Clinical Pediatrics

Children’s musculoskeletal (MSK) injury pain remains poorly managed. This survey of pediatric emergency physicians and orthopedic surgeons assessed analgesia administration practices and discharge advice for children with acute MSK pain; 683 responses were received. Ibuprofen was the most commonly reported analgesic used in the emergency department (52%) and at discharge (68%). Most (85%) reported using oral opioids in the previous 6 months. Codeine use was the most commonly reported opioid used in the emergency department (38%) and at home (51%). For equal levels of pain, younger children received less opioids than older children. Younger physicians and recent graduates chose acetaminophen and codeine more than older and more experienced colleagues, who preferred ibuprofen and non-codeine containing opioid compounds (P < .001 and .006, respectively). Orthopedic surgeons reported less ibuprofen use than pediatric emergency physicians (P < .001). Choice of analgesic agents is heterogeneous among physicians and is influenced by pain severity, child’s age, and physician characteristics.

Problem/Background. Adolescent depression is a growing problem for today’s society with only 30% receiving services. Aim and Methods. The aim of this project was to increase identification and treatment of depressed adolescents, and comfort levels of primary care providers with the implementation of a depression-screening program and use of a clinical depression toolkit within a primary care setting. Setting. The setting was a private pediatric practice in central Maine. Results. Over an 8-week period, 266 adolescents were screened. Twelve adolescents (4.5%) received a diagnosis of depression and 11 received treatment within 8 days. Survey results showed a significant increase in providers’ feelings of comfort and accountability. Conclusion. This project demonstrates that it is feasible to implement a depression screening and treatment program in primary care. It demonstrates that primary care providers can increase their comfort and feelings accountability in treating depression in primary care, thus increasing access for this monumental and potential catastrophic problem.

Background. Vitamin D has important skeletal and extraskeletal roles but those living at northerly latitudes are at risk of suboptimal levels because of reduced sunlight exposure. Aim. To describe the vitamin D status of Irish children and identify factors predictive of vitamin D status. Methods. A prospective cross sectional study was undertaken over a 12 month period. Two hundred and fifty two healthy children attending for minor medical or surgical procedures were recruited. All had 25-hydroxyvitamin D (25OHD), parathyroid hormone and bone profiles measured. Results. The mean (standard deviation) for 25OHD was 51(25) nmol/L (20.4 (10) ng/mL). Forty-five percent had levels >50 nmol/L (20 ng/mL). The following variables were significantly associated with 25OHD levels >50 nmol/L (20 ng/mL): sample drawn in April-September, use of vitamin D supplements, consumption of formula milk, and non-African ethnicity. Conclusion. More than half of the children in this study had 25OHD levels less than 50 nmol/L (20 ng/mL). Vitamin D status was significantly improved by augmented oral vitamin D intake.

Background and Objectives. Chronic, severe iron-deficiency anemia (IDA) in the first years of life increases the risk of irreversibly compromised cognitive, affective, and motor development. While IDA in infants has decreased because of dietary changes (iron-fortified formula and delaying cow’s milk), toddlers (13-36 months) are equally vulnerable to the adverse effects of IDA. We aimed to show that despite public health efforts, severe IDA remains a problem in toddlers and is associated with excess milk consumption. Methods. Retrospective chart review of children 6 to 36 months admitted to or evaluated by hematology at a children’s hospital from January 1, 2005 to December 31, 2010 with a severe microcytic anemia (hemoglobin [Hb] <9 g/dL and mean corpuscular volume (MCV) <75 fL). Results. We identified 68 infants and toddlers with severe IDA; most (84%) were 13 to 36 months old. The mean Hb and MCV were 6.0 g/dL (range = 2.2-8.9 g/dL) and 54.0 fL (range = 45.5-69.8 fL), respectively. Fatigue, poor appetite, and pica were the most common symptoms, found in 43%, 29%, and 22% of patients, respectively. Only 41% of parents reported pale skin while 77% of physicians recorded it on physical exam. Daily cow’s milk consumption surpassed 24 ounces for 47 of 48 children with reported intake; 11 consumed more than 64 ounces per day. Conclusions. Despite current screening recommendations, severe IDA continues to be a problem in toddlers and strongly correlates with excess cow’s milk consumption. This reiterates the importance of screening for IDA into routine toddler care.

We examined mental health–related visits to emergency departments (EDs) among children from 2001 to 2011. We used the National Hospital Ambulatory Medical Care Survey—Emergency Department, 2001-2011 to identify visits of children 6 to 20 years old with a reason-for-visit code or ICD-9-CM diagnosis code reflecting mental health issues. National percentages of total visits, visit counts, and population rates were calculated, overall and by race, age, and sex. Emergency department visits for mental health issues increased from 4.4% of all visits in 2001 to 7.2% in 2011. Counts increased 55 000 visits per year and rates increased from 13.6 visits/1000 population in 2001 to 25.3 visits/1000 in 2011 (P < .01 for all trends). Black children (all ages) had higher visit rates than white children and 13- to 20-year-olds had higher visit rates than children 6 to 12 years old (P < .01 for all comparisons). Differences between groups did not decline over time.

Background. Primary care is an ideal setting to treat pediatric obesity. Effective, low-intensity (≤25 contact hours over 6 months) interventions that reduce standardized body mass index (z-BMI) and can be delivered by primary care providers are needed. Objective. This pilot randomized controlled trial investigated the effect of 3 low-intensity (≤25 contact hours over 6 months) pediatric obesity treatments on z-BMI. Methods. Twenty-two families (children 8.0 ± 1.8 years, z-BMI of 2.34 ± 0.48) were randomized into 1 of 3, 6-month, low-intensity conditions: newsletter (N), newsletter and growth monitoring (N + GM), or newsletter and growth monitoring plus family-based behavioral counseling (N + GM + BC). Anthropometrics and child eating and leisure-time behaviors were measured. Results. Mixed-factor analyses of variance found a significant (P < .05) main effect of time for z-BMI and servings per day of sugar sweetened beverages, with both decreasing over time. Conclusion. Low-intensity obesity treatments can reduce z-BMI and may be more feasible in primary care.

Partially hydrolyzed formulas (pHF) represent a significant percentage of the infant formula market. A new whey-based, palm olein oil (PO)–free pHF was developed and a masked, randomized, parallel growth study was conducted in infants fed this formula or a commercially available whey-based pHF with PO. Infants between 0 and 8 days were to be enrolled and studied to 119 days of age. Growth and tolerance of infants were evaluated. Mean weight gain from 14 to 119 days of age was similar between groups. There were no significant differences between groups in weight, length, head circumference (HC), or length or HC gains. Infants fed the new PO-free pHF had significantly softer stools than those fed the PO-containing formula except at 119 days of age. This study demonstrates that whereas growth of infants fed different formulas during the first 4 months of life may be similar, infants may tolerate individual formulas differently.

Background. Integrating age appropriate injury prevention messages during a well-child visit is challenging in the face of competing demands. Purpose. To describe a 7-month pilot using technology to facilitate injury prevention risk assessment and education integration. Methods. We prospectively tracked responses to the computer-based injury prevention self-assessment tool, safety product distribution, and any subsequent contact with the local hospital system for related unintentional injuries. Results. A total of 2091 eligible visits by 1368 unique patients were assessed. Eight hundred forty-three unique patients completed the Safe N’ Sound assessment and 7 were subsequently injured, with an injury related to a Safe N’ Sound target area. Conclusions. A kiosk-based tailored injury assessment tool can be successfully integrated into a busy pediatric practice. Unintentional injury outcomes can be linked to the tailored anticipatory guidance and can identify the effectiveness of this electronic integration of injury prevention messaging into well-child examinations.