March 2012, VOLUME 129 / ISSUE 3 - مركز مديريت دانش بيماريهاي كودكان

پنجشنبه 4 بهمن 1403 - 22 رجب 1446

English | فارسی

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شما اینجا هستید صفحه اصلیMarch 2012, VOLUME 129 / ISSUE 3

مطالی آموزشی

March 2012, VOLUME 129 / ISSUE 3

· Abstract 1 of 67Pediatrics Digest

· Abstract 2 of 67Pediatrics Perspective

· Abstract 3 of 67Article

Changing Epidemiology of Bacteremia in Infants Aged 1 Week to 3 Months

BACKGROUND Bacteremia in young infants has remained an important ongoing concern for decades. Despite changes in prenatal screening and infant immunizations, the current epidemiology of this problem has received little attention.

METHODS: We conducted a retrospective analysis of all blood cultures collected at Kaiser Permanente Northern California on full-term, previously healthy infants presenting for care between 1 week to 3 months of age for whom a blood culture was drawn from January 1, 2005, through December 31, 2009.

RESULTS: During the study period, 4255 blood cultures were collected from 160 818 full-term infants. Only 2% of all blood cultures were positive for pathogens (93/4255), whereas 247 positive cultures were due to contaminants. The incidence rate of true bacteremia was 0.57 in 1000 full-term births. The most common pathogen was Escherichia coli (56%). Ninety-eight percent of infants with E coli bacteremia had a urinary tract infection. Group B Streptococcus and Staphylococcus aureus were the second and third most common pathogens, respectively. There were no cases of Listeria monocytogenes bacteremia or meningococcemia and only 1 case of enterococcal bacteremia. Ampicillin resistant pathogens accounted for 36% of organisms.

CONCLUSIONS: Our study indicates bacteremia in young infants occurs infrequently and in only 2.2% of those who had a blood culture drawn. On the basis of the epidemiology of pathogens found in this large cohort, these data suggest a change in currently recommended presumptive antibiotic coverage in 1-week to 3-month-old infants with suspected bacteremia.

KEY WORDS

bacteremia
infant
antibiotic resistance
group B Streptococcus
Escherichia coli

Accepted November 18, 2011.

· Abstract 4 of 67Article

Impact of a Guideline on Management of Children Hospitalized With Community-Acquired Pneumonia

OBJECTIVES: We sought to describe the impact a clinical practice guideline (CPG) had on antibiotic management of children hospitalized with community-acquired pneumonia (CAP).

PATIENTS AND METHODS: We conducted a retrospective study of discharged patients from a children’s hospital with an ICD-9-CM code for pneumonia (480–486). Eligible patients were admitted from July 8, 2007, through July 9, 2009, 12 months before and after the CAP CPG was introduced. Three-stage least squares regression analyses were performed to examine hypothesized simultaneous relationships, including the impact of our institution\x{2019}s antimicrobial stewardship program (ASP).

RESULTS: The final analysis included 1033 patients: 530 (51%) before the CPG (pre-CPG) and 503 (49%) after the CPG (post-CPG). Pre-CPG, ceftriaxone (72%) was the most commonly prescribed antibiotic, followed by ampicillin (13%). Post-CPG, the most common antibiotic was ampicillin (63%). The effect of the CPG was associated with a 34% increase in ampicillin use (P < .001). Discharge antibiotics also changed post-CPG, showing a significant increase in amoxicillin use (P < .001) and a significant decrease in cefdinir and amoxicillin/clavulanate (P < .001), with the combined effect of the CPG and ASP leading to 12% (P < 0.001) and 16% (P < .001) reduction, respectively. Overall, treatment failure was infrequent (1.5% vs 1%).

CONCLUSIONS: A CPG and ASP led to the increase in use of ampicillin for children hospitalized with CAP. In addition, less broad-spectrum discharge antibiotics were used. Patient adverse outcomes were low, indicating that ampicillin is appropriate first-line therapy for otherwise healthy children admitted with uncomplicated CAP.

KEY WORDS

clinical practice guideline
community-acquired pneumonia
pediatric

Accepted November 17, 2011.

· Abstract 5 of 67Article

Discharged on Supplemental Oxygen From an Emergency Department in Patients With Bronchiolitis

BACKGROUND AND OBJECTIVE: Bronchiolitis is the most common reason for hospital admission in patients aged <1 year. Admissions have been increasing with hypoxia frequently cited as the determinant. Home oxygen (O₂) has been shown to be feasible, although safety data are lacking. The objective of this study was to evaluate the impact of a home O₂ clinical care protocol on admission rates in patients with bronchiolitis from the pediatric emergency department.

METHODS: We performed a retrospective chart review of patients with bronchiolitis who presented to a children’s hospital pediatric emergency department (altitude 1600 m) between 2005 and 2009. Patients between the ages of 1 and 18 months were included in the analysis. Patients requiring baseline O₂ were excluded. We calculated the percentage of patients discharged on O₂ and their readmission rates. We reviewed charts of patients who were admitted after home O₂ for adverse outcomes. We also compared rates of admission before and after initiation of the protocol.

RESULTS: In this study, 4194 illnesses were analyzed; 2383 (57%) were discharged on room air, 649 (15%) were discharged on O₂, and 1162 (28%) were admitted. Of those discharged on room air, 4% were subsequently admitted, and 6% of those discharged on O₂ were admitted. There were no ICU admissions or need for advanced airway management in those patients discharged on O₂. Our overall admission rates for bronchiolitis dropped from a rate of 40% to 31%.

CONCLUSIONS: Home O₂ is an effective way to decrease hospital admissions in a select group of patients with bronchiolitis.

KEY WORDS

bronchiolitis
oxygen
emergency department

Accepted November 2, 2011.

· Abstract 6 of 67Article

A Primary Care–Based, Multicomponent Lifestyle Intervention for Overweight Adolescent Females

BACKGROUND AND OBJECTIVE: Most clinic-based weight control treatments for youth have been designed for preadolescent children by using family-based care. However, as adolescents become more autonomous and less motivated by parental influence, this strategy may be less appropriate. This study evaluated a primary care–based, multicomponent lifestyle intervention specifically tailored for overweight adolescent females.

METHODS: Adolescent girls (N = 208) 12 to 17 years of age (mean ± SD: 14.1 ± 1.4 years), with a mean ± SD BMI percentile of 97.09 ± 2.27, were assigned randomly to the intervention or usual care control group. The gender and developmentally tailored intervention included a focus on adoptable healthy lifestyle behaviors and was reinforced by ongoing feedback from the teen’s primary care physician. Of those randomized, 195 (94%) completed the 6-month posttreatment assessment, and 173 (83%) completed the 12-month follow-up. The primary outcome was reduction in BMI z score.

RESULTS: The decrease in BMI z score over time was significantly greater for intervention participants compared with usual care participants (−0.15 in BMI z score among intervention participants compared with −0.08 among usual care participants; P = .012). The 2 groups did not differ in secondary metabolic or psychosocial outcomes. Compared with usual care, intervention participants reported less reduction in frequency of family meals and less fast-food intake.

CONCLUSIONS: A 5-month, medium-intensity, primary care–based, multicomponent behavioral intervention was associated with significant and sustained decreases in BMI z scores among obese adolescent girls compared with those receiving usual care.

KEY WORDS

adolescent obesity
behavioral intervention
primary care
randomized controlled trial
weight management

Accepted November 9, 2011.

· Abstract 7 of 67Article

Early Childhood Family Intervention and Long-term Obesity Prevention Among High-risk Minority Youth

OBJECTIVES: To test the hypothesis that family intervention to promote effective parenting in early childhood affects obesity in preadolescence.

METHODS: Participants were 186 minority youth at risk for behavior problems who enrolled in long-term follow-up studies after random assignment to family intervention or control condition at age 4. Follow-up Study 1 included 40 girls at familial risk for behavior problems; Follow-up Study 2 included 146 boys and girls at risk for behavior problems based on teacher ratings. Family intervention aimed to promote effective parenting and prevent behavior problems during early childhood; it did not focus on physical health. BMI and health behaviors were measured an average of 5 years after intervention in Study 1 and 3 years after intervention in Study 2.

RESULTS: Youth randomized to intervention had significantly lower BMI at follow-up relative to controls (Study 1 P = .05; Study 2 P = .006). Clinical impact is evidenced by lower rates of obesity (BMI ≥95th percentile) among intervention girls and boys relative to controls (Study 2: 24% vs 54%, P = .002). There were significant intervention-control group differences on physical and sedentary activity, blood pressure, and diet.

CONCLUSIONS: Two long-term follow-up studies of randomized trials show that relative to controls, youth at risk for behavior problems who received family intervention at age 4 had lower BMI and improved health behaviors as they approached adolescence. Efforts to promote effective parenting and prevent behavior problems early in life may contribute to the reduction of obesity and health disparities.

KEY WORDS

obesity
prevention
child
early childhood
families

Accepted November 3, 2011.

· Abstract 8 of 67Article

Prevalence of Autism Spectrum Disorders in Hispanic and Non-Hispanic White Children

OBJECTIVE: The number of individuals diagnosed with autism spectrum disorders (ASDs) continues to increase in the United States and other developed countries; however, ASD is diagnosed less commonly in Hispanic than in non-Hispanic white individuals. This report analyzes differences in ASD prevalence between Hispanic and non-Hispanic whites in a large, population-based sample of 8-year-old children, and explores how prevalence has changed over time.

METHODS: Population-based surveillance of ASD was conducted on 142 717 8-year-old children. Evaluation of clinical and educational records resulted in 1212 children meeting the case definition criteria in 4 study years between 2000 and 2006.

RESULTS: ASD prevalence in Hispanic children was lower than in non-Hispanic white children (P < .005) for all study years. More Hispanic than non-Hispanic white children met the case definition for intellectual disability (P < .05) in study years 2004 and 2006. Prevalence of ASD diagnosis increased in both groups; the Hispanic prevalence almost tripled, from 2.7 per 1000 in 2000 to 7.9 per 1000 in 2006. A comparison of prevalence ratios found that Hispanic and non-Hispanic white ASD prevalence became significantly more similar from 2000 to 2006 (χ² = 124.89, P < .001).

CONCLUSIONS: The ASD prevalence for Hispanic individuals in this population-based sample is substantially higher than previously reported. Nonetheless, Hispanic children continue to have a significantly lower ASD prevalence in comparison with non-Hispanic whites. The prevalence of ASD is increasing in both populations, and results indicate that the gap in prevalence between groups is decreasing.

KEY WORDS

autism spectrum disorder
prevalence
Hispanic
surveillance

Accepted November 17, 2011.

· Abstract 9 of 67Article

Impact of an Active Video Game on Healthy Children’s Physical Activity

OBJECTIVE: This naturalistic study tests whether children receiving a new (to them) active video game spontaneously engage in more physical activity than those receiving an inactive video game, and whether the effect would be greater among children in unsafe neighborhoods, who might not be allowed to play outside.

METHODS: Participants were children 9 to 12 years of age, with a BMI >50th percentile, but <99th percentile; none of these children a medical condition that would preclude physical activity or playing video games. A randomized clinical trial assigned children to receiving 2 active or 2 inactive video games, the peripherals necessary to run the games, and a Wii console. Physical activity was monitored by using accelerometers for 5 weeks over the course of a 13-week experiment. Neighborhood safety was assessed with a 12 item validated questionnaire.

RESULTS: There was no evidence that children receiving the active video games were more active in general, or at anytime, than children receiving the inactive video games. The outcomes were not moderated by parent perceived neighborhood safety, child BMI z score, or other demographic characteristics.

CONCLUSIONS: These results provide no reason to believe that simply acquiring an active video game under naturalistic circumstances provides a public health benefit to children.

KEY WORDS

exergames
Wii

Accepted November 9, 2011.

· Abstract 10 of 67Article

Self-Referral and Serious Illness in Children With Fever

OBJECTIVE: The goal of this study was to evaluate parents’ capability to assess their febrile child’s severity of illness and decision to present to the emergency department. We compared children referred by a general practitioner (GP) with those self-referred on the basis of illness-severity markers.

METHODS: This was a cross-sectional observational study conducted at the emergency departments of a university and a teaching hospital. GP-referred or self-referred children with fever (aged <16 years) who presented to the emergency department (2006–2008) were included. Markers for severity of illness were urgency according to the Manchester Triage System, diagnostic interventions, therapeutic interventions, and follow-up. Associations between markers and referral type were assessed by using logistic regression analysis. Subgroup analyses were performed for patients with the most common presenting problems that accompanied the fever (ie, dyspnea, gastrointestinal complaints, neurologic symptoms, fever without specific symptoms).

RESULTS: Thirty-eight percent of 4609 children were referred by their GP and 62% were self-referred. GP-referred children were classified as high urgency (immediate/very urgent categories) in 46% of the cases and self-referrals in 45%. Forty-three percent of GP referrals versus 27% of self-referrals needed extensive diagnostic intervention, intravenous medication/aerosol treatment, hospitalization, or a combination of these (odds ratio: 2.0 [95% confidence interval: 1.75–2.27]). In all subgroups, high urgency was not associated with referral type. GP-referred and self-referred children with dyspnea had similar frequencies of illness-severity markers.

CONCLUSIONS: Although febrile self-referred children were less severely ill than GP-referred children, many parents properly judged and acted on the severity of their child’s illness. To avoid delayed or missed diagnoses, recommendations regarding interventions that would discourage self-referral to the emergency department should be reconsidered.

KEY WORDS

emergency medical services
general practitioners
referral and consultation, illness severity, triage, resource utilization, fever, hospitalization

Accepted November 18, 2011.

· Abstract 11 of 67Article

Nicotine Replacement Therapy During Pregnancy and Infantile Colic in the Offspring

OBJECTIVE: To investigate the associations between use of nicotine replacement therapy (NRT) and smoking during pregnancy and infantile colic in the offspring.

METHODS: We used data from maternal interviews (from pregnancy and at 6 months post partum) from the Danish National Birth Cohort (1996–2002). We included 63 128 live-born singletons with complete information on nicotine exposure during pregnancy and infantile colic symptoms as recorded at 6 months of age.

RESULTS: A total of 46 660 infants (73.9%) were unexposed to nicotine during pregnancy; 207 (0.3%) were exposed to NRT, 15 016 (23.8%) were exposed to smoking, and 1245 (2.0%) to both. A total of 4974 (7.9%) infants fulfilled Wessel’s modified criteria for infantile colic. Prenatal nicotine exposure was associated with elevated risk for infantile colic in the offspring. Compared with the unexposed, NRT users had an adjusted odds ratio (OR) (95% confidence interval) of 1.6 (1.0–2.5; P = .03), smokers had OR = 1.3 (1.2–1.4), and women who both smoked and used NRT had OR = 1.6 (1.3–1.9). Partners’ smoking was not associated with infantile colic after adjustment for maternal smoking.

CONCLUSIONS: We corroborated the association between smoking and infantile colic after adjustment for several possible confounders in a large cohort study. Moreover, we found that infants exposed to NRT prenatally had an increased risk for infantile colic of the same magnitude as those exposed to tobacco smoke. Thus, nicotine may play a role in the pathogenesis of infantile colic.

KEY WORDS

infantile colic
smoking
nicotine replacement therapy

Accepted November 15, 2011.

· Abstract 12 of 67Article

The Effect of Simulated Ostracism on Physical Activity Behavior in Children

OBJECTIVES: To assess the effects of simulated ostracism on children’s physical activity behavior, time allocated to sedentary behavior, and liking of physical activity.

METHODS: Nineteen children (11 boys, 8 girls; age 11.7 ± 1.3 years) completed 2 experimental sessions. During each session, children played a virtual ball-toss computer game (Cyberball). In one session, children played Cyberball and experienced ostracism; in the other session, they were exposed to the inclusion/control condition. The order of conditions was randomized. After playing Cyberball, children were taken to a gymnasium where they had free-choice access to physical and sedentary activities for 30 minutes. Children could participate in the activities, in any pattern they chose, for the entire period. Physical activity during the free-choice period was assessed via accelerometery and sedentary time via observation. Finally, children reported their liking for the activity session via a visual analog scale.

RESULTS: Children accumulated 22% fewer (P < .01) accelerometer counts and 41% more (P < .04) minutes of sedentary activity in the ostracized condition (8.9^e+4 ± 4.5^e+4 counts, 11.1 ± 9.3 minutes) relative to the included condition (10.8^e+4 ± 4.7^e+4 counts, 7.9 ± 7.9 minutes). Liking (8.8 ± 1.5 cm included, 8.1 ± 1.9 cm ostracized) of the activity sessions was not significantly different (P > .10) between conditions.

CONCLUSIONS: Simulated ostracism elicits decreased subsequent physical activity participation in children. Ostracism may contribute to children’s lack of physical activity.

KEY WORDS

ostracism
children
peer
physical activity

Accepted October 27, 2011.

· Abstract 13 of 67Article

Hemodynamic Effects of Delayed Cord Clamping in Premature Infants

BACKGROUND AND OBJECTIVE: Delayed cord clamping (DCC) has been advocated during preterm delivery to improve hemodynamic stability during the early neonatal period. The hemodynamic effects of DCC in premature infants after birth have not been previously examined. Our objective was to compare the hemodynamic differences between premature infants randomized to either DCC or immediate cord clamping (ICC).

METHODS: This prospective study was conducted on a subset of infants who were enrolled in a randomized controlled trial to evaluate the effects of DCC versus ICC. Entry criteria included gestational ages of 24⁰ to 31⁶ weeks. Twins and infants of mothers with substance abuse were excluded. Serial Doppler studies were performed at 6 ± 2, 24 ± 4, 48 ± 6, and 108 ± 12 hours of life. Measurements included superior vena cava blood flow, right ventricle output, middle cerebral artery blood flow velocity (BFV), superior mesenteric artery BFV, left ventricle shortening fraction, and presence of a persistent ductus arteriosus.

RESULTS: Twenty-five infants were enrolled in the DCC group and 26 in the ICC group. Gestational age, birth weight, and male gender were similar. Admission laboratory and clinical events were also similar. DCC resulted in significantly higher superior vena cava blood flow over the study period, as well as greater right ventricle output and right ventricular stroke volumes at 48 hours. No differences were noted in middle cerebral artery BFV, mean superior mesenteric artery BFV, shortening fraction, or the incidence of a persistent ductus arteriosus.

CONCLUSIONS: DCC in premature infants is associated with potentially beneficial hemodynamic changes over the first days of life.

KEY WORDS

delayed cord clamping
premature infants

Accepted October 27, 2011.

· Abstract 14 of 67Article

Bed- and Sofa-Sharing Practices in a UK Biethnic Population

OBJECTIVE: To describe the prevalence and associations of bed- and sofa-sharing in a biethnic UK birth cohort.

METHODS: We surveyed 3082 participants in the Born in Bradford birth cohort study by using a telephone interview when infants were aged 2 to 4 months. We asked families about sleep surface sharing behaviors, and other sudden unexpected death in infancy (SUDI)-related behaviors.

RESULTS: There were 15.5% of families that had ever bed-shared, 7.2% of families regularly bed-shared, and 9.4% of families had ever sofa-shared with their infants; 1.4% reported both. Regular bed-sharers were more commonly Pakistani (adjusted odds ratio [aOR] = 3.02, 95% confidence interval [CI] 1.96–4.66), had further or higher educational qualifications (aOR = 1.62, 95% CI 1.03–2.57), or breastfed for at least 8 weeks (aOR = 3.06, 95% CI 2.00–4.66). The association between breastfeeding and bed-sharing was greater among white British than Pakistani families. Sofa-sharing occurred in association with smoking (aOR = 1.79, 95% CI 1.14–2.80) and breastfeeding for more than 8 weeks (aOR = 1.76, 95% CI 1.19–2.58), and was less likely in Pakistani families (aOR = 0.21, 95% CI 0.14–0.31), or single-parent families (aOR = 0.50, 95% CI 0.29–0.87).

CONCLUSIONS: The data confirm that bed-sharing and sofa-sharing are distinct practices, which should not be combined in studies of unexpected infant deaths as a single exposure. The determinants of sleep-surface sharing differ between the UK Pakistani and UK majority communities, and from those of US minority communities. Caution is needed in generalizing SUDI/SIDS risk factors across populations with differing risk factor profiles, and care should be taken in adopting SUDI/SIDS reduction guidelines from other contexts.

KEY WORDS

bed-sharing
sofa-sharing
SIDS
infant care
Bradford Infant Care Study
breastfeeding
infant sleep
Born in Bradford (BiB)

Accepted November 11, 2011.

· Abstract 15 of 67Article

Prospective Analysis of Pulmonary Hypertension in Extremely Low Birth Weight Infants

OBJECTIVES: Pulmonary hypertension is associated with bronchopulmonary dysplasia in extremely low birth weight (ELBW) infants and contributes to morbidity and mortality. The objective was to determine the prevalence of pulmonary hypertension among ELBW infants by screening echocardiography and evaluate subsequent outcomes.

METHODS: All ELBW infants admitted to a regional perinatal center were evaluated for pulmonary hypertension with echocardiography at 4 weeks of age and subsequently if clinical signs suggestive of right-sided heart failure or severe lung disease were evident. Management was at discretion of the clinician, and infants were evaluated until discharge from the hospital or pre-discharge death occurred.

RESULTS: One hundred forty-five ELBW infants (birth weight: 755 ± 144 g; median gestational age: 26 weeks [interquartile range: 24–27]) were screened from December 2008 to February 2011. Overall, 26 (17.9%) were diagnosed with pulmonary hypertension at any time during hospitalization (birth weight: 665 ± 140 g; median gestational age: 26 weeks [interquartile range: 24–27]): 9 (6.2%) by initial screening (early pulmonary hypertension) and 17 (11.7%) who were identified later (late pulmonary hypertension). Infants with pulmonary hypertension were more likely to receive oxygen treatment on day 28 compared with those without pulmonary hypertension (96% vs 75%, P < .05). Of the 26 infants, 3 died (all in the late group because of cor pulmonale) before being discharged from the hospital.

CONCLUSIONS: Pulmonary hypertension is relatively common, affecting at least 1 in 6 ELBW infants, and persists to discharge in most survivors. Routine screening of ELBW infants with echocardiography at 4 weeks of age identifies only one-third of the infants diagnosed with pulmonary hypertension. Further research is required to determine optimal detection and intervention strategies.

KEY WORDS

premature infant
bronchopulmonary dysplasia
pulmonary hypertension

Accepted October 27, 2011.

· Abstract 16 of 67Article

Trends in Computed Tomography Utilization in the Pediatric Emergency Department

OBJECTIVE: The purpose of this study was to determine the overall trend of computed tomography (CT) utilization in the pediatric emergency department (PED) from 2003 to 2010 and to determine trends categorized by common chief complaints.

METHODS: Electronic chart records at 2 tertiary care PEDs within a large pediatric health care system were reviewed from January 2003 through December 2010. The annual CT utilization rate, by anatomic location, was determined. Annual CT utilization rates were compared with alternative imaging trends for visits with chief complaints of head injury, seizure, and abdominal pain. Analysis was performed with linear regression.

RESULTS: There was no change in overall CT utilization from 2003 to 2010 (β 0.25, 95% confidence interval [CI] [−1.61 to 2.73]) or within anatomic subgroups. Head CT utilization for the chief complaints of seizure (β −0.97, 95% CI [−1.44 to −0.90]) and head injury (β −0.93, 95% CI [−1.71 to −0.73]) showed significant declines. Although there was no change in the abdominal CT utilization rate for abdominal pain, abdominal ultrasound utilization for abdominal pain significantly increased (β 0.89, 95% CI [0.25–0.79]).

CONCLUSIONS: Our data showed no overall increase in CT utilization through 2010. In areas where alternative non–radiation-based modalities were options, there were decreased CT trends and increased use of potential alternative non–radiation-based modalities. This is the first large PED cohort study to show a decrease in CT utilization in recent years in a regional pediatric referral center and may correlate with increased awareness of radiation risk in children.

KEY WORDS

emergency department
emergency medicine
computed tomography
radiation reduction in children

Accepted October 28, 2011.

· Abstract 17 of 67Article

Impaired Fetal Growth and Arterial Wall Thickening: A Randomized Trial of Omega-3 Supplementation

OBJECTIVES: Impaired fetal growth is an independent cardiovascular risk factor and is associated with arterial wall thickening in children. No preventive strategy has been identified. We sought to determine whether dietary omega-3 fatty acid supplementation during early childhood prevents the association between impaired fetal growth and carotid arterial wall thickening.

METHODS: The Childhood Asthma Prevention Study was a randomized, controlled single-blind trial in 616 children born at term, recruited antenatally from maternity hospitals in Sydney. Participants were randomized to either a 500-mg-daily fish oil supplement and canola-based margarines and cooking oil (omega-3 group), or a 500-mg-daily sunflower oil supplement and omega-6 fatty acid–rich margarines and cooking oil (control group), from the start of bottle-feeding or 6 months of age until 5 years of age. Carotid intima-media thickness (IMT), a noninvasive measure of subclinical atherosclerosis, was the primary endpoint of a cardiovascular substudy (CardioCAPS) at age 8 years. We examined the association of fetal growth with carotid IMT in children with birth weight <90th percentile (omega-3 group [n = 187], control group [n = 176]).

RESULTS: In the control group, fetal growth was inversely associated with carotid IMT, but this was prevented in the omega-3 group (difference between groups of 0.041 mm [95% confidence interval 0.006, 0.075] per kg birth weight, adjusted for gestational age and gender, P_{heterogeneity} = .02).

CONCLUSIONS: The inverse association of fetal growth with arterial wall thickness in childhood can be prevented by dietary omega-3 fatty acid supplementation over the first 5 years of life.

KEY WORDS

fetal growth
atherosclerosis
omega-3
dietary supplementation

Accepted November 18, 2011.

· Abstract 18 of 67Article

Effect of Repeated Dietary Counseling on Serum Lipoproteins From Infancy to Adulthood

BACKGROUND AND OBJECTIVE: As atherosclerosis is a lifelong process, prevention of exposure to its risk factors should start at an early age. Our aim was to study the influences of repeated low saturated fat dietary counseling on dietary intakes and lipoprotein measures from infancy to adulthood.

METHODS: Dietary intakes (food records) and serum lipid profile were studied annually from 7 months to 19 years of age in an atherosclerosis prevention study (Special Turku Coronary Risk Factor Intervention Project), comprising 540 children in the intervention group and 522 children in the control group. Serum total and high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were measured and used to estimate very low-density lipoprotein–TG, intermediate-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and HDL₂-C, as well as apolipoproteins A-1 and B.

RESULTS: Compared with controls, the intervention children had a lower saturated fat intake (mean daily difference [95% confidence interval] between groups: −2.1 [−2.3, −1.9] percentage of total energy intake in boys; −1.9 [−2.1, −1.7] percentage of total energy intake in girls, both P < .001) and LDL-C concentration (difference [95% confidence interval] between groups: −0.18 [−0.26, −0.10] mmol/L, P < .001 in boys; −0.10 [−0.19, −0.01] mmol/L, P = .037 in girls), whereas HDL-C and apolipoprotein A-1 did not differ between the study groups. In boys, total cholesterol and intermediate-density lipoprotein cholesterol, very low-density lipoprotein–TG, apolipoprotein B, and TG concentrations were also lower in the intervention than in the control group, whereas no differences were found in girls.

CONCLUSIONS: Repeated dietary counseling is effective in decreasing saturated fat intake and serum LDL-C values from infancy until 19 years of age in both genders. In boys, significant intervention effects are evident in various lipoprotein measures, indicating a more favorable lipid profile in the counseling group.

KEY WORDS

cholesterol
lipoprotein
nutrition
pediatrics
prevention

Accepted October 28, 2011.

· Abstract 19 of 67Article

Functional Difficulties and Health Conditions Among Children With Special Health Needs

OBJECTIVES: To describe the functional difficulties of children with special health needs and to demonstrate the shared and unique contributions in predicting health outcomes and informing therapeutic interventions, policies, and research by using data from the 2005–2006 National Survey of Children With Special Health Care Needs.

RESULTS: Children with special health care needs experience an array of health conditions and functional difficulties that are interrelated. Although health conditions tend not to change, the characteristics of functional difficulties are subject to changes over time with age or as a result of interventions. Descriptive data highlight common functional difficulties across health conditions. Multiple regression analyses support both health conditions and functional difficulties predicting (1) health services, such as emergency department visits, (2) personal limitations such as impairment of daily activities and school absences, and (3) family impact, stopping or reducing work. Functional difficulties were, however, the stronger predictor for all outcomes except school absences.

CONCLUSIONS: The results support the utility of expanding measures of children with special health care needs to include functional difficulties in survey research, as well as clinical and public health practice. Systematic inclusion of functional difficulties will inform policy development, program planning, outcome assessment, and resource allocation for this vulnerable population. A focus on functional difficulties facilitates stronger coordination of services across sectors including physical health, mental health, education, and other social services to improve the health and well-being for these children and youth.

KEY WORDS

children
health condition
functioning
disability
special health care needs

Accepted November 15, 2011.

· Abstract 20 of 67Article

The Population Cost-effectiveness of Interventions Designed to Prevent Childhood Depression

BACKGROUND AND OBJECTIVES: Depression in childhood and adolescence is common and often persists into adulthood. This study assessed the population-level cost-effectiveness of a preventive intervention that screens children and adolescents for symptoms of depression in schools and the subsequent provision of a psychological intervention to those showing elevated signs of depression. The target population for screening comprised 11- to 17-year-old children and adolescents in the 2003 Australian population.

METHODS: Economic modeling techniques were used to assess the incremental cost-effectiveness of the intervention compared with no intervention. The perspective was that of the health sector, and outcomes were measured by using disability-adjusted life-years (DALYs). Multivariate probabilistic and univariate sensitivity testing was applied to quantify variations in the model parameters.

RESULTS: The modeled psychological intervention had an incremental cost-effectiveness ratio of $5400 per DALY averted, with just 2% of iterations falling above a $50 000 per DALY value-for-money threshold. Results were robust to model assumptions.

CONCLUSIONS: After school screening, screening and the psychological intervention represent good value-for-money. Such an intervention needs to be seriously considered in any national package of preventive health services. Acceptability issues, particularly to intervention providers, including schools and mental health professionals, need to be considered before wide-scale adoption.

KEY WORDS

childhood depression
prevention
economic evaluation
cost-effectiveness

Accepted October 31, 2011.

· Abstract 21 of 67Article

Morbidity and Mortality of Neonatal Respiratory Failure in China: Surfactant Treatment in Very Immature Infants

OBJECTIVES: We retrospectively investigated incidence, morbidity, and mortality of neonatal respiratory failure (NRF) in China, with special emphasis on surfactant treated very immature infants.

METHODS: NRF was defined as respiratory hypoxemia requiring mechanical ventilation and/or nasal continuous positive airway pressure for at least 24 hours.

RESULTS: There were 6864 cases of NRF, composing 19.7% of total admissions to 55 NICUs in 2008. Of these cases, 62.8% were preterm, and 16.4% of very low birth weight (VLBW, <1500 g). The primary diseases were respiratory distress syndrome (RDS, 43.9%), pneumonia/sepsis (21.7%), transient respiratory insufficiency (14.7%), transient tachypnea (8.1%), and meconium aspiration syndrome (7.0%). Surfactant was given to 26.8% of infants with NRF and 54.8% infants with RDS. The survival rate of surfactant-treated RDS was 79.9% compared to 71.8% in those not receiving surfactant (P < .001). This was also true in those of VLBW, 59.8% vs 52.2% (P = .035), respectively. The overall survival rate in NRF cases was 75.3%, but it was 58.1% among VLBW infants; for those infants of 25, 26, and 27 to 28 weeks’ gestational age, the survival rates were ∼6%, 30%, and 50%, respectively; and the survival rates for infants with meconium aspiration syndrome and pneumonia/sepsis were 70.3% and 71.4%, respectively. The care burden was associated with high treatment withdrawal and death rate.

CONCLUSIONS: The outcomes of NRF, especially in extremely premature infants, reflect both progress and persistent limitations in providing respiratory support in the emerging NICUs of China, but overall survival for sick newborns had improved steadily.

KEY WORDS

bronchopulmonary dysplasia
chronic lung disease
epidemiology
mortality
neonate
prematurity
respiratory distress syndrome
respiratory failure
respiratory therapy
surfactant

Accepted October 27, 2011.

· Abstract 22 of 67Article

Discomfort and Pain in Newborns With Myelomeningocele: A Prospective Evaluation

OBJECTIVE: In a worldwide debate on deliberately terminating the lives of newborns, proponents point at newborns with very severe forms of myelomeningocele (MMC) and their assumed suffering, claiming there are no effective means of alleviating their distress. Nevertheless, the degree of discomfort and pain in these newborns has never been assessed in a structured manner.

METHODS: In a prospective cohort study, 28 consecutive newborns with MMC were included over a 5-year period and were followed up throughout their hospital stay for initial treatment. We created 2 disease severity groups on the basis of the Lorber criteria. The primary outcomes were discomfort and pain, assessed by simultaneously scoring 2 validated scales: the visual analog scale for pain and the Comfort Behavioral Scale for discomfort. These scores were coupled to a validated and evidence-based analgesia algorithm.

RESULTS: Overall, discomfort related to pain was measured in 3.3% of the scores. This percentage differed little between the preoperative and postoperative periods and did not significantly differ between newborns with less severe MMC and severe MMC (3.9% vs 2.8%; P = .3). The mean dosage of paracetamol was 35 mg/kg per day (95% confidence interval: 32–39); the mean dosage of morphine was 0.9 μg/kg per hour (95% confidence interval: 0.6 –1.2).

CONCLUSION Over the length of their hospital stays for initial treatment, all newborns with MMC presented with low levels of discomfort and pain independent of disease severity and time frame.

KEY WORDS

decision-making
infant
newborn
pain measurements/standards
spinal dysraphism/therapy

Accepted November 15, 2011.

· Abstract 23 of 67Article

Nonconvulsive Status Epilepticus: The Encephalopathic Pediatric Patient

OBJECTIVE: A high prevalence of nonconvulsive status epilepticus (NCSE) has been reported in critically ill adults and neonates. Recent prospective pediatric studies focus on critically ill children and show wide variability in the frequency of NCSE. This study examines prevalence of pediatric NCSE regardless of inpatient setting and retrospectively identifies risk factors indicating a need for urgent continuous EEG.

METHODS: Medical records from patients aged 3 months to 21 years were identified either by (1) searching a clinical EEG database (n = 18) or (2) consecutive inpatient EEG referrals for NCSE over an 8-month period (n = 57).

RESULTS: Seventy-five children, mean age of 7.8 years, were studied. NCSE was identified in 26 patients (35%) and in 8 of 57 (14%) patients referred for possible NCSE. More than half of the patients referred were outside of the ICU. A witnessed clinical seizure was observed in 24 of 26 (92%) patients with NCSE. Acute cortical neuroimaging abnormalities were significantly more frequent in patients with NCSE. The presence of clinical seizures and acute neuroimaging abnormality was associated with an 82% probability of NCSE. All but 1 patient with NCSE had electrographic or electroclinical seizures within the first hour of monitoring.

CONCLUSIONS: A high prevalence of NCSE was observed, comparable to adult studies, but within a wider range of inpatient settings. Children with acute encephalopathy should undergo continuous EEG. This evaluation is more urgent if certain clinical risk factors are present. Optimal duration of monitoring and the effect of NCSE on prognosis should be studied.

KEY WORDS

nonconvulsive status epilepticus
status epilepticus
pediatric epilepsy
diagnosis
MRI abnormal
risk factors

Accepted November 3, 2011.

· Abstract 24 of 67Article

Association Between a Functional Polymorphism in the MAOA Gene and Sudden Infant Death Syndrome

OBJECTIVES: Abnormalities in the serotonergic as well as the noradrenergic neuronal systems are believed to contribute to sudden infant death syndrome (SIDS). The X-chromosomal monoamine oxidase A (MAOA) gene is of importance for both systems and up to now no systematic study on a functional polymorphism in this gene has been performed in a sufficiently large group.

METHODS: We investigated a functional MAOA promoter length polymorphism in 156 white SIDS cases and 260 gender- and age-matched control subjects by using capillary electrophoresis and fluorescence dye labeled primers.

RESULTS: The pooled low-expressing alleles *2 and *3 were more frequent in the 99 male SIDS cases than in 161 male control subjects (44.4% vs 25.5%). However, there were no differences in female cases. The frequency of low expression alleles varied significantly with the age at death and were significantly more frequent in children who died between an age of 46 and 154 days than at an older age (54.9% vs 22.6%).

CONCLUSIONS: Our results indicate a relationship between SIDS and the MAOA genotype in boys via influencing serotonergic and noradrenergic neurons in the brainstem. This locus is the first X-chromosomal locus associated with SIDS. Our results support the theory that abnormalities in the brainstem contribute to a subset of SIDS, at least in boys. Moreover, we argue that not only the serotonergic system but also other neuronal systems, among those the noradrenergic one, are involved.

KEY WORDS

sudden infant death syndrome
monoamine oxidase A
serotonin
noradrenalin
brainstem hypothesis

Accepted November 9, 2011.

· Abstract 25 of 67Article

Resilience in Children Undergoing Stem Cell Transplantation: Results of a Complementary Intervention Trial

BACKGROUND: Children undergoing stem cell transplantation (SCT) are thought to be at risk for increased distress, adjustment difficulties, and impaired health-related quality of life (HRQL). We report results of a multisite trial designed to improve psychological adjustment and HRQL in children undergoing SCT.

METHODS: A total of 171 patients and parents from 4 sites were randomized to receive a child-targeted intervention; a child and parent intervention; or standard care. The child intervention included massage and humor therapy; the parent intervention included massage and relaxation/imagery. Outcomes included symptoms of depression and posttraumatic stress, HRQL, and benefit finding. Assessments were conducted by patient and parent report at admission and SCT week+24.

RESULTS: Across the sample, significant improvements were seen on all outcomes from admission to week+24. Surprisingly, patients who had SCT reported low levels of adjustment difficulties at admission, and improved to normative or better than average levels of adjustment and HRQL at week+24. Benefit finding was high at admission and increased at week+24; however, there were no statistically significant differences between intervention arms for any of the measures.

CONCLUSIONS: Although the results do not support the benefits of these complementary interventions in pediatric SCT, this may be explained by the remarkably positive overall adjustment seen in this sample. Improvements in supportive care, and a tendency for patients to find benefit in the SCT experience, serve to promote positive outcomes in children undergoing this procedure, who appear particularly resilient to the challenge.

KEY WORDS

stem cell transplantation
children
depression
posttraumatic stress
resilience

Accepted November 3, 2011.

· Abstract 26 of 67Article

Childhood Gender Nonconformity: A Risk Indicator for Childhood Abuse and Posttraumatic Stress in Youth

OBJECTIVES: Childhood gender nonconformity has been associated with poorer relationships with parents, but it is unknown if childhood gender nonconformity is associated with childhood abuse or risk of posttraumatic stress disorder (PTSD) in youth.

METHODS: We examined whether gender nonconformity before age 11 years was associated with childhood sexual, physical, and psychological abuse and lifetime risk of probable PTSD by using self-report questionnaire data from the 2007 wave of the Growing Up Today Study (n = 9864, mean age = 22.7 years), a longitudinal cohort of US youth. We further examined whether higher exposure to childhood abuse mediated possible elevated prevalence of PTSD in nonconforming children. Finally, we examined whether association of childhood gender nonconformity with PTSD was independent of sexual orientation.

RESULTS: Exposure to childhood physical, psychological, and sexual abuse, and probable PTSD were elevated in youth in the top decile of childhood gender nonconformity compared with youth below median nonconformity. Abuse victimization disparities partly mediated PTSD disparities by gender nonconformity. Gender nonconformity predicted increased risk of lifetime probable PTSD in youth after adjustment for sexual orientation.

CONCLUSIONS: We identify gender nonconformity as an indicator of children at increased risk of abuse and probable PTSD. Pediatricians and school health providers should consider abuse screening for this vulnerable population. Further research to understand how gender nonconformity might increase risk of abuse and to develop family interventions to reduce abuse risk is needed.

KEY WORDS

child abuse
gender nonconformity
femininity
masculinity
posttraumatic stress disorders
sexual orientation

Accepted September 9, 2011.

· Abstract 27 of 67Article

Children and Adolescents With Gender Identity Disorder Referred to a Pediatric Medical Center

OBJECTIVES: To describe the patients with gender identity disorder referred to a pediatric medical center. We identify changes in patients after creation of the multidisciplinary Gender Management Service by expanding the Disorders of Sex Development clinic to include transgender patients.

METHODS: Data gathered on 97 consecutive patients <21 years, with initial visits between January 1998 and February 2010, who fulfilled the following criteria: long-standing cross-gender behaviors, provided letters from current mental health professional, and parental support. Main descriptive measures included gender, age, Tanner stage, history of gender identity development, and psychiatric comorbidity.

RESULTS: Genotypic male:female ratio was 43:54 (0.8:1); there was a slight preponderance of female patients but not significant from 1:1. Age of presentation was 14.8 ± 3.4 years (mean ± SD) without sex difference (P = .11). Tanner stage at presentation was 4.1 ± 1.4 for genotypic female patients and 3.6 ± 1.5 for genotypic male patients (P = .02). Age at start of medical treatment was 15.6 ± 2.8 years. Forty-three patients (44.3%) presented with significant psychiatric history, including 20 reporting self-mutilation (20.6%) and suicide attempts (9.3%).

CONCLUSIONS: After establishment of a multidisciplinary gender clinic, the gender identity disorder population increased fourfold. Complex clinical presentations required additional mental health support as the patient population grew. Mean age and Tanner Stage were too advanced for pubertal suppressive therapy to be an affordable option for most patients. Two-thirds of patients were started on cross-sex hormone therapy. Greater awareness of the benefit of early medical intervention is needed. Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation.

KEY WORDS

gender identity disorder
Gender Management Service
pubertal suppression
cross-sex hormones
GnRH analog
transgender

Accepted December 16, 2011.

· Abstract 28 of 67Article

Impact of State Laws That Extend Eligibility for Parents’ Health Insurance Coverage to Young Adults

BACKGROUND AND OBJECTIVES: The 2010 Affordable Care Act mandates that health insurance companies make those up to age 26 eligible for their parents’ policies. Thirty-four states previously enacted similar laws. The authors sought to examine the impact on access to care of state laws extending eligibility of parents’ insurance to young adults.

METHODS: By using a difference-in-differences analysis, we examined the 2002–2004 and 2008–2009 Behavior Risk Factor Surveillance System to compare 3 states enacting laws in 2005 or 2006 with 17 states that have not enacted laws on 4 outcomes: self-reported health insurance coverage, identification of a personal physician/clinician, physical exam from a physician within the past 2 years, and forgoing care in the past year due to cost.

RESULTS: For each outcome there was differential improvement among states enacting laws compared with states without laws. Health insurance differentially increased 0.2% (95% confidence interval [CI], −3.8% to 4.2%), from 67.6% to 68.1% pre-post in states enacting laws and from 68.5% to 68.7% in states without. Personal physician/clinician identification differentially increased 0.9% (95% CI −3.1% to 5.0%), from 62.4% to 65.5% in states enacting laws and from 58.0% to 60.2% in states without. Recent physical exams differentially increased significantly 4.6% (95% CI, 0%–9.2%), from 77.3% to 81.2% in states enacting laws and from 76.2% to 75.5% in states without. Forgone care due to cost differentially decreased significantly 3.9% (95% CI, −0.3% to −7.5%), from 20.4% to 18.2% in states enacting laws and from 17.8% to 19.4% in states without.

CONCLUSIONS: States that expanded eligibility to parents’ insurance in 2005 or 2006 experienced improvements in access to care among young adults.

KEY WORDS

parental insurance
state laws
Affordable Care Act

Accepted October 28, 2011.

· Abstract 29 of 67Article

Quality Measures for Primary Care of Complex Pediatric Patients

OBJECTIVES: A well-recognized gap exists in assessing and improving the quality of care for medically complex patients. Our objective was to examine evidence for primary care based on the patient-centered medical home model and to identify valid and meaningful quality measures for use in complex pediatric patients.

METHODS: We conducted literature searches on Medline and the National Quality Measures Clearinghouse for existing measures, as well as evidence to inform the development of new quality measures. We used a 3-step process to select relevant sources from published literature: (1) the titles were screened by 2 independent reviewers; (2) the abstracts were reviewed for quality-of-care contents or constructs; and (3) full-text articles were obtained and reviewed for measure specification. All materials were reviewed for the Oxford Centre For Evidence-Based Medicine level of evidence and for relevance to primary care of complex pediatric patients. A national expert panel was convened to evaluate and rate the measures by using the Rand/University of California Los Angeles Appropriateness Method.

RESULTS: We presented 74 quality measures to the expert panel for review and discussion. The panel rated and accepted 35 measures as valid and feasible for assessing primary care quality in complex pediatric patients. The final set of quality measures was grouped in the following domains: primary care–general (14), patient/family-centered care (8), chronic care (2), coordination of care (9), and transition of care (2).

CONCLUSIONS: By using the patient-centered medical home framework of accessible, continuous, family-centered, coordinated, and culturally effective care, a national expert panel selected 35 primary care quality measures for complex pediatric patients.

KEY WORDS

quality measures
complex patients
primary care
patient-centered medical home

Accepted November 9, 2011.

· Abstract 30 of 67Article

Secondhand Smoke Exposure in Cars Among Middle and High School Students—United States, 2000–2009

OBJECTIVES: Exposure to secondhand smoke (SHS) from cigarettes poses a significant health risk to nonsmokers. Among youth, the home is the primary source of SHS. However, little is known about youth exposure to SHS in other nonpublic areas, particularly motor vehicles.

METHODS: Data were obtained from the 2000, 2002, 2004, 2006, and 2009 waves of the National Youth Tobacco Survey, a nationally representative survey of US students in grades 6 to 12. Trends in SHS exposure in a car were assessed across survey years by school level, gender, and race/ethnicity by using binary logistic regression.

RESULTS: From 2000 to 2009, the prevalence of SHS exposure in cars declined significantly among both nonsmokers (39.0%–22.8%; trend P < .001) and smokers (82.3%–75.3%; trend P < .001). Among nonsmokers, this decline occurred across all school level, gender, and race/ethnicity subgroups.

CONCLUSIONS: SHS exposure in cars decreased significantly among US middle and high school students from 2000 to 2009. Nevertheless, in 2009, over one-fifth of nonsmoking students were exposed to SHS in cars. Jurisdictions should expand comprehensive smoke-free policies that prohibit smoking in worksites and public places to also prohibit smoking in motor vehicles occupied by youth.

KEY WORDS

smoking
tobacco smoke pollution
motor vehicles
adolescent

Accepted November 8, 2011.

· Abstract 31 of 67Article

Variation in Teen Driver Education by State Requirements and Sociodemographics

OBJECTIVES: There is renewed attention on national standardization of formal driver education (DE) instruction and momentum toward realigning DE with its original goal of producing safer teen drivers. However, teen DE participation rates and how they differ among sociodemographic groups and in states with and without DE requirements remain largely unknown. Thus, our objective was to estimate national teen participation rates in formal classroom and behind-the-wheel DE instruction in relevant demographic subgroups and also estimate subgroup-specific participation rates by presence of a state DE requirement.

METHODS: Data were collected via the National Young Driver Survey, administered to a nationally representative sample of 5665 public school 9th- through 11th-graders in Spring 2006. Analyses were restricted to 1770 students with driver licenses. Survey data were weighted to reflect national prevalence estimates.

RESULTS: Overall, 78.8% of students reported participating in formal DE. However, in states without DE requirements, more than 1 in 3 students had no formal DE before licensure, and more than half had no behind-the-wheel training. Hispanics, blacks, males, and students with lower academic achievement participated in DE at markedly lower levels than counterparts in states with requirements. Notably, 71% of Hispanic students in states with no requirement received a license without receiving formal DE.

CONCLUSIONS: Considerable racial/ethnic, socioeconomic, and gender disparities in DE participation may exist in states with no DE requirements. State DE requirements may be an effective strategy to reduce these disparities.

KEY WORDS

adolescence
driving
driving instruction
graduated driver licensing laws
novice driver
injury prevention

Accepted November 2, 2011.

· Abstract 32 of 67Article

Using US Data to Estimate the Incidence of Serious Physical Abuse in Children

BACKGROUND There are limited data on the epidemiology of serious injuries due to physical abuse of children.

METHODS: We used the 2006 Kids’ Inpatient Database to estimate the incidence of hospitalizations due to serious physical abuse among children <18 years of age. Abuse was defined by using International Classification of Diseases, Ninth Revision, Clinical Modification codes for injuries (800–959) and for physical abuse (995.50, 995.54, 995.55, or 995.59), selected assault codes (E960-966, 968), or child battering (E967). We examined demographic characteristics, mean costs, and length of stay in 3 groups of hospitalized children: abusive injuries, nonabusive injuries, and all other reasons for hospitalization. Incidence was calculated using the weighted number of cases of physical abuse and the number of children at risk based on 2006 intercensal data.

RESULTS: The weighted number of cases due to abuse was 4569; the incidence was 6.2 (95% confidence interval [CI]: 5.5–6.9) per 100 000 children <18 years of age. The incidence was highest in children <1 year of age (58.2 per 100 000; 95% CI: 51.0–65.3) and even higher in infants covered by Medicaid (133.1 per 100 000; 95% CI: 115.2–151.0 [or 1 in 752 infants]). Overall, there were 300 children who died in the hospital due to physical abuse.

CONCLUSIONS: This is the first study to provide national US data on the occurrence of serious injuries due to physical abuse in hospitalized children. Data from the 2006 Kids’ Inpatient Database on hospitalizations due to serious physical abuse can be used to track trends over time and the effects of prevention programs on serious physical abuse.

KEY WORDS

abuse
epidemiology-injury
injury severity

Accepted October 27, 2011.

· Abstract 33 of 67Article

Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

OBJECTIVES: The objective of this study was to assess the cost-effectiveness of a quality improvement (QI) program in reducing asthma emergency department (ED) visits, hospitalizations, limitation of physical activity, patient missed school, and parent missed work.

METHODS: Urban, low-income patients with asthma from 4 zip codes were identified through logs of ED visits or hospitalizations, and offered enhanced care including nurse case management and home visits. QI evaluation focused on parent-completed interviews at enrollment, and at 6- and 12-month contacts. Hospital administrative data were used to assess ED visits and hospitalizations at enrollment, and 1 and 2 years after enrollment. Hospital costs of the program were compared with the hospital costs of a neighboring community with similar demographics.

RESULTS: The program provided services to 283 children. Participants were 55.1% male; 39.6% African American, 52.3% Latino; 72.7% had Medicaid; 70.8% had a household income <$25 000. Twelve-month data show a significant decrease in any (≥1) asthma ED visits (68.0%) and hospitalizations (84.8%), and any days of limitation of physical activity (42.6%), patient missed school (41.0%), and parent missed work (49.7%) (all P < .0001). Patients with greatest functional impairment from ED visits, limitation of activity, and missed school were more likely to have any nurse home visit and greater number of home visits. There was a significant reduction in hospital costs compared with the comparison community (P < .0001), and a return on investment of 1.46.

CONCLUSIONS: The program showed improved health outcomes and cost-effectiveness and generated information to guide advocacy efforts to finance comprehensive asthma care.

KEY WORDS

asthma
cost analysis
community health worker
emergency department visits
health disparities
health outcomes
hospitalizations
nurse case management
pediatrics
return on investment

Accepted November 11, 2011.

· Abstract 34 of 67Article

Longitudinal Follow-up of Poor Inner-city Youth Between Ages 8 and 18: Intentions Versus Reality

OBJECTIVES: (1) To document, at ages 8 to 10, children’s perceptions of their future and, at ages 16 to 18, youth outcomes; and (2) to assess early childhood factors associated with trajectory-altering events (TAEs), defined as youth risk behaviors that may modify developmental trajectories.

METHODS: A prospective longitudinal study of 97 poor, inner-city, African American youth followed since birth who completed (1) early childhood environment, cognitive, and social-emotional evaluations, as well as an inventory at ages 8 to 10 of perceptions of their futures; and (2) evaluation for presence or absence of 4 TAEs documented at ages 16 to 18: drug use, adjudication, school failure, and teen parenthood.

RESULTS: At age 9.4 ± 0.5, 94% of participants felt it unlikely they would try marijuana; 93% felt they were unlikely to get arrested; 92% felt they were likely to attend college or trade school; 81% did not know one could become pregnant with first-time sex. Age 18.1 ± 0.8 outcomes showed that 33% had used drugs, 33% had been adjudicated, 19% had school failure, and 20% had become parents. Fifty-six percent had ≥1 TAE. No relationship was found between childhood perceptions and intentions and documented outcomes. Odds of having a TAE increased with greater exposure to violence and poorer home environment.

CONCLUSIONS: Young inner-city children are idealistic regarding their future. By ages 16 to 18 however, more than half of this cohort had a TAE. Factors most strongly associated with a TAE were greater exposure to violence and poorer home environment.

KEY WORDS

poverty
urban population
home environment
early intervention
risk taking

Accepted November 14, 2011.

· Abstract 35 of 67Article

Enrollment of Extremely Low Birth Weight Infants in a Clinical Research Study May Not Be Representative

BACKGROUND AND OBJECTIVE: The Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial (SUPPORT) antenatal consent study demonstrated that mothers of infants enrolled in the SUPPORT trial had significantly different demographics and exposure to antenatal steroids compared with mothers of eligible, but not enrolled infants. The objective of this analysis was to compare the outcomes of bronchopulmonary dysplasia, severe retinopathy of prematurity, severe intraventricular hemorrhage or periventricular leukomalacia (IVH/PVL), death, and death/severe IVH/PVL for infants enrolled in SUPPORT in comparison with eligible, but not enrolled infants.

METHODS: Perinatal characteristics and neonatal outcomes were compared for enrolled and eligible but not enrolled infants in bivariate analyses. Models were created to test the effect of enrollment in SUPPORT on outcomes, controlling for perinatal characteristics.

RESULTS: There were 1316 infants enrolled in SUPPORT; 3053 infants were eligible, but not enrolled. In unadjusted analyses, enrolled infants had significantly lower rates of death before discharge, severe IVH/PVL, death/severe IVH/PVL (all < 0.001), and bronchopulmonary dysplasia (P = .003) in comparison with eligible, but not enrolled infants. The rate of severe retinopathy of prematurity was not significantly different. After adjustment for perinatal factors, enrollment in the trial was not a significant predictor of any of the tested clinical outcomes.

CONCLUSIONS: The results of this analysis demonstrate significant outcome differences between enrolled and eligible but not enrolled infants in a trial using antenatal consent, which were likely due to enrollment bias resulting from the antenatal consent process. Additional research and regulatory review need to be conducted to ensure that large moderate-risk trials that require antenatal consent can be conducted in such a way as to ensure the generalizability of results.

KEY WORDS

antenatal steroids
clinical research/trials
informed consent
neonatal

Accepted November 4, 2011.

· Abstract 36 of 67Article

Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development

OBJECTIVES: To determine the association between maternal serum 25(OH)-vitamin D concentrations during a critical window of fetal neurodevelopment and behavioral, emotional, and language outcomes of offspring.

METHODS: Serum 25(OH)-vitamin D concentrations of 743 Caucasian women in Perth, Western Australia (32°S) were measured at 18 weeks pregnancy and grouped into quartiles. Offspring behavior was measured with the Child Behavior Checklist at 2, 5, 8, 10, 14, and 17 years of age (n range = 412–652). Receptive language was assessed with the Peabody Picture Vocabulary Test—Revised at ages 5 (n = 534) and 10 (n = 474) years. Raw scores were converted to standardized scores, incorporating cutoffs for clinically significant levels of difficulty.

RESULTS: χ² analyses revealed no significant associations between maternal 25(OH)-vitamin D serum quartiles and offspring behavioral/emotional problems at any age. In contrast, there were significant linear trends between quartiles of maternal vitamin D levels and language impairment at 5 and 10 years of age. Multivariate regression analyses, incorporating a range of confounding variables, found that the risk of women with vitamin D insufficiency (≤46 nmol/L) during pregnancy having a child with clinically significant language difficulties was increased close to twofold compared with women with vitamin D levels >70 nmol/L.

CONCLUSIONS: Maternal vitamin D insufficiency during pregnancy is significantly associated with offspring language impairment. Maternal vitamin D supplementation during pregnancy may reduce the risk of developmental language difficulties among their children.

KEY WORDS

vitamin D
neurocognitive
language impairment
behavioral problems
emotional problems
Raine study

Accepted November 3, 2011.

· Abstract 37 of 67Article

Antenatal Antecedents of Cognitive Impairment at 24 Months In Extremely Low Gestational Age Newborns

BACKGROUND AND OBJECTIVES: Extremely low gestational age neonates are more likely than term infants to develop cognitive impairment. Few studies have addressed antenatal risk factors of this condition. We identified antenatal antecedents of cognitive impairment determined by the Mental Development Index (MDI) portion of the Bayley Scales of Infant Development, Second Edition (BSID-II), at 24 months corrected age.

METHODS: We studied a multicenter cohort of 921 infants born before 28 weeks of gestation during 2002 to 2004 and assessed their placentas for histologic characteristics and microorganisms. The mother was interviewed and her medical record was reviewed. At 24 months adjusted age, children were assessed with BSID-II. Multinomial logistic models were used to estimate odds ratios.

RESULTS: A total of 103 infants (11%) had an MDI <55, and 99 infants (11%) had an MDI between 55 and 69. No associations were identified between organisms recovered from the placenta and developmental delay. Factors most strongly associated with MDI <55 were thrombosis of fetal vessels (OR 3.1; 95% confidence interval [CI] 1.2, 7.7), maternal BMI >30 (OR 2.0; 95% CI 1.1, 3.5), maternal education ≤12 years (OR 3.4; 95% CI 1.9, 6.2), nonwhite race (OR 2.2; 95% CI 1.3, 3.8), birth weight z score < −2 (OR 2.8; 95% CI 1.1, 6.9), and male gender (OR 2.7; 95% CI 1.6, 4.5).

CONCLUSIONS: Antenatal factors, including thrombosis of fetal vessels in the placenta, severe fetal growth restriction, and maternal obesity, convey information about the risk of cognitive impairment among extremely premature newborns.

KEY WORDS

prematurity
placenta
chorioamnionitis
fetal growth restriction
mental development

Accepted November 9, 2011.

· Abstract 38 of 67Article

Stability of Cognitive Outcome From 2 to 5 Years of Age in Very Low Birth Weight Children

OBJECTIVES: This study assessed the stability of cognitive outcomes of premature, very low birth weight (VLBW; ≤1500 g) children.

METHODS: A regional cohort of 120 VLBW children born between 2001 and 2004 was followed up by using the Bayley Scales of Infant Development, Second Edition, at 2 years of corrected age and the Wechsler Preschool and Primary Scale of Intelligence–Revised at the age of 5 years. The Mental Development Index (MDI) and the full-scale IQ (FSIQ) were measured, respectively. A total of 168 randomly selected healthy term control children born in the same hospital were assessed for MDI and FSIQ.

RESULTS: In the VLBW group, mean ± SD MDI was 101.2 ± 16.3 (range: 50–128), mean FSIQ was 99.3 ± 17.7 (range: 39–132), and the correlation between MDI and FSIQ was 0.563 (P < .0001). In the term group, mean MDI was 109.8 ± 11.7 (range: 54–128), mean FSIQ was 111.7 ± 14.5 (range: 73–150), and the correlation between MDI and FSIQ was 0.400 (P < .0001). Overall, 83% of those VLBW children who had significant delay (–2 SD or less) according to MDI had it also in FSIQ. Similarly, 87% of those children who were in the average range in MDI were within the average range in FSIQ as well.

CONCLUSIONS: Good stability of cognitive development over time was found in VLBW children and in term children between the ages of 2 and 5 years. This conclusion stresses the value and clinical significance of early assessment at 2 years of corrected age. However, we also emphasize the importance of a long-term follow-up covering a detailed neuropsychological profile of these at-risk children.

KEY WORDS

intelligent quotient
Mental Development Index
very preterm

Accepted November 11, 2011.

· Abstract 39 of 67Article

A Statewide Trial of the SafeCare Home-based Services Model With Parents in Child Protective Services

OBJECTIVES: In this trial, we compared Child Protective Services (CPS) recidivism outcomes between the home-based SafeCare (SC) model for child neglect and comparable home-based services, but without SC modules, for parents in the CPS system across 2 quality control strategies: coached (C) and uncoached implementation. SC is a home-based behavioral skills training model designed for neglecting or maltreating parents. The study was conducted in a scaled-up, statewide implementation setting.

METHODS: Two thousand one hundred seventy-five maltreating parents, treated by 219 home visitors, were enrolled and treated in a 2 × 2 (SC versus services as usual × C versus uncoached implementation strategy) randomized cluster experiment. Cases were followed for an average of 6 years for CPS recidivism events. Subpopulation analyses were conducted for parents meeting customary SC inclusion criteria.

RESULTS: Consistently significant main effects in favor of SC were found across simple and more complex modeling approaches (hazard ratios = 0.74–0.83). Larger effects were found among the subpopulation meeting customary SC inclusion criteria. C implementation yielded smaller and occasionally significant effects in analyses that included more diverse cases falling outside customary SC inclusion criteria.

CONCLUSIONS: Findings support the adoption and use of SC within CPS home-based services systems. C implementation may be especially valuable for cases where the client-model fit is less strong.

KEY WORDS

parenting
Child Protective Services
child neglect

Accepted October 27, 2011.

· Abstract 40 of 67Article

What the Orphan Drug Act Has Done Lately for Children With Rare Diseases: A 10-Year Analysis

OBJECTIVES: The 1983 US Orphan Drug Act (ODA) provided incentives to stimulate treatment product development for patients with rare disease. This article highlights a decade of ODA contributions to this goal for children with RDs.

METHODS: An internal US Food and Drug Administration database was the information source for orphan designations, marketing approvals, and prevalence numbers for 2000 to 2009. Product categorization was based on the disease age of onset for which they received designation. Category 1 products were for diseases with onset exclusively in Childhood; Category 2 products were for diseases with onset at any age; and Category 3 products were for diseases with adult onset only. Disease prevalence distributions were analyzed by using population intervals of 20 000.

RESULTS: From 2000 to 2009, 1138 orphan drugs were designated and 148 received marketing approval, of which 38 (26%) were for pediatric diseases. The proportion of approvals for pediatric products increased from 17.5% (10 of 57) in the first half of the decade, to 30.8% (28 of 91) in the second. More products received designation and marketing approval for pediatric diseases with prevalence numbers fewer than 20 000 than for any other prevalence subgroup. The median disease prevalence for all pediatric orphan designations that received marketing approval was 8972. Among the pediatric orphan drug approvals categorized by therapeutic class, the endocrine/metabolic drugs had the largest representation (39%).

CONCLUSIONS: The ODA incentives have led to increased product availability for RDs overall, with an increasing number of marketing approvals for children this past decade.

KEY WORDS

orphan drugs
rare diseases
Orphan Drug Act
pediatrics

Accepted October 27, 2011.

· Abstract 41 of 67Article

Pediatric Training and Career Intentions, 2003–2009

OBJECTIVES: To examine trends in pediatric residents’ training and job search experiences from 2003 through 2009.

METHODS: Annual national random samples of 500 graduating pediatric residents from 2003 through 2005 and 1000 from 2006 through 2009 were surveyed. Responses were compared across years to identify trends. We examined resident demographics, training, satisfaction, career intentions, and job search experiences. Overall response rate was 61%.

RESULTS: Between 2003 and 2009, there was an increase in the proportion of female graduating pediatric residents (69%–75%), residents from international medical schools (15%–23%), and levels of educational debt among the subgroup of residents with debt ($139 945 in 2003 to $166 972 in 2009). Residents consistently reported (>90% of residents) that they would choose pediatrics again if they had the choice. By 2009, the majority was very satisfied with the quality of their training in most areas, with ratings improving across years in caring for children with special health care needs, evidence-based medicine, and using information technology in practice. Although primary care remained the most common clinical practice goal, there was a modest decline in interest in primary care practice across survey years, whereas interest in subspecialty practice increased. Residents accepting both general pediatric practice and hospitalist positions reported less difficulty in their job search over time.

CONCLUSIONS: Despite continually changing demographics of pediatric training programs, residents overall remain very satisfied with their decision to become pediatricians. Pediatricians continue to face difficult financial challenges associated with rising debt, but they also report increasing job search success.

KEY WORDS

residency training
pediatric work force
resident debt

Accepted October 27, 2011.

· Abstract 42 of 67Review Article

Antipsychotics for Children and Young Adults: A Comparative Effectiveness Review

BACKGROUND AND OBJECTIVE: Despite increasing on-label and off-label use of antipsychotics, prescribing antipsychotics to children remains controversial due to uncertainty of their relative benefits and safety. We systematically reviewed the effectiveness and safety of first- (FGA) and second-generation antipsychotics (SGA) for patients aged ≤24 years with psychiatric and behavioral conditions.

METHODS: We searched 10 databases from January 1987 to February 2011, gray literature, trial registries, and reference lists. Two reviewers independently selected studies, assessed methodologic quality, and graded the evidence. One reviewer extracted, and a second verified, data. We summarized findings qualitatively and conducted meta-analyses when appropriate.

RESULTS: Sixty-four trials and 17 cohort studies were included. Most trials had a high risk of bias; cohort studies had moderate quality. All comparisons of FGAs versus SGAs, FGAs versus FGAs, and FGAs versus placebo had low or insufficient strength of evidence. There was moderate strength of evidence for the following comparisons. Olanzapine caused more dyslipidemia and weight gain, but fewer prolactin-related events, than risperidone. Olanzapine caused more weight gain than quetiapine. Compared with placebo, SGAs improved clinical global impressions (schizophrenia, bipolar and disruptive behavior disorders) and diminished positive and negative symptoms (schizophrenia), behavior symptoms (disruptive behavior disorders), and tics (Tourette syndrome).

CONCLUSIONS: This is the first comprehensive review comparing the effectiveness and safety across the range of antipsychotics for children and young adults. The evidence on the comparative benefits and harms of antipsychotics is limited. Some SGAs have a better side effect profile than other SGAs. Additional studies using head-to-head comparisons are needed.

KEY WORDS

antipsychotics
psychiatric disorders
behavioral disorders
systematic review

Accepted November 17, 2011.

· Abstract 43 of 67Review Article

Transfusion Associated Necrotizing Enterocolitis: A Meta-analysis of Observational Data

BACKGROUND AND OBJECTIVES: Several studies have reported the possibility of an association between recent exposure to transfusion and development of necrotizing enterocolitis (NEC). Our objective was to systematically review and meta-analyze the association between transfusion and NEC (TANEC), identify predictors of TANEC, and the assess impact of TANEC on outcomes.

METHODS: Medline, Embase, CINAHL, and bibliographies of identified articles were searched for studies assessing association with recent (within 48 hours) exposure to transfusion and NEC. Two reviewers independently collected data and assessed the quality of the studies for bias in sample selection, exposure assessment, confounders, analyses, outcome assessments, and attrition. Meta-analyses were performed by using random effect model, and odds ratio and 95% confidence interval were calculated.

RESULTS: Eleven retrospective case-control studies and 1 cohort study of moderate risk of bias were included. Ten case-control studies had NEC not associated with transfusion as control patients (unmatched). Recent exposure to transfusion was associated with NEC. Neonates who developed TANEC were younger by 1.5 weeks, were of 528 g lower birth weight, were more likely to have patent ductus arteriosus, and were more likely receiving ventilatory support. TANEC infants had higher risk of mortality. Two pre-post comparative studies of 20 patients reported reduction of TANEC after withholding feeds during transfusion.

CONCLUSIONS: Recent exposure to transfusion was associated with NEC in neonates. Neonates who developed TANEC were at overall higher risk of NEC. TANEC patients were at higher risk of mortality, but additional studies adjusting for confounders are needed.

KEY WORDS

infant
newborn
gut immaturity
anemia
ischemia

Accepted November 11, 2011.

· Abstract 44 of 67State-of-the-Art Review Article

Toward a Unifying Hypothesis of Metabolic Syndrome

Despite a lack of consistent diagnostic criteria, the metabolic syndrome (MetS) is increasingly evident in children and adolescents, portending a tsunami of chronic disease and mortality as this generation ages. The diagnostic criteria for MetS apply absolute cutoffs to continuous variables and fail to take into account aging, pubertal changes, and race/ethnicity. We attempt to define MetS mechanistically to determine its specific etiologies and to identify targets for therapy. Whereas the majority of studies document a relationship of visceral fat to insulin resistance, ectopic liver fat correlates better with dysfunctional insulin dynamics from which the rest of MetS derives. In contrast to the systemic metabolism of glucose, the liver is the primary metabolic clearinghouse for 4 specific foodstuffs that have been associated with the development of MetS: trans-fats, branched-chain amino acids, ethanol, and fructose. These 4 substrates (1) are not insulin regulated and (2) deliver metabolic intermediates to hepatic mitochondria without an appropriate “pop-off” mechanism for excess substrate, enhancing lipogenesis and ectopic adipose storage. Excessive fatty acid derivatives interfere with hepatic insulin signal transduction. Reactive oxygen species accumulate, which cannot be quenched by adjacent peroxisomes; these reactive oxygen species reach the endoplasmic reticulum, leading to a compensatory process termed the “unfolded protein response,” driving further insulin resistance and eventually insulin deficiency. No obvious drug target exists in this pathway; thus, the only rational therapeutic approaches remain (1) altering hepatic substrate availability (dietary modification), (2) reducing hepatic substrate flux (high fiber), or (3) increasing mitochondrial efficiency (exercise).

KEY WORDS

metabolic syndrome
insulin resistance
dyslipidemia
hypertension
diabetes
pediatrics

Accepted November 28, 2011.

· Abstract 45 of 67Special Article

End-of-Life Decisions in Abusive Head Trauma

Abusive head trauma is a significant and tragic cause of morbidity and mortality in infants and its victims often have a poor prognosis. With such high rates of morbidity and mortality, health care providers and parents are often faced with the decision to continue or discontinue life support for an affected child. Sadly, however, this decision becomes complicated when parents are accused of causing the victim-child's current state. In this situation, if life support is withdrawn, criminal charges for the accused may escalate from assault to murder. This escalation of legal charges creates a conflict of interest for accused parents. As a result, parents have a strong incentive to avoid murder charges by using their parental decision-making rights to keep the child alive, even when treatment is deemed futile or inhumane. In this article, we discuss the legal challenges health care providers may face when parents place their interest above their child’s. We also propose solutions that give greater deference to the rights and interest of these critically ill children while still preserving protected parental rights.

KEY WORDS

abusive head trauma
child abuse/neglect
life support
conflicts of interest
human rights
medical ethics
end of life

Accepted October 27, 2011.

· Abstract 46 of 67Special Article

Never Enough Sleep: A Brief History of Sleep Recommendations for Children

BACKGROUND AND OBJECTIVE: There is a common belief that children are not getting enough sleep and that children’s total sleep time has been declining. Over the century, many authors have proposed sleep recommendations. The aim of this study was to describe historical trends in recommended and actual sleep durations for children and adolescents, and to explore the rationale of sleep recommendations.

METHODS: A systematic literature review was conducted to identify recommendations for children’s sleep requirements and data reporting children’s actual total sleep time. For each recommendation identified, children’s actual sleep time was determined by identifying studies reporting the sleep duration of children of the same age, gender, and country in the same years. Historical trends in age-adjusted recommended sleep times and trends in children’s actual sleep time were calculated. A thematic analysis was conducted to determine the rationale and evidence-base for recommendations.

RESULTS: Thirty-two sets of recommendations were located dating from 1897 to 2009. On average, age-specific recommended sleep decreased at the rate of –0.71 minute per year. This rate of decline was almost identical to the decline in the actual sleep duration of children (–0.73 minute per year). Recommended sleep was consistently ∼37 minutes greater than actual sleep, although both declined over time.

CONCLUSIONS: A lack of empirical evidence for sleep recommendations was universally acknowledged. Inadequate sleep was seen as a consequence of “modern life,” associated with technologies of the time. No matter how much sleep children are getting, it has always been assumed that they need more.

KEY WORDS

adolescents
children
recommendations
sleep

Accepted November 9, 2011.

· Abstract 47 of 67Commentary

· Abstract 48 of 67Commentary

· Abstract 49 of 67Commentary

· Abstract 50 of 67Quality Report

A Multicenter Collaborative Approach to Reducing Pediatric Codes Outside the ICU

OBJECTIVES: The Child Health Corporation of America formed a multicenter collaborative to decrease the rate of pediatric codes outside the ICU by 50%, double the days between these events, and improve the patient safety culture scores by 5 percentage points.

METHODS: A multidisciplinary pediatric advisory panel developed a comprehensive change package of process improvement strategies and measures for tracking progress. Learning sessions, conference calls, and data submission facilitated collaborative group learning and implementation. Twenty Child Health Corporation of America hospitals participated in this 12-month improvement project. Each hospital identified at least 1 noncritical care target unit in which to implement selected elements of the change package. Strategies to improve prevention, detection, and correction of the deteriorating patient ranged from relatively simple, foundational changes to more complex, advanced changes. Each hospital selected a broad range of change package elements for implementation using rapid-cycle methodologies. The primary outcome measure was reduction in codes per 1000 patient days. Secondary outcomes were days between codes and change in patient safety culture scores.

RESULTS: Code rate for the collaborative did not decrease significantly (3% decrease). Twelve hospitals reported additional data after the collaborative and saw significant improvement in code rates (24% decrease). Patient safety culture scores improved by 4.5% to 8.5%.

CONCLUSIONS: A complex process, such as patient deterioration, requires sufficient time and effort to achieve improved outcomes and create a deeply embedded culture of patient safety. The collaborative model can accelerate improvements achieved by individual institutions.

KEY WORDS

quality improvement
collaboration
outcomes research

Accepted October 10, 2011.

· Abstract 51 of 67Quality Report

Prevention of Tracheostomy-related Pressure Ulcers in Children

BACKGROUND AND OBJECTIVES: Pressure ulcers are commonly acquired in pediatric institutions, and they are a key indicator of the standard and effectiveness of care. We recognized a high rate of tracheostomy-related pressure ulcers (TRPUs) in our ventilator unit and instituted a quality improvement program to develop and test potential interventions for TRPU prevention, condensed them into a clinical bundle, and then implemented the bundle into our standard practice.

METHODS: The intervention model used a rapid-cycle, Plan-Do-Study-Act (PDSA), framework for improvement research. All tracheostomy-dependent patients admitted to our 18-bed ventilator unit from July 2008 through December 2010 were included. TRPU stage and description, number of days each TRPU persisted, and bundle compliance were recorded in real time. All TRPUs were staged by a wound-care expert within 24 hours. The interventions incorporated into the TRPU-prevention bundle included frequent skin and device assessments, moisture-reducing device interface, and pressure-free device interface.

RESULTS: There was a significant decrease in the rate of patients who developed a TRPU from 8.1% during the preintervention period, to 2.6% during bundle development, to 0.3% after bundle implementation. There was a marked difference between standard and extended tracheostomy tubes in TRPU occurrence (3.4% vs 0%, P = .007) and days affected by a TRPU (5.2% vs 0.1%, P < .0001).

CONCLUSIONS: Education and ongoing assessment of skin integrity and the use of devices that minimize pressure at the tracheostomy–skin interface effectively reduce TRPU even among a population of children at high risk. These interventions can be integrated into daily workflow and result in sustained effect.

KEY WORDS

pressure ulcer
tracheostomy
quality improvement

Accepted October 31, 2011.

· Abstract 52 of 67Case Report

Macrolide Treatment Failure in Streptococcal Pharyngitis Resulting in Acute Rheumatic Fever

Macrolide resistance (MR) in group A Streptococcus (GAS) has been well documented in several countries and has become clinically significant since the large increases in macrolide usage during the 1970s. Macrolides are recommended as an alternative therapy for GAS pharyngitis, the most common cause of bacterial pharyngitis. Macrolide resistance has been associated with certain emm types, a sequence-based typing system of the hypervariable region of the GAS M-protein gene. Clinical failure of macrolide treatment of GAS infections can be associated with complications including acute rheumatic fever and rheumatic heart disease, the leading cause of acquired heart disease in children worldwide. Here we report 2 pediatric cases of MR and/or treatment failure in the treatment of GAS pharyngitis with the subsequent development of acute rheumatic fever. We also review the literature on worldwide MR rates, molecular classifications, and emm types, primarily associated with GAS pharyngeal isolates between the years of 2000 and 2010. The use of macrolides in the management of GAS pharyngitis should be limited to patients with significant penicillin allergy.

KEY WORDS

macrolides
anti-bacterial agents
child
pediatrics
Streptococcus pyogenes
streptococcal infections
pharyngitis
drug resistance
bacterial drug resistance
rheumatic fever
phenotype
genotype
bacterial antigens

Accepted October 25, 2011.

· Abstract 53 of 67Case Report

Watery Eyes During Urination

We report the unusual case of tear production with painless micturition, only once described in the medical literature in 1932. We report on a 3-year-old girl with painless “watering of her eyes every time she passed urine” present since birth and occasionally associated with a vacant look and dropping of her jaw. With only 1 previously described case in the literature but clear evidence from online fora, we describe how this phenomenon may be more common than previously thought.

KEY WORDS

crying
urology
voiding pattern
genitourinary tract

Accepted October 25, 2011.

· Abstract 54 of 67Case Report

Good Outcome With Early Empiric Treatment of Neural Larva Migrans Due to Baylisascaris procyonis

We report a remarkably good outcome in a 14-month-old boy with early clinical diagnosis and aggressive empirical treatment of neural larva migrans caused by the raccoon roundworm Baylisascaris procyonis. He presented with fever, meningismus, lethargy, irritability and asymmetric spastic extremity weakness. Early findings of marked blood and cerebrospinal fluid eosinophilia and of diffuse white matter signal abnormality in the brain and spinal cord on MRI suggested a parasitic encephalomyelitis. Rapid presumptive treatment with albendazole and high-dose steroids halted progression of clinical signs. The diagnosis was confirmed by 2 sequential enzyme-linked immunosorbent assay studies positive for B procyonis serum immunoglobulin G and by Western blot. Field examination with soil sampling yielded infective Baylisascaris eggs. Repeat MRI 3 months later showed atrophy and diffuse, chronic white matter abnormalities, discordant with the marked clinical improvement in this interval. At 10 months, residual neurologic deficits included subtle paraparesis and moderate language delay. This case is the first in which spinal involvement in human Baylisascaris infection was clinically suspected and confirmed by neuroimaging. Importantly, early diagnosis and aggressive treatment of Baylisascaris meningo-encephalitis and myelitis with albendazole and high-dose steroids likely contributed to the good outcome in this patient, in contrast with previous reports.

KEY WORDS

raccoon
Baylisascaris
larva migrans
meningoencephalitis
encephalomyelitis

Accepted October 27, 2011.

· Abstract 55 of 67Case Report

Successful Use of Bisphosphonate and Calcimimetic in Neonatal Severe Primary Hyperparathyroidism

Neonatal primary hyperparathyroidism (NPHT) is associated with an inactivating homozygous mutation of the calcium sensing receptor (CaSR). The CaSR is expressed most abundantly in the parathyroid glands and the kidney and regulates calcium homeostasis through its ability to modulate parathormone secretion and renal calcium reabsorption. NPHT leads to life threatening hypercalcemia, nephrocalcinosis, bone demineralization, and neurologic disabilities. Surgery is the treatment of choice. While waiting for surgery, bisphosphonates offer a good alternative to deal with hypercalcemia. Cinacalcet is a class II calcimimetic that increases CaSR affinity for calcium, leading to parathormone suppression and increased calcium renal excretion. At present, there is little evidence as to whether cinacalcet could improve the function of mutant CaSR in NPHT. We report a case of NPHT, treated successfully with bisphosphonates and cinacalcet after surgery failure. To our knowledge, it is the first time cinacalcet has been used for NPHT.

KEY WORDS

neonatal primary hyperparathyroidism
parathormone
calcium sensing receptor
calcimimetic of class II

Accepted October 13, 2011.

· Abstract 56 of 67Case Report

Growth and Development in a Child With Resistance to Thyroid Hormone and Ectopic Thyroid Gland

Resistance to thyroid hormone is an uncommon problem, which has rarely been associated with thyroid dysgenesis. We report a case with both thyroid gland ectopy and resistance to thyroid hormone and, thus, a reduced capacity to produce and respond to thyroid hormone. The patient presented at 2 years of age with developmental delay, dysmorphic features, and elevation in both thyroxine and thyrotropin. We document her response to therapy with thyroxine, with particular regard to her growth and development. Persistent elevation of thyrotropin is commonly recognized during treatment of congenital hypothyroidism. Resistance to thyroid hormone may be an important additional diagnosis to consider in cases where thyrotropin remains persistently elevated.

KEY WORDS

thyroid hormone resistance
thyroid dysgenesis
child
growth

Accepted October 25, 2011.

· Abstract 57 of 67Case Report

Thrombotic Microangiopathy and Purtscher-like Retinopathy as a Rare Presentation of Juvenile Dermatomyositis

Juvenile dermatomyositis is a rare systemic vasculopathy that may sometimes present with acute complications. We report here the case of a 7-year-old boy with severe dermatomyositis associated with thrombocytopenia and blurry vision. The presence of schistocytosis and the secondary occurrence of hemolytic anemia were consistent with a diagnosis of thrombotic thrombocytopenic purpura (TTP). Further investigations demonstrated the association of TTP with muscular microangiopathy and Purtscher-like retinopathy. Retinal and hematologic involvements dramatically improved after the initiation of plasma exchange in emergency. This report emphasizes that early recognition of TTP and prompt plasmapheresis are important in a child with severe juvenile dermatomyositis associated with thrombocytopenia.

KEY WORDS

juvenile dermatomyositis
thrombotic thrombocytopenic purpura
Purtscher-like retinopathy

Accepted October 27, 2011.

· Abstract 58 of 67Erratum

· Abstract 59 of 67Erratum

· Abstract 60 of 67Erratum

· Abstract 61 of 67Erratum

· Abstract 62 of 67Erratum

· Abstract 63 of 67From the American Academy of PediatricsStatement of Endorsement

· Abstract 64 of 67From the American Academy of PediatricsStatement of Endorsement

· Abstract 65 of 67From the American Academy of PediatricsPolicy Statement

Breastfeeding and the Use of Human Milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice. The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare. Infant growth should be monitored with the World Health Organization (WHO) Growth Curve Standards to avoid mislabeling infants as underweight or failing to thrive. Hospital routines to encourage and support the initiation and sustaining of exclusive breastfeeding should be based on the American Academy of Pediatrics-endorsed WHO/UNICEF “Ten Steps to Successful Breastfeeding.” National strategies supported by the US Surgeon General’s Call to Action, the Centers for Disease Control and Prevention, and The Joint Commission are involved to facilitate breastfeeding practices in US hospitals and communities. Pediatricians play a critical role in their practices and communities as advocates of breastfeeding and thus should be knowledgeable about the health risks of not breastfeeding, the economic benefits to society of breastfeeding, and the techniques for managing and supporting the breastfeeding dyad. The “Business Case for Breastfeeding” details how mothers can maintain lactation in the workplace and the benefits to employers who facilitate this practice.

KEY WORDS

breastfeeding
complementary foods
infant nutrition
lactation
human milk
nursing

· Abstract 66 of 67From the American Academy of PediatricsPolicy Statement

Baseball and Softball

Baseball and softball are among the most popular and safest sports in which children and adolescents participate. Nevertheless, traumatic and overuse injuries occur regularly, including occasional catastrophic injury and even death. Safety of the athlete is a constant focus of attention among those responsible for modifying rules. Understanding the stresses placed on the arm, especially while pitching, led to the institution of rules controlling the quantity of pitches thrown in youth baseball and established rest periods between pitching assignments. Similarly, field maintenance and awareness of environmental conditions as well as equipment maintenance and creative prevention strategies are critically important in minimizing the risk of injury. This statement serves as a basis for encouraging safe participation in baseball and softball. This statement has been endorsed by the Canadian Paediatric Society.

KEY WORDS

balls
bats
commotio cordis
elbow
equipment
helmets
injury
pitch count
safety
shoulder

· Abstract 67 of 67From the American Academy of PediatricsPolicy Statement

HPV Vaccine Recommendations

On October 25, 2011, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommended that the quadrivalent human papillomavirus vaccine (Gardasil; Merck & Co, Inc, Whitehouse Station, NJ) be used routinely in males. The American Academy of Pediatrics has reviewed updated data provided by the Advisory Committee on Immunization Practices on vaccine efficacy, safety, and cost-effectiveness as well as programmatic considerations and supports this recommendation. This revised statement updates recommendations for human papillomavirus immunization of both males and females.

KEY WORDS

human papillomavirus
HPV
vaccine
males
females
adolescents
immunization
cancer

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میلادی:23 ژانویه 2025

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