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1.  Impact of Individual Values on Adherence to Emergency Contraception Practice Guidelines Among Pediatric Residents 
Objective
To evaluate the impact of individual, system, and interpersonal factors on emergency contraception practices. We hypothesized that abortion attitudes and attitudes toward teen sex would be significant individual factors influencing emergency contraception practices.
Design
This was a cross-sectional, anonymous Internet survey.
Setting
Four pediatric residency programs in the Baltimore, Maryland–Washington, DC, metropolitan area during April to June 2007.
Participants
One hundred forty-one pediatric residents completed the survey.
Main Exposure
Abortion attitudes were assessed by participants’ level of agreement with abortion in 7 scenarios. Attitudes toward teen sex were assessed by participants’ level of agreement with 5 statements about the acceptability of teens having sex.
Main Outcome Measures
Emergency contraceptive counseling behavior was assessed by reported frequency of including emergency contraception in routine contraceptive counseling. Intention to prescribe emergency contraception was assessed by reported likelihood of prescribing in 5 scenarios.
Results
When controlling for demographics and other predictors, residents with less favorable abortion attitudes were more likely to have the lowest intention to prescribe emergency contraception. Residents with more positive attitudes toward teen sex and who had a preceptor encourage emergency contraception prescription were more likely to include emergency contraception in routine contraceptive counseling most/all the time and to have the highest intention to prescribe.
Conclusion
Efforts to challenge and affect attitudes toward teen sex and to prompt residents to prescribe emergency contraception in clinical settings may be needed to encourage more proactive emergency contraceptive practice in accordance with national practice guidelines.
doi:10.1001/archpediatrics.2009.160
PMCID: PMC4332886  PMID: 19805714
2.  Asthma Care Quality for Children with Minority-Serving Providers 
Objective
To compare asthma care quality for children with and without minority-serving providers.
Design
Cross-sectional telephone survey of parents, linked with a mailed survey of their children’s providers.
Setting
A Medicaid-predominant health plan and multispecialty provider group in Massachusetts.
Participants
Children with persistent asthma identified from claims and encounter data.
Main Exposure
Whether the child’s provider was minority-serving (>25% of patients black or Latino).
Outcomes
Parent report of whether the child had: 1) ever received inhaled steroids; 2) received influenza vaccination during the past season and 3) received an asthma action plan in the past year.
Results
The study included 563 children. In unadjusted analyses, Latino children and those with minority-serving providers were more likely to have never received inhaled steroids. In adjusted models, the odds of never receiving inhaled steroids were not significantly different for children with minority-serving providers (OR 1.29, 95% CI 0.63–2.64), or for Latino vs. white children (OR 1.76, 95% CI 0.74–4.18); odds were increased for children receiving care in community health centers (OR 4.88, 95% CI 1.70–14.02) or hospital clinics (OR 4.53, 95% CI 1.09–18.92) vs. multi-specialty practices. Such differences were not seen for influenza vaccinations or action plans.
Conclusions
Children with persistent asthma were less likely to receive inhaled steroids if they received care in community health centers or hospital clinics. Practice setting mediated initially-observed disparities in inhaled steroid use by Latino children and those with minority-serving providers. No differences by race/ethnicity or minority-serving provider were observed for influenza vaccinations and asthma action plans.
doi:10.1001/archpediatrics.2009.243
PMCID: PMC4319182  PMID: 20048240
3.  Environment, Developmental Origins, and Attention-Deficit/Hyperactivity Disorder 
doi:10.1001/archpediatrics.2011.905
PMCID: PMC4319356  PMID: 22213603
4.  Relationship Between Insulin Resistance-Associated Metabolic Parameters and Anthropometric Measurements With Sugar-Sweetened Beverage Intake and Physical Activity Levels in US Adolescents 
Objective
To evaluate the relationship between insulin resistance-associated metabolic parameters and anthropometric measurements with sugar-sweetened beverage intake and physical activity levels.
Design
A cross-sectional analysis of the National Health and Nutrition Examination Survey data collected by the National Center for Health Statistics.
Setting
Nationally representative samples of US adolescents participating in the National Health and Nutrition Examination Survey during the years 1999-2004.
Participants
A total of 6967 adolescents aged 12 to 19 years.
Main Exposure
Sugar-sweetened beverage consumption and physical activity levels.
Outcome Measures
Glucose and insulin concentrations, a homeostasis model assessment of insulin resistance (HOMA-IR), total, high-density lipoprotein, and low-density lipoprotein cholesterol concentrations, triglyceride concentrations, systolic and diastolic blood pressure, waist circumference, and body mass index (calculated as weight in kilograms divided by height in meters squared) percentile for age and sex.
Results
Multivariate linear regression analyses showed that increased sugar-sweetened beverage intake was independently associated with increased HOMA-IR, systolic blood pressure, waist circumference, and body mass index percentile for age and sex and decreased HDL cholesterol concentrations; alternatively, increased physical activity levels were independently associated with decreased HOMA-IR, low-density lipoprotein cholesterol concentrations, and triglyceride concentrations and increased high-density lipoprotein cholesterol concentrations. Furthermore, low sugar-sweetened beverage intake and high physical activity levels appear to modify each others' effects of decreasing HOMA-IR and triglyceride concentrations and increasing high-density lipoprotein cholesterol concentrations.
Conclusions
Sugar-sweetened beverage intake and physical activity levels are each independently associated with insulin resistance-associated metabolic parameters and anthropometric measurements in adolescents. Moreover, low sugar-sweetened beverage intake and high physical activity levels appear to modify each others' effects on several health-related outcome variables.
doi:10.1001/archpediatrics.2009.21
PMCID: PMC4264593  PMID: 19349561
6.  Enduring Effects of Prenatal and Infancy Home Visiting by Nurses on Children: Age-12 Follow-Up of a Randomized Trial 
Objective
To test, with an urban, primarily black sample, the effect of prenatal and infancy home visits by nurses on 12-year-old first-born children's use of substances, behavioral adjustment, and academic achievement.
Design
Randomized controlled trial.
Setting
Public system of obstetric and pediatric care in Memphis, Tennessee.
Participants
12-year-old first-born children (N=613) of primarily African-American, economically disadvantaged women (N=743 randomized during pregnancy).
Intervention
Program of prenatal and infancy home visits by nurses.
Main Outcome Measures
Use of tobacco, alcohol, and marijuana; internalizing, externalizing, and total behavioral problems; academic achievement.
Results
By the time the first-born child was 12 years of age, those visited by nurses, compared to those in the control group, reported fewer days of having used tobacco, alcohol, and marijuana during the 30-day period prior to the 12-year interview (0.03 versus 0.18, p=.019), and were less likely to report having internalizing disorders that met the clinical/borderline threshold (22% versus 31%, p=.043). Nurse-visited children born to mothers with low psychological resources, compared to control-group counterparts, scored higher on the PIAT achievement tests in reading and math (88.78 versus 85.70, p =.009) and, over their first 6 years of education, scored higher on group-administered standardized tests of math and reading achievement (40.52 versus 34.85, p=.023). There were no statistically significant program effects on children's externalizing or total behavioral problems.
Conclusions
Through child age 12, the program reduced children's use of substances and internalizing mental health problems; and improved the academic achievement of children born to mothers with low psychological resources.
doi:10.1001/archpediatrics.2010.76
PMCID: PMC4225617  PMID: 20439791
nurse; home visits; pregnancy; child development; substance use
7.  Ability to Delay Gratification at Age 4 Years and Risk of Overweight at Age 11 Years 
Objectives
To determine if limited ability to delay gratification (ATDG) at age 4 years is independently associated with an increased risk of being overweight at age 11 years and to assess confounding or moderation by child body mass index z score at 4 years, self-reported maternal expectation of child ATDG for food, and maternal weight status.
Design
Longitudinal prospective study.
Setting
Ten US sites.
Participants
Participants in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development.
Main Exposure
Ability to delay gratification at 4 years, measured as pass or fail on a validated task.
Outcome Measures
Overweight at 11 years, defined as a body mass index greater than or equal to the 85th percentile based on measured weight and height.
Results
Of 805 children, 47% failed the ATDG task. Using multiple logistic regression, children who failed the ATDG task were more likely to be overweight at 11 years (relative risk, 1.29; 95% confidence interval, 1.06–1.58), independent of income to needs ratio. Body mass index z score at 4 years and maternal expectation of child ATDG for food did not alter the association, but maternal weight status reduced the association significantly.
Conclusions
Children with limited ATDG at age 4 years were more likely to be overweight at age 11 years, but the association was at least partially explained by maternal weight status. Further understanding of the association between the child’s ATDG and maternal and child weight status may lead to more effective obesity intervention and prevention programs.
doi:10.1001/archpediatrics.2009.12
PMCID: PMC4174459  PMID: 19349558
8.  Body Mass Index and Timing of Pubertal Initiation in Boys 
Objective
To examine the association between body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) and timing of pubertal onset in a population-based sample of US boys.
Design
Longitudinal prospective study.
Setting
Ten US sites that participated in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development.
Participants
Of 705 boys initially enrolled in the study, information about height and weight measures and pubertal stage by age 11.5 years was available for 401 boys.
Main Exposure
The BMI trajectory created from measured heights and weights at ages 2, 3, 4.5, 7, 9, 9.5, 10.5, and 11.5 years.
Main Outcome Measure
Onset of puberty at age 11.5 years as measured by Tanner genitalia staging.
Results
Boys in the highest BMI trajectory (mean BMI z score at age 11.5 years, 1.84) had a greater relative risk of being prepubertal compared with boys in the lowest BMI trajectory (mean BMI z score at age 11.5 years, −0.76) (adjusted relative risk=2.63; 95% confidence interval, 1.05–6.61; P=.04).
Conclusions
The relationship between body fat and timing of pubertal onset is not the same in boys as it is in girls. Further studies are needed to better understand the physiological link between body fat and timing of pubertal onset in both sexes.
doi:10.1001/archpediatrics.2009.258
PMCID: PMC4172573  PMID: 20124142
9.  Association Between Swimming Lessons and Drowning in Childhood 
Objective
To estimate the association between swimming lessons and the risk of drowning among children aged 1 to 19 years.
Design
Case-control study.
Setting
Cases were identified from medical examiners’/ coroners’ offices between mid-2003 and mid-2005. Jurisdictions included the states of Maryland and North Carolina, 14 districts (33 counties) in Florida, 3 counties in California, 1 county in Texas, and 1 county in New York.
Participants
Cases were children and adolescents aged 1 to 19 years who died of unintentional drowning. Interviews were conducted with 88 families of children who drowned and 213 matched controls.
Main Exposure
Swimming lessons.
Main Outcome Measure
Death due to unintentional drowning. Drownings that were intentional, of undetermined intent, or that occurred under conditions in which swimming ability was unlikely to impact risk (eg, in ice water or bathtubs) were excluded.
Results
Of the 61 cases in the 1- to 4-year age group, 2 (3%) had participated in formal swimming lessons vs 35 of 134 matched controls (26%) (adjusted odds ratio [OR], 0.12; 95% confidence interval [CI], 0.01–0.97). Among the 27 cases aged 5 to 19 years, 7 (27%) had ever taken formal swimming lessons vs 42 of 79 matched controls (53%) (adjusted OR, 0.36; 95% CI, 0.09–1.51). In adjusted analyses, there was no statistically significant association between informal instruction and drowning risk.
Conclusions
Participation in formal swimming lessons was associated with an 88% reduction in the risk of drowning in the 1- to 4-year-old children, although our estimates were imprecise and 95% CIs included risk reductions ranging from 3% to 99%.
doi:10.1001/archpediatrics.2008.563
PMCID: PMC4151293  PMID: 19255386
10.  Sustained Decreases in Risk Exposure and Youth Problem Behaviors After Installation of the Communities That Care Prevention System in a Randomized Trial 
Objective
To test whether the Communities That Care (CTC) prevention system reduced levels of risk and adolescent problem behaviors community-wide 6 years after installation of CTC and 1 year after study-provided resources ended.
Design
A community-randomized trial.
Setting
24 small towns in 7 states, matched within state, randomly assigned to control or intervention condition in 2003.
Participants
A panel of 4407 fifth-grade students was surveyed annually through tenth grade from 2004-2009.
Intervention
A coalition of community stakeholders received training and technical assistance to install CTC, used epidemiologic data to identify elevated risk factors and depressed protective factors in the community, and implemented programs to address their community’s elevated risks from a menu of tested and effective programs for youths aged 10 to 14, their families, and schools.
Outcome Measures
Levels of risk and incidence and prevalence of tobacco, alcohol, and other drug use, delinquency, and violent behavior by grade 10.
Results
Mean levels of targeted risks increased less rapidly between grades 5 and 10 in CTC than in control communities and were significantly lower in CTC than control communities in grade 10. The incidence of delinquent behavior, alcohol use, and cigarette use, and the prevalence of current cigarette use and past-year delinquent and violent behavior were significantly lower in CTC than in control communities in grade 10.
Conclusions
Using the CTC system can produce enduring reductions in community-wide levels of risk factors and problem behaviors among adolescents beyond the years of supported implementation, potentially contributing to long-term public health benefits.
doi:10.1001/archpediatrics.2011.183
PMCID: PMC4137869  PMID: 21969362
11.  Cultural and Gender Convergence in Adolescent Drunkenness 
Objective
To investigate time-trend changes in the frequency of drunkenness among European and North American adolescents.
Design
Cross-sectional surveys in the 1997/1998 and 2005/2006 Health Behaviour in School-Aged Children Study (HBSC).
Setting
High schools in 23 countries.
Participants
A sample of 77 586 adolescents aged 15 years was analyzed by means of hierarchical linear modeling.
Main Outcome Measure
The frequency of drunkenness.
Results
We observed a significant increase of about 40% in the mean frequency of drunkenness in all 7 participating Eastern European countries. This increase was evident among both genders, but most consistently among girls. Meanwhile, it declined in 13 of 16 Western countries, about 25% on average. Declines in Western countries were particularly notable among boys and in North America, Scandinavia, the United Kingdom, and Ireland. Despite this gender convergence, with few exceptions (Greenland, Norway, United Kingdom) boys continued to have a higher frequency of drunkenness in 2005/2006 than girls.
Conclusions
The confirmed cultural convergence implies that adoption and implementation of evidence-based measures to mitigate the frequency of adolescent drunkenness such as tax increases and restricting alcohol access and advertisement should get the same priority in Eastern European countries as in Western countries. Policy measures that might facilitate decreases in drunkenness such as server training and the promotion of alcohol-free leisure-time activities should be reinforced in Western countries. The gender convergence implies that prevention policy should be less exclusively focused on male adolescents.
doi:10.1001/archpediatrics.2010.191
PMCID: PMC4133118  PMID: 20921343
12.  Growth and relations between auxology, caregiving environment and cognition in socially deprived Romanian children randomized to foster vs. ongoing institutional care 
Objective
To determine the effects of improved nurture compared with institutional care on physical growth and the relations between growth and cognitive development.
Design
A randomized controlled trial beginning at baseline (mean 21.0, range 5.4–32 months) with follow-up at 30, 42 and 54 months of age.
Setting
Institutionalized and community children in Bucharest, Romania
Participants
136 institutionalized though otherwise healthy children from six orphanages and 72 typically developing, never-institutionalized children.
Intervention
Institutionalized children were randomly assigned to foster care or to receive institutional care as usual.
Outcome Measures
Auxology and measures of intelligence over time.
Results
Growth in institutionalized children was compromised, particularly in infants <2,500 grams. Mean height and weight, though not head size, increased to near normal within 12 months in foster care. Significant independent predictors for greater catch-up in height and weight included age <12 months at randomization and higher caregiving quality, particularly caregiver sensitivity and positive regard. At 54 months, birth weight < 2500 grams was associated with a 11.0±3.7(standard error) point lower IQ and each incremental increase of one in standardized height scores between baseline and 42 months was associated with a 6.2±3.0 point increase in IQ (p<.05).
Conclusions
Foster care had a significant effect on growth particularly with early placement and high quality care. Growth and IQ in low birth weight children are particularly vulnerable to social deprivation. Catch-up growth in height under more nurturing conditions is a useful correlate of caregiving quality and cognitive abilities.
Trial Registration
clinicaltrials.gov Identifier: NCT00747396
doi:10.1001/archpediatrics.2010.56
PMCID: PMC4126580  PMID: 20368481
13.  Patterns of Care at End of Life in Children With Advanced Heart Disease 
Objective
To describe patterns of care for pediatric patients with advanced heart disease who experience inhospital death.
Design
Retrospective single-institution medical record review.
Setting
A tertiary care pediatric hospital.
Participants
All patients younger than 21 years who died in the inpatient setting between January 1, 2007, and December 31, 2009, with primary cardiac diagnoses or who had ever received a cardiology consult (N = 468). After excluding patients with significant noncardiac primary diagnoses, 111 children formed the analytic sample.
Main Outcome Measure
In-hospital deaths of children with heart disease during a 3-year period.
Results
Median age at death was 4.8 months (age range, 1 day to 20.5 years), with 84 deaths (75.7%) occurring before age 1 year. Median length of terminal hospital stay was 22 days (range, 1–199 days). Diagnoses included 84 patients (75.7%) with congenital heart disease, 10 (9.0%) with cardiomyopathy/myocarditis, 9 (8.1%) with pulmonary hypertension, and 8 (7.2%) with heart transplants. Sixty-two patients (55.9%) had received cardiopulmonary resuscitation during their last hospital admission. At the end of life, 21 children (18.9%) had gastrostomy tubes and 26 (23.4%) had peritoneal drains. Most patients (91.9%) received ventilation, with half also receiving mechanical circulatory support. Eighty-three patients (74.8%) experienced additional end-organ failure. Classified by mode of death, 76 patients (68.5%) had disease-directed support withdrawn, 28 (25.2%) died during resuscitation, and 7 (6.3%) died while receiving comfort care after birth. Eighty-three percent of parents were present at the time of death.
Conclusion
Infants and children who die of advanced heart disease frequently succumb in the intensive care setting with multisystem organ failure and exposure to highly technical care.
doi:10.1001/archpediatrics.2011.1829
PMCID: PMC4119813  PMID: 22473887
14.  The Impact of Statistical Choices on Neonatal Intensive Care Unit Quality Ratings Based on Nosocomial Infection Rates 
Objective
To examine the extent to which performance assessment methodologies affect the percent of neonatal intensive care units (NICUs) and very low birth weight (VLBW) infants included in performance assessments, distribution of NICU performance ratings, and level of agreement in those ratings.
Design
Cross-sectional study based on risk-adjusted nosocomial infection rates.
Setting
NICUs belonging to the California Perinatal Quality Care Collaborative 2007–2008.
Participants
126 California NICUs and 10,487 VLBW infants.
Main Exposure
Three performance assessment choices: 1. Excluding “low-volume” NICUs (those caring for < 30 VLBW infants in a year) vs. a criterion based on confidence intervals, 2. Using Bayesian vs. frequentist hierarchical models, and 3. Pooling data across one vs. two years.
Main Outcome Measures
Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the kappa statistic.
Results
Depending on the methods applied, between 51% and 85% of NICUs were included in performance assessment, the percent of VLBW infants included in performance assessment ranged from 72% to 96%, between 76–87% NICUs were considered “average,” and the level of agreement between NICU ratings ranged from 0.26 to 0.89.
Conclusions
The percent of NICUs included in performance assessment and their ratings can shift dramatically depending on performance measurement methodology. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methodologies are most appropriate for evaluating pediatric care quality.
doi:10.1001/archpediatrics.2011.41
PMCID: PMC4104272  PMID: 21536958
Quality; quality improvement; performance incentives; pay-for-performance; public reporting; neonatal intensive care units; Very Low Birth Weight infants; Nosocomial infections
15.  Stereotypies in children with a history of early institutional care 
Objectives
To investigate the prevalence of stereotypies in children with a history of early institutional care, to evaluate the efficacy of a foster care intervention compared with institutional care on the course of stereotypies, and to describe correlates in language, cognition, and anxiety for children who exhibit stereotypies.
Design
Randomized controlled trial.
Setting
Institutions in Bucharest, Romania.
Participants
136 children with a history of early institutional care.
Intervention
Comparison of a foster care intervention with continued care as usual in an institution.
Outcome Measures
The presence of stereotypies as well as outcomes in language, cognition, and anxiety.
Results
At the baseline assessment prior to placement in foster care (average age of 22 months), over 60% of children in institutional care exhibited stereotypies. Follow-up assessments at 30 months, 42 months, and 54 months indicate that being placed in families significantly reduces stereotypies, and with earlier and longer placements, reductions become larger. For children in the foster care group, but not in the care as usual group, stereotypies were significantly associated with lower outcomes on measures of language and cognition.
Conclusions
Stereotypies are prevalent in children with a history of institutional care. A foster care intervention appears to have a beneficial/moderating role on reducing stereotypies, underscoring the need for early placement in home-based care for abandoned children. Children who continue to exhibit stereotypies after foster care placement are significantly more impaired on outcomes of language and cognition than children without stereotypies, and thus may be a target for further assessments or interventions.
doi:10.1001/archpediatrics.2010.47
PMCID: PMC4086785  PMID: 20439790
16.  School bullying perpetration and other childhood risk factors as predictors of adult intimate partner violence perpetration 
Objective
School bullying perpetration and intimate partner violence perpetration are both thought to stem from desire for power and control over others. The current study seeks to assess the relationship between bullying peers as a child and adult intimate partner violence perpetration in a clinic-based sample of adult men.
Design
A cross-sectional survey was conducted between January 2005 and December 2006.
Setting
Three urban community health centers in Boston, MA.
Participants
Men aged 18–35 years (N=1,491) seeking services at participating community health centers.
Main Exposure
School bullying perpetration
Outcome Measure
Past year physical or sexual violence (IPV) perpetration against a female partner.
Results
Two-fifths of men reported perpetrating school bullying as a child (N=610; 40.9%). Men that rarely bullied in school were 1.53 times more likely to perpetrate past-year IPV (95%CI: 1.02, 2.29) as compared to men that did not bully; this risk was elevated to 3.82 times more likely to perpetrate any past-year IPV (95%CI: 2.55, 5.73) for those men who bullied peers frequently.
Conclusions
The present study indicates that bullying peers in school as a child, especially frequent bullying perpetration, is associated with increased risk for men’s perpetration of IPV as an adult. The effect remains strong after controlling for common prior risk factors for both bullying and IPV perpetration. Future research is needed to discern the mechanisms and underlying root causes of abusive behavior, such as power and control, as a means to prevent violence perpetration across settings and life stages.
doi:10.1001/archpediatrics.2011.91
PMCID: PMC4084883  PMID: 21646570
17.  Banning All Sugar-Sweetened Beverages in Middle Schools 
Objective
To determine whether state policies that regulate beverages in schools are associated with reduced in-school access and purchase of sugar-sweetened beverages (SSBs) and reduced consumption of SSBs (in and out of school) among adolescents.
Design
Cross-sectional.
Setting
Public schools in 40 states.
Participants
Students sampled in fifth and eighth grades (spring 2004 and 2007, respectively).
Main Exposures
State policies that ban all SSBs and state policies that ban only soda for 2006-2007.
Main Outcome Measures
In-school SSB access, in-school SSB purchasing behavior, and overall SSB consumption (in and out of school) in eighth grade.
Results
The proportions of eighth-grade students who reported in-school SSB access and purchasing were similar in states that banned only soda (66.6% and 28.9%, respectively) compared with states with no beverage policy (66.6% and 26.0%, respectively). In states that banned all SSBs, fewer students reported in-school SSB access (prevalence difference, −14.9; 95% CI, −23.6 to −6.1) or purchasing (−7.3; −11.0 to −3.5), adjusted for race/ethnicity, poverty status, locale, state obesity prevalence, and state clustering. Results were similar among students who reported access or purchasing SSBs in fifth grade compared with those who did not. Overall SSB consumption was not associated with state policy; in each policy category, approximately 85% of students reported consuming SSBs at least once in the past 7 days. Supplementary analyses indicated that overall consumption had only a modest association with in-school SSB access.
Conclusion
State policies that ban all SSBs in middle schools appear to reduce in-school access and purchasing of SSBs but do not reduce overall consumption.
doi:10.1001/archpediatrics.2011.200
PMCID: PMC4077154  PMID: 22064875
18.  Early Volume Expansion During Diarrhea and Relative Nephroprotection During Subsequent Hemolytic Uremic Syndrome 
Objectives
To determine if interventions during the pre–hemolytic uremic syndrome (HUS) diarrhea phase are associated with maintenance of urine output during HUS.
Design
Prospective observational cohort study.
Settings
Eleven pediatric hospitals in the United States and Scotland.
Participants
Children younger than 18 years with diarrhea-associated HUS (hematocrit level <30% with smear evidence of intravascular erythrocyte destruction), thrombocytopenia (platelet count <150 × 103/mm3), and impaired renal function (serum creatinine concentration>upper limit of reference range for age).
Interventions
Intravenous fluid was given within the first 4 days of the onset of diarrhea.
Outcome Measure
Presence or absence of oligoanuria (urine output ≤0.5 mL/kg/h for >1 day).
Results
The overall oligoanuric rate of the 50 participants was 68%, but was 84% among those who received no intravenous fluids in the first 4 days of illness. The relative risk of oligoanuria when fluids were not given in this interval was 1.6 (95% confidence interval, 1.1–2.4; P=.02). Children with oligoanuric HUS were given less total intravenous fluid (r = −0.32; P = .02) and sodium (r=−0.27; P=.05) in the first 4 days of illness than those without oligoanuria. In multivariable analysis, the most significant covariate was volume infused, but volume and sodium strongly covaried.
Conclusions
Intravenous volume expansion is an underused intervention that could decrease the frequency of oligoanuric renal failure in patients at risk of HUS.
doi:10.1001/archpediatrics.2011.152
PMCID: PMC4064458  PMID: 21784993
20.  Perils and Opportunities of Comparative Performance Measurement 
doi:10.1001/archpediatrics.2011.810
PMCID: PMC4028026  PMID: 22312179
21.  Determination of Tobacco Smoke Exposure by Plasma Cotinine Levels in Infants and Children Attending Urban Public Hospital Clinics 
Objective
To determine the prevalence of secondhand smoke (SHS) exposure among infants and young children who received preventive care at pediatric preventative care clinics associated with an urban public hospital. Cotinine, a metabolite of nicotine, has been used to study SHS exposure in population-based studies of children 3 years of age or older.
Design
Retrospective study using a convenience sample.
Setting
Urban county pediatric primary care clinics in San Francisco, California.
Participants
A total of 496 infants and children (mean [SD] age, 2.4 [1.9] years).
Interventions
Discarded plasma samples (which were routinely collected for lead screening) were tested, and medical records were reviewed, for SHS exposure.
Main Outcome Measure
Secondhand smoke exposure based on cotinine plasma level and history of exposure in the medical record.
Results
Thirteen percent of parents reported that their child was exposed to SHS, yet biochemical testing detected cotinine in 55% of samples, at a geometric mean (SD) of 0.23 (3.55) ng/mL. There were no significant sex or age differences. African American children had much higher mean cotinine levels than did Latino children (geometric mean difference, 6.07 ng/mL [95% CI, 4.37 to 8.43 ng/mL]).
Conclusion
In a city with a low smoking rate (12%) and public smoking bans, we documented 55% exposure among infants and young children, using a plasma biomarker, compared with 13% exposure reported by parents. Because SHS is associated with significant respiratory diseases and parents underreport exposure, routine biochemical screening should be considered as a tool to identify and reduce SHS exposure.
doi:10.1001/archpediatrics.2012.170
PMCID: PMC3997061  PMID: 22566513
22.  Prenatal exposure to mercury and fish consumption during pregnancy and ADHD-related behavior in children 
Objective
To investigate the association of prenatal mercury exposure and fish intake with ADHD-related behavior.
Design
Population-based prospective cohort study.
Setting
Birth cohort recruited 1993-1998 at main hospital in New Bedford, Massachusetts.
Participants
421 8-year old children with mercury measures (515 had fish consumption data).
Main Exposures
Mercury measured in peripartum maternal hair and fish consumption during pregnancy.
Main outcome measures
Inattentive and impulsive/hyperactive behaviors assessed with a teacher rating scale and neuropsychological testing.
Results
Median maternal hair mercury level was 0.45 μg/g (range=0.03-5.14) and 52% of mothers consumed >2 fish servings/week. In multivariable regression models mercury was associated with inattention and impulsivity/hyperactivity; for some outcomes there was an apparent threshold with associations at ≥1 μg/g mercury. For example, at ≥1 μg/g, the adjusted risk ratio (RR) for mild/markedly atypical DSM-IV Inattentive and Impulsive/Hyperactive behaviors was 1.4 (95% confidence interval (CI): 1.0, 1.8) and 1.7 (95% CI: 1.2, 2.4), respectively for an interquartile range (0.5 μg/g) mercury increase; there was no confounding by fish consumption. For neuropsychological assessments, mercury and behavior associations were detected primarily for boys. There was a protective association for fish consumption (>2 servings/week) with ADHD-related behaviors, particularly DSM-IV Impulsive/Hyperactive behaviors (RR=0.4; 95% CI: 0.2, 0.6).
Conclusions
Our results indicate that low-level prenatal mercury exposure is associated with greater risk for ADHD-related behaviors and that fish consumption during pregnancy is protective of these behaviors. These findings underscore the difficulties of balancing the benefits of fish with the detriments of low-level mercury in developing dietary recommendations in pregnancy.
doi:10.1001/archpediatrics.2012.1286
PMCID: PMC3991460  PMID: 23044994
23.  Comparative Efficacy and Safety of Four Randomized Regimens to Treat Early Pseudomonas aeruginosa Infection in Children with Cystic Fibrosis 
Context
While therapy for early Pa acquisition has been shown to be efficacious, the best regimen to achieve airway clearance has not been delineated.
Objectives
To investigate the efficacy and safety of four anti-pseudomonal treatments in children with cystic fibrosis (CF) with recently acquired Pa.
Design, Setting, and Patients
In a multicenter trial in the US, 304 children with CF ages 1–12 years within 6 months of Pa detection were randomized to one of four antibiotic regimens for an 18-month period (six 12-week quarters) between December 2004 and June 2009. Participants randomized to cycled therapy received tobramycin inhalation solution (300 mg BID) for 28 days, with oral ciprofloxacin (15–20 mg/kg BID) or oral placebo for 14 days every quarter, while participants randomized to culture-based therapy received the same treatments only during quarters with positive Pa cultures.
Main outcome measures
The primary endpoints were time to pulmonary exacerbation requiring intravenous antibiotics and proportion of Pa-positive cultures.
Results
The intention-to-treat analysis included 304 participants. There was no interaction between treatments. There were no statistically significant differences in exacerbation rates between cycled and culture-based groups (hazard ratio [HR], 0.95, 95%CI, 0.54–1.66) or ciprofloxacin and placebo (HR 1.45, 95%CI, 0.82–2.54). The ORs of Pa positive culture comparing cycled vs. culture-based group were 0.78 (95%CI, 0.49–1.23) and OR 1.10; 95%CI, 0.71–1.71) comparing ciprofloxacin vs. placebo. Adverse events were similar across groups.
Conclusions
No difference in rate of exacerbation or prevalence of Pa positivity was detected between cycled and culture-based therapies. Adding ciprofloxacin produced no benefits.
doi:10.1001/archpediatrics.2011.136
PMCID: PMC3991697  PMID: 21893650
Antimicrobials; Tobramycin Inhalation Solution; Ciprofloxacin; Pseudomonas aeruginosa; Mucoviscidosis; Clinical trial; Cystic Fibrosis
24.  Methamphetamine and Young Men who have Sex with Men: Patterns, Correlates and Consequences of Use 
Objectives
To examine patterns, consequences and correlates of methamphetamine use among adolescent/young adult men who have sex with men (YMSM).
Design
Descriptive, bivariate and hierarchical regression analyses of cross-sectional data.
Setting
Howard Brown Health Center, a community-based facility in Chicago, IL from 2004-2005.
Participants
310 YMSM age 16-24 completed an anonymous, computer-assisted survey.
Main Outcome Measure
Methamphetamine use in the past year.
Results
Participants ranged in age from 16-24 years (M=20.3); 70% were of color. Participants reported a number of high-risk sexual and substance use behaviors. Thirteen percent used methamphetamine in the past year. Methamphetamine use was more common among HIV-infected participants, odds ratio (OR) = 2.8; 95% confidence interval (CI) = 1.3-5.3, and varied by age and race/ethnicity; substantially higher prevalence was reported by older and non African-American YMSM (p<0.001). Compared to other illicit substance users, methamphetamine users reported more memory difficulties, impairments in daily activities and unintended risky sex resulting from substance use (all p<0.01). Hierarchical regression identified sexual risk (unprotected intercourse and multiple partners), sexualized social context (e.g. internet sex, sex in a bathhouse/sex club, sex with older partners, and commercial sex), lower self-esteem and psychological distress as correlated with methamphetamine use among participants (p<0.05).
Conclusions
A substantial proportion of YMSM in this sample use methamphetamine. Methamphetamine use is a public health problem with significant implications for the health and well-being of adolescent/young adult MSM. Methamphetamine use was associated with HIV-related risk and patterns of use were predicted by demographics, sexualized social contexts, and psychological variables.
doi:10.1001/archpedi.161.6.591
PMCID: PMC3985401  PMID: 17548765
25.  Malnutrition at Age 3 Years and Lower Cognitive Ability at Age 11 Years 
Background
Early malnutrition is linked to poor cognition, but long-term effects have not been extensively examined and psychosocial confounds have not always been controlled.
Objective
To test the hypothesis that malnutrition at age 3 years will be associated with poorer cognitive ability at age 11 years independent of psychosocial confounds.
Design
A prospective, longitudinal study of a birth cohort of 1559 children originally assessed at age 3 years for malnutrition (low hemoglobin level, angular stomatitis, kwashiorkor, and sparse, thin hair) and followed up to age 11 years.
Setting and Participants
A community sample of 1559 children (51.4% boys and 48.6% girls) born between September 1, 1969, and August 31, 1970, in 2 towns in the island of Mauritius, with 68.7% Indians and 25.7% Creoles (African origin).
Main Outcome Measures
Verbal and spatial ability measured at ages 3 and 11 years and reading, scholastic ability, and neuropsychologic performance measured at age 11 years.
Results
Malnourished children had poorer cognition at both ages. Deficits were stable across time, applied to all sex and ethnic groups, and remained after controlling for multiple measures of psychosocial adversity. Children with 3 indicators of malnutrition had a 15.3-point deficit in IQ at age 11 years.
Conclusions
Malnutrition at age 3 years is associated with poor cognition at age 11 years independent of psychosocial adversity. Promoting early childhood nutrition could enhance long-term cognitive development and school performance, especially in children with multiple nutritional deficits.
doi:10.1001/archpedi.157.6.593
PMCID: PMC3975917  PMID: 12796242

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