African ancestry, early life exposures, and respiratory morbidity in early childhood.

BACKGROUND: Racial disparities persist in early childhood wheezing and cannot be completely explained by known risk factors. OBJECTIVE: To evaluate the associations of genetic ancestry and self-identified race with early childhood recurrent wheezing, accounting for socio-economic status (SES) and early life exposures. METHODS: We studied 1034 children in an urban, multi-racial, prospective birth cohort. Multivariate logistic regression was used to evaluate the association of genetic ancestry as opposed to self-identified race with recurrent wheezing (>3 episodes). Sequential models accounted for demographic, socio-economic factors and early life risk factors. Genetic ancestry, estimated using 150 ancestry informative markers, was expressed in deciles. RESULTS: Approximately 6.1% of subjects (mean age 3.1 years) experienced recurrent wheezing. After accounting for SES and demographic factors, African ancestry (OR: 1.16, 95% CI: 1.02-1.31) was significantly associated with recurrent wheezing. By self-reported race, hispanic subjects had a borderline decrease in risk of wheeze compared with African Americans (OR: 0.44, 95% CI: 0.19-1.00), whereas white subjects (OR: 0.46, 95% CI: 0.14-1.57) did not have. After further adjustment for known confounders and early life exposures, both African (OR: 1.19, 95% CI: 1.05-1.34) and European ancestry (OR: 0.84, 95% CI: 0.74-0.94) retained a significant association with recurrent wheezing, as compared with self-identified race (OR(whites) : 0.31, 95% CI: 0.09-1.14; OR(hispanic) : 0.47, 95% CI: 0.20-1.08). There were no significant interactions between ancestry and early life factors on recurrent wheezing. CONCLUSIONS AND CLINICAL RELEVANCE: In contrast to self-identified race, African ancestry remained a significant, independent predictor of early childhood wheezing after accounting for early life and other known risk factors associated with lung function changes and asthma. Genetic ancestry may be a powerful way to evaluate wheezing disparities and a proxy for differentially distributed genetic and early life risk factors associated with childhood recurrent wheezing.

Cord blood immune biomarkers in small for gestational age births.

Fetal growth restriction is a risk factor for development of adulthood diseases, but the biological mechanism of this association remains unknown. Limited biomarkers have been studied in settings of preterm birth and maternal inflammation, but the relationship between a wide range of immune biomarkers and fetal growth has not been studied. The hypothesis of this study was that fetal growth restriction is associated with altered immune biomarker levels. We examined the relationship between small for gestational age (SGA) status and 27 umbilical cord blood immune biomarkers. This study was part of a large-scale cohort study of preterm birth and low birth weight conducted at Boston Medical Center, an inner city, predominantly minority patient population. Growth status was determined based on birth weight standardized to an internal reference. There were 74 SGA births and 319 appropriate for age (AGA) births with complete clinical and biomarker data. Adjusting for covariates and using AGA as reference, SGA births had lower levels of log IL-1ß (ng/l; ß -0.38, 95% CI -0.57, -0.19, P < 0.01), log BDNF (ß -0.29, 95% CI -0.55, -0.03, P < 0.05) and log NT-3 (ß -0.46, 95% CI -0.77, -0.15, P < 0.01). No associations were found between other biomarkers and SGA. In conclusion, three biomarkers were selectively associated with SGA status. Our results provide information that could be used to guide additional studied aimed at determining mechanisms that contribute to fetal growth.

A picture is worth a thousand words.

The diagnosis of weight faltering can be challenging and often controversial. The determination should be made based on careful evaluation of growth parameters, including longitudinal patterns plotted on age- and gender-appropriate growth charts. For children with suspected or diagnosed weight faltering, the initial work-up should be limited, with laboratory tests and studies directed by findings on history and physical examination. Treatment should include nutritional counselling, familial support, and close outpatient follow-up. Hospitalisation may be useful in some cases but should not be used routinely to assist in the diagnostic work-up. Patients with limited response to these interventions may require further evaluation.

Metered-dose inhaler: the emergency department orphan.

OBJECTIVE: Physicians providing emergency department care to children primarily use nebulizers for the delivery of bronchodilators and these physicians have misconceptions regarding the advantages and disadvantages of using metered-dose inhalers (MDIs) with a spacer (MDI + S) for acute asthma exacerbations. DESIGN: Self-administered mail survey. SETTING: Emergency department. PARTICIPANTS: Emergency medicine section members of the American Academy of Pediatrics and Canadian Pediatric Society. INTERVENTIONS: Bronchodilator delivery methods in acute pediatric asthma. MAIN OUTCOME MEASURES: The 2 principal outcomes for bivariate analysis were self-reported nebulizer use in all patients and MDI + S use in patients with mild acute asthma. RESULTS: Of eligible physicians, 333 (51%) of 567 responded. The majority were dual trained in pediatrics and pediatric emergency medicine (72%) and practiced full time (83%) in an urban (83%) pediatric emergency department (80%). The most commonly cited advantages of MDIs were their cost (33%) and speed of use (28%). The most commonly cited disadvantages were patient or parent dissatisfaction (24%) and relative ease of nebulizer use (23%). Only 10% to 21% of participants used MDIs in the emergency department and reserved this delivery method for children with mild asthma exacerbations. There were no significant associations between selected respondent demographic variables and the use of MDIs. CONCLUSIONS: Misconceptions regarding the efficacy and safety of MDI + S for the treatment of acute asthma exacerbations exist but are limited to a minority of surveyed emergency medicine physicians caring for children. Nebulizers remain the preferred method of routine bronchodilator delivery by physicians providing care to pediatric asthmatics in the emergency department.

Improving parent knowledge about antibiotics: a video intervention.

OBJECTIVE: To determine whether an educational video could improve parent knowledge, beliefs, and behaviors about the appropriate use of oral antibiotics. STUDY DESIGN: A randomized, controlled trial was conducted in an urban primary care clinic and a suburban pediatric practice. Parents were randomly assigned to the intervention or control groups. Parents in the intervention group were asked to view a 20-minute video, specifically developed for this project, over a 2-month period, and given a brochure about antibiotics. Parent knowledge, beliefs, and behaviors were assessed at the time of enrollment and then by telephone 2 months later. RESULTS: A total of 193 (94%) of 206 parents completed the study. The groups were equivalent with respect to all important baseline characteristics. No differences were found for adjusted posttest means between the intervention and control groups for knowledge, beliefs, or behavior. For example, the intervention group scored 8.04 on the knowledge questionnaire (11 true-false questions), compared with 7.82 for the control group. Subgroup analysis, based on site of enrollment, indicated that families in the intervention group from the primary care urban clinic improved their knowledge score (6.03 to 6.92) and were more likely to report that there were problems with children receiving too many antibiotics (intervention 67% vs control 34%). CONCLUSION: Overall, this video had only a modest effect on parent knowledge, beliefs, and self-reported behaviors regarding oral antibiotics. We believe that any campaign promoting the judicious use of oral antibiotics must use a multifaceted approach and target both parents and physicians.

Daily multivitamins with iron to prevent anemia in infancy: a randomized clinical trial.

This study assessed the effectiveness of multivitamins (MV) with iron as prophylaxis against iron deficiency (ID) and anemia in infancy. The study was a double-blind, randomized trial at 2 urban primary care clinics. Subjects included healthy, full-term infants enrolled at their 6-month well-child visit. Parents administered MV, either with iron or without iron, by mouth daily for 3 months. At 9 months of age, 28.3% of 310 had either anemia or ID without anemia. Among infants with any adherence, anemia was found in 11.1% of the iron group and 21.7% in the noniron group (RR=0.5, 95% CI=0.3-1.0). Iron deficiency without anemia was found in 18.5% of the iron group; 14.4% of the noniron group (p=0.46). When administered daily starting at age 6 months, standard-dose multivitamins with iron appear to reduce anemia prevalence at 9 months of age.

Pediatric pre-hospital advanced life support care in an urban setting.

OBJECTIVE: To describe pediatric advanced life support (PALS) in a single urban environment and clarify educational priorities for ALS pre-hospital providers and pediatric medical control physicians. METHODS: Retrospective observational review of all pediatric pre-hospital PALS transport and medical control records of the two-tiered, unified, municipal emergency medical service of the City of Boston (catchment area 590,000) over a 1-year period. RESULTS: Of the 555 pediatric patients receiving ALS transport, 38% were for respiratory emergencies, 24% for nonrespiratory medical emergencies, 19% for traffic-related blunt trauma, and 10% for penetrating trauma. Two percent involved cardiac arrests. The most frequent procedures performed were intravenous (IV) cannulation (n = 184, 33%), bag-mask ventilation (n = 28, 5%) and intubation (n = 15, 3%). Intraosseous access was only performed in three patients (0.5%). Fifty ALS providers in the EMS system averaged pediatric IV cannulation 3.7 times, intubation 0.3 times, and intraosseous access 0.06 times per provider per year. On-line medical control was requested in 28 % of PALS transports. The chief complaints managed by medical control closely mirrored the distribution of all ALS transports. The most frequent medication ordered by on-line medical control was additional nebulized albuterol after standing orders (off-line medical control) had been exhausted. CONCLUSIONS: A limited number of chief complaints make up the majority of PALS transports. Initial and continuing education for ALS providers needs to reflect the importance of these critical entities. Education for urban pre-hospital providers should reflect that certain procedures will be only executed every few years (eg, pediatric intubation) or once in the career of an ALS pre-hospital provider (eg, intraosseous access). With a limited amount of pediatric teaching time, paramedic education will have to strike a careful balance between teaching about the chief complaints most frequently encountered and teaching rare, high-risk procedures that could provide maximal support for the uncommon critically ill child. On-line medical control physicians need to be prepared to direct and support the management by ALS pre-hospital providers for the chief complaints most frequently seen in pediatric patients.

Verve and Jolt: deadly new Internet drugs.

As regulatory agencies have increased restrictions on the sale and marketing of gamma-hydroxybutyrate (GHB), they have been frustrated by the appearance of precursor molecules such as gamma-butyrolactone (GBL) that have become widely available over the Internet. These dangerous precursors are vigorously marketed to adolescents and young adults as dietary supplements that increase muscle mass and enhance sexual performance with seductive names such as Verve and Jolt, both easily recognizable teen icons. We present the case of an adolescent who ingested both of these GBL products 2 weeks apart, resulting in life-threatening respiratory depression and emergent intubation on both occasions. The GBL toxidrome, necessary acute interventions, and public health implications are reviewed. We urge all health care providers to report similar cases immediately to the FDA MedWatch system. Gamma-butyrolactone, gamma-hydroxybutyrate, respiratory insufficiency, central nervous system depressants, substance abuse.

A comparison of suburban and urban daytime telephone triage calls.

OBJECTIVE: To compare daytime nurse telephone triage calls received by a suburban practice with those received by a hospital-based, inner-city pediatric practice. METHODS: A research assistant, listening simultaneously with triage personnel, prospectively coded all calls received by the nurse triage telephone offices in 2 pediatric practices. Calls were coded the first full, nonholiday week of 3 consecutive summer and 3 consecutive winter months, alternating morning and afternoon sessions. One practice was suburban and had almost all commercially insured patients; the other was hospital-based, in an inner-city, and consisted mostly of patients with Medicaid coverage or no health insurance. RESULTS: A total of 901 calls were triaged in the suburban practice (SP) and 768 in the urban practice (UP). The chief complaints of calls regarding medical problems were similar at both sites. Difficulties with language were noted less often in SP compared with UP (1% vs 17%). The reason for the calls differed by site: medical problem relating to illness or injury (SP 55% vs UP 40%); social issue (SP 1% vs UP 9%); documentation request (SP 2% vs UP 7%); request for laboratory work (SP.3% vs UP 4%); and well child advice (SP 9% vs UP 5%). The disposition of calls also differed by site: telephone advice was offered significantly more in SP than in UP (32% vs 20%); fewer calls required the need for the medical record in SP than in UP (2% vs 12%). CONCLUSIONS: Calls received by a daytime nurse telephone triage office in an affluent SP and a UP are similar in regard to medical problems. Training programs can feasibly prepare physicians and nurses for both kinds of practice settings. The urban site received more calls affected by language and social issues. This could have administrative implications for staffing ratios, language skills of staff and knowledge of available support services.