From the publishers of

The New England Journal of Medicine

based on estimated weight, and using error-proofing technology (e.g., bar coding, computer order entry).

July 2008

Vol. 7 No. 7

NEWS IN CONTEXT

First Do No Harm Avoiding Medication Errors in Children

Conventional and Alternative Treatments Might Not Mix Well

omplementary and alternative medicine treatments are used widely in children, often in conjunction with conventional treatments. Researchers at a pediatric emergency department in Toronto interviewed 1804 families of children (age range, 018 years) about use of natural health products (NHPs; e.g., vitamins, herbal remedies, homeopathic medicine, probiotics) and conventional prescribed and over-the-counter (OTC) medications. The researchers identified potential interactions between NHPs and conventional drugs or other NHPs based on a search of three online drug information databases. During the 3 months before the interview, 44% of children used prescribed medications, 26% used OTC medications, and 45% used NHPs or visited complementary providers. Concurrent

Comment:
These recommendations are relevant for both inpatient and outpatient settings. Among hospital therapies, chemotherapy and total parenteral nutrition pose particular challenges because of the complexity of the protocols. Not mentioned, but another important source of errors is illegible handwriting. All prescriptions should be printed by hand or computer.
F. Bruder Stapleton, MD Takata GS et al. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US childrens hospitals. Pediatrics 2008 Apr; 121:e927.

edication errors are among the most common causes of adverse events in hospitalized patients. The Joint Commission on Accreditation of Healthcare Organizations recently issued a Sentinel Event Alert (http:// tinyurl.com/3sge52) about the high risk for medication errors in children. Data reported in the April issue of Pediatrics demonstrated a mean of 11 adverse drug events per 100 randomly selected patients from 12 childrens hospitals, 16 events per 1000 patient-days, and 1 event per 1000 medication doses. Twenty-two percent of the errors were classified as preventable, and 2.5% led to patient harm. Medication errors are especially problematic in children for a variety of reasons, including that many drugs are formulated for adults, many healthcare settings do not have reference materials or safeguards designed specifically for children, children have developmental differences in metabolization and excretion of drugs, proper dosing for children often requires additional calculation and fractional dosing with decimal points, and children might not be able to communicate adverse effects. Recommendations from the Joint Commission to prevent pediatric medication errors include standardizing protocols for pharmacy ordering and timing of medications, ensuring equivalent home and hospital dosing of medications, using oral syringes for oral medications to avoid inadvertent intravenous administration, weighing patients in kilograms only, avoiding administering drugs

TA B L E O F C O N T E N T S
News in Context: First Do No Harm Avoiding Medication Errors in Children .......... 49 Conventional and Alternative Treatments Might Not Mix Well ........ 49 Needle-Free Delivery of Lidocaine ........ 50 Sleep Duration and Risk for Overweight in Preschoolers ........ 50 Corticosteroids in Children with Bacterial Meningitis: The Debate Continues ........................51 Congenital Head and Neck Asymmetry Is Common and Often Unrecognized ....................51 Klinefelter Syndrome Revisited ............. 52 Info on Suicide: Whats Available on the Net? ............. 52 Postnatal Depression in Fathers Has Adverse Effects on Their Childrens Mental Health ................... 52 Congenital Hearing Loss and CMV Infection ................................... 53 Does Supplemental Oxygen Keep Infants with Bronchiolitis in the Hospital? ..... 53 Hypothermia for Head Trauma in Children ......................................... 53 Autism Screening Is Important in Children Who Were Extremely Premature at Birth ............................. 54 Practice Watch: Assessing Skeletal Health in Children and Adolescents ................................. 54 News in Context: Is Infant Formula Too Sweet? ............. 55 We Worry About Jaundice in Young Infants, but Maltreatment Is a Bigger Problem .................................. 55 Annual Review of Vital Statistics ........... 56

Journal Watch (and its design) is a registered trademark of the Massachusetts Medical Society.
An editorially independent literature-surveillance newsletter summarizing articles from major medical journals. 2008 Massachusetts Medical Society. All rights reserved. Disclosure information about our authors can be found at http://pediatrics.jwatch.org/misc/board_disclosures.dtl

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JOURNAL WATCH PEDIATRICS AND ADOLESCENT MEDICINE

EDITOR-IN-CHIEF

Volume 7

Number 7

F. Bruder Stapleton, MD
Ford/Morgan Professor and Chair, Department of Pediatrics, University of Washington School of Medicine Chief Academic Officer, Childrens Hospital and Medical Center, Seattle
EXECUTIVE EDITOR

Lyn Whinston-Perry
Massachusetts Medical Society
A S S O C I AT E E D I T O R S

Howard Bauchner, MD
Guideline Watch Editor Professor of Pediatrics and Public Health, Director, Division of General Pediatrics, Boston University School of Medicine, Boston Medical Center

Robin Drucker, MD
Chief, Department of Pediatrics, Palo Alto Medical Foundation, Palo Alto

Judith G. Hall, OC, MD

Professor of Pediatrics and Medical Genetics, University of British Columbia, Vancouver, B.C., Canada

conventional drug and NHP use was reported in 20%, and use of more than one NHP was reported in 15%. Potential drugNHP or NHPNHP interactions were identified in 16% of children. The most commonly used combinations of drugs and NHPs that could have potential interactions were vitamins with acetaminophen, ibuprofen, or steroids. The most commonly used combinations of NHPs that could have potential interactions were vitamins in conjunction with aloe vera, chamomile, echinacea, or ginger. Potential drugNHP interactions primarily involved altered absorption of one or more components. Potential NHPNHP interactions primarily involved pharmacodynamic effects that increased the risk for bleeding. The authors did not examine actual adverse events from these interactions.

Alain Joffe, MD, MPH, FAAP

Director, Student Health and Wellness Center, Johns Hopkins University, Associate Professor of Pediatrics, Johns Hopkins School of Medicine, Baltimore

Comment:
This study shows a noteworthy frequency of potential interactions between NHPs and conventional drugs or other NHPs, and this frequency could represent a low estimate from under reporting. Pediatricians must take careful histories and have knowledge of potential interactions. Although many interactions noted in this study are theoretical, pediatricians should investigate their patients use of medications and NHPs, including vitamins and OTC medications, to anticipate possible adverse clinical situations. The authors advise that accessible, evidencebased interaction alert databases (like those for conventional medications) are needed for complementary treatments so that pediatricians can have informed riskbenefit discussions with their patients and their patients families. Cornelius W. Van Niel, MD
Goldman RD et al. Potential interactions of drugnatural health products and natural health productsnatural health products among children. J Pediatr 2008 Apr; 152:521.

William P. Kanto, Jr., MD

Professor and Chairman, Department of Pediatrics; Medical Director, Childrens Medical Center, Medical College of Georgia, Augusta

undergoing venipuncture or intravenous cannulation received treatment with either a needle-free powder lidocaine delivery system (helium gas releases lidocaine from a cylinder into the epidermis) or a shamplacebodelivery system 1 to 3 minutes before the procedure. The success rate of venous procedures on the first attempt was about 96% in both the treatment and sham groups. Mean pain scores immediately after administration, as assessed by patients on a pain-rating scale using facial expressions (0 = no hurt to 5 = hurts worst), were low in both the treatment and sham groups (0.54 vs. 0.24). After the procedure, mean pain scores were significantly lower in the treatment group on the faces scale (1.77 vs. 2.10) and on a visual analog scale assessed by children aged 8 and older and by parents. The number of treatment-related adverse events was similar in the two groups (12 and 9, respectively) and included three events of moderate severity in the treatment group (bruising, cellulitis, and contusion).

Comment:
This needle-free delivery system holds promise as a pain-reducing intervention in children undergoing various procedures. The device seems to work quickly, to reduce pain, and to not affect the success rate of venous procedures. Howard Bauchner, MD
Zempsky WT et al. Needle-free powder lidocaine delivery system provides rapid effective analgesia for venipuncture or cannulation pain in children: Randomized, double-blind Comparison of Venipuncture and Venous Cannulation Pain After Fast-Onset Needle-Free Powder Lidocaine or Placebo Treatment trial. Pediatrics 2008 May; 121:979.

Martin T. Stein, MD
Professor of Pediatrics, University of California, San Diego; Childrens Hospital, San Diego

Cornelius W. Van Niel, MD

Pediatrician, Sea Mar Community Health Centers; Clinical Assistant Professor, Department of Pediatrics, University of Washington School of Medicine, Seattle

Peggy Sue Weintrub, MD

Clinical Professor, Chief, Pediatric Infectious Diseases, University of California, San Francisco
M A S S AC H U S E T T S M E D I C A L S O C I E T Y

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Vice President for Publishing Alberta L. Fitzpatrick, Publisher Matthew ORourke, Director, Editorial Operations and Development Art Wilschek, Christine Miller, Lew Wetzel, Advertising Sales William Paige, Publishing Services Bette Clancy, Customer Service Published 12 times a year. Subscription rates U.S.: $99 per year; Residents/Students/Nurses/PAs: $65; Institutions: $179. Canada: C$127.62 per year; Residents/Students/Nurses/PAs: C$89.52; Institutions: C$224.76. Intl: US$123 per year; Physicians in Training/Nurses/PAs: US$69; Institutions: US$179. Prices do not include GST, HST, or VAT. Remittance to: Journal Watch Pediatrics and Adolescent Medicine, P.O. Box 9085, Waltham, MA 02454-9085 or call 1-800-843-6356. E-mail inquiries or comments via the Contact Us page at www.jwatch.org. Information on our conflict-ofinterest policy can be found at www.jwatch.org/ misc/conflict.dtl

Sleep Duration and Risk for Overweight in Preschoolers

everal studies in adults have linked sleep deprivation with weight gain, obesity, and coronary artery disease. Lack of sleep causes decreases in the hormone leptin and increases in the hormone ghrelin, and this combination might cause increased hunger beyond a persons energy expenditure. To examine whether sleep duration in infancy and early childhood correlates with adiposity at age 3 years, researchers

Needle-Free Delivery of Lidocaine

arious options are available for local anesthesia prior to venipuncture, but onset of action often is slow. In an industry-supported, multicenter, randomized trial, 579 hospitalized children (age range, 318 years) who were

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conducted a longitudinal study in 915 infants (defined as ages 6 months to 2 years). Mothers reported their childrens total daily sleep duration (naps and nighttime sleep) at ages 6 months, 1 year, and 2 years and hours of active play and television watching at 2 years. Childrens weight, height, and skinfold thickness were measured at ages 6 months and 3 years. Overall, only 9% of children were overweight (BMI >95th percentile for age and sex) at age 3 years. However, the proportion of children who were overweight at age 3 years was significantly higher among those who slept fewer than 12 hours per day on average than among those who slept 12 or more hours (12% vs. 7%). Average sleep duration of fewer than 12 hours per day was significantly associated with higher BMI z scores and higher subscapular and triceps skinfold thicknesses (after adjustment for maternal education, income, prepregnancy BMI, marital status, and prenatal smoking; breast-feeding duration; and childs ethnicity, birth weight, weight-for-length z score at 6 months, average daily television time, and average daily active time). Further, children who slept fewer than 12 hours per day were more than twice as likely to be overweight at age 3 years as those who slept longer. Children who slept fewer than 12 hours and spent more than 2 hours per day watching television were nearly six times more likely to be overweight at age 3 years than those who slept 12 hours or more and watched fewer than 2 hours of television per day.

Corticosteroids in Children with Bacterial Meningitis: The Debate Continues

se of adjuvant corticosteroids for treatment of bacterial meningitis in children is controversial. The AAP guidelines state that in children older than 6 weeks, corticosteroids should be considered after weighing the potential benefits and risks. Results are conflicting from studies that have examined whether corticosteroids reduce mortality in children with bacterial meningitis. To further examine this issue, investigators analyzed data from the Pediatric Health Information System (representing 27 tertiary care childrens hospitals) for 2001 through 2006. Of 2780 children (age, <18 years) who were discharged with a diagnosis of bacterial meningitis, only 8.9% received adjuvant corticosteroids (mostly dexamethasone) during the first day of hospitalization; the percentage increased from 5.8% in 2001 to 12.2% in 2006. No statistically significant differences in mortality (overall rate, 4.2%), time to death, or length of stay were found between children who did and did not receive corticosteroids.

as administration of corticosteroids at any time during the first day of hospitalization. Previous studies have demonstrated the benefit of corticosteroids on morbidity in children with meningitis when corticosteroids were given before the first dose of antibiotics, and other studies have shown that when steroids are first given as early as 4 hours after the first antibiotic dose, the beneficial effect is negated. Therefore, the results should not change the current recommendation for corticosteroid use in children with bacterial meningitis. The risks associated with corticosteroids in children with bacterial meningitis are primarily theoretical and unproven, while the benefit of corticosteroids in reducing hearing loss in children with H. influenzae is evidence-based. Peggy Sue Weintrub, MD
Mongelluzzo J et al. Corticosteroids and mortality in children with bacterial meningitis. JAMA 2008 May 7; 299:2048.

Congenital Head and Neck Asymmetry Is Common and Often Unrecognized

Comment:
This study, which found no mortality benefit from corticosteroids in children with bacterial meningitis, is fraught with methodologic problems. The study used retrospective administrative data based on ICD-9 discharge diagnosis codes and included children younger than 6 months, and about 65% of children in the study did not have documentation of the three most common causes of bacterial meningitis (Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae). In addition, corticosteroid use was defined

Comment:
Many variables affect sleep duration in infants, including hours at day care, parents wanting to spend time with their children, co-sleeping, and frequent night waking. Parents often state: My baby is like me and doesnt need much sleep or If I put him to bed too early, I will never see him. These results can help support discussions with parents about the detrimental effects of inadequate sleep on childrens health. Robin Drucker, MD
Taveras EM et al. Short sleep duration in infancy and risk of childhood overweight. Arch Pediatr Adolesc Med 2008 Apr; 162:305.

he Back to Sleep campaign encourages the supine sleep position during infancy, but this practice might be associated with an increasing incidence of posterior cranial deformations. To examine the incidence of and characteristics associated with congenital cranial deformation, investigators prospectively examined neck range of motion and torticollis, plagiocephaly, and facial asymmetry (by photographic analysis) in 102 healthy newborns. Overall, 92% of babies were in the vertex position in utero, 73% were delivered vaginally, and 10% experienced birth trauma. Nearly all babies were described as active, although 36% were described

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JOURNAL WATCH PEDIATRICS AND ADOLESCENT MEDICINE sperm counts also have fallen during the same period. In the second study, researchers used a variety of neuropsychological studies to examine cognitive and motor development during childhood in 50 boys with Klinefelter syndrome. Overall, boys with Klinefelter syndrome were more likely to be left-handed than the general population and to have various motor difficulties and attention deficits (but without impulsivity).

Volume 7

Number 7

as stuck or in the same position during the third trimester. Seventy-three percent of newborns had at least one asymmetry (10% had more than one). Torticollis measuring more than 15 degrees difference in mobility between right and left sides was present in 16% of infants and was most common among babies described as stuck for longer than 6 weeks. Forty-two percent of infants had facial asymmetry, 62% had asymmetry of the head, and 13% had mandible asymmetry. Facial asymmetry was associated with second stage of labor longer than 60 minutes, forceps delivery, birth trauma, and larger birth size.

Comment:
Klinefelter syndrome is often noticed by pediatricians by chance because of small testes, relatively small penis, or lack of full masculinization at puberty. The specific combination of abnormal complex language processing, impaired attention, and poor motor skills can easily be missed as a sign of the syndrome. Clearly, these boys would benefit from early intervention and education support that addresses their learning problems and motor skills. The possibility of environmental interference with human male meiosis is worrisome and requires confirmation but is consistent with the recently observed decreases in sperm count. Judith G. Hall, OC, MD
Morris JK et al. Is the prevalence of Klinefelter syndrome increasing? Eur J Hum Genet 2008 Feb; 16:163. Ross JL et al. Cognitive and motor development during childhood in boys with Klinefelter syndrome. Am J Med Genet A 2008 Mar 15; 146:708.

sites); 43 discussed the pros and cons of different methods without encouraging the act (factual sites); 62 offered support or promoted suicide prevention; and 59 discouraged suicide. Twelve chat rooms involved discussions about suicide methods. The most common topranking sites across searches were prevention and antisuicide sites, prosuicide sites, and factual sites. However, about half of all listings, including nearly all factual information sites (e.g., Wikipedia), provided details about methods of suicide, such as speed, certainty of death, and likely amount of pain.

Comment:
Although antisuicide and prevention sites were among the most likely topranking listings, prosuicide sites were equally available. Factual sites might influence individuals by indirectly providing information about suicide methods. In addition to finding ways to limit access to prosuicide sites, increased accessibility to antisuicide and prevention sites during routine Internet searches is needed. Pediatricians need to counsel families of depressed teens about what is available on the Internet and how to openly discuss with their child the information that they might be viewing. Robin Drucker, MD
Biddle L et al. Suicide and the internet. BMJ 2008 Apr 12; 336:800.

Comment:
I had no idea that head and neck asymmetry was so common in newborns. With the important emphasis on the supine sleep position, infants with congenital asymmetries could be at increased risk for developing secondary posterior plagiocephaly. Therefore, early recognition of these normal variants is important so that interventions such as prone positioning during awake time or physical therapy can be implemented. F. Bruder Stapleton, MD
Stellwagen L et al. Torticollis, facial asymmetry and plagiocephaly in normal newborns. Arch Dis Child 2008 Apr 1; [e-pub ahead of print]. (http://dx.doi.org/ 10.1136/adc.2007.124123)

Klinefelter Syndrome Revisited

wo recent studies of Klinefelter syndrome (47XXY) are of interest to pediatricians. The first study examined the changing prevalence of the syndrome. In popu lation studies from the 1960s and 1970s, the three sex chromosome trisomies (XYY, XXY, and XXX) had similar prevalence, about 1 per 1000 same-sex births. Recently, increased prevalence has been noted for Klinefelter syndrome only. Now, researchers have examined its prevalence in live births using data from 16 studies and report an increase per 1000 male births from 1.09 in 1967 to 1.72 in 1988. According to the authors, the higher prevalence suggests that the rate of nondisjunction occurring at the first paternal meiotic division has increased during the last 30 to 40 years. They suspect the influence of an environmental factor because human

Info on Suicide: Whats Available on the Net?

Postnatal Depression in Fathers Has Adverse Effects on Their Childrens Mental Health

he Internet often is implicated as a possible cause or information source after highly publicized suicide-massacre tragedies. Previous studies have shown how suicide Web forums and suicide pacts have helped depressed individuals facilitate their own suicides. Investigators report the results of an Internet search that they conducted in May 2007 to see what information about suicide was available. The authors entered 12 broad terms based on the word suicide into the four most popular search engines (Google, Yahoo, MSN, and Ask). They compiled the 10 top-ranking sites for each term and search engine, yielding a total of 480 Web pages (hits), including 90 dedicated suicide sites: 45 encouraged, promoted, or facilitated suicide (prosuicide

any studies have established a link between postpartum depression in women and adverse effects on maternal health and subsequent child development. Does depression in fathers during the postnatal period have similar effects on a childs mental health? In a population-based cohort study from England, researchers followed 10,975 fathers and their children for 7 years. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess paternal depressive symptoms at several time points, and a standardized instrument was used to assess psychiatric disorders in the children at age 7 years. Eight weeks after children were born, 3% of the fathers had depressivesymptom scores considered significant on the EPDS. Children were significantly

July 2008

JOURNAL WATCH PEDIATRICS AND ADOLESCENT MEDICINE firmed hearing loss and CMV infection, 4 had clinical signs that suggested congenital infection, but the failed hearing test was the only manifestation of congenital CMV infection among the remaining 12 infants.

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more likely to have psychiatric disorders at age 7 years if their fathers had high depressive-symptom scores at 8 weeks after birth than if their fathers did not have depressive symptoms (rates of child psychiatric disorders, 12% vs. 6%). Paternal depressive symptoms at 8 weeks were most strongly associated with oppositional defiant and conduct disorders. Analyses controlled for maternal postpartum depression, fathers education levels, and fathers depressive symptoms at 21 months.

Comment:
This rather simple study might have important implications for clinicians. When newborns fail hearing screening tests, a repeat screen is recommended but sometimes is not completed until the infant is several weeks old. Because the diagnosis of congenital CMV infection can be made with certainty only during the first 2 to 3 weeks of life, clinicians should consider ordering a urine CMV culture before the infant is 3 weeks old. Whether or not to treat infants with congenital CMV infection remains controversial. Therefore, a positive culture would not be an indication for treatment with ganciclovir, but the result would help parents understand the etiology of any hearing loss. The importance of early diagnosis might increase as more data are available about the efficacy of treatment. Of note, nearly half of infants with CMV-related hearing loss pass the newborn hearing screen, but their hearing deteriorates afterward, and hearing loss shows up in later testing. Howard Bauchner, MD, and Peggy Sue Weintrub, MD
Stehel EK et al. Newborn hearing screening and detection of congenital cytomegalovirus infection. Pediatrics 2008 May; 121:970.

Comment:
These findings suggest an association between depressive symptoms in fathers during the postnatal period and externalizing disorders (oppositional defiant and conduct disorders) in their school-age children. The study should be interpreted cautiously because evaluation of depressive symptoms was based on a screening test only and not on diagnostic interviews for major depression. Pending further studies, this report reminds us to be sensitive to the mental health of fathers during a time of transition and vulnerability following the birth of a child. Martin T. Stein, MD
Ramchandani PG et al. Depression in men in the postnatal period and later child psychopathology: A population cohort study. J Am Acad Child Adolesc Psychiatry 2008 Apr; 47:390.

uous SpO2 monitoring and supplemental oxygen at SpO2 of <94% in room air and did not receive any unproven treatments (bronchodilators, corticosteroids, antibiotics). Respiratory syncytial virus infection was documented in 76%. Infants admitted to the pediatric ICU (PICU) were excluded. Overall, 22% of infants required oxygen at admission, 70% required supplemental oxygen (mean duration, 56 hours) during hospitalization, and 82% had feeding problems (mean duration, 27 hours) requiring nasogastric tube feedings (none required intravenous fluid). SpO2 levels at admission (mean, 94%) and at 6 hours did not correlate significantly with LOS. Duration of oxygen supplementation strongly correlated with LOS. The primary determinant of LOS was use of oxygen supplementation in 57% of infants (mean LOS, 94 hours) and feeding problems in 26% (mean LOS, 30 hours). The average time from resolution of feeding problems to resolution of oxygen requirement was 66 hours. No infant required PICU admission.

Comment:
Although this study is limited by its observational retrospective design, it is strengthened by the standardized treatment of patients. The findings suggest that use of oxygen supplementation usually determines LOS for infants with bronchiolitis when the supplementation threshold is <94% SpO2. However, the approach to supplementation used in this study differs from the AAP guideline for management of bronchiolitis: The AAP recommends intermittent instead of continuous SpO2 measurements and an oxygen supplementation threshold of <90% SpO2 instead of <94% SpO2. A similar study that adheres to the AAP guideline might find that supplemental oxygen treatment decreases LOS without adversely affecting patient outcomes. Cornelius W. Van Niel, MD
Unger S and Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics 2008 Mar; 121:470.

Congenital Hearing Loss and CMV Infection

ongenital cytomegalovirus (CMV) infection is associated with sensorineural hearing loss and is the leading nongenetic cause of hearing impairment in infants, but the majority of newborns infected with CMV do not have any clinical signs of CMV disease. To examine the incidence of CMV infection among infants with hearing loss, researchers reviewed the charts of 79,047 infants who were born at one hospital in Texas during a 5-year period in which urine cultures for CMV were performed in all newborns who did not pass hearing screening tests. Of 572 newborns who did not pass screening tests, 256 infants (0.3% of those screened) had hearing loss that was confirmed by subsequent testing. CMV infection was detected in 16 of these patients (6% of infants with hearing loss). Of the 16 infants with con-

Does Supplemental Oxygen Keep Infants with Bronchiolitis in the Hospital?

lthough the AAP Clinical Practice Guideline for management of bronchiolitis ( JW Pediatr Adolesc Med Feb 2007, p. 12, and Pediatrics 2006; 118:1774) does not recommend routine supplemental oxygen for infants and young children with bronchiolitis and pulse oxygen saturation (SpO2) values 90%, decisions to start and stop supplemental oxygen vary widely in practice. To examine the effect of supplemental oxygen on length of stay (LOS), Scottish investigators conducted a retrospective case study of 102 randomly selected infants (mean age, 24 weeks) who were admitted to a medical ward with acute viral bronchiolitis. Infants received standardized care with contin-

Hypothermia for Head Trauma in Children

oth animal studies and studies involving limited numbers of children suggest that hypothermia might improve

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JOURNAL WATCH PEDIATRICS AND ADOLESCENT MEDICINE

Hutchison JS et al. Hypothermia therapy after traumatic brain injury in children. N Engl J Med 2008 Jun 5; 358:2447.

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neurologic outcomes after head trauma. In an international trial, researchers randomized 225 children (age range, 117 years) with traumatic brain injury (Glasgow Coma Scale score 8) to receive either hypothermia therapy (esophageal temperature, 32.5C for 24 hours) initiated within 8 hours after injury or routine care (normothermia). At 6 months after discharge, an unfavorable outcome (severe disability, persistent vegetative state, or death) was more likely in the hypothermia group than in the normothermia group (31% vs. 22%; P=0.14). Mortality was greater in the hypothermia group than in the control group (21% vs. 12%; P=0.06).

Autism Screening Is Important in Children Who Were Extremely Premature at Birth

Comment:
Hypothermia, as used in this study, did not improve neurologic outcomes and possibly increased mortality in children with traumatic brain injury. Whether earlier or more-sustained hypothermia would be more effective is unclear. Note that hypothermia was also ineffective in a study conducted in adults with traumatic brain injury (N Engl J Med 2001; 344:556). Howard Bauchner, MD

opulation-based studies have identified prematurity and low birth weight as risk factors for later development of autism spectrum disorders. To examine this association, investigators in Boston prospectively followed a cohort of 91 extremely premature infants (gestational age, 2330 weeks) to age 2 years. At a mean corrected age of 22 months, infants were evaluated using the Modified Checklist for Autism in Toddlers (M-CHAT), the Child Behavior Checklist (CBCL), and the Vineland Adaptive Behavior Scale (VABS). Prenatal, birth, and neonatal ICU clinical data were collected, and brain MRI was performed during initial hospitalizations. Overall, 25% of children had positive screening results on the M-CHAT. Independent risk factors for a positive screen were lower birth weight and gestational

age, male sex, evidence of chorioamnionitis, and greater illness severity at birth. Abnormal MRI findings (particularly cerebellar hemorrhage) and acute maternal intra- or antepartum hemorrhage were significantly associated with positive screening tests. Abnormal M-CHAT scores were highly correlated with internalizing behavioral problems on the CBCL and with communication and socialization deficits on the VABS.

Comment:
The authors note the important fact that an abnormal M-CHAT result is only a positive screening test and that diagnostic testing for autism was not conducted in these children. In addition, the results of the M-CHAT when used as a screening test in this special population of premature children might differ from results in the general population. A high prevalence of developmental delays in this cohort could have contributed to the high prevalence of positive autism screening tests. The authors note, however, that positive M-CHAT screening results did not correlate with functional motor deficits on the VABS. Overall prevalence of autism spectrum dis-

PR AC TI CE

WATCH
Measurements in children with linear growth delay or maturational delay should be adjusted for absolute height or height age or compared to a sufficiently large reference data set of measurements from healthy children and adolescents to account for normal variations and include age-, gender-, and height-specific Z-scores. Therapeutic interventions should not be undertaken on the basis of a single DXA measurement. A minimum 6-month interval is recommended for monitoring disease process or response to a bone-active agent. The terms T-scores and osteopenia should not be used in pediatric DXA reports, and osteoporosis should not be used unless the patient has both low BMD/BMC and a clinically significant fracture history (e.g., a lower extremity long bone fracture, vertebral compression fractures, or 2 or more upper extremity long bone fractures). The ISCD prefers the terms low bone mineral content or low bone mineral density when Z-scores are less than or equal to 2.0, adjusted for age, sex, and body size. The radiologist who prepares the report should be able to detail the norms used to generate your patients results.
Alain Joffe, MD, MPH, FAAP The International Society for Clinical Densitometry. 2007 Pediatric Official Positions. Oct 2007. (http://www.iscd.org/Visitors/pdfs/ ISCD2007OfficialPositions-Pediatric.pdf)

Assessing Skeletal Health in Children and Adolescents

easurement of bone density is becoming increasingly common in pediatrics, but confusion persists about which areas to measure (hip, spine), what terminology to use (osteoporosis, osteopenia), how to report results (tor Z-scores), and what technique is best. To address these issues, the International Society for Clinical Densitometry (ISCD) conducted a series of Position Development Conferences in 2007 that provided international experts with the opportunity to make recommendations based on the current scientific literature. Highlights of the new standards for children and adolescents aged 5 to 19 include: Dual energy x-ray absorptiometry (abbreviated as DXA rather than DEXA) is the preferred method for assessing bone mineral content (BMC) and areal bone mineral density (BMD). Indications for DXA include prolonged amenorrhea, very low weight (BMI <18), and chronic use of oral steroids. The posterior anterior spine and total body less head (TBLH) are the most accurate and reproducible skeletal sites for performing BMD and BMC measurements. In contrast, the hip (total hip/proximal femur) is not a reliable site in growing children because of variability in skeletal development and lack of reproducible measurements at regions of interest.

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NEWS

IN

CO NTE X T
commissioned a professional tasting panel to taste eight formulas, Similac Organic was reported to be the sweetest (as sweet as grape juice or Country Time lemonade), whereas the other brands were likened to unsweetened apple juice.

Is Infant Formula Too Sweet?

ccording to the New York Times, Similac Organic infant formula represented 36% of all organic formula sales in 2007 its first full year on the market. Recently, however, the formula has come under scrutiny because it is sweetened with cane sugar (also known as sucrose). Added sugars in infant formulas help infants digest the protein from cows milk or soy. Since the 1950s, sucrose has been gradually replaced by lactose in infant formulas, but it still can be found in all major brands of lactose-free and soy formulas. The FDA says that sucrose is safe and that it doesnt regulate which type of sugar is used in formulas. Pediatricians worry that sucrose is more likely than other sugars to erode tooth enamel and that its sweeter taste will lead to overeating during the first year of life and a lifetime preference for sweeter foods, both of which can be predisposing factors to later childhood obesity. Some studies have shown that animals crave sucrose more than fructose and glucose. So why would Abbott Laboratories choose to use cane sugar in organic formula? Cost is the most likely reason, since lactose derived from organic milk is expensive. Others argue that once infants get used to the sweet taste, they might resist a switch to other brands. When the New York Times orders is now reported as high as 1 in 150 children; the recently published AAP statement on autism recommends use of the M-CHAT or other suitable screening tests in all children at ages 18 or 24 months ( JW Pediatr Adolesc Med Mar 2008, p. 20, and Pediatrics 2007; 120:1183). Despite the weaknesses of this study, autism screening for survivors of extreme prematurity and formal diagnostic testing in those with positive screening tests seem prudent. (For a summary of a study that suggested an association between newborn encephalopathy and autism, see JW Pediatr Adolesc Med Aug 2006, p. 62, and Dev Med Child Neurol 2006; 48:85.) Cornelius W. Van Niel, MD
Limperopoulos C et al. Positive screening for autism in ex-preterm infants: Prevalence and risk factors. Pediatrics 2008 Apr; 121:758.

Comment:
With the increase in childhood obesity, the importance of ingredients in infant food and formula increases. Excessive intake of high-fructose corn syrup has been linked with obesity, cardiovascular disease, and renal disease epidemics ( JW Pediatr Adolesc Med Feb 2008, p. 9, and Am J Clin Nutr 2007; 86:1174). All soy-based and lactose-free formulas are sweetened with both corn syrup solids and sucrose. In the European Union, use of sucrose in infant formula will be banned by the end of 2009. In the U.S., the FDA needs to regulate the amount and type of sweetener in infant formulas. Pediatricians must educate parents about reading food labels and understanding the types of sweeteners, proteins, and fats that are added to foods. Cane sugar sounds much more natural and healthy than it actually is sucrose, the sweetest of the sugars. Robin Drucker, MD
Moskin J. For an all-organic formula, baby, thats sweet. New York Times. May 19, 2008. (http://tinyurl.com/58v7nq)

We Worry About Jaundice in Young Infants, but Maltreatment Is a Bigger Problem

hild abuse is a major cause of morbidity and mortality in the pediatric population, and prevention requires an understanding of high-risk ages and circumstances. To examine the risk for

nonfatal maltreatment among infants, CDC investigators analyzed cases reported to the National Child Abuse and Neglect Data System. From October 2005 to September 2006, 905,000 cases of maltreatment were substantiated by child protective services. Of these, 91,278 were infants younger than 1 year who experienced nonfatal maltreatment (annual rate, 23.2/1000 population). Among maltreated infants (52% male), 44% were white, 25% were black, 19% were Latino, 1% were Native American, and 1% were Asian. About 40% of infants were younger than 1 month, and 84% of infants younger than 1 month were younger than 1 week. Neglect was the form of maltreatment in 66% of infants younger than 1 week. Most (60%) cases of maltreatment among infants younger than 1 week and younger than 1 month were reported by medical personnel. Only 32% of reports among infants younger than 1 year were made by medical personnel, indicating that most reports among infants younger than 1 year were made by law enforcement and social service personnel. The CDC editorial note suggests that the high concentration of neglect reports during the first week of life results from maternal and newborn drug testing.

Comment:
These numbers are chilling. Even if most cases of maltreatment that are identified during the first week of life result from referral for maternal and newborn drug testing, nearly 4000 (13%) maltreated infants younger than 1 week were victims of physical abuse. This form of abuse often results in shaken baby syndrome or head trauma, which can cause death or severe physical injury. Although hospitalbased parent education programs have been shown to reduce abuse, I am concerned that we are not focused enough on preventive measures. We place a great deal of emphasis on identifying infants at risk for hyperbilirubinemia during the initial hospitalization and within 48 to 72 hours of discharge. Maybe a similar focus is needed on counseling parents about abuse. The number of physically abused children is far in excess of the reported numbers of infants with kernicterus. William P. Kanto, Jr., MD
Centers for Disease Control and Prevention (CDC). Nonfatal maltreatment of infants United States, October 2005September 2006. MMWR Morb Mortal Wkly Rep 2008 Apr 4; 57:336.

Journal Watch Online CME Program Subscribers have 10 FREE exam credits
Can you answer the following question about the summary Reducing Teen Pregnancy (see summary online)? Which of the following best describes the results of a nationally representative survey of adolescents about the effects of sex education on sexual behavior? A. Neither abstinence-only nor comprehensive sex education affected adolescent reporting of a sexually transmitted infection diagnosis. B. Teens who received comprehensive sex education were 61% less likely than teens who did not receive sex education to report involvement in a pregnancy. C. Teens who received comprehensive sex education were marginally less likely than teens who did not receive sex education to have initiated sexual intercourse. D. All of the above.

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* Category: Pediatrics/Adolescent Medicine Exam Title: JW Pediatrics and Adolescent Medicine: Teen Pregnancy, Erythema, Pharmacotherapy Posted Date: Jun 10 2008
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Page 56

JOURNAL WATCH PEDIATRICS AND ADOLESCENT MEDICINE after a rise of more than 400% during the 1980s and 1990s. The rates of preterm birth (<37 weeks gestation), very preterm birth (<32 weeks gestation), low birth weight infants (<2500 g), and very low birth weight infants (<1500 g) continued to climb slightly in 2006 as they have since 1990. Rates in 2006 were 12.8%, 2.0%, 8.3%, and 1.5%, respectively. Infant mortality remained stable at 6.8/1000 live births and continues to lag behind rates in about 25 other countries. Neonatal mortality rate was 4.5/1000 live births, and postneonatal mortality rate was 2.3/1000. In 2005, life expectancy at birth was 80.8 years for white women, 76.5 for black women, 75.7 for white men, and 69.6 for black men. Among children and adolescents aged 1 to 19 years, accidents (42%) and assaults (11%) were the leading causes of death.

Volume 7

Number 7

Annual Review of Vital Statistics

hat does a recent snapshot of infant and child health in the U.S. look like? In 2006, the number of live births (4,265,996) increased by about 130,000 from 2005 and by about 200,000 from 2000. Teen pregnancy rate has been declining since 1990 (by almost 34%, from 60 to 42 births/1000 women aged 1519 years), but the rate increased slightly in 2006. The cesarean delivery rate reached a record high of 31% in 2006, representing almost a 50% increase since 1996. The twin birth rate has stabilized at 32 per 1000 total births since 2004 after an increase of 70% since 1980. The number of live births in twin deliveries has doubled since 1980. The rate of triplet and higher multiple births continues to decline (from 177/100,000 in 2004 to 162/100,000 in 2005). The decline started in 1999

Comment:
I always find this report fascinating. I am delighted that the birth rate is up thats good for pediatricians. The decline in teen pregnancy during the past 15 years is an important success story. Even slight increases in rates of very preterm and very low birth weight infants are concerning because of the health needs and neurocognitive development of these infants. That accidents and assaults remain the major killers of our children is sad, and the disparity in life expectancy remains an important ethical dilemma. Howard Bauchner, MD
Martin JA et al. Annual summary of vital statistics: 2006. Pediatrics 2008 Apr; 121:788.

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