Improved outcome in South African children of mixed ethnicity treated for all

A historical cohort study with an analytical component was conducted to determine whether risk-appropriate chemotherapy can improve survival in children of mixed ethnicity with ALL. Eighty-one coloured children treated for ALL in South Africa were divided into 2 groups: group A (n = 39), treated prior to 1992, and group B (n = 42), treated after 1992. A comparison was made of survival, treatment complications, and supportive measures. The two groups were comparable. The mean nadirs of the white cell count (p < .01), platelet count (p = .01), and hemoglobin value (p < .01) were significantly lower in group B. The survival rate of 37% in group A improved to 66% in group B (p = .025). The results show that a risk-adapted regimen increased survival in children of mixed ethnicity in the Western Cape, despite increased hematological toxicity and episodes of febrile neutropenia.

Phase II study of clofarabine in pediatric patients with refractory or relapsed acute lymphoblastic leukemia

PURPOSE

To evaluate the efficacy and safety of clofarabine, a novel deoxyadenosine analog, in pediatric patients with refractory or relapsed acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

In a phase II, open-label, multicenter study, 61 pediatric patients with refractory or relapsed ALL received clofarabine 52 mg/m2 intravenously over 2 hours daily for 5 days, every 2 to 6 weeks. The median age was 12 years (range, 1 to 20 years), and the median number of prior regimens was three (range, two to six regimens).

RESULTS

The response rate was 30%, consisting of seven complete remissions (CR), five CRs without platelet recovery (CRp), and six partial remissions. Remissions were durable enough to allow patients to proceed to hematopoietic stem-cell transplantation (HSCT) after clofarabine. Median CR duration in patients who did not receive HSCT was 6 weeks, with four patients maintaining CR or CRp for 8 weeks or more (8+, 12, 37+, and 48 weeks) on clofarabine therapy alone. The most common adverse events of grade > or = 3 were febrile neutropenia, anorexia, hypotension, and nausea.

CONCLUSION

Clofarabine is active as a single agent in pediatric patients with multiple relapsed or refractory ALL. The toxicity profile is as expected in this heavily pretreated patient population. Studies exploring rational combinations of clofarabine with other agents are ongoing in an effort to maximize clinical benefit.

Prevalence of risk for type 2 diabetes in school children

According to the Centers for Disease Control and Prevention, 1 in 3 children born in 2000 in the United States will become diabetic. The odds are higher for African American and Hispanic children as nearly 50% of them will develop diabetes. Random screening is not effective in identifying children at risk for type 2 diabetes mellitus (T2DM); therefore, there is a need to apply screening strategies that guide the development of appropriate primary prevention efforts. To assess the prevalence of risk factors for T2DM, 1066 fifth-grade children were screened using American Diabetes Association guidelines. Overall, 22.6% were found at risk; African American and Hispanic children were almost 8 times more likely to be at risk when compared to Caucasians (odds ratio = 7.41 and 7.87). Children who reported watching TV/playing video games 2 or more hours/day were 73% more likely to be at risk. Children identified to be at risk were referred to their primary care provider and were invited to participate in a counseling session. The environmental risk factors for T2DM identified in this study are modifiable and should be targeted in preventive interventions at the school and community level to reduce overweight and consequently prevent T2DM in children, especially among minority children.

Remission of primary low-grade gastric lymphomas of the mucosa-associated lymphoid tissue type in immunocompromised pediatric patients

We report the remission of primary gastric lymphoma of the mucosa-associated lymphoid tissue (MALT) type in two immunocompromised pediatric patients. Patient 1, a 14-year-old boy in an immunocompromised state of unknown cause, complained of repeated abdominal pain. Examinations revealed gastric MALT with local invasion and lymph node involvement. Serum anti-Helicobacter pylori (H pylori) antibody was positive. H pylori eradication was abandoned due to its adverse effects. The MALT lesion spontaneously regressed over the next 24 months without any treatment for lymphoma. Patient 2, a 6-year-old boy, underwent cord blood transplantation for the treatment of adrenoleukodystrophy. He was administered immunosuppressants for graft-versus-host disease after transplantation. Nausea and hematochezia appeared and further examinations revealed gastric MALT with H pylori gastritis. Treatment consisting of medication for the H pylori infection alone eradicated the H pylori and completely resolved the patient’s MALT lesion, as well. Patients 1 and 2 were followed up over periods of 10 years and 3 years, respectively, without any signs of relapse. In conclusion, gastric lymphoma of the MALT type can be cured by conservative treatment even in immunocompromised pediatric patients.

Angiotensin-converting enzyme gene polymorphism in children with idiopathic nephrotic syndrome

AIMS

To investigate the genetic polymorphism of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) in children with idiopathic nephrotic syndrome (INS), as well as its relationship with patient's clinical response to steroid therapy.

METHODS

Fifty-nine patients with INS were recruited and divided into 2 groups according to their clinical response to steroids: steroid-sensitive (SS) with 19 patients and non-SS with 40 patients, which was further divided into steroid-dependent (SD) and steroid-resistant (SR) groups with 35 and 5 patients, respectively. Seventy-nine children without previous renal diseases and negative proteinuria were enrolled as a control group. The genotypes for ACE I/D polymorphism, including DD, ID, and II, were analyzed.

RESULTS

The distribution of ACE DD, ID, and II genotypes in INS patients were 52.5, 10.2 and 37.3%, respectively; the corresponding numbers for the control group were 2.5, 25.3 and 72.2%, respectively. Patients with INS had a significantly higher percentage of DD genotype (p <0.001) than the control group. This higher incidence of the DD genotype was observed in both the SS and non-SS groups. A higher percentage of the DD genotype in the non-SS group and in the SD group as compared to the SS group (both p < 0.05) was also noted.

CONCLUSION

Our data shows that INS is associated with a higher incidence of the DD genotype, especially in non-SS patients. This finding suggests that the DD genotype may be a risk factor for INS and play a role in the clinical response to steroids.

Costs and complications of hospitalizations for children with cerebral palsy

BACKGROUND

Although many children with cerebral palsy (CP) develop secondary conditions requiring hospitalization, in-patient hospital utilization by this population has not been characterized.

OBJECTIVE

To characterize hospitalizations in children with CP and to compare them with hospitalizations of those without CP using a large national data set.

METHODS

Analysis of the Healthcare Utilization Project Kid Inpatient Database, a weighted survey of paediatric discharges from US hospitals in 1997.

RESULTS

In 1997, 37,000 children with CP were hospitalized, generating charges approaching 600 million dollars. Children with CP demonstrated longer lengths of stay (6.3 vs 4.1 days, p < 0.001), higher total charges (16,024 vs 9952 dollars, p < 0.001), more diagnoses (5.6 vs 3.0, p < 0.001) and more procedures (1.7 vs 1.1, p < 0.001) per admission. Five major diagnostic categories accounted for 83.2% of the discharge diagnoses for children with CP (48.6% for those without CP, p < 0.001). Children with CP were more often transferred to other facilities (p < 0.001) or prescribed home health care (p < 0.001) upon discharge.

CONCLUSIONS

Hospitalization of children with CP represents a major expenditure for health care systems. Studies to improve the management of conditions associated with CP could result in better outcomes for children and families and potentially decrease costs associated with hospitalization.

What type of diabetes do young people have?

Although type 1 diabetes remains the most common type of diabetes in the pediatric population, there has been a dramatic rise in type 2 diabetes in youth. Clinical distinctions between these two major types have become blurred. As genetic and biochemical measures become more affordable and available, practical applications of these measures to better understand diabetes type in youth and the implications of diabetes type on the evolution of the disease are needed.

Sexy media matter: exposure to sexual content in music, movies, television, and magazines predicts black and white adolescents' sexual behavior

OBJECTIVE

To assess over time whether exposure to sexual content in 4 mass media (television, movies, music, and magazines) used by early adolescents predicts sexual behavior in middle adolescence.

METHODS

An in-home longitudinal survey of 1017 black and white adolescents from 14 middle schools in central North Carolina was conducted. Each teen was interviewed at baseline when he or she was 12 to 14 years old and again 2 years later using a computer-assisted self interview (audio computer-assisted self-interview) to ensure confidentiality. A new measure of each teen's sexual media diet (SMD) was constructed by weighting the frequency of use of 4 media by the frequency of sexual content in each television show, movie, music album, and magazine the teen used regularly.

RESULTS

White adolescents in the top quintile of sexual media diet when 12 to 14 years old were 2.2 times more likely to have had sexual intercourse when 14 to 16 years old than those who were in the lowest SMD quintile, even after a number of other relevant factors, including baseline sexual behavior, were introduced. The relationship was not statistically significant for black adolescents after controlling for other factors that were more predictive, including parental disapproval of teen sex and perceived permissive peer sexual norms.

CONCLUSIONS

Exposure to sexual content in music, movies, television, and magazines accelerates white adolescents' sexual activity and increases their risk of engaging in early sexual intercourse. Black teens appear more influenced by perceptions of their parents' expectations and their friends' sexual behavior than by what they see and hear in the media.

Criminal Poisoning: Munchausen by Proxy

The diagnosis and subsequent prosecution of Munchausen by proxy (MBP) cases require the collaborative teamwork of health care teams, laboratory personnel, law enforcement, and social services. Poisoning occurs in a significant number of the MBP cases with a diverse variety of agents used. To aid laboratory professionals in determining the appropriate toxicology tests to perform in such criminal cases, health care professionals must focus their testing requests on substances that correspond to the victim's signs, symptoms, and ancillary test values. This article reviews MBP, with particular focus on poisoning agents that have been used in past reported cases.

Parents' perceptions of their child's weight and health

OBJECTIVE

This study explored parents' perceptions about their child's appearance and health and evaluated a tool to determine parents' visual perception of their child's weight.

METHODS

Parents of children aged 2 to 17 years were surveyed concerning their child's appearance and health and opinions about childhood overweight. They also selected the sketch (from 7 choices) that most closely matched the body image of their child using 1 of 8 gender-and age-range-specific panels of sketches. Children's height and weight were measured. Respondents were grouped by child body mass index (BMI) percentile (<5th, 5-84th, 85-94th [at risk for overweight (AROW)], and > or =95th [overweight]). Those with BMI > or =5th percentile were analyzed. Logistic regression was used to examine factors influencing parental perceptions and levels of worry about their overweight or AROW child.

RESULTS

Of the 223 children, 60% were <6 years old, 42% were male, 17% were black, 35% were Hispanic, 42% were white, and 7% were other; 19% were AROW, and 20% were overweight. Few parents (36%) identified their overweight or AROW child as "overweight" or "a little overweight" using words, but more (70%) selected a middle or heavier sketch. Among parents of overweight and AROW children, 18% recalled a doctor's concern and 26% were worried about their child's weight. If the overweight or AROW child was age > or =6 years, parents were more likely to identify their child as "overweight" or "a little overweight" using words, select a middle or heavier sketch, and to be worried. Parents of older children were more likely to be worried if they perceived their child as less active/slower than other children or recalled a doctor's concern.

CONCLUSIONS

Few parents of overweight and AROW children recognized their child as overweight or were worried. Recognition of physical activity limitations and physicians' concerns may heighten the parent's level of concern. Sketches may be a useful tool to identify overweight children when measurements are not available.

The contribution of intermittent hypoxia, sleep debt and sleep disruption to daytime performance deficits in children: consideration of respiratory and non-respiratory sleep disorders

In children, the most abundant available information regarding the effects of paediatric sleep disturbance on daytime function has been obtained by studying children with sleep disordered breathing (SDB). The purported underlying pathophysiological mechanisms responsible for these deficits include hypoxia secondary to obstructive apneas/hypopneas and/or disrupted sleep architecture from frequent arousals during sleep. This review will present evidence that, while hypoxia is likely to play a role for many children with SDB, sleep disruption is an important and often overlooked factor that can contribute to daytime deficits in children with SDB. Indeed, sleep deprivation and disruption appear to have a potent impact on the daytime functioning of the much larger number of children with non-respiratory sleep disorders. It is concluded that sleep deprivation, sleep disruption, and intermittent hypoxia independently may be sufficient to cause daytime effects in vulnerable children, and the combination of two or more of these factors can result in particularly impaired daytime functioning. These conclusions have significant implications for research and clinical practice.

A role for Hox A5 in regulating angiogenesis and vascular patterning

BACKGROUND

Homeobox (Hox) genes are transcriptional regulators which modulate embryonic morphogenesis and pathological tissue remodeling in adults via regulation of genes associated with cell-cell or cell extracellular matrix (ECM) interactions. We previously showed that while Hox 3 genes promote angiogenesis, Hox D10 inhibits this process.

METHODS AND RESULTS

Here we show that another Hox family gene, Hox A5, also blocks angiogenesis but accomplishes this by targeting different downstream genes than Hox D10. Sustained expression of Hox A5 leads to down regulation of many pro-angiogenic genes including VEGFR2, ephrin A1, Hif1alpha and COX-2. In addition, Hox A5 also upregulates expression of anti-angiogenic genes including Thrombospondin-2. Furthermore, we show that while Hox A5 mRNA is expressed in quiescent endothelial cells (EC), its expression is diminished or absent in active angiogenic EC found in association with breast tumors or in proliferating infantile hemangiomas.

CONCLUSIONS

Together our results suggest that restoring Hox A5 expression may provide a novel means to limit breast tumor growth or expansion of hemangiomas.

Complementary and alternative medicine for upper-respiratory-tract infection in children

PURPOSE

Evidence on the efficacy and safety of complementary and alternative medicine (CAM) for the prevention and treatment of upper-respiratory-tract infection (URTI) in children is reviewed.

SUMMARY

A search of the literature to June 2005 identified six clinical trials examining the use of herbal medicines and nine trials of other CAM therapies. All articles were critically evaluated for adherence to standards of efficacy and safety research. Echinacea did not reduce the duration and severity of URTI. Andrographis paniculata or echinacea decreased nasal secretions (p < 0.01) but not URTI symptoms. A combination of echinacea, propolis, and ascorbic acid decreased the number of URTI episodes, the duration of symptoms, and the number of days of illness (p < 0.001). Echinacea was associated with a higher frequency of rash compared with placebo (p = 0.008). Neither ascorbic acid nor homeopathy was effective. The efficacy of zinc was not clear, and zinc may be associated with adverse effects in children. Osteopathic manipulation decreased episodes of acute otitis media (p = 0.04) and the need for tympanostomy tube insertion (p = 0.03) in children with recurrent acute otitis media. Stress-management therapy reduced the duration of URTI compared with relaxation therapy with guided imagery or standard care (p < 0.05).

CONCLUSION

Current data are generally inadequate to support CAM for the prevention or treatment of URTI in children.

Improving adolescent sexual risk assessment with event history calendars: a feasibility study

INTRODUCTION

Nurses assess adolescent sexual risk to prevent pregnancy and sexually transmitted infections. However, barriers to sexual risk assessment include lack of time and adolescent-friendly services. The purpose of this feasibility study is to evaluate the clinical utility and feasibility of using an Event History Calendar (EHC) for sexual risk assessment.

METHOD

Latina females aged 15 to 19 years (n = 30) completed an adolescent risk assessment EHC, reviewed it with a nurse, and reported their perceptions of the EHC. Two nurse practitioners used the EHCs to identify the adolescent's risk behavior and reported their perceptions of EHC risk assessment and communication.

RESULTS

Descriptive statistics and qualitative analysis indicated the EHC is a time-efficient, adolescent-friendly risk assessment tool that facilitates identification and discussion of sexual risk and co-morbid risk behaviors.

DISCUSSION

Although larger scale evaluation of the EHC is needed, it is useful for improving adolescent risk assessment and communication.

Myths and Lessons from the Adult/Pediatric Interface in Acute Lymphoblastic Leukemia

The development of effective therapy for children with acute lymphoblastic leukemia (ALL) is one of the great successes of clinical oncology, with long-term survival achieved in over 80% of patients. However, cure rates for adults with ALL remain relatively low, with only 40% of patients cured. With an age-unrestricted, biology-based approach, we anticipate a better understanding about why these outcome differences exist, and think that by extending successful pediatric clinical programs to include adult patients with ALL, we can directly compare uniformly treated adults and children in terms of response to therapy, toxicity and underlying biology.

Characterization of symptoms of sleep disorders in children with headache

To investigate the prevalence of sleep disorders and their symptoms in children with headaches, 64 patients in the outpatient clinics of the University of Chicago Department of Pediatric Neurology were interviewed. Investigated disorders included excessive daytime sleepiness, narcolepsy, insomnia, sleep apnea, restlessness, and parasomnias. Unlike previous studies, subjects were compared with matched control patients by age and sex. Both headache and nonheadache groups completed a 111-item questionnaire detailing sleep symptoms and behaviors. It was found that children with headaches have a significantly higher prevalence of excessive daytime sleepiness, narcolepsy, and insomnia than children without headaches (P < 0.005), which is consistent with prior literature. A similar result was obtained in examining only migraines. However, we did not find a significantly higher prevalence of symptoms of sleep apnea, restlessness, and parasomnias, which contradicts previous literature. Also, the effect of medications taken by headache patients as a confounding factor was insignificant. Overall, pediatricians may find it beneficial to ask about daytime sleepiness, narcolepsy, and insomnia when treating a headache patient.

Failure to thrive: still a problem of definition

The term 'failure to thrive' (FTT) is widely used to describe inadequate growth in early childhood. However, no consensus exists concerning the specific anthropometrical criteria to define this description. The aim of this study was to make an updated assessment concerning the use of FTT definitions and describe possible trends regarding the use of specific criteria. A cross-sectional review was done covering English-language articles published from January 2003 until June 2004, and recent textbooks of general pediatrics. Most of the reviewed literature broadly defined FTT as inadequate growth and total agreement existed to define FTT based solely on anthropometrical parameters. Large differences, however, were seen regarding which growth parameters to use and whether to use attained values or velocities. Weight was the most predominant choice, but many included more than one anthropometrical parameter. Failure to thrive in children is currently described solely based on anthropometrical indicators, with weight gain as the predominant choice of indicator and cut off around the 5th percentile. Discussion is needed as to whether the term 'failure to thrive' is still a useful common term for pediatric undernutrition of different types.

Adolescent depression: challenges and opportunities: a review and current recommendations for clinical practice

Many aspects of the treatment for adolescent depression are still uncertain. However, our body of knowledge continues to accumulate, and our approaches continue to be refined. When we remember that 40 years ago the field was still arguing about the existence of depression in youth, it is clear that significant progress has been made. Recent controversies have provided another opportunity to step back and re-evaluate. Given the chronicity, morbidity, and mortality associated with adolescent depression, the risks of doing nothing are too great. Evidence-based research has provided us with some direction during this unsettling time. After careful reviews, the major professional organizations representing pediatric medicine and psychiatry all support the continued use of SSRI antidepressant medications but emphasize close monitoring. The debates also have heightened interest in effective psychotherapy approaches, particularly CBT and IPT. Given the risk for suicidality in depressed adolescents, assessment and management of safety concerns remain critical, regardless of medication usage. Above all, it is most important that we remain hopeful about our ability to guide adolescents and families through the struggles with depression toward recovery.

Hemangioma versus vascular malformation: presence of nerve bundle is a diagnostic clue for vascular malformation

CONTEXT

Arteriovenous vascular malformations and hemangiomas are benign vascular lesions that are difficult to distinguish from one another clinically. Also, they may be confused with each other at histopathology. Therefore, histochemical stains for the presence of an artery are frequently used to distinguish between the two.

OBJECTIVE

Because it is clinically relevant to differentiate between arteriovenous vascular malformations and hemangiomas, this study was carried out to explore additional diagnostic clues that may help in the diagnosis and differentiation of these lesions.

DESIGN

A total of 167 cases of benign extracranial vascular lesions were retrieved from the anatomic pathology file of our institution. These comprised 66 cases diagnosed as arteriovenous vascular malformations and 101 cases previously diagnosed as hemangiomas. The hematoxylin-eosin-stained glass slides were reviewed, Movat pentichrome histochemical stain was used to identify elastic vessels (arteries/arterioles), and S100 immunostain was used to identify nerves within these vascular lesions. For immunohistochemistry, the avidin-biotin detection method was used.

RESULTS

With Movat stain, the presence of thick-walled elastic arteries was detected in 12 of the 101 cases previously diagnosed as hemangiomas, and these cases were therefore reclassified as vascular malformations. Using the same criterion, 2 of the 66 cases originally diagnosed as arteriovenous vascular malformations were reclassified as hemangiomas because they lacked arterial structures. Thus, with this strict criterion, we ended up with 91 cases of hemangiomas and 76 cases of arteriovenous vascular malformations. Intralesional nerves were identified in 91% (69/76) of cases of arteriovenous vascular malformations, including all the 12 arteriovenous vascular malformations previously diagnosed as hemangiomas. In contrast, no intralesional nerve was detected in any of the 91 hemangiomas.

CONCLUSIONS

These results show that nerve bundles are consistently present in vascular malformations and absent in hemangiomas and so can be used as a diagnostic clue to differentiate between these lesions. Also, in addition to describing a previously unreported component of vascular malformations, these data further confirm the hamartomatous nature of these lesions.

[Naturopathic therapy for acute otitis media. An alternative to the primary use of antibiotics]

BACKGROUND

First line antibiotic treatment of uncomplicated acute otitis media has been questioned.

PATIENTS AND METHODS

In an prospective, open, controlled study, 390 children aged 1-10 years were treated either conventionally (free combinations of decongestant nose drops, mucolytics, analgesics and antibiotics) or alternatively with Otovowen, supplemented by conventional medications when considered necessary.

RESULTS

Patients treated conventionally took more antibiotics (80.5% vs 14.4%) and analgesics (66.8% vs 53.2%). The time to recovery (5.3 vs 5.1 days) and absence from school or pre-school nursery (both 1.7 days) were not significantly different between groups. Pain resolution was slightly better with conventional treatment (-5.8 vs -5.2 score points). The alternative treatment was judged both by doctors, and parents, to be significantly better tolerated.

CONCLUSION

In uncomplicated acute otitis media of childhood, an alternative treatment strategy with the natural medicine Otovowen may substantially reduce the use of antibiotics without disadvantage to the clinical outcome.

The association between television viewing and irregular sleep schedules among children less than 3 years of age

BACKGROUND

Regular sleep schedules are an important part of healthy sleep habits. Although television viewing is associated with altered sleep patterns and sleep disorders among children and adolescents, the effect of television viewing on the sleep patterns of infants and toddlers is not known.

OBJECTIVE

To test the hypothesis that television viewing by infants and toddlers is associated with having irregular naptime and bedtime schedules.

METHODS

We used data from the National Survey of Early Childhood Health, a nationally representative, cross-sectional study of the health and health care of children 4 to 35 months of age. Our main outcome measures were whether children had irregular naptime and bedtime schedules. Our main predictor was hours of television watched on a daily basis. We performed multivariate logistic regression analyses, adjusting for a variety of factors including demographic information, measures of maternal mental health, and measures of family interactions, to test the independent association of television viewing and irregular naptime and bedtime schedules.

RESULTS

Data were available for 2068 children. Thirty-four percent of all children had irregular naptime schedules, and 27% had irregular bedtime schedules. Mean hours of television viewing per day were as follows: 0.9 hours/day (95% confidence interval [CI]: 0.8-1.0 hours/day) for children <12 months of age, 1.6 hours/day (95% CI: 1.4-1.8 hours/day) for children 12 to 23 months of age, and 2.3 hours/day (95% CI: 2.1-2.5 hours/day) for children 24 to 35 months of age. In our logistic regression model, the number of hours of television watched per day was associated with both an irregular naptime schedule (odds ratio: 1.09; 95% CI: 1.01-1.18) and an irregular bedtime schedule (odds ratio: 1.13; 95% CI: 1.04-1.24).

CONCLUSIONS

Television viewing among infants and toddlers is associated with irregular sleep schedules. More research is warranted to determine whether this association is causal.

Actigraphy correctly predicts sleep behavior in infants who are younger than six months, when compared with polysomnography

Actigraphy has been widely used in adults and children. In infants, validation of actigraphy has typically used a comparison with behaviorally determined sleep state classification rather than polysomnography (PSG). This study validated actigraphy against PSG for determining sleep and waking states in infants who were younger than 6 mo. Twenty-two healthy infants, 13 term and 9 preterm, were studied at three different matched postconceptional ages. Actigraph data were compared with PSG recordings in 1-min epochs. Agreement rate (AR), predictive value for sleep, predictive value for wake, sensitivity. and specificity were calculated and compared between activity thresholds and across ages with two-way ANOVA for repeated measures. Thirty-two validation studies were analyzed. Overall AR with PSG of 93.7 +/- 1.3 and 91.6 +/- 1.8 were obtained at 2-4 wk and 5-6 mo, respectively, at the low activity threshold setting, whereas the auto activity threshold gave the best agreement with PSG at 2-4 mo (AR 89.3 +/- 1.3%). Sensitivity values of 96.2 +/- 1.1% at 2-4 wk, 91.2 +/- 1.5% at 2-4 mo, and 94.0 +/- 1.9% were obtained at these same settings. There was no difference across ages in AR or sensitivity. PVW and specificity values were low in this study. We conclude that actigraphy is a valid method for monitoring sleep in infants who are younger than 6 mo.

Type 2 diabetes mellitus in children and adolescents

Over the last decade, there has been an alarming increase of Type 2 diabetes mellitus (T2DM) in youths, concomitant with the rise of obesity in this age group. T2DM is a progressive disease with a gradual increase in insulin resistance associated later with a decline in insulin secretion with fasting hyperglycemia. Prevalence of T2DM in children is mostly linked to some risk factors: obesity and sedentary lifestyle, puberty, membership of ethnic minorities, features of insulin resistance, family history of T2DM, female gender and perinatal factors. Prevention is essential and can be considered a public health approach directed to the general population. Treatment of T2DM in youth is complex and based on different strategies: diet, exercise and pharmacotherapy. An appropriated intervention program must be started early, in order to prevent or retard the progression of the disease and associated comorbidities.

Unidades de salud medioambiental pediátrica en Europa: de la teoría a la acción

BACKGROUND

The World Health Organization encourages the development of strategies to identify, increase awareness and solve problems of Pediatric Environmental Health (PEH) in units and centers of excellence. Pediatricians are in an excellent position to identify children at environmental risk, advise parents about the best way to reduce or prevent these risks, and recommend changes in health policies to politicians.

OBJECTIVE

To inform pediatricians about the underlying principles and activities of pediatric environmental health specialty units (PEHSU) in Spain and Europe. To analyze up-to-date knowledge and the steps required for the development of PEH in Spain and Europe.

MATERIAL AND METHODS

Review of the strategies, initiatives and examples of useful practices for national and international organizations involved in the development and implementation of PEH. Report of activities of PEHSUs.

RESULTS

In Spain and Europe pediatricians do not receive training in PEH. PEHSUs are centers specialized in the diagnosis, treatment, and prevention of environmentally-related diseases. These centers are composed of multidisciplinary teams of health and other professionals, coordinated by pediatricians specialized in PEH, that have the study of environment-related pediatric problems as a common denominator. The activity of these units emphasizes teaching, research, scientific activity, the development of environmental history in pediatrics, diagnosis and treatment of the "pediatric environmental wound", assessment of risks in pediatrics, and specialization in the critical review of the literature on PEH to train pediatricians to be experts in environmental health. The activities and fields of PEHSU can be summarized as: medical care, training, research, and community health (school health).

CONCLUSIONS

PEH should be considered by Ministries of Health and Pediatrics Associations as an important emergent area for current and future generations of pediatricians. Thus, it is necessary: a) to develop an integral plan for pediatric training in PEH; b) to actively seek funding and support to increase the presence of PEHSUs in Europe, and c) to create expert committees in PEH in National Associations of Pediatrics in Europe.

The ADHD and sleep conundrum: a review

The relationship between attention-deficit hyperactivity disorder (ADHD) and sleep is a complex one that poses many challenges in clinical practice. Recent studies have helped to elucidate the nature of the brain mechanisms and neuromodulator systems underlying the theoretical associations among sleepiness, arousal, and attention. Studies of sleep disturbances in children with academic and behavioral problems have also underscored the role that primary sleep disorders such as obstructive sleep apnea hypopnea syndrome play in the clinical presentation of symptoms of inattention and behavioral dysregulation. In addition, new methodologies used in examining sleep and sleep patterns in children diagnosed with ADHD have shed further light on the prevalence, type, risk factors for, and impact of sleep disturbances in these children. The following discussion of the multilevel relationships among sleep quality and quantity, neurobehavioral functioning, and the clinical syndrome of ADHD expands on previous reviews of the literature and synthesizes what is currently known about the interaction of sleep and attention/arousal in children to propose possible underlying mechanisms, integrate more recent findings, and highlight important areas for future study. In addition, guidelines are provided for a clinical approach to evaluation and management of children with ADHD and sleep problems.

Effectiveness of a Primary Care Intervention to Support Reading Aloud: A Multicenter Evaluation

OBJECTIVE

Failure to read at grade level predicts life-long economic and social disability. Early exposure to reading aloud may prevent reading problems. This study seeks to determine whether institution of Reach Out and Read (ROR) programs is associated with increased reading aloud in a national sample.

DESIGN

Before-after intervention study: separate convenience samples were studied before and after institution of ROR programs at multiple sites.

PARTICIPANTS AND SETTING

A convenience sample of parents of children age 6-72 months seeking routine health care at 19 clinical sites in 10 states.

INTERVENTIONS

The ROR model incorporates anticipatory guidance about reading aloud and distribution of free picture books at health supervision visits from 6 months through 5 years as well as reading aloud in the waiting room.

MAIN OUTCOME MEASURES

Parents were interviewed about their attitudes and practices related to reading aloud, using questions drawn from validated instruments.

RESULTS

The sample included 1647 subjects (730 intervention, 917 comparison). After controlling for multiple potential confounding factors, significant associations were found between exposure to ROR and reading aloud as a favorite parenting activity (Adjusted Odds Ratio [AOR] 1.6, P < .001); reading aloud at bedtime (Adjusted Odds Ratio [AOR*rsqb; 1.5, P < .001); reading aloud 3 or more days per week (AOR 1.8, P < .001); and ownership of > or = 10 picture books (AOR 1.6, P < .001).

CONCLUSIONS

In a national sample, implementation of ROR programs was associated with increased parental support for reading aloud. This study provides evidence of the effectiveness of a primary care intervention strategy to promote reading aloud to young children.

Human subjects issues and IRB review in practice-based research

PURPOSE

This article explores the challenges that practice-based research networks (PBRNs) face with respect to the regulatory requirements for institutional review board (IRB) review and the protection of human subjects in research.

METHODS

We used a regulatory and literature review, our previous research involving PBRN researchers, and our experience to identify issues in regulatory compliance and human subjects protections that present challenges to PBRNs and to suggest possible responses.

RESULTS

We identified 3 challenges that PBRNs face with respect to regulatory compliance and human subjects protections. First, ensuring compliance with federal regulations governing human subjects research across all participating practices may be difficult. Clinicians may be unfamiliar with the regulatory requirements and may not have access to an IRB that can provide the required protocol review; moreover, different IRBs may impose inconsistent requirements. Second, conducting research in the practice setting presents unique issues regarding identification of human subjects, consent, and confidentiality. Finally, the use of electronic databases across practices for research raises concerns about how to respect the wishes of participants when combining data and how to maintain confidentiality of data.

CONCLUSIONS

PBRN research makes unique contributions to the clinical evidence base by collecting data in community settings where most clinical care is provided. Such research, however, also presents unique challenges to human subject protections and regulatory compliance. Addressing these challenges is necessary to maintain public trust in and support for PBRN research. With careful planning, these ethical and regulatory challenges can be overcome.

Update on Munchausen syndrome by proxy

PURPOSE OF REVIEW

Munchausen syndrome by proxy (MBP) is a complicated form of child maltreatment. Difficulties remain in properly defining the condition, as well as in detection and differentiation from organic illness. This review will discuss the epidemiology and diagnosis of MBP, as well as the role of the physician in sorting out these cases.

RECENT FINDINGS

Several recent case studies, including two in which children were diagnosed with celiac disease, add to our knowledge of the protean manifestations of MBP. There is growth in our understanding of how sudden infant death syndrome (SIDS) and the symptom complex seen in acute life-threatening events (ALTEs) may in fact represent manifestations of MBP. Recent legal issues in the United Kingdom pose concern for all physicians engaged in child protection work.

SUMMARY

In spite of these challenges, the high mortality and recidivism rates associated with MBP make it imperative that pediatricians be familiar with the condition, the subtle signs and symptoms with which it may present, and methods to best protect the children in their care.

A systematic literature review of the clinical and epidemiological burden of acute lymphoblastic leukaemia (ALL)

Our goal was to identify and summarize the published literature pertaining to the incidence, prevalence, mortality, aetiology, clinical diagnosis, and management of acute lymphoblastic leukaemia (ALL). Acute lymphoblastic leukaemia represents 12% of all leukaemia cases, with a worldwide incidence projected to be 1-4.75 per 100,000 people. Italy, the United States (US), Switzerland, and Costa Rica are the countries with the highest incidence of ALL. Hereditary link, genetic defects, and possibly radiation or chemical exposures are listed amongst the most significant risk factors. Acute lymphoblastic leukaemia is predominantly a disease of childhood, but it affects adults as well. It accounts for 80% of all leukaemia cases in children. The incidence is slightly higher in men than in women and greater in white people than in black people. In 2003 in the US, there were an estimated 5800 deaths from ALL. Presenting signs and symptoms of ALL are fairly non-specific and include fever, anaemia, petechiae, and bone and joint pain. Staging of the disease and patient risk profile are routinely performed to define ALL subtypes and guide management. Chemotherapy, cranial radiation in patients with high-risk disease, and stem cell transplantation for selected patients are the prevalent therapies. Complete remission rates are high, especially amongst children (even 100%); however, long-term survival at 10 years (event-free survival) is in the range of 63% for children and 25-35% for adults. This implies that there is still a strong need for new therapies to maintain remission and prolong survival. Future treatment strategies may be driven by the patient's minimal residual disease status, a measure that more precisely defines remission, prognosis, responsiveness to therapy, and expected long-term survival.

Contribution of primary care to health systems and health

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

The treatment of adolescents and young adults with acute lymphoblastic leukemia

Intensive chemotherapy regimens for children with acute lymphoblastic leukemia (ALL) have greatly improved, and the majority of children with precursor B-cell ALL are able to achieve a complete remission (CR), with an induction rate approaching 98% and a 5-year estimated event-free survival rate (EFS) of approximately 80%. Although there have been dramatic improvements over the last several decades in both the EFS and overall survival (OS) rates in young children with ALL, the results in adult clinical trials have not kept pace. Current adult treatment regimens result in CR rates in the 80% range, with EFS at 5 years of only 30%-40%. Adolescents and young adults represent a minority of patients enrolled onto either adult or pediatric clinical trials. As a result, little information is available regarding CR, EFS, and OS rates for this age group, and the appropriate treatment regimen for this group of patients remains elusive. Recent studies suggest that young adult patients have far superior outcomes when treated on more intensive pediatric regimens. In addition, new insights into the molecular pathogenesis of T cell ALL have led to new therapeutic strategies.

Screening for autism in young children: The Modified Checklist for Autism in Toddlers (M-CHAT) and other measures

The literature on the importance of early identification and early intervention for children with developmental disabilities such as autism continues to grow. The increased prevalence of autistic spectrum disorders has fostered research efforts on the development and validation of autism-specific screening instruments for use with young children. There are currently several such autism-specific screening tools meant to be used with young children in various stages of development. Data from a few of these screening instruments have been published, and they include the Checklist for Autism in Toddlers (CHAT), Pervasive Developmental Disorders Screening Test (PDDST), Screening Tool for Autism in Two year olds (STAT), Checklist for Autism in Toddlers-23 (CHAT-23), and the Modified Checklist for Autism in Toddlers (M-CHAT). In this review, these five tools designed for use with children under three years old will be highlighted. In particular, the Modified Checklist for Autism in Toddlers (M-CHAT) will be discussed.

Airway hemangiomas: contemporary management

METHODS

A review of the literature and the author's pediatric otolaryngology experience regarding the clinical presentation and contemporary management of airway hemangiomas, with an emphasis on subglottic hemangiomas.

CONCLUSION

A myriad of medical and surgical treatment options exist for children with airway hemangiomas. Careful application of these technologies allows for satisfying outcomes in most cases.

Sociodemographic and symptom correlates of fatigue in an adolescent primary care sample

PURPOSE

To describe the prevalence of prolonged fatigue, chronic fatigue syndrome (CFS)-like illness, and associated symptom patterns in adolescents attending primary care.

METHODS

The design was cross-sectional. A questionnaire designed by the authors assessing fatigue and associated symptoms was administered to 901 adolescents (aged 11-18 years) attending 12 primary care clinics in the Chicago area. Prevalence rates for prolonged fatigue and CFS-like illness were calculated. Univariate comparisons involving sociodemographic data and fatigue severity were made between adolescents with and without prolonged fatigue, and sociodemographic and symptom predictors of prolonged fatigue were identified using logistic regression analysis.

RESULTS

Prolonged fatigue (> or = 1 month) occurred at a rate of 8.0% and CFS-like illness occurred at a rate of 4.4%. Adolescents with prolonged fatigue were significantly older and also reported greater fatigue severity than those without fatigue. Findings from logistic regression indicated that, in addition to increasing age, headaches, muscle pains, fever, and fatigue made worse by exercise were significantly associated with prolonged fatigue.

CONCLUSIONS

Abnormal fatigue is a disabling and prevalent condition in adolescents in primary care. It is associated with a number of additional symptoms, many of which may have viral origins.

Prevalence and correlates of high-quality basic pediatric preventive care

BACKGROUND

The list of recommended pediatric preventive services has grown considerably in the past decade, and clinician variability, clinician distribution, and other correlates of provision of these basic preventive services (BPS) are not known.

OBJECTIVE

To describe the proportion of high-quality basic pediatric preventive services, exclusive of immunizations, reported by parents and to identify sociodemographic and health system predictors and health service correlates of provision of these services.

STUDY DESIGN

The study used cross-sectional data on 2041 children, 4 to 35 months of age, in the 2000 National Survey of Early Childhood Health.

OUTCOME MEASURES

The BPS measure assesses the receipt of (1) developmental assessment, (2) injury prevention counseling, (3) screening for parental smoking, (4) guidance on reading to the child, and (5) guidance on 14 other topics (assessed as a composite score). The BPS scale categorizes the receipt of services as excellent, good, fair, or poor.

RESULTS

Most children received excellent (34.9%) or good (31.5%) care, but many received fair (24.9%) or poor (8.7%) care. Sociodemographic and health care factors such as race/ethnicity, insurance, and practice setting were not associated with BPS levels. Higher BPS scores were associated with parental reports of longer well-child visits, more counseling regarding family and community risk factors, lower rates of delayed or missed care, and greater satisfaction.

CONCLUSIONS

Two thirds of children receive good or excellent basic preventive care, as determined with this composite, and no disparities according to race/ethnicity, income, or health insurance status of families (which are often found to be associated with health care access) were found. This equitable distribution of high-quality care suggests a high level of clinician professionalism. Duration of visits may be a key factor to improve quality of care. Because of its association with other services, processes, and outcomes of care, the BPS scale may serve as a useful construct for monitoring quality and stimulating efforts to improve national pediatric preventive care.

Environmental health promotion: bridging traditional environmental health and health promotion

This article highlights the juncture between environmental health and health promotion and underscores the need for health promotion involvement in environmental health practice. It begins with a synopsis of current issues in environmental public health and deficiencies in environmental public health practice that could be partly ameliorated by an increased focus on environmental health promotion. Environmental health promotion lies at the intersection between the two disciplines and can be defined as any planned process employing comprehensive health promotion approaches to assess, correct, control, and prevent those factors in the environment that can potentially harm the health and quality of life of present and future generations. An introduction is also provided to the six articles contained in this special issue focused on environmental health promotion, and a brief discussion of crosscutting themes and issues is presented.

The Potential Role of HMG-CoA Reductase Inhibitors in Pediatric Nephrotic Syndrome

OBJECTIVE

To evaluate the safety and efficacy of the hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) as a potential treatment option for the dyslipidemia associated with childhood nephrotic syndrome.

DATA SOURCES

Searches of MEDLINE (1966–April 2004), Cochrane Library, International Pharmaceutical Abstracts (1977–April 2004), and an extensive manual review of journals were performed using the key search terms nephrotic syndrome, familial hypercholesterolemia, dyslipidemia, and HMG-CoA reductase inhibitor.

STUDY SELECTION AND DATA EXTRACTION

Two prospective uncontrolled studies evaluating the safety and efficacy of statin therapy in pediatric nephrotic syndrome were included.

DATA SYNTHESIS

While an extensive amount of data is available in adult nephrotic syndrome in which statin therapy decreases total plasma cholesterol 22–39%, low-density lipoprotein cholesterol (LDL-C) 27–47%, and total plasma triglycerides 13–38%, only 2 small uncontrolled studies have been conducted evaluating the utility of these agents in pediatric nephrotic syndrome. These studies indicate that statins are capable of safely reducing total cholesterol up to 42%, LDL-C up to 46%, and triglyceride levels up to 44%.

CONCLUSIONS

Lowering cholesterol levels during childhood may reduce the risk for atherosclerotic changes and may thus be of benefit in certain patients with nephrotic syndrome. Statins have demonstrated short-term safety and efficacy in the pediatric nephrotic syndrome population. Implementing pharmacologic therapy with statins in children with nephrotic syndrome must be done with care until controlled studies are conducted in this population.

Immunostimulation and growth faltering in UK infants

The purpose of the study was to determine whether chronic immunostimulation could explain growth faltering in disadvantaged children in the UK, as it does in developing countries such as The Gambia. In all, 216 infants, age 10-21 months, were recruited when blood samples were taken for the routine or clinical purposes of a longitudinal study tracking a larger cohort of children. Aliquots of blood were collected on Guthrie cards to determine blood concentrations of albumin (Alb), alpha(1)-antichymotrypsin (ACT), and immunoglobulin G (IgG). Haemoglobin concentrations were determined by routine hospital laboratory analysis. Heights and weights were measured and converted to z-scores; birth weights were used with recruitment weight to calculate a 'thrive index' for each child. Age-corrected plasma IgG concentration was negatively associated with both height- and weight-for-age z-scores (P = 0.042 and 0.038, respectively) but not with the thrive index or body mass index z-scores. Blood haemoglobin levels were positively related to height- and weight-for age z-scores, as well as to the thrive index (P = 0.026, 0.014, and 0.007, respectively). Although significant, these relationships could only account for a small part the observed growth variation. Although the relationships were weak, the results suggest that some of the observed variation in growth of these UK infants may be explained on the basis of persistent immunostimulation or poor iron status. In terms of markers of immunostimulation (Alb, ACT, ACT:Alb ratio, IgG), both absolute levels and relationships with height-for-age are substantially different than those previously observed in cohort studies of infants in The Gambia.

The endocannabinoid-CB1 receptor system in pre- and postnatal life

Recent research suggests that the endogenous cannabinoids ("endocannabinoids") and their cannabinoid receptors have a major influence during pre- and postnatal development. First, high levels of the endocannaboid anandamide and cannabinoid receptors are present in the preimplantation embryo and in the uterus, while a temporary reduction of anandamide levels is essential for embryonal implantation. In women accordingly, an inverse association has been reported between fatty acid amide hydrolase (the anandamide degrading enzyme) in human lymphocytes and miscarriage. Second, CB(1) receptors display a transient presence in white matter areas of the pre- and postnatal nervous system, suggesting a role for CB(1) receptors in brain development. Third, endocannabinoids have been detected in maternal milk and activation of CB(1) receptors appears to be critical for milk sucking by newborn mice, apparently activating oral-motor musculature. Fourth, anandamide has neuroprotectant properties in the developing postnatal brain. Finally, prenatal exposure to the active constituent of marihuana (Delta(9)-tetrahydrocannabinol) or to anandamide affects prefrontal cortical functions, memory and motor and addictive behaviors, suggesting a role for the endocannabinoid CB(1) receptor system in the brain structures which control these functions. Further observations suggest that children may be less prone to psychoactive side effects of Delta(9)-tetrahydrocannabinol or endocannabinoids than adults. The medical implications of these novel developments are far reaching and suggest a promising future for cannabinoids in pediatric medicine for conditions including "non-organic failure-to-thrive" and cystic fibrosis.