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General paediatrics General paediatrics Presentation Transcript

  • WHAT YOU SHOULD HAVE READ BUT….2010
    • General Paediatrics
    University of Verona, Italy Attilio Boner
    • antibiotici
  • Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219
    • Prescribing for children is more complicated than for adults, with doses calculated according to weight, surface area or postnatal age;
    • The General Medical Council emphasises the importance of being able “to work out drug dosages, and write safe prescriptions for different types of drugs,” and that graduates should “have the ability to calculate drug dosages”.
  • Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219
    • Junior doctors’ prescribing competency should not be assumed;
    • Only three out of 319 centres in the UK declared that they routinely provide assessment of paediatric prescribing competency;
    • Only 31% of junior doctors answered correctly, in an assessment of paediatric prescribing competency.
  • Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219 undergraduate training both at a national level following GMC guidance General Medical Council. Tomorrow’s doctors. London: General Medical Council, 2003. http://www.gmc-uk.org/education/undergraduate/GMC_tomorrows_doctors.pdf
  • Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219
    • 30 junior doctors were assessed in 2007
    • 32 in 2001–2004
    Example of four prescribing questions involving commonly used medicines
  • Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219
    • 30 junior doctors were assessed in 2007
    • 32 in 2001–2004
    100 - 90 - 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % junior doctors answering correctly the 4 questions 2001-2004 2007 31% 73.3%
  • Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219
    • 30 junior doctors were assessed in 2007
    • 32 in 2001–2004
    100 - 90 - 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % junior doctors answering correctly the 4 questions 2001-2004 2007 31% 73.3% Ongoing monitoring of junior doctors’ prescribing ability has demonstrated improvements which may be due to local and national training initiatives
    • Sulfonamides were associated with:
    • Case-control study of women who had pregnancies affected by major birth defects (n=13155) and control women randomly selected from the same geographical regions (n=4941)
    • Reported maternal use of antibacterials ( 1 month before pregnancy through the end of the first trimester )
    ANTIBACTERIAL MEDICATION USE DURING PREGNANCY AND RISK OF BIRTH DEFECTS Crider Arch Ped Adoles Med 2009;163:978
    • Anencephaly (OR=3.4)
    • Coarctation of the aorta (OR=2.7)
    • Choanal atresia (OR=8.0)
    • Diaphragmatic hernia (OR=2.4)
    • Nitrofurantois were associated with:
    • Hypoplastic left heart syndrome (OR=4.2)
    • Cleft lip with cleft palate (OR=2.1)
    • Case-control study of women who had pregnancies affected by major birth defects (n=13155) and control women randomly selected from the same geographical regions (n=4941)
    • Reported maternal use of antibacterials ( 1 month before pregnancy through the end of the first trimester )
    • Sulfonamides were associated with:
    ANTIBACTERIAL MEDICATION USE DURING PREGNANCY AND RISK OF BIRTH DEFECTS Crider Arch Ped Adoles Med 2009;163:978
    • Anencephaly (OR=3.4)
    • Coarctation of the aorta (OR=2.7)
    • Choanal atresia (OR=8.0)
    • Diaphragmatic hernia (OR=2.4)
    • Nitrofurantois were associated with:
    • Hypoplastic left heart syndrome (OR=4.2)
    • Cleft lip with cleft palate (OR=2.1)
    Reassuringly, penicillins, erythromycins , and cephalosporins , although used commonly by pregnant women, were not associated with many birth defects
  • % children receiving antibiotics 19.5% Intervention 40.8% Control Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial Francis BMJ 2009;339:b2885
    • 61 general practices in Wales and England.
    • 558 children, ages 6 months to 14 years, who presented to primary care with an acute respiratory tract infection with ≤7 days of symptoms.
    • Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections. ( www.equipstudy.com )
    p<0.001 50 – 40 – 30 – 20 – 10 – 0
  • % of parents who said they would seek care in the future if their child developed a similar illness 55.3% Intervention 76.4% Control Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial Francis BMJ 2009;339:b2885 80 – 60 – 40 – 20 – 0
    • 61 general practices in Wales and England.
    • 558 children, ages 6 months to 14 years, who presented to primary care with an acute respiratory tract infection with ≤7 days of symptoms.
    • Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections. ( www.equipstudy.com )
    OR =0.34
    • Avvelenamenti
    • Incidenti domestici
    • Venous samples at age 30 months
    • Avon Longitudinal Study of Parents and Children (ALSPAC) (488 cases)
    • Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) at age 7–8 years
    EFFECTS OF EARLY CHILDHOOD LEAD EXPOSURE ON ACADEMIC PERFORMANCE AND BEHAVIOUR OF SCHOOL AGE CHILDREN Chandramouli Arch Dis Child 2009;94:844
    • Venous samples at age 30 months
    • Avon Longitudinal Study of Parents and Children (ALSPAC) (488 cases)
    • Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) at age 7–8 years
    EFFECTS OF EARLY CHILDHOOD LEAD EXPOSURE ON ACADEMIC PERFORMANCE AND BEHAVIOUR OF SCHOOL AGE CHILDREN Chandramouli Arch Dis Child 2009;94:844
    • Lead-based paint
    • Household dust
    • Lead water pipes
    • Soil around the home
    • Herbal and traditional remedies
    • Old-fashioned/ethnic make-up
    • Lead glazed pottery/crystal
    • Paint on children’s toys
    • Children’s bead necklaces
    • Christmas lights
    • Lead smelters/industries
    Sources of lead
    • Venous samples at age 30 months
    • Avon Longitudinal Study of Parents and Children (ALSPAC) (488 cases)
    • Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) at age 7–8 years
    EFFECTS OF EARLY CHILDHOOD LEAD EXPOSURE ON ACADEMIC PERFORMANCE AND BEHAVIOUR OF SCHOOL AGE CHILDREN Chandramouli Arch Dis Child 2009;94:844 Effect of blood lead concentration on writing. KS1, Key Stage 1
    • Venous samples at age 30 months
    • Avon Longitudinal Study of Parents and Children (ALSPAC) (488 cases)
    • Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) at age 7–8 years
    EFFECTS OF EARLY CHILDHOOD LEAD EXPOSURE ON ACADEMIC PERFORMANCE AND BEHAVIOUR OF SCHOOL AGE CHILDREN Chandramouli Arch Dis Child 2009;94:844 Effect of blood lead concentration on writing. KS1, Key Stage 1 Exposure to lead early in childhood has effects on subsequent educational attainment, even at blood levels below 10 µg/dl. These data suggest that the threshold for clinical concern should be reduced to 5 µg/dl
    • 72 motor vehicle passengers aged 0–16 years ( 58 <12 years of age, 14 ≥ 12 years of age)
    SPINAL INJURY IN MOTOR VEHICLE CRASHES: ELEVATED RISK PERSISTS UP TO 12 YEARS OF AGE Brown Arch Dis Child 2009;94:546 OR for serious spinal injury 7.1 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 IN CHILDREN AGED <12 YEARS
    • 72 motor vehicle passengers aged 0–16 years ( 58 <12 years of age, 14 ≥ 12 years of age)
    SPINAL INJURY IN MOTOR VEHICLE CRASHES: ELEVATED RISK PERSISTS UP TO 12 YEARS OF AGE Brown Arch Dis Child 2009;94:546 OR for serious spinal injury 7.1 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0
    • Children up to age 12 have an elevated risk of serious spinal injury in car crashes.
    • Use of adult seatbelts alone before age 12 may increase a child’s risk of serious spinal injury
    IN CHILDREN AGED <12 YEARS
  • Abuso IL BAMBINO BATTUTO
  • Nonaccidental Head Injury Is the Most Common Cause of Subdural Bleeding in Infants <1 Year of Age Matschke Pediatrics 2009;124:1587
    • 715 autopsies of infants <1 year of age.
    % OF CASES WITH SUBDURAL BLEEDING 7% 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0
  • Nonaccidental Head Injury Is the Most Common Cause of Subdural Bleeding in Infants <1 Year of Age Matschke Pediatrics 2009;124:1587 % OF CASES WITH SUBDURAL BLEEDING 82.4% 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 5.2% 8.0% NON-ACCIDENTAL HEAD INJURY OTHER CAUSES OF DEATH UNEXPLAINED CT scan
  • Screening for Occult Abdominal Trauma in Children With Suspected Physical Abuse Lane Pediatrics 2009;124:1595 % CHILDREN WHO WERE SCREENED FOR OCCULT ABDOMINAL TRAUMA 20% 30 – 20 – 10 – 0
    • Occult abdominal trauma (OAT)
    • Liver and pancreatic enzyme measurements
    • 244 children evaluated for abusive injury
  • Screening for Occult Abdominal Trauma in Children With Suspected Physical Abuse Lane Pediatrics 2009;124:1595 % CHILDREN WHO WERE SCREENED FOR OCCULT ABDOMINAL TRAUMA 30 – 20 – 10 – 0 20% Positive results were identified for 41% of those screened
    • Occult abdominal trauma (OAT)
    • Liver and pancreatic enzyme measurements
    • 244 children evaluated for abusive injury
  • 30 – 20 – 10 – 0 OR FOR OCCULT ABDOMINAL TRAUMA SREENING 20.4 8.5 CONSULTATION WITH THE CHILD PROTECTION TEAM
    • Our findings support OAT screening with liver and pancreatic enzyme measurements for physically abused children.
    • This study also supports the importance of subspecialty input, especially that of a child protection team.
    CHILDREN PRESENTING WITH PROBABLE ABUSIVE HEAD TRAUMA Screening for Occult Abdominal Trauma in Children With Suspected Physical Abuse Lane Pediatrics 2009;124:1595
  • Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce Pediatrics 2010;125:67
    • Children 0 to 48 months of age because of trauma
    • Victims of physical abuse (N =42)
    • Control subjects (N=53) accidental trauma
    Characteristics predictive of abuse were bruising on the torso , ear , or neck for a child ≤4 years of age and bruising in any region for an infant <4 months of age.
  • Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce Pediatrics 2010;125:67 Comparison of cumulative numbers of bruises for patients with abusive versus accidental trauma. Several bruises are present in case of abuse
  • Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce Pediatrics 2010;125:67 Bruise distribution for patients with abusive and accidental trauma. * Indicates regions significantly predictive of abusive trauma * * * * * *
  • WHICH CLINICAL FEATURES DISTINGUISH INFLICTED FROM NONINFLICTED BRAIN INJURY? A SYSTEMATIC REVIEW Maguire Arch Dis Child 2009;94:860
    • 14 studies representing 1655 children
    APNOEA 17.0 p<0.001 RETINAL HEAMORRHAGE RIB FRACTURES 20 – 15 – 10 – 5 – 0 In a child with intracranial injury OR for inflicted brain injury 3.5 p=0.03 3.03
  • WHICH CLINICAL FEATURES DISTINGUISH INFLICTED FROM NONINFLICTED BRAIN INJURY? A SYSTEMATIC REVIEW Maguire Arch Dis Child 2009;94:860
    • 14 studies representing 1655 children
    APNOEA 17.0 p<0.001 RETINAL HEAMORRHAGE RIB FRACTURES 20 – 15 – 10 – 5 – 0 In a child with intracranial injury OR for inflicted brain injury 3.5 p=0.03 3.03 Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more associated with niBI
    • 1046 adolescents aged 13 to 21 years
    • Self-report questionnaire
    • On average, adolescents were exposed to 4.71 traumatic events
    % subjects with symptom criteria for post traumatic stress disorder 60 – 50 – 40 – 30 – 20 – 10 – 0 52.2% SCREENING FOR TRAUMATIC EXPOSURE AND POSTTRAUMATIC STRESS SYMPTOMS IN ADOLESCENTS IN THE WAR AFFECTED EASTERN DEMOCRATIC REPUBLIC OF CONGO Mels Arch Ped Adoles Med 2009;163:525
  • SCREENING FOR TRAUMATIC EXPOSURE AND POSTTRAUMATIC STRESS SYMPTOMS IN ADOLESCENTS IN THE WAR AFFECTED EASTERN DEMOCRATIC REPUBLIC OF CONGO Mels Arch Ped Adoles Med 2009;163:525
    • During the conflict, civilians were targeted for massacre , mutilation , rape , cannibalism , torture , house-to-house raids , or the looting and burning of their houses and sometimes entire villages
    • Moreover, all associated armed groups recruited children for military service , amounting to an estimated 30000 child soldiers participating in conflicts
  • SCREENING FOR TRAUMATIC EXPOSURE AND POSTTRAUMATIC STRESS SYMPTOMS IN ADOLESCENTS IN THE WAR AFFECTED EASTERN DEMOCRATIC REPUBLIC OF CONGO Mels Arch Ped Adoles Med 2009;163:525
    • During the conflict, civilians were targeted for massacre, mutilation, rape, cannibalism, torture, house-to-house raids, or the looting and burning of their houses and sometimes entire villages
    • Moreover, all associated armed groups recruited children for military service , amounting to an estimated 30 000 child soldiers participating in conflicts
    stupro saccheggio
  • FEVER CONTROL
    • 231 children who experienced their first febrile seizure
    • 2 years follow-up
    • All febrile episodes during follow-up were treated first with either rectal diclofenac or placebo . After 8 hours, treatment was continued with oral ibuprofen, acetaminophen, or placebo
    % children experiencing recurrent febrile seizure 30 – 25 – 20 – 15 – 10 – 5 – 0 23.4% ANTIPYRETIC AGENTS FOR PREVENTING RECURRENCES OF FEBRILE SEIZURES Strengell Arch Ped Adoles Med 2009;163:799 23.5% ANTIPIRETICS PLACEBO
  • ANTIPYRETIC AGENTS FOR PREVENTING RECURRENCES OF FEBRILE SEIZURES Strengell Arch Ped Adoles Med 2009;163:799
    • 231 children who experienced their first febrile seizure
    • 2 years follow-up
    • All febrile episodes during follow-up were treated first with either rectal diclofenac or placebo . After 8 hours, treatment was continued with oral ibuprofen, acetaminophen, or placebo
    % children experiencing recurrent febrile seizure 30 – 25 – 20 – 15 – 10 – 5 – 0 23.4% 23.5% ANTIPIRETICS PLACEBO Fever was significantly higher during the episodes with seizure than in those without seizure (39.7°C vs 38.9°C; difference, p<0.001 ) and this phenomenon was independent of the medication given
  • PAIN CONTROL
    • 261 children, 2-12 years,
    • tonsillectomy and adenoidectomy
    Pediatric Pain After Ambulatory Surgery: Where's the Medication? Fortier Pediatrics 2009;124;e588 % CHILDREN 86% EXPERIENCING SIGNIFICANT PAIN 24% RECEIVED 0 OR JUST 1 MEDICATION DOSE ON THE 1 st DAY AT HOME 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
  • Pediatric Pain After Ambulatory Surgery: Where's the Medication? Fortier Pediatrics 2009;124;e588 % CHILDREN 67% EXPERIENCING SIGNIFICANT PAIN 41% RECEIVED 0 OR JUST 1 MEDICATION DOSE ON THE 3 rd DAY AT HOME 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • 261 children, 2-12 years,
    • tonsillectomy and adenoidectomy
  • Pediatric Pain After Ambulatory Surgery: Where's the Medication? Fortier Pediatrics 2009;124;e588 % CHILDREN 67% EXPERIENCING SIGNIFICANT PAIN 41% RECEIVED 0 OR JUST 1 MEDICATION DOSE 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • 261 children, 2-12 years,
    • tonsillectomy and adenoidectomy
    A large proportion of children receive little analgesic medication after surgery ON THE 3 rd DAY AT HOME
    • Minerali
    • ferro
  • In Utero Iron Status and Auditory Neural Maturation in Premature Infants as Evaluated by Auditory Brainstem Response Amin J Pediatr 2010;156:377 Bilateral monaural a uditory b rainstem evoked r esponse ( ABR ) was assessed using 80-dB nHL click stimuli at a repetition rate of 29.9/seconds within 48 hours after birth.
    • Cord ferritin (CF).
    • Auditory neural maturation.
    • Infants with latent iron deficiency (CF 11-75 ng/mL) and infants with normal iron status (CF > 75 ng/mL).
    • 27-33 weeks gestational age.
  • In Utero Iron Status and Auditory Neural Maturation in Premature Infants as Evaluated by Auditory Brainstem Response Amin J Pediatr 2010;156:377
    • Cord ferritin (CF).
    • Auditory neural maturation.
    • Infants with latent iron deficiency (CF 11-75 ng/mL) and infants with normal iron status (CF > 75 ng/mL).
    • 27-33 weeks gestational age.
    infants with latent iron deficiency had significantly prolonged absolute wave latencies and decreased frequency of mature ABR waveforms compared with the infants with normal iron status.
    • Minerali
    • zinco
    • Vitamine
    • Vitamina D
  • Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981
    • Serum 25 hydroxyvitamin D [25(OH)D] levels.
    • Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI)
    • Subjects without respiratory symptoms (n = 92).
  • Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981
    • Serum 25 hydroxyvitamin D [25(OH)D] levels.
    • Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI)
    • Subjects without respiratory symptoms (n = 92).
    The mean vitamin D level for the entire ALRI group was not significantly different from the control group (81 ± 40 vs. 83 ± 30 nmol/L, respectively).
  • Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981
    • Serum 25 hydroxyvitamin D [25(OH)D] levels.
    • Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI)
    • Subjects without respiratory symptoms (n = 92).
    87 49 P=0.001
  • Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981
    • Serum 25 hydroxyvitamin D [25(OH)D] levels.
    • Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI)
    • Subjects without respiratory symptoms (n = 92).
    The mean vitamin D level for the ALRI subjects admitted to the pediatric intensive care unit (49 ± 24 nmol/L) was significantly lower (p=0.001) than that observed for both control (83 ± 30 nmol/L) and ALRI subjects admitted to the general pediatrics ward (87 ± 39 nmol/L). P=0.001 87 49
  • Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981
    • Serum 25 hydroxyvitamin D [25(OH)D] levels.
    • Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI)
    • Subjects without respiratory symptoms (n = 92).
    P=0.001 Vitamin D deficiency (<50 nmol/L) remained associated with ALRI requiring admission to pediatric intensive care unit after the inclusion of prematurity into a multivariate logistic regression model. 87 49
    • Vitamin D influences antimicrobial activity, inflammation, and coagulation partly by regulating calcium and phosphorous homeostasis and by acting on lymphocytes , neutrophils , macrophages , and respiratory epithelial cells through vitamin D receptors .
    • In addition, the activity of Toll-like receptor (TLR)-4 , responsible for initiating the immune response through pathogen associated
    • molecular patterns, are modulated by vitamin D.
    • Vitamin D also stimulates the innate immune system through vitamin D receptor-dependent expression of antimicrobial peptides ( cathelicidin and defensins ) and regulation of TLR signaling. Human antimicrobial peptides synthesized and expressed by macrophages,
    • neutrophils, and respiratory epithelium have activity against bacteria and some respiratory viruses, including influenza and respiratory syncytial virus
    Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981
  • Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey. Ginde AA Arch Intern Med. 2009;169:384-90. 30 – 20 – 10 – 0 24% % patients with recent URTI 25(OH)D level ng/mL < 10 10-<30 20% ≥ 30 17% P<0.001 for trend OR=1.36 OR=1.24 OR=1.0
    • Vitamin D levels in 18883 participants ≥12 years in the Third National Health and Nutrition Examination Survey in the USA;
    • Symptoms suggestive of an URTI in the preceding few days .
  • Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey. Ginde AA Arch Intern Med. 2009;169:384-90. 30 – 20 – 10 – 0 24% % patients with recent URTI 25(OH)D level ng/mL < 10 10-<30 20% ≥ 30 17% P<0.001 for trend OR=1.36 OR=1.24 OR=1.0
    • Vitamin D levels in 18883 participants ≥12 years in the Third National Health and Nutrition Examination Survey in the USA;
    • Symptoms suggestive of an URTI in the preceding few days.
    The association between 25(OH)D level and URTI seemed to be stronger in individuals with asthma (OR, 5.67) and chronic obstructive pulmonary disease (OR, 2.26).
  • Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey. Ginde AA Arch Intern Med. 2009;169:384-90. 30 – 20 – 10 – 0 24% % patients with recent URTI 25(OH)D level ng/mL < 10 10-<30 20% ≥ 30 17% P<0.001 for trend OR=1.36 OR=1.24 OR=1.0
    • Vitamin D levels in 18883 participants ≥12 years in the Third National Health and Nutrition Examination Survey in the USA;
    • Symptoms suggestive of an URTI in the preceding few days.
    patients with asthma had an odds ratio of 5.67 of recent URTI with vitamin D levels ,<10 ng/ml compared with those with vitamin D levels >30 ng/ml, and for COPD the odds ratio was 2.26.
  • Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospective cohort study Banajeh, Ped Pul 2009;44:1207 19.9 35.2
    • Prospective cohort study.
    • 152 children aged 2-59 months with very severe pneumonia (VSP).
    50 – 40 – 30 – 20 – 10 – 0 37.2% 47.3% p=0.019 % circulating neutrophils ≤ 30nmol/L >30nmol/L Vitamin D levels
  • 19.9 35.2
    • Prospective cohort study.
    • 152 children aged 2-59 months with very severe pneumonia (VSP).
    85.9% 89.8% Day–5 Oxigen saturation ≤ 30nmol/L >30nmol/L 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 p=0.03 Vitamin D levels Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospective cohort study Banajeh, Ped Pul 2009;44:1207
  • Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospective cohort study Banajeh, Ped Pul 2009;44:1207 19.9 35.2
    • Prospective cohort study.
    • 152 children aged 2-59 months with very severe pneumonia (VSP).
    25 – 20 – 15 – 10 – 5 – 0 20.6% 6% p=0.031 % treatment failure Vitamin D levels ≤30nmol/L rachitic non-rachitic
  • 19.9 35.2
    • Prospective cohort study.
    • 152 children aged 2-59 months with very severe pneumonia (VSP).
    85.9% 89.8% ≤ 30nmol/L >30nmol/L 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 p=0.03 Vitamin D levels Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospective cohort study Banajeh, Ped Pul 2009;44:1207 Vitamin D deficiency is significantly associated with treatment outcome and significantly predicts both reduced circulating PMNs, and Day-5 hypoxemia (SpO 2 % <88%). Day–5 Oxigen saturation
  • Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population Reis Pediatrics 2009; 124:e371
    • 3577 adolescents.
    MEAN 25(OH) Vitamin D ng/ml BLACK MEXICAN AMERICAN WHITE 30 – 20 – 10 – 0 15.5 21.5 28 p<0.001 p<0.001
  • Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population Reis Pediatrics 2009; 124:e371
    • 3577 adolescents.
    BLACK MEXICAN AMERICAN WHITE 30 – 20 – 10 – 0 15.5 21.5 28 p<0.001 p<0.001 Low 25(OH)D levels were strongly associated with overweight status and abdominal obesity ( P for trend.<001) with high systolic blood pressure ( P =.02) and plasma glucose concentrations ( P =.01). MEAN 25(OH) Vitamin D ng/ml
  • In the Lowest Quartile (<15 ng/ml) vs the Highest Quartile (>26 ng/ml) OR for 2.36 LOW HIGH-DENSITY LIPOPROTEIN CHOLESTEROL HYPERTENSION HYPERGLICEMIA 4 – 3 – 2 – 1 – 0 1.54 3.88 2.54 METABOLIC SY Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population Reis Pediatrics 2009; 124:e371
    • Retrospective record review of pediatric outpatients (age, 2-18 years)
    • simultaneous measurement of 25-hydroxyvitamin D and fasting plasma glucose (n = 302) or a lipid panel (n = 177).
    Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients Johnson J Pediatr 2010;156:444 Correlation between 25(OH) D level and fasting plasma glucose
  • Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients Johnson J Pediatr 2010;156:444 Correlation between 25(OH) D level and HDL level
    • Retrospective record review of pediatric outpatients (age, 2-18 years)
    • simultaneous measurement of 25-hydroxyvitamin D and fasting plasma glucose (n = 302) or a lipid panel (n = 177).
  • Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients Johnson J Pediatr 2010;156:444 Comparison of fasting glucose, total cholesterol, HDL, triglyceride, and non-HDL levels in subjects with 25(OH)D levels greater or less than 30 ng/mL (*p=0.002; **p<0.001)
    • Retrospective record review of pediatric outpatients (age, 2-18 years)
    • simultaneous measurement of 25-hydroxyvitamin D and fasting plasma glucose (n = 302) or a lipid panel (n = 177).
  • Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients Johnson J Pediatr 2010;156:444 Comparison of fasting glucose, total cholesterol, HDL, triglyceride, and non-HDL levels in subjects with 25(OH)D levels greater or less than 30 ng/mL (*p=0.002; **p<0.001)
    • Retrospective record review of pediatric outpatients (age, 2-18 years)
    • simultaneous measurement of 25-hydroxyvitamin D and fasting plasma glucose (n = 302) or a lipid panel (n = 177).
    Low 25(OH) D levels in children and adolescents are associated with higher plasma glucose and lower HDL concentrations.
    • Children aged 1 to 21
    • years ( n = 6275)
    • Serum 25(OH)D deficiency (<15 ng/mL) and insufficiency (15–29 ng/mL),
    Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004 Kumar Pediatrics 2009;124;e362 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % CHILDREN 9% Deficent (<15 mg/ml) 61% Insufficient (15-29 mg/ml) VITAMIN D
    • Children aged 1 to 21
    • years ( n = 6275)
    • Serum 25(OH)D deficiency (<15 ng/mL) and insufficiency (15–29 ng/mL),
    Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004 Kumar Pediatrics 2009;124;e362 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % CHILDREN 9% Deficent (<15 mg/ml) 61% Insufficient (15-29 mg/ml) VITAMIN D Only 4% had taken 400 IU of vitamin D per day for the past 30 days.
  • OR FOR VIT D DEFICIENCY (<15 ng/mL) 1.16 DRANK MILK LESS THAN ONCE A WEEK OLDER GIRLS 5 – 4 – 3 – 2 – 1 – 0 1.6 4.9 1.9 OBESE 21.9 1.9 BLACK >4 HOURS OF TELEVISION VIDEO OR COMPUTER/DAY 0.4 VITAMIN D SUPPLEMEN-TATION Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004 Kumar Pediatrics 2009;124;e362
    • 25(OH)D deficiency (<15 ng/ml) compared with those
    • with 25(OH)D levels ≥30 ng/mL.was associated with:
    • elevated parathyroid hormone levels (OR: 3.6),
    • higher systolic blood pressure (OR:2.24)
    • lower serum level of high-density lipoprotein cholesterol (OR: 3.03)
    Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004 Kumar Pediatrics 2009;124;e362
  • Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor Pediatrics 2010;125:105
    • Network pediatricians completed a survey
    • Parents of children 6 to 24 months old
    % pediatricians recommending vitamin D supplementation for all breastfed infants 36.4% 40 – 30 – 20 – 10 – 0
  • Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor Pediatrics 2010;125:105
    • Network pediatricians completed a survey
    • Parents of children 6 to 24 months old
    % breast fed infants for ≥6 mo supplemented with vit D 15.9% 20 – 15 - 10 – 5 - 0
  • Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor Pediatrics 2010;125:105
    • Network pediatricians completed a survey
    • Parents of children 6 to 24 months old
    % breast fed infants for ≥6 mo supplemented with vit D 15.9% 20 – 15 - 10 – 5 - 0 OD for supplementation=7.8 if pediatricians gave advice
  • Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor Pediatrics 2010;125:105
    • Network pediatricians completed a survey
    • Parents of children 6 to 24 months old
    % advised parents who gave the supplementation to their child 44.6% 50 - 40 – 30 – 20 – 10 – 0
  • Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? Mansbach Pediatrics 2009;124:1404
    • 4558 US children aged 1 to 11 years.
    • Serum 25(OH)D levels by radioimmunoassay.
    • categorized as <25, <50, and <75 nmol/L. (≈ 10, 20, 30 ng/mL)
    1% 18% 69% % CHILDREN WITH <25 <50 <75 Vitamin D serum levels nmol/L 70 – 60 - 50 - 40 - 30 – 20 – 10 – 0
  • Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? Mansbach Pediatrics 2009;124:1404
    • 4558 US children aged 1 to 11 years.
    • Serum 25(OH)D levels by radioimmunoassay.
    • categorized as <25, <50, and <75 nmol/L.
    1% 18% 69% % CHILDREN WITH <25 <50 <75 Vitamin D serum levels nmol/L 70 – 60 - 50 - 40 - 30 – 20 – 10 – 0 The prevalence of serum 25(OH)D levels of <75 nmol/L was higher among children aged 6 to 11 years (73%) compared with children aged 1 to 5 years (63%); girls (71%) compared with boys (67%); and black (92%) children.
  • Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? Mansbach Pediatrics 2009;124:1404
    • 4558 US children aged 1 to 11 years.
    • Serum 25(OH)D levels by radioimmunoassay.
    • categorized as <25, <50, and <75 nmol/L.
    1% 18% 69% % CHILDREN WITH <25 <50 <75 Vitamin D serum levels nmol/L 70 – 60 - 50 - 40 - 30 – 20 – 10 – 0 The American Academy of Pediatrics recommendations for vitamin D intakes of 400 IU with a 25(OH)D threshold for vitamin D sufficiency of 50 nmol/L are largely based on studies in non-Hispanic white infants.
  • CARDIOLOGY
    • 107 patients (19 neonates and 88 children) with a diagnosis of A rterial I schemic S troke ( AIS )
    Delayed Recognition of Initial Stroke in Children: Need for Increased Awareness Srinivasan Pediatrics 2009;124;e227 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 MEDIAN TIME TO AIS DIAGNOSIS (HOURS) 87.9 NEONATES p=0.002 24.8 CHILDREN
  • % OF INPATIENTS AT THE TIME OF STROKE 60 - 50 – 40 – 30 – 20 – 10 – 0 58% Delayed Recognition of Initial Stroke in Children: Need for Increased Awareness Srinivasan Pediatrics 2009;124;e227
    • 107 patients (19 neonates and 88 children) with a diagnosis of A rterial I schemic S troke ( AIS )
  • Delayed Recognition of Initial Stroke in Children: Need for Increased Awareness Srinivasan Pediatrics 2009;124;e227
  • Kawasaki Disease at the Extremes of the Age Spectrum Manlhiot Pediatrics 2009; 124:e410
    • Retrospective review
    • 1374 Patients were stratified into 5 groups on the basis of age at diagnosis.
    % children <0.5 4% 8% 19% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% 6% 0.5-1 1-4 5-9 >9 Years at Diagnosis
  • Kawasaki Disease at the Extremes of the Age Spectrum Manlhiot Pediatrics 2009; 124:e410
    • Retrospective review
    • 1374 Patients were stratified into 5 groups on the basis of age at diagnosis.
    % children <0.5 4% 8% 19% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% 6% 0.5-1 1-4 5-9 >9 Years at Diagnosis Patients <1 year of age and those >9 years of age were more likely to have coronary artery abnormalities
  • Kawasaki Disease at the Extremes of the Age Spectrum Manlhiot Pediatrics 2009; 124:e410
    • Retrospective review
    • 1374 Patients were stratified into 5 groups on the basis of age at diagnosis.
    % children <0.5 4% 8% 19% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% 6% 0.5-1 1-4 5-9 >9 Years at Diagnosis Patients at both extremes of the age spectrum were more likely to present with <4 of the classic KD features
  • Kawasaki Disease at the Extremes of the Age Spectrum Manlhiot Pediatrics 2009; 124:e410
    • Retrospective review
    • 1374 Patients were stratified into 5 groups on the basis of age at diagnosis.
    % children <0.5 4% 8% 19% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% 6% 0.5-1 1-4 5-9 >9 Years at Diagnosis Patients >9 years of age were less likely to receive intravenous immunoglobulin treatment
    • 1-year prospective multicenter cohort study
    • Patients <18 years old admitted for prolonged but initially unexplained fever or suspected KD
    • Diagnosis of KD in 39 children
    Increased Detection Rate of Kawasaki Disease Using New Diagnostic Algorithm, Including Early Use of Echocardiography T Heuclin, J Ped 2009;155;695 had incomplete KD met the classic case definition KD uncertain, but successfully treated for it n° children 30 – 20 – 10 – 0 26 7 6
    • 1-year prospective multicenter cohort study
    • Patients <18 years old admitted for prolonged but initially unexplained fever or suspected KD
    • Diagnosis of KD in 39 children
    Increased Detection Rate of Kawasaki Disease Using New Diagnostic Algorithm, Including Early Use of Echocardiography T Heuclin, J Ped 2009;155;695 had incomplete KD met the classic case definition KD uncertain, but successfully treated for it n° children 30 – 20 – 10 – 0 26 7 6 Cardiac ultrasound scanning was helpful in the diagnosis of 6 of 7 patients with incomplete KD
  • Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement of American Heart Association Newburger Pediatrics 2004;114:1708 Classic clinical criteria of Kawasaki Disease Fever persisting at least 5 days Presence of at least 4 principal features: 1) Changes in extremities Acute: Erythema of palms, soles; edema of hands, feet Subacute: Periungual peeling of fingers, toes in weeks 2 and 3 2) Polymorphous exanthem 3) Bilateral bulbar conjunctival injection without exudate 4) Changes in lips and oral cavity: Erythema, lips cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosae 5) Cervical lymphadenopathy (1.5-cm diameter), usually unilateral
  • Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement of American Heart Association Newburger Pediatrics 2004;114:1708 Classic clinical criteria of Kawasaki Disease Fever persisting at least 5 days Presence of at least 4 principal features: 1) Changes in extremities Acute: Erythema of palms, soles; edema of hands, feet Subacute: Periungual peeling of fingers, toes in weeks 2 and 3 2) Polymorphous exanthem 3) Bilateral bulbar conjunctival injection without exudate 4) Changes in lips and oral cavity: Erythema, lips cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosae 5) Cervical lymphadenopathy (1.5-cm diameter), usually unilateral Patients with fever of at least 5 days and < 4 principal criteria can be diagnosed with Kawasaki disease when coronary artery abnormalities are detected by 2-dimensional echocardiography or angiography.
  • Laboratory findings in acute Kawasaki disease * (Thrombocytopenia in sone infants) *
  • Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Newburger JW, Pediatrics. 2004 Dec;114:1708-33.
  • Refractory pneumonia and high fever Falcini, Lancet 2010;373:1818
    • A previously healthy 30-month-old girl was seen with a 7-day history of fever up to 40°C;
    • Tests for common viral and bacterial infections were negative;
    • Intravenous ceftriaxone and oral clarithromycin yelded no effect;
    • Chest radiography showed a massive right-sided pleural effusion;
    • meropenem and fluconazole were initiated
  • Refractory pneumonia and high fever Falcini, Lancet 2010;373:1818
    • A repeat full blood count showed:
    • leucocytosis (21·8×109/L),
    • anaemia (haemoglobin 95 g/L),
    • thrombocytosis (platelets 71·0×109/L),
    • raised aspartate and alanine amino-transferases,
    • VES and PCR very high;
    • Bilateral conjunctival redness appeared on day 10;
    • Echocardiogram showed a pericardial effusion, and dilatation of the right coronary artery (Z score=3·23)
  • Refractory pneumonia and high fever Falcini, Lancet 2010;373:1818 (A) Frontal view showing marked pleural effusion on the right. (B) After therapy with IVIg and methylprednisolone
  • Refractory pneumonia and high fever Falcini, Lancet 2010;373:1818
    • Kawasaki disease is a multisystemic vasculitis complicated
    • by coronary damage in around 25–35% of untreated patients;
    • Delayed diagnosis and treatment are risks for long-term heart damage;
    • Diagnosis is challenging and often delayed when patients do not completely meet the criteria for Kawasaki disease;
    • Some of these cases are diagnosed as incomplete or atypical Kawasaki disease according to specific criteria;
    • In contrast to other vasculitides, lung involvement is seldom reported in Kawasaki disease;
    • In our patient, the appearance of conjunctival redness was crucial in making the correct diagnosis .
  • Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452
    • Slowly resolving or nonresolving pneumonia is a challenge for physicians.
    • The most common clinical error when approaching these patients is to subsequently treat the patient with different antibiotics over an extended period of time, without questioning the cause of treatment failure.
    • Mostly, slowly resolving pneumonias are due to host defence or infectious causes .
    • Nonresolving pneumonias are usually of noninfectious origin and, in the majority of cases, require invasive diagnostic techniques to be confirmed.
  • Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452
    • A 19-yr-old male developed dyspnoea, dry cough and bilateral reticulo-nodular infiltrates on chest radiograph.
    • On admission he was still febrile (38.5°C), had generalised oedema and required 6 L·min –1 oxygen to achieve a saturation of 96%.
    • On physical examination crackles were noted on lung auscultation, along with bi-basal dullness to percussion of the thorax.
  • Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452
    • Additionally, bilateral conjunctival injections, cervical and axillary lymphadenopathy and markedly reddened pharynx were observed.
    • Computed tomography scan revealed massive bilateral pleural effusions with bilaterally disseminated patchy infiltrates and ground-glass alterations , modest pericardial effusion and enlarged axillary and mediastinal lymph-nodes.
  • Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452
    • Additionally, bilateral conjunctival injections, cervical and axillary lymphadenopathy and markedly reddened pharynx were observed.
    • Computed tomography scan revealed massive bilateral pleural effusions with bilaterally disseminated patchy infiltrates and ground-glass alterations , modest pericardial effusion and enlarged axillary and mediastinal lymph-nodes.
    Based on the assumption of progressive, therapy was piperacillin/tazobactam and clarithromycin.
  • Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452
    • Maculo-squamous exanthema was progressive and he developed palmo-plantar desquamations .
    • He remained febrile and serological markers of infections continued to be elevated.
    • All serological and rheumatological analyses, as well as microbiology and virology were negative.
  • Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452
    • Maculo-squamous exanthema was progressive and he developed palmo-plantar desquamations.
    • He remained febrile and serological markers of infections continued to be elevated.
    • All serological and rheumatological analyses, as well as microbiology and virology were negative.
    The next diagnostic step would have been bronchoscopy including bronchoalveolar lavage.
  • Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452
    • As no infectious aetiology could be established and the patient fulfilled the major criteria for the diagnosis of Kawasaki's disease , antibiotic treatment was withdrawn and high-dose intravenous immunoglobulins at a dose of 2.0 g per kg bodyweight and acetylsalicylic acid were administered.
    • The patient remained febrile for >30 h after administration of the first dose of i.v. immunoglobulins; thus, a second dose was given , according to the American Heart Association's statement on the management of Kawasaki's disease.
    • Thereafter, the patient was finally afebrile.
  • 200 – 150 – 100 – 50 – 0
    • 28 patients with KD (7-20 years after acute illness)
    • 27 age-matched healthy control
    • carotid intimal-medial thickness (CIMT)
    • with vascular ultrasound scanning and arterial stiffness with applanation tonometry
    Colesterol (mg/dL) Kawasaki Atherosclerosis in Survivors of Kawasaki Disease M Gupta-Malhotra, J Ped 2009;155;572 control 175 mg 157 mg P=0.034
  • 100 – 75 – 50 – 25 – 0
    • 28 patients with KD (7-20 years after acute illness)
    • 27 age-matched healthy control
    • carotid intimal-medial thickness (CIMT)
    • with vascular ultrasound scanning and arterial stiffness with applanation tonometry
    Apolipoprotein B (mg/mL) Kawasaki Atherosclerosis in Survivors of Kawasaki Disease M Gupta-Malhotra, J Ped 2009;155;572 control 78 mg 65 mg P=0.004
  • 100 – 75 – 50 – 25 – 0
    • 28 patients with KD (7-20 years after acute illness)
    • 27 age-matched healthy control
    • carotid intimal-medial thickness (CIMT)
    • with vascular ultrasound scanning and arterial stiffness with applanation tonometry
    Apolipoprotein B (mg/mL) Kawasaki Atherosclerosis in Survivors of Kawasaki Disease M Gupta-Malhotra, J Ped 2009;155;572 control 78 mg 65 mg P=0.004 Small but significant differences in cholesterol and apolipoprotein B levels could suggest increased future risk for atherosclerosis
    • 28 patients with KD (7-20 years after acute illness)
    • 27 age-matched healthy control
    • carotid intimal-medial thickness (CIMT)
    • with vascular ultrasound scanning and arterial stiffness with applanation tonometry
    Atherosclerosis in Survivors of Kawasaki Disease M Gupta-Malhotra, J Ped 2009;155;572
  • Early Life Origins of Low-Grade Inflammation and Atherosclerosis Risk in Children and Adolescents Idoia Labayen, J Ped 2009;155:673
    • 166 children and 126 adolescents from the Swedish part of the European Youth Heart Study
    • Low-grade inflammatory markers include C-reactive protein, fibrinogen, and complement factors
    • C3 and C4
    • Birth weight was negatively associated with:
    • fibrinogen (P = 0.036);
    • C3 (P = 0.010);
    • C4 (P = 0.031).
  • Early Life Origins of Low-Grade Inflammation and Atherosclerosis Risk in Children and Adolescents Idoia Labayen, J Ped 2009;155:673
    • Our results showed that smaller birth weight is associated with chronic low-grade inflammation in children and adolescents.
    • Because of the implication of complement factors on atherosclerosis process, these results contribute to explain the increased cardiovascular risk associated with low birth weight.
  • Simple Table to Identify Children and Adolescents Needing Further Evaluation of Blood Pressure Kaelber Pediatrics 2009;123:e972
    • Threshold value of abnormal systolic and diastolic blood pressure, by gender, for each year of life (ages 3 to >18)
    • Any blood pressure readings ≥ than these values represent blood pressures in the prehypertensive, stage 1 hypertensive, or stage 2 hypertensive range and should be further evaluated by a physician.
  • Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010 (362): 9-17 Background Nasal carriers of Staphylococcus aureus are at increased risk for health care–associated infections with this organism. Decolonization of nasal and extranasal sites on hospital admission may reduce this risk.
    • Identification of S. aureus nasal carriers by real-time polymerase-chain-reaction (PCR).
    • Treatment with mupirocin nasal ointment and chlorhexidine soap or placebo for five days.
    • 1251 patients positive for S. aureus.
    10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 3.4% 7.7% Rate of S. aureus infection mupirocin–chlorhexidine group placebo group RR=0.42 p=0,008 Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010;362:9-17
    • Identification of S. aureus nasal carriers by real-time polymerase-chain-reaction (PCR).
    • Treatment with mupirocin nasal ointment and chlorhexidine soap or placebo for five days.
    • 1251 patients positive for S. aureus.
    10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 3.4% 7.7% Rate of S. aureus infection mupirocin–chlorhexidine group placebo group RR=0.42 p=0,008 Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010;362:9-17 The effect of mupirocin–chlorhexidine treatment was most pronounced for deep surgical-site infections (relative risk = 0.21)
    • Identification of S. aureus nasal carriers by real-time polymerase-chain-reaction (PCR).
    • Treatment with mupirocin nasal ointment and chlorhexidine soap or placebo for five days.
    • 1251 patients positive for S. aureus.
    10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 3.4% 7.7% Rate of S. aureus infection mupirocin–chlorhexidine group placebo group RR=0.42 p=0,008 Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010;362:9-17 The usual therapeutic regimen for mupirocin is 3 times daily application for 1 week
    • Nasal carriers of S. aureus are also colonized at extranasal sites. It is unlikely that nasal application of mupirocin will directly affect these sites. However, decolonization of the skin can be achieved by washing with disinfecting soap, such as chlorhexidine gluconate products.
    • Mupirocin and chlorhexidine are considered to be relatively safe. However, since S. aureus strains can become resistant to mupirocin, we recommend restricting the use of this agent to known carriers who are at risk for infection.
    • The prevalence of methicillin-resistant S. aureus carriage in the Netherlands is only 0.03%.
    • It is plausible that this strategy would also be effective in carriers of methicillin-resistant strains of S. aureus that are susceptible to mupirocin.
    Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010;362:9-17
  • Minimizing Surgical-Site Infections RP Wenzel, NEJM 2010 (362): 75-77
    • Some experts estimate that the total number of human cells is 10 13 and the total number of colonizing microbes is 10 14 .
    • Results of a recent metaanalysis suggested that topical mupirocin applied intranasally would reduce the rate of surgical-site infections due to S. aureus by 45% in the subgroup of patients who are carriers.
    • The skin is an important extranasal reservoir not only for S. aureus but also for other organisms implicated in postoperative infections.
  • Minimizing Surgical-Site Infections RP Wenzel, NEJM 2010: 362: 75-77
    • Chlorhexidine–alcohol has been recommended by the Centers for Disease Control and Prevention as the antiseptic of choice to reduce vascular catheter–associated bloodstream infections.
    • Compared with povidone–iodine, the chlorhexidine– alcohol solution has been found to reduce catheter-associated infections by approximately 50%.
  • Chronic fatigue syndrome
  • Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz Pediatrics 2009;124:189
    • 301 adolescents with infectious mononucleosis
    • a telephone interview
    13% 15 – 10 – 5 – 0 7% 4% % ADOLESCENTS WHO MET THE CRITERIA FOR CHRONIC FATIGUE SYNDROME 6 12 24 MONTH POST MONONUCLEOSIS
  • Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz Pediatrics 2009;124:189
    • 301 adolescents with infectious mononucleosis
    • a telephone interview
    13% 15 – 10 – 5 – 0 7% 4% % ADOLESCENTS WHO MET THE CRITERIA FOR CHRONIC FATIGUE SYNDROME 6 12 24 MONTH POST MONONUCLEOSIS All 13 adolescents with chronic fatigue syndrome 24 months after infectious mononucleosis were female
  • Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz Pediatrics 2009;124:189
    • 301 adolescents with infectious mononucleosis
    • a telephone interview
    13% 15 – 10 – 5 – 0 7% 4% % ADOLESCENTS WHO MET THE CRITERIA FOR CHRONIC FATIGUE SYNDROME 6 12 24 MONTH POST MONONUCLEOSIS Infectious mononucleosis may be a risk factor for chronic fatigue syndrome in adolescents
  • The chronic fatigue syndrome: a comprehensive approach to its definition and study. Fukuda K, Ann Intern Med. 1994;121:953–959
    • Major Classification Criteria:
    • Persistent or relapsing chronic fatigue that is of new or definite onset (has not been lifelong); and results in substantial reduction in previous levels of occupational, educational, social, or personal activities ;
    • The concurrent occurrence of four or more of the following symptoms, persisted or recurred during 6 or more consecutive months:
    • 1. self-reported impairment in short-term memory or concentration
    • 2. tender cervical or axillary lymph nodes
    • 3. muscle pain, multijoint pain without joint swelling or redness;
    • 4. headaches of a new type, pattern, or severity;
    • 5. unrefreshing sleep;
    • 6. postexertional malaise lasting more than 24 hours.
  • Risk Factors for Persistent Fatigue With Significant School Absence in Children and Adolescent Robert Pediatrics 2009;124;e89
    • 91 patients, aged 8 to 18 years
    • Questionnaires about sleep, somatic symptoms, physical activity, and fatigue
    • Follow-up: 12 mounths
    50.6% % CHILDREN AT FOLLOW-UP 60 – 50 – 40 – 30 – 20 – 10 – 0 29.1% 20.3% PERSISTENT FATIGUE IMPROVEMENT PERSISTENT FATIGUE WITH SIGNIFICANT SCHOOL ABSENCE
  • 2 – 1 – 0 1.4 2.1 2.0 1.8 1.7 1.8 1.9 SLEEP PROBLEMS BLURRED VISION PAIN IN ARMS OR LEGS BACK PAIN COSTIPATION MEMORY DEFICITS HOT AND COLD SPELLS OR FOR PERSISTENCE Risk Factors for Persistent Fatigue With Significant School Absence in Children and Adolescent Robert Pediatrics 2009;124;e89
    • Chronic fatigue syndrome ( CFS ) or myalgic encephalopathy ( ME )
    • 20 children with a diagnosis of CFS/ME
    • 10 tests to measure: processing speed; attention; immediate and delayed memory; working memory; executive function
    • Children with CFS/ME, their parents and teachers described problems with focussed attention , sustained attention , recall and stress
    • These cognitive problems may explain some of the educational difficulties associated with CFS
    MEMORY AND ATTENTION PROBLEMS IN CHILDREN WITH CHRONIC FATIGUE SYNDROME OR MYALGIC ENCEPHALOPATHY Haig-ferguson Arch Dis Child 2009;94:757
    • Chronic fatigue syndrome (CFS) or myalgic encephalopathy (ME) is the commonest cause of school absence in the UK. It is a relatively common condition, affecting between 0.1% and 2% of children aged under 18 years.
    • CFS/ME is defined as “generalised fatigue persisting after routine tests and investigations have failed to identify an obvious underlying cause”
    • A minimum of 3 months of fatigue is required before a diagnosis of CFS/ME is made in children.
    ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
    • 68% of children report that having CFS/ME prevented them attending school at some stage, with a mean time out of school estimated at more than one academic year .
    • Children with CFS/ME can also have poor physical function, with over 57% of children being bed-bound at some stage.
    ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
    • Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME)
    • Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS)
    • 211 children with CFS/ME
    % children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
    • Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME)
    • Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS)
    • 211 children with CFS/ME
    % children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752 The factor most strongly associated with reduced school attendance was poor physical function . Worse physical function was associated with higher levels of fatigue, pain and low mood
    • Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME)
    • Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS)
    • 211 children with CFS/ME
    % children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752 We found no evidence that school attendance was associated with anxiety measured either by the SCAS or the HADS
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
    2.5 – 2.0 – 1.5 – 1.0 – 0.5 – 0 2.2% FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences 11 – 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 8% 11% SERIOUS ORGANIC DISEASE SYMPTOM-DEFINED SYNDROMES
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences 11 – 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 8% 11% SERIOUS ORGANIC DISEASE SYMPTOM-DEFINED SYNDROMES
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
    The remainder had physical symptoms and minor medical illness
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with psychiatric disorders CONTROLS 50 – 40 – 30 – 20 – 10 – 0 CASES p<0.001 17% 45%
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with psychiatric disorders CONTROLS 50 – 40 – 30 – 20 – 10 – 0 CASES p<0.001 17% 45%
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
    Only 34% with a psychiatric diagnosis had attended NHS psychiatric services
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 ADHD , attention deficit hyperactivity disorder; DISC , Diagnostic Interview Schedule for Children; OCD , obsessive compulsive disorder; OR , odds ratio; PTSD , post-traumatic stress disorder; SDQ , Strengths and Difficulties Questionnaire for SDQ
  • Dermatology
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423
    • 32 children (mean age: 4.2 mo) with infantile hemangiomas.
    • Clinical and ultrasound evaluations.
    • Propranolol 2 to 3 mg/kg per day, in 2 or 3 divided doses .
    • Blood pressure and heart rate were monitored during the first 6 hours of treatment. In the absence of side effects, treatment was continued at home.
    • Ultrasound after 60 days of treatment.
    1) Immediate effects on color and growth were noted in all cases. 2) In ulcerated IHs, complete healing occurred in2 months. 3) Objective clinical and ultrasound evidence of longer-term regression was seen in 2 months.
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 1) Infantile hemangiomas (IHs) are the most-common soft-tissue tumors of infancy, occurring in 4% to 10% of children 1 year of age , with a clear female predominance. 2) At birth , IHs may not be apparent or may appear as flat circumscribed lesions with telangiectatic vessels on the surface. Within the first weeks of life, IHs enter a phase of rapid growth with superficial and/or deep components, which lasts usually 3 to 6 months and sometimes up to 24 months . 3) A period of stabilization for a few months follows, and spontaneous involution usually occurs in several years. 4) Regression is complete for 60% of 4-year-old patients and 76% of 7-year-old patients .
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 A) 10% of IHs require treatment during the proliferative phase, because of life-threatening locations , local complications , or cosmetic/functional risks . B) IHs can be life-threatening when present in upper airways and liver, inducing acute respiratory failure and congestive heart failure, respectively. C) Local complications such as hemorrhage, ulceration, and necrosis can be very painful and may lead to scars that are difficult to repair. D) IHs in some locations can impair sensory functions; for example, IHs of the upper eyelid can induce anisometropia, astigmatism, and amblyopia. IHs in other locations, such as the lip, nasal tip, or ear, may lead to permanent deformities.
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 A) 10% of IHs require treatment during the proliferative phase, because of life-threatening locations , local complications , or cosmetic/functional risks . B) IHs can be life-threatening when present in upper airways and liver, inducing acute respiratory failure and congestive heart failure, respectively. C) Local complications such as hemorrhage, ulceration, and necrosis can be very painful and may lead to scars that are difficult to repair. D) IHs in some locations can impair sensory functions; for example, IHs of the upper eyelid can induce anisometropia, astigmatism, and amblyopia. IHs in other locations, such as the lip, nasal tip, or ear, may lead to permanent deformities. We observed serendipitously that propranolol , a well-tolerated, nonselective, β -adrenergic receptor blocker commonly used for cardiologic indications in young children, can control the growth of IHs efficiently.
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 Patient with palpebral occlusion. A, Palpebral occlusion at 2 months of age, after 1 week of systemic steroid treatment (2 mg/kg per day) and 1 day before treatment with propranolol. B, Spontaneous eye reopening after 7 days of propranolol treatment at 2 mg/kg per day. C, Further improvement after 2 months of propranolol treatment while prednisone treatment was tapered progressively. D, Residual telangiectases at 12 months of age, after cessation of propranolol treatment. Time 0 7 days after 2 months 12 months
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 Patient with a painful ulcerated IH. Standard treatment with wound care dressings and analgesics was also used. A, At 5 months of age, 1 day before treatment with propranolol. B, Beginning of healing after 2 weeks of propranolol treatment at 2 mg/kg per day. C, Limited ulceration relapse at 8 months of age, after 3 months of propranolol treatment. Complete healing was achieved after the propranolol dosage was increased to 3 mg/kg per day. After 2 weeks
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 Patient at risk of cosmetic disfigurement and ulceration because of a large IH of the inferior lip. A, At 4 months of age, 1 day before treatment with propranolol. B, After 2 months of propranolol treatment at 2 mg/kg per day. C, After 3 months of propranolol treatment at 2 mg/kg per day. D, After 5 months of propranolol treatment at 2 mg/kg per day.
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 Patient with a life-threatening laryngeal IH. The improvement of the cutaneous component should be noted. A, At 2 months of age, 1 day before treatment with propranolol. B, Seven days after initiation of propranolol treatment at 2 mg/kg per day, with a change in color from intense red to purple and palpable softening. C, Further improvement after 2 months of propranolol treatment at 2 mg/kg per day. D, Residual telangiectases at 11 months of age, 1 month after cessation of propranolol treatment.
  • Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 α ) Propranolol is a nonselective β -adrenergic receptor blocker. β ) Capillary endothelial cells express β 2 -adrenergic receptors , which modulate the release of nitric oxide, causing endothelium-dependent vasodilatation. γ ) β -Adrenergic receptor stimulation can induce modifications of signal transduction pathways of angiogenic factors such as VEGF or bFGF.
    • A 9-year-old boy presented to the emergency room with various macular erythematoses and ecchymotic lesions with geometric shapes and well-defined edges on his left hand and forearm.
    • The child denied that the lesions were self-inflicted.
    An Unusual Dermatosis in a Child García J Pediatr 2010;156:505
    • His grandmother mentioned that she had noticed that her albuterol inhaler had run out before she had expected.
    • We confirmed that the shape of the distal part of the inhaler corresponded exactly with the borders of the child’s skin lesions.
    • Finally, the child confessed that he had created the lesions by heating the inhaler on a vitroceramic hotplate and then applying it to his skin.
    An Unusual Dermatosis in a Child García J Pediatr 2010;156:505
  • An Unusual Dermatosis in a Child García J Pediatr 2010;156:505
    • Dermatitis artefacta is a self-inflected dermatologic injury.
    • It is rare in children, with the peak frequency occurring in adolescence.
    • The morphology of the skin lesions is variable and is typically dependent on the mechanism of injury.
    • Features may include sharp margins adjacent to normal skin, geometric shapes, and linear tracks.
    • The lesions are usually seen at sites accessible to the patient and do not conform to any known dermatologic condition.
  • Emergency Department
  • MAKING CHOICES: WHY PARENTS PRESENT TO THE EMERGENCY DEPARTMENT FOR NON-URGENT CARE Williams Arch Dis Child 2009;94:817
    • 355 parents were surveyed
    RATED THEIR CHILD’S CONDITION AS MODERATE TO VERY SERIOUS SOUGHT ADVICE PRIOR TO ATTENDING THE EMERGENCY DEPARTMENT PRESENTED WITHIN 2-7 DAYS OF THE ONSET OF THE ILLNESS % parents 68% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 54% 41%
  • Emergency Department Reliance: A Discriminatory Measure of Frequent Emergency Department Users Kroner Pediatrics 2010;125:133
    • Frequent ED users were defined as having 2 ≥ED visits/year
    • A total of 8823 children
    OR for frequent use of ED 0.55 1 – 0.5 - 0 0.72 Young children Children with special health care need
  • Emergency Department Reliance: A Discriminatory Measure of Frequent Emergency Department Users Kroner Pediatrics 2010;125:133
    • Frequent ED users were defined as having 2 ≥ED visits
    • A total of 8823 children
    OR for frequent use of ED 0.55 1 – 0.5 - 0 0.72 Young children Children with special health care need Whereas those with lower education and low income were more likely to have high EDR.
  • gastroenterology
  • % children with AGE treated according to guidelines 65.5% 80 – 60 – 40 – 20 – 0 The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians Albano J Pediatr 2010;156:226
    • A 2-hour course based on the guidelines for management of AGE.
    • 75 primary care pediatricians underwent training in AGE management (group A) , and 75 pediatricians served as controls (group B) .
    • Each pediatrician enrolled 10 children age 1-36 months with acute-onset diarrhea.
    • Children in groups A (n = 617) and B (n = 692).
    3% Group A Group B
  • % children with AGE treated according to guidelines 65.5% 80 – 60 – 40 – 20 – 0 The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians Albano J Pediatr 2010;156:226
    • A 2-hour course based on the guidelines for management of AGE.
    • 75 primary care pediatricians underwent training in AGE management (group A) , and 75 pediatricians served as controls (group B) .
    • Each pediatrician enrolled 10 children age 1-36 months with acute-onset diarrhea.
    • Children in groups A (n = 617) and B (n = 692).
    3% Group A Group B Most violations involved administration of unnecessary drugs or diets.
  • DURATION OF DIARRHEA (hours) 83.3 90.9 Group A Group B 100 – 80 – 60 – 40 – 20 – 0
    • A 2-hour course based on the guidelines for management of AGE.
    • 75 primary care pediatricians underwent training in AGE management (group A) , and 75 pediatricians served as controls (group B) .
    • Each pediatrician enrolled 10 children age 1-36 months with acute-onset diarrhea.
    • Children in groups A (n = 617) and B (n = 692).
    The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians Albano J Pediatr 2010;156:226 P<0.001
  • The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians Albano J Pediatr 2010;156:226 The pediatricians in group A were instructed to adhere to 4 major recommendations in the guidelines: 1) rapid oral rehydration for 3-4 hours with hypoosmolar solution (Na 60 mmol/L); 2) rapid refeeding after 4 hours of rehydration with the child’s normal diet, including solids, full-strength milk, or formula, with no restriction of lactose intake; 3) avoidance of unnecessary medications; 4) avoidance of microbiological investigations.
  • Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate Neville J Pediatr 2010;156:313 Plasma sodium concentrations fell in both N/2 groups at T 8 (P < 0.01)
    • 124 children admitted for surgery.
    • 0.9% saline solution (NS) or 0.45% saline solution (N/2) saline solution at 100% or 50% maintenance rates.
    • Plasma electrolytes, osmolality, and Antidiuretic hormone values 8 hours (T8), and 24 hours (T24; n = 67) after surgery.
  • Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate Neville J Pediatr 2010;156:313
    • 124 children admitted for surgery.
    • 0.9% saline solution (NS) or 0.45% saline solution (N/2) saline solution at 100% or 50% maintenance rates.
    • Plasma electrolytes, osmolality, and Antidiuretic hormone values 8 hours (T8), and 24 hours (T24; n = 67) after surgery.
    % children with hyponatriemia at T 8 10% 40 – 30 – 20 – 10 – 0 30% NS N/2 P=0.02
    • 124 children admitted for surgery.
    • 0.9% saline solution (NS) or 0.45% saline solution (N/2) saline solution at 100% or 50% maintenance rates.
    • Plasma electrolytes, osmolality, and Antidiuretic hormone values 8 hours (T8), and 24 hours (T24; n = 67) after surgery.
    Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate Neville J Pediatr 2010;156:313 % children with hyponatriemia at T 8 10% 40 – 30 – 20 – 10 – 0 30% NS N/2 P=0.02 On multiple linear regression analysis, fluid type, not rate determined risk of hyponatremia (P < 0.04).
  • Questionnaire-Based Case Finding of Celiac Disease in a Population of 8- to 9-Year-Old Children Toftedal Pediatrics 2010;125:e518
    • 9880 children aged 8 to 9 years.
    • A questionnaire on the basis of 5 simple items suggestive of CD.
    • 2835 children had 1 or more symptoms. These children were invited for IgA anti–tissue transglutaminase antibody.
  • Questionnaire-Based Case Finding of Celiac Disease in a Population of 8- to 9-Year-Old Children Toftedal Pediatrics 2010;125:e518
    • 9880 children aged 8 to 9 years.
    • A questionnaire on the basis of 5 simple items suggestive of CD.
    • 2835 children had 1 or more symptoms. These children were invited for IgA anti–tissue transglutaminase antibody.
    The proportion of patients with newly diagnosed CD was 1.22% (21 of 1720).
    • 9880 children aged 8 to 9 years.
    • A questionnaire on the basis of 5 simple items suggestive of CD.
    • 2835 children had 1 or more symptoms. These children were invited for IgA anti–tissue transglutaminase antibody.
    Questionnaire-Based Case Finding of Celiac Disease in a Population of 8- to 9-Year-Old Children Toftedal Pediatrics 2010;125:e518 A number of preclinical and low-grade symptomatic patients with CD may be identified by their responses to a mailed questionnaire.
  • % children with acute gastroenteritis at the time of gluten introduction 2.3% 1.8% CD subjects Controls ns Infectious Disease and Risk of Later Celiac Disease in Childhood Welander Pediatrics 2010;125:e530
    • To examine whether parent-reported infection at the time of gluten introduction increases the risk of future celiac disease (CD).
    • 9408 children.
    • 44 children with biopsy-verified CD diagnosed after 1 year of age
    3 – 2 – 1 – 0
  • % children with acute gastroenteritis at the time of gluten introduction 2.3% 1.8% CD subjects Controls Infectious Disease and Risk of Later Celiac Disease in Childhood Welander Pediatrics 2010;125:e530
    • To examine whether parent-reported infection at the time of gluten introduction increases the risk of future celiac disease (CD).
    • 9408 children.
    • 44 children with biopsy-verified CD diagnosed after 1 year of age
    3 – 2 – 1 – 0 Parent-reported infection at the time of gluten introduction is not a major risk factor for CD. ns
  • The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing McGowan Pediatrics 2009;124:1572
    • Impact of IgA endomysial antibody testing the incidence and clinical presentation of childhood celiac disease.
    • In 1990 –1996 (pretesting group) vs 2000 –2006 (testing group)
    MEDIAN AGE AT DIAGNOSIS (YEARS) 2.0 9.0 PRE-TESTING TESTING 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 P<0.001
  • The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing McGowan Pediatrics 2009;124:1572 Incidence of celiac disease (cases per 100.000 children) 2.0 7.3 PRE-TESTING TESTING 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 P=0.03
    • Impact of IgA endomysial antibody testing the incidence and clinical presentation of childhood celiac disease.
    • In 1990 –1996 (pretesting group) vs 2000 –2006 (testing group)
  • The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing McGowan Pediatrics 2009;124:1572 FREQUENCY OF CLASSIC CELIAC DISEASE PRESENTATION 67% 19% PRE-TESTING TESTING P=0.03 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • Impact of IgA endomysial antibody testing the incidence and clinical presentation of childhood celiac disease.
    • In 1990 –1996 (pretesting group) vs 2000 –2006 (testing group)
  • The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing McGowan Pediatrics 2009;124:1572 In the testing group, 13 previously unrecognized clinical presentations were observed in 98 children, including
    • 35 with family history
    • 18 with abdominal pain
    • 14 with type1 diabetes mellitus.
  • Minutes crying and fussing 500 – 400 – 300 – 200 – 100 – 0 YES 103 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 314 colic
    • 36 term infants from 14 to 81 days
    • fecal calprotectin (a marker of neutrophil infiltration)
    • stool microorganisms
  • Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042
    • 36 term infants from 14 to 81 days
    • fecal calprotectin (a marker of neutrophil infiltration)
    • stool microorganisms
  • Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 Klebsiella species were detected in more colic patients than in control patients (8 vs 1, P = 0.02)
    • 36 term infants from 14 to 81 days
    • fecal calprotectin (a marker of neutrophil infiltration)
    • stool microorganisms
  • Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 These differences could not be attributed to differences in formula versus breast milk feeding, consumption of elemental formula, or exposure to antibiotics
    • 36 term infants from 14 to 81 days
    • fecal calprotectin (a marker of neutrophil infiltration)
    • stool microorganisms
  • Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 Infants with colic, a condition previously believed to be nonorganic in nature, have evidence of intestinal neutrophilic infiltration and a less diverse fecal microflora
    • 36 term infants from 14 to 81 days
    • fecal calprotectin (a marker of neutrophil infiltration)
    • stool microorganisms
  • Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 We plan to prospectively study the effect of treatment of children with colic with a probiotic, Lactobacillus reuteri, in a placebo-controlled, masked investigation to confirm previous observations Savino, Pediatrics 2007;119:124
    • 36 term infants from 14 to 81 days
    • fecal calprotectin (a marker of neutrophil infiltration)
    • stool microorganisms
    • children affected by IBS according to Rome II criteria (n = 43)
    • control population (n = 56)
    • lactulose/methane
    • breath test (LBT) to assess small intestinal bacterial overgrowth (SIBO)
    Prevalence of Small Intestinal Bacterial Overgrowth in Children with Irritable Bowel Syndrome: A Case-Control Study E Scarpellini, J Ped 2009;155:416 Prevalence of abnormal LBT ( bacterial overgrowth ) P<0.05
    • children affected by IBS according to Rome II criteria (n = 43)
    • control population (n = 56)
    • lactulose/methane
    • breath test (LBT) to assess small intestinal bacterial overgrowth (SIBO)
    Prevalence of Small Intestinal Bacterial Overgrowth in Children with Irritable Bowel Syndrome: A Case-Control Study E Scarpellini, J Ped 2009;155:416 P<0.05 Placebo-controlled interventional studies with antibiotics used to treat bacterial overgrowth are warranted to clarify the real impact of the disease on IBS symptoms Prevalence of abnormal LBT ( bacterial overgrowth )
  • Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Children U Halac, J Ped 2010;156:60
    • rectal sensory threshold for pain (RSTP)
    • 51 patients with abdominal pain >2 months
    • a series of rectal distensions with an electronic barostat
    • 35 patients had a functional gastrointestinal disorder (irritable bowel syndrome or functional
    • abdominal pain)
    • 16 had an organic disease
  • Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Children U Halac, J Ped 2010;156:60
  • Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Children U Halac, J Ped 2010;156:60 P<0.001
    • rectal sensory threshold for pain (RSTP)
    • 51 patients with abdominal pain >2 months
    • a series of rectal distensions with an electronic barostat
    FGID = functional gastrointestinal disease
    • rectal sensory threshold for pain (RSTP)
    • 51 patients with abdominal pain >2 months
    • a series of rectal distensions with an electronic barostat
    Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Children U Halac, J Ped 2010;156:60 In children RSTP is a diagnostic marker of irritable bowel syndrome and functional abdominal pain P<0.001 FGID = functional gastrointestinal disease
  • Increased Auditory Startle Reflex in Children with Functional Abdominal Pain Bakker J Pediatr 2010;156:285
    • The activity of 6 left-sided muscles and the sympathetic skin response were obtained
    • by an electromyogram.
    • We presented sudden loud noises to the subjects through headphones.
    • Auditory startle reflexes.
    • 20 children with irritable bowel syndrome (n=13), functional abdominal pain syndrome (n=7).
    • 23 control subjects.
  • The multiple muscle ASR (response probability, 0% to 100%), for the 8 repetitive stimuli, is significantly enlarged in patients with abdominal pain (n = 20) compared with control subjects (n = 23) but not compared with patients with anxiety disorder (n = 25). Increased Auditory Startle Reflex in Children with Functional Abdominal Pain Bakker J Pediatr 2010;156:285 The multiple muscle ASR (EMG magnitude), for the 8 repetitive stimuli, is significantly enlarged in patients with abdominal pain (n = 20) compared with control subjects (n = 23) but not compared with patients with anxiety (n = 25).
  • The multiple muscle ASR (response probability, 0% to 100%), for the 8 repetitive stimuli, is significantly enlarged in patients with abdominal pain (n = 20) compared with control subjects (n = 23) but not compared with patients with anxiety disorder (n = 25). Increased Auditory Startle Reflex in Children with Functional Abdominal Pain Bakker J Pediatr 2010;156:285 The multiple muscle ASR (EMG magnitude), for the 8 repetitive stimuli, is significantly enlarged in patients with abdominal pain (n = 20) compared with control subjects (n = 23) but not compared with patients with anxiety (n = 25). Children with abdominal pain–related functional gastrointestinal disorders may have a generalized hypersensitivity of the central nervous system.
  • Recurrent Abdominal Pain in Childhood Urolithiasis Polito Pediatrics 2009;124:e1088
    • 1000 children with reccurent abdominal pain and diagnosed as having urolithiasis
    % CHILDREN WITH 53% NO HISTORY OF DYSURIA OR GROSS HEMATURIA PREVIOUSLY HOSPITALIZED FOR ABDOMINAL SYMPTOMS 60 – 50 – 40 – 30 – 20 – 10 – 0 29% 16% PREVIOUS APPENDECTOMY
  • Recurrent Abdominal Pain in Childhood Urolithiasis Polito Pediatrics 2009;124:e1088 % children undergoing abdominal ultrasonography not showing urinary stones 2-28 mounths before the diagnosis was made 40 – 30 – 20 – 10 – 0 37%
    • 1000 children with reccurent abdominal pain and diagnosed as having urolithiasis
  • Recurrent Abdominal Pain in Childhood Urolithiasis Polito Pediatrics 2009;124:e1088 % children undergoing abdominal ultrasonography not showing urinary stones 2-28 mounths before the diagnosis was made 40 – 30 – 20 – 10 – 0 37%
    • 1000 children with reccurent abdominal pain and diagnosed as having urolithiasis
    69% of subjects younger than 8 years of age had central/diffuse abdominal pain. The mean frequency of pain attacks was 4 to 9 times lower than in patients with functional or organic gastrointestinal RAP.
  • Recurrent Abdominal Pain in Childhood Urolithiasis Polito Pediatrics 2009;124:e1088 % children undergoing abdominal ultrasonography not showing urinary stones 2-28 mounths before the diagnosis was made 40 – 30 – 20 – 10 – 0 37%
    • 1000 children with reccurent abdominal pain and diagnosed as having urolithiasis
    The possibility of urolithiasis should be considered in children with RAP who have a family history of urolithiasis and/or infrequent pain attacks , even when dysuria and hematuria are lacking
  • Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG Bekkali Pediatrics 2009;124:e1108
    • Children (4 –16 years) with functional constipation .
    • Patients assigned to receive enemas once daily or polyethylene glycol ( PEG ) (1.5 g/kg per day) for 6 consecutive days.
    % SUCCESSFUL DISIMPACTION 80% 68% ENEMAS PEG 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 ns
  • Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG Bekkali Pediatrics 2009;124:e1108
    • Children (4 –16 years) with functional constipation .
    • Patients assigned to receive enemas once daily or polyethylene glycol ( PEG ) (1.5 g/kg per day) for 6 consecutive days.
    % SUCCESSFUL DISIMPACTION 80% 68% ENEMAS PEG 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 ns Enemas and PEG were equally effective
  • Lactobacillus Reuteri In Infants With Functional Chronic Constipation: A Doubleblinded, Randomized, Placebo-controlled Study. M. Martinelli J Pediatr 2010 in press
    • 44 infants with functional chronic constipation. (mean age 8.2 mo)
    • group A (n=22) L. Reuteri (5 drops) and
    • group B (n=22) placebo
    • once daily for 8 weeks.
    • Infants who received L. Reuteri had a significantly higher frequency of bowel movements than placebo
    • at week 2 of treatment (p=0.042),
    • at week 4 (p=0.008) and
    • at week 8 (p=0.027).
  • Objectives: To determine the benefits of Lactobacillus rhamnosus GG (LGG) in an extensively hydrolyzed casein formula (EHCF) in improving hematochezia and fecal calprotectin over EHCF alone. Study design: Fecal calprotectin was compared in 30 infants with hematochezia and 4 weeks after milk elimination with that of a healthy group. We also compared fecal calprotectin and hematochezia on 26 formula-fed infants randomly assigned to EHCF with LGG (Nutramigen LGG) (EHCF + LGG) or without (Nutramigen) (EHCF - LGG) and on 4 breastfed infants whose mothers eliminated dairy. Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397
  • Fecal calprotectin µg/g stool 326 Hematochezia 38 Control
    • 30 infants with hematochezia.
    • 32 control infant.
    p<0.0001 Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397 350 – 300 – 250 – 200 – 150 – 100 – 50 – 0
  • Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397
  • Decrease in fecal calprotectin µg/g stool in infants with hematochezia after 4 week of -225 µg/g BREAST FEEDING without dairy NUTRAMIGEN
    • 30 infants with hematochezia.
    • 32 control infant.
    Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397 0 – -50 – -100 – -200 – -250 – -112 µg/g -214 µg/g NUTRAMIGEN + Lactobacillus GG p<0.0001
  • Decrease in fecal calprotectin µg/g stool in infants with hematochezia after 4 week of -225 µg/g BREAST FEEDING NUTRAMIGEN
    • 30 infants with hematochezia.
    • 32 control infant.
    Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397 0 – -50 – -100 – -200 – -250 – -112 µg/g -214 µg/g NUTRAMIGEN + Lactobacillus GG p<0.0001 EHCF + LGG resulted in significant improvement of hematochezia and fecal calprotectin compared with the EHCF alone.
    • 30 of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding
    • Multicare AR-Bed (Peos, Ninove, Belgium)
    • oesophageal pH monitoring at inclusion and after 1 week
    A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SYMPTOMS AND ACID REFLUX Vandenplas Arch Dis Child 2010;95:26 The Multicare AR-Bed
  • A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SYMPTOMS AND ACID REFLUX Vandenplas Arch Dis Child 2010;95:26 % children who did not tolerate the 40°positioning 30 – 20 – 10 – 0 27%
    • 30 of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding
    • Multicare AR-Bed (Peos, Ninove, Belgium)
    • oesophageal pH monitoring at inclusion and after 1 week
  • A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SYMPTOMS AND ACID REFLUX Vandenplas Arch Dis Child 2010;95:26 % children with improved ph monitoring 73% 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • 30 of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding
    • Multicare AR-Bed (Peos, Ninove, Belgium)
    • oesophageal pH monitoring at inclusion and after 1 week
  • A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SYMPTOMS AND ACID REFLUX Vandenplas Arch Dis Child 2010;95:26 % children with improved ph monitoring 73% 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • 30 of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding
    • Multicare AR-Bed (Peos, Ninove, Belgium)
    • oesophageal pH monitoring at inclusion and after 1 week
    The mean duration of use of the Multicare AR-Bed was 3.2 months
  •  
    • Intensive care
    • 77 intensive care units.
    • 2,796 patients.
    % PATIENTS WHO DIED 41.6% 50 – 40 – 30 – 20 – 10 – 0 Effectiveness of Treatments for Severe Sepsis: A Prospective, Multicenter, Observational Study Ferrer AJRCCM 2009:180:861
  • Effectiveness of Treatments for Severe Sepsis: A Prospective, Multicenter, Observational Study Ferrer AJRCCM 2009:180:861
    • 77 intensive care units.
    • 2,796 patients.
    OR FOR DEATH 0.67 P=0.008 In subjects treated early with broad-spectrum antibiotic (treatment within 1 hour vs. no treatment within first 6 hours of diagnosis. 1.0 – 0.5 – 0
  • Association Between ICU Admission During Morning Rounds and Mortality Afessa CHEST 2009; 136:1489
    • Retrospective study (49844 patients).
    • Patients, 3,580 were admitted to the ICU during round time
    • (8:00 AM to 10:59 AM)
    • and 46,264 were admitted during non round time
    • (1:00 PM to 6:00 AM).
    % HOSPITAL MORTALITY RATE 20 – 15 – 10 – 5 – 0 16.2 % 8.8 % P<0.001 YES NO ROUND TIME OR=1.3
  • Association Between ICU Admission During Morning Rounds and Mortality Afessa CHEST 2009; 136:1489
    • Retrospective study (49844 patients).
    • Patients, 3,580 were admitted to the ICU during round time
    • (8:00 AM to 10:59 AM)
    • and 46,264 were admitted during non round time
    • (1:00 PM to 6:00 AM).
    % HOSPITAL MORTALITY RATE 20 – 15 – 10 – 5 – 0 16.2 % 8.8 % P<0.001 YES NO ROUND TIME OR=1.3 Most of the round-time ICU admissions and deaths occurred in the medical ICU
  • Association Between ICU Admission During Morning Rounds and Mortality Afessa CHEST 2009; 136:1489
    • Retrospective study (49844 patients).
    • Patients, 3,580 were admitted to the ICU during round time
    • (8:00 AM to 10:59 AM)
    • and 46,264 were admitted during non round time
    • (1:00 PM to 6:00 AM).
    % HOSPITAL MORTALITY RATE 20 – 15 – 10 – 5 – 0 16.2 % 8.8 % P<0.001 YES NO ROUND TIME OR=1.3 Rounds may include going from one patient bed to the next, not from the sickest patient to the least sick. This approach may result in delayed resuscitation of critically ill patients admitted to the ICU during rounds, providing a potential explanation for the increased mortality we observed in this study.
  • Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock Kumar CHEST 2009; 136:1237
    • Appropriateness of initial antimicrobial therapy, retrospectively determined for 5,715 patients with septic shock
    80.1% % patients with appropriate antimicrobial agents 100 – 80 – 60 – 40 – 20 - 0
  • 52% % PATIENTS SURVIVING 60 – 50 – 40 – 30 – 20 – 10 - 0 10.3% APPROPRIATE INAPPROPRIATE INITIAL THERAPY Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock Kumar CHEST 2009; 136:1237 P<0.0001
    • Appropriateness of initial antimicrobial therapy, retrospectively determined for 5,715 patients with septic shock
  • 52% % PATIENTS SURVIVING 60 – 50 – 40 – 30 – 20 – 10 - 0 10.3% APPROPRIATE INAPPROPRIATE INITIAL THERAPY Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock Kumar CHEST 2009; 136:1237 P<0.0001
    • Appropriateness of initial antimicrobial therapy, retrospectively determined for 5,715 patients with septic shock
    The decrease in survival with inappropriate initial therapy ranged from 2.3-fold for pneumococcal infection to 17.6-fold with primary bacteremia
  • 52% % PATIENTS SURVIVING 60 – 50 – 40 – 30 – 20 – 10 - 0 10.3% APPROPRIATE INAPPROPRIATE INITIAL THERAPY Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock Kumar CHEST 2009; 136:1237 P<0.0001
    • Appropriateness of initial antimicrobial therapy, retrospectively determined for 5,715 patients with septic shock
    Inappropriate initial antimicrobial therapy for septic shock occurs in about 20% of patients and is associated with a 5 fold reduction in survival
  • Contamination of Portable Radiograph Equipment With Resistant Bacteria in the ICU Levin Chest 2009;136:426 Background: Approximately 15% of nosocomial infections in the ICU result from spread of bacteria on caregivers’ hands. The routine chest radiograph provides an unexamined opportunity for bacterial spread: close contact with each patient and sequential examination of ICU patients. This study examined infection control procedures performed during routine chest radiographs, assessed whether resistant bacteria were transferred to the radiograph machine, and determined whether improved infection control practices by radiograph technicians could reduce bacterial transfer.
  • Contamination of Portable Radiograph Equipment With Resistant Bacteria in the ICU Levin Chest 2009;136:426
    • Culture specimens were taken from the radiograph machine
    • An educational intervention directed at technicians was instituted
    % of X-ray performed with adequate infection control 1% BEFORE 42% AFTER 50 – 40 – 30 – 20 – 10 – 0 10% DURING education
  • Contamination of Portable Radiograph Equipment With Resistant Bacteria in the ICU Levin Chest 2009;136:426 % (+) cultures samples from X-ray machine 39% BEFORE 0% AFTER 50 – 40 – 30 – 20 – 10 – 0 50% DURING education Areas of radiograph machine cultured
  • Contamination of Portable Radiograph Equipment With Resistant Bacteria in the ICU Levin Chest 2009;136:426 % (+) cultures samples from X-ray machine 39% BEFORE 0% AFTER 50 – 40 – 30 – 20 – 10 – 0 50% DURING education Areas of radiograph machine cultured Multiresistant bacteria are frequently transferred from patients to the radiograph machine in the presence of poor infection control practices, and may be a source of cross-infection/ colonization.
    • All children intubated and mechanically ventilated from 16 US PICUs for pediatric acute lung injury (ALI)
    • 12,213 children between 2 weeks and 18 years of age
    % children 22% Respiratory failure Characteristics of Children Intubated and Mechanically Ventilated in 16 PICUs Khemani Chest 2009;136:765 7% Upper airway obstruction 30 – 20 – 10 – 0 5% 26% 8% Chronic respiratory disease Cyanotic congenital heart disease Reactive airway disease
    • All children intubated and mechanically ventilated from 16 US PICUs for pediatric acute lung injury (ALI)
    • 12,213 children between 2 weeks and 18 years of age
    % children 22% Respiratory failure Characteristics of Children Intubated and Mechanically Ventilated in 16 PICUs Khemani Chest 2009;136:765 7% Upper airway obstruction 30 – 20 – 10 – 0 5% 26% 8% Chronic respiratory disease Cyanotic congenital heart disease Reactive airway disease 1,457 patients (15%) with respiratory failure lacked an arterial line.
  • immunology
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • There are 4 major types of gastrointestinal manifestations associated with humoral immunodeficiencies
    NLH (Nodular lymphoid hyperplasia).
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • Gastrointestinal diseases are not treated with immunoglobulin because preparations contain IgG, which cannot reach the lumen of the intact gut, and very little IgA or IgM.
    • Treatment with oral immunoglobulin has not been successful because IgG is rapidly destroyed before reaching the small intestine.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • XLA is an intrinsic B-cell disorder resulting in failure to generate mature B cells.
    • Serum IgG levels are usually less than 200 mg/dL, and IgM and IgA levels are less than 20 mg/dL.
    • Peripheral blood CD19 + B-cell counts are commonly less than 0.1%.
    X-linked agammaglobulinemia (XLA)
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • XLA is an intrinsic B-cell disorder resulting in failure to generate mature B cells.
    • Serum IgG levels are usually less than 200 mg/dL, and IgM and IgA levels are less than 20 mg/dL.
    • Peripheral blood CD19 + B-cell counts are commonly less than 0.1%.
    X-linked agammaglobulinemia (XLA) Compared with other antibody deficiency syndromes, patients with XLA present with gastrointestinal symptoms less often, presumably because T-cell dysfunction present in other immunodeficiency syndromes drives intestinal disease, and in patients with XLA, T-cell function is generally preserved.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • However, XLA patients who do have gastrointestinal manifestations usually present with chronic diarrhea and may have malabsorption.
    • Cases of infectious diarrhea are most commonly caused by Giardia lamblia , followed by Salmonella species, Campylobacter species, and rotavirus.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • The majority of IgA-deficient patients are asymptomatic, although the absence of IgA has been associated with the development of recurrent infections and autoimmune diseases (possibly in association with IgG subclass deficiency).
    • Patients with concurrent IgG2 deficiency present with frequent upper respiratory tract infections and diarrhea.
    • The serum IgA level is usually very low to absent (often <5 mg/dL).
    Selective IgA deficiency 
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • Secretory IgA plays a major role in excluding antigens entering through the mucosal route.
    • IgM, might compensate for the lack of IgA.
    • Gastrointestinal infections leading to chronic diarrhea and steatorrhea occur with an increased frequency in patients with IgA deficiency commonly related to G lamblia.
    • Steatorrhea and villous flattening from chronic infection occur because of effacement of the mucosa and disruption of the absorptive capacity for lipids and carbohydrates .
    Selective IgA deficiency 
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • Secretory IgA plays a major role in excluding antigens entering through the mucosal route.
    • IgM, might compensate for the lack of IgA.
    • Gastrointestinal infections leading to chronic diarrhea and steatorrhea occur with an increased frequency in patients with IgA deficiency commonly related to G lamblia.
    • Steatorrhea and villous flattening from chronic infection occur because of effacement of the mucosa and disruption of the absorptive capacity for lipids and carbohydrates .
    Selective IgA deficiency  The diagnosis is made based on the results of stool examination for cysts or trophozoites of G lamblia ; however, duodenal aspirates can yield more positive findings.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658
    • Secretory IgA plays a major role in excluding antigens entering through the mucosal route.
    • IgM, might compensate for the lack of IgA.
    • Gastrointestinal infections leading to chronic diarrhea and steatorrhea occur with an increased frequency in patients with IgA deficiency commonly related to G lamblia.
    • Steatorrhea and villous flattening from chronic infection occur because of effacement of the mucosa and disruption of the absorptive capacity for lipids and carbohydrates .
    Selective IgA deficiency  Giardia species infections can be treated with metronidazole but are often unremitting in IgA-deficient patients.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658 Selective IgA deficiency 
    • There is a 10- to 20-fold increased risk for celiac disease in patients with IgA deficiency.
    • Secretory IgA can bind to wheat gluten and gliadin; thus in the absence of IgA, there might be abnormal handling of these antigens.
    • the specific IgA-class antibodies against gliadin, endomysium, and tissue transglutaminase are not produced in IgA-deficient patients.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658 Selective IgA deficiency 
    • There is a 10- to 20-fold increased risk for celiac disease in patients with IgA deficiency.
    • Secretory IgA can bind to wheat gluten and gliadin; thus in the absence of IgA, there might be abnormal handling of these antigens.
    • the specific IgA-class antibodies against gliadin, endomysium, and tissue transglutaminase are not produced in IgA-deficient patients.
    However, serum IgG tissue transglutaminase levels are increased in IgA-deficient patients with coexisting celiac disease and can be used as a diagnostic marker.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658 Selective IgA deficiency 
    • Another intestinal abnormality in patients with IgA deficiency is NLH ( Nodular lymphoid hyperplasia ).
    • These nodules are usually multiple number and commonly 5 mm or greater in size.
    • They are found largely in the lamina propria, superficial submucosa of the small intestine,
    • The lesions can be associated with mucosal flattening, leading to malabsorption, if large enough, the nodules can cause obstruction.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658 Selective IgA deficiency 
    • Another intestinal abnormality in patients with IgA deficiency is NLH ( Nodular lymphoid hyperplasia ).
    • These nodules are usually multiple number and commonly 5 mm or greater in size.
    • They are found largely in the lamina propria, superficial submucosa of the small intestine,
    • The lesions can be associated with mucosal flattening, leading to malabsorption, if large enough, the nodules can cause obstruction.
    These nodules contain large amounts of IgM-bearing cells, this represents an attempt by the intestine to compensate for the absent IgA.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658 CVID: common variable immunodeficiency
    • The most common symptomatic primary immunodeficiency.
    • The diagnosis of CVID is established based on reduced levels of 2 serum immunoglobulins (ie, IgG and IgA, IgM, or both) at least 2 standard deviations below the age-specific mean values in addition to impaired specific antibody production in response to vaccination in vivo or recent infections.
    • Most common clinical manifestations are recurrent sinopulmonary infections, although autoimmunity and gastrointestinal disease are also quite prevalent and may be the initial presentation of CVID.
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658 CVID: common variable immunodeficiency
    • The most common symptomatic primary immunodeficiency.
    • The diagnosis of CVID is established based on reduced levels of 2 serum immunoglobulins (ie, IgG and IgA, IgM, or both) at least 2 standard deviations below the age-specific mean values in addition to impaired specific antibody production in response to vaccination in vivo or recent infections.
    • Most common clinical manifestations are recurrent sinopulmonary infections, although autoimmunity and gastrointestinal disease are also quite prevalent and may be the initial presentation of CVID.
    • D iarrhea.
    • S teatorrhea.
    • Giardiasis.
    • Malabsorption
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658 CVID: common variable immunodeficiency
    • The most common symptomatic primary immunodeficiency.
    • The diagnosis of CVID is established based on reduced levels of 2 serum immunoglobulins (ie, IgG and IgA, IgM, or both) at least 2 standard deviations below the age-specific mean values in addition to impaired specific antibody production in response to vaccination in vivo or recent infections.
    • Most common clinical manifestations are recurrent sinopulmonary infections, although autoimmunity and gastrointestinal disease are also quite prevalent and may be the initial presentation of CVID.
    • G lamblia
    • Cryptosporidium parvum
    • Cytomegalovirus
    • Salmonella
    • Clostridium difficile
    • Campylobacter jejuni
    • Helicobacter pylori
  • Pathogenesis and treatment of gastrointestinal disease in antibody deficiency syndromes Agarwal JACI 2009;124:658 Conclusion  
    • P atients with humoral immunodeficiency would benefit from routine evaluation of the gut given the frequency of gastrointestinal manifestations.
    • These intestinal diseases do not necessarily correlate with the severity of underlying immunodeficiency, and treatment of the antibody deficiency with replacement immunoglobulin in most cases does not reverse progression of the gastrointestinal disease.
  • Common Variable Immunodeficiency Disorders in Children: Delayed Diagnosis Despite Typical Clinical Presentation S. Urschel, J Ped 2009;154:807
    • Common variable immunodeficiency disorders (CVID) represent the most frequent symptomatic primary immunodeficiency in North America and Europe.
    • Incidence of 1:25000 to 1:66000.
    • The diagnosis requires a history of:
    • recurrent or chronic bacterial infections;
    • significant reduction of immunoglobulin G (IgG) (2 DS);
    • reduction of immunoglobulin A (IgA) or immunoglobulin M (IgM);
    • defective specific antibody production after vaccination.
    • (www.ESID.org)
  • Common Variable Immunodeficiency Disorders in Children: Delayed Diagnosis Despite Typical Clinical Presentation S. Urschel, J Ped 2009;154:807
    • clinical findings
    • in 32 children
    • with primary CVID
    100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % children 88% 88% 78% 78% 34% 25% 16% Recurrent or chronic respiratory tract infections Sinusitis Otitis media Intestinal tract infections Sepsis Meningitis
  • Common Variable Immunodeficiency Disorders in Children: Delayed Diagnosis Despite Typical Clinical Presentation S. Urschel, J Ped 2009;154:807
    • clinical findings
    • in 32 children
    • with primary CVID
    % children 50 – 40 – 30 – 20 – 10 – 0 Allergic disorders Growth retardation 28% 38% 34% 16% Bronchiectasis Pyelonephritis
  • Common Variable Immunodeficiency Disorders in Children: Delayed Diagnosis Despite Typical Clinical Presentation S. Urschel, J Ped 2009;154:807
    • clinical findings
    • in 32 children
    • with primary CVID
    % children 50 – 40 – 30 – 20 – 10 – 0 Allergic disorders Growth retardation 28% 38% 34% 16% Bronchiectasis Pyelonephritis Mean time between symptoms and induction of immunoglobulin substitution therapy was 5.8 years
  • Effectiveness of Adenotonsillectomy in PFAPA Syndrome: A Randomized Study W Garavello, J Ped 2009;155:250 % patients experiencing complete resolution after 18 month 63% surgery p<0.001 5% control 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • PFAPA syndrome
    • (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis)
    • 39 children with PFAPA syndrome
    • adenotonsillectomy (surgery group; n = 19) or expectant management (control group; n = 20)
    • PFAPA syndrome
    • (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis)
    • 39 children with PFAPA syndrome
    • adenotonsillectomy (surgery group; n = 19) or expectant management (control group; n = 20)
    n° of episodes in 18 months follow-up 0.7 surgery p<0.001 8.1 controls 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 Effectiveness of Adenotonsillectomy in PFAPA Syndrome: A Randomized Study W Garavello, J Ped 2009;155:250
    • PFAPA syndrome
    • (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis)
    • 39 children with PFAPA syndrome
    • adenotonsillectomy (surgery group; n = 19) or expectant management (control group; n = 20)
    n° of episodes in 18 months follow-up 0.7 surgery p<0.001 8.1 controls 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 Effectiveness of Adenotonsillectomy in PFAPA Syndrome: A Randomized Study W Garavello, J Ped 2009;155:250 Adenotonsillectomy is an effective treatment strategy for children with PFAPA syndrome
  • INFECTIOUS DISEASES
    • children aged 3–36 months;
    • extreme leucocytosis (white blood cell (WBC) count >25,000/mm³);
    • WBC counts of 15,000–24,999/mm³ (moderate leucocytosis);
    • 146 patients with extreme leucocytosis;
    • 292 patients with moderate leucocytosis.
    % children with serious bacterial infection 50 – 40 – 30 – 20 – 10 – 0 EXTREME Extreme leucocytosis and the risk of serious bacterial infections in febrile children M Brauner, Arch Dis Child 2010;95:209 MODERATE 39% 15.4% LEUCOCYTOSIS
  • % children with lobar pneumonia 50 – 40 – 30 – 20 – 10 – 0 EXTREME Extreme leucocytosis and the risk of serious bacterial infections in febrile children M Brauner, Arch Dis Child 2010;95:209 MODERATE 28% RR=3.8 0.2% LEUCOCYTOSIS P<0.001
    • children aged 3–36 months;
    • extreme leucocytosis (white blood cell (WBC) count >25,000/mm³);
    • WBC counts of 15,000–24,999/mm³ (moderate leucocytosis);
    • 146 patients with extreme leucocytosis;
    • 292 patients with moderate leucocytosis.
  • % children with lobar pneumonia 50 – 40 – 30 – 20 – 10 – 0 EXTREME Extreme leucocytosis and the risk of serious bacterial infections in febrile children M Brauner, Arch Dis Child 2010;95:209 MODERATE 28% RR=3.8 0.2% LEUCOCYTOSIS P<0.001
    • children aged 3–36 months;
    • extreme leucocytosis (white blood cell (WBC) count >25,000/mm³);
    • WBC counts of 15,000–24,999/mm³ (moderate leucocytosis);
    • 146 patients with extreme leucocytosis;
    • 292 patients with moderate leucocytosis.
    In febrile children aged 3–36 months, the presence of extreme leucocytosis is associated with a 39% risk of having serum bacterial infections (SBIs). The increased risk for SBI is mainly due to a higher risk for pneumonia.
  • Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review A Van den Bruel, Lancet 2010;375:834
    • Clinical features with a positive likelihood ratio of more than 5.0 were deemed red flags (ie, warning signs for serious infection);
    • 30 studies
    • Cyanosis
    • Rapid breathing
    • Poor peripheral perfusion (>2”)
    • Parental concern
    • Clinician instinct
    • Temperature ≥40°C in settings with a low prevalence of serious infection (ambulatory pediatrics)
  • Identifying sick children in primary care Dawes, Lancet 2010;375:784
    • In developed countries, every child will present to a primary health-care practitioner more than once every year with symptoms of an acute infection
    • Primary care physicians know that the likelihood of serious disease is about 1% Van Der Bruel, Lancet 2010;375:834
    • Cyanosis, rapid breathing, poor peripheral perfusion, and petechial rash are red flags (ie, warning signs) for serious infection
    raising the probability of severe illness from 1% to between 25% and 30%
  • Identifying sick children in primary care Dawes, Lancet 2010;375:784
    • Parental concern and clinician’s instinct were also identified as strong red flags
    • A high temperature of more than 40°C has a post-test probability of 5% for serious illness
    • The false reassurance of a normal temperature is also disturbing, since this is not a useful rule-out sign
    • 700 children (median age 3 years)
    • Severity of infection categorised as Serious , Intermediate , Minor or not Infection
    HOW WELL DO VITAL SIGNS IDENTIFY CHILDREN WITH SERIOUS INFECTIONS IN PAEDIATRIC EMERGENCY CARE? Thompson Arch Dis Child 2009;94:888
    • Temperature ≥39°C
    • Tachycardia
    • Saturations ≤94%
    • Capillary refill time (CRT) > 2 seconds
    Children with serious or intermediate infections were significantly more likely than those with minor or no infection to have:
    • 700 children (median age 3 years)
    • Severity of infection categorised as Serious , Intermediate , Minor or not Infection
    HOW WELL DO VITAL SIGNS IDENTIFY CHILDREN WITH SERIOUS INFECTIONS IN PAEDIATRIC EMERGENCY CARE? Thompson Arch Dis Child 2009;94:888 Having one or more of: -temperature ≥39°C, -saturations ≤94%, -tachycardia and -tachypnoea was 80% sensitive and 39% specific for serious or intermediate infection.
  • Receiver operating characteristic curves for procalcitonin ( PCT ), C reactive protein ( CRP ), and leucocyte count ( WCC ).
    • Serious bacterial infection (SBI)
    • 347 infants < 3 months of age seen in the emergency department for a febrile syndrome with no identifiable focus
    MARKERS THAT PREDICT SERIOUS BACTERIAL INFECTION IN INFANTS UNDER 3 MONTHS OF AGE PRESENTING WITH FEVER OF UNKNOWN ORIGIN Olaciregui Arch Dis Child 2009;94:501
  • Receiver operating characteristic curves for procalcitonin ( PCT ), C reactive protein ( CRP ), and leucocyte count ( WCC ).
    • Serious bacterial infection (SBI)
    • 347 infants < 3 months of age seen in the emergency department for a febrile syndrome with no identifiable focus
    MARKERS THAT PREDICT SERIOUS BACTERIAL INFECTION IN INFANTS UNDER 3 MONTHS OF AGE PRESENTING WITH FEVER OF UNKNOWN ORIGIN Olaciregui Arch Dis Child 2009;94:501 PCT and CRP were stronger predictors than leucocyte count
  • MARKERS THAT PREDICT SERIOUS BACTERIAL INFECTION IN INFANTS UNDER 3 MONTHS OF AGE PRESENTING WITH FEVER OF UNKNOWN ORIGIN Olaciregui Arch Dis Child 2009;94:501
  • MARKERS THAT PREDICT SERIOUS BACTERIAL INFECTION IN INFANTS UNDER 3 MONTHS OF AGE PRESENTING WITH FEVER OF UNKNOWN ORIGIN Olaciregui Arch Dis Child 2009;94:501
    • 153 febrile infants with a bulging fontanelle who underwent a lumbar puncture
    • age range 3–11 months
    BULGING FONTANELLE IN FEBRILE INFANTS: IS LUMBAR PUNCTURE MANDATORY? Shacham Arch Dis Child 2009;94:690 % infants with good-excellent appearance at presentation 73.8% None of whom had bacterial meningitis 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • 153 febrile infants with a bulging fontanelle who underwent a lumbar puncture
    • age range 3–11 months
    BULGING FONTANELLE IN FEBRILE INFANTS: IS LUMBAR PUNCTURE MANDATORY? Shacham Arch Dis Child 2009;94:690 % infants with good-excellent appearance at presentation 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 All infants who appeared well on admission and had normal clinical, laboratory and imaging studies had benign (non-bacterial) disease 73.8% None of whom had bacterial meningitis
    • 153 febrile infants with a bulging fontanelle who underwent a lumbar puncture
    • age range 3–11 months
    BULGING FONTANELLE IN FEBRILE INFANTS: IS LUMBAR PUNCTURE MANDATORY? Shacham Arch Dis Child 2009;94:690 Final diagnosis in 153 febrile infants with a bulging fontanelle
  • Fulminant pertussis: A multi-center study with new insights into the clinico-pathological mechanisms Sawal , Ped Pul 2009;44:970
    • Pertussis carries a high risk of mortality in very young infants.
    • Multi-center review of clinical records and post-mortem findings of 10 patients with fulminant pertussis.
    • All cases were < 8 weeks of age, and required ventilation for worsening respiratory symptoms and inotropic support for severe hemodynamic compromise.
    • All died or underwent extra corporeal membrane oxygenation (ECMO) within 1 week.
    • All had increased leukocyte counts (from 54 to 132 × 10 9 /L) with prominent neutrophilia in 9/10.
    • Pertussis carries a high risk of mortality in very young infants.
    • Multi-center review of clinical records and post-mortem findings of 10 patients with fulminant pertussis.
    • The post-mortem demonstrated necrotizing bronchitis and bronchiolitis with extensive areas of necrosis of the alveolar epithelium.
    • Other organisms were isolated as follows; 2/10 cases Para influenza type 3 , 2/10 Moraxella catarrhalis , 1/10 each with respiratory syncytial virus (RSV), a coliform organism , methicillin-resistant Staphylococcus aureus (MRSA), Haemophilus influenzae , Stenotrophomonas maltophilia , methicillin-sensitive Staphylococcus aureus (MSSA), and candida tropicalis .
    Fulminant pertussis: A multi-center study with new insights into the clinico-pathological mechanisms Sawal , Ped Pul 2009;44:970
    • Severe hypoxemia and intractable cardiac failure may be due to the effects of pertussis toxin,
    • Necrotizing bronchiolitis, extensive damage to the alveolar epithelium, tenacious airway secretions, and possibly leukostasis with activation of the immunological cascade, all contributing to increased pulmonary vascular resistance.
    Fulminant pertussis: A multi-center study with new insights into the clinico-pathological mechanisms Sawal , Ped Pul 2009;44:970
    • Pertussis carries a high risk of mortality in very young infants.
    • Multi-center review of clinical records and post-mortem findings of 10 patients with fulminant pertussis.
  • mean days in hospital 10 PCR (+) 4 PCR (-)
    • 33 patients aged 30 days or less who had a positive pertussis polymerase chain reaction (PCR).
    • Compared with 35 infants who had a negative pertussis PCR.
    p<0.001 Clinical Characteristics and Outcomes of Neonatal Pertussis: A Comparative Study Castagnini J Pediatr 2010;156:498 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0
  • % children PCR (+) PCR (-) 39% 15% P=0.02 Clinical Characteristics and Outcomes of Neonatal Pertussis: A Comparative Study Castagnini J Pediatr 2010;156:498 WITH TACHYPNEA % children PCR (+) PCR (-) 27% 58% P=0.013 WITH APNEA 60 - 50 – 40 – 30 – 20 – 10 – 0 40 – 30 – 20 – 10 – 0
  • mean lymphocyte count x 1000/dL 14.5 PCR (+) 7.5 PCR (-)
    • 33 patients aged 30 days or less who had a positive pertussis polymerase chain reaction (PCR).
    • Compared with 35 infants who had a negative pertussis PCR.
    p<0.001 Clinical Characteristics and Outcomes of Neonatal Pertussis: A Comparative Study Castagnini J Pediatr 2010;156:498 15 – 10 – 5 – 0
  • Incidence of Invasive Community-Onset Staphylococcus aureus Infections in Children in Central New York M Suryadevara, J Ped 2010;156:152
    • S aureus isolates from sterile sites in children
    • <19 years of age, hospitalized between January 1996 and December 2006
    • community-onset
    • S aureus infection when
    • the cultures were obtained <48 hours after hospitalization
    The prevalence of invasive S aureus infections in our institution remained <1% between 1996 and 2006, although the proportion of methicillin resistant S aureus infections significantly increased
  • Incidence of Invasive Community-Onset Staphylococcus aureus Infections in Children in Central New York M Suryadevara, J Ped 2010;156:152
    • S aureus isolates from sterile sites in children
    • <19 years of age, hospitalized between January 1996 and December 2006
    • community-onset
    • S aureus infection when
    • the cultures were obtained <48 hours after hospitalization
  • Incidence of Invasive Community-Onset Staphylococcus aureus Infections in Children in Central New York M Suryadevara, J Ped 2010;156:152
    • S aureus isolates from sterile sites in children
    • <19 years of age, hospitalized between January 1996 and December 2006
    • community-onset
    • S aureus infection when
    • the cultures were obtained <48 hours after hospitalization
    The Proportion of MRSA cases increased significantly from 3% (1/37) in 1996-1999 to 17% (10/60) in 2003-2006, p = 0.023
    • 5 RCT involving children (3 weeks to 16 years)
    SHORT VERSUS LONG DURATION OF ANTIBIOTIC THERAPY FOR BACTERIAL MENINGITIS: A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS IN CHILDREN Karageorgopoulos Arch Dis Child 2009;94:607
    • 5 RCT involving children (3 weeks to 16 years)
    SHORT VERSUS LONG DURATION OF ANTIBIOTIC THERAPY FOR BACTERIAL MENINGITIS: A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS IN CHILDREN Karageorgopoulos Arch Dis Child 2009;94:607 No difference was demonstrated between short-course (4–7 days) and long-course (7–14 days) treatment (intravenous ceftriaxone) regarding: end-of-therapy clinical success
    • Metabolism
    • Obesity
    • Metabolism
    • Obesity causes
    • Infants receiving no breast milk grew faster than those whose mothers initiated breastfeeding, as did those breastfed for less than 4 months versus those breastfed 4 months or longer
    • Early introduction of solids was not associated with faster weight gain
    • effect of breastfeeding initiation, breastfeeding duration and age at introduction of solid foods on weight gain from birth to 3 years
    • weight gain z-scores from birth to 3 years (adjusted for birthweight)
    EFFECTS OF INFANT FEEDING PRACTICE ON WEIGHT GAIN FROM BIRTH TO 3 YEARS Griffiths Arch Dis Child 2009;94:577
    • Infants receiving no breast milk grew faster than those whose mothers initiated breastfeeding, as did those breastfed for less than 4 months versus those breastfed 4 months or longer
    • Early introduction of solids was not associated with faster weight gain
    • effect of breastfeeding initiation, breastfeeding duration and age at introduction of solid foods on weight gain from birth to 3 years
    • weight gain z-scores from birth to 3 years (adjusted for birthweight)
    EFFECTS OF INFANT FEEDING PRACTICE ON WEIGHT GAIN FROM BIRTH TO 3 YEARS Griffiths Arch Dis Child 2009;94:577 Initiating and prolonging breastfeeding may reduce excess weight gain by preschool age.
  • Clustering of Dietary Intake and Sedentary Behavior in 2-Year-Old Children J Gubbels, J Ped 2009;155:194
    • Lifestyle habits are formed at an early age and track in later life
    • Parents of 2578 2-year-old children completed a questionnaire
    • Two clusters emerged:
    • ‘‘ sedentary-snacking cluster’’
    • ‘‘ fiber cluster”
    • 2. Lower maternal education and maternal obesity were associated with high scores on the sedentary-snacking cluster, whereas higher educational level was associated with high fiber cluster scores
  • Clustering of Dietary Intake and Sedentary Behavior in 2-Year-Old Children J Gubbels, J Ped 2009;155:194
    • Lifestyle habits are formed at an early age and track in later life
    • Parents of 2578 2-year-old children completed a questionnaire
    • Two clusters emerged:
    • ‘‘ sedentary-snacking cluster’’
    • ‘‘ fiber cluster”
    • 2. Lower maternal education and maternal obesity were associated with high scores on the sedentary-snacking cluster, whereas higher educational level was associated with high fiber cluster scores
    Obesity-prone behavioral clusters in 2-year-old children are related to maternal characteristics . The findings suggest that obesity prevention should apply an integrated approach to physical activity and dietary intake in early childhood
  • Maternal Perception of Weight Status and Health Risks Associated With Obesity in Children Warschburger Pediatrics 2009;124;e60
    • 219 mothers with children between 3 and 6 years of age were presented with 9 silhouettes representing different age- and genderspecific BMI percentiles
    • 219 mothers with children between 3 and 6 years of age were presented with 9 silhouettes representing different age- and genderspecific BMI percentiles
    Maternal Perception of Weight Status and Health Risks Associated With Obesity in Children Warschburger Pediatrics 2009;124;e60 64.5% % MOTHERS 48.8% IDENTIFIED THE OVERWEIGHT SILHOUETTES CORRECTLY IDENTIFIED THE OVERWEIGHT SILHOUETTES ASSOCIATED WITH AN INCREASED RISK FOR PHYSICAL HEALTH PROBLEMS 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • 219 mothers with children between 3 and 6 years of age were presented with 9 silhouettes representing different age- and genderspecific BMI percentiles
    Maternal Perception of Weight Status and Health Risks Associated With Obesity in Children Warschburger Pediatrics 2009;124;e60 Mothers with a lower educational background were more likely to misclassify the overweight silhouettes and underestimate the associated health problems 64.5% % MOTHERS 48.8% IDENTIFIED THE OVERWEIGHT SILHOUETTES CORRECTLY IDENTIFIED THE OVERWEIGHT SILHOUETTES ASSOCIATED WITH AN INCREASED RISK FOR PHYSICAL HEALTH PROBLEMS 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • 219 mothers with children between 3 and 6 years of age were presented with 9 silhouettes representing different age- and genderspecific BMI percentiles
    Maternal Perception of Weight Status and Health Risks Associated With Obesity in Children Warschburger Pediatrics 2009;124;e60 This underestimation was associated with a higher maternal and child weight status 64.5% % MOTHERS 48.8% IDENTIFIED THE OVERWEIGHT SILHOUETTES CORRECTLY IDENTIFIED THE OVERWEIGHT SILHOUETTES ASSOCIATED WITH AN INCREASED RISK FOR PHYSICAL HEALTH PROBLEMS 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • Perceived body size was assessed using a visual method matching to images representing body mass indexes (BMI) from 3rd to 97th percentiles and verbal descriptors from ‘‘too thin’’ to ‘‘too fat’’.
    WEIGHT STATUS AND PERCEIVED BODY SIZE IN CHILDREN Saxton Arch Dis Child 2009;94:944
    • Perceived body size was assessed using a visual method matching to images representing body mass indexes (BMI) from 3rd to 97th percentiles and verbal descriptors from ‘‘too thin’’ to ‘‘too fat’’.
    WEIGHT STATUS AND PERCEIVED BODY SIZE IN CHILDREN Saxton Arch Dis Child 2009;94:944 Mean inaccuracy (standard error) of body size perception using visual ratings
    • Perceived body size was assessed using a visual method matching to images representing body mass indexes (BMI) from 3rd to 97th percentiles and verbal descriptors from ‘‘too thin’’ to ‘‘too fat’’.
    WEIGHT STATUS AND PERCEIVED BODY SIZE IN CHILDREN Saxton Arch Dis Child 2009;94:944 Mean inaccuracy (standard error) of body size perception using visual ratings Conclusions: Children show greater underestimation at higher weights, especially in girls
  • % of misperceivers 29% 1999 33% 2007 Where Perception Meets Reality: Self-Perception of Weight in Overweight Adolescents Edwards Pediatrics 2010;125:e452
    • Youth Risk Behavior Surveillance System, from 1999 through 2007.
    • Overweight and obese respondents (BMI 85th percentile) were classified into 2 groups: (1) misperceivers ( weight perception “about right” or “underweight” ) or (2) accurate perceivers (weight perception “overweight”).
    50 – 40 – 30 – 20 – 10 – 0
  • in 2007 % of misperceivers Where Perception Meets Reality: Self-Perception of Weight in Overweight Adolescents Edwards Pediatrics 2010;125:e452 50 – 40 – 30 – 20 – 10 – 0 boys girls 23% 40% P<0.001
    • Youth Risk Behavior Surveillance System, from 1999 through 2007.
    • Overweight and obese respondents (BMI 85th percentile) were classified into 2 groups: (1) misperceivers ( weight perception “about right” or “underweight” ) or (2) accurate perceivers (weight perception “overweight”).
    overweight
    • Youth Risk Behavior Surveillance System, from 1999 through 2007.
    • Overweight and obese respondents (BMI 85th percentile) were classified into 2 groups: (1) misperceivers (weight perception “about right” or “underweight”) or (2) accurate perceivers (weight perception “overweight”).
    in 2007 % of misperceivers Where Perception Meets Reality: Self-Perception of Weight in Overweight Adolescents Edwards Pediatrics 2010;125:e452 50 – 40 – 30 – 20 – 10 – 0 boys girls 23% 40% P<0.001 Both male and female accurate perceivers were significantly more likely than misperceivers to report trying to maintain or lose weight, exercising for weight control, and eating less for weight control. overweight
    • Youth Risk Behavior Surveillance System, from 1999 through 2007.
    • Overweight and obese respondents (BMI 85th percentile) were classified into 2 groups: (1) misperceivers (weight perception “about right” or “underweight”) or (2) accurate perceivers (weight perception “overweight”).
    in 2007 % of misperceivers Where Perception Meets Reality: Self-Perception of Weight in Overweight Adolescents Edwards Pediatrics 2010;125:e452 50 – 40 – 30 – 20 – 10 – 0 boys girls 23% 40% P<0.001 Nearly 3 in 10 overweight adolescents do not consider themselves overweight. overweight
  • Sugar-Sweetened Beverages, Serum Uric Acid, and Blood Pressure in Adolescents S. Nguyen, J Ped 2009;154:807
    • 4867 adolescents
    • 24-hour dietary recall interviews
    p=0.01 for trend
  • Sugar-Sweetened Beverages, Serum Uric Acid, and Blood Pressure in Adolescents S. Nguyen, J Ped 2009;154:807
    • 4867 adolescents
    • 24-hour dietary recall interviews
    p=0.01 for trend Also systolic blood pressure z -score increased from the lowest to the highest category of sugar-sweetened beverage consumption ( P for trend=0.03)
  • Sugar-Sweetened Beverages, Serum Uric Acid, and Blood Pressure in Adolescents S. Nguyen, J Ped 2009;154:807
    • High fructose corn syrup has become the most popular sweetener used in processed foods , especially in beverages such as sodas and fruit drinks.
    • Fructose, unlike glucose or other monosaccharide sugars, is solely metabolized in the liver, where it induces nucleotide catabolism , thereby producing uric acid .
    • This may be important because serum uric acid has been suggested to be a marker of cardiovascular disease risk and a potential intermediate step toward the development of hypertension.
  • % obese children 14.3% 24.5% YES none of the 3
    • 8550 four-year-old US children in 2005 in the Early Childhood Longitudinal Study, Birth Cohort.
    • 3 household routines: regularly eating the evening meal as a family (>5 nights per week); obtaining adequate nighttime sleep on weekdays (≥10.5 hours per night); and having limited screen-viewing (television, video, digital video disk) time on weekdays (≤2 hours/day).
    Household Routines and Obesity in US Preschool-Aged Children Anderson Pediatrics 2010;125:420 exposed to all 3 routines 30 – 20 – 10 – 0
  • % obese children 1.0 Household Routines and Obesity in US Preschool-Aged Children Anderson Pediatrics 2010;125:420 n° of Routines exposed 0.84 0.64 0.63 1.0 – 0.5 – 0 0 1 2 3
    • 8550 four-year-old US children in 2005 in the Early Childhood Longitudinal Study, Birth Cohort.
    • 3 household routines: regularly eating the evening meal as a family (>5 nights per week); obtaining adequate nighttime sleep on weekdays (≥10.5 hours per night); and having limited screen-viewing (television, video, digital video disk) time on weekdays (≤2 hours/day).
    • 8550 four-year-old US children in 2005 in the Early Childhood Longitudinal Study, Birth Cohort.
    • 3 household routines: regularly eating the evening meal as a family (>5 nights per week); obtaining adequate nighttime sleep on weekdays (≥10.5 hours per night); and having limited screen-viewing (television, video, digital video disk) time on weekdays (≤2 hours/day).
    % obese children 1.0 0 Household Routines and Obesity in US Preschool-Aged Children Anderson Pediatrics 2010;125:420 n° of Routines exposed 0.84 0.64 0.63 1.0 – 0.5 – 0 Preschool-aged children exposed to the 3 household routines of regularly eating the evening meal as a family, obtaining adequate nighttime sleep, and having limited screen-viewing time had an ~40% lower prevalence of obesity than those exposed to none of these routines. 2 1 3
    • Metabolism
    • Obesity consequences
    • a school-based longitudinal study in 1997, 2000, 2005.
    • 923 adolescents
    80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % children 20.8% never childhood only adolescence only persistent Comorbidities of overweight/obesity experienced in adolescence: longitudinal study M Wake, Arch Dis Child 2010;95:162 8.5% 63.5% 7.3% classified as overweight/obese
  • 10 - 9 - 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 Comorbidities of overweight/obesity experienced in adolescence: longitudinal study M Wake, Arch Dis Child 2010;95:162 OR in current obesity compared to non over-weight for Lower QoL hypertension dieting 8.86 3.52 5.79
    • a school-based longitudinal study in 1997, 2000, 2005.
    • 923 adolescents
  • 10 - 9 - 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 Comorbidities of overweight/obesity experienced in adolescence: longitudinal study M Wake, Arch Dis Child 2010;95:162 OR in current obesity compared to non over-weight for Lower QoL hypertension dieting 8.86 3.52 5.79
    • a school-based longitudinal study in 1997, 2000, 2005.
    • 923 adolescents
    Only dieting (OR 2.30) was associated with resolved childhood overweight
  • Childhood Obesity, Other Cardiovascular Risk Factors, and Premature Death Franks N Engl J Med 2010;362:485
    • A cohort of 4857 American Indian children without diabetes born between 1945 and 1984.
    • There were 166 deaths from endogenous causes (3.4% of the cohort) during a median follow-up period of 23.9 years.
    OR for death 2.3 Among children in the highest quartile of BMI 3 – 2 – 1 – 0
    • A cohort of 4857 American Indian children without diabetes born between 1945 and 1984.
    • There were 166 deaths from endogenous causes (3.4% of the cohort) during a median follow-up period of 23.9 years.
    1.73 2 – 1 – 0 Among children in the highest quartile of glucose intolerance OR for death Childhood Obesity, Other Cardiovascular Risk Factors, and Premature Death Franks N Engl J Med 2010;362:485
  • Metabolic Risk Varies According to Waist Circumference (WC) Measurement Site in Overweight Boys and Girls Johnson J Pediatr 2010;156:247 With logistic regression, WC2 and WC3 were revealed to be more consistently associated with metabolic syndrome by using 3 different definitions.
    • Overweight (mean body mass index percentile, 98.7) children and adolescents (n = 73; 41 girls, 32 boys; mean age, 12.5 years).
    • WC measured at 4 sites: iliac crest (WC1), narrowest waist (WC2), midpoint between the floating rib and iliac crest (WC3), and umbilicus (WC4).
    • Overweight (mean body mass index percentile, 98.7) children and adolescents (n = 73; 41 girls, 32 boys; mean age, 12.5 years).
    • WC measured at 4 sites: iliac crest (WC1), narrowest waist (WC2), midpoint between the floating rib and iliac crest (WC3), and umbilicus (WC4).
    Waist circumference (cm) 120 – 100 – 80 – 60 – 40 – 20 – 0 97.4 104.3 108.7 108.5 P=0.02 P<0.003 WC1 WC2 WC3 WC4 Metabolic Risk Varies According to Waist Circumference (WC) Measurement Site in Overweight Boys and Girls Johnson J Pediatr 2010;156:247
  • Association of the Metabolic Syndrome With Pulmonary Venous Hypertension Robbins Chest 2009;136:31
    • 122 consecutive patients referred for diagnosis and treatment of pulmonary hypertension(PH)
    • Pulmonary venous hypertension (PVH)
    • Pulmonary arterial hypertension (PAH)
    • Metabolic syndrome (MS)
    PVH 94.1% 34.3% PAH 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 P<0.001 % subjects with ≥2 features of the MS OR=30.7
  • Association of the Metabolic Syndrome With Pulmonary Venous Hypertension Robbins Chest 2009;136:31
    • 122 consecutive patients referred for diagnosis and treatment of pulmonary hypertension(PH)
    • Pulmonary venous hypertension (PVH)
    • Pulmonary arterial hypertension (PAH)
    • Metabolic syndrome (MS)
    % subjects with ≥2 features of the MS PVH 34.3% PAH 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 P<0.001
    • Hypertension
    • Obesity
    • Diabetes mellitus
    • Hyperlipidemia
    94.1% OR=30.7
    • Metabolism
    • Obesity remedies
  • Parental Confidence in Making Overweight-Related Behavior Changes Taveras Pediatrics 2009;124:151
    • 446 parents of children, aged 2 to 12 years, with a BMI of ≥ 85th percentile
    • Parental confidence score from 6 questions regarding parental confidence in:
    • 1) limiting television viewing,
    • 2) removing televisions from children’s bedrooms,
    • 3) reducing fast-food intake,
    • 4) reducing sugar-sweetened beverage intake,
    • 5)increasing physical activity, and
    • 6)improving overall eating patterns for their family.
    Clinician assessment of parental confidence and readiness to change was associated with higher parent confidence in making changes to keep their child from being overweight
  • Nutrition Menu Labeling May Lead to Lower-Calorie Restaurant Meal Choices for Children Tandon Pediatrics 2010;125:244
    • 99 p arents were presented with a McDonald’s menu and were asked to select meals for themselves and their child.
    • Intervention group had a menu reporting calories
    Menu calories ordered 567.1 700 – 600 – 500 – 400 – 300 – 200 – 100 – 0 671.5 p= 0.04 Groups Intervention Control
    • Secular changes in body mass index (BMI) and cardiorespiratory fitness (20 m shuttle-run test performance)
    • 10-year-old children
    • In 1998 (n=303) and 2008 (n= 315)
    TEN YEAR SECULAR DECLINES IN THE CARDIORESPIRATORY FITNESS OF AFFLUENT ENGLISH CHIDREN ARE LARGELY INDEPENDENT OF CHARGES IN BODY MASS INDEX Sandercock Arch Dis Child 2010;95:46 BMI (Kg/m 2 ) 1998 17.6 30 – 20 – 10 – 0 2008 18.3 18.6 18.4 1998 2008 BOYS GIRLS p=0.02
    • Secular changes in body mass index (BMI) and cardiorespiratory fitness (20 m shuttle-run test performance)
    • 10-year-old children
    • In 1998 (n=303) and 2008 (n= 315)
    TEN YEAR SECULAR DECLINES IN THE CARDIORESPIRATORY FITNESS OF AFFLUENT ENGLISH CHIDREN ARE LARGELY INDEPENDENT OF CHARGES IN BODY MASS INDEX Sandercock Arch Dis Child 2010;95:46 BMI (Kg/m 2 ) 1998 17.6 30 – 20 – 10 – 0 2008 18.3 18.6 18.4 1998 2008 BOYS GIRLS p=0.02 Girls ’ BMI did not change over the 10 year period. There was a significant increase in boys ’ BMI ( p=0.02 )
    • Secular changes in body mass index (BMI) and cardiorespiratory fitness (20 m shuttle-run test performance)
    • 10-year-old children
    • In 1998 (n=303) and 2008 (n= 315)
    TEN YEAR SECULAR DECLINES IN THE CARDIORESPIRATORY FITNESS OF AFFLUENT ENGLISH CHIDREN ARE LARGELY INDEPENDENT OF CHARGES IN BODY MASS INDEX Sandercock Arch Dis Child 2010;95:46 20 m SRT (km/h) 1998 11.6 15 – 10 – 5 – 0 2008 10.8 11.1 10.2 1998 2008 BOYS GIRLS p<0.001 p<0.001
    • Secular changes in body mass index (BMI) and cardiorespiratory fitness (20 m shuttle-run test performance)
    • 10-year-old children
    • In 1998 (n=303) and 2008 (n= 315)
    TEN YEAR SECULAR DECLINES IN THE CARDIORESPIRATORY FITNESS OF AFFLUENT ENGLISH CHIDREN ARE LARGELY INDEPENDENT OF CHARGES IN BODY MASS INDEX Sandercock Arch Dis Child 2010;95:46 20 m SRT (km/h) 1998 11.6 15 – 10 – 5 – 0 2008 10.8 11.1 10.2 1998 2008 BOYS GIRLS p<0.001 p<0.001 Cardiorespiratory fitness declined significantly ( p<0.001 ) in both boys (7%) and girls (9%)
  • TEN YEAR SECULAR DECLINES IN THE CARDIORESPIRATORY FITNESS OF AFFLUENT ENGLISH CHIDREN ARE LARGELY INDEPENDENT OF CHARGES IN BODY MASS INDEX Sandercock Arch Dis Child 2010;95:46
  • Activity-Promoting Video Games and Increased Energy Expenditure L. Lanningham, J Ped 2009;154:819
    • 22 healthy children
    • 12 +/- 2 years
    • Energy expenditure and physical activity
    • playing a traditional sedentary video game,
    • and while playing an
    • activity-promoting video game (Nintendo Wii Boxing)
    Energy expenditure mean increase over resting (Kcal/h) 200 – 100 – 0 189 When children played Nintendo Wii
  • Activity-Promoting Video Games and Increased Energy Expenditure L. Lanningham, J Ped 2009;154:819
    • 22 healthy children
    • 12 +/- 2 years
    • Energy expenditure and physical activity
    • playing a traditional sedentary video game,
    • and while playing an
    • activity-promoting video game (Nintendo Wii Boxing)
    Energy expenditure mean increase over resting (Kcal/h) 200 – 100 – 0 189 When children played Nintendo Wii Activity-promoting video games have the potential to increase movement and energy expenditure in children
    • 14 boys and 9 girls (10 –13 years; BMI at 3–98th percentile for age and gender)
    • watching television at rest, playing Dance Dance Revolution (DDR) at 2 skill levels,
    • playing Wii bowling and boxing,
    • walking at 2.6, 4.2, and 5.7 km/h.
    Playing Active Video Games Increases Energy Expenditure in Children Graf Pediatrics 2009;124;534
    • Compared with watching television, energy expenditure
    • while gaming or walking increased 2- to 3-fold.
    • Similarly, high rates of
    • energy expenditure, heart rate, and perceived exertion were elicited from playing Wii boxing, DDR level 2, or walking at 5.7 km/h.
    • 871 children of European mothers were recruited at birth
    • Follow-up at 7 years of age
    • Sleep and daytime activity were measured objectively by an actigraph worn for 24 h
    Median sleep latency (minutes) 30 – 25 – 20 – 15 – 10 – 5 – 0 26 min Higher mean daytime activity counts were associated with a decrease in sleep latency (-1.2 minutes per 10 2 movement count per minute, p=0.05) FALLING ASLEEP: THE DETERMINANTS OF SLEEP LATENCY Nixon Arch Dis Child 2009;94:686
    • 871 children of European mothers were recruited at birth
    • Follow-up at 7 years of age
    • Sleep and daytime activity were measured objectively by an actigraph worn for 24 h
    Median sleep latency (minutes) 30 – 25 – 20 – 15 – 10 – 5 – 0 Time spent in sedentary activity was associated with an increase in sleep latency (3.1 minutes per hour of sedentary activity, p=0.01) FALLING ASLEEP: THE DETERMINANTS OF SLEEP LATENCY Nixon Arch Dis Child 2009;94:686 26 min
    • 871 children of European mothers were recruited at birth
    • Follow-up at 7 years of age
    • Sleep and daytime activity were measured objectively by an actigraph worn for 24 h
    Median sleep latency (minutes) 30 – 25 – 20 – 15 – 10 – 5 – 0 Time spent in sedentary activity was associated with an increase in sleep latency (3.1 minutes per hour of sedentary activity, p=0.01) FALLING ASLEEP: THE DETERMINANTS OF SLEEP LATENCY Nixon Arch Dis Child 2009;94:686 26 min These findings emphasise the importance of physical activity for children, not only for fitness, cardiovascular health and weight control, but also for promoting good sleep
  • Metabolism Failure to thrive
    • Weight gain of 1996 infants
    • z Scores for weights at birth and at 6–8 weeks were used to calculate a ‘‘thrive index’’ (z score for weight gain)
    • Their development was assessed at 4 and 9 months using the Bayley Scales
    % infants with weight faltering over the first 6–8 weeks 6.1% These infants had more feeding problems and showed some developmental delay as assessed using the Bayley Scales at 4 months THE DETECTION OF EARLY WEIGHT FALTERING AT THE 6–8-WEEK CHECK AND ITS ASSOCIATION WITH FAMILY FACTORS, FEEDING AND BEHAVIOURAL DEVELOPMENT McDougall Arch Dis Child 2009;94:549 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0
    • Weight gain of 1996 infants
    • z Scores for weights at birth and at 6–8 weeks were used to calculate a ‘‘thrive index’’ (z score for weight gain)
    • Their development was assessed at 4 and 9 months using the Bayley Scales
    % infants with weight faltering over the first 6–8 weeks 6.1% These infants had more feeding problems and showed some developmental delay as assessed using the Bayley Scales at 4 months THE DETECTION OF EARLY WEIGHT FALTERING AT THE 6–8-WEEK CHECK AND ITS ASSOCIATION WITH FAMILY FACTORS, FEEDING AND BEHAVIOURAL DEVELOPMENT McDougall Arch Dis Child 2009;94:549 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 vacillare
    • Weight gain of 1996 infants
    • z Scores for weights at birth and at 6–8 weeks were used to calculate a ‘‘thrive index’’ (z score for weight gain)
    • Their development was assessed at 4 and 9 months using the Bayley Scales
    % infants with weight faltering over the first 6–8 weeks 6.1% These infants had more feeding problems and showed some developmental delay as assessed using the Bayley Scales at 4 months THE DETECTION OF EARLY WEIGHT FALTERING AT THE 6–8-WEEK CHECK AND ITS ASSOCIATION WITH FAMILY FACTORS, FEEDING AND BEHAVIOURAL DEVELOPMENT McDougall Arch Dis Child 2009;94:549 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 Infants whose early weight gain is slow show more feeding problems than controls, and some developmental delay. They can be identified using a thrive index at the 6–8 week check
    • Weight faltering in the first few months after birth is associated with particularly adverse intellectual effects, suggesting that early intervention could be particularly important.
    • Early intervention would depend on the early identification of slow weight gain, which would be most practical using weights collected at birth and at the 6–8-week check
    THE DETECTION OF EARLY WEIGHT FALTERING AT THE 6–8-WEEK CHECK AND ITS ASSOCIATION WITH FAMILY FACTORS, FEEDING AND BEHAVIOURAL DEVELOPMENT McDougall Arch Dis Child 2009;94:549
  • Failure to Thrive: When to Suspect Inborn Errors of Metabolism Ficicioglu Pediatrics 2009; 124:972
    • As many as 10% of children seen in primary care settings show signs of FTT.
    • FTT is most commonly a result of inadequate energy intake in diet or constitutional or genetic small size and is rarely caused by an organic disease.
    • When children exhibit persistent FTT that does not respond to increased energy intake through diet, primary care physicians should consider organic causes including inborn errors of metabolism (IEM).
    • IEM are usually caused by partial or full enzyme deficiencies or transport defects that result in either accumulation of toxic products or lack of an important end product.
  • Failure to Thrive: When to Suspect Inborn Errors of Metabolism Ficicioglu Pediatrics 2009; 124:972 Diagnostic Approach to a Patient With FTT to not miss and IEM
  • Failure to Thrive: When to Suspect Inborn Errors of Metabolism Ficicioglu Pediatrics 2009; 124:972 Red-Flag Findings for IEM in Patients with FTT
  • Malattie metaboliche
  • Very Long-Chain Acyl-CoA Dehydrogenase Deficiency in a Patient with Normal Newborn Screening by Tandem Mass Spectrometry Ficicioglu J Pediatr 2010;156:492 Very long-chain acyl-CoA dehydrogenase deficiency ( VLCADD ) can be detected through newborn screening with tandem mass spectrometry. We report a patient who died as a result of severe brain injury due to hypoglycemia. Newborn screening was normal. Postmortem enzyme analysis and molecular testing confirmed the diagnosis of VLCADD.
  • nefrologia
  • Automated microscopy, dipsticks and the diagnosis of urinary tract infection A Lunn, Arch Dis Child 2010;95:193
    • Automated microscopy of urine using flow cytometers is therefore increasingly utilised;
    • Automated microscopy can issue an instant negative report using pre-set criteria based on bacterial and white cell counts;
    • Only samples which are positive on automated microscopy criteria are sent for culture, thus reducing the burden on laboratory staff and laboratory costs.
    (+) culture
  • Automated microscopy, dipsticks and the diagnosis of urinary tract infection A Lunn, Arch Dis Child 2010;95:193
    • Automated microscopy was performed using the Sysmex UF-100 flow cytometer using the standard UK algorithm;
    • This identifies a sample as needing culture if the bacterial count is > 8040/μl or if the white cell count is less than 40/μl and bacteria are also present with a mean size greater than 18 μM.
  • Automated microscopy, dipsticks and the diagnosis of urinary tract infection A Lunn, Arch Dis Child 2010;95:193
    • Samples were tested with dipstick, the UF-100 flow cytometer (automated microscopy) and culture
    • 280 urine samples collected from 263 patients, median age 10.2 years
    100 - 90 - 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 SENSITIVITY Urine dipstick Automated microscopy 95% 89%
  • Automated microscopy, dipsticks and the diagnosis of urinary tract infection A Lunn, Arch Dis Child 2010;95:193
    • Samples were tested with dipstick, the UF-100 flow cytometer (automated microscopy) and culture
    • 280 urine samples collected from 263 patients, median age 10.2 years
    100 - 90 - 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 SPECIFICITY Urine dipstick Automated microscopy 72% 85%
  • Automated microscopy, dipsticks and the diagnosis of urinary tract infection A Lunn, Arch Dis Child 2010;95:193
    • Samples were tested with dipstick, the UF-100 flow cytometer (automated microscopy) and culture
    • 280 urine samples collected from 263 patients, median age 10.2 years
    100 - 90 - 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 SPECIFICITY Urine dipstick Automated microscopy 72% 85% Automated microscopy performed comparably to urine dipstick in the diagnosis of UTI with improved Specificity and with slightly reduced Sensitivity
  • Serum Procalcitonin for Prediction of Renal Parenchymal Involvement in Children with Urinary Tract Infections: A Meta-analysis of Prospective Clinical Studies E Mantadakis, J Ped 2009;155:875 Objective: To determine by meta-analysis whether serum procalcitonin (PCT) is a useful marker of acute renal parenchymal involvement (RPI) in children with culture-proven urinary tract infection (UTI), as diagnosed by acute-phase DMSA (Tc-99m dimercaptosuccinic acid) renal scintigraphy.
  • 14.25 OR for renal parenchimal involment Serum PCT>0.5 ng/ml Serum Procalcitonin for Prediction of Renal Parenchymal Involvement in Children with Urinary Tract Infections: A Meta-analysis of Prospective Clinical Studies E Mantadakis, J Ped 2009;155:875
    • 10 studies
    • 627 children
    20 – 10 – 0
  • 14.25 OR for renal parenchimal involment Serum PCT>0.5 ng/ml Serum Procalcitonin for Prediction of Renal Parenchymal Involvement in Children with Urinary Tract Infections: A Meta-analysis of Prospective Clinical Studies E Mantadakis, J Ped 2009;155:875
    • 10 studies
    • 627 children
    20 – 10 – 0
    • In children with
    • culture-proven UTI,
    • a serum PCT value >0.5 ng/mL predicts reasonably well the presence of RPI,
    • as evidenced by DMSA scintigraphy.
    • PCT may aid in the identification of children with UTI, necessitating
    • more intense evaluation
    • and management
  • Moving from Bag to Catheter for Urine Collection in Non-Toilet-Trained Children Suspected of Having Urinary Tract Infection: A Paired Comparison of Urine Cultures C. Etoubleau, J Ped 2009;154:803
    • 192 non-toilet-trained children <3 years of age
    • All had positive urinalysis results from bag-obtained specimens that were systematically checked with catheter-obtained specimen
    % with bag-obteined specimen 30 – 20 – 10 – 0 7.5% False (+) 29% False (-) Bag collection for more than 30 minutes Due to antimicrobial cleansing agent used before the bag was fitted
  • Moving from Bag to Catheter for Urine Collection in Non-Toilet-Trained Children Suspected of Having Urinary Tract Infection: A Paired Comparison of Urine Cultures C. Etoubleau, J Ped 2009;154:803
    • 192 non-toilet-trained children <3 years of age
    • All had positive urinalysis results from bag-obtained specimens that were systematically checked with catheter-obtained specimen
    % with bag-obteined specimen 30 – 20 – 10 – 0 7.5% False (+) 29% False (-) Bag collection for more than 30 minutes Due to antimicrobial cleansing agent used before the bag was fitted Altogether, bag-obtained specimens led to either a misdiagnosis or an impossible diagnosis in 40% of cases
  • newborn
  • Effect of Music by Mozart on Energy Expenditure in Growing Preterm Infants Lubetzky Pediatrics 2010;125:e24
    • 20 healthy preterm infants
    • Exposed to a 30-minute period of Mozart music or no music on 2 consecutive d ays
    % reduction in resting energy expenditure -11.5% In subjects exposed to music 0 -5 – -10 – -15 -
  • Effect of Music by Mozart on Energy Expenditure in Growing Preterm Infants Lubetzky Pediatrics 2010;125:e24
    • 20 healthy preterm infants
    • Exposed to a 30-minute period of Mozart music or no music on 2 consecutive d ays
    % reduction in resting energy expenditure -11.5% In subjects exposed to music 0 -5 – -10 – -15 - This effect of music might explain, in part, the improved weight gain that results from this “Mozart effect.”
    • Neonates of 24 to 28 weeks of gestation initially resuscitated with fractions of inspired oxygen of 30% or 90%.
    • Randomized assignment to receive 30% ( N =37) or 90% ( N =41) oxygen
    Preterm Resuscitation With Low Oxygen Causes Less Oxidative Stress, Inflammation, and Chronic Lung Disease Vento Pediatrics 2009;124;e439 DAYS OF O 2 SUPPLEMENTATION 6 O 2 30% 22 30 – 20 – 10 – 0 O 2 90% p<0.01
  • DAYS OF O 2 MECHANICAL VENTILATION 13 O 2 30% 27 30 – 20 – 10 – 0 O 2 90% p<0.02 INCIDENCE OF BRONCHO-PULMUNARY DYSPLASIA AT DISCHARGE 15.4% O 2 30% 31.7% 30 – 20 – 10 – 0 O 2 90% p<0.05 Preterm Resuscitation With Low Oxygen Causes Less Oxidative Stress, Inflammation, and Chronic Lung Disease Vento Pediatrics 2009;124;e439
  • DAYS OF O 2 MECHANICAL VENTILATION 13 O 2 30% 27 30 – 20 – 10 – 0 O 2 90% p<0.02 INCIDENCE OF BRONCHO-PULMUNARY DYSPLASIA AT DISCHARGE 15.4% O 2 30% 31.7% 30 – 20 – 10 – 0 O 2 90% p<0.05 Preterm Resuscitation With Low Oxygen Causes Less Oxidative Stress, Inflammation, and Chronic Lung Disease Vento Pediatrics 2009;124;e439 Urinary markers of oxidative stress were increased significantly in the high-oxygen group, in the first week after birth and correlated significantly with development of chronic lung disease.
  • ORL
    • 36 Cases of epistaxis over a 6-year period
    • median age at admission was 12 weeks
    THE INCIDENCE AND AETIOLOGY OF EPISTAXIS IN INFANTS: A POPULATION-BASED STUDY Paranjothy Arch Dis Child 2009;94:421 23 of the infants had a recognised cause for their epistaxis; - trauma (5), - coagulation disorder (4), - congenital anomaly (2), - acute rhinitis or coryza (11), - abusive smothering event (1).
    • 36 Cases of epistaxis over a 6-year period
    • median age at admission was 12 weeks
    THE INCIDENCE AND AETIOLOGY OF EPISTAXIS IN INFANTS: A POPULATION-BASED STUDY Paranjothy Arch Dis Child 2009;94:421 23 of the infants had a recognised cause for their epistaxis; - trauma (5), - coagulation disorder (4), - congenital anomaly (2), - acute rhinitis or coryza (11), - abusive smothering event (1). A bleeding disorder should always be considered and, if additional evidence suggests physical abuse, this must be excluded
  •  
  • psychology
  • psychology parents
  • Objective: The goal was to describe the accuracy of the Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory II (BDIII), and Postpartum Depression Screening Scale (PDSS) in identifying major depressive disorder (MDD) or minor depressive disorder (MnDD) among low-income, urban mothers attending well-child care (WCC) visits during the postpartum year. Accuracy of Depression Screening Tools for Identifying Postpartum Depression Among Urban Mothers Chaudron Pediatrics 2010;125:e609
  • % mothers with 37% 19 % major minor
    • Mothers ( N= 198) attending well child care (WCC) visits with their infants 0 to 14 months of age completed a psychiatric diagnostic interview (standard method) and 3 screening tools.
    Accuracy of Depression Screening Tools for Identifying Postpartum Depression Among Urban Mothers Chaudron Pediatrics 2010;125:e609 40 – 30 - 20 – 10 - 0 depressive disorder
  • % mothers with 37% 19 % major minor
    • Mothers ( N= 198) attending WCC visits with their infants 0 to 14 months of age completed a psychiatric diagnostic interview (standard method) and 3 screening tools.
    Accuracy of Depression Screening Tools for Identifying Postpartum Depression Among Urban Mothers Chaudron Pediatrics 2010;125:e609 40 – 30 - 20 – 10 - 0 depressive disorder All scales performed equally well.
  • Paternal Depressive Symptoms During Pregnancy Are Related to Excessive Infant Crying Mijke P. van den Berg Pediatrics 2009;124;e96
    • prospective, population-based study
    • maternal and paternal depressive symptoms at 20 weeks of pregnancy
    • 4426 two-month- old infants
    • excessive crying (ie, crying >3 hours for >3 days in the past week)
    OR FOR EXCESSIVE INFANT CRYING 2 – 1 – 0 1.29 PER SD OF PATERNAL DEPRESSIVE SYMPTOMS
  • Paternal Depressive Symptoms During Pregnancy Are Related to Excessive Infant Crying Mijke P. van den Berg Pediatrics 2009;124;e96
    • prospective, population-based study
    • maternal and paternal depressive symptoms at 20 weeks of pregnancy
    • 4426 two-month- old infants
    • excessive crying (ie, crying >3 hours for >3 days in the past week)
    OR FOR EXCESSIVE INFANT CRYING 2 – 1 – 0 1.29 PER SD OF PATERNAL DEPRESSIVE SYMPTOMS Paternal depressive symptoms during the pregnancy might be a risk factor for excessive infant crying
  • Screening for Postpartum Depression at Well-Child Visits: Is Once Enough During the First 6 Months of Life? Sheeder Pediatrics 2009;123:e982 % of mother with a score ≥10
    • Ask the mothers to complete the Edinburgh Postpartum Depression Scale .
    • Incident cases represented mothers who crossed the referral threshold (score ≥ 10).
    16.5% 10.3% 5.7% 2 MONTH 4 MONTH 6 MONTH 25 – 20 – 15 – 10 – 5 – 0 POST-PARTUM
    • Ask the mothers to complete the Edinburgh Postpartum Depression Scale.
    • Incident cases represented mothers who crossed the referral threshold (score ≥ 10).
    16.5% 10.3% 5.7% 2 MONTH 4 MONTH 6 MONTH 25 – 20 – 15 – 10 – 5 – 0 POST-PARTUM Screening 2 months after delivery detects most mothers who become depressed during the first 6 postpartum months Screening for Postpartum Depression at Well-Child Visits: Is Once Enough During the First 6 Months of Life? Sheeder Pediatrics 2009;123:e982 % of mother with a score ≥10
  • OR for psychologiclly aggressive acts 2.3
    • Mothers who retained custody of a child aged 0 to 15 years following a maltreatment investigation and completed at least 2 of 3 surveys (n= 2386 )
    A LONGITUDINAL STUDY OF MATERNAL DEPRESSION AND CHILD MALTREATMENT IN A NATIONAL SAMPLE OF FAMILIES INVESTIGATED BY CHILD PROTECTIVE SERVICES Conron Arch Ped Adoles Med 2009;163:922 2.5 – 2 – 1.5 – 1 – 0 DEPRESSED MOTHER
  • Parental Depressive Symptoms: Relationship to Child Development, Parenting, Health, and Results on Parent-Reported Screening Tools A LaRosa, J Ped 2009;155:124
    • 382 parent-child ages 0 to 2 years
    • caretaker depression screen
    % depressed parents 20 – 10 – 0 15%
  • 3 – 2 – 1 – 0 2.3 Read often to children OR in non depressed parents vs depressed 2.5 1.9 Talk to children Helping children to learn Parental Depressive Symptoms: Relationship to Child Development, Parenting, Health, and Results on Parent-Reported Screening Tools A LaRosa, J Ped 2009;155:124
    • 382 parent-child ages 0 to 2 years
    • caretaker depression screen
  • psychology neurology newborn pre-school
  • Breastfeeding, the use of docosahexaenoic acid (DHA)-fortified formulas in infancy and neuropsychological function in childhood C R Gale, Arch Dis Child 2010;95:174
    • There has been considerable interest in the role that
    • long-chain polyunsaturated fatty acids (LCPUFAs)
    • might play in neurodevelopment .
    • LCPUFAs, particularly the n-3 docosahexaenoic acid ( DHA ) and the n-6 arachidonic acid (AA), are found in
    • high concentrations in the brain and retina , and
    • accumulate during the spurt in brain growth that occurs
    • between the last trimester of pregnancy and the first
    • year of life.
    • LCPUFAs, especially DHA , are involved in cell signalling ,
    • regulation of gene expression and neuronal growth .
    • 241 children aged 4 years followed up from birth
    • IQ, visual attention, visuomotor precision, sentence repetition and verbal fluency
    In unadjusted analyses, children for whom breast milk or DHA-fortified formula was the main method of feeding throughout the first 6 months of life had higher mean full-scale and verbal IQ scores at age 4 years than those fed mainly unfortified formula Breastfeeding, the use of docosahexaenoic acid (DHA)-fortified formulas in infancy and neuropsychological function in childhood C R Gale, Arch Dis Child 2010;95:174
    • 241 children aged 4 years followed up from birth
    • IQ, visual attention, visuomotor precision, sentence repetition and verbal fluency
    After adjustment for potential confounding factors, particularly maternal IQ and educational attainment , the differences in IQ between children in the breast milk and unfortified formula groups were severely attenuated, but children who were fed DHA-fortified formula had full-scale and verbal IQ scores that were respectively 5.62 and 7.02 points higher than children fed unfortified formula Breastfeeding, the use of docosahexaenoic acid (DHA)-fortified formulas in infancy and neuropsychological function in childhood C R Gale, Arch Dis Child 2010;95:174
  • Short Nighttime Sleep-Duration and Hyperactivity Trajectories in Early Childhood Touchette Pediatrics 2009;124:e985
    • Nighttime sleep duration and hyperactivity
    • questionnaires administered to mothers of 2057 children (1.5 to 5 yrs)
    OR OF REPORTING SHORT NIGHTTIME SLEEP DURATION 6 – 5 – 4 – 3 – 2 – 1 – 0 5.1 HYPERACTIVE CHILDREN
  • Short Nighttime Sleep-Duration and Hyperactivity Trajectories in Early Childhood Touchette Pediatrics 2009;124:e985
    • The risk factors for reporting short nighttime sleep duration and high hyperactivity scores
    • Being a boy,
    • Having insufficient household income,
    • Having a mother with a low education,
    • Being comforted outside the bed after a nocturnal awakening at 1.5 years of age.
  • Childhood Language Skills and Adult Literacy: A 29-Year Follow-up Study Schoon Pediatrics 2010;125:e459
    • The 1970 British Cohort Study.
    • A sample of 11 349 cohort members who completed the English Picture Vocabulary Test at 5 years of age were studied again at 34 years of age.
    1) Cohort members with receptive language problems at age 5 had disadvantaged socioeconomic resources and education level of their parents. 2) However , the majority of these children develop competent functional literacy levels by the age of 34 .
  • Childhood Language Skills and Adult Literacy: A 29-Year Follow-up Study Schoon Pediatrics 2010;125:e459 Factors that reduce the risk for persistent language problems include: A) The child being born into a working family. B) Parental education beyond minimum school-leaving age. C) Advantageous housing conditions. D) Preschool attendance.
  • Mixed-Handedness Is Linked to Mental Health Problems in Children and Adolescents Rodriguez Pediatrics 2010;125:340 OBJECTIVE: Problems with language and symptoms of attention-deficit/ hyperactivity disorder (ADHD) in childhood and adolescence are often strongly linked to low scholastic performance. Early recognition of children who are at increased risk is necessary. Our objective was to determine whether mixed-handedness, which is associated with atypical cerebral laterality , is associated with language, scholastic, and ADHD symptoms in childhood and adolescence.
  • Mixed-Handedness Is Linked to Mental Health Problems in Children and Adolescents Rodriguez Pediatrics 2010;125:340 Handedness is an attribute of humans defined by their unequal distribution of fine motor skill between the left and right hands . An individual who is more dexterous with the right hand is called right-handed , and one who is more skilled with the left is said to be left-handed . A minority of people are equally skilled with both hands, and are termed ambidextrous . People who demonstrate awkwardness with both hands are said to be ambilevous or ambisinister . Ambisinistrous motor skills or a low level of dexterity may be the result of a debilitating physical condition. There are four main types of handedness:
  • Right-handedness is most common. Right-handed people are more dexterous with their right hand when performing a task Left-handedness is less common than right-handedness. Left-handed people are more dexterous with their left hand when performing a task. About 8–15% of people are left-handed. [1] Mixed-handedness , also known as cross-dominance, is being able to do different tasks better with different hands. For example, mixed-handed persons might write better with their left hand but throw a ball more efficiently with their right hand. However, many writers[ who ? ] define handedness by the hand used for writing, so mixed-handedness is often neglected. Ambidexterity is exceptionally rare, although it can be learned. A true ambidextrous person is able to do any task equally well with either hand. Those who learn it still tend to sway towards their originally dominant hand.
    • Birth cohort with assessments when children were 7-8 and 16 years of age ( N= 7871).
    2.44 2.16 Weaker speaking ability Mixed-Handedness Is Linked to Mental Health Problems in Children and Adolescents Rodriguez Pediatrics 2010;125:340 3 – 2 – 1 – 0 1.52 Hyperactivity Weaker overall performance OR in mixed-Handedness compared to Right Handedness
    • Birth cohort with assessments when children were 7-8 and 16 years of age ( N= 7871).
    2.44 2.16 Weaker speaking ability Mixed-Handedness Is Linked to Mental Health Problems in Children and Adolescents Rodriguez Pediatrics 2010;125:340 3 – 2 – 1 – 0 1.52 Hyperactivity Weaker overall performance OR in mixed-Handedness compared to Right Handedness These results suggest that mixed-handedness , particularly in the presence of difficulties, could aid in the recognition of children who are at risk for stable problems .
  • psychology adolescents
  • Timing of Parent and Child Communication About Sexuality Relative to Children’s Sexual Behaviors Beckett Pediatrics 2010;125:34
    • 141 parents, along with their children (13–17 years)
    % children have intercourse before any discussion about sexually transmitted disease, condom use, choosing birth control 40% 40 – 30 – 20 – 10 – 0
  • Sexual Intercourse Among Adolescents Maltreated Before Age 12: A Prospective Investigtion Black Pediatrics 2009; 124:941
    • Maltreatment history .
    • Emotional distress by Trauma Symptom Checklist at the age of 12 years.
    • Sexual intercourse at ages 14 and 16.
  • Sexual Intercourse Among Adolescents Maltreated Before Age 12: A Prospective Investigtion Black Pediatrics 2009; 124:941
    • Maltreatment history .
    • Emotional distress by Trauma Symptom Checklist at the age of 12 years.
    • Sexual intercourse at ages 14 and 16.
    Maltreatment (all types) significantly predicted sexual intercourse
  • Sexual Intercourse Among Adolescents Maltreated Before Age 12: A Prospective Investigtion Black Pediatrics 2009; 124:941
    • Maltreatment history .
    • Emotional distress by Trauma Symptom Checklist at the age of 12 years.
    • Sexual intercourse at ages 14 and 16.
    2.15 14 YRS 2.03 16 YRS BY AGE 3 – 2 – 1 – 0 IN CASE OF ANY MALTREATMENT OR FOR SEXUAL INTERCOURSE
  • Sexual Intercourse Among Adolescents Maltreated Before Age 12: A Prospective Investigtion Black Pediatrics 2009; 124:941
    • Maltreatment history .
    • Emotional distress by Trauma Symptom Checklist at the age of 12 years.
    • Sexual intercourse at ages 14 and 16.
    2.15 14 YRS 2.03 16 YRS BY AGE 3 – 2 – 1 – 0 IN CASE OF ANY MALTREATMENT OR FOR SEXUAL INTERCOURSE Maltreated children are at risk for early initiation of sexual intercourse and sexually active adolescents should be evaluated for possible maltreatment .
  • % women acquiring STI by the age 15 years 30 – 20 – 10 – 0 25%
    • Sexually transmitted infection ( STI ) with Chlamydia trachomatis , Neisseria gonorrhoeae , or Trichomonas vaginalis
    • 386 urban young women aged 14 to 17 years at enrollment
    • Participants had first intercourse at a young age (13-15 yrs)
    TIME FROM FIRST INTERCOURSE TO FIRST SEXUALLY TRANSMITTED INFECTION DIAGNOSIS AMONG ADOLESCENT WOMEN Tu Arch Ped Adoles Med 2009;163:1106
  • % women acquiring STI by the age 15 years 30 – 20 – 10 – 0 25%
    • Sexually transmitted infection ( STI ) with Chlamydia trachomatis , Neisseria gonorrhoeae , or Trichomonas vaginalis
    • 386 urban young women aged 14 to 17 years at enrollment
    • Participants had first intercourse at a young age (13-15 yrs)
    TIME FROM FIRST INTERCOURSE TO FIRST SEXUALLY TRANSMITTED INFECTION DIAGNOSIS AMONG ADOLESCENT WOMEN Tu Arch Ped Adoles Med 2009;163:1106 Median interval between first intercourse and first STI diagnosis was 2 years
  • % women acquiring STI by the age 15 years 30 – 20 – 10 – 0 25%
    • Sexually transmitted infection ( STI ) with Chlamydia trachomatis , Neisseria gonorrhoeae , or Trichomonas vaginalis
    • 386 urban young women aged 14 to 17 years at enrollment
    • Participants had first intercourse at a young age (13-15 yrs)
    TIME FROM FIRST INTERCOURSE TO FIRST SEXUALLY TRANSMITTED INFECTION DIAGNOSIS AMONG ADOLESCENT WOMEN Tu Arch Ped Adoles Med 2009;163:1106 Considerable delay in STI testing was found for those who began sex at a younger age
    • Communities That Care ( CTC ) prevention
    • 24 small towns in 7 states, randomly assigned to control or CTC
    • 4407 fifth-grade students was surveyed annually through eighth grade
    RESULTS OF A TYPE 2 TRANSLATIONAL RESEARCH TRIAL TO PREVENT ADOLESCENT DRUG USE AND DELINQUENCY Hawkins Arch Ped Adoles Med 2009;163:789 Alcohol use
    • Communities That Care ( CTC ) prevention
    • 24 small towns in 7 states, randomly assigned to control or CTC
    • 4407 fifth-grade students was surveyed annually through eighth grade
    RESULTS OF A TYPE 2 TRANSLATIONAL RESEARCH TRIAL TO PREVENT ADOLESCENT DRUG USE AND DELINQUENCY Hawkins Arch Ped Adoles Med 2009;163:789 Cigarettes smoke
    • Communities That Care ( CTC ) prevention
    • 24 small towns in 7 states, randomly assigned to control or CTC
    • 4407 fifth-grade students was surveyed annually through eighth grade
    RESULTS OF A TYPE 2 TRANSLATIONAL RESEARCH TRIAL TO PREVENT ADOLESCENT DRUG USE AND DELINQUENCY Hawkins Arch Ped Adoles Med 2009;163:789 Predicted hazard of initiating delinquent behaviors
    • School-based programs (All-Stars, Life Skills Training, Lion’s Quest Skills for Adolescence, Project Alert, Olweus Bullying Prevention Program, and Program Development Evaluation Training)
    • Community-based youth-focused programs (Participate and Learn Skills, Big Brothers Big Sisters, Stay Smart, and academic tutoring)
    • Family-focused programs (Strengthening Families 10-14, Guiding Good Choices, ParentsWhoCare, Family Matters, and Parenting Wisely)
    RESULTS OF A TYPE 2 TRANSLATIONAL RESEARCH TRIAL TO PREVENT ADOLESCENT DRUG USE AND DELINQUENCY Hawkins Arch Ped Adoles Med 2009;163:789 CTC IMPLEMENTATION
    • School-based programs (All-Stars, Life Skills Training, Lion’s Quest Skills for Adolescence, Project Alert, Olweus Bullying Prevention Program, and Program Development Evaluation Training)
    • Community-based youth-focused programs (Participate and Learn Skills, Big Brothers Big Sisters, Stay Smart, and academic tutoring)
    • Family-focused programs (Strengthening Families 10-14, Guiding Good Choices, ParentsWhoCare, Family Matters, and Parenting Wisely)
    RESULTS OF A TYPE 2 TRANSLATIONAL RESEARCH TRIAL TO PREVENT ADOLESCENT DRUG USE AND DELINQUENCY Hawkins Arch Ped Adoles Med 2009;163:789 CTC IMPLEMENTATION Programs selected were required to have been found effective in well-controlled trials in preventing alcohol, tobacco, or other drug use or delinquent behavior in youths in grades 5 through 9
  • ADOLESCENTS AND DATING VIOLENCE Moreno Arch Ped Adoles Med 2009;163:776
    • Dating violence is physical, sexual, or psychological violence within a dating relationship. Examples include hitting or punching, forced sexual contact, or threats of violence. About 10% to 20% of high school teenagers are physically injured by a dating partner each year. Adolescent dating violence is associated with:
    • Intimate partner violence (partner abuse) in adulthood
    • Injuries and other health risk behaviors such as unsafe sex, substance use, and suicide risk
    • Unlike adult intimate partner violence, rates of being the abuser are similar for adolescent boys and girls.
  • ADOLESCENTS AND DATING VIOLENCE Moreno Arch Ped Adoles Med 2009;163:776 HOW DO I RECOGNIZE SIGNS OF DATING ABUSE IN MY CHILD?
  • ADOLESCENTS AND DATING VIOLENCE Moreno Arch Ped Adoles Med 2009;163:776 PREVENTION OF ADOLESCENT DATING VIOLENCE
    • 10% to 20% of adolescents experience physical forms of intimate partner abuse
    • adolescents who are victimized experiencing higher rates of depression, anxiety, and associated social and health problems
    • adolescent dating violence also predicts involvement in domestic violence in adulthood
    CAN ADOLESCENT DATING VIOLENCE BE PREVENTED THROUGH SCHOOL-BASED PROGRAMS? Odgers Arch Ped Adoles Med 2009;163:767 As a result, the prevention of relationship violence among adolescents is now recognized as an important public health problem and a prime candidate for intervention efforts.
    • Adolescent dating violence is one of the strongest precursors to intimate partner violence in adulthood and is associated with injuries and health-compromising behaviors, such as unsafe sex, substance use, and suicide attempts . For adolescents, physical dating violence (PDV), defined as acts ranging from threats of harm to punching or hitting with an object, emerges during critical and stressful transition periods that involve new pressures and responsibilities for handling conflict and emotions in unfamiliar contexts
    A SCHOOL-BASED PROGRAM TO PREVENT ADOLESCENT DATING VIOLENCE Wolfe Arch Ped Adoles Med 2010;163:692
  • A SCHOOL-BASED PROGRAM TO PREVENT ADOLESCENT DATING VIOLENCE Wolfe Arch Ped Adoles Med 2010;163:692 3 – 2 – 1 – 0 OR for physical dating violence
    • lessons on healthy relationships, sexual health
    • 2.5-year follow-up
    • 1722 students aged 14-15
    2.42 p=0.05 CONTROL VS INTERVENTION
  • A SCHOOL-BASED PROGRAM TO PREVENT ADOLESCENT DATING VIOLENCE Wolfe Arch Ped Adoles Med 2010;163:692
    • Focus on healthy relationships (myths/facts about teen relationships, relationship rights and responsibilities)
    • Barriers to healthy relationships (active listening skills, types of violence and abuse)
    • Contributors to violence (group effects on violence, individual differences)
    • Conflict and conflict resolution (communication styles: passive, assertive, and aggressive; conflict scenarios)
    • Media violence (student presentations of examples of violence in the media)
    • Conflict resolution skills (rights and responsibilities when ending a relationship)
    • Action in the school and community
    UNIT 1: PERSONAL SAFETY AND INJURY PREVENTION Each of the 3 units consists of 7 classroom sessions of 75 minutes each. Examples of content are in parentheses.
  • A SCHOOL-BASED PROGRAM TO PREVENT ADOLESCENT DATING VIOLENCE Wolfe Arch Ped Adoles Med 2010;163:692
    • Focus on healthy sexuality (review of sexuality, myths clarified)
    • Sexuality in the media (media and peer pressure to have a partner or to have sex)
    • Responsible sexuality (communication with your partner, healthy relationships)
    • Preventing pregnancies and sexually transmitted infections
    • Assertiveness skills to deal with pressure in relationships (negotiation, delay, and refusal skills)
    • Sexuality: responsibilities and consequences (sexual abuse, dating violence, decision making)
    • Sexual decision making and community resources (scenarios and discussion, research community resources)
    UNIT 2: HEALTHY GROWTH AND SEXUALITY
  • A SCHOOL-BASED PROGRAM TO PREVENT ADOLESCENT DATING VIOLENCE Wolfe Arch Ped Adoles Med 2010;163:692
    • Myths/facts and definitions (interactive game to get students to examine their opinions and values)
    • Effects of substance use and abuse (discussion of physical and nonphysical effects)
    • Making informed choices about smoking (discussion: why teens may smoke, health and financial costs)
    • Factors influencing decisions about drug use (discussion of media, culture, and peer pressure)
    • Building skills to avoid pressure to use substances (negotiation, delay, and refusal skills)
    • Practicing skills and community resources (role-play excercises: using skills and decision-making model)
    • Coping and making the connection between drug use, sex, and violence
    UNIT 3: SUBSTANCE USE AND ABUSE
  • OR for witnessing IPV 1.5 – 1 – 0 1.29
    • Intimate partner violence (IPV)
    • 1288 women aged 18 to 64 years
    • Abused women with children were asked about their history of having witnessed IPV as a child
    THE INTERGENERATIONAL TRANSMISSION OF WITNESSING INTIMATE PARTNER VIOLENCE Cannon Arch Ped Adoles Med 2009;163:706 in children of women who had witnessed IPV during childhood
  • OR for witnessing IPV 1.5 – 1 – 0 1.29
    • Intimate partner violence (IPV)
    • 1288 women aged 18 to 64 years
    • Abused women with children were asked about their history of having witnessed IPV as a child
    THE INTERGENERATIONAL TRANSMISSION OF WITNESSING INTIMATE PARTNER VIOLENCE Cannon Arch Ped Adoles Med 2009;163:706 in children of women who had witnessed IPV during childhood Social learning theory is accepted as an explanation for the intergenerational transmission of IPV whereby a child who witnesses IPV learns to have positive outcome expectations associated with the use of violence to resolve conflict and may perpetrate or be the victim of violence in subsequent relationships
  • Young Driver Education Programs That Build Resilience Have Potential to Reduce Road Crashes Senserrick Pediatrics 2009;124:1287
    • 20 822 first-year drivers aged 17 to 24.
    • 2 specific education programs: - focusing on driving risks (“driver-focused”) and - focus on reducing risk-taking and building resilience (“resilience-focused”).
    % REDUCTION IN CRASH RISK IN THE RESILIENCE-FOCUSED PROGRAM 0 – -10 – -20 – -30 – -40 - -50 – -44%
  • Young Driver Education Programs That Build Resilience Have Potential to Reduce Road Crashes Senserrick Pediatrics 2009;124:1287
    • 20 822 first-year drivers aged 17 to 24.
    • 2 specific education programs: focusing on driving risks (“driver-focused”) and focus on reducing risk-taking and building resilience (“resilience-focused”).
    % REDUCTION IN CRASH RISK IN THE RESILIENCE-FOCUSED PROGRAM 0 – -10 – -20 – -30 – -40 - -50 – -44% Resilience in psychology is the positive capacity of people to cope with stress and catastrophe . It also includes the ability to bounce back to homeostasis after a disruption . Thirdly, it can be used to indicate having an adaptive system that uses exposure to stress to provide resistance to future negative events . In this sense &quot;resilience&quot; corresponds to cumulative &quot;protective factors&quot; and is used in opposition to cumulative &quot;risk factors&quot;.
  • Young Driver Education Programs That Build Resilience Have Potential to Reduce Road Crashes Senserrick Pediatrics 2009;124:1287
    • 20 822 first-year drivers aged 17 to 24.
    • 2 specific education programs: focusing on driving risks (“driver-focused”) and focus on reducing risk-taking and building resilience (“resilience-focused”).
    % REDUCTION IN CRASH RISK IN THE RESILIENCE-FOCUSED PROGRAM 0 – -10 – -20 – -30 – -40 - -50 – -44% Elasticità, capacità di recupero
    • A parenting style variable was based on adolescent reports and separated parents into 4 groups:
    • authoritative (high support and high rules/monitoring),
    • authoritarian (low support and high rules/monitoring),
    • permissive (high support and low rules/monitoring),
    • uninvolved (low support and low rules/monitoring)
    Associations Between Parenting Styles and Teen Driving, Safety-Related Behaviors and Attitudes Ginsburg Pediatrics 2009;124;1040 % Children with Parents 50% AUTORITATIVE 50 – 40 – 30 – 20 – 10 – 0 23% 8% 19% PERMISSIVE AUTHORITARIAN UNIVOLVED
  • Associations Between Parenting Styles and Teen Driving, Safety-Related Behaviors and Attitudes Ginsburg Pediatrics 2009;124;1040 2 – 1 – 0 0.47 0.71 1.94 CRASH RISK USING CELLULAR PHONE DURING DIVING USING SEAT BELTS IN AUTHORITATIVE PARENTS OR FOR
    • 2167 examined patterns of vehicle access (primary access [ie, the teen is the main driver of the vehicle] versus shared access)
    Primary Access to Vehicles Increases Risky Teen Driving Behaviors and Crashes: National Perspective García-España Pediatrics 2009;124;1069 % OF DRIVERS HAVING PRIMARY ACESS TO VEHICLES 70% 100– 80 – 60 – 40 – 20 – 0
  • Primary Access to Vehicles Increases Risky Teen Driving Behaviors and Crashes: National Perspective García-España Pediatrics 2009;124;1069 IN DRIVERS WITH PRIMARY ACCESS OR FOR 2.05 3 – 2 – 1 – 0 1.23 1.24 CRASH RISK USING CELLULAR TELEPHONES WHILE DRIVING SPEEDING ≥10 MPH ABOVE THE POSTED LIMIT
    • Chronic fatigue syndrome ( CFS ) or myalgic encephalopathy ( ME )
    • 20 children with a diagnosis of CFS/ME
    • 10 tests to measure: processing speed; attention; immediate and delayed memory; working memory; executive function
    • Children with CFS/ME, their parents and teachers described problems with focussed attention , sustained attention , recall and stress
    • These cognitive problems may explain some of the educational difficulties associated with CFS
    MEMORY AND ATTENTION PROBLEMS IN CHILDREN WITH CHRONIC FATIGUE SYNDROME OR MYALGIC ENCEPHALOPATHY Haig-ferguson Arch Dis Child 2009;94:757
    • Chronic fatigue syndrome (CFS) or myalgic encephalopathy (ME) is the commonest cause of school absence in the UK. It is a relatively common condition, affecting between 0.1% and 2% of children aged under 18 years.
    • CFS/ME is defined as “generalised fatigue persisting after routine tests and investigations have failed to identify an obvious underlying cause”
    • A minimum of 3 months of fatigue is required before a diagnosis of CFS/ME is made in children.
    ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
    • 68% of children report that having CFS/ME prevented them attending school at some stage, with a mean time out of school estimated at more than one academic year .
    • Children with CFS/ME can also have poor physical function, with over 57% of children being bed-bound at some stage.
    ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
    • Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME)
    • Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS)
    • 211 children with CFS/ME
    % children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
    • Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME)
    • Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS)
    • 211 children with CFS/ME
    % children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752 The factor most strongly associated with reduced school attendance was poor physical function . Worse physical function was associated with higher levels of fatigue, pain and low mood
    • Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME)
    • Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS)
    • 211 children with CFS/ME
    % children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752 We found no evidence that school attendance was associated with anxiety measured either by the SCAS or the HADS
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
    2.5 – 2.0 – 1.5 – 1.0 – 0.5 – 0 2.2% FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences 11 – 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 8% 11% SERIOUS ORGANIC DISEASE SYMPTOM-DEFINED SYNDROMES
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences 11 – 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 8% 11% SERIOUS ORGANIC DISEASE SYMPTOM-DEFINED SYNDROMES
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
    The remainder had physical symptoms and minor medical illness
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with psychiatric disorders CONTROLS 50 – 40 – 30 – 20 – 10 – 0 CASES p<0.001 17% 45%
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with psychiatric disorders CONTROLS 50 – 40 – 30 – 20 – 10 – 0 CASES p<0.001 17% 45%
    • Prevalence of frequent absence (>20% of the school year)
    • secondary schools in Edinburgh
    • cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group)
    Only 34% with a psychiatric diagnosis had attended NHS psychiatric services
  • FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 ADHD , attention deficit hyperactivity disorder; DISC , Diagnostic Interview Schedule for Children; OCD , obsessive compulsive disorder; OR , odds ratio; PTSD , post-traumatic stress disorder; SDQ , Strengths and Difficulties Questionnaire for SDQ
  • Psicologia Media TV
    • Screen time and attachment to parents and peers
    • 2 cohorts of adolescents in 1987-1988 (n=976) and in 2004 (n=3043).
    Adolescent Screen Time and Attachment to Parents and Peers Richards, Arch Pediatr Adolesc Med. 2010;164:258-262 More time spent television viewing and less time spent reading and doing homework were associated with low attachment to parents and to peers. + - - =
    • Internet addiction prevalence
    TRAPPED IN THE NET Christakis Arch Ped Adoles Med 2009;163:959
    • 4% children in Korea
    • 15% children in China
    • 12% adults in USA
    • 2293 adolescents
    • Internet addiction as assessed using the Chen Internet Addiction Scale
    DEPRESSION ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER SOCIAL PHOBIA 2.5 – 2 – 1.5 – 1 – 0 OR for internet addiction PREDICTIVE VALUES OF PSYCHIATRIC SYMPTOMS FOR INTERNET ADDICTION IN ADOLESCENTS Ko Arch Ped Adoles Med 2009;163:937 1.56 2.02 1.35
  • AUDIBLE TELEVISION AND DECREASED ADULT WORDS, INFANT VOCALIZATIONS, AND CONVERSATIONAL TURNS Christakis Arch Ped Adoles Med 2009;163:554 Child z scores of vocalization vs total television hours per day
    • 329 2-48-month-old children
    • Children wore a digital recorder on random days for up to 24 months
  • AUDIBLE TELEVISION AND DECREASED ADULT WORDS, INFANT VOCALIZATIONS, AND CONVERSATIONAL TURNS Christakis Arch Ped Adoles Med 2009;163:554 Child z scores of vocalization vs total television hours per day
    • 329 2-48-month-old children
    • Children wore a digital recorder on random days for up to 24 months
    Each hour of audible television was associated with significant reductions in age-adjusted z scores for child vocalizations
  • AUDIBLE TELEVISION AND DECREASED ADULT WORDS, INFANT VOCALIZATIONS, AND CONVERSATIONAL TURNS Christakis Arch Ped Adoles Med 2009;163:554 Child z scores of vocalization vs total television hours per day
    • 329 2-48-month-old children
    • Children wore a digital recorder on random days for up to 24 months
    These results may explain the association between infant television exposure and delayed language development
  • Adolescents and MP3 Players: Too Many Risks, Too Few Precautions Vogel Pediatrics 2009;123:e953 % adolescent listening to music through earphones on MP3 players
    • 1687 adolescents (12–19 years of age)
    • Questionnaires about their music-listening behaviors
    100 – 80 – 60 – 40 – 20 – 0 90%
  • % adolescent 32.8% 50 – 40 – 30 – 20 – 10 – 0 48.0% 6.8% FREQUENT USERS USED HIGH VOLUME SETTINGS ALWAYS OR NEARLY ALWAYS USED A NOISE-LIMITER Adolescents and MP3 Players: Too Many Risks, Too Few Precautions Vogel Pediatrics 2009;123:e953
    • 1687 adolescents (12–19 years of age)
    • Questionnaires about their music-listening behaviors
  • % adolescent 32.8% 50 – 40 – 30 – 20 – 10 – 0 48.0% 6.8% FREQUENT USERS USED HIGH VOLUME SETTINGS ALWAYS OR NEARLY ALWAYS USED A NOISE-LIMITER Adolescents and MP3 Players: Too Many Risks, Too Few Precautions Vogel Pediatrics 2009;123:e953
    • 1687 adolescents (12–19 years of age)
    • Questionnaires about their music-listening behaviors
    Frequent users were >4 times more likely to listen to high-volume
  • % adolescent 32.8% 50 – 40 – 30 – 20 – 10 – 0 48.0% 6.8% FREQUENT USERS USED HIGH VOLUME SETTINGS ALWAYS OR NEARLY ALWAYS USED A NOISE-LIMITER Adolescents and MP3 Players: Too Many Risks, Too Few Precautions Vogel Pediatrics 2009;123:e953
    • 1687 adolescents (12–19 years of age)
    • Questionnaires about their music-listening behaviors
    When using MP3 players, adolescents are very likely to engage in risky listening behaviors
    • 346 a dolescents (14 –17 yrs) with home Internet access .
    • Internet-tracking software was installed on home computers
    Exposure to Tobacco on the Internet: Content Analysis of Adolescents' Internet Use Jenssen Pediatrics 2009;124;e180
    • Participants viewed 1.2 million Web pages , of which 8702 (0.72%) contained tobacco or smoking content .
    • Content was protobacco on 1916 pages, antitobacco on 1572, and complex or unclear on 5055.
  • Exposure to Tobacco on the Internet: Content Analysis of Adolescents' Internet Use Jenssen Pediatrics 2009;124;e180 % ADOLESCENT EXPOSED TO PRO-TOBACCO IMAGERY 60 - 50 – 40 – 30 – 20 – 10 – 0 43%
    • 346 a dolescents (14 –17 yrs) with home Internet access .
    • Internet-tracking software was installed on home computers
  • Movie Character Smoking and Adolescent Smoking: Who Matters More, Good Guys or Bad Guys? Tanski Pediatrics 2009;124:135
    • telephone survey of 6522 US adolescents.
    • movie exposure assessed at 4 time points over 24 months.
    15.9% 25 – 20 – 15 – 10 – 5 – 0 % OF BASELINE NEVERSMOKERS HAD TRIED SMOKING
  • Movie Character Smoking and Adolescent Smoking: Who Matters More, Good Guys or Bad Guys? Tanski Pediatrics 2009;124:135
    • telephone survey of 6522 US adolescents.
    • movie exposure assessed at 4 time points over 24 months.
    For instance, Harrison Ford in The Fugitive is portrayed to the viewer as a good character, although the other characters in the film suspect him of murder.” Coding categories were negative (a “bad” character), neutral (not positive or negative), positive (a “good” character), and mixed portrayal.
  • Movie Character Smoking and Adolescent Smoking: Who Matters More, Good Guys or Bad Guys? Tanski Pediatrics 2009;124:135
    • telephone survey of 6522 US adolescents.
    • movie exposure assessed at 4 time points over 24 months.
  • Movie Character Smoking and Adolescent Smoking: Who Matters More, Good Guys or Bad Guys? Tanski Pediatrics 2009;124:135
    • telephone survey of 6522 US adolescents.
    • movie exposure assessed at 4 time points over 24 months.
    Character smoking predicts adolescent smoking initiation regardless of character type, which demonstrates the importance of limiting exposure to all movie smoking
    • All food advertisements broadcast on 4 popular channels in Canada and 3 channels in the UK in 2006
    • 2315 food related advertisements broadcast in Canada and 1365 broadcast in the UK
    FOOD ADVERTISING DURING CHILDREN’S TELEVISION IN CANADA AND THE UK Adams Arch Dis Child 2009;94:658 % of advertising for “less healthy” products 52% 61% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • All food advertisements broadcast on 4 popular channels in Canada and 3 channels in the UK in 2006
    • 2315 food related advertisements broadcast in Canada and 1365 broadcast in the UK
    FOOD ADVERTISING DURING CHILDREN’S TELEVISION IN CANADA AND THE UK Adams Arch Dis Child 2009;94:658 % of advertising for “less healthy” products 52% 61% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 5-11% were ‘‘of particular appeal” to children
  • Childhood Abuse, Avatar Choices, and Other Risk Factors Associated With Internet-Initiated Victimization of Adolescent Girls Noll Pediatrics 2009;123:e1078 % girls reporting
    • Adolescent girls aged 14 to 17 years
    40% 26% ONLINE SEXUAL ADVANCES MEETING SOMEONE OFFLINE WHO THEY FIRST MET ONLINE 50 – 40 – 30 – 20 – 10 – 0
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • Nearly 3000 studies have found a significant relationship between media violence and real-life aggression.
    • Media violence may be causing 10% of real-life violence
    • VIOLENCE
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • The media have arguably become the leading sex educator of young people.
    • There are now five longitudinal studies linking exposure to sexy media to earlier onset of sexual intercourse and one to teen pregnancy.
    • SEX
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • Witnessing smoking scenes in movies may be the leading cause of smoking among teenagers . Similarly viewing alcohol use in movies is a significant predictor of teenage drinking
    • Several countries have successfully banned the advertising of tobacco in all media and restricted alcohol advertising
    • SMOKING
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • Media use is contributing to the current epidemic of obesity worldwide
    • Viewing television is associated with unhealthier eating habits . Surprisingly, the evidence that media use displaces more active physical pursuits is mixed. For example, some recent research shows that sedentary children and teens will remain sedentary, even if the TV set and internet connection are removed
    • OBESITY
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • Many young teen girls think they are fat when they are, in fact, normal weight, and the media can be a major contributor to the formation of a teen’s body self-image.
    • In Fiji the prevalence of eating disorders increased dramatically after the introduction of American TV programmes like ‘‘Beverly Hills 90210’’ with its attractive and thin female role models.
    • EATING DISORDERS
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • Intensive media use may contribute to poor school performance, and the development of attention deficit disorder. Much more research is needed here.
    • SCHOOL PERFORMANCE
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • There are six studies documenting possible language delays among babies exposed to TV or videos. The infant brain is ‘‘plastic’’ and develops in response to environmental stimulation. Surprisingly, infants are ‘‘smart’’ enough to be able to distinguish a live human being from a televised one.
    • EARLY LANGUAGE DEVELOPMENT
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • Media can be powerfully prosocial. Just as media can teach unhealthy or harmful attitudes , they can also teach empathy, respect for other races and ethnicities, the need for cooperation,
    • The tragedy of modern media is that they can be so powerfully good yet often are not,
    • Less graphic violence, more sexual responsibility, less smoking and casual drug use, less emphasis on thinness—all would produce healthier viewing for young people.
    • PROSOCIAL EFFECTS
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • Total entertainment screen time should be limited to no more than 1–2 h per day , and TV sets and internet connections do not belong in children’s or teenagers’ bedrooms . Parents need to coview media with their children and discuss what they are seeing .
    • Parents need to avoid screen time for infants under the age of 2 years
    • The advertising industry needs to get busy advertising products which protect young people from harm — oral contraceptives, condoms and emergency contraception. Such products need to be advertised worldwide.
    • PROSOCIAL EFFECTS
  • CHILDREN, ADOLESCENTS AND THE MEDIA: WHAT WE KNOW, WHAT WE DON’T KNOW AND WHAT WE NEED TO FIND OUT (QUICKLY!) Strasburger Arch Dis Child 2009;94:655
    • In their clinical practices, paediatricians need to ask at least two key questions:
    • How much entertainment screen time does the child or teen spend per day?
    • Is there a TV set or internet connection in the bedroom?
    • The media have become powerful teachers of children and adolescents. The only questions remaining are: (1) what are they learning and (2) how can harmful media effects be minimised and prosocial effects be maximised?
    • PROSOCIAL EFFECTS
  •  
  • ADHD
  • REUMATOLOGY
  • Sudden Infant Death Syndrome
  • The sudden infant death syndrome. Kinney HC N Engl J Med. 2009;361:795-805. Five Steps in the Putative Terminal Respiratory Pathway Associated with the Sudden Infant Death Syndrome.
  • The sudden infant death syndrome. Kinney HC N Engl J Med. 2009;361:795-805. Death results from one or more failures in protective mechanisms against a life-threatening event during sleep in the vulnerable infant during a critical period. Complex genetic and environmental interactions influence the pathway . Environmental Estrinsic risk factors * * * * * *
  • Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. Blair BMJ 2009;339: b3666 Median Age at Death 66 days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • 184.800 births
    • 80 (0.043%) SIDS infants
  • Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. Blair BMJ 2009;339: b3666 % Death Associated With 54% 60 – 50 – 40 – 30 – 20 – 10 – 0 29% Cosleeping Prone position
    • 184.800 births
    • 80 (0.043%) SIDS infants
  • What is the mechanism of sudden infant deaths associated with co-sleeping? McIntosh CG, N Z Med J. 2009;122:69-75.
    • Half the cases now occur when the infant has been sleeping in bed with another person .
    • It is often presumed that co-sleeping deaths are due to 'overlaying', when the adult rolls on top of the baby, stopping baby from breathing.
    it is not necessary to cover the face, or squash the body of a baby to restrict or prevent breathing and cause oxygen deprivation.
  • What is the mechanism of sudden infant deaths associated with co-sleeping? McIntosh CG, N Z Med J. 2009;122:69-75.
    • At birth, the temporo-mandibular joint is not yet fully formed, and thus the jaw can be easily displaced upwards and backwards pushing the tongue into the upper airway to form a partial or complete block of the airway .
    • Indeed, this can happen with firm flexion of the infant's head so that the chin pushes against its own chest.
    • 1021 mothers highly motivated to breastfeed
    • to offer versus not
    • to offer pacifiers
    % infants exclusively breastfed at 3 mo 85.8% yes ns 86.2% no 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 Does the Recommendation to Use a Pacifier Influence the Prevalence of Breastfeeding? A Jenik, J Ped 2009;155:350 Offer pacifier
    • 1021 mothers highly motivated to breastfeed
    • to offer versus not
    • to offer pacifiers
    % infants exclusively breastfed at 3 mo 85.8% yes ns 86.2% no 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 Does the Recommendation to Use a Pacifier Influence the Prevalence of Breastfeeding? A Jenik, J Ped 2009;155:350 Offer pacifier Because pacifier use is associated with reduced incidence of sudden infant death syndrome, the recommendation to offer a pacifier appears safe
  • % infants 70.4% 42.6% Nonsupine sleep Maternal smoking
    • Retrospective review of 244 SIDS cases (1996 –2000)
    Concurrent Risks in Sudden Infant Death Syndrome Ostfeld Pediatrics 2010;125:447 80 – 60 – 40 – 20 – 0
  • Risk factors were defined as: 1) nonsupine placement, 2) maternal smoking, 3) URI, 4) scene risks (the use of sofas , quilts , blankets , pillows , or the presence of other children), 5) paternal smoking, 6) birth<37 weeks’ gestational age, 7) bed-sharing. Concurrent Risks in Sudden Infant Death Syndrome Ostfeld Pediatrics 2010;125:447
  • Risk factors were defined as: 1) nonsupine placement, 2) maternal smoking, 3) URI, 4) scene risks (the use of sofas, quilts, blankets, pillows, or the presence of other children), 5) paternal smoking, 6) birth<37 weeks’ gestational age, 7) bed-sharing. Concurrent Risks in Sudden Infant Death Syndrome Ostfeld Pediatrics 2010;125:447 On the basis of complete data, 2 cases ( 0.8% of all cases ) were risk free .
  • OR for SIDS Side sleeping positioning 2.0 3.9 1.5 Mother Father smoking Head under the cover 16.9 SIDS: past, present and future Mitchell EA Acta Paediatrica 2009;98:1712 20 – 18 – 16 – 14 – 12 – 10 – 8 – 6 – 4 – 2 - 0
  • OR for SIDS Side sleeping positioning 2.0 3.9 1.5 Mother Father smoking Head under the cover 16.9 SIDS: past, present and future Mitchell EA Acta Paediatrica 2009;98:1712 After the “Back to Sleep” campaigns has become the major risk factor. HEAD COVERING 20 – 18 – 16 – 14 – 12 – 10 – 8 – 6 – 4 – 2 - 0
  • Recommendation: 1. Back to sleep : Infants should be placed for sleep in a supine position (wholly on the back) for every sleep . 2. Use a firm sleep surface : Soft materials or objects such as pillows , quilts , comforters , or sheepskins should not be placed under a sleeping infant. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk Pediatrics 2005;116:1245
  • 3. Keep soft objects and loose bedding out of the crib : pillows, quilts, and other soft objects should be kept out of an infant’s sleeping environment. Sleep sacks that are designed to keep the infant warm without the possible hazard of head covering. 4. Do not smoke during pregnancy . The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk Pediatrics 2005;116:1245 sleep sacks
  • 5. A separate but proximate sleeping environment is recommended . 6. Consider offering a pacifier at nap time and bedtime. Although the mechanism is not known, the reduced risk of SIDS associated with pacifier use during sleep is compelling. 7. Avoid overheating . The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk Pediatrics 2005;116:1245
  • 8. Avoid commercial devices marketed to reduce the risk of SIDS. 9. Do not use home monitors . 10. Avoid development of positional plagiocephaly : avoid having the infant spend excessive time in car-seat carriers and “bouncers,” in which pressure is applied to the occiput. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk Pediatrics 2005;116:1245
  • papilloma
  • Mothers’ Intention for Their Daughters and Themselves to Receive the Human Papillomavirus Vaccine: A National Study of Nurses Kahn Pediatrics 2009;123:1439 % of mother who intended to vaccinate a daughter
    • 10 521 mothers, all nurses, between June 2006 and February 2007
    48% 68% 86% If she were 9 to 12 yr 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 If she were 13 to 15 yr If she were 16 to 18 yr of age
  • Mothers’ Intention for Their Daughters and Themselves to Receive the Human Papillomavirus Vaccine: A National Study of Nurses Kahn Pediatrics 2009;123:1439 % of mother who intended to vaccinate a daughter
    • 10 521 mothers, all nurses, between June 2006 and February 2007
    48% 68% 86% If she were 9 to 12 yr 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 If she were 13 to 15 yr If she were 16 to 18 yr of age mothers’ intention to vaccinate a daughter <13 years of age was contrasting with national recommendations to target 11- to 12-year-old girls for vaccination
  • Sustained efficacy and immunogenicity of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine : analysis of a randomised placebo-controlled trial up to 6·4 years Romanowsky Lancet 2009;374:1948 VACCINE EFFICACY AGAINST incident infection with HPV 16/18 95.3%
    • Women aged 15–25 yrs HPV-16/18 seronegative
    • double-blind (n=1113; 560 vaccine group vs 553 placebo group)
    • 6·4 years follow-up
    100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
  • 100%
    • Women aged 15–25 yrs HPV-16/18 seronegative
    • double-blind (n=1113; 560 vaccine group vs 553 placebo group)
    • 6·4 years follow-up
    100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 VACCINE EFFICACY AGAINST 12 months persistent infection with HPV 16/18 Sustained efficacy and immunogenicity of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine : analysis of a randomised placebo-controlled trial up to 6·4 years Romanowsky Lancet 2009;374:1948
  • 100% YES NO 72% lesions associated with HPV-16/18 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • Women aged 15–25 yrs HPV-16/18 seronegative
    • double-blind (n=1113; 560 vaccine group vs 553 placebo group)
    • 6·4 years follow-up
    VACCINE EFFICACY AGAINST cervical intraepithelial neoplasia grade 2 and above (CIN2+) Sustained efficacy and immunogenicity of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine : analysis of a randomised placebo-controlled trial up to 6·4 years Romanowsky Lancet 2009;374:1948
  • 100% YES NO 72% lesions associated with HPV-16/18 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
    • Women aged 15–25 yrs HPV-16/18 seronegative
    • double-blind (n=1113; 560 vaccine group vs 553 placebo group)
    • 6·4 years follow-up
    VACCINE EFFICACY AGAINST cervical intraepithelial neoplasia grade 2 and above (CIN2+) Antibody concentrations remained 12-fold or more higher than after natural infection (both antigens) safety outcomes were similar Sustained efficacy and immunogenicity of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine : analysis of a randomised placebo-controlled trial up to 6·4 years Romanowsky Lancet 2009;374:1948
  • Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women Paavonen LANCET 2009;374:301 70.2%
    • Women (15–25 years) vaccinated at months 0, 1, and 6 (vaccine, n=8093; control, n=8069).
    • Mean follow-up 34·9 months after the third dose.
    80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 In women receiving at least one vaccine dose w ith no evidence of oncogenic HPV infection at baseline VACCINE EFFICACY AGAINST cervical intraepithelial neoplasia 2+ (CIN2+)
  • 70.2%
    • Women (15–25 years) vaccinated at months 0, 1, and 6 (vaccine, n=8093; control, n=8069).
    • Mean follow-up 34·9 months after the third dose.
    80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 VACCINE EFFICACY AGAINST cervical intraepithelial neoplasia 2+ (CIN2+) Individual cross-protection against CIN2+ associated with HPV-31, HPV-33, and HPV-45 was seen. In women receiving at least one vaccine dose w ith no evidence of oncogenic HPV infection at baseline Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women Paavonen LANCET 2009;374:301
  • Comparison of the immunogenicity and safety of Cervarix TM and Gardasil ® human papillomavirus cervical cancer vaccines in healthy women aged 18–45 years Einstein, Human Vaccines 2009;5: 705 Geometric mean titers of serum neutralizing antibodies fold higher after vaccination with Cervarix ™ compared with Gardasil ®, across all age strata. 2.3 9.1 6.8 4.8 HPV-16 HPV-18 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0
    • Observer-blind study compared the prophylactic human HPV-vaccines, Cervarix ™(GlaxosmithKline) and Gardasil ® (Merck).
    • Immunogenicity and safety through 1 month after completion of the 3-dose vaccination course.
    • Women (n = 1106) stratified by age ( 18–26, 27–35, 36–45 yrs ) and randomized (1:1) to receive Cervarix ™ (Months 0, 1, 6) or Gardasil ® (Months 0, 2, 6).
    • Observer-blind study compared the prophylactic human HPV-vaccines, Cervarix ™(GlaxosmithKline) and Gardasil ® (Merck).
    • Immunogenicity and safety through 1 month after completion of the 3-dose vaccination course.
    • Women (n = 1106) stratified by age (18–26, 27–35, 36–45 yrs) and randomized (1:1) to receive Cervarix ™ (Months 0, 1, 6) or Gardasil ® (Months 0, 2, 6).
    Comparison of the immunogenicity and safety of Cervarix TM and Gardasil ® human papillomavirus cervical cancer vaccines in healthy women aged 18–45 years Einstein, Human Vaccines 2009;5: 705 2.3 9.1 6.8 4.8 HPV-16 HPV-18 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 Cervarix ™ induced significantly higher serum neutralizing antibody titers in all age strata (p<0.0001) . Geometric mean titers of serum neutralizing antibodies fold higher after vaccination with Cervarix ™ compared with Gardasil ®, across all age strata.
    • Observer-blind study compared the prophylactic human HPV-vaccines, Cervarix ™(GlaxosmithKline) and Gardasil ® (Merck).
    • Immunogenicity and safety through 1 month after completion of the 3-dose vaccination course.
    • Women (n = 1106) stratified by age (18–26, 27–35, 36–45 yrs) and randomized (1:1) to receive Cervarix ™ (Months 0, 1, 6) or Gardasil ® (Months 0, 2, 6).
    Comparison of the immunogenicity and safety of Cervarix TM and Gardasil ® human papillomavirus cervical cancer vaccines in healthy women aged 18–45 years Einstein, Human Vaccines 2009;5: 705 2.3 9.1 6.8 4.8 HPV-16 HPV-18 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 Specific memory B-cell frequencies were also higher after vaccination with Cervarix ™ compared with Gardasil ®. Geometric mean titers of serum neutralizing antibodies fold higher after vaccination with Cervarix ™ compared with Gardasil ®, across all age strata.
    • Observer-blind study compared the prophylactic human HPV-vaccines, Cervarix ™(GlaxosmithKline) and Gardasil ® (Merck).
    • Immunogenicity and safety through 1 month after completion of the 3-dose vaccination course.
    • Women (n = 1106) stratified by age (18–26, 27–35, 36–45 yrs) and randomized (1:1) to receive Cervarix ™ (Months 0, 1, 6) or Gardasil ® (Months 0, 2, 6).
    Comparison of the immunogenicity and safety of Cervarix TM and Gardasil ® human papillomavirus cervical cancer vaccines in healthy women aged 18–45 years Einstein, Human Vaccines 2009;5: 705 2.3 9.1 6.8 4.8 HPV-16 HPV-18 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 Although the importance of differences in magnitude of immune response between these vaccines is unknown, they may represent determinants of duration of protection against HPV-16/18. Geometric mean titers of serum neutralizing antibodies fold higher after vaccination with Cervarix ™ compared with Gardasil ®, across all age strata.
    • A process for the manufacture of a vaccine composition comprising the admixture of
    • an adjuvant composition comprising an immunostimulant which is 3-de-O-acylated monophosphoryl lipid A, adsorbed onto an aluminium salt particle , characterised in that not more than 20% by mass of the total material capable of adsorbing to the aluminium salt particle is an antigen, and
    • an antigen.
    AS04 -adjuvanted vaccine
  • % serious adverse events
    • A pooled analysis of the safety of the human papillomavirus (HPV)-16/18 AS04-adjuvanted cervical cancer vaccine Cervarix (GlaxoSmithKline) was performed in a cohort of almost 30,000 girls and women aged ≥10 years, 16,142 who received at least one dose of the HPV-16/18 vaccine and 13,811 who received one of three controls [Al(OH) 3 ] or hepatitis A vaccine.
    2.8% Cervarix 3.1% Controls Safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine for cervical cancer prevention Descamps Human Vaccines 2009;5:332 4 – 3 – 2 – 1 – 0
  • % new onset chronic autoimmune disease 0.4% Cervarix 0.3% Controls Safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine for cervical cancer prevention Descamps Human Vaccines 2009;5:332 0.5 – 0.4 – 0.3 – 0.2 – 0.1 – 0 ns
    • A pooled analysis of the safety of the human papillomavirus (HPV)-16/18 AS04-adjuvanted cervical cancer vaccine Cervarix (GlaxoSmithKline) was performed in a cohort of almost 30,000 girls and women aged ≥10 years, 16,142 who received at least one dose of the HPV-16/18 vaccine and 13,811 who received one of three controls [Al(OH) 3 ] or hepatitis A vaccine.
  • Rates of autoimmune events
    • Newly licensed vaccines against human papillomavirus (HPV) and hepatitis B (HBV) contain a novel Adjuvant System, AS04, composed of 3-O-desacyl-4’ monophosphoryl lipid A and aluminium salts.
    • To assess safety of AS04 adjuvanted vaccines with regard to potential autoimmune aetiology.
    • All randomised, controlled trials.
    • Individual data ( N = 68,512 ).
    • Mean follow-up of 21.4 months.
    0.5% Analysis of adverse events of potential autoimmune aetiology in a large integrated safety database of AS04 adjuvanted vaccines Verstraeten Vaccine 2008;26:6630 1.0 – 0.5 – 0 And did not differ between the AS04 and control groups
  • Rates of autoimmune events
    • Newly licensed vaccines against human papillomavirus (HPV) and hepatitis B (HBV) contain a novel Adjuvant System, AS04, composed of 3-O-desacyl-4’ monophosphoryl lipid A and aluminium salts.
    • To assess safety of AS04 adjuvanted vaccines with regard to potential autoimmune aetiology.
    • All randomised, controlled trials.
    • Individual data ( N = 68,512).
    • Mean follow-up of 21.4 months.
    0.5% 1.0 – 0.5 – 0 And did not differ between the AS04 and control groups This integrated analysis of over 68,000 participants who received AS04 adjuvanted vaccines or controls demonstrated a low rate of autoimmune disorders, without evidence of an increase in relative risk associated with AS04 adjuvanted vaccines. Analysis of adverse events of potential autoimmune aetiology in a large integrated safety database of AS04 adjuvanted vaccines Verstraeten Vaccine 2008;26:6630
    • Both Cervarix and Gardasil provided more than 90% efficacy in preventing cervical intraepithelial neoplasia grade 2+ (CIN 2+) disease caused by HPV 16 and 18 in women 16–26 years who were seronegative and PCR-negative for HPV 16 and 18 at baseline.
    • Cervarix provides more than 75% efficacy in independent cross-protection against persistent HPV 31 and 45, and 47% efficacy against HPV 33; whereas Gardasil offers 50% efficacy only against persistent HPV 31.
    • Cervarix efficacy is documented to 6.4 years; Gardasil’s to 5 yrs.
    • Cervarix induces three to nine-fold higher peak-neutralizing antibody titers to HPV 16/18 than Gardasil, has significantly higher cervicovaginal mucus-neutralizing antibody presence than Gardasil, and significantly higher B memory cell response than Gardasil.
    Current prophylactic HPV vaccines and gynecologic premalignancies Harper Curr Opin Obstet and Gynecol 2009, 21:457–464
    • Cervical screening programs offer secondary, not primary prevention.
    • Vaccination against the HPV, which is the major cause of cervical cancer, is a significant step forward.
    • Cross protection against oncogenic non-vaccine HPV types, in particular HPV-45, may be important in the prevention of cervical adenocarcinoma, which is currently not well served by screening.
    Human papillomavirus (HPV) vaccine: Cervarix Szarewski Expert Opin. Biol. Ther 2010 10(3):477-487
  • Take home
    • Ricordare segni e sintomi del maltrattamento e delle indagini da richiedere nel sospetto di…
    • Non dimentichiamo i bambini che non vengono nei nostri ambulatori, ho la sensazione che rimangono comunque un problema anche nostro,
    • La morte improvvisa nella culla riguarda ancora lo 0.04% dei lattanti ed il pediatra può fare molto per ridurla dal momento che nel 99.2% dei casi sono presenti fattori ambientali evitabili !
  • Take home
    • Il dolore nel bambino viene sottotrattato,
    • La vitamina D .. non solo rachitismo,
    • Propanololo per gli emangiomi infantili gravi,
    • I disturbi funzionali dell’intestino non sono solo funzionali…antibiotici e probiotici possono aiutare,
    • Attenti alla depressione , anche a quella del papà,
    • Acido docosahexaenoico ( DHA ) è OK,
    • Se non dorme può diventare iperreattivo,
    • Attenti ai bambini che riescono a fare bene qualcosa con una mano e qualcosa di diverso con l’altra
  • Take home
    • La sessualità inizia prima di quanto non si pensi, è più precoce nel caso di maltrattamento e può essere una spia tardiva del problema,
    • Una ragazzina su quattro, sessualmente attiva, acquisisce malattie sessualmente trasmesse che vengono diagnosticate con ritardo maggiore quanto più giovane è la paziente,
    • È importante che il pediatra acquisisca competenze sempre maggiori sull’ adolescenza ,
    • Il vaccino anti-papilloma virus è efficace e sicuro.