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1.  Maternal satisfaction with a novel filtered-sunlight phototherapy for newborn jaundice in Southwest Nigeria 
BMC Pediatrics  2014;14:180.
In many resource-limited settings, the availability of effective phototherapy for jaundiced infants is frequently hampered by lack of, or inadequate resources to acquire and maintain conventional electric-powered phototherapy devices. This study set out to ascertain maternal experience and satisfaction with a novel treatment of infants with significant hyperbilirubinemia using filtered sunlight phototherapy (FSPT) in a tropical setting with irregular access to effective conventional phototherapy.
A cross-sectional satisfaction survey was conducted among mothers of jaundiced infants treated with FSPT in an inner-city maternity hospital in Lagos, Nigeria from November 2013 to March 2014. Mothers’ experience during treatment was elicited with a pretested questionnaire consisting of closed and open-ended items. Satisfaction was rated on a five-point Likert scale. Correlates of overall maternal satisfaction were explored with descriptive and inferential non-parametric statistics.
A total of 191 mothers were surveyed, 77 (40%) of whom had no prior knowledge of neonatal jaundice. Maternal satisfaction was highest for quality of nursing care received (mean: 4.72 ± 0.55, median: 5[IQR: 5–5]) and lowest for physical state of the test environment (mean: 3.85 ± 0.74, median: 4[IQR: 3–4]). The overall rating (mean: 4.17 ± 0.58, median: 4[IQR: 4–5]) and the observed effect of FSPT on the babies (mean: 4.34 ± 0.58, 4[IQR: 4–5]) were quite satisfactory. FSPT experience was significantly correlated with the adequacy of information received (p < 0.0005), test environment (p = 0.002) and the observed effect of FSPT on the child (p < 0.0005). Almost all mothers (98.4%) indicated willingness to use FSPT in future or recommend it to others, although some (30 or 15.7%) disliked the idea of exposing newborns to sunlight.
Mothers of jaundiced newborns in this population are likely to be satisfied with FSPT where it is inevitable as an alternative to conventional electric-powered phototherapy. Adequate information, good test environment and friendly nursing care must be ensured for satisfactory maternal experience.
PMCID: PMC4099408  PMID: 25012576
Neonatal jaundice; Newborn care; Sunlight exposure; Patient satisfaction; Phototherapy; Developing country
2.  Fitness, fatness, and academic performance in seventh-grade elementary school students 
BMC Pediatrics  2014;14:176.
In addition to the benefits on physical and mental health, cardiorespiratory fitness has shown to have positive effects on cognition. This study aimed to investigate the relationship between cardiorespiratory fitness and body weight status on academic performance among seventh-grade students.
Participants included 1531 grade 7 students (787 male, 744 female), ranging in age from 12 to 14 years (Mage = 12.3 ± 0.60), from 3 different cohorts. Academic performance was measured using the marks students had, at the end of their academic year, in mathematics, language (Portuguese), foreign language (English), and sciences. To assess cardiorespiratory fitness the Progressive Aerobic Cardiovascular Endurance Run, from Fitnessgram, was used as the test battery. The relationship between academic achievement and the independent and combined association of cardiorespiratory fitness/weight status was analysed, using multinomial logistic regression.
Cardiorespiratory fitness and weight status were independently related with academic achievement. Fit students, compared with unfit students had significantly higher odds for having high academic achievement (OR = 2.29, 95% CI: 1.48-3.55, p < 0.001). Likewise, having a normal weight status was also related with high academic achievement (OR = 3.65, 95% CI: 1.82-7.34, p < 0.001).
Cardiorespiratory fitness and weight status were independently and combined related to academic achievement in seventh-grade students independent of the different cohorts, providing further support that aerobically fit and normal weight students are more likely to have better performance at school regardless of the year that they were born.
PMCID: PMC4094753  PMID: 25001376
Physical fitness; Academic performance; Weight status; School
3.  Systemic antibiotic prescribing to paediatric outpatients in 5 European countries: a population-based cohort study 
BMC Pediatrics  2014;14:174.
To describe the utilisation of antibiotics in children and adolescents across 5 European countries based on the same drug utilisation measures and age groups. Special attention was given to age-group-specific distributions of antibiotic subgroups, since comparison in this regard between countries is lacking so far.
Outpatient paediatric prescriptions of systemic antibiotics during the years 2005-2008 were analysed using health care databases from the UK, the Netherlands, Denmark, Italy and Germany. Annual antibiotic prescription rates per 1,000 person years were estimated for each database and stratified by age (≤4, 5-9, 10-14, 15-18 years). Age-group-specific distributions of antibiotic subgroups were calculated for 2008.
With 957 prescriptions per 1000 person years, the highest annual prescription rate in the year 2008 was found in the Italian region Emilia Romagna followed by Germany (561), the UK (555), Denmark (481) and the Netherlands (294). Seasonal peaks during winter months were most pronounced in countries with high utilisation. Age-group-specific use varied substantially between countries with regard to total prescribing and distributions of antibiotic subgroups. However, prescription rates were highest among children in the age group ≤4 years in all countries, predominantly due to high use of broad spectrum penicillins.
Strong increases of antibiotic prescriptions in winter months in high utilising countries most likely result from frequent antibiotic treatment of mostly viral infections. This and strong variations of overall and age-group-specific distributions of antibiotic subgroups across countries, suggests that antibiotics are inappropriately used to a large extent.
PMCID: PMC4099488  PMID: 24997585
Drug utilisation study; Antibiotic resistance; Paediatric; Prescription rate; Cephalosporins; Macrolides; Penicillins; Electronic healthcare database
4.  Mediterranean-style diet reduces metabolic syndrome components in obese children and adolescents with obesity 
BMC Pediatrics  2014;14:175.
The beneficial effects of the Mediterranean diet have been amply proven in adults with cardiovascular risk factors. The effects of this diet have not been extensively assessed in pediatric populations with obesity, insulin resistance (IR) and metabolic syndrome (MetS). The aim of this study was to assess the efficacy of the Mediterranean style diet (MSD) to decrease cardiovascular risk factors in children and adolescents with obesity.
Participants were randomly assigned to a MSD rich in polyunsaturated fatty acids, fiber, flavonoids and antioxidants (60% of energy from carbohydrate, 25% from fat, and 15% from protein, (n = 24); or a standard diet (55% of carbohydrate, 30% from fat and 15% from protein, (n = 25), the caloric ingest was individualized. At baseline and 16-week of intervention, the glucose, triglycerides (TG), total cholesterol (TC), HDL-C, LDL-C were measured as well as the body composition and anthropometric data. The diet compliance was determined by the 24-hour recalls.
Paired Student’s t and Macnemar’s test were used to compare effects in biochemical, body composition, anthropometric, and dietary variables.
The MSD group had a significantly decrease in BMI, lean mass, fat mass, glucose, TC, TG, HDL-C and LDL-C. (p < 0.05); the diet compliance increased consumption of omega 9 fatty acids, zinc, vitamin E, selenium, and decreased consumption of saturated fatty acids (p < 0.05). The standard diet group decrease in glucose levels and frequency of glucose >100 mg/dL (p < 0.05).
The MSD improves the BMI, glucose and lipid profile in children and adolescents with obesity and any MetS component.
PMCID: PMC4102089  PMID: 24997634
Obesity; Metabolic syndrome; Mediterranean diet; Children; Adolescents
5.  Spontaneous pneumothorax as indicator for Birt-Hogg-Dubé syndrome in paediatric patients 
BMC Pediatrics  2014;14:171.
Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominantly inherited disorder caused by germline mutations in the folliculin (FLCN) gene. Clinical manifestations of BHD include skin fibrofolliculomas, renal cell cancer, lung cysts and (recurrent) spontaneous pneumothorax (SP). All clinical manifestations usually present in adults > 20 years of age.
Case presentations
Two non-related patients with (recurrent) pneumothorax starting at age 14 accompanied by multiple basal lung cysts on thoracic CT underwent FLCN germline mutation analysis. A pathogenic FLCN mutation was found in both patients confirming suspected BHD. The family history was negative for spontaneous pneumothorax in both families.
Although childhood occurrence of SP in BHD is rare, these two cases illustrate that BHD should be considered as cause of SP in children.
PMCID: PMC4088368  PMID: 24994497
Birt-Hogg-Dubé syndrome; BHD; Folliculin; FLCN; Spontaneous pneumothorax; Renal cell cancer; Fibrofolliculomas
6.  A mathematical model for predicting the adult height of girls with advanced puberty after spontaneous growth 
BMC Pediatrics  2014;14:172.
Advanced puberty in girls is defined as the onset of puberty between the ages of 8 yr and 10 yr. The objective was to predict adult height (AH) at initial evaluation and to characterize patients with an actual AH below -2 SD (152 cm) and/or lower than their target height (TH) by > one SD (5.6 cm).
Data analysis using multiple linear regression models was performed in 50 girls with advanced puberty who reached their AH after spontaneous puberty.
The actual AH (159.0 ± 6.1 cm) was similar to the TH (161.2 ± 4.6 cm) and to the AH predicted at the initial evaluation (160.8 ± 6.0 cm), and the actual AH correlated positively with both (R = 0.76, P = 0.0003; R = 0.71, P = 0.008, respectively).
The AH was below 152 cm in 7 girls, of whom 3 were characterized by paternal transmission of the advanced puberty. The AH was lower than the TH by >5.6 cm in 8 girls.
The AH (cm) could be calculated at the initial evaluation: 1.8822 age + 3.3510 height (SD) - 0.7465 bone age – 1.7993 pubic hair stage + 2.8409 TH (SD) + 150.32.
The formula is available online at
The calculated AH (159.0 ± 5.7 cm) and the actual AH were highly correlated (R = 0.93). The actual AH was lower than the calculated AH by > 0.5 SD in only one case (4.35 cm).
We established a formula that can be used at an initial evaluation to predict the AH, and then to assess the risk of reduced AH as a result of advanced puberty. According to this formula, the actual AH was lower than the calculated AH by more than 2.8 cm (0.5 SD) in only one girl. The AHs of the untreated girls with advanced puberty did not differ from those predicted at the initial evaluation by the Bayley and Pinneau table or from the THs. However, this study provides a useful and ready-to-use formula that can be an additional assessment of girls with advanced puberty.
PMCID: PMC4094405  PMID: 24994575
7.  Prevalence of abuse among young children with femur fractures: a systematic review 
BMC Pediatrics  2014;14:169.
Clinical factors that affect the likelihood of abuse in children with femur fractures have not been well elucidated. Consequently, specifying which children with femur fractures warrant an abuse evaluation is difficult. Therefore the purpose of this study is to estimate the proportion of femur fractures in young children attributable to abuse and to identify demographic, injury and presentation characteristics that affect the probability that femur fractures are secondary to abuse.
We conducted a systematic review of published articles written in English between January 1990 and July 2013 on femur fracture etiology in children less than or equal to 5 years old based on searches in PubMed/MEDLINE and CINAHL databases. Data extraction was based on pre-defined data elements and included study quality indicators. A meta-analysis was not performed due to study population heterogeneity.
Across the 24 studies reviewed, there were a total of 10,717 children less than or equal to 60 months old with femur fractures. Among children less than 12 months old with all types of femur fractures, investigators found abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures, abuse rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status, a suspicious history, and the presence of additional injuries were associated with findings of abuse. Diaphyseal fractures were associated with a lower abuse incidence in multiple studies. Fracture side and spiral fracture type, however, were not associated with abuse.
Studies commonly find a high proportion of abuse among children less than 12 months old with femur fractures. The reported trauma history, physical examination findings and radiologic results must be examined for characteristics that increase or decrease the likelihood of abuse determination.
PMCID: PMC4085378  PMID: 24989500
Child abuse; Child maltreatment; Femur fracture; Accident; Trauma
8.  Predictors of effectiveness of early intervention on children with intellectual disability: a retrospective cohort study 
BMC Pediatrics  2014;14:170.
The Taiwanese government has been promoting early intervention to children with intellectual disability for years, but data on its effectiveness are limited.
We recruited children who were treated for intellectual disability at a teaching hospital and had two IQ tests from 2001 to 2005 and used the difference between the two tests as the indicator of effectiveness.
The participants included 23 boys and 13 girls 56.5 ± 5.9 months of age at the first test and 73.4 ± 4.9 months at the second. The IQ increased from 57.0 ± 8.0 to 65.1 ± 12.3 (p < 0.001). Multi-variate regressions showed that a low maternal educational level, male gender, and a younger age at the first test were significant independent predictors of the effectiveness.
Early intervention can improve the IQ of children with intellectual disability, and the earlier the intervention the better. The effectiveness is demonstrable in boys and more prominent in children whose mothers had a low educational level.
PMCID: PMC4094398  PMID: 24989708
9.  Infants fed formula with added long chain polyunsaturated fatty acids have reduced incidence of respiratory illnesses and diarrhea during the first year of life 
BMC Pediatrics  2014;14:168.
Long chain polyunsaturated fatty acids (LCPUFAs) may influence the immune system. Our objective was to compare the frequency of common illnesses in infants who received formula with or without added LCPUFAs.
In this observational, multi-center, prospective study, infants consumed formula with 17 mg DHA and 34 mg ARA/100 kcal (n = 233) or with no added DHA or ARA (n = 92). Pediatricians recorded respiratory illnesses, otitis media, eczema, and diarrhea through 1 year of age.
Infants who consumed formula with DHA/ARA had lower incidence of bronchitis/bronchiolitis (P = 0.004), croup (P = 0.044), nasal congestion (P = 0.001), cough (P = 0.014), and diarrhea requiring medical attention (P = 0.034). The odds ratio (OR) of having at least one episode of bronchitis/bronchiolitis (0.41, 95% CI 0.24, 0.70; P = 0.001), croup (0.23, 95% CI 0.05, 0.97; P = 0.045), nasal congestion (0.37, 95% CI 0.20, 0.66; P = 0.001), cough (0.52, 95% CI 0.32, 0.86; P = 0.011), and diarrhea requiring medical attention (0.51, 95% CI 0.28, 0.92; P = 0.026) was lower in infants fed DHA/ARA. The OR of an increased number of episodes of bronchitis/bronchiolitis, croup, nasal congestion, cough, and diarrhea, as well as the hazard ratio for shorter time to first episode of bronchitis/bronchiolitis, nasal congestion, cough, and diarrhea were also significantly lower in the DHA/ARA group.
In healthy infants, formula with DHA/ARA was associated with lower incidence of common respiratory symptoms and illnesses, as well as diarrhea.
PMCID: PMC4098921  PMID: 24989353
DHA; ARA; LCPUFAs; Infant; Infant formula; Infant nutrition; Respiratory illness; Diarrhea
10.  Early childhood risk and resilience factors for behavioural and emotional problems in middle childhood 
BMC Pediatrics  2014;14:166.
Mental disorders in childhood have a considerable health and societal impact but the associated negative consequences may be ameliorated through early identification of risk and protective factors that can guide health promoting and preventive interventions. The objective of this study was to inform health policy and practice through identification of demographic, familial and environmental factors associated with emotional or behavioural problems in middle childhood, and the predictors of resilience in the presence of identified risk factors.
A cohort of 706 mothers followed from early pregnancy was surveyed at six to eight years post-partum by a mail-out questionnaire, which included questions on demographics, children’s health, development, activities, media and technology, family, friends, community, school life, and mother’s health.
Although most children do well in middle childhood, of 450 respondents (64% response rate), 29.5% and 25.6% of children were found to have internalising and externalising behaviour problem scores in the lowest quintile on the NSCLY Child Behaviour Scales. Independent predictors for problem behaviours identified through multivariable logistic regression modelling included being male, demographic risk, maternal mental health risk, poor parenting interactions, and low parenting morale. Among children at high risk for behaviour problems, protective factors included high maternal and child self-esteem, good maternal emotional health, adequate social support, good academic performance, and adequate quality parenting time.
These findings demonstrate that several individual and social resilience factors can counter the influence of early adversities on the likelihood of developing problem behaviours in middle childhood, thus informing enhanced public health interventions for this understudied life course phase.
PMCID: PMC4083129  PMID: 24986740
11.  Body mass index is not a reliable tool in predicting celiac disease in children 
BMC Pediatrics  2014;14:165.
Untreated celiac disease is traditionally believed to be associated with malabsorption and underweight. However, studies describing body mass index (BMI) in individuals at the time of diagnosis have shown contradictory results. We investigated the differences in weight, height, and BMI in 12- year-old children with screening-detected celiac disease compared to their healthy peers.
In a population-based screening study of 12,632 12-year-old children, blood samples were analyzed for markers of celiac disease. Children with elevated markers were referred for a small bowel biopsy. Weight and height were measured in 239 out of 242 children with screening-detected celiac disease (57.3% girls) and in 12,227 children without celiac disease (48.5% girls). BMI was categorized according to the International Obesity Task Force. Age- and sex-specific cut-off points for underweight, normal weight, and overweight were used.
Children with celiac disease weighed less and were shorter than their peers (median weight 45.2 kg, interquartile range (IQR) 40.2–52.2 kg vs. 47.0 kg, IQR 41.1–54.4 kg, respectively, p = 0.01; median height 156.5 cm, IQR 151.0–162.0 cm vs. 157.5 cm, IQR 152.0–163.0 cm, respectively, p = 0.04). In comparing those with celiac disease to their healthy peers, 4.2% vs. 5.2% were underweight, 82.0% vs. 72.8% were normal weight, and 13.8% vs. 21.9% were overweight, respectively. There was no association between being underweight and the risk of having undiagnosed celiac disease (Odds ratio (OR) 1.3, 95% CI 0.7–2.4), but the risk was significantly lower among overweight children (OR 0.56, 95% CI 0.4–0.8). Median BMI was slightly lower among the children with screening-detected celiac disease compared to their healthy peers (18.6 kg/m2, IQR 17.1–19.8 kg/m2 vs. 18.8 kg/m2, IQR 17.2–21.1 kg/m2, respectively, p = 0.05), but most of the celiac disease cases had a normal BMI.
At a population level, children with celiac disease weigh less, are shorter, and have a lower BMI compared to their peers without celiac disease, and this emphasizes the importance of early recognition and treatment of the condition. However, at an individual level, growth parameters are not reliable in establishing the diagnosis.
PMCID: PMC4094403  PMID: 24981433
Body mass index; Celiac disease; Children; Height; Screening study; Weight
12.  Development and acceptability testing of ready-to-use supplementary food made from locally available food ingredients in Bangladesh 
BMC Pediatrics  2014;14:164.
Inadequate energy and micronutrient intake during childhood is a major public health problem in developing countries. Ready-to-use supplementary food (RUSF) made of locally available food ingredients can improve micronutrient status and growth of children. The objective of this study was to develop RUSF using locally available food ingredients and test their acceptability.
A checklist was prepared of food ingredients available and commonly consumed in Bangladesh that have the potential of being used for preparing RUSF. Linear programming was used to determine possible combinations of ingredients and micronutrient premix. To test the acceptability of the RUSF compared to Pushti packet (a cereal based food-supplement) in terms of amount taken by children, a clinical trial was conducted among 90 children aged 6–18 months in a slum of Dhaka city. The mothers were also asked to rate the color, flavor, mouth-feel, and overall liking of the RUSF by using a 7-point Hedonic Scale (1 = dislike extremely, 7 = like extremely).
Two RUSFs were developed, one based on rice-lentil and the other on chickpea. The total energy obtained from 50 g of rice-lentil, chickpea-based RUSF and Pushti packet were 264, 267 and 188 kcal respectively. Children were offered 50 g of RUSF and they consumed (mean ± SD) 23.8 ± 14 g rice-lentil RUSF, 28.4 ± 15 g chickpea based RUSF. Pushti packet was also offered 50 g but mothers were allowed to add water, and children consumed 17.1 ± 14 g. Mean feeding time for two RUSFs and Pushti packet was 20.9 minutes. Although the two RUSFs did not differ in the amount consumed, there was a significant difference in consumption between chickpea-based RUSF and Pushti packet (p = 0.012). Using the Hedonic Scale the two RUSFs were more liked by mothers compared to Pushti packet.
Recipes of RUSF were developed using locally available food ingredients. The study results suggest that rice-lentil and chickpea-based RUSF are well accepted by children.
Trial registration NCT01553877. Registered 24 January 2012.
PMCID: PMC4098698  PMID: 24972632
Ready-to-use supplementary food (RUSF); Local food ingredients; Development; Acceptability
13.  Performance of capnometry in non-intubated infants in the pediatric intensive care unit 
BMC Pediatrics  2014;14:163.
Assessing the ventilatory status of non-intubated infants in the Pediatric Intensive Care Unit (PICU) is a constant challenge. Methods to evaluate ventilation include arterial blood gas analysis (ABG), which is invasive and intermittent, and transcutaneous carbon dioxide monitoring (PtcCO2), which, while non-invasive, is also intermittent. A method that is non-invasive and continuous would be of great benefit in this population. We hypothesized that non-invasive capnometry via sidestream monitoring of exhaled carbon dioxide (CO2) would provide an acceptable measurement of ventilatory status when compared to ABG or PtcCO2.
Preliminary prospective study of infants less than one year of age admitted to the PICU in a large urban teaching hospital. Infants not intubated and not requiring non-invasive ventilation were eligible. A sidestream CO2 reading was obtained in a convenience sample of 39 patients. A simultaneous ABG was collected in those with an arterial catheter, and a PtcCO2 was obtained in those without.
Correlation of sidestream CO2 with ABG was excellent (r2 = 0.907). Sidestream correlated less well with PtcCO2 (r2 = 0.649). Results were not significantly altered when weight and respiratory rate were added as independent variables. Bland-Altman analysis revealed a bias of -2.7 with a precision of ±6.5 when comparing sidestream CO2 to ABG, and a bias of -1.7 with a precision of ±9.9 when comparing sidestream CO2 to PtcCO2.
Performance of sidestream monitoring of exhaled CO2 is acceptable clinical trending to assess the effectiveness of ventilation in non-intubated infants in the PICU.
PMCID: PMC4080582  PMID: 24965523
Capnometry; Ventilation; Monitoring; Infants; Microstream; Carbon dioxide
14.  Perinatal mortality in pregnancies with omphalocele: data from the Chinese national birth defects monitoring network, 1996–2006 
BMC Pediatrics  2014;14:160.
Previous studies on the mortality rate of omphalocele are limited. The risk of death of non-isolated omphalocele and that of cases of omphalocele that are diagnosed prenatally by ultrasound are unclear. This study aimed to estimate the perinatal mortality of pregnancies with omphalocele. This study also examined the potential risk of death of non-isolated omphalocele and that of cases that are prenatally diagnosed by ultrasound.
Data were retrieved from the national birth defects registry in China, for 1996–2006. Multinomial logistic regression was used to calculate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) between perinatal mortality and selected maternal and fetal characteristics.
Among 827 cases of omphalocele, 309 (37.4%) cases resulted in termination of pregnancy and stillbirth, and 124 (15.0%) cases resulted in death in the first 7 days after delivery, yielding a perinatal mortality rate of 52.4% (95% CI: 49.0–55.8%). The late fetal death rate (LFDR) of omphalocele that was diagnosed prenatally by ultrasound was 15.91-fold (AOR: 15.91, 95% CI: 10.18–24.87) higher than that of postnatally diagnosed cases. The LFDR of non-isolated omphalocele was 2.64-fold (AOR: 2.64, 95% CI: 1.62–4.29) higher than that of isolated cases. For the early neonatal death rate, neonates with non-isolated omphalocele had a 2.96-fold (AOR: 2.96, 95% CI: 1.82–4.81) higher risk than isolated cases, but the difference between prenatal ultrasound diagnosis and postnatal diagnosis was not significant.
Selected fetal characteristics are significantly associated with the perinatal risk of death from omphalocele. Our findings suggest that improving pregnancy and delivery care, as well as management for omphalocele are important.
PMCID: PMC4075420  PMID: 24953381
Omphalocele; Abdominal wall defects; Mortality; Perinatal outcome; Associated anomalies; Prenatal diagnosis; Ultrasound
15.  Variability of physicians’ thresholds for neuroimaging in children with recurrent headache 
BMC Pediatrics  2014;14:162.
We sought to determine the extent to which physicians agree about the appropriate decision threshold for recommending magnetic resonance imaging in a clinical practice guideline for children with recurrent headache.
We surveyed attending physicians in Canada practicing in community pediatrics, child neurology, pediatric radiology, and pediatric neurosurgery. For children in each of six risk categories, physicians were asked to determine whether they would recommend for or against routine magnetic resonance imaging of the brain in a clinical practice guideline for children with recurrent headache.
Completed surveys were returned by 114 physicians. The proportion recommending routine neuroimaging for each risk group was 100% (50% risk), 99% (10% risk), 93% (4% risk), 54% (1% risk), 25% (0.4% risk), 4% (0.01% risk). Community pediatricians, physicians in practice >15 years, and physicians who believed they ordered neuroimaging less often than peers were less likely to recommend neuroimaging for the 1% risk group (all p < 0.05).
There is no consensus among pediatric specialists regarding the appropriate decision threshold for neuroimaging in a clinical practice guideline for children with recurrent headache. Because of the impact that individual threshold preferences may have on guidelines, these findings support the need for careful composition of guideline committees and consideration of the role of patient and family preferences. Our findings also support the need for transparency in guidelines regarding how evidence was translated into recommendations and how conflicts were resolved.
PMCID: PMC4079181  PMID: 24957861
Risk; Decision threshold; Clinical practice guideline; Medical decision-making; Headache
16.  The CANadian Pediatric Weight Management Registry (CANPWR): Study protocol 
BMC Pediatrics  2014;14:161.
Over recent decades, the prevalence of pediatric obesity has increased markedly in developed and developing countries, and the impact of obesity on health throughout the lifespan has led to urgent calls for action. Family-based weight management interventions that emphasize healthy lifestyle changes can lead to modest improvements in weight status of children with obesity. However, these interventions are generally short in duration, reported in the context of randomized controlled trials and there are few reports of outcomes of these treatment approaches in the clinical setting. Answering these questions is critical for improving the care of children with obesity accessing outpatient health services for weight management. In response, the CANadian Pediatric Weight management Registry (CANPWR) was designed with the following three primary aims:
1. Document changes in anthropometric, lifestyle, behavioural, and obesity-related co-morbidities in children enrolled in Canadian pediatric weight management programs over a three-year period;
2. Characterize the individual-, family-, and program-level determinants of change in anthropometric and obesity-related co-morbidities;
3. Examine the individual-, family-, and program-level determinants of program attrition.
This prospective cohort, multi-centre study will include children (2–17 years old; body mass index ≥85th percentile) enrolled in one of eight Canadian pediatric weight management centres. We will recruit 1,600 study participants over a three-year period. Data collection will occur at presentation and 6-, 12-, 24-, and 36-months follow-up. The primary study outcomes are BMI z-score and change in BMI z-score over time. Secondary outcomes include anthropometric (e.g., height, waist circumference,), cardiometabolic (e.g., blood pressure, lipid profile, glycemia), lifestyle (e.g., dietary intake, physical activity, sedentary activity), and psychosocial (e.g., health-related quality of life) variables. Potential determinants of change and program attrition will include individual-, family-, and program-level variables.
This study will enable our interdisciplinary team of clinicians, researchers, and trainees to address foundational issues regarding the management of pediatric obesity in Canada. It will also serve as a harmonized, evidence-based registry and platform for conducting future intervention research, which will ultimately enhance the weight management care provided to children with obesity and their families.
PMCID: PMC4082676  PMID: 24957705
Pediatric; Obesity; Family; Treatment; Canada; Health services
17.  Haemophilus influenzae type b as an important cause of culture-positive acute otitis media in young children in Thailand: a tympanocentesis-based, multi-center, cross-sectional study 
BMC Pediatrics  2014;14:157.
Streptococcus pneumoniae (S. pneumoniae) and Haemophilus influenzae (H. influenzae) are considered major causes of bacterial acute otitis media (AOM) worldwide, but data from Asia on primary causes of AOM are limited. This tympanocentesis-based, multi-center, cross-sectional study assessed bacterial etiology and antimicrobial susceptibility of AOM in Thailand.
Children 3 to 59 months presenting with AOM (< 72 hours of onset) who had not received prescribed antibiotics, or subjects who received prescribed antibiotics but remained symptomatic after 48–72 hours (treatment failures), were eligible. Study visits were conducted from April 2008 to August 2009. Bacteria were identified from middle ear fluid collected by tympanocentesis or spontaneous otorrhea swab sampling (< 20% of cases). S. pneumoniae and H. influenzae serotypes were determined and antimicrobial resistance was also assessed.
Of the 123 enrolled children, 112 were included in analysis and 48% of the 118 samples were positive for S. pneumoniae (23% (27/118)), H. influenzae (18% (21/118)), Moraxella catarrhalis (6% (7/118)) or Streptococcus pyogenes (3% (4/118)). The most common pneumococcal serotypes were 19F (26%) and 14 (22%). The majority of H. influenzae isolates were encapsulated (18/21), with 13 type b (Hib) representing 62% of all H. influenzae isolate or 11% of all samples (13/118), and there were only 3 non-typeable isolates. Despite high antibiotic resistance, amoxicillin/clavulanate susceptibility was high. No pneumococcal vaccine use was reported.
S. pneumoniae and H. influenzae, both frequently antibiotic resistant, were leading causes of bacterial AOM and there was an unexpectedly high burden of Hib in this population unvaccinated by any Hib conjugate vaccine. Conjugate vaccines effective against pneumococcus and H. influenzae could potentially reduce the burden of AOM in this population.
PMCID: PMC4075543  PMID: 24947736
Acute otitis media; Hib; Streptococcus pneumoniae; Haemophilus influenzae and antibiotic resistance
18.  Systematic review of outcome measures in trials of pediatric anaphylaxis treatment 
BMC Pediatrics  2014;14:158.
Considerable heterogeneity has been observed in the selection and reporting of disease-specific pediatric outcome measures in randomized controlled trials (RCTs). This makes interpretation of results and comparison across trials challenging. Outcome measures in pediatric anaphylaxis trials have never previously been systematically assessed. This systematic review (SR) identified and assessed outcome measures used in RCTs of anaphylaxis treatment in children. As a secondary objective, this SR assessed the evidence for current treatment modalities for anaphylaxis in the pediatric population.
We searched MEDLINE, EMBASE, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL from 2001 until December 2012. We also searched websites listing ongoing trials. We included randomized and controlled trials of anaphylaxis treatment in patients 0–18 years of age. Two authors independently assessed articles for inclusion.
No published studies fulfilled the inclusion criteria.
There is an alarming absence of RCTs evaluating the treatments for anaphylaxis in children. High quality studies are needed and are possible to design, despite the severe and acute nature of this condition. Consensus about the selection and validation of appropriate outcome measures will enhance the quality of research and improve the care of children with anaphylaxis.
Trial registration
PMCID: PMC4088301  PMID: 24950840
19.  Chronic granulomatous disease mimicking early-onset Crohn’s disease with cutaneous manifestations 
BMC Pediatrics  2014;14:156.
Chronic granulomatous disease is a rare inherited disorder of the innate immune system. In patients with a clinical history of recurrent or persistent infections, especially infections caused by uncommon species, chronic granulomatous disease should be considered.
Case presentation
We report the case of a 5-year-old boy with a presumptive diagnosis of Crohn’s disease with extraintestinal manifestations. Chronic granulomatous disease was suspected in this case after Serratia marcescens was isolated from a skin ulcer culture. Granulomas were confirmed on histology and chronic granulomatous disease was diagnosed.
This case emphasizes the importance of high clinical suspicion of an alternative diagnosis of immune deficiency in patients with presumed inflammatory bowel disease and opportunistic infections, especially when disease occurs in early life.
PMCID: PMC4097086  PMID: 24947584
Chronic granulomatous disease; Crohn’s disease; Serratia marcescens; Celiac disease; Skin infection; Nitroblue tetrazolium test; Pigment laden histiocytes
20.  Predictors for an unsuccessful INtubation-SURfactant-Extubation procedure: a cohort study 
BMC Pediatrics  2014;14:155.
The INtubation-SURfactant-Extubation (INSURE) is a procedure that is increasingly being used to treat the respiratory distress syndrome in preterm infants. The objective of this study was to identify predictors for an unsuccessful INSURE procedure.
The neonates included were less than 32 weeks’ gestation, treated with surfactant in the neonatal intensive care unit, and born 1998–2010. INSURE was defined as surfactant administration during intubation for less than 2 hours without the need for mechanical ventilation. INSURE success was defined as no re-intubation within 72 hours after INSURE, and INSURE failure was defined as re-intubation within 72 hours after INSURE. An unsuccessful INSURE procedure was either INSURE failure or mechanical ventilation for more than 24 hours immediately after surfactant administration. All predictors were defined a priori and were present before surfactant administration. Multivariate logistic regression was performed.
In total, 322 neonates were included: 31% (n = 100) had INSURE success, 10% (n = 33) had INSURE failure, 49% (n = 158) needed mechanical ventilation for more than 24 hours, and the remaining 10% (n = 31) needed mechanical ventilation for less than 24 hours. Predictors for INSURE failure were low gestational age and hemoglobin below 8.5 mmol/l. Predictors for mechanical ventilation for more than 24 hours were low gestational age, Apgar at 5 minutes below 7, oxygen need above 50%, CO2 pressure above 7 kPa (~53 mmHg), pH below 7.3, lactate above 2.5 mmol/l, need for inotropes, and surfactant administration shortly after birth, whereas preeclampsia reduced the risk.
We identified specific predictors associated with an unsuccessful INSURE procedure. Keeping high-risk neonates with one or several predictors intubated and treated with mechanical ventilation after surfactant may prevent a re-intubation procedure.
PMCID: PMC4072617  PMID: 24947477
Respiratory distress syndrome; Pulmonary surfactants; Premature neonates; Mechanical ventilation; Continuous positive airway pressure
21.  Characterizing severe obesity in children and youth referred for weight management 
BMC Pediatrics  2014;14:154.
Severe obesity (SO) in pediatrics has become increasing prevalent in recent decades.
The objective of our study was to examine differences in demographic, anthropometric, cardiometabolic, and lifestyle variables in children and youth with SO versus their less overweight/obese (OW/OB) peers.
A retrospective medical record review of 6-19 year old participants enrolled in an outpatient pediatric weight management clinic was conducted. SO (body mass index [BMI] ≥99th percentile) and OW/OB (BMI ≥85th and <99th percentile) groups were created according to Centers for Disease Control and Prevention definitions. Demographic, anthropometric, cardiometabolic and lifestyle data reported at baseline (pre-intervention) were retrieved.
Of the 345 participants, most were girls (56.2%), Caucasian (78.7%), and had family incomes > $50,000/year (65.7%). The SO group (n = 161) had lower HDL-cholesterol and higher liver enzymes, insulin resistance and blood pressure than the OW/OB group (n = 184; all p < 0.01). They also reported higher total energy intakes, fewer steps/day, less moderate-to-vigorous physical activity, and more leisure time screen time (all p < 0.02) than their leaner peers. Compared to the OW/OB group, a higher proportion of individuals in the SO group possessed cardiometabolic risk factors, including high triglycerides (45.8% vs 58.5%), alanine aminotransferase (55.4% vs 81.4%), insulin resistance (55.6% vs 82.1%), systolic blood pressure (11.5% vs 27.3%), diastolic blood pressure (17.8% vs 30.0%), and low HDL-cholesterol (44.6% vs 64.6%; all p < 0.02). Aside from the ~75% of participants (groups combined) who met the daily recommended intakes of grain and meat products, <50% of boys and girls met any of the remaining nutrition and physical activity-related recommendations. Compared to the OW/OB group, greater proportions of children and youth in the SO group failed to meet moderate-to-vigorous physical activity (48.4% vs 31.9%) and leisure-time-screen-time recommendations (43.4% vs 28.3%; both p < 0.05).
Children and youth with SO have a worse cardiometabolic profile and less favorable lifestyle habits than their OW/OB peers. These differences emphasize the heightened obesity-related health risks associated with SO in the pediatric years.
PMCID: PMC4074846  PMID: 24947311
Severe obesity; Pediatric; Cardiometabolic risk; Nutrition; Physical activity; Canada
22.  A randomised, double-blind study of polyethylene glycol 4000 and lactulose in the treatment of constipation in children 
BMC Pediatrics  2014;14:153.
Chronic constipation is frequent in children. The objective of this study is to compare the efficacy and safety of PEG 4000 and lactulose for the treatment of chronic constipation in young children.
This randomised, double-blind study enrolled 88 young children aged 12 to 36 months, who were randomly assigned to receive lactulose (3.3 g per day) or PEG 4000 (8 g per day) for four weeks. The primary efficacy variable was stool frequency during the fourth week of treatment. Secondary outcomes were the number and frequency of subjective symptoms associated with defecation at each visit.
Stool frequency was comparable in the two groups at baseline (lactulose: 0.7 ± 0.5; PEG 4000: 0.5 ± 0.55). Mean stool frequency increased from 0.70 ± 0.50 stools/day at baseline to 0.80 ± 0.41 at Week 4 in the lactulose group and from 0.50 ± 0.55 to 1.10 ± 0.55 stools/day in the PEG 4000 group. A significant difference was observed in the adjusted mean change from baseline, which was 0.15 stools/day in the lactulose group and 0.51 stools/day in the PEG 4000 group, with a least-squares mean difference of 0.36 stools/day [95% CI: 0.16 to 0.56]. With respect to secondary outcome variables, stool consistency and ease of stool passage improved more in the PEG 4000 group (p = 0.001). The incidence of adverse events was similar in both groups, the majority of which were mild.
PEG 4000 has superior efficacy to lactulose for the treatment of chronic constipation in young children and is well tolerated.
Trial registration
US National Institute of Health Clinical Trials database; study NCT00255372 first registered 17th November 2005.
PMCID: PMC4075982  PMID: 24943105
Constipation; Macrogol; Lactulose; Children; Stool frequency
23.  Reduced crying in term infants fed high beta-palmitate formula: a double-blind randomized clinical trial 
BMC Pediatrics  2014;14:152.
Beta-palmitate (sn-2 palmitate) mimics human milk fat, enabling easier digestion.
Therefore, we hypothesized that infants consuming high beta-palmitate formula would have more frequent, softer stools and reduced crying compared to infants consuming low beta-palmitate formula.
Formula-fed infants were randomly assigned to receive either (1) formula with high beta-palmitate (HBP, n = 21) or (2) regular formula with a standard vegetable oil mix (LBP, n = 21). A matched group of breastfed infants served as a reference (BF, n = 21). Crying and stool characteristics data were recorded by the parents for 3 days before the 6- and 12-week visits.
We found no significant differences in the stool frequency or consistency between the two formula groups. The percentage of crying infants in the LBP group was significantly higher than that in the HBP and BF groups during the evening at 6 weeks (88.2% vs. 56.3% and 55.6%, p < 0.05) and during the afternoon at 12 weeks (91.7% vs. 50.0% and 40%, p < 0.05). The infants fed HBP had significantly shorter crying durations when compared with infants fed LBP formula (14.90 ± 3.85 vs.63.96 ± 21.76 min/day, respectively; p = 0.047).
Our study indicates that consumption of a high beta-palmitate formula affects infant crying patterns during the first weeks of life. Comparable to breastfeeding, it reduced crying duration and frequency, primarily during the afternoon and evening hours, thereby improving the well-being of formula-fed infants and their parents.
Trial registration
Registration date March 31, 2009
PMCID: PMC4081465  PMID: 24942975
Beta-palmitate; sn-2 palmitate; Infant formula; Crying; Stool characteristics; Breastfeeding
24.  Impact of a Telenursing service on satisfaction and health outcomes of children with inflammatory rheumatic diseases and their families: a crossover randomized trial study protocol 
BMC Pediatrics  2014;14:151.
Pediatric rheumatic diseases have a significant impact on children’s quality of life and family functioning. Disease control and management of the symptoms are important to minimize disability and pain. Specialist clinical nurses play a key role in supporting medical teams, recognizing poor disease control and the need for treatment changes, providing a resource to patients on treatment options and access to additional support and advice, and identifying best practices to achieve optimal outcomes for patients and their families. This highlights the importance of investigating follow-up telenursing (TN) consultations with experienced, specialist clinical nurses in rheumatology to provide this support to children and their families.
This randomized crossover, experimental longitudinal study will compare the effects of standard care against a novel telenursing consultation on children’s and family outcomes. It will examine children below 16 years old, recently diagnosed with inflammatory rheumatic diseases, who attend the pediatric rheumatology outpatient clinic of a tertiary referral hospital in western Switzerland, and one of their parents. The telenursing consultation, at least once a month, by a qualified, experienced, specialist nurse in pediatric rheumatology will consist of providing affective support, health information, and aid to decision-making. Cox’s Interaction Model of Client Health Behavior serves as the theoretical framework for this study. The primary outcome measure is satisfaction and this will be assessed using mixed methods (quantitative and qualitative data). Secondary outcome measures include disease activity, quality of life, adherence to treatment, use of the telenursing service, and cost. We plan to enroll 56 children.
The telenursing consultation is designed to support parents and children/adolescents during the course of the disease with regular follow-up. This project is novel because it is based on a theoretical standardized intervention, yet it allows for individualized care. We expect this trial to confirm the importance of support by a clinical specialist nurse in improving outcomes for children and adolescents with inflammatory rheumatisms.
Trial registration identifier: NCT01511341 (December 1st, 2012).
PMCID: PMC4067521  PMID: 24939642
Telenursing; Hotlines; Nursing; Child; Health outcomes; Rheumatic diseases
25.  A national survey of admission practices for late preterm infants in England 
BMC Pediatrics  2014;14:150.
Infants born at 34+0 to 36+6 weeks gestation are defined as ‘late preterm’ infants. It is not clear whether these babies can be managed on the postnatal ward (PNW) or routinely need to be admitted to the neonatal unit after birth.
To conduct a national survey of admission practice for late preterm and low birth weight infants directly to the PNW after birth in England.
All neonatal units were identified from the Standardised Electronic Neonatal Database (SEND). Individual units were contacted and data collected on their admission practice.
All 180 neonatal units in England responded. 49, 84 and 47 Units were Special Care Units (SCUs), Local Neonatal Units (LNUs) and Neonatal Intensive Care Units (NICUs) respectively. 161 units (89%) had written guidelines in relation to direct PNW admission for late preterm infants.
The mean gestational age of infants admitted directly to the PNW was significantly lower in LNUs compared to SCUs and NICUs compared to LNUs. Mean birth weight limit for direct PNW admission was significantly lower in NICUs compared to SCUs.
72 units had PNW nursery nurses. There was no significant difference in gestational age or birth weight limit for direct PNW admission in the presence of PNW nursery nurses.
Admission practices of late preterm infants directly to the PNW varies according to designation of neonatal unit in England. Further studies are needed to establish the factors influencing these differences.
PMCID: PMC4067689  PMID: 24939510
Late preterm infant; Low birth weight; Postnatal ward admission; Nursery nurse; Guideline

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