May 2011, VOLUME127 /ISSUE 5

Pediatrics Digest

Clinical Features That Identify Children With Primary Immunodeficiency Diseases

Children with severe, recurrent, or unusual infections may have an underlying primary immunodeficiency disease (PID). Ten warning signs have been promoted by patient support groups to help identify children with PID, but the signs have never been tested in a rigorous scientific study.

Family history, intravenous antibiotics for sepsis, and failure to thrive predict at least 89% of children with T-lymphocyte, complement, and neutrophil PID. B-lymphocyte PID are more difficult to diagnose from the clinical features, and a lower threshold is required for assessing antibody levels.

Early Onset Neonatal Sepsis: The Burden of Group B Streptococcal and E. coli Disease Continues

Early onset neonatal sepsis causes serious morbidity and mortality in newborns. Substantial disease reduction has occurred with intrapartum antibiotic prophylaxis treatment of at-risk women to reduce vertical transmission of early onset group B streptococcal disease. Predominant neonatal pathogens are thought to change over time.

In a national cohort of ∼400 000 infants, rates of early onset sepsis were 0.98 cases per 1000 live births. Infection rates increased with decreasing gestational age and birth weight. The most frequent pathogens were group B streptococci (GBS) in term infants and Escherichia coli in preterm infants. Opportunities for GBS prevention continue to be missed.

Risk-Taking Behaviors of Adolescents With Extreme Obesity: Normative or Not?

Today's obese youth are heavier than in previous decades. Increasing focus has been placed on characterizing the medical and psychosocial risks that extremely obese youth experience and the disease burden they will likely carry into young adulthood.

This is the first study to reveal that adolescents with extreme obesity engage in many high-risk behaviors at rates comparable with their healthy weight peers. In addition, those who engage in these behaviors may do so in even more dangerous ways.

Vitamin D Status in Abused and Nonabused Children Younger Than 2 Years Old With Fractures

Bone fragility attributed to suboptimal levels of vitamin D has been offered as an alternative explanation for suspected nonaccidental trauma in young children with fractures. Although common, it is unknown whether vitamin D insufficiency increases fracture susceptibility in children.

This study is the first to examine vitamin D levels in young children presenting with fractures and indicates that a strong association between suboptimal vitamin D status and fractures related to abuse is unlikely.

Victimization, Aggression, and Visits to the School Nurse for Somatic Complaints, Illnesses, and Physical Injuries

Children who are frequent targets (victims) or perpetrators of peer aggression are at increased risk for psychosocial problems. Linkages between health and involvement in peer aggression have been proposed, but research evidence remains sparse.

This study shows that self-reported victimization and classmate-reported aggression toward peers are both associated with more frequent visits to a school nurse for illness with objective symptoms, somatic complaints without objective symptoms, and injuries.

Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior

Approximately 178 million children younger than 5 years in developing countries are growth-retarded (stunted) and generally do not attain their developmental potential. Early child development programs benefit concurrent development, but there is no information on adult benefits.

Early psychosocial intervention in growth-retarded children benefits adult educational attainment and psychological functioning and reduces violent behavior. This has important policy implications and indicates that both beneficiaries and society will gain from early child development programs in developing countries.

Preterm Birth and Attention-Deficit/Hyperactivity Disorder in Schoolchildren

Attention problems have been described in survivors of neonatal intensive units in school age.

This study demonstrates that not only extremely preterm birth, but also moderately preterm birth, increases the risk of ADHD by degree of immaturity at birth. Social adversity, as expressed by low maternal education, modifies the risk of ADHD in moderately preterm birth.

The Each Child Study: Systematic Screening for Autism Spectrum Disorders in a Pediatric Setting

Autism screening at 18- and 24-month well-child visits can optimize early identification and outcome. Although promising screening questionnaires exist, no studies have shown how they can be systematically applied to all children who present to a health care setting.

Developing a supportive partnership between pediatricians and autism experts resulted in a high rate of screening for all children, including those from minority groups and the uninsured. Formal screening was much more effective than relying on clinical judgment alone.

Outcomes of Laparoscopic Versus Open Fundoplication in Children's Hospitals: 2005–2008

Fundoplication is the third most common major surgical procedure performed in children in the United States, and the laparoscopic approach has increased in popularity in the absence of strong evidence to support its adoption.

In the study population, laparoscopic fundoplication was associated with shorter length of stay, reduced costs, and lower complication rates when compared with the open approach, even after adjustment for age and severity.

Are Parents of Young Children Practicing Healthy Nutrition and Physical Activity Behaviors?

Becoming a parent is a common life event in early adulthood, but little is known about the connection between parenthood and weight-related health. Understanding parents' health behaviors is important, because health habits may be perpetuated into adulthood and transmitted to children.

Results of this study shed light on the relationship between parenthood and weight status, dietary intake, and physical activity in both mothers and fathers and indicate that mothers may be at greater risk for overweight and other negative health behaviors than fathers.

The Relationship Between Hispanic Parents and Their Preschool-Aged Children's Physical Activity

Little is known about how physical activity patterns are set in early childhood. Compared with black or white populations, Hispanics have the least amount of leisure time activity, yet there has been little research that has focused on the activity of preschool-aged Hispanic children.

Results suggest that Hispanic parents of preschool-aged children set physical activity patterns at a time of critical development in early childhood. For Hispanic preschool-aged children, sedentary behavior seems to be the norm when Hispanic parents are sedentary themselves.

The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth

Lesbian, gay, and bisexual (LGB) youth attempt suicide at significantly higher rates than heterosexuals. The social environment may contribute to this elevated risk, but few empirical studies have used objective measures of the social environment to examine this hypothesis.

This study demonstrated that negative characteristics of the social environment increase risk for suicide attempts among LGB youth, independent of individual-level risk factors. These results suggest that identifying structural interventions may help to reduce sexual orientation–related disparities in suicide attempts.

Validating Office-Based Screening for Psychosocial Strengths and Difficulties Among Youths in Foster Care

Youths in foster care have a high prevalence of social-emotional problems, but specific strategies for identifying these problems are less clear. Mental health resources are limited, so screening practices should identify at-risk youths who are most likely to benefit from services.

Youths in foster care have psychosocial strengths as well as difficulties. Primary care–based psychosocial screening for youths in foster care should use combined youth and parent reports for the most accurate identification of those who may have social-emotional problems.

Educational Effectiveness of an HIV Pretest Video for Adolescents: A Randomized Controlled Trial

Adolescents are affected disproportionately by HIV. An urban emergency department provides a venue for HIV testing and counseling. Innovative approaches are needed to normalize HIV testing and improve HIV knowledge among adolescents.

The results demonstrate that video-based educational messages tailored toward adolescents improve their HIV knowledge and increase HIV-testing rates within an emergency department.

Novel Approach to Parental Permission and Child Assent for Research: Improving Comprehension

It is generally acknowledged that the assent and consent process for research does not result in acceptable levels of comprehension by research participants. Various causes have been posited as contributing to poor comprehension, including the legal tone of forms.

Efforts to improve participant comprehension have focused on improving the readability of forms. This article reports on a novel approach in which visual and audio media (multimedia), not a paper-based written text document, were used to improve the process.

Cost-effectiveness of Metered-Dose Inhalers for Asthma Exacerbations in the Pediatric Emergency Department

Treatment of mild and moderate asthma exacerbations in emergency departments can be efficaciously delivered by using either metered-dose inhalers or wet nebulization. Cost is a frequently cited reason for not using metered-dose inhalers over nebulization in emergency departments.

Metered-dose inhalers are a cost-efficient mode of delivery for bronchodilators, and transitioning from nebulization to metered-dose inhaler in pediatric emergency departments may result in significant cost savings associated with each admission averted.

Computerized Physician Order Entry With Decision Support Decreases Blood Transfusions in Children

Studies reveal red blood cell transfusion practices to be variable among pediatricians. Recent data suggests significant risks to children receiving transfusions, and supports a conservative transfusion strategy. Computerized physician order entry with decision support has potential to improve transfusion utilization.

A significant lag exists between the dissemination of evidence-based recommendations and integration into clinical practice. This study reveals a strategy where computerized decision support improved the use of red blood cell transfusions, suggesting enhanced adoption of evidence-based recommendations.

Racial and Ethnic Differences in Use of Intubation for Periviable Neonates

There are racial and ethnic differences in preferences for heroic measures and resuscitative care at the end of life among adult, terminally ill, and pediatric populations. However, little is known about racial/ethnic differences in the resuscitation of periviable neonates.

This study reveals higher use of neonatal intubation for periviable neonates born to black and Hispanic women. These findings may reflect differences in preferences for resuscitative care in periviability similar to those seen in end-of-life decision-making.

Racial/Ethnic Disparities in Risk of Early Childhood Mortality Among Children With Congenital Heart Defects

Congenital heart defects (CHDs) are the leading cause of death among all infants with birth defects. Mortality and survival vary greatly and are influenced by several factors including length of follow-up, phenotype, number of co-occurring, and severity of defects.

Numerous reports have described growing disparities in infant and childhood mortality between non-Hispanic white and minority children. However, little is known about survival among minority children with CHDs. These data demonstrate racial/ethnic disparities in early childhood survival among children with CHDs.

Evaluation of Immunization Rates and Safety Among Children With Inborn Errors of Metabolism

Children with inborn errors of metabolism (IEMs) are a potential high-risk group for vaccine-preventable diseases, yet information regarding immunization rates and vaccine safety within this vulnerable population is limited.

Using Northern California Kaiser Permanente's integrated medical record, we found that children with IEMs received vaccines on similar schedules as healthy infants and that immunization was not associated with increased risk for serious adverse events during the month after vaccination.

Vaccines Are Not Associated With Metabolic Events in Children With Urea Cycle Disorders

There have been no large controlled studies on vaccine safety in the vulnerable population of children with urea cycle disorders.

The results provide substantial reassurance of the safety of vaccinations in medically fragile children with urea cycle disorders.

Impact of Provider Specialty on Pediatric Procedural Sedation Complication Rates

Pediatric procedural sedation is provided by a variety of pediatric specialists. Low patient numbers, single-institution experience, and evaluation of single-specialty groups have limited previous reports on complications.

We used a large multiinstitution procedural sedation database to compare the major complication rates among providers. We found that provider specialty did not affect major complication rates in our consortium of organized sedation systems.

Influenza A/H1N1 MF59-Adjuvanted Vaccine in Preterm and Term Children Aged 6 to 23 Months

Preterm infants are among the children with the highest risk of influenza-related complications. It is still unclear whether preterm infants can be protected against the novel pandemic influenza and whether the adjuvanted vaccines in these subjects.

A single dose of 2009 pandemic A/H1N1 MF59-adjuvanted influenza vaccine evoked an immune response in children aged 6 to 23 months (including those with a gestational age of <32 weeks) that can be considered protective from pandemic influenza A/H1N1 virus.

Adolescent Chronic Fatigue Syndrome: Prevalence, Incidence, and Morbidity

Adolescent chronic fatigue syndrome (CFS) is a disabling illness. The majority of adolescents with CFS miss significant amounts of school. Little is known about the epidemiology of CFS in adolescents.

The prevalence of adolescent chronic fatigue syndrome (CFS) diagnosed by general practitioners was approximately 111 per 100 000 (0.11%) per year and the incidence of CFS diagnosed by pediatricians was 12 per 100 000 (0.012%) per year. Adolescent CFS is a well-accepted diagnosis among pediatricians but is probably underrecognized by primary health care providers.

Cost-effectiveness of Essential Newborn Care Training in Urban First-Level Facilities

Training of birth attendants in essential newborn care courses can reduce neonatal and perinatal mortality, but the cost of effective interventions may prevent their adoption.

The World Health Organization's Essential Newborn Care training for midwives with implementation of improved newborn care in low-risk first-level facilities is a very cost-effective intervention that may have a major positive impact and lead to decreased early neonatal mortality.

Intrapartum-Related Stillbirths and Neonatal Deaths in Rural Bangladesh: A Prospective, Community-Based Cohort Study

Estimates of prevalence for birth asphyxia in low income community settings vary according to the definition used. Resuscitation trials are aimed at infants who do not breathe at birth. Outcome studies require the measurement of intrapartum-related stillbirths and neonatal deaths.

In rural Bangladesh 12.5% of newborns do not breathe immediately, half of whom undergo some form of resuscitation. Poor condition at 5 minutes carries a high mortality risk and intrapartum-related deaths accounted for a third of all neonatal deaths.

A Cluster-Randomized Evaluation of a Responsive Stimulation and Feeding Intervention in Bangladesh

Parenting education for feeding and stimulation of infants and young children is needed, particularly in South Asia, where 45% of children are malnourished and many do not achieve their learning potential. Responsive stimulation is sometimes associated with better language development.

Six group sessions with mothers and young children in rural Bangladesh used demonstration and coached practice to promote responsive stimulation and feeding. Compared with an informational control, children in the intervention group had better developmental and nutritional outcomes, including language and mouthfuls eaten.

Association of Neck Circumference With Perioperative Adverse Respiratory Events in Children

Obesity is a highly prevalent condition. Regional deposition of fat is more pathogenic than total body adiposity. Central obesity is associated with chronic cardiometabolic diseases in adults and children. Association of central obesity with short-term complications has not been previously explored.

Central obesity (indicated by large neck circumference) is associated with airway-related acute perioperative complications. Measuring neck circumference could be a useful screening tool for perioperative complications.

Knowledge and Practice of Prechewing/Prewarming Food by HIV-Infected Women

Although associations between prechewing and transmission of pathogens including HIV have been reported, purported health benefits of this feeding practice have also been debated. The extent of this practice and a related practice of oral prewarming of food is unclear.

The infant/child feeding practices of prechewing and oral prewarming of food are not uncommon in Latin America. Health care providers could be missing information about cultural feeding practices, which patients may not report unless specifically asked.

Maternal Periodontitis Treatment and Child Neurodevelopment at 24 to 28 Months of Age

Some maternal infections increase the risk of impaired infant neurodevelopment. Periodontitis is a bacterial infection that leads to more frequent bacteremia and increased serum inflammatory biomarker levels. No studies have determined whether maternal periodontitis treatment is associated with child neurodevelopment.

We compared cognitive, motor, and language development between children of mothers who were or were not treated for periodontitis during pregnancy. Neither receipt of treatment nor change in periodontitis status during pregnancy was associated with these outcomes in children.

Ethics of Resuscitation at Different Stages of Life: A Survey of Perinatal Physicians

Canadian studies have revealed that neonatologists and other health professionals do not uphold the best-interest standard in making decisions for preterm infants in need of life-saving resuscitation, in contrast to other patients with similar prognoses for survival and disability.

This study's results reveal that, when presented with a variety of clinical vignettes, decision-making by US neonatologists and high-risk obstetricians in emergent situations is not strictly based on traditional ethical principles (particularly in the case of extremely preterm infants).

Parents' Experiences of Their Children's Presence in Discussions With Physicians About Leukemia

Physicians are expected to communicate openly with seriously ill children. Maximizing children's inclusion in discussions and limiting separate parent-physician meetings may be important in implementing open communication, but it is unclear how parents experience these procedures.

Many parents felt that their child's presence constrained communication, interfered with their concentration, and hindered the emotional care of their child. Physicians should consider conveying significant information to parents before children and involving parents in managing communication with their children.

Familial Aggregation of Autoimmune Disease in Juvenile Dermatomyositis

Autoimmune diseases frequently run in families, and some families are predisposed to multiple types of autoimmune disease. Genetic factors and specific immune system mediators frequently are shared between autoimmune diseases and may provide insight into the familial tendency toward autoimmunity.

We report the prevalence of autoimmune conditions in families of children with juvenile dermatomyositis. Lupus and type 1 diabetes were significantly increased in these families, suggesting shared pathogenic factors. A family history of lupus was associated with increased serum interferon-α.

Impact at Age 11 Years of Major Neonatal Morbidities in Children Born Extremely Preterm

Children born extremely preterm are at risk for neurosensory, cognitive, behavioral, and academic impairments. Severe retinopathy of prematurity, brain injury, and bronchopulmonary dysplasia are associated with poorer outcomes at early ages.

Extremely preterm children, especially those with brain injury and severe retinopathy, have shown increased risk for poor outcome and increased needs for educational support services. This is the first study to examine the combined effect of the 3 most serious neonatal morbidities at 11 years in extremely preterm-born children.

Natural Progression of Neurological Disease in Mucopolysaccharidosis Type II

The few available reports on the progression of neurological disease in patients with mucopolysaccharidosis type II (Hunters syndrome) describe clinical impressions of a wide range of neurological involvement, some secondary to somatic disease and some the result of brain involvement.

A large cohort of patients with mucopolysaccharidosis type II was followed longitudinally for almost 8 years. Two distinct disease manifestations were identified, primarily brain disease and somatic disease. This information may be helpful in the development and evaluation of therapies for this illness.

Interobserver Agreement in the Assessment of Clinical Findings in Children With First Unprovoked Seizures

Few data are available to determine whether clinicians practicing in acute settings assess children with first-time seizures in a similar way. This is important for the study of clinical predictors potentially associated with intracranial abnormalities in these children. In particular, findings such as seizure focality are often used to determine the need for emergent and nonemergent neuroimaging.

Among patient history and physical examination findings, interobserver agreement beyond chance was consistently substantial only for the seizure specific history. Those clinical variables that have been associated with the presence of intracranial abnormalities and show reliability between assessors, such as seizure focality, may be more useful than other predictors in the emergency department assessment of children with first unprovoked seizures.

Birth Weight, Postnatal Weight Change, and Risk for High Blood Pressure Among Chinese Children

Previous studies have identified an inverse association between birth weight and childhood hypertension. In addition, postnatal weight gain may contribute to this predisposition toward hypertension.

Previous studies evaluating the association between birth weight and childhood hypertension were conducted largely in Western countries but may be relevant in developing countries, where the occurrence of metabolic disorders is increasing.

Reference Values for Amplitude-Integrated EEGs in Infants From Preterm to 3.5 Months of Age

Characteristics of amplitude-integrated electroencephalograms (aEEG), such as amplitudes of upper and lower margins, change with maturation and reflect the functional brain development. Normal aEEG characteristics have been explored in preterm and term neonates, but data in older infants are scarce.

Amplitudes of aEEGs rise with increasing postmenstrual age during early infancy after the neonatal period. The amplitude-integrated electroencephalogram bandwidth, defined as the graphic distance, was found to decrease in infants from 30 to 55 weeks' postmenstrual age.

Parents' Attitudes Toward Pediatric Genetic Testing for Common Disease Risk

Direct-to-consumer genetic tests assess large panels of genetic variants associated with risk for common health conditions and traits. The swift pace of these developments raises expectations and concerns about their social and clinical impact.

As genetic susceptibility testing for common, adult-onset health conditions proliferates, pediatricians should anticipate parents' interest in testing children and be prepared to facilitate informed decision making about such testing.

Genetic and Environmental Factors Shape Infant Sleep Patterns: A Study of 18-Month-Old Twins

Sleeping behavior is associated with health in general, behavioral disorders, and school performance. To distinguish between the genetic and environmental factors that influence sleeping behavior, twin studies can be of use, although few have been performed.

We evaluated the contribution of genetic and environmental factors to sleep measures in early childhood using a twin design. We found evidence of strong shared environmental influences, although heritability was not negligible. These results are important for choosing appropriate therapy.


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