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1.  Predictors of Early Adult Outcomes in Pediatric-Onset Obsessive-Compulsive Disorder 
Pediatrics  2009;124(4):1085-1093.
The aim of this study was to determine the childhood clinical predictors of early adult outcomes in pediatric-onset obsessive-compulsive disorder (OCD) and to assess whether dimensional subtypes of OCD and the presence of comorbid tic symptoms influence long-term outcomes.
We conducted a longitudinal cohort study in which 45 of 62 eligible children with OCD were reassessed an average of 9 years later, in early adulthood. Main outcome measures included expert-rated, obsessive-compulsive (OC) symptom severity and time to remission of OC symptoms. Baseline clinical characteristics were evaluated in terms of their influence on OCD severity in adulthood and time to remission of OC symptoms.
Forty-four percent of subjects were determined to have subclinical OC symptoms at the follow-up evaluation. The absence of a comorbid tic disorder and the presence of prominent hoarding symptoms were associated with the persistence of OCD symptoms. Female gender, earlier age at childhood assessment, later age of OCD onset, more-severe childhood OCD symptoms, and comorbid oppositional defiant disorder also were associated with persistence of OCD symptoms into adulthood.
These results confirm that a significant proportion of treated children with OCD experience remission by adulthood. The presence of comorbid tics heralds a positive outcome, whereas primary hoarding symptoms are associated with persistent OCD.
PMCID: PMC3974608  PMID: 19786445
obsessive-compulsive disorder; longitudinal study; compulsive hoarding; tic disorder
2.  Low 25-Hydroxyvitamin D Levels in Adolescents: Race, Season, Adiposity, Physical Activity, and Fitness 
Pediatrics  2010;125(6):1104-1111.
The objectives were to characterize the vitamin D status of black and white adolescents residing in the southeastern United States (latitude: 33°N) and to investigate relationships with adiposity.
Plasma 25-hydroxyvitamin D levels were measured with liquid chromatography-tandem mass spectroscopy for 559 adolescents 14 to 18 years of age (45% black and 49% female). Fat tissues, physical activity, and cardiovascular fitness also were measured.
The overall prevalences of vitamin D insufficiency (<75nmol/L) and deficiency (≤50 nmol/L) were 56.4% and 28.8%, respectively. Black versus white subjects had significantly lower plasma 25-hydroxyvitamin D levels in every season (winter, 35.9±2.5 vs 77.4±2.7 nmol/L; spring, 46.4±3.5 vs 101.3±3.5 nmol/L; summer, 50.7±4.0 vs 104.3±4.0 nmol/L; autumn, 54.4± 4.0 vs 96.8±2.7 nmol/L). With adjustment for age, gender, race, season, height, and sexual maturation, there were significant inverse correlations between 25-hydroxyvitamin D levels and all adiposity measurements, including BMI percentile (P=.02), waist circumference (P<.01), total fat mass (P<.01), percentage of body fat (P <.01), visceral adipose tissue (P <.015), and subcutaneous abdominal adipose tissue (P<.039). There were significant positive associations between 25-hydroxyvitamin D levels and vigorous physical activity (P <.01) and cardiovascular fitness (P =.025).
Low vitamin D status is prevalent among adolescents living in a year-round sunny climate, particularly among black youths. The relationships between 25-hydroxyvitamin D levels, adiposity, physical activity, and fitness seem to be present in adolescence.
PMCID: PMC3935324  PMID: 20439594
vitamin D deficiency; 25(OH)D; adolescents; race; adiposity; physical activity; fitness
3.  The Relationship Between Reported Sleep Quality and Sleep Hygiene in Italian and American Adolescents 
Pediatrics  2005;115(1 0):257-265.
The purpose of the study was to examine the relationship between self-reported sleep quality and sleep hygiene in Italian and American adolescents and to assess whether sleep-hygiene practices mediate the relationship between culture and sleep quality.
Two nonprobability samples were collected from public schools in Rome, Italy, and Hattiesburg, Mississippi. Students completed the following self-report measures: Adolescent Sleep-Wake Scale, Adolescent Sleep Hygiene Scale, Pubertal Developmental Scale, and Morningness/Eveningness Scale.
The final sample included 776 Italian and 572 American adolescents 12 to 17 years old. Italian adolescents reported much better sleep hygiene and substantially better sleep quality than American adolescents. A moderate-to-strong linear relationship was found between sleep hygiene and sleep quality in both samples. Separate hierarchical multiple regression analyses were performed on both samples. Demographic and individual characteristics explained a significant proportion of the variance in sleep quality (Italians: 18%; Americans: 25%), and the addition of sleep-hygiene domains explained significantly more variance in sleep quality (Italians: 17%; Americans: 16%). A final hierarchical multiple regression analysis with both samples combined showed that culture (Italy versus United States) only explained 0.8% of the variance in sleep quality after controlling for sleep hygiene and all other variables.
Cross-cultural differences in sleep quality, for the most part, were due to differences in sleep-hygiene practices. Sleep hygiene is an important predictor of sleep quality in Italian and American adolescents, thus supporting the implementation and evaluation of educational programs on good sleep-hygiene practices.
PMCID: PMC3928632  PMID: 15866860
Pediatrics; adolescence; sleep quality; sleep hygiene; cultural differences
4.  High Mortality Rates for Very Low Birth Weight Infants in Developing Countries Despite Training 
Pediatrics  2010;126(5):e1072-e1080.
The goal was to determine the effect of training in newborn care and resuscitation on 7-day (early) neonatal mortality rates for very low birth weight (VLBW) infants. The study was designed to test the hypothesis that these training programs would reduce neonatal mortality rates for VLBW infants.
Local instructors trained birth attendants from 96 rural communities in 6 developing countries in protocol and data collection, the World Health Organization Essential Newborn Care (ENC) course, and a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP), by using a train-the-trainer model. To test the impact of ENC training, data on infants of 500 to 1499 g were collected by using a before/after, active baseline, controlled study design. A cluster-randomized, controlled trial design was used to test the impact of the NRP.
A total of 1096 VLBW (500–1499 g) infants were enrolled, and 98.5% of live-born infants were monitored to 7 days. All-cause, 7-day neonatal mortality, stillbirth, and perinatal mortality rates were not affected by ENC or NRP training.
Neither ENC nor NRP training of birth attendants decreased 7-day neonatal, stillbirth, or perinatal mortality rates for VLBW infants born at home or at first-level facilities. Encouragement of delivery in a facility where a higher level of care is available may be preferable when delivery of a VLBW infant is expected.
PMCID: PMC3918943  PMID: 20937655
neonatal mortality; perinatal mortality; stillbirth; developing countries; health care systems; very low birth weight; prematurity
5.  The regionalization of pediatric health care: a state of the art review 
Pediatrics  2010;126(6):1182-1190.
Regionalization of health care is a method to provide high quality, cost-efficient health care to the largest number of patients. Within pediatric medicine, regionalization has been undertaken in two areas: neonatal intensive care and pediatric trauma care. The supporting literature for the regionalization of these areas demonstrates the range of studies within this field: studies of neonatal intensive care primarily compare different levels of hospitals, while studies of pediatric trauma care primarily compare the impact of institutionalizing a trauma system in a single geographic region. However, neither specialty has been completely regionalized, possibly because of methodologic deficiencies in the evidence base. Research with improved study designs, controlling for differences in illness severity between different hospitals; a systems approach to regionalization studies; and measurement of parental preferences will improve the understanding of the advantages and disadvantages of regionalizing pediatric medicine and ultimately optimize the outcomes of children.
PMCID: PMC3915403  PMID: 21041285
Neonatal Intensive Care; Pediatric Trauma Care; Regionalization of Care; Health Care Systems
6.  Isolation of tracheal aspirate mesenchymal stromal cells predicts bronchopulmonary dysplasia 
Pediatrics  2010;126(5):10.1542/peds.2009-3445.
We have isolated mesenchymal stromal cells (MSCs) from tracheal aspirates of premature infants with respiratory distress. Under the influence of transforming growth factor-β, MSCs differentiate into α-smooth muscle actin-expressing myofibroblasts. Myofibroblasts are increased in the lungs of patients with bronchopulmonary dysplasia (BPD), a chronic lung disease of prematurely-born infants.
We tested whether isolation of MSCs from tracheal aspirates of premature infants with respiratory distress during the first week of life correlates with BPD.
Patients and Methods
Eighty-four infants born at gestational age <33 weeks and requiring mechanical ventilation were studied. Aspirates were collected during suctioning and centrifuged. Cell pellets were resuspended in culture medium and plated. Adherent cells were grown to confluence.
MSCs were isolated from the tracheal aspirates of 56 infants; 28 infants showed no MSCs. There was no statistical difference in gestational age or birth weight between the ‘MSC’ and ‘no MSC’ groups. In the MSC group, 12 died and 25 developed BPD, as defined by a requirement for supplemental O2 at 36 wks post-menstrual age. In the ‘no MSC’ group, 6 infants died and 1 developed BPD. Accounting for the potential influences of gender, birth weight, gestational age, number of tracheal aspirate samples taken and the duration of endotracheal intubation (up to 7 days), isolation of MSCs increased the adjusted odds ratio of BPD over 21-fold (95% confidence intervals: 1.82, 265.85).
Isolation of tracheal aspirate MSCs predicts the development of BPD, which suggests that MSCs play an important role in the pathogenesis of this disease.
PMCID: PMC3887445  PMID: 20937656
chronic lung disease; lipofibroblast; myofibroblast
7.  Biliary Atresia screening: why, when and how? 
Pediatrics  2009;123(5):10.1542/peds.2008-3108.
PMCID: PMC3881183  PMID: 19403487
8.  Predicting stuttering onset 
Pediatrics  2009;123(1):10.1542/peds.2007-3219.
PMCID: PMC3879585  PMID: 19117892
9.  Cardiac Safety of Methylphenidate Versus Amphetamine Salts in the Treatment of ADHD 
Pediatrics  2009;124(1):10.1542/peds.2008-3138.
Safety concerns about central nervous system stimulants for the treatment of attention-deficit/hyperactivity disorder (ADHD) include adverse cardiac effects. This study aimed to compare the risk for cardiac events in users of methylphenidate and amphetamine salts.
A retrospective cohort design using claims data from the Florida Medicaid fee-for-service program representing a total of 2 131 953 children and adolescents was used. The analysis included all beneficiaries who were between 3 and 20 years of age, enrolled between July 1994 and June 2004, had at least 1 physician diagnosis of ADHD and were newly started on methylphenidate or amphetamine salts. Each month of follow-up was classified according to stimulant use into current use or former use. We defined cardiac events as first emergency department (ED) visit for cardiac disease or symptoms. Risk between current users of methylphenidate versus amphetamine salts and former users of drugs in these categories was compared by using a time-dependent Cox proportional hazard model that adjusted for differences in gender; race; age; year of the index date; disability; congenital anomalies; history of circulatory disease; history of hospital admission; and use of antidepressants, antipsychotics, and bronchodilators.
A total of 456 youth visited the ED for cardiac reasons during 52 783 years of follow-up. After adjustment for differences in covariates, the risk for cardiac ED visits was similar among current users of methylphenidate or amphetamines. Periods of former use had a similar risk between youth with an exposure history to methylphenidate or amphetamine.
Exposure to methylphenidate and amphetamines salts showed similar risk for cardiac ED visits. Additional population-based studies that address manifestation of serious heart disease, especially after long-term use, dosage comparisons, and interactions with preexisting cardiac risk factors are needed to inform psychiatric treatment decisions.
PMCID: PMC3856396  PMID: 19564272
central nervous system stimulants; methylphenidate; amphetamine; safety; cardiac events; psychopharmacology; attention-deficit/hyperactivity disorder; child and adolescent mental health; pharmacoepidemiology
10.  Child Health Research Funding and Policy: Imperatives and Investments for a Healthier World 
Pediatrics  2010;125(6):10.1542/peds.2009-2635.
Although pediatric research enjoyed significant benefits during the National Institutes of Health (NIH) doubling era, the proportion of the NIH budget devoted to the pediatric-research portfolio has declined overall. In light of this declining support for pediatric biomedical research, the Federation of Pediatric Organizations held a topic symposium at the 2009 Pediatric Academic Societies annual meeting as a forum for discussion of the past and future states of funding, the rationale for directing public funds toward the understanding of child health and disease, and new programs and paradigms for promoting child health research. This report of the symposium is intended to disseminate more broadly the information presented and conclusions discussed to encourage those in the child health research community to exert influence with policy makers to increase the allocation of national funding for this underfunded area.
PMCID: PMC3857014  PMID: 20457684
child heath; pediatrics; pediatric-research funding; National Institutes of Health, NIH; Eunice Kennedy Shriver National Institute of Child Health and Development, NICHD; Federation of Pediatric Organizations, FOPO
11.  Racial/Ethnic Differences in Early Life Risk Factors for Childhood Obesity 
Pediatrics  2010;125(4):10.1542/peds.2009-2100.
By the preschool years, racial/ethnic disparities in obesity prevalence are already present.
To examine racial/ethnic differences in early life risk factors for childhood obesity.
Design, Setting, Participants
343 white, 355 black, and 128 Hispanic mother-child pairs in a prospective study.
Main Exposure
Mother’s report of child’s race/ethnicity.
Main Outcome Measures
Risk factors from the prenatal period through age 4 years known to be associated with child obesity.
In multivariable models, compared to their white counterparts, black and Hispanic children exhibited a range of risk factors related to child obesity. In pregnancy, these included higher rates of maternal depression (OR: 1.55 for blacks; 1.89 for Hispanics); in infancy more rapid weight gain (OR: 2.01 for blacks; 1.75 for Hispanics), more likely to introduce solid foods before 4 months of age (OR: 1.91 for blacks; 2.04 for Hispanics), higher rates of maternal restrictive feeding practices (OR: 2.59 for blacks; 3.35 for Hispanics), and after age 2 years, more televisions in their bedrooms (OR: 7.65 for blacks; 7.99 for Hispanics), higher intake of sugar-sweetened beverages (OR: 4.11 for blacks; 2.48 for Hispanics), and higher intake of fast food (OR: 1.65 for blacks; 3.14 for Hispanics). Blacks and Hispanics also had lower rates of exclusive breastfeeding and were less likely to sleep at least 12 hours/day in infancy.
Racial/ethnic differences in risk factors for obesity exist prenatally and in early childhood. Racial/ethnic disparities in childhood obesity may be determined by factors operating at the earliest stages of life.
PMCID: PMC3836212  PMID: 20194284
Obesity; Race/Ethnicity; Pregnancy; Infancy; Childhood; Prevention
12.  Sleep Problems in Childhood Predict Neuropsychological Functioning in Adolescence 
Pediatrics  2009;123(4):10.1542/peds.2008-0825.
Our goal was to examine the association between parent-rated sleep problems during childhood and neuropsychological functioning during adolescence.
Longitudinal prospective data on an entire birth cohort from Dunedin, New Zealand, were obtained. One thousand thirty-seven children were enrolled in the study (52% male). Parents reported on sleep problems when the study members were 5, 7, and 9 years of age. Neuropsychological functioning was assessed by using 7 tests when the participants were 13 years of age.
After adjusting for gender and socioeconomic status, persistent sleep problems during childhood predicted scores on 2 neuropsychological tests: the copy score of the Rey-Osterrieth Complex Figure Test and 2 measures of performance on the Halstead Trail Making Test. These results were substantively replicated when sleep was assessed at the 5- and 9-year (but not 7-year) assessments separately.
Sleep problems during childhood may be associated with certain aspects of neuropsychological functioning during adolescence. This adds to the growing body of literature suggesting that childhood sleep problems may be a risk indicator of later difficulties.
PMCID: PMC3826614  PMID: 19336377
sleep; neuropsychological; longitudinal; prospective
13.  Macrophage Migration Inhibitory Factor and Stereotypical Behavior in Autism Spectrum Disorders 
Pediatrics  2008;122(2):10.1542/peds.2007-3604.
Autism-spectrum disorders (ASD) are childhood neurodevelopmental disorders characterized by social and communicative impairment and repetitive and stereotypical behavior. Macrophage migration inhibitory factor (MIF) is an upstream regulator of innate immunity that promotes monocyte/macrophage activation responses by increasing the expression of Toll-like receptors and inhibiting activation-induced apoptosis. Based on results of prior genetic linkage studies and reported altered innate immune response in ASD, we hypothesized that MIF could represent a candidate gene for ASD or its diagnostic components.
Genetic association between ASD and MIF was investigated in two independent sets of families of probands with ASD, from USA (527 participants from 152 families) and Holland (532 participants from 183 families). Probands and their siblings, when available, were evaluated with clinical instruments used for ASD diagnoses. Genotyping was performed for two polymorphisms in the promoter region of the MIF gene in both samples sequentially. In addition, MIF plasma analyses were carried out in a subset of Dutch patients from whom plasma was available.
There were genetic associations between known functional polymorphisms in the promoter for MIF and ASD-related behaviors. Also, probands with ASD exhibited higher circulating MIF levels than did their unaffected siblings; the amount of MIF in the plasma correlated with the severity of multiple ASD symptoms.
These results identify MIF as a susceptibility gene for ASD. Further research is warranted on the precise relationship between MIF and the behavioral components of ASD, the mechanism by which MIF contributes to ASD pathogenesis, and the clinical utility of MIF genotyping.
PMCID: PMC3816765  PMID: 18676531
14.  Laboratory-Diagnosed Sexually Transmitted Infections in Former Foster Youth Compared With Peers 
Pediatrics  2010;126(1):10.1542/peds.2009-2424.
The objective of this study was to evaluate the association between having resided in foster care and risk for sexually transmitted infection (STI) during young adulthood.
Multiple regression analyses were performed by using Waves I to III of the National Longitudinal Study of Adolescent Health (1994–2002) to evaluate the association between foster care status and STI biomarkers and risk behaviors. Female (N = 7563) and male participants (N = 6759) were evaluated separately. Covariates in all models included baseline age, race, ethnicity, parental education level, parental income level, and average neighborhood household income level.
Female participants who had been in foster care were more likely to have Trichomonas (odds ratio [OR]: 3.23 [95% confidence interval (CI): 1.45–7.23) but not gonorrhea or chlamydia and reported increased sexual risk behaviors compared with nonfostered peers. Male participants who had been in foster care were more likely to have both gonorrhea (OR: 14.28 [95% CI: 2.07–98.28]) and chlamydia (OR: 3.07 [95% CI: 1.36–6.96]) but not Trichomonas and did not report a higher risk for most sexual risk behaviors than nonfostered peers.
Results suggest that individuals who have been in foster care are at increased risk for STIs during young adulthood. The pattern of exposure may differ between male and female individuals. If findings are confirmed, they suggest that health care providers who work with these youth should adjust their STI screening practices. Child welfare agencies should also consider targeted interventions to reduce STI risk in this population.
PMCID: PMC3816982  PMID: 20547646
foster care; sexually transmitted infection; adolescent sexual behaviors; sexual and reproductive health; sexual activity
15.  Variation in Methods of Predicting Adult Height in Children with Idiopathic Short Stature 
Pediatrics  2010;126(5):938-944.
Recombinant human growth hormone (GH) is approved for treatment of children with idiopathic short stature (ISS). Endocrinologists often depend on algorithms to predict adult height. As algorithm performance is often included in treatment decision, we sought to evaluate agreement among height prediction formulas.
We identified 3 commonly used algorithms for height prediction: Bayley-Pinneau (BP), Roche-Wainer-Thissen (RWT), and Khamis-Roche (KR). We constructed simulated samples of children with typical distributions of ages, heights, weights, bone ages, and parental heights seen in patients with ISS, and applied the algorithms to the simulated children to determine if predicted adult height was <160 cm for boys or <150 cm for girls, the 1.2nd height percentiles for adults.
We found substantial disagreement amongst algorithms in the percentage of simulated children with predicted adult height < 1.2nd percentile, a cut-off that may influence GH treatment decisions. Using the BP formula, 43% of boys and 81% of girls had predicted adult height below this threshold, whereas only 3% of boys and 0.2% of girls had predicted heights < 1.2nd percentile using the KR method. RWT predictions fell in between. Overall agreement of the methods was poor (kappa = 0.21) in boys and negative in girls.
Wide variation exists among formulas used to predict adult height. As these algorithms may be used in decisions about whether to initiate GH treatment and to assess GH’s efficacy in research trials, it is important for parents, pediatricians, and investigators to recognize the considerable variation involved in height prediction.
PMCID: PMC3793344  PMID: 20974789
growth hormone; idiopathic short stature; height prediction
17.  Beliefs About the Health Effects of “Thirdhand” Smoke and Home Smoking Bans 
Pediatrics  2009;123(1):e74-e79.
There is no safe level of exposure to tobacco smoke. Thirdhand smoke is residual tobacco smoke contamination that remains after the cigarette is extinguished. Children are uniquely susceptible to thirdhand smoke exposure. The objective of this study was to assess health beliefs of adults regarding thirdhand smoke exposure of children and whether smokers and nonsmokers differ in those beliefs. We hypothesized that beliefs about thirdhand smoke would be associated with household smoking bans.
Data were collected by a national random-digit-dial telephone survey from September to November 2005. The sample was weighted by race and gender within Census region on the basis of US Census data. The study questions assessed the level of agreement with statements that breathing air in a room today where people smoked yesterday can harm the health of children.
Of 2000 eligible respondents contacted, 1510 (87%) completed surveys, 1478 (97.9%) answered all questions pertinent to this analysis, and 273 (18.9%) were smokers. Overall, 95.4% of nonsmokers versus 84.1% of smokers agreed that secondhand smoke harms the health of children, and 65.2% of nonsmokers versus 43.3% of smokers agreed that thirdhand smoke harms children. Strict rules prohibiting smoking in the home were more prevalent among nonsmokers: 88.4% vs 26.7%. In multivariate logistic regression, after controlling for certain variables, belief that thirdhand smoke harms the health of children remained independently associated with rules prohibiting smoking in the home. Belief that secondhand smoke harms the health of children was not independently associated with rules prohibiting smoking in the home and car.
This study demonstrates that beliefs about the health effects of thirdhand smoke are independently associated with home smoking bans. Emphasizing that thirdhand smoke harms the health of children may be an important element in encouraging home smoking bans.
PMCID: PMC3784302  PMID: 19117850
smoking; tobacco; pediatrics; family practice; parent; smoking cessation; secondhand smoke; environmental tobacco smoke; tobacco control
18.  Evaluation of Long-term Treatment of Children With Congenital Lactic Acidosis With Dichloroacetate 
Pediatrics  2008;121(5):e1223-e1228.
The purpose of this research was to report results on long-term administration of dichloroacetate in 36 children with congenital lactic acidosis who participated previously in a controlled trial of this drug.
We conducted a randomized control trial, followed by an open-label study. Data were analyzed for each patient from the time they began treatment through May 2005.
Subject exposure to dichloroacetate totaled 110.42 years. Median height and weight increased over time, but the standardized values declined slightly and remained below the first percentile. There were no significant changes in biochemical metabolic indices, except for a 2% rise in total protein and a 22% increase in 24-hour urinary oxalate. Both the basal and carbohydrate meal-induced rises in lactate were blunted by dichloroacetate. The median cerebrospinal fluid lactate also decreased over time. Conduction velocity decreased and distal latency increased in peroneal nerves. Mean 3-year survival for all of the subjects was 79%.
Oral dichloroacetate is generally well tolerated in young children with congenital lactic acidosis. Although continued dichloroacetate exposure is associated with evidence of peripheral neuropathy, it cannot be determined whether this is attributable mainly to the drug or to progression of underlying disease.
PMCID: PMC3777225  PMID: 18411236
dichloroacetate; lactic acidosis; mitochondria; pyruvate dehydrogenase; respiratory chain
Pediatrics  2009;123(2):636-642.
Early transition from intravenous to oral antimicrobial therapy for acute osteomyelitis in children has been suggested as a safe and effective alternative to traditional prolonged intravenous therapy via central venous catheter, but no studies have directly compared these two treatment modalities. We sought to compare the effectiveness of early transition from intravenous to oral antimicrobial therapy vs. prolonged intravenous antimicrobial therapy for the treatment of children with acute osteomyelitis.
We conducted a retrospective cohort study of children ages 2 months to 17 years diagnosed with acute osteomyelitis between 2000 and 2005 at 29 free-standing children’s hospitals in the United States to confirm the extent of variation in use of early transition to oral therapy. We used a propensity scores to adjust for potential differences between children treated with prolonged intravenous therapy, and logistic regression to model the association of outcome (treatment failure rates within 6 months of diagnosis and difference in the mode of therapy within hospitals and across hospitals.
Of the 1969 children who met inclusion criteria, 1021 received prolonged intravenous therapy and 948 received oral therapy. Use of prolonged intravenous therapy varied significantly across hospitals (10% to 95%, P<0.001). The treatment failure rate was 5% (54 of 1021) in the prolonged intravenous therapy group and 4% (38 of 948) in the oral therapy group. There was no significant association between treatment failure and the mode of antimicrobial therapy (adjusted odds ratio=0.77, 95% confidence interval=0.49 to 1.22). Thirty-five children (3.4%) in the prolonged intravenous therapy group were readmitted for a catheter-associated complication.
Treatment of acute osteomyelitis with early transition to oral therapy is not associated with a higher risk of treatment failures and avoids the risks of prolonged intravenous therapy through central venous catheters.
PMCID: PMC3774269  PMID: 19171632
Osteomyelitis; therapy; children
20.  Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? 
Pediatrics  2009;124(5):1404-1410.
Single-center studies have suggested that hypovitaminosis D is widespread. Our objective was to determine the serum levels of 25-hydroxyvitamin D (25[OH]D) in a nationally representative sample of US children aged 1 to 11 years.
Data were obtained from the 2001–2006 National Health and Nutrition Examination Survey. Serum 25(OH)D levels were determined by radioimmunoassay and categorized as <25, <50, and <75 nmol/L. National estimates were obtained by using assigned patient visit weights and reported with 95% confidence intervals (CIs).
During the 2001–2006 time period, the mean serum 25(OH)D level for US children aged 1 to 11 years was 68 nmol/L (95% CI: 66 –70). Children aged 6 to 11 years had lower mean levels of 25(OH)D (66 nmol/L [95% CI: 64 –68]) compared with children aged 1 to 5 years (70 nmol/L [95% CI: 68 –73]). Overall, the prevalence of levels at <25 nmol/L was 1% (95% CI: 0.7–1.4), <50 nmol/L was 18% (95% CI: 16–21), and <75 nmol/L was 69% (95% CI: 65–73). The prevalence of serum 25(OH)D levels of <75 nmol/L was higher among children aged 6 to 11 years (73%) compared with children aged 1 to 5 years (63%); girls (71%) compared with boys (67%); and non-Hispanic black (92%) and Hispanic (80%) children compared with non-Hispanic white children (59%).
On the basis of a nationally representative sample of US children aged 1 to 11 years, millions of children may have suboptimal levels of 25(OH)D, especially non-Hispanic black and Hispanic children. More data in children are needed not only to understand better the health implications of specific serum levels of 25(OH)D but also to determine the appropriate vitamin D supplement requirements for children.
PMCID: PMC3765249  PMID: 19951983
vitamin D; deficiency; prevalence; supplementation
21.  Risk Factors in Children Hospitalized With RSV Bronchiolitis Versus Non–RSV Bronchiolitis 
Pediatrics  2010;126(6):e1453-e1460.
The trends in hospitalization rates and risk factors for severe bronchiolitis have not been recently described, especially after the routine implementation of prophylaxis for respiratory syncytial virus (RSV) infections.
To define the burden of hospitalizations related to RSV and non-RSV bronchiolitis in a tertiary-care children’s hospital from 2002 to 2007 and to identify the risk factors associated with severe disease.
Medical records of patients hospitalized for bronchiolitis were reviewed for demographic, clinical, microbiologic, and radiologic characteristics as well as the presence of underlying medical conditions. Differences were evaluated between children with RSV and non-RSV bronchiolitis, and multivariable logistic regression analyses were performed to identify independent risk factors for severe disease.
Bronchiolitis hospitalizations in children younger than 2 years old (n =4800) significantly increased from 536 (3.3%) in 2002 to 1241 (5.5%) in 2007, mainly because of RSV infections. Patients with RSV bronchiolitis (n = 2840 [66%]) were younger at hospitalization and had a lower percentage of underlying medical conditions than children hospitalized with non-RSV bronchiolitis (27 vs 37.5%; P < .001). However, disease severity defined by length of hospitalization and requirement of supplemental oxygen, intensive care, and mechanical ventilation was significantly worse in children with RSV bronchiolitis. RSV infection and prematurity, regardless of the etiology, were identified as independent risk factors for severe bronchiolitis.
There was a significant increase in hospitalizations for RSV bronchiolitis from 2002 to 2007. A majority of the children with RSV bronchiolitis were previously healthy, but their disease severity was worse compared with those hospitalized with non-RSV bronchiolitis.
PMCID: PMC3761792  PMID: 21098154
bronchiolitis; RSV; disease severity; ICD-9
22.  Parenting Attitudes and Infant Spanking: The Influence of Childhood Experiences 
Pediatrics  2009;124(2):e278-e286.
To assess associations among maternal childhood experiences and subsequent parenting attitudes and use of infant spanking (IS), and determine if attitudes mediate the association between physical abuse exposure and IS.
We performed a prospective study of women who received prenatal care at community health centers in Philadelphia, Pennsylvania. Sociodemographic characteristics, adverse childhood experiences (ACEs), attitudes toward corporal punishment (CP), and IS use were assessed via face-to-face interviews, conducted at the first prenatal care visit, 3 months postpartum, and 11 months postpartum. Bivariate and multiple logistic regression analyses were conducted.
The sample consisted of 1265 mostly black, low-income women. Nineteen percent of the participants valued CP as a means of discipline, and 14% reported IS use. Mothers exposed to childhood physical abuse and verbal hostility were more likely to report IS use than those not exposed (16% vs 10%, P = .002; 17% vs 12%, P = .02, respectively). In the adjusted analyses, maternal exposure to physical abuse, other ACEs, and valuing CP were independently associated with IS use. Attitudes that value CP did not mediate these associations.
Mothers who had childhood experiences of violence were more likely to use IS than mothers without such experiences. Intergenerational transmission of CP was evident. Mothers who had experienced physical abuse as a child, when compared to those who had not, were 1.5 times more likely to use IS. Child discipline attitudes and maternal childhood experiences should be discussed early in parenting in order to prevent IS use, particularly among at-risk mothers.
PMCID: PMC3760718  PMID: 19620204
physical punishment; adverse childhood experiences; positive influences in childhood; Adult-Adolescent Parenting Inventory
23.  Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001–2004 
Pediatrics  2009;124(3):e362-e370.
To determine the prevalence of 25-hydroxyvitamin D (25[OH]D) deficiency and associations between 25(OH)D deficiency and cardiovascular risk factors in children and adolescents.
With a nationally representative sample of children aged 1 to 21 years in the National Health and Nutrition Examination Survey 2001–2004 (n = 6275), we measured serum 25(OH)D deficiency and insufficiency (25[OH]D <15 ng/mL and 15–29 ng/mL, respectively) and cardiovascular risk factors.
Overall, 9% of the pediatric population, representing 7.6 million US children and adolescents, were 25(OH)D deficient and 61%, representing 50.8 million US children and adolescents, were 25(OH)D insufficient. Only 4% had taken 400 IU of vitamin D per day for the past 30 days. After multivariable adjustment, those who were older (odds ratio [OR]: 1.16 [95% confidence interval (CI): 1.12 to 1.20] per year of age), girls (OR: 1.9 [1.6 to 2.4]), non-Hispanic black (OR: 21.9 [13.4 to 35.7]) or Mexican-American (OR: 3.5 [1.9 to 6.4]) compared with non-Hispanic white, obese (OR: 1.9 [1.5 to 2.5]), and those who drank milk less than once a week (OR: 2.9 [2.1 to 3.9]) or used >4 hours of television, video, or computers per day (OR: 1.6 [1.1 to 2.3]) were more likely to be 25(OH)D deficient. Those who used vitamin D supplementation were less likely (OR: 0.4 [0.2 to 0.8]) to be 25(OH)D deficient. Also, after multivariable adjustment, 25(OH)D deficiency was associated with elevated parathyroid hormone levels (OR: 3.6; [1.8 to 7.1]), higher systolic blood pressure (OR: 2.24 mm Hg [0.98 to 3.50 mm Hg]), and lower serum calcium (OR: –0.10 mg/dL [–0.15 to –0.04 mg/dL]) and high-density lipoprotein cholesterol (OR: –3.03 mg/dL [–5.02 to –1.04]) levels compared with those with 25(OH)D levels ≥30 ng/mL.
25(OH)D deficiency is common in the general US pediatric population and is associated with adverse cardiovascular risks.
PMCID: PMC3749840  PMID: 19661054
rickets; vitamin D; cardiovascular risk factors; obesity; racial disparities
24.  Special Report—Pediatric Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 
Pediatrics  2010;126(5):e1345-e1360.
PMCID: PMC3741664  PMID: 20956430
automatic external defibrillator; cardiopulmonary resuscitation; pediatrics
25.  Mental Health Problems and Overweight in a Nationally Representative Sample of Adolescents: Effects of Race and Ethnicity 
Pediatrics  2009;123(2):697-702.
In this study we examined the relation between mental health problems and weight in a population-based study of youth aged 12 to 17 years and whether the association between mental health problems and weight is moderated by race and ethnicity.
We used 2003 National Survey on Children’s Health data. Logistic regression was used to arrive at adjusted odds ratios showing the relation between BMI and mental health problems.
Compared with their nonoverweight counterparts, both white and Hispanic youth who were overweight were significantly more likely to report depression or anxiety, feelings of worthlessness or inferiority, behavior problems, and bullying of others. Odds ratios relating mental health problems and BMI in black subjects were not statistically significant except for physician diagnosis of depression.
Our results suggest that, when addressing youth overweight status, mental health problems also need to be addressed. Given that the relationship between mental health problems and youth overweight differs according to race/ethnic group, public health programs that target overweight youth should be cognizant of potential comorbid mental health problems and that race/ethnicity may play a role in the relationship between mental health and overweight status.
PMCID: PMC3740571  PMID: 19171640
adolescent health; black; Latino health; mental health; obesity

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