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Doing better
December 2014 Volume 165 Number 6
Caffeine, booze, and kids — Thomas R. Welch, MD
Obesity and early evidence of cardiovascular abnormality — Stephen R. Daniels, MD, PhD
Family participation during intensive care unit rounds — Robert W. Wilmott, MD
Copyright ª 2014 by Elsevier Inc.
T
he next time you are filling up at the neighborhood gas station/junk food emporium, check out the array of “energy drinks.” These very popular concoctions, composed of water, sugar, caffeine, and a few random nutritional supplements, are heavily used by youth today. When considering the risks of these products, most would probably think first of caries and obesity. Although this may be correct, another risk has been reported in college-aged youth: an association with problematic alcohol use. This association has never been carefully studied in younger children. In this issue of The Journal, Emond et al from Dartmouth analyzed data from a national survey of media use and alcohol consumption to see if this association already established in college students also could be present in 15-17 year olds. Among these children, many aspects of energy drinks, especially their use with alcohol, were strong predictors of binge drinking and other dangerous alcohol consumption patterns. Article page 1194<
I
n adults, it is clear that obesity plays an important role in elevating risk for cardiovascular outcomes such as myocardial infarction and stroke. It has been somewhat less clear if childhood and adolescent obesity also increases risk of cardiovascular disease. There are several potential lines of evidence that could be helpful in establishing that relationship. One is evidence that obesity in young individuals is already associated with markers of risk for cardiovascular disease. In this issue of The Journal, Di Bonito et al evaluate children and adolescents, including some with obesity and some with severe obesity. They found a combination of “cardiometabolic” factors that were associated with obesity, including elevated blood pressure, elevated triglyceride/HDL-C, high normal fasting blood glucose, and concentric left ventricular hypertrophy (LVH). The finding of concentric LVH is particularly important because it demonstrates that structural abnormalities of the heart are already occurring at this young age. Concentric LVH is a pattern of hypertrophy that is associated with adverse cardiovascular outcomes in adults. These findings emphasize that we must work to prevent obesity in childhood and treat it when it occurs. Article page 1184<
I
n an earlier study, published in The Journal, Stickney et al from Boston Children’s Hospital evaluated the level of parental satisfaction with family attendance during pediatric intensive care unit rounds (J Pediatr 2014;164:404-6.e4). They found a high degree of parental satisfaction but a lower degree of healthcare provider satisfaction. In the current issue of The Journal, they report a new study of the goals and expectations of parents and healthcare providers in this setting. This was performed using qualitative methods; the parents were interviewed at bedside, and the healthcare providers participated in focus group discussions. The results show many important areas of agreement between providers and parents regarding goals for rounds when parents are present, including helping parents achieve an understanding of the child’s status and plan of care. However, 1073
providers and parents disagreed about the nature of opportunities to ask questions. Parents additionally reported that they wanted to provide important information about their children to the healthcare team and that they expected transparency from the team. In contrast, providers stated that parental presence sometimes inhibited frank discussion and education. The authors conclude that even though there is some agreement in goals for parent participation in morning rounds in the pediatric intensive care unit, there are opportunities to adjust the expectations of both parents and healthcare providers. They suggest several possible solutions that could help address this problem. Article page 1245<
Doing better — Thomas R. Welch, MD
Head growth in very low birth weight prematures predicts later cognition — Paul G. Fisher, MD
Retinal vessels: a window for adverse vascular changes? — Stephen R. Daniels, MD, PhD
1074
A
nyone involved in hospital medicine these days has been hearing a lot about quality and safety. Most of us find ourselves participating in some kinds of national benchmarking collaboratives, and many are probably involved with rapid cycle improvement projects in their clinical areas. External forces are pushing some of this work, but thoughtful pediatricians know that this simply is the right thing to be doing. Even though The Journal receives a lot of submissions related to quality improvement projects, most of which are quite meritorious, few rise to the level above local interest, with a broad message to the readership. An exception is an article by McClead et al in the current issue of The Journal. This report describes a multipronged approach to reduce the frequency of adverse drug events at Nationwide Children’s Hospital. The fact that the program was quite successful is almost beside the point. The article provides a comprehensive, practical report of the many different interventions used in this endeavor, as well as a nice introduction to many facets of quality improvement science. Article page 1222<
S
ammallahti et al conducted a cohort study of 103 former very low birth weight preterm infants now at mean age 25 years to distinguish whether faster growth from birth to term age and during the first year thereafter predicted neurocognitive abilities. After adjustment for confounding neonatal complications, the investigators found that faster growth from birth to term in head circumference, but not weight or length, predicted intelligence quotient in young adulthood. Growth in weight, length, and head circumference from term to age 12 months did not predict cognitive outcome. The first weeks after birth may well be critical for brain development. This study points once again to the importance of following head circumference for premature infants. Measurement of occipitofrontal circumference in the intensive care nursery may add predictive neurocognitive outcome data for both physicians and parents. Article page 1109<
D
eveloping a clear picture of vascular changes related to atherosclerosis has been difficult in young patients. One reason for this has been the paucity of noninvasive ways of following the development of pathology of the vasculature. This has forced an emphasis on evaluation of risk factors, which do not always provide the best prediction. In this issue, Kurniawan et al use retinal photographs to evaluate retinal arteriolar and venular caliber. A computer-based program provided measures including the central retinal artery equivalent and central retinal vein equivalent. They found that increased BMI is associated with increasing retinal venular caliber over time. This suggests that following retinal venular widening could be a way to assess adverse microvascular changes in research and possibly in clinical practice. Article page 1166< Vol. 165, No. 6
Recovery from concussion — Thomas R. Welch, MD
T
he professional and lay media have been filled with discussions about concussion, especially among young and adult athletes. The practitioner may have difficulty keeping track of all these new developments and understanding the important points that should become incorporated into practice. This issue of The Journal contains an interesting and important article that certainly will inform practice. Corwin et al from Philadelphia studied a cohort of children in their institution with concussion, asking the question whether there were ways in which the children who had a prolonged recovery (over 4 weeks of symptoms) could be recognized early. These children had fairly significant disability, and recognizing them early in their course could be very helpful in working with children, their families, and schools. Corwin et al present a number of simple historical and physical examination findings, which, when present at the time of initial evaluation, identify children at risk for prolonged symptoms. This is not a battery of high-tech diagnostic interventions, but some easily identifiable markers that can quickly become incorporated into practice. Article page 1207<
December 2014
1075
Caffeine, booze, and kids — Thomas R. Welch, MD
Obesity and early evidence of cardiovascular abnormality — Stephen R. Daniels, MD, PhD
Family participation during intensive care unit rounds — Robert W. Wilmott, MD
Copyright ª 2014 by Elsevier Inc.
T
he next time you are filling up at the neighborhood gas station/junk food emporium, check out the array of “energy drinks.” These very popular concoctions, composed of water, sugar, caffeine, and a few random nutritional supplements, are heavily used by youth today. When considering the risks of these products, most would probably think first of caries and obesity. Although this may be correct, another risk has been reported in college-aged youth: an association with problematic alcohol use. This association has never been carefully studied in younger children. In this issue of The Journal, Emond et al from Dartmouth analyzed data from a national survey of media use and alcohol consumption to see if this association already established in college students also could be present in 15-17 year olds. Among these children, many aspects of energy drinks, especially their use with alcohol, were strong predictors of binge drinking and other dangerous alcohol consumption patterns. Article page 1194<
I
n adults, it is clear that obesity plays an important role in elevating risk for cardiovascular outcomes such as myocardial infarction and stroke. It has been somewhat less clear if childhood and adolescent obesity also increases risk of cardiovascular disease. There are several potential lines of evidence that could be helpful in establishing that relationship. One is evidence that obesity in young individuals is already associated with markers of risk for cardiovascular disease. In this issue of The Journal, Di Bonito et al evaluate children and adolescents, including some with obesity and some with severe obesity. They found a combination of “cardiometabolic” factors that were associated with obesity, including elevated blood pressure, elevated triglyceride/HDL-C, high normal fasting blood glucose, and concentric left ventricular hypertrophy (LVH). The finding of concentric LVH is particularly important because it demonstrates that structural abnormalities of the heart are already occurring at this young age. Concentric LVH is a pattern of hypertrophy that is associated with adverse cardiovascular outcomes in adults. These findings emphasize that we must work to prevent obesity in childhood and treat it when it occurs. Article page 1184<
I
n an earlier study, published in The Journal, Stickney et al from Boston Children’s Hospital evaluated the level of parental satisfaction with family attendance during pediatric intensive care unit rounds (J Pediatr 2014;164:404-6.e4). They found a high degree of parental satisfaction but a lower degree of healthcare provider satisfaction. In the current issue of The Journal, they report a new study of the goals and expectations of parents and healthcare providers in this setting. This was performed using qualitative methods; the parents were interviewed at bedside, and the healthcare providers participated in focus group discussions. The results show many important areas of agreement between providers and parents regarding goals for rounds when parents are present, including helping parents achieve an understanding of the child’s status and plan of care. However, 1073
providers and parents disagreed about the nature of opportunities to ask questions. Parents additionally reported that they wanted to provide important information about their children to the healthcare team and that they expected transparency from the team. In contrast, providers stated that parental presence sometimes inhibited frank discussion and education. The authors conclude that even though there is some agreement in goals for parent participation in morning rounds in the pediatric intensive care unit, there are opportunities to adjust the expectations of both parents and healthcare providers. They suggest several possible solutions that could help address this problem. Article page 1245<
Doing better — Thomas R. Welch, MD
Head growth in very low birth weight prematures predicts later cognition — Paul G. Fisher, MD
Retinal vessels: a window for adverse vascular changes? — Stephen R. Daniels, MD, PhD
1074
A
nyone involved in hospital medicine these days has been hearing a lot about quality and safety. Most of us find ourselves participating in some kinds of national benchmarking collaboratives, and many are probably involved with rapid cycle improvement projects in their clinical areas. External forces are pushing some of this work, but thoughtful pediatricians know that this simply is the right thing to be doing. Even though The Journal receives a lot of submissions related to quality improvement projects, most of which are quite meritorious, few rise to the level above local interest, with a broad message to the readership. An exception is an article by McClead et al in the current issue of The Journal. This report describes a multipronged approach to reduce the frequency of adverse drug events at Nationwide Children’s Hospital. The fact that the program was quite successful is almost beside the point. The article provides a comprehensive, practical report of the many different interventions used in this endeavor, as well as a nice introduction to many facets of quality improvement science. Article page 1222<
S
ammallahti et al conducted a cohort study of 103 former very low birth weight preterm infants now at mean age 25 years to distinguish whether faster growth from birth to term age and during the first year thereafter predicted neurocognitive abilities. After adjustment for confounding neonatal complications, the investigators found that faster growth from birth to term in head circumference, but not weight or length, predicted intelligence quotient in young adulthood. Growth in weight, length, and head circumference from term to age 12 months did not predict cognitive outcome. The first weeks after birth may well be critical for brain development. This study points once again to the importance of following head circumference for premature infants. Measurement of occipitofrontal circumference in the intensive care nursery may add predictive neurocognitive outcome data for both physicians and parents. Article page 1109<
D
eveloping a clear picture of vascular changes related to atherosclerosis has been difficult in young patients. One reason for this has been the paucity of noninvasive ways of following the development of pathology of the vasculature. This has forced an emphasis on evaluation of risk factors, which do not always provide the best prediction. In this issue, Kurniawan et al use retinal photographs to evaluate retinal arteriolar and venular caliber. A computer-based program provided measures including the central retinal artery equivalent and central retinal vein equivalent. They found that increased BMI is associated with increasing retinal venular caliber over time. This suggests that following retinal venular widening could be a way to assess adverse microvascular changes in research and possibly in clinical practice. Article page 1166< Vol. 165, No. 6
Recovery from concussion — Thomas R. Welch, MD
T
he professional and lay media have been filled with discussions about concussion, especially among young and adult athletes. The practitioner may have difficulty keeping track of all these new developments and understanding the important points that should become incorporated into practice. This issue of The Journal contains an interesting and important article that certainly will inform practice. Corwin et al from Philadelphia studied a cohort of children in their institution with concussion, asking the question whether there were ways in which the children who had a prolonged recovery (over 4 weeks of symptoms) could be recognized early. These children had fairly significant disability, and recognizing them early in their course could be very helpful in working with children, their families, and schools. Corwin et al present a number of simple historical and physical examination findings, which, when present at the time of initial evaluation, identify children at risk for prolonged symptoms. This is not a battery of high-tech diagnostic interventions, but some easily identifiable markers that can quickly become incorporated into practice. Article page 1207<
December 2014
1075