Pediatrics Digest

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Bene

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ts of Strict Rest After Acute Concussion:

A Randomized Controlled Trial

Expert consensus recommends rest after concussion with stepwise return to activity. Animal and retrospective human data suggest that early mental and physical activity may worsen outcome. There are no pediatric studies testing the efﬁcacy of recommending strict rest after concussion.

Recommending strict rest postinjury did not improve outcome and may have contributed to increased symptom reporting. Usual care (rest for 1–2 days with stepwise return to activity) is currently the best discharge strategy for pediatric mild traumatic brain injury/concussion.

Discrepancies Between Transcutaneous and Serum

Bilirubin Measurements

In most previous studies, transcutaneous bilirubin measurement has been found to provide an accurate estimate of total serum bilirubin levels. However, most of these studies were conducted in settings that optimized accuracy.

This study provides a“real-world”assessment of the accuracy of transcutaneous bilirubin measurements in multiple clinical settings and identiﬁcation of sources of discrepancy between transcutaneous and total serum bilirubin measurements.

A Comparison of Acute Treatment Regimens for

Migraine in the Emergency Department

Migraine headaches are a common presenting complaint in emergency departments. Abortive treatment in this setting is not well studied, leading to considerable variation in treatment.

The relationship between acute medications and emergency department revisits has not been studied.

Eighty-ﬁve percent of children with migraine are successfully discharged from the emergency department; only 1 in 18 children require a return visit. Prochlorperazine is associated with less revisits than metoclopramide, and diphenhydramine use is associated with increased risk of return visits.

Age at Gluten Introduction and Risk of Celiac

Disease

Both early and late introduction to gluten has been associated with increased risk for celiac disease (CD) and being breastfed at time of gluten introduction has been associated with a lower risk for CD.

In this prospective multinational study, time toﬁrst introduction to gluten-containing cereals is not an independent risk factor for developing CD, by a 5-year follow-up, neither on an overall level nor on country-level comparison.

Adolescents

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Perceptions of Light and Intermittent

Smoking in the United States

Light and intermittent smoking are harmful, but increasingly common, smoking patterns. It is unknown how adolescents perceive these smoking patterns, and whether these views differ by sociodemographic characteristics, and exposure to and use of tobacco.

US adolescents perceive light and intermittent smoking as signiﬁcantly less dangerous than heavier smoking. One in 4 adolescents believes intermittent smoking causes little to no

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Earlyﬁrst sexual intercourse (FSI) is a risk factor for unplanned teenage pregnancy, sexually transmitted infection, and adverse health outcomes in adolescence and into adulthood. In girls, externalizing behaviors are more strongly associated with earlier FSI than internalizing behaviors.

Externalizing behavior from as early as 5 in boys and 10 in girls is a signiﬁcant risk factor for earlier age at FSI. Internalizing behavior at ages 8 and 10 was associated with early FSI for boys but not girls.

Misdiagnosis and Missed Diagnoses in Foster and

Adopted Children With Prenatal Alcohol Exposure

Researchers speculate that children with fetal alcohol spectrum disorders often are not recognized or diagnosed correctly.

This is theﬁrst study to assess the rate of missed diagnoses and misdiagnosis in foster and adopted children with fetal alcohol spectrum disorders.

Heterogeneity in Asthma Care in a Statewide

Collaborative: the Ohio Pediatric Asthma Repository

Asthma is heterogeneous and 40% to 70% of patients fail to achieve control with current treatment strategies. To delineate relevant subphenotypes of asthma, identify key factors, and test novel interventions, comprehensive repositories linking clinical, environmental, and biologic data are required.

This is theﬁrst statewide repository for inpatient pediatric asthma. The data collected will better deﬁne asthma phenotypes, identify care practices associated with the best health outcomes, and inform personalized care plans to reduce reutilization and readmission for pediatric asthma.

Geographic Clusters in Underimmunization and

Vaccine Refusal

Parent refusal and delay of childhood vaccines has increased in recent years and is believed to cluster in communities. Such clustering could pose public health risks and barriers to achieving quality benchmarks for immunization coverage.

We found that underimmunization and vaccine refusal cluster geographically. Spatial scan analysis may be a useful tool to identify locations where clinicians may face challenges to

a lower likelihood of leaving their childhood home, and starting romantic relationships, and are older when experiencingﬁrst intercourse or having theirﬁrst child than their term-born peers.

Compared with term-born individuals, those born preterm perceived themselves less attractive and were less likely to have cohabited or experienced ﬁrst-time sexual in-tercourse by young adulthood. This outcome indicates that social outcomes are different among preterm-born individuals.

Strategic Modeling of the Pediatric Nurse

Practitioner Workforce

The number of nurse practitioner graduates in the United States has nearly doubled over the past 2 decades. However, the number of pediatric nurse practitioner (PNP) graduates has remained relativelyﬂat, although the demand for PNPs is expected to increase.

This study estimates the best-case shortage of PNPs over the next 25 years. We propose possible policy interventions to address key areas of the PNP workforce system and we compute their impact on the forecasted PNP shortage.

Morphine or Ibuprofen for Post-Tonsillectomy

Analgesia: A Randomized Trial

Sleep apnea is a common condition in childhood, mainly managed by tonsillectomy. Codeine was recently contra-indicated for pain management after surgery. Controversy exists regarding the safety and effectiveness of alternative medications, morphine, and ibuprofen.

Ourﬁndings suggest that ibuprofen does not increase tonsillar bleeding and in combination with acetaminophen is effective for pain management after tonsillectomy. Furthermore, standard morphine doses increased postoperative respiratory events and were not safe in all children.

Early Discharge of Infants and Risk of Readmission

for Jaundice

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for jaundice; however, the impact of early discharge on this group has not been investigated.

Early postnatal discharge was signiﬁcantly associated with readmission for jaundice. Of the infants discharged early, those born 37 to 38 weeks’gestation, born via vaginal delivery, born to Asian mothers, or were breastfed had the greatest risk for readmission.

Energy and Nutrient Intake From Pizza in the United

States

Among all age groups, children aged 6 to 11 years and ado-lescents aged 12 to 19 are the most frequent consumers of pizza. Pizza consumption is the second highest source of daily energy among children 2 to 18 years old.

This study examines changes in children’s patterns of pizza consumption by demographic characteristics, source, and meal occasion. Using an individual-levelﬁxed effects model, we examined the impact of pizza consumption on excess energy intake and diet quality.

Addressing Social Determinants of Health at Well

Child Care Visits: A Cluster RCT

Although pediatric professional guidelines emphasize addressing a child’s social environment in the context of well child care, it remains unclear whether screening for unmet basic needs at visits increases low-income families’receipt of community-based resources.

This study demonstrates that systematically screening and referring for social determinants of health during primary care can lead to the receipt of more community resources for families.

Epidemiology of Infant Meningococcal Disease in

the United States, 2006-2012

Meningococcal disease is a serious but rare infectious disease. In 2012, the incidence of meningococcal disease was at a historic low in the United States; however, incidence remained highest among infants aged,1 year.

This report describes the epidemiology and burden of me-ningococcal disease in infants aged,1 year in the United States and potential risk factors for transmission to this vulnerable group. These data are key to informing future meningococcal disease vaccination strategies.

Development of Hospital-Based Guidelines for

Skeletal Survey in Young Children With Bruises

Bruising is common in young victims of physical abuse as well as in cases of accidental trauma. There is uncertainty

regarding which young children with bruising require evaluation with skeletal survey for possible abuse.

The results of this study provide guidelines, based on the literature and knowledge of experts, for identifying children

,24 months presenting for care in the hospital setting with bruises, who should and should not undergo skeletal survey.

Safety of Measles-Containing Vaccines in 1-Year-Old

Children

Measles-containing vaccines are associated with several types of adverse events. Because measles-mumps-rubella-varicella (MMRV) versus separate measles-mumps-rubella (MMR) and varicella (MMR + V) vaccine increases a toddler’s risk for fe-brile seizures, we investigated whether MMRV is riskier than MMR + V and whether either vaccine elevates risk for addi-tional safety outcomes.

Comparing MMRV with MMR + V, no increased risk of immune thrombocytopenia purpura, anaphylaxis, ataxia, arthritis, meningitis/encephalitis, acute disseminated encephalomyelitis, and Kawasaki disease was detected. No new safety concerns were identiﬁed after either vaccine, and most outcomes studied were unlikely after either vaccine.

Identifying Autism in a Brief Observation

Behavioral observations inﬂuence a clinician’s decision to diagnose or refer, and may even override formal screening results. In the case of autism spectrum disorder, an expected rate of atypical behavior during the span of a medical visit is unknown.

We are theﬁrst to quantify the high base rates of typical behavior in young children who have autism and language delay. When observation times are brief, the preponderance of typical behaviors may negatively impact referral decision accuracy.

Paternal Depression in the Postnatal Period and

Child Development: Mediators and Moderators

Parental depression is associated with adverse child outcomes. It is important to understand possible mediators and mod-erators. Several studies suggest that the family environment or parenting style may be potential pathways for transmission of risk from parents to children.

Paternal depression appears to exert its inﬂuence on children’s outcomes through an effect on family functioning (couple conﬂict and maternal depression), whereas maternal post-natal depression appears to affect children through other mechanisms, potentially including direct mother-infant interaction and care.

ARTICLE SUMMARIES

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This is theﬁrst published study consistent with the 2007 Food and Drug Administration–recommended study design evaluating growth velocity in children aged 3–9 years with perennial allergic rhinitis treated with triamcinolone acetonide or placebo for 12 months.

Oropharyngeal Colostrum Administration in

Extremely Premature Infants: An RCT

Immune-related bioactive proteins are highly concentrated in the colostrum of mothers who deliver preterm infants. Oropharyngeal administration was proposed as a safe and feasible alternative method of providing colostrum to immu-nocompromised premature infants.

Oropharyngeally administered colostrum during theﬁrst few days of life increased urinary secretory immunoglobulin A and lactoferrin, decreased urinary interleukin-1b, reduced salivary transforming growth factor-b1 and interleukin-8, and reduced the occurrence of clinical sepsis in extremely premature infants.

Sleep Duration, Restfulness, and Screens in the

Sleep Environment

Inadequate sleep has been identiﬁed as a risk factor for obesity and other outcomes. Screen time and the presence of a tele-vision in the bedroom have been associated with inadequate sleep, but little is known about small screens (eg, smart-phones).

Among 2048 fourth- and seventh-graders, children who slept near a small screen reported shorter sleep durations and perceived insufﬁcient rest or sleep. Presence of a television in the bedroom and more screen time were also associated with poorer sleep.

Potential Effect of Physical Activity Calorie

Equivalent Labeling on Parent Fast Food Decisions

Menu labels depicting physical activity calorie equivalents may lead to ordering of fast food meals totaling fewer calories for adults. The effects of physical activity calorie equivalent labeling on parents’fast food decisions for their children have not been examined.

Parents shown menus with any type of caloric content label may order fast food meals totaling fewer calories for their children.

Increased central adrenergic activity occurs with opiate withdrawal. Clonidine is an effective drug as an adjunct to morphine in the treatment of neonatal abstinence syndrome. It is unclear whether clonidine is effective as single-drug therapy.

Clonidine, aa2-adrenergic agonist, seems to be as effective as

morphine when used as a single-drug therapy for neonatal abstinence syndrome. Its administration results in improve-ment in neurobehavioral performance.

Tapentadol Toxicity in Children

Tapentadol is used in the treatment of chronic pain, speciﬁcally diabetic neuropathy. It has known action on them-opioid re-ceptor leading to drowsiness and apneas. There is no pub-lished information on the effects of tapentadol in small children.

After an accidental overdose in a child, tapentadol may be expected to causem-opioid clinical effects similar to other opioids. While the opioid effects predominate sympathomi-metic effects are also seen. The risk of respiratory depression and dyspnea should be acknowledged.

Regional Variation in Antenatal Corticosteroid Use:

A Network-Level Quality Improvement Study

Application of antenatal corticosteroids to mothers before delivery is highly beneﬁcial to very low birth weight infants. Yet despite widespread quality improvement efforts, many eligible infants fail to receive this therapy.

We demonstrate improvement in antenatal corticosteroid use during the study period. However, signiﬁcant regional variation persists, which network-level quality improvement efforts might help eliminate.

Cardiovascular Risk Factors in Children After

Repeat Doses of Antenatal Glucocorticoids: An RCT

Administration of repeat doses of antenatal glucocorticoids to women at risk for preterm birth after an initial course reduces neonatal morbidity, without affecting rates of neurologic dis-ability in early childhood. However, data on long-term effects on cardiometabolic health are limited.

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Clinicians wishing to use repeat antenatal glucocorticoids can be reassured that the risk of future cardiometabolic disease from this therapy is low.

Family Hardships and Serum Cotinine in Children

With Asthma

Poverty is prevalent among children in the United States, and it has a clear association with negative health outcomes. Smoking and passive smoke exposure are both more common among socioeconomically disadvantaged populations and are asso-ciated with asthma morbidity.

Reported family hardships were common among children admitted for asthma or wheezing, and most were associated with detectable tobacco smoke exposure. The cumulative number of hardships was also associated with greater odds of tobacco smoke exposure.

Cognitive-Behavioral Counseling for Exclusive

Breastfeeding in Rural Pediatrics: A Cluster RCT

Exclusive breastfeeding until 6 months of an infant’s age is described as the safest, most powerful and cost-effective intervention to reduce infant morbidity and mortality glob-ally. In developing countries, only∼25% of infants are ex-clusively breastfed for 6 months.

We developed a psycho-educational intervention combining education with techniques of cognitive-behavioral therapy, integrated it into the routine work of community health workers, which increased the rate and duration of exclusive breastfeeding until 6 months of an infant’s age.

Variation in Rotavirus Vaccine Coverage by Provider

Location and Subsequent Disease Burden

Uptake of rotavirus vaccines has increased steadily since introduction. Despite their demonstrated impact, rotavirus vaccine coverage is lower than for other vaccines recommended in infancy and disease continues to occur.

We observed higher rotavirus detection rates among patients from provider locations with lower rotavirus vaccine coverage; providers who do not offer rotavirus vaccine to age-eligible children may create pockets of susceptible children that serve as reservoirs of ongoing disease transmission.

Cognitive Ability at Kindergarten Entry and

Socioeconomic Status

Previous research has established steep socioeconomic status gradients in children’s cognitive ability at kindergarten entry.

Few studies have had comprehensive data to examine the contribution of a wide range of risk and protective factors across early childhood to these gradients.

Family background, health, home learning, parenting, and early care and education factors explain over half the gaps in reading and math ability between US children in the lowest versus highest socioeconomic status quintiles, suggesting a need for comprehensive early interventions.

Changes in Body Mass Index Associated With Head

Start Participation

Head Start, a federally funded preschool program for low-income US children, has been reported to have beneﬁcial effects on developmental outcomes. The association of Head Start participation with changes in children’s BMI has not been examined.

Preschool-aged children with an unhealthy weight status who participated in Head Start had a signiﬁcantly healthier BMI by kindergarten entry age than comparison children in a primary care health system (both those receiving and those not re-ceiving Medicaid).

Sustained Lung In

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ation at Birth for Preterm

Infants: A Randomized Clinical Trial

Sustained lung inﬂation and positive end-expiratory pressure would permit lung recruitment immediately after birth, im-proving lung mechanics and reducing the need for respiratory support. Previous clinical studies in preterm infants provided promising results but have some limitations.

This randomized controlled study found that prophylactic sustained lung inﬂation and positive end-expiratory pressure in the delivery room decreased the need for mechanical ventilation in theﬁrst 72 hours of life in preterm infants at high risk of respiratory distress syndrome.

Talking With Parents About End-of-Life Decisions for

Their Children

Retrospective studies have shown that the majority of parents, independent of their country of origin, prefer a shared approach over a paternalistic approach or an informed approach when an end-of-life decision must be made for their children.

In actual conversations parents act in line with their preference for a shared approach. This behavior contrasts with the“some sharing”approach of physicians who carefully prepare parents for an end-of-life decision already being made by the medical team.

ARTICLE SUMMARIES

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OSAS managed nonsurgically.

A prospective, randomized controlled study of adenotonsillectomy for pediatric OSAS showed signiﬁcantly greater QoL and symptom improvements in children undergoing adenotonsillectomy than in the nonsurgical control arm. The extent of improvement was not appreciably inﬂuenced by baseline OSAS severity or obesity.

This large randomized clinical trial in adolescents with TBI is the only study to examine maintenance of treatment effects. Findings reveal that brief, online treatment may result in long-term improvements in child functioning, particularly among families of lower socioeconomic status.

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DOI: 10.1542/peds.digest1352

2015;135;D1

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