Anthony J. Alario

Television-viewing Habits and Sleep Disturbance in School Children

Objective. To investigate the relationship between specific television-viewing habits and both sleep habits and sleep disturbances in school children. Methods. The parents of 495 children in grades kindergarten through fourth grade in three public elementary schools completed two retrospective survey questionnaires, one assessing their childrens sleep behaviors and the other examining television-viewing habits of both the child and the family. Sleep domains assessed included bedtime resistance, sleep onset delay, sleep duration, anxiety around sleep, parasomnias, night wakings, and daytime sleepiness. Teachers from all three schools also completed daytime sleepiness questionnaires (N = 402) for the sample. Results. Most of the television-viewing practices examined in this study were associated with at least one type of sleep disturbance. Despite overall close monitoring of television-viewing habits, one quarter of the parents reported the presence of a television set in the childs bedroom. The television-viewing habits associated most significantly with sleep disturbance were increased daily television viewing amounts and increased television viewing at bedtime, especially in the context of having a television set in the childs bedroom. The sleep domains that appeared to be affected most consistently by television were bedtime resistance, sleep onset delay, and anxiety around sleep, followed by shortened sleep duration. The parents threshold for defining “problem sleep behavior” in their child was also important in determining the significance of the association between sleep disturbance and television-viewing habits. Conclusion. Health care practitioners should be aware of the potential negative impact of television viewing at bedtime. Parents should be questioned about their childrens television-viewing habits as part of general screening for sleep disturbances and as part of anticipatory guidance in regards to healthy sleep habits in children. In particular, the presence of a television set in the childs bedroom may be a relatively underrecognized, but important, contributor to sleep problems in school children.

Health risk behaviors and attempted suicide in adolescents who report prior maltreatment

We hypothesized that high school students who experienced prior maltreatment would be more likely than their peers to report health risk behaviors and suicide attempts. Before the establishment of a high school-based clinic, an anonymous needs assessment survey was completed by 600 adolescents (grades 9 to 12). Sociodemographic information was obtained and questions were asked about physical and sexual abuse, health-related behaviors and habits, and suicide attempts. Thirteen percent of the adolescents had been maltreated: 5.2% reported prior physical abuse, 5.4% sexual abuse, and 2.7% both physical and sexual abuse. Multivariate statistical techniques were used to clarify how previous abuse was related to adolescent risk-taking behaviors and suicide. Students with a history of physical abuse were three times more likely than non-abused peers to drink alcohol and smoke cigarettes, almost twice as likely to use illicit drugs, six times more likely to self-induce vomiting, and five times more likely to attempt suicide. A student with a history of prior sexual abuse had a three and one-half times greater chance of being sexually active and was more than three times more likely to attempt suicide. These data on a nonclinical, nondeviant population of adolescents indicate that physical or sexual abuse in childhood may have a significant impact on adolescent health risk behaviors and suicide attempts.

Child temperament, parenting discipline style, and daytime behavior in childhood sleep disorders.

Fifty-two children without significant sleep disturbance seen at a primary care clinic for well-child care were compared on measures of temperament, parenting style, daytime behavior, and overall sleep disturbance to three diagnostic subgroups identified in a pediatric sleep clinic: children with obstructive sleep apnea (n=33), parasomnias (night terrors, sleepwalking, etc.) (n=16), and behavioral sleep disorders (limitsetting disorder, etc.) (n=31). The mean age of the entire sample was 5.7 years. Temperamental emotionality in the behavioral sleep disorders group was associated with a higher level of sleep disturbance (p<.001); parenting laxness was associated with sleep disturbance in the general pediatric population (p<.01); and intense and negative temperament characteristics seemed to be associated with clinically significant behavioral sleep disturbances. Ineffective parenting styles and daytime disruptive behaviors were more likely to be associated with the milder sleep disturbances found in children in a primary care setting. J Dev Behav Pediatr 18:314-321, 1997.

Literacy promotion for Hispanic families in a primary care setting : A randomized, controlled trial

Background. Reading aloud is an important activity to prepare children to succeed in learning to read. Many Hispanic children have reading difficulties and therefore are at increased risk for school failure. Methods. We conducted a prospective, randomized, controlled study to evaluate the effectiveness of a literacy promoting intervention delivered to low-income Hispanic families with infants. We consecutively enrolled 135 low-income Hispanic parents of healthy 5 to 11 month old infants. Families were randomly assigned to an intervention (n = 65) or control (n = 70) group. At enrollment and at two consecutive well-child visits, pediatricians gave intervention families: 1) an age-appropriate bilingual childrens book, 2) a bilingual handout explaining the benefits of reading to children, and 3) literacy-promoting anticipatory guidance. Ten months after enrollment we reinterviewed 130 parents. Results. Both groups were comparable at baseline. At follow-up, intervention parents were more likely to read books with their child at least 3 days/week (intervention = 66% vs control parents = 24%) and to report that reading books was one of their three most favorite things to do with their child (intervention = 43% vs controls = 13%). Intervention families also had a greater number of childrens books and total books at home. Using a multiple logistic regression model, controlling for child and parental age, reading habits, and English proficiency, we found that the odds of parents reading to their child at least 3 days/week were 10 times greater in intervention families (OR 10.1, 95% CI 4.0–25.6) compared with control families. Conclusions. This simple, culturally appropriate intervention significantly increased literacy behaviors in low-income Hispanic families.

Appropriate use of a pediatric emergency department: is the pediatrician called before the visit?

The objective of this study was to examine the appropriateness of utilization of an urban pediatric emergency department (ED) by children who had a pediatrician and factors relating to whether the pediatrician was called before an ED visit. This was done prospectively and randomly in an urban teaching hospital pediatric ED. One hundred and sixty-six patients, 18 years old and younger, who presented for nontraumatic conditions and had a pediatrician, classified as private or nonprivate, were enrolled. A questionnaire was completed and appropriateness of visit was determined using previously published criteria. No difference in appropriateness of visit was found between private and nonprivate patients (58/98, 40/68, NS). Thirty-five of 54 (65%) parents who called their pediatrician were classified as an appropriate ED visit as opposed to 62 of 112 who did not call (55%, NS). Private patients called their physicians more often then nonprivate patients (P<0.001). Lack of access to their primary care providers was the more common reason among nonprivate patients (P<0.05) for not calling their pediatricians. We conclude that appropriateness of pediatric ED visits is independent of type of physician. Nonprivate patients tend to consult their physician less often before ED visits because of access problems.

Encopresis Treatment Outcome: Long-term Follow-up of 45 Cases

Among children diagnosed and treated for encopresis (N=88) at either of two incontinence clinics between 1986 and 1994, 45 could be assessed for long-term (>12 months) outcome. Measures consisted of retrospective analysis of clinical charts and parent report of child soiling status. At follow-up (mean duration 53 months, range 15 to 99 months), 26 children (58%) were in remission, 13 (29%) were improved, and six (13%) snowed no improvement. Logistic regression showed that children who presented with no previous encopresis treatment(s) (odds ratio 5.88, 95% confidence interval 1.61 to 21.55, p<.01) and/or children who presented with fecal retention (odds ratio 17.8, 95% confidence interval 2.70 to 153.37, p<.01) were more likely to be in remission. The interval between treatment and follow-up was significantly longer (mean 62 months, range 26 to 94) for children in remission than for children still soiling (mean 45 months, range 15 to 75) (p<.01). At follow-up 1 year or more after treatment for encopresis, a significant number of children may continue to soil. Previous encopresis treatment(s) and/or nonretentive encopresis may be risk factors for persistent soiling. The chances of complete remission of encopresis tend to increase with the passage of time.

The relationship between oxygen saturation and the clinical assessment of acutely wheezing infants and children.

The objective of this study was to determine the relationship between oxygen saturation (Sao2) and traditional clinical assessment measures in infants and young children presenting as outpatients with acute wheezing. To accomplish this, Sao2 before and after medication was compared in a post hoc analysis with the clinical response to treatment (respiratory rate and a standardized index of respiratory distress) in children who participated in a randomized, placebo controlled medication trial. The study was done in a pediatric emergency department and outpatient clinic, and the particpants were 74, full-term previously well infants and young children, aged 1 to 36 months (mean age 16.1 months), presenting with acute wheezing and participating in the randomized trial. The results showed that Sao2 was found to be inversely correlated with both respiratory rate (r=—0.29, P ≤ 0.05) and an index of respiratory distress (r=—0.36, P≤0.01) prior to medication but not afterward. There was no significant difference in Sao2 when infants, who had a clinical response to treatment based on a priori criteria, were compared to nonresponders (mean difference per patient: responders=0.86% vs nonresponders=0.79%, P=0.51). This was due to a large amount of individual variability in postmedication Sao, in both groups. We conclude that, before therapy, there are only weak correlations between Sao, and both respiratory rate and an index of respiratory distress in acutely wheezing infants and children. After therapy, young children can appear clinically improved but measured oxygen saturation may be variable and not correlated with traditional clinical assessment measures

Persistent elevation of fibrin D-dimer predicts longterm outcome in systemic juvenile idiopathic arthritis.

Objective. We previously demonstrated that levels of fibrin d-dimer correlate with disease activity and response to therapies in systemic juvenile idiopathic arthritis (sJIA). We hypothesized that persistence of D-dimer elevation in the patterns previously described, but over a longer followup period, would signal poor outcome. Methods. We studied 31 children identified from 2 centers. Subjects were assigned a risk category based on their first obtained D-dimer concentration. Risk categories were based on results of our initial study, where normalization of D-dimer in patients no longer taking immunosuppressive therapy predicted good short-term outcome, and persistent D-dimer elevation while taking immunosuppressives predicted bad outcome (radiographic abnormalities, joint replacement surgery, or poor functional class) or a severe systemic manifestation. Outcome was determined at the last followup visit, a minimum of 2 years after measurement of the initial d-dimer level. Results. The 31 children were a mean 16.4 years old at an average of 8.8 years after their initial diagnosis. Ten children had a severe outcome during this period; all 10 had a study baseline risk category of “high.” Of the 14 subjects who had a high risk category at study baseline, none had a mild outcome. Conclusion Our study indicated that a paradigm of risk of severe disease based upon persistent elevation of fibrin d-dimer on first measurements (greater than a mean of 29 months in our initial study and at least 24 months in the additional subjects) is promising to predict poor longer-term outcome in sJIA. A larger prospective study is warranted to substantiate the preliminary data and assess the relative comparative value to other biomarkers and clinical endpoints.

Synovial fluid levels of E-selectin and intercellular adhesion molecule-1: relationship to joint inflammation in children with chronic arthritis

Abstract. E-selectin and intercellular adhesion molecule (ICAM)-1 are crucial to the inflammatory response in chronic inflammatory arthritis. Soluble (s) levels of these molecules in sera and synovial fluid (SF) correlate with some clinical parameters and synovial tissue expression of the same molecules in rheumatoid arthritis. Studies of sera from children with chronic inflammatory arthritis corroborate this information; corresponding SF data are relatively lacking. We thus studied SF sE-selectin and sICAM-1 in 28 children with active juvenile rheumatoid arthritis or a spondyloarthropathy. Levels were correlated with erythrocyte sedimentation rate (ESR), SF leukocyte counts, duration of disease, and duration of response to concomitant intra-articular corticosteroid injection. Levels were compared according to use of methotrexate and/or sulfasalazine. Synovial fluid sE-selectin correlated with ESR and SF leukocyte counts. There was a trend toward lower sICAM-1 in patients treated with sulfasalazine and/or methotrexate. We conclude that SF levels of sE-selectin accurately reflect intra-synovial inflammation. Soluble ICAM-1 levels may reflect the effects of disease-modifying agents.

Felty syndrome complicating juvenile rheumatoid arthritis.

Purpose: To describe a case of Felly syndrome (FS) in a child with (JRA) and review the previous literature on this rare entity. Methods: Review of clinical data including results of serial blood counts, bone marrow aspirate, human leukocyte antigen (HLA)-typing, and abdominal sonography. Results: Serial blood counts over 2 years revealed persistent leukopeniu and thrombocytopenia. Bone marrow aspirate showed normal trilineage hematopoiesis. abdominal sonography demonstrated an enlarged spleen, but normal liver and portal circulation. HLA-typing was most significant for positivity of the DR 1 allclc. Conclusion: This is only the third child, and the first preadoles-cent. to be reported with FS complicating juvenile rheumatoid arthritis. This condition needs to be considered in the differential diagnosis when leukopenia. thrombocytopenia. or both develop in patients with JRA.