Tuesday, March 26, 2013

Future Criminals Can Be Identified as Early as Age 6

Fran Lowry
Mar 22, 2013
 Conduct problems and hurtful and uncaring behavior in children as young as 6 years are accurate predictors of violent and nonviolent criminal convictions in young adulthood, new research shows.
Investigators from the Université de Montréal in Canada found that negative behavior at age 6, such as fighting, disobedience, and a lack of empathy, predicted criminal convictions by age 24.
"Most nonviolent and violent crimes are committed by a small group of males and females who display conduct problems that onset in childhood and remain stable across the lifespan," study author Sheilagh Hodgins, PhD, toldMedscape Medical News.
"If their conduct problems could be identified and reduced early in life, this would potentially allow these children to alter their developmental trajectories, live healthy and happy lives, and to make positive rather than negative contributions to our society."
The study is published in the March issue of the Canadian Journal of Psychiatry.
Need for Early Intervention
The aim for the study was to further the understanding of how to prevent crime and thereby reduce the human and economic costs associated with criminal activity, she said.
The researchers examined teacher assessments of conduct problems such as fighting, disobedience, school absenteeism, destruction of property, theft, lying, bullying, blaming others, and a lack of empathy among students at age 6 years.
The 1593 boys and 1423 girls were recruited when they were in kindergarten at French-speaking public schools in the province of Quebec from 1986 to 1987.
The same groups of boys and girls were assessed again at age 10 years. They were also assessed for aggressive behavior at age 12.
The researchers later obtained juvenile and adult criminal records and found that teacher ratings of pupils' behaviors at ages 6 and 10 were associated with criminal convictions between the ages of 12 and 24.
Specifically, they found that boys aged 6 who were rated by their teachers as having the highest degree of conduct behavior problems and hurtful and uncaring behaviors were 4 times more likely to be convicted of violent crimes and 5 times more likely to be convicted of nonviolent crimes than boys with lower ratings.
Similarly, girls aged 6 with high ratings for conduct problems and hurtful and uncaring behaviors were 5 times more likely than girls with lower ratings to have a conviction for nonviolent crimes by age 24.
Boys who had high ratings for uncaring and hurtful behaviors but who did not have conduct behavior problems also had an elevated risk for violent and nonviolent crime convictions, and girls with high ratings for uncaring and hurtful behaviors but no conduct behavior problems had a high risk for nonviolent crime convictions.
Such students, Dr. Hodgins added, require "interventions to reduce these behaviors at an early age, which, in turn, will promote better relations with family, peers, and teachers, better academic performance, and the development of prosocial skills."
Pediatricians may be able to identify children who exhibit these behaviors by observing and talking to the children and their parents, she added.
"When these problems are thought to be present, families could be referred to child psychiatric services or other agencies that provide parent training and other interventions aimed at reducing these problems," she said.
Commenting on the study for Medscape Medical News, Michael Brody, MD, a child psychiatrist in private practice in Potomac, Maryland, said he has reservations about the study.
Dr. Brody, who was not involved in the research, said he was concerned about "putting a label on a child as young as 6. If you label the child as likely to become a criminal, it could have problems down the road."
Nevertheless, if labeling a child would result in some guarantee of treatment or intervention, it might be worthwhile, Dr. Brody said.
"Often, it does not. In fact, this is a major problem with all of these studies that call for intervention. In our country, there just are no facilities to deal with these children. Even when the kid does something really terrible, who is going to see the child? All the services are overwhelmed. The resources to deal with these problems are nonexistent. Therefore, I have problems about the practicality of this research," he said.
Finally, Dr. Brody questioned the ability of teachers to accurately predict criminality.
"I think teachers are great. What they do is unbelievable, especially in the younger grades, to sit in the classroom for 6 or 7 hours with the kids, but I just wonder about their ability to accurately evaluate them. [The researchers] based their predictions on observations that the child was bullying or hitting or biting and so forth, but I question the reliability of their observations."
The study was supported by the Groupe de Recherche sur L'Inadaptation Psychosociale and the Centre de Recherche at the Institut Philippe Pinel de Montreal. Dr. Hodgins and Dr. Brody report no relevant financial relationships.
Can J Psychiatry. 2013;58:143-150. Abstract

      Diet and Oral Health

      Updated: May 4, 2012  Medscape Education

      Diet, Caries, and Dental Erosion

       Jeff Burgess, DDS, MSD; Chief Editor: Arlen D Meyers, MD, MBA 

      Many years of research have established that dietary factors are directly related to dental caries and erosion. Significant risk factors for these abnormalities include fat and sugar intake in both children and adults.[1, 2, 3, 4, 5, 6] In fact, not only does childhood sugar intake contribute to the development of caries, but the development of pediatric caries in children aged 5 years and younger is significantly associated with maternal weight and intake of sugar and fat by expectant mothers during pregnancy.[7] Dietary habits and the risk of caries in children may also be confounded by maternal educational level.[8]
      Caries also occurs in adults, and its incidence appears to increase with age. In fact, incidence rates are similar to those observed in children. Numerous studies in Europe (Ireland, Netherlands, United Kingdom, France) and in the United states suggest that the dietary factors in children may be as important as they are in adults.[9] In a recent study, severe tooth loss in older adults was found to be a key indicator of a compromised dietary quality.[10] Evidence also shows that sport drinks may be increasing the incidence of dental erosion, which can precede caries in both child and adult athletes.[11]
      Specific dietary elements and related factors that have demonstrated significant potential for causing caries include the following:[12, 13]
      • Number of fruit-based sugary soft drinks imbibed
      • Frequency of fruit-based sugary drink intake
      • Length of time taken to consume acidic drinks
      • Eating processed starches as snacks (cooked starches: bread, crackers, cereal, chips/pretzels, pasta, fries)
      • Eating fermentable carbohydrates
      • Intake of long-lasting sources of sugars, such as hard candies, breath mints, and lollipops
      • Clearance properties of the carbohydrate
      • When the food is eaten
      • The level of salivation or lack thereof
      • The type of starch that is eaten
      • The co-presence of buffers, such as calcium taken with fermentable carbohydrates
      Foods and dietary habits that should be recommended because of their minimal risk of caries potential or their caries risk reduction include the following:
      • Eating fruits such as apples, oranges, pears, and bananas
      • Eating vegetables such as carrots, celery, tomatoes, lettuce, cucumber, nuts, and crisps
      • Eating aged cheese or drinking milk
      • Eating eggs and yogurt
      • Imbibing xylitol-containing food products
      • Eating of sugar-containing foods with meals rather than between meals
      • Eating less sugar-containing food or carbohydrates
      • Drinking versus sipping sugary drinks
      • Rinsing with water after imbibing sugary snacks
      • Eating fruit instead of drinking unsweetened fruit juices that have sugar and that are acidic
      • Drinking sugar-free tea or coffee
      • Avoiding the intake of sugar or sticky carbohydrates before retiring to bed
      Numerous foods have alleged anticaries activity. These include foods with added xylitol or fluoride, green tea, apple, red grape seeds, red wine, nutmeg, ajowan caraway, coffee, barley coffee, chicory, mushroom, cranberry, glycyrrhiza root, ethanolic extract of Myrtus communis, garlic aqueous extract, cocoa extracts, and propolis.[14, 15, 16] The extent to which these various anticaries foods or ingredients have been studied is limited, but some evidence does suggest an effect on the development of caries.[17]

      Infants Often Introduced to Solid Food Too Early

      Larry Hand
      Mar 25, 2013
      Early introduction to solid foods for infants under 4 months old is highly prevalent in the United States, even though recommendations call for solid food introduction between 4 and 6 months of age, according to an article published onlineMarch 25 in Pediatrics. The early introduction may leave affected infants vulnerable to higher risk for chronic diseases, such as diabetes and obesity, researchers note.
      Heather B. Clayton, PhD, MPH, from the Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues analyzed the responses of 1334 mothers who participated in the Infant Feeding Practices Study II between 2005 and 2007. The study group included women who returned completed questionnaires during the months after birth and indicated when they introduced solid foods to their infants and why.
      Overall, 40.4% of mothers introduced solid foods before their infants were 4 months old (P < .05), and some did so earlier than 4 weeks of age. Mothers were more likely to do so if they were younger, were unmarried, had less education, earned less, and participated in the Women, Infants, and Children program.
      When the researchers accounted for the type of milk feeding of infants, they found that 52.7% of mothers who formula-fed started solid feeding before 4 months, compared with 50.2% of mothers who reported mixed feeding and 24.3% of mothers who breast-fed.
      Most mothers (88.9%) gave their reason as "My baby was old enough to begin eating solid food," and many others (71.4%) said, "My baby seemed hungry a lot of the time." Using logistic regression analysis adjusting for age, marital status, education, and other variables, the researchers found that mothers who breast-fed were less likely to cite the reason as "I wanted to feed my baby something in addition to breast milk or formula" compared with women who formula-fed (adjusted odds ratio [aOR], 0.62; 95% confidence interval [CI], 0.39 - 0.99). Mothers who formula-fed were almost twice as likely as mothers who breast-fed to give the reason "A doctor or other health care professional said my baby should begin eating solid food" (aOR 1.79; 95% CI, 1.15 - 2.80).
      At the time of the surveys, the American Academy of Pediatrics recommendation for solid food introduction was 4 months. However, in 2012 the AAP changed that to 4 to 6 months, which would equate to a rate of early introduction of 92.9%, the researchers note.
      Limitations of the study include the fact that most mothers were white and had moderate incomes. The researchers note that because mothers of lower socioeconomic status are at higher risk for early introduction of solid food, the study results may underestimate the true prevalence.
      The researchers conclude, "Our study provides key information on why mothers introduced solid food earlier than recommended and how the commonly cited reasons varied by milk feeding type. This information can be used by health professionals to develop targeted interventions to improve adherence with infant feeding recommendations, with the goal of reducing any morbidity associated with early introduction of solid foods."
      Pediatrics. Published online March 25, 2013. Abstract

      Sunday, March 24, 2013

      Urine collection in newborns

      A New Technique for Fast and Safe Collection of Urine in Newborns

      María Luisa Herreros Fernández, Noelia González Merino, Alfredo Tagarro García, Beatriz Pérez Seoane, María de la Serna Martínez, María Teresa Contreras Abad, Araceli García-Pose,
      Arch Dis Child. 2013;98(1):27-29. 


      Two people (trained nurses and/or physicians) were needed to perform the procedure, and a third to measure the time taken. This technique involves a combination of fluid intake and non-invasive bladder stimulation manoeuvres.
      The first step is either breast-feeding or providing formula intake appropriate to the age and weight of the newborn. In babies fed infant formula, 10 ml was provided on the first day of life, increasing to 10ml per day during the first week. From the second week onwards, 25 ml/kg were administered before the onset of stimulation. Twenty-five minutes after feeding, the infant's genitals were cleaned thoroughly with warm water and soap and dried with sterile gauze. A sterile collector was placed near the baby in order to avoid losing urine samples. Before performing the technique, we administered non-pharmacological analgesia, such as non-nutritive sucking or 2% sucrose syrup, to prevent/lessen crying.
      The second step is to hold the baby under their armpits with their legs dangling. One examiner then starts bladder stimulation which consists of a gentle tapping in the suprapubic area at a frequency of 100 taps or blows per minute for 30 s.
      The third step is stimulation of the lumbar paravertebral zone in the lower back with a light circular massage for 30 s.
      Both stimulation manoeuvres are repeated until micturition starts, and a midstream urine sample can be caught in a sterile collector (figure 1). Success is defined as the collection of a sample within 5 min of starting the stimulation manoeuvres.
      Figure 1.
      New stimulation technique to obtain midstream urine in newborns. (A) Tapping in the suprapubic area. (B) Stimulation of the lower back. (C) Midstream urine sample collection in a sterile container.

      Chlorhexidine Cleansing of Umbilical Cord Increases Cord Separation Time

      Mar 18, 2013
      By Will Boggs, MD
      NEW YORK (Reuters Health) Mar 18 - Chlorhexidine cleansing of the umbilical cord reduced infant mortality in a study in Bangladesh, but the increased separation time associated with it was troublesome to some parents, researchers said today in a paper online in Pediatrics.
      Umbilical cord cleansing is known to reduce neonatal mortality in low-resource settings with high risk of infection. Doctors therefore need to prepare mothers and fathers in advance, telling them that longer separation times are normal with chlorhexidine and are a sign that the treatment is helping to make the baby safer, lead author Dr. Luke C. Mullany from Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland told Reuters Health.
      "Cleansing of the cord with 4% chlorhexidine, starting as soon as possible after birth and continuing through the first week of life, is the most appropriate care of the cord" wherever neonatal infections are likely, Dr. Mullany said. "I would suggest this includes almost all facility and home birth settings in low and middle income countries."
      Dr. Mullany and colleagues investigated separation times and other outcomes of 29,532 newborns in Bangladesh assigned to one of three cord regimens in a cluster-randomized trial: dry and clean cord care, or single- or multiple cleansing with 4.0% chlorhexidine.
      Cord separation times were significantly longer with vs without chlorhexidine (mean, 6.90 vs 4.78 days). Separation times were longer than seven days in 13.5% of infants not receiving chlorhexidine, compared with 45.9% of infants in the single-cleansing group and 55.7% of infants in the multiple-cleansing group.
      The risk of moderate or severe omphalitis increased by 3.1% for each additional day the cord did not separate. As a result, the risk was 13.8% higher among infants whose cords separated after seven days. These associations, however, were not statistically significant.
      Mothers in the multiple-cleansing group were 2.55 times more likely than mothers of infants in the no-chlorhexidine group to report that separation took "longer than usual." Each 24-hour increase in directly observed separation time brought an 18.3% increase in the likelihood of reporting "longer than usual."
      Similarly, dissatisfaction with the time to separation was more frequent in the single- (11.1%) and multiple-cleansing (17.6%) groups than in the no-chlorhexidine group (2.5%).
      "We know from our community trials that chlorhexidine cord cleansing saves lives and greatly reduces cord infections," Dr. Mullany said. "These additional analyses confirm that putting chlorhexidine on the cord can make the time to separation a little bit longer. Physicians should assure moms and dads that is normal and is a sign that the baby's cord is cleaner and their baby is more protected from infections because of the chlorhexidine."
      "I think that dry and clean cord care could be favored only in situations where providers are really confident that they can eliminate exposure of pathogens to the freshly cut cord stump," Dr. Mullany added. "In most resource poor settings, using topical chlorhexidine on the cord provides the simple and cost-effective way to eliminate these exposures."
      Pediatrics 2013;131:708-715

      Friday, March 8, 2013

      Corticosteroid Therapy Yields Mixed Results in Children With Pneumonia

      Laurie Barclay, MD
      Jan 21, 2011
      January 21, 2011 — Corticosteroid treatment in children with community-acquired pneumonia (CAP) who also have received a beta-agonist benefits those with wheezing but may lead to worse outcomes in children without wheezing, according to the results of a multicenter, retrospective cohort study published in the January issue of Pediatrics.
      "Corticosteroids inhibit the expression of many proinflammatory cytokines released during the course of [CAP] infection," write Anna K. Weiss, MD, from Children's Hospital of Philadelphia, Pennsylvania, and colleagues. "Corticosteroids have been found in some studies to be associated with improved clinical outcomes in adults with pneumonia. No studies have investigated corticosteroid use in children with pneumonia."
      The study goal was to examine outcomes associated with use of systemic corticosteroid therapy for children hospitalized with CAP, using data from 36 children's hospitals for 20,703 children aged 1 to 18 years (median age, 4 years). The primary exposure was the use of adjunct systemic corticosteroids, and the primary study endpoints were length of stay (LOS), readmission, and total costs of hospitalization. The investigators adjusted for potential confounders using multivariable regression models and propensity scores.
      Median LOS was 3 days. Of the 20,703 children, 7234 (35%) received adjunctive treatment with corticosteroids. Readmission was needed in 245 patients (1.2%). Overall, systemic corticosteroid therapy was associated with shorter LOS, with an adjusted hazard ratio (HR) of 1.24 (95% confidence interval [CI], 1.18 - 1.30). Among children who received treatment with beta-agonists, LOS was shorter in children treated with corticosteroids than in children not treated with corticosteroids (adjusted HR, 1.36; 95% CI, 1.28 - 1.45).
      In contrast, however, among children not treated with beta-agonists, LOS was longer in those given corticosteroids than in those not receiving them (adjusted HR, 0.85; 95% CI, 0.75 - 0.96), and hospital readmission was more likely (adjusted odds ratio, 1.97; 95% CI, 1.09 - 3.57).
      "Results showed that corticosteroid treatment in children with pneumonia is common and its use is highly variable across institutions," the study authors write. "Although corticosteroid therapy may benefit children with acute wheezing treated with beta-agonists, corticosteroid therapy may lead to worse outcomes for children without wheezing."
      Limitations of this study include possible inclusion of patients with simple asthma exacerbation rather than CAP, possible unmeasured confounding or residual confounding by indication, and the ability to record only readmissions that occurred at the same hospital as the index admission. In addition, the effect of adjunct corticosteroid therapy on other important outcomes such as progression of illness and the development of pneumonia-associated complications such as empyema could not be evaluated in this study.
      "Our results do not support the routine use of corticosteroid treatment of children with CAP," the study authors conclude. "Our findings also have important implications for the design of future clinical trials, particularly with regard to planning of sample size and study cohorts. Because the practice of prescribing adjunct corticosteroids to children with CAP is both common and highly variable, a randomized trial is warranted to allow further exploration of which pediatric populations might benefit from systemic corticosteroid therapy."
      The National Institutes of Health supported this study. The study authors have disclosed no relevant financial relationships.
      Pediatrics. 2011;127:e255-e263.

      Skin Signals Severe Outbreak of Hand, Foot, and Mouth Disease

      Damian McNamara
      Mar 07, 2013
      MIAMI BEACH, Florida — Children with a severe form of hand, foot, and mouth disease infected during a recent enterovirus outbreak in the United States displayed unusual skin signs that could confuse clinicians, researchers report.
      "We were surprised by the variety and extent of this exanthema," said Vikash Oza, MD, a second-year dermatology resident from the University of California at San Francisco, who presented study results here at the American Academy of Dermatology 71st Annual Meeting. "Classic hand, foot, and mouth disease has vesicles restricted to the hands, feet, and diaper region, but this new form is widespread over the entire body."
      This insight stems from a case series of 81 affected children assessed at 7 academic dermatology centers in various states.
      The analysis, presented during a crowded late-breaking research session, showed that the severe disease was caused by coxsackievirus A6 (CVA6).
      Dr. Oza pointed out that CVA6 infection can cause a wide variety of skin manifestations, which can be confused with eczema herpeticum, vasculitis, impetigo, or primary immunobullous disease. When appropriate, herpes simplex and varicella zoster virus infection must also be ruled out, he noted.
      Cutaneous Features
      "While the cutaneous features can vary, there is usually a clue — such as typical oral erosions, football-shaped vesicles on hands and feet, and viral symptoms — that the patient has an underlying enteroviral infection," Dr. Oza said.
      In most of North America, enterovirus season is approaching.
      The infections in this study could be distinguished from more serious infections caused by other enteroviral strains by a lack of serious systemic illness.
      Although cases can present anytime throughout the calendar year, the peak incidence of enterovirus infection tends to occur in the spring, Dr. Oza said. "In most of North America, enterovirus season is approaching."
      To find out more about these atypical exanthems, the researchers, led by Erin Mathes, MD, from the University of California at San Francisco, used clinical criteria to diagnose 63 children with atypical hand, foot and mouth disease and 17 children with CVA6 infection. The median age was 1.5 years old (range, 4 months to 16 years).
      To aid in the differential diagnosis, the researchers identified 5 morphologic features of CVA6 infection:
      • In 99% of cases, vesiculobullous and erosive eruptions are widespread on the trunk and elsewhere (in infants younger than 1 year, they can include marked perioral distribution and large bullae).
      • In 55% of cases, eczema coxsackium, caused by widespread replication of the CVA6 on the skin of children with atopic dermatitis, creates a condition that clinically resembles eczema herpeticum.
      • In 33% of cases, Gianotti-Crosti-like eruptions develop.
      • In 17% of cases, petechiae and purpura develop.
      • Delayed onychomadesis and acral desquamation can arise weeks later.
      "CVA6 is an emerging and important cause of hand, foot, and mouth disease worldwide and in the United States," Dr. Oza said.
      Scott Norton, MD, from the Children's National Medical Center in Washington, DC, who was asked byMedscape Medical News to comment on the findings, explained that this "new form of hand, foot, and mouth disease can have a dramatic presentation with red, almost hemorrhagic, blisters all over the body."
      Benign, But Startling
      Ordinarily, hemorrhagic blisters are considered a serious dermatologic emergency because they are typically seen only in the most serious of disorders, he noted. "In this new hand, foot, and mouth disease situation, however, families can be reassured that things are fine."
      Dr. Norton added that "one should add this to the differential for disorders with widespread blisters."
      Hundreds of emergency department visits across the United States each year are driven by this benign but startling condition.
      During the discussion period at the meeting, a delegate asked why researchers are sure that the viral pathogen is driving this phenotype.
      "Great question," Dr. Oza replied. "The only pathogen we isolated was coxsackievirus A6. Other data from Taiwan [obtained during a CVA6 outbreak] show the same phenotype with the same oral predilection."
      Last March, the Centers for Disease Control and Prevention published initial findings of some of the earlier cases from an outbreak in 4 states (MMWR Morb Mortal Wkly Rep. 2012;61:213-214).
      The researchers and Dr. Norton have disclosed no relevant financial relationships.
      American Academy of Dermatology (AAD) 71st Annual Meeting. Presented March 2, 2013.