Pediatrics Digest

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Management of Febrile Neonates in US Pediatric

Emergency Departments

Recommended management of febrile neonates (#28 days) includes blood, urine, and cerebrospinalﬂuid cultures with hospital admission for antibiotic therapy. No study has reported adherence to standard recommendations in the management of febrile neonates in US pediatric emergency departments.

There is wide variation in adherence to recommended man-agement of febrile neonates. High rates of serious infections in admitted patients but low return rates for missed infections in discharged patients suggest additional studies needed to understand variation from current recommendations.

2010 Perinatal GBS Prevention Guideline and

Resource Utilization

An algorithm for neonatal early-onset sepsis risk based on Centers for Disease Control and Prevention 2002 guidelines for prevention of perinatal Group B_{Streptococcus}disease results in the evaluation of∼12–15% of well-appearing term and late preterm infants.

A revised algorithm based on the Centers for Disease Control and Prevention 2010 guidelines eliminated 25% of all early-onset sepsis evaluations and resulted in signiﬁcant cost sav-ings, without short-term evidence of harm.

Antidepressants and Suicide Attempts in Children

Warnings of increased risk for suicidality have been placed on antidepressant medications. Because antidepressants differ in

their characteristics, including effects on neurotransmitters, it is possible that the risk of suicidal behavior for individual medications may differ.

In a cohort of 36 842 children with review of medical records for conﬁrmation of suicide attempts, we found no difference for risk of suicide attempts among individual medications compared withﬂuoxetine, the currently recommended anti-depressant for treatment of depression.

Usefulness of Symptoms to Screen for Celiac

Disease

Celiac disease (CD) often goes undiagnosed. Current guidelines suggest intensified active case-finding, with liberal testing of children with CD-associated symptoms and/or conditions. However, methods for alsofinding undiagnosed CD cases in the general population should be explored and evaluated. In a population-based CD screening, information on CD-asso-ciated symptoms and conditions, obtained before knowledge of CD status, was not useful in discriminating undiagnosed CD cases from non-CD children. The majority of screening-detected CD cases had no CD-associated symptoms or conditions.

Hospitalizations Due to Firearm Injuries in Children

and Adolescents

Firearm injuries are the second leading cause of death among American children. Previous estimates of nonfatal injuries have relied on small samples of emergency department visits and do not allow a detailed understanding of these injuries among children and adolescents.

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Trisomy 13 or Trisomy 18

Infants with trisomy 13 (T13) or trisomy 18 (T18) are known to have poor survival. Little is known about how very low birth weight (VLBW) impacts survival and morbidities among infants with T13 or T18.

We examined the risks of mortality and neonatal morbidities for VLBW infants with T13 or T18 compared with VLBW infants with trisomy 21 and VLBW infants without birth defects in a 16-year cohort from the Neonatal Research Network.

Changes in the Incidence of Candidiasis in Neonatal

Intensive Care Units

The incidence of invasive candidiasis in hospitalized infants is related to postnatal exposures, but large-scale studies relating the incidence of invasive candidiasis to changes in exposures over time are not available.

This study describes the association between the incidence of invasive candidiasis and changes in use of antifungal pro-phylaxis, empirical antifungal therapy, and broad-spectrum antibacterial antibiotics over time.

Cost-effectiveness Analysis of the National

Perinatal Hepatitis B Prevention Program

Infant postexposure prophylaxis prevents perinatal hepatitis B (HepB) virus transmission and mortality and morbidity caused by chronic HepB virus infection. The US Perinatal Hepatitis B Prevention Program (PHBPP) identiﬁes and manages infants born to HepB surface antigen–positive women.

It presents theﬁrst estimates of the long-term costs and outcomes of postexposure prophylaxis with the PHBPP. It analyzes the effects of the PHBPP, and alternative immunization scenarios, on health and economic outcomes for the 2009 US birth cohort.

Emergency Department Visits Resulting From

Intentional Injury In and Out of School

Injuries sustained by children in the school setting have a signiﬁcant public health impact. A concerning subgroup of school injuries are due to intentional and violent etiologies. Several studies have identiﬁed a need for further research to understand intentional school-based injuries.

Age-appropriate child safety seat use in the United States is suboptimal, particularly among children older than 1 year. Minority children have higher rates of inappropriate child safety seat use based on observational studies. Explan-ations for observed differences include socioeconomic factors.

White parents reported greater use of age-appropriate child safety seats for 1- to 7-year-old children than nonwhite parents. Race remained a signiﬁcant predictor of age-appropriate re-straint use after adjusting for parental education, family in-come, and information sources.

Shoulder Injuries Among US High School Athletes,

2005/2006

–

2011/2012

Shoulder injuries are common among high school athletes. These injuries, both traumatic and overuse, contribute to signiﬁcant time loss from athletic activity. Understanding sport-speciﬁc injury patterns is critical for development of targeted injury prevention programs.

This study is the most comprehensive analysis of high school shoulder injuries to date, providing national injury estimates while examining injury rates, diagnoses, severity, and mech-anisms of injury in 9 interscholastic sports.

Variation in Quality of Tonsillectomy Perioperative

Care and Revisit Rates in Children

’

s Hospitals

Tonsillectomy is one of the most commonly performed sur-geries in children and is one of the most cumulatively expensive conditions in pediatric hospital care. Little is known about how the quality of tonsillectomy care varies across hospitals. In a large cohort of low-risk children undergoing same-day ton-sillectomy, there was substantial variation in quality measures of process, dexamethasone and antibiotic use, and outcome, revisits to the hospital within theﬁrst 30 days after surgery.

Xylitol Syrup for the Prevention of Acute Otitis Media

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Sexting and Sexual Behavior in At-Risk Adolescents

Sending sexual messages and/or pictures (sexting) has been associated with sexual intercourse among high school–age students.

This study is theﬁrst to examine sexting’s prevalence among at-risk middle school students and its associations with a range of sexual behaviors. It also examines differences in sexual risk between sending sexual messages and sexual photos.

Adherence to Label and Device Recommendations

for Over-the-Counter Pediatric Liquid Medications

Due to reports of unintentional overdoses, in 2011 the US Food and Drug Administrationﬁnalized voluntary recommendations for dosing devices included with over-the-counter (OTC) liquid medications. The Consumer Healthcare Products Association previously endorsed similar recommendations for devices and dosing directions.

This study assessed dosing directions and devices for national brand name OTC liquid medications, available after a voluntary FDA guidance, and found high levels of adherence to most recom-mendations. Further improvement efforts should prioritize rec-ommendations directly addressing potential dosing errors.

Association of Maternal Self-Medication and

Over-the-Counter Analgesics for Children

Self-medication with over-the-counter (OTC) analgesics, particu-larly paracetamol (PCM), among children is widespread and increasing. Parents often administer the medicine. The health care system has little knowledge or possibility to regulate OTC medication, and use of PCM for children may be partly unjustiﬁed.

Maternal frequent self-medication with OTC analgesics is as-sociated with frequent use of OTC analgesics, particularly PCM, among 6- to 11-year-old schoolchildren, even when the child’s frequency of pain is accounted for.

Effect of Cognitive Activity Level on Duration of

Post-Concussion Symptoms

Cognitive rest is recommended for the management of sport-related concussions. There are limited data to support this recommendation.

This study adds empirical data supporting the recommendation for cognitive rest after a sport-related concussion.

Long-term Cardiovascular Outcomes in Survivors of

Kawasaki Disease

Kawasaki disease (KD) results in coronary aneurysm formation and an increased risk of cardiovascular complications. Modern

treatment of acute KD with intravenous immunoglobulin sub-stantially reduces the rate of acute aneurysm formation. This study reveals that long-term cardiovascular outcomes for KD patients in the current era are not signiﬁcantly different than matched controls without KD. Late cardiovascular com-plications are almost exclusively seen in patients with per-sistent coronary aneurysms.

Human Rhinovirus and Disease Severity in Children

Human rhinovirus has been known as the common cold agent. Recently, studies have reported that this virus is responsible for severe infections of the lower respiratory tract in children. Reports of factors that increase disease severity have been contradictory.

This study identiﬁes some of the factors involved in disease severity in HRV infections in children. We expect that children at risk for developing severe disease could be identiﬁed sooner and appropriate measures could be taken.

Risk Factors and Outcomes for Multidrug-Resistant

Gram-Negative Bacteremia in the NICU

There is a perception that Gram-negative bacilli (GNB) blood-stream infection is increasing in the NICU, and those infections caused by a multidrug-resistant (MDR) strain are a growing threat to hospitalized patients.

Exposure to broad-spectrum antibiotics is the most important risk factor for MDR GNB bacteremia, which is associated with higher mortality. Neonates with risk factors for bacteremia caused by a MDR GNB strain may beneﬁt from empirical an-timicrobial therapy with carbapenem.

Diagnostic Performance of BMI Percentiles to

Identify Adolescents With Metabolic Syndrome

The Centers for Disease Control and FITNESSGRAM BMI per-centile thresholds are commonly used for obesity screening in youth. It is assumed that these thresholds are predictive of metabolic health risk, but little diagnostic data are available. Both thresholds are predictive of metabolic syndrome, more so for boys than for girls, although with differing sensitivity and spec-iﬁcity. The diagnostic details of the thresholds can inform clini-cians and practitioners about how these standards perform in practice.

Preterm Infant

’

s Early Crying Associated With

Child

’

s Behavioral Problems and Parents

’

Stress

Preterm infants are at an increased risk of regulatory difﬁ -culties during infancy and of behavioral problems in childhood.

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Preventing Early Infant Sleep and Crying Problems

and Postnatal Depression: A Randomized Trial

Infant sleep and crying problems are common and associated with postnatal depression. No programs aiming to prevent all 3 issues have been rigorously evaluated.

A prevention program targeting these issues improves care-giver mental health, behaviors, and cognitions around infant sleep. Implementation at a population level may be best re-stricted to infants who are frequent feeders because they experience fewer crying and daytime sleep problems.

Cotinine in Children Admitted for Asthma and

Readmission

Serum and salivary cotinine have previously been identiﬁed as reliable biomarkers for exposure to tobacco smoke.

We found that detectable serum and salivary cotinine is common among children admitted for asthma and is associ-ated with readmission. Thisﬁnding may inform clinical care for children at increased risk of asthma morbidity.

Diagnostic and Prognostic Value of Procalcitonin

and C-Reactive Protein in Malnourished Children

Biomarkers such as C-reactive protein (CRP) and procalcitonin are elevated in children with severe bacterial infections. Children with severe malnutrition are at increased risk of bacterial infections and early markers for the diagnosis of infection in these children are needed.

Despite elevated values in severely malnourished children with invasive bacterial infection or infectious diarrhea, CRP and procalcitonin have limited diagnostic value. CRP could predict death in these children with a good negative predictive value.

School-Based Health Promotion and Physical

Activity During and After School Hours

The effects of previous school-based physical activity promotion interventions have been modest, and none have demonstrated signiﬁcant or meaningful increases in children’s physical ac-tivity outside of school, a period characterized by dispropor-tionally low levels of physical activity in youth.

Preterm Infants: A Randomized Controlled Trial

In preterm infants receiving supplemental oxygen, manual control of the inspired oxygen fraction is often difﬁcult and time consuming, which may increase the risk of complications. We developed a system for automatic oxygen control and proved its efﬁcacy in the past.

A multicenter study adds evidence for the proposed automatic oxygen control system to signiﬁcantly improve oxygen admin-istration to preterm infants receiving mechanical ventilation or nasal continuous positive airway pressure while reducing workload compared with routine manual oxygen control.

Uppsala Longitudinal Study of Childhood Obesity:

Protocol Description

Childhood obesity poses a serious threat to human health. Obesity is caused by genetic and environmental factors and linked to type 2 diabetes and cardiovascular disease. Pediatric obesity cohorts aim at understanding early events in the pathophysiology of obesity-related complications.

Cohort subjects are examined at consecutive visits, including measurements of glucose tolerance and hormones regulating nutrient handling (enhanced glucose tolerance tests) and body composition (MRI and bioimpedance). Mechanisms causing obese children to progress to type 2 diabetes are delineated.

Sibship Size, Sibling Cognitive Sensitivity, and

Children

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s Receptive Vocabulary

Sibship size has been negatively associated with children’s language, cognitive, and academic outcomes. This phenome-non is often explained in terms of resource dilution, wherein more children in the home is associated with fewer parental resources allocated to each child.

The current study identifies a moderator of this relationship. Specifically, if children’s next-in-age older siblings exhibit high levels of cognitive sensitivity then sibship size is not signifi -cantly related to children’s vocabulary.

Patient Health Questionnaire for School-Based

Depression Screening Among Chinese Adolescents

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has examined the psychometric properties of the PHQ-9 among Chinese adolescents in school settings.

This is theﬁrst study to validate the use of the PHQ-9, Patient Health Questionnaire–2 item, and Patient Health

Questionnaire–1 item among Chinese adolescents in Tai-wan. The PHQ-9 and its 2 subscales have good sensitivity and speciﬁcity for detecting depression among school adolescents.

See the table of contents of this issue to learn more about these articles.

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