Clinical Pediatrics

The study goals were to assess, via survey (a) parental knowledge regarding the use of over-the counter (OTC) cough and cold medicines in children younger than the age of 6 years and (b) the effects of the Food and Drug Administration (FDA) recommendations on community pediatricians following voluntary withdrawal of these medications. Of the 179 parents surveyed, approximately 60% had used OTC cough and cold medicines in the past, and many parents indicated an inappropriate dose when asked. Parents who were aware of the recall were significantly less likely to continue use (P < .05). All 33 physicians surveyed were aware of the withdrawal of these medications for children younger than age 2 years and most were aware of consideration to remove these medications for children <6 years old. A total of 15% of physicians reported that FDA considerations were likely to change their practice by reducing or discontinuing use of these medications, whereas 6% would continue recommending these medications.

Several studies have demonstrated the importance of achieving the American Diabetes Association (ADA) clinical guidelines in adults. However, research is limited on adherence to these guidelines in the pediatric population. This retrospective chart review examined 56 charts from 6 physician offices and 1 multispecialty health care system in Ohio. Variables of interest included recommendations from the 2007 ADA Standards of Medical Care in Diabetes. HgA1c was measured every 3 months in 44.6% of patients, while 55% achieved A1c goal. Blood pressure was monitored in all patients, with 57% meeting goal. Lipids and urine microalbumin were tested annually in 51.7% and 26.7% of patients, respectively. Dilated eye and foot exams were performed on 53.5% and 37.5% of patients, respectively. Adherence to ADA clinical guidelines for pediatric patients with type 2 diabetes is suboptimal. The authors recommend that specific evidence-based guidelines be evaluated for children with type 2 diabetes.

Background. Previous research has shown that overweight Latino children underestimate their body size. Erroneous perception of body size may have important health and behavioral implications and serve as a significant barrier to weight control. Objective. The aim of this study was to determine whether children’s perceptions of their body size became more accurate following a pediatric obesity intervention focused on increasing physical activity. Design/ methods. This analysis includes 61 overweight (body mass index ≥85%) Latino children (aged 8-11 years) parent—child dyads who completed a pilot randomized control trial. Results. After the intervention, 40.7% (11/27) of children in the intervention group rated their body size accurately compared with 21.2% (7/33) in the control group. The difference indicates a trend toward significance (P = .09). Conclusions. Participating in monthly physical activity skill building sessions may increase children’s accuracy in body size perception.This may be an important first step toward behavior modification.

Objective.To assess weight stigma, self-perception of weight status, and factors contributing to accurate self-perception of weight status in obese youth presenting for treatment at a hospital-based multidisciplinary weight management program. Methods. Participants (N = 97; mean age = 8.56 ± 1.66 years) used a figural rating scale to assess weight stigma and their current and ideal body type, and Sizing Me Up, a measure of obesity-specific health-related quality of life (HRQOL). Results. The majority endorsed negative/stereotypical attributes toward an obese body type, chose an average or underweight figure as their ideal, and 39% misperceived their weight status. Older child age and greater HRQOL impairment were significant predictors (P < .01) of correct self-perception. Conclusion. Pediatricians may find that talking with the elementary school—aged patient and family about whether weight/size affects their day-to-day life will prove to be a salient and neutral opening to discussing the child’s obesity and need for intervention.

The authors sought to develop and test a breath-controlled video game using a digital spirometer that, by providing visual breath biofeedback, could promote awareness of breathing techniques in children with cystic fibrosis (CF). To assess improvement in game performance during hospitalizations for CF exacerbations, the authors conducted a trial on 10 inpatients. Subjects had at least five 15-minute exposures to a breath biofeedback game that challenged them to track a moving target using their breath. Subjects reacted positively to the breath tracking challenge. Repeated-measures analysis of variance of a tracking fidelity statistic showed improvement in eye—breath coordination over 5 sessions ( P = .026). It was concluded that an electronic breath game is safe and can improve breath awareness among children with CF. This technology could also contribute to awareness of respiratory symptoms and foster social ties among CF patients.

We hypothesized that parents of infants prefer growth at higher percentiles and are averse to growth at lower percentiles. Of 279 participating parents, only 10% desired their child’s weight to be in the lowest quartile. For children weighing in the lowest quartile, 57% of parents thought their child’s weight was “too low.” In contrast, 66% of parents whose child’s weight was in the top quartile preferred their child weigh that much. When viewing hypothetical infant growth trajectories, 47% ranked a growth chart demonstrating growth along the 10th percentile for weight as “least healthy” of 6 growth patterns, and 29% chose charts showing an infant at the 90th percentile for weight at age 1 as “healthiest.” In conclusion, parents are averse to growth at the bottom of the weight growth chart but are much less likely to feel negatively about growth at higher percentiles. This is troubling given the childhood obesity epidemic.

The authors conducted a chart review of all febrile infants between 28 and 90 days of age who presented to the emergency department (ED) between December 1 and March 31 during 2004-2006. The objectives of the study were to describe the practice patterns of pediatric ED physicians caring for these infants and to determine whether the evaluation and management of these infants differed based on their age at presentation. Two groups were compared—infants aged 28 to 59 days (n = 79) and infants aged 60 to 90 days (n = 88). As compared with the younger age group, infants in the older age group had fewer complete blood cell counts (relative risk, RR = 3.57; 95% confidence interval [CI], 2.15-5.95), fewer blood cultures (RR = 3.38; 95% CI, 1.99-5.74), fewer urine cultures (RR = 3.83; 95% CI, 1.81-8.13), and fewer cerebrospinal fluid cultures (RR = 2.56; 95% CI, 1.94-3.40). Overall, there was poor adherence to current guidelines for the diagnostic evaluation of young febrile infants.

Interventions to improve pediatric blood pressure (BP) screening have not been well studied. The authors measured staff acceptance of 2 simple in-office interventions and measured the effect on physician recognition of elevated BP measurements. Group 1 used simplified normative pediatric BP tables affixed to the growth chart, group 2 used a personal digital assistant program (PDA) to calculate BP percentiles as part of the vital signs, and group 3 served as the control. Group detection rates by compliant (C) and noncompliant (NC) with the intervention were: (1) (BP table) C = 18%, NC = 12%; (2) (PDA) C = 33%, NC = 26%; and (3) (control) 18%. There was no statistically significant intervention effect with documented compliance (P = .27) nor was there an effect in the noncompliant records (P = .12). Although the interventions were used inconsistently, their presence in the medical record did not improve performance. Future education and interventions are needed to reduce barriers to elevated pediatric BP recognition.

We describe a simplified method for interpreting a pediatric electrocardiogram (EKG). The method uses 4 steps and requires only a few memorized rules, and it can aid health care providers who do not have immediate access to pediatric cardiology services. Most pediatric EKGs are normal. However, both abnormal and normal EKGs should be sent to a pediatric cardiologist for later, confirmatory interpretation.

Objective: To describe parents’ and adolescents’ perceptions about vaccination. Methods: Qualitative interviews of 22 mothers/grandmothers and 25 10- to 14-year-olds. Results: Themes emerged in 3 focus areas. (a) Understanding: Both adults and adolescents had difficulty understanding concepts of risks, benefits, prevention, and vaccination. (b) Decision making: Adults saw vaccination as an opportunity to help their adolescent develop skills for transition to adulthood. Adolescents worried about being lied to (reinforced by being told “it won’t hurt”), physical pain, and cleanliness. ( c) Preventing sexually transmitted infections: Adults were divided between those who felt their child would not need such a vaccine and those who wanted to “be safe” to protect their child in the future. Conclusions: At the same time that even basic concepts about vaccination should be explained to both adults and adolescents, adolescence represents a time for learning about responsible decision making. Discussion regarding the risks and benefits of vaccines can be part of transitioning to adult decision making.

A 5-year-old child with Down syndrome (DS) diagnosed with mild to moderate obstructive sleep apnea (OSA) and subsequently found to have severe hypothyroidism is presented. Following 3 months of treatment with levothyroxine, she had full resolution of her OSA. This case underscores the importance of routine thyroid function screening in children with DS and demonstrates that OSA in children with DS can be caused by other underlying medical issues that themselves require therapy, such as the hypothyroidism in this child. Although empiric testing of thyroid function is not recommended as part of the routine workup of patients with OSA, when caring for children at higher risk for thyroid dysfunction, such as those with DS, it is important to establish whether or not it is present, as treating it may bring about partial or full resolution of the OSA, as was shown to occur in this patient.

Barriers to swallowing tablets and capsules can impact adherence to medication regimens. Few tools are currently available to assist adolescent children who have difficulty swallowing tablets and capsules. A convenience sample of adolescent children, identified through selfreport as having difficulty in swallowing tablets or capsules in the past, were provided Pill Glide, a flavored spray promoted to aid swallowing. To emulate medication administration, a tic tac (candy) was placed in the middle of the tongue, and with a drink of water, the participant was instructed to swallow the tic tac. Success or failure to swallow the tic tac was recorded. A total of 11 adolescent children ranging in age from 9 to 17 years reported past difficulty with swallowing medication. Seven of the 11 participants were successful in swallowing the tic-tac with the use of Pill Glide. This initial assessment of Pill Glide spray demonstrates positive findings for improving the ease of swallowing tablets and capsules for adolescents.

The authors present the case of a 6.5-year-old girl with bilateral temporomandibular joint (TMJ) pain, generalized arthralgias, inability to walk, and absence of deep tendon reflexes in the context of Guillain—Barrè syndrome. TMJ pain was the sole manifestation for 3 days, before other typical symptoms appeared, an issue that initially led to an improper diagnosis. A thorough clinical examination along with laboratory and radiographic evaluation excluded other possible causes of TMJ pain. To the best of the authors’ knowledge, this is the first case of Guillain—Barrè syndrome in the pediatric population initially presenting with bilateral TMJ pain. Guillain—Barrè syndrome may be quite atypical in its expression, especially in young children, with pain being a common presenting symptom, and pediatricians should be alert to avoid misdiagnosis.