JAMA Pediatrics Current Issue

In This Issue of JAMA Pediatrics

Sat, 01 Jun 2013 00:00:00 GMT

Clostridium difficile Infection in Children Clostridium difficile Infection in Children

Sammons J, Toltzis P, Zaoutis TE. — Sat, 01 Jun 2013 00:00:00 GMT

Clostridium difficile is the most common cause of health care–associated diarrhea among adults in the United States and is associated with significant morbidity and mortality. During the past decade, the epidemiology of C difficile infection (CDI) has changed, including a rise in the rate and severity of infection related to the emergence of a hypervirulent strain as well as an increase in disease among outpatients in community settings. Although less is known about CDI among pediatric patients, C difficile is increasingly recognized as an important pathogen among children. In this review, we discuss recent updates in the incidence and epidemiology of CDI among children, including risk factors for infection, and highlight the importance of CDI in special populations of children, particularly those with inflammatory bowel disease or cancer. In addition, we review current knowledge in the areas of diagnosis and management of CDI among children and highlight future areas for research.

Clostridium difficile : A Cause of Diarrhea in Children

Moreno MA, Furtner F, Rivara FP. — Sat, 01 Jun 2013 00:00:00 GMT

Clostridium difficile is a bacterium that causes inflammation of the part of the intestine called the colon. It is sometimes called C diff for short. These bacteria are found in feces (bowel movement). A major risk factor for getting a C difficile infection is being on antibiotics. People can also become infected by C difficile if they touch an object such as a toy or a surface such as a counter that has feces on it and then touch their mouth or a mucous membrane such as the eye or nose. It is the most common cause of health care–associated diarrhea in the United States. While most health care–associated infections are caused by getting someone else's infection, C difficile infection is most commonly caused by antibiotic treatment, which changes the bacteria in your intestines.

About This Journal

Sat, 01 Jun 2013 00:00:00 GMT

Accountable Care Organizations in Pediatrics Irrelevant or a Game Changer for Children? Accountable Care Organizations in Pediatrics

Homer CJ, Patel KK. — Sat, 01 Jun 2013 00:00:00 GMT

The term accountable care organization (ACO) is the new buzzword in health care. Enshrined in the Affordable Care Act as well as being advanced by private payers, ACOs are becoming real in adult health care systems and are starting to appear in pediatrics. (Indeed, the Affordable Care Act calls for the establishment of a pediatric demonstration project, although the specified starting time for the project [June 2012] has passed without any guidance from the US Department of Health and Human Services.) But, what is an ACO? What does it intend to accomplish? Is it relevant for child health and health care? What concerns need to be addressed for ACOs to benefit children?

Assessment of Maternal Attributions of Infant's Hostile Intent and Its Use in Child Maltreatment Prevention/Intervention Efforts Mother's Attributions of Infant's Hostile Intent

Milner JS, Crouch JL. — Sat, 01 Jun 2013 00:00:00 GMT

Cognitive models of aggression propose that when an individual attributes hostile intent to another person's behavior, these attributions increase the likelihood of aggression toward that person. This proposition has been supported by a large body of literature. Similar speculations are found in cognitive behavioral models of child physical abuse. Specifically, these models propose that, when parents make attributions of hostile intent with respect to their children's behavior, they are more likely to use harsh parenting practices and are at increased risk for physically abusing their children. As expected, studies have found that, in the general population, parents' child-related attributions of hostile intent are associated with harsh discipline practices. Furthermore, research has found that these high-risk parents and physically abusive parents, relative to comparison parents, make more attributions of hostile intent with respect to children's behavior.

Association Between State Laws Governing School Meal Nutrition Content and Student Weight Status Implications for New USDA School Meal Standards School Meal Nutrition Standards and Weight Status

Taber DR, Chriqui JF, Powell L, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

This study assessed whether stronger school meal nutrition standards may improve student weight status. Results have immediate implications because of the ongoing implementation of new nutrition standards for the National School Lunch Program.

Objective

To determine if state laws with stricter school meal nutrition standards are inversely associated with adolescent weight status, while controlling for unmeasured state-level confounders.

Design

Quasi-experiment.

Setting

Public schools.

Participants

Four thousand eight hundred seventy eighth-grade students in 40 states. Students were categorized by type of school lunch they usually obtained (free/reduced price, regular price, or none).

Interventions

State laws governing school meal nutrition standards. States with standards that exceeded US Department of Agriculture (USDA) school meal standards were compared with states that did not exceed USDA standards. The parameter of interest was the interaction between state laws and student lunch participant status, ie, whether disparities in weight status between school lunch participants and nonparticipants were smaller in states with stricter standards.

Main Outcome Measures

Body mass index percentile and obesity status.

Results

In states that exceeded USDA standards, the difference in obesity prevalence between students who obtained free/reduced-price lunches and students who did not obtain school lunches was 12.3 percentage points smaller (95% CI, −21.5 to −3.0) compared with states that did not exceed USDA standards. Likewise, differences in mean body mass index percentile between those student populations were 11 units smaller in states that exceeded USDA standards (95% CI, −17.7 to −4.3). There was little evidence that students compensated for school meal laws by purchasing more sweets, salty snacks, or sugar-sweetened beverages from other school venues (eg, vending machines) or other sources (eg, fast food).

Conclusions and Relevance

Stringent school meal standards that reflect the latest nutrition science may improve weight status among school lunch participants, particularly those eligible for free/reduced-price lunches.

Call for Papers for 2014 Theme Issue of JAMA Pediatrics Media, Technology, and Pediatric Health Call for Papers for 2014 Theme Issue

Christakis D, Rivara FP. — Sat, 01 Jun 2013 00:00:00 GMT

In May of 2006, the Archives of Pediatrics & Adolescent Medicine (now JAMA Pediatrics) published a theme issue on children and media. At the time, our call for papers stressed that the media exerted broad and diverse effects on children of all ages. That is more true now than it was then, and, in fact, the media have evolved considerably in just 7 years. There were no tablets or smartphones in 2006, nor was there Twitter, and Facebook was in its infancy. The explosion of these new technologies and new platforms has created additional ways for children to be affected by media both positively and negatively, and it has also opened new avenues for reaching parents and patients and influencing health and health behaviors.

Cardiac Status of Children Infected With Human Immunodeficiency Virus Who Are Receiving Long-term Combination Antiretroviral Therapy Results From the Adolescent Master Protocol of the Multicenter Pediatric HIV/AIDS Cohort Study Cardiac Status of HIV-Infected Children

Lipshultz SE, Williams PL, Wilkinson JD, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

Prior to contemporary antiretroviral therapies (ARTs), children infected with human immunodeficiency virus (HIV) were more likely to have heart failure. This study suggests that highly active ART (HAART) does not appear to impair heart function.

Objective

To determine the cardiac effects of prolonged exposure to HAART on HIV-infected children.

Design

In the National Institutes of Health–funded Pediatric HIV/AIDS Cohort Study's Adolescent Master Protocol (AMP), we used linear regression models to compare echocardiographic measures.

Setting

A total of 14 US pediatric HIV clinics.

Participants

Perinatally HIV-infected children receiving HAART (n = 325), HIV-exposed but uninfected children (n = 189), and HIV-infected (mostly HAART-unexposed) historical pediatric controls from the National Institutes of Health–funded Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV Infection (P²C²-HIV) Study (n = 70).

Exposure

Long-term HAART.

Main Outcomes and Measures

Echocardiographic measures of left ventricular (LV) function and structure.

Results

The 325 AMP HIV-infected children had lower viral loads, higher CD4 counts, and longer durations of ART than did the 70 HIV-infected children from the P²C²-HIV Study (all P < .001). The z scores for LV fractional shortening (a measure of cardiac function) were significantly lower among HIV-infected children from the P²C²-HIV Study than among the AMP HIV-infected group or the 189 AMP HIV-exposed but uninfected controls (P < .05). For HIV-infected children, a lower nadir CD4 percentage and a higher current viral load were associated with significantly lower cardiac function (LV contractility and LV fractional shortening z scores; all P = .001) and an increased LV end-systolic dimension z score (all P < .03). In an interaction analysis by HIV-infected cohort, the HIV-infected children from the P²C²-HIV Study with a longer ART exposure or a lower nadir CD4 percentage had lower mean LV fractional shortening z scores, whereas the mean z scores were relatively constant among AMP HIV-infected children (P < .05 for all interactions).

Conclusions and Relevance

Long-term HAART appears to be cardioprotective for HIV-infected children and adolescents.

Deconstructing Debriefing for Simulation-Based Education Debriefing for Simulation-Based Education

Edelson DP, LaFond CM. — Sat, 01 Jun 2013 00:00:00 GMT

Simulation-based education has become increasingly popular in medicine, especially for rare, complex, and high-risk events such as cardiac resuscitations. Championed by the patient safety movement and supported by technological advances in patient simulators, it is difficult to find training programs today that do not use the technique in some form. However, the implementation of simulation often varies so widely, both across and within institutions, that the findings are difficult to generalize and variables, such as the level of realism, experience of the instructor, and content of the debriefing, are often insufficiently described to replicate. That was not the case with the Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing (EXPRESS) trial, an ambitious multicenter, randomized study, the results of which are published in this issue of JAMA Pediatrics. In it, the investigators developed a debriefing script for leading Pediatric Advanced Life Support instructors through a postsimulation debrief, covering both medical management and team dynamics, and demonstrated that its use, in the hands of novice instructors, was associated with greater improvements in knowledge and subsequent team leader performance. In addition, the trial demonstrated no benefit to high realism simulator technology. This study affirms the relative importance of debriefing in simulation-based education and establishes a roadmap for generalized dissemination of the technique in a reproducible format.

Electronic Media–Based Health Interventions Promoting Behavior Change in Youth A Systematic Review Electronic Media–Based Health Interventions

Hieftje K, Edelman E, Camenga DR, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

Little research has been done on the efficacy of electronic media–based interventions, especially on their effect on health or safety behavior. The current review systematically identified and evaluated electronic media–based interventions that focused on promoting health and safety behavior change in youth.

Objective

To assess the type and quality of the studies evaluating the effects of electronic media–based interventions on health and safety behavior change.

Evidence Review

Studies were identified from searches in MEDLINE (1950 through September 2010) and PsycINFO (1967 through September 2010). The review included published studies of interventions that used electronic media and focused on changes in behavior related to health or safety in children aged 18 years or younger.

Findings

Nineteen studies met the criteria and focused on at least 1 behavior change outcome. The focus was interventions related to physical activity and/or nutrition in 7 studies, on asthma in 6, safety behaviors in 3, sexual risk behaviors in 2, and diabetes mellitus in 1. Seventeen studies reported at least 1 statistically significant effect on behavior change outcomes, including an increase in fruit, juice, or vegetable consumption; an increase in physical activity; improved asthma self-management; acquisition of street and fire safety skills; and sexual abstinence. Only 5 of the 19 studies were rated as excellent.

Conclusions and Relevance

Our systematic review suggests that interventions using electronic media can improve health and safety behaviors in young persons, but there is a need for higher-quality, rigorous interventions that promote behavior change.

Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing A Multicenter Randomized Trial Pediatric Resuscitation Education

Cheng A, Hunt EA, Donoghue A, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

Resuscitation training programs use simulation and debriefing as an educational modality with limited standardization of debriefing format and content. Our study attempted to address this issue by using a debriefing script to standardize debriefings.

Objective

To determine whether use of a scripted debriefing by novice instructors and/or simulator physical realism affects knowledge and performance in simulated cardiopulmonary arrests.

Design

Prospective, randomized, factorial study design.

Setting

The study was conducted from 2008 to 2011 at 14 Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing (EXPRESS) network simulation programs. Interprofessional health care teams participated in 2 simulated cardiopulmonary arrests, before and after debriefing.

Participants

We randomized 97 participants (23 teams) to nonscripted low-realism; 93 participants (22 teams) to scripted low-realism; 103 participants (23 teams) to nonscripted high-realism; and 94 participants (22 teams) to scripted high-realism groups.

Intervention

Participants were randomized to 1 of 4 arms: permutations of scripted vs nonscripted debriefing and high-realism vs low-realism simulators.

Main Outcomes and Measures

Percentage difference (0%-100%) in multiple choice question (MCQ) test (individual scores), Behavioral Assessment Tool (BAT) (team leader performance), and the Clinical Performance Tool (CPT) (team performance) scores postintervention vs preintervention comparison (PPC).

Results

There was no significant difference at baseline in nonscripted vs scripted groups for MCQ (P = .87), BAT (P = .99), and CPT (P = .95) scores. Scripted debriefing showed greater improvement in knowledge (mean [95% CI] MCQ-PPC, 5.3% [4.1%-6.5%] vs 3.6% [2.3%-4.7%]; P = .04) and team leader behavioral performance (median [interquartile range (IQR)] BAT-PPC, 16% [7.4%-28.5%] vs 8% [0.2%-31.6%]; P = .03). Their improvement in clinical performance during simulated cardiopulmonary arrests was not significantly different (median [IQR] CPT-PPC, 7.9% [4.8%-15.1%] vs 6.7% [2.8%-12.7%], P = .18). Level of physical realism of the simulator had no independent effect on these outcomes.

Conclusions and Relevance

The use of a standardized script by novice instructors to facilitate team debriefings improves acquisition of knowledge and team leader behavioral performance during subsequent simulated cardiopulmonary arrests. Implementation of debriefing scripts in resuscitation courses may help to improve learning outcomes and standardize delivery of debriefing, particularly for novice instructors.

Examining Pregnant Women's Hostile Attributions About Infants as a Predictor of Offspring Maltreatment Women's Hostile Attributions About Offspring

Berlin LJ, Dodge KA, Reznick J. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

Child maltreatment is a serious public health problem that disproportionately affects infants and toddlers. In the interest of informing prevention and intervention efforts, this study examined pregnant women's attributions about infants as a risk factor for child maltreatment and harsh parenting during their children's first and second years. We also provide specific methods for practitioners to assess hostile attributions.

Objective

To evaluate pregnant women's hostile attributions about infants as a risk factor for early child maltreatment and harsh parenting.

Design

Prospective longitudinal study.

Setting

A small Southeastern city and its surrounding county.

Participants

A diverse, community-based sample of 499 pregnant women.

Main Outcomes and Measures

Official records of child maltreatment and mother-reported harsh parenting behaviors. Hostile attributions were examined in terms of women's beliefs about infants' negative intentions (eg, the extent to which infants purposefully dirty their diapers).

Results

Mothers' hostile attributions increased the likelihood that their child would be maltreated by the age of 26 months (adjusted odds ratio, 1.26 [90% CI, 1.02-1.56]). Mothers who made more hostile attributions during pregnancy reported engaging in more harsh parenting behaviors when their children were toddlers (β = 0.14, P < .05). Both associations were robust to the inclusion of 7 psychosocial covariates.

Conclusions and Relevance

A pregnant woman's hostile attributions about infant's intentions signal risk for maltreatment and harsh parenting of her child during the first years of life. Practitioners' attention to women's hostile attributions may help identify those in need of immediate practitioner input and/or referral to parenting services.

Factors That Influence Parental Decisions to Participate in Clinical Research Consenters vs Nonconsenters Consent in Pediatric Clinical Trials

Hoberman A, Shaikh N, Bhatnagar S, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

A child's health, positive perceptions of the research team and consent process, and altruistic motives play significant roles in the decision-making process for parents who consent for their child to enroll in clinical research. This study identified that nonconsenting parents were better educated, had private insurance, showed lower levels of altruism, and less understanding of study design.

Objective

To determine the factors associated with parental consent for their child's participation in a randomized, placebo-controlled trial.

Design

Cross-sectional survey conducted from July 2008 to May 2011. The survey was an ancillary study to the Randomized Intervention for Children with VesicoUreteral Reflux Study.

Setting

Seven children's hospitals participating in a randomized trial evaluating management of children with vesicoureteral reflux.

Participants

Parents asked to provide consent for their child's participation in the randomized trial were invited to complete an anonymous online survey about factors influencing their decision. A total of 120 of the 271 (44%) invited completed the survey; 58 of 125 (46%) who had provided consent and 62 of 144 (43%) who had declined consent completed the survey.

Main Outcomes and Measures

A 60-question survey examining child, parent, and study characteristics; parental perception of the study; understanding of the design; external influences; and decision-making process.

Results

Having graduated from college and private health insurance were associated with a lower likelihood of providing consent. Parents who perceived the trial as having a low degree of risk, resulting in greater benefit to their child and other children, causing little interference with standard care, or exhibiting potential for enhanced care, or who perceived the researcher as professional were significantly more likely to consent to participate. Higher levels of understanding of the randomization process, blinding, and right to withdraw were significantly positively associated with consent to participate.

Conclusions and Relevance

Parents who declined consent had a relatively higher socioeconomic status, had more anxiety about their decision, and found it harder to make their decision compared with consenting parents, who had higher levels of trust and altruism, perceived the potential for enhanced care, reflected better understanding of randomization, and exhibited low decisional uncertainty. Consideration of the factors included in the conceptual model should enhance the quality of the informed consent process and improve participation in pediatric clinical trials.

Havasu Falls, Supai, Arizona. 2004

Sat, 01 Jun 2013 00:00:00 GMT

Photographer: Mark H. Christianson, Seattle, Washington, 2004.

Impact of Specific Medical Interventions in Early Childhood on Increasing the Prevalence of Later Intellectual Disability Medical Interventions and Intellectual Disability

Brosco JP, Sanders LM, Dowling M, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

For the past 100 years, medicine in industrialized nations has become increasingly focused on specific medical interventions designed to improve the health of individual patients. Substantial evidence suggests that broader improvements in public health, nutrition, and economic well-being are more salient than medical or surgical interventions for the remarkable decrease in infant and child deaths since 1900. Less is known about the impact of specific medical interventions on morbidity such as intellectual disability (ID).

Objective

To explore the impact of medical interventions in early childhood on increasing the prevalence of later ID, as reported in the literature from 1950 through 2000.

Design

We reviewed the medical literature and other data from 1950 through 2000 to construct estimates of the condition-specific prevalence of ID over time. We further explored the existing literature to document historically relevant influences on condition-specific prevalence, including the introduction of effective interventions, the timing of these introductions, and the likelihood of their widespread use.

Setting

Twentieth century United States and Western Europe.

Participants

Populations of children who received a life-saving intervention within the first 5 years of life and were evaluated for ID after 5 years of age.

Main Outcome Measures

Case-specific prevalence of ID from 1950 through 2000.

Results

Low birth weight is associated with approximately 10% to 15% of the total prevalence of ID. No other new medical therapies introduced during this period were associated with a clinically significant increase in ID prevalence.

Conclusions and Relevance

Previous research has shown that specific medical interventions, such as newborn screening for congenital thyroid deficiency and phenylketonuria, have decreased the prevalence of ID approximately 16% in the United States since 1950. These results suggest that other medical interventions, particularly the advent of intensive care technologies, have also increased the prevalence of ID.

Medicaid Expansion Good for Children, Their Parents, and Providers Medicaid Expansion

Carroll AE, Frakt AB. — Sat, 01 Jun 2013 00:00:00 GMT

Since the passage of the State Children's Health Insurance Program (SCHIP) in 1997, the percentage of uninsured children in the United States has decreased dramatically. In the year before its passage, 16% of children were uninsured. In 2011, only 9.4% of children remained without coverage. Together, Medicaid and SCHIP cover more than one-third of children in the United States.

Picture of the Month—Diagnosis

Sat, 01 Jun 2013 00:00:00 GMT

Picture of the Month—Quiz Case

Johnson EF, Lau EG, Smidt AC. — Sat, 01 Jun 2013 00:00:00 GMT

A 5-year-old girl presented with a 2½-year history of persistently dry, itchy, tender skin around the mouth. The mother denied frequent lip licking. Treatment involved topical antibiotics, hydrocortisone cream, and lip balms, without improvement. She was afebrile and otherwise healthy. There was no family history of similar dermatologic conditions. Examination demonstrated marked erythema and prominent scale periorally with blurring of the vermilion border (Figure 1). There was no warmth or drainage. Complete mucocutaneous examination revealed inflammation and edema of the upper gingival margins without ulceration. Her upper front teeth were covered with metal caps (Figure 2). Erythematous, scaly plaques on the bilateral earlobes were also noted (Figure 3).

Playing the Odds

Stein J. — Sat, 01 Jun 2013 00:00:00 GMT

The early devastation of the human immunodeficiency virus (HIV) plague coincided with my formative years as a young adult and as a new physician. Even now, these years retain a distinct brilliance among my memories, more salient than those before or since. In the subsequent decades, I have gradually transitioned into a sedate middle age, and the HIV plague has similarly settled into a more routine narrative of a serious but manageable, almost normal, disease, albeit one that continues to cause much heartache to this day. Yet I cannot forget the days when it was a mysterious terror with unknown powers, spreading inexorably like our worst nightmares of the archetypal bubonic plague itself.

Prevalence of Allergic Disease in Foreign-Born American Children Allergic Disease in Foreign-Born Americans

Silverberg JI, Simpson EL, Durkin HG, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

Improved understanding of allergic disease epidemiology lead to novel therapeutic and prevention strategies.

Objectives

To study the association between US birthplace and prevalence of childhood allergic disease and to determine the effects of prolonged US residence on allergic disease.

Design, Setting, Participants

Cross-sectional questionnaire distributed to 91 642 children aged 0 to 17 years enrolled in the 2007-2008 National Survey of Children's Health.

Exposure

Place of birth.

Main Outcome and Measure

Prevalence of allergic disease, including asthma, eczema, hay fever, and food allergies.

Results

Children born outside the United States had significantly lower odds of any atopic disorders than those born in the United States (logistic regression OR, 0.48; 95% CI, 0.38-0.61), including ever-asthma (0.53; 0.39-0.72), current-asthma (0.34; 0.23-0.51), eczema (0.43; 0.30-0.61), hay fever (0.39; 0.27-0.55), and food allergies (0.60; 0.37-0.99). The associations between child's birthplace and atopic disorders remained significant in multivariate models including age, sex, race/ethnicity, annual household income, residence in metropolitan areas, and history of child moving to a new address. Children born outside the United States whose parents were also born outside the United States had significantly lower odds of any atopic disorders than those whose parents were born in the United States (P = .005). Children born outside the United States who lived in the United States for longer than 10 years when compared with those who resided for only 0 to 2 years had significantly higher odds of developing any allergic disorders (adjusted OR, 3.04; 95% CI, 1.08-8.60), including eczema (4.93; 1.18-20.62; P = .03) and hay fever (6.25; 1.70-22.96) but not asthma or food allergies (P ≥ .06).

Conclusions and Relevance

Children born outside the United States have a lower prevalence allergic disease that increases after residing in the United States for 1 decade.

Psychological Distress in Parents of Children With Advanced Cancer Parent Psychological Distress in Pediatric Cancer

Rosenberg AR, Dussel V, Kang T, et al. — Sat, 01 Jun 2013 00:00:00 GMT

Importance

Parent psychological distress can impact the well-being of childhood cancer patients and other children in the home. Recognizing and alleviating factors of parent distress may improve overall family survivorship experiences following childhood cancer.

Objectives

To describe the prevalence and factors of psychological distress (PD) among parents of children with advanced cancer.

Design

Cohort study embedded within a randomized clinical trial (Pediatric Quality of Life and Evaluation of Symptoms Technology [PediQUEST] study).

Setting

Multicenter study conducted at 3 children's hospitals (Boston Children's Hospital, Children's Hospital of Philadelphia, and Seattle Children's Hospital).

Participants

Parents of children with advanced (progressive, recurrent, or refractory) cancer.

Main Outcome Measure

Parental PD, as measured by the Kessler-6 Psychological Distress Scale.

Results

Eighty-six of 104 parents completed the Survey About Caring for Children With Cancer (83% participation); 81 parents had complete Kessler-6 Psychological Distress Scale data. More than 50% of parents reported high PD and 16% met criteria for serious PD (compared with US prevalence of 2%-3%). Parent perceptions of prognosis, goals of therapy, child symptoms/suffering, and financial hardship were associated with PD. In multivariate analyses, average parent Kessler-6 Psychological Distress Scale scores were higher among parents who believed their child was suffering highly and who reported great economic hardship. Conversely, PD was significantly lower among parents whose prognostic understanding was aligned with concrete goals of care.

Conclusions and Relevance

Parenting a child with advanced cancer is strongly associated with high to severe levels of PD. Interventions aimed at aligning prognostic understanding with concrete care goals and easing child suffering and financial hardship may mitigate parental PD.

School Meals A Starting Point for Countering Childhood Obesity School Meals

Nestle M. — Sat, 01 Jun 2013 00:00:00 GMT

On December 11, 2012, the New York Times devoted its front-page, right-hand column—the most important news of the day—to a welcome surprise: several cities were reporting declines in the prevalence of childhood obesity. Although the declines were small, 5% or less, they were hopeful signs of a possible reverse in the sharp increase in childhood obesity observed since the early 1980s. And although the cause of the reversals could not be definitively established, the cities reporting them were the ones that had made “strong, far-reaching changes—those that make healthy foods available in schools and communities and integrate physical activity into people's daily lives.”

The Adolescence of Child Health Services Research Child Health Services Research

Simpson LA. — Sat, 01 Jun 2013 00:00:00 GMT

It has been 15 years since child health services research (CHSR) began emerging as a distinct field, living at the intersection of the greater health services research (HSR) community and the pediatric research world. In 1999, an invitational conference explored the state of the science in CHSR, including public and private funding opportunities, networks for conducting research, and uses of research in policy and practice. Since that time, CHSR has become listed as a distinct topic in the National Library of Medicine's HSR resource center, and child health is an annual theme at the Annual Research Meeting of AcademyHealth. We have also learned much about the care that children and adolescents receive—its safety, quality, and effectiveness—and about which children are most at risk for poor health outcomes. Health policy has been successfully informed by CHSR, most notably in the reauthorization of the Children's Health Insurance Program. Finally, a decade of quality efforts is resulting in care improvements, albeit modest ones and not for all children.

Omission in eTable in: Prevention of Adult Obesity: How Much Weight Change Is Necessary for Normalization of Weight Status in Children?

Sat, 01 Jun 2013 00:00:00 GMT

Omission in eTable. In the Original Article titled “Indicated Prevention of Adult Obesity: How Much Weight Change Is Necessary for Normalization of Weight Status in Children?” by Goldschmidt et al, published online November 5, 2012, and also in the January 2013 issue of JAMA Pediatrics (2013;167[1]:21-26), a footnote was inadvertently omitted from the eTable, and an eReference also should have appeared in the Supplement. In the Supplement, a citation for footnote a should have been attached to the eTable title, and the corresponding footnote below the eTable should have read as follows: “^aWeight thresholds were calculated from Centers for Disease Control and Prevention height growth data.¹” The corresponding eReference should have been given as follows: 1. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Adv Data. June 8, 2000;(314):1-27.