Pediatrics Digest

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Bacteremia Risk and Outpatient Management of

Febrile Patients With Sickle Cell Disease

Before the introduction of conjugate pneumococcal vaccines and routine penicillin prophylaxis, febrile patients with sickle cell disease were known to have a 3% to 5% risk of bacteremia. Consequently, hospitalization rates for febrile episodes are.70%.

We observed no mortality or morbidity among those managed completely as outpatients, and bacteremia occurred in,1%. Physicians should strongly consider outpatient management of febrile children with sickle cell disease if there are no other indications for admission.

Intussusception After Rotavirus Vaccines Reported

to US VAERS, 2006

–

2012

A low-level risk of intussusception after rotavirus vaccines,∼1 to 2 cases per 100 000 vaccinees, exists in some settings. In the United States, a risk of 1 in 65 000 was excluded, but lower risk could exist.

A persistent clustering of intussusception events 3 to 6 days after dose 1 indicates the possibility of a low-level risk of in-tussusception of∼0.8 cases per 100 000 vaccinees. The documented beneﬁts of rotavirus vaccine far outweigh this low-level risk of intussusception.

Resource Utilization for Observation-Status Stays

at Children

’

s Hospitals

Hospitalizations under observation status are presumed to be shorter and less resource-intensive, but utilization for pediatric observation-status stays has not been studied.

Children’s hospitals use observation status with great varia-tion. Resource utilization for pediatric patients under obser-vation status overlaps substantially with inpatient-status utilization, calling into question the utility of segmenting pe-diatric patients according to billing status.

Effect of Early Limited Formula on Duration and

Exclusivity of Breastfeeding in At-Risk Infants: An

RCT

Public health policy focuses on reducing formula use for breastfed infants during the birth hospitalization. Observa-tional evidence supports this approach, but no previous studies have examined the effect of early use of small volumes of formula on eventual breastfeeding duration.

Use of limited volumes of formula during the birth hospitali-zation may improve breastfeeding duration for newborns with high early weight loss. Reducing the use of formula during the birth hospitalization could be detrimental for some sub-populations of healthy term newborns.

Prevalence of Use of Human Milk in US Advanced

Care Neonatal Units

The American Academy of Pediatrics recommends that all preterm infants receive human milk; however, little is known about the use of human milk in US advanced care neonatal units.

Routine use of human milk and use of donor milk in neonatal advanced care units increased from 2007 to 2011, particularly among units providing intensive care. There is geographic variation in the use of human milk in these units.

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resources. Little is known about pediatricians’awareness of the economics of health care delivery in the inpatient setting.

Both general pediatric attending physicians and trainees ac-knowledged a limited understanding of hospitalﬁnances, and they demonstrated a lack of awareness of costs, charges, and reimbursements for inpatient care.

Elevated Blood Lead Levels and Reading Readiness

at the Start of Kindergarten

Blood lead levels well below 10mg/dL are now recognized as causing adverse cognitive effects, including lower scores on standardized reading and math tests.

This is theﬁrst study to show that reading readiness early in kindergarten is independently associated with blood lead levels well below 10mg/dL. Results suggest that lead exposure may have a larger impact on urban education than national esti-mates suggest.

Current Status of Transition Preparation Among

Youth With Special Needs in the United States

The importance of transition from pediatric to adult health care for youth with special health care needs has gained increasing attention over the past decade, but fewer than half of this population received needed transition preparation in 2005– 2006.

This study reports on transitionﬁndings from the 2009–2010 National Survey of Children with Special Health Care Needs andﬁnds no discernible improvements since 2005–2006. New clinical recommendations and care processes should help to accelerate transition improvements in the future.

Race and Acute Abdominal Pain in a Pediatric

Emergency Department

Abdominal pain is a frequent complaint in pediatric emergency departments, with a broad differential diagnosis. The impact of demographic and clinical characteristics of patients on the evaluation and management of these children is not well known.

The most common cause of abdominal pain is constipation, which rarely requires hospital admission. Demographic fac-tors, in particular race, do not seem to affect evaluation and management.

pensive oral health treatment has not been well established.

Using an econometric method that accounts for time-invariant differences between children, and thus helps mitigate selection bias, we found a positive impact of preventive dental visits on oral health. However, there is less evidence regarding the cost-effectiveness of preventive visits.

Effectiveness of Decision Support for Families,

Clinicians, or Both on HPV Vaccine Receipt

Despite proven health beneﬁts, human papillomavirus (HPV) vaccination rates are among the lowest of all routine immu-nizations. No previous large-scale trial has compared the beneﬁt of automated decision support directed at clinicians, families, or both in any context.

We found that a clinician-focused intervention was most ef-fective for initiating the HPV vaccine series, whereas a family-focused intervention supported completion. Decision support directed at both clinicians and families most effectively pro-motes HPV vaccine series receipt.

Analysis of Pediatric Clinical Drug Trials for

Neuropsychiatric Conditions

Neuropsychiatric conditions comprise a substantial and growing disease burden among children. Pharmacotherapy represents an important treatment option for these conditions, although most drugs are not approved for use in children.

Very few drug trials studying neuropsychiatric conditions focus on children. Furthermore, these trials examine and provide pediatric evidence for only a fraction of all available drugs in the treatment of common neuropsychiatric conditions.

A Qualitative Study of the Day-to-Day Lives of Obese

Mexican-American Adolescent Females

Obesity is a growing concern for Mexican-American adoles-cents, with both behavioral and cultural variables that are related to the increasing trend.

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Pediatric Hydrocarbon-Related Injuries in the

United States: 2000

–

2009

Hydrocarbons are dangerous household products commonly found in homes with young children. Unintentional ingestion continues to be a problem despite existing prevention efforts. Aspiration is often associated with ingestion of hydrocarbons by children.

The National Poison Database System and National Electronic Injury Surveillance System data sets demonstrate similar rates of hydrocarbon-related injuries in children. Rates of hydro-carbon exposure were highest in summer. Gasoline was the product most associated with hydrocarbon injuries.

Malpractice Risk Among US Pediatricians

Despite evidence on how malpractice risk varies according to physician specialty, there is growing but still limited evidence about malpractice among US pediatricians. The frequency of malpractice claims against pediatricians is low among spe-cialties, but payments are among the highest.

This study describes malpractice risk among US pediatricians using data from a nationwide liability insurer covering 1630 pediatricians from 1991 to 2005. It compares pediatric mal-practice experience with other specialties and studies patient factors associated with pediatric malpractice claims.

Texting While Driving and Other Risky Motor Vehicle

Behaviors Among US High School Students

Distracted driving due to texting while driving (TWD) has emerged as an important teenage safety issue. Previous studies have shown that the self-reported prevalence of TWD among teenagers varies widely.

In 2011, 45% of US high school students aged$16 years reported TWD during the past 30 days. TWD was positively associated with other risky motor vehicle behaviors; this as-sociation strengthened as frequency of TWD increased.

Comparative Effectiveness of Acellular Versus

Whole-Cell Pertussis Vaccines in Teenagers

The United States switched from whole-cell to acellular per-tussis vaccines during the 1990s. Whether perper-tussis risk during a California outbreak differed between teenagers who pre-viously received whole-cell or acellular pertussis vaccines early in life has not been reported.

We evaluated pertussis risk in 10 to 17 year olds at Kaiser Per-manente Northern California during a recent pertussis outbreak. Those given whole-cell pertussis vaccines in childhood were more protected than those given acellular pertussis vaccines.

Pediatric Organ Donation and Transplantation

The gap between organ availability and need continues to grow, and infants are among the most vulnerable candidates on the wait-list. The scarcity of donor organs has led the transplant community to look for alternative donor sources.

Children are receiving more grafts from pediatric donors, but they also continue to receive adult donor grafts. Donation after circulatory determination of death increases organ availability. Allocation changes have also helped increase pediatric transplantation and decrease wait-list deaths.

Obesity in Men With Childhood ADHD: A 33-Year

Controlled, Prospective, Follow-up Study

Cross-sectional studies in children and adults have reported a signiﬁcant positive association between attention-deﬁcit/ hyperactivity disorder (ADHD) and obesity.

This controlled, prospective, follow-up study of boys with ADHD found signiﬁcantly higher BMI and obesity rates in adulthood, compared with men without childhood ADHD, regardless of socioeconomic status and other lifetime mental disorders.

RCT of Timolol Maleate Gel for Super

ﬁ

cial Infantile

Hemangiomas in 5- to 24-Week-Olds

The systemic nonselectiveb-blocker propranolol hydrochlo-ride is increasingly used asfirst-line management for infantile hemangiomas. Superficial nonulcerating lesions do not re-quire systemic medications. Case series have suggested the efficacy of timolol; however, its safety has been questioned.

This randomized controlled trial indicates that timolol maleate 0.5% gel is a well-tolerated, safe, and effective treatment of superﬁcial infantile hemangiomas.

Pregnancy Dose Tdap and Postpartum Cocooning

to Prevent Infant Pertussis: A Decision Analysis

Infants aged,2 months are at highest risk for pertussis morbidity and mortality but are too young to receive pertussis vaccines. To protect young infants, the Advisory Committee on Immunization Practices recommends mothers receive 1 dose of Tdap during pregnancy.

This article evaluates the effect of Tdap during pregnancy compared with postpartum Tdap and cocooning in preventing infant pertussis cases, hospitalizations, and deaths, as well as their relative cost-effectiveness.

Accuracy of Point-of-Care Ultrasound for Diagnosis

of Skull Fractures in Children

Head injuries and concern for skull fracture are common in pediatrics. Point-of-care ultrasound is an imaging tool that can

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Usefulness of Routine Head Ultrasound Scans

Before Surgery for Congenital Heart Disease

Routine head ultrasound scans (HUSs) are frequently per-formed in the preoperative evaluation of the infants with congenital heart disease, and brain MRI is being increasingly used in the research setting. The utility of HUSs in this pop-ulation has not yet been established.

This is theﬁrst study to prospectively evaluate the utility of routine HUSs compared with MRIs in asymptomatic newborns and young infants undergoing cardiac surgery. Ourﬁndings suggest that routine HUS is not indicated in asymptomatic term or near-term neonates undergoing surgery for CHD.

Factors Affecting Caregivers

’

Use of Antibiotics

Available Without a Prescription in Peru

Self-medication with antibiotics available without pre-scription is among the main causes of antibiotic misuse in the developing world and is associated with antibiotic re-sistance. Inappropriate antibiotic prescription is common in children. Patient expectations seem to inﬂuence physicians’ advice.

This study demonstrates that even in places where antibiotics are unregulated, improving physician prescribing habits could reduce irrational use overall and also future caregiver-driven misuse. Physician training in adequate antibiotic prescription could be a cost-effective intervention in these settings.

Health of Children Classi

ﬁ

ed as Underweight by

CDC Reference but Normal by WHO Standard

Many US children aged 6 to 24 months who would be classiﬁed as low weight-for-age by the Centers for Disease Control and Prevention 2000 reference will be classiﬁed as normal weight-for-age by the World Health Organization 2006 standard.

Children who will be reclassiﬁed from low to normal weight-for-age using the World Health Organization growth standard are at higher risk of adverse health outcomes than children who are not low weight-for-age by the Centers for Disease Control and Prevention reference.

The positive effects of FITNET were maintained at long-term follow-up (.2.5 years).Patients following usual-care treatment achieve similar recovery rates at long-term follow-up.

Trends in Hospitalization Rates and Severity of

Injuries From Abuse in Young Children, 1997

–

2009

Child welfare data show declines in child physical abuse since the early 1990s, but analysis of national data from hospitalized children in the Kids’Inpatient Database showed an increased incidence of serious physical abuse in children from 1997 to 2009.

We found no signiﬁcant change in hospitalization rates for injury from abuse in young children and increases in injury severity using the National Inpatient Sample from 1997 to 2009. This data helps provide a more complete perspective of the problem.

Oxygen Saturation Nomogram in Newborns

Screened for Critical Congenital Heart Disease

Universal oxygen saturation screening by pulse oximetry is now recommended for early detection of critical congenital heart disease. The distribution of saturations in asymptomatic newborns in a large population has not been described.

Our study is the largest to date to establish simultaneous pre-and postductal oxygen saturation nomograms in asymptomatic newborns at∼24 hours after birth. The mean postductal saturation is higher than preductal during this time.

Safety and Utilization of In

ﬂ

uenza Immunization in

Children With In

ﬂ

ammatory Bowel Disease

Yearly influenza immunization is recommended in patients with inflammatory bowel disease (IBD). However, concern regarding vaccine-related adverse events may limit uptake, and case reports in the literature detail diseaseflares after immuni-zation.

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Weight Gain in Infancy and Vascular Risk Factors in

Later Childhood

Excessive weight gain over theﬁrst 18 months of life may have consequences for later body size. However, the relationship of weight gain in this period to atherogenic risk factors in later childhood is not well characterized.

Early postnatal weight gain from birth to 18 months is in-dependently associated with childhood overweight and obesity, excess central adiposity, and greater arterial wall thickness at age 8 years.

Paci

ﬁ

er Cleaning Practices and Risk of Allergy

Development

Infants with a diverse gut microbialﬂora are less likely to develop eczema and allergy.

Parental sucking of their infant’s paciﬁer is associated with a reduced risk of allergy development and an altered oral

ﬂora in their child. Transfer of oral microbes from parent to infant via the paciﬁer might be used in primary prevention.

Honey Paci

ﬁ

er Use Among an Indigent Pediatric

Population

Botulinum spores are ubiquitous, found in the soil of most countries worldwide, and also in honey. It is well established that ingestion of honey by children aged,1 year can lead to infant botulism.

This study examines the prevalence of honey paciﬁer use among a pediatric population aged,1 year. We also assessed parental knowledge of the dangers of giving honey to children in this age group.

Etiology of Ethnic Differences in Childhood

Spirometry

There are ethnic differences in lung function, with white people generally having higher values of FVC and FEV1than people of

South Asian origin, whereas differences in forced expiratoryﬂows are absent or less marked. The underlying reasons are unknown.

Lung function differences were not explained by cultural, so-cioeconomic, or perinatal factors, nor by environmental exposures or wheezing illness. This suggests that genetic factors are responsible, and supports the use of ethnicity-speciﬁc prediction equations for children of South Asian origin.

Disparities in Disability After Traumatic Brain Injury

Among Hispanic Children and Adolescents

Previous studies report Hispanic adults have lower access to rehabilitation services, especially among those who only speak

Spanish, and higher disability after traumatic brain injury (TBI) compared with non-Hispanic white subjects. No studies have examined disparities in disability after TBI for Hispanic chil-dren.

Hispanic children experience disparities in long-term dis-ability after TBI. Compared with non-Hispanic white children, Hispanic children report signiﬁcantly larger reductions in health-related quality of life, participation in activities, and ability to communicate and care for themselves 3 years after injury.

Inconsolable Infant Crying and Maternal

Postpartum Depressive Symptoms

Studies reveal that mothers of infants with colic (deﬁned by Wessel’s criteria of.3 hours per day of distress) are more likely to develop depression. No studies have examined whether the consolability of infant crying predicts maternal depression risk.

Prolonged inconsolable infant crying has a stronger associa-tion with maternal depressive symptoms than overall daily duration of fussing and crying, suggesting that a mother’s report of inability to soothe her infant may be a powerful indicator of her depression risk.

Use of Antihypotensive Therapies in Extremely

Preterm Infants

Extremely preterm infants who receive antihypotensive therapy have worse outcomes than untreated infants. The reasons for this are not clear. High-quality randomized trials have not been performed to date because of logistical challenges, thereby necessitating alternative methods of investigation.

Antihypotensive therapy administration was not associated with improved in-hospital outcomes for any of the 15 deﬁnitions of low blood pressure investigated. Alternative methods of deciding who to treat are needed to maximize patient beneﬁt and minimize harm.

Genetic and Environmental In

ﬂ

uences on Daytime

and Nighttime Sleep Duration in Early Childhood

Sleep patterns of adult monozygotic twins are more similar than those of dizygotic twins, showing moderate heritability and little effects of environmental inﬂuences. There have been very few genetically informative studies of sleep in preschool children and results appear inconsistent.

From previous studies, we investigated daytime and nighttime continuous sleep duration longitudinally. This is theﬁrst time that the etiologies of daytime and nighttime continuous sleep duration trajectories were studied in early childhood.

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This retrospective multicenter study revealed the long-term effects of sapropterin on metabolic control, dietary tolerance, and the outcome of BH4-responsive phenylketonuria patients harboring speciﬁc phenotypes and genotypes. It also conﬁrmed that the minor adverse events disappeared by lowering the dose.

Although our population is mostly religious, we observed a decline in maximal intensive care along with increasing redirection of care over a decade. Changes in the team ap-proach and increasing level of parental involvement inﬂuence type and duration of treatment.

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DOI: 10.1542/peds.digest1316

2013;131;D1

Pediatrics

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