Clinical Pediatrics

Background: The built environment may influence weight status. Method: Using cross-sectional data for children aged 2 to 18 years, the authors linked clinical and spatial data using geographic information systems and analyzed for associations between body mass index (BMI) and density of and distance to nearest built environment variable (schools, sidewalks, subway stations, bicycle trails, open space, and fast-food restaurants) using bivariate and multilevel analyses. Results: The study sampled 21 008 children; 54% were white, 26% Hispanic, 37% overweight, and 20% obese. In bivariate analysis, distance to nearest fast-food restaurant was inversely associated with BMI, whereas density of fast-food restaurants was positively associated with BMI. Distance to school and subway station, amount of open space, and density of subway stations were inversely associated with BMI. Controlling for sociodemographic factors, only living near a greater density of subway stations was inversely associated with overweight (odds ratio, 0.87; 95% confidence interval, 0.81-0.94) and obesity (odds ratio, 0.90; 95% confidence interval, 0.82-0.99). Conclusion: Distance to nearest subway station is associated with BMI among Massachusetts children.

Background. Legislation requiring bittering of antifreeze enables assessment of the impact on frequency, volume, and severity of pediatric antifreeze ingestions. Methods. US poison control data for antifreeze ingestions in children younger than 5 years were analyzed comparing 232 ingestions occurring in states after enactment of bittering requirements with 6218 cases occurring in states (or at times) where bittering was not required. Results. The frequency of pediatric antifreeze ingestions was unchanged after implementation of bittering in Oregon and California. The medical outcome distribution, median volume ingested, and observed clinical effects were no different in bittered compared with nonbittered groups. Likewise, the rates of hospital admission, critical care treatment, and use of alkalinization, hemodialysis, or intubation showed no differences with bittering. Conclusion. Despite the appealing logic of limiting the ingested volume and thereby the severity of poisonings by adding aversive agents, and despite promising results in volunteer studies, bittering agents do not decrease the frequency or severity of pediatric antifreeze poisonings. The addition of bittering agents to household products cannot be justified based on actual poisoning data.

We compare 4 short-term outcomes—namely admission to special care nursery (SCN), length of stay (LOS), age at full feeds (AFF) and respiratory morbidity/need for ventilation—in 1015 late preterm singletons and 366 twins and triplets born at our institution over a 4-year period. Birth weight (BW) and gestational age (GA) rather than plurality of birth determined need for admission to SCN, LOS, AFF, and need for respiratory support. When matched for GA, compared to singletons, twins and triplets needed less admission to SCN and respiratory support at 36 weeks, whereas at 34 weeks, they had longer LOS and took longer to get to full feeds. We conclude that the outcomes of interest are affected by GA and BW rather than plurality.

The National High Blood Pressure Education Program (NHBPEP) report recommends a retinal exam seeking evidence of target organ damage in hypertensive children. This study aimed to determine the prevalence and severity of hypertensive retinopathy among hypertensive children, evaluated by pediatric ophthalmologists in the “real world” clinical setting using direct ophthalmoscopy. The authors retrospectively reviewed the medical records of the 83 children diagnosed with hypertension by a pediatric nephrologist between 1999 and 2006. Of the 35 children examined by an ophthalmologist within 12 months of the diagnosis of hypertension, only 3 (8.6%; 95% CI, 1.8%-23.1%) were diagnosed with hypertensive retinopathy. Despite the fact that those selected for retinal examination were likely at higher risk for retinopathy, the prevalence of retinopathy was low, and only mild abnormalities were detected. Given the lack of evidence linking mild retinal abnormalities with adverse outcomes, the NHBPEP recommendation for retinal examinations in hypertensive children should be reconsidered.

Objective. To describe the time and actions on 3 key health topics during health supervision (HS) visits of children aged 0 to 1 years. Method. HS visits were observed at 5 offices. Parents provided demographics and children’s measurements were obtained. Using special computer software, visits were observed for frequency and time for growth measurements, charting and interpretations, and for discussions on growth, diet, and safety. Results. A total of 128 visits were analyzed. Almost all children had weight (100%) and height (98%) measured and >80% had weight-for-age and height-for-age plotted. Growth interpretation (weight-for-height) was determined for 1 child. Nearly all visits included discussions of growth (88%), diet (97%), and safety (84%). When a topic was addressed, median times were as follows: growth, 9 seconds; diet, 42 seconds; and safety, 22 seconds. Median time on all 3 topics was 86 seconds. Conclusion. Growth, diet, and safety are frequently, but briefly, discussed at HS visits of young children.

Introduction. The literature supports a high rate of error in physician coding for professional services, suggesting that residency training in this area is inadequate to meet the needs in clinical practice. Method. From the American Board of Pediatrics database of recent graduates, 1200 generalists and 1100 subspecialists were selected to receive a structured questionnaire. Participants rated the adequacy of their training in billing and coding using 3 choices. Results. The response rate was 76% among the generalists and 77% among the subspecialists. Eighty-one percent of generalists (N = 549) and 78% (N = 423) of subspecialists indicated that they could have used additional training in billing and coding. This finding was common throughout all practice settings. Conclusions. Pediatric residency training programs are not meeting the needs of generalist or subspecialist physicians in training of billing and coding. Residency programs must enhance this training component to prepare physicians to maintain a financially viable practice.

Food-dependent exercise-induced anaphylaxis (FDEIA) was prevented from recurring in 2 children by sodium cromoglycate (SCG) before intake of the causative food. Case 1: A 14-year-old girl who had suffered recurrent symptoms of anaphylaxis when she exercised after lunch. Radioallergosorbent test (RAST) was 1.49 UA/mL for wheat. She was advised to take SCG before lunch. In 2007, she ate bread at lunchtime without taking SCG and developed anaphylaxis. After this, she always took SCG and did not develop anaphylaxis. Case 2: A 9-year-old boy who had recurrent symptoms of anaphylaxis when he exercised after lunch. RAST was 0.46 UA/mL for wheat. He started taking SCG before lunch. In June 2008, he forgot to take SCG and ate fu (a food made from wheat). He exercised after lunch and developed anaphylaxis. Since then, he has always taken SCG and has not developed anaphylaxis. Conclusion: Our findings suggest that SCG prevents FDEIA caused by wheat allergy.

Early childhood trichotillomania (TTM) has often been considered to be benign. However, untreated early childhood TTM can have significant negative physical and psychological consequences. This report describes the behavioral treatment of a 29-month-old girl with TTM. Treatment consisted of 14 daily sessions of behavioral intervention, followed by 3 consecutive days of follow-up treatment conducted 7 weeks after the end of initial treatment. The hair pulling was addressed by using reinforcers for not pulling, provided at intervals of increasing length. At the end of initial treatment, the hair pulling improved significantly. At follow-up, although some of the initial treatment gains were reduced, the patient maintained significant improvement compared with baseline.

Objective. To assess the feasibility and acceptability of a brief tool to help pediatricians communicate with parents of preschoolers about obesity risk, prevention, and treatment. Methods. The 2-sided Assessment and Targeted Messages (ATM) tool developed by the investigators included sections to assess nutrition and physical activity, self-efficacy and readiness-to-change, obesity-related family history, and treatment/prevention recommendations. Twenty-five pediatricians were recruited to use the ATM and then surveyed regarding their opinions of its feasibility and acceptability. Results. Response rate was 60%. Most ATM features were considered somewhat or very useful by the majority of respondents. The majority of physicians (62%) indicated that they were somewhat likely to use the ATM in the future, with only 23% indicating that they were very likely to use it. The greatest barrier to its use was time. Conclusion. Pediatricians considered the ATM tool moderately feasible and acceptable. Time-efficient methods to help physicians address obesity should be explored.

An older-adolescent patient becomes incapable of making medical decisions due to the progression of his illness. The medical team members are faced with a conflict between what the law requires and their ethical convictions regarding who should be the surrogate decision maker. A discussion of relevant law and ethical standards is presented as it applies to similar situations.