Mary Ann Limbos

Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children: A Systematic Review

CONTEXT Acute otitis media (AOM) is the most common condition for which antibiotics are prescribed for US children; however, wide variation exists in diagnosis and treatment. OBJECTIVES To perform a systematic review on AOM diagnosis, treatment, and the association of heptavalent pneumococcal conjugate vaccine (PCV7) use with AOM microbiology. DATA SOURCES PubMed, Cochrane Databases, and Web of Science, searched to identify articles published from January 1999 through July 2010. STUDY SELECTION Diagnostic studies with a criterion standard, observational studies and randomized controlled trials comparing AOM microbiology with and without PCV7, and randomized controlled trials assessing antibiotic treatment. DATA EXTRACTION Independent article review and study quality assessment by 2 investigators with consensus resolution of discrepancies. RESULTS Of 8945 citations screened, 135 were included. Meta-analysis was performed for comparisons with 3 or more trials. Few studies examined diagnosis; otoscopic findings of tympanic membrane bulging (positive likelihood ratio, 51 [95% confidence interval {CI}, 36-73]) and redness (positive likelihood ratio, 8.4 [95% CI, 7-11]) were associated with accurate diagnosis. In the few available studies, prevalence of Streptococcus pneumoniae decreased (eg, 33%-48% vs 23%-31% of AOM isolates), while that of Haemophilus influenzae increased (41%-43% vs 56%-57%) pre- vs post-PCV7. Short-term clinical success was higher for immediate use of ampicillin or amoxicillin vs placebo (73% vs 60%; pooled rate difference, 12% [95% CI, 5%-18%]; number needed to treat, 9 [95% CI, 6-20]), while increasing the rate of rash or diarrhea by 3% to 5%. Two of 4 studies showed greater clinical success for immediate vs delayed antibiotics (95% vs 80%; rate difference, 15% [95% CI, 6%-24%] and 86% vs 70%; rate difference, 16% [95% CI, 6%-26%]). Data are absent on long-term effects on antimicrobial resistance. Meta-analyses in general showed no significant differences in antibiotic comparative effectiveness. CONCLUSIONS Otoscopic findings are critical to accurate AOM diagnosis. AOM microbiology has changed with use of PCV7. Antibiotics are modestly more effective than no treatment but cause adverse effects in 4% to 10% of children. Most antibiotics have comparable clinical success.

Policy Statement—Child Passenger Safety

Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death of children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats for most infants up to 2 years of age; (2) forward-facing car safety seats for most children through 4 years of age; (3) belt-positioning booster seats for most children through 8 years of age; and (4) lap-and-shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health-supervision visit.

Schools and neighborhoods: organizational and environmental factors associated with crime in secondary schools

BACKGROUND While crime and violence in schools are derived primarily from factors external to schools, violent behavior may also be aggravated by factors in the school environment, including the physical environment, its educational and social climate, and its organizational capacity and composition. The objective of this study is to examine the effect of the schools organizational and educational environment on crime rates in secondary schools and to examine how neighborhood factors influence these relationships. METHODS School and neighborhood crime rates for 95 middle (MS) and high (HS) schools were calculated using data from the Los Angeles Unified School District (LAUSD) Police Department and Los Angeles Police Department, respectively. School-level organizational and educational variables, including the academic performance index (API), were obtained from the California Department of Education. A measure of neighborhood dilapidation was created using variables collected on a neighborhood environmental survey. Linear regression was used to examine the relationship between organizational and educational school variables and school crime rates. Community crime and dilapidation were added to the model to examine the influence of the school-community context relationships. RESULTS HS had higher crime rates than MS. As the percentage of certified teachers and student to staff ratios increased, school crime decreased (p < .01). An API of below basic performance was significantly associated with increasing school crime rates (p < .05). Neighborhood crime was not significantly associated with school crime, although dilapidation was positively and significantly associated with school crime even after controlling for community crime (p < .05). CONCLUSIONS Both school- and neighborhood-level factors were associated with increasing crime rates in secondary schools. School violence prevention efforts should include school and community partnerships to address these potentially modifiable factors.

Documentation of Child Physical Abuse: How Far Have We Come?

Objectives. To determine the effects of increased physician training and a structured clinical form on physician documentation of child physical abuse. Design. Retrospective chart review. Participants. Children evaluated in the pediatric emergency department in 1980 and 1995 who were given the diagnosis of physical abuse. Measurements. The unstructured pediatric emergency department form and the structured child abuse reporting form were reviewed for documentation of 20 items including history, physical examination, diagnostic procedures, and disposition. Data documented in 1980 were compared with that in 1995. Results. The only significant differences between 1980 and 1995 concerning documentation on the unstructured pediatric emergency department form were better recording in the latter year of Child Protective Services involvement and case disposition. Half or more of the records omitted documentation of at least one of the following: witnesses to injury, past injuries, description of size and/or color of injuries, illustration, and a genital exam. None of the records contained a developmental history. Significantly fewer skeletal surveys were obtained in 1995, although notation of the results was similar to 1980. For both years, the structured child abuse reporting form improved documentation of only two items: time of arrival to the pediatric emergency department and illustrations of injuries. Conclusions. Little improvement in physician documentation of child physical abuse was noted between 1980 and 1995 despite increased efforts to educate housestaff in the evaluation of child abuse during this time period. Although a structured form prompted physicians to document dates and times and to illustrate physical injuries on the diagram provided, it did not significantly improve documentation of other items.

Policy Statement—Prevention of Drowning

Drowning is a leading cause of injury-related death in children. In 2006, fatal drowning claimed the lives of approximately 1100 US children younger than 20 years. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in the prevention of drowning.

Sports Injuries to High School Athletes With Disabilities

INTRODUCTION. Physical activity in sports comes with an inherent risk for injury. For children with disabilities, their injury risk may be complicated by preexisting disability. However, very little research exists on sports injuries to young athletes with disabilities. To best manage potential injuries to children with disabilities, data on sports injury patterns are needed. The purpose of this study was to measure the frequency of and risk factors for injury to high school athletes with disabilities. METHODS. A total of 210 athletes from 8 special education high schools that are part of an interscholastic sports league participated in the study. Seven of the 8 schools were followed for 1 season each of basketball, softball, soccer, and field hockey, and 1 school enrolled only during field hockey. Data were collected from coaches on daily exposure sessions (game, practice, and conditioning, as well as length of session), athlete characteristics (disability, gender, age, seizure history, and behavioral problems), and nature of injuries resulting in any type of medical treatment. RESULTS. Thirty-eight injuries were reported among 512 special athletes for a rate of 2.0 per 1000 athlete exposures. Soccer (3.7 per 1000) had the highest rate of injury. More than half of the injuries were abrasions and contusions. Those at highest risk for injury were athletes with autism, athletes with histories of seizures, and starters. Athletes with autism had ∼5 times the injury rate of athletes with mental disabilities. Athletes with seizures had >2.5 times the rate of injury reported among those with no seizure history. CONCLUSIONS. This adapted sports program is a reasonably safe activity for children with disabilities. Nonetheless, findings have important implications for prevention. The preparticipation medical examination may be an excellent opportunity to create special guidelines, particularly for athletes with autism and seizure history.

Policy statement - Child fatality review

Injury remains the leading cause of pediatric mortality and requires public health approaches to reduce preventable deaths. Child fatality review teams, first established to review suspicious child deaths involving abuse or neglect, have expanded toward a public health model of prevention of child fatality through systematic review of child deaths from birth through adolescence. Approximately half of all states report reviewing child deaths from all causes, and the process of fatality review has identified effective local and state prevention strategies for reducing child deaths. This expanded approach can be a powerful tool in understanding the epidemiology and preventability of child death locally, regionally, and nationally; improving accuracy of vital statistics data; and identifying public health and legislative strategies for reducing preventable child fatalities. The American Academy of Pediatrics supports the development of federal and state legislation to enhance the child fatality review process and recommends that pediatricians become involved in local and state child death reviews.

Knowledge and Behaviors of Parents in Planning for and Dealing with Emergencies

In recent years, a number of large-scale disasters have occurred both locally and internationally, heightening our awareness of potential dangers. If a disaster were to occur at a school, there is the potential for a large number of children to be injured or affected in some way. The school community includes not only the staff and students who are on campus each day, but also students’ parents and the surrounding neighborhood. How parents react during emergencies and disasters at schools is likely associated with their knowledge and perceptions of emergencies and disasters. Parents’ preparedness levels and their planned response to a school-based emergency and how schools plan and manage for these reactions have not been explored. Utilizing a mixed methods design that included surveys, semi-structured interviews and focus groups with members of the communities in two South Los Angeles school districts, this study aims to provide an overview of parents’ levels of emergency and disaster preparedness and the challenges they face in preparing for these events. Additionally, parents’ planned responses to a school-based emergency or disaster are discussed as well as the challenges that schools may face as a result. Data from this study confirm that there are a number of challenges related to parents’ planned response to a school-based emergency, including an expected inundation of parents to the schools, lack of communication between schools and parents and language barriers. Recommendations for schools are provided to take advantage of parent populations to better integrate them into schools’ emergency planning processes.

Clinical report - Intimate partner violence

The American Academy of Pediatrics and its members recognize the importance of improving the physicians ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children.American Academy of Pediatrics and its members recognize the importance of improving the physicians ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatri- cians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children. Pediatrics 2010;125:1094-1100