February 2012, VOLUME 129 / ISSUE 2 - مركز مديريت دانش بيماريهاي كودكان

پنجشنبه 4 بهمن 1403 - 22 رجب 1446

English | فارسی

جستجو :

شما اینجا هستید صفحه اصلیFebruary 2012, VOLUME 129 / ISSUE 2

مطالب آموزشی

February 2012, VOLUME 129 / ISSUE 2

· Abstract 1 of 67Pediatrics Digest

· Abstract 2 of 67Pediatrics Perspective

· Abstract 3 of 67Article

Drinking Frequency as a Brief Screen for Adolescent Alcohol Problems

OBJECTIVE: Routine alcohol screening of adolescents in pediatric settings is recommended, and could be facilitated by a very brief empirically validated alcohol screen based on alcohol consumption. This study used national sample data to test the screening performance of 3 alcohol consumption items (ie, frequency of use in the past year, quantity per occasion, frequency of heavy episodic drinking) in identifying youth with alcohol-related problems.

METHODS: Data were from youth aged 12 to 18 participating in the annual National Survey on Drug Use and Health from 2000 to 2007. The screening performance of 3 alcohol consumption items was tested, by age and gender, against 2 outcomes: any Diagnostic and Statistical Manual, Fourth Edition alcohol use disorder symptom (“moderate”-risk outcome), and a diagnosis of Diagnostic and Statistical Manual, Fourth Edition alcohol dependence (“high”-risk outcome).

RESULTS: Prevalence of the 2 outcomes increased with age: any alcohol use disorder symptom ranged from 1.4% to 29.2%; alcohol dependence ranged from 0.2% to 5.3%. Frequency of drinking had higher sensitivity and specificity in identifying both outcomes, compared with quantity per occasion and heavy episodic drinking frequency. For both outcomes, results indicate the utility of similar cut points for drinking frequency for males and females at each age. Age-specific frequency cut points, however, are recommended for both moderate- and high-risk outcomes to maximize screening performance.

CONCLUSIONS: Drinking frequency provides an empirically supported brief screen to efficiently identify youth with alcohol-related problems.

KEY WORDS

adolescent
alcohol screen
alcohol use

Accepted October 6, 2011.

· Abstract 4 of 67Article

Hepatitis A Vaccination Coverage Among Adolescents in the United States

OBJECTIVE: Hepatitis A infection causes severe disease among adolescents and adults. The Advisory Committee on Immunization Practices instituted incremental recommendations for hepatitis A vaccination (HepA) at 2 years of age based on risk (1996), in selected states (1999), and universally at 1 year of age, with vaccination through 18 years of age based on risk or desire for protection (2006). We assessed adolescent HepA coverage in the United States and factors independently associated with vaccination.

METHODS: Data from the 2009 National Immunization Survey–Teen (n = 20 066) were analyzed to determine ≥1- and ≥2-dose HepA coverage among adolescents 13 to 17 years of age. We used bivariate and multivariable analyses to test associations between HepA initiation and sociodemographic characteristics stratified by state groups: group 1, universal child vaccination since 1999; group 2, consideration for child vaccination since 1999; group 3, universal child vaccination at 1 year of age since 2006.

RESULTS: In 2009, national 1-dose HepA coverage among adolescents was 42.0%. Seventy percent of vaccinees completed the 2-dose series. One-dose coverage was 74.3% among group 1 states, 54.0% for group 2 states, and 27.8% for group 3 states. The adjusted prevalence ratios of vaccination initiation were highest for states with a vaccination requirement and for adolescents whose providers recommended HepA.

CONCLUSIONS: HepA coverage was low among most adolescents in the United States in 2009 leaving a large population susceptible to hepatitis A infection maturing into adulthood.

KEY WORDS

adolescents
hepatitis A
immunizations

Accepted September 26, 2011.

· Abstract 5 of 67Article

Cardiac Screening Prior to Stimulant Treatment of ADHD: A Survey of US-Based Pediatricians

OBJECTIVES: To determine pediatricians’ attitudes, barriers, and practices regarding cardiac screening before initiating treatment with stimulants for attention-deficit/hyperactivity disorder.

METHODS: A survey of 1600 randomly selected, practicing US pediatricians with American Academy of Pediatrics membership was conducted. Multivariate models were created for 3 screening practices: (1) performing an in-depth cardiac history and physical (H & P) examination, (2) discussing potential stimulant-related cardiac risks, and (3) ordering an electrocardiogram (ECG).

RESULTS: Of 817 respondents (51%), 525 (64%) met eligibility criteria. Regarding attitudes, pediatricians agreed that both the risk for sudden cardiac death (SCD) (24%) and legal liability (30%) were sufficiently high to warrant cardiac assessment; 75% agreed that physicians were responsible for informing families about SCD risk. When identifying cardiac disorders, few (18%) recognized performing an in-depth cardiac H & P as a barrier; in contrast, 71% recognized interpreting a pediatric ECG as a barrier. When asked about cardiac screening practices before initiating stimulant treatment for a recent patient, 93% completed a routine H & P, 48% completed an in-depth cardiac H & P, and 15% ordered an ECG. Almost half (46%) reported discussing stimulant-related cardiac risks. Multivariate modeling indicated that ≥1 of these screening practices were associated with physicians’ attitudes about SCD risk, legal liability, their responsibility to inform about risk, their ability to perform an in-depth cardiac H & P, and family concerns about risk.

CONCLUSIONS: Variable pediatrician attitudes and cardiac screening practices reflect the limited evidence base and conflicting guidelines regarding cardiac screening. Barriers to identifying cardiac disorders influence practice.

KEY WORDS

attention-deficit/hyperactivity disorder
stimulants
sudden cardiac death
pediatrics
electrocardiogram

Accepted September 26, 2011.

· Abstract 6 of 67Article

Public Attitudes Regarding the Use of Residual Newborn Screening Specimens for Research

BACKGROUND AND OBJECTIVES: Many state newborn screening (NBS) programs retain residual NBS bloodspots after the completion of screening. Potential uses for residual specimens include laboratory quality assurance, biomedical research, and, rarely, forensic applications. Our objective was to evaluate public opinion about the policies and practices relevant to the retention and use of residual bloodspots for biomedical research.

METHODS: A total of 3855 respondents were recruited using 3 methods: focus groups (n = 157), paper or telephone surveys (n = 1418), and a Knowledge Networks panel (n = 2280). Some participants (n = 1769) viewed a 22-minute movie about the retention and use of residual specimens while other participants were provided only written information about this practice. All participants were surveyed using a 38-item questionnaire.

RESULTS: A diverse set of participants was recruited. Respondents were very supportive of NBS in general and accepting of the use of residual bloodspots for important research activities. Respondents were evenly divided on the acceptability of NBS without parental permission, but the majority of respondents supported the use of an “opt-in” process for parental permission for residual bloodspot retention and use. Viewing the educational movie was associated with greater support for bloodspot retention and use.

CONCLUSIONS: Our results show that the general public surveyed here was supportive of NBS and residual sample retention and research use. However, there was a clear preference for an informed permission process for parents regarding these activities. Education about NBS was associated with a higher level of support and may be important to maintain public trust in these important programs.

KEY WORDS

newborn screening
biobank
informed consent
survey

Accepted September 7, 2011.

· Abstract 7 of 67Article

Citizens’ Values Regarding Research With Stored Samples From Newborn Screening in Canada

OBJECTIVES: Newborn screening (NBS) programs may store bloodspot samples and use them for secondary purposes. Recent public controversies and lawsuits over storage and secondary uses underscore the need to engage the public on these issues. We explored Canadian values regarding storage and use of NBS samples for various purposes and the forms of parental choice for anonymous research with NBS samples.

METHODS: We conducted a mixed-methods, public engagement study comprising 8 focus groups (n = 60), an educational component, deliberative discussion, and pre- and post-questionnaires assessing knowledge and values toward storage and parental choice.

RESULTS: Canadian citizens supported the storage of NBS samples for quality control, confirmatory diagnosis, and future anonymous research (>90%). There was broad support for use of NBS samples for anonymous research; however, opinions were split about the extent of parental decision-making. Support for a “routinized” approach rested on trust in authorities, lack of concern for harms, and an assertion that the population’s interest took priority over the interests of individuals. Discomfort stemmed from distrust in authorities, concern for harms, and prioritizing individual interests, which supported more substantive parental choice. Consensus emerged regarding the need for greater transparency about the storage and secondary use of samples.

CONCLUSIONS: Our study provides novel insights into the values that underpin citizens’ acceptance and discomfort with routine storage of NBS samples for research, and supports the need to develop well-designed methods of public education and civic discourse on the risks and benefits of the retention and secondary use of NBS samples.

KEY WORDS

newborn screening
storage
blood spots
policy
public engagement
public health
research

Accepted October 31, 2011.

· Abstract 8 of 67Article

The Risk of Immune Thrombocytopenic Purpura After Vaccination in Children and Adolescents

BACKGROUND: The risk of immune thrombocytopenic purpura (ITP) after childhood vaccines other than measles-mumps-rubella vaccine (MMR) is unknown.

METHODS: Using data from 5 managed care organizations for 2000 to 2009, we identified a cohort of 1.8 million children ages 6 weeks to 17 years. Potential ITP cases were identified by using diagnostic codes and platelet counts. All cases were verified by chart review. Incidence rate ratios were calculated comparing the risk of ITP in risk (1 to 42 days after vaccination) and control periods.

RESULTS: There were 197 chart-confirmed ITP cases out of 1.8 million children in the cohort. There was no elevated risk of ITP after any vaccine in early childhood other than MMR in the 12- to 19-month age group. There was a significantly elevated risk of ITP after hepatitis A vaccine at 7 to 17 years of age, and for varicella vaccine and tetanus-diphtheria-acellular pertussis vaccine at 11 to 17 years of age. For hepatitis A, varicella, and tetanus-diphtheria-acellular pertussis vaccines, elevated risks were based on one to two vaccine-exposed cases. Most cases were acute and mild with no long-term sequelae.

CONCLUSIONS: ITP is unlikely after early childhood vaccines other than MMR. Because of the small number of exposed cases and potential confounding, the possible association of ITP with hepatitis A, varicella, and tetanus-diphtheria-acellular pertussis vaccines in older children requires further investigation.

KEY WORDS

immune thrombocytopenia purpura
children
vaccines
adverse reactions
thrombocytopenia

Accepted October 6, 2011.

· Abstract 9 of 67Article

A National Profile of Childhood Epilepsy and Seizure Disorder

OBJECTIVE: To determine sociodemographics, patterns of comorbidity, and function of US children with reported epilepsy/seizure disorder.

METHODS: Bivariate and multivariable cross-sectional analysis of data from the National Survey of Children’s Health (2007) on 91 605 children ages birth to 17 years, including 977 children reported by their parents to have been diagnosed with epilepsy/seizure disorder.

RESULTS: Estimated lifetime prevalence of epilepsy/seizure disorder was 10.2/1000 (95% confidence interval [CI]: 8.7–11.8) or 1%, and of current reported epilepsy/seizure disorder was 6.3/1000 (95% CI: 4.9–7.8). Epilepsy/seizure disorder prevalence was higher in lower-income families and in older, male children. Children with current reported epilepsy/seizure disorder were significantly more likely than those never diagnosed to experience depression (8% vs 2%), anxiety (17% vs 3%), attention-deficit/hyperactivity disorder (23% vs 6%), conduct problems (16% vs 3%), developmental delay (51% vs 3%), autism/autism spectrum disorder (16% vs 1%), and headaches (14% vs 5%) (all P < .05). They had greater risk of limitation in ability to do things (relative risk: 9.22; 95% CI: 7.56–11.24), repeating a school grade (relative risk: 2.59; CI: 1.52–4.40), poorer social competence and greater parent aggravation, and were at increased risk of having unmet medical and mental health needs. Children with prior but not current seizures largely had intermediate risk.

CONCLUSIONS: In a nationally representative sample, children with seizures were at increased risk for mental health, developmental, and physical comorbidities, increasing needs for care coordination and specialized services. Children with reported prior but not current seizures need further study to establish reasons for their higher than expected levels of reported functional limitations.

KEY WORDS

epilepsy
seizure disorder
children

Accepted October 13, 2011.

· Abstract 10 of 67Article

Societal Values and Policies May Curtail Preschool Children’s Physical Activity in Child Care Centers

BACKGROUND AND OBJECTIVES: Three-fourths of US preschool-age children are in child care centers. Children are primarily sedentary in these settings, and are not meeting recommended levels of physical activity. Our objective was to identify potential barriers to children’s physical activity in child care centers.

METHODS: Nine focus groups with 49 child care providers (55% African American) were assembled from 34 centers (inner-city, suburban, Head Start, and Montessori) in Cincinnati, Ohio. Three coders independently analyzed verbatim transcripts for themes. Data analysis and interpretation of findings were verified through triangulation of methods.

RESULTS: We identified 3 main barriers to children’s physical activity in child care: (1) injury concerns, (2) financial, and (3) a focus on “academics.” Stricter licensing codes intended to reduce children's injuries on playgrounds rendered playgrounds less physically challenging and interesting. In addition, some parents concerned about potential injury, requested staff to restrict playground participation for their children. Small operating margins of most child care centers limited their ability to install abundant playground equipment. Child care providers felt pressure from state mandates and parents to focus on academics at the expense of gross motor play. Because children spend long hours in care and many lack a safe place to play near their home, these barriers may limit children's only opportunity to engage in physical activity.

CONCLUSIONS: Societal priorities for young children—safety and school readiness—may be hindering children’s physical development. In designing environments that optimally promote children’s health and development, child advocates should think holistically about potential unintended consequences of policies.

KEY WORDS

child care
physical activity
health promotion
health policy

Accepted October 5, 2011.

· Abstract 11 of 67Article

Trends in US Pediatric Drowning Hospitalizations, 1993–2008

BACKGROUND: In the United States, drowning is the second leading cause of unintentional injury death in children aged 1 to 19 years, accounting for nearly 1100 deaths per year. Although a decline in overall fatal drowning deaths among children has been noted, national trends and disparities in pediatric drowning hospitalizations have not been reported.

METHODS: To describe trends in pediatric drowning in the United States and provide national benchmarks for state and regional comparisons, we analyzed existing data (1993–2008) from the Nationwide Inpatient Sample, the largest, longitudinal, all-payer inpatient care database in the United States. Children aged 0 to 19 years were included. Annual rates of drowning-related hospitalizations were determined, stratified by age, gender, and outcome.

RESULTS: From 1993 to 2008, the estimated annual incidence rate of pediatric hospitalizations associated with drowning declined 49% from 4.7 to 2.4 per 100 000 (P < .001). The rates declined for all age groups and for both males and females. The hospitalization rate for males remained consistently greater than for females at each point in time. Rates of fatal drowning hospitalization declined from 0.5 (95% confidence interval, 0.4–0.7) deaths per 100 000 in 1993–1994 to 0.3 (95% confidence interval, 0.2–0.4) in 2007–2008 (P < .01). No difference was observed in the mean hospital length of stay over time.

CONCLUSIONS: Pediatric hospitalization rates for drowning have decreased over the past 16 years. Our study provides national estimates of pediatric drowning hospitalization that can be used as benchmarks to target and assess prevention strategies.

KEY WORDS

drowning
pediatric
hospitalization
incidence
trends

Accepted October 24, 2011.

· Abstract 12 of 67Article

Value of Follow-up Examinations of Children and Adolescents Evaluated for Sexual Abuse and Assault

OBJECTIVE: The purpose of this study was to determine whether follow-up examinations of suspected victims of child sexual abuse influence medical diagnosis or treatment.

METHODS: A retrospective chart review of patients with initial and follow-up examinations (examinations 1 and 2, respectively) over a 5-year study period was conducted. Patient and abuse characteristics, interval between examinations and abuse, and examiner experience levels were collected; examination findings and test results for sexually transmitted infections (STIs) were compared for examinations 1 and 2.

RESULTS: Among 727 patients, examination 2 resulted in a change in interpretation of trauma likelihood in 129 (17.7%) patients and identified STIs in 47 (6.5%) patients. Changes in trauma likelihood and detection of additional STIs during follow-up examinations were more likely in adolescent, female, and sexually active patients and those with a history of genital−genital contact, unknown examination 1 findings, or drug-facilitated sexual assault. Although examination 2 was less likely to affect the interpretation of trauma likelihood and STIs in preadolescent patients, a change in interpretation of trauma likelihood was noted for 49 (15.5%) of these patients, and 16 (5.1%) were diagnosed with a new STI on examination 2. The level of clinician experience during examination 1 did affect the likelihood of changes in examination findings during examination 2.

CONCLUSIONS: Follow-up examinations by specialists affected the interpretation of trauma and detection of STIs in ∼23% of pediatric patients undergoing sexual abuse assessments.

KEY WORDS

child abuse, sexual
child molestation, sexual
sexually transmitted diseases
sex offenses
condylomata acuminata
gynecologic examination
nucleic acid amplification techniques
antibiotic prophylaxis

Accepted October 26, 2011.

· Abstract 13 of 67Article

Carpooling and Booster Seats: A National Survey of Parents

OBJECTIVE: Booster seat use among school-aged children has been consistently lower than national goals. In this study, we sought to explore associations between parental experiences with booster seats and carpooling.

METHODS: We conducted a cross-sectional Web-based survey of a nationally representative panel of US parents in January 2010. As part of a larger survey, parents of 4- to 8-year-old children responded to 12 questions related to booster seats and carpooling.

RESULTS: Of 1612 parents responding to the full survey (response rate = 71%), 706 had a 4- to 8-year-old child and 681 met inclusion rules. Most parents (76%) reported their child used a safety seat when riding in the family car. Of children reported to use seat belts, 74% did so in accordance with their state law. Parent report of child safety seat use was associated with younger child age and with the presence of state booster seat laws. Sixty-four percent of parents carpool. Among parents who carpool and whose children use a child safety seat: 79% indicated they would always ask another driver to use a booster seat for their child and 55% reported they always have their child use their booster seat when driving friends who do not have boosters.

CONCLUSIONS: Carpooling is a common driving situation during which booster seat use is inconsistent. Social norms and self-efficacy are associated with booster seat use. Clinicians who care for children should increase efforts to convey the importance of using the size-appropriate restraint for every child on every trip.

KEY WORDS

car seats
child passenger safety
parental attitudes
survey

Accepted October 24, 2011.

· Abstract 14 of 67Article

Oral Sucrose and “Facilitated Tucking” for Repeated Pain Relief in Preterms: A Randomized Controlled Trial

OBJECTIVES: To test the comparative effectiveness of 2 nonpharmacologic pain-relieving interventions administered alone or in combination across time for repeated heel sticks in preterm infants.

METHODS: A multicenter randomized controlled trial in 3 NICUs in Switzerland compared the effectiveness of oral sucrose, facilitated tucking (FT), and a combination of both interventions in preterm infants between 24 and 32 weeks of gestation. Data were collected during the first 14 days of their NICU stay. Three phases (baseline, heel stick, recovery) of 5 heel stick procedures were videotaped for each infant. Four independent experienced nurses blinded to the heel stick phase rated 1055 video sequences presented in random order by using the Bernese Pain Scale for Neonates, a validated pain tool.

RESULTS: Seventy-one infants were included in the study. Interrater reliability was high for the total Bernese Pain Scale for Neonates score (Cronbach’s α: 0.90–0.95). FT alone was significantly less effective in relieving repeated procedural pain (P < .002) than sucrose (0.2 mL/kg). FT in combination with sucrose seemed to have added value in the recovery phase with lower pain scores (P = .003) compared with both the single-treatment groups. There were no significant differences in pain responses across gestational ages.

CONCLUSIONS: Sucrose with and without FT had pain-relieving effects even in preterm infants of <32 weeks of gestation having repeated pain exposures. These interventions remained effective during repeated heel sticks across time. FT was not as effective and cannot be recommended as a nonpharmacologic pain relief intervention for repeated pain exposure.

KEY WORDS

infant premature
pain
analgesia
nonpharmacologic pain relief
sucrose
facilitated tucking

Accepted September 28, 2011.

· Abstract 15 of 67Article

Prospective Study of Sunburn and Sun Behavior Patterns During Adolescence

OBJECTIVES: Early childhood UV light radiation (UVR) exposures have been shown to be associated with melanoma development later in life. The objective of this study was to assess sunburn and changes in sunburn and sun behaviors during periadolescence.

METHODS: A prospective, population-based study was conducted in fifth-grade children (∼10 years of age) from Framingham, Massachusetts. Surveys were administered at baseline (September–October 2004) and again 3 years later (September–October 2007). Surveys were analyzed to assess prevalence of reported sunburn and sun behaviors and to examine changes in response over the follow-up period.

RESULTS: Data were analyzed from 360 participants who had complete information regarding sunburn at both time points. In 2004, ∼53% of the students reported having at least 1 sunburn during the previous summer, and this proportion did not significantly change by 2007 (55%, P = .79), whereas liking a tan and spending time outside to get a tan significantly increased (P < .001). In 2004, 50% of students reported “often or always” use of sunscreen when outside for at least 6 hours in the summer; this proportion dropped to 25% at the follow-up evaluation (P < .001).

CONCLUSIONS: With at least 50% of children experiencing sunburns before age 11 and again 3 years later, targeting children in pediatric offices and community settings regarding unprotected UV exposure may be a practical approach. Because periadolescence is a time of volatility with regard to sun behaviors, learning more about children who receive sunburns versus those who avoid them is a critical research task.

KEY WORDS

sunburn
suntan
adolescent
melanoma

Accepted October 12, 2011.

· Abstract 16 of 67Article

Predictors of Cognitive Function and Recovery 10 Years After Traumatic Brain Injury in Young Children

BACKGROUND AND OBJECTIVES: Childhood traumatic brain injury (TBI) has implications for functional outcomes, but few studies have documented long-term outcomes. The purpose of this study was to plot recovery of cognitive and functional skills after early childhood TBI to 10 years postinjury and to identify the contribution of injury, environment, preinjury characteristics, and acute functional recovery.

METHODS: Subjects were recruited consecutively to this prospective, longitudinal study, which used a between-factor design, with injury severity as the independent variable. Forty children with TBI aged 2 and 7 years were recruited on admission to a tertiary pediatric hospital, divided according to injury severity, and compared with 16 healthy controls acutely and 12 and 30 months and 10 years postinjury. Cognition, adaptive ability, executive function, and social/behavioral skills were examined.

RESULTS: Children with severe TBI had poorest outcomes, with deficits greatest for cognition. Recovery trajectories were similar across severity groups but with significant gains in verbal skills from 12 and 30 months to 12 months and 10 years. Predictors of outcome included preinjury ability (for adaptive function) and family function (social/behavioral skills).

CONCLUSIONS: Results confirm a high risk of persisting deficits after severe TBI in early childhood. Children with less severe TBI appear to recover to function normally. Contrary to speculation about “growing into deficits,” after protracted recovery to 30 months, young children make age-appropriate progress at least to 10 years postinsult. Environmental factors were found to contribute to adaptive and social/behavioral recovery.

KEY WORDS

traumatic brain injury
young
children
recovery of function
intelligence

Accepted October 10, 2011.

· Abstract 17 of 67Article

Intellectual, Behavioral, and Social Outcomes of Accidental Traumatic Brain Injury in Early Childhood

OBJECTIVE: The intellectual, behavioral, and social function of children who sustained traumatic brain injury (TBI) before 3 years of age were compared with a group of uninjured children. The role of injury and environmental factors in recovery was examined.

METHODS: A group of 53 children who sustained a TBI before 3 years of age (20 mild and 33 moderate/severe) and 27 uninjured children (control group) were assessed on an IQ measure and parent measures of behavior and social skills. Children were aged 4 to 6 years and were an average of 40 months since sustaining their injury.

RESULTS: There were no demographic differences between the groups. Although all group scores were in the average range, children with moderate/severe TBI performed significantly below uninjured children on an IQ measure. No significant differences were found on parent behavior ratings, although effect sizes between groups were medium to large. No differences were found for social skills. All outcomes were significantly influenced by environmental but not injury factors.

CONCLUSIONS: Moderate/severe TBI at an early age appears to be associated with lowered intellectual function and possibly behavior problems. A child’s environment influences cognitive and behavior function after TBI.

KEY WORDS

traumatic brain injury
children
infants
intellectual functioning

Accepted October 10, 2011.

· Abstract 18 of 67Article

Randomized Trial of Oral Versus Sequential IV/Oral Antibiotic for Acute Pyelonephritis in Children

OBJECTIVE: To confirm whether oral antibiotic treatment is as efficacious as sequential intravenous/oral antibiotic treatment in the prevention of renal scarring in children with acute pyelonephritis and scintigraphy-documented acute lesions.

METHODS: In a prospective multicenter trial, children aged 1 to 36 months with their first case of acute pyelonephritis, a serum procalcitonin concentration ≥0.5 ng/mL, no known uropathy, and a normal ultrasound exam were randomized into 2 treatment groups. They received either oral cefixime for 10 days or intravenous ceftriaxone for 4 days followed by oral cefixime for 6 days. Patients with acute renal lesions detected on early dimercaptosuccinic acid scintigraphy underwent a follow-up scintigraphy 6 to 8 months later.

RESULTS: The study included 171 infants and children. There were no significant differences between the 2 groups in any clinical characteristic. Initial scintigraphy results were abnormal for 119 children. Ninety-six children were measured for renal scarring at the follow-up scintigraphy (per protocol analysis population). The incidence of renal scarring was 30.8% in the oral treatment group and 27.3% for children who received the sequential treatment.

CONCLUSIONS: Although this trial does not statistically demonstrate the noninferiority of oral treatment compared with the sequential treatment, our study confirmed the results of previously published reports and therefore supports the use of an oral antibiotic treatment of primary episodes of acute pyelonephritis in infants and young children.

KEY WORDS

acute pyelonephritis
pediatric
procalcitonin
renal scarring

Accepted October 10, 2011.

· Abstract 19 of 67Article

Prevalence, Patterns, and Persistence of Sleep Problems in the First 3 Years of Life

OBJECTIVE: Examine the prevalence, patterns, and persistence of parent-reported sleep problems during the first 3 years of life.

METHODS: Three hundred fifty-nine mother/child pairs participated in a prospective birth cohort study. Sleep questionnaires were administered to mothers when children were 6, 12, 24, and 36 months old. Sleep variables included parent response to a nonspecific query about the presence/absence of a sleep problem and 8 specific sleep outcome domains: sleep onset latency, sleep maintenance, 24-hour sleep duration, daytime sleep/naps, sleep location, restlessness/vocalization, nightmares/night terrors, and snoring.

RESULTS: Prevalence of a parent-reported sleep problem was 10% at all assessment intervals. Night wakings and shorter sleep duration were associated with a parent-reported sleep problem during infancy and early toddlerhood (6–24 months), whereas nightmares and restless sleep emerged as associations with report of a sleep problem in later developmental periods (24–36 months). Prolonged sleep latency was associated with parent report of a sleep problem throughout the study period. In contrast, napping, sleep location, and snoring were not associated with parent-reported sleep problems. Twenty-one percent of children with sleep problems in infancy (compared with 6% of those without) had sleep problems in the third year of life.

CONCLUSIONS: Ten percent of children are reported to have a sleep problem at any given point during early childhood, and these problems persist in a significant minority of children throughout early development. Parent response to a single-item nonspecific sleep query may overlook relevant sleep behaviors and symptoms associated with clinical morbidity.

KEY WORDS

sleep problems
infants
toddlers
prevalence
persistence

Accepted September 26, 2011.

· Abstract 20 of 67Article

RCT of Montelukast as Prophylaxis for Upper Respiratory Tract Infections in Children

BACKGROUND: Infections with viruses causing upper respiratory tract infection (URI) are associated with increased leukotriene levels in the upper airways. Montelukast, a selective leukotriene-receptor antagonist, is an effective treatment of asthma and allergic rhinitis.

OBJECTIVE: To determine whether prophylactic treatment with montelukast reduces the incidence and severity of URI in children.

METHODS: A randomized, double-blind, placebo-controlled study was performed in 3 primary care pediatric ambulatory clinics in Israel. Healthy children aged 1 to 5 years were randomly assigned in a 1:1 ratio to receive 12-week treatment with 4 mg oral montelukast or look-alike placebo. Patients were excluded if they had a previous history of reactive airway disease. A study coordinator contacted the parents by phone once a week to obtain information regarding the occurrence of acute respiratory episodes. The parents received a diary card to record any acute symptoms of URI. The primary outcome measure was the number of URI episodes.

RESULTS: Three hundred children were recruited and randomly assigned into montelukast (n = 153) or placebo (n = 147) groups. One hundred thirty-one (85.6%) of the children treated with montelukast and 129 (87.7%) of the children treated with placebo completed 12 weeks of treatment. The number of weeks in which URI was reported was 30.4% in children treated with montelukast and 30.7% in children treated with placebo. There was no significant difference in any of the secondary variables between the groups.

CONCLUSIONS: In preschool-aged children, 12-week treatment with montelukast, compared with placebo, did not reduce the incidence of URI.

KEY WORDS

children
leukotriene-receptor antagonist
montelukast
upper respiratory tract infection

Accepted September 26, 2011.

· Abstract 21 of 67Article

Late Intravenous Immunoglobulin Treatment in Patients With Kawasaki Disease

OBJECTIVE: To evaluate the effectiveness of intravenous immunoglobulin (IVIG) treatment of Kawasaki disease ≥10 days after illness onset.

METHODS: We selected patients initially treated with IVIG on days 11 to 20 in the database of the 20th nationwide survey in Japan. We then selected pair-matched control subjects of the same gender and age, who were initially treated with IVIG on days 4 to 8 with the same dose at the same institutions. We compared the proportions of additional treatments and coronary artery lesions (CALs) between the groups. We also compared fractional changes in various laboratory data before and after IVIG. Fractional change was defined as follows: (Y − X)/X, in which X represents the data before treatment and Y the data after treatment.

RESULTS: One hundred fifty patients (75 pairs) were studied. The proportion of patients who received additional treatments among those given initial IVIG after days 10 was slightly lower than those treated earlier (12% vs 16%). The fractional changes in the white blood cell count, % neutrophils, and C-reactive protein were similar. Among all patients, the proportions of CALs during the convalescent phase were significantly higher in the late than in the early group (27% vs 1%). Among patients who had not developed CALs before initial treatment, the proportions with CALs during the acute phase were similar (8% vs 8%).

CONCLUSIONS: IVIG treatment ≥10 days after illness onset achieves resolution of inflammation but was found to be insufficient for preventing CALs.

KEY WORDS

Kawasaki disease
coronary artery aneurysm
immunoglobulin

Accepted October 24, 2011.

· Abstract 22 of 67Article

Incidence and Timing of Presentation of Necrotizing Enterocolitis in Preterm Infants

OBJECTIVES: To examine the variation in the incidence and to identify the timing of the presentation of necrotizing enterocolitis (NEC) in a cohort of preterm infants within the Canadian Neonatal Network (CNN).

METHODS: This was a population-based cohort of 16 669 infants with gestational age (GA) <33 weeks, admitted to 25 NICUs participating in the CNN between January 1, 2003, and December 31_, 2008. Variations in NEC incidence among the participating NICUs for the study period were examined. We categorized early-onset NEC as occurring at <14 days of age and late-onset NEC occurring at ≥14 days. Multivariate logistic regression analysis was performed to identify risk factors for early-onset NEC.

RESULTS: The overall incidence of NEC was 5.1%, with significant variation in the risk adjusted incidence among the participating NICUs in the CNN. Early-onset NEC occurred at a mean of 7 days compared with 32 days for late-onset NEC. Early-onset NEC infants had lower incidence of respiratory distress syndrome, patent ductus treated with indomethacin, less use of postnatal steroids, and shorter duration of ventilation days. Multivariate logistic regression analysis identified that greater GA and vaginal delivery were associated with increased risk of early-onset NEC.

CONCLUSIONS: Among infants <33 weeks’ gestation, NEC appears to present at mean age of 7 days in more mature infants, whereas onset of NEC is delayed to 32 days of age in smaller, lower GA infants. Further studies are required to understand the etiology of this disease process.

KEY WORDS

necrotizing enterocolitis
preterm infant
incidence

Accepted October 11, 2011.

· Abstract 23 of 67Article

Co-occurring Conditions and Change in Diagnosis in Autism Spectrum Disorders

OBJECTIVE: This study aimed to investigate descriptive characteristics and co-occurring neurodevelopmental and psychiatric conditions in young children, children, and adolescents with a current and consistent or past but not current (PBNC) diagnosis of autism spectrum disorder (ASD) and how such characteristics and conditions may engender a change in diagnosis of an ASD.

METHODS: Cross-sectional data of 1366 children with a parent-reported current or PBNC ASD diagnosis were obtained from the National Survey of Children’s Health 2007 data set across 3 developmental stages: young children (aged 3–5 years), children (aged 6–11 years), and adolescents (aged 12–17 years). Multinomial logistic regression was used to examine demographic characteristics and co-occurring conditions that differentiate the groups with a current ASD from groups with a PBNC ASD.

RESULTS: Results indicated the co-occurring conditions that distinguish groups currently diagnosed with an ASD from groups with a PBNC ASD diagnosis. In young children, current moderate/severe learning disability, and current moderate/severe developmental delay; in children, past speech problem, current moderate/severe anxiety, and past hearing problem; and in adolescents, current moderate/severe speech problem, current mild seizure/epilepsy, and past hearing problem.

CONCLUSIONS: These findings suggest that the presence of co-occurring psychiatric and neurodevelopmental conditions are associated with a change in ASD diagnosis. Questions remain as to whether changes in diagnosis of an ASD are due to true etiologic differences or shifts in diagnostic determination.

KEY WORDS

autism spectrum disorder
co-occurring conditions
diagnosis change

Accepted September 28, 2011.

· Abstract 24 of 67Article

Maternal Asthma Medication Use and the Risk of Selected Birth Defects

OBJECTIVES: Approximately 4% to 12% of pregnant women have asthma; few studies have examined the effects of maternal asthma medication use on birth defects. We examined whether maternal asthma medication use during early pregnancy increased the risk of selected birth defects.

METHODS: National Birth Defects Prevention Study data for 2853 infants with 1 or more selected birth defects (diaphragmatic hernia, esophageal atresia, small intestinal atresia, anorectal atresia, neural tube defects, omphalocele, or limb deficiencies) and 6726 unaffected control infants delivered from October 1997 through December 2005 were analyzed. Mothers of cases and controls provided telephone interviews of medication use and additional potential risk factors. Exposure was defined as maternal periconceptional (1 month prior through the third month of pregnancy) asthma medication use (bronchodilator or anti-inflammatory). Associations between maternal periconceptional asthma medication use and individual major birth defects were estimated by using adjusted odds ratios (aOR) and 95% confidence intervals (95%CI).

RESULTS: No statistically significant associations were observed for maternal periconceptional asthma medication use and most defects studied; however, positive associations were observed between maternal asthma medication use and isolated esophageal atresia (bronchodilator use: aOR = 2.39, 95%CI = 1.23, 4.66), isolated anorectal atresia (anti-inflammatory use: aOR = 2.12, 95%CI = 1.09, 4.12), and omphalocele (bronchodilator and anti-inflammatory use: aOR = 4.13, 95%CI = 1.43, 11.95).

CONCLUSIONS: Positive associations were observed for anorectal atresia, esophageal atresia, and omphalocele and maternal periconceptional asthma medication use, but not for other defects studied. It is possible that observed associations may be chance findings or may be a result of maternal asthma severity and related hypoxia rather than medication use.

KEY WORDS

anti-inflammatory
asthma
birth defects
bronchodilator
medication

Accepted October 13, 2011.

· Abstract 25 of 67Article

Multicenter Analysis of Quality Indicators for Children Treated in the Emergency Department for Asthma

OBJECTIVE: To test the hypothesis that an association exists between process and outcome measures of the quality of acute asthma care provided to children in the emergency department.

METHODS: Investigators at 14 US sites prospectively enrolled consecutive children 2 to 17 years of age presenting to the emergency department with acute asthma. In models adjusted for variables commonly associated with the quality of acute asthma care, we measured the association between 7 measures of concordance with national asthma guideline-recommended processes and 2 outcomes. Specifically, we modeled the association between 5 receipt/nonreceipt process measures and successful discharge and the association between 2 timeliness measures and admission.

RESULTS: In this cohort of 1426 patients, 62% were discharged without relapse or ongoing symptoms (successful discharge), 15% were discharged with relapse or ongoing symptoms, and 24% were admitted. The composite score for receipt of all 5 receipt/nonreceipt process measures was 84%, and for timeliness measures, 57% receive a timely corticosteroid and 92% a timely β-agonist. Our adjusted models showed no association between process and outcome measures, with 1 exception: timely β-agonist administration was associated with admission, likely reflecting confounding by severity rather than a true process-outcome association.

CONCLUSIONS: We found no clinically significant association between process and outcome quality measures in the delivery of asthma-related care to children in a multicenter study. Although the quality of emergency department care does not predict successful discharge, other factors, such as outpatient care, may better predict outcomes.

KEY WORDS

asthma
outcome and process assessments (health care)
quality of health care
Severity of Illness Index
practice guideline
antiasthmatic agents
asthma
preschool child
child
adolescent

Accepted October 26, 2011.

· Abstract 26 of 67Article

Nasal Continuous Positive Airway Pressure With Heliox in Preterm Infants With Respiratory Distress Syndrome

OBJECTIVE: To assess the therapeutic effects of breathing a low-density helium and oxygen mixture (heliox, 80% helium and 20% oxygen) in premature infants with respiratory distress syndrome (RDS) treated with nasal continuous positive airway pressure (NCPAP).

METHODS: Infants born between 28 and 32 weeks of gestational age with radiologic findings and clinical symptoms of RDS and requiring respiratory support with NCPAP within the first hour of life were included. These infants were randomly assigned to receive either standard medical air (control group) or a 4:1 helium and oxygen mixture (heliox group) during the first 12 hours of enrollment, followed by medical air until NCPAP was no longer needed.

RESULTS: From February 2008 to September 2010, 51 newborn infants were randomly assigned to two groups, 24 in the control group and 27 in the heliox group. NCPAP with heliox significantly decreased the risk of mechanical ventilation in comparison with NCPAP with medical air (14.8% vs 45.8%).

CONCLUSIONS: Heliox increases the effectiveness of NCPAP in the treatment of RDS in premature infants.

KEY WORDS

preterm infants
nasal CPAP
heliox
respiratory distress syndrome

Accepted October 26, 2011.

· Abstract 27 of 67Article

A Decision-Tree Approach to Cost Comparison of Newborn Screening Strategies for Cystic Fibrosis

OBJECTIVE: Because cystic fibrosis can be difficult to diagnose and treat early, newborn screening programs have rapidly developed nationwide but methods vary widely. We therefore investigated the costs and consequences or specific outcomes of the 2 most commonly used methods.

METHODS: With available data on screening and follow-up, we used a simulation approach with decision trees to compare immunoreactive trypsinogen (IRT) screening followed by a second IRT test against an IRT/DNA analysis. By using a Monte Carlo simulation program, variation in the model parameters for counts at various nodes of the decision trees, as well as for costs, are included and applied to fictional cohorts of 100 000 newborns. The outcome measures included the numbers of newborns given a diagnosis of cystic fibrosis and costs of screening strategy at each branch and cost per newborn.

RESULTS: Simulations revealed a substantial number of potential missed diagnoses for the IRT/IRT system versus IRT/DNA. Although the IRT/IRT strategy with commonly used cutoff values offers an average overall cost savings of $2.30 per newborn, a breakdown of costs by societal segments demonstrated higher out-of-pocket costs for families. Two potential system failures causing delayed diagnoses were identified relating to the screening protocols and the follow-up system.

CONCLUSIONS: The IRT/IRT screening algorithm reduces the costs to laboratories and insurance companies but has more system failures. IRT/DNA offers other advantages, including fewer delayed diagnoses and lower out-of-pocket costs to families.

KEY WORDS

cystic fibrosis
immunoreactive trypsinogen
DNA
newborn screening
costs
sensitivity

Accepted October 7, 2011.

· Abstract 28 of 67Article

Comparison of the US and Australian Cystic Fibrosis Registries: The Impact of Newborn Screening

BACKGROUND AND OBJECTIVES: National data registries for cystic fibrosis (CF) enable comparison of health statistics between countries. We examined the US and Australian CF data registries to compare demographics, clinical practice and outcome measures.

METHODS: We compared the 2003 US and Australian registries. Differences in pulmonary and growth outcomes were assessed by creating models controlling for differences in age, gender, genotype, and diagnosis after newborn screening.

RESULTS: Data on 12 994 US and 1220 Australian patients aged ≤18 years were analyzed. A significant difference was noted in the proportion who had been diagnosed after newborn screening (Australian 65.8% vs United States 7.2%; P < .001). Australian children had significantly greater mean height percentile (41.0 vs 32.6; P < .001) and weight percentile (43.5 vs 36.1; P = .028) than US children. Mean forced expiratory volume in 1 second (FEV₁) percent predicted adjusted for age, gender, and genotype was similar in the 2 countries (P = .80). Patients diagnosed after newborn screening had higher mean FEV₁ (5.3 [95% confidence interval (CI): 3.6–7.0]) percent predicted and BMI (0.26 [95% CI: 0.09–0.43]). Mean FEV₁ of Australian patients diagnosed after newborn screening was lower by 5.2 (95% CI: 2.8–7.6) percent predicted compared with US children.

CONCLUSIONS: Children diagnosed with CF after newborn screening benefited from better lung function and BMI than those diagnosed clinically. The benefit of newborn screening on lung function was significantly less in Australian children compared with US children. Statistical comparisons between CF registries are feasible and can contribute to benchmarking and improvements in care.

KEY WORDS

cystic fibrosis
lung function
newborn screening

Accepted July 20, 2011.

· Abstract 29 of 67Article

Urinary Proteome Analysis to Exclude Severe Vesicoureteral Reflux

OBJECTIVES: High-grade vesicoureteral reflux (VUR, grade IV or V) is a risk factor for renal scarring, impaired renal function, and arterial hypertension. Voiding cystourethrography is the gold standard for detecting the severity of VUR. High-grade VUR is present in the minority of children with urinary tract infection (UTI), thus exposing the majority to invasive diagnostics that have no surgical consequence. We therefore aimed at establishing a noninvasive test to identify children with high-grade VUR.

METHODS: In a case-control study, a specific urinary proteome pattern was established by capillary electrophoresis coupled to mass spectrometry in 18 patients with primary VUR grade IV or V, distinguishing these from 19 patients without VUR after UTI. This proteome pattern was independently validated in a blinded cohort of 17 patients with VUR grade IV or V and 19 patients without VUR.

RESULTS: Sensitivity in detecting VUR grade IV or V in the blinded study was 88%, specificity was 79%. The test’s accuracy was independent of age, gender, and grade of VUR in the contralateral kidney. The odds ratio of suffering from VUR grade IV or V when tested positive was 28 (95% confidence interval: 4.5 to 176.0).

CONCLUSIONS: This noninvasive test is ready for prospective validation in large cohorts with the aim of identifying those children with UTI and hydronephrosis in need of further invasive diagnostics, such as voiding cystourethrography, thus sparing most children without pathologic urinary proteome patterns from additional diagnostics.

KEY WORDS

vesicoureteral reflux
screening
proteomics
noninvasive diagnostics

Accepted October 5, 2011.

· Abstract 30 of 67Article

Bronchoscopic Findings in Children With Chronic Wet Cough

OBJECTIVES: Protracted bacterial bronchitis is defined as the presence of more than 4 weeks of chronic wet cough that resolves with appropriate antibiotic therapy, in the absence of alternative diagnoses. The diagnosis of protracted bacterial bronchitis is not readily accepted within the pediatric community, however, and data on the incidence of bacterial bronchitis in children are deficient. The objective of this study was to determine the frequency of bacterial bronchitis in children with chronic wet cough and to analyze their bronchoscopic findings.

METHODS: We performed a retrospective review of charts of children who presented with chronic wet cough, unresponsive to therapy, before referral to the pediatric pulmonary clinic.

RESULTS: A total of 197 charts and bronchoscopy reports were analyzed. Of 109 children who were 0 to 3 years of age, 33 (30.3%) had laryngomalacia and/or tracheomalacia. The bronchoscopy showed purulent bronchitis in 56% (110) cases and nonpurulent bronchitis in 44% (87). The bronchoalveolar lavage bacterial cultures were positive in 46% (91) of the children and showed nontypable Haemophilus influenzae (49%), Streptococcus pneumoniae (20%), Moraxella catarrhalis (17%), Staphylococcus aureus (12%), and Klebsiella pneumoniae in 1 patient. The χ² analysis demonstrated that positive bacterial cultures occurred more frequently in children with purulent bronchitis (74, 69.8%) than in children with nonpurulent bronchitis (19, 19.8%) (P < .001).

CONCLUSIONS: Children who present with chronic wet cough are often found to have evidence of purulent bronchitis on bronchoscopy. This finding is often indicative of a bacterial lower airway infection in these children.

KEY WORDS

cough
infection

Accepted October 5, 2011.

· Abstract 31 of 67Article

Association of Center Volume With Mortality and Complications in Pediatric Heart Surgery

OBJECTIVE: Previous analyses have suggested center volume is associated with outcome in children undergoing heart surgery. However, data are limited regarding potential mediating factors, including the relationship of center volume with postoperative complications and mortality in those who suffer a complication. We examined this association in a large multicenter cohort.

METHODS: Children 0 to 18 years undergoing heart surgery at centers participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2006–2009) were included. In multivariable analysis, we evaluated outcomes associated with annual center volume, adjusting for patient factors and surgical risk category.

RESULTS: A total of 35 776 patients (68 centers) were included. Overall, 40.6% of patients had ≥1 complication, and the in-hospital mortality rate was 3.9%. The mortality rate in those patients with a complication was 9.0%. In multivariable analysis, lower center volume was significantly associated with higher in-hospital mortality. There was no association of center volume with the rate of postoperative complications, but lower center volume was significantly associated with higher mortality in those with a complication (P = .03 when volume examined as a continuous variable; odds ratio in centers with <150 vs >350 cases per year = 1.59 [95% confidence interval: 1.16–2.18]). This association was most prominent in the higher surgical risk categories.

CONCLUSIONS: These data suggest that the higher mortality observed at lower volume centers in children undergoing heart surgery may be related to a higher rate of mortality in those with postoperative complications, rather than a higher rate of complications alone.

KEY WORDS

congenital heart disease
heart surgery
outcomes research

Accepted September 26, 2011.

· Abstract 32 of 67Article

Social-Emotional Screening for Infants and Toddlers in Primary Care

BACKGROUND AND OBJECTIVES: Recommendations in pediatrics call for general developmental screening of young children; however, research suggests social-emotional development, in particular, is important as an initial indicator of general well-being versus risk. We aim to describe a program designed to identify the social-emotional status of young children in the pediatric setting by using the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) as a universal screening tool, and to assess the effect of interventions by a colocated psychologist on changes in ASQ:SE scores over time.

METHODS: In a prospective cohort design we analyzed scores on ASQ:SE surveys completed on children 6 to 36 months of age, to determine if children were at risk for problems in social-emotional development. The probability of remaining at risk over time was then compared between subjects receiving intervention by the psychologist, and those who declined intervention. Logit specifications were used in multivariate comparisons to control for a set of covariates.

RESULTS: Three thousand one hundred and sixty-nine children were screened; 711 (22.4%) scored at or above the risk cutoff. Among the 711 at-risk children, 170 were rescreened. At the time of rescreening, those children who received intervention from the psychologist showed significant improvement on ASQ:SE scores compared with those who declined intervention (P = .01).

CONCLUSIONS: Universal social-emotional screening in a busy pediatric practice is challenging. Significant percentages of children can be identified as being at risk for social-emotional problems, and colocation of a psychologist promotes the ability to effectively address young children’s social-emotional development within their medical home.

KEY WORDS

preventive mental health services
colocation
infant mental health
social-emotional screening

Accepted October 4, 2011.

· Abstract 33 of 67Article

Perioperative Methylprednisolone and Outcome in Neonates Undergoing Heart Surgery

BACKGROUND: Recent studies have called into question the benefit of perioperative corticosteroids in children undergoing heart surgery, but have been limited by the lack of placebo control, limited power, and grouping of various steroid regimens together in analysis. We evaluated outcomes across methylprednisolone regimens versus no steroids in a large cohort of neonates.

METHODS: Clinical data from the Society of Thoracic Surgeons Database were linked to medication data from the Pediatric Health Information Systems Database for neonates (≤30 days) undergoing heart surgery (2004–2008) at 25 participating centers. Multivariable analysis adjusting for patient and center characteristics, surgical risk category, and within-center clustering was used to evaluate the association of methylprednisolone regimen with outcome.

RESULTS: A total of 3180 neonates were included: 22% received methylprednisolone on both the day before and day of surgery, 12% on the day before surgery only, and 28% on the day of surgery only; 38% did not receive any perioperative steroids. In multivariable analysis, there was no significant mortality or length-of-stay benefit associated with any methylprednisolone regimen versus no steroids, and no difference in postoperative infection. In subgroup analysis by surgical-risk group, there was a significant association of methylprednisolone with infection consistent across all regimens (overall odds ratio 2.6, 95% confidence interval 1.3–5.2) in the lower-surgical-risk group.

CONCLUSIONS: This multicenter observational analysis did not find any benefit associated with methylprednisolone in neonates undergoing heart surgery and suggested increased infection in certain subgroups. These data reinforce the need for a large randomized trial in this population.

KEY WORDS

congenital heart disease
heart surgery
outcomes

Accepted October 24, 2011.

· Abstract 34 of 67Article

Lead Poisoning in United States-Bound Refugee Children: Thailand-Burma Border, 2009

BACKGROUND: Elevated blood lead levels lead to permanent neurocognitive sequelae in children. Resettled refugee children in the United States are considered at high risk for elevated blood lead levels, but the prevalence of and risk factors for elevated blood lead levels before resettlement have not been described.

METHODS: Blood samples from children aged 6 months to 14 years from refugee camps in Thailand were tested for lead and hemoglobin. Sixty-seven children with elevated blood lead levels (venous ≥10 µg/dL) or undetectable (capillary <3.3 µg/dL) blood lead levels participated in a case-control study.

RESULTS: Of 642 children, 33 (5.1%) had elevated blood lead levels. Children aged <2 years had the highest prevalence (14.5%). Among children aged <2 years included in a case-control study, elevated blood lead levels risk factors included hemoglobin <10 g/dL, exposure to car batteries, and taking traditional medicines.

CONCLUSIONS: The prevalence of elevated blood lead levels among tested US-bound Burmese refugee children was higher than the current US prevalence, and was especially high among children <2 years old. Refugee children may arrive in the United States with elevated blood lead levels. A population-specific understanding of preexisting lead exposures can enhance postarrival lead-poisoning prevention efforts, based on Centers for Disease Control and Prevention recommendations for resettled refugee children, and can lead to remediation efforts overseas.

KEY WORDS

lead poisoning
refugees
anemia
environmental exposure

Accepted September 28, 2011.

· Abstract 35 of 67Article

Fetal and Maternal Candidate Single Nucleotide Polymorphism Associations With Cerebral Palsy: A Case-Control Study

OBJECTIVE: Previous studies have suggested associations between certain genetic variants and susceptibility to cerebral palsy (CP). This study was designed to assess established and novel maternal and child genetic and epidemiologic risk factors for CP along with their interactions.

METHODS: DNA from 587 case and 1154 control mother-child pairs was analyzed. A panel of 35 candidate single nucleotide polymorphisms (SNPs) were examined and included SNPs in genes associated with (1) thrombophilia, (2) inflammation, and (3) risk factors for CP (eg, preterm birth). Comparisons were specified a priori and made by using a χ² test.

RESULTS: There were 40 fetal and 28 maternal associations with CP when analyzed by CP subtype, gestational age, genotypes of apolipoprotein E, and haplotypes of mannose-binding-lectin. After Bonferroni correction for multiple testing, no fetal or maternal candidate SNP was associated with CP or its subtypes. Only fetal carriage of prothrombin gene mutation remained marginally associated with hemiplegia in term infants born to mothers with a reported infection during pregnancy. Odds ratio directions of fetal SNP associations were compared with previously reported studies and confirmed no trend toward association.

CONCLUSIONS: Except for the prothrombin gene mutation, individual maternal and fetal SNPs in our candidate panel were not found to be associated with CP outcome. Past reported SNP associations with CP were not confirmed, possibly reflecting type I error from small numbers and multiple testing in the original reports.

KEY WORDS

cerebral palsy
candidate gene
SNP association
case-control

Accepted October 27, 2011.

· Abstract 36 of 67Article

Pertussis Pseudo-outbreak Linked to Specimens Contaminated by Bordetella pertussis DNA From Clinic Surfaces

BACKGROUND AND OBJECTIVES: We investigated a pertussis outbreak characterized by atypical cases, confirmed by polymerase chain reaction (PCR) alone at a single laboratory, which persisted despite high vaccine coverage and routine control measures. We aimed to determine whether Bordetella pertussis was the causative agent and advise on control interventions.

METHODS: We conducted case ascertainment, confirmatory testing for pertussis and other pathogens, and an assessment for possible sources of specimen contamination, including a survey of clinic practices, sampling clinics for B pertussis DNA, and review of laboratory quality indicators.

RESULTS: Between November 28, 2008, and September 4, 2009, 125 cases were reported, of which 92 (74%) were PCR positive. Cases occurring after April 2009 (n = 79; 63%) had fewer classic pertussis symptoms (63% vs 98%; P < .01), smaller amounts of B pertussis DNA (mean PCR cycle threshold value: 40.9 vs 33.1; P < .01), and a greater proportion of PCR-positive results (34% vs 6%; P < .01). Cultures and serology for B pertussis were negative. Other common respiratory pathogens were detected. We identified factors that likely resulted in specimen contamination at the point of collection: environmentally present B pertussis DNA in clinics from vaccine, clinic standard specimen collection practices, use of liquid transport medium, and lack of clinically relevant PCR cutoffs.

CONCLUSIONS: A summer pertussis pseudo-outbreak, multifactorial in cause, likely occurred. Recommendations beyond standard practice were made to providers on specimen collection and environmental cleaning, and to laboratories on standardizing PCR protocols and reporting results, to minimize false-positive results from contaminated clinical specimens.

KEY WORDS

Bordetella pertussis
cross contamination
disease outbreak
polymerase chain reaction
false positive result
diagnostic errors

Accepted October 13, 2011.

· Abstract 37 of 67Article

Genetic Causes of Macroglossia: Diagnostic Approach

OBJECTIVE: Evaluate the contribution of standard diagnostic tests for macroglossia when clinical features are not suggestive of Beckwith-Wiedemann syndrome (BWS).

METHODS: A retrospective analysis of data from clinical, laboratory, and imaging information from children with macroglossia seen at Cincinnati Children’s Hospital Medical Center between 1997 and 2010 was performed.

RESULTS: One hundred thirty-five children with macroglossia were identified. Macroglossia was the main reason for consultation in 84 children. Patients were classified on initial examination as isolated macroglossia (n = 24), provisional BWS (n = 36), and syndromic (n = 24). A final diagnosis was reached in 74 patients, and in 10 patients the reason for macroglossia remained undetermined. Among the elucidated cases, BWS was the most common cause of macroglossia (39/84). Six of the 24 patients in the isolated macroglossia group had an abnormal molecular test for BWS (P = .006). Thirteen diagnostic conditions were confirmed in this study, and 42% of the population had a specific diagnosis that was not BWS (35/84).

CONCLUSIONS: These results can be used to improve our strategy in the evaluation of macroglossia. Distinction between isolated macroglossia and BWS may be difficult when only taking into account clinical features. These findings suggest that all patients with apparently isolated macroglossia have at least initial evaluation with abdominal ultrasounds and molecular studies for BWS before a final diagnosis is given. BWS was the most common cause of macroglossia even in the absence of additional clinical findings.

KEY WORDS

Macroglossia
Beckwith-Wiedemann syndrome
α-fetoprotein
ultrasonography
molecular genetics

Accepted September 27, 2011.

· Abstract 38 of 67Article

Calculation of Expected Body Weight in Adolescents With Eating Disorders

OBJECTIVE: To examine the agreement between three methods to calculate expected body weight (EBW) for adolescents with eating disorders: (1) BMI percentile, (2) McLaren, and (3) Moore methods.

METHODS: The authors conducted a cross-sectional analysis of baseline information from adolescents seeking treatment of disordered eating at The University of Chicago. Adolescents (N = 373) aged 12 to 18 years (mean = 15.84, SD = 1.72), with anorexia nervosa (n = 130), bulimia nervosa (n = 59), or eating disorder not otherwise specified (n = 184). Concurrence between the BMI percentile, McLaren, and Moore methods was assessed for agreement above or below arbitrary cut points used in relation to hospitalization (75%), diagnosis (85%), and healthy weight (100%). Patterns of absolute discrepancies were examined by height, age, gender, and menstrual status. Limitations to some of these methods allowed comparison between all 3 methods in only 204 participants.

RESULTS: Moderate agreement was seen between the 3 methods (κ values, 0.48–0.74), with pairwise total classification accuracy at each cut point ranging from 84% to 98%. The most discrepant calculations were observed among the tallest (>75th percentile) and shortest (<20th percentile) cases and older ages (>16 years). Many of the most discrepant cases fell above and below 85% EBW when comparing the BMI percentile and Moore methods, indicating disagreement on possible diagnosis of anorexia nervosa.

CONCLUSIONS: These methods largely agree on percent EBW in terms of clinically significant cut points. However, the McLaren and Moore methods present with limitations, and a commonly agreed-upon method for EBW calculation such as the BMI percentile method is recommended for clinical and research purposes.

KEY WORDS

adolescence
body weight
eating disorders

Accepted September 26, 2011.

· Abstract 39 of 67Article

Intrapartum Temperature Elevation, Epidural Use, and Adverse Outcome in Term Infants

OBJECTIVES: To examine the association of intrapartum temperature elevation with adverse neonatal outcome among low-risk women receiving epidural analgesia and evaluate the association of epidural with adverse neonatal outcome without temperature elevation.

METHODS: We studied all low-risk nulliparous women with singleton pregnancies ≥37 weeks delivering at our hospital during 2000, excluding pregnancies where infants had documented sepsis, meningitis, or a major congenital anomaly. Neonatal outcomes were compared between women receiving (n = 1538) and not receiving epidural analgesia (n = 363) in the absence of intrapartum temperature elevation (≤99.5°F) and according to the level of intrapartum temperature elevation within the group receiving epidural (n = 2784). Logistic regression was used to evaluate neonatal outcome while controlling for confounders.

RESULTS: Maternal temperature >100.4°F developed during labor in 19.2% (535/2784) of women receiving epidural compared with 2.4% (10/425) not receiving epidural. In the absence of intrapartum temperature elevation (≤99.5°F), no significant differences were observed in adverse neonatal outcomes between women receiving and not receiving epidural. Among women receiving epidural, a significant linear trend was observed between maximum maternal temperature and all neonatal outcomes examined including hypotonia, assisted ventilation, 1- and 5-min Apgar scores <7, and early-onset seizures. In regression analyses, infants born to women with fever >101°F had a two- to sixfold increased risk of all adverse outcomes examined.

CONCLUSIONS: The proportion of infants experiencing adverse outcomes increased with the degree of epidural-related maternal temperature elevation. Epidural use without temperature elevation was not associated with any of the adverse outcomes we studied.

KEY WORDS

maternal fever
epidural analgesia
pregnancy
labor
infant
neonatal outcome
neurologic
seizures

Accepted September 27, 2011.

· Abstract 40 of 67Article

Genetic and Environmental Components of Neonatal Weight Gain in Preterm Infants

BACKGROUND AND OBJECTIVES: Postnatal nutrition and subsequent weight gain or failure in the neonatal period are likely regulated by both the environment and the genetic background. With the goal of estimating the variability of postnatal weight gain due to genes and environment, comparison between monozygotic (ie, genetically identical) and dizygotic (genetically similar as 2 siblings) twins can be performed.

METHODS: This study selected a very homogenous set of monozygotic and dizygotic twins who met the following inclusion criteria: gestational age between 30 and 36 weeks, birth weight between 1250 and 2200 g, and length of stay >12 days. Opposite-gender pairs and pairs that differed >20% in terms of birth weight were excluded from this analysis. The outcome measure of this study was the daily weight gain expressed in grams per kilogram per day during the period between day of birth and day of discharge. The average difference between members of a pair was computed in the 2 groups of twins, and heritability was estimated.

RESULTS: The within-pair differences of the outcome measure were lower for monozygotic twins than for dizygotic twins, suggesting a strong genetic component. The total variance of the phenotype under study is explained by 2 sources of variation, additive genetic (87% [95% confidence interval: 67% to 94%]) and unique environment (13% [95% confidence interval: 6% to 33%]) components.

CONCLUSIONS: This high heritability estimate could suggest using this set of criteria to identify genes that regulate postnatal weight gain or failure.

KEY WORDS

twins
growth
preterm infants

Accepted September 27, 2011.

· Abstract 41 of 67Review Article

Ethanol Locks to Prevent Catheter-Related Bloodstream Infections in Parenteral Nutrition: A Meta-Analysis

OBJECTIVE: Patients with pediatric intestinal failure (IF) depend on parenteral nutrition for growth and survival, but are at risk for complications, such as catheter-related bloodstream infections (CRBSIs). CRBSI prevention is crucial, as sepsis is an important cause of IF-associated liver disease and mortality. We aim to estimate the pooled effectiveness and safety of ethanol locks (ELs) in comparison with heparin locks (HLs) with regard to CRBSI rate and catheter replacements for pediatric IF patients with chronic parenteral nutrition dependence.

METHODS: A systematic review without language restriction was performed on Medline (1948–2010), Embase (1980–2010), and conference programs and trial registries up to December 2010. Search terms included “Catheter-Related Infections,” “Catheter,” “Catheters, Indwelling,” “alcohol,” “ethanol,” and “lock.” Two authors identified 4 retrospective studies for the pediatric IF population. Double, independent data extraction using predefined data fields and risk of bias assessment (Newcastle-Ottawa scale) was performed.

RESULTS: In comparison with HLs, ELs reduced the CRBSI-rate per 1000 catheter days by 7.67 events and catheter replacements by 5.07. EL therapy decreased the CRBSI rate by 81% and replacements by 72%. One hundred eight to 150 catheter days of EL exposure were necessary to prevent 1 CRBSI and 122 to 689 days of exposure avoided 1 catheter replacement. Adverse events were rare and included thrombotic events.

CONCLUSIONS: In pediatric patients with IF, EL is a more effective alternative to HL. Adverse events include thrombotic events.

KEY WORDS

sepsis
ethanol lock
catheter-related bloodstream infection
parenteral nutrition
intestinal failure

Accepted September 26, 2011.

· Abstract 42 of 67State-of-the-Art Review Article

The Diet Factor in Attention-Deficit/Hyperactivity Disorder

This article is intended to provide a comprehensive overview of the role of dietary methods for treatment of children with attention-deficit/hyperactivity disorder (ADHD) when pharmacotherapy has proven unsatisfactory or unacceptable. Results of recent research and controlled studies, based on a PubMed search, are emphasized and compared with earlier reports. The recent increase of interest in this form of therapy for ADHD, and especially in the use of omega supplements, significance of iron deficiency, and the avoidance of the “Western pattern” diet, make the discussion timely.

Diets to reduce symptoms associated with ADHD include sugar-restricted, additive/preservative-free, oligoantigenic/elimination, and fatty acid supplements. Omega−3 supplement is the latest dietary treatment with positive reports of efficacy, and interest in the additive-free diet of the 1970s is occasionally revived. A provocative report draws attention to the ADHD-associated “Western-style” diet, high in fat and refined sugars, and the ADHD-free “healthy” diet, containing fiber, folate, and omega-3 fatty acids.

The literature on diets and ADHD, listed by PubMed, is reviewed with emphasis on recent controlled studies. Recommendations for the use of diets are based on current opinion of published reports and our practice experience. Indications for dietary therapy include medication failure, parental or patient preference, iron deficiency, and, when appropriate, change from an ADHD-linked Western diet to an ADHD-free healthy diet. Foods associated with ADHD to be avoided and those not linked with ADHD and preferred are listed.

In practice, additive-free and oligoantigenic/elimination diets are time-consuming and disruptive to the household; they are indicated only in selected patients. Iron and zinc are supplemented in patients with known deficiencies; they may also enhance the effectiveness of stimulant therapy. In patients failing to respond or with parents opposed to medication, omega-3 supplements may warrant a trial. A greater attention to the education of parents and children in a healthy dietary pattern, omitting items shown to predispose to ADHD, is perhaps the most promising and practical complementary or alternative treatment of ADHD.

KEY WORDS

additive-free
attention
behavior
diet
elimination
hyperactivity
iron
ketogenic
oligoantigenic
omega-3
pediatrics
sucrose
zinc

Accepted October 5, 2011.

· Abstract 43 of 67Special Article

Annual Summary of Vital Statistics: 2009

The number of births in the United States decreased by 3% between 2008 and 2009 to 4 130 665 births. The general fertility rate also declined 3% to 66.7 per 1000 women. The teenage birth rate fell 6% to 39.1 per 1000. Birth rates also declined for women 20 to 39 years and for all 5-year groups, but the rate for women 40 to 44 years continued to rise. The percentage of all births to unmarried women increased to 41.0% in 2009, up from 40.6% in 2008. In 2009, 32.9% of all births occurred by cesarean delivery, continuing its rise. The 2009 preterm birth rate declined for the third year in a row to 12.18%. The low-birth-weight rate was unchanged in 2009 at 8.16%. Both twin and triplet and higher order birth rates increased. The infant mortality rate was 6.42 infant deaths per 1000 live births in 2009. The rate is significantly lower than the rate of 6.61 in 2008. Linked birth and infant death data from 2007 showed that non-Hispanic black infants continued to have much higher mortality rates than non-Hispanic white and Hispanic infants. Life expectancy at birth was 78.2 years in 2009. Crude death rates for children and adolescents aged 1 to 19 years decreased by 6.5% between 2008 and 2009. Unintentional injuries and homicide, the first and second leading causes of death jointly accounted for 48.6% of all deaths to children and adolescents in 2009.

KEY WORDS

birth
death
teenaged fertility
infant mortality
low birth weight
mortality
multiple births
cesarean rate
vital statistics
International Classification of Diseases
Tenth Revision
revised certificates

Accepted November 23, 2011.

· Abstract 44 of 67Special Article

Intravenous Acetaminophen in the United States: Iatrogenic Dosing Errors

An intravenous formulation of acetaminophen was introduced to the United States in 2011. Experience from Europe indicates that serious dosing errors are likely to occur. Most events have involved a 10-fold dosing error in small children caused by calculating the dosage in milligrams, but then administering the solution in milliliters. The solution is 10 mg/mL; therefore, a 10-fold overdose occurs. Evaluation of overdose with the intravenous formulation is similar to oral overdose. A serum acetaminophen concentration should be drawn 4 hours after the infusion was started or as soon thereafter as possible. If the serum acetaminophen concentration plots above the treatment line on the Rumack-Matthew nomogram, treatment with acetylcysteine should be initiated. Health care providers are encouraged to contact their regional poison center (1-800-222-1222) so that dosing errors will be reported, and the experience with this new product can be accumulated.

KEY WORDS

acetaminophen
paracetamol
adverse event
intravenous administration
human

Accepted October 24, 2011.

· Abstract 45 of 67Special Article

Pediatric Analgesic Clinical Trial Designs, Measures, and Extrapolation: Report of an FDA Scientific Workshop

Analgesic trials pose unique scientific, ethical, and practical challenges in pediatrics. Participants in a scientific workshop sponsored by the US Food and Drug Administration developed consensus on aspects of pediatric analgesic clinical trial design. The standard parallel-placebo analgesic trial design commonly used for adults has ethical and practical difficulties in pediatrics, due to the likelihood of subjects experiencing pain for extended periods of time. Immediate-rescue designs using opioid-sparing, rather than pain scores, as a primary outcome measure have been successfully used in pediatric analgesic efficacy trials. These designs maintain some of the scientific benefits of blinding, with some ethical and practical advantages over traditional designs. Preferred outcome measures were recommended for each age group. Acute pain trials are feasible for children undergoing surgery. Pharmacodynamic responses to opioids, local anesthetics, acetaminophen, and nonsteroidal antiinflammatory drugs appear substantially mature by age 2 years. There is currently no clear evidence for analgesic efficacy of acetaminophen or nonsteroidal antiinflammatory drugs in neonates or infants younger than 3 months of age. Small sample designs, including cross-over trials and N of 1 trials, for particular pediatric chronic pain conditions and for studies of pain and irritability in pediatric palliative care should be considered. Pediatric analgesic trials can be improved by using innovative study designs and outcome measures specific for children. Multicenter consortia will help to facilitate adequately powered pediatric analgesic trials.

KEY WORDS

pain
pediatric
infant
child
neonate
analgesic
clinical trial
placebo

Accepted October 26, 2011.

· Abstract 46 of 67Special Article

An Integrated Scientific Framework for Child Survival and Early Childhood Development

Building a strong foundation for healthy development in the early years of life is a prerequisite for individual well-being, economic productivity, and harmonious societies around the world. Growing scientific evidence also demonstrates that social and physical environments that threaten human development (because of scarcity, stress, or instability) can lead to short-term physiologic and psychological adjustments that are necessary for immediate survival and adaptation, but which may come at a significant cost to long-term outcomes in learning, behavior, health, and longevity. Generally speaking, ministries of health prioritize child survival and physical well-being, ministries of education focus on schooling, ministries of finance promote economic development, and ministries of welfare address breakdowns across multiple domains of function. Advances in the biological and social sciences offer a unifying framework for generating significant societal benefits by catalyzing greater synergy across these policy sectors. This synergy could inform more effective and efficient investments both to increase the survival of children born under adverse circumstances and to improve life outcomes for those who live beyond the early childhood period yet face high risks for diminished life prospects.

KEY WORDS

child
child development
child survival
early childhood development
global health
health disparities
poverty
risk factors
social policy

Accepted September 28, 2011.

· Abstract 47 of 67Special Article

Pediatric Self-management: A Framework for Research, Practice, and Policy

Self-management of chronic pediatric conditions is a formidable challenge for patients, families, and clinicians, with research demonstrating a high prevalence of poor self-management and nonadherence across pediatric conditions. Nevertheless, effective self-management is necessary to maximize treatment efficacy and clinical outcomes and to reduce unnecessary health care utilization and costs. However, this complex behavior is poorly understood as a result of insufficient definitions, reliance on condition-specific and/or adult models of self-management, failure to consider the multitude of factors that influence patient self-management behavior, and lack of synthesis of research, clinical practice, and policy implications. To address this need, we present a comprehensive conceptual model of pediatric self-management that articulates the individual, family, community, and health care system level influences that impact self-management behavior through cognitive, emotional, and social processes. This model further describes the relationship among self-management, adherence, and outcomes at both the patient and system level. Implications for research, clinical practice, and health care policy concerning pediatric chronic care are emphasized with a particular focus on modifiable influences, evidence-based targets for intervention, and the role of clinicians in the provision of self-management support. We anticipate that this unified conceptual approach will equip stakeholders in pediatric health care to (1) develop evidence-based interventions to improve self-management, (2) design programs aimed at preventing the development of poor self-management behaviors, and (3) inform health care policy that will ultimately improve the health and psychosocial outcomes of children with chronic conditions.

KEY WORDS

adherence
children
family
model
individual
family
community
health care system
influences

Accepted September 28, 2011.

· Abstract 48 of 67Special Article

The Sudden Unexpected Infant Death Case Registry: A Method to Improve Surveillance

This article describes a multistate population-based surveillance system for monitoring sudden unexpected infant deaths (SUIDs) known as the SUID Case Registry pilot program. The pilot program represents collaboration between the Centers for Disease Control and Prevention and the National Center for Child Death Review (NCCDR), which is funded by the Health Resources and Services Administration. The SUID Case Registry builds on existing child death review system activities and protocols. The objectives of the SUID Case Registry are to collect accurate and consistent population-based data about the circumstances and events associated with SUID cases, to improve the completeness and quality of SUID case investigations, and to use a decision-making algorithm with standardized definitions to categorize SUID cases. States who participate in the pilot program commit to review all SUID cases in their state by using their multidisciplinary state and local child death review teams. These teams request and review data from death scene investigators, medical examiners and coroners, law enforcement, social services, pediatric and obstetric providers, and public health per usual, but as part of the pilot program, supplement their SUID case reviews by discussing additional medical, environmental, and behavioral factors, and entering this data using the NCCDR Web-based Case Reporting System. This new surveillance system aims to improve knowledge of factors surrounding SUID events and improve investigation practices. The surveillance system will allow researchers and program planners to create prevention strategies and interventions, ultimately reducing SUIDs and injury-related infant deaths.

KEY WORDS

SIDS
SUID
child death review
surveillance
infant mortality
infant injury

Accepted October 7, 2011.

· Abstract 49 of 67Commentary

· Abstract 50 of 67Commentary

· Abstract 51 of 67Commentary

· Abstract 52 of 67Quality Report

Improving the Quality of Immunization Delivery to an At-Risk Population: A Comprehensive Approach

OBJECTIVE: Immunization quality improvement (QI) interventions are rarely tested as multicomponent interventions within the context of a theoretical framework proven to improve outcomes. Our goal was to study a comprehensive QI program to increase immunization rates for underserved children that relied on recommendations from the Centers for Disease Control and Prevention’s Task Force on Community Preventive Services and the framework of the Chronic Care Model.

METHODS: QI activities occurred from September 2007 to May 2008 at 6 health centers serving a low-income, minority population in Washington, DC. Interventions included family reminders, education, expanding immunization access, reminders and feedback for providers, and coordination of activities with community stakeholders. We determined project effectiveness in improving the 4:3:1:3:3:1:3 vaccination series (4 diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 measles-mumps-rubella vaccine, 3 Haemophilus influenzae type b vaccines, 3 hepatitis B vaccines, 1 varicella vaccine, and three 7-valent pneumococcal conjugate vaccines) compliance.

RESULTS: We found a 16% increase in immunization rates overall and a 14% increase in on-time immunization by 24 months of age. Improvement was achieved at all 6 health centers and maintained beyond 18 months.

CONCLUSION: We were able to implement a comprehensive immunization QI program that was sustainable over time.

KEY WORDS

immunizations
quality improvement
vaccines
pediatric
pediatric outpatient clinics

Accepted October 10, 2011.

· Abstract 53 of 67Quality Report

Enhancing Accurate Identification of Food Insecurity Using Quality-Improvement Techniques

BACKGROUND AND OBJECTIVES: Infants who live in households experiencing food insecurity are at risk for negative health and developmental outcomes. Despite large numbers of households within our population experiencing food insecurity, identification of household food insecurity during standard clinical care is rare. The objective of this study was to use quality-improvement methods to increase identification of household food insecurity by the second-year pediatric residents working in the Pediatric Primary Care Center from 1.9% to 15.0% within 6 months. A secondary aim was to increase the proportion of second-year pediatric residents identifying food insecurity.

METHODS: A team was formed to identify key drivers thought to be critical to the process of identifying food insecurity during well-child care. This project addressed 5 key drivers and tested interventions based on these drivers over a 6-month period at a hospital-based primary care site that serves ∼15 000 children from underserved neighborhoods. Tests included implementing an evidence-based electronic screen for food insecurity, educational interventions to improve understanding of food insecurity, empowerment exercises targeting clinicians and families, and gaining buy-in and support from ancillary personnel.

RESULTS: Implementation of these changes led to an increase in the identification rate of household food insecurity from 1.9% to 11.2% over the 6 months (P < .01). The proportion of residents identifying food insecurity increased from 37.5% to 91.9% (P < .01).

CONCLUSIONS: Application of quality-improvement methods in a primary care clinic increased ability to effectively screen and positively identify households with food insecurity in this population.

KEY WORDS

food insecurity
quality improvement
primary care
pediatrics

Accepted October 10, 2011.

· Abstract 54 of 67Case Report

Successful Treatment of Type 1 Diabetes and Seizures With Combined Ketogenic Diet and Insulin

Diabetic ketoacidosis (DKA) is a life-threatening condition and a major cause of morbidity and mortality in children with type 1 diabetes mellitus. The deficiency of insulin leads to metabolic decompensation, causing hyperglycemia and ketosis that resolves with the administration of insulin and fluids. However, an induced state of ketosis is the basis for the success of the ketogenic diet (KD), which is an effective therapy for children with intractable epilepsy. We report the case of a 2-year-old girl who presented to the emergency department with 1-week history of decreased activity, polyuria, and decreased oral intake. Her past medical history was remarkable for epilepsy, for which she was started on the KD with a significant improvement. Her laboratory evaluation was compatible with DKA, and fluids and insulin were given until correction. Because of concerns regarding recurrence of her seizures, the KD was resumed along with the simultaneous use of insulin glargine and insulin aspart. Urine ketones were kept in the moderate range to keep the effect of ketosis on seizure control. Under this combined therapy, the patient remained seizure-free with no new episodes of DKA.

KEY WORDS

diabetes
seizures
ketogenic diet
insulin
diabetic ketoacidosis

Accepted September 9, 2011.

· Abstract 55 of 67Case Report

Malrotation of the Intestine and Chronic Volvulus as a Cause of Protein-Losing Enteropathy in Infancy

Protein-losing enteropathy in children is caused by intestinal metabolic, inflammatory, or infectious processes, or by lymphatic obstruction (intestinal lymphangiectasia). In this report, a 17-month-old child is presented with protein-losing enteropathy due to intestinal malrotation and chronic midgut volvulus causing lymphatic obstruction and spillage of lymph in the intestine and the peritoneum. This report should alert the pediatrician that intestinal malrotation should be added to the wide list of possible causes of protein-losing enteropathy in children.

KEY WORDS

children
chronic midgut volvulus
intestinal malrotation
protein-losing enteropathy

Accepted September 16, 2011.

· Abstract 56 of 67Case Report

Cytokine Dermatitis and Febrile Seizure From Imiquimod

Cytokine dermatitis is a well-known and common clinical adverse effect of imiquimod 5% cream (Aldara, 3M). Data from initial Phase III clinical trials reveal a minority of study drug patients experience systemic adverse effects, including fever, arthralgia, headache, myalgia, and lymphadenopathy. These adverse effects are caused, presumably, from increased absorption of study drug over the area of dermatitis, leading to systemic cytokine release. Furthermore, the incidence of systemic reactions was rarely statistically increased above control patients. We describe herein a case of severe cytokine dermatitis in a 2-year-old female patient treated with daily imiquimod for molluscum contagiosum who subsequently developed febrile seizure. We believe this to be the first reported case of seizure associated with imiquimod 5% cream (Aldara, 3M) in a pediatric setting.

KEY WORDS

adverse effect
carcinoma
fever
imiquimod
immunomodulator
keratosis
seizure
Toll-like receptor 7
topical

Accepted October 5, 2011.

· Abstract 57 of 67Case Report

Skin Lesions in a Boy With X-linked Lymphoproliferative Disorder: Comparison of 5 SH2D1A Deletion Cases

SH2D1A gene defects are the cause of X-linked lymphoproliferative disorder (XLP-1), a rare condition characterized by severe immune dysregulation. We present a patient lacking the typical symptoms of XLP-1, but experiencing a severe unusual skin condition encompassing features of dermatosclerosis and vesiculobullous skin disease. A maternal cousin of the patient was diagnosed with XLP-1 and found to carry a deletion of the SH2D1A gene. SH2D1A deletion was also identified in our patient, which offered a possible explanation for his skin symptoms. Subsequent analysis showed that the deletion in both cousins was identical and involved the whole SH2D1A gene and a part of the adjacent ODZ1 gene. High phenotypic variability of XLP-1 observed in this family prompted us to analyze the genotype-phenotype correlation of 2 different-sized deletions involving SH2D1A and ODZ1 in 5 patients from 2 families, and we report the clinical and laboratory data on these individuals. Our findings illustrate the wide clinical variability of XLP-1, both inter- and intrafamilial, which may complicate the diagnosis of this condition. The comparison of phenotypes of our patients argues against a strong involvement of the ODZ1 gene in the skin disorder and other symptoms observed in our index patient. His hitherto not described severe skin condition extends the phenotypic range of XLP-1.

KEY WORDS

SH2D1A
ODZ1
SAP
teneurin
X-linked lymphoproliferative syndrome
aplastic anemia
lymphoma
dermatitis
psoriasis
dermatosclerosis
vesiculobullous skin disease

· Abstract 58 of 67Case Report

Panhypopituitarism Presenting as Life-Threatening Heart Failure Caused by an Inherited Microdeletion in 1q25 Including LHX4

Clinical presentation of hypopituitarism in the neonate may be variable, ranging from absent to severe nonspecific symptoms and may be life-threatening in patients with adrenocorticotropic hormone deficiency. The LIM homeobox gene 4 (LHX4) transcription factor regulates early embryonic development of the anterior pituitary gland. Autosomal dominant mutations in LHX4 cause congenital hypopituitarism with variable combined pituitary hormone deficiency (CPHD). We report on a neonate with unexplained heart failure and minor physical anomalies, suggesting a midline defect. She was diagnosed with complete CPHD. Cardiac function was rescued by replacement with hydrocortisone and thyroxine; hypoglycaemia stopped under growth hormone therapy. Magnetic resonance imaging revealed a dysgenetic pituitary gland suggesting an early developmental defect. Array comparative genomic hybridization showed a maternally inherited 1.5-megabase microdeletion in 1q25.2q25.3, including the LHX4 gene. Haploinsufficiency of LHX4 likely explains the predominant pituitary phenotype in the proposita and we suggest variable intrafamilial penetrance of the inherited microdeletion. To the best of our knowledge, we are the first to report on heart failure as a rare nonspecific symptom of treatable CPHD in the newborn. Variably penetrant pituitary insufficiency, including this severe and atypical presentation, can be correlated with LHX4 insufficiency and highlights the role of LHX4 for pituitary development.

KEY WORDS

heart failure
panhypopituitarism
CPHD
neonate
microdeletion
1q25
LHX4

Accepted October 5, 2011.

· Abstract 59 of 67Case Report

Clinical, Genetic, and Therapeutic Diversity in 2 Patients With Severe Mevalonate Kinase Deficiency

Mevalonic aciduria (MA) represents the severest form of mevalonate kinase deficiency due to recessively inherited, loss-of-function MVK mutations. MA is an early-onset disorder characterized by a marked failure to thrive, diverse neurologic symptoms, dysmorphic features, and recurrent febrile episodes. However, significant clinical differences have been reported in the few cases published to date. Here we describe 2 unrelated Spanish patients with MA, emphasizing the clinical heterogeneity observed. One patient presented with the severe classic MA phenotype due to the homozygous p.Ile-268-Thr MVK genotype, with a poor response to conventional treatments. However, the anti-interleukin 1 agent anakinra in this patient resulted in improvement in many clinical and laboratory parameters. The second patient presented with an atypical milder phenotype because of an older age at disease onset, mild neurologic symptoms, absence of febrile episodes and dysmorphic features, and moderate-to-good response to conventional treatments. The novel p.Arg-241-Cys MVK mutation, associated with the already known p.Ser-135-Leu mutation, detected in this patient expands the genetic diversity of mevalonate kinase deficiency. This atypical presentation of MA suggests that it should be included in the differential diagnosis of unclassified patients with psychomotor retardation, failure to thrive or ataxia, even in the absence of febrile episodes.

KEY WORDS

Mevalonic aciduria
hyper-IgD and periodic fever
HIDS
mevalonate kinase deficiency
autoinflammatory diseases
metabolic diseases
anti-IL-1 therapy

Accepted October 13, 2011.

· Abstract 60 of 67From the American Academy of PediatricsClinical Report

Neonatal Drug Withdrawal

Maternal use of certain drugs during pregnancy can result in transient neonatal signs consistent with withdrawal or acute toxicity or cause sustained signs consistent with a lasting drug effect. In addition, hospitalized infants who are treated with opioids or benzodiazepines to provide analgesia or sedation may be at risk for manifesting signs of withdrawal. This statement updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal and is expanded to include evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.

KEY WORDS

opioid
methadone
heroin
fentanyl
benzodiazepine
cocaine
methamphetamine
SSRI
drug withdrawal
neonate
abstinence syndrome

· Abstract 61 of 67From the American Academy of PediatricsPolicy Statement

· Abstract 62 of 67From the American Academy of Pediatrics

Dispensing Medications at the Hospital Upon Discharge From an Emergency Department

Although most health care services can and should be provided by their medical home, children will be referred or require visits to the emergency department (ED) for emergent clinical conditions or injuries. Continuation of medical care after discharge from an ED is dependent on parents or caregivers’ understanding of and compliance with follow-up instructions and on adherence to medication recommendations. ED visits often occur at times when the majority of pharmacies are not open and caregivers are concerned with getting their ill or injured child directly home. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing ED discharge medications from the ED’s outpatient pharmacy within the facility is a major convenience that overcomes this obstacle, improving the likelihood of medication adherence. Emergency care encounters should be routinely followed up with primary care provider medical homes to ensure complete and comprehensive care.

KEY WORDS

emergency department
medication
pharmacy
hospital
discharge

· Abstract 63 of 67From the American Academy of Pediatrics

· Abstract 64 of 67From the American Academy of PediatricsPOLICY STATEMENT

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

School-Based Health Centers and Pediatric Practice

School-based health centers (SBHCs) have become an important method of health care delivery for the youth of our nation. Although they only represent 1 aspect of a coordinated school health program approach, SBHCs have provided access to health care services for youth confronted with age, financial, cultural, and geographic barriers. A fundamental principle of SBHCs is to create an environment of service coordination and collaboration that addresses the health needs and well-being of youth with health disparities or poor access to health care services. Some pediatricians have concerns that these centers are in conflict with the primary care provider’s medical home. This policy provides an overview of SBHCs and some of their documented benefits, addresses the issue of potential conflict with the medical home, and provides recommendations that support the integration and coordination of SBHCs and the pediatric medical home practice.

KEY WORDS

school-based health centers
school health services
medical home

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

Patient- and Family-Centered Care and the Pediatrician's Role

Drawing on several decades of work with families, pediatricians, other health care professionals, and policy makers, the American Academy of Pediatrics provides a definition of patient- and family-centered care. In pediatrics, patient- and family-centered care is based on the understanding that the family is the child’s primary source of strength and support. Further, this approach to care recognizes that the perspectives and information provided by families, children, and young adults are essential components of high-quality clinical decision-making, and that patients and family are integral partners with the health care team. This policy statement outlines the core principles of patient- and family-centered care, summarizes some of the recent literature linking patient- and family-centered care to improved health outcomes, and lists various other benefits to be expected when engaging in patient- and family-centered pediatric practice. The statement concludes with specific recommendations for how pediatricians can integrate patient- and family-centered care in hospitals, clinics, and community settings, and in broader systems of care, as well.

KEY WORDS

patient care

· Abstract 67 of 67Tribute

بازگشت

امروز

پنجشنبه

بهمن 1403

قمری:22 رجب 1446

میلادی:23 ژانویه 2025

آدرس پست الکترونیک :
info@ckmu.tbzmed.ac.ir

تمامی حقوق این سایت برای مرکز تحقیقات طب فیزیکی و توانبخشی محفوظ است