Clinical Pediatrics

Aims. The aims of this study were to detect the infection rates of DNA viruses in liver tissue of biliary atresia and to investigate the effect of perinatal infection of cytomegalovirus in biliary atresia. Methods. A total of 85 liver biopsies (taken during Kasai portoenterostomy) were tested by fluorescence quantitative polymerase chain reaction for DNA viruses (herpes simplex virus [HSV], Epstein–Barr virus [EBV], varicella zoster virus [VZV], cytomegalovirus [HCMV], and adenovirus). Immunocytochemical detection of CMV-pp65 antigenemia assay was used to detect the presence of viral protein in liver samples. Human intrahepatic biliary epithelial cells was infected by the laboratory strain AD169 of HCMV in vitro. Results. Virus DNA was found in the biopsies (51/85 HCMV, 5/85 ADV, 3/85 EBV). The biopsies of 2 patients were tested positive for 2 viruses simultaneously. They include one case of HCMV in combination with ADV and one case of ASV in combination with EBV. CMV-pp65 antigenemia were distributed in hepatocyte, vascular endothelial cell, and biliary duct endothelial cell. The cytopathic effect and apoptosis were observed after HCMVAD169 infected human intrahepatic biliary epithelial cells at 6 days. Conclusion. Human intrahepatic biliary epithelial cell is the target cell of HCMV. The etiology of biliary atresia is probably multifactorial. The perinatal infection of HCMV is one of the important etiologies for biliary atresia in China.

Purpose. This pilot study assessed the feasibility, acceptability, and utility of a text messaging system that allowed teenagers with asthma to generate and control medical reminders sent to their mobile phones. Methods. The 12 teens in the study group were able to create their own reminder text messages, add or change reminders, and determine when and how often the messages were sent to their cell phone. Results. In total, 18 of the 21 unique messages created were reminders to take medication. No teen made changes to their original text messages or delivery schedule on their own. They gave high ratings on the usefulness, acceptability, and ease of use of the text messaging system. Self-reported asthma control at baseline was similar for both the study and comparison groups and did not change significantly. Conclusions. Allowing teens to control the timing and content of reminder text messages may support self-management of chronic disease.

Objective. To examine objectively measured physical activity levels by age, sex, and BMI for children and adolescents in a nationally representative sample. Methods. Data were from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Surveys, which included physical activity assessment by accelerometer and measured height and weight. The authors calculated minutes of moderate and vigorous activity. Results. Boys were more active than girls, and activity levels were lower at older ages. Younger children met daily recommendations for physical activity, whereas older children, especially girls, did not. Typically, weight status was inversely related to activity, though differences were less apparent among boys. Underweight children were not always more active than heavier peers.

Objective. The etiology of an apparent life-threatening event (ALTE) has been attributed to a wide range of causes. Physicians rely on caregiver narratives, which are often unreliable given the distressing nature of the event, which in turn leads to variation in the evaluation and management. The objective of this study was to study this variation in the management of ALTE among emergency physicians in Michigan. Design and methods. The authors developed and conducted a survey that contained questions on the evaluation and management of 2 common ALTE scenarios. These surveys were then mailed to 1000 randomly selected emergency physicians from a comprehensive physician database. Results. A total of 25.5% responded. Majority of the respondents were trained in emergency medicine residency. Fourth-seven percent of the respondents work in suburban areas. Most respondents said that they would perform diagnostic laboratory workup on children presenting with ALTE although there is wide variation in the extent of the workup. Ninety-two percent of ALTE patients are likely to get pediatric subspecialist consultation from the emergency department. Conclusions. There is a wide variation in the evaluation and management of ALTE among emergency medicine physicians in Michigan. These children with ALTE are very likely to be seen by pediatric subspecialists subsequently.

Introduction. Well child care is taught with individual visits in pediatric residency. Teaching residents how to deliver well child care efficiently is critical. Group well child care brings multiple families together for visits. The authors piloted group visits in pediatric residency clinic. Methods. The authors conducted group visits for 1- to 12-month old children. Seven families completed the group visits and were surveyed. Nine residents (intervention group) conducted group visits. Eighteen months after implementation, the intervention and control groups in the same clinic surveyed. Results. All families recommended group visits. The intervention group residents reported significantly more direct observations (P < .05). Trends toward improvement of teaching and role modeling for the intervention group were also observed. Discussion. The authors’ continuity clinic had success implementing group visits, and families were recommended the visits. Group visits offer a natural environment to observe residents while exposing them to another way to deliver well child care.

Postinfectious gastroparesis (PIGP) is a subgroup of idiopathic gastroparesis rarely reported in adolescents. This study describes 3 adolescent females with severe PIGP, who each underwent extensive workup prior to referral to a pediatric gastroenterologist. PIGP may be an underrecognized disorder in pediatrics, particularly in adolescents, and if untreated, can lead to significant morbidity.

Aims/Hypothesis. Vitamin D insufficiency has not been well studied in Native American (NA) children, who are at risk for obesity and diabetes. The authors examined vitamin D insufficiency and its association with body mass index (BMI) and insulin resistance. Methods. In a cross-section of NA children 5 to 18 years old (N = 198), anthropometrics, biomarkers of insulin resistance, and 25-hydroxy-vitamin D concentration [25(OH) vitamin D] were measured. BMI% and homeostatic model assessment of insulin resistance (HOMA-IR) were calculated. Results. Mean age was 10.8 ± 0.3 years (mean ± SEM). Mean serum 25(OH) vitamin D was 17.8 ± 0.4 ng/mL and 97% had vitamin D insufficiency [25(OH) vitamin D <30 ng/mL]. After adjusting for BMI, 25(OH) vitamin D was inversely associated with HOMA-IR (P < .0001) and several other markers of insulin resistance. Conclusions/Interpretation. Vitamin D insufficiency was nearly universal in this cohort of NA children and was associated with diabetes and vascular risk markers. Whether vitamin D supplementation can improve insulin resistance must be studied further.

Many physicians use surveillance questions to assess development; the American Academy of Pediatrics recommends screening at 9-, 18-, and 24-month health supervision visits (HSVs). There are no studies directly comparing surveillance with screening. The authors directly compared systematic surveillance with standardized screening using a cross-sectional observational study of children with no known delays. Surveillance questions were completed at each HSV. The Ages and Stages Questionnaire (ASQ) was administered following the 9-, 18-, or 24-month HSV. The authors compared detection of delays by surveillance with ASQ screening. Using surveillance, 11/95 subjects were identified as delayed. Using the ASQ, 15/95 subjects scored fail; 28/95 scored monitor. Among the 11 delayed surveillance subjects, 5 scored fail on the ASQ and 5 scored monitor. Ten of the 15 subjects scoring fail on the ASQ were not identified by surveillance. The study’s findings support the American Academy of Pediatrics recommendations for periodic formal screening in addition to continued surveillance.

Objectives. The aims of this study were to determine the frequency at which spurious diagnoses and unnecessary treatment occurs prior to the diagnosis of Graves disease (GD) and to evaluate the economic consequences of these events. Methods. Retrospective chart review of children diagnosed with GD. Results. A total of 76 children (61 girls) aged 11.9 ± 3.8 years were identified. In all, 17 (22.4%) were referred to other subspecialists prior to diagnosis of GD. Six were hospitalized, and 2 visited emergency rooms. A total of 15 (19.7%) underwent nonthyroid-related studies. Estimated cost of testing and procedures ranged from $49 to $14 000. Twelve (15.8%) were diagnosed with attention deficit/hyperactivity disorder, and 16 (21.1%) were started on medications for other conditions prior to diagnosis of GD. Conclusions. Evaluation and treatment for presumed other disorders are common in children with GD. A high index of suspicion for hyperthyroidism by primary care providers may help to avoid clinical detours that may be costly and delay diagnosis.

Objective. To determine the effectiveness of an interactive Web-based module on knowledge acquisition, retention, and clinical practice by residents. Methods. Residents were randomized to complete an interactive Web-based module on injury prevention or a noninteractive Web-based module of identical content. Acquisition and retention of medical knowledge were measured by pretest, posttest, and long-term test scores, and change in clinical practice was measured by videotaped clinical encounters. Results. Fifty-seven residents completed the modules. The control group had higher posttest scores than the intervention group (P = .036). Thirty-seven residents completed the long-term test with scores that were significantly higher than pretest scores (P = .00). Thirty-six residents had videotaped encounter scores (232 visits), with no difference in these scores after the intervention (P = .432). Conclusion. The noninteractive module was more effective in promoting knowledge acquisition. Residents successfully demonstrated knowledge retention with completion of either module. The modules were insufficient to change clinical practice.

Pediatric headache is a common pain complaint in children and adolescents, and pediatricians are the first source of headache assessment and treatment. This article provides guidelines for pediatricians in managing difficult headache patients typically seen in our practice. The 3 categories we typically evaluates and treats include (a) “It’s medical, not psychological”; (b) “You’re the only doctor who can help me”; and (c) “My child is perfect.” A brief case presentation illustrates each of these categories of patients. Specific recommendations for treatment, as well as guidelines for parents, are provided.

The problem of tooth discoloration is emerging in our society because of the poor oral hygiene, physical agents, environmental chemicals, mouth rinses, some dental procedures, general systemic conditions, and drugs. Other common causes of tooth discoloration include excessive use of tea, coffee, tobacco smoking and chewing, chewing of betel morsel (piper betel, paan), and so on. Drug-induced tooth discoloration can be prevented by avoiding prescriptions of well-known offender drugs known to cause tooth discoloration during pregnancy and in young children. This review describes some important groups of drugs that cause tooth discoloration.

In the article by Patricia A. Cluss, Linda J. Ewing, Kristin A. Long, William G. Krieger, and John Lovelace, Adapting Pediatric Obesity Treatment Delivery for Low-Income Families: A Public-Private Partnership, CLIN PEDIATR February 2010; 49: 123 129. (DOI:10.1177/0009922809346572)