Phenotypic variance in childhood coeliac disease and the HLA-DQ/DR dose effect

OBJECTIVE

Coeliac disease (CD) is associated with HLA-DQ2 and DQ8. The clinical picture is variable and certain human leucocyte antigen (HLA) DQ/DR combinations have a higher relative risk (RR) for CD than others. Moreover, the HLA-DQ gene-dose effect has an impact on the strength of the gluten-specific T-cell response and thus may correlate with clinical presentation and severity of CD. The aim of this study was to determine the correlation between HLA-DQ/DR-based genotypes and the variation in phenotypes of the disease.

MATERIAL AND METHODS

A total of 113 non-related Caucasian children clinically diagnosed with CD during the period 1980-2003 with a known HLA type were included in the study. Patients were divided into four categories according to amount of disease expression predisposing to HLA-DQ2 or HLA-DQ8 molecules and the known RR of their HLA-DR/DQ type for CD: high (DR3DQ2 homozygous and DR3DQ2/DR7DQ2), substantial (DR3DQ2/DR5DQ7 and DR5DQ7/DR7DQ2), moderate (DR3DQ2-DR4DQ8 and DR3DQ2/DR*DQ*) and low (DR7DQ2/DR*DQ*, DR4DQ8- DR*DQ* and DR*DQ*- DR*DQ*). The clinical data and HLA genotypes of these patients were compared.

RESULTS

The 113 children were diagnosed with CD at a mean age of 4.6 years and boys were significantly older than girls when diagnosed (p=0.01). RR for having CD was highest for the high HLA-risk group (RR 8.1). With the exception of a greater frequency of abdominal distension and fewer non-gastrointestinal symptoms in the substantial HLA-risk group, there were no significant differences in clinical characteristics or degree of severity of the small-bowel histological findings between the children in the different HLA-risk groups.

CONCLUSION

No correlation was found between disease severity and a double HLA-DQ2 gene dose.

Pediatric pharmacotherapy issues in Africa

Pediatric pharmacotherapy in Africa is constrained by a variety of factors, not all of them unique to the continent. While affordability of medicines and the availability of sustainable financing for healthcare are constant challenges to African health systems, other issues of particular importance for pediatric care are also hampering access. These include the burden of disease in such settings, the lack of appropriate human resources for health, and the lack of child-appropriate dosage forms, especially for ambulatory care. Access to medicines for children has been recognized as a global priority. Examples of developments that have the potential to improve pediatric pharmacotherapy in resource-constrained settings are the WHO Essential Medicines List for Children and the 'Make medicines child size' campaign.

[Congenital cytomegalovirus infection]

INTRODUCTION

Cytomegalovirus (CMV) is the most frequent cause of intrauterine infection and an important cause of auditory system damage and mental retardation in humans. Clinical presentation varies from asymptomatic form to lethal systemic dissemination.

OBJECTIVES

To describe clinical and laboratories manifestations, age at the moment of diagnostic, treatment and diagnostic test used in congenital cytomegalovirus infection.

POPULATION, MATERIAL AND METHODS

Observational, retrospective and descriptive study. Clinical histories of congenital CMV infected infants evaluated by Infectology Department of the Hospital General de Niños Dr. Ricardo Gutiérrez between January 2002 and December 2006 were analyzed.

RESULTS

Seventeen patients were evaluated. Mean age at diagnosis was 2.6 months. The most frequent symptom/sign were hepato-splenomegaly (76 %), jaundice (47 %), petechiae and hearing deficit (41 %). Anemia (53 %) and thrombocytopenia (40 %) were the most common laboratory abnormalities. Diagnosis was made exclusively by polymerase chain reaction (PCR)-CMV in one third of the patients, whereas one third was diagnosed by serology and the other third for both test. Five patients received ganciclovir as treatment. Only one had neutropenia.

CONCLUSIONS

Differential diagnosis of all newborns with hepatoesplenomegaly, jaundice and petechiae and anemia and/or thrombocytopenia must include congenital cytomegalo-virus infection. Early diagnosis allows a prompt intervention and a strict audiological follow up.

Young people in the United Kingdom and Ireland with perinatally acquired HIV: the pediatric legacy for adult services

Children with perinatally acquired HIV-1 infection are surviving into adolescence and increasingly transitioning toward adult services. Planning appropriate services in adult life requires an understanding of their progress through pediatric care. We describe the demographic features, disease progression, antiretroviral therapy (ART), and resistance in young people aged 10 years or more living in the United Kingdom and Ireland reported to the National Study of HIV in Pregnancy and Childhood (NSHPC) with prospective annual follow-up in the Collaborative HIV Paediatric Study (CHIPS) between 1996 and September 2007. Six hundred fifty-four perinatally infected young people were identified; 76% black African, 57% born abroad. Median age at presentation and duration of follow-up was 1 and 11 years, respectively, if born in the United Kingdom/Ireland, and 8 and 5 years if born elsewhere. One hundred sixty-nine (26%) ever had an AIDS-defining illness. Ten died during adolescence. At last follow-up, 64% were on ART, 18% off treatment having previously received ART and 18% were ART naive. Of 518 who had received highly active antiretroviral therapy (HAART), 47% were triple class experienced. At last follow-up 77 (12%) had CD4 counts less than 200 per microliter; of those on HAART, 78% had HIV-1 RNA </=400 copies per milliliter, median CD4 count 554 (interquartile range [IQR] 324-802). Among 166 with resistance assays on HAART, 52% and 12% had dual- and triple-class HIV-1-associated resistance mutations, respectively. One hundred three (16%) young people had transferred to adult services. Young adults with perinatally acquired HIV-1 infection require coordinated multidisciplinary transitional care services and careful long-term follow-up in adult life.

Prevalence of vertebral fractures in children with chronic rheumatic diseases at risk for osteopenia

OBJECTIVES

To determine the prevalence of and the risk factors for vertebral fractures in a cohort of children with chronic rheumatic diseases considered at risk for osteopenia.

STUDY DESIGN

We conducted a cross-sectional study of patients with chronic rheumatic diseases at the Montreal Children's Hospital.

RESULTS

Of the 90 study participants (22 boys, 68 girls), 10 boys and 7 girls (19%) were found to have vertebral fractures. These 17 children had a total of 50 fractures, an average of 2.9 per affected child. Fractures in the upper thoracic region (T5-8) accounted for 55%. Only 56% of all fractures were symptomatic. With multivariate regression, we identified male sex (P < .01), body mass index z-score (P < .02), and cumulative glucocorticoid dose (P < .01) as significant predictors of the number of vertebral fractures.

CONCLUSIONS

Our study examined the prevalence of vertebral fractures in a high-risk pediatric population. Nineteen percent of our cohort had vertebral fractures. Significant risk factors for the development of vertebral fractures include male sex and cumulative glucocorticoid dose. Better understanding of the extent of the problem in this population will allow us to further refine screening guidelines and treatment in these patients.

Soropositividade para doença celíaca em crianças e adolescentes com baixa estatura

OBJETIVO: Avaliar a frequência da positividade do marcador sorológico para doença celíaca em crianças e adolescentes com baixa estatura, utilizando-se o anticorpo anti-transglutaminase humana como teste de triagem. MÉTODOS: Estudo descritivo com amostra obtida por conveniência. Foi realizado no período de abril a setembro de 2004 no Ambulatório Geral de Pediatria do Instituto Materno Infantil Professor Fernando Figueira e no Ambulatório de Crescimento e Desenvolvimento do Hospital das Clínicas. Foram considerados casos as crianças e os adolescentes portadores de baixa estatura, definida como aquela abaixo do percentil 3 para idade e sexo, utilizando como referência o gráfico de altura/idade do National Center for Health Statistics, 2000. Foi pesquisado o anticorpo anti-transglutaminase humana (AATGh), considerado positivo se concentração >20U/mL e, nos positivos, o anticorpo antiendomísio (AAE). RESULTADOS: Foram avaliados 78 pacientes, sendo 41 (53%) do sexo feminino. O AATGh foi positivo em 3/78 (3,8%) dos pacientes. O AAE foi positivo em um paciente, naquele com concentração mais elevada do AATGh. Considerando-se a positividade para os dois testes, a soropositividade foi de 1,3%. CONCLUSÕES: A presença de marcador sorológico para doença celíaca em crianças e adolescentes portadoras de baixa-estatura e pertencentes a famílias de baixa-renda aponta para a necessidade de investigação sistemática da doença celíaca nesses pacientes.

Psychiatric phenotypes associated with neurogenetic disorders

Advances in understanding the human genome and clinical application have led to identification of genetically based disorders that have distinctive behavioral phenotypes and risk for serious psychiatric disorders. Some patients have unrecognized genetic disorders presenting as psychiatric symptoms. Practitioners must be knowledgeable about the association between symptoms and underlying genetic bases. Treatment of neurogenetic disorders includes providing information about causes and prognoses. Patients are served best if they remain long term with a multidisciplinary team of providers who recognize the realities of a lifetime course, the high risk for symptom recurrence, and the need for providing information and support to families and coordinating medical and psychiatric care.

Disease-associated pathophysiologic structures in pediatric rheumatic diseases show characteristics of scale-free networks seen in physiologic systems: implications for pathogenesis and treatment

BACKGROUND

While standard reductionist approaches have provided some insights into specific gene polymorphisms and molecular pathways involved in disease pathogenesis, our understanding of complex traits such as atherosclerosis or type 2 diabetes remains incomplete. Gene expression profiling provides an unprecedented opportunity to understand complex human diseases by providing a global view of the multiple interactions across the genome that are likely to contribute to disease pathogenesis. Thus, the goal of gene expression profiling is not to generate lists of differentially expressed genes, but to identify the physiologic or pathogenic processes and structures represented in the expression profile.

METHODS

RNA was separately extracted from peripheral blood neutrophils and mononuclear leukocytes, labeled, and hybridized to genome level microarrays to generate expression profiles of children with polyarticular juvenile idiopathic arthritis, juvenile dermatomyositis relative to childhood controls. Statistically significantly differentially expressed genes were identified from samples of each disease relative to controls. Functional network analysis identified interactions between products of these differentially expressed genes.

RESULTS

In silico models of both diseases demonstrated similar features with properties of scale-free networks previously described in physiologic systems. These networks were observable in both cells of the innate immune system (neutrophils) and cells of the adaptive immune system (peripheral blood mononuclear cells).

CONCLUSION

Genome-level transcriptional profiling from childhood onset rheumatic diseases suggested complex interactions in two arms of the immune system in both diseases. The disease associated networks showed scale-free network patterns similar to those reported in normal physiology. We postulate that these features have important implications for therapy as such networks are relatively resistant to perturbation.

Congenital CMV infection: prevalence in newborns and the impact on hearing deficit

Congenital cytomegalovirus (CMV) infection is asymptomatic in 90% of infected newborns but approximately 10-20% of these infants are at risk of developing sequelae later, mostly hearing deficit. The aims of the study were to investigate the prevalence of congenital CMV infection in a Swedish population of newborns and investigate the relative risk of hearing deficit in newborns with congenital CMV infection. The dried blood spot (DBS) samples of 6060 newborns in southern Stockholm during 12 months (October 2003-June 2004; August 2004-October 2004) were analysed for CMV DNA by TaqMan based real-time PCR. Hearing deficit was assessed by otoacoustic emission (OAE) within a newborn screening programme. 12 infants out of 6060 or 0.2% (95% CI 0.1-0.3%) had congenital CMV infection. One boy among the 12 infected infants had unilateral hearing loss, indicating that the risk of hearing loss is greatly increased (about 20 times) in CMV infected infants. No child developed ocular complications such as chorioretinopathy during 3 y of follow-up. Congenital CMV has an impact on child health but can easily be overlooked due to lack of signs in the neonatal period. Surveillance for congenital CMV is important in addition to programmes for prevention and treatment.

Potential of immunomodulatory agents for prevention and treatment of neonatal sepsis

Prevention of neonatal infection-related mortality represents a significant global challenge particularly in the vulnerable premature population. The increased risk of death from sepsis is likely due to the specific immune deficits found in the neonate as compared to the adult. Stimulation of the neonatal immune system to prevent and/or treat infection has been attempted in the past largely without success. In this review, we identify some of the known deficits in the neonatal immune system and their clinical impact, summarize previous attempts at immunomodulation and the outcomes of these interventions, and discuss the potential of novel immunomodulatory therapies to improve neonatal sepsis outcome.

Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes

OBJECTIVE

The authors sought to evaluate 2 approaches with varying time and complexity in engaging adolescents with an Internet-based preventive intervention for depression in primary care. The authors conducted a randomized controlled trial comparing primary care physician motivational interview (MI, 5-10 minutes) + Internet program versus brief advice (BA, 1-2 minutes) + Internet program.

SETTING

Adolescent primary care patients in the United States, aged 14 to 21 years.

PARTICIPANTS

Eighty-four individuals (40% non-white) at increased risk for depressive disorders (subthreshold depressed mood >3-4 weeks) were randomly assigned to either the MI group (n = 43) or the BA group (n = 40).

MAIN OUTCOME MEASURES

Patient Health Questionnaire-Adolescent and Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Both groups substantially engaged the Internet site (MI, 90.7% vs BA 77.5%). For both groups, CES-D-10 scores declined (MI, 24.0 to 17.0, p < .001; BA, 25.2 to 15.5, p < .001). The percentage of those with clinically significant depression symptoms based on CES-D-10 scores declined in both groups from baseline to 12 weeks, (MI, 52% to 12%, p < .001; BA, 50% to 15%, p < .001). The MI group demonstrated declines in self-harm thoughts and hopelessness and was significantly less likely than the BA group to experience a depressive episode (4.65% vs 22.5%, p = .023) or to report hopelessness (MI group of 2% vs 15% for the BA group, p = .044) by 12 weeks.

CONCLUSIONS

An Internet-based prevention program in primary care is associated with declines in depressed mood and the likelihood of having clinical depression symptom levels in both groups. Motivational interviewing in combination with an Internet behavior change program may reduce the likelihood of experiencing a depressive episode and hopelessness.

Environment and obesity in the National Children's Study

OBJECTIVE

In this review we describe the approach taken by the National Children's Study (NCS), a 21-year prospective study of 100,000 American children, to understanding the role of environmental factors in the development of obesity.

DATA SOURCES AND EXTRACTION

We review the literature with regard to the two core hypotheses in the NCS that relate to environmental origins of obesity and describe strategies that will be used to test each hypothesis.

DATA SYNTHESIS

Although it is clear that obesity in an individual results from an imbalance between energy intake and expenditure, control of the obesity epidemic will require understanding of factors in the modern built environment and chemical exposures that may have the capacity to disrupt the link between energy intake and expenditure. The NCS is the largest prospective birth cohort study ever undertaken in the United States that is explicitly designed to seek information on the environmental causes of pediatric disease.

CONCLUSIONS

Through its embrace of the life-course approach to epidemiology, the NCS will be able to study the origins of obesity from preconception through late adolescence, including factors ranging from genetic inheritance to individual behaviors to the social, built, and natural environment and chemical exposures. It will have sufficient statistical power to examine interactions among these multiple influences, including gene-environment and gene-obesity interactions. A major secondary benefit will derive from the banking of specimens for future analysis.

The development of hyperactive-impulsive behaviors during the preschool years: the predictive validity of parental assessments

The objectives of this study were to establish the different developmental trajectories of hyperactive-impulsive behaviors on the basis of both mother and father ratings at 19, 32, 50, and 63 months, and to examine the predictive validity of these trajectories with respect to later hyperactive-impulsive behaviors, as rated by teachers in the first 2 years of school. Hyperactive-impulsive behaviors were assessed in a population-based sample of 1,112 twins (565 boys and 547 girls) at 19, 32, 50, and 63 months of age. The results revealed a differentiated and consistent view of developmental trajectories of hyperactive-impulsive behaviors derived from these repeated assessments, with 7.1% of children seen by mothers (7% for fathers) as displaying high and stable hyperactive-impulsive behaviors. According to mother ratings, children on a high-chronic trajectory were more likely than other children to display hyperactive-impulsive behaviors at 72 and 84 months according to their teachers. Repeated measures over time and father-based trajectories significantly added to the prediction teacher later ratings of hyperactive-impulsive behaviors. These results support the predictive validity of parental assessment of hyperactive-impulsive behaviors during the preschool years and their use to identify children at risk for further evaluation and possible intervention.

An educational program in a pediatric hospice setting

Canuck Place Children's Hospice, a family-centered pediatric hospice in Vancouver, Canada, provides family support and respite, pain and symptom management, and end-of-life care. One of the goals of pediatric hospice palliative care is to create an environment that supports a normal way of life and enhances quality of life. At Canuck Place, a unique school program for children with progressive life-threatening illnesses has been set up to meet this goal. This article describes the Canuck Place educational program, gives insights into the importance and challenges of providing a complete school experience, and discusses the expanded role of the teacher in the pediatric hospice setting.

Distal radius strength: a comparison of DXA-derived vs pQCT-measured parameters in adolescent females

Although quantitative computed tomography (QCT) is considered the gold standard for in vivo densitometry, dual-energy X-ray absorptiometry (DXA) scans assess larger bone regions and are more appropriate for pediatric longitudinal studies. Unfortunately, DXA does not yield specific bone architectural output. To address this issue in healthy, postmenarcheal girls, Sievänen's distal radius formulae [1996] were applied to derive indices of bone geometry, volumetric bone mineral density (vBMD), and strength from DXA data; results were compared to peripheral quantitative computed tomography (pQCT) output. Contemporaneous scans were performed on the left, distal radii of 35 gymnasts, ex-gymnasts, and nongymnasts (aged 13.3-20.4 yr, mean 16.6 yr). For 4% and 33% regions, pQCT measured cross-sectional areas (CSAs) and vBMD; comparable DXA indices were generated at ultradistal and 1/3 regions. Index of structural strength in axial compression was calculated from 4% pQCT and DXA output for comparison; 33% pQCT strength-strain index was compared to 1/3 DXA section modulus. Sievänen DXA indices were significantly, positively correlated with pQCT output (R=+0.61 to +0.98; p<0.0001). At the distal radius, in healthy postmenarcheal girls, Sievänen's method yielded potentially useful DXA indices of diaphyseal cortical CSA and bone strength at both the diaphysis (section modulus) and the metaphysis (index of structural strength in axial compression).

[Attention deficit hyperactivity disorder (ADHD) in preschoolers: nature, assessment and treatment]

Attention deficit hyperactivity disorder (ADHD) is the most frequently diagnosed behaviour problem in school-age children. Although more and more preschool-age children are referred in clinical settings for typical ADHD symptoms, few studies have examined the nature, the assessment as well as the treatment of ADHD in this age group. This literature review addresses the nature, the assessment, and the treatment of ADHD during the preschool period. The main themes reviewed are: prevalence, symptomatology, etiology, comorbidity, consequences on normal development and adaptation of the child, evolution of symptoms from preschool to school period, difficulties related to diagnosis, assessment modalities, psychosocial treatment, and pharmacological treatment.

Televised sexual content and parental mediation: Influences on adolescent sexuality

Little research has been conducted to examine the influence of exposure to televised sexual content on adolescent sexuality or how parental intervention may reduce negative effects of viewing such content. This study uses self-report data from 1,012 adolescents to investigate the relations among exposure to sexually suggestive programming, parental mediation strategies, and three types of adolescent sexuality outcomes: participation in oral sex and sexual intercourse, future intentions to engage in these behaviors, and sex expectancies. As predicted, exposure to sexual content was associated with an increased likelihood of engaging in sexual behaviors, increased intentions to do so in the future, and more positive sex expectancies. Often, parental mediation strategies were a significant factor in moderating these potential media influences.

Experience with tacrolimus in children with steroid-resistant nephrotic syndrome

Children with steroid-resistant nephrotic syndrome (SRNS) are at risk of developing renal failure. We report here the results of a single-center retrospective observational study of the remission rate in pediatric patients with SNRS receiving tacrolimus. Serial renal biopsies from children on tacrolimus therapy were evaluated for tubulointerstitial fibrosis and transforming growth factor-beta immunostaining. Of the 16 children with SRNS, 15 went into complete remission after a median of 120 days of therapy. Nine children were able to stop steroids, while the others were on tapering doses. Forty-seven percent had relapses, most of which were steroid-responsive. Serial renal biopsies were obtained from seven children after a median treatment duration of 24 months; two of these children had increased tubulointerstitial fibrosis and four showed increased transforming growth factor-beta tissue staining. Children with worsening histological findings were younger. There was no significant association between tacrolimus exposure and biopsy changes, although the average trough level was higher in those children with worsening histological findings. In conclusion, tacrolimus may be a safe and effective alternative agent for inducing remission in children with SRNS. However, caution needs to be taken when prescribing this agent due to its narrow therapeutic index. Serial renal biopsies are necessary to check for subclinical nephrotoxicity, especially in younger children and those with higher trough levels.

Clinical features of adolescents with deliberate self-harm: A case control study in Lisbon, Portugal

Deliberate self-harm (DSH) among adolescents is a high-risk condition for suicide. The aim of the present study is to describe the characteristic clinical features of adolescents with DSH according to our local context (Lisbon, Portugal), using easily available information from clinical settings. A case control study was constructed from a sample of 100 adolescents (aged 12 to 21 years). The sample was divided into two groups: adolescents with and without DSH. Case files were examined and data was completed by clinical interviews. Demographic, psychosocial, and psychopathological data were assessed and compared. Ninety-eight subjects completed the protocol. The DSH group was associated with the following: suicidal ideation or suicidal behavior as consultation motive, emergency room referral, previous follow-up attempts, suicidal ideation, psychosocial difficulties, or lack of therapeutic goals. There was a nonsignificant trend towards diagnosis of depression in the DSH group. These results reflect our clinical practice with adolescents and add data about teenagers who self-harm to the literature. Prevention and early recognition of DSH (and frequently associated depression) in adolescents are essential and could be life-saving measures. An integrated approach, which takes into account psychosocial difficulties, family dysfunction, and negative expectations, seems to be of great importance.

Polymorphism of Biotransformation Genes and Risk of Relapse in Childhood Acute Leukemia

Leukemia is a hematological malignancy that involves bone marrow. Polymorphism of biotransformation genes plays an important role in primary childhood leukemia and affects the incidence and character of acute leukemia relapse. A biochip designed to assess some polymorphisms of biotransformation genes was used to determine the frequency of the polymorphic variants ofCYP1A1, CYP2D6, GSTT1, GSTM1, MTHFR, MTRR, NQO1, CYP2C9, CYP2C19andNAT2in 332 children with acute lymphoblastic leukemia (ALL) and 71 children with acute myeloblastic leukemia (AML). TheCYP1A1 *1/*2A, GSTT1non null andGSTM1non null genotypes were more frequent in patients with primary leukemia than in relapse. Analysis of theNAT2genotype frequency revealed a characteristic genotype for each type of leukemia, which prevailed in patients with relapse: the genotype341C/-, 481T/-, 590G/G, 857G/Gprevailed in ALL patients with relapse, and the genotype341T/T, 481C/C, 590A/- in AML patients with relapse when compared with patients having primary ALL or AML, respectively. Thus, the polymorphisms ofCYP1A1, GSTT1, GSTM1andNAT2genes can be considered as markers for risk of relapse in childhood acute leukemia and can be used for the prognosis and individualization of standard therapy.

Development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS) questionnaire in school-based health centers

INTRODUCTION

The purpose of this study is to describe the development and clinical use of Rapid Assessment for Adolescent Preventive Services (RAAPS), a time-efficient screening tool to assess for multiple adolescent risk behaviors.

METHOD

A retrospective chart audit was conducted to obtain descriptive data of middle school (N = 106) and alternative high school (N = 39) adolescents who completed the 17- to 18-item RAAPS questionnaire. Surveys assessed providers' evaluations of the RAAPS.

RESULTS

Descriptive statistics and qualitative analysis indicated that providers using the RAAPS were able to identify risk behaviors/factors, provide counseling for these behaviors, and refer 26% of 9- to 15-year-olds and 43% of 16- to 20-year-olds for further assessment or ongoing risk counseling. In one brief clinic visit, the providers were able to address and document most risk behaviors/factors reported by the adolescents.

DISCUSSION

Although psychometric analysis is needed, the RAAPS is a time efficient and comprehensive risk assessment tool. Early risk identification can assist providers in tailoring specific preventative education counseling and intervention programs that are geared to meet the specific needs of the adolescent population.

Improving Psychological and Psychiatric Aspects of Palliative Care: The National Consensus Project and the National Quality Forum Preferred Practices for Palliative and Hospice Care

As patients with terminal disease enter into the final stage of their illness, psychiatric symptoms and psychological responses to the disease contribute to overall suffering of both patient and family. Until recently, no nationally accepted guidelines or practices had been established to support assessment and management of this type of suffering. In 2007, the National Quality Forum published A National Framework and Preferred Practices for Palliative and Hospice Care Quality that included a list of preferred practices for assessing and treating symptoms of psychiatric illness, anticipatory grief and psychologic distress prior to death, and bereavement after the death, of the patient. While specialized care may be provided to patient and families in the context of advanced disease, all clinicians involved in palliative and end-of-life care are responsible for having a basic understanding of effectively managing psychologic and psychiatric aspects of this care. Evidence from current literature supports these best practices.

Newborn resuscitation in resource-limited settings

Every year, an estimated 4 million newborn infants die worldwide in the first 4 weeks of life. A large majority of these deaths occurs during the first day of life. One of the United Nations' eight Millennium Development Goals is to decrease child mortality; prevention of neonatal deaths by appropriate resuscitation will have a significant impact on achieving this goal. Newborn resuscitation needs to be carried out in all the settings where asphyxiated babies are born, including: community or domiciliary settings for home births; rural health centers/midwifery stations, where attendants with basic resuscitation skills might be available; district-level facilities where staff are available but skills vary; and urban referral and tertiary care centers. Individuals at all levels require training and seldomly used skills need to be maintained so that, when required, resuscitation can be carried out efficiently and effectively. Simple resuscitation techniques include: positioning, drying, and keeping the baby warm; assessing the heart rate, color, and respirations; recognizing the need for, and administering, assisted ventilation with a bag and mask or tube and mask. These maneuvers can be carried out with simple equipment and appropriate training. Research in developing countries remains sparse, with 90% of research being done in more developed parts of the world, which experience just 10% of the problems. The significant gaps in our understanding include: failing to agree on a definition of the term 'asphyxia', lack of knowledge of the impact of community approaches on the prevention and management of asphyxia, and a failure to recognize the best method to determine heart rate.

Sleep hygiene for children with neurodevelopmental disabilities

Sleep disturbances in children with neurodevelopmental disabilities are common and have a profound effect on the quality of life of the child, as well as the entire family. Although interventions for sleep problems in these children often involve a combination of behavioral and pharmacologic strategies, the first line of treatment is the promotion of improved sleep habits or "hygiene." Despite the importance of sleep-hygiene principles, defined as basic optimal environmental, scheduling, sleep-practice, and physiologic sleep-promoting factors, clinicians often lack appropriate knowledge and skills to implement them. In addition, sleep-hygiene practices may need to be modified and adapted for this population of children and are often more challenging to implement compared with their healthy counterparts. This first comprehensive, multidisciplinary review of sleep hygiene for children with disabilities presents the rationale for incorporating these measures in their treatment, outlines both general and specific sleep-promotion practices, and discusses problem-solving strategies for implementing them in a variety of clinical practice settings.

Mortalidade infantil por doenças infecciosas e parasitárias: reflexo das desigualdades sociais em um município do Nordeste do Brasil

OBJETIVOS: estudar a relação entre o coeficiente de mortalidade infantil (CMI) por doenças infecciosas e parasitarias (DIP) e o indicador de carência social (ICS), identificando áreas geográficas de maior risco no município de Jaboatão dos Guararapes, Pernambuco, Brasil. MÉTODOS: trata-se de um estudo ecológico cujas unidades de análise foram os bairros do município. Os sistemas de informações de mortalidade e de nascidos vivos do Ministério da Saúde foram utilizados para o cálculo do CMI por DIP e o ICS foi construído utilizando dados socioeconômicos do Censo 2000. RESULTADOS: o CMI por DIP foi de 3,56 por 103 nascidos vivos (NV) e o coeficiente de mortalidade pós-neonatal foi de 3,39 por 10³ NV. Houve correlação entre ICS e o CMI por DIP (r=0,87; p=0,008; F=12,88). Encontrou-se um risco 48% (RR=1,479) maior das crianças irem a óbito por DIP antes de completarem um ano no estrato de maior carência social. CONCLUSÕES: o ICS é um útil instrumento para o planejamento de ações locais de saúde, contribuindo para a adoção de medidas que promovam a redução da mortalidade infantil, não descartando a necessidade de demandar atenção para o desenvolvimento de políticas sociais e econômicas nas áreas com maiores carências sociais.

Endocrinological analysis of 122 Japanese childhood cancer survivors in a single hospital

With recent improvements in the diagnosis and treatment of cancer, the number of childhood cancer survivors (CCSs) has been increasing in Japan. The importance of quality of life during the lifetime of CCSs has now been recognized, and the late effects of cancer treatments are essential and important issues. In this study we analyzed the endocrinological abnormalities of CCSs by retrospectively evaluating 122 outpatients (62 males and 60 females) who had been referred from pediatric oncologists to our follow-up clinic among 151 CCSs attending our hospital more than two years after their cancer treatment. Follow-up duration varied from 2 to 30 (median 8.0) years. Their average age was 17.3 (range 4-36, median 17.0) years, and 38 patients (31.1%) reached adulthood. Endocrinological abnormalities were found in 82 (67%) of 122 survivors. Gonadal dysfunction was observed in 60 patients (49%). Thirty-nine patients (32%) were short or grew at a slower rate. Twenty-six patients (21%) showed thyroid dysfunction. Other abnormalities were as follows: obesity in 20 patients (16%), leanness in 10 (8%), central diabetes insipidus in 11 (9%) and adrenocortical dysfunction in 9 (7%). Low bone mineral density was observed in 41 (42%) of 98 patients evaluated. These endocrinological abnormalities were caused by the combined effects of cancer itself and various treatments (chemotherapy, radiation therapy, surgery, and hematopoietic stem cell transplantation). Lifetime medical surveillance and continuous follow-up are necessary for CCSs, because treatment-related complications may occur during childhood and many years after the therapy as well. Endocrinologists should participate in long-term follow-up of these survivors in collaboration with pediatric oncologists.

Insulin resistance and obesity in childhood

Childhood obesity is a significant health problem that has reached epidemic proportions around the world and is associated with several metabolic and cardiovascular complications. Insulin resistance is a common feature of childhood obesity and is considered to be an important link between adiposity and the associated risk of type 2 diabetes and cardiovascular disease. Insulin resistance is also a key component of the metabolic syndrome, and its prevalence in the paediatric population is increasing, particularly among obese children and adolescents. Several factors are implicated in the pathogenesis of obesity-related insulin resistance, such as increased free fatty acids and many hormones and cytokines released by adipose tissue. Valid and reliable methods are essential to assess the presence and the extent of insulin resistance, the associated risk factors and the effect of pharmacological and lifestyle interventions. The two most common tests to assess insulin resistance are the hyperinsulinemic euglycemic clamp and the frequently sampled i.v. glucose tolerance test utilizing the minimal model. However, both these tests are not easily accomplished, are time consuming, expensive and invasive. Simpler methods to assess insulin resistance based on surrogate markers derived from an oral glucose tolerance test or from fasting insulin and glucose levels have been validated in children and adolescents and widely used. Given the strong association between obesity, insulin resistance and the development of metabolic syndrome and cardiovascular disease, prevention and treatment of childhood obesity appear to be essential to prevent the development of insulin resistance and the associated complications.

American Academy of Pediatrics. The use of complementary and alternative medicine in pediatrics

The American Academy of Pediatrics is dedicated to optimizing the well-being of children and advancing family-centered health care. Related to these goals, the American Academy of Pediatrics recognizes the increasing use of complementary and alternative medicine in children and, as a result, the need to provide information and support for pediatricians. From 2000 to 2002, the American Academy of Pediatrics convened and charged the Task Force on Complementary and Alternative Medicine to address issues related to the use of complementary and alternative medicine in children and to develop resources to educate physicians, patients, and families. One of these resources is this report describing complementary and alternative medicine services, current levels of utilization and financial expenditures, and associated legal and ethical considerations. The subject of complementary and alternative medicine is large and diverse, and consequently, an in-depth discussion of each method of complementary and alternative medicine is beyond the scope of this report. Instead, this report will define terms; describe epidemiology; outline common types of complementary and alternative medicine therapies; review medicolegal, ethical, and research implications; review education and training for complementary and alternative medicine providers; provide resources for learning more about complementary and alternative medicine; and suggest communication strategies to use when discussing complementary and alternative medicine with patients and families.

Coeliac disease screening in children: assessment of a novel anti-gliadin antibody assay

Coeliac disease (CD) screening has progressed rapidly with tissue transglutaminase (TTG), the screening tool of choice. However, TTG may be unreliable in young children and advances in CD etiology understanding have seen improvements in anti-gliadin (AGA) assay technology. The aim of this study was to investigate the utility of an updated and refined AGA (Neogliadin) assay for CD screening in children with gastrointestinal symptoms. Children attending the Sydney Children's Hospital, Randwick, with gastrointestinal symptoms had sera collected and assayed by Neogliadin and commercial TTG assays in addition to the usual clinical work-up. One hundred and fifteen children were recruited in which 32 were diagnosed with CD. AGA-IgA screening by Neogliadin showed improved sensitivity (83%) and specificity (91%) but did not eclipse the sensitivity (93%) and specificity (90%) of TTG-IgA screening. In the children diagnosed with CD, 7 were identified as younger than 5 years of age with 4/7 AGA-IgA positive, 5/7 AGA-IgG positive, and 6/7 TTG-IgA positive. The updated Neogliadin IgA assay does not improve on the accuracy achieved by TTG screening. TTG appears to be a suitable screening tool for children younger than 5 years of age although this preliminary finding requires confirmation.

Commentary - ordering lab tests for suspected rheumatic disease

One of the least-appreciated advances in pediatric rheumatology over the past 25 years has been the delineation of the many ways in which children with rheumatic disease differ from adults with the same illnesses. Furthermore, we are now learning that paradigms that are useful in evaluating adults with musculoskeletal complaints have limited utility in children. Nowhere is that more true than in the use of commonly used laboratory tests, particularly antinuclear antibody (ANA) and rheumatoid factor (RF) assays. This short review will provide the practitioner with the evidence base that supports a more limited use of ANA and RF testing in children.

Loss of mouse Ikbkap, a subunit of elongator, leads to transcriptional deficits and embryonic lethality that can be rescued by human IKBKAP

Familial dysautonomia (FD), a devastating hereditary sensory and autonomic neuropathy, results from an intronic mutation in the IKBKAP gene that disrupts normal mRNA splicing and leads to tissue-specific reduction of IKBKAP protein (IKAP) in the nervous system. To better understand the roles of IKAP in vivo, an Ikbkap knockout mouse model was created. Results from our study show that ablating Ikbkap leads to embryonic lethality, with no homozygous Ikbkap knockout (Ikbkap(-)(/)(-)) embryos surviving beyond 12.5 days postcoitum. Morphological analyses of the Ikbkap(-)(/)(-) conceptus at different stages revealed abnormalities in both the visceral yolk sac and the embryo, including stunted extraembryonic blood vessel formation, delayed entry into midgastrulation, disoriented dorsal primitive neural alignment, and failure to establish the embryonic vascular system. Further, we demonstrate downregulation of several genes that are important for neurulation and vascular development in the Ikbkap(-)(/)(-) embryos and show that this correlates with a defect in transcriptional elongation-coupled histone acetylation. Finally, we show that the embryonic lethality resulting from Ikbkap ablation can be rescued by a human IKBKAP transgene. For the first time, we demonstrate that IKAP is crucial for both vascular and neural development during embryogenesis and that protein function is conserved between mouse and human.

Management of pediatric migraine: Current concepts and controversies

Migraine in children and adolescents is a common condition. Emerging knowledge about the pathophysiology of migraine is leading to new targeted treatments toward specific mechanisms of migraine. This review explores the evidence for different treatments for pediatric migraine including the periodic syndromes of childhood that commonly represent precursors to migraine.

Predicting future risk of depressive episode in adolescents: the Chicago Adolescent Depression Risk Assessment (CADRA)

PURPOSE

A risk prediction index, similar to those used for other disorders, such as cardiovascular disease, would facilitate depression prevention by identifying those who would benefit most from preventative measures in primary care settings.

METHODS

The National Longitudinal Study of Adolescent Health enrolled a representative sample of US adolescents and included a baseline survey in 1995 and a 1-year follow-up survey in 1996 (n = 4,791). We used baseline risk factors (social and cognitive vulnerability and mood) to predict onset of a depressive episode at 1-year follow-up (eg, future risk of episode) and used boosted classification and regression trees to develop a prediction index, The Chicago Adolescent Depression Risk Assessment, suitable for a personal computer or hand-held device. True and false positives and negatives were determined based on concordance and discordance, respectively, between the prediction-category-based index and actual classification-category-based 1-year follow-up outcome. We evaluated the performance of the index for the entire sample and with several depressive episode outcomes using the standard Center for Epidemiologic Studies Depression (CES-D) scale cutoffs.

RESULTS

The optimal prediction model (including depressed mood and social vulnerability) was a 20-item model with an area under the receiver operating characteristics curve of 0.80 (95% CI, 0.714-0.870), a sensitivity of 75%, and a specificity of 76.5%. For depressive episode, the positive predictive values in the highest risk group (level 4) was from 13.75% for a depressive episode to 63.57% for CES-D score of greater than 16 (mild to moderate depressed mood or above) at follow-up. Conversely, the negative predictive value of being in the lowest 2 levels (0 or 1) was 99.38% for a depressive episode and 89.19% for a CES-D score of greater than 16.

CONCLUSIONS

Our model predicts a depressive episode and other depressive outcomes at 1-year follow-up. Positive and negative predictive values could enable primary care physicians and families to intervene on adolescents at highest risk.

Opportunities for prevention in primary care in a country with universal insurance coverage

Data from studies in the United States suggest that young people engaging in health-compromising behaviors have lower access to health care. Using data from a Swiss national survey we tested the hypothesis that in a country with universal insurance coverage, adolescents engaging in health-compromising behaviors access primary care to the same extent as those who do not engage in these behaviors.

Quality of life in adolescents with treated coeliac disease: influence of compliance and age at diagnosis

OBJECTIVE

To assess the influence of gluten-free diet (GFD) compliance on the quality of life (QOL) of adolescents with coeliac disease (CD), and the impact of patient's age at time of diagnosis.

STUDY DESIGN

Participants included 365 subjects: 283 adolescents (10-20 years old) with biopsy-proven CD and 82 adolescents without a chronic condition matched for age, sex, education, and social status. Their subjective QOL-comprising physical, mental, and social dimensions as defined by the World Health Organization-was measured and has been analyzed according to compliance status and age at CD diagnosis.

RESULTS

Adolescents noncompliant with GFD reported a lower general QOL, more physical problems, a higher burden of illness, more family problems, and more problems in leisure time than adolescents who are compliant with GFD. More frequent GFD transgressions were associated with poorer QOL. Higher problem anticipation and higher feelings of "ill-being" were found in the noncompliant group. No differences between compliant patients with CD and adolescents without any chronic condition were found in all QOL aspects. Adolescents with a late CD diagnosis showed more problems at school and in social contact with peers, as well as worse physical health and higher CD-associated burden.

CONCLUSIONS

Compliance with GFD is an essential factor to obtain optimal QOL. Psychosocial and educational support should be provided for patients having difficulties strictly adhering to GFD. Early CD onset and diagnosis is associated with better physical health, lower CD-associated burden and fewer social problems, indicating the importance of the earliest CD diagnosis possible.

Seconds for care: evaluation of five health supervision visit topics using a new method

OBJECTIVE

To describe content and time devoted to 5 preventive health topics during health supervision visits (HSVs).

STUDY DESIGN

New software (Pediatric Health Supervision Timer Software, PHSTS) run in handheld computers was developed to record time and content while observing HSVs. 185 visits of children ages 2 to 10 years (58% Medicaid/self-pay) to 28 clinicians were observed at 6 practices. Parents were surveyed on demographics. Data on times and actions related to assessments and counseling of growth, diet, physical activity, safety, and tobacco were collected using PHSTS.

RESULTS

The PHSTS method was well accepted (89% participation rate). Most visits included assessment/counseling for diet (95%), growth (84%), and safety (71%) and less often physical activity (52%) and tobacco (43%). Discussions occurring were short (median time [25th to 75th percentiles]: diet, 42 seconds [21 to 85 seconds]; safety, 24 seconds [11 to 61 seconds]; growth, 15 seconds [7 to 31 seconds]; physical activity, 12 seconds [5 to 22 seconds]; and tobacco, 3 seconds [2 to 6 seconds]). Clinicians expressed concerns about child weight during 18 of 33 visits (55%) that included an obese child and provided tobacco-related counseling at 6 of 30 visits (20%) that included a child living with a smoker.

CONCLUSIONS

The PHSTS method was successfully used. Our observations found that limited time was devoted to assessment and counseling on key health topics during HSVs.

Translating research on healthy lifestyles for children: meeting the needs of diverse populations

This article provides two examples of approaches nursing can take to reach diverse populations of children and their families to enhance health lifestyles. First, a descriptive summary of a brief after-school intervention program aimed at influencing 8- and 9-year-old children's media habits and the prevention of negative health behaviors is presented. Design consideration for translating health lifestyles research findings into a nurse-managed inner city primary care practice is reviewed in the second example.

Factitious disorder by proxy: pediatric condition falsification

We present a comprehensive overview of the condition factitious disorder by proxy, also known as Munchausen syndrome by proxy. The review begins by highlighting essential definitions and the etiology and epidemiology of the disorder. It then analyzes relevant clinical issues such as assessment and diagnostic methods. The final section is a detailed discussion of the complex issues facing the clinician, including the process of confronting the perpetrator, relevant legal issues, and the treatment of the caretaker, child, and family through a multidisciplinary, team approach.

Motivational interviewing and pediatric health behavior interventions

Motivational interviewing (MI) is an empirically supported intervention with a large evidentiary base in the adult behavioral medicine and addictions literature. In the last decade, a growing body of research has shown promise for the use of MI in health behavior change settings with pediatric populations. This article provides a description of MI and its differences from other pediatric counseling and medical management approaches. A review of outcome studies of health behavior change interventions using MI with pediatric populations (age 18 and younger) and parents is provided, and implications for clinical development, research, and training are discussed.

Overweight children and adolescents referred for weight management: are they meeting lifestyle behaviour recommendations?

Adopting and maintaining healthy lifestyle behaviours can help overweight boys and girls manage their weight and reduce obesity-related health risks. However, we currently know very little about the lifestyle habits of overweight children and adolescents referred for weight management in Canada and whether or not they are meeting current lifestyle recommendations. The objectives of this study were (i) to determine the demographic characteristics and lifestyle behaviours of overweight children and adolescents referred for clinical weight management, and (ii) to examine sex (boys vs. girls) and (or) age (child vs. youth) differences with respect to the achievement of lifestyle behaviour recommendations. Overweight (age- and sex-specific body mass index ≥ 85th percentile) children (n = 27 girls, n = 24 boys) and adolescents (n = 29 girls, n = 19 boys) were referred to and enrolled in weight-management programs at the Pediatric Centre for Weight and Health (PCWH) at the Stollery Children’s Hospital (Edmonton, Alta.) from January 2006–September 2007. Information was collected at intake regarding demography, anthropometry, and lifestyle behaviours before participants started a formal weight-management program. Lifestyle behaviour recommendations for nutrition, physical activity, screen time, and sleep were used to determine whether participants were meeting established guidelines. Overall, participants presented with poor lifestyle behaviours. Although most consumed adequate servings of grain products (93.9%) and meat and alternatives (68.7%), few met the serving recommendations for milk and alternatives (31.3%) or vegetables and fruit (14.1%). Physical activity levels were low – 7.4% and 4.1% achieved the recommended time and steps per day goals, respectively. Approximately 1/4 (22.7%) met the screen time recommendation, whereas fewer than 1/2 (47.4%) achieved the nightly sleep duration goal. Sex and age-group comparisons revealed subtle, but potentially important, differences in lifestyle behaviours that have implications for pediatric weight management. This study highlights the sub-optimal lifestyle behaviours of overweight children and adolescents referred for weight management. Intervention studies are needed to determine whether overweight boys and girls who achieve the lifestyle behaviour targets included in this study are able to successfully manage their weight and (or) reduce obesity-related health risks.