Maltreatment reports predict sudden infant death syndrome

Maltreatment reports predict sudden infant death syndrome

January 2014  Volume 164  Number 1 You can't diagnose hypertension if you don't know what it is! — Thomas R. Welch, MD Sensory deprivation in priv...

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January 2014  Volume 164  Number 1

You can't diagnose hypertension if you don't know what it is! — Thomas R. Welch, MD

Sensory deprivation in private rooms in the NICU — Alan H. Jobe, MD, PhD

Copyright ª 2014 by Mosby Inc.

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number of studies have suggested that pediatricians are not good at recognizing hypertension in children, even when the child has a recorded blood pressure that is abnormal by normative data. How could this be? Do we not think that hypertension is important, or do we not appreciate that a specific value is abnormal? Of course, recognizing that a specific child’s blood pressure is abnormal generally requires consulting age-, sex-, and height-specific tables. Because physicians probably do not consult such tables for every child at every visit, they must somehow “triage” the children for whom such consultation will be undertaken. Could that be the problem? This issue of The Journal includes a fascinating report by Bijlsma et al in the Netherlands. These authors questioned nearly 200 pediatricians in regard to their practice in assessing blood pressure. Approximately two-thirds of those responding indicated that they only consulted reference tables if they suspected that a blood pressure measurement was elevated. These physicians were then queried about specific measurements in hypothetical children; nearly one-half of them missed at least one of the cases as having hypertension or prehypertension. So, if we only consult reference tables if we suspect that hypertension is present, but if our ability to recognize the child in whom we should be “suspect” is not good, what should we do? Consulting reference tables for virtually every child one sees is probably the only sure fire way to address this issue. Of course, a better solution would be medical informatics support that would regularly identify and flag blood pressures that are abnormal. Article page 173<

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eonatal care has become appropriately “humanized” over past years. Infants are not removed from the mothers and family at birth and early breast-feeding and attachment is encouraged. In the neonatal intensive care unit (NICU) environment, frequent parental visits are encouraged as is skin-to-skin contact with parents. Excessive noise and light are controlled in the NICU environment, and developmental care strategies are used to minimize infant stress. The current trend is to build the NICU to offer small private rooms for the parents and the infant with further noise and light reduction. Parents may appreciate the privacy, but Pineda et al have compared neurodevelopmental outcomes for the infants born at <30 weeks gestational age that were cared for within a large intercity NICU with both open wards and private rooms. Contrary to their hypothesis, at term the infants from the private rooms had less brain maturation, and at 2 years of age they had lower language scores than infants cared for in open wards. The results are biologically plausible as sensory deprivation is known to degrade neurodevelopment, and private rooms will decrease the sensory experiences (sound and light) of the preterm infants. These exposures will be further decreased if parents visit infrequently and only for short periods, which was the case in this NICU. The optimal types and frequencies of stimulations for development of the very preterm brain are unknown, but isolation of these infants in relatively dark and quiet private rooms may be going in the wrong direction. Article page 52< 1

Maltreatment reports predict sudden infant death syndrome — Robert W. Wilmott, MD

Does fetal life influence cardiovascular risk? — Stephen R. Daniels, MD, PhD

Early psychosocial deprivation harms motor development — Robert W. Wilmott, MD

Vitamin D and anemia — Thomas R. Welch, MD

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n the US, approximately 4500 infants die every year with no obvious cause of death and are classified as sudden and unexpected infant deaths (SUID). More than onehalf of these are eventually classified as sudden infant death syndrome (SIDS). In this issue of The Journal, Putnam-Hornstein et al from the University of Southern California have investigated the hypothesis that infants reported for maltreatment face a heightened risk of SIDS and SUID. Data from the California Department of Health and the California Department of Social Services were used, and infant death records were linked to administrative child protection data. Infants were prospectively followed from birth through death or age 1 year. The results show that a previous maltreatment report is a significant predictor of SIDS and SUID. After adjusting for baseline risk factors, the rate of SIDS was more than three times greater among infants reported for possible maltreatment. The results of this prospective study suggest that improved services and communication between child protective services and pediatric healthcare might enhance infant well-being and reduce the risk of SIDS. Article page 142<

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he Barker Hypothesis suggests that fetal growth is an important determinant of later risk of cardiovascular disease. In this issue of The Journal, Mullett et al report the results of a study of over 3000 infants who were followed from birth to fifth grade in West Virginia. They found that overweight and obesity in the fifth grade is strongly associated with having coronary artery risk factors at that age. Being large for gestational age at birth was associated with overweight and obesity later in life. However, the impact of the combination of being small for gestational age and being overweight in fifth grade was associated with the highest level of triglycerides. These results suggest that fetal exposures and growth during fetal life may play a role in longer term risk of heart disease, but the relationships are likely to be complex. Article page 78<

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he hypothesis that early psychosocial deprivation impedes motor development and might be positively impacted by foster care was investigated by Levin et al. They completed a randomized controlled trial of children living in Romanian institutions who were randomly assigned to care as usual in the institution or placed in familycentered foster care as part of an early intervention program. The average time in foster care was 23 months. Children were evaluated with a standard instrument and results show that children who had never been institutionalized had significantly better motor development than children who had never been institutionalized. However, surprisingly, there was no significant difference in outcomes between children in the care as usual group and the family-centered foster care group. Differences in motor development were largely mediated by IQ. The study shows the importance of evaluating and treating motor delays in children with a history of institutionalization, especially for those with a low IQ. Article page 123<

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he significant prevalence of vitamin D deficiency (VDD) in many groups of children is well known today. Indeed, studies showing VDD in various chronic childhood conditions are no longer surprising or novel. In light of this, the report in this issue of The Journal from Atkinson et al at Johns Hopkins is not surprising. Using data from National Health and Nutrition Examination Survey, the authors found an association between low levels of 25-Hydroxyvitamin D and anemia in children. Superficially, one might predict that some of the social and nutritional conditions that could lead to VDD also would be risks for anemia; the study, however, controlled for such obvious confounders as obesity, as well as other measures of nutritional adequacy. Although the study was not designed to demonstrate causality, there are intriguing possible explanations for this finding. Among the many non-skeletal effects of calcitriol, there may be Vol. 164, No. 1

a direct effect on bone marrow; the known immunomodulatory effects of calcitriol might modulate cytokine production, modifying inflammatory pathways that could contribute to anemia. Anemia and VDD are common in children, have serious consequences, and now may be linked. Article page 153<

Long-term respiratory impairment with the new BPD — Robert W. Wilmott, MD

Molecular epidemiology of Staphylococcus aureus colonization — Sarah S. Long, MD

January 2014

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n the presurfactant era, bronchopulmonary dysplasia (BPD) was common and was associated with significant long-term respiratory morbidity. Although survival after extreme preterm birth has been improving and the rate of severe BPD has declined over the past 20 years, a new pattern of lung injury with disruption of lung growth has emerged. This new pattern of BPD seems less severe but long-term data have been sparse. To investigate the long-term outcomes of former very low birth weight (VLBW) preterm infants born in the surfactant era, vom Hove et al from the University of Leipzig have completed a study of pulmonary function tests in children with a history of BPD and VLBW, compared with a matched preterm VLBW control group. They were studied at a mean age of 9.5 years and found to have had significantly more respiratory symptoms and asthma treatments compared with controls. They also had significantly lower values on pulmonary function testing, showing that this newer form of BPD is far from benign. These findings are discussed in an accompanying editorial by Waldemar A. Carlo, MD, from the University of Alabama at Birmingham. Carlo concluded that the results of this study are important because they show that VLBW infants who survived with BPD have high rates of abnormal pulmonary symptoms and pulmonary function tests indicative of expiratory flow limitation at school age which improve with bronchodilator therapy. In addition, many of the asymptomatic children had abnormal pulmonary function tests. Moreover, even children with VLBW who did not have BPD had high rates of abnormal pulmonary symptoms and abnormal pulmonary function tests. It seems that many children are at risk for airflow obstruction and respiratory impairment following prematurity. This emphasizes the need for continued research into therapies that reduce the incidence and severity of BPD. Article page 40< Editorial page 12<

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odriguez et al performed a year-long prospective study of molecular epidemiology of Staphylococcus aureus colonization of 163 children with S aureus skin and soft tissue infections and their 562 household contacts. Samples of the infected site of index cases and swabs from potential colonizing sites of nares, axilla, and inguinal folds were obtained repeatedly from cases and once at case diagnosis from households. Strain relatedness was determined by repetitive sequence-based PCR testing. Results refuted a simplistic idea that a single strain affected a single patient or a single household, let alone multiple patients and multiple households. The study clarifies only the complexity of S aureus niches, potential modes of acquisition and transmission of colonizing organisms, and events that lead to infection. A better understanding of each will be required before postulating and studying strategies for control or eradication. Article page 105<

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