Matilda Eide

Wartime Military Deployment and Increased Pediatric Mental and Behavioral Health Complaints

BACKGROUND: Children of military personnel face stress when a parent deploys. OBJECTIVE: Our goal was to determine the effect of parental military deployment on the relative rate of outpatient visits for mental and behavioral health disorders in children aged 3 to 8 years. METHODS: This was a retrospective cohort study. Records of children of active-duty personnel during fiscal years 2006 and 2007 were linked with their parents deployment records. Mental and behavioral health visits were identified by using International Classification of Diseases, Ninth Revision, codes. The incidence rate ratio (IRR) of visits per year according to parental deployment status was determined with random-effects negative binomial regression modeling with longitudinal data analysis. RESULTS: A total of 642 397 children aged 3 to 8 years and 442 722 military parents were included. Mean child age was 5.0 years (SD: 1.9 years); 50.6% were male, and 68.0% were white. Ninety percent of the parents were male, and 90.5% were married; 32.0% of the parents were deployed during the study. There were 1 049 081 person-years with 611 115 mental and behavioral health visits (0.6 visit per year). The IRR of mental and behavioral health visits for children with a deployed parent compared with when a parent was home was 1.11 (95% confidence interval [CI]: 1.07–1.14; P < .001). IRRs of pediatric anxiety, behavioral, and stress disorders when a parent deployed were 1.14 (95% CI: 0.98–1.32; P = .095), 1.19 (95% CI: 1.07–1.32; P < .001), and 1.18 (95% CI: 1.10–1.26; P < .001), respectively. Older children and children with military fathers and married parents had larger increases in rates of mental and behavioral health visits during parental deployments. In contrast, the overall outpatient rate and rates of visits for other diagnoses decreased when a parent was deployed. CONCLUSIONS: Mental and behavioral health visits increased by 11% in these children when a military parent deployed; behavioral disorders increased 19% and stress disorders increased 18%. Rates especially increased in older children and children of married and male military parents.

Azithromycin in Early Infancy and Pyloric Stenosis

BACKGROUND AND OBJECTIVE: Use of oral erythromycin in infants is associated with infantile hypertrophic pyloric stenosis (IHPS). The risk with azithromycin remains unknown. We evaluated the association between exposure to oral azithromycin and erythromycin and subsequent development of IHPS. METHODS: A retrospective cohort study of children born between 2001 and 2012 was performed utilizing the military health system database. Infants prescribed either oral erythromycin or azithromycin as outpatients in the first 90 days of life were evaluated for development of IHPS. Specific diagnostic and procedural codes were used to identify cases of IHPS. RESULTS: A total of 2466 of 1 074 236 children in the study period developed IHPS. Azithromycin exposure in the first 14 days of life demonstrated an increased risk of IHPS (adjusted odds ratio [aOR], 8.26; 95% confidence interval [CI], 2.62–26.0); exposure between 15 and 42 days had an aOR of 2.98 (95% CI, 1.24–7.20). An association between erythromycin and IHPS was also confirmed. Exposure to erythromycin in the first 14 days of life had an aOR of 13.3 (95% CI, 6.80–25.9), and 15 to 42 days of life, aOR 4.10 (95% CI, 1.69–9.91). There was no association with either macrolide between 43 and 90 days of life. CONCLUSIONS: Ingestion of oral azithromycin and erythromycin places young infants at increased risk of developing IHPS. This association is strongest if the exposure occurred in the first 2 weeks of life, but persists although to a lesser degree in children between 2 and 6 weeks of age.

Association of Constipation and Fecal Incontinence With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE: Functional constipation and fecal incontinence are common childhood gastrointestinal conditions. Both conditions may be associated with behavioral problems. Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder of childhood, characterized by shortened attention span and hyperactivity. We hypothesize that a diagnosis of ADHD increases the risk for functional constipation and fecal incontinence. METHODS: A retrospective cohort study of children was performed by using the military health system database. Children of active-duty military personnel, aged 4 to 12 years, from October 2005 to September 2007, were included. ADHD, constipation, and fecal incontinence were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Relative risks and adjusted incidence rate ratios (IRRs) were calculated. A subgroup analysis of subjects receiving medical therapy was performed. RESULTS: There were 742 939 children identified in the study, 32 773 (4.4%) of whom had ADHD. Children with ADHD had an increased prevalence of constipation (4.1% of children with ADHD vs 1.5% children without ADHD; P < .001) and fecal incontinence (0.9% of children with ADHD vs 0.15% of children without ADHD; P < .0001). Children with ADHD had more visits than those without ADHD for both constipation (IRR 3.39; 95% confidence interval 2.59–4.43) and fecal incontinence (IRR 7.74; 95% confidence interval 5.01–11.98). Children with ADHD receiving medicinal therapy did not differ significantly from children with ADHD not receiving medicinal therapy on rates of constipation visits (P = .57) or fecal incontinence visits (P = .32). CONCLUSIONS: Children with ADHD are significantly more likely to have constipation and fecal incontinence. Medical therapy for ADHD does not impact visit rates for defecation disorders.

Children with Down Syndrome Are High-Risk for Severe Respiratory Syncytial Virus Disease

OBJECTIVE To assess Down syndrome as an independent risk factor for respiratory syncytial virus (RSV) hospitalization in children younger than 3 years of age and to evaluate illness severity. STUDY DESIGN A retrospective cohort study of children enrolled in the military health system database was conducted. The effect of Down syndrome on RSV hospitalization was assessed by Cox proportional hazards model, while we controlled for risk factors. Disease severity was assessed by length of hospital stay, need for respiratory support, and age at hospitalization. RESULTS The study included 633 200 children and 3 209 378 person-years. Children with Down syndrome had a hospitalization rate of 9.6% vs 2.8% in children without Down syndrome. Down syndrome had a greater adjusted hazard ratio (HR) for RSV hospitalization than most risk factors, 3.46 (95% CI 2.75-4.37). A sensitivity analysis demonstrated HR 3.21 (95% CI 2.51-4.10) for patients with Down syndrome ages 0-23 months and HR 5.07 (95% CI 2.21-11.59) ages 24-36 months. The median (IQR) length of stay of children with and without Down syndrome was 4 days (2-7) and 2 days (1-4) (P < .001). Patients with Down syndrome had a greater risk of requiring respiratory support (relative risk 5.5; 95% CI, 2.5-12.3). The median (IQR) ages at admission for children with and without Down syndrome were 9.8 months (5.5-17.7) and 3.5 months (1.7-8.7) (P < .001). CONCLUSIONS Down syndrome is independently associated with an increased risk for RSV hospitalization. Children with Down syndrome are older at time of RSV hospitalization and have more severe RSV illness than children without Down syndrome. This increased risk for hospitalization continues beyond 24 months.

Healthy Late-preterm infants born 33–36 + 6 weeks gestational age have higher risk for respiratory syncytial virus hospitalization

BACKGROUND Respiratory syncytial virus (RSV) is a leading cause of hospitalization for children <1year old and is more severe in premature infants. OBJECTIVE To assess whether late preterm (LPT) birth is an independent risk factor for RSV hospitalization and more severe RSV disease in children less than 24months old. METHODS We conducted a retrospective cohort study of children enrolled in the military health system. LPT birth was defined as 33+0 through 36+6weeks gestation. Patients who received palivizumab or had known risk factors for RSV were excluded. Adjusted hazard ratios (HR) for LPT birth were calculated using a Cox proportional hazard model, while controlling for sex and RSV season. Severity of illness was assessed by comparing the need for respiratory support, length of stay, and age at RSV hospitalization between LPT and term children. RESULTS A total of 599,535 children for 1,216,382 person-years were studied, of which 7597 children were admitted for RSV infection. LPT infants accounted for 643 (8.5%) of these RSV hospitalizations. The incidence density for RSV hospitalization of LPT infants was higher than term children (12.1 vs 7.8 per 1000 person-years). LPT infants had an increased adjusted risk for RSV hospitalization; specifically, those born 33+0 through 34+6weeks (HR 2.45; 95% confidence interval (CI) 1.96-3.07), and 35+0 through 36+6weeks (HR, 1.92; 95% CI, 1.66-2.22). LPT infants had longer hospital stays and required more respiratory support than term children. CONCLUSIONS LPT birth is an independent risk factor for severe RSV disease and need for hospitalization.

The effect of rotavirus immunization on rotavirus gastroenteritis hospitalization rates in military dependents

We conducted a retrospective review of all U.S. military dependents less than 5 years old hospitalized with rotavirus-associated gastroenteritis from July 2003 to June 2009. The two post-vaccine seasons showed a significant reduction of 62.4% (95% CI, 58.6-65.8, P<0.001) in rotavirus gastroenteritis hospitalization rate compared to the three pre-vaccine seasons. Infants less than 12 months old showed the greatest reduction in incidence at 75.3%. A substantial decrease was also seen in unvaccinated children as well. Vaccine efficacy against hospitalization was 86.0% (95% CI, 77.7-91.3) after just a single dose. The overwhelming majority of children hospitalized for rotavirus since the introduction of the vaccine (ranging from 91.8 to 100% per season) had not received any of the rotavirus vaccine series.

Hypertension Prevalence, Cardiac Complications, and Antihypertensive Medication Use in Children

OBJECTIVE To determine the prevalence of hypertension diagnosis in children of US military members and quantify echocardiography evaluations, cardiac complications, and antihypertensive prescriptions in the post-2004 guideline era. STUDY DESIGN Using billing data from military health insurance (TRICARE) enrollees, hypertension cases were defined as 2 or more visits with a primary or unspecified hypertension diagnosis during any calendar year or 1 such visit if with a cardiologist or nephrologist. RESULTS During 2006-2011, the database contained an average 1.3 million subjects aged 2-18 years per year. A total of 16 322 met the definition of hypertension (2.6/1000). The incidence of hypertension increased by 17% between 2006 and 2011 (from 2.3/1000 to 2.7/1000; P < .001). Hypertension was more common in adolescents aged 12-18 years than in younger children (5.4/1000 vs 0.9/1000). Among patients with hypertension, 5585 (34%) underwent echocardiography. The frequency of annual echocardiograms increased from 22.7% to 27.7% (P < .001). In patients with echocardiography, 8.0% had left ventricular hypertrophy or dysfunction. Among the patients with hypertension, 6353 (38.9%) received an antihypertensive medication. CONCLUSION The prevalence of hypertension in children has increased. Compliance with national guidelines is poor. Of pediatric patients with hypertension who receive an echocardiogram, 1 in 12 had identified cardiac complications, supporting the current recommendations for echocardiography in children with hypertension. Less than one-half of children with hypertension are treated with medication.

Attention Deficit Hyperactivity Disorder and Medication Use by Children During Parental Military Deployments

OBJECTIVE Parental deployment is associated with childrens increased mental health needs. Attention Deficit Hyperactivity Disorder (ADHD) is the most common pediatric mental health diagnosis. We hypothesize children with ADHD will have increased mental health and medication needs during parental deployment. METHODS Retrospective cohort study of children with ADHD aged 4-8 years in the Military Health System. RESULTS Of 413,665 children aged 4-8 years, 34,205 (8.3%) had ADHD and 19,123 (55.9%) of these were prescribed ADHD medications. During parental deployments, children with ADHD had a 13% increased rate of mental and behavioral health care visits (IRR 1.13 [95% CI 1.12-1.14; p < 0.00001]) and a decreased rate of medication changes (IRR 0.94 [95% CI 0.91-0.96; p < 0.00001]) compared to when parents were at home. Medication changes related to deployment varied by age; school-aged children had decreased medication events (IRR 0.88 [95% CI 0.86-0.91; p < 0.00001]) and preschool-aged children had increased medication events (IRR 1.05 [95% CI 1.02-1.10; p = .006]) during parental deployment. CONCLUSIONS During parental deployment, children with ADHD aged 4-8 years have increased mental health visits and decreased ADHD medication changes. Younger children have increased medication changes, whereas older children have decreased changes during a parents deployment.

Early Diagnosis of Extrahepatic Biliary Atresia in an Open-Access Medical System

Introduction Biliary atresia (BA) is the most common cause of cholestatic jaundice in infancy. Early diagnosis and surgical management, ideally before 60 days of age, result in improved outcomes. We aimed to determine the age at diagnosis of BA in the Military Health System (MHS) and to compare the age at diagnosis by access to care models. We hypothesized that children with BA receiving primary care in military facilities have an earlier age at diagnosis due to decreased economic and access barriers. Methods Data for all Tricare enrollees born in fiscal years 2004–2008 with a diagnosis of BA were extracted from MHS databases. Non-parametric tests, Kaplan-Meier curves and log rank tests compared differences in age at diagnosis by type of primary care facility, gender, prematurity and presence of additional anomalies. Results 64 subjects were identified within the five year period. Median age at diagnosis was 40 days [range 1–189], with 67% diagnosed by 60 days and 80% by 90 days. 45 (70%) received civilian primary care within the MHS. There was no difference in the median age at diagnosis between subjects in the MHS with civilian primary care vs. military primary care (37 days [1–188] vs. 46 days [1–189]; p = 0.58). Conclusion In the MHS, two-thirds of infants with biliary atresia are diagnosed prior to 60 days of life. Gender, prematurity or presence of additional anomalies do not affect the timing of diagnosis. Civilian and military primary care models within the MHS make timely diagnoses of biliary atresia at equivalent rates.