Effects of a Sleep Health Education Program for Children and Parents on Child Sleep Duration and Difficulties: A Stepped-Wedge Cluster Randomized Clinical Trial

IMPORTANCE

Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration.

OBJECTIVE

To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data.

INTERVENTIONS

A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school.

MAIN OUTCOMES AND MEASURES

Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used.

RESULTS

The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months.

CONCLUSIONS AND RELEVANCE

The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03556462.

Mental Disorders and Learning Disabilities in Children and Adolescents: Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral condition that affects more than 9% of US children and adolescents and often is seen in family medicine settings. A comprehensive evaluation for ADHD gathers information across time and settings; considers common comorbid or alternative conditions, such as learning disabilities and disorders of mood or anxiety, vision, hearing, and sleep; and includes a thorough physical examination. The need for additional evaluation is determined by the history and physical examination results. Diagnosis requires a sufficient number and duration of symptoms of inattention, or hyperactive/impulsive symptoms, or symptoms in each domain, beginning before age 12 years. Evidence-based management varies depending on patient age and may include psychosocial-behavioral approaches and pharmacotherapy. Behavioral treatment is the first-line recommended therapy for preschool-aged children and has been shown to benefit school-aged children. Stimulant drugs address core ADHD symptoms for a majority of patients but the incidence of adverse effects is greater for preschool-aged children. Alternative second-line drugs are available. Monthly monitoring is advised until the dosage is optimized, then patients should be monitored quarterly for the first year, followed by at least two annual visits. Individuals with ADHD may experience symptoms in adulthood.

Sleep and Gastrointestinal Symptoms in a Community-Based Survey of Children

We examined whether gastrointestinal (GI) symptoms were associated with sleep disturbances in a community-based sample of 337 school-aged children from Ypsilanti, Michigan. Parents completed the sleep-related breathing disorder scale of the Pediatric Sleep Questionnaire and the Conners' parents rating scale, which included questions concerning GI symptoms. One fifth of the children screened positive for sleep-disordered breathing; the same fraction had sleepiness, and one-quarter snored more than half the time. Similarly, one quarter of children had 2 or more GI symptoms. Children with positive sleep-disordered breathing scores were 2.22 times as likely to have 2 or more GI symptoms in the past month after confounder adjustment (95% confidence interval = 1.39-3.55). In particular, this relationship appeared to be driven by daytime sleepiness, as children with sleepiness had about a 2-fold higher prevalence of 2 or more GI symptoms (adjusted prevalence ratio = 1.96, 95% confidence interval = 1.18-3.26). Neither snoring nor sleep duration were associated with GI symptoms.

Prenatal Iron Deficiency and Auditory Brainstem Responses at 3 and 10 Months: A Pilot Study

PURPOSE

To examine whether prenatal iron deficiency delays auditory brainstem response (ABR) maturation in infancy.

METHODS

One hundred and fifteen full-term healthy Chinese infants with maternal and cord blood haemoglobin and serum ferritin determinations were recruited into this study. Forty-eight infants received ABR testing at 3 months, and 45 infants were tested at 10 months. Comparison of the ABR variables were made between infants with and those without evidence of prenatal iron deficiency (maternal 3rd trimester haemoglobin <110 g/L, cord blood ferritin <75 μg/L); or anaemia at 10 months (haemoglobin <110 g/L).

RESULTS

Latencies for wave V and wave III-V and I-V intervals were prolonged at 3 months in infants of anaemic mothers (effect sizes 1.02-1.19 SD). At 10 months, infants with low cord blood serum ferritin (indicating low iron stores at birth) showed longer wave I latency and possibly wave V latency also, besides demonstrating a smaller wave V amplitude (effect sizes 0.58-0.62 SD). Infants with low ferritin at birth and anemia at 10 months had longer wave III-V latency than other groups.

CONCLUSION

In full-term healthy infants, prenatal iron deficiency appears to have adverse effects on the developing central nervous system and auditory system as assessed by ABRs at 3 and/or 10 months.

Improved behavior after adenotonsillectomy in children with higher and lower IQ

OBJECTIVES

To examine whether high intellectual ability, in comparison to average or lower performance, reflects the consequences of sleep-disordered breathing and limits behavioral benefit observed 6 months after adenotonsillectomy.

METHODS

Children aged 3-12 years (n=147) recruited from otolaryngology practices at two hospitals and assessed with Conners' Parent Rating Scales and an age range-appropriate intellectual measure, the Stanford-Binet Intelligence Scale at baseline and 6 months after clinically-indicated adenotonsillectomy. Subjects were classified as having high (IQ≥110), average (90≤IQ<110), or low (IQ<90) cognitive ability.

RESULTS

After adenotonsillectomy, improvements in Conners' internalizing, externalizing, hyperactivity, and cognitive domains were observed across IQ groups (main effects for time, all p<0.01 or better), with no evidence for differential improvements among the groups (no significant time by IQ group interactions). The magnitude of behavioral improvement among children with high IQ resembled that observed among the other two groups. Changes in the Conners' domains were not significantly correlated with baseline IQ, age, socioeconomic status, body mass index z-score, or respiratory disturbance index.

CONCLUSION

Behavioral function can improve after adenotonsillectomy even among children with relatively high intellectual ability at baseline. Diagnosis and treatment with expectation of neurobehavioral benefit should be considered among high-performing children as readily as it is more traditionally among their lower-performing peers.

Diagnosis and management of ADHD in children

Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder in children, and the prevalence is increasing. Physicians should evaluate for ADHD in children with behavioral concerns (e.g., inattention, hyperactivity, impulsivity, oppositionality) or poor academic progress using validated assessment tools with observers from several settings (home, school, community) and self-observation, if possible. Physicians who inherit a patient with a previous ADHD diagnosis should review the diagnostic process, and current symptoms and treatment needs. Coexisting conditions (e.g., anxiety, learning, mood, or sleep disorders) should be identified and treated. Behavioral treatments are recommended for preschool-aged children and may be helpful at older ages. Effective behavioral therapies include parent training, classroom management, and peer interventions. Medications are recommended as first-line therapy for older children. Psychostimulants, such as methylphenidate and dextroamphetamine, are most effective for the treatment of core ADHD symptoms and have generally acceptable adverse effect profiles. There are fewer supporting studies for atomoxetine, guanfacine, and clonidine, and they are less effective than the psychostimulants. Height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence should be recorded at follow-up visits.

Do respiratory cycle-related EEG changes or arousals from sleep predict neurobehavioral deficits and response to adenotonsillectomy in children?

STUDY OBJECTIVES

Pediatric obstructive sleep apnea (OSA) is associated with hyperactive behavior, cognitive deficits, psychiatric morbidity, and sleepiness, but objective polysomnographic measures of OSA presence or severity among children scheduled for adenotonsillectomy have not explained why. To assess whether sleep fragmentation might explain neurobehavioral outcomes, we prospectively assessed the predictive value of standard arousals and also respiratory cycle-related EEG changes (RCREC), thought to reflect inspiratory microarousals.

METHODS

Washtenaw County Adenotonsillectomy Cohort II participants included children (ages 3-12 years) scheduled for adenotonsillectomy, for any clinical indication. At enrollment and again 7.2 ± 0.9 (SD) months later, children had polysomnography, a multiple sleep latency test, parent-completed behavioral rating scales, cognitive testing, and psychiatric evaluation. The RCREC were computed as previously described for delta, theta, alpha, sigma, and beta EEG frequency bands.

RESULTS

Participants included 133 children, 109 with OSA (apnea-hypopnea index [AHI] ≥ 1.5, mean 8.3 ± 10.6) and 24 without OSA (AHI 0.9 ± 0.3). At baseline, the arousal index and RCREC showed no consistent, significant associations with neurobehavioral morbidities, among all subjects or the 109 with OSA. At follow-up, the arousal index, RCREC, and neurobehavioral measures all tended to improve, but neither baseline measure of sleep fragmentation effectively predicted outcomes (all p > 0.05, with only scattered exceptions, among all subjects or those with OSA).

CONCLUSION

Sleep fragmentation, as reflected by standard arousals or by RCREC, appears unlikely to explain neurobehavioral morbidity among children who undergo adenotonsillectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT00233194.

Periodic leg movements during sleep in children scheduled for adenotonsillectomy: frequency, persistence, and impact

OBJECTIVE

The aim of this study was to assess the frequency and potential clinical impact of periodic leg movements during sleep (PLMS), with or without arousals, as recorded incidentally from children before and after adenotonsillectomy (AT).

METHODS

Children scheduled for AT for any clinical indications who participated in the Washtenaw County Adenotonsillectomy Cohort II were studied at enrollment and again 6 months thereafter. Assessments included laboratory-based polysomnography, a Multiple Sleep Latency Test (MSLT), parent-completed behavioral rating scales, neuropsychological testing, and psychiatric evaluation.

RESULTS

Participants included 144 children (81 boys) aged 3-12 years. Children generally showed mild to moderate obstructive sleep apnea (median respiratory disturbance index 4.5 (Q1 = 2.0, Q3 = 9.5)) at baseline, and 15 subjects (10%) had at least five periodic leg movements per hour of sleep (PLMI ≥ 5). After surgery, 21 (15%) of n = 137 subjects who had follow-up studies showed PLMI ≥ 5 (p = 0.0067). Improvements were noted after surgery in the respiratory disturbance index; insomnia symptoms; sleepiness symptoms; mean sleep latencies; hyperactive behavior; memory, learning, attention, and executive functioning on NEPSY assessments; and frequency of attention-deficit/hyperactivity disorder (DSM-IV criteria). However, PLMI ≥ 5 failed to show associations with worse morbidity in these domains at baseline or follow-up. New appearance of PLMI ≥ 5 after surgery failed to predict worsening of these morbidities (all p > 0.05), with only one exception (NEPSY) where the magnitude of association was nonetheless negligible. Similar findings emerged for periodic leg movements with arousals (PLMAI ≥ 1).

CONCLUSION

PLMS, with and without arousals, become more common after AT in children. However, results in this setting did not suggest substantial clinical impact.

Medications for sleep disturbances in children

At least 25% of infants, children, and adolescents have a sleep problem at some point during this developmental period. The management of pediatric sleep-related disorders often begins with behavioral strategies. While medications can be a useful adjunct, they are used off-label for sleep problems in this age group. When used, medications should be chosen carefully and targeted to specific outcomes as part of a comprehensive approach to management. This article reviews medications used for common pediatric sleep problems with a focus on pediatric insomnia and the importance of a multifactorial approach to evaluation and management.

Esophageal pressures, polysomnography, and neurobehavioral outcomes of adenotonsillectomy in children

BACKGROUND

Esophageal pressure monitoring during polysomnography in children offers a gold-standard, “preferred” assessment for work of breathing, but is not commonly used in part because prospective data on incremental clinical utility are scarce. We compared a standard pediatric apnea/hypopnea index to quantitative esophageal pressures as predictors of apnea-related neurobehavioral morbidity and treatment response.

METHODS

Eighty-one children aged 7.8 ± 2.8 (SD) years, including 44 boys, had traditional laboratory-based pediatric polysomnography, esophageal pressure monitoring, multiple sleep latency tests, psychiatric evaluations, parental behavior rating scales, and cognitive testing, all just before clinically indicated adenotonsillectomy, and again 7.2 ± 0.8 months later. Esophageal pressures were used, along with nasal pressure monitoring and oronasal thermocouples, not only to identify respiratory events but also more quantitatively to determine the most negative esophageal pressure recorded and the percentage of sleep time spent with pressures lower than -10 cm H(2)O.

RESULTS

Both sleep-disordered breathing and neurobehavioral measures improved after surgery. At baseline, one or both quantitative esophageal pressure measures predicted a disruptive behavior disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-defined attention-deficit/hyperactivity disorder, conduct disorder, or oppositional defiant disorder) and more sleepiness and their future improvement after adenotonsillectomy (each P < .05). The pediatric apnea/hypopnea index did not predict these morbidities or treatment outcomes (each P > .10). The addition of respiratory effort-related arousals to the apnea/hypopnea index did not improve its predictive value. Neither the preoperative apnea/hypopnea index nor esophageal pressures predicted baseline hyperactive behavior, cognitive performance, or their improvement after surgery.

CONCLUSIONS

Quantitative esophageal pressure monitoring may add predictive value for some, if not all, neurobehavioral outcomes of sleep-disordered breathing.

Maternal serum ferritin concentration is positively associated with newborn iron stores in women with low ferritin status in late pregnancy

Iron deficiency (ID) is common in pregnant women and infants, particularly in developing countries. The relation between maternal and neonatal iron status remains unclear. This study considered the issue in a large sample of mother-newborn pairs in rural southeastern China. Hemoglobin (Hb) and serum ferritin (SF) were measured in 3702 pregnant women at ≥37 wk gestation and in cord blood of their infants born at term (37-42 wk gestation). Maternal anemia (Hb <110 g/L) was present in 27.5% and associated with maternal SF <20 μg/L in 86.9%. Only 5.6% of neonates were anemic (Hb <130 g/L) and 9.5% had cord-blood SF <75 μg/L. There were low-order correlations between maternal and newborn iron measures (r = 0.07-0.10 for both Hb and SF; P ≤ 0.0001 due to the large number). We excluded 430 neonates with suggestion of inflammation [cord SF >370 μg/L, n = 208 and/or C-reactive protein (CRP) >5 mg/L, n = 233]. Piecewise linear regression analyses identified a threshold for maternal SF at which cord-blood SF was affected. For maternal SF below the threshold of 13.6 μg/L (β = 2.4; P = 0.001), cord SF was 0.17 SD lower than in neonates whose mothers had SF above the threshold (167 ± 75 vs. 179 ± 80 μg/L). The study confirmed that ID anemia remains common during pregnancy in rural southeastern China. Despite widespread maternal ID, however, iron nutrition seemed to meet fetal needs except when mothers were very iron deficient. The impact of somewhat lower cord SF on iron status later in infancy warrants further study.

Long-term neuroendocrine effects of iron-deficiency anemia in infancy

INTRODUCTION

Iron-deficiency anemia (IDA) is recognized to have long-lasting effects on neurodevelopment, but there is little research on neuroendocrine systems.

METHODS

This study examined the effects of IDA in early or later infancy on plasma cortisol and prolactin stress-response patterns for 1 h after a venipuncture and catheter placement in 10-y-old healthy Chilean children. Children identified with IDA at 6 mo (IDA-6; n = 13) or 12 mo (IDA-12; n = 24) and who were iron sufficient (IS) at other infancy time points were compared to children who were IS at all time points during infancy (n = 23). All children received at least 6 mo of oral iron treatment in infancy.

RESULTS

At 10 y of age, IDA-6 and IDA-12 children demonstrated altered cortisol response patterns; both showed a more immediate decline and IDA-12 children showed a blunted curvature as compared to IS children. IDA-12 children showed significantly lower cortisol levels at 30 and 45 min after venipuncture and catheter placement than did IS children. There were no significant differences for stress-responsive plasma prolactin patterns between groups.

DISCUSSION

The results indicate that having IDA during infancy is associated with long-term neuroendocrine effects on stress-responsive cortisol patterns.

Aggressive behavior, bullying, snoring, and sleepiness in schoolchildren

BACKGROUND

To assess whether urban schoolchildren with aggressive behavior are more likely than peers to have symptoms suggestive of sleep-disordered breathing.

METHODS

Cross-sectional survey of sleep and behavior in schoolchildren. Validated screening assessments for conduct problems (Connor's rating scale), bullying behavior, and sleep-disordered breathing (pediatric sleep questionnaire) were completed by parents. Teachers completed Connor's teacher rating scale.

RESULTS

Among 341 subjects (51% female), 110 (32%) were rated by a parent or teacher as having a conduct problem (T-score ⩾65) and 78 (23%) had symptoms suggestive of sleep-disordered breathing. Children with conduct problems, bullying, or discipline referrals, in comparison to non-aggressive peers, more often had symptoms suggestive of sleep-disordered breathing (each p<0.05). Children with vs. without conduct problems were more likely to snore habitually (p<0.5). However, a sleepiness subscale alone, and not a snoring subscale, predicted conduct problems after accounting for age, gender, a measure of socioeconomic status, and stimulant use.

CONCLUSIONS

Urban schoolchildren with aggressive behaviors may have symptoms of sleep-disordered breathing with disproportionate frequency. Sleepiness may impair emotional regulation necessary to control aggression.

Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis

OBJECTIVE

To examine the efficacy of an enhanced intervention (EI) compared to standard care (SC) in increasing daily water intake and fluid goal adherence in children seeking treatment for retentive encopresis.

METHODS

Changes in beverage intake patterns and fluid adherence were examined by comparing 7-week diet diary data collected during participation in the EI to achieved data for families who had previously completed the SC.

RESULTS

Compared to children in SC (n = 19), children in the EI (n = 18) demonstrated a significantly greater increase in daily water intake from baseline to the conclusion of treatment ( p ≤ .001), and were four and six times more likely to meet fluid targets in Phases 1 (Weeks 3-4) and 2 (Weeks 5-6) of fluid intervention, respectively (both p ≤ .001).

CONCLUSIONS

Enhanced education and behavioral strategies were efficacious in increasing children's intake of water and improving fluid adherence. Future research should replicate the findings in a prospective randomized clinical trial to discern their effectiveness.

Iron stores, periodic leg movements, and sleepiness in obstructive sleep apnea

STUDY OBJECTIVES

Most clinical sleep studies are performed for suspected obstructive sleep apnea (OSA), yet one-quarter to one-half show periodic leg movements (PLMs), for reasons that remain unknown. Several other disparate sleep disorders also increase the risk for PLMs. We examined the novel hypotheses that OSA as a representative sleep disorder could promote lower body iron stores, as reflected by serum ferritin levels, and, through downstream effects on dopaminergic transmission, increase PLMs and daytime sleepiness.

METHODS

Subjects were recruited as they underwent laboratory-based polysomnography for suspected OSA. Serum ferritin levels were measured the next morning. Each subject completed an Epworth Sleepiness Scale and a brief questionnaire to assess for restless legs syndrome (RLS).

RESULTS

The frequency of apneic events showed no association with serum ferritin levels, before or after adjustment for age, sex, body mass index, and likely RLS (each p value > 0.3). Serum ferritin levels did not predict the frequency of PLMs (p = 0.7) or Epworth scores (p = 0.8). Iron deficiency as a dichotomous variable, determined by ferritin levels less than < 50 microg/L or in combination with low transferrin saturation or mean corpuscular volume, showed similar results. In exploratory analyses, contrary to expectations, lower minimum oxygen saturation and increased sleep-stage shifts predicted increased rather than decreased ferritin levels (p = 0.03 and p = 0.02, respectively).

CONCLUSIONS

Results of this study, powered to detect small to moderate effect sizes, strongly suggest that OSA does not cause lower serum ferritin levels, which, in turn, cannot explain PLMs or daytime sleepiness in these patients.

Altered dopaminergic profile in the putamen and substantia nigra in restless leg syndrome

Restless leg syndrome (RLS) is a sensorimotor disorder. Clinical studies have implicated the dopaminergic system in RLS, while others have suggested that it is associated with insufficient levels of brain iron. To date, alterations in brain iron status have been demonstrated but, despite suggestions from the clinical literature, there have been no consistent findings documenting a dopaminergic abnormality in RLS brain tissue. In this study, the substantia nigra and putamen were obtained at autopsy from individuals with primary RLS and a neurologically normal control group. A quantitative profile of the dopaminergic system was obtained. Additional assays were performed on a catecholaminergic cell line and animal models of iron deficiency. RLS tissue, compared with controls, showed a significant decrease in D2R in the putamen that correlated with severity of the RLS. RLS also showed significant increases in tyrosine hydroxylase (TH) in the substantia nigra, compared with the controls, but not in the putamen. Both TH and phosphorylated (active) TH were significantly increased in both the substantia nigra and putamen. There were no significant differences in either the putamen or nigra for dopamine receptor 1, dopamine transporters or for VMAT. Significant increases in TH and phosphorylated TH were also seen in both the animal and cell models of iron insufficiency similar to that from the RLS autopsy data. For the first time, a clear indication of dopamine pathology in RLS is revealed in this autopsy study. The results suggest cellular regulation of dopamine production that closely matches the data from cellular and animal iron insufficiency models. The results are consistent with the hypothesis that a primary iron insufficiency produces a dopaminergic abnormality characterized as an overly activated dopaminergic system as part of the RLS pathology.

Individual differences in cortisol responses to fear and frustration during middle childhood

The purpose of this study was to examine individual differences in the activation and regulation of the hypothalamic-pituitary-adrenal (HPA) axis in prepubertal children after exposure to two different stress modalities and to evaluate the utility of an individual differences approach to the examination of HPA axis functioning. After a 30-min controlled baseline period, 73 7-year-olds (40 boys and 33 girls) were randomly assigned to a validity check condition or one of two experimental tasks designed to elicit fear or frustration. This was followed by a 60-min controlled regulation phase. A total of 17 saliva samples were collected, including 12 poststress samples at 5-min intervals. There was a significant stress modality effect, with children exposed to the fear condition reaching peak cortisol levels at 25min poststress and those exposed to the frustration condition reaching peak levels at 45min poststress. There was no difference in peak cortisol levels between the stress modalities. Individual variability across conditions was significant, with participants reaching peak levels as early as 10min poststress and as late as 60min poststress. Our data suggest that analysis of individual curves prior to making group-level comparisons may improve the explanatory power of HPA axis behavior models.

Brief report: Adherence to fluid recommendations in children receiving treatment for retentive encopresis

OBJECTIVE

Limited data are available regarding whether children being treated for retentive encopresis are adherent to recommendations to increase their daily fluid intake. The purpose of this study was to examine fluid adherence in children who received treatment for retentive encopresis.

METHODS

A retrospective chart review was performed using diet diary data for 26 children (ages 3-12) who completed a group behavioral intervention for retentive encopresis.

RESULTS

Mean daily intake of clear fluid increased significantly during treatment and children relied primarily on water and juice to make this dietary change. However, adherence rates to clear fluid goals were <50%.

CONCLUSIONS

Children's increased clear fluid intake did not equate to high fluid adherence. Children's high juice consumption is concerning as it could place them at risk for other negative health consequences. Future research should examine whether enhanced fluid education and use of behavior change strategies yield higher fluid adherence.

Persistent neurochemical and behavioral abnormalities in adulthood despite early iron supplementation for perinatal iron deficiency anemia in rats

BACKGROUND

Iron deficiency anemia (IDA) has been associated with altered cognitive, motor, and social-emotional outcomes in human infants. We recently reported that rats with chronic perinatal IDA, had altered regional brain iron, monoamines, and sensorimotor skill emergence during early development.

OBJECTIVE

To examine the long-term consequences of chronic perinatal IDA on behavior, brain iron and monoamine systems after dietary iron treatment in rats.

METHODS

Sixty dams were randomly assigned to iron-sufficient (CN) or low-iron (EID) diets during gestation and lactation. Thereafter, all offspring were fed the iron-sufficient diet, assessed for hematology and behavior after weaning and into adulthood and for brain measures as adults (regional brain iron, monoamines, dopamine and serotonin transporters, and dopamine receptor). Behavioral assessments included sensorimotor function, general activity, response to novelty, spatial alternation, and spatial water maze performance.

RESULTS

Hematology and growth were similar for EID and CN rats by postnatal day 35. In adulthood, EID thalamic iron content was lower. Monoamines, dopamine transporter, and dopamine receptor concentrations did not differ from CN. EID serotonin transporter concentration was reduced in striatum and related regions. EID rats had persisting sensorimotor deficits (delayed vibrissae-evoked forelimb placing, longer sticker removal time, and more imperfect grooming chains), were more hesitant in novel settings, and had poorer spatial water maze performance than CN. General activity and spatial alternation were similar for EID and CN.

CONCLUSION

Rats that had chronic perinatal IDA showed behavioral impairments that suggest persistent striatal dopamine and hippocampal dysfunction despite normalization of hematology, growth and most brain measures.

Alterations in intracerebral hemorrhage-induced brain injury in the iron deficient rat

BACKGROUND

Iron contributes to brain edema and cellular toxicity after intracerebral hemorrhage (ICH). Knowledge regarding ICH in the context of iron deficiency anemia (IDA), a common nutritional disorder, is limited.

OBJECTIVE

To determine the effect of IDA on brain and behavioral outcome after ICH in rats.

METHODS

Six-week-old male rats (n = 75) were randomized to non-IDA or IDA groups. After 1 month of iron sufficient or deficient diets, 100 microl autologous blood was infused into the right basal ganglia (BG). Brains were assessed for iron concentration, regional water content, BG transferrin, and transferrin receptor concentrations after ICH. Recovery of upper extremity sensorimotor function was assessed. Brain and behavioral variables were compared by diet group. Significance was set at p < 0.05.

RESULTS

Whole brain iron was decreased and water content was increased for IDA rats in injured cortex and BG at day 3 (p < 0.05) compared with non-IDA rats. Transferrin and transferrin receptor content were increased in injured BG for IDA compared to non-IDA in the first week after ICH (p < 0.05). IDA rats had greater left vibrissae-stimulated forelimb-placing deficits and forelimb-use asymmetry than non-IDA after ICH (p < 0.05).

CONCLUSIONS

Brain iron status may be an important determinant of injury severity and recovery after ICH.

Early appearance of functional deficits after neonatal excitotoxic and hypoxic-ischemic injury: fragile recovery after development and role of the NMDA receptor

We sought to determine whether neonatal rats that sustain unilateral cerebral hypoxic-ischemic or excitotoxic insults (1) manifest contralateral sensorimotor deficits during development or in adulthood and (2) recover from those deficits. Seven-day-old (P7) rats received a right intrastriatal injection of the glutamate analog N-methyl-D-aspartate (NMDA). Unilateral hypoxia-ischemia (HI) was induced by right carotid ligation followed by 1.5 h in 8% O2. Both procedures produce neuronal loss in the striatum and sensorimotor cortex. Nonlesioned controls were included. We scored percent forepaw placement on the edge of a horizontal surface, with lateral vibrissa stimulation, from P9 to P19, and at P33 and P50. Then, on P50, rats were treated with the NMDA antagonist MK-801 to determine whether deficits could be reinstated. NMDA- and HI-lesioned rats exhibited a deficit in contralateral vibrissa-stimulated forepaw placing that emerged during the second week of life. Yet, by P33 and P50, the lesioned groups and controls were indistinguishable. MK-801 injection on P50 resulted in transient reinstatement of the placing deficit. After unilateral neonatal excitotoxic or HI brain injury, contralateral sensorimotor deficits are detected, but in many animals, these deficits have resolved by adulthood. Thus, timing of sensorimotor tests may influence their sensitivity for detection of focal neuropathology originating in the neonatal period.

Use of the child development review increases residents' discussion of behavioral problems

OBJECTIVE

To assess whether use of a parent questionnaire, the Child Development Review (CDR), before health maintenance examinations (HMEs) increases parent identification and increases resident discussion and documentation of behavioral issues for toddler and preschool-aged children.

STUDY DESIGN

Quasi-experimental design using convenience samples with comparisons before and after questionnaire implementation.

SAMPLE

Children 15 to 47 months of age and their parents attending a hospital-based, primary care clinic serving a low-income population, and the residents caring for them.

METHODS

Participants were enrolled into early control, concurrent control, and intervention groups. All parents completed an exit interview about 9 behavioral issues and were asked if they had discussed these issues with the doctor. Before the visit, the intervention group parents completed the CDR, which was available for the residents to review. Information from the CDR and exit interview, and resident documentation were compared for control and intervention groups.

RESULTS

There were 122 intervention and 135 control group HMEs. Parents using the CDR identified more behavioral issues for their children at the exit interview (median, 2.0 vs 1.0, P =.01). The 6 issues on both the CDR and the exit interview accounted for this increase. Intervention group parents reported discussion of more behavioral issues (median, 2.0 vs 0.0, P <.001). Discussion increased for all issues. Documentation was not increased for the intervention group.

CONCLUSION

Use of the CDR before HMEs increased parent identification and reported discussion of behavioral topics for toddler and preschool children.

Coding of pediatric behavioral and mental disorders

BACKGROUND

In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges.

OBJECTIVE

Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty.

METHODS

We conducted a mail survey of 1492 physicians--497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson's chi2 and multivariate logistic regression.

RESULTS

Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding--both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions.

CONCLUSIONS

Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics.

Behavioral/environmental intervention improves learning after cerebral hypoxia-ischemia in rats

BACKGROUND AND PURPOSE

In premature infants, many of whom experience ischemic brain insults, the environment of rearing influences cognitive outcome. We developed a model to evaluate the effect of rearing conditions on learning after unilateral cerebral hypoxia-ischemia (HI) in 7-day-old (P7) rats. We hypothesized that neonatal handling would benefit rats recovering from an episode of HI.

METHODS

Seventeen litters of P7 Long-Evans rats underwent either HI (right carotid ligation followed by 1.5 hours in 8% O(2)) or control procedures. From P8 to P14, randomized litters were either handled (15 minutes of separation from dam per day) or nonhandled. After P55, learning was tested in the Morris water maze. To evaluate injury severity, hippocampal, cortical, and striatal volumes were measured.

RESULTS

In water-maze performance, ANCOVA revealed an interaction between handling and severity of hippocampal damage. Among HI rats, handled rats learned faster when hippocampal damage was moderate (P<0.01, repeated-measures ANOVA), with no benefit when damage was mild or severe.

CONCLUSIONS

These observations suggest the beneficial cognitive effect of neonatal handling was limited to animals with moderate damage. Neonatal handling in post-HI rats may be a useful model in which to study mechanisms underlying the benefits of post-HI developmental intervention.

Behavioral interventions reduce infant distress at immunization

OBJECTIVE

To assess the effectiveness of simple behavioral interventions at immunization on behavioral and biochemical indicators of distress in infants and parents in a primary care setting.

DESIGN

Subjects were enrolled sequentially to control (standard care) and intervention groups. Intervention parents (n=57) were provided information about techniques to help their infants at immunization. Standard care parents (n=45) did not receive this information. Immunizations were videotaped and coded for infant and parent behaviors. Using a visual analog scale, parents rated their infant's and their own comfort at study enrollment, immediately after immunization, and at check-out. Saliva samples collected from infants and parents at study enrollment and at 15, 30, and 60 minutes after immunization were assayed for cortisol concentration by standard radioimmunoassay. Data were analyzed using chi2, analysis of variance, and general linear modeling. Patterns of salivary cortisol change after immunization were analyzed using hierarchical linear modeling.

SETTING

A single, urban pediatric practice during 2 summers (1997 and 1998).

SUBJECTS

Infants 2 to 24 months of age (n= 102) and their parents.

MAIN OUTCOME MEASURES

Duration of infant distress (in seconds); parent use of behavioral intervention; infant and parent salivary cortisol concentrations (in nanomoles per liter).

RESULTS

Intervention parents were more likely to use a behavioral technique with their infants before immunization (P<.05). Total infant distress was shorter for intervention infants at immunization (P<.01), and these infants were rated as more comfortable by their parents (P<.001) immediately after immunization. Salivary cortisol levels were lower for intervention infants at 15, 30, and 60 minutes after immunization (P<.05).

CONCLUSION

Simple behavioral interventions before immunization are associated with reductions in behavioral and biochemical indicators of infant distress.

Brain iron and behavior of rats are not normalized by treatment of iron deficiency anemia during early development

Previous studies in rats have shown that iron deficiency anemia (IDA) during brain development results in lower brain iron concentration and behavioral deficits that persist despite iron treatment after weaning. The present study used a developmental IDA model to determine whether earlier iron treatment might normalize brain iron concentration and behavior. One and one-half week periods of IDA were instituted during early or late gestation or lactation by providing low iron diet to adolescent rat dams and oral iron treatment at the end of the anemia period. The iron deficiency anemia of dams during gestation and lactation resulted in significantly lower pup brain iron concentration at 3 mo of age (15-33% lower than control), despite iron treatment of dams as early as mid-gestation. Dam IDA during lactation lowered pup brain iron concentration significantly more than IDA during gestation (21% lower). All IDA groups had significantly poorer performance and lower activity compared with controls on a screen of home orientation at 8 d of age. Activity on this test was significantly less than controls at 12 d of age. Homing ability on d 12 and 16 and activity on d 16 did not differ from controls. Groups that were anemic around delivery had significant behavioral differences at 3 mo which included less defecation in the open field and greater swim distance in the Morris maze. These results raise the concern that iron sufficiency throughout the course of rain development is crucial to the achievement of normal brain iron concentration and behavior in rats.

Serum prolactin levels and behavior in infants

This study examined the relationship between serum prolactin levels and behavior in infants and toddlers who experienced two potentially stressful experiences (developmental testing and venipuncture). Serum prolactin levels showed considerable consistency over a 3-month period (r = 0.64 between study entry and three months, p < 0.001, n = 50). There was also stability in having either a normal or a high value (> or = 25 ng/ml). Among children who had a normal value on initial testing, 97% also has a normal value after 3 months; 55% of those with initial high values continued to have high values (chi 2 = 19.26, p < 0.001). Children with high serum prolactin levels were more likely to be rated as unusually hesitant and unhappy during developmental testing. Overall, 53% of the children with serum prolactin levels > or = 25 ng/ml were considered abnormal in affect, compared to 20% of those with lower serum prolactin values (total n = 138, chi 2 = 13.56, p < 0.001). These results suggest that, even in early life, serum prolactin levels may reflect characteristic individual behavioral and neuroendocrine responses to stress.

Regulation of hippocampal corticosterone receptors by a vasopressin analogue

Vasopressin can alter hippocampal corticosterone receptor number, as a congenital absence of a peptide in the Brattleboro rat results in decreased concentrations of the receptor; this deficit can be reversed with des-glycinimide arginine vasopressin (dGVP), a centrally-acting VP analogue. We examined whether vasopressin might regulate less dramatic fluctuations of hippocampal corticosterone receptor number in the normal rat. Administration of dGVP failed to alter the rate of or extent of down- or up-regulation of hippocampal corticosterone receptors by circulating corticosterone, suggesting that alteration of neural VP content is not a mediating step in such regulation.

Development and use of a nonrestraining waveguide chamber for rapid microwave radiation killing of the mouse and neonate rat

The use of microwave energy for rapid killing of small rodents such as the mouse or rat has become a standard pharmacologic technique since approximately 1975. This method allows investigation of rapidly modulated neurochemical indices, neuromodulatory substances, and some neurotransmitters to be determined at basal concentrations in brain regions and microregions. Previously described devices for use with microwave generators have relied on total body restraining holders in order to properly position rodents and neonates within a closed waveguide during microwave energy exposures. The present information describes two alternate chamber designs which do not require restraint of the rodent. A positioning device is described which must be used with the waveguide chambers. The animal chambers are designed to be used with 2450 MHz energy.

Cyclic AMP in female mouse brain is altered by the adrenocorticotropic hormone(4-9) analogue organon 2766

Cyclic AMP content was determined in 12 brain regions of young adult female mice at 30 min and at 24 h following an intraperitoneal injection of the tri-substituted adrenocorticotropic hormone(4-9) [ACTH(4-9)] analogue Organon 2766 [ORG 2766]. Animals were killed by focused 3.5 kW microwave radiation applied for 350 ms. Unlike previously reported responses in male mice, at 30 min post-injection there were no detectable differences in cyclic AMP content between the placebo and ORG 2766-treated animals. By contrast, 24 h after injection, the content of cyclic AMP was changed significantly in 8 of the 12 brain regions examined: medulla-pons, septal area, thalamus, hypothalamus, hippocampus, olfactory bulb, and parietal and occipital cortices. In most of the regions examined, differences consisted of 50% or greater reductions of tissue cyclic AMP content. The changes were unrelated to the estrus cycle of these animals.

Effect of diesel particulate exposure on adenylate and guanylate cyclase of rat and guinea pig liver and lung

An examination of the effects of 250 or 1500 micrograms m-3 concentrations of diesel particulate from diesel exhaust on the activity of adenylate or guanylate cyclase was undertaken using liver and lung tissue of rats and guinea pigs. These membrane and cytosolic enzymes were selected to screen for functional or regulatory alterations in these tissues. The studies for adenylate cyclase used the microsomal membrane fraction of each tissue; for guanylate cyclase, the microsomal membrane and supernate fractions were used. Basal and fluoride-stimulated adenylate cyclase activity were measured. Basal and sodium azide-stimulated guanylate cyclase activity were also determined. The basal activity of rat liver adenylate cyclase is generally unchanged throughout 52 weeks of diesel exposure. Stimulated adenylate cyclase shows an age-related decrease for all animal treatments throughout the study. Changes in enzyme activity occurred at 12 weeks and 52 weeks after 1500 micrograms m-3 exposure. Soluble stimulated guinea pig lung guanylate cyclase was first increased (6 weeks) and then decreased (24 weeks) by diesel exposure. At 52 weeks, there was no change. The data suggest the following trends: (1) an increased basal adenylate cyclase in the rat lung; (2) an age-related decrease in adenylate cyclase activity in rat liver, and (3) a biphasic exposure-related response of soluble guanylate cyclase for the guinea pig lung during the first 24 weeks, but no change at 52 weeks. In general, however, these studies suggest that diesel exposure does not substantially alter either of these intracellular regulating enzymes.

Cyclic nucleotides in the rat neostriatum: push-pull perfusion studies

A push-pull perfusion technique was employed for in vivo study of adenosine 3',5'-monophosphate (cAMP) and guanosine 3',5'-monophosphate (cGMP) in the rat caudate nucleus. Addition of dopamine to the perfusion fluid elicited dose-dependent increases of both cAMP and cGMP perfusate concentrations. In separate experiments, it was found that pretreatment of animals with the dopamine antagonist, pimozide, significantly depressed both nucleotide responses to dopamine perfusion over the dose range studied. Mechanistic interpretations of the observations are considered. The push-pull perfusion technique appears to provide an extremely useful means of examining extracellular cyclic nucleotide levels in a discrete brain region, in vivo, under dynamic conditions.

Cerebral blood flow after treatment with ORG-2766, a potent analog of ACTH 4--9

Regional cerebral blood flows (rCBF) were measured in conscious, male rats at 10, 30, 60 min and 24 hr after intravenous administration of a potent, behaviorally active analog of ACTH/MSH 4--9 (ORG-2766). Flows in the basal ganglia, hippocampus, septal area and frontal cortex were depressed significantly throughout the 60 min postinjection period. HYpothalamic and parietal flows were depressed at 10 and 30 min, but recovered by 60 min, whereas flow to the cerebellum was depressed between 30 and 60 min postinjection. The least changed and therefore relatively better perfused area throughout the first 60 min period was the occipital cortex. By contrast, at 24 hr, when perfusion of all brain regions had returned to near control levels, flow to the occipital cortex was elevated. During the first hour after treatment with either ORG-2766 or alphaMSH the patterns of regional circulation in the brain were qualitatively the same. The data suggest that ORG-2766 and, probably, alpha MSH trigger serially linked neurophysiologic changes in the brain lasting at least 24 hr, which organize the behavioral actions of this class of peptides on memory and attentional processes.

Ultrastructure of the blowfly chemoreceptor sensillum (Phormia regina)

The ultrastructure of a well studied insect chemosensory unit is presented in this report. Two separate lumina are present in this chemosensory unit, the trichogen and sensillar lumina. The fluid within the trichogen lumen exclusively bathes the dendritic terminals, and may be involved with the reception and/or modulation of environmental stimuli. Cytoplasmic extensions of the trichogen cell which line the trichogen lumen may be involved in the production of the cuticular sheath. The sensillar lumen is bordered by the tormogen and a sleeve cell, and is continuous with the unoccupied channel of the setal shaft. Functions for the various cellular components of the blowfly chemoreceptor sensillum are offered.