Lynnette J. Mazur

Lead exposure in children: Prevention, detection, and management

Fatal lead encephalopathy has disappeared and blood lead concentrations have decreased in US children, but approximately 25% still live in housing with deteriorated lead-based paint and are at risk of lead exposure with resulting cognitive impairment and other sequelae. Evidence continues to accrue that commonly encountered blood lead concentrations, even those less than 10 μg/dL, may impair cognition, and there is no threshold yet identified for this effect. Most US children are at sufficient risk that they should have their blood lead concentration measured at least once. There is now evidence-based guidance available for managing children with increased lead exposure. Housing stabilization and repair can interrupt exposure in most cases. The focus in childhood lead-poisoning policy, however, should shift from case identification and management to primary prevention, with a goal of safe housing for all children.

Global climate change and children's health

There is a broad scientific consensus that the global climate is warming, the process is accelerating, and that human activities are very likely (>90% probability) the main cause. This warming will have effects on ecosystems and human health, many of them adverse. Children will experience both the direct and indirect effects of climate change. Actions taken by individuals, communities, businesses, and governments will affect the magnitude and rate of global climate change and resultant health impacts. This technical report reviews the nature of the global problem and anticipated health effects on children and supports the recommendations in the accompanying policy statement on climate change and childrens health.

Weight-training injuries : common injuries and preventative methods

SummaryThe use of weights is an increasingly popular conditioning technique, competitive sport and recreational activity among children, adolescents and young adults. Weight-training can cause significant musculoskeletal injuries such as fractures, dislocations, spondylolysis, spondylolisthesis, intervertebral disk herniation, and meniscal injuries of the knee. Although injuries can occur during the use of weight machines, most apparently happen during the aggressive use of free weights. Prepubescent and older athletes who are well trained and supervised appear to have low injury rates in strength training programmes. Good coaching and proper weightlifting techniques and other injury prevention methods are likely to minimise the number of musculoskeletal problems caused by weight-training.

Spectrum of Noninfectious Health Effects From Molds

Molds are multicellular fungi that are ubiquitous in outdoor and indoor environments. For humans, they are both beneficial (for the production of antimicrobial agents, chemotherapeutic agents, and vitamins) and detrimental. Exposure to mold can occur through inhalation, ingestion, and touching moldy surfaces. Adverse health effects may occur through allergic, infectious, irritant, or toxic processes. The cause-and-effect relationship between mold exposure and allergic and infectious illnesses is well known. Exposures to toxins via the gastrointestinal tract also are well described. However, the cause-and-effect relationship between inhalational exposure to mold toxins and other untoward health effects (eg, acute idiopathic pulmonary hemorrhage in infants and other illnesses and health complaints) is controversial and requires additional investigation. In this report we examine evidence of fungal-related illnesses and the unique aspects of mold exposure to children. Mold-remediation procedures are also discussed.

Chemical-biological terrorism and its impact on children.

Children remain potential victims of chemical or biological terrorism. In recent years, children have even been specific targets of terrorist acts. Consequently, it is necessary to address the needs that children would face after a terrorist incident. A broad range of public health initiatives have occurred since September 11, 2001. Although the needs of children have been addressed in many of them, in many cases, these initiatives have been inadequate in ensuring the protection of children. In addition, public health and health care system preparedness for terrorism has been broadened to the so-called all-hazards approach, in which response plans for terrorism are blended with plans for a public health or health care system response to unintentional disasters (eg, natural events such as earthquakes or pandemic flu or manmade catastrophes such as a hazardous-materials spill). In response to new principles and programs that have appeared over the last 5 years, this policy statement provides an update of the 2000 policy statement. The roles of both the pediatrician and public health agencies continue to be emphasized; only a coordinated effort by pediatricians and public health can ensure that the needs of children, including emergency protocols in schools or child care centers, decontamination protocols, and mental health interventions, will be successful.

Temperature response to acetaminophen and risk of occult bacteremia: A case-control study

A case-control study of 34 children with occult bacteremia was conducted to test the hypothesis that nonresponse to acetaminophen (decrease less than or equal to 0.8 degrees C) is a risk factor for occult bacteremia. Febrile children visiting the emergency center from May 1986 to October 1987 were monitored for occult bacteremia. Inclusion criteria were age 2 months to 6 years, temperature greater than or equal to 38.9 degrees C, and having a blood culture. Exclusion criteria were serious acute or chronic illness, sponging for fever reduction, current therapy with antibiotics or steroids, and admission to the hospital. Records of 3892 febrile children were reviewed. Of these, 2101 (54%) had a blood culture and 1028 (26%) were eligible. All patients (positive blood culture) were matched with two control subjects (negative blood culture). Patients and control subjects had similar age, gender, ethnicity, height of initial temperature, time to second temperature, and dose of acetaminophen. The estimated risk of occult bacteremia for nonresponders was 9.2 (95% confidence interval 2.7, 32.0). We conclude that children who do not respond to acetaminophen by at least a 0.8 degrees C decrease in temperature have an increased risk of occult bacteremia. However, achieving a response to acetaminophen does not eliminate the possibility that the child has occult bacteremia.

Fractures at Diagnosis in Infants and Children With Osteogenesis Imperfecta

Background: In infants and children with fractures from an unclear cause, osteogenesis imperfecta (OI) is often included as a potential etiology. In infants and children with OI there exists a gap in the published literature regarding the fracture pattern seen at the time of diagnosis. As an additional aid to the diagnosis of OI, we sought to characterize the fracture patterns in infants and children at the time of their diagnosis. Methods: We performed a retrospective chart review of a series of infants and children under 18 years of age who have the diagnosis of OI (any type) from a single institution. Results: We identified 68 infants and children with OI: 23 (34%) type 1, 1 (2%) type 2, 17 (25%) type 3, 24 (35%) type 4, and 3 (4%) unknown type. A family history of OI was present in 46% of children. Forty-nine (72.0%) patients were diagnosed solely on clinical characteristics, without genetic or fibroblast confirmation. Rib fractures were noted in 21% of the subjects with none being identified during infancy. The number of fractures identified at diagnosis ranged from 1 to >37 with 7 (10%) having more than 2 fractures. All subjects with more than 2 fractures were diagnosed prenatally or in the immediate newborn period. Seventeen (25%) infants were diagnosed after 1 week of age but before 12 months of age. None of these infants had either rib fractures or more than 1 fracture at the time of diagnosis. Conclusions: The majority of children diagnosed with OI are diagnosed by clinical features alone. The fracture pattern at the time of diagnosis in OI is variable with 10% having more than 2 fractures. The diagnosis of OI was made in utero or at delivery in 43% of children. Multiple rib fractures in an infant would be an unexpected finding in OI. Level of Evidence: Level III.

Diagnostic tests for occult bacteremia: Temperature response to acetaminophen versus WBC count

A cohort of 484 febrile children were examined to (1) assess the utility of temperature response to acetaminophen as a diagnostic test for occult bacteremia (OB) and (2) compare it with the white blood cell (WBC) count. For a period of 18 months, the records of all febrile children seen in the emergency department were reviewed. Testing a response to acetaminophen of a < or = 0.8 degrees C decrease in temperature, the sensitivity, specificity, and positive and negative predictive values were 47%, 74%, 12%, and 95%, respectively. When compared with a WBC count > or = 15,000/microL, the corresponding values were 76%, 65%, 15%, and 97%. Receiveroperator characteristic curves were constructed to compare temperature responses with WBC values. The difference was not significant (P > 0.05). The conclusion reached was that temperature response to acetaminophen has predictive values that are similar to the WBC count, and it may provide useful information. However, neither test is impressive, and the clinician cannot reliably predict which febrile children are at risk.

Is omeprazole helpful in the management of children with reflux oesophagitis

An 18 month old boy with cerebral palsy is brought to your office because of “spitting up” after feeds. It has been a problem for the past several months, but is progressively worsening and now occurs after every meal and even at night. He was breast fed for 12 months and has slight developmental delay. Height and head circumference are between 25–50th centile, but weight is below 5th centile for age. A barium swallow reveals significant gastro-oesophageal reflux to the pharynx. A …

Risk factors for vitamin D deficiency in children with osteogenesis imperfecta.

Background: The purpose of this study was to evaluate the prevalence of vitamin D deficiency and possible risk factors influencing the vitamin D serum levels in patients with osteogenesis imperfecta (OI). Methods: Charts of all children with OI seen at Shriners Hospitals for Children in Houston, TX, between November 2008 and June 2011 were reviewed for daily milk and soda consumption, multivitamin and vitamin D supplementation, time spent outside, use of sunscreen, amount of screen time, ambulatory status, height, weight, body mass index (BMI), serum 25 hydroxyvitamin D (25OHD), parathyroid hormone levels, and history of bisphosphonate treatment. Results: Of the 80 children with OI, charts of 44 children (26 female) had documentation of the variables of interest. Mean level of 25OHD was 23 ng/mL (±11) (range, 7 to 58) and 35 (79.5%) patients had insufficient or deficient levels. Significant correlations with low vitamin D levels were found for older age (P<0.001), African American descent (P=0.01), BMI (P<0.001), BMI percentile (P=0.30), consumption of soda (P=0.009), and pamidronate therapy (P=0.004). Evaluated together, the studied variables accounted for a large proportion of the variability of 25OHD levels in patients with OI (P=0.004). Conclusions: To optimize bone health in children with OI, health care providers need to be aware of patients’ risk factors for low vitamin D levels and educate families on the modifiable risk factors of milk and soda consumption, obesity, and vitamin D supplementation. Future research is needed to address the relationship between fractures and vitamin D levels in patients with OI and on the cause and effect relationship between bisphosphonate therapy and vitamin D. Level of Evidence: Level II.