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  • 1. WHAT YOU SHOULD HAVE READ BUT….2012  General Paediatrics Bonomo Beatrice Caldonazzi Federico Cattazzo Elena Deganello Marco Gallo Giuseppe Mazzei FedericaAttilio Boner Melotti Giulia Paiola GiuliaUniversity of Olivieri FrancescaVerona, Italy Tenero Laura Tezza Giovanna Villotti Valentina
  • 2. •antibiotici
  • 3. 5 vs 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Molyneux, Lancet 2011;377:1837 % Outcomes 1004 children with 30 – purulent meningitis 25 – 26% 27% (S.pneumoniae, H.influ 20 – enzae B, N.meningitidis) 15 – aged 2 mo-12 yrs. 10 – 496 ceftriaxone 05 – 6% 0% 0% 0% 0% 4% 4% 4% for 5 days. 00 – 508 ceftriaxone for 10 days.
  • 4. 5 vs 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Molyneux, Lancet 2011;377:1837 % Outcomes 1004 children with •Hearing loss 30 – purulent meningitis 25 – 26% 27% •Visual loss (S.pneumoniae, H.influ 20 – enzae •Cranial nerve palsy B, N.meningitidis) 15 – •Afebrile seizures aged 2 mo-12 yrs. 10 – •Hydrocephalus 496 ceftriaxone 05 – 6% 0% 0% 0% 0% 4% 4% 4% for 5 days. •Developmental 00 – 508 ceftriaxone delay for 10 days.
  • 5. 5 vs 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Molyneux, Lancet 2011;377:1837 In children beyond % Outcomes the neonatal 1004 children with 30 – age-group with purulent meningitis 25 – 27% 26% purulent meningitis (S.pneumoniae, H.influ 20 – (S.pneumoniae, H.influ enzae enzae B B, N.meningitidis) 15 – or N.meningitidis) aged 2 mo.-12stable who are yrs. 10 – 496 ceftriaxoneof by day 5 05 – 6% for 5 days. treatment, ceftriaxone 0% 0% 0% 0% 4% 4% 4% 00 – the antibiotic can be 508 ceftriaxone safely discontinued. for 10 days.
  • 6. •Avvelenamenti•Incidenti: domestici & fuori casa
  • 7. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337 % children who had never received dog bite prevent education 100 – 90 – 80 – Cross-sectional study. 70 – 300 parent/guardian-child pairs presenting with 60 – 50 – 70% nonurgent complaints 40 – or dog bites. 30 – 20 – 10 – 0
  • 8. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:3371) Children are highly vulnerable to dog bites and make up a large percentage of dog bite victims.2) Younger children, aged 5 to 9 yrs, are disproportionately at risk, with the highest incidence among all children and a large portion of their injuries occurring to the head, face, or neck.3) Consequences of dog bite injuries can be temporary or lasting and include pain, disfigurement, infection, time lost from school or employment, fear, and anxiety. Evidence of post-traumatic stress disorder 1 month after injury has been seen in over 50% of children who have been bitten by a dog.
  • 9. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:3374) Dog ownership does not necessarily equate to knowledge of how to prevent dog bites, evidenced by the fact that the majority of dog bites to children are by familiar dog.5) Having an experience of a dog bite does not mean that the victim or his or her family member has subsequently learned how to prevent dog bites.6) Dog bite recommendations are typically stated in the negative tense (eg, ‗‗Do not pet a dog that is behind a fence‘‘ and ‗‗Do not pet a dog that is eating‘‘).
  • 10. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  • 11. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  • 12. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  • 13. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  • 14. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  • 15. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  • 16. Grandparents Driving Grandchildren: An Evaluation of Child Passenger Safety and Injuries Henretig, Pediatrics 2011;128:289 OR for injuries 1.0 – Motor vehicle crashes involving children aged ≤15 years. Grandparent-driven 0.5 – vs parent-driven 0.50 vehicles. 0.0 in grandparent-driven crashes
  • 17. Grandparents Driving Grandchildren: An Evaluation of Child Passenger Safety and Injuries Henretig, Pediatrics 2011;128:289 OR for injuries Although nearly 1.0 – Motor vehicle crashes all children involving childrento have were reported aged ≤15 years. been restrained, childre Grandparent-driven n in crashes with 0.5 – vs parent-driven drivers grandparent 0.50 vehicles. used optimal restraint slightly less often. 0.0 in grandparent-driven crashes
  • 18. Grandparents Driving Grandchildren: An Evaluation of Child Passenger Safety and Injuries Henretig, Pediatrics 2011;128:289 OR for injuries Grandchildren 1.0 – Motor vehiclebe safer seem to crashes involving children driven in crashes when aged by grandparents ≤15 years. than by their parents. Grandparent-driven 0.5 – However, safety could be vs parent-driven enhanced if grandparents 0.50 vehicles. followed current child-restraint guidelines. 0.0 in grandparent-driven crashes
  • 19. Abuso nelBAMBINO
  • 20. Abusive head trauma during a time of increased unemployment: a multicenter analysis Berger Pediatrics 2011;128:637 Overall rate of AHT in 100.000 15 – Abusive head trauma 14.7 10 – (AHT). on In 442 children younger than 5 yrs. 05 – 8.9 100.000 on 5 ½ yrs study period. 100.000 00 Before the During the recession recession
  • 21. Abusive head trauma during a time of increased unemployment: a multicenter analysis Berger Pediatrics 2011;128:637 Overall rate of AHT in 100.000 15 – The rate of AHT Abusive head trauma increased 14.7 10 – (AHT). significantly on In 442 children months during the 19 youngeran economic of than 5 yrs. 05 – 8.9 100.000 on recession compared 5 ½ yrs study period. with the 47 months 100.000 00 before the recession. Before the During the recession recession
  • 22. Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review Kemp Arch dis Child 2011;96:1103 OR for abusive head trauma Neuroradiological 9.0 – features that 8.0 – differentiate 7.0 – 8.2 abusive head 6.0 – trauma (AHT) 5.0 – from 4.0 – non-abusive 3.0 – head trauma (nAHT). 2.0 – 21 studies of children predominantly <3 yrs. 1.0 – 0 0 0.1 Subdural Extradural haemorrhages haemorrhages
  • 23. Recidivism in the Child Protection System. Identifying Children at Greatest Risk of Reabuse Among Those Remaining in the Home. Dakil APAM 2011;165:1006 Incidence of Reabuse. A 5-year prospective 50 – cohort study. Children reported to the 40 – 45% child protection system 30 – for child abuse. 20 – A total of 2578 children remained in the home 10 – following an abuse report. 0
  • 24. Recidivism in the Child Protection System. Identifying Children at Greatest Risk of Reabuse Among Those Remaining in the Home. Dakil APAM 2011;165:1006 Incidence of Reabuse. 1) children with A 5-year prospective 50 – behavior cohort study. problems, 2) Children reported toan caregivers with the 40 – 45% child protection system abuse history and 30 – for 3) families with an child abuse. 20 – A total of 2578lower than annual income children remained$20the home in 000 10 – were more likely following an abuse report. to be rereported. 0
  • 25. FEVER andFEVER CONTROL
  • 26. Paracetamol prescription by age or by weight? Lenney, Arch Dis Child 2012;97:277 New dosing tables
  • 27. Paracetamol prescription by age or by weight? Lenney, Arch Dis Child 2012;97:277 New dosing tables In general, childrens dosages are based on a single dose of 10 (7.5-15) mg paracetamol per kilogram bodyweight, which can be repeated 4-6 hourly, not exceeding four doses per 24 hours. (TACHIPIRINA 120 mg/5 ml sciroppo TACHIPIRINA 100 mg/ml gocce orali, soluzione)
  • 28. Prospective Longitudinal Study of Signs and Symptoms Associated With Primary Tooth Eruption Ramos-Jorge Pediatrics 2011;128:471 Tympanic and Axillary Temperature Determined on Noneruption Days, Day Before Eruption, Day of Eruption, and Day After Eruption An 8- month, longitudinal study. 47 infants receiving care at home between 5 and 15 months. Daily tympanic and axillary temperature reading.
  • 29. Prospective Longitudinal Study of Signs and Symptoms Associated With Primary Tooth Eruption Ramos-Jorge Pediatrics 2011;128:471 Tympanic and Axillary Temperature Determined on Noneruption Days, Day Before Eruption, The most frequent Day of Eruption, and Day After Eruption signs and symptoms An 8- associated with month, longitudinal teething were: irritability study.(47 infantsincreased p<0.001), receiving salivation (p<0.001), care at home between runny nose 5 and 15 months. (p<0.001), and loss of appetite (p<0.001). Daily tympanic and axillary temperature reading.
  • 30. Prospective Longitudinal Study of Signs and Symptoms Associated With Primary Tooth Eruption Ramos-Jorge Pediatrics 2011;128:471 Tympanic and Axillary Temperature Determined on Noneruption Days, Day Before Eruption, Day of Eruption, and Day After Eruption Occurrence of An 8- severe signs month, longitudinal study. and symptoms, such 47 infants receiving care as home between at fever, could not be 5 and 15 months. attributed to Daily tympanic and teething. axillary temperature reading.
  • 31. AlimentazioneLatte materno Formule
  • 32. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355• The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-administered scale. Cox, Br J Psychiatry 1987;150:782 Benvenuti, J Affect Disord 1999;53:137• Maternal depression is suspected when a mother scores higher than a cut-off value (usually >9 or >12).• Recent data suggest that mothers with high EPDS scores (>12) tend to breast feed less in the first 2 months, but it is not known if mothers with mild depressive symptoms and with normal scores are at increased risk.
  • 33. Edimburg Postnatal Depression Scale (EPDS) http://www.google.it/urlsa=t&rct=j&q=edinburgh+postnatal+depression+scale+italian o&source= www.envicon.it
  • 34. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355 % mothers with EPDS>9 20 – Edinburgh Postnatal Depression Scale (EPDS). 15 – 15.7% Later breast feeding problems. 10 – 592 mothers of a healthy baby. 05 – Feeding method recorded at 12–14 wks. 00
  • 35. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355 Distribution of EPDS scores and the odds of bottle feeding at each score. Edinburgh Postnatal Depression Scale 0 (EPDS). Later breast feeding problems. 592 mothers of a healthy baby. Feeding method recorded at 12–14 wks.
  • 36. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355 Distribution of EPDS scores and the Mothers with odds of bottle feeding at each score. Edinburgh Postnatal higher EPDS Depression Scale 0 were more likely (EPDS). to bottle feed Later breast feeding at 3 months. problems. The odds of bottle 592 mothers feeding increased of a healthy baby. with EPDS Feeding method at result, even low scores. recorded at 12–14 wks.
  • 37. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355 Distribution of EPDS scores and the There odds of bottle feeding at each score. was no cut-off Edinburgh Postnatal Depression Scale risk under which no 0 increase was seen. (EPDS). Later breast feeding problems.of bottle the OR feeding associated 592 mothers with healthy baby.of of a an increase 1 point in the EPDS Feeding method score was 1.06 recorded at 12–14 wks. ( p=0.02),
  • 38. Breastfeeding is associated with increased lung function at 18 years of age: a cohort Study Soto-Ramı´rez, Eur Respir J 2012;39:985 Effect of breastfeeding (FVC) (Litres) at 18 yrs of age by height A birth cohort. Breastfeeding duration. Spirometric tests at 10 and 18 yrs.
  • 39. Association of Exclusive Breastfeeding Duration and Fibrinogen Levels in Childhood and Adolescence Labayen I, APAM 2012;166:56 Mean fasting serum fibrinogen levels according to duration of exclusive 704 children age breastfeeding duration in the whole sample(A) 9.5 yrs. 665 adolescents 15.5 yrs. Fasting fibrinogen level.
  • 40. Erythrocyte zinc levels in children with bronchial asthma Yilmaz Pediatr Pulmonol 2011;46:1189 Mean concentrations of erythrocyte zinc (μg/dl) 1500 – Erythrocyte zinc levels. ns 1000 – 1215.8 1206 67 asthmatic and 45 healthy children. 0500 – 0000 Asthmatics Controls
  • 41. Erythrocyte zinc levels in children with bronchial asthma Yilmaz Pediatr Pulmonol 2011;46:1189 Mean concentrations (μg/dl) of erythrocyte zinc in children hospitalized for an asthma attack in the previous 12 mo. 1500 – p<0.0001 Erythrocyte zinc levels. 1248 1000 – 1095 67 asthmatic and 45 healthy children. 0500 – 0000 NO YES
  • 42. Erythrocyte zinc levels in children with bronchial asthma Yilmaz Pediatr Pulmonol 2011;46:1189 The decreased amount of antioxidants in the diet in recent years has been reported to contribute to the increased incidence of asthma. Romieu I Am J Respir Crit Care Med 2002; 166: 703-709 Glutathione peroxidase and superoxide dismutase, the important antioxidant enzymes of the body, contain zinc in their structure. Wright DT Environ Health Perspect 1994; 102: 85-90 Therefore, zinc is an important antioxidant element. It is found in the respiratory tract epithelium, plays a role in the regulation of the cellular and humoral immune response and possesses antiapoptotic and anti-inflammatory features indicating a possible role in asthma pathogenesis and treatment. Zalevski PD, Pharmacol Ther 2005; 105: 127 -149 Truong-Tran AQ, Am J Physiol Lung Cell Mol Physiol 2000; 279: 1172-1183
  • 43. Erythrocyte zinc levels in children with bronchial asthma Yilmaz Pediatr Pulmonol 2011;46:1189 Allergen-sensitized mice where zinc-deficiency was created through diet showed 1.6 and 3.2 times the rate of the number of airway eosinophils and epithelial cell apoptosis, respectively, than those fed a diet containing normal amounts of zinc. Truong-Tran AQ, Am J Respir Cell Mol Biol 2002; 27: 286–296 Airway epithelial damage plays an important role in asthma pathogenesis Zalevski PD, Pharmacol Ther 2005; 105: 127-149 . The damage to this barrier function is directly related to caspase 3 activation and the proteolysis of proteins that No provide intercellular connection. Zinc protect airway epithelial integrity by both preventing caspase 3 activation and the lysis of proteins that provide intercellular connection.
  • 44. A randomized controlled trial of zinc as adjuvant therapy for severe pneumonia in young children Basnet Pediatrics 2012;129:701 610 children aged 2 to 35 months. HR in zinc supplemented for Severe pneumonia defined by the World Health Organization as cough and/or breathing combined 1.0 – 1.10 with lower chest indrawing. All children 0.88 0.5 – antibiotic treatment. Zinc (10mg in 2- to 11- month-olds and 20mg in older children) or placebo 0 daily for up to 14 days. Faster Treatment recovery failure
  • 45. A randomized controlled trial of zinc as adjuvant therapy for severe pneumonia in young children Basnet Pediatrics 2012;129:701 610 children aged 2 to 35 months. HR in zinc supplemented for Adjunct treatment Severe pneumonia defined with zinc by the World Health Organization as cough time reduced the to cessation and/or breathing combined 1.0 – 1.10 with lower chest indrawing. of severe pneumonia All children the risk 0.88 and antibiotic treatment. 0.5 – of treatment failure Zinc (10mg in 2- to 11- only marginally month-olds and 20mg in . older children) or placebo 0 daily for up to 14 days. Faster Treatment recovery failure
  • 46. •Vitamina D•deficit
  • 47. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485 Analyses revealed no Serum 25(OH)-vitamin D significant associations concentrations. between maternal 743 Caucasian women at 25(OH)-vitamin D 18 weeks pregnancy serum quartiles and (grouped into quartiles). offspring behavioral/ emotional problems Child Behavior Checklist at any age. at 2, 5, 8, 10, 14, and 17 years of age. But…….
  • 48. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485 There were significant linear trends between quartiles of Serum 25(OH)-vitamin D maternal vitamin D levels and concentrations. language impairment at 5 and 10 years of age.The risk of 743 Caucasian women at women with vitamin D 18 weeks pregnancy insufficiency (≤46 nmol/L) (grouped into quartiles). during pregnancy having a child with clinically Child Behavior Checklist significant language at 2, 5, 8, 10, 14, and 17 difficulties was increased years of age. close to 2x compared with women with vitamin D levels ≥70 nmol/L.
  • 49. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485 Proportion of offspring with mild or moderate-severe language impairmentat 5 (Y5)a and 10 years (Y10)b of age according to maternalserum 25(OH)-vitamin D levels at 18 weeks’ pregnancy.
  • 50. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485Association Between Maternal 25(OH)-Vitamin D Concentration at 18 Weeks’ Pregnancy and Offspring Language Impairment During Childhood
  • 51. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485Association Between Maternal 25(OH)-Vitamin D Concentration Vitamin DWeeks’ Pregnancy and Offspring at 18 performs a number of biological Language Impairment fundamental to functions that are During Childhood neurodevelopment, including a signaling role in neuronal differentiation, a regulation role in the metabolism of neurotrophic factors and neurotoxins, and a protective role during brain inflammation.
  • 52. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485Association Between Maternal 25(OH)-Vitamin D Concentration Vitamin18 Weeks’ Pregnancy and Offspring in at D may also be indirectly involved Language Impairment During Childhood fetal brain growth through its role in a number of endocrine functions. Reduced levels of vitamin D may disrupt 1 or more of these functions during critical phases of neurodevelopment.
  • 53. Cord Blood Vitamin D Deficiency Is Associated With Respiratory Syncytial Virus Bronchiolitis Belderbos Pediatrics 2011;127:e1513 156 healthy term Cord blood concentrations of 25-OHD in neonates. neonates who subsequently developed RSV LRTI (n=18) and those who did not (n=138) 25-hydroxyvitamin D (25-OHD) in cord blood plasma. Lower respiratory tract infection (LRTI) caused by Respiratory Syncytial Virus (RSV) in the first year of life, defined as LRTI symptoms and presence of RSV RNA in a nose-throat specimen.
  • 54. Cord Blood Vitamin D Deficiency Is Associated With Respiratory Syncytial Virus Bronchiolitis Belderbos Pediatrics 2011;127:e1513 156 healthy term Relative Risk (RR) of RSV LRTI per quartile of 25-OHD levels. neonates. Because of the limited number of cases, the lower quartiles (25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled 25-hydroxyvitamin D (25-OHD) in cord blood plasma. Lower respiratory tract infection (LRTI) caused by Respiratory Syncytial Virus (RSV) in the first year of life, defined as LRTI symptoms and presence of RSV RNA in a nose-throat specimen.
  • 55. Cord Blood Vitamin D Deficiency Is Associated With Respiratory Syncytial Virus Bronchiolitis Belderbos Pediatrics 2011;127:e1513 156 healthy term Relative Risk (RR) of RSV LRTI per quartile of 25-OHD levels. neonates. Because of the limited number of cases, the lower quartiles Vitamin D (25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled 25-hydroxyvitamin D deficiency in (25-OHD) in cord blood healthy neonates is plasma. associated with Lower respiratory tract increased risk of infection (LRTI) caused RSV LRTI in the by Respiratory Syncytial Virus (RSV) in year first the first of life. year of life, defined as LRTI symptoms and presence of RSV RNA in a nose-throat specimen.
  • 56. Cord Blood Vitamin D Deficiency Is Associated With Respiratory Syncytial Virus Bronchiolitis Belderbos Pediatrics 2011;127:e1513 156 healthy term Relative Risk (RR) of RSV LRTI per quartile of 25-OHD levels. neonates. Because of the limited number of cases, the lower quartiles Intensified (25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled 25-hydroxyvitamin D D routine vitamin (25-OHD) in cord blood supplementation plasma. during pregnancy may be a useful Lower respiratory tract infection (LRTI) caused strategy to prevent by Respiratory Syncytial RSV LRTI Virus (RSV) in the first year during defined as of life, infancy. LRTI symptoms and presence of RSV RNA in a nose-throat specimen.
  • 57. A cross-sectional study of vitamin D and insulin resistance in children Kelly Arch Dis Child 2011;96:447 Cross-sectional study of 85 (4–18 yrs). % children with vitamin D 50 – Fasting blood glucose, insulin and 25- 40 – 47% OH-D were measured. 30 – Homeostasis model 20 – 26% 27% assessment (HOMA), a measure 10 – of insulin sensitivity, was 0 calculated as (fasting sufficient intermediate insufficient blood glucose (≥75 nmol/l) (50–75 nmol/l) (25–50 nmol/l) (mmol/l)×insulin (μU/ml))/22.5.
  • 58. A cross-sectional study of vitamin D and insulin resistance in children Kelly Arch Dis Child 2011;96:447 Cross-sectional study of 85 (4–18 yrs). % children with vitamin D Lower 25-OH-D 50 –was associated with Fasting blood higher , fasting blood glucose insulin and 25- 40 – 47% OH-D were measured. glucose, 30 – insulin andmodel Homeostasis HOMA 20 – 26% 27% after assessment (HOMA), a measure adjustment for 10 – of insulin sensitivity, was puberty calculated as (fasting 0 sufficient intermediate insufficient and BMI-Z. blood glucose (≥75 nmol/l) (50–75 nmol/l) (25–50 nmol/l) (mmol/l)×insulin (μU/ml))/22.5.
  • 59. Vitamin D Deficiency, Adiposity, and Cardiometabolic Risk in Urban Schoolchildren Sacheck, J Ped 2011;159:945 263 schoolchildren living in % children northeastern US. 80 – Serum 25-hydroxyvitamin D [25(OH)D]. 70 – 60 – 74.6% Body mass index (BMI) z-score (BMIz). 50 – 6 cardiometabolic risk factors: 40 – - total cholesterol; 30 – - HDL cholesterol; 20 – - LDL cholesterol; - triglycerides; 10 – - interleukin-6; 0 Vitamin D deficient - C-reactive protein [CRP]. [25(OH)D <50 nmol/L]
  • 60. Vitamin D Deficiency, Adiposity, and Cardiometabolic Risk in Urban Schoolchildren Sacheck, J Ped 2011;159:945 263 schoolchildren living in % children northeastern US. 80 – Serum 25-hydroxyvitamin D The 25(OH)D level [25(OH)D]. 70 – 60 – 74.6% was not associated Body mass index (BMI) z-score (BMIz). with 50 – BMIz, but was 6 cardiometabolic risk factors: 40 – positively associated - total cholesterol; 30 – -with cholesterol; HDL the cardiometabolic 20 – risk factor - LDL cholesterol; - triglycerides; 10 – - interleukin-6; 0 Vitamin D deficient - C-reactive protein [CRP]. [25(OH)D <50 nmol/L]
  • 61. Determinants of 25(OH)D Sufficiency in Obese Minority Children:Selecting Outcome Measures and Analytic Approaches Zhou, J Ped 2011;158:930 Smoothed relationships of Systolic Blood Pressure to Vitamin D levels Serum 25-(OH) vitamin D (ng/mL). (r=-0.261; P=0.038) 140 healthy obese children age 6 to 21 years.
  • 62. Determinants of 25(OH)D Sufficiency in Obese Minority Children:Selecting Outcome Measures and Analytic Approaches Zhou, J Ped 2011;158:930 Smoothed relationships of Systolic Blood Pressure to Vitamin D levels Serum 25-(OH) Systolic blood vitamin D. (r=-0.261; P=0.038) pressure (SBP) was significantly 140 healthy obese children age 6 with correlated to 21 years. 25(OH)D.
  • 63. Recent trends and clinical features of childhood vitamin D deficiency presenting to a children’s hospital in Glasgow Ahmed Arch Dis Child 2011;96:694 Number of cases presenting each year between 2002 and 2008 categorized Between 2002 and 2008. according to four broad ethnic backgrounds.Cases of symptomaticvitamin D deficiency.(bowed legs, fractures, limbpain, X-ray which highlightedrickets, swollen wrists, asymptomatichypocalcaemia, raised alkalinephosphatase (ALP)concentration, developmentaldelay, cardiac failure andhypocalcaemia and which resolvedfollowing treatment with calcium andvitamin D.)
  • 64. Recent trends and clinical features of childhood vitamin D deficiency presenting to a children’s hospital in Glasgow Ahmed Arch Dis Child 2011;96:694 Reason for referral for investigation and management of 160 children with suspected Between 2002 and 2008. of cases D deficiency according to age The number vitamin of vitamin D deficiency is currently increasing. categories at presentation.Cases of symptomatic The change in the relative proportion ofvitamin D deficiency.(bowed legs, fractures, limbfrom different ethnic origins casespain, X-ray which highlighted reflects therickets, swollen wrists, asymptomatic changing patterns of immigrationhypocalcaemia, raised alkalinephosphatase (ALP) and birth patternsconcentration, developmentaldelay, cardiac failure and in the West of Scotland.hypocalcaemia and which resolvedfollowing treatment with calcium andvitamin D.)
  • 65. Recent trends and clinical features of childhood vitamin D deficiency presenting to a children’s hospital in Glasgow Ahmed Arch Dis Child 2011;96:694 Reason for referral for investigation and management of 160 children with suspected Between 2002 and 2008. vitamin D deficiency according to ageCases of symptomatic It is imperative that the categories at presentation.vitamin D deficiency. priority remains the first(bowed legs, fractures, limbpain, eradication of X-ray which highlighted profound, symptomaticrickets, swollen wrists, asymptomatichypocalcaemia, raised alkalinephosphatase (ALP) vitamin D deficiency.concentration, developmentaldelay, cardiac failure andhypocalcaemia and which resolvedfollowing treatment with calcium andvitamin D.)
  • 66. •Vitamina D•raccomandazioni
  • 67. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. Ross AC, J Clin Endocrinol Metab. 2011;96:53-8.RDA = Recommended Dietary Allowance; UL= tolerable upper intake level; c= not well defined
  • 68. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. Ross AC, J Clin Endocrinol Metab. 2011;96:53-8. Dietary Reference Intake shown in Table 1 are based on dietary requirements using bone health as an indicator.RDA = Recommended Dietary Allowance; UL= tolerable upper intake level; c= not well defined
  • 69. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. Ross AC, J Clin Endocrinol Metab. 2011;96:53-8.For vitamin D, the 2011 Dietary Reference Intake (DRIs) arebased primarily on the integration of bone health outcomes withevidence concerning 25OHD levels, which suggest that levels of16 ng/ml (40 nmol/liter) meet the needs of approximately half thepopulation (median population requirement), and levels of at least20 ng/ml (50 nmol/liter) meet the needs of at least 97.5% of thepopulation.These levels will be useful to clinicians as they considermanagement of patients under their care.Thus, serum 25OHD levels above 50 ng/ml (125 nmol/liter) shouldraise concerns among clinicians about potential adverse effects.
  • 70. The IOM D-lemma. Holick MF. Public Health Nutr. 2011;14:939-41Pregnant and lactating womenneed more than 15µg (600 IU)vitamin D/d.However in forty mother–infant pairs where70% of the women were taking on average15µg vitamin D/d, it was reported that 76% of the mothers and81% of the newborns at the time of birth had 25-hydroxyvitaminD level <20 ng/mlLee JM, Smith JR, Philipp BL et al. Vitamin D deficiency in a healthy group ofmothers and newborn infants. Clin Pediatr 2007;46:42–44.
  • 71. The IOM D-lemma. Holick MF. Public Health Nutr. 2011;14:939-41Furthermore it was reported thatPre-eclampsiaBodnar LM, J Clin EndocrinolMetab, 2007; 92: 3517–3522.andthe need for a primaryCaesarean sectionMerewood A, J Clin Endocrinol Metab. 2009;94: 940–945.were associated withVitamin D deficiency (<20 ng/mL).
  • 72. Inappropriate and inconsistent modalities of treatment of vitamin D deficiency in children Gupta Arch Did Child 2011;96:787 • Pearce and Cheetham (BMJ 2010;340:b5664) in their article on ―Diagnosis and management of vitamin D deficiency‖, quite clearly recommend the use of calciferol (3000-6000 IU/day) in the treatment of vitamin D deficiency in children. • Expert opinion from the British Society for Paediatric Endocrinology and Diabetes also confirm this reccomendation.
  • 73. Micronutrienti:Acido folicoFatty AcidsDHA EPA
  • 74. High Folate Intake Is Related to Better Academic Achievement in Swedish Adolescents Nilsson, Pediatrics 2011;128:e358An increased plasma total homocysteine (tHcy)serves as a marker for functional deficiency of certain Bvitamins, such as B12, B6, riboflavin, and, in particular, folate.The genetic model disease homocystinuria is characterized byhigh plasma tHcy levels, mental retardation, and a range ofpsychiatric symptoms, in addition to premature atherosclerosis.In more recent studies, links have been found betweenimpaired homocysteine metabolism and a wide range ofneuropsychiatric conditions such asdepression, cognitive impairment, and dementiain adult populations and in the elderly.
  • 75. High Folate Intake Is Related to Better Academic Achievement in Swedish Adolescents Nilsson, Pediatrics 2011;128:e358 386 Swedish adolescents aged 15 yrs. The sum of school grades in 10 core subjects obtained Academic achievement in the final semester of was compulsory 9 years of strongly correlated to schooling used as outcome tertiles of tHcy measure of academic (negatively; P=0.023) achievement. and toAdolescents are vulnerable tertiles of folate intake to increased plasma total (positively; P<0.001). homocysteine (tHcy) and to insufficient folate status.
  • 76. High Folate Intake Is Related to Better Academic Achievement in Swedish Adolescents Nilsson, Pediatrics 2011;128:e358
  • 77. Folic Acid Use in Pregnancy and the Development of Atopy, Asthma, and Lung Function in Childhood Magdelijns Pediatrics 2011;128:e144 KOALA Birth Cohort •Maternal folic acid supplement Study (n=2834). use during pregnancy was not Data on eczema associated with increased risk and wheeze at of wheeze, lung 3, 7, 12, and 24 function, asthma, or related months, 4 atopic outcomes in the to 5 years, and offspring. 6 to 7 years. Intracellular folic acid •Maternal ICF level in late pregnancy was inversely (ICF) determined in blood samples taken at associated with asthma risk at ~35 weeks of pregnancy age 6 to 7 years in a (n=837). dose-dependent manner
  • 78. Folic Acid Use in Pregnancy and the Development of Atopy, Asthma, and Lung Function in Childhood Magdelijns Pediatrics 2011;128:e144 OR for asthma at 6-7 yrs1.0 – 1.0 p<0.05 for trend 0.730.5 – 0.46 0.41 0.310.0 1st Quintile 2nd Quintile 3rd Quintile 4th Quintile 5th Quintile (≤ 480 nmol/L) (481–643 (644–862 (863–1139 (≥ 1140 nmol/L) nmol/L) nmol/L) nmol/L) Intracellular folic acid Levels (Divided Into Quintiles)
  • 79. Decreased Postnatal Docosahexaenoic and ArachidonicAcid Blood Levels in Premature Infants are Associatedwith Neonatal Morbidities Martin, J Ped 2011;159:74388 infants born at <30 Docosahexaenoic acid weeks‘ gestation. (DHA) and arachidonic acidFatty acid profiles levels declined during the first rapidly in the first postnatal month. postnatal week, with a concomitantInfant increase in linoleic outcomes, including acid levels. chronic lung disease (CLD).
  • 80. Decreased Postnatal Docosahexaenoic and ArachidonicAcid Blood Levels in Premature Infants are Associatedwith Neonatal Morbidities Martin, J Ped 2011;159:74388 infants born at <30 weeks‘ gestation.Fatty acid profiles during the first postnatal month.Infant outcomes, including chronic lung disease (CLD).
  • 81. Decreased Postnatal Docosahexaenoic and ArachidonicAcid Blood Levels in Premature Infants are Associatedwith Neonatal Morbidities Martin, J Ped 2011;159:743 OR for chronic lung disease88 infants born at <30 3 – weeks‘ gestation.Fatty acid profiles 2 – 2.5 during the first postnatal month. 1 –Infant outcomes, including chronic lung disease 0 (CLD). Decreased DHA level
  • 82. Decreased Postnatal Docosahexaenoic and ArachidonicAcid Blood Levels in Premature Infants are Associatedwith Neonatal Morbidities Martin, J Ped 2011;159:743 HR for late onset sepsis88 infants born at <30 3 – weeks‘ gestation.Fatty acid profiles 2 – during the first postnatal month. 1 – 1.4Infant outcomes, including chronic lung disease 0 (CLD). Decreased arachidonic acid level
  • 83. High-Dose Docosahexaenoic Acid Supplementation of Preterm Infants: Respiratory and Allergy Outcomes Manley Pediatrics 2011;128:e71 657 preterm infants 33 weeks‘ RR of BDP in all infants with gestation who consumed a birth weight of 1250 g expressed breast milk from 1.0 – mothers taking either 0.9 – tuna oil (high-DHA diet) or 0.8 – 0.75 0.7 – soy oil (standard-DHA) 0.6 – capsules. 0.5 – 0.4 – p=0.04 Incidence of bronchopulmonary 0.3 – dysplasia (BPD) and parental 0.2 – 0.1 – reporting of atopic conditions 0 over the first 18 months of DHA diet life.
  • 84. High-Dose Docosahexaenoic Acid Supplementation of Preterm Infants: Respiratory and Allergy Outcomes Manley Pediatrics 2011;128:e71 657 preterm infants 33 weeks‘ RR of reported hay fever gestation who consumed in all infants at either expressed breast milk from 12 or 18 months 1.0 – mothers taking either 0.9 – tuna oil (high-DHA diet) or 0.8 – soy oil (standard-DHA) 0.7 – capsules. 0.6 – 0.5 – 0.4 – Incidence of bronchopulmonary dysplasia (BPD) and parental 0.3 – 0.2 – 0.41 reporting of atopic conditions 0.1 – p=0.03 over the first 18 months of 0 life. DHA diet
  • 85. Impaired Fetal Growth and Arterial Wall Thickening:A Randomized Trial of Omega-3 Supplementation Skilton, Pediatrics 2012;129;e698 WHAT’S KNOWN ON THIS SUBJECT: Impaired fetal growth is an independent risk factor for cardiovascular diseases in adulthood and is associated with arterial wall thickening, a noninvasive measure of subclinicalatherosclerosis, in early childhood. No preventive strategy has been identified. WHAT THIS STUDY ADDS: Dietary omega-3 fatty acidsupplementation in early childhood prevented the association of impaired fetal growth with arterial wall thickening, suggesting that this early-life intervention may mitigate the risk of cardiovascular disease in those with impaired fetal growth.
  • 86. Impaired Fetal Growth and Arterial Wall Thickening: A Randomized Trial of Omega-3 Supplementation Skilton, Pediatrics 2012;129;e698 616 children born at term. Fetal growth was inversely associated with carotid Either a 500-mg-daily fish oil intima-media supplement and canola based margarines and cooking oil thickness (IMT), (omega-3 group). but this was prevented in the omega-3 group. 500-mg-daily sunflower oil supplement and omega-6 fatty Pheterogeneity = 0.02 acid–rich margarines and cooking oil (control group). From the start of bottle-feeding or 6 months of age until 5 years of age.
  • 87. Impaired Fetal Growth and Arterial Wall Thickening: A Randomized Trial of Omega-3 Supplementation Skilton, Pediatrics 2012;129;e698 616 children born at term. Fetal growth was inversely The inverse association associated with carotid Either a 500-mg-daily fish oil intima-media of fetal growth with supplement and canola based margarines wallcooking oil arterial and thickness thickness (IMT), (omega-3 group). can be at age 8 yrs but this was prevented prevented by dietary in the omega-3 group. 500-mg-daily sunflower oil omega-3 fatty acid supplement and omega-6 fatty Pheterogeneity = 0.02 supplementation acid–rich margarines and cooking over the first oil (control group). 5 years of life. From the start of bottle-feeding or 6 months of age until 5 years of age.
  • 88. CARDIOLOGYmalformations
  • 89. Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. Ewer, Lancet 2011;378:785 Number of babies with major congenital heart disease 6 maternity units in the UK. 60 – 20055 asymptomatic 53 50 – newborn babies. 40 – Pulse oximetry before discharge. (0.26%) 30 – Infants who did not achieve (24 critical) oxygen saturation thresholds 20 – underwent echocardiography. 10 – 0
  • 90. Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease SECTION ON CARDIOLOGYAND CARDIAC SURGERY EXECUTIVE COMMITTEE Pediatrics 2012;129;190 The screening is targeted toward healthy newborn infants in the newborn nursery. Screening should be performed with motion-tolerant pulse oximeters. Screening should not be undertaken until 24 hours of life or as late as possible if early discharge is planned to reduce the number of false positive results.
  • 91. Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease SECTION ON CARDIOLOGYAND CARDIAC SURGERY EXECUTIVE COMMITTEE Pediatrics 2012;129;190 •O2 saturations should be obtained in the right hand and one foot. •Screening that has a pulse oximetry reading of ≥95% in either extremity with a ≤3% absolute difference between the upper and lower extremity would be considered a pass, and the screening would end. It is recommended that repeated measurements be performed in those cases in which the initial screening result was positive, again in an effort to reduce false-positive results. •Infants with saturations <90% should receive immediate evaluation.
  • 92. Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease SECTION ON CARDIOLOGYAND CARDIAC SURGERY EXECUTIVE COMMITTEE Pediatrics 2012;129;190 •O2 saturations should be obtained in the right hand and one foot. •Screening that has a pulse oximetry reading of ≥95% in either In the event of a positive screening extremity with a ≤3% absolute differenceexcluded result, CCHD needs to be between the upper and lower extremity would be considered a pass, and the screening with a diagnostic echocardiogram. would end. It is recommended that repeated measurements be performed Infectious andwhich the initial screening result in those cases in pulmonary causes was positive, again in an effort to reduce excluded. of hypoxemia should also be false-positive results. •Infants with saturations <90% should receive immediate evaluation.
  • 93. CARDIOLOGY-dolore toracico-tachicardia-sincope collasso
  • 94. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:2221) The diagnosis of orthostatic intolerance (OI) and postural orthostatic tachycardia syndrome (POTS) is based on a symptomatic, excessive orthostatic rise in heart rate (HR).2) Common symptoms of OI and POTS include lightheadedness, palpitations, pre-syncopal feelings, tremulousness, and leg weakness when assuming the upright position.3) These symptoms are considered related to a combination of reduced cerebral perfusion and increased sympathetic activation.4) OI and POTS occur predominately in females, with female:male of approximately 5:1.
  • 95. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 Orthostatic HR increment 654 pediatric patients during head-up tilt in normal controls referred with symptoms and patients with symptoms of OI of orthostatic intolerance OI. 106 normal controls aged 8-19 yrs. Standardized autonomic testing, including 5 min of 70° head-up tilt after supine resting for at least 30 min.
  • 96. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 Orthostatic HR increment 654 pediatric patients during head-up tilt in normal controls referred with symptoms and patients with symptoms of OI of orthostatic intolerance The HR increment OI. was mildly higher in patients referred 106 normalOI/POTS, for controls aged 8-19 yrs. but there was considerable overlap Standardizedthe patient between autonomic testing, includinggroups. and control 5 min of 70° head-up tilt after supine resting for at least 30 min.
  • 97. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 Our study demonstrates that: an orthostatic HR increment of 30 bpm (the main diagnostic criterion for OI in adults) is still well within the normal range for children and adolescents. x
  • 98. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 We suggest the following diagnostic criteria for Pediatric Orthostatic Intolerance:1) Symptoms of OI, such as lightheadedness and palpitations, occurring frequently (>50% of the time) when assuming the upright position &2) orthostatic HR increment ≥40 bpm within 5 minutes of head-up tilt. OI=orthostatic intolerance POTS= postural tachycardia syndrome
  • 99. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 We suggest the following diagnostic criteria for pediatric postural orthostatic tachycardia syndrome:1) Symptoms and HR increment fulfilling criteria for pediatric OI &2) absolute orthostatic HR ≥130 bpm (for age ≤13 years), or ≥120 bpm (for age ≥14 years) within 5 minutes of head-up tilt. OI=orthostatic intolerance POTS= postural tachycardia syndrome
  • 100. Plasma Hydrogen Sulfide (H2S) in Differential Diagnosis between Vasovagal Syncope and Postural Orthostatic Tachycardia Syndrome in Children, Zhang, J Pediatr 2012;160:2271) Orthostatic intolerance (OI) is a constellation of signs and symptoms that are elicited by standing upright and relieved by recumbency. Symptoms include headache, nausea, abdominal pain, lightheadedness, diminished concentration, tremulousness, syncope, near syncope, and hyperpnea.2) Postural orthostatic tachycardia syndrome (POTS) and vasovagal syncope (VVS) are common causes of OI in children.3) POTS is defined operationally by symptoms of OI in association with excessive tachycardia.4) Vaso Vagal Syndrome is defined by a sudden transient loss of consciousness and postural tone caused by blood pressure drops and bradicardia with consequent cerebral hypoperfusion.
  • 101. Plasma Hydrogen Sulfide (H2S) in Differential Diagnosis between Vasovagal Syncope and Postural OrthostaticTachycardia Syndrome in Children, Zhang, J Pediatr 2012;160:227 Plasma concentrations of H2S in the Vasovagal syncope control, POTS and VVS groups. (VVS) (n=17). Postural Orthostatic Tachycardia Syndrome (POTS) in children (n=60). Healthy children (control group) (n=28). Plasma concentrations of hydrogen sulfide H2S.(acido solfidrico)
  • 102. Plasma Hydrogen Sulfide (H2S) in Differential Diagnosis between Vasovagal Syncope and Postural OrthostaticTachycardia Syndrome in Children, Zhang, J Pediatr 2012;160:2271) Hydrogen sulfide (H2S) had long been known as a toxic gas, but only recently has it been regarded as a novel endogenous gasotransmitter.2) It is produced endogenously in mammalian tissues from L-cysteine by mainly 3 enzymes: cystathionine b-synthetase, cystathionine γ- lyase, and 3-mercaptosulfurtransferase.3) H2S could be produced by vascular smooth muscle cells and endothelial cells. It contributes to endothelium-dependent vasorelaxation and exerts regulatory effects on the pathogenesis of various diseases, such as hypertension, pulmonary hypertension and shock.4) For POTS, the abnormal vascular relaxation and cardiothoracic hypovolemia are thought to be the mechanisms.
  • 103. Dermatology
  • 104. Association of microbial IgE sensitizations with asthma in young children with atopic dermatitis Ong, Ann Allergy Asthma Immunol 2012;108:206 OR for persistent asthma 53 children (1-6 yrs) 5 – with mild to moderate AD. Total serum IgE and 4 – 4.3 4.2 specific IgE for: - inhalant allergens 3 – 3.5 - common food 2- - microbial allergens (Staphylococcal 1 – enterotoxins, Aspergillus fumigatus, Cladosporium Nature Genetics, 00 2006:38:399 herbarum, Malassezia C albicans C herbarum Malassezia species, and Candida albicans). SENSITIZATION to
  • 105. Association of microbial IgE sensitizations with asthma in young children with atopic dermatitis Ong, Ann Allergy Asthma Immunol 2012;108:206 OR for persistent asthma 53 children (1-6 yrs) 5 – with mild to moderate AD. Total serum IgE and Persistent asthma 4 – 4.3 4.2 specific IgE for: was associated with - inhalant allergens 3 – 3.5 - common food IgE fungal 2- sensitizations. - microbial allergens (Staphylococcal 1 – enterotoxins, Aspergillus fumigatus, Cladosporium Nature Genetics, 00 2006:38:399 herbarum, Malassezia C albicans C herbarum Malassezia species, and Candida albicans). SENSITIZATION to
  • 106. Depression, anxiety and dermatologic quality of life in adolescents with atopic dermatitis Slattery JACI 2011;128:668 % children with anxiety 30 – disorders 36 adolescents, mean age 20 – 26% 14.7 yrs with AD. Social SCORAD index. anxiety 10 – Children‘s Depression disordes was 6% most common Inventory and the 3% (14%) Multidimensional Anxiety 0 Scale for Children. AD Community estimates
  • 107. Depression, anxiety and dermatologic quality of life in adolescents with atopic dermatitis Slattery JACI 2011;128:668 % children with current depressive disorders 10 – 36 adolescents, mean age 14.7 yrs with AD. 9% 6% 05 – SCORAD index. Children‘s Depression Inventory and the Multidimensional Anxiety 0 Scale for Children. AD Community estimates
  • 108. Depression, anxiety and dermatologic quality of life in adolescents with atopic dermatitis Slattery JACI 2011;128:668 % children with current depressive disorders Subjective report 10 – of sleep loss was the 36 adolescents,severity only AD mean age 14.7 yrs with AD. 9% measure found 05 6% – SCORAD index. to be associated with symptoms Children‘s Depression Inventorydepression. of and the Multidimensional Anxiety 0 Scale for Children. AD Community estimates
  • 109. Emollients, education and quality of life: the RCPCH care pathway for children with eczema Cox Arch dis Child 2011;96:i19The Royal College of Paediatrics andChild Health (RCPCH)• Effective eczema management is holistic and encompasses: - assessment of severity and impact on quality of life, - treatment of the inflamed epidermal skin barrier, - recognition and treatment of infection, - assessment and management of environmental and allergy trigger.• Patient and family education which seeks to maximise understanding and concordance with treatment is also important in all children with eczema.
  • 110. Emollients, education and quality of life: the RCPCH care pathway for children with eczema Cox Arch dis Child 2011;96:i19Stepped approach to treatment
  • 111. Effect of moisturizers on epidermal barrier function. Lodén M. Clin Dermatol. 2012;30:286-96. Time to outbreak of eczema in patients with controlledA daily moisturizing atopic eczema being treated with a barrier-improvingroutine is a vital part moisturizer, being untreated or a being treated with aof the management of potentially barrier deteriorating moisturizerpatients with atopic (vaseline suggested to promote relapse of eczema).dermatitis and otherdry skin conditions.The composition ofthe moisturizerdetermines whetherthe treatmentstrengthens ordeteriorates the skinbarrierfunction, which mayhave consequences forthe outcome of thedermatitis.
  • 112. A pilot study of silver-loaded cellulose fabric with incorporated seaweed for the treatment of atopicdermatitis.Park KY, Clin Exp Dermatol. 2012 [Epub ahead of print]newly developed silver-loadedcellulose fabric with incorporatedseaweed,12 subjects with mild tomoderate atopic dermatitis into a Silverclinical control study. loadedThe subjects wore a two-piecegarment (top and leggings), each Cottonpiece of which was divided into 100%two parts: one side was made ofSkinDoctor(®) fabric, and theother of 100% cotton
  • 113. A pilot study of silver-loaded cellulose fabric with incorporated seaweed for the treatment of atopicdermatitis.Park KY, Clin Exp Dermatol. 2012 [Epub ahead of print] Mean SCORAD index of areas covered with SkinDoctor compared with thosenewly developed silver-loaded covered with cottoncellulose fabric with incorporatedseaweed,12 subjects with mild tomoderate atopic dermatitis into aclinical control study.The subjects wore a two-piecegarment (top and leggings), eachpiece of which was divided intotwo parts: one side was made ofSkinDoctor(®) fabric, and theother of 100% cotton
  • 114. New Insights About Infant and Toddler Skin:Implications for Sun Protection Paller Pediatrics 2011;128:92 Infant epidermal structure 1) The outermost layer of (SC) epidermis, the SC, protects skin from adverse environmental conditions, including ultraviolet radiation (UVR) penetration and systemic absorption of topically applied materials such as sunscreens. 2) Although the SC is present at birth, it gains thickness, hydration capacity, and acidification throughout infancy as it increases its capacity to adapt
  • 115. New Insights About Infant and Toddler Skin:Implications for Sun Protection Paller Pediatrics 2011;128:92 1) Accumulating evidence suggests not only that the skin‘s barrier protection remains immature throughout at least the first 2 years of life but also that accumulation of UVR-induced changes in the skin may begin as early as the first summer of life. 2) Such evidence affirms the importance of sun protection during the infant and toddler years.
  • 116. Prospective Study of Sunburn and Sun BehaviorPatterns During Adolescence Dusza, Pediatrics 2012;129;309 1) Melanoma is a significant and growing public health concern. 2) UV light radiation (UVR) exposure is the most important modifiable melanoma risk factor. 3) Studies have shown that intense, intermittent exposures to UVR, as measured by sunburn frequency, have a higher melanoma-attributable risk than chronic UVR exposure. 4) UVR exposures at an early age are particularly important for the development of cutaneous melanoma in adulthood. 5) A recent meta-analysis of 51 studies found that ever reporting a sunburn during childhood almost 2X the risk for the development of cutaneous melanoma in adulthood.
  • 117. Prospective Study of Sunburn and Sun Behavior Patterns During Adolescence Dusza, Pediatrics 2012;129;309 % students reported having at least 1 sunburn during the previous summer 60 - A prospective, population- 50 – 53% 55% based study in 360 40 – fifthgrade children (∼10 years of age). 30 – At baseline 20 – (September–October 2004) and 10 – again 3 years later (September–October 2007). 000 2004 2007
  • 118. Prospective Study of Sunburn and Sun Behavior Patterns During Adolescence Dusza, Pediatrics 2012;129;309 % children reporting “often or always” use of sunscreen when outside for at least 6 hours in the summer 60 - A prospective, population- 50 – based study in 360 40 – 50% fifthgrade children p<0.001 (∼10 years of age). 30 – At baseline (September– October 2004) and 20 – 25% again 3 years later 10 – (September–October 2007). 000 2004 2007
  • 119. Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections Williams Pediatrics 2011;128:e479 OR for treatment failures Retrospective cohort of 2.5 – 6407children 0 to 17 yrs. Treatment of pediatric 2.0 – 2.23 skin and soft-tissue 1.5 – 1.92 infections (SSTIs). 1.0 – Treatment failure 0.5 – (SSTI ≤14 days after the treatment of incident 0 0 SSTI) and recurrence Trimethoprim β-lactams -sulfamethoxazole (SSTI >15 and ≤365 days). Compared with clindamycin
  • 120. Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections Williams Pediatrics 2011;128:e479 Retrospective cohort of OR for recurrences 6407children 0 to 17 yrs. Treatment of pediatric 1.5 – 1.26 skin and soft-tissue 1.49 infections (SSTIs). 1.0 – Treatment failure 0.5 – (SSTI ≤14 days after the treatment of incident 0 0 Trimethoprim β-lactams SSTI) and recurrence -sulfamethoxazole (SSTI >15 and ≤365 days). Compared with clindamycin
  • 121. Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections Williams Pediatrics 2011;128:e479• The growing burden of community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA), which is estimated to account for70% of staphylococcal infections in some regions of the United States, is a major problem in childhood.• A frequent cause of skin and soft-tissue infections (SSTIs), CA-MRSA infections often are more severe and lead to poor clinical outcomes.• CA-MRSA isolates are uniformly resistant to β-lactam antibiotics, previously the most commonly used agents for SSTIs, which makes prompt recognition and initiation of effective empiric therapy for CA-MRSA extremely important.
  • 122. Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections Williams Pediatrics 2011;128:e479• The growing burden of community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA), which is estimated to account for70% of staphylococcal infections in some regions of the United States, is a major problem in childhood. Currently,• A frequent cause most commonly recommended, the of skin and soft-tissue infections (SSTIs), orally administered antibiotics CA-MRSA infections often are more severe and lead to poor clinical outcomes. SSTIs include clindamycin for pediatric• CA-MRSA (10-25 mg/kg/day in 3-4 divided doses) isolates are uniformly resistant to β-lactam antibiotics, and trimethoprim-sulfamethoxazole. previously the most commonly used agents for SSTIs, which makes prompt di TM/Kg/die) (6 mg recognition and initiation of effective empiric therapy for CA-MRSA extremely important.
  • 123. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:631) Growth hormone (GH) therapy has now been available for over 5 decades, with all GH now biosynthetically produced, and administered by daily injection2) Paediatric GH is currently licensed in 6 different conditions: growth hormone deficiency (GHD), Turner syndrome (TS), small for gestational age (SGA), Prader-Willi syndrome (PWS), chronic renal insufficiency (CRI) and short stature due to SHOX deficiency (short stature homeobox- containing gene); all of these have been ratified by the most recent (2010) NICE review3) Whilst the primary purpose of paediatric GH therapy in most indications is to improve short and long-term growth, in others (eg. PWS) it has a role in improvement of body composition
  • 124. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63 Doses of growth hormone (GH) for paediatric GH licenses
  • 125. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63 Growth hormone deficiency (GHD)This is the commonest endocrine disorder presenting with shortstature. Most (~70%) of patients with GHD have an isolateddeficiency of GH.The commonest causes of GHD are as follows:- Congenital (midline embryonic anomalies and transcription factor defects)- Acquired (tumour, trauma, irradiation, infiltration, infection)- IdiopathicThe classical clinical phenotype includes:- short stature (both in relation to peers and also parents)- poor growth (Height Velocity <25th centile for at least 1 year)- delayed bone age (with associated delayed dentition and puberty)GHD is confirmed by a peak plasma GH level <6.7 μg/L to twoprovocative tests
  • 126. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63Turner syndrome (TS)This is the commonest gonadal dysgenesis infemales (1 in 2000), and is due to abnormalitieswithin the X-chromosome (45 XO).The short stature in TS is multifactorial, due toa combination of: intrauterine growthretardation, poor growth in childhood, anabsent pubertal growth spurt and amild skeletal dysplasia, for example, shortneck, wide carrying angle, hand and nail abnormalities.As a result final height is reduced by 21 cm from mid-parentalheight.Different studies indicate that the earlier GH is started thebetter the height outcome; in addition to GH therapy sex hormones
  • 127. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63Prader-Willi syndrome (PWS)PWS is a dysmorphic syndrome withclinical features including shortstature, hypogonadism, obesity, abnormal bodycomposition, hypotonia, hyperphagia andlearning and behavioural problems.It is due to loss of paternally derivedgenes on 15q.In PWS the aim of therapy is bothto improve body composition as well as promoting growth, and GHresults in improvements in both height, body composition and musclestrength/tone. There have, however, been several reports of suddendeath in PWS patients treated with GH, especially if patients areseverely obese, and in these patients sleep studies should be
  • 128. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63 Small for gestational age (SGA)SGA is usually defined as a birth weight and/or length more than−2.5 SDS below the mean.These patients are a heterogeneous group, including normalchildren, and those growth retarded by maternal, placental and fetalfactors. Approximately 80% of children born SGA show catch-upgrowth in the 6 months of life.Overall, approximately 10% of patients born SGA remain short(height <−2 SDS).GH is licensed for children born SGA who fail to show catch-upgrowth (HV SDS <0 during the last year) by 4 years of age orlater, and who are short both compared to their peers(height <−2.5 SD) and parents (parental adjusted height <−1 SD).
  • 129. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63 Small for gestational age (SGA)SGA is usually defined as a birth weight and/or length more than−2.5 SDS below the mean.These patients are a heterogeneous group, including normalchildren, and those growthHeight + by maternal,Height + and fetal BOYS: Cm: (Fathers retarded Mothers placental 13) / 2factors. Approximately 80% of children born SGA show catch-upgrowth in the 6 months of life.Overall, approximately 10% of patients + Mothers Height) / 2 GIRLS: Cm: (Fathers Height - 13 born SGA remain short(height <−2 SDS).GH is licensed for children born SGA who fail to show catch-upgrowth (HV SDS <0 during the last year) by 4 years of age orlater, and who are short both compared to their peers(height <−2.5 SD) and parents (parental adjusted height <−1 SD).
  • 130. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis Stalvey Pediatr Pulmonol 2012;47:252 Height standard deviation score (SDS) by visit (as randomized subjects) 68 prepubertal children <14 years with CF. Daily rhGH (Nutropin AQ) or no treatment (control) for 12 months, followed by a 6-month observation (month 18).
  • 131. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis Stalvey Pediatr Pulmonol 2012;47:252 Weight and lean body mass (LBM) change from baseline to Month 12 (as randomized subjects) 68 prepubertal children <14 years with CF. Daily rhGH (Nutropin AQ) or no treatment (control) for 12 months, followed by a 6-month observation (month 18).
  • 132. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis Stalvey Pediatr Pulmonol 2012;47:252 350 – Increase in FVC (ml) 68 prepubertal children 300 – 325 p=0.032 <14 years with CF. ml 250 – Daily rhGH 200 – (Nutropin AQ) or no treatment (control) for 150 – 178 12 months, followed by 100 – ml a 6-month observation 150 – (month 18). 150 Rh GH Controls
  • 133. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis Stalvey Pediatr Pulmonol 2012;47:252 Mean increase in FEV1 (ml) 300 – 68 prepubertal children 250 – <14 years with CF. p=0.004 Daily rhGH (Nutropin 200 – 224 AQ) or no treatment 150 – ml (control) for 12 100 – months, followed by a 108 6-month observation 150 – (month 18). ml 150 Rh GH Controls
  • 134. 1) Quale di queste risposte è esatta:a) Se guidano i nonni ,è più facile che il bambino subisca un trauma in un eventuale incidente stradale.b) Se guidano i nonni, è meno probabile che il bambino subisca un trauma nell‘eventualità d‘incidente stradale, anche se è meno probabile che sia adeguatamente allacciato con le cinture di sicurezzac) Durante i periodi di recessione economica gli abusi sui minori si riduconod) Raramente l‘abuso su un minore è un fenomeno ricorrente
  • 135. 1) Quale di queste risposte è esatta:a) Se guidano i nonni ,è più facile che il bambino subisca un trauma in un eventuale incidente stradale.b) Se guidano i nonni, è meno probabile che il bambino subisca un trauma nell’eventualità d’incidente stradale, anche se è meno probabile che sia adeguatamente allacciato con le cinture di sicurezzac) Durante i periodi di recessione economica gli abusi sui minori si riduconod) Raramente l‘abuso su un minore è un fenomeno ricorrente
  • 136. 2) Quale di queste risposta è falsa:a) L‘eruzione dentaria si associa a comparsa di rialzo febbrile quasi sempreb) Le mamme con depressione post partum allattano al seno meno frequentemente delle mamme non depressec) L‘allattamento al seno aumenta lo sviluppo polmonared) L‘allattamento al seno riduce i livelli di fibrinogeno nel bambino
  • 137. 2) Quale di queste risposta è falsa:a) L’eruzione dentaria si associa a comparsa di rialzo febbrile quasi sempreb) Le mamme con depressione post partum allattano al seno meno frequentemente delle mamme non depressec) L‘allattamento al seno aumenta lo sviluppo polmonared) L‘allattamento al seno riduce i livelli di fibrinogeno nel bambino
  • 138. 3) Quale di queste risposta è esatta:a) Il difetto di zinco può favorire la presenza di asma più grave che richiede l‘ospedalizzazione e protegge marginalmente dalla comparsa di polmonite di lunga duratab) Il difetto di vitamina D in gravidanza non ha ripercussioni sul bambinoc) Il difetto di vitamina D non ha alcun effetto sul rischio di infezione da RSV e bronchiolited) Il difetto di vitamina D nel bambino non riduce la resistenza all‘insulina, non aumenta il rischio di glicemia più alta e non aumenta il rischio di pressione sistolica più alta nel bambino obeso
  • 139. 3) Quale di queste risposta è esatta:a) Il difetto di zinco può favorire la presenza di asma più grave che richiede l’ospedalizzazione e protegge marginalmente dalla comparsa di polmonite di lunga duratab) Il difetto di vitamina D in gravidanza non ha ripercussioni sul bambinoc) Il difetto di vitamina D non ha alcun effetto sul rischio di infezione da RSV e bronchiolited) Il difetto di vitamina D nel bambino non riduce la resistenza all‘insulina, non aumenta il rischio di glicemia più alta e non aumenta il rischio di pressione sistolica più alta nel bambino obeso
  • 140. 4) Livelli adeguati di acido folico:a) Si associano ad alti livelli di omocisteinab) Si associano ad un aumentato rischio di allergia in età prescolarec) Si associano a risultati scolastici migliorid) Nessuna delle risposte è corretta
  • 141. 4) Livelli adeguati di acido folico:a) Si associano a alti livelli di omocisteinab) Si associano ad un aumentato rischio di allergia in età prescolarec) Si associano a risultati scolastici migliorid) Nessuna delle risposte è corretta
  • 142. 5) La supplementazione con DHA durante la gravidanza e/o nei primi mesi di vita:a) Riduce il rischio di comparsa di displasia broncopolmonareb) Riduce il rischio di sepsi nei primi mesi di vitac) Riduce il rischio di aterosclerosid) Tutte le risposte sono corrette
  • 143. 5) La supplementazione con DHA durante la gravidanza e/o nei primi mesi di vita:a) Riduce il rischio di comparsa di displasia broncopolmonareb) Riduce il rischio di sepsi nei primi mesi di vitac) Riduce il rischio di aterosclerosid) Tutte le risposte sono corrette
  • 144. 6) La terapia con ormone della crescita:a) E‘ utilizzata nei bambini con difetto di GHb) Può essere utilizzata nella sindrome di Turner e nella sindrome di Prader Willic) Può essere utilizzata nell‘insufficienza renale e nella fibrosi cisticad) Tutte le risposte sono corrette
  • 145. 6) La terapia con ormone della crescita:a) E‘ utilizzata nei bambini con difetto di GHb) Può essere utilizzata nella sindrome di Turner e nella sindrome di Prader Willic) Può essere utilizzata nell‘insufficienza renale e nella fibrosi cisticad) Tutte le risposte sono corrette
  • 146. gastroenterology
  • 147. Toddler diarrhoea: is it a useful diagnostic label? Powell, Arch Dis Child 2012;97:84Definition1) A variety of different terms, including irritable colon of childhood, irritable bowel syndrome (IBS) variant, fast transit diarrhoea, chronic nonspecific diarrhoea (CNSD) and non-specific diarrhoea in children, have been used to describe the typical presentation of toddler diarrhoea.2) CNSD typically presents between the age of 1 and 5 years and is self-limiting in 90% of cases.3) Toddler diarrhoea is a term coined many years ago to describe a young child who passes several loose stools a day but who is otherwise healthy with excellent growth and normal examination.
  • 148. Toddler diarrhoea: is it a useful diagnostic label? Powell, Arch Dis Child 2012;97:84Suggested initial investigation Full blood count C reactive protein Erythrocyte sedimentation rate Coeliac disease screen—anti-tissue transglutaminase antibody and total serum IgA Stool culture (including Clostridium difficile and giardia)
  • 149. Toddler diarrhoea: is it a useful diagnostic label? Powell, Arch Dis Child 2012;97:84Differential diagnoses1) A postenteritis syndrome/cow’s milk protein intolerance2) Excessive juice intake/fructose intolerance3) Chronic infection: - Giardia lamblia (giardiasis) - Cryptosporidium parvum (cryptosporidiosis)4) Coeliac disease5) Constipation with overflow diarrhoea6) Factitious diarrhoea and laxative use7) Inflammatory bowel disease8) IBS variant in childhood
  • 150. Toddler diarrhoea: is it a useful diagnostic label? Powell, Arch Dis Child 2012;97:84Management strategies A 6-week trial of a cows milk- and egg-free diet with dietetic help Reduce fructose/juice intake Trial of metronidazole Loperamide for symptomatic relief once other diagnoses are excluded Reassurance Follow-up
  • 151. Early Life Events: Infants with Pyloric Stenosis Have a Higher Risk of Developing Chronic Abdominal Pain in Childhood Saps, J Ped 2011;159:551 OR for chronic abdominal pain 100 children diagnosed with pyloric stenosis during infancy 5 - (cases). 4.3 4 – 91 siblings aged 4-20 yrs without a history of pyloric 3 – stenosis selected as controls. 2 – p=0.0045 Mean time to follow-up was 1 – 7.2 ± 1.6 yrs. 0 cases vs controls
  • 152. Early Life Events: Infants with Pyloric Stenosis Have a Higher Risk of Developing Chronic Abdominal Pain in Childhood Saps, J Ped 2011;159:551 OR for pain-associated functional gastrointestinal 100 children diagnosed with disorder (irritable bowel pyloric stenosis during infancy syndrome, functional (cases). dyspepsia, functional abdominal 7 - pain) 91 siblings aged 4-20 yrs without a history of pyloric 6 - 5 - 6.8 stenosis selected as controls. 4 – 3 – Mean time to follow-up was 2 – p=0.043 7.2 ± 1.6 yrs. 1 – 0 cases vs controls
  • 153. Randomized clinical trial of rapid versus 24-hour rehydration for children with acute gastroenteritis Powell Pediatrics 2011;128:e771 Standard Nasogastric Rehydration involved admission 254 children 6 to 72 to the hospital ward, where the months of age with estimated fluid deficit acute viral (5%–7% of body weight) gastroenteritis and was replaced with moderate dehydration. Oral Rehydration Solution Randomly to receive over 6 hours, at a constant rate, either standard through a nasogastric tube. nasogastric rehydration Patients were reassessed for signs (SNR) over 24 hours of dehydration after 6 hours. in the hospital ward or rapid nasogastric The 24-hour maintenance fluid rehydration (RNR) requirement then was administered over 4 hours in the ED. over the subsequent 18 hours.
  • 154. Randomized clinical trial of rapid versus 24-hour rehydration for children with acute gastroenteritis Powell Pediatrics 2011;128:e771 Rapid Nasogastric Rehydration 254 children 6 to 72 consisted of 100 mL/kg Oral months of age with Rehydration Solution, which was acute viral administered over 4 hours gastroenteritis and (25 mL/kg per hour) moderate dehydration. in the Emergency Department. Randomly to receive The patient then was discharged either standard nasogastric rehydration from the hospital and was (SNR) over 24 hours reassessed by a nurse on the in the hospital ward following day, or rapid nasogastric either in a home visit or with a rehydration (RNR) over 4 hours in the ED. telephone call after 24 hours.
  • 155. Randomized clinical trial of rapid versus 24-hour rehydration for children with acute gastroenteritis Powell Pediatrics 2011;128:e771 The primary failure rates were similar for Rapid Nasogastric Rehydration 254 childrentreatment Primary 6 to 72 (RNR) months of age with (11.8% [95% CI: 6.0%–17.6%]) acute viralwas defined failure and Standard Nasogastric Rehydration as an additional loss gastroenteritis and (SNR) (9.2% [95% CI: 3.7%–14.7%]; moderate at any time of 2% dehydration. p=0.52).during the rehydration Randomly to receive either standard Secondary treatment failure was process, compared nasogastric rehydration more common in the SNR group with the admission (SNR) over 24 hours (44% [95% CI: 34.6%–53.4%]) in the hospital ward than in the RNR group weight. (30.3% [95% CI: 22.5%–38.8%]; or rapid nasogastric rehydration (RNR) over p= 0.03). 4 hours in the ED.
  • 156. Randomized clinical trial of rapid versus 24-hour rehydration for children with acute gastroenteritis Powell Pediatrics 2011;128:e771 Secondary treatment failure The primary failure rates were similar was defined as: for Rapid Nasogastric Rehydration inability to tolerate72 254 children 6 to the (RNR)insertion of aage with months of nasogastric tube, (11.8% [95% CI: 6.0%–17.6%]) acute viralfrequent or persistent and Standard Nasogastric Rehydration gastroenteritis andvomiting, (SNR) (9.2% [95% CI: 3.7%–14.7%]; moderate dehydration.commencement of intravenous p=0.52).rehydration, Randomly to receive continued signs of moderate Secondary treatment failure was either standarddehydration (3 clinical signs), nasogastric rehydration more common in the SNR groupneed for nasogastric fluids (44% [95% CI: 34.6%–53.4%]) (SNR) over 24 hoursbeyond 24 hours (SNR only), in the hospital ward than in the RNR groupimpending circulatory collapse. (30.3% [95% CI: 22.5%–38.8%]; or rapid nasogastric rehydration (RNR) over p= 0.03). 4 hours in the ED.
  • 157. Zinc, Vitamin A, and Micronutrient Supplementation inChildren with Diarrhea: A Randomized Controlled Clinical Trial of Combination Therapy versus Monotherapy Dutta, J Ped 2011;159:633 Children aged 6 to 24 months All 3 supplemented with diarrhea. groups demonstrated a Supplementation of zinc significant reduction in outcome (group 1). Zinc plus combination of variables (P<.0001) compared with micronutrients and vitamins the placebo group (group 4). (iron, copper, selenium, vitami n B12, folate, and vitamin A) Supplementation with a (group 2). combination of micronutrients Zinc plus vitamin A (group 3). and vitamins was not superior to Placebo (group 4) as an zinc alone, confirming the clinical adjunct to oral rehydration benefit of zinc in children with solution diarrhea.
  • 158. Zinc, Vitamin A, and Micronutrient Supplementation inChildren with Diarrhea: A Randomized Controlled Clinical Trial of Combination Therapy versus Monotherapy Dutta, J Ped 2011;159:633 Survival function analysis ofrecovery status of the children in the 4 study groups.
  • 159. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis. Kim, NEJM 2012;366:1596Background:• Computed tomography (CT) has become the predominant test fordiagnosing acute appendicitis in adults.• In children and young adults, exposure to CT radiation is ofparticular concern.• We evaluated the rate of negative (unnecessary) appendectomyafter low-dose vs standard-dose abdominal CT in young adults withsuspected appendicitis.
  • 160. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis. Kim, NEJM 2012;366:1596 Negative appendectomy rate 4 – 891 patients with NS suspected appendicitis. 3 – 3.5% 3.2% Either low-dose CT (116 mGy.cm; 444 patients) 2 – or standard-dose CT (521 mGy.cm; 447 patients). 1 –Gy = SI derived unit of absorbed radiation dose of ionizing radiation. 0 low-dose CT standard-dose CT
  • 161. Sequential Therapy Compared with Standard TripleTherapy for Helicobacter Pylori Eradication in Children: A Double-Blind, Randomized, Controlled Trial Albrecht, J Ped 2011;159:45 % children with H. pylori 107 children with 100 – eradication H. pylori infection. 190 – Sequential treatment (amoxicillin and omeprazole 180 – 170 – 86% p=0.05 for 5 days followed by clarithromycin, tinidazole, and 160 – 150 – 68% omeprazole for 5 days) 140 – to a 7-day standard triple 130 – eradication regimen 120 – (amoxicillin and clarithromycin 210 – plus omeprazole) followed by 120 placebo for 3 days. sequential standard triple eradication therapy therapy
  • 162. Sequential Therapy Compared with Standard TripleTherapy for Helicobacter Pylori Eradication in Children: A Double-Blind, Randomized, Controlled Trial Albrecht, J Ped 2011;159:45 Flagyl (metronidazole) is an oral synthetic antiprotozoal and antibacterial agent, l-β-hydroxyethyl)-2-methyl-5-nitroimidazole (∼ 25 mg/kg/day)
  • 163. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions Pedersen, Arch Dis Child 2012;97:2271) Oesophageal atresia is a congenital anomaly of the oesophagus and in most cases involves the trachea.2) The prevalence in reported case series varies from 1 in 2500 to 1 in 4500 births.3) In 78–90% of reported cases there is a tracheo-oesophageal fistula between the lower segment of the oesophagus and trachea (gross type C)
  • 164. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions Pedersen, Arch Dis Child 2012;97:227Associated anomalies can be: 1) chromosomal (Down‘ssyndrome, Edward‘s syndrome(trisomy 18)),2) part of a genetic syndrome(CHARGE syndrome, Feingoldsyndrome and others),3) an association such asVACTERL-association or4) multiple anomalies without apattern.
  • 165. CHARGE syndrome (formerly known as CHARGE association), isa syndrome caused by a genetic disorder. It was first described in1979.In 1981, the term "CHARGE" came into use as an acronym for theset of unusual congenital features seen in a number of newbornchildren. The letters stand for: Coloboma of the eye, Heartdefects, Atresia of the nasal choanae, Retardation of growthand/or development, Genital and/or urinary abnormalities, and Earabnormalities and deafness. These features are no longer used inmaking a diagnosis of CHARGE syndrome, but the name remains.CHARGE syndrome is the leading cause of congenital deafblindnessA coloboma (from theGreek koloboma, meaning defect,[1]) is ahole in one of the structures ofthe eye, such asthe iris, retina, choroid or optic disc.
  • 166. VACTERL association (also VATER syndrome) is a non-randomassociation of birth defects. The reason it is called anassociation, rather than a syndrome is that while the complicationsare not pathogenetically related they tend to occur together morefrequently than expected by chance. V - Vertebral anomalies A - Anal atresia C - Cardiovascular anomalies TE - Tracheoesophageal fistula R - Renal and/or radial anomalies L - Limb defects
  • 167. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions Pedersen, Arch Dis Child 2012;97:227 Population-based The overall prevalence was study 2.43 cases per 10 000 23 participating births. registries 1222 cases of oesophageal atresia in Prenatal detection rates a population of varied by registry from >50% 5 019 804 births of cases to <10% of cases.
  • 168. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions Pedersen, Arch Dis Child 2012;97:227 % of children with 50 – 40 – 44.7% 30 – 31.6% 20 – 23.7% 10 – 0 Isolated Multiple An oesophageal malformed association or anomaly a syndrome
  • 169. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions Pedersen, Arch Dis Child 2012;97:227Classification of oesophageal atresia cases, sex distribution and birth outcome V: Vertebral anomalies A: Anal atresia C: Cardiovascular anomalies T: Tracheoesophageal fistula E: Esophageal atresia R: Renal anomalies L: Preaxial limb C: Coloboma of the eye H: Heart defects A: Atresia of the choanae R: Retardetion of growth G: Genital anomalies E: Ear anomalies
  • 170. Hypotonic Versus Isotonic Maintenance Fluids After Surgery for Children: A Randomized Controlled Trial Choong Pediatrics 2011;128:857 % children with plasma 50 – Na+ ≤134 mmol/l Risk of hyponatremia (Na+ ≤134 mmol/l) following administration 40 – of isotonic (0.9% saline) compared to 30 – 40.8% hypotonic (0.45% saline) parenteral maintenance 20 – solution (PMS) for 48 hours to postoperative. 10 – 22.7% RR =1.82 p=0.004 258 patients. 0 ISOTONIC HYPOTONIC
  • 171. Hypotonic Versus Isotonic Maintenance Fluids After Surgery for Children: A Randomized Controlled Trial Choong Pediatrics 2011;128:857 % children with plasma 50 – Na+ ≤134 mmol/l Risk of hyponatremia (Na+ ≤134Isotonic mmol/l) following administration 40 – parenteral of isotonic (0.9% saline) maintenance solution – compared to 30 40.8% did not increase hypotonic (0.45% saline) the risk parenteral maintenance 20 – solution (PMS) of hypernatremia.10 – for 48 hours to postoperative. 22.7% RR =1.82 p=0.004 258 patients. 0 ISOTONIC HYPOTONIC
  • 172. Prevention of Hospital-Acquired Hyponatremia: Do We Have the Answers? Moritz Pediatrics 2011;128:980 Hyponatremia (serum sodium <135 mEq/L) is the most frequently occurring electrolyte abnormality in children and affects 25% of hospitalized patients. The majority of the hyponatremia seen in children is hospital acquired and occurs in children who are receiving hypotonic intravenous fluids. A serious complication of hyponatremia is acute hyponatremic encephalopathy, for which children are at particularly high risk because of their larger brain/intracranial-volume ratio. There have been numerous reports of death and permanent neurologic injury from hospital-acquired hyponatremia, all of which have been associated with administration of hypotonic fluids.
  • 173. Prevention of Hospital-Acquired Hyponatremia: Do We Have the Answers? Moritz Pediatrics 2011;128:980 There are numerous potential stimuli for arginine vasopressin (AVP) production in hospitalized children (eg, pain, stress, nausea, vomiting, and volume depletion) and disease states associated with AVP excess (eg, the postoperative state and pulmonary or central nervous system diseases). We posited that the most physiologic approach for the prevention of hospital-acquired hyponatremia would be to administer isotonic maintenance fluids (0.9% NaCl, Na154 mEq/L) and primarily reserve hypotonic maintenance fluids for patients with either ongoing free-water losses or hypernatremia.
  • 174. immunology
  • 175. Clinical Features That Identify Children With Primary Immunodeficiency Diseases Subbarayan, Pediatrics 2011;127:810The 10 warning signs developed are:1. ≥4 new ear infections within 1 year;2. ≥2 serious sinus infections within 1 year;3. ≥2 months of oral antibiotic treatment with little effect;4. ≥2 episodes of pneumonia within 1 year;5. failure of an infant to gain weight or grow normally;6. recurrent, deep skin or organ abscesses;7. persistent thrush in mouth or fungal infection on skin;8. need for intravenous antibiotics to clear infections;9. ≥2 deep-seated infections, including septicemia;10. family history of Primary Immunodeficiency Diseases (PID).
  • 176. Clinical Features That Identify Children With Primary Immunodeficiency Diseases Subbarayan, Pediatrics 2011;127:810 Effectiveness of the 10 warning signs The strongest in predicting defined identifiers of PID were: primary immunodeficiency 1) a family history diseases (PID). of immunodeficiency disease Clinical records of 2) use of intravenous 430 patients antibiotics for sepsis in with a defined PID children with neutrophil and 133 patients PID; for whom detailed 3) failure to thrive investigations failed to in children with establish a specific PID. T-lymphocyte PID.
  • 177. Clinical Features That Identify Children With Primary Immunodeficiency Diseases Subbarayan, Pediatrics 2011;127:810 Effectiveness of the 10 warning signs The strongest With these 3 signs, in predicting defined identifiers of PID were: 96% immunodeficiency primary of patients with 1) a family history diseases (PID). and neutrophil of immunodeficiency complement deficiencies disease and Clinical records of 2) use of intravenous 89% of children with 430 patients antibiotics for sepsis in with a T-lymphocyte defined PID children with neutrophil and immunodeficiencies 133 patients PID; could be identified for whom detailed 3) failure to thrive correctly. investigations failed to in children with establish a specific PID. T-lymphocyte PID.
  • 178. Clinical Features That Identify Children With Primary Immunodeficiency Diseases Subbarayan, Pediatrics 2011;127:810A SIMPLE SCHEMA FOR IDENTIFYING PRIMARY IMMUNODEFICIENCY DISEASES IN CHILDREN WITH SEVERE, UNUSUAL, OR RECURRENT INFECTIONS. Igs = immunoglobulins; UTI= urinary tract infection.
  • 179. Clinical Features That Identify Children With Primary Immunodeficiency Diseases Subbarayan, Pediatrics 2011;127:810 A SIMPLE SCHEMA FOR IDENTIFYING PRIMARY IMMUNODEFICIENCY DISEASES IN CHILDREN WITH SEVERE, UNUSUAL, OR RECURRENT INFECTIONS. Note that this flow diagram is not all-inclusive; if a clinician hasconcerns, he or she Igs = immunoglobulins; should refer the patient UTI= urinary tract infection.
  • 180. Clinical Features That Identify Children With Primary Immunodeficiency Diseases Subbarayan, Pediatrics 2011;127:810NONPEDIATRIC IMMUNOLOGISTS’ GUIDE TO SCREENING TESTS FOR PID SUBGROUPS.
  • 181. Clinical Features That Identify Children With Primary Immunodeficiency Diseases Subbarayan, Pediatrics 2011;127:810 If considering NONPEDIATRIC IMMUNOLOGISTS’ GUIDE TO SCREENING TESTS more complex FOR PID SUBGROUPS.tests, re fer the patient to a pediatric immunologist.
  • 182. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 To evaluate widely % children diagnosed with promulgated ‗warning signs an underlying primary of primary immunodeficiency immunodeficiency‘. 30 – To evaluate the relationship 25 – between primary 20 – immunodeficiency and atopy. 15 – 23% A retrospective analysis of 10 – 141 children who underwent 05 –. testing for possible primary 0 immunodeficiency.
  • 183. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 To evaluate widely % children diagnosed with promulgated ‗warning signs an underlying primary of primary immunodeficiency immunodeficiency‘. Published warning signs 30 – To evaluate the relationship were neither sensitive 25 – between primary nor specific for 20 – immunodeficiency and atopy. primary 15 – 23% immunodeficiency A retrospective analysis of 10 – 141 children who underwent 05 –. testing for possible primary 0 immunodeficiency.
  • 184. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 To evaluate widely % children diagnosed with promulgated ‗warning signs an underlying primary of primary immunodeficiency immunodeficiency‘. 30 – Patients with allergy To evaluate the relationship 25 – were more likely to between primary 20 – be diagnosed with immunodeficiency and immunodeficiency. atopy. 15 – 23% A retrospective analysis of 10 – 141 children who underwent 05 –. testing for possible primary 0 immunodeficiency.
  • 185. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 To evaluate widely % children diagnosed with promulgated promulgated Widely ‗warning signs an underlying primary of primary signs did not warning immunodeficiency immunodeficiency‘. distinguish between 30 – To evaluate thewith and patients relationship 25 – between primary without primary 20 – immunodeficiency and immunodeficiency. atopy.Likewise, primary 15 – 23% immunodeficiency and A retrospective analysis of 10 – 141 children may underwent allergy who coexist. 05 –. testing for possible primary 0 immunodeficiency.
  • 186. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671The Jeffrey Modell Foundation(JMF) has promulgated warningsigns for primaryimmunodeficiency, but thesecriteria are based on expertopinion and their performancein identifying patients with PIDhas not been evaluated.Jeffrey Modell Foundation [homepage on theInternet]. New York: Jeffrey Modell Foundation.Available at: http://www.jmfworld.org
  • 187. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 Number of patients who met To evaluate widely published warning signs for primary promulgated ‗warning signs immunodeficiency (PID), and whether of primary PID was confirmed or excluded. immunodeficiency‘. To evaluate the relationship between primary immunodeficiency and atopy. A retrospective analysis of 141 children who underwent testing for possible primary immunodeficiency.
  • 188. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 Number of patients who met To evaluate widely published warning signs for primary promulgated ‗warning signs immunodeficiency (PID), and whether of primary PID was confirmed or excluded. Of the 104 warning immunodeficiency‘. sign–positive (WS+) To patients,the relationship evaluate 20 (19%) between primary 19% were diagnosed with immunodeficiency and a primary atopy. immunodeficiency A retrospective analysis of 141 children who underwent testing for possible primary immunodeficiency.
  • 189. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 Number of patients who met To evaluate widely published warning signs for primary promulgated ‗warning signs immunodeficiency (PID), and whether of primary PID was confirmed or excluded. Of the 37 patients immunodeficiency‘. who were warning To evaluate the relationship sign negative between primary (WS−), 12 (32%) immunodeficiency and had a primary atopy. immunodeficiency. A retrospective analysis of 141 children who underwent testing for possible primary immunodeficiency.
  • 190. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 Detection of antigen-specific IgE To evaluate widely in patients with and without promulgated ‗warning signs primary immunodeficiency (PID). of primary immunodeficiency‘. To evaluate the relationship between primary immunodeficiency and atopy. A retrospective analysis of 141 children who underwent testing for possible primary immunodeficiency.
  • 191. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency MacGinnitie Pediat Allergy Immunol 2011;22:671 Detection of antigen-specific IgE To evaluate widely in patients with and without Patients who had evidence of promulgated ‗warningby skin antigen-specific IgE signs primary immunodeficiency (PID). of primaryblood testing were prick or immunodeficiency‘.diagnosed more likely to be To evaluate thedeficiency with with an immune relationship 9 of 29 patients (31%) with between primary IgE (atopic) antigen-specific immunodeficiency and being diagnosed with atopy. immunodeficiency compared to A6retrospective those without of 68 (9%) of analysis of specific IgE (non-atopic). 141 children = 0.011) (p who underwent testing for possible primary immunodeficiency.
  • 192. When is susceptibility to infections abnormal? Wahn Pediat Allergy Immunol 2011;22:650 Physiological and pathological susceptibility to infections **Pneumonia, sepsis, meningitis, encephalitis, osteomyelitis, septicarthritis, empyema, deep visceral abscesses (not single unproblematic episodes ofcervical lymphadenitis). The overlap of symptoms in atopic children and children with Primary Immunodeficiency (PID) indicates the necessity that allergists are trained to identify children with PID.
  • 193. Long-Term Follow-Up of Children with (PFAPA) Periodic Fever, Aphthous Stomatitis, Pharyngitis, andCervical Adenitis Syndrome Wurster, J Ped 2011;159:958 % participants with complete 59 patients with symptom resolution 90 – PFAPA. 85% 80 – 70 – Follow-up time from 60 – 12 to 21 years. 50 – 40 – 30 – mean symptom 20 – duration of 10 – 6.3 years 0
  • 194. Long-Term Follow-Up of Children with (PFAPA) Periodic Fever, Aphthous Stomatitis, Pharyngitis, andCervical Adenitis Syndrome Wurster, J Ped 2011;159:958 % participants with complete 59 patients with with In subjects symptom resolution persistent PFAPA 90 – PFAPA. 85% (15%), the mean duration 80 – of fever >38.3°C 70 – decreasedtime from days at Follow-up from 3.6 60 – 12 to 21 years. days at onset to 1.8 50 – follow-up (P=0.01), and the 40 – mean symptom-free interval between episodes increased 30 – mean symptom from 29 to 159 days 20 – duration of (P<0.005). 10 – 6.3 years 0
  • 195. Long-Term Follow-Up of Children with (PFAPA) Periodic Fever, Aphthous Stomatitis, Pharyngitis, andCervical Adenitis Syndrome Wurster, J Ped 2011;159:958 % participants with complete 59 patients with symptom resolution 90 – PFAPA. Patients underwent 85% 80 – tonsillectomy or 70 – Follow-up time from adenotonsillectomy 60 – 12 to 21experienced years. 50 – markedly reduced 40 – symptoms 30 – mean symptom 20 – duration of 10 – 6.3 years 0
  • 196. Tonsillectomy in Children with Periodic Fever withAphthous Stomatitis, Pharyngitis, and Adenitis Syndrome Garavello, J Ped 2011;159:138 % children with complete A comprehensive 100 – resolution literature search of 190 – studies evaluating 180 – the efficacy of tonsillectomy or 170 – 83% 160 – adenotonsillectomy 150 – on PFAPA. 140 – 130 – 15 studies including 120 – 149 treated children. 210 – 120
  • 197. Tonsillectomy in Children with Periodic Fever withAphthous Stomatitis, Pharyngitis, and Adenitis Syndrome Garavello, J Ped 2011;159:138 OR for complete resolution A comprehensive literature search of 15 – studies evaluating the efficacy of tonsillectomy or 10 – 13.0 adenotonsillectomy on PFAPA. 05 – 15 studies including 149 treated children. 00 with A&T
  • 198. •Intensive care
  • 199. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e11951. Pediatric cardiopulmonary arrest is a rare event that occurs in 0.1% to 3% of children admitted to the hospital.2. Outcomes are poor ; reported rates of survival to discharge after these events ranges from 12% to 36%.3. Improved cardiopulmonary resuscitation (CPR), therefore, provides an opportunity for better patient outcomes.
  • 200. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Guidelines clearly define how CPR is to be performed, but poor CPR quality and frequent deviation from the American Heart Association protocols are reported. Suboptimal quality of CPR is associated with poorer outcomes in animals and humans. Berg MD. Circulation. 2010;122:S862. Kleinman ME. Circulation. 2010;122:S876.
  • 201. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Mean ventilation rate for various providers. Simulated pediatric medical emergencies. Pediatric residents and interns 8 (MDs), respiratory therapists (RTs), and nurses (RNs). RN; registered nurse All sessions were RT; respiratory therapist video-recorded. MD; medical doctor, pediatric resident, or intern PALS; pediatric advanced life support BVM; bag-valve-mask
  • 202. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Mean ventilation rate for various providers. All ventilation rates were significantly higher Simulated pediatric than the recommended medical emergencies. rate of 8 to 20 BPM Pediatric residentsAdvanced (per Pediatric and interns Support Life 8 (MDs), respiratory guidelines, varies with therapists (RTs), and nurses patient age) (P<0.001) . (RNs). RN; registered nurse All sessions were RT; respiratory therapist video-recorded. MD; medical doctor, pediatric resident, or intern PALS; pediatric advanced life support BVM; bag-valve-mask
  • 203. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Mean ventilation rate for various providers. Hyperventilation occurred in simulated pediatric resuscitation Simulated did not vary and pediatric medical according to emergencies. provider type Pediatric residents . and interns educational Future 8 (MDs), respiratory should interventions therapists (RTs), and nurses focus on avoidance (RNs). All sessions were of excessive video-recorded. RN; registered nurse ventilation. RT; respiratory therapist RT; respiratory therapist MD; medical doctor, pediatric resident, or intern PALS; pediatric advanced life support BVM; bag-valve-mask
  • 204. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Mean ventilation rate for various providers. This study used the 2005 PALS recommended a Simulated pediatric medical compression emergencies. Pediatric residents ratio ventilation and interns of 15:2 8 (MDs), respiratory or a ventilation rate therapists (RTs), and nurses (RNs). of 10-12 sessions All per RN; registered nurse were video-recorded. minute. RT; respiratory therapist MD; medical doctor, pediatric resident, or intern PALS; pediatric advanced life support BVM; bag-valve-mask
  • 205. PALS: Paediatric Advanced Life Support 2. Oxygenate, ventilate, and start chest compression:• Provide positive-pressure ventilation with high-concentration inspiredoxygen.• Provide ventilation initially by bag and mask. Ensure a patent airway byusing an airway manoeuvre as described in the paediatric basic life supportchapter.•If it can be performed by a highly skilled operator with minimal interruption tochest compressions, the trachea should be intubated. This will both controlthe airway and enable chest compression to be given continuously, thusimproving coronary perfusion pressure.•Take care to ensure that ventilation remains effective when continuous chestcompressions are started.•Use a compression rate of 100 - 120/min•Once the child has been intubated and compressions are uninterrupted, usea ventilation rate of approximately 10 – 12/min
  • 206. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Mean ventilation rate for various providers. Although no data currently exist linking pediatric resuscitation outcomes with Simulated pediatric ventilation rates, medical emergencies. animal data reveal a Pediatric residents compromised cardiac and interns 8 (MDs), respiratory can output that therapists (RTs), and nurses (RNs). result All sessions from werehyperventilation. video-recorded. RN; registered nurse RT; respiratory therapist MD; medical doctor, pediatric resident, or intern PALS; pediatric advanced life support BVM; bag-valve-mask
  • 207. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Mean ventilation rate for various providers. Aufderheide Circulation. 2004;109:1960. showed: 1) significantly Simulated pediatric increased thoracic medical emergencies. pressure, 2) decreased coronary Pediatric residents perfusion pressure, and interns 8 (MDs), respiratory 3) decreased survival therapists (RTs), and nurses in hyperventilated (RNs). All sessions were pigs in cardiac video-recorded. RN; respiratory nurse registered RT; therapist arrest. MD; medical doctor, pediatric resident, or intern PALS; pediatric advanced life support BVM; bag-valve-mask
  • 208. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Mean ventilation rate for various Ewy providers. (Circulation. 2007;116:2525.) also reported: 1) significantly Simulated coronary perfusion higher pediatric medical emergencies. pressure Pediatric residents 2) better survival and interns in pigs resuscitated without 8 (MDs), respiratory compared ventilations when therapists (RTs), and nurses (RNs). those All sessions with resuscitated were video-recorded. RN; respiratory nurse with 30:2 CPR. RT; registered therapist MD; medical doctor, pediatric resident, or intern PALS; pediatric advanced life support BVM; bag-valve-mask
  • 209. Hyperventilation in Pediatric Resuscitation:Performance in Simulated Pediatric Medical Emergencies Niebauer Pediatrics 2011;128:e1195 Mean ventilation rate for various providers. These data reveal the danger of Simulated pediatric medical emergencies. chest interrupting compressions Pediatric residents (100-120 min) and interns (MDs), respiratory 8 to provide therapists (RTs), and nurses (RNs). All sessions were ventilation. video-recorded. RN; registered nurse RT; respiratory therapist MD; medical doctor, pediatric resident, or intern PALS; pediatric advanced life support BVM; bag-valve-mask
  • 210. • Metabolism• Diabetes
  • 211. Predicting babies’ risk of obesity Rudolf Arch dis Child 2011;96:995
  • 212. Predicting babies’ risk of obesity Rudolf Arch dis Child 2011;96:995Odds ratios (95% CI) for a baby developing obesity* by the age of 8 years
  • 213. Predicting babies’ risk of obesity Rudolf Arch dis Child 2011;96:995An example of how a paper version of an obesity risk tool might look
  • 214. Predicting babies’ risk of obesity Rudolf Arch dis Child 2011;96:995An example of how a paper version of an obesity risk tool might look.Points for the various risk factors are added up and the predicted probability read offfrom the scale at the bottom of the fi gure. For this high birthweight baby who is Asianwith an uneducated obese mother who has shown weight gain in the normal range, the scorewould be 148 (38+62+18+14+16). The scale indicates a predicted probability of 0.29 –a roughly one in three chance of being obese at age 6–8 years.
  • 215. Crossing Growth Percentiles in Infancy and Risk of Obesity in Childhood. Taveras APAM 2011;165:993 % of children crossing upwards ≥ 2 weight-for-length percentiles in the first 6 months of life. 50 – 44 622 children aged 1mo-11 yrs. 40 – 43% Length/height and weight 30 – measurements from January 1, 1980 through 20 – December 31, 2008. 10 – 0
  • 216. Crossing Growth Percentiles in Infancy and Risk of Obesity in Childhood. Taveras APAM 2011;165:993 OR for obesity at ages 5 yrs and 10 yrs. 3 – 44 622 children 2.08 aged 1mo-11 yrs. 2 – Length/height and weight 1.75 measurements from 1 – January 1, 1980 through December 31, 2008. 5 yrs 10 yrs 0 Crossing upwards ≥ 2 weight-for-length percentiles in the first 24 months.
  • 217. Crossing Growth Percentiles in Infancy and Risk of Obesity in Childhood. Taveras APAM 2011;165:993 OR for obesity at ages 5 yrs and 10 yrs. 3 – 44Crossing upwards ≥ 2 622 children 2.08 major weight aged 1mo-11 yrs. 2 – for-length percentiles Length/height and weight in the first 24 months 1.75 measurements from of life is associated 1 – January later obesity. with 1, 1980 through December 31, 2008. 5 yrs 10 yrs 0 Crossing upwards ≥ 2 weight-for-length percentiles in the first 24 months.
  • 218. • Metabolism• Obesity causes: food
  • 219. Is Frequency of Shared Family Meals Related to the Nutritional Health of Children and Adolescents? Hammons Pediatrics 2011;127:e1565 •Children and adolescents who share family meals 3 or more times per week are more likely to be in a normal 182 836 children weight range and have and adolescents healthier dietary and eating (mean sample age: patterns than those who 2.8 –17.3 yrs). share fewer than 3 family meals together. Frequency of •In addition, they are less shared family meals. likely to engage in disordered eating.
  • 220. Is Frequency of Shared Family Meals Related to the Nutritional Health of Children and Adolescents? Hammons Pediatrics 2011;127:e1565 Summary of effects
  • 221. • Metabolism• Obesity causes: physical activity
  • 222. • Metabolism• Obesity causes: psychology
  • 223. Quality of Early Maternal–Child Relationship and Riskof Adolescent Obesity Anderson, Pediatrics 2012;129;132 977 participants in the Study % obese adolescent of Early Child Care and Youth 30 – Development. Child attachment security and 26.1% maternal sensitivity assessed 20 – by observing mother–child interaction at 15, 24, and 36 15.5% months of age. 12.2% 13.0% 10 – Adolescent obesity defined as BMI ≥95th percentile at age 15 years. 0 ≥3 2 1 0 RISK SCORE FOR INSECURELY ATTACHED AND LOW MATERNAL SENSITIVITY
  • 224. Quality of Early Maternal–Child Relationship and Riskof Adolescent Obesity Anderson, Pediatrics 2012;129;132 977 participants in the Study OR of adolescent obesity of Early Child Care and Youth Development. 3 – Child attachment security and maternal sensitivity assessed by observing mother–child 2 – 2.45 interaction at 15, 24, and 36 months of age. 1 – Adolescent obesity defined as BMI ≥95th percentile at age 15 years. 00 in those with the poorest quality early maternal–child relationships (score: ≥3) compared with those with the highest quality (score: 0)
  • 225. Quality of Early Maternal–Child Relationship and Riskof Adolescent Obesity Anderson, Pediatrics 2012;129;132 977 participants in the Study OR of adolescent obesity of Early Child Care and Youth Development. 3 – Low maternal sensitivity was more Child attachment security and maternal sensitivity assessed strongly associated by observing mother–child 2 – 2.45 with obesity interaction at 15, 24, and 36 than insecure months of age. 1 – attachment. Adolescent obesity defined as BMI ≥95th percentile at age 15 years. 00 in those with the poorest quality early maternal–child relationships (score: ≥3) compared with those with the highest quality (score: 0)
  • 226. Quality of Early Maternal–Child Relationship and Riskof Adolescent Obesity Anderson, Pediatrics 2012;129;132Most childhood obesity prevention strategies are focused on energy balanceand target behaviors and environments that directly affect energyintake or expenditure, such as increasing physical activity, reducingsedentary behavior, or limiting intake of energy-dense foods and beverages.The limited success of these strategies underscores the importance ofconsidering new approaches. We have proposed that insecure attachmentmay be a risk factor for obesity in preschool-aged children.The mechanism underlying this association is uncertain.However, attachment security reflects the development of children‘semotion regulation and stress response. These capacities could influenceadiposity through their effects on appetite, sleep, and activity.
  • 227. Quality of Early Maternal–Child Relationship and Risk of Adolescent Obesity Anderson , Pediatrics 2012;129;132 Assessment of attachment security is based on a child‘s behaviors during interactions with a primary caregiver, usually the mother. Secure attachment is indicator of the quality of the mother–child relationship. Specifically, it reflects the child‘s awareness that the mother can be used as a ―secure base‖ from which to explore and that returning to the mother after a stressful experience will be comforting. Maternal sensitivity, another indicator of maternal–child relationship quality, refers to the mother‘s capacity to recognize the child‘s emotional state and respond with comfort, consistency, and warmth. Although a child‘s secure attachment is more likely to develop within the context of maternal sensitivity, additional factors such as the child‘s temperament, innate capacity for self-regulation, relationships with other caregivers, or the household environment may also influence attachment security.
  • 228. Conditions of long term success in a lifestyle intervention for overweight and obese youths Frölich Pediatrics 2011;128:e779 Long-term success 111 parent-child dyads (at least 5% weight reduction by with overweight and obese children/adolescents the 1-year follow-up) (BMI mean: 29.07). versus failure (dropping out Best-practice lifestyle or less weight reduction) was intervention of 1 year‘s significantly predicted by: duration. 1) family adversity, 3 assessment waves (baseline, conclusion, 2) maternal depression, 1-year follow-up). 3) attachment insecurity.
  • 229. Conditions of long term success in a lifestyle intervention for overweight and obese youths Frölich Pediatrics 2011;128:e779 Long-term success 111 parent-child dyads (at least 5% weight reduction by Maternal depression with overweight and obese the 1-year follow-up) proved to be children/adolescents (BMI mean: 29.07). the versus failure (dropping out best predictor. Best-practice lifestyle or less weight reduction) was intervention of 1 year‘s significantly predicted by: duration. 1) family adversity, 3 assessment waves (baseline, conclusion, 2) maternal depression, 1-year follow-up). 3) attachment insecurity.
  • 230. Maternal smoking during pregnancy and offspring growth in childhood: 1993 and 2004 Pelotas cohort studies Matijasevich Arch Dis Child 2011;96:513 • Maternal smoking during Population-based pregnancy was associated with birth cohort reduced z scores of studies in length/height-for-age at each Pelotas, Brazil, in follow-up. 1993 and 2004. • Children older than 3 months born Followed up at to smoking women showed a 3, 12, 24 and 48 higher body mass index-for-age months. z score than children of nonsmoking women.
  • 231. Maternal smoking during pregnancy and offspring growth in childhood: 1993 and 2004 Pelotas cohort studies Matijasevich Arch Dis Child 2011;96:513 • Maternal smoking during Population-based strongly The results pregnancy was associated with birth cohortsupport reduced z scores of the hypothesis that studies in length/height-for-age at each maternal smoking during Pelotas, Brazil, in follow-up. pregnancy 1993 and 2004. • Children older than 3 months born impairs linear growth Followed up at overweight to smoking women showed a and promotes 3, 12, 24 and 48 higher body mass index-for-age in months. childhood. z score than children of nonsmoking women.
  • 232. Newborn
  • 233. A Randomized Trial of Single Home Nursing Visits vsOffice-Based Care After Nursery/Maternity Discharge Paul I, APAM 2012;166:263 % newborn evaluated no more than 2 days after discharge 100 – p=0.002 90 – office-based care (OBC). 80 – 85.9% 70 – 78.8% home nursing visit (HNV). 60 – 50 – ―well‖ breastfeeding 40 – new-borns and mothers. 30 – 20 – 1154 postpartum mothers. 10 – 0 OBC HNV
  • 234. A Randomized Trial of Single Home Nursing Visits vsOffice-Based Care After Nursery/Maternity Discharge Paul I, APAM 2012;166:263 % newborn to be breastfeeding at 2 months 100 – 90 – office-based care (OBC). 80 – p=0.05 70 – home nursing visit (HNV). 72.1% 60 – 50 – 66.4% ―well‖ breastfeeding 40 – new-borns and mothers. 30 – 20 – 1154 postpartum mothers. 10 – 0 OBC HNV
  • 235. A Randomized Trial of Single Home Nursing Visits vsOffice-Based Care After Nursery/Maternity Discharge Paul I, APAM 2012;166:263 % newborn to be breastfeeding at 2 months 100 – 90 – office-based mothers HNV group care (OBC). 80 – had a greater 70 – p=0.05 parenting sense of home nursing visit (HNV). 72.1% competence 60 – 50 – 66.4% P<0.01 at 2 weeks and (―well‖ breastfeeding 40 – 2 months) new-borns and mothers. 30 – 20 – 1154 postpartum mothers. 10 – 0 OBC HNV
  • 236. Effectiveness of an Early Intervention on Infant Feeding Practices and “Tummy Time” Wen APAM 2011;165:701 An important aspect of 667 first-time mothers and infant development is regular their infants. ―tummy time‖, a colloquial term used to encourage parents to ensure that 5-6 home visits from a their infants spend time in the specially trained research prone position. nurse delivering a staged This leads to strengthening of the infant’s neck and back muscle home-based intervention in motor movement, which are crucial the antenatal period and for more complicated at 1, 3, 5, 9, and 12 months. movements, such as sitting, rolling over, crawling, and pulling bodies to Intervention group a standing position, as well as vs control group. enhanced motor development.
  • 237. Effectiveness of an Early Intervention on Infant Feeding Practices and “Tummy Time” Wen APAM 2011;165:701 667 first-time mothers and Breastfeeding rates by intervention group. their infants. 5-6 home visits from a specially trained research nurse delivering a staged p=0.03 home-based intervention in the antenatal period and at 1, 3, 5, 9, and 12 months. Intervention group vs control group.
  • 238. Effectiveness of an Early Intervention on Infant Feeding Practices and “Tummy Time” Wen APAM 2011;165:701 667 first-time mothers and Median duration of breastfeeding their infants. (weeks) at 12 months follow-up 5-6 home visits from a 20 – specially trained research p=0.03 nurse delivering a staged 15 – 17 w home-based intervention in the antenatal period and 10 – 13 w at 1, 3, 5, 9, and 12 months. 50 – Intervention group vs control group. 0 Intervention Control
  • 239. Effectiveness of an Early Intervention on Infant Feeding Practices and “Tummy Time” Wen APAM 2011;165:701 667 first-time mothers and Median duration of breastfeeding The intervention also: their infants. (weeks) at 12 months follow-up • decreased the age at 20 – 5-6 home infants started which visits from a specially trained research p=0.03 tummy time nurse delivering a staged (P=0.03 for trend); 15 – 17 w home-based intervention in • increased the daily the antenatal period and 10 – 13 w practice of tummy time at 1, 3, 5, 9, and 12 months. (P=0.05). 50 – Intervention group vs control group. 0 Intervention Control
  • 240. Prevention and Management of Positional Skull Deformities in Infants Laughlin Pediatrics 2011;128:1236 Positional molding Positional skull deformities may be present at birth or may develop during the first few months, particularly unilateral flattening of the occiput, likely attributable to parents following the “Back to Sleep” positioning recommendations aimed at decreasing the risk of sudden infant death syndrome.
  • 241. Prevention and Management of Positional SkullDeformities in Infants Laughlin Pediatrics 2011;128:1236 Positional skull deformities are generally benign, reversible head-shape anomalies that do not require surgical intervention, as opposed to craniosynostosis, which can result in neurologic damage and progressive craniofacial distortion. Pediatricians need to be able to properly differentiate infants with benign skull deformities from those with craniosynostosis, educate parents on methods of proactively decreasing the likelihood of the development of occipital flattening, initiate appropriate management, and make referrals when necessary.
  • 242. Craniosynostosis (from cranio, cranium; + syn, together; + ostosis relating tobone) is a condition in which one or more of the fibrous sutures in an infant skullprematurely fuses by ossification,[1] thereby changing the growth pattern of theskull.[2] Because the skull cannot expand perpendicular to the fused suture, itcompensates by growing more in the direction parallel to the closed sutures.Sometimes the resulting growth pattern provides the necessary space for thegrowing brain, but results in an abnormal head shape and abnormal facialfeatures.[2] In cases in which the compensation does not effectively provideenough space for the growing brain, craniosynostosis results inincreased intracranial pressure leading possibly to visual impairment, sleepingimpairment, eating difficulties, or an impairment of mental development combinedwith a significant reduction in IQ.[3]Craniosynostosis occurs in one in 2000 births.Craniosynostosis is part of a syndrome in 15 to 40% of the patients, but it usuallyoccurs as an isolated condition.[4][5]It is important that families seek out the opinion of a Pediatric CraniofacialPhysician who has experience with craniosynostosis for proper diagnosis, surgicalcare, and follow up.
  • 243. Prevention and Management of Positional SkullDeformities in Infants Laughlin Pediatrics 2011;128:1236 Preventive Counseling (1)To prevent the deformity, parents should be counseled duringthe new-born period (by 2– 4 weeks of age) when the skull ismaximally deformable.When awake and being observed, the infant should spend timein the prone position for at least 30 to 60 minutes/day.The infant should spend minimal time in car seats (when not apassenger in a vehicle) or other seating that maintains supinepositioning.
  • 244. Prevention and Management of Positional SkullDeformities in Infants Laughlin Pediatrics 2011;128:1236 Preventive Counseling (2)Aside from potentially preventing positional skulldeformity, routine awake tummy time has been shown toenhance infant motor developmental scores during the first15 months of life. Once positional skull deformity hasdeveloped, these same preventive strategies may be used tominimize progression.
  • 245. Prevention and Management of Positional SkullDeformities in Infants Laughlin Pediatrics 2011;128:1236 Mechanical adjustments and exercises (1)• Once positional skull deformity is diagnosed, most infants improve if the appropriate measures are conducted for a 2- to 3-month period.• These measures include positioning the infant so that the rounded side of the head is placed dependent against the mattress.• In addition, the position of the crib in the room may be changed to require the child to look away from the flattened side to see the parents and others in his or her room.
  • 246. Prevention and Management of Positional SkullDeformities in Infants Laughlin Pediatrics 2011;128:1236 Mechanical adjustments and exercises (2)•If torticollis is present, neck-motion exercises should betaught to the parents as part of management.•Neck exercises should be performed with each diaper change.•One hand is placed on the child‘s upper chest, and the otherhand rotates the child‘s head gently so that the chin touchesthe shoulder. This is held for approximately 10 seconds.The head is then rotated toward the opposite side and held forthe same count.This will stretch out the sternocleidomastoid muscle.
  • 247. Prevention and Management of Positional SkullDeformities in Infants Laughlin Pediatrics 2011;128:1236 Mechanical adjustments and exercises (3)•Next, the head is tilted so that the infant‘s ear touches his orher shoulder. Again, the position is held for a count of 10 andrepeated for the opposite side.This second exercise stretches the trapezius muscle.•In addition, the parents may be taught the previouslymentioned rotating chair or stool technique as a therapy toenhance neck motion in the infant.
  • 248. psychology
  • 249. psychologyparents – child interactions
  • 250. The immediate impact of different types of television on young children’s executive function Lillard Pediatrics 2011;128:644 Children who watched 60 children 4 yrs olds. fast-paced television cartoon performed significantly worse on Randomly assigned to the executive function tasks watch a fastpaced than children television cartoon or an educational cartoon in the other 2 groups when or draw for 9 min. controlling for  child attention, They were given 4 tasks.  age,  television exposure.
  • 251. The immediate impact of different types of television on young children’s executive function Lillard Pediatrics 2011;128:644 Preschool-aged children watch >90 minutes of television daily, and correlational studies link early television viewing with deficits in executive function (EF), a collection of prefrontal skills underlying goal-directed behavior, including attention, working memory, inhibitory control, problem solving, self-regulation, and delay of gratification.
  • 252. The immediate impact of different types of television on young children’s executive function Lillard Pediatrics 2011;128:644 Preschool-aged children watch >90 minutes of television daily, and correlational studies link early television viewing with deficits in executive function (EF), a collection of prefrontal skills underlying goal-directed behavior, including attention, working memory, inhibitory control, problem solving, self-regulation, and delay of gratification. Executive Function is increasingly recognized as key to positive social and cognitive functioning and is strongly associated with success in school.
  • 253. The immediate impact of different types of television on young children’s executive function Lillard Pediatrics 2011;128:644 Fast-paced shows seem particularly likely to have a negative impact on attention, one reason for this being that rapidly presented events capture attention in a bottom-up fashion, involving the sensory rather than prefrontal cortices.
  • 254. The immediate impact of different types of television on young children’s executive function Lillard Pediatrics 2011;128:644  Fast-paced shows seem particularly likely to have a negative impact on attention, one reason for this being that rapidly presented events capture attention in a bottom-up fashion, involving the sensory rather than prefrontal cortices.  Thus, fast-paced television would do nothing to train internally controlled (prefrontal) attention over the long-term.Attention and motivation are controlled by the prefrontal cortex.It‘s responsible for higher judgements, planning, focusing attention,and control of social behavior.It‘s the part of the brain that develops the most slowly throughout life,not maturing fully until age 25.
  • 255. The immediate impact of different types of television on young children’s executive function Lillard Pediatrics 2011;128:644 Fast-paced shows seem particularly likely to have a negative impact on attention, one reason for this being that rapidly presented events capture attention in a bottom-up fashion, involving the sensory rather than prefrontal cortices. Thus, fast-paced television would do nothing to train internally controlled (prefrontal) attention over the long-term. In the short term, the effort to encode rapidly presented events could tax children’s executive resources.
  • 256. The effects of fast paced cartoons Christakis Pediatrics 2011;128:772 The typical child began watching television at 4 years of age in 1970 and consumed 3-4 hours/day, the typical child today begins watching at 4 months of age and is engaged with media for up to 8 hours/day.
  • 257. The effects of fast paced cartoons Christakis Pediatrics 2011;128:772 The typical child began watching television at 4 years of age in 1970 and consumed 3-4 hours/day, the typical child today begins watching at 4 months of age and is engaged with media for up to 8 hours/day. The effects of media are mediated more by what is watched than how much is watched.
  • 258. The effects of fast paced cartoons Christakis Pediatrics 2011;128:772 The typical child began watching television at 4 years of age in 1970 and consumed 3-4 hours/day, the typical child today begins watching at 4 months of age and is engaged with media for up to 8 hours/day. The effects of media are mediated more by what is watched than how much is watched. Simply put, television is both good and bad : there are good programs and bad ones.
  • 259. The effects of fast paced cartoons Christakis Pediatrics 2011;128:772 Some shows change scenes more than 3 times per minute, whereas others have greater continuity. The “overstimulation hypothesis” is based on the theory that the surreal pacing and sequencing of some shows might tax the brain or parts of it, leading to short-term (or long-term) deficits.
  • 260. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 As predicted in the 1999 American Academy of Pediatrics (AAP) policy statement, industry has also targeted those in the 0- to 2-year age group (and their parents) as key consumers of electronic media. Currently, 90% of parents report that their children younger than 2 years watch some form of electronic media. By 3 years, almost one third of children have a television in their bedroom. Parents report that they view television as a peacekeeper and a safe activity for their children while they are preparing dinner, getting ready for work, or doing household chores.
  • 261. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 Some children are exposed to 4 hours or more of televised programs per day. On average, children younger than 2 years watch televised programs 1 to 2 hours/day. 14% of children aged 6 to 23 months watch ≥ 2 hours/day of media.
  • 262. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 It seems that audible television is associated with decreased parent-child interactions. Although a leading survey of family media use has reported that 40% of parents watch with their child all the time and 28% watch with their child most of the time, parents also report that they avoid co- viewing because their child‘s media time provides an opportunity for them to do other things. Children who live in homes with lower socioeconomic status and children with single mothers or mothers with less than a high school education are spending more time in front of a screen on a daily basis.
  • 263. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 Can children learn from media? To be beneficial, children need to understand the content of programs and pay attention to it. There is a paucity of research on this topic, but the existing literature suggests that media use does not promote language skills in this age group. Children 12 to 18 months of age are more likely to learn from a live presentation than from a televised one and are also more likely to remember the information from a live presentation afterward. Children aged 12 months and younger do not follow sequential screen shots or a program‘s dialogue. A developmental shift in attention to televised programs occurs between 1.5 and 2.5 years of age.
  • 264. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 Foreground media The part of a scene or picture that is nearest to and in front of the viewer.background media
  • 265. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 Secondhand television: foreground (for children) versus background media (for adults) (1)Many families have reported that they have a television on at least 6 hours/day or that a television is “always on” as background noise.39% of families with infants and young children have a television on constantly.Young children may not be paying close attention to a televised program that they cannot understand, but their parents are watching. It might be background media to the child, but it is foreground media to the parent. It distracts the parent and decreases parent-child interaction.Infant vocabulary growth is directly related to the amount of―talk time‖ or the amount of time parents spend speaking to them.
  • 266. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 Secondhand television: foreground (for children) versus background media (for adults) (2)Heavy television use in a household can interfere with a child’s language development simply because parents likely spend less time talking to the child.Children play and interact less with adults when a television is on, perhaps because the adult‘s attention is focused on the television program.Background media might interfere with cognitive processing, memory, and reading comprehension.Background television has the direct effect of distracting a child and the indirect effect of taking a parent’s attention away from the child.
  • 267. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 A good use of time? (1) Children younger than 5 years who watch television spend less time in creative play and less time interacting with parents or siblings. For every hour of television that a child younger than 2 years watches alone, he or she spends an additional 52 minutes less time per day interacting with a parent or sibling. Does television displace more developmentally valuable playtime?
  • 268. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 A good use of time? (2) Children who live in households with heavy media use spend between 25% (for 3- to 4-year-olds) and 38% (for 5- to 6-year-olds) less time being read to or reading. These children have a lower likelihood of being able to read compared with their peers from households with low media use. What is known is that unstructured playtime is critical to learning problem-solving skills and fostering creativity.
  • 269. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 Health consequences Media use has been associated with obesity, sleep issues, aggressive behaviors, and attention issues in preschool- and school aged children. One area of concern, however, is media’s effect on sleep. Television is part of the bedtime routine for many children. Although parents perceive a televised program to be a calming sleep aid, some programs actually increase bedtime resistance, delay the onset of sleep, cause anxiety about falling asleep, and shorten sleep duration.
  • 270. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 Developmental consequences Children younger than 2 years who watch more television or videos have expressive language delays, and Children younger than 1 year with heavy television viewing who are watching alone have a significantly higher chance of having a language delay.
  • 271. Media Use by Children Younger Than 2 Years Pediatrics 2011;128:1040 Media -both foreground (for children) and background (for adults) have potentially negative effects and no known positive effects for children younger than 2 years. Thus, the AAP reaffirms its recommendation to discourage media use in this age group. This statement also discourages the use of background television intended for adults when a young child is in the room.
  • 272. psychology behaviour newborn pre-school
  • 273. Secondhand Smoke Exposure and Neurobehavioral Disorders Among Children in the United States Kabir, Pediatrics 2011;128:263 % children exposed to SHS in the home Children ≤12 yrs 7 – in the United States. 6 – Excess neurobehavioral 5 – 6% disorders attributable to 4 – secondhand smoke (SHS) exposure in the home. 3 – 2 – 1 – 0
  • 274. Secondhand Smoke Exposure and Neurobehavioral Disorders Among Children in the United States Kabir, Pediatrics 2011;128:263 PREVALENCE OF (exposed vs nonexposed)20 –18 –16 –14 – 15.1%12 – 13.0%10 –08 – 8.7%06 – 7.2%04 – 5.5% 2.8%02 – 0 LEARNING ATTENTION- BEHAVIORAL AND DISABILITIES DEFICIT/HYPERACTIVITY CONDUCT DISORDER DISORDERS
  • 275. Secondhand Smoke Exposure and Neurobehavioral Disorders Among Children in the United States Children exposed to SHS at home had a 50% increased odds of2011;128:263 Kabir, Pediatrics having ≥2 childhood neurobehavioral disorders PREVALENCE OF (exposed vs nonexposed)20 – compared with children who were18 – not exposed to SHS.16 –14 – 15.1%12 – 13.0%10 –08 – 8.7%06 – 7.2%04 – 5.5% 2.8%02 – 0 LEARNING ATTENTION- BEHAVIORAL AND DISABILITIES DEFICIT/HYPERACTIVITY CONDUCT DISORDER DISORDERS
  • 276. Never Enough Sleep: A Brief History of Sleep Recommendations for Children Matricciani, Pediatrics 2012;129;548 A systematic On average, age-specific literature review. recommended sleep decreased at the rate Identify of –0.71 minute per year. recommendations for This rate of decline was children‘s sleep almost identical to the decline requirements. in the actual sleep duration of children (–0.73 minute per year). Data reporting Recommended sleep was children‘s actual total consistently ∼37 minutes sleep time from 1897 greater than actual to 2009. (112 years) sleep, although both declined over time.
  • 277. Never Enough Sleep: A Brief History of Sleep Recommendations for Children Matricciani, Pediatrics 2012;129;548 A systematic On average, age-specific Inadequate review.was literature sleep recommended sleepseen as a consequence decreased at the rate of “modern life”. Identify of –0.71 minute per year. No matter how much recommendations for This rate of decline was children‘s sleep are sleep children almost identical to the decline requirements. has getting, it in the actual sleep duration of always been children (–0.73 minute per year). assumed that Data reporting Recommended sleep was they need children‘s actual total consistently ∼37 minutes more. sleep time from 1897 greater than actual to 2009. (112 years) sleep, although both declined over time.
  • 278. Genetic and Environmental Factors Shape Infant Sleep Patterns: A Study of 18-Month-Old Twins Brescianini, Pediatrics 2011;127:e1296OBJECTIVE:Between 25% and 30% of children and adolescents experiencesleep disorders.These disorders are complex phenotypes that are regulated bymany genes, the environment, and gene-environment interactions.The objective of this study was to evaluate the contributionof genetic and environmental factors to sleep behaviorsin early childhood and to contribute to the knowledgeon appropriate therapeutic approaches, using a twin design.
  • 279. Genetic and Environmental Factors Shape Infant Sleep Patterns: A Study of 18-Month-Old Twins Brescianini, Pediatrics 2011;127:e1296 % OF THE TOTAL VARIANCE IN COSLEEPING (i.e. sleeping in the same room with parents) Sleeping behavior. 100 – 314 18-mo-old twin pairs (127 monozygotic and 80 – 98.3% 187 dizygotic). 60 – Parent-rated questionnaire. 40 – Different sleep behaviors (cosleeping, sleep 20 – duration, and night awakenings). 0 Explained by shared environment
  • 280. Genetic and Environmental Factors Shape Infant Sleep Patterns: A Study of 18-Month-Old Twins Brescianini, Pediatrics 2011;127:e1296 DURATION OF NOCTURNAL SLEEP Sleeping behavior. 100 – 314 18-mo-old twin pairs (127 monozygotic and 80 – 187 dizygotic). 60 – Parent-rated questionnaire. 64.1% 40 – Different sleep behaviors (cosleeping, sleep 20 – duration, and night awakenings). 0 influenced by environmental factors
  • 281. Genetic and Environmental Factors Shape Infant Sleep Patterns: A Study of 18-Month-Old Twins Brescianini, Pediatrics 2011;127:e1296 % NOCTURNAL WAKING EPISODES Sleeping behavior. 100 – 314 18-mo-old twin pairs (127 monozygotic and 80 – 187 dizygotic). 60 – Parent-rated questionnaire. 63.2% 40 – Different sleep behaviors (cosleeping, sleep 20 – duration, and night awakenings). 0 influenced by environmental factors
  • 282. Genetic and Environmental Factors Shape Infant Sleep Patterns: A Study of 18-Month-Old Twins Brescianini, Pediatrics 2011;127:e1296 Most sleep disturbances % NOCTURNAL WAKING EPISODES during early childhood Sleeping behavior. by are explained 100 – common shared environmental 314 18-mo-old twin pairs factors, (127 monozygotic and 80 – 187 dizygotic). behavioral and interventions adopted by parents 60 – Parent-rated questionnaire. and focused on 63.2% modifying sleep behavior 40 – Different sleep behaviors could contribute to solving (cosleeping, sleep sleep disturbances in 20 – duration, and night this age group. awakenings). 0 influenced by environmental factors
  • 283. Late Talking and the Risk for Psychosocial Problems During Childhood and Adolescence Whitehouse, Pediatrics 2011;128:e3241. There is considerable variation in early language development, with some children beginning to talk much later than others.2. Previous studies have benchmarked 24 months as the age at which children with an expressive vocabulary delay, or ―late talkers‖, can be ascertained reliably.3. The prevalence of late talkers, defined as children who demonstrate limited expressive vocabulary in the face of otherwise typical development, ranges from 7% to 18% dependent on the vocabulary threshold used.4. Although these difficulties may persist to the school-aged years, often resulting in a diagnosis of specific language impairment, 70%-80% of late talkers are able to compensate for this initial delay and present with age-appropriate language skills by the time they enter school.
  • 284. Late Talking and the Risk for Psychosocial Problems During Childhood and Adolescence Whitehouse, Pediatrics 2011;128:e3241. There is considerable variation in early language development, with some children beginning to talk much later than others. A “wait-and-see” strategy often is adopted2. Previous studies have benchmarked 24 months as the age at which vs children with an expressive vocabulary delay, or ―late talkers‖, initiating speech and can be ascertained reliably. language intervention.3. The prevalence of late talkers, defined as children who demonstrate limited expressive vocabulary in the face of otherwise typical development, ranges from 7% to 18% dependent on the vocabulary threshold used.4. Although these difficulties may persist to the school-aged years, often resulting in a diagnosis of specific language impairment, 70%-80% of late talkers are able to compensate for this initial delay and present with age-appropriate language skills by the time they enter school.
  • 285. Late Talking and the Risk for Psychosocial Problems During Childhood and Adolescence Whitehouse, Pediatrics 2011;128:e324 Pregnancy Cohort Study. CBCL- Child Behavior Checklist Early expressive vocabulary was measured at age 2 yrs using the Language Development Survey. Late talkers were defined as toddlers who scored at or below the 15th percentile.
  • 286. Late Talking and the Risk for Psychosocial Problems During Childhood and Adolescence Whitehouse, Pediatrics 2011;128:e324 Pregnancy Cohort Study. At age 2 CBCL- Child Behavior Checklist Early expressive late years, vocabulary was talkers measuredn=142) 2 yrs ( at age using the Language had higher Development Survey. Child Behavior Late talkers scores Checklist were defined aspoorer (representing toddlers who scored behavior) at or below than control toddlers the 15th (n=1245) percentile. in total.
  • 287. Late Talking and the Risk for Psychosocial Problems During Childhood and Adolescence Whitehouse, Pediatrics 2011;128:e324 Pregnancy Cohort Study. Regression CBCL- Child Behavior Checklist Early expressive models revealed vocabulary was no association between measured at age 2 yrs late-talking status using the Language at age 2 years Development Survey. and behavioral and Late talkers problems emotional at thedefined as were 5-, 8-, 10-, 14- toddlers who scored , and 17- year at or below follow-ups. the 15th percentile.
  • 288. Late Talking and the Risk for Psychosocial Problems During Childhood and Adolescence Whitehouse, Pediatrics 2011;128:e324 Pregnancy Cohort Study. CBCL- Child Behavior Checklist Early expressive Expressive vocabulary was measured at agedelay vocabulary 2 yrs using theage of 2 years at the Language is not Survey. Developmentin itself a risk factor for Late later behavioral talkers were defined as and emotional toddlers who scored disturbances. at or below the 15th percentile.
  • 289. Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior Walker, Pediatrics 2011;127:849 129 growth-retarded children aged 9-24 months. No significant A 2-year trial of benefits nutritional supplementation from (1 kg milk-based formula per week) supplementation. and/or psychosocial stimulation (weekly play sessions to improve mother-child interaction). Follow-up: 22 yrs.
  • 290. Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior Walker, Pediatrics 2011;127:849 OR IN PARTECIPANTS WHO RECEIVED STIMULATION FOR 129 growth-retarded 1.0 – children aged 9-24 months. A 2-year trial of nutritional supplementation (1 kg milk-based formula per week) 0.5 – and/or psychosocial stimulation (weekly play sessions to improve 0.36 0.33 mother-child interaction). 0 Follow-up: 22 yrs. INVOLVEMENT SERIOUS IN FIGHTS VIOLENT BEHAVIOR
  • 291. Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior Walker, Pediatrics 2011;127:849 OR IN PARTECIPANTS WHO RECEIVED STIMULATION FOR 129 growth-retarded 1.0 – They also had: children aged 9-24 months. 1) higher adult IQ, A 2-year trial of 2) higher educational nutritional supplementation attainment, (1 kg 3) betterformula per week) 0.5 – milk-based general and/or knowledge psychosocial stimulation 4) fewer symptoms of (weekly play sessions to improve depression and social 0.36 0.33 mother-child interaction). inhibition. 0 Follow-up: 22 yrs. INVOLVEMENT SERIOUS IN FIGHTS VIOLENT BEHAVIOR
  • 292. Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior Walker, Pediatrics 2011;127:849CONCLUSIONS: Early psychosocial intervention hadwide-ranging benefits in adulthood that are likely tofacilitate functioning in everyday life.The reductions in violent behavior are extremely importantgiven the high levels of violence in many developing countries.The study provides critical evidence thatearly intervention can lead to gains in adult functioning.
  • 293. Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior Walker, Pediatrics 2011;127:849STIMULATION PROGRAM:•To increase the mother‘s ability to promote her child‘s development throughplay, to improve mother-child interaction, and to promote the self-esteem of bothmother and child.•We used a structured curriculum which included some Piagetian concepts forchildren <24 months, and concepts such as shape, quantity, position, and colorfor children ≥24 months.•Mothers were encouraged to continue play activities between the visits andto integrate them in their daily routines. They were encouraged to chat with theirchildren and to label objects and actions.•Emphasis was placed on the use of praise and positive reinforcement, andphysical punishment was discouraged.•Toys made from commonly discarded household materials and simple picture bookswere left in the home and exchanged each week.
  • 294. psychologyadolescents
  • 295. Overlooked and Underserved: “Action Signs” forIdentifying Children With Unmet Mental Health Needs Jensen Pediatrics 2011;128:970 Final list of action/warning signs.
  • 296. School bullying perpetration and other childhood riskfactors as predictors of adult intimate partner violence perpetration Falb APAM 2011;165:890 % men reported perpetrating Men aged 18 to 35 school bullying as a child yrs (n=1491) seeking services at 50 – community health centers. 40 – 40.9% Past-year physical or 30 – sexual violence perpetration against 20 – a femal partner 10 – (intimate-partner violence [IPV]) 0
  • 297. School bullying perpetration and other childhood riskfactors as predictors of adult intimate partner violence perpetration Falb APAM 2011;165:890 OR for perpetrate past year IPV Men aged 18 to 35 4 – yrs (n=1491) seeking services at 3 – 3.82 community health centers. 2 – Past-year physical or sexual violence 1 – 1.53 perpetration against a femal partner 00 1 (intimate-partner violence [IPV]) no rarely frequently BULLYING PEERS IN SCHOOL
  • 298. School bullying perpetration and other childhood riskfactors as predictors of adult intimate partner violence perpetration Falb APAM 2011;165:890 OR for perpetrate past year IPV Men aged 18 to 35 4 – Bullying peers yrs (n=1491) seeking in school as a services at 3 – 3.82 child community health centers. is associated 2 – Past-yearincreased with physical or risk for men’s sexual violence 1 – 1.53 perpetration of perpetration against a femal partneran IPV as 00 1 (intimate-partner adult. violence [IPV]) no rarely frequently BULLYING PEERS IN SCHOOL
  • 299. Sudden Infant Death Syndrome andUnespected Death
  • 300. Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis Hauck Pediatrics 2011;128:103 OR for SIDS 1.0 – 18 original case-control 0.5 – studies were identified that provided data on the relationship between breastfeeding 0.27 and SIDS risk. 0.0 exclusive breastfeeding of any duration
  • 301. Bed Sharing and the Risk of Sudden Infant Death Syndrome: Can We Resolve the Debate? Vennemann, J Pediatr 2012;160:44 OR for SIDS in bed sharing. 11 – 10 – 09 – 10.37Meta-analysis. 08 – 07 –Relationship 06 – between 05 – 6.27 04 – bed sharing 03 – and SIDS risk. 02 – 2.89 01 – 0011 studies. vs non-bed with smoking in infants sharing mothers <12 weeks old
  • 302. Risk factors changes for sudden infant death syndrome after initiation of back to sleep campaign Trachtenberg Pediatrics 2012;129:630 % SIDS infants 10 – Risk factors for 568 SIDS deaths from 1991 to 2008. 50 – 5% Standardized death scene investigations and autopsies. 0 with no extrinsic factors
  • 303. Risk factors changes for sudden infant death syndrome after initiation of back to sleep campaign Trachtenberg Pediatrics 2012;129:630The triple-risk model for SIDS. Factors contributing to the vulnerability may include intrinsic risk factors. The exogenous stressorsare the extrinsic risk factors for SIDS.
  • 304. Surgery& anesthesia
  • 305. Defining Safe Use of Anesthesia in Children Rappaport, NEJM 2011;364:1387Background:Anesthetic agents are commonly used for a variety of medicalprocedures in infants and children, but little is known abouttheir effects on the developing brain.A growing body of data from studies in animals suggeststhat under certain circumstances, such as prolongedanesthesia, these drugs could adversely affectneurologic, cognitive & social development of neonates andyoung children.
  • 306. Defining Safe Use of Anesthesia in Children Rappaport, NEJM 2011;364:1387DiMaggio J Neurosurg Anesthesiol 2009;21:286 Adjusted HR for 3 – 383 children with inguinal hernia repair in the first 2 – 2.3 3 yrs of life. 1 – 5050 control children. 0 – diagnosis of a developmental or behavioral disorder.
  • 307. Defining Safe Use of Anesthesia in Children Rappaport, NEJM 2011;364:1387Wilder Anesthesiology 2009;110:796 Adjusted HR for 3 – 449 children exposed to a single anesthetic. 2 – 2.6 100 children exposed 1 – 1.6 to 2 anesthetics. 1 44 children exposed 0 – single 2 more to more anesthetics. anesthetic anesthetics anesthetics risk of learning disabilities
  • 308. Defining Safe Use of Anesthesia in Children Rappaport, NEJM 2011;364:1387Results:No conclusions about causality can be drawn on the basis of thesenonrandomized studies in humans because of the substantialpotential for confounding.The FDA‘s Anesthetic and Life Support Drugs Advisory Committee:1) additional research is essential to understanding the implications of the animal data for children (3 Ongoing Clinical Trials in the World);2) insufficient information to warrant changing the practice of pediatric anesthesia.
  • 309. Cognitive and Behavioral Outcomes After Early Exposure to Anesthesia and Surgery Flick Pediatrics 2011;128:e1053 HR for Learning Disabilities Learning disabilities 3 – (LDs). 2.12 In children exposed 2 – to anesthesia (n=350) before the age of 2. 1 – In children unexposed controls 0 Exposure to multiple, but not (n=700). single, anesthetic/surgery
  • 310. Cognitive and Behavioral Outcomes After Early Exposure to Anesthesia and Surgery Flick Pediatrics 2011;128:e1053 HR for Learning Disabilities A similar pattern Learning disabilities 3 – (LDs). observed for was 2.12 decrements in In children exposed 2 – group administered to anesthesia (n=350) before the age of 2. tests of 1 – achievement and In children cognition. unexposed controls 0 Exposure to multiple, but not (n=700). single, anesthetic/surgery
  • 311. Cognitive and Behavioral Outcomes After Early Exposure to Anesthesia and Surgery Flick Pediatrics 2011;128:e1053 HR for Learning Disabilities We cannot exclude the Learning disabilities possibility that 3 – (LDs). multiple exposures 2.12 to anesthesia/surgery In children exposed 2 – to at an early(n=350) anesthesia age may before the affect 2. adversely age of human 1 – neurodevelopment In children with long lasting unexposed controls 0 consequence. Exposure to multiple, but not (n=700). single, anesthetic/surgery
  • 312. Cognitive and Behavioral Outcomes After Early Exposure to Anesthesia and Surgery Flick Pediatrics 2011;128:e10531. Exposure of developing animal brains to anesthetics may cause neurodegenerative changes with adverse effects on learning and behavior.2. Implicated drugs include N-methyl-D-aspartate glutamate receptor agonists and γ-aminobutyric acid antagonists.3. When these drugs, including virtually all anesthetics, are administered to young animals (including primates), neurodegeneration results.
  • 313. Cognitive and Behavioral Outcomes After Early Exposure to Anesthesia and Surgery Flick Pediatrics 2011;128:e1053 In children with ≥ 2 exposure to anesthesia3 – HR for Learning Disabilities in 2.142 –1 – 1.97 1.8400 Mathematics Reading Written Language
  • 314. Association of Neck Circumference With Perioperative Adverse Respiratory Events in Children Nafiu, Pediatrics 2011;127:e1198 PREVALENCE OF 1102 children HIGH NECK CIRCUMFERENCE aged 6-18 years 30 – undergoing elective non-cardiac surgeries. Patients stratified into 20 – 24.3% 2 classes: 1) high neck ii circumference (NC); 10 – 2) low NC; on the basis of age and gender. 0
  • 315. Association of Neck Circumference With Perioperative Adverse Respiratory Events in Children Nafiu, Pediatrics 2011;127:e1198 PREVALENCE OF 1102More likely to be • children HIGH NECK CIRCUMFERENCE aged 6-18 years loud snorers and have 30 – undergoing elective a history of bronchial non-cardiac surgeries. asthma, hypertension, and type 2 Patients stratified into 20 – 24.3% diabetes. 2 classes: 1) high neck There was no significant 10 – • ii circumference (NC); 2) association between low NC; on thehigh NC and basis of age difficult laryngoscopy. and gender. 0
  • 316. Association of Neck Circumference With Perioperative Adverse Respiratory Events in Children% Nafiu, Pediatrics 2011;127:e1198100 –90 – % children NC ≤ 90th Percentile80 – NC > 90th Percentile70 – p<0.00160 – 67.550 –40 – p<0.00130 – 37.2 p<0.001 p=0.02420 – 25.4 p=0.03 p<0.001 19.5 21.110 – 11.3 18.8 2.8 5.3 13.8 0 8.1 6.4 LOUD OSA ABDOMINAL BRONCHIAL HYPER- MALLAMPATI SNORER DIAGNOSIS OBESITY ASTHMA TENSION ≥3
  • 317. Take home

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