31.8.11

Identification of developmental-behavioral problems in primary care: a systematic review.


Pediatrics. 2011 Aug;128(2):356-63. Epub 2011 Jul 4.

Sheldrick RC, Merchant S, Perrin EC.

CONTEXT: Recent mandates and recommendations for formal screening programs are based on the claim that pediatric care providers underidentify children with developmental-behavioral disorders, yet the research to support this claim has not been systematically reviewed.
OBJECTIVE: To review research literature for studies regarding pediatric primary care providers' identification of developmental-behavioral problems in children.
METHODS: On the basis of a Medline search conducted on September 22, 2010, using relevant key words, we identified 539 articles for review. We included studies that (1) were conducted in the United States, (2) were published in peer-reviewed journals, (3) included data that addressed pediatric care providers' identification of developmental-behavioral problems in individual patients, (4) included an independent assessment of patients' developmental-behavioral problems, such as diagnostic interviews or validated screening instruments, and (5) reported data sufficient to calculate sensitivity and specificity. Studies were not limited by sample size. Eleven articles met these criteria. We used Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria to evaluate study quality. Although the studies were similar in many ways, heterogeneous methodology precluded a meta-analysis.
RESULTS: Sensitivities for pediatric care providers ranged from 14% to 54%, and specificities ranged from 69% to 100%. The authors of 1 outlier study reported a sensitivity of 85% and a specificity of 61%.
CONCLUSIONS: Pediatricians are often the first point of entry into developmental and mental health systems. Knowing their accuracy in identifying children with developmental-behavioral disabilities is essential for implementing optimal evaluation programs and achieving timely identification. Moreover, these statistics are important to consider when planning large-scale screening programs.
PMID: 21727101  [PubMed - in process]

Composite measures quantify households' obesogenic potential and adolescents' risk behaviors.


Pediatrics. 2011 Aug;128(2):e308-16. Epub 2011 Jul 4.
Grunseit AC, Taylor AJ, Hardy LL, King L.

OBJECTIVE: The aims of this study were to generate composite measures quantifying a household's obesogenic potential and to examine the relationship of the composite variables with older children's eating, physical activity (PA), and small screen recreation.
METHODS: Data were from surveys with 1685 child-parent pairs in which the child was in grade 6, 8, or 10 (mean age: 14 years). Composite measures of the obesogenic household environment were generated from 11 measures using nonlinear  principal components analysis. Associations between the composite measures and the children's healthy and unhealthy food intake, PA, and screen time were tested (adjusting for demographic characteristics).
RESULTS: Two scales were generated: (1) obesogenic control, which clustered together factors that mitigate risk; and (2) obesogenic risk. Higher scores on the control scale were associated with higher adolescent intake of healthy foods, lower intake of unhealthy foods, higher PA, and less screen time. Higher scores on the risk scale were associated with lower adolescent intake of healthy foods,  higher intake of unhealthy foods, lower PA, and more screen time. There were significant 2-way interactions between the scales for soft drink consumption and  PA.
CONCLUSIONS: Household obesogenic potential may be quantified as 2 factors reflecting cumulative risk and control practices. These factors have both additive associations with obesogenic behaviors and, in some cases, modify each other, suggesting that a healthy home environment requires attention to both. Health promotion messages could incorporate these 2 different but interacting factors that parents can use to modify the obesogenic potential of their household.

The Association of BMI Status With Adolescent Preventive Screening



Pediatrics. 2011 Aug;128(2):e317-23. Epub 2011 Jul 18.
Jasik CB, Adams SH, Irwin CE Jr, Ozer E.

OBJECTIVE: To examine the relationship between BMI status (normal, overweight, and obese) and preventive screening among adolescents at their last checkup.
METHODS: We used population-based data from the 2003-2007 California Health Interview Surveys, telephone interviews of adolescents aged 12 to 17 years with a checkup in the past 12 months (n = 9220). Respondents were asked whether they received screening for nutrition, physical activity, and emotional distress. BMI  was calculated from self-reported height and weight: (1) normal weight or underweight (<85th percentile); (2) overweight (85th-94th percentile); and (3) obese (>95th percentile). Multivariate logistic regression models tested how screening by topic differed according to BMI status, adjusting for age, gender, income, race/ethnicity, and survey year.
RESULTS: Screening percentages in the pooled sample (all 3 years) were higher for obese, but not overweight, adolescents for physical activity (odds ratio: 1.4; P  < .01) and nutrition (odds ratio: 1.6; screening did not differ P < .01). Stratified analysis by year revealed higher screening for obese (versus normal-weight) adolescents for nutrition and physical activity in 2003 and for all 3 topics in 2005. However, by 2007, screening did not differ according to BMI status. Overall screening between 2003 and 2007 declined for nutrition (75%-59%;  P < .01), physical activity (74%-60%; P < .01), and emotional distress (31%-24%;  P < .01).
CONCLUSIONS: Obese adolescents receive more preventive screening versus their normal-weight peers. Overweight adolescents do not report more screening, but standards of care dictate increased attention for this group. These results are discouraging amid a rise in pediatric obesity and new guidelines that recommend screening by BMI status.
PMCID: PMC3146353 [Available on 2012/8/1] PMID: 21768313  [PubMed - in process]

29.8.11

Non-pharmacologic management of procedure-related pain in the breastfeeding infant.

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #23: Non-pharmacologic management of procedure-related pain in the breastfeeding infant. Breastfeed Med 2010 Dec;5(6):315-9.

Major Recommendations
Soothing the Newborn

There are several techniques that have been shown to provide pain relief for newborns (0–28 days of age) undergoing painful procedures. In breastfed newborns, breastfeeding itself is the preferred method to alleviate procedural pain. In addition to being safe, effective, natural, and without added cost, it provides an additional opportunity to promote and support breastfeeding. The individual components of breastfeeding (sucking, sweet taste, and warm contact) may be used separately or, preferably, in combinations when breastfeeding itself is not possible.

Breastfeeding or Human Milk

When available, breastfeeding should be the first choice to alleviate procedural pain in neonates undergoing a single painful procedure, such as venipuncture or heel lance (Codipietro, Ceccarelli, & Ponzone, 2008; Carbajal et al., 2003; Gray et al., 2002). Breastfeeding should not be discontinued prior to the procedure. Studies show that when breastfeeding was stopped shortly before a painful procedure, no significant differences were found (compared to control groups) in outcomes in terms of the orogustatory, emotional, tactile, or thermal experience (Gradin, Finnstrom, & Schollin, 2004). When breastfeeding is not possible, whether because of the unavailability of the mother or difficulties with breastfeeding, consider the use of expressed human milk by dropper, syringe, or bottle, which has been shown to soothe newborns experiencing procedural pain (Mathew & Mathew, 2003; Upadhyay et al., 2004; Taddio et al., 2008; Shah, Aliwalas, & Shah, 2006). Administration of human milk can also be combined with sucking, by dipping a pacifier (dummy) in the milk, as described below for sucrose.
Although some studies have demonstrated the efficacy of human milk alone (Upadhyay et al., 2004; Shah, Aliwalas, & Shah, 2007), human milk may not be equivalent to breastfeeding because of breastfeeding's multicomponent experience. Breastfeeding throughout the painful procedure is likely to be superior to human milk alone on the basis of synergism between the components of breastfeeding (Gradin, Finnstrom, & Schollin, 2004; Shah, Aliwalas, & Shah, 2007).
Skin-to-Skin Contact

Coordinating a breastfeeding session with the timing of the procedure is best, but, if this is not possible, skin-to-skin contact can comfort infants undergoing a procedure such as a heel lance. Skin-to-skin contact also gives the mother a caretaking role during the procedure that is unobtrusive, and by diminishing infant stress, it can increase maternal confidence as to her value to the infant (Gray, Watt, & Blass, 2000).
Parental contact and sucrose may act synergistically to reduce pain in neonates. Therefore if feasible, this combination can be employed (Schechter et al., 2007). Sucrose taste—first studied 20 years ago—is readily available for increasing the efficacy of other non-pharmacologic techniques (Gradin, Finnstrom, & Schollin, 2004). Sucrose administration is covered in more detail in the section below. Sucrose and pacifier can both be combined with the skin-to-skin component of parental contact.
Sucrose and Sucking (in Combination or Separately)

Sucrose taste has been shown to be effective analgesia for newborns and young infants for minor procedures, but not for more painful experiences like bladder catheterizations:

Sucrose and pacifier. The combination of oral sucrose and pacifier or non-nutritive sucking is remarkably soothing (Blass & Watt, 1999). This technique offers pain reduction to infants undergoing a wide variety of painful procedures, including heel lance, umbilical or percutaneous venous or arterial catheter insertion, central venous line placement, subcutaneous or intramuscular injection, lumbar puncture, circumcision, and endotracheal suction (Anand, 2001; Stevens, Yamada, & Ohlsson, 2004; Stevens et al., 2005). Because pain reduction achieved when using both sucrose and non-nutritive sucking is similar to that with breastfeeding, using a pacifier (dummy) dipped in 24% sucrose (by weight) solution whenever breastfeeding is not possible is an effective option (Blass & Watt, 1999; Akman et al., 2002). Sucrose administration should begin 2 minutes prior to the procedure. If use of a pacifier is not an available or acceptable option, sucrose can also be combined with sucking by dipping a clean, gloved (or non-gloved parental) finger in the sucrose solution. If sucking a pacifier or finger is not an option, administer a sucrose solution orally before the procedure (Anand, 2001). When parents are present, they should be educated that sweet substances other than breast milk and pacifiers both are recommended in the newborn period only for procedural pain.
Glucose versus sucrose. Glucose has also been shown to be an acceptable and effective alternative analgesic (Axelin et al., 2009; Idam-Siuriun et al., 2008). Taste difference is not a factor. Studies in rat (Blass & Shide, 1994) and human (Okan et al., 2007) newborns have not shown a preference for sucrose over glucose. The commercial availability of sucrose (table sugar) may have increased its use.
Sucrose by syringe. If use of a pacifier is not possible, administer 0.5–2mL of a 24% sucrose solution orally via syringe 2 minutes before the painful procedure (Anand, 2001; Shann, 2007). Several 24% sucrose solutions are commercially available. Sucrose administered by oro- or nasogastric tube is not analgesic.
Pacifier alone. While pacifiers alone may decrease crying associated with painful procedures, they do not have the same effect on physiological parameters such as heart rate or vagal tone (Taddio, 2001: Porges & Lipsitt, 1993). Moreover, sucking a pacifier has been found to reduce pain only when the suck rate exceeds 30 sucks/minute (Stevens, Yamada, & Ohlsson, 2004). A pacifier (or clean gloved or parental finger) should be used as the sole soothing intervention only if breastfeeding, human milk, sucrose (or glucose), and skin-to-skin contact are unavailable because non-nutritive sucking has consistently been found to be better than no intervention at all (Pinelli, Symington, & Ciliska, 2002).
Sucrose better than human milk? At least one study indicates that sucrose is more effective than human milk, when both are administered orally via syringe, at reducing infants' cry time, recovery time (heart rate peak returns to baseline), and change in heart rate (Ors et al., 1999). The sugar in human milk is lactose, which has been shown to be an ineffective analgesic agent (Blass & Shide, 1994). The analgesic component of human milk may be attributed to its fat content or other constituent
Y SIGUE.../...

23.8.11

Reduced or modified dietary fat for preventing cardiovascular disease

Editorial Group: Cochrane Heart Group.Published Online: 6 JUL 2011

Assessed as up-to-date: 1 DEC 2010 DOI: 10.1002/14651858.CD002137.pub2
Abstract

Background

Reduction and modification of dietary fats have differing effects on cardiovascular risk factors (such as serum cholesterol), but their effects on important health outcomes are less clear.


Objectives

To assess the effect of reduction and/or modification of dietary fats on mortality, cardiovascular mortality, cardiovascular morbidity and individual outcomes including myocardial infarction, stroke and cancer diagnoses in randomised clinical trials of at least 6 months duration.


Search strategy

For this review update, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, were searched through to June 2010. References of Included studies and reviews were also checked.


Selection criteria

Trials fulfilled the following criteria: 1) randomised with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) adult humans with or without cardiovascular disease, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available.


Data collection and analysis

Participant numbers experiencing health outcomes in each arm were extracted independently in duplicate and random effects meta-analyses, meta-regression, sub-grouping, sensitivity analyses and funnel plots were performed.


Main results

This updated review suggested that reducing saturated fat by reducing and/or modifying dietary fat reduced the risk of cardiovascular events by 14% (RR 0.86, 95% CI 0.77 to 0.96, 24 comparisons, 65,508 participants of whom 7% had a cardiovascular event, I2 50%). Subgrouping suggested that this reduction in cardiovascular events was seen in studies of fat modification (not reduction - which related directly to the degree of effect on serum total and LDL cholesterol and triglycerides), of at least two years duration and in studies of men (not of women). There were no clear effects of dietary fat changes on total mortality (RR 0.98, 95% CI 0.93 to 1.04, 71,790 participants) or cardiovascular mortality (RR 0.94, 95% CI 0.85 to 1.04, 65,978 participants). This did not alter with sub-grouping or sensitivity analysis.

Few studies compared reduced with modified fat diets, so direct comparison was not possible.


Authors' conclusions

The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates. The ideal type of unsaturated fat is unclear.



Plain language summary

Cutting down or changing the fat we eat may reduce our risk of heart disease

Modifying fat in our food (replacing some saturated (animal) fats with plant oils and unsaturated spreads) may reduce risk of heart and vascular disease, but it is not clear whether monounsaturated or polyunsaturated fats are more beneficial. There are no clear health benefits of replacing saturated fats with starchy foods (reducing the total amount of fat we eat). Heart and vascular disease includes heart attacks, angina, strokes, sudden cardiovascular death and the need for heart surgery. Modifying the fat we eat seems to protect us better if we adhere in doing so for at least two years. It is not clear whether people who are currently healthy benefit as much as those at increased risk of cardiovascular disease (people with hypertension, raised serum lipids or diabetes for example) and people who already have heart disease, but the suggestion is that they would all benefit to some extent.

22.8.11

Child passenger safety.

Pediatrics. 2011 Apr;127(4):e1050-66. Epub 2011 Mar 21.
Durbin DR; Committee on Injury, Violence, and Poison Prevention.
Collaborators: Gardner HG, Baum CR, Dowd MD, Durbin DR, Ebel BE, Ewald MB,Lichenstein R, Limbos MA, O'Neil J, Powell EC, Quinlan KP, Scholer SJ, Sege RD,Turner MS, Weiss J, Weinberg S, Gilchrist J, Haverkos LJ, Midgett JD, Sinclair AS, Yanchar NL, Kozial B.
Despite significant reductions in the number of children killed in motor vehicle crashes over the past decade, crashes continue to be the leading cause of death for children 4 years and older. Therefore, the American Academy of Pediatrics continues to recommend inclusion of child passenger safety anticipatory guidance  at every health-supervision visit. This technical report provides a summary of the evidence in support of 5 recommendations for best practices to optimize safety in passenger vehicles for children from birth through adolescence that all pediatricians should know and promote in their routine practice. These recommendations are presented in the revised policy statement on child passenger safety in the form of an algorithm that is intended to facilitate their implementation by pediatricians with their patients and families. The algorithm is designed to cover the majority of situations that pediatricians will encounter in practice. In addition, a summary of evidence on a number of additional issues that affect the safety of children in motor vehicles, including the proper use and installation of child restraints, exposure to air bags, travel in pickup trucks, children left in or around vehicles, and the importance of restraint laws, is provided. Finally, this technical report provides pediatricians with a number of resources for additional information to use when providing anticipatory guidance to families.

17.8.11

Associations between problems with crying, sleeping and/or feeding in infancy and long-term behavioural outcomes in childhood: a meta-analysis.

Associations between problems with crying, sleeping and/or feeding in infancy and long-term behavioural outcomes in childhood: a meta-analysis. Hemmi MH, Wolke D, Schneider S.  Arch Dis Child. 2011 Jul;96(7):622-9. Epub 2011 Apr 20. (Review) PMID: 21508059

BACKGROUND: Excessive crying, sleeping or feeding problems are found in approximately 20% of infants and may predict behavioural problems in childhood.

METHODS: A quantitative meta-analysis of 22 longitudinal studies from 1987 to 2006 that statistically tested the association between infant regulatory problems and childhood internalising, externalising and attention-deficit/hyperactivity disorder (ADHD) problems was carried out; 1935 children with regulatory problems were tested. Cohen`s d was used to express the association between regulatory problems and behavioural problems. Heterogeneity of the effect sizes was assessed using the I(2) statistic and meta-analysis of variance and meta-regressions were conducted to assess the influence of moderators. Rosenthal`s classic fail-safe N and correlation of sample sizes to effect sizes were used to assess publication bias.

RESULTS: The weighted mean effect size for the main regulatory problems-behavioural problems association was 0.41 (95% CI 0.28 to 0.54), indicating that children with previous regulatory problems have more behavioural problems than controls. Externalising and ADHD problems were the strongest outcome of any regulatory problem, indicated by the highest fail-safe N and lowest correlation of sample size to effect size. Meta-analyses of variance revealed no significant moderating influences of regulatory problem comorbidity (I(2)=44.0, p>0.05), type (I(2)=41.8, p>0.05) or duration (I(2)=44.0, p>0.05). However, cumulative problems and clinical referral increased the risk of behavioural problems.

CONCLUSIONS: The meta-analyses suggest that children with previous regulatory problems have more behavioural problems than controls, particularly in multi-problem families. Further studies are required to assess the behavioural outcomes of previously sleep, feeding or multiply disturbed children. 



12.8.11

Secondhand Smoke Exposure and Neurobehavioral

Zubair Kabir, MD, PhD,a Gregory N. Connolly,
DMD, MPH,b and Hillel R. Alpert, ScMb.aTobacco Free Research Institute, Dublin, Ireland; and bCenter
for Global Tobacco Control, Harvard School of Public Health,
Boston, Massachusetts
Relación entre el tabaquismo pasivo y los trastornos neuroconductuales en niños
El tabaquismo pasivo en el hogar se asocia a un mayor riesgo de que los niños menores de 12 años padezcan algun trastorno neuroconductual.
En un trabajo publicado en la revista Pediatrics, para examinar los trastornos neuroconductuales pediátricos más comunes, incluyendo el trastorno por déficit de atención/hiperactividad, problemas de aprendizaje y los trastornos de conducta, en niños expuestos al humo del tabaco en el hogar, los investigadores accedieron a la Encuesta Nacional de Salud Infantil realizada entre abril de 2007 y julio de 2008, analizando los datos de un total de 55.358 niños menores de 12 años.

El 6% de los niños menores de 12 años había estado expuestos al humo del tabaco en el hogar. De éstos, el 8,2% presentaba problemas de aprendizaje, el 5,9% trastorno por déficit de atención/hiperactividad y el 3,6% trastornos de comportamiento y conducta. Las probabilidades de que un niño presentase dos o más de estas trastornos era un 50% superior en los hogares donde había personas fumadoras.

4.8.11

Christina N. Lessov-Schlaggar, PhDa, Dennis R. Wahlgren, MAb, Sandy Liles, MPHb, Ming Ji, PhDc, Suzanne C. Hughes, PhD, MPHb, Jonathan P. Winickoff, MD, MPHd, Jennifer A. Jones, MPHb, Gary E. Swan, PhDe, Melbourne F. Hovell, PhD, MPHb Sensitivity to

OBJECTIVE: Susceptibility to cigarette smoking in tobacco-naive youth
is a strong predictor of smoking initiation. Identifying mechanisms
that contribute to smoking susceptibility provide information about
early targets for smoking prevention. This study investigated whether
sensitivity to secondhand smoke exposure (SHSe) contributes to smoking
susceptibility.

PARTICIPANTS AND METHODS: Subjects were high-risk, ethnically diverse
8- to 13-year-old subjects who never smoked and who lived with at
least 1 smoker and who participated in a longitudinal SHSe reduction
intervention trial. Reactions (eg, feeling dizzy) to SHSe were
assessed at baseline, and smoking susceptibility was assessed at
baseline and 3 follow-up measurements over 12 months. We examined the
SHSe reaction factor structure, association with demographic
characteristics, and prediction of longitudinal smoking susceptibility
status.

RESULTS: Factor analysis identified "physically unpleasant" and
"pleasant" reaction factors. Reported SHSe reactions did not differ
across gender or family smoking history. More black preteens reported
feeling relaxed and calm, and fewer reported feeling a head rush or
buzz compared with non-Hispanic white and Hispanic white counterparts.
Longitudinally, 8.5% of subjects tracked along the trajectory for high
(versus low) smoking susceptibility. Reporting SHSe as "unpleasant or
gross" predicted a 78% reduction in the probability of being assigned
to the high–smoking susceptibility trajectory (odds ratio: 0.22 [95%
confidence interval: 0.05–0.95]), after covariate adjustment.

CONCLUSIONS: Assessment of SHSe sensitivity is a novel approach to the
study of cigarette initiation etiology and informs prevention
interventions.


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Un Saludo
Jose Galbe