Clinical Pediatrics recent issues

Peripheral Difficult Venous Access in Children

Rauch, D., Dowd, D., Eldridge, D., Mace, S., Schears, G., Yen, K. — Mon, 19 Oct 2009 15:00:15 PDT

Moderate and Severe Microcytic Anemia in the Emergency Department: Indicators of Care

Mekky, M., Jasuja, M., Parkin, P. C. — Mon, 19 Oct 2009 15:00:15 PDT

Obesity and the Built Environment Among Massachusetts Children

Oreskovic, N. M., Winickoff, J. P., Kuhlthau, K. A., Romm, D., Perrin, J. M. — Thu, 01 Nov 1951 00:00:00 PST

Background: The built environment may influence weight status. Method: Using cross-sectional data for children aged 2 to 18 years, the authors linked clinical and spatial data using geographic information systems and analyzed for associations between body mass index (BMI) and density of and distance to nearest built environment variable (schools, sidewalks, subway stations, bicycle trails, open space, and fast-food restaurants) using bivariate and multilevel analyses. Results: The study sampled 21 008 children; 54% were white, 26% Hispanic, 37% overweight, and 20% obese. In bivariate analysis, distance to nearest fast-food restaurant was inversely associated with BMI, whereas density of fast-food restaurants was positively associated with BMI. Distance to school and subway station, amount of open space, and density of subway stations were inversely associated with BMI. Controlling for sociodemographic factors, only living near a greater density of subway stations was inversely associated with overweight (odds ratio, 0.87; 95% confidence interval, 0.81-0.94) and obesity (odds ratio, 0.90; 95% confidence interval, 0.82-0.99). Conclusion: Distance to nearest subway station is associated with BMI among Massachusetts children.

The Impact of Bittering Agents on Pediatric Ingestions of Antifreeze

Mon, 19 Oct 2009 15:00:15 PDT

Background. Legislation requiring bittering of antifreeze enables assessment of the impact on frequency, volume, and severity of pediatric antifreeze ingestions. Methods. US poison control data for antifreeze ingestions in children younger than 5 years were analyzed comparing 232 ingestions occurring in states after enactment of bittering requirements with 6218 cases occurring in states (or at times) where bittering was not required. Results. The frequency of pediatric antifreeze ingestions was unchanged after implementation of bittering in Oregon and California. The medical outcome distribution, median volume ingested, and observed clinical effects were no different in bittered compared with nonbittered groups. Likewise, the rates of hospital admission, critical care treatment, and use of alkalinization, hemodialysis, or intubation showed no differences with bittering. Conclusion. Despite the appealing logic of limiting the ingested volume and thereby the severity of poisonings by adding aversive agents, and despite promising results in volunteer studies, bittering agents do not decrease the frequency or severity of pediatric antifreeze poisonings. The addition of bittering agents to household products cannot be justified based on actual poisoning data.

Comparison of Short-Term Outcomes of Late Preterm Singletons and Multiple Births: An Institutional Experience

Vachharajani, A. J., Vachharajani, N. A., Dawson, J. G. — Mon, 19 Oct 2009 15:00:15 PDT

We compare 4 short-term outcomes—namely admission to special care nursery (SCN), length of stay (LOS), age at full feeds (AFF) and respiratory morbidity/need for ventilation—in 1015 late preterm singletons and 366 twins and triplets born at our institution over a 4-year period. Birth weight (BW) and gestational age (GA) rather than plurality of birth determined need for admission to SCN, LOS, AFF, and need for respiratory support. When matched for GA, compared to singletons, twins and triplets needed less admission to SCN and respiratory support at 36 weeks, whereas at 34 weeks, they had longer LOS and took longer to get to full feeds. We conclude that the outcomes of interest are affected by GA and BW rather than plurality.

Prevalence and Severity of Hypertensive Retinopathy in Children

Foster, B. J., Ali, H., Mamber, S., Polomeno, R. C., Mackie, A. S. — Mon, 19 Oct 2009 15:00:15 PDT

The National High Blood Pressure Education Program (NHBPEP) report recommends a retinal exam seeking evidence of target organ damage in hypertensive children. This study aimed to determine the prevalence and severity of hypertensive retinopathy among hypertensive children, evaluated by pediatric ophthalmologists in the "real world" clinical setting using direct ophthalmoscopy. The authors retrospectively reviewed the medical records of the 83 children diagnosed with hypertension by a pediatric nephrologist between 1999 and 2006. Of the 35 children examined by an ophthalmologist within 12 months of the diagnosis of hypertension, only 3 (8.6%; 95% CI, 1.8%-23.1%) were diagnosed with hypertensive retinopathy. Despite the fact that those selected for retinal examination were likely at higher risk for retinopathy, the prevalence of retinopathy was low, and only mild abnormalities were detected. Given the lack of evidence linking mild retinal abnormalities with adverse outcomes, the NHBPEP recommendation for retinal examinations in hypertensive children should be reconsidered.

Health Supervision Visits of Very Young Children: Time Addressing 3 Key Topics

Mon, 19 Oct 2009 15:00:15 PDT

Objective. To describe the time and actions on 3 key health topics during health supervision (HS) visits of children aged 0 to 1 years. Method. HS visits were observed at 5 offices. Parents provided demographics and children’s measurements were obtained. Using special computer software, visits were observed for frequency and time for growth measurements, charting and interpretations, and for discussions on growth, diet, and safety. Results. A total of 128 visits were analyzed. Almost all children had weight (100%) and height (98%) measured and >80% had weight-for-age and height-for-age plotted. Growth interpretation (weight-for-height) was determined for 1 child. Nearly all visits included discussions of growth (88%), diet (97%), and safety (84%). When a topic was addressed, median times were as follows: growth, 9 seconds; diet, 42 seconds; and safety, 22 seconds. Median time on all 3 topics was 86 seconds. Conclusion. Growth, diet, and safety are frequently, but briefly, discussed at HS visits of young children.

Inadequate Training in Billing and Coding as Perceived by Recent Pediatric Graduates

Andreae, M. C., Dunham, K., Freed, G. L. — Mon, 19 Oct 2009 15:00:15 PDT

Introduction. The literature supports a high rate of error in physician coding for professional services, suggesting that residency training in this area is inadequate to meet the needs in clinical practice. Method. From the American Board of Pediatrics database of recent graduates, 1200 generalists and 1100 subspecialists were selected to receive a structured questionnaire. Participants rated the adequacy of their training in billing and coding using 3 choices. Results. The response rate was 76% among the generalists and 77% among the subspecialists. Eighty-one percent of generalists (N = 549) and 78% (N = 423) of subspecialists indicated that they could have used additional training in billing and coding. This finding was common throughout all practice settings. Conclusions. Pediatric residency training programs are not meeting the needs of generalist or subspecialist physicians in training of billing and coding. Residency programs must enhance this training component to prepare physicians to maintain a financially viable practice.

Effect of Oral Sodium Cromoglycate in 2 Children With Food-Dependent Exercise-Induced Anaphylaxis (FDEIA)

Mon, 19 Oct 2009 15:00:15 PDT

Food-dependent exercise-induced anaphylaxis (FDEIA) was prevented from recurring in 2 children by sodium cromoglycate (SCG) before intake of the causative food. Case 1: A 14-year-old girl who had suffered recurrent symptoms of anaphylaxis when she exercised after lunch. Radioallergosorbent test (RAST) was 1.49 UA/mL for wheat. She was advised to take SCG before lunch. In 2007, she ate bread at lunchtime without taking SCG and developed anaphylaxis. After this, she always took SCG and did not develop anaphylaxis. Case 2: A 9-year-old boy who had recurrent symptoms of anaphylaxis when he exercised after lunch. RAST was 0.46 UA/mL for wheat. He started taking SCG before lunch. In June 2008, he forgot to take SCG and ate fu (a food made from wheat). He exercised after lunch and developed anaphylaxis. Since then, he has always taken SCG and has not developed anaphylaxis. Conclusion: Our findings suggest that SCG prevents FDEIA caused by wheat allergy.

Behavioral Treatment of Trichotillomania and Trichophagia in a 29-Month-Old Girl

Rahman, O., Toufexis, M., Murphy, T. K., Storch, E. A. — Mon, 19 Oct 2009 15:00:15 PDT

Early childhood trichotillomania (TTM) has often been considered to be benign. However, untreated early childhood TTM can have significant negative physical and psychological consequences. This report describes the behavioral treatment of a 29-month-old girl with TTM. Treatment consisted of 14 daily sessions of behavioral intervention, followed by 3 consecutive days of follow-up treatment conducted 7 weeks after the end of initial treatment. The hair pulling was addressed by using reinforcers for not pulling, provided at intervals of increasing length. At the end of initial treatment, the hair pulling improved significantly. At follow-up, although some of the initial treatment gains were reduced, the patient maintained significant improvement compared with baseline.

Feasibility and Acceptability of a 1-Page Tool to Help Physicians Assess and Discuss Obesity With Parents of Preschoolers

Woolford, S. J., Clark, S. J., Ahmed, S., Davis, M. M. — Mon, 19 Oct 2009 15:00:14 PDT

Objective. To assess the feasibility and acceptability of a brief tool to help pediatricians communicate with parents of preschoolers about obesity risk, prevention, and treatment. Methods. The 2-sided Assessment and Targeted Messages (ATM) tool developed by the investigators included sections to assess nutrition and physical activity, self-efficacy and readiness-to-change, obesity-related family history, and treatment/prevention recommendations. Twenty-five pediatricians were recruited to use the ATM and then surveyed regarding their opinions of its feasibility and acceptability. Results. Response rate was 60%. Most ATM features were considered somewhat or very useful by the majority of respondents. The majority of physicians (62%) indicated that they were somewhat likely to use the ATM in the future, with only 23% indicating that they were very likely to use it. The greatest barrier to its use was time. Conclusion. Pediatricians considered the ATM tool moderately feasible and acceptable. Time-efficient methods to help physicians address obesity should be explored.

Clinical Investigation of Feeding Difficulties in Young Children: A Practical Approach

Kerzner, B. — Mon, 19 Oct 2009 15:00:15 PDT

Factors Associated With Completion of the Human Papillomavirus Vaccine Series

Mon, 19 Oct 2009 15:00:15 PDT

Surrogate Decision Making for the Previously Capable Minor

Rogers, C. G., Duhon, G. — Mon, 19 Oct 2009 15:00:15 PDT

An older-adolescent patient becomes incapable of making medical decisions due to the progression of his illness. The medical team members are faced with a conflict between what the law requires and their ethical convictions regarding who should be the surrogate decision maker. A discussion of relevant law and ethical standards is presented as it applies to similar situations.

Skin Lesions in a Neonate

Bafumi, T. R., Carroll, V. G. — Mon, 19 Oct 2009 15:00:15 PDT

Recurrent Bacterial Meningitis in a Child With Mondini Dysplasia

Liu, F.-C., Chen, P.-Y., Huang, F.-L., Lee, C.-Y., Lin, C.-F. — Mon, 19 Oct 2009 15:00:15 PDT

An Infant With Erythroderma, Skin Scaling, Chronic Emesis, and Intractable Diarrhea

Redding, A. R., Lew, D. B., Conley, M. E., Pivnick, E. K. — Mon, 19 Oct 2009 15:00:15 PDT

Storage of Cord Blood

Abell, S., Ey, J. L., Steele, R. — Mon, 19 Oct 2009 15:00:15 PDT

Have JumpDrive, Will Travel: Medical Lecturing in the Age of PowerPoint

Strasburger, V. C. — Thu, 17 Sep 2009 11:20:12 PDT

Vaccine Adherence in Adolescents

Lehmann, C., Benson, P. A. S. — Thu, 17 Sep 2009 11:20:13 PDT

Although a number of routine and catch-up vaccinations are currently recommended for adolescents, coverage rates of these vaccines are currently suboptimal. Routine recommended immunizations for this cohort include vaccines for influenza, human papillomavirus, and meningococcal disease, as well as a booster for tetanus, diphtheria, and acellular pertussis. Adolescence is also a critical period for administration of catch-up vaccines for those not fully immunized during childhood. Adolescents who do not seek appropriate preventive healthcare are at risk for significant morbidity and possible mortality. Increasing adolescent adherence to recommended vaccine schedules presents a challenge and opportunity for pediatricians and public health advocates. This article outlines barriers to vaccine compliance among adolescents and discusses strategies to increase vaccine uptake.

Obesity in Children Is Associated With Increased Health Care Use

Hering, E., Pritsker, I., Gonchar, L., Pillar, G. — Thu, 17 Sep 2009 11:20:13 PDT

Background: The prevalence of obesity in children has steadily risen during recent years in developed countries. There is increasing data associating this rise in obesity with a rise in morbidity. In adults, data show clear association between obesity and health care use. This study examined the effects of obesity on health care use in children of several age groups. Methods: The population consisted of children from Tirat HaCarmel, Israel, who are patients at the town’s Clalit Health Care, Child Care Center (CCC). All obese children (body mass index [BMI] > 95%) participated and were matched by age and gender with nonobese children (BMI < 85%) who served as a control group. Children were further divided into 3 age groups: ages 4 to 7 years, 8 to 11 years, and 12 to 18 years. Health care use was measured by 4 criteria over a 2-year time period: clinic visits, emergency department visits, hospitalizations, and medication use. Results: Of more than 4000 children treated in the CCC, 363 obese children were matched to 382 control children. Obese children had significantly more clinic visits (4942 vs 4058, P < .001), had more hospitalizations (67 vs 34, P < .001), were hospitalized for longer periods (207 vs 79 days, P < .001), and used significantly more medications (5945 vs 4638, P < .001) than did the control group. Conclusion: This study provides objective clinical evidence that obesity in children is associated with increased health care use. This information has clear implications for both the public health and health insurance sectors and supports the need to invest in efforts to reduce childhood obesity.

Safety of Propofol Sedation for Pediatric Outpatient Procedures

Thu, 17 Sep 2009 11:20:13 PDT

Propofol sedation is used more frequently in pediatric procedures because of its ability to provide varying sedation levels. The authors evaluated all outpatient pediatric procedures using propofol sedation over a 6-year period. All sedation was provided by pediatric intensivists at a single institution. In all, 4716 procedures were recorded during the study period; 15% of procedures were associated with minor complications, whereas only 0.1% of procedures were associated with major complications. Significantly more major complications associated with propofol occurred during bronchoscopy (P = .001). Propofol administered by a pediatric intensivist is a safe sedation technique in the pediatric outpatient setting.

A Longitudinal Study of Developmental and Behavioral Screening and Referral in North Carolina's Assuring Better Child Health and Development Participating Practices

Earls, M. F., Andrews, J. E., Hay, S. S. — Thu, 17 Sep 2009 11:20:13 PDT

Screening children for developmental and behavioral delays is an important part of primary care practice. Well-child visits provide an ideal opportunity to engage parents and to do periodic screening. Screening identifies children who may be at risk and need further evaluation. In North Carolina’s Assuring Better Child Health and Development project best-practices process, screening was incorporated as a routine part of well-child visits regardless of payor. The schedule of screenings, using the Ages and Stages Questionnaire, was 6, 12, 18 or 24, 36, 48, and 60 months. From the practices’ population, a cohort of 526 children, screened from the age of 6 months during August 2001 through November 2003, was retrospectively reviewed. The main objectives of this descriptive study were to determine the number of children who were screened and whether this rate improved with time, observe patterns and trajectories for children identified at risk in 1 or more of the 5 developmental domains, and examine referral rates and physician referral patterns.

Hair-Grooming Syncope in Children

Evans, W. N., Acherman, R., Kip, K., Restrepo, H. — Thu, 17 Sep 2009 11:20:13 PDT

Objectives. This report describes children undergoing pediatric cardiology evaluation for syncope in which a hair-grooming trigger was determined as the stimulus. Methods. A review of our database revealed 1525 patients with syncope seen by our program of whom 111 had a hair-grooming trigger determined as a cause. Results. Of the 111 patients, 78% were girls. We found characteristic difference between boys and girls with boys experiencing syncope more during hair cutting whereas girls experienced syncope more during hair combing and brushing. Electrocardiograms and echocardiograms were performed as part of syncope evaluation and no significant abnormalities were found in either test in this patient group. Conclusions. This is the largest reported group of children presenting with syncope that had a hair-grooming trigger. Our data also include the first series of boys with the condition. The hair-grooming trigger appears to stimulate a benign form of neurocardiogenic reflex syncope.

Overweight Prevention in Pediatric Primary Care: A Needs Assessment of an Urban Racial/Ethnic Minority Population

Asante, P. A., Cox, J., Sonneville, K., Samuels, R. C., Taveras, E. M. — Thu, 17 Sep 2009 11:20:13 PDT

The authors studied the prevalence of overweight-related behaviors in an urban clinic population, parents’ perceived willingness to change, and identified potential gaps in nutrition and physical activity promotion. A total of 324 parents of children aged 3 to 13 years were surveyed. Clinical heights and weights were used to calculate body mass index (BMI). Of the 324 children in the study, 55% were black and 28% were Hispanic. Approximately 151 (47%) children had a BMI ≥85th percentile, and overweight-related behaviors, such as TV viewing, were highly prevalent. Overall, parents reported a need for counseling to help their children eat healthier and be more active and seemed willing to make behavior changes in these areas. However, their willingness to change appeared lowest in areas that may improve their child’s weight status such as decreasing sedentary time and portion sizes. Overweight prevention efforts in primary care should include strategies to help clinicians negotiate behavior change with families.

Outcomes of Late-Preterm Infants: A Retrospective, Single-Center, Canadian Study

Thu, 17 Sep 2009 11:20:13 PDT

Objective. To study the prevalence of major morbidities and mortality of inborn, late-preterm infants. Methods. A retrospective review was conducted from 2004 to 2008. Descriptive outcomes were compared with predefined aggregate outcomes of term infants during the same period. Results. Data on 1193 late-preterm and 8666 term infants were compared. Majority of late-preterm infants were 36 weeks (43.6%), followed by 35 weeks (29.2%) and 34weeks (27.2%), respectively. The prevalence of intensive care admission, respiratory support, pneumothorax, and mortality in late preterm infants was significantly higher compared with term infants. Mechanical ventilation and continuous positive airway pressure rates substantially decreased with increased gestational age. Although only 1.0% had positive cultures, 28.5% received parenteral antibiotics. The late-preterm group had a 12-fold higher risk of death with an overall mortality rate of 0.8%. Conclusion. This study confirmed the high-risk status of late-preterm infants with worse mortality and morbidities compared with term infants.

Injuries From Furniture Tip-overs Among Children and Adolescents in the United States, 1990-2007

Gottesman, B. L., McKenzie, L. B., Conner, K. A., Smith, G. A. — Thu, 17 Sep 2009 11:20:13 PDT

Objective. To describe the epidemiology of pediatric injuries associated with furniture tip-overs in the United States. Methods. Data from the National Electronic Injury Surveillance System were analyzed for patients ≤17 years treated in emergency departments for a furniture tip-over-related injury from 1990 through 2007. Results. An estimated 264 200 furniture tip-over-related injuries occurred during the study period, yielding an average of 14 700 injuries annually, or 20.7 per 100 000 population per year. There was a significant increase in the number and rate of these injuries during the 18-year period. Three-quarters of injuries were to children ≤6 years. Televisions were the item most commonly involved (47.4%). Head/neck injuries were the most common (42.2%) injury type among children 0 to 9 years of age. Conclusions . The number and rate of injuries to children associated with furniture tip-overs are increasing. Pediatricians and caregivers should be aware of this important source of pediatric injury and the strategies for prevention.

Adding Omalizumab to the Therapy of Adolescents With Persistent Uncontrolled Moderate--Severe Allergic Asthma

Thu, 17 Sep 2009 11:20:13 PDT

Objective. This study aimed to evaluate the effectiveness of omalizumab among adolescents with moderate—severe allergic asthma inadequately controlled with inhaled corticosteroids. Patients and methods. Data from patients 12 to 17 years of age were pooled from 5 placebo-controlled registration trials of omalizumab. Impact on asthma control was assessed by need for rescue bursts of oral corticosteroids, lung function, symptom scores, and unscheduled office visits. Results. In adolescents (n = 146), addition of omalizumab decreased mean number of rescue bursts (0.3 vs 0.9) versus placebo; relative risk 0.47 (95% confidence interval [CI], 0.22-0.99; P = .047). At study conclusion, mean forced expiratory volume in 1 second increased 268 mL (13.8%) in omalizumab-treated subjects versus 98 mL (5.5%) for placebo (least squares mean treatment difference 146 mL [95% CI, 19.4-272.6; P = .024]). Omalizumab significantly improved asthma symptom scores and reduced unscheduled office visits. Conclusion. Omalizumab added to baseline therapy improves measures of asthma control in adolescents with persistent moderate—severe allergic asthma.

Successful Treatment of Prolonged Henoch-Schonlein Purpura With Colchicine

Saulsbury, F. T. — Thu, 17 Sep 2009 11:20:13 PDT

Posterior Scleritis: A Rare Pediatric Disorder

Farooq, O., Buccilli, A., Varma, C., Reidy, J. J., Faden, H. — Thu, 17 Sep 2009 11:20:13 PDT

Recurrent Cellulitis in a Case of Aagenaes Syndrome

Dang, S., Sigal, Y., Davies, D. — Thu, 17 Sep 2009 11:20:13 PDT

Aagenaes syndrome, also called Lymphedema Cholestasis Syndrome (LSC 1), is a form of idiopathic familial intrahepatic cholestasis associated with lymphedema of the lower extremities. It is named after the Norwegian pediatrician Oyestein Aagenaes, who described the syndrome in 1968. The presence of lymphedema is likely the predisposing factor for development of recurrent infections in such patients.1 Recurrent cellulitis as such has never been described in the literature with Aagenaes syndrome. This case highlights recurrent cellulitis as one of the potential complications of Aagenaes syndrome.

Is It "Time to Cut the Cord?"

Hanel, E., Ahmed, M. N. — Thu, 17 Sep 2009 11:20:13 PDT

A Toddler With Stridor

Lachman, D. C., Boyd, J. T., Veling, M. C., Hayes, D. — Thu, 17 Sep 2009 11:20:13 PDT

Rhabdomyolysis and Acute Renal Failure: An Unusual Cause

Veldhouse, P., Hussain, E., Olivero, A., Kane, J. M. — Thu, 17 Sep 2009 11:20:13 PDT

Ensuring the Safe Use of Genomic Medicine in Children

Haga, S. B., Terry, S. F. — Wed, 12 Aug 2009 14:12:02 PDT

Several clinical guidelines recommend that genetic testing in children be limited to tests with immediate clinical benefit. However, use of genome risk profiling will not likely meet this requirement, as the benefits are anticipated to be years away. Children who are at higher risk, though, will benefit the most from early initiation of treatment or interventions. The shift in benefit from immediate to long-term benefit warrants a reevaluation of the current practices of testing in children. In this commentary, the authors advocate the use of genomic risk profiling to identify children at increased risk who would benefit from early intervention, but recognize that its integration in clinical practice for this population will require a more nuanced approach to delivery and follow-up. In particular, the importance of counseling, context, consent, communication, and follow-up in the delivery of genomic risk testing to children and adolescents is highlighted.

Peanut Allergies in Children--A Review

Pansare, M., Kamat, D. — Wed, 12 Aug 2009 14:12:02 PDT

Televisions in the Bedrooms of Racial/Ethnic Minority Children: How Did They Get There and How Do We Get Them Out?

Taveras, E. M., Hohman, K. H., Price, S., Gortmaker, S. L., Sonneville, K. — Wed, 12 Aug 2009 14:12:02 PDT

The purpose of this study was to describe the prevalence of TVs in the bedrooms of an urban, largely racial/ethnic minority population of children and parents’ reasons for putting the TV in their child’s room. The authors surveyed 200 parents of children age 2 to 13 years in a primary care clinic; 57% of the children were non-Hispanic black, 33% were Hispanic. Sixty-seven percent of all children had a TV in the room where they slept; high rates of TVs were present in bedrooms of black (70%) and Hispanic (74%) children compared with white children (22%). The top 3 reasons parents cited for putting a TV in the room where their child sleeps were (a) to keep the child occupied so that the parent could do other things around the house, ( b) to help the child sleep, and (c) to free up the other TVs so that other family members could watch their shows.

"Don't Call Me 'Mom'": How Parents Want to Be Greeted by Their Pediatrician

Amer, A., Fischer, H. — Wed, 12 Aug 2009 14:12:02 PDT

Background. Physician—patient interaction during the medical interview is essential in establishing the rapport necessary for a successful relationship. Physicians are generally encouraged to shake hands with patients, address patients by name, and identify themselves. Objective. To define parents expectations for greetings by pediatricians and to determine the frequency with which these expectations are met. Design and methods. A total of 100 parents visiting the General Pediatric Clinic at Childrens Hospital of Michigan were recruited. Parents were interviewed at the end of their medical encounter to determine expectations for greeting by their doctor. They were questioned about preferences for shaking hands, the doctors’ use of their names, and the way doctors should introduce themselves. They were then asked if the experience at this visit conformed to these expectations. Results. Overall, 81% of the parents were the childrens mother and 86% were African-American. Over 80% of parents expected physicians to shake hands; 70% of residents and 66% of attendings did. 88% of parents wanted to be addressed by their names; only 14% of residents and 24% of attending physicians did so. All of the parents wanted the physicians to introduce themselves; 84% of residents and 93% of attendings did so. Conclusions. Physicians neither shook hands with many parents who expected it, nor did they address parents by their last names. About 90% of physicians introduced themselves. These disappointingly low results may predispose to parent dissatisfaction. Attending physicians need to teach these small, but important features, and to model them as well.

Once-Daily Atomoxetine for Treating Pediatric Attention-Deficit/Hyperactivity Disorder: Comparison of Morning and Evening Dosing

Wed, 12 Aug 2009 14:12:02 PDT

In this 3-arm, randomized, double-blind trial, once-daily morning-dosed atomoxetine, evening-dosed atomoxetine, and placebo were compared for treating pediatric attention-deficit/hyperactivity disorder (ADHD). Patients received morning atomoxetine/evening placebo (n = 102), morning placebo/evening atomoxetine (n = 93), or morning placebo/evening placebo (n = 93) for about 6 weeks. Core symptom efficacy was measured at weeks 0, 1, 3, and 6. Parent assessments of the child’s home behaviors in the evening and early morning were collected daily during the first 2 weeks of treatment. Morning-dosed and evening-dosed atomoxetine significantly decreased core ADHD symptoms relative to placebo and produced symptom improvements that were measured up to 24 hours later. Morning dosing was superior to evening dosing on some efficacy measures. Evening dosing showed greater tolerability with significantly more patients receiving morning atomoxetine reporting at least 1 adverse event than those receiving evening atomoxetine.

Growth and Tolerance of Healthy Term Infants Receiving Hydrolyzed Infant Formulas Supplemented With Lactobacillus rhamnosus GG: Randomized, Double-Blind, Controlled Trial

Wed, 12 Aug 2009 14:12:02 PDT

Healthy, term infants received extensively hydrolyzed casein formula (EHF; control), the same formula supplemented with Lactobacillus rhamnosus GG (EHF-LGG), or partially hydrolyzed whey:casein (60:40) formula supplemented with LGG (PHF-LGG), in this double-blind, randomized, controlled, parallel, prospective study. Anthropometric measures and 24-hour dietary and tolerance recalls were obtained at 30, 60, 90, 120, and 150 days of age. Blood collected in a subset of infants was analyzed for fatty acid profiles in plasma and red blood cells and for markers of allergic sensitization. Adverse events were recorded throughout the study. Growth rates were not statistically different between EHF and PHF-LGG and between EHF and EHF-LGG from day 14 to day 30, 120, or 150. No relevant differences in formula tolerance, adverse events, or allergic and immune markers were demonstrated between groups. The extensively and partially hydrolyzed formulas supplemented with LGG support normal growth in healthy, term infants and are well tolerated and safe.

A 6-Month, Office-Based, Low-Carbohydrate Diet Intervention in Obese Teens

Wed, 12 Aug 2009 14:12:02 PDT

Background. Previous studies have shown the success of a low-carbohydrate diet (LCD) in adults. In one study, the LCD has also been shown as safe and effective in teens, the study period was only 12 weeks. Furthermore, there is no information on whether the LCD is a practical intervention in a pediatric office setting. Objective. The object of this study was to demonstrate the effectiveness of a LCD in obese children in a primary care pediatric setting. Design/Methods . The study was done in 11 community pediatric practices. Children ages 12 to 18 years with a body mass index (BMI) greater than 95th percentile were put on a LCD of less than 50 grams of carbohydrate daily. Results . A total of 38 of the 63 teens finished the 6-month study and 32 (84%) lost weight (range from a gain of 5.5 kg to a loss of 23.9 kg). There was also a significant decrease in mean BMI (34.9 to 32.5). Conclusions. The LCD appears to an effective and practical office-based intervention in obese teenagers.

Breastfeeding Does Not Protect Against Urinary Tract Infection in the First 3 Months of Life, but Vitamin D Supplementation Increases the Risk by 76%

Katikaneni, R., Ponnapakkam, T., Ponnapakkam, A., Gensure, R. — Wed, 12 Aug 2009 14:12:02 PDT

Our goal was to determine if breastfeeding provides any protection against urinary tract infection (UTI) and if vitamin D supplementation imposes any additional risks for UTI in infants < 3 months of age. In this study, 40% of the children who had urine cultures were breastfed, and 18.7% of the children were exclusively breastfed. Twenty percent of all of the urine cultures tested positive, and this number was greater in females (22.5%) than in males (18.1%, P < .05). There was no significant difference between the rates of positive urine cultures in exclusively breastfed (22% vs 21%, nonsignificant [NS]) formula-fed infants. The relative risk of UTI with breastfeeding versus formula feeding was 1.03 (0.58-1.82), and any breastfeeding versus no breastfeeding was 0.92 (0.58-1.45). Vitamin D supplementation increased the UTI risk, with a relative risk of 1.76 (1.07-2.91, P < .05). However, only formula-fed infants showed an increased risk of UTI after vitamin D supplementation.

Is Environmental Tobacco Smoke Exposure a Risk Factor for Acute Gastroenteritis in Young Children?

Kum-Nji, P., Mangrem, C. L., Wells, P. J., Herrod, H. G. — Wed, 12 Aug 2009 14:12:02 PDT

Because passive smoke exposure has not been previously linked to diarrhea diseases in children, it was hypothesized that very young children exposed to environmental tobacco smoke (ETS) exposure at home would also be more likely to develop infectious gastroenteritis (GE) than their unexposed counterparts. During 1-year period, 260 children 36 months and younger were prospectively followed up in a private pediatric practice in a southern community in the United States. Multiple logistic regression analysis showed that ETS was strongly predictive of acute GE in the univariate analysis (P = .003). Even after controlling for the various confounders, ETS exposure was still significantly associated with acute GE (relative risk = 2.55; 95% CI = 1.26-5.18). It is speculated that, similar to acute respiratory infections, the same mechanisms may explain why ETS may also be associated with acute infectious GE.

Escherichia coli--Infected Cephalohematoma in an Infant

Weiss, K. J., Edwards, M. S., Hay, L. M., Allen, C. H. — Wed, 12 Aug 2009 14:12:02 PDT

This report describes a 1-month-old female with bacteremia and meningitis complicated by an infected cephalohematoma that resulted from hematogenous seeding. This report serves as a reminder that, although occurring rarely, inflammation overlying a cephalohematoma in an infant with bacteremia can indicate focal infection that requires incision and drainage for resolution.

Extreme Hyponatremia in a Child With Vegetative State and Water Intoxication

Baird, J. S. — Wed, 12 Aug 2009 14:12:02 PDT

A Four-Year-Old with Streptococcus pneumoniae--Associated Hemolytic Uremic Syndrome and Gall Bladder Disease Necessitating Cholecystectomy

Schwab, J., Setty, M. — Wed, 12 Aug 2009 14:12:02 PDT

Purulent Vaginal Discharge Secondary to Ureteral Ectopia

Narayan, A., Wiener, J. S. — Wed, 12 Aug 2009 14:12:02 PDT

The Influence of Pediatric Resident Counseling on Limiting Sugar-Sweetened Drinks in Children

Doymaz, S., Neuspiel, D. R. — Wed, 12 Aug 2009 14:12:02 PDT

"Operation Housecall": A Family-Centered Pediatric Residency Experience

Gosney, J. E., Storman, D., Geving, M., Liu, Y. H. — Wed, 12 Aug 2009 14:12:02 PDT

An Unusual Cause of Acute Torticollis

Sankar, J., Srinivasan, A., Ramakrishnan, V., Balasubramaniam, C. — Wed, 12 Aug 2009 14:12:02 PDT

An Adolescent With Fever, Weakness, and Pain

Rogo, T., Kamat, R., Arabshahi, B., Lateef, T. — Wed, 12 Aug 2009 14:12:02 PDT

Letter to the Editor

Finley, J. P., Warren, A. E. — Wed, 12 Aug 2009 14:12:02 PDT

Tics in Childhood

Abell, S., Ey, J. — Wed, 12 Aug 2009 14:12:02 PDT

Ludwig's Angina in the Pediatric Population

Lin, H. W., O'Neill, A., Cunningham, M. J. — Thu, 04 Jun 2009 14:59:57 PDT

As many as 1 in 3 of cases of Ludwig's angina occur in children and adolescents, and pediatricians are therefore ideally situated to detect these individuals at an early stage of their potentially life-threatening disease. The early identification and referral of children afflicted with Ludwig's angina to tertiary care centers allows for the rapid initiation of medical therapy and the consultation of those emergency services critical to providing such patients with optimal diagnostic and therapeutic interventions. This review provides an overview of the anatomical and pathophysiological considerations in Ludwig's angina and describes practical management principles to assist pediatricians in the diagnosis and treatment of this disease. Included in this review is an evidence-based algorithm for airway management.

The Red Eye: Evaluation and Management

Sethuraman, U., Kamat, D. — Thu, 04 Jun 2009 14:59:57 PDT

Late Effects in Long-Term Survivors After Treatment for Childhood Acute Leukemia

Haddy, T. B., Mosher, R. B., Reaman, G. H. — Thu, 04 Jun 2009 14:59:57 PDT

Background. This is a report of late effects in childhood cancer survivors seen in the follow-up clinic of a single institution. Materials and methods. There were 324 acute leukemia survivors in the database of the Long Term Follow Up Clinic of Children's National Medical Center from January 1, 1997, through June 30, 2005. Results. Of the 324 acute leukemia survivors, 228 were white, 48 black, 20 Hispanic, and 12 other. Their follow-up time was 0 to 25 years (mean 5.3 years). One or more adverse events occurred in 74.1% of the 324 survivors. Defective physical growth was most commonly reported, followed by disturbed neurocognitive function, emotional difficulties, cardiac abnormalities, hypertension, osteoporosis/osteopenia, fractures, and second neoplasms. More black and Hispanic children had acute myeloid leukemia, relapses, cardiac problems, and hypertension than white and other subjects. Conclusion. Childhood cancer survivors require lifelong monitoring, with prompt identification and treatment of adverse late effects.

Formulary Coverage for Lipid-Lowering Drugs Recommended for Children

Yoon, E. Y., Freed, G. L., Davis, M. M., Clark, S. J. — Thu, 04 Jun 2009 14:59:57 PDT

Objective/methods. A cross-sectional assessment to describe availability, coverage, and pediatric labeling status of lipid-lowering drugs offered by 1 private and 1 public insurance plan formularies. Results. Both insurance plans had equal medication availability of bile acid sequestrants (7), statins (10), and cholesterol-absorption blockers (CAB; 1). The private plan had 3 bile acid sequestrants and 3 statins listed as preferred drugs; the CAB was not preferred. In contrast, the public plan had 5 bile acid sequestrants, 7 statins, and the CAB as preferred drugs. For medications with pediatric labeling, the private plan covered 50% as preferred drugs whereas the public plan covered 70% as preferred drugs. Conclusions. If new recommendations of the American Academy of Pediatrics for treatment of dyslipidemia in children were implemented today, children with the public plan would have equal choice but better coverage of lipid-lowering drugs as preferred drugs, including those with FDA approval, compared with children with the private plan.

Another Duel in the Sun: Weighing the Balances Between Sun Protection, Tanning Beds, and Malignant Melanoma

Roberts, D. J., Hornung, C. A., Polk, H. C. — Thu, 04 Jun 2009 14:59:57 PDT

Objective. The purpose of this report is to put the dueling factors of risk and prevention for melanoma in perspective for the thoughtful pediatric specialist to facilitate preteen preventive health counseling. Study Design. We examined the rate of malignant melanoma among Kentucky residents and compared this rate with indicators of tanning bed prevalence in a large metropolitan area and sunscreen sales from a major distributor. We obtained malignant melanoma annual incidence data from the Kentucky Cancer Registry, which recorded Kentucky population incidence rates over the years 1995 to 2004. The rates reflected 2 malignant melanoma classifications: pre-invasive cancer only, or both invasive and noninvasive cancers combined. Results. The age-adjusted incidence rate per hundred thousand for combined invasive and pre-invasive malignant melanoma swelled from 21.9 in 1995 to 31.3 in 2004. The respective invasive-only malignant melanoma incidence rates increased less dramatically, from 17.3 to 20.7, during this same 10-year time period. Since 1983, the number of separate tanning bed businesses increased from 1 in 1983 to 119 by the mid-1990s, and then declined to about 74 separate businesses by 2003. Sunscreen sales data is uneven between states and is currently inconclusive. Conclusions. Although current data cannot draw a precise link between melanoma and the use of tanning beds, the associated risk is implicit, as the ultraviolet A (UVA) and ultraviolet B (UVB) radiation in tanning bed usage is a well-established melanoma risk factor. In advising patients, the pediatric specialist should consider that melanoma rates are poised as a balance of some known risk factors and a few potential preventive factors.

The Role of Pediatricians in Families with a History of Familial Adenomatous Polyposis

Augustyn, A. M., Wallerstein, R. — Thu, 04 Jun 2009 14:59:57 PDT

Colon cancer is not an entity that pediatricians routinely confront; however, a family history of colon cancer can have pediatric implications when it is part of familial adenomatous polyposis syndrome. Colonic (multiple intestinal polyps) and extracolonic manifestations (such as hepatoblastoma or brain tumors) can be the presenting features in children. The authors present 2 patients from different families with familial adenomatous polyposis who presented with the extracolonic manifestation of this syndrome and a family history of colon cancer. Identification of these families and education of their primary care givers can lead to improved screening and management of these high-risk individuals.

The Clinical Course of Childhood Asthma in Association with Fever

Sahib El-Radhi, A., Patel, S. — Thu, 04 Jun 2009 14:59:57 PDT

Little attention has been given to the relationship between fever and the severity of asthma. The authors studied 202 successive admissions of children with asthma over a period of 16 months to investigate the relationship between fever and the clinical course of asthma. There were 38 febrile children (18.8%), who were mostly younger than 5 years. Febrile children had a shorter mean hospital stay than afebrile children (1.7 vs 2.0 days). There were 25 episodes of acute severe asthma (13%): 2 among the 38 febrile children (5.2%), compared with 23 episodes among the remaining 164 afebrile children (14%). Three children, who had very severe asthma requiring transfer to an intensive care unit, were afebrile. Radiological abnormalities (collapse/consolidation) occurred in 13 cases: 3 from the febrile and 10 from the afebrile group. Monitoring body temperature is important in cases of asthma. Febrile children tend to be younger and are more likely to have a less severe clinical course of asthma.

Travel Patterns to School Among Children with Asthma

Oreskovic, N. M., Sawicki, G. S., Kinane, T. B., Winickoff, J. P., Perrin, J. M. — Thu, 04 Jun 2009 14:59:57 PDT

Background. Active commuting to school provides regular exercise, which can improve asthma symptoms. Little is known about how children with asthma travel to school. Objective. To identify travel patterns and parental perceptions surrounding mode of travel to school among children with asthma. Methods. Cross-sectional study of 176 children with asthma aged 5 to 15 years. Parents completed questionnaires assessing mode of travel to school, physical activity, asthma control, physician counseling, and factors influencing parental decisions. Data analysis included descriptive and bivariate statistics. Results. Few (16%) children with asthma actively commute to school. Active travelers lived closer to school, and "distance" was the most frequently reported factor influencing a parent's decision regarding travel mode to school. Parents reported few concerns about pollution and little physician counseling on active travel. Conclusion. Few children with asthma actively travel to school. Asthma-specific concerns do not appear to guide parental decisions on travel mode to school.

Rapid Diagnosis of Sepsis and Bacterial Meningitis in Children with Real-Time Fluorescent Quantitative Polymerase Chain Reaction Amplification in the Bacterial 16S rRNA Gene

Chen, L.-H., Duan, Q.-J., Cai, M.-T., Wu, Y.-D., Shang, S.-Q. — Thu, 04 Jun 2009 14:59:57 PDT

A method for the detection of bacterial pathogens in sepsis and bacterial meningitis with 16S rRNA gene— based real-time fluorescent quantitative polymerase chain reaction (FQ-PCR) is developed. A total of 190 blood specimens and 5 cerebrospinal fluid specimens from neonates with suspected sepsis or bacterial meningitis were evaluated with 16S rRNA gene—based real-time FQ-PCR assay. The positive rate of the real-time FQ-PCR assay was significantly higher (25/195, 12.82%) than that of bacterial culture (15/195, 7.69%; P = .002). When bacterial culture was used as a control, the sensitivity of the real-time FQ-PCR was 100%, the specificity was 94.4%, and Youden's index was 0.944. This study suggests that 16S rRNA gene—based real-time FQ-PCR assay is an important and accurate method in the detection of bacterial pathogens of sepsis and bacterial meningitis and should have a promising usage in the diagnosis of sepsis and bacterial meningitis.

Developmental Screening: Is There Enough Time?

Schonwald, A., Horan, K., Huntington, N. — Thu, 04 Jun 2009 14:59:57 PDT

Objectives. The American Academy of Pediatrics recommends routine developmental screening in well-child care. Providers cite time restraints as a limitation preventing its widespread adoption. The objectives were to determine whether routine screening lengthened well-visits and was associated with changes in parent satisfaction and report of anticipatory guidance. Methods. Visits before and after implementation of routine screening were timed. Parents whose children were seen before or after screening began were contacted to query their perceptions of the visit. Results. There was no change in visit lengths after the screener was included. With screening, more parents reported their provider talked about their concerns, and that their questions were answered. There were no changes in parent satisfaction ratings or reports of anticipatory guidance discussions. Conclusions. The perceived obstacle that routine screening requires more time than pediatricians have should not prevent its adoption. Screening tools may empower some parents otherwise reluctant to raise concerns unsolicited.

Periurethral Cleaning Prior to Urinary Catheterization in Children: Sterile Water versus 10% Povidone-Iodine

Al-Farsi, S., Oliva, M., Davidson, R., Richardson, S. E., Ratnapalan, S. — Thu, 04 Jun 2009 14:59:57 PDT

Objective. To compare urinary infection rate in children cleaned with sterile water versus a 10% povidone-iodine before bladder catheterization. Methods. Prospective randomized controlled study of children requiring bladder catheterization in the emergency department whose parents consented to the study were randomly assigned to either of 2 groups, in which sterile water (the "sterile water" group) or 10% povidone-iodine (the "10% povidone-iodine" group) was to be used for peri-urethral cleansing prior to catheterization. Results. The sterile water group had 92 patients and the povidone-iodine group had 94. Most children (87%) were under 12 months of age. Urine cultures were positive in 16% of children in the povidone-iodine group and in 18% in the water group. There was no significant difference in signs and symptoms between the 2 groups. There was no significant association between solution preparation and cultures on univariate regression analysis. Conclusions. Cleaning the periurethral area of children with sterile water prior to catheterization is not inferior to cleaning with povidone-iodine.

Building Communication Between Professionals at Children's Specialty Hospitals and the Medical Home

Stille, C. J., Frantz, J., Vogel, L. C., Lighter, D. — Thu, 04 Jun 2009 14:59:57 PDT

Objective. Build a quality improvement (QI) intervention to improve communication between a children's specialty hospital and referring primary care providers (PCPs). Methods. A network of charitable children's hospitals identified improving communication as a systemwide goal. At one model hospital, we used qualitative telephone interviewing of hospital specialists and staff, and referring PCPs, to characterize the communication system and identify potential improvements. We identified potential high-impact areas through content analysis and developed a QI change package with hospital leadership. Results. Participants described inconsistent communication, with no systematic identification of PCPs. Families were the typical means of inter-physician communication. Multiple non-PCP referral sources were a major contributor to communication breakdowns. Respondents identified a system for identification and communication with PCPs as an essential first step. Conclusions. Systems for communication with PCPs are underdeveloped at a children's charitable specialty hospital. Straightforward changes could build an effective system that is generalizable to other hospitals.

Successful Treatment with High-Dose Intravenous Immunoglobulin for Parvovirus B19 Infection Associated With Acute Fulminant Hepatitis in a Chinese Child

Cao, Y.-H., Zhang, G.-Y., Zhang, G.-C. — Thu, 04 Jun 2009 14:59:57 PDT

Periodic Paralysis as an Unusual Presentation of Autoimmune Hypothyroidism With Goiter

Bandhakavi, M. — Thu, 04 Jun 2009 14:59:57 PDT

Recurrent Fever and Rash

Cashen, K., Kamat, D. — Thu, 04 Jun 2009 14:59:57 PDT

Periodic fever is uncommon in children. The differential diagnosis is large, even though associated symptoms such as rash may help narrow the differential diagnosis. Atypical presentations require thoughtful evaluation. This article describes a case of a 4-year-old boy who presented to the emergency department with recurrent fever, vomiting, abdominal pain, myalgias, and rash. His hospital course is described along with a review on the background, evaluation, management, and complications of tumor necrosis receptor-1 alpha periodic syndrome.

False-Positive Sweat Chloride Test in a Child with Pyelonephritis in a Single Kidney

Jackson, J. A., Simon, D., Greenbaum, L. A. — Thu, 04 Jun 2009 14:59:57 PDT

An Infant with Diffuse Lung Masses

Douvoyiannis, M., Bordy, L., Fakioglu, E. — Thu, 04 Jun 2009 14:59:57 PDT

Chronic granulomatous disease presenting as invasive pulmonary aspergillosis in an infant is described in this report. Symptoms of chronic, intermittent respiratory distress had been previously attributed to gastroesophageal regurgitation and asthma. The isolation of an unusual pathogen even from a nonsterile site, particularly when symptoms persist, should not be considered as a contamination but prompt further investigation to exclude phagocytic or other immune deficiencies.

Persistent Belly Bulge in an Adolescent

Smith, E. A., Someshwar, S., Nield, L. S. — Thu, 04 Jun 2009 14:59:57 PDT

Bipolar Disorder

Abell, S., Ey, J. L. — Thu, 04 Jun 2009 14:59:57 PDT