First Read

Taking the Lead in Lead Prevention Can Improve Reading Readiness

noreply@blogger.com (Dr. Lewis R. First) — Fri, 17 May 2013 07:01:00 +0000

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

noreply@blogger.com (Dr. Lewis R. First) — Fri, 17 May 2013 07:01:00 +0000

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?

noreply@blogger.com (Dr. Lewis R. First) — Thu, 16 May 2013 07:01:00 +0000

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

noreply@blogger.com (Dr. Lewis R. First) — Thu, 16 May 2013 07:01:00 +0000

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

noreply@blogger.com (Dr. Lewis R. First) — Wed, 15 May 2013 07:01:00 +0000

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?

noreply@blogger.com (Dr. Lewis R. First) — Tue, 14 May 2013 07:01:00 +0000

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

noreply@blogger.com (Dr. Lewis R. First) — Mon, 13 May 2013 07:01:00 +0000

“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.

A Mouthful of Studies on Pacifiers

noreply@blogger.com (Dr. Lewis R. First) — Thu, 09 May 2013 07:01:00 +0000

This week we share two interesting studies on pacifiers that will expand your knowledge-base about these items. The first, by Hesselmar et al. (doi: 10.1542/peds.2012-3345) studied whether parental cleaning of pacifiers by sucking on them when their infants were six months of age led to less asthma, eczema, and sensitization at 18 months of age. The results may surprise you, especially when it is also shown that the microbiome via saliva samples differ between children whose parents used their own mouths to clean their baby’s pacifier and those who did not. This suggested that microbes from a parent’s mouth may be stimulating the baby’s immune system and leading to less allergic symptoms and signs.

The second study by Benjamins et al. (doi: 10.1542/peds.2012-3835) looked at the prevalence of honey pacifier use by infants under a year of age at a county hospital clinic in Houston, Texas. While no cases of botulism occurred, the significant prevalence of this practice certainly puts infants at risk. So why are parents even using a honey pacifier? The study notes reasons such as tradition, assistance with constipation or colic and infant preference, although none of these reasons reflect evidence-based medicine at its best.

If you want some short but sweet studies on pacifiers that certainly don’t suck, then give these two studies some attention, and in turn share what you learn with parents whose babies love a good clean pacifier — but hopefully one not dipped in honey.

Malpractice and Pediatricians: A Rare But Costly Combination

noreply@blogger.com (Dr. Lewis R. First) — Wed, 08 May 2013 07:01:00 +0000

Ever wonder how often pediatricians are involved in malpractice claims? Perhaps you haven’t needed to, and we hope you never do, but it does happen. Just how frequently and how high are the indemnity payments when a claim is paid become the takeaway findings of a study by Jena et al. (doi: 10.1542/peds.2012-3443) analyzing malpractice claims of more than 1,600 pediatricians nationally covered by a liability insurer. This may not be the most rewarding study you have ever read — (unless you happen to be the plaintiff in some cases) — but it is an important one if you want to see what happens in our profession and how our rates of indemnity payments and their magnitude compare with that of other medical specialties. It would be good practice to read this study to learn more about what kinds of clinical situations result in a pediatric malpractice claim, so give this article a trial — I mean a try — to learn more.

Immunotherapy for Asthma and Rhinoconjunctivitis: Nothing to Sneeze At

noreply@blogger.com (Dr. Lewis R. First) — Tue, 07 May 2013 07:01:00 +0000

We all have patients or know of patients that are sent to pediatric allergists for immunotherapy. Sometimes this therapy is given subcutaneously and recently some of our patients have received sublingual therapy, although that modality does not yet have regulatory approval. To determine just how effective both modes of immunotherapy are, Kim et al. (doi: 10.1542/peds.2013-0343) performed a systematic review of subcutaneous and sublingual immunotherapy when used for treatment of asthma and allergic rhinoconjunctivitis. Thirteen randomized controlled studies were found for subcutaneous immunotherapy, 18 for sublingual immunotherapy and three compared both methods to each other. Just how strong is the evidence for both when compared to each other? Rather than scratch the surface in this paragraph, I encourage you to read the review for yourself so you can better understand the safety and efficacy of immunotherapy treatments for your patients since your patients will be itching to learn the results of this review just as much as you will.

Reducing Pressure Ulcers

noreply@blogger.com (Dr. Lewis R. First) — Mon, 06 May 2013 07:01:00 +0000

Our Quality Reports Editor Dr. Alex Kemper offers the following preview of what’s being published in the newest section of our journal:

Do you know how frequently pressure ulcers occur in the PICU or NICU? Do you know how you can keep pressure ulcer "never events" from happening in your hospital? Before reading the Quality Report by Dr. Visscher et al. (doi: 10.1542/peds.2012-1626) I knew little about the frequency of pressure ulcers, how to prevent them, and which equipment to be wary of. This is a great example of how to improve hospital safety. One of the key factors was developing an approach to not only recognize but anticipate the development of pressure ulcers. This required substantial work, including having special "skin champions." If you work in a hospital, consider this blog to be peer pressure to read this pressing article.

Can a Procalcitonin Level Predict Acute Pyelonephritis?

noreply@blogger.com (Dr. Lewis R. First) — Tue, 30 Apr 2013 07:01:00 +0000

We always worry that a urinary tract infection (UTI) may be a sign of a more serious renal infection such as acute pyelonephritis but recognize, especially in the setting of the recent AAP Guidelines on UTIs, that overimaging the genitourinary system with a VCUG or DMSA scan should be avoided. It would be great to have a serologic marker for inflammation that is extremely sensitive and specific, but we often turn to nonspecific inflammatory markers like the CRP or WBC count. This week Leroy et al. (doi: 10.1542/peds.2012-2408) study procalcitonin as a marker and compare it to these two other tests. The results of their study should have you streaming over to your local laboratory to see if this test can be made readily available to you, given how it compared to the CRP or WBC count. Rather than just share the results in my blog, I encourage you to go with the flow and read this study for yourself and your patients to learn more about the role of procalcitonin in the diagnosis of pyelonephritis and renal scarring.

To Err is Human When It Comes to Administering Medications to Chronically Ill Children — Not Just in the Hospital, But at Home Too!

noreply@blogger.com (Dr. Lewis R. First) — Mon, 29 Apr 2013 07:01:00 +0000

Electronic health records and computerized provider order entry (CPOE) have been designed to help minimize error when medications are required for a patient after an inpatient or outpatient evaluation. In oncology patients, the margin for error is minimal given the side effects that can occur if chemotherapeutic or other therapeutic and/or analgesic medications are given incorrectly. Yet, even when we use CPOE technology to ensure the correct dosage of a medication is being prescribed for home use, is the correct dose actually administered to our patients? Walsh et al. (doi: 10.1542/peds.2012-2434) tell us to be wary and alert us to the variety of medication errors that can occur at home, no matter how precise our prescribing and educational efforts may be. The authors share data form a prospective observational study of three oncology clinics over 3 ½ years. Using home visits and reviews of medical records and recommended doses documented more home medication errors than I ever imagined, and that will likely be your take as well after reading this study.

Some of these errors were quite serious and even life-threatening. Chemotherapeutic and non-chemotherapeutic agents and the total number of errors were viewed as similaror even worse than other studies documenting inpatient errors. Finding out what the errors are and how they might be prevented makes for an interesting discussion after reviewing the data. Most importantly, one needs to consider that what Dr. Walsh et al. found in cancer patients is likely occurring in non-cancer patients also prescribed home medications by us. To provide a more generalizable perspective on the lessons learned from this study, we have added a commentary from hospitalist and patient safety expert Dr. Christopher Landrigan (doi: 10.1542/peds.2013-0647). Make no mistake — both this study and the commentary are well-worth your time and attention (and perhaps that of your patients who need to give medication at home).

The Just or Unjust “Rewarts” of Transmitting Warts in Families and Schools

noreply@blogger.com (Dr. Lewis R. First) — Fri, 26 Apr 2013 07:01:00 +0000

It is rare nowadays not to find a wart or two on many of our patients, and while we often attribute the transmission of wart-causing viruses like HPV to be passed in public places, we also often disregard the role that family or a classroom setting may play in increasing overall transmission. Fortunately, Bruggink et al. (doi: 10.1542/peds.2012-2946) did not ignore these roles and set up a prospective cohort study to monitor the incidence of warts and HPV exposure in more than 1,000 Dutch children followed for 11 to 18 months. Just which environmental risk factors (e.g. family members, classroom prevalence, etc.) play a role is nicely revealed in this study and may help you wart off more opportunities to prevent the spread of this virus and the subsequent onset of warts.

Transition a Teen with Asthma into Young Adulthood: Who Accesses Health Care Better?

noreply@blogger.com (Dr. Lewis R. First) — Wed, 24 Apr 2013 07:01:00 +0000

Our journal has run a series of State-of-the-Art articles over the past few years on transitioning care for adolescents as they become young adults, especially those with chronic diseases. This week we share a regular article by Chua et al. (doi: 10.1542/peds.2012-2881) that looked at access to care for teens with asthma, use of primary care to establish a medical home, and emergency visits for teens age 14-17 and young adults 19-25 (with 18 year olds being excluded since this was considered a transitional year in regard to schooling, living situation, and possibly insurance). The authors also assessed the role of such variables as having health insurance, level of schooling, and whether living at home with a parent influenced access. You can guess which group has worse access, but you may not guess which variables contribute more to a better or worse outcome. Transition from this blog into the journal and learn more of what you can do to insure your teen and young adult asthmatic patients get what they need along the continuum of care provided by a medical home.

The Cinnamon Challenge: A Fad That is Tough to Swallow

noreply@blogger.com (Dr. Lewis R. First) — Mon, 22 Apr 2013 07:01:00 +0000

During the past year or two, teens have been trying what is called the “cinnamon challenge” — accepting a dare to try to swallow a teaspoon of cinnamon, with disastrous results — often life-threatening. Grant-Alfieri et al. (doi: 10.1542/peds.2012-3418) alert us to the dangers in trying to swallow this substance, including airway closure in a Pediatrics Perspectives article. I have found that almost all teens I ask know about this stunt and have watched others try to do it on many YouTube videos, but most parents and grandparents (as well as pediatricians) do not. Educate yourself on why this challenge should be avoided at all costs by reading this informative column.

Family-Centered Rounds Made Simpler and More Effective

noreply@blogger.com (Dr. Lewis R. First) — Fri, 19 Apr 2013 07:01:00 +0000

As I travel around the country and join students, residents, and faculty on rounds in various children’s hospitals, I get asked if I know of ways to make rounding more family-centered and yet at the same time an educationally valuable experience for all involved, from trainee to patient. Fortunately, this week Nagappan et al. (doi: 10.1542/peds.2013-0489) share some great tips and pearls about family-centered rounding in the column we run quarterly from the Council on Medical Student Education in Pediatrics (COMSEP). Round up all your colleagues who round at your hospital and teach students, residents, and fellows, and tell them to read this article to become even more effective and efficient at being teacher-clinicians.

Just How Common is the Amoxicillin Rash with Mononucleosis? Not as Common as You Might Think

noreply@blogger.com (Dr. Lewis R. First) — Thu, 18 Apr 2013 07:01:00 +0000

We are all taught to be aware that if amoxicillin is used to treat a pharyngitis that we think may be strep or other potential bacterial infection, and the cause turns out to be mononucleosis due to Ebstein-Barr virus (EBV), then the incidence of developing a rash has previously been thought to be 80% and higher. Yet, how true is this data in 2013? Chovel-Sella et al. (doi: 10.1542/peds.2012-1575) decided to look at this and followed more than 200 children treated with antibiotics who were found subsequently to have mono. While amoxicillin was the most common antibiotic used associated with this rash, the incidence was less than 30%. To get more information regarding antibiotics used, rashes that occurred and possible variables that might be associated with an increased or decreased risk of rash, follow the link to this study and learn more. You won’t find it tiring at all to read.

Working out the Bugs for Good Antimicrobial Stewardship

noreply@blogger.com (Dr. Lewis R. First) — Wed, 17 Apr 2013 07:01:00 +0000

Our Quality Reports Editor Dr. Alex Kemper offers the following preview of what’s being published in the newest section of our journal:

Ambroggio et al. (doi: 10.1542/peds.2012-2635) present their work to implement new guidelines for community-acquired pneumonia. Pneumonia is a common reason for hospitalization, and there is surprising variation in management. To help with this, the Pediatric Infectious Disease Society and the Infectious Disease Society of America recently management guidelines in 2011. Of course, minimizing use of broad-spectrum antibiotics is important. This Quality Report shows how this can be done with great efficiency. However, there are even larger lessons here related to team development and interventions to implement new guidelines. This is an excellent case study for quality improvement in general.

Music May Make the Health of a Premature Infant Grow Fonder (or at Least Better)

noreply@blogger.com (Dr. Lewis R. First) — Tue, 16 Apr 2013 07:01:00 +0000

We recently published a few articles on the role of music in helping preterm infants to relax and focus on growing and developing while in the NICU. This week, Loewy et al. (doi: 10.1542/peds.2012-1367) probably offer the largest randomized clinical multi-site trial we have published to date on the subject, involving close to 300 premature infants over 32 weeks gestation who were randomized in 11 sites to receive rhythmic sounds, breathing sounds, or parent-preferred live sung lullabies. Randomized infants were studied for changes in their cardiac and respiratory function as well as feeding behaviors and sucking patterns. The results were music to the ears of the investigators and may be to you now that you are tuned in to this fascinating study.

So Who or What is Most Influential in Helping Parents Make Decisions about Vaccines?

noreply@blogger.com (Dr. Lewis R. First) — Mon, 15 Apr 2013 07:01:00 +0000

We spend quite a bit of time educating our patients and families about the benefits versus the risks of vaccination. Yet, are our efforts at patient education what matters in helping parents decide and sign a consent form? This week, anthropologist Dr. Emily Brunson (doi: 10.1542/peds.2012-2452) shares with us the results of an online survey of parents in King County, Washington. Sheasked about who their top go-to” people sources” (e.g. friends, family, clinicians) were as well as their “non-people sources” (e.g. internet, books, magazines) when it comes to getting information about vaccines. Dr. Brunson also made sure she had sizable numbers of “conformers” and “non-conformers” when it comes to getting children vaccinated. The results show different sources and people have different levels of influence as to whether or not a family tells you they want their child vaccinated. Asking about where our patients get their information and then educating them accordingly based on what they learned from these sources may be what it takes when it comes to improving vaccine rates in your own office and at a statewide if not national level as well. To add further import to the take-home lessons learned from this study, don’t miss the accompanying commentary by Drs. Opel and Marcuse (doi: 10.1542/peds.2013-0531) also being released today. Take a shot at reading this interesting study and commentary to learn more.

Dishing Out Some New Findings on Plate Size and Children’s Appetites

noreply@blogger.com (Dr. Lewis R. First) — Fri, 12 Apr 2013 07:01:00 +0000

Ever wonder whether children given bigger plates will serve themselves bigger portions? You can stop wondering because DiSantis et al. (doi: 10.1542/peds.2012-2330) have attempted to answer that question by observing the behaviors of first graders randomized during school lunch buffets to use child or adult-size dishware and then have the portions they self-served assessed for calories served and eaten. There’s more than a plateful of results to be digested and reflected upon by reading this article. It may even have you asking about serving-plate size the next time you’re talking nutrition with your patients.

TV, Computers and Video Game Use: What Happens to BMI When These Devices Are Used for Prolonged Periods?

noreply@blogger.com (Dr. Lewis R. First) — Fri, 12 Apr 2013 07:01:00 +0000

It is a rare issue of our journal nowadays that does not contain an article pointing out how sedentary activities might be contributing more than we would like to the obesity epidemic in this country and other countries around the world. Although television, computer use, and video-game paying are common popular activities, no one seems to have documented whether the duration of time and attention spent with these devices when they are on influences upward changes in BMI — at least none have looked at this until Bickham et al. (doi: 10.1542/peds.2012-1197) decided to do so in a unique study being released online this week. The authors measured baseline BMIs and then asked teens to record their use of these devices, as well as whether they were actually paying attention to them when on. If you are thinking all of these technologic devices are deleterious to stability or reduction of BMI, think again. Only one of the three sedentary inventions shows an association with increased BMI and that one involves not time the device is on in a house, but when attention is primarily being paid to it. Turn on your computer and find the online version of this study to learn more about what is myth or reality regarding the association of BMI with these three specific sedentary activities.

Forgoing Artificial Nutrition and Hydration at the End of a Child’s Life: What Do Parents Think?

noreply@blogger.com (Dr. Lewis R. First) — Wed, 10 Apr 2013 07:01:00 +0000

While we have either cared for or heard about parents deciding to stop artificial nutrition and hydration when their child, stricken with a terminal illness, can no longer tolerate feeds or when feeding seems to exacerbate the level of pain, the question remains: is this what parents in this difficult situation want? Rapoport et al. (doi: 10.1542/peds.2012-1916) share with us a qualitative study involving interviews with parents whose children passed away and for which a decision to forego artificial hydration and nutrition was arrived at by those parents. Has this been an approach you have ever recommended or do you hesitate to offer it to families in devastating situations at the end of life? This study may make you want to consider the option and share it with families, although a commentary by Frader et al. (doi: 10.1542/peds.2013-0380) also being released this week offers another perspective and points out where a qualitative study of a small number of families may not be as generalizable as Rapoport might have hoped. Read both articles and offer your own perspective on this ethically challenging topic.

Taking a Peek at Secondhand Smoke and the Kidney

noreply@blogger.com (Dr. Lewis R. First) — Tue, 09 Apr 2013 07:01:00 +0000

The effects of secondhand smoke on the respiratory system are certainly well known to health care clinicians and our patients thanks to the myriad of journal articles on this topic as well as numerous public service announcements (PSAs) that air every day on television. However, you never see a PSA for the effects of secondhand tobacco smoke on the kidney. While it is known smoking exposure can contribute to chronic renal disease in adults, we have not really looked at this issue in children, at least until Garcia-Esquinas et al. (doi: 10.1542/peds.2012-3201) opted to study the effect and share their results with us this week in our journal. The investigators looked cross-sectionally at six national survey datasets over a decade that contained information on more than 7,500 teens with serum creatinine and cotinine levels also available. Active and secondhand smoking behaviors were defined and then quantitated as was kidney function in terms of glomerular filtration rate. The results suggest that smoke exposure may be associated with declines in renal function early on in childhood and not just in those who actively smoke. Add this study to your many lists of reasons why you need to encourage your patients who do smoke to not do so at home or in their cars, and to continue to advocate for a smoke free community as possible, especially in public places like restaurants and stores where children and families gather.