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1.  Vaccines: Can Transparency Increase Confidence and Reduce Hesitancy? 
Pediatrics  2014;134(2):377-379.
PMCID: PMC4187240  PMID: 25086161
vaccine safety; vaccine confidence
2.  Mechanisms to Provide Safe and Effective Drugs for Children 
Pediatrics  2014;134(2):e562-e563.
PMCID: PMC4187241  PMID: 25022746
pediatric exclusivity; off-label drug use; clinical trials
3.  HIV and Child Mental Health: A Case-Control Study in Rwanda 
Pediatrics  2014;134(2):e464-e472.
The global HIV/AIDS response has advanced in addressing the health and well-being of HIV-positive children. Although attention has been paid to children orphaned by parental AIDS, children who live with HIV-positive caregivers have received less attention. This study compares mental health problems and risk and protective factors in HIV-positive, HIV-affected (due to caregiver HIV), and HIV-unaffected children in Rwanda.
A case-control design assessed mental health, risk, and protective factors among 683 children aged 10 to 17 years at different levels of HIV exposure. A stratified random sampling strategy based on electronic medical records identified all known HIV-positive children in this age range in 2 districts in Rwanda. Lists of all same-age children in villages with an HIV-positive child were then collected and split by HIV status (HIV-positive, HIV-affected, and HIV-unaffected). One child was randomly sampled from the latter 2 groups to compare with each HIV-positive child per village.
HIV-affected and HIV-positive children demonstrated higher levels of depression, anxiety, conduct problems, and functional impairment compared with HIV-unaffected children. HIV-affected children had significantly higher odds of depression (1.68: 95% confidence interval [CI] 1.15–2.44), anxiety (1.77: 95% CI 1.14–2.75), and conduct problems (1.59: 95% CI 1.04–2.45) compared with HIV-unaffected children, and rates of these mental health conditions were similar to HIV-positive children. These results remained significant after controlling for contextual variables.
The mental health of HIV-affected children requires policy and programmatic responses comparable to HIV-positive children.
PMCID: PMC4187226  PMID: 25049342
mental health; child; HIV/AIDS; HIV-affected; HIV-infected; Rwanda
4.  Reducing Distress in Mothers of Children With Autism and Other Disabilities: A Randomized Trial 
Pediatrics  2014;134(2):e454-e463.
Compared with other parents, mothers of children with autism spectrum disorder or other neurodevelopmental disabilities experience more stress, illness, and psychiatric problems. Although the cumulative stress and disease burden of these mothers is exceptionally high, and associated with poorer outcomes in children, policies and practices primarily serve the identified child with disabilities.
A total of 243 mothers of children with disabilities were consented and randomized into either Mindfulness-Based Stress Reduction (mindfulness practice) or Positive Adult Development (positive psychology practice). Well-trained, supervised peer mentors led 6 weeks of group treatments in 1.5-hour weekly sessions, assessing mothers 6 times before, during, and up to 6 months after treatment. Mothers had children with autism (65%) or other disabilities (35%). At baseline, 85% of this community sample had significantly elevated stress, 48% were clinically depressed, and 41% had anxiety disorders.
Using slopes-as-outcomes, mixed random effects models, both treatments led to significant reductions in stress, depression, and anxiety, and improved sleep and life satisfaction, with large effects in depression and anxiety. Mothers in Mindfulness-Based Stress Reduction versus Positive Adult Development had greater improvements in anxiety, depression, sleep, and well-being. Mothers of children with autism spectrum disorder improved less in anxiety, but did not otherwise differ from their counterparts.
Future studies are warranted on how trained mentors and professionals can address the unmet mental health needs of mothers of children with developmental disabilities. Doing so improves maternal well-being and furthers their long-term caregiving of children with complex developmental, physical, and behavioral needs.
PMCID: PMC4187227  PMID: 25049350
autism spectrum disorders; developmental disabilities; maternal stress and mental health; mindfulness based stress reduction; positive psychology
5.  Successful Schools and Risky Behaviors Among Low-Income Adolescents 
Pediatrics  2014;134(2):e389-e396.
We examined whether exposure to high-performing schools reduces the rates of risky health behaviors among low-income minority adolescents and whether this is due to better academic performance, peer influence, or other factors.
By using a natural experimental study design, we used the random admissions lottery into high-performing public charter high schools in low-income Los Angeles neighborhoods to determine whether exposure to successful school environments leads to fewer risky (eg, alcohol, tobacco, drug use, unprotected sex) and very risky health behaviors (eg, binge drinking, substance use at school, risky sex, gang participation). We surveyed 521 ninth- through twelfth-grade students who were offered admission through a random lottery (intervention group) and 409 students who were not offered admission (control group) about their health behaviors and obtained their state-standardized test scores.
The intervention and control groups had similar demographic characteristics and eighth-grade test scores. Being offered admission to a high-performing school (intervention effect) led to improved math (P < .001) and English (P = .04) standard test scores, greater school retention (91% vs 76%; P < .001), and lower rates of engaging in ≥1 very risky behaviors (odds ratio = 0.73, P < .05) but no difference in risky behaviors, such as any recent use of alcohol, tobacco, or drugs. School retention and test scores explained 58.0% and 16.2% of the intervention effect on engagement in very risky behaviors, respectively.
Increasing performance of public schools in low-income communities may be a powerful mechanism to decrease very risky health behaviors among low-income adolescents and to decrease health disparities across the life span.
PMCID: PMC4187228  PMID: 25049339
disparities; education; risk-taking behavior
6.  Stool Microbiota and Vaccine Responses of Infants 
Pediatrics  2014;134(2):e362-e372.
Oral vaccine efficacy is low in less-developed countries, perhaps due to intestinal dysbiosis. This study determined if stool microbiota composition predicted infant oral and parenteral vaccine responses.
The stool microbiota of 48 Bangladeshi infants was characterized at 6, 11, and 15 weeks of age by amplification and sequencing of the 16S ribosomal RNA gene V4 region and by Bifidobacterium-specific, quantitative polymerase chain reaction. Responses to oral polio virus (OPV), bacille Calmette-Guérin (BCG), tetanus toxoid (TT), and hepatitis B virus vaccines were measured at 15 weeks by using vaccine-specific T-cell proliferation for all vaccines, the delayed-type hypersensitivity skin-test response for BCG, and immunoglobulin G responses using the antibody in lymphocyte supernatant method for OPV, TT, and hepatitis B virus. Thymic index (TI) was measured by ultrasound.
Actinobacteria (predominantly Bifidobacterium longum subspecies infantis) dominated the stool microbiota, with Proteobacteria and Bacteroidetes increasing by 15 weeks. Actinobacteria abundance was positively associated with T-cell responses to BCG, OPV, and TT; with the delayed-type hypersensitivity response; with immunoglobulin G responses; and with TI. B longum subspecies infantis correlated positively with TI and several vaccine responses. Bacterial diversity and abundance of Enterobacteriales, Pseudomonadales, and Clostridiales were associated with neutrophilia and lower vaccine responses.
Bifidobacterium predominance may enhance thymic development and responses to both oral and parenteral vaccines early in infancy, whereas deviation from this pattern, resulting in greater bacterial diversity, may cause systemic inflammation (neutrophilia) and lower vaccine responses. Vaccine responsiveness may be improved by promoting intestinal bifidobacteria and minimizing dysbiosis early in infancy.
PMCID: PMC4187229  PMID: 25002669
vaccine; intestinal; microbiota; Bifidobacterium; Actinobacteria; Proteobacteria; Bangladesh; T lymphocyte; antibody; polio; tetanus; tuberculosis; hepatitis
7.  Longitudinal Profiles of Adaptive Behavior in Fragile X Syndrome 
Pediatrics  2014;134(2):315-324.
To examine longitudinally the adaptive behavior patterns in fragile X syndrome.
Caregivers of 275 children and adolescents with fragile X syndrome and 225 typically developing children and adolescents (2–18 years) were interviewed with the Vineland Adaptive Behavior Scales every 2 to 4 years as part of a prospective longitudinal study.
Standard scores of adaptive behavior in people with fragile X syndrome are marked by a significant decline over time in all domains for males and in communication for females. Socialization skills are a relative strength as compared with the other domains for males with fragile X syndrome. Females with fragile X syndrome did not show a discernible pattern of developmental strengths and weaknesses.
This is the first large-scale longitudinal study to show that the acquisition of adaptive behavior slows as individuals with fragile X syndrome age. It is imperative to ensure that assessments of adaptive behavior skills are part of intervention programs focusing on childhood and adolescence in this condition.
PMCID: PMC4187230  PMID: 25070318
fragile X syndrome; adaptive behavior; children; adolescents; Vineland
8.  The Role of Social Impact Bonds in Pediatric Health Care 
Pediatrics  2014;134(2):e331-e333.
PMCID: PMC4187231  PMID: 25049341
social impact bonds; pay for success; prevention; social finance
9.  Treatment Outcomes of Overweight Children and Parents in the Medical Home 
Pediatrics  2014;134(2):290-297.
To test in the primary care setting the short- and long-term efficacy of a behavioral intervention that simultaneously targeted an overweight child and parent versus an information control (IC) targeting weight control only in the child.
Two- to 5-year-old children who had BMI ≥85th percentile and an overweight parent (BMI >25 kg/m2) were randomized to Intervention or IC, both receiving diet and activity education over 12 months (13 sessions) followed by 12-month follow-up (3 sessions). Parents in the Intervention group were also targeted for weight control and received behavioral intervention. Pediatricians in 4 practices enrolled their patients with the assistance of embedded recruiters (Practice Enhancement Assistants) who assisted with treatment too.
A total of 96 of the 105 children randomized (Intervention n = 46; IC n = 50) started the program and had data at baseline. Children in the Intervention experienced greater reductions in percent over BMI (group × months; P = .002) and z-BMI (group × months; P < 0.001) compared with IC throughout treatment and follow-up. Greater BMI reduction was observed over time for parents in the Intervention compared with IC (P < .001) throughout treatment and follow-up. Child weight changes were correlated with parent weight changes at 12 and 24 months (r = 0.38 and 0.26; P < .001 and P = .03).
Concurrently targeting preschool-aged overweight and obese youth and their parents in primary care with behavioral intervention results in greater decreases in child percent over BMI, z-BMI, and parent BMI compared with IC. The difference between Intervention and IC persists after 12 months of follow-up.
PMCID: PMC4187232  PMID: 25049340
overweight; obesity; patient centered medical home; percent over BMI; preschool children; expert committee recommendations
10.  Obstructive Sleep Apnea and Sickle Cell Anemia 
Pediatrics  2014;134(2):273-281.
To ascertain the prevalence of and risk factors for obstructive sleep apnea syndrome (OSAS) in children with sickle cell anemia (SCA).
Cross-sectional baseline data were analyzed from the Sleep and Asthma Cohort Study, a multicenter prospective study designed to evaluate the contribution of sleep and breathing abnormalities to SCA-related morbidity in children ages 4 to 18 years, unselected for OSAS symptoms or asthma. Multivariable logistic regression assessed the relationships between OSAS status on the basis of overnight in-laboratory polysomnography and putative risk factors obtained from questionnaires and direct measurements.
Participants included 243 children with a median age of 10 years; 50% were boys, 99% were of African heritage, and 95% were homozygous for βS hemoglobin. OSAS, defined by obstructive apnea hypopnea indices, was present in 100 (41%) or 25 (10%) children at cutpoints of ≥1 or ≥5, respectively. In univariate analyses, OSAS was associated with higher levels of habitual snoring, lower waking pulse oxygen saturation (Spo2), reduced lung function, less caretaker education, and non–preterm birth. Lower sleep-related Spo2 metrics were also associated with higher obstructive apnea hypopnea indices. In multivariable analyses, habitual snoring and lower waking Spo2 remained risk factors for OSAS in children with SCA.
The prevalence of OSAS in children with SCA is higher than in the general pediatric population. Habitual snoring and lower waking Spo2 values, data easily obtained in routine care, were the strongest OSAS risk factors. Because OSAS is a treatable condition with adverse health outcomes, greater efforts are needed to screen, diagnose, and treat OSAS in this high-risk, vulnerable population.
PMCID: PMC4187233  PMID: 25022740
sickle cell anemia; obstructive sleep apnea; polysomnography; sleep disorders; epidemiology; cohort study; blood disorders; sleep medicine
11.  Unit of Measurement Used and Parent Medication Dosing Errors 
Pediatrics  2014;134(2):e354-e361.
Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship.
Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site.
Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2–4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03–3.5) dose; associations greater for parents with low health literacy and non–English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon–associated measurement errors.
Findings support a milliliter-only standard to reduce medication errors.
PMCID: PMC4187234  PMID: 25022742
medication errors; health literacy; ambulatory care; health communication
12.  Sleep Environment Risks for Younger and Older Infants 
Pediatrics  2014;134(2):e406-e412.
Sudden infant death syndrome and other sleep-related causes of infant mortality have several known risk factors. Less is known about the association of those risk factors at different times during infancy. Our objective was to determine any associations between risk factors for sleep-related deaths at different ages.
A cross-sectional study of sleep-related infant deaths from 24 states during 2004–2012 contained in the National Center for the Review and Prevention of Child Deaths Case Reporting System, a database of death reports from state child death review teams. The main exposure was age, divided into younger (0–3 months) and older (4 months to 364 days) infants. The primary outcomes were bed-sharing, objects in the sleep environment, location (eg, adult bed), and position (eg, prone).
A total of 8207 deaths were analyzed. Younger victims were more likely bed-sharing (73.8% vs 58.9%, P < .001) and sleeping in an adult bed/on a person (51.6% vs 43.8%, P < .001). A higher percentage of older victims had an object in the sleep environment (39.4% vs 33.5%, P < .001) and changed position from side/back to prone (18.4% vs 13.8%, P < .001). Multivariable regression confirmed these associations.
Risk factors for sleep-related infant deaths may be different for different age groups. The predominant risk factor for younger infants is bed-sharing, whereas rolling into objects in the sleep area is the predominant risk factor for older infants. Parents should be warned about the dangers of these specific risk factors appropriate to their infant’s age.
PMCID: PMC4187235  PMID: 25022735
SIDS; suffocation; injury
13.  Maternal Obesity in Pregnancy, Gestational Weight Gain, and Risk of Childhood Asthma 
Pediatrics  2014;134(2):e535-e546.
Environmental or lifestyle exposures in utero may influence the development of childhood asthma. In this meta-analysis, we aimed to assess whether maternal obesity in pregnancy (MOP) or increased maternal gestational weight gain (GWG) increased the risk of asthma in offspring.
We included all observational studies published until October 2013 in PubMed, Embase, CINAHL, Scopus, The Cochrane Database, and Ovid. Random effects models with inverse variance weights were used to calculate pooled risk estimates.
Fourteen studies were included (N = 108 321 mother–child pairs). Twelve studies reported maternal obesity, and 5 reported GWG. Age of children was 14 months to 16 years. MOP was associated with higher odds of asthma or wheeze ever (OR = 1.31; 95% confidence interval [CI], 1.16–1.49) or current (OR = 1.21; 95% CI, 1.07–1.37); each 1-kg/m2 increase in maternal BMI was associated with a 2% to 3% increase in the odds of childhood asthma. High GWG was associated with higher odds of asthma or wheeze ever (OR = 1.16; 95% CI, 1.001–1.34). Maternal underweight and low GWG were not associated with childhood asthma or wheeze. Meta-regression showed a negative association of borderline significance for maternal asthma history (P = .07). The significant heterogeneity among existing studies indicates a need for standardized approaches to future studies on the topic.
MOP and high GWG are associated with an elevated risk of childhood asthma; this finding may be particularly significant for mothers without asthma history. Prospective randomized trials of maternal weight management are needed.
PMCID: PMC4187236  PMID: 25049351
childhood asthma; asthma risk factors; maternal obesity; gestational weight gain; meta-analysis
14.  Invasive Pneumococcal Disease After Implementation of 13-Valent Conjugate Vaccine 
Pediatrics  2014;134(2):210-217.
To examine whether there is a different clinical profile and severity of invasive pneumococcal disease (IPD) in children caused by nonvaccine types in the era of 13-valent pneumococcal conjugate vaccine (PCV13).
Observational study of childhood IPD in Massachusetts based on state public health surveillance data comparing pre-PCV13 (2007–2009) and post-PCV13 (2010–2012) eras.
There were 168 pre-PCV13 cases of IPD and 85 post-PCV13 cases of IPD in Massachusetts children ≤5 years of age. PCV13 serotypes declined by 18% in the first 2 years after PCV13 use (P = .011). In the post-PCV13 phase, a higher proportion of children were hospitalized (57.6% vs 50.6%), and a higher proportion of children had comorbidity (23.5% vs 19.6%). Neither difference was statistically significant, nor were comparisons of IPD caused by vaccine and nonvaccine types. Children with comorbidities had higher rates of IPD caused by a nonvaccine type (27.6% vs 17.2%; P = .085), were more likely to be hospitalized (80.4% vs 50%; P < .0001), and were more likely to have a longer hospital stay (median of 3 days vs 0.5 days; P = .0001).
Initial data suggest that nonvaccine serotypes are more common in children with underlying conditions, who have greater morbidity from disease. In the post-PCV13 era, a larger proportion of patients are hospitalized, but mortality rates are unchanged. Routine vaccination with PCV13 may not be enough to reduce the risk in patients with comorbidity.
PMCID: PMC4187237  PMID: 25002663
invasive pneumococcal disease; conjugate vaccine; children; comorbidity; severity
15.  Prevention of Traumatic Stress in Mothers of Preterms: 6-Month Outcomes 
Pediatrics  2014;134(2):e481-e488.
Symptoms of posttraumatic stress disorder are a well-recognized phenomenon in mothers of preterm infants, with implications for maternal health and infant outcomes. This randomized controlled trial evaluated 6-month outcomes from a skills-based intervention developed to reduce symptoms of posttraumatic stress disorder, anxiety, and depression.
One hundred five mothers of preterm infants were randomly assigned to (1) a 6- or 9-session intervention based on principles of trauma-focused cognitive behavior therapy with infant redefinition or (2) a 1-session active comparison intervention based on education about the NICU and parenting of the premature infant. Outcome measures included the Davidson Trauma Scale, the Beck Depression Inventory II, and the Beck Anxiety Inventory. Participants were assessed at baseline, 4 to 5 weeks after birth, and 6 months after the birth of the infant.
At the 6-month assessment, the differences between the intervention and comparison condition were all significant and sizable and became more pronounced when compared with the 4- to 5-week outcomes: Davidson Trauma Scale (Cohen's d = −0.74, P < .001), Beck Anxiety Inventory (Cohen's d = −0.627, P = .001), Beck Depression Inventory II (Cohen's d = −0.638, P = .002). However, there were no differences in the effect sizes between the 6- and 9-session interventions.
A brief 6-session intervention based on principles of trauma-focused cognitive behavior therapy was effective at reducing symptoms of trauma, anxiety, and depression in mothers of preterm infants. Mothers showed increased benefits at the 6-month follow-up, suggesting that they continue to make use of techniques acquired during the intervention phase.
PMCID: PMC4187238  PMID: 25049338
neonatal intensive care; premature infants; posttraumatic stress disorder; intervention; PTSD; preterm infants; neonatal ICU; intervention
16.  Growth After Adenotonsillectomy for Obstructive Sleep Apnea: An RCT 
Pediatrics  2014;134(2):282-289.
Adenotonsillectomy for obstructive sleep apnea syndrome (OSAS) may lead to weight gain, which can have deleterious health effects when leading to obesity. However, previous data have been from nonrandomized uncontrolled studies, limiting inferences. This study examined the anthropometric changes over a 7-month interval in a randomized controlled trial of adenotonsillectomy for OSAS, the Childhood Adenotonsillectomy Trial.
A total of 464 children who had OSAS (average apnea/hypopnea index [AHI] 5.1/hour), aged 5 to 9.9 years, were randomized to Early Adenotonsillectomy (eAT) or Watchful Waiting and Supportive Care (WWSC). Polysomnography and anthropometry were performed at baseline and 7-month follow-up. Multivariable regression modeling was used to predict the change in weight and growth indices.
Interval increases in the BMI z score (0.13 vs 0.31) was observed in both the WWSC and eAT intervention arms, respectively, but were greater with eAT (P < .0001). Statistical modeling showed that BMI z score increased significantly more in association with eAT after considering the influences of baseline weight and AHI. A greater proportion of overweight children randomized to eAT compared with WWSC developed obesity over the 7-month interval (52% vs 21%; P < .05). Race, gender, and follow-up AHI were not significantly associated with BMI z score change.
eAT for OSAS in children results in clinically significant greater than expected weight gain, even in children overweight at baseline. The increase in adiposity in overweight children places them at further risk for OSAS and the adverse consequences of obesity. Monitoring weight, nutritional counseling, and encouragement of physical activity should be considered after eAT for OSAS.
PMCID: PMC4187239  PMID: 25070302
BMI; height; weight
17.  Autism Spectrum Disorders and Race, Ethnicity, and Nativity: A Population-Based Study 
Pediatrics  2014;134(1):e63-e71.
Our understanding of the influence of maternal race/ethnicity and nativity and childhood autistic disorder (AD) in African Americans/blacks, Asians, and Hispanics in the United States is limited. Phenotypic differences in the presentation of childhood AD in minority groups may indicate etiologic heterogeneity or different thresholds for diagnosis. We investigated whether the risk of developing AD and AD phenotypes differed according to maternal race/ethnicity and nativity.
Children born in Los Angeles County with a primary AD diagnosis at ages 3 to 5 years during 1998–2009 were identified and linked to 1995–2006 California birth certificates (7540 children with AD from a cohort of 1 626 354 births). We identified a subgroup of children with AD and a secondary diagnosis of mental retardation and investigated heterogeneity in language and behavior.
We found increased risks of being diagnosed with AD overall and specifically with comorbid mental retardation in children of foreign-born mothers who were black, Central/South American, Filipino, and Vietnamese, as well as among US-born Hispanic and African American/black mothers, compared with US-born whites. Children of US African American/black and foreign-born black, foreign-born Central/South American, and US-born Hispanic mothers were at higher risk of exhibiting an AD phenotype with both severe emotional outbursts and impaired expressive language than children of US-born whites.
Maternal race/ethnicity and nativity are associated with offspring’s AD diagnosis and severity. Future studies need to examine factors related to nativity and migration that may play a role in the etiology as well as identification and diagnosis of AD in children.
PMCID: PMC4067639  PMID: 24958588
autistic disorder; emigration and immigration; epidemiology; continental population groups
18.  Cardiovascular Responses to Caffeine by Gender and Pubertal Stage 
Pediatrics  2014;134(1):e112-e119.
Caffeine use is on the rise among children and adolescents. Previous studies from our laboratory reported gender differences in the effects of caffeine in adolescents. The purpose of this study was to test the hypotheses that gender differences in cardiovascular responses to caffeine emerge after puberty and that cardiovascular responses to caffeine differ across the phases of the menstrual cycle.
To test these hypotheses, we examined heart rate and blood pressure before and after administration of placebo and 2 doses of caffeine (1 and 2 mg/kg) in prepubertal (8- to 9-year-olds; n = 52) and postpubertal (15- to 17-year-olds; n = 49) boys (n = 54) and girls (n = 47) by using a double-blind, placebo-controlled, dose-response design.
There was an interaction between gender and caffeine dose, with boys having a greater response to caffeine than girls. In addition, we found interactions between pubertal phase, gender, and caffeine dose, with gender differences present in postpubertal, but not in prepubertal, participants. Finally, we found differences in responses to caffeine across the menstrual cycle in post-pubertal girls, with decreases in heart rate greater in the midluteal phase and blood pressure increases greater in the midfollicular phase of the menstrual cycle.
These data suggest that gender differences in response to caffeine emerge after puberty. Future research will determine the extent to which these gender differences are mediated by physiological factors, such as steroid hormones, or psychosocial factors, such as more autonomy and control over beverage purchases.
PMCID: PMC4067640  PMID: 24935999
19.  Firearm Homicide and Other Causes of Death in Delinquents: A 16-Year Prospective Study 
Pediatrics  2014;134(1):63-73.
Delinquent youth are at risk for early violent death after release from detention. However, few studies have examined risk factors for mortality. Previous investigations studied only serious offenders (a fraction of the juvenile justice population) and provided little data on females.
The Northwestern Juvenile Project is a prospective longitudinal study of health needs and outcomes of a stratified random sample of 1829 youth (657 females, 1172 males; 524 Hispanic, 1005 African American, 296 non-Hispanic white, 4 other race/ethnicity) detained between 1995 and 1998. Data on risk factors were drawn from interviews; death records were obtained up to 16 years after detention. We compared all-cause mortality rates and causes of death with those of the general population. Survival analyses were used to examine risk factors for mortality after youth leave detention.
Delinquent youth have higher mortality rates than the general population to age 29 years (P < .05), irrespective of gender or race/ethnicity. Females died at nearly 5 times the general population rate (P < .05); Hispanic males and females died at 5 and 9 times the general population rates, respectively (P < .05). Compared with the general population, significantly more delinquent youth died of homicide and its subcategory, homicide by firearm (P < .05). Among delinquent youth, racial/ethnic minorities were at increased risk of homicide compared with non-Hispanic whites (P < .05). Significant risk factors for external-cause mortality and homicide included drug dealing (up to 9 years later), alcohol use disorder, and gang membership (up to a decade later).
Delinquent youth are an identifiable target population to reduce disparities in early violent death.
PMCID: PMC4067641  PMID: 24936005
alcohol use; drug dealing; gangs; firearms; juvenile delinquents; longitudinal studies; mortality; prospective studies; public health; substance use
20.  Adjustment Among Area Youth After the Boston Marathon Bombing and Subsequent Manhunt 
Pediatrics  2014;134(1):7-14.
The majority of research on terrorism-exposed youth has examined large-scale terrorism with mass casualties. Limited research has examined children’s reactions to terrorism of the scope of the Boston Marathon bombing. Furthermore, the extraordinary postattack interagency manhunt and shelter-in-place warning made for a truly unprecedented experience in its own right for families. Understanding the psychological adjustment of Boston-area youth in the aftermath of these events is critical for informing clinical efforts.
Survey of Boston-area parents/caretakers (N = 460) reporting on their child’s experiences during the attack week, as well as psychosocial functioning in the first 6 attack months.
There was heterogeneity across youth in attack- and manhunt-related experiences and clinical outcomes. The proportion of youth with likely attack/manhunt-related posttraumatic stress disorder (PTSD) was roughly 6 times higher among Boston Marathon–attending youth than nonattending youth. Attack and manhunt experiences each uniquely predicted 9% of PTSD symptom variance, with manhunt exposures more robustly associated than attack-related exposures with a range of psychosocial outcomes, including emotional symptoms, conduct problems, hyperactivity/inattention, and peer problems. One-fifth of youth watched >3 hours of televised coverage on the attack day, which was linked to PTSD symptoms, conduct problems, and total difficulties. Prosocial behavior and positive peer functioning buffered the impact of exposure.
Clinical efforts must maintain a broadened focus beyond simply youth present at the blasts and must also include youth highly exposed to the intense interagency pursuit and manhunt. Continued research is needed to understand the adjustment of youth after mass traumas and large-scale manhunts in residential communities.
PMCID: PMC4067642  PMID: 24918223
trauma; terrorism; PTSD; mental health; disaster
21.  Cognitive Deficit and Mental Health in Homeless Transition-Age Youth 
Pediatrics  2014;134(1):e138-e145.
There is increasing recognition of the cognitive consequences of socioeconomic adversity during childhood, which can impair learning and negatively affect social and emotional development. However, there is a paucity of research on cognitive functioning and mental health among transition-age homeless youth. This study aimed to address this knowledge gap by examining the prevalence and functional significance of cognitive impairment and mental health disorders in a sample of 18- to 22-year-old homeless youth.
Participants (N = 73) were recruited from a vocational support program at Covenant House New York, a care agency for homeless youth. Assessments included diagnostic assessment for mental health disorders and evaluation of neurocognition and vocational outcomes.
Youth demonstrated histories of academic instability, academic achievement below expectation, and high rates of untreated psychiatric disorders, the most prominent of which were anxiety, substance use, and mood disorders. Of those who had a mental health diagnosis, more than half demonstrated cognitive deficits. Performance on measures of working memory and verbal memory was <70% of that of the age-matched normative population. Cognitive impairment was associated with a significant risk for making a wage insufficient for independent living.
These data confirm the need to focus on cognitive as well as emotional and physical health in transition-age youth. Comprehensive intervention at this later developmental stage has the potential to facilitate the acquisition of skills needed for academic, vocational, and independent living success in adulthood.
PMCID: PMC4067643  PMID: 24958581
homeless youth; transition-age; cognition; mental health
22.  Hypertension Screening Using Blood Pressure to Height Ratio 
Pediatrics  2014;134(1):e106-e111.
The definition of hypertension in children is too complex to be used by medical professionals and children and their parents because of the age-, gender-, and height-specific blood pressure (BP) algorithm. The aim of this study was to simplify the pediatric BP percentile references using BP to height ratio (BPHR, equal to BP/height) for screening for prehypertension and hypertension in Chinese children.
Data were obtained from the China Health and Nutrition Survey, which was conducted from 1991 to 2009 and included 11 661 children aged 6 to 17 years with complete data on age, gender, height, and BP values. Receiver operating characteristic curve analysis was performed to assess the performance of systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) for screening for pediatric prehypertension and hypertension.
The optimal thresholds for defining prehypertension were 0.81 in children aged 6 to 11 years and 0.70 in adolescents aged 12 to 17 years for SBPHR and 0.52 in children and 0.46 in adolescents for DBPHR, respectively. The corresponding values for hypertension were 0.84, 0.78, 0.55, and 0.50, respectively. The negative predictive values were much higher (all ≥99%) for prehypertension and hypertension, although the positive predictive values were relatively lower, ranging from 13% to 75%.
BPHR index is simple and accurate for screening for prehypertension and hypertension in Chinese children aged 6 to 17 years and can be used for early screening or treating Chinese children with hypertension.
PMCID: PMC4067644  PMID: 24913794
blood pressure to height ratio; high blood pressure; children; diagnostic criteria
23.  Elucidating Challenges and Opportunities in the Transition to ICD-10-CM 
Pediatrics  2014;134(1):169-170.
PMCID: PMC4067645  PMID: 24918216
ICD-10; informatics; diagnostic codes; medical billing; electronic health records
24.  Development of Guidelines for Skeletal Survey in Young Children With Fractures 
Pediatrics  2014;134(1):45-53.
To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties.
Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children <24 months old. After discussion on the initial ratings, panelists rerated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary.
Panelists agreed that SS is “appropriate” for 191 (80%) of 240 scenarios rated and “necessary” for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type.
A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse.
PMCID: PMC4067633  PMID: 24935996
child abuse; child maltreatment; fracture; skeletal survey; trauma
25.  Five-Year Follow-up of Community Pediatrics Training Initiative 
Pediatrics  2014;134(1):83-90.
To compare community involvement of pediatricians exposed to enhanced residency training as part of the Dyson Community Pediatrics Training Initiative (CPTI) with involvement reported by a national sample of pediatricians.
A cross-sectional analyses compared 2008–2010 mailed surveys of CPTI graduates 5 years after residency graduation with comparably aged respondents in a 2010 mailed national American Academy of Pediatrics survey of US pediatricians (CPTI: n = 234, response = 56.0%; national sample: n = 243; response = 59.9%). Respondents reported demographic characteristics, practice characteristics (setting, time spent in general pediatrics), involvement in community child health activities in past 12 months, use of ≥1 strategies to influence community child health (eg, educate legislators), and being moderately/very versus not at all/minimally skilled in 6 such activities (eg, identify community needs). χ2 statistics assessed differences between groups; logistic regression modeled the independent association of CPTI with community involvement adjusting for personal and practice characteristics and perspectives regarding involvement.
Compared with the national sample, more CPTI graduates reported involvement in community pediatrics (43.6% vs 31.1%, P < .01) and being moderately/very skilled in 4 of 6 community activities (P < .05). Comparable percentages used ≥1 strategies (52.2% vs 47.3%, P > .05). Differences in involvement remained in adjusted analyses with greater involvement by CPTI graduates (adjusted odds ratio 2.4, 95% confidence interval 1.5–3.7).
Five years after residency, compared with their peers, more CPTI graduates report having skills and greater community pediatrics involvement. Enhanced residency training in community pediatrics may lead to a more engaged pediatrician workforce.
PMCID: PMC4067634  PMID: 24982098
community health services; pediatrics/manpower; child advocacy/education

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