American Academy of Pediatrics Recommended Cardiac Screening Questions in Preparticipation Physical Evaluation Forms.

To evaluate the utilization of the American Academy of Pediatrics' (AAP) cardiovascular screening questions within preparticipation physical evaluation forms from the 50 state high school athletic associations. We found that fewer than one-half of state forms incorporated all 10 AAP questions; moreover, a subset failed to adhere to criteria recommended by either the AAP or American Heart Association.

Diagnosis of vesicoureteral reflux according to the 1999 and 2011 guidelines of the Subcommittee on Urinary Tract Infection of the American Academy of Pediatrics.

INTRODUCTION: In 1999, the American Academy of Pediatrics (AAP) recommended perform a renal ultrasonography and avoiding cystourethrography to all infants between 2 and 24 months of age after their first urinary tract infection (UTI). In 2011, the AAP restricted voiding cystourethrography to children with a pathological ultrasonography, recurrent and/ or atypical infections. Our objective was to compare, in patients with vesicoureteral reflux (VUR) and normal renal ultrasonography, the prevalence of a relevant pathology as if patients had been studied as per the 1999 guidelines (for first UTI) or the 2011 guidelines (for recurrent and/or atypical UTI). POPULATION AND METHODS: We conducted a retrospective analysis of patients with UTI, aged between 2 and 24 months old, seen at our department between January 2010 and August 2014 and who had a normal renal ultrasonography and VUR. A relevant pathology was defined as a finding of grade III VUR or higher and/or pathological renal scintigraphy. RESULTS: Forty-five patients (31 girls) were included and were grouped as if they had been treated as per the 1999 or 2011 guidelines. The prevalence of a relevant pathology among patients studied as per the 1999 guidelines (9 out of 24 cases, 3 with atypical UTI) or as per the 2011 guidelines (11 out of 21 cases) was similar (37.5% versus 52%, respectively; p= 0.31). Six patients (25%) with a relevant pathology diagnosed as per the 1999 guidelines would not have been identified in a timely manner with the 2011 version. CONCLUSIONS: The prevalence of a relevant pathology identified in children with VUR and normal renal ultrasonography was similar with both guidelines. However, considering the present guidelines, one out of four patients would have been exposed to a delayed or potentially missed diagnosis if recurrence would have been expected to complete the assessment.

INTRODUCCIÓN: En 1999, la Academia Americana de Pediatría recomendó realizar una ecografía renal y una cistouretrografía miccional a todos los niños de entre 2 y 24 meses con un primer episodio de infección del tracto urinario (ITU). En 2011, limitó la cistouretrografía miccional a aquellos con ecografía patológic infecciones recurrentes y/o atípicas. Nuestro objetivo fue comparar, en pacientes con reflujo vesicoureteral (RVU) y ecografía renal normal, la prevalencia de patología relevante según hubieran sido estudiados con las guías de 1999 (en la primera ITU) o de 2011 (ante ITU recurrente y/o atípica). POBLACIÓN Y MÉTODOS: Estudiamos retrospectivamente pacientes con ITU de entre 2 y 24 meses atendidos entre enero de 2010 y agosto de 2014 con ecografía renal normal y RVU. Consideramos patología relevante al hallazgo de RVU > grado III y/o centellograma renal patológico. RESULTADOS: Incluimos 45 pacientes (31 niñas), que fueron agrupados según hubieran sido estudiados con las guías de 1999 o de 2011. La prevalencia de patología relevante entre los estudiados con las guías de 1999 (9 de 24 casos, 3 con ITU atípica) o de 2011 (11 de 21 casos) fue comparable (37,5% vs. 52%, respectivamente; p= 0,31). Seis pacientes (25%) con patología relevante diagnosticados con las guías de 1999 no se hubieran identificado oportunamente con las de 2011. CONCLUSIONES: La prevalencia de patología relevante identificada en niños con RVU y ecografía renal normal con ambas guías fue comparable. Sin embargo, con las guías actuales, uno de cada cuatro pacientes hubiera estado expuesto a la demora o eventual pérdida diagnóstica si se hubiera esperado la recurrencia para completar la evaluación.

Diagnóstico de reflujo vesicoureteral según las guías de 1999 y de 2011 del Subcomité de Infección Urinaria de la Academia Americana de Pediatría / Diagnosis of vesicoureteral reflux according to the 1999 and 2011 guidelines of the Subcommittee on Urinary Tract Infection of the American Academy of Pediatrics

Introducción. En 1999, la Academia Americana de Pediatría recomendó realizar una ecografía renal y una cistouretrografía miccional a todos los niños de entre 2 y 24 meses con un primer episodio de infección del tracto urinario (ITU). En 2011, limitó la cistouretrografía miccional a aquellos con ecografía patológica, infecciones recurrentes y/o atípicas. Nuestro objetivo fue comparar, en pacientes con reflujo vesicoureteral (RVU) y ecografía renal normal, la prevalencia de patología relevante según hubieran sido estudiados con las guías de 1999 (en la primera ITU) o de 2011 (ante ITU recurrente y/o atípica). Población y métodos. Estudiamos retrospectivamente pacientes con ITU de entre 2 y 24 meses atendidos entre enero de 2010 y agosto de 2014 con ecografía renal normal y RVU. Consideramos patología relevante al hallazgo de RVU > grado III y/o centellograma renal patológico. Resultados. Incluimos 45 pacientes (31 niñas), que fueron agrupados según hubieran sido estudiados con las guías de 1999 o de 2011. La prevalencia de patología relevante entre los estudiados con las guías de 1999 (9 de 24 casos, 3 con ITU atípica) o de 2011 (11 de 21 casos) fue comparable (37,5% vs. 52%, respectivamente; p= 0,31). Seis pacientes (25%) con patología relevante diagnosticados con las guías de 1999 no se hubieran identificado oportunamente con las de 2011. Conclusiones. La prevalencia de patología relevante identificada en niños con RVU y ecografía renal normal con ambas guías fue comparable. Sin embargo, con las guías actuales, uno de cada cuatro pacientes hubiera estado expuesto a la demora o eventual pérdida diagnóstica si se hubiera esperado la recurrencia para completar la evaluación.

Introduction. In 1999, the American Academy of Pediatrics (AAP) recommended perform a renal ultrasonography and avoiding cystourethrography to all infants between 2 and 24 months of age after their first urinary tract infection (UTI). In 2011, the AAP restricted voiding cystourethrography to children with a pathological ultrasonography, recurrent and/ or atypical infections. Our objective was to compare, in patients with vesicoureteral reflux (VUR) and normal renal ultrasonography, the prevalence of a relevant pathology as if patients had been studied as per the 1999 guidelines (for first UTI) or the 2011 guidelines (for recurrent and/or atypical UTI). Population and methods. We conducted a retrospective analysis of patients with UTI, aged between 2 and 24 months old, seen at our department between January 2010 and August 2014 and who had a normal renal ultrasonography and VUR. A relevant pathology was defined as a finding of grade III VUR or higher and/or pathological renal scintigraphy. Results. Forty-five patients (31 girls) were included and were grouped as if they had been treated as per the 1999 or 2011 guidelines. The prevalence of a relevant pathology among patients studied as per the 1999 guidelines (9 out of 24 cases, 3 with atypical UTI) or as per the 2011 guidelines (11 out of 21 cases) was similar (37.5% versus 52%, respectively; p= 0.31). Six patients (25%) with a relevant pathology diagnosed as per the 1999 guidelines would not have been identified in a timely manner with the 2011 version. Conclusions. The prevalence of a relevant pathology identified in children with VUR and normal renal ultrasonography was similar with both guidelines. However, considering the present guidelines, one out of four patients would have been exposed to a delayed or potentially missed diagnosis if recurrence would have been expected to complete the assessment.

Pediatric primary care provider practices, knowledge, and attitudes of human immunodeficiency virus screening among adolescents.

OBJECTIVES: To evaluate pediatric primary care provider (PCP) HIV screening practices, knowledge, and attitudes. STUDY DESIGN: Anonymous cross-sectional, internet-based survey of pediatric PCPs from 29 primary care practices. Survey items assessed current HIV screening practices and knowledge, attitudes, and perceived barriers towards screening. Provider demographics and practice characteristics were analyzed for associations with screening through logistic regression. RESULTS: Of 190 PCPs, there were 101 evaluable responses (response rate: 53.2%). PCPs reported a screening rate for HIV of 39.6% ("most" or "all of the time") during routine adolescent visits compared with violence (60.4%), substance abuse (92.1%), and depression (94.1%) (P < .001). Less than 10% of PCPs correctly answered questions related to Centers for Disease Control and Prevention and state HIV screening recommendations. Of 20 potential HIV screening barriers assessed, mean number of reported barriers was 4.8 (SD ± 2.9); with most concerns related to confidentiality, time for counseling, and follow-up. In a multivariable model, the only factor significantly associated with HIV screening "most" or "all of the time" during routine adolescent visits was urban practice site (aOR 9.8, 95% CI 2.9, 32.9). Provider type, sex, years since training, HIV screening guideline knowledge, and endorsing ≤5 barriers were not associated with HIV screening. CONCLUSIONS: Although providers practicing in urban areas were more likely to report screening adolescents for HIV than those in suburban areas, overall self-reported screening rates were low, and several barriers were identified commonly. Future interventions should target increasing providers' knowledge and addressing concerns about confidentiality, requirements and counseling time, and follow-up of results.

Pediatric global health education: correlation of website information and curriculum.

OBJECTIVE: Web sites describing residency programs are initial sources of information for applicants. The correlation of global health content on pediatric residency program Web sites with reported curricula is unknown. To determine the accuracy of global health education, information on program Web sites was compared with queried program content responses. STUDY DESIGN: The Fellowship and Residency Electronic Interactive Database was used to assess pediatric residency programs' Web sites for global health education, applying American Academy of Pediatrics consensus guidelines. The authors developed a questionnaire using these consensus guidelines and contacted each program to assess Web site findings, and χ(2) tests were used to compare data from these 2 sources. RESULTS: Of 194 programs, 177 had operational Web sites, of which 98 participated in the questionnaire (55%). Ninety-three of 177 programs (53%) reported global health education on Web sites, whereas 80 of 98 programs (82%) reported global health education through direct questioning (P < .001). Results include provision of resident salaries during global health elective (Web site 5% vs questionnaire 98%, P < .001), mandatory training before global health elective (8% vs 20%, P = .02), presence of global health elective curriculum (24% vs 75%, P < .001), postexperience debriefing (16% vs 29%, P = .05), and bidirectional resident exchange (2% vs 13%, P = .01). CONCLUSIONS: Results indicate continued expansion of pediatric global health education, but significant differences exist between information on Web sites and data obtained through direct questioning. Accurate representation of global health opportunities would allow for more informed decision-making among prospective applicants. Findings also suggest substantial variability in global health curricula that needs to be addressed through improved planning and cooperation among training programs.

Urinary tract infections caused by community-acquired extended-spectrum ß-lactamase-producing and nonproducing bacteria: a comparative study.

OBJECTIVE: To study the clinical characteristics and associated risk factors of urinary tract infections (UTIs) caused by community-acquired extended-spectrum ß-lactamase (CA-ESBL)-producing Enterobacteriaceae. STUDY DESIGN: A case-control study at a large community hospital in northern Israel, comparing children who had UTI due to CA-ESBL (n = 25) and CA non-ESBL (n = 125) in 2008-2011. Data were collected from medical charts, telephonic questionnaires administered to all participants, and groups were compared. RESULTS: During the study period, the yearly incidence of CA-ESBL UTI increased significantly. There were no significant differences between the CA-ESBL and CA non-ESBL groups in demographics and clinical outcome. Compared with CA non-ESBL UTI, children with CA-ESBL UTI had a longer hospital stay (5.9 ± 3.3 vs 3.9 ± 2.3 days; P = .003) and higher rates of recent hospitalization (28% vs 4%; P = .001), previous UTI (40% vs 13%; P = .003), urinary tract anomalies (32% vs 5%; P < .001), UTI prophylaxis with cephalexin (32% vs 2%; P < .005), and aminoglycoside resistance. In a multivariate analysis, UTI prophylaxis (OR 12.5 [CI 2.7-58]), recent hospitalization (OR 4.8 [CI 1.1-21]), and Klebsiella spp. UTI (OR 4.7 [CI 1.3-17]), were risk factors for CA-ESBL UTI. CONCLUSIONS: Children prescribed UTI prophylaxis (due to urinary tract anomalies or recurrent UTI) with cephalexin and those with previous hospitalizations are at increased risk for CA-ESBL UTI. Although not associated with higher rates of complications, the multidrug resistant phenotype of CA-ESBL isolates poses a challenge in choosing appropriate empiric and definitive therapy and prolongs hospital stay.

Hyponatremia in children with bronchiolitis admitted to the pediatric intensive care unit is associated with worse outcomes.

OBJECTIVE: To characterize the relationship between hyponatremia (serum sodium <135 mEq/L) and clinical outcomes in children ages 1 month to 2 years admitted to the pediatric intensive care unit (PICU) with bronchiolitis. STUDY DESIGN: Single-center retrospective cohort study comprising children who were admitted to the PICU between January 2009 and April 2011. Serum sodium concentrations, collected within the first 2 hours after admission to the PICU, were recorded and associations with clinical outcomes were calculated. Quantitative data are presented as mean ± SD or percentage. Student t-test, Fisher exact test, and χ(2) analyses were performed as appropriate. Subjects were excluded if they were previously diagnosed with chronic disease that would affect initial serum sodium concentration. RESULTS: Children with bronchiolitis were enrolled (n = 102; age = 10.7 ± 6.7 months). Twenty-three patients (22%) were diagnosed with hyponatremia within 2 hours of admission. Mortality (13% vs 0%; P = .011), ventilator time (8.41 ± 2 days vs 4.11 ± 2 days; P = .001), duration of stay in the PICU (10.63 ± 2.5 days vs 5.82 ± 2.09 days; P = .007), and noninvasive ventilator support (65% vs 24%; P = .007) were significantly different between subjects with hyponatremia vs those without. There were no differences in the number of patients with seizures, bronchodilator use, steroid use, intubation requirement, oxygen use at discharge, or hospital readmission. CONCLUSIONS: Pediatric patients diagnosed with bronchiolitis who present with a serum sodium concentration less than 135 mEq/L within 2 hours of admission to the PICU fare worse than their cohorts with normonatremia. A prospective study to evaluate the effects of hyponatremia appears justified.

Pediatric providers' attitudes toward retail clinics.

OBJECTIVE: To describe pediatric primary care providers' attitudes toward retail clinics and their experiences of retail clinics use by their patients. STUDY DESIGN: A 51-item, self-administered survey from 4 pediatric practice-based research networks from the midwestern US, which gauged providers' attitudes toward and perceptions of their patients' interactions with retail clinics, and changes to office practice to better compete. RESULTS: A total of 226 providers participated (50% response). Providers believed that retail clinics were a business threat (80%) and disrupted continuity of chronic disease management (54%). Few (20%) agreed that retail clinics provided care within recommended clinical guidelines. Most (91%) reported that they provided additional care after a retail clinic visit (median 1-2 times per week), and 37% felt this resulted from suboptimal care at retail clinics "most or all of the time." Few (15%) reported being notified by the retail clinic within 24 hours of a patient visit. Those reporting prompt communication were less likely to report suboptimal retail clinic care (OR 0.20, 95% CI 0.10-0.42) or disruption in continuity of care (OR 0.32, 95% CI 0.15-0.71). Thirty-six percent reported changes to office practice to compete with retail clinics (most commonly adjusting or extending office hours), and change was more likely if retail clinics were perceived as a threat (OR 3.70, 95% CI 1.56-8.76); 30% planned to make changes in the near future. CONCLUSIONS: Based on the perceived business threat, pediatric providers are making changes to their practice to compete with retail clinics. Improved communication between the clinic and providers may improve collaboration.

Young physicians' recall about pediatric training in ethics and professionalism and its practical utility.

OBJECTIVE: To assess the adequacy of ethics and professionalism education in residency by examining the recollections of young pediatricians in practice. STUDY DESIGN: We surveyed a random sample of members of the American Academy of Pediatrics Section on Young Physicians between February and June 2012. RESULTS: The majority of young pediatricians reported that ethics and professionalism were taught ad hoc in their training programs. Compared with physicians in practice for >5 years, those in practice for ≤ 5 years were significantly more likely to report having had an organized curriculum (72 of 181 [40%] vs 27 of 113 [24%]; P < .01) and that the ethics and professionalism training in their program was adequate (124 of 180 [69%] vs 62 of 113 [55%]). Of the topics encountered in practice by at least two-thirds of pediatricians, more than two-thirds of the respondents stated that residency training adequately prepared them to address issues of consent, privacy, truth-telling, and child abuse/neglect, but less than one-third felt adequately prepared to address conduct on social media and requests for prescriptions by family, friends, and colleagues outside of clinical encounters. CONCLUSION: The majority of recent graduates from pediatric training programs described themselves as competent to address the ethical and professionalism issues faced in practice, but nonetheless reported gaps in their education. As pediatric residency programs adopt more structured curricula for ethics and professionalism education, issues commonly faced by practitioners should be incorporated.

Reanimación neonatal: ¿qué hay de nuevo? / Neonatal resuscitation: What is new?

A escala mundial, alrededor de 5 a 10% de recién nacidos requieren algún tipo de asistencia en el momento del nacimiento que puede ir desde maniobras de reanimación tan sencillas como la aspiración de secreciones y estimulación táctil, a otras más complejas como ventilación con presión positiva, compresiones torácicas externas y administración de epinefrina. Esto obliga a difundir un programa de reanimación que proporcione una oportunidad para aprender de manera organizada, apropiada y oportuna, la asistencia a recién nacidos para asegurar su adecuada transición a la vida extrauterina y disminuir los riesgos de daño neurológico. El Programa de Reanimación Neonatal (PRN) constituye un modelo preciso de educación médica de trascendental importancia, pues representa una prioridad dentro de los programas de salud reproductiva. Aquí se presentan las últimas recomendaciones de la Academia Americana de Pediatría y la Asociación Americana del Corazón para actualizar el PRN, basadas en diferentes niveles de evidencia. El conocimiento de las mismas y la destreza de quienes apliquen el programa seguramente ayudarán a disminuir uno de los grandes problemas de salud pública en México: la asfixia neonatal y sus complicaciones.

Worldwide, 5-10% of all newborns require some kind of intervention at birth. Thus, it is important to teach the Neonatal Resuscitation Program (NRP) to all personnel attending deliveries. This program provides a systematic approach to different situations encountered at birth to facilitate neonatal resuscitation. The NRP has been embraced by public health authorities among different countries. In this paper we summarize the most recent recommendations from the American Academy of Pediatrics (AAP) and American Heart Association (AHA) to update the NRP; these are based on different levels of evidence. The knowledge and practice of these recommendations will certainly help to improve neonatal outcomes and to decrease asphyxia and its complications.