Patricia Flanagan

Effects of intraventricular hemorrhage and socioeconomic status on perceptual, cognitive, and neurologic status of low birth weight infants at 5 years of age

A prospective longitudinal study assessed the effects of intraventricular hemorrhage (IVH) and socioeconomic status on the perceptual, cognitive, and neurologic status of preterm infants at 5 years of age. The preterm group consisted of infants with no IVH, grade I to II IVH, and grade III to IV IVH; a control group of normal term infants was also studied. Outcome was evaluated at 3, 4, and 5 years of age. Twenty-four percent of infants with grade III to IV IVH had abnormal neurologic diagnoses at 5 years of age. Correlations of predictor variables including IVH status, latency of visual evoked response, days of hospitalization, and socioeconomic status with 5-year neurologic outcome indicated that IVH status and visual evoked response at 1, 2, and 3 years continued to have an effect on neurologic outcome, but socioeconomic status and days of hospitalization did not; socioeconomic status did have a significant effect on the McCarthy cognitive scores but not on the perceptual scores at 5 years. Multiple regression analyses revealed that duration of hospitalization (reflecting neonatal morbidity), visual evoked response, and socioeconomic status all have independent effects on the cognitive index, whereas only duration of hospitalization has an independent effect on the perceptual index. These data support the concept that a complex interaction of biologic and environmental risk factors determines the degree of recovery from IVH by high-risk preterm infants.

Low Vitamin D Status Among Obese Adolescents: Prevalence and Response to Treatment

PURPOSE To explore the prevalence of low vitamin D status among obese adolescents and to examine the effect of current management of low vitamin D status in these patients. METHODS A retrospective chart review of obese adolescents who had been screened for vitamin D status by serum total 25-hydroxyvitamin D (25(OH)D) level. Vitamin D deficiency was defined as 25(OH)D level of <20 ng/mL, vitamin D insufficiency as 25(OH)D level of 20-30 ng/mL, and vitamin D sufficiency as 25(OH)D level of >30 ng/mL. Adolescents with vitamin D deficiency were treated with 50,000 IU of vitamin D once a week for 6-8 weeks, whereas adolescents with vitamin D insufficiency were treated with 800 IU of vitamin D daily for 3 months. Repeat 25(OH)D was obtained after treatment. RESULTS The prevalence rate of low vitamin D status among 68 obese adolescents (53% females, 47% males, age: 17 ± 1 years, body mass index: 38 ± 1 kg/m(2), Hispanic: 45%, African American: 40%, Caucasian: 15%) was 100% in females and 91% in males. Mean (±SE) 25(OH)D level was significantly higher in summer (20 ± 8 ng/mL) than in spring (14 ± 4 ng/mL, p < .02), and significantly lower in winter (15 ± 7 ng/mL) than in fall (25 ± 15 ng/mL, p < .05). Although there was a significant (p < .00001) increase in mean 25(OH)D after the initial course of treatment with vitamin D, 25(OH)D levels normalized in only 28% of the participants. Repeat courses with the same dosage in the other 72% did not significantly change their low vitamin D status. CONCLUSIONS Increased surveillance and possibly higher vitamin D doses are warranted for obese adolescents whose total 25(OH)D levels do not normalize after the initial course of treatment.

Redesigning Health Care Practices to Address Childhood Poverty

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Serotesting versus presumptive varicella vaccination of adolescents with a negative or uncertain history of chickenpox

OBJECTIVE To review the current practice of adolescent health care providers when an adolescent reports a negative or uncertain history of chickenpox in order to provide information for future practice. METHODS Retrospective chart review of a sample of patients seen in a hospital-based adolescent primary care clinic between 1996 and 1999. RESULTS Among adolescents who reported a positive history of chickenpox (190 patients, aged 15 +/- 1 years), varicella occurred before age 5 years in 30%, between 5 and 10 years in 56%, and at older than age 10 years in 14% of the patients. When adolescents reported a negative or uncertain history of varicella (55 patients, aged 15 +/- 1 years), serotesting was ordered for the majority (73%) of cases, while only 16% were presumptively vaccinated with varicella vaccine. In six patients no intervention was noted in the charts, and these patients were contacted. In 80% of the patients who were serotested, varicella IgG titers of > or = 1:32 indicated a previous unnoticed infection and lifelong immunity to varicella. In only 20% of the patients sera were negative for varicella IgG titer, requiring varicella vaccination. There was no statistical difference between the number of siblings of patients with a positive serologic test (3 +/- 1) and the number of siblings of seronegative patients (2 +/- 1, p = 0.41). Seven of the eight seronegative patients consented to varicella vaccination and were vaccinated within 10 months of serotesting. CONCLUSIONS These data support the practice of serotesting for a previously unnoticed varicella infection rather than presumptive vaccination in the adolescent age group. A follow-up vaccination of seronegative adolescents should be scheduled as close to serotesting as possible.

Bone accretion in adolescents using the combined estrogen and progestin transdermal contraceptive method Ortho Evra: a pilot study.

OBJECTIVE To date, there are no data regarding the effect of the transdermal combined estrogen and progestin contraceptive Ortho Evra on bone mineral content (BMC) and bone mineral density (BMD). We examined the effects of transdermally delivered ethinyl estradiol and norelgestromin on whole body (WB) BMC and BMD of the hip and lumbar spine (LS) of adolescent girls. METHODS In a matched case-control study, girls (n = 5) who applied Ortho Evra for days 1-21 followed by days 22-28 free of medication for 13 cycles (about 12 months) were compared with 5 age- and ethnicity-matched control girls. Evaluations of calcium intake; bone-protective physical activity; bone densitometry (DXA, QDR 4500A, Hologic); bone formation markers serum osteocalcin (OC) and bone-specific alkaline phosphatase (BAP); bone resorption marker urinary N-telopeptide (uNTX); insulin growth factor-1 (IGF-1); and sex hormone binding globulin (SHBG) were carried out at initiation, 6 months, and 12 months. Changes from baseline were compared using mixed models, adjusting for follow-up comparisons using the Holm Test (sequential Bonferroni). RESULTS There were no significant differences (SD) between groups at baseline in age, gynecologic age, WBBMC, hip BMD, and LSBMD. Girls on Ortho Evra did not change significantly in WBBMC (12-month mean increase 0.2% +/- 0.8%), whereas controls did (3.9% +/- 1.8%, P < or = .001, adjusted P = .002), with SD between the 2 groups (P = .007, adjusted P = .036). Adolescents on Ortho Evra did not change significantly in hip BMD (12-month mean increase 0.5% +/- 0.6%), whereas controls did (2.7% +/- 0.6%, P < or = .001, adjusted P = .004), with SD between the 2 groups (P = .024) prior to adjustment for multiple comparisons, but no SD after adjustment (P = .096). Similarly, although the increase in LSBMD within the control group after 12 months (mean increase 2.8% +/- 1.0%) was statistically significant (P = .009, adjusted P = .044), the change within the treatment group (12-month mean increase 0.8% +/- 0.8%) was not. However, percent LSBMD changes after 12 months did not significantly differ between the 2 groups before or after adjustment for multiple comparisons. Calcium intake and bone-protective physical activity did not significantly predict BMC and BMD changes of study participants. There was a significantly greater increase in SHBG levels in the treatment group after 6 months (P = .003, adjusted P = .013) and 12 months (P < or = .001, adjusted P < or = .001) than in controls. Changes in levels of OC, BAP, uNTX, and IGF-1 were not significantly different between the 2 groups. CONCLUSIONS Ortho Evra use attenuates bone mass acquisition in young women who are still undergoing skeletal maturation. This attenuation may be attributed in part to increased SHBG levels, which reduce the concentrations of free estradiol and free testosterone that are available to interact with receptors on the bone. Clinical implications remain to be determined in studies with a larger number of adolescents.

Isolated Low HDL Cholesterol Emerges as the Most Common Lipid Abnormality Among Obese Adolescents

A 12-hour fasting lipid profile was obtained from 88 otherwise healthy obese (BMI ≥ 95%) adolescents (age 16 ± 1 years, BMI 36 ± 1 kg/m2, 55 males, 33 females, 57% Hispanic, 23% African American, 19% Caucasian, 1% Asian American). About 56% of the obese adolescents exhibited lipid abnormalities based on cutoff points established by American Heart Association (AHA) guidelines, and about 57% exhibited lipid abnormalities based on percentile values established by the Lipid Research Clinic Pediatric Prevalence Study. Isolated low high-density lipoprotein—cholesterol (HDL-C) was the most common abnormality (43% based on AHA, 36% based on the Lipid Research Clinic Pediatric Prevalence Study) among the obese adolescents with lipid disorders. While there was no significant statistical difference (SSD) between genders in the levels of total cholesterol and low-density lipoprotein—cholesterol (LDL-C), triglyceride (TG) levels were significantly higher (P = .003) in males (120 ± 11 mg/dL) than in females (81 ± 7 mg/dL), and levels of HDL-C were significantly higher (P = .006) in females (42 ± 2 mg/dL) than in males (35 ± 1 mg/dL). There was no SSD between races in total cholesterol and LDL-C levels. TG levels were significantly lower in African-American participants (81 ± 9 mg/ dL) compared with levels in Caucasian participants (117 ± 15 mg/dL, P ≤ .05) and with levels in Hispanic participants (112 ± 11 mg/dL, P = .03). HDL-C levels were significantly higher in African-American participants (43 ± 3 mg/dL) compared with levels in Hispanic participants (36 ± 1 mg/dL, P = .03), but there was no SSD when compared with HDL-C levels in Caucasian participants (37 ± 2 mg/dL).

Pseudocyesis in an adolescent using the long-acting contraceptive Depo-Provera.

A case report documents a Hispanic adolescent, 17 years of age, with pseudocyesis, who became amenorrheic using Depo-Provera to prevent a second pregnancy. Pseudocyesis includes classic symptoms of pregnancy such as nausea, breast enlargement and pigmentation, abdominal distention, and amenorrhea in nonpregnant women. It demonstrates the to control ones physical aspect at the level of hypothalamus. The involvement that contributed to her pseudocyesis--in this case, of her mother and boyfriend -- was not unusual. The abrupt resolution was brought on by normal menstrual period that began after she voluntarily missed her Depo-Provera injection. However, her ambivalence about a pregnancy became clear after she and her family received counseling. While the agenda had been to help her prevent a pregnancy, hers had not been as clear and uncomplicated. Her subsequent conception was a very positive one for her and her family, which helped to resolve the situation.

Supplementation with vitamin C and / or vitamin B6 in the prevention of Depo-Provera side effects in adolescents.

BACKGROUND/OBJECTIVES Depo-Provera-induced menstrual irregularity is believed to be secondary to relative estrogen deficiency. Weight gain associated with this contraceptive method is believed to be due to Depo-Proveras steroid-like appetite stimulation effect and to an altered tryptophan metabolism. We examined whether vitamin C, an important factor in uterine estrogen binding, and vitamin B(6), a glucocorticoid antagonist and an important coenzyme in the tryptophan-serotonin pathway, might alleviate menstrual irregularities and weight gain associated with Depo-Provera. METHODS Fifty-five adolescent girls (age 16 +/- 1 yr, gyn age 4 +/- 1 yr, body mass index 25.2 +/- 0.9) who decided to initiate Depo-Provera (150 mg intramuscularly every 3 months) were randomly assigned to one of four groups (group 1: vitamin B(6) 50 mg plus placebo pill/day; group 2: vitamin C 500 mg plus placebo pill/day; group 3: vitamin B(6) 50 mg plus vitamin C 500 mg/day; group 4 (control): 2 placebo pills/day) for 6 months. Participants were assessed by their care providers every 3 months. SETTING Two urban hospital-based adolescent clinics. RESULTS Number of days of bleeding during the first interval (first 3 months) as well as during the second interval (months 4-6) among groups 1, 2, and 3 did not differ statistically from days of bleeding in control group. There were no significant body mass index (BMI) changes among groups 1-3 (-0.15 +/- 0.18, 0.34 +/- 0.56, 0.01 +/- 0.31) compared with control (-0.38 +/- 0.38) during the first interval as well as during the second interval (0.68 +/- 0.37, -0.39 +/- 0.21, 0.45 +/- 0.32, compared with 0.28 +/- 0.43). When data from all 55 participants were collapsed, there was no significant change in BMI during the first 6 months of Depo-Provera use. About 48% at 3 months and 44% at 6 months were very or somewhat concerned about menstrual irregularity; 41% at 3 months and 18% at 6 months were very or somewhat concerned about weight changes. More than half (57%) at 3 months and 74% at 6 months reported less tampon/pad use, and 77% at 3 months and 78% at 6 months reported decreased menstrual cramps. Overall, 59% at 3 months and 70% at 6 months were very satisfied with Depo-Provera; 97% at 3 months and 96% at 6 months said that they would recommend Depo-Provera to a friend or a relative. CONCLUSIONS This study does not support a role for vitamin C in the prevention of Depo-Provera-induced menstrual irregularities or for vitamin B(6) in the prevention of weight changes associated with Depo-Provera. The unchanged BMI during the first 6 months of Depo-Provera use in the present study suggests that raising awareness and close follow-up may prevent weight gain among adolescent girls using this contraceptive method.

Renal bleeding in early pregnancy associated with an undiagnosed hemoglobinopathy

Abstract A 16-year-old black female presented with painless genitourinary tract bleeding of 3 days duration. She suspected pregnancy and examination revealed a 10-week-old intrauterine gestation. Hemoglobin sickle cell disease was diagnosed by hemoglobin electrophoresis. The patients renal anatomy was normal and no obstruction was seen on ultrasound. She was admitted to the hospital for rest, hydration, and monitoring. Renal bleeding stopped spontaneously after 4 days of hospitalization. Her renal bleeding was probably triggered by the increased metabolic and hemodynamic demands of early pregnancy.

Formative research to underpin a text messaging home safety intervention for young mothers

Objective: Unintentional injury is the leading cause of death for infants and young children in the USA, and the children of young mothers are at an even higher risk. Mobile health (mHealth) interventions have been successful in promoting behaviour change for many health conditions. This study assessed interest in mSafety, a text and video messaging mHealth intervention targeting injury prevention knowledge, behaviour and self-efficacy in young mothers. Design: Interviews with young mothers were conducted using a semi-structured interview guide. Setting: Interviews took place at a health clinic for teenage mothers and their children and at a local public charter high school which serves pregnant teenagers and young mothers. Method: A trained research assistant conducted semi-structured interviews with 20 young mothers (ages 15–20). Participants were asked both closed and open-ended questions to elicit opinions about their willingness to utilise mSafety. Results: The results of the interviews were positive. Participants were most interested in learning about the prevention of falls and poisonings, as well as safe sleep. Many emphasised that the language of the messages should be simple and that videos could be included to demonstrate methods of injury prevention. Most interviewees were willing to participate in a ‘virtual home safety visit’ in which participants text home photos to an expert to evaluate home safety practices. Conclusion: The concept of an mHealth intervention that would provide young mothers with the tools to prevent injuries among their children received positive feedback.