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Cartoon characters on food packages influence taste and snack preferences in young children
THE JOURNAL OF PEDIATRICS
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The dose-response effect showing a greater increase in quality of life associated with number of calls supports the potential benefit of this intervention. As the authors suggest, the practical lessons learned may be the most useful finding of this study. Using call-center nurses to provide the intervention is a creative use of existing resources, given their experience in providing phone-based care. Future efforts could explore more cost-effective methods given success in studies using other types of providers. Joseph Zorc, MD Children’s Hospital of Philadelphia Philadelphia, Pennsylvania
Vol. 158, No. 1 a valuable contribution and should inspire vaccine and drug safety researchers outside the United States. The doubling of febrile seizure risk after MMRV complicates which vaccine to recommend. When discussing risks and benefits for the individual child, it will be important to assess other febrile seizure risk factors such as prematurity and personal or familial history of seizures. If these are present, a doubling of risk will be much more clinically significant than among children without febrile seizure risk factors. Such considerations highlight the importance and the need for more research into the potential heterogeneity of vaccine effects between individuals. Anders Hviid, MSc, Dr Med Sci Statens Serum Institut Copenhagen, Denmark
Measles-mumps-rubella-varicella combination vaccine increases risk of febrile seizure Klein NP, Fireman B, Yih WK, Lewis E, Kulldorff M, Ray P, et al. Measles-Mumps-Rubella-Varicella Combination Vaccine and the Risk of Febrile Seizures. Pediatrics 2010;126:e1-8.
Cartoon characters on food packages influence taste and snack preferences in young children
Question Among children receiving the combination measles-mumps-rubella-varicella (MMRV) vaccine, is there an increased risk of seizure?
Roberto CA, Baik J, Harris JL, Brownell KD. Influence of Licensed Characters on Children’s Taste and Snack Preferences. Pediatrics 2010;126:88-93.
Design Post-marketing surveillance.
Question In young children, does the presence of popular licensed cartoon characters on food packaging affect their taste and snack preferences?
Setting 7 Vaccine Safety Datalink (VSD) clinical sites in the United States. Participants Children aged 12 to 23 months who had received MMRV (n = 83 107) and separate MMR and varicella (MMR+V) vaccines (n = 376 354). Intervention Using the VSD, the investigators defined a seizure event as the first instance within 42 days after vaccination. Outcomes Seizure risk after MMRV vaccine to that after MMR+V vaccines. Main Results Seizure and fever significantly clustered 7 to 10 days after vaccination with all measles-containing vaccines but not after varicella vaccination alone. Seizure risk during days 7 to 10 was higher after MMRV than after MMR+V vaccination (relative risk, 1.98 [95% confidence interval, 1.43 to 2.73]). Supplementary analyses yielded similar results. The excess risk for febrile seizures 7 to 10 days after MMRV compared with separate MMR and varicella vaccination was 4.3 per 10 000 doses (95% confidence interval, 2.6 to 5.6). Conclusions Among 12- to 23-month-olds who received their first dose of measles-containing vaccine, fever and seizure were elevated 7 to 10 days after vaccination. Vaccination with MMRV results in 1 additional febrile seizure for every 2300 doses given instead of separate MMR and varicella vaccines. Commentary The study by Klein et al demonstrates an additional increased risk of febrile seizures after MMRV compared with MMR+V. The study utilizes novel methodology. Most notable is the use of rapid cycle analysis. This method has been developed by the Vaccine Safety Datalink team to identify safety issues in a timely manner for new vaccines. This is 170
Design Controlled trial with children serving as their own controls. Setting Four child care centers in New Haven, Connecticut. Participants 40 children aged 4 to 6 years. Intervention Children tasted 3 pairs of identical foods (graham crackers, gummy fruit snacks, and carrots) presented in packages either with or without a popular cartoon character. Outcomes Taste preference for each of the paired foods and choice of one of the pair as a snack. Main Results Children significantly preferred the taste of foods that had popular cartoon characters on the packaging, compared with the same foods without characters. The majority of children selected the food sample with a licensed character on it for their snack, but the effects were weaker for carrots than for gummy fruit snacks and graham crackers. Conclusions Branding food packages with licensed characters substantially influences young children’s taste preferences and snack selection and does so most strongly for energy-dense, nutrient-poor foods. These findings suggest that the use of licensed characters to advertise junk food to children should be restricted. Commentary This report addresses a timely topic using a straightforward study design that generated robust results. There are some limitations to interpretation. The sample is quite diverse yet small, and power may therefore be limited to determine if the effect differed across subgroups (ie, those experiencing more versus less media exposure at home). Though results were relatively consistent across measures,
CURRENT BEST EVIDENCE
January 2011 there was also no direct test of the validity or test-retest reliability of the children’s stated food preferences, assessment issues which have been the focus of significant prior work. The fact that the evaluator was not blind to study hypotheses is also a significant limitation. Overall, the study confirms a number of concepts that have been well-described in the eating behavior literature for several decades,1 though it cannot be determined from the design which mechanism is actually at work here. Specifically, foods are more liked when they are associated with an admired model, linked with a positive affective experience, or made to seem more familiar. Any or all of these three mechanisms could be responsible for the observed effect. Mechanism, however, may be less relevant here than the practical implications of this study: these types of characters should not be used to advertise foods that are obesity-promoting to children. Julie Lumeng, MD University of Michigan Ann Arbor, Michigan
Reference 1. Birch L, Fisher J. Development of eating behaviors among children and adolescents. Pediatrics 1998;101:539–49.
Short course of intravenous antibiotics is as effective as longer course in infants with urinary tract infection Brady PW, Conway PH, Goudie A. Length of Intravenous Antibiotic Therapy and Treatment Failure in Infants With Urinary Tract Infections. Pediatrics 2010;126:196-203. Question In young infants hospitalized with urinary tract infections (UTIs), is there a difference in treatment failure between those treated with short duration (#3 days) and long-duration ($4 days) intravenous antibiotic therapy? Design Retrospective cohort study. Setting Twenty-four children’s hospitals in the United States affiliated with a single corporation. Participants Infants <6 months of age who were hospitalized with UTIs between 1999 and 2004. Outcomes Treatment failure, defined as readmission because of UTI within 30 days. Main Results Of the 12 333 infants who met the inclusion criteria, 240 (1.9%) experienced treatment failure. The treatment failure rates were 1.6% for children who received short-course intravenous antibiotic treatment and 2.2% for children who received long-course treatment. Treatment courses varied substantially across hospitals and with patient-level characteristics. After multivariate adjustment, including propensity scores, there was no significant association between treatment group and outcomes, with an odds ratio for long versus short treatment of 1.02 (95% confidence
interval, 0.77 to 1.35). Known presence of genitourinary abnormalities, but not age, predicted treatment failure. Conclusions Treatment failure for generally healthy young infants hospitalized with UTIs is uncommon and is not associated with the duration of intravenous antibiotic treatment. Treating more infants with short courses of intravenous antibiotic therapy might decrease resource use without affecting readmission rates. Commentary When infants are admitted with UTI, empirical antibiotics will usually be started intravenously. Ideally, after 2 to 4 days this will be switched to appropriate oral antibiotics based on a reassessment of the clinical response and the results of the blood and/or urine culture. In this respect, early switch to oral antibiotics may shorten hospital stay and thus reduce medical costs. However, the success of antimicrobial stewardship programs supporting such ‘‘early switch’’ might be hindered by physicians’ preference for intravenous treatment, especially among those with persistent fever or insufficient clinical improvement.1 In the present study, the length of intravenous treatment was not associated with treatment failure. This indicates that an early switch to oral treatment in children with UTI is safe and should be achieved to save health care expenditures. However, it should be emphasized that though the authors used adequate statistical methods to avoid bias, residual confounding by indication might still explain their main outcome, as it is a retrospective study. Nevertheless, this large study supports previous findings that oral antibiotic treatment is as effective as intravenous antibiotic treatment in children with UTI.2,3 Interestingly, this study also showed that age and the presence of bacteremia were not predictors for treatment failure. Therefore, such factors should not prolong intravenous treatment. Furthermore, there were huge differences between hospitals with respect to duration of intravenous treatment. This supports that local policies, habits, and physician behavior, rather than patient factors, determine the duration of intravenous treatment. Efforts should therefore be focused on behavioral change according to the rationale and evidencebased principle that oral antibiotics with good bioavailability are as effective as intravenous ones. Cees van Nieuwkoop, MD Leiden University Medical Center Leiden, The Netherlands
References 1. Mertz D, Koller M, Lampert ML, Plagge H, Hug B, Koch G, et al. Outcomes of early switching from intravenous to oral antibiotics on medical wards. J Antimicrob Chem 2009;64. 188–99. 2. Hoberman A, Wald ER, Hickey RW, Baskin M, Charron M, Majd M, et al. Oral versus initial intravenous therapy for urinary tract infection in young febrile children. Pediatrics 1999;104:79-86. 3. Montini G, Toffolo A, Zuccchetta P, Dall’Amico R, Gobber D, Calderan A, et al. Antibiotic treatment for pyelonephritis in children: multicentre randomized controlled non-inferiority trial. BMJ 2007;335:386. 171
www.jpeds.com
The dose-response effect showing a greater increase in quality of life associated with number of calls supports the potential benefit of this intervention. As the authors suggest, the practical lessons learned may be the most useful finding of this study. Using call-center nurses to provide the intervention is a creative use of existing resources, given their experience in providing phone-based care. Future efforts could explore more cost-effective methods given success in studies using other types of providers. Joseph Zorc, MD Children’s Hospital of Philadelphia Philadelphia, Pennsylvania
Vol. 158, No. 1 a valuable contribution and should inspire vaccine and drug safety researchers outside the United States. The doubling of febrile seizure risk after MMRV complicates which vaccine to recommend. When discussing risks and benefits for the individual child, it will be important to assess other febrile seizure risk factors such as prematurity and personal or familial history of seizures. If these are present, a doubling of risk will be much more clinically significant than among children without febrile seizure risk factors. Such considerations highlight the importance and the need for more research into the potential heterogeneity of vaccine effects between individuals. Anders Hviid, MSc, Dr Med Sci Statens Serum Institut Copenhagen, Denmark
Measles-mumps-rubella-varicella combination vaccine increases risk of febrile seizure Klein NP, Fireman B, Yih WK, Lewis E, Kulldorff M, Ray P, et al. Measles-Mumps-Rubella-Varicella Combination Vaccine and the Risk of Febrile Seizures. Pediatrics 2010;126:e1-8.
Cartoon characters on food packages influence taste and snack preferences in young children
Question Among children receiving the combination measles-mumps-rubella-varicella (MMRV) vaccine, is there an increased risk of seizure?
Roberto CA, Baik J, Harris JL, Brownell KD. Influence of Licensed Characters on Children’s Taste and Snack Preferences. Pediatrics 2010;126:88-93.
Design Post-marketing surveillance.
Question In young children, does the presence of popular licensed cartoon characters on food packaging affect their taste and snack preferences?
Setting 7 Vaccine Safety Datalink (VSD) clinical sites in the United States. Participants Children aged 12 to 23 months who had received MMRV (n = 83 107) and separate MMR and varicella (MMR+V) vaccines (n = 376 354). Intervention Using the VSD, the investigators defined a seizure event as the first instance within 42 days after vaccination. Outcomes Seizure risk after MMRV vaccine to that after MMR+V vaccines. Main Results Seizure and fever significantly clustered 7 to 10 days after vaccination with all measles-containing vaccines but not after varicella vaccination alone. Seizure risk during days 7 to 10 was higher after MMRV than after MMR+V vaccination (relative risk, 1.98 [95% confidence interval, 1.43 to 2.73]). Supplementary analyses yielded similar results. The excess risk for febrile seizures 7 to 10 days after MMRV compared with separate MMR and varicella vaccination was 4.3 per 10 000 doses (95% confidence interval, 2.6 to 5.6). Conclusions Among 12- to 23-month-olds who received their first dose of measles-containing vaccine, fever and seizure were elevated 7 to 10 days after vaccination. Vaccination with MMRV results in 1 additional febrile seizure for every 2300 doses given instead of separate MMR and varicella vaccines. Commentary The study by Klein et al demonstrates an additional increased risk of febrile seizures after MMRV compared with MMR+V. The study utilizes novel methodology. Most notable is the use of rapid cycle analysis. This method has been developed by the Vaccine Safety Datalink team to identify safety issues in a timely manner for new vaccines. This is 170
Design Controlled trial with children serving as their own controls. Setting Four child care centers in New Haven, Connecticut. Participants 40 children aged 4 to 6 years. Intervention Children tasted 3 pairs of identical foods (graham crackers, gummy fruit snacks, and carrots) presented in packages either with or without a popular cartoon character. Outcomes Taste preference for each of the paired foods and choice of one of the pair as a snack. Main Results Children significantly preferred the taste of foods that had popular cartoon characters on the packaging, compared with the same foods without characters. The majority of children selected the food sample with a licensed character on it for their snack, but the effects were weaker for carrots than for gummy fruit snacks and graham crackers. Conclusions Branding food packages with licensed characters substantially influences young children’s taste preferences and snack selection and does so most strongly for energy-dense, nutrient-poor foods. These findings suggest that the use of licensed characters to advertise junk food to children should be restricted. Commentary This report addresses a timely topic using a straightforward study design that generated robust results. There are some limitations to interpretation. The sample is quite diverse yet small, and power may therefore be limited to determine if the effect differed across subgroups (ie, those experiencing more versus less media exposure at home). Though results were relatively consistent across measures,
CURRENT BEST EVIDENCE
January 2011 there was also no direct test of the validity or test-retest reliability of the children’s stated food preferences, assessment issues which have been the focus of significant prior work. The fact that the evaluator was not blind to study hypotheses is also a significant limitation. Overall, the study confirms a number of concepts that have been well-described in the eating behavior literature for several decades,1 though it cannot be determined from the design which mechanism is actually at work here. Specifically, foods are more liked when they are associated with an admired model, linked with a positive affective experience, or made to seem more familiar. Any or all of these three mechanisms could be responsible for the observed effect. Mechanism, however, may be less relevant here than the practical implications of this study: these types of characters should not be used to advertise foods that are obesity-promoting to children. Julie Lumeng, MD University of Michigan Ann Arbor, Michigan
Reference 1. Birch L, Fisher J. Development of eating behaviors among children and adolescents. Pediatrics 1998;101:539–49.
Short course of intravenous antibiotics is as effective as longer course in infants with urinary tract infection Brady PW, Conway PH, Goudie A. Length of Intravenous Antibiotic Therapy and Treatment Failure in Infants With Urinary Tract Infections. Pediatrics 2010;126:196-203. Question In young infants hospitalized with urinary tract infections (UTIs), is there a difference in treatment failure between those treated with short duration (#3 days) and long-duration ($4 days) intravenous antibiotic therapy? Design Retrospective cohort study. Setting Twenty-four children’s hospitals in the United States affiliated with a single corporation. Participants Infants <6 months of age who were hospitalized with UTIs between 1999 and 2004. Outcomes Treatment failure, defined as readmission because of UTI within 30 days. Main Results Of the 12 333 infants who met the inclusion criteria, 240 (1.9%) experienced treatment failure. The treatment failure rates were 1.6% for children who received short-course intravenous antibiotic treatment and 2.2% for children who received long-course treatment. Treatment courses varied substantially across hospitals and with patient-level characteristics. After multivariate adjustment, including propensity scores, there was no significant association between treatment group and outcomes, with an odds ratio for long versus short treatment of 1.02 (95% confidence
interval, 0.77 to 1.35). Known presence of genitourinary abnormalities, but not age, predicted treatment failure. Conclusions Treatment failure for generally healthy young infants hospitalized with UTIs is uncommon and is not associated with the duration of intravenous antibiotic treatment. Treating more infants with short courses of intravenous antibiotic therapy might decrease resource use without affecting readmission rates. Commentary When infants are admitted with UTI, empirical antibiotics will usually be started intravenously. Ideally, after 2 to 4 days this will be switched to appropriate oral antibiotics based on a reassessment of the clinical response and the results of the blood and/or urine culture. In this respect, early switch to oral antibiotics may shorten hospital stay and thus reduce medical costs. However, the success of antimicrobial stewardship programs supporting such ‘‘early switch’’ might be hindered by physicians’ preference for intravenous treatment, especially among those with persistent fever or insufficient clinical improvement.1 In the present study, the length of intravenous treatment was not associated with treatment failure. This indicates that an early switch to oral treatment in children with UTI is safe and should be achieved to save health care expenditures. However, it should be emphasized that though the authors used adequate statistical methods to avoid bias, residual confounding by indication might still explain their main outcome, as it is a retrospective study. Nevertheless, this large study supports previous findings that oral antibiotic treatment is as effective as intravenous antibiotic treatment in children with UTI.2,3 Interestingly, this study also showed that age and the presence of bacteremia were not predictors for treatment failure. Therefore, such factors should not prolong intravenous treatment. Furthermore, there were huge differences between hospitals with respect to duration of intravenous treatment. This supports that local policies, habits, and physician behavior, rather than patient factors, determine the duration of intravenous treatment. Efforts should therefore be focused on behavioral change according to the rationale and evidencebased principle that oral antibiotics with good bioavailability are as effective as intravenous ones. Cees van Nieuwkoop, MD Leiden University Medical Center Leiden, The Netherlands
References 1. Mertz D, Koller M, Lampert ML, Plagge H, Hug B, Koch G, et al. Outcomes of early switching from intravenous to oral antibiotics on medical wards. J Antimicrob Chem 2009;64. 188–99. 2. Hoberman A, Wald ER, Hickey RW, Baskin M, Charron M, Majd M, et al. Oral versus initial intravenous therapy for urinary tract infection in young febrile children. Pediatrics 1999;104:79-86. 3. Montini G, Toffolo A, Zuccchetta P, Dall’Amico R, Gobber D, Calderan A, et al. Antibiotic treatment for pyelonephritis in children: multicentre randomized controlled non-inferiority trial. BMJ 2007;335:386. 171