Search

Background: Attention-deficit/hyperactivity disorder (ADHD) has been shown to pose considerable clinical and economic burden; however, research quantifying the excess burden attributable to common psychiatric comorbidities of ADHD among pediatric patients is scarce. This study assessed the impact of anxiety and depression on healthcare resource utilization (HRU) and healthcare costs in pediatric patients with ADHD in the United States. Methods: Patients with ADHD aged 6–17 years were identified in the IQVIA PharMetrics Plus database (10/01/2015-09/30/2021). The index date was the date of initiation of a randomly selected ADHD treatment. Patients with ≥ 1 diagnosis for anxiety and/or depression during both the baseline (6 months pre-index) and study period (12 months post-index) were classified in the ADHD+anxiety/depression cohort; those without diagnoses for anxiety nor depression during both periods were classified in the ADHD-only cohort. Entropy balancing was used to create reweighted cohorts. All-cause HRU and healthcare costs during the study period were compared using regression analyses. Cost analyses were also performed in subgroups by comorbid conditions. Results: The reweighted ADHD-only cohort (N = 204,723) and ADHD+anxiety/depression cohort (N = 66,231) had similar characteristics (mean age: 11.9 years; 72.8% male; 56.2% had combined inattentive and hyperactive ADHD type). The ADHD+anxiety/depression cohort had higher HRU than the ADHD-only cohort (incidence rate ratios for inpatient admissions: 10.3; emergency room visits: 1.6; outpatient visits: 2.3; specialist visits: 5.3; and psychotherapy visits: 6.1; all p < 0.001). The higher HRU translated to greater all-cause healthcare costs; the mean per-patient-per-year (PPPY) costs in the ADHD-only cohort vs. ADHD+anxiety/depression cohort was $3,988 vs. $8,682 (p < 0.001). All-cause healthcare costs were highest when both comorbidities were present; among patients with ADHD who had only anxiety, only depression, and both anxiety and depression, the mean all-cause healthcare costs were $7,309, $9,901, and $13,785 PPPY, respectively (all p < 0.001). Conclusions: Comorbid anxiety and depression was associated with significantly increased risk of HRU and higher healthcare costs among pediatric patients with ADHD; the presence of both comorbid conditions resulted in 3.5 times higher costs relative to ADHD alone. These findings underscore the need to co-manage ADHD and psychiatric comorbidities to help mitigate the substantial burden borne by patients and the healthcare system. [ABSTRACT FROM AUTHOR]

Background: While prevention protocols have been implemented, skiing-related musculoskeletal injuries and concussions continue to present to emergency departments in the United States. Previous literature has suggested the pediatric population may constitute up to 40% of skiing-related injuries. Purpose: To assess injury trends and the underlying mechanisms of skiing injuries in pediatric patients seen at emergency departments in the United States. Study Design: Descriptive epidemiology study. Methods: The National Electronic Injury Surveillance System (NEISS) was queried for pediatric (age ≤18 years) skiing injuries between January 1, 2012, and December 31, 2022. Injury mechanism, location, disposition, and diagnosis were recorded, and the statistical sample weight assigned by NEISS by hospital was used to calculate national estimates (NEs). Injury trends were evaluated with linear regression analysis. Results: Overall, 2951 pediatric skiing injuries were included (NE = 123,386). The mean age of the patients was 12.4 ± 3.5 years, with 61.3% of the injuries occurring in male patients. Impact with the ground was the most common injury mechanism (NE = 87,407; 70.8%). Fractures were the most common diagnosis (NE = 38,527, 31.2%), followed by strains/sprains (NE = 22,562, 18.3%), contusions/abrasions (NE = 16,257, 13.2%), and concussions (NE = 12,449, 10.1%). The lower leg was the most common fracture site (NE = 9509, 24.7%), followed by the shoulder (NE = 7131, 18.5%) and lower arm (NE = 5876, 15.3%). Analysis of annual injuries revealed no significant trend between 2012 and 2022 (P =.17), with fluctuations apparent throughout the study period. Significant decreases were seen in strains/sprains (P <.01) and contusions/abrasions (P <.01), but not in concussions (P =.57) or fractures (P =.70). Conclusion: Impacts with the snow/ground made up 70.8% of all injuries. Fractures were the most common injury diagnosis, followed by strains/sprains, with the lower leg being most frequently fractured. While strains/sprains and contusions/abrasions showed a significant decline, there were no significant trends in fractures and concussions between 2012 and 2022. [ABSTRACT FROM AUTHOR]

Objective: To estimate and compare the proportion of foreign-born Middle Eastern/North African (MENA) children without health insurance, public, or private insurance to foreign- and US-born White and US-born MENA children. Methods: Using 2000 to 2018 National Health Interview Survey data (N = 311 961 children) and 2015 to 2019 American Community Survey data (n = 1 892 255 children), we ran multivariable logistic regression to test the association between region of birth among non-Hispanic White children (independent variable) and health insurance coverage types (dependent variables). Results: In the NHIS and ACS, foreign-born MENA children had higher odds of being uninsured (NHIS OR = 1.50, 95%CI = 1.10-2.05; ACS OR = 2.11, 95%CI = 1.88-2.37) compared to US-born White children. In the ACS, foreign-born MENA children had 2.11 times higher odds (95%CI = 1.83-2.45) of being uninsured compared to US-born MENA children. Conclusion: Our findings have implications for the health status of foreign-born MENA children, who are currently more likely to be uninsured. Strategies such as interventions to increase health insurance enrollment, updating enrollment forms to capture race, ethnicity, and nativity can aid in identifying and monitoring key disparities among MENA children. [ABSTRACT FROM AUTHOR]

Background This study examined the trends and patterns of opioid and non-opioid pharmacotherapy use among a large national sample of privately insured pediatric patients with cancer in the United States. Materials and Methods We identified pediatric (aged < 21) patients diagnosed with central nervous system (CNS), lymphoma, gonadal, leukemia, or bone cancer from MarketScan data 2005-2019. We examined the proportion of patients who filled a prescription for the following 5 types of pharmacotherapy: opioid, anticonvulsant, non-steroidal anti-inflammatory drug (NSAID), antidepressant, and muscle relaxant during active cancer treatment. We assessed the trends and patterns in pharmacotherapy using multivariable logistic regressions. Results Among 4174 patients included, 2979 (71%) had an opioid prescription; 746 (18%), 384 (9%), 202 (5%), and 169 (4%) had anticonvulsant, NSAID, antidepressant and muscle relaxant prescriptions, respectively. Multivariable logistic regression showed a nonlinear trend in the use of opioids among pediatric patients with cancer over time such that use slightly increased until 2012 (OR of 1.40 [95% CI, 1.12-1.73] for 2012 vs. 2006) but then decreased thereafter (OR of 0.51 [0.37-0.68] for 2018 vs. 2012). The use of anticonvulsants, NSAIDs, and muscle relaxants increased significantly linearly over time (all P  < .005). Conclusion There has been a downward trend in the use of opioids in recent years among pediatric patients with cancer and an upward trend in the use of non-opioid pharmacotherapy for pain management potentially as an alternative to opioids. [ABSTRACT FROM AUTHOR]

Background Retinoblastoma is the most common intraocular malignant tumor occurring among children, with an incidence rate of 1/15 000. This study built a joinpoint regression model to assess the incidence trend of retinoblastoma from 2004 to 2015 and constructed a nomogram to predict the overall survival (OS) in children. Materials and Methods Patients less than 19 years diagnosed with retinoblastoma from 2004 to 2015 were selected from the SEER database. Joinpoint regression analysis (version 4.9.0.0) was performed to evaluate the trends in retinoblastoma incidence rates from 2004 to 2015. Cox Regression Analysis was applied to investigate prognostic risk factors that influence OS. Results Joinpoint regression revealed that retinoblastoma incidence exhibited no significant increase or decrease from 2004 to 2015. As per the multiple Cox regression, tumor size, laterality, and residence (rural-urban continuum code) were correlated with OS and were used to construct a nomogram. The nomogram exhibited a good C-index of 0.71 (95% CI, 0.63 to 0.79), and the calibration curve for survival probability demonstrated that the predictions corresponded well with actual observations. Conclusions and Relevance A prognostic nomogram integrating the risk factors for retinoblastoma was constructed to provide comparatively accurate individual survival predictions. If validated, this type of assessment could be used to guide therapy in patients with retinoblastoma. [ABSTRACT FROM AUTHOR]

BACKGROUND: Ambient air pollution may be a developmental endocrine disruptor. In animal models, gestational and perinatal exposure to diesel exhaust and concentrated particulate matter alters anogenital distance (AGD), a marker of prenatal androgen activity, in both sexes. Little is known in humans. OBJECTIVES: We examined exposure to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) in relation to human AGD at birth and at 1 year of age, focusing on exposures during critical windows of reproductive development: the male programming window (MPW; gestational weeks 8–14) and mini-puberty (postnatal months 1–3). METHODS: The Infant Development and Environment Study (TIDES) recruited first trimester pregnant women (β = 687) at four U.S. sites (Minneapolis, Minnesota; Rochester, New York; San Francisco, California; and Seattle, Washington) from 2010 to 2012. We measured anus to clitoris (AGD-AC) and anus to fourchette (AGD-AF) in female infants at birth; in males, we measured anus to penis (AGD-AP), anus to scrotum (AGDAS), and penile width at birth and at 1 year of age. Using advanced spatiotemporal models, we estimated maternal exposure to PM2.5 and NO2 in the MPW and mini-puberty. Covariate-adjusted, sex-stratified linear regression models examined associations between PM2.5 and NO2 and AGD. RESULTS: In males, a 1-μg/m³ increase in PM2.5 exposure during the MPW was associated with shorter AGD at birth, but a longer AGD at 1 year of age (e.g., birth AGD-AP: β = -0.35 mm; 95% CI: -0.62, -0.07; AGD-AS: β = 0.37 mm; 95% CI: 0.02, 0.73). Mini-pubertal PM2.5 exposure was also associated with shorter male AGD-AP (β = -0.50 mm; 95% CI: -0.89, -0.11) at 1 year of age. Although not associated with male AGD measures, 1-ppb increases in NO2 exposure during the MPW (β = -0.07 mm; 95% CI: -0.02, -0.12) and mini-puberty (β = -0.04 mm; 95% CI: -0.08, 0.01) were both associated with smaller penile width at 1 year of age. Results were similar in multipollutant models, where we also observed that in females AGD-AC was inversely associated with PM2.5 exposure, but positively associated with NO2 exposure. DISCUSSION: PM2.5 and NO2 exposures during critical pre- and postnatal windows may disrupt reproductive development. More work is needed to confirm these novel results and clarify mechanisms. [ABSTRACT FROM AUTHOR]

BACKGROUND: Gestational phthalate and phenol exposure disrupts adipogenesis, contributing to obesity in mice. Whether gestational phthalate or phenol exposure is associated with infant body composition has not been investigated in humans. OBJECTIVE: We examined associations between biomarkers of phthalate and phenol exposure in midpregnancy and infant size and body composition at birth and at 5 months of age. METHODS: Analyses were conducted among 438 infants from the Healthy Start prospective pregnancy cohort. Sixteen phthalate and phenol biomarkers were quantified in spot urine samples collected at 24–28 wk of gestation. Infant outcomes measured at birth and at 5 months of age included size [weight (in grams)] and body composition [fat and lean masses (in grams); percentage fat mass]. Single- (linear) and multipollutant (quantile g-computation) models were used to estimate associations of phthalate and phenol biomarkers with infant outcomes at birth and at 5 months of age. Models were adjusted for sociodemographics, sample collection timing, and lifestyle factors and used to examine for effect modification by infant sex. RESULTS: In single-pollutant models, mono-benzyl phthalate and di-n-butyl phthalate were inversely associated with percentage fat mass [ß: -0.49 (95% CI: -0:91, -0:08) and -0:51 (95% CI: -1.02, 0.01), respectively] in male but not female infants at birth. Similar, but less precise, associations were observed at 5 months of age. In multipollutant models, a 1-quartile increase in the phthalate and phenol biomarker mixture was inversely associated with percentage fat mass at birth [-1.06 (95% CI: -2.21, 0.1)] and at 5 months of age [-2.14 (95% CI: -3.88, -0.39)] among males, but associations were null among females [0.48 (95% CI: -0.78, 1.75) and -0.64 (95% CI: -2.68, 1.41), respectively]. Similar associations were observed with infant weight. CONCLUSION: In this U.S.-based prospective cohort, gestational phthalate and phenol biomarkers were inversely associated with infant weight and fat mass, particularly in males. [ABSTRACT FROM AUTHOR]

Background Despite guidelines recommending narrow-spectrum perioperative antibiotics (NSPA) as prophylaxis for most children undergoing congenital heart disease (CHD) surgery, broad-spectrum perioperative antibiotics (BSPA) are variably used, and their impact on postoperative outcomes is poorly understood. Methods We used administrative data from U.S. hospitals participating in the Vizient Clinical Data Base. Admissions from 2011 to 2018 containing a qualifying CHD surgery in children 0–17 years old were evaluated for exposure to BSPA versus NSPA. Propensity score-adjusted models were used to compare postoperative length of hospital stay (PLOS) by exposure group, while adjusting for confounders. Secondary outcomes included subsequent antimicrobial treatment and in-hospital mortality. Results Among 18 088 eligible encounters from 24 U.S. hospitals, BSPA were given in 21.4% of CHD surgeries, with mean BSPA use varying from 1.7% to 96.1% between centers. PLOS was longer for BSPA-exposed cases (adjusted hazard ratio 0.79; 95% confidence interval [CI]: 0.71–0.89, P <.0001). BSPA was associated with higher adjusted odds of subsequent antimicrobial treatment (odds ratio [OR] 1.24; 95% CI: 1.06–1.48), and there was no significant difference in adjusted mortality between exposure groups (OR 2.06; 95% CI: 1.0–4.31; P =.05). Analyses of subgroups with the most BSPA exposure, including high-complexity procedures and delayed sternal closure, also did not find (but could not exclude) a measurable benefit from BSPA on PLOS. Conclusions BSPA use was common in high-risk populations, and varied substantially between centers. Standardizing perioperative antibiotic practices between centers may reduce unnecessary broad-spectrum antibiotic exposure and improve clinical outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: National guidelines recommend that children with sickle cell anemia receive annual transcranial Doppler (TCD) screening to assess stroke risk. Our objectives were to estimate the rate of TCD screening among privately insured children with sickle cell anemia, estimate out-of-pocket spending for TCD screening, and evaluate the association between TCD screening and enrollment in high-deductible health plans (HDHPs). STUDY DESIGN: Cross-sectional. METHODS: Using the 2009-2017 IBM MarketScan Commercial Database, we identified children aged 2 to 15 years who met a validated claims-based definition of sickle cell anemia. We calculated the proportion of children receiving annual TCD screening and out-of-pocket spending per TCD screen. Using logistic regression with generalized estimating equations, we modeled the receipt of annual TCD screening as a function of HDHP enrollment, controlling for demographics and year. RESULTS: The 2519 children in the analysis accounted for 7197 person-years of enrollment; 14% of person-years were from HDHP enrollees. During 2009-2017, the proportion of children receiving TCD screening ranged from 40% to 44%. Median out-of-pocket spending for TCD screening was $20 overall and $65 among HDHP enrollees. Out-of-pocket spending exceeded $100 for 27% of all screens and 42% of screens among HDHP enrollees. HDHP enrollment was not associated with TCD screening (adjusted odds ratio, 0.99; 95% CI, 0.85-1.15). CONCLUSIONS: Among privately insured children with sickle cell anemia, fewer than half received annual TCD screening. Out-of-pocket spending exceeded $100 for 27% of TCD screens. Although HDHP enrollment was not associated with TCD screening, additional studies are needed to assess whether cost sharing might deter this screening. [ABSTRACT FROM AUTHOR]

Background/Objective. Growth and obesity have been associated with increased risk of islet autoimmunity (IA) and progression to type 1 diabetes. We aimed to estimate the effect of energy-yielding macronutrient intake on the development of IA through BMI. Research Design and Methods. Genetically at-risk children (n = 5,084) in Finland, Germany, Sweden, and the USA, who were autoantibody negative at 2 years of age, were followed to the age of 8 years, with anthropometric measurements and 3-day food records collected biannually. Of these, 495 (9.7%) children developed IA. Mediation analysis for time-varying covariates (BMI z-score) and exposure (energy intake) was conducted. Cox proportional hazard method was used in sensitivity analysis. Results. We found an indirect effect of total energy intake (estimates: indirect effect 0.13 [0.05, 0.21]) and energy from protein (estimates: indirect effect 0.06 [0.02, 0.11]), fat (estimates: indirect effect 0.03 [0.01, 0.05]), and carbohydrates (estimates: indirect effect 0.02 [0.00, 0.04]) (kcal/day) on the development of IA. A direct effect was found for protein, expressed both as kcal/day (estimates: direct effect 1.09 [0.35, 1.56]) and energy percentage (estimates: direct effect 72.8 [3.0, 98.0]) and the development of GAD autoantibodies (GADA). In the sensitivity analysis, energy from protein (kcal/day) was associated with increased risk for GADA, hazard ratio 1.24 (95% CI: 1.09, 1.53), p = 0.042. Conclusions. This study confirms that higher total energy intake is associated with higher BMI, which leads to higher risk of the development of IA. A diet with larger proportion of energy from protein has a direct effect on the development of GADA. [ABSTRACT FROM AUTHOR]

Background Comparing body fat and the effect of body fat on metabolic abnormalities in Chinese and USA teenagers may provide clues for the early prevention and control of cardiovascular disease (CVD). We aimed to compare the prevalence of glucose and lipid metabolism abnormalities, body fat amount and distribution, and the effect of body fat on glucose and lipid metabolism in Chinese and US teenagers. Methods We included 5424 Chinese teenagers (48.5% male) from the China Child and Adolescent Cardiovascular Health (CCACH) study and 8704 USA teenagers (55.6% male) from the USA National Health and Nutrition Examination Survey (NHANES). Blood lipid, blood glucose, and body fat indicators were obtained using the same standardised measurements. Results The prevalence of dyslipidaemia in Chinese teenagers was of those in the USA (hypercholesterolaemia = 3.5% vs 7.4%; high low-density lipoprotein cholesterol (LDL-C) = 3.6% vs 5.0%; low high-density lipoprotein cholesterol (HDL-C)=9.9% vs 14.3%; hypertriglyceridaemia=3.7% vs 10.1%) (P<0.05). However, with the increase in body mass index (BMI), the prevalence of high LDL-C increased more in Chinese than in US teenagers, even exceeding them in the obese group (2.7% in non-overweight to 9.7% in overweight group in China, P<0.05; 3.5% in non-overweight to 6.5% in the obese group in the USA, P<0.05). The prevalence of impaired fasting glucose was higher in China than in the USA (28.0% vs 17.5%, P<0.05). Besides, Chinese adolescents are more likely to accumulate fat in the abdomen, and the per-unit fat increase would bring a higher risk of dyslipidaemia in Chinese boys than in USA boys. Conclusions Dyslipidaemia was more prevalent in US teenagers than in Chinese teenagers, but with the increase in BMI, the prevalence of high LDL-C increased more in Chinese than in US teenagers. Impaired fasting glucose (IFG) was significantly more prevalent in China than in the USA. The unfavoured body fat and higher risk of body fat on metabolic disorders in Chinese teenagers suggest that Chinese teenagers should pay more attention to the adverse effect of body fat on metabolic abnormalities. [ABSTRACT FROM AUTHOR]

Background: To slow the spread of COVID-19, many nonessential businesses, daycares, and schools closed, and areas imposed "stay-at-home" orders. Closures led to young children spending more time at home, traditionally, the place where more than one-half of unintentional pediatric injuries occur. The objective of the current study was to describe parental safety perceptions and confidence, safety device purchase and installation, and injury prevention practices and behaviors, in homes with children 6 years of age and younger, before and during the COVID-19 pandemic. Methods: A cross-sectional survey with a convenience sample of US participants, 18 years or older, was conducted from November 2020 to February 2021. Parents of children (≤ 6 years) were recruited via social media ads and posts on Facebook and Twitter and invited to complete an anonymous, online survey about their home safety practices before and during the COVID-19 stay-at-home order. Upon completion, parents could participate in a prize drawing to receive one of five $100 gift cards. Results: A total of 499 participants completed the survey. Most (47.9%) were 45–54 years of age and reported the amount of time at home increased for them (93.9%) and their children (90.6%) during the stay-at-home period. Thirty-seven percent (36.9%) of parents considered their homes safe but recognized room for improvement and felt confident in their ability to make their homes safe for their children (72.8%). From the time before until the COVID-19 stay-at-home orders were in place, parents increased their home injury prevention practices (42.3%). Parents that had identified unsafe areas in the home before the stay-at-home order were significantly more likely to increase their safety behaviors, take childproofing actions, and purchase or install safety devices during the stay-at-home order (p < 0.0001). Parents with younger children (5 years) were significantly more likely than parents with older children to take childproofing actions (p <.0001) including purchasing and installing safety devices (p < 0.0001). Conclusions: Spending more time at home during the COVID-19 pandemic may have helped the sampled parents, especially those with younger children, identify unsafe areas in their homes and encourage them to modify their behaviors, and purchase and install safety devices to help make their homes safer for their children. [ABSTRACT FROM AUTHOR]

To evaluate the relationship between infant age of egg introduction and malnutrition‐related growth outcomes in the United States, we analysed secondary data of 1716 mother–child dyads in the Infant Feeding Practices Study II and its Year 6 Follow‐Up Study. Malnutrition‐related growth outcomes included body mass index z‐score (BMIZ), obesity (weight‐for‐height z‐score [WHZ] ≥3 or BMIZ ≥ 2), WHZ, wasting (WHZ < −2), height‐for‐age z‐score (HAZ), and stunting (HAZ < –2). Infant age at egg introduction was analysed as a continuous variable. We used generalised estimating equations to estimate the mean difference in continuous outcomes and relative risk [RR]) for binary outcomes, adjusting for related maternal and child confounders. We also explored interactions with child sex, maternal race/ethnicity, maternal educational level, ever breastfeeding, and formula feeding. In the total sample, a later infant age at egg introduction was associated with a lower mean difference in HAZ (confounder‐adjusted mean difference = −0.08, 95% confidence interval [CI]: −0.12 to −0.03 per month) and a higher risk of stunting (confounder‐adjusted RR = 1.17, 95% CI: 1.03–1.33 per month) at 6 years. The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Among females but not among males, later introduction of eggs was associated with a lower mean WHZ (−0.06 [−0.12 to 0.00] per month) at 12 months. Later egg introduction during infancy was associated with a lower mean HAZ and a higher risk of stunting in 6‐year‐old children. Besides this, it was associated with a lower WHZ among females at 12 months. Key messages: This secondary data analysis evaluated the relationship between infant age at egg introduction and malnutrition‐related growth outcomes among young US children within the Infant Feeding Practices Study II and its Year 6 Follow‐up Study.In the total sample, a later infant age at egg introduction was associated with a lower mean 6‐year height‐for‐age z‐score and a higher risk of stunting at 6 years.The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Later introduction of eggs was associated with a lower mean weight‐for‐height z‐score among females. However, this association was not observed among males. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID-19) vaccine hesitancy has remained a significant concern among adults worldwide. However, not much is known about parental vaccine hesitancy for getting children vaccinated for COVID-19 in the U.S. Thus, the purpose of this study was to conduct a national assessment of parents' preferences for COVID-19 vaccination of children using the evidence-based Multi-Theory Model (MTM) and explore the predictors of vaccine hesitancy. Methods: To participate in this study, a national random sample of parents (n=263) took a valid and reliable online questionnaire based on the MTM. Independent samples t test, chi-square test, multiple logistic regression was utilized to analyze data. Results: More than two-fifths (42%) of the participating parents were not willing to get their children vaccinated for COVID-19. Parental vaccination status, booster dose acceptance, education, and political affiliation were significant predictors of willingness to get children vaccinated for COVID-19. In the multiple logistic regression analyses, behavioral confidence and participatory dialogue (i.e., perceived advantages versus disadvantages) were statistically significant predictors of COVID-19 vaccination hesitancy for children among the participating parents. Conclusion: Given the multiple factors that were found influential in parental hesitancy for COVID-19 vaccination among children, multimodal and evidence-based interventions are needed to increase the uptake of COVID-19 vaccines among children by influencing the parents' perceptions, increasing their confidence, dispelling misinformation, and reducing constraints for vaccination. Such interventions should emphasize communication and messaging that is truthful, interactive, scientifically correct, and to be delivered in a variety of community-based settings. [ABSTRACT FROM AUTHOR]

Early childhood is an important development period for establishing healthy physical activity (PA) habits. The objective of this study was to evaluate PA levels in a representative sample of U.S. preschool-aged children. The study sample included 301 participants (149 girls, 3–5 years of age) in the 2012 U.S. National Health and Examination Survey National Youth Fitness Survey. Participants were asked to wear an ActiGraph accelerometer on their wrist for 7 days. A machine learning random forest classification algorithm was applied to accelerometer data to estimate daily time spent in moderate- and vigorous-intensity PA (MVPA; the sum of minutes spent in running, walking, and other moderate- and vigorous-intensity PA) and total PA (the sum of MVPA and light-intensity PA). We estimated that U.S. preschool-aged children engaged in 28 min/day of MVPA and 361 min/day of total PA, on average. MVPA and total PA levels were not significantly different between males and females. This study revealed that U.S. preschool-aged children engage in lower levels of MVPA and higher levels of total PA than the minimum recommended by the World Health Organization. [ABSTRACT FROM AUTHOR]

This study examines the risk-related factors during the pandemic and protective factors that might reduce its effects on family functioning in a sample of 161 low-income Hispanic parents in the United States, recruited from an ongoing longitudinal intervention study. They were surveyed about family functioning six months into the pandemic. We focused on the associations between social (e.g., exposure to the virus) and economic (e.g., job loss) pandemic-related risks on parental stress, parenting, and children's socioemotional problems and skills, as well as the degree to which coparenting support, parents' positivity, economic support, and access to services and information mitigated (protected) the negative effects of these stressors on family functioning. We found that increases in economic risk were associated with more child competence skills, whereas increases in social risk were associated with less parental engagement. Positivity and economic support moderated the effects of economic risk on parental stress and engagement. These findings show that to intervene effectively with low-income Hispanic families, we need to strengthen and support the resources for coping with adversity. [ABSTRACT FROM AUTHOR]

BACKGROUND: Prenatal phthalate exposure has been associated with lower birth weight but also higher weight in childhood. Few studies have examined weight or adiposity from birth to childhood and thus cannot assess growth trajectories associated with exposure. OBJECTIVE: We assessed associations between maternal phthalate exposures in pregnancy and child weight and adiposity measured prenatally through childhood (3–6 years of age). METHODS: Within The Infant Development and the Environment Study (TIDES), a prospective pregnancy cohort, we analyzed a panel of phthalate metabolites in urine collected at two visits from early and late gestation (푁 = 780). We estimated average phthalate metabolite associations with child weight 푧-scores from ~20 wk gestation (estimated by ultrasound), birth, and 1, 3, 4, and 6 years of age using linear mixed-effects (LME) models. We also modeled associations with adiposity 푧-scores from birth (weight for length) and 1, 3, 4, and 6 years of age [body mass index (BMI)] using LME models. RESULTS: For weight, we observed inverse associations between several phthalate metabolites and birth weight 푧-scores, but no associations were observed with postnatal weight 푧-scores in LME models. Regarding adiposity, we observed inverse associations between phthalate metabolites and weight-for-length 푧-scores at birth, but positive associations were observed with BMI 푧-scores at 3–4 years of age in LME models. For example, mono-ethyl phthalate was associated with a 0.17-unit decrease in birth weight-for-length 푧-score [95% confidence interval (CI): –0:29, –0:05] and a 0.18-unit increase in 4-years-of-age BMI 푧-score (95% CI: 0.04, 0.32). DISCUSSION: We observed associations between prenatal exposure to phthalates and lower weight at birth but not at childhood follow-up visits. However, for adiposity, we observed an interesting pattern of association with low adiposity at delivery as well as high adiposity at 3–4 years of age. Although it is not clear from our results whether these associations occur within the same children, such a pattern of adiposity in early life has been linked to cardiometabolic disease in adulthood and deserves special attention as an outcome in the study of prenatal exposures in the developmental origins of health and disease. [ABSTRACT FROM AUTHOR]

Aim: The American Academy of Pediatrics and the European Centre for Pediatric and Adolescent Medicine guideline define fever as a temperature >38.0°C for all ages and recommend use of rectal thermometers in children <3 years. Based on new literature, this definition of fever using a fixed threshold of 38.0°C needs to be re‐examined. Design: A multi‐site diagnostic accuracy study was conducted to compare an "age‐based" threshold model with a "fixed" threshold over 38.0°C on a total of 894 patients of which 373 were ill. Methods: The "age‐based" and "fixed" threshold fever determinations were then compared to a clinical categorization ("well" or "ill") conducted by a clinician through a comprehensive examination. Results: The sensitivity and accuracy for the age‐based thresholds were found to be superior to the fixed thresholds in all ages and current ear thermometers were found equivalent to rectal thermometers in infants <6 months. [ABSTRACT FROM AUTHOR]

This study aimed to examine the association between breastfeeding and childhood obesity. A multinational cross‐sectional study of 4,740 children aged 9–11 years was conducted from 12 countries. Infant breastfeeding was recalled by parents or legal guardians. Height, weight, waist circumference, and body fat were obtained using standardized methods. The overall prevalence of obesity, central obesity, and high body fat were 12.3%, 9.9%, and 8.1%, respectively. After adjustment for maternal age at delivery, body mass index (BMI), highest maternal education, history of gestational diabetes, gestational age, and child's age, sex, birth weight, unhealthy diet pattern scores, moderate‐to‐vigorous physical activity, sleeping, and sedentary time, exclusive breastfeeding was associated with lower odds of obesity (odds ratio [OR] 0.76, 95% confidence interval, CI [0.57, 1.00]) and high body fat (OR 0.60, 95% CI [0.43, 0.84]) compared with exclusive formula feeding. The multivariable‐adjusted ORs based on different breastfeeding durations (none, 1–6, 6–12, and > 12 months) were 1.00, 0.74, 0.70, and 0.60 for obesity (Ptrend =.020) and 1.00, 0.64, 047, and 0.64 for high body fat (Ptrend =.012), respectively. These associations were no longer significant after adjustment for maternal BMI. Breastfeeding may be a protective factor for obesity and high body fat in 9‐ to 11‐year‐old children from 12 countries. [ABSTRACT FROM AUTHOR]

Background Quantify the influenza vaccine coverage is essential to identify emerging concerns and to immunization programs for targeting interventions. Methods Data from National Health Interview Survey were used to estimate receipt of at least one dose of influenza vaccination among children 6 months to 17 years of age. Results Influenza vaccination coverage increased from 16.70% during 2004/2005 to 49.43% during 2015/2016 (3.18% per year, P < 0.001); however, the coverage increased slightly after 2010/2011. Children at high risk of influenza complications had higher influenza vaccination coverage than non at-risk children. Boys and girls had similar coverage each year. While the coverage increased from 2004/2005 to 2015/2016 for all age groups, the coverage decreased with age each year (−0.64 to −1.58% per age group). There was a higher and rapid increase of coverage in Northeast than Midwest, South and West. American Indian or Alaskan Native and Asian showed higher coverage than other race groups (White, Black/African American, Multiple race). Multivariable analysis showed that high-risk status and region had the greatest associations with levels of vaccine coverage. Conclusions Although the influenza vaccination coverage among children had increased remarkably since 2004/2005, establishing more effective immunization programs are warranted to achieve the Healthy People 2020 target. [ABSTRACT FROM AUTHOR]

Nutritional quality of children's diets is a public health priority in the fight against childhood obesity and chronic diseases. The main purpose of this study was to determine contribution of snacks to energy and nutrient intakes and to identify leading snack food sources of energy, total fat, and added sugars amongst young children in the United States. Using the 2005-2012 NHANES data, dietary intakes of 2- to 5-year-old children were analysed from a parent-reported 24-hour dietary recall ( n = 3,429). Snacking occasions were aggregated to determine the proportion of total food/beverage intake obtained from snacks, estimate energy, and nutrient intakes, and identify the leading snack food sources of energy, added sugars, and total fat. Nearly all children consumed a snack on the reported day (62% morning, 84% afternoon, and 72% evening). Snacks accounted for 28% of total energy intake, 32% of carbohydrates, 39% of added sugars, and 26% of total fat and dietary fiber intakes for the day. Snacking occasions accounted for 46.6% of all beverages consumed on the reported day. Snacks and sweets food category (i.e., cookies and pastries) were the leading sources of energy (44%), total fat (52%), and added sugars (53%) consumed during snacking occasions. Sweetened beverages (e.g., fruit and sport drinks) contributed 1-quarter of all added sugars obtained from snacks. Snacks contribute considerable amount of energy and nutrients to young children's diets, with a heavy reliance on energy-dense foods and beverages. Targeted interventions are needed to improve the nutritional quality of snacks consumed by young children. [ABSTRACT FROM AUTHOR]

Context: Whereas researchers have provided estimates for the number of head impacts sustained within a youth football season, less is known about the number of plays across which such impact exposure occurs. Objective: To estimate the number of plays in which youth football players participated during the 2013 season and to estimate injury incidence through play-based injury rates. Design: Descriptive epidemiology study. Setting: Youth football. Patients or Other Participants: Youth football players (N = 2098; age range, 5-15 years) from 105 teams in 12 recreational leagues across 6 states. Main Outcome Measure(s): We calculated the average number of athlete-plays per season and per game using independent-samples t tests to compare age groups (5-10 years old versus 11-15 years old) and squad sizes (,20 versus <20 players); game injury rates per 1000 athlete-exposures (AEs) and per 10 000 athlete-plays; and injury rate ratios (IRRs) with 95% confidence intervals (CIs) to compare age groups. Results: On average, youth football players participated in 333.9 6 178.5 plays per season and 43.9 6 24.0 plays per game. Age groups (5- to 10-year-olds versus 11- to 15-yearolds) did not differ in the average number of plays per season (335.8 versus 332.3, respectively; t2086.4 = 0.45, P = .65) or per game (44.1 versus 43.7, respectively; t2092.3 = 0.38, P = .71). However, players from smaller teams participated in more plays per season (373.7 versus 308.0; t1611.4 = 8.15, P < .001) and per game (47.7 versus 41.4; t1523.5 = 5.67, P < .001). Older players had a greater game injury rate than younger players when injury rates were calculated per 1000 AEs (23.03 versus 17.86/1000 AEs; IRR=1.29; 95% CI=1.04, 1.60) or per 10 000 athlete-plays (5.30 versus 4.18/10 000 athlete-plays; IRR=1.27; 95% CI = 1.02, 1.57). Conclusions: A larger squad size was associated with a lower average number of plays per season and per game. Increasing youth football squad sizes may help reduce headimpact exposure for individual players. The AE-based injury rates yielded effect estimates similar to those of play-based injury rates. [ABSTRACT FROM AUTHOR]

Background Research on the impact of psychosocial stressors on child and adolescent lung function is uncommon, and has primarily relied either on parents' own stress measures or parent-reported stressors the child experienced, which may be a poor proxy for perceived stress in older children and adolescents. Methods We performed multivariate linear regression of spirometry measures (FVC, FEV1 and FEF25-75) and psychosocial stressors in 584 adolescents in the Los Angeles Family and Neighborhood Survey. We examined family conflict, unsafe neighborhood or school, and the absence of a father in models stratified by gender, adjusting for PM2.5 and potential confounders. Results We observed reductions in lung function in males related to the absence of a father in the house (FEV1: -176.2 ml, 95% CI -322.7, -29.7) and family conflict (FEV1: -156.2 ml, 95% CI -327.8, 15.5); associations were stronger in older males ages 15-17 years for each stressor(P for interaction of age and sex was 0.009 and 0.06, respectively). Conclusions This research informs a very small literature on psychosocial stressors and lung function in adolescents. Our finding of differential vulnerability by age and gender warrants further exploration of adolescent psychosocial stressor response on lung function. [ABSTRACT FROM AUTHOR]

Context: Variations in knee-sprain incidence among competition levels are unclear but may help inform prevention strategies in American football players. Objective: To describe the epidemiology of knee sprains in youth, high school, and collegiate football players. Design: Descriptive epidemiology study. Setting: Injury and athlete-exposure (AE) data were collected from 3 injury-surveillance programs at the youth, high school, and collegiate competition levels. Patients or Other Participants: Data from 310 youth, 184 high school, and 71 collegiate football team-seasons were collected during the 2012 through 2014 seasons. Main Outcome Measure(s): Knee-sprain rates and risks were calculated for each competition level. Injury rate ratios (IRRs) and risk ratios (RRs) compared knee-sprain rates by competition level. Injury proportion ratios (IPRs) compared differences in surgery needs, recurrence, injury mechanism, and injury activity by competition level. Results: Knee-sprain rates in youth, high school, and collegiate football were 0.16/1000 AEs, 0.25/1000 AEs, and 0.69/1000 AEs, respectively. Knee-sprain rates increased as the competition level increased (high school versus youth: IRR = 1.60; 95% confidence interval [CI]=1.12, 2.30; collegiate versus high school: IRR = 2.73; 95% CI = 2.38, 3.96). Knee-sprain risk was highest in collegiate (4.3%), followed by high school (2.0%) and youth (0.5%) athletes. Knee-sprain risk increased as the competition level increased (high school versus youth: RR = 3.73; 95% CI = 2.60, 5.34; collegiate versus high school: RR = 2.14; 95% CI = 1.83, 2.51). Collegiate football had the lowest proportion of knee sprains that were noncontact injuries (collegiate versus youth: IPR = 0.54; 95% CI = 0.31, 0.95; collegiate versus high school: IPR = 0.59; 95% CI = 0.44, 0.79) and the lowest proportion that occurred while being tackled (collegiate versus youth: IPR = 0.44; 95% CI = 0.26, 0.76; collegiate versus high school: IPR =0.71; 95% CI=0.51, 0.98). Conclusions: Knee-sprain incidence was highest in collegiate football. However, level-specific variations in the distributions of knee sprains by injury activity may highlight the need to develop level-specific policies and prevention strategies that ensure safe sports play. [ABSTRACT FROM AUTHOR]

Background: As US health care increasingly focuses on outcomes as a means for quantifying quality, there is a growing demand for risk models that can account for the variability of patients treated at different hospitals so that equitable comparisons between institutions can be made. We sought to apply aspects of prior risk-standardization methodology to begin development of a risk-standardization tool for the National Cardiovascular Data Registry (NCDR) IMPACT (Improving Pediatric and Adult Congenital Treatment) Registry.Methods and Results: Using IMPACT, we identified all patients undergoing diagnostic or interventional cardiac catheterization between January 2011 and March 2013. Multivariable hierarchical logistic regression was used to identify patient and procedural characteristics predictive of experiencing a major adverse event after cardiac catheterization. A total of 19,608 cardiac catheterizations were performed between January 2011 and March 2013. Among all cases, a major adverse event occurred in 378 of all cases (1.9%). After multivariable adjustment, 8 variables were identified as critical for risk standardization: patient age, renal insufficiency, single-ventricle physiology, procedure-type risk group, low systemic saturation, low mixed venous saturation, elevated systemic ventricular end-diastolic pressure, and elevated main pulmonary artery pressures. The model had good discrimination (C statistic, 0.70), confirmed by bootstrap validation (validation C statistic, 0.69).Conclusions: Using prior risk-standardization efforts as a foundation, we developed and internally validated a model to predict the occurrence of a major adverse event after cardiac catheterization for congenital heart disease. Future efforts should be directed toward further refinement of the model variables within this large, multicenter data set. [ABSTRACT FROM AUTHOR]

Background: Maternal diet during pregnancy has been proposed to increase the risk of autoimmune diseases. Objective: The objective was to investigate the association between maternal consumption of gluten-containing foods during late pregnancy and subsequent risk of celiac disease in the offspring. Design: Genetically susceptible children prospectively followed from birth were screened annually for tissue transglutaminase autoantibodies (tTGAs). Children testing persistently positive for tTGAs were further evaluated for celiac disease. Diagnosis of celiac disease was confirmed by intestinal biopsy or was considered likely if the mean tTGA concentration was .100 units in 2 consecutive samples. A questionnaire on the mother's diet in late pregnancy was completed by 3-4.5 mo postpartum. Mothers were divided into 3 groups based on the tertiles of their consumption of gluten-containing foods (servings/d). The association between maternal gluten-containing food consumption and the risk of celiac disease was studied by using a time-to-event analysis. Results: At the time of analysis, 359 (5%) of the 6546 children developed celiac disease. Compared with the middle category of maternal gluten-containing food consumption (servings/d), low (HR: 0.87; 95% CI: 0.67, 1.13; P = 0.296) and high (HR: 0.84; 95% CI: 0.65, 1.09; P = 0.202) consumption was not associated with risk of celiac disease in the child after adjustment for country, human leukocyte antigen genotype, family history of celiac disease, maternal education, and sex of the child. Median maternal daily consumption frequency of gluten-containing foods was higher (P < 0.0001) in Finland (5.3; IQR: 3.9-6.9), Germany (4.3; IQR: 3.1-5.5), and Sweden (3.7; IQR: 2.8-4.9) than in the United States (3.4; IQR: 2.3-4.9). No significant interaction was found between country of residence and the mothers' consumption of gluten-containing foods in relation to risk of celiac disease. Conclusion: The frequency of gluten-containing food consumption during late pregnancy is not associated with risk of celiac disease in the offspring. [ABSTRACT FROM AUTHOR]

Infant's age at introduction to certain complementary foods (CF) has in previous studies been associated with islet autoimmunity, which is an early marker for type 1 diabetes (T1D). Various maternal sociodemographic factors have been found to be associated with early introduction to CF. The aims of this study were to describe early infant feeding and identify sociodemographic factors associated with early introduction to CF in a multinational cohort of infants with an increased genetic risk for T1D. The Environmental Determinants of Diabetes in the Young study is a prospective longitudinal birth cohort study. Infants (N = 6404) screened for T1D high risk human leucocyte antigen‐DQ genotypes (DR3/4, DR4/4, DR4/8, DR3/3, DR4/4, DR4/1, DR4/13, DR4/9 and DR3/9) were followed for 2 years at six clinical research centres: three in the United States (Colorado, Georgia/Florida, Washington) and three in Europe (Sweden, Finland, Germany). Age at first introduction to any food was reported at clinical visits every third month from the age of 3 months. Maternal sociodemographic data were self‐reported through questionnaires. Age at first introduction to CF was primarily associated with country of residence. Root vegetables and fruits were usually the first CF introduced in Finland and Sweden and cereals were usually the first CF introduced in the United States. Between 15% and 20% of the infants were introduced to solid foods before the age of 4 months. Young maternal age (<25 years), low educational level (<12 years) and smoking during pregnancy were significant predictors of early introduction to CF in this cohort. Infants with a relative with T1D were more likely to be introduced to CF later. [ABSTRACT FROM AUTHOR]

Background: Deficient soluble fiber intake has been suggested to dysregulate the immune response either directly or through alterations of the microbial composition in the gut. Objective: We hypothesized that a high intake of dietary soluble fiber in early childhood decreases the risk of type 1 diabetes (T1D)-associated islet autoimmunity. Design: We analyzed 17,620 food records collected between age 9 and 48 mo from 3358 children from the United States and Germany prospectively followed in the TEDDY (The Environmental Determinants of Diabetes in the Young) study. HRs for the development of any/multiple islet autoantibodies (242 and 151 events, respectively) and T1D (71 events) by soluble fiber intake were calculated in Cox regression models and adjusted for potential confounders. Results: There were no statistically significantly protective associations observed between a high intake of soluble fiber and islet autoimmunity or T1D. For example, the adjusted HRs (95% CIs) for high intake (highest compared with lowest quintile) at age 12 mo were 0.90 (0.55, 1.45) for any islet autoantibody, 1.20 (0.69, 2.11) for multiple islet autoantibodies, and 1.24 (0.57, 2.70) for T1D. In analyzing soluble fiber intake as a time-varying covariate, there were also no short-term associations between soluble fiber intake and islet autoimmunity development, with adjusted HRs of 0.85 (0.51, 1.42) for high intake and development of any islet autoantibody, for example. Conclusion: These results indicate that the intake level of dietary soluble fiber is not associated with islet autoimmunity or T1D in early life. [ABSTRACT FROM AUTHOR]

Background: The impact of protein intake on outcomes in pediatric critical illness is unclear. Objective: We examined the association between protein intake and 60-d mortality in mechanically ventilated children. Design: In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for ≥48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay ≤10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy. Results: We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the post-pyloric route. Mean ± SD prescribed energy and protein goals were 69 ± 28 kcal/kg per day and 1.9 ± 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 ± 35% and 37 ± 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P < 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake <20%, intake ≥60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery. Conclusions: Delivery of >60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. This trial was registered at clinicaltrials.gov as NCT02354521. [ABSTRACT FROM AUTHOR]

Background: Autism spectrum disorder (ASD) is a developmental disorder with increasing prevalence worldwide, yet has unclear etiology. Objective: We explored the association between maternal exposure to particulate matter (PM) air pollution and odds of ASD in her child. Methods: We conducted a nested case–control study of participants in the Nurses’ Health Study II (NHS II), a prospective cohort of 116,430 U.S. female nurses recruited in 1989, followed by biennial mailed questionnaires. Subjects were NHS II participants’ children born 1990–2002 with ASD (n = 245), and children without ASD (n = 1,522) randomly selected using frequency matching for birth years. Diagnosis of ASD was based on maternal report, which was validated against the Autism Diagnostic Interview-Revised in a subset. Monthly averages of PM with diameters ≤ 2.5 μm (PM2.5) and 2.5–10 μm (PM10–2.5) were predicted from a spatiotemporal model for the continental United States and linked to residential addresses. Results: PM2.5 exposure during pregnancy was associated with increased odds of ASD, with an adjusted odds ratio (OR) for ASD per interquartile range (IQR) higher PM2.5 (4.42 μg/m3) of 1.57 (95% CI: 1.22, 2.03) among women with the same address before and after pregnancy (160 cases, 986 controls). Associations with PM2.5 exposure 9 months before or after the pregnancy were weaker in independent models and null when all three time periods were included, whereas the association with the 9 months of pregnancy remained (OR = 1.63; 95% CI: 1.08, 2.47). The association between ASD and PM2.5 was stronger for exposure during the third trimester (OR = 1.42 per IQR increase in PM2.5; 95% CI: 1.09, 1.86) than during the first two trimesters (ORs = 1.06 and 1.00) when mutually adjusted. There was little association between PM10–2.5 and ASD. Conclusions: Higher maternal exposure to PM2.5 during pregnancy, particularly the third trimester, was associated with greater odds of a child having ASD. [ABSTRACT FROM AUTHOR]

We demonstrate how direct, indirect, total, and overall effectiveness estimates and absolute benefits of rotavirus vaccines vary through the years following vaccine introduction. Privately insured US children in a large claims database were followed from age 8 months until they 1) experienced a hospitalization for rotavirus or acute gastroenteritis; 2) lost continuous health plan enrollment; 3) turned 20 months of age; or 4) reached the end of the study period. Vaccine effectiveness estimates in preventing rotavirus and acute gastroenteritis hospitalizations were estimated using Cox proportional hazards regression, stratified by calendar year and adjusted for birth month. Incidence rate differences were estimated to determine the absolute number of gastroenteritis hospitalizations prevented in the cohort. Among 905,718 children, 51%, 66%, 80%, and 86% received 1 or more doses of rotavirus vaccine in each year from 2007 to 2010. The direct vaccine effectiveness of 1 or more doses of rotavirus vaccine in preventing rotavirus gastroenteritis hospitalizations ranged from 87% to 92% each year. Accounting for indirect protection increased estimates of vaccine effectiveness by an additional 3%–8% among those vaccinated. Failing to account for population-level vaccine benefits in 2010, when circulation of rotavirus was low, could underestimate the sustained impact of the vaccine program. [ABSTRACT FROM AUTHOR]

Evidence shows that asthma originates in early life. Studies have found that phototherapy and/or neonatal jaundice may be associated with asthma. We investigated the association between neonatal bilirubin levels and childhood asthma without phototherapy intervention in the Collaborative Perinatal Project, a multicenter prospective cohort study conducted in the United States from 1959 to 1965. A total of 54,795 livebirths were included, and 40,063 children were followed up until 7 years of age or older. Total serum bilirubin (TSB) levels were examined at 48 hours postpartum in newborns with birthweights of 2,250 g or more. Information on asthma and other diseases through age 7 years was summarized and confirmed by a group of pediatricians and child neurologists. Among 28,807 term infants, the overall prevalence of asthma was 5.26%. Risks of asthma increased with both maximum TSB levels and TSB levels at 48 hours postpartum (P for trend < 0.01). Neonatal maximum TSB levels greater than 15 mg/dL were associated with a 61% increase in the risk of childhood asthma (odds ratio = 1.61, 95% confidence interval: 1.04, 2.08) after adjustment for confounders. In this prospective cohort study of infants born at a time when phototherapy was unavailable, neonatal hyperbilirubinemia was associated with an increased risk of childhood asthma. [ABSTRACT FROM PUBLISHER]

Background: In some previous studies, prenatal exposure to persistent organochlorines such as 1,1,-dichloro-2,2-bis(p-chlorophenyl)ethylene (p,p′−DDE), polychlorinated biphenyls (PCBs), and hexachlorobenzene (HCB) has been associated with higher body mass index (BMI) in children. Objective: Our goal was to evaluate the association of maternal serum levels of β-hexachlorocyclohexane (β HCH), p,p′−DDE, dichlorodiphenyltrichloroethane (p,p′−DDT), dieldrin, heptachlor epoxide, HCB, trans-nonachlor, oxychlordane, and PCBs with offspring obesity during childhood. Methods: The analysis was based on a subsample of 1,915 children followed until 7 years of age as part of the U.S. Collaborative Perinatal Project (CPP). The CPP enrolled pregnant women in 1959-1965; exposure levels were measured in third-trimester maternal serum that was collected before these organochlorines were banned in the United States. Childhood overweight and obesity were defined using age- and sex-specific cut points for BMI as recommended by the International Obesity Task Force. Results: Adjusted results did not show clear evidence for an association between organochlorine exposure and obesity; however, a suggestive finding emerged for dieldrin. Compared with those in the lowest quintile (dieldrin, < 0.57 µg/L), odds of obesity were 3.6 (95% CI: 1.3, 10.5) for the fourth and 2.3 (95% CI: 0.8, 7.1) for the highest quintile. Overweight and BMI were unrelated to organochlorine exposure. Conclusions: In this population with relatively high levels of exposure to organochlorines, no clear associations with obesity or BMI emerged. [ABSTRACT FROM AUTHOR]

Objective: Air pollution contains many toxicants known to affect neurological function and to have effects on the fetus in utero. Recent studies have reported associations between perinatal exposure to air pollutants and autism spectrum disorder (ASD) in children. We tested the hypothesis that perinatal exposure to air pollutants is associated with ASD, focusing on pollutants associated with ASD in prior studies. Methods: We estimated associations between U.S. Environmental Protection Agency-modeled levels of hazardous air pollutants at the time and place of birth and ASD in the children of participants in the Nurses' Health Study II (325 cases, 22,101 controls). Our analyses focused on pollutants associated with ASD in prior research. We accounted for possible confounding and ascertainment bias by adjusting for family-level socioeconomic status (maternal grandparents' education) and census tract-level socioeconomic measures (e.g., tract median income and percent college educated), as well as maternal age at birth and year of birth. We also examined possible differences in the relationship between ASD and pollutant exposures by child's sex. Results: Perinatal exposures to the highest versus lowest quintile of diesel, lead, manganese, mercury, methylene chloride, and an overall measure of metals were significantly associated with ASD, with odds ratios ranging from 1.5 (for overall metals measure) to 2.0 (for diesel and mercury). In addition, linear trends were positive and statistically significant for these exposures (p < .05 for each). For most pollutants, associations were stronger for boys (279 cases) than for girls (46 cases) and significantly different according to sex. Conclusions: Perinatal exposure to air pollutants may increase risk for ASD. Additionally, future studies should consider sex-specific biological pathways connecting perinatal exposure to pollutants with ASD. INSET: CORRECTION. [ABSTRACT FROM AUTHOR]

Background: The role of environmental exposure to lead as a risk factor for chronic kidney disease (CKD) and its progression remains controversial, and most studies have been limited by a lack of direct glomerular filtration rate (GFR) measurement. Objective: We evaluated the association between lead exposure and GFR in children with CKD. Methods: In this cross-sectional study, we examined the association between blood lead levels (BLLs) and GFR measured by the plasma disappearance of iohexol among 391 participants in the Chronic Kidney Disease in Children (CKiD) prospective cohort study. Results: Median BLL and GFR were 1.2 µg/dL and 44.4 mL/min per 1.73 m2, respectively. The average percent change in GFR for each 1-µg/dL increase in BLL was −2.1 (95% CI: −6.0, 1.8). In analyses stratified by CKD diagnosis, the association between BLL and GFR was stronger among children with glomerular disease underlying CKD; in this group, each 1-µg/dL increase in BLL was associated with a −12.1 (95% CI: −22.2, −1.9) percent change in GFR. In analyses stratified by anemia status, each 1-µg/dL increase in BLL among those with and without anemia was associated with a −0.3 (95% CI: −7.2, 6.6) and −4.6 (95% CI: −8.9, −0.3) percent change in GFR, respectively. Conclusions: There was no significant association between BLL and directly measured GFR in this relatively large cohort of children with CKD, although associations were observed in some subgroups. Longitudinal analyses are needed to examine the temporal relationship between lead and GFR decline, and to further examine the impact of underlying cause of CKD and anemia/hemoglobin status among patients with CKD. [ABSTRACT FROM AUTHOR]

Childhood obesity, a major public health problem, can lead to cardiovascular disease in adulthood. Studies have implicated exposure to bisphenol A (BPA), a commonly used chemical, in the development of obesity in adults. However, literature is limited on this association in children. We examined the association between urinary BPA and obesity in children aged 6–18 years from the National Health and Nutrition Examination Survey (2003–2008). The primary exposure was urinary BPA and the outcome was obesity, defined as the ≥95th percentile of body mass index specific for age and sex. We found a positive association between increasing levels of urinary BPA and obesity, independent of age, sex, race/ethnicity, education, physical activity, serum cotinine, and urinary creatinine. Compared with children in the lowest quartile of BPA (<1.5 ng/mL), children in the highest quartile (>5.4 ng/mL) had a multivariable odds ratio for obesity of 2.55 (95% confidence interval (CI): 1.65, 3.95) (Ptrend < 0.01). The observed positive association was predominantly present in boys (odds ratio = 3.80, 95% CI: 2.25, 6.43) (Ptrend < 0.001) and in non-Hispanic whites (odds ratio = 5.87, 95% CI: 2.15, 16.05) (Ptrend < 0.01). In a representative sample of children, urinary BPA was associated with obesity, predominantly in non-Hispanic white boys, independent of major risk factors. [ABSTRACT FROM PUBLISHER]

Objectives. We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. Methods. Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. Results. In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. Conclusions. Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities. [ABSTRACT FROM AUTHOR]

The protective effect of family meals on unhealthy weight gain and diet has been shown across multiple age groups; however, it is unknown whether a similar effect is present among diverse immigrant populations. In addition, little research has focused on factors associated with the frequency of evening family meals, such as feeding styles (how parents interact with their child around feeding). Therefore the goals of this paper are to explore the 1) association between the frequency of evening family meals and child weight status among new immigrant families, and 2) influence of immigrant mothers’ feeding styles on the frequency of evening family meals. Baseline self-reported socio-demographic information and measured heights and weights were collected for both mother and child (age range: 3-12 years) among 387 mother-child dyads enrolled in Live Well, a community-based, participatory-research, randomized controlled lifestyle intervention to prevent excessive weight gain in recent (<10 years in the U.S.) immigrant mothers and children. For children, height and weight measurements were transformed into BMI z-scores using age-and sex-specific CDC standards and categorized as overweight (85th-94th percentile) and obese (≥95th percentile); mothers’ BMI was calculated. Frequency of evening family meals, eating dinner in front of the TV, acculturation and responses to the Caregiver’s Feeding Styles Questionnaire (CFSQ) were also obtained from the mother. Children were categorized as “eating evening family meals regularly” if they had an evening family meal ≥5 times per week. Overall, 20% of children were overweight and 25% were obese. Less than half (40.9%) of families had regular evening family meals. In multivariate analyses, adjusting for covariates, children who were overweight/obese were significantly less likely to have ≥5 evening family meals/week compared with normal weight children (OR = 0.51, 95% CI 0.32-0.82) . Mothers who had a low demanding/high responsive or a low demanding/low responsive feeding style, were less likely to have ≥5 evening family meals/week compared to mothers with a high demanding/high responsive feeding style (OR = 0.41, 95% CI 0.18-0.0.96, OR = 0.33, 95% CI 0.13-0.87, respectively). Future interventions and programs that seek to help parents establish healthy household routines, such as family meals, may consider tailoring to specific maternal feeding styles. [ABSTRACT FROM AUTHOR]

Objectives. We developed a content review for state policies related to childhood obesity, and we have quantitatively described the predictors of enactment. Methods. We collected an inventory of 2006 through 2009 state legislation on 27 childhood obesity topics from legislative databases. We coded each bill for general information, topic content, and other appropriate components. We conducted a general descriptive analysis and 3 multilevel analyses using bill- and state-level characteristics to predict bill enactment. Results. Common topics in the 27% of the bills that were enacted were community physical activity access, physical education, and school food policy. Committee and bipartisan sponsorship and having term limits significantly predicted enactment in at least 1 model. Bills with safe routes to school or health and nutrition content were twice as likely to be enacted. Bills containing product and menu labeling or soda and snack taxes were significantly less likely to be enacted. Conclusions. Bipartisan and committee support and term limits are important in bill enactment. Advocacy efforts can be tailored to increase awareness and sense of priority among policymakers. (Am J Public Health. 2012;102:2294-2302.) [ABSTRACT FROM AUTHOR]

Background: In adult populations, emerging evidence indicates that humans are exposed to arsenic by ingestion of contaminated foods such as rice, grains, and juice; yet little is known about arsenic exposure among children. Objectives: Our goal was to determine whether rice consumption contributes to arsenic exposure in U.S. children.Methods: We used data from the nationally representative National Health and Nutrition Examination Survey (NHANES) to examine the relationship between rice consumption (measured in 0.25 cups of cooked rice per day) over a 24-hr period and subsequent urinary arsenic concentration among the 2,323 children (6-17 years of age) who participated in NHANES from 2003 to 2008. We examined total urinary arsenic (excluding arsenobetaine and arsenocholine) and dimethylarsinic acid (DMA) concentrations overall and by age group: 6-11 years and 12-17 years. Results: The median [interquartile range (IQR)] total urinary arsenic concentration among children who reported consuming rice was 8.9 µg/L (IQR: 5.3-15.6) compared with 5.5 µg/L (IQR: 3.1-8.4) among those who did not consume rice. After adjusting for potentially confounding factors, and restricting the study to participants who did not consume seafood in the preceding 24 hr, total urinary arsenic concentration increased 14.2% (95% confidence interval: 11.3, 17.1%) with each 0.25 cup increase in cooked rice consumption. Conclusions: Our study suggests that rice consumption is a potential source of arsenic exposure in U.S. children. [ABSTRACT FROM AUTHOR]

Background: Children from ethnic minority and low-income families in the United States have higher rates of poor health and higher mortality rates. Diet, an acknowledged correlate of health, may mediate the known race-ethnic and socioeconomic differentials in the health of US children. Objective: The objective was to examine the independent association of race-ethnicity, family income, and education with nutritional and lipid biomarkers in US children. Design: We used data from the NHANES 2003-2006 to examine serum concentrations of vitamins A, D, E, C, B-6, and B-12; serum concentrations of folate, carotenoids, and lipids; and dietary intakes of corresponding nutrients for 2-19-y-old children (n - ~2700- 7500). Multiple covariate-adjusted regression methods were used to examine the independent and joint associations of race-ethnicity, family income, and education with biomarker status. Results: Non-Hispanic blacks had lower mean serum concentrations of vitamins A, B-6, and E and α-carotene than did non- Hispanic whites. Both non-Hispanic blacks and Mexican Americans had higher mean serum vitamin C, β-cryptoxanthin, and lutein + zeaxanthin but lower folate and vitamin D concentrations compared with non-Hispanic whites. In comparison with non-Hispanic whites, non-Hispanic blacks were less likely to have low serum HDL cholesterol or high triglycerides. Family income and education predicted few biomarker or dietary outcomes, and the observed associations were weak. Moreover, modification of race-ethnic differentials by income or education (or vice versa) was noted for very few biomarkers. Conclusion: Race-ethnicity, but not family income or education, was a strong independent predictor of serum nutrient concentrations and dietary micronutrient intakes in US children and adolescents. [ABSTRACT FROM AUTHOR]

Objective To compare sentinel and population-based surveillance of the effect of seven-valent pneumococcal conjugate vaccine (PCV7), introduced in 2000, on the hospitalization of children aged under 5 years with invasive pneumococcal disease (IPD) in the United States of America. Methods Population surveillance data were used to identify children hospitalized between 1998 and 2006 with IPD caused by Streptococcus pneumoniae serotypes. The change from 1998 and 1999 (baseline) to 2006 in the number of hospitalized IPD cases recorded by sentinel surveillance systems involving single hospitals or groups of hospitals was compared with the change in the incidence of hospitalized IPD cases measured by population-based surveillance. Findings The change in incidence in the eight surveillance areas varied from -37 to -82% for IPD caused by any serotype and from -96 to -100% for IPD caused by serotypes contained in PCV7. All individual sentinel hospitals with more than three cases annually at baseline reported a decrease in cases by 2006. In addition, over 95% of sentinel systems with an average of more than 30 cases annually at baseline recorded a change by 2006 in the number of cases caused by any serotype that fell within the 95% confidence interval for the change in the incidence of hospitalized cases in the corresponding population surveillance area. The change in cases caused by PCV7 serotypes was accurately measured by 93% and 100% of sentinel systems with ≤20 and > 20 cases annually at baseline, respectively. Conclusion Sentinel surveillance can accurately measure the effect of PCV7 on the number of children hospitalized with IPD, provided sufficient cases are detected at baseline. Serotyping increases accuracy. [ABSTRACT FROM AUTHOR]

The article focuses on research which was conducted to examine changes in physical activity among children and adolescents by race/ethnicity in the United States from 2003-2004 to 2005-2006. Researchers evaluated data from more than 3,000 children. They found that physical activity decreased with age, boys were more active than girls, and non-Hispanic black children were more active than non-Hispanic whites. They concluded that because a lack of improvement in physical activity and an emerging race-ethnic disparity were found, more research was needed on physical activity among U.S. children.

Objectives. We evaluated the relationship between secondhand tobacco smoke (SHS) exposure and blood lead levels in US children and adolescents. Methods. We analyzed data from 6830 participants aged 3-19 years in the National Health and Nutrition Examination Survey (1999-2004) who were not active smokers and for whom SHS exposure information and blood lead measurements were available. Results. After multivariable adjustment, participants in the highest quartile of serum cotinine (‡0.44 lg/L) had 28% (95% confidence interval=21%, 36%) higher blood lead levels than had those in the lowest quartile (<0.03 lg/L). Similarly, blood lead levels were 14% and 24% higher in children who lived with 1 or with 2 or more smokers, respectively, than they were in children living with no smokers. Among participants for whom lead dust information was available, the associations between SHS and blood lead levels were similar before and after adjustment for lead dust concentrations. Conclusions. SHS may contribute to increased blood lead levels in US children. Lead dust does not appear to mediate this association, suggesting inhalation as a major pathway of exposure. Eliminating SHS exposure could reduce lead exposure in children. [ABSTRACT FROM AUTHOR]

Background: The etiologies of the male urogenital anomalies--cryptorchidism and hypospadias--are poorly understood. Given positive associations between chlordane isomers and testicular germ cell tumors, it is reasonable to assume that chlordanes might also be associated with other testicular dysgenesis syndrome disorders, namely cryptorchidism and hypospadias. Objective: To examine whether exposure to in utero chlordane is related to cryptorchidism and hypospadias, we evaluated levels of chlordane derivatives, trans-nonachlor and oxychlordane, among pregnant women enrolled in the Collaborative Perinatal Project (CPP). Methods: From 1959 to 1965, the CPP enrolled pregnant women at 12 U.S. medical centers. We analyzed serum trans-nonachlor and oxychlordane levels measured in third-trimester serum from the mothers of 217 sons with cryptorchidism, 197 sons with hypospadias, and 557 sons with neither condition. Adjusted odds ratios (ORs) and 95% confidence intervals were calculated using conditional logistic regression. Results: The quartile-specific ORs for cryptorchidism or hypospadias show no notable associations with trans-nonachlor or oxychlordane. Further, there were no significant trends with increasing quartile of maternal trans-nonachlor or oxychlordane level in either cryptorchidism or hypospadias (p-trend all > 0.45). Conclusions: The results do not support an association between chlordane levels and cryptorchidism or hypospadias. It is unlikely that current chlordane exposure is related to the development of either anomaly, given that serum chlordane levels at the time of sample collection, the early 1960s, were considerably higher than levels at present. [ABSTRACT FROM AUTHOR]

Pediatric thyroid carcinoma is relatively uncommon. But variability in incidence rate by race, sex, age at onset/diagnosis, and geographic local had been observed in adult thyroid carcinoma in the USA. We aimed to examine the patterns, rates, and temporal trends of thyroid carcinoma among pediatric patients (0-19 years) between 1973 and 2007. The Surveillance, Epidemiology, and End Results (SEER) data of the National Cancer Institute were utilized. Data were available on sex, age at diagnosis, race/ethnicity, and geographic locale (9 SEER registries) and were used for rates and trends computation. The frequency and percentage, percent changes (PCs) were calculated by using 1 year of each endpoint. Similarly, the annual percent changes (APCs) were calculated as well, with APCs estimated using weighted least square methods. Between 1973 and 2007, 1,360 thyroid cancer cases were ascertained in the 9 SEER areas (n = 247,638,734) in the USA. The percent change was 47.9, while the APC was significantly different from 0, 1.0 (95% CI: 0.5-1.6, P < 0.0001). The rate ratio (RR) was significantly lower in 1975 (RR: 0.62, 95% CI: 0.38-0.98, P = 0.03) relative to the rate between 1973 and 2007 (RR: 1.60, per 100,000, 95% CI: 1.50-1.70), but higher in 2007 (RR: 2.3 per 100,000, 95% CI: 1.70-3.10; RR: 1.44, 95% CI: 1.05-1.93, P = 0.02). The rate was significantly higher in whites relative to blacks, highest among age group of 15-19 years and girls, and in some SEER registries, with some significant PC in Connecticut. This temporal trend study of pediatric thyroid carcinoma indicates increase in the rate of this malignancy given the percent change and the annual percent change between 1973 and 2007. In addition, the incidence was higher among girls, lower among blacks, highest in age group of 15-19 years, and relatively higher in SEER registries with predominantly white or Hispanic populations. [ABSTRACT FROM AUTHOR]

Background: Since 2006, banning smoking in cars with children has become a rapidly growing tobacco control policy. However, to date, there have been few studies examining support and correlates of support for car smoking bans, and none of the existing studies have been international in nature. We conducted such a study among smokers in four countries. Methods: 6716 adult current smokers from the 2007 Wave of the International Tobacco Control Four Country Survey, a nationally representative, longitudinal cohort telephone survey of smokers in the USA, Canada, UK and Australia. Controlling for demographics, heaviness of smoking, smoking health knowledge/beliefs and quit intentions, we compared support and correlates of support for banning smoking in cars with children across the four countries. Results: The majority of smokers supported banning smoking in cars with children. Support was highest in Australia (83%), followed by the UK (75%) and Canada (74%); support was lower—but still high—in the USA (60%). Support was highest among smokers who: had stronger quit intentions, were lighter smokers, had lower education, had no children in the home, believed that cigarette smoke is dangerous to non-smokers and could cause asthma in children, and were concerned about modelling smoking to children. Conclusions: These findings indicate that a majority of smokers in the four countries support banning smoking in cars with children, and lend support to banning smoking in cars with children. Additionally, they suggest that support may be increased by educating smokers about the dangers of cigarette smoke exposure. [ABSTRACT FROM AUTHOR]

Many studies have reported that antibiotic use may be associated with increased risk of childhood asthma. Respiratory tract infections in small children may be difficult to distinguish from early symptoms of asthma, and studies may have been confounded by “protopathic” bias, where antibiotics are used to treat early symptoms of asthma. These analyses of a cohort including 1,401 US children assess the association between antibiotic use within the first 6 months of life and asthma and allergy at 6 years of age between 2003 and 2007. Antibiotic exposure was associated with increased risk of asthma (adjusted odds ratio = 1.52, 95% confidence interval (CI): 1.07, 2.16). The odds ratio if asthma was first diagnosed after 3 years of age was 1.66 (95% CI: 0.99, 2.79) and, in children with no history of lower respiratory infection in the first year of life, the odds ratio was 1.66 (95% CI: 1.12, 3.46). The adverse effect of antibiotics was particularly strong in children with no family history of asthma (odds ratio = 1.89, 95% CI: 1.00, 3.58) (Pinteraction = 0.03). The odds ratio for a positive allergy blood or skin test was 1.59 (95% CI: 1.10, 2.28). The results show that early antibiotic use was associated with asthma and allergy at 6 years of age, and that protopathic bias was unlikely to account for the main findings. [ABSTRACT FROM PUBLISHER]

Objectives: The objective was to describe the emergency department (ED) resource burden of the spring 2009 H1N1 influenza pandemic at U.S. children's hospitals by quantifying observed-to-expected utilization. Methods: The authors performed an ecologic analysis for April through July 2009 using data from 23 EDs in the Pediatric Health Information System (PHIS), an administrative database of widely distributed U.S. children's hospitals. All ED visits during the study period were included, and data from the 5 prior years were used for establishing expected values. Primary outcome measures included observed-to-expected ratios for ED visits for all reasons and for influenza-related illness (IRI). [ABSTRACT FROM AUTHOR]