Barriers, goals, and enablers of transition of care in pediatric dermatology

Adolescent patients with complex skin disorders may require ongoing care for their conditions as they "age out" of the pediatric setting into adult care. Yet despite consensus from the Canadian Paediatric Society and American Academy of Pediatrics on the importance of dedicated transition programs for these patients, there is a scarcity of such programs worldwide, and no formal programs in Canada. This paper explores several barriers, goals, and potential enablers of transition programs in this discipline and proposes principles of transition versus transfer in the context of pediatric dermatology.

Case report: Drug reaction with eosinophilia and systemic symptoms (DRESS)-induced hemophagocytic disorder

Hemophagocytic disorders are severe and life-threatening conditions that can be genetic in origin [i.e., primary hemophagocytic lymphohistiocytosis (HLH)] or result from infections (i.e., secondary hemophagocytic lymphohistiocytosis), rheumatologic disease [i.e., macrophage activation syndrome (MAS)], and less frequently immunodeficiency or metabolic disease. Although rare, drug-induced hemophagocytosis needs to be considered in the work-up as it requires specific management strategies. Most drug-induced hemophagocytic disorders are related to Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). We present the case of a 7-year-old girl who initially presented with fever, maculopapular rash, and unilateral lymphadenopathy, who went on to develop hemophagocytosis secondary to DRESS caused by prolonged combination treatment with amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole. This case illustrates the importance of considering adverse drug reactions in the evaluations of patients with a hemophagocytic process.

Temporal trends in severe obesity prevalence in children and youth from primary care electronic medical records in Ontario: a repeated cross-sectional study

BACKGROUND

There are no current estimates of severe obesity in Canadian children. The objectives of this study were to determine the prevalence of severe obesity in children aged 18 years or less in Ontario and to determine temporal trends from 2004 to 2015.

METHODS

This was a repeated cross-sectional study using height/length and weight of children aged 18 years or less from the Electronic Medical Record Administrative data Linked Database (EMRALD), a database of primary care electronic medical records in Ontario. We calculated body mass index (for age and sex) z-scores (zBMI). Two years of data (2014 and 2015) were used to determine the period prevalence of severe obesity. We used multivariable linear regression generalized estimating equations to estimate the association of calendar year and mean zBMI.

RESULTS

In total, 55 233 children were included. The prevalence of severe obesity (zBMI > 3) increased with increasing age: it was 0.9% (95% confidence interval [CI] 0.7% to 1.0%) among children less than 5 years of age, 2.7% (95% CI 2.3% to 3.1%) among 5- to 9-year-olds, 2.9% (95% CI 2.4% to 3.3%) among 10- to 14-year-olds and 3.7% (95% CI 3.1% to 4.3%) among those aged 15-18. Boys aged 5-9 years had a significantly higher prevalence of severe obesity than their female counterparts (3.5% [95% CI 2.9% to 4.2%] v. 1.7% [95% CI 1.3% to 2.2%]). From 2004 to 2015, the mean zBMI decreased by 0.015 (95% CI -0.018 to -0.012) units per year, with the overall prevalence of severe obesity in all ages highest in 2005 (3%) and a decrease to 2% in 2015.

INTERPRETATION

The prevalence of severe obesity among children and adolescents in Ontario is consistent with that in other developed countries with the exception of the United States. There is evidence of plateauing of estimates and a small decrease in zBMI over time. Further understanding of the impact of prevention efforts on these estimates is an important next step.

Association Between Maternal Pre-Pregnancy Body Mass Index, Gestational Weight Gain, and Offspring Atopic Dermatitis: A Prospective Cohort Study

BACKGROUND

Maternal weight status may contribute to the development of atopic disorders in children.

OBJECTIVE

The objective of this study was to assess associations of maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) with risk of atopic dermatitis (AD) in children.

METHODS

Maternal pre-pregnancy BMI and GWG were assessed by questionnaire through the Growing Up Today Study (GUTS), a prospective cohort study of US children. Mothers reported whether GUTS participants had ever been diagnosed with AD by a clinician in either 1997 or 1999, when GUTS participants were between 10 and 17 years old. We used multivariable logistic regression to estimate the association of BMI and GWG with AD in offspring (expressed as odds ratios [ORs] with 95% CIs).

RESULTS

Among 13,269 GUTS participants, 2,058 (16%) had childhood AD. Higher maternal pre-pregnancy BMI was not associated with AD (P trend = .48). In contrast, GWG was associated with increased AD risk (P trend = .005). Compared with children of mothers who gained 25 to 34 lb, children of mothers who gained 35 to 44 lb (OR, 1.11; 95% CI, 0.98-1.26) and 45 lb or more (OR, 1.23; 95% CI, 1.05-1.43) had an increased risk of AD. These associations appeared stronger with pre-pregnancy BMI greater than 25 (GWG, 35-44 lb: OR, 1.20; 95% CI, 0.84-1.69; GWG, ≥45 lb: OR, 1.57; 95% CI, 1.07-2.31), but the statstical interaction between BMI and GWG was not significant.

CONCLUSIONS

In this study, increased GWG was associated with increased risk of AD in offspring. This supports existing evidence that prenatal exposures contribute to the development of atopic disorders.

Mental health of extremely low birth weight survivors: A systematic review and meta-analysis

Although individuals born at extremely low birth weight (ELBW; < 1,000 g) are the most vulnerable of all preterm survivors, their risk for mental health problems across the life span has not been systematically reviewed. The primary objective of this systematic review and meta-analysis was to ascertain whether the risk for mental health problems is greater for ELBW survivors than their normal birth weight (NBW) peers in childhood, adolescence, and adulthood. Forty-one studies assessing 2,712 ELBW children, adolescents, and adults and 11,127 NBW controls were reviewed. Group differences in mental health outcomes were assessed using random effects meta-analyses. The impacts of birthplace, birth era, and neurosensory impairment on mental health outcomes were assessed in subgroup analyses. Children born at ELBW were reported by parents and teachers to be at significantly greater risk than NBW controls for inattention and hyperactivity, internalizing, and externalizing symptoms. ELBW children were also at greater risk for conduct and oppositional disorders, autistic symptoms, and social difficulties. Risks for parent-reported inattention and hyperactivity, internalizing, and social problems were greater in adolescents born at ELBW. In contrast, ELBW teens self-reported lower inattention, hyperactivity, and oppositional behavior levels than their NBW peers. Depression, anxiety, and social difficulties were elevated in ELBW survivors in adulthood. Group differences were robust to region of birth, era of birth, and the presence of neurosensory impairments. The complex needs faced by children born at ELBW continue throughout development, with long-term consequences for psychological and social well-being. (PsycINFO Database Record