Spring 2013 Journal Watch


Eisenberg ME, Wall M, Neumark-Sztainer D. Muscle-enhancing Behaviors Among Adolescent Girls and Boys. Pediatrics 2012; 130 (6):1019-26.
This is a cross-sectional study of 2793 adolescents at 20 urban middle and high schools in a socioeconomically and ethnically diverse community (Minneapolis/St. Paul area). These students were given a 235-item survey to self-report the use of 5 muscle enhancing behaviors: changing eating, exercising more, using protein powders/shakes, using steroids or using other muscle-building substances. Healthy behaviors included the first two while the unhealthy habits were the later three. Each behavior was rated as never, rarely, sometimes or often and a frequency was calculated for each permutation. Chi-squared analysis was done and found that muscle enhancing behaviors were common among boys and girls. Both reported at about 65% in changing their diets and about 80-90% exercised more. Unhealthy behaviors were also not uncommon- for boys/girls, at 34.7%/21.2% for protein powders, 5.9%/4.6% in steroids use, and 10.5%/5.5% for other muscle-enhancing substances. It was also found that 12% of boys used at least 3 of the categories and in girls, the percentage was 6.2%. Multiple demographic and personal characteristics were also obtained in this study and it showed that there was a higher prevalence of muscle-enhancing behaviors in boys, people of Asian race, higher BMI students, and sports team participants. The data also showed that almost all of the students reported at least one behavior and up to 33% reported at least 1 unhealthy behavior. This highlights the risk that adolescents are at for unhealthy behaviors that can have long term health effects. The study was done to assess the risk of adolescents for unsafe muscle-enhancing behaviors in a world where media portrays masculinity with large muscles and femininity with thinness and a toned and firm look. It showed that adolescents were at a significant risk for unhealthy behaviors to achieve what the media portrays as desirable. In our offices, we need to screen for muscle-enhancing behaviors so that we can best guide our patients to achieve their goals through safe and healthy methods.
Submitted by Diana Hou
Comment: I agree with Dr. Hou. This study highlights the importance of discussing these products and behaviors, and their potential dangers in clinic, even starting at a young age, to hopefully prevent their use. Unfortunately, the products are often marketed as safe, and even parents may not know the risks. Laura Caserta MD

Behavioral-Developmental Peds

Radesky, J. et al. When the Prescription Pad Is Not Enough: Attention-Deficit Hyperactivity Disorder Management 2.0. Journal of Developmental & Behavioral Pediatrics. 2013; 34:138–140.
This article offers some non-pharmacological approaches to Attention-Deficit Hyperactivity Disorder (ADHD) that can be provided from the setting of the primary care pediatrician’s office. These are based on behavior modification, rewarding desirable behavior and consistently giving consequences for negative behaviors. In addition, there are recommended parent-training programs that can help improve their participation in these approaches as well as improved possible strained relationships caused by a child’s ADHD. Community pediatricians often site lack of knowledge of local behavioral health programs and lack of reimbursement as common reasons not to use these resources. This article also suggests additional ADHD approaches, such as assuring parents have a library card to ensure maximal reading opportunities for children with ADHD, cognitive training to increase attention and focus. The many restraints placed on parents with ADHD can all factor in to their limited ability to be successful with non-pharmaceutical modalities. Rather than medications, which wear out throughout the day, many of these approaches encourage long term changes and generalization to broader academic tasks as children progress through their education. It is important for pediatricians to be aware of these opportunities in their area.
Submitted by: Anat Cohen
Comment: Previous studies have shown that behavioral therapy is an important component in ADHD treatment. I feel that is it very important for all children with ADHD, medicated or not, to have behavioral therapy as part of the treatment plan. Laura Caserta MD


Daymont C, et al. Growth in Children with Congenital Heart Disease. Pediatrics. 2013; 131: e236-e242 .
This was a retrospective cohort study that identified children with ICD-9 codes for children with CHD that had two weight measurements before age three. They compared these children with matched controls from a primary care network, as well as published references. They found that the differences between cases and controls were most significant at 4 months of age, especially when controls were compared to cases requiring repairs. Cases requiring repair were significantly more likely to be less than the 3rd percentile by at 1 month of age compared to controls, a trend which persisted throughout the first 24 months of life.
The article discussed the possibilities for growth failure in children with CHD as multifactorial, first addressing the issues of poor caloric intake in CHD kids secondary to poor oral-motor skills, and increased metabolic demand. However, they also showed that the growth deficiencies in kids with CHD were global (all parameters) and not showing “lag” as one would see between parameters (weight before length and HC) seen typically in poor caloric intake alone. This suggests possible genetic or metabolic components of CHD requiring repair in addition to poor caloric intake and increased expenditure.
This study underscores the increased risk of growth failure in CHD patients which is an issue that can be directly addressed by the general pediatrician. Playing close attention to growth parameters in children with CHD and taking steps to ensure early intervention to aid in growth for this population seems of utmost importance
Submitted by: PJ Tate
Comment: This article focuses attention on the poor growth of children with CHD and endorses 4 months as a “watershed” age-what is new here is that underlying genetic or metabolic conditions may be as important as calories. Work reported in the endocrine literature (Dinleyici et al, Neuro Endocrinol Letters, 2007) additionally suggests that chronic hypoxemia and malnutrition interact and are associated with reduced levels of IGF-1. Lydia Furman MD


Greer FR, et al. Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008; 121: 183-191.
This clinical report provided a nice summary of studies evaluating risk factors for development of atopic disease in infants. While some food allergens in human milk can induce allergic reactions in high-risk infants, there is no clear evidence that a maternal exclusion diet is beneficial to decreasing the risk of developing atopic disease. For children with family history of allergy (i.e. high-risk), exclusive breastfeeding or supplementing with hydrolyzed formula for 3-4 months decreases the risk of eczema as compared to supplementing with cow’s-milk-based formula. No benefit seen in low-risk infants. For asthma, there was no clear benefit of exclusive breastfeeding, although it does appear to decrease wheezing associated with upper respiratory infections (URI) in children <4 years old. While nearly 25% of children who have a family history of atopy will develop a food allergy between birth and 7 years old, there is no clear finding about if breastfeeding changes the age of onset. For high-risk children who are formula-fed, extensively hydrolyzed formulas may be beneficial in decreasing risk of atopic disease, but this is not well-studied and costly; and soy-based formulas do not prevent development of allergies. Finally, delaying solid food introduction beyond 4-6 months does not affect atopic disease (even with eggs, fish, and peanut-containing food). The evidence from these studies are useful in guiding parents’ decisions about feeding their potentially high-risk children, and especially helpful for questions about introduction of “highly allergenic” foods. Ultimately, breastfeeding benefits are known and there is not much that can be done to prevent development of atopic disease.
Submitted by Anandhi Gunder
Comment: Lots of good guidance in this article with perhaps the most significant “urban myth busting” related to lack of any benefit of delaying introduction of “allergenic” foods such as eggs and fish. I note that the large AHRQ study which used meta-analysis (Ip et al, Breastfeeding Benefits in Developed Countries, 2007) concluded that breastfeeding does reduce asthma risk (with or without positive family history), though “additional studies are needed.” Lydia Furman MD

Emergency Medicine

Batra, Prerna, Goyal, Sudhanshu. Comparison of Rectal, Axillary, Tympanic, and Temporal Artery Thermometry in the Pediatric Emergency Room. Pediatric Emergency Care. 2013; 29:63-66.
A cross-sectional observational study of 50 febrile and 50 afebrile children between 2 and 12 years of age presenting to a pediatric emergency department was performed to compare the following forms of temperature measurement: rectal, axillary, tympanic, and temporal artery. Temporal artery thermometry most correlated with rectal temperatures in both febrile and afebrile children with correlational coefficients of 0.99 and 0.91 respectively.
An accurate temperature measurement is crucial for appropriate care of a child. It is a vital sign used to determine the acuity level of the patient as well as the process for working up the child in search of a diagnosis. Invasive temperature measurements are most accurate but not feasible for emergency and clinic settings. Thus, a non-invasive measurement that most closely reflects the true core temperature is important. Based on the results of this study, replacing rectal temperature measurements with temporal artery thermometry in children would be appropriate. Temporal artery thermometry provides a quick and comfortable way to measure temperature without the risk of rectal perforation. I feel the accurate results from temporal artery thermometry will help me assess my patients in clinic. Unfortunately, this study did not assess children <2 years of age; these children will still need routine rectal temperature measurement.
Submitted by: Erin Richardson
Comment: Nice summary by Dr. Richardson, and indeed this device would likely most benefit those under 2 years of age (or at least ages 0-4 years), since it is not hard to take an oral temperature at older ages. A larger sample size would add support to the conclusion. Regarding home use, the device is priced at $31.75 on Amazon… Lydia Furman MD


Copleland, et al. Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. Pediatrics. 2013; 131 (2): 364 -382
This journal article was based on a systematic review that was done by a committee to develop practice guidelines for management of adolescents (10- 18yr olds) with T2DM. The AAP developed a committee that included the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians and the Academy of Nutrition and Dietetics. Medline, the Cochrane Collaboration, and Embase were searched for articles addressing questions regarding treatment of T2DM in children/adolescents, efficacy of medications for treatment, screening recommendations for comorbidities of T2DM, and treatment for those comorbidities. Subsequently, 78 abstracts were reviewed and the clinical practice guidelines were developed from these results.
The first recommendation was for children with T2DM where insulin or metformin was the preferred treatment. While earlier recommendations suggested lifestyle modifications only, this study recommended starting medication at the same time as lifestyle modifications. The study recommended insulin as first-line therapy in children who are ketotic, in DKA, have a random blood glucose (BG) greater than 250, HbA1C greater than 9%, or whom it is unclear whether diabetes is type 1 or 2. The study recommended that in all other cases metformin and lifestyle modifications should be started. HbA1c should be monitored every 3 months and BG checks should be done if taking insulin or other medications that cause hypoglycemia, if they have not met treatment goals, or if they are changing their treatment for diabetes. Lastly, the committee recommended dietary and exercise counseling.
Submitted by: Lauren Riney
Comment: It seems that guidelines such as these can be very helpful, especially at diagnosis, since it is sometimes unclear if children have type I or type II diabetes upon presentation. Laura Caserta MD

General Pediatrics

Freedman et. al. Health Care Provider and Caregiver Preferences Regarding Nasogastric and Intravenous Rehydration. Pediatrics. 2012; 130: e1504.
In patients with gastroenteritis, oral hydration is recommended, but in the ER and hospital, IV rehydration is used more often than nasogastric (NG). This study evaluated caregiver and health care provider perspective on the use of NG and IV rehydration. Children (3-48 months) with gastroenteritis within the previous 24 hours and within 7 days were enrolled. Health care providers included ER physicians, fellows, and nurses. Participants were given a survey asking their preference for NG versus IV rehydration. A question was asked regarding which method was preferred, followed by a 1 page document outlining the advantages and disadvantages of both IV and NG rehydration and then the participant was offered the opportunity to modify their answer.
A total of 435 children were eligible and enrolled. Caregivers of the children were more familiar with IV rehydration and believed that this method was easier, less painful, and more effective than NG. Of caregivers, 10% chose NG rehydration before reading the handout. After reading, 27% favored NG. Caregivers who had children who had IV hydration in the past were less likely to switch to NG after reading the handout as compared with those who had children who had never had IV rehydration. Among health care providers, 14% chose NG hydration which increased to 43% after education.
This study showed that in order for patients and health care providers to favor NG hydration, more education is needed. We will not be able to expect parents to prefer NG hydration until we educate them on the benefits and health care providers are more educated and willing to provide it.
Submitted by: Jamee Walters
Comment: We have the luxury of ready availability of IV hydration in the US, while in resource-poor settings mildly or moderately dehydrated children are successfully rehydrated with spoon/syringe/cup or NG tube. This study is a good start for parent/provider education aimed at following the CDC and WHO guidelines (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm) which support intravenous rehydration just for severely dehydrated children. Lydia Furman MD

Balaraman, B, Buesbroeck, LK, Lickerman SH, Cornelius LA, Jeffe DB. Practices of Unregulated Tanning Facilities in Missouri: Implications of Statewide Legislation. Pediatrics. 2013; 131 (3) 415--22.
Given the rise in cases of skin cancer worldwide, multiple global health organizations, including the World Health Organization and the US Food and Drug Administration (FDA) have recommended restrictions on indoor tanning bed use by children and adolescents. Not all states have adopted the recommendations. This study looked at a wide variety of tanning bed companies in one of those states, Missouri, to see if they followed the FDA recommendations and whether they provided accurate information about the risks of cancer and indoor tanning to their young clients. Companies were randomly selected and the callers, who were trained medical students, pretended to be prospected adolescent customers. Two calls, at different times of day, were made. The callers asked the employees about age restrictions, rules regarding eyewear, the dangers of indoor tanning, and the need of parental consent. The results showed that 43 percent of companies denied that there were any risks associated with tanning. In fact, 80 percent reported that indoor tanning would prevent future sunburns. Unlike Missouri, tanning companies in Ohio follow some of the FDA regulations and require parental consent for a minor to receive an indoor tan. Nonetheless, this article shows that companies will misrepresent the risks of indoor tanning. Even with parental consent, a company could still misinform a parent. Therefore, anticipatory guidance in relation to tanning and sun exposure is quite important.
Submitted by: Ronen Stein
Comment: It is sad that some people place more importance on money-making than children’s health. Unfortunately, teenagers tend to live in the moment, and even when told about health risks of tanning, they may care more about their current appearance than possible cancer down the road. Parents and pediatricians need to caution teens about such risks. Laura Caserta MD

Infectious Disease

Poeling, Katherine A. et al. The Burden of Influenza in Young Children, 2004-2009. Pediatrics 2013; 131(2): 207-16.
This study looked at how influenza burdened the health care system in 2004 through 2009 in children less than 5 years old. This time period was selected because this was when influenza vaccine recommendations expanded to all children older than 6 months. Children who presented to outpatient offices, emergency departments, or hospitalized with fever and/or respiratory symptoms in the studied counties were eligible for enrollment in the study. All children in the study were swabbed for influenza PCR testing. Physicians had ordered viral testing for 35% of enrolled children, with the highest percentage in the <6 month old age group. It was more commonly to have physician ordered influenza testing in children whom tested positive for influenza per the study protocol. The researchers found the hospitalization rates were 0.4 to 1.0 per 1000 children aged <5 years old and it was the highest for infants <6 months. Children presenting to outpatient offices had an influenza positive rate of 10-25%. Interestingly, of children hospitalized for the flu <2% received antiviral treatment, even in the 43% of the study population who were hospitalized within 2 days of symptoms. Immunization rates were <50% and did not increase in later years in the population that had been previously hospitalized for influenza. Overall the study showed that despite the expanded recommendations, many children are insufficiently vaccinated and treated for influenza with antivirals.
This study highlights the need to increase complete influenza vaccination in all children, especially in the age group 6 months to 5 years old. One of the most interesting findings in this study is the poor use of antivirals, even in children hospitalized for flu-like symptoms within the first 2 days of illness. It is important to keep in mind the use of antivirals in children in outpatient, ED, and inpatient settings. Also, following up with patients who were hospitalized for influenza in previous years and ensuring they receive appropriate influenza vaccination is of utmost importance.
Submitted by: Shelia Bigelow
Comment: It amazes me how many people chose not to vaccinate their children against influenza. There is still a significant amount of misinformation out in the public regarding the flu vaccine. Perhaps the best approach would be more grassroots efforts out in communities to give people proper information. Laura Caserta MD


Saito, J et al. Use and Accuracy of Diagnostic Imaging by Hospital Type in Pediatric Appendicitis. Pediatrics. 2013; 13: e37-e44.
This is a retrospective single institution cohort study to assess the imaging modality in patients who underwent appendectomy (Computed Tomography (CT) vs. ultrasound). The study also assessed where the initial work up/imaging occurred (community hospital vs. children’s hospital). Of the 423 patients with appendectomies performed assessed in this study about 7% did not have appendicitis. Only 6% of the 423 patients had no imaging performed preoperatively; with only 4% having no image if assessed at a community hospital and 8% if assessed at the children’s hospital first. They found patients first assessed at a community hospital were more likely to have a CT for acute abdominal pain. These CT machines were more likely to expose pediatric patients to higher amounts of radiation compared to CT performed at the children’s hospital as well as have less accurate images when compared to pre/post operative diagnosis (i.e. negative image on CT with acute appendicitis diagnosed intra-operatively or post-operatively via pathology). Patients assessed first at a tertiary children’s hospital were more likely to have ultrasound rather than CT for acute abdominal pain. However, a higher percentage of patients at the children’s hospital were more likely to have both ultrasound and CT. The authors propose many hypotheses for why community hospitals have such an increased rate of CT scans. The two reasons are availability of scanners compared to ultrasound and increased worry for misdiagnosis of appendicitis and malpractice ramifications. Third, the mindset surgeons would trust CT images over ultrasound if the patient needed an evaluation by pediatric surgeons.
Submitted by: Andrea Mertz
Comment: Other work has also identified “initial presentation to a referring hospital” as a significant predictor for use of abdominal CT in diagnosis of appendicitis (Ladd et al, Am Surg, 2012). Effective clinical algorithms are likely to support improved clinical decision making, which may reduce avoidable radiation in kids with concern for appendicitis. Lydia Furman MD

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