Showing papers in "Pediatrics in 2002"

Late-Onset Sepsis in Very Low Birth Weight Neonates: The Experience of the NICHD Neonatal Research Network

Abstract: Objective. Late-onset sepsis (occurring after 3 days of age) is an important problem in very low birth weight (VLBW) infants. To determine the current incidence of late-onset sepsis, risk factors for disease, and the impact of late-onset sepsis on subsequent hospital course, we evaluated a cohort of 6956 VLBW (401–1500 g) neonates admitted to the clinical centers of the National Institute of Child Health and Human Development Neonatal Research Network over a 2-year period (1998–2000). Methods. The National Institute of Child Health and Human Development Neonatal Research Network maintains a prospective registry of all VLBW neonates admitted to participating centers within 14 days of birth. Expanded infection surveillance was added in 1998. Results. Of 6215 infants who survived beyond 3 days, 1313 (21%) had 1 or more episodes of blood culture-proven late-onset sepsis. The vast majority of infections (70%) were caused by Gram-positive organisms, with coagulase-negative staphylococci accounting for 48% of infections. Rate of infection was inversely related to birth weight and gestational age. Complications of prematurity associated with an increased rate of late-onset sepsis included patent ductus arteriosus, prolonged ventilation, prolonged intravascular access, bronchopulmonary dysplasia, and necrotizing enterocolitis. Infants who developed late-onset sepsis had a significantly prolonged hospital stay (mean length of stay: 79 vs 60 days). They were significantly more likely to die than those who were uninfected (18% vs 7%), especially if they were infected with Gram-negative organisms (36%) or fungi (32%). Conclusions. Late-onset sepsis remains an important risk factor for death among VLBW preterm infants and for prolonged hospital stay among VLBW survivors. Strategies to reduce late-onset sepsis and its medical, social, and economic toll need to be addressed urgently.

Centers for Disease Control and Prevention 2000 Growth Charts for the United States: Improvements to the 1977 National Center for Health Statistics Version

Abstract: Objective. To present a clinical version of the 2000 Centers for Disease Control and Prevention (CDC) growth charts and to compare them with the previous version, the 1977 National Center for Health Statistics (NCHS) growth charts. Methods. The 2000 CDC percentile curves were developed in 2 stages. In the first stage, the empirical percentiles were smoothed by a variety of parametric and nonparametric procedures. To obtain corresponding percentiles and z scores, we approximated the smoothed percentiles using a modified LMS estimation procedure in the second stage. The charts include of a set of curves for infants, birth to 36 months of age, and a set for children and adolescents, 2 to 20 years of age. Results. The charts represent a cross-section of children who live in the United States; breastfed infants are represented on the basis of their distribution in the US population. The 2000 CDC growth charts more closely match the national distribution of birth weights than did the 1977 NCHS growth charts, and the disjunction between weight-for-length and weight-for-stature or length-for-age and stature-for-age found in the 1977 charts has been corrected. Moreover, the 2000 CDC growth charts can be used to obtain both percentiles and z scores. Finally, body mass index-for-age charts are available for children and adolescents 2 to 20 years of age. Conclusion. The 2000 CDC growth charts are recommended for use in the United States. Pediatric clinics should make the transition from the 1977 NCHS to the 2000 CDC charts for routine monitoring of growth in infants, children, and adolescents.

A Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity

Abstract: Background. Adolescent obesity is a strong predictor of adult obesity, and adult obesity has been associated with depression, especially in women. Studies have also suggested an association between depression in adolescence and higher body mass index (BMI) in adulthood. Whether depression leads to obesity or obesity causes depression is unclear. Objective. To determine in longitudinal analyses whether depressed mood predicts the development and persistence of obesity in adolescents. Methods. A prospective cohort study of 9374 adolescents in grades 7 through 12 who completed in-home interviews for the National Longitudinal Study of Adolescent Health. Assessments were made at baseline (1995) and at follow-up 1 year later. Depressed mood was assessed with the Center for Epidemiologic Studies Depression Scale. BMI (kg/m2) was calculated from self-reported height and weight. BMI percentiles and z scores were computed using the 2000 Centers for Disease Control and Prevention growth charts. Obesity was defined as BMI ≥95th percentile, overweight as BMI ≥85th percentile and Results. At baseline, 12.9% were overweight, 9.7% were obese, and 8.8% had depressed mood. Baseline depression was not significantly correlated with baseline obesity. Among the 9.7% who were obese at follow-up, 79.6% were obese at baseline, 18.6% were overweight at baseline, and 1.8% were normal weight at baseline. Having depressed mood at baseline independently predicted obesity at follow-up (odds ratio: 2.05; 95% confidence interval: 1.18, 3.56) after controlling for BMI z score at baseline, age, race, gender, parental obesity, number of parents in the home, and family socioeconomic status. This finding persisted after controlling further for the adolescents’ report of smoking, self-esteem, delinquent behavior (conduct disorder), and physical activity. After controlling for all these same factors, depressed mood at baseline also predicted obesity at follow-up among those not obese at baseline (odds ratio: 2.05; 95% confidence interval: 1.04, 4.06) and follow-up BMI z score among those obese at baseline (β = 0.11; standard error β = 0.05). In contrast, baseline obesity did not predict follow-up depression. Conclusions. Depressed adolescents are at increased risk for the development and persistence of obesity during adolescence. Understanding the shared biological and social determinants linking depressed mood and obesity may inform the prevention and treatment of both disorders.

Television Viewing and Television in Bedroom Associated With Overweight Risk Among Low-Income Preschool Children

Abstract: Context. Television (TV) viewing is associated with obesity among school-aged children, adolescents, and adults, but this relationship has not been evaluated in preschool-aged children. Objective. To describe the TV/video viewing habits of a multiethnic, low-income preschool population of children and to determine whether TV/video viewing is related to their adiposity. Design. Cross-sectional survey of parents/guardians with measurements of children’s height and weight. Setting and Participants. Two thousand seven hundred sixty-one adults with children, 1 through Outcome Measures. Cross-sectional relationships between the amount of time the child spends viewing TV/video and the presence of a TV set in the child’s bedroom, with the prevalence of overweight children (body mass index [BMI] >85th percentile) after adjustment for potential confounders. Results. Mean TV/video viewing times were higher among black children and Hispanic children than white children and increased with the child’s age. In multiple logistic regression, the odds ratio of children having a BMI >85th percentile was 1.06 (95% confidence interval [CI]: 1.004–1.11) for each additional hour per day of TV/video viewed, independent of child age, child sex, parental educational attainment, and race/ethnicity. Almost 40% of children had a TV set in their bedroom; they were more likely to be overweight and spent more time (4.6 hours per week) watching TV/video than children without a TV in their bedroom. In multiple logistic regression, the odds ratio of having a BMI >85th percentile was 1.31 (95% CI: 1.01–1.69) among those with a TV in their bedroom versus those without a TV, after statistical adjustment for child age, child sex, child TV/video viewing hours per week, maternal BMI, maternal education, and race/ethnicity. Conclusions. This study extends the association between TV viewing and risk of being overweight to younger, preschool-aged children. A TV in the child’s bedroom is an even stronger marker of increased risk of being overweight. Because most children watch TV by age 2, educational efforts about limiting child TV/video viewing and keeping the TV out of the child’s bedroom need to begin before then.

Trends in childhood asthma: prevalence, health care utilization, and mortality.

Abstract: Objectives. Our objective was to use national data to produce a comprehensive description of trends in childhood asthma prevalence, health care utilization, and mortality to assess changes in the disease burden among US children. Methods. Five data sources from the National Center for Health Statistics were used to describe trends in asthma for children aged 0 to 17 years from 1980 to the most recent year for which data were available. These included the National Health Interview Survey (NHIS), the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, the National Hospital Discharge Survey, and the Mortality Component of the National Vital Statistics System. Results. Asthma prevalence increased by an average of 4.3% per year from 1980 to 1996, from 3.6% to 6.2%. The peak prevalence was 7.5% in 1995. In 1997, asthma attack prevalence was 5.4%, but changes in the NHIS design in 1997 preclude comparison to previous estimates. Asthma attack prevalence remained level from 1997 to 2000. After a decrease between 1980 and 1989, the asthma office visit rate increased by an average of 3.8% per year from 1989 to 1999. The asthma hospitalization rate grew by 1.4% per year from 1980 to 1999. Although childhood asthma deaths are rare, the asthma death rate increased by 3.4% per year from 1980 to 1998. Children aged 0 to 4 years had the largest increase in prevalence and had greater health care use, but adolescents had the highest mortality. The asthma burden was borne disproportionately by black children throughout the period. Racial disparities were largest for asthma hospitalizations and mortality: compared with white children, in 1998–1999, black children were >3 times as likely to be hospitalized and in 1997–1998 >4 times as likely to die from asthma. Conclusions. Recent data suggest that the burden from childhood asthma may have recently plateaued after several years of increasing, although additional years of data collection are necessary to confirm a change in trend. Racial and ethnic disparities remain large for asthma health care utilization and mortality.

Trends in mortality and morbidity for very low birth weight infants, 1991-1999.

Abstract: Background. Medical care for very low birth weight (VLBW) infants and their mothers has changed dramatically during the 1990s, yet it is unclear how these changes have affected mortality and morbidity. Objective. We used the Vermont Oxford Network Database to identify trends in clinical practice and patient outcomes for VLBW infants born from 1991 to 1999. Methods. Logistic regression was used to evaluate temporal trends in practices and outcomes while adjusting for patient characteristics and accounting for clustering of cases within hospitals. Results. There were 118 448 infants 501 to 1500 g from 362 neonatal intensive care units enrolled in the Network Database from 1991 to 1999. Prenatal care, cesarean section, multiple births, antenatal steroids, and 1-minute Apgar scores increased during this period, as did the use of nasal continuous positive airway pressure, high-frequency ventilation, surfactant, and postnatal steroids. The proportion of white infants decreased; the proportions of Hispanic infants and those of other races increased. The crude and adjusted rates of mortality, pneumothorax, intraventricular hemorrhage (IVH), and severe IVH declined from 1991 to 1995, whereas from 1995 to 1999, the rates of mortality, IVH, and severe IVH did not change significantly, and pneumothorax increased. Conclusions. There have been major changes in both obstetric and neonatal care during the 1990s. These changes were associated with decreases in mortality and morbidity for VLBW infants during the first half of the decade. However, since 1995, no additional improvements in mortality or morbidity have been seen, ending a decades-long trend of improving outcomes for these infants.

Home Visiting by Paraprofessionals and by Nurses: A Randomized, Controlled Trial

Abstract: Objective. To examine the effectiveness of home visiting by paraprofessionals and by nurses as separate means of improving maternal and child health when both types of visitors are trained in a program model that has demonstrated effectiveness when deliv- ered by nurses. Methods. A randomized, controlled trial was con- ducted in public- and private-care settings in Denver, Colorado. One thousand one hundred seventy-eight con- secutive pregnant women with no previous live births who were eligible for Medicaid or who had no private health insurance were invited to participate. Seven hun- dred thirty-five women were randomized to control, paraprofessional, or nurse conditions. Nurses completed an average of 6.5 home visits during pregnancy and 21 visits from birth to the children's sec- ond birthdays. Paraprofessionals completed an average of 6.3 home visits during pregnancy and 16 visits from birth to the children's second birthdays. The main outcomes consisted of changes in women's urine cotinine over the course of pregnancy; women's use of ancillary services during pregnancy; subsequent preg- nancies and births, educational achievement, workforce participation, and use of welfare; mother-infant respon- sive interaction; families' home environments; infants' emotional vulnerability in response to fear stimuli and low emotional vitality in response to joy and anger stim- uli; and children's language and mental development, temperament, and behavioral problems. Results. Paraprofessional-visited mother-child pairs in which the mother had low psychological resources interacted with one another more responsively than their control-group counterparts (99.45 vs 97.54 standard score points). There were no other statistically significant para- professional effects. In contrast to their control-group counterparts, nurse- visited smokers had greater reductions in cotinine levels from intake to the end of pregnancy (259.0 vs 12.32 ng/ mL); by the study child's second birthday, women visited by nurses had fewer subsequent pregnancies (29% vs 41%) and births (12% vs 19%); they delayed subsequent pregnancies for longer intervals; and during the second year after the birth of their first child, they worked more than women in the control group (6.83 vs 5.65 months). Nurse-visited mother-child pairs interacted with one another more responsively than those in the control group (100.31 vs 98.99 standard score points). At 6 months of age, nurse-visited infants, in contrast to their control- group counterparts, were less likely to exhibit emotional vulnerability in response to fear stimuli (16% vs 25%) and nurse-visited infants born to women with low psy- chological resources were less likely to exhibit low emo- tional vitality in response to joy and anger stimuli (24% vs 40% and 13% vs 33%). At 21 months, nurse-visited children born to women with low psychological re- sources were less likely to exhibit language delays (7% vs 18%); and at 24 months, they exhibited superior mental development (90.18 vs 86.20 Mental Development Index scores) than their control-group counterparts. There were no statistically significant program effects for the nurses on women's use of ancillary prenatal services, educa- tional achievement, use of welfare, or their children's temperament or behavior problems. For most outcomes on which either visitor produced significant effects, the paraprofessionals typically had effects that were about half the size of those produced by nurses. Conclusions. When trained in a model program of prenatal and infancy home visiting, paraprofessionals produced small effects that rarely achieved statistical or clinical significance; the absence of statistical signifi- cance for some outcomes is probably attributable to lim- ited statistical power to detect small effects. Nurses pro- duced significant effects on a wide range of maternal and child outcomes. Pediatrics 2002;110:486 - 496; home visits, paraprofessionals, nurses, pregnancy, development.

Infant Weight Gain and Childhood Overweight Status in a Multicenter, Cohort Study

Abstract: Objective. To determine whether a rapid rate of weight gain in early infancy is associated with overweight status in childhood. Design. Prospective, cohort study from birth to age 7 years. Setting. Twelve sites across the United States. Participants. Twenty-seven thousand, eight hundred ninety-nine (27 899) eligible participants born at full term between 1959 and 1965. Main Outcome Measure. Overweight status at age 7 years, defined by a body mass index above the 95th percentile of the Centers for Disease Control and Prevention reference data. Results. In the 19 397 participants with complete data (69.6%), the prevalence of overweight status at age 7 years was 5.4%. The rate of weight gain during the first 4 months of life (as 100 g/month) was associated with being overweight at age 7 years, after adjustment for several confounding factors: odds ratio: 1.38; 95% confidence interval: 1.32–1.44. This association was present in each birth weight quintile, and remained significant after adjustment for the weight attained at age 1 year (odds ratio: 1.17; 95% confidence interval: 1.11–1.24). Conclusions. A pattern of rapid weight gain during the first 4 months of life was associated with an increased risk of overweight status at age 7 years, independent of birth weight and weight attained at age 1 year. These findings may lead to new hypotheses regarding the cause of childhood obesity, which may contribute to our understanding of this increasing public health problem in the United States.

Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979–1999

Abstract: Objective. To examine the trend of obe- sity-associated diseases in youths and related economic costs. Methods. Using a multiyear data file of the National Hospital Discharge Survey, 1979 -1999, we analyzed the changes in obesity-associated diseases and economic costs in youths (6 -17 years of age) over time. Diabetes, obesity, sleep apnea, and gallbladder disease were exam- ined to explore the trend of the disease burden. Other obesity-associated diseases for which obesity was listed as a secondary diagnosis were also analyzed. Obesity- associated hospital costs were estimated from the dis- charges with obesity listed as a principal or secondary diagnosis. Results. From 1979 -1981 to 1997-1999, the percentage of discharges with obesity-associated diseases increased. The discharges of diabetes nearly doubled (from 1.43% to 2.36%), obesity and gallbladder diseases tripled (0.36% to 1.07% and 0.18% to 0.59%, respectively), and sleep apnea increased fivefold (0.14% to 0.75%). Ninety-six percent of discharges with a diagnosis of obesity listed obesity as a secondary diagnosis. Asthma and some mental disorders were the most common principal diagnoses when obesity was listed as a secondary diagnosis. Obesity-associated annual hospital costs (based on 2001 constant US dollar value) increased more than threefold; from $35 million (0.43% of total hospital costs) during 1979 -1981 to $127 million (1.70% of total hospital costs) during 1997-1999. Conclusions. Among all hospital discharges, the pro- portion of discharges with obesity-associated diseases has increased dramatically in the past 20 years. This increase has led to a significant growth in economic costs. These findings may reflect the impact of increasing prev- alence and severity of obesity. Diet and physical activity interventions should be developed for weight loss and prevention of weight gain in youths. Pediatrics 2002; 109(5). URL: http://www.pediatrics.org/cgi/content/full/ 109/5/e81; children, adolescents, obesity, hospitalization, comorbidities, costs.

Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome

Abstract: To the Editor. — I have major reservations in respect to the recent clinical practice guideline on obstructive sleep apnea syndrome (OSAS).1 Although it is important to alert pediatricians to the existence of this condition, the ramifications of following the guideline do not appear to have been given adequate consideration. The authors signed letters stating they did not have a conflict of interest. I assume this means they do not run polysomnography (PSG) labs, as an obvious consequence of the report will be a markedly increased demand for their use. One problem concerns children with primary snoring (PS). This can be seen, according to the report, in up to 12% of preschool-aged children. Furthermore, there is apparently no way to rule out OSAS in these children, without doing PSG. The unmistakable conclusion, therefore, is that up to 12% of preschool-aged children should be undergoing PSG. Do other pediatricians find this concept as ludicrous as I do? A second issue concerns those children with mild OSAS, mild meaning that they are not demonstrating obvious problems such as daytime somnolence or pulmonary hypertension. These children are diagnosed when their sleep studies are found to be abnormal (ie, at the tail end of the distribution curve). The guideline indicates, in one sentence in the section on research recommendations, that the natural history of these children is not known. That did not stop the committee from recommending that these children undergo adenotonsillectomy, however, even though it is not known whether mild OSAS is an actual disease or merely a statistical finding. In summary, I believe the guideline to be poorly thought out, and it …

Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis.

Abstract: Objective. Childhood diarrhea accounts for substantial morbidity and mortality worldwide. Multiple studies in children have shown that Lactobacillus, administered orally, may have antidiarrheal properties. We conducted a meta-analysis of randomized, controlled studies to assess whether treatment with Lactobacillus improves clinical outcomes in children with acute infectious diarrhea. Methods. Studies were sought in bibliographic databases of traditional biomedical as well as complementary and alternative medicine literature published from 1966 to 2000. Search terms were “competitive inhibition,” “diarrhea,” “gastroenteritis,” “Lactobacillus,” “probiotic,” “rotavirus,” and “yog(h)urt.” We included studies that were adequately randomized, blinded, controlled trials in which the treatment group received Lactobacillus and the control group received an adequate placebo and that reported clinical outcome measures of diarrhea intensity. These inclusion criteria were applied by blind review and consensus. The original search yielded 26 studies, 9 of which met the criteria. Multiple observers independently extracted study characteristics and clinical outcomes. Data sufficient to perform meta-analysis of the effect of Lactobacillus on diarrhea duration and diarrhea frequency on day 2 were contained in 7 and 3 of the included studies, respectively. Results. Summary point estimates indicate a reduction in diarrhea duration of 0.7 days (95% confidence interval: 0.3–1.2 days) and a reduction in diarrhea frequency of 1.6 stools on day 2 of treatment (95% confidence interval: 0.7–2.6 fewer stools) in the participants who received Lactobacillus compared with those who received placebo. Details of treatment protocols varied among the studies. A preplanned subanalysis suggests a dose-effect relationship. Conclusion. The results of this meta-analysis suggest that Lactobacillus is safe and effective as a treatment for children with acute infectious diarrhea.

Is Obesity Associated With Early Sexual Maturation? A Comparison of the Association in American Boys Versus Girls

Abstract: Background. Increasing evidence sug- gests a close association between early sexual maturation (SM) and obesity in girls and female adults. Earlier ma- turing girls are more likely to be obese than nonearly maturers. However, limited research has been conducted in boys. Objective. To examine the influence of early SM on fatness in boys and compare it with girls, and to test the hypothesis that the associations differ by gender because of the differences in growth and SM patterns in boys and girls. Study Design. Cross-sectional study. Subjects. One thousand five hundred one girls and 1520 boys (aged 8 -14 years) who participated in the Third National Health and Nutrition Examination Survey sur- vey (1988 -1994) and had complete anthropometry (weight, height, skinfold thickness) and SM data. Methods. Based on each individual's age and SM sta- tus (Tanner stages: genitalia stages for boys and breast stages for girls), the subjects were classified as: 1) early maturers (those who reached a certain Tanner stage ear- lier than the median age for that stage), and 2) the others (average and later maturers). Overweight was defined as a body mass index (BMI) >85th percentile, and obesity >95th percentile. Logistic regression analysis was to test how early maturation affected the risks for overweight and obese. Using multiple linear regression models, the associations between fatness (BMI and skinfold thick- ness) and SM were systematically examined. Covariates including age, ethnicity, residence, family income, en- ergy intake, and physical activity were adjusted. Results. Early SM was positively associated with overweight and obesity in girls, but the associations were reverse for boys. The prevalence of overweight in early maturers versus the others was 22.6% versus 31.6% in boys and 34.4% versus 23.2% in girls; the figures for obesity were 6.7% versus 14.8% and 15.6% versus 8.1%, respectively. Odd ratios and 95% confidence intervals for obesity were 0.4 (0.2, 0.8) for boys and 2.0 (1.1, 3.5) for girls, and covariates were adjusted. Most significant dif- ferences in overweight and obesity among ethnic groups disappeared after controlling for SM. Fatness (BMI and skinfold thickness) was associated with SM stages and with early maturation in boys and girls, but the associa- tions were in opposite directions. Compared with their counterparts, early maturing boys were thinner, whereas early maturing girls were fatter. Conclusions. Obesity is associated with sexual matu- ration in both boys and girls, but the association differs. There is positive association in girls, but a negative one in boys. Maturation status should be taken into consid- eration when assessing child and adolescent obesity. Pediatrics 2002;110:903-910; child, adolescent, fatness, body mass index, obesity, overweight, sexual maturation. ABBREVIATIONS. SM, sexual maturation; BMI, body mass index; NHANES III, Third National Health and Nutrition Examination Survey; CDC, Centers for Disease Control and Prevention; SES, socioeconomic status; CI, confidence interval; OR, odds ratio.

Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke.

Abstract: The National Institute of Neurological Disorders and Stroke and the Office of Rare Disorders sponsored a workshop on perinatal and childhood stroke in Bethesda, Maryland, on September 18 and 19, 2000. This was an international workshop to bring together experts in the field of perinatal and childhood stroke. Topics covered included epidemiology, animal models, risk factors, outcome and prognosis, and areas of future research for perinatal and childhood stroke. Stroke in infants and children is an important cause of morbidity and mortality and an emerging area for clinical and translational research. Currently, there is no consensus on the classification, evaluation, outcome measurement, or treatment of perinatal and childhood stroke. Pediatric stroke registries are needed to generate data regarding risk factors, recurrence, and outcome. The impact of maternal and perinatal factors on risk and outcome of neonatal stroke needs to be studied. This information is essential to identifying significant areas for future treatment and prevention.

Comparison of skin-to-skin (Kangaroo) and traditional care: Parenting outcomes and preterm infant development

Abstract: Objective. To examine whether the kangaroo care (KC) intervention in premature infants affects parent–child interactions and infant development. Methods. Seventy-three preterm infants who received KC in the neonatal intensive care unit were matched with 73 control infants who received standard incubator care for birth weight, gestational age (GA), medical severity, and demographics. At 37 weeks’ GA, mother–infant interaction, maternal depression, and mother perceptions were examined. At 3 months’ corrected age, infant temperament, maternal and paternal sensitivity, and the home environment (with the Home Observation for Measurement of the Environment [HOME]) were observed. At 6 months’ corrected age, cognitive development was measured with the Bayley-II and mother–infant interaction was filmed. Seven clusters of outcomes were examined at 3 time periods: at 37 weeks’ GA, mother–infant interaction and maternal perceptions; at 3-month, HOME mothers, HOME fathers, and infant temperament; at 6 months, cognitive development and mother–infant interaction Results. After KC, interactions were more positive at 37 weeks’ GA: mothers showed more positive affect, touch, and adaptation to infant cues, and infants showed more alertness and less gaze aversion. Mothers reported less depression and perceived infants as less abnormal. At 3 months, mothers and fathers of KC infants were more sensitive and provided a better home environment. At 6 months, KC mothers were more sensitive and infants scored higher on the Bayley Mental Developmental Index (KC: mean: 96.39; controls: mean: 91.81) and the Psychomotor Developmental Index (KC: mean: 85.47; controls: mean: 80.53). Conclusions. KC had a significant positive impact on the infant’s perceptual-cognitive and motor development and on the parenting process. We speculate that KC has both a direct impact on infant development by contributing to neurophysiological organization and an indirect effect by improving parental mood, perceptions, and interactive behavior.

Technical Report: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

Abstract: Objective. This technical report describes the procedures involved in developing the recommendations of the Subcommittee on Obstructive Sleep Apnea Syndrome in children. The group of primary interest for this report was otherwise healthy children older than 1 year who might have adenotonsillar hypertrophy or obesity as underlying risk factors of obstructive sleep apnea syndrome (OSAS). The goals of the committee were to enhance the primary care clinician’s ability to recognize OSAS, identify the most appropriate procedure for diagnosis of OSAS, identify risks associated with pediatric OSAS, and evaluate management options for OSAS. Methods. A literature search was initially conducted for 2the years 1966–1999 and then updated to include 2000. The search was limited to English language literature concerning children older than 2 and younger than 18 years. Titles and abstracts were reviewed for relevance, and committee members reviewed in detail any possibly appropriate articles to determine eligibility for inclusion. Additional articles were obtained by a review of literature and committee members’ files. Committee members compiled evidence tables and met to review and discuss the literature that was collected. Results. A total of 2115 titles were reviewed, of which 113 provided relevant original data for analysis. These articles were mainly case series and cross-sectional studies; overall, very few methodologically strong cohort studies or randomized, controlled trials concerning OSAS have been published. In addition, a minority of studies satisfactorily differentiated primary snoring from true OSAS. Reports of the prevalence of habitual snoring in children ranged from 3.2% to 12.1%, and estimates of OSAS ranged from 0.7% to 10.3%; these studies were too heterogeneous for data pooling. Children with sleep-disordered breathing are at increased risk for hyperactivity and learning problems. The combined odds ratio for neurobehavioral abnormalities in snoring children compared with controls is 2.93 (95% confidence interval: 2.23–3.83). A number of case series have documented decreased somatic growth in children with OSAS; right ventricular dysfunction and systemic hypertension also have been reported in children with OSAS. However, the risk growth and cardiovascular problems cannot be quantified from the published literature. Overnight polysomnography (PSG) is recognized as the gold standard for diagnosis of OSAS, and there are currently no satisfactory alternatives. The diagnostic accuracy of symptom questionnaires and other purely clinical approaches is low. Pulse oximetry appears to be specific but insensitive. Other methods, including audiotaping or videotaping and nap or home overnight PSG, remain investigational. Adenotonsillectomy is curative in 75% to 100% of children with OSAS, including those who are obese. Up to 27% of children undergoing adenotonsillectomy for OSAS have postoperative respiratory complications, but estimates are varied. Risk factors for persistent OSAS after adenotonsillectomy include continued snoring and a high apnea-hypopnea index on the preoperative PSG. Conclusions. OSAS is common in children and is associated with significant sequelae. Overnight PSG is currently the only reliable diagnostic modality that can differentiate OSAS from primary snoring. However, the PSG criteria for OSAS have not been definitively validated, and it is not clear that primary snoring without PSG-defined OSAS is benign. Adenotonsillectomy is the first-line treatment for OSAS but requires careful postoperative monitoring because of the high risk of respiratory complications. Adenotonsillectomy is usually curative, but children with persistent snoring (and perhaps with severely abnormal preoperative PSG results) should have PSG repeated postoperatively.

Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals.

Abstract: The primary aim of this study was to evaluate among health care professionals their attitudes, perceived barriers, perceived skill level, and training needs in the management of child and adolescent obesity. A national needs assessment consisting of a mailed questionnaire was conducted among a random sample of health care professionals. The survey was completed by 202 pediatricians, 293 pediatric nurse practitioners, and 444 registered dietitians. The majority of all respondents felt that childhood obesity was a condition that needs treatment), and affects chronic disease risk and future quality of life. The most frequent barriers were lack of parent involvement, lack of patient motivation, and lack of support services. Registered dietitians were less likely to identify barriers to treatment compared with pediatricians or pediatric nurse practitioners. The most common areas of self-perceived low proficiency were in the use of behavioral management strategies,guidance in parenting techniques, and addressing family conflicts. All 3 groups expressed high interest in additional training on obesity management of children and adolescents. Several important barriers interfere with treatment efforts and need to be addressed.There is also a need for increased training opportunities related to obesity prevention and treatment. The results of this study provide directions and priorities for training, education, and advocacy efforts.

National estimates of the timing of sexual maturation and racial differences among US children.

Abstract: Objective. To provide clinically meaningful, normative reference data that describe the timing of sexual maturity indicators among a national sample of US children and to determine the degree of racial/ethnic differences in these estimates for each maturity indicator. Methods. Tanner staging assessment of sexual maturity indicators was recorded from 4263 non-Hispanic white, black, and Mexican American girls and boys aged 8.00 to 19.00 years as part of the Third National Health and Nutrition Examination Survey (NHANES III) conducted between 1988 and 1994. NHANES III followed a complex, stratified, multistage probability cluster design. SUDAAN was used to calculate the mean age and standard error for each maturity stage and the proportion of entry into a maturity stage and to incorporate the sampling weight and design effects of the NHANES III complex sampling design. Probit analysis and median age at entry into a maturity stage and its fiducial limits were calculated using SAS 8.2. Results. Reference data for age at entry for maturity stages are presented in tabular and graphical format. Non-Hispanic black girls had an earlier sexual development for pubic hair and breast development either by median age at entry for a stage or for the mean age for a stage than Mexican American or non-Hispanic white girls. There were few to no significant differences between the Mexican American and non-Hispanic white girls. Non-Hispanic black boys also had earlier median and mean ages for sexual maturity stages than the non-Hispanic white and Mexican American boys. Conclusion. Non-Hispanic black girls and boys mature early, but US children completed their sexual development at approximately the same ages. The present reference data for the timing of sexual maturation are recommended for the interpretation of assessments of sexual maturity in US children.

Inattention, hyperactivity, and symptoms of sleep-disordered breathing.

Abstract: Objective. Inattention and hyperactivity are frequent among children with sleep-disordered breathing (SDB) and often improve when SDB is treated. However, the frequency of SDB symptoms among inattentive and hyperactive children has received little study. Design. Cross-sectional survey. Setting. Two university-affiliated but community-based general pediatrics clinics. Patients. Patients consisted of N = 866 children (469 boys), aged 2.0 to 13.9 years (mean: 6.8 ± 3.2 years), with clinic appointments. Measures. A validated Pediatric Sleep Questionnaire assessed for habitual snoring (1 item), snoring severity (a 4-item subscale), sleepiness (4 items), and overall risk of SDB (16 items). Parents also completed 2 common behavioral measures, an inattention/hyperactivity scale (IHS) derived from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the hyperactivity index (HI, expressed as a t score) of the Conners’ Parent Rating Scale. Results. Habitual snoring was reported in 16% (95% confidence interval [CI]: 13, 19) of the participants. High HI scores (>60) were found in 13% (95% CI: 11, 16) of all participants, 22% (95% CI: 15, 29) of habitual snorers, and 12% (95% CI: 9, 14) of nonsnorers. Odds ratios between HI >60 and each of the following were: habitual snoring, 2.2 (95% CI: 1.4, 3.6); 1 additional positive symptom-item on the snoring scale, 1.3 (95% CI: 1.1, 1.5); 1 additional positive item on the sleepiness scale, 1.6 (95% CI: 1.4, 2.0); and a 1-standard deviation increase in the overall SDB score, 1.7 (95% CI: 1.4, 2.0; all odds ratios age- and sex-adjusted). Results were similar for high IHS scores (>1.25). Stratification by age and sex showed that most of the association with snoring (but not sleepiness) derived from boys Conclusions. Inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness and—especially in young boys—snoring and other symptoms of SDB. If sleepiness and SDB do influence daytime behavior, the current results suggest a major public health impact.

Breastfeeding continues to increase into the new millennium.

Abstract: Objective. To update reported rates of breastfeeding and exclusive breastfeeding through 2001 and to compare rates in 2001 to those from 1996. Methods. The Ross Laboratories Mothers Survey (RLMS) is a large, national survey designed to determine patterns of milk feeding during infancy. Questionnaires were mailed each month to a representative sample of mothers when their infant was 1 month of age, 2 months of age, 3 months or age, and so forth. In 1996, approximately 744 000 questionnaires were mailed, and in 2001, 1.4 million questionnaires were mailed. Mothers were asked to recall the type of milk fed to their infant in the hospital, and during each month of age. Two categories of breastfeeding were considered: breastfeeding (human milk or a combination of human milk and formula or cow’s milk) and exclusive breastfeeding (only human milk). Rates of breastfeeding and exclusive breastfeeding in the hospital and at 6 months of age were evaluated. Results. In 2001, the prevalence of the initiation of breastfeeding and breastfeeding to 6 months of age in the United States reached their highest levels recorded to date, 69.5% and 32.5%, respectively. Comparing rates in 2001 and 1996, increases in the initiation of breastfeeding and continued breastfeeding to 6 months of age were observed across all sociodemographic groups but were greater among groups that have been historically less likely to breastfeed: women who were black, younger ( Conclusions. If increases in breastfeeding continue at the current rate (approximately 2% per year), in-hospital breastfeeding in the United States should meet or exceed the Healthy People 2010 goal of 75% for the early postpartum period. However, the Healthy People 2010 goal for continued breastfeeding to 5 to 6 months of age (50%) may not be reached in every subgroup. To ensure that these goals are achieved, educational and promotional strategies for breastfeeding must be continued to support mothers who are young, less educated, and participating in WIC.

Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae

Abstract: Objective. The frequency of children who are hospitalized with pneumococcal pneumonia complicated by necrosis, empyema/complicated parapneumonic effusion, and lung abscess seems to be increasing. The factors that contribute to this increase are unclear; therefore, the objective of this study was to describe and compare the relative frequency, clinical characteristics, and outcome of hospitalized children with complicated pneumonia with those of children with uncomplicated pneumonia caused by Streptococcus pneumoniae in the era of antibiotic resistance. Methods. A multicenter, retrospective study of 8 children’s hospitals in the United States was undertaken. A total of 368 children who were hospitalized with pneumococcal pneumonia identified from patients enrolled in the US Pediatric Multicenter Pneumococcal Surveillance Study over the period from September 1, 1993, to January 31, 2000 were studied. Demographic and clinical variables, antibiotic susceptibility, pneumococcal serotypes, antimicrobial therapy, and clinical outcome in hospitalized children with complicated versus uncomplicated pneumococcal pneumonia were measured. Results. A total of 368 patients with pneumococcal pneumonia were identified. Of the 368 isolates, 47 (12.8%) were intermediate and 37 (10.1%) were resistant to penicillin; 18 (5%) were intermediate to ceftriaxone, and 9 (2.5%) were resistant to ceftriaxone. A total of 133 patients met the criteria for complicated pneumonia and had a chest tube placed; 56 of these patients subsequently underwent decortication. The proportion of hospitalized patients with complicated pneumococcal pneumonia increased progressively over the study period from 22.6% in 1994 to 53% in 1999. Patients with complicated disease were older (median age: 45 vs 27 months) and significantly more likely to be of white race and have chest pain on presentation compared with patients with uncomplicated disease. Patients who had complicated disease and underwent decortication were more likely to have pleural fluid lactate dehydrogenase levels of >7500 IU/L compared with those patients who had chest tube placement alone. Fifty-three percent of children who were ≥61 months of age and were hospitalized had complicated pneumonia. This group of children accounted overall for 42% of the patients with complicated pneumonia, 48.2% of the patients who subsequently underwent decortication, and 44% of the patients who had received a course of antibiotics before diagnosis. Pneumococcal serotypes 1, 6, 14, and 19 were the most prevalent serotypes causing disease, with serotype 1 causing 24.4% of the complicated cases versus 3.6% of the uncomplicated cases. Ninety-eight percent of the patients in both groups recovered from their pneumonia. Antibiotic resistance was not found to be more prevalent in those patients with complicated disease. Conclusions. The relative frequency of complicated disease in hospitalized children with pneumococcal pneumonia is increasing. Patients with complicated pneumococcal disease were older and significantly more likely to be of white race compared with those patients with uncomplicated disease. Pneumococcal serotype 1 caused significantly more disease in patients with complicated versus uncomplicated pneumonia. Patients with complicated disease were not more likely to be infected with an antibiotic-resistant isolate.

Hunger: Its Impact on Children's Health and Mental Health

Abstract: Objective. Hunger, with its adverse consequences for children, continues to be an important national problem. Previous studies that document the deleterious effects of hunger among children cannot distinguish child from family hunger and do not take into account some critical environmental, maternal, and child variables that may influence child outcomes. This study examines the independent contribution of child hunger on children’s physical and mental health and academic functioning, when controlling for a range of environmental, maternal, and child factors that have also been associated with poor outcomes among children. Methods. With the use of standardized tools, comprehensive demographic, psychosocial, and health data were collected in Worcester, Massachusetts, from homeless and low-income housed mothers and their children (180 preschool-aged children and 228 school-aged children). Mothers and children were part of a larger unmatched case-control study of homelessness among female-headed households. Hunger was measured by a set of 7 dichotomous items, each asking the mother whether she has or her children have experienced a particular aspect of hunger during the past year—1 concerns food insecurity for the entire family, 2 concern adult hunger, and 4 involve child hunger. The items, taken from the Childhood Hunger Identification Project measure, are summed to classify the family and divided into 3 categories: no hunger, adult or moderate child hunger, or severe child hunger (indicating multiple signs of child hunger). Outcome measures included children’s chronic health condition count using questions adapted from the National Health Interview Survey, Child Health Supplement, and internalizing behavior problems and anxiety/depression, measured by the Child Behavior Checklist. Additional covariates included demographic variables (ie, age, gender, ethnicity, housing status, number of moves, family size, income), low birth weight, child life events (ie, care and protection order, out of home placement, abuse, severe life events count), developmental problems (ie, developmental delay, learning disability, emotional problems), and mother’s distress and psychiatric illness. Multivariate regression analyses examined the effect of child hunger on physical and mental health outcomes. Results. The average family size for both preschoolers and school-aged children was 3; about one third of both groups were white and 40% Puerto Rican. The average income of families was approximately $11 000. Among the school-aged children, on average 10 years old, 50% experienced moderate child hunger and 16% severe child hunger. Compared with those with no hunger, school-aged children with severe hunger were more likely to be homeless (56% vs 29%), have low birth weights (23% vs 6%), and have more stressful life events (9 vs 6) when compared with those with no hunger. School-aged children with severe hunger scores had parent-reported anxiety scores that were more than double the scores for children with no hunger and significantly higher chronic illness counts (3.4 vs 1.8) and internalizing behavior problems when compared with children with no hunger. There was no relationship between hunger and academic achievement. Among preschool-aged children, who averaged 4 years of age, 51% experienced moderate child hunger and 8% severe child hunger. For preschoolers, compared with children with no hunger, severe hunger was associated with homelessness (75% vs 48%), more traumatic life events (8.5 vs 6), low birth weight (23% vs 6%), and higher levels of chronic illness and internalizing behavior problems. Mothers of both preschoolers and school-aged children who reported severe hunger were more likely to have a lifetime diagnosis of posttraumatic stress disorder. For school-aged children, severe hunger was a significant predictor of chronic illness after controlling for housing status, mother’s distress, low birth weight, and child live events. For preschoolers, moderate hunger was a significant predictor of health conditions while controlling for potential explanatory factors. For both preschoolers and school-aged children, severe child hunger was associated with higher levels of internalizing behavior problems. After controlling for housing status, mother’s distress, and stressful life events, severe child hunger was also associated with higher reported anxiety/depression among school-aged children. Conclusion. This study goes beyond previous research and highlights the independent relationship between severe child hunger and adverse physical health and mental health outcomes among low-income children. Study findings underscore the importance of clinical recognition of child hunger and its outcomes, allowing for preventive interventions and efforts to increase access to food-related resources for families.

Weight criticism during physical activity, coping skills, and reported physical activity in children.

Abstract: Objective. National health guidelines advocate increased physical activity in children and ad- olescents, but specific goals are not being achieved. Data are needed on variables that influence children's deci- sion to be active or sedentary. Methods. We tested the association of weight criti- cism during physical activity (WCA) with attitudes to- ward physical activity and reported physical activity lev- els in children. We also tested whether these associations were moderated by children's ability to cope with weight criticism. Subjects were 576 fifth- through eighth-graders who completed a questionnaire on physical activity pat- terns, weight criticism history, and coping skills. Results. WCA was more common among girls than boys and among heavier children. In multiple regression analyses, WCA was associated with reduced sports en- joyment, perceived activity compared with peers, and mild-intensity leisure activity. These associations, how- ever, were moderated by problem-focused coping skills such that the relationships were attenuated in children who were better able to cope with weight criticism. Avoidant coping skills also moderated the relationship between WCA and sports enjoyment. Conclusions. Children who are the targets of weight criticism by family and peers have negative attitudes toward sports and report reduced physical activity levels, although these relationships may be buffered by certain coping skills. Assessing WCA and related coping skills may be clinically useful for identifying barriers to phys- ical activity in certain children (eg, the obese) and may be a potential target for interventions. Pediatrics 2002;110(2). URL: http://www.pediatrics.org/cgi/content/full/110/2/ e23; physical activity, children, obesity, teasing, coping skills.

Trends in the prevalence of cerebral palsy in a population-based study

Abstract: Objective To determine trends in the prevalence of congenital cerebral palsy (CP) over a 16-year period for 1-year survivors using a large, population-based surveillance program Methods We determined birth weight-specific trends in the prevalence of CP in live birth and 1-year survivor cohorts of children in a 5-county metropolitan Atlanta area for the periods from 1975–1977, 1981–1985, and 1986–1991 We ascertained children with CP in metropolitan Atlanta by record review as part of an ongoing developmental disability surveillance program conducted by the Centers for Disease Control and Prevention and the Georgia Department of Human Resources A total of 110, 262, and 443 cases of congenital CP were identified for the birth years 1975–1977, 1981–1985, and 1986–1991, respectively Data were analyzed by birth weight, race, subtypes of CP, and whether the CP existed as an isolated disability or was accompanied by another disability Results There was a modest increase in the overall prevalence of congenital CP from 17 to 20 per 1000 1-year survivors during the period from 1975–1991 This trend was primarily attributable to a slight increase in CP in infants of normal birth weight—CP rates in moderately low and very low birth weight infants did not show consistent trends There was an increase in the proportion of children who had CP and no other disabilities that was most apparent in infants of normal birth weight from 17% in 1975–1977 to 39% in 1986–1991 For children weighing Conclusions In the only ongoing population-based study of CP in the United States, there has been a modest increase in the prevalence of CP in 1-year survivors born from 1975–1991 This increase however was seen only in infant survivors of normal birth weight No change was seen in the trends in CP prevalence in low birth weight and very low birth weight infant based on infant survivors

Racial/Ethnic Variation in Asthma Status and Management Practices Among Children in Managed Medicaid

Abstract: Objective. Raciallethnic disparities in hospitalization rates among children with asthma have been documented but are not well-understood. Medicaid programs, which serve many minority children, have markedly increased their use of managed care in recent years. It is unknown whether racial/ethnic disparities in health care use or other processes of care exist in managed Medicaid populations. This study of Medicaid-insured children with asthma in 5 managed care organizations aimed to 1) compare parent-reported health status and asthma care processes among black, Latino, and white children and 2) test the hypothesis that racial/ ethnic variations in processes of asthma care exist after adjusting for socioeconomic status and asthma status. Methods. This cross-sectional study collected data via telephone interviews with parents and computerized records for Medicaid-insured children with asthma in 5 managed care organizations in California, Washington, and Massachusetts. The American Academy of Pediatrics (AAP) Children's Health Survey for Asthma was used to measure parent-reported asthma status. We used multivariate models to evaluate associations between race/ ethnicity and asthma status while controlling for other sociodemographic variables. We evaluated racial/ethnic variations in selected processes of asthma care while controlling for other demographic variables and asthma status. Results. The response rate was 63%. Of the 1658 children in the respondent group, 38% were black, 19% were Latino, and 31% were white. Black children had worse asthma status than white children on the basis of the AAP asthma physical and emotional health scores, symptom-days, and school days missed in the past 2 weeks. Latino children had equivalent AAP scores but missed more school days than white children. On the basis of the AAP asthma physical health score, the black-white disparity persisted after adjusting for other sociodemographic variables. After adjusting for sociodemographic variables and asthma status, black and Latino children were less likely to be using inhaled antiinflammatory medication than white children (relative risk for blacks: 0.69; relative risk for Latinos: 0.58). They were more likely to have home nebulizers. Other processes of asthma care, including ratings of providers and asthma care, use of written management plans, use of preventive visits and specialists, and having no pets or smokers at home, were equal or better for minority children compared with white children. Conclusions. Black and Latino children had worse asthma status and less use of preventive asthma medications than white children within the same managed Medicaid populations. Most other processes of asthma care seemed to be equal or better for minorities in the populations that we studied. Increasing the use of preventive medications is a natural focus for reducing racial disparities in asthma. Pediatrics 2002;109:857-865; asthma, race, race/ethnicity, health status, quality of care, processes of care, managed care.

Mutation of a New Gene Encoding a Putative Pyrin-Like Protein Causes Familial Cold Autoinflammatory Syndrome and Muckle-Wells Syndrome

Abstract: Purpose of the Study. Some patients with severe congenital neutropenia harbor mutations in the carboxyl terminus of the granulocyte colony-stimulating factor (G-CSF) receptor. It is this subgroup of patients with severe congenital neutropenia that is markedly predisposed to acute myeloid leukemia. This predisposition poses a significant hurdle to management. Patients with severe congenital neutropenia are …

Psychological outcomes in long-term survivors of childhood leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma: a report from the Childhood Cancer Survivor Study.

Abstract: Objective To evaluate and compare psychological outcomes in long-term survivors of pediatric leukemia, Hodgkin’s disease, and non-Hodgkin’s lymphoma and sibling controls Methods Adult survivors of childhood leukemia, Hodgkin’s disease, and non-Hodgkin’s lymphoma (N = 5736) and sibling controls (N = 2565) were administered a long-term follow-up questionnaire allowing assessment of symptoms associated with depression and somatic distress Results The majority of respondents in this study did not demonstrate symptomatology indicative of depression or somatic distress Survivors, however, were significantly more likely than sibling controls to report symptoms of depression and somatic distress Women were significantly more likely to indicate symptoms of depression and somatic distress than were men; however, this difference did not vary by survivor/sibling status Similarly, socioeconomic (SES) variables predicted symptomatic levels of depression and somatic distress for both survivors and siblings, and these effects did not vary by survivor/sibling status Among leukemia, Hodgkin’s disease, and non-Hodgkin’s lymphoma survivors, in addition to gender and SES, the only treatment variable that predicted scores indicating depressive symptomatology was exposure to intensive chemotherapy Exposure to intensive chemotherapy also predicted scores indicative of somatic distress symptoms No other medical variables, including diagnostic category, age at diagnosis, time since diagnosis, and duration of treatment, predicted symptomatic scores for depression and somatic distress Conclusions This large, sibling-controlled, multisite study of young adult survivors of childhood leukemia, Hodgkin’s disease, and non-Hodgkin’s lymphoma found that survivors had significant increased risk for reporting symptoms of depression and somatic distress and that intensive chemotherapy added to this risk However, being a cancer survivor did not compound the effects of gender and SES variables on the 2 outcomes measured The ability of SES, gender, and treatment-related variables to predict psychological symptoms in this cohort of childhood survivors and sibling controls calls for future research into varied biological and psychosocial pathways by which cancer influences future psychosocial functioning

Ethnic differences in the presence of secondary sex characteristics and menarche among US girls: the Third National Health and Nutrition Examination Survey, 1988-1994.

Abstract: Objective To assess measures of puberty—presence of pubic hair, breast development, and menarche—for 3 racial/ethnic groups of girls in the United States Methods Using data from the Third National Health and Nutrition Examination Survey, this study sample was restricted to 1623 girls aged 8 to 16 years (466 non-Hispanic white, 589 non-Hispanic black, and 568 Mexican American) for whom information was available on Tanner stages of pubic hair and breast development Subsequently, the sample was restricted to 1168 girls aged 10 to 16 years (330 non-Hispanic white, 419 non-Hispanic black, and 419 Mexican American) for whom menarche data were available Tanner stage II or higher was used to define pubic hair and breast development; menarche status was self-reported The percentage of girls who had pubic hair and breast development and had achieved menarche was computed by age and race/ethnicity Probit and failure time models were applied to estimate mean ages at onset of pubic hair, breast development, and menarche The racial/ethnic differences also were examined after adjustment for social and economic variables and current body mass index Results Black and Mexican American girls had pubic hair and breast development and had achieved menarche at younger ages than white girls For example, 494% of black girls aged 9 years had breast development compared with 245% of Mexican American girls and 158% of white girls The mean age at onset of pubic hair, breast development, and menarche was 95, 95, and 121 year for black girls; 103, 98, and 122 years for Mexican American girls; and 105, 103, and 127 years for white girls These ethnic differences remained even after adjustment for current body mass index and several social and economic variables Conclusion Black girls on average enter puberty first, followed by Mexican American and then white girls

Use of sunscreen, sunburning rates, and tanning bed use among more than 10 000 US children and adolescents.

Abstract: Objectives. To describe the association of sunscreen use, sunburning, and tanning bed use by age, sex, residence, and psychosocial variables associated with tan-seeking behaviors, and to compare these findings with sun protection recommendations from federal agencies and cancer organizations. Methods. A cross-sectional study, from all 50 states, of 10 079 boys and girls 12 to 18 years of age in 1999. Data were collected from self-report questionnaires with the children of the participants from the Nurses Health Study (Growing Up Today Study). Results. The prevalence of sunscreen use was 34.4% with girls more likely to use sunscreen than boys (40.0 vs 26.4, odds ratio: 1.86; 95% confidence interval: 1.70–2.03). Eighty-three percent of respondents had at least 1 sunburn during the previous summer, and 36% had 3 or more sunburns. Nearly 10% of respondents used a tanning bed during the previous year. Girls were far more likely than boys to report tanning bed use (14.4 vs 2.4), and older girls (ages 15–18) were far more likely than younger girls (ages 12–14) to report tanning bed use (24.6% vs 4.7). Tanning bed use increased from 7% among 14-year-old girls to 16% by age 15, and more than doubled again by age 17 (35%; N = 244). Multivariate analysis demonstrated that attitudes associated with tanning, such as the preference for tanned skin, having many friends who were tanned, and belief in the worth of burning to get a tan, were generally associated with sporadic sunscreen use, more frequent sunburns, and increased use of tanning beds. Conclusions. Our findings suggest that many children are at subsequent risk of skin cancer because of suboptimal sunscreen use, high rates of sunburning, and tanning bed use. Recommendations in the United States for improved sun protection and avoidance of tanning beds and sunburning, which began in the early 1990s, have been primarily unheeded. Nationally coordinated campaigns with strong policy components must be developed and sustained to prevent skin cancer in a new generation of children and adolescents.

Infant Feeding and Blood Cholesterol: A Study in Adolescents and a Systematic Review

Abstract: Objective. To examine the influence of infant feeding method on serum total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol. Methods. A cross-sectional study of 13- to 16-year-olds and a systematic review of studies (all observational) on the effects of infant feeding on cholesterol in infancy ( Results. Mean TC in childhood or adolescence (including the new study) was not related to infant feeding pattern (mean TC difference = 0.00; 95% confidence interval [CI]: −0.07 to 0.07 mmol/L). However, in infancy, mean TC was higher among those breastfed (mean TC difference = 0.64; 95% CI: 0.50–0.79 mmol/L), whereas in adults, mean TC was lower among those breastfed (mean TC difference = −0.18; 95% CI: −0.30 to −0.06 mmol/L). Patterns for LDL were similar to those for TC throughout. Conclusions. Breastfeeding is associated with increased mean TC and LDL levels in infancy but lower levels in adulthood/adult life. These results suggest that breastfeeding may have long-term benefits for cardiovascular health and may have implications for the content of formula feed milks.