Barriers, goals, and enablers of transition of care in pediatric dermatology.

Adolescent patients with complex skin disorders may require ongoing care for their conditions as they "age out" of the pediatric setting into adult care. Yet despite consensus from the Canadian Paediatric Society and American Academy of Pediatrics on the importance of dedicated transition programs for these patients, there is a scarcity of such programs worldwide, and no formal programs in Canada. This paper explores several barriers, goals, and potential enablers of transition programs in this discipline and proposes principles of transition versus transfer in the context of pediatric dermatology.

Case report: Drug reaction with eosinophilia and systemic symptoms (DRESS)-induced hemophagocytic disorder.

Hemophagocytic disorders are severe and life-threatening conditions that can be genetic in origin [i.e., primary hemophagocytic lymphohistiocytosis (HLH)] or result from infections (i.e., secondary hemophagocytic lymphohistiocytosis), rheumatologic disease [i.e., macrophage activation syndrome (MAS)], and less frequently immunodeficiency or metabolic disease. Although rare, drug-induced hemophagocytosis needs to be considered in the work-up as it requires specific management strategies. Most drug-induced hemophagocytic disorders are related to Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). We present the case of a 7-year-old girl who initially presented with fever, maculopapular rash, and unilateral lymphadenopathy, who went on to develop hemophagocytosis secondary to DRESS caused by prolonged combination treatment with amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole. This case illustrates the importance of considering adverse drug reactions in the evaluations of patients with a hemophagocytic process.

Association between Weight Status and Mental Health Service Utilization in Children and Adolescents.

BACKGROUND: Previous literature reports inconsistent associations between obesity and mental health. The objective of this study was to determine the association between weight status and mental health service utilization in Ontario children and youth. METHODS: A cross-sectional study of children 0 to 18 years, identified using primary care electronic medical records from the EMRPC database in Ontario, Canada was conducted. Height and weight data were extracted to calculate BMI and linked to administrative data on mental health related outpatient visits, emergency department visits, and hospitalizations. Multivariable logistic regression models were performed. RESULTS: A total of 50,565 children were included. Overall, 2.2% were underweight, 70.4% had a normal weight, 18.3% were overweight, 6.9% had obesity and 2.2% had severe obesity. 28.2% of all children had at least one mental health visit. Multivariable analyses showed children with overweight, obesity, and severe obesity were 1.11 (95% CI 1.05-1.17), 1.18 (95% CI 1.08-1.27) and 1.39 (95% CI 1.22-1.59) times more likely to have an outpatient mental health visit compared to children with normal weight. CONCLUSION: Increased weight status was associated with mental health related outpatient visits and emergency department visits. This study may inform policy makers' planning of mental health resources for children with obesity and severe obesity.

CONTEXTE: La littérature antérieure rapporte des associations irrégulières entre obésité et santé mentale. L'objectif de la présente étude était de déterminer l'association entre le statut pondéral et l'utilisation des services de santé mentale chez les enfants et les adolescents de l'Ontario. MÉTHODES: Une étude transversale d'enfants de 0 à 18 ans qui utilisait des dossiers médicaux électroniques des soins primaires tirés de la base de donnés EMRPC de l'Ontario, Canada a été menée. Les données sur la taille et le poids ont été extraites pour calculer l'indice de masse corporelle (IMC) et couplées aux données administratives sur la santé mentale liées aux visites de patients ambulatoires, aux visites au service d'urgence, et aux hospitalisations. Des modèles de régression logistique multivariée ont été exécutés. RÉSULTATS: Au total, 50 565 enfants ont été inclus. En général, 2,2 % avaient un poids insuffisant, 70,4 % avaient un poids normal, 18,3 % avaient un excès de poids, 6,9 % présentaient une obésité et 2,2 % avaient une grave obésité. Parmi tous les enfants, 28,2 % avaient au moins une visite de santé mentale. Les analyses multivariées ont indiqué que les enfants ayant un excès de poids, une obésité et une grave obésité étaient 1,11 fois (IC à 95 % 1,05 à 1,17), 1,18 fois (IC à 95 % 1,08 à 1,27) et 1,39 fois (IC à 95 % 1,22 à 1,59) plus susceptibles d'avoir une visite ambulatoire de santé mentale comparé aux enfants de poids normal. CONCLUSION: Le statut pondéral accru était associé à des visites ambulatoires pour des raisons de santé mentale et à des visites au service d'urgence. Cette étude peut éclairer les décideurs dans leur planification des ressources de santé mentale pour les enfants souffrant d'obésité et de grave obésité.

Temporal trends in severe obesity prevalence in children and youth from primary care electronic medical records in Ontario: a repeated cross-sectional study.

BACKGROUND: There are no current estimates of severe obesity in Canadian children. The objectives of this study were to determine the prevalence of severe obesity in children aged 18 years or less in Ontario and to determine temporal trends from 2004 to 2015. METHODS: This was a repeated cross-sectional study using height/length and weight of children aged 18 years or less from the Electronic Medical Record Administrative data Linked Database (EMRALD), a database of primary care electronic medical records in Ontario. We calculated body mass index (for age and sex) z-scores (zBMI). Two years of data (2014 and 2015) were used to determine the period prevalence of severe obesity. We used multivariable linear regression generalized estimating equations to estimate the association of calendar year and mean zBMI. RESULTS: In total, 55 233 children were included. The prevalence of severe obesity (zBMI > 3) increased with increasing age: it was 0.9% (95% confidence interval [CI] 0.7% to 1.0%) among children less than 5 years of age, 2.7% (95% CI 2.3% to 3.1%) among 5- to 9-year-olds, 2.9% (95% CI 2.4% to 3.3%) among 10- to 14-year-olds and 3.7% (95% CI 3.1% to 4.3%) among those aged 15-18. Boys aged 5-9 years had a significantly higher prevalence of severe obesity than their female counterparts (3.5% [95% CI 2.9% to 4.2%] v. 1.7% [95% CI 1.3% to 2.2%]). From 2004 to 2015, the mean zBMI decreased by 0.015 (95% CI -0.018 to -0.012) units per year, with the overall prevalence of severe obesity in all ages highest in 2005 (3%) and a decrease to 2% in 2015. INTERPRETATION: The prevalence of severe obesity among children and adolescents in Ontario is consistent with that in other developed countries with the exception of the United States. There is evidence of plateauing of estimates and a small decrease in zBMI over time. Further understanding of the impact of prevention efforts on these estimates is an important next step.

Association Between Maternal Pre-Pregnancy Body Mass Index, Gestational Weight Gain, and Offspring Atopic Dermatitis: A Prospective Cohort Study.

BACKGROUND: Maternal weight status may contribute to the development of atopic disorders in children. OBJECTIVE: The objective of this study was to assess associations of maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) with risk of atopic dermatitis (AD) in children. METHODS: Maternal pre-pregnancy BMI and GWG were assessed by questionnaire through the Growing Up Today Study (GUTS), a prospective cohort study of US children. Mothers reported whether GUTS participants had ever been diagnosed with AD by a clinician in either 1997 or 1999, when GUTS participants were between 10 and 17 years old. We used multivariable logistic regression to estimate the association of BMI and GWG with AD in offspring (expressed as odds ratios [ORs] with 95% CIs). RESULTS: Among 13,269 GUTS participants, 2,058 (16%) had childhood AD. Higher maternal pre-pregnancy BMI was not associated with AD (P trend = .48). In contrast, GWG was associated with increased AD risk (P trend = .005). Compared with children of mothers who gained 25 to 34 lb, children of mothers who gained 35 to 44 lb (OR, 1.11; 95% CI, 0.98-1.26) and 45 lb or more (OR, 1.23; 95% CI, 1.05-1.43) had an increased risk of AD. These associations appeared stronger with pre-pregnancy BMI greater than 25 (GWG, 35-44 lb: OR, 1.20; 95% CI, 0.84-1.69; GWG, ≥45 lb: OR, 1.57; 95% CI, 1.07-2.31), but the statstical interaction between BMI and GWG was not significant. CONCLUSIONS: In this study, increased GWG was associated with increased risk of AD in offspring. This supports existing evidence that prenatal exposures contribute to the development of atopic disorders.

Audiovisual interventions for parental preoperative anxiety: A systematic review and meta-analysis.

OBJECTIVE: To systematically review and meta-analyze studies assessing the effectiveness of audiovisual (AV) interventions aimed at reducing anxiety in parents whose children are undergoing elective surgery. METHODS: A comprehensive search of multiple electronic databases was performed. A narrative synthesis of findings and random-effects meta-analyses were used to summarize the results. Our primary outcome was parental anxiety. Secondary outcomes included children's preoperative anxiety and postoperative outcomes; parental satisfaction, knowledge, and need for anesthesia information. Risk of bias was appraised within and across studies. RESULTS: Our search yielded 723 studies and 11 were included. A Standardized Mean Difference (SMD) of -0.53 (95% CI [-0.91, -0.15], p < .01) was found between parental anxiety scores in AV interventions and control groups. In terms of children's preoperative anxiety, there was a SMD of -0.59 (95% CI [-1.11, -0.07], p < .05) between children's anxiety scores in AV intervention and nonintervention participants. Furthermore, AV interventions were shown to shorten the recovery time for children undergoing surgery (SMD = -0.21; 95% CI [-0.39, -0.02], p = .03) but did not lead to improvements on other postoperative outcomes. CONCLUSIONS: These findings suggest that AV interventions have modest, positive effects on both parental and children's preoperative anxiety. Although a statistically significant medium size effect was detected, the clinical significance of this finding requires further exploration. Further research aimed at developing better AV interventions to help guide future practice is warranted. (PsycINFO Database Record

Mental health of extremely low birth weight survivors: A systematic review and meta-analysis.

Although individuals born at extremely low birth weight (ELBW; < 1,000 g) are the most vulnerable of all preterm survivors, their risk for mental health problems across the life span has not been systematically reviewed. The primary objective of this systematic review and meta-analysis was to ascertain whether the risk for mental health problems is greater for ELBW survivors than their normal birth weight (NBW) peers in childhood, adolescence, and adulthood. Forty-one studies assessing 2,712 ELBW children, adolescents, and adults and 11,127 NBW controls were reviewed. Group differences in mental health outcomes were assessed using random effects meta-analyses. The impacts of birthplace, birth era, and neurosensory impairment on mental health outcomes were assessed in subgroup analyses. Children born at ELBW were reported by parents and teachers to be at significantly greater risk than NBW controls for inattention and hyperactivity, internalizing, and externalizing symptoms. ELBW children were also at greater risk for conduct and oppositional disorders, autistic symptoms, and social difficulties. Risks for parent-reported inattention and hyperactivity, internalizing, and social problems were greater in adolescents born at ELBW. In contrast, ELBW teens self-reported lower inattention, hyperactivity, and oppositional behavior levels than their NBW peers. Depression, anxiety, and social difficulties were elevated in ELBW survivors in adulthood. Group differences were robust to region of birth, era of birth, and the presence of neurosensory impairments. The complex needs faced by children born at ELBW continue throughout development, with long-term consequences for psychological and social well-being. (PsycINFO Database Record

Comparing pyridoxine and doxylamine succinate-pyridoxine HCl for nausea and vomiting of pregnancy: A matched, controlled cohort study.

Nausea and vomiting of pregnancy (NVP) is a common gestational condition. This is the first study to compare the use of vitamin B6 (pyridoxine) versus Diclectin (doxylamine succinate-pyridoxine HCl) for NVP symptoms. Participants were pregnant women with NVP who used either pyridoxine or doxylamine succinate-pyridoxine HCl for ≥4 days prior to calling the Motherisk NVP Helpline. Women receiving pyridoxine only (n = 80) were matched to a woman taking doxylamine succinate-pyridoxine HCl only (n = 80), accounting for potential confounders and baseline level of NVP, measured by the Pregnancy Unique Quantification of Emesis (PUQE) score. Change in NVP severity after a week of therapy with either pyridoxine or doxylamine succinate-pyridoxine HCl was quantified using the PUQE-24 scale, which describes NVP symptoms 24 hours prior to their call. Doxylamine succinate-pyridoxine HCl use found a significant reduction in PUQE score, compared with pyridoxine (+0.5 versus -0.2, P < .05; negative denotes worsening). This association was especially prominent in women with more severe symptoms, where doxylamine succinate-pyridoxine HCl use saw a mean improvement of 2.6 versus 0.4 with pyridoxine (P < .05). As well, doxylamine succinate-pyridoxine HCl use was associated with fewer women experiencing moderate to severe scores after a week of treatment, compared with the pyridoxine group (7 versus 17, P < .05), despite similar baseline PUQE scores.

Sugar substitutes during pregnancy.

QUESTION: I have a pregnant patient who regularly consumes sugar substitutes and she asked me if continuing their use would affect her pregnancy or child. What should I tell her, and are there certain options that are better for use during pregnancy? ANSWER: Although more research is required to fully determine the effects of in utero exposure to sugar substitutes, the available data do not suggest adverse effects in pregnancy. However, it is recommended that sugar substitutes be consumed in moderate amounts, adhering to the acceptable daily intake standards set by regulatory agencies.