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Autism spectrum disorder is a neurodevelopmental disorder in which genetic factors play key roles. Limited research has been conducted on genetic testing of children with autism spectrum disorder in low middle-income countries. This prospective cross-sectional study was conducted at the pediatric neurology clinics of three university hospitals in Jordan. Data were obtained from a convenience sample of parents of children with autism spectrum disorder who received care at these hospitals. Research personnel interviewed the parents and completed a questionnaire. A total of 274 parents were interviewed. A minority of children received chromosomal microarray (14.6%) or fragile X syndrome (4.4%) testing, as recommended by clinical guidelines. Karyotyping was performed in 103 (37.6%) patients, and whole-exome sequencing was performed in 9 (3.3%). The most common reason for not performing the recommended diagnostic investigations was that they were not ordered by the physician (185; 67.5%). The majority of children underwent non-genetic evaluations, including brain magnetic resonance imaging (222; 81.0%), electroencephalogram (221; 80.7%), and brain computed tomography scans (136; 49.6%). Only a minority of children with autism spectrum disorder in Jordan receive genetic workup, which may reflect a gap in physicians’ knowledge of clinical guidelines, as well as the availability and affordability of these tests. Lay abstract Autism is the most common neurodevelopmental disorder in children worldwide. Genetic factors play an important role in the risk of developing autism. Determining the genetic cause of autism is key to understanding the biological processes that lead to the clinical manifestations of autism, and can inform the management and even prevention of this condition. Establishing genetic causes of autism requires collection of genetic data on a global scale. Limited research on genetic testing for individuals with autism is available from developing countries in low-resource regions. In this study, we explored the types of investigations ordered for Jordanian children with autism by their physicians. A representative sample of parents of children with autism in Jordan was questioned about the studies that their children received. We found that the recommended genetic testing was only performed in a small number of children with autism. In contrast, most children in the sample received non-genetic testing, which is not routinely recommended. We also explored the sociocultural factors that may influence the decision to perform genetic testing in this population. We discuss our findings in light of the data available from other developing and developed countries.

Background: The COVID-19 pandemic created circumstances with the potential to increase rates of overweight and obesity. We aimed to assess whether there were significant increases in BMI among a sample of children and adolescents during the year 2020 compared to the two years prior to the pandemic. Methods: For this retrospective cohort study, data was obtained from the electronic medical records of 8398 children 3-17 years of age who attended 3 consecutive well visits between June 1 and October 31 in 2018, 2019 and 2020 in a single center in the Midwest. Generalized linear mixed models were used to calculate the differences in average BMI and obesity rates over the three years. Findings: Between 2019 and 2020, the mean BMI for the whole sample increased 3.2 percentile points (from the 70·5 th to the 73·7 th percentile; p < 0·001) compared to an increase of 0.8 percentile point between 2018 and 2019 (p = 0·008).The proportion of children and adolescents with obesity rose from 13% in 2019 to 15·2% in 2020 (p < 0·001) compared to no significant increase from 2018 to 2019. Significant disparities in BMI were observed between socioeconomic and ethnic groups. Interpretation: Significant increases in BMI and obesity rates occurred in 2020 in this sample. We propose that the circumstances surrounding the COVID-19 pandemic contributed significantly to these increases. Funding: No funding or grant support related to this research was obtained. Declaration of Interest: None to declare. Ethical Approval: The study protocol was approved by the Joint Pediatric Institutional Review Board of the University of Nebraska Medical Center and Children’s Hospital Medical Center.

Background: Shared reading has many benefits to children’s language and literacy development. The practice of shared reading varies widely among different cultural groups and is influenced by sociocultural factors. Promotion of shared reading in the healthcare setting has been shown to be effective in many western countries. Very little data are available from other nations, particularly those in the Middle East about parental experiences and attitudes towards shared reading with children. The aim of this study was to explore sociocultural factors that influence shared reading with children in Jordan, a low-middle income Arabic speaking country. Methods: We used survey methodology to collect information on shared reading from a sample of parents of children 3-8 years of age presenting to the Jordan University Hospital Pediatrics clinic in Amman, Jordan. Data were also gathered through solicitation of narrative unstructured comments from parents. Qualitative and statistical data analysis were performed. Findings: Mothers universally believed that shared reading is beneficial for children. However, only a small minority (16.4%) reported reading to their children daily. Shared reading behaviors correlated with frequency of mothers’ personal reading and with the number of books in the home. Mothers indicated a preference for culturally appropriate books, written in classical Arabic and books having a moral or a lesson. Barriers to shared reading included a perceived lack of encouragement of this practice from society and schools and lack of access to books and public libraries.Discussion: Promotion of shared reading is an effective way to enhance the literacy of children from varying ethnic and cultural backgrounds and represents an opportunity to reduce health disparities worldwide. Understanding regional sociocultural dynamics is an essential factor in planning successful interventions to promote literacy. We identified barriers to reading as well as cultural values that may be leveraged to enhance shared reading in Jordan.

IntroductionPediatric behavioral and mental health disorders are a leading cause of childhood morbidity worldwide. International and regional data from Arab countries confirm the high prevalence and societal cost of these problems. No data exist that describe the range of childhood behavioral problems encountered by pediatricians in Arab countries.MethodsQualitative phenomenological methodology was used to collect information. We conducted 8 focus group interviews with physicians in different practice settings across the capital of Jordan. A total of 36 physicians participated in the interviews.ResultsThemes that emerged were organized in 4 categories:Specific behavioral disorders: A number of behavioral and mental health disorders were commonly encountered. Autism was reported to be the most commonly encountered severe neurodevelopmental disorder. The scarcity of effective and affordable management and referral options compounded the impact on families and physicians.System related themes: Physicians perceived deficiencies in training, detection and management of behavioral disorders, a lack of mental health services and quality referral options.Family related themes: Several factors were perceived to contribute to behavioral morbidity such as family structure and parenting practices.Sociocultural themes: Societal perceptions that childhood behavioral problems were a family responsibility resulting in reluctance of medicalization or discussion with physicians. Cultural differences in the interpretation and tolerance of certain childhood behaviors rendered ‘standard’ diagnostic criteria problematic.Discussion and conclusionsPediatricians frequently encounter childhood behavioral problems in clinical practice. Barriers to management of these issues include inadequate training and unique sociocultural, family and system factors. Tailored strategies will need to be developed to improve the detection and management of childhood mental health and behavioral problems in Jordan. Further research to explore, develop and test culturally grounded strategies to address these disorders in Arab countries is needed.What is already known?Pediatric behavioral problems are antecedents of adult mental health problems. Little is known about pediatric behavioral and mental health problems encountered by pediatricians in Arab countries or the specific barriers to addressing these problems from the perspective of practicing clinicians.What are the new findings?Jordanian pediatricians encountered a range of pediatric behavioral problems in their clinical practices. The specific factors that contributed to the prevalence of and perceived difficulty in the diagnosis and management of pediatric behavioral and mental health problems were identified. These related to medical systems, family factors and psychosocial factors.What do the new findings imply?A contextual and holistic understanding of specific problems encountered by pediatricians in practice as well as the barriers to addressing them is critical to the development of culturally informed interventions to detect and effectively manage pediatric behavioral and mental health problems in Arab countries.

Children develop in the context of the family. Family functioning prominently shapes the psychosocial adaptation and mental health of the child. Several family psychosocial risk factors have been shown to increase the risk of behavioral problems in children. Early identification of families with psychosocial profiles associated with a higher risk of having children with behavioral problems may be valuable for targeting these children for prevention and early intervention services. Methods We developed the Family Health Questionnaire (FHQ) for the purpose of evaluating families’ psychosocial risk profiles in the primary care setting. The questionnaire included 10 formative indicators that have been shown to influence children’s behavioral health. We aimed to establish a correlation between the family risk factors on the FHQ and child behavioral health. In addition, we examined the properties of the questionnaire as a screening tool for use in primary care. Families of 313 of children 4–6 years of age presenting for well child examinations at two primary care clinics completed both the FHQ and the Pediatric Symptom Checklist 17 (PSC-17), a validated screening instrument for pediatric behavioral problems. Results We found that the FHQ was positively and significantly correlated with the PSC score (r = .50, p

Most physicians who work in the United Nations Relief and Works Agency (UNRWA) infant and child health programme in Jordan are general practitioners with no postgraduate training in paediatrics. Furthermore, in resource-poor or remote settings, the ability to deliver live continuing medical education (CME) is often limited. A questionnaire exploring the resources available for accessing CME, preferences for types of CME, current sources of CME and topics of interest in the field of paediatric care was sent to all 92 physicians practising in UNRWA clinics in Jordan. Of the 89 respondents 80% had attended live medical lectures for CME and 70% CME meetings. Despite most physicians having access to the Internet only 52.8% were interested in Internet-based courses for accessing CME. There was a statistically significant relationship between year of graduation from medical school and preference for Internet-based CME. Implications for CME participation and paediatric CME topics are discussed.احتياجات أطباء الأونروا في الأردن وما يفضلونه بخصوص التعليم الطبي المستمر في مجال طب الأطفال.أروى عبد الحق ناصر، علي خضر، ليث ناصر، اشتيوي آبو زايد، أكيهيرو سيتا.إن معظم الأطباء الذين يعملون في برنامج صحة الرضع والأطفال التابع لوكالة الأمم المتحدة لغوث وتشغيل اللاجئن (الأونروا) في الأردن هم ممارسون عامون لم يدرَّبوا بعد التخرج عى طب الأطفال. وعاوة عى ذلك فإن القدرة عى تقديم تعليم طبي مستمر مباشر - في الأماكن شحيحة الموارد أو في المناطق النائية - غالباً ما تكون محدودة. فقد أُرسل لجميع الأطباء ال 92 الذين يمارسون العمل في عيادات الأونروا في الأردن استبيان لاستقصاء الموارد المتاحة والمصادر الحالية للتعليم الطبي المستمر، واستكشاف ما يفضلونه من أناط التعليم الطبي المستمر، والوقوف عى الموضوعات ذات الاهتام في مجال الرعاية الطبية للأطفال. فذكر % 80 من المجيبن ال 89 أنهم حروا محاضرات طبية مباشرة للتعليم الطبي المستمر، كا ذكر % 70 أنهم حروا اجتماعات للتعليم الطبي المستمر. وعى الرغم من أن معظم الأطباء تتوافر لديهم إمكانية الوصول إلى الإنترنت فإن % 52.8 منهم فقط كان مهتاً بدورات شبكة الإنترنت للحصول عى التعليم الطبي المستمر. وكانت هناك علاقة ذات دلالة إحصائية بن سنة التخرج من كلية الطب وبن تفضيل التعليم الطبي المستمر عن طريق شبكة الإنترنت. إن الآثار المترتبة عى المشاركة في التعليم الطبي المستمر ومواضيع التعليم الطبي المستمر في مجال طب الأطفال هي قيد المناقشة.Besoins et préférences en matière de formation médicale continue en pédiatrie des médecins exerçant en Jordanie de l’Office de secours et de travaux des Nations Unies pour les réfugiés de Palestine dans le Proche-Orient.La plupart des médecins qui travaillent pour le programme de santé du nourisson et de l’enfant en Jordanie à l’Office de secours et de travaux des Nations Unis pour les réfugiés de Palestine dans le Proche-Orient (UNRWA) sont des médecins généralistes sans spécialisation en pédiatrie. Par ailleurs, dans un contexte de ressources limitées ou dans des zones isolées, la capacité à dispenser une formation médicale continue (FMC) est souvent limitée. Un questionnaire étudiant les ressources disponibles qui permettent d’accéder à la formation médicale continue, les types de formation préférés, les sources actuelles de formation médicale continue et les sujets d’intérêt dans le domaine des soins pédiatriques a été envoyé à l’ensemble des 92 médecins exerçant dans des cliniques de l’UNRWA en Jordanie. Sur un total de 89 répondants, 80 % avaient assisté en personne à des conférences médicales dans le cadre de la formation médicale continue et 70 % à des réunions de formation médicale continue. Si la plupart des médecins avaient accès à l'Internet, seuls 52,8 % étaient intéressés par des cours en ligne permettant d’accéder à la formation médicale continue. Il existait une relation statistiquement significative entre l’année de fin d’études en faculté de médecine et la préférence pour une formation médicale continue sur l'Internet. Les implications pour une participation à la formation médicale continue et les sujets de formation médicale continue en pédiatrie sont en cours de discussion.

We aimed to study ferritin as an acute phase marker in pediatric infections, and investigate its' clinical significance in the emergency department management of the febrile child. Multiple inflammatory markers, including C-reactive protein, procalcitonin, and serum ferritin, and other iron studies were measured in 37 children, from 3 months through 8 years of age, presenting to the emergency department with temperature of ≥ 39 degrees Celsius, and 38 patients in the same age group with non-febrile illness. Mean serum ferritin was significantly higher in the febrile group 71.4 ng/mL compared to the non-febrile group 45.1 ng/mL (p

AimIncreasing evidence exists with respect to the relation between stressful life events and functional constipation (FC). We aimed to investigate the prevalence of FC in Palestinian refugee preschool children and to determine if stress and trauma exposure are risk factors of FC in these children.MethodsFrom November 2013 until May 2014, a cross-sectional survey was conducted in West Bank, Gaza and Jordan. Mothers of 862 Palestinian refugee children aged 7-48 months were interviewed on defecation pattern, socio-economic factors and the child's exposure to traumatic events.ResultsTwelve percent of the Palestinian refugee children fulfilled the criteria for FC. The prevalence of constipation was significantly lower in Gaza compared to Jordan (2% vs. 17%, p ConclusionThe overall prevalence of FC in Palestinian preschool children is comparable to prevalence rates among older children worldwide. In this age group stressful life events and trauma exposure seem not to play an important role in the development of FC.

Objectives To describe the development and introduction of patient education materials in a primary care setting in Jordan. Methods During the 2003–2004 academic year, the authors collaborated to produce more than 25 Arabic language written patient education materials designed to conform to cultural and social norms and expectations. Results Patient education materials were frequently shared with friends and family members. Readability of materials was judged to be excellent when materials were presented at approximately a sixth grade reading level. Conclusions Patient education materials are greatly needed in Jordan. A thorough understanding of the culture facilitates alignment of the health message with social norms and establishment of credibility with the target audience. The materials developed were well received by patients and physicians. Practice implications The routine integration of patient education into all medical consultations in Jordan is an important goal. Practice based research will be vital in identifying and eliminating barriers to the introduction of patient education in the clinical setting.

Purpose: The developmental, psycho-social and educational benefits of reading to children are well documented. The potential use of children literature as a tool to enhance health literacy in children has not been explored. Methods: We used a qualitative design to collect data and generate theories regarding the use of children’s literature as a tool to …

Purpose: The AAP recommends exclusive breastfeeding for the first six months of an infant's life. However, in the U.S., only a minority of women accomplish this goal. According to the CDC, 4 of every 5 U.S. infants initiate breastfeeding, but only 1 of every 5 are exclusively breastfed through 6 months of age. Maternal age, education level, marital status, race/ethnicity, income, and previous breastfeeding experience have all been well-associated with breastfeeding duration. Our goal was to identify maternal attitudes, experiences, and support associated with breastfeeding duration in the first 4 …

The aim of this research was to explore primary care pediatricians' experiences in delivering behavioral health services in their own practices within the Nebraska context. An online survey was sent to the 154 primary care pediatricians who are members of the Nebraska chapter of the American Academy of Pediatrics. Questions explored their management of behavioral problems, attitudes, and perceived barriers to providing behavioral health services in their practices. Seventy pediatricians completed the survey (47%). The majority of pediatricians reported seeing substantial numbers of children with behavioral problems. Eighty-five percent believed that most emotional and behavioral complaints could be managed by the pediatrician. Eighty-eight percent believed that the parents would prefer to receive services for their children's behavioral problems in the primary care office. Most felt that their training in mental health issues was inadequate. Pediatricians in this survey feel that pediatric behavioral problems are best managed in the primary care office and perceive that parents also prefer this setting. Improving training in behavioral health in pediatrics is necessary to meet the delivery of much needed behavioral health care to children and families.

Familial pseudohypoaldosteronism type 1 (PHA1) occurs in two genetically and clinically distinguishable variants. Autosomal-recessive PHA1 that involves a genetic defect in the epithelial sodium channel that affects all aldosterone target organs including the kidney, colon and sweat glands.1 ,2 Two published case reports describe Meibomian gland involvement. …

Kawasaki disease (KD) is an inflammatory condition of unknown etiology that affects children, with a peak incidence in the second year of life. KD is uncommon in the first year of life and is rare in the newborn period. The present report describes three newborn infants who were admitted to hospital with fever and nearly identical clinical features of generalized inflammation. The presentations did not meet the criteria for KD; however, all three patients responded promptly and completely to intravenous immunoglobulin treatment. Specifically, the association of these presentations with very high levels of serum ferritin is reported. The authors propose that this clinical syndrome represents a variant of KD, and that serum ferritin level may be a useful marker in diagnosing KD and its variants. Additionally, the association of this clinical picture with very high serum ferritin levels raises the possibility of a link with hemophagocytic lymphohistiocytosis.

Echocardiography available directly to primary care physicians represents an alternative strategy to pediatric cardiology consultation for childhood heart murmur evaluation. A decision analysis model compared the costs of two diagnostic strategies: (1) echocardiography first, referral to the cardiologist if appropriate; and (2) cardiologist evaluates murmur, echocardiography if appropriate. The model incorporated probability of heart disease, frequency of cardiologist-ordered echocardiography, and echocardiography results established by review of 388 records of consecutive patients evaluated for murmurs in a pediatric cardiology clinic. Echocardiography-first strategy costs were $257 greater than referral-strategy costs. Referral-strategy advantages were not highly sensitive to changes in model assumptions. Pediatric cardiology consultation is the preferred approach provided (1) consultation costs are moderate, (2) echocardiography costs are moderate to high, and (3) the rate at which the cardiologist orders echocardiography for patients with innocent murmurs is low.

Introduction Ferritin is the major intracellular iron binding protein in the body. Serum ferritin is an inflammatory marker. Iron sequestration is one of the innate immune responses to infection. The goal of this research was to investigate the role of serum ferritin and serum iron as clinically useful markers of infection in the paediatric emergency department. Methods Multiple inflammatory markers, including C-reactive protein, procalcitonin, and serum ferritin, and other iron studies were measured in 37 children, from 3 months through 8 years of age, presenting to the emergency department with temperature of ≥39 degrees Celsius, and 38 patients in the same age group with non-febrile illness (controls). Patients with chronic inflammatory or rheumatologic conditions and those with renal or hepatic failure were excluded. Results Mean serum ferritin, and ferritin/iron ratio were significantly higher among febrile children when compared to controls. Mean serum iron levels were significantly lower among febrile patients and in the subgroup of children who had bacterial infections when compared with children who had viral infections and those who had a non-infectious illness. Conclusion Serum iron and ferritin/iron ratio may be clinically useful markers for the differentiation of bacterial from viral infection in the emergency department. Further studies are needed to confirm our findings and to further explore the role of iron metabolism in paediatric infections.

To the Editor. Poisoning with over-the-counter medication is a common problem faced by pediatricians in primary care. Accidental ingestion is usually seen in younger children. Older children and adolescents may use acetaminophen in suicide attempts or gestures. Experimentation is a less common cause of acetaminophen overdose. In the following report, a case of severe acetaminophen poisoning resulted from the ingestion of a novel substance prepared from a modern dosage unit, the “gelcap.” A male 10-year-old fourth grader presented to the general pediatric clinic with malaise, vomiting, and abdominal pain of 2 days' duration. He denied discoloration of urine or stools. Physical examination revealed an ill-appearing young boy with scleral icterus and a tender right hypochondrium. The liver was just palpable below the costal margin. The patient was afebrile, and …