Child sexual exploitation. An analysis of serious case reviews in England: poor communication, incorrect assumptions and adolescent neglect.

BACKGROUND: Child sexual exploitation (CSE) has evolved from being a largely concealed and unrecognised form of child abuse to being the subject of substantial political and public attention. The purpose of this research was to explore health professionals' role in detection and prevention. METHODS: A systematic thematic analysis and synthesis of serious case review (SCR) reports of CSE in England using a socioecological theoretical framework was undertaken. RESULTS: Themes identified included health professionals' lack of understanding of CSE, limited knowledge of the UK law, reluctance to apply relevant policies, and lack of appropriate action. Suboptimal communication with the child, between agencies and with families, lack of understanding of the young person's context, their vulnerabilities and their continued needs for care and protection were also important. CONCLUSIONS: This is the first time, to our knowledge, that an analysis and synthesis of all SCRs related to CSE in England has been conducted. The potential to recognise young people vulnerable to CSE is essential for public health prevention and intervention. Acknowledging that the SCRs represent the worst case scenario; nevertheless, this research highlighted the multi-factorial and complex nature of CSE and identified factors that require system-level awareness, training and intervention.

Blood pressure differences between blacks and whites in relation to body size among US children and adolescents.

No large national studies of ethnic differences in blood pressure among children accounting for body size differences have been published, to the authors' knowledge. This report details the similarities and differences in systolic and diastolic blood pressures between Black children and White children in the United States and examines the effects of age, sex, and body size on ethnic differences in blood pressure levels. Standardized measurements of seated systolic and diastolic pressures from eight large epidemiologic studies published between 1978 and 1991 that included measurements of 47,196 children on 68,556 occasions for systolic pressure and for 38,184 children on 52,053 occasions for diastolic pressure were used; 51 percent (24,048 children) were boys and 37 percent (17,466 children) were Black. Overall, there appear to be few substantive ethnic differences in either systolic or diastolic pressure during childhood and adolescence. The differences that were observed were small, inconsistent, and often explained by differences in body size. There was an ethnic group-body mass index (BMI) interaction that resulted in these findings that at lower levels of BMI Blacks have higher blood pressure and more hypertension than do Whites, but that at the highest levels of BMI, Whites have more hypertension (systolic or diastolic pressure) than do Blacks.

Prevalence and correlates of blood pressure elevation in children with Guillain-Barré syndrome.

While there have been case reports describing blood pressure elevation in adults and children with Guillain-Barré syndrome (GBS), no previous systematic study has explored the prevalence of hypertension in children with this condition. In a retrospective review, blood pressure elevation was seen in 20 of 30 (66.7%) patients with GBS admitted to a children's hospital during a 10-year period. There was a significant correlation between highest GBS stage and deviation of systolic blood pressure from age- and gender-specific norms (r = 0.93, p < 0.05). Since blood pressure may be markedly elevated in GBS, the clinician caring for a child with this condition should be aware of this complication.

Left ventricular geometry and severe left ventricular hypertrophy in children and adolescents with essential hypertension.

BACKGROUND: Left ventricular (LV) hypertrophy has been established as an independent risk factor for cardiovascular disease in adults. Recent research has refined this relationship by determining a cutpoint of 51 g/m(2.7) for LV mass index indicative of increased risk and defining LV geometric patterns that are associated with increased risk. The purpose of this study was to evaluate severe LV hypertrophy and LV geometry in children and adolescents with essential hypertension. METHODS AND RESULTS: A cross-sectional study of young patients (n=130) with persistent blood pressure elevation above the 90th percentile was conducted. Nineteen patients (14%) had LV mass greater than the 99th percentile; 11 of these were also above the adult cutpoint of 51 g/m(2.7). Males, subjects with greater body mass index, and those who had lower heart rate at maximum exercise were at significantly (P<.05) higher risk of severe LV hypertrophy. In addition, 22 patients (17%) had concentric LV hypertrophy, a geometric pattern that is associated with increased risk of cardiovascular disease in adults. Seven patients had LV mass index above the cutpoint and concentric hypertrophy. No consistent significant determinants of LV geometry were identified in these children and adolescents with hypertension. CONCLUSIONS: Severe LV hypertrophy and abnormal LV geometry are relatively prevalent in young patients with essential hypertension. These findings suggest that these patients may be at risk for future cardiovascular disease and underscore the importance of recognition and treatment of blood pressure elevation in children and adolescents. Weight loss is an important component of therapy in young patients with essential hypertension who are overweight.

Percentiles for body mass index in U.S. children 5 to 17 years of age.

OBJECTIVES: It has been recommended that body mass index (BMI) (weight in kilograms/height in meter2) be used routinely to evaluate obesity in children and adolescents. This report describes the distribution of BMI in children and adolescents in the United States. METHODS: Standardized measurements of height and weight from 9 large epidemiologic studies including 66,772 children age 5 to 17 years were used to develop tables for the distributions of BMI that are age, race, and gender specific. RESULTS: The mean BMI increases with age and is slightly higher for girls than boys. Mean BMI for black and Hispanic girls was noticeably higher than for white girls. The percentiles of BMI are consistently higher than those based on the NHANES I measures, particularly for the 95th percentile. The proportion of obese children compared with NHANES I standards is higher and is highest for Hispanic boys and black and Hispanic girls. CONCLUSION: The tables and figures will allow pediatricians to determine the relative ranking of BMI for patients compared with values derived from a large sample of healthy children and adolescents. The identified gender and ethnic differences may be guides to understanding the cause and prevention of obesity.

Blood pressure nomograms for children and adolescents, by height, sex, and age, in the United States.

Because height is a more appropriate index of maturation than weight for use with normative blood pressure (BP) data, we developed normative BP levels for children, by sex, while accounting for age and height simultaneously. Eight U.S. studies used in the Report of the Second Task Force on Blood Pressure Control in Children and one additional study of BP in U.S. children were reanalyzed to develop age-sex-height-specific values for normative BP values among 56,108 children, aged 1 to 17 years, seen at 76,018 visits. Height percentiles were computed on the basis of standard National Center for Health Statistics growth charts. When height is taken into account, more short children (10th age-sex-specific height percentile) and fewer tall children (90th age-sex-specific height percentile) are likely to be classified as hypertensive than when the current age-sex-specific percentiles of BP alone are used. Tables are provided for boys and girls separately, by single year of age (1 to 17 years) and by the 90th and 95th percentiles of systolic blood pressure and diastolic blood pressure (fifth phase of Korotkoff sounds) for selected age-sex-specific height percentiles based on standard U.S. growth charts.

Distribution and correlates of creatinine clearance in children and adolescents with blood pressure elevation.

The kidney has been implicated as both an etiologic factor and as a target organ in patients with essential hypertension. Renal function has not been studied extensively in children and adolescents with essential hypertension. Eighty-eight subjects, aged 6 to 23 years, with blood pressure persistently above the 90th percentile for age were studied. Creatinine clearance was determined from a single 24-hour urine collection. The mean creatinine clearance was 129.3 +/- 55.3 ml/min per 1.73 m2. Multiple regression analysis was used to investigate potential correlates of creatinine clearance. Because creatinine clearance was not normally distributed, the logarithm of creatinine clearance was used as the dependent variable. Body mass index, resting heart rate, and basal supine plasma renin activity were significant direct independent correlates. Peripheral vascular resistance at maximal exercise was an inverse correlate of the logarithm of creatinine clearance. These findings are consistent with previous studies of adults and may provide the basis for strategies to identify young patients with essential hypertension who are at risk for the development of renal dysfunction.

Determinants of retinal vascular abnormalities in children and adolescents with essential hypertension.

The predictors of retinal vascular abnormalities in patients with elevated BP have not been studied extensively in children or adults. The purpose of this study was to investigate potential correlates of arteriolar narrowing, tortuosity and arteriovenous nicking in a population of children and adolescents with essential hypertension. A total of 97 subjects, aged 6-23 years, were studied. Retinal vascular abnormalities were determined by photographs of the optic fundus which were interpreted independently by two opthalmologists. In 50 subjects (51%) there were one or more abnormalities. Potential correlates of retinal abnormalities included: (1) demographic factors, (2) body size, (3) level of BP and duration of hypertension, (4) family history of cardiovascular disease, (5) treatment with antihypertensive medication, (6) dietary sodium intake, (7) laboratory analyses, (8) the reactivity of BP and heart rate to playing a video game, and (9) cardiovascular reactivity to exercise. Using stepwise multiple logistic regression, the variables that were independently associated with the presence of retinal vascular abnormalities were family income, dietary sodium intake, fasting blood glucose, pulse pressure during mental stress and the change in SBP from rest to maximum exercise. In addition, subjects with more than one retinal vascular abnormality had higher average DBP during follow-up in the Hypertension Clinic and a smaller rise in SBP from rest to maximum exercise. Identification of these independent predictors of retinal vascular abnormalities and factors associated with more than one abnormality may provide insight into the pathogenesis of hypertensive vascular disease.

Relation of left ventricular mass, preload, afterload and contractility in pediatric patients with essential hypertension.

OBJECTIVES: The aim of this study was to determine if left ventricular preload, afterload or contractility is a correlate of left ventricular mass index in hypertensive pediatric patients. BACKGROUND: It is believed that decreased contractility and increased preload are associated with left ventricular hypertrophy in adult hypertensive patients. METHODS: Ninety pediatric hypertensive patients underwent echocardiography to assess left ventricular mass, preload (diastolic dimension and volume) and afterload (end-systolic wall stress, vascular resistance and blood pressure). Contractility was assessed by 1) the end-systolic stress/volume ratio, and 2) the difference between measured and predicted velocity of circumferential fiber shortening. Univariate and multivariate analyses were performed. RESULTS: Univariate analysis showed significant correlations between left ventricular mass and 1) body mass (r = 0.33, p < 0.001), 2) black race (r = 0.37, p < 0.0003), 3) diastolic dimension (r = 0.26, p < 0.01), 4) diastolic volume (r = 0.20, p < 0.05), and 5) stress/volume ratio (r = -0.53, p < 0.0001) but not the difference between measured and predicted velocity of circumferential fiber shortening. A multivariate model included body mass, age at diagnosis, diastolic dimension, wall stress and vascular resistance but not the difference between measured and predicted velocity of circumferential fiber shortening. CONCLUSIONS: Contractility is not significantly related to left ventricular mass. The positive correlation between mass and stress/volume may be due to the dependence of the latter variable on loading conditions. We speculate that both elevated preload and systemic vascular resistance may have a role in the development of hypertrophy in hypertensive pediatric patients.

Discordant segregation of Na+,K(+)-adenosine triphosphatase alleles and essential hypertension.

OBJECTIVES: To determine whether the alpha 2 and or beta 1 isoforms of the Na+,K(+)-adenosine triphosphatase (Na+,K(+)-ATPase) are involved in the pathogenesis of essential hypertension. DESIGN: Segregation analysis of polymorphic DNA markers was used to test the involvement of Na+,K(+)-ATPase in essential hypertension. PARTICIPANTS: Children with persistent hypertension having one parent with essential hypertension were included in the study. Criteria for persistent hypertension were blood pressure readings with systolic and/or diastolic levels exceeding the 95th percentile based upon age and sex. The diagnosis of hypertension for adults, including parents and older siblings, was confirmed using criteria recommended in the 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. RESULTS: In three essential hypertensive families consisting of 18 members including 11 hypertensives, several obligate recombinants between the Na+,K(+)-ATPase alpha 2 isoform marker and the hypertension phenotype were observed. Similarly, in one hypertension family consisting of four members, obligate recombinants between the beta 1 isoform marker and the disease were observed. CONCLUSIONS: The discordant segregation of the alpha 2 and beta 1 isoform markers and essential hypertension suggests that neither the Na+,K(+)-ATPase alpha 2 nor beta 1 isoform genes play a primary role in the pathogenesis of hypertension in the families studied.

Hypertension in Children and Adolescents.

In brief For hypertensive children and adolescents who participate in sports, hygienic interventions may already be adequate-or may be unachievable. Yet, the decision to initiate pharmacotherapy is difficult. Physicians must weigh factors such as the presence of end-organ damage or a family history of early hypertensive complications with possible adverse effects of antihypertensive drugs, including depressant effects on the heart and reduced exercise tolerance. The authors favor long-lasting ACE inhibitors or calcium channel blockers, which usually do not alter heart rate and are relatively free of side effects.

Hypertension in Children and Adolescents.

In brief Once a physician has identified elevated blood pressure in a young patient, the first focus should be on lowering it through nonpharmacologic measures, such as reduction of dietary sodium, weight loss, and exercise. Epidemiologic studies indicate that exercise can be a clinically useful treatment. However, strenuous exercise may be contraindicated for some children who have hypertension, including those who have markedly elevated blood pressure at rest or with maximal exercise and those who have target-organ disease. Physicians must evaluate the safety of exercise for such children.

The prevalence of retinal vascular abnormalities in children and adolescents with essential hypertension.

We studied 97 children and adolescents with essential hypertension by evaluating photographs of the optic fundus and fluorescein angiography. Photographs were examined for the presence of arteriolar narrowing, tortuosity, and arteriovenous nicking. Intraobserver and interobserver variability in determination of abnormalities was low with agreement of 75% for narrowing, 90% for tortuosity, and 100% for arteriovenous nicking. The prevalence of abnormalities was 41% (95% confidence interval, 31% to 50%) for arteriolar narrowing, 14% (95% confidence interval, 19% to 21%) for tortuosity, and 8% (95% confidence interval, 5% to 11%) for arteriovenous nicking. Of 97 patients, 50 (51%) had one or more abnormality. Retinal abnormalities are relatively common in young patients with essential hypertension.

Determinants of cardiac involvement in children and adolescents with essential hypertension.

Left ventricular hypertrophy is often found in association with systemic hypertension and may be an independent risk factor for cardiovascular disease morbidity and mortality. Few studies have investigated the determinants of left ventricular mass (LVM) in young patients with essential hypertension. Therefore, we studied 104 children and adolescents with blood pressure persistently greater than the 90th percentile for age and sex and with no known cause of blood pressure elevation. LVM was determined by echocardiography and was indexed by height to account for body size. The mean LVM index was 90.2 +/- 26.0 g/m. Using the gender-specific 95th percentile from normal children, 40 subjects (38.5%) had left ventricular hypertrophy. Using multiple regression analysis, the significant independent direct correlates of LVM index were male sex, body mass index, dietary sodium intake, age at diagnosis, and systolic blood pressure at maximum exercise. The significant independent inverse correlate of LVM index was resting heart rate (p less than 0.05). These variables accounted for a substantial portion of the LVM index variance in this population (multiple R2 = 0.56, p less than 0.001). The results indicate that left ventricular hypertrophy is prevalent in children and adolescents with essential hypertension. The direct association of LVM index with body mass index and dietary sodium intake suggests weight reduction and dietary salt restriction might be useful to prevent or treat the development of left ventricular hypertrophy in pediatric patients with essential hypertension.

Distribution of target-organ abnormalities by race and sex in children with essential hypertension.

The prevalence of left ventricular hypertrophy, glomerular hyperfiltration and retinovascular abnormalities was investigated in 43 black and 45 white children with essential hypertension. Whilst 36% of subjects had left ventricular hypertrophy, 49% had glomerular hyperfiltration and 50% had retinal abnormalities, no differences were found between blacks and whites. This pattern differs from that found in adult hypertensives.

Clinical spectrum of intrinsic renovascular hypertension in children.

In the past two decades, 853 children and adolescents have been evaluated for elevated BP as inpatients and outpatients by the hypertension service at Children's Hospital Medical Center, Cincinnati. Most children with hypertension secondary to coarctation of the aorta and all children with glomerulonephritis are managed by other services and are not included in that total. In a retrospective study, 27 children (3%) were identified as having hypertension secondary to intrinsic renal arterial stenosis. The age at presentation ranged from 5 months to 20 years. The mean BP at that time was 171.6/114.2 mm Hg. Ten categories of causes were identified, including fibromuscular dysplasia, arteritis, Williams syndrome, neurofibromatosis, congenital malformations, blunt abdominal trauma, surgical vascular trauma-irradiation, thrombosis, congenital rubella syndrome, and unknown. Overall, symptoms were not common. However, findings of end-organ response, such as left ventricular hypertrophy and retinal vascular abnormalities were prevalent. This is not surprising given the mean BP level at presentation. Physical examination, laboratory tests, and radiologic evaluations (exclusive of renal angiography) were not useful in detecting or identifying the location and extent of the renovascular lesions. Fourteen patients were treated surgically, and 13 were managed medically. The outcome was variable for both treatment modalities. The management of renovascular hypertension in children must be individualized depending on the cause, location, and severity of the lesion, as well as the size of the child. Some forms of renovascular pathology, particularly the arteritides, may resolve spontaneously, and children with these entities should have their BP treated medically until the inflammatory process has subsided.(ABSTRACT TRUNCATED AT 250 WORDS)