PEDIATRICS recent issues

The Missing Siblings of Infants Born Preterm

BACKGROUND:

Parents of very or extremely low birth weight infants have fewer subsequent children after preterm birth. Whether this applies to parents of less preterm infants is unknown.

METHODS:

In this nationwide cohort study, we identified all 230 308 traceable (>99%) singletons (9983 preterm, 4.3%) live born in Finland between January 1, 1987, and September 30, 1990, and their parents. Quantitative contribution of gestational age of child to the birth of parental subsequent children was assessed by multivariate Cox regression models, stratifying by the number of previous children. The impact of gestational age on sibling count was estimated at individual and population level.

RESULTS:

Mothers of extremely preterm (23–27 completed weeks) infants were, compared with mothers of term infants (39–41 weeks), less likely to have a subsequent live-born child (adjusted hazard ratio [HR]: 0.74; 95% confidence interval: 0.63–0.86). Corresponding HRs and confidence intervals were as follows: 28 to 31 weeks: 0.72 (0.65–0.80), 32 to 33 weeks: 0.82 (0.74–0.90), and 34 to 36 weeks: 0.90 (0.87–0.93). These HRs were consistent with those of fathers and couples. The cohort included 8002 firstborn preterm children, of whom 356 (4.4%) died in infancy. The 8002 children had a total of 13 826 subsequent siblings (1138 less than expected); per 1000 preterm births, this translates to the death of 44 preterm infants and 142 missing subsequent siblings.

CONCLUSIONS:

Families with a preterm singleton child have fewer subsequent children. In a high-income country, the main population effect of preterm birth is caused by these "missing siblings," whose number exceeds the number of those preterm infants who die.

Cerebral Palsy in Extremely Preterm Infants

BACKGROUND AND OBJECTIVES:

The risk of cerebral palsy (CP) is high in preterm infants and is often accompanied by additional neurodevelopmental comorbidities. The present study describes lifetime prevalence of CP in a population-based prospective cohort of children born extremely preterm, including the type and severity of CP and other comorbidities (ie, developmental delay and/or cognitive impairment, neurobehavioral morbidity, epilepsy, vision and hearing impairments), and overall severity of disability. In this study, we also evaluate whether age at assessment, overall severity of disability, and available sources of information influence outcome results.

METHODS:

All Swedish children born before 27 weeks’ gestation from 2004 to 2007 were included (the Extremely Preterm Infants in Sweden Study). The combination of neonatal information, information from clinical examinations and neuropsychological assessments at 2.5 and 6.5 years of age, original medical chart reviews, and extended chart reviews was used.

RESULTS:

The outcome was identified in 467 (94.5%) of eligible children alive at 1 year of age. Forty-nine (10.5%) children had a lifetime diagnosis of CP, and 37 (76%) were ambulatory. Fourteen (29%) had CP diagnosed after 2.5 years of age, 37 (76%) had at least 1 additional comorbidity, and 27 (55%) had severe disability. The probability for an incomplete evaluation was higher in children with CP compared with children without CP.

CONCLUSIONS:

Children born extremely preterm with CP have various comorbidities and often overall severe disability. The importance of long-term follow-up and of obtaining comprehensive outcome information from several sources in children with disabilities is shown.

An Integrated Clinic-Community Partnership for Child Obesity Treatment: A Randomized Pilot Trial

BACKGROUND AND OBJECTIVES:

Effective treatment of childhood obesity remains elusive. Integration of clinical and community systems may achieve effective and sustainable treatment. However, the feasibility and effectiveness of this integrated model are unknown.

METHODS:

We conducted a randomized clinical trial among children aged 5 to 11 presenting for obesity treatment. We randomized participants to clinical care or clinical care plus community-based programming at a local parks and recreation facility. Primary outcomes were the change in child BMI at 6 months and the intensity of the program in treatment hours. Secondary outcomes included health behaviors, fitness, attrition, and quality of life.

RESULTS:

We enrolled 97 children with obesity, and retention at 6 months was 70%. Participants had a mean age of 9.1 years and a mean baseline BMI z score of 2.28, and 70% were living in poverty. Intervention participants achieved more treatment hours than controls (11.4 vs 4.4, SD: 15.3 and 1.6, respectively). We did not observe differences in child BMI z score or percent of the 95th percentile at 6 months. Intervention participants had significantly greater improvements in physical activity (P = .010) and quality of life (P = .008).

CONCLUSIONS:

An integrated clinic-community model of child obesity treatment is feasible to deliver in a low-income and racially diverse population. As compared with multidisciplinary treatment, the integrated model provides more treatment hours, improves physical activity, and increases quality of life. Parks and recreation departments hold significant promise as a partner agency to deliver child obesity treatment.

Improving Time to Antibiotic Administration for Bone Marrow Transplant Patients With First Fever

BACKGROUND AND OBJECTIVE:

Timely antibiotic administration in immunocompromised patients is associated with improved outcomes. The aim of our study was to decrease the mean time to administration of antibiotics in hospitalized bone marrow transplant patients with fever from 75 to <60 minutes.

METHODS:

By using the Model of Improvement, we performed plan-do-study-act cycles to design, test, and implement high-reliability interventions to decrease time to antibiotics. Nursing, physician, and pharmacy interventions were successfully applied to improve timely antibiotic administration.

RESULTS:

The study period was from April 2014 through March of 2017. Through heightened awareness, dedicated roles and responsibilities, a standardized order set specifically used for first fever patients, notification to the pharmacy about newly febrile first fever patients through a dedicated order, the creation of a dedicated sticker ("STAT first dose antibiotic, give directly to nurse") to be printed when antibiotics were entered via the order set in the pharmacy, and prioritization of antibiotic delivery on arrival on the floor, we saw an increase in the percentage of patients receiving antibiotics within 60 minutes of documented fever from a mean of 40% to over 90%. Our mean time for antibiotic administration decreased from 75 to 45 minutes.

CONCLUSIONS:

Implementation of a standardized process for notifying providers of new fever in patients, prioritization of antibiotic preparation in the central pharmacy, and timely antibiotic order entry resulted in improved times to antibiotic administration in the febrile bone marrow transplant population.

Attention-Deficit/Hyperactivity Disorder and Very Preterm/Very Low Birth Weight: A Meta-analysis

CONTEXT:

Although very preterm (VP), extremely preterm (EP), very low birth weight (VLBW), and extremely low birth weight (ELBW) newborns seem to have a higher risk of later attention-deficit/hyperactivity disorder (ADHD), the magnitude of the risk is not well-defined.

OBJECTIVE:

To systematically review and meta-analyze the risk of VP/VLBW and EP/ELBW individuals to develop a ADHD categorical diagnosis or dimensional symptomatology compared with controls with normal weight and/or birth age.

DATA SOURCES:

We used PsycINFO, Medline, Embase, and Cochrane databases.

STUDY SELECTION:

We selected cross-sectional, prospective, or retrospective studies with no time or language restriction.

DATA EXTRACTION:

Independent reviewers screened and extracted data using predefined standard procedures.

RESULTS:

In 12 studies (N = 1787), researchers relying on a categorical diagnosis showed that both VP/VLBW and EP/ELBW subjects have a higher ADHD risk (odds ratio [OR] = 3.04 higher than controls; 95% confidence interval [CI] 2.19 to 4.21). In subgroup analyses, we demonstrated that the more extreme the cases, the higher the ORs (VP/VLBW: OR = 2.25 [95% CI 1.56 to 3.26]; EP/ELBW: OR = 4.05 [95% CI 2.38 to 6.87]). We drew data from 29 studies (N = 3504) on ADHD symptomatology and found significant associations with inattention (standardized mean difference [SMD] = 1.31, 95% CI 0.66 to 1.96), hyperactivity and impulsivity (SMD = 0.74, 95% CI 0.35 to 1.13), and combined symptoms (SMD = 0.55, 95% CI 0.42 to 0.68) when compared with controls.

LIMITATIONS:

Heterogeneity was significantly high for all analyses involving the 3 ADHD dimensions.

CONCLUSIONS:

With our results, we provide evidence that VP/VLBW subjects have an increased risk of ADHD diagnosis and symptomatology compared with controls, and these findings are even stronger in the EP/ELBW group. Future researchers should address which risk factors related to prematurity or low birth weight lead to ADHD.

Adolescent Loss-of-Control Eating and Weight Loss Maintenance After Bariatric Surgery

BACKGROUND:

Loss-of-control (LOC) eating is common in adults undergoing bariatric surgery and is associated with poorer weight outcomes. Its long-term course in adolescent bariatric surgery patients and associations with weight outcomes are unclear.

METHODS:

Adolescents (n = 234; age range = 13–19 years) undergoing bariatric surgery across 5 US sites were assessed for postsurgery follow-up at 6 months and 1, 2, 3, and 4 years. Descriptive statistics and generalized linear mixed models were used to describe the prevalence of LOC eating episodes involving objectively large amounts of food and continuous eating, respectively. Generalized linear mixed models investigated the association of any LOC eating with short- and long-term BMI changes.

RESULTS:

At baseline, objectively large LOC eating was reported by 15.4% of adolescents, and continuous LOC eating by 27.8% of adolescents. Both forms of LOC eating were significantly lower at all postsurgical time points relative to presurgery (range = 0.5%–14.5%; Ps < .05). However, both behaviors gradually increased from 6-month to 4-year follow-up (Ps < .05). Presurgical LOC eating was not related to percent BMI change over follow-up (P = .79). However, LOC eating at 1-, 2-, and 3-year follow-up was associated with lower percent BMI change from baseline at the next consecutive assessment (Ps < .05).

CONCLUSIONS:

Although presurgical LOC eating was not related to relative weight loss after surgery, postoperative LOC eating may adversely affect long-term weight outcomes. Rates of LOC eating decreased from presurgery to 6-months postsurgery but increased thereafter. Therefore, this behavior may warrant additional empirical and clinical attention.

Pediatric Disorders of Orthostatic Intolerance

Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ~40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.

Age at Menarche, Depression, and Antisocial Behavior in Adulthood

BACKGROUND:

Early pubertal timing in girls is one of the best-replicated antecedents of a range of mental health problems during adolescence, but few researchers have examined the duration of these effects.

METHODS:

We leverage a nationally representative sample (N = 7802 women) managed prospectively from adolescence over a period of ~14 years to examine associations of age at menarche with depressive symptoms and antisocial behaviors in adulthood.

RESULTS:

Earlier ages at menarche were associated with higher rates of both depressive symptoms and antisocial behaviors in early-middle adulthood largely because difficulties that started in adolescence did not attenuate over time.

CONCLUSIONS:

These findings indicate that the emotional sequelae of puberty extend further than documented in previous research, and suggest that earlier development may place girls on a life path from which it may be difficult to deviate. The American Academy of Pediatrics already provides guidelines for identifying and working with patients with early pubertal timing. Pediatricians and adolescent health care providers should also be attuned to early maturers’ elevated mental health risk and sensitive to the potential duration of changes in mental health that begin at puberty.

Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis

CONTEXT:

Lactobacillus reuteri DSM17938 has shown promise in managing colic, but conflicting study results have prevented a consensus on whether it is truly effective.

OBJECTIVE:

Through an individual participant data meta-analysis, we sought to definitively determine if L reuteri DSM17938 effectively reduces crying and/or fussing time in infants with colic and whether effects vary by feeding type.

DATA SOURCES:

We searched online databases (PubMed, Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, the Database of Abstracts of Reviews of Effects, and Cochrane), e-abstracts, and clinical trial registries.

STUDY SELECTION:

These were double-blind randomized controlled trials (published by June 2017) of L reuteri DSM17398 versus a placebo, delivered orally to infants with colic, with outcomes of infant crying and/or fussing duration and treatment success at 21 days.

DATA EXTRACTION:

We collected individual participant raw data from included studies modeled simultaneously in multilevel generalized linear mixed-effects regression models.

RESULTS:

Four double-blind trials involving 345 infants with colic (174 probiotic and 171 placebo) were included. The probiotic group averaged less crying and/or fussing time than the placebo group at all time points (day 21 adjusted mean difference in change from baseline [minutes] –25.4 [95% confidence interval (CI): –47.3 to –3.5]). The probiotic group was almost twice as likely as the placebo group to experience treatment success at all time points (day 21 adjusted incidence ratio 1.7 [95% CI: 1.4 to 2.2]). Intervention effects were dramatic in breastfed infants (number needed to treat for day 21 success 2.6 [95% CI: 2.0 to 3.6]) but were insignificant in formula-fed infants.

LIMITATIONS:

There were insufficient data to make conclusions for formula-fed infants with colic.

CONCLUSIONS:

L reuteri DSM17938 is effective and can be recommended for breastfed infants with colic. Its role in formula-fed infants with colic needs further research.

Trajectories of E-Cigarette and Conventional Cigarette Use Among Youth

BACKGROUND:

Electronic cigarette (e-cigarette) use is common among youth, and there are concerns that e-cigarette use leads to future conventional cigarette use. We examined longitudinal associations between past-month cigarette and e-cigarette use to characterize the stability and directionality of these tobacco use trajectories over time.

METHODS:

High school students (N = 808, 53% female) completed surveys across 3 waves (2013, 2014, and 2015) in 3 public schools in Connecticut. Using autoregressive cross-lagged models, we examined bidirectional relationships between past-month cigarette and e-cigarette use over time. Models were adjusted for covariates related to tobacco use (ie, sex, race/ethnicity, socioeconomic status, and use of other tobacco products).

RESULTS:

Past-month e-cigarette use predicted future cigarette use (wave 1–2: odds ratio [OR] = 7.08, 95% confidence interval [CI] = 2.34–21.42; wave 2–3: OR = 3.87, 95% CI = 1.86–8.06). However, past-month cigarette use did not predict future e-cigarette use (wave 1–2: OR = 2.02, 95% CI = 0.67–6.08; wave 2–3: OR = 1.90, 95% CI = 0.77–4.71). Additionally, frequency of cigarette and e-cigarette use increased over time. By wave 3, 26% of cigarette users and 20.5% of e-cigarette users reported using 21–30 days out of the past month.

CONCLUSIONS:

E-cigarette use was associated with future cigarette use across 3 longitudinal waves, yet cigarette use was not associated with future e-cigarette use. Future research needs to examine mechanisms through which e-cigarette use leads to cigarette use. E-cigarette regulation and prevention programs may help prevent future use of cigarettes among youth.

Trends in Regionalization of Hospital Care for Common Pediatric Conditions

OBJECTIVES:

We have previously observed that hospital care for children is concentrating significantly in Massachusetts. We now extend those observations to include 4 US states and give closer attention to the management patterns of specific clinical conditions.

METHODS:

We used inpatient and emergency department administrative data sets from California, Florida, Massachusetts, and New York to measure transfer frequency and identify the site of care completion for >252 million hospital encounters from 2006 through 2013. We compared the concentration of pediatric care to adult care by using the Hospital Capability Index for all acute-care hospitals and quantified the regionalization of clinical conditions by using the Regionalization Index.

RESULTS:

The availability of hospital care was significantly more limited for children than adults in all 4 states (median Hospital Capability Index: 0.19 vs 0.74 in CA, 0.08 vs 0.79 in FL, 0.18 vs 0.69 in MA, and 0.16 vs 0.75 in NY). Between 2006 and 2011, care was concentrated for both adults and children but much more so for children. Although pediatric admissions decreased by 9.3% (from 545 330 to 494 645), interhospital transfers increased by 24.6% (from 64 285 to 80 101). The largest change in transfer rate was among children with common conditions, such as abdominal pain and asthma.

CONCLUSIONS:

Definitive pediatric hospital care is less available than adult care and is increasingly dependent on referral centers. This should be accounted for in public health plans, disaster preparedness, and determinations of network adequacy.

Trends in Executive Functioning in Extremely Preterm Children Across 3 Birth Eras

BACKGROUND AND OBJECTIVES:

To determine if executive functioning outcomes at school age are different for extremely preterm (EP; <28 weeks’ gestation) or extremely low birth weight (ELBW; <1000 g birth weight) children born in 1991 to 1992, 1997, and 2005 relative to their term-born peers.

METHODS:

Population-based cohorts of all EP/ELBW survivors born in the state of Victoria, Australia, in 1991 to 1992, 1997, and 2005, and contemporaneous controls (matched for expected date of birth, sex, mother’s country of birth [English speaking or not], and health insurance status) were recruited at birth. At 7 to 8 years of age, parents of 613 children who were EP/ELBW and 564 children who were controls rated their children’s executive functioning on the Behavior Rating Inventory of Executive Function (BRIEF). The proportion of children with elevated BRIEF scores (in the clinically significant range) in each birth group and era was compared by using logistic regression. Sensitivity analyses explored these associations after excluding children with intellectual impairment.

RESULTS:

Across the eras, EP/ELBW children had higher rates of elevated scores than controls in almost all BRIEF domains. The 2005 EP/ELBW cohort had increased executive dysfunction compared with earlier cohorts, particularly in working memory and planning and organization. This effect persisted after accounting for demographic factors and weakened slightly when those with intellectual impairment were excluded.

CONCLUSIONS:

These results indicate a concerning trend of increasing executive dysfunction for EP/ELBW children who were born more recently. This may have adverse implications for other functional domains, such as academic achievement and social-emotional well-being.

Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency Department

BACKGROUND AND OBJECTIVES:

Variability exists in the evaluation of nonaccidental trauma (NAT) in the pediatric emergency department because of misconceptions and individual bias of clinicians. Further maltreatment, injury, and death can ensue if these children are not evaluated appropriately. The implementation of guidelines for NAT evaluation has been successful in decreasing differences in care as influenced by race and ethnicity of the patient and their family. Our Specific, Measurable, Achievable, Realistic, and Timely aim was to increase the percent of patients evaluated in the emergency department for NAT who receive guideline-adherent evaluation from 47% to 80% by December 31, 2016.

METHODS:

The team determined key drivers for the project and tested them by using multiple plan-do-study-act cycles. Interventions included construction of a best practice guideline, provider education, integration of the guideline into workflow, and order set construction to support guideline recommendations. Data were compiled from electronic medical records to identify patients <3 years of age evaluated in the pediatric emergency department for suspected NAT based on chart review. Adherence to guideline recommendations for age-specific evaluation (<6, 6–12, and >12–36 months) was tracked over time on statistical process control charts to evaluate the impact of the interventions.

RESULTS:

A total of 640 encounters had provider concern for NAT and were included in the analysis. Adherence to age-specific guideline recommendations improved from a baseline of 47% to 69%.

CONCLUSIONS:

With our improvement methodology, we successfully increased guideline-adherent evaluation for patients with provider concern for NAT. Education and electronic support at the point of care were key drivers for initial implementation.

BMI Trajectories Associated With Resolution of Elevated Youth BMI and Incident Adult Obesity

BACKGROUND AND OBJECTIVES:

Youth with high BMI who become nonobese adults have the same cardiovascular risk factor burden as those who were never obese. However, the early-life BMI trajectories for overweight or obese youth who avoid becoming obese adults have not been described. We aimed to determine and compare the young-childhood BMI trajectories of participants according to their BMI status in youth and adulthood.

METHODS:

Bayesian hierarchical piecewise regression modeling was used to analyze the BMI trajectories of 2717 young adults who had up to 8 measures of BMI from childhood (ages 3–18 years) to adulthood (ages 34–49 years).

RESULTS:

Compared with those with persistently high BMI, those who resolved their high youth BMI by adulthood had lower average BMI at age 6 years and slower rates of BMI change from young childhood. In addition, their BMI levels started to plateau at 16 years old for females and 21 years old for males, whereas the BMI of those whose high BMI persisted did not stabilize until 25 years old for male subjects and 27 years for female subjects. Compared with those youth who were not overweight or obese and who remained nonobese in adulthood, those who developed obesity had a higher BMI rate of change from 6 years old, and their BMI continued to increase linearly until age 30 years.

CONCLUSIONS:

Efforts to alter BMI trajectories for adult obesity should ideally commence before age 6 years. The natural resolution of high BMI starts in adolescence for males and early adulthood for females, suggesting a critical window for secondary prevention.

Retrospective Consent in a Neonatal Randomized Controlled Trial

BACKGROUND AND OBJECTIVES:

The requirement for prospective consent in clinical trials in acute settings may result in samples unrepresentative of the study population, potentially altering study findings. However, using retrospective consent may raise ethical issues. We assessed whether using retrospective consent affected recruitment, participant characteristics, and outcomes within a randomized controlled trial.

METHODS:

We conducted a secondary analysis of a randomized trial, which compared nasal high flow (nHF) with nasal continuous positive airway pressure (CPAP) for primary respiratory support in preterm infants. In Era 1, all infants were consented prospectively; in Era 2, retrospective consent was available. We assessed inclusion rates of eligible infants, demographic data, and primary trial outcome (treatment failure within 72 hours).

RESULTS:

In Era 1, recruitment of eligible infants was lower than in Era 2: 111 of 220 (50%) versus 171 of 209 (82%), P < .001; intrapartum antibiotic administration was lower: 23 of 111 (21%) versus 84 of 165 (51%), P < .001; full courses of antenatal steroids were higher: 86 of 111 (78%) versus 103 of 170 (61%), P = .004; and more infants received pre-randomization CPAP: 77 of 111 (69%) versus 48 of 171 (28%), P < .001. In Era 1, nHF failure (15 of 56, 27%) and CPAP failure (14 of 55, 26%) rates were similar, P = .9. In Era 2, failure rates differed: 24 of 85 (28%) nHF infants versus 13 of 86 (15%) CPAP infants, P = .04. The 2 interaction test was nonsignificant (P = .20).

CONCLUSIONS:

The use of retrospective consent resulted in greater recruitment and differences in risk factors between eras. Using retrospective consent altered the study sample, which may be more representative of the whole population. This may improve scientific validity but requires further ethical evaluation.

How Parents of Children With Cancer Learn About Their Childrens Prognosis

OBJECTIVES:

To determine which prognostic information sources parents find informative and which are associated with better parental understanding of prognosis.

METHODS:

Prospective, questionnaire-based cohort study of parents and physicians of children with cancer at 2 academic pediatric hospitals. We asked parents how they learned about prognoses and evaluated relationships between information sources and prognostic understanding, defined as accuracy versus optimism. We excluded parents with pessimistic estimates and whose children had such good prognoses that optimism relative to the physician was impossible. Analytic cohort of 256 parent-physician pairs.

RESULTS:

Most parents considered explicit sources (conversations with oncologists at diagnosis, day-to-day conversations with oncologists, and conversations with nurses) "very" or "extremely" informative (73%–85%). Implicit sources (parent’s sense of how child was doing or how oncologist seemed to feel child was doing) were similarly informative (84%–87%). Twenty-seven percent (70/253) of parents reported prognostic estimates matching physicians’ estimates. Parents who valued implicit information had lower prognostic accuracy (odds ratio [OR] 0.50; 95% confidence interval 0.29–0.88), especially those who relied on a "general sense of how my child’s oncologist seems to feel my child is doing" (OR 0.47; 0.22–0.99). Parents were more likely to use implicit sources if they reported receiving high-quality prognostic information (OR 3.02; 1.41–6.43), trusted the physician (OR 2.01; 1.01–3.98), and reported high-quality physician communication (OR 1.81; 1.00–3.27).

CONCLUSIONS:

Reliance on implicit sources was associated with overly-optimistic prognostic estimates. Parents who endorsed strong, trusting relationships with physicians were not protected against misinformation.

Pediatric Injuries Related to Window Blinds, Shades, and Cords

OBJECTIVES:

To provide an epidemiologic description of fatal and nonfatal window blind–related injuries among US children younger than 6 years of age.

METHODS:

Data from the Consumer Product Safety Commission’s National Electronic Injury Surveillance System and In-Depth Investigation (IDI) databases were retrospectively analyzed.

RESULTS:

From 1990 to 2015, there were an estimated 16 827 (95% confidence interval: 13 732–19 922) window blind–related injuries among children younger than 6 years of age treated in emergency departments in the United States, corresponding to an injury rate of 2.7 per 100 000 children. The most common mechanism of injury was "struck by" (48.8%). Entanglement injuries accounted for 11.9% of all cases, and among this subgroup, 98.9% involved blind cords, and 80.7% were to the neck. Overall, most injuries (93.4%) were treated and released. In IDI reports for 1996 through 2012, we identified 231 window blind cord entanglement incidents among children <6 years of age, and 98.7% involved the child’s neck; entanglements with the window blind’s operating cords (76.4%) or inner cords (22.1%) were the most common. Two-thirds of entanglement incidents included in the IDI database resulted in death (67.1%).

CONCLUSIONS:

Despite existing voluntary safety standards for window blinds, these products continue to pose an injury risk to young children. Although many of the injuries in this study were nonfatal and resulted in minor injuries, cases involving window blind cord entanglements frequently resulted in hospitalization or death. A mandatory safety standard that eliminates accessible window blind cords should be adopted.

Exemptions From Mandatory Immunization After Legally Mandated Parental Counseling

BACKGROUND:

The success of health care provider counseling–based interventions to address vaccine hesitancy is not clear. In 2011, Washington State implemented Senate Bill 5005 (SB5005), requiring counseling and a signed form from a licensed health care provider to obtain an exemption. Evaluating the impact of a counseling intervention can provide important insight into population-level interventions that focus on interpersonal communication by a health care provider.

METHODS:

We used segmented regression and interaction and aggregation indices to assess the impact of SB5005 on immunization coverage and exemption rates in Washington State from school years 1997–1998 through 2013–2014.

RESULTS:

After SB5005 was implemented, there was a significant relative decrease of 40.2% (95% confidence interval: –43.6% to –36.6%) in exemption rates. This translates to a significant absolute reduction of 2.9 percentage points (95% confidence interval: –4.2% to –1.7%) in exemption rates. There were increases in vaccine coverage for all vaccines required for school entrance, with the exception of the hepatitis B vaccine. The probability that kindergarteners without exemptions would encounter kindergarteners with exemptions (interaction index) decreased, and the probability that kindergarteners with exemptions would encounter other such kindergarteners (aggregation index) also decreased after SB5005. Moreover, SB5005 was associated with a decline in geographic clustering of vaccine exemptors.

CONCLUSIONS:

States in the United States and jurisdictions in other countries should consider adding parental counseling by health care provider as a requirement for obtaining exemptions to vaccination requirements.

Persistent Opioid Use Among Pediatric Patients After Surgery

BACKGROUND:

Despite efforts to reduce nonmedical opioid misuse, little is known about the development of persistent opioid use after surgery among adolescents and young adults. We hypothesized that there is an increased incidence of prolonged opioid refills among adolescents and young adults who received prescription opioids after surgery compared with nonsurgical patients.

METHODS:

We performed a retrospective cohort study by using commercial claims from the Truven Health Marketscan research databases from January 1, 2010, to December 31, 2014. We included opioid-naïve patients ages 13 to 21 years who underwent 1 of 13 operations. A random sample of 3% of nonsurgical patients who matched eligibility criteria was included as a comparison. Our primary outcome was persistent opioid use, which was defined as ≥1 opioid prescription refill between 90 and 180 days after the surgical procedure.

RESULTS:

Among eligible patients, 60.5% filled a postoperative opioid prescription (88 637 patients). Persistent opioid use was found in 4.8% of patients (2.7%–15.2% across procedures) compared with 0.1% of those in the nonsurgical group. Cholecystectomy (adjusted odds ratio 1.13; 95% confidence interval, 1.00–1.26) and colectomy (adjusted odds ratio 2.33; 95% confidence interval, 1.01–5.34) were associated with the highest risk of persistent opioid use. Independent risk factors included older age, female sex, previous substance use disorder, chronic pain, and preoperative opioid fill.

CONCLUSIONS:

Persistent opioid use after surgery is a concern among adolescents and young adults and may represent an important pathway to prescription opioid misuse. Identifying safe, evidence-based practices for pain management is a top priority, particularly among at-risk patients.

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