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Pediatrics

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PEDIATRICS

Childhood vaccinations mildly increase the risk of febrile seizures in the general pediatric population, during specific risk periods. However, vaccinations are common precipitants for (first) seizures in the genetically determined, fever-sensitive Dravet syndrome (formerly severe myoclonic epilepsy of infancy).

This study shows that in most children with epilepsy onset after vaccination, genetic or structural causes of epilepsy can be identified. This claim includes children with Dravet syndrome (~35%) but also children with benign epilepsy or preexistent encephalopathy. (Read the full article)


Various low-risk criteria have been developed to guide management of the febrile young infant (<90 days), but they differ in age criteria, recommendations, and implementation. Therefore, variation in care is likely but has not been previously studied.

There is wide variation in testing, treatment, and overall resource utilization in management of the febrile young infant across all 3 age groups: ≤28, 29 to 56, and 57 to 89 days. There may be opportunities to improve care variation without compromising outcomes. (Read the full article)


Partner violence victimization is associated with mental and behavioral health effects linked to weight gain. Childhood maltreatment is directly linked to obesity and associated with neuroanatomic and psychosocial changes, which heighten vulnerability to subsequent stressors.

This study finds that dating violence victimization is associated with greater increases in BMI from adolescence to young adulthood among women. Women with previous exposure to childhood sexual abuse are especially vulnerable to dating violence–related increases in BMI. (Read the full article)


Hydroxyurea is a treatment option for young patients with sickle cell disease (SCD). Establishing the safety of hydroxyurea is of paramount importance. The effect of hydroxyurea on immune function and immunizations in SCD has not been studied previously.

Children with SCD receiving hydroxyurea have lower lymphocyte, CD4, and memory T-cell counts compared with those receiving placebo, but still in the range for healthy children. Despite slower response to measles vaccine, measles, mumps, and rubella and pneumococcal vaccines are effective. (Read the full article)


Puberty suppression has rapidly become part of the standard clinical management protocols for transgender adolescents. To date, there is only limited evidence for the long-term effectiveness of this approach after gender reassignment (cross-sex hormones and surgery).

In young adulthood, gender dysphoria had resolved, psychological functioning had steadily improved, and well-being was comparable to same-age peers. The clinical protocol including puberty suppression had provided these formerly gender-dysphoric youth the opportunity to develop into well-functioning young adults. (Read the full article)


Health care–associated infections are harmful, costly, and preventable, yet there remain limited data as to their population incidence among hospitalized neonates and children in the United States.

Incidence rates of central line–associated bloodstream infections and ventilator-associated pneumonia decreased among critically ill neonates and children during a 5-year period in the United States. National efforts to improve patient safety through decreasing HAIs have been effective. (Read the full article)


Parental reduced antigen diphtheria-tetanus-acellular pertussis (Tdap) vaccination is difficult to implement, and empirical data on its impact is limited to a single hospital-based study in Texas, which found no reduction in infant pertussis hospitalization.

In New South Wales, Australia, a case-control study found both parents receiving Tdap ≥4 weeks before disease onset was associated with a significant reduction in risk of early infant pertussis and suggestive of persistent protection in subsequent pregnancies. (Read the full article)


Childhood immunization might contribute to an increase in asthma prevalence. Previous studies have been contradictory, and many lack sufficiently large control groups of nonimmunized children.

Pertussis immunization in infancy does not increase the risk of asthma medication in adolescents. Our study presents convincing evidence that pertussis immunization in early childhood can be considered safe with respect to long-term development of asthma. (Read the full article)


Asthma and food allergy are common chronic conditions impacting 14% and 8% of US school-aged children, respectively. School districts must be prepared to track students who have these conditions to ensure proper daily management and emergency response.

This study examines the demographic distribution of asthma and food allergy and the existence of school health management plans in a large, urban school district. The findings show that school health management plans are underused for both conditions. (Read the full article)


Behavioral health (BH) screening is known to increase identification of children with BH issues, but in small-scale studies, rates of follow-up after screening have been reported to be low.

This study examines the relationship between BH screening and the receipt of BH services in Massachusetts Medicaid children. Nearly 60% of children identified with BH problems received BH services, but only 30% of newly identified children received BH services. (Read the full article)


Pediatric primary care has undergone a cultural shift. Changes in electronic health records, certification requirements, and practice structure have left many physicians feeling too busy to participate in research. Practice-based research networks must adapt to fit the current climate.

Adding quality improvement activities that meet Maintenance of Certification Part 4 criteria to research study design adds value to a practice-based research protocol. This incentive meets the needs of busy physicians, and may help researchers meet study recruitment goals. (Read the full article)


The single-family room (SFR) NICU is a major response to improve care and reduce developmental morbidity in preterm infants. However, no studies have examined how and why this model is associated with changes in medical and neurobehavioral outcome.

This study shows improved medical and neurodevelopmental outcome in infants hospitalized in the SFR model of care. More important, improvements occurred specifically in relation to increases in maternal involvement and developmental support afforded by the SFR environment. (Read the full article)


The fetal origins of adult disease hypothesis proposes that suboptimal fetal development may condition the later risk of disease, particularly cardiovascular disease. However, this hypothesis has never been tested for diseases of the aging brain.

This first study of its kind provides clinical measures suggesting that small birth size, as an indicator of an adverse intrauterine environment, has lifelong consequences for brain tissue volume and cognitive function. In addition, it shows that the effects of a suboptimal intrauterine environment on late-life cognitive function were particularly present in those with lower educational levels. (Read the full article)


Stimulant medications are indicated for treatment of childhood attention-deficit/hyperactivity disorder (ADHD), but there is concern that stimulants may negatively affect growth. However, no longitudinal, population-based studies have examined height into adulthood for childhood ADHD cases.

This longitudinal, population-based study shows that neither childhood ADHD itself nor treatment with stimulants is associated with significant deficits in height into adulthood. (Read the full article)


Cancer continues to be the leading disease-related cause of death among children and adolescents in the United States. More information is needed about recent trends.

This study provides recent, robust data supporting the increasing incidence of pediatric thyroid cancer and rising overall cancer rates among African American children and adolescents and is the first study to describe increasing rates of pediatric renal carcinoma. (Read the full article)


Many pediatric acute respiratory tract infections (ARTI) are viral and do not require antimicrobial treatment. Recent estimates of antimicrobial overprescribing for these infections, defined based on the published bacterial disease prevalence among all ARTI, are not available.

Based on the published bacterial prevalence rates for pediatric ARTI, antimicrobial agents are prescribed almost twice as often as expected to outpatients nationally, amounting to an estimated 11.4 million potentially preventable antimicrobial prescriptions annually. (Read the full article)


Public awareness and usage of physician-rating Web sites have been increasing over the last few years. Such ratings can influence adults’ decisions about choosing a physician, but their influence on decisions for children’s physicians has not been characterized.

In this nationally representative survey of parents, we found that the majority (74%) are aware of rating Web sites and slightly more than one-quarter (28%) had sought information on rating Web sites when choosing a primary care physician for their children. (Read the full article)


Continuously aerosolized albuterol been shown to be safe and effective for the treatment of severe status asthmaticus in the emergency department and ICU. Little evidence supports its use in the non–intensive care setting.

With the appropriate resources and support, continuous albuterol may be administered in the non–ICU setting with a low incidence of clinical deterioration and adverse effects. Certain clinical factors may help identify which patients may benefit from higher acuity care. (Read the full article)


Influenza leads to respiratory deteriorations in cystic fibrosis (CF) patients. In children, live attenuated influenza virus vaccine (LAIV) is more efficacious than inactivated influenza vaccines, which could be beneficial for CF. Data on the safety of LAIV in this population are scarce.

This study assesses LAIV’s safety in patients with CF and is necessary to determine whether the anticipated benefits associated with LAIV will outweigh potential risks. This can potentially lead to a recommendation for preferential LAIV use in this population. (Read the full article)


Children who have attention-deficit/hyperactivity disorder (ADHD) attending clinical services have poorer outcomes in adolescence on a range of measures. However, it is unknown how early in development these impairments appear, particularly for community-ascertained samples.

At age 6 to 8 years, children in the community with ADHD have significantly poorer mental health, academic performance and social function compared with control children. Children who have impairing ADHD symptoms should be referred early for assessment and intervention. (Read the full article)


More than 200 million children <5 years old in low- and middle-income countries are not reaching their potential in cognitive development because of factors associated with poverty.

Poverty affects children’s cognition as early as 7 months and continues to increase until 5 years of age. It is mainly mediated by parental education, birth weight, home stimulation throughout the 5 years, and growth in the first 24 months. (Read the full article)


Despite child-resistant packaging requirements for most medications and safe storage education for all medicines, tens of thousands of young children are brought to emergency departments and thousands are hospitalized annually after ingesting prescription medications. Targeted prevention efforts may be needed.

Twelve medications were implicated in nearly half of hospitalizations for prescription medication ingestions. Buprenorphine and clonidine were most commonly implicated and had the highest hospitalization rates when accounting for outpatient use. Prevention efforts should focus on most commonly implicated medications. (Read the full article)


Evidence from cohort studies has consistently found that universal bilirubin screening is associated with reductions in rates of severe hyperbilirubinemia but has shown variation in other outcomes such as phototherapy use, length of stay, emergency department visits, and readmission rates.

Universal bilirubin screening may not increase neonatal length of stay or postdischarge hospital use. Preexisting trends in health care utilization have an impact on observed effects of universal bilirubin screening. (Read the full article)


Although frequent utilizers of emergency departments (EDs) are targeted for quality improvement initiatives across the United States, little is known about the health services these patients receive in the ED.

Eight percent of children account for 24% of ED visits and 31% of all costs. Frequent utilizers of pediatric EDs, especially infants without a chronic condition, are least likely to need medications, testing, and hospital admission during their ED visits. (Read the full article)


Recent reviews suggest that children bullied by siblings are at increased risk of internalizing symptoms. It is not known whether being bullied by a sibling increases risk of psychiatric disorders such as depression, anxiety, and self-harm.

Using a large, community-based birth cohort, we found that being bullied by a sibling is prospectively associated with a doubling in the odds of both depression and self-harm at 18 years in young adults. (Read the full article)


Being bullied can lead to adverse physical and mental health outcomes. Individuals who experience a sudden traumatic event often have short-term disturbances in their sleep patterns. Ongoing trauma may result in extended periods of sleep disruption.

Being bullied in elementary school predicts parasomnias, such as nightmares and night terrors, years later. General practitioners, pediatricians, parents, and teachers may consider parasomnias as potential signs of being bullied. (Read the full article)


Vaccinating youth is among the nation’s highest health care priorities. Despite proven health benefits, human papillomavirus vaccination rates remain low.

This is the first known study to test whether vaccination of high-risk adolescents is related to their or their parents’ previous knowledge levels. In the results presented, neither parental nor adolescent knowledge is related to subsequent adolescent vaccination. (Read the full article)


Infants who require positive pressure ventilation at birth are considered to be at risk for subsequent compromise and are recommended to receive postresuscitation care. The supportive evidence and details of this care have not been fully investigated.

We investigate the need for postresuscitation care in infants who require positive pressure ventilation at birth, review the aspects of care needed, and explore the important risk factors most predictive of it. (Read the full article)


Physical activity programs have been shown to have positive implications for children’s cognitive performance and brain structure and function. However, additional randomized controlled trials are needed to determine whether daily physical activity influences executive control and its neural underpinnings.

The randomized controlled trial, designed to meet daily physical activity recommendations, used behavioral and electrophysiological measures of brain function to demonstrate enhanced attentional inhibition and cognitive flexibility among prepubertal children. (Read the full article)


Adolescents and adults born early preterm have higher blood pressure and altered glucose metabolism compared with their term born peers. Evidence of an atherogenic lipid profile is inconsistent. Whether these risks apply to those born less preterm is not known.

In adolescence, girls have higher blood pressure and boys a more atherogenic lipid profile than their term born peers. Overall, our results are consistent with a dose-response relationship between shorter length of gestation and increasing levels of cardiovascular risk factors. (Read the full article)


Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an important risk factor for neonatal jaundice in Nigeria. It is associated with severe hyperbilirubinemia among infants exposed to icterogenic agents. Elevated bilirubin levels have occasionally been demonstrated in G6PD-deficient infants without exposure to icterogenic agents.

Even without exposure to known icterogens, G6PD-deficient infants have a more rapid hematocrit decline and higher bilirubin levels than their G6PD-intermediate and G6PD-normal counterparts throughout the first week of life. (Read the full article)


Lung ultrasound outperforms conventional radiology in the emergency diagnosis of pneumothorax and pleural effusions. In the pediatric age, lung ultrasound has been also successfully applied to the fluid-to-air transition after birth and to rapid pneumonia diagnosis.

Nasal ventilation has dramatically decreased the need for invasive mechanical respiratory support. This study demonstrates that, after a short trial on nasal continuous positive airway pressure, lung ultrasonography reliably predicts the failure of noninvasive ventilation unlike the conventional chest radiogram. (Read the full article)


Sleep disorders are common in children and adolescents and have a substantial negative impact on daily life and school performance. Long-term evaluations of the efficacy and safety of pharmacologic treatment options for sleep disorders are lacking in pediatric patients.

These 2 studies provide the first evaluation of the effectiveness and safety of eszopiclone in children and adolescents with insomnia associated with ADHD. Data presented here encompass longer-term (up to 1 year) pediatric exposure to eszopiclone. (Read the full article)


In HIV-infected children, decisions to start antiretroviral therapy must weigh immunologic benefits against potential risks. Current guidelines recommend using CD4 percentage and age when deciding to start treatment. Population-level effects of these factors on immunologic recovery are unknown.

Starting antiretroviral therapy at higher CD4 percentages and younger ages maximizes potential for immunologic recovery. However, not all benefits are sustained, and viral failure may occur. Our results help clinicians better weigh immunologic benefits against viral failure risks. (Read the full article)




OBJECTIVES:

This study was an assessment of the incidence, course, and etiology of epilepsy with vaccination-related seizure onset in a population-based cohort of children.

METHODS:

The medical data of 990 children with seizures after vaccination in the first 2 years of life, reported to the National Institute for Public Health and Environment in the Netherlands in 1997 through 2006, were reviewed. Follow-up data were obtained of children who were subsequently diagnosed with epilepsy and had had seizure onset within 24 hours after administration of an inactivated vaccine or 5 to 12 days after a live attenuated vaccine.

RESULTS:

Follow-up was available for 23 of 26 children (median age: 10.6 years) with epilepsy onset after vaccination. Twelve children developed epileptic encephalopathy, 8 had benign epilepsy, and 3 had encephalopathy before seizure onset. Underlying causes were identified in 15 children (65%) and included SCN1A–related Dravet syndrome (formerly severe myoclonic epilepsy of infancy) or genetic epilepsy with febrile seizures plus syndrome (n = 8 and n = 1, respectively), a protocadherin 19 mutation, a 1qter microdeletion, neuronal migration disorders (n = 2), and other monogenic familial epilepsy (n = 2).

CONCLUSIONS:

Our results suggest that in most cases, genetic or structural defects are the underlying cause of epilepsy with onset after vaccination, including both cases with preexistent encephalopathy or benign epilepsy with good outcome. These results have significant added value in counseling of parents of children with vaccination-related first seizures, and they might help to support public faith in vaccination programs.


BACKGROUND AND OBJECTIVES:

Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs).

METHODS:

Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization.

RESULTS:

We identified 35 070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0–73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2–49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5–13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R2 = 0.10, P = .06) or revisits resulting in hospitalization (R2 = 0.08, P = .09).

CONCLUSIONS:

Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed.


BACKGROUND AND OBJECTIVES:

This study tested whether dating violence (DV) victimization is associated with increases in BMI across the transition from adolescence to young adulthood and whether gender and previous exposure to child maltreatment modify such increases.

METHODS:

Data were from participants (N = 9295; 49.9% female) in the National Longitudinal Study of Adolescent Health. BMI was calculated from measured height and weight at waves 2, 3, and 4 of the study. DV victimization was measured at waves 2, 3, and 4 by using items from the revised Conflict Tactics Scales. Linear regression by using generalized estimating equations with robust SEs was used to test the association. Models were stratified according to gender and history of child maltreatment.

RESULTS:

From baseline to wave 4, BMI increased on average 6.5 units (95% confidence interval [CI]: 6.2–6.7) and 6.8 units (95% CI: 6.5–7.1) among men and women, respectively, and nearly one-half (45.5% of men; 43.9% of women) reported DV at some point. In stratified models, DV victimization (β: 0.3 [95% CI: 0.0–0.6]) independently predicted BMI increase over time in women. Exposure to childhood sexual abuse magnified the increase in BMI associated with DV victimization (β: 1.3 [95% CI: 0.3–2.3]). No other types of childhood maltreatment were significant modifiers of the DV–BMI association. Violence victimization was not associated with BMI among men.

CONCLUSIONS:

Screening and support for DV victims, especially women who have also experienced childhood maltreatment, may be warranted to reduce the likelihood of health consequences associated with victimization.


BACKGROUND AND OBJECTIVE:

Susceptibility to encapsulated bacteria is well known in sickle cell disease (SCD). Hydroxyurea use is common in adults and children with SCD, but little is known about hydroxyurea’s effects on immune function in SCD. Because hydroxyurea inhibits ribonucleotide reductase, causing cell cycle arrest at the G1–S interface, we postulated that hydroxyurea might delay transition from naive to memory T cells, with inhibition of immunologic maturation and vaccine responses.

METHODS:

T-cell subsets, naive and memory T cells, and antibody responses to pneumococcal and measles, mumps, and rubella vaccines were measured among participants in a multicenter, randomized, double-blind, placebo-controlled trial of hydroxyurea in infants and young children with SCD (BABY HUG).

RESULTS:

Compared with placebo, hydroxyurea treatment resulted in significantly lower total lymphocyte, CD4, and memory T-cell counts; however, these numbers were still within the range of historical healthy controls. Antibody responses to pneumococcal vaccination were not affected, but a delay in achieving protective measles antibody levels occurred in the hydroxyurea group. Antibody levels to measles, mumps, and rubella showed no differences between groups at exit, indicating that effective immunization can be achieved despite hydroxyurea use.

CONCLUSIONS:

Hydroxyurea does not appear to have significant deleterious effects on the immune function of infants and children with SCD. Additional assessments of lymphocyte parameters of hydroxyurea-treated children may be warranted. No changes in current immunization schedules are recommended; however, for endemic disease or epidemics, adherence to accelerated immunization schedules for the measles, mumps, and rubella vaccine should be reinforced.


BACKGROUND:

In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach.

METHODS:

A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13.6 years), when cross-sex hormones were introduced (mean age, 16.7 years), and at least 1 year after gender reassignment surgery (mean age, 20.7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated.

RESULTS:

After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.

CONCLUSIONS:

A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults.


BACKGROUND:

Health care–associated infections (HAIs) are harmful and costly and can result in substantial morbidity for hospitalized children; however, little is known about national trends in HAIs in neonatal and pediatric populations. Our objective was to determine the incidence of HAIs among a large sample of hospitals in the United States caring for critically ill children from 2007 to 2012.

METHODS:

In this cohort study, we included NICUs and PICUs located in hospitals reporting data to the Centers for Disease Control and Prevention’s National Healthcare Safety Network for central line–associated bloodstream infections (CLABSIs), ventilator-associated pneumonias, and catheter-associated urinary tract infections. We used a time-series design to evaluate changes in HAI rates.

RESULTS:

A total of 173 US hospitals provided data from NICUs, and 64 provided data from PICUs. From 2007 to 2012, rates of CLABSIs decreased in NICUs from 4.9 to 1.5 per 1000 central-line days (incidence rate ratio (IRR) per quarter = 0.96, 95% confidence interval 0.94–0.97) and in PICUs from 4.7 to 1.0 per 1000 central-line days (IRR per quarter = 0.96 [0.94–0.98]). Rates of ventilator-associated pneumonias decreased in NICUs from 1.6 to 0.6 per 1000 ventilator days (IRR per quarter = 0.97 [0.93–0.99]) and PICUs from 1.9 to 0.7 per 1000 ventilator-days (IRR per quarter = 0.95 [0.92–0.98]). Rates of catheter-associated urinary tract infections did not change significantly in PICUs.

CONCLUSIONS:

Between 2007 and 2012 there were substantial reductions in HAIs among hospitalized neonates and children.


BACKGROUND:

Although recommended for almost a decade, evidence for field effectiveness of vaccinating close adult contacts of newborn infants against pertussis ("cocooning") is lacking. We evaluated the impact of a government-funded cocoon program during a pertussis epidemic in New South Wales, Australia.

METHODS:

We matched all New South Wales laboratory-confirmed pertussis cases aged <4 months with onset between April 1, 2009, to March 30, 2011 to controls from the state birth register by date of birth and area of residence. Parental vaccine receipt was by self-report, with a subset verified. Parents were considered "immunized" if vaccinated ≥4 weeks before case symptom onset. The effectiveness of parental immunization (versus neither vaccinated) was quantified as (1 – odds ratio) x 100%.

RESULTS:

Case households had fewer immunized mothers (22% vs 32%) or fathers (20% vs 31%) but were more likely to include additional and older children. After adjustment, when both parents met our definition of immunized, risk of pertussis at<4 months of age was reduced by 51% (95% confidence interval 10% to 73%). Maternal vaccination prepregnancy and an immunized father reduced the risk by 51% (95% confidence interval 0% to 76%).

CONCLUSIONS:

Timely parental pertussis boosters provided significant protection. Evidence of protection from maternal vaccination prepregnancy is biologically plausible, and more precise data on the magnitude and duration of this is important for future policy recommendations.


BACKGROUND AND OBJECTIVES:

Childhood immunization may influence the development of asthma, possibly due to lack of infections or a shift in the T-helper cell type 1/T-helper cell type 2/regulatory T cells balance. We therefore investigated whether pertussis immunization in infancy is associated with asthma medication in adolescence.

METHODS:

After 14 years of no general pertussis vaccination, almost 82 000 Swedish children were immunized for pertussis in a vaccination trial between June 1, 1993, and June 30, 1994. In a follow-up analysis of almost 80 000 children, their data were compared with those of ~100 000 nonvaccinated children, born during a 5-month period before and a 7-month period after the vaccination trial. Data for the main outcome variable (ie, dispensed prescribed asthma medication for each individual in the cohort during 2008–2010) were obtained from the national prescription database. Multivariate regression models were used to calculate the effect size of vaccination on dispensed asthma medication (odds ratios [OR], 95% confidence intervals [CI]). Approaches similar to intention-to-treat and per-protocol methods were used.

RESULTS:

The prevalence rates of various asthma medications for study patients at 15 years of age differed between 4.6% and 7.0%. The crude ORs for any asthma medication and antiinflammatory treatment in pertussis-vaccinated children after intention-to-treat analysis were 0.97 (95% CI: 0.93–1.00) and 0.94 (95% CI: 0.90–0.98), respectively. Corresponding adjusted ORs were 0.99 (95% CI: 0.95–1.03) and 0.97 (95% CI: 0.92–1.01). Similar ORs were found after per-protocol analysis.

CONCLUSIONS:

Pertussis immunization in infancy does not increase the risk of asthma medication use in adolescents. Our study presents evidence that pertussis immunization in early childhood can be considered safe with respect to long-term development of asthma.


OBJECTIVES:

This study aimed to characterize asthma and food allergy reporting and management in Chicago Public Schools.

METHODS:

Demographic and health data for students who have asthma and food allergy were extracted from the Chicago Public Schools database. Demographic and geographic variability and the existence of school health management plans were analyzed, and multiple logistic regression models were computed. Home addresses were geocoded to create maps of case counts per community area.

RESULTS:

Approximately 18 000 asthmatic and 4000 food allergic students were identified. Of asthmatic students, 9.3% had a food allergy; of food allergic students, 40.1% had asthma. Asthma odds were significantly higher among black and Hispanic students (odds ratio [OR] = 2.3 and 1.3, respectively), whereas food allergy odds were significantly higher among black students (OR = 1.1; 95% confidence interval [CI], 1.0–1.3) and significantly lower among Hispanic students (OR = 0.8; 95% CI, 0.7–0.9). Only 24.3% of students who had asthma and 50.9% of students who had food allergy had a school health management plan on file. Odds of having a school health management plan were significantly higher among students with both conditions, but the likelihood of having a plan on file was significantly lower among racial/ethnic minority and low-income students, regardless of medical condition.

CONCLUSIONS:

Only 1 in 4 students who have asthma and half of food allergic students have health management plans in schools, with lower numbers among minority and low-income students. Improving chronic disease reporting and access to school health management plans is critical.


OBJECTIVES:

To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children.

METHODS:

After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007–June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services.

RESULTS:

Of 261 160 children in the cohort, 45% (118 464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22–11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53–4.06).

CONCLUSIONS:

Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.


BACKGROUND:

Competing priorities in pediatric practice have created challenges for practice-based research. To increase recruitment success, researchers must design studies that provide added value to participants. This study evaluates recruitment of pediatricians into a study, before and after the development and addition of a quality improvement (QI) curriculum approved for American Board of Pediatrics Maintenance of Certification (MOC) Part 4 Credit as an enrollment incentive.

METHODS:

Researchers implemented multiple outreach methods to enroll pediatric practices over 28 months. Field note review revealed that many physicians declined enrollment, stating that they prioritized MOC Part 4 projects over research studies. A QI curriculum meeting standards for MOC Part 4 Credit was developed and added to the study protocol as an enrollment incentive. Enrollment rates and characteristics of practitioners enrolled pre- and post-MOC were compared.

RESULTS:

Pre-MOC enrollment contributed 48% of practices in 22 months; post-MOC enrollment contributed 49% of practices in 6 months. An average of 3.5 practices enrolled per month pre-MOC, compared with 13.1 per month post-MOC (P < .001). Clinicians in pre- and post-MOC groups were similar in age, gender, race, and time spent on patient care; practices enrolled post-MOC were more likely to be located in federally designated Medically Underserved Areas than those enrolled pre-MOC (28.6% vs 12%, P = .03).

CONCLUSIONS:

Addition of MOC Part 4 Credit increased recruitment success and increased enrollment of pediatricians working in underserved areas. Including QI initiatives meeting MOC Part 4 criteria in practice-based research protocols may enhance participation and aid in recruiting diverse practice and patient populations.


OBJECTIVE:

To determine whether a single-family room (SFR) NICU, including factors associated with the change to a SFR NICU, is associated with improved medical and neurobehavioral outcomes.

METHODS:

Longitudinal, prospective, quasi-experimental cohort study conducted between 2008 and 2012 comparing medical and neurobehavioral outcomes at discharge in infants born <1500 g. Participants included 151 infants in an open-bay NICU and 252 infants after transition to a SFR NICU. Structural equation modeling was used to determine the role of mediators of relations between type of NICU and medical and neurobehavioral outcomes.

RESULTS:

Statistically significant results (all Ps ≤.05) showed that infants in the SFR NICU weighed more at discharge, had a greater rate of weight gain, required fewer medical procedures, had a lower gestational age at full enteral feed and less sepsis, showed better attention, less physiologic stress, less hypertonicity, less lethargy, and less pain. NICU differences in weight at discharge, and rate of weight gain were mediated by increased developmental support; differences in number of medical procedures were mediated by increased maternal involvement. NICU differences in attention were mediated by increased developmental support. Differences in stress and pain were mediated by maternal involvement. Nurses reported a more positive work environment and attitudes in the SFR NICU.

CONCLUSIONS:

The SFR is associated with improved neurobehavioral and medical outcomes. These improvements are related to increased developmental support and maternal involvement.


BACKGROUND:

There are several lines of evidence pointing to fetal and other early origins of diseases of the aging brain, but there are no data directly addressing the hypotheses in an older population. We investigated the association of fetal size to late-age measures of brain structure and function in a large cohort of older men and women and explored the modifying effect of education on these associations.

METHODS:

Within the AGES (Age Gene/Environment Susceptibility)-Reykjavik population-based cohort (born between 1907 and 1935), archived birth records were abstracted for 1254 men and women who ~75 years later underwent an examination that included brain MRI and extensive cognitive assessment.

RESULTS:

Adjustment for intracranial volume, demographic and medical history characteristics, and lower Ponderal index at birth (per kg/m3), an indicator of third-trimester fetal wasting, was significantly associated with smaller volumes of total brain and white matter; βs (95% confidence intervals) were –1.0 (–1.9 to –0.0) and –0.5 (–1.0 to –0.0) mL. Furthermore, lower Ponderal index was associated with slower processing speed and reduced executive functioning but only in those with low education (β [95% confidence interval]: –0.136 [–0.235 to –0.036] and –0.077 [–0.153 to –0.001]).

CONCLUSIONS:

This first study of its kind provides clinical measures suggesting that smaller birth size, as an indicator of a suboptimal intrauterine environment, is associated with late-life alterations in brain tissue volume and function. In addition, it shows that the effects of a suboptimal intrauterine environment on late-life cognitive function were present only in those with lower educational levels.