Christine Kilgore

Azithromycin may be an adequate agent for treating drug-resistant shigellosis, but physicians need to be aware that interpreting susceptibility of Shigella sonnei to it using standard in vitro susceptibility testing is difficult, investigators at Johns Hopkins University have reported.

Antimicrobial-resistant S. sonnei—the most common serogroup in the United States—is a growing problem in the United States, and azithromycin is recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America as an oral agent for the treatment of shigellosis that can be used as an alternative to ampicillin or trimethoprim/sulfamethoxazole (TS).

There are no guidelines for in vitro azithromycin susceptibility testing for Shigella, however, and there is a lack of adequate data correlating the drug's minimal inhibitory concentration—a key component of what's measured during susceptibility testing—with clinical efficacy for the treatment of shigellosis.

In their own testing of azithromycin susceptibility, the investigators found that there were two zones of inhibition of growth for S. sonnei isolates, and that interpretations of susceptibility for a particular isolate can vary by which zone is used.

“Because azithromycin … is being increasingly used in the United States, there is an urgent need for development of validated in vitro antimicrobial breakpoints,” reported Sanjay K. Jain, M.D., and colleagues at Johns Hopkins (Pediatr. Infect. Dis. J. 2005;24:494–7).

Many pediatricians prescribe antimicrobials for children with shigellosis because they shorten the duration of illness and hasten bacteriologic cure, they said.

The investigators reviewed all Shigella isolates submitted to the Johns Hopkins microbiology laboratory during 1996–2000 and 2002—the year in which an outbreak of Shigella was observed at Johns Hopkins and nationally.

Of the 111 isolates submitted during the 1996–2000 period, 63% were resistant to ampicillin, 12% were resistant to TS, and 7% were multiresistant (resistant to both drugs).

In 2002, among 205 isolates submitted, 91% were resistant to ampicillin, 67% were resistant to TS, and 65% were multiresistant, the investigators reported.

Azithromycin may be an adequate agent for treating drug-resistant shigellosis, but physicians need to be aware that interpreting susceptibility of Shigella sonnei to it using standard in vitro susceptibility testing is difficult, investigators at Johns Hopkins University have reported.

Antimicrobial-resistant S. sonnei—the most common serogroup in the United States—is a growing problem in the United States, and azithromycin is recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America as an oral agent for the treatment of shigellosis that can be used as an alternative to ampicillin or trimethoprim/sulfamethoxazole (TS).

There are no guidelines for in vitro azithromycin susceptibility testing for Shigella, however, and there is a lack of adequate data correlating the drug's minimal inhibitory concentration—a key component of what's measured during susceptibility testing—with clinical efficacy for the treatment of shigellosis.

In their own testing of azithromycin susceptibility, the investigators found that there were two zones of inhibition of growth for S. sonnei isolates, and that interpretations of susceptibility for a particular isolate can vary by which zone is used.

“Because azithromycin … is being increasingly used in the United States, there is an urgent need for development of validated in vitro antimicrobial breakpoints,” reported Sanjay K. Jain, M.D., and colleagues at Johns Hopkins (Pediatr. Infect. Dis. J. 2005;24:494–7).

Many pediatricians prescribe antimicrobials for children with shigellosis because they shorten the duration of illness and hasten bacteriologic cure, they said.

The investigators reviewed all Shigella isolates submitted to the Johns Hopkins microbiology laboratory during 1996–2000 and 2002—the year in which an outbreak of Shigella was observed at Johns Hopkins and nationally.

Of the 111 isolates submitted during the 1996–2000 period, 63% were resistant to ampicillin, 12% were resistant to TS, and 7% were multiresistant (resistant to both drugs).

In 2002, among 205 isolates submitted, 91% were resistant to ampicillin, 67% were resistant to TS, and 65% were multiresistant, the investigators reported.

Azithromycin may be an adequate agent for treating drug-resistant shigellosis, but physicians need to be aware that interpreting susceptibility of Shigella sonnei to it using standard in vitro susceptibility testing is difficult, investigators at Johns Hopkins University have reported.

Antimicrobial-resistant S. sonnei—the most common serogroup in the United States—is a growing problem in the United States, and azithromycin is recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America as an oral agent for the treatment of shigellosis that can be used as an alternative to ampicillin or trimethoprim/sulfamethoxazole (TS).

There are no guidelines for in vitro azithromycin susceptibility testing for Shigella, however, and there is a lack of adequate data correlating the drug's minimal inhibitory concentration—a key component of what's measured during susceptibility testing—with clinical efficacy for the treatment of shigellosis.

In their own testing of azithromycin susceptibility, the investigators found that there were two zones of inhibition of growth for S. sonnei isolates, and that interpretations of susceptibility for a particular isolate can vary by which zone is used.

“Because azithromycin … is being increasingly used in the United States, there is an urgent need for development of validated in vitro antimicrobial breakpoints,” reported Sanjay K. Jain, M.D., and colleagues at Johns Hopkins (Pediatr. Infect. Dis. J. 2005;24:494–7).

Many pediatricians prescribe antimicrobials for children with shigellosis because they shorten the duration of illness and hasten bacteriologic cure, they said.

The investigators reviewed all Shigella isolates submitted to the Johns Hopkins microbiology laboratory during 1996–2000 and 2002—the year in which an outbreak of Shigella was observed at Johns Hopkins and nationally.

Of the 111 isolates submitted during the 1996–2000 period, 63% were resistant to ampicillin, 12% were resistant to TS, and 7% were multiresistant (resistant to both drugs).

In 2002, among 205 isolates submitted, 91% were resistant to ampicillin, 67% were resistant to TS, and 65% were multiresistant, the investigators reported.

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill, low BMI, and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with high functional scores had lower BMI and shorter preoperative symptoms, reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge.

MRI demonstrated good repair-tissue fill in the defect in 55% of patients, moderate fill in 29%, and poor fill in 17%. Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” he said. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with also had higher BMI and a longer duration of symptoms, he reported.

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill, low BMI, and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with high functional scores had lower BMI and shorter preoperative symptoms, reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge.

MRI demonstrated good repair-tissue fill in the defect in 55% of patients, moderate fill in 29%, and poor fill in 17%. Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” he said. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with also had higher BMI and a longer duration of symptoms, he reported.

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill, low BMI, and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with high functional scores had lower BMI and shorter preoperative symptoms, reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge.

MRI demonstrated good repair-tissue fill in the defect in 55% of patients, moderate fill in 29%, and poor fill in 17%. Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” he said. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with also had higher BMI and a longer duration of symptoms, he reported.

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

“Be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” urged Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–54).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins. (Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGNR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said that they hypothesize the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”—just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic, the investigators reported.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/eL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued.

His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

“Be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” urged Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–54).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins. (Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGNR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said that they hypothesize the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”—just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic, the investigators reported.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/eL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued.

His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

“Be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” urged Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–54).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins. (Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGNR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said that they hypothesize the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”—just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic, the investigators reported.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/eL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued.

His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

WASHINGTON — At least 13% of all adolescents and 54% of overweight teens are insulin resistant, and a significant proportion of these adolescents have metabolic syndrome—even according to adult definitions.

These findings, reported in various presentations at the annual meeting of the Pediatric Academic Societies, add to knowledge of the increasing prevalence of metabolic syndrome in U.S. youth.

The findings come from analyses of 1999–2000 data from the National Health and Nutrition Examination Survey (NHANES), and thus represent a national sample of U.S. adolescents.

The prevalence of the syndrome, using age-specific criteria applied to the National Cholesterol Education Program (NCEP) definition, has been reported as 4% of U.S. adolescents in 1988–1994, and 7% in 1999–2000.

The new analyses show that rates of metabolic syndrome remain sizable when teens are identified according to the two known adult definitions of the syndrome, rather than with the use of age-specific criteria.

“There is a controversy about how we should define [metabolic syndrome] in kids. Here we treated teens like adults, and we still found a significant number,” said Stephen Cook, M.D., who presented most of the findings at the meeting, in a later interview.

“These are kids who are already manifesting adult cardiovascular health problems … who could potentially be very disabled by their health early on,” he said. “You're not going to prescribe statins, but these kids need to improve their lifestyle.”

Dr. Cook and his colleagues at the American Academy of Pediatrics' Center for Child Health Research at the University of Rochester (N.Y.) analyzed the NHANES data for almost 940 adolescents, aged 12–19 years, who had not eaten for 6 hours.

Less than 5% had metabolic syndrome using the NCEP definition, and more than 5% had the syndrome according to the definition of the World Health Organization. Among overweight teens, 25% met the NCEP criteria, and 30% met the WHO criteria, Dr. Cook reported at the meeting sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

The NCEP defines metabolic syndrome as three or more of five criteria: high triglycerides, low HDL, high blood pressure, abdominal obesity, and high fasting glucose.

The WHO requires a finding of insulin resistance—by either high fasting glucose or homeostasis model assessment (HOMA) of at least the 75th percentile—plus any two of the other criteria.

In looking specifically at insulin resistance, which Dr. Cook describes as “driving” the metabolic syndrome, the investigators used two validated surrogate markers: elevated fasting insulin levels and HOMA (insulin × glucose/22.5).

The markers have been shown to correlate well with euglycemic clamp techniques in children and adolescents. Insulin resistance is defined according to these markers as fasting insulin equal to or greater than 20 μU/mL, or HOMA greater than or equal to the top quartile of the nondiabetic population.

The investigators found that insulin resistance affected 25% of U.S. teens when it was defined by HOMA (predictably, since it's a statistical definition) and 13% when it was defined by hyperinsulinemia. There were no gender or age differences.

Overweight and at risk for overweight were significantly associated with insulin resistance by both definitions. By the HOMA definition, 39% of teens at risk for overweight and 72% of overweight teens were insulin resistant. By the hyperinsulinemia definition, these numbers were 18% and 54%, respectively.

The NHANES sample was “well distributed” in terms of weight, noted Dr. Cook of the Golisano Children's Hospital at Strong, part of the University of Rochester. He is trained in pediatrics and internal medicine.

In another analysis, Dr. Cook and his associates sought to determine the association of insulin resistance with the prevalence of metabolic syndrome (defined with age-specific criteria) for this U.S. sample.

They found that more than 25% of adolescents who were insulin resistant by HOMA, and more than 40% of adolescents who were insulin resistant by the hyperinsulinemia definition had the metabolic syndrome.

“Insulin resistance is independently associated with not only the metabolic syndrome, but also with each of its components,” said Todd Florin, M.D., at the meeting. Dr. Florin, who worked with Dr. Cook as a medical student, is now a resident at the Children's Hospital of Philadelphia.

Measuring fasting insulin levels may be a “quick, inexpensive” method for assessing insulin resistance, and risk for metabolic syndrome, in adolescents, he said.

Some degree of insulin resistance is associated with puberty and is transient, Dr. Cook noted. “So while there may be 54% of overweight kids with insulin resistance, we might find it's less if we could follow them over time.”

Still, he said, the rates would remain significant—as would the fact that “metabolic syndrome and insulin resistance do predict diabetes and heart disease.”

Metabolic Syndrome: Not Just for Teens Anymore

Nearly 4% of children ages 5–11 years, and 17% of overweight children, met criteria for metabolic syndrome in a separate analysis performed by Dr. Cook and his associates.

Here they used data from the National Health and Nutrition Examination Survey III, which spanned from 1988 to 1994, rather than the more recent NHANES data that they used for their study of adolescents.

The more recent survey data did not contain enough of the elements needed to evaluate age-specific criteria for metabolic syndrome for children under 8 years of age, explained Dr. Cook.

Although the data are older, the study is the first to document metabolic syndrome in a national sample of children, he said.

Another study reported recently at the annual meeting of the American College of Sports Medicine documented metabolic syndrome in as many as 5% of 7- to 9-year-olds in Kansas. (“Insulin Resistance in 5% of Youngsters,” July 1, 2005, p. 1).

The NHANES study did not reveal any significant differences in the prevalence of metabolic syndrome by age, region of the country, or poverty level.

Gender and ethnic differences were significant, however. Almost 3% of boys and 6% of girls met criteria for the syndrome.

Metabolic syndrome was also identified in approximately 7% of Mexican Americans, 5% of whites, and 3% of African Americans.

Less than 1% of normal-weight children met the criteria, as opposed to 6% of those at risk for overweight, and 17% of overweight children.

Among overweight children, 41% had one risk factor for the syndrome, and 24% had two risk factors, Dr. Cook reported.

WASHINGTON — At least 13% of all adolescents and 54% of overweight teens are insulin resistant, and a significant proportion of these adolescents have metabolic syndrome—even according to adult definitions.

These findings, reported in various presentations at the annual meeting of the Pediatric Academic Societies, add to knowledge of the increasing prevalence of metabolic syndrome in U.S. youth.

The findings come from analyses of 1999–2000 data from the National Health and Nutrition Examination Survey (NHANES), and thus represent a national sample of U.S. adolescents.

The prevalence of the syndrome, using age-specific criteria applied to the National Cholesterol Education Program (NCEP) definition, has been reported as 4% of U.S. adolescents in 1988–1994, and 7% in 1999–2000.

The new analyses show that rates of metabolic syndrome remain sizable when teens are identified according to the two known adult definitions of the syndrome, rather than with the use of age-specific criteria.

“There is a controversy about how we should define [metabolic syndrome] in kids. Here we treated teens like adults, and we still found a significant number,” said Stephen Cook, M.D., who presented most of the findings at the meeting, in a later interview.

“These are kids who are already manifesting adult cardiovascular health problems … who could potentially be very disabled by their health early on,” he said. “You're not going to prescribe statins, but these kids need to improve their lifestyle.”

Dr. Cook and his colleagues at the American Academy of Pediatrics' Center for Child Health Research at the University of Rochester (N.Y.) analyzed the NHANES data for almost 940 adolescents, aged 12–19 years, who had not eaten for 6 hours.

Less than 5% had metabolic syndrome using the NCEP definition, and more than 5% had the syndrome according to the definition of the World Health Organization. Among overweight teens, 25% met the NCEP criteria, and 30% met the WHO criteria, Dr. Cook reported at the meeting sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

The NCEP defines metabolic syndrome as three or more of five criteria: high triglycerides, low HDL, high blood pressure, abdominal obesity, and high fasting glucose.

The WHO requires a finding of insulin resistance—by either high fasting glucose or homeostasis model assessment (HOMA) of at least the 75th percentile—plus any two of the other criteria.

In looking specifically at insulin resistance, which Dr. Cook describes as “driving” the metabolic syndrome, the investigators used two validated surrogate markers: elevated fasting insulin levels and HOMA (insulin × glucose/22.5).

The markers have been shown to correlate well with euglycemic clamp techniques in children and adolescents. Insulin resistance is defined according to these markers as fasting insulin equal to or greater than 20 μU/mL, or HOMA greater than or equal to the top quartile of the nondiabetic population.

The investigators found that insulin resistance affected 25% of U.S. teens when it was defined by HOMA (predictably, since it's a statistical definition) and 13% when it was defined by hyperinsulinemia. There were no gender or age differences.

Overweight and at risk for overweight were significantly associated with insulin resistance by both definitions. By the HOMA definition, 39% of teens at risk for overweight and 72% of overweight teens were insulin resistant. By the hyperinsulinemia definition, these numbers were 18% and 54%, respectively.

The NHANES sample was “well distributed” in terms of weight, noted Dr. Cook of the Golisano Children's Hospital at Strong, part of the University of Rochester. He is trained in pediatrics and internal medicine.

In another analysis, Dr. Cook and his associates sought to determine the association of insulin resistance with the prevalence of metabolic syndrome (defined with age-specific criteria) for this U.S. sample.

They found that more than 25% of adolescents who were insulin resistant by HOMA, and more than 40% of adolescents who were insulin resistant by the hyperinsulinemia definition had the metabolic syndrome.

“Insulin resistance is independently associated with not only the metabolic syndrome, but also with each of its components,” said Todd Florin, M.D., at the meeting. Dr. Florin, who worked with Dr. Cook as a medical student, is now a resident at the Children's Hospital of Philadelphia.

Measuring fasting insulin levels may be a “quick, inexpensive” method for assessing insulin resistance, and risk for metabolic syndrome, in adolescents, he said.

Some degree of insulin resistance is associated with puberty and is transient, Dr. Cook noted. “So while there may be 54% of overweight kids with insulin resistance, we might find it's less if we could follow them over time.”

Still, he said, the rates would remain significant—as would the fact that “metabolic syndrome and insulin resistance do predict diabetes and heart disease.”

Metabolic Syndrome: Not Just for Teens Anymore

Nearly 4% of children ages 5–11 years, and 17% of overweight children, met criteria for metabolic syndrome in a separate analysis performed by Dr. Cook and his associates.

Here they used data from the National Health and Nutrition Examination Survey III, which spanned from 1988 to 1994, rather than the more recent NHANES data that they used for their study of adolescents.

The more recent survey data did not contain enough of the elements needed to evaluate age-specific criteria for metabolic syndrome for children under 8 years of age, explained Dr. Cook.

Although the data are older, the study is the first to document metabolic syndrome in a national sample of children, he said.

Another study reported recently at the annual meeting of the American College of Sports Medicine documented metabolic syndrome in as many as 5% of 7- to 9-year-olds in Kansas. (“Insulin Resistance in 5% of Youngsters,” July 1, 2005, p. 1).

The NHANES study did not reveal any significant differences in the prevalence of metabolic syndrome by age, region of the country, or poverty level.

Gender and ethnic differences were significant, however. Almost 3% of boys and 6% of girls met criteria for the syndrome.

Metabolic syndrome was also identified in approximately 7% of Mexican Americans, 5% of whites, and 3% of African Americans.

Less than 1% of normal-weight children met the criteria, as opposed to 6% of those at risk for overweight, and 17% of overweight children.

Among overweight children, 41% had one risk factor for the syndrome, and 24% had two risk factors, Dr. Cook reported.

WASHINGTON — At least 13% of all adolescents and 54% of overweight teens are insulin resistant, and a significant proportion of these adolescents have metabolic syndrome—even according to adult definitions.

These findings, reported in various presentations at the annual meeting of the Pediatric Academic Societies, add to knowledge of the increasing prevalence of metabolic syndrome in U.S. youth.

The findings come from analyses of 1999–2000 data from the National Health and Nutrition Examination Survey (NHANES), and thus represent a national sample of U.S. adolescents.

The prevalence of the syndrome, using age-specific criteria applied to the National Cholesterol Education Program (NCEP) definition, has been reported as 4% of U.S. adolescents in 1988–1994, and 7% in 1999–2000.

The new analyses show that rates of metabolic syndrome remain sizable when teens are identified according to the two known adult definitions of the syndrome, rather than with the use of age-specific criteria.

“There is a controversy about how we should define [metabolic syndrome] in kids. Here we treated teens like adults, and we still found a significant number,” said Stephen Cook, M.D., who presented most of the findings at the meeting, in a later interview.

“These are kids who are already manifesting adult cardiovascular health problems … who could potentially be very disabled by their health early on,” he said. “You're not going to prescribe statins, but these kids need to improve their lifestyle.”

Dr. Cook and his colleagues at the American Academy of Pediatrics' Center for Child Health Research at the University of Rochester (N.Y.) analyzed the NHANES data for almost 940 adolescents, aged 12–19 years, who had not eaten for 6 hours.

Less than 5% had metabolic syndrome using the NCEP definition, and more than 5% had the syndrome according to the definition of the World Health Organization. Among overweight teens, 25% met the NCEP criteria, and 30% met the WHO criteria, Dr. Cook reported at the meeting sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

The NCEP defines metabolic syndrome as three or more of five criteria: high triglycerides, low HDL, high blood pressure, abdominal obesity, and high fasting glucose.

The WHO requires a finding of insulin resistance—by either high fasting glucose or homeostasis model assessment (HOMA) of at least the 75th percentile—plus any two of the other criteria.

In looking specifically at insulin resistance, which Dr. Cook describes as “driving” the metabolic syndrome, the investigators used two validated surrogate markers: elevated fasting insulin levels and HOMA (insulin × glucose/22.5).

The markers have been shown to correlate well with euglycemic clamp techniques in children and adolescents. Insulin resistance is defined according to these markers as fasting insulin equal to or greater than 20 μU/mL, or HOMA greater than or equal to the top quartile of the nondiabetic population.

The investigators found that insulin resistance affected 25% of U.S. teens when it was defined by HOMA (predictably, since it's a statistical definition) and 13% when it was defined by hyperinsulinemia. There were no gender or age differences.

Overweight and at risk for overweight were significantly associated with insulin resistance by both definitions. By the HOMA definition, 39% of teens at risk for overweight and 72% of overweight teens were insulin resistant. By the hyperinsulinemia definition, these numbers were 18% and 54%, respectively.

The NHANES sample was “well distributed” in terms of weight, noted Dr. Cook of the Golisano Children's Hospital at Strong, part of the University of Rochester. He is trained in pediatrics and internal medicine.

In another analysis, Dr. Cook and his associates sought to determine the association of insulin resistance with the prevalence of metabolic syndrome (defined with age-specific criteria) for this U.S. sample.

They found that more than 25% of adolescents who were insulin resistant by HOMA, and more than 40% of adolescents who were insulin resistant by the hyperinsulinemia definition had the metabolic syndrome.

“Insulin resistance is independently associated with not only the metabolic syndrome, but also with each of its components,” said Todd Florin, M.D., at the meeting. Dr. Florin, who worked with Dr. Cook as a medical student, is now a resident at the Children's Hospital of Philadelphia.

Measuring fasting insulin levels may be a “quick, inexpensive” method for assessing insulin resistance, and risk for metabolic syndrome, in adolescents, he said.

Some degree of insulin resistance is associated with puberty and is transient, Dr. Cook noted. “So while there may be 54% of overweight kids with insulin resistance, we might find it's less if we could follow them over time.”

Still, he said, the rates would remain significant—as would the fact that “metabolic syndrome and insulin resistance do predict diabetes and heart disease.”

Metabolic Syndrome: Not Just for Teens Anymore

Nearly 4% of children ages 5–11 years, and 17% of overweight children, met criteria for metabolic syndrome in a separate analysis performed by Dr. Cook and his associates.

Here they used data from the National Health and Nutrition Examination Survey III, which spanned from 1988 to 1994, rather than the more recent NHANES data that they used for their study of adolescents.

The more recent survey data did not contain enough of the elements needed to evaluate age-specific criteria for metabolic syndrome for children under 8 years of age, explained Dr. Cook.

Although the data are older, the study is the first to document metabolic syndrome in a national sample of children, he said.

Another study reported recently at the annual meeting of the American College of Sports Medicine documented metabolic syndrome in as many as 5% of 7- to 9-year-olds in Kansas. (“Insulin Resistance in 5% of Youngsters,” July 1, 2005, p. 1).

The NHANES study did not reveal any significant differences in the prevalence of metabolic syndrome by age, region of the country, or poverty level.

Gender and ethnic differences were significant, however. Almost 3% of boys and 6% of girls met criteria for the syndrome.

Metabolic syndrome was also identified in approximately 7% of Mexican Americans, 5% of whites, and 3% of African Americans.

Less than 1% of normal-weight children met the criteria, as opposed to 6% of those at risk for overweight, and 17% of overweight children.

Among overweight children, 41% had one risk factor for the syndrome, and 24% had two risk factors, Dr. Cook reported.

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said.

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said.

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

“We can delete (items from the record), as long as we note that something has been deleted and who did it,” said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a Webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

“The real reason patients don't ask to make deletions [now] is because most people don't look at their records,” he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), “now there's a federal right of access to medical records.”

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces “the idea that patients should be in control,” and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether “a patient [should] be able to delete accurate, factual information [from medical records],” he said.

The bottom line, however, is that “we're in the process of radically changing the medical record … into the patient's record,” Mr. Annas said.

There are “lots of mistakes in medical records,” making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate “you could argue that patients should be able to change anything,” he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that “patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added,” Mr. Annas explained.

The physicians who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH clinical social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. “He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him,” said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. “And if he wanted it out of a paper record, I'd still say yes,” though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from “physician's record” to “patient's record” would hinder communication among providers.

“Part of the purpose [of the medical record] is it helps individuals plan care,” said one physician. “So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers],” she said.

It's true, Mr. Annas said, that “defense attorneys still say today that your best defense is a complete medical record.”

Still, physicians, overall, “take the record too seriously” and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the content of the record before the visit ends, he said.

When James A. Taylor, M.D., and his colleagues found that an educational pamphlet and a video changed parents' attitudes about antibiotic use 2 years ago, they assumed that such a change would lead to fewer demands on pediatricians and fewer antibiotic prescriptions.

They were wrong.

In a randomized controlled trial, their educational intervention did not result in a decrease in antibiotic prescriptions.

Prescriptions were high over a 12-month postintervention period, with antibiotics prescribed during 46% of all visits for upper respiratory infection (URI) symptoms—regardless of whether the parent had received the pamphlet and video or another control intervention.

It could be that “although attitudes about antibiotic use were modified, parents still desired these medications when their child was ill,” said Dr. Taylor of the Child Health Institute at the University of Washington, Seattle, and his colleagues.

It's also possible that “pediatricians may have failed to detect a change in expectations for antibiotics by parents of children in the intervention group,” they wrote (Pediatr. Infect. Dis. J. 2005;24:489–93). Their study was conducted by the Puget Sound Pediatric Research Network, a regional practice-based research group composed of Seattle-area pediatricians.

Parents of 499 healthy children under age 2 years were enrolled at the time of an office visit and randomized to receive either a pamphlet and video promoting the judicious use of antibiotics (the intervention) or brochures about injury prevention (the control group).

The educational pamphlet, “Your Child and Antibiotics,” was developed by the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the American Society of Microbiology. The video was professionally produced and featured one of the physicians from the child's pediatric practice.

At the end of a 12-month period, each child's medical record was reviewed. Of 4,924 outpatient visits, almost 1,420 (29%) were for URI symptoms as the chief complaint. Pediatricians were not informed about which children/parents were involved in the project.

At least one antibiotic was prescribed during 46% of the visits for URI, 92% of which were for a diagnosis of otitis media or sinusitis. Antibiotics were prescribed at only 10 visits at which the only diagnosis made was URI and at 7 visits at which the diagnosis was bronchitis.

Overall, the “average” study patient had approximately 10 visits—a remarkably high level of utilization, the investigators noted—3 of which were visits for URI symptoms. The average patient also had two diagnoses of otitis media and received two prescriptions for antibiotics during the 12-month period. There were no significant differences in any of the outcomes—number of visits, specific diagnoses, or prescriptions—between children in the intervention and control groups.

Although antibiotics were “clearly indicated” for a proportion of patients with the diagnoses of otitis media or sinusitis, “it is equally certain that for a significant proportion … there was uncertainty regarding the diagnosis and/or need for antibiotic therapy, or the diagnosis was made by the practitioners to justify the use of antibiotics,” Dr. Taylor and his associates said.

In an earlier study of the pamphlet and video, they had found that these educational tools resulted in “changes in parental attitudes that were more supportive of the judicious use of [antibiotics],” the investigators said. “We postulated that if parental expectations could be altered by an educational intervention, pediatricians would perceive less demand for antibiotics and prescribe fewer of these medications.”

Now, they said, “it is clear that more research is needed to identify methods for reducing antibiotic use in children that are effective, inexpensive, and easily implemented.”

When James A. Taylor, M.D., and his colleagues found that an educational pamphlet and a video changed parents' attitudes about antibiotic use 2 years ago, they assumed that such a change would lead to fewer demands on pediatricians and fewer antibiotic prescriptions.

They were wrong.

In a randomized controlled trial, their educational intervention did not result in a decrease in antibiotic prescriptions.

Prescriptions were high over a 12-month postintervention period, with antibiotics prescribed during 46% of all visits for upper respiratory infection (URI) symptoms—regardless of whether the parent had received the pamphlet and video or another control intervention.

It could be that “although attitudes about antibiotic use were modified, parents still desired these medications when their child was ill,” said Dr. Taylor of the Child Health Institute at the University of Washington, Seattle, and his colleagues.

It's also possible that “pediatricians may have failed to detect a change in expectations for antibiotics by parents of children in the intervention group,” they wrote (Pediatr. Infect. Dis. J. 2005;24:489–93). Their study was conducted by the Puget Sound Pediatric Research Network, a regional practice-based research group composed of Seattle-area pediatricians.

Parents of 499 healthy children under age 2 years were enrolled at the time of an office visit and randomized to receive either a pamphlet and video promoting the judicious use of antibiotics (the intervention) or brochures about injury prevention (the control group).

The educational pamphlet, “Your Child and Antibiotics,” was developed by the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the American Society of Microbiology. The video was professionally produced and featured one of the physicians from the child's pediatric practice.

At the end of a 12-month period, each child's medical record was reviewed. Of 4,924 outpatient visits, almost 1,420 (29%) were for URI symptoms as the chief complaint. Pediatricians were not informed about which children/parents were involved in the project.

At least one antibiotic was prescribed during 46% of the visits for URI, 92% of which were for a diagnosis of otitis media or sinusitis. Antibiotics were prescribed at only 10 visits at which the only diagnosis made was URI and at 7 visits at which the diagnosis was bronchitis.

Overall, the “average” study patient had approximately 10 visits—a remarkably high level of utilization, the investigators noted—3 of which were visits for URI symptoms. The average patient also had two diagnoses of otitis media and received two prescriptions for antibiotics during the 12-month period. There were no significant differences in any of the outcomes—number of visits, specific diagnoses, or prescriptions—between children in the intervention and control groups.

Although antibiotics were “clearly indicated” for a proportion of patients with the diagnoses of otitis media or sinusitis, “it is equally certain that for a significant proportion … there was uncertainty regarding the diagnosis and/or need for antibiotic therapy, or the diagnosis was made by the practitioners to justify the use of antibiotics,” Dr. Taylor and his associates said.

In an earlier study of the pamphlet and video, they had found that these educational tools resulted in “changes in parental attitudes that were more supportive of the judicious use of [antibiotics],” the investigators said. “We postulated that if parental expectations could be altered by an educational intervention, pediatricians would perceive less demand for antibiotics and prescribe fewer of these medications.”

Now, they said, “it is clear that more research is needed to identify methods for reducing antibiotic use in children that are effective, inexpensive, and easily implemented.”

When James A. Taylor, M.D., and his colleagues found that an educational pamphlet and a video changed parents' attitudes about antibiotic use 2 years ago, they assumed that such a change would lead to fewer demands on pediatricians and fewer antibiotic prescriptions.

They were wrong.

In a randomized controlled trial, their educational intervention did not result in a decrease in antibiotic prescriptions.

Prescriptions were high over a 12-month postintervention period, with antibiotics prescribed during 46% of all visits for upper respiratory infection (URI) symptoms—regardless of whether the parent had received the pamphlet and video or another control intervention.

It could be that “although attitudes about antibiotic use were modified, parents still desired these medications when their child was ill,” said Dr. Taylor of the Child Health Institute at the University of Washington, Seattle, and his colleagues.

It's also possible that “pediatricians may have failed to detect a change in expectations for antibiotics by parents of children in the intervention group,” they wrote (Pediatr. Infect. Dis. J. 2005;24:489–93). Their study was conducted by the Puget Sound Pediatric Research Network, a regional practice-based research group composed of Seattle-area pediatricians.

Parents of 499 healthy children under age 2 years were enrolled at the time of an office visit and randomized to receive either a pamphlet and video promoting the judicious use of antibiotics (the intervention) or brochures about injury prevention (the control group).

The educational pamphlet, “Your Child and Antibiotics,” was developed by the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the American Society of Microbiology. The video was professionally produced and featured one of the physicians from the child's pediatric practice.

At the end of a 12-month period, each child's medical record was reviewed. Of 4,924 outpatient visits, almost 1,420 (29%) were for URI symptoms as the chief complaint. Pediatricians were not informed about which children/parents were involved in the project.

At least one antibiotic was prescribed during 46% of the visits for URI, 92% of which were for a diagnosis of otitis media or sinusitis. Antibiotics were prescribed at only 10 visits at which the only diagnosis made was URI and at 7 visits at which the diagnosis was bronchitis.

Overall, the “average” study patient had approximately 10 visits—a remarkably high level of utilization, the investigators noted—3 of which were visits for URI symptoms. The average patient also had two diagnoses of otitis media and received two prescriptions for antibiotics during the 12-month period. There were no significant differences in any of the outcomes—number of visits, specific diagnoses, or prescriptions—between children in the intervention and control groups.

Although antibiotics were “clearly indicated” for a proportion of patients with the diagnoses of otitis media or sinusitis, “it is equally certain that for a significant proportion … there was uncertainty regarding the diagnosis and/or need for antibiotic therapy, or the diagnosis was made by the practitioners to justify the use of antibiotics,” Dr. Taylor and his associates said.

In an earlier study of the pamphlet and video, they had found that these educational tools resulted in “changes in parental attitudes that were more supportive of the judicious use of [antibiotics],” the investigators said. “We postulated that if parental expectations could be altered by an educational intervention, pediatricians would perceive less demand for antibiotics and prescribe fewer of these medications.”

Now, they said, “it is clear that more research is needed to identify methods for reducing antibiotic use in children that are effective, inexpensive, and easily implemented.”

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

Physicians “should be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” said Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–4).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins.

(Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGHR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said, they hypothesize that the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”— just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/μL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued. His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

Physicians “should be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” said Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–4).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins.

(Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGHR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said, they hypothesize that the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”— just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/μL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued. His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

Physicians “should be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” said Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–4).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins.

(Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGHR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said, they hypothesize that the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”— just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/μL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued. His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

As Paul L. Rowland III, M.D., now sees it, physicians can talk to parents and their overweight children about diet and physical activity, or they can really counsel—that is, ask, listen, listen some more, and talk.

It's only through real counseling, he said, that doctors can hope to prevent and treat obesity and overweight—and all the morbidities that accompany it. “I've learned how to approach this in a positive way, how not to alienate [the families].”

Dr. Rowland is 1 of 20 pediatricians in the Pittsburgh area who participated in a two-pronged practice-based pilot project in which they changed and intensified their counseling—and implemented behavioral treatment programs in their two practices for overweight 8- to 12-year-old children and their families.

The short-term results have encouraged Dr. Rowland and his colleagues to continue. Thirty-seven children who were counseled during well-child visits and subsequently completed the 5-month-long intervention had a mean weight loss of 4 pounds. Seventeen of these children, who were followed for 6 months or more, had a mean decrease in BMI of 2 absolute units, or approximately 7% of their baseline BMI.

Perhaps more importantly, the children made dietary changes and changes in their activity levels that Dr. Rowland and his colleagues believe will have a long-lasting impact.

“We didn't see great weight loss. But these children are at an age where they're expected to gain weight and height, so any weight loss is fabulous,” said Ellen Wald, M.D., who codirected the project.

The call for physicians to incorporate weight management into their practices is intensifying. Numerous bodies have recommended that childhood obesity be prevented and treated in the primary care setting, and both the American Academy of Pediatrics (AAP) and the American Medical Association soon plan to issue clinical guidelines for weight management in children.

Surveys have repeatedly revealed what holds back primary care physicians: a lack of training and perceived competence, a lack of time, parent unwillingness to become involved, few available treatment options, and a lack of third-party reimbursement.

Dr. Rowland said he “didn't need any prompting” when asked to participate in the project almost 2 years ago. He and the five other full-time pediatricians in his ethnically and economically diverse practice, Pittsburgh Pediatric Associates, had only recently begun measuring BMI in some patients. Still, he said, overweight “was a concern that [had been] weighing on our minds for a long time.”

Dr. Rowland also is a member of a 3-year-old practice-based research network—Pediatric PitNet—comprising physicians in practices that are partially owned by Children's Hospital of Pittsburgh. The network had been awarded a $125,000 grant through the Robert Wood Johnson Foundation's “Prescription for Health” program—an initiative that funds practice-based pilot projects aimed at combating unhealthy behaviors in primary care.

For their part, he and the other physician participants completed a 60-minute self-study packet that included 7-year-old recommendations on obesity management from the federal Maternal and Child Health Bureau, the AAP's 2003 policy statement on pediatric overweight and obesity, and reports by Leonard H. Epstein, Ph.D., on his successes with behavioral family-based treatment.

(In 1994, Dr. Epstein and his colleagues reported 10-year outcomes showing that significant numbers of children who lost weight through family-based behavioral treatment maintained that weight loss, or lost more, through adolescence and into adulthood.)

They then attended a 90-minute session—led by health psychologists from the Western Psychiatric Institute and Clinic—in which they revamped their approach to talking during well-child visits about weight and BMI, nutrition, and physical activity.

“The important thing is not to come off sounding judgmental, but to solicit and tease out their concerns a little bit better,” said Dr. Rowland. “I learned to see where the family's coming from—to ask open-ended questions and restate what they're saying—before I start sharing my opinions.”

He said he was surprised by how many parents are concerned about their child's excess weight, but just need to be prompted to talk about it. When parents don't voluntarily express concern, “I show them the [BMI] curve and see how they respond. I might ask, are you concerned? Many will say 'Yes, I didn't bring it up before, but yes.'”

“We almost always end up talking about activity or snacking. Parents will sometimes say, 'He's eating a lot of healthy foods' but when I restated their thoughts, they'd start talking about portion size, how 'He eats seconds or thirds.'”

Per the study protocol, Dr. Rowland encouraged children with a BMI at the 85th percentile or higher, whenever possible, to participate with their parents in a behavioral treatment program. Each run of the program consisted of eight weekly group sessions and three individual follow-up sessions held right in his practice. (See box below at right.)

On his own initiative, Dr. Rowland went further. He attended many of the sessions, sitting in with the kids and keeping his own food and activity logs.

“I don't have any weight issues, and I am physically fit, but I really wanted to learn what these kids were thinking. And I started thinking, maybe I could also do better. I realized what a huge issue these lifestyle changes are,” Dr. Rowland said. “That's why the whole family has to be on board—one member can't make [the] change if other members aren't trying, too.”

Of 73 families who enrolled in the program, 37 completed it. (Families were “completers” if they attended six of the eight group sessions and one of the three follow-up sessions.)

In addition to the mean drop in weight and BMI, the 37 children decreased their consumption of high-fat, low-nutrient foods by half or more. Twenty-one of these children who used pedometers throughout the intervention period also saw a 50% increase in steps per day. (All children started the intervention using pedometers, but many discontinued using the pedometers after the first few weeks.)

Interviews with parents showed that the physicians used what they'd been taught, said Linda Ewing, Ph.D., a codirector of the project who presented some of the findings at the annual meeting of the Pediatric Academic Societies.

Twenty-seven randomly selected parents were interviewed before and after the program. Prior to the training, 37% reported that their child's doctor had discussed physical activity during their well-child visit; after training, this jumped to 89%.

The percentage of parents who reported that the doctor had discussed their child's eating habits jumped from 37% before training to 82% afterward, she said.

“We've shown that it's feasible—that pediatricians will [adopt new skills] and address issues of weight more confidently, and that parents will come to an evidence-based intervention in the office,” said Dr. Ewing of the University of Pittsburgh. “It's the first step, but by no means the last.”

Clinical Growth Charts 'To Go'

If your practice is already working on weight management or getting ready to work with the upcoming clinical guidelines on weight management, the Centers for Disease Control and Prevention's National Center for Health Statistics can help with the record keeping. Copyright-free, customizable PowerPoint charts for tracking boys' and girls' stature-for-age, weight-for-age, and BMI-for-age are available online (

www.cdc.gov/nchs/about/major/nhanes/growthcharts/Powerpt.htm

From Weigh-Ins to Group Sessions: What Behavioral Treatment Entails

Children who attended the behavioral treatment program at Dr. Rowland's practice started each of the eight weekly sessions with a “weigh-in” and an individual family “coaching” session.

The children then met in a group with a clinical psychologist from outside the practice while the parents met primarily with the pediatric office's nurse-practitioner, M. Kathleen Kelly.

“The kids are very honest, and they're encouraged by small changes,” said Dr. Rowland, who attended many of the children's group sessions. “They would readily answer to 'What was difficult for you?' and 'What can you do for next week?'”

Sessions for both parents and children focused on self-monitoring of diet and activity, stimulus control, goal setting, positive reinforcement, social assertion, and relapse prevention.

The goals were to decrease intake of high-fat, low-nutrient foods; to increase intake of low-fat, high-nutrient foods; to decrease sedentary behaviors; and to increase activity and exercise.

Many of the children already had received a small BMI chart color-coded into red, yellow, and green zones to indicate overweight, at-risk, and healthy ranges of BMI. The colors correspond to the red, yellow, and green categories of food in the “stop-light diet”—a concept that the project directors incorporated into the nutritional counseling element of the project. They had the chart designed as an educational tool.

Of 73 children who enrolled, only 4 had a BMI between the 85th and 94th percentiles; the rest of the children were heavier.

Each run of the program in each of the two participating practices—Pittsburgh Pediatric Associates, Dr. Rowland's practice, and Children's Community Care, a rural practice right outside Pittsburgh—consisted of fairly even numbers of boys and girls, with a mean age of 10 years.

As Paul L. Rowland III, M.D., now sees it, physicians can talk to parents and their overweight children about diet and physical activity, or they can really counsel—that is, ask, listen, listen some more, and talk.

It's only through real counseling, he said, that doctors can hope to prevent and treat obesity and overweight—and all the morbidities that accompany it. “I've learned how to approach this in a positive way, how not to alienate [the families].”

Dr. Rowland is 1 of 20 pediatricians in the Pittsburgh area who participated in a two-pronged practice-based pilot project in which they changed and intensified their counseling—and implemented behavioral treatment programs in their two practices for overweight 8- to 12-year-old children and their families.

The short-term results have encouraged Dr. Rowland and his colleagues to continue. Thirty-seven children who were counseled during well-child visits and subsequently completed the 5-month-long intervention had a mean weight loss of 4 pounds. Seventeen of these children, who were followed for 6 months or more, had a mean decrease in BMI of 2 absolute units, or approximately 7% of their baseline BMI.

Perhaps more importantly, the children made dietary changes and changes in their activity levels that Dr. Rowland and his colleagues believe will have a long-lasting impact.

“We didn't see great weight loss. But these children are at an age where they're expected to gain weight and height, so any weight loss is fabulous,” said Ellen Wald, M.D., who codirected the project.

The call for physicians to incorporate weight management into their practices is intensifying. Numerous bodies have recommended that childhood obesity be prevented and treated in the primary care setting, and both the American Academy of Pediatrics (AAP) and the American Medical Association soon plan to issue clinical guidelines for weight management in children.

Surveys have repeatedly revealed what holds back primary care physicians: a lack of training and perceived competence, a lack of time, parent unwillingness to become involved, few available treatment options, and a lack of third-party reimbursement.

Dr. Rowland said he “didn't need any prompting” when asked to participate in the project almost 2 years ago. He and the five other full-time pediatricians in his ethnically and economically diverse practice, Pittsburgh Pediatric Associates, had only recently begun measuring BMI in some patients. Still, he said, overweight “was a concern that [had been] weighing on our minds for a long time.”

Dr. Rowland also is a member of a 3-year-old practice-based research network—Pediatric PitNet—comprising physicians in practices that are partially owned by Children's Hospital of Pittsburgh. The network had been awarded a $125,000 grant through the Robert Wood Johnson Foundation's “Prescription for Health” program—an initiative that funds practice-based pilot projects aimed at combating unhealthy behaviors in primary care.

For their part, he and the other physician participants completed a 60-minute self-study packet that included 7-year-old recommendations on obesity management from the federal Maternal and Child Health Bureau, the AAP's 2003 policy statement on pediatric overweight and obesity, and reports by Leonard H. Epstein, Ph.D., on his successes with behavioral family-based treatment.

(In 1994, Dr. Epstein and his colleagues reported 10-year outcomes showing that significant numbers of children who lost weight through family-based behavioral treatment maintained that weight loss, or lost more, through adolescence and into adulthood.)

They then attended a 90-minute session—led by health psychologists from the Western Psychiatric Institute and Clinic—in which they revamped their approach to talking during well-child visits about weight and BMI, nutrition, and physical activity.

“The important thing is not to come off sounding judgmental, but to solicit and tease out their concerns a little bit better,” said Dr. Rowland. “I learned to see where the family's coming from—to ask open-ended questions and restate what they're saying—before I start sharing my opinions.”

He said he was surprised by how many parents are concerned about their child's excess weight, but just need to be prompted to talk about it. When parents don't voluntarily express concern, “I show them the [BMI] curve and see how they respond. I might ask, are you concerned? Many will say 'Yes, I didn't bring it up before, but yes.'”

“We almost always end up talking about activity or snacking. Parents will sometimes say, 'He's eating a lot of healthy foods' but when I restated their thoughts, they'd start talking about portion size, how 'He eats seconds or thirds.'”

Per the study protocol, Dr. Rowland encouraged children with a BMI at the 85th percentile or higher, whenever possible, to participate with their parents in a behavioral treatment program. Each run of the program consisted of eight weekly group sessions and three individual follow-up sessions held right in his practice. (See box below at right.)

On his own initiative, Dr. Rowland went further. He attended many of the sessions, sitting in with the kids and keeping his own food and activity logs.

“I don't have any weight issues, and I am physically fit, but I really wanted to learn what these kids were thinking. And I started thinking, maybe I could also do better. I realized what a huge issue these lifestyle changes are,” Dr. Rowland said. “That's why the whole family has to be on board—one member can't make [the] change if other members aren't trying, too.”

Of 73 families who enrolled in the program, 37 completed it. (Families were “completers” if they attended six of the eight group sessions and one of the three follow-up sessions.)

In addition to the mean drop in weight and BMI, the 37 children decreased their consumption of high-fat, low-nutrient foods by half or more. Twenty-one of these children who used pedometers throughout the intervention period also saw a 50% increase in steps per day. (All children started the intervention using pedometers, but many discontinued using the pedometers after the first few weeks.)

Interviews with parents showed that the physicians used what they'd been taught, said Linda Ewing, Ph.D., a codirector of the project who presented some of the findings at the annual meeting of the Pediatric Academic Societies.

Twenty-seven randomly selected parents were interviewed before and after the program. Prior to the training, 37% reported that their child's doctor had discussed physical activity during their well-child visit; after training, this jumped to 89%.

The percentage of parents who reported that the doctor had discussed their child's eating habits jumped from 37% before training to 82% afterward, she said.

“We've shown that it's feasible—that pediatricians will [adopt new skills] and address issues of weight more confidently, and that parents will come to an evidence-based intervention in the office,” said Dr. Ewing of the University of Pittsburgh. “It's the first step, but by no means the last.”

Clinical Growth Charts 'To Go'

If your practice is already working on weight management or getting ready to work with the upcoming clinical guidelines on weight management, the Centers for Disease Control and Prevention's National Center for Health Statistics can help with the record keeping. Copyright-free, customizable PowerPoint charts for tracking boys' and girls' stature-for-age, weight-for-age, and BMI-for-age are available online (

www.cdc.gov/nchs/about/major/nhanes/growthcharts/Powerpt.htm

From Weigh-Ins to Group Sessions: What Behavioral Treatment Entails

Children who attended the behavioral treatment program at Dr. Rowland's practice started each of the eight weekly sessions with a “weigh-in” and an individual family “coaching” session.

The children then met in a group with a clinical psychologist from outside the practice while the parents met primarily with the pediatric office's nurse-practitioner, M. Kathleen Kelly.

“The kids are very honest, and they're encouraged by small changes,” said Dr. Rowland, who attended many of the children's group sessions. “They would readily answer to 'What was difficult for you?' and 'What can you do for next week?'”

Sessions for both parents and children focused on self-monitoring of diet and activity, stimulus control, goal setting, positive reinforcement, social assertion, and relapse prevention.

The goals were to decrease intake of high-fat, low-nutrient foods; to increase intake of low-fat, high-nutrient foods; to decrease sedentary behaviors; and to increase activity and exercise.

Many of the children already had received a small BMI chart color-coded into red, yellow, and green zones to indicate overweight, at-risk, and healthy ranges of BMI. The colors correspond to the red, yellow, and green categories of food in the “stop-light diet”—a concept that the project directors incorporated into the nutritional counseling element of the project. They had the chart designed as an educational tool.

Of 73 children who enrolled, only 4 had a BMI between the 85th and 94th percentiles; the rest of the children were heavier.

Each run of the program in each of the two participating practices—Pittsburgh Pediatric Associates, Dr. Rowland's practice, and Children's Community Care, a rural practice right outside Pittsburgh—consisted of fairly even numbers of boys and girls, with a mean age of 10 years.

As Paul L. Rowland III, M.D., now sees it, physicians can talk to parents and their overweight children about diet and physical activity, or they can really counsel—that is, ask, listen, listen some more, and talk.

It's only through real counseling, he said, that doctors can hope to prevent and treat obesity and overweight—and all the morbidities that accompany it. “I've learned how to approach this in a positive way, how not to alienate [the families].”

Dr. Rowland is 1 of 20 pediatricians in the Pittsburgh area who participated in a two-pronged practice-based pilot project in which they changed and intensified their counseling—and implemented behavioral treatment programs in their two practices for overweight 8- to 12-year-old children and their families.

The short-term results have encouraged Dr. Rowland and his colleagues to continue. Thirty-seven children who were counseled during well-child visits and subsequently completed the 5-month-long intervention had a mean weight loss of 4 pounds. Seventeen of these children, who were followed for 6 months or more, had a mean decrease in BMI of 2 absolute units, or approximately 7% of their baseline BMI.

Perhaps more importantly, the children made dietary changes and changes in their activity levels that Dr. Rowland and his colleagues believe will have a long-lasting impact.

“We didn't see great weight loss. But these children are at an age where they're expected to gain weight and height, so any weight loss is fabulous,” said Ellen Wald, M.D., who codirected the project.

The call for physicians to incorporate weight management into their practices is intensifying. Numerous bodies have recommended that childhood obesity be prevented and treated in the primary care setting, and both the American Academy of Pediatrics (AAP) and the American Medical Association soon plan to issue clinical guidelines for weight management in children.

Surveys have repeatedly revealed what holds back primary care physicians: a lack of training and perceived competence, a lack of time, parent unwillingness to become involved, few available treatment options, and a lack of third-party reimbursement.

Dr. Rowland said he “didn't need any prompting” when asked to participate in the project almost 2 years ago. He and the five other full-time pediatricians in his ethnically and economically diverse practice, Pittsburgh Pediatric Associates, had only recently begun measuring BMI in some patients. Still, he said, overweight “was a concern that [had been] weighing on our minds for a long time.”

Dr. Rowland also is a member of a 3-year-old practice-based research network—Pediatric PitNet—comprising physicians in practices that are partially owned by Children's Hospital of Pittsburgh. The network had been awarded a $125,000 grant through the Robert Wood Johnson Foundation's “Prescription for Health” program—an initiative that funds practice-based pilot projects aimed at combating unhealthy behaviors in primary care.

For their part, he and the other physician participants completed a 60-minute self-study packet that included 7-year-old recommendations on obesity management from the federal Maternal and Child Health Bureau, the AAP's 2003 policy statement on pediatric overweight and obesity, and reports by Leonard H. Epstein, Ph.D., on his successes with behavioral family-based treatment.

(In 1994, Dr. Epstein and his colleagues reported 10-year outcomes showing that significant numbers of children who lost weight through family-based behavioral treatment maintained that weight loss, or lost more, through adolescence and into adulthood.)

They then attended a 90-minute session—led by health psychologists from the Western Psychiatric Institute and Clinic—in which they revamped their approach to talking during well-child visits about weight and BMI, nutrition, and physical activity.

“The important thing is not to come off sounding judgmental, but to solicit and tease out their concerns a little bit better,” said Dr. Rowland. “I learned to see where the family's coming from—to ask open-ended questions and restate what they're saying—before I start sharing my opinions.”

He said he was surprised by how many parents are concerned about their child's excess weight, but just need to be prompted to talk about it. When parents don't voluntarily express concern, “I show them the [BMI] curve and see how they respond. I might ask, are you concerned? Many will say 'Yes, I didn't bring it up before, but yes.'”

“We almost always end up talking about activity or snacking. Parents will sometimes say, 'He's eating a lot of healthy foods' but when I restated their thoughts, they'd start talking about portion size, how 'He eats seconds or thirds.'”

Per the study protocol, Dr. Rowland encouraged children with a BMI at the 85th percentile or higher, whenever possible, to participate with their parents in a behavioral treatment program. Each run of the program consisted of eight weekly group sessions and three individual follow-up sessions held right in his practice. (See box below at right.)

On his own initiative, Dr. Rowland went further. He attended many of the sessions, sitting in with the kids and keeping his own food and activity logs.

“I don't have any weight issues, and I am physically fit, but I really wanted to learn what these kids were thinking. And I started thinking, maybe I could also do better. I realized what a huge issue these lifestyle changes are,” Dr. Rowland said. “That's why the whole family has to be on board—one member can't make [the] change if other members aren't trying, too.”

Of 73 families who enrolled in the program, 37 completed it. (Families were “completers” if they attended six of the eight group sessions and one of the three follow-up sessions.)

In addition to the mean drop in weight and BMI, the 37 children decreased their consumption of high-fat, low-nutrient foods by half or more. Twenty-one of these children who used pedometers throughout the intervention period also saw a 50% increase in steps per day. (All children started the intervention using pedometers, but many discontinued using the pedometers after the first few weeks.)

Interviews with parents showed that the physicians used what they'd been taught, said Linda Ewing, Ph.D., a codirector of the project who presented some of the findings at the annual meeting of the Pediatric Academic Societies.

Twenty-seven randomly selected parents were interviewed before and after the program. Prior to the training, 37% reported that their child's doctor had discussed physical activity during their well-child visit; after training, this jumped to 89%.

The percentage of parents who reported that the doctor had discussed their child's eating habits jumped from 37% before training to 82% afterward, she said.

“We've shown that it's feasible—that pediatricians will [adopt new skills] and address issues of weight more confidently, and that parents will come to an evidence-based intervention in the office,” said Dr. Ewing of the University of Pittsburgh. “It's the first step, but by no means the last.”

Clinical Growth Charts 'To Go'

If your practice is already working on weight management or getting ready to work with the upcoming clinical guidelines on weight management, the Centers for Disease Control and Prevention's National Center for Health Statistics can help with the record keeping. Copyright-free, customizable PowerPoint charts for tracking boys' and girls' stature-for-age, weight-for-age, and BMI-for-age are available online (

www.cdc.gov/nchs/about/major/nhanes/growthcharts/Powerpt.htm

From Weigh-Ins to Group Sessions: What Behavioral Treatment Entails

Children who attended the behavioral treatment program at Dr. Rowland's practice started each of the eight weekly sessions with a “weigh-in” and an individual family “coaching” session.

The children then met in a group with a clinical psychologist from outside the practice while the parents met primarily with the pediatric office's nurse-practitioner, M. Kathleen Kelly.

“The kids are very honest, and they're encouraged by small changes,” said Dr. Rowland, who attended many of the children's group sessions. “They would readily answer to 'What was difficult for you?' and 'What can you do for next week?'”

Sessions for both parents and children focused on self-monitoring of diet and activity, stimulus control, goal setting, positive reinforcement, social assertion, and relapse prevention.

The goals were to decrease intake of high-fat, low-nutrient foods; to increase intake of low-fat, high-nutrient foods; to decrease sedentary behaviors; and to increase activity and exercise.

Many of the children already had received a small BMI chart color-coded into red, yellow, and green zones to indicate overweight, at-risk, and healthy ranges of BMI. The colors correspond to the red, yellow, and green categories of food in the “stop-light diet”—a concept that the project directors incorporated into the nutritional counseling element of the project. They had the chart designed as an educational tool.

Of 73 children who enrolled, only 4 had a BMI between the 85th and 94th percentiles; the rest of the children were heavier.

Each run of the program in each of the two participating practices—Pittsburgh Pediatric Associates, Dr. Rowland's practice, and Children's Community Care, a rural practice right outside Pittsburgh—consisted of fairly even numbers of boys and girls, with a mean age of 10 years.

Watchful waiting for nonsevere acute otitis media can be as acceptable to parents as immediate antibiotic treatment—if parents are properly educated about the options, new study findings and survey results indicate.

Parents' satisfaction with their children's care was no different among parents whose children were randomized to receive either immediate antibiotic treatment or watchful waiting in an outcomes study of the two approaches. The parents all were educated at the study site—a pediatric clinic in Galveston, Texas—about the risks and benefits of treatment.

In a separate study, only a minority of parents who were randomly surveyed by mail about a hypothetical visit for an ear infection—without being given much information—said they would feel comfortable with a watchful waiting approach. Most said they would feel neutral or dissatisfied with such an approach.

The studies show that “when it's properly explained, parents are equally satisfied with watchful waiting and antibiotic treatment [for nonsevere acute otitis media],” said Allan S. Lieberthal, M.D., who led development of the American Academy of Pediatrics' guidelines on the diagnosis and management of acute otitis media.

“Now we need tools for educating parents within the confines of a busy pediatric office,” he said in an interview.

Investigators in the randomized study used a handheld flip chart for a 5- to 10-minute review with parents of the definition and causes of ear infections, characteristics of nonsevere and severe acute otitis media (AOM), antibiotic resistance and costs, rate of symptom response to antibiotics, and possible adverse outcomes associated with immediate treatment versus observation.

Parent satisfaction was no different between a group of 111 children randomized to a watchful waiting group and 112 randomized to receive immediate antibiotics, either at day 12 or day 30 after the children were seen, reported David P. McCormick, M.D., of the University of Texas, Galveston, and his colleagues (Pediatrics 2005:115;1455–65).

In the survey, 5,129 parents in 16 Massachusetts communities were asked to rate their level of satisfaction “if your child's doctor diagnosed an ear infection and recommended waiting 1 or 2 days before starting antibiotics (to see if the symptoms get better on their own).”

Of 2,054 parents who returned the survey, 34% said they would be somewhat or extremely satisfied. Another 26% indicated they would be neutral, and the remaining 40% said they would be somewhat or extremely dissatisfied, reported Jonathan A. Finkelstein, M.D., of Harvard Medical School, Boston, and his associates (Pediatrics 2005:115;1466–73).

Both studies were conducted before the AAP guidelines were published last year.

In addition to offering new insight into issues of parent acceptance, findings from the randomized study affirm what the guidelines say: that some children with nonsevere AOM may be observed with watchful waiting as long as they maintain nonsevere status and are kept comfortable with appropriate symptom management, Dr. Lieberthal said.

Of the children randomized to the watchful waiting group, 66% completed the study without antibiotics.

Immediate antibiotic treatment was associated with 16% fewer treatment failures—a difference that the investigators said was larger than they “expected from [their] review of the literature”—and improved symptom control.

Antibiotic treatment also was associated, however, with increased antibiotic-related adverse events. And although immediate treatment resulted in eradication of Streptococcus pneumoniae carriage in the majority of children, the S. pneumoniae strains cultured from children in the antibiotic group at day 12 were more likely to be multidrug-resistant than were strains from the watchful waiting group, the investigators reported.

“Watchful waiting seems to be an alternative that is acceptable to parents, reduces the number and cost of antibiotic prescriptions, and reduces the percent of multidrug-resistant bacteria colonizing the nasopharynx of children after an episode of AOM,” Dr. McCormick and his associates said.

Regardless of the intervention, children who had received antibiotics within the previous 30 days were more than twice as likely to fail treatment as those who had not recently received antibiotics.

In addition to parent education, key factors for implementation of a watchful waiting strategy include access to follow-up care, management of AOM symptoms, and a method to classify AOM severity, the investigators said.

They assessed AOM severity based on four factors: parental perception of severity, otoscopic examination, body temperature, and tympanogram scores.

However, “in retrospect,” they reported, they “could have obtained the same results”—identifying 87% of the nonsevere cases identified with the four-factor scoring system—by using a two-factor scoring system that omitted body temperature and tympanogram.

“Most children with AOM are afebrile at the time of diagnosis as a result of antipyretic medication,” they said. “Practicing clinicians rarely use the tympanogram to make a diagnosis of AOM.”

Dr. Lieberthal, cochair of the AAP's subcommittee on management of AOM and professor of pediatrics at the University of Southern California, Los Angeles, said the issue of how to accurately and uniformly assess AOM severity is still unresolved. “We still need a validated scoring system.”

Watchful waiting for nonsevere acute otitis media can be as acceptable to parents as immediate antibiotic treatment—if parents are properly educated about the options, new study findings and survey results indicate.

Parents' satisfaction with their children's care was no different among parents whose children were randomized to receive either immediate antibiotic treatment or watchful waiting in an outcomes study of the two approaches. The parents all were educated at the study site—a pediatric clinic in Galveston, Texas—about the risks and benefits of treatment.

In a separate study, only a minority of parents who were randomly surveyed by mail about a hypothetical visit for an ear infection—without being given much information—said they would feel comfortable with a watchful waiting approach. Most said they would feel neutral or dissatisfied with such an approach.

The studies show that “when it's properly explained, parents are equally satisfied with watchful waiting and antibiotic treatment [for nonsevere acute otitis media],” said Allan S. Lieberthal, M.D., who led development of the American Academy of Pediatrics' guidelines on the diagnosis and management of acute otitis media.

“Now we need tools for educating parents within the confines of a busy pediatric office,” he said in an interview.

Investigators in the randomized study used a handheld flip chart for a 5- to 10-minute review with parents of the definition and causes of ear infections, characteristics of nonsevere and severe acute otitis media (AOM), antibiotic resistance and costs, rate of symptom response to antibiotics, and possible adverse outcomes associated with immediate treatment versus observation.

Parent satisfaction was no different between a group of 111 children randomized to a watchful waiting group and 112 randomized to receive immediate antibiotics, either at day 12 or day 30 after the children were seen, reported David P. McCormick, M.D., of the University of Texas, Galveston, and his colleagues (Pediatrics 2005:115;1455–65).

In the survey, 5,129 parents in 16 Massachusetts communities were asked to rate their level of satisfaction “if your child's doctor diagnosed an ear infection and recommended waiting 1 or 2 days before starting antibiotics (to see if the symptoms get better on their own).”

Of 2,054 parents who returned the survey, 34% said they would be somewhat or extremely satisfied. Another 26% indicated they would be neutral, and the remaining 40% said they would be somewhat or extremely dissatisfied, reported Jonathan A. Finkelstein, M.D., of Harvard Medical School, Boston, and his associates (Pediatrics 2005:115;1466–73).

Both studies were conducted before the AAP guidelines were published last year.

In addition to offering new insight into issues of parent acceptance, findings from the randomized study affirm what the guidelines say: that some children with nonsevere AOM may be observed with watchful waiting as long as they maintain nonsevere status and are kept comfortable with appropriate symptom management, Dr. Lieberthal said.

Of the children randomized to the watchful waiting group, 66% completed the study without antibiotics.

Immediate antibiotic treatment was associated with 16% fewer treatment failures—a difference that the investigators said was larger than they “expected from [their] review of the literature”—and improved symptom control.

Antibiotic treatment also was associated, however, with increased antibiotic-related adverse events. And although immediate treatment resulted in eradication of Streptococcus pneumoniae carriage in the majority of children, the S. pneumoniae strains cultured from children in the antibiotic group at day 12 were more likely to be multidrug-resistant than were strains from the watchful waiting group, the investigators reported.

“Watchful waiting seems to be an alternative that is acceptable to parents, reduces the number and cost of antibiotic prescriptions, and reduces the percent of multidrug-resistant bacteria colonizing the nasopharynx of children after an episode of AOM,” Dr. McCormick and his associates said.

Regardless of the intervention, children who had received antibiotics within the previous 30 days were more than twice as likely to fail treatment as those who had not recently received antibiotics.

In addition to parent education, key factors for implementation of a watchful waiting strategy include access to follow-up care, management of AOM symptoms, and a method to classify AOM severity, the investigators said.

They assessed AOM severity based on four factors: parental perception of severity, otoscopic examination, body temperature, and tympanogram scores.

However, “in retrospect,” they reported, they “could have obtained the same results”—identifying 87% of the nonsevere cases identified with the four-factor scoring system—by using a two-factor scoring system that omitted body temperature and tympanogram.

“Most children with AOM are afebrile at the time of diagnosis as a result of antipyretic medication,” they said. “Practicing clinicians rarely use the tympanogram to make a diagnosis of AOM.”

Dr. Lieberthal, cochair of the AAP's subcommittee on management of AOM and professor of pediatrics at the University of Southern California, Los Angeles, said the issue of how to accurately and uniformly assess AOM severity is still unresolved. “We still need a validated scoring system.”

Watchful waiting for nonsevere acute otitis media can be as acceptable to parents as immediate antibiotic treatment—if parents are properly educated about the options, new study findings and survey results indicate.

Parents' satisfaction with their children's care was no different among parents whose children were randomized to receive either immediate antibiotic treatment or watchful waiting in an outcomes study of the two approaches. The parents all were educated at the study site—a pediatric clinic in Galveston, Texas—about the risks and benefits of treatment.

In a separate study, only a minority of parents who were randomly surveyed by mail about a hypothetical visit for an ear infection—without being given much information—said they would feel comfortable with a watchful waiting approach. Most said they would feel neutral or dissatisfied with such an approach.

The studies show that “when it's properly explained, parents are equally satisfied with watchful waiting and antibiotic treatment [for nonsevere acute otitis media],” said Allan S. Lieberthal, M.D., who led development of the American Academy of Pediatrics' guidelines on the diagnosis and management of acute otitis media.

“Now we need tools for educating parents within the confines of a busy pediatric office,” he said in an interview.

Investigators in the randomized study used a handheld flip chart for a 5- to 10-minute review with parents of the definition and causes of ear infections, characteristics of nonsevere and severe acute otitis media (AOM), antibiotic resistance and costs, rate of symptom response to antibiotics, and possible adverse outcomes associated with immediate treatment versus observation.

Parent satisfaction was no different between a group of 111 children randomized to a watchful waiting group and 112 randomized to receive immediate antibiotics, either at day 12 or day 30 after the children were seen, reported David P. McCormick, M.D., of the University of Texas, Galveston, and his colleagues (Pediatrics 2005:115;1455–65).

In the survey, 5,129 parents in 16 Massachusetts communities were asked to rate their level of satisfaction “if your child's doctor diagnosed an ear infection and recommended waiting 1 or 2 days before starting antibiotics (to see if the symptoms get better on their own).”

Of 2,054 parents who returned the survey, 34% said they would be somewhat or extremely satisfied. Another 26% indicated they would be neutral, and the remaining 40% said they would be somewhat or extremely dissatisfied, reported Jonathan A. Finkelstein, M.D., of Harvard Medical School, Boston, and his associates (Pediatrics 2005:115;1466–73).

Both studies were conducted before the AAP guidelines were published last year.

In addition to offering new insight into issues of parent acceptance, findings from the randomized study affirm what the guidelines say: that some children with nonsevere AOM may be observed with watchful waiting as long as they maintain nonsevere status and are kept comfortable with appropriate symptom management, Dr. Lieberthal said.

Of the children randomized to the watchful waiting group, 66% completed the study without antibiotics.

Immediate antibiotic treatment was associated with 16% fewer treatment failures—a difference that the investigators said was larger than they “expected from [their] review of the literature”—and improved symptom control.

Antibiotic treatment also was associated, however, with increased antibiotic-related adverse events. And although immediate treatment resulted in eradication of Streptococcus pneumoniae carriage in the majority of children, the S. pneumoniae strains cultured from children in the antibiotic group at day 12 were more likely to be multidrug-resistant than were strains from the watchful waiting group, the investigators reported.

“Watchful waiting seems to be an alternative that is acceptable to parents, reduces the number and cost of antibiotic prescriptions, and reduces the percent of multidrug-resistant bacteria colonizing the nasopharynx of children after an episode of AOM,” Dr. McCormick and his associates said.

Regardless of the intervention, children who had received antibiotics within the previous 30 days were more than twice as likely to fail treatment as those who had not recently received antibiotics.

In addition to parent education, key factors for implementation of a watchful waiting strategy include access to follow-up care, management of AOM symptoms, and a method to classify AOM severity, the investigators said.

They assessed AOM severity based on four factors: parental perception of severity, otoscopic examination, body temperature, and tympanogram scores.

However, “in retrospect,” they reported, they “could have obtained the same results”—identifying 87% of the nonsevere cases identified with the four-factor scoring system—by using a two-factor scoring system that omitted body temperature and tympanogram.

“Most children with AOM are afebrile at the time of diagnosis as a result of antipyretic medication,” they said. “Practicing clinicians rarely use the tympanogram to make a diagnosis of AOM.”

Dr. Lieberthal, cochair of the AAP's subcommittee on management of AOM and professor of pediatrics at the University of Southern California, Los Angeles, said the issue of how to accurately and uniformly assess AOM severity is still unresolved. “We still need a validated scoring system.”

WASHINGTON — Auden C. McClure, M.D., and her colleagues noticed some time ago that children and young teens in their New Hampshire community and pediatric practice often wore T-shirts, hats, and other merchandise bearing alcohol brand names and logos.

Now, armed with research findings showing that ownership of such merchandise is associated with early-onset drinking, Dr. McClure is calling on the alcohol industry to follow the example of the tobacco industry and stop distributing the merchandise.

“The alcohol industry should institute a voluntary ban … because of the association with early drinking and because students become a walking advertisement for alcohol consumption,” Dr. McClure said at the annual meeting of the Pediatric Academic Societies.

She reported on a survey of fifth- to eighth-grade students in eight rural public schools in New Hampshire. Approximately 2,400 who said they had never used alcohol were asked by telephone 1–2 years later whether they owned an alcohol promotional item and if they had begun using alcohol.

Fourteen percent reported owning at least one alcohol promotional item (mostly clothing), and 15% reported using alcohol.

Those who owned alcohol promotional items had higher rates of alcohol use, compared with those who did not own the merchandise—approximately 25% vs. 13%, said Dr. McClure, a pediatrician at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Ownership of alcohol promotional items was associated with peer drinking, poor school performance, and high-risk behaviors, such as sensation seeking and rebelliousness.

Even after adjusting for these factors, Dr. McClure and her associates found that students who owned alcohol promotional items were more than 1.5 times more likely to try drinking than their peers.

Tobacco companies spent more than $2 billion in the 1990s on cigarette promotional items, but in 1999 they voluntarily gave up distribution and sale of the products after the practice was found to be associated with adolescent smoking.

Tobacco companies agreed to the ban as part of the master settlement agreement with the state attorneys general.

“Multiple studies during that time documented that tobacco promotional items are prevalent among adolescents, that ownership is associated with smoking, that it's independent of other adolescent risk factors, and also that ownership … precedes the decision to smoke,” Dr. McClure said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

Unlike the smoking research, their study on alcohol promotional items does not prove causality, she said. The survey also did not ascertain where the items came from—whether they were purchased or received free at sporting events, for instance—and it did not ascertain alcohol brands.

The study also excluded students who, at baseline, had already begun drinking, which means “we potentially could have eliminated a higher-risk population,” Dr. McClure said.

Alcohol use was assessed in the telephone survey with the question, “Have you ever had beer, wine, or another drink of alcohol that your parents didn't know about?” The other main question was: “Do you own something that has the name of a beer or alcohol brand on it like a T-shirt, or a backpack, or a hat?”

A national sample of adolescents is being surveyed currently, she said.

Until more research is completed and action is taken, “parents and schools should help … to eliminate the ownership and display of alcohol promotional items in our schools and homes,” she said.

WASHINGTON — Auden C. McClure, M.D., and her colleagues noticed some time ago that children and young teens in their New Hampshire community and pediatric practice often wore T-shirts, hats, and other merchandise bearing alcohol brand names and logos.

Now, armed with research findings showing that ownership of such merchandise is associated with early-onset drinking, Dr. McClure is calling on the alcohol industry to follow the example of the tobacco industry and stop distributing the merchandise.

“The alcohol industry should institute a voluntary ban … because of the association with early drinking and because students become a walking advertisement for alcohol consumption,” Dr. McClure said at the annual meeting of the Pediatric Academic Societies.

She reported on a survey of fifth- to eighth-grade students in eight rural public schools in New Hampshire. Approximately 2,400 who said they had never used alcohol were asked by telephone 1–2 years later whether they owned an alcohol promotional item and if they had begun using alcohol.

Fourteen percent reported owning at least one alcohol promotional item (mostly clothing), and 15% reported using alcohol.

Those who owned alcohol promotional items had higher rates of alcohol use, compared with those who did not own the merchandise—approximately 25% vs. 13%, said Dr. McClure, a pediatrician at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Ownership of alcohol promotional items was associated with peer drinking, poor school performance, and high-risk behaviors, such as sensation seeking and rebelliousness.

Even after adjusting for these factors, Dr. McClure and her associates found that students who owned alcohol promotional items were more than 1.5 times more likely to try drinking than their peers.

Tobacco companies spent more than $2 billion in the 1990s on cigarette promotional items, but in 1999 they voluntarily gave up distribution and sale of the products after the practice was found to be associated with adolescent smoking.

Tobacco companies agreed to the ban as part of the master settlement agreement with the state attorneys general.

“Multiple studies during that time documented that tobacco promotional items are prevalent among adolescents, that ownership is associated with smoking, that it's independent of other adolescent risk factors, and also that ownership … precedes the decision to smoke,” Dr. McClure said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

Unlike the smoking research, their study on alcohol promotional items does not prove causality, she said. The survey also did not ascertain where the items came from—whether they were purchased or received free at sporting events, for instance—and it did not ascertain alcohol brands.

The study also excluded students who, at baseline, had already begun drinking, which means “we potentially could have eliminated a higher-risk population,” Dr. McClure said.

Alcohol use was assessed in the telephone survey with the question, “Have you ever had beer, wine, or another drink of alcohol that your parents didn't know about?” The other main question was: “Do you own something that has the name of a beer or alcohol brand on it like a T-shirt, or a backpack, or a hat?”

A national sample of adolescents is being surveyed currently, she said.

Until more research is completed and action is taken, “parents and schools should help … to eliminate the ownership and display of alcohol promotional items in our schools and homes,” she said.

WASHINGTON — Auden C. McClure, M.D., and her colleagues noticed some time ago that children and young teens in their New Hampshire community and pediatric practice often wore T-shirts, hats, and other merchandise bearing alcohol brand names and logos.

Now, armed with research findings showing that ownership of such merchandise is associated with early-onset drinking, Dr. McClure is calling on the alcohol industry to follow the example of the tobacco industry and stop distributing the merchandise.

“The alcohol industry should institute a voluntary ban … because of the association with early drinking and because students become a walking advertisement for alcohol consumption,” Dr. McClure said at the annual meeting of the Pediatric Academic Societies.

She reported on a survey of fifth- to eighth-grade students in eight rural public schools in New Hampshire. Approximately 2,400 who said they had never used alcohol were asked by telephone 1–2 years later whether they owned an alcohol promotional item and if they had begun using alcohol.

Fourteen percent reported owning at least one alcohol promotional item (mostly clothing), and 15% reported using alcohol.

Those who owned alcohol promotional items had higher rates of alcohol use, compared with those who did not own the merchandise—approximately 25% vs. 13%, said Dr. McClure, a pediatrician at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Ownership of alcohol promotional items was associated with peer drinking, poor school performance, and high-risk behaviors, such as sensation seeking and rebelliousness.

Even after adjusting for these factors, Dr. McClure and her associates found that students who owned alcohol promotional items were more than 1.5 times more likely to try drinking than their peers.

Tobacco companies spent more than $2 billion in the 1990s on cigarette promotional items, but in 1999 they voluntarily gave up distribution and sale of the products after the practice was found to be associated with adolescent smoking.

Tobacco companies agreed to the ban as part of the master settlement agreement with the state attorneys general.

“Multiple studies during that time documented that tobacco promotional items are prevalent among adolescents, that ownership is associated with smoking, that it's independent of other adolescent risk factors, and also that ownership … precedes the decision to smoke,” Dr. McClure said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

Unlike the smoking research, their study on alcohol promotional items does not prove causality, she said. The survey also did not ascertain where the items came from—whether they were purchased or received free at sporting events, for instance—and it did not ascertain alcohol brands.

The study also excluded students who, at baseline, had already begun drinking, which means “we potentially could have eliminated a higher-risk population,” Dr. McClure said.

Alcohol use was assessed in the telephone survey with the question, “Have you ever had beer, wine, or another drink of alcohol that your parents didn't know about?” The other main question was: “Do you own something that has the name of a beer or alcohol brand on it like a T-shirt, or a backpack, or a hat?”

A national sample of adolescents is being surveyed currently, she said.

Until more research is completed and action is taken, “parents and schools should help … to eliminate the ownership and display of alcohol promotional items in our schools and homes,” she said.