October 2011 Journal Watch

Behavior and Development:

Lindstrom K, Lindblad F, Hjern A. Preterm birth and attention-deficit/hyperactivity in schoolchildren. Pediatrics 2011;127:858-865.
Summary and Implications For Your Practice:
This Swedish register study examined the prevalence of Attention-Deficit/Hyperactivity Disorder (ADHD), indicated by recorded prescription of ADHD stimulant medication, within a 1987-2000 cohort (1,180,616 children) followed up in 2006 at ages 6 to 19 years to assess the increased odds ratio of ADHD in preterm births. As expected, increasing immaturity correlated with increasing rates of ADHD—children born at 23 -28 weeks gestation were noted to have 2.1 (1.4-2.7) odds ratio for ADHD as compared to a 1.1 odds ratio at 37-38 weeks gestation. The effects of prematurity were found to be equivalent for boys and girls. Presence of cerebral palsy, previously associated with increased risk of ADHD in term infants, did not have a similar effect on ADHD rates in preterm infants. A within-mother-between-pregnancy component was also added to the study to control for potential genetic confounding and socioeconomic factors. It found that rates of ADHD even within families similarly correlated with degree of immaturity. Of greatest significance for clinical practice, was the observation that moderately preterm infants (those born at 33-36 weeks) also had significantly increased rates of ADHD. Thus, while practitioners are already on the look-out for learning disabilities and problems with concentration in very preterm infants, we must also remain alert to the potential for similar challenges in moderately preterm infants, whose post-preemie follow-up may be less comprehensive and who may, therefore, be at overall increased risk for missed diagnosis of ADHD in early childhood and elementary school.
Submitted by: Anya Kleinman

McPheeters M, et al. A systematic review of medical treatments for children with autism spectrum disorders. Pediatrics, 2011;127(5):1312-1321.
Summary and Implications For Your Practice:
This article is an important review of the existing evidence for pharmacologic interventions for behavioral outbursts and repetitive behaviors in children with autistic spectrum disorders (ASD). Outcomes reviewed relied primarily on focused behavioral checklists such as the Aberrant Behavior Checklist Community Version (ABC-C). This study reports that prospective studies for pharmaceutical treatment in autistic children are limited; nonetheless existing evidence supports the use of risperidone and aripiprazole for symptom control. These antipsychotics, however, also have significant side effects such as considerable weight gain (with accompanying risk for metabolic syndrome with long term use), somnolence, extrapyramidal symptoms (dyskinesia, tremor, rigidity) and elevated serum prolactin. These side effects must be kept in mind given the fact that both medications control comorbid symptoms of autism, but do not correct the core symptoms. Evidence for the use of selective serotonin reuptake inhibitors and stimulant medications is at this time insufficient, yet their potential for “activation”, decreased sleep, and dis-inhibition is well-documented. Therefore, although autistic children are often hyperactive and/or anxious, the specific use of such medications for ASD has not been proven. Even before reading this review, I was wary of the increasing use of antipsychotics and other psychiatric medications to control behavioral problems in ASD. It is reassuring that evidence exists for risperidone and aripiprazole use, yet equally important to note the dearth of data for other interventions when deciding with families about the best options to minimize ASD disruptive and repetitive behaviors long-term.
Submitted by: Anya Kleinman
Comment: The authors point out that even though there is evidence that antipsychotics can help symptoms, given the side-effect profile, they should be used cautiously and only in cases of severe behavior problems, such as risk of injury. LC

Yoshimasu K et al. Written-language disorder among children with and without ADHD in a population-based birth cohort. Pediatrics 2011;128(3):e605-613.
Summary and Implications For Your Practice:
Attention-deficit/hyperactivity disorder (ADHD) affects roughly 8-10% of children and is co-morbid with many conditions including depression, anxiety, learning disorders, and sensory processing disorders. Through a population-based birth cohort this study retrospectively evaluated the prevalence of written-language disorder (WLD) in children with and without ADHD. Researchers reviewed medical records to identify children born between 1976-1982 in the townships of Minnesota Independent School District 535 who still lived in the area until at least 5 years of age (N=5718). The researchers used medical records, school data, and private psychiatric practice information to identify children in the cohort with a WLD, ADHD and/or reading disorder (RD). Using specific criteria defined in the article, they identified 379 children with ADHD, and 806 children with a WLD of which 603 also had a RD. Patients with severe intellectual disability were excluded. The majority of the patients enrolled were white and middle class. Of the children with ADHD, 74.9% were male. The study found that the incidence of WLD is higher in both girls and boys with ADHD compared to those without. The writing problems were more multifaceted in boys. This article reinforces the need to evaluate children with ADHD for learning disorders such as WLD and RD, in addition to the other co-morbid conditions mentioned above.
Submitted by: Lauren Ebe
Comment: The take home point (for me) is that learning disabilities, especially language disorders, can masquerade as inattentive ADHD, and therefore educational evaluation is a key component of the assessment of ADHD symptoms. LF

Drahota A et al. Effects of cognitive behavioral therapy on daily living skills in children with high-functioning autism and concurrent anxiety disorders. J Autism Dev Disord 2011;41:257-265.
Summary and Implications For Your Practice:
The prevalence of Autism Spectrum Disorders (ASD) which includes autistic disorder, Asperger syndrome, pervasive developmental disorder (PDD) and PDD-NOS, has been increasing over the past years. It is reported that up to 80% of children with high-functioning ASD also have an anxiety disorder, which can be debilitating. New research puts forward that anxiety has a negative effect on daily living skills (toileting, grooming, dressing, etc). This study evaluated the utility of cognitive behavioral therapy (CBT) in alleviating anxiety and improving daily living skills in patients with ASD. Researchers recruited 40 children age 7-11 years old with high functioning ASD (IQ ≥ 70) and an anxiety disorder (separation anxiety disorder, social phobia, obsessive compulsive disorder). Patients were excluded if they were receiving behavioral or psychosocial treatment, or were already in family therapy/parenting class. Patients/parents were randomized into either an immediate CBT treatment or a 3-month waitlist group. Patients in the CBT treatment group received sixteen 90-minute weekly CBT sessions. Assessments for daily living skills were done at baseline and post-treatment/post-waitlist. This study found that the parents of the children who received CBT thought their children had improved daily living skills and decreased anxiety post-treatment. Parents also reported being less involved in their children’s daily activities of living after CBT. This study is valuable because it reinforces the importance of screening patients with autism for anxiety and referring them for treatment which could include CBT. Managing the anxiety will hopefully help patients function more independently and successfully throughout life.
Submitted by: Lauren Ebe

Emergency Medicine:

Nigrovic, et al. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics 2011;127(6):1067-1063
Summary and Implications For Your Practice:
Minor head trauma is a common reason for children to present to the emergency department (ED). Despite the low prevalence of traumatic brain injury (TBI), the use of CT scans is the standard for emergently diagnosing TBI. This study examined the prevalence of CT scans done in groups of children that were either “observed” before deciding to CT scan or “not observed”. Twenty-five EDs were used as study sites and case report forms were filled out for all 40,113 enrolled patients. Based on these case report forms, patients were separated into either the “observation group” or the “non-observation” group. Once enrolled, patient medical records in each group were reviewed to determine 2 outcomes – the rate of CT scan use and the frequency of clinically important TBI. This study concluded that patients who were observed had a significantly lower rate of overall CT use and there was no difference between groups in the rate of clinically important TBI. Because CT scans are not without consequences, and children are more susceptible to develop malignancy induced from the radiation exposure, this study will be useful in reducing the number of unnecessary CT scans done in the ED. The results are limited in that they failed to record the duration of observation before CT making decision and therefore cannot make recommendations about the length of observation. Further studies are needed to examine the most appropriate length of observation and to look at the impact of CT use rates and overall length of emergency department stay.
Submitted by: Lori Schillaci

Berger RP, et. al. Abusive head trauma during a time of increased unemployment: a multicenter analysis. Pediatrics 2011;128:637-643.
Summary and Implications For Your Practice:
This study looks at the rates of abusive head trauma (AHT) in response to the societal-level risk factor of the recent economic recession. The authors reviewed all medical records of patients diagnosed with unequivocal abusive head trauma by hospital-based child protection teams in three US regions from January 1, 2004 until June 30, 2009. They chose catchment sites in Seattle, western Pennsylvania, and part of southern Ohio and northern Kentucky, selecting these areas because they have only one level I pediatric trauma center in the region, a stable child protection team throughout the time period, and IRB permission to obtain county of residence of each case. For every case of AHT, they also tracked what counties the patients came from, and looked for a correlation in AHT rates with local unemployment rates in each of these 74 counties over the time period. Using the National Bureau of Economic Research definition, the recession was dated from December 1, 2007 to June 30, 2009. Rates of AHT in children younger than 5 years were found to significantly increase with the onset of the recession over the entire 74-county study region, from an incidence of 8.9 to 14.7. Each catchment area showed a significant increase in incidence of AHT. This study did not find a correlation in AHT rates and county unemployment rates, which the authors attribute to known inaccuracies of unemployment reports. After reading this article, I will be more vigilant about primary prevention, as well as evaluation of patients with some suspicion for abuse.
Submitted by: Leslie White
Comment: Any kind of stress in the home can be a set up for violence. I think it is important to remember, however, that non-accidental trauma can occur across all socioeconomic levels. LC

The purpose of this study was to determine whether the rate of abusive head trauma (AHT) increases during times of economic recession. Data was collected over five-and-a-half years (the recession period and four years before the recession) at three encatchment areas in Ohio, Pennsylvania, and Washington. The investigators used a chart review and categorized subjects as having suffered AHT if the diagnosis was unequivocal. The results showed that the rate of AHT increased from 8.9 in 100,000 pre-recession to 14.7 in 100,000 during the recession. The investigators also looked at whether unemployment rates were associated with increased rates of AHT, but found no such association, possibly because unemployment rates do not include individuals who have used up all their unemployment benefits as well as those who are underemployed. Although pediatricians should always have a high index of suspicion for abuse, the results of this study suggest that this should be even heightened during periods of economic stress. Additionally, anticipatory guidance for parents may need to focus even more on stress reduction and abuse during tough economic times.
Submitted by: Ronen Stein

Gastroenterology:

Teitelbaum, JE, Arora, R. Long-term efficacy of low-dose tricyclic antidepressants for children with functional gastrointestinal disorders. Journal of Pediatric Gastroenterology & Nutrition. 53(3):260-264, September 2011.
Summary and Implications For Your Practice:
Functional gastrointestinal disorders (FGIDs) are common pediatric diagnoses, including irritable bowel syndrome, functional abdominal pain, and functional dyspepsia. Physicians struggle to treat these patients without an organic cause to address. Patients often have poor response to therapy, with high rates of psychiatric comorbidity further complicating matters. Teitelbaum and Arora performed a simple retrospective study by chart review of pediatric patients treated for FGIDs with tricyclic antidepressants (TCAs). The authors evaluated the efficacy of TCAs in ameliorating FGID symptoms over an average treatment duration of 10.5 months. 146 children were prescribed TCAs, with 98 starting TCAs and following-up. 78% of these responded to treatment. 26% were able to stop the medication without reoccurrence of symptoms. This study has implications for every pediatric GI practice. A study weakness is the poor generalizability to other practices. The decision to treat with TCAs was a clinical one, as was the choice of imiprimine vs amitryptyline. Also, there is no control group in a retrospective study. Of note, it would be interesting to see how TCAs fared in a head-to-head trial against other IBS treatments. The verbal response of patients is a poorly standardized endpoint on which to base a treatment endpoint, when compared to the IBS quality of life tools used in previous work.
Submitted by: James Brown
Comment: I agree with Dr. Brown regarding the noted weaknesses of the study. Despite clinical frustration with treatment of functional GI disorders, the risks and side effects of the tricyclic antidepressants should not be minimized- this study is not a mandate to treat! An appropriately conducted trial of psychological care for the same conditions might be less well received but far less risky. LF

General Pediatrics:

Lillard AS, Peterson J. The immediate impact of different types of television on young children's executive function. Pediatrics 2011;128:644-649.
Summary and Implications For Your Practice:
This study focused on the immediate effects of fast-paced television on executive function in 4 year old children. Sixty 4-year-old children, mostly white and from middle class families, were randomly assigned one of three tasks—watching fast-paced television (TV), watching educational television, or drawing). For the fast paced TV show, a scene changed every 11 seconds on average while an educational TV show’s scenes changed every 34 seconds. Total length of TV show watched during the study was 9 minutes. After completing one of the three tasks, children were given 4 executive function tasks and parents had to complete surveys regarding their child’s attention and television watching. The tasks assessed attention, problem solving, self-regulation and delay of gratification. Results showed that the fast-paced television group did significantly worse on the executive function tasks than the drawing group (P=0.004). The educational TV group was near statistical significance when compared with the drawing group (P=0.05). These results are consistent with other studies showing that there are many short-term and long-term negative links between attention and entertainment television. This is important in our pediatric practice today because a large portion of our pediatric patients watch many hours of TV each day and many of these children have televisions in their bedroom. We should advise every parent on the adverse affects of television on their children’s executive functioning and attention, which can in turn lead to poor school performance.
Submitted by: Lauren Riney
Comment: This is a very interesting study, and received a lot of press. As Dr. Riney points out, it can serve as a reminder to discuss limiting TV use in the home. More studies are needed before we could tell parents that certain types of programs “cause” ADD symptoms. LC

The authors of this article had four year old children complete one of three tasks: drawing for nine minutes, watching a slow-paced television (TV) show (Sesame Street) for nine minutes, or watching a fast-paced TV show (Sponge Bob) for nine minutes. Pacing was defined by how often the total scene changed. After the activity, standardized tests were used to test the children’s executive function. The children who watched Sponge Bob performed statistically worse than children who drew or watched slow-paced television. (Slow paced television was not quite as good as drawing.) The watching of television also impacted the scale of delay of gratification. Given these results, parents should be aware of the potentially damaging effects of television for their children’s cognition. While multiple studies have shown a connection between long term attention deficits and television, this study looked at short term cognition after watching television. Watching faced-paced television could very well make it difficult for children to complete their homework, for example. It appears that my Mom was correct—“TV rots your brain!”
Submitted by: Sarah Youssef

Gawande A. Personal Best. New Yorker. Oct 2011
Summary and Implications For Your Practice:
In this article, Dr. Gawande poses the question of why athletes and singers, etc have coaches, but physicians do not. It is an interesting point, which I have never heard before, but essentially asks, “Why do we assume our training is over at the end of fellowship or residency?” He speaks to several leaders and experts of other professions and is surprised to find that they often have coaches that are not publicized (i.e. a classical musician whose wife is also a musician and constantly gives feedback). In the article, Dr. Gawande finds a retired colleague whom he hires as a coach. His colleague watches him operate and interact with his staff, and finds a few minor changes which Dr. Gawande makes resulting in some modest improvements in his surgical efficiency. Dr. Gawande continues with his coach for several months, resulting in several small further changes which he finds helpful. Towards the end of the article Dr. Gawande notes the awkwardness at times of an attending physician being followed around by a coach and notes that this may make some of his patients uncomfortable. He ends the article without concluding if the coach was overall worthwhile, but he does bring up an interesting point in his experiment.
Submitted by: Seth Rotz

Fent, JF. et. al. The decision to access patient information from a social media site: what would you do? Journal of Adolescent Health 2011;49:414-420.
Summary and Implications For Your Practice:
Social media sites (SMS), like Facebook, have become a large part of social communication. This study surveyed 109 pediatric medical and behavioral faculty and trainees at a medical school in South Florida to determine the rate of SMS use and how they would respond to concerning information posted on fictional SMS profiles. 88% have a SMS account; trainees were more likely than faculty and only trainees reported conducting searches for patients in the past. Participants felt that it was not an invasion of privacy to access patient SMSs - if there were no privacy settings then this was public information. There was no significant difference in rating of the level of concern across the vignettes, which included suicidal ideation, drug abuse, statutory rape, domestic violence, physical abuse, intent to harm or risky sexual behavior. Faculty were more likely to immediately contact parents, law enforcement, while trainees were more likely to talk to the patient at the next session without disclosing that they accessed the SMS. A duty to protect was the most common reason to immediately contact parents or law enforcement while uncertainty in the accuracy of information was the most prevalent rationale to do nothing. Searching SMSs for patient information raises the question of ethical and legal responsibilities but also the question of informed consent and the implications this could have on the patient-provider relationship by searching without consenting the patient. Guidelines on conducting searches and responding to the information are needed but I do not intend on searching for patients on SMSs.
Submitted by: Megan Knowles
Comment: I totally agree with Dr. Knowles that it does not seem prudent to look for information about patients on SMSs. There are already legal considerations that need to be considered when using e-mail to communicate with patients. Issues such as confidentiality and documentation of doctor-patient interactions would need to be addressed prior to using SMSs in this fashion. LC

Kerns S et. al. Adolescent use of school-based health centers and high school dropout. Arch Pediatr Adolesc Med. 2011;165(7):617-623.
Summary and Implications For Your Practice:
School based dropout is a significant public healthcare concern. High school dropout in particular results in significant health risks including death. Factors associated with school based dropout include educational and instructional quality, socioeconomic status, and school climate. In the previous literature, there has been limited data linking health and academic benefits. School based healthcare centers (SBHC) have been linked to higher graduation rates in high risk populations (for example, pregnant teenagers), but previous literature has failed to generalize these findings. In this study, the authors collected data in an urban school district and observed those who used SBHC. Overall, there was a significant relationship between low SBHC usage (0.125-0.5 visits on average per semester) and a decreased likelihood of dropout in all categories except Caucasian individuals and those who did not receive free/reduced lunches. For those in the moderate (0.51-2.5 visits) and high (>2.5 visits) SBHC usage categories, the significant decreased likelihood of dropout was seen in high risk populations – African Americans, free-reduced lunches, GPA <2.5, and attendance <90%. This article shows how medical and mental health support can affect overall health of high school individuals. I found it extremely interesting that these health centers, while rare in the inner city, could be an extremely helpful and cost effective way to provide medical and mental healthcare to patients who generally fail to attend well child visits, and could increase graduation rates across the country. I think it could be beneficial for the general practitioner to research these centers in their area to provide support.
Submitted by: Ben Goldstein

Janssens K et al. Pubertal status predicts back pain, overtiredness, and dizziness in American and Dutch adolescents. Pediatrics. 2011;128:553-559.
Summary and Implications For Your Practice:
This longitudinal study examines if there is an association between baseline pubertal status and functional somatic symptoms (FSS), including back pain, overtiredness, dizziness, abdominal pain, and headache. Additionally, the study assesses any statistically significant gender differences between pubertal status and specific FSS, since FSS are more common in females. The longitudinal study is based on two populations: adolescents in the United States and in the Netherlands, in an attempt to limit a racial or cultural bias. There were approximately 4,000 participants in the study. After conducting an ordinal logistic regression analysis, the authors conclude that both American and Dutch adolescents at a later pubertal stage at baseline were more likely to report back pain, overtiredness, and dizziness, but not abdominal pain or headache. No statistically significant gender differences were found. Consequently, the authors predict that gender differences attributed to pubertal development may become apparent during an even later pubertal stage, when physiological signals associated with menstruation are stronger and psychological factors are heightened. Moreover, back pain was not associated with pubertal growth spurt, decreasing the possibility of a physiologic bias for a functional somatic symptom. Furthermore, the authors acknowledge that the main limitation of their study is that most participants were assessed at mid-pubertal stage, missing some effects of early pubertal development. In turn, future studies should explore both early pubertal and post-pubertal associations with specific FSS. General pediatricians should be aware of the functional somatic symptoms most commonly associated with puberty in order to reassure parents, provide supportive care, and evaluate possible pathological causes in a cost-effective manner.
Submitted by: Hassan Hamandi

Kim et al. Relationship between weekend catch up sleep and poor performance on attention tasks in Korean adolescents. Arch. Peds and Adol Med. 2011;165(9):806- 812.
Summary and Implications For Your Practice:
During adolescence, there are many sleep changes that develop secondary to increased daily academic and social stressors. Sleep changes include shorter sleep duration, delayed sleep phase, and greater discrepancy between week day and weekend sleep. In order to compensate for that sleep discrepancy, adolescents tend to sleep more on weekends. In this study, the authors followed urban high school students ages 14-19 years. Each student completed questionnaires regarding sleep habits, a Korean version of the Beck Depression Inventory, and computerized attention tasks (sustained tasks and divided attention tasks). In these attention tasks, omission errors are defined as failure to respond to target while commission errors are defined as inappropriate response to target (impulsive response). Results showed that weekday sleep duration, once controlled for age, sex, depressive mood, and snoring, did not predict the number of omission and commission errors. However, increased weekend catch up sleep was significantly associated with omission errors, but not commission errors, on sustained and divided attention tasks. The authors do mention that sleep duration during the week is not consistent across the population, and some individuals have different sleep needs. Sleep on school nights also does not represent cumulative sleep insufficiency. Second, the basis of the study was self-reporting which can have associated pitfalls. Lastly, the design is cross-sectional and not a prospective study with interventions. I think this study shows the necessity to ask patients, especially adolescents, about their sleep habits during the week. I feel the question regarding sleep is sometimes overlooked, and this experiment shows the need to discuss sleep hygiene with patients and their families. Unfortunately, the authors did not discuss interventions to aid in sleep hygiene or institute theories to improve adolescent wakefulness during the week.
Submitted by: Ben Goldstein

Garrison M, et. al. Media use and child sleep: the impact of content, timing, and environment. Pediatrics. 2011;128(1): 29-35.
Summary and Implications For Your Practice:
The purpose of this study was to determine the effects of media on sleep problems in children between the ages of 3 and 5. Data was obtained prospectively from families in community pediatric practices. Parents were asked to complete a media diary detailing the amount and the time of day that their child watched television, as well as the violence ratings of the programs they watched (e.g. PG for movies, Y for television). The diary also included information on video games and computer time. Parents were also asked to report whether their child had a television set in his/her room. Additionally, parents completed a sleep questionnaire. The data showed that increased evening screen time, as well as increased exposure to violent media during the day, was associated with increased sleep disturbances (e.g. increased sleep onset latency, nightmares, frequent nighttime awakenings, difficulty waking up in the morning). This finding was not present with violent nighttime programming. Children who had a television in their room had more sleep problems overall (29 percent versus 17 percent) than children without a television in their room. Children with a TV in their room watched more television both overall (109 minutes per day versus 69 minutes per day) and after 7pm (27.6 minutes per day versus 12.6 minutes per day). As pediatricians, not only should we tell parents that minimizing evening screen time can help alleviate sleep problems, but eliminating exposure to violent programs, even hours before bedtime, can also have beneficial results.
Submitted by: Ronen Stein

Wenger O, et al. Underimmunization in Ohio’s Amish: parental fears are a greater obstacle than access to care. Pediatrics. 2011;128(1):79--85.
Summary and Implications For Your Practice:
The purpose of this study was to explore vaccination patterns and attitudes towards vaccination among the Amish community in Holmes County, Ohio. The county is located 100 miles south of Cleveland and is home to the largest Amish community in the United States. Of the 1,000 surveys mailed to Amish homes in the county (5% of the population) only 360 completed surveys were received. The results showed that 68% of respondents had vaccinated all of their children, 17% had vaccinated at least one of their children, and 14% had not vaccinated any of their children. The top three reasons given for not vaccinating children were health related (too many side effects, dangerous chemicals in vaccines, dangerous germs in vaccines). In fact, 82% of parents who completely refused to vaccinate their children stated that they would reconsider if they knew that the vaccines were safe. Complete refusals to vaccinate related to religious beliefs or the cost and availability of vaccines were cited by fewer than 10% of respondents. The study also explored reasons why parents in the community would choose to give their children some, but not all, vaccines. Common responses included concerns about the number of shots on the vaccine schedule, the number of shots given at one time, the ability of babies to handle shots at a young age, and the belief that some vaccines come from aborted fetuses (according to the article, the Rubella and Varicella attenuated viruses were originally developed using tissues obtained from an aborted fetus). This study provides a better understanding about Amish attitudes regarding vaccination. The beliefs presented in the study are not too different from attitudes in the general population. Clearly clinicians need to explore reasons for vaccine refusal on an individual basis, but the knowledge that concerns regarding safety are the more frequently cited reason for vaccine refusal in the Amish community may help guide discussions with individual patients.
Submitted by: Ronen Stein
Comment: This article is highly relevant to us since many children of Amish families receive care at Rainbow. It is interesting that safety concerns included developmental regression and neurologic sequellae but no mention of autism. One wonders if the adverse events were reported to VAERS and/or are “rural legend”. LF

Hematology and Oncology:

Korbling et al. Adult stem cells for tissue repair - a new therapeutic concept? NEJM 2003;349(6):570-582.
Summary and Implications For Your Practice:
This article describes a wide variety of the potential uses of adult stem cells. In current practice, there are limited implications; however the future research potential is enormous, especially in the bone marrow transplant (BMT) patient population. This article is a comprehensive review of the research to date on peripheral stem cells and their potential application to multiple medical issues. The most interesting study mentioned in this review involved a group of male patients who received a matched peripheral stem cell transplant from a female donor. In this group of patients, liver biopsy was performed which showed between 4 and 43% of hepatocytes were female in origin. The importance of this is two-fold. First, peripheral stem cells have some ability to generate non-hematopoietic adult cells (whether by transformation or if they represent a population of solid organ stem cells in circulation is not clear). Second, this represents a potential therapeutic intervention for patients with organ damage. However, to date there has been limited progress in determining the necessary signaling to generate clinic results.
Submitted by: Seth Rotz

Infectious Disease:

Schnadower, D et al. Sterile cerebrospinal fluid pleocytosis in young febrile infants with urinary tract infections. Arch Pediatr Adolesc Med. 2011;165(7):635-641. Summary and Implications For Your Practice:
Urinary tract infections (UTI) are the most common serious bacterial infection in febrile infants. Sterile cerebrospinal pleocytosis (SCP) is sometimes seen in these infants and thought to be caused by a systemic inflammatory response and/or concomitant viral meningitis. This multi-center retrospective review of 20 North American emergency departments examined the prevalence of SCP (≥10 WBCs without bacterial meningitis) in febrile infants with a UTI. Patients were 29-60 days old with 1) documented temperature ≥38°C, 2) positive single organism urine culture from suprapubic aspiration or catheterization, and 3) non-traumatic lumbar puncture(<1000 RBCs). From 1190 patients, 241 had SCP (18%). Patients with a peripheral WBC ≥15 were found to have twice the odds for developing SCP. In low risk patients (no significant medical history, not clinically ill in ED), the clinical course was the same regardless of SCP. Course was compared by time to defervescence, length of antibiotic treatment, length of hospitalization and adverse events (ex. PICU, surgery, death). However, patients with SCP usually had longer antibiotic treatment. This study had a large and varied sample, but limited age range and lack of testing for concomitant viral meningitis. However, it is reassuring to recognize that SCP may occur in febrile infants with UTI and their clinical course is likely the same as an infant without SCP. This may help decrease costs and adverse events from longer hospitalizations and antibiotic courses in otherwise healthy patients. Further studies with wider age range and viral CSF testing may be helpful to make these results more generalizable. Submitted by: Julie Abraham
Comment: This very interesting finding was reported well over a decade ago (Pediatr Infec Dis J 2001) and the mechanism appears still speculative (?endotoxin/inflammatory molecule effect from gram negative organisms?). However, it is a remarkably common event, and as Dr. Abraham points out, this information should save affected infants unnecessary treatment. LF

Neonatology:

Franck LS, Oulton K, Nderitu S, Lim M, Fang S, Kaiser A. Parent involvement in pain management for NICU infants: a randomized controlled trial. Pediatrics 2011; 128(3):510-518.
Summary and Implications For Your Practice:
This is a randomized controlled trial done in four NICUs in London to demonstrate the feasibility as well as benefits of parental involvement in pain management of NICU patients. Two NICUs were controls, in which parents received only a general booklet about NICU care and a general visit from a research nurse. The other two NICUs were the intervention group, where parents received the generic booklet as well as a booklet about infant pain assessment, management, and comforting techniques. This group of parents also received two visits from a research nurse to be educated about comforting techniques. Parents were given standardized surveys to assess stress related to NICU admission, attitudes about infant pain, nursing pain assessment, and parent competence and role attainment after discharge. Of the 169 parents in the final sample, there were some population differences between the control and intervention groups; e.g. more control mothers had medical problems, more parents in the intervention group had to wait longer than 24 hours to hold their infants, and the intervention group of parents had lower mean state anxiety levels at baseline. Results of the surveys showed that the parents who received education about infant pain and comforting techniques had the same level of stress compared to the control group, but importantly they were more satisfied with pain information, assessment, and management, and they demonstrated a higher level of role attainment after discharge. Parents value involvement in infant comforting, and education about pain management helps parents feel more competent in their roles after discharge.
Submitted by: Lauren Ebe
Comment: Although these results may seem intuitive, this level of parent engagement is one more step along the remarkable path that Drs. Kennell and Klaus began decades ago with their work on bonding. LF

Psychiatry:

Sawyer, Michael, et.al. Four year prospective study of BMI and mental health problems in young children. Pediatrics October 2011;128(4):e677-684
Summary and Implications For Your Practice:
This prospective study examined the relationship of high body mass index (BMI) levels at 4-5 years of age and future quality of life and mental health at 8-9 years of age. Mental health was evaluated using the Strengths and Difficulties Questionnaire and heath-related quality of life was assessed using the Pediatric Quality of Life Inventory. Results showed that an increased BMI at 4-5 years of age by one SD correlated with a 15-20% chance of increased peer problems (95% CI: 1.02-1.28 reported by parents and 1.04-1.37 by teachers) at age 8-9 years. In addition, teachers reported more emotional problems for those with increased BMI. Children at age 8-9 years who had experienced a large increase in BMI were reported to have problems with teasing and rejection by peers, not participating in activities with peers, and had less friends. There was no association with increased BMI and mental health issues in this cohort. Previous studies showed a relationship between mental health issues and being overweight, but this association was seen after ending regular schooling. With the childhood obesity epidemic present today, pediatricians should recognize increased BMI at a young age and discuss with parents and patients the importance of a healthy weight and exercise. It is also important to talk with obese children about their interactions with peers and school issues. Although this study did not find an association with mental health problems and increased BMI, it appears that many overweight children suffer from poor peer relationships and emotional issues.
Submitted by: Lauren Riney

Pulmonology:

Garrison, M et al. Cotroller medication use and sleep in pediatric asthma. Arch Pediatr Adolesc Med. 2011;165(9):826-830.
Summary and Implications For Your Practice:
Children with asthma have increased risk for sleep problems, including delayed onset, increased awakenings and daytime fatigue, which can lead to negative outcomes in behavior, academic performance and health (i.e. obesity). Previous studies demonstrate that use of asthma controller medications, compared to placebo, have improved sleep. This case-crossover study examined the impact of controller medication use and adherence on sleep problems in 2-10 year old children enrolled in an Internet-based asthma education study. Patients were on controller medications prescribed by their primary medical doctor and had persistent asthma classified by the National Asthma Education and Prevention Program guidelines. Outcomes were based on parental report of symptoms at baseline, 6 months and 1 year, with education as the intervention. Results were significant for decreased odds of daytime sleepiness with any inhaled corticosteroid (ICS) use and decreased risk of sleep onset delay with leukotriene inhibitor (LTI) use, regardless of concurrent ICS. Outcomes regarding sleep were not controlled for factors such as home environment or smoke exposure, which are commons problems in our patients. However, the demonstrated effectiveness of LTI’s may be applicable as it was thought to be due to the high co-morbidity of obstructive sleep apnea and allergic rhinitis in patients with asthma. This may be a useful application of LTI’s in our RAP clinic population with asthma and sleep problems.
Submitted by: Julie Abraham
Comment: This information supports adding a LTI to an asthma regimen especially if the patient is having sleep issues. It would also make sense to screen for other issues such as obstructive sleep apnea. LC

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