Thursday, October 16, 2014

Off-Hours Admission to Pediatric Intensive Care and Mortality

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our October issue. To learn more about Dr. Schulte, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by Philip Dean via Flickr
Timing counts, especially for critically ill children admitted to pediatric intensive care units (ICUs). The time of day and day of the week are important, as is the kind of illness encountered, the staffing numbers and experience levels of the ICU. All are factors that can shape a child's outcome and determine whether he or she survives to go home.

New research published this month in Pediatrics (doi: 10.1542/peds.2014-1071) found off-hour admissions were associated with a decreased risk of mortality, but morning admissions were associated with an increased likelihood of death. The study was based on a retrospective cohort, assembled using information from a database containing data from 234,192 admissions to 99 hospitals between January 2009 and September 2012. The study ICUs represent about 30 percent of the pediatric ICUs in the United States. The team at Wake Forest University in North Carolina, headed by Dr. Michael McCrory, used a primary outcome of ICU death and defined off-hour admissions as any occurring after 7 p.m. and weekends as Saturday and Sunday.

Other factors associated with an increased risk of mortality included neonatal and infant ages, trauma admission and transfer admissions from inpatient locations or other ICUs. The authors said additional work is needed to evaluate why the morning time period was associated with the peak morality in this study.

This study is important because it adds information about factors associated with leaving the pediatric ICU to go home. So what should this article tell you as a general pediatrician or as a sub-specialist who might have a patient admitted to the ICU? And if you’re practicing in an ICU, what should you tell the referring physician or patient’s parents?

If you’re the referring physician, perhaps you ought to ask about the 24/7 coverage of the ICU and how it is staffed. Does your patient admitted to the ICU have specific issues or parameters or labs that are especially important to monitor no matter what time of day it is? If you’re the ICU physician, has your unit done any monitoring to know temporal patterns of mortality among patients?

This Pediatrics article presents evidence that physicians, no matter what their practice area, need to understand more about the content of care their patients receive day or night in an inpatient setting—in this study, one that focuses on critical care.

Obesity and Interpersonal Dynamics at Family Meals

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Phyllis Buchanan via Flickr
We certainly run a lot of studies on the role of proper nutrition and exercise in preventing a child from becoming overweight or obese, but what about the dynamics of a family meal itself? Could certain characteristics regarding a family eating together be protective against obesity and other characteristics that contribute to excess weight gain?

Berge et al. (doi:10.1542/peds.2014-1936) performed a cross-sectional observational study in which family meals were videoed in the homes of 120 low-income and minority communities. Communication among family members and other aspects of parent-child and child-sibling dynamics were studied and compared to a child’s weight status. The results are fascinating and indicate the more positive the family dynamic around the table, the less risk of a child being overweight.

While this study cannot prove causality, it is certainly food for thought in regard to our promoting the importance not just having healthy food on the table, but the whole family being gathered together to share and support each other through conversation and other positive dynamics practiced at the family table. Read this study and learn more that you, in turn, can share with your patients’ families.

Related Reading:

Wednesday, October 15, 2014

Sofas and SIDS: A Dangerous Combination

Photo by stevepb via Pixabay
By: Lewis First, MD, MS; Editor-in-Chief 

Recently we received a manuscript from Dr. Rechtman et al. we found so worrisome that we are early-releasing the results of their study this week prior to official publication next month (doi:10.1542/peds.2014-1543).

The study uses data from a national database to look at infant deaths that occurred on sofas in 24 states from 2004 through 2012. The authors then compared demographic and environmental data from sofa deaths to other sleep-related infant deaths in other locations. The fact that sofas account for almost 13 percent of sleep-related infant deaths is concerning, and it’s worth knowing, and sharing with your infant patients’ parents, that these deaths are more apt to be labeled as suffocation or strangulation.

This blog post cannot do justice to the myriad of risk factors associated with infant deaths, so rather than try, check out the study and learn more. After reading this study, I hope you will agree that the sofa is off limits when it comes to safe sleep environments for babies!

Related Reading:

Wednesday, October 8, 2014

Is Teen Sexting a Predictor of Subsequent Sexual Behavior?

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by BdwayDiva1 via Flickr
We have published a number of recent studies on the increasing prevalence of sexting amongst teens, but have not published data on the role of active sexting (sending a nude picture) in mediating or promoting the relationship between passive sexting (being asked for a nude picture) and then going on to have intercourse. But this week, Temple and Choi (doi:10.1542/peds.2014-1974) share relevant data from a six-year longitudinal study of more than 950 high school students.

These students were asked about sexting at baseline entry into the study and one year later as well as whether sending a nude picture encouraged sexual intercourse in that relationship. The results are well worth your attention. It's interesting to note that while sexting overall was not temporally associated with risky sexual behaviors, active versus passive sexting was more associated with having intercourse over the next 12 months.

Since the study was cross-sectional, it cannot prove cause and effect, but it can still identify sexting as a key component in the ongoing sexual development of teens and potentially be considered a potential harbinger for future (if not current) adolescent sexual activity.

Do you ask your teen patients about sexting, or if their friends sext? Do you get positive responses and if so, what do you then say? We would love to hear your approach to helping teens deal with sexting. Leave a comment, send us an eLetter through our journal site, or join in the discussion via Facebook or Twitter.

Related Reading:

Monday, October 6, 2014

Beware the Dangers of Overdiagnosis!

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by opensource via Flickr
Overdiagnosis, when a true finding is discovered but is of no benefit to the patient, can be just as much an issue as misdiagnosis (making the wrong diagnosis) or overtreatment (when excess medication or treatments are used for correct or incorrect diagnoses). So how much do we know about overdiagnosis in children compared to adults?

Coon et al. (doi:10.1542/peds.2014-1778) share their thoughts on this issue in a special article being early released this week. The authors find cause for overdiagnosis in such conditions as attention deficit hyperactivity disorder (ADHD), food allergy, hyperbilirubinemia, obstructive sleep apnea, urinary tract infection and even bacteremia.

So what can we do about this problem? This article will raise your awareness and provide some strategies to perhaps reduce the chances that overdiagnosis will permeate your practice unnecessarily. You can’t over-read this article no matter how many times you go through it—so give it a read and then share your thoughts on this provocative topic below, via an eLetter or on Facebook or Twitter.

Related Reading:

Wednesday, October 1, 2014

Healthcare-Associated Infections in Critically Ill Children

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our October issue. To learn more about Dr. Schulte, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by daveynin via Flickr
Nosocomial infections have been bad news since the days of Ignaz Philipp Semmelweis who proved that washing hands drastically reduced the incidence of puerperal fever in mid-19th-century hospitals.

He has modern day counterparts in the infection control practitioners and hospital epidemiologists who combat healthcare-associated infections (HAIs) in US hospitals. There’s some good news about HAIs among children who got care in neonatal ICUs (NICUs) and pediatric ICUs (PICUs) documented in the October issue of Pediatrics (doi: 10.1542/peds.2014-0613).

A cohort study done with data reported to the US Centers for Disease Control and Prevention found the incidence rates of central-line associated blood infections and ventilator-associated pneumonia declined during a 5-year period between 2007 and 2012. The study examined data from 173 NICUs and 64 PICUs. Infections associated with central lines in NICUs declined from 4.9 to 1.5 per 1,000 central-line days and from 4.7 to 1.0 per 1,000 central line days in PICUs. Rates of pneumonia declined in NICUs from 1.6 to 0.6 per 1,000 ventilator days and in PICUs from 1.9 to 0.7 per 1,000 ventilator days. Rates of urinary tract infections associated with catheters did not change significantly in PICUs.

The team of investigators, led by Dr. Stephen Patrick at Vanderbilt University, used a time-series design to evaluate the changes in HAIs among hospitalized neonates and children. The investigators estimated the reduction in infections associated with central lines saved $131 million. The physicians and researchers who are the intellectual descendants of Semmelweis have done important work.  

Tuesday, September 30, 2014

The Role of Parenting & Home Stimulation in Overcoming Cognitive Deficits in Bangladesh

By: Lewis First, MD, MS; Editor-in-Chief 

Bangladeshi children. Photo by Mahmud Rassel via Flickr
Poverty certainly takes its toll on children's health given the association between poverty and cognitive deficit in infancy, but is it possible to improve this deficit with environmental and parental influence?

The answer is a resounding yes according to Hamadani et al. (doi: 10.1542/peds.2014-0694) who performed a longitudinal study of development in more than 2,800 infants in Bangladesh. They followed these infants for IQ changes over their first five years of life as impacted by such factors as parental education and home stimulation by parents. The results are impressive and stress the import of such factors in a way that can be generalizable to our own young patients born into poverty in this country.

To share even more lessons learned from this study, we invited Dr. Andrew Racine (doi: 10.1542/peds.2014-1375) to comment in an accompanying editorial that we are also early releasing this week.

Both the study and commentary are rich in take-aways that will be useful to you and the underserved families you care for.

Related Reading: