We compared injury incidence and mechanisms among youth, high school (HS), and National Collegiate Athletic Association (NCAA) boys’ and men’s lacrosse athletes for the 2014–2015 to 2016–2017 lacrosse seasons.METHODS:
Multiple injury surveillance systems were used to capture 21 youth boys’, 22 HS boys’, and 20 NCAA men’s lacrosse team-seasons of data during the 2014–2015 to 2016–2017 seasons. Athletic trainers reported game and practice injuries and athlete exposures (AEs). Injuries included those occurring during a game and/or practice and requiring evaluation from an athletic trainer and/or physician. Injury counts, rates per 1000 AEs, and injury rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated.RESULTS:
The injury rate in youth was higher than those reported in HS (10.3 vs 5.3 per 1000 AEs; IRR = 2.0; 95% CI: 1.6–2.4) and the NCAA (10.3 vs 4.7 per 1000 AEs; IRR = 2.2; 95% CI: 1.9–2.5). When considering time loss injuries only (restricted participation of ≥24 hours), the injury rate in youth was lower than those reported in HS (2.0 vs 2.9 per 1000 AEs; IRR = 0.7; 95% CI: 0.5–0.95) and the NCAA (2.0 vs 3.3 per 1000 AEs; IRR = 0.6; 95% CI: 0.4–0.8). The concussion rate in youth was higher than those in HS (0.7 vs 0.3 per 1000 AEs; IRR = 2.4, 95% CI: 1.1–5.2) and the NCAA (0.7 vs 0.3 per 1000 AEs; IRR = 2.1, 95% CI: 1.2–3.7). Injuries at the youth, HS, and NCAA levels were most commonly associated with stick contact, inflammatory conditions (including bursitis, tendonitis, and other unspecified inflammation), and noncontact mechanisms, respectively.CONCLUSIONS:
Although the time loss injury rate was lowest in youth boys’ lacrosse, the concussion rate was the highest. Injury prevention approaches should be specific to the mechanisms associated with each level of play (eg, equipment skill development in youth).
After the Affordable Care Act (ACA) took full effect in 2014, 900 000 children obtained health insurance. Researchers have found variable effects of insurance on adult emergency department (ED) use, but the effect in pediatric patients is unknown. We examined ED visit rates before and after 2014 among children.METHODS:
We used estimates of ED visit counts from the Nationwide Emergency Department Sample and population estimates from the American Community Survey in a cross-sectional, retrospective study of ED visit rates among children. We compared the trend in ED visit rates before (2009–2013) and after (2014–2016) the ACA took full effect, controlling for age, sex, and census region.RESULTS:
The mean ED use rate was 35.2 visits per 100 children from 2009 to 2013 and 36.6 from 2014 to 2016. ED visit rates increased by 1.1% per year pre-2014 and 9.8% from 2014 to 2016 (incidence rate ratio 1.09, 95% confidence interval 1.03–1.15, P = .005). Results did not vary significantly when insurance was included as a control variable.CONCLUSIONS:
There was no immediate change in pediatric ED visit rates the year after the ACA took full effect in 2014, but the rate of change from 2014 to 2016 was significantly higher than previous rate trends. In our model, increased pediatric insurance coverage neither drove nor counteracted the observed trends.
Naphthalene poisoning due to exposure to mothballs is a common cause of toxicity in children worldwide. Naphthalene toxicity is known to cause hemolytic anemia, methemoglobinemia, and hepatic and renal injury. Neonates are more susceptible to the effects of oxidative stress from naphthalene because of their low glutathione stores and immaturity of hepatic enzymes. However, there are no reported cases of chronic fetal exposure to naphthalene during pregnancy. We report a novel case of chronic fetal exposure to naphthalene-containing mothballs that occurred from the second trimester through the third trimester of pregnancy. Our patient presented with hyperbilirubinemia, requiring exchange transfusion, severe hemolytic anemia, pulmonary hypertension, respiratory failure, and renal failure and progressed to develop "bronze baby" syndrome. Pregnant mothers should be diligently screened for such exposures and if found should receive psychiatric evaluation and counseling to prevent such devastating effects in neonates.
Patients with Kawasaki disease can develop life-altering coronary arterial abnormalities, particularly in those resistant to intravenous immunoglobulin (IVIg) therapy. We tested the tumor necrosis factor α receptor antagonist etanercept for reducing both IVIg resistance and coronary artery (CA) disease progression.METHODS:
In a double-blind multicenter trial, patients with Kawasaki disease received either etanercept (0.8 mg/kg; n = 100) or placebo (n = 101) subcutaneously starting immediately after IVIg infusion. IVIg resistance was the primary outcome with prespecified subgroup analyses according to age, sex, and race. Secondary outcomes included echocardiographic CA measures within subgroups defined by coronary dilation (z score >2.5) at baseline. We used generalized estimating equations to analyze z score change and a prespecified algorithm for change in absolute diameters.RESULTS:
IVIg resistance occurred in 22% (placebo) and 13% (etanercept) of patients (P = .10). Etanercept reduced IVIg resistance in patients >1 year of age (P = .03). In the entire population, 46 (23%) had a coronary z score >2.5 at baseline. Etanercept reduced coronary z score change in those with and without baseline dilation (P = .04 and P = .001); no improvement occurred in the analogous placebo groups. Etanercept (n = 22) reduced dilation progression compared with placebo (n = 24) by algorithm in those with baseline dilation (P = .03). No difference in the safety profile occurred between etanercept and placebo.CONCLUSIONS:
Etanercept showed no significant benefit in IVIg resistance in the entire population. However, preplanned analyses showed benefit in patients >1 year. Importantly, etanercept appeared to ameliorate CA dilation, particularly in patients with baseline abnormalities.
Early HIV testing is needed for treatment success in young infants, but universal testing is expensive. In this study, we examined the feasibility of early infant HIV risk scores for targeted polymerase chain reaction (PCR) testing and early HIV diagnosis.METHODS:
A cross-sectional cohort of newborns exposed to HIV was enrolled and PCR tested within 72 hours. We quantified associations between HIV infection and clinical and laboratory maternal-infant parameters by logistic regression models and determined sensitivity and specificity for derived risk scores.RESULTS:
From August 2014 to December 2016, 1759 participants were enrolled. Mothers without antenatal care (5.7% [97 of 1688]) were more likely to deliver newborns who are PCR-positive (P = .0005). A total of 1 in 5 mothers (217 of 990; 21.9%) had HIV viral load (VL) >1000 copies per µL. A total of 432 of 1655 (26.1%) infants were preterm. Low birth weight was documented in 398 of 1598 (24.55%) and 13 of 31 (40.63%) newborns who are PCR-negative and -positive, respectively (P = .0329). A total of 204 of 1689 (12.08%) were growth restricted or small for gestational age, and 6 of 37 (16.22%) were PCR-positive. Symptomatic newborns frequently tested positive (P = .0042). The HIV PCR positivity rate was 2.2% (37 of 1703). Two-risk (combined 3-drug antiretroviral therapy [cART] duration, VL), 3-risk (cART duration, VL, symptomatic newborn), and 4-risk (cART duration, VL, symptomatic, small for gestational age newborn) models for HIV acquisition had predictive probability of 0.28, 0.498, and 0.57, respectively; this could guide targeted birth testing. However, using the 3- and 4-risk scores (probability 0.02 and 0.04), 20% and 24% will be missed compared with universal testing.CONCLUSIONS:
Targeted newborn testing requires access to maternal VL. Even if risk models include parameters such as maternal cART history, birth weight, weeks’ gestation, and symptoms, 1 in 5 newborns who are infected will not be targeted. At present, we support universal PCR testing at birth within the South African prevention of mother-to-child transmission of HIV context.
The American Academy of Pediatrics recommends literacy promotion and developmental assessment during well-child visits. Emergent literacy skills are well defined, and the use of early screening has the potential to identify children at risk for reading difficulties and guide intervention before kindergarten.METHODS:
The Reading House (TRH) is a children’s book designed to screen emergent literacy skills. These are assessed by sharing the book with the child and using a 9-item, scripted scoring form. Get Ready to Read! (GRTR) is a validated measure shown to predict reading outcomes. TRH and GRTR were administered in random order to 278 children (mean: 43.1 ± 5.6 months; 125 boys, 153 girls) during well-child visits at 7 primary care sites. Parent, child, and provider impressions of TRH were also assessed. Analyses included Rasch methods, Spearman- correlations, and logistic regression, including covariates age, sex, and clinic type.RESULTS:
Psychometric properties were strong, including item difficulty and reliability. Internal consistency was good for new measures (rCo-α = 0.68). The mean TRH score was 4.2 (±2.9; range: 0–14), and mean GRTR was 11.1 (±4.4; range: 1–25). TRH scores were positively correlated with GRTR scores (rs = 0.66; high), female sex, private practice, and child age (P < .001). The relationship remained significant controlling for these covariates (P < .05). The mean TRH administration time was 5:25 minutes (±0:55; range: 3:34–8:32). Parent, child, and provider impressions of TRH were favorable.CONCLUSIONS:
TRH is a feasible, valid, and enjoyable means by which emergent literacy skills in 3- and 4-year-old children can be directly assessed during primary care.
Ensuring children are fasting for blood draws is necessary to diagnose abnormalities in glucose homeostasis. We sought to determine if serum free fatty acid (FFA) concentrations might be a useful marker to differentiate the fed and fasted states among children.METHODS:
A total of 442 inpatient (fasting) and 323 (postglucose load) oral glucose tolerance test samples of glucose, insulin, and FFA from children (age 5–18 years) who had healthy weight, overweight, or obesity were examined by receiver operating characteristic (ROC) curve analysis to identify a cut point for nonfasting. In a cross-sectional study, we compared mean FFA and percentage of FFA values below this cut point as a function of inpatient (n = 442) versus outpatient (n = 442) setting.RESULTS:
The area under the curve of FFA was significantly better (P values < .001) than the area under the curve of glucose or insulin for identifying nonfasting. FFA <287 mEq/mL had 99.0% sensitivity and 98.0% specificity for nonfasting. Mean FFA was lower in outpatients than inpatients (P < .001); only 1.6% inpatient but 9.7% outpatient FFA values were consistent with nonfasting (P < .001).CONCLUSIONS:
Clinicians cannot assume that pediatric patients are adequately fasted on arrival for fasting blood work. On the basis of having significantly lower outpatient than inpatient FFA values and more frequently suppressed FFA, children appeared less likely to be fasting at outpatient appointments. FFA value <287 mEq/mL was a sensitive and specific cutoff for nonfasting in children that may prove clinically useful.
One of the most common dilemmas faced by physicians and genetic counselors is the discovery of misattributed paternity. In this article, we present a case in which misattributed paternity was discovered as an incidental finding. Experts analyze the competing moral obligations that might dictate disclosure or nondisclosure.
Whether to resuscitate extremely premature infants (EPIs) is a clinically and ethically difficult decision to make. Indications and practices vary greatly across different countries and institutions, which suggests that resuscitation decisions may be influenced more by the attitudes of the individual treating physicians. Hence, gaining in-depth insight into physicians’ attitudes improves our understanding of decision-making regarding resuscitation of EPIs.OBJECTIVE:
To better understand physicians’ attitudes toward resuscitation of EPIs and factors that influence their attitudes through a systematic review of the empirical literature.DATA SOURCES:
Medline, Embase, Web of Science, and Scopus.STUDY SELECTION:
We selected English-language articles in which researchers report on empirical studies of physicians’ attitudes toward resuscitation of EPIs.DATA EXTRACTION:
The articles were repeatedly read, themes were identified, and data were tabulated, compared, and analyzed descriptively.RESULTS:
Thirty-four articles were included. In general, physicians were more willing to resuscitate, to accept parents’ resuscitation requests, and to refuse parents’ nonresuscitation requests as gestational age (GA) increased. However, attitudes vary greatly for infants at GA 23 to 24 weeks, known as the gray zone. Although GA is the primary factor that influences physicians’ attitudes, a complex interplay of patient- and non–patient-related factors also influences their attitudes.LIMITATIONS:
Analysis of English-only articles may limit generalizability of the results. In addition, authors of only 1 study used a qualitative approach, which may have led to a biased reductionist approach to understanding physicians’ attitudes.CONCLUSIONS:
Although correlations between GA and attitudes emerged, the results suggested a more complex interplay of factors influencing such attitudes.
Pregnancy, infancy, and toddlerhood are sensitive times in which families are particularly vulnerable to household food insecurity and when disparities in child obesity emerge. Understanding obesity-promoting infant-feeding beliefs, styles, and practices in the context of food insecurity could better inform both food insecurity and child obesity prevention interventions and policy guidelines.METHODS:
We performed purposive sampling of low-income Hispanic mothers (n = 100) with infants in the first 2 years of life, all of whom were participants in a randomized controlled trial of an early child obesity prevention intervention called the Starting Early Program. Bilingual English-Spanish interviewers conducted semistructured qualitative interviews, which were audio recorded, transcribed, and translated. By using the constant comparative method, transcripts were coded through an iterative process of textual analysis until thematic saturation was reached.RESULTS:
Three key themes emerged: (1) contributors to financial strain included difficulty meeting basic needs, job instability, and high vulnerability specific to pregnancy, infancy, and immigration status; (2) effects on infant feeding included decreased breastfeeding due to perceived poor maternal diet, high stress, and limiting of healthy foods; and (3) coping strategies included both home- and community-level strategies.CONCLUSIONS:
Stakeholders in programs and policies to prevent poverty-related disparities in child obesity should consider and address the broader context by which food insecurity is associated with contributing beliefs, styles, and practices. Potential strategies include addressing misconceptions about maternal diet and breast milk adequacy, stress management, building social support networks, and connecting to supplemental nutrition assistance programs.