Pediatrics 2013 Pediatrics Digest Summary D1 6

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Inuenza-Associated Pediatric Deaths in the United

States, 20042012

Inuenza-associated deaths in children occur every year among

children of all ages. Young children and those with high-risk

medical conditions are at higher risk of inuenza-related

complications.

This study describes inuenza-associated pediatric deaths over

8 inuenza seasons in the United States and compares char-

acteristics of deaths in children with high-risk medical con-

ditions with those in children without high-risk medical

conditions.

Athlete Endorsements in Food Marketing

Food marketing can lead to increases in food intake, purchase

intentions, and brand preferences. Food companies use athlete

endorsements as 1 form of food marketing. One study revealed

that parents perceive athlete-endorsed food products as

healthier than nonendorsed products.

This study assessed the (1) prevalence of athlete endorsementsof food, (2) nutritional prole of foods endorsed by athletes, and

(3) youth exposure to athlete endorsements of foods. This study

reveals that adolescents saw more athlete-endorsement food

commercials than adults.

Effect of Palivizumab Prophylaxis on Subsequent

Recurrent Wheezing in Preterm Infants

Palivizumab prophylaxis prevents respiratory syncytial virus

lower respiratory tract infection. An association between re-

spiratory syncytial virus infection and subsequent recurrent

wheezing has been suggested by many studies. Only a few

studies conducted from Europe and North America have

addressed this causal association.

In a prospective, multicenter, case-control study of 440 children

with high follow-up rate of 98.4%, palivizumab prophylaxis

administered to preterm Japanese infants (3335 weeks

gestational age) in their rst respiratory season reduced the

incidence of subsequent recurrent wheezing up to 3 years.

Approval and Perceived Impact of Duty Hour

Regulations: Survey of Pediatric Program Directors

Several studies have been published evaluating the impact of

2011 Accreditation Council for Graduate Medical Education duty

hour regulations. Although resident quality of life may be

improved, it appears that resident education and patient care

may be worse.

This is the rst study to evaluate pediatric program director

approval of 2011 Accreditation Council for Graduate Medical

Education Common Program Requirements and the perceivedimpact of the regulations on patient care, resident education,

and quality of life.

Nonmedical Prescription Opioid and Sedative Use

Among Adolescents in the Emergency Department

Unintentional overdose and emergency department visits

secondary to nonmedical use of prescription drugs are on the

rise with peak age of onset in midadolescence for these risk

behaviors. Also, risk behaviors, such as substance use and

violence, tend to cluster.

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Approximately 1 in 10 adolescents or young adults using the

emergency department endorse nonmedical prescription

opioid or sedative use in the past year. Rates of current opioid

or sedative prescriptions are low among this group.

Psychotropic Medication Use and Polypharmacy in

Children With Autism Spectrum Disorders

Psychotropic use is common and increasing in children with

mental disorders but little is known about the long-term

patterns of psychotropic use and polypharmacy among com-

mercially insured children with autism spectrum disorders.

Among 33 565 children with autism spectrum disorders, 64%

used psychotropic medications and 35% had evidence of pol-

ypharmacy. Older children and those who had seizures,

attention-decit disorders, anxiety, bipolar disorder, or de-pression had increased risk of psychotropic use and poly-

pharmacy.

Active Versus Passive Cooling During Neonatal

Transport

Cooling infants with hypoxic-ischemic encephalopathy shortly

after birth improves survival and neurodevelopmental out-

come. The optimal way to cool infants during transfer to re-

gional NICUs is unclear.

Data from a regional neonatal transfer team, using rst passive

and subsequently active cooling for these infants, suggest thatactive cooling results in improved thermal control and a re-

duction in stabilization time.

Health Outcomes Associated With Transition From

Pediatric to Adult Cystic Fibrosis Care

Transition from pediatric to adult care is often reported to be un-

successful. Little evidential research has examined the actual pro-

portion of youth in pediatric versus adult care or impact on health

status outcomes after transferring from pediatric to adult care.

Our article extends the literature by providing health transition

outcome data, something that has been recognized as a criticalgap to developing evidence-based programming and health

care transition policy.

Association of Hospital and Provider Types on

Sickle Cell Disease Outcomes

As more children with sickle cell disease survive into adulthood,

they are increasingly hospitalized in both childrens and gen-

eral hospitals and managed by different provider specialists.

But it is unknown if hospital type and provider specialty affect

patient outcomes.

Using a large national administrative dataset, this study

revealed that general hospitals were associated with higher

rates of intubation and longer lengths of stay compared with

childrens hospitals for adolescents and young adults with SCD

admitted with acute chest syndrome.

Gunshot Injuries in Children Served by Emergency

Services

Gunshot injuries are an important cause of preventable injury

and mortality in children, with emergency services often

providing the initial care for patients. However, there is little

recent population-based research to guide public health, injury

prevention, and health policy efforts.

Gunshot injuries are uncommon in children, but cause greater

injury severity, need for major surgery, mortality, and costscompared with other injury mechanisms. There is also large

variation in the population-adjusted incidence of pediatric

gunshot injuries between regions.

Spanking and Child Development Across the First

Decade of Life

A large and growing literature has demonstrated signicant

associations between the use of spanking and later child ag-

gression, but we know less about paternal spanking, effects of

spanking on cognitive development, and longer-term effects.

Accounting for a broad array of risk factors, spanking predictsboth aggression and receptive vocabulary across the rst

decade of life. Importantly, we include paternal spanking,

cognitive outcomes, and a longitudinal span longer than that of

much of the literature.

Measles in Children Vaccinated With 2 Doses of

MMR

School outbreak investigation in Quebec, Canada suggested that

adolescents previously vaccinated with 2 doses of measles

vaccine beginning at 12 months of age were at greater measles

risk than those whose

rst dose was given at$

15 months of age.Greater measles risk among earlier rst-of-2-dose vaccine

recipients was replicated as a generalized provincial nding

during the 2011 epidemic in Quebec, Canada. The mechanism

remains unknown, but the ndings warrant additional evalu-

ation in the context of measles elimination efforts.

Impact of a Routine Two-Dose Varicella Vaccination

Program on Varicella Epidemiology

The 1-dose childhood varicella vaccination program in the

United States resulted in dramatic declines in varicella

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incidence, hospitalizations, and deaths. There is little in-

formation on the impact of the 2006 recommendation for 2-dose

varicella vaccination of children on varicella epidemiology.

In the rst 5 years of the 2-dose varicella vaccination program,declines in varicella incidence were seen in all age groups,

including infants who are not eligible for varicella vaccination,

providing evidence of the benet of high population immunity.

Narrow Vs Broad-spectrum Antimicrobial Therapy

for Children Hospitalized With Pneumonia

Recent guidelines for the management of childhood pneu-

monia recommend narrow-spectrum antimicrobial agents

(eg, ampicillin) for most children; however, few studies have

directly compared the effectiveness of narrow-spectrum

agents to the broader spectrum third-generation cepha-losporins commonly used among children hospitalized with

pneumonia.

By using data from 43 childrens hospitals in the United States,

we demonstrate equivalent outcomes and costs for children

hospitalized with pneumonia and treated empirically with ei-

ther narrow- (ampicillin/penicillin) or broad-spectrum (cef-

triaxone/cefotaxime) antimicrobial therapy.

Infant Hospitalizations for Pertussis Before and

After Tdap Recommendations for Adolescents

Pertussis rates are on the rise in the United States. Infantsoften require hospitalization for pertussis. Vaccination can

change hospitalization patterns for vaccine-preventable dis-

eases. It is unknown if vaccinating adolescents for pertussis

(recommended in 2006) might change infant hospitalization

utilization.

Universal vaccination policy among adolescents against per-

tussis appears to have been effective in 3 of the 4 years we

examined postvaccination. Further vaccination efforts among

adolescents and adults are needed to prevent infantile hos-

pitalization on a more consistent basis.

Childhood Anemia at High Altitude: Risk Factors forPoor Outcomes in Severe Pneumonia

Pneumonia is the leading cause of death in young children

worldwide. Anemia, widely prevalent globally, is not rou-

tine ly ass esse d when treating pneu monia. The effe ct of

anemia and high altitude on outcome of pneumonia is not

well described.

Anemia at high altitude increases the risk of poor outcome with

severe pneumonia. Children with severe pneumonia at high

altitude present with more severe hypoxemia and have a longer

time to recovery than children at low altitude.

Cognitive Behavior Therapy for Pediatric Functional

Abdominal Pain: A Randomized Controlled Trial

Pediatric functional abdominal pain is common and costly.

Cognitive behavior therapy (CBT) is a promising treatment for

these complaints, but solid evidence for its effectiveness is

lacking.

This randomized controlled trial shows that CBT reduces ab-

dominal pain in 60% of children 1 year after treatment. Six

sessions of CBT delivered by trained master s students in

psychology were equally effective as 6 visits to an experienced

pediatrician.

Complementary and Conventional Medicine Use

Among Youth With Recurrent Headaches

Use of complementary and alternative medicine (CAM) is in-

creasingly common among American youth; however, in-

formation on use of CAM among youth with recurrent headache

(HA) is limited.

Youth across a range of chronic conditions experience HA.

These youth are more likely to use CAM. Use and expenditures

for conventional medical care, and increased difculties in

activity and functioning are greater for youth with HA who use

CAM.

Changes in Bedtime Schedules and Behavioral

Difculties in 7 Year Old Children

Links between clinically diagnosed sleep problems and ad-

verse behavioral outcomes are well documented. However, in

nonclinical populations, causal links between disrupted sleep

and the development of behavioral difculties are far from

clear.

Seven-year-old children with nonregular bedtimes had more

behavioral difculties than children who had regular bedtimes.

There were clear doseresponse relationships, and the effects

of not having regular bedtimes appeared to be reversible.

Apnea in Children Hospitalized With Bronchiolitis

Apnea is a life-threatening complication of bronchiolitis and has

been associated with younger age, prematurity, and a parental

report of apnea. Apnea is classically attributed to the re-

spiratory syncytial virus, but little is known about the role of

other viruses.

Among hospitalized children, low or high respiratory rates or

low oxygen saturation on presentation were associated with

subsequent apnea in the hospital. Several bronchiolitis

pathogens were associated with apnea, with similar apnea risk

across the major viral pathogens.



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Early Feeding and Risk of Celiac Disease in

a Prospective Birth Cohort

Lower risk of early celiac disease (CD) has been observed with

breastfeeding and low dose of gluten at introduction. Gluten

introduction before 4 or after 6 months has been associated

with increased risk. For CD diagnosed after 2 years, the as-

sociation is unclear.

Gluten introduction delayed to .6 months as well as breast-

feeding .12 months was associated with a modest increase in

CD in this rst population-based birth cohort study, and gluten

introduction under continued breastfeeding was not protective.

Association of Constipation and Fecal Incontinence

With Attention-Decit/Hyperactivity Disorder

Several studies have shown that behavioral problems can be

associated with defecation and voiding disorders, although few

studies have looked directly at a link between a diagnosis of

attention-decit/hyperactivity disorder (ADHD) and con-

stipation or fecal incontinence.

We identied an increased risk for both constipation and fecal

incontinence in children with ADHD. In patients with concom-

itant ADHD and defecation disorders, more aggressive medical

and behavioral treatment of the constipation or fecal in-

continence may be warranted.

Hypospadias and Residential Proximity to PesticideApplications

Some studies suggest a contribution of environmental expo-

sures such as pesticides to risk of hypospadias, whereas

others do not. One of the challenges that has limited current

knowledge is the lack of detailed exposure data.

This study examined a more detailed assessment of exposure to

pesticides than previous studies. Exposure assignments,

whether to groups of chemicals, specic chemicals, or

a composite involving a number of chemicals, showed a general

lack of association with hypospadias.

Microbial Contamination of Human Milk Purchased

Via the Internet

Sharing human milk between those with an abundant supply

and those seeking milk for their child may be growing in

popularity, facilitated by Web sites recently established to link

providers and recipients.

This study documents the potential for human milk shared via

the Internet to cause infectious disease by estimating the extent

of microbial contamination among samples purchased via

a leading Internet Web site.

Pediatrician-led Motivational Interviewing to Treat

Overweight Children: An RCT

Obesity and overweight can seriously affect health outcomes.

Many obesity prevention interventions have been proposed, but

few have been effective. Motivational interviewing in primary

care seems promising, but results in BMI control are con-

troversial and require further investigation.

This is the rst study to demonstrate the effectiveness of

pediatrician-led motivational interviewing for BMI control in

overweight children aged 4 to 7 years. Nevertheless, no effect was

observed in boys or when the mothers education level was low.

Neonatal ECMO Study of Temperature (NEST): A

Randomized Controlled Trial

Although providing improved survival for infants with very

severe cardiorespiratory problems, the use of neonatal ex-

tracorporeal membrane oxygenation has high rates of disability

in survivors. Mild hypothermia has been shown to limit brain

injury in a range of patient groups, including newborns.

Infants who received extracorporeal membrane oxygenation

and mild hypothermia did not show an improved neuro-

developmental outcome, and nonsignicant trends in the data

suggested a small adverse effect. Use of hypothermia in other

potential patient groups should be thoroughly tested.

Clinical Utility of the Colorado Learning DifcultiesQuestionnaire

Caregiver behavioral symptom ratings are frequently used to

assist in diagnosing childhood behavioral disorders. Although

behavioral disorders are highly comorbid with learning dis-

abilities (LDs), little work has examined the utility of caregiver

ratings of learning concerns for screening of comorbid LD.

The validity of a time- and cost-efcient caregiver rating of ac-

ademic concerns (Colorado Learning Difculties Questionnaire)

was examined. The screening measure accurately predicted

children without LD, suggesting that the absence of parent-

reported dif

culties may be adequate to rule out overt LD.

Fetal Growth and Childhood Cancer: A

Population-Based Study

The etiology of childhood cancers is largely unknown. However,

excessive fetal growth has been associated with some childhood

cancers. One of the most consistent ndings is that high birth

weight is associated with an increased risk of childhood leukemia.

Examining large, population-based birth and cancer registry

data from 4 Nordic countries, high birth weight was the most

strongly associated with risk of many childhood cancers among

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several measures of fetal growth that have not previously been

extensively assessed.

Maternal Prenatal Weight Gain and Autism

Spectrum Disorders

Previous studies have found links between prepregnancy BMI

and/or pregnancy weight gain and autism spectrum disorders

(ASD) risk. Several contributing factors to BMI and pregnancy

weight gain (ie, prematurity, advanced maternal age, parental

education, and parity) overlap with established ASD risk factors.

This study identies an association between ASD risk and

prenatal weight gain, but not prepregnancy BMI, and accounts

for important confounding variables excluded in previous

analyses. It provides the rst within-mother comparison of

these factors by including unaffected sibling controls.

Prenatal Exposure to Air Pollution, Maternal

Psychological Distress, and Child Behavior

Prenatal exposures to diverse pollutants and psychosocial

stressors have been shown independently to adversely affect

child development. Less is known about the potential inter-

actions between these factors, although they commonly co-

occur, especially in disadvantaged populations.

The combination of high prenatal exposure to environmental

polycyclic aromatic hydrocarbons and maternal demoralization

adversely affects child behavior, and maternal demoralization hasa greater effect among children with high prenatal polycyclic

aromatic hydrocarbon exposure for a majority of behavioral

symptoms.

Parent Health and Functioning 13 Months After

Infant or Child NICU/PICU Death

Research has focused on primarily white parents, months to

years after their infant/child or adult child died of cancer, ac-

cidental injury, sudden infant death syndrome, or suicide. Many

parents experience depression and/or posttraumatic stress

disorder and greater risk for some physical health problems.Data on hospitalizations, changes in and management of

chronic conditions, complexity of medication regimens, de-

pression, and posttraumatic stress disorder were collected

over 13 months from 249 Hispanic, black, and white parents in

188 families who experienced an infant/child NICU/PICU death.

Higher-Hazard, No Benet Research Involving

Children: Parental Perspectives

Higher-hazard, no-benet research involving children may be

approved by local institutional review boards only when the

protocol enrolls children with the medical condition under

study. The ethics of this distinction have been debated, but

parental opinions have not been explored.

We found that parental opinions support federal regulations. Wediscuss parental motivations for and against research participa-

tion and the extent to which enrolling a child in higher-hazard, no-

benet research reects appropriate surrogate decision-making.

Physical Activity in Children Attending Preschools

Physical activity (PA) levels in preschool children vary con-

siderably between preschools, and are positively associated

with the overall quality of the preschool. However, knowledge

regarding specic characteristics of the preschool environ-

ment hypothesized to promote PA is inconsistent and lacking.

This study tested multiple potential correlates of preschoolchildrens objectively measured moderate and vigorous PA

level during preschool attendance, identifying size of indoor

area per child and location of preschool building on the

playground as new potentially modiable correlates.

End-Stage Kidney Disease After Pediatric Nonrenal

Solid Organ Transplantation

End-stage kidney disease (ESKD) causes signicant morbidity

and mortality after solid organ transplantation. Adults com-

monly develop advanced kidney disease, particularly after liver

and intestinal transplantation. Previous pediatric studies havenot compared the relative incidence of ESKD by organ type.

This national cohort study shows the highest risk of ESKD

among pediatric lung and intestinal transplant recipients,

reecting unique organ-specic causes of kidney injury. Our

ndings have implications for screening for and treating early

kidney disease in transplant recipients.

Off-Label Topical Calcineurin Inhibitor Use in Children

In January 2006, a public health advisory and boxed warning for

long-term safety and the risk of malignancies and a medication

guide were issued for topical calcineurin inhibitors, tacrolimusand pimecrolimus.

Evaluation of off-labeluse of topical calcineurin inhibitors in children

before and after regulatory action by the Food and Drug Admin-

istration is important to understand the impact of regulatory action.

Maternal Inuence on Child HPA Axis: A Prospective

Study of Cortisol Levels in Hair

Stress affects health of children, potentially persisting as

a trajectory into adulthood. Earlier biological markers assess

only momentary stress, making it difcult to investigate stress



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over longer periods of time. Cortisol in hair is a new biomarker

of prolonged stress.

Mother and child hair cortisol association suggests a heri-

table part or maternal calibration. Cortisol output gradually

stabilizes, has a stable trait, and is positively correlated to

birth weight. Hair cortisol is a promising noninvasive bio-

marker of prolonged stress, especially applicable for chil-

dren.

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