Repeat Concussion and Recovery Time in a Primary Care Pediatric Office.

The authors enrolled 95 patients in a primary care office who presented with a concussion. Of these patients, 63% were sport concussions. The authors matched 90 of these patients to children in the authors' practice presenting for sports physicals or regular check-ups in the following demographics: age, participating in a particular sport, having attention-deficit disorder/attention-deficit hyperactivity disorder, gender, and grade. The authors found the odds of recurrent concussions, in a primary care pediatric office, to be a ratio of 2.909 (95% confidence interval 1.228-7.287). Recovery time for repeat concussion versus an initial concussion was analyzed. Patients with a recurrent concussion after a year recovered an average of 12.0 days after injury versus 13.4 days for those with no previous concussion (NS). Patients with a recurrent concussion within a year recovered a mean of 6.27 (SD 1.29) days sooner than patients with no previous concussion (P < .0001). This unexpected finding is preliminary, and the authors encourage further research.

The Timing of Cognitive and Physical Rest and Recovery in Concussion.

Immediate cognitive and physical rest in the concussed patient is almost universally recommended in the concussion literature. The authors conducted a prospective observational in a primary care pediatric office to examine the effect of delayed cognitive and physical rest had on recovery time in pediatric concussion. The authors found that patients who started cognitive and physical rest immediately after injury were more likely to recover within 30 days compared to patients who delayed cognitive and physical rest for 1-7 days after their injury (67% vs 35%, P = .016). Within the group of patients who recovered within 30 days those with immediate cognitive and physical rest recovered 4.6 days sooner than those with delayed cognitive and physical rest (10.29 ± 5.83 vs 14.42 ± 6.15 days, P = .005). These data support the recommendation that cognitive and physical rest should be implemented immediately after injury in concussed patients.

Prevalence of asymptomatic celiac disease in children with fibromyalgia: a pilot study.

BACKGROUND: The objective of this study was to prospectively determine the prevalence of asymptomatic celiac disease among children presenting with fibromyalgia. The secondary objective was to investigate if their symptoms resolved on a gluten free diet. FINDINGS: All children seen in the Amplified Musculoskeletal Pain clinic between the ages of 12 and 17 years of age who fulfilled the 1990 American College of Rheumatology diagnostic criteria for fibromyalgia were invited to participate. A total immunoglobulin A (IgA) level, IgA antiendomysial (EMA) and IgA anti-TTG antibodies was obtained on all study subjects. A visual analog scale for pain and a functional disability inventory were obtained on all patients. If a patient had elevated EMA or TTG a small bowel biopsy was done. Patients with celiac disease were placed on a gluten-free diet and observed to see if their symptoms resolved.50 patients, 45 females, completed the study. Only one patient was found to have celiac disease. On a gluten-free diet her tissue transglutaminase antibody level returned to normal but her visual analog scale scores increased and her functional disability inventory was 40 initially and 21 at follow up. CONCLUSIONS: In this pilot, single center study at a tertiary children's hospital patients with fibromyalgia do not seem to have occult celiac disease at an increased rate over the population as a whole.

Why is toilet training occurring at older ages? A study of factors associated with later training.

Recent studies suggest that children are completing toilet training much later than the preceding generation. Our objective was to identify factors associated with later toilet training. Children between 17 and 19 months of age (n=406) were enrolled in the study. At enrollment, parents completed the Parenting Stress Index and the Receptive-Expressive Emergent Language Scale. Follow-up parent interviews were conducted every 2 to 3 months until children completed daytime toilet training. Information obtained at follow-up interviews included steps parents were taking to toilet train their child, child toilet training behaviors, presence and frequency of constipation, birth of a sibling, and child care arrangements. In a stepwise linear regression model predicting age at completion of toilet training, 3 factors were consistently associated with later training: initiation of toilet training at an older age, presence of stool toileting refusal, and presence of frequent constipation. Models including these variables explained 25% to 39% of the variance in age at completion of toilet training. In conclusion, a later age at initiation of toilet training, stool toileting refusal, and constipation may explain some of the trend toward completion of toilet training at later ages.

During toilet training, constipation occurs before stool toileting refusal.

BACKGROUND: Previous studies demonstrated that constipation and painful defecation are associated with stool toileting refusal (STR), but whether they are the result of STR or occur before this behavior is not known. OBJECTIVE: To determine whether constipation and painful defecation occur as a result of STR or occur before STR. METHODS: Three hundred eighty children between 17 and 19 months of age participated in a prospective longitudinal study of toilet training. Children were monitored with telephone interviews every 2 to 3 months until the completion of daytime toilet training. Information obtained in follow-up interviews included parents' reports on the presence and frequency of hard bowel movements, painful defecation, and child toilet training behaviors. Children were defined as completing daytime toilet training when they were experiencing <4 urine accidents per week and < or =2 episodes of fecal soiling per month. Children were defined as having frequent hard bowel movements if the parents reported a hard bowel movement approximately once per week in > or =2 follow-up telephone interviews or more than once per week in 1 follow-up telephone interview. RESULTS: The mean age at the completion of daytime toilet training was 36.8 +/- 6.1 months (range: 22-54 months). Ninety-three children (24.4%) developed STR. Parents of children who developed STR, in comparison with the rest of the sample, were more likely to report that the child had experienced hard bowel movements (67.7% vs 50.9%), frequent hard bowel movements (29.0% vs 14.3%), and painful defecation (41.9% vs 27.9%). Of the children who experienced both STR and hard bowel movements, 93.4% demonstrated constipation before the onset of STR. In that group, parents reported hard bowel movements at almost one-half of all follow-up telephone interviews before the onset of STR. Of the children who experienced both STR and painful defecation, 74.4% experienced the first episode of painful defecation before the onset of STR. Children with frequent hard bowel movements demonstrated a longer duration of STR (9.0 +/- 6.5 vs 4.8 +/- 3.0 months). CONCLUSIONS: When hard bowel movements or painful defecation is associated with STR, the first episode of constipation usually occurs before the STR. The fact that hard bowel movements frequently occur before the onset of STR suggests that for many of these children constipation is a chronic problem that is not being treated effectively. Therefore, hard bowel movements and painful defecation are factors that potentially contribute to the STR and for the majority of children are not caused solely by the STR behavior. Additional studies are needed to determine whether earlier and more effective treatment of constipation could decrease the incidence of STR.

Children who hide while defecating before they have completed toilet training: a prospective study.

OBJECTIVE: To examine the incidence and age at onset of hiding while defecating in children before they have been toilet trained and its association with difficulties in toilet training. DESIGN: Prospective study. SETTING: Suburban private pediatric practice. Subjects Three hundred seventy-eight children aged 17 to 19 months. METHODS: Children were followed up by telephone interviews with the parents every 2 to 3 months until the child completed daytime toilet training. Children who were described at any follow-up telephone call as always or almost always hiding when defecating prior to completing toilet training were defined as the hiding group. The remainder of the children, who were described as never hiding or only sometimes hiding, was defined as the nonhiding group. RESULTS: Two hundred sixty-three children (69.6%) met the criteria for the hiding group. The median age at initiation of hiding for the group was 22 months. Thirty-eight began hiding before toilet training was initiated and 64 started hiding after intensive toilet training had begun. The nonhiders (115 [30.4%]) were significantly less likely to have stool toileting refusal, frequent constipation, or stool withholding. They also completed toilet training at an earlier age than the hiders (34.5 +/- 5.9 months vs 38.1 +/- 5.9 months; P<.001). CONCLUSIONS: The behavior of hiding while defecating before completion of toilet training is associated with stool toileting refusal, constipation, and stool withholding. These behaviors may make toilet training more difficult.

Stool toileting refusal: a prospective intervention targeting parental behavior.

OBJECTIVE: To evaluate the effect of an intervention targeting parental behavior on stool toileting refusal. METHODS: This study population comprised 406 children aged 17 through 19 months from a single suburban private practice. Children were randomly assigned to receive 1 of 2 written toilet-training instructions. Both groups were advised to use a child-oriented approach to toilet training. In addition, those in the intervention group were requested to avoid using negative terms for feces and, before training began, to praise the children when they defecated in the diaper. Follow-up telephone calls were made every 2 to 3 months, and 381 children were followed up until they developed stool toileting refusal or completed daytime toilet training. RESULTS: The incidence of stool toileting refusal was 23% in the control group and 26% in the intervention group (P>.10). The mean +/- SD duration was 5.2 +/- 4.9 months in the intervention group vs 7.6 +/- 4.9 in the control group (P =.04). Children with stool toileting refusal in the intervention group trained at 40.0 +/- 6.4 months vs 43.0 +/- 6.5 months in the control group (P =.04). CONCLUSIONS: The intervention did not decrease the incidence of stool toileting refusal but did shorten its duration, leading to earlier completion of toilet training. This should help to ameliorate some of the negative consequences of stool toileting refusal.

Relationship between age at initiation of toilet training and duration of training: a prospective study.

OBJECTIVE: To study the relationship between age at initiation of toilet training, age at completion of toilet training, and the duration of toilet training. METHODS: A total of 406 children seen at a suburban private pediatric practice were enrolled in a study of toilet training between 17 and 19 months of age, and 378 (93%) were followed by telephone interviews with the parents every 2 to 3 months until the child completed daytime toilet training. Information obtained at follow-up interviews included how often parents were asking their child to sit on the toilet or potty and where the child urinated and defecated. Parents were considered to have initiated toilet training when they first took out a potty chair and discussed some aspect of training with the child. Intensive toilet training was defined as asking the child to use the toilet or potty >3 times per day. RESULTS: Age of initiation of toilet training correlated with age of completion of training (r = 0.275). The correlation between age at initiation of intensive training and age at completion was even stronger (r = 0.459). Younger age at initiation of intensive toilet training was not associated with constipation, stool withholding, or stool toileting refusal. However, age at initiation of intensive toilet training was negatively correlated with duration of toilet training (r = -0.481), indicating that initiation of training at younger ages was associated with a longer duration of training. In addition, the correlation between age at initiation of intensive toilet training and age at completion of training was not significant for those who began intensive training before 27 months of age (r = 0.107). CONCLUSIONS: Early initiation of intensive toilet training correlates with an earlier age at completion of toilet training but also a longer duration of toilet training. Although earlier toilet training is not associated with constipation, stool withholding, or stool toileting refusal, initiation of intensive training before 27 months does not correlate with earlier completion of toilet training, suggesting little benefit in beginning intensive training before 27 months of age in most children.

Maternal ratings of infant intensity and distractibility: relationship with crying duration in the second month of life.

OBJECTIVE: To investigate the relationship between infant temperament characteristics assessed at 4 weeks of age and the duration of infant crying and fussing during the second month of life. DESIGN: Families were enrolled in this prospective study during prenatal classes, and 60 infants completed the study. Temperament was assessed when the infant was 4 weeks of age using the Early Infancy Temperament Questionnaire, and crying and fussing was assessed on 16 days during the second month of life using a parent-completed infant behavior diary. RESULTS: Ratings of the total duration of infant crying and fussing correlated significantly with the sum score on the temperament questionnaire (r = 0.36; P =.005). A longer duration of crying and fussing was associated with infants with high intensity (r = 0.43; P =.001) and low distractibility (r = 0.37; P =.003). CONCLUSIONS: The finding that mothers rating their infants as having high intensity and low distractibility is associated with increased crying duration supports a growing body of literature suggesting that infants with high levels of crying are more reactive to sensory stimuli and harder to soothe than those who cry less. Physicians counseling parents of infants with persistent crying should recognize the infant characteristics associated with increased crying.