The Food and Drug Administration's deliberations on antidepressant use in pediatric patients

On February 2, 2004, the Food and Drug Administration organized a joint meeting of the Neuro-Psychopharmacologic Advisory Committee and Pediatric Subcommittee of the Anti-Infective Drugs Advisory Committee to examine the occurrence of suicidality in clinical trials that investigate the use of the newer antidepressant drugs in pediatric patients. Committee members reconvened on September 13-14, 2004, and concluded that there was a causal link between the newer antidepressants and pediatric suicidality. This article provides a summary of the Food and Drug Administration deliberations for the pediatric clinician. We also provide research, regulation, education, and practice implications for care for children and adolescents who may be eligible for treatment with these medications.

Low-level environmental lead exposure and children's intellectual function: an international pooled analysis

Lead is a confirmed neurotoxin, but questions remain about lead-associated intellectual deficits at blood lead levels < 10 microg/dL and whether lower exposures are, for a given change in exposure, associated with greater deficits. The objective of this study was to examine the association of intelligence test scores and blood lead concentration, especially for children who had maximal measured blood lead levels < 10 microg/dL. We examined data collected from 1,333 children who participated in seven international population-based longitudinal cohort studies, followed from birth or infancy until 5-10 years of age. The full-scale IQ score was the primary outcome measure. The geometric mean blood lead concentration of the children peaked at 17.8 microg/dL and declined to 9.4 microg/dL by 5-7 years of age; 244 (18%) children had a maximal blood lead concentration < 10 microg/dL, and 103 (8%) had a maximal blood lead concentration < 7.5 microg/dL. After adjustment for covariates, we found an inverse relationship between blood lead concentration and IQ score. Using a log-linear model, we found a 6.9 IQ point decrement [95% confidence interval (CI), 4.2-9.4] associated with an increase in concurrent blood lead levels from 2.4 to 30 microg/dL. The estimated IQ point decrements associated with an increase in blood lead from 2.4 to 10 microg/dL, 10 to 20 microg/dL, and 20 to 30 microg/dL were 3.9 (95% CI, 2.4-5.3), 1.9 (95% CI, 1.2-2.6), and 1.1 (95% CI, 0.7-1.5), respectively. For a given increase in blood lead, the lead-associated intellectual decrement for children with a maximal blood lead level < 7.5 microg/dL was significantly greater than that observed for those with a maximal blood lead level > or = 7.5 microg/dL (p = 0.015). We conclude that environmental lead exposure in children who have maximal blood lead levels < 7.5 microg/dL is associated with intellectual deficits.

Preschoolers' physical activity behaviours: parents' perspectives

OBJECTIVES

To understand parents' perspectives of their preschoolers' physical activity behaviours.

METHODS

A maximum variation sample of 71 parents explored their preschoolers' physical activity behaviours through 10 semi-structured focus group discussions.

RESULTS

Parents perceived Canada's Physical Activity Guidelines for Children as inadequate; that their preschoolers get and need more than 30-90 minutes of activity daily; and that physical activity habits must be established during the preschool years. Nine barriers against and facilitators toward adequate physical activity were proposed: child's age, weather, daycare, siblings, finances, time, society and safety, parents' impact, and child's activity preferences.

DISCUSSION

The need for education and interventions that address current barriers are essential for establishing physical activity as a lifestyle behaviour during early childhood and, consequently, helping to prevent both childhood and adulthood obesity.

Prediction of drug disposition in infants and children by means of physiologically based pharmacokinetic (PBPK) modelling: theophylline and midazolam as model drugs

AIMS

To create a general physiologically based pharmacokinetic (PBPK) model for drug disposition in infants and children, covering the age range from birth to adulthood, and to evaluate it with theophylline and midazolam as model drugs.

METHODS

Physiological data for neonates, 0.5-, 1-, 2-, 5-, 10- and 15-year-old children, and adults, of both sexes were compiled from the literature. The data comprised body weight and surface area, organ weights, vascular and interstitial spaces, extracellular body water, organ blood flows, cardiac output and glomerular filtration rate. Tissue: plasma partition coefficients were calculated from rat data and unbound fraction (f u) of the drug in human plasma, and age-related changes in unbound intrinsic hepatic clearance were estimated from CYP1A2 and CYP2E1 (theophylline) and CYP3A4 (midazolam) activities in vitro. Volume of distribution (V dss), total and renal clearance (CL and CL R) and elimination half-life (t(1/2)) were estimated by PBPK modelling, as functions of age, and compared with literature data.

RESULTS

The predicted V dss of theophylline was 0.4-0.6 l kg(-1) and showed only a modest change with age. The median prediction error (MPE) compared with literature data was 3.4%. Predicted total CL demonstrated the time-course generally reported in the literature. It was 20 ml h(-1) kg(-1) in the neonate, rising to 73 ml h(-1) kg(-1) at 5 years and then decreasing to 48 ml h(-1) kg(-1) in the adult. Overall, the MPE was - 4.0%. Predicted t(1/2) was 18 h in the neonate, dropping rapidly to 4.6-7.2 h from 6 months onwards, and the MPE was 24%. The predictions for midazolam were also in good agreement with literature data. V dss ranged between 1.0 and 1.7 l kg(-1) and showed only modest change with age. CL was 124 ml h(-1) kg(-1) in the neonate and peaked at 664 ml h(-1) kg(-1) at 5 years before decreasing to 425 ml h(-1) kg(-1) in the adult. Predicted t(1/2) was 6.9 h in the neonate and attained 'adult' values of 2.5-3.5 h from 1 year onwards.

CONCLUSIONS

A general PBPK model for the prediction of drug disposition over the age range neonate to young adult is presented. A reference source of physiological data was compiled and validated as far as possible. Since studies of pharmacokinetics in children present obvious practical and ethical difficulties, one aim of the work was to utilize maximally already available data. Prediction of the disposition of theophylline and midazolam, two model drugs with dissimilar physicochemical and pharmacokinetic characteristics, yielded results that generally tallied with literature data. Future use of the model may demonstrate further its strengths and weaknesses.

Hepatitis C virus (HCV) genotypes in 373 Italian children with HCV infection: changing distribution and correlation with clinical features and outcome

BACKGROUND AND AIMS

Little is known of hepatitis C virus (HCV) genotypes in HCV infected children. This retrospective, multicentre study investigated genotype distribution and correlation with clinical features and outcome in a large series of Italian children.

METHODS

Between 1990 and 2002, 373 HCV RNA positive children, consecutively recruited in 15 centres, were assayed for genotypes by a commercial line probe assay.

RESULTS

The following genotype distribution pattern was recorded: genotype 1b = 41%; 1a = 20%; 2 = 17%; 3 = 14.5%; 4 = 5%; other = 2.5%. The prevalence of genotypes 1b and 2 decreased significantly (p<0.001) among children born from 1990 onwards compared with older children (46% v 70%) while the rate of genotypes 3 and 4 increased significantly (from 8% to 30%). Children infected with genotype 3 had the highest alanine aminotransferase levels and the highest rate of spontaneous viraemia clearance within the first three years of life (32% v 3% in children with genotype 1; p<0.001). Of 96 children enrolled in interferon trials during the survey, 22% definitely lost HCV RNA, including 57% of those with genotypes 2 and 3.

CONCLUSION

HCV genotypes 1 and 2 are still prevalent among infected adolescents and young adults in Italy but rates of infection with genotypes 3 and 4 are rapidly increasing among children. These changes could modify the clinical pattern of hepatitis C in forthcoming years as children infected with genotype 3 have the best chance of spontaneous viraemia clearance early in life, and respond to interferon in a high proportion of cases.

Interpretation of tuberculin skin-test results in the diagnosis of tuberculosis in children

INTRODUCTION

The tuberculin skin test is one of the most valuable tests for demonstrating tuberculous infection in both symptomatic and asymptomatic children. However, its application is often undermined by difficulties in interpretation of results arising from its low sensitivity and specificity.

OBJECTIVES

This review aimed to use the concept of induration distribution analysis to estimate the induration size demarcating positive from negative results in a group of children with suspected tuberculosis, and to compare this cut-off with available guidelines for interpretation of the Mantoux test in the diagnosis of tuberculosis in children.

METHODS

The results of Mantoux tests of children presenting with suspected tuberculosis over a 12-month period were retrospectively reviewed and plotted on a frequency distribution curve. The distribution was used to define a demarcation between positive and negative reactions. The resultant cut-off was compared with currently published guidelines for interpretation of the Mantoux test.

RESULTS

Two hundred (200) Mantoux results were analysed out of 202 records reviewed. Induration sizes ranged from 0 to 60 mm, with a mean of 9.4 mm. The induration distribution showed a bimodal pattern, with 103 patients showing no reaction (0 mm), and 96 (48%) patients with an induration size of (3) 5 mm, with the second mode at 15-19 mm. The demarcating antimode was at 5 mm.

CONCLUSIONS

The induration distribution showed that a cut-off induration size of 5 mm was appropriate for this group of patients. This was in agreement with currently published guidelines for the interpretation of the Mantoux test in the diagnosis of tuberculosis in children.

Complementary and Alternative Medicine Approaches for Pediatric Pain: A Review of the State-of-the-science

In recent years, the use of complementary and alternative medicine (CAM) in pediatric populations has increased considerably, especially for chronic conditions such as cancer, rheumatoid arthritis and cystic fibrosis in which pain may be a significant problem. Despite the growing popularity of CAM approaches for pediatric pain, questions regarding the efficacy of these interventions remain. This review critically evaluates the existing empirical evidence for the efficacy of CAM interventions for pain symptoms in children. CAM modalities that possess a published literature, including controlled trials and/or multiple baseline studies, that focused on either chronic or acute, procedural pain were included in this review. The efficacy of the CAM interventions was evaluated according to the framework developed by the American Psychological Association (APA) Division 12 Task Force on Promotion and Dissemination of Psychological Procedures. According to these criteria, only one CAM approach reviewed herein (self-hypnosis/guided imagery/relaxation for recurrent pediatric headache) qualified as an empirically supported therapy (EST), although many may be considered possibly efficacious or promising treatments for pediatric pain. Several methodological limitations of the existing literature on CAM interventions for pain problems in children are highlighted and future avenues for research are outlined.

Health-related quality of life measurement in pediatric clinical practice: an appraisal and precept for future research and application

Health-related quality of life (HRQOL) measurement has emerged as an important health outcome in clinical trials, clinical practice improvement strategies, and healthcare services research and evaluation. HRQOL measures are also increasingly proposed for use in clinical practice settings to inform treatment decisions. In settings where HRQOL measures have been utilized with adults, physicians report such measures as useful, some physicians alter their treatment based on patient reports on such instruments, and patients themselves generally feel the instruments to be helpful. However, there is a dearth of studies evaluating the clinical utility of HRQOL measurement in pediatric clinical practice. This paper provides an updated review of the literature and proposes a precept governing the application of pediatric HRQOL measurement in pediatric clinical practice. Utilizing HRQOL measurement in pediatric healthcare settings can facilitate patient-physician communication, improve patient/parent satisfaction, identify hidden morbidities, and assist in clinical decision-making. Demonstrating the utility of pediatric HRQOL measurement in identifying children with the greatest needs, while simultaneously demonstrating the cost advantages of providing timely, targeted interventions to address those needs, may ultimately provide the driving force for incorporating HRQOL measurement in pediatric clinical practice.

Jack Tizard Lecture: Cognitive Behaviour Therapies for Children: Passing Fashion or Here to Stay?

The aim of this article is to consider the current and likely future status of cognitive behaviour therapy (CBT) for disturbed children and adolescents. Two definitions of CBT, narrow and broad, are provided and their core components described. Subsequently the historical development of these therapies and their reception by psychotherapists with different orientations is discussed. Assessment and therapeutic CBT approaches are described and the strength of the evidence for their use is briefly reviewed. Finally the challenges these therapies are currently meeting that might enhance or diminish their value are outlined. It is concluded that CBTs offer a most promising approach in the child and adolescent field and are likely to establish and maintain an important place in the therapeutic armoury of the next generation of professionals concerned to help children and young people with psychiatric disorders.

Acute respiratory diseases and carboxyhemoglobin status in school children of Quito, Ecuador

Outdoor carbon monoxide comes mainly from vehicular emissions, and high concentrations occur in areas with heavy traffic congestion. CO binds to hemoglobin, forming carboxyhemoglobin (COHb), and reduces oxygen delivery. We investigated the link between the adverse effects of CO on the respiratory system using COHb as a marker for chronic CO exposure. We examined the relationship between acute respiratory infections (ARIs) and COHb concentrations in school-age children living in urban and suburban areas of Quito, Ecuador. We selected three schools located in areas with different traffic intensities and enrolled 960 children. To adjust for potential confounders we conducted a detailed survey. In a random subsample of 295 children, we determined that average COHb concentrations were significantly higher in children attending schools in areas with high and moderate traffic, compared with the low-traffic area. The percentage of children with COHb concentrations above the safe level of 2.5% were 1, 43, and 92% in low-, moderate-, and high-traffic areas, respectively. Children with COHb above the safe level are 3.25 [95% confidence interval (CI), 1.65-6.38] times more likely to have ARI than children with COHb < 2.5%. Furthermore, with each percent increase in COHb above the safety level, children are 1.15 (95% CI, 1.03-1.28) times more likely to have an additional case of ARI. Our findings provide strong evidence of the relation between CO exposure and susceptibility to respiratory infections.

Interstitial lung disease in children -- genetic background and associated phenotypes

Interstitial lung disease in children represents a group of rare chronic respiratory disorders. There is growing evidence that mutations in the surfactant protein C gene play a role in the pathogenesis of certain forms of pediatric interstitial lung disease. Recently, mutations in the ABCA3 transporter were found as an underlying cause of fatal respiratory failure in neonates without surfactant protein B deficiency. Especially in familiar cases or in children of consanguineous parents, genetic diagnosis provides an useful tool to identify the underlying etiology of interstitial lung disease. The aim of this review is to summarize and to describe in detail the clinical features of hereditary interstitial lung disease in children. The knowledge of gene variants and associated phenotypes is crucial to identify relevant patients in clinical practice.

Variation in organophosphate pesticide metabolites in urine of children living in agricultural communities

Children of migrant farmworkers are at increased risk of exposure to organophosphate pesticides because of "carry-home" transport processes and residential location. Although this at-risk status is generally recognized, few available reports describe the extent of this exposure among agricultural communities. We quantified dialkyl phosphate (DAP) levels in serial samples of urine from 176 children, 2-6 years of age, in three Oregon communities hosting differing agricultural industries: pears, cherries, and fruit berries. Up to three spot samples of urine were collected from children at the beginning, mid-point, and end of their parents' work seasons. The median levels of dimethylthiophosphate (DMTP), the most commonly detected metabolite, was significantly higher in urine samples from children in each of the three agricultural communities (17.5, 19.0, and 41.0 ng/mL) relative to a reference group of children who lived in an urban community and whose parents did not work in agriculture (6.5 ng/mL; Kruskal-Wallis, p < 0.001). After controlling for age, sex, and weight, the median level of DMTP in children in the pear community was 1.92 times higher than the level in children of the berry community [95% confidence interval (CI), 1.14-3.23] and 1.75 times higher than the level in children of the cherry community (95% CI, 0.95-3.23). We observed increasing levels of DMTP across the work season only within the berry community. Levels decreased in the cherry community and remained constant in the pear community. Substantial temporal variation within the children followed demonstrates the need for multiple urine samples to most accurately characterize longer term and/or cumulative exposure. The observed variability in urinary DAP levels, between communities and over time, could be attributed to the types and amounts of organophosphate pesticides used, the timing of applications and degradation of residues in the environment, work operations and hygiene practices, the proximity of housing to orchards and fields, or the movement of these working families. Additional studies of variation in pesticide exposure across agricultural regions are needed.

Psychological aspects of risk appraisal in asphyxiation accidents: a review of the factors influencing children's perception and behaviour

Psychological aspects determining children's behaviour in response to asphyxiation risk due to ingestion of foreign matter have been rarely and non-systematically examined in the literature. Aim of this report is to highlight--through a review of the most significant psychological research in the literature--which factors influence the behaviour, perception and assessments of children 0 to 14 years of age, in a risk situation. In particular, attention is focused on the direct experience of a child at risk, assuming that this experience can play a significant role in future dangerous situations. Outcomes of studies taken into consideration have highlighted the influence of age, sex, socio-economic status, parents' role, peer group, personal traits, television and personal experience. The latter refutes the initial hypotheses, showing an unexpected and clearly negative effect on future evaluation and behaviour in response to similar contexts of asphyxiation risk. The implications for research on asphyxiation due to ingestion of foreign matter are examined.

Blepharokeratoconjunctivitis in children: diagnosis and treatment

AIM

Blepharokeratoconjunctivitis (BKC) is a poorly described entity in children. This study characterises this syndrome in childhood and evaluates epidemiology, clinical grading, and treatment strategies.

METHODS

44 children (20 white, 22 Asian, 2 Middle Eastern, median age 5.4 (range 1-14) years) with a diagnosis of BKC were followed for a median of 7 years. Diagnostic criteria included recurrent episodes of chronic red eye, watering, photophobia, blepharitis including recurrent styes or meibomian cysts, and a keratitis. Clinical features were graded as mild, moderate, or severe. The lids and conjunctiva were cultured. The treatment regimen incorporated lid hygiene, topical and/or systemic antibiotics, and topical corticosteroids.

RESULTS

The disease was most severe in the Asian and Middle Eastern children (p <0.001), who had a statistically higher risk of subepithelial punctate keratitis (p = 0.008), corneal vascularisation (p <0.001), and marginal corneal ulcerations (p = 0.003), than the white group. 15 children had culture positive lid swabs. Most children had a reduction in symptoms and signs with treatment, and progression of disease after the age of 8 was rare.

CONCLUSIONS

BKC in children can be defined as "a syndrome usually associated with anterior or posterior lid margin blepharitis, accompanied by episodes of conjunctivitis, and a keratopathy including punctate erosions, punctate keratitis, phlyctenules, marginal keratitis, and ulceration." BKC is common in children in a tertiary referral corneal and external diseases clinic, with the more severe manifestations in the Asian and Middle Eastern populations. Therapy is effective and loss of sight can be prevented in most cases.

Environmental risk factors in paediatric inflammatory bowel diseases: a population based case control study

BACKGROUND

Environmental exposures in early life have been implicated in the aetiology of inflammatory bowel disease.

OBJECTIVE

To examine environmental risk factors prior to the development of inflammatory bowel disease in a paediatric population based case control study.

METHODS

A total of 222 incident cases of Crohn's disease and 60 incident cases of ulcerative colitis occurring before 17 years of age between January 1988 and December 1997 were matched with one control subject by sex, age, and geographical location. We recorded 140 study variables in a questionnaire that covered familial history of inflammatory bowel disease, events during the perinatal period, infant and child diet, vaccinations and childhood diseases, household amenities, and the family's socioeconomic status.

RESULTS

In a multivariate model, familial history of inflammatory bowel disease (odds ratio (OR) 4.3 (95% confidence interval 2.3-8)), breast feeding (OR 2.1 (1.3-3.4)), bacille Calmette-Guerin vaccination (OR 3.6 (1.1-11.9)), and history of eczema (OR 2.1 (1-4.5)) were significant risk factors for Crohn's disease whereas regular drinking of tap water was a protective factor (OR 0.56 (0.3-1)). Familial history of inflammatory bowel disease (OR 12.5 (2.2-71.4)), disease during pregnancy (OR 8.9 (1.5-52)), and bedroom sharing (OR 7.1 (1.9-27.4)) were risk factors for ulcerative colitis whereas appendicectomy was a protective factor (OR 0.06 (0.01-0.36)).

CONCLUSIONS

While family history and appendicectomy are known risk factors, changes in risk based on domestic promiscuity, certain vaccinations, and dietary factors may provide new aetiological clues.

Asthma and farm exposures in a cohort of rural Iowa children

Epidemiologic studies of farm children are of international interest because farm children are less often atopic, have less allergic disease, and often have less asthma than do nonfarm children--findings consistent with the hygiene hypothesis. We studied a cohort of rural Iowa children to determine the association between farm and other environmental risk factors with four asthma outcomes: doctor-diagnosed asthma, doctor-diagnosed asthma/medication for wheeze, current wheeze, and cough with exercise. Doctor-diagnosed asthma prevalence was 12%, but at least one of these four health outcomes was found in more than a third of the cohort. Multivariable models of the four health outcomes found independent associations between male sex (three asthma outcomes), age (three asthma outcomes), a personal history of allergies (four asthma outcomes), family history of allergic disease (two asthma outcomes), premature birth (one asthma outcome), early respiratory infection (three asthma outcomes), high-risk birth (two asthma outcomes), and farm exposure to raising swine and adding antibiotics to feed (two asthma outcomes). The high prevalence of rural childhood asthma and asthma symptoms underscores the need for asthma screening programs and improved asthma diagnosis and treatment. The high prevalence of asthma health outcomes among farm children living on farms that raise swine (44.1%, p = 0.01) and raise swine and add antibiotics to feed (55.8%, p = 0.013), despite lower rates of atopy and personal histories of allergy, suggests the need for awareness and prevention measures and more population-based studies to further assess environmental and genetic determinants of asthma among farm children.

Childhood inflammatory bowel disease: parental concerns and expectations

AIM

To document the concerns and expectations of parents of children with inflammatory bowel disease (IBD) within the context of a multidisciplinary IBD clinic, and to highlight the importance of a holistic approach to the care of these children.

METHODS

The parents of 60 children with IBD were surveyed by mailed questionnaire. Parents were asked to provide details of their concerns regarding their child's condition and to express their expectations of medical care. In addition, enquiry was made in respect to the respondents' learning about IBD.

RESULTS

Forty-six questionnaires (77%) returned. Fifty-two percent of the patients were male. Patients were aged a mean of 10.9 (+/-4.1) years and diagnosed at an average age of 2.1 (+/-1.8) years previously. The most common concerns expressed by the parents related to the side- effects of medications and the future prospects for their child. Overall, parents were satisfied with aspects of care within the IBD clinic but many suggested additional personnel such as counselors or educators should be available. Parents also reported the need for continuing education and easy access to up-to-date information.

CONCLUSION

Parents of children and adolescents with IBD have many common concerns regarding their child's condition. On-going attention to holistic care, including psychosocial and educational elements for patients and families, is appropriate in the context of the chronic and unpredictable nature of IBD.

[Assessment of the risk of type 1 diabetes mellitus in children with borderline fasting hyperglycemia by determining islet-cell autoantibodies]

The role of borderline fasting hyperglycemia (BFHG) as a risk factor of type 1 diabetes mellitus was studied in children without a family history of diabetes. A prospective study included 19 children (mean age 10.31±4.53 years; M±σ) with BFHG and 69 children without glucose exchange impairments (mean age 10.78±3.47years). Islet-cell autoantibodies (ICAs) were determined once at the beginning of the study. The three-year cumulative risk of type 1 diabetes mellitus in children without glucose metabolic disorders and in those with BFHG who had no ICAs was equal to zero and that in children with BFHG and ICAs was 100%. It has been established that the presence of ICAs in children with BFHG points to the preclinical period of type 1 diabetes mellitus. It is recommended that ICAs and other markers of autoimmune β-cell destruction should be studied in all children with BFHG. When these markers are detected, it is necessary to make preventive measures aimed at suppressing the progression of the disease and at preventing its sudden manifestation.

Mapping brain development and aggression

INTRODUCTION

This article provides an overview of the basic principles guiding research on brain-behaviour relationships in general, and as applied to studies of aggression during human development in particular.

METHOD

Key literature on magnetic resonance imaging of the structure and function of a developing brain was reviewed.

RESULTS

The article begins with a brief introduction to the methodology of techniques used to map the developing brain, with a special emphasis on magnetic resonance imaging (MRI). It then reviews briefly the current knowledge of structural maturation, assessed by MRI, of the human brain during childhood and adolescence. The last part describes some of the results of neuroimaging studies aimed at identifying neural circuits involved in various aspects of aggression and social cognition.

CONCLUSION

The article concludes by discussing the potential and limitations of the neuroimaging approach in this field.

Genetic and environmental determinants of bitter perception and sweet preferences

OBJECTIVE

Flavor is the primary dimension by which young children determine food acceptance. However, children are not merely miniature adults because sensory systems mature postnatally and their responses to certain tastes differ markedly from adults. Among these differences are heightened preferences for sweet-tasting and greater rejection of bitter-tasting foods. The present study tests the hypothesis that genetic variations in the newly discovered TAS2R38 taste gene as well as cultural differences are associated with differences in sensitivity to the bitter taste of propylthiouracil (PROP) and preferences for sucrose and sweet-tasting foods and beverages in children and adults.

DESIGN

Genomic DNA was extracted from cheek cells of a racially and ethnically diverse sample of 143 children and their mothers. Alleles of the gene TAS2R38 were genotyped. Participants were grouped by the first variant site, denoted A49P, because the allele predicts a change from the amino acid alanine (A) to proline (P) at position 49. Henceforth, individuals who were homozygous for the bitter-insensitive allele are referred to as AA, those who were heterozygous for the bitter-insensitive allele are referred to as AP, and those who were homozygous for the bitter-sensitive allele are referred to as PP. Using identical procedures for children and mothers, PROP sensitivity and sucrose preferences were assessed by using forced-choice procedures that were embedded in the context of games that minimized the impact of language development and were sensitive to the cognitive limitations of pediatric populations. Participants were also asked about their preferences in cereals and beverages, and mothers completed a standardized questionnaire that measured various dimensions of their children's temperament.

RESULTS

Genetic variation of the A49P allele influenced bitter perception in children and adults. However, the phenotype-genotype relationship was modified by age such that 64% of heterozygous children, but only 43% of the heterozygous mothers, were sensitive to the lowest concentration (56 micromoles/liter) of PROP. Genotypes at the TAS2R38 locus were significantly related to preferences for sucrose and for sweet-tasting beverages and foods such as cereals in children. AP and PP children preferred significantly higher concentrations of sucrose solutions than did AA children. They were also significantly less likely to include milk or water as 1 of their 2 favorite beverages (18.6% vs 40%) and were more likely to include carbonated beverages as 1 of their most preferred beverages (46.4% vs 28.9%). PP children liked cereals and beverages with a significantly higher sugar content. There were also significant main effects of race/ethnicity on preferences and food habits. As a group, black children liked cereals with a significantly higher sugar content than did white children, and they were also significantly more likely to report that they added sugar to their cereals. Unlike children, there was no correspondence between TAS2R38 genotypes and sweet preference in adults. Here, the effects of race/ethnicity were the strongest determinants, thus suggesting that cultural forces and experience may override this genotype effect on sweet preferences. Differences in taste experiences also affected mother-child interaction, especially when the 2 resided in different sensory worlds. That is, children who had 1 or 2 bitter-sensitive alleles, but whose mothers had none, were perceived by their mothers as being more emotional than children who had no bitter-sensitive alleles.

CONCLUSION

Variations in a taste receptor gene accounted for a major portion of individual differences in PROP bitterness perception in both children and adults, as well as a portion of individual differences in preferences for sweet flavors in children but not in adults. These findings underscore the advantages of studying genotype effects on behavioral outcomes in children, especially as they relate to taste preferences because cultural forces may sometimes override the A49P genotypic effects in adults. New knowledge about the molecular basis of food likes and dislikes in children, a generation that will struggle with obesity and diabetes, may suggest strategies to overcome diet-induced diseases.

Cost-Effectiveness of Individual versus Group Psychotherapy for Sexually Abused Girls

BACKGROUND

  Children who have been sexually abused may suffer from emotional and behavioural difficulties. Recent research found that individual and group psychotherapy have similar outcomes. In this study we compare the costs and cost-effectiveness of the two therapies and support for carers.

METHODS

  Subjects were recruited to two clinics in London and randomly allocated to the two treatments. The different components of each intervention were identified and costed.

RESULTS

  Total mean costs of individual therapy were found to be £1246 greater than for group therapy. Costs as they would apply in routine practice were relatively unchanged. Group therapy was thus more cost-effective than individual therapy.

DISCUSSION

  Carefully considering the impact of different therapies could allow more treatment to be offered from available staff resources and budgets. However, this is a single small study and further work is required to strengthen the evidence-base before change in practice is readily undertaken.

Chlorpyrifos accumulation patterns for child-accessible surfaces and objects and urinary metabolite excretion by children for 2 weeks after crack-and-crevice application

The Children's Post-Pesticide Application Exposure Study (CPPAES) was conducted to look at the distribution of chlorpyrifos within a home environment for 2 weeks after a routine professional crack-and-crevice application and to determine the amount of the chlorpyrifos that is absorbed by a child living within the home. Ten residential homes with a 2- to 5-year-old child in each were selected for study, and the homes were treated with chlorpyrifos. Pesticide measurements were made from the indoor air, indoor surfaces, and plush toys. In addition, periodic morning urine samples were collected from each of the children throughout the 2-week period. We analyzed the urine samples for 3,5,6-trichloropyridinol, the primary urinary metabolite of chlorpyrifos, and used the results to estimate the children's absorbed dose. Average chlorpyrifos levels in the indoor air and surfaces were 26 (pretreatment)/120 (posttreatment) ng/m3 and 0.48 (pretreatment)/2.8 (posttreatment) ng/cm2, respectively, reaching peak levels between days 0 and 2; subsequently, concentrations decreased throughout the 2-week period. Chlorpyrifos in/on the plush toys ranged from 7.3 to 1,949 ng/toy postapplication, with concentrations increasing throughout the 2-week period, demonstrating a cumulative adsorption/absorption process indoors. The daily amount of chlorpyrifos estimated to be absorbed by the CPPAES children postapplication ranged from 0.04 to 4.8 microg/kg/day. During the 2 weeks after the crack-and-crevice application, there was no significant increase in the amount of chlorpyrifos absorbed by the CPPAES children.

A Korean family of hypokalemic periodic paralysis with mutation in a voltage-gated calcium channel (R1239G)

Hypokalemic periodic paralysis (HOPP) is a rare disease characterized by reversible attacks of muscle weakness accompanied by episodic hypokalemia. Recent molecular work has revealed that the majority of familial HOPP is due to mutations in a skeletal muscle voltage-dependent calcium-channel: the dihydropyridine receptor. We report a 13-yr old boy with HOPP from a family in which 6 members are affected in three generations. Genetic examination identified a nucleotide 3705 C to G mutation in exon 30 of the calcium channel gene, CACNA1S. This mutation predicts a codon change from arginine to glycine at the amino acid position #1239 (R1239G). Among the three known mutations of the CACNA1S gene, the R1239G mutation was rarely reported. This boy and the other family members who did not respond to acetazolamide, showed a marked improvement of the paralytic symptoms after spironolactone treatment.

Influence of voice similarity on talker discrimination in children with normal hearing and children with cochlear implants

The perception of voice similarity was examined in 5-year-old children with normal hearing sensitivity and in pediatric cochlear implant users, 5-12 years of age. Recorded sentences were manipulated to form a continuum of similar-sounding voices. An adaptive procedure was then used to determine how acoustically different, in terms of average fundamental and formant frequencies, 2 sentences needed to be for a child to categorize the sentences as spoken by 2 different talkers. The average spectral characteristics of 2 utterances (including their fundamental frequencies) needed to differ by at least 11%-16% (2-2.5 semitones) for normal-hearing children to perceive the voices as belonging to different talkers. Introducing differences in the linguistic content of the 2 sentences to be compared did not change performance. Although several children with cochlear implants performed similarly to normal-hearing children, most found the task very difficult. Pediatric cochlear implant users who scored above the group mean of 64% of words correct on a monosyllabic open-set word identification task categorized the voices more like children with normal hearing sensitivity.

A quantitative look at fluorosis, fluoride exposure, and intake in children using a health risk assessment approach

The prevalence of dental fluorosis in the United States has increased during the last 30 years. In this study, we used a mathematical model commonly employed by the U.S. Environmental Protection Agency to estimate average daily intake of fluoride via all applicable exposure pathways contributing to fluorosis risk for infants and children living in hypothetical fluoridated and nonfluoridated communities. We also estimated hazard quotients for each exposure pathway and hazard indices for exposure conditions representative of central tendency exposure (CTE) and reasonable maximum exposure (RME) conditions. The exposure pathways considered were uptake of fluoride via fluoridated drinking water, beverages, cow's milk, foods, and fluoride supplements for both age groups. Additionally, consumption of infant formula for infants and inadvertent swallowing of toothpaste while brushing and incidental ingestion of soil for children were also considered. The cumulative daily fluoride intake in fluoridated areas was estimated as 0.20 and 0.11 mg/kg-day for RME and CTE scenarios, respectively, for infants. On the other hand, the RME and CTE estimates for children were 0.23 and 0.06 mg/kg-day, respectively. In areas where municipal water is not fluoridated, our RME and CTE estimates for cumulative daily average intake were, respectively, 0.11 and 0.08 mg/kg-day for infants and 0.21 and 0.06 mg/kg-day for children. Our theoretical estimates are in good agreement with measurement-based estimates reported in the literature. Although CTE estimates were within the optimum range for dental caries prevention, the RME estimates were above the upper tolerable intake limit. This suggests that some children may be at risk for fluorosis.

Emergence of Mands and Tacts of Novel Objects among Preschool Children

According to Skinner's (1957) analysis of verbal behavior, the mand and the tact are functionally independent verbal operants, each of which is acquired through a unique history of reinforcement. The present study attempted to replicate the findings of Lamarre and Holland (1985), who empirically demonstrated functional independence of mands and tacts in typically developing preschool children. Five children participated. All were initially trained to complete two 4-piece assembly tasks. Four children were then trained to tact the four pieces that comprised one of the assembly tasks, and to mand for the four pieces that comprised the other task, using arbitrary vocal response forms. The remaining child received tact training only, and only on one task. The effects of training on the untrained operant were evaluated in a multiple-probe design across tasks. Following mand training, 4 out of 4 children reliably emitted tacts under testing conditions, while the effects of tact training differed across participants. The results differ from those of Lamarre and Holland, but are not necessarily surprising from the point of view of either Skinner's analysis or more recent behavioral accounts of language. Future research should attempt to identify variables that affect transfer between mand and tact relations.

Quantitation of adenovirus genome during acute infection in normal children

BACKGROUND

Adenovirus infection causes a wide range of clinical illness in normal children. New molecular techniques allow quantitation of viral genome to study the natural history of adenovirus infection and viral load in normal children.

METHODS

Clinical samples were collected from 38 previously healthy, febrile children, and viral cultures were performed. Quantitative polymerase chain reaction (PCR) was used to detect adenovirus genome and to determine viral load. Adenovirus isolates were genotyped with a PCR-based assay.

RESULTS

Adenovirus culture was positive in 6 children who were diagnosed with acute adenovirus infection. Throat swabs contained high copy numbers of adenovirus genome (1.6 x 10(6)-6 x 10(7) copies/swab) from 4 of 4 adenovirus culture-positive children. Only 2 of 32 adenovirus culture-negative children had detectable adenovirus genome from throat swabs, but with a lower copy number (8 x 10(2) copies/swab). Adenovirus genome was not detected in blood samples from 5 of 6 adenovirus culture-positive children with uncomplicated upper respiratory tract infection and from all adenovirus culture-negative children. High level viremia (1.8 x 10(8)/ml) was detected in an adenovirus culture-positive 6-month-old infant with fever, pneumonia, conjunctivitis and hepatitis. Subsequent reduction in viral load paralleled her clinical recovery. Adenovirus viruria (1 x 10(9) copies/ml) with normal urinanalysis was detected in another adenovirus culture-positive child. All 6 adenovirus isolates were genotyped as adenovirus type 7h.

CONCLUSION

Viral load assessment in clinical samples determined by quantitative PCR can be useful in the diagnosis of adenovirus infection in immunocompetent, febrile children.

Racial differences in reported napping and nocturnal sleep in 2- to 8-year-old children

OBJECTIVES

The objectives of this study were to examine racial differences in reported napping and nighttime sleep of 2- to 8-year-old children, to identify factors accounting for these differences, and to determine if variability in napping was related to psychosocial functioning.

METHODS

Caretakers of 1043 children (73.5% non-Hispanic white; 50.4% male) 2 to 8 years old from a community sample reported on their children's napping behavior and nighttime sleep. Caretakers of 255 preschool children (3-5 years old) also completed the Behavior Assessment System for Children.

RESULTS

A more gradual age-related decline in napping was found for black children. At age 8, 39.1% of black children were reported to nap, compared with only 4.9% of white children. Black children also napped significantly more days per week, had shorter average nocturnal sleep durations, and slept significantly less on weekdays than on weekend nights. Despite differences in sleep distribution, total weekly sleep duration (diurnal and nocturnal) was nearly identical for the 2 racial groups at each year of age. Logistic regression analysis revealed that demographic variables were related to but did not fully explain napping differences. Napping in a subset of preschoolers was not significantly related to psychosocial functioning.

CONCLUSIONS

There are remarkable racial differences in reported napping and nighttime sleep patterns beginning as early as age 3 and extending to at least 8 years of age. These differences are independent of commonly investigated demographic factors. Differences in napping behavior do not seem to have psychosocial significance in a sample of preschool children.

Temperament and its role in developmental psychopathology

Temperament refers to early-appearing variation in emotional reactivity. The core dimensions of temperament and optimal method for assessment continue to be sources of considerable discussion. Nevertheless, the moderate stability of most temperamental traits and the strong influence of genetic and unique environmental factors have been well established, along with temperament's association with childhood psychiatric disorders. Both temperamental predisposition toward experiencing negative emotions and low inhibitory control are linked to many psychiatric conditions, while other dimensions, such as levels of extraversion, vary by, and likely even within, disorders. Accumulating research directed at understanding the mechanism of these links between temperament and psychopathology indicate that, at least for most disorders, the two constructs cannot be viewed as simply different points along a shared continuum. The effect of temperament upon psychopathology has been found to be mediated and moderated by a number of both internal and external factors. Additional research is needed to help further define the core dimensions of temperament and the complex mechanisms through which temperamental traits interact with other influences in affecting developmental trajectories.

Somatoform and dissociative disorders in children and adolescents: A comparative study

Background:

Somatoform and dissociative (conversion) disorders in adults have been reported to have a close relationship because of a diagnostic overlap and comparable aetiological models. The literature on these disorders in children and adolescents is scarce.

Aim:

The present study attempted to compare these two disorders in children and adolescents since antecedents of these disorders are said to be laid in childhood.

Methods:

Case files of 118 patients (69 of somatoform disorders and 49 of dissociative disorders) were reviewed and the two groups were compared with respect to sociodemographic profile, clinical profile, neurotic traits, behavioural problems, temperament, intelligence and family dysfunction.

Results:

Age at presentation and intelligence were significantly higher in those with somatoform disorders than in those with dissociative disorders. Patients with dissociative disorders had a significantly higher number of co-morbid somatoform symptoms.

Conclusion:

Somatoform and dissociative disorders are closely linked.

Improving the use of hands in daily activities: aspects of the treatment of children with cerebral palsy

Effective treatment for children with cerebral palsy requires a careful analysis of the behavior taking into consideration the complex issue of using the hands. In addition, it is important that the treatment is grounded in well-defined theories and methods. With the assistance of the International Classification of Functioning, the ICF, examples are provided of the effect of treatment on the level of Body Function. On the Activity Level, examples are given of treatment that applies recent knowledge of motor control and principles of motor learning. This paper is not intended to be a review of the literature, but rather, a set of examples from basic science, clinical practice and studies of intervention that highlight the possibilities of improving the usefulness of the hands in daily life.

Laparoscopic inguinal hernia repair in children

BACKGROUND

This study aimed to document the authors' experience with laparoscopic inguinal hernia repair in children.

METHODS

Ninety-three hernia repairs were performed in 64 children. The neck was closed with a purse string suture by using 4-0 absorbable suture.

RESULTS

Ninety-three indirect inguinal hernial sacs were closed in 64 children. Nine percent of children had an ectopic testis. The mean operating time for laparoscopic ring closure was 25 minutes (range, unilateral 21 to 35; bilateral, 28 to 50). The contralateral processus vaginalis was patent in 20% of children. In 24% of children, the final procedure was modified based on the findings of a dilated internal ring. A laparoscopic ilio-pubic tract repair was done in these cases. Laparoscopic mobilization, orchiopexy followed by ilio-pubic tract repair was done in 9% of children. Scrotal swelling occurred in one child. Hydrocoele occurred in one patient. Recurrence rate was 3.1%.

CONCLUSION

Laparoscopic inguinal hernia repair in children can be offered, as it is safe, reproducible, and technically easy for experienced laparoscopic surgeons. Ilio-pubic tract repair may be added in cases with dilated internal ring. Recurrence following laparoscopic ring closure can be managed with laparoscopic ilio-pubic tract repair. The long-term follow-up of laparoscopic ilio-pubic tract repair is awaited.

Weight status in childhood as a predictor of becoming overweight or hypertensive in early adulthood

OBJECTIVE

To assess the extent to which weight status in childhood or adolescence predicts becoming overweight or hypertensive by young adulthood.

RESEARCH METHODS AND PROCEDURES

We conducted a prospective study of 314 children, who were 8 to 15 years old at baseline, and were followed up 8 to 12 years later. Weight, height, and blood pressure were measured by trained research staff. Incident overweight was defined as BMI>or=25 kg/m2 among participants who had not been overweight as children.

RESULTS

More male subjects (48.3%) than female subjects (23.5%) became overweight or obese between their first childhood visit and the young adult follow-up (p<0.001). Being in the upper one half of the normal weight range (i.e., BMI between the 50th and 84th percentiles for age and gender in childhood) was a good predictor of becoming overweight as a young adult. Compared with children with a BMI<50th percentile, girls and boys between the 50th and 74th percentiles of BMI were approximately 5 times more likely [boys, odds ratio (OR)=5.3, p=0.002; girls, OR=4.8, p=0.07] and those with a BMI between the 75th and 84th percentiles were up to 20 times more likely (boys, OR=4.3, p=0.02; girls, OR=20.2, p=0.001) to become overweight. The incidence of high blood pressure was greater among the male subjects (12.3% vs. 1.9%). Compared with boys who had childhood BMI below the 75th percentile, boys between the 75th and 85th percentiles of BMI as children were four times more likely (OR=3.6) and those at above the 85th percentile were five times more likely (OR=5.1) to become hypertensive.

DISCUSSION

High normal weight status in childhood predicted becoming overweight or obese as an adult. Also, among the boys, elevated BMI in childhood predicted risk of hypertension in young adulthood.

Derived manding in children with autism: synthesizing Skinner's verbal behavior with relational frame theory

Mand functions for two stimuli (A1 and A2) were trained for 3 children with autism and were then incorporated into two related conditional discriminations (A1-B1/A2 -B2 and B1-C1/B2-C2). Tests were conducted to probe for a derived transfer of mand response functions from A1 and A2 to C1 and C2, respectively. When 1 participant failed to demonstrate derived transfer of mand response functions, transfer training using exemplars was conducted. When participants had demonstrated derived transfer of mand functions, the X1 and X2 tokens that were employed as reinforcers for mand responses were incorporated into two conditional discriminations (X1-Y1/X2-Y2 and Y1-Z1/Y2-Z2). Tests were conducted for derived transfer of reinforcing functions. Finally, tests were conducted to determine if the participants would demonstrate derived manding for the derived reinforcers (present C1 and C2 to mand for Z1 and Z2, respectively). Derived transfer of functions was observed when the sequence of training and testing was reversed (i.e., training and testing reinforcing functions before mand response functions) and when only minimal instructions were provided.

children and adolescents

We used the Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994, to investigate the relationship between environmental tobacco smoke (ETS) exposure and cognitive abilities among U.S. children and adolescents 6-16 years of age. Serum cotinine was used as a biomarker of ETS exposure. Children were included in the sample if their serum cotinine levels were less than or equal to 15 ng/mL, a level consistent with ETS exposure, and if they denied using any tobacco products in the previous 5 days. Cognitive and academic abilities were assessed using the reading and math subtests of the Wide Range Achievement Test-Revised and the block design and digit span subtests of the Wechsler Intelligence Scale for Children-III. Analyses were conducted using SUDAAN software. Of the 5,365 6- to 16-year-olds included in NHANES III, 4,399 (82%) were included in this analysis. The geometric mean serum cotinine level was 0.23 ng/mL (range, 0.035-15 ng/mL); 80% of subjects had levels < 1 ng/mL. After adjustment for sex, race, region, poverty, parent education and marital status, ferritin, and blood lead concentration, there was a significant inverse relationship between serum cotinine and scores on reading (beta = -2.69, p = 0.001), math (beta = -1.93, p = 0.01), and block design (beta = -0.55, p < 0.001) but not digit span (beta = -0.08, p = 0.52). The estimated ETS-associated decrement in cognitive test scores was greater at lower cotinine levels. A log-linear analysis was selected as the best fit to characterize the increased slope in cognitive deficits at lower levels of exposure. These data, which indicate an inverse association between ETS exposure and cognitive deficits among children even at extremely low levels of exposure, support policy to further restrict children's exposure.

Depression in Children with HIV Infection: A Case Series

About 46,000 individuals younger than 25 years of age currently have a diagnosis of human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). During their lifetime, approximately one-third of patients with HIV may develop depression. While antidepressants have been studied in adults with HIV, no data exist to support the use of antidepressants in children and adolescents with HIV. We report a case series of seven pediatric patients with HIV who were prescribed antidepressants. Six of seven patients had mild to moderate improvements in depressive symptoms. None of our patients experienced any suicidal ideations, and adverse events were minor. No drug-drug interactions were reported, and no significant changes in CD4 counts, CD4 percentages, or viral loads occurred during antidepressant therapy. Placebo-controlled, randomized studies are needed to confirm our results in this patient population.

Enhanced surveillance for childhood hepatitis B virus infection in Canada, 1999-2003

Since hepatitis B virus (HBV) infection can have serious sequelae, especially if infection occurs during childhood, there is a continuing need to examine its epidemiology so as to inform control measures. We analyzed trends in disease incidence and patterns of hepatitis B virus (HBV) transmission in both Canadian-born and non-Canadian-born children from 1999 to 2003, through the Enhanced Hepatitis Strain Surveillance System. Amongst Canadian-born children, the incidence of newly identified HBV infection per 100,000 declined significantly during the study period from 1.4 in 1999, to 0.5 in 2003 (RR, 0.75 per year; 95% CI, 0.60-0.95). Amongst non-Canadian-born children, the incidence of HBV infection per 100,000 ranged from 9.4 to 16.3, during the study period (linear trend test, p=0.69). Poisson regression analysis revealed that non-Canadian-born children were more likely to have HBV infection (RR, 12.3; 95% CI, 7.6 to 19.8), than Canadian-born children. HBV infection was found to be more common among children emigrating from high endemic area, than among Canadian-born children. Current Canadian immunization policy should take into consideration the protection of all children against HBV infection, including those coming from countries where mass hepatitis B vaccination programs have still not been launched.

Laparoscopic splenectomy in children

BACKGROUND

Laparoscopic splenectomy is being performed more commonly in children, although its advantages are not clear. We sought to determine whether laparoscopic splenectomy was superior to open splenectomy.

METHODS

The records of all pediatric patients undergoing splenectomy without significant comorbidities over a 12-year period were examined. The patients were divided into those undergoing laparoscopic splenectomy and those undergoing open splenectomy. Demographics, operative time, estimated blood loss, spleen size, length of stay, and total charges were compared between the groups.

RESULTS

Eighty-one (58%) children underwent laparoscopic splenectomy, and 59 (42%) children underwent open splenectomy. The groups were similar in age and sex; hereditary spherocytosis was more common in the LS group. Operating time was longer in the laparoscopic splenectomy group (231 +/- 10 min vs 138 +/- 9 min; P<0.001), but blood loss and complication rates were similar. Twelve (15%) conversions were necessary primarily due to spleen size. Although children undergoing LS had a shorter length of stay (2.4 +/- 0.1 vs 4.1 +/- 0.3 days; P<0.001), they incurred higher charges (dollars 21199 +/- 664 vs dollars 15723 +/- 1737; P<0.002).

CONCLUSION

Laparoscopic splenectomy is a safe procedure in children, resulting in shorter hospital stay, which may translate into earlier return to activity and a smaller burden on the child's caretakers.

Pulmonary epithelial integrity in children: relationship to ambient ozone exposure and swimming pool attendance

Airway irritants such as ozone are known to impair lung function and induce airway inflammation. Clara cell protein (CC16) is a small anti-inflammatory protein secreted by the nonciliated bronchiolar Clara cells. CC16 in serum has been proposed as a noninvasive and sensitive marker of lung epithelial injury. In this study, we used lung function and serum CC16 concentration to examine the pulmonary responses to ambient O3 exposure and swimming pool attendance. The measurements were made on 57 children 10-11 years of age before and after outdoor exercise for 2 hr. Individual O3 exposure was estimated as the total exposure dose between 0700 hr until the second blood sample was obtained (mean O3 concentration/m3 times symbol hours). The maximal 1-hr value was 118 microg/m3 (59 ppb), and the individual exposure dose ranged between 352 and 914 microg/m3hr. These O3 levels did not cause any significant changes in mean serum CC16 concentrations before or after outdoor exercise, nor was any decrease in lung function detected. However, children who regularly visited chlorinated indoor swimming pools had significantly lower CC16 levels in serum than did nonswimming children both before and after exercise (respectively, 57 +/- 2.4 and 53 +/- 1.7 microg/L vs. 8.2 +/- 2.8 and 8.0 +/- 2.6 microg/L; p < 0.002). These results indicate that repeated exposure to chlorination by-products in the air of indoor swimming pools has adverse effects on the Clara cell function in children. A possible relation between such damage to Clara cells and pulmonary morbidity (e.g., asthma) should be further investigated.

Long-term sequelae of SARS in children

Severe acute respiratory syndrome (SARS) runs a more benign course in children during the acute phase. Unlike adult patients, no fatalities were reported among the paediatric SARS patients. Published data on long-term sequelae of SARS are very limited. In our follow-up study, although patients have clinically recovered from their initial illness, exercise impairment and residual radiological abnormalities were demonstrated at 6 months after diagnosis. It is important to assess these patients on a regular basis to detect and provide appropriate management for persistent or emerging long-term sequelae in the physical, psychological and social domains.

Endoluminal gastroplication in children with significant gastro-oesophageal reflux disease

AIMS

To describe paediatric experience, and to assess complications and therapeutic effectiveness of the use of endoluminal gastroplication in children with gastro-oesophageal reflux disease (GORD) refractory to, or dependent on, proton pump inhibitors.

METHODS

Seventeen (five male) consecutive children/adolescents (median (range) age 12.4 (6.1-15.9) years, median (range) weight 46.0 (16.5-87.5) kg) with GORD either dependent for more than 12 months on proton pump inhibitors or non-responsive to medical treatment underwent endoscopic gastroplication using a flexible endoscopic sewing device (EndoCinch). Three plications were placed in gastric tissue below the lower oesophageal sphincter. Drug dose requirement, pH measurements, daily symptom severity and frequency, and validated reflux (QOLRAD) and general gastrointestinal (GSRS) quality of life scores were compared before and after endoscopic gastroplication.

RESULTS

All patients showed post-treatment improvement in symptom severity, frequency, and quality of life scores (p<0.0001). Three patients with recurrent symptomatic GORD had a repeat procedure within six weeks and did well subsequently. At up to 33 months of follow up (median 23), 14/17 patients remained off all antireflux medications, and 14/17 had maintained their symptomatic improvement. All pH parameters improved and had returned to normal values in 14/16 patients post-treatment and in 6/9 after one year of follow-up: in particular the reflux index had decreased from a median of 16.6% (0.9-67%) to 2.5% (0.7-15.7%) (p<0.0001) six weeks and 4.3% (2.2-20.6) (p<0.02) 12 months post-procedure. The only complication observed was gastric bleeding in one patient due to previously undiagnosed coagulopathy, which spontaneously resolved.

CONCLUSIONS

Endoluminal gastroplication is an effective and safe procedure in children/adolescents with significant GORD refractory to, or dependent on, medical anti-GORD therapy.

Clinical picture, diagnosis, treatment and outcome of severe acute respiratory syndrome (SARS) in children

Children are susceptible to infection by SARS-associated coronavirus (SARS-CoV) but the clinical picture of SARS is milder than in adults. Teenagers resemble adults in presentation and disease progression and may develop severe illness requiring intensive care and assisted ventilation. Fever, malaise, cough, coryza, chills or rigor, sputum production, headache, myalgia, leucopaenia, lymphopaenia, thrombocytopaenia, mildly prolonged activated partial thromboplastin times and elevated lactate dehydrogenase levels are common presenting features. Radiographic findings are non-specific but high-resolution computed tomography of the thorax in clinically suspected cases may be an early diagnostic aid when initial chest radiographs appear normal. The improved reverse transcription-polymerase chain reaction (RT-PCR) assays are critical in the early diagnosis of SARS, with sensitivity approaching 80% in the first 3 days of illness when performed on nasopharyngeal aspirates, the preferred specimens. Absence of seroconversion to SARS-CoV beyond 28 days from disease onset generally excludes the diagnosis. The best treatment strategy for SARS among children remains to be determined. No case fatality has been reported in children and the short- to medium-term outcome appears to be good. The importance of continued monitoring for any long-term complications due to the disease or its empiric treatment, cannot be overemphasised.

Associations between temperament and DSM-IV externalizing disorders in children and adolescents

This study investigated associations between child temperament and DSM-IV disorders in children. A total of 156 probands (97 boys, 59 girls; mean age = 10.78 years) and 154 randomly selected siblings were assessed using the Junior Temperament and Character Inventory (JTCI) and a structured DSM-IV interview. Subjects were placed in nonoverlapping groups of (1) attention-deficit hyperactivity disorder (ADHD) only, (2) disruptive behavior disorders (DBD) only, (3) DBD plus an affective and/or anxiety disorder (DBD+Int), and (4) controls with no diagnosis. Many JTCI scales were found to differ between diagnostic groups and controls. Regression analyses showed independent associations between low persistence and ADHD-only group membership, high novelty seeking (NS), and the DBD-only group and between high harm avoidance (HA) and DBD+Int group membership. The interaction NS x HA was related to the ADHD-only group. Future research is needed to determine the mechanism of these association.

PEG 3350 (Transipeg) versus lactulose in the treatment of childhood functional constipation: a double blind, randomised, controlled, multicentre trial

BACKGROUND

Recently, polyethylene glycol (PEG 3350) has been suggested as a good alternative laxative to lactulose as a treatment option in paediatric constipation. However, no large randomised controlled trials exist evaluating the efficacy of either laxative.

AIMS

To compare PEG 3350 (Transipeg: polyethylene glycol with electrolytes) with lactulose in paediatric constipation and evaluate clinical efficacy/side effects.

PATIENTS

One hundred patients (aged 6 months-15 years) with paediatric constipation were included in an eight week double blinded, randomised, controlled trial.

METHODS

After faecal disimpaction, patients <6 years of age received PEG 3350 (2.95 g/sachet) or lactulose (6 g/sachet) while children > or =6 years started with 2 sachets/day. Primary outcome measures were: defecation and encopresis frequency/week and successful treatment after eight weeks. Success was defined as a defecation frequency > or =3/week and encopresis < or =1 every two weeks. Secondary outcome measures were side effects after eight weeks of treatment.

RESULTS

A total of 91 patients (49 male) completed the study. A significant increase in defecation frequency (PEG 3350: 3 pre v 7 post treatment/week; lactulose: 3 pre v 6 post/week) and a significant decrease in encopresis frequency (PEG 3350: 10 pre v 3 post/week; lactulose: 8 pre v 3 post/week) was found in both groups (NS). However, success was significantly higher in the PEG group (56%) compared with the lactulose group (29%). PEG 3350 patients reported less abdominal pain, straining, and pain at defecation than children using lactulose. However, bad taste was reported significantly more often in the PEG group.

CONCLUSIONS

PEG 3350 (0.26 (0.11) g/kg), compared with lactulose (0.66 (0.32) g/kg), provided a higher success rate with fewer side effects. PEG 3350 should be the laxative of first choice in childhood constipation.

Dutch general practitioners' referral of children to specialists: a comparison between 1987 and 2001

BACKGROUND

Although children are frequently referred to specialists, detailed information on referral patterns of them is scarce. Even less information is available on how referral patterns evolve over time.

AIMS

To examine current referral patterns for children aged 0-17 years and compare these with referral patterns reported for 1987.

DESIGN OF STUDY

Data were analysed from two national cross-sectional surveys, performed in 2001 (91 general practices) and in 1987 (103 general practices).

SETTING

Dutch general practice.

METHOD

All new referrals to specialists were assessed by age, sex, International Classification of Primary Care (ICPC) category, specialty referred to, and specific episodes of disease. Referral measures were quantified as new referrals per 1000 person-years and per 100 new episodes, a measure of likelihood of a young person with a specific diagnosis to be referred. Rates in 2001 were compared with those from 1987.

RESULTS

Referral rates decreased from 138 per 1000 person-years in 1987, to 84 per 1000 person-years in 2001. Age differences in referral rates were similar in both surveys. Compared with 1987, more boys than girls were referred to specialists. The overall likelihood of a condition being referred decreased from 8.0 per 100 episodes in 1987 to 6.5 per 100 episodes in 2001. Reasons for referral had also changed by 2001, particularly for the ear, nose, and throat (ENT) specialist and ophthalmologist. Moreover, referral rates for acute otitis media, refractive disorders, and vision problems decreased two- to fourfold in 2001.

CONCLUSION

Presently, Dutch general practitioners tend to manage more health problems themselves and refer less young people to specialists.

Maternal and paternal risk factors for cryptorchidism and hypospadias: a case-control study in newborn boys

Little is known on environmental risk factors for cryptorchidism and hypospadias, which are among the most frequent congenital abnormalities. The aim of our study was to identify risk factors for cryptorchidism and hypospadias, with a focus on potential endocrine disruptors in parental diet and occupation. In a case-control study nested within a cohort of 8,698 male births, we compared 78 cryptorchidism cases and 56 hypospadias cases with 313 controls. The participation rate was 85% for cases and 68% for controls. Through interviews, information was collected on pregnancy aspects and personal characteristics, lifestyle, occupation, and dietary phytoestrogen intake of both parents. Occupational exposure to potential endocrine disruptors was classified based on self-reported exposure and ratings of occupational hygienists based on job descriptions. Our findings indicate that paternal pesticide exposure was associated with cryptorchidism [odds ratio (OR) = 3.8; 95% confidence interval (95% CI), 1.1-13.4]. Smoking of the father was associated with hypospadias (OR = 3.8; 95% CI, 1.8-8.2). Maternal occupational, dietary, and lifestyle exposures were not associated with either abnormality. Both abnormalities were associated with suboptimal maternal health, a lower maternal education, and a Turkish origin of the parents. Being small for gestational age was a risk factor for hypospadias, and preterm birth was a risk factor for cryptorchidism. Because paternal pesticide exposure was significantly associated with cryptorchidism and paternal smoking was associated with hypospadias in male offspring, paternal exposure should be included in further studies on cryptorchidism and hypospadias risk factors.

Neuropsychological predictors of academic underachievement in pediatric epilepsy: moderating roles of demographic, seizure, and psychosocial variables

PURPOSE

Academic underachievement is common in pediatric epilepsy. Attempts to identify seizure and psychosocial risk factors for underachievement have yielded inconsistent findings, raising the possibility that seizure and psychosocial variables play a complex role in combination with other variables such as neuropsychological functioning. This study cross-validated a neuropsychological measurement model for childhood epilepsy, examined the relation between neuropsychological functioning and academic achievement, and tested the degree to which demographic, seizure, and psychosocial variables moderate that relation.

METHODS

Children with chronic epilepsy (N = 173; ages 8 to 15 years; 49% girls; 91% white/non-Hispanic; 79% one seizure type; 79% taking one medication; 69% with active seizures) completed a comprehensive neuropsychological battery. Children diagnosed with mental retardation were excluded.

RESULTS

Structural equation modeling identified a three-factor measurement model of neuropsychological function: Verbal/Memory/Executive (VME), Rapid Naming/Working Memory (RN/WM), and Psychomotor (PM). VME and RN/WM were strongly related to reading, math, and writing; PM predicted writing only. Family environment moderated the impact of neuropsychological deficits on writing (p < or = 0.01) and possibly for reading (p = 0.05); neuropsychological deficits had a smaller impact on achievement for children in supportive/organized homes compared with children in unsupportive/disorganized homes.

CONCLUSIONS

These findings lend partial support for our theoretical model showing direct effects of neuropsychological function on achievement and the moderating role of family factors. This study suggests that a subgroup of children with epilepsy (those who have not only neuropsychological deficits but also disorganized/unsupportive home environments) are particularly at risk for adverse academic outcomes. Implications for intervention are discussed.

Survey of hepatitis B surface variant infection in children 15 years after a nationwide vaccination programme in Taiwan

BACKGROUND

It is not known whether hepatitis B virus (HBV) with mutations in the a determinant (amino acids (aa) 121-149) of the hepatitis B surface antigen (HBsAg) affect vaccination efficacy.

AIM

To investigate the prevalence and clinical significance of these mutants in children, 15 years after universal vaccination in Taiwan.

METHODS

Nucleotide sequences encoding the a determinant region (aa 110-160) of HBsAg were analysed in all HBV-DNA positive sera from 1357 children and 219 adolescents serosurveyed in 1999. We then compared the prevalence and changes in the mutants in these children with our previous surveys in the same area conducted in 1984 (just before vaccination), 1989, and 1994.

RESULTS

The prevalence of a determinant mutants in HBV-DNA positive children was 7.8% (8/103) in 1984, which significantly increased to 19.6% (10/51) in 1989, peaked at 28.1% (9/32) in 1994, and remained at 23.1% ((3/13) (T131I, G145R, G145R)) in 1999; it was higher in those fully vaccinated compared with those not vaccinated (15/46 v 15/153; p<0.001). However, the number of mutant infected children in each survey was stable in the first 5-10 year period but decreased 10-15 years post vaccination. Increased amino acid variation in the a determinant region occurred in carrier children in the post vaccination survey. Mutated residues tended to occur more frequently in the region with greater local hydrophilicity (residues 140-149) in those vaccinated than in unvaccinated children with variant infection (12/15 v 6/15; p = 0.062). More HBsAg positive a determinant mutants emerged in children fully vaccinated with plasma derived vaccine than those given recombinant vaccine (10/2399 (0.46%) v 0/503; p = 0.122).

CONCLUSION

We found that a determinant variants have an advantage in infecting immunised children but do not threaten current HBV vaccination strategies in Taiwan.

Nonword repetition by children with cochlear implants: accuracy ratings from normal-hearing listeners

Seventy-six children with cochlear implants completed a nonword repetition task. The children were presented with 20 nonword auditory patterns over a loud-speaker and were asked to repeat them aloud to the experimenter. The children's responses were recorded on digital audiotape and then played back to normal-hearing adult listeners to obtain accuracy ratings on a 7-point scale. The children's nonword repetition performance, as measured by these perceptual accuracy ratings, could be predicted in large part by their performance on independently collected measures of speech perception, verbal rehearsal speed, and speech production. The strongest contributing variable was speaking rate, which is widely argued to reflect verbal rehearsal speed in phonological working memory. Children who had become deaf at older ages received higher perceptual ratings. Children whose early linguistic experience and educational environments emphasized oral communication methods received higher perceptual ratings than children enrolled in total communication programs. The present findings suggest that individual differences in performance on nonword repetition are strongly related to variability observed in the component processes involved in language imitation tasks, including measures of speech perception, speech production, and especially verbal rehearsal speed in phonological working memory. In addition, onset of deafness at a later age and an educational environment emphasizing oral communication may be beneficial to the children's ability to develop the robust phonological processing skills necessary to accurately repeat novel, nonword sound patterns.