Sleep Technology.

Pediatric sleep providers frequently encounter issues related to sleep technology in clinical settings. In this review article, we discuss technical issues related to standard polysomnography, research on putative complementary novel metrics derived from polysomnographic signals as well as research on home sleep apnea testing in children and consumer sleep devices. Although developments across several of these domains are exciting, it remains a rapidly evolving area. When evaluating innovative devices and home sleep testing approaches, clinicians should be mindful of accurately interpreting diagnostic agreement statistics to apply these technologies appropriately.

Intravenous iron therapy in the pediatric sleep clinic: a single institution experience.

STUDY OBJECTIVES: Initial reports of intravenous (IV) iron administration have been promising for children with restless legs syndrome, periodic limb movement disorder, and restless sleep disorder. The aim of the current study was to evaluate further the clinical response to IV iron supplementation in children seen in a pediatric sleep clinic. METHODS: We performed a retrospective chart review of children cared for in a single pediatric sleep clinic who also underwent IV iron infusion. Pre and post IV data regarding their sleep symptoms and ferritin levels were abstracted. RESULTS: Overall, 63 pediatric sleep patients underwent IV iron infusion, mostly with ferric carboxymaltose (n = 60), for restless legs syndrome (n = 30), periodic limb movement disorder (n = 22), and restless sleep disorder (n = 17). Of the 59 patients with clinical follow-up, 39 (73%) noted improvement in at least 1 symptom, and 14 (26%) did not notice improvement or noticed worsening symptoms. Of the 59 patients with preinfusion and postinfusion labs, the average ferritin level increased from 21.7 (13.3) to 147.9 (120.9) µg/L, P < .001. Comparing patients who experienced clinical improvement vs those who did not, there were no statistically significant differences in change in ferritin levels (P = .278), sex (P = .452), or age (P = .391). Ferritin change with infusion according to diagnostic subgroups (restless legs syndrome/periodic limb movement disorder/restless sleep disorder) was examined, and no significant differences were noted (F(2,56) = 0.852, P = .432). In terms of immediate adverse reactions to the IV infusion, 7 (11%) experienced at least 1 side effect, with the most common being behavior change (n = 6) or gastrointestinal discomfort (n = 4); no episodes of anaphylaxis or extravasation were noted. CONCLUSIONS: These data provide additional support for the efficacy and safety of IV iron for pediatric restless legs syndrome, periodic limb movement disorder, and restless sleep disorder recalcitrant to oral iron. CITATION: Ingram DG, Al-Shawwa B, DelRosso LM, Sharma M. Intravenous iron therapy in the pediatric sleep clinic: a single institution experience. J Clin Sleep Med. 2022;18(11):2545-2551.

Terrible twos: intravenous iron ameliorates a toddler's iron deficiency and sleep disturbance.

The relation between iron deficiency and restless legs syndrome has been widely described and investigated in both adults and children. However, the diagnosis of restless legs syndrome relies on patients voicing their symptoms, which is very difficult for patients younger than age 5 years. Frequently, we evaluate children between ages 2 and 4 years whom parents describe as "restless sleepers," "difficult to settle down," or having "frequent awakening" or "bedtime resistance." Parents are concerned that their child's poor sleep quality is leading to daytime dysfunction such as increased sleepiness, behavioral outbursts, or hyperactivity. Many of these children are diagnosed with behavioral insomnia of childhood, and behavior modification therapy is recommended with variable degrees of success. Herein, we describe a 2-year-old with similar symptoms of restless sleep, bedtime resistance, and daytime sleepiness who was found to have an underlying iron deficiency without anemia that was treated successfully with iron infusion. We highlight the importance of evaluating for underlying iron deficiency even without anemia in patients with restless sleep and associated poor daytime behavior. We also describe some common challenges associated with iron therapy and clarify iron therapeutic targets. CITATION: Al-Shawwa B, Sharma M, Ingram DG. Terrible twos: intravenous iron ameliorates a toddler's iron deficiency and sleep disturbance. J Clin Sleep Med. 2022;18(2):677-680.

Enuresis and sleep fellowship education.

PURPOSE: Enuresis is a common sleep-related concern in school aged children that gradually decreases into adulthood. We performed a survey of sleep providers in order to assess their comfort level in managing patients with enuresis. METHODS: Survey participants were recruited via the Pedsleep listserv and sleep medicine program directors in the USA on basecamp application. The Pedsleep list includes a mixture of physicians, psychologists, and other sleep providers/researchers. RESULTS: Forty-two sleep providers completed the survey. Forty (95%) were board certified in sleep medicine, and 32 (76%) were board certified in pediatrics. Practice patterns for management of enuresis varied among respondents, with 69% who evaluate for possible contributions from other sleep disorders such as obstructive sleep apnea then refer for additional management. Nineteen (45%) respondents felt that they received inadequate or very inadequate training during their sleep fellowship for management of enuresis. While 83% of respondents worked in an academic medical center setting, none of their respective sleep clinics were the primary managing clinic at their own situation. Participants who endorsed their training as adequate/very adequate were significantly more likely to feel comfortable/very comfortable managing enuresis (90% vs 37.5%, p = 0.009). CONCLUSIONS: A large percentage of sleep providers are lacking essential training to manage enuresis patients. These results suggest the need for additional educational initiatives in this area.

The challenges in scoring hypopneas in children: is pulse wave amplitude drop the answer?

BACKGROUND: Identifying electroencephalogram (EEG) cortical arousals are crucial in scoring hypopneas and respiratory efforts related arousals (RERAs) during a polysomnogram. As children have high arousal threshold, many of the flow limited breaths or hypopneas may not be associated with visual EEG arousals, hence this may lead to potential underestimation of the degree of sleep disordered breathing. Pulse wave amplitude (PWA) is a signal obtained from finger photoplethysmography which correlates directly to finger blood flow. The drop in PWA has been shown to be a sensitive marker for subcortical/autonomic and cortical arousals. Our aim was to use the drop in PWA as a surrogate for arousals to guide scoring of respiratory events in pediatric patients. METHODS: Ten polysomnograms for patients between the ages of 5-15 years who had obstructive apnea-hypopnea indices between 1 and 5 events/hour were identified. Patients with syndromes were excluded. A drop in PWA signal of at least 30% that lasted for 3 s was needed to identify subcortical/autonomic arousals. Arousals were rescored based on this criteria and subsequently respiratory events were rescored. Paired t-tests were employed to compare PSG indices scored with or without PWA incorporation. RESULTS: The sample of 10 children included 2 females, and the average age was 9.8 ± 3.1 years. Overall, polysomnography revealed an average total sleep time of 464.1 ± 25 min, sleep efficiency of 92% +/-4.2, sleep latency of 19.6 ± 17.0 min, rapid eye movement (REM) latency 143 ± 66 min, N1 3.9% +/-2.0, N2 50.3% +/-12.0, N3 28.2% +/-9.1, REM 16.7% +/-4.0, and wakefulness after sleep onset (WASO) 18.1 ± 7.5 min. Including arousals from PWA changes, respiratory indices significantly increased including total AHI (2.3 ± 0.7 vs 5.7 ± 2.1, p < 0.001), obstructive AHI (1.45 ± 0.7 vs 4.8 ± 1.8, p < 0.001), and RDI (2.36 ± 0.7 vs 7.6 ± 2.0, p < 0.001). Likewise, total arousal index was significantly higher (8.7 ± 2.3 vs 29.4 ± 6.5, p < 0.001). CONCLUSIONS: The drop in pulse wave amplitude signal is a useful marker to guide scoring arousals that are not otherwise easily identified in pediatric polysomnography and subsequently helped in scoring respiratory events that otherwise would not be scored. Further studies are needed to delineate if such methodology would affect clinical outcome.

Small sleepers, big data: leveraging big data to explore sleep-disordered breathing in infants and young children.

STUDY OBJECTIVES: Infants represent an understudied minority in sleep-disordered breathing (SDB) research and yet the disease can have a significant impact on health over the formative years of neurocognitive development that follow. Herein we report data on SDB in this population using a big data approach. METHODS: Data were abstracted using the Cerner Health Facts database. Demographics, sleep diagnoses, comorbid medication conditions, healthcare utilization, and economic outcomes are reported. RESULTS: In a cohort of 68.7 million unique patients, over a 9-year period, there were 9,773 infants and young children with a diagnosis of SDB (obstructive sleep apnea [OSA], nonobstructive sleep apnea, and "other" sleep apnea) who met inclusion criteria, encompassing 17,574 encounters, and a total of 27,290 diagnoses across 62 U.S. health systems, 172 facilities, and 3 patient encounter types (inpatient, clinic, and outpatient). Thirty-nine percent were female. Thirty-nine percent were ≤1 year of age (6,429 infants), 50% were 1-2 years of age, and 11% were 2 years of age. The most common comorbid diagnoses were micrognathia, congenital airway abnormalities, gastroesophageal reflux, chronic tonsillitis/adenoiditis, and anomalies of the respiratory system. Payor mix was dominated by government-funded entities. CONCLUSIONS: We have used a novel resource, large-scale aggregate, de-identified EHR data, to examine SDB. In this population, SDB is multifactorial, closely linked to comorbid medical conditions and may contribute to a significant burden of healthcare costs. Further research focusing on infants at highest risk for SDB can help target resources and facilitate personalized management.

Outpatient health care utilization for sleep disorders in the Cerner Health Facts database.

STUDY OBJECTIVES: Sleep disorders are common in the general population. This study aimed to identify direct health care utilization for sleep disorders using big data through the Cerner Health Facts database. METHODS: The Cerner Health Facts database has 68.7 million patients in the data warehouse, documenting approximately 506.9 million encounters from 100 nonaffiliated health care systems. To identify sleep-related health care utilization, we examined the frequency of outpatient encounters related to sleep disorders between the years 2000 and 2017. Sleep disorders were grouped-based on the International Classification of Sleep Disorders-Third Edition. RESULTS: Approximately 20.5 million patients were identified with a total of 127.4 million outpatient encounters. In pediatric patients (ages 0-18 years), health care utilization for major sleep diagnoses was measured per 100,000 encounters. Sleep-related breathing disorders ranked first among common sleep disorders for pediatric patients followed by parasomnia, insomnia, sleep movement disorders, hypersomnolence, then circadian rhythm disorders (820.1, 258.1, 181.6, 68.3, 48.1, and 16.2 per 100,000 encounters, respectively). However, in adult patients, the ranking was slightly different, with sleep-related breathing disorders ranked first, followed by insomnia, sleep-related movement disorders, hypersomnolence, parasomnia, then circadian rhythm disorders (1352.6, 511.6, 166.3, 79.1, 25.7, and 4.2 per 100,000 encounters, respectively). In general, there was a bimodal pattern with a clear dip in sleep-related health care utilization in young adults age (age 19-29 years), with the exception of insomnia. CONCLUSIONS: Patients with sleep disorders show relatively low health care utilization despite a known high prevalence of sleep disorders in the general population. This finding may highlight under-recognition of sleep problems or decreased access to health care for sleep disorders. In addition, this study highlights the effect of age-based variation on different sleep disorders, which may have an impact on allocating resources.

Vitamin D and sleep in children.

STUDY OBJECTIVES: The impact of vitamin D on human health including sleep has been well described in adults. Its deficiency has been associated with multiple sleep disorders such as decrease in sleep duration, worsening of sleep quality, and even OSA. Such correlation is less evident in the pediatric population. In the current study, we examined the relationship between sleep architecture and vitamin D status in children referred to a sleep clinic. METHODS: This was a retrospective-cohort study in a tertiary care children's hospital over a 1-year period. Children who underwent an in-laboratory overnight-polysomnogram and had a 25-hydroxy vitamin D level obtained within 120 days of the sleep study were included. Patients with OSA or central sleep apnea were excluded. Data from polysomnograms and Pediatric Sleep Questionnaires were collected and analyzed. RESULTS: A total of 39 patients (mean age, 6.6 years; 46% female) were included in the study. Twenty (51%) patients had vitamin D deficiency (25-hydroxy vitamin D level < 30 ng/mL). Children with vitamin D deficiency had less total sleep time (470.3 minutes ± 35.6 vs 420.3 minutes ± 61.7; P = .004) and poorer sleep efficiency (91.9% ± 5.6% vs 84.5% ± 9.5%; P = .015) compared with children with sufficient vitamin D. In addition, children with vitamin D deficiency had later weekday bedtimes (21:02 Pm ± 1:01 vs 20:19 Pm ± 0:55; P = .037) and later weekend bedtimes (21:42 Pm ± 0:59 vs 20:47 Pm ± 1:08; P = .016) than children with sufficient vitamin D, with a tendency for later wake time that did not reach statistical significance. The remainder of the polysomnogram findings and Pediatric Sleep Questionnaire data were not different between the 2 groups. CONCLUSIONS: Vitamin D deficiency in children was associated with objectively measured decreased sleep duration and poorer sleep efficiency. Furthermore, vitamin D deficiency was associated with delayed bedtimes, suggesting that vitamin D and circadian rhythm could be related. Future prospective studies in children would be helpful to learn if vitamin D deficiency leads to sleep disturbance or vice versa.

Limb movements during sleep in children: effects of age, sex, and iron status in more than 1,000 patients referred to a pediatric sleep center.

STUDY OBJECTIVES: Limb movements during sleep (LMS) and periodic limb movements during sleep (PLMS) have been shown to vary by age in children. In the current study, we examined this relationship in more detail in a large clinically referred sample adjusting for iron status and sex. METHODS: Retrospective data analysis was done on a large pediatric population who underwent an overnight sleep study and had ferritin levels measured within 30 days of sleep study between May 2013 and October 2017 at pediatric sleep center. Patients with obstructive or central sleep apneas were excluded. RESULTS: A total of 1,070 patients were included in the study, with 60% males. Younger age and male sex were associated with increased PLMS and LMS. In addition, there was an increase in PLMS and LMS during adolescence that subsided at a later age, independent of sex. These associations remained significant in models controlling for ferritin level. Ferritin level, in contrast, was not a significant predictor of PLMS or LMS when controlling for sex and age. CONCLUSIONS: Age and sex may need to be considered when interpreting limb movement indices in pediatric sleep patients regardless of ferritin level.

Assessing readiness to drive in adolescents with narcolepsy: what are providers doing?

PURPOSE: There are no universally accepted guidelines for assessing driving readiness in adolescents with narcolepsy. The purpose of the present study was to survey pediatric sleep medicine providers regarding their current practice patterns for assessing driving readiness in adolescents with narcolepsy, knowledge of their state laws regarding physician reporting of unsafe drivers, and opinions regarding what physician duty ought to be. METHODS: This was an anonymous web-based survey distributed via the PedSleep listserv, which serves as a hub of communication for pediatric sleep medicine providers. RESULTS: A total of 52 pediatric sleep providers from 25 different states completed the survey. Eighty-eight percent of providers routinely assess driving readiness in adolescents with narcolepsy. Factors rated as "absolutely essential" by at least 50% of respondents included the following: history of previous fall-asleep crash or near miss, sleepiness (reported by patient), sleepiness (reported by caregiver), and cataplexy (reported by patient). Providers included maintenance of wakefulness testing: never (34%), if patient reports no/mild sleepiness (10%), if patient reports moderate/severe sleepiness (25%), or always regardless of patient symptoms (30%), and the median minimally acceptable result was 30 min (25-75th: 20-40 min). There was substantial lack of knowledge regarding legal obligations for reporting. CONCLUSIONS: These results demonstrate great variability in practice patterns among pediatric sleep medicine providers for assessing driving readiness in adolescents with narcolepsy. In addition, it shows limited knowledge of the providers about their respective states' laws. Further studies are required to identify the best approach to assess residual sleepiness in this population.

Rapid-onset obesity, hypothalamic dysfunction, hypoventilation, and autonomic dysregulation in Saudi Arabia.

Rapid-onset obesity, hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) is a rare disease, but could be fatal if not diagnosed early. It mimics many other diseases and it may take few years after the onset of rapid obesity to have the other clinical features. Therefore, any patient with rapid-onset obesity after the age of 2 years should have high index of suspicion and long term follow up. We report a case of ROHHAD in Saudi Arabia and we highlight the clinical features and the importance of early diagnosis and management.

Defining common outcome metrics used in obstructive sleep apnea.

Sleep-disordered breathing a spectrum that ranges from snoring through disorder of increased airway resistance, to overt sleep apnea affects many clinical disease outcomes. Traditionally, disease outcomes have been measured by polysomnography, with the most common metric being the apnea hypopnea index (AHI). Multiple other clinical metrics are commonly used to assess the severity and impact of disease on important outcomes of obstructive sleep apnea (OSA). These allow assessment of sleepiness, quality of life, performance, and medical, especially cardiovascular outcomes. Currently the available metrics only partially explain the associated disease outcomes in different patients. This review highlights the available clinical, physiological and biomarker metrics in measuring OSA and associated co-morbidities and defines treatment goals.

Candida esophageal perforation and esophagopleural fistula: a case report.

INTRODUCTION: Esophageal perforation is a rare disease, which can lead to significant morbidity and mortality. Its clinical presentation can mimic other disease processes and, therefore, it can be easily misdiagnosed. Candida infection of the esophagus is an extremely rare cause of esophageal perforation. CASE PRESENTATION: We report the youngest pediatric case in the medical literature of spontaneous esophageal perforation and an esophagopleural fistula due to Candida infection. CONCLUSION: A high index of suspicion, especially in the presence of Candida empyema and the absence of disseminated infection, should raise the possibility of esophageal perforation with esophagopleural fistula formation. This can lead to early diagnosis and surgical intervention, which would decrease the high mortality rate of this rare condition.

Asthma and insulin resistance in morbidly obese children and adolescents.

BACKGROUND: Obesity is well recognized as a state of increased insulin resistance and has been implicated as a significant risk factor for both asthma prevalence and asthma severity in children and adolescents. However, little is known about the specific factors that relate asthma and obesity. Recently, the pro-inflammatory state in obesity and its association with insulin resistance have been recognized. We hypothesize that the effect of morbid obesity on asthma is related to insulin resistance. METHODS: The patient cohort in the obesity management program at the Children's Hospital of Wisconsin was retrospectively reviewed. Variables were collected from the program data base and chart review was done for missing variables. Patients were considered to have asthma if the evaluating physician confirmed the diagnosis through history and/or the patient had been on inhaled corticosteroids. Insulin resistance (IR) was calculated using a homeostasis model assessment (HOMA). Multivariate logistic regression was performed to identify variables that were significantly related to the odds of having asthma. RESULTS: Of the 415 patients included in the study, 146 (35%) were asthmatic and 269 (65%) were non-asthmatic. The asthma (AG) and non-asthma (NAG) groups were similar with respect to mean age (11.3 vs. 11.5 years), gender (45% vs. 43% males), mean body mass index (BMI) (36.4 vs. 34.9), and exposure to smoking (43% vs. 42%). Fhx of asthma was significantly higher in AG (71%) compared to NAG (40%). IR level+/-SD was 8.5+/-9.7 in AG compared to 5.3+/-6.7 in NAG (p<0.0001). Multivariate regression analysis found the following variables to be associated with having asthma: younger age (p<0.05), smoking exposure (p<0.05), positive Fhx of asthma (p<0.0001, odds ratio of 3.1), and IR (p<0.0001, odds ratio of 4.1). CONCLUSION: Morbidly obese asthma patients have a higher degree of insulin resistance compared to morbidly obese non-asthma patients. We speculate that the pro-inflammatory state of insulin resistance may contribute to the pathogenesis of asthma in obese patients. Future prospective studies should address insulin resistance as a possible risk factor for asthma in obese children and adolescents.

Cystic fibrosis and renal disease: a case report.

BACKGROUND: Cystic fibrosis (CF) is an autosomal recessive disease that is predominantly seen in the Caucasian population and involves multiple organs. Traditionally it has been thought that the kidney is the only organ which does not seem to be generally affected by the disease although the cystic fibrosis transmembrane conductance regulator (CFTR) gene is expressed in the kidney. CASE PRESENTATION: We report the case of an 11 year old boy with cystic fibrosis and nephrotic syndrome and review the literature that describes nephrotic syndrome and renal involvement in cystic fibrosis. CONCLUSION: With continued advances in the management of cystic fibrosis and improvement in life expectancy, several unrecognized co-morbidities are expected to emerge. It is important to screen patients for possible co-morbidities. Urine analysis may be helpful in this group of patients and any proteinuria should raise the suspicion of cystic fibrosis-related renal disease.

Clinical and therapeutic variables influencing hospitalisation for bronchiolitis in a community-based paediatric group practice.

AIM: To examine the effect of different clinical characteristics and different treatments on the hospitalisation of infants with bronchiolitis seen in an outpatient clinic setting. METHODS: The medical records of infants under 2 years of age who presented with a first episode of wheezing over a two-year period were reviewed retrospectively. Hospitalisation within ten days of evaluation was used as the primary outcome measure. RESULTS: Data from 320 patients were included. 17% were hospitalised. Age was lower in the hospitalised patients (4.9 months vs. 7.1, p<0.001). Hospitalisation was higher in RSV-positive versus RSV-negative patients (38% vs. 10%, p<0.001) and was higher in those children who had been exposed to tobacco smoke versus those who hadn't (24% vs. 12%, p<0.01). Treatment with oral corticosteroids was associated with fewer hospitalisations in those patients with a family history of asthma or allergic rhinitis (9.7% vs. 24%, p=0.02) and in RSV-negative patients (2.5% vs. 16.7%, p<0.05). CONCLUSION: Early treatment of bronchiolitis with oral corticosteroid in an outpatient clinic setting was associated with lower hospitalisation rates in patients with a family history of asthma or allergic rhinitis and in RSV-negative patients.

Hypercholesterolemia is a potential risk factor for asthma.

INTRODUCTION: The effect of hyperlipidemia on asthma has never been addressed. Recent literature implicates a pro-inflammatory role for hypercholesterolemia. This study evaluates the effect of serum cholesterol level on asthma frequency. METHODS: Factors associated with asthma risk were examined in a retrospective study design. Study subjects were between the 4 and 20 years of age who presented to a rural pediatric clinic and whose total serum cholesterol level was obtained. Diagnosis of asthma was determined by the treating physician. Multivariable logistic regression was performed to identify variables that were related to the odds of having asthma. RESULTS: A total of 188 patients were included. Asthma was present in 50 patients. Total serum cholesterol (mean +/- SD) for the asthma group was 176.7 +/- 39.8 compared to 162.9 +/- 12.8 in the non-asthma group (P = 0.028). A total of 21 of the 50 (42%) asthma patients were obese compared to 31 of the 138 (22%) non-asthma patients (p = 0.014). There was no difference between both groups regarding age and gender. Hypercholesterolemia and obesity were identified by logistic regression analysis to increase the probability of asthma independently. CONCLUSION: Hypercholesterolemia is a potential risk factor for asthma independent of obesity.

Trimethoprim-sulfamethoxazole plus topical antibiotics as therapy for acute otitis media with otorrhea caused by community-acquired methicillin-resistant Staphylococcus aureus in children.

OBJECTIVE: To report our experience in identification and treatment of acute otitis media (AOM) with otorrhea secondary to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), which is seen in children at increasing rates. DESIGN: Clinical and laboratory records were retrospectively reviewed between January 2003 and December 2003. SETTING: Primary pediatric clinic. PATIENTS: Six pediatric patients who had AOM with otorrhea caused by CA-MRSA. MAIN OUTCOME MEASURES: Clinical resolution of AOM with otorrhea. RESULTS: All patients had acute-onset otorrhea associated with their AOM. Five patients had tympanostomy tubes and 1 had perforation of the tympanic membrane. None of the patients were responding to treatment with oral antibiotics (amoxicillin sodium-clavulanate potassium, cefpodoxime proxetil, and cefprozil) or fluoroquinolone ear drops (ofloxacin, ciprofloxacin). Specimens were obtained from the ears for cultures, and MRSA was present in the cultures. The organisms were resistant to levofloxacin and erythromycin in all patients and resistant to clindamycin hydrochloride in 2 patients. The cultures were sensitive to trimethoprim-sulfamethoxazole, gentamicin sulfate, rifampin, and vancomycin hydrochloride. All patients were treated successfully with oral trimethoprim-sulfamethoxazole and ear drops (gentamicin sulfate or polymyxin B sulfate-neomycin sulfate-hydrocortisone [Cortisporin]). CONCLUSIONS: The rising rate of CA-MRSA as a cause for many pediatric infections is a major concern. It is very important to obtain cultures from patients with nonresponsive or persistent otorrhea with AOM to look for MRSA and determine the sensitivity of the pathogen to antibacterial therapy. Trimethoprim-sulfamethoxazole is a good choice for initial, empirical therapy when combined with a topical agent for AOM with otorrhea if CA-MRSA is suspected. Further studies are needed to determine whether there is a link between the overuse of topical fluoroquinolones in pediatric patients and the recent rising rate of CA-MRSA.