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1.  Behavioral Health Services Following Implementation of Screening in Massachusetts Medicaid Children 
Pediatrics  2014;134(4):737-746.
To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children.
After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007–June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services.
Of 261 160 children in the cohort, 45% (118 464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22–11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53–4.06).
Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.
PMCID: PMC4179096  PMID: 25225135
behavioral health services; screening; primary care; Medicaid; children
2.  Using CD4 Percentage and Age to Optimize Pediatric Antiretroviral Therapy Initiation 
Pediatrics  2014;134(4):e1104-e1116.
Quantifying pediatric immunologic recovery by highly active antiretroviral therapy (HAART) initiation at different CD4 percentage (CD4%) and age thresholds may inform decisions about timing of treatment initiation.
HIV-1-infected, HAART-naive children in Europe and the Americas were followed from 2002 through 2009 in PENPACT-1. Data from 162 vertically infected children, with at least World Health Organization “mild” immunosuppression and CD4% <10th percentile, were analyzed for improvement to a normal CD4% (≥10th percentile) within 4 years after HAART initiation. Data from 209 vertically infected children, regardless of immune status, were analyzed for CD4% outcomes at 4 years and viral failure within 4 years.
Seventy-two percent of baseline immunosuppressed children recovered to normal within 4 years. Compared with “severe” immunosuppression, more children with “mild” immunosuppression (difference 36%, 95% confidence interval [CI]: 22% to 49%) or “advanced” immunosuppression (difference 20.8%, 95% CI: 5.8% to 35.9%) recovered a normal CD4%. For each 5-year increase in baseline age, the proportion of children achieving a normal CD4% declined by 19% (95% CI: 11% to 27%). Combining baseline CD4% and age effects resulted in >90% recovery when initiating HAART with “mild” immunosuppression at any age or “advanced” immunosuppression at age <3 years. Baseline CD4% effects became greater with increasing age (P = .02). At 4 years, most immunologic benefits were still significant but diminished. Viral failure was highest in infancy (56%) and adolescence (63%).
Initiating HAART at higher CD4% and younger ages maximizes potential for immunologic recovery. Guidelines should weigh immunologic benefits against long-term risks.
PMCID: PMC4179097  PMID: 25266426
child; HIV; immunologic; reconstitution; treatment failure
3.  Immunologic Effects of Hydroxyurea in Sickle Cell Anemia 
Pediatrics  2014;134(4):686-695.
Susceptibility to encapsulated bacteria is well known in sickle cell disease (SCD). Hydroxyurea use is common in adults and children with SCD, but little is known about hydroxyurea’s effects on immune function in SCD. Because hydroxyurea inhibits ribonucleotide reductase, causing cell cycle arrest at the G1–S interface, we postulated that hydroxyurea might delay transition from naive to memory T cells, with inhibition of immunologic maturation and vaccine responses.
T-cell subsets, naive and memory T cells, and antibody responses to pneumococcal and measles, mumps, and rubella vaccines were measured among participants in a multicenter, randomized, double-blind, placebo-controlled trial of hydroxyurea in infants and young children with SCD (BABY HUG).
Compared with placebo, hydroxyurea treatment resulted in significantly lower total lymphocyte, CD4, and memory T-cell counts; however, these numbers were still within the range of historical healthy controls. Antibody responses to pneumococcal vaccination were not affected, but a delay in achieving protective measles antibody levels occurred in the hydroxyurea group. Antibody levels to measles, mumps, and rubella showed no differences between groups at exit, indicating that effective immunization can be achieved despite hydroxyurea use.
Hydroxyurea does not appear to have significant deleterious effects on the immune function of infants and children with SCD. Additional assessments of lymphocyte parameters of hydroxyurea-treated children may be warranted. No changes in current immunization schedules are recommended; however, for endemic disease or epidemics, adherence to accelerated immunization schedules for the measles, mumps, and rubella vaccine should be reinforced.
PMCID: PMC4179098  PMID: 25180279
sickle cell disease; hydroxyurea; immunology; vaccines
4.  Pertussis Immunization in Infancy and Adolescent Asthma Medication 
Pediatrics  2014;134(4):721-728.
Childhood immunization may influence the development of asthma, possibly due to lack of infections or a shift in the T-helper cell type 1/T-helper cell type 2/regulatory T cells balance. We therefore investigated whether pertussis immunization in infancy is associated with asthma medication in adolescence.
After 14 years of no general pertussis vaccination, almost 82 000 Swedish children were immunized for pertussis in a vaccination trial between June 1, 1993, and June 30, 1994. In a follow-up analysis of almost 80 000 children, their data were compared with those of ∼100 000 nonvaccinated children, born during a 5-month period before and a 7-month period after the vaccination trial. Data for the main outcome variable (ie, dispensed prescribed asthma medication for each individual in the cohort during 2008–2010) were obtained from the national prescription database. Multivariate regression models were used to calculate the effect size of vaccination on dispensed asthma medication (odds ratios [OR], 95% confidence intervals [CI]). Approaches similar to intention-to-treat and per-protocol methods were used.
The prevalence rates of various asthma medications for study patients at 15 years of age differed between 4.6% and 7.0%. The crude ORs for any asthma medication and antiinflammatory treatment in pertussis-vaccinated children after intention-to-treat analysis were 0.97 (95% CI: 0.93–1.00) and 0.94 (95% CI: 0.90–0.98), respectively. Corresponding adjusted ORs were 0.99 (95% CI: 0.95–1.03) and 0.97 (95% CI: 0.92–1.01). Similar ORs were found after per-protocol analysis.
Pertussis immunization in infancy does not increase the risk of asthma medication use in adolescents. Our study presents evidence that pertussis immunization in early childhood can be considered safe with respect to long-term development of asthma.
PMCID: PMC4179099  PMID: 25246621
asthma; immunization; national cohort; medication; pertussis
5.  Quality Health Care for Children and the Affordable Care Act: A Voltage Drop Checklist 
Pediatrics  2014;134(4):794-802.
The Affordable Care Act (ACA) introduces enormous policy changes to the health care system with several anticipated benefits and a growing number of unanticipated challenges for child and adolescent health. Because the ACA gives each state and their payers substantial autonomy and discretion on implementation, understanding potential effects will require state-by-state monitoring of policies and their impact on children. The “voltage drop” framework is a useful interpretive guide for assessing the impact of insurance market change on the quality of care received. Using this framework we suggest a state-level checklist to examine ACA statewide implementation, assess its impact on health care delivery, and frame policy correctives to improve child health system performance. Although children’s health care is a small part of US health care spending, child health provides the foundation for adult health and must be protected in ACA implementation.
PMCID: PMC4179100  PMID: 25225140
health insurance; Affordable Care Act; health reform; children; child health financing; federal policy; advocacy
6.  Birth Size and Brain Function 75 Years Later 
Pediatrics  2014;134(4):761-770.
There are several lines of evidence pointing to fetal and other early origins of diseases of the aging brain, but there are no data directly addressing the hypotheses in an older population. We investigated the association of fetal size to late-age measures of brain structure and function in a large cohort of older men and women and explored the modifying effect of education on these associations.
Within the AGES (Age Gene/Environment Susceptibility)-Reykjavik population-based cohort (born between 1907 and 1935), archived birth records were abstracted for 1254 men and women who ∼75 years later underwent an examination that included brain MRI and extensive cognitive assessment.
Adjustment for intracranial volume, demographic and medical history characteristics, and lower Ponderal index at birth (per kg/m3), an indicator of third-trimester fetal wasting, was significantly associated with smaller volumes of total brain and white matter; βs (95% confidence intervals) were −1.0 (−1.9 to −0.0) and −0.5 (−1.0 to −0.0) mL. Furthermore, lower Ponderal index was associated with slower processing speed and reduced executive functioning but only in those with low education (β [95% confidence interval]: −0.136 [−0.235 to −0.036] and −0.077 [−0.153 to −0.001]).
This first study of its kind provides clinical measures suggesting that smaller birth size, as an indicator of a suboptimal intrauterine environment, is associated with late-life alterations in brain tissue volume and function. In addition, it shows that the effects of a suboptimal intrauterine environment on late-life cognitive function were present only in those with lower educational levels.
PMCID: PMC4179101  PMID: 25180277
birth size; education; brain atrophy; cognition; aging
7.  Dating Violence, Childhood Maltreatment, and BMI From Adolescence to Young Adulthood 
Pediatrics  2014;134(4):678-685.
This study tested whether dating violence (DV) victimization is associated with increases in BMI across the transition from adolescence to young adulthood and whether gender and previous exposure to child maltreatment modify such increases.
Data were from participants (N = 9295; 49.9% female) in the National Longitudinal Study of Adolescent Health. BMI was calculated from measured height and weight at waves 2, 3, and 4 of the study. DV victimization was measured at waves 2, 3, and 4 by using items from the revised Conflict Tactics Scales. Linear regression by using generalized estimating equations with robust SEs was used to test the association. Models were stratified according to gender and history of child maltreatment.
From baseline to wave 4, BMI increased on average 6.5 units (95% confidence interval [CI]: 6.2–6.7) and 6.8 units (95% CI: 6.5–7.1) among men and women, respectively, and nearly one-half (45.5% of men; 43.9% of women) reported DV at some point. In stratified models, DV victimization (β: 0.3 [95% CI: 0.0–0.6]) independently predicted BMI increase over time in women. Exposure to childhood sexual abuse magnified the increase in BMI associated with DV victimization (β: 1.3 [95% CI: 0.3–2.3]). No other types of childhood maltreatment were significant modifiers of the DV–BMI association. Violence victimization was not associated with BMI among men.
Screening and support for DV victims, especially women who have also experienced childhood maltreatment, may be warranted to reduce the likelihood of health consequences associated with victimization.
PMCID: PMC4179102  PMID: 25201793
adolescents; child neglect; domestic violence; sexual abuse
8.  Cardio-Facio-Cutaneous Syndrome: Clinical Features, Diagnosis, and Management Guidelines 
Pediatrics  2014;134(4):e1149-e1162.
Cardio-facio-cutaneous syndrome (CFC) is one of the RASopathies that bears many clinical features in common with the other syndromes in this group, most notably Noonan syndrome and Costello syndrome. CFC is genetically heterogeneous and caused by gene mutations in the Ras/mitogen-activated protein kinase pathway. The major features of CFC include characteristic craniofacial dysmorphology, congenital heart disease, dermatologic abnormalities, growth retardation, and intellectual disability. It is essential that this condition be differentiated from other RASopathies, as a correct diagnosis is important for appropriate medical management and determining recurrence risk. Children and adults with CFC require multidisciplinary care from specialists, and the need for comprehensive management has been apparent to families and health care professionals caring for affected individuals. To address this need, CFC International, a nonprofit family support organization that provides a forum for information, support, and facilitation of research in basic medical and social issues affecting individuals with CFC, organized a consensus conference. Experts in multiple medical specialties provided clinical management guidelines for pediatricians and other care providers. These guidelines will assist in an accurate diagnosis of individuals with CFC, provide best practice recommendations, and facilitate long-term medical care.
PMCID: PMC4179092  PMID: 25180280
cardio-facio-cutaneous syndrome; BRAF mutation; management guidelines; MEK1 mutation; MEK2 mutation; RASopathy
9.  Effects of the FITKids Randomized Controlled Trial on Executive Control and Brain Function 
Pediatrics  2014;134(4):e1063-e1071.
To assess the effect of a physical activity (PA) intervention on brain and behavioral indices of executive control in preadolescent children.
Two hundred twenty-one children (7–9 years) were randomly assigned to a 9-month afterschool PA program or a wait-list control. In addition to changes in fitness (maximal oxygen consumption), electrical activity in the brain (P3-ERP) and behavioral measures (accuracy, reaction time) of executive control were collected by using tasks that modulated attentional inhibition and cognitive flexibility.
Fitness improved more among intervention participants from pretest to posttest compared with the wait-list control (1.3 mL/kg per minute, 95% confidence interval [CI]: 0.3 to 2.4; d = 0.34 for group difference in pre-to-post change score). Intervention participants exhibited greater improvements from pretest to posttest in inhibition (3.2%, 95% CI: 0.0 to 6.5; d = 0.27) and cognitive flexibility (4.8%, 95% CI: 1.1 to 8.4; d = 0.35 for group difference in pre-to-post change score) compared with control. Only the intervention group increased attentional resources from pretest to posttest during tasks requiring increased inhibition (1.4 µV, 95% CI: 0.3 to 2.6; d = 0.34) and cognitive flexibility (1.5 µV, 95% CI: 0.6 to 2.5; d = 0.43). Finally, improvements in brain function on the inhibition task (r = 0.22) and performance on the flexibility task correlated with intervention attendance (r = 0.24).
The intervention enhanced cognitive performance and brain function during tasks requiring greater executive control. These findings demonstrate a causal effect of a PA program on executive control, and provide support for PA for improving childhood cognition and brain health.
PMCID: PMC4179093  PMID: 25266425
cognition; physical activity; aerobic fitness; randomized controlled trial
10.  Maintenance of Certification Part 4 Credit and Recruitment for Practice-Based Research 
Pediatrics  2014;134(4):747-753.
Competing priorities in pediatric practice have created challenges for practice-based research. To increase recruitment success, researchers must design studies that provide added value to participants. This study evaluates recruitment of pediatricians into a study, before and after the development and addition of a quality improvement (QI) curriculum approved for American Board of Pediatrics Maintenance of Certification (MOC) Part 4 Credit as an enrollment incentive.
Researchers implemented multiple outreach methods to enroll pediatric practices over 28 months. Field note review revealed that many physicians declined enrollment, stating that they prioritized MOC Part 4 projects over research studies. A QI curriculum meeting standards for MOC Part 4 Credit was developed and added to the study protocol as an enrollment incentive. Enrollment rates and characteristics of practitioners enrolled pre- and post-MOC were compared.
Pre-MOC enrollment contributed 48% of practices in 22 months; post-MOC enrollment contributed 49% of practices in 6 months. An average of 3.5 practices enrolled per month pre-MOC, compared with 13.1 per month post-MOC (P < .001). Clinicians in pre- and post-MOC groups were similar in age, gender, race, and time spent on patient care; practices enrolled post-MOC were more likely to be located in federally designated Medically Underserved Areas than those enrolled pre-MOC (28.6% vs 12%, P = .03).
Addition of MOC Part 4 Credit increased recruitment success and increased enrollment of pediatricians working in underserved areas. Including QI initiatives meeting MOC Part 4 criteria in practice-based research protocols may enhance participation and aid in recruiting diverse practice and patient populations.
PMCID: PMC4179094  PMID: 25180282
quality improvement; research methods
11.  ADHD, Stimulant Treatment, and Growth: A Longitudinal Study 
Pediatrics  2014;134(4):e935-e944.
There is ongoing concern that stimulant medications may adversely affect growth. In a sample of attention-deficit/hyperactivity disorder (ADHD) cases and controls from a population-based birth cohort, we assessed growth and the association between stimulant treatment and growth.
Subjects included childhood ADHD cases (N = 340) and controls (N = 680) from a 1976 to 1982 birth cohort (N = 5718). Height and stimulant treatment information were abstracted from medical records and obtained during a prospective, adult follow-up study. For each subject, a parametric penalized spline smoothing method modeled height over time, and the corresponding height velocity was calculated as the first derivative. Peak height velocity (PHV) age and magnitude were estimated from the velocity curves. Among stimulant-treated ADHD cases, we analyzed height Z scores at the beginning, at the end, and 24 months after the end of treatment.
Neither ADHD itself nor treatment with stimulants was associated with differences in magnitude of PHV or final adult height. Among boys treated with stimulants, there was a positive correlation between duration of stimulant usage before PHV and age at PHV (r = 0.21, P = .01). There was no significant correlation between duration of treatment and change in height Z scores (r = −0.08 for beginning vs end change, r = 0.01 for end vs 24 months later change). Among the 59 ADHD cases treated for ≥3 years, there was a clinically insignificant decrease in mean Z score from beginning (0.48) to end (0.33) of treatment (P = .06).
Our findings suggest that ADHD treatment with stimulant medication is not associated with differences in adult height or significant changes in growth.
PMCID: PMC4179095  PMID: 25180281
attention-deficit/hyperactivity disorder; stimulant medications; adult outcomes; height; growth
12.  Infliximab/Plasmapheresis in Vanishing Bile Duct Syndrome Secondary to Toxic Epidermal Necrolysis 
Pediatrics  2014;134(4):e1194-e1198.
Vanishing bile duct syndrome (VBDS) is a rare disorder characterized by loss of interlobular bile ducts and progressive worsening cholestasis. The acute presentation of this disease is typically associated with a drug hypersensitivity and Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN). The mainstay of treatment has been ursodeoxycholic acid with mixed results from immunosuppressive regimens. Anti–tumor necrosis factor-α and plasmapheresis have been speculated to be of potential benefit. It is hoped that early identification and intervention in VBDS secondary to Stevens-Johnson syndrome/TEN with continued reporting will lead to better regimens and outcomes. Our case report details the first reported use of infliximab and plasmapheresis, in addition to steroids, in a patient with VBDS secondary to TEN, as well as a literature review that supports a mechanism for why these modalities could be effective treatments. Unfortunately, our patient died, and the use of these therapies had an unclear benefit on his liver and skin disease. We hope that additional work can be published to confirm or refute their utility in the treatment of these diseases.
PMCID: PMC4535040  PMID: 25246624
vanishing bile duct; Stephens-Johnson syndrome; toxic epidermal necrolysis; TNF-α inhibitor; plasmapheresis
13.  Challenges to School-Located Vaccination: Lessons Learned 
Pediatrics  2014;134(4):803-808.
School-located vaccination (SLV) has a long history in the United States and has successfully contributed to lower morbidity and mortality due to vaccine-preventable diseases.1 Historically, SLV efforts, which tended to be single-vaccine programs intended to provide catch-up immunization to a defined school-age cohort or were implemented in response to an outbreak, were unfunded, funded by local health department, or were funded by industry or federal grants. The growing palette of vaccines recommended for routine use in adolescents along with limited success of office-based adolescent immunization create a compelling argument for the creation of financially sustainable SLV programs. An arguably significant barrier to both office-based and school-located adolescent immunization is the modest reimbursement rates afforded to immunizers. Because the immunization promotion and consent process is expensive, these costs must be reduced to a minimum to reach financial viability. Although there are challenges to creating a financially sustainable SLV program coordinated by an academic medical center, (AMC), the ability of AMCs to bill private and public insurers, the nonprofit status of medical centers, the allowances for faculty for academic pursuit, and the substantial infrastructure already present make AMCs a potentially practical site for the administration of SLV programs. Alternatively, as health departments throughout the nation continue to explore methods for billing private insurance, we may find health departments to be uniquely suited for coordinating the administration and billing of these services.
PMCID: PMC4535041  PMID: 25225142
school-located vaccination; adolescents; financial lessons
14.  Breastfeeding and Later Psychosocial Development of Children at 6 Years of Age 
Pediatrics  2014;134(Suppl 1):S36-S41.
To examine the association of breastfeeding duration with psychosocial development at 6 years of age.
We analyzed data from the 2005–2007 Infant Feeding Practices Study II and its 2012 Year 6 Follow-Up (N = 1442). Our breastfeeding duration variable combined overall and exclusive breastfeeding reported during infancy (never breastfed, breastfed <6 months, breastfed ≥6 months + exclusive breastfeeding <3 months, and breastfed ≥6 months + exclusive breastfeeding ≥3 months). Maternal responses to the Strengths and Difficulties Questionnaire were used to create our child psychosocial outcome domains (emotional symptoms, conduct problems, hyperactivity, peer problems, prosocial behavior, and total difficulties). Separate multivariable logistic regression models controlling for maternal sociodemographic characteristics, maternal mental health, and child characteristics were used to assess the likelihood of having difficulties on the 6 domains based on breastfeeding duration.
Compared with children who were never breastfed, those who were breastfed for ≥6 months and exclusively breastfed for ≥3 months had decreased odds of difficulties with emotional symptoms (odds ratio [OR]: 0.52; 95% confidence interval [CI]: 0.27–0.99), conduct problems (OR: 0.24; 95% CI: 0.10–0.54), and total difficulties (OR: 0.39; 95% CI: 0.18–0.85) before adjustment. These associations were no longer significant after adjustment.
Although in our unadjusted analyses we observed significant associations between breastfeeding duration and later psychosocial development, including decreased odds of emotional, conduct, and total difficulties at 6 years of age, these findings were no longer detectable after adjusting for the many potential confounding factors that play a role in psychosocial development.
PMCID: PMC4258843  PMID: 25183753
breastfeeding; child; social psychology; behavior; Strengths and Difficulties Questionnaire
15.  Infant Feeding Practices and Reported Food Allergies at 6 Years of Age 
Pediatrics  2014;134(Suppl 1):S21-S28.
The goal of this study was to identify the frequency of physician-diagnosed food allergies among 6-year-old US children and study the impact of exclusive breastfeeding and complementary food introduction on this frequency.
Data were analyzed from children who participated in the Infant Feeding Practices Study II Year 6 Follow-Up Study (Y6FU). Children with probable food allergy (pFA) were defined as children with report of physician-diagnosed food allergy at age 6 years. Subgroups of pFA included children who were not diagnosed before 1 year of age (new pFA) and those with atopic risk factors (high risk).
Prevalence of total pFA in the Y6FU was 6.34%. The majority of these children had new pFA and high-risk factors. Higher maternal education, higher family income, family history of food allergy, and reported eczema before 1 year of age were significantly associated with higher odds of total or new pFA. Exclusive breastfeeding duration and timing of complementary food introduction were not significantly associated with total pFA. However, exclusive breastfeeding of ≥4 months compared with no breastfeeding was marginally associated with lower odds of new pFA (adjusted odds ratio: 0.51; P = .07); this effect was not observed with high-risk children.
Analysis of infant and maternal variables in the Y6FU cohort of US children revealed that socioeconomic and atopic factors were the main predictors of pFA at age 6 years. Exclusive breastfeeding of ≥4 months may have a preventive effect on development of pFA after 1 year of age in non high-risk children.
PMCID: PMC4258844  PMID: 25183751
breastfeeding; children; complementary foods; food allergy; physician diagnosis; prevalence; risk factors
16.  Fruit and Vegetable Intake During Infancy and Early Childhood 
Pediatrics  2014;134(Suppl 1):S63-S69.
To examine the association of timing of introduction and frequency of fruit and vegetable intake during infancy with frequency of fruit and vegetable intake at age 6 years in a cohort of US children.
We analyzed data on fruit and vegetable intake during late infancy, age of fruit and vegetable introduction, and frequency of fruit and vegetable intake at 6 years from the Infant Feeding Practices Study II and the Year 6 Follow-Up (Y6FU) Study. We determined the percent of 6-year-old children consuming fruits and vegetables less than once per day and examined associations with infant fruit and vegetable intake using logistic regression modeling, controlling for multiple covariates (n = 1078).
Based on maternal report, 31.9% of 6-year-old children consumed fruit less than once daily and 19.0% consumed vegetables less than once daily. In adjusted analyses, children who consumed fruits and vegetables less than once daily during late infancy had increased odds of eating fruits and vegetables less than once daily at age 6 years (fruit, adjusted odds ratio: 2.48; vegetables, adjusted odds ratio: 2.40). Age of introduction of fruits and vegetables was not associated with intake at age 6 years.
Our study suggests that infrequent intake of fruits and vegetables during late infancy is associated with infrequent intake of these foods at 6 years of age. These findings highlight the importance of infant feeding guidance that encourages intake of fruits and vegetables and the need to examine barriers to fruit and vegetable intake during infancy.
PMCID: PMC4258845  PMID: 25183758
fruits; vegetables; frequency of intake; age of introduction; Infant Feeding Practice Study II; Year 6 Follow-Up Study
17.  Breastfeeding and Risk of Infections at 6 Years 
Pediatrics  2014;134(Suppl 1):S13-S20.
Previous studies have shown that breastfeeding is associated with reductions in the risk of common infections among infants; however, whether breastfeeding confers longer term protection is inconclusive.
We linked data from the 2005–2007 IFPS II (Infant Feeding Practices Study II) and follow-up data collected when the children were 6 years old. Multivariable logistic regression was used, controlling for sociodemographic variables, to examine associations of initiation, duration, exclusivity of breastfeeding, timing of supplementing breastfeeding with formula, and breast milk intensity (proportion of milk feedings that were breast milk from age 0–6 months) with maternal reports of infection (cold/upper respiratory tract, ear, throat, sinus, pneumonia/lung, and urinary) and sick visits in the past year among 6-year-olds (N = 1281).
The most common past-year infections were colds/upper respiratory tract (66%), ear (25%), and throat (24%) infections. No associations were found between breastfeeding and colds/upper respiratory tract, lung, or urinary tract infections. Prevalence of ear, throat, and sinus infections and number of sick visits differed according to breastfeeding duration, exclusivity, and timing of supplementing breastfeeding with formula (P < .05). Among children ever breastfed, children breastfed for ≥9 months had lower odds of past-year ear (adjusted odds ratio [aOR]: 0.69 [95% confidence interval (95% CI): 0.48–0.98]), throat (aOR: 0.68 [95% CI: 0.47–0.98]), and sinus (aOR: 0.47 [95% CI: 0.30–0.72]) infections compared with those breastfed >0 to <3 months. High breast milk intensity (>66.6%) during the first 6 months was associated with lower odds of sinus infection compared with low breast milk intensity (<33.3%) (aOR: 0.53 [95% CI: 0.35–0.79]).
This prospective longitudinal study suggests that breastfeeding may protect against ear, throat, and sinus infections well beyond infancy.
PMCID: PMC4258846  PMID: 25183750
breastfeeding; infection; Infant Feeding Practice Study II; Year 6 Follow-Up Study
18.  Bottle-Feeding Practices During Early Infancy and Eating Behaviors at 6 Years of Age 
Pediatrics  2014;134(Suppl 1):S70-S77.
Evidence suggests an association of breastfeeding with a maternal feeding style (MFS) that is less controlling than formula feeding, which, in turn, may improve a child’s self-regulation of eating. This study examines associations of bottle-feeding practices during infancy with MFS and children’s eating behavior (CEB) at 6 years old.
We linked data from the Infant Feeding Practices Study II to the Year 6 Follow-Up, which include 8 MFS and CEB measures adapted from previous validated instruments. Bottle-feeding practices during the first 6 months estimated by using the Infant Feeding Practices Study II were bottle-feeding intensity (BFI), mother’s encouragement of infant to finish milk in the bottle, and infant finishing all milk in the bottle. Adjusted odds ratios (aORs) for associations of bottle-feeding practices with MFS and CEB at 6 years old were calculated by using multivariable logistic regressions controlling for sociodemographic characteristics and other feeding practices (N = 1117).
Frequent bottle emptying encouraged by mothers during infancy increased odds of mothers encouraging their child to eat all the food on their plate (aOR: 2.37; 95% confidence interval [CI]: 1.65–3.41] and making sure their child eats enough (aOR: 1.62; 95% CI: 1.14–2.31) and of children eating all the food on their plate at 6 years old (aOR: 2.01; 95% CI: 1.05–3.83). High BFI during early infancy also increased the odds of mothers being especially careful to ensure their 6-year-old eats enough.
Bottle-feeding practices during infancy may have long-term effects on MFS and CEB. Frequent bottle emptying encouraged by mothers and/or high BFI during early infancy increased the likelihood of mothers pressuring their 6-year-old child to eat and children’s low satiety responsiveness.
PMCID: PMC4258847  PMID: 25183759
bottle feeding; maternal feeding style; children’s eating behaviors; Infant Feeding Practice Study II; Year 6 Follow-Up Study
20.  A Longitudinal Analysis of Sugar-Sweetened Beverage Intake in Infancy and Obesity at 6 Years 
Pediatrics  2014;134(Suppl 1):S29-S35.
To examine whether sugar-sweetened beverage (SSB) intake during infancy predicts obesity at age 6 years.
We included 1189 children who participated in the Infant Feeding Practices Study II in 2005–2007 and were followed up at 6 years in 2012. Children’s weight and height were measured by mothers. Obesity was defined as gender-specific BMI-for-age ≥95th percentile. We used logistic regression to estimate the associations of any SSB intake and age at SSB introduction before 12 months and mean SSB intake during ages 10 to 12 months with obesity at 6 years controlling for baseline characteristics.
The obesity prevalence at 6 years among children who consumed SSBs during infancy was twice as high as that among non–SSB consumers (17.0% vs 8.6%). The adjusted odds of obesity at 6 years was 71% higher for any SSB intake and 92% higher for SSB introduction before 6 months compared with no SSB intake during infancy. Children who consumed SSBs ≥3 times per week during ages 10 to 12 months had twice the odds of obesity compared with those who consumed no SSBs in this period. However, among children who consumed SSBs, the odds of obesity at 6 years did not differ by age at SSB introduction during infancy or by mean weekly SSB intake during ages 10 to 12 months.
Children who consumed SSBs during infancy had higher odds of obesity at 6 years than non–SSB consumers. SSB consumption during infancy may be a risk factor for obesity in early childhood. Whether unmeasured behaviors contributed to the association is unclear.
PMCID: PMC4258849  PMID: 25183752
childhood obesity; sugar-sweetened beverages; infancy; population-based studies; public health
21.  Breastfeeding Duration Is Associated With Child Diet at 6 Years 
Pediatrics  2014;134(Suppl 1):S50-S55.
Breastfeeding has been associated with early infant food preferences, but less is known about how breastfeeding is associated with later child diet. The objective of this study was to assess whether any and exclusive breastfeeding duration are associated with child diet at 6 years.
We linked data from the Infant Feeding Practices Study II and Year 6 Follow-Up. We used approximately monthly questionnaires throughout infancy to calculate any and exclusive breastfeeding duration (n = 1355). We calculated median daily frequency of intake of water, milk, 100% juice, fruits, vegetables, sugar-sweetened beverages, sweets, and savory snacks at 6 years from a dietary screener and examined frequency of consumption of each food or beverage group by any and exclusive breastfeeding duration. We used separate multivariable logistic regression models to calculate odds of consuming more than the median daily frequency of intake of food or beverage items, adjusting for confounders.
Intake of milk, sweets, and savory snacks at 6 years was not associated with any or exclusive breastfeeding duration in unadjusted analyses. Frequency of consumption of water, fruits, and vegetables was positively associated, and intake of sugar-sweetened beverages was inversely associated with any and exclusive breastfeeding duration in adjusted models; 100% juice consumption was inversely associated with exclusive breastfeeding duration only.
Among many other health benefits, breastfeeding is associated with a number of healthier dietary behaviors at age 6. The association between breastfeeding and child diet may be an important factor to consider when examining associations between breastfeeding and child obesity and chronic diseases.
PMCID: PMC4258850  PMID: 25183756
breastfeeding duration; exclusive breastfeeding; diet; fruits; vegetables; sugar-sweetened beverages
22.  The Association of Sugar-Sweetened Beverage Intake During Infancy With Sugar-Sweetened Beverage Intake at 6 Years of Age 
Pediatrics  2014;134(Suppl 1):S56-S62.
To examine whether sugar-sweetened beverage (SSB) intake during infancy predicts SSB intake at 6 years of age.
A longitudinal cohort analysis of 1333 US children was conducted by using data from the 2005–2007 Infant Feeding Practices Study II and the 2012 Follow-Up Study at 6 years of age. The exposure variables were maternal-reported SSB intakes during infancy. The outcome variable was maternal-reported SSB intake at age 6 years. Multivariable logistic regression analyses were used to calculate adjusted odds ratios (aOR) for associations of SSB intake during infancy with consuming SSBs ≥1 time/day at 6 years old after controlling for baseline child’s and parent’s characteristics.
Based on maternal recall, approximately one-fifth of children consumed SSBs at least 1 time/day at age 6 years. Adjusted odds of consuming SSBs at age 6 years ≥1 time/day was significantly associated with any SSB intake during infancy (aOR, 2.22 vs none), age at SSB introduction (aOR, 2.33 for age ≥6 months and 2.01 for age <6 months vs never), and mean SSB intake during age 10 to 12 months (aOR, 2.72 for 1 to <2 times/week and 2.57 for ≥3 times/week vs none).
SSB intake during infancy significantly increased the likelihood of consuming SSBs ≥1 time/day at 6 years of age. Our findings suggest that infancy may be an important time for mothers to establish healthy beverage practices for their children and these findings can be used to inform intervention efforts to reduce SSB intake among children.
PMCID: PMC4258851  PMID: 25183757
sugar-sweetened beverage; children; Infant Feeding Practice Study II
23.  Methods for the Year 6 Follow-Up Study of Children in the Infant Feeding Practices Study II 
Pediatrics  2014;134(Suppl 1):S4-S12.
We describe methods used in the Year 6 Follow-Up (Y6FU) of children who participated in the Infant Feeding Practices Study II (IFPSII). This study consists of a questionnaire administered 6 years after the IFPSII to characterize the health, development, and diet quality of the children.
The Y6FU sample was a subset of those who participated in IFPSII. The IFPSII participants were drawn from a national consumer opinion panel; neither the IFPSII nor the Y6FU sample is nationally representative. The Y6FU sampling frame included all qualified participants who answered at least the first postnatal questionnaire. One questionnaire was administered by mail in 2012, and nonrespondents were contacted for a telephone interview. Survey topics included measures of health, development, diet, physical activity, screen time, and family medical history. We attempted to contact 2958 mothers and obtained completed questionnaires from 1542, a response rate of 52.1%. We conducted 2 sample evaluations, 1 comparing respondents and nonrespondents on data from IFPSII and the other comparing Y6FU respondents with 6-year-old participants in the National Survey of Children’s Health.
Y6FU mothers are more likely to be white, married, older, and of higher education and income than both nonresponders and nationally representative mothers. Comparisons also revealed health-related differences and similarities.
Although not nationally representative, the Y6FU provides a valuable database because of its wide coverage of diet and health issues and its unique ability to link early feeding patterns with outcomes at age 6 years.
PMCID: PMC4258852  PMID: 25183754
breastfeeding; bottle feeding; infant nutrition; child nutrition; cohort study; health outcomes
24.  Progressive Paranoid Psychosis in a 20-Year-Old With Central Congenital Hypoventilation Syndrome 
Pediatrics  2014;134(3):e900-e902.
A 20-year-old man with a history of congenital central hypoventilation syndrome presented with recent-onset psychosis, catatonia, and a diagnosis of schizophrenia. Psychiatric symptoms were resistant to conventional treatment. A fluorodeoxyglucose positron emission tomography scan of the brain obtained during the hospitalization revealed a hypometabolism distribution more consistent with hypoperfusion than with primary central nervous system disease. Increased mechanical ventilation was successfully used to treat the psychiatric symptoms.
PMCID: PMC4143995  PMID: 25092945
schizophrenia; psychosis; congenital central hypoventilation syndrome; PET scan; catatonia
25.  Pharmacokinetics of Fluoride in Toddlers After Application of 5% Sodium Fluoride Dental Varnish 
Pediatrics  2014;134(3):e870-e874.
The prevalence of dental caries (tooth decay) among preschool children is increasing, driven partially by an earlier age of onset of carious lesions. The American Academy of Pediatrics recommends application of 5% sodium fluoride varnish at intervals increasing with caries risk status, as soon as teeth are present. However, the varnishes are marketed for treatment of tooth sensitivity and are regulated as medical devices rather than approved by the US Food and Drug Administration for prevention of dental caries (tooth decay). The objective of this research is to examine the safety of use in toddlers by characterizing the absorption and distribution profile of a currently marketed fluoride varnish. We measured urinary fluoride for 5 hours after application of fluoride varnish to teeth in 6 toddlers aged 12 to 15 months. Baseline levels were measured on a separate day. The urine was extracted from disposable diapers, measured by rapid diffusion, and extrapolated to plasma levels. The mean estimated plasma fluoride concentration was 13 μg/L (SD, 9 μg/L) during the baseline visit and 21 μg/L (SD, 8 μg/L) during the 5 hours after treatment. Mean estimated peak plasma fluoride after treatment was 57 μg/L (SD, 22 μg/L), and 20 μg/kg (SD, 4 μg/L) was retained on average. Retained fluoride was 253 times lower than the acute toxic dose of 5 mg/kg. Mean plasma fluoride after placement of varnish was within an SD of control levels. Occasional application of fluoride varnish following American Academy of Pediatrics guidance is safe for toddlers.
PMCID: PMC4143996  PMID: 25136045
fluorides; fluoride varnishes; pharmacokinetics; drug safety; toddler

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