January 2012, VOLUME 129 / ISSUE 1 - مركز مديريت دانش بيماريهاي كودكان

پنجشنبه 4 بهمن 1403 - 22 رجب 1446

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شما اینجا هستید صفحه اصلیJanuary 2012, VOLUME 129 / ISSUE 1

مطالب آموزشی

January 2012, VOLUME 129 / ISSUE 1

· Abstract 1 of 60Pediatrics Digest

· Abstract 2 of 60Pediatrics Perspective

Overview of the Global Health Issues Facing Children

This first Pediatrics Perspectives column on global health joins the monthly rotation with other columns on medical history, graduate medical education, and medical student education. It makes good sense to add global health to the rotation. After all, the future of our world depends on the health and well-being of all its children. Medical history will be determined by the global health issues facing children today, and surely our education programs must broaden their content to include worldwide issues to meet the demands of future pediatric practice. It has been said by many pediatricians that any disease found on this planet is no farther than a plane ride from your local hospital. Clearly, the world is a very small place for all its inhabitants, and every day, travel continues to bring us closer. Global Health Perspectives will bring issues to the readership that will stimulate our thinking about strategies and initiatives to improve child health in the broadest context. For our initial column, Drs Cabral and Soares de Moura have traced the recent history of global child health, sharing perspectives that should cause each of us to think about the future of humankind.

Accepted October 11, 2011.

· Abstract 3 of 60Article

Antihypertensive Prescribing Patterns for Adolescents With Primary Hypertension

Background: Hypertension is an increasingly common problem in adolescents yet current medical management of primary hypertension in adolescents has not been well-described.

Methods: We identified adolescents with primary hypertension by International Classification of Diseases, Ninth Revision codes and looked at prescription patterns chronologically for antihypertensive drug class prescribed and the specialty of prescribing physician. We also examined patient demographics and presence of obesity-related comorbidities.

Results: During 2003–2008, there were 4296 adolescents with primary hypertension (HTN); 66% were boys; 73% were aged 11 to 14 years; 53% were black, 41% white, and 4% Hispanic; and 48% had obesity-related comorbidity. Twenty-three percent (977) received antihypertensive prescription. White subjects (odds ratio [OR]: 1.61; confidence interval [CI]: 1.39–1.88), older adolescents (≥15 years, OR: 2.11; CI: 1.79–2.48), and those with comorbidity (OR: 1.57; CI: 1.36–1.82) were more likely to receive antihypertensive prescriptions controlling for gender and years of Medicaid eligibility in logistic regression. Angiotensin converting enzyme inhibitors were the most frequently prescribed monotherapy. Nearly two-thirds of adolescents received prescriptions from adult primary care physicians (PCPs) only. More than one-quarter of adolescents who received a prescription received combination therapy, which was most often prescribed by adult PCPs.

Conclusions: Adult PCPs were the leading prescribers of antihypertensives for adolescents with primary HTN. Race differences exist in physicians’ prescribing of antihypertensives to adolescents with primary HTN. The choice of antihypertensives by physicians of different specialties warrants additional study to understand the underlying rationale for treatment decisions and to determine treatment effectiveness.

KEY WORDS

hypertension
adolescents
primary care
specialty differences
antihypertensive prescribing

Accepted September 9, 2011.

· Abstract 4 of 60Article

Early Intervention Improves Behavioral Outcomes for Preterm Infants: Randomized Controlled Trial

Objective: The aim of this study was to examine the effectiveness of an early intervention program on behavioral outcomes at corrected age of 5 years for children with birth weights (BWs) of <2000 g.

Methods: A randomized controlled trial of a modified version of the Mother-Infant Transaction Program was performed. Outcomes were measured by the Child Behavior Check List report (parents) and Strengths and Difficulties Questionnaire at 5 years (parents and preschool teachers).

Results: A total of 146 infants were assigned randomly (intervention group: 72 infants; reference group: 74 infants). A term group was recruited (75 infants). The mean BWs were 1396 ± 429 g for the intervention group, 1381 ± 436 g for the control group, and 3619 ± 490 g for the term reference group. Parents in the intervention group reported significantly fewer behavioral problems measured by both instruments at 5 years. There were no differences in behavior problems reported by preschool teachers. Significantly more children in the preterm control group scored within the clinical area of both instruments.

Conclusions: This modified version of the Mother-Infant Transaction Program led to fewer behavioral problems reported by parents at corrected age of 5 years for children with BWs of <2000 g.

KEY WORDS

preterm infants
early intervention
behavior
randomized controlled trial
Mother-Infant Transaction Program

Accepted September 15, 2011.

· Abstract 5 of 60Article

Corticosteroid Pulse Combination Therapy for Refractory Kawasaki Disease: A Randomized Trial

Objective: This study examined the clinical efficacy and safety of intravenous methylprednisolone-pulse plus intravenous immunoglobulin (IVIG) combination therapy (IVMP+IVIG) for the initial treatment of patients predicted to have refractory Kawasaki disease (KD).

Methods: One hundred twenty-two patients with KD were studied at Kitasato University. Refractory KD was predicted at diagnosis using the Egami score, and the patients were randomly divided to receive either IVMP+IVIG or IVIG alone. The Egami score is used to predict refractory KD patients before treatment using the patient’s age, days of illness, platelet count, C-reactive protein, and alanine aminotransferase level (cutoff: ≥3 points; 78% sensitivity and 76% specificity).

Results: Forty-eight patients (39.3%) were predicted to have refractory KD on the basis of the Egami score. The predicted IVIG responders (n = 74) received the standard therapy. The 48 predicted refractory KD patients were randomly assigned to a single-IVIG group (n = 26) or an IVMP+IVIG group (n = 22). Nineteen of the 22 patients (86.4%) in the IVMP+IVIG group had a prompt defervescence compared with 6 of the 26 patients (23.1%) in the single-IVIG group. The number of patients who had a z score ≥2.5 at 1 month was significantly higher in the single-IVIG group than in the IVMP+IVIG group. No serious adverse events were observed in either treatment group.

Conclusions: This study demonstrated that IVMP+IVIG therapy is safe and effective for KD patients predicted as refractory.

KEY WORDS

Kawasaki disease
intravenous immunoglobulin
methylpredonine pulse
resistant patient
prediction score

Accepted September 9, 2011.

· Abstract 6 of 60Article

US Estimates of Hospitalized Children With Severe Traumatic Brain Injury: Implications for Clinical Trials

Objectives: To estimate sample sizes available for clinical trials of severe traumatic brain injury (TBI) in children, we described the patient demographics and hospital characteristics associated with children hospitalized with severe TBI in the United States.

Methods: We analyzed the 2006 Kids’ Inpatient Database. Severe TBI hospitalizations were defined as children discharged with TBI who required mechanical ventilation or intubation. Types of high-volume severe TBI hospitals were categorized based on the numbers of discharged patients with severe TBI in 2006. National estimates of demographics and hospital characteristics were calculated for pediatric severe TBI. Simulation analyses were performed to assess the potential number of severe TBI cases from randomly selected hospitals for inclusion in future clinical trials.

Results: The majority of children with severe TBI were discharged from either a children’s unit in general hospitals (41%) or a nonchildren’s hospital (34%). Less than 5% of all hospitals were high-volume TBI hospitals, which discharged >78% of severe TBI cases and were more likely to be a children’s unit in a general hospital or a children’s hospital. Simulation analyses indicate that there is a saturation point after which the benefit of adding additional recruitment sites decreases significantly.

Conclusions: Children with severe TBI are infrequent at any one hospital in the United States, and few hospitals treat large numbers of children with severe TBI. To effectively plan trials of therapies for severe TBI, much attention has to be paid to selecting the right types of centers to maximize enrollment efficiency.

KEY WORDS

severe traumatic brain injury
clinical trials
children

Accepted September 9, 2011.

· Abstract 7 of 60Article

Headache After Pediatric Traumatic Brain Injury: A Cohort Study

Objective: To determine the prevalence of headache 3 and 12 months after pediatric traumatic brain injury (TBI).

Methods: This is a prospective cohort study of children ages 5 to 17 years in which we analyzed the prevalence of headache 3 and 12 months after mild TBI (mTBI; n = 402) and moderate/severe TBI (n = 60) compared with controls with arm injury (AI; n = 122).

Results: The prevalence of headache 3 months after injury was significantly higher after mTBI than after AI overall (43% vs 26%, relative risk [RR]: 1.7 [95% confidence interval (CI): 1.2–2.3]), in adolescents (13–17 years; 46% vs 25%, RR: 1.8 [95% CI: 1.1–3.1]), and in girls (59% vs 24%, RR: 2.4 [95% CI: 1.4–4.2]). The prevalence of headache at 3 months was also higher after moderate/severe TBI than AI in younger children (5–12 years; 60% vs 27%; RR: 2.0 [95% CI: 1.2–3.4]). Twelve months after injury, TBI was not associated with a significantly increased frequency of headache. However, girls with mTBI reported serious headache (≥ 5 of 10 pain scale rating) more often than controls (27% vs 10%, RR: 2.2 [95% CI: 0.9–5.6]).

Conclusions: Pediatric TBI is associated with headache. A substantial number of children suffer from headaches months after their head injury. The prevalence of headache during the year after injury is related to injury severity, time after injury, age, and gender. Girls and adolescents appear to be at highest risk of headache in the months after TBI.

KEY WORDS

traumatic brain injury
headache
child
epidemiology
posttraumatic headache
adolescents

Accepted September 22, 2011.

· Abstract 8 of 60Article

Ranitidine is Associated With Infections, Necrotizing Enterocolitis, and Fatal Outcome in Newborns

Background And Objective: Gastric acidity is a major nonimmune defense mechanism against infections. The objective of this study was to investigate whether ranitidine treatment in very low birth weight (VLBW) infants is associated with an increased risk of infections, necrotizing enterocolitis (NEC), and fatal outcome.

Methods: Newborns with birth weight between 401 and 1500 g or gestational age between 24 and 32 weeks, consecutively observed in neonatal intensive care units, were enrolled in a multicenter prospective observational study. The rates of infectious diseases, NEC, and death in enrolled subjects exposed or not to ranitidine were recorded.

Results: We evaluated 274 VLBW infants: 91 had taken ranitidine and 183 had not. The main clinical and demographic characteristics did not differ between the 2 groups. Thirty-four (37.4%) of the 91 children exposed to ranitidine and 18 (9.8%) of the 183 not exposed to ranitidine had contracted infections (odds ratio 5.5, 95% confidence interval 2.9–10.4, P < .001). The risk of NEC was 6.6-fold higher in ranitidine-treated VLBW infants (95% confidence interval 1.7–25.0, P = .003) than in control subjects. Mortality rate was significantly higher in newborns receiving ranitidine (9.9% vs 1.6%, P = .003).

Conclusions: Ranitidine therapy is associated with an increased risk of infections, NEC, and fatal outcome in VLBW infants. Caution is advocated in the use of this drug in neonatal age.

KEY WORDS

gastric acidity inhibitors
histamine-2 receptor antagonists
sepsis
pneumonia
urinary tract infections
microflora
very low birth weight

Accepted September 9, 2011.

· Abstract 9 of 60Article

Validation of a Clinical Prediction Rule to Distinguish Lyme Meningitis From Aseptic Meningitis

Objectives: The “Rule of 7′s,” a Lyme meningitis clinical prediction rule, classifies children at low risk for Lyme meningitis when each of the following 3 criteria are met: <7 days of headache, <70% cerebrospinal fluid (CSF) mononuclear cells, and absence of seventh or other cranial nerve palsy. The goal of this study was to test the performance of the Rule of 7′s in a multicenter cohort of children with CSF pleocytosis.

Methods: We performed a retrospective cohort study of children evaluated at 1 of 3 emergency departments located in Lyme disease–endemic areas with CSF pleocytosis and Lyme serology obtained. Lyme meningitis was defined using the Centers for Disease Control and Prevention criteria (either positive Lyme serology test result or an erythema migrans [EM] rash). We calculated the performance of the Rule of 7′s in our overall study population and in children without physician-documented EM.

Results: We identified 423 children, of whom 117 (28% [95% confidence interval (CI): 24%–32%]) had Lyme meningitis, 306 (72% [95% CI: 68%–76%]) had aseptic meningitis, and 0 (95% CI: 0%–1%) had bacterial meningitis. Of the 130 classified as low risk, 5 had Lyme meningitis (sensitivity, 112 of 117 [96% (95% CI: 90%–99%)]; specificity, 125 of 302 [41% (95% CI: 36%–47%)]). In the 390 children without EM, 3 of the 127 low-risk patients had Lyme meningitis (2% [95% CI: 0%–7%]).

Conclusions: Patients classified as low risk by using the Rule of 7′s were unlikely to have Lyme meningitis and could be managed as outpatients while awaiting results of Lyme serology tests.

KEY WORDS

Lyme meningitis
aseptic meningitis
clinical prediction rule
validation

Accepted September 9, 2011.

· Abstract 10 of 60Article

Trivalent Inactivated Influenza Vaccine Is Not Associated With Sickle Cell Crises in Children

Background and Objectives: Children with sickle cell disease are considered at high risk for complications from influenza infection and are recommended to receive annual influenza vaccination. However, data on the safety of influenza vaccination in children with sickle cell anemia are sparse.

Methods: Using a retrospective cohort of children aged 6 months to 17 years in 8 managed care organizations that comprise the Vaccine Safety Datalink and who had a diagnosis of sickle cell anemia from 1999 to 2006, we conducted matched case-control and self-controlled case series studies to examine the association of trivalent inactivated influenza vaccination with hospitalization for sickle cell crisis in the 2 weeks after vaccination.

Results: From an original pool of 1085 pediatric subjects with a diagnosis of sickle cell anemia, we identified 179 children with at least 1 sickle cell crisis during any influenza season (October 1–March 31). In the matched case-control study (matching on age category, gender, Vaccine Safety Datalink site, and season), the odds ratio of hospitalization for a crisis in vaccinated compared with unvaccinated children was not significant: 1.3 (95% confidence interval 0.8–2.2). In the self-controlled case series study of hospitalized cases, the incident rate ratio for hospitalization with sickle cell crisis in the 2 weeks after trivalent inactivated influenza vaccination was also not significant: 1.2 (95% confidence interval 0.75–1.95).

Conclusions: This large cohort study did not find an association of influenza vaccination and hospitalization for sickle cell crises in children with sickle cell anemia.

KEY WORDS

children and adolescents
childhood immunization
influenza vaccine
sickle cell disease
vaccines

Accepted September 19, 2011.

· Abstract 11 of 60Article

Human Rhinoviruses in Severe Respiratory Disease in Very Low Birth Weight Infants

Objectives: To assess incidence, burden of illness, and risk factors for human rhinoviruses (HRVs) in a cohort of very low birth weight (VLBW) infants.

Methods: A 2-year prospective cohort study was conducted among VLBW premature infants in Buenos Aires, Argentina. Infants were enrolled in the NICU from June 1, 2003, to May 31, 2005, and managed monthly and with every acute respiratory illness (ARI) during the first year of life. Nasal wash samples were obtained during every respiratory episode and tested for HRV, respiratory syncytial virus (RSV), human parainfluenza viruses, influenza viruses, and human metapneumovirus using reverse transcriptase-polymerase chain reaction.

Results: Of 119 patients, 66 (55%) had HRV-associated ARIs. The incidence of HRV-associated ARI was 123 events per 100 child-years of follow-up. Of those infants experiencing an episode of bronchiolitis, 40% had HRV versus 7% with RSV. The incidence of HRV-associated bronchiolitis was 75 per 100 infant-years of follow-up. HRV was associated with 12 of 36 hospitalizations (33%), and RSV was associated with 9 of 36 hospitalizations (25%). The incidence of HRV-associated hospitalization was 12 per 100 infant-years of follow-up. The risk of HRV-associated hospitalization was higher for infants with bronchopulmonary dysplasia and those who were not breastfed.

Conclusions: HRV is an important and frequent pathogen associated with severe respiratory infections in VLBW infants. Bronchopulmonary dysplasia and the absence of breastfeeding are risk factors for hospitalization. The results of our study reveal that HRV is the predominant pathogen of respiratory infections in premature infants.

KEY WORDS

premature infants
rhinovirus
very low birth weight

Accepted September 9, 2011.

· Abstract 12 of 60Article

Childhood Cumulative Risk and Obesity: The Mediating Role of Self-Regulatory Ability

Objectives: We tested whether early childhood risk exposures are related to weight gain in adolescence and evaluate an underlying mechanism, self-regulatory behavior, for the risk-obesity link.

Methods: Cumulative risk exposure to 9 sociodemographic (eg, poverty), physical (eg, substandard housing), and psychosocial (eg, family turmoil) stressors was assessed in 244 nine-year-old children. BMI was calculated at age 9 and then 4 years later. At age 9, children’s ability to delay gratification as an index of self-regulatory behavior was assessed. Path analyses were then estimated to evaluate our mediational model (Cumulative risk → Self-regulation → BMI) over a 4-year period in a prospective, longitudinal design.

Results: Nine-year-old children exposed to a greater accumulation of multiple risk factors show larger gains in adiposity over the next four year period, net of their initial BMI. These gains in BMI during early adolescence are largely accounted for by deteriorated self-regulatory abilities among children facing more cumulative risks.

Conclusions: Early childhood risk exposure leads to larger gains in BMI in adolescence. Given the importance of childhood adiposity to the development of obesity later in life, understanding the underlying mechanisms that link early experience to weight gain is an essential task. Deficiencies in self-regulation in response to chronic stress appears to be an important agent in the obesity epidemic.

KEY WORDS

BMI
chronic stress
cumulative risk
obesity
self-regulation

Accepted September 9, 2011.

· Abstract 13 of 60Article

Correlates of Mother-to-Child Transmission of HIV in the United States and Puerto Rico

OBJECTIVE: The goal of this study was to examine associations between demographic, behavioral, and clinical variables and mother-to-child HIV transmission in 15 US jurisdictions for birth years 2005 through 2008.

METHODS: The study used Enhanced Perinatal Surveillance system data for HIV-infected women who gave birth to live infants. Multivariable logistic regression was used to assess variables associated with mother-to-child transmission.

RESULTS: Among 8054 births, 179 infants (2.2%) were diagnosed with HIV infection. Half of the births had at least 1 missed prevention opportunity: 74.3% of infected infants, 52.1% of uninfected infants. Among 7757 mother–infant pairs with sufficient data for analysis, the odds of having an HIV-infected infant were higher for women who received late testing or no prenatal antiretroviral medications (odds ratio: 2.5 [95% confidence interval (CI): 1.5–4.0] and 3.5 [95% CI: 2.0–6.4], respectively). The odds for mothers who breastfed were 4.6 times (95% CI: 2.2–9.8) the odds for those who did not breastfeed. The adjusted odds for women with CD4 counts <200 cells per microliter were 2.4 times (95% CI: 1.4–4.2) those for women with CD4 counts ≥500 cells per microliter. The odds for women who abused substances were twice (95% CI: 1.4–2.9) those for women who did not.

CONCLUSIONS: The odds of having an HIV-infected infant were higher among HIV-infected women who were tested late, had no antiretroviral medications, abused substances, breastfed, or had lower CD4 cell counts. Increases in earlier HIV diagnosis, substance abuse treatment, avoidance of breastfeeding, and use of prenatal antiretroviral medications are critical in eliminating perinatal HIV infections in the United States.

KEY WORDS

HIV
risk factors
United States
vertical infectious disease transmission

Accepted September 7, 2011.

· Abstract 14 of 60Article

Clinical Characteristics and Risk Factors for Symptomatic Pediatric Gallbladder Disease

Objective: Our center previously reported its experience with pediatric gallbladder disease and cholecystectomies from 1980 to 1996. We aimed to determine the current clinical characteristics and risk factors for symptomatic pediatric gallbladder disease and cholecystectomies and compare these findings with our historical series.

Study Design: Retrospective, cross-sectional study of children, 0 to 18 years of age, who underwent a cholecystectomy from January 2005 to October 2008.

Results: We evaluated 404 patients: 73% girls; 39% Hispanic and 35% white. The mean age was 13.10 ± 0.91 years. The primary indications for surgery in patients 3 years or older were symptomatic cholelithiasis (53%), obstructive disease (28%), and biliary dyskinesia (16%). The median BMI percentile was 89%; 39% were classified as obese. Of the patients with nonhemolytic gallstone disease, 35% were obese and 18% were severely obese; BMI percentile was 99% or higher. Gallstone disease was associated with hemolytic disease in 23% (73/324) of patients and with obesity in 39% (126/324). Logistic regression demonstrated older age (P = .019) and Hispanic ethnicity (P < .0001) as independent risk factors for nonhemolytic gallstone disease. Compared with our historical series, children undergoing cholecystectomy are more likely to be Hispanic (P = .003) and severely obese (P < .0279).

Conclusion: Obesity and Hispanic ethnicity are strongly correlated with symptomatic pediatric gallbladder disease. In comparison with our historical series, hemolytic disease is no longer the predominant risk factor for symptomatic gallstone disease in children.

KEY WORDS

children
cholecystectomy
gallbladder
Hispanic
obesity

Accepted September 9, 2011.

· Abstract 15 of 60Article

Preterm Birth Alters the Maturation of Baroreflex Sensitivity in Sleeping Infants

Objective: Impaired blood pressure (BP) control may underpin the increased incidence of the sudden infant death syndrome (SIDS) in preterm infants. This study aimed to examine the effects of preterm birth, postnatal age, and sleep state on BP control by measuring baroreflex sensitivity (BRS) across the first 6 months of term-corrected age (CA), when SIDS risk is greatest.

Methods: Preterm (n = 25) and term (n = 31) infants were studied longitudinally at 2 to 4 weeks, 2 to 3 months, and 5 to 6 months CA using daytime polysomnography. BP was recorded during quiet (QS) and active (AS) sleep using a photoplethysmographic cuff placed around the infant’s wrist (Finometer [FMS, Finapres Medical Systems, Amsterdam, Netherlands]). BRS (milliseconds/mm Hg) was assessed in 1- to 2-minute epochs using cross-spectral analysis.

Results: In preterm infants, postnatal age had no significant effect on BRS within either QS or AS. This was in contrast to the maturational increase in QS observed in term infants. Compared with term infants, BRS of preterm infants was 38% higher at 2 to 4 weeks CA and 29% lower at 5 to 6 months CA during QS (P <.05). Comparing sleep states, BRS of preterm infants was 26% lower in QS compared with AS at 2 to 3 months CA (P <.05).

Conclusions: Preterm birth impairs the normal maturational increase in BRS, resulting in a substantial reduction in BRS at 5 to 6 months CA during QS. Lower BRS during QS compared with AS at 2 to 3 months CA may place preterm infants at an increased risk for cardiovascular instability at this age of peak incidence of SIDS.

KEY WORDS

cardiovascular control
preterm infant
sleep
sudden infant death syndrome

Accepted September 19, 2011.

· Abstract 16 of 60Article

Aerobic Capacity and Exercise Performance in Young People Born Extremely Preterm

Objectives: The goal of this study was to compare aerobic capacity and exercise performance of children and adolescents born extremely preterm and at term, and to relate findings to medical history and lifestyle factors. Potential cohort effects were assessed by studying subjects born in different decades.

Methods: Two area-based cohorts of subjects born with gestational age ≤28 weeks or birth weight ≤1000 g in 1982–1985 and 1991–1992 and matched control subjects born at term were compared by using standardized maximal treadmill exercise and pulmonary function tests. Background data were collected from questionnaires and medical records.

Results: Seventy-five of 86 eligible preterm subjects (87%) and 75 control subjects were assessed at mean ages of 17.6 years (n = 40 + 40) and 10.6 years (n = 35 + 35). At average, measures of aerobic capacity for subjects born preterm and at term were in the same range, whereas average running distance was modestly reduced for those born preterm. Leisure-time physical activity was similarly and positively associated with exercise capacity in preterm and term-born adolescents alike, although participation was lower among those born preterm. Neonatal bronchopulmonary dysplasia and current forced expiratory vol in 1 second was unrelated to exercise capacity. Differences between subjects born preterm and at term had not changed over the 2 decades studied.

Conclusion: Despite their high-risk start to life and a series of potential shortcomings, subjects born preterm may achieve normal exercise capacity, and their response to physical training seems comparable to peers born at term.

KEY WORDS

exercise capacity
exercise test
oxygen consumption
premature infant
bronchopulmonary dysplasia

Accepted September 14, 2011.

· Abstract 17 of 60Article

Peer-led Education for Adolescents With Asthma in Jordan: A Cluster-Randomized Controlled Trial

Objectives: To determine the impact of a peer-led education program, developed in Australia, on health-related outcomes in high school students with asthma in Jordan.

Methods: In this cluster-randomized controlled trial, 4 high schools in Irbid, Jordan, were randomly assigned to receive the Adolescent Asthma Action program or standard practice. Bilingual health workers trained 24 peer leaders from Year 11 to deliver asthma education to younger peers from Year 10 (n = 92), who in turn presented brief asthma skits to students in Years 8 and 9 (n = 148) and to other members of the school community in the intervention schools. Students with asthma (N = 261) in Years 8, 9, and 10 completed baseline surveys in December 2006 and 3 months after the intervention.

Results: Students from the intervention group reported clinically significant improvements in health-related quality of life (mean difference: 1.35 [95% confidence interval: 1.04–1.76]), self-efficacy to resist smoking (mean difference: 4.63 [95% confidence interval: 2.93–6.35]), and knowledge of asthma self- management (mean difference: 1.62 [95% confidence interval: 1.15–2.19]) compared with the control group.

Conclusions: This trial demonstrated that the Adolescent Asthma Action program can be readily adapted to suit different cultures and contexts. Adolescents in Jordan were successful in teaching their peers about asthma self-management and motivating them to avoid smoking. The findings revealed that peer education can be a useful strategy for health promotion programs in Jordanian schools when students are given the opportunity and training.

KEY WORDS

adolescent
asthma
health education
intervention
peer group

Accepted September 8, 2011.

· Abstract 18 of 60Article

Factors Affecting Health Care Utilization for Children in Japan

Background And Objective: Studies on the ecology of medical care for children have been reported only from the United States. Our objective was to describe proportions of children receiving care in 6 types of health care utilization seeking behaviors in Japan on a monthly basis and to identify care characteristics.

Methods: A population-weighted random sample from a nationally representative panel of households was used to estimate the number of health-related symptoms, over-the-counter medicine doses, and health care utilizations per 1000 Japanese children per month. Variations in terms of age, gender, socioeconomic status, and residence location were also examined.

Results: Based on 1286 households (3477 persons including 1024 children) surveyed, on average per 1000 children, 872 had at least 1 symptom, 335 visited a physician's office, 82 a hospital-based outpatient clinic, 21 a hospital emergency department, and 2 a university-based outpatient clinic. Two were hospitalized, and 4 received professional health care in their home. Children had 2 times more physician visits and 3 times more emergency visits than adults in Japan, and Japanese children had 2.5 times more physician visits and 11 times more hospital-based outpatient clinic visits than US children. Pediatric health care utilization is influenced significantly by age but not affected by income or residence location in Japan.

Conclusions Compared with the data from the United States, more children in Japan visit community physicians and hospital-based outpatient clinics. Results of this study would be useful for further delineation of health care utilization of children in the context of a health care system unique to Japan.

KEY WORDS

ecology
medical care
physician visit
primary care
health diary

Accepted October 11, 2011.

· Abstract 19 of 60Article

Prognostic Models for Stillbirth and Neonatal Death in Very Preterm Birth: A Validation Study

Objectives: To validate externally 2 prognostic models for stillbirth and neonatal death in very preterm infants who are either known to be alive at the onset of labor or admitted for neonatal intensive care.

Patients And Methods: All infants, with gestational age 22 to 32 weeks, of European ethnicity, known to be alive at the onset of labor (n = 17 582) and admitted for neonatal intensive care (n = 11 578), who were born in the Netherlands between January 1, 2000, and December 31, 2007. The main outcome measures were stillbirth or death within 28 days for infants known to be alive at the onset of labor and death before discharge from the NICU for infants admitted for intensive care. Model performance was studied with calibration plots and c statistic.

Results: Of the infants known to be alive at the onset of labor, 16.7% (n = 2939) died during labor or within 28 days of birth, and 7.8% (n = 908) of the infants admitted for neonatal intensive care died before discharge from intensive care. The prognostic model for infants known to be alive at the onset of labor showed good calibration and excellent discrimination (c statistic 0.92). The prognostic model for infants admitted for neonatal intensive care showed good calibration and good discrimination (c statistic 0.82).

Conclusions: The 2 prognostic models for stillbirth and neonatal death in very preterm Dutch infants showed good performance, suggesting their use in clinical practice in the Netherlands and possibly other Western countries.

KEY WORDS

neonatal death
stillbirth
external validation
prognostic model
very preterm birth

Accepted September 14, 2011.

· Abstract 20 of 60Article

Symptoms and Time to Medical Care in Children With Accidental Extremity Fractures

Background And Objective: Delay in seeking medical care is one criterion used to identify victims of abuse. However, typical symptoms of accidental fractures in young children and the time between injury and the seeking of medical care have not been reported. We describe patient and injury characteristics that influence the time from injury to medical care.

Methods: Parental interviews were conducted for children <6 years old with accidental extremity fractures. Demographic characteristics, signs and symptoms of the injury, and fracture location and severity were described and examined for their association with a delay (>8 hours) in seeking medical care.

Results: Among 206 children, 69% had upper extremity fractures. The median time to the first medical evaluation was 1 hour, but 21% were seen at >8 hours after injury. Although 91% of children cried after the injury, only 83% were irritable for >30 minutes. Parents observed no external sign of injury in 15% of children, and 12% used the injured extremity normally. However, all parents noted at least 1 sign or symptom. Minority children (odds ratio [OR]: 2.54 [95% confidence interval [CI]: 1.18–5.47), those with lower extremity injuries (OR: 2.23 [95% CI: 1.01–4.90]), those without external signs of injury (OR: 3.40 [95% CI: 1.36–8.51]), and those with continued extremity use (OR: 3.26 [95% CI: 1.22–8.76]) were more likely to delay seeking medical care.

Conclusions: Although some children did not manifest all expected responses, no child with an accidental fracture was asymptomatic. Delay in seeking medical care was associated with more subtle signs of injury; however, delays identified in minority patients are unexplained.

KEY WORDS

children
child abuse
extremity fractures
medical care
parental perception

Accepted September 7, 2011.

· Abstract 21 of 60Article

Histologic Chorioamnionitis Is Associated With Reduced Risk of Late-Onset Sepsis in Preterm Infants

Background: Histologic chorioamnionitis (HCA) is implicated in the onset of preterm labor and delivery. Chorioamnionitis is a known risk factor for early-onset sepsis and may modulate postnatal immunity. Preterm infants are at greatly increased risk of late-onset sepsis (LOS), particularly with coagulase-negative staphylococci (CoNS), but the impact of HCA on the risk of LOS is unknown.

Methods: Eight hundred thirty-eight preterm infants born at <30 weeks gestational age at a single tertiary center were included. Histologic examination of placenta and extraplacental membranes was performed, and clinical data were extracted from hospital databases. The influence of HCA on the incidence of early-onset sepsis and LOS was examined using logistic regression analysis and Cox proportional hazards regression.

Results: Mean gestational age was 26.9 ± 1.9 weeks, and mean birth weight was 936 ± 277 g. Two hundred and seventy-six (33%) of 838 infants developed LOS. The presence of fetal or maternal HCA, or maternal HCA and fetal HCA alone, was associated with a significantly decreased risk of LOS with any organism. Histologic chorioamnionitis correlated with a significantly decreased risk of CoNS LOS.

Conclusions: HCA is associated with a significantly reduced risk of acquiring LOS, both with CoNS and other bacteria. Perinatal inflammation may enhance the functional maturation of the preterm immune system and provide protection against LOS in high-risk preterm infants.

KEY WORDS

chorioamnionitis
late-onset sepsis
perinatal inflammation
premature infant

Accepted September 9, 2011.

· Abstract 22 of 60Article

Wide Variation in Reference Values for Aluminum Levels in Children

Background: Some parents are requesting aluminum testing in their children with developmental issues. Although aluminum can be measured in plasma, serum, or urine, there is scant scientific information about normal ranges. We sought to determine the basis for laboratory reference ranges and whether these ranges are applicable to children.

Methods: From texts, published lists, and Internet sources, we obtained the names of 10 clinical laboratories that perform aluminum testing. Contact was made by telephone or e-mail, or Internet sites were viewed to obtain information regarding the establishment of aluminum reference ranges and testing methods in biological samples. Seven laboratories provided supporting literature that was reviewed regarding details of the study populations.

Results: For laboratories using the atomic absorption spectrometry method, aluminum reference ranges varied from <5.41 μg/L to <20 μg/L (serum), <7.00 μg/L to 0 to 10 μg/L (plasma) and 5 to 30 μg/L (urine). For those using the inductively coupled plasma mass spectroscopy methodology, ranges varied from 0 to 6 μg/L to <42 μg/L (serum), 0 to 10 μg/L to 0 to 15 μg/L (plasma), and 0 to 7 μg/L to 5 to 30 μg/L (urine). None of the reference ranges are known to be derived from studies of healthy children, but relied instead on small studies of adult populations, adult dialysis patients, workers, or sick children on aluminum-containing parenteral therapy.

Conclusions: Aluminum reference ranges provided by laboratories are widely divergent, may not represent “normal” ranges of a healthy population, especially children, and thus it is difficult to interpret serum or urine aluminum ranges clinically. Further studies of aluminum in children are warranted and should be considered as part of the Centers for Disease Control and Prevention Biomonitoring Project.

KEY WORDS

aluminum
aluminum toxicity
childhood aluminum
reference range

Accepted September 9, 2011.

· Abstract 23 of 60Article

The Natural Course of Infantile Spinal Muscular Atrophy With Respiratory Distress Type 1 (SMARD1)

Background: Only scarce information is available on the long-term outcome and the natural course of children with infantile spinal muscular atrophy with respiratory distress type 1 (SMARD1) due to mutations in the IGHMBP2 gene.

Objective: To describe the natural disease course, to systematically quantify the residual capacities of children with SMARD1 who survive on permanent mechanical respiration, and to identify markers predicting the disease outcome at the time of manifestation.

Methods: We conducted a longitudinal study of 11 infantile SMARD1 patients over a mean observational period of 7.8 (SD 3.2) years. Disease-specific features were continuously assessed by using a semiquantitative scoring system. Additionally, we analyzed the residual enzymatic activity of 6 IGHMBP2 mutants in our patients.

Results: After an initial rapid decline of the clinical score until the age of 2 years, residual capabilities reached a plateau or even improved. The overall clinical outcome was markedly heterogeneous, but clinical scores at the age of 3 months showed a positive linear correlation with the clinical outcome at 1 year and at 4 years of age. If expressed in an in vitro recombinant system, mutations of patients with more favorable outcomes retained residual enzymatic activity.

Conclusions: Despite their severe disabilities and symptoms, most SMARD1 patients are well integrated into their home environment and two thirds of them are able to attend kindergarten or school. This information will help to counsel parents at the time of disease manifestation.

KEY WORDS

diaphragmatic paralysis
distal muscular weakness
natural disease course, neuromuscular disease
SMARD1

Accepted September 7, 2011.

· Abstract 24 of 60Article

How Often Are Teens Arrested for Sexting? Data From a National Sample of Police Cases

Objective: To examine characteristics of youth sexting cases handled by police and their outcomes in response to clinical and other concerns about the risks of sexting behavior.

Methods: Mail surveys were sent to a stratified national sample of 2712 law enforcement agencies followed by detailed telephone interviews with investigators about a nationally representative sample of sexting cases handled by police during 2008 and 2009 (n = 675). The cases involved “youth-produced sexual images” that constituted child pornography under relevant statutes according to respondents.

Results: US law enforcement agencies handled an estimated 3477 cases of youth-produced sexual images during 2008 and 2009 (95% confidence interval: 3282–3672). Two-thirds of the cases involved an “aggravating” circumstance beyond the creation and/or dissemination of a sexual image. In these aggravated cases, either an adult was involved (36% of cases) or a minor engaged in malicious, non-consensual, or abusive behavior (31% of cases). An arrest occurred in 62% of cases with an adult involved, in 36% of the aggravated youth-only cases, and in 18% of the “experimental” cases (youth-only and no aggravating elements). Most of the images (63%) were distributed by cell phone only and did not reach the Internet. Sex offender registration applied in only a few unusual cases.

Conclusions: Many of the youth sexting cases that come to the attention of police include aggravating circumstances that raise concerns about health and risky sexual behavior, although some cases were relatively benign. Overall, arrest is not typical in cases with no adults involved.

KEY WORDS

sexting
child pornography

Accepted September 19, 2011.

· Abstract 25 of 60Article

Prevalence and Characteristics of Youth Sexting: A National Study

Objectives: To obtain national estimates of youth involved in sexting in the past year (the transmission via cell phone, the Internet, and other electronic media of sexual images), as well as provide details of the youth involved and the nature of the sexual images.

Methods: The study was based on a cross-sectional national telephone survey of 1560 youth Internet users, ages 10 through 17.

Results: Estimates varied considerably depending on the nature of the images or videos and the role of the youth involved. Two and one-half percent of youth had appeared in or created nude or nearly nude pictures or videos. However, this percentage is reduced to 1.0% when the definition is restricted to only include images that were sexually explicit (ie, showed naked breasts, genitals, or bottoms). Of the youth who participated in the survey, 7.1% said they had received nude or nearly nude images of others; 5.9% of youth reported receiving sexually explicit images. Few youth distributed these images.

Conclusions: Because policy debates on youth sexting behavior focus on concerns about the production and possession of illegal child pornography, it is important to have research that collects details about the nature of the sexual images rather than using ambiguous screening questions without follow-ups. The rate of youth exposure to sexting highlights a need to provide them with information about legal consequences of sexting and advice about what to do if they receive a sexting image. However, the data suggest that appearing in, creating, or receiving sexual images is far from being a normative behavior for youth.

KEY WORDS

sexting
child pornography
Internet
naked images

Accepted September 19, 2011.

· Abstract 26 of 60Article

Cumulative Prevalence of Arrest From Ages 8 to 23 in a National Sample

Objective: To estimate the cumulative proportion of youth who self-report having been arrested or taken into custody for illegal or delinquent offenses (excluding arrests for minor traffic violations) from ages 8 to 23 years.

Methods: Self-reported arrest history data (excluding arrests for minor traffic violations) from the National Longitudinal Survey of Youth 1997 (N = 7335) were examined from 1997 to 2008.

Results: By age 18, the in-sample cumulative arrest prevalence rate lies between 15.9% and 26.8%; at age 23, it lies between 25.3% and 41.4%. These bounds make no assumptions at all about missing cases. If we assume that the missing cases are at least as likely to have been arrested as the observed cases, the in-sample age-23 prevalence rate must lie between 30.2% and 41.4%. The greatest growth in the cumulative prevalence of arrest occurs during late adolescence and the period of early or emerging adulthood.

Conclusions: Since the last nationally defensible estimate based on data from 1965, the cumulative prevalence of arrest for American youth (particularly in the period of late adolescence and early adulthood) has increased substantially. At a minimum, being arrested for criminal activity signifies increased risk of unhealthy lifestyle, violence involvement, and violent victimization. Incorporating this insight into regular clinical assessment could yield significant benefits for patients and the larger community.

KEY WORDS

crime
criminals
arrest
health risk factors

Accepted September 9, 2011.

· Abstract 27 of 60Article

Pediatric Sports-Related Concussion Produces Cerebral Blood Flow Alterations

Objectives: The pathophysiology of sports-related concussion (SRC) is incompletely understood. Human adult and experimental animal investigations have revealed structural axonal injuries, decreases in the neuronal metabolite N-acetyl aspartate, and reduced cerebral blood flow (CBF) after SRC and minor traumatic brain injury. The authors of this investigation explore these possibilities after pediatric SRC.

Patients And Methods: Twelve children, ages 11 to 15 years, who experienced SRC were evaluated by ImPACT neurocognitive testing, T1 and susceptibility weighted MRI, diffusion tensor imaging, proton magnetic resonance spectroscopy, and phase contrast angiography at <72 hours, 14 days, and 30 days or greater after concussion. A similar number of age- and gender-matched controls were evaluated at a single time point.

Results: ImPACT results confirmed statistically significant differences in initial total symptom score and reaction time between the SRC and control groups, resolving by 14 days for total symptom score and 30 days for reaction time. No evidence of structural injury was found on qualitative review of MRI. No decreases in neuronal metabolite N-acetyl aspartate or elevation of lactic acid were detected by proton magnetic resonance spectroscopy. Statistically significant alterations in CBF were documented in the SRC group, with reduction in CBF predominating (38 vs 48 mL/100 g per minute; P = .027). Improvement toward control values occurred in only 27% of the participants at 14 days and 64% at >30 days after SRC.

Conclusions: Pediatric SRC is primarily a physiologic injury, affecting CBF significantly without evidence of measurable structural, metabolic neuronal or axonal injury. Further study of CBF mechanisms is needed to explain patterns of recovery.

KEY WORDS

concussion
pediatrics
MRI
cerebral blood flow
magnetic resonance spectroscopy

Accepted September 7, 2011.

· Abstract 28 of 60Article

Computerized Neurocognitive Testing for the Management of Sport-Related Concussions

Objectives: To describe the prevalence of computerized neurocognitive testing for the assessment of high school athletes who sustain concussions, and to describe associations between using computerized neurocognitive tests, timing of return-to-play, and medical provider managing the athlete.

Methods: Concussions recorded in the High School Reporting Information Online injury surveillance system during the 2009–2010 academic year were included. Measures of association between use of computerized neurocognitive testing and outcomes were analyzed. A questionnaire was sent to athletic trainers (ATs) querying the use of computerized neurocognitive testing. χ² analyses were conducted for categorical variables. Logistic regression analyses were used to adjust for potential confounders. Statistical significance was set at P < .05.

Results: High School Reporting Information Online recorded 1056 concussions. Athletes who underwent computerized neurocognitive testing were less likely to be returned to play within 10 days of injury (38.5% vs 55.7%, P < .001) and more likely to be returned to play by a physician (60.9% vs 45.6%, P < .001). We had a response rate of 97.3% for the survey. Of respondents, 39.9% used computerized neurocognitive testing; 93.0% of those used ImPACT. Tests were most often interpreted by ATs (78.9%) and/or physicians (78.8%), as opposed to neuropsychologists (16.9%).

Conclusions: Approximately 40% of US high schools that employ an AT use computerized neurocognitive tests when managing sport-related concussions. Tests are most often interpreted by ATs and physicians, as opposed to neuropsychologists. Computerized neurocognitive tests are significantly associated with the timing of return-to-play.

KEY WORDS

concussion
injuries
high school
neuropsychological testing

Accepted September 7, 2011.

· Abstract 29 of 60Article

Parental Smoking and Vascular Damage in Their 5-year-old Children

Background: The relation between smoke exposure in early life, the prenatal period in particular, and the vascular development of young children is largely unknown.

Methods: Data from the birth cohort participating in the WHISTLER-Cardio study were used to relate the smoking of parents during pregnancy to subsequent vascular properties in their children. In 259 participating children who turned 5 years of age, parental smoking data were updated and children’s carotid artery intima-media thickness (CIMT) and arterial wall distensibility were measured by using ultrasonography.

Results: Children of mothers who had smoked throughout pregnancy had 18.8 μm thicker CIMT (95% confidence interval [CI] 1.1, 36.5, P = .04) and 15% lower distensibility (95% CI −0.3, −0.02, P = .02) after adjustment for child’s age, maternal age, gender, and breastfeeding. The associations were not found in children of mothers who had not smoked in pregnancy but had smoked thereafter. The associations were strongest if both parents had smoked during pregnancy, with 27.7 μm thicker CIMT (95% CI 0.2, 55.3) and 21% lower distensibility (95% CI −0.4, −0.03).

Conclusion: Exposure of children to parental tobacco smoke during pregnancy affects their arterial structure and function in early life.

Accepted September 7, 2011.

· Abstract 30 of 60Article

Use of Palivizumab in Primary Practice

Objective: To describe the implementation of a program for the use of palivizumab in a general pediatrics office and evaluate adherence to the 2009 American Academy of Pediatrics (AAP) guidelines.

Methods: Pediatricians in a large practice were educated in the diagnosis and management of bronchiolitis, with specific attention to the AAP’s palivizumab administration guidelines. During the 2009–2010 and 2010–2011 respiratory syncytial virus seasons, children were systematically identified and enrolled for palivizumab administration. Indication for administration was determined by gestational age, age at the beginning of the respiratory syncytial virus season, pertinent diagnoses, and presence of risk factors.

Results: In the 2009–2010 season, 161 children were enrolled to receive palivizumab, 86 of whom (53%) conformed with AAP guidelines. In contrast, in 2010–2011, a total of 85 children were enrolled to receive palivizumab, and 73 (86%) conformed with the guidelines. As a consequence, the total cost of palivizumab (US $: 511 559 vs 1 500 670) and the cost per child (US $: 6018 vs 9438) were lower in 2010–2011 than in 2009–2010. However, of the children selected within the AAP guidelines, only 29% received the appropriate number of doses, whereas 62% and 9% received fewer or excessive doses, respectively; these findings were similar for the 2 seasons.

Conclusions: In a primary practice, use of palivizumab outside of the AAP guidelines was frequent and manifested as inadequate indications or inadequate number of doses. The former improved with education and standardization of care (suggesting provider problems), while the latter did not (suggesting system problems). Additional interventions are required.

KEY WORDS

RSV
bronchiolitis
primary care
palivizumab
public health

Accepted September 7, 2011.

· Abstract 31 of 60Article

Trends in Preventive Asthma Medication Use Among Children and Adolescents, 1988–2008

Objectives: To examine trends in preventive asthma medication (PAM) use among children with current asthma in the United States from 1988 to 2008.

Methods: We performed a cross-sectional analysis of PAM use among 2499 children aged 1 to 19 years with current asthma using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) during 3 time periods: 1988–1994, 1999–2002, and 2005–2008. PAMs included inhaled corticosteroids, leukotriene receptor antagonists, long-acting β-agonists, mast-cell stabilizers, and methylxanthines.

Results: Among children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988–1994 to 34.9% (SE: 3.3) in 2005–2008 (P < .001 for trend). Adjusting for age, gender, race/ethnicity, and health insurance status, the odds of PAM use were higher in 2005–2008 compared with 1988–1994 (adjusted odds ratio [aOR] = 2.6; 95% confidence interval [CI]: 1.5–4.5). A multivariate analysis, combining all 3 time periods, showed lower use of PAMs among non-Hispanic black (aOR = 0.5 [95% CI: 0.4–0.7]) and Mexican American (aOR = 0.6 [95% CI: 0.4–0.9]) children compared to non-Hispanic white children. PAM use was also lower in 12 to 19 year olds compared with 1 to 5 year olds and also in children who did not have health insurance compared with those who did.

Conclusions: Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American children, adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM.

KEY WORDS

asthma
anti-asthmatic agents
health care disparities
medically uninsured
quality indicators, health care

Accepted September 9, 2011.

· Abstract 32 of 60Article

Early Childhood Overweight and Asthma and Allergic Sensitization at 8 Years of Age

Objectives: Our aim was to examine the associations between high BMI and changes in BMI status during the first 7 years of life and asthma and allergic sensitization at age 8 years.

Methods: A birth cohort of newborn infants was followed for 8 years. Repeated parental questionnaires provided information on environmental exposures and health outcomes. Information on height and weight during childhood was retrieved from preschool and school health care records. The analyses included the 2075 children for whom information was available on weight and height, as well as on asthma, at age 8 years.

Results: A high BMI (≥85th percentile) at age 1, 4, and/or 7 years was associated with an increased risk of asthma at age 8 years. However, no significant association was observed among children with high BMI at age 12 and/or 18 months (early age) or at age 4 years who developed a normal BMI by age 7 years. The risk was increased among children with high BMI at age 7 years, regardless of their earlier weight. Moreover, we observed an increased risk of sensitization to inhalant allergens among children with high BMI at age 7 years.

Conclusions: Our study indicates that high BMI during the first 4 years does not increase the risk of asthma at school age among children who have developed a normal weight by age 7 years. However, high BMI at age 7 years is associated with an increased risk of asthma and sensitization to inhalant allergens.

KEY WORDS

asthma
allergic sensitization
overweight
BMI
child
cohort study

Accepted September 9, 2011.

· Abstract 33 of 60Article

Impact of a Transcutaneous Bilirubinometry Program on Resource Utilization and Severe Hyperbilirubinemia

Objectives: Our goal was to assess the impact of programmatic and coordinated use of transcutaneous bilirubinometry (TcB) on the incidence of severe neonatal hyperbilirubinemia and measures of laboratory, hospital, and nursing resource utilization.

Methods: We compared the neonatal hyperbilirubinemia-related outcomes of 14 796 prospectively enrolled healthy infants ≥35 weeks gestation offered routine TcB measurements in both hospital and community settings by using locally validated nomograms relative to a historical cohort of 14 112 infants assessed by visual inspection alone.

Results: There was a 54.9% reduction (odds ratio [OR]: 2.219 [95% confidence interval (CI): 1.543–3.193]; P < .0001) in the incidence of severe total serum bilirubin values (≥342 µmol/L; ≥20 mg/dL) after implementation of routine TcB measurements. TcB implementation was associated with reductions in the overall incidence of total serum bilirubin draws (134.4 vs 103.6 draws per 1000 live births, OR: 1.332 [95% CI: 1.226–1.446]; P < .0001) and overall phototherapy rate (5.27% vs 4.30%, OR: 1.241 [95% CI: 1.122–1.374]; P < .0001), a reduced age at readmission for phototherapy (104.3 ± 52.1 vs 88.9 ± 70.5 hours, P < .005), and duration of phototherapy readmission (24.8 ± 13.6 vs 23.2 ± 9.8 hours, P < .05). There were earlier (P < .01) and more frequent contacts with public health nurses (1.33 vs 1.66, P < .01) after introduction of the TcB program.

Conclusions: Integration of routine hospital and community TcB screening within a comprehensive public health nurse newborn follow-up program is associated with significant improvements in resource utilization and patient safety.

KEY WORDS

hyperbilirubinemia
transcutaneous bilirubinometry
screening
neonatal

Accepted September 9, 2011.

· Abstract 34 of 60Article

The Value of the Medical Home for Children Without Special Health Care Needs

Objective: Although the medical home is promoted by the American Academy of Pediatrics and the Affordable Care Act, its impact on children without special health care needs is unknown. We examined whether the medical home is associated with beneficial health care utilization and health-promoting behaviors in this population.

Methods: This study was a secondary data analysis of the 2003 National Survey of Children’s Health. Data were available for 70 007 children without special health care needs. We operationalized the medical home according to the National Survey of Children’s Health design. Logistic regression for complex sample surveys was used to model each outcome with the medical home, controlling for sociodemographic characteristics.

Results: Overall, 58.1% of children without special health care needs had a medical home. The medical home was significantly associated with increased preventive care visits (adjusted odds ratio [aOR]: 1.32 [95% confidence interval (CI): 1.22–1.43]), decreased outpatient sick visits (aOR: 0.71 [95% CI: 0.66–0.76), and decreased emergency department sick visits (aOR: 0.70 [95% CI: 0.65–0.76]). It was associated with increased odds of “excellent/very good” child health according to parental assessment (aOR: 1.29 [95% CI: 1.15–1.45) and health-promoting behaviors such as being read to daily (aOR: 1.46 [95% CI: 1.13–1.89]), reported helmet use (aOR: 1.18 [95% CI: 1.03–1.34]), and decreased screen time (aOR: 1.12 [95% CI: 1.02–1.22]).

Conclusions: For children without special health care needs, the medical home is associated with improved health care utilization patterns, better parental assessment of child health, and increased adherence with health-promoting behaviors. These findings support the recommendations of the American Academy of Pediatrics and the Affordable Care Act to extend the medical home to all children.

KEY WORDS

patient-centered care
pediatrics
health policy
Outcome Assessment (Health Care)
medical home

Accepted September 7, 2011.

· Abstract 35 of 60Article

Shared Decision-Making and Health Care Expenditures Among Children With Special Health Care Needs

Background And Objectives To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN).

Methods We identified CSHCN <18 years in the 2002–2006 Medical Expenditure Panel Survey by using the CSHCN Screener. Outcomes included health care expenditures (total, out-of-pocket, office-based, inpatient, emergency department [ED], and prescription) and utilization (hospitalization, ED and office visit, and prescription rates). The main exposure was the pattern of SDM over the 2 study years (increasing, decreasing, or unchanged high or low). We assessed the impact of these patterns on the change in expenditures and utilization over the 2 study years.

Results Among 2858 subjects representing 12 million CSHCN, 15.9% had increasing, 15.2% decreasing, 51.9% unchanged high, and 17.0% unchanged low SDM. At baseline, mean per child total expenditures were $2131. Over the 2 study years, increasing SDM was associated with a decrease of $339 (95% confidence interval: $21, $660) in total health care costs. Rates of hospitalization and ED visits declined by 4.0 (0.1, 7.9) and 11.3 (4.3, 18.3) per 100 CSHCN, and office visits by 1.2 (0.3, 2.0) per child with increasing SDM. Relative to decreasing SDM, increasing SDM was associated with significantly lower total and out-of-pocket costs, and fewer office visits.

Conclusions We found that increasing SDM was associated with decreased utilization and expenditures for CSHCN. Prospective study is warranted to confirm if fostering SDM reduces the costs of caring for CSHCN for the health system and families.

KEY WORDS

children with special health care needs
communication
decision-making
health care expenditures

Accepted September 7, 2011.

· Abstract 36 of 60Article

Family-centered Program Deters Substance Use, Conduct Problems, and Depressive Symptoms in Black Adolescents

Objectives: The present research addressed the following important question in pediatric medicine: Can participation in a new family-centered preventive intervention, the Strong African American Families–Teen (SAAF–T) program, deter conduct problems, substance use, substance use problems, and depressive symptoms among rural black adolescents across 22 months?

Methods: Data were collected from 502 black families in rural Georgia, assigned randomly to SAAF–T or an attention control condition. The prevention condition consisted of 5 consecutive meetings at community facilities with separate, concurrent sessions for caregivers and adolescents followed by a caregiver-adolescent session in which families practiced skills they learned in the separate sessions. Adolescents self-reported conduct problem behaviors, substance use, substance use problems, and depressive symptoms at ages 16 years (pretest) and 17 years 10 months (long-term assessment).

Results: Adolescents who participated in SAAF–T evinced lower increases in conduct problem behavior, substance use, substance use problems, and depressive symptom frequencies than did adolescents in the attention control condition across the 22 months between pretest and long-term assessment.

Conclusions: This is the first study to demonstrate efficacy in a prevention program designed to deter conduct problems, substance use, substance use problems, and depressive symptoms among rural black adolescents. Because SAAF–T is a manualized, structured program, it can be easily disseminated to public health agencies, schools, churches, boys’ and girls’ clubs, and other community organizations.

KEY WORDS

adolescent
black
depression
drug-seeking behavior
family intervention
parents
prevention
social adjustment

Accepted September 14, 2011.

· Abstract 37 of 60Article

Bovine Lactoferrin Prevents Invasive Fungal Infections in Very Low Birth Weight Infants: A Randomized Controlled Trial

Background: Lactoferrin is a mammalian milk glycoprotein involved in innate immunity. Recent data show that bovine lactoferrin (bLF) prevents late-onset sepsis in preterm very low birth weight (VLBW) neonates.

Methods: This is a secondary analysis of data from a multicenter randomized controlled trial where preterm VLBW neonates randomly received bLF (100 mg/day; group A1), bLF + Lactobacillus rhamnosus GG (10⁶ colony-forming units per day; group A2), or placebo (group B) for 6 weeks. Here we analyze the incidence rates of fungal colonization, invasive fungal infection (IFI), and rate of progression from colonization to infection in all groups.

Results: This study included 472 neonates whose clinical, nutritional, and demographical characteristics were similar. Overall, the incidence of fungal colonization was comparable (17.6%, 16.6%, and 18.5% in A1, A2, and B, respectively; P = .89 [A1] and .77 [A2]). In contrast, IFIs were significantly decreased in A1 and A2 (0.7% and 2.0%, respectively) compared with B (7.7%; P = .002 [A1] and .02 [A2]), and this was significantly true both in <1000 g (0.9% [A1] and 5.6% [A2], vs 15.0%) and in 1001 to 1500 g infants (0% and 0% vs 3.7%). The progression rate colonization-infection was significantly lower in the bLF groups: 3.7% (A1) and 12% (A2), vs 41.9%; P < .001 (A1) and P = .02 (A2). No IFI-attributable deaths occurred in the treatment groups, versus 2 in placebo. No adverse effects or intolerances occurred.

Conclusions: Prophylactic oral administration of bLF reduces the incidence of IFI in preterm VLBW neonates. No effect is seen on colonization. The protective effect on IFI is likely due to limitation of ability of fungal colonies to progress toward invasion and systemic disease in colonized infants.

KEY WORDS

lactoferrin
VLBW neonates
Candida
fungal sepsis
prophylaxis

Accepted September 8, 2011.

· Abstract 38 of 60Article

Mortality and Adverse Neurologic Outcomes Are Greater in Preterm Male Infants

Objective: To determine whether male gender has an effect on survival, early neonatal morbidity, and long-term outcome in neonates born extremely prematurely.

Methods: Retrospective review of the New South Wales and Australian Capital Territory Neonatal Intensive Care Unit Data Collection of all infants admitted to New South Wales and Australian Capital Territory neonatal intensive care units between January 1998 and December 2004. The primary outcome was hospital mortality and functional impairment at 2 to 3 years follow-up.

Results: Included in the study were 2549 neonates; 54.7% were male. Risks of grade III/IV intraventricular hemorrhage, sepsis, and major surgery were found to be increased in male neonates. Hospital mortality (odds ratio 1.285, 95% confidence interval 1.035–1.595) and moderate to severe functional disability at 2 to 3 years of age (odds ratio 1.877, 95% confidence interval 1.398–2.521) were more likely in male infants. Gender differences for mortality and long-term neurologic outcome loses significance at 27 weeks gestation.

Conclusions: In the modern era of neonatal management, male infants still have higher mortality and poorer long-term neurologic outcome. Gender differences for mortality and long-term neurologic outcome appear to lose significance at 27 weeks gestation.

KEY WORDS

development
gender
outcome
neonate
preterm
survival

Accepted September 14, 2011.

· Abstract 39 of 60Article

Quality of Early Maternal–Child Relationship and Risk of Adolescent Obesity

Objectives: The goal of this study was to determine whether obesity in adolescence is related to the quality of the early maternal–child relationship.

Methods: We analyzed data from 977 of 1364 participants in the Study of Early Child Care and Youth Development. Child attachment security and maternal sensitivity were assessed by observing mother–child interaction at 15, 24, and 36 months of age. A maternal–child relationship quality score was constructed as the number of times across the 3 ages that the child was either insecurely attached or experienced low maternal sensitivity. Adolescent obesity was defined as a measured BMI ≥95th percentile at age 15 years.

Results: Poor-quality maternal–child relationships (score: ≥3) were experienced by 24.7% of children compared with 22.0% who, at all 3 ages, were neither insecurely attached nor exposed to low maternal sensitivity (score: 0). The prevalence of adolescent obesity was 26.1%, 15.5%, 12.1%, and 13.0% for those with risk scores of ≥3, 2, 1, and 0, respectively. After adjustment for gender and birth weight, the odds (95% confidence interval) of adolescent obesity was 2.45 (1.49–4.04) times higher in those with the poorest quality early maternal–child relationships (score: ≥3) compared with those with the highest quality (score: 0). Low maternal sensitivity was more strongly associated with obesity than insecure attachment.

Conclusions: Poor quality of the early maternal–child relationship was associated with a higher prevalence of adolescent obesity. Interventions aimed at improving the quality of maternal–child interactions should consider assessing effects on children’s weight and examining potential mechanisms involving stress response and emotion regulation.

KEY WORDS

attachment security
maternal sensitivity
parenting
obesity
BMI
Study of Early Child Care and Youth Development
children
adolescents
prospective

Accepted September 21, 2011.

· Abstract 40 of 60Review Article

Parental Smoking Cessation to Protect Young Children:A Systematic Review and Meta-analysis

BACKGROUND: Young children can be protected from much of the harm from tobacco smoke exposure if their parents quit smoking. Some researchers encourage parents to quit for their children's benefit, but the evidence for effectiveness of such approaches is mixed.

OBJECTIVE: To perform a systematic review and meta-analysis to quantify the effects of interventions that encourage parental cessation.

METHODS: We searched PubMed, the Cochrane Library, Web of Science, and PsycINFO. Controlled trials published before April 2011 that targeted smoking parents of infants or young children, encouraged parents to quit smoking for their children's benefit, and measured parental quit rates were included. Study quality was assessed. Relative risks and risk differences were calculated by using the DerSimonian and Laird random-effects model.

RESULTS: Eighteen trials were included. Interventions took place in hospitals, pediatric clinical settings, well-baby clinics, and family homes. Quit rates averaged 23.1% in the intervention group and 18.4% in the control group. The interventions successfully increased the parental quit rate. Subgroups with significant intervention benefits were children aged 4 to 17 years, interventions whose primary goal was cessation, interventions that offered medications, and interventions with high follow-up rates (>80%).

CONCLUSIONS: Interventions to achieve cessation among parents, for the sake of the children, provide a worthwhile addition to the arsenal of cessation approaches, and can help protect vulnerable children from harm due to tobacco smoke exposure. However, most parents do not quit, and additional strategies to protect children are needed.

KEY WORDS

parenting
second hand smoke
smoking cessation
systematic reviews
tobacco use/smoking

Accepted September 9, 2011.

· Abstract 41 of 60State-of-the-Art Review Article

Translational Research in Pediatrics: Tissue Sampling and Biobanking

Translational research is expanding and has become a focus of National Research funding agencies, touted as the primary avenue to improve health care practice. The use of human tissues for research on disease etiology is a pillar of translational research, particularly with innovations in research technologies to investigate the building blocks of disease. In pediatrics, translational research using human tissues has been hindered by the many practical and ethical considerations associated with tissue procurement from children and also by a limited population base for study, by the increasing complexities in conducting clinical research, and by a lack of dedicated child-health research funding. Given these obstacles, pediatric translational research can be enhanced by developing strategic and efficient biobanks that will provide scientists with quality tissue specimens to render accurate and reproducible research results. Indeed, tissue sampling and biobanking within pediatric academic settings has potential to impact child health by promoting bidirectional interaction between clinicians and scientists, helping to maximize research productivity, and providing a competitive edge for attracting and maintaining high-quality personnel. The authors of this review outline key issues and practical solutions to optimize pediatric tissue sampling and biobanking for translational research, activities that will ultimately reduce the burden of childhood disease.

KEY WORDS

translational research
pediatrics
tissue repository
biological specimen bank

Accepted August 17, 2011.

· Abstract 42 of 60Special Article

· Abstract 43 of 60Commentary

· Abstract 44 of 60Commentary

· Abstract 45 of 60Quality Report

Identifying Quality Improvement Opportunities in a Universal Newborn Hearing Screening Program

Background And Objectives: Hospital-based universal newborn hearing screening (UNHS) programs are encouraged to maintain quality assurance protocols, but many hospitals lack the time and resources to initiate this process. We studied a practical approach to measuring baseline quality indicators and identifying improvement opportunities in UNHS programs.

Methods: We determined screening processes and quality indicators for UNHS programs at 4 hospitals through site visits and a 2-year retrospective review of nursery and audiology records. Nurses, audiologists, and otolaryngologists met for feedback of hospital-specific quality indicators. The sessions identified improvement opportunities and proposed system changes for immediate implementation.

Results: Hospitals screened 21 957 newborns for hearing loss. Screening rates were >99% at all hospitals. Rates of referral and diagnostic testing varied significantly between hospitals. Low referral rates prompted 2 hospitals to adjust screening processes to reduce potential false-negative screening results. Two other hospitals addressed poor diagnostic follow-up by changing the referral process to include additional family contact information. Hospitals also increased referrals to Early Intervention Child Find services on the basis of our finding that these referrals increased the likelihood of diagnostic follow-up fourfold. We could not fully assess indicators of hearing aid eligibility and enrollment in early intervention services due to insufficient documentation.

Conclusions: Review of nursery and audiology records successfully established most quality indicators for the UNHS programs we studied. Feedback of quality indicators identified multiple improvement opportunities and facilitated endorsement of immediate system changes. This study demonstrates a practical and data-driven approach to quality improvement that can be used by any UNHS program.

KEY WORDS

neonatal screening
hearing loss
early intervention
health care quality, access, and evaluation
quality improvement

Accepted September 9, 2011.

· Abstract 46 of 60Quality Report

Sustained Reduction in Neonatal Nosocomial Infections Through Quality Improvement Efforts

Background: Although reports of reduced nosocomial infections (NI) in very low birth weight infants have been published, the durability of these gains and changes in secondary outcomes, and clinical practices have less often been published.

Methods: This was a retrospective, observational study of NI reduction in very low birth weight infants at two hospital campuses. The intervention began in 2005 with our renewed quality improvement efforts to reduce NI. We compared outcomes before (2000–2005) and after (2006–2009) the intervention by using univariate and multiple regression analyses.

Results: We reduced NI by 50% comparing 2000–2005 to 2006–2009 (23.6% vs 11.6%, P < .001). Adjusting for covariates, the odds ratio for NI was 0.33 (confidence interval, 0.26 – 0.42, P < .001) in the more recent era. NI were lower even in infants with birth weight 501-1000 grams (odds ratio = 0.38, confidence interval, 0.29 – 0.51, P < .001). We also reduced bronchopulmonary dysplasia (30.2% vs 25.5%, P = .001), median days to regain birth weight (9 vs 8, P = .04), percutaneously placed central venous catheter use (54.8% vs 43.9%, P = .002), median antibiotic days (8 vs 6, P = .003), median total central line days (16 vs 15, P = .01), and median ventilator days (7 vs 5, P = .01). We sustained improvements for three years.

Conclusions: Quality improvement efforts were associated with sustained reductions in NI, bronchopulmonary dysplasia, antibiotic use, central line use, and ventilator days.

KEY WORDS

neonatal morbidity
neonatal care
NICU
nosocomial infections
quality improvement

Accepted August 14, 2011.

· Abstract 47 of 60Case Report

Long-term Follow-up of 2 Newborns With a Combined Birth Weight of 540 Grams

Long-term growth and developmental data are presented for the smallest and third smallest surviving newborns in the world literature to 5 and 20 years of age, respectively. Both patients exhibited normal motor and language development. Although head circumference for both newborns demonstrated catchup growth, significant differences in height and weight growth velocities persisted.

KEY WORDS

extremely low birth weight
small for gestational age
micropreemies
fetal infant

Accepted July 20, 2011.

· Abstract 48 of 60Case Report

Recurrent Parotitis as a Presentation of Primary Pediatric Sjögren Syndrome

Parotitis is a common condition seen in the pediatric population, usually as an isolated occurrence associated with viral or bacterial infection. The differential diagnosis expands when recurrent parotitis is encountered. One etiology is primary pediatric Sjögren syndrome (SS), an autoimmune condition typically associated with dryness of the eyes and mouth in adults. Pediatric patients often present with isolated recurrent bilateral parotitis, however, and we describe 4 such cases in children aged 9 to 17 years at presentation. Despite lack of ocular complaints, 3 of these patients had ocular findings on ophthalmologic exam. Our patients also exhibited classic laboratory abnormalities, including positive antinuclear antibody, SS A, and SS B antibodies; presence of rheumatoid factor; and hypergammaglobulinemia. Consideration of SS in the child with recurrent parotitis is important for timely and appropriate referral and treatment. We review the differential diagnosis of parotitis in children as well as the salient features of pediatric SS.

KEY WORDS

parotitis
Sjögren syndrome

Accepted September 8, 2011.

· Abstract 49 of 60Case Report

Mosaic 7q31 Deletion Involving FOXP2 Gene Associated With Language Impairment

We report on a 10-year-old patient with childhood apraxia of speech (CAS) and mild dysmorphic features. Although multiple karyotypes were reported as normal, a bacterial artificial chromosome array comparative genomic hybridization revealed the presence of a de novo 14.8-Mb mosaic deletion of chromosome 7q31. The deleted region involved several genes, including FOXP2, which has been associated with CAS. Interestingly, the deletion reported here was observed in about 50% of cells, which is the first case of mosaicism in a 7q31 deletion. Despite the presence of the deletion in only 50% of cells, the phenotype of the patient was not milder than other published cases. To date, 6 cases with a deletion of 9.1-20 Mb involving the FOXP2 gene have been reported, suggesting a new contiguous gene deletion syndrome characterized mainly by CAS caused by haploinsufficiency of the genes encompassed in the 7q critical region. This report suggests that children found with a deletion involving the FOXP2 region should be evaluated for CAS and that analysis of the FOXP2 gene including array comparative genomic hybridization should be considered in selected patients with CAS. Mosaic deletions in this area may also be considered as causative of CAS.

KEY WORDS

aCGH
childhood apraxia of speech
FOXP2
7q31 deletion
mosaicism

Accepted September 9, 2011.

· Abstract 50 of 60Case Report

Unmanipulated Donor Lymphocytes for EBV-Related PTLD After T-Cell Depleted HLA-Haploidentical Transplantation

Epstein-Barr virus (EBV)–related post-transplantation lymphoproliferative disorder (PTLD) is a life-threatening complication in patients given T-cell-depleted hematopoietic stem cell transplantation from an HLA-haploidentical relative (haplo-HSCT). We report the case of a child who developed severe EBV-related PTLD after haplo-HSCT from his mother. Despite receiving the anti-CD20 monoclonal antibody, the patient presented with intestinal obstruction due to huge abdominal lymphadenopathy, hematemesis, and nodulary pulmonary lesions. Histology showed that the lesions were due to CD20−/CD19+ large neoplastic B cells. The patient underwent double intestinal resection with partial abdominal lymphadenectomy and then received 3 monthly doses of donor-derived unmanipulated mononuclear cells. The initial dose of CD3+ cells was 3 × 10⁵/kg recipient body weight. The 2 additional doses consisted of 5 × 10⁵ CD3+ cells/kg. No sign or symptom attributable to graft-versus-host disease was observed, and the patient completely cleared EBV-related lesions. The child was disease-free for 13 months after the first lymphocyte infusion. This case demonstrates that repeated infusions of controlled numbers of donor CD3+ cells cure EBV-related PTLD in haplo-HSCT without inducing graft-versus-host disease.

KEY WORDS

post-transplantation lymphoproliferative disorders
donor lymphocyte infusion
graft-versus-host disease
EBV-immunity

Accepted July 20, 2011.

· Abstract 51 of 60Case Report

Plasmapheresis to Treat Hypertriglyceridemia in a Child With Diabetic Ketoacidosis and Pancreatitis

A 10-year-old girl presented with diabetic ketoacidosis, shock, and severe abdominal pain. She was found to have acute pancreatitis and acute kidney injury after shock resuscitation and severe persistent hypertriglyceridemia. The severe hypertriglyceridemia was treated with 1 course of plasmapheresis, which corrected the triglyceride level and was temporally associated with improvement of the abdominal pain and renal dysfunction. Diabetes is known to contribute to an elevated triglyceride level, especially in the setting of an underlying lipid disorder. However, no such disorders were found in this patient. To the best of our knowledge, this is the first report of a pediatric patient presenting with the triad of severe hypertriglyceridemia, diabetic ketoacidosis, and pancreatitis treated successfully with plasmapheresis.

KEY WORDS

diabetic ketoacidosis
acute pancreatitis
hyperlipidemia

Accepted September 8, 2011.

· Abstract 52 of 60Case Report

Multicentric Castleman Disease in an HHV8-Infected Child Born to Consanguineous Parents With Systematic Review

Childhood multicentric Castleman disease (MCD) is a rare and unexplained lymphoproliferative disorder. We report a human herpesvirus-8 (HHV-8)-infected child, born to consanguineous Comorian parents, who displayed isolated MCD in the absence of any known immunodeficiency. We also systematically review the clinical features of the 32 children previously reported with isolated and unexplained MCD. The characteristics of this patient and the geographic areas of origin of most previous cases suggest that pediatric MCD is associated with HHV-8 infection. Moreover, as previously suggested for Kaposi sarcoma, MCD in childhood may result from inborn errors of immunity to HHV-8 infection.

KEY WORDS

Children
human herpes virus 8
multicentric Castleman disease
systematic review

Accepted September 8, 2011.

· Abstract 53 of 60From the American Academy of PediatricsClinical Report

The Importance of Play in Promoting Healthy Child Development and Maintaining Strong Parent-Child Bond: Focus on Children in Poverty

Play is essential to the social, emotional, cognitive, and physical well-being of children beginning in early childhood. It is a natural tool for children to develop resiliency as they learn to cooperate, overcome challenges, and negotiate with others. Play also allows children to be creative. It provides time for parents to be fully engaged with their children, to bond with their children, and to see the world from the perspective of their child. However, children who live in poverty often face socioeconomic obstacles that impede their rights to have playtime, thus affecting their healthy social-emotional development. For children who are underresourced to reach their highest potential, it is essential that parents, educators, and pediatricians recognize the importance of lifelong benefits that children gain from play.

KEY WORDS

children
development
parents
pediatrician
play
poverty

· Abstract 54 of 60From the American Academy of PediatricsClinical Report

Comprehensive Health Evaluation of the Newly Adopted Child

Children who join families through the process of adoption often have multiple health care needs. After placement in an adoptive home, it is essential that these children have a timely comprehensive health evaluation. This evaluation should include a review of all available medical records and a complete physical examination. Evaluation should also include diagnostic testing based on the findings from the history and physical examination as well as the risks presented by the child’s previous living conditions. Age-appropriate screens should be performed, including, for example, newborn screening panels, hearing, vision, dental, and formal behavioral/developmental screens. The comprehensive assessment can occur at the time of the initial visit to the physician after adoptive placement or can take place over several visits. Adopted children should be referred to other medical specialists as deemed appropriate. The Section on Adoption and Foster Care is a resource within the American Academy of Pediatrics for physicians providing care for children who are being adopted.

KEY WORDS

adoption
developmental assessment
diagnostic testing
medical screening
preadoption visit

· Abstract 55 of 60From the American Academy of PediatricsPolicy Statement

Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health

Advances in a wide range of biological, behavioral, and social sciences are expanding our understanding of how early environmental influences (the ecology) and genetic predispositions (the biologic program) affect learning capacities, adaptive behaviors, lifelong physical and mental health, and adult productivity. A supporting technical report from the American Academy of Pediatrics (AAP) presents an integrated ecobiodevelopmental framework to assist in translating these dramatic advances in developmental science into improved health across the life span. Pediatricians are now armed with new information about the adverse effects of toxic stress on brain development, as well as a deeper understanding of the early life origins of many adult diseases. As trusted authorities in child health and development, pediatric providers must now complement the early identification of developmental concerns with a greater focus on those interventions and community investments that reduce external threats to healthy brain growth. To this end, AAP endorses a developing leadership role for the entire pediatric community—one that mobilizes the scientific expertise of both basic and clinical researchers, the family-centered care of the pediatric medical home, and the public influence of AAP and its state chapters—to catalyze fundamental change in early childhood policy and services. AAP is committed to leveraging science to inform the development of innovative strategies to reduce the precipitants of toxic stress in young children and to mitigate their negative effects on the course of development and health across the life span.

KEY WORDS

advocacy
brain development
ecobiodevelopmental
framework
family pediatrics
health promotion
human capital investments
new morbidity
toxic stress
resilience

· Abstract 56 of 60From the American Academy of PediatricsTechnical Report

The Lifelong Effects of Early Childhood Adversity and Toxic Stress

Advances in fields of inquiry as diverse as neuroscience, molecular biology, genomics, developmental psychology, epidemiology, sociology, and economics are catalyzing an important paradigm shift in our understanding of health and disease across the lifespan. This converging, multidisciplinary science of human development has profound implications for our ability to enhance the life prospects of children and to strengthen the social and economic fabric of society. Drawing on these multiple streams of investigation, this report presents an ecobiodevelopmental framework that illustrates how early experiences and environmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health. The report also examines extensive evidence of the disruptive impacts of toxic stress, offering intriguing insights into causal mechanisms that link early adversity to later impairments in learning, behavior, and both physical and mental well-being. The implications of this framework for the practice of medicine, in general, and pediatrics, specifically, are potentially transformational. They suggest that many adult diseases should be viewed as developmental disorders that begin early in life and that persistent health disparities associated with poverty, discrimination, or maltreatment could be reduced by the alleviation of toxic stress in childhood. An ecobiodevelopmental framework also underscores the need for new thinking about the focus and boundaries of pediatric practice. It calls for pediatricians to serve as both front-line guardians of healthy child development and strategically positioned, community leaders to inform new science-based strategies that build strong foundations for educational achievement, economic productivity, responsible citizenship, and lifelong health.

KEY WORDS

ecobiodevelopmental framework
new morbidity
toxic stress
social inequalities
health disparities
health promotion
disease prevention
advocacy
brain development
human capital development
pediatric basic science

· Abstract 57 of 60From the American Academy of PediatricsTechnical Report

Immunizing Parents and Other Close Family Contacts in the Pediatric Office Setting

Additional strategies are needed to protect children from vaccine-preventable diseases. In particular, very young infants, as well as children who are immunocompromised, are at especially high risk for developing the serious consequences of vaccine-preventable diseases and cannot be immunized completely. There is some evidence that children who become infected with these diseases are exposed to pathogens through household contacts, particularly from parents or other close family contacts. Such infections likely are attributable to adults who are not fully protected from these diseases, either because their immunity to vaccine-preventable diseases has waned over time or because they have not received a vaccine. There are many challenges that have added to low adult immunization rates in the United States. One option to increase immunization coverage for parents and close family contacts of infants and vulnerable children is to provide alternative locations for these adults to be immunized, such as the pediatric office setting. Ideally, adults should receive immunizations in their medical homes; however, to provide greater protection to these adults and reduce the exposure of children to pathogens, immunizing parents or other adult family contacts in the pediatric office setting could increase immunization coverage for this population to protect themselves as well as children to whom they provide care.

KEY WORDS

parental immunization
adults
vaccines
Tdap
cocooning

· Abstract 58 of 60From the American Academy of PediatricsPolicy Statement

Scope of Health Care Benefits for Children From Birth Through Age 26

The optimal health of all children is best achieved with access to appropriate and comprehensive health care benefits. This policy statement outlines and defines the recommended set of health insurance benefits for children through age 26. The American Academy of Pediatrics developed a set of recommendations concerning preventive care services for children, adolescents, and young adults. These recommendations are compiled in the publication Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, third edition. The Bright Futures recommendations were referenced as a standard for access and design of age-appropriate health insurance benefits for infants, children, adolescents, and young adults in the Patient Protection and Affordable Care Act of 2010 (Pub L No. 114–148).

KEY WORDS

ancillary services
diagnosis
durable medical equipment
emergency care
health care insurance benefits
hospitalization
preventive services
physician services
prescriptions
therapeutic services

· Abstract 59 of 60From the American Academy of PediatricsPolicy Statement

Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease

Incorporation of pulse oximetry to the assessment of the newborn infant can enhance detection of critical congenital heart disease (CCHD). Recently, the Secretary of Health and Human Services (HHS) recommended that screening for CCHD be added to the uniform screening panel. The American Academy of Pediatrics (AAP) has been a strong advocate of early detection of CCHD and fully supports the decision of the Secretary of HHS.

The AAP has published strategies for the implementation of pulse oximetry screening, which addressed critical issues such as necessary equipment, personnel, and training, and also provided specific recommendations for assessment of saturation by using pulse oximetry as well as appropriate management of a positive screening result. The AAP is committed to the safe and effective implementation of pulse oximetry screening and is working with other advocacy groups and governmental agencies to promote pulse oximetry and to support widespread surveillance for CCHD.

Going forward, AAP chapters will partner with state health departments to implement the new screening strategy for CCHD and will work to ensure that there is an adequate system for referral for echocardiographic/pediatric cardiac evaluation after a positive screening result. It is imperative that AAP members engage their respective policy makers in adopting and funding the recommendations made by the Secretary of HHS.

KEY WORDS

pulse oximetry
critical congenital heart disease
recommended uniform screening panel
screening
newborn infants

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

Allergy Testing in Childhood: Using Allergen-Specific IgE Tests

A variety of triggers can induce common pediatric allergic diseases which include asthma, allergic rhinitis, atopic dermatitis, food allergy, and anaphylaxis. Allergy testing serves to confirm an allergic trigger suspected on the basis of history. Tests for allergen-specific immunoglobulin E (IgE) are performed by in vitro assays or skin tests. The tests are excellent for identifying a sensitized state in which allergen-specific IgE is present, and may identify triggers to be eliminated and help guide immunotherapy treatment. However, a positive test result does not always equate with clinical allergy. Newer enzymatic assays based on anti-IgE antibodies have supplanted the radioallergosorbent test (RAST). This clinical report focuses on allergen-specific IgE testing, emphasizing that the medical history and knowledge of disease characteristics are crucial for rational test selection and interpretation.

KEY WORDS

allergy
allergy testing
immunoglobulin
IgE
immunotherapy
pediatrics

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بهمن 1403

قمری:22 رجب 1446

میلادی:23 ژانویه 2025

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