Archives of Pediatrics recent issues

Archives of Pediatrics & Adolescent Medicine is a monthly peer-reviewed, primary source journal for pediatricians in office and hospital settings. Archives provides a forum for dialogue on a range of clinical and humanistic issues relevant to the care of pediatric patients, from infancy through young adulthood.

Word Learning From Baby Videos [Article]

Objective  To examine whether children between 12 and 25 months of age learn words from an infant-directed DVD designed for that purpose.

Design  Half of the children received a DVD to watch in their home over the course of 6 weeks.

Setting  All participants returned to a laboratory for testing on vocabulary acquisition every 2 weeks.

Participants  Ninety-six 12- to 24-month-old children.

Main Exposure  Baby videos.

Main Outcome Measures  Parent report and observational measures of vocabulary acquisition related to words highlighted in the DVD; parent report of general language development; and parent report of children's media use.

Results  The age at first viewing of baby DVDs was related to children's general language development. There was no evidence of learning words highlighted in the infant-directed DVD independent of parental intervention.

Conclusions  Researchers should continue to examine whether infant-directed media are effective in teaching infants and toddlers content and consider the cognitive factors related to whether very young viewers should be expected to learn from a DVD.

Published online March 1, 2010 (doi:10.1001/archpediatrics.2010.24).

top

Targeted Antiviral Prophylaxis With Oseltamivir in a Summer Camp Setting [Article]

Objective  To describe the effectiveness of containment of novel influenza A(H1N1) infection at a summer camp.

Design  Targeted use of oseltamivir phosphate by individuals in close contact with influenza-confirmed cases.

Setting  Boys' camp in Alabama in July 2009.

Participants  A total of 171 campers, 48 camp counselors, and 27 camp staff.

Interventions  Campers with confirmed influenza received oseltamivir and were immediately isolated and sent home. All boys and counselors in the infected child's adjoining cabins received prophylactic oseltamivir for 10 days, including 8 campers at higher risk for influenza infection (eg, those with asthma, seizure disorder, or diabetes). Alcohol-based hand sanitizer was provided at each of the daily activities, in the boys' cabins, and in the dining hall, and counselors were educated by the medical staff on the spread of influenza and its prevention through good hand hygiene. All cabins, bathrooms, and community sports equipment were sprayed or wiped down with disinfectant each day.

Main Outcome Measure  Virologic confirmation of influenza.

Results  Three of the 171 campers tested positive for influenza A during the course of the 2-week fourth session, for an attack rate of 1.8%. The probability of observing 3 or fewer infected campers if the attack rate was 12% is less than 1 in 10 000 000 (P < .0000001). An exact 95% confidence interval based on 3 events among 171 individuals estimates the attack rate to be between 0.3% and 5.0%. While 31% to 57% of campers, counselors, or staff experienced nausea with the treatment, this did not result in discontinuation of therapy. No campers tested positive for influenza A after returning home at the end of the camp session.

Conclusion  In conjunction with comprehensive hand sanitization and surface decontamination, a targeted approach to antiviral prophylaxis contained the spread of influenza in a summer camp setting.

Published online January 22, 2010 (doi:10.1001/archpediatr.2009.299).

top

Night diving in Bonaire, March 2009 [About the Cover]

top

About This Journal [About This Journal]

top

This Month in Archives of Pediatrics & Adolescent Medicine [This Month in Archives of Pediatrics & Adolescent Medicine]

top

No Evidence of a Trial Effect in Newly Diagnosed Pediatric Acute Lymphoblastic Leukemia [Article]

Objective  To determine whether clinical trial enrollment by itself is associated with improved outcome.

Design  Retrospective cohort study.

Setting  Seattle Children's Hospital from 1997 to 2005.

Participants  Data were drawn from 322 patients with newly diagnosed acute lymphoblastic leukemia.

Main Exposure  Enrollment in a Children's Oncology Group or Children's Cancer Group clinical trial.

Main Outcome Measures  (1) Demographic variables associated with trial participation. (2) Event-free survival, which was defined as the time from initial diagnosis to either leukemia recurrence or death from any cause.

Results  No outcome advantage was found for participants in a clinical trial compared with nonparticipants. Additionally, there were not demographic factors associated with increased clinical trial participation.

Conclusions  Clinical trial participation does not, by itself, lead to improved outcome for pediatric patients with acute lymphoblastic leukemia in the current era. Discussions about participation in a clinical trial should focus on improvement of future therapy, not the direct benefit of the research participant.

top

Differences in Non-Hodgkin Lymphoma Survival Between Young Adults and Children [Article]

Objective  To examine differences in non-Hodgkin lymphoma (NHL) survival between young adults and children/adolescents.

Design  Survival analysis using 13 Surveillance, Epidemiology, and End Results registries.

Setting  Cancer survival information from population-based cancer registries from 1992 through 2001.

Participants  A total of 2442 cases of NHL among children/adolescents (aged 0-19 years) and young adults (aged 20-29 years).

Main Exposure  Differences in NHL survival between young adults and children.

Main Outcome Measures  Comparison of 5-year survival by constructing Kaplan-Meier survival curves and modeling 5-year survival with multivariate Cox proportional hazards.

Results  Young adults were more likely to die compared with children/adolescents (hazard ratio = 2.06; 95% confidence interval, 1.65-2.56) even after accounting for NHL subtype and stage at diagnosis. Persons diagnosed with stage III disease (hazard ratio = 1.71; 95% confidence interval, 1.20-2.46) and stage IV disease (hazard ratio = 3.19; 95% confidence interval, 2.47-4.13) were more likely to die compared with persons diagnosed with stage I disease.

Conclusions  Being a young adult at diagnosis and having a higher stage of disease at diagnosis were associated with higher risk of death from NHL. Increasing survival with NHL is dependent on receiving appropriate cancer therapy. Therefore, efforts to address survival should include improving enrollment in clinical trials as well as increasing access to care.

top

Palliative Care of Children With Brain Tumors: A Parental Perspective [Article]

Objective  To explore the end-of-life experience of children with brain tumors and their families.

Design  Qualitative analysis of focus group interviews.

Setting  Children's Hospital, London Health Sciences Center.

Participants  Twenty-five parents of 17 children who had died of brain tumors.

Intervention  Parents participated in 3 semistructured focus group interviews.

Main Outcome Measures  Themes identified through thematic analysis of interview transcripts.

Results  Qualitative analysis identified 3 primary themes. (1) Parents described the dying trajectory of their child as characterized by progressive neurologic deterioration, with the loss of the ability to communicate as a turning point. Parental coping mechanisms included striving to maintain normality and finding spiritual strength through maintaining hope and in the resilience of their child. (2) Parental struggles during this phase included balancing competing responsibilities and speaking with their child about death. (3) Barriers to achieving a home death included suboptimal symptom management, financial and practical hardships, and inadequate community support. A fourth, secondary theme concerned the therapeutic benefits of the interview.

Conclusion  The neurologic deterioration that characterizes the dying trajectory of children with brain tumors may create significant challenges for health care professionals and the children's parents, supporting the need for increased awareness of the distinct issues in the palliative care of children with brain tumors and for early anticipatory guidance provided for families.

top

Considerations About Hastening Death Among Parents of Children Who Die of Cancer [Article]

Objectives  To estimate the frequency of hastening death discussions, describe current parental endorsement of hastening death and intensive symptom management, and explore whether children's pain influences these views in a sample of parents whose child died of cancer.

Design  Cross-sectional survey.

Setting  Two tertiary-care US pediatric institutions.

Participants  A total of 141 parents of children who died of cancer (response rate, 64%).

Outcome Measures  Proportion of parents who (1) considered or (2) discussed hastening death during the child's end of life and who endorsed (3) hastening death or (4) intensive symptom management in vignettes portraying children with end-stage cancer.

Results  A total of 19 of 141 (13%; 95% confidence interval [CI], 8%-19%) parents considered requesting hastened death for their child and 9% (95% CI, 4%-14%) discussed hastening death; consideration of hastening death tended to increase with an increase in the child's suffering from pain. In retrospect, 34% (95% CI, 26%-42%) of parents reported that they would have considered hastening their child's death had the child been in uncontrollable pain, while 15% or less would consider hastening death for nonphysical suffering. In response to vignettes, 50% (95% CI, 42%-58%) of parents endorsed hastening death while 94% (95% CI, 90%-98%) endorsed intensive pain management. Parents were more likely to endorse hastening death if the vignette involved a child in pain compared with coma (odds ratio, 1.4; 95% CI, 1.1-1.8).

Conclusions  More than 10% of parents considered hastening their child's death; this was more likely if the child was in pain. Attention to pain and suffering and education about intensive symptom management may mitigate consideration of hastening death among parents of children with cancer.

top

Trends in Childhood Violence and Abuse Exposure: Evidence From 2 National Surveys [Article]

Objective  To assess trends in children's exposure to abuse, violence, and crime victimizations.

Design  An analysis based on a comparison of 2 cross-sectional national telephone surveys using identical questions conducted in 2003 and 2008.

Setting  Telephone interview.

Participants  Experiences of children aged 2 to 17 years (2030 children in 2003 and 4046 children in 2008) were assessed through interviews with their caretakers and the children themselves.

Outcome Measure  Responses to the Juvenile Victimization Questionnaire.

Results  Several types of child victimization were reported significantly less often in 2008 than in 2003: physical assaults, sexual assaults, and peer and sibling victimizations, including physical bullying. There were also significant declines in psychological and emotional abuse by caregivers, exposure to community violence, and the crime of theft. Physical abuse and neglect by caregivers did not decline, and witnessing the abuse of a sibling increased.

Conclusion  The declines apparent in this analysis parallel evidence from other sources, including police data, child welfare data, and the National Crime Victimization Survey, suggesting reductions in various types of childhood victimization in recent years.

top

Association Between Child Immunization and Availability of Health Infrastructure in Slums in India [Article]

Objective  To examine the association between presence of an urban health center (UHC) in proximity to a slum and immunization status of slum children in a city in India.

Design  Cross-sectional study.

Setting  Slums of Agra, India.

Participants  Data were obtained from a baseline survey conducted by the US Agency for International Development Environmental Health Project in 2005 in slums in Agra. The study population consisted of 1728 children aged 10 to 23 months. Information about children's immunization was obtained from interviews with mothers aged 15 to 44 years.

Main Exposure  Availability and proximity to a UHC that provides immunization services.

Main Outcome Measures  Immunization status of children, which was measured as "complete" if the child had received 1 dose of BCG vaccine, 3 doses each of diphtheria, pertussis, and tetanus and oral polio vaccines, and 1 dose of measles vaccine; "partial" if any 1 or more vaccines were missing; and "not" if no vaccine was received. Adjusted relative risk ratios compared children receiving complete or partial immunization with those not immunized.

Results  Adjusted models showed that presence of a UHC within 2 km of a slum was associated with more than twice the likelihood of children being completely (relative risk ratio, 2.03; 95% confidence interval, 1.12-3.66) or partially (relative risk ratio, 2.33; 95% confidence interval, 1.55-3.50) immunized.

Conclusions  We found that presence of a UHC was positively associated with immunization status of children in slums. These results suggest a need for greater public attention to expand coverage of slums through UHCs.

top

Prevalence of and Early-Life Influences on Childhood Strabismus: Findings From the Millennium Cohort Study [Article]

Background  Strabismus is a common disorder of largely unknown cause reported to occur more frequently in children with neurodevelopmental conditions and in children born prematurely or of low birth weight. Population-based investigation of other potential early-life influences has been limited.

Objective  To investigate the prevalence of and the early-life risk factors associated with childhood strabismus.

Design  Cross-sectional analytical study of a nationally representative sample of children participating in the Millennium Cohort Study.

Setting  United Kingdom.

Participants  A population-based sample of 14 980 children aged 3 years.

Main Outcome Measures  Parental report of "isolated" strabismus and "neurodevelopmental" strabismus (ie, in the context of neurologic disorders), considered separately.

Results  Three hundred forty-three children had strabismus (of whom 20 [5.8%] had neurodevelopmental/neurologic disorders), giving a total weighted prevalence of 2.1% (95% confidence interval, 1.8%-2.4%). In multivariable analysis, the risk of isolated strabismus was reduced in children of nonwhite maternal ethnicity and was increased in those born after an assisted or cesarean delivery and in those who were of low birth weight and preterm (in particular, late preterm). An increased risk of neurodevelopmental strabismus was independently associated with maternal smoking into later pregnancy, maternal illnesses in pregnancy, and decreasing birth weight for gestational age and sex. Socioeconomic status was associated with isolated (inverse relationship) and neurodevelopmental (U-shaped relationship) strabismus.

Conclusions  Several early-life social and biological factors are associated with strabismus, with differences in patterns between isolated and neurodevelopmental forms. Further collaborative research could explore this hypothesis to identify modifiable risk factors.

top

Adolescent Screen Time and Attachment to Parents and Peers [Article]

Objective  To examine associations between screen time (television, video or DVD, gaming, and computer use) and attachment to parents and peers in 2 cohorts of adolescents 16 years apart.

Design  Cross-sectional data regarding screen time and attachment to parents and peers were collected for 2 cohorts of adolescents, one in 1987-1988 (the Dunedin Multidisciplinary Health and Development Study [DMHDS] cohort) and the other in 2004 (the Youth Lifestyle Study [YLS] cohort).

Setting  Members of the DMHDS cohort were interviewed as part of a full day of assessment, and members of the YLS cohort completed a self-report questionnaire in a supervised classroom setting.

Participants  The DMHDS cohort (n = 976) was aged 15 years in 1987-1988. The YLS cohort (n = 3043) was aged 14 to 15 years in 2004.

Main Outcome Measures  Screen time and low attachment to parents and peers as measured by the Inventory of Parent and Peer Attachment.

Results  More time spent television viewing and less time spent reading and doing homework were associated with low attachment to parents for both cohorts. Among the YLS cohort, more time spent playing on a computer was also associated with low attachment to parents. Among the DMHDS cohort, more time spent television viewing was associated with low attachment to peers.

Conclusions  Screen time was associated with poor attachment to parents and peers in 2 cohorts of adolescents 16 years apart. Given the importance of attachment to parents and peers in adolescent health and development, concern about high levels of screen time among adolescents is warranted.

top

Identifying Children at Low Risk for Bacterial Conjunctivitis [Article]

Objective  To identify a population of children at low risk for bacterial conjunctivitis on the basis of history and physical examination findings.

Design  Prospective observational cohort study.

Setting  Urban pediatric emergency department.

Participants  Children aged 6 months to 17 years with conjunctival erythema, eye discharge, or both. The exclusion criteria were eye trauma, exposure to a noxious chemical, contact lens use, and antibiotic drug use in the past 5 days.

Interventions  Clinicians completed a checklist of signs and symptoms and collected a conjunctival swab for bacterial culture.

Main Outcome Measures  The ² test, the Mann-Whitney test, and logistic regression were used to create a prediction model for a negative bacterial culture.

Results  Of 368 patients enrolled, 194 (52.7%) were males. The median patient age was 3 years (interquartile range, 1-5 years). Conjunctival cultures were negative in 130 patients (35.3%). Age 6 years or older, presentation in April through November, no or watery discharge, and no glued eye in the morning were the clinical factors found to be independently associated with a negative conjunctival culture. If 3 factors were present, 76.4% (95% confidence interval, 63.6%-85.6%) of patients had a negative culture. If all 4 factors were present, 92.3% (95% confidence interval, 66.1%-98.2%) of patients had a negative culture.

Conclusion  The combination of 4 clinical factors may enable clinicians to identify children at low risk for bacterial conjunctivitis and may reduce routine antibiotic drug administration.

top

Editorial Policies of Pediatric Journals: Survey of Instructions for Authors [Article]

Objective  To study whether specific recommendations aiming to improve publication practice were included in author instructions of pediatric journals.

Design  We identified 69 journals in the subject category "pediatrics" of the Journal Citation Report 2007 that publish original research articles. From the journals' online author instructions, we extracted information regarding endorsement of the Uniform Requirements for Manuscripts (URM) of the International Committee of Medical Journal Editors and of 5 major reporting guidelines such as the Consolidated Standards of Reporting Trials (CONSORT) statement, disclosure of conflicts of interest, and trial registration. Two investigators collected data independently.

Results  The URM were mentioned in author instructions of 38 of the 69 journals (55%). Endorsement of reporting guidelines was low: CONSORT was referred to most frequently (14 journals; 20%); each of the other 4 reporting guidelines was mentioned in less than 10% of author instructions. Fifty-four journals (78%) explicitly required authors to disclose conflicts of interest, and 16 (23%) either recommended or required trial registration. The odds of endorsing the URM increased by 2.25 (95% confidence interval [CI], 1.17-4.34) per additional impact factor point. Similarly, the odds increased by 2.32 (95% CI, 0.95-5.70) for requiring disclosure of conflicts of interest and by 3.66 (95% CI, 1.74-7.71) for requiring trial registration.

Conclusions  Many pediatric journals do not include recommendations that aim to improve publication practice in their author instructions. About one-fifth of journals do not require authors to disclose conflicts of interest on manuscript submission and more than three-quarters do not require/recommend trial registration.

top

Identification of HIV-Infected 12- to 24-Year-Old Men and Women in 15 US Cities Through Venue-Based Testing [Article]

Objective  To test whether "venue-based testing" could identify human immunodeficiency virus (HIV) infection in US youth, 12 to 24 years of age, who were otherwise not aware of their infection. Racial and ethnic minority women and men who have sex with men (WSM and MSM) compose the majority of new HIV cases among adolescents and young adults.

Design  Cross-sectional study.

Setting  Selected venues in communities surrounding the 15 Adolescent Trials Network for HIV/AIDS Interventions (ATN) clinical sites over a 3-month period.

Participants  At each venue, ATN sites recruited 20 to 30 English- or Spanish-speaking at-risk youth (12 to 24 years of age), resulting in a total of 1217 study participants, including 611 MSM and 606 WSM.

Intervention  Venue-based HIV testing with 2 components: an anonymous audio computer-assisted self-administered interview and an anonymous HIV antibody assay.

Main Outcome Measure  The prevalence of HIV infection in MSM and WSM.

Results  The prevalence of HIV infection in MSM and WSM was 15.3% and 0.3%, respectively. Sixty percent of the MSM and 100% of the WSM claimed to not know of their infection.

Conclusion  Venue-based testing may be an important strategy to identify HIV-infected younger MSM; however, other strategies are needed for WSM.

top

Source of Admission and Outcomes for Critically Injured Children in the Mountain States [Article]

Objective  To determine whether mortality and length of stay at a pediatric trauma center differ between patients admitted by interhospital transfer and those admitted directly from the injury scene.

Design  Analysis of prospectively collected data from a pediatric trauma center database.

Setting  A designated regional level I pediatric trauma center.

Participants  Injured children from birth to 17 years of age hospitalized between January 1, 2006, and September 30, 2007.

Main Exposure  Incident in-hospital mortality rates and length of stay at the trauma center were compared between patients admitted directly and those admitted by interhospital transfer, controlling for potential confounders.

Outcome Measures  In-hospital mortality and duration of hospitalization.

Results  Of 2192 patients admitted to the trauma center, 1175 (53.6%) were admitted directly from the injury scene. Patients admitted by interhospital transfer had higher injury severity and lower Glasgow Coma Scale scores at admission (P < .01). Of 31 deaths during the study period, 26 (83.9%) were among patients admitted by interhospital transfer. These patients had a 7-fold higher unadjusted incident rate of death (incidence rate ratio, 7.16; 95% confidence interval, 2.49-20.58) compared with those admitted directly. This finding remained (incidence rate ratio, 3.01; 95% confidence interval, 1.01-8.98) after adjustment for injury severity and Glasgow Coma Scale scores, elapsed time from injury until admission at the trauma center, and age. Among survivors, patients admitted by interhospital transfer stayed longer in the hospital than those admitted directly.

Conclusion  Pediatric trauma center mortality rates are lower among children admitted directly from the injury scene compared with those admitted by interhospital transfer.

top

Child vs Adult Randomized Controlled Trials in Specialist Journals: A Citation Analysis of Trends, 1985-2005 [Review Article]

Objective  To compare secular trends in the age representation of published randomized controlled trials (RCTs) in specialty journals during a period of 20 years.

Data Source  A validated electronic search strategy using Ovid MEDLINE was conducted to identify RCTs published in the years 1985 through 2005.

Study Selection  The publications retrieved were subdivided into age-specific groups: adults, children, both adults and children, and studies with no age group identified. Within 31 specialties, we chose up to 5 specialty journals and 5 pediatric specialty journals.

Main Outcome Measure  Number of RCTs targeting children compared with adults over time. Linear trends were identified using regression modeling, and an interaction term was included to compare rates of increase between age groups.

Results  A total of 174 unique journals with 43 326 unique RCTs with age-specific categorization were included. Adult RCTs increased by 90.5 RCTs per year (95% confidence interval [CI], 78-103), which was significantly higher than either pediatric RCTs, which rose by 16.9 RCTs per year (95% CI, 12-22) or RCTs involving both children and adults, which rose by 22.7 RCTs per year (95% CI, 10-35). Twenty four of 31 specialties (77%) demonstrated a greater rise in the number of published RCTs per year involving adults than those enrolling children.

Conclusion  Adult RCT publications are increasing at a faster rate than pediatric RCTs in almost all specialties.

top

Picture of the Month--Quiz Case [Special Feature]

top

Picture of the Month--Diagnosis [Special Feature]

top

2010 Certifying Examinations of the American Board of Pediatrics [Announcement]

top

Framing the Benefits of Cancer Clinical Trials [Editorial]

top

Rethinking Hard-to-Reach Communities in the Realm of Global Pediatrics: The Urban Poor and Community Health Workers [Editorial]

top

Randomized Controlled Trials and Pediatric Research [Editorial]

top

Adherence to Prophylactic Antibiotic Guidelines Among Medicaid Infants With Sickle Cell Disease [The Pediatric Forum]

top

Swimming Proficiency in a Multiethnic Sample in a High-Risk Area for Drowning [The Pediatric Forum]

top

Strabismus [Advice for Patients]

top

Dappled Streambed, Olympic National Park, Washington State, 2008 [About the Cover]

top

About This Journal [About This Journal]

top

This Month in Archives of Pediatrics & Adolescent Medicine [This Month in Archives of Pediatrics & Adolescent Medicine]

top

Metformin Extended Release Treatment of Adolescent Obesity: A 48-Week Randomized, Double-Blind, Placebo-Controlled Trial With 48-Week Follow-up [Article]

Background  Metformin has been proffered as a therapy for adolescent obesity, although long-term controlled studies have not been reported.

Objective  To test the hypothesis that 48 weeks of daily metformin hydrochloride extended release (XR) therapy will reduce body mass index (BMI) in obese adolescents, as compared with placebo.

Design  Multicenter, randomized, double-blind, placebo-controlled clinical trial.

Setting  The 6 centers of the Glaser Pediatric Research Network from October 2003 to August 2007.

Participants  Obese (BMI≥95th percentile) adolescents (aged 13-18 years) were randomly assigned to the intervention (n = 39) or placebo groups.

Intervention  Following a 1-month run-in period, subjects following a lifestyle intervention program were randomized 1:1 to 48 weeks' treatment with metformin hydrochloride XR, 2000 mg once daily, or an identical placebo. Subjects were monitored for an additional 48 weeks.

Main Outcome Measure  Change in BMI, adjusted for site, sex, race, ethnicity, and age and metformin vs placebo.

Results  After 48 weeks, mean (SE) adjusted BMI increased 0.2 (0.5) in the placebo group and decreased 0.9 (0.5) in the metformin XR group (P = .03). This difference persisted for 12 to 24 weeks after cessation of treatment. No significant effects of metformin on body composition, abdominal fat, or insulin indices were observed.

Conclusion  Metformin XR caused a small but statistically significant decrease in BMI when added to a lifestyle intervention program.

Trial Registration  clinicaltrials.gov Identifiers: NCT00209482 and NCT00120146

top

Fasting Plasma Glucose Levels Within the Normoglycemic Range in Childhood as a Predictor of Prediabetes and Type 2 Diabetes in Adulthood: The Bogalusa Heart Study [Article]

Objectives  To determine whether childhood elevated fasting plasma glucose (FPG) levels within the normoglycemic range predict diabetes in adulthood.

Design  Retrospective cohort study.

Setting  Community of Bogalusa, Louisiana.

Participants  Normoglycemic (n = 1723), prediabetic (n = 79), and type 2 diabetic (n = 47) adults aged 19 to 44 years followed up serially for an average of 21 years since childhood.

Main Exposures  Association of elevated baseline childhood FPG levels with the prediabetic or diabetic status at the last survey in adulthood.

Main Outcome Measures  Receiver operating characteristic analysis and longitudinal logistic regression odds ratios.

Results  The prevalent rate of adult diabetes status by quartiles of baseline childhood FPG levels showed an adverse trend for prediabetes (P < .001) and diabetes (P = .03), with an apparent threshold occurring at or above the 50th percentile (86 mg/dL). Regarding the predictive value of the above threshold, the area under the receiver operating curve analysis yielded a C value of 0.855 for prediabetes and 0.789 for diabetes models, with sensitivity and specificity, respectively, of 76.9% and 85.2% for prediabetes and 75.0% and 76.0% for diabetes. In a multivariate analysis that included anthropometric, hemodynamic, and metabolic variables from childhood to adulthood and baseline childhood FPG status (≥ vs <50th percentile), individuals with elevated childhood FPG levels were 3.40 times more likely to develop prediabetes (P < .001) and 2.06 times more likely to develop diabetes (P = .05) as adults.

Conclusion  The fact that elevated FPG level in childhood, even within the normoglycemic range, is a predictor of type 2 diabetes in younger adulthood has implications for health care policy.

top

Roles of Gastrointestinal and Adipose Tissue Peptides in Childhood Obesity and Changes After Weight Loss Due to Lifestyle Intervention [Review Article]

Childhood obesity is a global epidemic and associated with an increased risk of hypertension, diabetes mellitus, and coronary heart disease, in addition to psychological disorders. Interventions such as bariatric surgery are highly invasive and lifestyle modifications are often unsuccessful because of disturbed perceptions of satiety. New signaling peptides discovered in recent years that are produced in peripheral tissues such as the gut, adipose tissue, and pancreas communicate with brain centers of energy homeostasis, such as the hypothalamus and hindbrain. This review discusses the major known gut- and adipose tissue–derived hormones involved in the regulation of food intake and energy homeostasis and their serum levels in childhood obesity before and after weight loss as well as their relationship to consequences of obesity. Since most of the changes of gastrointestinal hormones and adipokines normalize in weight loss, pharmacological interventions based on these hormones will likely not solve the obesity epidemic in childhood. However, a better understanding of the pathways of body weight– and food intake–regulating gut- and adipose tissue–derived hormones will help to find new strategies to treat obesity and its consequences.

top

Body Mass Index and Timing of Pubertal Initiation in Boys [Article]

Objective  To examine the association between body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) and timing of pubertal onset in a population-based sample of US boys.

Design  Longitudinal prospective study.

Setting  Ten US sites that participated in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development.

Participants  Of 705 boys initially enrolled in the study, information about height and weight measures and pubertal stage by age 11.5 years was available for 401 boys.

Main Exposure  The BMI trajectory created from measured heights and weights at ages 2, 3, 4.5, 7, 9, 9.5, 10.5, and 11.5 years.

Main Outcome Measure  Onset of puberty at age 11.5 years as measured by Tanner genitalia staging.

Results  Boys in the highest BMI trajectory (mean BMI z score at age 11.5 years, 1.84) had a greater relative risk of being prepubertal compared with boys in the lowest BMI trajectory (mean BMI z score at age 11.5 years, –0.76) (adjusted relative risk = 2.63; 95% confidence interval, 1.05-6.61; P = .04).

Conclusions  The relationship between body fat and timing of pubertal onset is not the same in boys as it is in girls. Further studies are needed to better understand the physiological link between body fat and timing of pubertal onset in both sexes.

top

Effectiveness of a School-Based Physical Activity Injury Prevention Program: A Cluster Randomized Controlled Trial [Article]

Objective  To study the effects of a school-based injury prevention program on physical activity injury incidence and severity.

Design  Cluster randomized controlled trial performed from January 1, 2006, through July 31, 2007.

Setting  Forty Dutch primary schools.

Participants  A total of 2210 children (aged 10-12 years).

Intervention  Schools were randomized to receive either the regular curriculum or an intervention program that targeted physical activity injuries.

Outcome Measures  Incidence and severity of physical activity injuries per 1000 hours of physical activity participation.

Results  A total of 100 injuries in the intervention group and 104 injuries in the control group were registered. Nonresponse at baseline or follow-up was minimal (8.7%). The Cox regression analyses adjusted for clustering showed a small nonsignificant intervention effect on total (HR, 0.81; 95% confidence interval [CI], 0.41-1.59), sports club (0.69; 0.28-1.68), and leisure time injuries (0.75; 0.36-1.55). However, physical activity appeared to be an effect modifier. In those who were less physically active, the intervention had a larger effect. The intervention reduced the total and leisure time injury incidence (HR, 0.47; 95% CI, 0.21-1.06; and 0.43; 0.16-1.14; respectively). Sports club injury incidence was significantly reduced (HR, 0.23; 95% CI, 0.07-0.75).

Conclusion  We found a substantial and relevant reduction in physical activity injuries, especially in children in the low active group, because of the intervention. This school-based injury prevention program is promising, but future large-scale research is needed.

top

Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months: A Randomized Controlled Trial With Young Adolescents [Article]

Objective  To evaluate the efficacy of an abstinence-only intervention in preventing sexual involvement in young adolescents.

Design  Randomized controlled trial.

Setting  Urban public schools.

Participants  A total of 662 African American students in grades 6 and 7.

Interventions  An 8-hour abstinence-only intervention targeted reduced sexual intercourse; an 8-hour safer sex–only intervention targeted increased condom use; 8-hour and 12-hour comprehensive interventions targeted sexual intercourse and condom use; and an 8-hour health-promotion control intervention targeted health issues unrelated to sexual behavior. Participants also were randomized to receive or not receive an intervention maintenance program to extend intervention efficacy.

Outcome Measures  The primary outcome was self-report of ever having sexual intercourse by the 24-month follow-up. Secondary outcomes were other sexual behaviors.

Results  The participants' mean age was 12.2 years; 53.5% were girls; and 84.4% were still enrolled at 24 months. Abstinence-only intervention reduced sexual initiation (risk ratio [RR], 0.67; 95% confidence interval [CI], 0.48-0.96). The model-estimated probability of ever having sexual intercourse by the 24-month follow-up was 33.5% in the abstinence-only intervention and 48.5% in the control group. Fewer abstinence-only intervention participants (20.6%) than control participants (29.0%) reported having coitus in the previous 3 months during the follow-up period (RR, 0.94; 95% CI, 0.90-0.99). Abstinence-only intervention did not affect condom use. The 8-hour (RR, 0.96; 95% CI, 0.92-1.00) and 12-hour comprehensive (RR, 0.95; 95% CI, 0.91-0.99) interventions reduced reports of having multiple partners compared with the control group. No other differences between interventions and controls were significant.

Conclusion  Theory-based abstinence-only interventions may have an important role in preventing adolescent sexual involvement.

Trial Registration  clinicaltrials.gov Identifier: NCT00640653

top

Attention-Deficit/Hyperactivity Disorder Outcomes for Children Treated in Community-Based Pediatric Settings [Article]

Objective  To determine if children treated by community physicians who participated in an attention-deficit/hyperactivity disorder (ADHD) quality improvement intervention demonstrate symptom and impairment improvements comparable with those achieved in university-based clinical trials.

Design  Case series.

Setting  Rural, suburban, and urban practices, with 28% of the 47 practices serving primarily (>50% of patients) Medicaid-receiving populations.

Participants  A total of 785 children aged between 7 and 11 years were treated for ADHD by community physicians participating in the study.

Intervention  A total of 158 community physicians from 47 separate practices participated in a quality improvement intervention, the ADHD Collaborative, designed to improve physician adherence to evidence-based ADHD treatment guidelines. The intervention included mapping and redesign of practice office flow to facilitate adherence to American Academy of Pediatrics ADHD guidelines as well as didactic sessions related to diagnosis and treatment of ADHD. Medical record reviews were completed at the initial assessment and every 3 months for 1 year to evaluate treatment outcome.

Outcome Measures  Improvement in parent- and teacher-rated ADHD symptoms and functional impairment.

Results  Children showed large improvements in parent- and teacher-rated ADHD symptoms, similar to some clinical trials, but made no significant improvements in functional impairment.

Conclusions  Large improvements in ADHD symptoms can be achieved in primary care settings when physicians provide evidence-based ADHD care using medication. Because many children with ADHD continued to have significant functional impairment despite symptom improvement, collaboration with other mental health or educational services in additional to medication appears warranted.

top

Longitudinal Development of Secondary Sexual Characteristics in Girls and Boys Between Ages 91/2 and 151/2 Years [Article]

Objectives  To identify ages when adolescents were in sexual maturity stages 2 through 5; to explain the relations between breast (girls), genital (boys), and pubic hair (girls and boys) development between ages 91/2 and 151/2 years; and to evaluate synchrony of pubertal development across characteristics.

Design  Annual pubertal assessments.

Setting  Ten locations in the United States.

Participants  A total of 859 adolescents (427 boys [49.7%] and 432 girls [50.3%]; 737 white [85.8%] and 122 black [14.2%]).

Main Outcome Measures  Changes in the 5 stages of breast, genital, and pubic hair development.

Results  Girls were in breast maturity stages 2 and 3 earlier than comparable pubic hair stages. Although breast development in girls started earlier than pubic hair development, girls completed breast and pubic hair development at approximately the same age. Black girls were in all stages of breast and pubic hair development earlier than white girls. Boys were in stages 2, 3, 4, and 5 of genital development before the comparable pubic hair stage. In boys, genital development started earlier than pubic hair development, but pubic hair development was completed in less time. Black boys were in genital and pubic hair development about 7 months earlier than white boys. Black and white boys completed genital development in approximately 41/2 years, but black boys took approximately 6 months longer than white boys to complete pubic hair development. At stage 2, for 66.2% of girls, breast development preceded their pubic hair development; for 91.1% of boys, genital development preceded their pubic hair development.

Conclusions  The results of this study are useful in understanding normative variation in the timing and change in the development of secondary sexual characteristics at puberty. They will help identify adolescents with atypical changes in sexual maturation and unusual progression of sexual maturation and growth disorders.

top

Television Viewing by Young Hispanic Children: Evidence of Heterogeneity [Article]

Objectives  To determine if hours of daily television viewed by varying age groups of young children with Hispanic mothers differs by maternal language preference and to compare these differences with young children with white mothers.

Design  Cross-sectional analysis of data collected in 2000 from the National Survey of Early Childhood Health.

Setting  Nationally representative sample.

Participants  One thousand three hundred forty-seven mothers of children aged 4 to 35 months.

Main Exposure  Subgroups of self-reported maternal race/ethnicity (white or Hispanic) and within Hispanic race/ethnicity, stratification by maternal language preference (English or Spanish).

Outcome Measure  Hours of daily television the child viewed.

Results  Bivariate analyses showed that children of English- vs Spanish-speaking Hispanic mothers watched more television daily (1.88 vs 1.31 hours, P < .01). Multivariable regression analyses stratified by age revealed differences by age group. Among 4- to 11-month-old infants, those of English- and Spanish-speaking Hispanic mothers watched similar amounts. However, among children aged 12 to 23 and 24 to 35 months, those of English-speaking Hispanic mothers watched more television than children of Spanish-speaking Hispanic mothers (incidence rate ratio [IRR], 1.61; 95% confidence interval [CI], 1.17-2.22; IRR, 1.66; 95% CI, 1.10-2.51, respectively). Compared with children of white mothers, children of both Hispanic subgroups watched similar amounts among the 4- to 11-month-old group. However, among 12- to 23-month-old children, those of English-speaking Hispanic mothers watched more compared with children of white mothers (IRR, 1.57; 95% CI, 1.18-2.11). Among 24- to 35-month-old children, those of English-speaking Hispanic mothers watched similar amounts compared with children of white mothers, but children of Spanish-speaking Hispanic mothers watched less (IRR, 0.69; 95% CI, 0.50-0.95).

Conclusion  Television-viewing amounts among young children with Hispanic mothers vary by child age and maternal language preference, supporting the need to explore sociocultural factors that influence viewing in Hispanic children.

top

Parents' Medication Administration Errors: Role of Dosing Instruments and Health Literacy [Article]

Objectives  To assess parents' liquid medication administration errors by dosing instrument type and to examine the degree to which parents' health literacy influences dosing accuracy.

Design  Experimental study.

Setting  Interviews conducted in a public hospital pediatric clinic in New York, New York, between October 28, 2008, and December 24, 2008.

Participants  Three hundred two parents of children presenting for care were enrolled.

Main Outcome Measures  Parents were observed for dosing accuracy (5-mL dose) using a set of standardized instruments (2 dosing cups [one with printed calibration markings, the other with etched markings], dropper, dosing spoon, and 2 oral syringes [one with and the other without a bottle adapter]).

Results  The percentages of parents dosing accurately (within 20% of the recommended dose) were 30.5% using the cup with printed markings and 50.2% using the cup with etched markings, while more than 85% dosed accurately with the remaining instruments. Large dosing errors (>40% deviation) were made by 25.8% of parents using the cup with printed markings and 23.3% of parents using the cup with etched markings. In adjusted analyses, cups were associated with increased odds of making a dosing error (>20% deviation) compared with the oral syringe (cup with printed markings: adjusted odds ratio [AOR] = 26.7; 95% confidence interval [CI], 16.8-42.4; cup with etched markings: AOR = 11.0; 95% CI, 7.2-16.8). Compared with the oral syringe, cups were also associated with increased odds of making large dosing errors (cup with printed markings: AOR = 7.3; 95% CI, 4.1-13.2; cup with etched markings: AOR = 6.3; 95% CI, 3.5-11.2). Limited health literacy was associated with making a dosing error (AOR = 1.7; 95% CI, 1.1-2.8).

Conclusions  Dosing errors by parents were highly prevalent with cups compared with droppers, spoons, or syringes. Strategies to reduce errors should address both accurate use of dosing instruments and health literacy.

top

Effect of Chorioamnionitis on Early Childhood Asthma [Article]

Objective  To examine the association between chorioamnionitis and childhood asthma based on gestational age at birth and race/ethnicity.

Design  A retrospective cohort study using the Kaiser Permanente Southern California (KPSC) Matched Perinatal records.

Setting  Kaiser Permanente Southern California, Pasadena, California.

Participants  All singleton children born in KPSC hospitals between 1991 and 2007 (N = 510 216).

Main Exposure  Clinically diagnosed chorioamnionitis.

Main Outcome Measures  Physician-diagnosed asthma in children aged 8 years or younger.

Results  The incidence rates of asthma among preterm- and full term–born children of pregnancies complicated by chorioamnionitis were 100.7 and 39.6 per 1000 person-years, respectively (incidence rate ratio, 2.9; 95% confidence interval [CI], 2.6-3.3). Children aged 8 years or younger with asthma were more likely to be born to women who were aged 35 years or older, African American, had 13 or more years of education, had maternal asthma, used antibiotics, had chorioamnionitis during the pregnancy, and had a male child. Multivariable Cox regression analysis revealed that children born at 23 to 28, 29 to 33, and 34 to 36 weeks' gestation after pregnancies complicated by chorioamnionitis had a 1.23-fold (95% CI, 1.02-1.49), 1.51-fold (95% CI, 1.26-1.80), and 1.20-fold (95% CI, 1.03-1.47), respectively, increased risk of asthma compared with children of similar gestational age born after pregnancies not complicated by chorioamnionitis. A preterm pregnancy complicated by chorioamnionitis was associated with increased risk of asthma among white (hazard ratio [HR], 1.66; 95% CI, 1.32-2.07), African American (HR, 1.98; 95% CI, 1.60-2.44), and Hispanic (HR, 1.70; 95% CI, 1.45-2.00), but not Asian/Pacific Islander (HR, 1.15; 95% CI, 0.83-1.58) women.

Conclusion  Findings suggest that chorioamnionitis at preterm gestation is independently associated with increased risk of childhood asthma.

top

P Values vs Estimates of Association With Confidence Intervals [Commentary]

top

Predicting Prediabetes and Diabetes: Can We Do It? Is It Worth It? [Editorial]

top

Research, Policy, and Adolescent Sexual Behavior [Editorial]

top

Video-Assisted Thorascopic Surgery vs Chest Drain With Fibrinolytics for the Treatment of Pleural Empyema in Children: A Systematic Review of Randomized Controlled Trials [The Pediatric Forum]

top

Klippel-Trenaunay Syndrome Was Not the Correct Answer [The Pediatric Forum]

top

Terminology Used to Describe Vascular Anomalies [The Pediatric Forum]

top

Terminology Used to Describe Vascular Anomalies--Reply [The Pediatric Forum]

top

Medication Safety for Children [Advice for Patients]

top

Mountain goat in Northern Cascades, from the top of the Cascade Pass/Sahale Arm trail, August 2009 [About the Cover]

top

About This Journal [About This Journal]

top

This Month in Archives of Pediatrics & Adolescent Medicine [This Month in Archives of Pediatrics & Adolescent Medicine]

top

Long-term Effects of Prenatal and Infancy Nurse Home Visitation on the Life Course of Youths: 19-Year Follow-up of a Randomized Trial [Article]

Objective  To examine the effect of prenatal and infancy nurse home visitation on the life course development of 19-year-old youths whose mothers participated in the program.

Design  Randomized trial.

Setting  Semirural community in New York.

Participants  Three hundred ten youths from the 400 families enrolled in the Elmira Nurse-Family Partnership program.

Intervention  Families received a mean of 9 home visits (range, 0-16) during pregnancy and 23 (range, 0-59) from birth through the child's second birthday.

Main Outcome Measures  Youth self-reports of educational achievement, reproductive behaviors, welfare use, and criminal involvement.

Results  Relative to the comparison group, girls in the pregnancy and infancy nurse-visited group were less likely to have been arrested (10% vs 30%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.13-0.82) and convicted (4% vs 20%; 0.20; 0.05-0.85) and had fewer lifetime arrests (mean: 0.10 vs 0.54; incidence RR [IRR], 0.18; 95% CI, 0.06-0.54) and convictions (0.04 vs 0.37; 0.11; 0.02-0.51). Nurse-visited girls born to unmarried and low-income mothers had fewer children (11% vs 30%; RR, 0.35; 95% CI, 0.12-1.02) and less Medicaid use (18% vs 45%; 0.40; 0.18-0.87) than their comparison group counterparts.

Conclusions  Prenatal and infancy home visitation reduced the proportion of girls entering the criminal justice system. For girls born to high-risk mothers, there were additional positive program effects consistent with results from earlier phases of this trial. There were few program effects for boys.

Trial Registration  clinicaltrials.gov Identifier: NCT00443638

top

Reducing Maternal Intimate Partner Violence After the Birth of a Child: A Randomized Controlled Trial of the Hawaii Healthy Start Home Visitation Program [Article]

Objectives  To estimate whether home visitation beginning after childbirth was associated with changes in average rates of mothers' intimate partner violence (IPV) victimization and perpetration as well as rates of specific IPV types (physical assault, verbal abuse, sexual assault, and injury) during the 3 years of program implementation and during 3 years of long-term follow-up.

Design  Randomized controlled trial.

Setting  Oahu, Hawaii.

Participants  Six hundred forty-three families with an infant at high risk for child maltreatment born between November 1994 and December 1995.

Intervention  Home visitors provided direct services and linked families to community resources. Home visits were to initially occur weekly and to continue for at least 3 years.

Main Outcome Measures  Women's self-reports of past-year IPV victimization and perpetration using the Conflict Tactics Scale. Blinded research staff conducted maternal interviews following the child's birth and annually when children were aged 1 to 3 years and then 7 to 9 years.

Results  During program implementation, intervention mothers as compared with control mothers reported lower rates of IPV victimization (incidence rate ratio [IRR], 0.86; 95% confidence interval [CI], 0.73-1.01) and significantly lower rates of perpetration (IRR, 0.83; 95% CI, 0.72-0.96). Considering specific IPV types, intervention women reported significantly lower rates of physical assault victimization (IRR, 0.85; 95% CI, 0.71-1.00) and perpetration (IRR, 0.82; 95% CI, 0.70-0.96). During long-term follow-up, rates of overall IPV victimization and perpetration decreased, with nonsignificant between-group differences. Verbal abuse victimization rates (IRR, 1.14, 95% CI, 0.97-1.34) may have increased among intervention mothers.

Conclusion  Early-childhood home visitation may be a promising strategy for reducing IPV.

Trial Registration  clinical trials.gov Identifier: NCT00218751

top

Novel Influenza A(H1N1) in a Pediatric Health Care Facility in New York City During the First Wave of the 2009 Pandemic [Article]

Objective  To describe the burden of care experienced by our pediatric health care facility in New York, New York, from May 3, 2009, to July 31, 2009, during the novel influenza A(H1N1) pandemic that began in spring 2009.

Design  Retrospective case series.

Setting  Pediatric emergency departments and inpatient facilities of New York–Presbyterian Hospital.

Patients  Children presenting to the emergency departments with influenza-like illness (ILI) and children aged 18 years or younger hospitalized with positive laboratory test results for influenza A from May 3, 2009, to July 31, 2009.

Main Outcome Measures  Proportion of children with ILI who were hospitalized and proportion of hospitalized children with influenza A with respiratory failure, bacterial superinfection, and mortality.

Results  When compared with the same period in 2008, the pediatric emergency departments experienced an excess of 3750 visits (19.9% increase). Overall, 27.7% of visits were for ILI; 2.5% of patients with ILI were hospitalized. Of the 115 hospitalized subjects with confirmed influenza A (median age, 4.3 years), 93 (80.9%) had underlying conditions. Four (3.5%) had identified bacterial superinfection, 1 (0.9%) died, and 35 (30.4%) were admitted to a pediatric intensive care unit; of these 35 patients, 11 had pneumonia and required mechanical ventilation, including high-frequency oscillatory ventilation (n = 3).

Conclusions  At our center, 2.5% of children with ILI presenting to the emergency departments during the first wave of the 2009 novel influenza A(H1N1) pandemic were hospitalized. Of the 115 hospitalized children with confirmed influenza A, 9.6% had respiratory failure and 0.9% died. These findings can be compared with the disease severity of subsequent waves of the 2009 novel influenza A(H1N1) pandemic.

top

Health Care Worker Knowledge, Attitudes, and Beliefs Regarding Mandatory Influenza Vaccination [Article]

Objective  To determine the attitudes, beliefs, and knowledge of children's hospital health care workers toward mandatory influenza vaccination.

Design  Self-administered, Web-based questionnaire.

Setting  A large, tertiary children's hospital.

Participants  A random sample of 585 health care workers, including physicians, nurses, and all other hospital employees.

Outcome Measure  Attitudes of health care workers toward mandatory policies for annual influenza vaccination of health care workers as related to their opinions on safety, effectiveness, and knowledge about influenza and influenza vaccination.

Results  Many employees (70%) thought influenza vaccination should be mandatory for health care workers who did not have a medical contraindication. Nearly everyone, 363 of 391 (94%), who favored mandatory immunization had been immunized themselves. Of those who opposed mandatory immunization, 45 of 81 (55.6%) had been immunized (P < .001). Individuals who supported mandatory policies were more likely to believe that the vaccine is safe for both children and adults. There was no significant difference between the percentages of promandate and antimandate employees who believed influenza was dangerous for the patients where they work (66.5% and 62%, respectively, P = .07). Only 29% of antimandate employees believed they were at high risk of contracting influenza, compared with 51% of promandate employees (P < .001).

Conclusions  Approval of mandatory influenza vaccine policies was high; however, attitudes about the dangers of influenza for patients were not associated with acceptance of mandatory vaccination policies for health care workers. Educational efforts targeting health care workers' fears and misconceptions about influenza vaccines might help to decrease the reservoir of unimmunized health care workers.

top

Asthma Care Quality for Children With Minority-Serving Providers [Article]

Objective  To compare asthma care quality for children with and without minority-serving providers.

Design  Cross-sectional telephone survey of parents, linked with a mailed survey of their children's providers.

Setting  A Medicaid-predominant health plan and multispecialty provider group in Massachusetts.

Participants  A total of 563 children with persistent asthma, identified by claims and encounter data.

Main Exposure  Whether the child's provider was minority serving (>25% of patients black or Latino).

Outcomes  Parent report of whether the child had (1) ever received inhaled steroids, (2) received influenza vaccination during the past season, and (3) received an asthma action plan in the past year.

Results  In unadjusted analyses, Latino children and those with minority-serving providers were more likely to have never received inhaled steroids. In adjusted models, the odds of never receiving inhaled steroids were not statistically significantly different for children with minority-serving providers (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.63-2.64), or for Latino vs white children (OR, 1.76; 95% CI, 0.74-4.18); odds were increased for children receiving care in community health centers (OR, 4.88; 95% CI, 1.70-14.02) or hospital clinics (OR, 4.53; 95% CI, 1.09-18.92) vs multispecialty practices. Such differences were not seen for influenza vaccinations or action plans.

Conclusions  Children with persistent asthma are less likely to receive inhaled steroids if they receive care in community health centers or hospital clinics. Practice setting mediated initially observed disparities in inhaled steroid use by Latino children and those with minority-serving providers. No differences by race/ethnicity or minority-serving provider were observed for influenza vaccinations or asthma action plans.

top

Sleep Duration and Hyperglycemia Among Obese and Nonobese Children Aged 3 to 6 Years [Article]

Objective  To investigate the association between sleep duration and risk of hyperglycemia among preschool Chinese children.

Design  A population-based cross-sectional study.

Setting  Seventy-one randomly selected kindergartens in Tianjin, China.

Participants  Six hundred nineteen obese (body mass index z score ≥1.65) and 617 nonobese (body mass index z score <1.65) children aged 3 to 6 years were recruited and matched by age.

Main Exposure  Sleep duration.

Main Outcome Measures  Hyperglycemia, defined as a fasting glucose level of 100 mg/dL or higher.

Results  Obese children were more likely to have shorter sleep duration (≤8 hours) compared with their nonobese counterparts (P < .001). Compared with those who slept for 9 or 10 hours per night, those who slept for 8 hours or less had a significantly higher likelihood of having hyperglycemia, controlling for age and sex (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.12-2.45). After further adjustment for other potential confounders, the association still remained statistically significant (OR, 1.64; 95% CI, 1.09-2.46). In the stratified multivariable analyses, those who were obese and slept for 8 hours or less had an increased risk of having hyperglycemia (OR, 2.12; 95% CI, 1.06-4.21) compared with those who were nonobese and slept for 9 hours or more.

Conclusions  Shorter sleep duration is associated with an increased risk of having hyperglycemia among preschool Chinese children. Whether adequate sleep may help maintain euglycemia among children, especially for those who are overweight or obese, warrants further investigation.

top

Childhood Predictors of Adult Type 2 Diabetes at 9- and 26-Year Follow-ups [Article]

Objective  To determine whether pediatric office measures (waist circumference, body mass index [BMI], systolic [SBP] and diastolic [DBP] blood pressure, and parental diabetes) and laboratory measures (glucose, triglyceride, high-density lipoprotein cholesterol, and insulin) predict risk of type 2 diabetes mellitus (T2DM) at ages 19 and 39 years.

Design  Nine- and 26-year prospective follow-ups of schoolchildren.

Setting  Urban and suburban schools.

Participants  One thousand sixty-seven girls starting at age 10 years in the National Growth and Health Study and 822 schoolchildren aged 6 to 18 years at entry from the Princeton Follow-up Study.

Outcome Measure  Development of T2DM.

Results  In the Princeton Follow-up Study, childhood SBP and BMI in the top fifth percentile and black race predicted T2DM at age 39 years (area under the receiver-operator curve [AUC] = 0.698). Adding a childhood glucose level of 100 mg/dL or higher, and high-density lipoprotein cholesterol in the bottom fifth percentile and triglyceride concentration in the top fifth percentile as explanatory variables increased AUC to 0.717 and 0.709, respectively. If childhood BMI, SBP, and DBP were all lower than the 75th percentile, likelihood of T2DM at age 39 years was 2%; the likelihood was 1% if the parents had no DM. In the National Growth and Heath Study, SBP in the top fifth percentile and parental diabetes predicted T2DM at age 19 years (AUC = 0.699). Adding insulin in the top fifth percentile increased AUC to 0.764, with insulin being a significant variable. If childhood BMI, SBP, and DBP were all lower than the 75th percentile, the likelihood of T2DM at age 19 years was 0.2%, 0.2% if the parents were also free of DM, and 0.3% if childhood insulin was also less than the 75th percentile.

Conclusions  Office-based childhood measures predict the presence and absence of future T2DM 9 and 26 years after baseline. Childhood insulin measurement improves prediction, facilitating approaches to primary prevention of T2DM.

top

Survival Sex Work Involvement as a Primary Risk Factor for Hepatitis C Virus Acquisition in Drug-Using Youths in a Canadian Setting [Article]

Objective  To examine whether there were differential rates of hepatitis C virus (HCV) incidence in injecting drug–using youths who did and did not report involvement in survival sex work.

Design  Data were derived from 2 prospective cohort studies of injecting drug users (May 1, 1996, to July 31, 2007). Analyses were restricted to HCV antibody–negative youths who completed baseline and at least 1 follow-up assessment.

Setting  Vancouver, British Columbia, Canada.

Participants  Of 3074 injecting drug users, 364 (11.8%) were youths (aged 14-24 years) with a median age of 21.3 years and a duration of injecting drug use of 3 years.

Main Exposure  Survival sex work involvement.

Main Outcome Measure  The Kaplan-Meier method and Cox proportional hazards regression were used to compare HCV incidence among youths who did and did not report survival sex work.

Results  Baseline HCV prevalence was 51%, with youths involved in survival sex work significantly more likely to be HCV antibody positive (60% vs 44%; P = .002). In baseline HCV antibody–negative youths, the cumulative HCV incidence at 36 months was significantly higher in those involved in survival sex work (68.4% vs 38.8%; P < .001). The HCV incidence density was 36.8 (95% confidence interval [CI], 24.2-53.5) per 100 person-years in youths reporting survival sex work involvement at baseline compared with 14.1 (9.4-20.3) per 100 person-years in youths not reporting survival sex work. In multivariate Cox proportional hazards analyses, survival sex work was the strongest predictor of elevated HCV incidence (adjusted relative hazard, 2.30; 95% CI, 1.27-4.15).

Conclusion  This study calls attention to the critical need for evidence-based social and structural HCV prevention efforts that target youths engaged in survival sex work.

top

Parental Refusal of Varicella Vaccination and the Associated Risk of Varicella Infection in Children [Article]

Objective  To quantify both the individual-level and attributable risk of varicella infection requiring medical care in children whose parents refuse varicella immunizations.

Design  Matched case-control study with conditional logistic regression analysis.

Setting  Kaiser Permanente of Colorado (KPCO) health plan between 1998 and 2008.

Participants  Each pediatric physician-diagnosed case of varicella (n = 133) was matched to 4 randomly selected controls (n = 493). Cases were matched by age, sex, and length of enrollment in KPCO.

Main Exposures  Varicella vaccine refusal.

Outcome Measures  Varicella infection.

Results  There were 7 varicella vaccine refusers (5%) among the cases and 3 (0.6%) among the controls. Children of parents who refused varicella immunizations were at a greatly increased risk of varicella infection requiring medical care (odds ratio, 8.6; 95% confidence interval, 2.2-33.3) compared with children of parents who accepted vaccinations (P = .004). In the entire KPCO pediatric population, 5% of varicella cases were attributed to parental vaccine refusal.

Conclusions  Children of parents who refuse varicella immunizations are at high risk of varicella infection relative to vaccinated children. These results will be helpful to health care providers and parents when making decisions about immunizing children.

top

Incidence and Seasonality of Hypothermia Among Newborns in Southern Nepal [Article]

Objective  To quantify incidence, age distribution, and seasonality of neonatal hypothermia among a large population cohort.

Design  Longitudinal cohort study.

Setting  Sarlahi, Nepal.

Participants  A total of 23 240 newborns born between September 2, 2002, and February 1, 2006.

Main Exposures  Community-based workers recorded axillary temperature on days 1 through 4, 6, 8, 10, 12, 14, 21, and 28 (213 636 total measurements).

Main Outcome Measures  Regression smoothing was used to describe axillary temperature patterns during the newborn period. Hypothermia incidence in the first day, week, and month were estimated using standard cutoffs. Ambient temperatures allowed comparison of mild hypothermia (36.0°C to <36.5°C) and moderate or severe hypothermia (<36.0°C) incidence over mean ambient temperature quintiles.

Results  Measurements lower than 36.5°C were observed in 21 459 babies (92.3%); half (48.6%) had moderate or severe hypothermia, and risk peaked in the first 24 to 72 hours of life. Risk of moderate or severe hypothermia increased by 41.3% (95% confidence interval, 40.0%-42.7%) for every 5°C decrease in average ambient temperature. Relative to the highest quintile, risk was 4.03 (95% confidence interval, 3.77-4.30) times higher among babies exposed to the lowest quintile of average ambient temperature. In the hot season, one-fifth of the babies (18.2%) were observed below the moderate hypothermia cutoff.

Conclusions  Mild or moderate hypothermia was nearly universal, with substantially higher risk in the cold season. However, incidence in the hot season was also high; thus, year-round thermal care promotion is required. Research on community, household, and caretaker practices associated with hypothermia can guide behavioral interventions to reduce risk.

top

Male Circumcision for the Prevention of Acquisition and Transmission of Sexually Transmitted Infections: The Case for Neonatal Circumcision [Review Article]

The American Academy of Pediatrics (AAP) male circumcision policy states that while there are potential medical benefits of newborn male circumcision, the data are insufficient to recommend routine neonatal circumcision. Since 2005, however, 3 randomized trials have evaluated male circumcision for prevention of sexually transmitted infections. The trials found that circumcision decreases human immunodeficiency virus acquisition by 53% to 60%, herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men. Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%. Genital ulcer disease was also reduced among males and their female partners. These findings are also supported by observational studies conducted in the United States. The AAP policy has a major impact on neonatal circumcision in the United States. This review evaluates the recent data that support revision of the AAP policy to fully reflect the evidence of long-term health benefits of male circumcision.

top

Interventions for Reducing Adolescent Alcohol Abuse: A Meta-analytic Review [Review Article]

Objective  To assess the effectiveness of substance abuse interventions for their ability to reduce adolescent alcohol use.

Data Sources  MEDLINE; PsycINFO; ERIC; Wilson Social Science Abstracts; Criminal Justice Abstracts; Social Work Abstracts; Social Science Citation Index; Dissertations Abstracts International; National Criminal Justice Research Service; Social, Psychological, Criminological, Educational Trials Register; and the PsiTri databases from 1960 through 2008.

Study Selection  Of 64 titles and abstracts identified, 16 studies and 26 outcomes constituted the sample. The researchers calculated Hedges g effect sizes and used a random-effects model to calculate adjusted pooled effect sizes. Heterogeneity was explored using stratified analyses.

Main Exposure  Completion of a substance abuse intervention that aimed to reduce or eliminate alcohol consumption.

Main Outcome Measures  Abstinence, frequency of alcohol use, and quantity of alcohol use measured between 1 month and 1 year upon completion of treatment.

Results  Pooled effects of standardized mean differences indicate that interventions significantly reduce adolescent alcohol use (Hedges g = –0.61; 95% confidence interval [CI], –0.83 to –0.40). Stratified analyses revealed larger effects for individual treatment (Hedges g = –0.75; 95% CI, –1.05 to –0.40) compared with family-based treatments (Hedges g = –0.46; 95% CI, –0.66 to –0.26).

Conclusions  Treatments for adolescent substance abuse appear to be effective in reducing alcohol use. Individual-only interventions had larger effect sizes than family-based interventions and effect sizes decreased as length of follow-up increased. Furthermore, behavior-oriented treatments demonstrated promise in attaining long-term effects.

top

Broadening Understanding of the Long-term Effects of Risk- and Protection-Focused Prevention on the Public Health: Lessons From Nurse-Family Partnerships [Editorial]

top

Newborn Circumcision: Routine or Not Routine, That Is the Question [Editorial]

top

Picture of the Month--Quiz Case [Special Feature]

top

Picture of the Month--Diagnosis [Special Feature]

top

Historical Trends in Low Birth Weight [The Pediatric Forum]

top

Risk of Parental Dissolution of Partnership Following the Loss of a Child to Cancer: A Population-Based Long-term Follow-up [The Pediatric Forum]

top

Male Circumcision: New Information About Health Benefits [Advice for Patients]

top

Polar bear at Lincoln Park Zoo, July 2009 [About the Cover]

top

About This Journal [About This Journal]

top

This Month in Archives of Pediatrics & Adolescent Medicine [This Month in Archives of Pediatrics & Adolescent Medicine]

top

Safety and Transparency of Pediatric Drug Trials [Article]

Objectives  To quantify the frequency and type of new safety information arising from studies performed under the auspices of the Pediatric Exclusivity Program, to describe the dissemination of these findings in the peer-reviewed literature and compare this with the US Food and Drug Administration (FDA) review, and to describe their effect on pediatric labeling.

Design  Cohort study of the 365 trials performed for 153 drugs.

Setting  The Pediatric Exclusivity incentive from December 1997 through September 2007.

Participants  Food and Drug Administration publicly available records and peer-reviewed literature retrievable by MEDLINE search.

Main Exposures  New safety findings obtained from the trials completed for exclusivity.

Outcome Measures  Concordance of the information highlighted in the peer-reviewed article abstracts with the information in the FDA labeling and drug reviews.

Results  There were 137 labeling changes; we evaluated 129 of these (the 8 selective serotonin reuptake inhibitors were excluded from review). Thirty-three products (26%) had pediatric safety information added to the labeling. Of these, 12 products had neuropsychiatric safety findings and 21 had other important safety findings. Only 16 of 33 of these trials (48%) were reported in the peer-reviewed literature; however, 7 of 16 focused on findings substantively different from those highlighted in the FDA reviews and labeling changes.

Conclusions  Medication adverse events in children often differ from those in adults, particularly those that are neuropsychiatric in nature. Labeling changes for pediatric use demonstrate that pediatric drug studies provide valuable and unique safety data that can guide the use of these drugs in children. Unfortunately, most of these articles are not published, and almost half of the published articles focus their attention away from the crucial safety data.

top

Influence of Changes in Supply on the Distribution of Pediatric Subspecialty Care [Article]

Objectives  To examine whether recently certified pediatric subspecialists enter markets that previously lacked subspecialists and to determine whether changes in overall supply are associated with changes in geographic availability of care.

Design  Multiple cross-sectional analyses.

Setting  United States.

Participants  Physician data for 2003 and 2006 from the American Board of Pediatrics.

Main Exposure  New entrants, defined as subspecialists who first obtained certification after 2003.

Main Outcome Measures  We examined the following: (1) whether new entrants were more likely to practice in locations lacking certified subspecialists; (2) changes in the percentage of hospital referral regions (HRRs) with at least 1 subspecialist; and (3) changes in the number of subspecialists per HRR.

Results  Ten pediatric subspecialties experienced increases in supply and 5 experienced decreases. For 8 of the 15 pediatric subspecialties studied, new entrants were more likely than previously certified physicians to locate in an HRR that lacked a subspecialist in 2003. The percentage of HRRs with a subspecialist increased significantly for 3 of the 10 pediatric subspecialties with increases in supply. Among HRRs with a subspecialist in 2003, the average number of subspecialists per HRR increased between 2003 and 2006 for 6 of the 10 pediatric subspecialties with total supply increases and decreased for 4 of the 5 subspecialties with decreases in supply.

Conclusions  Increases in the number of pediatric subspecialists generally did not lead to improvements in distribution and may actually reinforce the existing distribution for certain pediatric subspecialties. However, because newly certified subspecialists are more likely to enter an HRR that previously lacked a subspecialist, long-term increases in supply may lead to improvements in distribution.

top

Improving Health Outcomes for Youth Living With the Human Immunodeficiency Virus: A Multisite Randomized Trial of a Motivational Intervention Targeting Multiple Risk Behaviors [Article]

Objective  To determine if Healthy Choices, a motivational interviewing intervention targeting multiple risk behaviors, improved human immunodeficiency virus (HIV) viral load.

Design  A randomized, 2-group repeated measures design with analysis of data from baseline and 6- and 9-month follow-up collected from 2005 to 2007.

Setting  Five US adolescent medicine HIV clinics.

Participants  A convenience sample with at least 1 of 3 risk behaviors (nonadherence to HIV medications, substance abuse, and unprotected sex) was enrolled. The sample was aged 16 to 24 years and primarily African American. Of the 205 enrolled, 19 did not complete baseline data collections, for a final sample size of 186. Young people living with HIV were randomized to the intervention plus specialty care (n = 94) or specialty care alone (n = 92). The 3- and 6-month follow-up rates, respectively, were 86% and 82% for the intervention group and 81% and 73% for controls.

Intervention  Healthy Choices was a 4-session individual clinic-based motivational interviewing intervention delivered during a 10-week period. Motivational interviewing is a method of communication designed to elicit and reinforce intrinsic motivation for change.

Outcome Measure  Plasma viral load.

Results  Youth randomized to Healthy Choices showed a significant decline in viral load at 6 months postintervention compared with youth in the control condition (β = –0.36, t = –2.15, P = .03), with those prescribed antiretroviral medications showing the lowest viral loads. Differences were no longer significant at 9 months.

Conclusion  A motivational interviewing intervention targeting multiple risk behaviors resulted in short-term improvements in viral load for youth living with HIV.

Trial Registration  clinicaltrials.gov Identifier: NCT00103532

top

Predictors of Suboptimal Virologic Response to Highly Active Antiretroviral Therapy Among Human Immunodeficiency Virus-Infected Adolescents: Analyses of the Reaching for Excellence in Adolescent Care and Health (REACH) Project [Article]

Objective  To examine the prevalence and biopsychosocial predictors of suboptimal virologic response to highly active antiretroviral therapy (HAART) among human immunodeficiency virus–infected adolescents.

Design  Population-based cohort study.

Setting  Sixteen academic medical centers across 13 cities in the United States.

Participants  One hundred fifty-four human immunodeficiency virus–infected adolescents who presented for at least 2 consecutive visits after initiation of HAART.

Main Outcome Measures  Viral load (plasma concentration of human immunodeficiency virus RNA) and CD4⁺ lymphocyte count.

Results  Of the 154 adolescents enrolled in the study, 50 (32.5%) demonstrated early and sustained virologic suppression while receiving HAART. The remaining 104 adolescents (67.5%) had a poor virologic response. Adequate adherence (>50%)—reported by 70.8% of respondents—was associated with 60% reduced odds of suboptimal virologic suppression in a multivariable logistic regression model (adjusted odds ratio = 0.4; 95% confidence interval, 0.2-1.0). Exposure to suboptimal antiretroviral therapy prior to HAART, on the other hand, was associated with more than 2-fold increased odds of suboptimal virologic response (adjusted odds ratio = 2.6; 95% confidence interval, 1.1-5.7).

Conclusions  Fully two-thirds of human immunodeficiency virus–infected adolescents in the current study demonstrated a suboptimal virologic response to HAART. Nonadherence and prior single or dual antiretroviral therapy were associated with subsequent poor virologic responses to HAART. These predictors of HAART failure echo findings in pediatric and adult populations. Given the unique developmental stage of adolescence, age-specific interventions are indicated to address high rates of nonadherence and therapeutic failure.

top

Time From First Intercourse to First Sexually Transmitted Infection Diagnosis Among Adolescent Women [Article]

Objective  To determine the time between first intercourse and first sexually transmitted infection (STI) with Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis and time between repeated infections.

Design  Observational study.

Setting  Three adolescent medicine clinics.

Participants  A cohort of 386 urban young women aged 14 to 17 years at enrollment.

Main Outcome Measures  Age at first intercourse; organism-specific interval between first intercourse and first STI diagnosis; interval between repeated infections; and age at first STI test prior to study participation.

Results  Participants had first intercourse at a young age (first, second, and third quartiles were 13, 14, and 15 years of age, respectively). By age 15 years, 25% of the women acquired their first STI, most often C trachomatis. Median interval between first intercourse and first STI diagnosis was 2 years. Within 1 year of first intercourse, 25% had their first C trachomatis infection. Repeated infections were common; within 3.6, 6, and 4.8 months, 25% of the women with prior C trachomatis, N gonorrhoeae, and T vaginalis infection were reinfected with the respective organisms. Considerable delay in STI testing was found for those who began sex at a younger age. The median interval between first sex and first test were 4.9, 3.5, 2.1, 1.8, and 1.2 years for those who had first sex at ages 10, 11, 12, 13, and 14 years, respectively.

Conclusions  Timely screening and treatment are important for prevention of STI sequelae. For urban adolescent women, STI screening (especially for C trachomatis) should begin within a year after first intercourse and infected individuals should be retested every 3 to 4 months.

top

Efficacy of Sexually Transmitted Disease/Human Immunodeficiency Virus Sexual Risk-Reduction Intervention for African American Adolescent Females Seeking Sexual Health Services: A Randomized Controlled Trial [Article]

Objectives  To evaluate the efficacy of an intervention to reduce incident sexually transmitted disease (STD) and enhance STD/human immunodeficiency virus (HIV)–preventive behaviors and psychosocial mediators.

Design  A randomized controlled trial of an HIV prevention program.

Setting  Clinic-based sample in Atlanta, Georgia.

Participants  African American adolescent females (N = 715), aged 15 to 21 years, seeking sexual health services. Participants completed an audio computer-assisted self-interview and provided self-collected vaginal specimens for STD testing.

Intervention  Intervention participants received two 4-hour group sessions and 4 telephone contacts over a 12-month period, targeting personal, relational, sociocultural, and structural factors associated with adolescents' STD/HIV risk, and were given vouchers facilitating male partners' STD testing/treatment.

Main Outcome Measure  Incident chlamydial infections.

Results  Over the 12-month follow-up, fewer adolescents in the intervention had a chlamydial infection (42 vs 67; risk ratio [RR], 0.65; 95% confidence interval [CI], 0.42 to 0.98; P = .04) or recurrent chlamydial infection (4 vs 14; RR, 0.25; 95% CI, 0.08 to 0.83; P = .02). Adolescents in the intervention also reported a higher proportion of condom-protected sex acts in the 60 days preceding follow-up assessments (mean difference, 10.84; 95% CI, 5.27 to 16.42; P < .001) and less frequent douching (mean difference, –0.76; 95% CI, –1.15 to –0.37; P = .001). Adolescents in the intervention were also more likely to report consistent condom use in the 60 days preceding follow-up assessments (RR, 1. 41; 95% CI, 1.09 to 1.80; P = .01) and condom use at last intercourse (RR, 1.30; 95% CI, 1.09 to 1.54; P = .005). Intervention effects were observed for psychosocial mediators of STD/HIV–preventive behaviors.

Conclusion  Interventions for African American adolescent females can reduce chlamydial infections and enhance STD/HIV–preventive behaviors and psychosocial mediators of STD/HIV–preventive behaviors.

Trial Registration  clinicaltrials.gov Identifier: NCT00633906

top

Trends and Factors Associated With Infant Sleeping Position: The National Infant Sleep Position Study, 1993-2007 [Article]

Objective  To determine trends and factors associated with choice of infant sleeping position.

Design  Annual nationally representative telephone surveys from 1993 through 2007.

Setting  Forty-eight contiguous states of the United States.

Participants  Nighttime caregivers of infants born within the last 7 months; approximately 1000 interviews were given each year.

Main Outcome Measure  Whether infant is usually placed supine to sleep.

Results  For the 15-year period, supine sleep increased (P < .001) and prone sleep decreased (P < .001) for all infants, with no significant difference in trend by race. Since 2001, a plateau has been reached for all races. Factors associated with increased supine sleep between 1993 and 2007 included time, maternal race other than African American, higher maternal educational level, not living in Southern states, first-born infant, and full-term infant. The effect of these variables was reduced when variables related to maternal concerns about infant comfort, choking, and advice from physicians were taken into account. Between 2003 and 2007, there was no significant yearly increase in supine sleep. Choice of sleep position could be explained almost entirely by caregiver concern about comfort, choking, and advice. Race no longer was a significant predictor.

Conclusions  Since 2001, supine sleep has reached a plateau, and there continue to be racial disparities. There have been changes in factors associated with sleep position, and maternal attitudes about issues such as comfort and choking may account for much of the racial disparity in practice. To decrease sudden infant death syndrome rates, we must ensure that public health measures reach the populations at risk and include messages that address concerns about infant comfort and choking.

top

Effects of Local Institutional Review Board Review on Participation in National Practice-Based Research Network Studies [Article]

Objective  To describe the process and outcomes of local institutional review board (IRB) review for 2 Pediatric Research in Office Settings (PROS) studies.

Design  Pediatric Research in Office Settings conducted 2 national studies concerning sensitive topics: (1) Child Abuse Recognition Experience Study (CARES), an observational study of physician decision making, and (2) Safety Check, a violence prevention intervention trial. Institutional review board approval was secured by investigators' sites, the American Academy of Pediatrics, and practices with local IRBs. Practices were queried about IRB rules at PROS enrollment and study recruitment.

Setting  Pediatric Research in Office Settings practices in 29 states.

Participants  Eighty-eight PROS practices (75 IRBs).

Main Exposure  Local IRB presence.

Main Outcome Measures  Local IRB presence, level of PROS assistance, IRB process, study participation, data collection completion, and minority enrollment.

Results  Practices requiring additional local IRB approval agreed to participate less than those that did not (CARES: 33% vs 52%; Safety Check: 41% vs 56%). Of the 88 practices requiring local IRB approval, 55 received approval, with nearly 50% needing active PROS help, many requiring consent changes (eg, contact name additions, local IRB approval stamps), and 87% beginning data collection. Median days to obtain approval were 81 (CARES) and 109 (Safety Check). Practices requiring local IRB approval were less likely to complete data collection but more likely to enroll minority patients.

Conclusions  Local IRB review was associated with lower participation rates, substantial effort navigating the process (with approval universally granted without substantive changes), and data collection delays. When considering future reforms, the national human subject protections system should consider the potential redundancy and effect on generalizability, particularly regarding enrollment of poor urban children, related to local IRB review.

top

Adverse Childhood Experiences and Adult Risk Factors for Age-Related Disease: Depression, Inflammation, and Clustering of Metabolic Risk Markers [Article]

Objective  To understand why children exposed to adverse psychosocial experiences are at elevated risk for age-related disease, such as cardiovascular disease, by testing whether adverse childhood experiences predict enduring abnormalities in stress-sensitive biological systems, namely, the nervous, immune, and endocrine/metabolic systems.

Design  A 32-year prospective longitudinal study of a representative birth cohort.

Setting  New Zealand.

Participants  A total of 1037 members of the Dunedin Multidisciplinary Health and Development Study.

Main Exposures  During their first decade of life, study members were assessed for exposure to 3 adverse psychosocial experiences: socioeconomic disadvantage, maltreatment, and social isolation.

Main Outcome Measures  At age 32 years, study members were assessed for the presence of 3 age-related-disease risks: major depression, high inflammation levels (high-sensitivity C-reactive protein level >3 mg/L), and the clustering of metabolic risk biomarkers (overweight, high blood pressure, high total cholesterol, low high-density lipoprotein cholesterol, high glycated hemoglobin, and low maximum oxygen consumption levels.

Results  Children exposed to adverse psychosocial experiences were at elevated risk of depression, high inflammation levels, and clustering of metabolic risk markers. Children who had experienced socioeconomic disadvantage (incidence rate ratio, 1.89; 95% confidence interval, 1.36-2.62), maltreatment (1.81; 1.38-2.38), or social isolation (1.87; 1.38-2.51) had elevated age-related-disease risks in adulthood. The effects of adverse childhood experiences on age-related-disease risks in adulthood were nonredundant, cumulative, and independent of the influence of established developmental and concurrent risk factors.

Conclusions  Children exposed to adverse psychosocial experiences have enduring emotional, immune, and metabolic abnormalities that contribute to explaining their elevated risk for age-related disease. The promotion of healthy psychosocial experiences for children is a necessary and potentially cost-effective target for the prevention of age-related disease.

top

Error in Table in: Selective Serotonin Reuptake Inhibitor Exposure In Utero and Pregnancy Outcomes [Correction]

top

A National Survey of Obesity Prevention Practices in Head Start [Article]

Objective  To describe obesity prevention practices and environments in Head Start, the largest federally funded early childhood education program in the United States.

Design  Self-administered survey as part of the Study of Healthy Activity and Eating Practices and Environments in Head Start (SHAPES).

Setting  Head Start, 2008.

Participants  Directors of all 1810 Head Start programs, excluding those in US territories.

Outcome Measures  Descriptive measures of reported practices and environments related to healthy eating and gross motor activity.

Results  The 1583 (87%) programs responding to the survey enrolled 828 707 preschool children. Of these programs, 70% reported serving only nonfat or 1% fat milk. Ninety-four percent of programs reported that each day they served children some fruit other than 100% fruit juice; 97% reported serving some vegetable other than fried potatoes; and 91% reported both of these daily practices. Sixty-six percent of programs said they celebrated special events with healthy foods or nonfood treats, and 54% did not allow vending machines for staff. Having an on-site outdoor play area at every center was reported by 89% of programs. Seventy-four percent of programs reported that children were given structured (adult-led or -guided) gross motor activity for at least 30 minutes each day; 73% reported that children were given unstructured gross motor activity for at least 30 minutes each day, and 56% reported both of these daily practices.

Conclusion  Most Head Start programs report doing more to support healthy eating and gross motor activity than required by federal performance standards in these areas.

top

Formal Production Features of Infant and Toddler DVDs [Article]

Objective  To describe how DVDs designed for very young children are constructed, focusing on the formal production features used to present the program content.

Design  Descriptive study of the concentrations of perceptually salient, nonsalient, and reflective formal features.

Participants  Fifty-nine DVDs designed for children younger than 3 years.

Main Exposure  The presence and absence of specific formal features.

Outcome Measures  Concentrations of reflective (singing, rhyming, camera zooms, and moderate character action), perceptually salient (rapid pacing, fast action, camera cuts, sound effects, character vocalizations, and visual special effects), and nonsalient (low-action sequences, narration, and dialogue by men, women, or children) formal features.

Results  Programs were composed of high concentrations of perceptually salient features, such as rapid pace and camera cuts, which are difficult even for older children to understand. Reflective features, which provide opportunities to rehearse content, were relatively rare. Character action was typically nonsalient. The DVDs used speech only 24% of the time and failed to selectively use speakers, such as choosing a child over an adult for dialogue and narration, which garners slightly older children's visual attention.

Conclusions  Producers who claim that their programs are educational should pay more attention to how they transmit content. Most programs directed at infants and toddlers rely on perceptually salient features like rapid pacing and camera cuts, which may elicit attention and interest but are most likely very difficult for a young audience to understand.

top

Picture of the Month--Quiz Case [Special Feature]

top

Picture of the Month--Diagnosis [Special Feature]

top

Adequacy of the Supply of Pediatric Subspecialists: So Near, Yet So Far [Editorial]

top

Adolescent Human Immunodeficiency Virus Prevention: What We Have Accomplished and What Still Needs to Be Done [Editorial]

top

It Is Time to Professionalize Institutional Review Boards [Editorial]

top

Infant Sleep Position: Back to Sleep [Advice for Patients]

top

Health Insurance

Your health insurance policy lists a package of medical benefits such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy.

We are committed to your health more then others. Online-Insurance_advisor can offer you better options. Our plans provide long-term protection and comprehensive medical coverage for you and your family.

We are helping our customers by:

• Organizing access and coverage for medical services, prescription drugs, medical devices and diagnostic testing at the best possible cost
• Designing programs that help people get the right care from the right place at the right time
• Offering wellness programs and support to help people stay healthy and use medical care more wisely
• Simplifying service and administration

Everyone’s different. That's why Online-Insurance-Advisor has a huge range of health cover options – you’ll find the right level of hospital, extras or package cover for you, your partner and family here.

online-insurance-advisor.com

Worlds Best Pharmacy

The name says it all. This is the best online pharmacy on the web. The index page is set to show the most polular ED products, while the menu and quicksearch allow to find products in other categories.

worlds-best-pharmacy.com

Indian Meds

A most recent indian-themed, ethnic site. Includes generic and original (brand) products. al our standard navigational tools and support options are available. This site converts nicely on general pharmaceutical traffic as it has products for vurtually any need.

indianmeds.org

Health Insurance Quote health insurance quote california health insurance quote free health insurance quote health insurance online quote individual health insurance quote health insurance quote texas florida health insurance quote instant online health insurance quote family health insurance quote health care insurance quote instant health insurance quote arizona health insurance quote cheap health insurance quote small business health insurance quote affordable health insurance quote illinois health insurance quote arizona free health insurance quote health and medical insurance quote california health insurance online quote affordable individual health insurance quote private health insurance quote health insurance quote wisconsin california group health insurance quote california individual health insurance quote health insurance quote georgia missouri health insurance quote individual health insurance quote online self employed health insurance quote health insurance ohio quote free health insurance quote texas california life and health insurance quote health and life insurance quote online health insurance quote for child colorado health insurance quote affordable family health insurance quote health insurance life quote health insurance low cost health insurance family health insurance health insurance quote affordable health insurance texas health insurance california health insurance individual health insurance health insurance company florida health insurance short term health insurance health and dental insurance health insurance illinois health insurance houston cheap health insurance health insurance coverage student health insurance health insurance dallas temporary health insurance child health insurance health insurance chicago health insurance lead private health insurance free health insurance arizona health insurance health insurance indianapolis health insurance las vegas health insurance jacksonville health insurance in california health insurance nashville health insurance miami health insurance philadelphia affordable california health insurance health insurance new york long term care health insurance health insurance provider health insurance cincinnati medical health insurance california individual health insurance north carolina health insurance health insurance atlanta health insurance pittsburgh health insurance dayton health insurance greenville health insurance orlando oxford health insurance health insurance new orleans health insurance online health insurance denver michigan health insurance ohio health insurance personal health insurance health insurance indiana free health insurance quote online health individual insurance quote texas california family health insurance quote affordable health insurance quote online florida health insurance instant quote indiana health insurance quote free instant health insurance quote california free health insurance quote student health insurance quote health insurance quote short term michigan health insurance quote minnesota health insurance quote dental health insurance quote health insurance quote virginia best health insurance quote california cheap health insurance quote north carolina health insurance quote california care health insurance quote southern california individual health insurance quote health insurance quote new jersey personal health insurance quote low cost health insurance quote illinois affordable health insurance quote oregon health insurance quote instant health insurance quote california health insurance quote tennessee