·  Abstract 1 of 70Article

Medical Errors in US Pediatric Inpatients With Chronic Conditions

OBJECTIVE: To investigate the association between chronic conditions and iatrogenic medical errors in US pediatric inpatients.

METHODS: The 2006 Kids’ Inpatient Database (KID) was analyzed. Medical errors were defined by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Medical error rates per 100 hospital discharges and per 1000 inpatient days were calculated. Logistic regression models were fitted to study the association between number of chronic conditions and medical errors, controlling for patient characteristics, hospital characteristics, disease severity, and length of stay.

RESULTS: In the 2006 KID, 22.3% of pediatric inpatients had 1 chronic condition, 9.8% had 2 chronic conditions, and 12.0% had ≥3 chronic conditions. The overall medical error rate per 100 discharges was 3.0 (95% confidence interval [CI]: 2.8–3.3); it was 5.3 (95% CI: 4.9–5.7) in children with chronic conditions and 1.3 (95% CI: 1.2–1.3) in children without chronic conditions. The medical error rate per 1000 inpatient days was also higher in children with chronic conditions. The association between chronic conditions and medical errors remained statistically significant in logistic regression models adjusting for patient characteristics, hospital characteristics, disease severity, and length of stay. In the adjusted model, the odds ratio of medical errors for children with 1 chronic condition was 1.40 (95% CI: 1.32–1.48); for children with 2 conditions, the OR was 1.55 (95% CI: 1.45–1.66); and for children with 3 conditions, the OR was 1.66 (95% CI: 1.53–1.81).

CONCLUSIONS: The number of chronic conditions was significantly associated with iatrogenic medical errors in pediatric inpatients.

KEY WORDS

• children
• chronic condition
• medical errors
• medical injuries

• Accepted May 18, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 2 of 70Article

Antibiotic Exposure and IBD Development Among Children: A Population-Based Cohort Study

OBJECTIVE: To determine whether childhood antianaerobic antibiotic exposure is associated with the development of inflammatory bowel disease (IBD).

METHODS: This retrospective cohort study employed data from 464 UK ambulatory practices participating in The Health Improvement Network. All children with ≥2 years of follow-up from 1994 to 2009 were followed between practice enrollment and IBD development, practice deregistration, 19 years of age, or death; those with previous IBD were excluded. All antibiotic prescriptions were captured. Antianaerobic antibiotic agents were defined as penicillin, amoxicillin, ampicillin, penicillin/β-lactamase inhibitor combinations, tetracyclines, clindamycin, metronidazole, cefoxitin, carbapenems, and oral vancomycin.

RESULTS: A total of 1 072 426 subjects contributed 6.6 million person-years of follow-up; 748 developed IBD. IBD incidence rates among antianaerobic antibiotic unexposed and exposed subjects were 0.83 and 1.52/10 000 person-years, respectively, for an 84% relative risk increase. Exposure throughout childhood was associated with developing IBD, but this relationship decreased with increasing age at exposure. Exposure before 1 year of age had an adjusted hazard ratio of 5.51 (95% confidence interval [CI]: 1.66–18.28) but decreased to 2.62 (95% CI: 1.61–4.25) and 1.57 (95% CI: 1.35–1.84) by 5 and 15 years, respectively. Each antibiotic course increased the IBD hazard by 6% (4%–8%). A dose-response effect existed, with receipt of >2 antibiotic courses more highly associated with IBD development than receipt of 1 to 2 courses, with adjusted hazard ratios of 4.77 (95% CI: 2.13–10.68) versus 3.33 (95% CI: 1.69–6.58).

CONCLUSIONS: Childhood antianaerobic antibiotic exposure is associated with IBD development.

KEY WORDS

• antimicrobials
• epidemiology
• inflammatory bowel disease
• pediatric
• population-based studies

• Accepted May 17, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 3 of 70Article

Increased Expression of the Glucocorticoid Receptor β in Infants With RSV Bronchiolitis

OBJECTIVES: The majority of studies on glucocorticoid treatment in respiratory syncytial virus (RSV) bronchiolitis concluded that there are no beneficial effects. We hypothesized that RSV-infected patients may have an increased glucocorticoid receptor (GR) β expression, the isoform that is unable to bind cortisol and exert an antiinflammatory action.

METHODS: By using real-time polymerase chain reaction, we studied the expression of α and β GR in the peripheral blood mononuclear cells obtained from 49 RSV-infected infants (<1 year of age) with severe (n = 29) and mild to moderate (n = 20) illness. In plasma, we analyzed the level of cortisol by radioimmunoassay and inflammatory cytokines interleukin (IL)-10, IL-6, tumor necrosis factor-α, IL-1β, IL-8, IL-12p70, IL-2, IL-4, IL-5, interferon-γ, and IL-17 by cytometric beads assay. Statistical analysis was performed by nonparametric analysis of variance.

RESULTS: We found a significant increase of β GR expression in patients with severe illness compared with those with mild disease (P < .001) and with a group of healthy controls (P < .01). The α:β GR ratio decreased significantly in infants with severe disease compared with those with mild illness (P < .01) and with normal controls (P < .001). The expression of β GR was positively correlated with the clinical score of severity (r = .54; P < .0001).

CONCLUSIONS: The decrease of the α:β GR ratio by an increase of β receptors expression is related to illness severity and may partly explain the insensitivity to corticoid treatment in RSV-infected infants. The increased expression of β GR could be a marker of disease severity.

• RSV bronchiolitis
• infants
• glucocorticoid receptor
• interleukin-6
• interleukin-8

• Accepted June 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 4 of 70Article

Trends in Venous Thromboembolism-Related Hospitalizations, 1994–2009

OBJECTIVE: Information on trends in venous thromboembolism (VTE) in US children is scant and inconsistent. We assessed national trends in VTE-associated pediatric hospitalizations.

METHODS: All nonroutine newborn hospitalizations for children 0 to 17 years of age in the 1994–2009 Nationwide Inpatient Samples were included; routine newborn discharges were excluded. VTE diagnoses were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Variance weighted least square regression was used to assess trends in patient characteristics and rates of hospitalization per 100 000 population <18 years of age. Multivariable logistic regression models were used to estimate the probability of VTE diagnosis over the study period.

RESULTS: The rate of VTE-associated hospitalization increased for all age subgroups (<1, 1–5, 6–11, and 12–17 years), with the largest increase noted among children <1 year of age (from 18.1 per 100 000 during 1994 to 49.6 per 100 000 during 2009). Compared with 1994–1997, the adjusted odds of hospitalization with a VTE diagnosis were 88% higher during 2006–2009 (adjusted odds ratio: 1.88 [95% confidence interval: 1.64–2.17]). Venous catheter use, mechanical ventilation, malignancy, hospitalization ≥5 days, and VTE-related medical conditions were associated with increased likelihood of VTE diagnosis.

CONCLUSIONS: The rate of VTE-associated hospitalization among US children increased from 1994 through 2009. Increases in venous catheter procedures were associated with and may have contributed to the observed trends. The degree to which increased awareness of VTE influenced the temporal differences could not be determined.

KEY WORDS

• venous thromboembolism
• venous thrombosis
• pulmonary embolism
• central venous catheterization
• infant
• child
• adolescent

• Accepted May 23, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 5 of 70Article

Acute Bacterial Osteoarticular Infections: Eight-Year Analysis of C-Reactive Protein for Oral Step-Down Therapy

BACKGROUND: One of the most important decisions in the treatment of osteoarticular infections is the time at which parenteral therapy can be changed to oral therapy. C-reactive protein (CRP) is an acute inflammatory indicator with a half-life of 19 hours and thus can be helpful in assessing the adequacy of therapy for bacterial infections. At our institution, a combination of CRP and clinical findings is used to determine the transition to oral therapy.

METHODS: A search of 8 years of electronic records identified children with osteoarticular infections. Only children with culture-positive acute bacterial arthritis (ABA) or acute bacterial osteomyelitis (ABO) were studied further. A primary chart review of demographic and clinical data was conducted, and a secondary chart review of complicated outcomes was performed.

RESULTS: Of 194 total patients, complicated outcomes occurred in 40, of which 35 were prolonged therapy. Only 1 microbiologic failure occurred, presumably due to a retained intra-articular fragment of infected bone. CRP was highest initially among patients with simultaneous ABO + ABA and among those with complicated outcomes, and was lower at the transition to oral therapy in the complicated outcome group (1.5 vs 2.1 mg/dL; P = .012).

CONCLUSIONS: The combination of clinical findings and CRP is a useful tool to transition children with osteoarticular infections to oral therapy. Complicated outcomes were associated with higher early CRP at diagnosis and lower CRP at the end of parenteral therapy, suggesting that clinicians were more conservative with prolonged initial parenteral therapy in this group.

KEY WORDS

• acute bacterial arthritis
• acute bacterial osteomyelitis
• C-reactive protein
• CRP
• osteomyelitis
• septic arthritis

• Accepted May 17, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 6 of 70Article

Preterm Birth and Congenital Heart Defects: A Population-based Study

BACKGROUND AND OBJECTIVES: Preterm birth (PTB) and congenital heart defect (CHD) are 2 major causes of mortality and disability of perinatal origin. There are limited data on the relation between CHD and PTB. Our objective was to use population-based data to estimate the risk of PTB in newborns with CHD and to study specific associations between categories of CHD and PTB.

METHODS: We used data from a population-based cohort study of CHD (EPIdémiologique sur le devenir des enfants porteurs de CARDiopathies congénitales study), including 2189 live births with CHD (excluding isolated atrial septal defects) born between 2005 and 2008. We categorized CHD by using an anatomic and clinical classification. Data from the French National Perinatal Survey of 2003 were used to compare PTB in the EPIdémiologique sur le devenir des enfants porteurs de CARDiopathies congénitales study to that of the general population.

RESULTS: Of the newborns with CHD, 13.5% were preterm. The odds of PTB were twofold higher than for the general population (odds ratio 2.0, 95% confidence interval 1.6–2.5), essentially due to an increase in spontaneous PTB for newborns with CHD. The risk of PTB associated with CHD persisted after exclusion of chromosomal or other anomalies. There were significant variations in risk of PTB across the categories of CHD after adjustment for known risk factors of PTB and factors related to medical management of pregnancy and delivery.

CONCLUSIONS: We found a higher risk of PTB in newborns with CHD, which was essentially due to spontaneous PTB. Risk of PTB varied for categories of CHD. Our finding may be helpful for generating hypotheses about the developmental links between CHD and PTB.

KEY WORDS

• congenital heart defects
• preterm birth
• population-based study
• epidemiology

• Accepted June 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 7 of 70Article

Functioning of 7-Year-Old Children Born at 32 to 35 Weeks’ Gestational Age

OBJECTIVE: To compare neuropsychological functions in moderately preterm (32–35 weeks’ gestation) and full-term children at the age of 7 years and identify gender differences.

METHODS: Community-based prospective cohort study of 248 moderately preterm children (138 boys) and 130 full-term children (58 boys). Neuropsychological tests included IQ, memory, attention, visual perception, motor skills, visuomotor skills, and parental report of executive functioning.

RESULTS: The moderately preterm group performed significantly worse on total and performance IQ, visuospatial reasoning, attention control, inhibition, and executive functioning. No differences were found in verbal IQ, verbal memory, and visuomotor and motor skills. Preterm children were at higher risk for scores <10th percentile on intelligence, visuospatial reasoning (relative risk ratio both: 1.69 [95% confidence interval: 1.29–2.28]), and executive functioning problems (relative risk: 1.94 [95% confidence interval: 1.51–2.57]). Using gender-specific norms, preterm boys performed significantly worse than full-term boys on visuospatial reasoning (P < .01); preterm girls performed significantly worse than full-term girls on visuospatial reasoning, intelligence, attention, and executive functioning (P < .05).

CONCLUSIONS: Moderately preterm birth is associated with lower intelligence and poorer neuropsychological functioning at early school age. No differences in motor skills and verbal memory were found. Using gender-specific norms, our data suggest that moderately preterm boys catch up, whereas moderately preterm girls lag behind their peers on various neuropsychological functions by the age of 7 years.

KEY WORDS

• neurodevelopment
• cognition
• motor skill
• moderately preterm
• gender
• school age

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 8 of 70Article

Impact of Maternal Depressive Symptoms on Growth of Preschool- and School-Aged Children

OBJECTIVE: The aim of our study was to examine whether maternal depressive symptoms at 9 months postpartum adversely affect growth in preschool- and school-aged children.

METHODS: We used data from the US nationally representative Early Childhood Longitudinal Study, Birth Cohort. We fit multivariable logistic regression models to study maternal depressive symptoms at 9 months postpartum (using the Center for Epidemiologic Studies Depression Scale) in relation to child growth outcomes, ≤10% height-for-age, ≤10% weight-for-height, and ≤10% weight-for-age at 4 and 5 years.

RESULTS: At 9 months, 24% of mothers reported mild depressive symptoms and 17% moderate/severe symptoms. After adjustment for household, maternal, and child factors, children of mothers with moderate to severe levels of depressive symptoms at 9 months’ postpartum had a 40% increased odds of being ≤10% in height-for-age at age 4 (odds ratio = 1.40, 95% confidence interval: 1.04–1.89) and 48% increased odds of being ≤10% in height-for-age at age 5 (odds ratio = 1.48, 95% confidence interval: 1.03–2.13) compared with children of women with few or no depressive symptoms. There was no statistically significant association between maternal depressive symptoms and children being ≤10% in weight-for-height and weight-for-age at 4 or 5 years.

CONCLUSIONS: Maternal depressive symptoms during infancy may affect physical growth in early childhood. Prevention, early detection, and treatment of maternal depressive symptoms during the first year postpartum may prevent childhood height-for-age ≤10th percentile among preschool- and school-aged children.

KEY WORDS

• maternal depressive symptoms
• child growth
• mother-child relations

• Accepted May 23, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 9 of 70Article

Obesity and Metabolic Syndrome and Functional and Structural Brain Impairments in Adolescence

BACKGROUND: The prevalence of metabolic syndrome (MetS) parallels the rise in childhood obesity. MetS is associated with neurocognitive impairments in adults, but this is thought to be a long-term effect of poor metabolism. It would be important to ascertain whether these brain complications are also present among adolescents with MetS, a group without clinically manifest vascular disease and relatively short duration of poor metabolism.

METHODS: Forty-nine adolescents with and 62 without MetS, matched on age, socioeconomic status, school grade, gender, and ethnicity, received endocrine, MRI, and neuropsychological evaluations.

RESULTS: Adolescents with MetS showed significantly lower arithmetic, spelling, attention, and mental flexibility and a trend for lower overall intelligence. They also had, in a MetS-dose–related fashion, smaller hippocampal volumes, increased brain cerebrospinal fluid, and reductions of microstructural integrity in major white matter tracts.

CONCLUSIONS: We document lower cognitive performance and reductions in brain structural integrity among adolescents with MetS, thus suggesting that even relatively short-term impairments in metabolism, in the absence of clinically manifest vascular disease, may give rise to brain complications. In view of these alarming results, it is plausible that obesity-associated metabolic disease, short of type 2 diabetes mellitus, may be mechanistically linked to lower the academic and professional potential of adolescents. Although obesity may not be enough to stir clinicians or even parents into action, these results in adolescents strongly argue for an early and comprehensive intervention. We propose that brain function be introduced among the parameters that need to be evaluated when considering early treatment of childhood obesity.

KEY WORDS

• metabolic syndrome
• adolescence
• obesity
• diffusion tensor imaging
• brain abnormalities
• cognitive performance
• hippocampal volumes
• fractional anisotropy

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 10 of 70Article

Attributable Risks for Childhood Overweight: Evidence for Limited Effectiveness of Prevention

OBJECTIVE: Calculation of attributable risks (ARs) of childhood overweight to estimate effectiveness of prevention strategies.

METHODS: We used pooled data of 4 population-based German studies including 34 240 children and adolescents aged 3 to 18 years to calculate the impact of familial, social, “early life”, and lifestyle factors on overweight. ARs (joint for all determinants as well as partial risks) were calculated.

RESULTS: The prevalence of childhood overweight was 13.4%. Successfully tackling all determinants can reduce overweight by 77.7% (ie, from 13.4% to 3.0%; = joint AR) with partial effects of treating parental overweight (42.5%); improving social status (14.3%); reducing media time to <1 hour per day (11.4%); and not smoking during pregnancy, low weight gain during pregnancy, and breastfeeding (together 9.5%), respectively. Improving all preventable risk factors (ie, early life factors and lifestyle) the effect is 9.2%. Media time has the strongest effect.

CONCLUSIONS: The determinants identified explained 78% of the prevalence of overweight. Taking into account the partial ARs, the effectiveness of lifestyle interventions to prevent overweight in children is limited. Our data argue in favor of interventions aimed at families and social environments, with a major focus on promoting a lower screen time and computer use in children.

KEY WORDS

• overweight children
• prevention
• epidemiology
• public health

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 11 of 70Article

Decline in Gastroenteritis-Related Triage Calls After Rotavirus Vaccine Licensure

OBJECTIVE: We sought to determine the impact of rotavirus vaccine implementation on gastroenteritis (GE)-related calls to a large telephone triage service in Tennessee.

METHODS: Total and GE-related calls received by the Vanderbilt Telephone Triage Program for children <5 years of age were examined from May 1, 2004 to April 30, 2010. Time series adapted Poisson regression models were used to compare weekly GE-related call proportions between the prevaccine (May 2004 to April 2007) and postlicensure (May 2007 to April 2010) periods. Separate models compared GE-related call proportions in the historical rotavirus (February to April) and nonrotavirus (May to January) seasons. Associations between call data and laboratory-confirmed rotavirus detections and regionally reported norovirus activity were also assessed.

RESULTS: There were 156 362 total calls and 19 731 GE-related calls. Annual GE-related call proportions declined by 8% (95% confidence interval, 3%–12%) in the postlicensure period; declines ranging from 23% to 31% occurred during the historical rotavirus season in all 3 postlicensure years. No declines occurred in the nonrotavirus season. After vaccine licensure, reductions in laboratory-confirmed rotavirus activity were associated with declines in GE-related call proportions. Peak GE-related call proportions in the postlicensure period occurred earlier than in prevaccine years and were not strongly associated with laboratory-confirmed rotavirus but instead showed good correlation with norovirus outbreaks.

CONCLUSIONS: A decline in GE-related call proportions among young children after rotavirus vaccine licensure was documented by using a novel surveillance platform that captures mild GE not detected in other surveillance systems. Since rotavirus vaccine licensure, peak call proportions correlate with regional norovirus activity, highlighting the role of that pathogen in community GE.

KEY WORDS

• gastroenteritis
• rotavirus
• rotavirus vaccines
• norovirus

• Accepted May 23, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 12 of 70Article

Electronic Cigarette Use Among Teenagers and Young Adults in Poland

BACKGROUND: Electronic cigarettes (e-cigarettes) are battery-powered devices developed with the goal of mimicking the action of smoking, including nicotine delivery, without the toxic effects of tobacco smoke. Little is known about the uptake of e-cigarettes among young people.

METHODS: A survey was conducted with a cluster sample of 20 240 students enrolled at 176 nationally representative Polish high schools and universities between September 2010 and June 2011. We estimated national e-cigarette prevalence among various demographic groups by using population weights. Multiple logistic regression was used to evaluate which demographic factors were independent predictors of 2 outcomes: ever use of e-cigarettes and use in the previous 30 days.

RESULTS: Among high school students, aged 15 to 19 years, 23.5% had ever used e-cigarettes and 8.2% had done so within the previous 30 days. Among those in universities, aged 20 to 24 years, 19.0% had ever used an e-cigarette and 5.9% had done so in the previous 30 days. In multivariate analyses that controlled for covariates, smoking cigarettes, male gender, living in an urban area, and having parents who smoke were associated with ever use of e-cigarettes. Overall, 3.2% of never smoking students reported ever use of e-cigarettes.

CONCLUSIONS: About one-fifth of Polish youth have tried e-cigarettes; most of them had previously smoked cigarettes. It is unclear whether e-cigarettes are just a novelty that young people try only once or whether they have potential to compete in the marketplace with conventional cigarettes.

KEY WORDS

• adolescents
• electronic cigarettes
• e-cigarettes
• nicotine
• smoking
• students

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 13 of 70Article

Incidence of Chronic Bilirubin Encephalopathy in Canada, 2007–2008

BACKGROUND AND OBJECTIVES: Despite the implementation of screening guidelines to identify infants at risk for hyperbilirubinemia, chronic bilirubin encephalopathy (CBE) continues to be reported worldwide in otherwise healthy infants. The incidence of CBE in Canada is unknown. The objectives of this study were to establish the incidence of CBE in Canada and identify epidemiological and medical risk factors associated with its occurrence.

METHODS: Data on infants were collected prospectively through the Canadian Pediatric Surveillance Program. Infants born between January 1, 2007 and December 31, 2008 were included if they either had symptoms of CBE and a history of hyperbilirubinemia, or if they presented in the newborn period with severe hyperbilirubinemia and an abnormal MRI finding as per the reporting physician.

RESULTS: During the study period, 20 cases were identified; follow-up data were available for 14 of these. The causes for the hyperbilirubinemia included glucose-6-phosphate dehydrogenase deficiency (n = 5), sepsis (n = 2), ABO incompatibility and other red blood cell antibodies (n = 7). Fifteen infants had abnormal brain MRI findings during the neonatal period. At follow-up, 5 infants developed classic choreoathetoid cerebral palsy, 6 had spectrum of neurologic dysfunction and developmental delay (as described by the reporting physician), and 3 were healthy.

CONCLUSIONS: CBE continues to occur in Canada at an incidence that appears to be higher than previously reported.

KEY WORDS

• chronic bilirubin encephalopathy
• neonatal hyperbilirubinemia
• incidence
• neurologic outcomes

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 14 of 70Article

EEG for Predicting Early Neurodevelopment in Preterm Infants: An Observational Cohort Study

OBJECTIVE: To clarify the prognostic value of conventional EEG for the identification of preterm infants at risk for subsequent adverse neurodevelopment in the current perinatal care and medicine setting.

METHODS: We studied 780 EEG records of 333 preterm infants born <34 weeks’ gestation between 2002 and 2008. Serial EEG recordings were conducted during 3 time periods; at least once each within days 6 (first period), during days 7 to 19 (second period), and days 20 to 36 (third period). The presence and the grade of EEG background abnormalities were assessed according to an established classification system. Neurodevelopmental outcomes were assessed at a corrected age of 12 to 18 months.

RESULTS: Of the 333 infants, 33 (10%) had developmental delay and 34 (10%) had cerebral palsy. The presence of EEG abnormalities was significantly predictive of developmental delay and cerebral palsy at all 3 time periods: the first period (n = 265; odds ratio [OR], 4.5; 95% confidence interval [CI], 2.2–9.4), the second period (n = 278; OR, 7.6; 95% CI, 3.6–16), and the third period (n = 237; OR, 5.9; 95% CI, 2.8–13). The grade of EEG abnormalities correlated with the incidence of developmental delay or cerebral palsy in all periods (P < .001). After controlling for other clinical variables, including severe brain injury, EEG abnormality in the second period was an independent predictor of developmental delay (OR, 3.2; 95% CI, 1.1–9.7) and cerebral palsy (OR, 6.8; 95% CI 2.0–23).

CONCLUSIONS: EEG abnormalities within the first month of life significantly predict adverse neurodevelopment at a corrected age of 12 to 18 months in the current preterm survivor.

KEY WORDS

• EEG
• preterm
• neurodevelopmental

• Accepted June 5, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 15 of 70Article

Trends of Transcutaneous Bilirubin in Neonates Who Develop Significant Hyperbilirubinemia

OBJECTIVES: To provide data on the natural course of transcutaneous bilirubin (TcB) levels in neonates before the development of significant hyperbilirubinemia, and to assess the effect of different demographic and perinatal factors on the rate of TcB increase.

METHODS: We analyzed 2454 TcB measurements from 419 neonates before the development of significant hyperbilirubinemia. Mean TcB values and TcB percentiles for designated times were calculated, and the effect of different risk factors on the rate of TcB increase was assessed. TcB percentile curves were plotted for comparison on a population-based TcB nomogram.

RESULTS: Blood incompatibilities and glucose-6-phosphate dehy-drogenase deficiency were associated with higher rates of TcB in-crease during the first 36 to 48 postnatal hours, whereas smaller gestational age, increased weight loss, and exclusive breastfeeding had a similar but later effect. Compared with general population norms, a different pattern of TcB increase was noted in neonates who developed significant hyperbilirubinemia, but with a sub-stantial overlap of TcB values during the first 24 to 48 postnatal hours.

CONCLUSIONS: We provide data on the natural course of TcB levels before the development of significant hyperbilirubinemia in a white population of term and near-term neonates. Smaller gestational age, blood incompatibilities, glucose-6-phosphate dehydrogenase deficiency, increased weight loss, and exclusive breastfeeding significantly affected the rate of TcB increase in a time-dependent manner. These findings may assist in assessing the risk for significant hyperbilirubinemia and planning appropriate follow-up strategies for neonates with borderline bilirubin levels.

KEY WORDS

• hyperbilirubinemia
• jaundice
• neonates
• transcutaneous bilirubin

• Accepted May 29, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 16 of 70Article

Beliefs and Expectations of Canadian Parents Who Bring Febrile Children for Medical Care

OBJECTIVES: The purpose of this survey was to study the beliefs, expectations, and satisfaction of Canadian parents regarding fever and the treatment of their febrile children.

METHODS: A survey was developed exploring caregiver beliefs and treatment strategies, as well as expectations and satisfaction with medical care. Some items were modeled after previous studies to allow comparison. Caregivers with febrile children were recruited from 2005 to 2007 at 3 urgent care centers and emergency departments in Edmonton, Canada: a pediatric emergency department (n = 376), an urban urgent care center (n = 227), and a suburban urgent care clinic (n = 173).

RESULTS: High and rapidly rising temperature, as well as physical symptoms associated with fever, caused concern in most parents surveyed. Seventy-four percent of parents felt that the elevated temperature from fever was dangerous and 90.3% always try to treat it. Forty degrees Celsius was the most commonly sited threshold for danger. Identifying the cause (80.6%) and seriousness (87.4%) of fever were the most com-mon stressors identified. Caregivers expected to receive information about the child’s illness and appropriate treatment. The parents most often wanted information about febrile seizures and the potential dangers of febrile illness. Only 16.7% of caregivers expected anti-biotics. Nearly 92% of subjects were usually satisfied with medical care.

CONCLUSIONS: Fever phobia continues to be a significant issue for Canadian parents. As a result, they treat fever aggressively and often seek medical attention. Good communication is important for medical staff caring for febrile children and typically leads to satisfied parents.

KEY WORDS

• pediatrics
• emergency
• fever phobia
• fever
• management
• expectations
• satisfaction
• antibiotics
• parent
• caregiver
• beliefs

• Accepted May 21, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 17 of 70Article

Circulating 25-Hydroxyvitamin D₃ in Pregnancy and Infant Neuropsychological Development

OBJECTIVE: To investigate whether circulating 25-hydroxyvitamin D₃ [25(OH)D₃] concentration in pregnancy is associated with neuropsychological development in infants.

METHODS: The Spanish population-based cohort study INfancia y Medio Ambiente Project recruited pregnant women during the first trimester of pregnancy between November 2003 and February 2008. Completed data on 1820 mother-infant pairs were used. Maternal plasma 25(OH)D₃ concentration was measured by high-performance liquid chromatography in pregnancy (mean 13.5±2.1 weeks of gestation). Offspring mental and psychomotor scores were assessed by trained psychologists at age 14 months (range, 11–23) by using the Bayley Scales of Infant Development. β-Coefficients with 95% confidence intervals (CIs) of mental and psychomotor scores associated with continuous or categorical concentrations of maternal plasma 25(OH)D₃ were calculated by using linear regression analysis.

RESULTS: The median plasma value of 25(OH)D₃ in pregnancy was 29.6 ng/mL (interquartile range, 21.8–37.3). A positive linear relationship was found between circulating concentrations of maternal 25(OH)D₃ concentrations in pregnancy and mental and psychomotor scores in the offspring. After adjustment for potential confounders, infants of mothers with 25(OH)D₃ concentrations in pregnancy >30 ng/mL showed higher mental score (β = 2.60; 95% CI 0.63–4.56) and higher psychomotor score (β = 2.32; 95% CI 0.36–4.28) in comparison with those of mothers with 25(OH)D₃ concentrations <20 ng/mL.

CONCLUSIONS: Higher circulating concentration of maternal 25(OH)D₃ in pregnancy was associated with improved mental and psychomotor development in infants.

KEY WORDS

• child development
• cognition
• infancy
• intelligence
• vitamin D

• Accepted May 16, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 18 of 70Article

Vitamin D Status of Exclusively Breastfed 4-Month-Old Infants Supplemented During Different Seasons

OBJECTIVE: To examine the vitamin D status of 4-month-old exclusively breastfed infants supplemented with 400 IU daily of vitamin D and to determine whether there was any seasonal variation in serum 25-hydroxyvitamin D (25(OH)D) levels of infants.

METHODS: In this cross-sectional study, serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and 25(OH)D levels of 143 exclusively breastfed 4-month-old infants supplemented daily with 400 IU of vitamin D were measured in a temperate latitude, Izmir, Turkey, between May 2008 and April 2009. A questionnaire on demographic characteristics of infants and mothers, vitamin D supplementation of infants after birth, mothers' multivitamin supplementation, dressing habits, and consumption of dairy products during pregnancy was used.

RESULTS: Vitamin D deficiency (≤50 nmol/L) and insufficiency (51–74 nmol/L) were determined in 40 (28%) and 55 (38.5%) infants, respectively. During winter days, serum 25(OH)D levels were <20 ng/mL in 45.4% of infants and <10 ng/mL in 10.6% of infants. Season of blood sampling, compliance of vitamin D supplementation, maternal education level, and consumption of dairy products were highly predictive of serum 25(OH)D levels in multiple linear regression analysis (P < .05). The use of the Pearson correlation test found a statistically significant negative correlation between 25(OH)D and parathyroid hormone levels (r = −0.419, P < .001).

CONCLUSIONS: Despite supplementation with 400 IU of vitamin D daily, the rate of vitamin D deficiency was worryingly high in 4-month-old exclusively breastfed infants living in Izmir, Turkey. So, additional studies are needed to clarify optimal amount of vitamin D supplementation to the infants, especially during winter days.

KEY WORDS

• breastfeeding
• infant
• seasonal variation
• vitamin D

• Accepted June 11, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 19 of 70Article

A New Liquid Human Milk Fortifier and Linear Growth in Preterm Infants

OBJECTIVES: To evaluate the growth, tolerance, and safety of a new ultraconcentrated liquid human milk fortifier (LHMF) designed to provide optimal nutrients for preterm infants receiving human breast milk in a safe, nonpowder formulation.

METHODS: Preterm infants with a body weight ≤1250 g fed expressed and/or donor breast milk were randomized to receive a control powder human milk fortifier (HMF) or a new LHMF for 28 days. When added to breast milk, the LHMF provided ∼20% more protein than the control HMF. Weight, length, head circumference, and serum prealbumin, albumin, blood urea nitrogen, electrolytes, and blood gases were measured. The occurrence of sepsis, necrotizing enterocolitis, and serious adverse events were monitored.

RESULTS: This multicenter, third party–blinded, randomized controlled, prospective study enrolled 150 infants. Achieved weight and linear growth rate were significantly higher in the LHMF versus control groups (P = .04 and 0.03, respectively). Among infants who adhered closely to the protocol, the LHMF had a significantly higher achieved weight, length, head circumference, and linear growth rate than the control HMF (P = .004, P = .003, P = .04, and P = .01, respectively). There were no differences in measures of feeding tolerance or days to achieve full feeding volumes. Prealbumin, albumin, and blood urea nitrogen were higher in the LHMF group versus the control group (all P < .05). There was no difference in the incidence of confirmed sepsis or necrotizing enterocolitis.

CONCLUSIONS: Use of a new LHMF in preterm infants instead of powder HMF is safe. Benefits of LHMF include improvements in growth and avoidance of the use of powder products in the NICU.

KEY WORDS

• breastfeeding
• human milk fortifier
• preterm infants

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 20 of 70Article

Self-Reported Energy Intake by Age in Overweight and Healthy-Weight Children in NHANES, 2001–2008

OBJECTIVE: Variation in energy intake by weight status at different ages may explain inconsistencies in previous research on energy intake and obesity. Therefore, our objective was to determine the relationship between reported daily energy intake and categorized weight status across childhood.

METHODS: We examined dietary reports of children ages 1 to 17 years by using the National Health and Nutrition Examination Survey, 2001–2008 (N = 12 648). Using measured height and weight, we categorized weight status based on weight-for-length percentile (age <2 years) or BMI percentile (ages 2–17 years) using current recommendations. Dietary intake was reported by using the repeatedly validated automated multiple pass method, a detailed 2-day 24-hour recall. We used ordinary least squares regression to examine the interactions of age and weight category on total energy intake, controlling for gender, race, ethnicity, and income.

RESULTS: Weight status and age both have positive associations with self-reported energy intake. However, the interaction between weight and age demonstrates a negative effect throughout childhood, such that young obese/overweight children reported consuming significantly more calories and obese/overweight adolescents reported consuming fewer calories than their same-age healthy-weight peers.

CONCLUSIONS: In a nationally representative cross-sectional sample, overweight and obese girls older than 7 years and boys older than 10 years reported consuming fewer daily calories than their healthy-weight peers. One explanation for this would be that increased energy intake in early childhood is related to the onset of obesity, but other mechanisms, such as differences in energy expenditure, may contribute more to maintaining obese/overweight status through adolescence.

• Obesity
• energy intake
• population-based survey
• nutrition

• Accepted June 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 21 of 70Article

Bottle-feeding and the Risk of Pyloric Stenosis

OBJECTIVES: Bottle-feeding has been suggested to increase the risk of pyloric stenosis (PS). However, large population-based studies are needed. We examined the effect of bottle-feeding during the first 4 months after birth, by using detailed data about the timing of first exposure to bottle-feeding and extensive confounder information.

METHODS: We performed a large population-based cohort study based on the Danish National Birth Cohort, which provided information on infants and feeding practice. Information about surgery for PS was obtained from the Danish National Patient Register. The association between bottle-feeding and the risk of PS was evaluated by hazard ratios (HRs) estimated in a Cox regression model, adjusting for possible confounders.

RESULTS: Among 70 148 singleton infants, 65 infants had surgery for PS, of which 29 were bottle-fed before PS diagnosis. The overall HR of PS for bottle-fed infants compared with not bottle-fed infants was 4.62 (95% confidence interval [CI]: 2.78–7.65). Among bottle-fed infants, risk increases were similar for infants both breast and bottle-fed (HR: 3.36 [95% CI: 1.60–7.03]), formerly breastfed (HR: 5.38 [95% CI: 2.88–10.06]), and never breastfed (HR: 6.32 [95% CI: 2.45–16.26]) (P = .76). The increased risk of PS among bottle-fed infants was observed even after 30 days since first exposure to bottle-feeding and did not vary with age at first exposure to bottle-feeding.

CONCLUSIONS: Bottle-fed infants experienced a 4.6-fold higher risk of PS compared with infants who were not bottle-fed. The result adds to the evidence supporting the advantage of exclusive breastfeeding in the first months after birth.

KEY WORDS

• infantile hypertrophic pyloric stenosis
• bottle-feeding
• feeding practice
• infants
• risk factor

• Accepted June 8, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 22 of 70Article

The Relationship Between Motor Coordination and Intelligence Across the IQ Range

OBJECTIVE: In both clinical practice and research, motor delay is understood to be explained, at least in part, by intellectual abilities; however, no data are available to operationalize these criteria to guide clinical decision making. This study provides data on IQ and motor skills in children to answer 3 research questions concerning the relationship between IQ and motor skill: (1) Can motor coordination impairment be explained in terms of general intellectual retardation? (2) What level of motor performance should be expected given the person's measured intelligence? (3) At what point are motor difficulties considered to be in excess of those usually associated with mental retardation?

METHODS: IQ and motor skill data were analyzed from a group of 460 children identified with/without motor difficulties from both clinical and educational settings.

RESULTS: Typical and atypical motor skill was seen at all IQ levels, 19% of the variance in motor outcomes was explained by IQ scores, and for each SD lower IQ, a mean loss of 10 percentile motor points should be expected.

CONCLUSIONS: Although individuals with a lower measured IQ more often showed poorer motor performance than those with a higher measured IQ, motor skill at all levels of proficiency was seen in all IQ categories. These findings have important implications for clinical judgments and decision-making, as well as for future research directions to further operationalize the criteria relating to motor disorders in both the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, and the International Classification of Diseases, 10th Revision.

KEY WORDS

• motor development
• intelligence
• learning disability

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 23 of 70Article

Comparison of Mortality and Morbidity of Very Low Birth Weight Infants Between Canada and Japan

OBJECTIVE: To compare neonatal outcomes of very low birth weight (VLBW) infants admitted to NICUs participating in the Canadian Neonatal Network and the Neonatal Research Network of Japan.

METHODS: Secondary analyses of VLBW infants in both national databases between 2006 and 2008 were conducted. The primary outcome was a composite of mortality or any major morbidity defined as severe neurologic injury, bronchopulmonary dysplasia, necrotizing enterocolitis, or severe retinopathy of prematurity at discharge. Secondary outcomes included individual components of primary outcome and late-onset sepsis. Logistic regression adjusting for confounders was performed.

RESULTS: A total of 5341 infants from the Canadian Neonatal Network and 9812 infants from the Neonatal Research Network of Japan were compared. There were higher rates of maternal hypertension, diabetes mellitus, outborn, prenatal steroid use, and multiples in Canada, whereas cesarean deliveries were higher in Japan. Composite primary outcome was better in Japan in comparison with Canada (adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.79–0.96). The odds of mortality (AOR 0.40, 95% CI 0.34–0.47), severe neurologic injury (AOR 0.57, 95% CI 0.49–0.66), necrotizing enterocolitis (AOR 0.23, 95% CI 0.19–0.29), and late-onset sepsis (AOR 0.22, 95% CI 0.19–0.25) were lower in Japan; however, the odds of bronchopulmonary dysplasia (AOR 1.24, 95% CI 1.10–1.42) and severe retinopathy of prematurity (AOR 1.98, 95%CI 1.69–2.33) were higher in Japan.

CONCLUSIONS: Composite outcome of mortality or major morbidity was significantly lower in Japan than Canada for VLBW infants. However, there were significant differences in various individual outcomes identifying areas for improvement for both networks.

KEY WORDS

• infant
• very low birth weight
• mortality
• bronchopulmonary dysplasia
• intraventricular hemorrhage
• retinopathy of prematurity

• Accepted May 23, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 24 of 70Article

Variability of Growth in Children Starting Antiretroviral Treatment in Southern Africa

BACKGROUND: Poor growth is an indication for antiretroviral therapy (ART) and a criterion for treatment failure. We examined variability in growth response to ART in 12 programs in Malawi, Zambia, Zimbabwe, Mozambique, and South Africa.

METHODS: Treatment naïve children aged <10 years were included. We calculated weight for age z scores (WAZs), height for age z scores (HAZs), and weight for height z scores (WHZs) up to 3 years after starting ART, by using the World Health Organization standards. Multilevel regression models were used.

RESULTS: A total of 17 990 children (range, 238–8975) were followed for 36 181 person-years. At ART initiation, most children were underweight (50%) and stunted (66%). Lower baseline WAZ, HAZ, and WHZ were the most important determinants of faster catch-up growth on ART. WAZ and WHZ increased rapidly in the first year and stagnated or reversed thereafter, whereas HAZ increased continuously over time. Three years after starting ART, WAZ ranged from −2.80 (95% confidence interval [CI]: −3.66 to −2.02) to −1.98 (95% CI: −2.41 to −1.48) in children with a baseline z score < −3 and from −0.79 (95% CI: −1.62 to 0.02) to 0.05 (95% CI: −0.42 to 0.51) in children with a baseline WAZ ≥ −1. For HAZ, the corresponding range was −2.33 (95% CI: −2.62 to −2.02) to −1.27 (95% CI: −1.58 to −1.00) for baseline HAZ < −3 and −0.24 (95% CI: −0.56 to 0.15) to 0.84 (95% CI: 0.53 to 1.16) for HAZ ≥ −1.

CONCLUSIONS: Despite a sustained growth response and catch-up growth in children with advanced HIV disease treated with ART, normal weights and heights are not achieved over 3 years of ART.

KEY WORDS

• HIV
• growth
• antiretroviral therapy
• Southern Africa

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 25 of 70Article

Tanner Stage 4 Breast Development in Adults: Forensic Implications

BACKGROUND AND OBJECTIVE: Forensic testimony in alleged child pornography cases commonly asserts that Tanner stage (TS) 4 breast development, characterized by secondary mounding of the areola that is obliterated in TS 5, is evidence of age <18 years. Clinical experience does not support this notion, but there are no relevant studies. We sought to estimate how frequently TS 4 might be interpreted from nonclinical images by individual forensic experts.

METHOD: Published images of 547 adult women were independently examined by the authors and classified as having TS 4 or TS 5 breast development.

RESULTS: There was concordance among all 4 of the examiners for 17 of the images, agreement of 3 of the examiners on another 36 images, of 2 examiners on 39 images, and 53 images were designated TS 4 by only 1 examiner, for a total of 153 (26.5%) images that could have been considered by a single forensic expert to represent TS 4.

CONCLUSIONS: A substantial number of adults have persistent TS 4 breast development. This observation, and the frequent difficulty distinguishing TS 4 from TS 5, even by adolescent development specialists, especially in nonclinical images, renders testimony based on this distinction invalid. Without clinical relevance for distinguishing these advanced stages of breast development, they should both be considered indicative of full maturation. Testimony based on this inappropriate test of maturity should no longer be allowed.

KEY WORDS

• Tanner stage
• breast development
• child pornography
• forensics

• Accepted June 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 26 of 70Article

Evaluation of Interobserver Agreement of Apgar Scoring in Preterm Infants

BACKGROUND AND OBJECTIVES: Apgar scoring is accepted by medical professionals both as a measure of the infant’s clinical status and the infant’s response to resuscitation. Recent studies, however, have suggested significant variability when used for scoring preterm infants. We hypothesized that agreement in Apgar scoring would improve with increasing gestational age and at low levels of respiratory support. We also hypothesized that grimace and muscle tone would demonstrate the least agreement.

METHODS: Neonatologists from the Perinatal Section of the American Academy of Pediatrics were presented with 4 film clip cases via a secure online survey: (1) full-term infant in room air; (2) 28 weeks’ gestation infant with continuous positive airway pressure; (3) 28 weeks’ gestation infant intubated; and (4) 24 weeks’ gestation infant intubated. Participants were shown 30-second clips at 1, 5, and 10 minutes of life and were asked to provide Apgar scores. κ coefficients were used to compare agreement for each component.

RESULTS: A total of 335 neonatologists participated in the survey. κ coefficients in the full-term infant for respiratory effort (0.94, 0.91), grimace (0.91, 0.90), and muscle tone (0.91, 0.89) demonstrated almost perfect agreement at 1 and 5 minutes. For preterm infants, respiratory effort (range: 0.07–0.40), muscle tone (range: 0.10–0.75), and grimace (range: 0.11–0.71) all demonstrated disagreement at 1, 5, and 10 minutes of life unless the infants were apneic and limp.

CONCLUSIONS: An improved delivery room score that decreases variability among medical care professionals is needed to accurately reflect the clinical status of preterm infants.

KEY WORDS

• agreement
• Apgar score
• preterm infants

• Accepted May 24, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 27 of 70Article

Hypertension Screening During Ambulatory Pediatric Visits in the United States, 2000–2009

BACKGROUND AND OBJECTIVE: Hypertension occurs in 2% to 5% of children in the United States, and its prevalence has increased during the obesity epidemic. There is no consensus among professional organizations about how frequently blood pressure should be measured in children >3 years old. The purpose of this study was to estimate the frequency of hypertension screening during ambulatory pediatric visits in the United States and to determine patient- and provider-level factors associated with screening during visits specifically for preventive care.

METHODS: We analyzed data from a nationally representative sample of ambulatory visits by using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 2000 through 2009. In the subset of visits involving patients aged 3 to 18 years, we estimated the frequency of screening during all visits, preventive visits, and preventive visits in which overweight/obesity was diagnosed. We used multivariable logistic regression to identify patient- and provider-level factors associated with screening.

RESULTS: Hypertension screening occurred during 35% of ambulatory pediatric visits, 67% of preventive visits, and 84% of preventive visits in which overweight/obesity was diagnosed. Between 2000 and 2009, the frequency of screening increased in all visits and in preventive visits. Factors independently associated with screening included older age and overweight/obesity diagnosis.

CONCLUSIONS: Providers do not measure blood pressure in two-thirds of pediatric visits and one-third of pediatric preventive visits. Providers may understand the importance of screening among overweight/obese children; however, efforts to encourage routine screening, particularly in young children, may be needed.

• blood pressure
• hypertension
• screening

• Accepted June 11, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 28 of 70Article

Sodium Intake and Blood Pressure Among US Children and Adolescents

OBJECTIVE: To assess the association between usual dietary sodium intake and blood pressure among US children and adolescents, overall and by weight status.

METHODS: Children and adolescents aged 8 to 18 years (n = 6235) who participated in NHANES 2003–2008 comprised the sample. Subjects’ usual sodium intake was estimated by using multiple 24-hour dietary recalls. Linear or logistic regression was used to examine association between sodium intake and blood pressure or risk for pre-high blood pressure and high blood pressure (pre-HBP/HPB).

RESULTS: Study subjects consumed an average of 3387 mg/day of sodium, and 37% were overweight/obese. Each 1000 mg per day sodium intake was associated with an increased SD score of 0.097 (95% confidence interval [CI] 0.006–0.188, ∼1.0 mm Hg) in systolic blood pressure (SBP) among all subjects and 0.141 (95% CI: –0.010 to 0.298, ∼1.5 mm Hg) increase among overweight/obese subjects. Mean adjusted SBP increased progressively with sodium intake quartile, from 106.2 mm Hg (95% CI: 105.1–107.3) to 108.8 mm Hg (95% CI: 107.5–110.1) overall (P = .010) and from 109.0 mm Hg (95% CI: 107.2–110.8) to 112.8 mm Hg (95% CI: 110.7–114.9; P = .037) among those overweight/obese. Adjusted odds ratios comparing risk for pre-HBP/HPB among subjects in the highest versus lowest sodium intake quartile were 2.0 (95% CI: 0.95–4.1, P = .062) overall and 3.5 (95% CI: 1.3–9.2, P = .013) among those overweight/obese. Sodium intake and weight status appeared to have synergistic effects on risk for pre-HBP/HPB (relative excess risk for interaction = 0.29 (95% CI: 0.01–0.90, P < .05).

CONCLUSIONS: Sodium intake is positively associated with SBP and risk for pre-HBP/HPB among US children and adolescents, and this association may be stronger among those who are overweight/obese.

KEY WORDS

• sodium intake
• overweight
• blood pressure
• hypertension
• cardiovascular risk factor

• Accepted June 1, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 29 of 70Article

Unfilled Prescriptions in Pediatric Primary Care

BACKGROUND AND OBJECTIVES: Filling a prescription is the important first step in medication adherence, but has not been studied in pediatric primary care. The objective of this study was to use claims data to determine the rate of unfilled prescriptions in pediatric primary care and examine factors associated with prescription filling.

METHODS: This retrospective observational study of pediatric primary care patients compares prescription data from an electronic medical record with insurance claims data. Illinois Medicaid provided claims data for 4833 patients who received 16 953 prescriptions during visits at 2 primary care sites over 26 months. Prescriptions were compared with claims to determine filling within 1 day and 60 days. Clinical and demographic variables significant in univariate analysis were included in logistic regression models.

RESULTS: Patients were 51% male; most (84%) spoke English and were African American (38.7%) or Hispanic (39.1%). Seventy-eight percent of all prescriptions were filled. Among filled prescriptions, 69% were filled within 1 day. African American, Hispanic, and male patients were significantly more likely to have filled prescriptions. Younger age was associated with filling within 1 day but not with filling within 60 days. Prescriptions for antibiotics, from one of the clinic sites, from sick/follow-up visits, and electronic prescriptions were significantly more likely to be filled.

CONCLUSIONS: More than 20% of prescriptions in a pediatric primary care setting were never filled. The significant associations with clinical site, visit type, and electronic prescribing suggest system-level factors that affect prescription filling. Development of interventions to increase adherence should account for the factors that affect primary adherence.

KEY WORDS

• nonadherence
• unfilled prescriptions
• primary adherence
• medication adherence

• Accepted May 29, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 30 of 70Article

Communication During Pediatric Asthma Visits and Self-Reported Asthma Medication Adherence

OBJECTIVE: Our objectives were to examine how certain aspects of provider-patient communication recommended by national asthma guidelines (ie, provider asking for child and caregiver input into the asthma treatment plan) were associated with child asthma medication adherence 1 month after an audio-taped medical visit.

METHODS: Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at 5 pediatric practices in nonurban areas of North Carolina. All medical visits were audio-tape recorded. Children were interviewed 1 month after their medical visits, and both children and caregivers reported the child’s control medication adherence. Generalized estimating equations were used to determine if communication during the medical visit was associated with medication adherence 1 month later.

RESULTS: Children (n = 259) completed a home visit interview ∼1 month after their audio-taped visit, and 216 of these children were taking an asthma control medication at the time of the home visit. Children reported an average control medication adherence for the past week of 72%, whereas caregivers reported the child’s average control medication adherence for the past week was 85%. Child asthma management self-efficacy was significantly associated with both child- and caregiver-reported control medication adherence. When providers asked for caregiver input into the asthma treatment plan, caregivers reported significantly higher child medication adherence 1 month later.

CONCLUSIONS: Providers should ask for caregiver input into their child’s asthma treatment plan because it may lead to better control medication adherence.

KEY WORDS

• adherence
• asthma
• pediatric
• communication

• Accepted May 31, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 31 of 70Article

Pediatric Sleep Disorders and Special Educational Need at 8 Years: A Population-Based Cohort Study

OBJECTIVES: To examine associations between sleep-disordered breathing (SDB) and behavioral sleep problems (BSPs) through 5 years of age and special educational need (SEN) at 8 years.

METHODS: Parents in the Avon Longitudinal Study of Parents and Children reported on children’s snoring, witnessed apnea, and mouth-breathing at 6, 18, 30, 42, and 57 months, from which SDB symptom trajectories, or clusters, were derived. BSPs were based on report of ≥5 of 7 sleep behaviors at each of the 18-, 30-, 42-, and 57-month questionnaires. Parent report of SEN (yes/no) at 8 years was available for 11 049 children with SDB data and 11 467 children with BSP data. Multivariable logistic regression models were used to predict SEN outcome by SDB cluster and by cumulative report of SEN.

RESULTS: Controlling for 16 putative confounders, previous history of SDB and BSPs was significantly associated with an SEN. BSPs were associated with a 7% increased odds of SEN (95% confidence interval [CI] 1.01–1.15), for each ∼1-year interval at which a BSP was reported. SDB, overall, was associated with a near 40% increased odds of SEN (95% CI 1.18–1.62). Children in the worst symptom cluster were 60% more likely to have an SEN (95% CI 1.23–2.08).

CONCLUSIONS: In this population-based longitudinal study, history of either SDB or BSPs in the first 5 years of life was associated with increased likelihood of SEN at 8 years of age. Findings highlight the need for pediatric sleep disorder screening by early interventionists, early childhood educators, and health professionals.

KEY WORDS

• sleep-disordered breathing
• behavior sleep problem
• longitudinal
• special education

• Accepted May 16, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 32 of 70Article

Five-Year Follow-up of Harms and Benefits of Behavioral Infant Sleep Intervention: Randomized Trial

BACKGROUND AND OBJECTIVES: Randomized trials have demonstrated the short- to medium-term effectiveness of behavioral infant sleep interventions. However, concerns persist that they may harm children’s emotional development and subsequent mental health. This study aimed to determine long-term harms and/or benefits of an infant behavioral sleep program at age 6 years on (1) child, (2) child-parent, and (3) maternal outcomes.

METHODS: Three hundred twenty-six children (173 intervention) with parent-reported sleep problems at age 7 months were selected from a population sample of 692 infants recruited from well-child centers. The study was a 5-year follow-up of a population-based cluster-randomized trial. Allocation was concealed and researchers (but not parents) were blinded to group allocation. Behavioral techniques were delivered over 1 to 3 individual nurse consultations at infant age 8 to 10 months, versus usual care. The main outcomes measured were (1) child mental health, sleep, psychosocial functioning, stress regulation; (2) child-parent relationship; and (3) maternal mental health and parenting styles.

RESULTS: Two hundred twenty-five families (69%) participated. There was no evidence of differences between intervention and control families for any outcome, including (1) children’s emotional (P = .8) and conduct behavior scores (P = .6), sleep problems (9% vs 7%, P = .2), sleep habits score (P = .4), parent- (P = .7) and child-reported (P = .8) psychosocial functioning, chronic stress (29% vs 22%, P = .4); (2) child-parent closeness (P = .1) and conflict (P = .4), global relationship (P = .9), disinhibited attachment (P = .3); and (3) parent depression, anxiety, and stress scores (P = .9) or authoritative parenting (63% vs 59%, P = .5).

CONCLUSIONS: Behavioral sleep techniques have no marked long-lasting effects (positive or negative). Parents and health professionals can confidently use these techniques to reduce the short- to medium-term burden of infant sleep problems and maternal depression.

KEY WORDS

• mental health
• attachment
• stress
• psychological
• sleep disorders
• population surveillance
• child
• preschool
• cluster randomized controlled trial

• Accepted June 11, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 33 of 70Article

Feasibility and Preliminary Outcomes of a Scalable, Community-based Treatment of Childhood Obesity

OBJECTIVE: Clinic-based treatments of childhood obesity are effective but typically have limited reach and are costly. In this study, we evaluated the effects of a scalable weight management program for children and teenagers.

METHODS: Participants were 155 children and their parent/guardian. Children had a mean ± SD age of 11.3 ± 2.8 years, BMI z score of 2.23 ± 0.41, and a percentage overweight of 72.5 ± 34.0. Most (92%) were obese, and nearly half (46.5%) were ≥99th percentile for BMI. The primary outcome was change in percentage overweight from baseline to 6 months.

RESULTS: At 6 months, children experienced a 3.4 percentage point reduction in percentage overweight (P = .001). Children <13 years had a 4.3 percentage point reduction in percentage overweight, whereas those ≥13 years had a 1.0 percentage point reduction. Those who attended a greater number of face-to-face group sessions experienced greater changes in percentage overweight. There were significant improvements in child health-related quality of life as reported by both children and their parents.

CONCLUSIONS: These data suggest that a scalable, community-based pediatric obesity intervention can result in clinically significant reductions in percentage overweight, as well as improvements in health-related quality of life.

KEY WORDS

• childhood obesity
• community pediatrics

• Accepted June 5, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 34 of 70Article

Efficacy of Family-Based Weight Control Program for Preschool Children in Primary Care

OBJECTIVE: To test the efficacy of an innovative family-based intervention for overweight preschool-aged children and overweight parents conducted in the primary care setting.

METHODS: Children with BMI ≥85th percentile and an overweight parent were randomized to intervention or information control (IC). Trained staff delivered dietary and physical/sedentary activities education to parents over 6 months (10 group meetings and 8 calls). Parents in the intervention received also behavioral modification. An intention-to-treat analysis was performed by using mixed analysis of variance models to test changes in child percent over BMI (%OBMI) and z-BMI and to explore potential moderators of group differences in treatment response.

RESULTS: Ninety-six of 105 randomized families started the program: 46 children (31 girls/15 boys) in the intervention and 50 (33 girls/17 boys) in the IC, with 33 and 39 mothers and 13 and 11 fathers in intervention and IC, respectively. Baseline characteristics did not differ between groups. Children in the intervention group had greater %OBMI and z-BMI decreases at 3 and 6 months compared with those assigned to IC (P < .0021). A greater BMI reduction over time was also observed in parents in the intervention compared with parents assigned to IC (P < .0001). Child %OBMI and parent BMI changes were correlated (r = .31; P = .003). Children with greater baseline %OBMI were more likely to have a greater %OBMI decrease over time (P = .02).

CONCLUSIONS: Concurrently targeting preschool-aged overweight youth and their overweight parents for behavioral weight control in a primary care setting reduced child %OBMI and parent BMI, with parent and child weight changes correlating.

KEY WORDS

• obesity
• primary care
• percent over BMI
• preschool children

• Accepted June 11, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 35 of 70Article

Sexually Explicit Cell Phone Messaging Associated With Sexual Risk Among Adolescents

OBJECTIVES: Sexting (sending/receiving sexually explicit texts and images via cell phone) may be associated with sexual health consequences among adolescents. However, to date, no published data from a probability-based sample has examined associations between sexting and sexual activity.

METHODS: A probability sample of 1839 students was collected alongside the 2011 Youth Risk Behavior Survey in Los Angeles high schools. Logistic regressions were used to assess the correlates of sexting behavior and associations between sexting and sexual risk-taking.

RESULTS: Fifteen percent of adolescents with cell phone access reported sexting, and 54% reported knowing someone who had sent a sext. Adolescents whose peers sexted were more likely to sext themselves (odds ratio [OR] = 16.87, 95% confidence interval [CI]: 9.62–29.59). Adolescents who themselves sexted were more likely to report being sexually active (OR = 7.17, 95% CI: 5.01–10.25). Nonheterosexual students were more likely to report sexting (OR = 2.74, 95% CI: 1.86–4.04), sexual activity (OR = 1.52, 95% CI: 1.07–2.15), and unprotected sex at last sexual encounter (OR = 1.84, 95% CI: 1.17–2.89).

CONCLUSIONS: Sexting, rather than functioning as an alternative to “real world” sexual risk behavior, appears to be part of a cluster of risky sexual behaviors among adolescents. We recommend that clinicians discuss sexting as an adolescent-friendly way of engaging patients in conversations about sexual activity, prevention of sexually transmitted infections, and unwanted pregnancy. We further recommend that discussion about sexting and its associated risk behavior be included in school-based sexual health curricula.

KEY WORDS

• sexual risk behavior
• adolescents
• HIV
• sexting
• technology

• Accepted May 21, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 36 of 70Article

Postnatal Fish Oil Supplementation in High-Risk Infants to Prevent Allergy: Randomized Controlled Trial

BACKGROUND AND OBJECTIVE: Relative deficiency of dietary omega 3 polyunsaturated fatty acids (n-3 PUFA) has been implicated in the rising allergy prevalence in Westernized countries. Fish oil supplementation may provide an intervention strategy for primary allergy prevention. The objective of this study was to assess the effect of fish oil n-3 PUFA supplementation from birth to 6 months of age on infant allergic disease.

METHODS: In a double-blind randomized controlled trial, 420 infants at high atopic risk received a daily supplement of fish oil containing 280 mg docosahexaenoic acid and 110 mg eicosapentaenoic acid or a control (olive oil), from birth to age 6 months. PUFA levels were measured in 6-month-old infants’ erythrocytes and plasma and their mothers’ breast milk. Eczema, food allergy, asthma and sensitization were assessed in 323 infants for whom clinical follow-up was completed at 12 months of age.

RESULTS: At 6 months of age, infant docosahexaenoic acid and eicosapentaenoic acid levels were significantly higher (both P < .05) and erythrocyte arachidonic acid levels were lower (P = .003) in the fish oil group. Although n-3 PUFA levels at 6 months were associated with lower risk of eczema (P = .033) and recurrent wheeze (P = .027), the association with eczema was not significant after multiple comparisons and there was no effect of the intervention per se on the primary study outcomes. Specifically, between-group comparisons revealed no differences in the occurrence of allergic outcomes including sensitization, eczema, asthma, or food allergy.

CONCLUSIONS: Postnatal fish oil supplementation improved infant n-3 status but did not prevent childhood allergic disease.

KEY WORDS

• Fish oil supplementation
• infants
• omega 3 PUFA
• allergy
• eczema
• allergy prevention

• Accepted June 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 37 of 70Article

Erythropoietin for Neuroprotection in Neonatal Encephalopathy: Safety and Pharmacokinetics

OBJECTIVE: To determine the safety and pharmacokinetics of erythropoietin (Epo) given in conjunction with hypothermia for hypoxic-ischemic encephalopathy (HIE). We hypothesized that high dose Epo would produce plasma concentrations that are neuroprotective in animal studies (ie, maximum concentration = 6000–10 000 U/L; area under the curve = 117 000–140 000 U*h/L).

METHODS: In this multicenter, open-label, dose-escalation, phase I study, we enrolled 24 newborns undergoing hypothermia for HIE. All patients had decreased consciousness and acidosis (pH < 7.00 or base deficit ≥ 12), 10-minute Apgar score ≤ 5, or ongoing resuscitation at 10 minutes. Patients received 1 of 4 Epo doses intravenously: 250 (N = 3), 500 (N = 6), 1000 (N = 7), or 2500 U/kg per dose (N = 8). We gave up to 6 doses every 48 hours starting at <24 hours of age and performed pharmacokinetic and safety analyses.

RESULTS: Patients received mean 4.8 ± 1.2 Epo doses. Although Epo followed nonlinear pharmacokinetics, excessive accumulation did not occur during multiple dosing. At 500, 1000, and 2500 U/kg Epo, half-life was 7.2, 15.0, and 18.7 hours; maximum concentration was 7046, 13 780, and 33 316 U/L, and total Epo exposure (area under the curve) was 50 306, 131 054, and 328 002 U*h/L, respectively. Drug clearance at a given dose was slower than reported in uncooled preterm infants. No deaths or serious adverse effects were seen.

CONCLUSIONS: Epo 1000 U/kg per dose intravenously given in conjunction with hypothermia is well tolerated and produces plasma concentrations that are neuroprotective in animals. A large efficacy trial is needed to determine whether Epo add-on therapy further improves outcome in infants undergoing hypothermia for HIE.

KEY WORDS

• neonatal encephalopathy
• asphyxia
• hypoxia-ischemia
• neuroprotection

• Accepted June 5, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 38 of 70Article

Views of Adolescents and Parents on Pediatric Research Without the Potential for Clinical Benefit

OBJECTIVE: Critics argue that pediatric research without the potential for clinical benefit is unethical because it treats children as mere means, exposing those who cannot consent to risks for the benefit of others. The present survey was designed to assess whether this claim is consistent with the views of adolescents who actually participate in research, or their parents.

METHODS: Interviews were conducted with adolescents participating in research at the NIH Clinical Center or Seattle Children's Hospital, and their parents, from June 2008 through April 2010.

RESULTS: Interviews were completed with 177 of 186 adolescent/parent pairs (response rate= 95.2%). Overall, 90% of the adolescents and parents were willing to have the adolescent undergo a few extra blood draws, and 65% were willing to have the adolescent undergo an extra skin biopsy, for research purposes. The vast majority felt that the adolescents were making an important contribution to help others, and 80.8% of the adolescents felt proud to be doing so. Respondents overall were equally willing to have the adolescent face risks to help others in a research study or in a charitable activity.

CONCLUSIONS: The views and experiences of these respondents do not support the claim that pediatric research without the potential for clinical benefit treats subjects as mere means. Instead, the findings provide proof of principle for the claim that non-beneficial pediatric research involves a type of charitable activity which offers children the opportunity to contribute to a valuable project to help others.

KEY WORDS

• research
• adolescents
• ethics

• Accepted June 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 39 of 70Article

Resident Work Hour Changes in Children’s Hospitals: Impact on Staffing Patterns and Workforce Needs

BACKGROUND AND OBJECTIVE: Changes to the structure and nature of resident duty hour assignments can create compensatory workforce needs in hospital or outpatient settings to ensure appropriate patient care. The objective of this study was to understand what, if any, adjustments children’s hospitals have made in staffing and assignments of specific duties during the past 2 years as a result of residency duty hour changes, and what changes are anticipated in the upcoming 2 years.

METHODS: Mail survey to chief executive officers and chief operating officers of 114 freestanding children’s hospitals or children’s hospitals within a larger hospital.

RESULTS: Response rate was 65.4%. Respondents from more than half of hospitals (57%, N = 36) reported increasing the overall full-time equivalent (FTE) of hospitalists in response to the 2011 resident work hour changes. Forty-eight percent (N = 30) increased the overall FTE of pediatric nurse practitioners (PNPs), and 42% (N = 27) increased the FTE of neonatal nurse practitioners (NNPs). Most hospitals plan to increase the number of hospitalists (69%, N = 44), PNPs (59%, N = 37), or pediatric attending physicians (56%, N = 35) over the next 2 years. Forty-three percent (N = 27) of hospitals plan to increase the number of NNPs over the next 2 years, and a quarter plan to increase physician assistants (25%, N = 16) or pediatric house staff (24%, N = 15).

CONCLUSIONS: Changes in work hours for pediatric residents appear to have an impact on workforce planning within pediatric hospitals. Decreases in available resident work hours will create an increasing demand, primarily for nonresident physicians, PNPs, and NNPs.

KEY WORDS

• residents
• hospitals
• staffing
• economic workforce

• Accepted June 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 40 of 70Article

Pediatric Residents’ Knowledge, Use, and Comfort With Expedited Partner Therapy for STIs

OBJECTIVE: We examined California pediatric residents' knowledge, practices, and comfort of providing expedited partner therapy (EPT) for sexually transmitted infections, by postgraduate year of training and presence of an adolescent medicine fellowship. We hypothesized that few residents are aware of EPT, and fewer are comfortable providing it; knowledge, practices, and comfort increase during residency; and presence of an adolescent medicine fellowship increases knowledge, practices, and comfort.

METHODS: Online anonymous questionnaires were completed by pediatric residents from 14 California programs.

RESULTS: Two hundred eighty-nine pediatric residents (41% response; mean age, 29.4 ± 2.7 years; 78% female) responded. Twenty-two percent reported being moderately or very familiar with EPT. Most correctly identified several EPT methods. Incorrectly identified as EPT included patient (55%), health department (42%), and provider (37%) referrals. Only 8% were aware of California’s legal status regarding EPT. Sixty-nine percent knew that California law allows EPT for chlamydia and gonorrhea, but 38% incorrectly stated that EPT can be used to treat trichomoniasis. Fifty-two percent reported ever providing EPT, but 30% of them were uncomfortable doing so. Postgraduate year 1 residents were significantly more likely to report lack of experience as a barrier to prescribing EPT. Residents in programs with the presence of an adolescent medicine fellowship had significantly higher global knowledge scores and were more likely to practice EPT with fewer concerns.

CONCLUSIONS: California pediatric residents have knowledge gaps and discomfort providing EPT, and the presence of adolescent medicine fellowship is associated with increased EPT knowledge, use, and comfort among residents. Our findings demonstrate a need to improve EPT education in pediatric residencies.

KEY WORDS

• sexually transmitted diseases
• partner treatment
• expedited partner therapy
• adolescents

• Accepted June 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 41 of 70Article

Pediatric Residency Training Director Tobacco Survey II

OBJECTIVE: To assess the current status of pediatric residency training on tobacco use and smoke exposure.

METHODS: A nationwide survey of all pediatric residency training directors in the United States was conducted from November 2010 to May 2011 via use of surveymonkey.com. The survey assessed training director characteristics, attitudes and beliefs about pediatricians’ role in addressing tobacco control in patients and parents, past training in tobacco use and smoke exposure, inclusion of tobacco control in their training curriculum, and barriers to inclusion. Data are presented as percentages, with χ² tests of significance.

RESULTS: Sixty-five percent of programs included tobacco control in the curriculum, and training directors who received past training in tobacco prevention and control were significantly more likely to include tobacco use and smoke exposure than those without training. The vast majority of training programs focused on health effects as opposed to intervention, failed to employ active learning to teach tobacco intervention skills, did not evaluate resident tobacco knowledge and skills, and did not encourage use of medications to help parents quit smoking.

CONCLUSIONS: Pediatric residency training programs must do more to prepare residents to address tobacco use and smoke exposure. Given the many competing priorities of residency training, there is a need to explore new ways of integrating tobacco control into the 3-year curriculum.

KEY WORDS

• pediatric residency training
• residency training directors
• training curriculum
• tobacco use
• exposure to tobacco smoke

• Accepted May 21, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 42 of 70Review Article

Medications for Adolescents and Young Adults With Autism Spectrum Disorders: A Systematic Review

BACKGROUND AND OBJECTIVE: Although many treatments have been studied in children with autism spectrum disorders (ASDs), less attention has focused on interventions that may be helpful in adolescents and young adults with ASD. The goal of this study was to systematically review evidence regarding medication treatments for individuals between the ages of 13 and 30 years with ASD.

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

RESULTS: Eight studies of medications were identified that focused on 13- to 30-year-olds with ASD; 4 of the studies were of fair quality. The strength of evidence was insufficient for all outcomes associated with medications tested in this population; however, the 2 available studies of the atypical antipsychotic medication risperidone in this age range were consistent with the moderate evidence in children with ASD for treating problem behavior, including aggression, and high strength of evidence for adverse events, including sedation and weight gain.

CONCLUSIONS: There is a marked lack of data on use of medication treatments for adolescents and young adults with ASD. The evidence on the use of risperidone in this age range is insufficient when considered alone but is consistent with the data in the population of children with ASD.

• autism spectrum disorders
• antipsychotics
• risperidone
• serotonin reuptake inhibitors

• Accepted May 17, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 43 of 70State-of-the-Art Review Article

Cell Therapy: A Novel Treatment Approach for Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is a major cause of substantial lifelong morbidity in preterm infants. Despite a better understanding of the pathophysiology of BPD and significant research effort into its management, there remains today no effective treatment. Cell-based therapy is a novel approach that offers much promise in the prevention and treatment of BPD. Recent research supports a therapeutic role for cell transplantation in the management of a variety of acute and chronic adult and childhood lung diseases, with potential of such therapy to reduce inflammation and prevent acute lung injury. However, considerable uncertainties remain regarding cell therapies before they can be established as safe and effective clinical treatments for BPD. This review summarizes the current literature investigating cell therapies in lung disease, with particular focus on the various types of cells available and their specific properties in the context of a future therapy for BPD.

• bronchopulmonary dysplasia
• lung
• preterm
• stem cell
• cell transplantation

• Accepted June 29, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 44 of 70Special Article

A Framework for Elimination of Perinatal Transmission of HIV in the United States

The availability of effective interventions to prevent mother-to-child HIV transmission and the significant reduction in the number of HIV-infected infants in the United States have led to the concept that elimination of mother-to-child HIV transmission (EMCT) is possible. Goals for elimination are presented. We also present a framework by which elimination efforts can be coordinated, beginning with comprehensive reproductive health care (including HIV testing) and real-time case-finding of pregnancies in HIV-infected women, and conducted through the following: facilitation of comprehensive clinical care and social services for women and infants; case review and community action; allowing continuous quality research in prevention and long-term follow-up of HIV-exposed infants; and thorough data reporting for HIV surveillance and EMCT evaluation. It is emphasized that EMCT will not be a one-time accomplishment but, rather, will require sustained effort as long as there are new HIV infections in women of childbearing age.

KEY WORDS

• elimination
• HIV
• mother-to-child
• perinatal
• transmission

• Accepted May 23, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 45 of 70Quality Report

Improving Delivery of EPSDT Well-Child Care at Acute Visits in an Academic Pediatric Practice

BACKGROUND AND OBJECTIVE: Many patients with Medicaid do not receive timely, comprehensive well-child care through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Missed opportunities for EPSDT well-child check-ups (WCCs) at acute visits contribute to this problem. The authors sought to reduce missed opportunities for WCCs at acute visits for patients overdue for those services.

METHODS: A quality improvement team developed key drivers and used a people-process-technology framework to devise 3 interventions: (1) an electronic indicator based on novel definitions of EPSDT status (up-to-date, due, overdue, no EPSDT), (2) a standardized scheduling process for acute visits based on EPSDT status, and (3) a dedicated nurse practitioner to provide WCCs at acute visits. Data were collected for 1 year after full implementation.

RESULTS: At baseline, 10.3 acute visits per month were converted to WCCs. After intervention, 86.7 acute visits per month were converted. Of 13 801 acute visits during the project, 31.2% were not up-to-date. Of those overdue for WCCs, 51.4% (n = 552) were converted to a WCC in addition to the acute visit. Including all patients who were not up-to-date, a total of 1047 acute visits (7.6% of all acute visits) were converted to comprehensive WCCs. Deferring needed WCCs at acute visits resulted in few patients who scheduled or completed future WCC visits.

CONCLUSIONS: Implementation of interventions focused on people-process-technology significantly increased WCCs at acute visits within a feasible and practical model that may be replicated at other academic general pediatrics practices.

• EPSDT
• Medicaid
• missed opportunities
• well-child care
• quality improvement
• outpatient clinics
• nurse practitioner

• Accepted April 24, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 46 of 70Quality Report

Implementation of a Central Line Maintenance Care Bundle in Hospitalized Pediatric Oncology Patients

OBJECTIVE: To investigate whether a multidisciplinary, best-practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population.

METHODS: We performed a prospective, interrupted time series study of a best-practice bundle addressing all areas of central line care: reduction of entries, aseptic entries, and aseptic procedures when changing components. Based on a continuous quality improvement model, targeted interventions were instituted to improve compliance with each of the bundle elements. CLABSI rates and epidemiological data were collected for 10 months before and 24 months after implementation of the bundle and compared in a Poisson regression model.

RESULTS: CLABSI rates decreased from 2.25 CLABSIs per 1000 central line days at baseline to 1.79 CLABSIs per 1000 central line days during the intervention period (incidence rate ratio [IRR]: 0.80, P = .58). Secondary analyses indicated CLABSI rates were reduced to 0.81 CLABSIs per 1000 central line days in the second 12 months of the intervention (IRR: 0.36, P = .091). Fifty-nine percent of infections resulted from Gram-positive pathogens, 37% of patients with a CLABSI required central line removal, and patients with Hickman catheters were more likely to have a CLABSI than patients with Infusaports (IRR: 4.62, P = .02).

CONCLUSIONS: A best-practice central line maintenance care bundle can be implemented in hospitalized pediatric oncology patients, although long ramp-up times may be necessary to reap maximal benefits. Further research is needed to determine if this CLABSI rate reduction can be sustained and spread.

KEY WORDS

• oncology
• central line-associated blood stream infection
• quality improvement
• epidemiology
• pediatric
• central venous catheter/access device

• Accepted May 2, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 47 of 70Case Report

Favorable Outcome in a Newborn With Molybdenum Cofactor Type A Deficiency Treated With cPMP

Molybdenum cofactor deficiency (MoCD) is a lethal autosomal recessive inborn error of metabolism with devastating neurologic manifestations. Currently, experimental treatment with cyclic pyranopterin monophosphate (cPMP) is available for patients with MoCD type A caused by a mutation in the MOCS-1 gene. Here we report the first case of an infant, prenatally diagnosed with MoCD type A, whom we started on treatment with cPMP 4 hours after birth. The most reliable method to evaluate neurologic functioning in early infancy is to assess the quality of general movements (GMs) and fidgety movements (FMs). After a brief period of seizures and cramped-synchronized GMs on the first day, our patient showed no further clinical signs of neurologic deterioration. Her quality of GMs was normal by the end of the first week. Rapid improvement of GM quality together with normal FMs at 3 months is highly predictive of normal neurologic outcome. We demonstrated that a daily cPMP dose of even 80 μg/kg in the first 12 days reduced the effects of neurodegenerative damage even when seizures and cramped-synchronized GMs were already present. We strongly recommend starting cPMP treatment as soon as possible after birth in infants diagnosed with MoCD type A.

KEY WORDS

• cyclic pyranopterin monophosphate
• general movements
• molybdenum cofactor deficiency
• sulfite oxidase

• Accepted June 6, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 48 of 70Case Report

Water-Absorbing Balls: A “Growing” Problem

Foreign body ingestion is a potentially serious clinical problem in children. We report a case of an 8-month-old infant who developed complete bowel obstruction requiring laparotomy due to ingestion of a superabsorbent polymer ball with advertised growth up to 400 times its original size. Most ingested foreign bodies that pass through the pylorus will make it safely through the gastrointestinal tract. This is not true for water-absorbing balls that progressively increase in size and cause intestinal obstruction. Other household products and toys on the market use a similar polymer-based water-absorbing technology, thus increasing the risk for accidental ingestion by young children. These rapidly expanding objects can cause significant morbidity, and timely diagnosis and treatment are prudent to improve patient outcomes.

KEY WORDS

• bowel obstruction
• children
• complications
• foreign body ingestion
• superabsorbent polymer balls

• Accepted April 13, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 49 of 70Case Report

Blood Alcohol Levels for American Indian Mothers and Newborns

Very little is known about the alcohol elimination rates of newborns who have had chronic alcohol exposure in utero. In these case reports, blood alcohol levels were taken immediately before delivery, at delivery, and postdelivery for 2 mothers who drank alcohol during their pregnancies and 3 single-birth newborns. Newborn A1 of Mother A had no physical characteristics of fetal alcohol syndrome (FAS). The initial blood alcohol level for this newborn was 38.4 mg/dL 129 minutes after birth, with a subsequent blood alcohol level of 5.5 mg/dL 304 minutes after delivery, resulting in an alcohol elimination rate of 11.3 mg/dL per hour. The blood alcohol level for Mother A was 87.4 mg/dL 66 minutes before delivery. Newborn A2 of mother A had FAS. Sixty minutes after delivery, the blood alcohol level for this newborn was 39.5 mg/dL, and the alcohol level of the mother was 42.1 mg/dL. Newborn B1 of mother B had FAS. At 67 minutes after birth, newborn B1 had a blood alcohol level of 246.5 mg/dL, which dropped to 178.7 mg/dL 302 minutes after birth, resulting in an alcohol elimination rate of 17.3 mg/dL per hour. This alcohol elimination rate is within the metabolism range (15–49 mg/dL per hour) of adults with alcoholism. The maternal blood alcohol level was 265.9 mg/dL 27 minutes before delivery. Blood alcohol levels drawn on both the mother and newborn at delivery and 2 or 3 hourly follow-up levels can provide evidence that fetal alcohol dehydrogenase activity is induced by chronic maternal alcohol use.

KEY WORDS

• alcohol dehydrogenase
• American Indian
• fetal alcohol metabolism
• maternal and newborn blood alcohol levels

• Accepted April 13, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 50 of 70Case Report

Congenital Fibrosarcoma and History of Prenatal Exposure to Petroleum Derivatives

Congenital fibrosarcoma (CFS) is a rare fibrous tissue malignancy that usually presents in the first few years of life. It is unique among human sarcomas in that it has an excellent prognosis. We describe a temporal clustering of a number of cases of CFS and investigate the possible associated prenatal risk factors. The Pediatric Environmental History, a questionnaire developed in our clinic that is instrumental in determining environmental risk factors for tumor-related disease, was essential in documenting the presence or absence of risk factors considered as human carcinogens. We found a history of exposure to petroleum products in four cases of CFS that occurred at a greater than expected rate in a short time frame–an apparent cancer cluster. We call attention to the possibility that exposure to petroleum products raises the risk of developing CFS. While future studies should focus on systematic investigation of CFS and its underlying mechanisms, this report suggests the need for proactive measures to avoid exposure to solvents and petroleum products during pregnancy.

KEY WORDS

• environmental health
• childhood cancer
• prevention
• fibrosarcoma
• petroleum derivatives

• Accepted May 15, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 51 of 70Case Report

Severe Poisoning After Accidental Pediatric Ingestion of Glycol Ethers

Human glycol ether poisonings are sparsely reported in the medical literature. We describe a healthy 22-month-old boy who accidentally drank up to 330 mL of brake fluid containing a 75% bleed of various glycol ethers (5%–50% polyethylene glycol monomethyl ether, 15%–40% triethylene glycol monoethyl ether, 1%–30% triethylene glycol monomethyl ether, 1%–25% triethylene glycol monobutyl ether, 1%–20% polyethylene glycol, monobutyl ether, 1%–20% triethylene glycol, and <10% of other glycol ethers). Within 4 hours, he became somnolent and developed a persistent metabolic acidosis. Thirty minutes later, he received 1 dose of fomepizole. Neither progression nor improvement in clinical or metabolic status was noted after the fomepizole. He received hemodialysis for 3 hours ∼8 hours after ingestion, and his symptoms resolved resulting in an uneventfully recovery.

• toxicology
• toxicity
• pediatrics
• emergency medicine
• glycol ethers
• toxic alcohols
• fomepizole

• Accepted May 4, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 52 of 70Case Report

Amitriptyline Cream Ingestion in a 1-Year-Old Boy

A 1-year-old boy presented to the emergency department with drowsiness after intoxication from amitriptyline cream. The amitriptyline level in his blood was in the high-therapeutic range for adults. He was admitted for cardiac monitoring. Except for a short episode with irregular heart rate, he recovered completely within 24 hours without adjuvant treatment. Amitriptyline is known as an antidepressant but is also prescribed for neuropathic pain. It is usually prescribed in tablet form; the cream is a novel application. In children, intoxication with amitriptyline may cause drowsiness, seizures, coma, hypotension, tachycardia, and life-threatening cardiac arrhythmias. This is the first case report presenting intoxication in a child with amitriptyline cream. It stresses the importance of keeping children away from the medicine cabinet, even from creams or ointments.

KEY WORDS

• amitriptyline
• intoxication
• topical cream
• cardiac arrhythmia
• pediatric

• Accepted April 30, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 53 of 70Case Report

Defining the Phenotype in Congenital Disorder of Glycosylation Due to ALG1 Mutations

Deficiency of β-1,4 mannosyltransferase (MT-1) congenital disorder of glycosylation (CDG), due to ALG1 gene mutations. Features in 9 patients reported previously consisted of prenatal growth retardation, pregnancy-induced maternal hypertension and fetal hydrops. Four patients died before 5 years of age, and survivors showed a severe psychomotor retardation. We report on 7 patients with psychomotor delay, microcephaly, strabismus and coagulation abnormalities, seizures and abnormal fat distribution. Four children had a stable clinical course, two had visual impairment, and 1 had hearing loss. Thrombotic and vascular events led to deterioration of the clinical outcome in 2 patients. Four novel ALG1 mutations were identified. Pathogenicity was determined in alg1 yeast mutants transformed with hALG1. Functional analyses showed all novel mutations representing hypomorphs associated with residual enzyme activity. We extend the phenotypic spectrum including the first description of deafness in MT1 deficiency, and report on mildly affected patients, surviving to adulthood. The dysmorphic features, including abnormal fat distribution and strabismus highly resemble CDG due to phosphomannomutase-2 deficiency (PMM2-CDG), the most common type of CDG. We suggest testing for ALG1 mutations in unsolved CDG patients with a type 1 transferrin isoelectric focusing pattern, especially with epilepsy, severe visual loss and hemorrhagic/thrombotic events.

KEY WORDS

• β-1,4 mannosyltransferase
• CDG-Ik
• short chain lipid-linked oligosaccharides
• seizures
• microcephaly

• Accepted March 27, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 54 of 70Letter to the Editor

·  Abstract 55 of 70Letter to the Editor

·  Abstract 56 of 70Letter to the Editor

·  Abstract 57 of 70Letter to the Editor

·  Abstract 58 of 70Letter to the Editor

·  Abstract 59 of 70Erratum

·  Abstract 60 of 70Erratum

·  Abstract 61 of 70Erratum

·  Abstract 62 of 70Erratum

·  Abstract 63 of 70Erratum

·  Abstract 64 of 70Erratum

·  Abstract 65 of 70From the American Academy of PediatricsClinical Report

Assessment and Management of Inguinal Hernia in Infants

Inguinal hernia repair in infants is a routine surgical procedure. However, numerous issues, including timing of the repair, the need to explore the contralateral groin, use of laparoscopy, and anesthetic approach, remain unsettled. Given the lack of compelling data, consideration should be given to large, prospective, randomized controlled trials to determine best practices for the management of inguinal hernias in infants.

• inguinal hernia
• infants
• surgery
• anesthesia
• laparoscopy

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 66 of 70From the American Academy of PediatricsPolicy Statement

Trampoline Safety in Childhood and Adolescence

Despite previous recommendations from the American Academy of Pediatrics discouraging home use of trampolines, recreational use of trampolines in the home setting continues to be a popular activity among children and adolescents. This policy statement is an update to previous statements, reflecting the current literature on prevalence, patterns, and mechanisms of trampoline-related injuries. Most trampoline injuries occur with multiple simultaneous users on the mat. Cervical spine injuries often occur with falls off the trampoline or with attempts at somersaults or flips. Studies on the efficacy of trampoline safety measures are reviewed, and although there is a paucity of data, current implementation of safety measures have not appeared to mitigate risk substantially. Therefore, the home use of trampolines is strongly discouraged. The role of trampoline as a competitive sport and in structured training settings is reviewed, and recommendations for enhancing safety in these environments are made.

KEY WORDS

• trampoline
• injury
• sports medicine
• safety
• cervical spine injury

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 67 of 70From the American Academy of PediatricsPolicy Statement

Recommendations for Prevention and Control of Influenza in Children, 2012–2013

The purpose of this statement is to update recommendations for routine use of trivalent seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The key points for the upcoming 2012–2013 season are: (1) this year’s trivalent influenza vaccine contains A/California/7/2009 (H1N1)–like antigen (derived from influenza A [H1N1] pdm09 [pH1N1] virus); A/Victoria/361/2011 (H3N2)–like antigen; and B/Wisconsin/1/2010–like antigen (the influenza A [H3N2] and B antigens differ from those contained in the 2010–2011 and 2011–2012 seasonal vaccines); (2) annual universal influenza immunization is indicated; and (3) an updated dosing algorithm for administration of influenza vaccine to children 6 months through 8 years of age has been created. Pediatricians, nurses, and all health care personnel should promote influenza vaccine use and infection control measures. In addition, pediatricians should promptly identify influenza infections to enable rapid treatment, when indicated, to reduce morbidity and mortality.

KEY WORDS

• children
• influenza
• immunization
• live-attenuated influenza vaccine
• pediatrics
• trivalent inactivated influenza vaccine
• vaccine

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 68 of 70From the American Academy of PediatricsClinical Report

The Pediatrician’s Role in Supporting Adoptive Families

Each year, more children join families through adoption. Pediatricians have an important role in assisting adoptive families in the various challenges they may face with respect to adoption. The acceptance of the differences between families formed through birth and those formed through adoption is essential in promoting positive emotional growth within the family. It is important for pediatricians to be aware of the adoptive parents’ need to be supported in their communication with their adopted children.

KEY WORDS

• adoption
• kinship care
• adoption by same sex parents
• transracial adoption
• communication

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 69 of 70From the American Academy of Pediatrics

·  Abstract 70 of 70From the American Academy of Pediatrics