The relationship between childhood behaviour disorders and unintentional injury events

OBJECTIVE

To examine the controversy regarding the existence of a relationship between behavioural disorders and unintentional injuries in children.

DESIGN

A retrospective cohort analysis of children between six and 19 years of age, who were diagnosed with attention deficit hyperactivity disorder (ADHD) only (n=955), ADHD plus conduct problems (CP) (n=160), or CP only (n=234), were compared with a nondisorder group of children (n=21,308) for unintentional injury events resulting in a physician office or emergency room visit, or hospitalization.

RESULTS

The risk of an injury event was greater among children with a behaviour disorder diagnosis and severity of injury varied among the behaviour disorder groups. Children with ADHD were the only disorder group at increased risk for all three injury outcomes. Children with a comorbid diagnosis were at a greater risk for both minor and more serious emergency injury visits, and children with CP only were at greatest risk for the most serious injuries (hospital admission).

CONCLUSIONS

These findings provide further support that children with ADHD are at an increased risk for not only hospitalized injury events but also minor injury events. In addition, these findings provide evidence that serious injuries are more likely to be experienced by children with CP.     

Paediatric hanging and strangulation injuries: A 10-year retrospective description of clinical factors and outcomes

OBJECTIVE:

To identify early clinical factors that are correlated with death or severe disability in paediatric patients who have sustained an injury by hanging or strangulation.

METHODS:

A retrospective review of all patient records from January 1, 1997, to September 30, 2007, was conducted. Patient records were identified by International Classification of Diseases and Related Health Problems, Tenth Revision, Canada diagnostic codes for asphyxia, strangulation, hypoxic-ischemic encephalopathy, hanging, hypoxemia, hypoxia or anoxia.

RESULTS:

A total of 109 records were identified. Of these, 41 met the inclusion criteria for the study. Of 19 (46%) children who were pulse-less and received cardiopulmonary resuscitation, 16 died and the survivors were severely disabled. Of the 22 (54%) children who were found with a pulse, 18 made a full recovery.

CONCLUSIONS:

Children who are pulseless at discovery for hanging injuries are at high risk of death or severe disability. Early clinical and neurophysiological indicators should be applied systematically to best guide clinicians and parents in their decision making.     

Characteristics and outcomes of children with enterostomy feeding tubes: A study of 325 children

OBJECTIVES:

To examine the characteristics and outcomes of children with gastrostomy and gastrojejunostomy tubes inserted before age three years, and to identify the factors that predict removal of the enterostomy tubes within 12 months of insertion.

DESIGN:

Case review of a consecutive sample of 325 medical records.

SETTING:

A tertiary care paediatric hospital that is situated in a large metropolitan area.

PATIENTS:

All outpatients and inpatients from birth to 36 months of age who had an enterostomy tube inserted from 1994 to 1996.

METHODS:

No direct intervention was provided. In the subgroup of 203 patients with a follow-up period of at least 12 months after tube insertion, children whose tubes were removed within 12 months of insertion were compared with children who continued to receive tube feedings for 12 months or longer.

RESULTS:

At the time of tube insertion, the median age of patients was six months; 47% of the children for whom data were available were failing to thrive. Although 66 (21%) of 321 patients for whom data were available had their tubes removed, only 25 of the 203 (12%) patients with a follow-up period of 12 months or more had their tubes removed within 12 months of insertion. Children whose tubes were removed less than 12 months after insertion differed from children whose tubes were not removed with respect to medical diagnosis (no children with cerebral palsy had their tubes removed versus 33% of children with cancer who had their tube removed). Most children with failure to thrive at the time of tube insertion were also failing to thrive at the time of tube removal.

CONCLUSION:

Children with cerebral palsy are not likely to have enterostomy tubes removed within one year of insertion.     

Patterns of reporting by health care and nonhealth care professionals to child protection services in Canada

BACKGROUND:

All Canadian jurisdictions require certain professionals to report suspected or observed child maltreatment. The present study examined the types of maltreatment, level of harm and child functioning issues (controlling for family socioeconomic status, age and sex of the child) reported by health care and nonhealth care professionals.

METHODS:

χ² analyses and logistic regression were conducted on a national child welfare sample from the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003), and the differences in professional reporting were compared with its previous cycle (CIS-1998) using Bonferroni-corrected CIs.

RESULTS:

Analysis of the CIS-2003 data revealed that the majority of substantiated child maltreatment was reported to service agencies by nonhealth care professionals (57%), followed by other informants (33%) and health care professionals (10%). The number of professional reports increased 2.5 times between CIS-1998 and CIS-2003, while nonprofessional reports increased 1.7 times. Of the total investigations, professional reports represented 59% in CIS-1998 and 67% in CIS-2003 (P<0.001). Compared with nonhealth care professionals, health care professionals more often reported younger children, children who experienced neglect and emotional maltreatment, and those assessed as suffering harm and child functioning issues, but less often reported exposure to domestic violence.

CONCLUSION:

The results indicate that health care professionals play an important role in identifying children in need of protection, considering harm and other child functioning issues. The authors discuss the reasons why under-reporting is likely to remain an issue.     

Childhood drowning in Manitoba: A 10-year review of provincial Paediatric Death Review Committee data

BACKGROUND:

Drowning is the second leading cause of unintentional injury death for Canadian children up to 19 years of age. Specific regional drowning prevention strategies require a detailed understanding of patterns of injury, including risk factors. Paediatric death review committees have the opportunity to identify these risk factors, and to identify and advocate prevention strategies.

OBJECTIVES:

The purpose of the present study was to analyze Manitoba Paediatric Death Review Committee (PDRC) drowning data to identify drowning risk factors and potential prevention strategies.

METHODS:

A 10-year (1988–1997) review of the College of Physicians and Surgeons of Manitoba PDRC database was performed. Drowning deaths were summarized in terms of demographic variables and lack of supervision at the time of the drowning events.

RESULTS:

Seventy-three drowning deaths were reviewed by the PDRC during the study period. These children ranged from 29 days to 14 years of age. They included 50 boys and 30 First Nations children. The highest mortality rates were found in First Nations children (12.4/100,000 First Nations children compared with 1.9/100,000 non-First Nations children), boys (3.9/100,000 boys compared with 1.9/100,000 girls) and toddlers aged one to four years (5.9/100,000 children).

CONCLUSIONS:

Priority populations for drowning prevention in Manitoba include First Nations children, boys and toddlers. Death review committees can contribute to childhood injury prevention by reviewing injury deaths, analyzing and reporting injury mortality data, and identifying and advocating prevention strategies.     

Does parental body mass index status modify the associations among birth weight,early growth and childhood adiposity?

OBJECTIVES:

To examine the associations among birth weight, infant growth and childhood adiposity, and to test whether parental weight status modifies these associations.

METHODS:

The sample was comprised of 423 participants born at term who were an appropriate size for their gestational age from the Quebec Adipose and Lifestyle Investigation in Youth (QUALITY) study, a cohort of 630 children with a parental history of obesity. Infant growth velocity from zero to two years of age was estimated using slopes from simple linear regression for weight and body mass index (BMI) Z-scores. Child anthropometrics and body composition, and parental BMI were measured from eight to 10 years of age. Associations were modelled using multiple linear regressions.

RESULTS:

Increased birth weight and growth velocity independently predicted increased childhood adiposity. Effects of infant growth velocity on later adiposity were stronger with higher maternal BMI but not with higher paternal BMI. Similar interactions with birth weight were not found.

CONCLUSIONS:

Early childhood measures of growth and the mother’s BMI score should be included in investigations on obesity risk.     

Influenza vaccination options to prevent hospitalization

BACKGROUND:

Vaccination of children against influenza remains a controversial topic despite the substantial morbidity caused by this infection.

OBJECTIVE:

To estimate the effect of three different vaccination strategies on preventing hospitalization due to influenza.

METHODS:

A retrospective chart review was conducted of all children admitted to a tertiary health care centre who tested positive for influenza during three consecutive influenza seasons.

RESULTS:

The final analysis included 208 cases with an age range of five days to 16.1 years. Seventy-six children were considered ‘high-risk’ and 132 were considered ‘previously healthy’. Length of stay (LOS) ranged from one day to 46 days with a mean of 6.3 days. The mean LOS was 8.6 days for children with risk factors and 4.9 days for those without risk factors. The number of preventable influenza admissions was determined over three years and averaged over one year for the three vaccination strategies. A universal strategy of vaccinating all previously healthy and high-risk children over six months of age would have prevented 118 admissions. Using a selective strategy of vaccinating only children over six months of age with risk factors and a third strategy of vaccinating only two- to six-month-old infants would have prevented 58 and 55 admissions, respectively.

CLINICAL IMPLICATION:

Use of the universal vaccination strategy would have prevented over one-half of the influenza admissions, which was over twice that of targeted vaccination. Until the challenges of implementing universal vaccination are fully understood, targeted vaccination remains an acceptable alternative.     

Starting subcutaneous insulin doses in a paediatric population with newly diagnosed type 1 diabetes

BACKGROUND:

Starting subcutaneous insulin doses in children with newly diagnosed type 1 diabetes vary widely from 0.2 units/kg/day to 0.8 units/kg/day.

AIM:

To determine whether there are correlations between starting insulin dose and diabetes-related outcomes.

METHODS:

By reviewing the charts of children newly diagnosed with type 1 diabetes, the prevalence of hypoglycemia in the first 48 h was compared between those who received low (0.5 units/kg/day or less) and those who received high (greater than 0.5 units/kg/day) starting insulin doses.

RESULTS:

Forty-two children were initially prescribed a low dose of insulin, and 55 children were given a high dose. Approximately one-third of children (36.4%) younger than six years of age who received a high starting dose of insulin had mild hypoglycemia within 48 h of subcutaneous insulin initiation, compared with 16.0% of children six to 10 years of age and 5.3% of children older than 10 years of age.

CONCLUSIONS:

Hypoglycemia was not more frequent among children given high-insulin starting doses. However, children younger than six years of age remained at increased risk for hypoglycemia.     

Parental anxiety and family disruption following a first febrile seizure in childhood

OBJECTIVE:

To evaluate the degree of parental anxiety and family disruption following a child’s first febrile seizure.

PATIENTS AND METHODS:

The families of all children presenting with their first febrile seizure to any of the three emergency departments in the Saskatoon District, Saskatchewan, were invited to participate in a telephone interview to assess the degree of parental anxiety and family dysfunction that was experienced. Parameters measured included co-sleeping with the child, parental sleep disturbance, parental fatigue, monitor use, the number of night time checks on a child, child care use, parental outings, parental fear of missing a seizure, parental perception of a child’s increased vulnerability and the family’s stress level. The interview, which was conducted shortly after presentation at the emergency departments, compared anxiety and dysfunction experienced during the two weeks immediately preceding the visit with that experienced during the two weeks following a febrile seizure. Potential predictors of anxiety and dysfunction, including details of the presenting seizure, past medical illnesses, family history, the family’s socioeconomic status and parental perception of the risk of a febrile seizure were queried.

RESULTS:

Thirty-one (89%) of 35 families who were eligible for the study participated. Parental anxiety and family dysfunction were significantly greater for nearly all of the parameters assessed during the two weeks following a seizure. Socioeconomic factors correlated most closely with anxiety and dysfunction before a febrile seizure; however, socioeconomic factors were less predictive of anxiety and dysfunction during the two weeks following a seizure.

CONCLUSIONS:

Parental anxiety and family dysfunction are the rule following a child’s first febrile seizure. Neither higher socioeconomic status nor an understanding of the low risk of sequelae associated with febrile seizures was strongly predictive of improved coping during the two weeks following a seizure.     

Psychiatric treatment: A risk factor for obesity?

BACKGROUND:

People with psychiatric diagnoses have increased physical health difficulties.

OBJECTIVES:

To examine the physical growth parameters documented in children receiving psychiatric treatment.

METHODS:

A chart review was performed on consecutive paediatric consultations in 1997 and 1998 on 34 children six to 12 years of age admitted to an intermediate-stay psychiatric inpatient service. Growth parameters of each child were plotted on standard growth curves. The prevalence of obesity (body mass index at or above the 95th percentile), absolute weight at or above the 95th and 50th percentiles, underweight status, tall and short stature, macrocephaly and microcephaly were calculated. The prevalence of atypical findings was compared with the expected prevalence of typical growth parameters in the general population. Risk factors for atypical growth parameters were recorded. An association between weight and specific medication use was explored.

RESULTS:

It was found that 11.8% of the children were obese. It was also found that 23.5% of the children had weight at or above the 95th percentile, 79.3% had weight at or above the 50th percentile, 14.7% had macrocephaly and 79.4% had a head circumference above the 50th percentile; these results were statistically significant. The mean number of psychotropic medications prescribed was 6.4, although there was no significant association between higher weight and current medication type.

CONCLUSIONS:

Children receiving inpatient psychiatric treatment were more likely to have higher weight than typical children. Monitoring growth parameters is an important component of the paediatric care of children with psychiatric diagnoses. Guidelines are required for obesity prevention and intervention in the context of the risk factors experienced by this high risk population.     

Day of discharge and hospital readmission rates within 30 days in children: A population-based study

BACKGROUND

Adults discharged from hospital on a Friday are more likely to be readmitted within 30 days than are adults discharged midweek. No study has examined readmission rates for children by day of discharge.

OBJECTIVE

To determine the risk of readmission within 30 days by day of discharge in the paediatric population.

METHODS

The Canadian Institute for Health Information provided data on children 29 days to 18 years of age who were discharged from hospitals in Ontario between January 1996 and December 2000. Two groups of children (those who were readmitted within 30 days and those who were not) were compared on demographic and clinical characteristics. Multivariable modelling was used to account for potential confounding variables: age, sex, length of hospital stay, number of diagnoses, in-hospital operative procedure, in-hospital complication and hospital admission in the previous six months.

RESULTS

A total of 506,035 hospitalizations (involving 334,959 children) occurred over the study period. Of these children, 3.4% were readmitted within 30 days of discharge. In total, 3.6% of children discharged on a Friday were readmitted within 30 days compared with 3.3% of children discharged on a Wednesday. After adjusting for patient and hospital factors, Friday discharge was not associated with readmission within 30 days (adjusted RR 1.07, 95% CI 0.99 to 1.15). More significant predictors of readmission included number of diagnoses, in-hospital complications and hospital admission in the six months previous to the index admission date.

CONCLUSION

Risk of readmission within 30 days is not significantly increased for children discharged on a Friday compared with children discharged midweek. Significant risk factors for hospital readmission are patient complexity and disease severity.     

Demographic characteristics and needs of the Canadian urban adolescent mother and her child

INTRODUCTION:

There is a paucity of Canadian-based literature on urban adolescent mothers and their children. To inform clinical assessment and interventions and to mitigate the risks that adolescent mothers and their children face, it is essential to understand the characteristics of this high-risk population.

METHODS:

A retrospective review of 116 adolescent mothers attending an urban academic hospital-based outpatient clinic in Canada from 2005 to 2009 was conducted. The following information was collected: demographic characteristics, maternal maltreatment history, substance use, postpartum depression symptoms, and child socioemotional and developmental functioning.

RESULTS:

The mean maternal age was 16.1 years and the mean education level was grade 9. Ninety-nine percent of adolescent mothers were single, 47% had a history of child welfare involvement and 18% had previous involvement with the judicial system. More than one-half of participants reported a history of both maltreatment and substance abuse, and 20% of adolescent mothers scored in the clinical range for postpartum depression. A substantial proportion of children scored in the clinical range for behavioural problems, regulatory difficulties and suspected developmental delays.

CONCLUSION:

The present study serves to illustrate the high-risk nature of urban adolescent mothers. These observations can be used to improve clinical practice for health care providers in community and hospital-based settings working with this population.     

Prednisolone versus dexamethasone in croup: a randomised equivalence trial

Background

Croup remains a common respiratory problem presenting to emergency departments. A single oral treatment of oral dexamethasone results in improved outcome. Prednisolone has similar pharmacokinetic properties and has a significant advantage in that it is commercially available in liquid preparations.

Objective

To ascertain whether a single oral dose of prednisolone was equivalent to a single oral dose of dexamethasone (matched for potency) in children with mild to moderate croup.

Design

A double blind, randomised, controlled equivalence trial

Setting

Tertiary paediatric emergency department.

Patients

133 children aged 3 to 142 months presenting with mild to moderate croup.

Interventions

Children received either a single oral dose of dexamethasone 0.15 mg/kg or single oral dose of prednisolone 1 mg/kg.

Outcome

The main outcome measure was unscheduled re‐presentation to medical care as determined by telephone follow up at 7 to 10 days. Croup score, adrenaline (epinephrine) use, time spent in the emergency department, and duration of croup and viral symptoms were secondary outcome measures.

Results

Children treated with prednisolone were more likely to re‐present: 19 of 65 children (29%) reattended medical care compared with 5 of 68 (7%) from the dexamethasone group. The confidence intervals around this 22% difference in outcome were 8% to 35%, outside the 0% to 7.5% range of equivalence. There were no significant differences in other outcome measures.

Conclusion

A single oral dose of prednisolone is less effective than a single oral dose of dexamethasone in reducing unscheduled re‐presentation to medical care in children with mild to moderate croup.     

Parental perceptions regarding lifestyle interventions for obese children and adolescents with nonalcoholic fatty liver disease

BACKGROUND:

Nonalcoholic fatty liver disease (NAFLD) affects 30% of obese children globally. The main treatment for NAFLD is to promote gradual weight loss through lifestyle modification. Very little is known regarding parental perspectives about the barriers and facilitators that influence the ability to promote healthy lifestyle behaviours in children with NAFLD.

OBJECTIVES:

To explore and describe parental perspectives regarding barriers to and facilitators of implementing lifestyle modification in children with NAFLD.

METHODS:

A mixed-methods approach, including qualitative methodology (focus groups) and validated questionnaires (Lifestyle Behaviour Checklist), was used to assess parental perceptions regarding barriers to and facilitators of lifestyle change in parents of children with healthy body weights (control parents) and in parents of children with NAFLD (NAFLD parents).

RESULTS:

NAFLD parents identified more problem behaviours related to food portion size and time spent in nonsedentary physical activity, and lower parental self-efficacy than parents of controls (P<0.05). Major barriers to lifestyle change cited by NAFLD parents were lack of time, self-motivation and role modelling of healthy lifestyle behaviours. In contrast, control parents used a variety of strategies to elicit healthy lifestyle behaviours in their children including positive role modelling, and inclusion of the child in food preparation and meal purchasing decisions, and perceived few barriers to promoting healthy lifestyles. Internet sources were the main form of nutrition information used by parents.

CONCLUSIONS:

Lifestyle modification strategies focused on promoting increased parental self-efficacy and parental motivation to promote healthy lifestyle behaviour are important components in the treatment of obese children with NAFLD.     

Early neonatal discharge guidelines: Have we dropped the ball?

OBJECTIVES:

To determine patterns of follow-up and prenatal education by family physicians and to assess whether practice patterns comply with the 1996 Canadian Paediatric Society/Society of Obstetricians and Gynecologists of Canada (CPS/SOGC) guidelines for early neonatal discharge.

DESIGN:

Mail survey.

SETTING:

A community of 300,000 people who were served exclusively for obstetrical care by a tertiary care hospital that performs 5000 deliveries per year and provides an early discharge program (EDP).

PARTICIPANTS:

Family physicians who provide prenatal and/or newborn care.

MAIN OUTCOME MEASURES:

The timing of neonatal follow-up and parental teaching by family physicians.

RESULTS:

Thirty-two per cent of the respondents scheduled their first postnatal visits two or more weeks after early discharge. There was no significant difference (P=0.7) in scheduling of follow-up for babies who were part of an EDP compared with those who were not. Fewer than 20% of physician respondents provided antenatal education in preparation for early discharge.

CONCLUSIONS:

The 1996 CPS/SOGC guidelines for physician follow-up after early neonatal discharge and for anticipatory parental education are not being followed consistently; however, these guidelines were disseminated without reinforcement. Until further study supports a change in practice guidelines, appropriate implementation strategies must be employed to ensure compliance.     

Th1/Th2 Cytokine Profile and Its Diagnostic Value in Mycoplasma pneumoniae Pneumonia

Background:

The levels of Th₁/Th₂ cytokine can alter in pathogenic infection in children with pneumonia.

Objectives:

To evaluate Th₁/Th₂ cytokine profile and its diagnostic value in M. pneumoniae pneumonia in children.

Patients and Methods:

Children with M. pneumoniae mono-infection and 30 healthy children were tested with cytokines assay. We used real time PCR to detect M. pneumoniae in children with pneumonia.

Results:

M. pneumoniae test was positive in 2188 (16.62%) out of 13161 pneumonia children. Children aged 5 - 9 years had the highest rate and summer was a season with high rate of M. pneumoniae incidence in Zhejiang province. During the course of study, in 526 pneumonia children with M. pneumoniae mono-infection and 30 healthy children cytokines assay was performed. IL-2 level of M. pneumoniae pneumonia children was lower than that of healthy children (median levels, pg/mL: IL-2: 3.2 vs. 5.7, P = 0.00), while IL-4, IL-10 and IFN-γ were higher than in healthy children (median levels, pg/mL: IL-4: 3.2 vs. 1.5, P = 0.00; IL-10: 5.6 vs. 2.5, P = 0.001; IFN-γ: 20.4 vs. 4.8, P = 0.001).

Conclusions:

IL-2 decreases and IL-4, IL-10 and IFN-γ increase in children with M. pneumoniae pneumonia, which has a promising prospect in diagnosis of this disease in clinical practice.     

Characterisation of morbidity in a UK, hospital based, obesity clinic

Aim

To identify clinical features which predict those most at risk of co‐morbidities within an obesity clinic.

Methods

Children attending an obesity clinic had fasting glucose, insulin, and lipids measured prior to a standard oral glucose tolerance test (OGTT). History and examination established birth weight, family history of type 2 diabetes/obesity, pubertal status, and presence of acanthosis nigricans. Central and total fat mass was estimated by bio‐impedance.

Results

Of the 126 children evaluated, 10.3% (n = 13) had impaired glucose tolerance (IGT); the majority (n = 11) of these would not have been identified on fasting glucose alone. Those with IGT were more likely to have a parental history of type 2 diabetes (relative risk 3.5). IGT was not associated with acanthosis nigricans. Twenty five per cent (n = 19) of those evaluated (n = 75) had evidence of the “metabolic syndrome” (MS). HDL cholesterol and triglyceride levels were related to insulin sensitivity (HOMA‐R); HDL cholesterol was also related to birth weight SDS. We observed a trend for those with MS to have a lower birth weight SDS. The severity of obesity did not influence the likelihood of IGT or MS.

Conclusions

Significant numbers of obese children have associated co‐morbidities. Analysis of fasting blood glucose samples alone is not satisfactory to adequately evaluate glucose homoeostasis. The overall level of obesity does not predict co‐morbidities. Special attention should be given to those with parental diabetes and a history of low birth weight who are more likely to have IGT and abnormal lipid profiles respectively.     

Effect of Playing Interactive Computer Game on Distress of Insulin Injection Among Type 1 Diabetic Children

Background:

Diabetic children and their families experience high level stress because of daily insulin injection.

Objectives:

This study was conducted to investigate the impact of an interactive computer game on behavioral distress due to insulin injection among diabetic children.

Patients and Methods:

In this clinical trial, thirty children (3-12 years) with type 1 diabetes who needed daily insulin injection were recruited and allocated randomly into two groups. Children in intervention groups received an interactive computer game and asked to play at home for a week. No special intervention was done for control group. The behavioral distress of groups was assessed before, during and after the intervention by Observational Scale of Behavioral Distress–Revised (OSBD-R).

Results:

Repeated measure ANOVA test showed no significantly difference of OSBD-R over time for control group (P = 0.08), but this changes is signification in the study group (P = 0.001). Comparison mean score of distress were significantly different between two groups (P = 0.03).

Conclusions:

According to the findings, playing interactive computer game can decrease behavioral distress induced by insulin injection in type 1 diabetic children. It seems this game can be beneficial to be used alongside other interventions.