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Pediatrics

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PEDIATRICS


The American Academy of Pediatrics has identified bedding such as pillows, blankets, and quilts as potentially hazardous for the infant sleep environment. Bedding use is a modifiable risk factor for sudden infant death syndrome and unintentional sleep-related suffocation.

Reported bedding use over or under the infant for infant sleep substantially declined from 1993 to 2010. However, about one-half of US infants are still placed to sleep with potentially hazardous bedding despite recommendations against this practice. (Read the full article)



American Public Health Association reported >3.2 million students in the United States are bullied each year; 160 000 students skip school every day for fear of bullying. Little is known about whether bullying affects health-related quality of life (HRQOL) among college students.

Different types of bullying experiences affected different domains of HRQOL. Precollege bullying had long-term effects on HRQOL. Verbal/relational bullying-victimization experiences, mediated via depression, affected psychological HRQOL. Findings inform preventive and clinical practice to ameliorate the impact of bullying. (Read the full article)


Preparticipation physical evaluations (PPEs) are considered necessary for a high standard of care for US scholastic athletes. However, important questions remain regarding consistency of implementation and content of cardiovascular screening practices among states.

Our results show that PPE policies are variable among US states, and adoption of current PPE-4 best practices is slow, demonstrating the need for nationwide PPE standardization. (Read the full article)



Antibiotic overuse is common and is a major public health threat. The prevalence of antimicrobial stewardship programs in children’s hospitals is growing. Single-center studies reveal that antimicrobial stewardship programs are effective in reducing unnecessary antibiotic use. Multicenter evaluations are needed.

Antibiotic use is declining overall across a large network of freestanding children’s hospitals. Hospitals with formalized antimicrobial stewardship programs experienced greater reductions in antibiotic use than other hospitals, suggesting that these interventions are an effective strategy to address antibiotic overuse. (Read the full article)


Children and adolescents with attention-deficit/hyperactivity disorder are prone to sustaining trauma that requires emergency department (ED) admission. Methylphenidate can reduce attention-deficit/hyperactivity disorder symptoms and thus theoretically may reduce the risk of trauma-related ED admission, but previous studies did not provide a clear association.

For patients treated with methylphenidate, on-medication periods were associated with lower rates of trauma-related ED admission compared with off-medication periods. A similar protective association was found in both genders. Potential treatment benefit was greater for age ≥16 years. (Read the full article)



Off-label prescribing in children has been widely described. There has been growing awareness and action from regulatory bodies since 2006 to promote drug assessment in children and rational prescribing.

In comparison with a similar study done in 2000, there was no significant change in off-label prescribing in children. In contrast with the previous findings, off-label prescribing did not increase risk for adverse drug reactions. (Read the full article)



Maternal depression has been associated with adolescent engagement in risky behaviors such as substance use. However, there is a lack of longitudinal research examining timing-specific effects in this relationship.

The results of this study indicate that youth exposed to increasing levels of maternal depressive symptoms in middle childhood are more likely to engage in substance use and delinquent behaviors and have an earlier debut age of these behaviors. (Read the full article)


BACKGROUND AND OBJECTIVES:

The American Recovery and Reinvestment Act of 2009 accelerated the implementation of electronic health records (EHRs) in pediatric offices. We sought to determine the prevalence and functionalities of EHRs, as well as pediatricians’ perceptions of EHRs.

METHODS:

An 8-page self-administered questionnaire was sent randomly to 1621 nonretired US members of the American Academy of Pediatrics from July to December 2012. Responses were compared with a similar survey in 2009.

RESULTS:

The percent of pediatricians, who are using EHRs, increased significantly from 58% in the 2009 survey to 79% in 2012. Only 31% used an EHR considered to have basic functionality, and only 14% used a fully functional EHR. Providers with equal or greater than 20% public insurance patients (threshold for meaningful use eligibility) were more likely to have an EHR. Solo/2-physician practices were least likely to have adopted an EHR. Younger physicians were more likely to consider an EHR important to quality care and perceived the presence of an EHR as more important in recruiting.

CONCLUSIONS:

The number of office-based pediatricians who are using an EHR has steadily risen to almost 80%. EHR cost and reduction in productivity remain serious concerns. Despite the widespread adoption of EHRs by pediatricians, only few use a basic or fully functional EHR and even fewer have added pediatric functionality. There is a role for the EHR certification process to advance functionalities used by pediatricians and to increase efficiency, data exchange capability, and general EHR functionality.


Early diagnosis of LOS in preterm infants may be challenging because of the questionable accuracy of blood culture and the common markers of infections, such as C-reactive protein and procalcitonin.

Our study demonstrated for the first time that P-SEP is an accurate biomarker for the diagnosis of LOS in preterm infants and might contribute to the monitoring of infant response to therapeutic interventions. (Read the full article)


Adolescent relationship abuse (ARA) is prevalent in confidential clinic settings such as school health centers (SHCs) and is associated with poor health outcomes. No evidence-based interventions target reduction of ARA in the SHC setting.

This study provides the first evidence of the potential benefits of a brief provider-delivered universal education and counseling intervention in SHCs to address and prevent a major public health problem: ARA. (Read the full article)


BACKGROUND:

Use of potentially hazardous bedding, as defined by the American Academy of Pediatrics (eg, pillows, quilts, comforters, loose bedding), is a modifiable risk factor for sudden infant death syndrome and unintentional sleep-related suffocation. The proportion of US infants sleeping with these types of bedding is unknown.

METHODS:

To investigate the US prevalence of and trends in bedding use, we analyzed 1993–2010 data from the National Infant Sleep Position study. Infants reported as being usually placed to sleep with blankets, quilts, pillows, and other similar materials under or covering them in the last 2 weeks were classified as bedding users. Logistic regression was used to describe characteristics associated with bedding use.

RESULTS:

From 1993 to 2010, bedding use declined but remained a widespread practice (moving average of 85.9% in 1993–1995 to 54.7% in 2008–2010). Prevalence was highest for infants of teen-aged mothers (83.5%) and lowest for infants born at term (55.6%). Bedding use was also frequently reported among infants sleeping in adult beds, on their sides, and on a shared surface. The rate of decline in bedding use was markedly less from 2001–2010 compared with 1993–2000. For 2007 to 2010, the strongest predictors (adjusted odds ratio: ≥1.5) of bedding use were young maternal age, non-white race and ethnicity, and not being college educated.

CONCLUSIONS:

Bedding use for infant sleep remains common despite recommendations against this practice. Understanding trends in bedding use is important for tailoring safe sleep interventions.


Many population-based studies including pubertal children are based on self-assessment of pubertal maturation, the reliability of which is uncertain.

Self-assessment is not reliable for precise pubertal staging. Simple distinctions between prepuberty and puberty showed moderate agreement with clinical examinations. Parents and girls tended to underestimate and boys to overestimate pubertal development by up to 50% and 30%, respectively. (Read the full article)


Family engagement in the care of hospitalized children may improve outcomes, including medication safety. Although family-centered rounds (FCRs) provide a venue for family engagement in care, how families use this venue to influence medication-related topics is unknown.

Most families initiated medication-related dialogue during FCRs, discussing inpatient and home medications. Topics raised were important for medication adherence and safety, even altering treatment plans. Findings suggest specific medication topics that health care team members can anticipate addressing during FCR. (Read the full article)


Fathers’ attitude and support affects breastfeeding outcomes. Fathers are currently not targeted in breastfeeding support and care provided by health care professionals. Breastfeeding interventions delivered to fathers have been shown to increase breastfeeding exclusivity and duration.

A coparenting breastfeeding support intervention delivered to mothers and fathers in the postpartum period showed beneficial effects on breastfeeding duration, paternal breastfeeding confidence, breastfeeding help provided by fathers, and mothers’ satisfaction with fathers’ involvement with breastfeeding. (Read the full article)


Although we know breastfeeding is beneficial and infant weight gain can predict obesity later in life, the relationship between breastfeeding duration and infant weight gain patterns among populations exhibiting high risk for obesity is unexplored.

This study demonstrates the greater odds of increased infant weight gain for infants who breastfed for shorter durations among those exposed to a high number of maternal biopsychosocial risk factors for obesity. (Read the full article)


In 2009, only 58% of pediatricians were using electronic health records (EHRs), most of which were lacking pediatric functionality. The American Recovery and Reinvestment Act (ARRA) of 2009 accelerated the implementation of EHRs in pediatric offices.

The effects of ARRA have remained largely unmeasured in pediatrics. This study provides information on the prevalence and functionalities of EHRs, as well as physicians’ perceptions. (Read the full article)


Exclusively breastfed newborns lose weight daily in the first few days after birth. The amount of weight lost varies substantially between newborns, with higher amounts of weight loss increasing risk for morbidity.

This study presents nomograms demonstrating percentiles for weight loss by delivery mode for those who are exclusively breastfed. The nomograms have potential to be used for early identification of neonates on a trajectory for greater weight loss and related morbidities. (Read the full article)


Respiratory syncytial virus (RSV) infection is a common cause of pediatric hospitalizations. Mortality rates associated with RSV hospitalizations are based on estimates from studies conducted decades ago. Accurate understanding of mortality is required for identifying high-risk infants and children.

Mortality associated with RSV is uncommon in the 21st century, with annual deaths far lower than previous estimates. The majority of deaths occurred in infants with complex chronic conditions or in those with life-threatening conditions in addition to RSV infection. (Read the full article)


BACKGROUND:

The majority of newborns are exclusively breastfed during the birth hospitalization, and weight loss is nearly universal for these neonates. The amount of weight lost varies substantially among newborns with higher amounts of weight loss increasing risk for morbidity. No hour-by-hour newborn weight loss nomogram exists to assist in early identification of those on a trajectory for adverse outcomes.

METHODS:

For 161 471 term, singleton neonates born at ≥36 weeks’ gestation at Northern California Kaiser Permanente hospitals in 2009–2013, data were extracted from the birth hospitalization regarding delivery mode, race/ethnicity, feeding type, and weights from electronic records. Quantile regression was used to create nomograms stratified by delivery mode that estimated percentiles of weight loss as a function of time among exclusively breastfed neonates. Weights measured subsequent to any nonbreastmilk feeding were excluded.

RESULTS:

Among this sample, 108 907 newborns had weights recorded while exclusively breastfeeding with 83 433 delivered vaginally and 25 474 delivered by cesarean. Differential weight loss by delivery mode was evident 6 hours after delivery and persisted over time. Almost 5% of vaginally delivered newborns and >10% of those delivered by cesarean had lost ≥10% of their birth weight 48 hours after delivery. By 72 hours, >25% of newborns delivered by cesarean had lost ≥10% of their birth weight.

CONCLUSIONS:

These newborn weight loss nomograms demonstrate percentiles for weight loss by delivery mode for those who are exclusively breastfed. The nomograms can be used for early identification of neonates on a trajectory for greater weight loss and related morbidities.


White matter abnormality (WMA) on neuroimaging is considered a crucial link with adverse neurodevelopmental outcome in preterm infants. Brain MRI is more sensitive in detecting WMA than cranial ultrasound (CUS), but questions remain about timing and prognostic value of modalities.

Near-term CUS and MRI abnormalities were associated with adverse 18- to 22-month outcomes, independent of early CUS and other factors, underscoring the relative prognostic value of later neuroimaging in this large, extremely preterm cohort surviving to near-term. (Read the full article)


BACKGROUND AND OBJECTIVES:

Bullying is a commonly occurring problem behavior in youths that could lead to long-term health effects. However, the impact of school bullying experiences on health-related quality of life (HRQOL) among college students has been relatively underexplored. This study aimed to describe school bullying experiences and to empirically examine their associations with HRQOL among college students in Taiwan.

METHODS:

Self-administered survey data (response rate 84.2%) were collected from 1452 college students in 2013 by using proportional stratified cluster sampling. Different types of bullying experiences (ie, physical, verbal, relational, and cyber) before and in college, for bullies and victims, were measured. HRQOL was assessed by the World Health Organization Quality of Life (WHOQOL-BREF) Taiwan version.

RESULTS:

College students with cyber bullying-victimization experiences before college (β 0.060) reported significantly higher HRQOL in physical health. Regarding social relationships, those with verbal (β –0.086) and relational (β –0.056) bullying-victimization experiences, both before and in college, reported significantly lower HRQOL, whereas those with verbal (β 0.130) and relational (β 0.072) bullying-perpetration experiences in both periods reported significantly higher HRQOL. Students with cyber bullying–victimization experiences in college (β 0.068) reported significantly higher HRQOL in the environment domain. Last, the effects of verbal and relational bullying-victimization experiences on psychological HRQOL could be mediated and manifested through depression.

CONCLUSIONS:

Various types of bullying experiences occurring before and in college were differentially associated with HRQOL in different domains. These findings underscore the importance of developing school policies and health education initiatives to prevent school bullying and ameliorate its short-term and long-term effects on HRQOL.


There is a debate about whether e-cigarettes will benefit public health. However, there is little knowledge about how e-cigarette users and dual users (those using both e-cigarettes and tobacco cigarettes) differ from other adolescents on a range of variables.

Teenagers who only used e-cigarettes were intermediate in levels of risk and protective factors between nonusers and those who used both cigarettes and e-cigarettes. This raises a question about whether e-cigarettes recruit low-risk youth to tobacco product use. (Read the full article)


Prenatal alcohol exposure can cause congenital neuropsychological and behavioral disabilities in later life. These usually lead to secondary disabilities (adverse outcome when the individual interacts with environmental settings), such as problems with school, the law, alcohol, or drugs.

This was a 30-year psychosocial register–based follow-up on adults with fetal alcohol syndrome and state care comparison group. The FAS-group had lower education and higher rates of unemployment, social welfare, and mental health problems than peers. Rates of criminality did not differ. (Read the full article)


Infant mortality is an important indicator of societal health, and approximately two-thirds of all infant deaths occur during the neonatal period and in neonatal intensive care units.

We report detailed information on the cause of death in infants admitted for intensive care. Factors associated with death are multifactorial, diverse, and change with gestational age. Potentially modifiable factors were identified in 31%. (Read the full article)


Influenza represents a leading cause of morbidity and a rare cause of death in children. Annual influenza vaccination was gradually expanded to include all children ≥6 months in 2008. The impact of these recommendations on disease burden is unclear.

We assessed the burden of influenza-related health care encounters in children aged 6 to 59 months from 2000 to 2011. In this ecologic exploration, influenza vaccination and influenza-related emergency department visits increased over time, whereas hospitalizations decreased. Influenza-related health care encounters were greater when A(H3N2) circulated. (Read the full article)


Frequency of influenza vaccination is low, partially because of missed opportunities to vaccinate. Barriers to implementing successful influenza vaccination reminders in the electronic health record include alert fatigue and incomplete vaccination information due to scattered records.

A noninterruptive, immunization information system–linked influenza vaccination reminder can increase vaccination late in the winter when fewer vaccine doses are usually administered. Tailoring the reminder to clinicians’ needs can increase its use. (Read the full article)


Influenza vaccine coverage is low, and young children in need of 2 doses in a given season are at particular risk, with less than half receiving both doses. Text message vaccine reminders increase receipt of first dose of influenza vaccine.

Little is known about what types of text message reminders are most effective, including embedding educational information. We demonstrate that text message reminders increase timely receipt of the second dose of influenza vaccine and embedding health literacy information improves effectiveness. (Read the full article)


Cesarean delivery has previously been associated with increased risk of specific immune diseases in children. The mechanism remains unknown.

In 1 large population-based cohort, we demonstrate cesarean delivery as a shared risk factor for several immune-related diseases. Such common risk factor suggests early life commonality in the origins of these chronic immune disorders. (Read the full article)


BACKGROUND AND OBJECTIVE:

Respiratory syncytial virus (RSV) is a common cause of pediatric hospitalization, but the mortality rate and estimated annual deaths are based on decades-old data. Our objective was to describe contemporary RSV-associated mortality in hospitalized infants and children aged <2 years.

METHODS:

We queried the Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) for 2000, 2003, 2006, and 2009 and the Pediatric Health Information System (PHIS) administrative data from 2000 to 2011 for hospitalizations with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for RSV infection and mortality.

RESULTS:

The KID data sets identified 607 937 RSV-associated admissions and 550 deaths (9.0 deaths/10 000 admissions). The PHIS data set identified 264 721 RSV-associated admissions and 671 deaths (25.4 deaths/10 000 admissions) (P < .001 compared with the KID data set). The 2009 KID data set estimated 42.0 annual deaths (3.0 deaths/10 000 admissions) for those with a primary diagnosis of RSV. The PHIS data set identified 259 deaths with a primary diagnosis of RSV, with mortality rates peaking at 14.0/10 000 admissions in 2002 and 2003 and decreasing to 4.0/10 000 patients by 2011 (odds ratio: 0.27 [95% confidence interval: 0.14–0.52]). The majority of deaths in both the KID and PHIS data sets occurred in infants with complex chronic conditions and in those with other acute conditions such as sepsis that could have contributed to their deaths.

CONCLUSIONS:

Deaths associated with RSV are uncommon in the 21st century. Children with complex chronic conditions account for the majority of deaths, and the relative contribution of RSV infection to their deaths is unclear.


Hospitalized pediatric patients are often exposed to many medications during an inpatient admission. Drug–drug interactions may increase the risk of developing medication-related adverse drug events, leading to serious clinical morbidity and mortality.

Exposure to "major" potential drug–drug interactions occurs in 41% of pediatric hospitalizations in children’s hospitals. One-half of all these exposures were due to less common specific drug pairs (≤3% of patients exposed per hospital day) and thus may be less clinically familiar. (Read the full article)


OBJECTIVE:

This study evaluated the current preparticipation physical evaluation (PPE) administrative policies and cardiovascular screening content of all 50 states and Washington, DC.

METHODS:

PPE policies, documents, and forms from all 50 states and Washington, DC, were compared with the preparticipation physical evaluation–fourth edition (PPE-4) consensus recommendations. All electronic documents were publicly available and obtained from state interscholastic athletic associations.

RESULTS:

Fifty (98%) states required a PPE before participation. Most states (53%, n = 27) required a specific PPE form, whereas 24% (n = 12) of states recommended a specific form. Twenty-three states (45%) required or recommended use of the PPE-4 form or a modified version of it, and 27 states (53%) required or recommended use of outdated or unidentifiable forms. Ten states (20%) had not revised their PPE forms in >5 years. States permitted 9 different health care providers to administer PPEs. Only 22 states (43%) addressed all 12 of the PPE-4 personal and family history cardiovascular screening items, and 2 states (4%) addressed between 8 and 11 items. For the remaining 26 states, most (29%) addressed ≤3 screening items.

CONCLUSIONS:

Our results show that inconsistencies in PPE policies exist nationwide. Most states have been slow to adopt PPE-4 recommendations and do not adequately address the personal and family cardiovascular history questions. Findings suggest a need for PPE standardization nationwide and adoption of an electronic PPE process. This approach would enable creation of a national database and benefit the public by facilitating a more evidenced PPE.


There is extensive literature documenting that children experiencing foster care placement have myriad adverse developmental outcomes, including poor academic achievement. However, such children face a host of other risk factors that may jeopardize healthy development independent of foster care placement.

Using statewide administrative data from Wisconsin, we observed children before, during, and after foster care placement and compared their educational outcomes with those of the general population, as well as with children more similar in terms of unobserved characteristics. (Read the full article)


Necrotizing enterocolitis is associated with high mortality and morbidity in premature infants. Anaerobic antimicrobial therapy has been associated with increased risk of intestinal strictures in a small randomized trial. Optimal antimicrobial therapy for necrotizing enterocolitis is unknown.

Anaerobic antimicrobial therapy was associated with increased risk of stricture formation. Infants with surgical necrotizing enterocolitis treated with anaerobic antimicrobial therapy had lower mortality. For infants with medical necrotizing enterocolitis, there was no added benefit associated with anaerobic antimicrobial therapy. (Read the full article)


Syndrome-specific standardized growth curves are not currently available for non–growth hormone–treated subjects with Prader-Willi syndrome and are required for monitoring growth and development in this rare obesity-related disorder.

Standardized growth curves were useful in monitoring growth and development in these subjects with Prader-Willi syndrome and for the management of growth hormone treatment of both genders, particularly those aged 3 to 18 years. (Read the full article)


Germ cell tumors in children are heterogeneous and rare neoplasms that occur in various locations, such as gonads, the central nervous system, and the pelvis. The incidence rate has been increasing in some countries.

Population-based analyses of germ cell tumors in children are rare. This population-based study describes the incidence rates, trends, and survival of germ cell tumors in German children from 1987 to 2011. (Read the full article)


Fasting insulin levels in childhood are increasingly being used as a surrogate for insulin resistance and risk of later type 2 diabetes, despite only a moderate correlation with whole-body insulin sensitivity and few data related to adult outcomes.

Elevated insulin values between the ages of 3 and 6 years are associated with an elevated risk for later type 2 diabetes. In 9- to 18-year-olds, elevated BMI (but not insulin values) is associated with later type 2 diabetes. (Read the full article)


BACKGROUND:

Extremely preterm infants are at risk for neurodevelopmental impairment (NDI). Early cranial ultrasound (CUS) is usual practice, but near-term brain MRI has been reported to better predict outcomes. We prospectively evaluated MRI white matter abnormality (WMA) and cerebellar lesions, and serial CUS adverse findings as predictors of outcomes at 18 to 22 months’ corrected age.

METHODS:

Early and late CUS, and brain MRI were read by masked central readers, in a large cohort (n = 480) of infants <28 weeks’ gestation surviving to near term in the Neonatal Research Network. Outcomes included NDI or death after neuroimaging, and significant gross motor impairment or death, with NDI defined as cognitive composite score <70, significant gross motor impairment, and severe hearing or visual impairment. Multivariable models evaluated the relative predictive value of neuroimaging while controlling for other factors.

RESULTS:

Of 480 infants, 15 died and 20 were lost. Increasing severity of WMA and significant cerebellar lesions on MRI were associated with adverse outcomes. Cerebellar lesions were rarely identified by CUS. In full multivariable models, both late CUS and MRI, but not early CUS, remained independently associated with NDI or death (MRI cerebellar lesions: odds ratio, 3.0 [95% confidence interval: 1.3–6.8]; late CUS: odds ratio, 9.8 [95% confidence interval: 2.8–35]), and significant gross motor impairment or death. In models that did not include late CUS, MRI moderate-severe WMA was independently associated with adverse outcomes.

CONCLUSIONS:

Both late CUS and near-term MRI abnormalities were associated with outcomes, independent of early CUS and other factors, underscoring the relative prognostic value of near-term neuroimaging.


BACKGROUND AND OBJECTIVE:

Single-center evaluations of pediatric antimicrobial stewardship programs (ASPs) suggest that ASPs are effective in reducing and improving antibiotic prescribing, but studies are limited. Our objective was to compare antibiotic prescribing rates in a group of pediatric hospitals with formalized ASPs (ASP+) to a group of concurrent control hospitals without formalized stewardship programs (ASP–).

METHODS:

We evaluated the impact of ASPs on antibiotic prescribing over time measured by days of therapy/1000 patient-days in a group of 31 freestanding children’s hospitals (9 ASP+, 22 ASP–). We compared differences in average antibiotic use for all ASP+ and ASP– hospitals from 2004 to 2012 before and after release of 2007 Infectious Diseases Society of America guidelines for developing ASPs. Antibiotic use was compared for both all antibacterials and for a select subset (vancomycin, carbapenems, linezolid). For each ASP+ hospital, we determined differences in the average monthly changes in antibiotic use before and after the program was started by using interrupted time series via dynamic regression.

RESULTS:

In aggregate, as compared with those years preceding the guidelines, there was a larger decline in average antibiotic use in ASP+ hospitals than in ASP– hospitals from 2007 to 2012, the years after the release of Infectious Diseases Society of America guidelines (11% vs 8%, P = .04). When examined individually, relative to preimplementation trends, 8 of 9 ASP+ hospitals revealed declines in antibiotic use, with an average monthly decline in days of therapy/1000 patient-days of 5.7%. For the select subset of antibiotics, the average monthly decline was 8.2%.

CONCLUSIONS:

Formalized ASPs in children’s hospitals are effective in reducing antibiotic prescribing.


BACKGROUND AND OBJECTIVE:

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are prone to sustaining trauma that requires emergency department (ED) admission. Methylphenidate (MPH) can reduce ADHD symptoms and may thus theoretically reduce the risk of trauma-related ED admission, but previous studies do not make this association clear. This study examines this association.

METHODS:

A total of 17 381 patients aged 6 to 19 years who received MPH prescriptions were identified by using the Clinical Data Analysis & Reporting System (2001–2013). Using a self-controlled case series study design, the relative incidence of trauma-related ED admissions was compared with periods of patient exposure and nonexposure to MPH.

RESULTS:

Among 17 381 patients prescribed MPH, 4934 had at least 1 trauma-related ED admission. The rate of trauma-related ED admission was lower during exposed periods compared with nonexposed periods (incidence rate ratio [IRR]: 0.91 [95% confidence interval (CI): 0.86–0.97]). The findings were similar only when the incident trauma episode was assessed (IRR: 0.89 [95% CI: 0.82–0.96]). A similar protective association was found in both genders. In validation analysis using nontrauma-related ED admissions as a negative control outcome, no statistically significant association was found (IRR: 0.99 [95% CI: 0.95–1.02]). All sensitivity analyses demonstrated consistent results.

CONCLUSIONS:

This study supports the hypothesis that MPH is associated with a reduced risk of trauma-related ED admission in children and adolescents. A similar protective association was found in both male and female patients. This protective association should be considered in clinical practice.


OBJECTIVE:

To describe electronic cigarette (e-cigarette) use and cigarette use among adolescents and determine whether established risk factors for smoking discriminate user categories.

METHODS:

School-based survey of 1941 high school students (mean age 14.6 years) in Hawaii; data collected in 2013. The survey assessed e-cigarette use and cigarette use, alcohol and marijuana use, and psychosocial risk and protective variables (eg, parental support, academic involvement, smoking expectancies, peer smoking, sensation seeking). Analysis of variance and multinomial regression examined variation in risk and protective variables across the following categories of ever-use: e-cigarette only, cigarette only, dual use (use of both products), and nonuser (never used either product).

RESULTS:

Prevalence for the categories was 17% (e-cigarettes only), 12% (dual use), 3% (cigarettes only), and 68% (nonusers). Dual users and cigarette-only users were highest on risk status (elevated on risk factors and lower on protective factors) compared with other groups. E-cigarette only users were higher on risk status than nonusers but lower than dual users. E-cigarette only users and dual users more often perceived e-cigarettes as healthier than cigarettes compared with nonusers.

CONCLUSIONS:

This study reports a US adolescent sample with one of the largest prevalence rates of e-cigarette only use in the existing literature. Dual use also had a substantial prevalence. The fact that e-cigarette only users were intermediate in risk status between nonusers and dual users raises the possibility that e-cigarettes are recruiting medium-risk adolescents, who otherwise would be less susceptible to tobacco product use.


OBJECTIVE:

To study the characteristics of off-label prescribing and adverse drug reaction (ADR) occurrence in a sample of pediatric outpatients treated by general practitioners.

METHODS:

A survey on pediatric drug prescribing was implemented in 46 general practices in southwestern France. All consecutive patients aged 0 to 16 years were included. Patient characteristics, reasons for consultation, and drug prescribed (including indications) were collected. ADRs occurring ≤10 days after the date of consultation were recorded by the general practitioners (spontaneous notification). Off-label prescription was defined as prescribing outside the specifications of the Summary of Product Characteristics.

RESULTS:

Among the 2313 children seen between March 8, 2011 and July 31, 2011, 1960 were exposed to ≥1 prescribed drug. Mean age was 5.6 years, with a gender ratio of 1.1. Among children with prescriptions, 37.6% (n = 736) were exposed to ≥1 off-label prescription and 6.7% (n = 132) to ≥1 unlicensed drug. Off-label prescribing involved an unapproved indication in 56.4% of cases (n = 416), a lower dosage (26.5%, n = 195) or higher dosage (19.5%, n = 144) than specified, age not labeled (7.2%, n = 53), incorrect route of administration (3.5%, n = 26), and contraindication (0.3%, n = 2). A total of 23 ADRs were reported (1.5% of patients with off-label prescriptions). ADR occurrence was not significantly related to off-label drug prescribing.

CONCLUSIONS:

Despite the numerous initiatives implemented for promoting rational medicine use in children, the prevalence of off-label prescription in outpatient pediatric practice remains high.


BACKGROUND AND OBJECTIVE:

Primary disabilities in children prenatally exposed to alcohol have a major impact on their daily life. It is suggested that these issues persist into adulthood, but few studies have addressed the outcome in adults with prenatal exposure, especially those with fetal alcohol syndrome (FAS). The aim of this follow-up study was to investigate outcome variables, such as education, employment, health, and criminal acts, in 79 adults diagnosed with FAS.

METHODS:

We carried out a national register–based study of 79 adults with an FAS diagnosis, at a mean age of 32. Education, social adjustment, and mental health outcomes were analyzed and compared with 3160 comparison individuals matched on age, gender, and place of birth.

RESULTS:

The FAS group was much more likely to have received special education (25% vs 2%), be unemployed (51% vs 15%), and receive a disability pension (31% vs 3%) than the comparisons, but the levels of criminal offenses were similar. The FAS group had higher hospital admission rates for alcohol abuse (9% vs 2%) and psychiatric disorders (33% vs 5%) and was more likely to be prescribed psychotropic drugs (57% vs 27%).

CONCLUSIONS:

Swedish children with FAS have quite diverse psychosocial outcomes in adulthood, considerably worse than for majority population peers. Potential risk and protective factors within the FAS group deserve study to enable development of effective interventions.


OBJECTIVE:

Maternal depression is a risk factor for adolescent depression; however, the effect of childhood exposure to maternal depression on adolescent engagement in health risk behaviors (eg, substance use, delinquency) is unclear.

METHODS:

We examined the relationship between maternal depressive symptoms (child’s age 4–15) and engagement in health risk behaviors at age 16 to 17 by using data from 2910 mother–youth pairs in a nationally representative prospective Canadian cohort. Maternal depressive trajectories were estimated through finite mixture modeling, and multiple regression analyses examined the relationship between maternal depressive symptoms and engagement in various health risk behaviors (linear regression) and age of debut of various behaviors (Cox regression).

RESULTS:

Five trajectories of maternal depressive symptoms were found: recurrent maternal symptoms, midchildhood exposure to maternal symptoms, adolescent exposure to maternal symptoms, mild maternal symptoms, and low symptoms. Adolescents exposed to maternal depressive symptoms during middle childhood were more likely to use common substances (alcohol, cigarettes, marijuana), engage in violent and nonviolent delinquent behavior, and have an earlier debut ages of cigarette, alcohol, marijuana, and hallucinogen use.

CONCLUSIONS:

The results of this study suggest that exposure to maternal depressive symptoms, particularly in middle childhood, is associated with greater and earlier engagement in health risk behaviors.


BACKGROUND AND OBJECTIVES:

Infant mortality is an indicator of overall societal health, and a significant proportion of infant deaths occur in NICUs. The objectives were to identify causes of death and to define potentially preventable factors associated with death as areas for quality improvement efforts in the NICU.

METHODS:

In a prospectively defined study, the principal investigator in 46 level III NICUs agreed to review health care records of infants who died. For each infant, the principal investigator reviewed the medical record to identify the primary cause of death and to look for preventable factors associated with the infant’s death. Infants born at ≥22 weeks estimated gestational age who were born alive were included. Stillborn infants were excluded.

RESULTS:

Data were collected on 641 infants who died. At lower gestational ages, mortality was most commonly due to extreme prematurity and the complications of premature birth (respiratory distress progressing to respiratory failure, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis). With increasing gestational age, the etiology of mortality shifted to hypoxic–ischemic encephalopathy and genetic or structural anomalies. Reviewers of clinical care identified 197 (31%) infants with potentially modifiable factors that may have contributed to their deaths.

CONCLUSIONS:

The factors associated with death in infants admitted for intensive care are multifactorial and diverse, and they change with gestational age. In 31% of the deaths, potentially modifiable factors were identified, and these factors suggest important targets for reducing infant mortality.