Taking the Lead in Lead Prevention Can Improve Reading Readiness

It’s hard to believe how unconcerned we were with lead levels between 5 and 10 micrograms per deciliter just a few decades ago and how far we have come to recognize that even these single digit lead levels can affect cognitive development today. Perhaps one of the most striking findings we have seen recently regarding the effects of mildly elevated lead levels is a study by McLaine et al. (doi: 10.1542/peds.2012-2277) who looked at kindergarten readiness scores in public kindergartens in a predominant Hispanic population in Providence, Rhode Island. Even when the analysis was adjusted for a number of potentially confounding variables, decreases in reading readiness scores at kindergarten entry were associated with rising lead levels. While this represents only one population, the results are troubling and well-worth reading about. If you aren’t screening your younger patients annually for lead exposure (at least in the first few years of life), this study may have you rethinking the importance of doing just that and to increase lead prevention education efforts in your community simultaneously.

Good News for Febrile Patients with Sickle Cell Disease

It seems that one of the aphorisms of training over the years has been to fear and respect the febrile patient who also has sickle cell disease if you don’t want to miss a serious bacterial infection. This would then mean not just obtaining blood cultures, but also inpatient hospitalization until the cultures proved negative. Yet, in the midst of this very conservative approach has been the arrival of conjugate vaccines and, of course, routine penicillin prophylaxis — which might reduce the risk of serious bacterial infection in these patients. To prove that hypothesis, Baskin et al. (doi: 10.1542/peds.2012-2139) looked at 18 years of a retrospective cohort of patients with sickle cell at Boston Children’s Hospital to see how often a febrile episode meant bacteremia and what happened to these febrile patients. The results are reassuring and will cool down concerns about admitting these patients automatically — assuming they have been immunized, penicillin-prophylaxed, and are still treated with antibiotics prior to being sent home as outpatients while cultures pend. Careful follow-up is still critical, but not necessarily in your hospital. Read this hot study on fever and sickle-cell disease to learn more.

Transitioning Adolescents with Special Health Care Needs to Young Adulthood: Are We Getting It Done?

Given our success at improving outcomes for children with chronic diseases as well as developmental disabilities, we find these children aging into adulthood and needing to transition their medical home to adult clinicians. Does this happen as frequently and as easily as it should? Certainly the American Academy of Pediatrics, American Academy of Family Physicians and the American College of Physicians have all issued clinical recommendations on transitioning care, and even our journal has run a series of State-of-the-Art articles on this subject with the hope that families would be much more satisfied with their older child’s transition to adult providers. Yet, this week McManus et al. (doi: 10.1542/peds.2012-3050) show there is much more work to be done as they compare data from a 2009 - 2010 national survey on more than 17,000 teens ages 12 to 18 with special health care needs. A prior survey done in 2005-06 looked for evidence of successful transition to an adult provider, maintaining insurance coverage and other measures recommended for these patients. While there’s no place like the medical home, this study suggests that when it comes to transitioning care to this special population of patients, we are just building the foundation for such a home and there’s much more building to do. Transition from our blog into the journal and read this important article to learn more.

On the Road Again? Maybe Not If a Teen is Texting While Driving

One might think that with many states passing laws to forbid texting while driving and with the media providing public service messages that note the dangers of this activity, we should see less and less of it — yet adolescents seem to be immune to these warnings and laws — at least according to data shared this week by Olsen et al. (doi: 10.1542/peds.2012-3462). The authors reviewed data from the 2011 CDC National Youth Risk Behavior Survey and found that almost half of the 8,500 teens surveyed reported texting while driving at least once in the month before the survey was administered. What is even worse is that those who text are more likely to also report other risky behaviors such as not wearing a seatbelt, drinking alcohol while driving, or being a passenger with someone else who has been drinking. Perhaps this study will be a wake-up call to the remaining states who have not yet passed laws banning texting or at least for clinicians to do more education with their teen patients about texting while driving. At the very least, text your adolescent patients to alert them to this study which will be free to the public so they can join with you in trying to stop this activity in our teen drivers (and in adults as well).

Chronic Kidney Disease Risk for Premature Infants

This week Dr. Phyllis Dennery, Professor of Pediatrics and Chief of the Division of Neonatology at the Children’s Hospital of Philadelphia and University of Pennsylvania, and Associate Editor for our State of the Art articles includes the following information regarding a most interesting article:

The State of the Art series on transition to adult care previously highlighted the impact of prematurity in later life. This month’s review is focused specifically on the impact of prematurity on the kidney. As stated by J. Bryan Carmody and Jennifer R. Charlton, (doi: 10.1542/peds.2013-0009), only now can we estimate the anticipated increase in the risk of chronic kidney disease in the very low birth weight ex-premature infants entering adulthood. The article provides an overview of the experimental evidence and theoretical concerns that suggests how being born without a full complement of nephrons affects later kidney function.

Early Limited Formula at Birth: Does It Help or Hurt Exclusive Breastfeeding Months Later?

The benefits of exclusive breastfeeding are too numerous to list in this blog, but our journal has certainly shared many of them over the years. But what happens when breast milk is not in yet and a baby appears to have lost more birth weight than they should? Sometimes early limited formula is recommended following a breastfeed (e.g. 10 cc by syringe into a baby’s mouth) to ensure adequate hydration — but how does this impact a mother’s decision to exclusively breastfeed once her milk comes in? Flaherman et al. (dio: 10.1542/peds.2012-2809) share the results of a small randomized controlled study in which babies who were to be exclusively breastfed were given some early limited formula or simply encouraged to continue breastfeeding to insure adequate initial hydration. Despite the small numbers enrolled in this study, the results are impressive and suggest a role for early limited formula… or do they? Lactation specialist Dr. Lydia Furman (doi: 10.1542/peds.2013-0635) provides a counterpoint analysis of this study in a commentary we are also releasing this week that questions the generalizability of this technique and notes some limitations of the study. While exclusive breastfeeding is still optimal and should be encouraged, I suggest you evaluate whether the evidence for this practice is strong enough to recommend for your own patients.

Some Observations on Observation Status

“Observation status” was created for hospital stays that are presumed to be short and be less resource intensive than average hospital stay. Yet are observation stays really less resource-intensive? Fieldston et al. (doi: 10.1542/peds.2012-2494) decided to study this question by looking at resource utilization for children given “observation” or “inpatient” status using a national data base on hospitalized children admitted in 2010 from the emergency department. Adjusting for risk, the authors find the “observation emperor” essentially “has no clothes” in that no differences were seen in costs between observation and inpatient patients even with detailed analysis of four diseases— asthma, gastroenteritis, bronchiolitis, and seizures. The variability of resources used in both observation and inpatient status show in aggregate minimal of any differences except that we are reimbursed less for classifying a patient as being on observation status.

So what do we do about this situation? Fortunately, a commentary by Dr. Jack Percelay (doi: 10.1542/peds.2013-0898) helps us make sense of the study’s findings and possible next steps in regard to possibly doing away with observation status. To do that requires pediatric clinicians to first read this study, and then decide if observation status is something we want to continue to observe or more actively advocate doing away with. We welcome your thoughts on this study and commentary via your eLetters or comments on our Facebook page.