Michael J. Steiner

Impaired Flow-Mediated Vasodilation, Carotid Artery Intima-Media Thickening, and Elevated Endothelial Plasma Markers in Obese Children: The Impact of Cardiovascular Risk Factors

OBJECTIVES. Childhood obesity contributes to the development of adult obesity and subsequent cardiovascular disease. The present study aimed to assess vascular status (flow-mediated vasodilation [FMD], intima-media thickness [IMT]) and to analyze plasma surrogate endothelial markers (von Willebrand factor [vWf], E-selectin, and thrombomodulin) in obese children as compared with controls. Associations between early morphologic and functional vascular changes, surrogate soluble markers of early atherosclerosis, and the cardiovascular risk profile were determined. METHODS. We examined 32 obese children versus 20 control subjects. All of the children underwent identical screening, comprehensive risk factor assessment, and measurements of E-selectin, vWf, thrombomodulin, FMD, and IMT. RESULTS. Compared with controls, obese children demonstrated significantly impaired FMD and increased IMT. Concentrations of soluble E-selectin and thrombomodulin were significantly elevated in obese children, whereas vWf showed no significant differences between obese children and controls. FMD, IMT, E-selectin, and thrombomodulin were significantly associated with various risk factors, including the extent of obesity, arterial hypertension, fibrinogen, C-reactive protein, and low physical fitness. CONCLUSIONS. The present study documented increased IMT, impaired endothelial function, and elevated plasma markers of endothelial activation and injury in obese children. Morbid obesity, arterial hypertension, subclinical inflammation, and low physical fitness formed a risk profile associated with the risk of early atherosclerosis in these children. Sonographic assessment of vascular status and the estimation of soluble endothelial plasma markers, combined with comprehensive risk factor screening, may form a rationale to identify high-risk children susceptible to early atherosclerotic disease and to monitor vascular changes during follow-up studies and therapeutic measures.

Multiple Markers of Inflammation and Weight Status: Cross-sectional Analyses Throughout Childhood

OBJECTIVE: Inflammatory markers such as C-reactive protein (CRP) are related to obesity in adults, but the association is less clear in children. Our objective was to examine relationships between multiple markers of inflammation and childrens weight status; we hypothesized that the prevalence of inflammatory markers would increase as weight status increased. METHODS: We conducted a cross-sectional analysis of children in the United States aged 1 to 17 years in the National Health and Nutrition Examination Survey, 1999–2006. Children were categorized using weight-for-length when age <2 years and BMI for ≥2 years, as very obese (≥99th percentile), obese (<99th and ≥95th percentile), overweight (<95th and ≥85th percentile), and healthy weight (>5th to ≤85th percentile) according to expert consensus. Our main outcome measures were high-sensitivity CRP and absolute neutrophil count, in addition to a novel third measure: ferritin controlled for iron status using a ferritin/transferrin ratio. We used Cox proportional hazards models to examine risk of abnormal values of inflammatory markers according to weight. RESULTS: Increased risk of a CRP level of >1.0 mg/L was evident among very obese children from ages 3 to 5 years (hazard ratio [HR]: 2.29; P < .01) through 15 to 17 years (HR: 4.73; P < .01). Increased risk of abnormal neutrophil count among very obese children began at 6 to 8 years (HR: 2.00; P = .049), and increased prevalence of abnormal ferritin/transferrin ratio began at 9 to 11 years (HR: 7.06; P < .001). CONCLUSIONS: Multiple inflammatory markers are strongly and positively associated with increasing weight status in children, and this relationship starts as young as age 3. Elevated inflammatory markers in very young obese children are particularly concerning, because inflammation may cause long-term, cumulative vascular damage. This deserves additional research via longitudinal design.

Use of Antiemetic Agents in Acute Gastroenteritis : A Systematic Review and Meta-analysis

OBJECTIVE To perform a systematic review and meta-analysis to determine whether taking antiemetic drugs reduces vomiting and decreases the need for further intervention in children with gastroenteritis without causing significant adverse effects. DATA SOURCES Computerized databases, reference lists, and expert recommendations. STUDY SELECTION Prospective controlled trials evaluating medication use in children with vomiting from gastroenteritis. INTERVENTION Antiemetic drug therapy. MAIN OUTCOME MEASURES Emesis cessation, use of intravenous fluid for rehydration, hospital admission, return to care, and medication adverse effects. RESULTS The 11 articles that met the inclusion criteria evaluated various antiemetic agents: ondansetron (n = 6), domperidone (n = 2), trimethobenzamide (n = 2), pyrilamine-pentobarbital (n = 2), metoclopramide (n = 2), dexamethasone (n = 1), and promethazine (n = 1). Meta-analysis of 6 randomized, double-masked, placebo-controlled trials of ondansetron demonstrated decreased risk of further vomiting (5 studies; relative risk [RR], 0.45; 95% confidence interval [CI], 0.33-0.62; number needed to treat [NNT] = 5), reduced need for intravenous fluid (4 studies; RR, 0.41; 95% CI, 0.28-0.62; NNT = 5), and decreased risk of immediate hospital admission (5 studies; RR, 0.52; 95% CI, 0.27-0.95; NNT = 14). Diarrheal episodes increased in ondansetron-treated patients in 3 studies. Ondansetron use did not significantly affect return to care (5 studies; RR, 1.34; 95% CI, 0.77-2.35). CONCLUSIONS Ondansetron therapy decreases the risk of persistent vomiting, the use of intravenous fluid, and hospital admissions in children with vomiting due to gastroenteritis. Future treatment guidelines should incorporate ondansetron therapy for select children with gastroenteritis.

Fasting Might Not Be Necessary Before Lipid Screening: A Nationally Representative Cross-sectional Study

BACKGROUND: There are barriers to fasting lipid screening for at-risk children. Results of studies in adults have suggested that lipid testing might be reliably performed without fasting. OBJECTIVE: To examine population-level differences in pediatric lipid values based on length of fast before testing. METHODS: We used the National Health and Nutrition Examination Survey (1999–2008) to examine total cholesterol (TC), HDL (high-density lipoprotein), LDL (low-density lipoprotein), and triglyceride cholesterol components on the basis of the period of fasting. Young children fasted for varying times before being tested, and children older than 12 years were asked to fast; however, adherence was variable. We used ordinary least-squares regression to test for differences in lipid values that were based on fasting times, controlling for weight status, age, race, ethnicity, and gender. RESULTS: TC, HDL, LDL, or triglyceride values were available for 12 744 children. Forty-eight percent of the TC and HDL samples and 80% of the LDL and triglyceride samples were collected from children who had fasted ≥8 hours. Fasting had a small positive effect for TC, HDL, and LDL, resulting in a mean value for the sample that was 2 to 5 mg/dL higher with a 12-hour fast compared with a no-fast sample. Fasting time had a negative effect on triglycerides (β = −0.859; P = .02), which resulted in values in the fasting group that were 7 mg/dL lower. DISCUSSION: Comparison of cholesterol screening results for a nonfasting group of children compared with results for a similar fasting group resulted in small differences that are likely not clinically important. Physicians might be able to decrease the burden of childhood cholesterol screening by not requiring prescreening fasting for these components.

Physical Activity and BMI in a Nationally Representative Sample of Children and Adolescents

Objective. To examine objectively measured physical activity levels by age, sex, and BMI for children and adolescents in a nationally representative sample. Methods. Data were from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Surveys, which included physical activity assessment by accelerometer and measured height and weight. The authors calculated minutes of moderate and vigorous activity. Results. Boys were more active than girls, and activity levels were lower at older ages. Younger children met daily recommendations for physical activity, whereas older children, especially girls, did not. Typically, weight status was inversely related to activity, though differences were less apparent among boys. Underweight children were not always more active than heavier peers.

Oral Ondansetron Administration in Emergency Departments to Children with Gastroenteritis: An Economic Analysis

Stephen Freedman and colleagues performed a cost analysis of the routine administration of ondansetron in both the United States and Canada and show that its routine administration to eligible children in such settings could provide substantial benefit.

Surgical Treatments for Otitis Media With Effusion: A Systematic Review

BACKGROUND AND OBJECTIVE: The near universality of otitis media with effusion (OME) in children makes a comparative review of treatment modalities important. This studys objective was to compare the effectiveness of surgical strategies currently used for managing OME. METHODS: We identified 3 recent systematic reviews and searched 4 major electronic databases. Eligible studies included randomized controlled trials, nonrandomized trials, and cohort studies that compared myringotomy, adenoidectomy, tympanostomy tubes (tubes), and watchful waiting. Using established criteria, pairs of reviewers independently selected, extracted data, rated risk of bias, and graded strength of evidence of relevant studies. We incorporated meta-analyses from the earlier reviews and synthesized additional evidence qualitatively. RESULTS: We identified 41 unique studies through the earlier reviews and our independent searches. In comparison with watchful waiting or myringotomy (or both), tubes decreased time with OME and improved hearing; no specific tube type was superior. Adenoidectomy alone, as an adjunct to myringotomy, or combined with tubes, reduced OME and improved hearing in comparison with either myringotomy or watchful waiting. Tubes and watchful waiting did not differ in language, cognitive, or academic outcomes. Otorrhea and tympanosclerosis were more common in ears with tubes. Adenoidectomy increased the risk of postsurgical hemorrhage. CONCLUSIONS: Tubes and adenoidectomy reduce time with OME and improve hearing in the short-term. Both treatments have associated harms. Large, well-controlled studies could help resolve the risk-benefit ratio by measuring acute otitis media recurrence, functional outcomes, quality of life, and long-term outcomes. Research is needed to support treatment decisions in subpopulations, particularly in patients with comorbidities.

Healthy for Now? A Cross-Sectional Study of the Comorbidities in Obese Preschool Children in the United States:

Objective. Examine health of preschoolers by BMI status. Methods. A cross-sectional analysis of children 3 to 5 years old in the 1999-2008 National Health and Nutrition Examination Survey was carried out. The measured age- and sex-specific BMI percentiles were used to categorize children as very obese, obese, overweight, or healthy weight. The authors used logistic regression to examine the effect of weight status on 17 available measures of current child health potentially related to obesity. Results. Except for very obese children, weight status had minimal effect on most measures of health for preschool-aged children (n = 2792). Parents of very obese children reported poorer general health and more activity limitations for their children. Additionally, very obese girls had more frequent/severe headaches, and overweight/obese boys had more asthma diagnoses. Conclusions. Only severe obesity appears consistently related to immediate health problems in preschool-aged children. Parental perception that very obese children have worse health and more activity limitations may lead to decreases in physical activity, which would perpetuate obesity.

Self-Reported Energy Intake by Age in Overweight and Healthy-Weight Children in NHANES, 2001–2008

OBJECTIVE: Variation in energy intake by weight status at different ages may explain inconsistencies in previous research on energy intake and obesity. Therefore, our objective was to determine the relationship between reported daily energy intake and categorized weight status across childhood. METHODS: We examined dietary reports of children ages 1 to 17 years by using the National Health and Nutrition Examination Survey, 2001–2008 (N = 12 648). Using measured height and weight, we categorized weight status based on weight-for-length percentile (age <2 years) or BMI percentile (ages 2–17 years) using current recommendations. Dietary intake was reported by using the repeatedly validated automated multiple pass method, a detailed 2-day 24-hour recall. We used ordinary least squares regression to examine the interactions of age and weight category on total energy intake, controlling for gender, race, ethnicity, and income. RESULTS: Weight status and age both have positive associations with self-reported energy intake. However, the interaction between weight and age demonstrates a negative effect throughout childhood, such that young obese/overweight children reported consuming significantly more calories and obese/overweight adolescents reported consuming fewer calories than their same-age healthy-weight peers. CONCLUSIONS: In a nationally representative cross-sectional sample, overweight and obese girls older than 7 years and boys older than 10 years reported consuming fewer daily calories than their healthy-weight peers. One explanation for this would be that increased energy intake in early childhood is related to the onset of obesity, but other mechanisms, such as differences in energy expenditure, may contribute more to maintaining obese/overweight status through adolescence.

The Incidence of Catheter-Associated Venous Thrombosis in Noncritically Ill Children

OBJECTIVE Previous studies estimated the incidence of catheter-associated venous thrombosis to be between 2% and 81%. Our goals were to define the incidence rate of catheter-related thrombosis in a hospitalized, noncritically ill, pediatric population and to determine modifiable factors that alter the risk of thrombosis. METHODS A retrospective cohort study was performed at the North Carolina Childrens Hospital from 2009 to 2012. Chart review was performed with extraction of patient characteristics and line-related variables. Presence of symptomatic catheter-associated venous thrombosis was the primary outcome. Bivariable analysis and multivariable logistic regression were used to explore associations between line-related variables and thrombosis. RESULTS A total of 1135 lines were placed in 815 patients for 118,023 catheter-days. Thirty-six were complicated by venous thrombosis (3.2%) yielding a rate of 0.3 events per 1000 catheter-days. In multivariable analysis, increasing age (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.03-1.13; P=.002), renal dialysis (OR 3.2, 95% CI 1.09-9.66; P=.035), and a diagnosis of inflammatory bowel disease or short bowel syndrome (OR 4.3, 95% CI 1.2-15.0; P=.02) were associated with increased risk of thrombosis. Modifiable risk factors, such as line site, size, and lumens, were not significantly associated with thrombosis. No thromboembolic events were observed. CONCLUSIONS We observed a lower incidence rate of catheter-associated venous thrombosis than in most previous reports. No modifiable characteristics altered the risk of thrombosis. Additional investigation of measures to prevent thrombosis is warranted in higher-risk populations, such as patients undergoing dialysis or patients with inflammatory bowel disease.