Abstract 1 of 55Article

Socioeconomic Outcomes in Adults Malnourished in the First Year of Life: A 40-Year Study

OBJECTIVE: Lifelong functional, adaptive, and economic outcomes of moderate to severe infantile malnutrition are not well known. We assessed social status and income at midlife in a cohort of Barbadian adults, hospitalized for protein-energy malnutrition (PEM) during the first year of life, with good nutrition and health thereafter, in the context of a 40-year longitudinal case-control study. We also examined to what extent childhood IQ mediated any group differences.

METHODS: Educational achievement, occupational status, and standard of living were assessed by the Hollingshead scales and a site-specific Ecology Questionnaire in Barbadian adults (aged 37–43 years) with a history of malnutrition (n = 80) and a matched healthy control group (n = 63), classmates of the index cases. Malnutrition effects, adjusted for childhood standard of living, were estimated by longitudinal multiple regression analyses, with and without childhood IQ, in the models.

RESULTS: PEM predicted poorer socioeconomic outcomes with medium to large effect sizes (0.50–0.94), but childhood IQ substantially attenuated the magnitude of these effects (adjusted effect sizes: 0.17–0.34). The gap in weekly household income between the PEM and control groups increased substantially over the life span (P < .001).

CONCLUSIONS: Moderate to severe PEM during the first year of life with adequate nutrition and health care thereafter is associated with significant depression of socioeconomic outcomes in adulthood, mediated in part by cognitive compromise in affected individuals. This finding underscores the potential long-term economic burden of infant malnutrition, which is of major concern given the continued high prevalence of malnutrition worldwide.

KEY WORDS

• Hollingshead scales
• social position
• education
• occupation
• malnutrition
• protein-calorie
• life span
• cross-cultural
• longitudinal study

• Accepted March 8, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 2 of 55Article

Long-term Outcomes of Group B Streptococcal Meningitis

OBJECTIVE: Group B Streptococcus (GBS) is the leading cause of meningitis in young infants. We evaluated long-term outcomes among GBS meningitis survivors. We hypothesized that despite reduced mortality, GBS meningitis would remain a significant cause of morbidity among GBS survivors.

METHODS: Ninety term and near-term infants diagnosed with GBS meningitis from 1998 through 2006 were identified from 2 children’s hospitals. Five died acutely, and 5 died at 6 months to 3 years of age. Forty-three survivors (54%; mean age 6.8, range 3–12 years) were consented for evaluation and underwent physical and neurologic examinations, hearing and vision screening, and standardized developmental assessments. Associations among presenting features, laboratory parameters, neurologic status at hospital discharge, and later developmental outcomes were explored by using descriptive statistics and logistic regression.

RESULTS: Twenty-four of 43 (56%) children evaluated demonstrated age-appropriate development, 11 (25%) had mild-to-moderate impairment, and 8 (19%) had severe impairment. Admission features associated with death after hospital discharge or severe impairment included lethargy (P = .003), respiratory distress (P = .022), coma or semicoma (P = .022), seizures (P = .015), bulging fontanel (P = .034), leukopenia (P = .026), acidosis (P = .024), cerebrospinal fluid protein >300 mg/dL (P = .006), cerebrospinal fluid glucose <20 mg/dL (P = .026), and need for ventilator (P = .002) or pressor support (P < .001). Features at discharge associated with late death or severe impairment included failed hearing screen (P = .004), abnormal neurologic examination (P < .001), and abnormal end of therapy brain imaging (P = .038).

CONCLUSIONS: Survivors of GBS meningitis continue to have substantial long-term morbidity, highlighting the need for ongoing developmental follow-up and prevention strategies such as maternal immunization.

KEY WORDS

• group B Streptococcus
• meningitis
• development
• outcomes
• sepsis

• Accepted March 2, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 3 of 55Article

Costs and Infant Outcomes After Implementation of a Care Process Model for Febrile Infants

OBJECTIVE: Febrile infants in the first 90 days may have life-threatening serious bacterial infection (SBI). Well-appearing febrile infants with SBI cannot be distinguished from those without by examination alone. Variation in care resulting in both undertreatment and overtreatment is common.

METHODS: We developed and implemented an evidence-based care process model (EB-CPM) for the management of well-appearing febrile infants in the Intermountain Healthcare System. We report an observational study describing changes in (1) care delivery, (2) outcomes of febrile infants, and (3) costs before and after implementation of the EB-CPM in a children’s hospital and in regional medical centers.

RESULTS: From 2004 through 2009, 8044 infants had 8431 febrile episodes, resulting in medical evaluation. After implementation of the EB-CPM in 2008, infants in all facilities were more likely to receive evidence-based care including appropriate diagnostic testing, determination of risk for SBI, antibiotic selection, decreased antibiotic duration, and shorter hospital stays (P < .001 for all). In addition, more infants had a definitive diagnosis of urinary tract infection or viral illness (P < .001 for both). Infant outcomes improved with more admitted infants positive for SBI (P = .011), and infants at low risk for SBI were more often managed without antibiotics (P < .001). Although hospital admissions were shortened by 27%, there were no cases of missed SBI. Health Care costs were also reduced, with the mean cost per admitted infant decreasing from $7178 in 2007 to $5979 in 2009 (−17%, P < .001).

CONCLUSIONS: The EB-CPM increased evidence-based care in all facilities. Infant outcomes improved and costs were reduced, substantially improving value.

KEY WORDS

• fever
• infant
• outcomes
• cost

• Accepted March 22, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 4 of 55Article

Allergic Reactions to Foods in Preschool-Aged Children in a Prospective Observational Food Allergy Study

OBJECTIVE: To examine circumstances of allergic reactions to foods in a cohort of preschool-aged children.

METHODS: We conducted a prospective, 5-site observational study of 512 infants aged 3 to 15 months with documented or likely allergy to milk or egg, and collected data prospectively examining allergic reactions.

RESULTS: Over a median follow-up of 36 months (range: 0–48.4), the annualized reaction rate was 0.81 per year (367/512 subjects reporting 1171 reactions [95% confidence interval: 0.76–0.85]). Overall, 269/512 (52.5%) reported >1 reaction. The majority of reactions (71.2%) were triggered by milk (495 [42.3%]), egg (246 [21.0%]), and peanut (93 [7.9%]), with accidental exposures attributed to unintentional ingestion, label-reading errors, and cross-contact. Foods were provided by persons other than parents in 50.6% of reactions. Of 834 reactions to milk, egg, or peanut, 93 (11.2%) were attributed to purposeful exposures to these avoided foods. A higher number of food allergies (P < .0001) and higher food-specific immunoglobulin E (P < .0001) were associated with reactions. Of the 11.4% of reactions (n = 134) that were severe, 29.9% were treated with epinephrine. Factors resulting in undertreatment included lack of recognition of severity, epinephrine being unavailable, and fears about epinephrine administration.

CONCLUSIONS: There was a high frequency of reactions caused by accidental and nonaccidental exposures. Undertreatment of severe reactions with epinephrine was a substantial problem. Areas for improved education include the need for constant vigilance, accurate label reading, avoidance of nonaccidental exposure, prevention of cross-contamination, appropriate epinephrine administration, and education of all caretakers.

KEY WORDS

• food allergy
• IgE-mediated allergic reaction
• epinephrine

• Accepted February 27, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 5 of 55Article

RCT of a Mentoring and Skills Group Program: Placement and Permanency Outcomes for Foster Youth

OBJECTIVE: To examine the impact of a mentoring and skills group intervention for preadolescent children in foster care on placement stability and permanence at 1-year postintervention.

METHODS: A randomized controlled trial was conducted with 9- to 11-year-old children who were maltreated and placed in foster care (n = 54 control; n = 56 intervention). State child welfare records provided information on number of placement changes, placement in residential treatment, and case closure (ie, permanency). Rates of adoption and reunification were also examined. Analysis was by intention to treat.

RESULTS: After controlling for baseline functioning and preintervention placement history, intervention youth were 71% less likely to be placed in residential treatment (odds ratio [OR] = 0.29, 95% confidence interval [CI] 0.09–0.98). There were no significant treatment differences in predicting placement changes or permanency for the total sample. Among a subsample of children living in nonrelative foster care at baseline, intervention youth had 44% fewer placement changes (incidence ratio = 0.56, 95% CI 0.34–0.93), were 82% less likely to be placed in a residential treatment center (OR = 0.18, 95% CI 0.03–0.96), and were 5 times more likely to have attained permanency at 1 year postintervention (OR = 5.14, 95% CI 1.55–17.07). More intervention youth had reunified 1-year postintervention [χ²(1, N = 78) = 3.99; P < .05], and the pattern of findings suggested that intervention youth had higher rates of adoption. A significant interaction [χ²(1, N = 110) = 5.43; P = .02] demonstrated that the intervention attenuated the impact of baseline behavior problems on placement changes.

CONCLUSIONS: The findings suggest that participation in a 9-month mentoring and skills group intervention leads to greater placement stability and permanence, especially for children in nonrelative foster care.

KEY WORDS

• foster care
• child abuse and neglect
• child welfare
• clinical trial

• Accepted March 13, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 6 of 55Article

Sport-Related Kidney Injury Among High School Athletes

BACKGROUND AND OBJECTIVE: The American Academy of Pediatrics recommends a “qualified yes” for participation by athletes with single kidneys in contact/collision sports. Despite this recommendation, most physicians continue to discourage participation in contact/collision sports for patients with single kidneys. A major concern is the lack of prospective data quantifying the incidence of sport-related kidney injury. The objective was to quantify the incidence of sport-related kidney injury among high school varsity athletes and compare it with sport-related injuries of other organ systems.

METHODS: Data from the National Athletic Trainers’ Association High School Injury Surveillance Study, an observational cohort study collected during the 1995–1997 academic years, were used. Incidence rates for sport-specific injuries to select organs were computed and compared.

RESULTS: Over 4.4 million athlete-exposures, defined as 1 athlete participating in 1 game or practice, and 23 666 injuries were reported. Eighteen kidney injuries, none of which were catastrophic or required surgery, were reported compared with 3450 knee, 2069 head/neck/spine, 1219 mild traumatic brain, 148 eye, and 17 testicle injuries. Student athletes incurring kidney injuries were most often playing football (12 injuries) or girls’ soccer (2 injuries). Sport-specific rates of kidney injury were significantly lower than sport-specific rates of mild traumatic brain, head/neck/spine, and knee injuries for all sports as well as rates of baseball- and basketball-specific eye injuries (P < .01).

CONCLUSIONS: Kidney injuries occur significantly less often than other injuries during sport. These data do not support limiting sport participation by athletes with single kidneys.

KEY WORDS

• kidney
• sports
• wounds and injuries

• Accepted February 17, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 7 of 55Article

Trends in Candida Central Line-Associated Bloodstream Infections Among NICUs, 1999–2009

OBJECTIVES: To assess trends in incidence of Candida spp. central line-associated bloodstream infections (CLABSIs) in US NICUs, 1999–2009.

METHODS: Data from NICUs participating in the National Nosocomial Infections Surveillance (1999–2004) and National Healthcare Safety Network (2006–2009) were analyzed. Overall and birth weight-specific incidence rates of Candida spp. CLABSIs per 1000 central line-days were calculated. Trends in incidence were assessed by using Poisson regression, and trends in proportion of CLABSIs identified as Candida albicans were assessed by using weighted-linear regression.

RESULTS: Overall, 398 NICUs reported 1407 Candida spp. CLABSIs (706 due to C albicans) among 1400 neonates. Of the 1400 neonates, 963 (69%) were ≤1000 g at the time of birth, and 182 (13%) died. From 1999 to 2009, the overall incidence decreased significantly for CLABSIs due to Candida spp. (0.92 vs 0.2), C albicans (0.53 vs 0.09), and non-albicans Candida spp. (0.39 vs 0.1). Birth weight-specific incidence significantly decreased across all birth weight categories for C albicans. For CLABSIs due to non-albicans Candida spp., significant decreases were detected among all birth weight categories, except among neonates 1501 to 2500 g. The proportion of Candida spp. CLABSIs due to C albicans did not significantly change over time, remaining at ∼50%.

CONCLUSIONS: Incidence of Candida spp. CLABSIs decreased substantially among NICU patients, regardless of birth weight. Decreases in incidence across all birth weight categories, and not only among neonates ≤1000 g in whom antifungal prophylaxis may be more common, suggest that multiple factors contributed to the declining incidence.

KEY WORDS

• Candida
• central line-associated bloodstream infections
• NICU
• incidence
• health care-associated infection
• epidemiology

• Accepted March 8, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 8 of 55Article

A Population-Based Study of Stimulant Drug Treatment of ADHD and Academic Progress in Children

OBJECTIVE: We evaluated the hypothesis that later start of stimulant treatment of attention-deficit/hyperactivity disorder adversely affects academic progress in mathematics and language arts among 9- to 12-year-old children.

METHODS: We linked nationwide data from the Icelandic Medicines Registry and the Database of National Scholastic Examinations. The study population comprised 11 872 children born in 1994–1996 who took standardized tests in both fourth and seventh grade. We estimated the probability of academic decline (drop of ≥5.0 percentile points) according to drug exposure and timing of treatment start between examinations. To limit confounding by indication, we concentrated on children who started treatment either early or later, but at some point between fourth-grade and seventh-grade standardized tests.

RESULTS: In contrast with nonmedicated children, children starting stimulant treatment between their fourth- and seventh-grade tests were more likely to decline in test performance. The crude probability of academic decline was 72.9% in mathematics and 42.9% in language arts for children with a treatment start 25 to 36 months after the fourth-grade test. Compared with those starting treatment earlier (≤12 months after tests), the multivariable adjusted risk ratio (RR) for decline was 1.7 (95% confidence interval [CI]: 1.2–2.4) in mathematics and 1.1 (95% CI: 0.7–1.8) in language arts. The adjusted RR of mathematics decline with later treatment was higher among girls (RR, 2.7; 95% CI: 1.2–6.0) than boys (RR, 1.4; 95% CI: 0.9–2.0).

CONCLUSIONS: Later start of stimulant drug treatment of attention-deficit/hyperactivity disorder is associated with academic decline in mathematics.

KEY WORDS

• attention-deficit/hyperactivity disorder
• pharmacoepidemiology
• stimulant treatment
• academic performance
• children

• Accepted February 27, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 9 of 55Article

Early Vaccinations Are Not Risk Factors for Celiac Disease

OBJECTIVES: To investigate if changes in the national Swedish vaccination program coincided with changes in the celiac disease (CD) incidence rate in infants (ie, the Swedish CD Epidemic), and to assess the potential association between these vaccinations and CD risk.

METHODS: All studies were based on the National Swedish Childhood Celiac Disease Register. Using an ecological approach, we plotted changes over time in the national vaccination program in the graph displaying CD incidence rate. A population-based incident case-referent study of invited infants was performed. Exposure information was received through a questionnaire and child health clinic records. Vaccines explored were diphtheria/tetanus, pertussis (acellular), polio (inactivated), Haemophilus influenzae type b (conjugated), measles/mumps/rubella, and live attenuated bacillus Calmette-Guérin (BCG) in children with increased tuberculosis risk. Findings were subjected to a birth cohort analysis.

RESULTS: Introduction of pertussis vaccine coincided in time with decreasing CD incidence rates. In the infant case-referent study, however, neither vaccination against pertussis (odds ratio 0.91; 95% confidence interval 0.60–1.4), nor against Haemophilus influenzae type b or measles/mumps/rubella was associated with CD. Coverage for the diphtheria/tetanus and polio vaccines was 99%. BCG was associated with reduced risk for CD (adjusted odds ratio 0.54; 95% confidence interval 0.31–0.94). Discontinuation of general BCG vaccination did not affect the cumulative incidence of CD at age 15 years.

CONCLUSIONS: Early vaccinations within the national Swedish program were not associated with CD risk, nor could changes in the program explain the Swedish epidemic. A protective effect by BCG was suggested, which could be subject to further studies.

KEY WORDS

• celiac disease
• infant
• epidemiology
• vaccines

• Accepted February 28, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 10 of 55Article

Chronic Disabling Fatigue at Age 13 and Association With Family Adversity

OBJECTIVES: 1) Estimate the prevalence of chronic disabling fatigue at age 13, and 2) investigate associations with early family adversity, using a population-based birth cohort study.

METHODS: The subjects were 10 001 children, of whom 5657 had sufficient data to define chronic disabling fatigue at age 13. Chronic disabling fatigue was defined as tiredness reported by mothers that had lasted for ≥3 months or ≥6 months, was disabling (school absence or prevented participation in hobbies/sport/leisure activities “quite a lot” or a “great deal”), and not due to another cause. Family adversity was defined by using 14 questions addressing housing, education, social relationships, and maternal health assessed prospectively at birth. We used multiple imputation to correct estimates of prevalence and association for loss to follow-up.

RESULTS: Overall, 1995 teenagers had been tired for the last month, of whom 117 and 53 had chronic disabling fatigue of ≥3 and ≥6 months’ duration, respectively. The estimated prevalence of chronic disabling fatigue of ≥3 and ≥6 months’ duration was 2.07% and 0.94%, respectively, but increased to 2.44% and 1.30%, respectively, after imputing missing data. Prevalence was similar in boys and girls. The risk of chronic disabling fatigue increased with family adversity score (odds ratios: 1.25 [95% confidence interval: 1.09, 1.43] and 1.23 [1.01, 1.51] for ≥3 and ≥6 months’ duration, respectively). Only 36 (30.77%) children with chronic disabling fatigue had consulted a doctor about their fatigue.

CONCLUSIONS: Chronic disabling fatigue is more common in families who experienced early family adversity and is often not reported to health care services.

KEY WORDS

• chronic fatigue syndrome
• epidemiology
• statistics
• development
• family environment

• Accepted March 12, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 11 of 55Article

Impact of Language Proficiency Testing on Provider Use of Spanish for Clinical Care

OBJECTIVE: To measure the impact of an objective evaluation of provider Spanish-language skills on self-reported language proficiency and comfort using Spanish in a range of clinical scenarios.

METHODS: We enrolled pediatric residents with any self-reported Spanish language ability from 3 residency programs. Participants completed a baseline survey, objective language testing, and a posttest survey. We gathered demographics, self-reported Spanish ability, and comfort using Spanish in various clinical scenarios, which were grouped and analyzed by degree of complexity. Between surveys, a language testing service administered a 20-minute, telephone-based assessment of general Spanish proficiency. Scores were reported on a scale from 1 to 12, with scores ≥9 designated “proficient.” Participants received a numeric score and brief qualitative feedback on their language ability.

RESULTS: Following testing, residents (n = 76) were significantly less likely to report comfort using Spanish in straightforward clinical scenarios, from 64% to 51% (P = .007). That difference was accounted for entirely by residents who tested at a non-proficient level (56% to 39%, P = .006). Testing had no impact on comfort using Spanish in complex or medical-legal scenarios, at any proficiency level. We found no change in self-reported Spanish proficiency in any resident group.

CONCLUSIONS: Objective Spanish-language testing decreased nonproficient resident comfort using Spanish in straightforward clinical encounters, but it did not change comfort in complex or legal scenarios. In combination with education and enforceable policies, language testing may play an important role in decreasing nonproficient Spanish use and improving care for patients with limited English proficiency.

KEY WORDS

• communication barriers
• language
• multilingualism
• Hispanic Americans
• self-assessment
• physician-patient relations
• translating

• Accepted September 15, 2011.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 12 of 55Article

Tactile Sensory Capacity of the Preterm Infant: Manual Perception of Shape From 28 Gestational Weeks

OBJECTIVE: Recent studies have shown that from the postconceptional age of 33 weeks, preterm infants are able to memorize tactile information about the shape of an object by using their hands, and can detect differences with another shape. This study aimed to investigate tactile abilities earlier on in development, in very preterm and mildly preterm human infants.

METHODS: Infants were assigned to 2 groups according to postconceptional age: very preterm (before 32 weeks) and mildly preterm (from 32 to 33+6 weeks). The test consisted of the repeated presentation of an object (prism or cylinder) in the left hand. The experiment was conducted in 3 phases: habituation (repeated presentation of the same object), discrimination (presentation of a novel object), followed by recognition (presentation of the familiar object).

RESULTS: Forty-eight newborns were recruited (24 very preterm; 24 mildly preterm). During habituation, each infant showed a decrease in the holding time of the object. Then, when a novel shape was put into the preterm newborn’s hand, holding time increased. Finally, when the familiar shape was presented again, the holding time decreased. Preterm infants can memorize by touch specific features that differentiate prism and cylinder shapes, discriminate between them, and recognize them after interference.

CONCLUSIONS: From 28 weeks, and from the first days of life, the preterm newborn is endowed with tactile sensory capacities. The tactile stimulations that are presented to preterm infants during their hospitalization should be adapted while respecting their sleep-wake rhythms.

KEY WORDS

• preterm infants
• neonatal period
• tactile modality
• haptic perception
• shape

• Accepted March 1, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 13 of 55Article

Birth by Cesarean Delivery and Failure on First Otoacoustic Emissions Hearing Test

BACKGROUND: Neonatal hearing screening occasionally fails. We noticed that infants born by cesarean delivery (CD) appeared to fail the first otoacoustic emissions (OAE) test more frequently than infants delivered vaginally (VD). This might increase maternal anxiety. We aimed to evaluate the influence of mode of delivery on failure to pass the first OAE.

METHODS: Overall, 1653 infants of >35 weeks’ gestation were evaluated. OAE was performed before discharge. Perinatal-neonatal variables and results of OAE were recorded retrospectively.

RESULTS: Compared with VD infants, CD infants had lower gestational age and 1-minute Apgar, more small for gestational age (SGA), and earlier age at first OAE. Univariate analysis: CD, male gender, gestational age 35 to 37 weeks, birth weight ≤2500 g, SGA, and younger age at first OAE were significantly associated with failed first OAE. In infants weighing 2501 to 4000 g, CD infants had 3-fold higher rates of failed first OAE in comparison with VD infants (20.7% vs 7.1%) before 48 hours of age. In the multivariate analysis, variables independently significantly associated with failed first OAE were male gender (odds ratio [OR] 1.42 [1.02–1.98]), CD (emergency CD: OR 3.18 [2.21–4.57], elective CD: OR 3.32 [2.04–5.42]), age 12 to 23 hours at first OAE (OR 3.1 [2.1–4.58]) and SGA (OR 2.2 [1.15–4.28]).

CONCLUSIONS: CD infants had significantly higher failure rates on first OAE. We speculate that CD is accompanied by retained fluid in middle ear which may impair neonatal hearing. The timing of first OAE after CD should preferably be postponed beyond 48 hours of age to improve OAE passage and minimize maternal anxiety and costs.

• universal newborn hearing screening
• otoacoustic emissions
• automated auditory brainstem responses
• mode of delivery
• vaginal delivery
• cesarean delivery

• Accepted March 20, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 14 of 55Article

Preeclampsia and Retinopathy of Prematurity in Preterm Births

OBJECTIVE: The relationship between gestational hypertension, preeclampsia, and the risk of retinopathy of prematurity (ROP) remains unclear. Thus, we used a large cohort database to study the influence of maternal gestational hypertension and preeclampsia on the occurrence of ROP in preterm infants.

METHODS: We used data from a previous retrospective cohort study that includes 25 473 eligible preterm neonates. We examined the association between gestational hypertension, preeclampsia, and ROP while controlling for potential confounders by multiple logistic regression analysis.

RESULTS: Of the 8758 early preterm infants (gestational age <34 weeks), 1024 (11.69%) had ROP, while of the 16 715 late preterm infants, only 29 (0.17%) had ROP. After adjusting for confounders, preeclampsia was associated with a significantly reduced risk of ROP (adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI], 0.49–0.86 for early preterm birth; aOR, 0.10; 95% CI, 0.01–0.93 for late preterm birth; aOR, 0.66; 95% CI, 0.50–0.87 for all preterm births). Gestational hypertension was not significantly associated with ROP at early or late preterm births.

CONCLUSIONS: Preeclampsia, but not gestational hypertension, was associated with a reduced risk of ROP in preterm births.

KEY WORDS

• preeclampsia
• retinopathy of prematurity
• preterm births

• Accepted March 13, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 15 of 55Article

Concurrent Validity of Ages and Stages Questionnaires in Preterm Infants

BACKGROUND: Although preterm infants born at 29 to 36 gestational weeks (GW) are at risk for developmental delay, they do not always benefit from systematic follow-up. Primary care physicians are then responsible for their developmental surveillance and need effective screening tests. This study aimed to determine whether the Ages and Stages Questionnaires (ASQ) at 12 and 24 months’ corrected age (CA) identify developmental delay in preterm infants.

METHODS: With a cross-sectional design involving 2 observations at 12 and 24 months’ CA, 124 and 112 preterm infants were assessed. Infants were born between May 2004 and April 2006 at 29 to 36 GW. The ASQ and the Bayley Scales of Infant Development were used. Concurrent validity was calculated by using κ coefficient, sensitivity, and specificity.

RESULTS: At 12 months’ CA, the ASQ did not perform well in identifying infants with mental delay (κ = 0.08–0.19; sensitivity = 0.20–0.60; specificity = 0.68–0.88). Agreement (κ = 0.28–0.44) and specificity (0.90–0.97) were better for the psychomotor scale, but the sensitivity remained insufficient (0.25–0.52). At 24 months, the ASQ had good sensitivity (0.75–0.92) and specificity (0.55–0.78) for detecting mental delays (κ = 0.45). Results remained unsatisfactory for detecting motor delays (sensitivity = 0.31–0.50; specificity = 0.73–0.92).

CONCLUSIONS: Preterm infants with developmental delays at 12 months’ CA are not adequately identified with the ASQ. At 24 months’ CA, the ASQ identifies mental delays but not psychomotor delays. Additional measures should be used to increase yield of detecting at-risk preterm infants.

KEY WORDS

• Ages and Stages Questionnaires
• developmental delay
• developmental screening
• moderate and late preterm

• Accepted March 9, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 16 of 55Article

Outcome Trajectories in Extremely Preterm Infants

OBJECTIVE: Methods are required to predict prognosis with changes in clinical course. Death or neurodevelopmental impairment in extremely premature neonates can be predicted at birth/admission to the ICU by considering gender, antenatal steroids, multiple birth, birth weight, and gestational age. Predictions may be improved by using additional information available later during the clinical course. Our objective was to develop serial predictions of outcome by using prognostic factors available over the course of NICU hospitalization.

METHODS: Data on infants with birth weight ≤1.0 kg admitted to 18 large academic tertiary NICUs during 1998–2005 were used to develop multivariable regression models following stepwise variable selection. Models were developed by using all survivors at specific times during hospitalization (in delivery room [n = 8713], 7-day [n = 6996], 28-day [n = 6241], and 36-week postmenstrual age [n = 5118]) to predict death or death/neurodevelopmental impairment at 18 to 22 months.

RESULTS: Prediction of death or neurodevelopmental impairment in extremely premature infants is improved by using information available later during the clinical course. The importance of birth weight declines, whereas the importance of respiratory illness severity increases with advancing postnatal age. The c-statistic in validation models ranged from 0.74 to 0.80 with misclassification rates ranging from 0.28 to 0.30.

CONCLUSIONS: Dynamic models of the changing probability of individual outcome can improve outcome predictions in preterm infants. Various current and future scenarios can be modeled by input of different clinical possibilities to develop individual “outcome trajectories” and evaluate impact of possible morbidities on outcome.

KEY WORDS

• logistic models
• premature infant
• predictive value of tests
• prognosis

• Accepted March 8, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 17 of 55Article

Abnormalities of Vascular Structure and Function in Children With Perthes Disease

BACKGROUND AND OBJECTIVES: Perthes disease is a childhood precipitant to osteoarthritis of the hip, for which the etiology and mechanism are unknown. There is mounting evidence to suggest a vascular insult is responsible for disease, and it is suggested that this may have long-term implications for the vascular health of affected individuals. This study sought to use ultrasound measures to investigate vascular structure and function in children affected by Perthes disease.

METHODS: This case control study encompassed 149 cases and 146 controls, frequency matched for age and gender. Endothelial function was measured by using the technique of flow-mediated dilation of the brachial artery, and alterations in arterial flow were recorded in response to an ischemic stimulus.

RESULTS: There was a significant structural alteration in the vasculature among individuals with Perthes disease (resting brachial artery diameter (cases 2.97 mm versus controls 3.11 mm; P = .01), which remained even after adjusting for height. In addition, there was a notable reduction in blood velocity (cases 33.84 cm/s versus controls 37.83 cm/s; P = .01) and blood flow (cases 149.82 mL/min versus controls 184.67 mL/min; P = .001), which was independent of baseline arterial size. There was no evidence to suggest that flow-mediated dilation of the brachial artery was impaired among affected individuals (P = .71).

CONCLUSIONS: Children with Perthes disease exhibit small artery caliber and reduced function, which is independent of body composition. These data imply that that Perthes disease may reflect a wider vascular phenomenon that could have long-term implications for the vascular health of affected individuals.

KEY WORDS

• Legg-Perthes disease
• etiology
• risk factors

• Accepted March 8, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 18 of 55Article

Predicting Language Change Between 3 and 5 Years and Its Implications for Early Identification

BACKGROUND AND OBJECTIVE: Early language delays across the preschool period have important implications for children, parents, and services raising the significance of early identification. Screening tests are an appealing solution but have proved problematic. A combined risk model would seem promising but has yet to be tested. The goal of this study was to examine the factors that predict language change in a nationally representative sample of children between 3 and 5 years when most children are identified as being in need of services.

METHODS: By using data from children (n = 13 016) in the Millennium Cohort Study (a national UK birth cohort), linear regression was used to predict 5-year performance from 3-year test performance data coupled with sociodemographic and within-child factors and indicators of parental concern. Patterns of change were identified and logistic regression was used to predict the difference between children for whom profiles change and those for whom they do not.

RESULTS: The final model (predicting 32% of the variance) included maternal education, pattern construction, behavior, language concerns, and 3-year vocabulary. Four change patterns were identified: one consistently low (n = 201), one consistently high (n = 12 066), a group that is resilient (n = 572), and one with a declining profile (n = 177). The models accurately predicted 71% of the declining group and 99% of the resilient group. Maternal education (odds ratio: 0.49) and behavior (odds ratio: 0.9) were significant predictors for the former and maternal education (odds ratio: 0.6) and pattern construction (odds ratio: 1.03) the latter.

CONCLUSIONS: Early identification of delayed language remains problematic but, once identified, there are key indicators that predict which children are likely to be more or less at risk across time. The implications are discussed in terms of policy and practice.

KEY WORDS

• child development
• cohort studies
• language
• screening–developmental

• Accepted March 16, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 19 of 55Article

Serotonin Transporter Role in Identifying Similarities Between SIDS and Idiopathic ALTE

OBJECTIVE: Considering previous genetic studies on sudden infant death syndrome (SIDS) and the role of L/L serotonin transporter (5HTT) genotype and correlated genes monoamine oxidase A (MAOA) and dopamine transporter (DAT) in unexpected death, an investigation was carried out verifying their involvement in apparent life-threatening events (ALTE and idiopathic form [IALTE]), also assessing common molecular basis with SIDS.

METHODS: Differential diagnoses in 76 ALTE infants, distinguishing ALTE from IALTE was elaborated by using clinical-diagnostic data. Genotypes/allelic frequencies of DAT, MAOA, and 5HTT were determined in ALTE and IALTE infants and compared with data obtained from 20 SIDS and 150 controls.

RESULTS: No association was found between DAT polymorphisms and ALTE/IALTE groups either at the genotype or allelic level (P range .11–.94). MAOA genotypes and allele data comparison between ALTE and controls was not significant; IALTE data showed a tendency for genotypes (P = .09) and were statistically significant for alleles (P = .036); however, MAOA significance disappeared once the Bonferroni correction was applied. 5HTT polymorphisms in IALTE remarked the role of L/L genotype (P < .00001) and L (P < .00001), as previously demonstrated in SIDS.

CONCLUSIONS: Considering correspondence between 5HTT and MAOA in IALTE and SIDS, we hypothesize that the 2 syndromes are different expressions of a common ethiopathogenesis. In particular, genetic data suggest SIDS events could derive from IALTE episodes occurred during sleep, and therefore out of parental control. Despite its functional role, results highlight the usefulness of 5HTT as a valuable tracer of SIDS risk in IALTE infants. Owing to the small sample size, the results are to be considered preliminary and should be reevaluated in an independent sample.

KEY WORDS

• infant death
• 5HTT
• MAOA
• autonomic dysregulation
• IALTE
• prevention

• Accepted March 5, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 20 of 55Article

Cycled Light Exposure Reduces Fussing and Crying in Very Preterm Infants

OBJECTIVE: To examine whether cycled lighting (CL) conditions during neonatal care in very preterm infants (<32 weeks’ gestational age [GA]) decrease crying and fussing behavior, improve the consolidation of sleep, and influence activity behavior at 5 and 11 weeks’ postterm corrected age (CA) compared with preterm infants cared for in dim lighting (DL) conditions.

METHODS: Thirty-seven preterm infants were randomly assigned to CL (7 am–7 pm lights on, 7 pm–7 am lights off [n = 17; mean GA: 30.6 ± 0.95 weeks; 9 girls]) or DL (lights off whenever the child is asleep [n = 20; GA: 29.5 ± 2.1 weeks; 8 girls]) conditions. Sleeping, crying, and activity behavior was recorded by using parental diaries and actigraphy at 5 and 11 weeks’ CA.

RESULTS: A significant reduction of fussing (59.4 minutes/24 hours [±25.8 minutes]) and crying (31.2 minutes/24 hours [±14.4 minutes]) behavior and a trend to higher motor activity during daytime was found in CL-exposed infants at 5 and 11 weeks’ CA compared with infants cared for in DL conditions. No significant difference between groups was observed for sleep behavior at 5 and 11 weeks’ CA. Infants in CL conditions showed a trend to improved daily weight gain (average: 3.6 g/d) during neonatal care compared with DL conditions.

CONCLUSIONS: CL conditions in neonatal care have beneficial effects on infant’s fussing and crying behavior and growth in the first weeks of life. This study supports the introduction of CL care in clinical neonatal practice.

KEY WORDS

• actigraphy
• circadian rhythm
• crying
• light
• premature infant
• sleep

• Accepted February 28, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 21 of 55Article

Autism Spectrum Disorder, ADHD, Epilepsy, and Cerebral Palsy in Norwegian Children

BACKGROUND: Numerous studies have investigated the prevalence of neurologic and neurodevelopmental disorders individually, but few have examined them collectively, and there is uncertainty as to what extent they overlap.

METHODS: The study has determined the proportions of children aged 0 to 11 years with diagnoses of autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), epilepsy, and cerebral palsy (CP) in Norway. The data were obtained from the Norwegian Patient Register, which is nationwide and contains diagnoses assigned by Norwegian specialist health services (hospitals and outpatient clinics). The Norwegian Patient Register started collecting individual-level data in 2008, and the follow-up period for the study is years 2008 through 2010.

RESULTS: For ASD, ADHD, and epilepsy, the proportions were highest in the oldest children. At age 11 years, the incidence was 0.7% for ASD, 2.9% for ADHD, and 0.9% for epilepsy. The cumulative incidence is likely to be higher because some cases diagnosed before 2008 were probably missed. For CP, the proportions were ∼0.3% for age ≥5 years. There was considerable overlap between diagnoses. For all disorders, boys had a significantly increased risk. In school-age children (aged 6–11 years) the male/female ratio was 4.3 for ASD, 2.9 for ADHD, 1.2 for epilepsy, and 1.3 for CP.

CONCLUSIONS: The findings demonstrate the significant burden of disease associated with neurologic and neurodevelopmental disorders in children and that this burden is disproportionately skewed toward boys.

KEY WORDS

• developmental disabilities
• neurologic disorders
• cumulative incidence
• population register
• autism spectrum disorder
• attention-deficit/hyperactivity disorder
• epilepsy
• cerebral palsy

• Accepted March 12, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 22 of 55Article

Secular Trends in BMI and Blood Pressure Among Children and Adolescents: The Bogalusa Heart Study

OBJECTIVE: The prevalence of obesity among children and adolescents increased by almost threefold from the 1970s to 2000. We examined whether these secular changes in BMI were accompanied by increases in blood pressure levels.

METHODS: A total of 24 092 examinations were conducted among 11 478 children and adolescents (aged 5–17 years) from 1974 to 1993 in the Bogalusa Heart Study (Louisiana).

RESULTS: The prevalence of obesity increased from 6% to 17% during this period. In contrast, only small changes were observed in levels of systolic blood pressure (SBP) and diastolic blood pressure (DBP), and neither mean nor high (based on the 90th percentile from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents) levels increased over the 20-year period. Within each race–gender group, mean levels of SBP did not change, whereas mean levels of DBP decreased by 2 mm Hg (P < .001 for trend). Levels of BMI were positively associated with levels of SBP and DBP within each of the 7 examinations, and controlling for BMI (along with other covariates) indicated that only ∼60% as many children as expected had high levels of blood pressure in 1993.

CONCLUSIONS: Our finding that levels of DBP and SBP among children in this large sample did not increase despite the increases that were seen in obesity indicates that changes in blood pressure levels in a population do not necessarily parallel changes in obesity. Additional study of the potential characteristics that have ameliorated the expected increase in high blood pressure could lead to further reductions in risk.

KEY WORDS

• BMI
• children
• DBP
• hypertension
• obesity
• SBP
• secular trends

• Accepted March 14, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 23 of 55Article

Physical Activity and Sedentary Behaviors and Health-Related Quality of Life in Adolescents

OBJECTIVE: Our goal was to assess cross-sectional and longitudinal associations between physical activity and sedentary behaviors (television viewing, computer and video-game usage, and reading) with health-related QoL.

METHODS: Of 2353 children surveyed (median age: 12.7 years), 1216 were resurveyed 5 years later, and 475 were newly recruited into the study (N = 1691). Children completed detailed activity questionnaires. Health-related QoL was assessed by using the Pediatric Quality of Life Inventory (PedsQL).

RESULTS: Cross-sectionally, after multivariable adjustment, adolescents in the highest versus lowest tertile of time spent in outdoor physical activity and television viewing had a higher (P_trend = .001) and lower (P_trend = .0003) total PedsQL score, respectively. Adolescents who remained in the highest tertiles compared with those in the lowest tertiles of total physical activity over the 5 years had significantly higher scores in the following areas: total (P_trend = .04), physical summary (P_trend = .0001), and social (P_trend = .02) domains. Conversely, those in the highest versus lowest tertile of screen-viewing time during follow-up reported significantly lower values in the following areas: total score (6.34-unit difference), physical summary (4.86-unit difference), psychosocial summary (7.09-unit difference), and emotional (8.33-unit difference) and school (9.78-unit difference) domains.

CONCLUSIONS: Regular physical activity over the long-term was associated with higher perceived health-related QoL among adolescents. Conversely, lower PedsQL scores were observed among those who spent the most time in screen-viewing activities. Improved understanding of these relationships could help in developing interventions to promote general well-being among adolescents.

KEY WORDS

• adolescents
• physical activity
• quality of life
• screen time
• Sydney Childhood Eye Study

• Accepted March 15, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 24 of 55Article

Factors Associated With Uptake of Infant Male Circumcision for HIV Prevention in Western Kenya

BACKGROUND AND OBJECTIVES: Three randomized trials demonstrated male circumcision decreases female-to-male HIV incidence by 60%. Male circumcision research in sub-Saharan Africa has focused on adolescents and adults. Modeling suggests infant male circumcision (IMC) will be cost saving for HIV prevention in high to moderate seroprevalent regions. This study examined parental decision-making and differences in characteristics of parents accepting and declining IMC services in western Kenya.

METHODS: This case-control study was conducted in 2010 at 5 government hospitals in Nyanza Province, Kenya. Cases were mothers and fathers accepting circumcision for their son. Controls were parents who declined IMC services. A questionnaire comprising 41 questions was administered.

RESULTS: A total of 627 mothers and 493 fathers enrolled. In multivariable logistic regression modeling, factors associated with accepting IMC among mothers were the following: father circumcised (odds ratio [OR] = 2.30, P < .001) and agreeing with the father about the IMC decision (OR = 4.38, P < .001). Among fathers, factors associated with accepting IMC were the following: being circumcised (OR = 1.77, P = .016) and agreeing with the mother about IMC (OR = 11.0, P < .001). Fathers were the primary decision makers in most instances (66%). Few parents (3%) reported they would prefer a future son to remain uncircumcised.

CONCLUSIONS: Fathers are important in the IMC decision-making process. Fathers, as well as mothers, should be targeted for optimal scale-up of IMC services. Circumcision programs should offer services for males of all ages, as male circumcision at some age is highly acceptable to both men and women.

KEY WORDS

• Kenya
• sub-Saharan Africa
• infant
• newborn
• male circumcision
• HIV prevention and control
• health knowledge
• health attitudes
• health practice
• acceptance of health care

• Accepted March 22, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 25 of 55Article

Integrated Personal Health Record Use: Association With Parent-Reported Care Experiences

OBJECTIVE: To examine integrated personal health record (PHR) use patterns among parents of children with chronic disease and compare ratings of care experiences between integrated PHR users and nonusers.

METHODS: A survey was mailed to 600 randomly selected parents of children with chronic disease ≤5 years old and enrolled at Group Health for ≥1 year. Respondents reported integrated PHR use in the past 12 months, types of services used, or reasons for nonuse. We measured parent ratings of care experiences by using Consumer Assessments of Healthcare Providers and Systems (CAHPS) composite measures: Attention to Growth and Development, Attention to Safety and Health, Getting Care Quickly, Getting Needed Care, Prescription Medications, and Care Coordination. We used multivariate logistic regression to test the association between integrated PHR use and each CAHPS composite measure dichotomized by using the top box score method.

RESULTS: Of 256 respondents (43% eligible response rate), 166 (65%) were integrated PHR users and 90 (35%) were nonusers. The top integrated PHR services used were viewing immunization records, viewing medical records, secured messaging, and scheduling appointments. The top reasons for not using the integrated PHR were “too busy,” “forgot login/password,” and “my child does not have health care needs.” Adjusted logistic regression did not reveal any significant differences between users and nonusers.

CONCLUSIONS: Parents of children with chronic disease appear willing to use an integrated PHR to address health care needs for their child. Integrated PHR use was not associated with higher scores on CAHPS composite measures in this health plan.

KEY WORDS

• personal health records
• chronic disease
• integrated health system

• Accepted March 2, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 26 of 55Article

Vitamin B₆ Vitamer Concentrations in Cerebrospinal Fluid Differ Between Preterm and Term Newborn Infants

BACKGROUND AND OBJECTIVE: Vitamin B₆ plays a pivotal role in brain development and functioning. Differences in vitamin B₆ homeostasis between preterm and term newborn infants have been reported. The authors sought to investigate whether B₆ vitamers in cerebrospinal fluid (CSF) of preterm and term newborn infants are different.

METHODS: B₆ vitamer concentrations were determined in 69 CSF samples of 36 newborn infants (26 born preterm and 10 born term) by ultra performance liquid chromatography-tandem mass spectrometry. CSF samples, taken from a subcutaneous intraventricular reservoir, were bedside frozen and protected from light.

RESULTS: Concentrations of pyridoxal (PL), pyridoxal phosphate (PLP), pyridoxic acid (PA), and pyridoxamine (PM) in preterm newborns (postmenstrual age 30–37 weeks) were at least twice as high as in older newborns (postmenstrual age ≥42 weeks). Pyridoxine and pyridoxamine phosphate concentrations were below limits of quantification in all newborns. In CSF of 2 very preterm newborns (postmenstrual age <30 weeks), significant amounts of pyridoxine were present besides high concentrations of PL, PA, and PM, whereas PLP concentrations were relatively low. B₆ vitamers in CSF were positively correlated, especially PA, PLP, and PL.

CONCLUSIONS: In CSF of newborn infants, PL, PLP, PA, and PM are present, and concentrations are strongly dependent on postmenstrual age. Our results indicate that vitamin B₆ homeostasis in brain differs between preterm and term newborns. These results should be taken into account for diagnosis and treatment of epilepsy and vitamin B₆ deficiency in newborn infants.

KEY WORDS

• vitamin B₆
• cerebrospinal fluid
• newborn infants

• Accepted February 28, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 27 of 55Article

State of Dental Care Among Medicaid-Enrolled Children in the United States

OBJECTIVE: To evaluate the prevalence of dental care visits (DCV) in 2007 in the United States among Medicaid-enrolled children from birth to age 18 and measure progress since 2002.

METHODS: By using Medicaid research files and information from the Centers for Medicare & Medicaid Services 416 Early Periodic Screening, Diagnostic, and Treatment forms, we calculated the prevalence of DCV in 50 states and the District of Columbia, stratifying by age, race, type of health plan, and Children’s Health Insurance Program status.

RESULTS: The prevalence of having DCV ranged from 12% depending on age, to 49% with a median value of 33% but did not exceed 50% in any state. The median percent change between 2002 and 2007 was 16%. DCV among toddlers and infants were low in all but 3 states and in most states peaked at age of school entry to >60% in some states. In most states, there were few racial differences in the prevalence of DCV. Children enrolled in Primary Care Case Management tended to have the highest DCV, the effect of Children’s Health Insurance Program enrollment on the number of DCV was generally positive.

CONCLUSIONS: To our knowledge, this is the first study to evaluate the prevalence of dental care by using paid Medicaid claims. Consistent with other reports, levels of DCV were low; but when the number of DCV was stratified by age and type plan, striking patterns emerged suggesting that a combination of school programs and having a medical home may have a positive impact on dental care.

• children
• access to dental care
• health insurance
• Medicaid
• oral health

• Accepted March 5, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 28 of 55Article

Trends in Antibiotic Use in Massachusetts Children, 2000–2009

OBJECTIVE: Antibiotic use rates have declined dramatically since the 1990s. We aimed to determine if, when, and at what level the decline in antibiotic-dispensing rates ended and which diagnoses contributed to the trends.

METHODS: Antibiotic dispensings and diagnoses were obtained from 2 health insurers for 3- to <72-month-olds in 16 Massachusetts communities from 2000 to 2009. Population-based antibiotic-dispensing rates per person-year (p-y) were determined according to year (September–August) for 3 age groups. Fit statistics were used to identify the most likely year for a change in trend. Rates for the first and last years were compared according to antibiotic category and associated diagnosis.

RESULTS: From 2000–2001 to 2008–2009, the antibiotic-dispensing rate for 3- to <24-month-olds decreased 24% (2.3–1.8 antibiotic dispensings per p-y); for 24- to <48-month-olds, it decreased 18% (1.6–1.3 antibiotic dispensings per p-y); and for 48- to <72-month-olds, it decreased 20% (1.4–1.1 antibiotic dispensings per p-y). For 3- to <48-month-olds, rates declined until 2004–2005 and remained stable thereafter; the downward trend for 48- to <72-month-olds ended earlier in 2001–2002. Among 3- to <24-month-olds, first-line penicillin use declined 26%. For otitis media, the dispensing rate decreased 14% and the diagnosis rate declined 9%, whereas the treatment fraction was stable at 63%.

CONCLUSIONS: The downward trend in antibiotic dispensings to young children in these communities ended by 2004–2005. This trend was driven by a declining otitis media diagnosis rate. Continued monitoring of population-based dispensing rates will support efforts to avoid returning to previous levels of antibiotic overuse.

• antibiotic use
• managed care programs
• otitis media

• Accepted February 27, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 29 of 55Article

Trends of Outpatient Prescription Drug Utilization in US Children, 2002–2010

OBJECTIVE: To describe trends in outpatient prescription drug utilization in US children and the changes in major areas of pediatric therapeutic use for the years 2002 through 2010.

METHODS: Large prescription databases (the IMS Vector One: National and Total Patient Tracker) were used to examine national drug utilization patterns for the US pediatric population (ages 0–17 years) from 2002 through 2010.

RESULTS: In 2010, a total of 263.6 million prescriptions were dispensed to the US pediatric population, 7% lower than in 2002, while prescriptions dispensed to the adult population increased 22% during the same time. Analysis of pediatric drug utilization trends for the top 12 therapeutic areas in 2010 compared with 2002 showed decreases in systemic antibiotics (–14%), allergies (–61%), pain (–14%), depression (–5%), and cough/cold without expectorant (–42%) prescriptions, whereas asthma (14%), attention-deficit/hyperactivity disorder (46%), and contraceptive (93%) prescriptions increased. In 2010, amoxicillin was the most frequently dispensed prescription in infants (aged 0–23 months) and children (aged 2–11 years). Methylphenidate was the top prescription dispensed to adolescents (aged 12–17 years). Off-label use was identified, particularly for lansoprazole; ∼358 000 prescriptions were dispensed in 2010 for infants <1 year old.

CONCLUSIONS: Changes in the patterns of pediatric drug utilization were observed from 2002 to 2010. Changes include a decrease in antibiotic use and an increase in attention-deficit/hyperactivity disorder medication use during the examined time. This article provides an overview of pediatric outpatient drug utilization, which could set the stage for further in-depth analyses.

• ADHD
• antibiotic use
• children
• drug market
• drug safety
• frequency
• pediatric
• trends
• utilization

• Accepted March 19, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 30 of 55Article

Frequency of Alternative Immunization Schedule Use in a Metropolitan Area

OBJECTIVES: Recent studies have described an increase in parental hesitancy regarding vaccines as well as increases in parental adoption of vaccine schedules that delay or limit receipt of recommended vaccines. This study quantifies potential prevalence and trends in alternative schedule compliance by measuring consistent shot-limiting in a metropolitan area of Oregon.

METHODS: Retrospective cohort analysis using the Oregon ALERT Immunization Information System to track children born between 2003 and 2009 in the Portland metropolitan area. Joinpoint regression was used to analyze prevalence trends in consistent shot-limiting during that time period. The 2007–2009 Haemophilusinfluenzae type b vaccine shortage and increased availability of combination vaccines were also examined for their effects on shot-limiting rates.

RESULTS: A total of 4502 of 97 711 (4.6%) children met the definition of consistent shot-limiters. The proportion of consistent shot-limiters in the population increased from 2.5% to 9.5% between 2006 and 2009. Compared with those with no or episodic limiting, consistent shot-limiters by 9 months of age had fewer injections (6.4 vs 10.4) but more visits when immunizations were administered (4.2 vs 3.3). However, only a small minority of shot-limiters closely adhered to published alternative schedules.

CONCLUSIONS: The percentage of children consistently receiving 2 or fewer vaccine injections per visit between birth and age 9 months increased threefold within a 2-year period, suggesting an increase in acceptance of non–Advisory Committee on Immunization Practices vaccine schedules in this geographic area.

• immunization
• immunization schedules
• vaccine hesitancy
• vaccines

• Accepted March 13, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 31 of 55Article

Rates of Nonsuicidal Self-Injury in Youth: Age, Sex, and Behavioral Methods in a Community Sample

OBJECTIVE: The goal was to assess the rate and behavioral methods of nonsuicidal self-injury (NSSI) in a community sample of youth and examine effects of age and sex.

METHODS: Youth in the third, sixth, and ninth grades (ages 7–16) at schools in the community were invited to participate in a laboratory study. A total of 665 youth (of 1108 contacted; 60% participation rate) were interviewed about NSSI over their lifetime via the Self-Injurious Thoughts and Behaviors Interview.

RESULTS: Overall, 53 (8.0%) of the 665 youth reported engaging in NSSI; 9.0% of girls and 6.7% of boys reported NSSI engagement; 7.6% of third-graders, 4.0% of sixth-graders, and 12.7% of ninth-graders reported NSSI engagement. There was a significant grade by gender interaction; girls in the ninth grade (19%) reported significantly greater rates of NSSI than ninth-grade boys (5%). Behavioral methods of NSSI differed by gender. Girls reported cutting and carving skin most often, whereas boys reported hitting themselves most often. Finally, 1.5% of youth met some criteria for the proposed fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis of NSSI.

CONCLUSIONS: Children and adolescents engage in NSSI. Ninth-grade girls seem most at risk, as they engage in NSSI at 3 times the rate of boys. Behavioral methods of NSSI also vary by grade and gender. As possible inclusion of an NSSI diagnosis in the fifth edition of the DSM-5 draws near, it is essential to better understand NSSI engagement across development and gender.

• nonsuicidal self-injury
• children
• adolescents
• self-mutilation
• mental health

• Accepted March 9, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 32 of 55Article

Self-Reported Adolescent Health Status of Extremely Low Birth Weight Children Born 1992–1995

OBJECTIVES: To compare the self-reported health of extremely low birth weight (ELBW, <1 kg) adolescents with that of normal birth weight (NBW) controls and the children’s assessments of their general health at ages 8 versus 14 years.

METHODS: One hundred sixty-eight ELBW children and 115 NBW controls of similar gender and sociodemographic status completed the Child Health and Illness Profile–Adolescent Edition at age 14 years. It includes 6 domains: Satisfaction, Comfort, Resilience, Risk Avoidance, Achievement, and Disorders. At age 8 years, the children had completed the Child Health and Illness Profile–Child Edition. Results were compared between ELBW and NBW subjects adjusting for gender and sociodemographic status.

RESULTS: ELBW adolescents rated their health similar to that of NBW adolescents in the domains of Satisfaction, Comfort, Resilience, Achievement and Disorders but reported more Risk Avoidance (effect size [ES] 0.6, P < .001). In the subdomain of Resilience, they also noted less physical activity (ES −0.58, P < .001), and in the subdomain of Disorders, more long-term surgical (ES −0.49) and psychosocial disorders (ES −0.49; both P < .01). Both ELBW and NBW children reported a decrease in general health between ages 8 and 14 years, which did not differ significantly between groups.

CONCLUSIONS: ELBW adolescents report similar health and well-being compared with NBW controls but greater risk avoidance. Both ELBW and NBW children rate their general health to be poorer at age 14 than at age 8 years, possibly due to age-related developmental changes.

KEY WORDS

• preterm
• self-reported health
• adolescent
• extremely low birth weight

• Accepted March 8, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 33 of 55Article

Baby-Friendly Hospital Practices and Meeting Exclusive Breastfeeding Intention

OBJECTIVE: To describe mothers’ exclusive breastfeeding intentions and whether Baby-Friendly hospital practices are associated with achieving these intentions.

METHODS: In the 2005–2007 Infant Feeding Practices Study II, women completed a prenatal questionnaire and approximately monthly questionnaires through 12 months. Mothers met their prenatal exclusive breastfeeding intention if their duration after the hospital stay (excluding hospital supplementation) equaled or exceeded their intention. Primary predictor variables included 6 Baby-Friendly hospital practices: breastfeeding within 1 hour of birth, giving only breast milk, rooming in, breastfeeding on demand, no pacifiers, and information on breastfeeding support.

RESULTS: Among women who prenatally intended to exclusively breastfeed (n = 1457), more than 85% intended to do so for 3 months or more; however, only 32.4% of mothers achieved their intended exclusive breastfeeding duration. Mothers who were married and multiparous were more likely to achieve their exclusive breastfeeding intention, whereas mothers who were obese, smoked, or had longer intended exclusive breastfeeding duration were less likely to meet their intention. Beginning breastfeeding within 1 hour of birth and not being given supplemental feedings or pacifiers were associated with achieving exclusive breastfeeding intention. After adjustment for all other hospital practices, only not receiving supplemental feedings remained significant (adjusted odds ratio = 2.3, 95% confidence interval = 1.8, 3.1).

CONCLUSIONS: Two-thirds of mothers who intend to exclusively breastfeed are not meeting their intended duration. Increased Baby-Friendly hospital practices, particularly giving only breast milk in the hospital, may help more mothers achieve their exclusive breastfeeding intentions.

KEY WORDS

• exclusive breastfeeding
• intention
• duration
• Baby-Friendly Hospital Initiative

• Accepted February 28, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 34 of 55Article

Follow-up of Neonates With Total Serum Bilirubin Levels ≥25 mg/dL: A Danish Population-Based Study

OBJECTIVE: To study if severe hyperbilirubinemia in infants with no or minor neurologic symptoms in the neonatal period affects children’s development at the age of 1 to 5 years.

METHODS: Controlled descriptive follow-up study of a national cohort of Danish children. The exposed group consisted of all live-born infants in Denmark from 2004 to 2007 with a gestational age ≥35 weeks and severe hyperbilirubinemia in the neonatal period, defined as at least 1 measure of total serum bilirubin level ≥25 mg/dL during the first 3 weeks of life. The exposed group of 206 children was matched with a control group of 208 children. The Ages and Stages Questionnaire (ASQ), a method of evaluating the child’s development, was filled in by parents. Main outcome measure was effect size of ASQ total score. Statistical analyses comprised a matched analysis of 102 pairs and a nonmatched regression analysis of all participants.

RESULTS: The response rate was 79% (n = 162 of 206) in the study group and 70% (n = 146 of 208) in the control group. Neither the matched nor the nonmatched analysis showed any statistically significant differences between the groups; the effect size of the total score was 0.04 (−0.24 to 0.32) and −0.04 (−0.26 to 0.19), respectively.

CONCLUSIONS: Using the parent-completed ASQ, we found no evidence of developmental delay in children aged between 1 and 5 years with severe neonatal hyperbilirubinemia compared with a matched control group.

KEY WORDS

• neonates
• hyperbilirubinemia
• follow-up
• Ages and Stages Questionnaire
• development

• Accepted March 5, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 35 of 55Article

Obesity Counseling by Pediatric Health Professionals: An Assessment Using Nationally Representative Data

OBJECTIVE: Examine the rate of screening for adolescent overweight and obesity by pediatric health care professionals and the provision of advice on healthy eating and physical activity.

METHODS: Our sample contains adolescents 11 to 17 years old (6911 girls and 6970 boys) from the 2001–2007 Medical Expenditure Panel Survey who reported having at least 1 health provider visit in the previous 12 months. Using logistic regression, we investigated factors associated with whether parents reported that their children were weighed and measured and whether they or their children received counseling on their eating habits and physical activity. All models were estimated separately by gender.

RESULTS: Forty-seven percent of girls and 44% of boys who visited a health provider were advised to eat healthy, and 36% of boys and girls were advised to exercise more. Obese boys and girls were both more likely to be advised to eat healthy (odds ratio [OR] = 2.10, P < .001 and OR = 1.70, P < .001) and exercise more (OR = 2.37, P < .001 and OR = 1.90, P < .001) than adolescents who have normal weight. However, overweight boys and girls were counseled at a much lower rate than those who were obese. Adolescents who were more likely to receive such advice lived in the northeast, were from higher-income households, had parents with at least some college education, and had a usual source of medical care.

CONCLUSIONS: Greater efforts should be made to incorporate guidelines on childhood obesity screening and counseling into clinical practice.

KEY WORDS

• obesity
• counseling by health professionals
• healthy eating
• physical activity

• Accepted March 22, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 36 of 55Article

Maternal Cigarette Smoking and the Development of Necrotizing Enterocolitis

BACKGROUND: The maternal variables that affect fetal development and correlate with necrotizing enterocolitis (NEC), the most common gastrointestinal emergency in premature infants, are not well defined. We hypothesized that maternal risk factors were the primary determinant of future development of NEC.

METHODS: Patients with NEC were identified from an established NICU database and were control-matched with 2 neonates treated at the same institution. The medical records of each patient during the NICU admission as well as the prenatal and delivery record of the patient’s mother were reviewed. Perinatal data, including maternal smoking, maternal hypertension, maternal BMI, maternal gestational diabetes, conduct of labor and type of delivery, Apgar scores, types of feedings, and placental pathology, were examined, with P < .05 deemed significant.

RESULTS: A total of 73 neonates diagnosed with NEC and 146 matched controls were identified. Medical records for each subject and their mothers were reviewed (438 records total). Maternal cigarette smoking was significantly associated with the future development of NEC (P = .02). Maternal gestational diabetes, maternal hypertension, formula feeding, and pathologic chorioamnionitis or uteroplacental insufficiency did not correlate with NEC.

CONCLUSIONS: These data identified maternal cigarette smoking as the only risk factor that is associated with the development of NEC in premature infants. Our data imply that smoking delivers toxins and nicotine to the uterine microenvironment that can affect microvascular development and may predispose the fetus to future NEC.

KEY WORDS

• smoking
• pregnancy
• necrotizing enterocolitis

• Accepted March 1, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 37 of 55Article

Interfacility Transfers of Noncritically Ill Children to Academic Pediatric Emergency Departments

OBJECTIVES: We aimed to characterize the demographics, diagnoses, and management of transferred patients who were directly discharged from the emergency department (ED) or admitted less than 24 hours.

METHODS: We conducted a retrospective, cross-sectional study of patients classified as interfacility ED transfers over a 12-month period in the Pediatric Health Information System database, an administrative database of 42 tertiary care pediatric US hospitals. The primary study outcomes were ED resource utilization at the receiving facility with a focus on children who were discharged directly from the ED or admitted less than 24 hours.

RESULTS: Overall, 24 905 interfacility transfers were identified, accounting for 1.3% of the ED volume of these academic pediatric centers. Of these, 24.7% were discharged directly from the ED and 17.0% were admitted for less than 24 hours. Among those directly discharged from the ED, the 3 most common complaints were orthopedic problems, nonsurgical abdominal pain, and viral gastroenteritis; 20.7% received no medical or procedural intervention. Among those admitted for less than 24 hours, the 3 most common complaints were orthopedic problems, traumatic head injury, and gastrointestinal conditions.

CONCLUSIONS: A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.

KEY WORDS

• emergency department utilization
• transport
• health services research
• emergency medicine
• pediatrics

• Accepted March 2, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 38 of 55Article

Dynamic Evolution of Practice Guidelines: Analysis of Deviations From Assessment and Management Plans

OBJECTIVE: A Standardized Clinical Assessment and Management Plan (SCAMP) standardizes the care of patients with a predefined diagnosis while actively inviting and collecting data on clinician deviations (DEVs) from its recommendations. For 3 different pediatric cardiac diagnoses managed by SCAMPs, we determined the frequency of, types of, and reasons for DEVs, which are considered to be a valuable source of information and innovation.

METHODS: DEVs were collected as part of SCAMP implementation. DEVs were reviewed by the SCAMP committee chairperson and by a separate protocol deviation committee; they were characterized as either justifiable (J), possibly justifiable (PJ), or not justifiable (NJ).

RESULTS: We analyzed 415 patients, 484 clinic encounters, and 216 DEVs. Eighty-six (39.8%) of the DEVs were J, 21 (9.7%) were PJ, and 109 (50.4%) were NJ. The percentage of NJ DEVs relative to the number of opportunities for DEV was 4.1%. J and PJ DEVs were mostly due to management of unrelated conditions (11% overall) or special circumstances (22% overall). NJ DEVs primarily involved follow-up intervals (66%) and deleted tests (24%). The reason for deviating from SCAMP recommendations was not given for 31% of DEVs, even though such information was requested.

CONCLUSIONS: The overall low rate of NJ DEV suggests that practitioners generally accept SCAMP recommendations, but improved capture of practitioners' reasons for deviating from those recommendations is needed. This analysis revealed multiple opportunities for improving patient care, suggesting that this process can be useful in both promulgating sound practice and evolving improved approaches to patient management.

• Adherence
• guidelines
• quality improvement
• congenital heart disease
• health policy

• Accepted March 1, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 39 of 55Article

Pediatric Residents’ Perspectives on Reducing Work Hours and Lengthening Residency: A National Survey

OBJECTIVE: In 2011, the Accreditation Council on Graduate Medical Education increased restrictions on resident duty-hours. Additional changes have been considered, including greater work-hours restrictions and lengthening residency. Program directors tend to oppose further restrictions; however, residents’ views are unclear. We sought to determine whether residents support these proposals, and if so why.

METHODS: We surveyed US pediatric residents from a probability sample of 58 residency programs. We used multivariate logistic regression to determine predictors of support for (1) a 56-hour workweek and (2) the addition of 1 year to residency to achieve a 56-hour week.

RESULTS: Fifty-seven percent of sampled residents participated (n = 1469). Forty-one percent of respondents supported a 56-hour week, with 28% neutral and 31% opposed. Twenty-three percent of all residents would be willing to lengthen training to reduce hours. The primary predictors of support for a 56-hour week were beliefs that it would improve education (odds ratio [OR] 8.6, P < .001) and quality of life (OR 8.7, P < .001); those who believed patient care would suffer were less likely to support it (OR 0.10, P < .001). Believing in benefits to education without decrement to patient care also predicted support for a 56-hour-week/4-year program.

CONCLUSIONS: Pediatric residents who support further reductions in work-hours believe reductions have positive effects on patient care, education, and quality of life. Most would not lengthen training to reduce hours, but a minority prefers this schedule. If evidence mounts showing that reducing work-hours benefits education and patient care, pediatric residents’ support for the additional year may grow.

• internship and residency
• medical education
• work schedule tolerance
• quality of life
• depression
• burnout

• Accepted March 20, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 40 of 55Review Article

Maternal Exercise and Growth in Breastfed Infants: A Meta-analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES: Studies have revealed that women who breastfeed their infants may be reluctant to exercise due to concerns that to do so would adversely affect their breast milk and consequently the growth of their infants. In this review, we seek to systematically review and statistically synthesize evidence from randomized controlled trials (RCTs) that have assessed the effects of maternal exercise on breastfed infant growth (weight gain and gain in length).

METHODS: Searches of the following electronic bibliographic databases were performed to identify RCTs: Cochrane Library (CENTRAL), Medline/PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and SPORT Discus. RCTs that compared any type of exercise intervention with other treatments or no treatment in women exclusively or predominately breastfeeding were eligible for inclusion, as were trials involving exercise as a cointervention. Two authors extracted data from studies independently.

RESULTS: Four RCTs (5 comparisons) were included in the meta-analysis of infant weight gain that incorporated 170 participants. In breastfed infants, maternal exercise did not significantly affect infant weight gain (difference in mean weight gain = 18.6 g [95% confidence interval: −113.52 to 150.80, P = .73]). Only 1 trial assessed infant gain in length; no difference between the exercise and control groups was reported. Trials were classified as moderate or good methodological quality (moderate risk of bias).

CONCLUSIONS: It appears that mothers can exercise and breastfeed without detriment to the growth of their infants, but this is based on limited evidence, and more research is required before this finding is confirmed.

KEY WORDS

• infant growth
• breastfeeding
• exercise

• Accepted February 22, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 41 of 55Review Article

Screening, Brief Intervention, and Referral for Alcohol Use in Adolescents: A Systematic Review

BACKGROUND AND OBJECTIVE: Alcohol use by adolescents is widespread and is connected to a number of negative health and social outcomes. Adolescents receiving emergent care for injuries are often linked with risky use of alcohol. The trauma system has widely adopted the use of screening, brief intervention, and referral to treatment (SBIRT) for preventing alcohol-related injury recidivism and other negative outcomes. The purpose of this article is to review the evidence around SBIRT with adolescent patients in acute care settings.

METHODS: This article reviews 7 randomized controlled trials evaluating risky drinking interventions among adolescent patients in acute care settings. All studies took place in the emergency departments of level I trauma centers.

RESULTS: Four of the 7 studies reviewed demonstrated a significant intervention effect; however, no one intervention reduced both alcohol consumption and alcohol-related consequences. Two of these 4 studies only included patients ages 18 and older. Subgroup analyses with adolescents engaged in risky alcohol-related behaviors, conducted in 2 of the studies, showed significant intervention effects. Five studies showed positive consumption and/or consequences for all study participants regardless of condition, suggesting that an emergent injury and/or the screening process may have a protective effect.

CONCLUSIONS: Based on existing evidence, it is not clear whether SBIRT is an effective approach to risky alcohol use among adolescent patients in acute care. Additional research is needed around interventions and implementation.

• alcohol/drug use
• adolescents
• injury prevention and control
• emergency department

• Accepted February 22, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 42 of 55State-of-the-Art Review Article

Genetics of Pediatric Obesity

Onset of obesity has been anticipated at earlier ages, and prevalence has dramatically increased worldwide over the past decades. Epidemic obesity is mainly attributable to modern lifestyle, but family studies prove the significant role of genes in the individual’s predisposition to obesity. Advances in genotyping technologies have raised great hope and expectations that genetic testing will pave the way to personalized medicine and that complex traits such as obesity will be prevented even before birth. In the presence of the pressing offer of direct-to-consumer genetic testing services from private companies to estimate the individual’s risk for complex phenotypes including obesity, the present review offers pediatricians an update of the state of the art on genomics obesity in childhood. Discrepancies with respect to genomics of adult obesity are discussed. After an appraisal of findings from genome-wide association studies in pediatric populations, the rare variant–common disease hypothesis, the theoretical soil for next-generation sequencing techniques, is discussed as opposite to the common disease–common variant hypothesis. Next-generation sequencing techniques are expected to fill the gap of “missing heritability” of obesity, identifying rare variants associated with the trait and clarifying the role of epigenetics in its heritability. Pediatric obesity emerges as a complex phenotype, modulated by unique gene–environment interactions that occur in periods of life and are “permissive” for the programming of adult obesity. With the advent of next-generation sequencing techniques and advances in the field of exposomics, sensitive and specific tools to predict the obesity risk as early as possible are the challenge for the next decade.

KEY WORDS

• childhood
• genome-wide association study
• heritability
• obesity
• metabolic programming

• Accepted March 2, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 43 of 55Special Article

Full Text

·  Abstract 44 of 55Special Article

Feasibility of Evaluating the CHIPRA Care Quality Measures in Electronic Health Record Data

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) includes provisions for identifying standardized pediatric care quality measures. These 24 “CHIPRA measures” were designed to be evaluated by using claims data from health insurance plan populations. Such data have limited ability to evaluate population health, especially among uninsured people. The rapid expansion of data from electronic health records (EHRs) may help address this limitation by augmenting claims data in care quality assessments. We outline how to operationalize many of the CHIPRA measures for application in EHR data through a case study of a network of >40 outpatient community health centers in 2009–2010 with a single EHR. We assess the differences seen when applying the original claims-based versus adapted EHR-based specifications, using 2 CHIPRA measures (Chlamydia screening among sexually active female patients; BMI percentile documentation) as examples. Sixteen of the original CHIPRA measures could feasibly be evaluated in this dataset. Three main adaptations were necessary (specifying a visit-based population denominator, calculating some pregnancy-related factors by using EHR data, substituting for medication dispense data). Although it is feasible to adapt many of the CHIPRA measures for use in outpatient EHR data, information is gained and lost depending on how numerators and denominators are specified. We suggest first steps toward application of the CHIPRA measures in uninsured populations, and in EHR data. The results highlight the importance of considering the limitations of the original CHIPRA measures in care quality evaluations.

KEY WORDS

• health care quality assessment
• health care quality indicators
• pediatric care quality assessment
• CHIPRA measures
• electronic health record data collection

• Accepted March 8, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 45 of 55Commentary

·  Abstract 46 of 55Quality Report

Improving Timeliness of Antibiotic Delivery for Patients With Fever and Suspected Neutropenia in a Pediatric Emergency Department

OBJECTIVE: There is a high risk for morbidity and mortality in immunocompromised patients with fever if antibiotics are not received in a timely manner. We designed a quality improvement effort geared at reducing the time to antibiotic delivery for this high risk population.

METHODS: The setting was the emergency department in an academic pediatric tertiary care hospital that sees ∼60 000 patients annually. We assembled a multidisciplinary team who set a target of 60 minutes from time of presentation to antibiotic delivery for patients with known neutropenia and 90 minutes for patients with possible neutropenia. Quality improvement methods were used to effect change and evaluate when the targets were not met. Improved communication between providers and patients and timely feedback were implemented.

RESULTS: Mean time to antibiotic delivery in febrile oncology patients with known neutropenic status dropped from 99 minutes in the preimplementation period to 49 minutes in the postimplementation period, whereas it dropped from 90 minutes to 81 minutes in possibly neutropenic patients. The percentage of patients who met the targets for time to antibiotics rose from 50% to 88.5%.

CONCLUSIONS: A multidisciplinary team approach and standardization of the process of care were effective in reducing the time from arrival to antibiotic delivery for febrile neutropenic patients in the pediatric emergency department.

KEY WORDS

• febrile neutropenia
• pediatric emergency
• quality improvement

• Accepted February 16, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 47 of 55Quality Report

The Use of Patient Pictures and Verification Screens to Reduce Computerized Provider Order Entry Errors

OBJECTIVE: To determine whether an order verification screen, including a patient photograph, is an effective strategy for reducing the risk that providers will place orders in an unintended patient’s electronic medical record (EMR).

METHODS: We describe several changes to the EMR/provider interface and ordering workflow that were implemented as one part of a hospital-wide quality improvement effort to improve patient identification and verification practices. We measured the impact by comparing the number of reported incidents of care being provided to any patient other than for whom it was intended before the intervention, and directly after the intervention.

RESULTS: For the year before the interventions described herein, placement of orders in the incorrect patient’s chart was the second most common cause of care being provided to the wrong patient, comprising 24% of the reported errors. In the 15 months after the implementation of an order verification screen with the patient’s photo centrally placed on the screen, no patient whose picture was in the EMR was reported to have received unintended care based on erroneous order placement in his or her chart.

CONCLUSIONS: The incorporation of patient pictures within a computerized order entry verification process is an effective strategy for reducing the risk that erroneous placement of orders in a patient’s EMR will result in unintended care being provided to an incorrect patient.

KEY WORDS

• computerized physician order entry
• patient identification
• electronic medical record
• adverse events
• national patient safety goals
• joint commission
• patient safety
• medication administration
• just culture

• Accepted March 12, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 48 of 55Case Report

Hyponatremia-Associated Rhabdomyolysis Following Exercise in an Adolescent With Cystic Fibrosis

Adolescents with well-controlled cystic fibrosis, including good lung function and appropriate growth, commonly participate in competitive athletic activities. We present the case of an adolescent male with cystic fibrosis, hyponatremia, dehydration, and rhabdomyolysis after participating in football practice on a summer morning. The patient presented with severe myalgia and serum sodium of 129 mmol/L, chloride 90 mmol/L, and creatine phosphokinase 1146 U/L. Aggressive hydration with intravenous 0.9% saline resulted in clinical improvement with no renal or muscular sequelae. Health care providers need to educate patients with cystic fibrosis about maintaining adequate hydration and sodium repletion during exercise. Research is needed regarding the appropriate amount and composition of oral rehydration fluids in exercising individuals with cystic fibrosis, as the physiology encountered in these patients provides a unique challenge to maintaining electrolyte balance and stimulation of thirst.

KEY WORDS

• cystic fibrosis
• dehydration
• hyponatremia
• rhabdomyolysis
• adolescent

• Accepted February 2, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 49 of 55Case Report

Child Abuse in Medical Setting Presenting as Gross Hematuria: Diagnosis by DNA Short Tandem Repeats

Two sisters, aged 15 and 13 years, had previous epithelioid angiomyolipoma of the kidney and suspected thin basement membrane disease, respectively. They presented with 2 years of gross hematuria and new-onset heavy proteinuria. Extensive investigations failed to find an overt cause of their urinary manifestations. The diagnosis of child abuse in a medical setting was confirmed by DNA short tandem repeats analysis, which are the first documented cases in which factitious hematuria was thus diagnosed. Complex forms of child abuse in a medical setting may require forensic tests such as DNA short tandem repeats analysis for diagnosis.

KEY WORDS

• child abuse in a medical setting
• DNA short tandem repeats
• hematuria
• Munchausen syndrome by proxy

• Accepted February 29, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 50 of 55Case Report

Severe Abdominal Pain as a Presenting Symptom of Probable Catastrophic Antiphospholipid Syndrome

Catastrophic antiphospholipid syndrome (APS) in pediatric medicine is rare. We report 3 adolescents who presented with acute onset of severe abdominal pain as the first manifestation of probable catastrophic APS. The 3 patients, 2 male patients and 1 female patient were 14 to 18 years old. One had been diagnosed with systemic lupus erythematosus in the past, but the other 2 had no previous relevant medical history. All presented with excruciating abdominal pain without additional symptoms. Physical examination was noncontributory. Laboratory results were remarkable for high inflammatory markers. Abdominal ultrasonography was normal, and abdominal computed tomography scan showed nonspecific findings of liver infiltration. Only computed tomography angiography revealed evidence of extensive multiorgan thrombosis. All patients had elevated titers of antiphospholipid antibodies. The patients were treated with full heparinization, high-dose steroids, and intravenous immunoglobulin with a resolution of symptoms. One patient was resistant to the treatment and was treated with rituximab. In conclusion, severe acute abdominal pain can be the first manifestation of a thromboembolic event owing to catastrophic APS even in previously healthy adolescents. Diagnosis requires a high index of suspicion with prompt evaluation and treatment to prevent severe morbidity and mortality.

KEY WORDS

• abdominal pain
• catastrophic antiphospholipid syndrome
• adolescents

• Accepted February 10, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 51 of 55Case Report

Hallucinations After Withdrawal of Valproic Acid

We report 2 children with a history of epilepsy in whom valproic acid (VPA) withdrawal was identified as a potential cause of hallucinations. After a restart of VPA, the hallucinations disappeared. We suggest mechanisms for the occurrence of the hallucinations and a possible control of a predisposition to hallucinations by VPA.

KEY WORDS

• hallucinations
• valproic acid
• children

• Accepted January 18, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 52 of 55Case Report

Neonatal Erythroderma as a First Manifestation of Menkes Disease

Menkes disease is an X-linked recessive lethal multisystemic disorder of copper metabolism. Progressive neurodegeneration, connective tissue disturbances, and peculiar kinky hair are the main manifestations. The low serum copper and ceruloplasmin suggests the diagnosis, which is confirmed by mutation analysis of the ATP7A gene. We report an exceptional presentation of classic Menkes disease with neonatal erythroderma. Genetic study revealed a deletion in exons 8 to 12 in the ATP7A gene. This study could allow pediatricians and pediatric dermatologists to diagnose the disorder as early as possible to establish prompt treatment with parenteral copper-histidine supplementation to improve prognosis.

KEY WORDS

• Menkes disease
• erythroderma
• copper
• kinky hair

• Accepted March 12, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 53 of 55Case Report

Everolimus: A Challenging Drug in the Treatment of Multifocal Inoperable Cardiac Rhabdomyoma

Primary cardiac tumors are rare in childhood. The most common of these are rhabdomyomas. Considering that rhabdomyomas often show spontaneous regression, close follow-up may be sufficient in hemodynamically stable cases. However, hemodynamically significant cardiac rhabdomyomas confer a risk of morbidity and mortality. Herein, we report a newborn infant with multifocal cardiac rhabdomyomas treated with everolimus. The optimal dose of the drug was 0.25 mg 2 times per day, 2 days per week. Patients with inoperable cardiac rhabdomyomas and with symptoms may be candidates for everolimus treatment.

KEY WORDS

• cardiac
• heart
• rhabdomyoma
• newborn
• child
• everolimus

• Accepted February 28, 2012.

• Copyright © 2012 by the American Academy of Pediatrics

·  Abstract 54 of 55From the American Academy of Pediatrics

Pediatric Observation Units

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.

• pediatric
• observation unit
• observation status
• emergency department
• inpatient

• Copyright © 2012 by the American Academy of Pediatrics

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