January 2014 � Volume 164 � Number 1 Copyright ª 2014 by Mosby Inc.

You can't diagnosehypertension if you

don't know what it is!— Thomas R. Welch, MD

Anumber of studies have suggested that pediatricians are not good at recognizinghypertension in children, even when the child has a recorded blood pressure

that is abnormal by normative data. How could this be? Do we not think that hyper-tension is important, or do we not appreciate that a specific value is abnormal?

Of course, recognizing that a specific child’s blood pressure is abnormal generallyrequires consulting age-, sex-, and height-specific tables. Because physicians probablydo not consult such tables for every child at every visit, they must somehow “triage”the children for whom such consultation will be undertaken. Could that be the prob-lem?

This issue of The Journal includes a fascinating report by Bijlsma et al in theNetherlands. These authors questioned nearly 200 pediatricians in regard to theirpractice in assessing blood pressure. Approximately two-thirds of those respondingindicated that they only consulted reference tables if they suspected that a blood pres-sure measurement was elevated. These physicians were then queried about specificmeasurements in hypothetical children; nearly one-half of them missed at least oneof the cases as having hypertension or prehypertension.

So, if we only consult reference tables if we suspect that hypertension is present, butif our ability to recognize the child in whom we should be “suspect” is not good, whatshould we do? Consulting reference tables for virtually every child one sees is probablythe only sure fire way to address this issue. Of course, a better solution would be med-ical informatics support that would regularly identify and flag blood pressures that areabnormal.

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Sensory deprivationin private rooms

in the NICU— Alan H. Jobe, MD, PhD

Neonatal care has become appropriately “humanized” over past years. Infants arenot removed from the mothers and family at birth and early breast-feeding and

attachment is encouraged. In the neonatal intensive care unit (NICU) environment,frequent parental visits are encouraged as is skin-to-skin contact with parents. Exces-sive noise and light are controlled in the NICU environment, and developmental carestrategies are used to minimize infant stress. The current trend is to build the NICU tooffer small private rooms for the parents and the infant with further noise and lightreduction. Parents may appreciate the privacy, but Pineda et al have compared neuro-developmental outcomes for the infants born at <30 weeks gestational age that werecared for within a large intercity NICU with both open wards and private rooms. Con-trary to their hypothesis, at term the infants from the private rooms had less brainmaturation, and at 2 years of age they had lower language scores than infants caredfor in open wards. The results are biologically plausible as sensory deprivation isknown to degrade neurodevelopment, and private rooms will decrease the sensory ex-periences (sound and light) of the preterm infants. These exposures will be furtherdecreased if parents visit infrequently and only for short periods, which was thecase in this NICU. The optimal types and frequencies of stimulations for developmentof the very preterm brain are unknown, but isolation of these infants in relatively darkand quiet private rooms may be going in the wrong direction.

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Maltreatment reportspredict sudden infant

death syndrome— Robert W. Wilmott, MD

In the US, approximately 4500 infants die every year with no obvious cause of deathand are classified as sudden and unexpected infant deaths (SUID). More than one-

half of these are eventually classified as sudden infant death syndrome (SIDS). In thisissue of The Journal, Putnam-Hornstein et al from the University of Southern Califor-nia have investigated the hypothesis that infants reported for maltreatment face aheightened risk of SIDS and SUID. Data from the California Department of Healthand the California Department of Social Services were used, and infant death recordswere linked to administrative child protection data. Infants were prospectively fol-lowed from birth through death or age 1 year. The results show that a previousmaltreatment report is a significant predictor of SIDS and SUID. After adjusting forbaseline risk factors, the rate of SIDS was more than three times greater among infantsreported for possible maltreatment. The results of this prospective study suggest thatimproved services and communication between child protective services and pediatrichealthcare might enhance infant well-being and reduce the risk of SIDS.

Article page 142<

Does fetal lifeinfluence

cardiovascular risk?—Stephen R. Daniels, MD, PhD

The Barker Hypothesis suggests that fetal growth is an important determinant oflater risk of cardiovascular disease. In this issue of The Journal, Mullett et al report

the results of a study of over 3000 infants who were followed from birth to fifth gradein West Virginia. They found that overweight and obesity in the fifth grade is stronglyassociated with having coronary artery risk factors at that age. Being large for gesta-tional age at birth was associated with overweight and obesity later in life. However,the impact of the combination of being small for gestational age and being overweightin fifth grade was associated with the highest level of triglycerides.

These results suggest that fetal exposures and growth during fetal life may play a rolein longer term risk of heart disease, but the relationships are likely to be complex.

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Early psychosocialdeprivation harmsmotor development— Robert W. Wilmott, MD

The hypothesis that early psychosocial deprivation impedes motor development andmight be positively impacted by foster care was investigated by Levin et al. They

completed a randomized controlled trial of children living in Romanian institutionswho were randomly assigned to care as usual in the institution or placed in family-centered foster care as part of an early intervention program. The average time in fostercare was 23 months. Children were evaluated with a standard instrument and resultsshow that children who had never been institutionalized had significantly better motordevelopment than childrenwhohadnever been institutionalized.However, surprisingly,there was no significant difference in outcomes between children in the care as usualgroup and the family-centered foster care group. Differences in motor developmentwere largely mediated by IQ. The study shows the importance of evaluating and treatingmotor delays in children with a history of institutionalization, especially for those with alow IQ.

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Vitamin D and anemia— Thomas R. Welch, MD

The significant prevalence of vitamin D deficiency (VDD) in many groups of childrenis well known today. Indeed, studies showing VDD in various chronic childhood

conditions are no longer surprising or novel. In light of this, the report in this issueof The Journal from Atkinson et al at Johns Hopkins is not surprising. Using datafrom National Health and Nutrition Examination Survey, the authors found an associ-ation between low levels of 25-Hydroxyvitamin D and anemia in children. Superficially,one might predict that some of the social and nutritional conditions that could lead toVDD also would be risks for anemia; the study, however, controlled for such obviousconfounders as obesity, as well as other measures of nutritional adequacy. Althoughthe study was not designed to demonstrate causality, there are intriguing possible expla-nations for this finding. Among the many non-skeletal effects of calcitriol, there may be

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a direct effect on bone marrow; the known immunomodulatory effects of calcitriolmight modulate cytokine production, modifying inflammatory pathways that couldcontribute to anemia.

Anemia and VDD are common in children, have serious consequences, and nowmay be linked.

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Long-termrespiratory

impairment with thenew BPD

— Robert W. Wilmott, MD

In the presurfactant era, bronchopulmonary dysplasia (BPD) was common and wasassociated with significant long-term respiratory morbidity. Although survival after

extreme preterm birth has been improving and the rate of severe BPD has declinedover the past 20 years, a new pattern of lung injury with disruption of lung growthhas emerged. This new pattern of BPD seems less severe but long-term data havebeen sparse. To investigate the long-term outcomes of former very low birth weight(VLBW) preterm infants born in the surfactant era, vom Hove et al from the Univer-sity of Leipzig have completed a study of pulmonary function tests in children with ahistory of BPD and VLBW, compared with a matched preterm VLBW control group.They were studied at a mean age of 9.5 years and found to have had significantly morerespiratory symptoms and asthma treatments compared with controls. They also hadsignificantly lower values on pulmonary function testing, showing that this newerform of BPD is far from benign.

These findings are discussed in an accompanying editorial by Waldemar A. Carlo,MD, from the University of Alabama at Birmingham. Carlo concluded that the resultsof this study are important because they show that VLBW infants who survived withBPD have high rates of abnormal pulmonary symptoms and pulmonary function testsindicative of expiratory flow limitation at school age which improve with bronchodi-lator therapy. In addition, many of the asymptomatic children had abnormal pulmo-nary function tests. Moreover, even children with VLBW who did not have BPD hadhigh rates of abnormal pulmonary symptoms and abnormal pulmonary function tests.It seems that many children are at risk for airflow obstruction and respiratory impair-ment following prematurity. This emphasizes the need for continued research intotherapies that reduce the incidence and severity of BPD.

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Molecularepidemiology ofStaphylococcus

aureus colonization— Sarah S. Long, MD

Rodriguez et al performed a year-long prospective study of molecular epidemiologyof Staphylococcus aureus colonization of 163 children with S aureus skin and soft

tissue infections and their 562 household contacts. Samples of the infected site of indexcases and swabs from potential colonizing sites of nares, axilla, and inguinal folds wereobtained repeatedly from cases and once at case diagnosis from households. Strainrelatedness was determined by repetitive sequence-based PCR testing.

Results refuted a simplistic idea that a single strain affected a single patient or asingle household, let alone multiple patients and multiple households. The studyclarifies only the complexity of S aureus niches, potential modes of acquisitionand transmission of colonizing organisms, and events that lead to infection. A betterunderstanding of each will be required before postulating and studying strategies forcontrol or eradication.

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