Peter F. Belamarich

The Use of Statins in Pediatrics: Knowledge Base, Limitations, and Future Directions

The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, effectively reduce coronary morbidity and mortality in high-risk adults. They are also some of the most widely prescribed medications in the United States. Their use in pediatrics, however, remains circumscribed. In this article we review the cholesterol hypothesis and focus on the knowledge base of the use of statins in adults and children. We pay particular attention to the known effects of statins in primary and secondary prevention of cardiovascular events. The toxicities of statins and their limitations in pediatrics are then considered. The use of statins in conjunction with noninvasive modalities of assessing atherosclerotic burden are also reviewed. Finally, we suggest methods to advance the use of statins in childhood that introduce their potential benefits to those individuals at highest risk for future events.

Obesity and symptomatic cholelithiasis in childhood: epidemiologic and case-control evidence for a strong relation.

Objectives: The aims of this study were to correlate the temporal trends in obesity prevalence with hospitalization rates for symptomatic cholelithiasis and to estimate the strength of the association between obesity and symptomatic cholelithiasis in patients hospitalized at an urban childrens hospital in New York serving a multiethnic population. Methods: Using obesity prevalence data from the National Health and Nutrition Examination Survey and the rates of hospitalization for cholelithiasis derived from the Kids’ Inpatient Database for 1997–2007, we estimated a correlation and a linear regression. We conducted a retrospective, case-control study in which each case ages 4 to 20 years with symptomatic cholelithiasis was individually matched to a control admitted with appendicitis based on age, sex, ethnicity, and race. Results: The prevalence of obesity and the cholelithiasis hospitalization rate increased over time (R = 0.87, P = 0.0025). For every 1% increase in the obesity rate among children, the rate of hospitalization for gallstones increased by 0.65/100,000 children (R2 = 0.75, P = 0.0025, 95% confidence interval [CI] 0.32–0.99). The odds ratio for obesity in cases versus controls was 5.78 (n = 518, P < 0.0001, 95% CI 3.50–9.53). We found a significant dose-response effect, which showed that for every 1 z score increase in body mass index, the risk of cholelithiasis was increased by 79% (P < 0.0001, 95% CI 1.5–2.13). Conclusions: The national trend in the prevalence of obesity from 1997 to 2009 was significantly correlated with increasing rates of hospitalization for pediatric cholelithiasis. Our case-control study suggests that obesity is a significant risk factor for hospital admission because of cholelithiasis.

Upstairs downstairs : Vertical integration of a pediatric service

Background. The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources. Objective. To describe the development of a new vertically integrated pediatric service at an inner-city municipal hospital and to test whether its adoption was associated with the use of fewer inpatient resources. Design. A descriptive analysis of the rationale, goals, implementation strategies, and structure of the vertically integrated pediatric service combined with a before-and-after comparison of in-hospital resource consumption. Methods. A before-and-after comparison was conducted for two periods: the period before vertical integration, from January 1989 to December 1991, and the period after the adoption of vertical integration, from July 1992 to December 1994. Four measures of inpatient resource use were compared after adjustment for case mix index: mean certified length of stay per case, mean number of radiologic tests per case, mean number of ancillary tests per case, and mean number of laboratory tests per case. Difference-in-differences-in-differences estimators were used to control for institution-wide trends throughout the time period and regional trends in inpatient pediatric practice occurring across institutions. Results. In 1992, the Department of Pediatrics at the Albert Einstein College of Medicine reorganized the pediatric service at Jacobi Medical Center, one of its principal municipal hospital affiliates, into a vertically integrated pediatric service that combines ambulatory and inpatient activities into four interdependent practice teams composed of attending pediatricians, allied health professionals, house officers, and social workers. The new vertically integrated service was designed to improve continuity of care for patients, provide a model of practice for professional trainees, conserve scarce resources, and create a clinical research infrastructure. The vertically integrated pediatric service augmented the role of attending pediatricians, extended the use of allied health professionals from the ambulatory to the inpatient sites, established interdisciplinary practice teams that unified the care of pediatric patients and their families, and used less inpatient resources. Controlling for trends within the study institution and trends in the practice of pediatrics across institutions throughout the time period, the vertical integration was associated with a decline in 0.6 days per case, the use of 0.62 fewer radiologic tests per case, 0.21 fewer ancillary tests per case, and 2.68 fewer laboratory tests per case. Conclusions. We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources.

A Critical Review of the Marketing Claims of Infant Formula Products in the United States

A highly competitive infant formula market has resulted in direct-to-consumer marketing intended to promote the sale of modified formulas that claim to ameliorate common infant feeding problems. The claims associated with these marketing campaigns are not evaluated with reference to clinical evidence by the Food and Drug Administration. We aimed to describe the language of claims made on formula labels and compare it with the evidence in systematic reviews. Of the 22 product labels we identified, 13 product labels included claims about colic and gastrointestinal symptoms. There is insufficient evidence to support the claims that removing or reducing lactose, using hydrolyzed or soy protein or adding pre-/probiotics to formula benefits infants with fussiness, gas, or colic yet claims like “soy for fussiness and gas” encourage parents who perceive their infants to be fussy to purchase modified formula. Increased regulation of infant formula claims is warranted.

A comparison of the effect of aprotinin and ε-aminocaproic acid on renal function in children undergoing cardiac surgery

OBJECTIVE To assess the incidence of renal injury among pediatric patients who received aprotinin while undergoing cardiac surgery compared with those who received ε-aminocaproic acid (EACA). DESIGN A retrospective observational study. SETTING A single academic center. PARTICIPANTS Pediatric cardiac patients who had cardiopulmonary bypass and received aprotinin or EACA. INTERVENTION Patients undergoing pediatric cardiac surgery received aprotinin from 2005 to 2007 and EACA from 2008 to 2009. MEASUREMENTS AND MAIN RESULTS The primary outcome was acute kidney injury (AKI) defined as serum Cr elevation at discharge more than 1.5 times the baseline value. Secondary outcomes included bleeding, blood transfusion, and the volume of chest tube drainage in the first 24 hours postoperatively. One hundred seventy-eight patients met inclusion criteria; 120 patients received aprotinin, and 58 patients received EACA. These 2 groups did not differ significantly in age, weight, or duration of cardiac bypass. Logistic regression analysis, adjusted for confounding variables (ie, baseline Cr, sex, age, CPB time, inotropic support and vasopressors), showed a higher odds of suffering AKI at discharge with the usage of aprotinin (odds ratio = 4.7; 95% confidence interval, 1.1-19.5; p = 0.03). The volume of the first 24 hours of chest tube drainage was not significantly different between groups, as well as packed red blood cells and cryoprecipitate units. However, fresh frozen plasma and platelets showed statistically significant differences with more transfusion in the EACA group. CONCLUSION In this retrospective study, the authors observed a higher odds of AKI for aprotinin usage compared with EACA, suggesting that the known concern for adults with adverse kidney effects with aprotinin is also appropriate for pediatric patients.

A Quality Improvement Intervention to Increase Access to Pediatric Subspecialty Practice

OBJECTIVE: To improve access to new pediatric endocrinology appointments in an urban academic hospital faculty-based practice. METHODS: Three strategies were implemented to increase the number of appointment slots: new patient appointments were protected from conversion to follow-up appointments; all physicians, including senior faculty, were scheduled to see 3 to 4 new patients per session; and sessions devoted exclusively to follow-up appointments were added based on demand. The main outcomes for this quality improvement activity were waiting times for new and follow-up appointments, monthly visit volume, the per-provider visit volume, differences in the proportion of new visits, and clinic arrival rates pre- and postintervention. RESULTS: Thirteen months after the intervention, average wait for a new patient appointment decreased from 11.4 to 1.7 weeks (P < .001) and follow-up appointment wait time decreased from 8.2 to 2.9 weeks (P < .001). Mean monthly total visit volume increased from 284 to 366 patient visits (P < .01) and mean monthly visit volume per provider increased from 36.8 to 41.0 patients (P = .08). New patients were 27% of the visit volume and 35% after the intervention. CONCLUSIONS: Access to our pediatric specialty care clinic was improved without increasing the number of providers by improved scheduling.

Counterpoint: The evidence does not support universal screening and treatment in children

Few pediatric guidelines have generated the amount or intensity of controversy that the pediatric lipid guidelines have. In the following article, I will synthesize the arguments against universal lipid screening and treatment in childhood. Direct evidence that relates the presence of cardiovascular risk factors in childhood to cardiovascular disease outcomes in adulthood is unavailable, and as a consequence, the guidelines were formulated based on a chain of indirect evidence. The debate centers on the strength of the indirect evidence that links risk factors present in childhood to adult disease outcomes. The arguments against universal lipid screening and treatment of children include (1) a history of unanticipated harms caused by screening tests or treatments that were enacted based on indirect evidence, (2) the poor test performance characteristics of lipid profiles in childhood when used as a screening test, (3) problems with the effectiveness of lipid testing done in the office setting, and (4) concerns regarding the safety of statins when used in children.

Severe Hypoproteinemia and Edema in Association with Varicella Infection

*Division of Ambulatory Pediatric Care, Bronx Municipal Hospital Center, Pelham Parkway & Eastchester road, Bronx, New York 10461. **Pediatric Service of St. Luke’s-Roosevelt Hospital Center and the Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, The Babies Hospital, College of Physicians & Surgeons of Columbia University, New York, New York. Complications of acute varicella are many, and most often involve the skin, central nervous system and lungs. 1 Gastrointestinal complications are very rare. We report two infants with classic varicella exanthemata who con-

Screening for Poverty and Poverty-Related Social Determinants of Health

1. Rachel Stein Berman, MD, MPH*,† 2. Milani R. Patel, MD*,†,‡ 3. Peter F. Belamarich, MD*,† 4. Rachel S. Gross, MD, MS*,† 1. *Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 2. †Division of Academic General Pediatrics, Department of Pediatrics, Children’s Hospital at Montefiore, Bronx, NY 3. ‡Department of Family and Social Medicine, Montefiore Medical Center, Bronx, NY * Abbreviations: AAP: : American Academy of Pediatrics APA: : Academic Pediatric Association EITC: : Earned Income Tax Credit SNAP: : Supplemental Nutrition Assistance Program WIC: : Special Supplemental Nutrition Program for Women, Infants, and Children Pediatricians should screen for and address poverty and poverty-related social determinants of health because they have clear negative effects on children’s health and well-being. This task requires coordination of services beyond the medical home. Pediatricians may also advocate at local and federal levels to further serve patients living in poverty. After completing this article, readers should be able to: 1. Define social determinants of health and understand their effect on children’s health. 2. Access tools to screen for poverty and poverty-related social determinants of health. 3. Describe evidence-based interventions that address poverty and poverty-related social determinants of health. 4. Outline government policies and programs for impoverished families for which pediatricians may advocate. A 13-year-old girl has an appointment with her pediatrician for follow-up of her asthma. She had gone to the emergency department 3 times in the 10 days before the appointment for cough and difficulty breathing. Each time, she was given nebulizer treatments, improved, and was discharged home. She was also treated with oral corticosteroids and azithromycin. Her symptoms have persisted up to the day of the appointment. Her mother reports complete compliance with her inhaled medications, oral corticosteroids, and antibiotic. On further questioning, her mother reports that she, the patient, and the patient’s younger brother are living in a shelter. …

Tetanus After Vaccine Refusal and an Opportunity for the Pediatric Infectious Diseases Specialist

In the era of increasing vaccine refusal, the reemergence of “almost forgotten diseases” presents a challenge to timely diagnosis and therapy. A child who was completely unvaccinated and suffered tetanus was recently reported. Here, we describe in more detail his clinical presentation and course as we admitted and followed (MD) the child. The issue of vaccine refusal in the United States is briefly reviewed, and a suggestion for a more active role of the pediatric infectious diseases specialist is made.