September 2011 Journal Watch

Behavior and Development:

Ozonoff S, et al. Recurrence risk for autism spectrum disorders: a baby siblings research consortium study. Pediatrics, Sept 2011;128(3):e1-e8.
Summary and Implications For Your Practice:
Due to limitations of previous research, the actual recurrence risk of autism spectrum disorders among siblings is not clearly known. Small sample sizes of various studies have resulted in recurrence rates ranging from 3-10% whereas twin studies have shown rates as high as 90%. This paper describes a prospective longitudinal study that followed 684 infants that had an older sibling diagnosed with an autism spectrum disorder. They were followed until 36 months of age and then classified as being on the autism spectrum or not by the Autism Diagnostic Observation Schedule and by receiving a clinical diagnosis by an expert in the field. Among the infants followed, 18.7% developed an autism disorder and a higher risk correlation was present for males as well as if there was more than one older affected sibling. This paper is very helpful in being able to provide parents with concrete and accurate statistics of recurrence of autism spectrum disorders in siblings. It encourages the primary care pediatrician to have close surveillance of siblings of children with autism, as well as educate parents to monitor development and milestones carefully. Any red flags should prompt referral and appropriate intervention as opposed to simple close monitoring. Finally, this is the start of paving the way for genetic testing and genotyping for autism disorders in the future.
Submitted by: Ivana Dylag

Goulardins JB et. al. Quality of life and psychomotor profile of children with attention deficit hyperactivity disorder (ADHD). Archives of Neuro- Psychiatry. August 2011:69(4)
Summary and Implications For Your Practice:
This study investigates the possibility that there is a correlation between ADHD and psychomotor delay. Children with ADHD and developmental delay specifically psychomotor type can be a challenge to treat medically. It is imperative that that their developmental progress and evaluation be sought so that therapy for ADHD can be geared towards offering the best quality of life. This study looked at children between the ages of 7-10. In total, 14 children were scored using the Pediatric Quality of Life (Peds QL) and the motor development scale. The presence of hyperactivity and attention deficiency presented with adversely negative quality of life and a motor skill delay in a large majority. Although more than half the children were considered normal, others were categorized as normal low, and low. There was also a significant correlation between other developmental categories and ADHD including emotional, gross motor and organizational. Routinely we are keen to treat ADHD with medical therapy. The role of this article emphasizes the positive correlation between ADHD coexisting with psychomotor developmental delay impacting quality of life. We are encouraged to routinely screen individuals suspicious of delay. Additionally, by identifying these individuals we can gear therapy to improve their motor development and in turn their quality of life.
Submitted by: Madiha Raina

Ghanizadeh A. Sensory processing problems in children with attention deficit hyperactivity disorder (ADHD): a systematic review. Psychiatry Investigation 2011;8: 89-94.
Summary and Implications For Your Practice:
This article looks at the correlation of attention deficit hyperactive disorder (ADHD) with sensory processing problems. Sensory processing can be specifically divided into sensory hypersensitivity, sensory under-responsivity and sensory seeking. This study is based on a systemic review used to evaluate sensory processing problems in children with ADHD. It confirmed that sensory processing difficulties are more common in children with ADHD than in other children. Additionally, the review found that sensory symptoms positively correlate with behavioral problems such as aggression and delinquency. Various sensory components were evaluated in the review. Tactile defensiveness, such as not wanting your hair brushed, is associated with ADHD as well as an increase in anxiety. One-third of children with ADHD were also found to have deficits in vestibular systems leading to poor balance and coordination. In addition, although auditory processing is not well evaluated in children with ADHD, it has been found to be more impaired than those without any disability. Finally, olfaction and odor sensitivity is better in children with ADHD most likely due to their high stimulation at baseline. This review is helpful in making the pediatrician aware of sensory processing problems in patients with ADHD. Questions about sensory processing should be asked at visits and managed properly through various behavioral techniques. Minimization of sensory processing deficits may lead to improvement in aggression, delinquency, and hyperactivity. Anticipatory guidance should be given to parents in order to increase awareness and identification of difficulties in sensory processing.
Submitted by: Ivana Dylag

Rossignol DA, Frye RE. Melatonin in autism spectrum disorders: a systematic review and meta-analysis. Developmental Medicine & Child Neurology. 2011; 53:783-792.
Summary and Implications For Your Practice:
Rossignol and Frye perform a meta-analysis, including 5 randomized control trials, investigating the effectiveness of melatonin in autism spectrum disorders (ASD). Kids with ASD have a higher prevalence of sleep abnormalities (40% - 86%) and there are possible associations between developmental regression in ASD and sleep abnormalities. Patients with ASD have also been found to have disordered synthesis and metabolism of melatonin. This analysis found that the majority of individuals with ASD have low levels of melatonin or its derivatives, possibly contributing to higher rates of sleep disorders. While the prevalence of therapeutic use of melatonin in this population is only 7%, meta-analysis revealed significant improvements in sleep duration (+44 min v. placebo) and sleep onset latency (+39 min v. placebo) with minimal side effects. The mechanisms of melatonin action in ASD patients are potentially multifaceted. Possibilities include melatonin deficiency replacement, anti-inflammatory/anti-oxidant properties improving the chronic inflammation of ASD, stimulation of CD4+ cells (also potentially deficient in ASD), and effect on the reported imbalance of glutamatergic and GABAergic neurotransmitters. Appropriate systematic selection of articles and statistical analysis gives this article more credibility despite the small sizes and differing sleep parameters recorded across the studies. This study highlights some interesting benefits of melatonin in patients with ASD, demonstrating improvements in sleep patterns with minimal side effects. While the mechanism of action is unknown, the clinical benefits, side effects, cost and availability of melatonin make it an attractive choice for medical management of sleep disturbances in kids with ASD.
Submitted by: Ivana Dylag
Comment: This preliminary work supports a therapeutic trial of melatonin in children with ASD diagnosis and sleep problems, although there is no reason to abandon concurrent developmental guidance. LF

Pierce K, et al. Detecting, studying, and treating autism early: the one-year well-baby check-up approach. J Pediatr. 2011 Sep;159(3):458-465.e6. Epub 2011 Apr 27.
Summary and Implications For Your Practice:
The American Academy of Pediatrics has recently made screening for autism spectrum disorders a goal for all pediatricians at the 18 to 24 month well child visits. The improvement of early intervention of outcomes for children with autism spectrum disorders has brought to light emphasis on earlier screening and treatment for affected children. The goal of this study was to validate the Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist (CSBS-DPIT-Checklist) as a prospective measure for autism screening. In this study, 137 pediatricians participated and 10,479 infants were screened at 1 year of age without exclusion criteria. The screens were scored immediately and 346 of 1318 screens that were failed were referred to the academic center for further testing. Of those referrals, 184 infants were seen for two testing sessions and 66 controls made up the 225 infants in the final study population. Of the 184 infants who initially failed the screen, 32 infants received a provisional or final diagnosis of autism spectrum disorder, 56 of learning disability, nine of developmental delay, and 36 of ‘‘other.’’ The positive predictive value was estimated to be 0.75. Screening tests are designed to catch all individuals who might be at risk for certain disorders or diseases. Screening tests for autism at such an early age where communication and behavior assessments are limited can be a challenge. Taken together, these data suggest that earlier screening for autism might be beneficial in initiating therapy earlier by more timely screening and evaluation.
Submitted by: Andrew Dylag

Cardiology:

Kaneko K, Yoshimura K, Ohashi A, Kimata T, Shimo T, and Tsuji S. Prediction of the risk of coronary arterial lesions in kawasaki disease by brain natriuretic peptide. Pediatric Cardiology. April 2011.
Summary and Implications For Your Practice:
Many studies have focused on identifying biomarkers predictive of the risk of development of coronary arterial lesions (CAL) in patients with Kawasaki Disease (KD). Unfortunately, no single useful marker has been elucidated. This study examined the utility of serum concentrations of the N-terminal moiety of brain natriuretic peptide (NT-proBNP) as a predictor of the development of CAL in KD. 43 patients meeting the diagnostic criteria for KD were enrolled in the study, of which 6 went on to develop CAL despite appropriate IVIG therapy. Serum NT-proBNP levels as obtained from sampling performed on admission prior to initiation of IVIG therapy were found to be significantly higher in the children who later developed CAL than in those who did not (2,611 ± 1,699 vs. 1,073 ± 1,427 pg/ml; p = 0.03.) Implementing a cutoff value for serum NT-proBNP of 1,000 pg/ml to predict CAL resulted in a sensitivity of 0.83, specificity of 0.68, and an odds ratio of 10.4. No other significant differences were found between the CAL+ and CAL- groups. This study suggests that development of CAL in KD patients is associated with an increased serum NT-proBNP before IVIG and that KD patients with serum NT-proBNP levels elevated beyond 1,000 pg/ml may have up to a ten-fold increased risk for development of CAL as compared to patients exhibiting a lesser increase. This study is the first known to report an association between serum NT-proBNP measurement and development of CAL in KD and to suggest its utility in prediction of risk for development of CAL. Limitations of the study include small sample size and lack of in depth evaluation of underlying factors known to affect serum NT-proBNP levels. Further study is needed to examine the mechanism behind elevation in serum NT-proBNP level in KD as well as the potential relationship between NT-proBNP levels and treatment efficacy.
Submitted by: Danielle Bennett

Dermatology:

Hu S and Bigby M. Pityriasis versicolor: a systematic review of interventions. Archives of Dermatology. 2010; 146:1132-1140.
Summary and Implications For Your Practice:
This systematic review highlights the lack of universal guidelines in the treatment of pityriasis versicolor (PV). The authors analyzed controlled trials investigating the treatment of PV in children and adults. These trials compared oral or topical agents with placebo, the same agent at varying therapeutic doses, or different systemic or topical agents in the treatment or prevention of PV. Two outcomes were measured – the eradication of the infection as evidenced by potassium hydroxide preparations and the secondary outcomes as verified by Wood’s lamp examination and clinical resolution. Both systematic and topical treatments were found to be efficacious. However, the majority of studies did not meet the author’s inclusion criteria for a high-quality study. Topical agents were found to be more effective than placebo and longer duration with higher concentration agents result in lower rates of recurrence. One to four weeks of topical treatment, including ketoconazole shampoo, imidazole cream, selenium sulfide shampoo, or zinc pyrithione shampoo is recommended. The data also supports that oral agents at varying dosages and durations are safe and effective. Overall this review highlight the need for further high quality studies comparing different agents, concentrations, and durations as well as effective prophylaxis. Due to the lack of conclusive results, this review does not provide concise guidelines for the treatment of PV. However, it does provide an outline for duration and dosage of oral and topical treatments. These dosage and duration recommendations can be useful in my personal practice in RAP clinic.
Submitted by: Meg Oberle

Endocrinology:

Pacifico L, et al. Low 25(OH)D3 levels are associated with total adiposity, metabolic syndrome, and hypertension in caucasian children and adolescents. European Journal of Endocrinology. July 2011.
Summary and Implications For Your Practice:
This cross-sectional study is conducted to examine the association between serum levels of 25-OH Vitamin D and metabolic syndrome (MetS) with its components (obesity, hypertension, hypertriglyceridemia, low high-density lipoprotein (HDL), insulin resistance) in adolescents. The sample consisted of 304 overweight/obese children and 148 healthy children. The degree of obesity was quantified according to body mass index (BMI). Dietary intake of calcium and vitamin D (Vit D) were assessed via a 3- day recall, and adequate intake was defined as 200 IU/day. Blood fasting concentrations of 25(OH)D3, glucose, insulin, total cholesterol, high-density lipoprotein (HDL), cholesterol and triglycerides were determined for each participant. Levels of 25-OH Vitamin D were inversely related significantly to BMI, waist circumference, blood glucose, insulin, and triglyceride concentrations, and directly related to HDL concentrations. Serum 25(OH)D3 concentrations were significantly lower in patients with MetS compared with those without, and they decreased as the number of MetS components increased. Many studies in the adult population found this significant correlation between blood levels of Vit D and the components of MetS, and the protective role of Vit D against MetS. On the other hand, some pediatric studies showed association between low levels of Vit D and insulin resistance. This article focused on the importance of nutritional Vit D deficiency in overweight and obese children. Checking Vit D levels in this group is very important and replacement is necessary. I think additional studies looking into the effect of replacement of Vit D on weight loss and risk of MetS is necessary.
Submitted by: Nathalie El Ters

Balhara B, Madhusmita M, and Levitsky LL. Clinical monitoring guidelines for congenital hypothyroidism: laboratory outcome data in the first year of life. The Journal of Pediatrics. 2011;158(4):532-537.
Summary and Implications For Your Practice:
Left untreated, congenital hypothyroidism (CH) can have detrimental effects on normal brain development and children born with the condition are at risk of poor cognitive development in addition to behavioral problems. Newborn screening for CH has become common practice and early levothyroxine supplementation for these patients is the standard of care. Also crucial to improved outcomes in these children is appropriate laboratory monitoring to prevent development of clinical hypothyroidism and its potential sequelae. Current AAP guidelines for laboratory monitoring of thyroid function in CH recommend measurement of TSH and T4 every one to two months up to six months of age and every three to four months from six to twelve months of age, but these recommendations are based on little supporting data. This retrospective study sought to evaluate the adequacy of current guidelines for thyroid status monitoring through the first year of life. The charts of 70 children with CH were reviewed for initial TSH, frequency of follow-up, dosage changes, and T4/free T4 and TSH levels during the first year of life. Study criteria to determine need for monthly monitoring were based on guidelines for maintenance of T4/free T4 within the upper half of the normal range and rapid normalization of TSH. Based on study criteria, monthly monitoring was deemed necessary in 52 (74.3%) children in the first six months of life and in 25 (35.7%) children in the sixth through twelfth month of life. These results suggest that current recommendations may need to be reevaluated and that monthly monitoring through twelve months of age may be advisable. Further research is needed to determine the implications of this preliminary data on long-term outcomes as well as to help clarify the optimal frequency for monitoring of thyroid status in CH.
Submitted by: Danielle Bennett

Kaplowitz, Paul B. Subclinical hypothyroidism in children: normal variation or sign of failing thyroid gland. International Journal of Pediatric Endocrinology. 2010; 2010:1-8.
Summary and Implications For Your Practice:
This review focuses on the natural history and management of subclinical hypothyroidism (SCH). The authors analyzed several longitudinal studies following pediatric patients with initially elevated TSH and normal free T4. About one-third of patients showed a normalization of TSH over time; the majority of the remaining patients had persistent mild elevation of TSH with normal T4. The urge to treat SCH stems from the concern for delayed cognitive development and growth and increased lipid levels. From the literature reviewed, the authors made the following recommendations for the management of SCH: 1) Order only free T4 and TSH with initial evaluation. 2) If there is a normal total or free T4 with a TSH of 5-10 mU/L, the thyroid is generally not the cause of the patient’s symptoms. 3) If there a goiter or TSH>10 mU/L, treatment is indicated. 4) If there is no goiter and TSH <10, repeat TSH and T4 in 6-12 months. Thyroid antibodies can be measured with this evaluation. 5) TSH levels can be rechecked periodically for 2 years; although, more data is needed to establish a surveillance period. 6) If a patient under 2 years is treated for SCH, a one month trial off 1-thyroxine if the TSH is <5 mU/L is suggested at age 3 to revaluate thyroid function. These recommendations can be incorporated into my general pediatric practice. SCH can be initially followed without referral to endocrinology. This may prevent further blood draws and potential life-long treatment and is more cost and time effective.
Submitted by: Meg Oberle
Comment: These seem like very reasonable recommendations. True congenital hypothyroidism usually presents with very high TSH levels on the newborn screen, and these guidelines can serve to prevent unneeded referrals to endocrinologists. LC

Martin, David D. et. al. The use of bone age in clinical practice – part 1. Hormone Research in Paediatrics. 2011;76:1-9.
Summary and Implications For Your Practice:
This paper primarily reviews the role of bone age assessments in patients who present with short stature of undetermined etiology (other indications to assess a bone age include tall stature, precocious or delayed puberty, and congenital adrenal hyperplasia). A radiograph of the hand and wrist assesses the bone age. The bone age often corresponds better with parameters such as height velocity or menarche than the chronological age. Thus, pediatric endocrinologists can refer to the bone age for anticipatory guidance. Additionally, the bone age is “the only size-independent indicator of biological maturity routinely used from birth to adulthood.” The authors argue that assessing the bone age of patients with short stature is essential to narrowing the differential diagnosis, which includes constitutional growth delay, idiopathic short stature, small for gestational age, growth hormone deficiency, Turner syndrome, and chronic renal failure. As an example, a physician can feel comfortable ruling out growth hormone deficiency in a patient with short stature whose bone age is either equal to or advanced in relation to the chronological age. After reading this article, I am aware of the importance of assessing the bone age of patients with short stature, especially in regards to narrowing the differential diagnosis.
Submitted by: Hassan Hamandi

Gastroenterology:

Van der Pol, Rachel J., M.D. et. al. Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics 2011;127: 925-933.
Summary and Implications For Your Practice:
This systematic review assesses the efficacy of using proton-pump inhibitors (PPIs) to treat the symptoms of gastroesophageal reflux disease (GERD) in three pediatric age groups: infants, children and adolescents. In regards to the treatment of infants, the authors conclude that PPIs should not be used to treat GERD symptoms, based on multiple placebo-controlled studies that showed PPIs were either not effective or equally effective as placebo in relieving symptoms of GERD. Although pH- monitoring results indicated that PPIs are more effective in reducing gastric acidity, this did not translate into better relief of symptoms. Additionally, limited data on the short-term or long-term safety of using PPIs in infants supports this conclusion. In regards to the treatment of children and adolescents, randomized trials reported that PPIs are equally effective in reducing GERD symptoms compared with controls, which included ranitidine and various dosages of PPIs. It is important to note that PPIs were still more effective than ranitidine in reducing gastric acidity. Therefore, the authors conclude that physicians should be careful when prescribing PPIs for children and adolescents, because despite PPIs being well tolerated in the short-term, there is limited data about their safety in the long- term. After interpreting this systematic review, I will avoid using PPIs in infants to control the symptoms of GERD. Nonetheless, I would still consider using PPIs in children and adolescents, mainly due to their protective effects on the esophagus by reducing gastric acidity rather than their efficacy in actually treating symptoms. I would continually evaluate the need for children and adolescents to continue being on PPIs to ensure that these patients do not stay on these medications unnecessarily for extended periods.
Submitted by: Hassan Hamandi

General Pediatrics:

Carter et al, Longitudinal analysis of sleep in relation to BMI and body fat in children: the FLAME study. BMJ 2011; 342:d2712 Summary and Implications For Your Practice:
The rate of obesity among children is an ever-concerning problem. The Family Lifestyle, Activity, Movement and Eating (FLAME) study is a cohort observational study examining factors in early childhood that may contribute to obesity. Children that were born at Queen Mary Maternity Unit, the sole maternity hospital in Dunedin, New Zealand, between July 19, 2001 and January 19, 2002 and still living in Dunedin were recruited to participate in this study. Children were excluded if they were premature, one of a multiple birth, had major congenital anomalies, mother had postnatal illness, or they were likely to move in the next two years. 413 children were eligible and 244 children participated. The children were seen every 6 months between age 3 and age 7 years. Diet and accelerometry were assessed at ages 3, 4, and 5 years. Accelerometry measured sleep and physical activity with a device that attached to the child’s waste. This device was worn 24 hours a day for five consecutive days while the parents were simultaneously completing a daily activity log. Mean duration of sleep at all three ages was 11 hours per night. The reported length of sleep was greater than the measured length of sleep by about 20 minutes. Each additional hour of sleep per night at ages 3 to 5 years was associated with a reduction of 0.49 in BMI at age 7 years. This corresponds to 0.7kg. As a result of reading this article, I will encourage parents of my patients to ensure their 1-3 year old is getting 12-14 hours of sleep per night. Setting that pattern early will help create good sleep habits and possibly help in the fight against obesity.
Submitted by: Catherine Walker
Comment: There have been other studies that show a relationship between lack of sleep and obesity. It would be interesting to see if this holds true for other socio-economic and ethnic groups. It is fascinating how much information is being discovered about how sleep affects our health and well-being in general. LC

Kim JJ, Goldie SJ. Health and economic implications of HPV vaccination in the United States. New England Journal of Medicine. Aug 21, 2008; 359(8):821- 832. Summary and Implications For Your Practice:
In the United States, there were 11,150 new cases of cervical cancer and 3600 cervical cancer deaths in 2007. Human Papillomavirus (HPV) causes 100% of cervical cancers and 90% of anal cancers. HPV-16 and HPV-18 cause 70% of the cases of cervical cancers worldwide. HPV-6 and HPV-11 cause most of the cases of genital warts and juvenile-onset recurrent respiratory papillomatosis. Juvenile-onset recurrent respiratory papillomatosis occurs in children who were exposed to HPV during delivery and produces laryngeal papilloma that frequently recur and require many surgeries. It is the most common cause of hoarseness and airway obstruction in children. The Gardasil vaccine protects against HPV-6, HPV-11, HPV-16, and HPV-18. The goal of this study was to determine the cost-effectiveness for prophylactic vaccination against HPV in the US. Assuming the vaccine provided lifelong immunity, the cost-effectiveness ratio of vaccination of 12-year-old girls was $34,900 per quality-adjusted life-year (QALY) gained compared with current screening practices. Extending a temporary catch-up program for 18-year-old girls was $81,000 per QALY; $101,300 per QALY for 21-year-old women; and $133,600 per QALY for 26-year-old women. If immunity lasts for only 10 years, the vaccination of 12-year-old girls $144,100 per QALY and all catch-up strategies become less cost-effective than screening alone. In these types of studies, often $50,000 per QALY gained is considered a good outcome and $100,000 per QALY gained is considered an upper-bound threshold.
Submitted by: Catherine Walker

Horne RSC, et. al. Elevated blood pressure during sleep and wake in children with sleep-disordered breathing. Pediatrics. 2011;128:e85-e92. Summary and Implications For Your Practice:
This article addresses the association of hypertension and sleep disordered breathing in children. These concerns, including snoring and apnea, are primarily associated with adenotonsillar hypertrophy in the pediatric population. However, these patients are only surgically treated when the obstruction is severe. This study assessed 105 children that qualified for some degree of sleep disordered breathing based on the obstructive apnea/hypopnea index (OAHI). 36 non-snoring controls were included. The subjects were measured using routine polysomnography and had continuous blood pressure, mean arterial pressure, and heart rate monitoring. The blood pressure was observed right before falling asleep, during non-rapid eye movement, slow wave sleep, and REM sleep. The results were consistent with an elevation in blood pressure by 10 to 15 mm Hg in the sleep disordered breathing groups in comparison to the controls. The elevations were found in all categories of sleep disordered breathing (primary snoring, mild and severe obstructive sleep apnea, etc.) and did not correlate with the severity of sleep disruption. Due to this correlation between hypertension and sleep disordered breathing, it is crucial to ask at visits about problems with sleep including snoring and apnea. This may lead to early detection and prevention of cardiovascular abnormalities including resetting baroreceptors and/or endothelial damage of microvasculature. Sleep disordered breathing is also an additional etiology to consider with a patient with hypertension. The identification, screening and threshold for treatment of sleep disordered breathing are important factors the pediatrician should be aware of in order to prevent long term cardiac damage.
Submitted by: Ivana Dylag
Comment: It is reasonable to routinely ask about signs and symptoms of sleep apnea at well care visits; however, this study presents more questions than answers! Does transient hypertension affect long term cardiac morbidity, and if so, does treatment of “sleep disordered breathing” correct this hypertension, and so on. Food for thought; questions for future research. LF

Weiss K, Fattal-Valevski A, Reif S. How to evaluate the child presenting with an apparent life-threatening event? Isr Med Assoc J. 2010 Mar;12(3):154-7. Summary and Implications For Your Practice:
According to the National Institutes of Health, an apparent life-threatening event (ALTE) is “an episode that is frightening to the observer and is characterized by some combination of apnea, color change, change in muscle tone, choking or gagging.” The common practice is to admit infants for observation. This study looked at the yield of different tests performed during an ALTE admission between 2003 and 2006 at Dana Children’s Hospital. This retrospective study identified 69 infants, with the average age of 8 weeks. Patients were divided into high risk (41 infants) and low risk (28 infants) groups based on the presence of an abnormal perinatal history, recurrent episodes, or an abnormal physical exam. A diagnosis was reached in 36% of cases based on a diagnostic test. There was a significant positive correlation between abnormal tests results and abnormal findings on physical exam (p=0.001) and perinatal history (p=0.017), where the yield of a diagnostic testing in the low risk group was 14% and 51% in the high risk group. Tests that were non-contributory were CBC, urinalysis, electrolytes, blood gases, brain ultrasounds, blood/urine cultures. Tests with positive yield were upper GI, 24hr pH monitoring (43%), chest X-ray (21%), RSV antigen (8%) and electroencephalogram (4.5%). Thus, most diagnostic tests routinely done for an ALTE are not helpful, especially in an infant with a normal perinatal history and physical exam. In high risk infants, tests for gastroesophageal reflux, respiratory infections and seizures have the highest yield. ALTE is a common reason for admission that often includes an extensive and costly work-up for possible etiologies. The standard work-up for ALTEs could be more limited and cost-effective based on the findings of a good history and physical exam.
Submitted by: Gillian Tam
Comment: “ALTE” has always represented a vast array of symptoms and presentations. I agree that a thorough history and physical exam can and should be the guide for what work-up to perform. LC

Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010 Jun;125(6):1168-77. Summary and Implications For Your Practice:
This study looked at button battery ingestions and studied possible outcome predictors and trends. Three databases were used, including the National Poison Data System (56,535 cases, 1985-2009), the National Battery Ingestion Hotline (8,648 cases, 1990-2008) and cases reported in medical literature (86 cases). The number of battery ingestions in the US have not changed greatly over the last 20 years, with 68% occurring in children <6 years and 30% in children aged 6 through 9. However, major or fatal outcomes of button cell ingestions have increased almost 7-fold between 1985 and 2009. Complications include tracheoesophageal fistulas (47%), esophageal perforations (23%), esophageal strictures (38%), vocal cord paralysis (10%), infections, and fistulas into major vessels. The diameter of ingestions has increased, where large-diameter (>20mm) batteries accounted for 1% in 1990 and then 18% in 2008. The chemistry in battery has also changed, with an increased in the number of lithium battery ingestions and a decrease in alkaline, zinc and silver oxide batteries. Outcomes were significantly worse for large-diameter lithium batteries (92% of adverse cases) and children who were <4 years old (92% cases). It is unfortunate that most fatal (92%) or major outcome (56%) ingestions were un-witnessed, so 27% of major and 54% of fatal cases were misdiagnosed because of nonspecific presentations. As technology becomes more advanced, so are the toys and the batteries that power them. There should be emphasis to families about keeping small toys and batteries away from children. It is also important to correctly diagnose foreign body ingestions and keep it in mind as a possible diagnosis because ingestions are often times un-witnessed.
Submitted by: Gillian Tam

Terrell, LR et al. Acceptability of the vaginal contraceptive ring among adolescent women. J Pediatr Adolesc Gynecol 2011;24:204-210. Summary and Implications For Your Practice:
The authors of this study postulate that wider use of new forms of contraceptive delivery will help address unintended adolescent pregnancy. They designed this cross- sectional study to use computerized interview to identify patient factors that influence willingness to try the vaginal ring. Participants were 200 14-18 year old females from urban adolescent clinics in Indiana. Study measures included demographics, sexual history, contraceptive history, experience with pelvic exams/vaginal products, a genital comfort scale, and attitude towards using vaginal ring. Results of the study showed significant association between willingness to try a vaginal ring and with: previous use of the contraceptive patch, positive feeling about one’s genitals, not fearing ring dislocation, not embarrassed by their genitals, comfort with proposed insertion methods and appeal of ring advantages. The authors point out that doctors are the most trusted source for contraceptive information and that one-third of their study participants were willing to try the vaginal ring after education about the method. This study provides more evidence that discomfort with one’s genitalia is a main barrier to the use of the vaginal ring. Underage pregnancy is relevant to the patient population of Rainbow. Our patients could profit from the advantages of a vaginal ring providing contraceptive effect without the tri-monthly doctors visits, injections, daily pills, visible patches, and side effects of higher estrogen doses. Weaknesses of the study include the non-randomized, non-controlled design, small sample size, and unvaried population demographics. The study may have been underpowered to detect significant associations between willingness to use the vaginal ring and sexual history or contraceptive history. Finally, the NuvaRing is still under patent, and without the availability of generic forms, expense may be a real barrier to use.
Submitted by: James Brown

Rasmussen CA, Soleimani M, Pei J. Executive functioning and working memory deficits on the CANTAB among children with prenatal alcohol exposure. J Popul Ther Clin Pharmacol. 2011;18(1):e44-e53. Summary and Implications For Your Practice:
Fetal alcohol spectrum disorder (FASD) defines various physical and cognitive abnormalities among children with prenatal alcohol exposure. Facial dysmorphology, CNS deficits, growth deficiencies, and severity of prenatal alcohol exposure are graded. Neurobehavioral deficiencies common to FASD include deficits in attention, processing speed, visual-spatial ability, memory and executive functioning. Executive functioning is defined as higher-order cognitive processes involved in conscious goal-directed thought and action that utilize working memory, planning, inhibition, flexible thinking and strategy. This historical prospective study uses a computerized, interactive and non-verbal neuropsychological test, CANTAB, and applies it to FASD patients to examine executive functioning. By using this test in fifty 6-7 year old patients (26 controls), this study confirmed that children with prenatal alcohol exposure had deficits in spatial span and spatial recognition memory, important elements of executive functioning. This suggests that the underlying mechanism of cognitive impairment in FASD could be the decreased ability to hold and manipulate information and to manage goals in working memory. The CANTAB’s interactive and non-verbal methods control for attention-deficits in FASD patients that may confound results of other executive function testing. This study highlights the specific cognitive deficits common to many children that fall along the fetal alcohol spectrum. FASD is challenging to diagnose and treat because of the high variability of deficits observed. This study may help focus treatment goals of the physician and neurobehavioral teams on these executive function deficiencies. By doing so, the patients cognitive functioning may be improved by specifically targeting spatial recognition and working memory.
Submitted by: Kevin Overmann

Gooze, RA et al. Prolonged bottle use and obesity at 5.5 years of age in United States children. J Pediatr. 2011 Sep;159(3):431-6. Summary and Implications For Your Practice:
A constant goal of pediatric care is prevention of obesity and its related consequences. Interventions that can attain these goals, however, have not been shown to have significant consequences. The goal of this study was to examine a cohort of American children to see if any factors independently predicted obesity at a later age. The authors studied the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), 6750 children in all [change phrase after comma to, “which consisted of 6750 children.”]. The primary outcome was obesity and the exposure was parental report of bottle use at 24 months. Results of the study showed that the prevalence of obesity at 5.5 years was increased in children who were using a bottle at 24 months (22.9% vs 16.1%) and the odds ratio for prolonged bottle use was 1.33 (CI 1.05 to 1.68) after controlling for several potentially confounding variables. General pediatricians are always striving to improve anticipatory guidance during the short time of well care visits. While proper nutrition should be a focus of all well child visits, this article offers a targeted intervention that can improve obesity rates and potentially reduce the childhood obesity epidemic.
Submitted by: Andrew Dylag
Comment: Anticipatory guidance recommending open cup introduction by 9 months is one approach supporting this intervention. However, ongoing bottle use at 24 months can be the “tip of the iceberg” for behavioral issues relating to nutrition, dental hygiene, sleep, and self-soothing. LF

General Surgery:

Weihmiller S, et al. Risk stratification of children being evaluated for intussusception. Pediatrics 2011;127:e296-303.
Summary and Implications For Your Practice:
Intussusception is a common cause of intestinal obstruction in young children and is often consider in children presenting to the Emergency Department with nonspecific gastrointestinal complaints. This study sought to establish predictive clinical criteria and create a decision tree to risk stratify children with possible intussusception. Included in this prospective cohort study were 310 patients, 38 of which where ultimately found to have intussusception. Significant predictors included male gender, age older than 6 months, presence of bilious vomiting and lethargy by history. Patients with positive or concerning abdominal X-rays were also more likely to have intussusception. In contrast to previous studies, it was found in this study that the classic findings of abdominal pain, abdominal mass and guaiac-positive stools were not determined to be significant. Two low risk decision trees were created; the first included 3 variables: age, gender and lethargy. This tree determined that children who are either 5 months of age or younger, or older than 5 months and female without lethargy had a low risk with a sensitivity of 89% and a NPV of 97%. The second tree included an abdominal X-ray and found that a negative X-ray and being less than 5 months of age, or being older than 5 months with a negative X-ray, without bilious vomiting and without diarrhea were low risk with a sensitivity of 97% and NPV of 99%. The use of X-ray was significant and is recommended if there is any suspicion of intussusception after initial history and physical. If positive, the X-ray should be followed by an air contrast enema.
Submitted by: Sean Indra
Comment: It is interesting that this study had different positive predictive factors than previous studies. This information could be very helpful when evaluating a child with abdominal pain. LC

Hematology and Oncology:

Hakim H, Gaur A. Neutropenia in a child with cancer – the past, the present, and the future. Clinical Pediatric Emergency Medicine, Sept 2011;12(3):174- 184.
Summary and Implications For Your Practice:
The significant improvements in decreasing morbidity and mortality of neutropenic fever (NF) over the last decade have catalyzed an increasing attempt to better assess and stratify oncologic patients presenting with fever to the emergency department. These efforts have also been motivated by a desire to minimize hospital stays and exposure to unnecessary IV antibiotics. Nonetheless, as this review notes, there have been no prognostic parameters for distinguishing high and low-risk febrile, neutropenic oncology patients that have been successfully tested in multi-site prospective studies. Current protocols under development emphasize the following parameters for assessing risk: serum CRP levels > 90 mg/L, hypotension, relapsed leukemia, thrombocytopenia < 50,000 platelets/mm3, and chemotherapy administration within 7 days of NF presentation. In the absence of proven protocols to define “low-risk” patients that can be safely treated with oral antibiotics in the outpatient setting without hospital admission for observation, the management of the febrile neutropenic child remains inpatient IV anti-pseudomonal antibiotic therapy such as piperacillin-tazobactam, cefepime or a carbapenem. Vancomycin or linezolid should be considered if an infection with MRSA is suspected. This review helped clarify for me the current empiric, almost automatic hospitalization of pediatric patients with neutropenic fever in the ED. It also re-emphasized the key questions that should be asked in the history for febrile oncologic patients in the outpatient setting.
Submitted by: Anya Kleinman
Comment: Nice review and nice summary. It is difficult to conceptualize anything “low risk” about a child with fever, neutropenia and cancer diagnosis. Hopefully ongoing work can identify factors that will lead to use of fewer antibiotics or antifungals, or at least ones with more tolerable risk profiles. LF

Phillips B, MD et al. A home-based maintenance therapy program for acute lymphoblastic leukemia – practical and safe? J Pediatr Hematol Oncol 2011;33:433- 436.
Summary and Implications For Your Practice:
Maintenance Acute Lymphoblastic Leukemia (ALL) chemotherapy traditionally requires monthly hospital visits for intravenous medication in addition to weekly visits for laboratory monitoring. This study looked at the feasibility of performing some of these services near or in the patient’s homes. The study included 50 families in maintenance ALL chemotherapy, with inclusion criteria including the family’s ability to meet home program requirements and following a treatment protocol that allowed participation. Adherence with the program was evaluated by parental survey and by pill counting at monthly hospital visits. Remediation was used in response to poor initial adherence rates. The study found that 95% of families preferred the home based program. Demographic factors associated with increased adherence to the home based program were parents with stable partners and higher patient age. There were no critical incidents among the study population. Weaknesses of the study included the low sample size, the mid-study interventions to increase adherence, and lack of endpoint comparison with traditional hospital therapy. Poor adherence with the oral outpatient chemotherapy is not likely unique to the home program. This study population was in Leeds, England, and so may have significant differences from the urban Cleveland population. Our patient population features a large percentage of single parents with low socioeconomic status, increasing the risk of non-adherence should a home-based program be used at Rainbow. The use of a home-based maintenance program would help address the transportation and work/school disruption issues faced by our ALL population, but the programs do not yet have good evidence of superiority (or equivalence) with traditional hospital management.
Submitted by: James Brown

Infectious Disease:

Amarilyo G, et al. Diagnostic accuracy of clinical symptoms and signs of children with meningitis. Pediatric Emergency Care. 2011; 27(3):196-199.
Summary and Implications For Your Practice:
Every month patients with symptoms suggestive of meningitis are seen and admitted to the hospital. This was a prospective cohort study conducted to evaluate the accuracy of the typical symptoms and signs of meningitis in correctly diagnosing the disease. Two emergency departments in Israel enrolled a total of 108 patients ages 2 months to 16 years admitted for suspected meningitis. The clinical signs and symptoms evaluated on admission were fever, nuchal rigidity, headache, Kernig and Brudzinski signs, bulging fontanel, motor deficiency, photophobia, Glasgow Coma Scale less than 13 and nausea or vomiting. A lumbar puncture (LP) was performed on each patient and cerebrospinal fluid (CSF) with a white blood cell count (WBC) greater than or equal to 6 per microliter CSF was diagnosed as meningitis. 58 patients (55.7%) were diagnosed with meningitis of which 52 were aseptic and 6 were bacterial. The CSF confirmed the infectious agent in 8 patients. The patients with meningitis were significantly older than the patients without. Fever (93%) was the most common symptom overall but nonspecific for meningitis. Photophobia and low Glascow score were specific (88% and 92% respectively) for meningitis, but not sensitive. A bulging fontanel had low sensitivity, specificity and positive predictive value. They also analyzed various groupings of signs and symptoms. The highest specificity (97%) occurred with the grouping of headache, Kernig sign, nuchal rigidity and vomiting, but it had a low sensitivity (14%). Overall, this study found that the signs and symptoms we use to diagnose meningitis are not as accurate when it comes to differentiating between patients with and without meningitis. This study is clinically relevant since it provokes us as clinicians to think about what goes into our decision making process when evaluating a patient and deciding whether or not to do an LP or more diagnostic tests for possible meningitis.
Submitted by: Lauren Ebe

Neonatology:

Di Fiore J, Arko M, Herynk B, Martin R, Hibbs AM. Characterization of cardiorespiratory events following gastroesophageal reflux in preterm infants. J Perinatol. 2010 Oct;30(10):683-7.
Summary and Implications For Your Practice:
It is commonly believed that gastroesophasgeal reflux (GER) causes neonatal apneas, bradycardias and oxygen desaturations. This study looked at the correlation between GER and cardiorespiratory events, including apnea (>10 secs), bradycardia (<80bpm) and oxygen desaturation (<85%). GER was documented over a 12-hour overnight study using both intraluminal impedance probe (measures presence and acidity of liquid in the esophagus) and pH probe (measures esophageal acidity only). The study included 71 preterm infants with a mean gestational age of 29 weeks at birth and post menstrual age of 37 weeks at the time of the study. There were 12,957 cardiorespiratory events where 16% were apneas, 4% were bradycardias and 80% were oxygen desaturation events. There were a total of 4164 GER events detected. Less than 3% of all cardiorespiratory events were preceded by GER and 9% of all GER events were preceded by a cardiorespiratory event. GER was not associated with increasing the cardiorespiratory event duration or severity. In fact, GER was associated with a shorter duration of oxygen desaturation (p <0.5). Thus, GER is rarely associated with apneas, bradycardias, oxygen desaturations or have an effect on its duration or severity. GER is very common in preterm infants along with apneas, bradycardias, oxygen desaturations, but they are likely all related to the pathophysiology of a preterm infant and not a causal effect. Anti-reflux medications have potential side effects that should be more seriously considered prior to starting medication, especially if the main indication is cardiorespiratory events.
Submitted by: Gillian Tam

Van Haastert, et al. Decreasing incidence and severity of cerebral palsy in prematurely born children. J Pediatr. 2011 Jul;159(1):86-91.
Summary and Implications For Your Practice:
This was a study performed in the Netherlands and Ontario, Canada looking at a longitudinal cohort of infants and various factors relating to their neonatal course and long term outcome. Infants with a diagnosed genetic syndrome, a neuromuscular disorder, and/or a major congenital malformation were excluded. Cerebral Palsy (CP) outcome data were collected by standardized gross motor assessments at a mean age of 32.9 months. Researchers then split the cohort into time periods according to NICU admission and compared outcome trends across groups. Results of this study showed that cystic periventricular leukomalacia (C-PVL) and severe intraventricular hemorrhage (IVH) were independent risk factors for CP. Accordingly, when these risk factors decreased across time points, the incidence of CP did as well. Antenatal antibiotics, presence of an arterial line, Cesarean section, and increasing gestational age were all independent protective factors for CP development. As a budding neonatologist on my developmental rotation, it is always useful to know that we are improving on long term developmental outcomes for premature infants. The target for further improvement is decreasing the incidence of c-PVL and severe IVH in these populations. Continued longitudinal studies are needed to identify other risk factors clinicians can target to reduce poor neurodevelopmental outcomes.
Submitted by: Andrew Dylag

Dos Santos AM. Red blood cell transfusions are independently associated with intra-hospital mortality in very low birth weight preterm infants. J Pediatr 2011;159(3):371-376.
Summary and Implications For Your Practice:
It is well known that very low birth weight (VLBW) infants often need blood transfusions during their NICU course. However, the effects of red blood cell (RBC) transfusions including lung injury, organ dysfunction, hemolytic transfusion reaction, and transfusion related sepsis in neonates are not well characterized. The objective of this study was to determine if RBC transfusion are independently associated with intra-hospital mortality in VLBW infants. In this study out of Brazil, 1077 infants were studied, 574 of which received at least one RBC transfusion during their hospital stay. Mortality rates were studied and there was a relative risk of death of 1.49 among infants receiving at least one transfusion compared to no transfusions when adjusted for confounders. Furthermore, there seemed to be a dose- dependent relationship with increasing mortality for increased transfusion number among studied infants. Though this study was done in Brazil, it brings to light concerns about transfusion risk in the NICU. Any alteration of the immune system could pose long term consequences for neonates, though we do not know much about this field yet. Transfusion risks and benefits should be carefully considered before initiating this therapy in neonates.
Submitted by: Andrew Dylag

Neurology:

Hampers L, et al. Evaluation and management of pediatric febrile seizures in the emergency department. Emerg Med Clin North Am, Feb 2011;29(1):83- 93.
Summary and Implications For Your Practice:
Febrile seizures are divided into two categories: simple/typical and complex/atypical. If the patient’s seizure meets the criteria for a simple febrile seizure, the patient should be observed for a certain period in the Emergency Department (ED) without lab or imaging tests as shown by previous reviews. Multiple retrospective studies have failed to show any increased incidence of bacterial meningitis, occult bacteremia or urinary tract infections associated with febrile seizures. The American Academy of Pediatrics (AAP) guidelines recommend lumbar puncture (LP) for evaluation of children under 12 months. Shigatoxin from Shigella enteritis may increase the risk of febrile seizures, so stool cultures are indicated when a child presents with simple febrile seizure with bloody diarrhea or a history of recent travel to an endemic area. Complex febrile seizures have no standardized approach due to heterogeneity of these cases and no literature quantifies a relationship between complex febrile seizures and risk of bacterial infection. Starting empiric antibiotics, performing LP and other blood tests depend on the clinician’s suspicion and the appearance of the child. No practice guidelines recommend emergent neuroimaging in this group of patients. Discharging patients with simple febrile seizures from the ED is acceptable after reassurance and education of the parents. Risk of recurrence is 32% and is dependant on: age less than 18 months on first convulsion, temperature less than 40C on first convulsion, less than one hour between onset of fever and seizure, and first degree relative with febrile seizure. Antipyretics do not decrease the risk of recurrence. The AAP recommends the use of rectal diazepam when parental anxiety is severe and it may decrease recurrence of seizures.
Submitted by: Nathalie El Ters
Comment: This is a good review of current recommendations for febrile seizures. The patients that present the most dilemmas are the ones with complex febrile seizures, and in these cases, a careful history and physical exam can be your guide. LC

Fehr S, et. al. Altered attainment of developmental milestones influences the age of diagnosis of rett syndrome. Journal of Child Neurology, 2011;26:980- 987.
Summary and Implications For Your Practice:
Rett Syndrome is typically characterized by regression of acquired motor, hand, and vocal skills at about 18 months. However, there is variability in the development of these symptoms. Some patients never exhibit normal development and others function at an average skill level. This study used the Australian Rett Syndrome Database, the International Rett Syndrome Phenotype Database, and parental questionnaires to investigate age of sitting, walking, and level of vocalization. Results include that the average age of regression was 18 months whereas the average age of diagnosis was 33 months. The girls that were able to walk unassisted and had a higher level of vocalization were diagnosed much later on. However, most parents confirmed unusual behaviors during infancy including being overly calm, floppy, abnormal posturing, difficulty with rolling, etc. Additionally, specific genotypes were associated with earlier and later ages of regression. The variety in developmental regression in Rett Syndrome includes the specific skills that are lost, the rate of regression, as well as the genotype association. With this in mind, the pediatrician should check for developmental milestones, but also not hesitate to have more frequent follow ups for close monitoring. Due to the nature of the disease, the severity of developmental regression may be gradual and therefore concerns by parents should also not be taken lightly. For these reasons, genetic testing in females should not be put off and be completed with early clinical suspicion.
Submitted by: Ivana Dylag

Pulmonology:

Quynh D, Shefrin A, Johnson D. Cost effectiveness of metered-dose inhalers for asthma exacerbation in the pediatric emergency department. Pediatrics 2011;127: e1105-e1111.
Summary and Implications For Your Practice:
This study sought to measure the incremental cost-effectiveness of using metered-dose inhalers (MDIs) versus nebulizers for the delivery of albuterol to children presenting to the Emergency Department (ED) with asthma. Costs that were taken into account for the comparison included nursing fees, MDI albuterol per patient, nebulizer albuterol per patient and hospital admission stay per day. Although the use of MDIs, instead of wet nebulization, was $70 more expensive, its use resulted in lower hospital admissions and thus decreased overall costs, yielding a net savings of $154.95 per patient. The study also examined the costs associated with the addition of nebulized ipratropium bromide as an agent that has been suggested to reduce the number of hospitalizations, decrease asthma scores and improve lung function compared to nebulized beta-agonists alone. In taking into account these additional costs, the outcome of the cost-effectiveness model remained unchanged. The authors note their main limitation being the use of retrospective data with averaged group outcomes (length of stay, treatment doses and physician fees) rather than a prospective analysis. Additionally, this study took place in Canada, with a single-payer health care system, whereas in the United States, there is greater cost variability due to multiple different payers. With older children who do have the ability to use either method of albuterol delivery, this study gives something to consider in terms of cost savings during the upcoming winter season.
Submitted by: Sean Indra
Comment: Both younger and older children could benefit from an MDI/spacer approach in the Emergency Room; an additional benefit might be promotion of asthma health literacy, since many parents continue to believe that wet nebulization is more effective since it is what is done in the hospital! I agree with Dr. Indra that a prospective US study will be needed to confirm the reported cost and outcome findings. LF

Nelson KA, Highstein GR, Garbutt J, et al. A randomized controlled trial of parental asthma coaching to improve outcomes among urban minority children. Archives of Pediatrics and Adolescent Medicine. 2011;165(6):520-526.
Summary and Implications For Your Practice:
Prior studies have shown increases in primary care physician (PCP) follow-up visits and decreases in hospitalizations due to asthma coaching following an Emergency Department (ED) visit or hospitalization. In this study, the researchers hypothesized that 18 months of asthma coaching would lead to a decrease in ED visits and hospitalizations. They performed a randomized controlled trial through a single large, urban tertiary care hospital. Parents served as coaches, and patients were enrolled that were aged 2-10 years, had Medicaid, and had an asthma diagnosis from parent report plus from a preceding PCP/ED visit. Primary outcome was proportion of children with an ED visit because of asthma in the 2 years following enrollment. Patients who were in the treatment group did statistically have more asthma monitoring visits with their PCP following enrollment in the study. However, the number of ED visits and hospitalizations was not significantly different between the two groups. The investigators did find that patients with more recent ED visits and hospitalizations prior to enrollment in the study were more likely to have repeat ED encounters and hospitalizations respectively following enrollment.
Submitted by: Steve Posluszny

Psychiatry:

Benko CR, Farias AC, Farias LG, Pereira EF, Louzada FM, Cordeiro ML. Potential link between caffeine consumption and pediatric depression: a case-control study. BMC Pediatr. 2011 Aug 25;11(1):73.
Summary and Implications For Your Practice:
Depression arising in younger patients can contribute significantly to development and function. There are many causes of depression including exposures to certain diet. Specifically the consumption of caffeine was compared in depressed children and children without psychopathology. The study included 51 children between ages of 9 and 12 years who were initially screened using the Children Depressive Inventory. Additionally their behavior checklist and eating habits were assessed. Using linear regression and statistical analysis it was presented that caffeine aside from other foods and sweets was associated with depression symptoms. Their study concluded that children with depression tend to consume more caffeine than the non-depressed. This study is very intriguing and demonstrates although on a small scale that caffeine intake is higher in depression among children. It is not entirely clear whether caffeine is a cause of depression itself or is desirable in depressed children. We are aware of the pleasing affects of caffeine and the reward system it helps to explain some of these practices. I would likely question children with depressive symptoms about their caffeine intake after reading this article.
Submitted by: Madiha Raina

Sports Medicine:

Hamilton M, Mrazik M, Johnson DW. Incidence of delayed intracranial hemorrhage in children after uncomplicated minor head injuries. Pediatrics July 2010; 125(1):e33-9.
Summary and Implications For Your Practice:
Minor head injuries are extremely common in children and a frequent cause of Emergency Department (ED) visits. The most feared complication is a delay in diagnosis of intracranial injury either due to missed diagnosis of an injury that is present immediately or a delayed hemorrhage. The goal of this study was to determine how often delayed diagnosis (defined as > 6 hours) of intracranial hemorrhage occurs among children with initial signs of uncomplicated minor head injuries and to estimate the proportion of children who presented to the ED who were considered initially to have uncomplicated minor head injuries and received delayed diagnoses of intracranial hemorrhage (ICH). This was a retrospective cohort study conducted over an 8 year period in the Calgary Health Region. The incidence of delayed diagnosis in ICH with associated deterioration in level of consciousness (LOC) was 0.14 cases per 100,000 children per year. The incidence of delayed diagnosis of ICH without deterioration in LOC was 0.57 cases per 100,000 children per year. The incidence of delayed diagnosis of ICH was 2.5% of all cases of ICH.
Submitted by: Catherine Walker

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