhand smoke (SHS) exposure in the US population; however, such policies do not extend to private homes, where children continue to be exposed. Our objective was to assess SHS exposure among US children and adolescents by using serum cotinine measures to compare those who were exposed to SHS in the home and those without home exposure. METHODS: We analyzed serum cotinine data from the 2003–2006 National Health and Nutrition Examination Survey for 5518 children (3–11 years) and nonsmoking adolescents (12–19 years). We calculated geometric mean serum cotinine levels by sociodemographic and household characteristics according to self-reported home SHS exposure. Multiple regression analysis was conducted to evaluate independent predictors of serum cotinine levels. RESULTS: Geometric mean serum cotinine levels were 1.05 ng/mL among those with home SHS exposure and 0.05 ng/mL among those without home exposure. Among children who were exposed to SHS at home, serum cotinine levels were inversely associated with age and were similar for non-Hispanic black and non-Hispanic white children. Conversely, among children without SHS exposure at home, serum cotinine levels were higher among non-Hispanic black compared with non-Hispanic white children, and there was no relationship with age. Mexican American children had the lowest level of SHS exposure. CONCLUSIONS: Serum cotinine levels were an order of magnitude higher among children with reported SHS exposure at home compared with those with no exposure in the home.

Secondhand Smoke and Respiratory Symptoms Among Adolescent Current Smokers

OBJECTIVE: No study has ever reported the association between persistent respiratory symptoms and exposure to secondhand smoke (SHS) in adolescent smokers. The impact of SHS exposure on child health could be largely underestimated by not taking into account such effects. We investigated the association between exposure to SHS and respiratory symptoms among adolescent current smokers. METHODS: A total of 32506 students aged 11 to 20 years from 85 randomly selected secondary schools in Hong Kong completed a self-administered questionnaire that included persistent respiratory symptoms (for 3 consecutive months in the past 12 months), number of days of SHS exposure per week at home and outside home, smoking status, amount of active smoking, and other basic demographic characteristics and socioeconomic status. RESULTS: Adolescent current smokers who were exposed to SHS at home 1 to 4 and 5 to 7 days/wk were 50% (95% confidence interval [CI]: 3%–121%) and 77% (95% CI: 5%–199%) more likely, respectively, to report respiratory symptoms compared with those who were unexposed (P = .01 for trend). The corresponding figures for exposure outside home were 41% (95% CI: 3%–94%) and 85% (95% CI: 31%–161%; P = .004 for trend). Such associations were also observed among never-smokers, but they were weaker than those among current smokers (P < .01 for interaction). CONCLUSIONS: This is the first evidence that SHS exposure is associated with increased risks for persistent respiratory symptoms among adolescent current smokers. Health promotion programs should aim at SHS reduction as well as smoking cessation among adolescent smokers.

Disability Among Internationally Adopted Children in the United States

OBJECTIVES: The objective of this study was to estimate disability rates for internationally adopted children in the United States. METHODS: We conducted an analysis of restricted-access data from the complete long form of Census 2000 for internationally adopted children aged 5 to 15 in 2000, estimating disability rates by country of origin, controlling for gender, age at adoption, current age, and parental characteristics. RESULTS: Internationally adopted children have disability rates similar to those adopted domestically (11.7% vs 12.2%, respectively) and more than twice the rate for all children in that age range (5.8%). The adjusted odds of disability relative to domestic adoptees range from one half or less (China and Korea) to twice as large or more (Romania, Bulgaria, other Eastern Europe, and other Western Europe). CONCLUSIONS: The population of internationally adopted children is relatively small and diverse, posing challenges for researchers who hope to reach generalizable conclusions. Nevertheless, health, education, and social service professionals, as well as adoptive and prospective adoptive parents, should be aware of the risk for disabilities among internationally adopted children to devote the resources necessary to addressing them.

Autoerotic Asphyxiation: Secret Pleasure--Lethal Outcome?

OBJECTIVE: Voluntary asphyxiation among children, preteens, and adolescents by hanging or other means of inducing hypoxia/anoxia to enhance sexual excitement is not uncommon and can lead to unintended death. This study addresses autoerotic asphyxiation (AEA) with the intent of increasing pediatricians' knowledge of the syndrome and awareness of its typical onset among young patients. AEA is characteristically a clandestine and elusive practice. Provided with relevant information, pediatricians can identify the syndrome, demonstrate a willingness to discuss concerns about it, ameliorate distress, and possibly prevent a tragedy. METHODS: A retrospective study was undertaken of published cases both fatal and nonfatal and included personal communications, referenced citations, clinical experience, and theoretical formulations as to causation. Characteristic AEA manifestations, prevalence, age range, methods of inducing hypoxia/anoxia, and gender weighting are presented. All sources were used as a basis for additional considerations of etiology and possibilities for intervention. RESULTS: AEA can be conceptualized as a personalized, ritualized, and symbolic biopsychosocial drama. It seems to be a reenactment of intense emotional feeling-states involving an identification and sadomasochistic relationship with a female figure. Inept AEA practitioners can miscalculate the peril of the situation that they have contrived and for numerous reasons lose their gamble with death. CONCLUSIONS: Pediatricians should be alert to the earliest manifestations of AEA. Awareness of choking games among the young and, of those, a subset who eventually progress to potentially fatal AEA is strongly encouraged among all primary care professionals who may be able to interrupt the behavior.

Economic Evaluation of Inhaled Nitric Oxide in Preterm Infants Undergoing Mechanical Ventilation

OBJECTIVE: In the previously reported Nitric Oxide for Chronic Lung Disease (NO CLD) trial, ventilated preterm infants who received a course of inhaled nitric oxide (iNO) between 7 and 21 days of life had a significant improvement in survival without bronchopulmonary dysplasia (BPD), as well as a shorter duration of admission and ventilation. However, the price for the drug may be a barrier to widespread use. We sought to estimate the incremental cost-effectiveness of iNO therapy to prevent BPD in infants of <1250 g birth weight. METHODS: We used patient-level data from the NO CLD randomized trial. The study took a third-party payer perspective and measured costs and effects through hospital discharge. We applied previously reported hospital per-diem costs stratified according to intensity of ventilatory support, nitric oxide costs from standard market prices, and professional (physician) fees from the Medicare fee schedule. We compared log transformed costs by using multivariable modeling and performed incremental cost-effectiveness analysis with estimation of uncertainty through nonparametric bootstrapping. RESULTS: The mean cost per infant was $193125 in the placebo group and $194702 in the iNO group (adjusted P = .17). The point estimate for the incremental cost per additional survivor without BPD was $21297. For infants in whom iNO was initiated between 7 and 14 days of life, the mean cost per infant was $187407 in the placebo group and $181525 in the iNO group (adjusted P = .46). In this group of early treated infants, there was a 71% probability that iNO actually decreased costs while improving outcomes. CONCLUSIONS: Despite its higher price relative to many other neonatal therapies, iNO in this trial was not associated with higher costs of care, an effect that is likely due to its impact on length of stay and ventilation. Indeed, for infants who receive nitric oxide between 7 and 14 days of life, the therapy seemed to lower costs while improving outcomes.

Clinical and Economic Effects of iNO in Premature Newborns With Respiratory Failure at 1 Year

BACKGROUND: The long-term consequences of inhaled nitric oxide (iNO) use in premature newborns with respiratory failure are unknown. We therefore studied the clinical and economic outcomes to 1 year of corrected age after a randomized controlled trial of prophylactic iNO. METHODS: Premature newborns (gestational age ≤34 w, birth weight 500–1250 g) with respiratory failure randomly received 5 ppm iNO or placebo within 48 h of birth until 21 d or extubation. We assessed clinical outcomes via in-person neurodevelopmental evaluation at 1 y corrected age and telephone interviews every 3 m. We estimated costs from detailed hospital bills and interviews, converting all costs to 2008 US$. Of 793 trial subjects, 631 (79.6%) contributed economic data, and 455 (77.1% of survivors) underwent neurodevelopmental evaluation. RESULTS: At 1 y corrected age, survival was not different by treatment arm (79.2% iNO vs. 74.5% placebo, P = .12), nor were other post-discharge outcomes. For subjects weighing 750–999 g, those receiving iNO had greater survival free from neurodevelopmental impairment (67.9% vs. 55.6%, P = .04). However, in subjects weighing 500–749 g, iNO led to greater oxygen dependency (11.7% vs. 4.0%, P = .04). Median total costs were similar ($235 800 iNO vs. $198 300 placebo, P = .19). Quality-adjusted survival was marginally better with iNO (by 0.011 quality-adjusted life-years/subject). The incremental cost-effectiveness ratio was $2.25 million/quality-adjusted life-year. CONCLUSIONS: Subjects in both arms commonly experienced neurodevelopmental and pulmonary morbidity, consuming substantial health care resources. Prophylactic iNO beginning in the first days of life did not lower costs and had a poor cost-effectiveness profile.

A Pilot Trial of Pramlintide Home Usage in Adolescents With Type 1 Diabetes

OBJECTIVE: The objective of this study was to evaluate the safety and efficacy of home pramlintide use in adolescents with type 1 diabetes. PATIENTS AND METHODS: This was a randomized, 28-day pilot trial of pramlintide (maximum dose: 30 µg per meal) in 10 adolescents aged 13 to 17 years. End points included changes in hemoglobin A1c (HbA1c) values, body weight, and postprandial peak blood glucose levels and area under the curve on continuous glucose monitoring. RESULTS: Changes in HbA1c values, body weight, and total insulin dose declined in the treatment group compared with the control group (bootstrapped, P ≤ .02 for each). The treatment group also demonstrated lower average dinner area under the curve (P = .02) and lower maximum breakfast (P = .03) and dinner (P = .02) postprandial blood glucose values. CONCLUSIONS: Pramlintide can help some adolescents to decrease postprandial hyperglycemia, HbA1c values, body weight, and insulin dosages. Additional large-scale trials should now be considered.

Development of a New Patient-Based Measure of Pediatric Ambulatory Care

OBJECTIVE: In 1995, the Agency for Health Care Policy and Research initiated the Consumer Assessments of Healthcare Providers and Systems (CAHPS) project to develop and evaluate survey protocols for collecting reliable and valid assessments of health care from consumers. CAHPS surveys are used throughout the United States for evaluating ambulatory and hospital care experiences, including a version for assessing pediatric ambulatory care; however, pediatric experts thought that the existing pediatric instruments did not adequately assess developmental and preventive care. The objective of this study was to develop and test an Ambulatory Pediatric CAHPS survey that focuses on clinicians and groups and includes measures of developmental and preventive care. METHODS: To develop the survey, we conducted 2 focus groups and conducted 9 cognitive interviews. We conducted a telephone pretest with 20 parents and coded potential problems with the interview (behavioral coding). We conducted a dual-language field test of the instrument with 670 parents who reported about their children's ambulatory care. We used data from that survey to assess the reliability and validity of the measures. RESULTS: Questions about developmental monitoring and preventive care were developed and tested. Two scales that were based on those new questions had good internal consistency (coefficient ) and inter-physician reliability. A consortium of CAHPS investigators and federal sponsors have approved the resulting instrument as a national measure of pediatric care. CONCLUSIONS: A new instrument for assessing ambulatory pediatric care by clinicians and groups that includes questions about developmental and preventive care is now available for use.

Infant Neurobehavioral Dysregulation: Behavior Problems in Children With Prenatal Substance Exposure

OBJECTIVE: The objective of this study was to test a developmental model of neurobehavioral dysregulation relating prenatal substance exposure to behavior problems at age 7. METHODS: The sample included 360 cocaine-exposed and 480 unexposed children from lower to lower middle class families of which 78% were black. Structural equation modeling was used to test models whereby prenatal exposure to cocaine and other substances would result in neurobehavioral dysregulation in infancy, which would predict externalizing and internalizing behavior problems in early childhood. Structural equation models were developed for individual and combined parent and teacher report for externalizing, internalizing, and total problem scores on the Child Behavior Checklist. RESULTS: The goodness-of-fit statistics indicated that all of the models met criteria for adequate fit with 7 of the 9 models explaining 18% to 60% of the variance in behavior problems at age 7. The paths in the models indicate that there are direct effects of prenatal substance exposure on 7-year behavior problems as well as indirect effects, including neurobehavioral dysregulation. CONCLUSIONS: Prenatal substance exposure affects behavior problems at age 7 through 2 mechanisms. The direct pathway is consistent with a teratogenic effect. Indirect pathways suggest cascading effects whereby prenatal substance exposure results in neurobehavioral dysregulation manifesting as deviations in later behavioral expression. Developmental models provide an understanding of pathways that describe how prenatal substance exposure affects child outcome and have significant implications for early identification and prevention.

A Medical Home Versus Temporary Housing: The Importance of a Stable Usual Source of Care

OBJECTIVES: Little is known about how the stability of a usual source of care (USC) affects access to care. We examined the prevalence of USC changes among low-income children and how these changes were associated with unmet health care need. METHODS: We conducted a cross-sectional survey of Oregon's food stamp program in 2005. We analyzed primary data from 2681 surveys and then weighted results to 84087 families, adjusting for oversampling and nonresponse. We then ascertained the percentage of children in the Oregon population who had ever changed a USC for insurance reasons, which characteristics were associated with USC change, and how USC change was associated with unmet need. We also conducted a posthoc analysis of data from the Medical Expenditure Panel Survey to confirm similarities between the Oregon sample and a comparable national sample. RESULTS: Children without a USC in the Oregon population had greater odds of reporting an unmet health care need than those with a USC. This pattern was similar in national estimates. Among the Oregon sample, 23% had changed their USC because of insurance reasons, and 10% had no current USC. Compared with children with a stable USC, children who had changed their USC had greater odds of reporting unmet medical need, unmet prescription need, delayed care, unmet dental need, and unmet counseling need. CONCLUSIONS: This study highlights the importance of ensuring stability with a USC. Moving low-income children into new medical homes could disturb existing USC relationships, thereby merely creating "temporary housing."

Aluminum Exposure From Parenteral Nutrition in Preterm Infants: Bone Health at 15-Year Follow-up

OBJECTIVE: Aluminum has known neurotoxicity and may impair short-term bone health. In a randomized trial, we showed reduced neurodevelopmental scores in preterm infants who were previously exposed to aluminum from parenteral nutrition solutions. Here, in the same cohort, we test the hypothesis that neonatal aluminum exposure also adversely affects long-term bone health, as indicated by reduced bone mass. METHODS: Bone area (BA) and bone mineral content (BMC) of lumbar spine, hip, and whole body were measured with dual radiograph absorptiometry in 13- to 15-year-olds who were born preterm and randomly assigned standard or aluminum-depleted parenteral nutrition solutions during the neonatal period. RESULTS: Fifty-nine children (32% of survivors) were followed. Those who were randomly assigned to standard parenteral nutrition solution had lower lumbar spine BMC, apparently explained by a concomitant decrease in bone size. In nonrandomized analyses, children who were exposed to neonatal aluminum intakes above the median (55 µg/kg) had lower hip BMC (by 7.6% [95% confidence interval: 0.21–2.38]; P = .02), independent of bone (or body) size. CONCLUSIONS: Neonates who are exposed to parenteral aluminum may have reduced lumbar spine and hip bone mass during adolescence, potential risk factors for later osteoporosis and hip fracture. These findings need confirmation in larger, more detailed studies. Nevertheless, given our previous finding of adverse developmental outcome in these individuals and the sizeable number of contemporary infants who undergo intensive neonatal care and are still exposed to aluminum via parenteral feeding solutions, the potential adverse long-term consequences of early aluminum exposure now deserve renewed attention.

Motor Competence and Physical Activity in 8-Year-Old School Children With Generalized Joint Hypermobility

OBJECTIVE: Because the criteria used for diagnosing between generalized joint hypermobility (GJH) and musculoskeletal complaints, as well as relations between GJH and an insufficient motor development and/or a reduced physical activity level differ, the prevalence of GJH varies considerably. The aim of this study was to survey the prevalence of GJH defined by a Beighton score at ≥4, ≥5, or ≥6 positive tests of 9 and benign joint hypermobility syndrome (BJHS) in Danish primary school children at 8 years of age. A second aim was to compare children with and without GJH and BJHS regarding motor competence, self-reported physical activity, and incidence of musculoskeletal pain and injuries. METHODS: A cross-sectional study of 524 children in the second grade from 10 public schools was performed. A positive response rate was obtained for 416 (79.4%) children, and 411 (78.4%) children were clinically examined and tested for motor competence, whereas questionnaire response to items comprising musculoskeletal pain and injuries, in addition to daily level and duration of physical activity, corresponded to 377 (71.9%) children. RESULTS: In total, 29% of the children had GJH4, 19% had GJH5, 10% had GJH6, and 9% had BJHS, with no gender difference. There was no difference in daily level and duration of physical activity and in frequency of musculoskeletal pain and injuries between those with and without GJH. Children with ≥GJH5 as well as with ≥GJH6 performed better in the motor competence tests. CONCLUSION: Motor competence and physical activity are not reduced in primary school children at 8 years of age with GJH or BJHS. It is recommended that a potential negative influence on the musculoskeletal system over time, as a result of GJH, be investigated by longitudinal studies.

Multistate Outbreak of Salmonella Infections Associated With Small Turtle Exposure, 2007-2008

OBJECTIVE: Turtle-associated salmonellosis was increasingly recognized in the United States during the 1960s, leading to a federal ban in 1975 on the sale of turtles <4 inches in carapace length (small turtles). Although sporadic reports of turtle-associated Salmonella are frequent, outbreaks are rare. In September 2007, several patients with Salmonella enterica serotype Paratyphi B var Java infections reported recent turtle exposure. We conducted an investigation to determine the source and extent of the infections. PATIENTS AND METHODS: Patients with Salmonella Paratyphi B var Java infections with a specific pulsed-field gel electrophoresis pattern (outbreak strain) and illness onset between May 2007 and January 2008, were compared with healthy controls. Reptile exposure and awareness of a Salmonella-reptile link were assessed. Turtle size and purchase information were collected. RESULTS: We identified 107 patients with outbreak-strain infections. The median patient age was 7 years; 33% were hospitalized. Forty-seven (60%) of 78 patients interviewed reported exposure to turtles during the week before illness; 41 (87%) were small turtles, and 16 (34%) were purchased in a retail pet store. In the case-control study, 72% of 25 patients reported turtle exposure during the week before illness compared with 4% of 45 controls (matched odds ratio [mOR]: 40.9 [95% confidence interval (CI): 6.9–unbounded]). Seven (32%) of 22 patients versus 11 (28%) of 39 controls reported knowledge of a link between reptile exposure and Salmonella infection (mOR: 1.3 [95% CI: 0.4–4.6]). CONCLUSIONS: We observed a strong association between turtle exposure and Salmonella infections in this outbreak. Small turtles continue to be sold and pose a health risk, especially to children; many people remain unaware of the link between Salmonella infection and reptile contact.

Prevalence of Parent-Reported Diagnosis of Autism Spectrum Disorder Among Children in the US, 2007

OBJECTIVES: The reported increasing prevalence of autism spectrum disorder (ASD) and attendant health and family impact make monitoring of ASD prevalence a public health priority. METHODS: The prevalence of parent-reported diagnosis of ASD among US children aged 3 to 17 years was estimated from the 2007 National Survey of Children's Health (sample size: 78037). A child was considered to have ASD if a parent/guardian reported that a doctor or other health care provider had ever said that the child had ASD and that the child currently had the condition. The point-prevalence for ASD was calculated for those children meeting both criteria. We examined sociodemographic factors associated with current ASD and with a past (but not current) ASD diagnosis. The health care experiences for children in both ASD groups were explored. RESULTS: The weighted current ASD point-prevalence was 110 per 10,000. We estimate that 673,000 US children have ASD. Odds of having ASD were 4 times as large for boys than girls. Non-Hispanic (NH) black and multiracial children had lower odds of ASD than NH white children. Nearly 40% of those ever diagnosed with ASD did not currently have the condition; NH black children were more likely than NH white children to not have current ASD. Children in both ASD groups were less likely than children without ASD to receive care within a medical home. CONCLUSIONS: The observed point-prevalence is higher than previous US estimates. More inclusive survey questions, increased population awareness, and improved screening and identification by providers may partly explain this finding.

Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D?

OBJECTIVE: Single-center studies have suggested that hypovitaminosis D is widespread. Our objective was to determine the serum levels of 25-hydroxyvitamin D (25[OH]D) in a nationally representative sample of US children aged 1 to 11 years. METHODS: Data were obtained from the 2001–2006 National Health and Nutrition Examination Survey. Serum 25(OH)D levels were determined by radioimmunoassay and categorized as <25, <50, and <75 nmol/L. National estimates were obtained by using assigned patient visit weights and reported with 95% confidence intervals (CIs). RESULTS: During the 2001–2006 time period, the mean serum 25(OH)D level for US children aged 1 to 11 years was 68 nmol/L (95% CI: 66–70). Children aged 6 to 11 years had lower mean levels of 25(OH)D (66 nmol/L [95% CI: 64–68]) compared with children aged 1 to 5 years (70 nmol/L [95% CI: 68–73]). Overall, the prevalence of levels at <25 nmol/L was 1% (95% CI: 0.7–1.4), <50 nmol/L was 18% (95% CI: 16–21), and <75 nmol/L was 69% (95% CI: 65–73). The prevalence of serum 25(OH)D levels of <75 nmol/L was higher among children aged 6 to 11 years (73%) compared with children aged 1 to 5 years (63%); girls (71%) compared with boys (67%); and non-Hispanic black (92%) and Hispanic (80%) children compared with non-Hispanic white children (59%). CONCLUSIONS: On the basis of a nationally representative sample of US children aged 1 to 11 years, millions of children may have suboptimal levels of 25(OH)D, especially non-Hispanic black and Hispanic children. More data in children are needed not only to understand better the health implications of specific serum levels of 25(OH)D but also to determine the appropriate vitamin D supplement requirements for children.

Violence, Abuse, and Crime Exposure in a National Sample of Children and Youth

OBJECTIVE: The objective of this research was to obtain national estimates of exposure to the full spectrum of the childhood violence, abuse, and crime victimizations relevant to both clinical practice and public-policy approaches to the problem. METHODS: The study was based on a cross-sectional national telephone survey that involved a target sample of 4549 children aged 0 to 17 years. RESULTS: A clear majority (60.6%) of the children and youth in this nationally representative sample had experienced at least 1 direct or witnessed victimization in the previous year. Almost half (46.3%) had experienced a physical assault in the study year, 1 in 4 (24.6%) had experienced a property offense, 1 in 10 (10.2%) had experienced a form of child maltreatment, 6.1% had experienced a sexual victimization, and more than 1 in 4 (25.3%) had been a witness to violence or experienced another form of indirect victimization in the year, including 9.8% who had witnessed an intrafamily assault. One in 10 (10.2%) had experienced a victimization-related injury. More than one third (38.7%) had been exposed to 2 or more direct victimizations, 10.9% had 5 or more, and 2.4% had 10 or more during the study year. CONCLUSIONS: The scope and diversity of child exposure to victimization is not well recognized. Clinicians and researchers need to inquire about a larger spectrum of victimization types to identify multiply victimized children and tailor prevention and interventions to the full range of threats that children face.

Pediatric Burn Injuries Treated in US Emergency Departments Between 1990 and 2006

OBJECTIVE: The goal was to examine comprehensively the patterns and trends of burn-related injuries in children, adolescents, and young adults treated in US emergency departments between 1990 and 2006. METHODS: Through use of the National Electronic Injury Surveillance System database, cases of nonfatal burn-related injuries were selected by using diagnosis codes for burns (scalds, thermal, chemical, radiation, electrical, and not specified). Sample weights were used to calculate national estimates. US Census Bureau data were used to calculate injury rates per 10000 individuals ≤20 years of age. Computation of relative risks with 95% confidence intervals was performed. RESULTS: An estimated 2054563 patients ≤20 years of age were treated in US emergency departments for burn-related injuries, with an average of 120856 cases per year. Boys constituted 58.6% of case subjects. Children <6 years of age sustained the majority of injuries (57.7%), and more than one half of all injuries (59.5%) resulted from thermal burns. The body parts injured most frequently were the hand/finger (36.0%), followed by the head/face (21.1%). Of the 1542913 cases for which locale was recorded, 91.7% occurred at home. The rate of burn-related injuries per 10000 children decreased 31% over the 17-year time period. CONCLUSIONS: Burn-related injuries are a serious problem for individuals ≤20 years of age and are potentially preventable. Children <6 years of age consistently sustained a disproportionately large number of injuries during the study period. Increased efforts are needed to improve burn-prevention strategies that target households with young children.

Who Will Care for Me Next? Transitioning to Adulthood With Hydrocephalus

OBJECTIVES: Hydrocephalus is a prototypical chronic condition that follows children into adulthood. The objectives of this study were to (1) review how the health care needs of young adults with hydrocephalus are not being met, (2) estimate the numbers of adults with childhood-onset hydrocephalus, (3) describe a novel program to provide care for young adults with hydrocephalus and other chronic pediatric conditions, and (4) propose national strategies to promote successful hydrocephalus transition care. RESULTS: Adults with hydrocephalus need continuous access to expert surgical and medical providers. Existing care models fail to meet this need. The number of young adults who have hydrocephalus, are aged 18 to 35 and need treatment in the United States is predicted to exceed 40000 annually within the next 2 decades. We are developing integrated teams of pediatric and adult medical and surgical specialists to provide continuous, coordinated, comprehensive care for individuals with hydrocephalus in a pediatric setting. This setting will train our future physician workforce on optimal transition care. Coordinated national efforts are also needed. CONCLUSIONS: Providers need to implement appropriate management and transition care for individuals with hydrocephalus. We must work at local and national levels to transform the care model, improve the quality of health care delivery, and improve outcomes for young adults with hydrocephalus.

The Health and Obesity: Prevention and Education (HOPE) Curriculum Project--Curriculum Development

The Health and Obesity: Prevention and Education (HOPE) project is a multidisciplinary, healthy living counseling curriculum to educate pediatric clinicians in training on how to recognize children who are at risk for obesity and its comorbidities and how to promote healthy weight among children and their families. Curriculum topics were selected by experts of nutrition, medicine, dentistry, behavioral counseling, and education and incorporate the recent 2007 Expert Committee recommendations regarding the prevention, assessment, and treatment of childhood and adolescent obesity. The HOPE curriculum instructs medical and dental clinicians on the health consequences of childhood obesity and screening techniques to identify children and families at risk, reviews the current evidence for health intervention recommendations, and teaches trainees regarding the theoretical rationale and art of constructive and culturally sensitive weight counseling for behavioral change. Although designed and tailored specifically for and currently available medical and dental trainees, the HOPE curriculum is Web-based and will also be made available to currently practicing clinicians across the United States beginning in winter 2009. This educational tool, grounded in understanding of relevant sciences, literature, and research methods, provides clinicians with the skills necessary to identify and counsel patients who are at risk to promote healthy weight among youth. This article discusses the approach and methods used for curriculum development. Future publications will discuss HOPE project implementation and outcomes.

Consensus Statement on Diagnostic Criteria for PHACE Syndrome

OBJECTIVES: A subgroup of patients with infantile hemangiomas have associated structural anomalies of the brain, cerebral vasculature, eyes, sternum, and/or aorta in the neurocutaneous disorder known as PHACE syndrome. The diagnosis has been broadly inclusive by using a case definition of a facial hemangioma plus ≥1 extracutaneous features, leading to numerous reports of potential associated disease features, many of uncertain significance. This consensus statement was thus developed to establish diagnostic criteria for PHACE syndrome. METHODS: A multidisciplinary group of specialists with expertise in PHACE syndrome drafted initial diagnostic criteria on the basis of review of published, peer-reviewed medical literature and clinical experience. The group then convened in both executive and general sessions during the PHACE Syndrome Research Conference held in November 2008 for discussion and used a consensus method. All conflicting recommendations were subsequently reconciled via electronic communication and teleconferencing. RESULTS: These criteria were stratified into 2 categories: (1) PHACE syndrome or (2) possible PHACE syndrome. Major and minor criteria were determined for the following organ systems: cerebrovascular, structural brain, cardiovascular, ocular, and ventral/midline. Definite PHACE requires the presence of a characteristic segmental hemangioma or hemangioma >5 cm on the face or scalp plus 1 major criterion or 2 minor criteria. Possible PHACE requires the presence of a hemangioma >5 cm on the face or scalp plus 1 minor criterion. The group recognized that it may be possible to have PHACE syndrome with a hemangioma affecting the neck, chest, or arm only or no cutaneous hemangioma at all. In such cases, fulfillment of additional required criteria would also lead to a possible PHACE diagnosis. CONCLUSIONS: These criteria represent current knowledge and are expected to enhance future assessments of PHACE syndrome. It is understood that modifications are to be expected over time to incorporate new research findings.

Promoting Lifelong Health for Adolescents and Young Adults With Special Health Care Needs

Defining Vitamin D Deficiency in Children: Beyond 25-OH Vitamin D Serum Concentrations

Tobacco Use: A Pediatric Disease

Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobacco-use prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobacco-control measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in tobacco control to promote the health of children, adolescents, and young adults.

Impact of Music, Music Lyrics, and Music Videos on Children and Youth

Music plays an important role in the socialization of children and adolescents. Popular music is present almost everywhere, and it is easily available through the radio, various recordings, the Internet, and new technologies, allowing adolescents to hear it in diverse settings and situations, alone or shared with friends. Parents often are unaware of the lyrics to which their children are listening because of the increasing use of downloaded music and headphones. Research on popular music has explored its effects on schoolwork, social interactions, mood and affect, and particularly behavior. The effect that popular music has on children's and adolescents' behavior and emotions is of paramount concern. Lyrics have become more explicit in their references to drugs, sex, and violence over the years, particularly in certain genres. A teenager's preference for certain types of music could be correlated or associated with certain behaviors. As with popular music, the perception and the effect of music-video messages are important, because research has reported that exposure to violence, sexual messages, sexual stereotypes, and use of substances of abuse in music videos might produce significant changes in behaviors and attitudes of young viewers. Pediatricians and parents should be aware of this information. Furthermore, with the evidence portrayed in these studies, it is essential for pediatricians and parents to take a stand regarding music lyrics.

Media Violence

Exposure to violence in media, including television, movies, music, and video games, represents a significant risk to the health of children and adolescents. Extensive research evidence indicates that media violence can contribute to aggressive behavior, desensitization to violence, nightmares, and fear of being harmed. Pediatricians should assess their patients' level of media exposure and intervene on media-related health risks. Pediatricians and other child health care providers can advocate for a safer media environment for children by encouraging media literacy, more thoughtful and proactive use of media by children and their parents, more responsible portrayal of violence by media producers, and more useful and effective media ratings. Office counseling has been shown to be effective.

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ADDENDUM

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