Christy M. McKinney

Characteristics of 2733 Cases Diagnosed With Deformational Plagiocephaly and Changes in Risk Factors Over Time

Objectives: To describe infant and maternal characteristics among infants with plagiocephaly and to quantify time trends in potential risk factors for plagiocephaly. Design: Case-only study. We described the characteristics of individuals born between 1987 and 2002. We also compared characteristics of individuals born from 1987 through 1990, before the American Academy of Pediatrics 1992 sleep-position recommendations, with those of individuals born from 1991 to 2002. Setting: Childrens Craniofacial Center at Childrens Hospital and Regional Medical Center in Seattle, Washington. Participants: Subjects included 2733 infants diagnosed with deformational plagiocephaly or brachycephaly before 18 months of age who were born from 1987 to 2002. Main Outcome Measure: Descriptive statistics, odds ratios, and 95% confidence intervals. Results: Among individuals born from 1991 to 2002, 91.6% had occipital-only flattening, 17.2% were brachycephalic, 67.7% were boys, and 9.9% were multiple birth infants. As compared with individuals born from 1987 through 1990, those born from 1991 to 2002 were more apt to be a multiple birth (odds ratio [OR] 3.4, 95% confidence interval [CI]: 0.8, 14.1) and to have a mother ≥35 years of age (OR, 3.2; 95% CI, 1.4 to 7.3); they were hospitalized less commonly at birth for 4 or more days (OR, 0.02; 95% CI, 0.01 to 0.06). Conclusions: Several risk factors for plagiocephaly were more common among individuals born after the 1992 American Academy of Pediatrics sleep-position recommendations. These results are consistent with the explanation that supine sleeping modifies the association between such risk factors and plagiocephaly. Further studies with a control group are needed to validate this conclusion.

Visits to US emergency departments by 20- to 29-year-olds with toothache during 2001-2010

BACKGROUND Visits to emergency departments (EDs) for dental symptoms are on the rise, yet reliance on EDs for dental care is far from ideal. ED toothache visits represent opportunities to improve access to professional dental care. METHODS This research focuses on 20- to 29-year-olds, who account for more ED toothache visits than do other age groups. The authors analyzed publicly available ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2001 through 2010. They assessed trends in ED toothache visit rates compared with back pain and all cause ED visits during the past decade. The authors used NHAMCS data for years 2009 and 2010 to characterize the more recent magnitude, relative frequency, and independent risk factors for ED toothache visits. Statistical analyses accounted for the complex sampling design. RESULTS The average annual increase in ED visit rates among 20- to 29-year-olds during 2001-2010 was 6.1% for toothache, 0.3% for back pain, and 0.8% for all causes of ED visits. In 2009 and 2010, 20- to 29-year-olds made an estimated 1.27 million ED visits for toothaches and accounted for 42% of all ED toothache visits. Toothache was the fifth most common reason for any ED visit and third most common for uninsured ED visits by 20- to 29-year-olds. Independent risk factors for ED toothache visits were being uninsured or Medicaid-insured. CONCLUSIONS Younger adults increasingly rely on EDs for toothaches-likely because of barriers to accessing professional dental care. Expanding dental coverage and access to affordable dental care could increase options for timely dental care and decrease ED use for dental symptoms. PRACTICAL IMPLICATIONS Though additional research is needed to better understand why younger adults disproportionately use the ED for toothaches, findings from this study suggest the importance of maintaining access to a dental home from childhood through adolescence and subsequently into early adulthood.

Dental sealants and restorations and urinary bisphenol A concentrations in children in the 2003-2004 National Health and Nutrition Examination Survey

BACKGROUND Resin-based dental sealants and composites contain bisphenol A-glycidyl methacrylate, a bisphenol A (BPA) derivative. The authors hypothesized that a greater number of sealants or restorations would be associated with higher urinary BPA concentrations. METHODS The authors examined urinary BPA measurements (in nanograms per milliliter) and oral examination data for 1,001 children aged 6 to 19 years from data sets of the 2003-2004 National Health and Nutrition Examination Survey (NHANES). They categorized children according to number of occlusal sealants and number of restorations, with four categories in each of the two groups. They estimated associations by using unadjusted and adjusted tobit regression models. RESULTS The lowest quartile of BPA concentrations ranged from 0.3 ng/mL to 1.9 ng/mL, whereas the highest quartile ranged from 7.3 ng/mL to 149 ng/mL. In adjusted analysis, children with seven to 16 sealants had geometric mean BPA concentrations 25 percent higher than those of children with no sealants (95 percent confidence interval [CI], -14 percent to 82 percent; P = .23). In adjusted analysis, children with seven to 42 restorations had geometric mean BPA concentrations 20 percent higher than those of children with no restorations (95 percent CI, -6 percent to 53 percent; P = .13). Neither of these adjusted estimates was statistically significant. CONCLUSIONS Though the findings were in the direction hypothesized, the authors did not observe a statistically significant association between a greater number of sealants or restorations and higher urinary BPA concentrations. Additional studies are needed to determine the extent of oral and systemic exposure to BPA from resin-based dental restorative materials over time. PRACTICAL IMPLICATIONS Dentists should follow this issue carefully as it develops and as the body of evidence grows. There is insufficient evidence to change practice at this time.

Predictors of Unmet Dental Need in Children With Autism Spectrum Disorder: Results From a National Sample

OBJECTIVE Unmet dental need in children with autism spectrum disorder (ASD) is common. We tested hypotheses that lacking a medical home or having characteristics of more severe ASD is positively associated with having unmet dental need among children with ASD. METHODS Using data from the 2009 to 2010 National Survey of Children with Special Health Care Needs, we analyzed 2772 children 5 to 17 years old with ASD. We theorized that unmet dental need would be positively associated with not having a medical home and having characteristics of more severe ASD (eg, parent reported severe ASD, an intellectual disability, communication, or behavior difficulties). Prevalence of unmet dental need was estimated, and unadjusted and adjusted odds ratios, 95% confidence intervals, and P values were computed using survey methods for logistic regression. RESULTS Nationally, 15.1% of children with ASD had unmet dental need. Among children with ASD, those without a medical home were more apt to have unmet dental need than those with a medical home (adjusted odds ratio, 4.46; 95% confidence interval, 2.59-7.69). Children with ASD with intellectual disability or greater communication or behavioral difficulties had greater odds of unmet dental need than those with ASD without these characteristics. Parent-reported ASD severity was not associated with unmet dental need. CONCLUSIONS Children with ASD without a medical home and with characteristics suggestive of increased ASD-related difficulties were more apt to have unmet dental need. Pediatricians might use these findings to aid in identifying children with ASD who might not receive all needed dental care.

Micronutrients and Oral Clefts: A Case-Control Study

Little is known about oral clefts in developing countries. We aimed to identify micronutrient-related and environmental risk factors for oral clefts in Thailand. We tested hypotheses that maternal exposure during the periconceptional period to multivitamins or liver consumption would decrease cleft lip with or without cleft palate (CL ± P) risk and that menstrual regulation supplements would increase CL ± P risk. We conducted a multisite hospital-based case-control study in Thailand. We enrolled cases with CL ± P and 2 live births as controls at birth from the same hospital. Mothers completed a questionnaire. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Eighty-six cases and 172 controls were enrolled. Mothers who took a vitamin (adjusted OR, 0.39; 95% CI: 0.16, 0.94) or ate liver (adjusted OR, 0.26; 95% CI: 0.12, 0.57) were less likely than those who did not to have an affected child. Mothers who took a menstrual regulation supplement were more likely than mothers who did not to have an affected child. Findings did not differ for infants with a family history of other anomalies or with isolated CL ± P. If replicated, our finding that liver decreases CL ± P risk could offer a low-cost primary prevention strategy.

Adverse birth outcomes and childhood caries: a cohort study.

OBJECTIVES To examine the association between adverse birth outcomes and dental caries in primary teeth. METHODS This study included children in Khon Kaen, Thailand, who participated in the Prospective Cohort Study of Thai Children. Preterm was defined as a birth at <37 weeks gestation, low birthweight (LBW) as birthweight <2500 g, and small-for-gestational age (SGA) as birthweight <10th percentile of expected weight for gestational age. Two calibrated dentists measured dental caries in primary teeth when the children were 3-4 years old using decayed, missing and filled surfaces (dmfs) index following the World Health Organization criteria. We used negative binomial regression with generalize linear models to estimate relative risks (RRs) and their 95% confidence intervals (CIs), adjusted for confounding factors. Of 758 children with gestational age data and 833 with birthweight data, the 544 (follow-up rate of 71.8% in preterm and 65.3% in LBW) who had dental data available were included in the analysis. RESULTS Dental caries was observed in 480 children (88.2%), with a mean dmfs of 14.3 (standard deviation 12.8). The adjusted RR for dental caries was 0.61 (95% CI 0.43, 0.85) for preterm, 0.89 (95% CI 0.67, 1.21) for LBW, and 0.96 (95% CI 0.74, 1.26) for SGA. CONCLUSIONS There was an inverse association between preterm and childhood caries. LBW and SGA were not associated with dental caries in this population.

Breastfeeding Duration and Childhood Caries: A Cohort Study

This cohort study was conducted in Khon Kaen, Thailand, to test the hypothesis that a longer breastfeeding duration increases the risk for dental caries in primary teeth. We collected information on infant feeding practices and potential confounders using a structured questionnaire to interview mothers or caregivers during the second trimester of pregnancy and after birth at 21 days and at 3, 12, 18, 24, and 36 months. Regardless of other liquids and foods, full breastfeeding was defined as feeding breast milk but not formula, while any breastfeeding was feeding breast milk with or without formula. Two calibrated dentists measured dental caries when the children were 3-4 years of age using the decayed, missing, and filled surfaces (dmfs) index following the World Health Organization criteria. Negative binomial regression with a generalized linear model was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) using dmfs as an outcome. Log-binomial regression was performed to model the caries prevalence. Of 556 children, 88.1% had dental caries with a mean dmfs of 14.2. Full breastfeeding for 6-11 months was significantly associated with a lower dmfs (adjusted RR 0.77, 95% CI 0.63, 0.93) and a lower caries prevalence (adjusted RR 0.45, 95% CI 0.22, 0.90). The frequency of sleeping while breast- or bottle-feeding increased the caries risk in a dose-response manner. There was no association between duration of any breastfeeding and dental caries. In conclusion, full breastfeeding for 6-11 months may protect against dental caries in primary teeth. Prolonged breastfeeding was not associated with dental caries in this population.

Case–control study of nutritional and environmental factors and the risk of oral clefts in Thailand

BACKGROUND One infant in 700 is born with an oral cleft. Prior studies suggest low micronutrient status is associated with an increased risk of oral clefts. Environmental factors such as passive smoke exposure or supplement use may also affect oral cleft risk. We examined nutrition and environmental related risk factors for oral clefts. METHODS We conducted a case-control study in Northeast Thailand in 2012 to 2013. We enrolled 95 cases and 95 controls. We recruited cases with a nonsyndromic cleft lip with or without a cleft palate (CL±P) less than 24 months old. Cases were matched to controls on age and place of conception. We collected survey data, a food frequency questionnaire, and measured zinc concentrations in toenail trimmings. We calculated descriptive statistics by case and control status. We used conditional logistic regression to estimate unadjusted and adjusted associations, 95% confidence intervals (CIs), and p-values. RESULTS Any liver intake (adjusted OR [aOR] for ≥1/week versus none), 10.58; 95%CI, 1.74-64.37, overall p = 0.02) and the presence of food insecurity (aOR, 9.62; 95% CI, 1.52-61.05; p = 0.02) in the periconceptional period increased CL±P risk. Passive smoke exposure increased the risk of CL±P (aOR, 6.52; 95% CI, 1.98-21.44; p < 0.01). Toenail zinc concentrations were not associated with CL±P risk. CONCLUSION Our findings add to a growing body of knowledge of environmental risk factors for oral clefts from low- and middle-income countries. Our findings on liver are contradictory to prior results. Large multisite studies are needed to identify environmental and genetic risk factors for oral clefts. Birth Defects Research (Part A) 106:624-632, 2016.

Optimizing vitamin D naming conventions in computerized order entry to support high-value care

Objective: To reduce wasteful ordering of rare 1,25-OH vitamin D lab tests through use of a noninterruptive decision support tool. Materials and Methods: We conducted a time series quality improvement study at 2 academic hospitals. The titles of vitamin D tests and the order in which they appeared in search results were changed to reflect the purpose and rarity of the tests. We used interruptive time series analyses to evaluate the changes we made. Results: The estimated number of monthly tests ordered at the 2 hospitals increased, by 24.8 and 14.2, following the introduction of computerized provider order entry (CPOE) (both P < .001). When we changed the titles of the tests, the estimated number of monthly tests decreased at the 2 hospitals, by 22.1 and 11.3 (both P < .001). The search order did not affect test utilization. Discussion: Changing catalog names in CPOE systems for infrequently used tests can reduce unintentional overuse. Users may prefer this to interruptive or restrictive interventions. Conclusion: CPOE vendors and users should refine interfaces by incorporating human factors engineering. Health care institutions should monitor test utilization for unintended changes after CPOE implementation.

Factors That Influence Treatment Completion for Latent Tuberculosis Infection

Introduction: The aim of this study is to describe factors associated with noncompletion of latent tuberculosis infection (LTBI) therapy. Methods: We conducted a retrospective cohort study of adults who initiated LTBI treatment with isoniazid, rifampin, or isoniazid-rifapentine at 5 clinics. Demographic, treatment, and monitoring characteristics were abstracted. We estimated descriptive statistics and compared differences between completers and noncompleters using t tests and χ2 tests. Results: The rate of completion across LTBI regimens was 66% (n = 393). A greater proportion of noncompleters were unmarried, used tobacco and/or alcohol, and had more medical problems than completers (all P < .05). A larger proportion of noncompleters received charity care compared with completers (P < .001). The most common reason for treatment discontinuation was loss to follow-up; the majority of these participants were treated with the longest isoniazid-only regimen. Conclusions: Patients at risk of progression to active tuberculosis with factors associated with noncompletion may benefit from interventions that enhance adherence to LTBI therapy. These interventions could include enhanced outreach, incentive programs, or home visits.