Faculty Bibliography

OBJECTIVE: To determine clinical characteristics, demographics and short-term outcomes of neonates diagnosed with fetomaternal haemorrhage (FMH). DESIGN: The authors analysed the Nationwide Inpatient Sample, 1993 to 2008. Singleton births diagnosed with FMH were identified by International Classification of Diseases (ICD-9) code 762.3. Descriptive, univariate and multivariable regression analyses were performed to determine the national annual incidence of FMH over time as well as demographics and clinical characteristics of neonates with FMH. RESULTS: FMH was identified in 12 116 singleton births. Newborns with FMH required high intensity of care: 26.3% received mechanical ventilation, 22.4% received blood product transfusion and 27.8% underwent central line placement. Preterm birth (OR 3.7), placental abruption (OR 9.8) and umbilical cord anomaly (OR 11.4) were risk factors for FMH. Higher patient income was associated with increased likelihood of FMH diagnosis (OR 1.2), and Whites were more likely to be diagnosed than ethnic minorities (OR 1.9). There was reduced frequency of diagnosis in the Southern USA (OR 0.8 vs the Northeastern USA). CONCLUSIONS: Diagnosis of FMH is associated with significant morbidity as well as regional, socioeconomic and racial disparity. Further study is needed to distinguish between diagnostic coding bias and true epidemiology of the disease. This is the first report of socioeconomic and racial/ethnic disparities in FMH, which may represent disparities in detection that require national attention.

Congenital fibrosarcoma (CFS) is a rare fibrous tissue malignancy that usually presents in the first few years of life. It is unique among human sarcomas in that it has an excellent prognosis. We describe a temporal clustering of a number of cases of CFS and investigate the possible associated prenatal risk factors. The Pediatric Environmental History, a questionnaire developed in our clinic that is instrumental in determining environmental risk factors for tumor-related disease, was essential in documenting the presence or absence of risk factors considered as human carcinogens. We found a history of exposure to petroleum products in four cases of CFS that occurred at a greater than expected rate in a short time frame-an apparent cancer cluster. We call attention to the possibility that exposure to petroleum products raises the risk of developing CFS. While future studies should focus on systematic investigation of CFS and its underlying mechanisms, this report suggests the need for proactive measures to avoid exposure to solvents and petroleum products during pregnancy.

CONTEXT: Bisphenol A (BPA), a manufactured chemical, is found in canned food, polycarbonate-bottled liquids, and other consumer products. In adults, elevated urinary BPA concentrations are associated with obesity and incident coronary artery disease. BPA exposure is plausibly linked to childhood obesity, but evidence is lacking to date. OBJECTIVE: To examine associations between urinary BPA concentration and body mass outcomes in children. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of a nationally representative subsample of 2838 participants aged 6 through 19 years randomly selected for measurement of urinary BPA concentration in the 2003-2008 National Health and Nutrition Examination Surveys. MAIN OUTCOME MEASURES: Body mass index (BMI), converted to sex- and age-standardized z scores and used to classify participants as overweight (BMI >/=85th percentile for age/sex) or obese (BMI >/=95th percentile). RESULTS: Median urinary BPA concentration was 2.8 ng/mL (interquartile range, 1.5-5.6). Of the participants, 1047 (34.1% [SE, 1.5%]) were overweight and 590 (17.8% [SE, 1.3%]) were obese. Controlling for race/ethnicity, age, caregiver education, poverty to income ratio, sex, serum cotinine level, caloric intake, television watching, and urinary creatinine level, children in the lowest urinary BPA quartile had a lower estimated prevalence of obesity (10.3% [95% CI, 7.5%-13.1%]) than those in quartiles 2 (20.1% [95% CI, 14.5%-25.6%]), 3 (19.0% [95% CI, 13.7%-24.2%]), and 4 (22.3% [95% CI, 16.6%-27.9%]). Similar patterns of association were found in multivariable analyses examining the association between quartiled urinary BPA concentration and BMI z score and in analyses that examined the logarithm of urinary BPA concentration and the prevalence of obesity. Obesity was not associated with exposure to other environmental phenols commonly used in other consumer products, such as sunscreens and soaps. In stratified analysis, significant associations between urinary BPA concentrations and obesity were found among whites (P < .001) but not among blacks or Hispanics. CONCLUSIONS: Urinary BPA concentration was significantly associated with obesity in this cross-sectional study of children and adolescents. Explanations of the association cannot rule out the possibility that obese children ingest food with higher BPA content or have greater adipose stores of BPA.

OBJECTIVE: To determine the effect of mild fluid restriction on the hospital course of neonates with transient tachypnea of the newborn (TTN). STUDY DESIGN: In this pilot prospective randomized controlled trial of 64 late preterm and term neonates diagnosed with TTN at a single tertiary care hospital in the United States, patients were randomized to receive standard fluid management or mild fluid restriction. The primary outcome was duration of respiratory support. Secondary outcomes were duration of admission to the intensive care unit, time to first enteral feed, and total and composite hospital costs. Results were analyzed by t-test, chi(2) test, Kaplan-Meier estimation, and proportional hazards regression. RESULTS: Fluid restriction did not cause adverse events or unsafe dehydration. Fluid management strategy did not affect primary or secondary outcomes in the total study population. Fluid restriction significantly reduced the duration of respiratory support (P = .008) and hospitalization costs (P = .017) in neonates with severe TTN. CONCLUSION: Mild fluid restriction appears to be safe in late preterm and term neonates with uncomplicated TTN. Fluid restriction may be of benefit in decreasing the duration of respiratory support and reducing hospitalization costs in term and late preterm neonates with uncomplicated severe TTN

The obesity epidemic has transformed children's healthcare, such that diabetes, hypertension and the metabolic syndrome are phrases more commonly used by child health providers than ever before. This article reviews the economic consequences of this epidemic for healthcare delivery systems, both in the short term when obesity has been associated with increased utilization, and in the long term where increased likelihood of adult obesity and cardiovascular disease is well documented. Large investments through research and prevention are needed and are likely to provide strong returns in cost savings, and would optimally emerge through a cooperative effort between private and government payers alike

OBJECTIVE:To assess the association of the severity of obesity with diagnosis and health education, and to identify any differences within demographic or other subgroups.DESIGN:Clinician visits for 2-18 year olds from the 2005-2008 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were combined. Descriptive, bivariate and multivariate analyses were used to compare diagnosis of obesity and health education (nutrition, exercise and weight reduction) across elevated body mass index (BMI) groups (overweight, obese and extreme or very obese, defined as >120% of the 95th percentile for age and gender), patient socio-demographic characteristics, physician specialty and type of visit (well child visits (WCV) versus non-well child visits (non-WCV).RESULTS:A total of 17 808 visits had a calculated BMI, of which 5.8% were extremely obese, 13% were obese and 15.2% were overweight, with the highest percentages among older children, blacks and Hispanics. Diagnosis and weight reduction education were higher among children with an extreme BMI. Nutrition and exercise education were not correlated with severity of obesity. Race, ethnicity or gender biases were not identified. Severity of obesity was significantly associated with presentation to a non-WCV rather than a WCV. CONCLUSION:Extremely obese children have higher, but still insufficient, rates of diagnosis and health education. Nutrition and exercise education are not prevalent throughout all age groups. Providers may be relying inconsistently and insufficiently on visual cues to drive their obesity prevention practices. Furthermore, lower rates of diagnosis and education at non-WCV may result in a missed opportunity to prevent comorbidities. This is of particular concern as overweight children are less likely to be seen at WCV than non-WCV.

OBJECTIVES: We aimed to describe 17 months of experience with household recruitment of live births for the National Children's Study in Queens, a highly urban, diverse borough of New York City (NYC), and to assess predictors of recruitment success. METHODS: Recruitment data (enumeration, pregnancy screening of age-eligible women, identification of pregnancies, and consent) for the period of January 2009 through May 2010 were calculated. Geographic information systems were used to create 11 community-level variables for each of the 18 study segments where recruitment occurred, using US Census, NYC Office of Vital Statistics, NYC Department of City Planning, and NYC Police Department data. Recruitment yields were analyzed with respect to these variables at the segment level. RESULTS: Enumeration identified 4889 eligible women, of whom 4333 (88.6%) completed the pregnancy screener. At least 115 births were lost because of an inability of the pregnancy screener to identify pregnant women, whereas another 115 could be expected to be lost because of missed enumerations and pregnancy screeners. The consent rate was 60.3%. Segments with higher percentages of low birth weight had higher enumeration, pregnancy screening, and consent rates. CONCLUSIONS: In a highly immigrant, urban setting, households could be approached for recruitment of women to participate in the National Children's Study with consent rates equal to those experienced in clinical settings. Refinement of the pregnancy screener and other recruitment materials presents an opportunity to optimize recruitment, improve the representativeness of study participants, and improve the cost-effectiveness of study execution

The article under evaluation analyzed healthcare utilization data from the German Interview and Examination Survey for Children and Adolescents, a representative cross-sectional survey that quantifies healthcare services and costs by category. The author used widely accepted health economic methods to quantify incremental costs and utilization attributable to elevated BMI in children. There are important limits to consider for policy makers, clinicians and others who may use these data in isolation to quantify economic savings and other benefits to quantify cost-effectiveness and cost-benefit profiles of environmental, dietary, physical activity and/or pharmaceutical interventions to prevent or treat obesity in childhood. Longer term benefits of preventing obesity in childhood must be considered

BACKGROUND:: Acute exposure to outdoor air pollutants has been associated with increased pediatric asthma morbidity. However, the impact of subchronic exposures is largely unknown. OBJECTIVE:: To examine the association between subchronic exposure to 6 outdoor air pollutants (PM2.5, PM10, ozone, nitrogen oxides, sulfur oxides, carbon monoxide) and pediatric asthma hospitalization length of stay, charges, and costs. METHODS:: We linked pediatric asthma hospitalization discharge data from a nationally representative dataset, the 1999-2007 Nationwide Inpatient Sample, with outdoor air pollution data from the Environmental Protection Agency. Hospitals with no air quality data within 10 miles were excluded. Our predictor was the average concentration of 6 pollutants near the hospital during the month of admission. We conducted bivariate analyses using Spearman correlations and multivariable analyses using Poisson regression for length of stay and linear regression for log-transformed charges and costs, controlling for patient demographics, hospital characteristics, and month of admission. RESULTS:: In unadjusted analyses, all 6 pollutants had minimal correlation with the 3 outcomes ( rho<0.1, P<0.001). In multivariable analyses, a 1-unit (mug/m) increase in monthly PM2.5 led to a $123 increase in charges (95% confidence interval $40-249) and a $47 increase in costs (95% confidence interval $15-93). No other pollutants were significant predictors of charges or costs or length of stay. CONCLUSION:: Subchronic PM2.5 exposure is associated with increased costs for pediatric asthma hospitalizations. Policy changes to reduce outdoor subchronic pollutant exposure may lead to improved asthma outcomes and substantial savings in healthcare spending

A 2002 analysis documented $54.9 billion in annual costs of environmentally mediated diseases in US children. However, few important changes in federal policy have been implemented to prevent exposures to toxic chemicals. We therefore updated and expanded the previous analysis and found that the costs of lead poisoning, prenatal methylmercury exposure, childhood cancer, asthma, intellectual disability, autism, and attention deficit hyperactivity disorder were $76.6 billion in 2008. To prevent further increases in these costs, efforts are needed to institute premarket testing of new chemicals; conduct toxicity testing on chemicals already in use; reduce lead-based paint hazards; and curb mercury emissions from coal-fired power plants