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Ambulatory blood pressure and cardiac abnormalities
Do we have enough pediatric endocrinologists? Issues of workforce are currently very important. There is ongoing discussion regarding whether we have the right number and geographic distribution of pediatricians and pediatric subspecialists. One way of evaluating this is to look at the population prevalence of disease and match that to the number of available providers. In this issue of The Journal, Lee et al report on the evaluation of the geographic distribution of childhood diabetes and obesity and the supply of pediatric endocrinologists. They found that the distribution of endocrinologists does not parallel the distribution of children with diabetes and obesity. In fact, there is up to a 19-fold difference in the observed ratios of obese children and endocrinologists. This analysis raises important questions about the distribution of pediatric endocrinologists and the best methods to develop appropriate systems of care for children with diabetes and obesity in areas where there are fewer endocrinologists.
—Stephen R. Daniels, MD, PhD page 331
Off-label use and evidence of efficacy and safety for drugs in a tertiary-care neonatal intensive care unit In this issue of The Journal, Kumar et al report reassuring, as well as concerning findings from a Chicago neonatal intensive care unit (NICU). Of parenteral medications administered to NICU patients over a 3-year period, 45% were used off-label (i.e., not approved by the U.S. Food and Drug Administration for neonates). However, for more than 90% of parenteral medications used off-label, there was “Level 1” evidence of efficacy and safety in neonates (i.e., at least one randomized clinical trial regardless of size or the heterogeneity of patients). The authors and other neonatologists advocate for more robust, as well as longer outcome studies of medications used in this very vulnerable population.
—Sarah S. Long, MD page 412 (Kumar) page 416 (Cohen)
What is ALTE? Apparent life threatening events (ALTE) are a major headache for both parents and emergency rooms. Infants with these events are defined as having an episode that is frightening to the observer and characterized by some combination of apnea, color change, change in muscle tone, and choking or gagging that requires vigorous stimulation. This is a rather global and imprecise definition to use diagnostically, based on caretaker history. The concern has been that ALTE is an aborted SIDS event. The consistent result of an emergency room visit for ALTE is a complex and expensive evaluation that results in no clear answer as to what caused the ALTE in most cases. The CHIME study prospectively monitored term infants, siblings of SIDS, and preterm infants to learn about what kind of cardiorespiratory events were occurring. The study also enrolled 153 ALTE cases. Esani et al report that infants with ALTE differ from the well-established epidemiology of SIDS. The ALTE infants were younger, less frequently low birth weight or growth restricted, and had fewer teenage mothers. While not clearly separating the populations of ALTE and SIDS patients, the populations do have differences suggesting different etiologies. Only one infant presenting with ALTE died of SIDS. We still do not know what causes ALTE.
—Alan H. Jobe, MD, PhD page 365
Ambulatory blood pressure and cardiac abnormalities It is well-known that children with established hypertension are at increased risk to develop left ventricular hypertrophy. It is less clear whether children who are at risk of developing hypertension, or who have pre-hypertension, are also at risk of cardiac abnormalities. In this issue of The Journal, Richey et al evaluated young patients with blood pressure greater than the 90th percentile, or with a first degree relative with hypertension. They used 24-Hour Ambulatory Blood Pressure Monitoring (ABPM) to better characterize the level of blood pressure. They found a positive correlation between left ventricular mass index and ABPM measures. These results suggest that ABPM may be a useful method to evaluate blood pressure in young patients who have hypertension or are at risk of hypertension.
—Stephen R. Daniels, MD, PhD page 343
A2
March 2008
The Journal of Pediatrics
—Stephen R. Daniels, MD, PhD page 331
Off-label use and evidence of efficacy and safety for drugs in a tertiary-care neonatal intensive care unit In this issue of The Journal, Kumar et al report reassuring, as well as concerning findings from a Chicago neonatal intensive care unit (NICU). Of parenteral medications administered to NICU patients over a 3-year period, 45% were used off-label (i.e., not approved by the U.S. Food and Drug Administration for neonates). However, for more than 90% of parenteral medications used off-label, there was “Level 1” evidence of efficacy and safety in neonates (i.e., at least one randomized clinical trial regardless of size or the heterogeneity of patients). The authors and other neonatologists advocate for more robust, as well as longer outcome studies of medications used in this very vulnerable population.
—Sarah S. Long, MD page 412 (Kumar) page 416 (Cohen)
What is ALTE? Apparent life threatening events (ALTE) are a major headache for both parents and emergency rooms. Infants with these events are defined as having an episode that is frightening to the observer and characterized by some combination of apnea, color change, change in muscle tone, and choking or gagging that requires vigorous stimulation. This is a rather global and imprecise definition to use diagnostically, based on caretaker history. The concern has been that ALTE is an aborted SIDS event. The consistent result of an emergency room visit for ALTE is a complex and expensive evaluation that results in no clear answer as to what caused the ALTE in most cases. The CHIME study prospectively monitored term infants, siblings of SIDS, and preterm infants to learn about what kind of cardiorespiratory events were occurring. The study also enrolled 153 ALTE cases. Esani et al report that infants with ALTE differ from the well-established epidemiology of SIDS. The ALTE infants were younger, less frequently low birth weight or growth restricted, and had fewer teenage mothers. While not clearly separating the populations of ALTE and SIDS patients, the populations do have differences suggesting different etiologies. Only one infant presenting with ALTE died of SIDS. We still do not know what causes ALTE.
—Alan H. Jobe, MD, PhD page 365
Ambulatory blood pressure and cardiac abnormalities It is well-known that children with established hypertension are at increased risk to develop left ventricular hypertrophy. It is less clear whether children who are at risk of developing hypertension, or who have pre-hypertension, are also at risk of cardiac abnormalities. In this issue of The Journal, Richey et al evaluated young patients with blood pressure greater than the 90th percentile, or with a first degree relative with hypertension. They used 24-Hour Ambulatory Blood Pressure Monitoring (ABPM) to better characterize the level of blood pressure. They found a positive correlation between left ventricular mass index and ABPM measures. These results suggest that ABPM may be a useful method to evaluate blood pressure in young patients who have hypertension or are at risk of hypertension.
—Stephen R. Daniels, MD, PhD page 343
A2
March 2008
The Journal of Pediatrics