Autism Risk Linked to Particulate Air Pollution

By Reuters Staff

December 19, 2014

(Reuters) - Children whose mothers were exposed to high levels of fine particulate pollution in late pregnancy have up to twice the risk of developing autism as children of mothers breathing cleaner air, scientists at Harvard School of Public Health reported on Thursday.

The greater the exposure to fine particulates emitted by fires, vehicles and industrial smokestacks, the greater the risk, according to the study published online in Environmental Health Perspectives.

Earlier research also found an autism-pollution connection, including a 2010 study that found the risk of autism doubled if a mother, during her third trimester, lived near a freeway, a proxy for exposure to particulates. But this is the first to examine the link across the United States, and "provides additional support" to a possible link, said Heather Volk of the University of Southern California Children's Hospital, who led earlier studies.

U.S. diagnoses of autism soared to one in 68 children in 2010 (the most recent data) from one in 150 in 2000, government scientists reported in March. Experts are divided on how much of the increase reflects greater awareness and how much truly greater incidence.

Although the disorder has a strong genetic basis, the increasing incidence has spurred scientists to investigate environmental causes, too, since genes do not change quickly enough to explain the rise.

The Harvard study included children of the 116,430 women in the Nurses' Health Study II, which began in 1989. The researchers collected data on where the women lived while pregnant and levels of particulate pollution. They then compared the prenatal histories of 245 children with autism spectrum disorder to 1,522 normally-developing children, all born from 1990 to 2002.

There was no association between autism and fine particulate pollution exposure before or early in pregnancy, or after the child was born. But high levels of exposure during the third trimester doubled the risk of autism.

Evidence that a mother-to-be's exposure to air pollution affects her child's risk of autism "is becoming quite strong," said Harvard epidemiologist Marc Weisskopf, who led the study, suggesting a way to reduce the risk.

It is not clear how tiny particles might cause autism, but they are covered with myriad contaminants and penetrate cells, which can disrupt brain development.

Last year the Environmental Protection Agency, citing the link to asthma, lung cancer and cardiovascular disease, tightened air quality standards for fine particulate pollution. States have until 2020 to meet the new standards.

Almost All Infant Car Seats Misused

Jim Kling

October 14, 2014

SAN DIEGO — Most newborns going home from the hospital for the first time are placed incorrectly in their car safety seat, according to a study that found that a worrisome 93% of infants are buckled wrong.

Parents commonly make at least one critical mistake when installing and strapping their babies in car seats, reported presenter Benjamin Hoffman, MD, from Doernbecher Children's Hospital at Oregon Health and Science University in Portland.

The findings, presented here at the American Academy of Pediatrics (AAP) 2014 National Conference and Exhibition, are poignant, considering that car crashes are the leading cause of death for children 1 to 15 years of age, according to the Centers for Disease Control and Prevention.

To estimate the rate of car seat misuse and to determine factors associated with this problem, the investigators randomly sampled 267 caretaker–infant pairs. Parents were asked to put the child in a car seat and a certified child passenger safety technician recorded the results and then helped correct any errors.

The majority — 93% — were found to have committed at least one critical error, 90% made at least two mistakes, and 50% made at least five.

The most common fault was a loose harness, which can lead to injuries related to forward momentum. Another was the position of the retainer clip, which should be at armpit level. If it is too low, the shoulder straps can splay outward and the child could be ejected from the seat. The correct armpit level is "higher than most families feel it should be," said Dr Hoffman. A correctly placed harness can also be hard to gauge. The right fit "is snugger than most think it should be," he added.

In 8% of cases, families had not used the buckle. "They're stressed, they're busy, they're exhausted," explained Dr Hoffman.

Table 1. Most Common Car Seat Errors

Error	Percent
Loose harness	68
Low placement of harness clip	33
Wrong harness slot	28
Use of nonregulated product	20
Installation error motion >1 inch	43
Incorrect recline angle	36
Failure to lock seatbelt	23
Misuse of vehicle seat	17

Dr Hoffman said he hopes this study will help convince hospitals to institute new programs. "I'm constantly told that hospitals can't afford to do that, but if you know that 93% of babies are going home incorrectly, and in danger, then you know we can't afford not to," he said.

The researchers found some factors related to the odds of a parent making an error, including ethnicity, insurance type, and education level.

Table 2. Factors Related to Increased Odds for Car Seat Misuse

Factor	Odds Ratio	95% Confidence Interval
Hispanic race	4.0	1.2–14.2
Medicaid	6.8	1.5–30.0
Education level (no college)	5.6	1.6–19.7
No prenatal visit with technician	13.2	3.6–48.7

These findings quantify a problem that has long been known, according to Marilyn Bull, MD, neurodevelopment pediatrician at the Riley Hospital for Children at Indiana University Health in Indianapolis, and medical codirector of the hospital's auto safety program. "This is going to be very important in helping direct interventions to correct the problems," she told Medscape Medical News.

In April, the AAP, in concert with several other organizations, released guidelines to help hospitals develop programs to ensure safe child transportation.

Prior to that, the most recent research was a 10-year-old National Highway Traffic Safety Administration study that showed misuse in 73% of all car seats. "Those are the last good data we have," Dr Hoffman said. "The numbers have not improved."

Dr Bull called for all hospitals that care for children, especially those who discharge newborns, to have a child passenger safety program that includes training from a child passenger safety technician, similar to what is outlined in the AAP recommendations. The study results provide a compelling argument for those guidelines, she said. "I think it's extraordinarily timely."

Appendicitis: Surgery Safely Avoided in Some Children

Jennifer Garcia

April 25, 2014

Uncomplicated acute appendicitis in children may be managed successfully using nonsurgical techniques, according to a study published online April 12 in the Journal of the American College of Surgeons.

A prospective nonrandomized trial by Peter C. Minneci, MD, MHSc, from the Nationwide Children's Hospital, Columbus, Ohio, and colleagues compared surgical vs nonsurgical management of uncomplicated acute appendicitis in 77 children. The nonsurgical approach consisted of hospitalization for a minimum of 24 hours with intravenous antibiotic therapy, a minimum 12-hour period of nothing to eat or drink, and observation. Patients were switched to oral antibiotics (for a total 10-day course) as soon as they were tolerating a regular diet.

Patients were enrolled between October 2012 and October 2013, and all shared similar demographic and clinical characteristics. Patients were between 7 and 17 years of age and had 48 hours or less of abdominal pain. Only patients with radiographic (ultrasound or computed tomography) evidence of nonruptured acute appendicitis, an appendiceal diameter 1.1 cm or less, and no evidence of phlegmon, abscess, or fecalith were eligible in the study.

Among the 30 children in the nonsurgery group, the immediate and 30-day success rates were 93% and 90%, respectively. Of the 3 treatment failures in this group, 2 patients underwent laparoscopic appendectomy during their initial hospitalization when they did not show sufficient improvement with intravenous antibiotics. The third child initially responded but was readmitted to the hospital with recurrent pain and also had a laparoscopic appendectomy.

Compared with patients in the surgical group, all of whom underwent laparoscopic appendectomy (n = 47), nonsurgical patients returned to school sooner (3 vs 5 days; P = .008), experienced fewer disability days (3 vs 17 days; P < .0001), and reported higher quality-of-life scores for the patient (93 vs 88; P = .01), as well as the parent (96 vs 90; P = .03).

"This study is the first prospective trial of a non-operative management strategy for acute appendicitis in the United States and is the first in children internationally," write Dr. Minneci and colleagues. The authors note that nonsurgical management of these cases has a high success rate and add that among patients who failed nonoperative management (n = 3), "there was no progression to rupture at the time of appendectomy."

"These results support non-operative management of appendicitis as a viable treatment option for children with acute appendicitis," they conclude.

Patients in the nonoperative group had longer hospital stays compared with patients in the surgical group (38 vs 20 hours; P < .0001); however, the authors note that patients undergoing nonoperative management will still require in-hospital monitoring for clinical changes that may warrant surgical intervention.

The authors acknowledge the possibility of selection bias in the study but note they attempted to control for this by using a scripted consenting process and limiting the number of enrolling physicians. A 1-year follow-up evaluation of the safety, success rate, and cost-effectiveness of a nonsurgical approach to uncomplicated appendicitis in children is planned.

Dr. Minneci and colleagues point out that results of this study are consistent with previously reported results in adults and note that nonoperative management of appendicitis is the initial therapy for adults in many European hospitals.

"A successful non-operative treatment strategy for early appendicitis can markedly decrease the number of appendectomies performed, thereby limiting the number of children and families exposed to the risks and stress associated with surgery," the authors write.

Funding for this study was provided by grants from the National Institutes of Health and intramural funding from the Research Institute at Nationwide Children's Hospital. The authors have disclosed no relevant financial relationships.

J Am Coll Surg. Published online April 12, 2014. Abstract

Twice-Daily Amoxicillin Effective in Children With Pneumonia

By David Douglas

April 11, 2014

NEW YORK (Reuters Health) - Twice-daily dosing of oral amoxicillin is as effective as a three-times-a-day approach in treating mild pediatric pneumonia, according to Brazilian researchers.

As Dr. Cristiana Nascimento-Carvalho told Reuters Health by email, "Amoxicillin may be given as a 25 mg/kg/dose twice a day to children with non-severe community-acquired pneumonia because it is not only efficacious but also safe."

Moreover, the results are generally applicable, she added, "because the patients included in this study are similar to patients who seek assistance worldwide."

In a March 19 online paper in the Journal of Antimicrobial Chemotherapy, Dr. Nascimento-Carvalho of the Bahia School of Medicine in Salvador and colleagues note that the standard amoxicillin outpatient thrice-daily regimen is uniformly successful. Fewer doses could mean higher compliance, but twice- and thrice-daily regimens have not been directly compared.

"Although the study was carried out in only one center in Brazil," Dr. Nascimento-Carvalho said, "820 patients were enrolled by applying very strict criteria to diagnose and classify pneumonia as well as its evolution."

In this placebo-controlled study, the children, aged two to 59 months, were randomized to oral amoxicillin 50 mg/kg/day given twice daily or three times daily (at 16.7 mg/kg/dose). They were followed up at two, five, and 14 days.

In intention-to-treat analysis, treatment failure was seen in 23.0% of the twice-daily and 22.8% of the thrice-daily group. Corresponding proportions in per-protocol analysis were 21.3% and 20.1%. Tachypnea, fever, and wheezing were independent predictors of failure and the researchers note that such patients "should be followed up closely."

Pneumonia was radiologically confirmed in 277 (33.8%) patients. Of these, treatment failure was seen in 18.8% of both twice- and thrice-daily groups.

Severe adverse events were rare and "discontinuation was not necessary in the great majority of patients." Diarrhea was the most frequent reaction.

Dr. Nascimento-Carvalho pointed out that although a multicenter approach would have led to faster enrollment of an adequate number of patients, "The fact that the study was conducted in one single center adds the advantage that the procedures for enrolling and following-up the patients were more easily checked for quality control."

In such patients the twice-daily approach is all that's needed, she and her colleagues conclude. "Higher amounts of amoxicillin are unnecessary and money may be saved."

Commenting on the findings, Dr. Zulfiqar A. Bhutta told Reuters Health by email that they "are not surprising given that we know that short course therapy of non-severe pneumonia for two days is as effective as a five-day course."

"The bigger issue with antibiotic therapy for non-severe pneumonia is if antibiotic therapy is required at all," added Dr. Bhutta, of the University of Toronto. "There are preliminary studies now showing that the outcomes in non-severe pneumonia are not affected by antibiotic therapy, given that current diagnostic criteria are unable to distinguish viral and bacterial infections and the issue needs to be resolved with larger trials in representative settings."

Celiac Disease Screening Should Focus on Kids With IBS

Marcia Frellick

April 21, 2014

Children with irritable bowel syndrome (IBS) were 4 times more likely to have celiac disease than the general pediatric population, researchers report in a study published online April 21 in JAMA Pediatrics. According to the findings from the prospective study, screening should focus on children with IBS instead of generally among children reporting recurrent abdominal pain, the authors advise.

Previous studies of adults have shown a strong link between celiac disease and IBS, but few data were available on children.

Fernanda Cristofori, MD, from the University of Bari, Italy, and colleagues note that recurrent abdominal pain affects 10% to 15% of school-aged children and accounts for more than 50% of the consultations in pediatric gastroenterology and 2% to 4% of all general pediatric office visits.

To estimate the prevalence of celiac disease in children with recurrent abdominal pain, the researchers tested 782 children who presented with abdominal, pain-related disorders: 270 with IBS, 201 with functional dyspepsia, and 311 with functional abdominal pain.

The prospective observational study was conducted between 2006 and 2012 at the university hospital of Bari, which is the tertiary referral center for gastrointestinal disorders in the region. The researchers used serum tests for immunoglobulin A, immunoglobulin A antitissue transglutaminase, and endomysial antibodies as an initial screen for celiac disease and confirmed the diagnosis with upper endoscopy, including multiple duodenal biopsies.

Fifteen patients tested positive for celiac: 12 (4.4%; 95% confidence interval [CI], 2.5% - 7.6%) of the children with IBS, 2 (1.0%; 95% CI, 0.2% - 3.5%) of those with functional dyspepsia, and 1 (0.3%; 95% CI, 0.1% - 1.7%) of the children with functional abdominal pain.

"The identification of IBS as a high-risk condition for celiac disease might be of help in pediatric primary care because it might have become routine to test for celiac disease indiscriminately in all children with recurrent abdominal pain, although our finding suggests that the screening should be extended only to those with IBS," the authors write.

In an accompanying editorial, James E. Squires, MD, from the Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center in Ohio, and colleagues write: "Based on the study by Cristofori et al, we suggest that selective screening for celiac disease is warranted for children with IBS but not for children with other [functional gastrointestinal disorders (FGIDs)]. However, the lines distinguishing IBS from alternative FGIDs are often blurred."

Noting that the blood tests have a relatively high false-positive rate in the general pediatric population, the researchers recommend that pediatricians weigh the possible benefits against the risks, including endoscopy, and consider environmental factors in decisions to screen.

This study was sponsored by the Commonwealth Fund and Aetna. The authors have disclosed no relevant financial relationships.

Breast-fed Newborns: How Much Weight Loss Is Normal?

Diedtra Henderson

December 01, 2014

Exclusively breast-fed newborns typically lost as much as 10% or more of their birth weight before beginning to gain again in the first days after birth, according to a recent study. By 48 hours, almost 5% of babies born vaginally and 10% of those born by cesarean delivery lost at least 10% of their birth weight. By 72 hours, 25% of cesarean delivered infants lost at least 10% of their birth weight. These metrics may help identify babies with steeper weight loss trajectories that could increase morbidity risk.

Valerie J. Flaherman, MD, MPH, from the Department of Pediatrics and the Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, and colleagues report the findings of their study in an article published online December 1 in Pediatrics.

According to the authors, 60% of newborns in the United States are breast-fed exclusively in the first 2 days after birth, in keeping with recommendations from a number of expert organizations, including the American Academy of Pediatrics. Most of those infants lose weight daily, but a small number of infants suffer complications from excessive weight loss, including hyperbilirubinemia and dehydration.

"These results provide the first graphical depiction of hourly weight loss for exclusively breastfed newborns from a large, diverse population," Dr Flaherman and coauthors write. "Because weight changes steadily throughout the birth hospitalization and is measured at varied intervals from the hour of birth, these new nomograms should substantially aid medical management by allowing clinicians and lactation support providers to categorize newborn weight loss and calibrate decision-making to reflect hour of age."

The authors note that hour-by-hour bilirubin levels, tracked to guard against jaundice, have been incorporated into practice guidelines. To provide a similar type of nomogram for neonate weight loss in exclusively breast-fed newborns, Dr Flaherman and coauthors studied data from 108,907 newborns born at 36 weeks' gestation at Northern California Kaiser Permanente hospitals from January 1, 2009, through December 31, 2013.

Some 83,433 (76.6%) of the neonates were delivered vaginally, whereas 25,474 (23.4%) were born by cesarean delivery. For the 97.3% of mothers who had race or ethnicity noted, 43% were white non-Hispanic, 24% were Hispanic, 24% were Asian, and 7% were black non-Hispanic.

The researchers excluded infants who had received level 2 or 3 care and infants whose steep weight gain or loss was "implausible." Because infants delivered vaginally are hospitalized for shorter periods, they determined weight loss percentile from 6 to 72 hours compared with 6 to 96 hours for cesarean births.

Weight loss differences by delivery type were clear within 24 hours of birth, the authors write. Neonates delivered vaginally experienced a median weight loss of 4.2%, 7.1%, and 6.4%, respectively, at 24, 48, and 72 hours of age. That compared with median weight loss among infants born by cesarean delivery of 4.9%, 8.0%, 8.6%, and 5.8%, respectively, at 24, 48, 72, and 96 hours after delivery.

In an accompanying editorial, James A. Taylor, MD, and Elizabeth A. Simpson, MD, applauded the researchers for their "elegant methodology" and for providing "much needed data" to help provide instruction to the 79% of mothers who now breast-feed and to clinicians managing complications.

"With the nomograms, clinicians can plot the percent weight loss for a neonate at a specific age and determine, with precision, whether this percentage is normal for a breastfed newborn (eg, at the 50th percentile) or excessive (eg, ≥95th percentile). Although these assessments have been done informally for many years in newborn nurseries, the new nomograms provide much-needed rigor," the editorialists write.

Dr Taylor, from the University of Washington Department of Pediatrics, Seattle, and Dr Simpson, from the Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, call the weight loss seen among infants delivered by cesarean "jarring" but suggest that infants delivered vaginally also continued to shed weight postdischarge, when weight loss data were not collected systematically. Although they call the project a good first step, they call for strengthening the evidence base by using the nomograms "to characterize weight loss in a group of newborns and link specific patterns of weight loss with relevant outcomes."

Dr Flaherman and colleagues conclude by saying their "curves demonstrate that expected weight loss differs substantially by method of delivery and that this difference persists over time. Our results also show that weight loss ≥10% of birth weight is common and often occurs earlier in the postnatal course than previously documented."

Financial support for the study was provided by the Department of Health and Human Services and the National Institutes of Health. The study authors and the commentators have disclosed no relevant financial relationships.

Pediatrics. Published online December 1, 2014.

 

Medscape Medical News © 2014  WebMD, LLC 

Sodium Intake Tied to Obesity Among Teens

By Shereen Jegtvig

February 05, 2014

NEW YORK (Reuters Health) - Teenagers who eat a high-sodium diet tend to be heavier and have more body fat than those who eat less salt, according to a new study.

Researchers found that was the case regardless of how much total food teenagers ate or how often they drank sugary beverages.

Dietary sodium has been linked to obesity in previous studies. But most scientists believe it's only an indirect association, because people who consume a lot of sodium tend to eat more food in general.

"Our study and studies looking into national data all show that average dietary sodium consumed is 3,300-3,400 milligrams daily in children, as high as that of adults," Dr. Haidong Zhu told Reuters Health in an email. She led the new study at Georgia Regents University in Augusta.

The American Heart Association recommends that everyone keep sodium intake to less than 1,500 mg per day, but 90 percent of children exceed that amount, Zhu noted.

For their study, she and her colleagues measured the body composition of 766 healthy 14- to 18-year-olds. About half of the teens were African American and the other half were white.

The researchers also collected diet information from the participants by asking them to remember everything they had eaten in the past 24 hours up to seven different times over a few months. On average, the teens consumed about 3,280 mg of sodium every day.

Kids who ate more sodium tended to be heavier. Those in the top third of sodium intake weighed approximately four pounds more than those in the bottom third, on average - about 149 pounds versus 145 pounds.

Teens with a high-sodium diet also generally had a higher percentage of body fat and showed more signs of body-wide inflammation.

Those associations held up when the researchers took into account teens' physical activity levels as well as how much food they ate and how many sugar-sweetened beverages they drank, according to the findings published February 3 in Pediatrics.

Although the study links sodium intake to inflammation and weight regardless of calories and soft drink consumption, Zhu said, it doesn't explain why.

"Animal studies suggest that diets high in salt promote fat cells to grow bigger," Zhu said.

She added that high-salt diets might stimulate the brain's reward and pleasure center, which increases the chance of overeating and obesity.

"More research in humans is needed," Zhu said.

"This study suggests that limiting sodium intake will help reduce obesity - we already know that limiting sodium intake helps reduce high blood pressure," Dr. Elliott Antman told Reuters Health in an email.

"It reinforces the fact that our population - children and adults - consumes too much sodium in the course of a day," he added.

Antman is a cardiologist at Brigham and Women's Hospital in Boston and president-elect of the American Heart Association. He was not involved in the new study.

He commended the authors for enrolling a large number of African-American adolescents. African Americans tend to have higher risk of obesity, type 2 diabetes and high blood pressure than the general population.

Antman advised parents to be careful about how much sodium their children are getting.

"Taste preferences for salt appear to be formed early in life. Therefore, parents should worry about their kids' sodium intake since healthy dietary habits learned in childhood are carried forward to adulthood," he said.

Parents should read nutrition labels at the supermarket to shop wisely for the foods they feed their children, Antman added.

"Parents should also emphasize eating at home rather than eating at restaurants or fast food chains. Using spices rather than salt may help reduce the amount sodium their children eat," he said.

Zhu noted that more than 75 percent of consumed sodium comes from processed foods and fast food.

"This is why establishing a healthy food habit in early childhood is so important," she said. "People should eat less processed foods (and) fast food and eat more fresh fruits and vegetables."

SOURCE: http://bit.ly/1et1FpN

Pediatrics 2014.