Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.

OBJECTIVE: Although identifying adverse childhood experiences (ACEs) among children with behavioral disorders is an important step in providing targeted therapy and support, little is known about the burden of ACEs among children with attention deficit-hyperactivity disorder (ADHD). We described the prevalence of ACEs in children with and without ADHD, and examined associations between ACE type, ACE score, and ADHD diagnosis and severity. METHODS: Using the 2011 to 2012 National Survey of Children's Health, we identified children aged 4 to 17 years whose parents indicated presence and severity of ADHD, and their child's exposure to 9 ACEs. Multivariate logistic regression was used to estimate associations between ACEs, ACE score, and parent-reported ADHD and ADHD severity, adjusted for sociodemographic characteristics. RESULTS: In our sample (N = 76,227, representing 58,029,495 children), children with ADHD had a higher prevalence of each ACE compared with children without ADHD. Children who experienced socioeconomic hardship (adjusted odds ratio [aOR], 1.39; 95% confidence interval [CI], 1.21-1.59), divorce (aOR, 1.34; 95% CI, 1.16-1.55), familial mental illness (aOR, 1.55; 95% CI, 1.26-1.90), neighborhood violence (aOR, 1.47; 95% CI, 1.23-1.75), and incarceration (aOR, 1.39; 95% CI, 1.12-1.72) were more likely to have ADHD. A graded relationship was observed between ACE score and ADHD. Children with ACE scores of 2, 3, and ≥4 were significantly more likely to have moderate to severe ADHD. CONCLUSIONS: Children with ADHD have higher ACE exposure compared with children without ADHD. There was a significant association between ACE score, ADHD, and moderate to severe ADHD. Efforts to improve ADHD assessment and management should consider routinely evaluating for ACEs.

A Critical Review of the Marketing Claims of Infant Formula Products in the United States.

A highly competitive infant formula market has resulted in direct-to-consumer marketing intended to promote the sale of modified formulas that claim to ameliorate common infant feeding problems. The claims associated with these marketing campaigns are not evaluated with reference to clinical evidence by the Food and Drug Administration. We aimed to describe the language of claims made on formula labels and compare it with the evidence in systematic reviews. Of the 22 product labels we identified, 13 product labels included claims about colic and gastrointestinal symptoms. There is insufficient evidence to support the claims that removing or reducing lactose, using hydrolyzed or soy protein or adding pre-/probiotics to formula benefits infants with fussiness, gas, or colic yet claims like "soy for fussiness and gas" encourage parents who perceive their infants to be fussy to purchase modified formula. Increased regulation of infant formula claims is warranted.

Counterpoint: The evidence does not support universal screening and treatment in children.

Few pediatric guidelines have generated the amount or intensity of controversy that the pediatric lipid guidelines have. In the following article, I will synthesize the arguments against universal lipid screening and treatment in childhood. Direct evidence that relates the presence of cardiovascular risk factors in childhood to cardiovascular disease outcomes in adulthood is unavailable, and as a consequence, the guidelines were formulated based on a chain of indirect evidence. The debate centers on the strength of the indirect evidence that links risk factors present in childhood to adult disease outcomes. The arguments against universal lipid screening and treatment of children include (1) a history of unanticipated harms caused by screening tests or treatments that were enacted based on indirect evidence, (2) the poor test performance characteristics of lipid profiles in childhood when used as a screening test, (3) problems with the effectiveness of lipid testing done in the office setting, and (4) concerns regarding the safety of statins when used in children.

Obesity and symptomatic cholelithiasis in childhood: epidemiologic and case-control evidence for a strong relation.

OBJECTIVES: The aims of this study were to correlate the temporal trends in obesity prevalence with hospitalization rates for symptomatic cholelithiasis and to estimate the strength of the association between obesity and symptomatic cholelithiasis in patients hospitalized at an urban children's hospital in New York serving a multiethnic population. METHODS: Using obesity prevalence data from the National Health and Nutrition Examination Survey and the rates of hospitalization for cholelithiasis derived from the Kids' Inpatient Database for 1997-2007, we estimated a correlation and a linear regression. We conducted a retrospective, case-control study in which each case ages 4 to 20 years with symptomatic cholelithiasis was individually matched to a control admitted with appendicitis based on age, sex, ethnicity, and race. RESULTS: The prevalence of obesity and the cholelithiasis hospitalization rate increased over time (R=0.87, P=0.0025). For every 1% increase in the obesity rate among children, the rate of hospitalization for gallstones increased by 0.65/100,000 children (R²=0.75, P=0.0025, 95% confidence interval [CI] 0.32-0.99). The odds ratio for obesity in cases versus controls was 5.78 (n=518, P<0.0001, 95% CI 3.50-9.53). We found a significant dose-response effect, which showed that for every 1 z score increase in body mass index, the risk of cholelithiasis was increased by 79% (P<0.0001, 95% CI 1.5-2.13). CONCLUSIONS: The national trend in the prevalence of obesity from 1997 to 2009 was significantly correlated with increasing rates of hospitalization for pediatric cholelithiasis. Our case-control study suggests that obesity is a significant risk factor for hospital admission because of cholelithiasis.

A quality improvement intervention to increase access to pediatric subspecialty practice.

OBJECTIVE: To improve access to new pediatric endocrinology appointments in an urban academic hospital faculty-based practice. METHODS: Three strategies were implemented to increase the number of appointment slots: new patient appointments were protected from conversion to follow-up appointments; all physicians, including senior faculty, were scheduled to see 3 to 4 new patients per session; and sessions devoted exclusively to follow-up appointments were added based on demand. The main outcomes for this quality improvement activity were waiting times for new and follow-up appointments, monthly visit volume, the per-provider visit volume, differences in the proportion of new visits, and clinic arrival rates pre- and postintervention. RESULTS: Thirteen months after the intervention, average wait for a new patient appointment decreased from 11.4 to 1.7 weeks (P < .001) and follow-up appointment wait time decreased from 8.2 to 2.9 weeks (P < .001). Mean monthly total visit volume increased from 284 to 366 patient visits (P < .01) and mean monthly visit volume per provider increased from 36.8 to 41.0 patients (P = .08). New patients were 27% of the visit volume and 35% after the intervention. CONCLUSIONS: Access to our pediatric specialty care clinic was improved without increasing the number of providers by improved scheduling.

A survey of current and past Pediatric Infectious Diseases fellows regarding training.

BACKGROUND: The objectives of this study were to characterize the satisfaction of Pediatric Infectious Diseases fellows with their training and to understand how opinions about training have changed over time. METHODS: Anonymous survey studies were conducted with questions designed to include areas related to the 6 ACGME core competencies. Surveys for current fellows were distributed by fellowship directors, while surveys for graduates were mailed to all individuals with Pediatric Infectious Diseases certification. RESULTS: Response rates for current fellows and graduates were 50% and 52%, respectively. Most fellows (98%) and graduates (92%) perceived their overall training favorably. Training in most clinical care areas was rated favorably, however both groups perceived relative deficiencies in several areas. Current fellows rated their training in other competency areas (e.g., systems-based practice, research, and ethics) more favorably when compared to past graduates. Recent graduates perceived their training more favorably in many of these areas compared to past graduates. CONCLUSIONS: Pediatric Infectious Diseases fellowship training is well regarded by the majority of current and past trainees. Views of current fellows reflect improved satisfaction with training in a variety of competency areas. Persistent deficiencies in clinical training likely reflect active barriers to education. Additional study is warranted to validate perceived deficiencies and to establish consensus on the importance of these areas to infectious diseases training.

A comparison of the effect of aprotinin and ε-aminocaproic acid on renal function in children undergoing cardiac surgery.

OBJECTIVE: To assess the incidence of renal injury among pediatric patients who received aprotinin while undergoing cardiac surgery compared with those who received ε-aminocaproic acid (EACA). DESIGN: A retrospective observational study. SETTING: A single academic center. PARTICIPANTS: Pediatric cardiac patients who had cardiopulmonary bypass and received aprotinin or EACA. INTERVENTION: Patients undergoing pediatric cardiac surgery received aprotinin from 2005 to 2007 and EACA from 2008 to 2009. MEASUREMENTS AND MAIN RESULTS: The primary outcome was acute kidney injury (AKI) defined as serum Cr elevation at discharge more than 1.5 times the baseline value. Secondary outcomes included bleeding, blood transfusion, and the volume of chest tube drainage in the first 24 hours postoperatively. One hundred seventy-eight patients met inclusion criteria; 120 patients received aprotinin, and 58 patients received EACA. These 2 groups did not differ significantly in age, weight, or duration of cardiac bypass. Logistic regression analysis, adjusted for confounding variables (ie, baseline Cr, sex, age, CPB time, inotropic support and vasopressors), showed a higher odds of suffering AKI at discharge with the usage of aprotinin (odds ratio = 4.7; 95% confidence interval, 1.1-19.5; p = 0.03). The volume of the first 24 hours of chest tube drainage was not significantly different between groups, as well as packed red blood cells and cryoprecipitate units. However, fresh frozen plasma and platelets showed statistically significant differences with more transfusion in the EACA group. CONCLUSION: In this retrospective study, the authors observed a higher odds of AKI for aprotinin usage compared with EACA, suggesting that the known concern for adults with adverse kidney effects with aprotinin is also appropriate for pediatric patients.

Underrepresentation of non-White children in trials of statins in children with heterozygous familial hypercholesterolemia.

BACKGROUND: The elimination of disparities in cardiovascular health is a major focus of the Healthy People 2010 national public health agenda. However, identifying and addressing such disparities within the realm of pediatrics in general, and preventive cardiology in particular, has not received recent attention. In published pediatric clinical trials of statins in heterozygous familial hypercholesterolemia that report race, minority children are underrepresented. OBJECTIVES: The purpose of this analysis was 3-fold: 1) to obtain and report on the racial composition of statin trials in children with heterozygous familial hypercholesterolemia; 2) to explore the hypothesis that founder effects among populations of White children may have facilitated or favored their inclusion in statin trials; and 3) to determine whether the selective lipid screening guidelines based on family history may inadvertently identify fewer minority children who would otherwise qualify for investigative trials. DESIGN: We conducted a Medline search to identify all pediatric familial hypercholesterolemia statin trials. We contacted the corresponding authors to obtain race/ethnicity data and to obtain information about the presence of founder effects in the populations studied. We conducted a second literature search for evidence that selective, family medical history-based screening of children for hypercholesterolemia, as proposed by the National Cholesterol Education Program, might fail to identify minority children who would otherwise qualify for inclusion in these studies. RESULTS: Ninety-two percent of the 885 children enrolled in statin trials were White. A predominance of White children was found even in studies from countries with a sizable population of nonWhite children and where founder effects have not been described. Strong but indirect evidence from both the adult literature and the pediatric literature suggests that the family history-based selective screening engenders healthcare disparities for minority and disadvantaged children. CONCLUSIONS: Non-White children are underrepresented in international clinical trials of statins. Both ethical and pharmacogenomic arguments exist to justify efforts to correct this. Our findings suggest that intensive efforts will be required to arrive at a fair representation of minority children in studies of pediatric heterozygous familial hypercholesterolemia.

The use of statins in pediatrics: knowledge base, limitations, and future directions.

The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, effectively reduce coronary morbidity and mortality in high-risk adults. They are also some of the most widely prescribed medications in the United States. Their use in pediatrics, however, remains circumscribed. In this article we review the cholesterol hypothesis and focus on the knowledge base of the use of statins in adults and children. We pay particular attention to the known effects of statins in primary and secondary prevention of cardiovascular events. The toxicities of statins and their limitations in pediatrics are then considered. The use of statins in conjunction with noninvasive modalities of assessing atherosclerotic burden are also reviewed. Finally, we suggest methods to advance the use of statins in childhood that introduce their potential benefits to those individuals at highest risk for future events.

Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements.

OBJECTIVE: The proliferation of policy statements from the American Academy of Pediatrics presents pediatricians with an increasing amount of health advice to deliver, yet no quantitative estimates of pediatric health advice expectations exist in the literature. The objective of this study was to quantify and characterize verbal health advice that pediatricians are expected to deliver to patients/guardians. METHODS: The authors read and coded the 344 American Academy of Pediatrics policy statements that are contained in the American Academy of Pediatrics' Pediatric Clinical Practice Guidelines and Policies, Third Edition, and identified 57 policies that contained health advice directives that are broadly relevant to pediatric practice. We extracted the individual advice text to a database in which we also coded its date of issue, its theme, and whether (1) it was duplicated in another policy, (2) a screening question was required to identify a target population for the advice, (3) handouts or other aids to delivering the advice were referenced in the policy itself, or (4) the text of the statement referred to evidence of the effectiveness of office-based delivery of the advice. RESULTS: These 57 policies were found to contain 192 discrete health advice directives that pediatricians are expected to deliver to patients/guardians. Seven (4%) of these directives originated before 1993, and 185 (96%) were created from 1993 to 2002. After removal of the 30 (16%) duplicates, safety advice composed 67%, media use composed 12%, substance abuse composed 5%, environmental health hazards composed 4%, development/emotional health composed 4%, sexuality and pregnancy composed 3%, nutrition composed 2%, and miscellaneous composed 3%. In 41% of the directives, a screening question was required to identify the target population for the advice. Aids to delivering advice were referenced in 20% of the policies. In no policy statements did the text refer to evidence that office-based counseling was an effective method to achieve the desired health or behavioral outcome. CONCLUSIONS: We examined the American Academy of Pediatrics policy statements and found 162 different verbal health advice directives on which pediatricians should counsel parents and patients throughout childhood. The expectation that delivery of all of this advice can be achieved is unrealistic. Moreover, none of the reviewed statements were found to include an evidence-based discussion of the efficacy of the suggested advice. In light of these findings, we suggest that committees should consider both the feasibility and the evidence of efficacy of office-based health advice when generating future policy statements.