Pediatrics Digest

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Persistent Snoring in Preschool Children:

Predictors and Behavioral and Developmental

Correlates

Loud snoring, which spikes at∼2 to 3 years of age, has been associated with behavior problems in school-aged children in cross-sectional studies, but no longitudinal studies have quantiﬁed predictors and the behavioral impact of persistent snoring in preschool-aged children.

Persistent loud snoring, which occurs in 9% of children 2 to 3 years of age, is linked with behavior problems. Higher socio-economic status and a history of breastfeeding were associ-ated with lower rates of transient and persistent snoring in young children.

Neurologic Disorders Among Pediatric Deaths

Associated With the 2009 Pandemic In

ﬂ

uenza

The 2009 inﬂuenza A (H1N1) pandemic caused illness in all age groups, but children were disproportionately affected. Children with underlying neurologic disorders were at high risk of

in-ﬂuenza-related complications, including death.

This study provides theﬁrst detailed description of underlying neurologic disorders among children who died of inﬂuenza A (H1N1)pdm09 virus infection.

Comparison of Children Hospitalized With Seasonal

Versus Pandemic In

ﬂ

uenza A, 2004

–

2009

Although several studies have demonstrated increased morbidity and mortality with pH1N1 in children, others have found its

clinical course to be similar to seasonal inﬂuenza. Moreover, most studies were conducted at single centers, thus raising concerns about generalizability ofﬁndings.

This analysis provides national-level active hospital-based sur-veillance data comparing pH1N1 with 5 previous years of sea-sonal inﬂuenza A and demonstrates differences in risk factors and clinical presentation but not in ICU admission or mortality.

One-Year Outcomes of Prenatal Exposure to MDMA

and Other Recreational Drugs

3,4-Methylenedioxymetham-phetamine (MDMA, ecstasy) is a widely used recreational drug affecting the serotonergic system. Preclinical studies indicate learning/memory problems with fetal exposure. Human infant prenatal exposure was re-lated to alterations in gender ratio and poorer motor de-velopment at 4 months.

This is theﬁrst study documenting that heavier prenatal 3,4-methylenedioxymethamphetamine exposure predicts poorer infant mental and motor development at 12 months with sig-niﬁcant, persistent neurotoxic effects. Language and emotional regulation were unaffected.

Haemophilus in

ﬂ

uenzae

Type b Disease and Vaccine

Booster Dose Deferral, United States, 1998

–

2009

Since the introduction of effective vaccines in the United States, the incidence of invasive_{Haemophilus in}ﬂ_uenzaetype b (Hib) disease in children aged,5 years has decreased by 99%. In 2007, in response to limited vaccine supply, Hib booster doses were deferred for 18 months.

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Vitamin D is essential for bone health and for cardiovascular and immune function. In critically ill adults, vitamin D deﬁciency is common and associated with sepsis and with higher critical ill-ness severity. The inﬂuence on pediatric critical illness is unclear.

We found a high prevalence of vitamin D deﬁciency in critically ill children, which was associated with higher critical illness severity. Vitamin D deﬁciency was less common in younger patients, in non-Hispanic white patients, in patients admitted over the summer, and in children taking supplemental vitamin D, with increasing amounts being more protective.

The Association of Vitamin D Status With Pediatric

Critical Illness

Vitamin D is a pleiotropic hormone important for proper functioning of multiple organs. Adult critical care studies have suggested vitamin D as a modiﬁable risk factor. No studies have investigated the prevalence, risk factors, or role in pediatric critical illness.

This study provides evidence that the majority of critically ill children have vitamin D deficiency at the time of PICU ad-mission, and that lower levels are associated with hypocal-cemia, catecholamine administration, significantfluid bolus requirements, and longer PICU admissions.

Weight Status Among Adolescents in States That

Govern Competitive Food Nutrition Content

Policies that govern nutrition standards of foods and beverages sold outside of federal meal programs (“competitive foods”) have been associated with adolescent weight status in a small number of cross-sectional studies and pre-post analyses in individual states.

This longitudinal analysis of 6300 students in 40 states provides evidence that state competitive food laws are associated with lower within-student BMI change if laws contain strong language with speciﬁc standards and are consistent across grade levels.

Culturally Tailored, Family-Centered, Behavioral

Obesity Intervention for Latino-American

Preschool-aged Children

Childhood obesity is already prevalent by preschool age, particularly among Latinos. Parents have tremendous inﬂuence

with patterns suggesting the largest effect for obese children.

Effects of Systematic Screening and Detection of

Child Abuse in Emergency Departments

Systematic screening for child abuse of all children presenting at emergency departments might increase the detection rate of child abuse but studies to support this proposal are scarce.

Systematic screening for child abuse in emergency departments is effective in increasing the detection of suspected child abuse. Training emergency department staff and requiring screening legally at emergency departments increase the extent of screening.

Effect of Honey on Nocturnal Cough and Sleep

Quality: A Double-blind, Randomized,

Placebo-Controlled Study

Honey is recommended as a cough medication by the World Health Organization. To date, the efﬁcacy of this treatment has been shown in 2 studies: one tested only buckwheat honey and the other study was not blinded.

In a randomized controlled trial, we compared 3 types of honey versus placebo as a treatment of upper respiratory tract in-fection–associated cough. These types of honey were superior to placebo in alleviating cough.

Gender and Crime Victimization Modify

Neighborhood Effects on Adolescent Mental Health

Adolescents living in lower-poverty neighborhoods have better mental health than youth in high-poverty contexts, but it is unclear if associations are causal. Furthermore, it is unknown why some youth beneﬁt more than others from moving to more advantaged neighborhoods.

Using an experimental study that randomly assigned families to receive vouchers to move to lower-poverty neighborhoods, we found that recent violent crime victimization adversely modiﬁed the mental health effects of moving to better neighborhoods.

The Joint Commission Children

’

s Asthma Care

Quality Measures and Asthma Readmissions

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report compliance with 3 Children’s Asthma Care quality measures. High compliance with these measures should result in decreased admissions and emergency department visits.

Implementation of a standardized care process model for hospitalized asthmatic children resulted in high compliance with all 3 measures. Measures 1 and 2 did not provide an opportunity for improvement. Compliance with measure 3 resulted in signiﬁcant decreases in readmission.

The Impact of a Healthy Media Use Intervention on

Sleep in Preschool Children

Although observational studies have consistently reported an association between media use and child sleep problems, it is unclear whether the relationship is causal or if an intervention targeting healthy media use can improve sleep in preschool-aged children.

This study demonstrates that a healthy media use intervention can improve child sleep outcomes and adds evidence that the relationship between media and sleep in preschool-aged children is indeed causal in nature.

Cobedding and Recovery Time After Heel Lance in

Preterm Twins: Results of a Randomized Trial

Skin-to-skin contact with mothers and fathers has been as-sociated with lower pain reactivity and enhanced physiologic recovery after heel lance. The effect of skin-to-skin contact between preterm twins during cobedding on pain response has yet to be studied.

We demonstrate that cobedding signiﬁcantly diminished time to recovery in preterm twins after heel lance but did not lower pain reactivity.

Randomized Controlled Trial of an Immunization

Recall Intervention for Adolescents

Immunization recall systems have been found effective in in-creasing immunization rates in younger children and adults; however, there have been only a few studies in adolescents and they have produced mixed results.

In this randomized controlled trial, immunization rates were signiﬁcantly higher 4 weeks after a recall intervention in which both the adolescent’s parents and the adolescent were contacted, but this effect did not persist 1 year after the intervention.

Pro

ﬁ

ciency and Retention of Neonatal

Resuscitation Skills by Pediatric Residents

Skills learned in standardized courses are estimated to last only a few months. Neonatal Resuscitation Program certiﬁcation

is mandatory for all pediatric residents and is valid for 2 years. Exact timing of when proﬁciency is lost is unknown.

Neonatal Resuscitation Program skills deteriorate immediately after certification, whereas knowledge is better retained. Significant skill deficits were seen at baseline raising concerns regarding the efficacy of the current course structure. Dis-crepancies in knowledge and skill retention may impact caregiver performance.

Neonatal Hyperbilirubinemia in the

Low-Intermediate

–

Risk Category on the Bilirubin

Nomogram

The higher the predischarge bilirubin percentile reading on the hour of life–speciﬁc nomogram, the higher becomes that infant’s risk of developing signiﬁcant hyperbilirubinemia. Neonates in the low-risk zones (#75th percentile) have a low risk of developing hyperbilirubinemia.

Thirty-two percent of newborns readmitted for hybilirubinemia had low-risk zone predischarge bilirubin per-centile values, predominantly in the intermediate low-risk zone (41st–75th percentile). The intermediate low-risk zone may not be as low risk as previously thought.

Long-term Differences in Language and Cognitive

Function After Childhood Exposure to Anesthesia

Immature animals exposed to anesthetics display apoptotic neurodegeneration and long-term cognitive deﬁciencies. In children, studies of cognitive deﬁcits associated with anes-thesia exposure have yielded mixed results. No studies to date have used directly administered neuropsychological assess-ments as outcome measures.

This study examines the association between exposure to anesthesia in children under age 3 and deﬁcits at age 10 by using a battery of directly administered neuropsychological assessments, with deﬁcits found in language and abstract reasoning associated with exposure.

Lower Life Satisfaction Related to Materialism in

Children Frequently Exposed to Advertising

Materialism and life satisfaction are known to be associated with each other. Research among adults has shown that ma-terialism and life satisfaction negatively affect each other, leading to a downward spiral.

In contrast to research conducted among adults, no longitu-dinal effect of materialism on life satisfaction was found for 8-to 11-year-olds. However, life satisfaction did negatively affect materialism, but only for children who were frequently exposed to advertising.

ARTICLE SUMMARIES

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SEPTEMBER 2012

P E D I AT R I C S

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In children with bronchiolitis, we found several demographic, historical, and clinical factors that predicted the need for mechanical respiratory support including in utero smoke ex-posure. We also found a novel subgroup of children with bronchiolitis who have a rapid respiratory decline.

Unprovoked Status Epilepticus: The Prognosis for

Otherwise Normal Children With Focal Epilepsy

The outcome of status epilepticus in children depends on the etiology. In otherwise normal children who have$1 episodes of unprovoked status epilepticus as part of the evolution of their epilepsy, the seizure and intellectual outcome is unclear.

Based on population-based data and 20 to 30 years’follow-up of normal children with focal epilepsy, one-third with status epilepticus had recurrence of status. Reassuringly, in-telligence, seizure control, and rate of remission were not altered compared with those without status epilepticus.

An Evaluation of Mother-Centered Anticipatory

Guidance to Reduce Obesogenic Infant Feeding

Behaviors

Childhood obesity occurs in 20% of children before they enter kindergarten. Treatment is difﬁcult, making prevention desir-able, but little is known about effective methods using antic-ipatory guidance to prevent obesity in pediatric primary care.

This study provides a comparison of 2 approaches versus usual care using anticipatory guidance to improve infant feeding during theﬁrst year of life, and demonstrates positive speciﬁc feeding behavior differences at 1 year in the intervention groups.

Racial/Ethnic Differences in Infant Mortality

Attributable to Birth Defects by Gestational Age

Birth defects are associated with preterm birth and are a major contributor to infant mortality. There are persistent black-white differences in overall infant mortality and infant mortality attributable to birth defects (IMBD).

Among infants delivered at 37 to 44 weeks, blacks and Hispanics had signiﬁcantly higher IMBD than whites. Among infants de-livered at 20 to 33 or 34 to 36 weeks, neonatal mortality at-tributable to birth defects was signiﬁcantly lower among blacks.

A social gradient was found in childhood mental health according to maternal education level and social class, but none was found in HRQoL, although children from disadvan-taged social classes had somewhat lower HRQoL scores than their more advantaged counterparts.

Maternal Multiple Micronutrient Supplements and

Child Cognition: A Randomized Trial in Indonesia

Micronutrients are essential for brain development during gestation and infancy. Few randomized trials of maternal mul-tiple micronutrient supplementation during pregnancy and postpartum have examined child outcomes beyond the neonatal period or tested which cognitive domains show long-term effects.

Children of undernourished mothers given multiple micro-nutrients performed as well as children of well-nourished mothers in motor and visual attention/spatial ability at age 42 months; children of undernourished mothers given iron/folic acid showed 4- to 5-month delays in these abilities.

Effects of CPOE on Provider Cognitive Workload: A

Randomized Crossover Trial

Computerized provider order entry (CPOE) has been recognized to enhance the efﬁciency, safety, and quality of medical work. Yet vendors and organizations have not determined best practices for customizations, resulting in systems that have poor usability and unintended consequences of use.

This study demonstrated that systematically developed order sets reduce cognitive workload and order variation in the context of improved system usability and guideline adherence. The concept of cognitive workload reduction is novel in the setting of computer order entry.

Bone Mineral Density and Vitamin D Status Among

African American Children With Forearm Fractures

Forearm fractures are unique injuries which are associated with lower bone mineral density in adults and white children. The relationships among bone mineral density, 25-hydrox-yvitamin D status, and risk for forearm fracture have not been investigated in African American children.

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forearm fracture in African American children. Promotion of bone health is indicated in this population.

Randomized Trial of Vitamin D Supplementation and

Risk of Acute Respiratory Infection in Mongolia

A growing number of epidemiologic studies suggest that individuals with lower vitamin D levels are at higher risk of acute respiratory infection. Randomized controlled trials are needed to determine if vitamin D supplementation would de-crease this risk.

In a randomized controlled trial of 247 Mongolian children with vitamin D deﬁciency in winter, with double-blinding and 99% follow-up, vitamin D supplementation signiﬁcantly halved the risk of acute respiratory infections.

Risk Adjustment for Neonatal Surgery: A Method

for Comparison of In-Hospital Mortality

Evaluation of neonatal surgical outcomes is necessary to guide improvements in the quality of care. Meaningful comparisons must adjust for factors that alter outcomes independent of the surgical procedures.

Herein is described a method that permits risk adjustment for the broad range of noncardiac neonatal surgery, regardless of gestational age, to permit useful comparisons for quality im-provement.

Montelukast for Children With Obstructive Sleep

Apnea: A Double-blind, Placebo-Controlled Study

Children with obstructive sleep apnea (OSA) are usually treated by surgical removal of their upper airway lymphadenoid tissue. Recently, medications were offered to patients with nonsevere OSA. Montelukast, for this indication, had never been studied in a randomized controlled manner.

Montelukast effectively reduced polysomnographicfindings, symptoms, and the size of the adenoidal tissue in children with nonsevere OSA. Thefindings support the potential of a leuko-triene modifier as a novel, safe, noninvasive alternative for children with mild to moderate OSA.

Maternal HIV Infection and Vertical Transmission of

Pathogenic Bacteria

Neonatal sepsis is an important cause of under-5 childhood mortality. Infants born to HIV-infected mothers are at increased risk of morbidity and mortality, even if not having acquired HIV. This association needs further study during the neonatal period.

Maternal HIV infection was associated with increased vaginal colonization by_{Escherichia ecoli}but not group B_{Streptococcus.}

Neonates born to HIV-infected mothers were only at increased risk of sepsis if they had acquired infection, but not if HIV-uninfected.

Mortality and Clinical Outcomes in HIV-Infected

Children on Antiretroviral Therapy in Malawi,

Lesotho, and Swaziland

There is evidence from both developed and developing countries that antiretroviral treatment signiﬁcantly reduces mortality in HIV-infected children. However, in sub-Saharan Africa, numerous health system,ﬁnancial, and human resource obstacles make delivering quality pediatric HIV care a challenge.

We describe the experience of the Baylor International Pedi-atrics AIDS Initiative in Malawi, Lesotho, and Swaziland. Despite challenges delivering pediatric treatment in these countries, mortality and clinical outcomes approaching those from de-veloped countries are feasible.

Timing of Measles Immunization and Effective

Population Vaccine Coverage

Many children are vaccinated against measles with a delay. This may inﬂuence effective measles vaccine coverage even in countries with high overall immunization levels. Ofﬁcial vaccine coverage statistics do not usually report on the impact of timeliness of measles vaccination.

Delayed measles vaccination results in 48.6% effective coverage in children aged 6 months to 2 years when 84.5% of 25-month-olds are up-to-date for 1 measles vaccination. Analyzing pat-terns of measles vaccination could help to address low cov-erage in infants and toddlers.

Ef

ﬁ

cacy of Fat-Soluble Vitamin Supplementation in

Infants With Biliary Atresia

Cholestasis predisposes to the development of fat-soluble vi-tamin (FSV) deﬁciency. D-atocopheryl polyethylene glycol-1000 succinate and coadministered FSVs are absorbed in spite of cholestasis.

Infants with biliary atresia with total bilirubin.2 mg/dL are at risk for fat-soluble vitamin (FSV) deﬁciency. A multivitamin preparation containing d-a tocopheryl polyethylene glycol-1000 succinate alone is not effective in treating biochemical FSV insufﬁciency in cholestatic infants.

Pediatric-Speci

ﬁ

c Antimicrobial Susceptibility Data

and Empiric Antibiotic Selection

Ideal empirical antibiotic choices are based on local suscep-tibility data. These choices are important for ensuring positive

ARTICLE SUMMARIES

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SEPTEMBER 2012

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Thrombocytopenia in the First 24 Hours After Birth

and Incidence of Patent Ductus Arteriosus

To date, 4 small to moderate sized studies have revealed conﬂicting results on the clinically important question whether thrombocytopenia contributes to persistent patent ductus arteriosus (PDA) in very immature, preterm infants.

Thrombocytopenia in theﬁrst 24 hours after birth was not associated with the incidence of PDA at postnatal day of life 4 to

Early life nutrition may program pubertal timing. Limited evi-dence suggests breastfeeding is associated with later puberty and childhood milk consumption with earlier puberty; whether these observations are biologically mediated or confounded by socioeconomic position is unclear.

In a developed non-Western setting with little socioeconomic patterning of pubertal timing, neither breastfeeding nor child-hood milk consumption was associated with pubertal timing, suggesting nutritional exposures during potentially critical periods may not have long-term effects on rates of maturation.

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DOI: 10.1542/peds.digest1303

2012;130;D1

Pediatrics

Pediatrics Digest

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