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Associations Between Opioid Prescribing Patterns and Overdose Among Privately Insured Adolescents

Vie, 01/11/2019 - 09:01
OBJECTIVES:

Little is known about the risk for overdose after opioid prescription. We assessed associations between the type of opioid, quantity dispensed, daily dose, and risk for overdose among adolescents who were previously opioid naive.

METHODS:

Retrospective analysis of 1 146 412 privately insured adolescents ages 11 to 17 years in the United States captured in the Truven MarketScan commercial claims data set from January 2007 to September 2015. Opioid overdose was defined as any emergency department visit, inpatient hospitalization, or outpatient health care visit during which opioid overdose was diagnosed.

RESULTS:

Among our cohort, 725 participants (0.06%) experienced an opioid overdose, and the overall rate of overdose events was 28 events per 100 000 observed patient-years. Receiving ≥30 opioid tablets was associated with a 35% increased risk for overdose compared to receiving ≤18 tablets (hazard ratio [HR] = 1.35; 95% confidence interval: 1.05–1.73; P = .02). Daily prescribed opioid dose was not independently associated with an increased risk for overdose. Tramadol exposure was associated with a 2.67-fold increased risk for opioid overdose compared to receiving oxycodone (adjusted HR = 2.67; 95% confidence interval: 1.90–3.75; P < .0001). Adolescents with preexisting mental health conditions demonstrated increased risk for overdose, with HRs ranging from 1.65 (anxiety) to 3.09 (substance use disorders).

CONCLUSIONS:

One of 1600 (0.06%) previously opioid-naive adolescents who received a prescription for opioids experienced an opioid overdose a median of 1.75 years later that resulted in medical care. Preexisting mental health conditions, use of tramadol, and higher number of dispensed tablets (>30 vs <18) were associated with an increased risk of opioid overdose.

Congenital Heart Disease and Autism: A Case-Control Study

Vie, 01/11/2019 - 09:01
OBJECTIVES:

There has long been an association between congenital heart disease (CHD) and general neurodevelopmental delays. However, the association between CHD and autism spectrum disorders (AuSDs) is less well understood. Using administrative data, we sought to determine the association between CHD and AuSD and identify specific CHD lesions with higher odds of developing AuSD.

METHODS:

We performed a 1:3 case-control study of children enrolled in the US Military Health System from 2001 to 2013. Children with International Classification of Disease, Ninth Revision, Clinical Modification codes for AuSD were identified as cases and matched with controls on the basis of date of birth, sex, and enrollment time frame. Each child’s records were reviewed for CHD lesions and associated procedures. Conditional logistic regression determined odds ratios (ORs) and 95% confidence intervals (CIs) for comparative associations.

RESULTS:

There were 8760 cases with AuSD and 26 280 controls included in the study. After adjustment for genetic syndrome, maternal age, gestational diabetes, short gestation, newborn epilepsy, birth asphyxia, and low birth weight, there were increased odds of AuSD in patients with CHD (OR 1.32; 95% CI 1.10–1.59). Specific lesions with significant OR included atrial septal defects (n = 82; OR 1.72; 95% CI 1.07–2.74) and ventricular septal defects (n = 193; OR 1.65; 95% CI 1.21–2.25).

CONCLUSIONS:

Children with CHD have increased odds of developing AuSD. Specific lesions associated with increased risk include atrial septal defects and ventricular septal defects. These findings will be useful for counseling parents of children with CHD.

A Test for More Accurate Diagnosis of Pulmonary Tuberculosis

Vie, 01/11/2019 - 09:01
OBJECTIVES:

Xpert Mycobacterium tuberculosis and rifampicin (MTB/RIF) Ultra assay has increasingly been used in adult tuberculosis diagnosis, but data relating to its diagnostic accuracy in children are lacking. Because a qualified sputum specimen is difficult to obtain in children, this study evaluated the diagnostic value of Ultra in childhood tuberculosis using bronchoalveolar lavage fluid.

METHODS:

The accuracy of Ultra was calculated by using bacteriologic results and clinical evidence as reference standards. Concordance between Ultra and Xpert MTB/RIF assays was assessed by using coefficients.

RESULTS:

In total, 93 children with pulmonary tuberculosis and 128 children with respiratory tract infections were enrolled. The sensitivity of Ultra, in all pulmonary tuberculosis cases and in bacteriologically confirmed tuberculosis cases, was 70% and 91%, respectively. Ultra could detect Mycobacterium tuberculosis in 58% of cases with negative culture or acid-fast–staining results. The specificity of Ultra was 98%. There was no significant difference in sensitivity between samples with a volume ≤1 and >1 mL (66% vs 73%; P = .50; odds ratio [OR] = 0.71). Among 164 children for which Ultra and Xpert were simultaneously performed, the sensitivity was 80% and 67%, respectively, indicating good agreement ( = 0.84). An additional 6 children were identified as Ultra-positive but Xpert-negative. The positive rate decreased from 93% to 63% after 1 month (P = .01; OR = 0.12) and to 71% after 2 months (P = .03; OR = 0.18) of antituberculosis treatment.

CONCLUSIONS:

Ultra using bronchoalveolar lavage fluid has good sensitivity compared with bacteriologic tests and adds clinical value by assisting the rapid and accurate diagnosis of pulmonary tuberculosis in children.

A Child With Pancytopenia and Optic Disc Swelling

Vie, 01/11/2019 - 09:01

A previously healthy 16-year-old adolescent boy presented with pallor, blurry vision, fatigue, and dyspnea on exertion. Physical examination demonstrated hypertension and bilateral optic nerve swelling. Laboratory testing revealed pancytopenia. Pediatric hematology, ophthalmology and neurology were consulted and a life-threatening diagnosis was made.

Dietary Interventions for Autism Spectrum Disorder: A Meta-analysis

Vie, 01/11/2019 - 09:01
CONTEXT:

Dietary interventions such as restrictive diets or supplements are common treatments for young people with autism spectrum disorder (ASD). Evidence for the efficacy of these interventions is still controversial.

OBJECTIVE:

To assess the efficacy of specific dietary interventions on symptoms, functions, and clinical domains in subjects with ASD by using a meta-analytic approach.

DATA SOURCES:

Ovid Medline, PsycINFO, Embase databases.

STUDY SELECTION:

We selected placebo-controlled, double-blind, randomized clinical trials assessing the efficacy of dietary interventions in ASD published from database inception through September 2017.

DATA EXTRACTION:

Outcome variables were subsumed under 4 clinical domains and 17 symptoms and/or functions groups. Hedges’ adjusted g values were used as estimates of the effect size of each dietary intervention relative to placebo.

RESULTS:

In this meta-analysis, we examined 27 double-blind, randomized clinical trials, including 1028 patients with ASD: 542 in the intervention arms and 486 in the placebo arms. Participant-weighted average age was 7.1 years. Participant-weighted average intervention duration was 10.6 weeks. Dietary supplementation (including omega-3, vitamin supplementation, and/or other supplementation), omega-3 supplementation, and vitamin supplementation were more efficacious than the placebo at improving several symptoms, functions, and clinical domains. Effect sizes were small (mean Hedges’ g for significant analyses was 0.31), with low statistical heterogeneity and low risk of publication bias.

LIMITATIONS:

Methodologic heterogeneity among the studies in terms of the intervention, clinical measures and outcomes, and sample characteristics.

CONCLUSIONS:

This meta-analysis does not support nonspecific dietary interventions as treatment of ASD but suggests a potential role for some specific dietary interventions in the management of some symptoms, functions, and clinical domains in patients with ASD.

Mental Health Conditions and Hyperthyroidism

Vie, 01/11/2019 - 09:01
OBJECTIVES:

To evaluate the proportion of pediatric patients with concurrent diagnoses of hyperthyroidism and mental health conditions (MHCs) by using the Military Health System database. We hypothesized that the prevalence of mental health disorders would be higher in patients with hyperthyroidism compared with in the nonhyperthyroid population.

METHODS:

The prevalence of hyperthyroidism and MHCs was calculated by using data extracted from the Military Health System Data Repository on military beneficiaries between 10 and 18 years old who were eligible to receive care for at least 1 month during fiscal years 2008 through 2016. Prevalence ratios were used to compare MHC diagnoses in those with versus without a diagnosis of hyperthyroidism.

RESULTS:

There were 1894 female patients and 585 male patients diagnosed with hyperthyroidism during the study period. Prevalence ratios for MHCs in those with versus without hyperthyroidism ranged from 1.7 (attention-deficit/hyperactivity disorder [ADHD]) to 4.9 (bipolar disorder). Strikingly, suicidality was nearly 5 times more likely in patients diagnosed with hyperthyroidism than in patients who were never diagnosed with hyperthyroidism. For each of the MHCs examined, with the exception of suicidality, the MHC diagnosis was more commonly made before the diagnosis of hyperthyroidism, with the highest proportion of patients being diagnosed with ADHD before receiving a diagnosis of hyperthyroidism (68.3%).

CONCLUSIONS:

There is a clear association between hyperthyroidism and each of the following MHCs: ADHD, adjustment disorder, anxiety, bipolar disorder, depression, and suicidality. This study highlights the need to consider this association when evaluating patients with overlapping symptoms and for effective mental health screening tools and resources for clinicians.

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