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Prevalence and Trends of Developmental Disabilities among Children in the United States: 2009-2017

Mar, 01/10/2019 - 10:01
OBJECTIVES:

To study the national prevalence of 10 developmental disabilities in US children aged 3 to 17 years and explore changes over time by associated demographic and socioeconomic characteristics, using the National Health Interview Survey.

METHODS:

Data come from the 2009 to 2017 National Health Interview Survey, a nationally representative survey of the civilian noninstitutionalized population. Parents reported physician or other health care professional diagnoses of attention-deficit/hyperactivity disorder; autism spectrum disorder; blindness; cerebral palsy; moderate to profound hearing loss; learning disability; intellectual disability; seizures; stuttering or stammering; and other developmental delays. Weighted percentages for each of the selected developmental disabilities and any developmental disability were calculated and stratified by demographic and socioeconomic characteristics.

RESULTS:

From 2009 to 2011 and 2015 to 2017, there were overall significant increases in the prevalence of any developmental disability (16.2%–17.8%, P < .001), attention-deficit/hyperactivity disorder (8.5%–9.5%, P < .01), autism spectrum disorder (1.1%–2.5%, P < .001), and intellectual disability (0.9%–1.2%, P < .05), but a significant decrease for any other developmental delay (4.7%–4.1%, P < .05). The prevalence of any developmental disability increased among boys, older children, non-Hispanic white and Hispanic children, children with private insurance only, children with birth weight ≥2500 g, and children living in urban areas and with less-educated mothers.

CONCLUSIONS:

The prevalence of developmental disability among US children aged 3 to 17 years increased between 2009 and 2017. Changes by demographic and socioeconomic subgroups may be related to improvements in awareness and access to health care.

Food Insecurity, Health, and Development in Children Under Age Four Years

Mar, 01/10/2019 - 10:01
BACKGROUND AND OBJECTIVES:

Food insecurity and pediatric obesity affect young children. We examine how food insecurity relates to obesity, underweight, stunting, health, and development among children <4 years of age.

METHODS:

Caregivers of young children participated in a cross-sectional survey at medical centers in 5 US cities. Inclusion criteria were age of <48 months. Exclusion criteria were severely ill or injured and private health insurance. The Household Food Security Survey Module defined 3 exposure groups: food secure, household food insecure and child food secure, and household food insecure and child food insecure. Dependent measures were obesity (weight-age >90th percentile), underweight (weight-age <5th percentile), stunting (height/length-age <5th percentile), and caregiver-reported child health and developmental risk. Multivariable logistic regression analyses, adjusted for demographic confounders, maternal BMI, and food assistance program participation examined relations between exposure groups and dependent variables, with age-stratification: 0 to 12, 13 to 24, 25 to 36, and 37 to 48 months of age.

RESULTS:

Within this multiethnic sample (N = 28 184 children, 50% non-Hispanic African American, 34% Hispanic, 14% non-Hispanic white), 27% were household food insecure. With 1 exception at 25 to 36 months, neither household nor child food insecurity were associated with obesity, underweight, or stunting, but both were associated with increased odds of fair or poor health and developmental risk at multiple ages.

CONCLUSIONS:

Among children <4 years of age, food insecurity is associated with fair or poor health and developmental risk, not with anthropometry. Findings support American Academy of Pediatrics recommendations for food insecurity screening and referrals to help families cope with economic hardships and associated stressors.

Depression, Anxiety, and Emergency Department Use for Asthma

Mar, 01/10/2019 - 10:01
BACKGROUND AND OBJECTIVES:

Asthma is responsible for ~1.7 million emergency department (ED) visits annually in the United States. Studies in adults have shown that anxiety and depression are associated with increased asthma-related ED use. Our objective was to assess this association in pediatric patients with asthma.

METHODS:

We identified patients aged 6 to 21 years with asthma in the Massachusetts All-Payer Claims Database for 2014 to 2015 using International Classification of Diseases, Ninth and 10th Revision codes. We examined the association between the presence of anxiety, depression, or comorbid anxiety and depression and the rate of asthma-related ED visits per 100 child-years using bivariate and multivariable analyses with negative binomial regression.

RESULTS:

Of 65 342 patients with asthma, 24.7% had a diagnosis of anxiety, depression, or both (11.2% anxiety only, 5.8% depression only, and 7.7% both). The overall rate of asthma-related ED use was 17.1 ED visits per 100 child-years (95% confidence interval [CI]: 16.7–17.5). Controlling for age, sex, insurance type, and other chronic illness, patients with anxiety had a rate of 18.9 (95% CI: 17.0–20.8) ED visits per 100 child-years, patients with depression had a rate of 21.7 (95% CI: 18.3–25.0), and patients with both depression and anxiety had a rate of 27.6 (95% CI: 24.8–30.3). These rates were higher than those of patients who had no diagnosis of anxiety or depression (15.5 visits per 100 child-years; 95% CI: 14.5–16.4; P < .001).

CONCLUSIONS:

Children with asthma and anxiety or depression alone, or comorbid anxiety and depression, have higher rates of asthma-related ED use compared with those without either diagnosis.

Trends in Off-Label Drug Use in Ambulatory Settings: 2006-2015

Mar, 01/10/2019 - 10:01
BACKGROUND:

Off-label drug use in children is common and potentially harmful. In most previous off-label use research, authors studied hospitalized children, specific drug classes, or non-US settings. We characterized frequencies, trends, and reasons for off-label systemic drug orders for children in ambulatory US settings.

METHODS:

Using nationally representative surveys of office-based physicians (National Ambulatory Medical Care Surveys, 2006–2015), we studied off-label orders of systemic drugs for children age <18 based on US Food and Drug Administration–approved labeling for age, weight, and indication. We characterized the top classes and diagnoses with off-label orders and analyzed factors and trends of off-label orders using logistic regression.

RESULTS:

Physicians ordered ≥1 off-label systemic drug at 18.5% (95% confidence interval: 17.7%–19.3%) of visits, usually (74.6%) because of unapproved conditions. Off-label ordering was most common proportionally in neonates (83%) and in absolute terms among adolescents (322 orders out of 1000 visits). Off-label ordering was associated with female sex, subspecialists, polypharmacy, and chronic conditions. Rates and reasons for off-label orders varied considerably by age. Relative and absolute rates of off-label orders rose over time. Among common classes, off-label orders for antihistamines and several psychotropics increased over time, whereas off-label orders for several classes of antibiotics were stable or declined.

CONCLUSIONS:

US office-based physicians have ordered systemic drugs off label for children at increasing rates, most often for unapproved conditions, despite recent efforts to increase evidence and drug approvals for children. These findings can help inform education, research, and policies around effective, safe use of medications in children.

Rotavirus Epidemiology and Monovalent Rotavirus Vaccine Effectiveness in Australia: 2010-2017

Mar, 01/10/2019 - 10:01
BACKGROUND:

Rotavirus vaccine has been funded for infants under the Australian National Immunisation Program since 2007, with Rotarix vaccine used in New South Wales, Australia, from that time. In 2017, New South Wales experienced a large outbreak of rotavirus gastroenteritis. We examined epidemiology, genotypic profiles, and vaccine effectiveness (VE) among cases.

METHODS:

Laboratory-confirmed cases of rotavirus notified in New South Wales between January 1, 2010 and December 31, 2017 were analyzed. VE was estimated in children via a case-control analysis. Specimens from a sample of hospitalized case patients were genotyped and analyzed.

RESULTS:

In 2017, 2319 rotavirus cases were reported, representing a 3.1-fold increase on the 2016 notification rate. The highest rate was among children aged <2 years. For notified cases in 2017, 2-dose VE estimates were 88.4%, 83.7%, and 78.7% in those aged 6 to 11 months, 1 to 3 years, and 4 to 9 years, respectively. VE was significantly reduced from 89.5% within 1 year of vaccination to 77.0% at 5 to 10 years postvaccination. Equinelike G3P[8] (48%) and G8P[8] (23%) were identified as the most common genotypes in case patients aged ≥6 months.

CONCLUSIONS:

Rotarix is highly effective at preventing laboratory-confirmed rotavirus in Australia, especially in infants aged 6 to 11 months. Reduced VE in older age groups and over time suggests waning protection, possibly related to the absence of subclinical immune boosting from continuously circulating virus. G8 genotypes have not been common in Australia, and their emergence, along with equinelike G3P[8], may be related to vaccine-induced selective pressure; however, further strain-specific VE studies are needed.

Polysomnography and Treatment-Related Outcomes of Childhood Sleep Apnea

Mar, 01/10/2019 - 10:01
BACKGROUND:

Polysomnography is central to the diagnosis and management of childhood obstructive sleep apnea (OSA). However, it is not known whether the treatment-related outcomes of OSA are causally associated with its resolution or changes in severity as determined by polysomnography.

METHODS:

Polysomnographic, cognitive, behavioral, quality-of life, and health outcomes at baseline and at 7 months were obtained from the Childhood Adenotonsillectomy Trial, a randomized trial comparing the outcomes of early adenotonsillectomy to watchful waiting in children with OSA. We used causal mediation analysis to measure the changes in 18 outcomes independently attributable to polysomnographic resolution or changes in severity after adjusting for confounding variables.

RESULTS:

A total of 398 children aged 5 to 9 years were included. A total of 244 (61%) experienced resolution of OSA at follow-up. Polysomnographic resolution of the condition accounted for small but significant proportions of changes in symptoms (proportion mediated [95% confidence interval] 0.13 [0.07 to 0.21]; P < .001) and disease-specific quality of life (0.11 [0.04 to 0.20]; P = .004). Changes in polysomnographic severity similarly mediated symptom score (proportion mediated 0.18 [0.11 to 0.26]; P < .001) and disease-specific quality-of-life outcomes (0.20 [0.10 to 0.31]; P = .004). Importantly, significant mediation effects were not identified for any of the other 16 outcomes. No significant interactions were observed between the trial arms.

CONCLUSIONS:

The majority of the treatment-related changes in outcomes of OSA in school-aged children are not causally attributable to polysomnographic resolution or changes in its severity. These results underscore the limited utility of polysomnographic thresholds in the management of childhood OSA.

Successful Medical Management of Life-threatening Hepatic Hemangioma in Neonates

Mar, 01/10/2019 - 10:01

Hepatic hemangioma (HH) is a common asymptomatic, self-limiting benign vascular tumor of the liver in neonates. Although complicated HHs are rare, they have significant risks of morbidity and mortality, especially during the perinatal period. Because of the high risks of complications from surgical interventions, there is an unmet need for effective medical therapy. We report 2 neonates with life-threatening HH who were evaluated for a liver transplant before being treated successfully with combined medical therapy, which included sirolimus, corticosteroids, and propranolol.

Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in Pediatric Practice

Mar, 01/10/2019 - 10:01

Diagnostic point-of-care ultrasound (POCUS) is a growing field across all disciplines of pediatric practice. Machine accessibility and portability will only continue to grow, thus increasing exposure to this technology for both providers and patients. Individuals seeking training in POCUS should first identify their scope of practice to determine appropriate applications within their clinical setting, a few of which are discussed within this article. Efforts to build standardized POCUS infrastructure within specialties and institutions are ongoing with the goal of improving patient care and outcomes.

HPV Vaccine Delivery Practices by Primary Care Physicians

Mar, 01/10/2019 - 10:01
BACKGROUND AND OBJECTIVES:

To examine, among pediatricians and family physicians (FPs) (1) human papillomavirus (HPV) vaccine delivery practices, (2) delivery experiences, and (3) attitudes regarding new 2-dose HPV vaccination schedules.

METHODS:

We surveyed nationally representative networks of pediatricians and FPs by Internet or mail from July 2018 to September 2018. Multivariable regression was used to assess factors associated with refusal or deferral rates of ≥50% among 11- to 12-year-old patients.

RESULTS:

The response rate was 65% (302 pediatricians and 228 FPs included). Pediatricians who strongly recommended the HPV vaccine ranged from 99% for patients ≥15 years old (female) to 83% for those 11 to 12 years old (male); FPs ranged from 90% for patients ≥15 years old (female) to 66% for those 11 to 12 years old (male) (P < .0001 between specialties). Sixty-five percent of pediatricians and 42% of FPs always or almost always used presumptive style when discussing the HPV vaccine (P < .0001). Overall, 40% used standing orders and 42% had electronic alerts. Among pediatricians, the proportion reporting a refusal or deferral rate ≥50% was 19% for female patients and 23% for male patients 11 to 12 years old; FPs reported 27% and 36%, respectively. In the multivariable regression (both sexes), refusal or deferral was associated with physicians not strongly recommending the HPV vaccine to 11- to 12-year-old patients, not using a presumptive style, perceiving less resistance when introducing the HPV vaccine to a 13-year-old patient versus an 11- or 12-year-old patient, and anticipating an uncomfortable conversation when recommending the HPV vaccine to an 11- or 12-year-old patient. Eighty-nine percent of pediatricians and 79% of FPs reported that more adolescents <15 years old are completing the HPV series now that only 2 doses are recommended.

CONCLUSIONS:

Although most physicians strongly recommend the HPV vaccine to 11- to 12-year-old patients, our data reveal areas for improvement in recommendation and delivery methods. Most physicians perceive that the 2-dose schedule is resulting in higher HPV completion rates.

Congenital Syphilis Misdiagnosed as Suspected Nonaccidental Trauma

Mar, 01/10/2019 - 10:01

Congenital syphilis (CS) is a preventable infection, yet the incidence has surged to the highest rates in 20 years. Because 50% of live-born infants with CS are asymptomatic at birth, there is an increasing likelihood that pediatric providers will encounter older infants whose diagnoses were missed at birth, emphasizing the importance of timely prenatal screening and treatment. We present one such case of an infant admitted twice at 3 and 4 months of age with long bone fractures and suspected nonaccidental trauma. On her second presentation, several additional symptoms prompted evaluation for and eventual diagnosis of CS. In this case, it is demonstrated that an isolated long bone fracture can be a first presentation of CS, with other classic findings possibly appearing later. Pediatric providers should be familiar with the varied presentations of CS in older children, including the radiographic findings that we describe. The rising rates of CS reveal deficiencies in our current strategy to prevent CS and, thus, we recommend reconsideration of universal syphilis screening in the third trimester and at delivery, with timely treatment to prevent CS during pregnancy.

Screening Children for Social Determinants of Health: A Systematic Review

Mar, 01/10/2019 - 10:01
CONTEXT:

Screening children for social determinants of health (SDOHs) has gained attention in recent years, but there is a deficit in understanding the present state of the science.

OBJECTIVE:

To systematically review SDOH screening tools used with children, examine their psychometric properties, and evaluate how they detect early indicators of risk and inform care.

DATA SOURCES:

Comprehensive electronic search of PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection.

STUDY SELECTION:

Studies in which a tool that screened children for multiple SDOHs (defined according to Healthy People 2020) was developed, tested, and/or employed.

DATA EXTRACTION:

Extraction domains included study characteristics, screening tool characteristics, SDOHs screened, and follow-up procedures.

RESULTS:

The search returned 6274 studies. We retained 17 studies encompassing 11 screeners. Study samples were diverse with respect to biological sex and race and/or ethnicity. Screening was primarily conducted in clinical settings with a parent or caregiver being the primary informant for all screeners. Psychometric properties were assessed for only 3 screeners. The most common SDOH domains screened included the family context and economic stability. Authors of the majority of studies described referrals and/or interventions that followed screening to address identified SDOHs.

LIMITATIONS:

Following the Healthy People 2020 SDOH definition may have excluded articles that other definitions would have captured.

CONCLUSIONS:

The extent to which SDOH screening accurately assessed a child’s SDOHs was largely unevaluated. Authors of future research should also evaluate if referrals and interventions after the screening effectively address SDOHs and improve child well-being.

Mycoplasma pneumoniae Carriage With De Novo Macrolide-Resistance and Breakthrough Pneumonia

Mar, 01/10/2019 - 10:01

Mycoplasma pneumoniae pneumonia is prevalent in children and can be followed by upper airway carriage for months. Treatment of M pneumoniae pneumonia with macrolides is widespread and can lead to the development of macrolide resistance. The clinical consequences of chronic M pneumoniae carriage are unknown. In this article, we describe a child with acute lymphoblastic leukemia who developed macrolide-susceptible M pneumoniae pneumonia confirmed by nasopharyngeal secretions polymerase chain reaction and culture with good response to azithromycin. Five months later, the patient developed another M pneumoniae pneumonia that was diagnosed with positive macrolide-resistant M pneumoniae polymerase chain reaction and culture from the bronchoalveolar lavage. The child responded well to fluoroquinolones and eventually was discharged from the hospital. The M pneumoniae recovered from the second pneumonia is a novel strain and is genetically identical to the M pneumoniae that caused the first pneumonia, apart from the macrolide-resistance 23S ribosomal RNA gene. Both isolates are identical in both P1 (subtype 2 with a novel variant, 2bv) and multiple-locus variable number tandem repeat analysis type (53662). This is indicative of chronic M pneumoniae carriage with de novo macrolide-resistance mutation and subsequent breakthrough pneumonia that is reported for the first time here. Children with immunosuppression may be at increased risk of life-threatening macrolide-resistant pneumonia after M pneumoniae carriage. Further studies are required to evaluate the impact of this phenomenon. This will then guide strategies to limit the associated morbidity, such as testing for macrolide resistance, treatment of M pneumoniae pneumonia in high-risk children with bactericidal antibiotics (such as fluoroquinolones), and possibly eradication protocols of M pneumoniae carriage to prevent subsequent life-threatening infections.

ADHD Diagnosis and Treatment Guidelines: A Historical Perspective

Mar, 01/10/2019 - 10:01

Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. The observance of specific behaviors in multiple settings have remained the most successful method for diagnosing the condition, and although there are differences in specific areas of the brain, and a high heritability estimate (~76%), they are not diagnostically specific. Medications, and particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. Both medication and behavioral interventions are symptomatic treatments. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. Improved communication between patients and their families, primary and mental health providers, and school personnel is necessary for effective ADHD treatment. Further enhancement of electronic systems to facilitate family, school, and provider communication can improve monitoring of ADHD symptoms and functional performance. The American Academy of Pediatrics ADHD guidelines were initially developed to help primary care clinicians address the needs of their patients with ADHD and were further refined with the second revision in 2019.

The 2019 Joseph W. St. Geme, Jr Leadership Award Address: Ubuntu: The Power of Social Connections

Mar, 01/10/2019 - 10:01

The following is an address given by the author in receipt of the Joseph W. St. Geme, Jr Leadership Award, presented by the Federation of Pediatric Organizations at the Pediatric Academic Societies Meeting in Baltimore, Maryland, on April 27, 2019.

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