Abstract 1 of 61Article

Neonatal Hyperbilirubinemia in the Low-Intermediate–Risk Category on the Bilirubin Nomogram

OBJECTIVE: Predischarge bilirubin screening predicts neonatal hyperbilirubinemia. We evaluated the incidence of false-negative bilirubin screening among readmissions for hyperbilirubinemia.

METHODS: In healthy term and late preterm, predominantly breastfeeding newborns, predischarge transcutaneous bilirubin values were plotted on the hour of life–specific bilirubin nomogram and confirmed with plasma total bilirubin in those with a transcutaneous reading ≥75th percentile, or between the 41st and 75th percentiles in the presence of predictive icterogenic risk factors. False-negative bilirubin screen was defined as a predischarge bilirubin value ≤75th percentile in a newborn who was subsequently readmitted for phototherapy.

RESULTS: Of a total of 25 439 neonates born between 2008 and 2009, 143 (0.56%) were readmitted with a mean plasma total bilirubin of 18.7 ± 1.7 mg/dL at 125 ± 54 hours. False-negative predischarge bilirubin screen was identified in 46 (32.2%). Of these, 6 (4.2%) were in the low-risk zone (≤40th percentile, relative risk [RR] = 1) and 40 (28%) in the intermediate-low–risk zone (41st–75th percentile, RR 7.62 [95% confidence interval 3.23–17.96]). Of those in the high-risk zones, 76 (53.1%) were in the intermediate-high–risk zone (76th–95th percentile, RR 25.32 [11.03–58.10]) and 21 (14.7%) in the high-risk zone (>95th percentile, RR 27.78 [11.23–68.70]).

CONCLUSIONS: Predischarge bilirubin levels in newborns classified as low risk did not eliminate the risk of readmission for hyperbilirubinemia. All newborns including those at low risk must be vigilantly observed for subsequent hyperbilirubinemia.

KEY WORDS

• hyperbilirubinemia
• bilirubin
• predischarge bilirubin screening
• readmission
• Accepted May 10, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
1. Abstract 2 of 61Article

Long-term Differences in Language and Cognitive Function After Childhood Exposure to Anesthesia

BACKGROUND: Over the past decade, the safety of anesthetic agents in children has been questioned after the discovery that immature animals exposed to anesthesia display apoptotic neurodegeneration and long-term cognitive deficiencies. We examined the association between exposure to anesthesia in children under age 3 and outcomes in language, cognitive function, motor skills, and behavior at age 10.

METHODS: We performed an analysis of the Western Australian Pregnancy Cohort (Raine) Study, which includes 2868 children born from 1989 to 1992. Of 2608 children assessed, 321 were exposed to anesthesia before age 3, and 2287 were unexposed.

RESULTS: On average, exposed children had lower scores than their unexposed peers in receptive and expressive language (Clinical Evaluation of Language Fundamentals: Receptive [CELF-R] and Expressive [CELF-E]) and cognition (Colored Progressive Matrices [CPM]). After adjustment for demographic characteristics, exposure to anesthesia was associated with increased risk of disability in language (CELF-R: adjusted risk ratio [aRR], 1.87; 95% confidence interval [CI], 1.20–2.93, CELF-E: aRR, 1.72; 95% CI, 1.12–2.64), and cognition (CPM: aRR, 1.69; 95% CI, 1.13–2.53). An increased aRR for disability in language and cognition persisted even with a single exposure to anesthesia (CELF-R aRR, 2.41; 95% CI, 1.40–4.17, and CPM aRR, 1.73; 95% CI, 1.04–2.88).

CONCLUSIONS: Our results indicate that the association between anesthesia and neuropsychological outcome may be confined to specific domains. Children in our cohort exposed to anesthesia before age 3 had a higher relative risk of language and abstract reasoning deficits at age 10 than unexposed children.

KEY WORDS

• anesthesiology
• neurodevelopmental
• cognitive function
• neurotoxicity
• language development
• Accepted May 10, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
2. Abstract 3 of 61Article

Lower Life Satisfaction Related to Materialism in Children Frequently Exposed to Advertising

OBJECTIVE: Research among adults suggests that materialism and life satisfaction negatively influence each other, causing a downward spiral. So far, cross-sectional research among children has indicated that materialistic children are less happy, but causality remains uncertain. This study adds to the literature by investigating the longitudinal relation between materialism and life satisfaction. We also investigated whether their relation depended on children’s level of exposure to advertising.

METHODS: A sample of 466 children (aged 8–11; 55% girls) participated in a 2-wave online survey with a 1-year interval. We asked children questions about material possessions, life satisfaction, and advertising. We used structural equation modeling to study the relationship between these variables.

RESULTS: For the children in our sample, no effect of materialism on life satisfaction was observed. However, life satisfaction did have a negative effect on materialism. Exposure to advertising facilitated this effect: We only found an effect of life satisfaction on materialism for children who were frequently exposed to advertising.

CONCLUSIONS: Among 8- to 11-year-old children, life satisfaction leads to decreased materialism and not the other way around. However, this effect only holds for children who are frequently exposed to television advertising. It is plausible that the material values portrayed in advertising teach children that material possessions are a way to cope with decreased life satisfaction. It is important to reduce this effect, because findings among adults suggest that materialistic children may become less happy later in life. Various intervention strategies are discussed.

KEY WORDS

• life satisfaction
• materialism
• television advertising
• children
• Accepted May 3, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
3. Abstract 4 of 61Article

Prospective Multicenter Study of Children With Bronchiolitis Requiring Mechanical Ventilation

OBJECTIVE: To identify factors associated with continuous positive airway pressure (CPAP) and/or intubation for children with bronchiolitis.

METHODS: We performed a 16-center, prospective cohort study of hospitalized children aged <2 years with bronchiolitis. For 3 consecutive years from November 1 until March 31, beginning in 2007, researchers collected clinical data and a nasopharyngeal aspirate from study participants. We oversampled children from the ICU. Samples of nasopharyngeal aspirate were tested by polymerase chain reaction for 18 pathogens.

RESULTS: There were 161 children who required CPAP and/or intubation. The median age of the overall cohort was 4 months; 59% were male; 61% white, 24% black, and 36% Hispanic. In the multivariable model predicting CPAP/intubation, the significant factors were: age <2 months (odds ratio [OR] 4.3; 95% confidence interval [CI] 1.7–11.5), maternal smoking during pregnancy (OR 1.4; 95% CI 1.1–1.9), birth weight <5 pounds (OR 1.7; 95% CI 1.0–2.6), breathing difficulty began <1 day before admission (OR 1.6; 95% CI 1.2–2.1), presence of apnea (OR 4.8; 95% CI 2.5–8.5), inadequate oral intake (OR 2.5; 95% CI 1.3–4.3), severe retractions (OR 11.1; 95% CI 2.4–33.0), and room air oxygen saturation <85% (OR 3.3; 95% CI 2.0–4.8). The optimism-corrected c-statistic for the final model was 0.80.

CONCLUSIONS: In this multicenter study of children hospitalized with bronchiolitis, we identified several demographic, historical, and clinical factors that predicted the use of CPAP and/or intubation, including children born to mothers who smoked during pregnancy. We also identified a novel subgroup of children who required mechanical respiratory support <1 day after respiratory symptoms began.

KEY WORDS

• bronchiolitis
• continuous positive airway pressure
• intubation
• ICU
• respiratory syncytial virus
• human rhinovirus
• Accepted April 23, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
4. Abstract 5 of 61Article

Unprovoked Status Epilepticus: The Prognosis for Otherwise Normal Children With Focal Epilepsy

OBJECTIVE: To document the effect of unprovoked status epilepticus (SE) on the prognosis for otherwise normal children with focal epilepsy.

METHODS: From the Nova Scotia Childhood Epilepsy Study (population-based), we identified patients with focal epilepsy, normal intelligence, and neurologic examination and follow-up ≥10 years. We compared those with and without unprovoked SE.

RESULTS: One hundred eighty-eight cases had a mean follow-up of 27 ± 5 years with no deaths from SE. Thirty-nine (20%) had SE, 19 of whom experienced their first seizure. The number of episodes of SE was 1 in 27 patients (69%) and 2 to 10 in 12 patients. At onset 9 of 39 (23%) SE patients and 35 of 149 (23%) no-SE patients had specific learning disorders. At follow-up, 11 (28%) SE and 49 (33%) no-SE patients had learning disorders (P = not statistically different [ns]). Grades repeated, high school graduation, and advanced education did not differ. The number of antiepileptic drug (AED) used throughout the clinical course was the same: 22/39 (56%). SE patients used ≤2 AEDs versus 99 of 149 (64%) no-SE patients (P = .2). The distribution of patients using 3 to 11 AEDs was similar. The remission rate (seizure-free without AEDs at the end of follow-up) for SE patients was 24 of 39 (61%) versus 99 of 149 (66%) in no-SE (P = .5). Intractable epilepsy occurred in 15% SE and 11% of no-SE cases.

CONCLUSIONS: SE often recurs but apparently has little influence on long-term intellectual and seizure outcome in normally intelligent children with focal epilepsy.

KEY WORDS

• status epilepticus
• children
• epilepsy
• prognosis
• Accepted May 14, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
5. Abstract 6 of 61Article

An Evaluation of Mother-Centered Anticipatory Guidance to Reduce Obesogenic Infant Feeding Behaviors

OBJECTIVE: To evaluate the effect of 2 anticipatory guidance styles (maternal focused [MOMS] and infant focused [Ounce of Prevention]) directed at mothers of infants aged newborn to 6 months on their infant feeding behaviors at 1 year compared with routine advice as outlined in Bright Futures (BF).

METHODS: This is a cluster randomized trial. A total of 292 mother/infant dyads were enrolled at their first well-child visit to 3 urban pediatric clinics in Columbus, Ohio. Intervention-specific brief advice and 1-page handouts were given at each well visit. In addition to infant weights and lengths, surveys about eating habits and infant feeding practices were completed at baseline and 12 months.

RESULTS: Baseline data revealed a group with high rates of maternal overweight (62%) and obesogenic habits. At 12 months, the maternal-focused group gave their infants less juice (8.97 oz vs 14.37 oz, P < .05), and more daily servings of fruit (1.40 vs 0.94, P < .05) and vegetables (1.41 vs 1.03, P < .05) compared with BF mothers. Ounce of Prevention mothers also gave less juice (9.3 oz, P < .05) and more fruit servings (1.26 P < .05) than BF.

CONCLUSIONS: Brief specific interventions added to well-child care may affect obesogenic infant feeding behaviors of mothers and deserves further study as an inexpensive approach to preventing childhood obesity.

KEY WORDS

• well-child visit
• obesity prevention
• anticipatory guidance
• infant feeding
• Accepted April 27, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
6. Abstract 7 of 61Article

Racial/Ethnic Differences in Infant Mortality Attributable to Birth Defects by Gestational Age

OBJECTIVE: Birth defects are a leading cause of infant mortality in the United States. Previous reports have highlighted black-white differences in overall infant mortality and infant mortality attributable to birth defects (IMBD). We evaluated the impact of gestational age on US racial/ethnic differences in IMBD.

METHODS: We estimated the rate of IMBD as the underlying cause of death using the period-linked birth/infant death data for US residents for January 2003 to December 2006. We excluded infants with missing gestational age, implausible values based on Alexander’s index of birth weight for gestational age norms, or gestational ages <20 weeks or >44 weeks; we categorized gestational age into 3 groups: 20 to 33, 34 to 36, and 37 to 44 weeks. Using Poisson regression, we compared neonatal and postneonatal IMBD for infants of non-Hispanic black and Hispanic mothers with that for infants of non-Hispanic white mothers stratified by gestational age.

RESULTS: IMBD occurred in 12.2 per 10 000 live births. Among infants delivered at 37 to 44 weeks, blacks (and Hispanics, to a lesser degree) had significantly higher neonatal and postneonatal IMBD than whites; however, among infants delivered at 20 to 33 or 34 to 36 weeks, neonatal (but not postneonatal) IMBD was significantly lower among blacks compared with whites.

CONCLUSIONS: Racial/ethnic differences in IMBD were not explained in these data by differences in gestational age. Further investigation should include an assessment of possible racial/ethnic differences in severity and/or access to timely diagnosis and management of birth defects.

KEY WORDS

• infant mortality
• birth defects
• gestational age
• race
• ethnicity
• Accepted May 1, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
7. Abstract 8 of 61Article

Social Inequalities in Mental Health and Health-Related Quality of Life in Children in Spain

OBJECTIVES: To assess mental health and health-related quality of life (HRQoL) of children and adolescents in Spain and to investigate the existence of a social gradient in mental health and HRQoL.

METHODS: Within the Spanish National Health Survey (2006), the parents’ version of the Strengths and Difficulties Questionnaire was administered to a population aged 4 to 15 years, and the parents’ version of the modified KIDSCREEN-10 Index was given to a population aged 8 to 15 years. Sociodemographic data and information on family structure, socioeconomic status, health status, and discrimination were collected. Regression models were developed to analyze associations of socioeconomic status with mental health and HRQoL.

RESULTS: A total of 6414 children and adolescents aged 4 to 15 years participated. Mean Strengths and Difficulties Questionnaire score was 9.38 (SD, 5.84) and mean KIDSCREEN-10 Index score (n = 4446) was 85.21 (SD, 10.73). Children whose mothers had a primary school education (odds ratio [OR]: 1.37; 95% confidence interval [CI]: 1.29–1.46) or a secondary education (OR: 1.21; 95% CI: 1.14–1.29) presented poorer mental health than those whose mothers had a university degree. Children from disadvantaged social classes (IV–V) showed slightly poorer HRQoL scores (OR: 0.98; CI: 0.97–0.99) than the remaining children.

CONCLUSIONS: There is a social gradient in the mental health of children and young adolescents in Spain. No social gradient was found for HRQoL, although children from families of disadvantaged social classes had slightly worse HRQoL scores than their counterparts from more advantaged classes.

KEY WORDS

• adolescent
• children
• health disparities
• mental health
• quality of life
• Spain
• Accepted April 24, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
8. Abstract 9 of 61Article

Maternal Multiple Micronutrient Supplements and Child Cognition: A Randomized Trial in Indonesia

OBJECTIVES: We investigated the relative benefit of maternal multiple micronutrient (MMN) supplementation during pregnancy and until 3 months postpartum compared with iron/folic acid supplementation on child development at preschool age (42 months).

METHODS: We assessed 487 children of mothers who participated in the Supplementation with Multiple Micronutrients Intervention Trial, a cluster-randomized trial in Indonesia, on tests adapted and validated in the local context measuring motor, language, visual attention/spatial, executive, and socioemotional abilities. Analysis was according to intention to treat.

RESULTS: In children of undernourished mothers (mid-upper arm circumference <23.5 cm), a significant benefit of MMNs was observed on motor ability (B = 0.39 [95% confidence interval (CI): 0.08–0.70]; P = .015) and visual attention/spatial ability (B = 0.37 [95% CI: 0.11–0.62]; P = .004). In children of anemic mothers (hemoglobin concentration <110 g/L), a significant benefit of MMNs on visual attention/spatial ability (B = 0.24 [95% CI: 0.02–0.46]; P = .030) was also observed. No robust effects of maternal MMN supplementation were found in any developmental domain over all children.

CONCLUSIONS: When pregnant women are undernourished or anemic, provision of MMN supplements can improve the motor and cognitive abilities of their children up to 3.5 years later, particularly for both motor function and visual attention/spatial ability. Maternal MMN but not iron/folic acid supplementation protected children from the detrimental effects of maternal undernutrition on child motor and cognitive development.

KEY WORDS

• child development
• cognitive development
• international public health
• maternal health
• maternal nutrition
• motor development
• multiple micronutrient supplementation
• Accepted May 14, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
9. Abstract 10 of 61Article

Effects of CPOE on Provider Cognitive Workload: A Randomized Crossover Trial

OBJECTIVE: To evaluate whether systematically developed clinical decision supports provide usability benefit or decreased cognitive workload with their use.

METHODS: Seven surgeons at a pediatric hospital at different levels of training (3 residents, 3 fellows, and 1 attending) were randomized to use either a historical control (ad hoc developed order set) or a systematically developed order set for postoperative management of appendicitis in children. After a washout period, they were crossed over to the other order set. Participants were videorecorded and completed postsurveys, including the System Usability Scale and the National Aeronautic and Space Administration–Task Load Index.

RESULTS: Participants unanimously preferred using systematically developed order sets. These order sets resulted in higher usability scores (75 ± 10 vs 60 ± 19; P < .05) and lower cognitive workload scores (37.7 ± 15 vs 52.2 ± 12; P < .05), with comparable amounts of time spent, mouse clicks, and free text entry. Orders generated were more likely to conform to established clinical guidelines.

CONCLUSIONS: Systematically designed order sets provide a reduction in cognitive workload and order variation in the context of improved system usability and improved guideline adherence. The systematically designed order set did not improve time spent, reduce mouse clicks, or reduce free text entry.

KEY WORDS

• clinical decision support
• computer order entry
• cognitive workload
• health information technology
• order sets
• system usability
• Accepted May 3, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
10. Abstract 11 of 61Article

Bone Mineral Density and Vitamin D Status Among African American Children With Forearm Fractures

OBJECTIVE: To determine whether African American children with forearm fractures have decreased bone mineral density and an increased prevalence of vitamin D deficiency (serum 25-hydroxyvitamin D level ≤20 ng/mL) compared with fracture-free control patients.

METHODS: This case-control study in African American children, aged 5 to 9 years, included case patients with forearm fracture and control patients without fracture. Evaluation included measurement of bone mineral density and serum 25-hydroxyvitamin D level. Univariable and multivariable analyses were used to test for associations between fracture status and 2 measures of bone health (bone mineral density and 25-hydroxyvitamin D level) while controlling for other potential confounders.

RESULTS: The final sample included 76 case and 74 control patients. There were no significant differences between case and control patients in age, gender, parental education level, enrollment season, outdoor play time, height, or mean dietary calcium nutrient density. Cases were more likely than control patients to be overweight (49.3% vs 31.4%, P = .03). Compared with control patients, case patients had lower whole body z scores for bone mineral density (0.62 ± 0.96 vs 0.98 ± 1.09; adjusted odds ratio 0.38 [0.20–0.72]) and were more likely to be vitamin D deficient (47.1% vs 40.8%; adjusted odds ratio 3.46 [1.09–10.94]).

CONCLUSIONS: These data support an association of lower bone mineral density and vitamin D deficiency with increased odds of forearm fracture among African American children. Because suboptimal childhood bone health also negatively impacts adult bone health, interventions to increase bone mineral density and correct vitamin D deficiency are indicated in this population to provide short-term and long-term benefits.

KEY WORDS

• fracture
• injury
• bone mineral density
• vitamin D deficiency
• Accepted May 10, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
11. Abstract 12 of 61Article

Randomized Trial of Vitamin D Supplementation and Risk of Acute Respiratory Infection in Mongolia

OBJECTIVE: Observational studies suggest that serum levels of 25-hydroxyvitamin D (25[OH]D) are inversely associated with acute respiratory infections (ARIs). We hypothesized that vitamin D supplementation of children with vitamin D deficiency would lower the risk of ARIs.

METHODS: By using cluster randomization, classrooms of 744 Mongolian schoolchildren were randomly assigned to different treatments in winter (January–March). This analysis focused on a subset of 247 children who were assigned to daily ingestion of unfortified regular milk (control; n = 104) or milk fortified with 300 IU of vitamin D₃ (n = 143). This comparison was double-blinded. The primary outcome was the number of parent-reported ARIs over the past 3 months.

RESULTS: At baseline, the median serum 25(OH)D level was 7 ng/mL (interquartile range: 5–10 ng/mL). At the end of the trial, follow-up was 99% (n = 244), and the median 25(OH)D levels of children in the control versus vitamin D groups was significantly different (7 vs 19 ng/mL; P < .001). Compared with controls, children receiving vitamin D reported significantly fewer ARIs during the study period (mean: 0.80 vs 0.45; P = .047), with a rate ratio of 0.52 (95% confidence interval: 0.31–0.89). Adjusting for age, gender, and history of wheezing, vitamin D continued to halve the risk of ARI (rate ratio: 0.50 [95% confidence interval: 0.28–0.88]). Similar results were found among children either below or above the median 25(OH)D level at baseline (rate ratio: 0.41 vs 0.57; P_interaction = .27).

CONCLUSIONS: Vitamin D supplementation significantly reduced the risk of ARIs in winter among Mongolian children with vitamin D deficiency.

KEY WORDS

• vitamin D
• nutritional supplements
• respiratory infections
• randomized controlled trial
• Accepted April 20, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
12. Abstract 13 of 61Article

Risk Adjustment for Neonatal Surgery: A Method for Comparison of In-Hospital Mortality

OBJECTIVE: To develop a risk-adjustment method for evaluation of in-hospital mortality after noncardiac neonatal surgery regardless of gestational age.

METHODS: Infants ≤30 days old undergoing noncardiac surgical procedures were identified by using the Kids’ Inpatient Database (KID) 2000 + 2003. Neonates were included regardless of gestational age. International Classification of Disease, Ninth Revision, Clinical Modification codes were used to assign procedures to 1 of 4 previously derived risk categories. Prematurity and other clinical variables were assessed in logistic regression analysis. The final multivariable model was validated in 3 independent data sets: KID 2006, Pediatric Health Information System (PHIS) 2001–2003, and PHIS 2006–2008. The model was applied to generate standardized mortality ratios for institutions within PHIS 2006–2008.

RESULTS: Among 18 437 eligible cases in KID 2000 + 2003, 15 278 (83%) had 1 of 66 procedure codes assigned to a risk category and were eligible for analysis. In-hospital mortality for premature infants was 10.5% compared with 2.0% for full-term neonates. In addition to risk category, the clinical variables improving prediction of in-hospital death were prematurity, serious respiratory conditions, necrotizing enterocolitis, neonatal sepsis, and congenital heart disease. Area under the receiver-operator characteristic curve for the final model was 0.90. The model also showed excellent discrimination in the 3 validation data sets (0.90, 0.89, and 0.89). Within 41 institutions in PHIS, standardized mortality ratios ranged from 0.37 to 1.91.

CONCLUSIONS: This validated method provides a tool for risk adjustment of neonates undergoing noncardiac surgery to allow comparative analyses of in-hospital mortality.

KEY WORDS

• risk adjustment
• hospital mortality
• neonatal surgery
• term birth
• premature birth
• Accepted May 10, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
13. Abstract 14 of 61Article

Montelukast for Children With Obstructive Sleep Apnea: A Double-blind, Placebo-Controlled Study

OBJECTIVES: Children with nonsevere obstructive sleep apnea (OSA) benefit from alternative therapeutic interventions such as leukotriene modifiers. We hypothesized that montelukast might improve OSA in children. We tested this hypothesis in a double-blind, randomized, placebo-controlled fashion.

METHODS: Of 50 possible candidates, we recruited 46 children with polysomnographically diagnosed OSA. In this prospective, double-blind, randomized trial, children received daily oral montelukast at 4 or 5 mg (<6 or >6 years of age, respectively) or placebo for 12 weeks. Polysomnographic assessments, parent questionnaires, and radiographs to assess adenoid size were performed before and after therapy.

RESULTS: Compared with the 23 children that received placebo, the 23 children that received montelukast showed significant improvements in polysomnographic measures of respiratory disturbance (obstructive apnea index), children's symptoms, and adenoid size. The obstructive apnea index decreased by >50% in 65.2% of treated children. No attrition or side effects occurred.

CONCLUSIONS: A 12-week treatment with daily, oral montelukast effectively reduced the severity of OSA and the magnitude of the underlying adenoidal hypertrophy in children with nonsevere OSA.

KEY WORDS

• obstructive sleep apnea
• tonsillectomy and adenoidectomy
• sleep disordered breathing
• leukotrienes
• Accepted April 30, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
14. Abstract 15 of 61Article

Maternal HIV Infection and Vertical Transmission of Pathogenic Bacteria

BACKGROUND: HIV-exposed newborns may be at higher risk of sepsis because of immune system aberrations, impaired maternal antibody transfer and altered exposure to pathogenic bacteria.

METHODS: We performed a secondary analysis of a study (clinicaltrials.gov, number NCT00136370) conducted between April 2004 and October 2007 in South Africa. We used propensity score matching to evaluate the association between maternal HIV infection and (1) vaginal colonization with bacterial pathogens; (2) vertical transmission of pathogens to the newborn; and (3) sepsis within 3 days of birth (EOS) or between 4–28 days of life (LOS).

RESULTS: Colonization with group B Streptococcus (17% vs 23%, P = .0002), Escherichia coli (47% vs 45%, P = .374), and Klebsiella pneumoniae (7% vs 10%, P = .008) differed modestly between HIV-infected and uninfected women, as did vertical transmission rates. Maternal HIV infection was not associated with increased risk of neonatal EOS or LOS, although culture-confirmed EOS was >3 times higher among HIV-exposed infants (P = .05). When compared with HIV-unexposed, neonates, HIV-exposed, uninfected neonates (HEU) had a lower risk of EOS (20.6 vs 33.7 per 1000 births; P = .046) and similar rate of LOS (5.8 vs 4.1; P = .563). HIV-infected newborns had a higher risk than HEU of EOS (134 vs 21.5; P < .0001) and LOS (26.8 vs 5.6; P = .042).

CONCLUSIONS: Maternal HIV infection was not associated with increased risk of maternal bacterial colonization, vertical transmission, EOS, or LOS. HIV-infected neonates, however, were at increased risk of EOS and LOS.

KEY WORDS

• group B Streptococcus (GBS)
• newborns
• sepsis
• HIV
• pneumonia
• Accepted May 9, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
15. Abstract 16 of 61Article

Mortality and Clinical Outcomes in HIV-Infected Children on Antiretroviral Therapy in Malawi, Lesotho, and Swaziland

OBJECTIVE: To determine mortality and immune status improvement in HIV-infected pediatric patients on antiretroviral treatment (ART) in Malawi, Lesotho, and Swaziland.

METHODS: We conducted a retrospective cohort study of patients aged <12 years at ART initiation at 3 sites in sub-Saharan Africa between 2004 and 2009. Twelve-month and overall mortality were estimated, and factors associated with mortality and immune status improvement were evaluated.

RESULTS: Included in the study were 2306 patients with an average follow-up time on ART of 2.3 years (interquartile range 1.5–3.1 years). One hundred four patients (4.5%) died, 9.0% were lost to follow-up, and 1.3% discontinued ART. Of the 104 deaths, 77.9% occurred in the first year of treatment with a 12-month mortality rate of 3.5%. The overall mortality rate was 2.25 deaths/100 person-years (95% confidence interval [CI] 1.84–2.71). Increased 12-month mortality was associated with younger age; <6 months (hazard ratio [HR] = 8.11, CI 4.51–14.58), 6 to <12 months (HR = 3.43, CI 1.96–6.02), and 12 to <36 months (HR = 1.92, CI 1.16–3.19), and World Health Organization stage IV (HR = 4.35, CI 2.19–8.67). Immune status improvement at 12 months was less likely in patients with advanced disease and age <12 months.

CONCLUSIONS: Despite challenges associated with pediatric ART in developing countries, low mortality and good treatment outcomes can be achieved. However, outcomes are worse in younger patients and those with advanced disease at the time of ART initiation, highlighting the importance of early diagnosis and treatment.

KEY WORDS

• HIV
• AIDS
• pediatric
• antiretroviral therapy
• mortality
• Africa south of the Sahara
• Accepted April 23, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
16. Abstract 17 of 61Article

Timing of Measles Immunization and Effective Population Vaccine Coverage

OBJECTIVE: To describe measles vaccination patterns in a cohort of Swiss children aged up to 3 years insured with a single health insurer.

METHODS: A dynamic cohort study evaluating measles immunizations patterns in children born between 2006 and 2008 was conducted. Time-to-event analysis was used to describe timing of measles immunization. Effective vaccine coverage was calculated by using an area under the curve approach.

RESULTS: In the study cohort, 62.6% of 13-month-old children were up-to-date for the first measles immunization (recommended at 12 months of age). Approximately 59% of 25-month-old children were up-to-date for the second measles immunization (recommended at 15–24 months of age). Most doses were delivered during months in a child’s life when well-child visits are recommended (eg, 12 months of age). For second measles vaccine dose, accelerations in vaccine delivery occurred at time points for well-child visits during the months 19 and 25 of age but with lower final uptake than for the first measles vaccine dose. Until their second birthday, children in our cohort spent on average 177 days and 89 days susceptible to measles due to policy recommendations and additional delays, respectively. In a group of children aged 6 months to 2 years reflecting the age distribution in our cohort, effective vaccine coverage was only 48.6%.

CONCLUSIONS: Timing and timeliness of measles immunizations influence effective population vaccine coverage and should be routinely reported in addition to coverage whenever possible. Proposed timing and relation of recommended vaccinations to well-child visits could be relevant aspects in optimizing measles vaccine coverage to reach measles elimination.

KEY WORDS

• immunization programs
• immunization schedule
• measles
• time factors
• vaccination
• Accepted May 10, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
17. Abstract 18 of 61Article

Efficacy of Fat-Soluble Vitamin Supplementation in Infants With Biliary Atresia

OBJECTIVE: Cholestasis predisposes to fat-soluble vitamin (FSV) deficiencies. A liquid multiple FSV preparation made with tocopheryl polyethylene glycol-1000 succinate (TPGS) is frequently used in infants with biliary atresia (BA) because of ease of administration and presumed efficacy. In this prospective multicenter study, we assessed the prevalence of FSV deficiency in infants with BA who received this FSV/TPGS preparation.

METHODS: Infants received FSV/TPGS coadministered with additional vitamin K as routine clinical care in a randomized double-blinded, placebo-controlled trial of corticosteroid therapy after hepatoportoenterostomy (HPE) for BA (identifier NCT 00294684). Levels of FSV, retinol binding protein, total serum lipids, and total bilirubin (TB) were measured 1, 3, and 6 months after HPE.

RESULTS: Ninety-two infants with BA were enrolled in this study. Biochemical evidence of FSV insufficiency was common at all time points for vitamin A (29%–36% of patients), vitamin D (21%–37%), vitamin K (10%–22%), and vitamin E (16%–18%). Vitamin levels were inversely correlated with serum TB levels. Biochemical FSV insufficiency was much more common (15%–100% for the different vitamins) in infants whose TB was ≥2 mg/dL. At 3 and 6 months post HPE, only 3 of 24 and 0 of 23 infants, respectively, with TB >2 mg/dL were sufficient in all FSV.

CONCLUSIONS: Biochemical FSV insufficiency is commonly observed in infants with BA and persistent cholestasis despite administration of a TPGS containing liquid multiple FSV preparation. Individual vitamin supplementation and careful monitoring are warranted in infants with BA, especially those with TB >2 mg/dL.

KEY WORDS

• cholestasis
• nutrition
• liver
• vitamin deficiency
• Accepted May 3, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
18. Abstract 19 of 61Article

Pediatric-Specific Antimicrobial Susceptibility Data and Empiric Antibiotic Selection

OBJECTIVE: Duke University Health System (DUHS) generates annual antibiograms combining adult and pediatric data. We hypothesized significant susceptibility differences exist for pediatric isolates and that distributing these results would alter antibiotic choices.

METHODS: Susceptibility rates for Escherichia coli isolates from patients aged ≤12 years between July 2009 and September 2010 were compared with the 2009 DUHS antibiogram. Pediatric attending and resident physicians answered case-based vignettes about children aged 3 months and 12 years with urinary tract infections. Each vignette contained 3 identical scenarios with no antibiogram, the 2009 DUHS antibiogram, and a pediatric-specific antibiogram provided. Effective antibiotics exhibited >80% in vitro susceptibility. Frequency of antibiotic selection was analyzed by using descriptive statistics.

RESULTS: Three hundred seventy-five pediatric isolates were identified. Pediatric isolates were more resistant to ampicillin and trimethoprim-sulfamethoxazole (TMP-SMX) and less resistant to amoxicillin-clavulanate and ciprofloxacin (P < .0005 for all). Seventy-five resident and attending physicians completed surveys. In infant vignettes, physicians selected amoxicillin-clavulanate (P < .05) and nitrofurantoin (P < .01) more often and TMP-SMX (P < .01) less often with pediatric-specific data. Effective antibiotic choices increased from 68.6% to 82.2% (P = .06) to 92.5% (P < .01) across scenarios. In adolescent vignettes, providers reduced TMP-SMX use from 66.2% to 42.6% to 19.0% (P < .01 for both). Effective antibiotic choices increased from 32.4% to 57.4% to 79.4% (P < .01 and P = .01).

CONCLUSIONS: Pediatric E. coli isolates differ significantly in antimicrobial susceptibility at our institution, particularly to frequently administered oral antibiotics. Knowledge of pediatric-specific data altered empirical antibiotic choices in case vignettes. Care of pediatric patients could be improved with use of a pediatric-specific antibiogram.

KEY WORDS

• pediatric-specific antimicrobial susceptibility
• antimicrobial resistance
• quality of care
• Accepted April 27, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
19. Abstract 20 of 61Article

Thrombocytopenia in the First 24 Hours After Birth and Incidence of Patent Ductus Arteriosus

BACKGROUND: Experimental studies suggest that platelet-triggered ductal sealing is critically involved in definite ductus arteriosus closure. Whether thrombocytopenia contributes to persistently patent ductus arteriosus (PDA) in humans is controversial. This was a retrospective study of 1350 very low birth weight (VLBW; <1500 g) infants, including 592 extremely low birth weight (ELBW; <1000 g) infants.

METHODS: All infants who had a platelet count in the first 24 hours after birth and an echocardiogram performed on day of life 4 to 5 were included. The incidence of thrombocytopenia was analyzed in infants with and without PDA, and in those who did or did not undergo PDA intervention. The impact of thrombocytopenia, gestational age, birth weight, gender, and sepsis on PDA was determined by receiver operating characteristic curve, odds ratio, and regression analyses.

RESULTS: Platelet numbers within the first 24 hours after birth did not differ between VLBW/ELBW infants with and without spontaneous ductal closure. Platelet numbers were not associated with subsequent PDA treatment. Low platelet counts were not related to failure of pharma-cologic PDA treatment and the need for subsequent surgical ligation. Lower gestational age or birth weight, male gender, and sepsis were linked to the presence of PDA in VLBW infants on day of life 4 to 5.

CONCLUSIONS: Thrombocytopenia in the first 24 hours after birth was not associated with PDA in this largest VLBW/ELBW infant cohort studied to date. Impaired platelet function, due to immaturity and critical illness, rather than platelet number, might play a role in ductus arteriosus patency.

KEY WORDS

• ductal closure
• patent ductus arteriosus
• preterm infant
• platelets
• very low birth weight
• Accepted April 27, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
20. Abstract 21 of 61Article

Breastfeeding, Childhood Milk Consumption, and Onset of Puberty

OBJECTIVE: Early nutrition has been postulated as programming pubertal timing. Limited observational studies, mainly from Western settings, suggest puberty occurs later with breastfeeding and earlier with higher cow’s milk (including infant formula) consumption. However, these observations may be socioeconomically confounded. This study examined whether breastfeeding or childhood milk consumption was associated with pubertal onset in a setting with different associations of breastfeeding and puberty with socioeconomic position.

METHODS: The adjusted associations of breastfeeding or milk consumption at 6 months, 3 years, and 5 years with clinically assessed age at pubertal onset (Tanner stage II) were assessed by using interval-censored regression in a population-representative Hong Kong Chinese birth cohort, “Children of 1997,” with 90% follow-up (N = 7523).

RESULTS: Compared with never breastfeeding, exclusive breastfeeding for 3+ months was unrelated to age at pubertal onset (time ratio [TR] 1.001, 95% confidence interval [CI] 0.987–1.015), as was partial breastfeeding for any length of time or exclusive breastfeeding for <3 months (TR 1.003, 95% CI 0.996–1.010), adjusted for gender, socioeconomic position, birth weight-for-gestational age, birth order, second-hand smoke exposure, and mother’s age and place of birth. Daily milk consumption at 6 months (TR 1.004, 95% CI 0.991–1.018), 3 years (TR 0.995, 95% CI 0.982–1.008), or 5 years (TR 0.998, 95% CI 0.988–1.009) was also unrelated to age at pubertal onset compared with milk consumption for ≤1 time per week at the corresponding ages.

CONCLUSIONS: In a non-Western setting, neither breastfeeding nor childhood milk consumption was associated with age at pubertal onset, suggesting that associations may vary by setting.

KEY WORDS

• Child
• cohort studies
• breastfeeding
• milk
• puberty
• Accepted April 20, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
21. Abstract 22 of 61Article

Persistent Snoring in Preschool Children: Predictors and Behavioral and Developmental Correlates

OBJECTIVE: To clarify whether persistent snoring in 2- to 3-year-olds is associated with behavioral and cognitive development, and to identify predictors of transient and persistent snoring.

METHODS: Two hundred forty-nine mother/child pairs participated in a prospective birth cohort study. Based upon parental report of loud snoring ≥2 times weekly at 2 and 3 years of age, children were designated as nonsnorers, transient snorers (snored at 2 or 3 years of age, but not both), or persistent snorers (snored at both ages). We compared groups by using validated measures of behavioral and cognitive functioning. Potential predictors of snoring included child race and gender, socioeconomic status (parent education and income), birth weight, prenatal tobacco exposure (maternal serum cotinine), childhood tobacco exposure (serum cotinine), history and duration of breast milk feeding, and body mass relative to norms.

RESULTS: In multivariable analyses, persistent snorers had significantly higher reported overall behavior problems, particularly hyperactivity, depression, and inattention. Nonsnorers had significantly stronger cognitive development than transient and persistent snorers in unadjusted analyses, but not after demographic adjustment. The strongest predictors of the presence and persistence of snoring were lower socioeconomic status and the absence or shorter duration of breast milk feeding. Secondary analyses suggested that race may modify the association of childhood tobacco smoke exposure and snoring.

CONCLUSIONS: Persistent, loud snoring was associated with higher rates of problem behaviors. These results support routine screening and tracking of snoring, especially in children from low socioeconomic backgrounds; referral for follow-up care of persistent snoring in young children; and encouragement and facilitation of infant breastfeeding.

KEY WORDS

• sleep-disordered breathing
• behavior problems
• preschool
• environmental tobacco smoke
• breastfeeding
• overweight
• Accepted May 1, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
22. Abstract 23 of 61Article

Neurologic Disorders Among Pediatric Deaths Associated With the 2009 Pandemic Influenza

OBJECTIVE: The goal of this study was to describe reported influenza A (H1N1)pdm09 virus (pH1N1)-associated deaths in children with underlying neurologic disorders.

METHODS: The study compared demographic characteristics, clinical course, and location of death of pH1N1-associated deaths among children with and without underlying neurologic disorders reported to the Centers for Disease Control and Prevention.

RESULTS: Of 336 pH1N1-associated pediatric deaths with information on underlying conditions, 227 (68%) children had at least 1 underlying condition that conferred an increased risk of complications of influenza. Neurologic disorders were most frequently reported (146 of 227 [64%]), and, of those disorders, neurodevelopmental disorders such as cerebral palsy and intellectual disability were most common. Children with neurologic disorders were older (P = .02), had a significantly longer duration of illness from onset to death (P < .01), and were more likely to die in the hospital versus at home or in the emergency department (P < .01) compared with children without underlying medical conditions. Many children with neurologic disorders had additional risk factors for influenza-related complications, especially pulmonary disorders (48%). Children without underlying conditions were significantly more likely to have a positive result from a sterile-site bacterial culture than were those with an underlying neurologic disorder (P < .01).

CONCLUSIONS: Neurologic disorders were reported in nearly two-thirds of pH1N1-associated pediatric deaths with an underlying medical condition. Because of the potential for severe outcomes, children with underlying neurologic disorders should receive influenza vaccine and be treated early and aggressively if they develop influenza-like illness.

KEY WORDS

• influenza
• influenza vaccination
• neurologic disorders
• Accepted April 23, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
23. Abstract 24 of 61Article

Comparison of Children Hospitalized With Seasonal Versus Pandemic Influenza A, 2004–2009

BACKGROUND: The extent to which pandemic H1N1 influenza (pH1N1) differed from seasonal influenza remains uncertain.

METHODS: By using active surveillance data collected by the Immunization Monitoring Program, Active at 12 Canadian pediatric hospitals, we compared characteristics of hospitalized children with pH1N1 with those with seasonal influenza A. We compared demographics, underlying health status, ICU admission, and mortality during both pandemic waves versus the 2004/2005 through the 2008/2009 seasons; influenza-related complications and hospitalization duration during pH1N1 wave 1 versus the 2004/2005 through the 2008/2009 seasons; and presenting signs and symptoms during both pH1N1 waves versus the 2006/2007 through the 2008/2009 seasons.

RESULTS: We identified 1265 pH1N1 cases (351 in wave 1, 914 in wave 2) and 1319 seasonal influenza A cases (816 from 2006/2007 through 2008/2009). Median ages were 4.8 (pH1N1) and 1.7 years (seasonal influenza A); P < .0001. Preexisting asthma was overrepresented in pH1N1 relative to seasonal influenza A (13.8% vs 5.5%; adjusted P < .0001). Symptoms more often associated with pH1N1 wave 1 versus seasonal influenza A were cough, headache, and gastrointestinal symptoms (adjusted P < .01 for each symptom). pH1N1 wave 1 cases were more likely to have radiologically confirmed pneumonia (adjusted odds ratio = 2.1; 95% confidence interval = 1.1–3.8) and longer median length of hospital stay (4 vs 3 days; adjusted P = .003) than seasonal influenza A. Proportions of children requiring intensive care and deaths in both pH1N1 waves (14.6% and 0.6%, respectively) were not significantly different from the seasonal influenza A group (12.7% and 0.5%, respectively).

CONCLUSIONS: pH1N1 in children differed from seasonal influenza A in risk factors, clinical presentation, and length of hospital stay, but not ICU admission or mortality.

KEY WORDS

• pandemic H1N1 influenza
• seasonal influenza A
• child
• severity
• Accepted April 23, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
24. Abstract 25 of 61Article

One-Year Outcomes of Prenatal Exposure to MDMA and Other Recreational Drugs

OBJECTIVE: A widely used illicit recreational drug among young adults, 3,4-methylenedioxymethamphetamine (MDMA) or ecstasy, is an indirect monoaminergic agonist/reuptake inhibitor affecting the serotonin system. Preclinical studies found prenatal exposure related to long-term learning and memory impairments. There are no studies of sequelae of prenatal MDMA exposure in humans, despite potential harmful effects to the fetus.

METHODS: A total of 96 women in the United Kingdom (28 MDMA users; 68 non-MDMA) were interviewed about recreational drug use during pregnancy. Their infants were seen at 12 months using standardized assessments of cognitive, language, and motor development (Preschool Language Scale, Bayley Mental and Motor Development and Behavior Rating Scales [Mental Development Index, Psychomotor Development Index, Behavioral Rating Scale]). Mothers completed the Child Domain Scale of the Parenting Stress Index, The Home Observation of the Environment Scale (in interview), the Brief Symptom Inventory, and the Drug Abuse Screening Test. Women were primarily middle class with some university education, in stable partner relationships, and polydrug users. MDMA and other drug effects were assessed through multiple regression analyses controlling for confounding variables, and analysis of covariance comparing heavier versus lighter and nonexposed groups.

RESULTS: Amount of prenatal MDMA exposure predicted poorer infant mental and motor development at 12 months in a dose-dependent manner. Heavily exposed infants were delayed in motor development. Lighter-exposed infants were comparable to nonexposed infants. There were no effects on language, emotional regulation, or parenting stress.

CONCLUSIONS: Findings document persistent neurotoxic effects of heavier prenatal MDMA exposure on motor development through the first year of life.

KEY WORDS

• 3,4-methylenedioxymethamphetamine
• MDMA
• ecstasy
• infant development
• drugs
• serotonin
• motor skills
• Accepted May 1, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
25. Abstract 26 of 61Article

Haemophilus influenzae Type b Disease and Vaccine Booster Dose Deferral, United States, 1998–2009

BACKGROUND: Since the introduction of effective vaccines, the incidence of invasive Haemophilus influenzae type b (Hib) disease among children <5 years of age has decreased by 99% in the United States. In response to a limited vaccine supply that began in 2007, Hib booster doses were deferred for 18 months.

METHODS: We reviewed national passive and active surveillance (demographic and serotype) and vaccination status data for invasive H. influenzae disease in children aged <5 years before (1998–2007) and during (2008–2009) the vaccine shortage years to assess the impact of the vaccine deferral on Hib disease. We estimated the average annual number of Hib cases misclassified as unknown (not completed or missing) serotype.

RESULTS: From 1998 to 2007 and 2008 to 2009, the annual average incidence of Hib disease per 100 000 population was 0.2 and 0.18, respectively; no significant difference in incidence was found by age group, gender, or race. Among Hib cases in both time periods, most were unvaccinated or too young to have received Hib vaccine. During 2001 to 2009, there were <53 Hib cases per year, with an estimated 6 to 12 Hib cases misclassified as unknown serotype.

CONCLUSIONS: The booster deferral did not have a significant impact on the burden of invasive Hib disease in children <5 years of age. Continued surveillance and serotype data are important to monitor changes in Hib incidence, especially during vaccine deferrals. Hib booster deferral is a reasonable short-term approach to a Hib vaccine shortage.

KEY WORDS

• Haemophilus influenzae
• Haemophilus influenzae type b
• United States
• epidemiology
• children
• vaccine-preventable diseases
• Accepted May 1, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
26. Abstract 27 of 61Article

Vitamin D Deficiency in Critically Ill Children

OBJECTIVE: Vitamin D influences cardiovascular and immune function. We aimed to establish the prevalence of vitamin D deficiency in critically ill children and identify factors influencing admission 25-hydroxy vitamin D (25(OH)D) levels. We hypothesized that levels would be lower with increased illness severity and in children with serious infections.

METHODS: Participants were 511 severely or critically ill children admitted to the PICU from November 2009 to November 2010. Blood was collected near PICU admission and analyzed for 25(OH)D concentration by using Diasorin radioimmunoassay.

RESULTS: We enrolled 511 of 818 (62.5%) eligible children. The median 25(OH)D level was 22.5 ng/mL; 40.1% were 25(OH)D deficient (level <20 ng/mL). In multivariate analysis, age and race were associated with 25(OH)D deficiency; summer season, vitamin D supplementation, and formula intake were protective; 25(OH)D levels were not lower in the 238 children (46.6%) admitted with a life-threatening infection, unless they had septic shock (n = 51, 10.0%) (median 25(OH)D level 19.2 ng/mL; P = .0008). After adjusting for factors associated with deficiency, lower levels were associated with higher admission day illness severity (odds ratio 1.19 for a 1-quartile increase in Pediatric Risk of Mortality III score per 5 ng/mL decrease in 25(OH)D, 95% confidence interval 1.10–1.28; P < .0001).

CONCLUSIONS: We found a high rate of vitamin D deficiency in critically ill children. Given the roles of vitamin D in bone development and immunity, we recommend screening of those critically ill children with risk factors for vitamin D deficiency and implementation of effective repletion strategies.

KEY WORDS

• critical care
• vitamin D
• septic shock
• Accepted May 30, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
27. Abstract 28 of 61Article

The Association of Vitamin D Status With Pediatric Critical Illness

OBJECTIVES: Vitamin D is a pleiotropic hormone important for the proper functioning of multiple organ systems. It has been hypothesized that vitamin D deficiency could contribute to or worsen outcomes in critical illness. The study objective was to determine the prevalence of vitamin D deficiency, risk factors for its presence, and potential association with clinically relevant outcomes in critically ill children.

METHODS: A prospective cohort study, conducted from 2005 to 2008 in 6 tertiary-care PICUs in Canada. Data and biological samples from 326 critically ill children up to 17 years of age were available for analysis. Total serum 25 hydroxyvitamin D or 25(OH)D was measured by using liquid chromatography-mass spectrometry.

RESULTS: The prevalence of 25(OH)D <50 nmol/L was 69% (95% confidence interval, 64–74), and 23% (95% confidence interval, 19–28) for 25(OH)D between 50 to 75 nmol/L. Lower levels were associated with hypocalcemia, catecholamine utilization, and significant fluid bolus administration. Vitamin D deficiency was independently associated with a longer PICU length of stay (+1.92 days, P = .03) and increasing severity of illness as determined by the Pediatric Risk of Mortality score with every additional point increasing the likelihood of being vitamin D deficient by 8% (P = .005).

CONCLUSIONS: This study provides evidence that vitamin D deficiency is both common among critically ill children and associated with greater severity of critical illness. Further research will determine whether targeted vitamin D supplementation or rapid restoration will improve outcome.

KEY WORDS

• vitamin D
• pediatrics
• risk factors
• length of stay
• critically ill children
• Accepted May 30, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
28. Abstract 29 of 61Article

Weight Status Among Adolescents in States That Govern Competitive Food Nutrition Content

OBJECTIVES: To determine if state laws regulating nutrition content of foods and beverages sold outside of federal school meal programs (“competitive foods”) are associated with lower adolescent weight gain.

METHODS: The Westlaw legal database identified state competitive food laws that were scored by using the Classification of Laws Associated with School Students criteria. States were classified as having strong, weak, or no competitive food laws in 2003 and 2006 based on law strength and comprehensiveness. Objective height and weight data were obtained from 6300 students in 40 states in fifth and eighth grade (2004 and 2007, respectively) within the Early Childhood Longitudinal Study–Kindergarten Class. General linear models estimated the association between baseline state laws (2003) and within-student changes in BMI, overweight status, and obesity status. Fixed-effect models estimated the association between law changes during follow-up (2003–2006) and within-student changes in BMI and weight status.

RESULTS: Students exposed to strong laws at baseline gained, on average, 0.25 fewer BMI units (95% confidence interval: −0.54, 0.03) and were less likely to remain overweight or obese over time than students in states with no laws. Students also gained fewer BMI units if exposed to consistently strong laws throughout follow-up (β = −0.44, 95% confidence interval: −0.71, −0.18). Conversely, students exposed to weaker laws in 2006 than 2003 had similar BMI gain as those not exposed in either year.

CONCLUSIONS: Laws that regulate competitive food nutrition content may reduce adolescent BMI change if they are comprehensive, contain strong language, and are enacted across grade levels.

KEY WORDS

• competitive foods
• state laws
• BMI
• adolescent
• Accepted April 20, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
29. Abstract 30 of 61Article

Culturally Tailored, Family-Centered, Behavioral Obesity Intervention for Latino-American Preschool-aged Children

OBJECTIVE: To test the effect of a culturally tailored, family-centered, short-term behavioral intervention on BMI in Latino-American preschool-aged children.

METHODS: In a randomized controlled trial, 54 parent–child dyads were allocated to the intervention and 52 dyads were allocated to an alternative school-readiness program as the control condition. Parent–child dyads were eligible if the parent self-defined Latino, was at least 18 years old, had a 2- to 6-year-old child not currently enrolled in another healthy lifestyle program, had a valid telephone number, and planned on remaining in the city for the next 6 months. The Salud Con La Familia (Health with the Family) program consisted of 12 weekly 90-minute skills-building sessions designed to improve family nutritional habits and increase physical activity. Both programs were conducted in a community recreation center serving an urban neighborhood of mostly Spanish-speaking residents.

RESULTS: Forty-two percent of participating preschool-aged children were overweight or obese. Controlling for child age, gender, and baseline BMI, the effect of the treatment condition on postintervention absolute BMI was B = –0.59 (P < .001). The intervention effect seemed to be strongest for obese children.

CONCLUSIONS: A skills-building, culturally tailored intervention involving parent–child dyads changed short-term early growth patterns in these Latino-American preschool-aged children. Examining long-term effects would be a prudent next step.

KEY WORDS

• childhood obesity
• family-centered intervention
• Latino
• preschool-aged children
• Accepted April 20, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
30. Abstract 31 of 61Article

Effects of Systematic Screening and Detection of Child Abuse in Emergency Departments

OBJECTIVE: Although systematic screening for child abuse of children presenting at emergency departments might increase the detection rate, studies to support this are scarce. This study investigates whether introducing screening, and training of emergency department nurses, increases the detection rate of child abuse.

METHODS: In an intervention cohort study, children aged 0 to 18 years visiting the emergency departments of 7 hospitals between February 2008 and December 2009 were enrolled. We developed a screening checklist for child abuse (the “Escape Form”) and training sessions for nurses; these were implemented by using an interrupted time-series design. Cases of suspected child abuse were determined by an expert panel using predefined criteria. The effect of the interventions on the screening rate for child abuse was calculated by interrupted time-series analyses and by the odds ratios for detection of child abuse in screened children.

RESULTS: A total of 104 028 children aged 18 years or younger were included. The screening rate increased from 20% in February 2008 to 67% in December 2009. Significant trend changes were observed after training the nurses and after the legal requirement of screening by the Dutch Health Care Inspectorate in 2009. The detection rate in children screened for child abuse was 5 times higher than that in children not screened (0.5% vs 0.1%, P < .001).

CONCLUSIONS: These results indicate that systematic screening for child abuse in emergency departments is effective in increasing the detection of suspected child abuse. Both a legal requirement and staff training are recommended to significantly increase the extent of screening.

KEY WORDS

• child abuse
• mass screening
• emergency service
• hospital
• Accepted April 20, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
31. Abstract 32 of 61Article

Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study

OBJECTIVES: To compare the effects of a single nocturnal dose of 3 honey products (eucalyptus honey, citrus honey, or labiatae honey) to placebo (silan date extract) on nocturnal cough and difficulty sleeping associated with childhood upper respiratory tract infections (URIs).

METHODS: A survey was administered to parents on 2 consecutive days, first on the day of presentation, when no medication had been given the previous evening, and the following day, when the study preparation was given before bedtime, based on a double-blind randomization plan. Participants included 300 children aged 1 to 5 years with URIs, nocturnal cough, and illness duration of ≤7 days from 6 general pediatric community clinics. Eligible children received a single dose of 10 g of eucalyptus honey, citrus honey, labiatae honey, or placebo administered 30 minutes before bedtime. Main outcome measures were cough frequency, cough severity, bothersome nature of cough, and child and parent sleep quality.

RESULTS: In all 3 honey products and the placebo group, there was a significant improvement from the night before treatment to the night of treatment. However, the improvement was greater in the honey groups for all the main outcome measures.

CONCLUSIONS: Parents rated the honey products higher than the silan date extract for symptomatic relief of their children’s nocturnal cough and sleep difficulty due to URI. Honey may be a preferable treatment for cough and sleep difficulty associated with childhood URI.

KEY WORDS

• cough
• children
• honey
• Accepted April 23, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
32. Abstract 33 of 61Article

Gender and Crime Victimization Modify Neighborhood Effects on Adolescent Mental Health

OBJECTIVE: Leverage an experimental study to determine whether gender or recent crime victimization modify the mental health effects of moving to low-poverty neighborhoods.

METHODS: The Moving to Opportunity (MTO) study randomized low-income families in public housing to an intervention arm receiving vouchers to subsidize rental housing in lower-poverty neighborhoods or to controls receiving no voucher. We examined 3 outcomes 4 to 7 years after randomization, among youth aged 5 to 16 years at baseline (n = 2829): lifetime major depressive disorder (MDD), psychological distress (K6), and Behavior Problems Index (BPI). Treatment effect modification by gender and family’s baseline report of recent violent crime victimization was tested via interactions in covariate-adjusted intent-to-treat and instrumental variable adherence-adjusted regression models.

RESULTS: Gender and crime victimization significantly modified treatment effects on distress and BPI (P < .10). Female adolescents in families without crime victimization benefited from MTO treatment, for all outcomes (Distress B = –0.19, P = .008; BPI B = –0.13, P = .06; MDD B = –0.036, P = .03). Male adolescents in intervention families experiencing crime victimization had worse distress (B = 0.24, P = .004), more behavior problems (B = 0.30, P < .001), and nonsignificantly higher MDD (B = 0.022, P = .16) versus controls. Other subgroups experienced no effect of MTO treatment. Instrumental variable estimates were similar but larger.

CONCLUSIONS: Girls from families experiencing recent violent crime victimization were significantly less likely to achieve mental health benefits, and boys were harmed, by MTO, suggesting need for cross-sectoral program supports to offset multiple stressors.

KEY WORDS

• mental health
• depression
• adolescent behavior
• randomized controlled trial
• housing
• public housing
• adolescent
• victimization
• urban health
• Accepted May 11, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
33. Abstract 34 of 61Article

The Joint Commission Children’s Asthma Care Quality Measures and Asthma Readmissions

BACKGROUND AND OBJECTIVES: The Joint Commission introduced 3 Children’s Asthma Care (CAC 1–3) measures to improve the quality of pediatric inpatient asthma care. Validity of the commission’s measures has not yet been demonstrated. The objectives of this quality improvement study were to examine changes in provider compliance with CAC 1–3 and associated asthma hospitalization outcomes after full implementation of an asthma care process model (CPM).

METHODS: The study included children aged 2 to 17 years who were admitted to a tertiary care children’s hospital for acute asthma between January 1, 2005, and December 31, 2010. The study was divided into 3 periods: preimplementation (January 1, 2005–December 31, 2007), implementation (January 1, 2008–March 31, 2009), and postimplementation (April 1, 2009–December 31, 2010) periods. Changes in provider compliance with CAC 1–3 and associated changes in hospitalization outcomes (length of stay, costs, PICU transfer, deaths, and asthma readmissions within 6 months) were measured. Logistic regression was used to control for age, gender, race, insurance type, and time.

RESULTS: A total of 1865 children were included. Compliance with quality measures before and after the CPM implementation was as follows: 99% versus 100%, CAC-1; 100% versus 100%, CAC-2; and 0% versus 87%, CAC-3 (P < .01). Increased compliance with CAC-3 was associated with a sustained decrease in readmissions from an average of 17% to 12% (P = .01) postimplementation. No change in other outcomes was observed.

CONCLUSIONS: Implementation of the asthma CPM was associated with improved compliance with CAC-3 and with a delayed, yet significant and sustained decrease in hospital asthma readmission rates, validating CAC-3 as a quality measure. Due to high baseline compliance, CAC-1 and CAC-2 are of questionable value as quality measures.

KEY WORDS

• asthma
• compliance
• hospitalization
• quality improvement
• quality of care
• Accepted April 27, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
34. Abstract 35 of 61Article

The Impact of a Healthy Media Use Intervention on Sleep in Preschool Children

BACKGROUND: Although observational studies have consistently reported an association between media use and child sleep problems, it is unclear whether the relationship is causal or if an intervention targeting healthy media use can improve sleep in preschool-aged children.

METHODS: We conducted a randomized controlled trial of a healthy media use intervention in families of children aged 3 to 5 years. The intervention encouraged families to replace violent or age-inappropriate media content with quality educational and prosocial content, through an initial home visit and follow-up telephone calls over 6 months. Sleep measures were derived from the Child Sleep Habits Questionnaire and were collected at 6, 12, and 18 months after baseline; repeated-measures regression analyses were used.

RESULTS: Among the 565 children analyzed, the most common sleep problem was delayed sleep-onset latency (38%). Children in the intervention group had significantly lower odds of “any sleep problem” at follow-up in the repeated-measures analysis (odds ratio = 0.36; 95% confidence interval: 0.16 to 0.83), with a trend toward a decrease in intervention effect over time (P = .07). Although there was no significant effect modification detected by baseline sleep or behavior problems, gender, or low-income status, there was a trend (P = .096) toward an increased effect among those with high levels of violence exposure at baseline.

CONCLUSIONS: The significant effects of a healthy media use intervention on child sleep problems in the context of a randomized controlled trial suggest that the previously reported relationship between media use and child sleep problems is indeed causal in nature.

KEY WORDS

• sleep
• media
• preschool-aged children
• randomized controlled trial
• violence
• Accepted May 11, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
35. Abstract 36 of 61Article

Cobedding and Recovery Time After Heel Lance in Preterm Twins: Results of a Randomized Trial

OBJECTIVES: Cobedding of preterm twin infants provides tactile, olfactory, and auditory stimulation and may affect pain reactivity. We carried out a randomized trial to assess the effect of cobedding on pain reactivity and recovery in preterm twin neonates.

METHODS: Stable preterm twins (n = 67 sets) between 28 and 36 weeks of gestational age were randomly assigned to a cobedding group (cared for in the same incubator or crib) or a standard care group (cared for in separate incubators or cribs). Pain response (determined by the Premature Infant Pain Profile [PIPP]) and time to return to physiologic baseline parameters were compared between groups with adjustment for the nonindependence of twin infants.

RESULTS: Maternal and infant characteristics were not significantly different between twin infants in the cobedding and standard care groups except for 5-minute Apgar <7 and postnatal age and corrected gestational age on the day of the heel lance. Mean PIPP scores were not different between groups at 30, 60, or 120 seconds. At 90 seconds, mean PIPP scores were higher in the cobedding group (6.0 vs 5.0, P = .04). Recovery time was shorter in the cobedding group compared with the standard care group, (mean = 75.6 seconds versus 142.1 seconds, P = .001). No significant adverse events were associated with cobedding. Adjustment for nonindependence between twins and differences in baseline characteristics did not change the results.

CONCLUSIONS: Cobedding enhanced the physiologic recovery of preterm twins undergoing heel lance, but did not lead to lower pain scores.

KEY WORDS

• cobedding
• twin
• pain
• preterm
• infant
• physiologic stability
• recovery
• Accepted April 30, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
36. Abstract 37 of 61Article

Randomized Controlled Trial of an Immunization Recall Intervention for Adolescents

OBJECTIVE: Determine if adolescent immunization rates can be improved by contacting the parents or by contacting both the parents and adolescents.

METHODS: Thirteen- to 17-year-olds overdue for at least 1 of 3 immunizations were randomized to (1) a control arm (Control), (2) telephone calls to the parent/guardian (Parent Only), or (3) telephone calls to the parent/guardian and the adolescent (Parent/Adol). Immunization records were assessed 4 weeks and 1 year after the intervention. Two-sided χ² tests and logistic regression models were used to compare receipt of immunizations by study arm.

RESULTS: The intention-to-treat analysis showed improved immunization rates at 4 weeks (adjusted odds ratio 2.27, 95% confidence interval 1.00–5.18), but not at 1 year, in the Parent/Adol group compared with controls. There was a trend toward increased immunization in the Parent Only group (odds ratio 2.02, 95% confidence interval 0.89–4.56). However, phone contact was not achieved for many parents and adolescents in the intervention groups. A post hoc analysis of the impact of actual phone contact showed significant improvement in immunization rates both 4 weeks and 1 year after the intervention among those who were reached successfully.

CONCLUSIONS: Improvement in immunization rates was seen in the short term but not the long term after contacting both the parent and adolescent. Although telephone interventions may be effective when rapid immunization is necessary, the difficulty in reaching parents and adolescents by phone highlights the importance of up-to-date contact information and a need to assess the effectiveness of alternative means of communication.

KEY WORDS

• immunization
• vaccination
• diphtheria-tetanus-acellular pertussis vaccines
• chickenpox vaccine
• meningococcal vaccines
• adolescent
• pediatrics
• humans
• reminder systems
• intervention studies
• randomized controlled trial
• Accepted May 15, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
37. Abstract 38 of 61Article

Proficiency and Retention of Neonatal Resuscitation Skills by Pediatric Residents

BACKGROUND: The basic knowledge and skill base to resuscitate a newborn infant is taught in the Neonatal Resuscitation Program (NRP). We hypothesize that caregivers will perform below current acceptable standards before the recertification period of two years.

METHODS: This is a prospective descriptive study evaluating performance of pediatric residents’ NRP knowledge and skills over time. NRP scores are used as baseline data. Follow‐up is performed before the resident's first NICU rotation. Differences in the mean scores are analyzed for degree of retention. Subset score analysis is also performed.

RESULTS: Eighty-eight subjects completed both evaluations. Knowledge scores maintained close to passing throughout the academic year. Subset evaluation revealed significant deficits within the intubation lesson. Alarming deficits were seen in skills evaluation starting at initial NRP certification with 39.1% residents having failing scores. Mean scores were below passing for every group on follow-up testing. Subgroup analysis of skills revealed deficits in the initial phases of resuscitation (lessons 1–3).

CONCLUSIONS: Deterioration of skills is seen shortly after training. It appears that knowledge is generally better retained. Discrepancies between areas of knowledge and skill deterioration indicate that proficiency in one does not necessarily indicate proficiency of the other.

• Accepted May 3, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
38. Abstract 39 of 61Review Article

The Role of Herd Immunity in Parents’ Decision to Vaccinate Children: A Systematic Review

BACKGROUND AND OBJECTIVE: Herd immunity is an important benefit of childhood immunization, but it is unknown if the concept of benefit to others influences parents’ decisions to immunize their children. Our objective was to determine if the concept of “benefit to others” has been found in the literature to influence parents’ motivation for childhood immunization.

METHODS: We systematically searched Medline through October 2010 for articles on parental/guardian decision-making regarding child immunization. Studies were included if they presented original work, elicited responses from parents/guardians of children <18 years old, and addressed vaccinating children for the benefit of others.

RESULTS: The search yielded 5876 titles; 91 articles were identified for full review. Twenty-nine studies met inclusion criteria. Seventeen studies identified benefit to others as 1 among several motivating factors for immunization by using interviews or focus groups. Nine studies included the concept of benefit to others in surveys but did not rank its relative importance. In 3 studies, the importance of benefit to others was ranked relative to other motivating factors. One to six percent of parents ranked benefit to others as their primary reason to vaccinate their children, and 37% of parents ranked benefit to others as their second most important factor in decision-making.

CONCLUSIONS: There appears to be some parental willingness to immunize children for the benefit of others, but its relative importance as a motivator is largely unknown. Further work is needed to explore this concept as a possible motivational tool for increasing childhood immunization uptake.

KEY WORDS

• altruism
• child
• decision-making
• immunization
• intention
• motivation
• social responsibility
• systematic review
• vaccines
• Accepted May 3, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
39. Abstract 40 of 61Review Article

A Systematic Review of Vocational Interventions for Young Adults With Autism Spectrum Disorders

BACKGROUND AND OBJECTIVE: Many individuals with autism spectrum disorders (ASDs) are approaching adolescence and young adulthood; interventions to assist these individuals with vocational skills are not well understood. This study systematically reviewed evidence regarding vocational interventions for individuals with ASD between the ages of 13 and 30 years.

METHODS: The Medline, PsycINFO, and ERIC databases (1980–December 2011) and reference lists of included articles were searched. Two reviewers independently assessed each study against predetermined inclusion/exclusion criteria. Two reviewers independently extracted data regarding participant and intervention characteristics, assessment techniques, and outcomes, and assigned overall quality and strength of evidence ratings based on predetermined criteria.

RESULTS: Five studies were identified; all were of poor quality and all focused on on-the-job supports as the employment/vocational intervention. Short-term studies reported that supported employment was associated with improvements in quality of life (1 study), ASD symptoms (1 study), and cognitive functioning (1 study). Three studies reported that interventions increased rates of employment for young adults with ASD.

CONCLUSIONS: Few studies have been conducted to assess vocational interventions for adolescents and young adults with ASD. As such, there is very little evidence available for specific vocational treatment approaches as individuals transition to adulthood. All studies of vocational approaches were of poor quality, which may reflect the recent emergence of this area of research. Individual studies suggest that vocational programs may increase employment success for some; however, our ability to understand the overall benefit of supported employment programs is limited given the existing research.

KEY WORDS

• autism spectrum disorders
• supported employment
• vocational training
• Accepted May 14, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
40. Abstract 41 of 61Review Article

Preterm Birth and Body Composition at Term Equivalent Age: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE: Infants born preterm are significantly lighter and shorter on reaching term equivalent age (TEA) than are those born at term, but the relation with body composition is less clear. We conducted a systematic review to assess the body composition at TEA of infants born preterm.

METHODS: The databases MEDLINE, Embase, CINAHL, HMIC, “Web of Science,” and “CSA Conference Papers Index” were searched between 1947 and June 2011, with selective citation and reference searching. Included studies had to have directly compared measures of body composition at TEA in preterm infants and infants born full-term. Data on body composition, anthropometry, and birth details were extracted from each article.

RESULTS: Eight studies (733 infants) fulfilled the inclusion criteria. Mean gestational age and weight at birth were 30.0 weeks and 1.18 kg in the preterm group and 39.6 weeks and 3.41 kg in the term group, respectively. Meta-analysis showed that the preterm infants had a greater percentage total body fat at TEA than those born full-term (mean difference, 3%; P = .03), less fat mass (mean difference, 50 g; P = .03), and much less fat-free mass (mean difference, 460 g; P < .0001).

CONCLUSIONS: The body composition at TEA of infants born preterm is different than that of infants born at term. Preterm infants have less lean tissue but more similar fat mass. There is a need to determine whether improved nutritional management can enhance lean tissue acquisition, which indicates a need for measures of body composition in addition to routine anthropometry.

KEY WORDS

• infant
• premature
• body composition
• adiposity
• leanness
• nutrition assessment
• nutrition requirements
• infant nutrition
• growth
• Accepted May 1, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
41. Abstract 42 of 61Review Article

A Systematic Review of Long-Acting β2-Agonists Versus Higher Doses of Inhaled Corticosteroids in Asthma

OBJECTIVE: To compare the efficacy of inhaled corticosteroids (ICS) plus long-acting β2 agonist (LABA) versus higher doses of ICS in children/adolescents with uncontrolled persistent asthma.

METHODS: Randomized, prospective, controlled trials published January 1996 to January 2012 with a minimum of 4 weeks of LABA+ICS versus higher doses of ICS were retrieved through Medline, Embase, Central, and manufacturer’s databases. The primary outcome was asthma exacerbations requiring systemic corticosteroids; secondary outcomes were the pulmonary function test (PEF), withdrawals during the treatment period, days without symptoms, use of rescue medication, and adverse events.

RESULTS: Nine studies (n = 1641 patients) met criteria for inclusion (7 compared LABA+ICS versus double ICS doses and 2 LABA+ICS versus higher than double ICS doses). There was no statistically significant difference in the number of patients with asthma exacerbations requiring systemic corticosteroids between children receiving LABA+ICS and those receiving higher doses of ICS (odds ratio = 0.76; 95% confidence interval: 0.48–1.22, P = .25, I² = 16%). In the subgroup analysis, patients receiving LABA+ICS showed a decreased risk of asthma exacerbations compared with higher than twice ICS doses (odds ratio = 0.48; 95% confidence interval: 0.28–0.82, P = .007, I²= 0). Children treated with LABA+ICS had significantly higher PEF, less use of rescue medication, and higher short-term growth than those on higher ICS doses. There were no other significant differences in adverse events.

CONCLUSIONS: There were no statistically significant group differences between ICS+LABA and double doses of ICS in reducing the incidence of asthma exacerbations but it did decrease the risk comparing to higher than double doses of ICS.

KEY WORDS

• asthma
• children
• adolescents
• LABA
• inhaled corticosteroids
• efficacy
• Accepted May 17, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
42. Abstract 43 of 61State-of-the-Art Review ArticleEthics Rounds

Pediatric Minimally Invasive Surgery: Laparoscopy and Thoracoscopy in Infants and Children

This article discusses the potential benefits and challenges of minimally invasive surgery for infants and small children, and discusses why pediatric minimally invasive surgery is not yet the surgical default or standard of care. Minimally invasive methods offer advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, and better clinical information. But none of these benefits comes without cost, and these costs, both monetary and risk-based, rise disproportionately with the declining size of the patient. In this review, we describe recent progress in minimally invasive surgery for infants and children. The evidence for the large benefits to the patient will be presented, as well as the considerable, sometimes surprising, mechanical and physiological challenges surgeons must manage.

KEY WORDS

• laparoscopy
• thoracoscopy
• surgery
• neonate
• Accepted April 20, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
43. Abstract 44 of 61Special ArticleEthics Rounds

45. Abstract 45 of 61Special Article

Assessment of Controversial Pediatric Asthma Management Options Using GRADE

OBJECTIVES: To develop explicit and transparent recommendations on controversial asthma management issues in children and to illustrate the usefulness of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach in rating the quality of evidence and strength of recommendations.

METHODS: Health care questions were formulated for 3 controversies in clinical practice: what is the most effective treatment in asthma not under control with standard-dose inhaled corticosteroids (ICS; step 3), the use of leukotriene receptor antagonist for viral wheeze, and the role of extra fine particle aerosols. GRADE was used to rate the quality of evidence and strength of recommendations after performing systematic literature searches. We provide evidence profiles and considerations about benefit and harm, preferences and values, and resource use, all of which played a role in formulating final recommendations.

RESULTS: By applying GRADE and focusing on outcomes that are important to patients and explicit other considerations, our recommendations differ from those in other international guidelines. We prefer to double the dose of ICS instead of adding a long-acting β-agonist in step 3; ICS instead of leukotriene receptor antagonist are the first choice in preschool wheeze, and extra fine particle ICS formulations are not first-line treatment in children with asthma. Recommendations are weak and based on low-quality evidence for critical outcomes.

CONCLUSIONS: We provide systematically and transparently developed recommendations about controversial asthma management options. Using GRADE for guideline development may change recommendations, enhance guideline implementation, and define remaining research gaps.

KEY WORDS

• guidelines
• asthma
• drug therapy
• child
• evidence-based medicine
• glucocorticoids
• leukotriene antagonists
• bronchodilator agents
• Accepted May 11, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
45. Abstract 46 of 61Commentary
46. Abstract 47 of 61Commentary
47. Abstract 48 of 61Commentary
48. Abstract 49 of 61Quality Report

Improving Newborn Screening Follow-up in Pediatric Practices: Quality Improvement Innovation Network

OBJECTIVE: To implement a 6-month quality improvement project in 15 primary care pediatric practices to improve short-term newborn screening (NBS) follow-up.

METHODS: At the start of the project, each practice completed a survey to evaluate office systems related to NBS and completed a chart audit. Practice teams were provided information about NBS and trained in quality-improvement methods, and then implemented changes to improve care. Monthly chart audits over a 6-month period were completed to assess change.

RESULTS: At baseline, almost half of practices completed assessment of infants for NBS; after 6 months, 80% of practices completed assessment of all infants. Only 2 practices documented all in-range results and shared them with parents at baseline; by completion, 10 of 15 practices documented and shared in-range results for ≥70% of infants. Use of the American College of Medical Genetics ACTion sheets, a decision support tool, increased from 1 of 15 practices at baseline to 7 of 15 at completion.

CONCLUSIONS: Practices were successful in improving NBS processes, including assessment, documentation, and communication with families. Providers perceived no increase in provider time at first visit, 2- to 4-week visit, or during first contact with the family of an infant with an out-of-range result after implementation of improved processes. Primary care practices increased their use of decision support tools after the project.

KEY WORDS

• newborn screening
• quality of health care
• Accepted April 17, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
49. Abstract 50 of 61Quality Report

Decreased Pediatric Hospital Mortality After an Intervention to Improve Emergency Care in Lilongwe, Malawi

BACKGROUND AND OBJECTIVE: Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in the developing world. This deficiency contributes to high inpatient mortality rates, particularly early during hospitalization. Our referral hospital in Lilongwe, Malawi, experiences high volume, acuity, and mortality rates. The entry point to our hospital for most children presenting with acute illness is the Under-5 Clinic. We hypothesized that early inpatient mortality and total inpatient mortality rates would decrease with an intervention to prioritize and improve pediatric emergency care at our hospital.

METHODS: We implemented the following changes as part of our intervention: (1) reallocation of senior-level clinical support from other areas of the hospital to the Under-5 Clinic for supervision of emergency care, (2) institution of a formal triage process that improved patient flow, and (3) treatment and stabilization of patients before transfer to the inpatient ward. We compared early inpatient and total inpatient mortality rates before and after the intervention.

RESULTS: After the intervention, early mortality decreased from 47.6 to 37.9 deaths per 1000 admissions (relative risk 0.80, 95% confidence interval 0.67–0.93). Total mortality also decreased from 80.5 to 70.5 deaths per 1000 admissions after the intervention (relative risk 0.88, 95% confidence interval 0.78–0.98).

CONCLUSIONS: Simple, inexpensive interventions to improve pediatric emergency care at this underresourced hospital in sub-Saharan Africa were associated with decreased hospital mortality rates. The description of this process and the associated results may influence practice and resource allocation strategies in similar clinical environments.

KEY WORDS

• triage
• pediatric emergency medicine
• emergency medicine
• international
• hospital mortality
• child health
• ETAT
• global health
• Accepted April 18, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
50. Abstract 51 of 61Case Report

Successful Treatment of Pallid Breath-Holding Spells With Fluoxetine

Pallid breath-holding (PBH) is a childhood condition that presents with recurrent syncope. Although typically benign, severe cases can lead to asystole and anoxic seizures. Previous studies have advocated pacemaker placement to abbreviate symptoms. This was a retrospective study of patients treated with fluoxetine for PBH spells. Clinical response, side effects and avoidance of pacemaker implantation were reviewed in six patients (12–60 months) treated with fluoxetine for PBH. Patients were referred because of concern of arrhythmia and failed medical treatment strategies. Two patients had previously implanted loop recorders, 5 patients had documented episodes of asystole, and 2 patients had generalized seizures. Fluoxetine resulted in alleviation of syncope in 5 of 6 patients. Time to symptomatic improvement symptoms ranged from 2 days to 1 month (median, 2 weeks). Median duration of treatment with fluoxetine was 12 months (12–24 months). One patient demonstrated no improvement and had a pacemaker implanted. There were no reported side effects to fluoxetine. Fluoxetine can be used to treat childhood PBH spells and may obviate the need for permanent pacing in a significant subset of this population. Considering its safe side-effect profile it is a worthwhile first-line agent to treat this disorder.

KEY WORDS

• syncope
• pediatrics
• pacemaker
• breath-holding
• fluoxetine
• Accepted March 26, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
51. Abstract 52 of 61Case Report

Dexmedetomidine for Transport of a Spontaneously Breathing Combative Child

Interhospital transport presents a challenge for pediatricians, and airway protection is often a significant concern. The severely agitated child without respiratory compromise poses an extremely difficult dilemma, as most sedative agents can cause respiratory depression. Intubation offers definitive control of the airway but is not without risk, especially in an environment where experience and resources for pediatric intubation may be limited. Dexmedetomidine may be used for sedation in certain circumstances for the transport of a child without the need for intubation and mechanical ventilation.

KEY WORDS

• dexmedetomidine
• interhospital
• transport
• ingestion
• altered mental status
• Accepted March 14, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
52. Abstract 53 of 61Case Report

Copper Deficiency Presenting as Metabolic Bone Disease in Extremely Low Birth Weight, Short-Gut Infants

Copper deficiency can cause bone lesions in infants, which might be confused with child abuse. Two extremely low birth weight preterm infants had complicated medical courses requiring prolonged parenteral nutrition for short-gut syndrome, which led to the development of cholestasis. Both had spent their entire lives in the hospital. They had been on prolonged ventilator support for chronic lung disease. They developed signs of copper deficiency between 5 and 6 months of age, initially raising child abuse concerns. Musculoskeletal discomfort led to the recognition of radiographic findings of metabolic bone disease. Included were osteoporosis, metaphyseal changes, and physeal disruptions. Copper levels were low; both low copper parenteral nutrition and gut losses from refeeding diarrhea likely contributed to their deficiency. Therapeutic supplementation with copper corrected their deficits and clinical and radiologic findings. The information from these cases, in particular, their radiologic findings, indicate the need to monitor copper status in at-risk premature infants. These findings may aid prevention and earlier recognition of copper deficiency. Their specific radiologic and clinical findings should aid differentiation of such children from abused infants.

KEY WORDS

• copper deficiency
• short bowel
• metabolic bone disease
• child abuse
• pediatric radiology
• Accepted March 26, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
53. Abstract 54 of 61Case Report

Unawareness of the Effects of Soy Intake on the Management of Congenital Hypothyroidism

It has been established that soy products can interfere with thyroid hormone absorption resulting in continued hypothyroidism in individuals receiving recommended levothyroxine replacement. It has also been reported that achievement of euthyroidism in hypothyroid patients using soy products requires increased doses of levothyroxine. We have observed 2 patients with congenital hypothyroidism who continued to manifest clinical hypothyroidism while receiving recommended doses of hormone and ingesting soy products. The first patient was diagnosed by newborn screening (thyroid-stimulating hormone [TSH] =169 µIU/mL) and treated with 50 µg of levothyroxine since 6 days of age while simultaneously starting soy formula. At 3 weeks of age, she was clinically and biochemically hypothyroid (thyroxine = 4.0 µg/dL, TSH = 216 µIU/mL). We stopped her soy formula and decreased her levothyroxine dose. Three weeks later signs of hypothyroidism were resolving, and, by 10 weeks of age, she was clinically and biochemically euthyroid. Another patient was diagnosed by newborn screening, received levothyroxine, and did well. She was lost to us for 2 years. During this interval she began consuming soy milk and became profoundly hypothyroid (free thyroxine <0.4 ng/dL, TSH = 248 µIU/mL), even though the primary care physician had increased her levothyroxine dose to 112 µg/day. She was switched to cow milk, and her thyroid function slowly normalized with decreasing doses of levothyroxine. These 2 patients reinforce the importance of remembering that soy products interfere with levothyroxine absorption and can endanger infants and young children with congenital hypothyroidism who are at risk for developmental and growth delay.

KEY WORDS

• thyroid disease
• levothyroxine
• soy
• Accepted March 26, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
54. Abstract 55 of 61Case Report

Intravenous Artesunate for Transfusion-Transmitted Plasmodium vivax Malaria in a Preterm Neonate

Transfusion-transmitted malaria (TTM) in neonates is rare. TTM can occur in both endemic and nonendemic areas because the current tests used to screen the donor blood for malaria are unreliable when there is low parasitemia. Malaria must be considered as an important differential diagnosis for neonatal sepsis after exchange transfusion. Management strategy in TTM in the neonatal period is not standardized; exchange transfusion is often considered. We used intravenous artesunate in a case of severe malaria caused by Plasmodium vivax in a 30-week preterm neonate after packed red blood cell transfusion on day 19 of life. This is the first clinical report of parenteral artesunate successfully used in the neonatal period. We emphasize the need for further investigation of the safety and efficacy of intravenous artesunate in the treatment of severe neonatal malaria.

KEY WORDS

• artesunate
• neonatal malaria
• transfusion-transmitted malaria
• Plasmodium vivax
• Accepted March 26, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
55. Abstract 56 of 61Case Report

Acute Poststreptococcal Glomerulonephritis: A Manifestation of Immune Reconstitution Inflammatory Syndrome

Immune reconstitution inflammatory syndrome (IRIS) is a well-described complication of initiation of highly active antiretroviral therapy in HIV-infected patients. As the immune system recovers, an inappropriate inflammatory response often occurs that causes significant disease. It is most commonly seen in patients naïve to therapy with CD4+ T-lymphocyte counts <100 cells/cmm and usually presents as a flare of mycobacterial, cytomegalovirus, or herpes zoster infections. Less commonly, this syndrome occurs in response to noninfectious triggers and results in autoimmune or malignant disease. Here we present the first case of acute poststreptococcal glomerulonephritis associated with varicella zoster virus and IRIS in an adolescent with perinatally acquired HIV and hepatitis C virus infections. Our patient was not naïve to therapy but was starting a new regimen of therapy because of virologic failure and had a relatively high CD4+ T-lymphocyte count. This case report indicates that IRIS remains a concern after initiation of a new highly active antiretroviral therapy regimen in HIV-infected patients with high viral loads, even in the presence of CD4+ T-lymphocyte counts >100 cells/cmm. It may present as infectious, malignant, or autoimmune conditions including poststreptococcal glomerulonephritis.

KEY WORDS

• immune reconstitution inflammatory syndrome
• glomerulonephritis
• HIV
• Streptococcus
• varicella
• Accepted March 14, 2012.
• Copyright © 2012 by the American Academy of Pediatrics
56. Abstract 57 of 61From the American Academy of PediatricsClinical Practice Guideline

Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

OBJECTIVES: This revised clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of the obstructive sleep apnea syndrome (OSAS) in children and adolescents. This practice guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting.

METHODS: Of 3166 articles from 1999–2010, 350 provided relevant data. Most articles were level II–IV. The resulting evidence report was used to formulate recommendations.

RESULTS AND CONCLUSIONS: The following recommendations are made. (1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered. (3) Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy. (4) High-risk patients should be monitored as inpatients postoperatively. (5) Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy. (6) Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively. (7) Weight loss is recommended in addition to other therapy in patients who are overweight or obese. (8) Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.

KEY WORDS

• snoring
• sleep-disordered breathing
• adenotonsillectomy
• continuous positive airway pressure
• Copyright © 2012 by the American Academy of Pediatrics
57. Abstract 58 of 61From the American Academy of PediatricsPolicy Statement

Circumcision Policy Statement

Male circumcision is a common procedure, generally performed during the newborn period in the United States. In 2007, the American Academy of Pediatrics (AAP) formed a multidisciplinary task force of AAP members and other stakeholders to evaluate the recent evidence on male circumcision and update the Academy’s 1999 recommendations in this area. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. The American College of Obstetricians and Gynecologists has endorsed this statement.

KEY WORDS

• male circumcision
• penis
• prepuce
• phimosis
• sexually transmitted infections
• HIV
• urinary tract infection
• analgesia
• parental decision-making
• ethics
• Copyright © 2012 by the American Academy of Pediatrics
58. Abstract 59 of 61From the American Academy of PediatricsPolicy Statement

Levels of Neonatal Care

Provision of risk-appropriate care for newborn infants and mothers was first proposed in 1976. This updated policy statement provides a review of data supporting evidence for a tiered provision of care and reaffirms the need for uniform, nationally applicable definitions and consistent standards of service for public health to improve neonatal outcomes. Facilities that provide hospital care for newborn infants should be classified on the basis of functional capabilities, and these facilities should be organized within a regionalized system of perinatal care.

KEY WORDS

• neonatal intensive care
• high-risk infant
• regionalization
• maternal and child health
• health policy
• very low birth weight infant
• hospital newborn care services
• nurseries
• Copyright © 2012 by the American Academy of Pediatrics
59. Abstract 60 of 61From the American Academy of PediatricsTechnical Report

Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

OBJECTIVE: This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS).

METHODS: The literature from 1999 through 2011 was evaluated.

RESULTS AND CONCLUSIONS: A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.

KEY WORDS

• adenotonsillectomy
• continuous positive airway pressure
• sleep-disordered breathing
• snoring
• Copyright © 2012 by the American Academy of Pediatrics
60. Abstract 61 of 61From the American Academy of PediatricsTechnical Report

Male Circumcision

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP’s 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association’s template for evidence evaluation.

Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers.

Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners’ competency in discussing circumcision’s benefits and risks with parents.

The Task Force made the following recommendations:

• Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.
• Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.
• Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.
• Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.
• Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.
• Elective circumcision should be performed only if the infant’s condition is stable and healthy.
• Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.
• Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.
  • Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.
  • If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.
• Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:
  • Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;
  • Teach the procedure and analgesic techniques during postgraduate training programs;
  • Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;
  • Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.
• The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.

The American College of Obstetricians and Gynecologists has endorsed this technical report.

KEY WORDS

• circumcision
• Copyright © 2012 by the American Academy of Pediatrics