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Pediatrics

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PEDIATRICS

Noncigarette tobacco products are increasingly popular among youth, especially youth who smoke cigarettes. Although youth use of conventional cigarettes is on the decline, use of other tobacco products is rising and multiple product use may be an escalating trend.

More than twice as many youth in the United States currently use 2 or more tobacco products than cigarettes alone. Youth multiple product use is associated with increased nicotine dependence, raising concerns about the additive harms of noncigarette tobacco products. (Read the full article)


US children consume excessive amounts of sodium and substantial amounts of added sugars. Early life exposures to salt and sugar can set taste preferences and health trajectories.

A substantial proportion of toddler meals and other commercial foods meant for children age ≥12 months are of potential concern because of their high sodium content or presence of ≥1 added sugar. (Read the full article)


Previous studies have demonstrated racial and ethnic differences in glycemic control even after adjustment for variables such as insulin dosage, diabetes duration, and socioeconomic status. It is controversial whether genetic, physiologic, cultural, socioeconomic, and/or provider-related factors underlie these disparities.

This study in a large, racially/ethnically diverse sample of children with type 1 diabetes demonstrates that racial disparities in insulin treatment methods and diabetes outcomes remain even after adjustment for socioeconomic status. (Read the full article)


In adults, adverse drug events account for 5% to 25% of all hospital admissions and 12% of emergency department (ED) visits of which 50% to 70% are preventable. There remains a significant gap in our understanding of the magnitude and impact of medication-related ED visits in pediatrics.

This study is the largest and most rigorous study performed evaluating the impact of medication-related visits to the ED in pediatrics and provides important information regarding the magnitude of this problem in our health care system. (Read the full article)


Noninvasive ventilation (NIV) reduced the need of intubation in preterm infants with RDS. However, randomized studies comparing nasal synchronized intermittent positive pressure ventilation and bilevel continuous positive airway pressure are still lacking.

The present study shows no differences in short-term outcomes between 2 different NIV strategies, nasal synchronized intermittent positive pressure ventilation and bilevel continuous positive airway pressure, in preterm infants for the initial treatment of RDS. (Read the full article)


Little is known about the mental health of extremely low birth weight survivors in their 30s. It is also unclear whether being born small for gestational age or being exposed to antenatal corticosteroids increases risk in this group.

In their 30s, extremely low birth weight survivors are less likely to have substance problems but are at elevated risk for other psychiatric disorders. Those born small for gestational age are at higher risk, but those exposed to antenatal corticosteroids are at the greatest risk of all. (Read the full article)


Adequate sleep is critical for adolescent health. Available data suggest a historical downward trend in sleep behavior, but there has been no rigorous evaluation of recent US trends.

The proportion of adolescents who regularly obtain ≥7 hours of sleep is decreasing. Decreases in sleep exhibit period effects that are constant across adolescents according to gender, race, socioeconomic factors, and urbanicity. The gender gap in adequate sleep is widening. (Read the full article)


Current recommendations for the first outpatient visit for newborns are based on known health risks during the first week of life. Knowledge of the relationship between early well child visits and hospital readmissions may inform newborn health policy interventions.

Newborns who have a first well child visit within the recommended time period after hospital discharge are substantially less likely be readmitted. Obstacles to early follow-up should be addressed to reduce the risk of readmission in this population. (Read the full article)


Patients with sickle cell disease frequently express dissatisfaction with emergency department treatment of painful crises. Time to opioid administration has been suggested as a quality of care measure for painful crises.

Although not associated with hospital admission, time to opioid administration in sickle cell disease painful crises was associated with secondary outcomes including improvement between the first 2 pain scores, decreased pain score area under the curve at 4 hours, decreased emergency department length of stay, and increased total opioids. (Read the full article)


Exposure to oral erythromycin in the first few weeks of life has been associated with the development of pyloric stenosis. Although azithromycin has become an acceptable alternative, little is known on whether this medication increases the risk of pyloric stenosis.

Exposure to oral azithromycin in the newborn period increases the risk of developing pyloric stenosis. Although this risk is highest if the exposure occurred in the first 2 weeks of life, the risk extends out to 6 weeks of age. (Read the full article)


Medical home transformation is led by practice-level assessment, but much of the evidence supporting the medical home derives from individual-level assessment based on parental perception. The association between these 2 levels of assessment is unknown.

Among Boston-area community health centers, there was no association between the individual- and practice-level assessments of the medical home. This highlights the need for studies supporting the child health benefits of medical home practice transformation. (Read the full article)


Universal use of conjugated pneumococcal vaccines has resulted in dramatic decline in vaccine-type invasive pneumococcal disease. However, disease is not evenly distributed, and children with underlying clinical conditions are disproportionately represented, especially among children >5 years of age.

Invasive pneumococcal disease among children with comorbidity results in higher morbidity and mortality, and a large proportion of disease is due to serotypes not included in current conjugate vaccines. (Read the full article)


Although headache is a common symptom after minor blunt head trauma in children, controversy exists whether the presence of headache increases the risk of traumatic brain injury.

Clinically important traumatic brain injuries are rare, and traumatic brain injuries on computed tomography are very uncommon in children with minor blunt head trauma when headaches are their only sign or symptom. (Read the full article)


Worldwide prevalence estimates of Duchenne and Becker muscular dystrophies (DBMD) vary, likely due to differences in diagnostic criteria, ascertainment, and survival. To date, no population-based prevalence data for DBMD by race/ethnicity have been published in the United States.

Approximately 2 per 10 000 boys, ages 5 to 9 years, in 6 sites in the United States have DBMD; prevalence remained rather constant across 4 birth cohorts that spanned 2 decades. Prevalence differed among selected racial/ethnic groups across the time period examined. (Read the full article)


This is the first population-based study regarding the epidemiologic characteristics of pediatric zoster among only those who had contracted varicella.

The herpes zoster (HZ) incidence among only children with varicella infection is higher than previously reported. The HZ incidence increased for children contracting varicella aged <2 years. After a vaccination program, the HZ risk increased for those contracting varicella aged ≥2 years. (Read the full article)


Preterm infants experience disproportionate growth failure postnatally and may be large weight for length despite being small weight for age by hospital discharge. There is no routinely used measure to quantify and monitor disproportionate growth in the NICU.

BMI differs across gender and gestational age. We provide a set of validated reference curves to track changes in BMI for prematurely born infants for use with weight-, length-, and head-circumference-for-age intrauterine growth curves. (Read the full article)


Accountable care organizations are expanding. In pediatrics, however, there is no information on cost savings or quality generated by such organizations.

Partners for Kids is a pediatric accountable care organization that increased value for Medicaid children in 34 Ohio counties, primarily through cost savings. This slowing in cost growth was achieved without diminishing the overall quality or outcomes of care. (Read the full article)


Microbial exposure during early life may prevent, or reduce, the risk of allergy development.

Allergic diseases are less common in children whose parents use hand dishwashing instead of machine dishwashing, and we hypothesize that this allergy-preventive effect is mediated via an increased microbial exposure. (Read the full article)


Moisture damage and mold increase the risk of asthma and asthmatic symptoms. However, the location of the damage, or the specific group of children who are at greater risk of asthma, is rarely taken into account.

Inspector-observed moisture damage or mold in the child’s bedroom, living room, or kitchen increased the risk of asthma and persistent asthma during a 6-year follow-up. Atopic children may be more susceptible to the effects of moisture damage and mold. (Read the full article)


Increasing data suggest that neonatal pain has long-term consequences. Pharmacologic interventions for minor pain are ineffective, and nonpharmacologic techniques (sucrose taste, pacifier suckling, breastfeeding) are effective and now widely used.

The taste of sucrose has been shown to be an effective and widely used analgesic for infants, and this study demonstrates that combining brief exposure to natural radiant warmth with the taste of sucrose improves the analgesic effect for the infant. (Read the full article)


It is unclear whether developmental delays observed among infants with single-suture craniosynostosis (SSC) persist at school age. Few neurodevelopmental studies have examined children with SSC beyond age 3, with most having methodological limitations.

This study is the first to follow and test infants with SSC and a control group at school age. Infancy delays among children with SSC persisted at school age in some areas (IQ, math) but not others (reading, spelling). (Read the full article)


Surviving infants with neonatal encephalopathy treated with hypothermia have lower rates of moderate to severe cerebral palsy and cognitive impairment at 18 to 24 months. Limited data exist on the association between cognitive functioning and neuromotor, behavioral, and school outcomes.

Although the incidence of death or IQ <55 is reduced after therapeutic hypothermia, survivors of neonatal encephalopathy with and without cerebral palsy are at elevated risk for subnormal IQ and the need for specialized educational services at 6 to 7 years. (Read the full article)


Sleep deprivation is a worldwide problem in adolescents. The effectiveness of sleep education in enhancing sleep knowledge with consequent modification of sleep habits remains uncertain, in view of small sample sizes and lack of control groups in previous studies.

This large-scale, cluster randomized controlled study found that a school-based sleep education program was effective in enhancing sleep knowledge and improving behavioral and mental health, but it had no significant impact on sleep duration or pattern among adolescents. (Read the full article)


Motivational interviewing (MI) has been found to increase the effectiveness of weight loss programs in obese children and adolescents. Although parental involvement seems to be linked to its effectiveness, strong conclusions cannot be drawn.

The present study found that MI with parental involvement is an effective strategy in changing obesity-related outcomes and has additional effects beyond MI with adolescents only. These findings are important when administering MI interventions in school settings. (Read the full article)


Adolescent obesity is characterized by endothelial dysfunction at the macrovascular and microvascular level; high endothelial microparticle (EMP) and low endothelial progenitor cell (EPC) counts contribute to these processes. Although reversal of macrovascular endothelial dysfunction is feasible, clinical evidence regarding microvascular endothelial dysfunction is scarce.

Ten months of diet and exercise training improves microvascular endothelial function (peak response) in obese adolescents. EPC and EMP displayed a biphasic response, with an increase in EPC at 5 months and a decrease in EMP at the end of the treatment. (Read the full article)


Obstructive sleep apnea syndrome (OSAS) is associated with significant comorbidity: behavioral problems, sleepiness, and impaired quality of life. However, the utility of OSAS symptoms versus polysomnography in the prediction of comorbidities or response to treatment is not well known.

Among children with OSAS, the Pediatric Sleep Questionnaire, a well-validated, simple 1-page symptom inventory, predicts key adenotonsillectomy-responsive OSAS comorbidities and their improvement after adenotonsillectomy. In contrast, polysomnographic results do not offer similar predictive value. (Read the full article)


Almost one-half of Danish first-time mothers with expected uncomplicated delivery receive oxytocin for labor augmentation. Oxytocin is listed as a drug with potential harmful effects, and recent studies suggest a possible association with subsequent attention-deficit/hyperactivity disorder in the child.

Using large nationwide registers, we were unable to detect any association between augmentation of labor and ADHD in offspring. Our findings do not support a causal role of perinatal exposure to oxytocin during delivery on the development of ADHD. (Read the full article)


Little is known about the impact of tobacco smoke exposure on preterm children with bronchopulmonary dysplasia. It is essential to understand how environmental exposures, such as tobacco smoke, influence respiratory morbidities in this vulnerable population.

Chronic tobacco smoke exposure is common in children with bronchopulmonary dysplasia. In children who required home respiratory support, hair nicotine levels were a better predictor of hospitalization and activity limitation than caregiver self-report. (Read the full article)





BACKGROUND:

Noncigarette tobacco products are increasingly popular among youth, especially cigarette smokers. Understanding multiple tobacco product use is necessary to assess the effects of tobacco products on population health. This study examines multiple tobacco product use and associated risk factors among US youth.

METHODS:

Estimates of current use were calculated for cigarettes, cigars, smokeless tobacco, hookah, e-cigarettes, pipes, bidis, kreteks, snus, and dissolvable tobacco by using data from the 2012 National Youth Tobacco Survey (n = 24 658), a nationally representative sample of US middle and high school students. Associations between use patterns and demographic characteristics were examined by using multinomial logistic regression.

RESULTS:

Among youth, 14.7% currently use 1 or more tobacco products. Of these, 2.8% use cigarettes exclusively, and 4% use 1 noncigarette product exclusively; 2.7% use cigarettes with another product (dual use), and 4.3% use 3 or more products (polytobacco use). Twice as many youth use e-cigarettes alone than dual use with cigarettes. Among smokers, polytobacco use was significantly associated with male gender (adjusted relative risk ratio [aRRR] = 3.71), by using flavored products (aRRR = 6.09), nicotine dependence (aRRR = 1.91), tobacco marketing receptivity (aRRR = 2.52), and perceived prevalence of peer use of tobacco products (aRRR = 3.61, 5.73).

CONCLUSIONS:

More than twice as many youth in the United States currently use 2 or more tobacco products than cigarettes alone. Continued monitoring of tobacco use patterns is warranted, especially for e-cigarettes. Youth rates of multiple product use involving combustible products underscore needs for research assessing potential harms associated with these patterns.


OBJECTIVES:

To evaluate the sodium and sugar content of US commercial infant and toddler foods.

METHODS:

We used a 2012 nutrient database of 1074 US infant and toddler foods and drinks developed from a commercial database, manufacturer Web sites, and major grocery stores. Products were categorized on the basis of their main ingredients and the US Food and Drug Administration’s reference amounts customarily consumed per eating occasion (RACC). Sodium and sugar contents and presence of added sugars were determined.

RESULTS:

All but 2 of the 657 infant vegetables, dinners, fruits, dry cereals, and ready-to-serve mixed grains and fruits were low sodium (≤140 mg/RACC). The majority of these foods did not contain added sugars; however, 41 of 79 infant mixed grains and fruits contained ≥1 added sugar, and 35 also contained >35% calories from sugar. Seventy-two percent of 72 toddler dinners were high in sodium content (>210 mg/RACC). Toddler dinners contained an average of 2295 mg of sodium per 1000 kcal (sodium 212 mg/100 g). Savory infant/toddler snacks (n = 34) contained an average of sodium 1382 mg/1000 kcal (sodium 486 mg/100 g); 1 was high sodium. Thirty-two percent of toddler dinners and the majority of toddler cereal bars/breakfast pastries, fruit, and infant/toddler snacks, desserts, and juices contained ≥1 added sugar.

CONCLUSIONS:

Commercial toddler foods and infant or toddler snacks, desserts, and juice drinks are of potential concern due to sodium or sugar content. Pediatricians should advise parents to look carefully at labels when selecting commercial toddler foods and to limit salty snacks, sweet desserts, and juice drinks.


BACKGROUND AND OBJECTIVES:

Previous research has documented racial/ethnic disparities in diabetes treatments and outcomes. It remains controversial whether these disparities result from differences in socioeconomic status (SES) or other factors. We examined racial/ethnic disparities in therapeutic modalities and diabetes outcomes among the large number of pediatric participants in the T1D Exchange Clinic Registry.

METHODS:

The cohort included 10 704 participants aged <18 years with type 1 diabetes for ≥1 year (48% female; mean age: 11.9 ± 3.6 years; diabetes duration: 5.2 ± 3.5 years). Diabetes management and clinical outcomes were compared among 8841 non-Hispanic white (white) (83%), 697 non-Hispanic black (black) (7%), and 1166 Hispanic (11%) participants. The population included 214 high-income black and Hispanic families.

RESULTS:

Insulin pump use was higher in white participants than in black or Hispanic participants (61% vs 26% and 39%, respectively) after adjusting for gender, age, diabetes duration, and SES (P < .001). Mean hemoglobin A1c was higher (adjusted P < .001) in black participants than in white or Hispanic participants (9.6%, 8.4%, and 8.7%). More black participants experienced diabetic ketoacidosis and severe hypoglycemic events in the previous year than white or Hispanic participants (both, P < .001). There were no significant differences in hemoglobin A1c, diabetic ketoacidosis, or severe hypoglycemia between white and Hispanic participants after adjustment for SES.

CONCLUSIONS:

Even after SES adjustment, marked disparities in insulin treatment method and treatment outcomes existed between black versus Hispanic and white children within this large pediatric cohort. Barriers to insulin pump use and optimal glycemic control beyond SES should be explored in all ethnic groups.


BACKGROUND AND OBJECTIVE:

There are few data on the rate and characterization of medication-related visits (MRVs) to the emergency department (ED) in pediatric patients. We sought to evaluate the frequency, severity, preventability, and classification of MRVs to the ED in pediatric patients.

METHODS:

We performed a prospective observational study of pediatric patients presenting to the ED over a 12-month period. A medication-related ED visit was identified by using pharmacist assessment, emergency physician assessment, and an independent adjudication committee.

RESULTS:

In this study, 2028 patients were enrolled (mean age, 6.1 ± 5.0 years; girls, 47.4%). An MRV was found in 163 patients (8.0%; 95% confidence interval [CI]: 7.0%–9.3%) of which 106 (65.0%; 95% CI: 57.2%–72.3%) were deemed preventable. Severity was classified as mild in 14 cases (8.6%; 95% CI: 4.8%–14.0%), moderate in 140 cases (85.9%; 95% CI: 79.6%–90.8%), and severe in 9 cases (5.5%; 95% CI: 2.6%–10.2%). The most common events were related to adverse drug reactions 26.4% (95% CI: 19.8%–33.8%), subtherapeutic dosage 19.0% (95% CI: 13.3%–25.9%), and nonadherence 17.2% (95% CI: 11.7%–23.9%). The probability of hospital admission was significantly higher among patients with an MRV compared with those without an MRV (odds ratio, 6.5; 95% CI: 4.3–9.6) and, if admitted, the median (interquartile range) length of stay was longer (3.0 [5.0] days vs 1.5 [2.5] days, P = .02).

CONCLUSIONS:

A medication-related cause was found in ~1 of every 12 ED visits by pediatric patients, of which two-thirds were deemed preventable. Pediatric patients who present to the ED with an MRV are more likely to be admitted to hospital and when admitted have a longer length of stay.


BACKGROUND AND OBJECTIVES:

There is evidence that new methods of noninvasive ventilation (NIV) support have significantly changed respiratory distress syndrome (RDS) management in preterm infants. Further perspectives for neonatologists involve the assessment of different NIV strategies in terms of availability, effectiveness, and failure. This study evaluates the efficacy of 2 different NIV strategies for RDS treatment in very low birth weight (VLBW) infants: nasal synchronized intermittent positive pressure ventilation (NSIPPV), which is a modality of conventional ventilation with intermittent peak inspiratory pressure, and bilevel continuous positive airway pressure (BiPAP), not synchronized, with 2 alternate levels of continuous positive airway pressure.

METHODS:

We conducted a 2-center randomized control study in 124 VLBW infants (<1500 g and <32 weeks of gestational age) with RDS who received NIV support (NSIPPV, n = 62; BiPAP, n = 62) within 2 hours of birth. We evaluated the performance of NIV strategies by selected primary outcomes (failure rate and duration of ventilation) and secondary outcomes.

RESULTS:

The number of failures and duration of ventilation support did not differ between NSIPPV and BiPAP strategies (P > .05 for both). Moreover, no differences between groups were found regarding secondary outcomes (P > .05 for all).

CONCLUSIONS:

The present data show no statistically significant differences between NSIPPV and BiPAP strategies in terms of duration of ventilation and failures, suggesting that both NIV techniques are effective in the early treatment of RDS in VLBW infants. Further randomized investigations on wider populations are needed to evaluate the effect of NIV techniques on long-term outcomes.


OBJECTIVE:

To determine the risk for psychiatric disorders among extremely low birth weight (ELBW) survivors in their early to mid-30s and to determine whether those born small for gestational age or those exposed to a full course of antenatal corticosteroids (ACS) were at particularly high risk.

METHODS:

A prospective, longitudinal, population-based cohort of 84 ELBW survivors and 90 normal birth weight (NBW) control participants born in Ontario, Canada from 1977 to 1982 were assessed by interviewers naive to birth weight status using the Mini-International Neuropsychiatric Interview.

RESULTS:

ELBW survivors had lower odds of an alcohol or substance use disorder but higher odds of current non–substance-related psychiatric problems (odds ratio [OR] = 2.47; 95% confidence interval [CI], 1.19–5.14). Those born ELBW and SGA exhibited the same patterns with larger effects. ACS-exposed ELBW survivors had even higher odds of any current non–substance-related psychiatric disorder (OR = 4.41; 95% CI, 1.65–11.82), particularly generalized anxiety disorder (OR = 3.42; 95% CI, 1.06–11.06), the generalized type of social phobia (OR = 5.80; 95% CI, 1.20–27.99), and the inattentive subtype of attention-deficit/hyperactivity disorder (OR = 11.45; 95% CI, 2.06–63.50).

CONCLUSIONS:

In their early to mid-30s, ELBW survivors were less likely to have alcohol or substance use disorders but may be at greater risk for other psychiatric problems. Those exposed to ACS were at especially high risk and manifested no reduction in alcohol or substance use disorders. ELBW survivors exposed to ACS may be a special group at risk for psychopathology in adulthood.


BACKGROUND:

Average nightly sleep times precipitously decline from childhood through adolescence. There is increasing concern that historical shifts also occur in overall adolescent sleep time.

METHODS:

Data were drawn from Monitoring the Future, a yearly, nationally representative cross-sectional survey of adolescents in the United States from 1991 to 2012 (N = 272 077) representing birth cohorts from 1973 to 2000. Adolescents were asked how often they get ≥7 hours of sleep and how often they get less sleep than they should. Age-period-cohort models were estimated.

RESULTS:

Adolescent sleep generally declined over 20 years; the largest change occurred between 1991–1995 and 1996–2000. Age-period-cohort analyses indicate adolescent sleep is best described across demographic subgroups by an age effect, with sleep decreasing across adolescence, and a period effect, indicating that sleep is consistently decreasing, especially in the late 1990s and early 2000s. There was also a cohort effect among some subgroups, including male subjects, white subjects, and those in urban areas, with the earliest cohorts obtaining more sleep. Girls were less likely to report getting ≥7 hours of sleep compared with boys, as were racial/ethnic minorities, students living in urban areas, and those of low socioeconomic status (SES). However, racial/ethnic minorities and adolescents of low SES were more likely to self-report adequate sleep, compared with white subjects and those of higher SES.

CONCLUSIONS:

Declines in self-reported adolescent sleep across the last 20 years are concerning. Mismatch between perceptions of adequate sleep and actual reported sleep times for racial/ethnic minorities and adolescents of low SES are additionally concerning and suggest that health education and literacy approaches may be warranted.


BACKGROUND AND OBJECTIVES:

Recommendations for the timing of the first well-child visit (WCV) after discharge from a well-baby nursery (WBN) suggest that the visit occur within 48 hours of discharge for those with a WBN length of stay of ≤48 hours and within 3 to 5 days for those with a WBN length of stay of >48 hours. The purpose of these early visits is to detect conditions that may cause readmission in the first weeks after birth, but the effectiveness of early visits to accomplish this has not been shown. The objectives of this study were to determine (1) the frequency of early visits and (2) to compare readmission rates for those who had an early visit compared with those who did not.

METHODS:

Using data from a large health care system in Utah, we determined the readmission rates newborns with an estimated gestational age ≥34 weeks and compared the rates for those who had an early WCV with those who did not.

RESULTS:

Of 79 720 newborns, 50 606 (63%) were discharged within 48 hours of birth. Of these, 7638 (15%) had a visit within 72 hours of discharge. The readmission rate for newborns who had a visit within the recommended time frame was 15.7 per 1000 compared with 18.4 for those with a later visit (odds ratio 0.85; 95% confidence interval 0.73–0.99)

CONCLUSIONS:

The frequency of first WCVs that occurred within the recommended time frames was low. Early visits were associated with a 15% reduction in the rate of readmissions.


BACKGROUND AND OBJECTIVE:

Time to opioid administration (TTO) has been suggested as a quality of care measure for sickle cell disease patients with vaso-occlusive crisis (VOC). We sought to determine whether TTO was associated with outcomes of emergency department (ED) visits for VOC.

METHODS:

We conducted a single-center retrospective cohort study of ED visits for VOC. The primary outcome was hospital admission, with secondary outcomes of change between the first 2 pain scores, area under the curve (AUC) for pain scores at 4 hours (pain score AUC), total ED length of stay, and total intravenous opioids. In both univariate and multivariate analyses, mixed regression (logistic for admission, linear for secondary outcome variables) was used to evaluate association of TTO with outcome.

RESULTS:

In 177 subjects, 414 ED visits for VOC were identified. Inpatient admission occurred in 53% of visits. The median TTO for admitted patients was 86 minutes vs 87 minutes for those not admitted. TTO was not associated with inpatient admission in either univariate or multivariate analyses. In multivariate analyses with secondary outcomes, decreased TTO was associated with greater improvement between the first 2 pain scores, decreased pain score AUC, decreased total ED length of stay, and increased total opioids.

CONCLUSIONS:

Although TTO was not associated with admission, it was independently associated with 4 important secondary outcomes: change in initial pain scores, pain score AUC, total ED length of stay, and total intravenous opioids. The association of a process measure, TTO, with these outcomes encourages the institution of TTO reduction efforts in the ED.


BACKGROUND AND OBJECTIVE:

Use of oral erythromycin in infants is associated with infantile hypertrophic pyloric stenosis (IHPS). The risk with azithromycin remains unknown. We evaluated the association between exposure to oral azithromycin and erythromycin and subsequent development of IHPS.

METHODS:

A retrospective cohort study of children born between 2001 and 2012 was performed utilizing the military health system database. Infants prescribed either oral erythromycin or azithromycin as outpatients in the first 90 days of life were evaluated for development of IHPS. Specific diagnostic and procedural codes were used to identify cases of IHPS.

RESULTS:

A total of 2466 of 1 074 236 children in the study period developed IHPS. Azithromycin exposure in the first 14 days of life demonstrated an increased risk of IHPS (adjusted odds ratio [aOR], 8.26; 95% confidence interval [CI], 2.62–26.0); exposure between 15 and 42 days had an aOR of 2.98 (95% CI, 1.24–7.20). An association between erythromycin and IHPS was also confirmed. Exposure to erythromycin in the first 14 days of life had an aOR of 13.3 (95% CI, 6.80–25.9), and 15 to 42 days of life, aOR 4.10 (95% CI, 1.69–9.91). There was no association with either macrolide between 43 and 90 days of life.

CONCLUSIONS:

Ingestion of oral azithromycin and erythromycin places young infants at increased risk of developing IHPS. This association is strongest if the exposure occurred in the first 2 weeks of life, but persists although to a lesser degree in children between 2 and 6 weeks of age.


OBJECTIVE:

To determine the association between a widely used individual-level assessment of the medical home derived from parental perception and practice-level assessment of the medical home.

METHODS:

Thirty parents at each of 6 Boston-area community health centers (CHCs) were administered the 19-question medical home measure of the 2011 National Survey of Children’s Health (NSCH). Each CHC was scored in accordance with the National Committee for Quality Assurance (NCQA) 2011 Patient-Centered Medical Home Standards and Guidelines. Bivariate analysis of the independent variables against the dependent variable (the NCQA measure, assessed as both a continuous score and a categorical tier) was performed. Linear and logistical regression models accounting for the cluster design were then constructed, with the NSCH measure as the primary predictor.

RESULTS:

Of the 180 parents, 52% had a medical home according to the NSCH criteria. Of the 6 CHCs, 5 were a medical home according to the NCQA Standards (2 at Tier 3, 3 at Tier 2). Regression modeling demonstrated nonsignificant associations between both the continuous and categorical (tier) NCQA scores and the NSCH assessment of the medical home, with a β of –2.80 (95% confidence interval, –7.75 to 13.35) and an adjusted odds ratio of 2.17 (95% confidence interval, 0.82 to 5.74), respectively.

CONCLUSIONS:

There was no significant association between the individual-level and practice-level assessments of the medical home. Given this discrepancy, our results suggest that we may need to temper our expectations that the medical home transformation currently being implemented at the practice level will lead to the child health and health care utilization outcomes extensively demonstrated in the literature.


OBJECTIVES:

Children with underlying conditions remain at increased risk for invasive pneumococcal diseases (IPD). This study describes the epidemiology, serotype distribution, clinical presentations, and outcomes of IPD in children with and without comorbidity.

METHODS:

Cases of childhood IPD in Massachusetts were identified via enhanced surveillance from 2002 through 2014. Demographic and clinical data were collected via follow-up telephone interviews with parents and/or primary care providers. Underlying conditions were classified according to the 2012 Report of the Committee on Infectious Diseases and 2013 recommendations by the Advisory Committee on Immunization Practices.

RESULTS:

Among 1052 IPD cases in Massachusetts children <18 years old, 22.1% had at least 1 comorbidity. Immunocompromising conditions (32.7%) and chronic respiratory diseases (22.4%) were most common. Children with comorbidities were older at the time of IPD diagnosis (median 54 vs 23 months, P < .001), had higher hospitalization (odds ratio 2.5; 95% confidence interval 1.7–3.6) and case-fatality rates (odds ratio 3.7; 95% confidence interval 1.5–8.9) compared with children without known underlying conditions after adjusting for age, gender, year of diagnosis, and pneumococcal vaccination status. During the last 2 years of the study, IPD among children with comorbidities was caused by non–pneumococcal conjugate vaccine 13 serotypes in 23-valent polysaccharide pneumococcal vaccine (6/12, 50%) or serotypes that are not included in any of the vaccines (6/12; 50%).

CONCLUSIONS:

In children with comorbidity, IPD results in higher mortality, and a large proportion of disease is due to serotypes not included in current conjugate vaccines. Further research is needed, specifically to develop and evaluate additional strategies for prevention of IPD in the most vulnerable children.


OBJECTIVE:

To determine the risk of traumatic brain injuries (TBIs) in children with headaches after minor blunt head trauma, particularly when the headaches occur without other findings suggestive of TBIs (ie, isolated headaches).

METHODS:

This was a secondary analysis of a prospective observational study of children 2 to 18 years with minor blunt head trauma (ie, Glasgow Coma Scale scores of 14–15). Clinicians assessed the history and characteristics of headaches at the time of initial evaluation, and documented findings onto case report forms. Our outcome measures were (1) clinically important TBI (ciTBI) and (2) TBI visible on computed tomography (CT).

RESULTS:

Of 27 495 eligible patients, 12 675 (46.1%) had headaches. Of the 12 567 patients who had complete data, 2462 (19.6%) had isolated headaches. ciTBIs occurred in 0 of 2462 patients (0%; 95% confidence interval [CI]: 0%–0.1%) in the isolated headache group versus 162 of 10 105 patients (1.6%; 95% CI: 1.4%–1.9%) in the nonisolated headache group (risk difference, 1.6%; 95% CI: 1.3%–1.9%). TBIs on CT occurred in 3 of 456 patients (0.7%; 95% CI: 0.1%–1.9%) in the isolated headache group versus 271 of 6089 patients (4.5%; 95% CI: 3.9%–5.0%) in the nonisolated headache group (risk difference, 3.8%; 95% CI: 2.3%–4.5%). We found no significant independent associations between the risk of ciTBI or TBI on CT with either headache severity or location.

CONCLUSIONS:

ciTBIs are rare and TBIs on CT are very uncommon in children with minor blunt head trauma when headaches are their only sign or symptom.


OBJECTIVE:

To estimate prevalence of childhood-onset Duchenne and Becker muscular dystrophies (DBMD) in 6 sites in the United States by race/ethnicity and phenotype (Duchenne muscular dystrophy [DMD] or Becker muscular dystrophy [BMD]).

METHODS:

In 2002, the Centers for Disease Control and Prevention established the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet) to conduct longitudinal, population-based surveillance and research of DBMD in the United States. Six sites conducted active, multiple-source case finding and record abstraction to identify MD STARnet cases born January 1982 to December 2011. We used cross-sectional analyses to estimate prevalence of DBMD per 10 000 boys, ages 5 to 9 years, for 4 quinquennia (1991–1995, 1996–2000, 2001–2005, and 2006–2010) and prevalence per 10 000 male individuals, ages 5 to 24 years, in 2010. Prevalence was also estimated by race/ethnicity and phenotype.

RESULTS:

Overall, 649 cases resided in an MD STARnet site during ≥1 quinquennia. Prevalence estimates per 10 000 boys, ages 5 to 9 years, were 1.93, 2.05, 2.04, and 1.51, respectively, for 1991–1995, 1996–2000, 2001–2005, and 2006–2010. Prevalence tended to be higher for Hispanic individuals than non-Hispanic white or black individuals, and higher for DMD than BMD. In 2010, prevalence of DBMD was 1.38 per 10 000 male individuals, ages 5 to 24 years.

CONCLUSIONS:

We present population-based prevalence estimates for DBMD in 6 US sites. Prevalence differed by race/ethnicity, suggesting potential cultural and socioeconomic influences in the diagnosis of DBMD. Prevalence also was higher for DMD than BMD. Continued longitudinal surveillance will permit us to examine racial/ethnic and socioeconomic differences in treatment and outcomes for MD STARnet cases.


BACKGROUND AND OBJECTIVE:

Various nonpharmacologic treatments are available for pediatric abdominal pain–related functional gastrointestinal disorders (AP-FGIDs). Data on efficacy and safety are scarce. The goal of this study was to summarize the evidence regarding nonpharmacologic interventions for pediatric AP-FGIDs: lifestyle interventions, dietary interventions, behavioral interventions, prebiotics and probiotics, and alternative medicine.

METHODS:

Searches were conducted of the Medline and Cochrane Library databases. Systematic reviews and randomized controlled trials (RCTs) concerning nonpharmacologic therapies in children (aged 3–18 years) with AP-FGIDs were included, and data were extracted on participants, interventions, and outcomes. The quality of evidence was assessed by using the GRADE approach.

RESULTS:

Twenty-four RCTs were found that included 1390 children. Significant improvement of abdominal pain was reported after hypnotherapy compared with standard care/wait-list approaches and after cognitive behavioral therapy compared with a variety of control treatments/wait-list approaches. Written self-disclosure improved pain frequency at the 6-month follow-up only. Compared with placebo, Lactobacillus rhamnosus GG (LGG) and VSL#3 were associated with significantly more treatment responders (LGG relative risk: 1.31 [95% confidence interval: 1.08 to 1.59]; VSL#3: P < .05). Guar gum significantly improved irritable bowel syndrome symptom frequency; however, no effect was found for other fiber supplements (relative risk: 1.17 [95% confidence interval: 0.75 to 1.81]) or a lactose-free diet. Functional disability was not significantly decreased after yoga compared with a wait-list approach. No studies were found concerning lifestyle interventions; gluten-, histamine-, or carbonic acid–free diets; fluid intake; or prebiotics. No serious adverse effects were reported. The quality of evidence was found to be very low to moderate.

CONCLUSIONS:

Although high-quality studies are lacking, some evidence shows efficacy of hypnotherapy, cognitive behavioral therapy, and probiotics (LGG and VSL#3) in pediatric AP-FGIDs. Data on fiber supplements are inconclusive.


Schistosomiasis is a chronic disease that affects ~200 million people. The extended health impact of the disease has been estimated to exceed that of malaria or tuberculosis and to be nearer to that of HIV/AIDS. Within endemic areas, children carry the heaviest burden of infection. Infection/disease is controlled by the treatment of infected subjects with the anthelminthic drug praziquantel. Global initiatives from Partners of Parasite Control, including the World Health Organization (WHO), advocate regular school-based deworming strategies to reduce the development of severe morbidity, promote school–child health and development, and improve the cognitive potential of children. Until recently, preschool-aged children were excluded from schistosome treatment, creating a health inequity in affected populations. In 2010, the WHO updated their recommendations for the treatment of schistosomiasis in preschool-aged children (ie, children aged ≤5 years). This change was the culmination of several decades of research on schistosome epidemiology, immunology, and pathology in this age group. The recent development of a pediatric formulation of praziquantel (soon to enter clinical trials) should advance control efforts in preschool-aged children, with the goal of including these children in preventative chemotherapy (as currently occurs for soil-transmitted helminths). This review discusses the research work supporting the WHO revision of recommendations for treating preschool-aged children, as well as current barriers and knowledge gaps in pediatric schistosomiasis control.


One of the most difficult ethical dilemmas in pediatrics today arises when a child has complex chronic conditions that are not curable and cause discomfort with no prospect of any improvement on quality of life. In the context of medical futility, it is harmful to prolong medical treatment. The question is: How can medical treatment be discontinued when the child is not dependent on mechanical ventilation or ICU treatment? What is the appropriate palliative care and does it justify the use of sedatives or analgesics if this also might shorten life?