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Flag football is promoted as a safer alternative to tackle football. This may be 1 reason why participation rates have risen by 39% over the past 3 years. Despite rising participation, epidemiologic research on sport-specific injuries and associated relative risk is lacking. To prospectively document the epidemiology of injuries in youth flag football. Descriptive epidemiology study. Regional and national youth flag football tournaments. Athletes (N = 1939; 1744 boys and 195 girls), ages 6 to 12 years. An athletic trainer prospectively monitored the athletes for sport-related injury and exposures. Athlete risks of injury and injury rates were calculated overall and by sex. Injury characteristics were reported for the total population and by sex. Forty-seven injuries to unique individuals were recorded in 1939 athletes with a total of 9228 athlete-exposures (AEs). The overall risk of injury was 2.4% (95% CI = 1.79%, 3.21%), with an overall injury rate of 5.1 per 1000 AEs (95% CI = 3.75, 6.77). Of the 47 injuries, 36 occurred in boys (8365 AEs), and 11 occurred in girls (863 AEs). A higher risk in girls was evidenced by both the injury risk ratio (2.73; 95% CI = 1.41, 5.30) and injury rate ratio of 2.96 (95% CI = 1.51, 5.82). The most common injury sites were the head/face/neck (n = 15, 31.9%), followed by the ankle/foot (n = 9, 19.1%). The most frequent types of injury were contusion (55.3%), sprain/subluxation (14.9%), and general trauma (10.6%); 74.5% of all injuries resulted from direct impact. Although the competition injury rate for youth flag football was lower than the values from studies reporting comparable tackle football data, the frequencies by body part, type, and mechanism were similar. Given that most injuries were related to some form of impact and predominantly contusions, adopting minimal protective equipment or padding may reduce the numbers of these injuries. [ABSTRACT FROM AUTHOR]

Exposure to environmental tobacco smoke (ETS) is a major cause of morbidity and mortality among U.S. children. Despite African-American children's having a lower reported exposure to tobacco compared to whites, [...]

This study proposes a Bayesian joint model with extended random effects structure that incorporates nested repeated measures and provides simultaneous inference on treatment effects over time and drop-out patterns. The proposed model includes flexible splines to characterize the circadian variation inherent in blood pressure sequences, and we assess the effectiveness of an intervention to resolve pediatric obstructive sleep apnea. We demonstrate that the proposed model and its conventional two-stage counterpart provide similar estimates of nighttime blood pressure but estimates on the mean evolution of daytime blood pressure are discrepant. Our simulation studies tailored to the motivating data suggest reasonable estimation and coverage probabilities for both fixed and random effects. Computational challenges of model implementation are discussed. [ABSTRACT FROM AUTHOR]

Introduction/Aims: Glucocorticoid‐induced osteoporosis with vertebral fractures is frequent in patients with Duchenne muscular dystrophy (DMD). In this study, we evaluated the effects of oral bisphosphonate (BP) therapy on the prevalence and severity of vertebral fractures by vertebral morphometry assessment. Methods: We reviewed the records and radiographs of patients with DMD who had been treated with oral BP (weekly alendronate) and had undergone routine spine radiographic monitoring for glucocorticoid‐induced osteoporosis at Cincinnati Children's Hospital Medical Center between 2010 and 2017. Study outcomes were thoracic and lumbar vertebral fracture prevalence and severity, assessed by Genant semiquantitative grading of vertebral morphometry, for up to 5 years of treatment. Results: Fifty‐two patients (median age, 11.8 years; 88% prepubertal; 31% nonambulatory) had been treated with long‐term glucocorticoids (median duration, 4.7 years at BP start). Most patients (75%) had mild vertebral height loss or fractures (Genant grade = 0 or 1) at baseline. The prevalence of vertebral fractures at each year of treatment was not statistically different from that at baseline (P =.08‐1.00). Serial radiographs showed no longitudinal change in severity by Genant grade in most vertebrae (64%‐80%). Improvement in vertebral fracture grade was observed in some patients. Discussion: We observed stable prevalence of vertebral fractures and no change in severity by Genant grade in most vertebrae for up to 5 years of treatment. Oral BP may mitigate development or progression of vertebral fractures and be beneficial for secondary prevention of glucocorticoid‐induced osteoporosis in this population. [ABSTRACT FROM AUTHOR]

Background: The objective was to determine whether infant neurobehavior measured at five post-gestational weeks could predict social and communicative behavior (SCB) through five and eight years. Methods: Infant neurobehavior was assessed using the Neonatal Intensive Care Unit Network Neurobehavioral Scale, and SCB was measured using the Social Responsiveness Scale (SRS). Adjusted linear regression with generalized estimating equations were employed to estimate the association between infant neurobehavior and SCB. Interaction terms and stratification were used to identify potential effect modification by autism spectrum disorder risk factors. Results: The analyses include n = 214 and n = 227 participants who were examined at 5 weeks and followed to 4/5 and 8 years, respectively. Adjusting for maternal age, race, parity, and education as well as gestational age, only the Neonatal Intensive Care Unit Network Neurobehavioral Scale summary score of "attention" (measured at mean 43.9 gestational weeks) was inversely associated with total SRS T-score through 5 years. However, in analyses stratified by maternal age, the inverse association between "attention" and SCB was significant, but only among offspring of women of advanced maternal age (≥35 y); in addition, higher scores of "excitability," "lethargy," and "arousal" were associated with increased total SRS T scores among women of advanced maternal age. The associations were no longer statistically significant at 8 years. Conclusions: Newborns with lower scores on the attention subscale (determined by an ability to localize and track animate and inanimate objects) were more likely to demonstrate deficits in SCB. In addition, infants with increased excitability, lethargy, or increased arousal were more likely to have impaired SCB that persisted through 5 years, but not at 8 years of age. Further work is necessary to identify specific aspects of infant neurobehavior that may affect childhood SCBs. [ABSTRACT FROM AUTHOR]

We previously published rates of pediatric stroke using our population-based Greater Cincinnati Northern Kentucky Stroke Study (GCNK) for periods July 1993–June 1994 and 1999. We report population-based rates from 2 additional study periods: 2005 and 2010. We identified all pediatric strokes for residents of the GCNK region that occurred in July 1, 1993–June 30, 1994, and calendar years 1999, 2005, and 2010. Stroke cases were ascertained by screening discharge ICD-9 codes, and verified by a physician. Pediatric stroke was defined as stroke in those <20 years of age. Stroke rates by study period, overall, by age and by race, were calculated. Eleven children died within 30 days, yielding an all-cause case fatality rate of 15.7% (95% confidence interval 1.1%, 26.4%) with 3 (27.3%) ischemic, 6 (54.5%) hemorrhagic, and 2 (18.2%) unknown stroke type. The pediatric stroke rate of 4.4 per 100 000 in the GCNK study region has not changed over 17 years. [ABSTRACT FROM AUTHOR]

Background: Phthalates, used in a variety of consumer products, are a group of chemicals that are ubiquitous in the environment, and their metabolites are detectable in most humans. Some phthalates have anti-androgenic properties; a prior study reported an association between gestational exposure to phthalates and reduced masculine behaviors in preschool boys.Methods: Concentrations of 9 phthalate metabolites were measured in urine collected at 16 and 26 weeks' gestation from pregnant women enrolled in the HOME Study, a prospective pregnancy and birth cohort. Measures of gender-related play were collected at 8 years of age, including the Gender Identity Questionnaire (GIQ) completed by mothers, and the Playmate and Play Style Preferences Structured Interview (PPPSI) completed by children. We examined these measures as continuous variables using both bivariate and multivariable approaches with adjustment for covariates. Additional analyses included logistic regression of GIQ and PPPSI scores dichotomized by sex at the lower 25th percentile, indicating the least typical behavior.Results: Mothers' phthalate metabolite concentrations during pregnancy were similar to the reported national average among US women. All children scored within a typical range on both measures of gender-related play behavior. No statistically significant associations were found between averaged maternal phthalate metabolite concentrations and continuous PPPSI scores or any GIQ scores. For the dichotomized PPPSI; higher maternal monoethyl phthalate (MEP) concentrations were associated with more typical play behaviors for females (OR = 0.70, CI = 0.51-0.97). In contrast, higher maternal mono-isobutyl phthalate (MiBP) concentrations were associated with higher odds of membership in the least typical play behaviors group for males (OR = 1.69, CI = 1.00-2.86).Conclusions: In this sample of typically developing children, higher maternal urinary MEP concentrations during pregnancy were associated with more typical gender-related play behaviors in both males and females, and increased urinary MiBP concentrations were associated with less masculine gender-related play behaviors in males. [ABSTRACT FROM AUTHOR]

Background The Academy of Nutrition and Dietetics recommends children attending full-time child care obtain one-half to two-thirds of daily nutrient needs during their time at the child-care center, leaving one-third to one-half to be consumed away from the center. Although there are guidelines to optimize dietary intake of children attending child care, little is known about what these children consume away from the center. Objective To describe the dietary intake away from the child-care center for preschool-aged children relative to the expected one-third to one-half proportion of recommended intake, and to examine the relationships between energy intake away from the center with weight status, food group consumption, and low-income status. Design Cross-sectional study conducted between November 2009 and January 2011. Participants/setting Participants (n=339) attended 30 randomly selected, licensed, full-time child-care centers in Hamilton County, OH. Main outcome measures Child weight status and dietary intake (food/beverages consumed outside the child-care setting from the time of pickup from the center to the child’s bedtime), including energy and servings of fruits, vegetables, milk, 100% juice, sugar-sweetened beverages, and snack foods. Statistical analyses performed Generalized linear mixed models were used to examine independent associations of food group servings and low-income status to energy intake and energy intake to child weight status. Results The mean energy intake consumed away from the center (685±17 kcal) was more than the recommended target range (433 to 650 kcal). Intakes of fruits, vegetables, and milk were less than recommended. Food group servings and overweight/obesity status were positively associated with energy intake while away from the center. Conclusions Preschool-aged children consume more energy and less fruits, vegetables, and milk outside of child-care centers than recommended. Overweight status was associated with children’s dietary intake after leaving the child-care center. It may be beneficial to include parents in obesity prevention efforts targeting children attending child-care centers. [ABSTRACT FROM AUTHOR]

Background: Early-life exposure to bisphenol A (BPA) may increase childhood obesity risk, but few prospective epidemiological studies have investigated this relationship. Objective: We sought to determine whether early-life exposure to BPA was associated with increased body mass index (BMI) at 2–5 years of age in 297 mother–child pairs from Cincinnati, Ohio (HOME Study). Methods: Urinary BPA concentrations were measured in samples collected from pregnant women during the second and third trimesters and their children at 1 and 2 years of age. BMI z-scores were calculated from weight/height measures conducted annually from 2 through 5 years of age. We used linear mixed models to estimate BMI differences or trajectories with increasing creatinine-normalized BPA concentrations. Results: After confounder adjustment, each 10-fold increase in prenatal (β = –0.1; 95% CI: –0.5, 0.3) or early-childhood (β = –0.2; 95% CI: –0.6, 0.1) BPA concentrations was associated with a modest and nonsignificant reduction in child BMI. These inverse associations were suggestively stronger in girls than in boys [prenatal effect measure modification (EMM) p-value = 0.30, early-childhood EMM p-value = 0.05], but sex-specific associations were imprecise. Children in the highest early-childhood BPA tercile had lower BMI at 2 years (difference = –0.3; 95% CI: –0.6, 0.0) and larger increases in their BMI slope from 2 through 5 years (BMI increase per year = 0.12; 95% CI: 0.07, 0.18) than children in the lowest tercile (BMI increase per year = 0.07; 95% CI: 0.01, 0.13). All associations were attenuated without creatinine normalization. Conclusions: Prenatal and early-childhood BPA exposures were not associated with increased BMI at 2–5 years of age, but higher early-childhood BPA exposures were associated with accelerated growth during this period. [ABSTRACT FROM AUTHOR]

Background: More information is needed about modifiable child tobacco smoke exposure (TSE) patterns in racially diverse parental smokers to tailor interventions designed to help parents quit smoking and reduce their child's TSE. Our objectives were to determine whether there were differences in smoking and TSE patterns based on parental race and child age and whether these patterns differed based on child age within black and white parental smokers. Secondary objectives were to assess the relationship between parental perceptions about the effects of smoking and the benefits of quitting on their child based on child age, race, and reported TSE patterns and to examine biochemically verified TSE levels by child age, race, and parent-reported TSE patterns. Methods: Participants (N = 415) were non-Hispanic black and non-Hispanic white parental smokers, mean age (standard deviation [SD]) = 31.2 (7.2) years, who visited the Pediatric Emergency Department (PED) or Urgent Care (UC) with their child, mean age (SD) = 4.7 (4.6) years. Parents reported sociodemographics, smoking, and child TSE patterns. We conducted chi-square tests, independent t-tests, and general linear regression models to answer our primary objectives and linear regression models to answer our secondary objectives. Results: Parents were 56.1% non-Hispanic black; 87.5% women; mean (SD) number of cigarettes smoked/day was 10.5(6.8). A higher proportion of parents with younger children <3 years old reported smoking bans compared with parents with older children ⩾3 to <18 years old (41.3% vs 19.7%, P <.0001). Subsequent analyses revealed this pattern for both black and white parents. A total of 212 (51%) of children had biochemical assessment of TSE; 89.6% had detectable TSE. Younger children had significantly higher cotinine levels than older children independent of their race (P <.001). Conclusions: Children of parental smokers who visit the PED/UC were highly tobacco smoke exposed. Both black and white parental smokers with younger children were more likely to enforce smoking bans, but younger children had higher TSE levels than older children. Interventions that target this group of parental smokers with younger children may be more effective than interventions geared to all parental smokers. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The goal was to test the effects of high-efficiency, particulate-arresting (HEPA) air cleaners on unscheduled asthma visits and symptoms among children with asthma exposed to secondhand smoke. METHODS: We enrolled 225 eligible children who were 6 to 12 years of age, had physician-diagnosed asthma, and were exposed to ≥5 cigarettes per day. We conducted a double-blind, randomized trial. Children were assigned randomly to receive 2 active or inactive HEPA air cleaners. RESULTS: Of 225 enrolled children, 110 (49%) were assigned to the intervention group and 115 (51%) to the control group; 215 (95%) completed the trial. During the trial, there were 42 fewer unscheduled asthma visits among children in the intervention group (18.5% [95% confidence interval: 1.25%-82.75%1; P = .043), compared with those in the control group, after adjustment for baseline differences. There was a significant difference in the reductions of levels of particles of >0.3 μm according to group assignment; there was a 25% reduction in particle levels in the intervention group, compared with a 5% reduction in the control group (P = .026). There were no significant differences in parent-reported asthma symptoms, exhaled nitric-oxide levels, air nicotine levels, or cotinine levels according to group assignment. CONCLUSIONS: These results hold promise for using HEPA air cleaners as part of a multifaceted strategy to reduce asthma morbidity, but further research is necessary before they can be recommended routinely for the medical management of asthma. [ABSTRACT FROM AUTHOR]

Abstract: The problem described by Dr. Brian Gulson – confounding by unmeasured exposures to pesticides – is only the most recent in a series of potential confounders cited to explain the observed effect of lead on children''s intellectual abilities or behavioral problems. Despite the persistent problem of unmeasured confounders, there are several lines of evidence implicating lead as a toxicant at blood lead levels <10 μg/dL. First, in striking contrast with pesticides, there is considerable evidence from numerous studies linking low-level lead exposure with cognitive deficits and behavioral problems, even after controlling for a variety of potential confounders. Second, the consistency of evidence from diverse cohorts and distinct, if not always directly measured potential confounders — enhances our confidence that the lead effect observed at blood lead levels <10 μg/dL is not attributable to unmeasured confounders. Third, in our reanalysis of the Rochester Lead Study, the inclusion of parent-reported mouthing behaviors and breastfeeding status did not attenuate the effect of lead exposure on children''s intellectual function. Finally, although we can never entirely dismiss unmeasured confounding in observational studies, we can rely on experimental studies of lead-exposed animals to confirm that lead is a toxicant. Thus, while we must remain vigilant for unmeasured or poorly measured confounders, it is crucial to balance the endless search for confounders with the evidence of toxicity and the need to take action to protect public health. The alternative, to perpetually permit children to be exposed to lead and other emerging toxicants, is both absurd and unacceptable. [Copyright &y& Elsevier]

BACKGROUND AND OBJECTIVES: Iodine is an essential trace element for maintenance of normal thyroid function. Normal thyroid function is a prerequisite for neurocognitive development and growth in children. In the United States, iodine is not routinely added as a trace element in parenteral nutrition (PN). Our objective was to determine the prevalence of iodine deficiency and hypothyroidism in children on chronic PN. METHODS: This was a cross-sectional study of children <17 years of age and using PN for >6 months at a tertiary children's hospital. Primary outcomes were spot urine iodine concentration (UIC), serum thyrotropin, and free thyroxine levels. RESULTS: Twenty-seven patients were identified (74% male). The median age at screening was 48 months (range: 7-213 months). The median duration on PN was 27 months (range: 11-77 months). Seventeen out of 20 patients (85%) were iodine deficient (spot UIC <100 µg/L), whereas 11 out of 20 patients (55%) were severely iodine deficient (spot UIC <20 µg/L). The prevalence of acquired hypothyroidism (elevated thyrotropin, low free thyroxine, and UIC <100 µg/L) was 33% (n = 8). None of the children with hypothyroidism screened for autoimmune thyroiditis had positive test results. There was no statistically significant association between duration of PN use and development of iodine deficiency (P = .08) or hypothyroidism (P = .96). CONCLUSIONS: Children on chronic PN are at risk for developing iodine deficiency and resultant hypothyroidism; hence, these children should be screened for these outcomes. Further studies are needed to define the temporal onset of iodine deficiency and timing to thyroid dysfunction related to PN. [ABSTRACT FROM AUTHOR]

Patients with Spinal Muscular Atrophy (SMA) are at risk for poor bone health. The prevalence of fractures, low areal bone mineral density (aBMD; Z-score ≤−2.0) of the lateral distal femur and of osteoporosis by SMA subtype is not known. We aimed to describe the natural history of bone health in patients with SMA prior to bisphosphonate treatment. We reviewed data from 85 eligible patients with SMA ages 12 months to 18 years, seen at a single institution between January 2005 and July 2016. Fracture history was reported at annual clinic visits. aBMD was obtained from dual energy x-ray absorptiometry scans of the lumbar spine, total body, and lateral distal femur. 85% of patients had aBMD Z-scores ≤−2.0 SD and were progressively lower with worsening SMA severity. Longitudinal aBMD Z-scores of the lateral distal femur decreased with age. Fractures occurred in 38% (32/85) of patients with the femur being the most common location (25 of 57 fractures). Thirteen percent of patients fulfilled criteria for osteoporosis. Low aBMD and femur fractures are highly prevalent in all SMA subtypes from a young age; however, few patients met the criteria for osteoporosis. Poor bone health may be an under-recognized comorbidity of SMA. [ABSTRACT FROM AUTHOR]